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+{"text": "Defensins comprise a large family of cationic antimicrobial peptides that are characterized by the presence of a conserved cysteine-rich defensin motif. Based on the spacing pattern of cysteines, these defensins are broadly divided into five groups, namely plant, invertebrate, \u03b1-, \u03b2-, and \u03b8-defensins, with the last three groups being mostly found in mammalian species. However, the evolutionary relationships among these five groups of defensins remain controversial.Gallinacin 1\u201313, are clustered densely within a 86-Kb distance on the chromosome 3q3.5-q3.7. The deduced peptides vary from 63 to 104 amino acid residues in length sharing the characteristic defensin motif. Based on the tissue expression pattern, 13 \u03b2-defensin genes can be divided into two subgroups with Gallinacin 1\u20137 being predominantly expressed in bone marrow and the respiratory tract and the remaining genes being restricted to liver and the urogenital tract. Comparative analysis of the defensin clusters among chicken, mouse, and human suggested that vertebrate defensins have evolved from a single \u03b2-defensin-like gene, which has undergone rapid duplication, diversification, and translocation in various vertebrate lineages during evolution.Following a comprehensive screen, here we report that the chicken genome encodes a total of 13 different \u03b2-defensins but with no other groups of defensins being discovered. These chicken \u03b2-defensin genes, designated as We conclude that the chicken genome encodes only \u03b2-defensin sequences and that all mammalian defensins are evolved from a common \u03b2-defensin-like ancestor. The \u03b1-defensins arose from \u03b2-defensins by gene duplication, which may have occurred after the divergence of mammals from other vertebrates, and \u03b8-defensins have arisen from \u03b1-defensins specific to the primate lineage. Further analysis of these defensins in different vertebrate lineages will shed light on the mechanisms of host defense and evolution of innate immunity. HD5 are fully protected against the doses of Salmonella typhimurium that are otherwise lethal to the wide-type mice [S. typhimurium [Defensins constitute a large family of small, cysteine-rich, cationic peptides that are capable of killing a broad spectrum of pathogens, including various bacteria, fungi, and certain enveloped viruses -5. Theseype mice . Convershimurium .8\u201311-C-X3\u20135-C-X3-C-X9\u201312-C-X4\u201311-C-X1-C-X3-C; invertebrate defensin: C-X5\u201316-C-X3-C-X9\u201310-C-X4\u20137-C-X1-C; \u03b1-defensin: C-X1-C-X3\u20134-C-X9-C-X6\u201310-C-C; and \u03b2-defensin: C-X4\u20138-C-X3\u20135-C-X9\u201313-C-X4\u20137-C-C. The \u03b1- and \u03b2-defensins are unique to vertebrate animals with \u03b1-defensins only being found in rodents and primates, while \u03b2-defensins are present in all mammalian species investigated [Defensins have been identified in species ranging from plants, insects to animals and humans -5. CharaAnalysis of human and mouse genomes indicated that \u03b2-defensins form 4\u20135 distinct clusters on different chromosomes with each cluster consisting of multiple defensin genes . InteresExistence of a large number of expressed sequence tag (EST) sequences and recent completion of chicken genome sequencing at a 6.6\u00d7 coverage  providedGal 1\u20133) [Gal 4\u201312, have been found in the EST database with at least two hits for each, and such sequences have also been confirmed in genomic sequences , EST, high throughput genomic sequence (HTGS), and whole-genome shortgun sequence (WGS) databases in the GenBank by using the TBLASTN program. All potGal 1\u20133) ,23, nine GENSCAN  and confGal genes constitute the entire repertoire of the \u03b2-defensin family encoded in the chicken genome. Although it is highly unlikely, we could not rule out the possibility that additional defensin-related genes with distant homology might be uncovered in the chicken by different computational search methods such as the use of Hidden Markov models [No other sequence containing \u03b2-defensin-like six-cysteine motif has been found in NR, EST or genomic databases, suggesting that 13 v models ,15. It iSimilar to Gal 1\u20133, 10 novel \u03b2-defensins, deduced from either EST or genomic sequences, vary from 63 to 104 amino acid residues in length. Alignment of these peptides revealed a conservation of the signal sequence at the N-terminus and the characteristic six-cysteine defensin motif at the C-terminus , while mean pN was 0.369 \u00b1 0.040. In the mature defensin region, mean pS was 0.673 \u00b1 0.027, while mean pN was 0.534 \u00b1 0.051. Mean pN in the mature defensin was significantly greater than that in the propeptide , indicating lesser functional constraint on the amino acid sequence of the former. The high mean pS shows that chicken \u03b2-defensin genes have not duplicated recently, unlike \u03b2-defensin genes of the bovine [Gal6 and Gal7), mean pS in the mature defensin was 0.221 \u00b1 0.082, while mean pN was 0.331 \u00b1 0.076. While these values are not significantly different at the 5% level, the fact that pN was higher than pS suggested that positive selection may have acted to diversify the mature defensin region between these two genes.Comparison of the numbers of synonymous and nonsynonymous nucleotide substitutions provides a powerful test of the hypothesis that positive Darwinian selection has acted to favor changes at the amino acid level . This ape bovine . In the Gal genes except for Gal4 and Gal5. Later search of chicken WGS sequences released on February 29, 2004 confirmed the order of the genomic contig that we assembled and also revealed the locations of two remaining genes, Gal4 and Gal5, both of which reside on a WGS (accession no. AADN01058096) that overlaps with AC110874  using the TAM31-54I5 BAC DNA as probe  sequences, TAM31-54I5 (accession no. AC110874) and CH261-162O9 (accession no. AC146292), both of which were sequenced and deposited earlier by one of us (J.F. Chen). Alignment of these two sequences allowed to re-order three DNA fragments in AC110874 and to construct a continuous, gap-free genomic contig that includes 11 Gal gene. Unlike most mammalian \u03b2-defensin genes, which primarily consist of two exons and one intron, the Gal genes were found to be composed of four short exons separated by three introns with variable lengths ranging from 117 bp to 3,322 bp  and the majority of the last exon encodes 3'-UTR as well as a few C-terminal amino acids, two internal exons resemble mammalian \u03b2-defensin genes in that one exon encodes the signal and pro-sequence and the other encodes the mature sequence with six-cysteine motif [Gal genes have joined together during the evolution as a result of exon shuffling, which occurred in many other evolutionarily conserved gene families [Comparing the cDNA with genomic sequences also revealed the structure of each ne motif ,27-29. Afamilies , includiGal1 and Gal2 are expressed in bone marrow and lung, while Gal3 is more preferentially expressed in bone marrow, tongue, trachea, and bursa of Fabricius [Gal genes that we identified, RT-PCR was performed with a panel of 32 different chicken tissues. Similar to Gal 1\u20133, Gal 4\u20137 are highly restricted to bone marrow cells with Gal5 also expressed in tongue, trachea, lung, and brain at lower levels  are predominantly expressed in bone marrow and the respiratory tract, whereas the other six genes  are more restricted to liver and the urogenital tract. However, the functional significance and transcriptional regulatory mechanisms of these genes during inflammation and infection remain to be investigated.It has been shown that abricius . To studCTSB  and a human EST sequence (accession no. BE072524) immediately located centromeric to chicken defensins, were also found to be conserved in the defensin gene clusters on human chromosome 8p22 and mouse chromosome 14C3. Similarly, another gene, HARL2754 (accession no. XP_372011) that is 6-Kb telemetric to Gal4 is also conserved in another defensin cluster in human (8p23) or mouse (8A1.3) . In addition, a group of homologous \u03b2-defensin-like sequences, namely crotamine and myotoxins, have been found in several s snakes , which as snakes  is apparIn addition to the structural conservation between \u03b2-defensin-like sequences in the rattlesnake and mammals , a growiWe have showed that chicken genome encodes a total of 13 different \u03b2-defensin genes clustered densely within a 86-Kb distance on the chromosome 3q3.5-q3.7, but with no \u03b1-defensin genes. These peptides exhibit homology to different subgroups of mammalian \u03b2-defensins-, consistent with the hypothesis that \u03b1-defensins and \u03b2-defensins arose by gene duplication after the divergence of birds and mammals. The \u03b8-defensins are specific to primates; and thus appear to have arisen from \u03b1-defensins by gene duplication specific to the primate lineage. Apparently, the evolution of defensins is rapid and driven by duplication and positive diversifying selection. Collectively, this study represents the first large-scale detailed investigation of defensins in non-mammalian vertebrates. There is no doubt that further analysis of these defensin genes will lead to a better understanding of host defense mechanisms and evolution of innate immunity.To identify novel defensins in the chicken, all known cysteine-containing defensin-like peptide sequences discovered in plants, invertebrates, birds, and mammals were individually queried against the translated chicken NR, EST, HTGS, and WGS databases in the GenBank by using the TBLASTN program  with defS) and the proportion of nonsynonymous nucleotide differences per nonsynonymous site (pN) were estimated by the method of Nei and Gojobori [Multiple sequence alignment was constructed by using the ClustalW program (version 1.82) . A phyloGojobori . Again, To generate a continuous defensin gene cluster, the HTGS and WGS sequences containing the putative defensin genes were retrieved from the GenBank, aligned to generate a longer contig, which was confirmed later by searching through the assembled chicken genome released on February 29, 2004, by using the BLAT program  under thGal genes. Metaphase chromosome speads were prepared from mitogen-stimulated chicken splenocyte culture as we described [Fluorescence in situ hybridization (FISH) was used for chromosomal assignment of the chicken \u03b2-defensin gene cluster by using the BAC clone TAM31-54I4 as probe, which harbors 11 escribed ,42. The Total RNA was extracted with Trizol (Invitrogen) from a total of 32 different tissues from healthy, 2-month-old chickens (see Figure et al. reported independently discovery of seven novel chicken \u03b2-defensins in the chicken EST database by using homology search strategies [Gal 4\u20137 are primarily in bone marrow, while other genes are more restricted to liver and the genitourinary tract.Following submission of this manuscript, Lynn rategies . ConsistAbbreviations: Gal, Gallinacin; NR, nonredundant; EST, expressed sequence tag; HTGS, high throughput genomic sequence; WGS, whole-genome shortgun sequence; BAC, bacterial artificial chromosome; FISH, fluorescence in situ hybridization; UTR, untranslated region; GAPDH, glyceraldehyde-3-phosphate dehydrogenase.YX carried out the tissue collection, RT-PCR analysis of tissue expression patterns, and drafted the manuscript. ALH carried out the phylogenetic and molecular evolutionary analyses. JA and YM carried out the fluorescence in situ hybridization. JFC carried out the sequencing of two chicken defensin-containing BAC clones. DSN participated in tissue collection and preparation. GZ conceived of the study, carried out all computational analyses and annotation, drafted the manuscript, and participated in its design and coordination. All authors read and approved the final manuscript."}
+{"text": "Brucella abortus PrpA [for \u2018proline racemase\u2019 virulence factor A] and homologous proteins from two Brucella spp are bona fide HyPREs and not \u2018one way\u2019 directional PRACs as described elsewhere. Although the mechanisms of aminoacid racemization and epimerization are conserved between PRAC and HyPRE, our studies demonstrate that substrate accessibility and specificity partly rely on contraints imposed by aromatic or aliphatic residues distinctively belonging to the catalytic pockets. Analysis of PRAC and HyPRE sequences along with reaction center structural data disclose additional valuable elements for in silico discrimination of the enzymes. Furthermore, similarly to PRAC, the lymphocyte mitogenicity displayed by HyPREs is discussed in the context of bacterial metabolism and pathogenesis. Considering tissue specificity and tropism of infectious pathogens, it would not be surprising if upon infection PRAC and HyPRE play important roles in the regulation of the intracellular and extracellular amino acid pool profiting the microrganism with precursors and enzymatic pathways of the host.The first eukaryotic proline racemase (PRAC), isolated from the human Trypanosoma cruzi pathogen, is a validated therapeutic target against Chagas' disease. This essential enzyme is implicated in parasite life cycle and infectivity and its ability to trigger host B-cell nonspecific hypergammaglobulinemia contributes to parasite evasion and persistence. Using previously identified PRAC signatures and data mining we present the identification and characterization of a novel PRAC and five hydroxyproline epimerases (HyPRE) from pathogenic bacteria. Single-mutation of key HyPRE catalytic cysteine abrogates enzymatic activity supporting the presence of two reaction centers per homodimer. Furthermore, evidences are provided that  Clostridium sticklandii (CsPRAC) Trypanosoma cruzi pathogen (TcPRAC) and shown to be involved in the mechanisms of parasite escape from host immune responses for its mitogenic properties toward B lymphocytes TcPRAC is present in all T. cruzi life cycle stages, is essential for parasite viability and it appears to be involved in certain metabolic pathways during metacyclogenesis as parasites overexpressing TcPRAC genes gain better host infectivity TcPRAC as a lead for drug development against trypanosomiasis In recent years, an increasing interest rose concerning Proline Racemases (PRAC). Originally isolated in 1957 from \u03b1) of both amino acid enantiomers resulting in steroinversion of chiral centers in reactions depending or not on pyridoxal phosphate (PLP) cofactor. PRAC is a member of the PLP-independent enzyme family along with Glutamate and Aspartate Racemases and Diaminopimelate Epimerase TcPRAC in complex with its competitive inhibitor provided evidences that proline (Pro) racemization operates by stabilization of carbanionic transition-state species in a two-Cystein-dependent acid/base catalytic mechanism 130 and Cys300 ) per TcPRAC subunit.Racemases catalyze the deprotonation/reprotonation of the chiral carbon  Multiple alignment of functional PRAC amino acid sequences and the analysis of the conserved Cys has enabled the definition of minimal essential motifs  specifically from Pseudomonas aeruginosa, Burkholderia pseudomallei and 3 Brucella species. The studies also reveal that MIII*, considered to be a minimal pattern to identify putative PRAC, is not sufficiently stringent to discriminate PRAC from HyPRE. Additional element motifs are provided for the discrimination of PRAC and HyPRE sequences based for instance on polarity constraints imposed by precise residues of the catalytic pockets that contribute to ligand specificity.The presence of functional PRAC was investigated in a collection of 9 bacterial species of pathogenic importance  using molecular and biochemical approaches. Current work unveils a new functional PRAC isolated from \u03b1 of 4-hydroxyproline (OH-Pro). Enzymatic activities of bacterial PRAC and HyPREs identified here were fully characterized and specific maxV and mK determined. Furthermore, the data discloses that HyPRE enzymatic activity equally depends on two catalytic Cys residues, as shown by single mutation of Cys88 or Cys236 residues of P. aeruginosa HyPRE which drastically impairs OH-Pro epimerization. This is the first work associating simultaneously full-length HyPRE genes and functional enzymatic activity of the encoded proteins.HyPRE, a PLP-independent enzyme described in the late 1950's Brucella abortus virulence factor (PrpA), described as PRAC, as well as homologous proteins from B. melitensis and B. suis, are bona fide PLP-independent HyPREs that interconvert trans or cis OH-L-Pro into cis or trans OH-D-Pro respectively and no other amino acids.The present data challenges recently published studies Both Pro and OH-Pro are important compounds for growth and development of many organisms. They can be used as exclusive sources of carbon, nitrogen and energy and are the principal components of collagen-the most widespread molecule in higher organisms TcPRAC sequences resulted in 184 hits from which 111 possess the minimal PRAC stringent MIII* among which 62 hits were directly annotated as \u2018PRAC\u2019, without previous validation of the enzymatic activity. The present analysis revealed that MIII* and MCGH motif TcPRAC Cys300 and Cys130 crucial residues respectively, were consistently present in 92 sequences. We formerly suggested that predicted proteins originated from genes lacking these key Cys residues would display functions other than Pro racemization TcPRAC, to the conservation or not of homologous Cys130 and Cys300 and the recognized pathogenic importance of the microbial genomes.Blast searches of NCBI and Swiss-Prot/TrEMBL databases with full-length TcPRAC, present either a conservation of the couple of catalytic Cys or replacements of one or both Cys positions by serine (Ser) and/or threonine (Thr) residues. A comparison between Brucella spp sequences and the previously characterized TcPRAC and CsPRAC was of note. Therefore, from the two available homologous sequences for each Brucella specie only one meets the requirements for PRAC activity and presents both key Cys residues, the other presenting Ser and Thr substitutions.As summarized in C. difficile (Cd) recombinant protein racemized both L- and D-Pro but not OH-L/D-Pro or any other natural amino acid. CdPRAC activity is PLP-independent which closely resembles TcPRAC and CsPRAC B. pseudomallei and P. aeruginosa recombinant proteins presented no measurable PRAC activity but demonstrated strong epimerization of OH-L/D-Pro behaving as genuine OH-Pro epimerases. However, as predicted, control recombinant proteins produced from B. cenocepacia and P. aeruginosa sequences that present \u2018Cys-Thr\u2019 or \u2018Ser-Cys\u2019 couple replacements respectively did not show neither PRAC nor HyPRE enzymatic activities. Unexpectedly, three tested recombinant proteins, two produced from Bacillus anthracis and one from Vibrio parahaemolyticus, annotated as \u2018putative PRACs\u2019 and presenting the \u2018Cys-Cys\u2019 couple generated recombinant proteins that did not display PRAC or HyPRE activities.The function of 12 gene products and their ability to interconvert Pro residues was addressed. Purified recombinant proteins were analyzed in biochemical assays by measuring the shift in optical rotation of either L- or D-Pro. As shown in B. abortus sequences, presenting the \u2018Cys-Cys\u2019 couple, was reported elsewhere as a B-cell mitogen with PRAC activity  and was shown to be directly involved in bacterial virulence and immune system evasion BaPrpA produced from sequence 1 obtained in silico was then investigated. BaSeq1, derived from Ba-strain 544, is 100% homologous to Ba-strain 9-941 and BaPrpA  and possesses all PRAC motifs  and B. suis (Bs) all three recombinant homologous proteins were tested in parallel for PRAC and HyPRE activities. These proteins were unable to catalyze Pro racemization but exhibited equivalent strong ability to perform epimerization of both OH-L-Pro and OH-D-Pro , pH 8\u20139 buffers, respectively. On the other hand, when PRAC was radically inhibited by its specific competitive inhibitor pyrrole-2-carboxylic acid (PYC), no inhibition of HyPRE was observed with standard amounts of PYC (1 mM) . HyPRE rf TcPRAC . Graphicc values . Brucell PaHyPRE . HoweverTcPRAC sequence, MIII* and MCGH block, we demonstrated that a number of homologous hits corresponded to HyPRE, a PRAC-related enzyme. Sequences of PRAC and HyPRE were aligned and residues that may be useful for their discrimination were identified (TcPRAC with Pro ring carbon atoms that is missing in HyPRE (depicted in R1). In fact, Phe imposes polarity constraints precluding polar functions at the level of the substrate carbon ring. Instead, HyPRE holds Ser or valine  substitutions, i.e. small polar or aliphatic amino acids, that would account for better OH-Pro accessibility into the pocket. Other sequences encoding proteins without enzymatic activity may present at that position, polar tyrosine (Tyr) or histidine (His) residues which would restrict PRAC or HyPRE catalysis, as observed with B. anthracis sequences. Another feature is the presence in the TcPRAC pocket environment of a Cys  residue in position 270 while HyPREs possess in that position a consistent polar His residue (depicted in R2) optimally placed to favor H-bonding interaction with the OH- of the C\u03b3-atom of OH-Pro. Moreover, an additional block of three residues downstream of the highly conserved MIII*  is fully restrictive to discriminate HyPRE and PRAC enzymes. These three differences are complementary to the presence of the \u2018Cys-Cys\u2019 couple of the catalytic pockets as ascertained by the absence of both enzymatic activities exhibited by B. anthracis and V. parahaemolyticus proteins.Following blast searches using full-length entified . Thus, aPaHyPRE Cys88 or Cys236 into Ser residues  (V60GHyPRE) or Phe (V60FHyPRE), meeting or not size and stability limits imposed by Val. The absence of epimerization exhibited by the two mutants revealed that the Val60 aliphatic residue indeed accounts for OH-Pro ligand specificity and is consequently essential for HyPRE catalysis. Conversely, the Phe102 residue on the PRAC catalytic site environment offers hydrophobic restriction area to the pocket occupancy restraining the accessibility of OH-Pro.HyPRE homodimer was described as having both subunits participating in a single catalytic site residues . In comp subunit . To valiThe space and polarity constraints of PRAC and HyPRE active sites on protein\u2013ligand interactions are visualized better by comparing the closer views of the enzyme pockets . TherefoHaemophilus influenzae diaminopimelate epimerase (DapE). C. difficile and C. sticklandii cluster together with T. cruzi and T. vivax , the segregation of the tree branches reflecting their ancient origin. It is conceivable that the divergence between PRAC and HyPRE is phylogenetically older than the separation of bacteria, archea and eukaryotes. Alternatively, possible gene transfer between species can be envisaged.The significance and conservation of PRAC and HyPRE throughout evolution was investigated by a phylogram using another PLP-independent enzyme as an uncontroversial outgroup, i.e. the T. cruzi proline racemase (TcPRAC) full-length sequences, 73% of the hits were incorrectly annotated as PRAC or putative PRAC since most of the proteins do not experimentally display functional PRAC activity. Consistent with previous data determining critical residues for PRAC catalysis, the present study reveals that out of 12 \u2018PRAC-like\u2019 recombinant proteins from different pathogens only one (8%), from C. difficile, which is a significant nosocomial pathogen Brucella species, P. aeruginosa and B. pseudomallei. In addition, 33% of the studied sequences were erroneously annotated though missing fundamental catalytic residues. To our knowledge, apart from previous work using purified P. putida HyPRE which associated the enzyme active site to 14 residues The discovery of novel microbial genes and metabolic proteins through genome mining has proven to be a promising approach to identify potential candidates for drug discovery and therapy against infections. Despite increased availability of genome data, the attribution of putative functions to homologous genes annotations are at times too simple and errors can occur with the consequence of incorrect scientific dogmas. In this paper we report that from a selected database assembled from blast searches using PaHyPRE mutants supporting the key role of Cys88 and Cys236 residues in catalysis and the large overall structural similarity with TcPRAC, our data supports a reaction mechanism similar to PRAC where HyPRE equally possesses two active sites per dimer, each one including two catalytic Cys. Therefore, Cys88 and Cys236 residues are correctly positioned in the HyPRE pocket to perform epimerization of C\u03b1 OH-Pro chiral center. However, HyPRE is not inhibited by PYC, the transition state analogue of Pro. It has previously been shown that hydrophobic Phe102 (R1) and Phe290 residues present in the TcPRAC pocket impose polarity restrictions that enable interactions of the enzyme with the C\u03b1 Pro ring or the C2 atom of PYC. Instead, the absence of Phe residues in HyPRE pocket, most particularly Phe102, and its substitution by an aliphatic Val (or polar Ser), promotes an ideal environment for accessibility and stereoinversion of the C\u03b1 of OH-Pro. Indeed, mutagenesis of Val60 into Gly or Phe, results in radical loss of PaHyPRE activity, attributing a significant role to Val60 in the conformation of the enzyme, the pocket stability and the ligand specificity. It could though be hypothesized that a single replacement of this central Val60 residue by an aromatic Phe would be sufficient to affect the hydrosolubility of the HyPRE pocket environment thus favouring the accessibility and correct positioning of \u2018Pro\u2019 and its further \u2018racemization\u2019. Nonetheless, our data shows that this hypothesis is unlike since PaHyPRE V60F-mutant is unable to perform L-Pro < > D-Pro conversion. Per se this result is not surprising given that racemization of Pro by PRAC catalytic Cys is known to be assisted by neighbor residues of the pocket that are equally present on HyPRE, such as Leu127, His132 and Asp296, 290 which is absent in PaHyPRE sequence. These neighboring residues may be involved in significant hydrophobic interactions of the enzyme with its ligand and influence the pKa of the catalytic Cys residues thus determining the environment hydrophobicity and as such affecting the stability of the pocket and resulting catalysis.Based on overall comparisons between PRAC and HyPRE and despite the evident identities displayed by the peptide sequences, structural evidences were presented here that allow the discrimination of both enzymatic activities. Considering the results obtained with TcPRAC at position 270 which is absent and replaced by a polar His residue in HyPRE (R2) thus favouring its interaction with OH-Pro. Additionally, a block of residues (XLA) downstream of the previously identified minimal MIII* PRAC signature TcPRAC and PaHyPRE active sites. It would be interesting to verify if multiple replacements of discriminating R1, R2 and R3 HyPRE elements by PRAC specific residues would induce any changes in substrate specificity. Nevertheless, although HyPRE and PRAC catalytic sites are structurally very similar, full-sequence disparities between these two enzymes are still substantial (app. 35% homology). Consequently, conformational factors  that contribute to substrate recognition are certainly more subtle and intricate to distinguish than R1, R2 and R3 whose identification was exclusively based on sequence \u2018(dis)similarities\u2019. Eventhough, several coexistent mutations might introduce drastic reductions in catk and account for a restrained catalytic activity of the mutant and/or \u201casymmetric\u201d preferences for a particular substrate stereoisomer, thus affecting \u201cracemic principles\u201d. It is also conceivable that major (extra) distortions in the pocket geometry and charge delocalization-previously shown to play a role on ligand accessibility On the other hand, PRAC and HyPRE multiple alignments allowed identification of other important and non dissociated elements that account for the discrimination of the enzymes, such as the presence of the aliphatic Cys (or Leu) residue in B. abortus, that possibly due to its 40% homology with TcPRAC was described as a PRAC. Surprisingly, PrpA was described as displaying discrete racemization of L-Pro but as unable of catalyzing the conversion of D-Pro enantiomer. As such, this data would imply that some racemases do not follow fundamental racemic principles. The present data establishes that PrpA from B. abortus, B. melitensis and B. suis are in fact HyPRE that catalyze the interconversion of OH-L/D-Pro. These results are significant to prevent any misinterpretations of mechanisms linked to pathogenesis induced by Brucella spp.We report here a clarification of earlier work P. putida that, like other Pseudomonas spp, has been found to cause nosocomial infections with resulting septicemia and septic arthritis P. aeruginosa and several other important pathogens such as B. pseudomallei and Brucella spp agents of melioidosis and brucellosis, respectively P. aeruginosa, for instance, induces disruption of blood vessels through elastase by dissolution of the elastic lamina of arteries and arterioles, or by degrading major fragments of collagen IV HyPRE is a PLP-independent enzyme, shown to be essential in TcPRAC, PRAC from C. difficile and HyPREs from P. aeruginosa and B. abortus are also strong lymphocyte mitogens as they increase in vitro lymphoproliferation by up to 10 fold  and PRAC motif III* were used to blast genome databases. Default settings for Blast were used. Unrooted trees and alignments were obtained with ClustalW program.B. anthracis (strain 9131), C. difficile (strain VPI10463), V. parahaemolyticus (CNRVC 010089), B. abortus (strain 544), B. melitensis (strain 16M), B. suis (strain 1330) and B. pseudomallei (strain K96243). DNA was extracted from bacterial pellets of B. cenocepacia (strain J2315) and P. aeruginosa (strain PAK) with the DNA tissue culture extraction kit (Qiagen)Purified DNA was obtained from TcPRAC sequence toward specific sequences of the genes of interest (E. coli DH5\u03b1 cells were transformed with empty or ligated plasmids. Plasmids were extracted with the Qiaprep Spin Miniprep kit (Qiagen) from bacterial pellets from individual colony cultures and sequenced . Sequences, ORFs and the presence of C-terminal 6x-His Tag were verified. E. coli BL21 (DE3) cells were transformed with ligated plasmids. Recombinant proteins were purified as described Forward and Reverse primers were designed based on Optimum racemization and epimerization conditions were determined using 20 mM L-Pro or OH-L-Pro in 0.2 M NaOAc or Tris 20mM/EDTA 1 mM (TE) buffers respectively, as a function of pH. Percent of racemization or epimerization of serial concentrations of substrate was calculated by incubating 3\u201310 \u00b5g of recombinant protein, 20\u201380 mM substrate in NaOAc pH 6 or TE, pH 8 (q.s.p. 500 \u00b5l) for 30\u201360 min at 37\u00b0C. The reactions were stopped by incubating at \u221220\u00b0C and optical rotations measured in a polarimeter 241MC (Perkin Elmer) mK and maxV.Assays were performed at 37\u00b0C with 10\u2013160 mM of each substrate, 20 \u00b5g/ml of specific enzymes in optimum reaction buffer PaHyPRE was performed using a QuikChange XL kit (Stratagene), as described Site-directed mutagenesis of CdPRAC, C. difficile VPI10463), EF495341 , EF495342 , EF495343 , EF495344 , EF495345 .The following nucleotide sequences were submitted to GenBank\u2122 Data Bank with accession numbers EF495346 Click here for additional data file.Figure S2Inhibition of HyPRE reactions with alkylating agents.(0.29 MB TIF)Click here for additional data file.Figure S3Strategy for PaHyPRE site specific mutagenesis.(0.33 MB TIF)Click here for additional data file.Table S1Primers used for the production of recombinant proteins and site-directed mutagenesis.(0.42 MB TIF)Click here for additional data file.Table S2Mitogenic activity of PRAC and HyPRE enzymes.(0.40 MB TIF)Click here for additional data file."}
+{"text": "Chemokines and their receptors play important roles in host defense, organogenesis, hematopoiesis, and neuronal communication. Forty-two chemokines and 19 cognate receptors have been found in the human genome. Prior to this report, only 11 chicken chemokines and 7 receptors had been reported. The objectives of this study were to systematically identify chicken chemokines and their cognate receptor genes in the chicken genome and to annotate these genes and ligand-receptor binding by a comparative genomics approach.3C, or XC motif, whereas all the chemokine receptors had seven conserved transmembrane helices, four extracellular domains with a conserved cysteine, and a conserved DRYLAIV sequence in the second intracellular domain. The number of coding exons in these genes and the syntenies are highly conserved between human, mouse, and chicken although the amino acid sequence homologies are generally low between mammalian and chicken chemokines. Chicken genes were named with the systematic nomenclature used in humans and mice based on phylogeny, synteny, and sequence homology.Twenty-three chemokine and 14 chemokine receptor genes were identified in the chicken genome. All of the chicken chemokines contained a conserved CC, CXC, CXThe independent nomenclature of chicken chemokines and chemokine receptors suggests that the chicken may have ligand-receptor pairings similar to mammals. All identified chicken chemokines and their cognate receptors were identified in the chicken genome except CCR9, whose ligand was not identified in this study. The organization of these genes suggests that there were a substantial number of these genes present before divergence between aves and mammals and more gene duplications of CC, CXC, CCR, and CXCR subfamilies in mammals than in aves after the divergence. Chemokines are a family of small chemoattrative peptides that were originally recognized to be involved in host defense as regulators of leukocyte trafficking, but more recently have also been shown to have roles in organogenesis, hematopoiesis, and neuronal communication . Their c3C) subfamilies based on their four conserved cysteines. The first two cysteines in the two major subfamilies are either adjacent (CC) or separated by one amino acid (CXC). The first two cysteines in the CX3C chemokines are separated by three amino acids, whereas the XC chemokines contain only two of the cysteines [Chemokines are highly basic proteins, 70 to 125 amino acids long. Sequence identity among chemokines is usually low; however, all share a typical overall tertiary structure, which consists of at least four cysteines that form two disulfide bonds. Chemokines are divided into two major (CC and CXC) and two minor  and 36  in mouse, whereas there are 11 receptors for CCLs, 6 for CXCLs, 1 for CX3CL, and 1 for XCL in human and mouse. Only 11 chicken chemokines including 4 CXC, 6 CC, and 1 XC and seven chicken chemokine receptors including 2 CXCR and 5 CCR have been reported in the literature [At present, 42 chemokine genes have been identified in human . Eleven reported chicken genes were also named accordingly as CCL1L2 (L34552), CCL5 , CCL4L1 , CCL/MCP-L1 , CCL16 , CCL20 , CXCL8a , CXCL8b , CXCL12 , CXCL14 , and XCL1 . In summary, there are 13 CCL, 8 CXCL, 1 CX3CL, and 1 XCL genes identified in the chicken genome. The information used for the nomenclature is shown in the comparative genomic maps and phylogenetic trees.In addition to the 11 previously reported, 12 new chicken chemokine were identified. These include 7 new CC chemokines named CCL1L1 (BX935885), CCL3L1 (CF258095), CCL/MCP-L2 (CK610423), CCL/MCP-L3 (CK610627), CCL17 (BI067703), CCL19 (BX929857), and CCL21 (CR522995), 4 new chicken CXC chemokines named CXCL13a (BX262175), CXCL13b (BX264625), and CXCL13c (CR352598), CXCL15 (BX929947), and 1 CX3C chemokine was found , CCR6 , CCR7 (predicted sequence: chr27_random_59.1), CCR8a (AJ720982), CXCR2 (BX258468), CXCR5 (AJ450829), CX3CR1 . In contrast to chicken chemokines, chicken chemokine receptors share significant amino acid identity with their human receptor counterparts. The percents of amino acid identity between chicken and human chemokine receptors range from 48 to 81%. The lengths of these chicken receptors range from 335 to 382 amino acids. The complete sequence of chicken CXCR2 is unknown due to a sequence gap in the chicken genome sequence. The CXCR2 EST and a partial genome sequence contain the last 170 amino acids of the C-terminus.Fourty-four amino acid residues were highly conservated (>85% homologies) among all chicken chemokine receptors Figure . These r3CL1 and one CCL17 genes , 27 (CCR7), 7 (CXCR4), and 24 (CXCR5). Several human chemokine receptors, such as CCR1, CCR3, CCR10, CXCR3, and CXCR6 were not found in the chicken genome, though the syntenies associated with these receptors are present in the chicken genome.Chemokine receptor genes were also highly conserved between chicken, human, and mouse, and were similarly clustered. The largest cluster of chicken chemokine receptors was found on Chromosome 2, where 5 receptor genes  were identified. Another cluster on Chromosome 2 contains CCR4, CCR8, and CXAccording to the chicken genome sequence, chicken chemokine genes share typical three-exon CC and four-exon CXC gene structures with mammals except for CXCL13a and CXCL13b, which have only three exons. Chicken chemokine genes are shorter than the corresponding human genes due to shorter introns in chickens. The gene structure of chemokine receptors was also conserved between chicken and mammals. The EST sequences indicate that chicken chemokine receptor genes could have up to 5 exons, though the complete sequences were not available. However, the expressed sequences show that the amino acid sequences of identified chicken receptors are mostly encoded in a single exon as are most of the mammalian chemokine receptors. Chicken ESTs aligned with the chicken genome sequence indicate that these receptor mRNAs have approximately 2 kb of 5' UTR, as do those found in humans.The phylogenetic trees Figure , and 8 sChicken chemokine receptors can also be named according to mammalian nomenclature based on phylogenetic analysis Figure  and synt3C, XC, and cognate receptors as mouse. The results of phylogenetic analyses generally agree with the comparative chromosomal locations and syntenies of the genes. The independent nomenclature of chicken chemokines and chemokine receptors suggests that the chicken may have ligand-receptor pairings similar to mammals. The organization of these genes suggests that there were a substantial number of these genes present before divergence between aves and mammals and more gene duplications of CC, CXC, CCR, and CXCR subfamilies in mammals than in aves after the divergence.In summary, 23 chemokine and 14 chemokine receptor genes were identified from the chicken genome in this study. Many chicken genes display high degrees of similarity with their human and mouse orthologs in terms of gene structure, sequence homology, and synteny. Chicken has significantly fewer CCLs, CXCLs, CCRs, and CXCRs than mammals, but it has the same number of CXWe systematically searched for chicken chemokine and chemokine receptor genes in the recently available draft chicken genome sequence. Without this information, it may have taken years to find chicken chemokines and their receptors. The independent nomenclature of chicken chemokines and chemokine receptors and mammalian chemokine-receptor binding information suggest that most of the genes have been identified. One exception was CCL25, the only known ligand of CCR9 in mammals, which was not found in this study though its receptor was identified. Likewise, CXCL14, and CXCL15 were identified in both chickens and mice, but their receptors are unknown; therefore, it is very likely that there are additional chicken chemokine and chemokine receptor genes in the chicken genome.Although most of the systematic nomenclature of the chicken genes was unambiguous based on both phylogenetic trees and syntenies, the information that was used to name seven chicken CCLs as CCL1L1, CCL1L2, CCL3L1, CCL4L1, CCL/MCP-L1, CCL/MCP-L2, and CCL/MCP-L3 and to distinguish two chicken chemokine receptors into CCR2 and CCR5 is inadequate. CCR2 and CCR5 are closely related and tightly linked in the human, mouse, and chicken genomes. The phylogenetic analysis indicates these genes were duplicated after the divergence between mammals and aves. Chicken CCL/MCP-L1, -L2, and -L3 were related to a group of clustered mouse and human MCP CCLs; therefore, specific cognate receptors must be tested to distinguish them. In humans, the chemokines of this MCP group and MIPs, such as CCL3, CCL4, and CCL5, can bind to more than one receptor, such as CCR1, 2, 3, and/or 5, but not both CCR2 and CCR5. CCR1 and CCR3 were not found in the chicken genome and probably are not present in the species. Therefore, chicken CCR2 and CCR5 may be two receptors that recognize these two groups of CCL chemokines, such as CCR2 for MCPs and CCR5 for MIPs. Interestingly, two CCL1 like (CCL1L1 and CCL1L2) and two CCL1 receptor (CCR8a and CCR8b) genes were found in the chicken genome. The ligand-receptor binding for these four genes can not be determined in this study. Nerveless, the names assigned based on comparative analysis in this study may prove useful in order to apply the functional and physiological knowledge from other species to chickens. Further lab testing must be carried out to confirm the ligand-receptor binding and to understand their biological functions.Chicken chemokine ESTs are highly represented in the EST database. There are several ESTs aligned to each identified chicken chemokine gene in the UCSC Genome browser. The sequences assembled from ESTs probably contained most, if not all, of the full-length chemokine mRNA sequences. Promoter sequences with a typical TATAA were detected with promoter prediction software (data not shown). However, there were only a few ESTs that partially cover chicken chemokine receptor genes. Some of these EST contain translation start sites. These EST sequences and reported complete coding sequences indicate that the amino acid sequences of chicken chemokine receptors are mostly encoded in one exon. The predicted amino acid sequences were of the expected length and aligned very well with the coding sequences of non-chicken reference genes in the UCSC genome browser. The conserved gene structure of this receptor family and high sequence similarity between chicken and mammals suggest that the predicted coding sequences were very accurate, especially for those with ESTs containing translation start sites. CCR4 is the only predicted gene that does not have a matching EST and CXCR2 is the only identified gene with partial sequence. Further study including sequencing expressed sequences is needed to confirm these genes.Based on the organization, syntenies, and phylogenetic trees of chicken, mouse, and human chemokine and chemokine receptor genes, we conclude that there may be a substantial number of chemokine and cognate receptor genes before divergence between aves and mammals. The presence of a few chicken chemokine and chemokine receptor paralogs and orthologs of the mammalian genes indicated that most chicken chemokine and the receptor genes shared common ancestors with the human and mouse genes. There were significantly more gene duplications of CC, CXC, CCR, and CXCR subfamilies in mammals than in aves after the divergence of mammals and aves. The mammalian and chicken genome sequences and the genes identified in this study can be used for further investigation of the molecular evolution of these gene families and as a model for the study of the divergence between aves and mammals. Avian and mammalian species may share similar chemokine-receptor binding patterns. The results of this study may be used as functional inferences for these chicken genes before they are experimentally tested.To identify syntenies, genes closely linked to human and mouse chemokines were identified and localized on the chicken genome using the UCSC genome browser . Express3C motifs and aligned using the ClustalW program [Complete amino acid sequences of currently known human and mouse chemokines were retrieved from Genbank. The amino acid sequences of all putative chicken chemokines were predicted based on the open reading frames of the expressed nucleotide sequences (ESTs or mRNAs). The amino acid sequences were grouped according to CC, CXC, and CX program ,33. The  program .3CL1(NM_002996) and mouse chemokines CCL1 (NM_011329), mCCL2 (NM_011333), mCCL3 (NM_011337), mCCL4 (NM_013652), mCCL5 (BC033508), mCCL6 (BC002073), mCCL7 (BC061126), mCCL8 (NM_021443), mCCL9 (NM_011338), mCCL10 (U15209), mCCL11 (NM_011330), mCCL12 (BC027520), mCCL17 (BC028505), mCCL19 (BC051472), mCCL20 (BC028504 (NM_009138), mCCL27 (BC028511), mCCL28 (BC055864), and mCX3CL1 (BC054838) were retrieved from the GenBank. Reported chicken chemokines K60 (Y14971), cCAF (M16199), MIP-1\u03b2 (AJ243034), k203 (Y18692), AH294 (AY037859), AH221 (AY037860), AH189 (AY037861), JSC (AF285876), SDF-1(BX936268), Clone 391 (L34552) and lymphotactin (AF006742) are included in this study. Rat (BC070938) and monkey (AF449286) CX3CL1 were also retrieved for CX3CL sequence analysis. There are several human chemokine-like genes in the human genome, which were not included in this study.For comparison, human chemokines hCCL1 (GenBank accession number: (NM_002981), hCCL2 (BC009716), hCCL3 (BC071834), hCCL4 (NM_002984), hCCL5 (BC008600), hCCL7 (NM_006273), hCCL8 (NM_005623), hCCL11 (BC017850), hCCL13 (BC008621), hCCL14(BC045165), hCCL15 (NM_032964), hCCL16 (NM_004590), hCCL17 (BC069107), hCCL18 (BC069700), hCCL19 (BC027968), hCCL20 (BC020698), hCCL21 (BC027918), hCCL22 (BC027952), hCCL23 (NM_145898), hCCL24 (BC069072), hCCL25 (NM_005624), hCCL26 (BC069394), hCCL27 (AJ243542), hCCL28 (AF220210), hCXCL1 (BC011976), hCXCL2 (BC015753), hCXCL3 (BC065743), hCXCL4 (NM_002619), hCXCL5 (BC008376), hCXCL6 (BC013744), hCXCL7 (BC028217), hCXCL8 (BC013615), hCXCL9 (BC063122), hCXCL10 (BC010954), hCXCL11 (BC012532), hCXCL12 (BC039893), hCXCL13 (BC012589), hCXCL14 (BC003513), and hCXCL16 (BC017588), and hCXHuman and mouse chemokine receptors hCCR1 (NM_001295), hCCR2 (NM_000647), hCCR3 (NM_001837), hCCR4 (NM_005508), hCCR5 (NM_000579), hCCR6 (NM_004367), hCCR7 (NM_001838), hCCR8 (NM_005201), hCCR9 (NM_006641), hCCR10 (AY429103), hCXCR1 (NM_000634), hCXCR2 (BC037961), hCXCR3 (NM_001504), hCXCR4 (AY728138), hCXCR5 (NM_032966), hCXCR6 (NM_006564), hCX3CR1 (NP_001328), and hXCR1 (NM_005283), mCXCR1 (AY749637), mCXCR2 (NM_009909), mCXCR3 (NM_009910), mCXCR4 (NM_009911), mCXCR5 (NM_007551), mCXCR6 (NM_030712), mCCR1 (NM_009912), mCCR2 (NM_009915), mCCR3 (NM_009914), mCCR4 (NM_009916), mCCR5 (NM_009917), mCCR6 (NM_009835), mCCR7 (NM_007719), mCCR8 (NM_007720), mCCR9 (NM_0099130), mCCR10 (AF215982), mCX3CR1 (NM_009987), and mXCR1 (NM_011798), and reported chicken cCCR2 (CAF28776), cCCR5 , cCCR8L1(CAF28778), cCCR9 (CAF28781), cCXCR1 (AAG33964), cCXCR4 (NP_989948), and cXCR1 (CAF28779), were also retrieved from GenBank for comparisons.Phylogenetic analyses of protein sequences of chicken, human, and mouse chemokines and chemokine receptors were based on the amino acid sequences using neighbor-joining with options selected for bootstrap test, pairwise deletion and Poisson correction, using MEGA3 ,36. For 3CL1. However, partial chicken CX3CL1 gene sequences  were identified, with a gap of 123 nucleotides between the ESTs. Forward (TGTGACATCGGGAGTCGCTAC) and reverse (AAAATCCCCAGCGTTTGCTACT) PCR primers were used to amplify across the gap using cDNA prepared from white blood cells. PCR was performed as follows: An initial denaturation step at 94\u00b0C for 2 min and 35 cycles of denaturation, annealing, and extension at 94\u00b0C for 30 sec, 59\u00b0C for 45 sec, and 72\u00b0C for 1 min., and a final extension step was carried out at 72\u00b0C for 10 min. Unincorporated nucleotides were removed from amplified PCR products using BioMax spin-50 mini-columns . BigDye terminator cycle sequencing reaction kits and an ABI Prism 377XL DNA Sequencer (Applied Biosystems) were used for DNA sequencing.Chicken EST or mRNA sequences were identified for all chemokine genes. All sequences contained complete putative open reading frames except for CXAbbreviations: cCAF, chicken chemotactic and angiogenic factor; JSC, Jun-suppressed chemokine; SDF-1, stromal cell-derived factor-1; MCPs, monocyte chemoattractant proteins; MIPs, macrophage inflammatory proteins.JW collected most of the data and drafted the manuscript. DLA contributed to the interpretation of the data and final approval of the manuscript. AY performed the DNA sequencing and assisted with the preparation of the manuscript. SHS and YJ designed computer programs to search chicken chemokine sequences in chicken EST database. JJZ provided the conception and design of the study, collected some of the data, conducted phylogenetic analysis, and revised the manuscript."}
+{"text": "Defensins are antimicrobial peptides of innate immunity functioning by non-specific binding to anionic phospholipids in bacterial membranes. Their cationicity, amphipathicity and ability to oligomerize are considered key factors for their action. Based on structural information on human \u03b2-defensin 2, we examine homologous defensins from various mammalian species for conserved functional physico-chemical characteristics.Based on homology greater than 40%, structural models of 8 homologs of HBD-2 were constructed. A conserved pattern of electrostatics and dynamics was observed across 6 of the examined defensins; models backed by energetics suggest that the defensins in these 6 organisms are characterized by dimerization-linked enhanced functional potentials. In contrast, dimerization is not energetically favoured in the sheep, goat and mouse defensins, suggesting that they function efficiently as monomers.\u03b2-defensin 2 from some mammals may work as monomers while those in others, including humans, work as oligomers. This could potentially be used to design human defensins that may be effective at lower concentrations and hence have therapeutic benefits. Antimicrobial peptides (AMPs) are important components of the innate immunity of a wide range of organisms and present the first line of defence against invading microorganisms. Typically cationic, the peptides act against bacteria, fungi, and viruses through mechanisms involving membrane disruption or pore formation leading to leakage of cell content and destruction . A majorIt is postulated that cationicity, hydrophobicity as well as the ability to oligomerize are key determinants of the mode and intensity of action of antimicrobial peptides. The crystal structure of human \u03b1-defensin hNP3 revealed that it formed a dimer containing a six-stranded \u03b2-sheet region . NMR stuDefensins are highly cationic \u2013 mammalian defensins carry charges ranging from +6 to +12, and yet they are relatively small \u2013 25\u201345 amino acids long in the case of the mammalian mature peptides. In an attempt to understand how a protein so small and highly charged can overcome the gradient of charge-charge repulsions and aggregate, we have begun a series of detailed investigations. Using the dimer as the simplest model of oligomerization, we examine this feature from an evolutionary perspective and perform a comparative study of HBD2 and a series of homologous defensins from 8 other mammals (sequence identity greater than 40%). Based on a multiple sequence alignment of these 8 sequences against HBD-2, we construct structural models of the dimeric species and then examine the dynamic consequences of these structures through atomistic computer simulations, the energetics of these associations and their functional implications.2, is formed between the first \u03b2-strands of two monomers, mainly via hydrogen bonds between the backbone atoms of Cys15, and aided by van der Waals contacts made by the residues Pro5, Ala13, Ile14, Cys15, His16, and Pro17 [The human HBD-2 possesses 7 cationic residues , resulting in a charge of +12 for the dimeric form. A histidine residue that is present is neutral in the conditions examined. The charged residues are distributed on the surface of the molecule except at the dimeric interface, which is comprised largely of hydrophobic residues. The dimer interface, which buries a surface area of ~818\u00c5Multiple sequence alignment of HBD-2 and its 8 homologous sequences Table  reflectsTo gain structural insights into the spatial dispositions of these residues, we have used these alignments to construct 3-dimensional atomistic models of the dimeric forms of the 8 homologs using the program Modeller (see Methods). Further, to evaluate the accuracy of the employed modelling protocol, we compared the monomeric form of one of the models (pig homolog) with the corresponding model generated using a program that specializes in generating structural models based on homology of small disulfide-bonded proteins, the SDPMOD server . The twoAs expected from the alignment and the similarity of the distribution of the cationic residues Table , the oveWe subsequently carried out molecular dynamics simulations on each of the dimers. The drifts from the initial structures plateau for six dimers while those from mouse, sheep, and goat show large increases Figure . While tThe average dimerization energies, computed across the 10 ns simulations for each dimer, are strongly stabilizing of the dimeric forms except in the three outliers Figure . As expeWe see that the three outliers are characterized structurally by a higher density of cationic residues in the immediate vicinity of the putative dimerization interface Figure  when comCationicity is typically correlated with antimicrobial activity, and dimerization or oligomerization brings about a synergistic increase in cationicity of the peptide complex over that of the monomer. This oligomerization may indeed be an innate property as seen in these models, or it may be brought about by an increase in local concentrations that result as a response to some environmental conditions, such as the presence of other molecules . Howeverin silico mutation of HBD-2 to increase the overall cationicity. Based on the multiple sequence alignment, neutral residues in three positions within the human model structure were replaced with Arg  disrupt bacterial membranes? Clearly the process involves recognition, assembly and association (in some order), followed by one or more mechanisms whereby the defensin disrupts the regular structure and function of the membrane . One sugIt is known that unstructured clusters of basic residues on proteins can produce strong localized electrostatic potentials, which can enhance their attraction to anionic membranes . These lThis is the very first study to our knowledge which has looked at the propensity of defensins to oligomerize and the concomitant functional relevance. While there is very little experimental data to date on the kinetics or energetics of such processes in defensins, a better understanding of the mechanisms underlying the broad-spectrum bacterial killing by antimicrobial peptides remains of paramount interest. In view of the growing resistance of pathogens to conventional antibiotics, this would help accelerate developments of new potent antibiotics. We hope that this kind of study will lead to further and more detailed experimental and theoretical investigations on the mode of action of antimicrobial peptides.We have used the dimer as the simplest model of oligomerization for a comparative study of the dimerization and relative cationicity of defensin HBD-2 and modelled homologs from 8 other mammals. A clear clustering of overall cationicity and potential to oligomerize was seen. While the defensins from 6 species showed a propensity to dimerize, the dimerization potentials of those from mouse, sheep and goat tend to disfavour dimeric assemblies. This suggests that either these outlier defensins act in the monomeric form against bacterial membranes or that they function as much higher oligomeric species; the high charge densities tend to suggest that their monomeric forms are the functional units.Using the mature peptide sequence of HBD-2 as a query in Blastp , severalMonomer and dimer models of eight homologous mammalian sequences of HBD-2 were built using MODELLER  based onThe solvation energies of the monomeric and dimeric forms of each defensin species examined was calculated by solving the non-linearized form of the PB equation in parallel with the Adaptive Poisson-Boltzmann Solver (APBS) .Molecular dynamics (MD) simulations were performed using the AMBER 8.0 package and parm99 force field . The iniAS carried out the sequence alignment, molecular modeling and simulations, and drafted the manuscript. AS and CV conceived of the study. CV supervised the study design and coordination and edited the manuscript. Both authors read and approved the final manuscript."}
+{"text": "A common feature of chemosensory systems is the involvement of G protein-coupled receptors (GPCRs) in the detection of environmental stimuli. Several lineages of GPCRs are involved in vertebrate olfaction, including trace amine-associated receptors, type 1 and 2 vomeronasal receptors and odorant receptors (ORs). Gene duplication and gene loss in different vertebrate lineages have lead to an enormous amount of variation in OR gene repertoire among species; some fish have fewer than 100 OR genes, while some mammals possess more than 1000. Fascinating features of the vertebrate olfactory system include allelic exclusion, where each olfactory neuron expresses only a single OR gene, and axonal guidance where neurons expressing the same receptor project axons to common glomerulae. By identifying homologous ORs in vertebrate and in non-vertebrate chordates, we hope to expose ancestral features of the chordate olfactory system that will help us to better understand the evolution of the receptors themselves and of the cellular components of the olfactory system.Branchiostoma floridae. No ORs were identified in Ciona intestinalis. Phylogenetic analysis places the B. floridae OR genes in a monophyletic clade with the vertebrate ORs. The majority of OR genes in amphioxus are intronless and many are also tandemly arrayed in the genome. By exposing conserved amino acid motifs and testing the ability of those motifs to discriminate between ORs and non-OR GPCRs, we identified three OR-specific amino acid motifs common in cephalochordate, fish and mammalian and ORs.We have identified 50 full-length and 11 partial ORs in Here, we show that amphioxus has orthologs of vertebrate ORs. This conclusion demonstrates that the receptors, and perhaps other components of vertebrate olfaction, evolved at least 550 million years ago. We have also identified highly conserved amino acid motifs that may be important for maintaining receptor conformation or regulating receptor activity. We anticipate that the identification of vertebrate OR orthologs in amphioxus will lead to an improved understanding of OR gene family evolution, OR gene function, and the mechanisms that control cell-specific expression, axonal guidance, signal transduction and signal integration. Genes encoding odorant receptors (ORs) were first identified by Linda Buck and Richard Axel in 1991 -5 and haCiona intestinalis (subphylum Urochordata), and in amphioxus, Branchiostoma floridae .In mammals, phylogenetic analyses have shown that many of the OR-encoding genes are the products of relatively recent duplication events. There are fewer OR genes in fishes, however the fish genes are more variable at the sequence level ,13. DespC. intestinalis and B. floridae, but similarity-based surveys have not yet identified orthologs of vertebrate ORs in either genome  and theB. floridae ORs share several sequence features with other members of the Rhodopsin family of GPCRs, our next goal was to identify features specific to ORs. The WebLogo analysis of an alignment of 125 ORs revealed four areas that are conserved in vertebrate and amphioxus ORs . This motif occurred in 73.48% of ORs, but only in 0.24% of non-ORs.Having shown that B. floridae ORs, the L, P and Y residues are conserved though the Y residue appears to have been lost in many of the recent duplicates. Also, most human odorant receptors have the MAYDRYVAIC motif at the border of TM3 and IL2 . The prer GPCRs ,35.B. floridae genome assembly is not yet complete, the degree of linkage between B. floridae ORs is likely an underestimate.Another common feature of vertebrate odorant receptors is that they are often found tandemly arrayed in the genome ,13,36,37B. belcheri suggesting these genes function as ORs. Satoh  and melanocortin receptors . Although several other Rhodopsin-like genes were used as out-groups in our preliminary analyses  and is expected to be more closely related to the vertebrate ORs than the melanocortin receptor which belongs in another subgroup (group \u03b1) [All candidate ORs from ClustalW . A singlbelcheri  was alsobelcheri ). Non-ORgroup \u03b1) . An aliggroup \u03b1)  based onB. floridae ORs, we constructed an alignment of vertebrate (n = 64) and B. floridae (n = 61) ORs. Sequences from all nine clades of vertebrate ORs [Rhodopsin-like GPCRs) and IPR000725 (Olfactory receptors) and used them to construct two MySQL databases: one containing 5438 odorant receptors and the other containing the Rhodopsin-like sequences with the OR genes from IPR000725 excluded (N = 21 282). We searched these databases for the presence of the motifs using a series of regular expressions. An OR-specific motif was defined as one that is found in a large proportion of ORs but less than 1% of non-ORs.To identify amino acid motifs common in vertebrate and rate ORs  were userate ORs  from whirate ORs  IPR00027B. floridae ORs are also intronless and in tandem, we obtained exon number and gene orientation from the annotation file accompanying genome assembly v1.0. The locations of these genes were obtained from the more recent version of the assembly, v2.0. Our ability to identify single exon genes is limited by the incomplete annotation of the genome. However, as previously stated, we considered a full-length sequence to be one that spans all seven transmembrane domains.Vertebrate odorant receptors are intronless and are often found in tandem ,48,49. TAMC and JST conceived and designed this study. AMC collected and analyzed the data and JST assisted with sequence alignments. Both authors contributed to the writing of the manuscript and have read and approved the final manuscript.B. floridae ORsList of full-length and partial . This file contains B. floridae protein IDs, intron and exon information, and the location of each gene in the B. floridae genome assembly (v2.0). Full-length and partial sequences are denoted by 'F' and 'P' respectively.Click here for fileList of vertebrate odorant receptors and non-OR GPCRs used in the phylogenetic analyses. This file contains a list of sequences used in the phylogenetic analyses and the GenBank accession numbers where available.Click here for fileMultiple sequence alignment used for the phylogenetic analyses. This file contains the multiple sequence alignment used to generate the Neighbor-Joining trees in Figure Click here for filePhylogenetic analysis of vertebrate ORs, B. floridae ORs and non-OR Rhodopsin-like GPCRs. This file contains an unrooted Neighbor-Joining tree constructed using vertebrate ORs, cephalochordate ORs and non-OR GPCRs from the \u03b1, \u03b2, \u03b3 and \u03b4 groups of GPCRs from the Rhodopsin family [B. floridae GPCRs identified by [n family . Non-OR ified by  (see AddClick here for file"}
+{"text": "In a previous study, we have analysed the expression profile of apoptosis-regulating genes using a cDNA-based microarray and found overexpression of the antiapoptotic bcl-2 family member, bfl-1, in B-CLL cells with an apoptosis-resistant phenotype. In this study, bfl-1 mRNA levels have been determined by competitive PCR in an extended population of B-CLL patients to characterise its role in disease progression and development of chemoresistance. bfl-1 levels were significantly higher in patients with no response (NR) to last chemotherapy than in patients responding ) to last chemotherapy (P<0.05) and in patients who had not required treatment (P<0.05). We found no correlation between bfl-1 mRNA levels and disease progression, IGHV mutational status or other clinical parameters. In addition, bfl-1 mRNA levels were inversely correlated with apoptotic response to in vitro fludarabine treatment of B-CLL cells. Specific downregulation of bfl-1 using siRNA induced apoptosis in resistant cells. Our data suggest that bfl-1 contributes to chemoresistance and might be a therapeutic target in B-CLL.B-cell chronic lymphocytic leukaemia (B-CLL) is characterised by the progressive accumulation of monoclonal CD5 Patientin vivo results from defects in the apoptotic process . Fluorescein isothiocyanate (FITC)-F(ab\u2032)2 fragment of rabbit anti-human IgM, phycoerythrin (PE)-conjugated anti-CD25, anti-CD3-PE, anti-CD5-FITC and anti-CD20-PE were from Dakocytomation A/S . Anti-CD38-PE, allophycocyanin (APC) conjugated anti-CD19 and IgG1-FITC/IgG2a-PE simultest were from Becton Dickinson . Fludarabine and chlorambucil were from Sigma Chemicals .Primers for PCR amplification were synthesised by CyberGene AB . Trizol Reagent, oligo(dT)\u22121), in thrombocytopaenia (and platelet count <100 \u00d7 109\u2009l\u22121) and/or in spleen/liver/lymph node size  and/or in more than a doubling of the blood lymphocyte counts and/or appearance of constitutional symptoms. Response to chemotherapy treatment was classified as no response, partial response or complete response  according to the NCI\u2013WG criteria  centrifugation, and T cells were depleted by rosetting with sheep erythrocytes. Isolated cells were kept frozen in aliquots. Isolated non-rosetting, leukaemic B cells contained less than 2.0% CD36) were incubated for 30\u2009min at 4\u00b0C with anti-CD5-FITC, anti-CD19-APC, anti-CD25-PE, anti-CD20-PE, anti-CD38-PE, anti-CD3-PE or FITC-F(ab\u2032)2 anti-human IgM. FITC/PE-conjugated simultest was used as control. Forward and side-scatter gates were set to exclude dead cells. All samples were analysed in a Becton Dickinson FACScan system equipped with an argon laser, using 10\u2009000 cells for each determination.Isolated cells from all B-CLL patients were phenotyped by immunofluorescence and flow cytometry. Cells . Cells (0.5 \u00d7 106\u2009ml\u22121) were incubated in 96-well plates in medium alone (spontaneous apoptosis) or in the presence of fludarabine (5\u2009\u03bcM) or chlorambucil (40\u2009\u03bcM) for 48\u2009h to evaluate apoptotic response. The NIH3T3 mouse fibroblast cell line transfected with human CD40L were cultured in RPMI-1640 medium supplemented with 10% fetal bovine serum (FBS), 2\u2009mM glutamine, 100\u2009IU\u2009ml\u22121 penicillin, 100\u2009\u03bcg\u2009ml\u22121 streptomycin in 24-well plates (2 \u00d7 105 cells per well), and incubated overnight to adhere before addition of siRNA-transfected B-CLL cells.B-CLL cells were re-suspended in RPMI-1640 medium supplemented with 2\u2009m\u03bcl of binding buffer  containing AnnexinV-Fluos solution  and 2\u2009\u03bcg\u2009ml\u22121 propidium iodide . Cells were analysed with a FACScan (Becton Dickinson). For fludarabine- and chlorambucil-induced apoptosis percentages of specific apoptosis were calculated as (apoptosis in drug culture\u2212spontaneous apoptosis)/(100\u2212spontaneous apoptosis) \u00d7 100%.Percentage of apoptotic cells was determined by AnnexinV staining. Cells were washed with PBS and incubated 10\u2009min in 100\u200915 primers. Thereafter, 1\u2009\u03bcl of cDNA was amplified in a 20\u2009\u03bcl PCR mixture. Two microlitres of serial dilutions of competitor fragments, with different lengths but using the same primers as the target DNA, was added to the reaction. G3PDH competitor  was from Clontech  and the bfl-1 competitor (446\u2009bp) was from Gentaur Molecular Products . Competitor for bcl-2 (230\u2009bp) was built using composite primers and an exogenous DNA fragment (BamHI\u2013EcoRI restriction fragment from v-erb). Cycling conditions for bfl-1 and bcl-2 were 30 cycles of 1\u2009min at 94\u00b0C, 1\u2009min at 60\u00b0C and 2\u2009min at 72\u00b0C and for G3PDH 35 cycles of 1\u2009min at 94\u00b0C, 1\u2009min at 60\u00b0C, and 1\u2009min at 72\u00b0C. The samples were then resolved on a 2% agarose gel with 1\u2009\u03bcg\u2009ml\u22121 of ethidium bromide and photographed. Densitometric analysis was performed using Quantity One . Ratios of the intensity of the relevant PCR product pairs were plotted against the concentration of the competitor DNA used in a logarithmic plot. The point of intersection in the curve, where the amounts of target and competitor are equal was used to determine the amount of cDNA in the sample. The primers are as follows: sense bfl-1, 5\u2032-GGCAGAAGATGACAGACTGTGAA-3\u2032; antisense bfl-1, 5\u2032-TGGTCAACAGTATTGCTTCAGGA-3\u2032 (539\u2009bp); sense bcl-2, 5\u2032-CGACGACTTCTCCCGCCGCTACCGC-3\u2032; antisense bcl-2, 5\u2032-CCGCATGCTGGGGCCGTACAGTTCC-3\u2032 (319\u2009bp); sense G3PDH, 5\u2032-TGAAGGTCGGAGTCAACGGATTTGGT-3\u2032; antisense G3PDH, 5\u2032-CATGTGGGCCATGAGGTCCACCAC-3\u2032 (983\u2009bp).Total RNA was isolated from purified B-CLL cells using Trizol reagent. Three micrograms of total RNA was denatured and reverse transcribed using oligo-(dT)6) suspended in 200\u2009\u03bcl AIM V cell culture medium supplemented with 5% FBS, 100\u2009IU\u2009ml\u22121 penicillin and 100\u2009\u03bcg\u2009ml\u22121 streptomycin were seeded in each well in 48-well plates. For each well 9\u2009\u03bcl TransIT-TKO\u00ae and 80\u2009pmol siRNA diluted in Opti-MEM\u00ae culture medium were added or cells were left untransfected. Six hours after transfection, cells were transferred to hCD40L-expressing mouse fibroblast cultures. At 24 and 48\u2009h after transfection apoptotic response was determined by AnnexinV staining and mRNA expression was analysed by RT\u2013PCR.Transfection of B-CLL cells was performed according to a modified and optimised TransIT-TKO\u00ae Transfection Reagent  protocol for adherent cells. bfl-1-specific siRNA (Dharmacon SMARTpool\u00ae siRNA (proprietary target sequence)) and two nonspecific, scrambled siRNA, pooled together as \u2018control siRNA\u2019 were ordered from Dharmacon Research Inc. . B-CLL cells .Total RNA was isolated using RNeasy Mini Kit , and reverse transcribed using N6 and oligo-(dT)To detect the prognostically relevant chromosomal aberrations del(13q), del(11q), trisomy 12 and del(17p), FISH analysis was performed using commercial probes from Abbot Vysis  as described previously . PCR amplification of the IGH gene rearrangements was performed with either genomic DNA or cDNA using family-specific IGHV (framework region 1) primers together with one consensus IGHJ primer as described previously. The PCR conditions for the IGH analysis was as outlined earlier with minor modifications (http://joinsolver.niams.nih.gov), and aligned to the most homologous germline IGHV, IGHD and IGHJ genes. Using the classical IGHV homology cutoff value of 98%, cases were divided in unmutated (\u2a7e98% homology to the corresponding germline gene) or mutated (<98% homology) , IgBLAST  and JOINSOLVER\u00ae (omology) . Cases wU-test for comparison between two unpaired groups.Estimation of statistical differences between groups was carried out using the Kruskal\u2013Wallis test for comparison between three or more groups, and the Mann\u2013Whitney in vivo response to the last chemotherapy prior to date of sampling (P<0.05) and compared to the non-treated group . Since most of the treated patients received CLB as the last chemotherapy, the analysis was repeated including only untreated and the 14 CLB-treated patients and equal statistic differences in bfl-1 expression were found as compared to the analysis including all the treated patients . For bcl-2 there was a significant higher expression in the NR group  compared to the PR group , while the untreated group had levels in the same range as the NR group  (P<0.01). If only CLB-treated patients are included in the analysis, the difference in bcl-2 expression between NR and PR does not reach statistical significance (data not shown). High expression was seen of at least one of the genes, in a majority (10 out of 13) of cases in the NR group, comparing both genes together in the treated patients while the expression of both were in general low in the PR group  . HoweverPR group .in vitro fludarabine- and chlorambucil-induced as well as spontaneous apoptosis. Cells were cultured in the presence or absence of drug (5\u2009\u03bcM fludarabine or 40\u2009\u03bcM chlorambucil) for 48\u2009h and apoptosis quantified by AnnexinV staining. Specific drug-induced apoptosis was calculated after subtraction of spontaneous apoptosis as described in Materials and Methods section . There was no significant correlation between bfl-1 expression and apoptotic response to fludarabine in the treated group (data not shown). No difference in expression of bcl-2 mRNA was detected between cells that were either sensitive or resistant to fludarabine or chlorambucil treatment in vitro (data not shown). Cells from NR patients were significantly more resistant to fludarabine than those from PR or untreated patients (P<0.01) (data not shown).Leukaemic cells from the patients included were tested for  section . An arbiNext, we wanted to investigate if bfl-1 was involved in disease progression, and thus bfl-1 mRNA expression was compared between progressive and non-progressive patients. Although there was a tendency to higher bfl-1 expression in progressive patients the difference did not achieve statistical significance (data not shown). In addition, bfl-1 expression did not correlate with lymphocyte count, Rai stage, age, sex or CD38 expression (data not shown).The IGHV gene mutation status was analysed in 36 B-CLL cases included in this study using IGHV gene family-specific PCR amplification and nucleotide sequencing as described in Materials and Methods section . bfl-1 oin situ hybridisation (FISH) in 28 B-CLL cases. We found three B-CLL patients with no aberration (11) and 11 (39%) with the good prognostic aberration 13q deletion as single aberration, whereas the intermediate prognostic aberration trisomy 12 and the poor prognostic aberrations 11q deletion and 17p deletion were detected in 4 (14), 5 (18) and 4 (14%) patients, respectively. Among the patients with 17p deletion one was considered borderline (10\u201315% cells with the aberration). In one patient (3%), the FISH data were not conclusive  , trisomy 12, del(13q) and del(17p) were analysed by fluorescence nclusive . bfl-1 octively) . bfl-1 oTo test directly the contribution of blf-1 to apoptosis resistance in B-CLL we targeted bfl-1 expression by specific siRNA in fludarabine-resistant, bfl-1 high-expressing B-CLL cells  or \u2018normal\u2019 karyotype, as compared to the trisomy 12/del(11q)/del(17p) group. As a single cytogenetic defect, del(13q) is a good prognosis marker, associated with longer overall and treatment-free interval (in vitro fludarabine-induced apoptosis, but not with spontaneous or chlorambucil-induced apoptosis. However, bfl-1 expression correlated with in vivo response to chlorambucil. Previously, Mcl-1 expression was reported to correlate to in vitro chlorambucil-induced apoptosis but not to fludarabine-induced apoptosis (in vitro and in vivo response to chlorambucil might also be explained by differences in the mechanisms regulating the apoptotic process in vitro and in vivo.We found a correlation between bfl-1 expression and in vitro (in vivo, induces the expression of bfl-1 in B-CLL cells, protecting them from spontaneous and fludarabine-induced apoptosis in vitro, this finding suggests that bfl-1 may be important for the extended survival of the leukaemic cells in vivo.By selectively downmodulating bfl-1 using specific siRNA we could induce apoptosis in fludarabine-resistant B-CLL cells, showing that bfl-1 has a protective role against apoptosis in these cells. Together with our recent finding that bfl-1 mRNA expression levels are decreased in apoptosis-sensitive cells during spontaneous apoptosis Targeting bcl-2 family members is recognised as a promising therapeutic strategy in B-CLL. bcl-2 antisense therapeutic strategy has proven feasible without toxicity and is already in clinical trials for B-CLL patients ("}
+{"text": "JCH showed much higher protective ability than JC. These results suggest that JCH as a potential novel antiphotoaging agent from natural resources.Jellyfish collagen (JC) was extracted from jellyfish umbrella and hydrolyzed to prepare jellyfish collagen hydrolysate (JCH). The effects of JC and JCH on UV-induced skin damage of mice were evaluated by the skin moisture, microscopic analyses of skin and immunity indexes. The skin moisture analyses showed that moisture retention ability of UV-induced mice skin was increased by JC and JCH. Further histological analysis showed that JC and JCH could repair the endogenous collagen and elastin protein fibers, and could maintain the natural ratio of type I to type III collagen. The immunity indexes showed that JC and JCH play a role in enhancing immunity of photoaging mice  UV radiation is the main cause of skin damage, which includes photoaging, local and systemic immunosuppression, and photocarcinogenesis . UV radiAntioxidants have been proven to be effective in the protection of skin against UV-induced damage in recent years. Some dietary antioxidants have shown potential chemoprophylactic activities, including chlamys farreri peptide , ferulicetc. [Collagen is another newly founded antioxidant resource. It is a very important raw material in medicine and the food industry. Collagen hydrolysates, which are generally obtained by enzymatic proteolysis from collagen, have exhibited numerous bioactivities, including antioxidant activity, mineral binding capacity, antihypertensive activity, lipid-lowering effect, immunomodulatory activity, etc. . The proetc. . in vivo.In our previous study, jellyfish collagen (JC) and jellyfish collagen hydrolysate (JCH) showed protective effects on the activities of antioxidant enzymes and the content of glutathione in skin photoaging . FurtherICR male mice (20\u201322 g), aged about six weeks, were purchased from the Beijing Vital River Experiment Animal Technology Limited Company . All animal experiments were carried out in accordance with standard guidelines for the care of animals, which were approved by Welfare Committee of the Centre of Experimental Animal .g for 10 min. JC and JCH fractions were freeze-dried and used for the following experiments.JC was extracted as described previously . A progr2, and the animals were randomly divided into the following six groups (eight mice in each group), including NC: normal group; MC: model group; JC-1: at dose 50 mg/kg\u00b7day bw JC; JC-2: at dose 200 mg/kg\u00b7day bw JC; JCH-1: at dose 50 mg/kg\u00b7day bw JCH; JCH-2: at dose 200 mg/kg\u00b7day bw JCH by gavage. The mice in NC and MC groups were given normal saline. All mice, except the normal group, were irradiated with the same UV source.The mice were fed ad libitum and housed under conventional conditions at a controlled temperature (23 \u00b1 2 \u00b0C) humidity (55% \u00b1 10%) and light . After one week of acclimatization to the homecage, the mouse back was denuded using sulfureted sodium  over the depilation area of 4 cm2 of UVA and 28 mJ/cm2 of UVB were assembled 1 MED in this study. Mice were irradiated three times weekly . Then, intensities of UV were increased by 1 MED per week until week 5, and then maintained at 4 MED up to the 10th week, yielding a total dose of 26.76 and 2.55 J/cm2 of UVA and UVB, respectively.Toshiba FL20SE lamps were used as a UV source without any filtering. The distance from the lamps to the animals\u2019 back was 30 cm. The minimal erythemal dose (MED) was preliminarily measured with a UV-radiometer-305, and 290 mJ/cmThe moisture of the skin was measured by drying the samples in an oven at 105 \u00b0C for 4 h, as described by GB/T5009.3-2010, China [Skin specimens were taken for histochemical investigation 24 h after the final irradiation. Mouse skin samples were fixed in 4% buffered neutral formalin solution for 24 h, and embedded in paraffin. Serial sections (7 \u03bcm) were mounted onto silane-coated slides and stained with H & E, VG, Verhoeff-van Gieson, and picrosirius red staining. The images were recorded using the Olympus DP70 Digital Camera System at 200\u00d7 magnifications.The animals were weighed and executed by cervical dislocation. Spleen and thymus were excised from the animal and weighed immediately. The thymus and spleen index was calculated according to the following equation : thymus p value of <0.05 was taken as the level of statistical significance.All data were analyzed by one-way analysis of variance (ANOVA) using SPSS  and were displayed as mean \u00b1 SD. A JC and JCH were prepared as described in materials and methods . The molp < 0.05). However, in group JC-1 and JCH-1, 26.60% and 41.15% of water was rescued (p < 0.05).The water content of the skin is greatly influenced by ground substances, which may be responsible for wrinkling and laxity of the skin accompanying cutaneous ageing . Excessi rescued . This reSimilarly to the previous report , we founVG stain is generally used to determine the distribution of skin collagen, which appeared as a red deposit under the microscope. Collagen is the main component of the dermis, constituting 75% of the dry weight of the dermis . The loset al. (2010) reported that marine collagen hydrolysate was able to promote collagen synthesis, through the activation of Smad signaling pathway and inhibiting collagen degradation by attenuating MMP-1 expression and increasing TIMP-1 expression [More than 70% collagen is type I in human skin, which is the most abundant extracellular matrix protein in the human body. It provides the basis for tissue structure and cellular functions . Ultravipression . TherefoElastin protein fibers act as a structural support system and provide the skin with strength and resiliency . The prop < 0.05), indicating that ultraviolet radiation had a significant impact on thymus index of mice. However, JC and JCH could significantly increase TI of mice (p < 0.05), compared with the MC group. The effect of JCH was significantly stronger than that of JC at the same dose (p < 0.05). Even at the low doses, JCH-1 could effectively increase the TI, which had no significant difference with the NC mice (p > 0.05). Similarly, spleen index (SI) in the MC mice significantly (p < 0.05) decreased to 75.45% of that in NC mice (The spleen, the biggest immunity organ, contains a lot of lymphocytes and macrophages, and is the center of the cellular immunity and humoral immunity. The thymus is the most important place in which the T-lymphocytes transform and mature. The atrophy degeneration of thymus means the reduction in the T-lymphocytes, which play a leading role in the function of cellular immune system, and then causes the decline in the cellular immunity, or even suppression . Therefo NC mice . However NC mice . At the Ultraviolet radiation could cause skin photodamage including immunotoxicity, oxidative damage, decrease of moisture level and histological changes. This study showed that JC and JCH can alleviate the damage induced by UV radiation in dose-dependent manners. The mechanisms of this protection mainly involved enhancing immunity, reducing the loss of moisture, repairing endogenous collagen and elastin protein fibers, and maintaining the ratio of type III to type I collagen. JCH showed much higher bioactivities than JC. Further studies are still on going to elucidate the antiphotoaging mechanisms of JCH."}
+{"text": "We compared baseline sequence of gag CS between patients harbouring B or non-B HIV-1 subtype, and between those who achieved viral suppression and those who experienced virological failure while on LPV/r monotherapy up to Week 96. Baseline sequence of gag CS was available for 82/83 isolates; 81/82 carried at least one substitution in gag CS compared to HXB2 sequence. At baseline, non-B subtype isolates were significantly more likely to harbour mutations in gag CS than B subtype isolates (p<0.0001). Twenty-three patients experienced virological failure while on lopinavir/r monotherapy. The presence of more than two substitutions in p2/NC site at baseline significantly predicted virological failure (p\u200a=\u200a0.0479), non-B subtype isolates being more likely to harbour more than two substitutions in this specific site. In conclusion, gag cleavage site was highly polymorphic in antiretroviral-naive patients harbouring a non-B HIV-1 strain. We show that pre-therapy mutations in gag cleavage site sequence were significantly associated with the virological outcome of a first-line LPV/r single drug regimen in the Monark trial.Virological failure on a boosted-protease inhibitor (PI/r) first-line triple combination is usually not associated with the detection of resistance mutations in the protease gene. Thus, other resistance pathways are being investigated. First-line PI/r monotherapy is the best model to investigate  In the product of the gag open reading frame, Gag polyproteins are cleaved at five cleavage sites into p17 (MA), p24 (CA), p2 (SP1), p7 (NC), and p6gag. In the product of the gag-pol open reading frame, Gag-Pol polyproteins are cleaved at eight cleavage sites into p17 (MA), p24 (CA), p2 (SP1), p7 (NC), transframe protein (TFP), p6pol, protease, reverse transcriptase, and integrase The HIV protease cleaves the gag and gag-pol polyproteins by interacting with specific cleavage sites (CS) in protease gene but harbouring NC/p1 CS substitutions in the viral Gag polyprotein (K436E and or I437T/V) in protease gene Mutations in Gag CS emerge as compensatory mutations enabling specific protease mutants to have a greater efficiency of cutting the Gag polyprotein Though substitutions in gag CS are detected often in PI-experienced HIV-infected patients Monark was the first randomized trial comparing the efficacy of lopinavir/r (LPV/r) single drug regimen with a classical triple combination in antiretroviral-na\u00efve HIV-infected patients starting a first-line regimen 3, a plasma HIV-1 RNA below 100 000 copies/mL and no evidence of drug-resistance at screening visit. The primary endpoint was the proportion of patients with plasma HIV-1 RNA below 400 copies/mL at week 24 (W24) and below 50 copies/mL at W48. Follow up until W96 was planned for evaluation of the long-term safety and efficacy of the LPV/r monotherapy arm 10 copies/mL by W4, (ii) failure to achieve a viral load below 400 copies/mL by W24 and (iii) any viral rebound \u22651 log, after an HIV-1 RNA<400 copies/mL, confirmed by a second measurement at least 14 days later.Monark study design has been described elsewhere www.iasusa.org).Reverse transcriptase and protease genotypic resistance tests were performed at screening and at the time of VF according to the trial definition The HIV-1 subtype was determined after phylogenetic analysis of the reverse transcriptase sequences as previously described Gag genes were sequenced at baseline in all patients randomized to LPV/r monotherapy and at the time of confirmed virological failure. Viral RNA was extracted from plasma stored at \u221270\u00b0C using QIAamp\u00ae RNA Mini Kit . Amplification and sequencing were done with primers as previously described gag in the gag reading frame, transframe protein (TFP), TFP/p6pol and p6pol/PR in the gag-pol reading frame, with respect to the wild-type virus HXB2 were studied. Mixtures containing wild-type and mutant variants were scored as mutant.Different CS gag appellations have been used over time (the ones used in recent literature are between bracket). Differences in frequency of amino acid sequences for CS CA/p2 (or p24/p2), p2/NC (or p2/p7), NC/p1 (or p7/p1), p1/p6http://www.rnasoft.ca/cgi-bin/RNAsoft/CombFold/combfold.pl]).Baseline RNA folding and the stability of the hairpin structure of the gag-pol frameshift region were determined using measurement of free energy in accordance with Turner's rules  versus good adherence (no missed dose throughout follow-up).Gag gene sequence was available for 82 among the 83 patients randomized to LPV/r monotherapy and followed until W96. At baseline, 81/82 isolates carried at least one substitution in gag CS compared to HXB2 sequence, with a median number of 3 (range 0\u201310): 4/82 isolates carried at least one substitution in CA/p2, 76/82 in p2/NC, 15/82 in NC/p1, 45/82 in p1/p6 site in the gag reading frame, and 80/82 in TFP/p6pol and 81/82 in p6pol/PR in the gag-pol reading frame. Among the gag CS mutations in the gag reading frame previously described in therapy-experienced isolates  HIV-1 subtype distribution was well balanced at baseline between the two treatment groups. For patients on LPV/r monotherapy, the distribution of viral subtype was as follows: 56 B subtype (68%) and 27 non-B subtypes including CRF02_AG 16%, A 2%, G 4% and others subtypes 10%. Of note, the level of hairpin free energy was significantly higher in B viruses  compared with non-B viruses  (p\u200a=\u200a0.0005).gag reading frame tended to predict virological failure (p\u200a=\u200a0.053). Substitutions at position A374 were significantly more likely in non-B subtype (70%) versus B subtype viruses . Amino-acid residues G, I, P and S at position V484 in the gag-pol reading frame were significantly associated with virological failure (p\u200a=\u200a0.024). Non-B subtype viruses were significantly more likely to harbour substitutions at position V484 (85%) than B subtype viruses . In contrast, amino-acid residues G, N and R at position S451 in gag reading frame were significantly associated with virological success (p\u200a=\u200a0.026). The presence of more than two substitutions in p2/NC site at baseline significantly predicted virological failure (p\u200a=\u200a0.0479). In contrast, the presence of at least three substitutions in the TFPp6pol site or in the p6pol site was not associated with virological failure. Only the presence of substitutions at positions V484 (OR\u200a=\u200a4.87 (IQR 1.6\u201314.8), p\u200a=\u200a0.005) and S451 (OR\u200a=\u200a0.12 (IQR 0.02\u20130.6), p\u200a=\u200a0.01) remained significantly associated with subsequent virological outcome in multivariate analysis.The impact of baseline substitution in gag CS on subsequent LPV/r single-drug regimen treatment outcome was analyzed. Amino-acid residues G, T, N, P and S at position A374 in the gag-pol RNA frameshift on virological response was observed.No impact of folding and stability of Twenty-three patients experienced virological failure while on LPV/r during the study course. When focusing on gag CS mutations usually detected in treatment-experienced isolates , the L449F mutation was not detected at baseline and emerged at the time of failure in 2 cases . For these two patients, no minor or major changes in protease gene were evidenced.PI major resistance mutations were evidenced at the time of virological failure in 5 patients as described previously The major result of the MONARK trial was that LPV/r monotherapy demonstrated lower rates of virological suppression when compared to LPV/r triple therapy gag reading frame and both TFP/p6pol and p6pol sites in the gag-pol reading frame. Interestingly, the presence of more than two substitutions in p2/NC site at baseline was significantly associated with virological failure, non-B subtype isolates being more likely to harbour more than two substitutions in this specific site. This result brings now some light on our previous finding which suggest that, in spite of potential confounding factor evidenced in this study (adherence and non-B subtype), virological failure appeared significantly more frequent in non-B (46%) than in B subtype isolates  Gag CS and the gag-pol frameshift region were highly polymorphic at baseline in the 82 assessable patients, especially those infected with a non-B subtype strains. The most polymorphic gag CS were the p2/NC site in the Several studies reported that the p2/NC CS is highly polymorphic gag gene of non-B subtype isolates was evaluated in vitro on the drug susceptibility and the catalytic efficiency of the protease  and mutation 449 (p1/p6gag) at baseline were associated with subsequent virological failure protease gene, increasing the level of resistance to amprenavir Most virological failures were not associated with specific changes in Gag sequence at the time of failure. Of note, the selection of the mutation L449F was evident at the time of failure in two patients. As previously described, this mutation was observed only in protease inhibitor-experienced patients with protease resistance mutations Major PI mutations were evident in 5 patients among the 23 experiencing virological failure and studied in the present analysis. There was no consistent association between the emergence of major PI resistance mutations and baseline Gag CS region or changes in Gag sequence at the time of virological failure. We previously reported the selection of the L76V major PI mutation in 3 patients, all three infected with HIV-1 CRF02_AG subtype, confirming that the L76V mutation (+/\u2212 the M46I mutation) is a novel resistance pathway emerging during failure on a first line LPV/r-based regimen In conclusion, we show that pre-therapy mutations in gag cleavage site sequence were significantly associated with the virological outcome of a first-line LPV/r single drug regimen, in spite of the absence of consistent association with either the emergence of major PI resistance mutations or with changes in gag sequences at the time of virological failure. Gag cleavage site is highly polymorphic in antiretroviral-naive patients harbouring a non-B HIV strain. The non-B subtype may be associated with a high risk of virological failure on first-line LPV/r monotherapy. Our results, together with the similar outcome between B and non-B HIV-1 strains with PI/r-based triple combinations Table S1GAG cleavage site and protease mutations at screening and at failure in the 23 patients who experienced virological failure.(DOC)Click here for additional data file."}
+{"text": "Hypoxia induced oxidative stress incurs pathophysiological changes in hypertrophied cardiomyocytes by promoting translocation of p53 to mitochondria. Here, we investigate the cardio-protective efficacy of nanocurcumin in protecting primary human ventricular cardiomyocytes (HVCM) from hypoxia induced damages. Hypoxia induced hypertrophy was confirmed by FITC-phenylalanine uptake assay, atrial natriuretic factor (ANF) levels and cell size measurements. Hypoxia induced translocation of p53 was investigated by using mitochondrial membrane permeability transition pore blocker cyclosporin A (blocks entry of p53 to mitochondria) and confirmed by western blot and immunofluorescence. Mitochondrial damage in hypertrophied HVCM cells was evaluated by analysing bio-energetic, anti-oxidant and metabolic function and substrate switching form lipids to glucose. Nanocurcumin prevented translocation of p53 to mitochondria by stabilizing mitochondrial membrane potential and de-stressed hypertrophied HVCM cells by significant restoration in lactate, acetyl-coenzyme A, pyruvate and glucose content along with lactate dehydrogenase (LDH) and 5' adenosine monophosphate-activated protein kinase (AMPK\u03b1) activity. Significant restoration in glucose and modulation of GLUT-1 and GLUT-4 levels confirmed that nanocurcumin mediated prevention of substrate switching. Nanocurcumin prevented of mitochondrial stress as confirmed by c-fos/c-jun/p53 signalling. The data indicates decrease in p-300 histone acetyl transferase (HAT) mediated histone acetylation and GATA-4 activation as pharmacological targets of nanocurcumin in preventing hypoxia induced hypertrophy. The study provides an insight into propitious therapeutic effects of nanocurcumin in cardio-protection and usability in clinical applications. Histo in vivo ,6. But w in vivo \u201312. Hypo in vivo ,14. An o in vivo ,16. Sinc in vivo .2-terminal kinase (JNK)[m), activating caspases and promoting cell cycle arrest [e.t.c.) and disrupts MnSOD activity. Since ROS remains important regulator of p53 induced cellular damage, it is of prime importance to investigate the impact of excessive ROS leakage on (patho-) physiology of cardiomyocytes [The tumour suppressor p53 plays central role in maintaining cell-viability, cell-cycle regulation and apoptosis. The p53 undergoes MDM2 (Murine double minute 2) mediated degradation  and remaase (JNK) and accuase (JNK). Accumulase (JNK)\u201323. Oxide arrest ,25. Thismyocytes . Dependimyocytes ,28. SincUse of anti-oxidant therapies emerges out as an important countermeasure to protect from hypoxia induced damages. Natural dietary curry spice, curcumin has been known as pharmacological countermeasure that rescues the cells from stress-induced damages ,30. But Thus, in the present study, we investigated whether hypoxia induces pathological damages in hypertrophied HVCM cells under hypoxia and assessed the modulatory role of p53 in same. Here we show tremendous cardio-protective efficacy of nanocurcumin in HVCM cells experiencing severe mitochondrial stress due to modulation of critical cellular signalling cascades.Experiments were designed to cover two main aspects of the study, i.e. evaluation of efficacy of nanocurcumin in ameliorating hypoxia induced hypertrophy and damage in HVCM cells and analysis of changes in hypoxia induced translocation of p53 to mitochondria and associated defects in mitochondrial function under hypoxia. All experiments were compared to raw curcumin as control.4\u2212105 viable cells/cm2. The HVCM cells were incubated in the CO2 incubator  and maintained at 37\u00b0C temperature and 5% CO2 overnight for adhesion. The cells were grown to 70\u201380% confluence before onset of experiments. The one set of confluent cells were subjected to normoxia i.e. 21% O2 and another set with 0.5% O2 i.e. hypoxia condition  in the incubator. The cells were divided into six groups, i.e. normoxia only (N), normoxia plus curcumin (N+C), normoxia plus nanocurcumin (N+NC), hypoxia only (H), hypoxia plus curcumin (N+C) and hypoxia plus nanocurcumin (H+NC) for experiments. Stock solutions of curcumin or nanocurcumin were prepared in neutral PBS (1mg/ml) by sonication for 15 minutes at 4\u00b0C  as previously described [The cells were grown in 6, 12 or 96 well plates  with a cell count of 10escribed ,37. Stocescribed . The cel\u00ae GmbH (C12810), Heidelberg, Germany and maintained in myocyte growth medium . Molecular grade chemicals for cell-culture were procured from SIGMA ALDRICH or otherwise stated. Nanocurcumin of ultra-pure quality, was obtained as a kind gift from Prof. Santosh Kar  [Adult human primary ventricular cardiomyocytes were procured from PromoCell, India) . Native 2, 0.2 mM EDTA, 0.5 mM DTT, 0.5 mM PMSF, 0.1% PIC) on ice for 20 minutes and centrifuged at 12000 rpm for 30 minutes. The supernatant containing clear nuclear fraction was collected. The protein estimation was done with Lowry\u2019s method using bovine serum albumin (BSA) as internal standard [Cultured cells were de-adhered using trypsin-EDTA (0.1% v/v) for 5\u201310 minutes and counted by using Neubauer haemocytometer. Cells were homogenized on ice in RIPA (Radio-immunoprecipitation) buffer composition included Tris-HCl 50 mM, NaCl 150 mM, SDS 0.1%, NP-40 1%, Deoxycholate 0.5% and protease inhibitor cocktail (PIC) (1\u03bcl/mL buffer), centrifuged at 8000 rpm for 10 minutes and the supernatant containing cytosolic fraction was collected immediately on ice. To isolate mitochondrial fractions, the pellet was dissolved in mitochondrial isolation buffer  and centrifuged at 25000 rpm for 30 minutes to isolate clear supernatant containing mitochondrial fractions as described previously [standard . The cytet. al. as hallmark markers of hypertrophy and increment in protein synthesis respectively [Hypoxia induced apoptosis was assessed in HVCM cells by neutral red  uptake assay  and furtectively . The enh\u00ae Gold Antifade Reagent, P36934, Molecular Probes) and visualized (100X) under high resolution fluorescent microscope . Hypoxia induced acetylation of histone 3 and 4 was further confirmed by western blot analysis. In order to check the effect of nanocurcumin on HDAC, the nuclear fractions were assessed for HDAC activity using commercially available kit  and expressed as percentage change in HDAC activity.Histone acetylation is a critical marker of cardiac hypertrophy . StudiesMitochondrial Hsp70 (mtHsp70) assists the translocation of p53 to mitochondrial under stress . Thus, eIn order to investigate whether hypoxia induced hypertrophy in HVCM cells and associated mitochondrial stress were dependent upon translocation of p53 to mitochondria; we assessed the ANF levels of HVCM cells by preventing entry of p53 to mitochondria. The cells were divided into five groups, i.e. normoxia (N), hypoxia (H), hypoxia+CsA (H+CsA), hypoxia+curcumin (H+C) and hypoxia+nanocurcumin (H+NC). To achieve the same, HVCM cells were treated with cyclosporin A (CsA) as blocker of p53 entry to mitochondria  as described previously . Cells wm, efficiency to generate ATP and assessment of MnSOD activity using fluorescence microscopy, fluorescence-activated cell sorting (FACS) analysis and biochemical estimations.Mitochondrial homeostasis and function were assessed by evaluation of changes in metabolic, energetic and redox function under hypoxia in terms of change in acetyl coenzyme A (acetyl co-A) concentration, pyruvate concentration, glucose levels, lactate levels and lactate dehydrogenase (LDH) activity, \u0394\u03a8m were evaluated using rhodamine 123  and counterstained by propidium iodide  by using FACS at different time points of 1, 3, 6, 12 and 24 h. Assessment of mitochondrial energetic efficacy was done by measurement of cellular ATP pool  and confirmed by evaluating p-T172-5' adenosine monophosphate-activated protein kinase (AMPK\u03b1) activity  using commercially available kits and performed according to manufacturer\u2019s instructions. Qualitative assessment of MnSOD content was performed using commercially available kit  and performed according to manufacturer\u2019s instructions. Quantitative assessment of MnSOD was done according to method described previously [Changes in acetyl co-A concentration , pyruvate concentration , glucose , lactate concentrations  and LDH activity  were assessed using commercially available kits and performed according to manufacturer\u2019s instructions. Further confirmation of mitochondrial metabolic and substrate switching from fatty acids to glucose was done by evaluation of GLUT-1 and GLUT-4 expression levels,47. The eviously .For western blot analysis, 30 \u03bcg of cytosolic, nuclear or mitochondrial proteins were resolved in 10% or 15% SDS-PAGE (Sodium dodecyl sulphate-polyacrylamide gel electrophoresis). The resolved proteins were transferred on to nitrocellulose membrane  by semi-dry trans-blot system  at 15 V for 45 min. The membranes were blocked in blocking buffer  for one hour at room temperature. The membranes were washed with TBST (0.1%) thrice at 10 minutes interval and then were incubated with rabbit polyclonal anti-p53 antibody , rabbit polyclonal anti-c-Jun , rabbit polyclonal anti-c-Fos , rabbit polyclonal anti-histone 3 , rabbit polyclonal anti-histone 4 , rabbit polyclonal anti GLUT-4 , rabbit polyclonal anti GLUT-1, goat polyclonal anti GATA-4  or rabbit polyclonal p-GATA-4  antibodies for 2\u20133 h at room temperature. The membranes were again washed with TBST thrice at 10 minutes interval and re-incubated with bovine anti-rabbit-IgG-HRP (horse radish peroxidise) or mouse-anti-goat-IgG-HRP antibodies   at room temperature for 2 h. The membranes were washed twice and visualized by using chemiluminescent substrate and captured the image  on photographic film.Hypoxia induced oxidative stress was evaluated using enzymatic and non-enzymatic cellular anti-oxidants i.e. free radical generation by ROS estimation, GSH/GSSH, lipid peroxidation and xanthine oxidase assays at different time points of 1, 3, 6, 12 and 24 h of hypoxia by quantitative methods.et. al. [et. al. [Free radical generation was assessed by the method described by Cathcart et. al. . Reducedet. al. . Lipid p[et. al. . To evalQuantitative data was expressed as mean \u00b1 standard deviation (SD) for each experimental group. The results were analysed for statistical significance using one-way or two-way ANOVA. Differences were considered statistically significant at p\u22640.05, p\u22640.005, p\u22640.01 and p\u22640.001. Experiments were performed thrice (n = 3) for statistical significance.Hypoxia insult reduced the cellular viability to 21% (p\u22640.01) when compared to normoxia control cells as depicted by neutral red uptake assay as observed in vs 26% in curcumin), amino acid uptake by 42.8% (vs 56.3% in curcumin) and ANF levels by 64% (vs 25% in curcumin) in HVCM cells depicting induction of hypertrophy (vs normoxia control) confirming that hypoxia induced hypertrophy in HVCM cells was dependent on histone acetylation activity. This was further confirmed by western blots of acetylated histone 3 and 4 as depicted in vs 9% in curcumin compared to hypoxia control). Nanocurcumin treated cells showed decrease in p-300 HAT activity under hypoxia (decreased by 52.14% vs 14% in curcumin) compared to hypoxia control cells. No change in p-300 HAT or HDAC activity was observed in nanocurcumin or curcumin treated cells under normoxia.Histone acetylation, controlled by p-300 HAT and HDAC activities, is an important check point for induction of hypertrophy. Since maximum up-regulation of ANF was observed in cells exposed to 24 h of hypoxia, the p-300 HAT and HDAC activities were assessed in HVCM cells exposed to 24 h of hypoxia as shown in ertrophy . Also, tThe damages observed in HVCM cells might be due to oxidative stress experienced by the cells. In order to recognize a causal relationship between hypoxia induced hypertrophy and damages experienced by HVCM cells, it was important to assess the effect of hypoxia on cardiomyocyte hypertrophy in absence of p53 translocation to mitochondria. To accomplish the same, we evaluated the extent of hypertrophy and mitochondrial homeostasis by preventing translocation of p53 to mitochondria by using CsA, a blocker of mitochondrial translocation of p53. The p53 levels and ANF expression levels were assessed in HVCM cells exposed to 24 h of hypoxia since maximum expression of these markers were observed in cells exposed to 24 h of hypoxia as shown in m under hypoxia may result in cellular damaging events and lead to apoptosis. In order to assess the disturbance in \u0394\u03a8m, we analysed the HVCM cells stained with \u0394\u03a8m sensitive dye and screened using FACS as shown in m was disturbed as early as 1 h of hypoxia which corroborated with the observation that MnSOD activity was down-regulated in HVCM cells by 1 h (decreased by 66%) of hypoxia compared to normoxia as observed in m and down-regulation of mitochondrial protective antioxidant mechanism. Maximum restoration in disruption of \u0394\u03a8m and restoration of MnSOD activity (decreased by 43% compared to normoxia) were observed in 24 h of hypoxia exposed HVCM cells as shown in Figs m and MnSOD activity at all the time points than curcumin. No significant change was observed in HVCM cells treated with nanocurcumin or curcumin under normoxia.Maintenance of mitochondrial membrane potential is detrimental for sustaining normal physiological functioning of cells. The compromise in \u0394\u03a8m and down-regulation of MnSOD activity under hypoxia. This suggests that localization of p53 to mitochondria initiates damaging mitochondrial events which are accomplished in the form of down-regulation of protective anti-oxidant mechanisms and disruption of \u0394\u03a8m in HVCM cells under hypoxia. Treatment with nanocurcumin prevented translocation of p53 to mitochondria by down-regulating mtHsp70 levels and subsequent damage under hypoxia than curcumin as shown in The translocation of p53 to mitochondria is an initial event in the cascade that leads to cellular damaging events by disturbing mitochondrial homeostasis. We observed that p53 localization to mitochondria was increased under hypoxia within 1 h of exposure along with concomitant up-regulation of mtHsp70 as observed in 2, 24 h) as shown in Oxidative stress elicits cellular demand of energy which is fulfilled by generation of more ATP by oxidative phosphorylation and simultaneously, carbohydrates are utilized as prime source of energy in-spite of lipids. In order to assess hypoxia induced changes in metabolic parameters in HVCM cells, we examined the changes in metabolic and bio-energetic function of mitochondria by evaluating acetyl co-A and pyruvate concentrations along with ATP levels and p-AMPK\u03b1 activity. Also, the levels of lactate and glucose were evaluated to assess the effect of hypoxia on mitochondrial metabolism. We found that HVCM cells showed decrease in ATP, acetyl co-A and pyruvate concentrations and increase in p-AMPK\u03b1 activity under hypoxia (0.5% Om (82% compared to hypoxia only) and MnSOD (128% compared to hypoxia only) were observed in 24 h of hypoxia, we evaluated the efficacy of nanocurcumin in restoration of mitochondrial bio-energetic capacity after 24 h of hypoxia to HVCM cells. The efficacy of mitochondria to perform glycolysis was assessed by evaluating acetyl coenzyme A activity and pyruvate content as markers of oxidative stress induced metabolic changes. It was found that acetyl co-A concentration increased after 24 h of hypoxia with parallel decrease in pyruvate content and increase in lactate concentration (33.7% vs normoxia), glucose uptake (25.6%) and LDH activity (35.5% vs normoxia) depicting switching of substrate specificity from fatty acids to sugars to meet the enhanced energy requirements under hypoxia. Nanocurcumin treatment restored the acetyl co-A, pyruvate, lactate content and LDH activity in HVCM cells under hypoxia. However, curcumin did not show any significant result. Nanocurcumin treated cells showed significant restoration in acetyl co-A (48%), pyruvate (47%), glucose uptake (13.3%), lactate concentration (24%) and LDH activity (16%) compared to hypoxia control whereas curcumin treated cells did not show significant restoration. It was also found that ATP levels were halved and p-AMPK\u03b1 activity increased (by 200%) under hypoxia compared to normoxia controls depicting energy deficit in cardiomyocytes as shown in Under hypoxia, mitochondrial generation of ATP is decreased and levels of p-AMPK\u03b1 increase to stimulate enhancement of ATP synthesis to maintain vital functions. However, prolonged oxidative stress induces down-regulation of p-AMPK\u03b1 levels and ATP synthesis is compromised as observed in m post translocation of p53 to mitochondria suggesting that p53 might affects cellular redox-machinery in order to maintain homeostasis. Nanocurcumin treatment was found to be highly significant in restoration of GSH/GSSG  as shown in vs 11% in curcumin) as shown in vs 18% in curcumin) as observed in vs 6.3% in curcumin, as observed in Oxygen-sensitive cardiomyocytes experience severe oxidative stress under hypoxia. We analysed the effect of nanocurcumin in ameliorating cellular enzymatic and non-enzymatic antioxidants under hypoxia. Disturbance in GSH/GSSG content  induced accumulation of p53 and its translocation to mitochondria in hypertrophied adult human ventricular cardiomyocytes. We also sought to investigate the improvement in efficacy of nanocurcumin in ameliorating hypoxia induced stress in cardiomyocytes compared to curcumin.Oxidative stress induced hypertrophy and apoptosis remains a serious clinical situation in cardiac (patho-) physiology . Accumul2, 24 h) stress up-regulated p-300 HAT activity and down-regulated HDAC activity in cardiomyocytes and expression levels of acetylated histones 3 and 4, depicting induction of hypertrophy. These observations are in accordance with previous findings which state that p-300 HAT activities are detrimental in development of myocardial hypertrophy [2, 24 h) induces hypertrophy in HVCM cells by up-regulating p-300 HAT and down-regulating HDAC activity. This was confirmed by the observations that phosphorylation and activation of GATA-4 occurred in hypoxia exposed cells. these findings are in accordance with previous studies which state that phosphorylation of GATA-4 occurs in hypertrophied cardiomyocytes under stress [In the present study, we found that hypoxia induced hypertrophy in HVCM cells as early as 1 h of hypoxia and reached peak value by 24 h as depicted by increase in ANF levels and FITC-leucine uptake. The early increase in ANF levels depicts that onset of hypertrophy might be an initial adaptive response to hypoxia which further increased with increase in hypoxia exposure. In order to elucidate the molecular pathway by which hypoxia induces cardiomyocytes hypertrophy, we assessed the acetylation status of histones 3 and 4 and simultaneously evaluated the p-300 HAT and HDAC activities. Hypoxia induced hypertrophy was further confirmed by assessing the expression of hypertrophic genes GATA-4 in HVCM cells. It was found that hypoxia  induced hypertrophy might be initially an adaptive cellular strategy (as depicted by increased ANF levels by 1 h of hypoxia) which transforms into pathological form under prolonged stress (24 h). Although cardiomyocyte hypertrophy is an adaptive event to combat increased oxygen demand under hypoxia, but sustained oxygen stress might be lethal to oxygen sensitive cardiomyocytes.In order to check whether hypoxia induced hypertrophy was a pathological event, we assessed the mitochondrial function in cardiomyocytes. It was found that disruption in \u0394\u03a8m and caspase-3,-7 activation in cardiomyocytes after mitochondrial p53 accumulation. These findings are in accordance with the previous findings of Vaseva et. al. [2, 24 h) did not trigger nuclear translocation of p53 thus not resulting to DNA-damage in HVCM cells. In order to assess whether hypoxia induced hypertrophy in HVCM cells was dependent translocation of p53 to mitochondria, we assessed the hypertrophy marker ANF by blocking the entry of p53 to mitochondria using cyclosporin A (CsA). It was found that blocking the entry of p53 to mitochondria by CsA did not affect ANF levels in HVCM cells exposed to hypoxia for 24 h. This depicts that induction of hypertrophy was independent of translocation of p53 to mitochondria. These findings are in line with previous reports which state that silencing p53 expression does not prevent cardiomyocyte stress in vivo [The findings in the present study state that translocation of active p53 to mitochondria was time dependent. It was found that p53 translocated to mitochondria within 1 h of hypoxia and reached maximum by 24 h as depicted by co-immunofluorescence of p53, mitochondrial p53 import-motor protein  and western blot. Mitochondrial translocation of p53 in cardiomyocytes led to activation of a cascade of events which disturbed mitochondrial homeostasis, cellular redox balance and increased apoptosis. Corroborating to these findings was the observation that there was disruption in \u0394\u03a8 et. al.  which st in vivo . Howeverm, restoring MnSOD activity, down-regulating caspase-3,-7 activation and restoring cellular redox status at all the time points when compared to curcumin treated cells under hypoxia. These data confirm the improvement in protective efficacy of nanocurcumin under hypoxia when compared to curcumin.In order to assess the molecular regulation of translocation of p53 to mitochondria, we assess the expression levels of c-Fos and c-Jun in cardiomyocytes. Recent findings have shown that c-Fos/c-Jun are important negative modulators of p53 and prevent p53 up-regulation mediated cell-cycle arrest or cell-death in a variety of cells ,58,59. Ie.t.c. complexes [et. al. [The cardiomyocytes are imperatively aerobic in nature and consumes large amount of oxygen to sustain normal function. The high oxygen demand of cardiomyocytes is necessary to meet the constant energy expenditure largely by means of generation of ATP by oxidative phosphorylation. Deprivation in oxygen supply may promote de-compensatory and mal-adaptive response which may lead to more severe pathological conditions. Thus, assessment of efficiency in generation of ATP remains important to be assessed under hypoxia. We assessed hypoxia induced changes in mitochondrial function in hypertrophic cardiomyocytes by evaluating bio-energetic efficiency in terms of assessment of ATP generation and p-AMPK\u03b1 activity as the hallmarks of energy deficit in cells. Increased p-AMPK\u03b1 activity indicates adaptive response to hypoxia which promotes preservation of ATP for sustaining vital functions and promotes more ATP generation to meet the increased energy demands . In the omplexes . The max[et. al. . Also, tIn order to confirm whether hypoxia induced metabolic shift towards glucose as preferred substrate for generating energy, estimation of glucose uptake levels and western blots of GLUT-1and GLUT-4 were done. Previous studies have reported that foetal isoform of GLUT-1 expression increases in adult myocardium and concomitantly, the adult isoform of GLUT-4 expression levels increase under stress ,47. We fCollectively, the major findings of the present study implicate that hypoxia stress induces hypertrophy in HVCM cells by up-regulating p-300 HAT activity and GATA-4 levels. This was accompanied by accumulation of p53 in mitochondria indicating that, hypoxia induced hypertrophy and associated damages might be dependent upon translocation of p53 to mitochondria. The p53 translocation to mitochondria was c-Fos/c-Jun levels dependent and caused severe damages to mitochondrial metabolic, bio-energetic and redox function along with induction of apoptosis by caspase activation. These cellular damaging events were effectively restored by nanocurcumin treatment in cardiomyocytes when compared to curcumin. The data suggests that hypoxia stress promoted hypertrophy by p-300 HAT and GATA-4 activation induced (patho-) physiological damages by translocation of p53 to mitochondria in HVCM cells. However, whether hypoxia- induced hypertrophy is absolutely dependent upon translocation of p53 to mitochondria remains to be elaborated. Also, nanocurcumin treatment in cardiomyocytes prevented hypertrophy and preserved mitochondrial function and cellular redox homeostasis under hypoxia better than curcumin as depicted by restoration in p-300 HAT, HDAC activities, GATA-4 levels and preventing translocation of p53 to mitochondria. The study provides an insight into usability of nanocurcumin as potential therapeutic agent.The present study infers that prolonged hypoxic stress is a causative agent of pathological damages in hypertrophied cardiomyocytes. The data depicts that these pathological damages appear due to translocation of p53 to mitochondria and damages to mitochondrial bioenergetics, metabolic and redox functions. Nanocurcumin treatment protected HVCM cells from hypoxia induced hypertrophy and associated damages better than curcumin, in terms of cellular and mitochondrial bioenergetics and redox function. Also, nanocurcumin treatment prevented switching of preferred energy substrate from lipids to glucose in HVCM cells under hypoxia better than curcumin. The study represents the molecular basis of hypoxia induced cardio-damage and infers that nanocurcumin might be used as a potential therapeutic and cardio-protective agent.S1 Fig@@ p\u22640.01 vs normoxia, *p\u22640.05 vs hypoxia and #p\u22640.01 vs hypoxia.Figure showing changes in fluorescent intensity of p300 HAT in HVCM cells exposed to hypoxia for 24h. Values are mean \u00b1 SD, significant values represented as (TIF)Click here for additional data file.S2 Fig@@ p\u22640.01 vs normoxia, *p\u22640.05 vs hypoxia and #p\u22640.01 vs hypoxia.Figure showing densitometric analysis of acetylated histone 3, histone 4, GATA-4 and p-GATA-4 under various experimental groups, normalized to beta actin. Values are mean \u00b1 SD, significant values represented as (TIF)Click here for additional data file.S3 Figm under various experimental groups exposed to hypoxia for 24h compared to normoxia control. Values are mean \u00b1 SD, significant values represented as @@p\u22640.01 vs normoxia, *p\u22640.05 vs hypoxia and #p\u22640.01 vs hypoxia.Figure showing percentage changes in \u0394\u03a8(TIF)Click here for additional data file.S4 Fig@@p\u22640.01 vs normoxia, *p\u22640.05 vs hypoxia and #p\u22640.01 vs hypoxia. No significant change was observed in nanocurcumin or curcumin treated cells under normoxia (ns).Values are mean \u00b1 SD, significant values represented as (TIF)Click here for additional data file.S5 Fig@@p\u22640.01 vs normoxia, *p\u22640.05 vs hypoxia and #p\u22640.01 vs hypoxia. ns depicts non-significant changes.Values are mean \u00b1 SD, significant values represented as (TIF)Click here for additional data file."}
+{"text": "Among scientists, there exist mixed opinions whether equine influenza viruses infect man. In this report, we summarize a 2016 systematic and comprehensive review of the English, Chinese, and Mongolian scientific literature regarding evidence for equine influenza virus infections in man. Searches of PubMed, Web of Knowledge, ProQuest, CNKI, Chongqing VIP Database, Wanfang Data and MongolMed yielded 2831 articles, of which 16 met the inclusion criteria for this review. Considering these 16 publications, there was considerable experimental and observational evidence that at least H3N8 equine influenza viruses have occasionally infected man. In this review we summarize the most salient scientific reports. Influenza A virus-like-illnesses have been recognized in horses since at least 1299, with speculation that earlier outbreaks of equid diseases could have also been due to influenza A viruses . Morens We identified 2831 articles using multiple search techniques . Six hunIn this review we found considerable historical evidence of EIV infections in man. Although they are careful to explain confounders, Morens and Taubenberger  document6.75 TCID50 equine H3N8 virus. Thirteen (86.7%) of 15 volunteers developed signs of illness, and virus was cultured from samples obtained from all volunteers at day 4 post-inoculation. Systemic illness and febrile upper respiratory illness were the most common clinical signs. The experimental data suggested that the H3N8 virus was not attenuated following passage in humans, as it was still capable of infecting and causing illness in horses.Several healthy human EIV challenge experiments were conducted in the 1960s. In 1965, hospitalized volunteers received challenges with live equine H3N8 virus (A/Equi-2/Miami/63) and were carefully monitored for evidence of infection. Five healthy adult volunteers each received 2.5 mL of undiluted equine H3N8 inoculum , among which 1 mL was administered by pipette directly into the nasal cavities and 1.5 mL nebulized into the nasal cavities and oropharynx . Each suWhile there are scattered reports in the news media and historical science writings that horses, dogs, humans, and even cats concomitantly developed ILIs ,2,29, moThe country of Mongolia has the largest horse-to-man population ratio in the world and has often suffered large epizootics of EIV . For insSoon after, at least 1400 horses were infected with H3N8 EIV during a 2007 epizootic in New South Wales and Queensland, Australia. We conducted a cross-sectional study for EIV infections among 89 people exposed to those sick horses (and 11 controls) . Serum sMore recently, we reported results from our 2005 cross-sectional study of 94 horse-exposed adults and 34 non-exposed controls from three sites in the US state of Iowa. Employing three different types of assays against two strains of H3N8 and one strain of H7N7 EIV, data suggested that at least a portion of horse-exposed adults had been previously infected with an A/equine/Ohio/2003(H3N8)-like strain. Eleven  horse-exposed adults and two  control subjects had microneutralization titers \u22651:80. Among the horse-exposed adults, 18 (19.1%) were positive by a novel neuraminidase inhibition assay and eight (8.5%) had elevated enzyme-linked-lectin assay titers \u22651:10. In the biostatistical analyses, work as an equine veterinarian was associated with increased seroreactivity.At least three H3N8 EIV human challenge studies ,18,19 clWhile the observational studies of human EIV infection in Mongolia ,21 and ADuring our review we became aware that there have been a number of non-equine influenza A viral segments identified in horses. In searching the Influenza Research Database (IRD), we found that genome segments related to influenza A H1N8, H5N1, H7N1 and H9N2 strains have all been detected among samples collected from horses. Although these identifications seem to be rare, accounting for less than 0.5% of all EIV detections, it may indicate that horses are at least susceptible to more diverse strains of influenza A virus than previously thought. For example, in 2011 a novel H9N2 influenza A virus was detected, isolated, and fully sequenced in a study of horses in Guangxi Province, China . Additionally interesting findings are that equids are not always H3N8 EIV \u201cdead-end\u201d hosts. H3N8 EIVs have been detected in dogs in USA, UK and Australia ,33,34,35Even with the experimental and observational data supporting evidence that H3N8 EIVs may infect man, we must be careful to temper these findings with the knowledge that serological assays against zoonotic influenza, such as equine H3N8, may be confounded by non-specific assay inhibitors and pre-existing antibodies against other influenza strains such as those caused by other human H3 viruses or vaccine.In February and March 2016, we searched English, Chinese and Mongolian literature databases, as well as queried senior scientists in Mongolia for relevant literature. English-based databases included: PubMed, Web of Knowledge and ProQuest. Chinese-based databases included: Chinese National Knowledge Infrastructure (CNKI), Chongqing VIP Database and Wanfang Data. Similarly, MongolMed was queried for related Mongolian citations. The following search query was used for PubMed, Web of Knowledge, and ProQuest databases: (\u201cequine influenza\u201d OR \u201chorse influenza\u201d OR \u201cH3N8\u201d OR \u201cH7N7\u201d) AND (\u201chuman infection\u201d OR zoono*). The following search query was used for CNKI, Chongqing VIP Database, and Wanfang Data: SU = \u2018Maliugan\u2019 OR SU = \u2018Maliuxingxingganmao\u2019 OR SU = \u2018equine influenza\u2019 OR SU = \u2018horse influenza\u2019 OR SU = \u2018H3N8\u2019 OR SU = \u2018H7N7\u2019. The search terms \u201chuman infection\u201d OR zoono* were not included when searching the Chinese literature databases, as the number of articles identified when using these terms was very low. Chinese papers identified with equine influenza search terms were instead manually reviewed to select papers that also included \u201chuman infection\u201d or zoono*. We searched MongolMed for citations using \u201cequine influenza\u201d OR \u201chorse influenza\u201d OR \u201c\u0430\u0434\u0443\u0443\u043d\u044b \u0442\u043e\u043c\u0443\u0443\u201d. Mongolian influenza experts were also interviewed for their knowledge of related reports.The historical, observational, and experimental data are compelling in supporting the premise that EIV infections occasionally occur in man. While in recent years, human infections with EIVs have not often been associated with signs of infection, the propensity for influenza A viruses to change makes these viruses worthy of our attention. In particular, should H7N7 EIV strains again emerge, most humans would have little cross-reacting antibody, and the threat to humans might be quite different than that commonly seen today for H3N8. We believe these observations support close surveillance for novel influenza virus emergence among equids."}
+{"text": "To address this, we evolve genetically diverse populations of budding yeast, S.\u00a0cerevisiae, consisting of diploid cells with unique haplotype combinations. We study the asexual evolution of these populations under selective inhibition with chemotherapeutic drugs by time-resolved whole-genome sequencing and phenotyping. All populations undergo clonal expansions driven by de novo mutations but remain genetically and phenotypically diverse. The clones exhibit widespread genomic instability, rendering recessive de novo mutations homozygous and refining pre-existing variation. Finally, we decompose the fitness contributions of pre-existing and de novo mutations by creating a large recombinant library of adaptive mutations in an ensemble of genetic backgrounds. Both pre-existing and de novo mutations substantially contribute to fitness, and the relative fitness of pre-existing variants sets a selective threshold for new adaptive mutations.The joint contribution of pre-existing and   \u2022Clonal heterogeneity influences the acquisition of antimicrobial resistance\u2022de novo genetic variation in clonal evolutionJoint role of pre-existing and \u2022Clonal dynamics are shaped by background-dependent fitness effects of mutations\u2022Loss of clonal heterogeneity is balanced by genomic instability and diversification de novo genetic variation jointly contribute to clonal evolution. By building a library of adaptive mutations in multiple genetic backgrounds, they resolve the fitness effects of mutations in a clonal lineage.V\u00e1zquez-Garc\u00eda et\u00a0al. examine the role of clonal heterogeneity in the acquisition of antimicrobial resistance. They report that pre-existing and  The adaptive response of a cell population can thwart therapeutic control of a wide spectrum of diseases, from bacterial and viral infections to cancer. A prototypical scenario arises when individuals in a population acquire heritable genetic or non-genetic changes to adapt and thrive in a new environment . Since tde novo mutations are mutually dependent, and selection can only act on these sets of variants in their entirety. Genome evolution experiments on isogenic populations have revealed both adaptive sweeps and pervasive clonal competition in large populations where the mutation supply is high. This phenomenon, known as clonal interference, takes place as mutations in different individuals cannot recombine via sexual reproduction and is now relatively well understood both experimentally and theoretically  and small insertions or deletions (indels) acquired during the crossing phase from genome sequences of 173 founder individuals. This is consistent with a mutation rate of approximately We have delineated two lines of enquiry into our hypothesis. To what extent can the adaptive response be attributed to genetic variation already present in a population, and how much to acquired? How do the aggregate effects of pre-existing variation influence the fate of new mutations? To address these questions, we investigated the interaction between pre-existing (or background) genetic variation and new mutations in a population of diploid cells with unique combinations of alleles. The cells originate from two diverged  strains . We carr strains . The cro strains . We also7 cells in serial batch culture under drug inhibition with hydroxyurea (HU) and rapamycin (RM) at concentrations impeding, but not ending, cell proliferation. These drugs were chosen for having known targets and to cover two of the most common modes of action of antimicrobial and\u00a0chemotherapy drugs: inhibition of nucleic acid synthesis (hydroxyurea) and inhibition of protein synthesis and cell growth (rapamycin). We derived replicate lines of WA, NA (2 each in hydroxyurea and rapamycin), and WAxNA , propagating them for 32\u00a0days in 48-hr cycles , where the clonal peak grew 25% faster on average compared with the ancestral population, and the bulk grew 7% faster on average across all populations , offering a putative genetic cause for their growth advantage  for each of these genes existed in an ensemble of backgrounds, thus recreating a large fraction of the genotype space conditioned on the presence or absence of driver mutations. We measured the growth rates of both haploid spores and diploid hybrids, estimating and partitioning the variation in growth rate contributed by the background genotype and by de novo genotypes using a linear mixed model  pathway in rapamycin, the fitness distribution became multimodal. We were not able to attribute increases in the bulk of the fitness distribution to particular alleles beyond the as drugs . In contas drugs .FPR1 mutations needed a second hit by LOH. Additionally, the process gained a new dimension: although these rearrangements were mostly copy number-neutral, they led to fitness increments by changing scores of background variation from the heterozygous to the homozygous state in a single step. As a result, certain passenger mutations hitchhiking with a beneficial driver may provide an additional fitness advantage distributed across one or multiple loci  and are randomly mated by meiotic recombination to generate a large pool of recombinant mosaic haplotypes (crossing phase), followed by applying a selective constraint of the population under stress (selection phase).MAT\u03b1, ura3::KanMX, lys2::URA3, ho::HphMX) isolated from palm wine and a NA strain  isolated from the oak tree. These strains were selected from two diverged S.\u00a0cerevisiae lineages and feature 52,466 single-nucleotide differences uniformly distributed across the genome.Parental strains were derived from a WA strain  medium  for 14\u00a0days at 23\u00b0C. Sporulation of diploids was confirmed by visual inspection of asci. Over 90% of sporulation efficiency was observed after 14\u00a0days. Any remaining unsporulated cells were selectively removed using the ether protocol (\u22121) for 1\u00a0hr at 37\u00b0C. The cells were washed twice with 800\u00a0\u03bcL of sterile water, vortexed for 5\u00a0min to allow spore dispersion, plated in YPD, and incubated for 2\u00a0days at 23\u00b0C. The YPD plates were replica-plated in minimal medium to select diploid cells . The WAxNA F2/F12 generation was collected from the plates and used as a founder population for the selection experiments and stored at \u221280\u00b0C as a frozen stock.The selection experiments were carried out using WA, NA, WAxNA Fprotocol . The hap2, and WAxNA F12 founder populations  were evolved asexually in two selective environments and one control environment. Each of the ancestral populations consisted of a total population size of In the selection phase, WA, NA, WAxNA Fhr cycle . These e\u22121 or rapamycin (RM) at 0.025\u00a0\u03bcg mL\u22121 and maintained at constant drug concentration until day 34. The drug concentrations were chosen based on the dose response of the WA and NA strains. We selected concentrations that maximized the differential growth between the two diploid parents in each environment. We observed a clear dose response in hydroxyurea, with at least 10-fold differential growth between the two diploid parent strains at 10\u00a0mg mL\u22121  at 10\u00a0mg mL\u00a0mg mL\u22121 . For rap strains . This cob strain .t\u2006\u00a0= \u20060, 2, 4, 8, 16, and 32\u00a0days, and ancestral and evolved individuals were also sequenced (t\u2006\u00a0= \u20060 and 32\u00a0days using transmissive scanning (We followed the evolution of these populations over the course of the experiment using whole-genome sequencing and phenotyping of the bulk population and of ancestral and evolved isolates. WA and NA populations are labeled by their background, the environment in the selection phase, and the selection replicate; e.g., NA RM 1. WAxNA populations are labeled by background, number of crossing rounds, cross replicate, selection environment, and selection replicate; e.g., WAxNA F12 2 HU 1. Time series samples are labeled from T0 to T32, and isolate clones carry a suffix; e.g., C1, C2, etc. Whole-population sequencing was performed after equenced . Genomicscanning .I.V.-G., J.W., V.M., and G.L. designed the research. F.S., J.L., B.B., J.H., A.B., and E.A.P. conducted the experiments. I.V.-G., A.F., and V.M. developed the theory, implemented computational methods, and analyzed data. I.V.-G., V.M., and G.L. wrote the paper."}
+{"text": "Mammalian lifespan differs by >100 fold, but the mechanisms associated with such longevity differences are not understood. Here, we conducted a study on primary skin fibroblasts isolated from 16 species of mammals and maintained under identical cell culture conditions. We developed a pipeline for obtaining species-specific ortholog sequences, profiled gene expression by RNA-seq and small molecules by metabolite profiling, and identified genes and metabolites correlating with species longevity. Cells from longer lived species up-regulated genes involved in DNA repair and glucose metabolism, down-regulated proteolysis and protein transport, and showed high levels of amino acids but low levels of lysophosphatidylcholine and lysophosphatidylethanolamine. The amino acid patterns were recapitulated by further analyses of primate and bird fibroblasts. The study suggests that fibroblast profiling captures differences in longevity across mammals at the level of global gene expression and metabolite levels and reveals pathways that define these differences.DOI:http://dx.doi.org/10.7554/eLife.19130.001 The maximum lifespan of mammalian species differs by more than 100-fold, ranging from\u00a0~2 years in shrews to\u00a0>200 years in bowhead whales . While iOne way to study the control of longevity is to identify the genes, pathways, and interventions capable of extending lifespan or delaying aging phenotypes in experimental animals. Studies using model organisms have uncovered several important conditions, such as knockout of insulin-like growth factor 1 (IGF-1) receptor , inhibitTo address these questions, a popular approach has been to compare exceptionally long-lived species with closely related species of common lifespan and identify the features associated with exceptional longevity. Examples include the amino acid changes in Uncoupling Protein 1 (UCP1) and production of high-molecular-mass hyaluronan in the naked mole rat ; unique An extension of this approach has been cross-species analyses in a larger scale. For example, several biochemical studies across multiple mammalian and bird species identified some features correlating with species lifespan. Longevity of fibroblasts and erythrocytes in vitro , poly A, and ratWhile molecular profiling of mammals at the level of tissues may better represent the underlying biology, profiling in cell culture represents more defined experimental conditions and allows further manipulation to alter the identified molecular phenotypes. In this study, we examined the transcriptomes and metabolomes of primary skin fibroblasts across 16 species of mammals, to identify the molecular patterns associated with species longevity. We report that the genes involved in DNA repair and glucose metabolism were up-regulated in the longer\u00a0lived species, whereas proteolysis and protein translocation activities were suppressed. The longer\u00a0lived species also had lower levels of lysophosphatidylcholine and lysophosphatidylethanolamine and higher levels of amino acids; and the latter finding was validated in an independent dataset of bird and primate fibroblasts. Thus, molecular insights into longevity may indeed come from defined cell culture systems in mammals.To identify the molecular signatures associating with the differences in longevity, we obtained primary, sun-protected abdominal skin fibroblasts from 13 species of rodents, two species of bats and one species of shrew, representing a wide range of maximum lifespan  and adult weight  . Female The median nucleotide sequence identity for our ortholog sets with respect to mouse ranged from 83.2% (shrew) to 95.0% (African grass rat), and protein sequence identity from 88.0% (little brown bat) to 96.8% (African grass rat) , consistTo assess the gene expression patterns across the species, we performed Principal Component Analysis and projected the data on the first three Principal Components . The samTo identify the genes with significant correlation to longevity, we performed regression by generalized least squares between the gene expression values and AW, as well as the four longevity traits . The phylogenetic relationship of the species was incorporated in the variance-covariance matrix, and four different trait evolutionary models were tested to select the best models based on maximum likelihood  . A two-sWe qualified as top hits those genes meeting both criteria of p value.robust\u00a0<\u00a00.01 (~11% FDR) and p value.max\u00a0<\u00a00.05. The numbers of top hits were 675 for AW, 812 for ML, 830 for FTM, 508 for MLres, and 793 for FTMres, with roughly equal proportions in positive and negative correlations  and someMsh6, Pms2), nonhomologous end joining and possibly other repair pathways (Pnkp), nucleotide excision repair and DNA double-strand break repair (Ercc1), Fanconi anemia-associated DNA damage response network , and protection of telomeres . The products of checkpoint kinase Chek1 and anaphase promoting complex substrate Pttg1 were regulators of cell cycle.The top pathways for the genes with positive correlation included \u2018nucleotide binding\u2019 (15% of the genes with positive correlation to longevity), \u2018DNA repair\u2019 (4%), \u2018glucose metabolic process\u2019 (4%), and \u2018chromosome organization\u2019 (4%) . The \u2018DNHif1a encodes the alpha subunit of hypoxia-inducible factor 1 (HIF-1), a key transcription factor in mediating the metabolic responses to hypoxia, whereas Prdx3 encodes mitochondrial peroxiredoxin that regulates redox homeostasis. In particular, Pnkp , glucose phosphate isomerase (Gpi1), triose phosphate isomerase (Tpi1), phosphofructose kinase (Pfkp), and pyruvate dehydrogenase kinase (Pdk1), which are involved in glycolysis/gluconeogenesis. The glucan branching enzyme (encoded by Gbe1) and several phosphorylase kinases  regulate the metabolism of glycogen. In addition, the genes coding for NAD synthetase (Nadsyn1), which is involved in converting nicotinate adenine dinucleotide (NaAD) to nicotinamide adenine dinucleotide (NAD), also showed positive correlation with all four longevity traits , E3 ubiquitin-protein ligase , ubiquitin-like modifier , as well as several proteins containing RING finger domain  or F-box domain , both of which are known to be involved in the ubiquitination pathway. Also, low expression was observed for the genes encoding autophagy related proteins  and lysosomal cysteine proteinases . The genes implicated in \u2018protein transport/localization\u2019 included several vesicle trafficking proteins , mitochondrial membrane translocases , and nuclear transport receptors . As for \u2018regulation of transcription\u2019, we observed down-regulation of the genes coding for mediator complex subunits , zinc finger proteins , Kruppel-like factors , and members of the MYC/MAX/MAD network of transcription factors .With regard to the top hits showing negative correlation, the major enriched pathways included \u2018proteolysis\u2019 (9% of the genes with negative correlation to longevity), \u2018protein transport/localization\u2019 (9%), and \u2018regulation of transcription\u2019 (18%) . For \u2018prTrp53), BCL-2 associated X protein BAX (encoded by Bax), transcription factor FOXO3 (encoded by Foxo3), as well as mitogen-activated protein (MAP) kinase (encoded by Mapk1) (Tgfbr3) and transcription factor JunD (encoded by Jund), were also relatively low in longer\u00a0lived species . A closer examination revealed that the enrichment signal was due to a number of genes involved in apoptosis regulation, including the tumor suppressor TP53 (encoded by y Mapk1) ; they we species . In part species , and theongevity .\u221210 in both cases; \u221226), whereas the other categories were much less significant , as well as to\u00a0low-glucose culture medium. As expected, the results showed positive correlation between ML and the resistance to cadmium and paraquat , and were more resistant to the metabolic inhibition by rotenone treatment and in low-glucose medium . To see paraquat , althougFor 12 of the rodent species, we also performed metabolic analyses  Figure . After dTo identify the metabolites with significant correlation with the longevity traits, we also applied the phylogenetic regression method described above. At the cut-off of p value.robust\u00a0<\u00a00.01 (~11% FDR) and p value.max\u00a0<\u00a00.05, 13 metabolites showed significant correlation with AW, 26 metabolites with ML, 20 metabolites with FTM, 16 metabolites with MLres and 19 metabolites with FTMres . Twenty-To further examine our observation of the positive correlation between amino acids and the longevity traits, we independently obtained and quantified the amino acid levels in a larger collection of primary fibroblasts from 15 primate species and 33 bird species. All 10 of the amino acids associated with lifespan in rodent fibroblasts  were also found to have a significant positive association with lifespan in bird and primate fibroblasts . The assAll lines of mammals descended from the same common ancestor over the previous 230 million years and have since undergone remarkable diversification in body size, metabolic rate, fertility, and longevity, with corresponding changes in the gene expression and metabolite landscape . As fibrOur pipeline can be easily extended for a larger number of species. We defined gene orthology based on reciprocal best hit in BLAST  and ignoThe gene expression findings revealed a clear segregation based on phylogeny , suggestC. elegans  as a readout. While our study represents an initial study, this approach can be extended to a larger group of species and samples, refining the molecular signatures and then manipulating them via genetic and environmental manipulations. Ultimately, this should reveal the genetic basis for differences in species longevity and lead to new strategies for targeting them, thereby shifting cells, and ultimately organisms, to the state of cells from related longer-lived species.Blarina brevicauda), big brown bat (Eptesicus fuscus), little brown bat (Myotis lucifugus), guinea pig (Cavia porcellus), porcupine (Erethizon dorsatum), chinchilla (Chinchilla lanigera), chipmunk (Tamias striatus), fox squirrel (Sciurus niger), red squirrel (Sciurus vulgaris), beaver (Castor canadensis), gerbil (Meriones unguiculatus), African grass rat (Arvicanthis niloticus), meadow vole (Microtus pennsylvanicus), cotton rat (Sigmodon hispidus), white-footed mouse (Peromyscus leucopus), and deer mouse (Peromyscus maniculatus brandii)  and 0.25 \u00b5g mL\u22121 of fungizone  on ice and shipped overnight to our laboratory (Primary skin fibroblast samples were collected from shrew (brandii) . The posbrandii) . Abdominboratory . Biologiboratory .5 cells for 75 cm2 flask. These cells were then harvested 7 days later and cryopreserved at 106 cells per vial.The conditions for establishment and maintenance of the cultures have been reported previously . Briefly6 cells) for analysis. These cultures were kept under low-oxygen conditions (3% O2) after thawing to minimize selection for resistance to O2 toxicity  were performed, any excess PBS was drained, and the pellets were frozen at \u221280\u00b0C. Technical replicates were made by growing a minimum of 60\u00a0\u00d7\u00a0106 cells and labeling half of the cells after counting as separate samples.Production of cells for RNA sequencing and metabolite profiling always started by thawing a vial of cryopreserved cells and allowing them to expand until the culture had produced sufficient cells (at least 30\u00a0\u00d7\u00a010toxicity . Cells wSCR_001470) Database (0.153), was based directly on the documentation of the AnAge database (http://genomics.senescence.info/help.html#anage). The FTMres equation, FTMres = FTM/(78.1\u00d7AW0.217), was based on linear regression using the FTM and body mass records of 1330 mammalian species in the AnAge database.The Adult Weight (AW), Maximum Lifespan (ML) and Female Time to Maturity (FTM) data of the species  were obtained from the Animal Ageing and Longevity  (RNAseq libraries were prepared as previously described . Paired _011841)  to removEptesicus fuscus, Myotis lucifugus, Cavia porcellus, Chinchilla lanigera, Peromyscus maniculatus brandii). To ensure consistency across the entire dataset, we developed the following pipeline to identify species-specific ortholog sets, map the reads and obtain expression values  (RRID:SCR_006773), the longest transcript was extracted for each protein-coding gene locus, after confirming the presence of start and stop codons and the proper reading frame. Those transcripts containing highly repetitive or highly similar sequences were identified and removed using BLAST (RRID:SCR_004870)  (Step 1: generate mouse reference. Based on the ff 10\u22126) . This geff 10\u22126) .SCR_013048) (SCR_011812)  . BLAST (_013048) . The seq_013048) . Within _011812)  and the _011812) . For the_011812) . Seventy_011812) . When th_011812) .SCR_012919)   and thos_012919) . The fin_012919) .For rodent cells, the metabolite levels were quantified by mass spectrometry as previously described . From thPrincipal component analysis was performed on the standardized expression values or metabolite values and the first three Principal Components were extracted. The phylograms were constructed using the neighbor joining method , based oTo identify genes or metabolites with significant correlation to the longevity traits, regression was performed using the generalized least square approach, by incorporating the phylogenetic relationship in the variance-covariance matrix . As prevA two-step procedure was applied to verify the robustness of the results . In the SCR_003033) (Mus musculus. For those genes showing positive and negative correlation with longevity (supported by two or more longevity traits), we queried Gene Ontology , SwissProt and Protein Information Resource (\u2018SP PIR Keywords\u2019), and Kyoto Encyclopedia of Genes and Genomes (\u2018KEGG Pathway\u2019). For comparison, pathway enrichment was also performed using only the 9389 expressed orthologs as background. STRING (RRID:SCR_005223) version 10 (SCR_006442) \u2018STRINGdb\u2019. Selected nodes were highlighted based on the enriched pathways.For the genes, pathway enrichment analysis was performed using DAVID (RRID:_003033) , 2009b. rsion 10  was usedSCR_010223) (build 17) (SCR_004869) (SCR_002344)  and each of four functional groups of genes \u2013 aging genes, essential genes, transcription factor genes, and housekeeping genes. These human gene sets were originally collected and analyzed in a previous study . Human auild 17) . They in_004869) . Human h_004869) . Houseke_004869) . For the_002344) , and onlSCR_002231) (SCR_007712)   and Huma_007712) . For Con_007712) . Odd rat_007712) .An untargeted metabolomics screen was conducted using fibroblasts from 32 bird species and 13 species of non-human primates. The detailed methods were described in Although the original dataset contained information on 4383 metabolites, including 456 of known chemical identity, the analysis for this paper was restricted to the ten amino acids for which p<0.05 for association with maximum lifespan in the analysis of mammalian  fibroblasts . A regre4 cells in 100 \u00b5L CM in 96-well microtiter plates for 24 hr, followed by a period of 24 hr in medium lacking serum but containing 2% bovine serum albumin  with antibiotics and fungizone at the same concentration as CM. For assessment of resistance to H2O2, paraquat, and cadmium (Sigma), the cells in the 96-well plates were washed and exposed to the stress agent for 6 hr. For assessment of resistance to methyl methanesulfonate (MMS), the cells were incubated with MMS in DMEM for 24 hr, washed and then incubated with DMEM supplemented with 2% BSA, antibiotics, and fungizone for\u00a018 hr. For assessment of cell metabolism in low-glucose medium, cells were incubated in DMEM containing a range of glucose concentrations for 1 hr. Survival was assessed by WST-1 tests. All incubations were at 37\u00b0C in a humidified incubator with 5% CO2 in air.The methods used are as previously described . BrieflyFor calculation of the resistance of each cell line to chemical stressors, at each dose of chemical stressor, mean survival was calculated for triplicate wells for each cell line. The LD50, i.e. dose of stress agent that led to survival of 50% of the cells, was then calculated using Probit analysis as implemented in NCSS software . ED50 values for glucose withdrawal were calculated in a similar manner to estimate the level of glucose or rotenone associated with a 50% reduction in cellular metabolic activity. In the interests of transparency, eLife includes the editorial decision letter and accompanying author responses. A lightly edited version of the letter sent to the authors after peer review is shown, indicating the most substantive concerns; minor comments are not usually included.eLife. Your article has been favorably evaluated by Janet Rossant as the Senior Editor and three reviewers, one of whom is a member of our Board of Reviewing Editors. The following individuals involved in review of your submission have agreed to reveal their identity: Daniel Promislow (Reviewer #2) and Yousin Suh (Reviewer #3).Thank you for submitting your article \"Cell culture-based profiling across mammals reveals DNA repair and metabolism as determinants of species longevity\" for consideration by The reviewers have discussed the reviews with one another and the Reviewing Editor has drafted this decision to help you prepare a revised submission.Summary:The manuscript by Gladyshev and colleagues seeks to correlate gene expression and metabolite signatures in cultured fibroblasts from 16 different mammals with longevity phenotypes of the respective mammals, including maximal lifespan, body size, female time to maturity, and stress resistance. Using RNAseq and mass spec, the authors show that the constructed gene expression profiles reflect phylogenetic relationships, and identify subsets of genes and metabolites that correlate, positively or negatively, with multiple longevity traits (but not necessarily body size). The study presents a massive amount of work, particularly in compiling the various datasets and developing the informatics pipelines to specify species-specific ortholog sets and assess the robustness of the results, which will certainly be of interest to the community of researchers studying the biology of aging. All three reviewers agreed that the study provides interesting insights into aging and longevity, and should be of broad interest. However, as detailed below, a number of concerns were also raised, relating in large part to insufficient clarity in the current version with respect to the authors' methods and the limitations of their approach and data.Essential revisions:1) As this fibroblast culture system is the cornerstone of the authors' approach, it is essential that they provide clear and complete details regarding the experimental strategies used to isolate and culture these cells. In particular, detailed answers to the following key questions must be available in the present manuscript:A) What age and sex were the animals from which the fibroblasts were isolated ?B) From what region of the body were fibroblasts isolated? This is important since other studies have shown that fibroblasts retain a regional gene expression program  after isolation.C) What is the media system used, and strategy for cell passaging? How were these culture conditions chosen, and how can it be determined if they are optimal for all species . This information should be very clearly articulated and discussed in the manuscript text itself, since it forms the basis for the experimental system used.D) At what passage number were gene expression and metabolite profiles generated?E) What is the in vitro proliferation rate of the different fibroblast isolates, and does this correlate with any of the gene expression profiles or longevity traits analyzed?2) It should also be discussed that in vitro cell culture conditions dramatically change chromatin architecture , and so gene expression patterns. The gene expression signature detected may simply reflect the ability of cells to differentially adjust to the in vitro conditions, and may contribute to the multiplex stress resistance. This caveat should be discussed in the text.3) It is not clear whether the common 9,389 gene orthologs that were reliably detected across the 15 species are comparable to the number of expressed genes detected by RNA-seq in fibroblasts in the 5 species with annotated genomes. The base line information on how many transcripts are detected in the 5 species should be available as they may provide a way to estimate the number of potentially missing orthologs, due to sequence divergence, some of which may be critical contributors to longevity through drastic functional alterations of gene products. The text should be clarified to address this point.4) It is not clear what the baseline gene set was for the enrichment analysis of the 827 top hits . Was it b)) implies that residuals were taken from a least-squares regression of log(LS) vs. log(Mass) with an intercept of log(a) and a slope of b. But this is not mentioned in the present manuscript, and must be inferred from the Ma et al. manuscript. If a least-squares regression approach was used, one important assumption is that the residuals are normally distributed. The data for 5) Subsection \u201cLongevity trait variation across mammal\u201d. The authors need to provide more information on how they calculated residuals from body mass. The reference to Ma et al. 2015b gives allometric equations, but no information is provided regarding where those equations come from. The description in Ma et al.  The authors use maximum lifespan as a metric of aging, and thus should add to the text of their manuscript a discussion of the concerns that have been raised regarding this statistic . In particular, it does not provide a measure of aging per se, is quite sensitive to small sample size, and is not in itself under direct selection.7) Analyses of primate and bird species  does not appear to be size corrected. Numerous studies have shown strong size effects of life span not only in primates, but also in birds. Therefore, size effects should be addressed here as well.8) Subsection \u201cEvaluation of amino acid levels in bird and primate fibroblast cell lines\u201d. For the bird/primate analysis, the authors state, \"when two or more [\u2026] features were annotated as corresponding to the same amino acid, we tabulated the degree of association from the feature most strongly correlated with lifespan among the species studied.\" This approach will necessarily bias the result in favor of suggesting a stronger relationship between lifespan and metabolite levels than might be true, and this caveat must be mentioned. Essential revisions:1) As this fibroblast culture system is the cornerstone of the authors' approach, it is essential that they provide clear and complete details regarding the experimental strategies used to isolate and culture these cells. In particular, detailed answers to the following key questions must be available in the present manuscript:We agree that these are very important points. We have updated the Methods section to incorporate these reviewers\u2019 comments and suggestions. Additional comments are provided below.A) What age and sex were the animals from which the fibroblasts were isolated ?Fibroblasts were isolated from post-pubertal adults. Although ages of the wild-captured donors could not be reliably determined, it is a good assumption that most were young, i.e. their age was substantially less than the maximal lifespan that could be achieved by protected or captured members of the species. For mice, for example, maximum lifespan in the laboratory is approximately 3.5 to 4 years, but mice in their natural environment typically live about six months. Thus, most wild-captured adults were likely to be well below half of the species-specific maximal recorded longevity. The sex of the donors was not recorded. Variations in donor age or sex are unlikely to have generated false positive findings in our design. If such variations  did have any effects on our endpoints, such effects would have increased Type II error , but not have led us to false positive claims (Type I error), unless these demographic variables were confounded with species life history variables. For example, if most of the animals captured from short-lived species were males, and most of those captured from longer-lived species were females, this could in principle create a false positive error by confounding species lifespan with gender effects, but such a scenario seems unlikely.B) From what region of the body were fibroblasts isolated? This is important since other studies have shown that fibroblasts retain a regional gene expression program  after isolation.We used an identical procedure to prepare cells. Fibroblasts were taken from sun-protected abdominal skin, as previously reported . They were therefore consistent across all our species.C) What is the media system used, and strategy for cell passaging? How were these culture conditions chosen, and how can it be determined if they are optimal for all species . This information should be very clearly articulated and discussed in the manuscript text itself, since it forms the basis for the experimental system used.2) after thawing to minimize selection for resistance to O2 toxicity. All of the preparations used for RNA and metabolite testing were similar in degree of expansion, all were at the earliest possible passage number from the original skin biopsy, and were expanded under low O2 conditions.The detailed culture conditions are now incorporated under \u201cCell culture\u201d in the Materials and methods section. In particular, these cultures were kept under low-oxygen conditions , but in any case we tried to minimize any such effects by use of 3% O2 and by doing all analyses on cells at early passage numbers.The cell lines were all exposed to the same culture conditions. We do not know if the conditions were \"optimal\" for rapid growth of cells from each species, but clearly the use of identical culture conditions is needed to avoid confounding effects due to species origin with possible effects of culture variations. We recently showed that cells from wild mice and other wild rodents are much less sensitive to OD) At what passage number were gene expression and metabolite profiles generated?6 cells were then allowed to expand to 30 x 106 cells, an increase of approximately 4 or 5 doublings.See answer to point C) above and the revised Materials and methods section. Cryopreserved cells were prepared at passage 2 (counting the first transfer of confluent cells as passage 1); thawed aliquots of 10E) What is the in vitro proliferation rate of the different fibroblast isolates, and does this correlate with any of the gene expression profiles or longevity traits analyzed?6cells), so any variations in growth rate will be less likely to influence the gene expression pattern.We do not know the \"in vitro proliferation\" rate of our cell lines. This would vary in complex ways with seeding density, glucose and serum levels, degree of confluence at subculture, and days after seeding at which the proliferation was to be measured . It is possible that cell lines from different species might differ in some of these parameters, and that these differences could contribute to species differences in gene expression in a pattern that reflects longevity of the species tested, but evaluating this idea would be a complex undertaking. Nevertheless, the fibroblasts used for gene expression were collected at similar degree of confluency (with ~ 30 x 102) It should also be discussed that in vitro cell culture conditions dramatically change chromatin architecture , and so gene expression patterns. The gene expression signature detected may simply reflect the ability of cells to differentially adjust to the in vitro conditions, and may contribute to the multiplex stress resistance. This caveat should be discussed in the text.We agree with the reviewers and have included this point in the Discussion. We used cells from the second/third passage for the RNA-seq and metabolite measurements in order to minimize in vitro culture artifacts, but it is still possible that some of the features reflect the differential responses to in vitro culture stress.3) It is not clear whether the common 9,389 gene orthologs that were reliably detected across the 15 species are comparable to the number of expressed genes detected by RNA-seq in fibroblasts in the 5 species with annotated genomes. The base line information on how many transcripts are detected in the 5 species should be available as they may provide a way to estimate the number of potentially missing orthologs, due to sequence divergence, some of which may be critical contributors to longevity through drastic functional alterations of gene products. The text should be clarified to address this point.We appreciate these comments and have provided the additional information in the main text and in The number of annotated genes in these species ranged between ~14,000 to ~16,000. Such variations are likely due to the different pipelines used for gene annotation. Among these annotated genes, ~10,000-11,000 had >10 counts (the same criteria for the expressed orthologs). This is similar to the 9389 orthologs we identified, indicating that our list of expressed orthologs is likely to have captured at least 80% of the expressed genes.4) It is not clear what the baseline gene set was for the enrichment analysis of the 827 top hits . Was it We have clarified the pathway enrichment procedure in the Materials and methods section.Mus musculus. We have now also included pathway enrichment statistics performed using only the 9389 expressed orthologs as background  may be more conserved sequence-wise and therefore more enriched among the orthologs, and thus among top hits\u201d, we would like to discuss it in terms of the following aspects:1) We agree with the reviewers that the genes in the DNA repair and glucose metabolism pathways are likely well conserved across the species. In fact, our additional analysis suggested that many of our ML-associated genes are \u201chousekeeping genes\u201d . This is2) To the extent that our results are biased by sequence conservation , we do not believe this is the case for the following reasons:A) First, for those species with publicly available genomes, when we mapped the reads to the public genomes and used the public annotations, only ~10,000 to ~11,000 genes were expressed , even though ~14,000 to ~16,000 genes were annotated . This isB) To address the issue of sequence conservation and divergence, we calculated the median DNA distance (using Kimura 2-parameters distance) for each ortholog set . In partb)) implies that residuals were taken from a least-squares regression of log(LS) vs. log(Mass) with an intercept of log(a) and a slope of b. But this is not mentioned in the present manuscript, and must be inferred from the Ma et al. manuscript.5) Subsection \u201cLongevity trait variation across mammal\u201d. The authors need to provide more information on how they calculated residuals from body mass. The reference to Ma et al. 2015b gives allometric equations, but no information is provided regarding where those equations come from. The description in Ma et al. , was based directly on the documentation of the AnAge database (http://genomics.senescence.info/help.html#anage). The relevant paragraph was quoted here:We have now included an additional paragraph (\u201cLife history data of the species\u201d) under the Methods section to provide more information on the allometric equation. The ML equation, MLres = ML/(4.88\u00d7AWtmax) residual, expressed as a percentage of the expected maximum longevity calculated from the adult body size (M) and derived from the mammalian allometric equation: tmax = M0.153. This is useful to identify species that live longer than expected for their body size. Cetaceans were excluded because we have less confidence in their longevity records, obtained from studies in the wild often using indirect methods, than in those from other mammalian taxa.\u201d\u201cFor mammals, also included is the maximum longevity (0.217), was calculated by us, by linear regression using the FTM and body mass records of 1330 mammalian species in the AnAge database.The FTM equation, FTMres = FTM/(78.1\u00d7AW0.158), which is comparable to the AnAge documentation.If we had used the same procedure to calculate the MLres equation, we would obtain MLres = ML/:Therefore, none of the longevity traits violated normalcy assumption.10 scale.Furthermore, we also tested the normalcy of the gene expression data and metabolite data. Using Shapiro test, 89% of the genes and 90% of the metabolites did not violate normalcy assumption on log6) The authors use maximum lifespan as a metric of aging, and thus should add to the text of their manuscript a discussion of the concerns that have been raised regarding this statistic . In particular, it does not provide a measure of aging per se, is quite sensitive to small sample size, and is not in itself under direct selection.th percentile of longevity  should be used in place of ML in the long run, although at the moment such records are available for only a limited number of species.Thank you. We have included this point in the Discussion section. Additional parameters such as mean adult lifespan and 907) Analyses of primate and bird species  does not appear to be size corrected. Numerous studies have shown strong size effects of life span not only in primates, but also in birds. Therefore, size effects should be addressed here as well.We have now expanded A) Removal of body mass weakened the observed correlation . This isB) The same weakening of correlation is also observed in our previous studies . This is in fact expected, given the strong correlation between maximum lifespan and body mass. It is highly debatable whether one could completely disentangle these 2 traits, since they are likely under the same natural selection force.C) Whether the body-mass should be removed in cross-species longevity studies is an area where experts in comparative biology hold widely divergent views. Some (e.g. John Speakman) think that \"uncorrected\" data are not interpretable; another set, equally experienced (e.g. Tony Hulbert), thinks that an attempt to \"correct\" for mass will create a major risk for missing key associations, since mass and lifespan are so strongly confounded across species. Others suggest that one should report both unadjusted and adjusted values so that readers can see whichever set of results they feel is most valid.D) Such associations, whether or not corrected for mass, are only a first step towards more definite, causal, hypotheses. Some remain significant under both ML and MLres, while others do not. Nevertheless, they can all be potential candidates for further experimental verification.8) Subsection \u201cEvaluation of amino acid levels in bird and primate fibroblast cell lines\u201d. For the bird/primate analysis, the authors state, \"when two or more [\u2026] features were annotated as corresponding to the same amino acid, we tabulated the degree of association from the feature most strongly correlated with lifespan among the species studied.\" This approach will necessarily bias the result in favor of suggesting a stronger relationship between lifespan and metabolite levels than might be true, and this caveat must be mentioned.This selection reflects, in part, uncertainties in the annotation of specific features in the untargeted metabolomics protocol used for the bird and primate species. In most cases where two or more of the annotated features were thought to represent the same amino acid, there was very good agreement. The table below gives the key information on this point. It lists each amino acid for which there was more than one annotated feature, and gives the p-values for the relationship with species lifespan for each such feature.In four cases , all such features show a significant association with lifespan. For the other three, the features that do not meet the traditional p = 0.05 criterion have two-sided p-values between 0.05 and 0.2, with the same sign of the slope coefficient.We agree with the reviewer that our decision to present the feature with the best fit to the MLS regression could in principle create bias and thus increase Type I error, but in this case there are several reasons for confidence: the close fit between each of the nominal \"replicate\" features within the bird/primate data set, the good agreement across each of the 10 amino acids evaluated, and the excellent agreement to the relationship seen for the rodent cell lines evaluated with an entirely different method."}
+{"text": "Clostridium perfringens types B and D, a major causative agent of enterotoxaemia causes significant economic losses to animal industry. Conventional vaccines against these pathogens generally employ formalin-inactivated culture supernatants. However, immunization with the culture supernatant and full length toxin subjects the animal to antigenic load and often have adverse effect due to incomplete inactivation of the toxins. In the present study, an epitope-based vaccine against Clostridium perfringens Etx, comprising 40\u201362 amino acid residues of the toxin in translational fusion with heat labile enterotoxin B subunit (LTB) of E. coli, was evaluated for its protective potential. The ability of the fusion protein rLTB.Etx40\u201362 to form pentamers and biologically active holotoxin with LTA of E. coli indicated that the LTB present in the fusion protein retained its biological activity. Antigenicity of both the components in the fusion protein was retained as anti-fusion protein antisera detected both the wild type Etx and LTB in Western blot analysis. Immunization of BALB/c mice with the fusion protein resulted in\u00a0a significant increase in all isotypes, predominantly IgG1, IgG2a and IgG2b. Anti-fusion protein antisera neutralized the cytotoxicity of epsilon toxin both in vitro and in vivo. Thus, the results demonstrate the potential of rLTB.Etx40\u201362 as a candidate vaccine against C. perfringens.Epsilon toxin (Etx) produced by The online version of this article (10.1186/s13568-019-0824-3) contains supplementary material, which is available to authorized users. Clostridium perfringens, the causative agent of enteric diseases in domestic animals, is a non-motile, spore-forming, Gram-positive, anaerobic bacterium (Songer C. perfringens was classified into 5 groups (A to E)  conferred protection against the C. perfringens infection  of epsilon toxin of Vibrio cholerae JBK70 cells (ATCC Number: 39318) were a kind gift from Dr. M. Lewin, University of Maryland School of Medicine, Baltimore, USA. The V. cholerae JBK70 cells harbouring the recombinant plasmid pMMBltbEtx40\u201362 were induced with IPTG essentially as described earlier . Proteins were eluted with sodium phosphate buffer of different strengths , pH 7.4. Different fractions were analyzed on SDS-PAGE (15%) at constant current of 30\u00a0mA at room temperature (25\u00a0\u00b0C), and the fractions showing the presence of the fusion protein were pooled and dialyzed against 10\u00a0mM phosphate buffer, pH 7.4. The purified protein was flash frozen and stored at \u2212\u00a020\u00a0\u00b0C until further use.E. coli M15 cells  transformed with pQE60etx plasmid were grown till the absorbance of the culture at 600\u00a0nm reached 0.6. The cells were then induced with 1\u00a0mM IPTG  and grown further for 6\u00a0h. The induced culture was then subjected to centrifugation at 3000\u00d7g for 5\u00a0min at 4\u00a0\u00b0C, the supernatant was discarded and the cell pellet resuspended in 10\u00a0mM Tris\u2013HCl, pH 7.4 was sonicated for 10 cycles each of 30\u00a0s each with cooling for 30\u00a0s between the cycles, in a sonicator . The cell lysates thus obtained were then centrifuged  to obtain the soluble fraction and insoluble fraction. Anion exchange chromatography using diethylaminoethyl (DEAE)-Sepharose  was used to purify the rEtx from the soluble fraction. The column was pre-equilibrated with 10\u00a0mM Tris\u2013HCl, pH 8.0 prior to loading of the soluble fraction. The sample was then loaded onto the preequilibrated column followed by thorough washing (4 column volumes) with 10\u00a0mM Tris\u2013HCl, pH 8.0. Bound proteins were eluted using a continuous pH gradient of 10\u00a0mM of Tris\u2013HCl in the pH range between pH 8.0 to pH 5.0). Different fractions were analyzed by SDS-PAGE (12%) and the fractions showing the presence of rEtx were pooled. The protein concentration was determined using the BCA protein estimation kit .The method described by Mathur et al.  was follV. cholerae\u00a0cells harboring the\u00a0recombinant plasmid\u00a0pMBLTB . The bound proteins were eluted using 200\u00a0mM sodium phosphate buffer, pH 7.4 (30 fractions of 1\u00a0ml each). The collected fractions were analysed on 15% SDS-PAGE to check the purified protein and dialysed against the 10\u00a0mM phosphate buffer (pH 7.4).For the purification of rLTB, the k et al. ] were ins et al. . Briefly40\u201362 was investigated using CD spectroscopy according to  cells as described earlier  and wild type LTB were mixed with recombinant heat labile enterotoxin A subunit (LTA) to constitute the holotoxin. CHO-K1 cells were cultured in DMEM supplemented with 1% FCS, 2\u00a0mM glutamine, penicillin (100 U/ml) and streptomycin (100\u00a0\u00b5g/ml) at 37\u00a0\u00b0C in 5% CO2 humidified atmosphere. The CHO-K1 cells (2\u2009\u00d7\u2009104 cells/ml/well in a 24 well tissue culture plate) were treated with equal amounts of the reconstituted fusion protein holotoxin and wild type holotoxin and incubated for 16\u00a0h. Morphological examination of the cells was performed under a light microscope.In vitro biological activity of the LTB component in the purified rLTB.Etx40\u201362 (1\u00a0\u03bcg/g body weight) emulsified in alum. Pre-immune sera were collected prior to immunization. Four weeks after primary immunization, two booster doses with the same amount of protein emulsified in alum were administered at 2\u00a0weeks intervals. Mice were bled 1\u00a0week after 2nd booster. The blood was allowed to clot for 1\u00a0h at room temperature (RT) and the sera were collected by centrifugation at 10,000\u00d7g for 10\u00a0min at RT and stored in small aliquots at \u2212\u00a020\u00a0\u00b0C.After collection of pre-immune sera, a group of BALB/c mice  were immunized with the rLTB.Etx2HPO4, 1.5\u00a0mM KH2PO4, pH 7.4)] for 1\u00a0h at RT with shaking (100\u00a0rpm). Different dilutions of the sera in PBS with 2% BSA (100\u00a0\u03bcl/well) were added to each well and incubated for 2\u00a0h at 37\u00a0\u00b0C. This was followed by the addition of 100\u00a0\u03bcl of HRP-conjugated anti-mouse IgG  to each well and incubated at 37\u00a0\u00b0C for 1\u00a0h. Wells were washed thrice with 1\u00d7 PBST (10\u00a0min each) between successive incubations. Color was developed by addition of 100\u00a0\u03bcl orthophenylenediamine  supplemented with hydrogen peroxide (1\u00a0\u03bcl/ml). The reaction was terminated by the addition of 50\u00a0\u03bcl of 2\u00a0N H2SO4 and the absorbance was measured against PBS containing 0.2% BSA  at 490\u00a0nm using BioTek microplate reader.To determine the antigenic specificity of the antisera, antigen specific ELISA was performed as described by Sharma and Dixit . Briefly1, IgG2a or IgG2b antibodies (1:1000). Subsequent incubation was done with streptavidin-HRP (1:1000) and developed using orthophenylenediamine (OPD) as described earlier  against the Etx was determined essentially as described previously  in a 96 well cell culture plate in 10% DMEM [Dulbecco\u2019s modified Eagle\u2019s medium supplemented with 10% (v/v) heat-inactivated fetal bovine serum]. Different dilutions  of the anti-rLTB.Etx40\u201362 antisera collected after the 2nd booster were incubated with 7.5\u00a0ng of rEtx for 1\u00a0h at 37\u00a0\u00b0C prior to the addition to MDCK cells. The cells treated with the antisera-toxin mixture were maintained at 37\u00a0\u00b0C and 5% CO2 for 2\u00a0h in a humidified incubator. Cell viability was checked by staining the cells with metabolic indicator 3--2,5-diphenyl-2H-tetrazolium bromide (MTT)  as described by Mosmann  with different concentrations of the rEtx  and mice were monitored for survival. The LD50 dose of the rEtx was thus determined to be 1.5\u00a0ng/20\u00a0g body weight. To assess the neutralization potential of the antisera in mice, pre-determined 2\u2009\u00d7\u2009LD50 dose of the rEtx (3\u00a0ng/20\u00a0g body weight in 5\u00a0\u00b5l PBS) was pre-incubated with equal volume of the undiluted neat antisera for 30\u00a0min at 37\u00a0\u00b0C and administered  into BALB/c mice (n\u2009=\u200910 per group). Mice administered with the rEtx preincubated with equal volume of preimmune serum were included as control. The mice were monitored for survival for 5\u00a0days.p value) was performed by employing one way or two-way analysis of variance (ANOVA) test (Dunnett\u2019s multiple comparison test) using GraphPad Prism 7 software . The data show mean\u2009\u00b1\u2009SD of three independent experiments performed in triplicates.Statistical analysis to determine the significance values  precipitated proteins resulted in purification of the rLTB.Etx40\u201362 to near homogeneity  in comparison to the preimmune serum. The antigen specific end point titers in the fusion protein antisera were determined to be\u2009~\u20091:10,000 and\u2009>\u20091:100,000 for Etx and LTB, respectively  as well as the rEtx efficiently. The antigenic cross-reactivity of the fusion protein antisera against the parent protein (epsilon toxin) was also evaluated by Western blot analysis. It is clear that the antibodies present in the fusion protein antisera  could effectively detect a band of\u2009~\u200935\u00a0kDa corresponding to the recombinant Etx in Western blot  and fusion protein  were administered by themselves, confirming the self-adjuvanting activity of the LTB. Immunization of the LTB and the rLTB.Etx40\u201362 with alum as adjuvant  augmented the immune response as significantly higher absorbance in ELISA was obtained when compared to the absorbance obtained with the antisera generated against the LTB  and the fusion protein alone . To determine the type of immune response generated by the fusion protein, antibody isotype profiling of the anti-rLTB.Etx40\u201362 antisera was carried out. As evident from Fig.\u00a0p\u2009\u2264\u20090.005), IgG2a (p\u2009\u2264\u20090.001), IgG2b (p\u2009\u2264\u20090.001) was observed in comparison to the preimmune sera.ELISA results showed that the anti-rLTB.Etxp\u2009\u2264\u20090.005 to p\u2009\u2264\u20090.001). Pre-incubation of the rEtx with the neat anti-fusion protein antisera resulted in significant reduction in the rEtx toxicity (p\u2009\u2264\u20090.001) with 94.35\u2009\u00b1\u20094.05% survival of the cells with respect to untreated control cells. The percentage survival of the cells declined in a dilution dependent manner, when the cells were treated with rEtx preincubated with increasing dilution of antisera No significant improvement in the survival was noted when the cells were treated with rEtx pre-incubated with undiluted pre-immune sera. Microscopic analysis of these cells also confirmed the neutralization potential of the Etx toxicity by the fusion protein antisera   in the fusion protein and that the epitope spanning 40\u201362 amino acids was capable of generating an effective Etx-specific immune response. Our results thus suggest that the epitope chosen in the present study contributed significantly towards the antigenicity of the Etx and could generate an antibody response towards the Etx with a highly immunogenic fusion partner LTB. A similar ability of the fusion protein antisera to detect native as well fusion partners has been demonstrated in earlier studies  as well as humoral (Th2)], which is desirable for an effective vaccine. A similar immune response has been observed with a multi-epitope vaccine against Brucella\u00a0melitensis  may differ with the type of immunogen and adjuvant administered and are indicative of the type of immune response generated. An increase in IgG2a and IgG2b isotypes is linked with a Th1 immune response, whereas an increase in the IgG1 and IgG3 isotypes is linked with a Th2 immune response. The antibody isotype profile of the anti-rLTB.Etx40\u201362 antisera was able to neutralize the toxin. These data thus demonstrate that the epitope present in the fusion protein was capable of generating Etx neutralizing antibodies. Our results are in agreement with earlier reports where in a vaccine containing a specific epitope could produce the potent broadly neutralizing antibodies against the antigen and could effectively prevent the Streptococcus agalactiae, Streptococcus aureus and Mycobacterium tuberculosis H37Rv infection (Xu et al. C. perfringens, the neutralizing effect can vary in protective efficacy (Lobato et al. Both the in vitro and in vivo challenge studies using rEtx showed that the anti-rLTB.EtxC. perfringens epsilon toxin.Thus, in the present study we have demonstrated that use of genetic fusion of an immunodominant epitope of Etx with LTB generated an effective immune response capable of negating epsilon toxin toxicity both in vitro and in vivo, and demonstrated the potential of Etx epitope-LTB fusion proteins as a candidate vaccine against Additional file 1:Fig. S1. Additional Antibody titer determination. Fig. S2. Microscopic analysis of MDCK cells treated with the rEtx pre-inncubated with anti-rLTB.Etx40-62 antisera."}
+{"text": "Ipilimumab is a monoclonal antibody that enhances the efficacy of the immune system by targeting a cytotoxic T-lymphocyte-associated protein 4 (CTLA-4), which is a protein receptor that downregulates the immune system. Nivolumab is also a humanized monoclonal antibody that targets another protein receptor that prevents activated T cells from attacking the cancer; this receptor is called programmed cell death 1 (PD-1). The FDA approved ipilimumab combined with nivolumab as a frontline therapy for patients with metastatic melanoma or renal cell carcinoma and as a second-line therapy for patients with microsatellite instability-high (MSI-H) metastatic colon cancer. Immune-related adverse events such as autoimmune colitis, pneumonitis, hepatitis, nephritis, hypophysitis, and thyroiditis may occur during or weeks to months after therapy. We report a case of thrombotic thrombocytopenic purpura (TTP) in a patient with metastatic renal cell carcinoma following one cycle of ipilimumab and nivolumab. Only one case report of ipilimumab-induced TTP exists in the medical literature. With the wide use of immunotherapy to treat cancers, physicians need to be aware of this rare immune-related adverse event. Thrombotic thrombocytopenic purpura (TTP) is a thrombotic microangiopathy (TMA) characterized by thrombocytopenia due to platelet consumption, hemolytic anemia due to red blood cell (RBC) fragmentation, and organ damage due to blood flow blockage by clots that are high in platelets with little or no fibrin . TTP is A 42-year-old woman was admitted to our hospital with change in mental status, slurred speech, and fever 9 days following the administration of one cycle of the intravenous infusion of ipilimumab 1\u2009mg/kg and nivolumab 3\u2009mg/kg for the treatment of metastatic renal cell carcinoma (RCC). Her history is significant for a right radical nephrectomy with lymphadenectomy for a kidney mass identified on CT abdomen and pelvis during the work up of hematuria (January 2018). Pathology confirmed papillary RCC with extensive sarcomatoid features. Eight of the 11 lymph nodes were involved with cancer. She received Sutent  for 4 months and then stopped due to progression of disease. Spine MRI revealed a C3 compression deformity with tumor extension as well as osteolytic metastatic disease at C4 and the right C5 pedicle. She underwent C2 to C5 posterolateral arthrodesis and instrumentation. Ipilimumab and nivolumab were initiated on 06/04/2018. Four days later, she presented to clinic with significant fatigue. Laboratory results revealed hemoglobin (Hb) 4.9\u2009g/dL; hematocrit (HCT) 16.4%; and platelets (PLT) 36,000 per microliter. She was given prednisone 1\u2009mg/kg orally daily for presumed immunotherapy-induced immune thrombocytopenia (ITP) and received 2 units of packed RBCs. Her overall health deteriorated so she got admitted on 06/13/2018. Laboratory studies on admission are available in MRI brain revealed calvarial metastasis but no evidence of intracranial disease. Electroencephalogram (EEG) revealed moderate generalized disturbance in the cerebral slowing activity. A diagnosis of TTP was made on the basis of laboratory and clinical findings. Methylprednisolone 125\u2009mg IV every 6 hours, therapeutic plasma exchange , and rituximab (weekly 4 doses) were initiated. ADAMTS13 activity less than 3% and inhibitory titer 9.9 Bethesda Units/mL confirmed acquired TTP. Ten days after initiating the appropriate therapy, the mental status improved, the platelet count increased to 116,000 per microliter, and the LDH level decreased to 406 U/L.TTP was once identified by a clinical pentad: thrombocytopenia, microangiopathic hemolytic anemia, neurologic symptoms, renal function abnormalities, and fever. However, this pentad is a clinically rare finding in patients with TTP. Thrombocytopenia and microangiopathic hemolytic anemia remain the most consistent signs of TTP . NeuroloIpilimumab is a monoclonal antibody that binds to cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4). By blocking inhibitory signals transmitted by CTLA-4, ipilimumab reactivates cytotoxic T-lymphocytes (CTLs) and enables them to attack cancer cells . IpilimuThe platelet count of our patient was stable prior to the administration of ipilimumab and nivolumab, despite the aggressive and advanced nature of her disease."}
+{"text": "T\u2009=\u200910\u2009K) has been reached in tris-(8-hydroxyquinoline) aluminum (Alq3)-based organic spin valves (OSVs) using La0.67Sr0.33MnO3 as a magnetic electrode. Here we demonstrate that one type of perovskite manganites, i.e., a (La2/3Pr1/3)5/8Ca3/8MnO3 thin film with pronounced electronic phase separation (EPS), can be used in Alq3-based OSVs to achieve a large magnetoresistance (MR) up to 440% at T\u2009=\u200910\u2009K and a typical electrical Hanle effect as the Hallmark of the spin injection. The contactless magnetic field-controlled EPS enables us to achieve a nonvolatile tunable MR response persisting up to 120\u2009K. Our study suggests a new route to design high performance multifunctional OSV devices using electronic phase separated manganites.Tailoring molecular spinterface between novel magnetic materials and organic semiconductors offers promise to achieve high spin injection efficiency. Yet it has been challenging to achieve simultaneously a high and nonvolatile control of magnetoresistance effect in organic spintronic devices. To date, the largest magnetoresistance  effect in LPCMO/Alq It is challenging due to conductivity mismatch between the FM contact and the semiconductor7 that greatly suppresses the spin injection efficiency. Inserting a high-quality tunneling barrier/spin filterer at the FM/semiconductor interface8 will improve the spin injection efficiency whereas a sophisticated epitaxial layer growth is required making it difficult to be compatible with other heterostructure systems11. The discovery of MR effect through an organic semiconductor (OSEC) medium between two FM contacts, namely organic spin valves (OSVs)14, suggests a new route to enhance the spin injection efficiency into semiconductors: The formation of OSEC/FM interface  offers a promising spin-filtering effect to enhance the spin polarization of FM metals leading to a large MR effect (up to 300%) at low temperature23. While most recent OSV studies focus on optimizing the MR performance by tailoring the OSEC/FM spinterface and exploring the multi-functionalities of OSVs by utilizing photovoltaic response in OSECs28, the influence of the FM contacts on the MR effect has not been emphasized.Efficient spin injection from a ferromagnetic (FM) material into a nonmagnetic semiconductor is highly desirable for spin-based computing concepts such as spin transistors and spin storage/memory devices0.67Sr0.33MnO3 (LSMO) has been almost the only material used in OSVs30. This is probably because most other manganite films have pronounced electronic phase separation (EPS) featured by coexistence of ferromagnetic metallic (FMM) and non-ferromagnetic insulating phases, which would presumably lower the spin polarization and are thus considered as non-favorable materials for spin injection.In general, FM materials with high spin polarization are favorable for the FM contacts in the OSVs. In this regard, the half metallic perovskite manganites with near 100% spin polarization would be the most popular candidates. In spite of a large number of members in manganites family, La2/3Pr1/3)5/8Ca3/8MnO3 (LPCMO) film, a surprisingly large MR effect up to 440% is achieved in a conventional OSV geometry. Benefited from such a large magnetoresistance, a signature of electrical Hanle effect is successfully observed in the LPCMO-based OSV device, unambitiously showing the electrical spin injection and detection in the Alq3 layer. The LPCMO system has been well known for its pronounced EPS between the ferromagnetic metallic (FMM) and antiferromagnetic charge ordered insulating (COI) phases31. We show that magnetic field induced modulation of the FMM and COI phase in the LPCMO thin film leads to a tunable MR effect up to 120\u2009K above which the phase separation disappears. Our results open a new pathway of designing high performance organic spintronic devices by utilizing the electronic phase separation of the complex manganites, thus bridging the gap between organic spintronics and complex manganites materials.Here we demonstrate that by substituting the LSMO with a (La3 (tris-(8-hydroxyquinoline) aluminum, Aldrich) molecule thin film sandwiched between a 60-nm-thick LPCMO film epitaxially grown on the SrTiO3 substrate and a 10-nm-thick cobalt layer with Au capping. A schematic diagram of the fabricated OSV structure is shown in Fig. 3 films were used because it is the well-tested molecular material for constituting the organic/molecular spintronic devices. It provides a large spin filtering effect via the Alq3/ferromagnet spinterface as evidenced by two-photon photoemission spectroscopies19. The LPCMO thin film was selected since the high-quality LPCMO film grown by pulsed laser deposition exhibits a large-scale electronic phase separation that can be controlled by applying a pre-set field (Bpre) or varying the temperature32. The LPCMO thin film is also suitable for an efficient spin injection owing to its half-metallic nature that would significantly suppress the conductivity mismatch between organic molecules and oxide surface. In support of this assertion, the spin polarization of LPCMO is calculated from the tunneling magnetoresistance (TMR) response in a LPCMO/Al2O3/Co devices using the Julli\u00e8re model  and magnetization (M vs. T) measurements, as shown in Fig. 39: When the temperature decreases, the paramagnetic (PM) phase is replaced by the COI phase at TCO ~ 200\u2009K, as revealed by the sharp increase of the thin film resistance. This transition is consistent with the onset of ferromagnetism as presented in the M vs. T and the derivative peak of T curve  when most of COI phase domains are melt into the FMM phase.The phase competition between FMM and COI domains in the LPCMO thin filmI\u2013V) curves of the LPCMO-based OSV device at 10\u2009K, which exhibit similar characteristics to those of a conventional LSMO/Alq3/Co OSV14. All I\u2013V curves were measured at 1\u2009T after the following magnetic field history: (1) a pre-set magnetic field, Bpre, was applied along the in-plane direction; (2) The field was reduced to zero and then increased to 1\u2009T. This procedure was repeated for higher Bpre without any demagnetization process in between. The conductance (resistance) increases (decreases) with increasing Bpre, suggesting that the percolation of FMM phase in the LPCMO bottom electrode reduces the overall device resistance. For comparison, the LPCMO bottom electrode is replaced by La0.67Sr0.33MnO3 to form a LSMO-OSV. I\u2013V curves of the LSMO-OSV do not exhibit any measurable dependence on Bpre  are presented in Fig. Bpre was applied along the in-plane direction and then reduced to zero; (2) A sweeping in-plane field was applied from 1\u2009T to \u22121\u2009T and back to 1\u2009T. Upon sweeping field from 1\u2009T to \u22121\u2009T, the relative magnetization orientation of the two FM electrodes changes from parallel (P) to antiparallel (AP) and to parallel configurations, leading to a change of the device resistance (R) from RP to RAP and back to RP. A typical positive MR peak appears (RP\u2009<\u2009RAP) corresponding well with the coercive fields of Co and LPCMO electrodes determined by SQUID measurements , both RAP and RP decrease but the decrease of RP is much larger than RAP, resulting in a substantial enhancement of MR amplitude (up to ~440%) at high Bpre. Such a large MR amplitude has not been observed in similar OSV devices using LSMO electrode30, suggesting a higher spin polarization injection from LPCMO electrode that is superior to the well-known LSMO electrode. The change of MR amplitude shows a non-linear increase as a function of Bpre and saturates at high preset magnetic fields  A LPCMO/Alq3/Au device has no hysteretic MR response except for a weak anisotropic MR response from the LPCMO electrode; (3) A LPCMO/Al2O3/Co device exhibits a MR value of +30%. The device shows a negative Bpre-dependent MR response, namely the MR ratio decreases as Bpre increases which is opposite to that in the LPCMO/Alq3/Co device. Hence we conclude that the formation of spinterface between Alq3 and LPCMO is critical to achieve a large and tunable MR response by Bpre.Three control experiments were performed to cross-check our results as summarized below  shows no Hanle effect . It doesn\u2019t decrease to the same level of the resistance as that in the parallel configuration (~90\u2009M\u03a9), or vice versa. This indicates that the measured Hanle effect would be attributed to the partial spin precession under Bz when the spin carrier promptly transmits through the Alq3 interlayer53 due to the exchange-mediated spin transport55. Thus the obtained spin lifetime from the Hanle effect should be considered as the transit time, \u03c4transit or the lower bound of spin lifetime in the Alq3 interlayer.In contrast to the diffusion-dominated non-local Hanle measurement3-based OSVs. Due to the large in-plane magnetic anisotropy of the LPCMO electrode and the efficient spinterface, the large MR response up to 440% allows us to probe such a subtle Hanle effect in the LPCMO-OSV device, namely less than 4% of change in the device resistance at Bz\u2009=\u2009200\u2009mT that is two orders of magnitude smaller than its MR value. As a comparison, it is expected that the similar Hanle effect in the LSMO-based OSV device may be much smaller and beyond the instrument sensitivity , probably accounting for the absence of Hanle effect in most Alq3-based OSVs. In addition, the short transit time in the Alq3 layer (\u03c4transit ~ 45\u2009ps) would result in a very broad Hanle effect in the need of the perpendicular magnetic field at least up to 100\u2013200\u2009mT which is inaccessible in most OSVs using the soft LSMO electrode.It is the first time that the electrical Hanle effect is demonstrated in the AlqBpre and temperature (see Methods).The observed results suggest that the electronic phase separation (EPS) inside the LPCMO film plays a key role in the unusually large and tunable MR effect. To unravel the correlation between EPS and the observed MR response, a variable-temperature, high field magnetic force microscope (MFM) was used to visualize the FMM-to-COI phase interconversion as a function of Bpre\u2009=\u20091\u2009T, 3\u2009T, and 7\u2009T, respectively. MFM images were recorded following the same procedure used in the MR measurements. All the MFM images were taken at a constant magnetic field (Bext\u2009=\u20091\u2009T) after withdrawing Bpre. It is clear that increasing Bpre reduces the area fraction of the COI phase (blue area) and eventually all the COI phase domains transit into the FMM phase at a high Bpre. This is consistent with the increase of magnetization as Bpre increases  and LPCMO/Al2O3(1\u2009nm) indicates that the phase boundary and FMM volume fraction remain virtually unchanged with the Alq3 or Al2O3 capping layer  is about two times smaller than that at 10\u2009K, which is not surprising for OSV devices because the spin diffusion length in Alq3 thin film decreases with increasing temperature15. The high field MR response (near linear slope) becomes more pronounced at 75\u2009K than at 10\u2009K due to the decreased overall hysteric MR response in the device. The relations between the obtained MR values and the area fraction of the FMM phase at different temperature are summarized in Fig. Figure 2O3/Co device , i denotes the different layer), respectively . The spin-flip scattering rate is approximately proportional to the total area of the phase boundary. Thus Rsf is an effective resistance due to spin-flip scattering and should be inversely proportional to the area of the FMM/COI phase boundary. The modified two-current model yields the following :RAP):3 bulk, For the device resistance in the parallel configuration . The increase of Rsf compensates the overall reduction of RLPCMO\u2193 in Eq.  increases as a function of Bpre, making the MR response increase dramatically. We note that the absence of the enhanced MR response in the LPCMO/Al2O3/Co device suggests that a highly polarized spin filtering effect \u2193) at the LPCMO/Alq3 spinterface is required to realize the observed results \u2193 are larger than all other resistances, and A is the FMM ratio, and Rsf\u2009=\u2009C/L where L is the total length of the phase boundary and C is a constant. The MR becomes,By applying a large ses Fig. . The eff\u2193 in Eq. . It leadnect Eq.  with theComparing to Eq. , we findBpre at V\u2009=\u20090.2\u2009V. In the presence of Bpre, the MR response decreases monotonically with increasing temperature, and disappears above T\u2009~\u2009150\u2009K due to diminished magnetization of the LPCMO film  and MR(Bpre\u2009=\u20091\u2009T) is plotted as a function of temperature in Fig. MR(Bpre\u2009=\u20097\u2009T)/MR(Bpre\u2009=\u20091\u2009T) ratio shows a maximum around T\u2009=\u200950\u2009K, which is consistent with the trend of T plot in the inset of Fig. MR, RP, and RAP at each temperature and Bpre are put into Eqs. /MR(Bpre\u2009=\u20091\u2009T) ratio shown in Fig. Rsf) plays an essential role in determining the MR response in the LPCMO-OSV device.Our proposed model is further validated by the temperature dependence of MR response in the LPCMO-OSV device. Figure ilm Fig. . The rat1\u2009T Fig.  agrees w3 molecule-based spin valve device using a LPCMO thin film with pronounced EPS as the bottom electrode. The EPS state can be tuned by applying a Bpre, allowing the contactless control of area fraction of the FMM phase in the bottom electrode. As a result, the MR response can be tuned by Bpre within six times difference in magnitude. Such an unusually large yet tunable MR effect is likely governed by a tunable spin-flip scattering at the boundaries between FMM and COI phases inside the LPCMO film and a large spin filtering effect at the molecule/oxide spinterface. The large MR effect enables us to demonstrate the first electrical Hanle effect in the Alq3-based OSV device as the success of spin injection and detection in the organic layer. The obtained spin lifetime (or the transit time) of electrically injected spin carriers (~45\u2009ps) is surprisingly shorter than that of the bulk Alq3 layer despite its weak spin-orbit coupling, indicating the dominant role of the exchange-mediated spin transport. Our results demonstrate a novel approach for tuning MR response in organic spintronic devices via controlling EPS state in manganite electrodes. The proposed phase boundary-induced spin flip mechanism sheds light on understanding the origin of spin injection efficiency in the manganite films. Our study opens a new route towards logic switching for future high-performance molecular memory/storage devices.We demonstrate that a large MR effect of ~440% can be created in Alq3 (100) substrates under the oxygen pressure of 8\u2009\u00d7\u200910\u22124 Torr using pulsed laser deposition58. During the deposition, the film thickness was monitored by in-situ Reflection High Energy Electron Diffraction (RHEED). The LPCMO bottom electrodes were fabricated from the LPCMO thin films by wet photo-lithography59. After ultrasonic cleaning in alcohol and acetone, the LPCMO electrodes were immediately transferred into a vacuum chamber with a base pressure of 7.5\u2009\u00d7\u200910\u221211\u2009Torr. The Alq3  spacer layer (thickness: ~60\u2009nm) was thermally evaporated at room temperature, followed by e-beam deposition of Co (10\u2009nm)/Au (10\u2009nm) top electrodes in a crossbar configuration using a shadow mask. The substrate was kept at 280\u2009K during the top electrode deposition process to suppress the interdiffusion between the top electrode and the Alq3 layer10. The thickness of each layer was monitored by a quartz thickness monitor which had been calibrated by a profilometer. The active device area was about 20\u2009\u00d7\u2009120\u2009\u03bcm.LPCMO films (60\u2009nm) were grown on SrTiOMagnetization measurements were carried out using a Quantum Design superconducting quantum interference device system (SQUID). Magnetic fields were applied parallel to the device plane, which is the easy magnetization direction for both bottom and top magnetic electrodes.MR\u2009=\u2009/Rparallel, where Rantiparallel  is the device resistance in the antiparallel  magnetic configuration of the two ferromagnetic electrodes. The device resistance was measured by two-point probe method.Magnetoresistance measurements were carried out using a Quantum Design Physical Property Measurement System (PPMS) combined with a Keithley 2400 source meter. The magnetic fields were applied along the in-plane direction of the device. The MR is defined as T), pre-set magnetic field (Bpre), and applied bias (V). Prior to measurements at each chosen temperature , the device was always set to room temperature following by cooling under zero magnetic field. After the chosen temperature was reached, Bpre  was first applied to the device and then removed allowing us to control the area fraction of the FMM phase in the LPCMO bottom electrode. A voltage bias  was applied to the device from which the resistance of device was recorded using a LabVIEW program. The MR response was measured by sweeping the magnetic field continuously from 1\u2009T to \u22121\u2009T and back to 1\u2009T.The MR response is controlled by three factors: temperature . After the MR loop measurement, the in-plane magnetic field is directly sweeping back to zero in order to maintain a \u2018parallel\u2019 configuration of two magnetic layers of the device . Second, the device is rotated by 90 degrees to apply a perpendicular magnetic field  to measure the Hanle effect in this parallel configuration of the device.The Hanle effect measurements were taken at Bin-plane\u2009=\u2009+1\u2009T, the magnetic field is sweeping down to Bin-plane\u2009=\u2009\u221230\u2009mT and then reducing to zero to achieve an antiparallel configuration of two ferromagnetic layers . Then the device is rotated by 90 degrees to apply the perpendicular magnetic field  to perform the Hanle measurement.For the Hanle effect in the antiparallel configuration, the MR loop is firstly measured along the in-plane field direction to achieve the largest MR. From the After finishing the Hanle measurement, the device is rotated back to the in-plane field geometry to make sure that the same MR loop is repeated after applying the perpendicular magnetic field.Bext\u2009=\u20091\u2009T) after withdrawing Bpre. The calculated area fraction of the FMM phase based on the MFM images should thus be similar to that in the LPCMO bottom electrode of the device.MFM images were acquired from the same LPCMO thin film which was later used as the bottom electrode for LPCMO-OSV device. The MFM measurements were carried out in the PPMS System using Attocube scanning probe microscope following the same procedure for magnetoresistance measurements. For measurements at different temperatures, the temperature was first raised to room temperature at which the LPCMO becomes paramagnetic, and then cooled under zero field to a chosen temperature for MFM measurements on the LPCMO thin film. Note that the temperature cycle does not change the global resistivity and magnetization of the LPCMO film at a chosen temperature, although the EPS pattern varies even at the same chosen temperature after different temperature cycle. All the MFM images were taken at a constant magnetic field (Supplementary Information"}
+{"text": "There are major concerns about the suitability of immersive virtual reality (VR) systems  to be implemented in research and clinical settings, because of the presence of nausea, dizziness, disorientation, fatigue, and instability . Research suggests that the duration of a VR session modulates the presence and intensity of VRISE, but there are no suggestions regarding the appropriate maximum duration of VR sessions. The implementation of high-end VR HMDs in conjunction with ergonomic VR software seems to mitigate the presence of VRISE substantially. However, a brief tool does not currently exist to appraise and report both the quality of software features and VRISE intensity quantitatively. The Virtual Reality Neuroscience Questionnaire (VRNQ) was developed to assess the quality of VR software in terms of user experience, game mechanics, in-game assistance, and VRISE. Forty participants aged between 28 and 43 years were recruited (18 gamers and 22 non-gamers) for the study. They participated in 3 different VR sessions until they felt weary or discomfort and subsequently filled in the VRNQ. Our results demonstrated that VRNQ is a valid tool for assessing VR software as it has good convergent, discriminant, and construct validity. The maximum duration of VR sessions should be between 55 and 70 min when the VR software meets or exceeds the parsimonious cut-offs of the VRNQ and the users are familiarized with the VR system. Also, the gaming experience does not seem to affect how long VR sessions should last. Also, while the quality of VR software substantially modulates the maximum duration of VR sessions, age and education do not. Finally, deeper immersion, better quality of graphics and sound, and more helpful in-game instructions and prompts were found to reduce VRISE intensity. The VRNQ facilitates the brief assessment and reporting of the quality of VR software features and/or the intensity of VRISE, while its minimum and parsimonious cut-offs may appraise the suitability of VR software for implementation in research and clinical settings. The findings of this study contribute to the establishment of rigorous VR methods that are crucial for the viability of immersive VR as a research and clinical tool in cognitive neuroscience and neuropsychology. Immersive virtual reality (VR) has emerged as a novel tool for neuroscientific and neuropsychological research . NeverthLonger durations in a virtual environment have been associated with a higher probability of experiencing VRISE, while the intensity of VRISE also appears to increase proportionally with the duration of the VR session . HoweverTo our knowledge, there do not appear to be any guidelines as to the appropriate maximum duration of VR research and clinical sessions to evade or alleviate the presence of VRISE. Recently, our work has suggested that VRISE are substantially reduced or prevented by VR software that facilitates ergonomic navigation  and interaction  facilitated by the hardware capabilities  of commercial, contemporary VR HMDs comparable to or more advanced than the HTC Vive and/or Oculus Rift . HoweverWhile VRISE may occur for various reasons, they are predominantly the undesirable outcomes of hardware and software insufficiencies  . In termOur recent technological literature review of VR hardware and software pinpointed four domains that should be considered in the development or selection of VR research/clinical software . The domM = 32.08; SD = 3.54) and an educational level between 12 and 16 full-time years of education  were recruited for the study. Eighteen participants  identified themselves as gamers through self-report and 22 as non-gamers . The gamer experience was a dichotomous variable  based on the participants\u2019 response to a question asking whether they played games on a weekly basis. The participants responded to a call disseminated through mailing lists at the University of Edinburgh and social media. The study was approved by the Philosophy, Psychology and Language Sciences Research Ethics Committee of the University of Edinburgh. All participants provided written informed consent prior to taking part.Forty participants  aged between 28 and 43 years  hard disk, and Realtek High Definition Audio.An HTC Vive HMD with two lighthouse-stations for motion tracking was used with two HTC Vive\u2019s wands with 6 degrees of freedom (DoF) to facilitate navigation and interactions within the environment . The VR 1; (2) \u201cThe Lab\u201d (Session 2)2; and (3) \u201cRick and Morty: Virtual Rick-ality\u201d (Session 3)3. In \u201cJob Simulator,\u201d the participant becomes an employee who has several occupations, such as a cook (preparing simply recipes), car mechanic , and an office worker . In \u201cThe Lab,\u201d the participant needs to complete several mini-games like slingshot (shooting down piles of boxes), longbow (shooting down invaders), xortex (spaceship-battles), postcards (visiting exotic places), human medical scan (exploring the human body), solar system (exploring the solar system), robot repair (repairing a robot), and secret shop . In \u201cRick and Morty: Virtual Rick-ality,\u201d the participant needs to complete several imaginary home-chores as in \u201cJob Simulator,\u201d though, in this case, the participant is required to follow a sequence of tasks according to a fictional storyline.Three VR games were selected, which included ergonomic navigation  and interactions  with the virtual environment. In line with The VRNQ measures the quality of user experience, game mechanics, and in-game assistance, as well as the intensity of VRISE. The VRNQ involves 20 questions where each question corresponds to one of the criteria for appropriate VR research/clinical software . The participants went through an induction pertinent to the VR software for that session and the specific HMD and controllers used  before being immersed. Subsequently, the participants were asked to play the respective VR game until they completed it, or they felt any discomfort or fatigue. The duration of each VR session was recorded from the time the software was started until the participant expressed that they wanted to discontinue. At the end of each session, participants were asked to complete the VRNQ. The \u201cJob Simulator\u201d was always used in the 1st session, \u201cThe Lab\u201d was always used in the 2nd session, and \u201cRick and Morty: Virtual Rick-ality\u201d was always used in the 3rd session.2 by the degrees of freedom (df), which is an indicator of the sample distribution . The a priori sample size calculator for structural equation models was used to calculate the minimum sample size for model structure. This calculator uses the error function formula, the lower bound sample size formula for a structural equation model, and the normal distribution cumulative distribution function  mixed g-prior was used for the selection of the best model. JZS has the computational advantages of a g-prior in conjunction with the theoretical advantages of a Cauchy prior, which are valuable in variable selection for the best model (10) \u2265 10 was set for statistical inference, which indicates strong evidence in favor of the alternative hypothesis (\u2217 3 different software sessions). The post hoc statistical power calculator was used to calculate the observed power of the best model using Bayesian linear regression analysis , as well as the duration of the 1st session  indicated significant differences in the total score and every sub-score of VRNQ , while there was not a substantial difference between the duration of the 2nd and 3rd sessions (BF10 = 2.78), as well as between the duration of 1st and 2nd sessions  = 0.310, p < 0.001]. Furthermore, the VRISE score substantially correlated with the following VRNQ items: immersion, pleasantness, graphics, sound, pick and place, tutorial\u2019s difficulty, tutorial\u2019s usefulness, tutorial\u2019s duration, instructions, and prompts  which assesses the quality of VR software in terms of user experience, game mechanics, in-game assistance, and VRISE. The values of the fit indices of CFA  indicated that the VRNQ\u2019s structure was a good fit to the data, which postulates good construct validity for the VRNQ . In addiFurthermore, minimum and parsimonious cut-off scores were calculated for the VRNQ total score and sub-scores to inspect the suitability of the assessed VR software. The minimum cut-offs indicate the lowest acceptable quality that VR research/clinical software should be, while the parsimonious cut-offs are offered for more robust support of the VR software\u2019s suitability, which may be required in experimental and clinical designs with more conservative standards. However, the individual scores from the VRNQ may be modulated by individual differences and preferences unrelated to the quality of the software . In addi\u2217 4 sessions = 96 observations)  . Notablyvations) , while nvations) . Also, cThe VRNQ allows researchers to report the quality of VR software and/or the intensity of VRISE in their VR studies. However, an in-depth assessment of the numerous software features requires a questionnaire with more than the 20 questions of the VRNQ . For an The duration of the VR session is a crucial factor in research and/or clinical design. In our sample, the participants discontinued the VR session due to loss of interest, while none discontinued due to VRISE. In the 1st session, gamers spent significantly more time immersed than the non-gamers; a difference which modulated the difference between the two groups in the summed duration across all sessions. However, it is worth noting that there was not a significant difference between the two groups in the time spent in VR for the 2nd and 3rd sessions. The observed difference in the 1st session and the absence of a difference in the later sessions\u2019 durations postulates that when users are familiarized with the VR technology, while the influence of their gaming experience on the session\u2019s duration becomes insignificant. In support of this, a recent study showed that user gaming experience does not affect the perceived workload of the users in VR . Hence, Nevertheless, in the whole sample, irrespective of participants\u2019 gaming experience, the durations of the 2nd and 3rd sessions are sufficiently longer than the duration of the 1st session. The duration of the 3rd session is not significantly longer than the duration of the 2nd session. Furthermore, given that in each session, a different VR software was administered, the VRNQ correspondingly pinpointed significant differences amongst the implemented VR software\u2019 quality. All the VRNQ scores for the 3rd session\u2019s VR software are greater than the 2nd session\u2019s VR software scores. Similarly, all the VRNQ scores for the 2nd session\u2019s VR software are greater than the 1st session\u2019s VR software scores. Also, the duration of VR session was positively correlated with the total score of VRNQ. Thus, the quality of the VR software as measured by the VRNQ seems to be significantly associated with the duration of the VR session.Overall, in every session, the intensity of VRISE was reported as very mild to absent by the vast majority of the sample. However, comparable to the rest of the VRNQ scores, the VRISE score for the 3rd VR session was significantly higher  than the 2nd and 3rd sessions. Similarly, the VRISE score for the 2nd session\u2019s VR software was substantially higher than the 1st session\u2019s VR software score. Notably, there was not any difference between gamers and non-gamers in the VRNQ scores across the three sessions. Equally, the age and education of participants did not correlate with any of the VRNQ scores or the duration of sessions. Thus, the age, education, and gaming experience of the participants did not affect the responses in the VRNQ. Therefore, the observed differences in the VRISE scores between the VR sessions support that the quality of the VR software as measured by the VRNQ and the level of familiarization of the participants with the VR technology also affect the intensity of VRISE.The findings postulate that the implementation of VR software with a maximum duration between 55 and 70 min is substantially feasible. However, long exposures in VR have been found to increase the probability of experiencing VRISE and the intensity of VRISE . In our The VRISE score substantially correlated with almost every item under the section of user experience and in-game assistance see . HoweverThe items which correlated with the VRISE score were also included in the best models of predicting its value see . ImportaThis study also has some limitations. In this study, construct validity for the VRNQ is provided. However, future work should endeavor to provide convergent validation of the VRNQ with tools that measure VRISE symptomatology  and/or VR software attributes. Moreover, the sample size was relatively small, but it offered an adequate statistical power for the conducted analyses. Also, the VRNQ does not directly quantify linear or angular accelerations, which may induce intense VRISE in a relatively short period of time . HoweverThis study showed that the VRNQ is a valid and reliable tool which assesses the quality of VR software and intensity of VRISE. Our findings support the viability of VR sessions with a duration up to 70 min, when the participants are familiarized with VR tech through an induction session, and the quality of the VR software meets the parsimonious cut-offs of VRNQ. Also, our results offered insights on the software-related predictors of VRISE intensity, such as the level of immersion, the quality of graphics and sound, and the helpfulness of in-game instructions and prompts. Finally, the VRNQ enables researchers to quantitatively assess and report the quality of VR software features and intensity of VRISE, which are vital for the efficacious implementation of immersive VR systems in cognitive neuroscience and neuropsychology. The minimum and parsimonious cut-offs of VRNQ may appraise the suitability of VR software for implementation in research and clinical settings. The VRNQ and the findings of this study contribute to the endeavor of establishing thorough VR research and clinical methods that are crucial to guarantee the viability of implementing immersive VR systems in cognitive neuroscience and neuropsychology.The datasets generated for this study are available on request to the corresponding author.The studies involving human participants were reviewed and approved by Philosophy, Psychology and Language Sciences Research Ethics Committee of the University of Edinburgh. The patients/participants provided their written informed consent to participate in this study.PK had the initial idea and contributed to every aspect of this study. SC, LD, and SM contributed to the methodological aspects and the discussion of the results. The VRNQ may be downloaded from The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest."}
+{"text": "The synaptotagmin (syt)\u00a0proteins have been widely\u00a0studied for their role in regulating fusion of intracellular vesicles with the plasma membrane. Here we report that syt-17, an unusual isoform of unknown function, plays no role in exocytosis, and instead plays multiple roles in intracellular membrane trafficking. Syt-17 is localized to the Golgi complex in hippocampal neurons, where it coordinates import of vesicles from the endoplasmic reticulum to support neurite outgrowth and facilitate axon regrowth after injury. Further, we discovered a second pool of syt-17 on early endosomes in neurites. Loss of syt-17 disrupts endocytic trafficking, resulting in the accumulation of excess postsynaptic AMPA receptors and defective synaptic plasticity. Two distinct pools of syt-17 thus control two crucial, independent membrane trafficking pathways in neurons. Function of syt-17 appears to be one mechanism by which neurons have specialized their secretory and endosomal systems to support the demands of synaptic communication over sprawling neurite arbors. The functional role of synaptotagmin-17 (syt-17) has remained unanswered. In this study, authors demonstrate that syt-17 exists in two distinct pools in hippocampal neurons (Golgi complex and early endosomes), where it served two completely independent functions: controlling neurite outgrowth and synaptic physiology This function, regulated exocytosis of vesicular cargo, appears canonical, as structurally diverse syt isoforms appear to play similar roles. For example, syt-9 regulates FSH release from pituitary gonadotropes2, syt-4 regulates BDNF release in hippocampal neurons3, and syt-10 regulates IGF-1 release in the olfactory bulb4.Synaptotagmins (syt) are generally thought to regulate exocytosis at the plasma membrane. This protein family comprises seventeen isoforms, each possessing two C2 domains separated by a short flexible linker. The best-studied isoform, syt-1, is targeted to synaptic vesicles, where it triggers membrane fusion in response to Ca5, the most recently discovered syt, which possesses 36\u201344% sequence homology to syts 1\u20135. Unlike every other syt, syt-17 lacks an N-terminal transmembrane domain; rather, syt-17 associates with membranes via a string of fatty-acylated cysteine residues near the N-terminus of the protein6.Despite intense interest, only a minority of syt isoforms have been assigned any specific function. A particularly neglected isoform is syt-178 and in cultured hippocampal neurons9. Although syt-17 mRNA is also detectible in kidney , syt-17 protein expression appears restricted to brain6. Similarly, inconsistent data exists regarding the subcellular localization of the protein11. While the function of syt-17 has not been determined, expression of the protein is known to increase following kainite-induced seizures10 or transient ischemia14. Hence, expression of syt-17 is dynamically regulated.Conflicting data exist regarding the distribution of syt-17, although all reports find high levels of expression in hippocampus, particularly in pyramidal cell layersIn the present work, we localized syt-17 in primary hippocampal neurons to two compartments: the Golgi complex in the soma and Rab5-positive early endosomes in neurites. We conducted the first characterization of a newly generated syt-17 KO mouse and found that deletion of this protein results in impaired neurite outgrowth. Further experiments indicated that the outgrowth defect is due to a disruption of the early secretory pathway. Syt-17 interacts with resident Golgi proteins to control import of cargo from the ER. This regulation of neurite outgrowth is bidirectional, as overexpression of syt-17 increases axonal length and accelerates axonal regrowth following injury. Surprisingly, neurons lacking syt-17 show a substantial increase in glutamatergic synaptic transmission, attributable to a pathological accumulation of AMPA-type glutamate receptors on the postsynaptic membrane (apparently the consequence of an observed endocytic defect), and impaired synaptic plasticity. We conclude that syt-17 is a multifunctional regulator of intracellular protein trafficking in excitatory hippocampal neurons, modulating both neural development and synaptic physiology.15 -catalyzed membrane fusion, we functionally compared the canonical isoform, syt-1, with syt-17 . Such spillover may account for some of the previous discrepancies regarding syt-17 localization11. We therefore performed localization experiments in parallel using syt-17 that had been expressed at very low levels (with low-titer lentivirus instead of sparse transfection) and detected with a HaloTag/ligands. The same pattern of localization was observed. In summary, syt-17 localizes to two compartments in hippocampal neurons: the Golgi and early endosomes.To examine the localization of syt-17 in developing hippocampal neurons, we tagged it with superecliptic pHluorin and overexpressed it at 3 days in vitro  channels to an opposing (axon-only) chamber Fig.\u00a0. IsolateFinally, we sought to determine if these effects on neurite outgrowth are specific to axons. We examined the dendritic arbors of mature (14 DIV) neurons, and observed that those of KO neurons were shorter and less complex  of ICA1  of synaptic responses in hippocampal circuitsice Fig.\u00a0, confirmice Fig.\u00a0 without ice Fig.\u00a0, validatice Fig.\u00a0, consistSyt-17 thus plays two distinct roles in neurons. One pool of syt-17 is localized to the Golgi, where it coordinates import of vesicles from the ER to the Golgi, supporting neurite outgrowth. Another pool of syt-17 is targeted to neurites, where it mediates normal endocytic recycling of AMPARs to regulate synaptic strength and plasticity.2+ or anionic phospholipids and are unable to facilitate membrane fusion catalyzed by synaptic SNARES in vitro. We localized syt-17 in hippocampal neurons to the Golgi complex in the soma and to early endosomes in neurites. Loss of syt-17 results in impaired ER-to-Golgi trafficking, accounting for the defects in axonal and dendritic outgrowth we observed in syt-17 KO neurons. Further, a yeast two-hybrid screen revealed that separate domains of syt-17 physically interact with two resident Golgi proteins, each of which is putatively involved in tethering and import of vesicles into the Golgi from the ER27. Interaction with these two proteins is necessary for syt-17 to drive axonal outgrowth. Syt-17 thus appears to be a member of a cargo import complex on the surface of the neuronal Golgi.While a subset of synaptotagmin isoforms have been well-characterized, most have no known function in neurons; syt-17 in particular has received scant attention. In the current study, we found that the C2 domains of syt-17 do not bind Ca34 suggests a diversity of potential routes for secretory trafficking. Neurons contain multiple distinct secretory pathways35, including a molecularly-distinct protein translation/processing machinery that is specialized for local synthesis in dendrites36, and there is evidence for another specialized secretory pathway in axons37. We anecdotally observed that tagged syt-17 was occasionally (<1% of syt-17 puncta) colocalized with remote mannosidase-II puncta at apparent Golgi outposts in neuronal dendrites36, intermingled with more mobile endosomal puncta. Whether syt-17 exerts any similar modulatory effect on the trafficking of locally synthesized protein in neurites, and to what extent different secretory trafficking routes segregate distinct cargoes, are areas ripe for future study.Syt-17 is not ubiquitously expressed, but rather is selectively expressed in specific brain regions, so it is clearly not an essential component of the Golgi complex in most cells. Further, the molecular diversity of golgins in mammalian cells18, potentially resulting in paralysis in the case of spinal cord injury. We found that overexpression of syt-17 facilitated axonal outgrowth beyond that observed in WT neurons, and reasoned that overexpression may allow mature cells to more readily regenerate following injury. Indeed, we observed that neurons overexpressing syt-17 exhibit accelerated axonal regrowth, following axotomy, in vitro. Further, this effect was specific to axons, as overexpression produced no alteration in dendritic structure. These results indicate that upregulation of syt-17 expression may have potential clinical value for spinal regeneration, a topic we will explore in a subsequent work.Mature neurons exhibit limited capacity for axonal growth, and so, when severed, the axons of mature neurons generally fail to regenerate22. This increase was also detectible in hippocampal slices. After ruling out several possible mechanisms, we found that this phenotype has a postsynaptic locus, and is attributable to accumulation of excess AMPA-type glutamate receptors on the dendritic surface. This accumulation appears to alter dendritic spine morphology, resulting in more filopodia and few spines31. However, we cannot formally rule-out the possibility that these changes in spine shape or other synaptic phenotypes are somehow secondary to dysfunction in the secretory pathway. Novel tools to selectively delete proteins from specific intracellular compartments are needed to fully disentangle these two possibilities and confirm that the role of syt-17 in the phenotypes reported here is direct. We further observed that syt-17 KO neurons exhibit a deficiency in endosomal recycling. We reiterate that the pool of syt-17 that is expressed at or near synapses localizes to early endosomes, and endocytosis of surface AMPA-type receptors is mediated by these early endosomes33. We therefore proposed that the accumulation of excess glutamate receptors in the plasma membrane of dendrites in syt-17 KO neurons is due to a deficiency in Rab5-dependent early endosomal trafficking. Further, dysregulation of this process in syt-17 KO animals is associated with a specific deficit in LTD of synaptic responses, potentially providing an explanation for the observed hippocampal-dependent memory deficits in these animals.In addition to facilitating ER-Golgi membrane traffic, we discovered a second function of syt-17: it regulates the strength of glutamatergic neurotransmission. Namely, syt-17 KO neurons exhibited a surprising and marked increase in synaptic transmission\u2014contrary to the reduction in synaptic strength that may be expected from a defect in secretory trafficking2+-independent, functions in intracellular membrane trafficking that have no precedent in this protein family. A relatively small number of synaptotagmin isoforms (chiefly syt-1 and syt-7) have been the focus of intense study, and that body of research has overwhelmingly focused on explicating their role in Ca2+-triggered exocytosis. The present work suggests an untapped diversity of roles for more exotic synaptotagmins in neuronal and synaptic biology.In summary, syt-17 coordinates efficient Golgi import in the early secretory pathway to control neurite outgrowth, and it regulates the trafficking of early endosomes in dendrites to control the surface density of AMPA receptors. Syt-17 appears to be one shared element of neuron-specific adaptations in the secretory and endosomal systems, and dysregulation of either of these processes has profound effects on neuronal development and physiology. Syt-17 is therefore unusual among the syt family of proteins, as it executes two distinct, CaGuide for the Care and Use of Laboratory Animals handbook were conformed to in all cases.All animal experiments were conducted at the University of Wisconsin-Madison, and protocols were reviewed, and received approval, by the university\u2019s Animal Care and Use Committee (assurance # A3368-01). All relevant ethics regulations for animal testing and research were followed, and the guidelines set by the NIH E. coli, purified via glutathione-Sepharose affinity chromatography, and cleaved with thrombin in 100\u2009mM KCl, 25\u2009mM HEPES pH 7.4, 5% glycerol. HaloTag constructs were assembled by overlap extension PCR and subcloned into pTrcHis A vector (ThermoFisher) to yield N-terminal His6-HaloTag-syt constructs. These constructs were expressed in E. coli, purified via nickel-NTA chromatography, and eluted in Hisg-tag elution buffer . Full-length syt-17 was purified by affinity chromatography of E. coli lysates using HaloLink resin (Promega) and eluted by cleavage with TEV protease in 100\u2009mM KCl, 25\u2009mM HEPES pH 7.4, 5% glycerol, 1% Triton X-100 with 2\u2009mM DTT.Constructs encoding syt-1 C2AB (a.a. 96\u2013421) and syt-17 C2AB (a.a. 152\u2013474) were expressed as GST fusion proteins  in sn-glycero-3-phosphoethanolamine [phosphatidylethanolamine (PE)]; 1,2-dioleoyl-sn-glycero-3-phospho-l-serine [phosphatidylserine (PS)]; 1-palmitoyl-2-oleoyl-sn-glycero-3-phosphocholine [phosphatidylcholine (PC)]; 1,2-dipalmitoyl-sn-glycero-3-phospho-ethanolamine-N- (NBD-PE);\u00a0N-(lissamine rhodamine B sulfonyl)-1,2-dipalmitoyl-sn-glycero-3-phosphoethanolamine (rhodamine-PE); 1,2-dioleoyl-sn-glycero-3-phosphoethanolamine-N- (dansyl-PE).\u00a0N,N\u2032-dimethyl-N-(iodoacetyl)-N\u2032-ethylenediamine (IANBD-amide) was purchased from Invitrogen. v-SNAREs were reconstituted into vesicles containing membrane-bound FRET (fluorescence resonance energy transfer) donor-acceptor pairs, and t-SNARES were reconstituted into unlabeled vesicles38.The following lipids were purchased from Avanti Polar Lipids: 1-palmitoyl-2-oleoyl-Lipid compositions for the vesicles used in the in vitro fusion assays: 15% PS, 27% PE, 55% PC, 1.5% NBD-PE, and 1.5% Rhodamine-PE for synaptobrevin 2 (syb2) vesicles; 15% PS, 30% PE, and 55% PC for heterodimer syntaxin1a/SNAP-25B vesicles.39. For the protein titration 0\u201310\u2009\u03bcm of syt-1 C2AB or syt-17 C2AB was used. During each run, 1\u2009mM final free Ca2+ was added at 20\u2009min, and the reaction was monitored for an additional 120\u2009min. Traces were normalized to the first timepoint and the maximum fluorescence signal, determined from the addition of n-dodecyl-\u03b2-d-maltoside, to determine the %Fmax.Fusion between syb2 vesicles and heterodimer vesicles was monitored using a Synergy HT multidetection microplate reader (Bio-Tek)2+ dilutions. Samples were degassed before each experiment. Heat of binding was measured by 20 consecutive injections of Ca2+ into a sample cell containing the protein of interest. Corrections for heat of dilution were done by subtracting the signal of Ca2+ into buffer. Experiments were performed using a MicroCal iTC200 .Syt-1 C2AB and syt-17 C2AB were dialyzed overnight against 50\u2009mM HEPES-NaOH (pH 7.4), 200\u2009mM NaCl, and 10% glycerol; in order to remove divalent cations, the buffer was pre-treated with Chelex-100 resin (Bio-Rad). Filtered dialysis buffer was used to make all protein and Ca2  stored individually as chloroform stocks, except for brain PIP2 (stored in 20:9:1 CHCl3:MeOH:H2O). Liposome compositions for cosedimentations were as follows: PC:PE: 70% PC, 30% PE;\u2009+\u2009PS: 45% PC, 30% PE, 25% PS;\u2009+\u2009PS\u2009+\u2009PIP2: 44% PC, 30% PE, 25% PS, 1% PIP2;\u2009+\u2009cer: 55% PC, 25% PE, 5% PS, 15% ceramide. The lipids were combined, the solvent was evaporated under a stream of nitrogen, and the films were dried under vacuum for at least 2\u2009h. Films were rehydrated in reconstitution buffer  at a final concentration of 10\u2009mM [lipid] and extruded at least 29 times through a single 100-nm polycarbonate filter (Whatman).Liposomes were prepared from POPC, DOPS, POPE, 18:1 ceramide, and brain PIP2 added. The mixture was incubated for 15\u2009min at room temperature with shaking, loaded into a polycarbonate centrifuge tube, and centrifuged at 160,000\u00d7g for 30\u2009min in a TLA-100 rotor (Beckman). An aliquot of the supernatant was combined 1:1 with 2\u00d7 SDS sample buffer and subjected to SDS-PAGE. Gels were stained with Coomassie blue and the bands quantified by densitometry.Liposomes (2\u2009mM lipid), C2AB (4\u2009\u03bc\u039c), and EGTA (0.5\u2009mM) were combined and brought up to 100\u2009\u00b5l in reconstitution buffer with or without 1.5\u2009mM CaClwww.komp.org) by the Wellcome Trust Sanger Institute (WTSI). WTSI and the Children\u2019s Hospital Oakland Research Institute generated the targeting vectors as part of the KO Mouse Project . Animals were group-housed in the Wisconsin Institute for Medical Research vivarium at UW-Madison.The syt-17 KO mouse employed in this study was generated from ES cell clone EPD0659_3_A09, acquired from the KOMP repository (41. Hippocampi (CA subfields) from each pup in a litter were dissected and incubated in 0.25% trypsin-EDTA (Corning), 20\u2009mM D-Glc, and 25\u2009U/ml DNase for 22\u2009min. Tissue was washed twice, mechanically dissociated, and plated on poly-D-lysine (Life Technologies) coated glass coverslips in a solution of Dulbecco\u2019s Modified Eagle Medium (Gibco) with 10% fetal bovine serum. Once cells attached (<1\u2009h), media was changed to a growth media consisting of Neurobasal-A (GIBCO) supplemented with 2% B27 (GIBCO) and 2\u2009mM Glutamax (Invitrogen). Cultures were maintained in a 5% CO2-humidified incubator at 37\u2009\u00b0C; 1/3 of the media volume was replaced every three days, as we have found this feeding scheme optimal for neuronal health. All other reagents were purchased from Sigma except as indicated below.Primary hippocampal neurons (CA subfields) were harvested from newborn (P0) mice of both sexes and cultured2+-phosphate method42 at 3 DIV. For axonal regrowth experiments, postnatal mouse or E18 rat neurons were seeded in microfluidic devices  at a density of 55-65k cells per chamber. For experiments imaging fluorescent proteins in young (2\u20134 DIV) neurons, transfection was performed with a Neon (Invitrogen) electroporation system according to the manufacturer\u2019s instructions. For axon regeneration experiments, cells were transduced at 9 DIV with HaloTag-Syt-17_eGFP lentivirus, or a control lentivirus containing HaloTag-eGFP. For experiments using VSVG-YFP-2xUVR8, transfections were performed using Lipofectamine LTX (ThermoFisher) at 6DIV (24\u201336\u2009h before the experiment) according to the manufacturer\u2019s instructions, as prolonged expression of this probe results in leak to the plasma membrane.Most transfections were performed using the CaSuccessful knockout was verified with RT-PCR from brain lysates of six-week-old animals. Three separate sets of probes against syt-17 were used. 1F: AATCCAGCTGGTACACGGACTCAA, 1R: ACACTGTGAATACTAGGCTGGCGT, 2F: GCCAGTCCAGTGAAGATGAA, 2R: GATTGGAGTCGAGGGAGTAAAG, 3F: GAACGAGGGCTTGCTTTCTA, 3R: GCCAGCACTTGGGAGATAAT. Probes directed against \u03b2-actin were used as controls, and values were converted to a ratio of KO expression as a percentage of WT.Six-to-eight-week-old male and female mice were used for behavioral characterization. Tests were conducted in the Waisman Rodent Behavior core or the Wisconsin Institute for Medical Research vivarium at the University of Wisconsin-Madison. The experimenter was blind to genotype during testing and all photographic/video analysis. Animals were given a minimum of 24\u2009h between tests, and were moved to the testing rooms at least 30\u2009min prior to the assay for acclimation. First, each mouse received a single 30\u2009min open field exploration session. Each mouse was removed from its home cage and placed in the center of the arena, where the Omnitech Fusion system used photobeams to continuously monitor and record the animal\u2019s placement during the assay. Data was recorded using the Fusion system with a center ratio zone map.For the marble burying test, each mouse was tested in a clean home cage that had been filled to a depth of 4\u2009cm of fresh bedding. Twenty marbles were placed on top of the bedding in a grid arrangement (see below). Mice were placed into the test cages and allowed to explore for 30\u2009min. Following the completion of the test, mice were returned to their home cages. The number of marbles that were at least 50% buried was recorded. Photographs were taken, from a vantage point directly above each cage, to show position and arrangement of the marbles.43 was computed.For the novel object recognition task, animals were placed in a chamber with bedding, containing two identical unfamiliar objects spaced approximately six inches apart, and were permitted to explore for 10\u2009min. Following a twenty-four-hour interval, animals were returned to the same chamber, but one of the familiar objects had been replaced with a novel object. Animals were again permitted to explore the chamber and objects and ten minutes. Behavior during familiarization and testing phases were videotaped for offline analysis. The objects were Fisher-Price Little People Batman and Superman figures, or wooden toy police cars . The chamber and object were thoroughly cleaned between animals/trials to remove olfactory cues. Behavior during familiarization and testing phases were videotaped for offline analysis, and a Discrimination IndexAll mice were tested in the social interaction paradigm, a 3-trial assay with each trial lasting 10\u2009min. During the initial acclimation trial, the mouse was placed inside of the three-chambered box and allowed to explore freely with no objects presented. The mouse was removed, the arena was cleaned and prepared, and the mouse was returned to the arena for the sociability test. During the sociability test, a male juvenile mouse was placed in a mesh cup in one chamber of the box and an identical empty mesh cup was placed in the opposite chamber of the box to provide a neutral object control. The cups were weighted to prevent mice from moving them inside the arena. At the conclusion of the sociability test, the mouse was removed, the arena cleaned and prepared, and the mouse returned to the arena for the social recognition test. During the recognition trial, the juvenile stimulus mouse from the sociability test was kept in the test arena, and a novel male juvenile mouse was placed in a cup in the opposite chamber. The sociability and recognition trials were videotaped for subsequent analysis. Locations of the stimuli mice were counterbalanced. Videotapes were analyzed for interaction behavior. Interaction behavior included sniffing, biting at the cup, pawing, or other object-directed behavior. Climbing on the cup that did not involve sniffing the stimulus mouse inside the cup was not considered interaction behavior. Time spent engaged in investigative behavior for each cup was measured (in seconds), total investigative time calculated, and percent preference scores obtained.Finally, animals were subject to tone/shock fear conditioning. On day 1, animals were subject to a six-minute training phase, which consisted of 2 pairings of 30\u2009s of 87\u2009dB white noise and a 1.5-s 0.7\u2009mA shock, with an intertrial interval of 2\u2009min. Twenty-four hours later, mice were tested for conditioning to the tone in a novel chamber, by altering the chamber with plexiglass inserts and vanilla extract. These changes provide a novel environment so that response to the cue was minimally affected by any conditioning to context. Mice were placed back in the chambers for a 6\u2009min test and the noise was played for the final 3\u2009min of the test. Percent freezing during each portion of the assay was calculated by the FreezeFrame 3 software using video feed and a motion index.2 at 37\u2009\u00b0C; typical imaging duration was 8\u201312\u2009h . Outgrowth rate, growth cone area, and spontaneous growth cone collapse were measured offline in MetaMorph software (Molecular Devices). Live-cell imaging of overexpressed fusion proteins was conducted similarly, at ages indicated in the text. Localization of pHluorin-tagged syt-17 was performed, in parallel, with constructs tagged at both the N-termini and C-termini, to increase confidence that the protein was not mis-sorted and that both ends of the protein are located in the cytosol.Measurements of axonal outgrowth were performed at 2\u20134 DIV on an Olympus CellTIRF with DIC optics using a \u00d760 Apo N objective and Hamamatsu Orca-FLASH 4.0 camera. Only cells that were identifiably stage 3 (extending an axon at least 2\u20133\u00d7 longer than other neurites), with visible growth cones, whose axons were not growing along processes of other cells, were selected for imaging. Neurons were maintained in their native growth media in an environmentally controlled chamber with 5% CO44 kindly gifted by Gerard Marriott , which at low concentrations selectively labels the barbed ends of actin filaments. Retrograde flow rates were quantified by computing a kymograph in ImageJ from 2\u20133 filopodia per growth cone, fitting three lines per kymograph, and averaging the resultant values within a growth cone45.To measure retrograde actin flow, we incubated stage 3 cultured hippocampal neurons prior to imaging for 3\u2009min in 100 pM of SiTMR-KabC, a fluorescently labeled kabiramideFor measurements of axonal regeneration, axotomy was performed at DIV 14\u201315 by rapid aspiration and reperfusion of media from the axon channel. Conditioned media was removed from the axon side of the microfluidic prior to axotomy and replaced post-axotomy. Axons were labeled with Vybrant DiI Cell-Labeling solution (5\u2009nM) on the axon side for two hours and rinsed with media prior to imaging. Images were taken prior to axotomy and immediately after to establish a baseline, and again both 24 and 48\u2009h after axotomy to measure regrowth.Internalization of fluorescently labeled transferrin-546  was monitored on an upright Olympus FV1000 confocal laser-scanning confocal microscope with a \u00d760 LUMFL water immersion objective in an environmentally-controlled chamber.Measurements of ER-to-Golgi trafficking using VSVG-YFP-2xUVR8 were performed on an Olympus IX81 inverted microscope with a Lambda DG-4 light source, Olympus \u00d760 Plan Apo N objective, and Hamamatsu Orca-FLASH 4.0 camera. Z-series were collected every 30\u2009s for 40\u2009min at 7\u20138 DIV . For uncaging, a 300\u2009nm fiber-coupled LED (ThorLabs M300F2) was positioned ~0.5\u2009cm above the cell media, and the sample was illuminated for 10\u2009s. Offline, a small ROI was drawn in the Golgi and the timecourse of cargo accumulation was quantified for each cell.2+ imaging, 13\u201315 DIV neurons were depolarized with 40\u2009mM KCl and loaded with 14.8\u2009\u00b5M FM-464 (Thermo Scientific) for 10\u2009min to label synaptic boutons. Cells were washed with artificial cerebrospinal fluid (ACSF) containing 128\u2009mM NaCl, 5\u2009mM KCl, 2\u2009mM CaCl2, 1\u2009mM MgCl2, 30\u2009mM Glc, and 25\u2009mM HEPES . For this wash step, ACSF was supplemented with 1\u2009mM ADVASEP-7 (Sigma). Cells were then loaded with 13.6\u2009\u00b5M Fluo-5F AM  for a further 10\u2009min, washed, and transferred to a field stimulation chamber. Imaging was performed on an Olympus CellTIRF with a \u00d760 Apo N objective. Imaging fields of view were selected to maximize the number of boutons  on isolated processes, taking care to avoid glia . Images were acquired 100\u2009Hz with 2\u2009\u00d7\u20092 pixel binning (482\u2009nm excitation). During imaging, 50\u2009\u00b5M D-APV (Abcam), 100\u2009\u00b5m picrotoxin (Tocris), and 10\u2009\u00b5m CNQX were included in the ACSF. Atypically-large FM-464 puncta (likely representing either endosomes or closely adjacent boutons) were excluded from analysis. Ca2+ responses were quantified from individual boutons following a single action potential, converted to \u0394F/F0 (change in fluorescence divided by baseline fluorescence), and the peak of each response was extracted. For every imaging field of view, the baseline fluorescence of our synaptic ROIs was significantly greater than background  fluorescence, and this baseline fluorescence did not differ between genotypes (p\u2009=\u20090.9), justifying the \u0394F/F0 normalization.For Ca4Cl and 38\u2009mM NaCl). ROIs were selected on dendrites and spines (visible as puncta in during NH4Cl perfusion), and surface expression was calculated as ((pH 7.4 fluorescence\u2013pH 5.5 fluorescence)/(NH4Cl fluorescence\u2013pH 5.5 fluorescence))\u2009\u00d7\u200910046. Greater\u2009>\u200910 synapses across multiple dendrites were measured for each cell.Imaging of GluR2-pHluorin (Addgene plasmid #24001) was performed on the same CellTIRF setup as described above, substituting 0.5\u2009\u03bcM tetrodotoxin  for APV/CNQX/picrotoxin in the ACSF. Soluble mRuby2 was cotransfected with the pHluorin constructs to visualize dendritic morphology. To determine the surface expression level, cells were alternatively perfused with acidic ACSF  or ACSF with ammonium chloride , and immunostaining for the GFP (Abcam). This allowed full reconstruction of transfected cells. For most measurements, immunostaining against MAP2 was also performed to ensure accurate identification of axons and dendrites. Coverslips were imaged on an Olympus FV1000 confocal microscope with a \u00d720 XLUMPlanFL N, \u00d760 PlanApo N, or \u00d7100 UApo N objective. Resultant neurite arbors were reconstructed in ImageJ and Sholl analysis2. Neurons at 3 and 15 DIV were rapidly frozen under high pressure in a Wohlwend Compact 02 High-Pressure Freezer  and freeze substituted into acetone containing 2% osmium tetraoxide and 0.1% uranyl acetate at \u221280\u2009\u00b0C, then slowly warmed to room temperature and embedded in EPON-Araldite. Three hundred nm thick sections of embedded neurons were cut and stained using 2% uranyl acetate and lead citrate. Additional details on sample preparation have been described elsewhere48. Imaging was performed using a Tecnai F30  operated at 300\u2009kV and nominal magnification of \u00d720,000, and samples were tilted from 60\u00b0 to \u221260\u00b0 at 1.5\u00b0 increments along a dual axis. A total of 80 images with a pixel size of 1.0194\u2009nm were collected with CCD camera . Images were processed using 3dmod, version 4.9.0 software package50.Sapphire discs (3\u2009mm) were washed in acetone and subsequently in 95% ethanol. Discs were coated first with carbon followed by gold and baked overnight at 160\u2009\u00b0C. Discs were then plasma glow discharged, poly-L-lysine coated overnight at 37\u2009\u00b0C, and then coated with laminin for 2\u20133\u2009h. Discs were UV sterilized, and hippocampal neurons were plated at a density of 50\u2013100,000\u2009cells/cm53, was conducted. An initial screen of syt-17 mutants found that a construct lacking the C2A domain expressed at high levels, and was therefore used for initial testing. Briefly, syt-17 \u0394C2A was cloned in frame to the Gal4-DNA-binding domain housed in the TRP1-containing plasmid pGBKT7, which was subsequently transformed into PJ69-4A MATA cells54 and mated with PLY5725 MATalpha cells carrying a library of fragments derived from the human ORFeome55 housed in the LEU2-containing plasmid pGAL4-AD. Two additional library containing populations were made using empty pGBKT7. Yeast populations were divided and grown in the presence and absence of histidine to produce subpopulations that had not or had been selected based on their ability to produce a positive yeast two-hybrid interaction, respectively. After growth, library fragments were amplified by PCR and 1\u20132\u2009\u00d7\u2009107, 2\u2009\u00d7\u2009150 PE reads were obtained per sample on an Illumina HiSeq 4000. Reads were mapped to the hg38 genome using HiSTAT2 with the Mapster interface, and further analyzed using the DEEPN and statistics software53.DEEPN , a method for performing comparative Yeast two-hybrid assays in batchFor binary two-hybrid assays, yeast lysates from cells transformed with pGal4-AD plasmids containing GOLGA6A and ICA1 fragments corresponding to the regions delineated from DEEPN sequence data, were immunoblotted (anti-HA) for expression of the HA-tagged AD-fusion proteins. The pGal4-AD plasmids containing GOLGA6A or ICA1 were transformed into PLY5725, mated to PJ69-4A cells carrying the pGBKT7 vector alone or syt-17 plasmids, and plated onto minimal media with and without Histidine to measure binary interactions.\u00a0In certain incubations (indicated in figure legends), 1 mM or 10 mM of\u00a03-aminitriazole was included to increase the stringency of selection.Purified Halo-tagged constructs (100\u2009\u00b5g) were combined with HaloLink resin (100\u2009\u00b5l bed volume), and the mixture was brought up to 500\u2009\u00b5l with binding buffer  and incubated 30\u2009min at room temperature with rotation. Complete depletion of Halo-C2AB from the supernatant under these conditions was verified by SDS-PAGE. Beads were washed 3\u00d7 in binding buffer and stored for no longer than 4 days at 4\u2009\u00b0C.g, 10\u2009min). A 50% slurry of protein-bound HaloLink resin  was added to 6\u2009ml of clarified lysate, and the mixture incubated for 3\u2009h at 4\u2009\u00b0C with rotation. The beads were then collected, washed 3\u00d7 with 1\u2009ml lysis buffer containing 1% Triton X-100, and eluted in 60\u2009\u00b5l 4\u00d7 SDS sample buffer containing 1% Triton X-100. The input lysate and eluates were assayed by Western blot using primary antibodies to syntaxin-5 or syntaxin-13 (both from Synaptic Systems) with incubation overnight at 4\u2009\u00b0C followed by detection with goat anti-rabbit IgG-HRP secondary antibody (Abcam).For pulldowns from brain lysates, a single 3\u20134 week old C57/BL6 mouse was euthanized with CO2, decapitated, and its whole brain removed. The brain was transferred into 5\u2009ml ice-cold lysis buffer  with protease inhibitors added  and subjected to 12 strokes in a Teflon-glass Dounce homogenizer rotating at 900 RPM. The crude homogenate was assayed for protein content, diluted to 1\u2009mg/ml protein, and combined with Triton X-100 . This mixture was incubated for 30\u2009min with rotation at 4\u2009\u00b0C and clarified by centrifugation  and KO  from separate breeding pairs were harvested and homogenized in 6\u2009M Guanidine, 50\u2009mM HEPES (pH 8.5) in Precellys 24 (Program #2). Cysteines were alkylated with iodoacetamide  and incubated 20\u2009min at room temperature in the dark. Excess IAA was quenched with Dithiothreitol (DTT) for 15\u2009min. Samples were diluted with 200\u2009mM HEPES pH 8.5 to 1.5\u2009M Guanidine, followed by digestion at room temperature for 3\u2009h with LysC protease at a 1:100 protease-to-protein ratio. Following LysC digestion, trypsin was added at a 1:100 protease-to-protein ratio followed by overnight incubation at 37\u2009\u00b0C with shaking. The reaction was quenched with 2% formic acid, desalted using C18 solid-phase extraction , and vacuum centrifuged to dry. For TMT labeling, desalted peptides were dissolved in Triethylamonium bicarbonate (TAEB) solution. Peptide concentration was measured by \u03bcBCA (Pierce), and 100\u2009\u03bcg of peptide per sample were labeled with TMT reagents ). Samples were labeled as follows: WT_1 (TMT 127\u2009N); WT_2 (TMT 127\u2009C); WT_3 (TMT 128\u2009N); WT_4 (TMT 128\u2009C); KO_1 (TMT 129\u2009N); KO_2 (TMT 129\u2009C); KO_3 (TMT 130\u2009N); KO_4 (TMT 130\u2009C). Following incubation at room temperature for 75\u2009min, the reaction was quenched with hydroxylamine to a final concentration of 0.5% (v/v). TMT-labeled samples were combined at a 1:1:1:1:1:1:1:1 ratio, vacuum-centrifuged to near dryness, subjected to High pH Reversed-Phase Peptide Fractionation (Pierce), followed by C18 extraction (Pierce), and vacuum centrifugation to dryness.2O with 5% acetonitrile and 0.125% formic acid, and buffer B contained 99.875% acetonitrile with 0.125% formic acid. MultiNotchMS3-based TMT method was used for TMT samples1\u20133. The scan sequence began with an MS1 spectrum . MS2 analysis, \u2018Top speed\u2019 (2\u2009s), Collision-induced dissociation . MS3 analysis, top ten precursors, fragmented by HCD prior to Orbitrap analysis .Three micrograms of each sample was auto-sampler loaded with a Thermo RSLC UPLC pump onto a vented Acclaim Pepmap 100, 75\u2009\u00b5m\u2009\u00d7\u20092\u2009cm, nanoViper trap column coupled to a nanoViper analytical column  with stainless steel emitter tip assembled on the Nanospray Flex Ion Source with a spray voltage of 2000\u2009V. A coupled Orbitrap Fusion (Thermo Fisher Scientific) was used to generate MS data. Buffer A contained 94.785% Hhttp://fields.scripps.edu/downloads.php) and were searched against UniProt mouse protein database (released on 03-25-2014), matched to sequences using the ProLuCID/SEQUEST algorithm, and filtered with DTASelect2. Searches were performed using a 50 ppm precursor ion tolerance, 600 ppm fragment ions, and included all fully-tryptic and half-tryptic peptide candidates with no missed cleavages restriction. Protein false-discovery rate (FDR) was set to 0.01. Carbamidomethylation (+57.02146) of cysteine and N-termini lysine (+229.1629) were considered as static modifications. Resulting data was quantitated using software Census with batch-specific correction factors (TMT 10-plex lot no. RC231246), with intensity threshold set to 10,000. Statistical overrepresentation tests of gene ontology (GO) terms were performed with PANTHER gene analysis tools56 using UniProt accession numbers of canonical isoforms as inputs and Bonferroni correction for multiple testing.Protein identification and quantification analysis were done with Integrated Proteomics Pipeline  using ProLuCID, DTASelect2 and Census. Tandem mass spectra were extracted into ms1, ms2 files, and ms3 from raw files using RawConverter . Postsynaptic  neurons were clamped at \u221270\u2009mV. Measurements were aborted if a series resistance >15\u2009M\u03a9 was observed, or if the series resistance changed >10% during recording.Whole-cell patch-clamp recordings were acquired from 13\u201316 DIV neurons using a MultiClamp 700b amplifier and pClamp software (Molecular Devices). Patch pipettes (3\u20135\u2009M\u03a9 resistance) were filled with an intracellular solution containing 135\u2009mM cesium-methylsulfate, 5\u2009mM KCl, 2\u2009mM NaCl, 0.2\u2009mM EGTA, 10\u2009mM HEPES, 10\u2009mM NaFor evoked EPSC recordings, a bipolar electrode in theta glass was positioned at the soma of a neuron adjacent to the patched cell and a single biphasic pulse was applied. The stimulation voltage (using a Warner A350 stimulus isolator) was set at 5\u2009V and gradually increased/decreased to ensure the resulting response was unitary. EPSCs that lacked a smooth rising phase  were excluded from analysis. For measurement of mEPSCs, 0.5\u2009\u00b5m tetrodotoxin was added to the bath and spontaneous quantal currents were recorded for >3\u2009min. Miniature events were identified using a template-matching algorithm in Clampfit.For glutamate puffing experiments, neurons were first filled with 0.2% of Alexa 488 Biocytin (ThermoFisher) in intracellular solution through the patch pipette to visualize morphology. Only neurons with an obvious pyramidal-like morphology  were stimulated. Subsequently, a second patch pipette containing ACSF with 200\u2009\u00b5m L-glutamate and 200\u2009\u00b5m Alexa 488 Hydrazide (ThermoFisher) was positioned along the main  dendrite ~60\u2009\u00b5m away from the soma. Fluorescence from the stimulation pipette and membrane current in patch cell were monitored during approach to ensure minimal leak. Pulses of glutamate were then applied for 5\u2009ms with a Picospritzer III (Parker) as the cell holding voltage was varied from \u221270 to +40\u2009mV in 22\u2009mV increments. The ejection of the glutamate/dye was visually monitored during the experiment. The stimulation pipette was moved closer to the dendrite each trial. When the pipette was moved close enough to rupture the cell (and the patch was lost), the previous trial was selected for analysis. The peak current amplitude was quantified for analysis. Note that in this experimental configuration, the decay from peak of a given response can be affected by the vagaries of dendritic geometry and ACSF flow; as such, decay kinetics of these responses are not interpretable, and were not analyzed. Measurements for all experiments were made from \u22653 independent preparations.2PO4, 60\u2009mM NaCl, 28\u2009mM NaHCO3, 7\u2009mM MgCl2, 0.5\u2009mM CaCl2, 5\u2009mM D-glucose, and 110\u2009mM sucrose). Horizontal sections of the hippocampus (400\u2009\u00b5m) were isolated using a Vibratome while submerged in the CS slurry. After sectioning, slices recovered at room temperature for 45\u2009min in a solution containing 50% CS and 50% artificial cerebrospinal fluid . Hippocampal slices were equilibrated on the recording rigs for 2\u2009h while being perfused with ACSF warmed to 32\u2009\u00b0C  at a rate of 1.5\u2009ml/min using a peristaltic pump. All solutions used in the presence of live tissue were constantly carb-oxygenated (95% O2/5% CO2).Measurements of long-term depression (LTD) were performed on acute hippocampal slices prepared from adult littermate male mice . Hippocampal extractions were performed at the same time of day for every experiment. After decapitation, the brain was rapidly extracted and placed in a frozen slurry of cutting solution . Subsequent stimulations for the slice were set at 50% the maximum field excitatory post synaptic potential (fEPSP) slope elicited from the input:output paradigm.Bipolar stimulating electrodes were made using isonel enameled platinum-tungsten wire  and placed on the Schaeffer collateral axon bundles extending from the CA3 to CA1. Recording electrodes were made from single barrel borosilicate capillary glass pipettes with microfilaments (A-M Systems). The electrodes were filled with ACSF (4\u20135\u2009M\u03a9) and placed on the CA1 13. Following bath application of NMDA, slices were bathed in ACSF. Time 0 for LTD was deemed at the point when the evoked fEPSP responses fell below the average baseline response by greater than 10%. NMDAR-LTD was recorded for 90\u2009min following the initial depression of evoked fEPSP responses.Slices were stimulated every 20\u2009s, and the average of 2\u2009min sweeps were used to generate a single data point. The fEPSPs were amplified (A-M systems model 1800) and digitized  prior to being analyzed . Graphical representations of the data were generated by measuring post induction fEPSP slopes and normalizing them to the average fEPSP slope at baseline (60\u2009min prior to LTP or LTD induction). Slices with unstable baselines (>10% deviation from across the baseline) were not used in final data analysis. NMDAR-LTD was induced by perfusing 20\u2009\u00b5M NMDA (Tocris) over hippocampal slices for 3\u2009min2PO4, 3\u2009mM KCl, 25\u2009mM NaHCO3, 10\u2009mM glucose, 1\u2009mM sodium ascorbate, 3\u2009mM kynurenic acid, 3.6\u2009mM MgSO4, and 0.8\u2009mM CaCl2, bubbled with a carbogen mixture of 95% O2/5% CO2). Coronal hippocampal slices (400\u2009\u03bcm) were cut using a Vibratome (Campden Instruments model 7000smz2) and allowed to recover in artificial cerebral spinal fluid  at an elevated temperature (37\u2009\u00b0C). After 30\u2009min, slices were recovered in aCSF at room temperature for an additional 60\u2009min. Individual slices were placed in submerged recording chambers and perfused with aCSF using a peristaltic pump (Gilson model MINIPULS3) at a rate of 3\u2009mL/min. All recordings were taken at 30\u2009\u00b0C. A concentric bipolar stimulating electrode (World Precision Instruments) driven by a stimulus isolator (Multi Channel Systems model STG4004) was used to stimulate the Schaffer collateral pathway every 20\u2009s. Field excitatory post-synaptic potentials (fEPSPs) were recorded from the stratum radiatum of the CA1 hippocampal region using tungsten microelectrodes . The stimulation intensity was set below the population spike threshold for each slice, at 50% of the maximum fEPSP slope as determined by a input:output curve performed at the beginning of each experiment. fEPSP slopes were visualized and analyzed using WinLTP synaptic electrophysiology software .Long term potentiation (LTP) was measured in vitro from hippocampal slices of Syt-17 KO and WT mice. Adult littermate male mice  were anesthetized with isoflurane and decapitated. The brain was rapidly removed and placed in a frozen slurry of cutting solution  using theta-burst stimuli (TBS). In one set of experiments, the TBS paradigm consisted of one train of 10 bursts, with each burst consisting of 4 pulses at 100\u2009Hz, delivered every 200\u2009ms (TBSx1). In the second set of experiments, the paradigm consisted of three trains of 10 bursts, with trains delivered every 20\u2009s (TBSx3). LTP was recorded for 60\u2009min following TBS. For each slice, potentiation was defined as the average fEPSP slope during the last 10\u2009min divided by the baseline fEPSP slope (average of the 10\u2009min immediately preceding TBS).57 and MATLAB (Mathworks), and electrophysiology data were analyzed with Clampfit 10.2 (Molecular Devices) except where otherwise noted. The FIJI toolboxes MosiacJ58 and Simple Neurite Tracer59 were used for morphological reconstructions. Statistical analysis was performed in Prism software (GraphPad). Statistical significance was assessed with two-tailed t-tests, ANOVAs with post-hoc t-tests, or Mann-Whitney tests as indicated in the text or legends. Specific values tdf, Fdf, p, and r2 values are reported in the figure legends with r2 calculated as t2/(t2\u2009+\u2009df). In all figures, error bars indicate S.E.M.s, and statistical significance  is denoted with a black line and star above the bar graph.Image analysis was performed in ImageJ/FIJIFurther information on research design is available in the\u00a0Supplementary InformationPeer ReviewReporting SummaryDescription of Additional Supplementary FilesSupplementary Data 1Supplementary Data 2"}
+{"text": "The effect of thermal treatment of glass fibers (GF) on the mechanical and thermo-mechanical properties of polysulfone (PSU) based composites reinforced with GF was investigated. Flexural and shear tests were used to study the composites\u2019 mechanical properties. A dynamic mechanical analysis (DMA) and a heat deflection temperature (HDT) test were used to study the thermo-mechanical properties of composites. The chemical structure of the composites was studied using IR-spectroscopy, and scanning electron microscopy (SEM) was used to illustrate the microstructure of the fracture surface. Three fiber to polymer ratios of initial and preheated GF composites ) were studied. The results showed that the mechanical and thermo-mechanical properties improved with an increase in the fiber to polymer ratio. The interfacial adhesion in the preheated composites enhanced as a result of removing the sizing coating during the thermal treatment of GF, which improved the properties of the preheated composites compared with the composites reinforced with initial untreated fibers. The SEM images showed a good distribution of the polymer on the GF surface in the preheated GF composites. Tg) 185 \u00b0C, flexibility, and excellent thermal stability. These superior properties make PSU the most appropriate choice for wide applications such as medicine, food, processing equipment, and relatively high-temperature components [Polysulfone (PSU) is a high-performance amorphous thermoplastic with excellent mechanical properties, high service temperature due to its high glass transition temperature , which is widely and successfully used to study the dynamic mechanical response of composites. The data used as a function of temperature, time, frequency, and stress can also be an indicator of the interface, morphology, and presence of an internal defect in the composite structure. It is an excellent technique to study the effect of temperature on the mechanical properties of composite materials. Since polymeric composites in many applications exposed to different types of dynamic stressing during service, studying the viscoelastic behavior of these materials have become critical ,26,27. TRecently , we inve2) and PSU Ultrason S2010  powder were used as raw materials. A polysulfone solution was obtained by dissolving the PSU powder in N-methyl-2-pyrrolidone . Bulk composite samples were formed in accordance with the method described in [Woven glass fabrics   was used to study the chemical structures of the samples. The microstructure, fracture, interfacial bonding, and fiber pulling out were studied using a scanning electron microscope (VEGA 3 TESCAN)  in backscattered electron image mode. Before the SEM examination, the samples were coated with a thin layer (10\u201315 nm) of carbon in a sputter coater.An FTIR spectrometer Nicolet 380   provided with 1 and 20 kN sensors and a MultiXtens contact strain measurement system. Conforming with ISO 14125:1998 standards, the samples for the flexural tests were prepared in a dimension of 110 mm \u00d7 10 mm \u00d7 2 mm and 80 mm span. For shear tests (according to ASTM D 3846), 110 mm \u00d7 10 mm \u00d7 4 mm samples were used with a gauge length of 80 mm. According to this method, the shear strength was measured by applying a compressive load to a notched specimen of uniform width. The specimen was loaded edgewise in a supporting jig of the same description in ASTM D 695 for testing thin specimens. A failure of the specimen occurred in shear between two centrally located notches machined halfway through its thickness and spaced a fixed distance apart on opposing faces. The distance between the notches was 6.5\u20138 mm. The test speeds were 10 and 1.3 mm/min for the flexural and shear tests, respectively. At least five samples were examined at room temperature in each condition.A DMA Q800  dynamic mechanical analyzer was used to study the dynamic mechanical properties. The specimens sized 2 mm \u00d7 2 mm \u00d7 45 mm were used for the DMA tests. The measurements were realized using a double cantilever clamp at a frequency of 1 Hz and a deformation of 0.1%, in a temperature range from 30 to 220 \u00b0C; the heating rate was of 2 \u00b0C/min. The HDT tests were carried out using an Instron CEAST 6910 HDT/Vicat tester. The samples sized 80 mm \u00d7 10 mm \u00d7 4 mm were used in the HDT test at a load of 1.8 MPa and a span length of 64 mm (ISO 75). The deflection in the HDT test was set up to 1 mm as a maximum deflection. The DMA and HDT were performed for both PSU composites reinforced with initial and preheated GF. In each condition, three fiber to polymer weight ratios ) were used.\u22121. The peaks at 2800 and 3000 cm\u22121 related to symmetric and asymmetric bands of CH3 and CH2. The C\u2013C in-ring bands were revealed by 1401, 1501, and 1586 cm\u22121 peaks. The stretching vibration of the asymmetric O=S=O band occurred at 1292 and 1325 cm\u22121, while the peak at 1232 cm\u22121 referred to the stretching vibration of the C\u2013O band. The stretching of the symmetric O=S=O bands appeared at 1140 and 1168 cm\u22121, and the aryl group was indicated by 1019 cm\u22121 peak [m\u22121 peak ,40.\u22121 reduced because of the removal of GF sizing [Few differences could be distinguished in the spectral attribution of PSU composites. In the spectra of the composites, the C=O band appeared clearly due to the presence of some residual solvent . The ampF sizing . Based oThe flexural and shear tests were implemented to study the mechanical properties of the composites. The comparison of flexural strength and Young\u2019s modulus values for the initial GF reinforced composites are shown in The sizing coating prevents good adhesion between the fiber and the polymer, which mainly affects the composite\u2019s strength. A thermal treatment was carried out to remove the sizing coating of the fiber to enhance the interface bonding between the polymer and the fibers ,41. FiguShear strength, which is affected mainly by the interface bonding, is illustrated in Tg, while it started to fall around the Tg, which is the region of the transformation from glassy to rubbery state. It can be noted that the storage modulus increased with an increase in the GF content as a result of an increase in the stiffness and the thermo-resistance of the composites with increases in the GF ratio. The results recorded that the storage modulus of 22 GPa was found for the 70/30 composites, while the storage modulus values for the 50/50 and 60/40 composites were 15.5 and 20.5 GPa, respectively. It is considered that the thermo-mechanical characteristic of the composite was improved with increasing the GF/PSU ratio due to the enhancement of thermal stability of the composite as a result of an increase of the composite\u2019s stiffness and the interfacial interaction, which increased the thermodynamic compatibility between GF and the polymer [ polymer ,25. The effect of using the preheated GF on the storage modulus of the composites is investigated in Tg, which differentiates between the glassy and rubbery region of the thermo-mechanical behavior of the composite. Tan \u03b4 of a different initial GF to polymer ratio is shown in Tg increased from 163 \u00b0C for the 50/50 composites to 180 and 192 \u00b0C for the 60/40 and 70/30 composites, respectively, due to an increase of thermal stability of the composites. The reduction behavior of tan \u03b4 was due to a decrease of the molecular chain\u2019s mobility as a result of increasing the fiber/polymer interface bonding [Tg of the composites. The results showed an increase from 170 \u00b0C for the 50/50 composites to 187 and 198 \u00b0C for the 60/40 and 70/30 composites, respectively.Another way to evaluate thermal stability of the composites\u2019 mechanical properties is tangent delta (tan \u03b4) measurement. Tan \u03b4 refers to the ratio between loss and storage modulus, and the peak on the Tan \u03b4 curve refers to the Tg of the polymer matrix and drastically increased above the Tg. The HDT for the initial GF reinforced composites enhanced from 168 \u00b0C for the 50/50 composites to 197 and 209 \u00b0C for the 60/40 and 70/30 composites, respectively. It can be proposed that the HDT increases as a result of stiffness and thermal stability enhancement with increasing the GF/PSU ratio [Tg, whereas above the Tg the deflection increased rapidly. The same behavior was observed in the case of the preheated GF composites, as seen in The HDT tests for the initial and preheated GF reinforced composites were carried out to study the deformation behavior of the composites at the evaluated temperature. The maximum deflection was set to be 1 mm. The HDT results of the initial GF reinforced composites, shown in SU ratio . The valTg, tan \u03b4, and HDT for the initial and preheated GF composites are given in The values of the Tg values obtained from the DMA test and HDT obtained from the HDT test were increased in the preheated reinforced GF composites compared with those in the initial GF reinforced composites. The fiber to polymer ratio of 70/30 recorded the best properties for the initial and preheated GF reinforced composites. The 70/30 initial GF composites recorded 460 MPa, 26 GPa, and 22 GPa for flexural strength, Young\u2019s modulus, and storage modulus, respectively. Due to the improvement of the interfacial adhesion, these magnitudes were increased in the case of the 70/30 preheated GF composites to record 550 MPa, 30 GPa, and 26 GPa for flexural strength, Young\u2019s modulus, and storage modulus, respectively. FTIR of the PSU composites showed the main peaks of PSU and GF for the initial and preheated composites. Additionally, the FTIR spectra showed that the sizing coating was removed by heating the GF. It revealed that some of the solvent was not disposed of during the drying process. The SEM images showed a good distribution of the polymer on the GF surface, which improved with using the preheated GF that led to an increase in the interface bonding between the polymer and GF. Mechanical and thermo-mechanical properties of the PSU composites reinforced with initial and preheated GF for a different fiber to polymer weight ratio were studied. The flexural test showed that the composite stiffness and Young\u2019s modulus enhanced with increasing the fiber ratio in the initial GF reinforced composites. A remarkable improvement was achieved by using a preheated GF to reinforce PSU. Additionally, shear strength increased in the cases of using a preheated GF. The storage modulus, tangent delta, and"}
+{"text": "IntroductionThe interplay of vitamin D and glucose metabolism is an area of ongoing research. The need for vitamin D supplementation trials in individuals with prediabetes and hypovitaminosis D has been stressed by earlier research studies. The objective of this study was to assess the effect of vitamin D3 supplementation on oral glucose insulin sensitivity (OGIS) index in patients with prediabetes and hypovitaminosis D.Methods\u00a0We enrolled 120 individuals with prediabetes (ADA definition) and hypovitaminosis D (vitamin D < 30 ng/mL) and randomized them into the vitamin D supplementation  group and the placebo group. Primary outcome measure  and secondary outcome measures  were analyzed for change with the 12 weeks of intervention.Results\u00a02; p = 0.011) increased significantly on per-protocol analysis in the vitamin D group. There was no significant change observed in vitamin D levels and OGIS index in the placebo group. Between-group comparison showed a rise in OGIS index (15.3 \u00b1 47.1 mL/min/m2) in the vitamin D group and decrease in OGIS index (-10.4 \u00b1 44.7 mL/min/m2) in the placebo group, and the difference was statistically significant (p = 0.0029). The inter-group comparison showed relative fall in fasting glucose levels in the vitamin D group, with no significant change observed in the other secondary outcome measures.A total of 52 subjects in the vitamin D group and 49 in the placebo group completed the study. Serum vitamin D levels  and OGIS index (376.4 \u00b1 39.7 to 391.7 \u00b1 40.7 mL/min/mConclusionsThe correction of hypovitaminosis D in subjects with prediabetes led to improved insulin sensitivity as assessed by OGIS index at 120 minutes, signifying the role of vitamin D in glucose homeostasis. A recent Indian Council of Medical Research-India diabetes (ICMR-INDIAB) study has estimated a population prevalence of prediabetes in India to be 24.7%, i.e., almost a quarter of adult population belongs to a high-risk group that can progress to diabetes mellitus in the near future . Also, tThis parallel-group double-blind randomized placebo-controlled trial was conducted at Government Medical College in Marathwada region of Maharashtra. The hypothesis was that vitamin D3 supplementation improves OGIS index in prediabetes subjects with hypovitaminosis D. Sample size was calculated as 49 subjects per group for one-tailed hypothesis testing (\u03b1 error at 5% for 80% power of study) to compare the change in OGIS values between the groups. The mean OGIS index and anticipated improvement in OGIS from the available literature were used for the calculation ,7. Due tParticipants and eligibility criteriaEligible participants were adults aged >25 years with prediabetes and hypovitaminosis D. Prediabetes was defined as per the American Diabetes Association (ADA) criteria, i.e., fasting plasma glucose of 100 to 125 mg/dL or 2-hour glucose concentration of 140 to 199 mg/dL after 75-g oral glucose, or glycosylated hemoglobin (HbA1c) of 5.7% to 6.4% . HypovitOutcome measuresPrimary outcome measure was OGIS index at 120 minutes. Secondary outcome measures were fasting blood glucose, post-prandial blood glucose, HbA1c, body mass index (BMI), and insulin sensitivity indices (quantitative insulin sensitivity check index [QUICKI] and homeostatic model assessment for insulin resistance [HOMA-IR]).Screening2, physical inactivity, first degree relative of a diabetic)   ,15. HOMA/L)/22.5 .Randomization and interventionEligible participants were randomly assigned in a 1:1 ratio to receive oral vitamin D soft gel  or matching placebo once a week (after breakfast) for 12 weeks. Randomization was performed using a computer-generated random-number sequence by the pharmacist. Allocation concealment was done by opaque containers. Participants were advised to maintain their usual diet and physical activity and to avoid taking any supplements containing vitamin D during the study. Compliance with consumption of medicine or placebo was assessed by phone follow-up and returning the container. Twelve weeks after supplementation, participants came to the center for their repeat testing of the outcome parameters. Out of the 120 subjects enrolled, 101 subjects reported for the post-intervention follow-up visit. The entire program was offered free of charge. The investigator, study, subjects, and statistician were blinded regarding the subject allocation.Statistical analysishttp://www.graphpad.com/quickcalcs and https://www.socscistatistics.com. A p-value of <0.05 was considered as statistically significant. All the variables were measured in both the groups before and after the supplementation of placebo or vitamin D. Final analysis was performed after 12 weeks of supplementation. All the variables were assessed according to per-protocol analysis (n = 52 + 49 = 101), whereas serum 25(OH)D and the primary objective, i.e., OGIS index, were also assessed as per intention-to-treat (ITT) analysis (n = 60 + 60 = 120) with the baseline observations carried forward (BOCF). Test for normality of data (Shapiro-Wilk test) was applied and based on that parametric (paired and unpaired t-test) or nonparametric tests (Wilcoxon signed-rank test and Mann-Whitney U test) were used for analysis.The data were compiled and expressed as mean \u00b1 SD. The statistical analysis was performed using Microsoft Excel and online calculators available at 2 (p = 0.011), whereas there was a fall in the OGIS index in the placebo group, although the difference was not statistically significant D > 30 ng/mL) after supplementation with 60,000 IU of vitamin D3 soft gels weekly for 12 weeks. There was no significant change in vitamin D levels in the placebo group. There were no subjects with more than 100 ng/mL values of 25-hydroxy vitamin D in our study group. Normalization of vitamin D levels with high-dose vitamin D supplements for a short period has been reported earlier .The study results showed that there was an improvement in insulin sensitivity (OGIS index at 120 minutes) after correction of hypovitaminosis D. The improvement in OGIS index was around 4% in the vitamin D group, which is not large enough. Still, it was in contrast to a slight fall (3%) in the OGIS index observed in the placebo group. The between-group comparison reflects a 7% statistically significant difference between the groups. Among the secondary outcome measures, fasting glucose showed improvement. In contrast, there was no significant change in HbA1c, BMI, post-prandial glucose levels, and insulin sensitivity measures based on fasting glucose and insulin values, i.e., HOMA-IR and QUICKI.OGIS index included an overall assessment of insulin sensitivity and involved fasting and post-prandial status of glucose and insulin levels; therefore, change in either or both fasting and post-prandial insulin sensitivity impact the value of OGIS. Thus, even with moderate changes in HOMA-IR and QUICKI, which assess only the fasting status values of glucose and insulin, there can be a significant improvement in OGIS values. OGIS index has been reported to be a better surrogate marker of insulin sensitivity in comparison with other indices such as Matsuda index, QUICKI, and HOMA-IR, especially in subjects with prediabetes ,18.The presence of vitamin D response element has been demonstrated on the human insulin receptor gene promoter, and 1,25 dihydroxy D3 has been shown to induce activation of the insulin receptor gene, potentiating the insulin response ,20. InsuThe strengths of our study include recruiting prediabetes subjects who fall in a critical zone of suboptimal glucose metabolism spectrum. Also, the analysis of vitamin D levels at baseline and post-intervention was conducted. Furthermore, there was the attainment of vitamin D sufficiency in all subjects who completed vitamin D supplementation. The randomized placebo-controlled design and the study being done in a country which happens to be the diabetes capital of the world and has a high prevalence of hypovitaminosis D add to the significance of the study.LimitationsThere was no estimation of parathormone or serum calcium. The study was powered for OGIS index, and hence sample may not be sufficient to detect changes in other glycemic indices, and, for the same reason, a gender-based analysis was not conducted. Diet, sunlight exposure, physical activity, and other confounders affecting vitamin D metabolism were not taken into consideration; however, randomization may neutralize these limitations. Insulin area under the curve with multiple insulin measurement may better indicate insulin response as the values are dynamic.To conclude, the study results and available literature reflect that the OGIS index may be improved in subjects of prediabetes with hypovitaminosis D by correcting the vitamin D levels. The role of vitamin D as a contributor in glucose regulation needs to be explored further to define its role in the management of deranged glucose metabolism. We recommend that subjects with prediabetes should be screened for vitamin D levels and that repletion should be done in subjects with hypovitaminosis D."}
+{"text": "Portable, wearable, and implantable HD systems may improve clinical outcomes for patients with end-stage renal disease by increasing the frequency of dialysis. The ability of ultrathin silicon-based sheet membranes to clear toxins is tested along with an analytical model predicting long-term multi-pass experiments from single-pass clearance experiments. Advanced fabrication methods are introduced that produce a new type of nanoporous silicon nitride sheet membrane that features the pore sizes needed for middle-weight toxin removal. Benchtop clearance results with sheet membranes (~3 cm2) match a theoretical model and indicate that sheet membranes can reduce (by orders of magnitude) the amount of membrane material required for hemodialysis. This provides the performance needed for small-format hemodialysis.Developing highly-efficient membranes for toxin clearance in small-format hemodialysis presents a fabrication challenge. The miniaturization of fluidics and controls has been the focus of current work on hemodialysis (HD) devices. This approach has not addressed the membrane efficiency needed for toxin clearance in small-format hemodialysis devices. Dr. Willem Kolff built the first dialyzer in 1943 and many changes have been made to HD technology since then. However, conventional HD still uses large instruments with bulky dialysis cartridges made of ~2 m Ko, of ~45,000 mL/min/m2. This is 30 times greater than that of traditional polymer-based membranes.In 2017, the incidence of end-stage renal disease (ESRD) in the United States was over 124,000 and more than 61% of these ESRD patients used hemodialysis (HD) for renal replacement therapy ,4. ContiWhile there have been many improvements in HD technology since Dr. Kolff constructed the first dialyzer in 1943 , only a 2) that demonstrate the extraordinary clearance potential of these membranes (105 mL/min/m2), as well as their intrinsic hemocompatibility [Several types of ultrathin \u2264 100 nm) nanoporous, silicon-based membranes have been developed by our group and shown to improve efficiency and precision of size-based separations 0 nm nano,12,13,14tibility . We havetibility . Here, wHemocompatibility studies have been previously performed on the nanoporous nitride membranes . These s2) [Kt/V \u2265 1.8 in the small-animal model in four hours, above the clinical target of Kt/V = 1.2. Kt/V is a measure of the HD dose commonly used to quantify hemodialysis treatment adequacy, where K = dialyzer urea clearance in mL/min, t = time in min, and V = the fluid volume of the patient in which urea is distributed.Over the past decade, significant refinements have been made in the fabrication process, increasing our capacity to manufacture ultrathin membranes, maintaining a high yield while increasing the contiguous membrane area. The most dramatic example of this progress is the development of lift-off methods to create nanomembrane sheets with large active areas (up to 75 cm2) . SuccessHere, we present the fabrication of the NPN sheet membranes, which builds on the previously reported fabrication of chip-based NPN membranes  along wiNanoporous nitride nanomembranes were fabricated following previously described processes , with moSingle-pass benchtop studies were performed with chip-based devices, as described earlier . Brieflyk*, was determined using the urea fractional loss,Q is the analyte flow rate, and mA is the membrane area. Flow rates were increased in the same experimental setup and devices as in the previous experiment. Dialysate was always run at two times the analyte flow rate. The duration of the experiments was decreased as the flow rate increased in order to maintain a constant volume of fluid being pumped over the membrane for each flow rate. In order to determine whether reverse ultrafiltration was diluting the samples, fluid volumes were monitored.The area-normalized urea clearance rate, Benchtop dialysis experiments used a blood surrogate solution comprised of 50 mg/dL urea  in PBS. For all experiments, PBS pH 7.4 was used as the dialysate. For both blood and dialysate channels, a flow rate of 300 \u00b5L/min was used through the entire experiment with a set transmembrane pressure to achieve an ultrafiltration rate of 0.25 mL/h. Blood-side media was allowed to recirculate, while the PBS dialysate was run to endpoint over a four-hour dialysis duration. At specific timepoints, samples were removed for analysis to determine analyte concentration within the system. Urea concentrations were measured via a modified Jung reagent (OPA-Primaquine technique) method  using a NPN sheet membranes were fabricated as above for releasing large areas of NPN membrane from the supporting wafer substrate 2  that released the membranes from their wafer substrate. Under vacuum, the XeF2 diffused through the pores of the NPN to consume the poly-crystalline silicon proximally underlying the NPN layer, allowing for lift-off of the membrane by a custom vacuum transfer system. The thermal oxide layer acted as an etch stop for the XeF2 etchant.A 10 \u00b5m SU8 layer patterned with 50 \u00b5m hexagonal openings  was used as a physical scaffold to reinforce the NPN membranes during the subsequent through-pore etch step using XeF2) relative to the chip-based devices (1.4 mm2) discussed earlier.A simple device geometry was identified that enabled defect-free transfer of NPN sheet membranes from the Si support wafer to the prototype device\u2014the stack geometry of which is shown in Identical halves of the fluidic device housing see a were fa2 . Under vacuum, the XeF2 diffused through the pores of the NPN such that it consumed the poly-crystalline silicon proximally underlying the NPN layer, allowing for lift-off of the membrane by a custom vacuum transfer system. The thermal oxide layer acted as an etch stop for the XeF2 etchant. This lift-off technique was used to fabricate and release large areas of NPN membrane from the supporting wafer substrate (2) compared to the single-membrane chips described above (1.4 mm2). Device integrity was demonstrated via a leak check using suitable media (PBS stained with red food coloring). Further, the sheet membrane device was tested successfully using a variety of media including PBS, dilute serum, and whole blood .Unlike single-pass experiments with single-membrane chips, our sheet membrane studies recirculated the analyte solution (12.3 mL) through the device from a common media vessel to mimic the process used in the clinical setting. After four hours, the duration of a typical hemodialysis therapy, the average urea reduction ratio (URR) was 58.7% n = 2; . In termC0 = 61.1 mg/dL) and the ending urea concentration (C = 25.3 mg/dL).The urea concentration reduction over four hours was calculated with the starting urea concentration (The urea reduction ratio (URR) was calculated.Kt/V (0.88) for these sheet membrane device experiments as follows:We calculated \u03ba is the elimination rate constant for urea. This shows that the rate of urea loss is directly related to the concentration of urea above the membrane. Integrating Equation (4) yields,Rt is the residency time for which fluid is in the dialyzer. The exit concentration from the dialyzer is proportional to the initial concentration before it is dialyzed.In the context of dialysis, the ability of a membrane to remove toxins is represented as a clearance rate using Equation (2). It is important to note that dialysis systems are not setup in a single-pass fashion but are multi-pass systems, where the blood is continually circulated from the patients\u2019 body, through the membranes, and back to the body. It is necessary to cast the urea clearance data into multi-pass terms for the data to be meaningful to the dialysis community. We start with the first-order rate equation to find the single-pass clearance,Rt is the dialyzed volume (DV) over the flow rate (Q),\u03ba = f/t), which can be related to the simple-pass clearance (k = f\u2219Q), through the expression,Knowing Using Equations (6) and (7),r, correlates the volume in the dialyzer to the total volume. Since the same flow rate is used throughout the entire system, r is also equal to the ratio of time in the dialyzer (Rt) to the total circuit time (Ct). The average fractional clearance in the multi-pass system will then be,Now the main goal was to relate the single-pass to multi-pass to obtain a clear representation of how the membranes would perform in actual dialysis systems. For multi-pass, only a fraction of the sample is in the dialyzer at any given time, so a duty ratio is needed. The duty ratio, We then substituted this into Equation (8),For the first loop through the device, where all fluid has passed by the dialyzer once,eC with C1 to begin counting loops through the dialyzer,We replaced n loops,Generalizing for We recalled the general equation for hemodialysis treatment,K needs to be normalized for the area of the single-pass membrane (spA) and denormalized for the area of the multi-pass membrane (mpA).\u03b3 = (mp/AspA). With Equation (18), we have found a way to convert the quick and simple single-pass clearance studies to multi-pass clearance values that can be understood by the HD community.Equation (17) assume that the single-pass and multi-pass membranes are of equal size. If the surface areas are unequal, the value of k* , approaches the mass transfer coefficient for the dialyzer Ko [Ko = k* = ~45,000 mL/min/m2, or ~7.5 \u00d7 102 cm/s. Commercially available high-flux dialyzers, with a surface area of ~1.8 m2, have a Ko of ~560 mL/min/m2\u2014smaller by two orders of magnitude than the Ko of our nanoporous membranes [The single-pass clearance, lyzer Ko ,23 as thembranes .k*, for 300 mL/min in PBS . From k* and using r = 6.1 \u00d7 10\u20132 we calculate a normalized clearance. We calculated r from the ratio of DV to tV. Approximately one-third of the volume inside the dialyzer was actively being dialyzed (molecules in the upper 2/3 of the channel have no time to reach the membrane), and therefore DV was reduced to 0.075 mL. K* = 144.57 mL/min/m2 for the multi-pass experiments. We de-normalize with mpA = 2.88 \u00d7 10\u20134 m2 and find K = 0.042 mL/min. C(t)/C0 is calculated from K, t = 1080 min, and tV = 12.3 mL (the approximate blood volume of a Sprague\u2013Dawley rat). We arrived at Kt/V = 0.82, and the calculated number from the multi-pass sheet membrane experiments was Kt/V = 0.88. The same relationship between single-pass and multi-pass clearance was plotted in 2 = 0.98; Actual 2: R2 = 0.96.)From K. This will facilitate a much simpler development pathway for further membrane optimization on chips. By assuming that the analyte loss through the membrane is a steady first-order process, we derive K* = k*r , where r is a duty ratio describing the ratio of the volume being dialyzed, at any moment, to the total circuit volume in multi-pass experiments, and K* and k* are area-normalized clearance values for the multi-pass and single-pass systems, respectively. With this result, we predict that C(t)/C0-krt/Vt= e for the multi-pass system, where C(t) is the analyte concentration, 0C is the initial analyte concentration, Vt is the total volume of the multi-pass circuit and t is the dialysis time . Using the single-pass k values from 2 = 0.98; Experiment 2: R2 = 0.96).Having achieved clearance in both single-pass experiments with membrane chips see , we hypoUltrathin HD membranes (nanomembranes) could represent one of the disruptive technologies needed for the revolutionary change in therapy that can improve longevity, lifestyle, and daily patient well-being. Here, we presented the fabrication of the NPN sheet membranes which built on the previously reported fabrication of chip-based NPN membranes  along wiSheet membranes have been shown to have the ability to clear toxins at rates sufficient for small-animal dialysis. Future work will be undertaken to scale the devices for large-animal models and then clinical hemodialysis filters. The analytical equations presented here have been shown to make predictions about recirculating HD experiments from the results of single-pass experiments. Good results were shown from the blood surrogate used in this work. For future development of animal model studies, whole animal blood will need to be used in the single-pass study in order to account for the presence of cellular material.Having a means to predict the clearance results of recirculating hemodialysis experiments with microdialyzers from the much easier to conduct single-pass experiments will enable a more rapid development of benchtop, animal model, and clinical hemodialysis devices. This is true of both standard fibrous membranes and our nanomembranes. The benefit of the sheet membrane material is the flexibility to incorporate it in many form factors for benchtop and small- to large-animal model devices as well as clinical hemodialysis filters."}
+{"text": "The unique procedure, combining MAO and removal of the outer layer by blasting, enables to prepare a coating suitable for application in temporary traumatological implants. A bilayer formed in an alkaline electrolyte environment during the application of MAO enables the formation of a wear-resistant layer with silicon incorporated in the oxide phase. Following the removal of the outer rutile-containing porous layer, the required coating properties for traumatological applications were determined. The prepared surfaces were characterized by scanning electron microscopy, X-ray diffraction patterns, X-ray photoelectron spectroscopy, atomic force microscopy and contact angle measurements. Cytocompatibility was evaluated using human osteoblast-like Saos-2 cells. The newly-developed surface modifications of Ti\u20136Al\u20134V\u00a0ELI alloy performed satisfactorily in all cellular tests in comparison with MAO-untreated alloy and standard tissue culture plastic. High cell viability was supported, but the modifications allowed only relatively slow cell proliferation, and showed only moderate osseointegration potential without significant support for matrix mineralization. Materials with these properties are promising for utilization in temporary traumatological implants.Pulsed micro-arc oxidation (MAO) in a strongly alkaline electrolyte (pH\u2009>\u200913), consisting of Na However, the presence of these alpha and beta stabilizing elements  provides the alloy with great corrosion resistance and with suitable mechanical properties, such as moderate tensile and fatigue strength, formability and good creep resistance4.Titanium and titanium alloys are materials with an increasing share of applications in many fields, primarily in the aerospace industry, in healthcare, in the automotive industry, and now also in the offshore industry. Because of its favorable mechanical properties, Ti\u20136Al\u20134V\u00a0ELI alloy is currently one of the most widely-used titanium alloys for medical applications. The applications are successfully realized despite the presence of aluminum and vanadium, which are potentially harmful alloying elements that might be released in the form of ions from the bulk material under specific tribocorrosion conditions5.The basic requirement for materials used in biomedical implants is that they should be biocompatible. This involves mutual interplay among a number of key material properties that define the best-possible contact with an internal environment within the human body. Not only the surface morphology and the physical properties of the material are important, but also the chemistry of the surface layer and the physiological environment to which the implants are to be exposed. By selecting a suitable modification method, it is possible to achieve a functional surface that allows for desired biological interactions between a medical implant and the tissue, depending on its intended application. For these purposes, various mechanical methods , chemical methods  and physical methods  have been investigated and are now in use in practical applications6. Degreasing and pickling are used as chemical pre-treatments to remove contaminants and the thin naturally occurring oxide layer (<\u200910\u00a0nm)7.In recent years, the most widespread surface modification method for titanium and its alloys has been electrochemical anodization, in combination with mechanical and chemical methods for the necessary surface pre-treatment. Mechanical methods produce a specific surface topography and roughness, remove surface contamination and improve surface adhesion8, and by providing enhanced corrosion resistance of the material9. These properties of the materials then have a considerable impact on the interaction between a metallic implant and the surrounding cells5. In addition, the MAO method is relatively inexpensive and is non-toxic to the environment10.A promising technique which has emerged in recent years is micro-arc oxidation (MAO), also known as plasma electrolytic oxidation. MAO technology is used to prepare a very thin porous oxide layer with variable properties. This layer markedly improves the basic features of titanium alloy by decreasing the risk of potentially harmful ion release from the bulk material11.The MAO method is also known in the literature as Anodische Oxidation unter Funkenentladung (ASD), as plasma electrolytic oxidation (PEO), and as the anodic plasma-chemical process (APC). This material surface modification method is also clinically used under commercial names, e.g. Ticer , TiUnite  or Osstem . Other similar coating methods available for clinical use in orthopedics include DOTIZE  and the TioDark process 14. In order to achieve the required tribological, chemical, structural and biocompatible properties of the implant surface by electrochemical anodization, it is necessary to optimize several parameters of the process, e.g. the time, the voltage, the current density, the electrolyte composition and the temperature15. An important criterion for achieving the desired electrolyte effect is the presence of additives in alkaline or acidic electrolytes. The presence of additives such as calcium acetate hydrate (C4H6O4Ca\u2219H2O), disodium hydrogen phosphate (Na2HPO4), sodium silicate and Na2SiO3\u22199H2O in the alkaline electrolyte allows the chemical species to be incorporated into the coating. These species then influence its thickness, roughness, corrosion resistance, tribology, and also the adhesion and proliferation of cells on the coating17. Silicate coatings prepared by MAO show improved tribological properties, corrosion resistance18, and they can also modulate the bone growth19.MAO can be performed in an acidic or an alkaline electrolyte using the galvanostatic or potentiostatic mode of operationIn the field of traumatology, it is important to select a suitable electrolyte to achieve the desired chemical composition for the cell\u2013metal interaction in the final application. A combination of specific process conditions is used to ensure that the plasma discharge develops at the desired layer thickness. These process conditions and further treatment are used to ensure the unification of the surface, along with the desired topography, phase composition and surface wettability.20. The results showed that two layers with a different phase composition were prepared during the MAO process. The outer porous layer was then removed in order to reduce the average roughness and the TiO2 phase (rutile). The phase composition of the newly-developed coating correlated well with the choice of the electrolyte. It showed dependency on the total energy of each pulse, which was ensured using the unipolar source.The Ti\u20136Al\u20134V\u00a0ELI samples used in this study were modified in alkaline electrolytes with the use of MAO technology equipped with a unipolar pulse source. The aim was to prepare a coating suitable for temporary traumatological implants, e.g. screws, nails, wires, staples or splints. Our expectation for this coating was that it should be biocompatible, non-cytotoxic and supportive for cell viability. At the same time, however, it should not promote firm osseointegration, which would hamper the removal of a temporary implant from the body. A\u00a0novel technological procedure is proposed in this study aimed at eliminating the disadvantages of MAO, which are linked to the high surface roughness of the initially deposited oxide layerin\u00a0vitro, using human osteoblast-like cells of the Saos-2 line. The suitability of the surface properties of the samples and their effect on the cell behavior were evaluated at various stages of the cell culture. The following signs of the cell-material interactions were evaluated: the number, the spreading and the morphology of the initially adhering cells, the cell population density in the subsequent time intervals, which is an indicator of cell proliferation, the cell viability, which is an indicator of potential material cytotoxicity, the collagen type I deposition, the gene expression of selected osteogenic markers , and calcium deposition, which is a sign of bone matrix mineralization. The cell behavior was then correlated with the physicochemical properties of the material surface, i.e. its topography, roughness, wettability and the chemical composition of the surface layer. The results were also compared with those obtained in cells cultured on the control samples of MAO-untreated alloy (Ctrl) and on standard polystyrene cell culture plates (PS).The interactions of cells with the modified surface of the samples in this study were investigated a (average roughness), Rz (maximum height of the profile) and RSm (mean spacing of the profile irregularities). The surfaces of the samples after chip machining had roughness Ra\u2009=\u20090.65\u2009\u00b1\u20090.02\u00a0\u00b5m and Rz\u2009=\u20093.42\u2009\u00b1\u20090.15\u00a0\u00b5m. Surfaces with inlet roughness Ra\u2009=\u20090.28\u2009\u00b1\u20090.01\u00a0\u00b5m, Rz\u2009=\u20091.88\u2009\u00b1\u20090.05\u00a0\u00b5m and RSm\u2009=\u2009340\u2009\u00b1\u20090.03\u00a0\u00b5m were achieved using vibration tumbling technology  0.83\u2009\u00b1\u20090.11\u00a0\u00b5m in thickness was therefore related to the linearization of the increase in the voltage input. High voltage is required to allow the formation of a spark discharge, accompanied by an isolated discharge, which can be observed on the surface of the material. The strong discharge with a subsequent current drop resulted in the growth of a dielectric porous outer layer 6.86\u2009\u00b1\u20091.03\u00a0\u00b5m in thickness22. According to Zhang et al.23, during the formation of the outer porous layer a much lower voltage drop occurs than when the inner layer is forming. This can be explained by the much lower resistance of the outer porous layer in comparison with the compact inner layer. This corresponds with the slow growth of the outer porous layer after reaching spark discharge.The increase in the surface roughness of the MAO-treated samples is dependent on the input energy increase and a stronger spark discharge inside the channels. With increasing voltage and current density, the material melts and immediately oxidizes at the metal\u2013electrolyte interface inside the channels2 oxidic phase in the crystalline modification of rutile, (2) titanium (\u03b1\u2009+\u2009\u03b2), (3) AlTi3, (4) Al4Ti2SiO12, and (5) Ti0,75V0,25. The results of the diffraction records show that the rutile phase that was present was removed by blasting the outer porous surface in the sample of MA01-blasting type. According to the results of EDX and XRD analyses and the phases that were shown to be present, we can conclude that there is significant enrichment of the outer porous layer with silicon. This was confirmed in the Al4Ti2SiO12 crystalline phase that was present. According to Wang et al.24, we can also assume the presence of amorphous SiO2, which was incorporated into the coating from the electrolyte solution.The diffraction records of the samples before the application of MAO, i.e. after mechanical treatment, of samples after MAO and of samples after MAO with the porous layer removed by shot blasting Fig.\u00a0 all conf3/2 in the spectrum of the substrate sample and MA01 was determined, with the peak at 458.8\u00a0eV 25. The shape of the spectrum and the shift to binding energy of 457.4\u00a0eV in the MA01-blasting sample . This phase was not confirmed in the inner layer using the XRD method, due to the different sensitivities of the two methods.The results of the XPS analysis Fig.\u00a0 confirme2 was confirmed from the peak energy O\u00a01\u00a0s 530.7\u00a0eV , which may cause different charging of individual components of the coating.The present phases and the changes in the structure on the surface following the application of MAO and blasting of the outer layer affected the resulting shifts of the O\u00a01s peaks to higher binding energy values of 532.3\u00a0eV . The contact angle of both water droplets and glycerol droplets on the MA01 sample was several times lower than on the Ctrl and MA01-blasting samples. With a water contact angle of 16\u00b0, the wettability of MA01 was therefore the highest of all samples. Similarly, the polar component of the surface energy of MA01 was also higher than in the Ctrl and in the MA01-blasting samples . Additional surface treatment of the samples by shot blasting, however, changed the surface roughness of the samples and thus reduced their wettability significantly. This change is demonstrated by a higher contact angle (35\u00b0) and a lower polar component of the surface energy (42\u00a0mM/m) of the MA01-blasting sample. The reference Ctrl and PS samples (contact angle around 70\u00b0) can be regarded as moderately hydrophilic, which is considered beneficial for cell adhesion and growth. Mean values of the contact angles and the surface energy are given in Table 30. Advantageous material properties are reflected in the cytoskeleton and in the cell morphology, e.g. the cell being more polygonal in shape and occupying a larger area32. However, wettability is a result of combined properties of the material surface, i.e. topography, chemical composition and surface charge, all of which interact to affect the cell behavior. It is therefore difficult to assess these parameters individually.The wettability of a material is particularly important, as it can influence the adsorption of the proteins supporting cell adhesion and their spatial organizationThe average values of the coefficients of friction tested by a pin-on-disc tribometer were in the range of 0.63\u20130.68 in air. In a phosphate-buffered saline (PBS) solution, which acted as a lubricant, the values decreased to the range of 0.39\u20130.43. However, this was not the case for the MA01-blasting sample, in which the coefficient of friction increased to 0.72. In this case, the ball surface was damaged by adhesion wear in PBS and by abrasion in air. For the MA01 samples, the ball wear was minimal. Only scratches caused by contact with the tops of the rough surface were visible on the surface of the ball. For the Ctrl samples, the counterpart material adhered to the surface of the ball  with significantly larger spreading areas than to the MA01 and MA01-blasting samples, and even than to the standard cell culture polystyrene wells (PS). At the same time, the sizes of the cell spreading areas on the MA01, MA01-blasted and PS samples were similar, and without statistically significant differences . The lowest median values for each time interval were: 100% viability on day\u00a01 , 98.89% viability on day\u00a04 (MA01-blasting) and 98.04% viability on day\u00a07 (MA01) Fig.\u00a0D. With t29). It is known that cell adhesion to artificial materials is mediated by extracellular matrix (ECM) proteins, such as fibronectin, vitronectin, collagen or laminin. These proteins are adsorbed on the materials from biological fluids, including the serum supplement of cell culture media. On moderately wettable surfaces, these proteins are adsorbed in a flexible, physiological conformation, where specific amino acid sequences in these proteins, e.g. RGD, are well-accessible for the adhesion receptors on the cells, e.g. integrins. The adhesion receptors are then clustered into focal adhesion plaques, where they communicate with various structural and signaling molecules, and they deliver mechanical and biochemical signals to the cells. These signals then govern the cell behavior, including the proliferation activity of the cells32. However, on highly hydrophilic surfaces, the adsorption of cell adhesion-mediating proteins is weak and unstable, and these proteins cannot provide an adequately firm anchor for the adhering cells. Although the specific amino acid sequences in the protein molecules are still accessible for cell adhesion receptors, these receptors cannot be sufficiently assembled into focal adhesion plaques and cannot sufficiently support the cell spreading that is a prerequisite for further cell proliferation . This could offer an explanation for the slower proliferation of the cells on the MAO-treated samples, particularly on the MA01 samples, where the water drop contact angle was the lowest, i.e. the hydrophilicity was the highest. A similar phenomenon was observed on highly hydrophilic oxygen-terminated nanostructured diamond surfaces (water drop contact angle lower than 2\u00b0), which almost completely resisted the adhesion of human bone marrow mesenchymal stem cells. At the same time, less hydrophilic hydrogen-terminated nanodiamond surfaces  provided good support for the adhesion, spreading and growth of these cells34. Another example is a poly(DL-lactide) surface tethered with polyethylene oxide (PEO) chains, in which relatively high surface hydrophilicity (water drop contact angle less than 30\u00b0) was coupled with high mobility of the PEO chains. This disabled the adsorption of cell adhesion-mediating proteins, and they were therefore non-adhesive for vascular smooth muscle cells35.The surfaces of the control Ti\u20136Al\u20134V alloy samples (Ctrl) and the standard polystyrene culture wells (PS) exhibited very similar wettability values (due to the contact angle and the polar component of the solid surface energy); it is therefore not surprising that the cell proliferation on these samples was very similar. These surfaces with a water drop contact angle of about 70\u00b0 can be considered moderately wettable, i.e. suitable for the adhesion, migration and proliferation of cells , is not usually felt by cells which are spread over tens of micrometers, and it usually contributes to better mechanical anchorage of the implant in the bone tissue. Submicron roughness, and particularly nanoroughness, of a material can imitate the physiological irregularities within the ECM, such as various curvatures, helices or side chains in organic molecules, and crystals in the inorganic component of ECM, e.g. in the bone tissue, and usually supports the adhesion and growth of cells. However, irregularities several micrometers in size can hamper the adhesion, the spreading and the subsequent growth of the cells. The cells are forced to adhere in depressions among the prominences, which can limit their spreading area, or they need to bridge the prominences and cannot use the entire cytoplasmic membrane for adhesion. The cells can also adhere on both depressions and prominences, but this often leads to deformations of the cytoplasmic membrane, the actin cytoskeleton and the cell nucleus, and leads to delayed maturation of focal adhesions38 . The surface roughness of both MAO-modified samples, particularly the Rz parameter, was in the micron-scale, and together with high surface hydrophilicity, it can explain the lower spreading and proliferation rate of Saos-2 cells on these surfaces.The surface roughness of the material is another important parameter regulating the adhesion and growth of cells and the osseointegration of the implant. However, it seems that there is no consensus about universal roughness values supporting or hampering cell adhesion and growth. Several studies performed on various cell types and on various materials have shown that cells adhere, grow and differentiate better on rough surfaces than on smooth, polished surfaces. In those studies, the dimensions of the irregularities on the surface of the material were much bigger or much smaller than the bone cells themselves. In other words, the surface roughness in these cases was either in macroscale, or in submicron-scale or even in nanoscalem), which is ~ 62\u00a0\u00b5m in MA01 and ~ 127\u00a0\u00b5m in the MA01-blasting samples, seems to be sufficiently long to accommodate the cells. The cells usually need to spread over tens of micrometers for their good functional performance on a material. It can therefore be assumed that the high surface wettability had a predominant effect limiting the spreading and growth of the cells on both MAO-treated samples. In any case, materials supporting high cell viability of bone cells, but not high proliferation activity, are desirable for temporary bone implants, in which firm osseointegration would hamper removal of the implant.Taken together, our results indicate that high surface wettability and micron-scale surface roughness had a synergistic limiting effect on cell adhesion and growth. This limiting effect was most pronounced in the MA01 samples, i.e. in the samples with the highest hydrophilicity and the highest surface roughness. However, it should be taken into account that the mean spacing of the profile irregularities  in the standard cell culture medium (NORM), or for the first 7\u00a0days in the NORM medium and then for 7 additional days in an osteogenic differentiation-promoting medium (DIF), as previously described. As revealed by immunofluorescence, the cells produced type I collagen in comparable amounts under both types of cultivation conditions Fig.\u00a0A. At the32). However, this difference among the Ti\u20136Al\u20134V-based samples was lost when the cells were cultured in the DIF medium. Under these conditions, the highest calcium deposition was detected in the cells cultured in PS wells. Both MAO-treated samples showed significantly lower mineralization than the PS samples, and slightly, albeit not significantly, decreased mineralization in comparison with the Ctrl samples.The mineralization of the ECM, measured by the deposition of calcium Fig.\u00a0B by the 42.The osteogenic differentiation of the cells cultured on the tested samples was also characterized by qPCR analysis. The expression of three selected markers was investigated: collagen type\u00a0I (COL1A1 gene), alkaline phosphatase (ALPL gene), and osteocalcin (BGLAP gene). Collagen type\u00a0I is considered an early marker of cell osteogenic differentiation, as it is secreted by osteoblasts during the deposition of new ECM, and it accounts for almost 90% of the ECM in the bone tissue. Alkaline phosphatase is active during cell mineralization of the surrounding ECM, and in various studies it is considered either as an early marker of osteogenic cell differentiation or as a medium-term marker. Osteocalcin is produced by osteoblasts later during the mineralization phase; it therefore serves as a late marker of osteogenic cell differentiation41. Nevertheless, after 14\u00a0days of cultivation in the NORM medium, the expression values became significantly higher for the cells on the MA01 samples than for the cells on the Ctrl samples . However, in the cells on the MA01-blasting samples, where the cell proliferation activity was also low, the expression of type I collagen was lower than on the Ctrl samples  Ti\u20136Al\u20134V samples, but they are relatively supportive for osteogenic cell differentiation. The cells on the MA01 samples displayed (1) significantly higher expression of type I collagen (COL1A1), and (2) significantly higher calcium deposition than on the Ctrl samples after 14\u00a0days in the NORM medium, (3) significantly higher immunofluorescence of type I collagen in both the NORM and DIF media than on the PS samples, (4) significantly higher calcium deposition in the NORM media than on the PS samples, and (5) significantly higher expression of type I collagen than on the MA01-blasting samples after combined cultivation in the NORM and DIF media.43.The cells on the MA01-blasting samples displayed higher expression of (1) alkaline phosphatase  and (2) osteocalcin  than the cells on the MA01 samples, and (3) higher immunofluorescence of type I collagen in the NORM medium than the cells on PS. However, the cells on the MA01-blasting samples showed lower expression of type I collagen (DIF medium) and of alkaline phosphatase than on the Ctrl sample. In other words, the MA01-blasting samples showed higher osteogenic differentiation only in three cases, and none of these was observed in comparison with the control Ti\u20136Al\u20134V alloy sample. At the same time, the MA01 samples were better for osteogenic differentiation in five cases, and two of these were in comparison with the control Ti\u20136Al\u20134V alloy sample. The MAO-blasting samples can therefore be considered less suitable for osteogenic cell differentiation than the MA01 samples. From this point of view, the MA01-blasting samples seem to be more appropriate for temporary applications, e.g. in traumatology, for bone screws, nails, wires, staples or plates, where firm osseointegration  is not desirable. However, the MA01 samples, which exhibited the lowest proliferation of Saos-2 cells, also seem to be suitable for temporary and removable bone implants, because the formation of a sufficient mass of new bone tissue by proliferation of osteoblasts is also a prerequisite for the firm osseointegration of an implantSamples of Ti\u20136Al\u20134V alloy, i.e. a material currently used in orthopedic surgery (labelled as Ctrl), were modified by the pulsed micro-arc oxidation (MAO) technique in order to improve the tribological properties of the alloy and to modulate its interaction with osteoblasts. The use of a unipolar power supply with a combination of process parameters  and electrolyte composition (pH\u2009>\u200913) made it possible to create a thin layer with tuned chemical composition on top of the Ctrl samples (labelled as MA01 samples). This layer was highly hydrophilic , and also exhibited greater surface roughness. Final surface treatment by blasting (MA01-blasting samples) eliminated the rutile crystalline phase and reduced the surface wettability (contact angle ca. 35\u00b0). This can be attributed to thinning of the surface oxide layer and to lowering of the surface roughness by blasting, i.e. mechanical finishing.The cell\u2013material interactions were studied in vitro with the use of human osteoblast-like Saos-2 cells. On day 1 after seeding, the cells on the MA01 and MA01-blasting samples adhered with a smaller cell\u2013material projected area than on the Ctrl samples. In the following days, the proliferation rate of the cells was lower on both types of MAO-treated samples than on the Ctrl samples. This was more pronounced in the MA01 samples, i.e. in the samples with the highest wettability and roughness. However, the cells on the MA01 samples were more active in osteogenic differentiation and in bone matrix mineralization than the cells on the MA01-blasting samples, although these parameters in both MAO-treated samples were mostly similar to or even lower than on the Ctrl samples. The cells on both MAO-treated samples were highly viable. The technology presented here is therefore suitable for surface modification of temporary traumatological implants, where firm osseointegration is not desirable.To obtain the modified surface, the samples of titanium alloy Ti\u20136Al\u20134V in the form of discs  were mechanically pre-treated by machining and were used to apply MAO.In order to remove traces of the turning tool and to unify the surface prior to MAO application, the samples were treated by tumbling in an HV 20 centrifugal vibrator (OTEC Pr\u00e4zisionsfinish GmbH) using KF 10 plastic grinding wheels and 1.3\u00a0kW engine power for 1.5\u00a0h. Subsequently, the samples were polished for 1\u00a0h by ZSP 3/5 porcelain bodies.46:During the MAO process in an alkaline electrolyte, a complex mechanism involving electro-, thermal- and plasma-chemical reaction takes place48, in addition to the parameters of the voltage source.High voltage switching power supplies in unipolar or bipolar mode are used to achieve the required breakdown voltage and to form an oxide coating. MAO operating conditions depend on the type of electrolyte that is chosen, and its electrical properties3 and 2 wt.% HF for 1\u00a0min). After each of these pretreatment processes, the samples were rinsed 2\u00a0times in distilled water for 2\u00a0min. The MAO was performed in the pilot plant of VUHZ, a.s.   consisting of Na2SiO3\u22199H2O and NaOH. A unipolar switching power supply  with a voltage of 450\u00a0V for 60\u00a0min in a highly-cooled bath was used to achieve the necessary plasma conditions for the preparation of the oxide layer. This group of samples was labelled as MA01.Prior to MAO, the surfaces of the mechanically-treated samples were degreased in an alkaline medium (1\u00a0M NaOH for 5\u00a0min) and were pickled in a mixture of acids (20 wt.% HNOic) Fig.\u00a0. The proThe porous oxide layer after the MAO procedure was removed in the TTB 90 blasting box . After a series of tests with organic and ceramic blasting media, the following combination of parameters was determined as the most appropriate: a working distance (15\u00a0cm), pressure (1.5\u00a0bar), ballotine media (grain size of 65\u2013105\u00a0\u00b5m). This group of samples was labelled as MA01-blasting.a, Rz and RSm parameters were determined. The Ra parameter, i.e. the average roughness, is defined as the arithmetic average of the absolute values of the profile heights along the sampling length. The Rz parameter, i.e. the maximum height of the profile, is the absolute vertical distance between the maximum height of the profile peak and the maximum depth of the profile valley depth along the sampling length39. The RSm parameter, i.e. the mean spacing of the profile irregularities, is the mean value of the spacing between the profile irregularities within the evaluation length38. The topography of the samples was investigated by atomic force microscopy . The measurements were carried out in contact mode .The surface morphology and the cross-sections of the MAO-treated samples were observed by field emission scanning electron microscopy . The chemical composition of the MAO-created coating was analyzed using an energy dispersive X-ray spectrometer . The surface roughness was measured using a contact profilometer device . The R\u03b1 irradiation (\u03bb\u2009=\u20091.789\u00a0\u00c5) and a Bruker D8 Advance diffractometer  equipped with a fast position sensitive V\u00c5NTEC\u00a01 detector. The samples were rotated during the analysis and the measurements were carried out in Lock Coupled mode. The operation conditions of the Co lamp were U\u2009=\u200935\u00a0kV, I\u2009=\u200925\u00a0mA, and the scanning speeds were 0.03\u00b0 and 0.8\u00b0 s\u22121. The ICDD PDF\u00a02 Release 2014 database was used for evaluating the phase composition.The crystalline phases of the MAO-created coating were determined by the X-ray powder diffraction patterns (XRPD) with CoK\u22129\u00a0Torr. The spectra were obtained using an Omicron EA-125 electron energy analyser and a dual anode X-ray source. An aluminium K\u03b11,2 line with primary energy 1486.6\u00a0eV was used to stimulate the emission of photoelectrons. The films were studied as-prepared, without any additional cleaning.Chemical analyses of the surface of the prepared samples were performed using XPS (X-ray Photoelectron Spectroscopy) in an ultra-high vacuum chamber with a base pressure higher than 2\u2009\u00d7\u200910The wettability of the Ti\u20136Al\u20134V samples was evaluated by the sessile drop technique with the use of two probe liquids . Eight droplets of 3\u00a0\u03bcl volume for each liquid were used per sample. The measurements and the subsequent analysis of the static contact angles and the solid surface energies were performed by a Kr\u00fcss Drop Shape Analyzer 100 machine with Drop Shape Analyzer 4 software , using the Owens\u2013Wendt\u2013Rabel\u2013Kaelble method.The friction and wear testing were done using a pin-on-disc tribometer (CSM Instruments). The tests were performed at room temperature in air and in phosphate-buffered saline , which was used to simulate the human body environment.2O3 ball with a diameter of 6\u00a0mm was used as the sliding counterpart. The test parameters were: normal load (1\u00a0N), linear sliding speed (50\u00a0mm\u00a0s\u22121), number of laps\u00a0(5000), radius for air (5\u00a0mm) and radius for PBS (6\u00a0mm). The surface wear of the Al2O3 ball was analysed using an Olympus DSX1000 digital microscope, and the geometry of the wear track was measured using a Zygo NewView 72003D optical profilometer.An Al2), except in the qPCR experiments, where a higher seeding density of 30,000 cells per well  was needed in order to increase the RNA yield. As an additional control for all experiments, the cells were seeded into standard polystyrene wells (PS) of 24-well plates.The Ti\u20136Al\u20134V samples used in all experiments  were sterilized in ethanol for 2\u00a0h, were inserted into 24-well plates  and were seeded with human osteoblast-like Saos-2 cells . The initial seeding density for all experiments was 20,000 cells per well  and dexamethasone (10\u22128\u00a0M). According to J\u00f8rgensen et al.49, these media supplements stimulate cell osteogenic differentiation and the production of osteogenic markers in osteoblasts. Dexamethasone, for example, is known to stimulate alkaline phosphatase (ALP) production in cells, and to increase their receptor sensitivity to dihydroxyvitamin\u00a0D3\u00a050.Two types of cultivation media were used for the experiments. The first type was a normal growth medium (NORM), which contained McCoy 5A cultivation medium , 15% of Fetal Bovine Serum  and gentamicin (40\u00a0\u03bcg/ml). The second type was a differentiation medium (DIF), which had the same basic composition as NORM, but additionally it was supplemented with \u03b2-glycerolphosphate (10\u00a0mM), L-glutamine (2\u00a0mM), ascorbic acid (50\u00a0\u03bcg/ml), dihydroxyvitamin D2 saturation of the air atmosphere. For an assessment of the differentiation, the cells were seeded and cultured for 7\u00a0days in the NORM medium, and then the medium was changed to either the NORM medium or the DIF medium, in which the cells were cultivated for an additional 7\u00a0days. In other words, the cells were cultivated either for 7\u2009+\u20097\u00a0days in the NORM medium, or for 7\u2009+\u20097\u00a0days in the NORM and DIF medium. The media were changed on every 3rd day of cultivation.For a proliferation assessment, the cells were cultured for 1, 4, 7 and 14\u00a0days in the NORM media at 37\u00a0\u00b0C and 5% CO2 Maleimide  was used to visualize the cell membrane and the cytoplasmic proteins. Hoechst #33258  was used to visualize the cell nuclei.In order to evaluate the size of the initial cell spreading areas on day 1 after seeding and the cell population densities on days\u00a01, 4, 7 and 14 of cultivation in the NORM medium, the cells were washed with Phosphate-Buffered Saline, were fixed with 70% frozen ethanol  and were stained with fluorescent dyes for 1\u00a0h at room temperature in the dark. Texas Red COn days\u00a01, 4 and 7 of cultivation in the NORM medium, the cells were washed with PBS and were stained with LIVE/DEAD Viability/Cytotoxicity kit  according to the manufacturer\u2019s instructions. Staining with calcein AM (green stain) and with ethidium homodimer\u00a01 (red stain) made it possible to distinguish between live cells (green) and dead cells (red), and to determine the cell numbers and the cell viability in selected time intervals. Additional staining of the cell nuclei with Hoechst #33258 (blue stain) was performed on day 7 for easier cell counting.https://imagej.net/Fiji51;). The cell areas were measured using Altas software . The initial cell spreading area was presented in \u03bcm2 as a mean\u2009\u00b1\u2009S.E.M (Standard Error of Mean). The cell population density is presented as medians with IQR of cell number per cm2.The fluorescence signal was viewed and was photographed with an Olympus IX51 epifluorescence microscope , equipped with a DP70 camera . The microphotographs (15 per sample/well) were analyzed in ImageJ FIJI software  and were stained by immunofluorescence for collagen type I. A solution of 1% bovine albumin and 0.1% Triton X100 in PBS  was added to the samples in order to block non-specific binding sites for antibodies. After that, the samples were treated with 1% Tween in PBS (20\u00a0min) and then with Anti type I Collagen Rabbit primary antibody  overnight at 4\u00a0\u00b0C. Then the secondary antibody Alexa Fluor 488-conjugated F(ab\u2019) 2 fragment of goat anti-rabbit IgG  was added for 1\u00a0h at room temperature in the dark, along with Hoechst #33258  in order to stain the nuclei. The samples were washed with 1\u00a0ml of PBS after each step.52). The same single color plane threshold was set for all images to eliminate the non-protein area of the image data. The cumulative sum of all pixel intensities was then evaluated with subtraction of the background fluorescence intensity of the negative staining control. The obtained data were normalized to cell counts for each image separately, and are presented as medians with IQR.An Olympus IX51 epifluorescence microscope (obj. 20\u00d7), equipped with a DP70 camera , was then used to visualize and to document the fluorescence signal in two separate channels with the same exposition settings for each channel. The intensity of the fluorescence signal of collagen type I was measured in microphotographs (10 per sample/well) using a Fluorescent Image Analyser  in order to evaluate the expression of the following selected genes of interest: collagen type I (COL1A1 gene), an early marker, alkaline phosphatase (ALPL gene), an intermediate marker, and osteocalcin (BGLAP gene), a late marker of osteogenic cell differentiation. Glyceraldehyde 3-phosphate dehydrogenase (GAPDH) was used as a housekeeping (i.e. reference) gene. The cells for these experiments were cultivated for 7 or 14\u00a0days in the NORM medium, or consecutively for 7\u2009+\u20097\u00a0days in the NORM and DIF medium to stimulate osteogenic cell differentiation, as previously described.\u2212\u0394\u0394Ct method. Changes in the expression of the genes of interest were calculated according to the equation:The Total RNA Purification Plus Micro Kit  was used according to the manufacturer\u2019s instructions for RNA extraction from the cultured cells. Reverse transcription of RNA 300\u00a0ng/\u00b5l) to cDNA was performed using ProtoScript First Strand cDNA Synthesis Kit  with oligo-dT primers. The reaction ran in a T-Personal Thermocycler . The relative mRNA expression was quantified using SYBR Green  and Generi Biotech (Czech Republic) primers, the sequences of which are described in Table 00\u00a0ng/\u00b5l The data were normalized according to the gene expression in the cells grown on the PS samples in the NORM medium for 7\u00a0days after seeding .The extracellular matrix (ECM) mineralization was evaluated using the Calcium Colorimetric Assay kit  according to the manufacturer\u2019s instructions. The cells were cultivated either for 7\u2009+\u20097\u00a0days in the NORM medium, or consecutively for 7\u2009+\u20097\u00a0days in the NORM and DIF medium. Prior to the assay, all samples of Ti\u20136Al\u20134V were moved into a fresh 24-well plate in order to eliminate the influence of the cells growing on the original well bottoms under and around the samples. All samples and PS controls were washed twice with PBS and were left to dry out under non-sterile conditions at room temperature for 1\u00a0h. Afterwards, 700\u00a0\u03bcl of 0.5\u00a0M HCl was added to each sample for overnight incubation at 4\u00a0\u00b0C on an orbital SSL1 shaker. The cells were then scratched with a cell scraper and were collected into clean Eppendorf tubes. Twenty-five \u03bcl of solution from each sample were pipetted in triplicate into a 96-well plate , along with 45\u00a0\u03bcl of Chromogenic Reagent and 30\u00a0\u03bcl of Calcium Assay Buffer (5\u201310\u00a0min at room temperature in the dark). Immediately after the reaction, the Synergy HT Multi mode Reader  was used to measure the absorbance of each well at 575\u00a0nm. A calibration curve was created from standards containing known concentrations of calcium so that the absorbance could be converted to the calcium concentration. The data were normalized according to the sample surface area .p\u2009\u2264\u20090.05, except for qPCR, where the data were analyzed in the form of \u0394Ct using the One Way ANOVA, Holm\u2013Sidak test, statistical significance at p\u2009\u2264\u20090.001. The data are presented either as bar charts with mean\u2009\u00b1\u2009S.E.M (Standard Error of Mean) or as box plots with median, quartiles and interquartile range, with the exception of qPCR. The data from qPCR are presented as the mean\u2009\u00b1\u2009S.D. (Standard Deviation) from 3\u00a0measurements. All plots were created in GraphPad Prism 8.3.0 .SigmaStat 3.5  was used for the statistical analysis. The quantitative data were analyzed using Kruskal Wallis One Way ANOVA on Ranks with post hoc Dunn\u2019s analysis and statistical significance at"}
+{"text": "Recent life expectancy gains in high-income Asia-pacific countries have been largely the result of postponement of death from non-communicable diseases in old age, causing rapid demographic ageing. This study compared and quantified age- and cause-specific contributions to changes in old-age life expectancy in two high-income\u00a0Asia-pacific countries with ageing populations, South Korea and Japan.This study used Pollard\u2019s actuarial method of decomposing life expectancy to compare age- and cause-specific contributions to changes in old-age life expectancy between South Korea and Japan during 1997 and 2017.South Korea experienced rapid population ageing, and the gaps in life expectancy at 60\u2009years old between South Korea and Japan were reduced by 2.47\u2009years during 1997 and 2017. Decomposition analysis showed that mortality reductions from non-communicable diseases in South Korea were the leading causes of death contributing to the decreased gaps in old-age life expectancy between the two countries. More specifically, mortality reductions from cardiovascular diseases  and cancers  in South Korea contributed to the decreased gap by 1.34 and 0.41\u2009years, respectively. However, increased mortality from Alzheimer and dementia, lower respiratory tract disease, self-harm and falls in South Korea widened the gaps by 0.41\u2009years.Age- and cause- specific contributions to changes in old-age life expectancy can differ between high-income Asia-pacific countries. Although the gaps in old-age life expectancy between high-income Asia-pacific countries are primarily attributed to mortality changes in non-communicable diseases, these countries should also identify potential emerging threats of communicable diseases and injuries along with demographic ageing in pursuit of healthy life years in old age. Alth nations .Recent comparative studies of life expectancy and causes of death between high-income Asia-pacific countries showed that causes of death contributing to the changes in life expectancy can differ between them \u20137. TheseAmong high-income Asia-pacific countries, the Republic of Korea (hereafter South Korea) and Japan have both experienced demographic ageing due to rapidly increasing longevity and declining fertility rates. As a result, Japan has been widely regarded as the most aged country in the world and South Korea, with the fastest ageing population in the world, is projected to take the lead in life expectancy from Japan between 2030 and 2040 . AlthougAge 65 is usually used as an old age threshold, because in some countries it is the age at which people could be eligible for a full state pension. However, in South Korea, normal pension age is now in the process of change. As of 2020, individuals over 62\u2009years old were eligible for the normal pension in South Korea, and the criterion was 60\u2009years old until 2012. In Japan, the old age basic pension benefits are currently paid from 65\u2009years old, whereas the pension age was 60\u2009years old in the 1990s. Since this study compares old-age life expectancy between the two countries in 1997 and 2017, this study defines older adults as aged 60\u2009years or older. The aim of this study is therefore to report on a comprehensive comparative study of age- and cause-specific contributions to changes in life expectancy at 60\u2009years between South Korea and Japan. This study focuses on population data between 1997 and 2017 and observes (1) age structural changes; (2) age-standardised mortality rates; and explores (3) age- and cause-specific contributions to increasing life expectancy at 60\u2009years in South Korea and Japan and (4) age- and cause-specific contributions to decreasing gaps in life expectancy at 60\u2009years between South Korea and Japan.https://population.un.org/wpp/) and the Global Health Data Exchange . The GBD 2017 study follows the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER), which includes recommendations on documentation of data sources, estimation methods, and statistical analysis. Detailed methods for the GBD 2017 study are provided in other publications [\u2018Others\u2019 category. Figure Others\u2019 category slightly increased from 1997 to 2017 in both countries, the top 20 causes accounted for almost 80% of the total number of deaths in both countries for the two periods. In addition, the top 20 causes based on South Korea in 2017 were selected to explore the causes of death among the elderly in contemporary developed societies and investigate how South Korea caught up with the old-age life expectancy of Japan between 1997 and 2017.This study obtained data of the South Korean and Japanese population by five-year age groups from the World Population Prospects (WPP) 2019, and age- and cause-specific deaths from the Global Burden of Disease (GBD) 2017 Study . The WorA descriptive analysis of age structural changes in South Korea and Japan between 1997 to 2040 was carried out with the WPP 2019 data. Then, the multiple decrement table by five-year age groups for both countries between 1997 and 2017 was constructed to compute life expectancy (LE). A broad mathematical assumption of the multiple decrement life table is that an individual surviving to a certain age is the product of all independent risk-of-death probabilities. Although sampling variation is not an essential issue when calculating LE at national levels, we used Monte Carlo simulations using the probability of dying from an abridged life table to generate a binomial distribution of death numbers. The simulation was performed 10,000 times to generate the LE distribution, where the mean value was used as LE and the 2.5th and 97.5th percentiles of the distribution were used as the 95% confidence interval of LE. Calculation techniques for multiple decrement life tables and the standard error of LE are described elsewhere , 19.dit is the number of deaths for each specific cause of mortality\u00a0t at age i; pi denotes the number of persons at age i in the observed population; Nr is the total number of persons in the reference population; pir denotes the number of persons at age i in the reference population. The population to be used as a reference was derived from the average of the age distributions of South Korean and Japan in 1997 and 2017 at each age group. In addition, the Chi-square test was calculated for testing the significance of differences in age-standardised mortality rates (ASMR) of the two countries between 1997 and 2017.In order to compare cause-specific mortality rates, this study uses age-standardised mortality rates per 1000 persons, with a direct method of standardisation further calculated to eliminate the effect of different age structures among the different population structures across two countries and times. The directly standardised mortality rate is given by the following formula;Pollard\u2019s actuarial method of decomposing life expectancy was then used to estimate the age- and cause-specific contributions to changes in life expectancy , 21. Thix in 2017 and 1997 for the the decomposition of life expectancy within countries; n denotes the number of causes of death; i cause of death at age interval x with the weight \u03c9x. The values x years of age between different times.where The same decomposition method was further calculated to examine the difference in life expectancy between (3) South Korea and Japan in 1997, and (4) South Korea and Japan in 2017, which is given by the following formula;j corresponding to Japan and k corresponding to South Korea for the decomposition of life expectancy between countries with the weight \u03c9x between different countries. This study based all life expectancy estimates on the population aged 60-64. where Figure Although both countries experienced increases in old-age life expectancy between 1997 and 2017, South Korea rapidly caught up with life expectancy in Japan and cancers and, additionally, the average age of death from these diseases has shifted into older age with effective health prevention , 23. Thi\u2018the fourth stage of the epidemiologic transition: the age of delayed degenerative diseases\u2019 [This study also showed that the considerable contributions of CVD and cancers to the decreased gaps in old-age life expectancy between the two countries were largely related to the reduced ASMRs of CVD and cancers in South Korea. This result coincides with Olshansky and Ault\u2019s argument that death rates from degenerative diseases such as cancer and stroke rapidly decreased with effective and better healthcare services, as a country advances into, what they\u00a0referred to, iseases\u2019 . Previouiseases\u2019 \u201331. Partiseases\u2019  includiniseases\u2019 , 33. TheAlthough the epidemiological transition theory provides the theoretical background for the decreased gaps in life expectancy among the elderly between the two countries, any explanation of increases in the gaps between the two countries due to self-harms and falls, lower respiratory tract disease, Alzheimer\u2019s disease and dementia is incomplete. These causes may be a minor factor in the overall life expectancy; however, they are found in all three Level 1 classifications of cause of death . Furthermore, the increased gaps in old-life expectancy between South Korea and Japan resulted from three patterns of ASMRs from those causes. First, despite the similar levels of ASMRs of self-harm and falls in the two countries in 1997, in 2017 South Korea\u2019s ASMRs increased, whereas Japan\u2019s ASMRs decreased. Second, despite the overall higher ASMR of lower respiratory tract disease\u00a0in Japan between 1997 and 2017, South Korea\u2019s ASMR of lower respiratory tract disease increased, while Japan\u2019s ASMR decreased. Third, ASMRs of Alzheimer\u2019s disease and dementia increased in both countries between 1997 and 2017, but increased faster in South Korea. Although the main reasons behind the increase in the gaps from these patterns are undoubtedly multifactorial, rapid population ageing in South Korea may be the single most important factor.With regard to elderly mortality increases from self-harm and falls in South Korea, this is partly attributed to combined effects of South Korea\u2019s rapid family structural changes and population aging. For example, the proportion of the elderly population living alone in South\u00a0Korea rose almost two-fold from 17% in 1990 to 33% in 2015 , whereasWith regard to lower respiratory tract disease, the results showed that ASMRs of lower respiratory tract disease were higher in Japan than South Korea in both years, but the two countries had opposite trends. It is well documented that lower respiratory tract disease and pneumonia in high-income countries are more associated with old people and, increasingly, with the Nursing Home and Healthcare Associated Pneumonia (NHCAP) due to population ageing, in contrast to a large prevalence of Community Associated Pneumonia (CAP) among the younger population in low-income countries , 45. In With regard to Alzheimer\u2019s disease and dementia, the observed increase in the pattern between 1997 and 2017 in both countries should be interpreted carefully, in particular due to the difficulties in reporting dementia and Alzheimer\u2019s disease . First, The first limitation of this study is that it only focused on the top 20 causes of death based on South Korea in 2017, and thus the emerging causes of death among the elderly in both countries may have been missed. Secondly, although life expectancy is a valid indicator of a population\u2019s health status, this study cannot tell whether old adults in both countries lived longer and healthier lives or simply experienced extended periods of morbidity. Further studies to explore healthy life expectancy are required. Lastly, this case study investigated only two ageing countries in the Asia-pacific region. More comparative studies of increasing or decreasing gaps in life expectancy between other high or middle-income Asia-pacific countries\u00a0confronting a possible double burden of the increasing threat of non-communicable disease in parallel with emerging communicable disease due to demographic ageing should be carried out. Many countries in the Asian Pacific region are also experiencing accelerated population ageing, and therefore their governments are trying to prepare for sustainable health-care systems in response to the inevitable ageing of the population. This comparative study between high- income Asia-pacific countries in terms of cause-specific mortality and life expectancy can provide insights into how to relieve the future health burden associated with population ageing in countries in the Asian Pacific region.Taken together, old-age life expectancy can reflect health and wellbeing of an elderly population and investigating gaps in old-age life expectancy between countries can facilitate cross-national policy learning in an era of demographic ageing. This comparative study showed that age- and cause-specific contributions to the changes in old-age life expectancy can differ between two high-income and ageing countries. Moreover, although mortality changes in non-communicable diseases was a key influencing factor of decreasing gaps in old-age life expectancy between the two countries, the decreasing gaps might also be disturbed by emerging threats of communicable disease and injuries along with rapid demographic ageing.This study affirms that age- and cause-specific contributions to the changes in old-age life expectancy can differ between high-income Asia-pacific countries. Although the gaps in old-age life expectancy between high-income Asia-pacific countries are primarily attributed to mortality changes in non-communicable diseases, these countries should also identify potential emerging threats of communicable diseases and injuries along with demographic ageing in pursuit of healthy life years in old age."}
+{"text": "To determine the relationship between inflammation/immune-based indexes and deep venous thrombosis (DVT) incidence rate following tibial plateau fracturesRetrospective analysis of a prospectively collected data on patients undergoing surgeries of tibial plateau fractures between October 2014 and December 2018 was performed. Duplex ultrasonography (DUS) was routinely used to screen for preoperative DVT of bilateral lower extremities. Data on biomarkers  at admission were collected, based on which neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), monocyte/lymphocyte (MLR), and systemic immune-inflammation index  were calculated. Receiver operating characteristic (ROC) was used to determine the optimal cutoff value for each variable. Multivariate logistic regression analysis was used to evaluate the independent relationship of each biomarker or index with DVT, after adjustment for demographics, co-morbidities, and injury-related variables.Among 1179 patients included, 16.3% (192/1179) of them had a preoperative DVT. Four factors were identified to be significantly associated with DVT, including open fracture, increased D-dimer level. Among the biomarkers and indexes, only platelet and neutrophil were identified to be independently associated with DVT, and the significance remained after exclusion of open fracture. The other independent variables were elevated D-dimer level (> 0.55\u2009mg/L), male gender, and hypertension in the sensitivity analysis with open fractures excluded.These identified factors are conducive to the initial screening for patients at risk of DVT, individualized risk assessment, risk stratification, and accordingly, development of targeted prevention programs. Tibial plateau fracture represented 1\u20132% of adult fractures and 32% of peri-knee fractures . The preIn addition to external factors, there are increasing evidences that the internal factors, namely the systemic inflammation/immune response to trauma (hip fracture) or major surgical trauma (arthroplasty), played an important role in the development of DVT. Alexandru et al.  found thAs far as we know, specified at tibial plateau fracture, there remains no relevant data on the relationship between inflammation/immune indexes and preoperative DVT occurrence. In this study, we used the prospectively collected data in a level I trauma center to address this issue. Our aims were (1) to identify the optimal cutoff values of biomarkers or their derived indexes, (2) to evaluate their predictive ability for development of DVT, and (3) to evaluate their independent relationship with DVT after adjustment for demographics, co-morbidities, and injury-related characteristics.Data used in this study were obtained from the database of surgical site infection in orthopedic surgery (SSIOS), in which a prospective method was used to collect data on patients who underwent orthopedic surgeries between October 1, 2014, and December 31, 2018, and surveillance of surgical site during hospitalization and telephone follow-up after discharge were conducted to identify surgical site infections. The ethics committee of the 3rd Hospital of Hebei Medical University approved the SSIOS (NO 2014-015-1), and all the participants had written the informed consent.Patients meeting the following criteria were included: age of 18\u2009years or older, definite diagnosis of tibial plateau fracture, and complete data available. The exclusion criteria were pathological (metastatic) fracture, old fracture (> 3\u2009weeks from injury), tibial plateau fracture combined with vascular injury, concurrent fractures in other locations, patients with lower extremity myodynamia abnormality, patients with history of DVT or other thrombotic events, or current use of anticoagulants due to chronic comorbidities.According to our policy, all patients received basic thromboprophylaxis immediately after admission, consisting of chemical (low molecular weight heparin (LMWH), 2500\u20134100\u2009IU once daily, subcutaneous injection) and elevation of the injured lower extremity for each patient.Guideline for the diagnosis and treatment of deep vein thrombosis (3rd edition) proposed by Chinese Medical Association  was usedBiomarkers or biomarker-derived inflammatory/immune indexes were obtained from hematologic tests carried out after admission and before the definite operation. These data included neutrophil, lymphocyte, monocyte, and platelet counts. The NLR was defined as the neutrophil count divided by lymphocyte count, PLR as the platelet count divided by the lymphocyte count, and MLR as monocyte count divided by lymphocyte count. The systemic immune-inflammation index (SII) was calculated as: platelet count \u00d7 neutrophil count/lymphocyte count . Given tThe other potential factors included demographics ), current cigarette and alcohol consumption, the comorbidities , and fracture-related factors (injury mechanism (low- or high-energy trauma), open or closed fracture, fracture classification based on Schatzker classification system).2) was divided using the criteria recommended by the Chinese working group on obesity: normal (18.5\u201323.9), underweight (< 18.5), overweight (24.0\u201327.9), and obesity (\u2265 28.0) [The BMI (kg/m(\u2265 28.0) . Low-eneContinuous variables were expressed by mean and standard deviation (SD). The categorical data were expressed as number and percentage (%) and were evaluated by chi-square or Fisher\u2019s exact test, as appropriate.p < 0.05 as significance level. On basis of the cutoff values determined, each variable was divided in to two groups, and the chi-square or Fisher\u2019s exact test was performed, as appropriate. We also constructed ROC curve and used the generated AUC to evaluate the discriminatory ability of each biomarker or inflammation/immune index, when they were in dichotomous variable.For biomarker  and biomarker-derived inflammation/immune indexes  and the plasma D-dimer level in continuous variable, we constructed receiver operating characteristic (ROC) to determine the optimal cutoff value for each variable, when Youden index (sensitivity + specificity \u2212 1) was maximum. The significance of the ROC curve was tested using the area under the curve (AUC) analysis, with p < 0.10 were retained, and the correlation strength is indicated by odds ratio (OR) and 95% confidence interval (95% CI). The significance level was p < 0.05. Fitting degree of the final model was evaluated by Hosmer-lemeshow (H-L) test, and p > 0.05 indicated the acceptable result. SPSS23.0 was used to perform all the tests .In the multivariate logistics regression model, the included variables were those tested as statistically significant in the univariate analyses. The stepwise backward elimination method was used to exclude variables not significantly affecting the development of DVT. In the final model, variables with In this study, a total of 1179 patients with tibial plateau fractures were included, consisting of 742 males and 437 females, with an average of 45.6\u2009years . The mean days from admission to operation were 4.2 \u00b1 4.9\u2009days (0\u201316\u2009days). A total of 192 (16.3%) had a preoperative DVT. The preoperative DUS was performed at a mean of 3.9 \u00b1 3.6\u2009days (range 0\u201317\u2009days) after injury, by 5 different technicians.9/L; lymphocyte count, 1.24 \u00d7 109/L; monocyte, 0.78 \u00d7 109/L; platelet count, 278 \u00d7 109/L; NLR, 2.90; PLR, 207; MLR, 0.50; SII, 1066; and D-dimer, 0.55\u2009mg/L , D-dimer level (> 0.55\u2009mg/L), and PLT > 278 \u00d7 109/L .In the final multivariate logistic regression model, four risk factors were identified to be associated with DVT, including open fracture, neutrophil (> 5.02 \u00d7 10/L Table . The H-L9/L), D-dimer level (> 0.55\u2009mg/L), and PLT > 278 \u00d7 109/L remained significant in the multivariate model. Also, the gender  and hypertension were identified to be associated with occurrence of DVT .We also performed the sensitivity analysis after excluding the 71 open fractures. The results showed that neutrophil  but with a moderate specificity of 0.715; therefore, it might be a useful auxiliary tool to exclude patients without a DVT.In contrast, platelet and neutrophil count were found to be independently associated with DVT following tibial plateau fractures, regardless of the injury type. It is therefore suggested that increased number of neutrophils reflected the extent of inflammatory response, and activation of increased platelets is the necessity of the formation of DVT. The previous basic researches have described different mechanisms of DVT formation, including neutrophil extracellular traps (NETs), neutrophil histone modification \u201333, and D-dimer in plasma reflected the secondary increased fibrinolytic activity and the hypercoagulability, which was a well-established highly sensitive marker of thrombotic events, although the specificity was poor . AnotherThis study had some limitations. Firstly, as other multivariate analyses, not all the potential factors that affect the occurrence of DVT could be included, such as immobilisation of the injured extremity. As such, the residual confoundings remained. Secondly, C-reaction protein (CRP) was an important inflammatory biomarker predictive of DVT formation, but only a fraction of patients had the relevant data because it was not routinely measured in our hospital. Thirdly, the AUC for D-dimer, platelet, and neutrophil count was 0.628, 0.698, and 0.595, respectively, which indicated the moderate to poor predictive ability or reliability for DVT. Therefore, they should be treated cautiously, and in the current condition, combined diagnostic method with these factors may be a settlement. Fourthly, we determined the association rather than the causation between variables and DVT; therefore, these results should be interpreted with caution. Fifthly, this is a tertiary referral hospital, and patients referred would have more severe injury; therefore, the prevalence of DVT might be overestimated, and the generalizability of the results might be somewhat affected.In summary, 16.3% of patients had preoperative DVT after tibial plateau fracture, and among the common biomarkers or biomarker-based inflammatory/immune indexes, only platelet and neutrophil were identified to be associated with development of DVT, regardless of injury pattern. These factors are conducive to the initial screening for patients at risk of DVT, individualized risk assessment, risk stratification, and accordingly development of targeted prevention programs."}
+{"text": "The aim of this study was to investigate the presence of preoperative DVT following spinal fracture and the association between the presence of DVT and risk factors. Ultrasonography and blood analyses were performed preoperatively in patients diagnosed with spinal fracture between October 2014 and December 2018. Univariate analyses were performed on the data of demographics, comorbidities, location of injury, spinal cord injury (SCI) grading and laboratory biomarkers. The receiver operating characteristic (ROC) curve analysis was employed to obtain the optimal D-dimer cut-off value for diagnosis. In total, 2432 patients with spinal fractures were included, among whom 108 (4.4%) patients had preoperative DVTs. The average interval between fracture and initial diagnosis of DVT was 4.7\u00a0days , ranging from 0 to 20\u00a0days; 78 (72.2%) were diagnosed within 7\u00a0days after injury and 67 (62.0%) within 3\u00a0days; 19 (17.5%) patients had proximal vein involved and 89 (82.4%) presented in distal veins. Multivariate logistic regression suggested six risk factors independently correlated to DVT, including delay to DUS (in each day) (odds ratio [OR]\u2009=\u20091.11), ASA class III\u2013IV (OR\u2009=\u20092.36), ASIA grade (A/B) (OR\u2009=\u20092.36), ALB\u2009<\u20093.5\u00a0g/dL (OR\u2009=\u20092.08), HDL-C\u2009<\u20091.1\u00a0mmol/L (OR\u2009=\u20091.68) and  Consistent with the principles of Virchow\u2019s triad, spinal fracture is widely noted as a significant risk factor for DVT due to systematic hypercoagulability, possible injury in vascular endothelium and venous stasis (neurologic deficit or immobilization). Prior studies revealed\u00a0the prevalence of DVT was from 0.3 to 31% in patients who underwent spinal surgery, which were greatly heterogeneous on study population, follow-up duration and prophylactic strategy2. Specifically, traumatic patients with concomitant spinal cord injury had the occurrence rate of DVT as high as 80% without prophylaxis3.Venous thromboembolism, consisting of pulmonary embolism and deep venous thrombosis (DVT), is a major contributor to all-cause inpatient morbidity and mortality, particularly in patients undergoing traumatic injury. A previous survey based on the national fracture database in China reported the incidence of traumatic spinal fractures was 32.80/100,000 person-year6. Once DVT is diagnosed, it requires aggressive and prolonged therapeutic anticoagulation, and is often accompanied by the risk of bleeding, recurrence of DVT and significant healthcare cost, which increases the difficulty of perioperative management. Furthermore, a paucity of epidemiologic data on preoperative DVT following spinal fracture still exists, such as the incidence rate, locations and associated risk factors. It is therefore necessary to identify the preoperative DVT and perform timely evaluation by finding some certain predictive indicators.Although DVT is extensively studied in patients following major orthopedic surgery , the explicit guideline of perioperative prophylactic anticoagulation with regard to spinal fracture remains absent. However, in clinical practice, timely and accurate diagnosis can be hardly achieved due to occult characteristics of early DVT, which delays the thrombolysis treatment and presumably results in lethal complicationsThis retrospective study was designed to investigate the epidemiologic characteristics of preoperative DVT following spinal fracture based on the current diagnostic methodology and treatment algorithms in our institution, which might be conducive to early assessment on risk stratification for DVT. The secondary goal was to determine the risk factors for predicting the presence of DVT from the preexisting comorbidities or initial biomarkers at admission.The retrospective study was performed in accordance with Strengthening the Reporting of Cohort Studies in Surgery (STROCSS) guideline. The ethics committee of Third Hospital of Hebei Medical University approved this research and waived the requirement for informed consent due to the anonymous nature of data. This study included the patients with spinal fractures who underwent spinal surgery in Third Hospital of Hebei Medical University for surgical treatment between October 2014 and December 2018. The follow-up period lasted from injury to either diagnosis of DVT or surgical treatment. All the data were extracted from the electronic medical record system in our institution and retrospective analyses of overall 2432 patients were conducted, consisting of 1597 males and 835 females. Fasting blood analysis, duplex ultrasound (DUS) screening and detailed neurological examination were conducted after admission.7.In this study, patients who had spinal fracture and met the following criteria were included as eligible subjects. Inclusion criteria were: patients aged 18\u00a0years and older, definitive diagnosis of spinal fracture with complete medical data, presenting within 7\u00a0days after injury. Exclusion criteria were: pathological (metastatic) fracture, concomitant fracture at any other location, a history of venous thromboembolism, current oral contraceptive therapy, active malignancy, presence of hyper-coagulopathy or hematological disorders, or recent use of anticoagulants within 3\u00a0months for any other condition. Besides, we did not exclude the patients with suspected or diagnostic intraspinal hematoma (ISH), as previous findings suggested no convincing evidence was associated between ISH expansion and early initiation (<\u200948\u00a0h) of chemoprophylaxis8. This is a 5-level ranking system ranging from A to E, with ASIA Impairment Scale A representing a \u201ccomplete loss of neural function\u201d and patients who were \u201cneurologically intact\u201d were assigned an ASIA grade of E. In the current study, ASIA grading was grouped into grade A-B and grade C-E based on the presence or absence of motor function below neurologic level.Patients with spinal fracture included in this study received detailed neurological examination at admission. The American Spinal Injury Association (ASIA) Impairment Scale is a standardized neurological examination used to assess the severity of sensory and motor levels affected by SCI9. Venography was taken if DVT could not be diagnosed or ruled out by the DUS screening. Thrombosis present in the popliteal vein and/or above was defined as proximal DVT, whereas below the popliteal vein as distal DVT. Thrombus occurring both in calf and thigh veins were regarded as a case of proximal DVT. Prophylactic low-molecular-weight heparin (LMWH) was prescribed within the first 24\u00a0h after admission unless the spine surgeon determined an emergent need for spinal cord decompression or any other robust contraindication appeared. Intermittent pneumonic compression (IPC) was regularly used if a negative DUS result was reported. Therapeutic anticoagulants or interventional treatment would commence for DVT-positive patients according to our institutional protocol with complete resolution of symptoms.All the patients received DUS screening with Philips Affiniti 50 ultrasonographic machine  in bilateral lower limbs. An ultrasonography radiologist who was blind to any hematological results conducted the scanning to detect DVT within the first 48\u00a0h after admission, every 3\u20137\u00a0days and when any symptoms suggestive of DVT were exhibited. Therefore, all DVT reported in this study were symptomatic and asymptomatic at the time of diagnosis. Positive DUS results were confirmed with the presence of any signs as followed: direct visualization of intraluminal thrombus, loss of compressibility of the vein, vein dilated with a diameter greater than that of the adjacent artery, blunted or absent flow augmentation and lack of spontaneous flowThe comorbidities and demographic data consisted of gender, age, body mass index (BMI), current smoking, alcohol consumption, hypertension, diabetes, chronic heart disease, liver disease, kidney disease, time to DUS after injury, use of prophylactic LMWH and American Society of Anesthesiologists (ASA) classification, American Spinal Cord Injury Association (ASIA) Impairment Scale.d-dimer was performed using immunochromatographic assay kit. It was analyzed on Wondfo FS-301 Auto-Immunofluorescence Quantitative Analyzer . Other hematological values were analyzed on an automated hematological analyzer  and Automated Blood Coagulation Analyzer . All assays were performed within 60\u00a0min after sample collection in the central laboratory of our institution according to the manufacturers\u2019 instructions. Normal ranges for each assay were determined by the laboratory prior to evaluating the study specimens. Hematological biomarkers included total protein (TP) level, albumin (ALB) level, globulin (GLOB), alanine transaminase (ALT), aspartate transaminase (AST), alkaline phosphatase (ALP), gamma-glutamyl transpeptidase (GGT), cholinesterase (CHE), total bile acid (TBA), hypersensitive C-reactive protein (HCRP), lactate dehydrogenase (LDH), hydroxybutyrate dehydrogenase (HBDH), total cholesterol (TC) level, triglyceride (TG) level, high-density lipoprotein cholesterol (HDL-C) level, low-density lipoprotein cholesterol (LDL-C) level, very low-density lipoprotein (VLDL) level, serum sodium concentration (Na+), serum chlorine concentration (CL-) , white blood cell count (WBC) , neutrophil count (NEU), lymphocyte count (LYM), red blood cell count (RBC), hemoglobin (HGB) level, platelet (PLT), prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen (FIB), antithrombin III (AT III), platelet distribution width (PDW), mean platelet volume (MPV), d-dimer level and osmotic pressure (OSM).Overnight fasting blood samples were drawn by aseptic venipuncture from an antecubital vein after admission. The biochemical measurements were determined using an automated chemistry analyzer . Quantitative measurement of d-dimer is a useful screening parameter for DVT, while its cut-off value greatly varies for the diagnosis of DVT in different populations and settings11. In this study, receiver operating characteristic (ROC) curve analysis was employed and the area under the curve (AUC) was used to obtain the optimal cut-off value for DVT diagnosis.Plasma t test or Mann Whitney U test, as appropriate. Categorical data were expressed as number and percentage and were evaluated by Chi-square or Fisher\u2019s exact test, as appropriate. A multivariate logistic regression model was used to explore the independent risk factors predicting the occurrence of DVT, using the stepwise backward elimination method. Variables with P\u2009<\u20090.10 were retained in the final model, and the correlation strength is indicated by the odds ratio (OR) and 95% confidence interval (95% CI). The significance level was set as P\u2009<\u20090.05. The Hosmer\u2013Lemeshow (H\u2013L) test was used to evaluate the fitting degree of the final model, and a P value less than 0.05 represented an acceptable result.SPSS26.0 was used to perform all the statistical analyses . Continuous variables were presented by mean\u2009\u00b1\u2009standard deviation (SD), and were evaluated by Student Totally, 2432 patients with an operatively treated spinal fractures were included, among whom 108 patients had preoperative DVTs, indicating a morbidity of 4.4%. The details on locations of spinal fractures involved in this study were summarized in Table d-dimer, TP, ALB, ALT, AST, GGT, CHE, LDH, HBDH, HDL-C, Na+, WBC, NEU, RBC, HGB, PLT, PDW were tested as significantly different (Table d-Dimer\u2009>\u20091.08\u00a0\u00b5g/ml (OR\u2009=\u20092.49) (Table 2\u2009=\u20090.246).The optimal cut-off for D-dimer was 1.08ug/ml according to the AUC analysis  Table . The Hos2. This great variation could be explained by the heterogeneities in research design, method of surveillance and prophylactic strategy.The current study, to our best knowledge, is the first investigation that aimed at the preoperative rate of DVT for patients with spinal fractures who received early commencement of thromboprophylaxis and regular use of DUS screening. We found the preoperative incidence of DVT was 4.4% in this certain population, which largely varied from previous findings that basically focused on (ranging 0.3% to 31%)12, which predisposes patients to a hypercoagulable condition. Furthermore, in patients with paraplegia or quadriplegia, venous stasis would deteriorate due to the loss of motor function below the neurologic level. In this study, it is of noted that patients with ASIA (grade A/B) had a 2.36-fold increased risk for the following occurrence of DVT, compared to those graded C\u2013E. The independent association between ASIA (grade A/B) and preoperative DVT was identified in DVT predicting and stratifying among patients with spinal fracture, which was in concordance with the findings by Toker et al.13. In conjunction with chemoprophylaxis, timely and regular IPC might optimize the preoperative antithrombotic regimen formulated for such subgroup. Additionally, it is worth conducting a randomized controlled trial to verify the effect of aggressive intervention against DVT and whether there exists a long-term benefit during the neurologic rehabilitation period.Previous literature has well demonstrated physiologic responses that remarkably upregulate plasma procoagulant activity following trauma16. Although old age was notably related with higher ASA17, and older age was a widely-accepted risk factor of developing DVT, we found no significant association between the presence of DVT and older age, which might be due to that older age served as a confounding role in ASA class assignment for this study population. Given many morbidities and ASA class were identifiable after admission, the risk of DVT and other complications related to spinal fracture might be reduced following specific interventions.American Society of Anesthesiologists (ASA) classification was originally developed as a potential risk stratification tool that is used to assess patients\u2019 preoperative physical status. In the current study, the ASA class was analyzed as a surrogate of preoperative comorbidities to rank the risk of DVT in patients with spinal fracture. We found that patients with ASA class III-IV had 2.36-fold greater odds of developing DVT over patients with ASA class I-II before surgery. Similarly, the DVT-prediction effect of ASA class was also demonstrated and emphasized in previous studies18. Preoperative albumin level has been extensively studied as an important index in the estimation of complications and prognosis for patients undergoing surgery21. In this study, patients with low albumin levels following spinal fracture had 2.08-fold odds to develop DVT than those within normal albumin level, which was in consistent with the findings reported on other orthopedic population22. An increasing body of evidence indicates that hypoalbuminemia triggers hyperfibrinogenemia and platelet aggregability and can be reversed by infusing albumin24. As a modifiable and independent risk factor, hypoalbuminemia in this population could be improved with therapeutic strategies, although future prospective studies should be conducted to investigate whether the risk of DVT could be reduced by correcting malnutrition after spinal fracture.Hypoalbuminemia refers to serum albumin level lower than 3.5\u00a0g/dL, which is regarded as a marker of malnutrition in trauma patients25. Although epidemiological studies and experimental animal models conclude that HDL-C exerts the protection from atherosclerotic cardiovascular diseases27, its antithrombotic composition and function in venous thromboembolic events are more and more recognized28. As for the exact connection between HDL-C level and DVT, several underlying mechanisms have been proposed that HDL-C helps downregulate platelet hyperreactivity, inhibit the coagulation cascade as well as facilitate fibrinolysis29. Thus, the low HDL-C level contributes less to coagulation homeostasis in spinal fracture, potentially resulting in a thrombotic tendency. Before well-grounded evidence emerges, low HDL-C level should not be neglected in the stratification of DVT.In this study, the decreased HDL-C (<\u20091.1\u00a0mmol/L) was associated with the increased risk of DVT (OR\u2009=\u20091.68) after adjustment for confounding caused by other risk factors, which was strongly in line with the previous conclusions reported by Deguchi et al.d-dimer threshold used to determine a positive result was intentionally set low to maximize the sensitivity and reduce false negative rates. However, maximizing sensitivity comes along with lowering specificity30. There was a paucity regarding the upper cut-off value of d-dimer in predicting of positive DVT. In the univariate analysis, the pre-set D-dimer cut-off value (0.5\u00a0\u00b5g/ml) had a notable but statistically nonsignificant association with the subsequent DVT, which reflected that adjusting the threshold according to certain medical condition was warranted32. According to the results of ROC analysis, the optimal cut-off value of D-dimer was 1.08\u00a0\u00b5g/ml for the purpose of predicting DVT event, much higher than the pre-set threshold. The final analysis showed that patients with D-dimer level\u2009>\u20091.08\u00a0\u00b5g/ml had 2.49-fold increased risk for DVT in contrast with its counterparts, independent of presence of other comorbidities. Thus, we assumed that stratifying the risk for DVT based on the adjusted cut-off level seemed to be conducive to increasing the specificity as well as improving the predictive value in spinal fracture.Typically, the 33 observed a notable correlation between the period of delay and the incidence of thromboembolism event in the population with acute hip or femur fracture. Since all the patients included in this study were screened by DUS within the first 48\u00a0h after admission, the difference was mainly due to the referral events. As a tertiary trauma center, our impression was that patients referred from other hospitals  seemed to commence anticoagulant therapy later than the non-referral population. On account of the methodological limitation, it appeared to be unlikely to collect the detailed information on chemoprophylaxis therapy at the referring hospital. Due to the fact that IPC as an adjunctive treatment was initiated after the confirmation of absence of DVT, the late use of IPC may have some correlation with the formation of DVT, particularly in those who are delayed by referrals. Thus, the explicit association between IPC and occurrence of DVT should be further researched. Before the consensus emerges, it was worth considering to perform timely screening for DVT and early initiation of anticoagulation therapy in hospital of all levels for delayed hospitalized patients.There was a statistically significant association with the occurrence of DVT and prolonged time between injury and DUS detection. In this study, we found the delay to DUS in each day is independently associated with 11% elevated risk for DVT despite the use of prophylactic anticoagulation. Similarly, Smith et al.There were several inherent limitations in this study. Firstly, because of the nature of the multivariate analysis, we could hardly include all the variables that might potentially influence the statistical results. Secondly, the relations between the variables and DVT were of association, not of causality. Therefore, the results should be interpreted and integrated with clinical situations. Thirdly, the thromboprophylaxis in referring hospital might make some difference in the following DVTs occurred in our institution, yet it could be hardly captured in our database. Fourthly, to improve the internal validity, we exclude patients with several certain medical conditions , so our findings may be less applicable to such populations.d-Dimer\u2009>\u20091.08\u00a0\u00b5g/ml and the delay to DUS, helps surgeons to refine the risk stratification profile. In addition, by performing early interdisciplinary management, the DVT rate and associated medical burden can be diminished in patients undergoing spinal surgery, particularly those who are predisposed to it.In conclusion, the preoperative incidence of DVT was 4.4% following spinal fracture. Understanding the risk factors, including ASA class III-IV, ASIA grade A/B, ALB\u2009<\u20093.5\u00a0g/dL, HDL-C\u2009<\u20091.1\u00a0mmol/L,"}
+{"text": "Limited information exists on the incidence of postoperative deep venous thromboembolism (DVT) in patients with isolated patella fractures. The objective of this study was to investigate the postoperative incidence and locations of deep venous thrombosis (DVT) of the lower extremity in patients who underwent isolated patella fractures and identify the associated risk factors.Medical data of 716 hospitalized patients was collected. The patients had acute isolated patella fractures and were admitted at the 3rd Hospital of Hebei Medical University between January 1, 2016, and February 31, 2019. All patients met the inclusion criteria. Medical data was collected using the inpatient record system, which included the patient demographics, patient\u2019s bad hobbies, comorbidities, past medical history, fracture and surgery-related factors, hematological biomarkers, total hospital stay, and preoperative stay. Doppler examination was conducted for the diagnosis of DVT. Univariate analyses and multivariate logistic regression analyses were used to identify the independent risk factors.Among the 716 patients, DVT was confirmed in 29 cases, indicating an incidence of 4.1%. DVT involved bilateral limbs (injured and uninjured) in one patient (3.4%). DVT involved superficial femoral common vein in 1 case (3.4%), popliteal vein in 6 cases (20.7%), posterior tibial vein in 11 cases (37.9%), and peroneal vein in 11 cases (37.9%). The median of the interval between surgery and diagnosis of DVT was 4.0\u2009days . Six variables were identified to be independent risk factors for DVT which included age category (>\u200965\u2009years old), OR, 4.44 (1.34-14.71); arrhythmia, OR, 4.41 (1.20-16.15); intra-operative blood loss, OR, 1.01 (1.00-1.02); preoperative stay (delay of each day), OR, 1.43 (1.15-1.78); surgical duration, OR, 1.04 (1.03-1.06); LDL-C (>\u20093.37\u2009mmol/L), OR, 2.98 (1.14-7.76).Incidence of postoperative DVT in patients with isolated patella fractures is substantial. More attentions should be paid on postoperative DVT prophylaxis in patients with isolated patella fractures. Identification of associated risk factors can help clinicians recognize the risk population, assess the risk of DVT, and develop personalized prophylaxis strategies. Deep vein thrombosis (DVT) is common in hospitalized patients especially those with trauma. It is an important source of morbidity and causes fatal pulmonary embolism (PE). Researchers have investigated the occurrence of DVT in patients who had undergone orthopedic major surgeries . AuthorsHowever, studies on the incidence of DVT in patients with isolated fractures of the lower extremities are limited. Minimal studies have focused on the thromboembolic events in femoral shaft fracture , tibia fThis was a retrospective study. This research was approved before the start of the study by the ethics committee of the institution .This research consisted of hospitalized patients with isolated patella fractures admitted in the institution between January 1, 2016, and February 31, 2019. The demographic variables and clinical data were acquired from the medical records. Inclusion criteria were as follows: (a) age > 18\u2009years old, (b) confirmed isolated patella fracture, (c) underwent operation treatment, and (d) with complete medical data. Exclusion criteria were as follows: (a) pathological fracture, (b) old fracture (treatment delayed >\u20093\u2009weeks), (c) open fracture, (d) concurrent with other fractures or cerebral trauma, (e) nonsurgical treatment, (f) incomplete clinical data, (g) administration of anticoagulants on admission for treatment of other illnesses, (h) preoperative diagnosis of DVT, and (i) patients who had suffered hemorrhagic stroke.In the institution, routine anticoagulant therapy was administered to all the hospitalized patients with patella fractures . Mechanical thromboprophylaxis (ankle pump exercise) was also administered to each patient.DVT in lower extremities was identified using duplex ultrasound scanning. The diagnostic data of DVT was obtained from the Doppler ultrasound reports.Duplex ultrasound scanning was conducted in postoperative patients with suspected clinical symptoms such as swelling, lower limb pain, and superficial varicose veins. Deep venous obstruction or constant intraluminal filling defect was an indication of DVT diagnosed using Doppler ultrasound. Conventional scanning included the common femoral vein, superficial femoral, deep femoral vein, popliteal vein, anterior tibial vein, posterior tibial vein, and common fibular vein. Intermuscular vein thrombosis was excluded due to its less clinical significance .2) was grouped into four types: normal (18.5-23.9), underweight (<\u200918.5), overweight (24.0-27.9), and obesity (\u2265 28.0). Age was categorized into three categories: 18 and 44\u2009years, 45 and 64\u2009years, and > 65\u2009years old. Low energy damage was defined as the damage caused by falling from a standing height. Other damages, such as traffic accidents and falling from a height, were defined as high-energy injuries.Clinical data was collected using electronic medical records (EMR). The time when the postoperative duplex ultrasound examinations were conducted on patients was recorded. Data on patient demographic variables such as age, gender, BMI (body mass index), patients\u2019 bad hobbies such as cigarette smoking and alcohol consumption were also determined. Data on comorbidities collected in this study included hypertension, diabetes mellitus, ischemic heart disease, arrhythmia, and chronic lung diseases. Data on past medical history contained history of cerebral infarction and previous surgery. Fracture-related data consisted of injury mechanism (low or high energy) and fracture type (simple or comminuted). Surgery-related data included ASA (American Society of Anesthesiologists) classification, anesthesia, surgical duration, intraoperative blood loss, and tourniquet. Preoperative stay (from injury to operation) and total hospital stay were also included in the study. BMI  level, ALB  level, FBG (fasting blood glucose) level, RBC (red blood cell) count, WBC (white blood cell) count, NEUT (neutrophile) count, LYM (lymphocyte) count, HGB (hemoglobin) level, HCT (hematocrit), PLT (platelet), PDW (platelet distribution width), RDW (red cell distribution width), TC  level, TG (triglyceride) level, LDL-C (low-density lipoprotein cholesterol) level, HDL-C (high-density lipoprotein cholesterol) level, very low-density lipoprotein (VLDL) level, and D-dimer level. All the biomarkers data were obtained from the laboratory tests that were closest at the diagnostic time of postoperative DVT.t test  or Mann-Whitney U test . Categorical variables were compared with chi-square or Fisher\u2019s exact test. A multivariate logistics regression model was established and a stepwise backward elimination method was utilized to determine independent risk factors correlated with DVT. Variables with p <\u20090.10 were kept in the final model, and the correlation strength was expressed in terms of OR (odds ratio) and 95% CI . The statistical test level was p <\u20090.05. Hosmer-Lemeshow (H-L) test was performed to assess the fitting degree of the final model, and p >\u20090.05 indicated eligibility. All data were analyzed in SPSS23.0 .Continuous data were shown in the form of means and standard deviations (SD). Categorical data were shown in the form of numbers and percentages. Continuous variables were compared with Student p = 0.002; categorical, p = 0.000), hypertension (p = 0.008), arrhythmia (p = 0.000), chronic lung diseases (p = 0.038), preoperative stay (p = 0.004), intraoperative blood loss (p = 0.015), surgical duration (p = 0.000), LDL-C (>\u20093.37\u2009mmol/L) (p = 0.027), HCT (<lower limit) (p = 0.021), PLT (>\u2009300 \u00d7 109/L) (p = 0.010), D-dimer (>\u20090.3\u2009mg/L) (p = 0.007). Variables significantly different in the univariate analysis and the variable of alcohol consumption (p = 0.051) were involved in the multivariate model. Six variables were determined to be independent risk factors for DVT. These six variables included age category (>\u200965\u2009years old), OR, 4.44 (1.34-14.71); arrhythmia, OR, 4.41 (1.20-16.15); intra-operative blood loss, OR, 1.01 (1.00-1.02); preoperative stay (delay of per day), OR, 1.43 (1.15-1.78); surgical duration, OR, 1.04 (1.03-1.06); and LDL-C (>\u20093.37\u2009mmol/L), OR, 2.98 (1.14-7.76) (Table p = 0.727).A total of 716 patients with isolated patella fractures, who underwent surgical treatment, met the inclusion criteria. There were 425 male and 291 female patients. The average age was 51.3 \u00b1 14.6\u2009years . The average preoperative stay (from injury to operation) was 3.8 \u00b1 2.8\u2009days , and the average hospitalization stay was 11.8 \u00b1 5.4\u2009days . During the period of hospitalization, no one was diagnosed with symptomatic PE (pulmonary embolism). Of the 716 patients, 29 cases were diagnosed with postoperative DVT with the incidence rate of 4.1%. One case (3.4%) developed DVT in bilateral limbs (injured and uninjured). There was DVT located in superficial femoral common vein in 1 case (3.4%), popliteal vein in 6 cases (20.7%), posterior tibial vein in 11 cases (37.9%), and peroneal vein in 11 cases (37.9%). DVT was absent in the anterior tibial vein. The median of the interval between surgery and diagnosis of DVT was 4.0\u2009days . The results of univariate analysis were presented in Table Three of the diagnosed cases  of DVT were treated with insertion of retrievable IVCF (inferior vena cava filters) combined with anticoagulation therapy. The other diagnosed cases of DVT were treated with intravenous infusion of heparin during hospitalization, and oral warfarin for 3\u2009months after discharge. APTT  was used to monitor the therapeutic level of heparin while INR  was used to monitor the therapeutic level of warfarin.Researchers have focused on the incidences of DVT following surgical treatment of the lower extremity fractures. However, many researchers failed to differentiate specific fracture sites , 15. StuBoth of the above studies indicated that DVT following isolated patella fractures mostly referred to the calf vein . However, controversy exists on the treatment of isolated calf DVT. The effects of anticoagulation on the morbidity and mortality of calf DVT remain inconclusive , 16\u201319. Se-Jun Park et al. performed a study to compare the incidence of thrombus treated with and without thromboprophylaxis in patients with lower extremity fractures [The risk of PE and mortality grew greatly due to the complication of DVT in patients who underwent major orthopedic surgeries. Chemical thromboprophylaxis has become a routine procedure after major orthopedic surgeries . Howeverractures . Se-Jun ractures . Zheng eractures , 22. Theractures . Routinep = 0.015). This was slightly different with the Lee SY et al.\u2019s results [Identification of risk factors for postoperative DVT in patients who underwent patella fractures is of great significance. In this study, multivariate analysis revealed that age category (age > 65\u2009years old), arrhythmia, intra-operative blood loss, surgical duration, preoperative stay (each day delay in surgery), and LDL-C (>\u20093.37\u2009mmol/L) are independent risk factors for postoperative DVT in patients with isolated patella fractures. Advanced age correlated with increased occurrence of DVT. However, few studies indicated that there is no correlation between the occurrence of thromboembolic events and age . The vas results . This imStudies have analyzed the effect of various comorbidities on the occurrence of DVT. Comorbidities such as hypertension, coronary heart disease, arrhythmia, diabetes mellitus, and chronic lung disease have been reported to be risk factors for DVT in different studies . Howeverp <\u20090.001). The reasons for delay in surgery in the institution were mainly as follows: (a) many patients were referred to the hospital from lower-level hospitals, (b) multi-disciplinary consultation and preoperative evaluation in the elderly patient for severe comorbidities, etc.Delayed operation prolonged immobilization of the wounded lower extremity. This was one of the main etiological factors for DVT in trauma patients. Smith et al. found that if operation was delayed >\u20091\u2009day, the daily increment incidence was 14.5% while it was 33.3% if the operation was delayed >\u20097\u2009days in a prospective study . In thisThe surgery-related factors were reported to influence the occurrence of postoperative DVT. A study showed that an increase in surgical duration was closely correlated with an increase in the risk for VTE . This waThis research had some limitations. First, the research was retrospective which affected the precision of the data. Secondly, some cases were randomly abandoned for incomplete data which could have influenced the results. Thirdly, this was a single-center study; thus, multi-center study is needed in the future. Fourthly, Doppler ultrasound scanning was conducted only in the patients clinically suspected of DVT. Additionally, thrombus monitoring was limited to hospitalization. After discharge, the thrombus was not continuously monitored, which could have underestimated DVT incidence.Incidence of postoperative DVT in patients with isolated patella fractures is substantial. More attention should be paid on postoperative DVT prophylaxis in patients with isolated patella fractures. Identification of associated risk factors can help clinicians recognize the risk population, assess the risk of DVT, and develop personalized prophylaxis strategies."}
+{"text": "Despite the modern prophylactic regimen, the preoperative DVT in patients with pelvic and acetabular fractures still draws the attention of orthopaedic surgeons. Better understanding these risk factors can help surgeons refine the risk stratification profile and perform early interdisciplinary management for patients at high risk of DVT.The objective of this study was to investigate the prevalence of preoperative deep venous thrombosis (DVT) in the pelvic cavity and lower extremities following pelvic and acetabular fractures and to identify the risk factors of the occurrence of DVT. Duplex ultrasound (DUS) screening and blood tests were conducted in patients admitted from June 2012 to December 2020 for surgical treatment of pelvic and acetabular fractures. Univariate analyses were performed on data of demographics, comorbidities, time from injury to surgery, injury mechanism, accompanied injury, and laboratory results. The optimal cutoff values of continuous variables with statistical significance were obtained by using the receiver operating characteristic (ROC) curve. A multivariate logistic regression analysis was then employed to examine the independent values in terms of predicting preoperative DVT. A total of 607 patients with pelvic and acetabular fractures were included, among whom 82 (13.5%) patients sustained preoperative DVTs. Specifically, 31.7% (26/82) were diagnosed with proximal DVTs. Fifty-two (63.4%) patients had DVT within 7\u00a0days after injury, and 67 (81.7%) patients within 10\u00a0days. The multivariate logistic regression analysis identified 6 factors independently associated with the presence of preoperative DVT, including age\u2009>\u200946\u00a0years (odds ratio [OR]\u2009=\u20092.94), BMI\u2009>\u200926.73\u00a0kg/m Pelvic and acetabular fractures are commonly caused by blunt high-energy potentially life-threatening injuries, and their perioperative management remains controversial and challenging , 2. TrauConsensus on the routine chemoprophylaxis for elective orthopaedic surgeries (hip or knee arthroplasty) has been reached and explicitly validated. However, the importance of thromboprophylaxis following pelvic and acetabular fractures is undervalued due to a lack of refined data of DVT, manifesting large variations in incidence, risk factors, screening methodologies, anatomic locations of clots, and optimal thrombosis \u20139. DVTs Taken together, the data regarding incidence and risk factors specific to the subgroup with pelvic and acetabular fractures are scarce. The objectives of this study included: (1) to investigate the incidence of DVT during the preoperative hospital stay for surgically treated pelvic and acetabular fractures, and (2) to identify the risk factors independently associated with the occurrence of DVT by employing statistical analyses.This retrospective, single-center study was performed following principles of the international guidelines for human research protections, the Declaration of Helsinki, and it was in line with Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Guidelines. All components of the study were approved by and covered under the Institutional Review Board, Faculty of Medicine, Handan Central Hospital, Handan, China. Informed consent was signed by all the participants. All the patients included in this research were admitted to our hospital from June 2012 to December 2020 for surgical treatment of pelvic and acetabular fractures. The study period started from injury to either occurrence of DVT or operation. All the data were abstracted from the radiology information system and electronic medical record system.Inclusion criteria were (1) patients admitted to our institution from June 2012 to December 2020 and received surgical treatment, (2) age of 18\u00a0years and older, and (3) definite diagnosis of pelvic and/or acetabular fractures with complete medical data. Exclusion criteria were (1) pathological (metastatic) fracture, (2) injury associated with the fracture that required immediate surgical intervention, (3) active malignant tumor, (4) a history of venous thromboembolic disease, or (5) recent use of anticoagulants for other indications within 3\u00a0months.The inpatients\u2019 comorbidities and demographic data were retrieved from the electronic medical record system, radiographic image, and operation report system. The information included sex, age, body mass index (BMI), diabetes mellitus, chronic heart disease, hypertension, smoking habits (current smoker or not), alcohol consumption (daily drinker or not). Trauma-related data comprised the following information: (1) type of fracture: pelvic ring fractures being classified according to Young\u2013Burgess classification  and acetOvernight fasting blood samples were drawn and measured at the central laboratory of our institution according to the manufacturers' instructions. The reference value of each inspection item was determined by the laboratory before reporting the patient's test results. Hematological indicators of interest included albumin (ALB) level, high-density lipoprotein cholesterol (HDL-C) level, low-density lipoprotein cholesterol (LDL-C) level, very-low-density lipoprotein (VLDL) level, red blood cell (RBC) count, hemoglobin (HGB) level, platelet (PLT), prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen (FIB) and D-dimer level.Venography was taken as the golden standard if DVT could not be ruled out by the duplex ultrasound (DUS) screening. All the patients underwent DUS screening and monitoring on bilateral lower extremities and pelvis with Philips Affiniti50 ultrasonographic machine  after admission, every 5\u20137\u00a0days or when any suspected symptoms appeared, according to authors\u2019 institutional protocol. Senior sonographers performed the scanning from the calf veins to iliac veins for positive DVTs. The diagnostic criteria included direct visualization of intraluminal thrombus, the presence of an intraluminal defect, loss of compressibility of the vein, blunted or inadequate flow augmentation, and lack of spontaneous and respirophasic flow above the knee segments . Spiral After admitted to the hospital with a negative result of DVT, all the patients were administered with intermittent pneumatic compression on lower limbs and a prophylactic dose of the low-molecular-weight heparin  within 48\u00a0h. For those with hemodynamic instability, pharmacological prophylaxis was prescribed once stable. Patients with positive DVTs were given therapeutic anticoagulants , and withheld the mechanical prophylaxis immediately. For patients with proximal DVT, preoperative placement of a retrievable vena cava filter was performed as prophylaxis against intraoperative and postoperative pulmonary embolism. Chemical prophylaxis was stopped 12\u00a0h before surgery.t test or Mann\u2013Whitney U test, as appropriate. Variables with statistical significance (p\u2009<\u20090.05) were analyzed by using the receiver operating characteristic (ROC) curve to obtain the optimal cutoff values associated with the presence of DVT. Afterward, these factors were converted from continuous variables into categorical variables. A Pearson Chi-square test or Fisher's exact test was used, to evaluate the association between inter-groups, expressed as number and percentage. A multivariate logistic regression analysis was performed to examine the independent value of each significant variable from the univariable analyses in terms of predicting the outcome of preoperative DVT. Variables with a p-value less than 0.10 were retained in the final model, and the correlation strength was represented by odds ratio (OR) and 95% confidence interval (95% CI). The fitting degree of the model was evaluated by Hosmer\u2013Lemeshow (H\u2013L) test. Data with a p-value less than 0.05 were considered statistically significant.All the statistical analyses were employed by SPSS26.0 . Continuous variables were expressed as mean\u2009\u00b1\u2009standard deviation (SD)/median . The Kolmogorov\u2013Smirnov\u00a0test was performed to evaluate the normality of the continuous data, and then, these data were compared between DVT group non-DVT group by using Student-In total, 607 patients with pelvic and acetabular fractures were included in this study. There were 342 males and 265 females with a mean age of 45.4\u2009\u00b1\u200914.3\u00a0years (range:18\u201390). According to the results of fracture classification, 291 had pelvic fractures , and 316 patients sustained acetabular fractures   and specifically, 31.7% (26/82) was diagnosed with proximal DVTs, which required placement of a vena cava filter. To be noted, in those with proximal DVTs, only 5 patients had an isolated thrombus in the thigh or pelvic vein, each of the other 21 patients had multiple thrombi in both proximal and distal veins at the first detection time of DVT. There were 13 cases of DVT in bilateral lower limbs and 69 cases in unilateral extremities. Twenty-four cases of DVT occurred in the injured limbs, 3 in uninjured limbs, and 1 in bilateral limbs. The mean time from injury to the diagnosis of DVT was 6.4\u00a0days, ranging from 1 to 16. Fifty-two (63.4%) patients had DVT within 7\u00a0days after injury, and 67 (81.7%) patients within 10\u00a0days. During the research period, no pulmonary embolism or uncontrolled bleeding was observed in patients.The comparison of continuous variables in patients with or without DVT was conducted, and the results are listed in Table 2, 9\u00a0days, 32.8\u00a0g/L, 332.5 *109/L, and 3.09\u00a0g/L, respectively (Table 2), hypertension, time from injury to surgery (>\u20099\u00a0days), associated injury, ASA classification (III\u2013IV), ALB (<\u200932.8\u00a0g/L), PLT (>\u2009332.5) and FIB (>\u20093.095\u00a0g/L) , time from injury to surgery\u2009>\u20099\u00a0days (OR\u2009=\u20095.39), associated injury (OR\u2009=\u20097.85), ALB\u2009<\u200932.8\u00a0g/L (OR\u2009=\u20092.71) and FIB\u2009>\u20093.095\u00a0g/L (OR\u2009=\u20093.34). The Hosmer\u2013Lemeshow test demonstrated excellent fitness of the final model .The multivariate logistic regression analysis showed 6 factors were identified independently associated with the presence of preoperative DVT. The adjusted results are summarized in Table To the best of our knowledge, this is one of the largest retrospective studies conducted on the incidence and risk factors of preoperative DVT in patients undergoing pelvic and acetabular fractures. Despite the use of the modern prophylactic regimen, our results indicated a 13.5% incidence of DVT before surgery, with 31.7% of those being proximal veins in origin. In addition to some well-established predisposing factors such as older age or obesity, other risk factors also exhibited independent association with preoperative DVT, which was partially consistent with prior studies on population with fractures \u201320. Howep\u2009<\u20090.001), and the morbidity of DVT in patients aged older than 46\u00a0years was 67.1%, significantly higher than the rate of their counterparts . After adjusting the confounding factors, we found the patients with pelvic and acetabular fractures over 46\u00a0years old had a 2.94-fold increased risk of DVT than that of the younger ones. Similarly, Kim et al. [Increased age has been well-acknowledged as one of the principal risk factors for thromboembolic diseases, particularly in trauma patients , 20, 21,m et al.  identifim et al. . Given t2, which was determined according to the ROC analysis. It was found that obesity resulted in 3.91-time increased odds of developing DVT in this trauma group (p\u2009=\u20090.001). Similar findings have been reported by Morris et al. [It has been widely recognized that orthopaedic patients with elevated BMI have a higher risk of perioperative complications than patients within the normal range , 24. Hows et al.  who founs et al.  reporteds et al. . We did p\u2009<\u20090.001), consistent with previously published findings [In the present study, the incidence of DVT in patients with concurrent injuries was significantly higher than those with isolated pelvic and/or acetabular fractures. The regression model indicated it played an independent role in the formation of a venous clot, although pelvic and acetabular fractures themselves have been generally believed to be at high risk of thromboembolic events. It appeared to be an accumulative effect of polytrauma on amplifying the risk. Our results suggested that patients with accompanied injury demonstrated a remarkably elevated risk of DVT compared to those without other injuries  and outcome (DVT) in the certain population. Despite the numerous studies regarding FIB associations, the precise relationship between PLT count and FIB levels has yet to be fully investigated.Hypoalbuminemia is adversely associated with complications and prognosis after major orthopaedic surgeries , 31. A rWe conducted a large investigation on the incidence and risk factors of preoperative DVT in patients undergoing pelvic and acetabular fractures. However, the current study has some limitations. Firstly, this is a single-center, retrospective, case\u2013control study, which carries some inherent weaknesses. For example, the risk factors measured in our study represent associated instead of causal relationships, which should be interpreted with clinical practice. And, some variables that potentially influence the statistical results might not be included in this study. Secondly, the main diagnostic method of DVT is color Doppler ultrasonography that may miss the venous thrombosis in the pelvis, compromising the effectiveness of the analysis results. Thirdly, to improve the internal validity, patients with certain medical conditions  were excluded, so our findings may be less applicable to patients with such features.2, time from injury to surgery\u2009>\u20099\u00a0days, associated injury, ALB\u2009<\u200932.8\u00a0g/L, and FIB\u2009>\u20093.095\u00a0g/L. Better understanding these risk factors can help surgeons refine the risk stratification profile and perform early interdisciplinary management for patients at high risk of DVT.In summary, the modern prophylactic regimen reduced the incidence of preoperative DVT in patients with pelvic and acetabular fractures to 13.5%, but orthopaedic surgeons\u2019 attention should still be paid to patients with age\u2009>\u200946\u00a0years, BMI\u2009>\u200926.73\u00a0kg/m"}
+{"text": "The purpose of this study was to investigate the incidence of deep vein thrombosis (DVT) and clarify the risk factors of DVT in patients with femoral neck fracture.A self-designed questionnaire was used to collect the clinical data of 1209 patients with femoral neck fracture in our hospital from January 2019 to December 2019. The content of the questionnaire mainly includes general information, past medical history, history of present illness, operation related information, occurrence of DVT. The collected data were entered into Excel to analyze the incidence and risk factors of DVT in patients with femoral neck fracture. Chi square test and binary logistic regression model was used to screen the risk factors of DVT.1209 cases of femoral neck fracture were included in this study. The incidence of DVT was 28.0% (339 patients). Among them, 71.7% (243 patients) were preoperative DVT and 28.3% (96 patients) were postoperative DVT. For the risk-factor analysis, gender, age, time from injury to hospitalization, operative method, anesthesia method and intraoperative blood loss were independent risk factors for DVT.The incidence of DVT in patients with femoral neck fracture is relatively high, and there are many related risk factors. Femoral neck fracture is a common type of hip fracture. A cross-sectional study involving 27,462 people found that the incidence of femoral neck fracture in trauma patients is as high as 38.5% . With thGeneral information This retrospective study collected the clinical data of patients with femoral neck fracture who were hospitalized in our hospital from January 2019 to December 2019. A total of 1209 cases were included. Inclusion criteria were the following: (1) Age\u2009\u2265\u200914 years old; (2) After X-ray examination, it was diagnosed as femoral neck fracture. Exclusion criteria were the following: (1) Age\u2009<\u200914 years old; (2) Multiple fractures; (3) VTE was diagnosed before injury; (4) There was no deep vein ultrasound examination during hospitalization; (5) The length of stay was less than 3\u00a0days. In this study, patients without anticoagulant contraindications were given subcutaneous injection of low molecular weight heparin for prophylactic anti-coagulation; Patients without DVT were given antithrombotic pump  for thrombosis prevention.Methods The retrospective observational study was approved by the Ethics Committee of The Third Hospital of Hebei Medical University. According to the purpose of the study, combined with the literature and expert opinions, we designed the questionnaire. The content of questionnaire contained 6 aspects: general condition , history of past illness , history of present illness, operation related information , disease diagnosis and the location of the thrombosis.We retrieve the data contained in the questionnaire from the electronic medical record system. And enter the data into the EXCEL table for sorting and analysis. The epidemiological status and risk factors of DVT in patients with femoral neck fracture in 2019 were analyzed.Diagnostic methods and standards of DVT Color Doppler ultrasound was used to diagnose DVT. The first time is within 24\u00a0h after admission and 3\u20135\u00a0days after operation. If the preoperative time is more than 7\u00a0days and the D-dimer is increased, an additional ultrasonic examination is needed before operation. If the postoperative bedridden time is more than 7\u00a0days, a weekly ultrasonic examination is needed. The non-surgical patients were examined within 24\u00a0h after admission and once a week. If the patient found lower extremity pain, swelling and other DVT symptoms, ultrasound examination should be performed at any time.Statistical methods The Statistical Package for Social Sciences (SPSS) software version 21  was used for statistical analysis. Measurement date are presented as means and standard deviations. Numeration data are presented as frequency counts and percentages. The \u03c72 test was usedin the comparison of numeration data. Binary logistic regression was used to analyze the independent risk factors. A p value of\u2009\u2264\u20090.05 was considered statistically significant.1209 patients with femoral neck fracture were included in this study. The mean age and standard deviation was 65.9\u2009\u00b1\u200917.9 (range 14.0\u201396.0) years. The gender distribution was as follows: 433 males and 776 females. The incidence of DVT was 28%, among which the incidence of distal DVT was 25.3% and that of proximal DVT  was 2.7%. The incidence of intermuscular venous thrombosis was the highest (21.4%) (Table P\u2009<\u20090.05). However, there was no correlation between the cause of injury, fractured limbs, smoking history, diabetes, venous disease of lower extremity, tomour with DVT (P\u2009>\u20090.05) . The incidence of DVT increased in patients older than 40\u00a0years and increased further in patients older than 60\u00a0years (P\u2009<\u20090.01). The incidence of DVT was significantly increased in patients with time from injury to hospitalization more than one week (P\u2009<\u20090.01). In the past history of patients, hypertension, cardiovascular and cerebro-vascular diseases, respiratory diseases and DVT were correlated. The incidence of DVT in patients with the above diseases was higher than that in patients without the above diseases (P\u2009<\u20090.01)  Table .P\u2009<\u20090.01). After anesthesia for more than 3\u00a0h, the incidence of DVT increased (P\u2009<\u20090.05). The incidence of DVT in patients undergoing general anesthesia and intraspinal anesthesia was higher than that in patients undergoing local anesthesia (P\u2009<\u20090.01). When the intraoperative blood loss was more than 200\u00a0ml, the incidence of DVT increased (P\u2009<\u20090.01) ; the hospitalization expenses of thrombotic patients  were more than that of patients without thrombus  (P\u2009<\u20090.01)  was longer than that of patients without thrombus (11.5\u2009\u00b1\u20098.1) . Most scholars believe that intermuscular venous thrombosis is not enough to developinto life-threatening PTE , 10, 11.%. Most sIn the present study, gender, age, diabetes, hypertension, respiratory diseases, cardiovascular and cerebrovascular diseases, venous disease of lower extremity, operative method, anesthesia duration, anesthesia mothod, etc. were employed as risk factors multivariate analysis. Results showed that the independent risk factors of DVT were gender, age, time from injury to hospitalization, operative method, anesthesia method and intraoperative blood loss. In addition to the gender, the independent risk factors of DVT in this study were consistent with the risk items in Caprini score . CombineGender The incidence of DVT in women is higher than that in men. In the past, it was reported that the incidence of DVT in men is higher than that in women, and the risk of DVT in men's life is 2.3 times higher than that in women [in women , 18. AccAge The incidence of DVT is increasing with the increase of age. When the age of patients is lower than 40, the incidence of DVT is lower. After 40, the risk of DVT will increase gradually. The incidence of DVT in patients over 60 is as high as 30.2%, which is consistent with the conclusion of most studies. Naess IA [Naess IA , 20 has Time from injury to hospitalization The period of thrombus formation is relatively short, and the incidence of venous thrombus in passengers can be as high as 10% in a long flight over 8\u00a0h [over 8\u00a0h . ThroughHypertension Richad et al. [d et al.  have repd et al. .Cardiovascular and cerebrovascular diseases Cardiovascular and cerebrovascular diseases refer to the manifestations of general vascular diseases or systemic vascular diseases in the heart and brain. Like hypertension, it involves the changes of hemodynamics and hemorheology as well as the damage of blood vessel wall, so it will increase the risk of DVT to some extent. K \u00f6 nigsbr \u00fc GGE o reports that patients with congestive heart failure are three times more likely to develop DVT than patients without congestive heart failure [ failure , 25.Respiratory diseases A large number of studies have confirmed that patients with chronic obstructive pulmonary disease (COPD) have a higher risk of DVT. In addition to chronic obstructive pulmonary disease, the respiratory diseases included in this study include sleep apnea syndrome, chronic bronchitis, emphysema, etc. The results show that the above factors also increase the risk of DVT in patients. After analysis, it should be related to the patients with respiratory diseases often have limited activities, and some patients lie in bed for a long time, resulting in venous blood stasis, blood in a hypercoagulable state. In addition, the body is in a state of chronic hypoxia, which is easy to damage the vascular endothelial cells [al cells , 27. In Diabetes The impact of diabetes on DVT has been controversial. Some researches think that the damage of vascular endothelial cells in diabetic patients will accelerate the aggregation of coagulation factors, which will lead to the formation of thrombus, and diabetics have an increased risk of malunion, nonunion and reoperation [peration . To someOperative method Reduction and internal fixation and joint replacement are the two most commonly used surgical methods for femoral neck fracture, among which joint replacement has a higher risk of DVT than the other two because of its long operation time and large trauma. The results of this study also showed that the operation mode was an independent risk factor for DVT.Anesthesia method Anesthesia is also an independent risk factor for DVT in patients with femoral neck fractures, of which patients with general anesthesia and intraspinal anesthesia have a higher incidence of DVT. The operation that need general anesthesia and intraspinal anesthesia also needed for a long time. Soomro et al. found that when the anesthesia time was more than 45\u00a0min, the risk of DVT would be greatly increased [ncreased . In addincreased , 29. In Intraoperative bleed loss Intraoperative blood loss was also an independent risk factor for DVT. After analysis, it should be related to the larger trauma, the longer exposure time and the increased release of inflammatory factors [ factors . In the  factors .Other Caprini risk assessment scale lists both the history of venous diseases of lower extremities and tumor as the risk factors of venous thrombosis, and many scholars think that patients with history of venous diseases of lower extremities or tumor will increase the risk of venous thrombosis. Although the results of the study showed that the incidence of DVT in patients with the above diseases is high, but because the sample size of patients with the above diseases in this study is small, there is no statistical difference, which needs further study of large sample size.In addition, by analyzing the length of hospitalization and cost in two groups of people, we found that compared with non DVT patients, the length of hospitalization in DVT patients will be longer, and the cost of DVT patients will also increase. In addition, DVT patients need to extend the use of anticoagulants after discharge. Most of the proximal DVT patients need to put in the inferior vena cava filter before operation and need to be hospitalized again to take out the filter, all of which need to increase the additional cost. Therefore, from the perspective of economy and hospital bed turnover, the prevention and control of DVT should be done well in the early stage of admission to reduce the incidence of DVT. It is beneficial to reduce the economic burden of patients and the medical burden of the whole society.There are limitations in this study. The follow-up data of discharged patients were not collected; the statistics of patients' intraoperative complications and other related information were not perfect; the sample size was small, and the preoperative and postoperative data were not discussed and analyzed in a stratified manner.The incidence of DVT in patients with femoral neck fracture is high and there are many risk factors. The independent risk factors of DVT in this study include: gender, age, time from injury to hospitalization, operative method, anesthesia method, intraoperative blood loss. In order to improve the detection rate of DVT and reduce the incidence of DVT, it is very important to identify the risk factors of DVT formation in patients with femoral neck fracture, combined with related laboratory and imaging examination. This study is a single center study, only included the patients with femoral neck fracture in our hospital in 2019 and the results have certain limitations. In addition, there are many factors included in this study. Due to the limitation of sample size, no effective stratified analysis can be carried out, and more comprehensive data still need to be studied in large sample and multi-center study.In addition, due to the electronic system of our hospital, this study also failed to analyze the impact of specific surgical methods on venous thrombosis, which is also the deficiency of this study and needs to be paid attention to in the follow-up."}
+{"text": "Diet, dietary practices and exercise are modifiable risk factors for individuals living with mental distress. However, these relationships are intricate and multilayered in such a way that individual factors may influence mental health differently when combined within a pattern. Additionally, two important factors that need to be considered are gender and level of brain maturity. Therefore, it is essential to assess these modifiable risk factors based on gender and age group. The purpose of the study was to explore the combined and individual relationships between food groups, dietary practices and exercise to appreciate their association with mental distress in mature men and women. Adults 30 years and older were invited to complete the food\u2013mood questionnaire. The anonymous questionnaire link was circulated on several social media platforms. A multi-analyses approach was used. A combination of data mining techniques, namely, a mediation regression analysis, the K-means clustering and principal component analysis as well as Spearman\u2019s rank\u2013order correlation were used to explore these research questions. The results suggest that women\u2019s mental health has a higher association with dietary factors than men. Mental distress and exercise frequency were associated with different dietary and lifestyle patterns, which support the concept of customizing diet and lifestyle factors to improve mental wellbeing.  Interdisciplinary research on mental distress and lifestyle suggests that diet, dietary practices and exercise are modifiable risk factors that are associated with mental wellbeing . HoweverExercise supports the release of a number of growth and neurotrophic factors that are associated with neuroplasticity . PreciseThis study is part of a larger project that has been collecting data to investigate dietary patterns and mental distress in different cohorts. The anonymous questionnaire link was distributed on several social media platforms targeting social and professional groups. Participants consented to the study by agreeing to access the survey. The larger study collected data from all age groups; however, for the purpose of the current study, only data from adults 30 years or older were considered. The study protocol was reviewed and approved by the Institutional Internal Review Board. The only inclusion criteria used were healthy adults and over the age of 18 years. No pre-screening of mental health was performed beforehand, as the purpose was to assess the relationship between diet and different levels of mental distress. A minimum sample size with 95% confidence and a 5% margin of error for an estimated population size of 2000 was set at 322 samples for each gender. Data collection was performed over a 3-year period and at different intervals to account for the change in season as well as to diversify the target population. The Food\u2013Mood Questionnaire (FMQ) was used for dietary and mood data collection . Demograp < 0.01; CI 95%). The FMQ also has an external validity [The FMQ is a validated instrument that evaluates weekly servings of food groups known to influence brain function and chemistry. The FMQ is a 5-subscale item with an internal consistency, as reflected by Cronbach\u2019s alpha values \u2265 0.70 for all sub-scales. The FMQ is a reliable tool , as suggested in the literature ,22. To cData cleaning took place in Google sheets using the data cleaning option to remove duplicate entries. Data values were standardized into z scores. We used a multi-analyses approach to investigate the individual and combined relationships between dietary factors, dietary practices, exercise and their implication on mental distress among mature men and women. The first step was to perform a mediation regression analysis (MA) to identify: (1) the individual variables that are associated with mental distress, (2) the individual variables that are linked with exercise frequency and (3) the association of each independent variable on mental distress when exercise is a mediator. Next, a K-means cluster analysis (CA) was used to classify the dataset into clusters to extrapolate unidentified patterns within the dataset and with no prior labeling. K-means is an unsupervised machine learning technique that detects hidden patterns without human guidance. This step explained the MA results and further explored the direct and inverse associations between food groups, dietary practices and exercise with mental distress. A principal component analysis (PCA) was employed as a confirmatory method to validate the results obtained from MA and CA. The PCA reduces data dimensionality and identifies patterns within the dataset, while providing a loading factor that represents the weight of the variable within the pattern. This attribute clarified the potential contribution of each variable within a dietary pattern to mental status. The fourth step was to perform a two-tailed correlational study to further explore the relationships between the independent variables, exercise and mental distress and confirm the findings from previous analyses . The mediation analysis used PROCESS Macro version 3.0, model four , with a The K-means cluster analysis was an investigative step to produce different dietary, exercise and mental distress clusters. Standardization of variables as z-scores gave them an equal weight and minimized the influence of the outliers. The K-means clustering algorithm used iteration to partition the dataset into a pre-specified number of k distinct clusters. Each training instance was allocated to the closest centroid based on the Euclidean distance applied to the instance and cluster center. All centroids were then recalculated as the mean attribute value vectors of the instances that were assigned to specific clusters. The cluster centers were adjusted by randomly picking k training instances, where k was the assigned number of clusters. If the cluster centroids remained constant, the iterative process stopped. The K-means analysis was followed by an ANOVA analysis to confirm the significance of each variable within the clusters. The PCA analysis identified the different patterns within the dataset with a component loading. Data were stratified by gender and further by principal components (PC). Sampling adequacy and inter-correlation of variables were calculated using the Kaiser-Meyer-Olkin (KMO) test and Bartlett\u2019s test of sphericity, respectively. The eigenvalue \u22651.0 criterion was used to determine the number of PCs retained. Additionally, the number of PCs selected was confirmed by visually examining the first major infliction in the scree plot. The optimal number of components typically capture the highest amount of variance in the dataset. Using varimax rotation, PCs were orthogonally rotated (varimax) to simplify and enhance their interpretability . VariablAn assessment of data normality using Shapiro\u2013Wilk and Kolmogorov\u2013Smirnov tests suggested that the data are not normally distributed. Subsequently, a two-tailed Spearman\u2019s ank\u2013order correlation evaluated the strength and direction of the relationship between the variables of interest. Data analysis was performed using SPSS version 25.0. A total of 1209 records were analyzed from mature adults (30 years or older); 329 were from mature men, 880 were from mature women. Responses were collected from North America, Europe, the Middle East and North Africa (MENA). Participants\u2019 characteristics are described in The mediation analysis provided three significant sets of findings. (1) It identified the direct association of food groups and dietary practices on mental distress (c path). (2) It explained the effect of each of these independent variables on mental distress when exercise is a mediator (c\u2019 path). (3) It described the association between the independent variables and exercise frequency (a path). Since the b path always compared the association of exercise on mental distress, the results were similar for all generated models. Results of the mediation analysis are presented in Exercise significantly reduced the negative association of HGI food and fast food on mental distress. Interestingly, exercise reversed the negative outcome of caffeine on mental distress and it significantly improved the positive aspect of breakfast, fruits, DGLV, fish and mental stress. Exercise, as a mediator, also generated novel inverse associations between food groups such as whole grain, nuts, multivitamin and fish oil supplements and mental distress. Remarkably, exercise as a mediator produced a positive association between meat and mental distress (c\u2019 path). Among men, no dietary factors were positively associated with mental distress. There was a strong significant and inverse relationship between nuts (b = \u22120.4347), fish (b = \u22120.5430) and mental distress (c path). Exercise improved the positive outcome of nuts and fish on mental wellbeing. Exercise, as a mediator, also generated novel inverse associations between breakfast, whole grain, dairy, fruits, DGLV, beans, multivitamin and fish oil supplements and mental distress. Exercise did not have any significant relationship with caffeine and meat regarding mental wellbeing. A noteworthy observation was that although HGI food and fast food were significantly associated with mental distress, exercise as a mediator produced a significant positive relation with mental distress (c\u2019 path).Among women, factors that associated with exercise included breakfast (b = 0.2270), caffeine (b = 0.0652), whole grain (b = 0.1927), fruits (b = 0.1420), nuts (b = 0.2031), DGLV (b = 0.3329), beans (b = 0.1783), fish (b = 0.3926) and MV (b = 0.0725) and fish oil supplements (b = 0.1293). Those that are inversely associated with exercise included HGI food (b = \u22120.1829), meat (b = \u22120.0861) and fast food (b = \u22120.3646). Dairy was not significantly associated with exercise. In men, HGI (b = \u22120.2044) and fast food (b = \u22120.2168) had an inverse association with exercise. Factors that strongly correlated with exercise included breakfast (b = 0.4550), whole grain (b = 0.2651), dairy (b = 0.1782), fruits (b = 0.2614), nuts (b = 0.3096), DGLV (b = 0.2773), beans (b = 0.1746), fish (b = 0.3753) and MV (b = 0.1544) and fish oil (b = 0.2569) supplements. Meat was not significantly associated with exercise .The cluster analysis identified two dietary patterns (DP) and three DP for mature men and women, respectively. The significant variables for women in Cluster 1 consisted of a healthy dietary pattern and practices. It included exercise, breakfast, whole grain, dairy, caffeine, fruits, nuts, HGI food, meat, DGLV, beans, fish, fish oil and an inverse association with mental distress . Cluster 2 was a Western diet pattern and consisted of HGI food, meat and mental distress . Cluster 3 included mostly dietary practices, such as breakfast, fish, MV and fish oil, exercise and mental wellbeing . Among men, Cluster 1 included fast food and mental distress , which represented a Western diet pattern. Cluster 2 reflected all food groups including nuts and fish and excluded fast food, dietary practices and exercise. This pattern is associated with mental wellbeing  .The PCA revealed additional interesting findings. There were three principal components (PCs) identified for men and women with a total variance of 37.898% and 38.616%, respectively. Among women, PC 1 consisted of some exercise (CL = 0.241), a healthy diet and dietary practice. This pattern included triggers of mental distress such as caffeine (CL = 0.656) and HGI food (CL = 0.212) as well as impediments to mental distress such as fruits (CL = 0.77), breakfast (CL = 0.31) and DGLV (CL = 0.368). Interestingly no negative or positive CL was noted for mental distress. This PC explained 17.477% of the total variance. PC 2 was mostly supplement use with exercise (CL = 0.304). This pattern seemed to draw protein intake mostly from beans (CL = 0.677) and about half from fish (CL = 0.311), with no animal proteins included. Interestingly, no negative or positive CL were also noted for mental distress. This PC explained 10.775% of the total variance. PC3 was close to the Western diet, which included strong loadings for HGI food (CL = 0.685), fast food (CL = 0.583) and mental distress (CL = 0.523). This pattern excluded exercise, DGLV and fish. This PC explained 10.364% of the total variance.Among men, PC1 reflected a healthy dietary pattern, exercise (CL = 0.388) and a negative association with mental distress (CL = \u22120.214). This PC explained 14.812% of the total variance. PC2 was a dietary practices pattern with some healthy food groups and exercise (CL = 0.509). Interestingly, this pattern was also negatively associated with mental distress (CL = \u22120.288). This PC explained 13.968% of the total variance. PC3 was close to the Western diet which included strong loadings for meat (CL = 0.695), HGI food (CL = 0.657), DGLV (CL = 0.418) and caffeine (CL = 0.383). Although this pattern is known to be associated with mental distress, no loading (positive or negative) surfaced. This PC explained 9.118% of the total variance .p < 0.001). There was an inverse association between exercise, HGI and fast food and mental distress (p < 0.001). Mental distress positively correlated with HGI and fast food (p < 0.001) as well as caffeine (p < 0.05), and inversely associated with exercise, breakfast, fruits, DGLV and fish (p < 0.001). There was a strong association between consumption of one healthy food group with most other food groups, and exercise was associated with eating a spectrum of nutrient-rich food. Among men, exercise was correlated with breakfast, whole grain, dairy, fruits, nuts and DGLV, fish, MV and fish oil. It was negatively associated with HGI and fast food (p < 0.001). Interestingly, mental distress was not linked with any food groups. However, factors that were inversely related to mental distress included exercise, fruits, nuts, fish and MV supplements. When comparing men and women, dairy was the factor that was strongly associated with exercise in men, but not in women (r = 0.161 **). For women, beans were a factor that significantly correlated with exercise, but was not significant in men (r = 0.119 **). Results from Spearman\u2019s correlation analysis are presented in Several interesting findings were revealed in this study. Our results suggest that food groups within a dietary pattern and frequency of exercise have a differential relationship with the mental wellbeing of mature men and women. Additionally, mental distress in women is more likely to be impacted by dietary factors than men, which supports previous findings . Our resThe individual relationship between exercise, food groups and dietary practices was explored through MA. In general, exercise enhanced the positive relationship of mental distress impediments and reduced the negative impression of mental distress triggers. Several studies described that exercise improves mental health significantly ,10,31; tThe relationship between meat, exercise and mental distress is intriguing. The conventional thought is that meat is a good source of tryptophan and tyrosine, the precursors for serotonin and dopamine, respectively. However, digging into the biochemistry of these neurotransmitters may reveal a response. The transport of tryptophan and tyrosine across the blood brain barrier is insulin-dependent ,39. ExerThe data mining techniques were used to explore the dynamic interaction between dietary patterns, dietary practices and exercise on mental distress. The CA confirmed many of the MA findings and generated new perspectives as well. For women, Cluster 1 was comprised of exercise, a healthy diet and healthy dietary practices pattern, which are associated with mental wellbeing. This is in line with several studies that investigated dietary patterns, practices, exercise and mental distress ,38,39. CAs for Cluster 2, it was comprised of a healthy diet, healthy dietary practices and exercise and, as expected, it was associated with mental wellbeing. Cluster 2 confirmed MA results as exercise significantly improved the association between these food groups with mental health. When comparing the results between gender, the Western dietary pattern produced a higher mean value for mental distress in women than in men. This finding suggests that mood among women has a stronger relationship with dietary factors when compared to men ,44.The usefulness of the PCA is in the component loading (CL) which provides a weight of the variable within the pattern. According to the MA results, exercise reversed the negative relationship of caffeine among women. However, looking at the component loading weight of caffeine and exercise in PC1, caffeine had about three times that of exercise in the healthy dietary pattern and yet, no loading for mental distress (negative or positive) was detected. This discrepancy suggests that the relationship between caffeine and exercise is not as straightforward as anticipated. In addition, it suggests the significance of the food group within a pattern and frequency of exercise play a role in mental health. Three general observations were noted from the PCA results based on the component loading values: (1) low to moderate exercise supported mental wellbeing among men regardless of the food groups consumed; (2) low exercise did not produce mental wellbeing in women despite the inclusion of healthy food groups and practices; and (3) when mature women consumed triggers of mental distress or relied on beans as a main source of proteins, low exercise did not chemically modulate enough of the mental distress impediments to produce mental wellbeing. This suggests that with more triggers of mental distress and a vegetarian style pattern, there is potentially a higher need for exercise to achieve mental wellbeing. The PCA results for men confirmed the MA findings that no dietary triggers seem to be associated with mental distress in men. The observations from the PCA also supported the notion that inclusion of impediments to mental distress such as nuts and fish support mental wellbeing. This differential relationship between exercise and mental wellbeing among men and women is interesting. Dissecting this finding further, the difference could be explained by the frequency or intensity of exercise  or couldSpearman\u2019s correlation analysis confirmed the gender-based MA findings and revealed additional noteworthy conclusions. It confirmed the MA findings that triggers of mental distress for women were caffeine, HGI and fast food. Positive influencers of mental wellbeing were breakfast, fruits, DGLV and fish. The results also explained the association between HGI and fast food, low exercise and mental distress. They also proposed that consumption of healthy food groups may improve diet quality and frequency of exercise, which confirmed the findings from the MA. This evidence suggests that food groups may neurochemically promote the motivation to exercise. As for men, the results were comparable to the findings from the MA and corroborated that mental distress in men was not associated with any food group. However, Spearman\u2019s correlation added fruits and MV supplements to the positive influencers of mental wellbeing in men, which explained some observations noted in the cluster analysis and PCA results. The most important take away points of this study are: (1) women are sensitive to the inclusion of triggers in their diet despite consumption of a healthy diet; (2) exercise (type and frequency) may have a differential relation with the mental wellbeing of men and women; (3) the weight of a dietary factor within a pattern may significantly sway mental wellbeing, which is more pronounced in women; and (4) research on diet and mood should take into consideration the potential indirect effect of exercise as a mediator. Another remarkable theory emerged for women: the quality of protein consumed may be important for women\u2019s mental wellbeing, which requires further examination. Finally, our results suggest that despite following a healthy diet and lifestyle, if triggers of mental distress exceed certain thresholds, mood is negatively impacted.The major strengths of the study are the large sample size and the use of a multiple- analyses approach to extricate the findings and illustrate the complex relationship between food groups, dietary patterns and practices, exercise and mental distress. The study fills several gaps in the literature by reporting on the differential influence of dietary factors and exercise on the mood of mature men and women. Furthermore, the results provide compelling evidence that the customization of diet and lifestyle may enhance mental wellbeing in this population. Finally, new theories emerged from this study that are worth further exploration. Nonetheless, the limitations of this study include the convenience sample and its cross-sectional design. In addition, it does not take into consideration the disparities in genetic factors, socio-economic status, sleep pattern, cultural differences or any other factors that may have impacted the psychology of the individuals or their food intake. Our study revealed several interesting findings. Among women, mood is more sensitive to dietary factors than men. Exercise may lessen the intensity of negative triggers, but it may not completely reverse it when frequency is low. The weight of the trigger also has an impact within the dietary pattern. For men, consumption of fast food and absence of exercise were associated with mental distress. However, low to moderate exercise seemed to significantly improve their mental wellbeing. In essence, our findings suggest that the customization of diet and exercise for mature men and women is needed to improve mental wellbeing."}
+{"text": "Selective vaporization at 1300 \u00b0C ensured the avoidance of non-spectral effects and allowed the use of external calibration. Several spectral lines for each element even in the range 180\u2013210 nm could be selected. Generally, this spectral range is examined with large-scale instrumentation. Even in the absence of derivatization, the obtained detection limits were low (0.02\u20130.75 mg kg\u22121) and allowed analysis of environmental samples, such as cave and river sediments. The recovery was in the range of 86\u2013116%, and the accuracy was better than 10%. The method is of general interest and could be implemented on any miniaturized or classical laboratory spectrometric instrumentation.The simultaneous determination of chemical vapor-generating elements involving derivatization is difficult even by inductively coupled plasma optical emission spectrometry or mass spectrometry. This study proposes a new direct liquid microsampling method for the simultaneous determination of As, Bi, Se, Te, Hg, Pb, and Sn, using a fully miniaturized set-up based on electrothermal vaporization capacitively coupled plasma microtorch optical emission spectrometry. The method is cost-effective, free from non-spectral interference, and easy to run by avoiding derivatization. The method involves the vaporization of analytes from the 10 \u00b5L sample and recording of episodic spectra generated in low-power (15 W) and low-Ar consumption (150 mL min Its usefulness was demonstrated for the simultaneous determination of several toxic elements in liquid microsamples (environment and food) as an alternative to ICP OES with pneumatic nebulization and GFAAS [The increasing interest in the determination of As, Bi, Sb, Se, Te, Hg, Pb, and Sn is closely related to their special uses in emerging technologies for the synthesis of materials or medicine ,2,3,4. Ond SnCl2 ,12,13 cond SnCl2 ,17,18,19nd SnCl2 ,21,22 annd SnCl2 . Other wnd SnCl2 , HG-ICP-nd SnCl2 ,26, and nd SnCl2 . In addind SnCl2 ,29 couplnd SnCl2 , UV-PVG-nd SnCl2 ,32, and nd SnCl2 ,34 resulnd SnCl2 ,36. The nd SnCl2 ,35. The nd SnCl2 ,38, liqund SnCl2 ,40,41, ond SnCl2 ,43 were nd SnCl2  and ICP-nd SnCl2 ,46 usingnd SnCl2  and LIBSnd SnCl2  provide nd SnCl2 , ETV-ICPnd SnCl2 ,52,53,54nd SnCl2 ,56,57,58nd SnCl2 ,60,61,62nd GFAAS ,64,65,66\u22121). The tandem has been found ideal for the introduction of liquid microsamples into the microplasma torch due to the instantaneous heating of the Rh filament, which yields an efficient vaporization of the microsample and high flow of analytes into plasma. This allowed a simultaneous determination of elements of concern for the environment and food, including harmful elements of high priority , with very good detection limits. There are several benefits of using Rh for the filament, as this material is easily workable, and it exhibits high resistance to oxygen and aqua regia used for sample mineralization. Thus, it is not necessary to create a hydrogen-protecting atmosphere, which causes plasma destabilization and an increase of the background spectrum of the Ar plasma in the UV range with a detrimental effect on the detection limits. Unfortunately, the SSETV-\u00b5CCP-OES method was prone to non-spectral interferences arising from the mineral matrix when the Rh filament was heated to 1500 \u00b0C to accomplish vaporization of less volatile analytes. To avoid the matrix interference, quantification was performed using the standard addition. However, heating the filament to a lower temperature (1300 \u00b0C) provided a selective vaporization of Hg and thus, a new opportunity for the determination of total Hg and CH3 Hg+ by SSETV-\u00b5CCP-OES using external calibration [The SSETV-\u00b5CCP tandem incorporating the Rh-coiled filament was easy to interface due to similar demands in terms of operation power  and Ar flow for the two components  and calibration slope (m) [n = 5 parallel measurements).The SSETV-\u00b5CCP-OES method was characterized in terms of analytical performance, namely, LODs, parameters of the calibration curves established by the net peak area of transient signals and their maximum height , accuraclope (m) , while i2\u03a3+\u2192X2\u03a0; Eex = 5.45 eV; 205.28 nm ; 215.49 ; 226.94 nm ; 237.02 nm ; 247.87 nm ; 250.60 nm ) and OH ; 282.90 ; 289.27 nm ; 296.24 nm ; and 308.90 nm ). In a recent study aiming to determine total Hg and CH3 Hg+ in food and river sediment by SSETV-\u00b5CCP-OES, it was remarked the capability of microplasma to provide several emission lines of Fe, S, and P in the range 180\u2013200 nm [3 Hg+ [The UV background spectrum emitted by the low power and low Ar consumption \u00b5CCP consists of molecular emission from NO  in the \u22121 Ar indicated the possibility of the simultaneous determination of As, Bi, Sb, Hg, Se, Te, Pb, and Sn by visualizing the emission at 0.8 mm above the microelectrode tip (The optimization related to the observation height in plasma operated at 15 W and 150 mL minrode tip . The obs\u22121): 14\u2013As, 15\u2013Bi, 8\u2013Sb, 13\u2013Se, 30\u2013Te, 0.7\u2013Hg, 5\u2013Pb, 3\u2013Sn. The corresponding limits in solid were as follows (mg kg\u22121): 0.35\u2013As, 0.37\u2013Bi, 0.20\u2013Sb, 0.33\u2013Se, 0.75\u2013Te, 0.02\u2013Hg, 0.13\u2013Pb, and 0.08\u2013Sn. It should be observed an enhancement of 2\u201320 folds of LODs by using the Maya2000 Pro microspectrometer compared to the QE65 Pro used in this study and previously [\u22121 element and measurements at the most sensitive lines were better than 0.9991. The best LODs were achieved for Hg, Pb, and Sn, which were contaminants of concern for environment. The explanation is the low excitation energy corresponding to the resonance or non-resonance atomic lines . The LODs estimated using the maximum height of the transient peak . Another cause was the low vaporization temperature and thus slow sample vaporization, which resulted in the broadening of the transient signal of elements. For several spectral lines, the calibration curves for measurements with the QE65 Pro microspectrometer had a very low slope and a poor linearity, because of the low signals, and they were omitted.According to eviously ,64,65,66ent peak  were poo2 microplasma of lower power (3 W instead of 15 W) and lower sample volume (3 \u00b5L instead of 10 \u00b5L) [\u22121), because the dielectric barrier discharge was operated at higher power (37 W) and higher Ar flow (300 mL min\u22121) [\u22121) for Se (30/13), Sn (20/3), similar for As (10/14), Pb (3/5), and poorer for Bi (2/15) and Te (3/30) [Compared to other microplasma sources and microsample introduction by ETV used in OES analysis, several remarks can be made. The absolute LOD of 50 pg Pb at the spectral line 261.417 nm in the SSETV-\u00b5CCP-OES method was better than that obtained in an Ar\u2013Hf 10 \u00b5L) . The LODL min\u22121) . Howevere (3/30) . Againste (3/30) . The dete (3/30) , while te (3/30) . Compare/13), Sn /3, simile (3/30) . In this\u22121 element. Recoveries achieved using external calibration were in the range 92\u2013110%. Individual recoveries of added concentration were 102 \u00b1 10% Teand 101 \u00b1 3% Bi. These results demonstrated that the vaporization of the microsample at 1300 \u00b0C, rigorously adjusted, led to the separation of As, Bi, Sb, Se, Te, Hg, Pb, and Sn from the sample matrix, thus avoiding the non-spectral interference Data for the analysis of CRMs of soil and water sediment  by the Sn = 5) for the measurements of As, Bi, Sb, Se, Te, Hg, Pb, and Sn in river and cave sediment by external calibration. The concentrations decreased in the following order: Pb > Bi > Te > Sb \u2248 Se \u2248 Sn >> Hg. Some samples exhibited extreme concentrations, i.e., about 588 mg kg\u22121 Pb and 130 mg kg\u22121 Bi. In the river sediment collected near a former chlor-alkali plant, Hg concentration was by one order of magnitude higher than in the other samples (15\u201331 mg kg\u22121). Bismuth was also found in higher concentrations in these samples (94\u2013136 mg kg\u22121), while Pb was below the limit of detection (0.13 mg kg\u22121).The data in The prototype experimental set-up  for SSETThe operating sequence of the SSETV-\u00b5CCP-OES set-up was as follows. The Rh filament was extracted from the vaporization chamber by moving back the plunger. A volume of 10 \u03bcL sample was deposited on the filament with a Hamilton syringe and heated for 180 s in air at 80 \u00b0C. The temperature was controlled by adjusting the voltage and current passing through the filament based on a previously established relationship between electrical resistance and filament temperature. The IR Optris 3 ML Optris GmbH thermometer  was used for the measurement of temperature in this step. During sample drying, the Ar flow was directed into the plasma microtorch, bypassing the vaporization chamber via the two-way valve. In the next step, the dried sample was vaporized, and 3D spectral episodes (emission intensity\u2013wavelength\u2013time) were recorded in the High-Speed Acquisition mode of the Spectrasuite software. For this, the Rh filament was reinserted in the vaporization chamber and heated for 10 s at 1300 \u00b0C. The temperature was controlled based on the electrical resistance\u2013temperature relationship applicable in the range 800\u20131700 \u00b0C. Measurements were performed with the IR Optris 1 MH-CF3 thermometer, Optris GmbH . In this stage, the Ar flow was redirected through the vaporization chamber. As the vaporization of the microsample occurred, the vapor was transported into the plasma by the Ar flow, and recording of the 3D episode spectra was started. The Play Back option of the spectrometer software facilitated the visualization of each episode and finding in which the maximum signal occurred. The signal emission was assessed in two ways, namely, peak area obtained by summation of the net episodic signals that resulted after background correction using the two-point approach ,66 and m2O2 30% (m/m) pro-analysis, KBr suprapure, and KBrO3 pro-analysis. Single element standard solutions of 1000 \u00b5g mL\u22121 were used for the preparation of standards for external calibration over the range 0\u20135 \u00b5g mL\u22121 As, Bi, Sb, Se, Te, Sn, and Pb, and 0\u20131 \u00b5g mL\u22121 Hg (n = 10). In the standard addition approach, aliquots of up to 0.9 mL solution of CRM or the test sample were spiked at three levels to provide up to 2 \u00b5g mL\u22121 As, Bi, Sb, Se, Te, Pb, and Sn, and up to 0.5 \u00b5g mL\u22121 Hg to a final dilution of 1 mL. A multielement solution containing 3 \u00b5g mL\u22121 As, Bi, Se, Te, and Sn, 1 \u00b5g mL\u22121 Pb and Sb, and 0.2 \u00b5g mL\u22121 Hg was used for the optimization of the operating conditions of the SSETV-\u00b5CCP-OES analytical system and identifying the emission lines of elements in the spectrum. Blank solution of aqua regia was analyzed for testing the purity of chemical reagents used for the preparation of samples and calibration standards. All glassware and digestion vessels were daily cleaned by filling with a solution prepared by dissolving 1.5 g KBr and 1.08 g KBrO3 in 100 mL concentrated HCl and further diluted 1:10. Ultrapure water (18 M\u03a9 cm) prepared in the laboratory with the Milli-Q system  was used throughout the study.The following reagents purchased from Merck  were used: nitric acid 65% (m/m) ultrapure, HCl 35% (m/m) ultrapure, HThe following certified reference materials (CRMs) were analyzed to check the accuracy of the SSETV-\u00b5CCP-OES method: BCR-280 R Lake sediment, ERM-CC580 Estuarine Sediment, ERM-CC141 Loam soil, BCR-142 R Light sandy soil, BCR-287 A Thermally refined lead from the Institute for Reference Materials and Measurements\u2013IRMM , NC SDC 78301, LGC 6141 Soil Contaminated with Clinker Ash , AP-Metranal 32 Light sandy soil, elevated analyte levels, AP-Metranal 34 Loam metals from Analytika Spol , CRM025\u2013050 Metals in soil , CRM048\u201350 G Sandy soil, and SQC-001-30 G Loamy clay .The applicability of the proposed method was verified by analyzing 14 test samples, namely, 11 sediments collected from several caves in Romania: Lesu (Bihor), Movile (Constanta), Muierilor (Women\u2019s) (Gorj), Topolnita (Mehedinti), and 3 river sediments collected from the Aries River, in the vicinity of a former chemical plant (Turda).The analyte concentrations were determined by both external calibration and standard addition from 5 parallel measurements.A brief description of the caves and river where the sediment samples were collected is presented in the Reagents and solutions.Approximately 200 g test samples were dried at 100 \u00b1 5 \u00b0C in an oven for up to 4 h, minced, and sieved to <100 \u00b5m. The resulted powder was kept in brown glass containers until preparation for analysis. Amounts of 0.5\u20131 g CRMs of soil, water sediment, and refined Pb, and sediment test samples were mineralized in 12 mL aqua regia using the microwave digester Berghof MW3 S+  following an earlier protocol used by Frentiu et al. ,65,66,67\u22121 or less than 1 mg kg\u22121, which extended the applicability of miniaturized plasma instrumentation. The emission spectrum of the target analytes was simple and contained resonance and non-resonance lines with excitation energies in the range 4\u20137.6 eV. Therefore, the interfacing of low-power plasma with low-resolution microspectrometers (0.35 nm FWHM) was opportune. At the same time, the method was found to be versatile enough, since it allowed choosing several analytical lines for an element, even in the range 180\u2013210 nm. Overall, the strengths of the cost-effective method are related to simplicity, high-throughput for simultaneous analysis, lack of non-spectral interference, fewer operational parameters to optimize by avoiding the derivatization step, and easy interfacing of miniaturized components without loss of sensitivity. These relevant features make the method attractive to the general interest. Although primarily intended for our own miniaturized instrumentation, it could be implemented on any instrument with microplasma source or even classical ICP OES, if a miniaturized electrothermal vaporization device is available. The optimization of the operating conditions of other experimental set-ups should be taken into consideration to achieve the revealed advantages in this study.It has been demonstrated that a fully miniaturized set-up consisting of a low-power and low-Ar consumption microtorch interfaced with microspectrometers is suitable for the simultaneous determination of As, Bi, Sb, Se, Te, Hg, Pb, and Sn in liquid microsamples with complex matrices. The analytical performances of the new method were investigated using the SSETV-\u00b5CCP-OES prototype system developed in our laboratory. The direct liquid microsampling was performed by the controlled heating of the Rh filament and allowed the removal of the non-spectral interferences arising from the mineral matrix of the environmental samples. Under these circumstances, the analytes could be accurately determined using external calibration, instead of the tedious standard addition. Although no chemical derivatization was used, the proposed method offered detection limits of ng mL"}
+{"text": "The association of tracheostomy timing and clinical outcomes in ventilated COVID-19 patients remains controversial. We performed a meta-analysis to evaluate the impact of early tracheostomy compared to late tracheostomy on COVID-19 patients\u2019 outcomes.We searched Medline, Embase, Cochrane, and Scopus database, along with medRxiv, bioRxiv, and Research Square, from December 1, 2019, to August 24, 2021. Early tracheostomy was defined as a tracheostomy conducted 14\u00a0days or less after initiation of invasive mechanical ventilation (IMV). Late tracheostomy was any time thereafter. Duration of IMV, duration of ICU stay, and overall mortality were the primary outcomes of the meta-analysis. Pooled odds ratios (OR) or the mean differences (MD) with 95%CIs were calculated using a random-effects model.p\u2009<\u20090.01) and duration of ICU stay . Mortality was reported for 2343 patients and was comparable between groups .Fourteen studies with a cumulative 2371 tracheostomized COVID-19 patients were included in this review. Early tracheostomy was associated with significant reductions in duration of IMV .The online version contains supplementary material available at 10.1186/s13054-022-03904-6. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has become one of the largest known pandemic in human history affecting more than 233 million people across the globe . AlthougA shorter ventilator time and ICU stay were particularly valuable during the COVID-19 pandemic, when intensive care units (ICUs) had insufficient ventilator and beds . TracheoThis year, several studies have attempted to investigate how ET affects COVID-19 outcomes \u201323. Howehttps://doi.org/10.37766/inplasy2021.8.0088).We conducted a systematic review and meta-analysis according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement  systematically searched Medline, Embase, Cochrane, and Scopus database from December 1, 2019, to August 24, 2021, which was the date of our last search. Search terms included (novel coronavirus OR SARS-CoV-2 OR COVID19 OR COVID-19) AND (tracheostomy OR tracheotomy)  independently screened both titles and abstracts to determine suitability based on our primary outcomes. Relevant full-text articles were retrieved and analyzed for eligibility. A third reviewer (XF) adjudicated discrepancies, when necessary.Studies were included if they compared ET versus LT and provided data on at least 1 of our primary outcomes. Case reports, reviews, editorials, commentaries, and practice guidelines were excluded. Articles available only in abstract form or meeting reports were also excluded. The inclusion and exclusion criteria are given in detail in Additional file Data collection was performed by two independent reviewers (YJ and BC) using a prespecified data extraction form. Disagreements were resolved by discussion and consensus. We collected the following data: first author and location, study period, publication format, type of study, timing of tracheostomy, number of patients, age, gender, the rate of percutaneous dilatation procedures, duration of IMV, duration of ICU stay, mortality, VAP, time from tracheostomy to ventilator weaning, duration of sedation, major complications related to tracheostomy, and transmission of SARS-CoV-2 from patients to health care workers.The methodological quality of the selected articles was evaluated using the Newcastle\u2013Ottawa quality assessment scale, whereby a higher score indicated higher methodological quality . We assiWe defined ET as a tracheostomy conducted 14\u00a0days or less after initiation of IMV. LT was any time thereafter. If a study defined ET after 14\u00a0days, we did not include the study in this review. In other words, ET/LT cut-off was defined as equal to or less than 14\u00a0days after initiation of IMV. We had 3 distinct primary outcomes: duration of IMV (from IMV initiation to discontinuation), duration of ICU stay (the number of days of stay in the ICU), and overall reported mortality (as reported at specific time points by study authors). Secondary outcomes included (1) VAP (according to study authors\u2019 definitions of VAP), (2) time from tracheostomy to ventilator weaning (as defined by study authors), and (3) duration of sedation .www.statstodo.com). A random-effects model was used to analyze data. Statistical heterogeneity was evaluated using the I2 statistic. I2 values\u2009>\u20090%,\u2009>\u200930%,\u2009>\u200950%, and\u2009>\u200975% were considered to indicate low, moderate, substantial, and considerable heterogeneity, respectively. If I2 was\u2009>\u200950%, we performed a sensitivity analysis by removing 1 study at a time (guided by the highest I2) until the sensitivity was below the threshold of 50% [p value\u2009<\u20090.05 was considered significant.Meta-analysis was performed using Review Manager 5.4 . The estimation of combined continuous values and dichotomous values was expressed as mean differences (MD) or odds ratios (OR), respectively, with 95% confidence intervals (CI). When continuous values were presented as median and interquartile range (IQR), we calculated the mean and standard deviation (SD) as per Wan et al. . We combFigure\u00a0I2\u2009=\u200957%). ET was associated with decreased duration of IMV  . ET was associated with decreased duration of ICU stay  . There was no statistically detectable difference between patients undergoing ET versus LT regarding mortality  . The incidence of VAP was lower in patients with IMV who underwent ET compared with LT  . Patients undergoing ET had a numerically shorter time from tracheostomy to ventilator weaning, but this difference was not statistically significant  . . For the duration of IMV, 1 study [p\u2009<\u20090.01; I2\u2009=\u200931%)   and duration of ICU stay    or 14  days  or 14  days  or 14  days (Additional file Studies were divided into two groups according to the methodology of determining the cut-off timing for ET, they were divided into studies that considered ET within the first 7 or 14\u00a0days of endotracheal intubation. ET was associated with shorter duration of IMV in studies defining ET as that done within 7 (799 patients; MD\u2009\u2212\u20098.49\u00a0days, 95% CI\u2009\u2212\u200910.94 to\u2009\u2212\u20096.05\u00a0days, By incorporating data from 14 studies involving 2371 tracheostomized COVID-19 patients, our systematic review and meta-analysis showed that ET was associated with improvement in 3 major clinical outcomes: duration of IMV, duration of ICU stay, and VAP. No differences were noted in The timing of tracheostomy in ventilated COVID-19 patients has been the subject of debate , 42. OurEvidence showed that VAP is a frequent complication among ventilated COVID-19 patients, which has a negative effect on outcomes \u201346. Our Although a previous monocentric study found that ET reduced duration of IMV, the reduction was specifically as a result of shortening the period from intubation to tracheostomy . By contDuring the pandemic, the challenges of the logistics of patient selection, tracheostomy insertion and subsequent management, and health care worker safety may make LT seem more feasible in COVID-19 patients. One critique of ET is that ET will only free up ICU capacity in patients requiring prolonged ventilation. That is to say, it is possible that LT might lead to a reduced tracheostomy exposure, either because death occurs before tracheostomy is performed or because pulmonary recovery obviates the need for tracheostomy. However, our findings for the beneficial effect of ET on several clinical outcomes, such as duration of IMV, duration of ICU stay, and incidence of VAP, might question the current strategy of delaying tracheostomy in COVID-19 patients.This is the largest and most comprehensive meta-analysis to date examining tracheostomy timing in patients with COVID-19. Unlike a meta-analysis included studies published before March 4, 2021 , we obseOur meta-analysis also has limitations. First, our work is based on data from observational studies, which may suffer from residual confounding. Ideally, the outcomes of ET versus LT in ventilated COVID-19 patients should be evaluated in prospective, randomized trials; however, such studies are difficult to perform under pandemic conditions . Second,In summary, the findings from this meta-analysis suggest that ET in COVID-19 patients may reduce duration of IMV and ICU stay without modifying the mortality rate. This has implications for alleviating critical care capacity strain during the COVID-19 pandemic. Considering that tracheostomy is an aerosol-generating procedure, future studies are required to establish the role of timing in optimizing outcomes from tracheostomy and minimizing the risk of infection among health care workers.Additional file 1. PRISMA 2020 checklist.Additional file 2. Search strategy.Additional file 3: Table S1. PICOS criteria for inclusion and exclusion of studies into meta-analysis.Additional file 4: Table S2. Quality assessment of included studies by Newcastle\u2013Ottawa Scales.Additional file 5: Figure S1-S13. Figure S1. Time from tracheostomy to ventilator weaning in early vs late tracheostomy. Figure S2. Duration of sedation in early vs late tracheostomy. Figure S3. Sensitivity analysis of duration of IMV by excluding one study with high heterogeneity. Figure S4. Sensitivity analysis of duration of ICU stay by excluding one study with high heterogeneity. Figure S5. Sensitivity analysis of duration of IMV by restricting to studies published in peer-reviewed journals. Figure S6. Sensitivity analysis of duration of ICU stay by restricting to studies published in peer-reviewed journals. Figure S7. Sensitivity analysis of overall mortality by restricting to studies published in peer-reviewed journals. Figure S8. Subgroup analysis of duration of IMV in studies defining early tracheostomy as that done within 7 days. Figure S9. Subgroup analysis of duration of IMV in studies defining early tracheostomy as that done within 14 days. Figure S10. Subgroup analysis of duration of ICU stay in studies defining early tracheostomy as that done within 7 days. Figure S11. Subgroup analysis of duration of ICU stay in studies defining early tracheostomy as that done within 14 days. Figure S12. Subgroup analysis of overall mortality in studies defining early tracheostomy as that done within 7 days. Figure S13. Subgroup analysis of overall mortality in studies defining early tracheostomy as that done within 14 days."}
+{"text": "Hepatitis C virus reinfections in HIV-positive men-who-have-sex-with-men (MSM) challenge the effectiveness of antiviral treatment. To fight this problem, an adapted sexual risk reduction intervention was implemented within a hepatitis C treatment trial. Following this, the current study had two aims and describes 1) how the program was received by participants; and 2) their responses to the program regarding sexual risk taking. Based on the participants\u2019 input, we hoped to judge the intervention\u2019s potential for scale-up.Seventeen participants who received the sexual risk reduction intervention in addition to hepatitis C treatment were recruited for semi-structured interviews six to 12 months post-intervention. We evaluated the responses via reflexive thematic analysis and applied the concept of sense-making.Giving hepatitis C a place and living without it again illustrates how participants received the program and how their experiences were altered by the impact of sense-making. Based on their responses, we allocated participants to three groups: 1. Avoid risks: get rid of hepatitis C for life. For these men, hepatitis C remained a life-threatening disease: they actively modified their risk behavior and felt supported by the intervention in maintaining their behavioral changes. 2. Minimize risks: live as long as possible without hepatitis C. In contrast to group 1, these men saw hepatitis C as a manageable disease. The intervention facilitated reflection on risks and how to develop behavioral changes that suited them individually. 3. Accept risks; live with the risk of hepatitis C. These men perceived behavioral changes as much more difficult than \u201ceasy\u201d medical treatment. They expected to either undergo repeated rounds of treatment or stay HCV re-infected.These results illustrate the diversity of men\u2019s responses and their decisions regarding sexual risk behavior after participating in a combination of antiviral treatment and a sexual risk reduction intervention. Two major aspects were identified: 1) Teachable moments, particularly at the time of diagnosis/treatment, could offer an opportunity to develop openness for behavioral change; 2) adapting sexual risk reduction interventions to sense-making patterns could help to improve its effectiveness. Support for reducing infection risk and raising awareness of preventative measures are additional benefits.NCT02785666, 30.05.2016.Clinical Trial Number:  Since 2014, chronic hepatitis C virus (HCV) infection has been easily curable with direct acting antivirals (DAAs), leading to enhanced survival, reduced liver-related morbidity, improved quality of life, and prevention of extrahepatic complications . AccordiIn order to reach these targets, one key population for multiple HCV prevention strategies was identified: men who have sex with men (MSM) and who are living with HIV. Members of this group have a high anti-HCV prevalence 3\u201339%); and, as early as 2007, their incidence of infection was increasing by 2.34\u20135.11 per 100 person-years (py) \u201339%; and, 9.Swiss HCVree Trial to test a micro-elimination strategy in this population. Micro-elimination involves precise targeting of a single sub-group\u2019s needs  No one said, you should do this or that\u2014not at all! And that was something new. While the intervention sessions were positive, the experience of being cured of hepatitis C was also tremendously important. However, this was not necessarily interpreted in a positive way: Some reported that being cured evoked a feeling of personal vulnerability from being newly infected with HCV, which they had to learn to cope with. As one man explained,I have to deal with this whole crap again. Now, one has to be careful again. So a lot of stuff came up again. A lot of dark stuff and fears. And yeah, almost a little of the feeling that I don\u2019t go through this again. While the main theme (Giving hepatitis C a place and living without it again) was central for all participants, the following paragraphs describe how the three explanatory models reflect the wide range of belief systems and sense-making, all of which were influenced by the contextual realities of participants.For all interviewed men, their hepatitis C diagnosis was unexpected. They reported trying to understand not only how they became infected, but also how they could evaluate the disease\u2019s severity and its meaning for their lives. How they dealt with this phase influenced their later strategies to reduce the risk of possible reinfection. While some developed explanations that they considered valid, others reported lasting uncertainty, especially regarding transmission. One man said:Avoid risks: get rid of hepatitis C for life refers to a sense-making work shared by men who saw hepatitis C as serious and who took active steps to modify their risk behavior\u2014even before beginning treatment and counseling in most cases. These individuals had already initiated lifestyle changes, which were felt to be supported by the intervention, and aimed to avoid risks and stay free of hepatitis C for the rest of their lives.where in the past you went wild with drugs, in the scene, drugs and party culture. Where night after night you took Ecstasy and went wild dancing. And then of course you had a relatively large number of sex partners, which changed up a lot. That was before [my current] relationship. They assigned these risk situations to time periods characterized by carelessness and eagerness to experiment sexually. Three gave particularly noteworthy reports of their lifestyle adjustments\u2014of how they had to cut their risks partly because of their hepatitis C diagnoses and partly because they had formed lasting partnerships. As all but a few had received their diagnoses before any reliable therapy (DAAs) became available (median time since diagnosis: 5.8\u2009years) most had tried to come to terms with the thought that they carried a serious communicable chronic condition.Men who used this sense-making work found themselves confronted with an illness that they had not even considered before their diagnosis. They reported considering HCV infection something alien\u2014a virus relevant for intravenous drug users, not for them. The diagnosis forced them to think about hepatitis C seriously, to identify risk situations where they had been exposed, and to explain the reason for their infection. One man recalled a situation as one, hepatitis C was always on their mind. One recognized it as a \u201cserious and socially limiting problem.\u201d For example, \u201cHepC gobbles up energy,\u201d leads to liver damage, and poses a huge problem for any sexual partner because of the danger of transmission.For many, from the moment they were diagnosed\u201ca stroke of luck,\u201d \u201can immense chance.\u201d A 45-year-old man said \u201cthe therapy has given me a new life.\u201d Even after study screening and before treatment started, this group\u2019s appreciation appeared to motivate them toward intervention-independent behavioral changes. Two men had already tried to practice sex with multiple partners only with condoms or to stop sexualized drug use because they had observed themselves becoming more reckless in recent years. Two others said they had stopped all sexual contact when their participation in the trial began.These men embraced the possibility of being cured as wonderful. They viewed DAAs as \u201cIf it doesn\u2019t help, it at least won\u2019t make things worse.\u201d After all, they already had considerable knowledge and did not expect any personal gains. Many related how they had been positively surprised by the intervention, perceiving it as an environment in which they felt personally cared for and understood regarding the challenge of changing their sexual risk behavior. How one individual described it:[The counseling] was very informative and what did it bring? You also thought about yourself again a little. That had maybe gotten a little lost lately. And it was also nice somehow to know that there are people who are at all interested. And that is for me also a nice aspect of the story. At the time of the intervention, the participants generally felt they were already moving in the right direction, but wanted to achieve and maintain \u201cthe strict practice of safer sex.\u201d In the long run, they saw absolute avoidance of risk as the only way to maintain their health. This is why they used the intervention to discuss situations that were awkward and difficult for them: they wanted to be better prepared.Upon entering the intervention, based on their early reflections about the disease, transmission routes of hepatitis C and their behavioral changes, their attitude was: \u201cprevious high-risk sex life\u201d\u2014the lifestyle that had led them to acquire the disease. They recognized during the interview that their experiences with risks were something useful, an important resource in the current situation:The light went on for me. In the sense of just thinking before you do something. Before, I didn\u2019t have any knowledge of where you can get hepatitis C. You simply go too far and now you say to yourself: I won\u2019t let it go so far again. A general consensus among members of this participant group was that, combined with the behavioral intervention, their successful treatment had reinforced their intention to build on and maintain the lifestyle changes. For them, using condoms for anal intercourse, while avoiding both mucosal trauma and drugs, made sense. They saw the cure of their hepatitis C as a unique chance and decided to avoid any contact with the virus in the future. Feeling relieved and happy, they experienced the cure as liberating.They also appreciated that during the intervention, according to their own personal interests, they could decide on the direction of their discussions. Among the intervention\u2019s other benefits, they appreciated the opportunity it offered to reflect on their \u201ca success that [he] was permitted to experience thanks to the therapy.\u201d They considered a reinfection as a personal failure, as a disgrace not only to themselves but to their doctors. One man described how the risk of reinfection was a source of fear that led to increased caution after cure:It was strange in the beginning after the treatment. I was overly careful. I wasn\u2019t even able to enjoy it, because I was afraid. That it turned out so well and that I don\u2019t have it anymore. That was always a topic. Men in this group believed that their only hope for staying free of HCV was to avoid risks. Therefore, they had resolved not to expose themselves further. Their shared goal was never to be infected with hepatitis C again\u2014to get rid of hepatitis C for life.One described it as This theme showed a sense-making process prevalent in men who considered hepatitis C a problematic but manageable disease. They described the behavioral intervention as helpful to facilitate thinking about risks and how to develop behavioral changes suitable for their long-term aim of living well without hepatitis C.[I regularly participated in sexual practices] without a condom. I did it like this for a long time before that, and hepatitis C didn\u2019t happen until 2015. I surely didn\u2019t use \u2026 [condoms] for ten years. And I had unprotected sex just as often during these ten years. Like the earlier group, these men were concerned about infecting their sex partners. However, they adhered to their original explanatory model\u2014that they had contracted HCV during a single exceptional situation\u2014and did not report any changes in their behavior prior to the start of the intervention program.Compared with the first group, these men had only recently become aware of hepatitis C (median time since diagnosis: 1.6\u2009years), with diagnoses received, in most cases, during regular STI testing. Unlike the earlier group, before their diagnoses, they had had vague knowledge of hepatitis C, but had paid little attention to it until they tested positive. The diagnosis had typically come as a surprise because, compared to their peers, they did not consider to be at high risk. Their diagnoses had made them uncertain of how to gauge the relative risks of various behaviors. They concluded that they must have contracted the virus in an exceptional situation. They further said that they had practiced condomless anal sex with multiple (HIV-positive) partners for years. Since the hepatitis C diagnosis was made after such a long time, they concluded that this behavior couldn\u2019t be particularly risky and were uncertain about how to protect themselves and others:\u201chepatitis C can cause issues that are to some extent manageable.\u201dSimilar to the first group, these men were pleased to take part in the study, and to receive the highly-effective and expensive medication free of charge. They said that when they learned of the new DAAs treatment, which was both simpler and more effective than its Interferon-based version, they concluded that \u201cto return something because [they were] receiving DAAs with voluntary participation.\u201d Some also hoped to learn more about hepatitis C:The knowledge, that\u2019s what I was looking for. The knowledge about this, also in our community, is not really succinct or firmly understood. And for that reason, the probability of taking risks is much higher. All participants had enjoyed the behavioral intervention. In addition to the medical treatment, they appreciated the possibility of talking to a highly-knowledgeable nurse counselor who did not judge them. For this group, the knowledge gained during the intervention was a sudden insight. They were impressed by the fact that various situations could result in infection \u2014 for example, use of anal douching equipment (the act of flushing out one\u2019s rectum with water or other liquids) or even of straws for intranasal drug consumption. From the information they received, they concluded that one of the intervention\u2019s main messages was that \u201cHepC is easy to get and can also return.\u201d One even described the virus as particularly \u201cmalicious.\u201dUnlike the earlier group, these men agreed to the intervention mainly because they saw it as a possibility Another difference between this group and the first was that the behavioral intervention motivated them to reflect on their own sexual preferences and the associated risks. During discussions with the counselor, they reflected on their personal risk situations and openly discussed possible changes to their behavior.\u201cusing gloves when fisting in a safe way \u201cor \u201cnot sharing sex toys with other people.\u201dWith their counselling sessions, they were supported in their choices for or against certain changes which could be considered by them easier to make\u2014a dynamic reflected clearly in their perception of practicability. For example, these men did not see regular condom use as feasible, because they did not feel ready for it. Instead, members from this group chose changes they considered easily made, such as \u201ctrying and choosing behavioral changes suitable for myself.\u201d They felt that the intervention supported them in maintaining feasibly judged behavioral changes. Some said they participated less often in sex parties, opting instead to organize non-sexual leisure weekends with friends for diversion. Others cut back on their drug consumption by carrying less money with them, or by deleting their dating apps to avoid spontaneous blind dates. One explained:With the life I lead, it [the risk] can only be minimally reduced. And I\u2019d rather have, for example, one encounter less and with that have the risk only once instead of twice. Rather that than \u2026 use a rubber and then not have any fun anymore. Men in this group were also tremendously impressed by the effectiveness of the new medical treatment options. However, if the behavioral changes were insufficient to prevent reinfection, they could definitely imagine another round of medical treatment as an option. Aware that they were only partially changing their risk behavior\u2014and that this might not be enough\u2014they changed what they believed was feasible to achieve success. One participant explained:What I want or should do, I am absolutely still aware. I knew it before, but the program has created more awareness. But I am not so good at implementation, or actually not good at all so to speak. But I do think, I do some of the things, but just not all that I have wanted to do. For this group, risk reduction contributed importantly to living as long as possible without hepatitis C. Having chosen to minimize risks (to the best of their perceived ability) they knew this strategy left them vulnerable to reinfection. Compared with the first group, they made few compromises, but hoped to live as long as possible without hepatitis C.Regarding behavioral changes, this group\u2019s members also had less strict ideas than the first, adhering instead to the strategy of The third sense-making group included men who were highly concerned with hepatitis C more for fear of sexual rejection than health problems. They described the intervention as useful to help them reconsider their own sexual risk behavior and to realize that further behavior changes would require considerable effort to avoid reinfection\u2014in contrast to medical treatment, which they perceived as \u201ceasy.\u201d In this sense, they expected to either undergo repeated rounds of treatment or, if necessary, stay HCV re-infected.avoiding fisting.\u201dAs in the second group, men with this sense-making style had only known of their hepatitis C infection for a relatively short time (median 1.5\u2009years); however, as in the first group, the diagnosis had elicited an intervention-independent, active and intensive search for information to explain and understand the infection. Two stated, for example, that they had already undergone at least one successful Interferon-based therapy and that they had then sought information to allow them to consciously protect themselves against reinfection. Based on the extent of their knowledge at that time and how they viewed the first (successfully treated) infection, they had decided on certain behavioral changes, such as \u201cWhat was easy for us was that we had the same thing. He was positive [HIV and HCV] and me, too. That\u2019s why we got together, because we supported each other. Because how do you want to find a life partner that doesn\u2019t have it, that doesn\u2019t understand the problems? We complemented each other well. We each respected each other, supported, showed affection to one another. It was probably just as hard for him to find a life partner as it was for me\u2014someone that accepts and takes you as you are. Among members of this group, attitudes toward the behavioral intervention reflected their intense personal search for hepatitis-C-related information prior to the study. Similar to the first group, they had low expectations of the behavioral intervention and mainly participated to please their physicians, who they believed truly worried about them. However, having already gained considerable knowledge and practiced changing some of their behavior, they did not see themselves as the right people for an intervention. Unlike the first group, but analogous to the second, they had not tried to completely eliminate the risk of reinfection but had selected easy risk-reduction adaptations. Still, two members of this group who contracted HCV again despite such changes were dumbfounded. As one said:When you can\u2019t pin it [the infection] down\u2014you know, I mean\u2014the first time it was so nice, because I knew exactly where it [hepatitis C] came from, where I got it, from whom. I knew out of which situation it came. Then it\u2019s easy to say, \u2018Ok, I\u2019ll change something.\u2019 But when later I stand there and the liver values are high and I can\u2019t link it to any specific situation, then it\u2019s difficult to change anything. These men did not participate in the intervention primarily to learn and expand their knowledge, but rather as a place where they could openly talk about past difficult situations and about their failures. Therefore, they talked with the counselor, for example, about the difficulty of disclosing their HCV status. While they acknowledged that this was an important preventive measure, they found it difficult because of the rejection they experienced as a result:It\u2019s hard to change much. Because in the moment you don\u2019t want to talk about it. Because that\u2019s when you want to party, have sex, you want to enjoy and you don\u2019t want to say, \u2018Hey stop! Hepatitis C!\u2019 Then everything would be over. The men in this third group saw little possibility of protecting themselves more effectively in the future: similar to those in the second group, they considered strict use of condoms, monogamy or even total rejection of sexualized drug use as effective protective measures, but considered such adaptations too extreme and difficult. This was described particularly succinctly by one participant\u2014a self-professed \u201csex and drug addict\u201d\u2014who acknowledged that, while the intervention made sense, it was not intensive enough for his needs.Two men living together as partners reported other experiences. As both had HIV/HCV co-infection, they saw no need to change their behavior. They described their joint status even as a relief. They could set the topic of hepatitis C aside:\u201chaving fewer sexual encounters.\u201d Unlike the second group, these men knew how easily they could be infected with HCV, but insisted on continuing risky \u201cnon-negotiable behaviors\u201d and expected to be re-infected at any time. One man called this approach\u2014taking risks to enjoy sex\u2014\u201cRussian roulette.\u201d This group considered the new DAAs a good and important option compared to the challenges of behavioral change. One man exemplified this attitude:That would probably also go in that direction with hepatitis C. \u2026 It will become less expensive to treat and then it will become even less a topic for some people, like myself, to think about having sex with a condom. They recognized the great benefit of successful therapy: \u201cthe liver gets a break.\u201d At the same time, though, the cure appeared to elicit ambivalence. While it greatly decreased their potential liver-related morbidity, it also meant \u201chaving to watch out again.\u201d One described it anxiously as \u201cfeeling put back to the time with HIV before the [2008] Swiss Statement\u201d. At that time, when condom use was strongly promoted, he experienced his sexual life as more limited and less pleasurable.This group saw only one feasible restriction: live with the risk of hepatitis C, i.e., they believed that their only reasonable course of action was to accept the risks.Thanks to the availability of curative therapy, members of this group hoped that all MSM would regularly be tested for HCV and receive treatment as necessary. They were convinced that this would reduce the danger of HCV infection for their sexual partners. Having rejected major behavioral changes, they intended to This study adds considerably to the understanding of how HIV/HCV co- and/or re-infected men responded to one of the first HCV-specific sexual risk reduction interventions to be implemented in combination with DAAs treatment. Results show the processes engaged by participants in how they position themselves in relation to the program, as well as their sense-making regarding the intervention thereafter. We identified three sense-making groups that helped to summarize the variety of responses regarding individual sexual risk reduction appraisal, decision-making, strategies to avoid re-infection and challenges to behavioral change.Giving hepatitis C a place and living without it again, covers the continuum of sense-making, with the lasting effects from the intervention program influenced by two specific factors: the time of hepatitis C diagnosis and the effectiveness of the program\u2014including counseling and pharmaceutical treatment\u2014regarding the prospect of curing their HCV.The main theme, We noted that the first experience of hepatitis C diagnosis was usually unexpected and often a shock. Diagnosis led first to reflection, then to individual explanatory patterns regarding transmission and the perceived consequences of particular sexual practices. In line with previous studies , 44, theThe second important experience inherent in the main pattern was the prospect of being cured of HCV. Interestingly, and in contrast to other studies\u2019 findings, the prospect of cure also induced negative feelings in participants for various reasons. Whereas some men described feelings of shame (in relation to their physician) if a reinfection were to occur, others expressed ambivalence about once more taking the responsibility to not get infected with hepatitis C again. To our knowledge, this is the first time that negative feelings towards an HCV cure have been noted in the perceptions of MSM. This contrasts sharply with the results of a study during the era of interferon-based therapy, in which all interviewed HIV-positive MSM spoke completely positively about their HCV-free status . Underst1) Avoid risks: get rid of hepatitis C for life; 2) Minimize risks: live as long as possible without hepatitis C; and 3) Accept risks: live with the risk of hepatitis C , one did not. This finding might explain certain differences in the likelihood of behavior changes . For exas et al.  describeAvoid risks group seemed convinced that condomless anal intercourse or past sexual drug use had led to their HCV infection. As a consequence, they intended to protect themselves by avoiding virtually any risky situations. In contrast, many from the other two groups were convinced that it was not condomless anal intercourse that led to their HCV infection but other, more complex behaviors, e.g., using drugs, sharing sex toys or fisting without gloves. Therefore, they perceived that only changing such high-risk behaviors would offer adequate protection.Another meaningful difference between these groups was in the risk perception of participants, namely what they experienced as their personal risks regarding re-infection. For example, men from the The risk minimizers, who first recognized the risks entailed by many behaviors during the sexual risk reduction intervention, perceived the elimination of those practices as feasible. In contrast, as the risk accepters had already tried such changes without success, they saw no net value in renewing their earlier attempts. Importantly, this finding is consistent with Bandura\u2019s concept of self-efficacy , i.e., tThe groups were further differentiated regarding the timing and delivery of behavior changes after study recruitment. For this intervention, we recruited only men who reported condomless anal intercourse with non-steady partners in the last year. Whereas the risk avoiders had already initiated behavior change by the start of the behavioral intervention, the other two had not. According to the Transtheoretical model of change (TTM) , which dAccept risks group described no motivation for a new attempt at behavioral change but reported reflection of their behavior during the intervention. These men either relied completely on access to successful therapy or resigned themselves to life with chronic HCV infection. Accordingly, they seemed to be trapped between the TTM phases of \u201cprecontemplation\u201d and \u201ccontemplation.\u201dIn contrast, the risk minimizers responded to their counseling with their first serious reflection on their risk behavior. This led them to target and implement behavioral changes as encouraged via motivational interviewing techniques . In relaAvoid risks group, we could focus more on maintaining behavioral change; and for those reporting sexualized drug use behavior, extending the behavioral intervention would allow a sharper focus on overcoming their ambivalence and initiating change towards lower-risk practices.The diversity of responses to each step of the program illustrates that, in research studies, as in clinical practice, screening, diagnosis and treatment all offer teachable moments. That is, participants\u2019 openness to information and reflection can arise at any point of contact; and when it does, it can serve as a fulcrum for motivational support by clinicians , 50. AddConsidering the strengths and weakness of the methods described above, although the participant interviews were conducted 6 to 12\u2009months post-intervention, the stories from the interviewees reflected rich, meaningful, well-remembered experiences regarding the intervention. One clear limitation was our decision to use a purposive sampling strategy instead of interviewing all 51 participants. Whereas the used strategy worked well to include individual characteristics , we did not reach maximum variation between centers, as we were unable to recruit participants from Switzerland\u2019s French-speaking region. Therefore, our results fail to represent one major region. However, the diversity of responses to the complex intervention program  should be sufficient to support not only a subsequent mixed-methods quantitative outcome evaluation, but also the advancement and tailoring of an intervention program focusing on HCV micro-elimination.In summary, this study\u2019s findings indicate a need for further development regarding related interventions and clinical practice. It is essential to bear in mind that, for this subgroup of MSM co-infected with HIV and HCV, both the sexual risk reduction intervention and curative DAAs treatment influence future behavioral changes.Via an inductive interpretative approach to explore responses to a comprehensive HCV prevention initiative, this study helped us both to understand the diversity of participant responses and their decisions regarding sexual risk behavior. Participants responded to all aspects of the study, including HCV screening, diagnosis, treatment and counseling, with reflection toward behavioral change. The variety of experiences also impacted participants. Our results provide important insights into the wide range of responses after receiving a combined prevention intervention including treatment and counseling.The results will facilitate ongoing development of this and similar programs\u2019 behavioral interventions, particularly by identifying intervention components that can be tailored to fit each target group\u2019s attitudes/beliefs. Impact can be tailored by adjusting how much of the intervention is received and/or how long the intervention lasts. These results also imply important recommendations for clinical practice to enhance the effectiveness of infection prevention components. Participants appreciated individual counseling; and clinicians were well-positioned to first initiate and stimulate risk-related discussions, and then in turn those discussions into teachable moments by addressing and planning concrete behavioral changes."}
+{"text": "This paper scrutinises how AI and robotic technologies are transforming the relationships between people and machines in new affective, embodied and relational ways. Through investigating what it means to exist as human \u2018in relation\u2019 to AI across health and care contexts, we aim to make three main contributions. (1) We start by highlighting the complexities of philosophical issues surrounding the concepts of \u201cartificial intelligence\u201d and \u201cethical machines.\u201d (2) We outline some potential challenges and opportunities that the creation of such technologies may bring in the health and care settings. We focus on AI applications that interface with health and care via examples where AI is explicitly designed as an \u2018augmenting\u2019 technology that can overcome human bodily and cognitive as well as socio-economic constraints. We focus on three dimensions of \u2018intelligence\u2019 - physical, interpretive, and emotional - using the examples of robotic surgery, digital pathology, and robot caregivers, respectively. Through investigating these areas, we interrogate the social context and implications of human-technology interaction in the interrelational sphere of care practice. (3) We argue, in conclusion, that there is a need for an interdisciplinary mode of theorising \u2018intelligence\u2019 as relational and affective in ways that can accommodate the fragmentation of both conceptual and material boundaries between human and AI, and human and machine. Our aim in investigating these sociological, philosophical and ethical questions is primarily to explore the relationship between affect, relationality and \u2018intelligence,\u2019 the intersection and integration of \u2018human\u2019 and \u2018artificial\u2019 intelligence, through an examination of how AI is used across different dimensions of intelligence. This allows us to scrutinise how \u2018intelligence\u2019 is ultimately conveyed, understood and  configured in practice through emerging relationships that go beyond the conceptual divisions between humans and machines, and humans vis-\u00e0-vis artificial intelligence-based technologies. \u2022Challenges and opportunities of artificial intelligence in health and care.\u2022Conceptual issues surrounding AI, ethical machines and the human-machine boundary.\u2022Dimensions of AI in health: robotic surgery, digital pathology, robot caregivers.\u2022Interdisciplinary mode of theorising \u2018intelligence\u2019 as relational and affective.\u2022Intersection and integration of \u2018human\u2019 and \u2018artificial\u2019 intelligence. For instance, Nowadays, the focus of posthuman thought is on shifting away from the humanistic paradigm, deconstructing the notion of human uniqueness including in terms of emotional capabilities, and leading towards the future creation of machines that feel, and initiate feelings in return (2.2).The conceptual ambiguities around (human vs machine) intelligence bear directly upon questions around the integration of social and affective dimensions into \u2018artificial\u2019 systems, which has been a significant part of innovation in AI  intelligence, the location of agency itself changes to something achieved through interaction. A robot that is programmed to follow ethical rules can very easily be modified, through human intervention, to follow unethical rules  differences exhibited by humans become embedded within and reinforced via algorithms. Indeed, as It is also important to investigate how the human interpretation of pathologists increasingly relying on digital images co-analysed by algorithms is substantially changing how disease is interpreted and conceptualised as well as the responses to it. Moreover, there is currently no established way to explain why machine learning algorithms make a particular decision when interpreting digital slide images. This is a manifestation of the wider \u2018black box\u2019 problem that pertains to most contexts where these algorithms are employed  respond to the world, for example by producing new categories of illness and disease from the data through identifying novel patterns of malignancy or correlations between population sub-groups and types of disease. In the words of 3.Emotional Intelligence: Socially Assistive RobotsSecondly, the relationships (including of trust) that patients have with human physicians will be conditioned by algorithms as central actors in the making of their diagnoses, while the shift from traditional pathology and patient care to digital pathology will require technological solutions that pull information from a wide range of disparate medical databases. The convergence of advanced imaging, automation, and powerful analytics like natural language processing and machine learning, are bringing together the tools needed for scientists and clinicians to make medical breakthroughs at an unprecedented pace. It is thus crucial to analyse how these technologies are transforming practices of health and care and to critically interrogate the meaning and nature of \u2018fair,\u2019 \u2018inclusive,\u2019 \u2018transparent\u2019 and \u2018accountable\u2019 analysis algorithms. Thus, concerns that have been raised around fairness, transparency, bias and accountability with respect to algorithmic medicine must also be read with an understanding of how the shift to digital pathology alters the relational aspects of health and care practices. This includes questions around how algorithms embed and may reinforce socially and culturally conditioned \u2018habits of seeing\u2019 and processes of categorisation and interpretation that have the potential to reinforce existing social frameworks of difference and \u2018otherness\u2019 as well as to enable medical advances.kokoro) to robots is a common phenomenon (kokoro no fureai), which enables both the human and the robot to understand each other like human beings. In this light, the robot needs its own heart.\u201dRobotics in the delivery of care is expected to flourish in the face of shortages of healthcare personnel, ageing populations, and calls for improved quality of care. Developments in AI in combination with assistive physical technologies are currently facilitating the production of Socially Assistive Robots (SARs). These emotionally perceptive or intelligent machines represent a new site of affective relationality in care, designed to interact with humans via a communicative range that includes \u2018emotional\u2019 responses .In fact, human communication and interaction make significant use of complex non-verbal gestures such as facial expressions, hand and body movements, which support the perception of connectedness between the human communicators  intelligence in practice, where humans and machines form the new eco-system of health and care, we will not be able to ascertain what is lost and gained, by and for whom, or therefore to exercise agency in crafting our future relationships of health and care in transparent and equitable ways.The use of these technologies also pertains to the ways in which different kinds of capabilities, skills and forms of \u2018intelligence\u2019 are being modelled into human-interfacing AI and robotic systems. These timely questions can only be addressed through an interdisciplinary mode of research and scholarship that can accommodate the fragmentation of conceptual as well as material boundaries between humans and technology, and between \u2018human\u2019 and \u2018artificial\u2019 intelligence, and the consequences of this for practices of health and care. There is thus a need for further development of the conceptual, normative, and ethical tools that are used to understand and evaluate both AI-driven technologies and the changes they are making in the expression and manifestations of the affective and relational aspects of human experience. Through this paper, we hope to have contributed towards this effort by examining how \u2018intelligence,\u2019 in its different dimensions, is being manifested and co-constituted through the human-technology interface, in ways that are re-materialising the boundaries of the human and the machine identities in affective, embodied, and relational ways. We enjoin further exploration of AI and robotics in health and social care that centres how intelligence is being understood and created, the affective and relational practices that develop in different contexts, and the implications of this for our health and care practices.1. Dr Giulia De Togni (University of Edinburgh): Conceptualisation; Formal analysis; Investigation; Methodology; Writing Original draft preparation, Reviewing and Editing, and Writing Final draft preparation;2. Dr Sonja Erikainen (University of Edinburgh): Conceptualisation; Formal analysis; Investigation; Methodology; Writing- Original draft preparation, Reviewing and Editing;3. Dr Sarah Chan (University of Edinburgh): Conceptualisation; Formal analysis; Investigation; Methodology; Writing-Reviewing and Editing;4. Dr Sarah Cunningham-Burley (University of Edinburgh): Conceptualisation; Formal analysis; Funding acquisition; Investigation; Methodology; Writing-Reviewing and Editing; and Writing Final draft preparation."}
+{"text": "Escherichia coli, Gram-positive Streptomyces and Bacillus, and eukaryotes such as yeast are used for the production of these therapeutics  spectroscopy. These molecules were evaluated for their antibacterial activity and cytotoxicity. Among them, 6\u2032-N-acyl-3\u2033-N-methylated analogs showed improved antibacterial activity against the multidrug-resistant gram-negative bacteria tested. These molecules exhibited reduced in vitro nephrotoxicity in comparison to amikacin. This study demonstrated that the modifications of the 6\u2032-amino group as well as the 3\u2033-amino group have noteworthy advantages for circumventing the aminoglycoside resistance mechanism.Heo et al. utilized the heterologous host E. coli for de novo synthesis of 11-methoxy-bisnoryangonin through in-vivo production approach. For this purpose, the entire biosynthetic pathway was reconfigured and optimized for obtaining the yield quantity of product starting from a simple sugar. The cDNA (pnPKS) of chalcone synthase (CHS)-like type III PKS, was obtained from the leaves of Piper nigrum. The PnPKS protein was incubated with ferulic acid whereas the enzyme catalyzed lactonization instead of chalcone or stilbene formation. The new product was characterized as a styrylpyrone, 11-methoxy-bisnoryangonin. Furthermore, an artificial biosynthetic pathway was reconstructed which contained ferulic acid biosynthetic genes: optal, sam5, com, and 4cl2nt, along with the pnPKS. The engineered L-tyrosine overproducing E. coli \u0394COS1 strain was transformed with these five biosynthetic genes and cultured for 24 h in a minimal glucose medium. The final yield of 11-methoxy-bisnoryangonin production was ~52.8 mg/L, which is ~8.5-fold higher than that in the parental E. coli strain.Yan et al. used a directed evolution and host engineering approach in E. coli to improve the production of pterostilbene. First, the heterologous biosynthetic pathway of pterostilbene, including tyrosine ammonia lyase, p-coumarate: CoA ligase, stilbene synthase, and resveratrol O-methyltransferase, were successively generated by the error-prone PCR. The genetic circuit containing the engineered enzymes with higher biocatalytic efficiency elevated the pterostilbene production by 13.7-fold. Then, a biosensor-guided genome shuffling strategy was used to improve the availability of the precursor, L-tyrosine. E. coli TYR-30 was used to produce pterostilbene, whereas the shuffled strain produced 80.04 \u00b1 5.58 mg/L pterostilbene which is ~2.3-fold greater than the highest titer reported to date.Lu et al. utilized the whole cell biocatalysis by two fungal strains, Aspergillus awamori and Trichoderma reesei to process and convert arctiin from Fructus arctii powder into arctigenin. They developed an optimized fermentation process by adjusting the carbon and nitrogen source/ratio, fermentation time, pH, liquid volume, inoculation volume, and substrate solid-liquid ratio. This resulted in an arctiin conversion rate of 99.84%, and the dissolution rate of the final product was 95.74%, with a loss rate as low as 4.26%. After the fermentation of Fructus arctii powder, the average yield of arctigenin was ~19.51 mg/g.E. coli and fungi for generating products of interest. Recently, the availability of robust techniques for genome sequencing has assisted in exploring the possibility of unique and signature enzymes. In addition, the genome guided application of advanced tools for generating artificial genetic circuits/metabolic pathways, or multiplexed genome engineering utilizing CRISPR has advanced the engineering approaches to the next level. Further developments in computational approaches such as artificial intelligence (AI) and machine learning approaches (MLA) has a significant impact on fine-tuning the production profiles by targeted protein level engineering or holistic microbial engineering by reconfiguring the precursor pathways, regulation mechanism, and overall metabolic flux.These papers fundamentally illustrate the applicability of different microbial platforms such as DD wrote the manuscript. E-SK and MK revised and corrected the manuscript. The final draft of the manuscript was finalized and approved for publication by all the authors.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher."}
+{"text": "The elderly are particularly vulnerable to brain dysfunction after fracture surgery, but the mechanism underlying the cognitive decline due to anesthesia/surgery is not well understood. In this study, we observed hippocampus-dependent cognitive impairment in aged mice undergoing anesthesia and tibial fracture surgery, a common model of postoperative cognitive dysfunction in aged mice. We used Golgi staining and neuroelectrophysiological techniques to detect structurally and functionally impaired synaptic plasticity in hippocampal CA1 region of Postoperative cognitive dysfunction aged mice, respectively. Based on the \u2018third party synapse\u2019 hypothesis of astrocytes, we used glial fibrillary acidic protein to label astrocytes and found an increase in abnormal activation of astrocytes in the CA1 region of hippocampus. We hypothesize that abnormal astrocyte function is the driving force for impaired synaptic plasticity. So we used chemogenetic methods to intervene astrocytes. Injection of adeno-associated virus into the CA1 region of the hippocampus bilateral to aged mice resulted in the specific expression of the Gq receptor, a receptor specially designed to be activated only by certain drugs, within astrocytes. The results of novel object recognition and conditioned fear experiments showed that CNO activation of astrocyte Gq pathway could improve the learning and memory ability and the synaptic plasticity of Postoperative cognitive dysfunction aged mice was also improved. The results of this study suggest that activation of the Gq pathway in astrocytes alleviates Postoperative cognitive dysfunction induced by anesthesia and surgery in aged mice. With the continuous improvement and development of the economy and medical system, the quality of life has been improved and the life expectancy has been extended . Aging iA total of 55 18-month-old, weighing 25\u201332\u2009g, specific pathogen-free (SPF)-grade male C57BL/6\u2009J mice purchased from Hebei Ex&InVivo Biotechnology Co., Ltd. [License No.: SCXK(J)2020\u2013002] were used in this experiment. Two mice were excluded because anatomical repositioning was not achieved, and another three were excluded because the cerebral cortex was damaged during cranial drilling. All excluded mice were replenished afterwards, resulting in 10 mice per group (n\u2009=\u200910). All mice were housed in an animal room with temperature maintained at (25\u2009\u00b1\u20091) \u00b0C, humidity at (55\u2009\u00b1\u20095) %, and a light/dark cycle of 12\u2009h/12\u2009h. The Ethics Committee of the Third Hospital of Hebei Medical University has approved the experimental design and protocol [GA2017-026-1]. All mice were habituated in separate cages for 1\u2009week prior to surgery, and all mice received human care during the experiments with reference to the recommendations of the Guide for the Care and Use of Laboratory Animals published by the National Institutes of Health.n\u2009=\u200910): the control group (C) and the tibial fracture surgery group (TF). Mice in group C did not receive anesthesia or any surgical stimulation. Older mice in the TF group were placed in an anesthesia-inducing chamber pre-filled with 5% sevoflurane  and removed after the righting reflex disappeared. They were then fixed in the left lateral position on a heated blanket-lined operating table and maintained under anesthesia with 3% sevoflurane. To provide good intra-and postoperative analgesia, the incision site was infiltrated anesthesia with 0.5% lidocaine after disinfecting and removing the hair of the surgical site. A longitudinal incision of approximately 1\u2009cm was subsequently made along the medial surface of the tibia to fully expose the tibial plateau. An 8-mm long needle with an internal diameter of 0.3\u2009mm was inserted vertically into the tibial plateau and along the longitudinal axis of the tibial marrow cavity, and then the upper middle part of the tibia was cut with a scalpel. Finally, the incision was sutured, and the mice were kept warm and allowed to awaken naturally. The total time was about 20\u2009min : the TF\u2009+\u2009rAAV5-GfaABC1D-mCherry + CNO group (AAV-mCherry/CNO), the TF\u2009+\u2009rAAV5-GfaABC1D-hM3D(Gq)-mCherry + saline group , and the TF\u2009+\u2009rAAV5-GfaABC1D-hM3D(Gq)-mCherry + CNO group (AAV-hM3D/CNO). The experimental procedure is shown in a schematic diagram . BrifelyClozapine N-oxide  50\u2009mg was dissolved in 10\u2009ml of dimethyl sulfoxide  solution to prepare a CNO master mix at a concentration of 5\u2009mg/ml. For intraperitoneal injection, CNO was diluted to 0.25\u2009mg/ml working solution using saline. A dose of 2.5\u2009mg/kg CNO was administered intraperitoneally 30\u2009min before the behavioral test. The control solvent was saline containing the same dose of DMSO .n\u2009=\u200910). The bottom surface of the open field box  and two relative closed arms  and a central area (6\u2009cm\u2009\u00d7\u20096\u2009cm) connected. Mice were gently stroked in a quiet room for 5\u2009min and then placed with their heads facing the open arm in the central area of the elevated maze. The number of times the mice entered the open arm and the residence time within 5\u2009min were recorded using the animal behavior video analysis system , and the proportion of residence time in the open arm was calculated.Mice were trained in novel object recognition on the 7th postoperative day (n\u2009=\u200910). Briefly, two identical, odorless, non-smooth, non-movable objects A and B were placed in symmetrical positions and the mice were allowed to explore them for 10\u2009min for familiarization. Memory tests were performed on postoperative day 8. The familiar object B was replaced with a novel object C of a different shape, and then the mice were placed in a behavioral test chamber and their exploratory behavior was recorded for 5\u2009min by a behavioral analysis system . Percentage of novel object exploration\u2009=\u2009novel object exploration time/(novel object exploration time\u2009+\u2009familiar object exploration time)\u2009\u00d7\u2009100%; discrimination index\u2009=\u2009(novel object exploration time \u2013 familiar object exploration time)/(novel object exploration time\u2009+\u2009familiar object exploration time)\u2009\u00d7\u2009100%.Aging mice on day 10 post-anesthesia/surgery were subjected to 3\u2009cycles of conditioned fear memory training with context-cue-electric shock pairing (n\u2009=\u200910). Briefly, mice were placed in a square test chamber with a white background for 180\u2009s, then conditioned sound  was added for 30\u2009s, followed by an electric shock (0.75\u2009mA) for 2\u2009s. The entire procedure was repeated three times. The freezing time for the first 180\u2009s of placement in the conditioned fear box was recorded as a baseline. The chamber was wiped with 75% alcohol between each experiment to prevent residual odor from affecting the next experiment. The context association experiment and the cue association experiment were conducted separately on the second day. The context association test was performed as follows: the mice were placed in the same background test chamber for 180\u2009s without adding sound stimuli, and the freezing time of the mice was recorded using the animal behavior analysis software . Two hours later, the cue association test was performed. The procedure was as follows: the test chamber was modified from a white background to a blue background, and the square activity space was modified to a triangular shape. Mice were placed in the modified new contextual chamber for 180\u2009s. Mice were then subjected to a 180\u2009s sound spike  and their freezing time during this period was recorded. The percentage of freezing time associated with context or with sound was compared between groups of mice to assess fear memory function.n =\u20093). Mice were executed under deep anesthesia with 8% sevoflurane, and brain tissues were fixed in 4% paraformaldehyde  for 48\u2009h. The brain tissues were cut into 2\u2009mm thick pieces, gently rinsed several times with saline, and then placed in Golgi staining solution  and changed to new staining solution every 3\u2009days for 14\u2009days in a cool and ventilated place. The brain tissue was then washed 3 times with double distilled water (ddH2O) and incubated overnight in 80% glacial acetic acid . The brain tissue was then rinsed with ddH2O and dehydrated in 30% sucrose. The brain tissue was cut into 100\u2009\u03bcm sections using an oscillating microtome  and then attached to gelatin slides. The air-dried tissue slides were treated with concentrated ammonia for 15\u2009min, followed by ddH2O rinsing for 1\u2009min and then treated with acidic firm film fixative for 15\u2009min, ddH2O rinsing for 3\u2009min and air-drying, and sealed with glycerol gelatin. Two microscopic fields were taken from each mouse in the hippocampus bilaterally and quantitative analysis was performed using Image-Pro Plus 6.0 software. The number and length of dendritic spines in the 30\u2009~\u200990\u2009\u03bcm length range on the second or third branch of the neuron were measured, and the density of dendritic spines per 10\u2009\u03bcm was calculated according to the following formula: density\u2009=\u2009number of dendritic spines/dendritic length \u00d7 10. Ten concentric circles with 10\u2009\u03bcm spacing centered were drawn on the cell body using the Sholl analysis plug-in, and the number of intersections between the dendrites and the concentric circles was calculated.Three mice in each group were randomly selected for Golgi staining on day 10 after tibial fracture surgery (n\u2009=\u20093). Briefly, 0.2% sodium pentobarbital 50\u2009mg/kg was injected intraperitoneally and the mice were immobilized on a stereotaxic apparatus when the bracing reflex disappeared, then the head hair was removed after sterilization and the scalp was incised medially to expose the skull. Stimulating and receiving electrodes  were implanted after drilling at two sites: (1) the Schaffer lateral branch site: anteroposterior (AP), \u22121.2\u2009mm from Bregma, mediolateral (ML), \u22122.2\u2009mm, dorsoventral (DV), 1.3\u2009mm and (2) the granular cell layer site in the CA1 region: AP, \u22122.0\u2009mm, ML, \u22121.5\u2009mm, DV, 1.5\u2009mm. Subsequent stimulation was divided into two phases to induce long-term potential. Phase I: Stimulation parameters were adjusted to a frequency of 1/60\u2009Hz, a wave width of 100\u2009s, and a current of 0.3\u2009mA to induce a cluster peak potential. The stimulation electrode and recording electrode were then adjusted to obtain the optimal group spike (PS), and after 30\u2009min of stabilization, the stimulation intensity was adjusted so that the PS was 1/3\u20131/2 of the maximum value and recorded for 30\u2009min as a baseline; Phase II: the stimulation parameters were adjusted to 5 pulses of 400\u2009Hz, repeated 3 times with 10\u2009s interval, and then the PS was recorded for 120\u2009min after high frequency stimulation (HFS). The slope of the averaged field excitatory postsynaptic potential (fEPSP) recorded for the last 20\u2009min was used for analysis.On day 11 after tibial fracture surgery, three mice per group were randomly selected for neurophysiological testing (n\u2009=\u20094). Briefly, paraffin sections were sequentially immersed in xylene and graded concentrations of alcohol to elute the paraffin, and subsequently placed in a modified sodium citrate reagent  and boiled for 20\u2009min, then cooled to room temperature to repair the antigen. After washed thrice in PBS , the sections were incubated with the quick block solution  for 1\u2009h at room temperature. Sections were then washed again thrice in PBS before incubation with primary polyclonal rabbit antibody against GFAP ; primary polyclonal rabbit antibody against NEUN ; primary polyclonal rabbit antibody against Iba-1  and mouse monoclonal antibody mCherry  overnight at 4\u00b0C. After washing thrice with PBS, the secondary antibodies cy3-conjugated goat anti-rabbit IgG  and FITC-conjugated goat anti-mouse IgG  was added to incubation for 1\u2009h at room temperature. After washing thrice with PBS, DAPI  was added to stain the cell nuclei for 2\u2009min to show their locations. Images were captured using a laser scanning microscope . Two fields of visualization were taken from each hippocampal CA1 region on each side of each mouse for analysis, and the number of GFAP-labeled astrocytes under each visual field was counted. The fluorescence area of GFAP under each field of vision was measured using Image J . Three astrocytes with relatively intact structure were selected in each field of view to calculate the fluorescence area.Four mice in each group were randomly stained with immunofluorescence on day 11 after tibial fracture to observe the morphological and quantitative changes of astrocytes  was used to perform data analysis. The data were tested for normality using the Shapiro test, and normally distributed continuous variables were expressed as mean\u2009\u00b1\u2009standard deviation. The difference between the C and TF groups were compared by unpaired P > 0.05, P < 0.05, P >\u20090.05, p\u2009>\u20090.05, P >\u20090.05, P >\u20090.05, On day 7 after tibial fracture surgery, we tested the spontaneous mobility of the mice using the open field experiment . To elimP < 0.05, P < 0.05, P < 0.05, P < 0.05, To further determine the memory function in mice, we performed Golgi staining of the hippocampal CA1 brain region responsible for short-term memory to observe the changes in synaptic structure . The denP < 0.05, P < 0.05, P < 0.05, To further investigate the possible causes of impaired synaptic plasticity in neurons in the CA1 region of the hippocampus of aged mice with POCD, we observed morphological changes in astrocytes that are actively involved in maintaining synaptic function. We labeled astrocytes with glial fibrillary acidic protein (GFAP) and found increased abnormal activation of astrocytes in the hippocampal CA1 region of aged mice undergoing anesthesia and surgery . The resP >\u20090.05, P < 0.05, P >\u20090.05, Astrocytes can exchange information with neurons, respond to synaptic activity, and regulate synaptic transmission. Abnormal activation of astrocytes is often accompanied by functional abnormalities. To verify that abnormal activation and decreased function of astrocytes in the CA1 region are important factors contributing to POCD, we injected the chemical genetic reagent rAAV-GfaABC1D-hM3D(Gq)-mCherry (AAV-hM3D/CNO) into the bilateral hippocampal CA1 region of aged mice 3\u2009weeks before TF surgery to specifically activate hippocampal astrocytes in the CA1 region ,B. At 7\u2009P<0.05, P<0.05, We hypothesized that activation of the Gq pathway in astrocytes might be associated with improved synaptic plasticity. To confirm this, we observed synaptic structures by Golgi staining . The resOur study aimed to determine that astrocytes are important players in learning memory and that the occurrence of POCD in elderly patients may be related to their abnormal function. Our results suggest that activation of the astrocyte Gq pathway improves learning memory in POCD-aged mice. Astrocytes are known to be active participants in synaptic processing, and their functional state influences synaptic structure and function. Our findings suggest that the occurrence of POCD in aged mice is accompanied by abnormal astrocyte activation and altered synaptic plasticity. In contrast, activation of the Gq pathway in astrocytes using a chemical genetic approach improves learning memory capacity. This was evidenced by increases in dendritic length, number, branching and synaptic spine density; increases in LTP strength; enhanced fear memory in fear conditioning test and increased time to explore new objects in novel object recognition test. Overall, astrocytes can be used as a target for the prevention and treatment of POCD in elderly patients .With the aging of the population and the development of medical technology, more and more elderly fracture patients are given the opportunity to undergo surgery . POCD, a2+ transients and then release gliotransmitters that in turn alter synaptic connections. This reciprocal neuron astrocyte interaction has led to the concept of the \u2018tripartite synapse\u2019, in which astrocytes are considered active participants in synaptic processing , no experiments related to the observation of changes in astrocyte calcium activity using two-photon microscopy or miniscop were performed. Direct evidence for Gq pathway activation is lacking. The activation of the Gq pathway in astrocytes involves a wide range of molecular signaling pathways, and the molecular mechanisms that play a major role need to be further investigated.Overall, our results suggest that tibial fracture surgery in aged mice can lead to recent hippocampal-dependent cognitive dysfunction. Impaired synaptic plasticity due to abnormal activation of astrocytes is an important mechanism for the occurrence of POCD. In contrast, activation of the Gq pathway of astrocytes in the CA1 region of the hippocampus ameliorates POCD in aged mice caused by aging anesthesia/surgery.The original contributions presented in the study are included in the article/The animal study was reviewed and approved by Ethics Committee of the Third Hospital of Hebei Medical University.QW and XW conceived the idea of the study. ZH and FX analyzed the data. JZ and YZ interpreted the results. JY and QZ prepared the model and injected the virus into CA1 brain region. XW wrote the paper. QZ and CY conducted behavioral related test. All authors contributed to the article and approved the submitted version.Key project of Precision Medicine Joint Fund of Hebei Natural Science Foundation (H2021206021), and the Hebei Provincial government funded the provincial Medical Talents Project.This work was supported by grants from the The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher."}
+{"text": "Preparation of these derivatives was accomplished either through thermal replacement of CO in Mo(CO)6 (for 1) or substitution under milder conditions of piperidine ligands in the precursor cis-[Mo(CO)4(pip)2] (for 2). The crystal structures of the ligand [ptapzpy]Br and complexes 1 and 2 were determined. Thermal treatment of 2 at 125\u2013150 \u00b0C leads to mono decarbonylation and formation of 1. On the other hand, oxidative decarbonylation of 1 and 2 by reaction with tert-butylhydroperoxide  gives a molybdenum oxide hybrid material formulated as [Mo3O9([ptapzpy]Br)2]\u00b7nH2O (3), which was characterised by FT-IR and Raman spectroscopy, thermogravimetric analysis, and 13C{1H} CP MAS NMR spectroscopy. Compounds 1\u20133 were effective (pre)catalysts for the epoxidation of cis-cyclooctene at 55 \u00b0C with aqueous H2O2 or TBHP (slightly better results were obtained with the former). The characterisation of the Mo-containing solids isolated after the catalytic reaction showed that poorly soluble \u03b2-octamolybdate salts, (L)x[Mo8O26], were formed from 1\u20133 with TBHP and from 1 with H2O2, while soluble oxoperoxo species were formed from 3 with H2O2. These findings helped to explain the different catalytic performances obtained.The synthesis of molybdenum(0) tricarbonyl and tetracarbonyl complexes of the form [Mo(CO) The oxidative decarbonylation and catalytic chemistry of molybdenum(0) tricarbonyl and tetracarbonyl complexes containing the same diimine ligand are compared. For comparison, the latter complex was prepared by a different route and the molecular structures of both complexes have been determined. OD of the complexes with tert-butylhydroperoxide (TBHP) is shown to give a hybrid molybdenum oxide/organic material. The catalytic behavior and chemical transformations of all compounds in the epoxidation of cis-cyclooctene have been studied using TBHP or H2O2 as oxidant.As part of our continuing interest in pyrazolylpyridine ligands, we have prepared the cationic derivative 2-(1-propyltrimethylammonium-3-pyrazolyl)pyridine bromide ([ptapzpy]Br). The introduction of cation-bearing ligands into transition metal complexes can help improve solubility in polar solvents or target the complexes for immobilisation in solid supports with charged frameworks and/or functional groups. The reaction of [ptapzpy]Br with Mo(CO)1H and 13C solution NMR) were in line with those reported previously for related 2-pyridine derivatives.14 [ptapzpy]Br is highly hygroscopic, soluble in water, ethanol, acetonitrile, dichloromethane and chloroform, and insoluble in acetone, toluene, 1,2-dichloroethane and diethyl ether.The ligand [ptapzpy]Br was prepared by deprotonation of 2-(3-pyrazolyl)pyridine followed by addition of (3-bromopropyl)trimethylammonium bromide and reflux for 4 h . Charact6 in refluxing toluene usually gives tetracarbonyl complexes of the type cis-[Mo(CO)4(N\u2013N)].8 However, in the case of [ptapzpy]Br, this reaction led to the tricarbonyl derivative [Mo(CO)3(ptapzpy)Br] (1) (cis-[Mo(CO)4(ptapzpy)]Br (2) could be prepared by treatment of the precursor cis-[Mo(CO)4(pip)2]  with 1 equivalent of [ptapzpy]Br in ethanol at 50 \u00b0C. Complexes 1 and 2 are at best only sparingly soluble in nonpolar solvents such as chloroform. Dissolution of the compounds in polar, coordinating solvents such as water, acetonitrile and dimethyl sulfoxide is accompanied by solvolysis (X)]\u2212) and fast degradation involving decarbonylation. While complex 2 displays extended stability in the solid-state if stored cold in the dark and under inert atmosphere, complex 1 is unstable and undergoes decarbonylation over a period of a few days.Reaction of pyrazolylpyridine ligands with 1 equivalent of Mo(CO))Br] (1) . The unu\u22121), complex 1 displays two overlapping strong bands at 1742 and 1764 cm\u22121, and one very strong band at 1895 cm\u22121, in a pattern that is typical of fac-[Mo(CO)3(N\u2013N)(L/X)]0/\u2212 complexes.6 The two lower energy bands arise from splitting of the E mode, while the high-energy band is associated with the A1 mode. Four carbonyl stretching bands are observed for complex 2 as expected for cis-substituted tetracarbonyl complexes. These are assigned as A21 , B1 , A11  and B2 .16 From 300 to 1700 cm\u22121 the vibrational spectra of 1 and 2 exhibit numerous ligand (ptapzpy) modes. Upon complexation the ligand undergoes structural changes which affect the 1550\u20131650 cm\u22121 region.8 In particular, the pyridyl C\u2013N stretching mode shifts from 1590 cm\u22121 for the free ligand to 1604\u20131608 cm\u22121 for 1 and 2.The FT-IR spectra of freshly prepared 1 and 2 confirmed the formation of tricarbonyl and tetracarbonyl complexes, respectively  of 2 revealed a weight loss step of 4.2% between 90 and 125 \u00b0C Br]\u00b7CH3CN (1\u00b7CH3CN) and [Mo(CO)4(ptapzpy)]Br\u00b7CH3CN (2\u00b7CH3CN) suitable for X-ray diffraction (XRD) were obtained up P21/c . In 1, troup P21 , while iroup P1\u0304 .i.e. the two rings are rotated along the central C5\u2013C6 bond, thereby minimising repulsion between the lone pairs of the nitrogen atoms and between the protons H-4 and H-8. Crystal packing effects together with a complex network of weak intermolecular interactions (involving the bromide anion) may be responsible for this rare conformation of ptapzpy in the solid-state.A striking feature of the crystal structure of [ptapzpy]Br is that the pyrazolylpyridine group adopts a cisoid conformation with respect to the pyridine and pyrazole nitrogen atoms. In analogy with the situation usually encountered with uncoordinated 2,2\u2032-bipyridine derivatives in the solid-state, uncoordinated pyrazolylpyridine ligands typically adopt a transoid conformation, 0 centre coordinates to three carbonyl groups, one N,N-chelating pyrazolylpyridine ligand and one bromide anion, leading to a distorted octahedral coordination geometry with wide ranges for the bond lengths and internal bond angles (cis angles range between 72.13(19) and 101.9(3)\u00b0, while the trans angles are found in the range of 172.9(3)\u2013174.63(19)\u00b0.In complex 1, the Mod angles . The bon4N2} core of complex 2 are consistent with those observed in the handful of structures reported containing molybdenum tetracarbonyl complexes with chelating 2-(3-pyrazolyl)pyridine residues.18 The Mo0 centre is coordinated by four carbonyl groups and one N,N-chelating pyrazolylpyridine ligand, originating a distorted pseudo-octahedral geometry as confirmed by the distinct Mo\u2013C and Mo\u2013N bond lengths  scale\" fill=\"currentColor\" stroke=\"none\"><path d=\"M80 600 l0 -40 600 0 600 0 0 40 0 40 -600 0 -600 0 0 -40z M80 440 l0 -40 600 0 600 0 0 40 0 40 -600 0 -600 0 0 -40z M80 280 l0 -40 600 0 600 0 0 40 0 40 -600 0 -600 0 0 -40z\"/></g></svg>O(\u03c0*). The equatorial CO groups are competing with the less \u03c0-acidic N-donor atoms from the pyrazolylpyridine ligand, while the axial groups compete with each other.18 The geometric deformation of the octahedral coordination of the metal centre is further verified by an inspection of the internal bond angles: the cis angles are found between 71.71(6) and 101.82(8)\u00b0, while the trans angles are found in the range of 165.75(9)\u2013173.41(8)\u00b0.The main crystallographic features of the {MoC lengths . The Mo\u20133CN and 2\u00b7CH3CN is given in the ESI.\u2020A full account of the supramolecular interactions  and crystal packing arrangements in the crystal structures of [ptapzpy]Br, 1\u00b7CH2Cl2. After stirring at room temperature for 4 h, an off-white solid (3) was recovered by filtration. Thermogravimetric analysis 2]\u00b73H2O. Powder XRD (PXRD) showed that the solid was amorphous, with only a few very broad overlapping diffraction peaks being observed in the 2\u03b8 range of 5\u201330\u00b0  to a suspension of the complex in CH\u00b0 Fig. S3. The FT-r Fig. S5. Treatmer Fig. S5.\u22121 interval are assigned to Mo\u2013O vibrations. A very broad absorption band centred at 609 cm\u22121 in the IR spectrum is assigned to \u03bd(Mo\u2013O\u2013Mo) and points towards a polynuclear or polymeric structure. Molybdenum oxide-organonitrogen hybrid materials having the general composition [Mo3O9(N\u2013N)2] have been reported previously, namely the 1D materials with N\u2013N = bipy19 and 1,10-phenanthroline.19 The Raman spectrum of [Mo3O9(bipy)2] was reported by Twu et al. and found to exhibit three Mo\u2013O bands at 893, 923 and 946 cm\u22121 which coincide quite closely with the three bands observed for 3 at 895, 924 and 962 cm\u22121, suggesting that the two materials may possess the same type of molybdenum oxide substructure.20 The structure of the bipy hybrid consists of 1D chains built up from alternating {MoO4} tetrahedra and pairs of corner-linked {MoO4N2} octahedra.19New vibrational bands for 3 that arise in the 850\u20131000 cmD) or aqueous solution (TBHPA)], at 55 \u00b0C, using cis-cyclooctene (Cy) as a benchmark substrate for olefins . On the other hand, 1 led to lower CyO selectivity (71%) than 2 or 3 (86\u201388%), at 17\u201322% conversion 4(pzpy)] containing the unsubstituted organic ligand led to 78% epoxide yield under equivalent reaction conditions.8 The catalytic results for 1 and 2 are intermediate between those reported in the literature  for complexes of the type [Mo(CO)n(L)] containing chelating N-heterocyclic carbene (L) ligands (entries 6 and 7 of Table S3 in the ESI21 and those for [Mo(CO)4(pyim)] (pyim = N-(n-propyl)-2-pyridylmethanimine), which led to 100% conversion at 5 h  scale\" fill=\"currentColor\" stroke=\"none\"><path d=\"M0 440 l0 -40 320 0 320 0 0 40 0 40 -320 0 -320 0 0 -40z M0 280 l0 -40 320 0 320 0 0 40 0 40 -320 0 -320 0 0 -40z\"/></g></svg>C bond) and dl-limonene (which possesses endocyclic and exocyclic CC bonds), at 55 \u00b0C, without additional solvent. Compound 2 led to 20%/39% styrene conversion at 6 h/24 h, and the main reaction products were styrene oxide and benzaldehyde formed with 52%/64% and 42%/31% selectivity, respectively. These results demonstrate the ability of 2/TBHP for the epoxidation of terminal CC bonds, which are electron-richer.The catalytic system 2/TBHP was further investigated for the epoxidation of styrene 4(pzpy)] in Cy epoxidation with TBHPD led to a biphasic solid\u2013liquid mixture and the solid phase was identified as the tetranuclear species [Mo4O12(pzpy)4].8 Biphasic solid\u2013liquid mixtures were also obtained for the systems /TBHPD. Attempts to isolate metal species from the colourless liquid phases were unsuccessful, suggesting that the concentration of dissolved species after a 24 h batch run was either negligible or very low. The low solubility of the metal species is probably one reason for the poor catalytic results obtained with these systems. Accordingly, for the system 2/TBHPD (no cosolvent), a 1.5-fold increase in the catalyst amount (i.e. from ca. 0.9 mol% to 1.3 mol%) did not improve the epoxide yield  by ATR FT-IR spectroscopy indicated that 1\u20133 were converted to different types of metal species (x[Mo8O26] (where L is an organic cation such as pyridinium and imidazolium) indicates that a similar type of poorly soluble \u03b2-octamolybdate salt is formed in the catalytic reaction systems of 1\u20133 with TBHPD. In the region of the Mo\u2013O vibrations (<1000 cm\u22121), the solids exhibited bands at ca. 942, 910, 840, 705 and 659 cm\u22121, which match closely with literature values for several (L)x[Mo8O26] salts 4[Mo8O26]. PXRD data for this solid, designated as compound 4 in Characterisation of the off-white solid phases  species . CompariD, the oxidative decarbonylation of 1 and 2 with TBHPD in the absence of substrate gave 3. These contrasting outcomes may be attributed to the different reaction conditions used . It is still possible that in the catalytic reaction the hybrid material 3 may be an intermediate in the conversion of 1 and 2 to species of the type (L)x[Mo8O26].Whereas an octamolybdate salt was formed from 1\u20133 under the catalytic reaction conditions with TBHPD using the ionic liquid (IL) [bmim]NTf2 imide) as cosolvent at 55 \u00b0C  with respect to Mo\u2013O vibrations (700\u20131000 cm\u22121), but different in the region of the ligand modes (>1000 cm\u22121) (i-S-TBHPD-[bmim]PF6 (not shown). The spectra very closely match that reported previously for the solid obtained upon OD of the tetracarbonyl complex cis-[Mo(CO)4(ppzpy)] (ppzpy = 2-(1-pentyl-3-pyrazolyl)pyridine) during Cy epoxidation with TBHPD in the presence of [bmim]NTf2.8 CHN microanalyses (Table S5 in the ESID-[bmim]NTf2 were consistent with the formulation (bmim)3(H3O)[Mo8O26]. PXRD data for this solid, designated as compound 5 in 3NH4[Mo8O26] (6) suggests that the two salts may have similar structures.24 Accordingly, FT-IR spectra for the two compounds display a striking correspondence in the region 350\u20131000 cm\u22121  is due to the large excess of IL present in the reaction mixture.After 24 h-batch runs at 55 \u00b0C, the reaction mixtures were liquid (IL)-liquid (organic phase)-solid(S). The ATR FT-IR spectra of the recovered solids 00 cm\u22121) . Similar2O2 at 55 \u00b0C. Results with 2 and 3 (56\u201366% CyO yield at 24 h) were superior to those with 1 (9%) 4(ppzpy)] under identical reaction conditions.8Compounds 1\u20133 were further studied for Cy reaction with Hh 1 (9%) . With thD/55 \u00b0C and 3/H2O2/55 \u00b0C (without substrate) showed that the decomposition of TBHP was not considerable (31% TBHP conversion at 24 h), whereas that of H2O2 was very significant (ca. 98% decomposition). Hence, the epoxidation process with TBHP does not seem to be compromised by side-reactions of the oxidant (i.e. unproductive decomposition into molecular oxygen and tert-butanol). On the other hand, the unproductive decomposition of H2O2 (into molecular oxygen and H2O) may compete with use of the oxidant for the catalytic reaction. Increasing the reaction temperature from 55 to 70 \u00b0C for the systems (1 or 3)/H2O2 was only slightly beneficial for 1 and actually led to poorer results with 3  and the solid was off-white. The FT-IR spectrum of the recovered solid 1-S-H2O2 (at 24 h) indicated that it was a salt of the type (L)x[Mo8O26] (similar to that verified for the systems (1\u20133)/TBHP) , which exhibited a different ATR FT-IR spectrum from those of 3 and the recovered solids discussed above (vi) species. Accordingly, bands in the IR spectrum of the recovered solid may be assigned as \u03bd(MoO) at 938 cm\u22121, \u03bd(O\u2013O) at 855 cm\u22121, and \u03bd(Mo(O2)2) at 663, 585 and 530 cm\u22121. An additional strong and broad band at 732 cm\u22121 may be due to a Mo\u2013O\u2013Mo stretching vibration, suggesting the presence of a polynuclear species. From the characterisation studies, it seems that 1 possesses a different reactivity with H2O2 than 3, being converted to different types of metal species.The differences in catalytic results for TBHP or H3)/TBHP) . For 2/Hed above . The yel6) have been established for the synthesis of molybdenum(0) tricarbonyl and tetracarbonyl complexes containing a bidentate-coordinated pyrazolylpyridine ligand. The complexes display moderate activity when applied as (pre)catalysts for the epoxidation of cis-cyclooctene with TBHP, which can be attributed to the in situ formation of poorly soluble \u03b2-octamolybdate salts. Better results were obtained with H2O2 as oxidant and the tetracarbonyl precatalyst, despite significant non-productive decomposition of the oxidant. The active species are yellow oxoperoxo-molybdenum(vi) species formed by the oxidative decarbonylation of the precursor. Treatment of the carbonyl precursors with TBHP in the absence of olefin gave a molybdenum oxide\u2013organonitrogen hybrid material with a substructure that is proposed to consist of {MoO4} tetrahedra and {MoO4N2} octahedra. Work is ongoing to isolate a more crystalline form of this hybrid and determine its structure.Two distinct synthetic pathways (both starting with Mo(CO)3 (4 \u00d7 50 mL) and the combined extracts were evaporated to dryness under reduced pressure, giving a brown oil. The oil was washed with diethyl ether (50 mL) and then dissolved in acetone (50 mL). Diethyl ether (50 mL) was added to precipitate the product, which was filtered, washed with diethyl ether/acetone, and finally vacuum-dried to give the ligand [ptapzpy]Br as a cream solid. Yield: 2.0 g, 45%. Anal. calcd for C14H21BrN4\u00b71.6H2O (354.07): C, 47.49; H, 6.89; N, 15.82. Found: C, 47.60; H, 6.45; N, 15.74%. FT-IR : 404 (m), 470 (w), 524 (w), 619 (m), 630 (m), 698 (m), 728 (m), 750 (w), 777 (vs), 871 (m), 923 (m), 962 (s), 970 (s), 991 (w), 1037 (w), 1060 (m), 1095 (m), 1147 (w), 1160 (m), 1189 (w), 1240 (s), 1282 (w), 1303 (w), 1330 (w), 1359 (s), 1403 (m), 1432 (s), 1450 (w), 1465 (w), 1490 (s), 1519 (m), 1567 (m), 1590 (s) (\u03bdNC), 1649 (w), 2954 (m), 3002 (m), 3024 (m), 3083 (m), 3118 (w). 1H NMR : \u03b4 = 8.63 , 7.83 , 7.73 , 7.64 , 7.24 , 6.84 , 4.41 , 3.80 , 3.39 , 2.55  ppm : \u03b4 = 152.51 (C-7), 152.07 (C-11), 149.76 (C-3), 136.92 (C-9), 132.32 (C-5), 122.82 (C-8), 120.37 (C-10), 104.91 (C-4), 64.48 (N\u2013CH2), 53.88 (N\u2013CH3), 48.73 (N\u2013CH2), 24.26 (CH2) ppm. 13C{1H} CP MAS NMR: \u03b4 = 151.3 (C-7), 149.6 (C-11 and C-3), 138.0 (C-9), 129.3 (C-5), 124.4 (C-8), 121.1 (C-10), 107.4 (C-4), 61.2 (N\u2013CH2), 53.7 (N\u2013CH3), 47.8 (N\u2013CH2), 24.7 (CH2) ppm.2-[3(5)-Pyrazolyl]pyridine  was added slowly to a suspension of NaH  in THF (40 mL), resulting in a yellow mixture. A solution of (3-bromopropyl)trimethylammonium bromide  in acetonitrile (90 mL) was added dropwise and the mixture stirred under reflux for 4 h, resulting in a yellow solution and a white precipitate. The mixture was evaporated to dryness under reduced pressure. The residue was extracted with CHCl6  and [ptapzpy]Br  were added to toluene (20 mL) and the mixture was refluxed under N2 for 30 min, resulting in an orange solid and solution. Hexane (20 mL) was added to promote product precipitation. The solution was filtered off and the solid washed with hexane (2 \u00d7 20 mL), diethyl ether (2 \u00d7 20 mL), and finally vacuum-dried. Yield: 0.34 g, 83%. Anal. calcd for C17H21BrMoN4O3\u00b72H2O (541.25): C, 37.72; H, 4.66; N, 10.35. Found: C, 37.58; H, 4.81; N, 10.1%. TGA . Selected FT-IR : 494 (w), 629 (w), 771 (m), 873 (w), 960 (m), 1095 (w), 1157 (w), 1239 (m), 1365 (m), 1439 (m), 1477 (m), 1604 (w) (\u03bdNC), 1742 (vs) (\u03bdCO), 1764 (vs) (\u03bdCO), 1895 (vs) (\u03bdCO).In a Schlenk tube, Mo(CO)A Fig. S2 showed a4(pip)2]  was added to a solution of [ptapzpy]Br  in ethanol (10 mL) and the mixture was heated at 50 \u00b0C, with stirring, for 30 min. The solvents were evaporated under reduced pressure, and the resultant red solid was washed with hexane (2 \u00d7 7 mL) and ethanol (2 \u00d7 7 mL). Yield: 0.13 g, 79%. Anal. calcd for C18H21BrMoN4O4\u00b71.5H2O (560.25): C, 38.59; H, 4.32; N, 10.00. Found: C, 38.90; H, 4.58; N, 10.14%. TGA . Selected FT-IR : 364 (s), 471 (w), 580 (m), 650 (m), 765 (s), 962 (m), 1097 (w), 1241 (m), 1365 (m), 1438 (m), 1482 (w), 1608 (w) (\u03bdNC), 1815 (vs) (\u03bdCO), 1869 (vs) (\u03bdCO), 1888 (sh) (\u03bdCO), 2012 (s) (\u03bdCO).. The reactor containing the catalyst, olefin and cosolvent was preheated for 10 min at the reaction temperature. In a separate flask, the oxidant was preheated in a similar fashion, and subsequently added to the reactor to give a Mo\u2009:\u2009Cy\u2009:\u2009oxidant molar ratio of 1\u2009:\u2009113\u2009:\u2009172; this was marked as the initial instant of the catalytic reaction.The typical epoxidation experiments with TBHP (in decane or aqueous solution) were carried out in 10 mL borosilicate batch reactors possessing a valve for sampling. Reaction mixtures were stirred magnetically  and heated to 55 \u00b0C with a thermostatically controlled oil bath. The reactors were charged with the (pre)catalyst , 2O2 as oxidant were carried out using tubular borosilicate batch reactors with pear-shaped bottoms (ca. 12 mL capacity), equipped with a PTFE-coated magnetic stirring bar (1000 rpm) and a valve for (un)charging of the reactor. Catalyst (16 \u03bcmol Mo), Cy (1.8 mmol), CH3CN (1 mL) and H2O2 (Mo\u2009:\u2009Cy\u2009:\u2009oxidant molar ratio of 1\u2009:\u2009113\u2009:\u2009172) were added to the reactor, which was subsequently immersed in an oil bath heated to 55 or 70 \u00b0C. Separate catalytic experiments were carried out for each reaction time.Catalytic tests using 30 wt% aq. H2 as the carrier gas. The concentrations of reactant and products were determined using the internal calibration method, i.e. based on calibration curves with undecane as internal standard. The FID response was linear in the range of concentrations used for the calibration curves and sample analysis. Using the internal calibration method the determined concentrations of Cy and CyO are reliable , i.e. the conversion values account for substrate consumption irrespective of the types of products formed being detected or not by GC. The reactant/products were identified using GC-MS , using He as the carrier gas.The reaction mixtures were analysed by using a Varian 3900 GC equipped with a DB-5 capillary column (30 m \u00d7 0.25 mm \u00d7 0.25 \u03bcm) and a FID detector, with H2O2). The reactors containing the (pre)catalyst, solvent and oxidant, without substrate, were heated at 55 \u00b0C for 24 h. After cooling the reactors to ambient temperature, liquid samples were withdrawn for titration.Iodometric titrations were carried out in order to quantify the non-productive decomposition of the oxidants (TBHP or Hca. 4 mbar) for 1 h at 60 \u00b0C. The recovered solids are denoted i-S-oxid where oxid is the oxidant (TBHP or H2O2) and i is compound 1, 2 or 3. For epoxidation systems using ionic liquids, the recovered solids are denoted i-S-TBHPD-IL {IL = [bmim]NTf2 or [bmim]PF6}. For the system 3/H2O2, metal species could be isolated from the liquid phases of the catalytic reactions by precipitation of solids after addition of an appropriate organic solvent. The precipitated solid was washed and dried as described above for the recovery of the undissolved solids and denoted 3-L-H2O2.For reaction mixtures which were biphasic solid\u2013liquid, the solid phase was separated from the catalytic reaction mixture by centrifugation (3500 rpm), washed with organic solvents , dried overnight under atmospheric conditions, and subsequently under vacuum (There are no conflicts to declare.RA-008-C8RA01687A-s001RA-008-C8RA01687A-s002"}
+{"text": "Owing to the surge in greenhouse gas emissions, climate change is attracting increasing attention worldwide. As the world\u2019s largest carbon emitter, the achievement of emission peak and carbon neutrality by China is seen as a milestone in the global response to the threat. By setting different \u201cemission peak\u201d and \u201ccarbon neutrality\u201d paths, this study compares the different pathways taken by China towards regional emission reduction to illustrate China\u2019s possible contribution to global emission reduction, and analyzes the role that China\u2019s economy, population, and technology need to play in this process through the Stochastic Impacts by Regression on Population, Affluence, and Technology model. In terms of path setting, based on actual carbon emissions in various regions from 2000 to 2019 and grid data on land use from 2000 to 2020, the model simulates three emission peak paths to 2030 and two carbon neutrality paths to 2060, thus setting six possible carbon emission trends from 2000 to 2060 in different regions. It is found that the higher the unity of policy objectives at the emission peak stage, the lower the heterogeneity of the inter-regional carbon emission trends. In the carbon neutrality stage, the carbon emissions in the unconstrained symmetrical extension decline state scenario causes the greatest environmental harm. Certain regions must shoulder heavier responsibilities in the realization of carbon neutrality. The economic development level can lead to a rise in carbon emissions at the emission peak stage and inhibit it at the carbon neutrality stage. Furthermore, the dual effects of population scale and its quality level will increase carbon emissions at the emission peak stage and decrease it at the carbon neutrality stage. There will be a time lag between the output of science and technology innovation and its industrialization, while green innovation is a key factor in carbon neutrality. Based on the results, this study puts forward policy suggestions from a macro perspective to better realize China\u2019s carbon emission goals. Compared with the unconstrained scenario, optimal control can reduce emissions by nearly half, lower carbon emissions by approximately 50 billion tons by 2030, and decrease carbon emissions by approximately 25 billion tons even under the average state, which means that China\u2019s control over carbon emissions is of great significance globally. The proportions of the eastern, central, and western regions in peak carbon under the unconstrained scenario are 41.32%, 23.28% and 35.40%, respectively, while under optimal control, the proportions become 44.68%, 25.82%, and 29.50%. This result indicates that optimal control greatly restricts the carbon emissions of the western region, by as much as 21.5 billion tons. Additionally, the carbon emissions in the eastern and central regions are also greatly constrained. Only when all regions pursue the local optimization of carbon emissions under the same goal can they reach global optimization for the entire country.https://www.resdc.cn, accessed on 30 June 2022) from five different time periods of 2000, 2005, 2010, 2015 and 2020. In this database, land use types are divided into six categories and 25 subcategories, of which urban and rural, industrial and mining, and residential land hardly include carbon sink; therefore, only cultivated land, woodland, grassland, waters, and unused land are discussed. Compared with other carbon sink areas, permanent glacier and snow land in the subcategory corresponding to the water areas has low carbon sink capacity due to the lack of vegetation or microbial respiration in the barren surface moraine areas and the large pores of the surface moraine in the glacier movement. Therefore, it is difficult to retain CO2, hence, the carbon sink of permanent glacial and snow land are excluded. Using ArcGIS Pro, the classified and encoded grid data were read and processed into the corresponding number of pixels, and the area of the corresponding land use type were calculated [Area of land use type = number of pixels \u00d7 single pixel area (1 km2)]. The static carbon sink coefficient on different land use types were determined by referring to the extant research on carbon sink capacity for different land use types in high-impact journals. The ecosystem carbon sink model can be estimated as follows:iS is the area of the i-th land use type, and i\u03b1 is the carbon sink coefficient of the i-th  land use type, while the corresponding carbon sink coefficient is shown in C, is the sum of the different carbon sinks in the region, that is, the sum of the product of iS and i\u03b1.Regional carbon sequestration was measured based on 1-km land use grid data generated by Landsat TM images, with manual visual interpretation. The data were obtained from the Resources and Environmental Science and Data Center  to zero by 2060.Scenario 1: Symmetrical extended decline stateThe neutralization scenario of symmetrical extension decline state is to estimate the downward trend of the net carbon emission levels from 2031 to 2060 by referring to the historical changes from 2000 to 2030 and taking 2030 as the axis of symmetry, on the basis of the assumption that all regions will reach their emission peak by 2030 under three different scenarios , the GM  based on the new information priority principle, and the GM  based on the optimized background value. On the premise of using the exponential of smoothing ratio analysis data as a model, combined with an error square for optimal model selection, the average relative residual and average pole ratio deviation are used as criteria to judge the goodness of fit. Based on the estimated carbon sequestration, the carbon emissions during the stage of carbon neutrality wish under the divergent scenarios were estimated to render regional carbon emissions equal to carbon sequestration by 2060.In scenario 1, based on the actual carbon emission level from 2000 to 2019 and the three carbon neutrality wish scenarios from 2020 to 2030, the annual corresponding carbon sink is removed, and the predicted net carbon emissions from 2031 to 2060 are changed symmetrically, with 2030 as the axis. Considering that the carbon emission of each region in 2000 is not zero, the carbon emissions predicted from 2031 to 2060 are first standardized by 0\u20131, and then the extension treatment is carried out according to the value of peak carbon emission to reflect the regional carbon neutrality wish development trend under the symmetrical extension decline state from 2031 to 2060.In scenario 2, based on the actual carbon emission level measured from 2000 to 2019 and the three carbon neutrality wish scenarios from 2020 to 2030, the annual corresponding carbon sink is removed, and the predicted net carbon emissions from 2031 to 2060 are reduced at a uniform speed to reflect the development trend of regional carbon neutrality wish under the uniform decline state scenario from 2031 to 2060.Based on the possible settings of carbon emissions under multifarious scenarios, we predict the carbon emissions of different regions in China from 2031 to 2060, and the results are shown in Under the basic assumption of a symmetrical extension decline after the emission peak, in the unconstrained symmetrical extension decline state (scenario 11), the change in the trend of each region corresponds to the left-hand side of 2030. Shandong\u2019s carbon emissions rank first from 2030 to 2056 and experience a significant decline in 2057, while simultaneously, Guangdong\u2019s carbon emissions will be the largest. Hubei will be the largest emitting province from 2058 to 2060. In this scenario, the annual decline in China\u2019s total carbon emissions is within  billion tons and carbon emissions decrease gradually over time, with an average annual decline rate of approximately 11.82%; this rate lowers over time. In the ideal symmetrical extension decline state (scenario 21), the annual decline range of national total carbon emissions is within  billion tons, but the volatility of each region is relatively large. The carbon emission level in the early stage is lower than that in the other two symmetrical extension decline state scenarios, but always at the highest level of the three in the middle stage; the decline is most intense in the later stage. The average annual decline rate is approximately 10.00%; this rate decreases with time. In the average symmetrical extension decline state (scenario 31), the carbon emission scale is always at the middle level. From 2030 to 2034, around 15 provinces will have carbon emission values greater than the overall average, and then they decline. From 2044 to 2049, around 11 provinces have carbon emission levels higher than average but eventually, only four provinces will have carbon emissions higher than the average. Overall, it can be observed that the carbon emission level will gradually converge by 2060. Please replace with the following text:In this scenario, the annual decline in total carbon emissions in China is within ,4 a billUnder the basic assumption that carbon emissions will decline at a uniform rate after reaching the peak, the carbon emissions of each region in the unconstrained uniform decline state (scenario 12) shows a downward trend, with its rate slowly rising for all states. The total carbon emissions of the country will decline by approximately 3.85 billion tons every year, with an average annual decline rate of approximately 11.43%, and there is little difference in the decline rate of carbon emissions among the regions in the same year; especially, the decline rate of Guangdong, which is lower than that of the other provinces. In the ideal uniform decline state (scenario 22), the carbon emission of each region is similar to scenario 21, but the decline rate is the lowest under the three sub-scenarios in the ideal state. The total carbon emissions decline by approximately 2.12 billion tons per year, with an average annual decline rate of 10.74%. In the uniform decline state (scenario 32), the carbon emission of each region is similar to those in scenario 21. The total carbon emissions of the whole country decrease by approximately three billion tons every year, with an average annual decline rate of approximately 11.16%. Although the carbon emission gap under the three scenarios gradually narrowed over time and finally converged to the same carbon neutrality value, the sum of carbon emissions from 2031 to 2060 is very different due to the dissimilarities in emission peak values in the various scenarios. The cumulative carbon emissions of the three scenarios are 1729.8, 1011.5, and 1370.7 billion tons, respectively. The difficulty of regional carbon neutrality wish under diverse emission peak scenarios is not only different, but its impact on the ecological environment is not at the same level.Based on the comprehensive analysis of carbon neutrality wish in various regions, it is easier to complete carbon neutrality wish in Hubei than in other provinces, and the carbon emission level needs to be controlled to decrease by approximately 68.22% from 2030. Nevertheless, Tianjin shows the sharpest contrast. Owing to its weak carbon sink capacity, and with the extension of human activities and further economic development, the capacity will decline. By 2060, carbon emissions need to be 0.04% of the carbon emissions of the peak year, which also poses a significant challenge to these local governments.Under the combination of different emission peaking and neutralization scenarios, China\u2019s overall carbon emission intensity varies greatly. The cumulative carbon emissions in the unconstrained uniform decline state (scenario 12) are the largest from 2031 to 2060, and the smallest in the ideal uniform decline state (scenario 22), with a difference of 718.3 billion tons, that is, more than six times that of the unconstrained emission peaking and nearly 11 times the peak value of ideal state. Carbon neutrality wish under multiple scenarios also proves the importance of implementing carbon emission control policies as soon as possible; otherwise, large scale carbon emissions will affect the future development of mankind.I is the regional energy carbon emission intensity, A is the regional economic development level, P is the regional population scale, and T is the regional S&T innovation capacity, while a, b, c, f are the regression coefficients of these variables, and ie is the random error term of regression.Using the STIRPAT model , this stAccording to the STIRPAT model, before exploring the impact mechanism of economic development level, population scale, and S&T innovation on regional emission peak and carbon neutrality wish, it is necessary to quantify and estimate the values of economic development level, population scale, and S&T innovation in various regions and over different periods. Since the government generally does not inhibit the progress of economic development and S&T innovation, and China has begun to encourage fertility, the population growth will not be strictly limited. Therefore, the estimation of the three influencing factors is unconstrained. The estimation method for each determinant is as follows.Economic development level. The GDP of each region was selected to represent the regional economic development level. The actual data were obtained from the National Bureau of Statistics for 2000\u20132020. The forecast data consider the greater volatility of the economy. The forecast data are based on the GDP from 1992 to 2020 of the National Bureau of Statistics, and excludes 2008  and 2020 (COVID-19). With the help of the \u201ccurve fitting method\u201d in SPSS for rough projection and on the premise of passing the significance test, we selected the curve cluster with a high fitting degree and relatively close to the reality and performed arithmetic average processing. On this basis, according to the projection of China\u2019s economic growth over different periods by the Global Energy Interconnection Development and Cooperation Organization, the predicted values of the various regions over many periods were adjusted.mig_nP is the number of inter-provincial migrations in year n, migP is the total population of inter-provincial migration, and the data are for reference. Considering the changing characteristics of China\u2019s urbanization and in combination with the National New-type Urbanization Plan (2014\u20132020) issued by the State Council, China\u2019s urbanization is expected to reach more than 70% by 2035. After the urbanization rate reaches 70%, with the equalization of public services and the realization of urban\u2013rural integration, the inter-provincial population flow at the national level tends to become balanced. Therefore, in the mechanical projection process, the total inter-provincial population migration will not increase from 2035 to 2060.Population scale. The registered residence population in each district was characterized by population size. The actual data are from the \u201cFifth Population Census of China (2000)\u201d and the \u201cSixth Population Census of China (2010)\u201d, which include data related to the natural population change projection, such as registered residence population and annual population growth rate. There are also data related to machinery population change projection, such as registered residence migration. Considering the large error between the 1% sampling survey data (using samples to represent the population) and the real data in each region, we filled the missing values in the middle year using the linear interpolation method. The forecast of population size consists of two parts: natural and mechanical population growth. In terms of natural population growth, considering the limited data availability at the provincial-level administrative region, we used the trend extrapolation method (at a constant growth rate) for projection. Since the population growth rate is not constant in the long-term forecast, the predicted value of the total population of each region over different periods was adjusted according to the medium plan [the total population estimated by the natural population growth rate in the plan is more in line with the projection range of major institutions and scholars in China.] in the \u201cWorld Population Prospects of the 2019 Revision\u201d issued by the United Nations.  In terms of mechanical population growth, the Markov Chain (MC) model was used to describe the dynamic changes in population growth caused by cross-provincial migration. First, the initial immigration probability vector matrix Scientific and technological innovation. The number of patents is often used to measure the innovation level of enterprises  and regiThe measurement and estimation results for the economic development level, population scale, and S&T innovation in different regions of China are shown in A spatial panel data regression analysis was conducted with the carbon emission of each region in different scenarios and periods as the response variable and the economic development level, population scale, and S&T innovation as the explanatory variables. The Hausman test results show that the random effect model is rejected in the regression of each period, so the fixed effect model is selected for regression; the results are shown in Regarding the impact of economic development level in measurement periods (2000\u20132019), the economic development level affects carbon emissions at a significance level of 1% and the coefficient is positive, thereby indicating that the improvement in economic development level will promote the further growth of carbon emissions. For every 1 unit increase in economic level, carbon emissions will correspondingly increase by about 0.7042 units, and the three scenarios in the 2020\u20132030 emission peak periods differ. In scenarios 1 and 3, the economy affects carbon emissions at a significance level of 5% and the effect of economic development level on carbon emissions is weaker than in the historical periods. Each unit of economic growth will drive 0.2613 units and 0.1796 units of carbon emissions in these two scenarios, respectively. In scenario 2, economic growth will have a restraining effect of 0.0581 units on carbon emissions. This situation is due to the constraints of the ideal state scenario being very strict, such that the carbon emissions fall within the declining range of the EKC. It signifies that the improvement in the economic development level will lead to a decline in carbon emissions. In the 2031\u20132060 carbon neutrality wish period, the change in the carbon emissions and economic development levels extend to the end of the EKC, and compared with the uniform decline state , the economic development level in the symmetrical extension decline state  will have a stronger inhibitory effect on carbon emissions. At the 1% significance level, the inhibitory effect of economic development on carbon emission is greater than one time.Regarding the impact of population scale over the different periods, public awareness of environmental protection is low from 2000 to 2019. The population scale promotes the rise of carbon emissions at the 1% significance level. For each unit of population scale growth, carbon emissions will increase by 4.1285 units. During the emission peak period from 2020 to 2030, the population scale will further expand and form a population scale effect, that is, when the population scale reaches a certain value, the consumption of unit resources will be reduced. Simultaneously, given the augmented environmental protection awareness and the continuous improvement in population quality consequent to the higher education level, there will be a decoupling of the population scale and carbon emissions at this stage. In the carbon neutrality wish period from 2031 to 2060, the mechanical change in population scale in various regions tends to be stable and the annual natural growth rate is negative, which results in a greatly weakened population scale effect. In each scenario, the population scale will promote the increase in carbon emissions at a significance level of 1%, and one unit of population growth will bring 11.8982 (scenario 11), 11.0882 (scenario 12), 13.2984 (scenario 21) and 10.5214, respectively (scenario 22), 12.4422 (scenario 31) and 10.8326 (scenario 32) of carbon emission growth.Considering the time lag between the output of S&T innovation and their industrial application, the impact of S&T innovation on carbon emissions will show an obvious heterogeneity over the three periods. From 2000 to 2019, the progress of S&T has made social development more intelligent and reduced human participation in production activities to a certain extent, which will inhibit the growth of carbon emissions at the 1% significance level. Every unit of S&T innovation capacity will inhibit carbon emissions by 0.2977 units. The main technology application in the emission peak stage from 2020 to 2030 is the non-green innovation output during the rapid economic development in the early stage, which accelerates the growth of carbon emissions at the 1% significance level, and from 2031 to 2060, the main technology application in the carbon neutrality wish stage is the green innovation output in the emission peak stage. Except under scenario 21, which inhibits 0.4274 units of carbon emissions per unit of S&T innovation at the 5% significance level, the other five scenarios inhibit the growth of carbon emissions at the 1% significance level, and its effect is about twice that of the S&T innovation in curbing human activities. Therefore, improving the output of green innovation is a relevant factor in helping China\u2019s emission reduction.2 and other greenhouse gas emissions has become one of the biggest challenges of this century. China has gradually embarked on a new path of high-quality development, guided by ecological priority and green development, and put forward the major commitment of \u201cstriving to reach the peak of carbon emissions by 2030 and strive to achieve carbon neutrality by 2060\u201d. However, as the largest carbon emitter, the process of achieving its emission peak and carbon neutrality wish is worth delving into. To explore the low-carbon development path in the current period and emission peak and carbon neutrality wish periods from the land use perspective, this study considers emission peak and carbon neutrality wish as its objectives, and constructs six carbon emission paths from 2000 to 2060 by setting three emission peak scenarios\u2014unconstrained state scenario, ideal state scenario, and average state scenario\u2014and two carbon neutrality wish scenarios of symmetrical extension decline state scenario and uniform decline state scenario. To predict the emission peak stage, based on the final energy consumption data of the different provinces in China from 2000 to 2019, this study estimates future carbon emissions by simulating and predicting its growth rate. For the projection of the carbon neutrality stage, the projection of carbon sequestration is based on 1-km land use grid data with an interval of five years from 2000 to 2020. Based on actual regional carbon emissions from 2000 to 2018 and the carbon emission projection value under three scenarios from 2019 to 2030, the future carbon emission value is estimated by predicting the scale of net carbon emissions. To explore the impact mechanism of carbon emissions in different periods, this study uses the STIRPAT model, based on panel data of 30 provincial-level administrative regions from 2000 to 2060, and takes carbon emissions as the response variable, and economic development level, population scale, and S&T innovation as the explanatory variables, to explore the impact of various factors that influence the emission peak and carbon neutrality wish path.Global climate change caused by COIn achieving the emission peak in an unconstrained state (scenario 1), the total carbon emissions of all regions in China will increase from 645.74 billion tons (2020) to 1175.24 billion tons (2030), of which Shandong has the highest carbon emission intensity among all regions, while Hainan and Qinghai have the lowest. At the same time, the heterogeneity of carbon emissions among regions will increase year by year, and the standard deviation in carbon emissions in all provinces will expand from 15.57 billion tons (2020) to 30.89 billion tons (2030). Six provinces, including Inner Mongolia, will become the six regions with the fastest carbon emissions growth if they do not exercise control. Under this scenario, all regions in China will emit 9749.00 billion tons of carbon from 2020 to 2030. In the ideal state scenario (scenario 2), the total carbon emissions of all regions in China will increase from 636.90 billion tons (2020) to 675.15 billion tons (2030), and the development trend of carbon emissions among regions will converge, resulting in the standard deviation in carbon emissions in all provinces only expanding from 15.37 billion tons (2020) to 16.46 billion tons (2030). In this scenario, the total carbon emissions of all regions in China from 2020 to 2030 will be 7349.31 billion tons, which is 2399.69 billion tons less compared to the unconstrained state, indicating that the effect of decarbonization is significant. In the average state scenario (scenario 3), the total carbon emissions of all regions in China will increase from 639.10 billion tons (2020) to 922.83 billion tons (2030), but the difference between various regions and their maximum/minimum carbon emissions is still large (94.34%). The standard deviation in carbon emissions of all provinces will only expand from 15.43 billion tons (2020) to 23.30 billion tons (2030). In this scenario, China\u2019s regional carbon emissions from 2020 to 2030 will total 8523.97 billion tons, an increase of 1174.66 billion tons compared with the ideal state, and a decrease of 1225.03 billion tons compared with the unconstrained state. The local government should make reasonable decisions based on the specific development of the region since the total carbon emissions will vary greatly under different carbon peak paths.If realizing carbon neutrality in a state of unconstrained symmetrical extension decline scenario 11), the annual decline in China\u2019s total carbon emissions will be around 1, 7.4] billion tons with an average annual decline rate of about 11.82%, thus showing a gradual decline over time. Under this scenario, the cumulative carbon emissions from 2031-2060 will be around 14208.54 billion tons. In the ideal symmetrical extension decline state (scenario 21), the annual decline in China\u2019s total carbon emissions will be around  billion tons, albeit each region will see significant volatility, with an average annual decline rate of 10.00% and a gradual decline over time. Under this scenario, the cumulative carbon emissions from 2031\u20132060 will total 13,486.68 billion tons. In the average symmetrical extension decline state (scenario 22), the annual decline in China\u2019s total carbon emissions will be around [1, the an billion In light of the research on the pathways affecting carbon emissions from 2000 to 2019, the impact of economic development level, population scale, and S&T innovation on carbon emissions is consistent with the actual situation. This fact verifies that the STIRPAT model is reasonable and can be used to further explore the impact of the three influencing factors on carbon emissions in divergent scenarios. In the 2020\u20132030 carbon emission peak period, the economic level and carbon emissions under the optimal policy effect will fall within the declining range of the EKC, while the other two scenarios are in the growth range. Population development will be influenced by both the population scale effect and the popularization of environmental protection awareness, thus resulting in a decoupling phenomenon. For S&T innovation, the industrial application of S&T innovation is the non-green innovation produced in the period of rapid economic development in the previous stage, which will lead to a further increase in carbon emissions. In the carbon neutrality period from 2031 to 2060, with the development of China\u2019s economy and the implementation of emission reduction projects, the economic development level and carbon emissions will always fall within the declining range of the EKC, while the population scale will also decline to a certain extent at this stage, thus leading to the increase in carbon emissions. For S&T innovation, the industrial application of innovative technologies in the pre carbon-neutrality period is mainly based on the green innovation output for the emission peak period, which is essential to achieving carbon neutrality. In short, in the emission peak phase, the role of the economy and S&T in emission reduction depends on the choice of different emission peak paths, while population is decoupled from carbon emissions. In the pre-carbon neutrality phase, no matter the pathway, the economy and S&T will both play an active role in the emission reduction process.First, focusing on the development goal of reaching the emission peak by 2030, this study considers three scenarios under the unconstrained, ideal, and average state scenarios, which not only measures the possible range of the emission peak, but also estimates the most likely peak. Looking at the development prospects for carbon neutrality wish by 2060, this study further simulates the symmetrical extension decline state and uniform decline state, and constructs six combined scenarios of carbon emissions from 2000 to 2060 to predict the development path of emission peak and carbon neutrality wish in different regions and diverse scenarios.Second, there may be large errors in the projections based on China\u2019s total carbon emissions. In this study, carbon emissions were divided into three different periods according to measurement and projection. By predicting the carbon emission scale of provincial-level administrative regions and summing them up, we can obtain the overall carbon emissions of each time node. The carbon emissions of each region are small, meaning absolute errors are also small, which can reduce the overall error to a certain extent. Nevertheless, the estimation error of carbon emissions among regions can offset and reduce the overall error to a certain extent.Third, this study estimates not only the emission peak in 2030 and carbon neutrality wish in 2060 but also the economic development level, population scale, and scientific and technological innovation of each region. It further examines their impact on carbon emissions in different scenarios based on the STIRPAT model to explore the road of low-carbon development in China.Moreover, under the setting of various situations, the regional emission peak can seemingly be achieved instantaneously in 2030 in this paper theoretically. Yet in reality, such a change is difficult and improbable. Although many regions are striving to achieve carbon peaking in 2030 based on the emission peak target set by China, this only provides them with a clear deadline for reaching the emission peak. Based on this time point, this paper tries to set various theoretical scenarios and analyze the possible timelines of emission peaks in different regions based on the latest data of regional emission peaks. Nevertheless, combined with the target of carbon neutrality from 2030 to 2060, the regional emission peak in 2030 can still be divided into an ideal (emission peak with decreasing growth rate of carbon emissions) and non-ideal situation (unconstrained emission peak). If the emission peak is achieved in an ideal situation, the carbon neutrality pressure faced by the region in the future will be reduced, and the accumulated carbon emissions in the future will also be greatly reduced. In a non-ideal situation, the region will face the opposite situation. This paper also estimates the role that the economy, population, and S&T will play in different scenarios. Although these scenarios are theoretical, they can still provide local governments with insights for policy making. In addition, if the region has achieved emission peaking before 2030, by comparing the situation then to the various scenarios laid out in this paper, we can further clarify the contribution of the region in reducing total carbon emissions.Based on the scenario simulation of emission peak and carbon neutrality wish, this study puts forward the following policy suggestions as a reference for local governments to prepare reasonable emission reduction plans. First, we formulate a systematic long-term emission reduction strategic layout and implement regionally differentiated decarbonization policies. We should pay attention to not only short-term emission reduction targets, but also long-term carbon emissions control performance, especially to strengthen the implementation of emission reduction policies in Inner Mongolia, Fujian, Shaanxi, Qinghai, Ningxia, and Xinjiang, and control the growth rate of carbon emissions and smoothly complete the task of reaching the peak in 2030. Second, we should flexibly adjust emissions reduction policies according to the temporal and spatial patterns of carbon emissions. We should monitor the dynamic changes in carbon emissions in provincial-level administrative regions, thus maintaining the overall balance of emission reduction policies, especially the balance between the optimal-controlled area  and the worst-controlled area (Shandong), and realizing the optimal combination of overall policy and regional policy. Third, we must avoid blindly pursuing the carbon neutrality target of 2060 and ignoring the destructive effect of cumulative carbon emissions on the environment. On the premise of taking 2060 as the carbon neutrality target year, all regions should explore their optimal regional carbon neutrality wish paths based on the emission reduction principle of scientific decarbonization and seeking stability reduction.Based on the empirical analysis of the impact path of emission peak and carbon neutrality wish, this study holds that, first, the impact of economic development on carbon emissions falls within the declining range of the EKC, which is key to realizing carbon neutrality wish. According to the \u201cBlue Book of China\u2019s Society\u201d issued by the Chinese Academy of Social Sciences, China will become a high-income country in the 14th Five-Year Plan period. China must thus improve energy efficiency, develop renewable energy resources, optimize energy consumption structure, enhance industrial structure, and accelerate the transformation from a high energy consumption development mode to a low-carbon green development mode. Second, the population density of the control area should be in an adequate range to prevent the reduction in the population scale effect due to an extremely small population density or the enhancement of migration activities following an extremely large population density, thus resulting in an increase in carbon emissions. In addition, the relevant departments should promote clean energy, low-carbon lifestyle, and quality education to the majority of residents to reduce household carbon emissions. Third, environmentally friendly S&T innovation is the main driving force for carbon emission reduction. To realize the gradual decline in carbon emissions, we should strengthen the research and development and the industrial applications of low-carbon technologies, such as carbon capture technology. Additionally, the Chinese Central Government should improve the corresponding system construction, such as establishing a perfect carbon trading market to force high-energy-consuming enterprises to reduce energy consumption and improve energy output efficiency.First, this study assumes an ideal state in the scenario simulation. It does not consider the upheavals in natural factors, such as major disasters, the impact of human factors, including conflict and war, the basic constraints of revolutionary S&T innovation, and the application of new energy. In reality, there are many uncontrollable external factors that interfere with the operation of carbon emission systems, such as COVID-19. In future, we will attempt to build a System Dynamic model of the emission reduction system by taking into consideration a variety of external factors and provide more realistic conclusions and suggestions.Second, the scenario set in this study is based on a theoretical economic trend, meaning the actual future carbon emission trend will have a certain random deviation from the scenarios contemplated in this study. In the future, we will consider a multi-dimensional situation and introduce disturbance factors to build a more comprehensive simulation.Third, the data to measure historical carbon emissions are based on the \u201cChina Energy Statistics Yearbook\u201d. There are practical problems such as omissions, which produce a gap in information and will have a certain impact on follow-up research. We should thus consider using more accurate and complete carbon emissions data in future."}
+{"text": "The existing literature on the influencing factors of carbon emissions ignores the relationship between financial agglomeration and carbon emissions. Based on the analysis of the emission reduction history of major countries, this paper mainly uses the provincial-level data of China from 2002 to 2018 to explore the impact of financial agglomeration on carbon emissions. The conclusions are as follows: (1) China lacks carbon tax policies; there are many drawbacks in the carbon trading market, and a \u201cbottom-up\u201d voluntary emission reduction mechanism has not been formed. (2) China\u2019s carbon emissions and financial development are characterized by spatial agglomeration. (3) Financial agglomeration can reduce carbon emissions. In central China, the low-carbon region, and the pilot regions for carbon trading, financial agglomeration has a greater impact on reducing emissions. (4) Financial agglomeration can reduce emissions by reducing the proportion of the secondary industry and increasing the proportion of the third industry. (5) Financial agglomeration can still lower carbon emissions when the spacing effect is taken into account. Finally, according to the conclusion, this paper puts forward relevant suggestions to help China reduce carbon emissions. Excessive greenhouse gas emissions will lead to the superposition of various extreme climate crises, posing a serious threat to humans, economic development, food security, biodiversity, and ecosystems ,2. If glThe Solow model says that, in a perfectly competitive market, economic growth is stable, and the market can reach Pareto optimality . Most scFinancial support is required to achieve the two goals of \u201ccarbon peak\u201d and \u201ccarbon neutrality\u201d as soon as possible. Therefore, in February 2021, the State Council of China issued the Guiding Opinions on Accelerating the Establishment and Improvement of a Green Low-Carbon Circular Development Economic System, which suggested developing green credit, green direct financing, green insurance, and climate investment and financing. In March 2021, the People\u2019s Bank of China proposed to give play to the functions of financial resource allocation, risk management, and market pricing. They will contribute to carbon peak and carbon neutrality by improving the green financial standard system, strengthening supervision and information disclosure, improving incentive and restraint mechanisms, enriching green financial products, and expanding the international green finance cooperation space. At the same time, the Ministry of Ecology and Environment of China issued the Interim Regulations on the Administration of Carbon Emission Trading (Revised Draft), proposing to establish a national carbon emission trading fund and attaching importance to the financial attributes of the carbon market. Therefore, finance will play an important role in the process of carbon emission reduction in China.Some scholars believe that finance has increased carbon emissions by promoting production, increasing energy consumption, and promoting commodity sales ,13,14. SThe phenomenon of various financial entities gathering in specific regions is called financial agglomeration. Analyzing the relationship between the spatial agglomeration of economic variables and economic phenomena belongs to the new economic geography, which was created by Paul Krugman . After tTo make up for the shortage of existing literature, we designed the following research: First, this paper analyzes the research background, including the carbon emission status and related policies of major countries. Then, we use econometric models to analyze the direct impact, impact mechanism, heterogeneity analysis, and spatial effect of financial agglomeration on carbon emissions. Finally, we put forward relevant suggestions according to the finding. The research design of this paper makes up for the lack of existing research and has theoretical and practical significance.The rest is organized as follows: The section on \u201cResearch background and hypotheses\u201d reveals the carbon emission status and emission reduction policies of China and other major countries worldwide and introduces research hypotheses. The section on \u201cMaterials and methods\u201d shows the research design of this paper. The \u201cImperial Results and Analysis\u201d section reviews the impact, impact mechanism, and spatial effect of financial agglomeration on regional carbon emissions. Finally, the \u201cConclusion and Suggestions\u201d part summarizes the research and provides relevant suggestions.The European Union has always been an active advocate for the climate crisis. The EU put forward the 2020 Climate and Energy Package in 2007. The plan attempts to reduce emissions by 20 percent from 1990 levels. In 2011, the EU adopted the Energy Roadmap 2050 and the Roadmap towards a Competitive Low Carbon Economy 2050, which set a long-term goal of reducing greenhouse gas emissions by 80\u201395% by 2050. In 2014, the European Union proposed the 2030 Climate and Energy Policy Framework to reduce greenhouse gas emissions by 40% in 2030 based on 1990. The European Union adopted the European Energy Efficiency Designation in 2019 to improve energy efficiency by 32.5% by 2030. At the same time, the EU put forward the EU\u2019s 2030 and 2050 climate goals in the European Green Agreement. The European Climate Law adopted in 2020 to ensure carbon neutrality by 2050 in legal form.The major methods used by the EU to reduce carbon emissions are carbon taxes and emissions trading. The EU carbon emission trading system was officially launched in 2005 and has gone through four stages. The first stage was from 2005 to 2007. The EU\u2019s emission reduction targets are mainly based on the Kyoto Protocol. The second phase is 2008\u20132012. Based on 2005, the EU set a target of 6.5% emission reduction. The third stage is from 2013 to 2020. The EU\u2019s emission reduction goal is a 20% drop in emissions from 1990 levels. The fourth stage is 2021\u20132030. The EU will introduce the Market Stability Reserve (MSR) mechanism and strive to reduce emissions by 43% based on 2005 and 40% based on 1990 in 2030. From the perspective of the carbon tax, since 1990, the EU has gradually formed a carbon tax system that is separately disbursed; represented by Finland, Sweden, and Norway; and collectively paid by Italy and Germany. The entire carbon tax system in the EU is developed, with a wide range of taxation methods and a high rate of taxes. After 2018, the EU gradually implemented a linking policy between the carbon trading market and the carbon tax in order to put more financial pressure on high-emission businesses and strengthen the efficiency of the carbon tax system.Germany, a significant member of the European Union, actively promotes the growth of electric transportation through its economic recovery plan, finances the development of new energy sources and green technologies, and supports the use of low- and zero-emission vehicles. The UK published Promoting a Zero Carbon Future in 2020 with the intention of reducing carbon emissions through the robust development of wind power, supporting CCUS cluster construction, developing digital infrastructure construction, low-carbon industrial clusters, and a green economy.Since 1993, the United States has implemented several policies and laws, such as the National Environmental Policy Act, the Comprehensive Response, the 2007 Low Carbon Economy, and so on. The USA also adopted several strategies to improve energy efficiency, improve the energy structure, boost the economy, and address climate change, such as the National Energy Comprehensive Strategy, the Green Economy Recovery Plan, and the Administrative Order to Address Domestic and Foreign Climate Crises. At the same time, the US encourages businesses to create energy conservation and emission-reduction technologies, as well as carbon dioxide recovery and storage technology, through financial subsidies, environmental taxes, tax credits, tax incentives, financial subsidies, and other measures. Additionally, they have gradually formed financial means and market mechanisms to promote carbon emission reduction at the enterprise level and reduce carbon emission through a \u201cbottom-up\u201d voluntary emission reduction model. In particular, the United States promotes energy transformation and accelerates low-carbon development in all sectors by increasing investment in clean energy and optimizing market resource allocation through green finance.Since joining the United Nations Framework Convention on Climate Change in 1992, China has signed international agreements such as the Kyoto Protocol, the Copenhagen Agreement, and the Paris Agreement. In 2007, China established a national plan to address climate change. In 2010, it carried out pilot work for low-carbon cities in five provinces and eight cities and formally implemented the Environmental Protection Tax Law in 2018. From the perspective of carbon emissions trading, China started the pilot work of carbon emissions trading in 2011, started trading in the carbon market in 2013, and launched the national carbon emissions trading market in 2021. China\u2019s national independent contribution to addressing climate change and reducing carbon emissions has been increasing. In 2020, China promised to achieve a carbon peak by 2030 and carbon neutrality by 2060.China has formed a \u201c1 + N\u201d policy system; 1 refers to the Opinions on Fully, Accurately, and Comprehensively Implementing the New Development Concept and Doing a Good Job of Carbon Peak Carbon Neutralization. This opinion is the system planning and overall deployment of carbon peaking and carbon neutralization, covering two stages and playing a leading role in the relevant policy system. N refers to a series of policy documents led by the 2030 Carbon Peak Action Plan, covering implementation plans, support measures, and safeguard measures in the major areas, industries, and regions. Finance is one of these safety measures. China actively promotes green finance and works to use the financial sector to support efforts to reduce carbon emissions.Germany provides financial support for new energy R&D and green technology innovation. The United States promotes energy transformation by optimizing market resource allocation through green finance. China\u2019s \u201c1 + N\u201d policy system encourages green finance to play a role in resource allocation, risk management, and market pricing. Therefore, finance plays an important role in emission reduction. A region with strong financial development is more capable of promoting energy structure transformation to reduce regional carbon emissions. Meanwhile, financial agglomeration can promote the development of low-energy and green industries, improve energy consumption efficiency, and reduce carbon emissions. Based on this, this paper proposes hypothesis H0:H0.\u00a0Financial agglomeration can reduce regional carbon emissions.Secondary industrial carbon dioxide emissions have always accounted for a significant share of total carbon emissions. Financial agglomeration promotes enterprise competition and urges the high-carbon secondary industries to transfer to other regions due to high competition, high environmental-pollution control costs, and strict government regulation. The third industries generate fewer carbon emissions, have high added value, and easily survive fierce market competition. Hence, third industries can utilize financial resources more effectively. Based on this, this paper proposes hypotheses H1 and H2:H1.\u00a0Financial agglomeration can reduce carbon emissions by reducing the proportion of secondary industry.H2.\u00a0Financial agglomeration can reduce carbon emissions by increasing the proportion of third industry.The European Union, the United States, China, and other countries adopted carbon trading to control carbon emissions. The government allocates tradable carbon emission quotas to emission control institutions. The quota can be bought and sold on the trading market. Enterprises with high-carbon emissions will buy carbon emission quotas from the market. Carbon emission trading increases the production costs of high-carbon enterprises, forcing them to reduce carbon emissions. Financial agglomeration and the carbon market can complement each other in the fields of expertise, information, institutions, and services. Financial agglomeration can provide financing tools for the carbon market, which helps to play up the financial attributes of the carbon market. Based on this, this paper proposes hypothesis H3:H3.\u00a0Carbon emission trading can strengthen the emission reduction effect of financial agglomeration.Due to the serious lack of data from China\u2019s Tibet Autonomous Region, Hong Kong, Macao, and Taiwan, this paper focuses on the relevant data of 30 provinces, autonomous regions, and municipalities in China from 2002 to 2018. The variables are from the Guotai\u2019an Database, the China Statistical Yearbook, provincial statistical yearbooks, and China Energy Statistical Yearbook. This paper uses Stata 16 software for analysis.C). Among the greenhouse gases (GHGs) that cause climate change, carbon dioxide content accounts for the highest proportion, and the greenhouse effect is the most significant [Carbon emissions  ,24. The i energy in each province. i energy. i energy unit calorific value. i energy.In the above equation, fa). This paper selects the location entropy index to measure the financial agglomeration level of 30 provinces  in China.ite is the number of financial industry employees in region i. itP is the total number of employees in region i during period t. tE refers to the number of financial industry employees in the period t. Pt refers to the total number of employees at the time of period t. If the financial location entropy is greater than 1, it indicates that the financial industry in this region has a comparative advantage over the whole country. If the location entropy is less than 1, it indicates that the local financial industry does not have the advantage of professional development compared with the whole country.Financial agglomeration (ind) by dividing the output value of the regional secondary industry by the GDP of the region. We measure the proportion of third industries (third) by dividing the output value of the regional third industries by the GDP of the region.This paper selects two indicators of the proportion of secondary and third industries as intermediary transmission variables. We measure the proportion of secondary industry (lnp), the degree of opening up (lndow), the level of economic development (lngdp), the degree of government intervention (gov), and the degree of education (edu) as control variables. We take the logarithm of the number of permanent residents as a measure of the regional population size. This paper uses the proportion of the total import and export value in the total local product and takes logarithms to measure the degree of regional opening to the outside world. We measure the level of regional development by taking the logarithm of GDP. This paper uses the proportion of government fiscal expenditure to GDP to measure the degree of government intervention. We use the average years of education to measure the level of education in the region. We chose the population size  uses spatial data analysis techniques and methods to visually describe the spatial distribution rules and mechanisms of the research objects, mainly including the global Moran\u2019s I index, local Moran\u2019s I, and LISA aggregation map. ESDA can accurately measure the spatial distribution and mechanisms of China\u2019s total carbon emissions.The global Moran\u2019s I index mainly explores the spatial distribution characteristics of research objects in the whole region. The index ranges from \u22121 to 1. The strength of the spatial connection increases as the absolute value increases. Moran\u2019s I > 0 indicates a positive spatial correlation; otherwise, it indicates a negative correlation, and being close to 0 means no spatial autocorrelation. The calculation formula is as follows:j does not include the region i itself, that is, j \u2260 i. The calculation formula is as follows:Local Moran\u2019s I mainly explore the spatial heterogeneity of China\u2019s total carbon emissions in sub-regions and measure the degree of correlation between region and its neighbors. In the formula, the accumulation of N is the total number of provinces under study; In the above formula, The LISA cluster graph combines Moran scatter plot and local Moran\u2019s I index to graphically visualize the cluster type and significance level of the research object.i and t in the equations above represent provinces and years, respectively. This paper uses a panel model to measure the direct impact of financial agglomeration on carbon emissions. Therefore, our model was built as follows:The above model analyzes the direct impact of financial agglomeration on regional carbon emissions. However, further research is still needed to determine the precise process by which financial agglomeration affects carbon emission levels. Therefore, this paper chooses the percentage of secondary and third industries as its two channels for verification. In this paper, recursive equations (Equations (6) and (7)) are set to identify the specific impact mechanism of financial agglomeration on regional carbon emissions.In the above formula, Europe, the United States, and other countries have actively tried to use the carbon emission trading market mechanism to solve the problem of climate change. The government sets the overall quota for the carbon trading market\u2019s \u201ccarbon emission rights\u201d, which are the market\u2019s subject matter. The government will assign tradable carbon emission quotas to emission control organizations after the total has been calculated. On the trading market, the quota is available for purchase and sale. Enterprises with high carbon emissions will buy carbon emission quotas from the market. Therefore, carbon emission trading increases the production cost of high-carbon enterprises, forcing them to reduce carbon emissions. China is also actively trying to establish a carbon emission trading market to govern China\u2019s carbon emission level. The main topic to be addressed in this section is whether financial agglomeration can demonstrate an effective emission reduction effect under the pilot policy of carbon emission trading. To answer this question, we designed the following model for testing:W represent the spatial autocorrelation coefficient and the spatial weight matrix. \u03c6 is the coefficient of the spatial interaction term of control variables. Other variable settings are shown in Formula (5). We use the adjacency matrix as the spatial weight matrix to verify the spatial effect of financial agglomeration on carbon emissions. At the same time, we use a geographic distance matrix and economic geography matrix to test the robustness.This paper uses the spatial Dubin model to analyze the impact of financial agglomeration on carbon emissions under the spatial effect. Our model was built as follows:In To ensure the accuracy of the results, this paper conducts a robustness test. In To reduce the errors caused by missing variables, in model (3), the control variables increase the provincial innovation level (rd), post and telecommunications business (youdian), and foreign direct investment (waistz). The model (3) results show that the coefficient of financial agglomeration is \u22127.085, which is significant at the 1% significance level. Next, we use the lag term of financial agglomeration as an explanatory variable to consider the reverse causality. The results of model (4) show that the coefficient of the lag term of financial agglomeration is \u22128.569, which is significant at the 1% level.We divided China into three regions: the east, the middle, and the west, to verify the heterogeneous impact of financial agglomeration on carbon emissions. According to model (1) in We regard a region as high-carbon if its total carbon emissions are higher than the average for this year. Otherwise, it will be regarded as a low-carbon region. Model (4) in We select the proportion of secondary and third industries to test the impact mechanism of the financial agglomeration on carbon emissions. In the process of verification, we controlled the year-fixed effect. Model (1) in Model (3) shows that the coefficient of financial agglomeration is 0.073 and is highly significant. It shows that financial agglomeration promotes the proportion of third industries. Model (4) shows that the coefficient of the proportion of third industries is \u221265.203, which is significant at a significance level of 1%. That means that the proportion of third industries can inhibit regional carbon emissions. The results of models (3) and (4) mean that the financial agglomeration can inhibit regional carbon emissions by promoting the proportion of third industries. We believe that financial agglomeration has promoted the development of the third industry by reducing the secondary industry. The third industry has a high added value and low emissions. Finance can provide funds for developing the third industry, resulting in economies of scale. Therefore, financial agglomeration can reduce carbon emissions by increasing the proportion of the third industry. The research conclusion confirms hypothesis H2.In This paper uses the spatial Dubin model to test the spatial spillover effect of financial agglomeration on carbon emissions. First, we conduct spatial autocorrelation analysis based on Moran\u2019s I index. The results of the Moran\u2019s I index are shown in Second, we use the LM test to select the SEM or SAR. Controlling carbon emissions has become a global consensus. However, the existing literature rarely explores the impact of financial agglomeration on carbon emissions. Based on the analysis of the emission reduction history of major countries, this paper mainly uses the provincial-level data of China from 2002 to 2018 to study the impact, impact mechanisms, and spatial effects of financial agglomeration on regional carbon emissions. The following are the conclusions:First, this paper analyzes the situation of carbon emissions and emission reduction policies in China and major developed countries. China lacks carbon tax policies, and there are many drawbacks in the carbon trading market; a \u201cbottom-up\u201d voluntary emission reduction mechanism has not been formed. Compared with other developed countries, China has a low per capita income, a low urbanization rate, a high proportion of secondary industry, and high coal consumption.Second, we conduct research using ESDA and discover that the majority of China\u2019s carbon-emitting provinces are located in Inner Mongolia, Shanxi, Hebei, Liaoning, Shandong, Jiangsu, and Guangdong. The region with huge financial practitioners includes Beijing, Shandong, Zhejiang, Shanghai, Guangdong, Hunan, Henan, Hebei, Liaoning, Jiangsu, and Sichuan. The total carbon emissions and financial practitioners have characteristics of spatial agglomeration.Third, our empirical study found that financial agglomeration can reduce carbon emissions and passed a series of robustness tests. The heterogeneity analysis shows that the emission reduction effect of financial agglomeration is more significant in the central and high-carbon regions. The intermediary mechanism test found that financial agglomeration can reduce carbon emissions by reducing the secondary industry\u2019s proportion and increasing the third industry\u2019s proportion. The adjustment mechanism found that the emission reduction effect of financial agglomeration under carbon trading is more significant. It is worth noting that financial agglomeration can still reduce carbon emissions after considering the spatial effect. We find that financial agglomeration in regions with close economic geography will increase the region\u2019s total carbon emissions.Based on the conclusions of this paper, we propose the following suggestions.We first propose that China develop a sensible carbon tax policy, enhance the carbon trading mechanism, recruit qualified carbon trading professionals, work toward establishing a \u201cbottom-up\u201d voluntary emission reduction mechanism, assume the role of financial resource allocation, and direct funds toward environmentally friendly industries.Second, China needs to place severe limits on carbon production in high-carbon areas. To that end, we urge low-carbon areas to share their knowledge on emissions reduction with high-carbon areas. It is important to remember that high-carbon businesses should not be allowed to relocate to low-carbon regions. Meanwhile, we advocate for standardizing the spatial layout of industrial structure.Third, financial agglomeration can reduce the proportion of the secondary industry\u2019s proportion and increase the third industry\u2019s proportion. Consequently, we need to encourage the green transformation and upgrading of the secondary industry and reduce capital credit to industries with high pollution, high energy consumption, and high emissions. Financial institutions should provide green credit for low-carbon environmental protection enterprises and industries.Fourth, carbon emission trading plays an important role in the process of financial agglomeration to curb regional carbon emissions. Therefore, we should encourage carbon emissions trading, urge financial institutions to provide carbon financial derivatives transactions, establish a unified large carbon trading market in China, and promote market-oriented carbon trading.Fifth, financial institutions should vigorously promote green credit, green financial products, and mechanism innovation. We encourage financial institutions to give play to the financial attributes of the carbon trading market, promote the innovation of carbon financial products, improve the liquidity of the carbon trading market, enrich the product portfolio, and provide hedging tools.The main limitations of this study are: cities account for 2% of the earth\u2019s surface, but their residents consume 75% of the world\u2019s energy resources . Reducin"}
+{"text": "China's rapid economic growth is accompanied by industrial agglomeration (IA) and environmental pollution. Although IA has played an important role in reducing environmental pollution, its effect on carbon emissions is still debatable and deserves further study. In this context, this paper constructs a two-sector general equilibrium model including households and firms to explore the mechanisms of IA on carbon emissions and finds that IA mainly affects carbon emissions through the agglomeration effect and congestion effect. Then, based on the balanced panel data for 30 Chinese provinces from 2003 to 2019, this study employs the dynamic spatial panel model to investigate the nexus between different types of IA and carbon emissions. The empirical results reveal that a significant positive spatial dependence is verified in the regional carbon emissions of China, indicating that carbon emissions exhibit a remarkably spatial spillover effect. Meanwhile, there are significant variations in the influence of different types of IA on carbon emissions. Specifically, specialized agglomeration (SA) positively affects carbon emissions, while the impact of diversified agglomeration (DA) on carbon emissions is negative, implying that China's DA may contribute to carbon emission control. In addition, there is regional heterogeneity in the effect of IA on carbon emissions, with the western region having a significantly greater effect than the eastern and central regions. Therefore, the Chinese government should follow the notion of integrating territory administration and interregional communication and formulate regionally differentiated environmental governance policies to promote carbon emission reduction in the future. Climate change, which is mainly characterized by global warming, has seriously endangered the living environment of human beings and it is recognized as one of the most challenging problems facing mankind today . ReducinIn the process of economic development, production factors and economic activities are relatively concentrated in a certain geographical space, which was be known as IA , 7. In rThe purpose of this study is to explore the nexus between different forms of IA and China's carbon emissions from the perspective of spatial spillover. Specifically, by constructing a two-sector growth model, we first analyze the influence mechanisms of IA, which is divided into SA and DA, on carbon emissions. Then, by using a panel data for China's 30 provinces during 2003\u20132019, we calculate the level of carbon emissions for each province and employ Moran's I test to investigate the spatiotemporal evolutionary characteristics of China's regional carbon emissions. Furthermore, the spatial dynamic panel econometric model is used in this paper to explore the relationship between IA and carbon emissions. Considering the regional heterogeneity, we conduct regional heterogeneity analysis to verify the heterogeneous effects in different regions. Our main findings are listed below. First, there is a significant positive cumulative effect and spatial lag effect, as well as a negative spatiotemporal lag effect in China's carbon emissions, which indicates that the amount of carbon dioxide emitted in the region will be affected by adjacent regions. Second, different forms of IA have significantly different impacts on carbon emissions. Specifically, SA promotes carbon emissions, while DA inhibits carbon emissions. Third, the impacts of urbanization and infrastructure on carbon emissions are both significantly negative, but the impact of economic development is not significant. Meanwhile, there is an inverted U-shaped nexus between carbon emission and environmental regulation. Finally, at the regional level, the impact of IA on carbon emissions varies considerably, with the western region having a greater effect than the eastern and central regions.The main contributions of this paper to the existing literature can be outlined below. First, based on an endogenous growth model, the transmission mechanisms of IA on carbon emission are deeply analyzed in this study. Specifically, by incorporating IA and carbon emission into a unified analytical framework, we provide new insights for the causes of carbon emissions and the governance mode of environmental pollution in China, which contributes to give full play to the industrial advantages of different regions and promote green development of China's economy. Second, in order to illustrate whether the different mode of IA can improve China's carbon emissions, IA is divided into SA and DA, and the influence of IA on carbon emissions is then comprehensively investigated from the two dimensions, which expands the research perspective and makes up for the shortcomings of the existing literature. In addition, explaining how to reduce carbon emissions from the perspective of the mode of IA can provide useful decision-making references for optimizing China's regional industrial structure, promoting the rational layout of IA, and realizing the sustainable development of China's economy. Finally, we use the dynamic spatial lag model to analyze the nexus between IA and carbon emissions based on provincial panel data in China over the period from 2003 to 2019. The majority of existing studies on carbon emissions were based on non-spatial empirical methods, which fails to explain the conclusions of research effectively. However, the effects of IA on carbon emissions may be revealed in a more reasonable and accurate manner due to the spatial econometric models paying more attention to the spatial spillover effects of carbon emissions in neighboring economies. Furthermore, the impact of IA on carbon emissions is explored from a spatial dependence perspective, which provides useful policy guidance for establishing an interregional joint prevention and control mechanism for China's carbon emission reduction and improving the level of environmental governance in different regions.The rest of this study is organized as follows. Through sorting out the prior research, the literature related to the study can be divided into three streams: IA and economic development, the influencing factors of carbon emissions, IA and carbon emissions. An overview of recent research relating to these topics is presented as follows.The first stream examines the connection between IA and economic development. IA is defined as a process in which linked sectors are highly concentrated in a geographic region and capital elements are constantly converging . DespiteThe second stream related to this paper investigates the influencing factors of carbon emissions with the increasing attention to environmental issues \u201321. SpecThe third stream of the literature analyzes the nexus between IA and carbon emissions. With global warming problems gradually becoming more highlighted, IA, as one of the most significant economic development patterns, has received a lot of attention in terms of its impact on environmental pollution, but the results have not yet reached a consensus nowadays. The first view is that IA has a positive environmental externality on carbon emissions. Considering that green technology has been improved through knowledge spillovers and technology spillovers, IA can promote carbon emission reduction. According to Ehrenfeld , the estThis study, which is based on the findings of Copeland and Taylor , integrai. The formula is as follows:A is total factor productivity; Ki and Li are the amounts of capital and labor inputs, respectively. The parameter \u03b1 means the capital share of the output, 0\u2009<\u2009\u03b1\u2009<\u20091. When a great number of similar firms congregate in one location, the presence of agglomeration effect prevents the social total production function from simply being the sum of the production functions of all individual firms, and thus, the influence of agglomeration effect on production cannot be ignored. Supposing that the agglomeration function is G(\u00b7), the expression of social production function is as follows:G(\u2022) reflects the impact of agglomeration on the total social output; K and L are the total social capital and labor, respectively. Suppose that IA affects the total social output through scale effect, congestion effect, and technological progress, and manifests itself in two types of SA and DA, the agglomeration function is G(\u2022)\u2009=\u2009G(IA)\u2009=\u2009exp(\u03d51SA\u2009+\u2009\u03d52DA) and the signs of \u03d51 and \u03d52 depend on the size of three effects. For simplicity, the social production function is treated in per capita form, then the per capital potential output can be expressed as follows:y is the per capital potential output. It is assumed that the society produces a certain amount of carbon emissions while producing product. The increase in carbon emissions will bring negative externalities to the society. When property rights are clearly determined, firms should pay a certain fee for carbon emissions, thus increasing production costs. Therefore, some factors will be used for carbon emission control. Assuming that the proportion of factor inputs used to reduce carbon emissions in the social production process is \u03b8, then the per capita real output x can be described as follows:It is assumed that the Cobb\u2013Douglas form, which shows the feature of constant return to scale, can be used to defined the production function of representative firm \u03b8 equals to 0, it means that the society does not use any inputs to reduce carbon emissions, and the social output will be the potential output y; when \u03b8 is equal to 1, it indicates that the society devotes all essential resources to control carbon emissions, which is inconsistent with reality. In general, the value of \u03b8 is usually between 0 and 1. Hence, the amount of the social carbon emissions e can be presented as follows:Theoretically, when \u03c6(\u03b8)\u2009=\u2009A\u22121(1\u2212\u03b8)\u03b21/ is the decreasing function of \u03b8, and \u03c6\u2032(\u03b8)\u2009<\u20090, \u03c6\u2033(\u03b8)\u2009>\u20090, \u03b2\u2009\u2208\u2009. Equation ,,\u03c6(\u03b8)\u2009=\u2009Aquation  as follows:The purpose of firms' production is profit maximization, which can be realized in two ways. First, given the labor rewards and capital expenditure, firms minimize the production cost of potential output by selecting the optimal capital-labor ratio, which is expressed as follows:Cy is production cost per unit of potential output; Ce is carbon emission costs; and Cx is the production cost of real output. By solving the 11), the U is as follows:\u03b5 is the coefficient of relative risk aversion, \u03c1 is the degree of social desire for carbon emissions, and \u03b5\u2009>\u20090, \u03c1\u2009>\u20090. Assume that there is a social rule maker who decides on output x and carbon emissions e to maximize social welfare, the FOC of utility maximization can be derived as follows:As shown by Grimaud and Rouge , the socU/\u2202x\u2009=\u2009\u2202x/\u2202e, and then it can be flattened by inserting it into equation 15), the \u03bc\u2009=\u2009A\u03b2p(1\u2009\u2212\u2009\u03b8), \u03c0\u2009=\u20092/(\u03c1\u2009+\u20092), then equation , environmental regulation (er), urbanization rate (ur) and infrastructure (inf), respectively. Meanwhile, \u03b3 denotes the time-lagged coefficient of carbon emissions. \u03b2 represents the coefficients of the control variables to be estimated. In addition, \u03bci, \u03bbt, and \u03b5it denote individual effect, time effect, and random error term, respectively.First, we construct a dynamic nonspatial panel model to analyze the nexus between IA and carbon emissions. Since present carbon emissions may be affected by previous carbon emission, the first-order lag term of carbon emissions is also incorporated into the model as an explanatory variable to reflect the dynamic cumulative effect of carbon emissions. The model is depicted as follows:W represents a spatial weight matrix. The variables WlnCEit and WlnCEit\u22121 denote the carbon emissions of the neighboring regions in the current and previous periods, respectively. \u03b3, \u03c1, \u03b7, \u03b4, and \u03b2 stand for the regression coefficients to be estimated. Among them, \u03b3 denotes the time lag coefficient, capturing the effect of previous carbon emissions on current carbon emissions; \u03c1 is the spatial lag coefficient, reflecting the effect of other provinces' carbon emissions on the sample provinces in the current period, \u03b7 is the spatiotemporal lag coefficient, indicating the influence of other provinces' previous carbon emissions on the sample provinces. Most notably, in the model (\u03b4 is significantly more (less) than 0, which means that IA aggravates (curbs) carbon emissions. To assure the consistency and validity of the empirical findings, this study employs the maximum likelihood method to estimate the abovementioned model.According to the First Law of Geography, economic matters in a certain area have significant spatial dependence, and the closer the geographical distance is, the stronger the spatial connection is , 48. Obvln\u2009CEit=\u03b3Furthermore, the essential issue of the spatial econometric model is how to depict the spatial linkage across areas, that is, how to construct a spatial weight matrix. Geographical adjacency, geographical distance, economic distance and economic distance for the specification of spatial weight matrix are the four most common forms in the existing literature. Taking the availability and integrity of data into consideration, we use the geographical adjacency weight matrix (W1), economic geographic distance weight matrix (W2), and economic geography nested weight matrix (W3) to estimate the model . To be si and t are province and year, respectively, and k stands for the type of energy. CEit denotes the carbon emission for the t year in i province. Eitk, Sk, and Ck represent the standard coal conversion coefficient, carbon emission coefficient, and the amount of the k-th fossil energy consumed, respectively. Qit and Ccement reflect the carbon emission factor and the quantity of cement production. In equation . Although most developed countries have released relevant data on carbon emissions, the official data are still unpublished in China, and its measurement has always been a difficult problem in academic circles. The current mainstream views believe that carbon emissions are mostly from the burning of fossil fuels and the production of cement . TherefoCEit=\u2211k=1In order to achieve economies of scale and reduce production costs, firms that be characterized by similar product structures or relevant industrial chains are prone to gather in the same geographic area, thus IA is mainly manifested in two forms: SA and DA .Specialized agglomeration (SA). SA refers to the concentration of industries with homogeneous input and output in a specific geographic region, which distorts the allocation of production factors and causes a single industrial structure, and then, stimulates the carbon emissions. The formula for SA is as follows:Diversified agglomeration (DA). DA includes horizontal agglomeration with technology linkage and vertical agglomeration with the upstream and downstream relationship of the industrial chain. Generally, DA promotes the sharing of knowledge, technology, and basic equipment, which further improves the level of green technology development and the efficiency of energy, and curbs carbon emissions ultimately. The formula for DA is as follows:i and j is the regions and industry, respectively, wij is the employment rate of industry j in region i, and wj is the national employment rate of industry j. The greater the value of the index, the deeper the degree of regional IA.In equations  and 23)23), i anIn order to mitigate the endogenous problem caused by omitted important variables and to increase the accuracy of the regression results, five control variables are included in the model by referring to previous literature. Details of the control variables are shown below.Per-capita GDP (pgdp). Some researchers confirmed that the degree of economic progress and carbon emissions are highly correlated . SpecifiEnvironmental regulation (er). The government can regulate the production mode of enterprises by using reasonable environmental supervision, so as to effectively stimulate the innovation enthusiasm of enterprises in green energy-saving technology and decrease the need for fossil energy and promote carbon emission reduction . In ordeUrbanization rate (ur). Theoretically, compared with rural areas, there are more modern infrastructure and fossil fuel consumption in urban areas, thus emitting more carbon dioxide. Actually, the higher the degree of agglomeration in urban areas is, the greater the benefits of increasing returns to scale in energy use, such as convenient transportation and centralized heating supply, which is beneficial to reduce carbon emissions . TherefoInfrastructure (inf). Infrastructure should be included in the model to reflect its impact on regional carbon emissions and environmental quality by reducing energy use and transaction costs while boosting efficiency per unit of energy used , 54. In Considering the availability of sample data and the actual needs of research, this study utilizes a balanced panel data set of 30 provinces in mainland China  to empirically investigate the effects of different industrial agglomeration patterns on carbon emissions. Specifically, the China Energy Statistical Yearbook included the data on fossil fuels and cement production. The China Industrial Economic Statistical Yearbook provided the data for the IA. The data on the environmental regulation are collected from China Environment Statistical Yearbook. Other variables are collected and compiled from the Provincial Statistical Yearbook of each province. In addition, the moving average and interpolation methods are used to supplement the missing data in the study. Furthermore, all absolute value variables, except for the urbanization rate, are changed into logarithmic forms to remove heteroscedasticity. Meanwhile, in order to eliminate the price effect, we use a CPI index to deflate all nominal variables to real variables based on the 2003 constant price. The descriptive statistics for all variables are shown in Before conducting the empirical analysis, the panel stationarity test is performed on all variables to eliminate spurious regression problems. To be specific, this paper adopts four stationarity test methods, namely, Levin\u2013Lin\u2013Chu (LLC), Im\u2013Pesaran\u2013Shin (IPS), Augmented Dickey\u2013Fuller Fisher (ADF-Fisher), and Phillip Perron Fisher (PP-Fisher) tests to determine stationarity, and the results are shown in p values of AR test) and the overidentification test  show that the selection of model instrumental variables is reasonable, and the results of generalized method of moments estimation are reliable. In addition, the coefficients of SA and DA are also similar in sign and significance among the five estimation models, suggesting that the results of the empirical evidence are robust.The objective of this paper is to investigate the effects of SA and DA on carbon emissions. First, we adopt the traditional nonspatial model to explore the relationship between agglomeration and carbon emissions, which is a preliminary empirical analysis. Specifically, this paper uses five methods to estimate , includiIn Since there may be considerable spatial correlations in China's regional carbon emissions, the spatial dynamic econometric model is used to account for both the spatial and dynamic effects in order to assure more effective results.We must first determine whether there is a spatial correlation between provincial carbon emissions in China before proceeding with a spatial econometric analysis. Given the vast size of China, there are significant regional differences in the level of economic development; this paper draws quartile maps of carbon emissions in the years of 2003 and 2019, as shown in G test, Geary's C test, and Moran's I test. Among them, Moran's I test is the most widely used approach in academic circles. In view of this, following Moran [i and CEj are the per capita carbon emissions of provinces i and j, respectively, and represent the average values of CE; Wij represents the constituent elements of the spatial weight matrix, located in the i-th row and j-th column, and n stands for the number of provinces. There are three main methods for testing spatial correlation in practice, namely, Getis\u2013Ord's ng Moran , this paThe main objective of our paper is to explore the effect of SA and DA on carbon emissions by using the dynamic spatial lag model. Specifically, the Hausman test is used to choose the fundamental form of the spatial panel model, and the findings indicate that the two-way fixed effect model (FE) should be considered. Then, we introduce the three spatial weight matrices above and employ the maximum likelihood method to estimate the . The basit\u22121 (\u03b3) are positive in all models and significant at the 1% level, suggesting that carbon emissions have a significant positive lagged effect in the time dimension. If carbon emissions are quite high in the present time, carbon emissions in the following period will continue to climb, and a cumulative impact of carbon emissions may emerge. Furthermore, the coefficients of W\u2009\u00d7\u2009lnCEit (\u03c1) are all significant and positive, fully manifesting that carbon emissions have a remarkable spatial agglomeration effect. The main manifestation is that an increase in emissions concentration of neighboring provinces will aggravate the levels of carbon emissions of the sample province. This might be attributed to natural atmospheric movement, industry linkage, economic intercourse, and regional replication of environmental laws. Moreover, the coefficients of W\u2009\u00d7\u2009lnCEit\u22121 (\u03b7) are significantly negative in all models, indicating that the high carbon emissions degree of the surrounding provinces in the previous period can significantly decrease the current emissions level of the sample province. One feasible explanation is that as the central government has gradually strengthened efforts to supervise the environment among regions when formulating carbon emission policies in their jurisdictions, local governments must not only take into account the local level of green economic development but also assess the degree of carbon emission in neighboring regions, to gain more political promotion benefits in environmental governance.First, the study explores the temporal and spatial evolution characteristics of carbon emissions, and the results show that carbon emissions featured a double lag impact in both time and space. To be specific, the coefficients of lnCESecond, we further investigate the effects of SA and DA on carbon emissions. In terms of SA, its coefficients are significantly positive in all models, which demonstrates that the improved level of SA has significantly promoted carbon emission. We can summarize the reasonable explanations into the following two aspects. As the industries with homogeneous inputs and outputs continue to cluster in a region, the \u201ccongestion effect\u201d occurs when production factors are overly concentrated, disrupting the factor market's order. On the one hand, factor distortion reduces overall factors utilization efficiency and increases fossil energy consumption to aggravate the pollution discharge load, which exceeds the regional environmental carrying capacity and causes an increase in carbon emissions ultimately. On the other hand, ruthless competition among firms hinders the spillover of energy-saving and emission-reduction technology and knowledge, which weakens the motivation for innovation in technology and prevents technological progress, which results in high carbon emissions and resource waste per unit of output. In terms of DA, its coefficients are all significant and negative, indicating that the increase in the level of DA has significantly curbed carbon emissions. Actually, DA has an impact on carbon emissions through the scale effect and the effect of technology spillover. Notably, DA brings more heterogeneous knowledge, which is favorable to promote innovation in technology and improve production efficiency and thus effectively reduce carbon emissions. In addition, DA realizes the recycling and sharing of resources and infrastructure among firms, which is helpful to achieve scale economies and improve resource utilization efficiency, and curbs carbon emissions in agglomeration areas eventually.Third, we analyze the impacts of control variables on carbon emission. Specifically, the regression coefficients of per capita GDP are generally positive but not significant in all models, indicating that China's economic development is weakly decoupled from carbon emissions. The possible explanation is that although the governments actively promote green and low-carbon development, due to the limitations of technological innovation capability and industrial structure adjustment, environmental pollution control efforts are relatively small, so the decoupling effect of economic development and carbon emissions is not obvious. The conclusion is also supported by Gao et al.  and Liu According to the regression results for the full sample, the effect of SA on carbon emissions is significantly positive, whereas the impact of DA is negative. However, due to the step-by-step development strategy of China's regional economy, there are large differences in carbon emission levels and industrial development in various regions of China. Is there a regional heterogeneity in the effect of SA and DA on carbon emissions? To gain insights into regional heterogeneity, the full sample is divided into three subsamples, namely, eastern, central, and western regions, based on the geographic location and level of economic development. Then, this study uses the dynamic spatial econometric method to explore the impacts of SA and DA on carbon emissions for three subsamples, respectively. The heterogeneity regression results are shown in First, we analyze the regional heterogeneity in the impact of SA on carbon emissions. Specifically, the sign of the coefficient of SA is positive but insignificant in the eastern region. The conceivable explanation is that the local governments develop the concept of green development while focusing on industrial development. Moreover, the economic growth is progressively changing from an extensive mode to an intensive mode in the eastern region, which weakens the effect of SA in promoting carbon emissions. In addition, the SA coefficient is significantly positive in the central and western areas, and the sign and significance are in line with the baseline test results. Second, this study probes the regional heterogeneity in the influence of DA on carbon emissions. Specifically, the coefficient of DA is negative and insignificant in the eastern and central areas. The reasons can be summarized as follows: the long-term priority of industrial development in the eastern provinces leads to a low proportion of the primary and secondary industries and a low degree of inter-industry coupling, which ultimately nullifies the emission reduction effect of DA. Furthermore, the coefficient of DA is notably negative in the western region, implying that DA can effectively curb carbon emissions, which is in line with the baseline regression results. In summary, the significance of coefficients is slightly different among regions, which verifies the existence of regional heterogeneity.To assure the robustness, reliability, and consistency of the baseline regression results, the study implements robustness tests from three aspects. First, we adjust the sample period by intercepting the sample data for two years to remove the effect of sample outliers. Next, we replace the measurement methods of carbon emissions. To be specific, we use the ratio of the total carbon emissions to gross domestic product as a substitution variable for robustness analysis and then analyze the adjusted data. Finally, except for the three spatial weight matrices mentioned above, the economic distance weight matrix is used to further verify the robustness of the conclusion . The regColumns (1) and (2) in Excessive carbon emissions make economic development unsustainable, and the precise identification of driving factors of carbon emissions is an important precondition to implementing targeted emissions reduction policies. Under such circumstances, this study constructs a two-sector general equilibrium model to analyze the theoretical mechanism of IA on carbon emissions. Then, we find that IA mainly affects carbon emissions through agglomeration effects and congestion effects. Based on the theoretical analysis, this study explores the relationship between two different types of IA and carbon emissions by employing the dynamic spatial lag model and the sample data of 30 Chinese provinces from 2003 to 2019. The findings of the spatial econometric model can be concluded as follows. First, under different spatial weight matrices, carbon emissions have significant path dependence characteristics in the time dimension, positive correlation, and agglomeration in the space dimension and restrain the carbon emissions of adjacent regions in the next period in the space and time dimension. Second, there is a strong link between IA and carbon emissions. Among them, SA has a significant positive impact on carbon emissions, while DA has a negative impact. Third, environmental regulation and carbon emissions have an inverted U-shaped link, whereas urbanization and infrastructure have a negative link with carbon emissions, and economic development is weakly decoupling from carbon emissions. Finally, at the regional level, the significance of the coefficients of SA and DA differ among the three regions, indicating the existence of regional heterogeneity.In order to achieve high-quality development, we provide some feasible suggestions for reducing carbon emissions and promoting the healthy development of IA based on the abovementioned results.First, China should promote the green and low-carbon development approach, as well as energy conservation and emission reduction. Specifically, the government should enhance its support for green energy and encourage the upgrading of the energy consumption structure. Accelerating the promotion and use of clean energy is conducive to reducing the use of nonrenewable and heavily polluting energy, as well as reducing carbon emissions from the source. Simultaneously, environmental assessment should be implemented into the performance evaluation system of local governments to provide a long-term mechanism for emission reduction. In addition, only by crossing the barriers of administrative divisions and establishing a resource-sharing platform and cooperative projects for governance among regions could the long-term mechanism of carbon emissions reduction be achieved. Strengthening interprovincial collaboration and promoting joint governance is critical. Finally, the \u201cone-size-fits-all\u201d policy paradigm is unsuitable for China's current situation which requires consideration of the special attributes of economic level and resource endowments. Differentiated development strategies for carbon emissions reduction should be tailored to the needs of China's various regions.Second, the Chinese government should prolong the industry chain and promote industrial DA. Specifically, through policy support and tax incentives, the government guides local enterprises to form DA areas and realize the rationalization of the industrial structure. The government should promote enterprises to strengthen cooperation, speed up the movement of labor, information, knowledge, and technology among regions, and make full use of the emission reduction effect of the positive externality of DA. In addition, the government should encourage SA to carry out diversified structural adjustments, cultivate connected supporting industries on the basis of existing industries, prolong the industry chain, and promote enterprises to curb carbon emissions. Finally, when the congestion effect of IA begins to appear, the industrial transfer should be carried out to reduce the adverse influence of excessive clustering on the environment and achieve the sustainable development of the economy and environment.Third, to achieve China's \u201cdual carbon\u201d goal, we should take advantage of the synergistic impacts of economic development, environmental supervision, urbanization, and infrastructure to reduce carbon emissions. Specifically, (1) while developing the economy, we should pay attention to carbon emission reduction and environmental protection., accelerate the transition from an extensive to an intensive economy mode, achieve a balance between regional economic growth and carbon emissions, and achieve sustainable economic development. (2) The administration ought to tighten environmental regulations, add investments in emissions pollution control, mobilize social funds, and provide financial support for carbon emission reduction. (3) We should accelerate the construction of new urbanization with energy-saving and emission reduction as the core, speed up the layout of city that is compatible with the carrying capacity of resources and the environment, and take a new urbanization path that is intensive, intelligent, low in carbon, and green. (4) The state and local governments should improve infrastructure construction, which aids in the improvement of energy efficiency and the reduction of carbon emissions.The effect of different types of IA on the performance of regional carbon emissions in China is the focus of this paper. Although this study gives useful information, it does have several shortcomings that might be addressed in future studies. First, although this paper empirically analyzes the different effects of SA and DA on carbon emissions based on a dynamic spatial perspective, their impact mechanism and dynamic evolutionary process have not been adequately explored due to the limitation of sample data. Therefore, the subsequent research will try to develop a dynamic stochastic general equilibrium (DSGE) model to describe the transmission mechanisms of IA on carbon emissions and provide empirical evidences to deepen this study . Second,"}
+{"text": "Albumin is one of the major components of synovial fluid. Due to its negative surface charge, it plays an essential role in many physiological processes, including the ability to form molecular complexes. In addition, glycosaminoglycans such as hyaluronic acid and chondroitin sulfate are crucial components of synovial fluid involved in the boundary lubrication regime. This study presents the influence of Na Lubrication in natural joints is a complex multiscale process that involves interactions between constituents of articular cartilage and synovial fluid ,2,3. AltThe most recognizable components are: albumin, hyaluronan, phospholipids, lubricin . Human solecules ,11). It olecules ,13 that surfaces .This study presents the analysis of the interactions between HSA and hyaluronic acid (HA)/ chondroitin-6-sulfate (CS6) in terms of the influence on conformations. As the topic is extensive, we are skipping here the conformation changes within albumin, focusing only on the GAGs. Such analysis of interaction between HSA and HA has been performed recently in . HSA conGAGs are large complex carbohydrates. Depending on the monosaccharide types and the glycosidic bonds, GAGs can be divided into four groups: (i) hyaluronic acid, (ii) chondroitin sulfate, and dermatan sulfate (iii) heparan sulfate and heparin, and (iv) keratan sulfate. First, let us underline that HA is only a non-sulfated GAG. It is vital because sulfate groups in the GAG is one of the most crucial factors influencing the interaction map between a protein and the GAG . Thus, tThe analysis of the interaction between HSA and HA or CS6 in the presence of various species such as water and ions is a meaningful task; as such, interaction is closely related to synovial systems\u2019 unique properties . The useGAGs are important complexes that participate in many biological processes through the regulation of specific proteins. Hence, their secondary structure and stability are very important to study. Both of above-mentioned properties can be well quantified by conformational entropy. As conformational entropy, we understand the Shannon entropy computed for bivariate histograms of chosen pairs of dihedral angles see,  22]. Va. Va22]. In more detail, conformation description of the GAGs relays on the analysis of their structures bound to HSA domains in aqueous ionic solution. This analysis is carried out to check whether there are any differences in the conformation of the glycosidic linkages between each oligosaccharide monomer of the GAG, when the kind of the ion is changed in aqueous solution. The linkages are investigated basing on specific dihedral angles. In the present paper, conformational entropy is computed from the frequency distribution of those angles\u2019 values. We anticipate that those angles determine important characteristics, such as shape and stiffness. As the conformational entropy is calculated from the distribution of the angles, it is expected to be a crucial feature .We have performed all-atom simulations of the two model biosystems (one is HSA with HA and the other is HSA with CS6) in aqueous ionic solution. First, a molecular docking procedure has been executed to obtain preliminary information on the stability of the structure and to find the most energetically optimal places where each GAG attaches to the HSA. Next, energetically best-docked structures (sorted from the strongest connection to the weakest connected), with added water solution of chosen ions . This modification relied on connecting units of selected GAGs until polymers of desired length were obtained. To acquire the most stable complexes, we docked GAG ligand (HA or CS6) to HSA using the VINA method  with theMD simulations of HSA (PDB code: 1e78) with GAG have been run with YASARA software. Optimization of the hydrogen bonding network was included in the setup to increase the solute stability and a pKpH = 7.4 ,37. Optice field  for the ce field  for HA ace field . The parce field . Simulatof 1 fs) . The equAll analyses and computation have been performed using YASARA and in-house written data processing programs in Python 3.8 .The method of entropy calculation, used in this study, relies on computation of the frequency distribution of the backbone\u2019s dihedral angles  and galactosamine , while HA consists of glucuronic acid (GlcA) and acetylglucosamine (GlcNAc). Linkages between the two monosaccharides are as follows: in the case of CS6, it is [4)-1\u27f6] see, . Using alinkage) . Thus, iAll dihedral angles in Equation  have beeeen used ,31. Noteeen used ,43. UsinFor each pair of subsequent mers of GAG\u2019s chain, the time series (containing 1000 points) of the dihedral angles have been obtained. As described in analyzed . 2D histFollowing an approach described in  , Sudlow\u2019s site II (IIIA), and thyroxine-binding site (IIIB) . Compari CS6 see .The method for computation of conformational entropy, based on a Ramachandran-type plot created for the pairs of dihedral angles  ,42, has In the case of CS6,  see . Accordiange cf. , near  have beure 2 of , for  of entropy for various ions, angles and GAGs are presented in In CS6 cf., . ComplexEntropy values for CS6 and HA with different ions, taken separately for each of computer experiment realizations, have been presented in Relatively large variations of the entropy between realizations are observed in the case of HSA-HA simulation results. Entropy varies within the range of 53\u201362 The hypothesis that entropy value is tied to the value of the binding energy between the protein and the GAG is not supported by our simulation results. In more detail, the smallest entropy value, roughly A common pattern on the maps presented in orted in . The locorted in . Therefo) angles  show thaWe have demonstrated that conformational entropy is a parameter that enables us to characterize the structure of GAGs in interaction with HSA globally. We can see that it is slightly dependent on the pair of angles but rather for the CS6 case. In the case of CS6, the lower entropy value of the   and its Macromolecular complexes are building blocks in the functioning of physiological processes. When optimal conditions are fulfilled for given pairs, the system can function efficiently. Protein\u2013ligand interactions are critical to optimal biochemical, biological, or biophysical results. Often, a given complex can serve several functions, as in the case presented in this study, where HA-HSA complexes decrease friction and can be used in drug delivery systems. Our results show how crucial components of synovial fluid interplay with each other at equilibrium. We have shown that HA and CS6 can form stable complexes with HSA.Moreover, the binding sites for both molecules overlap, which indicates that they both can induce a similar effect on HSA while functioning. The molecular mass used in this study is one limitation of the presented results, as interactions  between GAGs and proteins strongly depend on their molecular mass and concentration. This fact emerges from the chemistry of polymers of interest. GAGs chain\u2019s amount of expansion is enormous for a semi-flexible polymer. The polymer configuration is constantly in a state of motion and change. However, the water increases the effective size of each hyaluronic acid because of its hydrophilic nature. The mass increase results in the average density decrease because the increase in mass is slower than in the volume. Thus, GAGs chains with a high molecular weight (more than"}
+{"text": "Pineal gland calcification is the formation of corpora arenacea predominantly composed of calcium and phosphorus. It plays an important role in regulating the light/dark circadian changes to synchronize their daily physiological activities like feeding, metabolism, reproduction, and sleep through the secretion of melatonin. Therefore, this study aimed to assess the pooled prevalence of pineal gland calcification.A systematic review was done using published research articles from different electronic databases. Cross-sectional studies were included for systematic review and only studies conducted on the human population were included for quantitative analysis. Published articles were selected by assessing the title and abstract for relevance to the review objectives. Finally, the full text was retrieved for further assessment.I2\u2009=\u200997.7%, P\u2009\u2264\u20090.001. According to the qualitative analysis, an increase in age, male sex, and white ethnicity are the major socio-demographic characteristics that increase the prevalence of pineal gland calcification.The pooled prevalence of pineal gland calcification was 61.65% , with a heterogeneity of The pooled prevalence of pineal gland calcification was higher compared with reports from previous studies. Different studies reported pineal gland calcification was most prevalent in the adult population compared with the pediatric age groups. According to the qualitative analysis, an increase in age, male sex, and white ethnicity are the major socio-demographic characteristics that increase the prevalence of pineal gland calcification. The pineal gland is a neuroendocrine organ that regulates daily body rhythm by the secretion of melatonin . It is tThis systematic review and meta-analysis were conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). A protocol was registered in the International Prospective Register of Systematic Reviews database .Published research works are accessed using computerized search engines such as PubMed, direct Google, Google Scholar, and Cochrane library. Published papers in different countries were identified and all the available articles entitled prevalence and associated factors of pineal gland calcification were included. The search language was limited to English. Published papers were searched using keywords, such as pineal gland, prevalence, pineal gland calcification, and associated factors, and only published articles were included in the meta-analysis. The title and abstract of each study were critically reviewed by two researchers and most of the retrieved articles were excluded here. The full documents were thoroughly read and reread to include the paper for quantitative analysis. Finally, only 8 studies that meet the inclusion criteria were included for the quantitative analysis.For this study, we included population-based studies, cross-sectional based studies, and studies that provide sufficient information on sample size and prevalence of pineal gland calcification. The quality of the articles was assessed by sample size, the aim of the study, measured variables, and study design. Therefore, all articles, which used cross-sectional based studies and report the prevalence of pineal gland calcification were included. Studies conducted at a specific population group and those done at a specific age group were excluded as it is not representative of the general population. For multiple studies on the same population, only the study that reported the most detailed data was included.All articles searched from 12/07/2020 to 26/08/2020 using different electronic databases were combined in Endnote and duplicates were removed. Two researchers (MG and DG) independently screened the titles and abstracts and reviewed the full text of the eligible citations. For each included study, two researchers (MG and DG) independently extracted the following information: general information , study characteristics , and all possible participant information. Only when reviewers agreed was the study included in the meta-analysis. Textual narrative synthesis and thematic synthesis methods were used to extract and generate important qualitative findings. The quality of the study included was assessed by Newcastle\u2013Ottawa scale (NOS) quality assessment tools for cross-sectional studies.Q test and I2 statistic, which shows the percentage of variation across studies  , with a heterogeneity of 2 to 76% , 25. Thi2 to 76% , 25; how2 to 76% , 27 and 2 to 76% . This re2 to 76% , 28, 29.2 to 76% . In this2 to 76% . As a liIn this study, the pooled prevalence of pineal gland calcification was higher compared with many previous reports, which is more prevalent in the adult population compared with the pediatric. According to the qualitative analysis, an increase in age, male sex, and white ethnicity are the major socio-demographic characteristics that increase the prevalence of pineal gland calcification."}
+{"text": "Radiologists routinely make life-altering decisions. Optimizing these decisions has been an important goal for many years and has prompted a great deal of research on the basic perceptual mechanisms that underlie radiologists\u2019 decisions. Previous studies have found that there are substantial individual differences in radiologists\u2019 diagnostic performance  due to experience, training, or search strategies. In addition to variations in sensitivity, however, another possibility is that radiologists might have perceptual biases\u2014systematic misperceptions of visual stimuli. Although a great deal of research has investigated radiologist sensitivity, very little has explored the presence of perceptual biases or the individual differences in these.Here, we test whether radiologists\u2019 have perceptual biases using controlled artificial and Generative Adversarial Networks-generated realistic medical images. In Experiment 1, observers adjusted the appearance of simulated tumors to match the previously shown targets. In Experiment 2, observers were shown with a mix of real and GAN-generated CT lesion images and they rated the realness of each image.We show that every tested individual radiologist was characterized by unique and systematic perceptual biases; these perceptual biases cannot be simply explained by attentional differences, and they can be observed in different imaging modalities and task settings, suggesting that idiosyncratic biases in medical image perception may widely exist.Characterizing and understanding these biases could be important for many practical settings such as training, pairing readers, and career selection for radiologists. These results may have consequential implications for many other fields as well, where individual observers are the linchpins for life-altering perceptual decisions. Medical image perception is fundamentally important for decisions that are made on a daily basis by clinicians in fields ranging from radiology and pathology to internal medicine . At a fuIt has been known for decades that radiologists have significant individual differences in their diagnostic performance . For exaIn recent years, more and more studies have documented and investigated the individual variations in the perceptual performance among groups of untrained observers e.g.,  and a feAnother example of striking individual differences is face recognition, which varies substantially between observers . For exaperceptual sensitivitysensitivity could be a natural consequence of variability in experience and training  was difficult in prior research is that the stimuli used were natural  and therefore not easily or well controlled. Hence, it is almost impossible to measure systematic perceptual biases in radiologists in those studies. In order to measure these idiosyncratic biases in the medical image perception performance of radiologists, we need controlled stimuli and experiments. The goal of this study was to test for idiosyncratic perceptual biases in a group of radiologists with controlled visual stimuli. We also compared the radiologists\u2019 results to a comparable group of na\u00efve participants who were untrained and inexperienced with medical images.Raw data for Experiment 1 were obtained from a previously published experiment on perceptual judgments by radiologists and untrained non-clinical observers .Fifteen radiologists  and eleven untrained college students  were tested in the experiment. Radiologists participated on site at RSNA annual meeting and college students were recruited at the University of California, Berkeley. Two radiologists did not finish the study, and their data were excluded. Sample size was determined based on radiologists\u2019 availability at RSNA and was similar to previous studies on the perceptual performance of radiologists and individual differences in visual perceptual biases . ExperimThree random objects were created to simulate tumor prototypes. Between each pair of prototypes, 48 morph images were generated using FantaMorph (Abrosoft Co.). This resulted in a continuum of 147 simulated tumors in total . In addiOn each trial, one of the 147 simulated tumors was randomly chosen and presented on top of a randomly chosen real mammogram background image  by fitting a Gaussian function on the response error frequency on individual observers, and calculated half of the distance between the 25th and 75th percentile of the cumulative Gaussian distribution that was transformed from the best-fitted Gaussian function.Fisher transformations were applied for all analyses when calculating the average of correlation values). We repeated this procedure 1,000 times so that we could estimate the mean within-subject correlations and 95% bootstrapped confidence intervals (CI) for radiologists and untrained observers separately , we correlated one half from one observer with one half from another observer. All pairwise correlations were averaged to estimate the between-subject consistency. By repeating the procedure 1,000 times, we obtained the mean between-subject correlations and 95% bootstrapped CIs separately for radiologists and untrained observers , and the shifted half was correlated with another unchanged half. For within-subject correlations, the unchanged half came from the same observer. For the between-subject correlations, the unchanged half came from a different observer. The resulting correlations from individual participants (within-subject) or different pairs of participants (between-subject) were averaged together to get the permuted within-subject or between-subject correlations. This permutation method allowed us to estimate the null correlations by correlating the response errors of different stimuli with each other while at the same time preserving the relationship between similar stimuli . This confirms that they were able to detect and recognize the simulated tumors. Our goal was to look for individual differences that may have been stable and consistent within a particular observer\u2014whether there are idiosyncrasies in clinician perception. To measure this, we calculated the consistency in the observer judgments of the simulated tumors. Each simulated tumor was different, and we measured systematic errors in judgments for each specific image. Insofar as there are differences in clinician perception, they might report deviations or biases and (mis)report a simulated tumor consistently.r\u2009=\u20090.37, p\u2009<\u20090.001, permutation test). Hence, each observer had idiosyncratic biases in their perceptual reports, and those were consistent within each observer. We also calculated the between-observer correlation, using the same approach. This is the correlation between different clinicians, or how similar their residual errors were to each other; it is a measure of how much agreement there is between observers. We found that there was significantly more correlation within a given clinician than between clinicians . This cannot be attributed to noise. Simply adding noise reduces the correlation both within and between observers; adding noise cannot increase the within observer correlation. The results suggest that individual clinicians have consistent biases in their perceptual reports. The source of these biases is unclear, but they are observer-specific.t\u2009=\u20090.64, p\u2009=\u20090.53). We also looked into the within-subject and between-subject consistency among untrained observers and found qualitatively similar results . This echoes the group of radiologists: there are individual differences in simulated tumor recognition, even in untrained observers.To compare this sample of clinicians with an untrained group, we collected data on the same experiment with another group of naive untrained non-clinical observers . The obs results . First, p\u2009<\u20090.05, bootstrap test). Clinicians are more consistent in their observer-specific biases than untrained observers. Given that clinicians and untrained observers do not differ significantly in their perceptual sensitivity measured by JNDs, this result echoes our hypothesis that idiosyncratic perceptual biases could be observed even without differences in overall perceptual sensitivity. Second, the between-subject correlation was not 0 in either group . There are therefore some consistencies between observers in how these stimuli are judged. The individual differences, however, significantly outweighed the commonality, since the within-subject correlations of both groups were significantly higher than the between-subject correlations (ps\u2009<\u20090.001). Together, the results in Experiment 1 showed that radiologists and untrained observers both demonstrated strong individual differences in their perceptual biases towards different simulated tumors in a shape matching task, and radiologists tend to have higher consistency in their own biases.There are, however, several differences between the radiologists and untrained observers that are worth noting. First, the within-observer correlation was higher for the radiologist group than for the untrained observers  and five untrained observers  were recruited in the experiment. Sample size was determined based on previous studies on the perceptual performance of radiologists and individual differences in visual perceptual biases . ExperimFifty CT lesion images were randomly sampled from the DeepLesion Dataset , and fifBoth radiologists and untrained observers were recruited to perform an image rating task . On eachTo estimate test\u2013retest reliability, 20 real images and 20 GAN-simulated images were randomly chosen from the aforementioned 100 images. These 40 images were randomly inserted in the previous 100 image list and were presented in the same manner. Thus, there were in total 140 trials for each participant.Due to a technical problem during image display, one of the 40 repeated images failed to show up for some participants, so only the ratings for 39 out of the 40 repeated images were used  in all following analyses.We recognized that the raw ratings could be influenced by participants\u2019 extreme response tendencies. For example, some might tend to give higher ratings across all images while some may rate lower. Throughout the manuscript we refer to these types of response tendencies as \u201cresponse propensities,\u201d to avoid confusion with other terms like response bias, that can mean different things in different circumstances. To reduce the effect of response propensities, for each participant, we first normalized their raw ratings by rescaling them to range from 0 to 10 using the equation below , we estimated the within-subject and between-subject consistency of their response errors. Within-subject consistency was estimated by the average test\u2013retest reliability among participants . After normalization, for each participant, we again used response errors as a proxy for perceptual biases. We estimated their response errors by calculating the absolute difference between the normalized ratings and the corresponding ground truth of each image . Then, similar to Experiment 1 (see Bootstrap distributions of the within and between-subject correlations were estimated to test whether the average correlations were simply driven by extreme observer(s). For within-subject correlations, on each iteration, we randomly sampled seven radiologists and five untrained observers with replacement, calculated each observer\u2019s within-subject correlation and then averaged the correlations through Fisher transformation , and the set of pairwise correlations were averaged across the group of observers to create one null sample. This procedure was repeated 10,000 times to create a null within-subject distribution. To create between-subject null distributions, we calculated all pairwise correlations between the shuffled initial response errors from one observer and the shuffled retest response errors from another observer. This was repeated 10,000 times to generate a between-subject null distribution. Permuted null distributions were calculated separately for radiologists and untrained observers, and, from these, 95% permuted confidence intervals (CIs) were estimated.In Experiment 2, we tested whether idiosyncratic perceptual biases can be observed with images from a different modality (CT images), a very different perceptual task and highly realistic GAN-generated images. Generative Adversarial Networks (GAN) were trained by d\u2019 values: 0.18 and 0.27 respectively) and there was no significant difference between different groups of participants . This suggested that the artificial GAN-generated images were highly realistic and even experts with training could not distinguish them effectively  and untrained observers (Pearson\u2019s r\u2009=\u20090.34) compared to their corresponding between-subject consistencies . This replicated the findings in Experiment 1, indicating that each radiologist and each untrained observer have their own unique biases in the perception of medical images that cannot be explained by shared biases among observers. We again found that between-subject correlations were significantly higher than the permuted null correlations for both groups of observers , suggesting that observers do share some of their biases. This could be due to some textures or features of the images that commonly influenced the observers\u2019 discrimination of the real or fake CT lesion images.The goal of the following analysis was to measure whether there are systematic and idiosyncratic stimulus-specific biases in the perception of CT lesions by radiologists and untrained observers. As in the first experiment, we measured within and between subject consistency of the perceptual judgments. Since raw ratings may be subject to observers\u2019 response propensities, we normalized the ratings for each observer and then calculated response errors to get a more accurate estimate of their perceptual biases based on the normalized ratings . d\u2019.Taken together, in Experiment 1 we found idiosyncratic biases in radiologists when they made perceptual judgments about artificial simulated tumor shapes, and their biases were stronger compared to untrained observers. Experiment 2 further extended these results and demonstrated strong individual variations in radiologists\u2019 biases in the perceived realness of GAN-generated and real CT lesion images, suggesting that idiosyncratic perceptual biases among radiologists are not tied to a specific type of medical images or tasks, but rather they can be generally observed among different modalities of medical images and different tasks. These individual observer specific biases are found even without significant difference between observers\u2019 perceptual sensitivity measured by We found significant individual differences in radiologists\u2019 perceptual biases. Experiment 1 showed that each radiologist demonstrates unique perceptual biases towards simulated tumors in a shape matching task, and their own internal biases were even more consistent than untrained observers . ExperimWhat are the potential mechanisms underlying these idiosyncratic perceptual biases among radiologists? One possibility is that different radiologists may have different perceptual templates or perceptual representations of the tumor or of medical images in different modalities, analogous to studies showing that human observers have different perceptual templates of faces e.g., . DiffereAnother possible explanation is natural statistics. Radiologists may not have literal \u201ctemplates,\u201d but may have some priors or learned distributions of the statistics in medical images, similar to how human observers represent the statistics of scenes . These pThere are several concerns raised by our results that we address here. First, it might be argued that stronger idiosyncratic biases in the radiologists in Experiment 1 could simply result from the radiologist group being more attentive to the task or lapsing less frequently. In principle, that may explain the higher within-subject correlation as well as the higher between-subject correlation in One limitation is that the task we used in the Experiment 1 was not realistic and arguably was not representative or typical of a radiologist\u2019s task because radiologists mostly perform detection or categorization tasks in their everyday routine, while our task was a continuous report adjustment method. However, the adjustment task can be more advantageous than detection or categorization tasks since it can measure the subjective perceptual representations and criterion of the observers , it provAnother related concern is that the task in Experiment 1 may be unrealistic because it required a variety of perceptual and memory related skills. Observers (na\u00efve observers or skilled radiologists) were asked to detect and recognize a simulated tumor. During this task, they had to hold information in visual short-term memory and subsequently match a stimulus to what was previously seen. This is indeed broader in scope than a traditional forced-choice paradigm. Nevertheless, the detection, recognition, and visual short term memory processes involved in our task are the kinds of abilities that are used by clinicians on a daily basis. Multitasking is not uncommon for radiologists in realistic settings; they often have multiple screens and multiple radiographs; they gaze between different regions of the visual field and integrate information separately from multiple radiographs and files; radiologists often need to hold in short term memory information about the patient, diagnostic history, etiology, referring physician, etc.; and, they may be interrupted mid-diagnosis by the phone, noise, and other realistic factors see . In otheOur experiment does not capture the full complexity of the radiologist\u2019s family of tasks, but the basic processes it taps are highly relevant to those used by radiologists. The results reinforce this: radiologists had higher within-subject consistency than the untrained observers. This suggests that individual radiologists have more consistent and systematic biases in this simulated tumor matching task compared to untrained observers, indicating that their expertise or experience is in fact reflected in this task. Although radiologists and untrained observers had similar sensitivity, as measured by JNDs, this is not surprising since previous studies have found that untrained, na\u00efve observers can perform significantly better than chance in the Vanderbilt Chest Radiograph Test , and othOne way to address this question about ecological validity is to test whether our results extend to other tasks, especially involving real medical images and stepping beyond the artificial radiographs. Therefore, we analyzed data from a second experiment that used realistic CT lesion images. Although this is a different area of medical image perception, we hypothesized that idiosyncratic perceptual biases can be observed across domains and should not be limited to any particular modality, stimulus, or task. In the second experiment, we used real CT lesion images combined with artificial but realistic lesion stimuli created by One might still be concerned about the internal consistency for these idiosyncratic biases. Using the split-half Pearson\u2019s correlation, we found that radiologists had an internal reliability of 0.37 (Experiment 1) and 0.42 (Experiment 2). While this may seem somewhat low, it is significantly higher compared to what was expected by chance  and it may appear low only because our stimuli were numerous and very finely spaced. In order to compare our results with previous published studies, in Experiment 1, we dummy-coded the data into binned categories  and the Cronbach alpha rises substantially , and in Experiment 2, the Cronbach alpha for radiologists was 0.95, which are indeed comparable to that reported in a previous study on individual difference in a radiograph-related task . This isThe between-observer consistency is typically the focus of most medical image perception research see . RecentlThe scarcity of the expert radiologist pool undoubtedly limited the number of available observers we were able to test. Although this is a limit in group-wide analyses, we analyzed every individual observer and measured trial-wise effects within each observer. In fact, even when sample size was limited, past research has been able to demonstrate strong and consistent idiosyncratic visual perceptual biases towards object location, size, motion and face perception with the help of psychophysics . Our resp\u2009<\u20090.005). That is to say, counterintuitively, some biases may get stronger with training, leading to more stable individual differences within radiologists compared to untrained observers. Combined with the fact that radiologists and untrained observers were not significantly different in terms of perceptual sensitivities (measured by JNDs in Experiment 1 and d\u2019 in Experiment 2), this result again echoes our hypothesis that variations in perceptual biases could exist even without overall differences in perceptual sensitivity. Third, our results show that even untrained observers bring with them individual biases and idiosyncrasies in their perceptual judgments. Fourth, idiosyncratic distortions were found across two different domains, two different modalities, and two different imaging techniques (see Experiment 1 vs. Experiment 2).There are several implications of the findings reported here. First, clinicians vary in their perceptual abilities. Although this is not at all surprising, the stimulus-specific way in which clinicians vary in the perceptual biases is novel. Second, we found that individual differences are not washed out by training. To address this, we performed a Fisher\u2019s combined probability test , which cMore importantly, the fact that there are individual differences between observers could have critical implications for diagnostic medical imaging. For example, in some countries, it is common practice to have multiple readers rate or diagnose radiographs . Given tAnother important implication of our results is that different clinician observers may show different native ability in particular specialties or even different imaging modalities. Returning briefly to the face recognition literature, the individual differences in face recognition arise because of many factors including age and experience, but also genetic differences . Some obOur findings provide a new insight about the individual differences that exist in the perceptual judgments of professional radiologists: apart from perceptual sensitivity, which has been proposed and investigated extensively in the past, there may actually be idiosyncratic and systematic biases in their perceptual judgments. Understanding these idiosyncratic perceptual biases could be critically important for a variety of reasons, including training, career selection, bias compensation, and employing paired readers in the field of medical imaging. At an even broader level, it is worth noting that individual differences in observer perception could have important consequences in many fields beyond medicine. For example, in TSA screeners, professional drivers, airline pilots, radar operators, and in many other fields where single observers are relied on for life-altering perceptual decisions.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by the Committee for the Protection of Human Subjects at the University of California, Berkeley. The patients/participants provided their written informed consent to participate in this study.ZW, MM, ZR, and CG programmed the software. MM, ZR, CG, and MZ performed the data collection. ZW, MM, ZR, and TC-B programmed the pipeline to perform the data analysis. ZW and DW drafted the manuscript. MM, YM, and DW reviewed and edited the manuscript. MM and ZW made the figures. All authors contributed to the article and approved the submitted version.This work was supported in part by the National Institutes of Health (grant number: R01 CA236793-01). Publication made possible in part by support from the Berkeley Research Impact Initiative (BRII) sponsored by the UC Berkeley Library.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher."}
+{"text": "This study aims to know the current scenario of speech audiology therapy activities at NHS in Brazil, identifying its obstacles and perspectives, as well as verifying the adequacy of national NHS Programs to the pre-established quality indicators.Analytical observational study, carried out with speech therapists in the exercise of NHS in Brazil, between August 2018 and August 2019, through a structured online questionnaire. Descriptive and correlational analyzes of the data were performed using the SPSS version 22.0 program.The effective practice of NHS was not entirely consistent with official protocols. 48.5% of speech therapists stated that NHS interruption at some point in the workplace, especially due to the need to repair the equipment (64.7%). As for the flow records and care-related data, which include quality indicators there was greater control over the total number of neonates who underwent NHS (87.9%) and less control over false-positive results (21.2%). 81.8% of speech-language-hearing therapists said they were available to use a system for recording and controlling NHS data.Although professionals\u2019 practices are generally consistent with official protocols, the non-linearity of the process and the lack of data control are important obstacles to the quality of NHS services. Most of the national NHS programs presented do not meet the pre-established quality indicators. It is considered that the computerization of records can benefit professionals and enhance the implementation of NHS provided for in Brazilian laws and public policies. In 1964, Downs and Sterrit assessed the behavioral responses of neonates before a narrow-band sound stimulus centered at 3000 Hz at 90 dBNPS. In this same study, a high false-negative rate was identified and the need to create a protocol with the risk indicators for hearing impairment was identified. Hearing screening programs specifically for newborns have been developed for over 35 years. After the validation of the Otoacoustic Emissions (OAE) by David Kemp, in England, the Newborn Hearing Screening (NHS) encountered a new impulse. However, approximately until the 1990s, NHS was performed in an inconsistent and non-systematic way all over the world, mainly due to the elevated cost.Hearing screening tests have been used for at least 60 years to identify children who need further hearing evaluation. In the 1940s, Ewing & Ewing observed the Cochlear Palpebral Reflex. In 1995, the first multi-professional recommendation on aspects related to children\u2019s hearing health was published, as a result of a workgroup that emerged at the X International Audiology Meeting (1995).In Brazil, the first sites that implemented NHS in 1987 were Hospital S\u00e3o Paulo  and Hospital Universit\u00e1rio de Santa Maria . In both places, the baby\u2019s behavioral responses were observed in this assessment. In the following year, Hospital Israelita Albert Einstein started the first NHS program that also used the electrophysiological method Brainstem Auditory Evoked Potential (BAEP). The first initiatives to disseminate and support the implementation of NHS happened in 1998 with the creation of the Universal Newborn Hearing Screening Support Group. In the following year (1999) the first national recommendation for the screening implementation was made by the Brazilian Committee on Hearing Losses in Childhood, which followed the international principles and guidelines. The Federal Council of Speech Therapy in 2000, in the Legal Opinion no. 05/00, said that the Speech Therapist is the professional qualified to implement and execute the hearing screening programs in hospitals and maternities, and must consider the use of objective methodologies, such as recording the OAE and BAEP.On November 12, 1997, law no. 3.842/1997 was presented to make the OAE test mandatory in all public and private hospitals and maternities in the country and SAS/MS no. 587 and 589/2004 allowed a massive breakthrough in early intervention, establishing and regulating the National Policy for Hearing Health Care, improving the hearing health actions of the Unified Health System (SUS) and proposing the organization of a hierarchical, regionalized, and integrated network between basic, medium, and high complexity care, trying to ensure hearing diagnosis and rehabilitation. The services of Hearing Health Care in the medium complexity level should partake in the execution of NHS and hearing monitoring in neonates.Therefore, the Administrative Acts GM/MS no. 2073/2004 made screening through OAE exam mandatory in all children born in maternities and hospitals, allowing the integrality of hearing health care in childhood, following the trend of what was already happening in developed countries, such as the United States and England. The Multi-professional Committee on Hearing Health (COMUSA) published an opinion to guide the actions of professionals involved in NHS programs, following two international recommendations: one from England, entitled \u201cGuidelines for early diagnosis and treatment of infants who failed UNHS\u201d, and one from the United States, entitled \u201cPrinciples and guidelines for early detection and intervention programs of hearing impairment\u201d, published by the Joint Committee on Infant Hearing (JCIH). The JCIH recommendations have been systematically adopted as guides for the Brazilian documentations, with scientific evidence that guides worldwide updates in the clinical practice of early identification and intervention for newborns and infants at risk of hearing loss.In 2010, Federal Law no. 12.303 established the National Plan of the Rights to the Person with Disability - Living without Limitation, where it established the Care Network for the Person with Disability and qualified hearing health services. Following Administrative Act no. 1.459, of June 24, 2011, which established the network Rede Cegonha, financial resources were also allocated for the purchase of NHS equipment. The following year, the Ministry of Health published the NHS Care Guidelines to guide multi-professional teams for the care of auditory health in childhood, in the different points of attention of the network, with a flowchart for such. Also in 2012 were published the Hearing Health Instructions referring to Administrative Acts GM 793 of April 24, 2012 and 835 of April 25, 2012, with guidelines for treatment, rehabilitation and/or habilitation of people with hearing, physical, intellectual and visual impairments. These documents also regulated the operation of the Specialized Rehabilitation Centers (SRC), including standards for physical facilities, hours, and human and material resources.In turn, the Federal Decree 7.612 of 2011. It is known the need for control of NHS results, monitoring, follow-up of hearing and language development, as well as diagnosis and (re)habilitation of children born throughout the national territory. Besides these, it is necessary the control quality indicators for the implementation and assessment of actions of comprehensive hearing health care in childhood.The NHS aims to be a precursor strategy in the process of evaluation of infant hearing, allowing early detection of possible hearing alterations by covering all neonates, including those who do not have risk indicators for hearing impairment (RIHI),20. However, the Brazilian rate is below this parameter. A study presented a positive evolution in the coverage of NHS in Brazil, estimating, between January 2008 and June 2015, the achievement of 31.8% of coverage, with strong inter and intraregional inequalities in the country. In addition, there is no integration of data for the effective monitoring of neonates, from screening to their (re)habilitation when necessary.In the literature, there is a consensus on the importance of universal screening, with coverage rates that should be equal to 95% of live births, to reach 100%. To ensure the successful implementation of NHS, it seems necessary to assess and contemplate the possibilities of each region, and the process can be multiplied and spread in different areas of the country. However, the final choice should consider primarily the current scientific evidence.Brazil has a continental extension, with regional, economic, social, health and cultural differences, which may interfere in the approach to the implementation of universal NHS programs in the national territory. In the current scenario, the protocols used differ. Many reasons lead professionals to adopt a specific protocol, such as the context and the constraints imposed by the socioeconomic environmentTo understand the current scenario of NHS implementation in several Brazilian settings, almost ten years after the implementation of the law that made this procedure mandatory in the country, this study identifies the protocols used for its implementation by speech therapy professionals, the obstacles and perspectives of this performance from the perspective of these professionals, and the adjustment of NHS programs to pre-established quality indicators. This study intends to understand the current scenario of speech therapy in NHS services in Brazil, identifying its obstacles and perspectives, and checking the adequacy of the national NHS programs concerning the pre-established quality indicators.The present study is an analytical observational research whose disclosure and data collection took place between August 2018 and August 2019. The study had the participation of 33 speech therapy professionals who perform NHS, who signed an Informed Consent Form made available online on Google Forms. A questionnaire  presenteThe study sample was conceived by convenience, based on the dissemination of the research in social media platforms and email. Emails were also sent to all the Regional Councils of Speech Therapy in Brazil and universities, so that they passed on the disclosure of the research to registered professionals and/or teachers in the area. Research disclosure was also made in congresses and lectures of NHS, ministered by the first author. Inclusion criteria: being a speech therapist, working with NHS and being registered in the Speech Therapy Council. Professionals who did not complete the questionnaire (n=2) were excluded from the study.The statistical analysis of the data collected included the descriptive analysis of variables and, as a measure of association between variables, the chi-square test was used. All analyses were performed using SPSS version 22.0. The study stems from the research project \u201cDevelopment of a database for integration of data from Newborn Hearing Screening in the State of Rio Grande do Sul\u201d , approved by the Research Ethics Committee of the Federal University of Health Sciences of Porto Alegre (Consubstantiated opinion no. 3.033.334).The Speech Therapy Service was implemented between the years 1970 and 2018 in the places where the speech therapists worked, and the implementation of NHS happened between 1998 and 2019 . Regarding the workload for the implementation of NHS by the professionals, a variation of 3 to 40 hours was identified (mean=14.45h). It was identified the prevalence of only one or two professionals responsible for performing NHS in each place . NHS is usually performed in the outpatient clinic (54.5%), rooming-in (51.5%) and/or office (39.4%).When asked about a possible interruption in the NHS execution in these places, 48.5% of professionals answered affirmatively. These interruptions happened between one and twelve times, and these were the most frequent reasons: need to repair the equipment (64.7%), absence of the Speech Therapy professional (35.3%), absence of equipment (23.5%) or accessory equipment (11.8%), and vacation or impossibility of work due to health reasons (5.9%).NHS professionals also worked in other areas of Audiology (n=14), in dysphagia (n=13), orofacial motricity (n=12), language (n=7), voice (n=5) and fluency (n=4), among others. Only three professionals did not work in any other activity or area. Regarding the protocols used for NHS, none of the questions was answered unanimously by the participants, and the use was adapted according to the case and the moment, as shown in Joint Committee on Infant Hearing (39.4%) and Multi-professional Committee on Hearing Health (36.4%). As for the flow records and data of NHS care, which result in quality indicators for the implementation and evaluation of actions of comprehensive hearing health care in childhood, we identified a higher control of the total number of neonates who performed NHS (87.9%) and lower control of false-positive results (21.2%) ,  (21.2%) . There iWhen asked whether, in case of a failure in NHS, professionals already had an established place to refer and perform the audiological diagnosis, 84.8% answered positively. Regarding having a place established for referral to ISAD (Re)habilitation, Speech Therapy and otorhinolaryngological follow-up, 75.8% answered affirmatively. Regarding the referral sites, (Re)habilitation Cochlear Implant, Speech Therapy and otorhinolaryngological follow-up, 66.7% indicated having possibilities.The factors identified by the speech therapists as reasons for not continuing the hearing evaluation by the newborns\u2019 caregivers were: care far from the place of residence (72.7%), socioeconomic level of the caregivers (60.6%), not considering it important to carry out the evaluation (60.6%), family structure (57.6%), lack of transportation (45.5%), fear of diagnosis (33.3%), forgetting the day of the evaluation (30.3%), education of the caregivers (21.2%), and absence of a caregiver (15.2%).Regarding data control, 81.8% of the speech therapists stated that they would use a database for NHS, taking into consideration the epidemiological control and patient referral. According to them, the information that should be in a unified database for the registration and control of NHS data include: date, place and time of NHS execution (93.9%), date, place and time of retesting (90.9%), RIHI identification (90.9%), final results (87.9%), full data of caregivers (81.8%), date, place and time of referral (78.8%), data of the responsible speech therapist (75.8%), full name of the neonate , history of follow-ups of the newborn (66.7%), clinical history of the newborn (69.7%), maternal clinical history (57.6%), the brand of equipment used (51.5%), date of equipment calibration (42.4%), results by frequency (36.4%), paternal clinical history (21.2%), delivery data (3%) and socioeconomic data (3%). indicates that the coverage of NHS in Brazil has grown over time, but it is still low and has an uneven territorial distribution. This inequality can also explain this scenario of distribution of respondents.Although the number of respondents of the study was not significant, professionals from different regions of the country participated, in different contexts, with constant execution of NHS over the years. A study. The offer of speech therapy care at SUS remains scarce, but, taking into account the growing demand, the poor distribution of such assistance persists in the country, showing that the continuous discussion about the universalization of access and the search for equity in assistance is necessary.The understanding of management, users and other health professionals about the importance of the speech therapist in the three levels of care , according to the principles of the SUS, is essential, considering the recent inclusion of speech therapy in the field of health sciences when compared to other already consolidated sciences,17,20,23. However, the results show a non-standardization of protocols for the execution of NHS, with predominance of the use of TOAE in all phases and cases. Therefore, the importance of implementing a universal protocol, sensitive and specific enough to avoid false-positive and false-negative results in NHS is reinforced. In cases where only TOAE is used, it is possible to assume that there will be an increase in the total workload that the professional must dedicate to NHS, since this protocol determines a greater number of retests. This finding probably results from the fact that, despite the guidance for the use of TOAE and BERA-A ,20,23, Law 12.303/2010 makes mandatory only the execution of OAE.Regarding the execution of NHS performance, the use of objective methodologies, such as automatic OAE and BAEP, according to pre-established criteria, allows for a safe and reliable initial assessment and reaffirmed by COMUSA and DANHS. After all, knowledge of the validity of procedures, the consequence of data recording, as well as false-positive rates, is fundamental to verify these indicators. The goal of NHS programs is to identify all newborns with hearing loss, with acceptable cost. However, the data from this study indicate a difficulty in the recording and management of such information by professionals. All results from the different stages of hearing assessment of newborns should be recorded in a digital database of data management, allowing the control of information and the assessment of the quality of UNHS programs already implemented. This reality is intended by most speech therapists, who mentioned their willingness to use such a database if it were available.It is not feasible to affirm that the services that partook in this research, distributed throughout various regions of the national territory, are complying with the NHS quality indicators proposed by the JCIH.It is not possible to affirm that all newborns, even with the test and retest performed, will be diagnosed with hearing changes. Healthcare professionals still do not have enough knowledge for subsequent follow-ups, stressing the importance of the schematic sequence proposed in NHSHearing development follows gradual steps of complexity, starting already in intrauterine life. The NHS guidelines propose that all newborns have this screening and that monitoring and follow-up of hearing and language development milestones are carried out according to growth. Babies who do not pass the test should be retested and, if necessary, diagnosed and rehabilitated for hearing. Any of these steps are deeply important for the entire process; their interruption will stir important functional losses for the child\u2019s development. In the Brazilian NHS services analyzed, the impossibility of such follow-up/monitoring was identified, according to the experience of the professionals surveyed in their workplaces. Although most infants are screened, there is no follow-up control for those who need to be retested or diagnosed, which may jeopardize the investments in the initial screening.In this line, it was possible to examine many interruptions in the flow of NHS in the places where professionals work for different reasons. The implementation of a NHS program requires an initial investment and, with the maintenance of the equipment, the hiring of a specialized professional, the attention to the environment and the need for a follow-up network. Although the professionals have mentioned this follow-up network, problems were identified in the maintenance of equipment and hiring of replacement professionals in periods of vacation and health licenses of the respondent speech therapists.. The importation of models and data from other countries may not fit the particularities of our population and healthcare system, although such a system seems to be seen positively and even necessary by the professionals in this study.There are no epidemiological studies on neonatal hearing loss in Brazil. Most studies in the field concern specific services. Therefore, efforts should be focused on the development of a national database, which intends to cover the information required for the care of the child at risk for hearing loss, including screening, diagnosis, and intervention when necessaryWe hope that the knowledge provided by this study allows to reflect on the performance of the speech therapy professional in the health network, resulting in the expansion of the hiring of these professionals for Primary Care, the promotion of comprehensive care of the child population, and the increase of their access to health. It is essential to strengthening the research efforts and the scientific publications, professional investment in the three levels of care, and attention to the current legislation, because the speech therapist is part of several public policies so that the execution of NHS strengthens the good practices of hearing prevention.We emphasize the scarcity of national literature about this study, making it difficult to compare the findings with other investigations in this area. The goal is to encourage the effective implementation of NHS guidelines in the Brazilian healthcare system, for its universalization of access and research, as well as to search for its quality indicators. This includes monitoring the entire process of infant hearing assessment follow-up, contributing to the better organization of the network of professionals and assistance to neonates.Regarding future perspectives, we emphasize the participants\u2019 openness to data computerization, which may require improvements in the monitoring of the NHS flow and its outcomes, allowing the implementation of Brazilian public policies regarding children\u2019s hearing health and its improvement.Although NHS is guaranteed in its universality, this is not yet verifiable in services in different regions of Brazil, because the difficulties and obstacles cover the supply of professionals, including the restriction of recording relevant information for quality indicators, to the maintenance of equipment and accessories. Most of the national NHS programs presented do not meet the quality indicators proposed by the JCIH, which were indicated by COMUSA and the Ministry of Health\u2019s Care Guidelines for NHS. Moreover, although access to actions and services should be guaranteed, there are several difficulties, often restricting the continuity of the NHS flow. Thus, knowledge of the difficulties and inequalities that affect access and effective implementation of NHS in the country allows creating further effective strategies for its universalization. . Downs e Sterrit, em 1964, avaliaram as respostas comportamentais de neonatos frente a est\u00edmulo sonoro de banda estreita centrada em 3000 Hz, a 90 dBNPS. Neste mesmo estudo foi observado um elevado \u00edndice de falso negativos, e a exposi\u00e7\u00e3o da necessidade de se elaborar um protocolo com os indicadores de risco para a defici\u00eancia auditiva. Os programas de triagem auditiva especificamente para rec\u00e9m-nascidos est\u00e3o sendo desenvolvidos h\u00e1 mais de 35 anos. Ap\u00f3s a comprova\u00e7\u00e3o das Emiss\u00f5es Otoac\u00fasticas (EOA), por David Kemp, na Inglaterra, a Triagem Auditiva Neonatal (TAN) ganhou novo impulso. Contudo, aproximadamente at\u00e9 a d\u00e9cada de 90, a TAN era realizada de forma inconsistente e assistem\u00e1tica em todo o mundo, principalmente devido ao alto custo.Os testes de triagem auditiva s\u00e3o usados h\u00e1 pelo menos 60 anos para detectar crian\u00e7as que necessitam avalia\u00e7\u00e3o auditiva adicional. Na d\u00e9cada de 40, Ewing & Ewing observaram em rec\u00e9m-nascidos o Reflexo C\u00f3cleo-palpebral. Em 1995 foi publicada a primeira recomenda\u00e7\u00e3o multiprofissional sobre aspectos relacionados \u00e0 sa\u00fade auditiva da crian\u00e7a, como resultado de um grupo de trabalho que surgiu no X Encontro Internacional de Audiologia (1995).No Brasil, os primeiros locais que implementaram a TAN, em 1987, foram o Hospital S\u00e3o Paulo  e o Hospital Universit\u00e1rio de Santa Maria . Em ambos os locais era utilizada a observa\u00e7\u00e3o de respostas comportamentais do beb\u00ea nessa avalia\u00e7\u00e3o. No ano seguinte, o Hospital Israelita Albert Einstein iniciou o primeiro programa de TAN que utilizou tamb\u00e9m o m\u00e9todo eletrofisiol\u00f3gico Potencial Evocado Auditivo de Tronco Encef\u00e1lico (PEATE). As primeiras iniciativas para a divulga\u00e7\u00e3o e apoio \u00e0 implanta\u00e7\u00e3o da TAN aconteceram em 1998, com a cria\u00e7\u00e3o do Grupo de Apoio \u00e0 Triagem Auditiva Neonatal Universal. No ano seguinte (1999) foi elaborada a primeira recomenda\u00e7\u00e3o nacional para a implanta\u00e7\u00e3o da triagem pelo Comit\u00ea Brasileiro sobre Perdas Auditivas na Inf\u00e2ncia, que seguiu os princ\u00edpios e diretrizes internacionais. O Conselho Federal de Fonoaudiologia, em 2000, sob Parecer n\u00ba 05/00, relatou que o Fonoaudi\u00f3logo \u00e9 o profissional capacitado para a implanta\u00e7\u00e3o e a execu\u00e7\u00e3o de programas de triagem auditiva em hospitais e maternidades e deve considerar o uso de metodologias objetivas, como o registro das EOA e PEATE.No dia 12 de novembro de 1997 foi apresentado o projeto de lei 3.842/1997, para tornar obrigat\u00f3ria a realiza\u00e7\u00e3o do exame EOA em todos os hospitais e maternidades p\u00fablicas e privadas do Pa\u00eds e SAS/MS n\u00ba 587 e 589/2004 permitiram grande avan\u00e7o no que diz respeito \u00e0 interven\u00e7\u00e3o precoce, instituindo e regulamentando a Pol\u00edtica Nacional de Aten\u00e7\u00e3o \u00e0 Sa\u00fade Auditiva, aprimorando as a\u00e7\u00f5es de sa\u00fade auditiva do Sistema \u00danico de Sa\u00fade (SUS) e propondo a organiza\u00e7\u00e3o de uma rede hierarquizada, regionalizada e integrada entre a aten\u00e7\u00e3o b\u00e1sica, a m\u00e9dia e a de alta complexidade, buscando garantir o diagn\u00f3stico e a reabilita\u00e7\u00e3o auditiva. Os servi\u00e7os de Aten\u00e7\u00e3o \u00e0 Sa\u00fade Auditiva na m\u00e9dia complexidade deveriam atuar na realiza\u00e7\u00e3o de TAN e no monitoramento da audi\u00e7\u00e3o em neonatos.Assim, as Portarias GM/MS n\u00ba 2073/2004 tornou obrigat\u00f3ria a realiza\u00e7\u00e3o da triagem, por meio do exame EOA, em todas as crian\u00e7as nascidas em maternidades e hospitais, possibilitando a integralidade da assist\u00eancia \u00e0 sa\u00fade auditiva na inf\u00e2ncia, seguindo a tend\u00eancia do que j\u00e1 estava acontecendo em pa\u00edses desenvolvidos, como Estados Unidos e Inglaterra. O Comit\u00ea Multiprofissional em Sa\u00fade Auditiva (COMUSA) elaborou um parecer para nortear as a\u00e7\u00f5es dos profissionais envolvidos nos programas de TAN, endossando duas recomenda\u00e7\u00f5es internacionais: da Inglaterra, intitulada \u201cDiretrizes para o diagn\u00f3stico e tratamento precoce de beb\u00eas que falharam na TANU\u201d, e dos Estados Unidos, denominada \u201cPrinc\u00edpios e diretrizes para os programas de detec\u00e7\u00e3o e interven\u00e7\u00e3o precoces da defici\u00eancia auditiva\u201d, publicada pelo Joint Committee on Infant Hearing (JCIH). As recomenda\u00e7\u00f5es do JCIH t\u00eam sido adotadas sistematicamente como norteadoras para as documenta\u00e7\u00f5es brasileiras, pois s\u00e3o pautadas em evid\u00eancias cient\u00edficas que direcionam atualiza\u00e7\u00f5es em n\u00edvel mundial na pr\u00e1tica cl\u00ednica de identifica\u00e7\u00e3o precoce e de interven\u00e7\u00e3o para rec\u00e9m-nascidos e beb\u00eas em risco de perda auditiva.Em 2010, a Lei Federal n\u00ba 12.303 estabeleceu o Plano Nacional dos Direitos \u00e0 Pessoa com Defici\u00eancia \u2013 Viver sem Limite, o qual criou a Rede de Cuidados \u00e0 Pessoa com Defici\u00eancia e qualificou servi\u00e7os de sa\u00fade auditiva. Pela Portaria n\u00b0 1.459, de 24 de junho de 2011, que instituiu a Rede Cegonha, tamb\u00e9m foram fornecidos recursos financeiros para a compra de equipamentos de TAN. No ano seguinte, o Minist\u00e9rio da Sa\u00fade publicou as Diretrizes de Aten\u00e7\u00e3o da TAN, com o objetivo de oferecer orienta\u00e7\u00f5es \u00e0s equipes multiprofissionais para o cuidado da sa\u00fade auditiva na inf\u00e2ncia, nos diferentes pontos de aten\u00e7\u00e3o da rede, apresentando um fluxograma para tal. Ainda em 2012 foram publicados os Instrutivos da Sa\u00fade Auditiva, referentes \u00e0s Portarias GM 793, de 24 de abril de 2012, e 835, de 25 de abril de 2012, referenciando diretrizes para tratamento, reabilita\u00e7\u00e3o e/ou habilita\u00e7\u00e3o de pessoas com defici\u00eancia auditiva, f\u00edsica, intelectual e visual. Tais documentos tamb\u00e9m regulamentaram o funcionamento dos Centros Especializados em Reabilita\u00e7\u00e3o (CER), incluindo normas para as instala\u00e7\u00f5es f\u00edsicas, hor\u00e1rio de funcionamento e recursos humanos e materiais.Por sua vez, o Decreto Federal 7.612 de 2011. Sabe-se da necessidade de controle dos resultados da TAN, de monitoramento, de acompanhamento do desenvolvimento da audi\u00e7\u00e3o e da linguagem, assim como do diagn\u00f3stico e da (re)habilita\u00e7\u00e3o das crian\u00e7as nascidas em todo o territ\u00f3rio nacional. Al\u00e9m destes, \u00e9 necess\u00e1rio o controle dos indicadores de qualidade para a implementa\u00e7\u00e3o e a avalia\u00e7\u00e3o das a\u00e7\u00f5es da aten\u00e7\u00e3o integral \u00e0 sa\u00fade auditiva na inf\u00e2ncia.A TAN tem como objetivo ser uma estrat\u00e9gia precursora no processo de avalia\u00e7\u00e3o da audi\u00e7\u00e3o infantil, permitindo a detec\u00e7\u00e3o precoce de poss\u00edveis altera\u00e7\u00f5es auditivas ao abranger todos os neonatos, inclusive os que n\u00e3o possuem indicadores de risco para defici\u00eancia auditiva (IRDA),20. Por\u00e9m, o \u00edndice brasileiro est\u00e1 abaixo desse par\u00e2metro. Um estudo apresentou uma evolu\u00e7\u00e3o positiva na cobertura da TAN no Brasil, estimando, entre janeiro de 2008 e junho de 2015, o alcance de 31,8% da cobertura, ainda com fortes desigualdades inter e intrarregionais no pa\u00eds. Al\u00e9m disso, n\u00e3o existe integra\u00e7\u00e3o dos dados para o efetivo acompanhamento dos neonatos, desde a triagem at\u00e9 a sua (re)habilita\u00e7\u00e3o, quando necess\u00e1rio.Na literatura h\u00e1 consenso quanto \u00e0 import\u00e2ncia da universalidade da triagem, com \u00edndices de cobertura que devem ser iguais a 95% dos nascidos vivos, com meta de alcan\u00e7ar 100%. Assim, para o sucesso da implanta\u00e7\u00e3o da TAN, parece ser necess\u00e1rio avaliar e contemplar as possibilidades de cada regi\u00e3o, de modo que o processo possa ser multiplicado e difundido nas mais variadas \u00e1reas do pa\u00eds. Entretanto, a escolha final deveria considerar prioritariamente as evid\u00eancias cient\u00edficas atuais.O Brasil tem uma extens\u00e3o continental, com diversidades regionais, econ\u00f4micas, sociais, sanit\u00e1rias e culturais, que podem interferir na abordagem a ser utilizada na implanta\u00e7\u00e3o dos programas de TAN universal no territ\u00f3rio nacional. No atual cen\u00e1rio, os protocolos utilizados diferem. H\u00e1 muitas raz\u00f5es pelas quais os profissionais optam por adotar um protocolo espec\u00edfico, como o contexto e as restri\u00e7\u00f5es impostas pelo ambiente socioecon\u00f4micoBuscando conhecer o cen\u00e1rio atual de execu\u00e7\u00e3o da TAN em diversos cen\u00e1rios do Brasil, transcorridos quase dez anos desde a implementa\u00e7\u00e3o da Lei que tornou esse procedimento obrigat\u00f3rio no pa\u00eds, este estudo identifica os protocolos utilizados para a sua realiza\u00e7\u00e3o por profissionais da Fonoaudiologia, os obst\u00e1culos e perspectivas dessa atua\u00e7\u00e3o na vis\u00e3o desses profissionais e a adequa\u00e7\u00e3o dos Programas de TAN aos indicadores de qualidade pr\u00e9-estabelecidos. Este estudo visa conhecer o cen\u00e1rio atual da atua\u00e7\u00e3o fonoaudiol\u00f3gica em servi\u00e7os de TAN no Brasil, identificando seus obst\u00e1culos e perspectivas, bem como verificar a adequa\u00e7\u00e3o dos Programas de TAN nacionais aos indicadores de qualidade pr\u00e9-estabelecidos.Trata-se de pesquisa observacional anal\u00edtica, cuja divulga\u00e7\u00e3o e coleta de dados ocorreu entre agosto de 2018 e agosto de 2019. Participaram do estudo 33 profissionais fonoaudi\u00f3logos atuantes na realiza\u00e7\u00e3o da TAN, que assinaram um Termo de Consentimento Livre e Esclarecido disponibilizado online via Google Forms. Foi utilizado um question\u00e1rio (Anexo 1), apresentado na mesma plataforma, com quest\u00f5es estruturadas, que tra\u00e7avam o perfil pessoal e profissional dos fonoaudi\u00f3logos, as caracter\u00edsticas dos locais de atua\u00e7\u00e3o, as pr\u00e1ticas profissionais, incluindo os protocolos utilizados para a execu\u00e7\u00e3o da TAN e as necessidades identificadas nesse contexto de atua\u00e7\u00e3o, e as perspectivas da TAN no Brasil. Essas quest\u00f5es estavam divididas em tr\u00eas se\u00e7\u00f5es  e foram revisadas pelos autores do estudo e por especialistas da \u00e1rea da Fonoaudiologia antes do in\u00edcio da coleta de dados.A amostra do estudo foi constitu\u00edda por conveni\u00eancia, a partir da divulga\u00e7\u00e3o da pesquisa em redes sociais e via e-mail. Tamb\u00e9m foram enviados e-mails para todos os Conselhos Regionais de Fonoaudiologia do Brasil e universidades, para que repassassem a divulga\u00e7\u00e3o da pesquisa aos profissionais cadastrados e/ou professores da \u00e1rea. Ainda, foram realizadas divulga\u00e7\u00f5es da pesquisa em congressos e palestras que abordavam a TAN, ministradas pela primeira autora. Os crit\u00e9rios de inclus\u00e3o empregados foram: ser fonoaudi\u00f3logo(a), atuar na TAN e estar registrado no Conselho de Fonoaudiologia. Foram exclu\u00eddos do estudo os profissionais que n\u00e3o completaram o preenchimento do question\u00e1rio (n=2).A an\u00e1lise estat\u00edstica dos dados coletados compreendeu a an\u00e1lise descritiva das vari\u00e1veis e, para medida de associa\u00e7\u00e3o entre vari\u00e1veis, utilizou-se o teste qui-quadrado. Todas as an\u00e1lises foram realizadas empregando-se o SPSS vers\u00e3o 22.0. O estudo deriva do projeto de pesquisa \u201cDesenvolvimento de um banco de dados para integra\u00e7\u00e3o de dados da Triagem Auditiva Neonatal no Estado do Rio Grande do Sul\u201d , aprovado pelo Comit\u00ea de \u00c9tica em Pesquisa da Universidade Federal de Ci\u00eancias da Sa\u00fade de Porto Alegre (Parecer consubstanciado n\u00famero 3.033.334).A O Servi\u00e7o de Fonoaudiologia foi implementado entre os anos de 1970 e 2018 nos locais de atua\u00e7\u00e3o atual dos fonoaudi\u00f3logos e a implementa\u00e7\u00e3o da TAN se deu entre 1998 e 2019 (apenas dois profissionais n\u00e3o sabiam datar esse acontecimento). Quanto \u00e0 carga hor\u00e1ria destinada \u00e0 realiza\u00e7\u00e3o da TAN pelos profissionais, observou-se uma varia\u00e7\u00e3o de 3 a 40 horas . Observou-se preval\u00eancia de somente um ou dois profissionais respons\u00e1veis pela realiza\u00e7\u00e3o da TAN em cada local . A TAN costuma ser realizada em ambulat\u00f3rio , alojamento conjunto  e/ou consult\u00f3rio .Quando questionados se, em algum momento, houve interrup\u00e7\u00e3o na execu\u00e7\u00e3o da TAN nesses locais, 48,5% dos profissionais responderam afirmativamente \u00e0 quest\u00e3o. Tais interrup\u00e7\u00f5es aconteceram de uma a doze vezes, sendo os motivos mais frequentes: necessidade do reparo do equipamento , aus\u00eancia do profissional da Fonoaudiologia , aus\u00eancia de equipamento  ou de acess\u00f3rio do equipamento , e f\u00e9rias ou impossibilidade de trabalho por quest\u00f5es de sa\u00fade .Os profissionais que atuam na TAN tamb\u00e9m atuavam em outras \u00e1reas da Audiologia (n=14), em disfagia (n=13), motricidade orofacial (n=12), linguagem (n=7), voz (n=5) e flu\u00eancia (n=4), entre outras. Somente tr\u00eas profissionais n\u00e3o trabalhavam em nenhuma outra atividade ou \u00e1rea. Sobre os protocolos utilizados para a realiza\u00e7\u00e3o da TAN, nenhum dos quesitos foi respondido de forma un\u00e2nime pelos participantes, sendo o uso adaptado de acordo com o caso e o momento, como consta na Joint Committee on Infant Hearing  e do Comit\u00ea Multiprofissional de Sa\u00fade Auditiva . Quanto aos registros do fluxo e dos dados de atendimento da TAN, que resultam em indicadores de qualidade para a implanta\u00e7\u00e3o e avalia\u00e7\u00e3o das a\u00e7\u00f5es voltadas \u00e0 aten\u00e7\u00e3o integral \u00e0 sa\u00fade auditiva na inf\u00e2ncia, observou-se maior controle do n\u00famero total de neonatos que realizaram a TAN  e menor controle dos resultados falsos positivos  , do   . N\u00e3o h\u00e1 Quando questionados se, em caso de falha na TAN, os profissionais j\u00e1 tinham um local estabelecido para o encaminhamento e a realiza\u00e7\u00e3o de diagn\u00f3stico audiol\u00f3gico, 84,8% responderam positivamente. J\u00e1 sobre ter um local estabelecido para encaminhamento para (Re)habilita\u00e7\u00e3o AASI, Terapia Fonoaudiol\u00f3gica e seguimento otorrinolaringol\u00f3gico, 75,8% responderam afirmamente. Quanto aos locais para encaminhamento, (Re)habilita\u00e7\u00e3o Implante Coclear, Terapia Fonoaudi\u00f3logica e seguimento otorrinolaringol\u00f3gico, 66,7% indicaram ter possibilidades.Os fatores que os fonoaudi\u00f3logos identificaram como motivos para a n\u00e3o continuidade da avalia\u00e7\u00e3o auditiva por parte dos respons\u00e1veis dos neonatos foram: atendimento distante da resid\u00eancia , n\u00edvel socioecon\u00f4mico dos respons\u00e1veis , n\u00e3o julgar importante a realiza\u00e7\u00e3o da avalia\u00e7\u00e3o , estrutura familiar , aus\u00eancia de transporte , receio do diagn\u00f3stico , esquecimento do dia do atendimento , escolaridade dos respons\u00e1veis , e aus\u00eancia de respons\u00e1vel .Visando o controle de dados, 81,8% dos fonoaudi\u00f3logos afirmaram que utilizariam um banco de dados para a TAN, pensando no controle epidemiol\u00f3gico e encaminhamento de pacientes. Segundo eles, as informa\u00e7\u00f5es que deveriam constar em um banco de dados unificado para o registro e controle de dados da TAN incluem: data, local e hor\u00e1rio de realiza\u00e7\u00e3o da TAN , data, local e hor\u00e1rio de realiza\u00e7\u00e3o do reteste , identifica\u00e7\u00e3o do IRDA , resultados finais , dados completos dos respons\u00e1veis , data, local e hor\u00e1rio do encaminhamento , dados do fonoaudi\u00f3logo respons\u00e1vel , nome completo do neonato , hist\u00f3rico de encaminhamentos do neonato , hist\u00f3rico cl\u00ednico do neonato , hist\u00f3rico cl\u00ednico materno , marca do equipamento utilizado , data de calibra\u00e7\u00e3o do equipamento , resultados por frequ\u00eancias , hist\u00f3rico cl\u00ednico paterno , dados do parto (3%) e socioecon\u00f4micos (3%). aponta que a cobertura da TAN no Brasil tem crescido ao longo do tempo, mas ainda \u00e9 baixa e apresenta uma distribui\u00e7\u00e3o desigual no territ\u00f3rio. Essa desigualdade tamb\u00e9m pode explicar esse panorama de distribui\u00e7\u00e3o dos respondentes.Embora o n\u00famero de respondentes do estudo n\u00e3o tenha sido expressivo, contou-se com a participa\u00e7\u00e3o de profissionais que atuam em regi\u00f5es distintas do pa\u00eds, em contextos diversos, com constante implanta\u00e7\u00e3o da TAN no decorrer dos anos. Um estudo. A oferta dos cuidados fonoaudiol\u00f3gicos no SUS ainda \u00e9 escassa, mas, com a crescente demanda, persiste uma m\u00e1 distribui\u00e7\u00e3o dessa assist\u00eancia no pa\u00eds, evidenciando a necessidade cont\u00ednua de discuss\u00f5es sobre a universaliza\u00e7\u00e3o do acesso e a busca pela equidade na assist\u00eancia.O entendimento por parte da gest\u00e3o, usu\u00e1rios e outros profissionais das sa\u00fade quanto \u00e0 import\u00e2ncia do fonoaudi\u00f3logo atuante nos tr\u00eas n\u00edveis de aten\u00e7\u00e3o , de acordo com os princ\u00edpios norteadores do SUS, \u00e9 essencial, levando em conta a recente inser\u00e7\u00e3o da Fonoaudiologia no campo das ci\u00eancias da sa\u00fade quando comparada a outras ci\u00eancias j\u00e1 consolidadas,17,20,23. Contudo, os resultados demonstram a n\u00e3o padroniza\u00e7\u00e3o de protocolos para a execu\u00e7\u00e3o da TAN, com predomin\u00e2ncia da utiliza\u00e7\u00e3o das EOAT em todas as etapas e em todos os casos. Sendo assim, refor\u00e7a-se a import\u00e2ncia da implanta\u00e7\u00e3o de um protocolo universal, que seja sens\u00edvel e espec\u00edfico o suficiente, a fim de evitar resultados falso-positivos e falsos-negativos na TAN. Nos casos de utiliza\u00e7\u00e3o somente de EOAT, \u00e9 poss\u00edvel supor que haver\u00e1 um aumento na carga hor\u00e1ria total que o profissional dever\u00e1 dedicar para realizar a TAN, uma vez que este protocolo determina maior n\u00famero de retestes. Esse achado provavelmente decorre do fato de que, apesar do direcionamento para a utiliza\u00e7\u00e3o das EOAT e PEATE-A,20,23, a Lei 12.303/2010 torna obrigat\u00f3ria somente a realiza\u00e7\u00e3o de EOA.Particularmente no que tange \u00e0 realiza\u00e7\u00e3o da TAN, a utiliza\u00e7\u00e3o de metodologias objetivas, como as EOA e o PEATE autom\u00e1ticos, de acordo com os crit\u00e9rios pr\u00e9-estabelecidos, permite que se realize a avalia\u00e7\u00e3o inicial de forma segura e confi\u00e1vel e reafirmados pela COMUSA e pela DATAN, porque o conhecimento, consequ\u00eancia do registro de dados, da validade dos procedimentos, bem como das taxas de falso-positivo, \u00e9 fundamental para a verifica\u00e7\u00e3o desses indicadores. A meta dos programas de TAN \u00e9 identificar todos os rec\u00e9m-nascidos com defici\u00eancia auditiva, com custo aceit\u00e1vel. Contudo, os dados do presente estudo indicam uma dificuldade no registro e no gerenciamento dessas informa\u00e7\u00f5es pelos profissionais. Entende-se que todos os resultados das diferentes etapas da avalia\u00e7\u00e3o auditiva dos rec\u00e9m-nascidos deveriam ser registrados em um banco de gerenciamento de dados digital, permitindo o controle das informa\u00e7\u00f5es e, com isso, a avalia\u00e7\u00e3o da qualidade dos programas de TANU j\u00e1 implantados. Essa realidade \u00e9 desejada pela maioria dos fonoaudi\u00f3logos, que apontaram a vontade de utilizar um banco de dados dessa natureza, caso estivesse dispon\u00edvel.N\u00e3o \u00e9 poss\u00edvel afirmar que os servi\u00e7os que participaram desta pesquisa, locados em diversas regi\u00f5es do territ\u00f3rio nacional, est\u00e3o cumprindo os indicadores de qualidade da TAN propostos pelo JCIH.Atenta-se ao fato de n\u00e3o ser poss\u00edvel afirmar que todos os rec\u00e9m nascidos, mesmo que com o teste e reteste realizados, ser\u00e3o diagnosticados com altera\u00e7\u00e3o auditiva, uma vez que ainda h\u00e1 falta de reconhecimento dos profissionais da \u00e1rea da sa\u00fade para os encaminhamentos subsequentes, refor\u00e7ando a import\u00e2ncia da sequ\u00eancia esquem\u00e1tica proposta na TANO desenvolvimento auditivo segue etapas graduais de complexidade, com in\u00edcio j\u00e1 na vida intra-uterina. As diretrizes da TAN prop\u00f5em que todos os rec\u00e9m-nascidos fa\u00e7am essa triagem e que se mantenha o monitoramento e o acompanhamento dos marcos do desenvolvimento da audi\u00e7\u00e3o e da linguagem, conforme o crescimento avan\u00e7a. Beb\u00eas que n\u00e3o passaram no teste dever\u00e3o realizar o reteste e, se necess\u00e1rio, o diagn\u00f3stico e a reabilita\u00e7\u00e3o auditiva. Quaisquer dessas etapas s\u00e3o de grande import\u00e2ncia para que todo o processo se complete; sua interrup\u00e7\u00e3o levar\u00e1, consequentemente, a preju\u00edzos funcionais importantes para o desenvolvimento da crian\u00e7a. No cen\u00e1rio dos servi\u00e7os brasileiros de TAN analisados, percebeu-se a impossibilidade desse acompanhamento/monitoramento, conforme a experi\u00eancia dos profissionais pesquisados nos seus locais de atua\u00e7\u00e3o. Com isso, embora a grande maioria dos beb\u00eas esteja sendo triada, n\u00e3o se tem o controle de seguimento para aqueles que precisam ser retestados ou diagnosticados, o que pode colocar a perder os investimentos na triagem inicial.Nessa mesma dire\u00e7\u00e3o, foi poss\u00edvel observar muitas interrup\u00e7\u00f5es no fluxo da TAN nos locais em que os profissionais atuavam, por diferentes motivos. Sabe-se que a implanta\u00e7\u00e3o de um programa de TAN requer um investimento inicial e com a manuten\u00e7\u00e3o do equipamento, a contrata\u00e7\u00e3o de profissional especializado, o cuidado com a ambi\u00eancia e a necessidade de uma rede para encaminhamentos. Embora os profissionais tenham mencionado essa rede de encaminhamentos, foram encontrados problemas para a manuten\u00e7\u00e3o dos equipamentos e a contrata\u00e7\u00e3o de profissionais substitutos em per\u00edodos de f\u00e9rias e licen\u00e7as de sa\u00fade dos fonoaudi\u00f3logos respondentes.. A importa\u00e7\u00e3o de modelos e dados de outros pa\u00edses pode n\u00e3o atender as particularidades da nossa popula\u00e7\u00e3o e do nosso sistema de sa\u00fade, embora um sistema dessa natureza pare\u00e7a ser bem visto e at\u00e9 mesmo necess\u00e1rio pelos profissionais desse estudo.N\u00e3o existem estudos epidemiol\u00f3gicos sobre a perda auditiva neonatal no Brasil. A maioria dos estudos da \u00e1rea se referem a servi\u00e7os espec\u00edficos. Portanto, esfor\u00e7os devem ser voltados para o desenvolvimento de um banco de dados nacional, que busque contemplar as informa\u00e7\u00f5es necess\u00e1rias ao cuidado da crian\u00e7a com risco para defici\u00eancia auditiva, incluindo a triagem, o diagn\u00f3stico e a interven\u00e7\u00e3o, quando necess\u00e1rioEspera-se que o conhecimento produzido nesse estudo forne\u00e7a subs\u00eddios para a reflex\u00e3o sobre a atua\u00e7\u00e3o do profissional da Fonoaudiologia na rede de sa\u00fade, resultando na amplia\u00e7\u00e3o da contrata\u00e7\u00e3o desse profissional na Aten\u00e7\u00e3o B\u00e1sica, para a promo\u00e7\u00e3o da integralidade do cuidado da popula\u00e7\u00e3o infantil e amplia\u00e7\u00e3o do seu acesso \u00e0 sa\u00fade. Mostra-se indispens\u00e1vel fortalecer as pesquisas e as publica\u00e7\u00f5es cient\u00edficas, investimento profissional nos tr\u00eas n\u00edveis de aten\u00e7\u00e3o, e aten\u00e7\u00e3o \u00e0s legisla\u00e7\u00f5es vigentes, visto que o fonoaudi\u00f3logo \u00e9 inserido em diversas pol\u00edticas p\u00fablicas, para que a realiza\u00e7\u00e3o da TAN efetivamente fortale\u00e7a as boas pr\u00e1ticas de preven\u00e7\u00e3o auditiva.Refor\u00e7a-se a escassez de literatura nacional sobre o tema desse estudo, o que dificulta a compara\u00e7\u00e3o dos achados com outras pesquisas da \u00e1rea. Almeja-se incentivar a implementa\u00e7\u00e3o efetiva das diretrizes da TAN no sistema de sa\u00fade brasileiro, para a sua universaliza\u00e7\u00e3o em termos de acesso e pesquisa, bem como buscar seus indicadores de qualidade, o que inclui o monitoramento de todo o processo de acompanhamento da avalia\u00e7\u00e3o auditiva infantil, contribuindo, assim, para a melhor organiza\u00e7\u00e3o da rede de profissionais e da assist\u00eancia aos neonatos.Como perspectivas futuras, ressalta-se a abertura dos participantes \u00e0 informatiza\u00e7\u00e3o dos dados, o que poder\u00e1 implicar em melhorias no monitoramento do fluxo da TAN e nos seus desfechos, possibilitando a efetiva implanta\u00e7\u00e3o das pol\u00edticas p\u00fablicas brasileiras referentes \u00e0 sa\u00fade auditiva infantil e o seu aperfei\u00e7oamento.Embora a TAN seja garantida na sua universalidade, ainda n\u00e3o se observa isso nos servi\u00e7os de diferentes regi\u00f5es do Brasil, visto que as dificuldades e obst\u00e1culos v\u00e3o desde a oferta de profissionais, incluindo a restri\u00e7\u00e3o de registro de informa\u00e7\u00f5es pertinentes aos indicadores de qualidade, at\u00e9 a manuten\u00e7\u00e3o de equipamentos e acess\u00f3rios. Verificou-se que a maioria dos programas de TAN nacionais apresentados n\u00e3o cumprem os indicadores de qualidade propostos pelo JCIH, os quais foram referenciados pelo COMUSA e pelas Diretrizes de Aten\u00e7\u00e3o da TAN do Minist\u00e9rio da Sa\u00fade. Al\u00e9m disso, embora o acesso \u00e0s a\u00e7\u00f5es e servi\u00e7os devam ser assegurados, dificuldades est\u00e3o presentes, muitas vezes restringindo a continuidade do fluxo da TAN. Assim, o conhecimento das dificuldades e desigualdades que afetam o acesso e a realiza\u00e7\u00e3o efetiva da TAN no pa\u00eds permite elaborar estrat\u00e9gias mais efetivas para a sua universaliza\u00e7\u00e3o."}
+{"text": "A parada cardiorrespirat\u00f3ria \u00e9 um evento cr\u00edtico cuja taxa de sobreviv\u00eancia \u00e9 relacionada \u00e0 qualidade das manobras de reanima\u00e7\u00e3o, aliada \u00e0 tecnologia. \u00c9 importante compreender a percep\u00e7\u00e3o do cansa\u00e7o durante esse procedimento visando a efetividade das compress\u00f5es e o aumento das chances na sobrevida. Aplicar a Escala de Borg para analisar o esfor\u00e7o percebido por enfermeiros durante as manobras de reanima\u00e7\u00e3o cardiopulmonar com dispositivo de feedback. Estudo experimental com distribui\u00e7\u00e3o randomizada de enfermeiros em hospital de ensino, simulando parada cardiorrespirat\u00f3ria, para avalia\u00e7\u00e3o da percep\u00e7\u00e3o do esfor\u00e7o utilizando a escala de Borg durante a reanima\u00e7\u00e3o cardiopulmonar com/sem dispositivo de feedback. Foi adotado n\u00edvel de signific\u00e2ncia estat\u00edstica 5%. Foram inclu\u00eddos 69 enfermeiros atuantes em unidades cr\u00edticas e n\u00e3o cr\u00edticas de atendimento ao adulto. A percep\u00e7\u00e3o de esfor\u00e7o e a frequ\u00eancia card\u00edaca foi menor no grupo interven\u00e7\u00e3o , influenciadas pelo dispositivo de feedback, sem diferen\u00e7a significativa quanto \u00e0s unidades de atua\u00e7\u00e3o. A escala de Borg mostrou-se adequada para os objetivos propostos. O dispositivo de feedback contribuiu no menor esfor\u00e7o e redu\u00e7\u00e3o da frequ\u00eancia card\u00edaca durante as manobras de reanima\u00e7\u00e3o. O baixo custo e a facilidade de aplica\u00e7\u00e3o favorecem o uso em treinamentos e atendimentos em tempo real para avaliar o desempenho durante a reanima\u00e7\u00e3o, utilizando dispositivo de feedback por reduzir os esfor\u00e7os e a percep\u00e7\u00e3o do cansa\u00e7o. Tamb\u00e9m permite a reflex\u00e3o sobre os fatores intervenientes e recursos que podem influenciar na qualidade da assist\u00eancia e nas chances de sobreviv\u00eancia. Apesar dos avan\u00e7os na ci\u00eancia da ressuscita\u00e7\u00e3o, desde 2012, a sobreviv\u00eancia ainda permanece em cerca de 8-10%. A compreens\u00e3o da epidemiologia ainda \u00e9 limitada pela car\u00eancia de dados globais, regionais e registros fidedignos do evento, particularmente em pa\u00edses de baixa e m\u00e9dia renda. As diretrizes daAmerican Heart Association(AHA) de 2020 destacam a reanima\u00e7\u00e3o cardiopulmonar (RCP) de alta qualidade como fator de sucesso na interven\u00e7\u00e3o e maior taxa de sobreviv\u00eancia.No panorama mundial, a parada cardiorrespirat\u00f3ria (PCR) \u00e9 respons\u00e1vel por cerca de 17,8 milh\u00f5es de mortes/ano.A qualidade da realiza\u00e7\u00e3o da RCP tamb\u00e9m depende da condi\u00e7\u00e3o f\u00edsica do socorrista, cansa\u00e7o e fadiga s\u00e3o fatores que comprometem a sobreviv\u00eancia. O revezamento entre os socorristas a cada 2 minutos visa evitar fadiga e m\u00e1 qualidade das manobras \u2013 comuns ap\u00f3s 1 minuto de RCP \u2013 n\u00e3o identificadas mesmo ap\u00f3s 5 minutos ou mais, do in\u00edcio da interven\u00e7\u00e3o. A mensura\u00e7\u00e3o dos n\u00edveis de recupera\u00e7\u00e3o tamb\u00e9m pode ser analisada pela escala de Borgap\u00f3s esfor\u00e7o f\u00edsico. No contexto da RCP, \u00e9 utilizada para avaliar a qualidade do desempenho e as chances de melhorar as tentativas de ressuscita\u00e7\u00e3o.Para mensurar a intensidade da atividade f\u00edsica \u00e9 aplicada a escala de esfor\u00e7o percebido ou classifica\u00e7\u00e3o do esfor\u00e7o percebido (PSE) ou escala de Borg. \u00c9 uma ferramenta eficaz para prever o desempenho e definir estrat\u00e9gias para aumentar a qualidade da atividade f\u00edsica.feedbacks\u00e3o encorajados em atendimento real ou treinamento. Apesar das evid\u00eancias claras de que oferecer RCP de alta qualidade melhora os resultados da ressuscita\u00e7\u00e3o, poucas organiza\u00e7\u00f5es de sa\u00fade aplicam estrat\u00e9gias consistentes no monitoramento da qualidade da RCP. Consequentemente h\u00e1 uma disparidade inaceit\u00e1vel na qualidade dos cuidados e resultados de ressuscita\u00e7\u00e3o, diante da enorme oportunidade para salvar mais vidas.No suporte \u00e0 RCP, o uso dos dispositivos defeedbackimediato. E tem por objetivo aplicar a Escala de Borg para analisar o esfor\u00e7o percebido por enfermeiros durante as manobras de reanima\u00e7\u00e3o cardiopulmonar com dispositivo de feedback.O presente estudo tem por hip\u00f3tese que h\u00e1 diferen\u00e7as na percep\u00e7\u00e3o do esfor\u00e7o, ao prover o Suporte B\u00e1sico de Vida, com ou sem dispositivos defeedbackna percep\u00e7\u00e3o do esfor\u00e7o durante a reanima\u00e7\u00e3o realizada por enfermeiros, distribu\u00eddos aleatoriamente em grupo controle e interven\u00e7\u00e3o, no per\u00edodo de outubro a novembro de 2020. O duplo cegamento foi inviabilizado, visto que o instrumento escala de Borg foi aplicado pela pr\u00f3pria pesquisadora, na avalia\u00e7\u00e3o das vari\u00e1veis percep\u00e7\u00e3o do esfor\u00e7o, e da FC aferida com frequenc\u00edmetro, considerado sensor preciso que fornece medi\u00e7\u00f5es de boa qualidade. Previamente ao uso da escala foi efetuado contato com os respons\u00e1veis (https://borgperception.se/) para esclarecimentos sobre a pesquisa e solicita\u00e7\u00e3o da anu\u00eancia para seu uso, o qual foi autorizado. A pesquisa foi aprovada pelo Comit\u00ea de \u00c9tica em Pesquisa.Estudo de natureza quantitativa, do tipo experimental, para comparar a influ\u00eancia do dispositivo deHospital de ensino, p\u00fablico, geral, de m\u00e9dio porte, do tipo secund\u00e1rio e m\u00e9dia complexidade, localizado na cidade de S\u00e3o Paulo, SP, Brasil.Enfermeiros atuantes em unidades de atendimento ao adulto, cr\u00edticas  e n\u00e3o cr\u00edticas .Foram inclu\u00eddos os enfermeiros assistenciais de unidades de atendimento ao adulto e exclu\u00eddos os que atuavam apenas em atividade administrativa ou como instrutores em cursos de Suporte B\u00e1sico ou Avan\u00e7ado de Vida. Em aten\u00e7\u00e3o \u00e0 seguran\u00e7a, os profissionais impossibilitados de realizar ou concluir a atividade na integralidade, por limita\u00e7\u00e3o f\u00edsica ou gesta\u00e7\u00e3o, ou que apresentavam sintomas de dor ou problemas de sa\u00fade tamb\u00e9m foram exclu\u00eddos.Apresenta\u00e7\u00e3o da pesquisa aos gestores do servi\u00e7o.e-mail,das informa\u00e7\u00f5es da pesquisa e obten\u00e7\u00e3o do consentimento.Recrutamento dos enfermeiros e envio, viaBaseline: verifica\u00e7\u00e3o das habilidades em suporte b\u00e1sico de vida. Para alinhamento te\u00f3rico e atualiza\u00e7\u00e3o das diretrizes AHA/2020 os participantes acessaram cursoonlinedesenvolvido pela pesquisadora. 2\u00aa) Ap\u00f3s o estudo te\u00f3rico, os enfermeiros participaram de segunda atividade pr\u00e1tica, nos moldes da primeira.Agendamento e realiza\u00e7\u00e3o da atividade pr\u00e1tica, em duas etapas: 1\u00aa)feedback. Ap\u00f3s orienta\u00e7\u00f5es ebriefingsobre a atividade e os recursos dispon\u00edveis, na apresenta\u00e7\u00e3o e ambi\u00eancia com o cen\u00e1rio e os instrumentos a serem utilizados, o frequenc\u00edmetro Polar H10\u00ae foi colocado em cada enfermeiro para medir a frequ\u00eancia card\u00edaca (FC). Os registros armazenados na mem\u00f3ria interna do equipamento eram transferidos viaBluetootha telefone celular etablet; posteriormente foram acessados nosite(https://flowpolar.com) e tabulados em planilhaExcel\u00ae para gest\u00e3o das informa\u00e7\u00f5es.Os participantes foram alocados em dois grupos, interven\u00e7\u00e3o e controle, conforme listagem de distribui\u00e7\u00e3o aleat\u00f3ria gerada em computador pelo estat\u00edstico. Respectivamente simularam atendimento em PCR e manobras de Suporte B\u00e1sico de Vida, com e sem dispositivo deLittle Anne QCPR\u00ae com dispositivo defeedbackvisualiz\u00e1vel emsmartphone(QCPR instructor app) e carro de emerg\u00eancia disponibilizado pelo servi\u00e7o com prancha r\u00edgida, bolsa-v\u00e1lvula-m\u00e1scara, flux\u00f4metro com extens\u00e3o e desfibrilador manual no modo DEA \u2013 modelo Desfibrilador Bif\u00e1sicoZoll M Series\u00ae.Sobre a din\u00e2mica da simula\u00e7\u00e3o RCP: a) apresenta\u00e7\u00e3o do caso cl\u00ednico; b) enfermeiro 1 identifica a PCR e inicia as compress\u00f5es tor\u00e1cicas; c) enfermeiro 2 assume as ventila\u00e7\u00f5es e usa o desfibrilador manual no modo DEA, durante 2 minutos; d) ao final, pausa e descanso, por cerca de 10 minutos, para higieniza\u00e7\u00e3o de m\u00e3os e materiais, e rein\u00edcio da atividade, com invers\u00e3o dos papeis entre os profissionais. A escala de Borg foi aplicada quando o enfermeiro realizava as compress\u00f5es. Cada atendimento foi acompanhado por dois avaliadores. Foram utilizados manequim simuladorA escala de Borg foi previamente apresentada aos participantes para esclarecimentos dos crit\u00e9rios e familiariza\u00e7\u00e3o com o instrumento. Ao longo da atividade pr\u00e1tica foi aplicada no primeiro e segundo minuto durante a realiza\u00e7\u00e3o das compress\u00f5es e ap\u00f3s o atendimento, em pausa para avaliar a recupera\u00e7\u00e3o do cansa\u00e7o. Os valores de FC no frequenc\u00edmetro foram registrados. Os valores da escala de Borg (6-20) utilizada na presente pesquisa variaram entre: 6-11 representa o esfor\u00e7o m\u00ednimo, 12-16 para o esfor\u00e7o sustent\u00e1vel e 16-20 quanto ao esfor\u00e7o n\u00e3o sustent\u00e1vel at\u00e9 a exaust\u00e3o.software R\u00ae 4.1.0 adotando n\u00edvel de signific\u00e2ncia 5%. As estat\u00edsticas descritivas foram utilizadas para explorar os dados demogr\u00e1ficos. As vari\u00e1veis de interesse em rela\u00e7\u00e3o ao desfecho dizem respeito ao escore na percep\u00e7\u00e3o de esfor\u00e7o da escala de Borg e varia\u00e7\u00e3o da frequ\u00eancia card\u00edaca, durante a RCP. As vari\u00e1veis categ\u00f3ricas inclu\u00edram atua\u00e7\u00e3o dos participantes em unidades cr\u00edticas e n\u00e3o cr\u00edticas e foram descritas em frequ\u00eancias relativas e absolutas. Foram utilizados testes Skewness, Kurtosis e Shapiro-Wilk para determinar a normalidade. As vari\u00e1veis cont\u00ednuas apresentaram distribui\u00e7\u00e3o normal, sendo descritas atrav\u00e9s de m\u00e9dia e desvio padr\u00e3o (DP). Utilizou-se modelo de efeitos mistos para comparar as vari\u00e1veis de esfor\u00e7o percebido e FC.Nas an\u00e1lises estat\u00edsticas descritivas e inferenciais utilizou-se oDos 190 enfermeiros na institui\u00e7\u00e3o, 72 (38%) foram exclu\u00eddos por atuarem em \u00e1reas n\u00e3o relacionadas ao foco do estudo. Dos 118 (62%) eleg\u00edveis, 62 (53%) atuavam em unidades cr\u00edticas e 56 (47%) em unidades n\u00e3o cr\u00edticas. Destes, 49 (41%) foram exclu\u00eddos por problemas de sa\u00fade, licen\u00e7a m\u00e9dica, trabalho remoto devido \u00e0 pandemia por COVID-19 e desligamento da institui\u00e7\u00e3o, conformeForam inclu\u00eddos 69 enfermeiros, 35 (51%) de unidade cr\u00edtica e 34 (49%) de unidade n\u00e3o cr\u00edtica; 3 (04%) conclu\u00edram doutorado, 15 (22%) mestrado, 44 (64%) especializa\u00e7\u00e3o e 7 (10%) sem titula\u00e7\u00e3o p\u00f3s-gradua\u00e7\u00e3o. Demais caracteriza\u00e7\u00f5es do perfil dos participantes conformeNa segunda etapa, indicada como tempo p\u00f3s, as descri\u00e7\u00f5es quantitativas dos valores s\u00e3o relacionadas \u00e0s medidas verificadas por meio da escala de Borg e do frequenc\u00edmetro durante os dois minutos de RCP e no per\u00edodo de recupera\u00e7\u00e3o, em pausa para descanso e recupera\u00e7\u00e3o do esfor\u00e7o, ao realizar as manobras de SBV, nos grupos interven\u00e7\u00e3o e controle. Na percep\u00e7\u00e3o do esfor\u00e7o verificou-se que, inicialmente, a m\u00e9dia 6 indicou aus\u00eancia do cansa\u00e7o ao iniciar a atividade pr\u00e1tica. Progressivamente, ao final do primeiro minuto de RCP, equivalente a cinco ciclos de 30 compress\u00f5es alternadas com 2 ventila\u00e7\u00f5es, o escore entre 13-14 indicava percep\u00e7\u00e3o de cansa\u00e7o moderado, no esfor\u00e7o toler\u00e1vel para a atividade. Ao final do segundo minuto, ap\u00f3s ter totalizado cerca de 10 ciclos alternando 30 compress\u00f5es e 2 ventila\u00e7\u00f5es, a varia\u00e7\u00e3o de escore 14 indicava esfor\u00e7o moderado, se aproximando do limite para escore 15 na percep\u00e7\u00e3o de alta intensidade e dificuldade para realizar a atividade. Nessa dire\u00e7\u00e3o, verificou-se o aumento progressivo da FC registrada desde o per\u00edodo inicial da atividade e durante a realiza\u00e7\u00e3o dos ciclos de 30 compress\u00f5es e 2 ventila\u00e7\u00f5es.Em contraposi\u00e7\u00e3o, na etapa de recupera\u00e7\u00e3o verificou-se o decr\u00e9scimo dos valores na escala de Borg e da FC, indicando, respectivamente, que ap\u00f3s quatro minutos o escore de percep\u00e7\u00e3o do esfor\u00e7o realizado se aproximava da medida verificada, ao in\u00edcio da atividade. Similarmente, a recupera\u00e7\u00e3o ocorreu na verifica\u00e7\u00e3o da FC, como medida fisiol\u00f3gica que foi se aproximando dos n\u00edveis basais, pr\u00e9vios, conformeEm rela\u00e7\u00e3o aos enfermeiros atuantes em unidades cr\u00edticas e n\u00e3o cr\u00edticas, ao analisar os escores da escala de Borg no primeiro e segundo minuto de RCP, os valores entre 11-13, se aproximando de 14 na realiza\u00e7\u00e3o das compress\u00f5es, indicaram o aumento da percep\u00e7\u00e3o de esfor\u00e7o leve para moderado, se aproximando do esfor\u00e7o intenso ao final do segundo minuto. No per\u00edodo de recupera\u00e7\u00e3o, o decr\u00e9scimo dos valores ao final do quarto minuto foi similar em ambos os grupos. As m\u00e9dias foram muito similares, sugerindo n\u00e3o haver diferen\u00e7a na percep\u00e7\u00e3o do esfor\u00e7o e na varia\u00e7\u00e3o de FC.Na an\u00e1lise comparativa entre as vari\u00e1veis esfor\u00e7o percebido e FC, respectivamente registradas por meio da escala de Borg e do frequenc\u00edmetro, utilizou-se o modelo de efeitos mistos, que incorpora efeitos fixos e aleat\u00f3rios simultaneamente. Efeitos fixos s\u00e3o aqueles que n\u00e3o t\u00eam variabilidade como aloca\u00e7\u00e3o em grupo controle/interven\u00e7\u00e3o, sexo ou idade de um sujeito , enquanto efeitos aleat\u00f3rios s\u00e3o os sujeitos e a variabilidade na sele\u00e7\u00e3o. No contexto de dados longitudinais, \u00e9 tipicamente o sujeito avaliado, ou quando h\u00e1 v\u00e1rios ju\u00edzes avaliando um conjunto de observa\u00e7\u00f5es, sendo que esses ju\u00edzes foram escolhidos de um grupo maior.baselinecorrespondeu \u00e0 fase denominada pr\u00e9 e a segunda etapa, com randomiza\u00e7\u00e3o dos participantes, para uso ou n\u00e3o do dispositivo defeedback, equivaleu a fase p\u00f3s. Para ambas as vari\u00e1veis, os resultados mostraram evid\u00eancia de intera\u00e7\u00e3o momento*grupo, o que indica que os grupos provavelmente n\u00e3o t\u00eam o mesmo desenvolvimento do in\u00edcio do procedimento at\u00e9 o fim da recupera\u00e7\u00e3o. O grupo controle apresentou aumento na percep\u00e7\u00e3o de esfor\u00e7o, na FC e recupera\u00e7\u00e3o mais demorada. O grupo interven\u00e7\u00e3o apresentou menor percep\u00e7\u00e3o de esfor\u00e7o, da FC m\u00e1xima e recupera\u00e7\u00e3o mais r\u00e1pida, com diferen\u00e7a significativa  na realiza\u00e7\u00e3o de RCP com dispositivo defeedback, conformeA primeira etapa oufeedbackinfluencia na atividade f\u00edsica e na redu\u00e7\u00e3o da percep\u00e7\u00e3o de esfor\u00e7o, medida pela Escala de Borg, na realiza\u00e7\u00e3o das manobras de SBV durante a RCP, assim como a FC tamb\u00e9m \u00e9 influenciada. Ao final da pr\u00e1tica simulada, durante odebriefing, v\u00e1rios enfermeiros relataram que o dispositivo contribuiu no dimensionamento da pr\u00f3pria for\u00e7a e ritmo de compress\u00e3o, aplicando esfor\u00e7os necess\u00e1rios para manter a qualidade das compress\u00f5es, evitar excessos e prevenir o cansa\u00e7o precoce, por considerarem a atividade extenuante, principalmente aos profissionais mais sedent\u00e1rios.Nos resultados encontrados corroborou-se a hip\u00f3tese desta pesquisa, indicando que o uso de dispositivo defeedback, durante a RCP. Tais medidas poder\u00e3o ser \u00fateis para melhor compreender os aspectos que influenciam aperformancee prover recomenda\u00e7\u00f5es no delineamento de diretrizes e protocolos, para elevar a qualidade das manobras nas reanima\u00e7\u00f5es e a sobreviv\u00eancia p\u00f3s-PCR.Os achados s\u00e3o relevantes para identificar o n\u00edvel de esfor\u00e7o despendido no atendimento em PCR e ponderar sobre as medidas de desempenho do profissional, ao prover o SBV com ou sem dispositivo deNessa dire\u00e7\u00e3o, a AHA complementou o estabelecido nas diretrizes de 2015, e em 2018 destacou, em rela\u00e7\u00e3o \u00e0s compress\u00f5es tor\u00e1cicas externas, sobre a possibilidade de revezamento nas compress\u00f5es, a cada 2 minutos \u2013 ou antes se houver cansa\u00e7o \u2013 visando prevenir a fadiga e o cansa\u00e7o, que comprometem a qualidade das manobras, principalmente das compress\u00f5es.2. O aumento dos valores dessas vari\u00e1veis \u00e9 diretamente proporcional \u00e0 percep\u00e7\u00e3o do esfor\u00e7o, evidenciando forte rela\u00e7\u00e3o com a FC, corroborando o identificado no presente estudo. O estresse f\u00edsico gera respostas fisiol\u00f3gicas, com VO2, ventila\u00e7\u00e3o, FC e concentra\u00e7\u00e3o de lactato, cujas altera\u00e7\u00f5es se traduzem em sinais sensitivos que modificam a escala de Borg. \u00c9 uma m\u00e9trica de f\u00e1cil aplica\u00e7\u00e3o e baixo custo; empregada em diversas \u00e1reas, inclusive esporte de alto rendimento e reabilita\u00e7\u00e3o. Permite monitorar altera\u00e7\u00f5es nos sistemas cardiorrespirat\u00f3rio, metab\u00f3lico, neuromuscular, decorrentes do exerc\u00edcio f\u00edsico.Para avaliar a percep\u00e7\u00e3o do esfor\u00e7o na RCP, a escala de Borg tem sido aplicada em diferentes contextos, como ferramenta de monitora\u00e7\u00e3o n\u00e3o invasiva da intensidade de esfor\u00e7o f\u00edsico. Est\u00e1 relacionada com vari\u00e1veis fisiol\u00f3gicas, como intensidade do exerc\u00edcio, FC e consumo de oxig\u00eanio - VO dentro da c\u00e2mara hipob\u00e1rica, simulando PCR em grandes altitudes, deteriora a condi\u00e7\u00e3o do reanimador, com maior percep\u00e7\u00e3o do esfor\u00e7o e cansa\u00e7o. Analogamente ocorre em RCP simulada em ambiente aeroespacial de microgravidade e no interior de ve\u00edculos em movimento, mais exaustivo no interior de helic\u00f3ptero do que na ambul\u00e2ncia.No contexto da reanima\u00e7\u00e3o, in\u00fameros estudos aplicaram a escala de Borg em diversos cen\u00e1rios. Em simula\u00e7\u00e3o de PCR em \u00e1reas montanhosas, a escala indicou que RCP com compress\u00f5es cont\u00ednuas em ambiente hip\u00f3xico, A percep\u00e7\u00e3o de esfor\u00e7o foi maior e sensa\u00e7\u00e3o de fadiga geral em RCP inclusive com compress\u00f5es cont\u00ednuas, em rela\u00e7\u00e3o aos ciclos de 30:2, durante 30 minutos.A avalia\u00e7\u00e3o da percep\u00e7\u00e3o de esfor\u00e7o em RCP realizada em diferentes ciclos fornece informa\u00e7\u00f5es importantes na compreens\u00e3o da exaust\u00e3o f\u00edsica e a rela\u00e7\u00e3o com a qualidade da reanima\u00e7\u00e3o. Em ciclos de 30:2 e 15:2, durante dois minutos, a fadiga foi semelhante em ambos, com piora da qualidade das compress\u00f5es em ciclos mais longos.Hawthornen\u00e3o pode ser descartado, ainda que os dados obtidos no registro de frequ\u00eancia card\u00edaca sejam mais objetivos.Na aplica\u00e7\u00e3o da escala de Borg, cabe ressaltar a import\u00e2ncia da familiariza\u00e7\u00e3o pr\u00e9via com o instrumento para que os escores indicados pelos participantes correspondam \u00e0 percep\u00e7\u00e3o mais pr\u00f3xima da realidade. Por vezes, o participante expressa um valor, equivalente \u00e0 menor percep\u00e7\u00e3o de esfor\u00e7o, quando na realidade, a manifesta\u00e7\u00e3o de esfor\u00e7o respirat\u00f3rio e cansa\u00e7o parece denotar correspond\u00eancia a outro valor mais alto. Ciente de que est\u00e1 participando de uma simula\u00e7\u00e3o avaliativa, o efeito No presente estudo, verificou-se eleva\u00e7\u00e3o acentuada da percep\u00e7\u00e3o de esfor\u00e7o nos dois primeiros minutos, alguns profissionais quase chegaram ao n\u00edvel de exaust\u00e3o. J\u00e1 os enfermeiros praticantes de atividades f\u00edsicas regulares relataram menor cansa\u00e7o durante as compress\u00f5es.Considerando que a qualidade das manobras de reanima\u00e7\u00e3o \u00e9 dependente da condi\u00e7\u00e3o f\u00edsica da pessoa que realiza as compress\u00f5es, cansa\u00e7o e fadiga s\u00e3o fatores que podem influenciar e por vezes comprometer, negativamente, na sobreviv\u00eancia do assistido. Dentre as estrat\u00e9gias de monitoramento, os dispositivos defeedbacks\u00e3o recursos tecnol\u00f3gicos que permitem o acompanhamento do desempenho na RCP, em rela\u00e7\u00e3o a diversos par\u00e2metros, como taxa de compress\u00e3o e profundidade, fra\u00e7\u00e3o de fluxo, frequ\u00eancia e volume de ventila\u00e7\u00e3o, entre outros e s\u00e3o empregados como indicadores de qualidade na an\u00e1lise dos atendimentos de PCR.O monitoramento da qualidade da RCP, em PCR intra e extra-hospitalar, ainda \u00e9 um desafio. Envolve m\u00e9tricas tradicionais de taxa e profundidade de compress\u00e3o tor\u00e1cica e recuo do t\u00f3rax, mas tamb\u00e9m inclui par\u00e2metros como a fra\u00e7\u00e3o de compress\u00e3o tor\u00e1cica, evitando ventila\u00e7\u00e3o excessiva, din\u00e2mica da equipe de ressuscita\u00e7\u00e3o e desempenho do sistema no monitoramento da qualidade.softwarese sensores de press\u00e3o, para avalia\u00e7\u00e3o de compress\u00f5es e ventila\u00e7\u00f5es, em treinamentos ou atendimentos em tempo real. Com o avan\u00e7o da tecnologia vest\u00edvel, recursos do tipowearablevisam evitar iatrogenias e les\u00e3o de pele durante as compress\u00f5es, e facilitar o posicionamento das m\u00e3os, considerando que em cerca de dois ter\u00e7os das reanima\u00e7\u00f5es h\u00e1 falhas na posi\u00e7\u00e3o. OSmartwatchcom aplicativo fornecefeedbackaudiovisual em tempo real; em simula\u00e7\u00e3o de RCP em ciclos de 30:2, por dois minutos, as taxas de compress\u00e3o, profundidade e porcentagem de RCP de alta qualidade foram significativamente melhores no grupo interven\u00e7\u00e3o. Assim como no presente estudo, a din\u00e2mica de simula\u00e7\u00e3o foi similar e ap\u00f3s a pr\u00e1tica, os enfermeiros referiram que o dispositivo ajuda a controlar a for\u00e7a empregada nas compress\u00f5es, reduzindo o esfor\u00e7o e menor percep\u00e7\u00e3o do cansa\u00e7o.Existem diversos tipos de dispositivos, desde os mais simples, como metr\u00f4nomos, aos mais complexos, como desfibriladores e simuladores integrados comfeedbackreceberam destaque nas diretrizes AHA/2020, considerando a import\u00e2ncia da avalia\u00e7\u00e3o precisa das habilidades e dofeedbackpara melhorar o desempenho subsequente. Infelizmente, o desempenho inadequado da RCP \u00e9 comum, ainda que seja dif\u00edcil para os provedores e instrutores detect\u00e1-lo, dificultando o direcionamento apropriado e a melhora do desempenho futuro. A recomenda\u00e7\u00f5es buscam equilibrar o benef\u00edcio potencial do desempenho aprimorado da RCP com o custo do uso dos dispositivos.Aplicando a tecnologia na reanima\u00e7\u00e3o, os dispositivos deDentre os desafios no manejo da PCR, enfatiza-se a educa\u00e7\u00e3o, desde a de forma\u00e7\u00e3o at\u00e9 a permanente aos profissionais; \u00e9 fundamental para melhorar a reten\u00e7\u00e3o do aprendizado, a habilidade na pr\u00e1tica das manobras e diminuir as barreiras para a a\u00e7\u00e3o dos provedores de Suporte B\u00e1sico e Avan\u00e7ado de Vida \u2013 SBV e SAV. Na discuss\u00e3o sobre as inadequa\u00e7\u00f5es dos modelos de cursos, a efetividade das a\u00e7\u00f5es educativas \u00e9 relacionada com o modelo de aprendizagem, a abordagem aprendizagem espacial, a maior frequ\u00eancia na oferta de refor\u00e7o em treinamentos r\u00e1pidos com menor tempo de dura\u00e7\u00e3o para pr\u00e1tica deliberada e maestria, utilizando dispositivos de feedback de RCP.Utilizar um manequim em pr\u00e1tica simulada envolve uma din\u00e2mica de atendimento diferente da vida real, o que pode trazer diferencia\u00e7\u00e3o em rela\u00e7\u00e3o aos resultados encontrados. O risco de efeito Hawthorne n\u00e3o pode ser descartado. Os participantes relataram dificuldade na respira\u00e7\u00e3o e aumento da sensa\u00e7\u00e3o de cansa\u00e7o, em raz\u00e3o do permanente uso de m\u00e1scara, na pandemia por COVID-19, o que pode influenciar nos resultados.feedbackinfluenciou na percep\u00e7\u00e3o do esfor\u00e7o e na frequ\u00eancia card\u00edaca, respectivamente registradas por meio da escala de Borg e frequenc\u00edmetro, durante a realiza\u00e7\u00e3o de manobras de SBV em simula\u00e7\u00e3o de PCR em adulto, indicando menor percep\u00e7\u00e3o de esfor\u00e7o e da FC no grupo de enfermeiros que utilizou o dispositivo, independentemente se atuantes em \u00e1reas cr\u00edticas ou n\u00e3o cr\u00edticas.O dispositivo de worldwide. Despite advances in the resuscitation field, since 2012, survival remains at around 8-10%. The understanding of epidemiology is still limited by the lack of global and regional data and reliable records of CPA events, particularly in low- and middle-income countries. The 2020 American Heart Association (AHA) guidelines highlight high-quality cardiopulmonary resuscitation (CPR) as a factor for successful intervention and a higher survival rate.Cardiopulmonary arrest (CPA) is responsible for approximately 17.8 million deaths/yearThe quality of CPR performance depends on different factors, including the rescuer\u2019s physical condition, tiredness, and fatigue, which can compromise survival. Rotation between rescuers every 2 minutes aims to avoid fatigue and poor-quality performance. Fatigue is common after 1 minute of CPR and is usually not identified by the rescuers, even 5 minutes or more after the beginning of the intervention.The measurement of recovery levels can also be analyzed using the Borg scaleafter physical exertion. In the context of CPR, it is used to assess the quality of performance and the chances of improving resuscitation attempts.The Borg rating of perceived exertion scale  can be applied to measure the intensity of physical activity. It is an effective tool to predict performance and define strategies to increase the quality of physical performance.Despite clear evidence that providing high-quality CPR improves resuscitation outcomes, few healthcare organizations apply consistent strategies for monitoring the quality of CPR. Consequently, there is an unacceptable disparity in the quality of care provided and consequent survival rates, reducing the opportunity to save more lives.Feedback devices are encouraged during real-life resuscitation attempts and CPR training.The present study hypothesizes differences in the perception of exertion when providing simulated CPR, with or without feedback devices. It aims to apply the Borg scale to analyze the exertion perceived by nurses during simulated CPR with a feedback device.Randomized controlled trial study to compare the influence of the feedback device on the perception of exertion during simulated CPR performed by nurses, from October to November 2020. Double blinding was not feasible since the researcher herself applied the Borg scale instrument. The variables perception of exertion and heart rate (HR) were measured with a frequency meter, considered a precise sensor that provides good quality measurements. Before using the scale, permission was requested (https://borgperception.se/) and permitted after an explanation of its use for this study. The Research Ethics Committee approved the research.Teaching, public, general, medium-sized, and medium complexity teaching hospital, located in S\u00e3o Paulo, SP, Brazil.Nurses working in critical  and non-critical  adult care units.Nurses from adult care units were included, and those who worked only in administrative activities or as instructors in Basic or Advanced Life Support courses were excluded. In attention to safety, professionals unable to perform or complete the activity in full due to physical limitations or pregnancy or who had symptoms of pain or health problems were also excluded.Presentation of the survey to service managers.Recruitment: e-mail with the research information was sent to the nurses, and consent was obtained before the study began.st) Baseline: verification of Basic Life Support skills. For theoretical alignment and updating of the AHA/2020 guidelines, participants accessed an online course developed by the researcher. 2nd) After the theoretical study, the nurses participated in a second practical activity, like the first.Scheduling and carrying out the practical activity in two stages: 1\u00aefrequency meter was placed on each nurse to measure heart rate (HR). The records stored in the equipment\u2019s internal memory were transferred via Bluetooth to cell phones and tablets, which were later accessed on the website (https://flowpolar.com) and tabulated in anExcel\u00aespreadsheet for information management.According to a computer-generated random distribution list established by the statistician, participants were allocated into two groups, intervention and control. Respectively, they simulated CPA care and Basic Life Support maneuvers, with and without a feedback device. After guidance and briefing on the activity and available resources, presentation and ambiance with the scenario and the instruments to be used, the Polar H10\u00aesimulator manikin with smartphone viewable feedback device (QCPR instructor app) and emergency trolley provided by the hospital containing a rigid board, bag-valve-mask, flowmeter with extension and manual defibrillator in AED mode \u2013Biphasic Defibrillator Zoll\u00aemodel were used.The practical scenario consisted of a) presentation of the clinical case; b) nurse 1 identifies the CPA and starts chest compressions; c) nurse 2 takes over the ventilations and uses the manual defibrillator in AED mode. This continued for 2 minutes; d) pause and rest for 10 minutes in the end, hand and material hygiene, and restart the activity, with role reversal between professionals. The Borg scale was applied when the nurse performed the compressions. Two evaluators monitored each scenario. Little Anne QCPRThe Borg scale was previously presented to the participants for clarification of the criteria and familiarization with the tool. It was used during the practical activity, in the first and second minutes of chest compressions, and after the scenario to assess the recovery from fatigue. The HR values on the frequency meter were recorded. The values of the Borg scale (6-20) used in the present research varied as follows: 6-11 representing the minimum exertion, 12-16 for sustainable exertion and 16-20 for non-sustainable exertion until exhaustion.\u00ae4.1.0 was used, adopting a 5% significance level. Descriptive statistics were used to explore demographics. Variables of interest included the outcome related to the Borg scale perceived exertion score and heart rate variation during CPR. Categorical variables, such as participants\u2019 performance in critical and non-critical units, were described in relative and absolute frequencies. Skewness, Kurtosis and Shapiro-Wilk tests were used to determine normality. Continuous variables showed normal distribution and were described through mean and standard deviation (SD). A mixed effects model was used to compare perceived exertion and HR variables.In the descriptive and inferential statistical analyses, the software ROf the 190 nurses at the institution, 72 (38%) were excluded for working in areas unrelated to the study\u2019s focus. Of the 118 (62%) eligible, 62 (53%) worked in critical units and 56 (47%) in non-critical units. Of these, 49 (41%) were excluded due to health problems, sick leave, remote work due to the COVID-19 pandemic and dismissal from the institution, as shown inSixty-nine nurses were included, 35 (51%) from a critical unit and 34 (49%) from a non-critical unit; three (04%) concluded a doctorate, 15 (22%) a master\u2019s degree, 44 (64%) a specialization and seven (10%) did not have a postgraduate degree. Other classifications of the participants\u2019 profiles are shown inIn the second stage of the study, indicated as post-time, the quantitative descriptions of the values are related to the measurements verified through the Borg scale and the frequency meter during the two minutes of CPR and in the recovery period in both the intervention and control groups. For the perception of exertion, it was found that initially, the average of 6 indicated an absence of tiredness when starting the practical activity. Progressively, at the end of the first minute of CPR, equivalent to five cycles of 30 compressions alternated with two ventilations, the score between 13-14 indicated the perception of moderate fatigue in the tolerable exertion of the activity. At the end of the second minute, after completing about 10 cycles alternating 30 compressions and two ventilations, the score variation 14 indicated moderate exertion, approaching the limit for score 15 in the perception of high intensity and difficulty in performing the activity. In this direction, there was a progressive increase in HR recorded from the initial activity period and during the cycles of 30 compressions and two ventilations.Conversely, in the recovery stage, there was a decrease in the values on the Borg and HR scales, indicating that after four minutes, the perceived exertion score and HR measure approached the values verified at the beginning of the activity, as demonstrated inRegarding nurses working in critical and non-critical units, when analyzing the Borg scale scores in the first and second minutes of CPR, the values varied between 11-13, approaching 14 during CPR performance, indicating an increase in the perception of light to moderate exertion, approaching intense exertion by the end of the second minute. In the recovery period, the decrease in values at the end of the fourth minute was similar in both groups. The means were very similar, suggesting that there was no difference in the perception of exertion and the variation of HR.In the comparative analysis between the variables (perceived exertion and HR), respectively measured through the Borg scale and the frequency meter, the mixed effects model was used, incorporating fixed and random effects simultaneously. Fixed effects are those that do not have variability, such as allocation to a control/intervention group, gender, or the age of a subject , while random effects are subjects and variability in selection. In the context of longitudinal data, it typically corresponds to the subject being evaluated or when several judges are evaluating a set of observations, and these judges are chosen from a larger group.The first stage or baseline was called the \u2018pre\u2019 phase, and the second stage, with randomization of the participants, with or without using the feedback device, was called the \u2018post\u2019 phase. For both variables, the results showed evidence of moment*group interaction, which indicates that the groups probably do not have the same development from the beginning of the procedure to the end of recovery. The control group showed increased perceived exertion, HR, and longer recovery. The intervention group showed lower perceived exertion, HR, and faster recovery, with a significant difference (p<0.001) in performing CPR with a feedback device, as shown inThe results from this study supported the hypothesis that using a feedback device influences physical activity with reduced perceived exertion, measured by the Borg Scale, in the performance of BLS maneuvers during CPR. Additionally, HR is also influenced by the use of a feedback device. At the end of the simulated practice, during the debriefing, several nurses reported that the device contributed to the perception of their own compression strength and rhythm. It enabled them to apply the necessary exertion to maintain the quality of compressions, avoid excesses and prevent early fatigue, as they considered the activity strenuous, especially for more sedentary professionals.The findings are relevant to identifying the level of exertion spent in CPA care and considering the measures of professional performance when providing the BLS with or without a feedback device during CPR. Such measures may be useful to understand better the aspects that influence performance and provide recommendations in the design of guidelines and protocols to improve the quality of maneuvers in resuscitation and post-CPA survival.In this direction, the AHA complemented what was established in the 2015 guidelines and highlighted in 2018 the possibility of alternating rescuers every 2 minutes - or sooner if there is fatigue \u2013 during CPR performance. This is in an attempt to prevent fatigue, which can compromise the quality of CPA care maneuvers, especially chest compressions.2. The increase in the values of these variables is directly proportional to the perception of exertion, showing a strong relationship with HR,supporting what was identified in the present study. Physical stress generates physiological responses, with VO2, ventilation, HR and lactate concentration, whose changes translate into sensitive signals that modify the Borg scale.It is an easy-to-apply and low-cost tool; used in various areas, including high-performance sports and rehabilitation. It allows monitoring changes in the cardiorespiratory, metabolic, and neuromuscular systems resulting from physical exercise,To assess perceived exertion in CPR, the Borg scale has been applied in different contexts as a tool for non-invasive monitoring of physical exertion intensity. It is related to physiological variables, such as exercise intensity, HR, and oxygen consumption - VOinside a hypobaric chamber, simulating CPR at high altitudes, deteriorates the rescuer\u2019s condition, with a greater perception of exertion and fatigue.Similar results are found in simulated CPR conducted in a microgravity aerospace environmentor inside moving vehicles, with more exhaustion perceived inside a helicopter than in an ambulance.In the context of resuscitation, several studies used the Borg scale in different scenarios. In two CPR simulation studies conducted in mountainous areas, the Borg scale indicated that CPR with continuous chest compressions in a hypoxic environment,However, the perception of exertion and the feeling of general fatigue during CPR performance was greater when 30:2 cycles were used for 30 minutes.The assessment of perceived exertion during CPR performed in different compression: and ventilation cycles provides important information in understanding physical exhaustion and its relationship with the quality of resuscitation attempts. During two minutes of CPR using 30:2 and 15:2 cycles, fatigue was similar in both, with worsening quality of compressions in longer cycles.It is worth highlighting the importance of prior familiarization with the tool so that the scores indicated by the participants using the Borg scale correspond to the closest perception of reality. Sometimes, participants may express a value equivalent to the lowest perception of exertion when in reality, the manifestation of respiratory exertion and fatigue seems to represent a higher value in the Borg scale. This may be explained by the Hawthorne effect, as participants know they were participating in an evaluative simulation study. Therefore, this phenomenon cannot be ruled out, even though the data obtained from HR recordings are more objective.In the present study, there was a marked increase in perceived exertion in the first two minutes, with some professionals almost reaching the level of exhaustion. Not surprisingly, nurses who practice regular physical activities reported less fatigue during chest compressions.Considering that the quality of resuscitation maneuvers depends on the physical condition of the person performing CPR, tiredness and fatigue are factors that can influence and sometimes negatively compromise the survival of the assisted person.Among the monitoring strategies, feedback devices are technological resources that allow assessment and quality indicators of CPR performance concerning several metrics, including compression rate, depth, flow fraction, ventilation frequency and volume.Monitoring CPR quality for in-hospital and out-of-hospital cardiac arrest is still a challenge. It involves traditional metrics such as chest compression rate, depth, and chest recoil but also includes parameters such as chest compression fraction, avoiding excessive ventilation, dynamics of the resuscitation team, and system performance for quality monitoring.With the advancement of technology, wearable devices aim to avoid iatrogenic and skin injuries during chest compressions and facilitate hand positioning, potentially improving this metric. This is an important function considering that about two-thirds of resuscitation attempts present failures in the hand position.Smartwatch with CPR-related apps, for example, provides real-time audio-visual feedback during CPR performance. A study from Cheng et al. demonstrated that during simulated CPR using the 30:2 cycles for two minutes, compression rate, depth and percentage of high-quality CPR were significantly better in the intervention group.As in the present study, CPR performance was similar in the intervention and control groups; however, after the scenario, the nurses reported that the device helped to control the force used during compressions, reducing the exertion and lessening the perception of fatigue.There are several types of feedback devices, from the simplest, such as metronomes, to the most complex, such as defibrillators and simulators integrated with software and pressure sensors, for evaluation of compressions and ventilations.Feedback devices have been highlighted in the AHA 2020 guidelines, considering the importance of accurate assessment of skills and feedback to improve subsequent performance. Unfortunately, poor CPR skills are still common, and it is challenging for providers and instructors to detect poor quality performance, making it difficult to target and improve future performance properly. Finding the balance between the potential benefit of improved CPR performance and the cost of investing in wearable devices is still recommended.Among the challenges in managing CPA, education is also emphasized, from training to the retention of CPR skills. It is essential to improve learning, maximize skill retention and reduce barriers to initiating Basic and Advanced Life Support. Evidence about the inadequacies of the training models suggests that the effectiveness of the educational actions, such as CPR knowledge and skills, is related to the training model. Different approaches have been suggested, including spaced learning, distributed or low-dose high-frequency practice, and mastery learning using feedback devices to reinforce knowledge and skills during CPR performance.Using a mannequin in simulated practice involves different care dynamics from real-life performance, which could affect the results. The risk of the Hawthorne effect cannot be ruled out. Participants reported difficulty in breathing and increased feelings of fatigue due to the permanent use of a mask during the COVID-19 pandemic, which could have influenced the results.The feedback device influenced the perception of exertion and heart rate, respectively recorded using the Borg scale and frequency meter, during the performance of BLS maneuvers in adult CPA simulation. The results indicated a lower perception of exertion and HR in the group of nurses who used the device, whether working in critical or non-critical areas."}
+{"text": "To evaluate the effect of an educational intervention on the attitudes of primary healthcare providers regarding patients with suicidal behavior. Clinical trial randomized by clusters, with a sample of 261 healthcare professionals, from 22 health units selected by stratified sampling, were chosen and randomly allocated, by drawing, into two groups: intervention (n = 87) and control (n = 174). The participants of the intervention group were exposed to a 20-hour training on suicidal behavior. All 261 participants were evaluated before and after the intervention; the groups were compared to evaluate their attitude towards suicidal behavior using the Suicide Behavior Attitude Questionnaire (SBAQ), an evaluation made by comparison of the means via t-Student test, for independent samples, and paired t-test, for dependent samples. The intervention group, in comparison to their evaluation before and after training, as well as in the comparison with the evaluation of the control group, showed statistically significant differences in attitudes towards suicidal behavior, according to the differences presented in the scores for the domains: \u201cperception of professional capacity,\u201d in all four items; \u201cnegative feeling,\u201d in six of the seven items; and in the \u201cright to commit suicide\u201d domain, in three of the five items. The brief training developed in primary health care was effective to improve the attitudes of the participants who were part of the intervention group regarding patients with suicidal behavior. Although the suicide mortality rate in some Western European countries has decreased in recent decades, other countries, such as Mexico, the United States, and Brazil, experienced an increase in cases during the same period2. According to national data, more than 10,000 Brazilians committed suicide, meaning 5.5 occurrences per 100,000 inhabitants, in 2015, and 6.5 deaths per 100,000 inhabitants, in 2016, proving an increase over the years3. Considering the magnitude of the problem, the World Health Organization \u2013 WHO recommends that the prioritization of suicide, both in the care offered and in the development of public health policies1.Approximately 800,000 people commit suicide annually, which corresponds to a rate of 11.4 deaths per 100,000 inhabitants worldwide, being among the top ten death causes in all age groups4. This is directly related to the insufficient number of professionals in the psychosocial care network to meet this demand, especially in middle-income countries, such as Brazil, where the coverage of these services encompass only 10% of the individuals who need it4.In this context, the mobilization of the health services is inevitable, since the primary care environment often provides the initial actions for mental health care5. Similar findings were described in a Norwegian study that investigated the use of primary healthcare services in 4,926 suicide cases (subjects aged > 15 years) from 2007 to 2015. The results showed that approximately 90% of the individuals consulted a generalist professional in primary care in the year prior to suicide and up to 46.4% in their last month of life6.A systematic review analyzed the contact individuals had with primary healthcare providers before committing suicide and the results showed that, on average, 80% sought the health service in the year prior to suicide and 44%, in the same month of death1. Most professionals, however, manifest negative attitudes when dealing with people with suicidal behavior7, commonly due to factors such as unpreparedness or difficulties in dealing with this demand, providing limited initial care, and often referring patients to other services10, compromising the quality of care provided.This suggests that professionals of this level of care are in a unique position to identify and intervene in subjects at suicidal risk, since primary health care is the first contact with the health network11.An attitude can be defined as a set of cognitive, affective, and behavioral attributes. Therefore, attitude is an inclination of the individual \u2013 acquired socially, from personal experiences, and from personality factors \u2013 to act in a specific way in relation to certain people, objects, and situations12. Corroborating these findings, subsequent studies observed a resistance in attending this clientele; care based on beliefs and stigmas; technical and routine activities prioritized over psychological support; deficient knowledge and skills; in addition to the need for training to facilitate therapeutic relationships13.In a meta-analysis that reviewed studies developed until 2018, negative attitudes, limited empathy, and some levels of hostility were observed from healthcare providers when attending to people with suicidal behavior. The data also indicated that training and professional qualification on how to deal with these cases promote more positive attitudes16.Studies that propose to analyze the effects of educational strategies on the modification of attitudes, although scarce in the Brazilian and international literature, show a predominance in interventions that have the hospital environment as the targeted audienceThus, this study questions: can the attitudes of primary healthcare providers be modified after professional training on dealing with suicidal behavior? To answer this question, our study aims to evaluate the effect of an educational intervention on the attitudes of primary healthcare providers regarding suicidal behavior.This is a two-arm parallel randomized controlled trial inscribed in the Brazilian Registry of Clinical Trials (ReBEC) under the code RBR-9pmjf5w.23.Developed in the city of Cuiab\u00e1, from May to August 2017, in Family Health Strategy (FHS) units, structured by multidisciplinary teams, composed of at least one nurse, a general practitioner or family doctor, a nursing technician, and community health agents, and can also have an expanded team, including oral health professionals. The city of Cuiab\u00e1, in the state of Mato Grosso, has 70 FHS teams, 3 in the rural area of the municipality and 67 in the urban area, distributed in four regions: 24 units in the northern region, 21 in the southern, 11 in the eastern, and 11 in the western. Totaling 298 healthcare providers, including physicians, nurses, and nursing technicians; 697 community health agents; and 86 oral health professionalsThe study population consisted of healthcare providers who functioned as physician, nurses, and nursing technicians; excluding from the study professionals from teams located in the rural area (since they composed the pilot test sample of this study), as well as health agents and oral health professionals (since the instrument used does not target these categories).A probabilistic sampling was obtained by clustering and stratification; the sampling unit was the health team, composed of a group of professionals, which was stratified by regional health units.24, in which the mean of the changes in attitude (pre- and post-intervention) and the standard deviations, obtained from a reference study, were determined25. A standard deviation of 2.92 was estimated, considering a minimum difference to be detected of 1.0, 95% confidence, and power of 0.80. Thus, the initial sample size adjusted for population (n = 298) was 56 individuals. Since it is a cluster sampling design, a design effect factor was established at 1.22 and an estimated non-response rate was estimated at 22%, which resulted in a final sample of 87 individuals for the intervention group. For the control group, 1 for 2 was considered, i.e., 174 individuals.To determine the number of subjects, a formula was used for paired dataThe random selection of participants for the intervention and control groups was performed by cluster sampling and stratification proportional to the size of the population, considering the regions  as strata and the FHS teams as randomization units, in order to obtain adequate control and reduce methodological bias. The number of professionals selected in each region was defined by multiplying the fraction of professionals by the sample size (87). Subsequently, to define the number of teams to be drawn, the number of healthcare providers per stratum was divided by the number of teams (four), totaling 22 teams randomly drawn by statistical program .26. This instrument is divided into factors relating to the feelings professionals have in relation to the patient with suicidal behavior, their self-perception on capacity for care, and the right to suicide. Investigating these factors allows for the positive or negative attitudes to be measured. According to the mean obtained by adding the values of each question and diving by the total number of questions in each domain, we can verify a more positive attitudes by the higher scores for the domain \u201cPerception of professional capacity\u201d and by the lower scores for the domains \u201cFeelings towards the patient\u201d and \u201cRight to suicide26.\u201d To verify other variables, such as sociodemographic , professional background , and professional practice ; a closed instrument was constructed, applied with the SBAQ.The Suicide Behavior Attitude Questionnaire (SBAQ), composed of clinical situations frequently experienced by healthcare providers, was used to identify the professional\u2019s attitude towards suicidal behaviorAt first, all participating units were visited in order to inform about the study and apply the instruments. The professionals selected for the intervention group, were invited to participate in the intervention (training) in addition to answering the instruments (pre-test). The questionnaires were previously coded and allowed pairing, it did not allow, however, for the personal identification of the participants. The participants who were absent from the health unit at the first attempt were sought two more times, at different moments. Whenever possible and necessary, visits were scheduled.Subsequently, the intervention group was offered a 20-hour training, aiming to improve the ability to recognize the degree of risk of an individual with suicidal behavior and to intervene; to learn strategies to care for and/or to refer individuals with suicidal behavior; and to recognize and improve one\u2019s own attitude towards a patient with suicidal behavior. The content was defined according to the manual of suicide prevention aimed at primary healthcare teams of the World Health Organization. The training was conducted by psychologists and researchers in Suicidology, with extensive clinical and pedagogical experience in this topic. Immediately after the end of the training, the SBAQ was reapplied to the intervention group (post-test). For the control group, no type of intervention was offered, and the post-test was reapplied later in the health units.The expected primary outcome was a difference in the level of attitudes towards suicidal behavior between the beginning and end of the intervention, verified through the SBAQ, based on the increase of scores equal to or greater than 3%; the analysis was performed on the principle of intention to treat.The distribution of the data was verified by the Shapiro-Wilk test. To compare the two groups, Pearson\u2019s chi-square homogeneity test, t-student test for two independent samples, and U-Mann Whitney test were used. Comparison within the pre- and post-intervention group were performed by the paired t-test for dependent samples and by the Wilcoxon signed-rank test. The level of significance adopted was 5% for all tests. The research project was approved by the research ethics committee in accordance with Resolution 466/2012.The analysis of sociodemographic data, of previous training, and of attending to suicidal behavior  showed n12.The literature shows that the care given to patients with suicidal behavior can be influenced by several factors, among which are the attitudes of healthcare providers27. Additionally, suicide behavior is surrounded by myths and beliefs, such as those that classify suicide attempts and threats as forms of seeking attention and not as actual intention, or even that people with this behavior are considered cowards31. An attitude is subject to change, which can be evidenced in our study; regarding the \u201cfeeling in relation to the patient,\u201d the post-intervention evaluation showed changes for all items in this domain. These findings demonstrated changes in the understanding of suicidal attempts and threats as potential risk factors and that people in these conditions are in intense suffering, providing a more empathic postures in relation to these patients.Attending to patients with suicidal behavior can lead to feelings of frustration, impotence, guilt, contempt, and anger31. The lack of desire to live can be conflicting for professionals, since they are instructed to save lives. Thus, aspects such as overcoming the dilemmas of omnipotence and omniscience, which usually cause distress in these situations, were widely discussed in training.The fact that the professional reacts negatively when attending to a patient with suicidal behavior may, among other aspects, be related to the training process that often does not provide tools for coping with situations of death, especially when associated with the subject\u2019s choice32. However, the discussions generated during the training showed that the professionals were less elusive in getting involved and establishing bonds with patients who attempted suicide and presented a reduction in the feeling of impotence. This may explain the significant changes in the questionnaire responses in this factor.Another aspect that was raised is that the feeling of anxiety, due to a possible error of conduct or evaluation, and the idea of responsibility over the patient\u2019s life can be expressed by the difficulty in establishing a bond or in the fear of talking about suicide for fear of inducing the patient to commit it19.Perceiving one\u2019s own negative feelings as defense mechanisms, considering death as part of human existence, and identifying the feelings involved in the process of death and dying were a part of the methodology employed and favored the understanding and modification of feelings among professionals. These findings corroborate the study developed with healthcare providers in which, after training, a significant reduction in negative feelings and better accuracy in risk assessment were found33.On the \u201cperception of professional capacity,\u201d the findings showed self-perception of greater capacity for care, better professional preparation, and confidence to deal with patients at risk of suicide. Similar results are found in a Japanese multicenter study that performed a two-hour intervention with 74 healthcare providers. There were significant increases in perceived skills, confidence, and attitude, as well as a greater competence in the assessment of suicidal risk, and more confidence in attending to patients in these conditions21. The literature has emphasized that negative attitudes towards suicidal patients among healthcare providers may be more related to lack of knowledge and uncertainties in how to care for than to a specific hostility20. Thus, misinformation about suicide can perpetuate a mistaken approach.A study conducted in Australia, in which 248 health professionals participated in a training on suicidal behavior, resulted in improved knowledge, more appropriate attitudes regarding expansion of communication capacity, and increased confidence in providing appropriate care17.Continuously updated knowledge, especially regarding the assessment of suicidal risk and treatment options, can decrease anxiety about failures and increase the perception of professional capacity. As professionals understand and fulfill their responsibilities in identifying, evaluating, and intervening therapeutically, performing professionally according to evidence, and planning the follow-up of a person at suicidal risk, they become aware that the factors related to professional skills and competences have been contemplated34.Healthcare providers live alongside suffering, pain, fear, hopelessness, losses in various ways and often face the processes of death and dying. Feeling helpless and powerless is common in these situations. The belief that only cure or recovery characterizes as good care, emphasized during academic training and reiterated daily by the culture of therapeutic obstinacy, may contribute to professional insecurity when faced with situations that signal a possible self-inflicted death35.Several authors also highlight the influence of organizational issues of the service, as well as the scarcity of physical structure and especially trained personnel, demonstrating the difficulties and fears of not having resources in the face of the unexpected. During the training, several factors such as those reported above were described as limiting an effective care, accompanied by feelings of insecurity, helplessness, and incompetence. It was emphasized, however, that the fear of error can be gradually replaced by the confidence to intervene when limits and potentials are recognized21.The third component investigated in our study refers to the \u201cright to suicide,\u201d in which we observed changes in three of its five items, in the evaluation after intervention. However, one of the items in which no significant changes were observed was the statement: \u201cdespite everything, I think a person has the right to suicide.\u201d An Australian study described similar result after a one-day training: in which only 30% agreed with the right to commit suicide. According to the authors, these findings reflect the nature of the items that make up this factor  are deeply ingrained, with less expectation of modifications, even after an educational intervention34.A healthcare providers should not prioritize their individual principles and convictions when attending a person with suicidal behavior, with the risk of inducing them to adapt to social standards, based on their personal values and beliefs that may not be relevant to the patient, endangering the therapeutic bond necessary for care. Thus, the care provided cannot, in any way, intensify the feeling of guilt in the person with suicidal ideation or tendency and in their familiesWhen asked about the possibility of changing a suicide intention by means of a conversation, significant positive effects were perceived after training. However, in the statement \u201cwhen a person talks about ending their life, I try to get it out of their head,\u201d which assumes that the professional themselves are actively involved in the event, the results were not statistically significant. A possible explanation for this refers to the fact that, although the professional believes in the possibility of prevention using therapeutic communication, they do not recognize themselves as an essential element in this process.35. Focusing exclusively on the biological aspects and investing in technological resources as alternatives for prolonging life avoid, to some extent, not only contact with death but also a therapeutic communication that could give access to the patient\u2019s feelings. Thus, indirectly, healthcare providers avoid contact with their own death and with their own emotions34.Dealing with death triggers countless reactions in humans, among them the perception of finitude itself. Focusing on exclusively technical, bureaucratic, and routine issues when it comes to this theme is part of a posture of denying death, to the extent that it provides power to the healthcare provider and softens the feeling of impotence35.Refusing to speak or think about death is, in a way, comforting since it feeds a fantasy that death can be driven away by not manifesting it with either words or thoughts. The death of the other is characterized as an announcement and anticipation of one\u2019s own death \u2013 a threat \u2013 and suicide also translates into a mutilation within society by breaking its natural course, stirring the moral bases31.Suicide, since it involves biological, cultural, and social aspects, demands that educational interventions comprise, in addition to clinical management, an understanding of the psychological distress factors that are involved, which are key elements for the therapeutic approach of the multidisciplinary team. Moreover, it is necessary to rethink suicide prevention strategies to provide knowledge that leads to a gaze less regulated by judgments and moral rules, so that the person who experiences this suffering can be welcomed in any context, allowing better conditions for recovery and social rehabilitationThis study presents as limitation the difficulty of comparative analyses with other interventions, both because they are scarce in the literature and because they differ substantially in relation to the target audience, content taught, teaching-learning methodologies, or forms of result analysis. However, our contributions lie in the type of experimental design that, by raising awareness to the role of the health professional and to the improvement of knowledge about suicidal behavior, has promoted positive change in attitudes and allowed the perception of capacity and confidence to increase regarding the care for these patients, as suggested by the results.More positive attitudes were observed among professionals towards suicidal behavior after the intervention. This finding contributes to the quality of care in primary care and reinforces the feasibility of training to prevent this condition in the population. Thus, the data evidenced are relevant both for scientific production and for the reality of the services within in the Brazilian Unified Health System.The results found in this study are in line with the existing literature and collaborate with the current scientific panorama, as they provide support for the development of strategies that contribute to the reduction of the high rates of attempts and suicides in the country.We suggest for new studies to conduct sequential evaluation or follow-up, observing whether such changes are sustained along the timeline; in addition to verifying the duration of educational intervention programs, aiming to optimize the time spent in such programs, as well as the contents addressed for validation of standardized educational material in order to test and replicate such results in other populations. 1. Embora a taxa de mortalidade por suic\u00eddio em alguns pa\u00edses da Europa Ocidental tenha diminu\u00eddo nas \u00faltimas d\u00e9cadas, outros pa\u00edses, como M\u00e9xico, Estados Unidos e Brasil, experimentaram um aumento dos casos durante o mesmo per\u00edodo2. De acordo com dados nacionais, mais de 10 mil brasileiros se suicidaram, ou seja, 5,5 ocorr\u00eancias a cada 100 mil habitantes em 2015 e em 2016, 6,5 \u00f3bitos para 100 mil habitantes, comprovando um crescimento ao longo dos anos3. Considerando a magnitude do problema, a OMS recomenda que o suic\u00eddio seja priorizado tanto no atendimento oferecido quanto no desenvolvimento de pol\u00edticas de sa\u00fade p\u00fablica1.Aproximadamente 800 mil pessoas cometem suic\u00eddio anualmente, o que corresponde a uma taxa de 11,4 mortes a cada 100 mil habitantes em todo o mundo, figurando entre as dez principais causas de morte em todas as faixas et\u00e1rias4. Tal fato relaciona-se diretamente ao n\u00famero insuficiente de profissionais na rede de aten\u00e7\u00e3o psicossocial para atender a essa demanda, sobretudo em pa\u00edses de m\u00e9dia renda, como o Brasil, em que a cobertura de servi\u00e7os dessa natureza atende somente a 10% dos indiv\u00edduos que necessitam4.Frente a esse contexto, \u00e9 inevit\u00e1vel que os servi\u00e7os de sa\u00fade sejam acionados, sendo as a\u00e7\u00f5es iniciais de cuidados em sa\u00fade mental, frequentemente prestadas em ambiente da aten\u00e7\u00e3o b\u00e1sica5. Achados semelhantes foram descritos em um estudo noruegu\u00eas, que investigou a utiliza\u00e7\u00e3o dos servi\u00e7os de sa\u00fade da aten\u00e7\u00e3o prim\u00e1ria em 4.926 casos de suic\u00eddio (sujeitos com idade > 15 anos) durante o per\u00edodo de 2007 a 2015. Os resultados comprovaram que aproximadamente 90% dos indiv\u00edduos consultaram um profissional generalista na aten\u00e7\u00e3o prim\u00e1ria no ano anterior ao suic\u00eddio e at\u00e9 46,4% no \u00faltimo m\u00eas de vida6.Uma revis\u00e3o sistem\u00e1tica analisou o contato dos indiv\u00edduos com profissionais de sa\u00fade da aten\u00e7\u00e3o prim\u00e1ria antes de cometer suic\u00eddio e os resultados evidenciaram que, em m\u00e9dia, 80% procuraram o servi\u00e7o de sa\u00fade no ano anterior ao suic\u00eddio, e 44% no mesmo m\u00eas do \u00f3bito1. Entretanto, grande parte dos profissionais, frente a pessoas com comportamento suicida, manifestam atitudes negativas7, comumente em decorr\u00eancia de fatores como despreparo ou dificuldades em lidar com essa demanda, proporcionando um atendimento inicial limitado e frequentemente revertido em encaminhamentos protocolares a outros servi\u00e7os10, comprometendo a qualidade do cuidado prestado.Isso sugere que os profissionais desse n\u00edvel de aten\u00e7\u00e3o est\u00e3o em uma posi\u00e7\u00e3o \u00fanica para identificar sujeitos em risco suicida e intervir, uma vez que a aten\u00e7\u00e3o prim\u00e1ria \u00e0 sa\u00fade configura-se porta de entrada na rede de sa\u00fade11.Uma atitude pode ser definida como um conjunto de atributos cognitivos, afetivos e comportamentais. Portanto, a atitude \u00e9 uma inclina\u00e7\u00e3o do indiv\u00edduo a agir de modo espec\u00edfico em rela\u00e7\u00e3o a determinadas pessoas, objetos e situa\u00e7\u00f5es, adquirida socialmente, a partir de experi\u00eancias pessoais e de fatores de personalidade12. Outros estudos, realizados posteriormente, corroboram esses achados, tamb\u00e9m em rela\u00e7\u00e3o \u00e0 resist\u00eancia em atender essa clientela; ao cuidado pautado por cren\u00e7as e estigmas; \u00e0s atividades t\u00e9cnicas e rotineiras priorizadas em detrimento de suporte psicol\u00f3gico, conhecimento e habilidades deficientes, al\u00e9m da necessidade de treinamento visando facilitar as rela\u00e7\u00f5es terap\u00eauticas13.Uma metan\u00e1lise realizada com pesquisas desenvolvidas at\u00e9 o ano de 2018 apontou atitudes negativas, empatia limitada e algum n\u00edvel de hostilidade dos profissionais de sa\u00fade no atendimento \u00e0s pessoas com comportamento suicida. Os dados indicaram ainda que treinamento e capacita\u00e7\u00e3o sobre como lidar com esses casos promovem atitudes mais positivas16.Dos estudos que se prop\u00f5em a analisar os efeitos de estrat\u00e9gias educativas na modifica\u00e7\u00e3o das atitudes, ainda que escassos na literatura brasileira, mesmo internacionalmente observa-se predom\u00ednio de interven\u00e7\u00f5es tendo o ambiente hospitalar como p\u00fablico-alvoDiante do exposto, este estudo questiona: as atitudes dos profissionais de sa\u00fade da aten\u00e7\u00e3o prim\u00e1ria poder\u00e3o ser modificadas ap\u00f3s uma capacita\u00e7\u00e3o profissional para o atendimento ao comportamento suicida? No intuito de alcan\u00e7ar a resposta para tal indaga\u00e7\u00e3o, este artigo tem como objetivo avaliar o efeito de uma interven\u00e7\u00e3o educativa sobre comportamento suicida nas atitudes dos profissionais de sa\u00fade da aten\u00e7\u00e3o prim\u00e1ria.Este \u00e9 um ensaio cl\u00ednico randomizado controlado, de aloca\u00e7\u00e3o paralela, com dois bra\u00e7os, inscrito no Registro Brasileiro de Ensaios Cl\u00ednicos (ReBEC) sob o c\u00f3digo RBR-9pmjf5w.23.Desenvolvido no munic\u00edpio de Cuiab\u00e1, no per\u00edodo de maio a agosto de 2017, nas unidades de estrat\u00e9gia de sa\u00fade da fam\u00edlia (ESF), que se estruturam equipes multiprofissionais, composta por no m\u00ednimo um enfermeiro, um m\u00e9dico generalista ou de fam\u00edlia, um t\u00e9cnico de enfermagem e agentes comunit\u00e1rios de sa\u00fade (ACS), podendo contar ainda com equipe ampliada, comportando profissionais de sa\u00fade bucal. O munic\u00edpio de Cuiab\u00e1-MT possui 70 equipes de ESF, sendo tr\u00eas na zona rural do munic\u00edpio e 67 da zona urbana, distribu\u00eddas em quatro regionais: 24 unidades na regional norte, 21 na sul, 11 na leste e 11 na regional oeste. Totalizando 298 profissionais de sa\u00fade, entre m\u00e9dicos, enfermeiros e t\u00e9cnicos de enfermagem, 697 agentes comunit\u00e1rios de sa\u00fade e 86 profissionais de sa\u00fade bucalA popula\u00e7\u00e3o do estudo consistiu em profissionais de sa\u00fade que exerciam a fun\u00e7\u00e3o de m\u00e9dico, enfermeiro e t\u00e9cnico de enfermagem, excluindo do estudo profissionais de equipes localizadas na zona rural, pois compuseram a amostra de teste piloto no presente estudo, al\u00e9m de agentes de sa\u00fade e profissionais de sa\u00fade bucal (uma vez que o instrumento utilizado n\u00e3o se direciona para tais categorias).Adotou-se amostragem probabil\u00edstica por conglomerados e estratificada, sendo a unidade amostral de sorteio a equipe de sa\u00fade que \u00e9 composta por um grupo de profissionais e estratificada por regionais de sa\u00fade.24, onde foram determinadas as m\u00e9dias de mudan\u00e7a de atitude pr\u00e9 e p\u00f3s-interven\u00e7\u00e3o e desvios padr\u00e3o amostrais, obtidos a partir de estudo de refer\u00eancia25. Foi estimado um desvio padr\u00e3o de 2,92, considerada uma m\u00ednima diferen\u00e7a a ser detectada de 1,0, confian\u00e7a de 95% e poder de 0,80. Assim, o tamanho inicial da amostra ajustada para popula\u00e7\u00e3o (n = 298) foi de 56 indiv\u00edduos. Por se tratar de delineamento amostral por conglomerado, foi estabelecido fator de efeito de desenho em 1,22 e estimada taxa de n\u00e3o resposta em 22%, o que resultou em uma amostra final 87 indiv\u00edduos para o grupo interven\u00e7\u00e3o. Para o grupo controle foi considerado 1 para 2, isto \u00e9, 174 indiv\u00edduos.Para a determina\u00e7\u00e3o do n\u00famero de sujeitos, utilizou-se f\u00f3rmula para dados pareadosPara sele\u00e7\u00e3o aleat\u00f3ria dos participantes dos grupos interven\u00e7\u00e3o e controle foi utilizada amostragem por conglomerados e estratificada proporcional ao tamanho da popula\u00e7\u00e3o, considerando como estratos as regi\u00f5es  e como unidade de randomiza\u00e7\u00e3o, a equipe de ESF, a fim de obter controle adequado e reduzir vi\u00e9s metodol\u00f3gico. Definiu-se o n\u00famero de profissionais selecionados em cada regi\u00e3o por multiplica\u00e7\u00e3o da fra\u00e7\u00e3o de profissionais pelo tamanho da amostra (87). Posteriormente, para definir o n\u00famero de equipes a serem sorteadas dividiu-se o n\u00famero de profissionais de sa\u00fade por estrato pelo n\u00famero de equipes (quatro), totalizando 22 equipes sorteadas aleatoriamente por programa estat\u00edstico, conforme ilustra a Suicide Behavior Attitude Questionnaire (SBAQ). Composto por situa\u00e7\u00f5es cl\u00ednicas frequentemente vivenciadas por profissionais de sa\u00fade26. Tal instrumento se divide em fatores que s\u00e3o distribu\u00eddos em sentimentos que o profissional tem em rela\u00e7\u00e3o ao paciente com comportamento suicida, a percep\u00e7\u00e3o de sua capacidade para o atendimento e o direito ao suic\u00eddio; investigando esses fatores \u00e9 poss\u00edvel medir uma atitude positiva ou negativa. Espera-se ent\u00e3o que, de acordo com a m\u00e9dia obtida pela soma dos valores em cada quest\u00e3o divididos pelo n\u00famero total de quest\u00f5es em cada dom\u00ednio, possamos verificar atitudes mais positivas por meio de pontua\u00e7\u00f5es mais elevadas no dom\u00ednio \u201cPercep\u00e7\u00e3o da capacidade profissional\u201d e mais baixas nos dom\u00ednios \u201cSentimentos em rela\u00e7\u00e3o ao paciente\u201d e \u201cDireito ao suic\u00eddio\u201d26. Para verificar outras vari\u00e1veis, sociodemogr\u00e1ficas , relacionadas \u00e0 forma\u00e7\u00e3o  e pr\u00e1tica profissional (atendimento anterior a pacientes com comportamento suicida), construiu-se instrumento fechado, aplicado com o SBAQ.Para a identifica\u00e7\u00e3o da atitude do profissional frente ao comportamento suicida foi utilizado o No primeiro momento, todas as unidades participantes foram visitadas, a fim de informar sobre o estudo e aplicar os instrumentos. Os profissionais das equipes sorteadas para o grupo interven\u00e7\u00e3o, al\u00e9m de responder os instrumentos (pr\u00e9-teste), foram convidados a participar da interven\u00e7\u00e3o (capacita\u00e7\u00e3o). Os question\u00e1rios foram previamente codificados e permitiram o pareamento, mas n\u00e3o a identifica\u00e7\u00e3o pessoal dos participantes. Os participantes ausentes na unidade de sa\u00fade na primeira tentativa, foram procurados, mais duas vezes em hor\u00e1rios diferentes. Quando foi poss\u00edvel e necess\u00e1rio, as visitas foram agendadas.Posteriormente, foi oferecida ao grupo interven\u00e7\u00e3o uma capacita\u00e7\u00e3o com dura\u00e7\u00e3o de 20 horas, visando aprimorar a capacidade de reconhecer o grau de risco de um indiv\u00edduo com comportamento suicida e intervir; conhecer estrat\u00e9gias de atendimento e/ou encaminhamento de indiv\u00edduos com comportamento suicida; reconhecer a pr\u00f3pria atitude perante um paciente com comportamento suicida e aperfei\u00e7o\u00e1-la. A defini\u00e7\u00e3o dos conte\u00fados abordados teve como direcionador o manual de preven\u00e7\u00e3o ao suic\u00eddio voltado para equipes de aten\u00e7\u00e3o prim\u00e1ria da Organiza\u00e7\u00e3o Mundial da Sa\u00fade. A capacita\u00e7\u00e3o foi conduzida por psic\u00f3logas e pesquisadoras em suicidologia, com ampla experi\u00eancia cl\u00ednica e pedag\u00f3gica nessa tem\u00e1tica. Imediatamente ap\u00f3s o t\u00e9rmino da capacita\u00e7\u00e3o foi reaplicado o SBAQ para o grupo interven\u00e7\u00e3o (p\u00f3s-teste). Para o grupo controle n\u00e3o foi oferecido nenhum tipo de interven\u00e7\u00e3o e o p\u00f3s-teste foi reaplicado posteriormente nas unidades de sa\u00fade.O desfecho prim\u00e1rio esperado foi diferen\u00e7a no n\u00edvel de atitudes frente ao comportamento suicida entre o in\u00edcio e fim da interven\u00e7\u00e3o, verificado por meio do SBAQ, a partir da constata\u00e7\u00e3o de aumentos de escores igual ou superior a 3%, avaliado antes e depois da interven\u00e7\u00e3o, a an\u00e1lise foi realizada sobre o princ\u00edpio de inten\u00e7\u00e3o de tratar.A A distribui\u00e7\u00e3o dos dados foi verificada pelo teste de Shapiro-Wilk, para a compara\u00e7\u00e3o entre os dois grupos foi utilizado o teste de homogeneidade qui-quadrado de Pearson, teste t-Student para duas amostras independentes e teste U-Mann Whitney. As compara\u00e7\u00f5es pr\u00e9 e p\u00f3s-interven\u00e7\u00e3o intragrupos foram realizadas a partir do teste t pareado para amostras dependentes e teste de postos com sinais de Wilcoxon. O n\u00edvel de signific\u00e2ncia adotado foi de 5% em todos os testes. O projeto de pesquisa foi aprovado pelo comit\u00ea de \u00e9tica em pesquisa de acordo com a Resolu\u00e7\u00e3o 466/2012.A an\u00e1lise dos dados sociodemogr\u00e1ficos, de capacita\u00e7\u00e3o anterior e de atendimento ao comportamento suicida  n\u00e3o evidranks . No entanto, na avalia\u00e7\u00e3o realizada ap\u00f3s a capacita\u00e7\u00e3o, verificaram-se diferen\u00e7as estatisticamente significativas entre os dois grupos em todos os itens dos fatores \u201csentimentos negativos em rela\u00e7\u00e3o ao paciente\u201d e \u201cpercep\u00e7\u00e3o da capacidade profissional\u201d. Em \u201cdireito ao suic\u00eddio\u201d dos cinco itens que comp\u00f5em o fator, os itens Q4, Q6 e Q16 sofreram modifica\u00e7\u00f5es estatisticamente significativas , todavia, as quest\u00f5es Q3 e Q18 n\u00e3o apresentaram modifica\u00e7\u00f5es significativas .A Na 12.A literatura demonstra que o atendimento ao paciente com comportamento suicida pode ser influenciado por diversos fatores, dentre os quais est\u00e3o as atitudes dos profissionais de sa\u00fade27, al\u00e9m de ser envolto por mitos e cren\u00e7as, como as que classificam as tentativas de suic\u00eddio como formas e amea\u00e7as para chamar a aten\u00e7\u00e3o e que n\u00e3o ir\u00e3o se concretizar, ou ainda que pessoas com esse comportamento s\u00e3o covardes31. A atitude \u00e9 pass\u00edvel de modifica\u00e7\u00e3o, o que pode ser evidenciado no presente estudo; quanto ao \u201csentimento em rela\u00e7\u00e3o ao paciente\u201d, ap\u00f3s a capacita\u00e7\u00e3o, foram observadas mudan\u00e7as em todos os itens desse dom\u00ednio. Os achados demonstraram mudan\u00e7as na compreens\u00e3o das tentativas e amea\u00e7as como potenciais fatores de risco e de que pessoas nessas condi\u00e7\u00f5es est\u00e3o em intenso sofrimento, propiciando posturas mais emp\u00e1ticas em rela\u00e7\u00e3o a esses pacientes.O atendimento ao paciente com comportamento suicida pode acarretar sentimentos de frustra\u00e7\u00e3o, impot\u00eancia, culpa, desprezo e raiva31. O desejo de n\u00e3o viver pode ser conflituoso para os profissionais, uma vez que se subentende que devem salvar vidas. Assim, aspectos como supera\u00e7\u00e3o dos dilemas de onipot\u00eancia e onisci\u00eancia, que costumam causar ang\u00fastia nessas situa\u00e7\u00f5es, foram amplamente discutidos na capacita\u00e7\u00e3o.O fato de o profissional reagir de forma negativa ao atender um paciente com comportamento suicida pode, dentre outros aspectos, relacionar-se com o processo de forma\u00e7\u00e3o que frequentemente n\u00e3o proporciona ferramentas para o enfrentamento de situa\u00e7\u00f5es de morte, sobretudo quando associada \u00e0 escolha do sujeito32. No entanto, as discuss\u00f5es geradas durante a capacita\u00e7\u00e3o evidenciaram que os profissionais esquivavam-se menos em se envolver e estabelecer v\u00ednculo com pacientes que tentaram suic\u00eddio e apresentaram redu\u00e7\u00e3o do sentimento de impot\u00eancia. Tal fato pode explicar as mudan\u00e7as significativas das respostas do question\u00e1rio nesse fator.Outro aspecto a ser aventado \u00e9 o de que o sentimento de ansiedade, por um eventual erro de conduta ou de avalia\u00e7\u00e3o, e a ideia de responsabilidade sobre a vida do paciente podem ser expressas pela dificuldade em estabelecer v\u00ednculo ou no receio de conversar sobre suic\u00eddio com medo de induzir o paciente a comet\u00ea-lo19.Perceber os pr\u00f3prios sentimentos negativos como mecanismos de defesa, considerar a morte com parte da exist\u00eancia humana e identificar os sentimentos envolvidos no processo de morte e morrer fez parte da metodologia empregada e favoreceu a compreens\u00e3o e modifica\u00e7\u00e3o dos sentimentos entre os profissionais. Tais achados corroboram o estudo desenvolvido com profissionais de sa\u00fade em que se verificou, ap\u00f3s uma capacita\u00e7\u00e3o, redu\u00e7\u00e3o significativa dos sentimentos negativos e melhor precis\u00e3o na avalia\u00e7\u00e3o de risco33.Sobre a \u201cpercep\u00e7\u00e3o da capacidade profissional\u201d, os achados evidenciaram autopercep\u00e7\u00e3o de maior capacidade para o atendimento, melhor preparo profissional e seguran\u00e7a para lidar com pacientes em risco de suic\u00eddio. Resultados similares s\u00e3o encontrados em uma interven\u00e7\u00e3o com dura\u00e7\u00e3o de duas horas, oferecida a partir de um estudo multic\u00eantrico japon\u00eas a 74 profissionais de sa\u00fade. Observou-se ganhos significativos nas habilidades percebidas, confian\u00e7a, atitude, maior compet\u00eancia na avalia\u00e7\u00e3o do risco suicida e mais confian\u00e7a ao cuidar de pacientes nessas condi\u00e7\u00f5es21. A literatura tem enfatizado que as atitudes negativas com pacientes suicidas entre os profissionais de sa\u00fade podem estar mais relacionadas \u00e0 falta de conhecimento e \u00e0s incertezas em como cuidar do que com a hostilidade especificamente20. Desse modo, a desinforma\u00e7\u00e3o sobre o suic\u00eddio pode perpetuar uma abordagem equivocada.Um estudo conduzido na Austr\u00e1lia, com 248 profissionais de sa\u00fade participantes de um treinamento sobre comportamento suicida, resultou em aprimoramento do conhecimento, atitudes mais adequadas com consequente amplia\u00e7\u00e3o da capacidade de comunica\u00e7\u00e3o e confian\u00e7a em fornecer assist\u00eancia apropriada17.O conhecimento continuamente atualizado, especialmente no que se refere \u00e0 avalia\u00e7\u00e3o do risco suicida e das op\u00e7\u00f5es de tratamento, pode diminuir a ansiedade por falhas e aumentar a percep\u00e7\u00e3o da capacidade profissional. \u00c0 medida que os profissionais compreendem e cumprem suas responsabilidades relacionadas \u00e0 identifica\u00e7\u00e3o, avalia\u00e7\u00e3o e interven\u00e7\u00e3o terap\u00eautica, na atua\u00e7\u00e3o profissional baseada em evid\u00eancias e no planejamento do monitoramento da pessoa com risco suicida, conscientizam-se de que os fatores relacionados a habilidades e compet\u00eancias profissionais foram contemplados34.Os profissionais de sa\u00fade convivem com sofrimento, dor, medo, desesperan\u00e7a, perdas de diversos modos e enfrentam frequentemente processos de morte e morrer. N\u00e3o \u00e9 raro o sentimento de impot\u00eancia e incapacidade diante dessas situa\u00e7\u00f5es. A cren\u00e7a de que apenas a cura ou a recupera\u00e7\u00e3o caracterizam o bom cuidado, enfatizado durante a forma\u00e7\u00e3o acad\u00eamica e reiterada diariamente pela cultura da obstina\u00e7\u00e3o terap\u00eautica, pode vir a contribuir para a inseguran\u00e7a profissional ao se deparar com situa\u00e7\u00f5es que sinalizem uma poss\u00edvel morte autoprovocada35.Diversos autores destacam ainda a influ\u00eancia de quest\u00f5es de ordem organizacional do servi\u00e7o, bem como a escassez de estrutura f\u00edsica e principalmente pessoal capacitado, demonstrando as dificuldades e o receio de n\u00e3o ter recursos frente ao inesperado. Durante a capacita\u00e7\u00e3o, diversos fatores como os relatados acima foram descritos como limitantes de um atendimento efetivo, acompanhados por sentimentos de inseguran\u00e7a, incapacidade e incompet\u00eancia. No entanto, foi ressaltado que, ao se reconhecerem os limites e potencialidades, o medo de errar pode ser substitu\u00eddo, gradativamente, pela confian\u00e7a em intervir21.O terceiro componente investigado no presente estudo refere-se ao \u201cdireito ao suic\u00eddio\u201d, em que se verificaram modifica\u00e7\u00f5es, ap\u00f3s a capacita\u00e7\u00e3o, em tr\u00eas dos cinco itens que o comp\u00f5em. No entanto, um dos itens em que n\u00e3o foram observadas mudan\u00e7as significativas foi a afirmativa: \u201capesar de tudo, penso que uma pessoa tem o direito de se matar\u201d. Resultado similar foi descrito em pesquisa australiana, ap\u00f3s capacita\u00e7\u00e3o com dura\u00e7\u00e3o de um dia: na ocasi\u00e3o apenas 30% concordavam com o direito de cometer suic\u00eddio. Segundo os autores, tais achados refletem a natureza dos itens que comp\u00f5em esse fator (cren\u00e7as morais e religiosas) profundamente arraigados, com menor expectativa de modifica\u00e7\u00f5es, mesmo ap\u00f3s uma interven\u00e7\u00e3o educativa34.N\u00e3o cabe aos profissionais de sa\u00fade priorizar seus princ\u00edpios e convic\u00e7\u00f5es individuais no atendimento \u00e0 pessoa com comportamento suicida, com o risco de induzi-lo \u00e0 adapta\u00e7\u00e3o aos padr\u00f5es sociais, baseados em seus valores e cren\u00e7as pessoais que podem n\u00e3o ser relevantes para o paciente, pondo em risco o v\u00ednculo terap\u00eautico necess\u00e1rio para o atendimento. Assim, o cuidado prestado n\u00e3o pode de forma alguma intensificar o sentimento de culpa na pessoa com idea\u00e7\u00e3o ou tentativa de suic\u00eddio e em seus familiaresQuando se questionou sobre a possibilidade de modificar uma decis\u00e3o de suic\u00eddio por meio de uma conversa, perceberam-se efeitos positivos significativos ap\u00f3s a capacita\u00e7\u00e3o. Por\u00e9m, na afirmativa \u201cquando uma pessoa fala de p\u00f4r fim \u00e0 vida, tento tirar aquilo da cabe\u00e7a dela\u201d, que presume o pr\u00f3prio profissional envolvido ativamente no evento, os resultados n\u00e3o foram significativos estatisticamente. Uma poss\u00edvel explica\u00e7\u00e3o para o achado refere-se ao fato de que, embora o profissional acredite na possibilidade de preven\u00e7\u00e3o utilizando-se da comunica\u00e7\u00e3o terap\u00eautica, ele n\u00e3o se reconhece como um elemento essencial nesse processo.35. O foco em cuidar apenas dos aspectos biol\u00f3gicos e o investimento em recursos tecnol\u00f3gicos como alternativas de prolongamento da vida evitam, at\u00e9 certo ponto, n\u00e3o s\u00f3 o contato com a morte, mas tamb\u00e9m a comunica\u00e7\u00e3o terap\u00eautica que poderia dar acesso aos sentimentos do paciente. Assim, indiretamente, os profissionais de sa\u00fade evitam o contato com a pr\u00f3pria morte e com as pr\u00f3prias emo\u00e7\u00f5es34.Lidar com a morte desencadeia in\u00fameras rea\u00e7\u00f5es no ser humano, dentre elas a percep\u00e7\u00e3o da pr\u00f3pria finitude. Atentar para quest\u00f5es exclusivamente t\u00e9cnicas, burocr\u00e1ticas e rotineiras, quando se trata desse tema, faz parte de uma postura de nega\u00e7\u00e3o da morte, na medida em que fornece poder ao profissional de sa\u00fade e ameniza o sentimento de impot\u00eancia35.Deixar de falar ou de pensar na morte conforta, de certo modo, pois alimenta a fantasia de que n\u00e3o concretiz\u00e1-la em palavras e pensamentos pode, assim, afast\u00e1-la. A morte do outro se caracteriza como o an\u00fancio e a antecipa\u00e7\u00e3o da pr\u00f3pria morte, uma amea\u00e7a a n\u00f3s, e o suic\u00eddio propriamente dito traduz-se ainda em uma mutila\u00e7\u00e3o na sociedade pela quebra do seu curso natural, mexendo em suas bases morais31.O suic\u00eddio, por envolver aspectos biol\u00f3gicos, culturais e sociais, demanda que as interven\u00e7\u00f5es educativas compreendam, al\u00e9m do manejo cl\u00ednico, fatores do sofrimento ps\u00edquico envolvido, elementos importantes para a abordagem terap\u00eautica da equipe multidisciplinar. Assim, faz-se necess\u00e1rio repensar estrat\u00e9gias de preven\u00e7\u00e3o ao suic\u00eddio que consigam, ao mesmo tempo, fornecer conhecimentos que levem a um olhar menos regulado por julgamentos e regras morais, para que a pessoa que vivencia esse sofrimento seja acolhida em qualquer contexto, possibilitando melhores condi\u00e7\u00f5es de recupera\u00e7\u00e3o e reabilita\u00e7\u00e3o socialEste artigo apresenta como limita\u00e7\u00e3o a dificuldade de an\u00e1lises comparativas com outras interven\u00e7\u00f5es, tanto por serem escassas na literatura quanto por diferir substancialmente em rela\u00e7\u00e3o ao p\u00fablico-alvo, conte\u00fado ministrado, metodologias de ensino-aprendizagem ou formas de an\u00e1lise dos resultados. Por\u00e9m, as suas contribui\u00e7\u00f5es residem no tipo de delineamento experimental que, por interm\u00e9dio da conscientiza\u00e7\u00e3o do papel do profissional de sa\u00fade e aprimoramento do conhecimento sobre o comportamento suicida, promoveu mudan\u00e7a positiva nas atitudes e possibilitou o aumento da percep\u00e7\u00e3o da capacidade e confian\u00e7a para o atendimento a esses pacientes, conforme sugerem os resultados.Observaram-se atitudes mais positivas entre os profissionais frente ao comportamento suicida ap\u00f3s a interven\u00e7\u00e3o. Tal achado contribui para a qualidade da assist\u00eancia na aten\u00e7\u00e3o prim\u00e1ria e refor\u00e7a a viabilidade de capacita\u00e7\u00f5es com vistas a prevenir esse agravo na popula\u00e7\u00e3o. Nesse sentido, os dados evidenciados s\u00e3o relevantes tanto para a produ\u00e7\u00e3o cient\u00edfica quanto para a realidade dos servi\u00e7os inseridos no Sistema \u00danico de Sa\u00fade.Os resultados encontrados neste estudo v\u00e3o ao encontro da literatura existente e colaboram com o panorama cient\u00edfico atual, na medida em que fornecem subs\u00eddio para o desenvolvimento de estrat\u00e9gias que contribuam para a redu\u00e7\u00e3o dos altos \u00edndices de tentativas e suic\u00eddios no pa\u00eds.Sugere-se em novos estudos, de avalia\u00e7\u00e3o sequencial ou de seguimento, observando se tais mudan\u00e7as s\u00e3o sustentadas ao longo da linha do tempo; al\u00e9m de verificar a dura\u00e7\u00e3o dos programas de interven\u00e7\u00f5es educativas, visando otimizar o tempo empregado em tais programa\u00e7\u00f5es, bem como os conte\u00fados abordados para valida\u00e7\u00e3o de material educativo padronizado na inten\u00e7\u00e3o de testar e replicar tais resultados em outras popula\u00e7\u00f5es."}
+{"text": "To review the effects of low-level laser photobiomodulation on masticatory function and mandibular movements in adults with temporomandibular disorder.Search in PubMed, Web of Science, Scopus, EMBASE, Cochrane, LILACS, ScienceDirect, and Google Scholar, using the following descriptors: \u201ctemporomandibular joint disorders\u201d, \u201clow-level light therapy\u201d, \u201clow-level laser therapy\u201d, \u201cmastication\u201d, and \u201cmandible\u201d.Randomized clinical trials in adults with temporomandibular disorder, using low-level laser and assessing the mastication and mandibular movements.Firstly, the titles and abstracts of all retrieved studies were read. Then, only the studies selected in the first stage were read in full and assessed regarding eligibility. After the selection, the characteristics, methodological quality, and quality of evidence of the studies included in the review were analyzed. In the meta-analysis, the mean amplitude of mouth opening was considered as a measure of intervention effect.The 10 articles included in the review had quite different results one from the other, especially regarding the amplitude of mouth opening, while the mastication was assessed in only one of them. Most studies had a high risk of bias, demonstrating a low methodological quality. Significantly higher results for photobiomodulation were identified in the six studies included in the meta-analysis.Due to the scarcity in the literature, there is not enough evidence of the effects of low-level laser photobiomodulation on mastication. As for the mandibular movements, this intervention presented significant results, particularly in the amplitude of mouth opening. This disorder has a variety of causes, including predisposition, precursors, and attenuators, such as deleterious habits, occlusal changes, condyle-disc imbalance, stress, and anxiety. Depending on its etiology and symptoms, TMD can be classified as myogenous, arthrogenous, or mixed.The temporomandibular disorder (TMD) is a set of dysfunctions involving the masticatory muscles, the temporomandibular joint (TMJ), and associated structures,4.The most common TMD symptoms are joint noises (crepitation and clicking), otalgia, tinnitus, head and neck pain, headache, hyper- or hypofunction of the masticatory muscles, tooth sensitivity, mandibular deviations, limited mouth opening, impaired sleep, and emotional changes, thus diminishing the patients\u2019 quality of life. Since its etiology is multifactorial, the treatment is carried out according to the signs and symptoms in each patient, always instructing them properly, as decreasing some habits may help the intervention.This pathology has been significantly growing, affecting more women than men, occurring mostly between 20 and 50 years old. TMD therapy in the field of speech-language-hearing pathology is quite effective in the rehabilitation of the masticatory system and mandibular movements, using oral-motor function exercises and techniques to achieve a more adequate and balanced muscle functioning.The treatments make use of less invasive or noninvasive procedures, such as medication therapy, orofacial myofunctional therapy, psychological treatment, interocclusal splint, acupuncture, electrostimulation, viscosupplementation, ultrasound therapy, and laser therapy. More invasive procedures are also used, as in the case of surgeries.The word laser is an acronym that stands for light amplification by stimulated emission of radiation. Better known as light therapy, phototherapy, or photobiomodulation (PBM), it is one of the oldest therapy methods manipulated by humans. It is classified into two types: high-power laser (which is ablative) and low-power laser (which is therapeutic).PBM therapy is a non-pharmacological, painless, noninvasive treatment without side effects and whose main functions are analgesic, anti-inflammatory, and tissue regenerative. It transforms light energy into chemical energy, inducing metabolic, energetic, and functional changes and helping increase cell resistance and vitality,10. Generally, though, the most studied outcomes are related to analgesic effects and mandibular movements-20.In other fields, such as dentistry and physical therapy, which have been using laser as a therapy technology for longer, there are many studies with scientific evidence of this resource in TMD.The pain and discomfort in TMD patients can have negative effects on the performance of the stomatognathic functions. A study in patients with moderate-to-severe chronic TMD identified, with functional and electromyographic assessment, significantly greater difficulty in mastication, worse orofacial scores, longer free mastication, unprecise muscle recruitment on the work and balance sides, lower symmetrical mastication rates, and increased patterned activity during the electromyographic test in comparison with healthy people.The analgesic and biomodulator effects of low-level laser (LLL) therapy, acting upon the algesic and inflammatory processes, can help ease these patients\u2019 pain and discomfort, improve muscle performance and diminish the sensitivity of the masticatory muscles and other pain points. Thus, combined with speech-language-hearing therapy, this resource may increase the amplitude of mandibular movements, improve the masticatory function, and provide greater harmony in the stomatognathic system,23,24.Secondary studies that researched the evidence of LLL in TMD revealed the importance of PBM therapy to ease the pain and improve mandibular functioning. They also investigated the effects obtained in combining it with other interventions. The reviews that have been carried out until now have mostly approached functioning; hence, they do not cover the topic in-depth, generally considering it a secondary objective and registered in the International Prospective Register of Systematic Reviews (PROSPERO), under number CRD42020187091.Therefore, this study was developed to analyze the available evidence of the use of this resource in mandibular movements and masticatory function. These mutually related aspects are of central interest in speech-language-hearing intervention in the field of oral-motor function in cases of TMD. This review was written based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)Hence, this study aimed to make a systematic review of the evidence of LLL PBM to investigate the effects of this technique on the masticatory function and mandibular movements in adults with TMD.The search strategy was developed with the guidance of a librarian who worked in the originating institution, being adapted to each database and using their specific descriptors. The terms were selected from descriptors in PubMed\u2019s Medical Subject Headings (MeSH) and EMBASE\u2019s Emtree, considering the pathology researched, the intervention, and the outcomes included in the review.The search strategy was simplified, encompassing the main index terms available in the vocabulary (thesaurus) of the databases. Previous tests of the search strategy revealed that these were enough to retrieve the eligible studies.The search was conducted in PubMed, LILACS , Web of Science, Cochrane Library, EMBASE, Scopus, and ScienceDirect, besides an additional search for gray literature on Google Scholar and Open Grey. The reference lists in the articles included in this study were also analyzed to include any additional references that had not been identified in the databases. The Brazilian Registry of Clinical Trials was also surveyed to obtain further information on the studies that were included and identify possible studies in the process of being published. The search strategies used in the databases are shown in The references were managed with the EndNote online software to remove the duplicate ones. All the database surveys took place between May 18 and 20, 2020, and were updated on September 16, 2020.The research question used to develop this research was based on the PICOT strategy, in which P (population) was adults with TMD; I (intervention) was LLL PBM; C (comparison) was other interventions or absence of interventions; O (outcomes) was masticatory function and/or mandibular movement measures; T (types of studies) was the randomized clinical trials. Thus, the research question was established as follows: \u201cWhat are the effects of LLL on the performance of the masticatory function and mandibular movements in TMD patients, compared with other interventions or the absence of other interventions?\u201d.Original articles designed as randomized clinical trials were eligible without restrictions of time or language. The studies involved adults aged 18 to 60 years old, clinically diagnosed with TMD, using LLL intervention, and assessing the masticatory function and/or mandibular movements. The articles with other designs, with either children or older adults, whose text was not fully available, with other comorbidities, or with other treatments combined and applied simultaneously with laser were excluded.These aspects were selected based on the age range used in most studies in the field, considering both the development of the stomatognathic system and the changes resulting from the natural aging process, as they might influence the measurement of the intervention effects. The presence of other comorbidities and other treatments applied simultaneously with LLL would likewise prevent a more precise analysis of the results. The main outcomes were chosen because of their clinical relevance in speech-language-hearing therapy in TMD cases.The studies were selected in two stages, independently carried out by the same investigators. Firstly, the titles and abstracts of all studies were read, excluding the ones that did not meet the previously established eligibility criteria. In the second stage, the texts were read in full. In both stages, there was a strong interrater agreement, verified with Cohen\u2019s kappa coefficient. The disagreements were discussed between the authors in both stages of the review process. When they still did not agree, a third reviewer got involved in the process, independently reading the studies and judging their eligibility.In the data extraction phase, the information was likewise collected independently by the two reviewers. A specific instrument was developed for this stage, and the data were checked in a consensus meeting. The data of the selected articles were tabulated based on some characteristics: author, country, sample, objective, intervention parameters, use of the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD), type of intervention, outcomes, results, and conclusion. When their data were incomplete or absent, the reviewers contacted the authors via the corresponding e-mail to obtain all the necessary information.. The analysis of the quality of evidence was made with the Grading of Recommendations Assessment, Development and Evaluation (GRADE).The methodological quality of the studies was individually and independently assessed by two reviewers, following the Cochrane risk-of-bias tool for randomized trials (RoB 2)The measure of intervention effect considered for the meta-analysis was the mean amplitude of mouth opening because it was verified as the main parameter used to assess mandibular movements in most studies included in the review. Only six studies presented in the results the mean, standard deviation, and the number of participants in each group, contributing directly to the synthesis. As for the assessment of the masticatory function, only one study considered this outcome. The measures used for the meta-analysis were the mean and standard deviation, with the inverse variance method, in the R statistical software.The study search and selection process is presented in detail in -15, and five are international-20. Four of the national ones are from the state of S\u00e3o Paulo,13-15, and one is from Rio Grande do Sul. As for the other articles, three are from Istanbul, in Turkey,18,20, and two from Tehran, in Iran,19.Five out of the 10 studies selected are Brazilian to 82 participants. Concerning the protocol to diagnose the TMD, eight used the RDC/TMD,14-20, and two did not report the instrument used for the diagnosis,13.The sample size ranged from 15,16,17,19, three analyzed the protrusive movements, opening movements, and lateral mandibular excursions,18,20, and only one approached the masticatory function. The characteristics, main outcomes, and conclusions of the studies included in the review are shown in detail in Regarding the masticatory function and the mandibular movements, six studies approached the amplitude of mouth opening alone as one of the outcomesThe studies that had significant results in the amplitude of mandibular movement showed that the higher the dose used, the more immediate and expressive the effects. The measures were taken between the first, fifth, tenth, and twelfth sessions, even up to one month after the laser intervention.,16,17,19. Concerning the vertical, lateral excursion, and protrusive movements, three articles,18,20 showed statistically significant results.Some studies pointed out that the results of the amplitude of mouth opening had not been statistically significant between the groups.Only one of the studies assessed the masticatory function, demonstrating that LLL PBM therapy in combination with oral myofunctional exercises is more effective than LLL alone, diminishing the signs and symptoms of TMD and improving the mandibular movements. In the study in question, the overall mobility and function score results indicated lower results in the group treated only with laser therapy, with significant differences between the groupsNine out of the 10 studies in this review were grouped for quantitative analysis of the results because they presented the amplitude measure of mouth opening. However, only six of them could be used in the meta-analysis. The studies were rather different from one another, especially regarding maximum mouth amplitude.2 was 60%, indicating moderate heterogeneity. The quantitative synthesis is shown in detail in In the quantitative analysis, the diamond at the end of the plot reflects the combination of results. It is on the right side and did not touch the axis, which means the treatment was better in the experimental group \u2013 i.e., it had significant results. In the difference of means column, the value reveals that the experimental group was better \u2013 2.78 points on a scale from 0 to 100 in the random models. Concerning the heterogeneity between the studies, the I,14,17,18 were generally classified with a high risk of bias, two were classified with some concern,20, and three, with a low risk,15,19 in the quality assessment.The studies included in the review had a quite heterogeneous methodology. Five articlesThe main methodological limitations in the studies were related to unreported information on generating random sequences, allocation concealment, and participants\u2019 blinding, as shown in Since the review used outcomes from randomized clinical trials, the assessment of the quality of evidence began with the maximum score, which was then decreased in some parameters, as shown in  and microelectric neurostimulation (MENS) regarding mandibular movements. On the other hand, a study compared transcutaneous electrical nerve stimulation (TENS) with LLL and reported the efficacy of both therapies, with a difference between the groups only in the cumulative effect. In another one, no significant differences were found between the LLL and TENS groups in any of the stages.There were no significant results in the comparison between laser with type A botulinum toxin interventions,18,19 revealed significant and higher results for the groups submitted to the intervention. The paper that compared the laser with orofacial myofunctional therapy identified great results from this therapy alone. However, it was not combined with LLL therapy, which may be an alternative to obtain more significant results.The comparison between two different LLL modalities or between LLL and a placebo groupAn important aspect to consider is the dose used. Some studies used a low dose (between 1.5 J and 3 J), which, given the objectives, may have prevented significance. Hence, a higher dose would be necessary. Considering the results, there is great inconsistency and methodological flaws between these studies, which deemed five studies with a high risk of bias, decreasing their quality of evidence and reliability.The laser protocol used in each study also varied greatly. The number of sessions in the studies was balanced in 10 to 12, which is the advocated in the literature for being considered the adequate number of sessions to obtain significant results. As for the frequency of sessions, it varied between once a week, every day for 4 weeks, for 5 weeks, or every 2 weeks.2 to 105.0 J/cm2, depending on the equipment they used. This shows how heterogeneous the studies were. Future clinical trials with laser must choose more homogeneous protocols, with greater methodological rigor, for the results to have more reliable evidence.The wavelength ranged from 780 nm to 904 nm, revealing that all studies used infrared wavelength. The greatest difference between the studies was the dose, which ranged from 1.5 J/cm-15, which shows that Brazil is strong in publications in the field of PBM and TMD. Moreover, three of these studies are from the same research group-15. Almost all clinical trials are from fields such as physical therapy or dentistry, whereas only one article had a speech-language-hearing therapist among its authors \u2013 which is also the only one that analyzed the masticatory function. This may have occurred because these sciences have been using the laser for longer, while in speech-language-hearing pathology its use was regulated only in 2019, with Resolution no. 541, and it has been applied in clinical practice only recently.Five out of the 10 studies are BrazilianSuch aspects show the need for further research on the masticatory function and mandibular movements on the part of these professionals, as they are essential in TMD therapy. We currently have positive clinical findings available, but further scientific evidence is necessary to recommend the therapeutic choice and decision-making for using this resource, instead of or in combination with the other ones already available in the field.. It must be highlighted that, in the speech-language-hearing clinic, this technology must not be used in place of consistent, highly relevant therapies in the field, but rather as a complementary and alternative intervention to speed the treatment process. Thus, the intervention must be directed and individualized, integrating the various approaches involved in the care for people with TMD and considering the different speech-language-hearing and dental aspects involved in rehabilitating this function.Since the laser can both stimulate and inhibit the tissue response, it can help develop functions that were changed in people with TMD, including mastication, which has a considerable impact on this pathologyGiven the above, some clinical implications stand out in this study. Intervention protocols evidently must be developed to better standardize important parameters, such as the dos\u00edmetry and the number and frequency of sessions, to obtain effective therapeutic results.This review has some contributions, as it points out the main parameters and their results currently approached in the scientific literature in the field. Moreover, it highlights the effects obtained with laser in comparison with other interventions, thus making the speech-language-hearing therapists\u2019 clinical practice easier in this field, in terms of choosing the best therapeutic approach to reach the desired objective.Another important aspect is that the most recurrent measure in the literature, as both the main and secondary outcome, was the amplitude of mouth opening. Hence, this parameter measure is greatly important to quantify the results obtained in the laser intervention. Nevertheless, more robust assessments with broader criteria to analyze the various mandibular movements are indispensable.Some limitations in this systematic review must be pointed out. The analysis of the studies revealed considerable variability. This may be due to the characteristics of each study, which applied rather diverging methodologies . Thus, even though there are some positive effects regarding the efficacy of laser on TMD, the diversity of methodological parameters interfere with the conclusions obtained in each study, whose results are different from and conflicting with one another.Besides the methodological differences found between the studies, they had a low quality of evidence, with a considerable bias in most studies. Moreover, the studies lacked some data, making it difficult to obtain information for a quantitative synthesis that would include all the results, enabling a broader analysis.Therefore, this study verified that LLL PBM did not provide evidence of the effect of LLL on the masticatory function, although it demonstrated beneficial effects in terms of increasing the amplitude of the mandibular movements. The LLL therapy had positive impacts on the increase of the amplitude of mouth opening, with better results than the other interventions or the absence of treatment, as demonstrated in the meta-analysis.Further clinical trials are needed, with more homogeneous, high-quality protocols, to find new clinical approaches and scientific evidence that can be replicated, especially in the field of speech-language-hearing pathology, which had few studies focused on the masticatory function.This study verified a scarcity in the literature regarding the masticatory function, as only one study analyzed this variable. Hence, the information available was not enough to analyze the effects of the LLL PBM therapy on this function. As for the mandibular movements, the methodological parameters and intended outcomes vary widely from one piece of research to another. In the intervention groups, the LLL PBM had significant results, which is made evident in the quantitative synthesis of the main outcome of the amplitude of mouth opening. . Existem diversas causas para essa disfun\u00e7\u00e3o, dentre elas est\u00e3o os fatores de pr\u00e9-disposi\u00e7\u00e3o, precursores e atenuadores, como h\u00e1bitos delet\u00e9rios, altera\u00e7\u00f5es oclusais, desequil\u00edbrio c\u00f4ndilo-disco, estresse e ansiedade. Sendo que, de acordo com a etiologia e os sintomas apresentados pelo paciente, essa desordem pode ser classificada em muscular, articular ou mista.A Disfun\u00e7\u00e3o Temporomandibular (DTM) pode ser definida como um conjunto de dist\u00farbios que envolvem os m\u00fasculos mastigat\u00f3rios, a articula\u00e7\u00e3o temporomandibular (ATM) e estruturas associadas,4.Os sintomas mais comuns dessa desordem s\u00e3o os ru\u00eddos articulares , otalgias, zumbido, dores na regi\u00e3o da cabe\u00e7a e pesco\u00e7o, cefaleia, hiperfun\u00e7\u00e3o ou hipofun\u00e7\u00e3o da musculatura mastigat\u00f3ria, sensibilidade dent\u00e1ria, desvios mandibulares, redu\u00e7\u00e3o na abertura de boca, preju\u00edzos no sono, altera\u00e7\u00f5es emocionais, diminuindo assim a qualidade de vida dos indiv\u00edduos. Por ter uma etiologia multifatorial, o tratamento deve ser realizado de acordo com os sinais e sintomas apresentados pelo paciente, sempre realizando as orienta\u00e7\u00f5es adequadas, e considerando que a redu\u00e7\u00e3o de alguns h\u00e1bitos pode contribuir para a interven\u00e7\u00e3o.Essa patologia tem crescido de forma significativa, atingindo mais mulheres do que homens, com maior ocorr\u00eancia na idade entre 20 e 50 anos. A terapia para DTM na \u00e1rea da Fonoaudiologia apresenta-se muito eficaz na reabilita\u00e7\u00e3o do sistema mastigat\u00f3rio e dos movimentos mandibulares, promovendo uma funcionalidade muscular mais adequada e equilibrada, utilizando exerc\u00edcios e t\u00e9cnicas da \u00e1rea de Motricidade Orofacial.Os tratamentos utilizados contemplam procedimentos menos invasivos ou n\u00e3o invasivos, como a terapia medicamentosa, terapia miofuncional orofacial (TMO), tratamento psicol\u00f3gico, placas interoclusais, acupuntura, eletroestimula\u00e7\u00e3o, viscossuplementa\u00e7\u00e3o, ultrassom terap\u00eautico e a laserterapia; como tamb\u00e9m, os mais invasivos, no caso de cirurgiaslaser \u00e9 uma sigla em ingl\u00eas que, traduzida para o portugu\u00eas, significa amplifica\u00e7\u00e3o de luz por emiss\u00e3o estimulada de radia\u00e7\u00e3o. \u00c9 mais conhecido como terapia com luz, fototerapia ou fotobiomodula\u00e7\u00e3o, sendo considerado um dos m\u00e9todos terap\u00eauticos mais antigos manipulados pelo homem, podendo ser classificados em dois tipos: lasers de alta pot\u00eancia, que s\u00e3o ablativos; e os de baixa pot\u00eancia, que s\u00e3o terap\u00eauticos.O .A terapia de fotobiomodula\u00e7\u00e3o \u00e9 um tratamento n\u00e3o medicamentoso, indolor, n\u00e3o invasivo e sem efeitos colaterais, que tem como principais fun\u00e7\u00f5es a analg\u00e9sica, anti-inflamat\u00f3ria e de regenera\u00e7\u00e3o tecidual. Transforma energia luminosa em energia qu\u00edmica, induzindo mudan\u00e7as metab\u00f3licas, energ\u00e9ticas e funcionais, contribuindo assim para a eleva\u00e7\u00e3o da resist\u00eancia e da vitalidade das c\u00e9lulas,10. No entanto, de um modo geral, observa-se que os desfechos mais estudados s\u00e3o a a\u00e7\u00e3o analg\u00e9sica e os movimentos mandibulares-20.Em outras \u00e1reas, como a Odontologia e Fisioterapia, que j\u00e1 utilizam o laser como tecnologia terap\u00eautica h\u00e1 mais tempo, existem v\u00e1rias pesquisas que demonstram a evid\u00eancia cient\u00edfica desse recurso na DTM.Nos indiv\u00edduos com DTM, a dor e o desconforto podem repercutir negativamente no desempenho das fun\u00e7\u00f5es estomatogn\u00e1ticas. Em estudo realizado com pacientes com DTM cr\u00f4nica moderada-grave, por meio de avalia\u00e7\u00e3o funcional e eletromiogr\u00e1fica, identificou-se uma dificuldade significativamente maior na mastiga\u00e7\u00e3o; piores escores orofaciais; maior tempo para mastiga\u00e7\u00e3o livre; um recrutamento menos preciso dos m\u00fasculos nos lados de trabalho e equil\u00edbrio; redu\u00e7\u00e3o do \u00edndice de mastiga\u00e7\u00e3o sim\u00e9trico; e aumento da atividade padronizada durante o teste eletromiogr\u00e1fico, quando comparados \u00e0s pessoas saud\u00e1veis.Nesses indiv\u00edduos, os efeitos analg\u00e9sico e biomodulador do LBP, atuando nos processos \u00e1lgicos e inflamat\u00f3rios, podem ajudar na diminui\u00e7\u00e3o da dor/desconforto e contribuir para a performance muscular, diminuindo a sensibilidade nos m\u00fasculos mastigat\u00f3rios e de outros pontos \u00e1lgicos. Assim, aliado \u00e0 interven\u00e7\u00e3o fonoaudiol\u00f3gica, o recurso pode permitir um aumento na amplitude dos movimentos mandibulares, promovendo melhora na fun\u00e7\u00e3o mastigat\u00f3ria e proporcionando uma maior harmonia para o sistema estomatogn\u00e1tico,23,24.Os estudos secund\u00e1rios que pesquisaram as evid\u00eancias do LBP na DTM evidenciam a import\u00e2ncia da terapia de fotobiomodula\u00e7\u00e3o no al\u00edvio da dor e na melhora da funcionalidade mandibular, como tamb\u00e9m investigam os efeitos obtidos com a sua associa\u00e7\u00e3o a outras interven\u00e7\u00f5es. Ao abordar a funcionalidade, as revis\u00f5es realizadas at\u00e9 o momento n\u00e3o possuem aprofundamento no assunto e geralmente a consideram como um objetivo secund\u00e1rioPreferred Reporting Items for Systematic Reviews and Meta-Analyses \u2013 PRISMA e registrada no International Prospective Register of Systematic Reviews (PROSPERO), sob o n\u00famero CRD42020187091.Nesse sentido, o presente estudo foi elaborado para analisar as evid\u00eancias dispon\u00edveis sobre o uso desse recurso nos movimentos mandibulares e na fun\u00e7\u00e3o mastigat\u00f3ria, aspectos que se integram e s\u00e3o de interesse central na interven\u00e7\u00e3o fonoaudiol\u00f3gica em Motricidade Orofacial, nos casos de DTM. Essa revis\u00e3o foi escrita com base no Desta forma, a proposta deste estudo foi realizar uma revis\u00e3o sistem\u00e1tica sobre as evid\u00eancias da fotobiomodula\u00e7\u00e3o com laser de baixa pot\u00eancia, com o objetivo de investigar os efeitos dessa t\u00e9cnica na fun\u00e7\u00e3o mastigat\u00f3ria e nos movimentos mandibulares em adultos com Disfun\u00e7\u00e3o Temporomandibular.Medical Subject Headings \u2013 MeSH da PubMed e dos EMTREE Terms algoritmo da EMBASE, considerando a patologia pesquisada, a interven\u00e7\u00e3o e os desfechos inclu\u00eddos na revis\u00e3o.A constru\u00e7\u00e3o da estrat\u00e9gia de busca foi realizada com a orienta\u00e7\u00e3o de uma bibliotec\u00e1ria, servidora da Institui\u00e7\u00e3o de origem, sendo adaptada para cada base de dados, utilizando os seus descritores espec\u00edficos. Os termos foram selecionados a partir da busca nos descritores Optou-se por utilizar uma estrat\u00e9gia de busca simplificada, escolhendo os principais termos indexadores dispon\u00edveis no vocabul\u00e1rio (tesauro) das bases de dados, pois com o teste pr\u00e9vio da estrat\u00e9gia de busca, percebeu-se que esses eram suficientes e permitiam a recupera\u00e7\u00e3o dos estudos eleg\u00edveis.Web of Science, Cochrane Library, Embase, Scopus, Science Direct, e realizou-se uma pesquisa adicional \u00e0 literatura cinzenta, no Google Scholar e Open Grey. Tamb\u00e9m foram analisadas as listas de refer\u00eancias dos artigos inclu\u00eddos no estudo, assim abrangendo alguma refer\u00eancia adicional que n\u00e3o tenha sido identificada durante a busca nos bancos de dados. Al\u00e9m disso, foi realizada a consulta no Registro Brasileiro de Ensaios Cl\u00ednicos, na tentativa de obter mais informa\u00e7\u00f5es acerca dos estudos inclu\u00eddos e identificar poss\u00edveis estudos em processo de andamento. A A busca foi realizada nas bases de dados: PubMed, Lilacs , software online (EndNote Web). Todas as pesquisas nos bancos de dados foram realizadas entre os dias 18 e 20 de maio de 2020. E foi realizada uma atualiza\u00e7\u00e3o da busca no dia 16 de setembro de 2020.Foi realizado o gerenciamento das refer\u00eancias e a remo\u00e7\u00e3o dos duplicados por meio do A quest\u00e3o norteadora para a elabora\u00e7\u00e3o dessa revis\u00e3o foi baseada na estrat\u00e9gia PICOT, sendo P- popula\u00e7\u00e3o \u2013 adultos com Disfun\u00e7\u00e3o Temporomandibular; I \u2013 interven\u00e7\u00e3o \u2013 Fotobiomodula\u00e7\u00e3o com Laser de Baixa Pot\u00eancia; C \u2013 comparador \u2013 Outras interven\u00e7\u00f5es ou aus\u00eancia de interven\u00e7\u00e3o; O \u2013 outcomes \u2013 medidas da fun\u00e7\u00e3o mastigat\u00f3ria e/ou movimentos mandibulares; T \u2013 tipos de estudos \u2013 Ensaios Cl\u00ednicos Randomizados. Assim, resultou-se na seguinte pergunta: \u201cQuais os efeitos do Laser de Baixa Pot\u00eancia no desempenho da fun\u00e7\u00e3o mastigat\u00f3ria e nos movimentos mandibulares em indiv\u00edduos com DTM, comparado a outras interven\u00e7\u00f5es ou \u00e0 aus\u00eancia de interven\u00e7\u00e3o?\u201d.Foram eleg\u00edveis artigos originais com delineamento de ensaio cl\u00ednico randomizado, sem restri\u00e7\u00f5es de per\u00edodo de tempo ou idioma. As pesquisas envolveram adultos com idade entre 18 e 60 anos, com diagn\u00f3stico cl\u00ednico de DTM, interven\u00e7\u00e3o com utiliza\u00e7\u00e3o do LBP e que avaliaram a fun\u00e7\u00e3o mastigat\u00f3ria e/ou os movimentos mandibulares. Foram exclu\u00eddos os artigos com outros delineamentos, com crian\u00e7as ou idosos, com texto completo indispon\u00edvel, com presen\u00e7a de outras comorbidades ou tratamentos associados e aplicados simultaneamente ao laser.Tais aspectos foram selecionados com base na faixa et\u00e1ria utilizada na maioria dos estudos da \u00e1rea, levando em considera\u00e7\u00e3o o desenvolvimento do sistema estomatogn\u00e1tico e as modifica\u00e7\u00f5es decorrentes do processo natural de envelhecimento, e como esses aspectos poderiam influenciar na mensura\u00e7\u00e3o dos efeitos da interven\u00e7\u00e3o. A presen\u00e7a de outras comorbidades e de outros tratamentos associados simultaneamente \u00e0 aplica\u00e7\u00e3o do LBP tamb\u00e9m impossibilitariam uma an\u00e1lise mais precisa dos resultados obtidos. E os principais desfechos elegidos se justificam pela sua relev\u00e2ncia cl\u00ednica na terapia fonoaudiol\u00f3gica nos casos de DTM.A sele\u00e7\u00e3o dos estudos envolveu duas etapas, sendo ambas realizadas pelos mesmos investigadores, de forma independente. Primeiramente, foi realizada a leitura dos t\u00edtulos e resumos de todos os estudos encontrados, com exclus\u00e3o daqueles que n\u00e3o se adequavam aos crit\u00e9rios de elegibilidade previamente estabelecidos. Na segunda etapa, foi realizada a leitura dos textos completos. Em ambas as etapas, foi verificada uma forte concord\u00e2ncia interavaliadores, por meio do Coeficiente Kappa de Cohen. As discord\u00e2ncias foram discutidas entre os autores em ambas as fases do processo de revis\u00e3o e quando n\u00e3o ocorreu o acordo final entre os mesmos, um terceiro revisor envolveu-se no processo, realizando independentemente a leitura dos estudos, bem como o julgamento da elegibilidade.Na fase de extra\u00e7\u00e3o dos dados, as informa\u00e7\u00f5es tamb\u00e9m foram coletadas de forma independente pelos dois revisores, sendo elaborado um instrumento espec\u00edfico para essa etapa e realizada a confer\u00eancia dos dados em uma reuni\u00e3o de consenso. Os dados dos artigos selecionados foram tabelados de acordo com algumas caracter\u00edsticas: autor, pa\u00eds, amostra, objetivo, par\u00e2metros de interven\u00e7\u00e3o, uso do RDC/TMD, tipo de interven\u00e7\u00e3o, desfechos, resultados e conclus\u00e3o. Quando os estudos apresentaram dados incompletos ou ausentes, os revisores entraram em contato por meio do e-mail dispon\u00edvel para correspond\u00eancia, buscando obter todas as informa\u00e7\u00f5es pertinentes.Risk-of-bias tool for randomized trials (RoB 2). E a an\u00e1lise da qualidade da evid\u00eancia foi realizada por meio do Grading of Recommendations Assessment, Development and Evaluation (GRADE).A qualidade metodol\u00f3gica dos estudos inclu\u00eddos foi avaliada individual e independentemente por dois revisores, de acordo com a ferramenta da Cochrane Para a metan\u00e1lise, a medida de efeito da interven\u00e7\u00e3o considerada foi a m\u00e9dia da amplitude de abertura da boca, pois verificou-se que era o principal par\u00e2metro utilizado para a avalia\u00e7\u00e3o dos movimentos mandibulares, na maioria dos estudos inclu\u00eddos. Apenas seis estudos apresentaram em seus resultados a m\u00e9dia, desvio padr\u00e3o e o n\u00famero de participantes de cada grupo, contribuindo diretamente para a s\u00edntese. J\u00e1 na avalia\u00e7\u00e3o da fun\u00e7\u00e3o mastigat\u00f3ria, apenas um estudo inclu\u00eddo considerou esse desfecho. A medida utilizada para fazer a metan\u00e1lise foi a m\u00e9dia e o desvio-padr\u00e3o, por meio do m\u00e9todo do inverso da vari\u00e2ncia, no software estat\u00edstico R.O detalhamento do processo de busca e sele\u00e7\u00e3o dos estudos est\u00e1 apresentado na -15 e cinco s\u00e3o internacionais-20. Dentre os trabalhos nacionais inclu\u00eddos, quatro s\u00e3o do estado de S\u00e3o Paulo,13-15 e um do Rio Grande do Sul. Com rela\u00e7\u00e3o aos demais artigos, tr\u00eas s\u00e3o de Istambul, na Turquia,18,20 e dois de Teer\u00e3, no Ir\u00e3,19.Dos dez estudos selecionados, cinco s\u00e3o brasileiros a 82 participantes. Quanto ao protocolo utilizado para o diagn\u00f3stico da DTM, oito utilizaram o Research Diagnostic Criteria for Temporomandibular Disorders RDC/TMD,14-20 e dois n\u00e3o apresentaram qual foi o instrumento utilizado para o diagn\u00f3stico,13.O tamanho da amostra teve uma varia\u00e7\u00e3o entre 15,16,17,19, tr\u00eas analisaram os movimentos protrusivos, de abertura e excurs\u00e3o lateral de mand\u00edbula,18,20 e, apenas um deles abordou a fun\u00e7\u00e3o mastigat\u00f3ria. O detalhamento das caracter\u00edsticas dos estudos inclu\u00eddos, bem como os seus principais resultados e conclus\u00f5es est\u00e1 apresentado no Sobre a fun\u00e7\u00e3o mastigat\u00f3ria e os movimentos mandibulares, seis estudos tiveram como um dos desfechos a amplitude de abertura da boca isoladamenteDos estudos que apresentaram resultados significativos com rela\u00e7\u00e3o \u00e0 amplitude de movimento mandibular, verificou-se que quanto maior a dose utilizada, os efeitos eram imediatos e mais expressivos, com mensura\u00e7\u00f5es entre a primeira, quinta, d\u00e9cima, d\u00e9cima segunda sess\u00f5es e at\u00e9 um m\u00eas ap\u00f3s a interven\u00e7\u00e3o com laser.,16,17,19. Com rela\u00e7\u00e3o aos movimentos verticais, de excurs\u00f5es laterais e protrus\u00e3o, tr\u00eas artigos,18,20 mostraram resultados estatisticamente significantes.Alguns estudos apontaram que os resultados de amplitude de abertura da boca n\u00e3o foram estatisticamente significativos entre os grupos.Apenas um estudo inclu\u00eddo avaliou a fun\u00e7\u00e3o mastigat\u00f3ria, demonstrando que a terapia de fotobiomodula\u00e7\u00e3o com LBP combinada com os exerc\u00edcios oromiofuncionais \u00e9 mais eficaz do que apenas o LBP isolado, com redu\u00e7\u00e3o dos sinais e sintomas da DTM e melhora dos movimentos mandibulares. Nesse estudo, os resultados dos escores gerais de mobilidade e de fun\u00e7\u00f5es indicaram resultados inferiores no grupo tratado apenas com a laserterapia, com diferen\u00e7as significativas entre os gruposDos dez estudos inclu\u00eddos, nove deles foram agrupados para a an\u00e1lise quantitativa dos resultados, por apresentarem a medida de amplitude de abertura da boca, sendo que, destes, apenas seis puderam ser utilizados na metan\u00e1lise. Verificou-se que os estudos eram muito distintos entre si, principalmente com rela\u00e7\u00e3o \u00e0 amplitude oral m\u00e1xima.2 = 60%, indicando heterogeneidade moderada. A Na an\u00e1lise quantitativa, pode-se observar que o losango do final do gr\u00e1fico reflete a combina\u00e7\u00e3o dos resultados. Como ele est\u00e1 do lado direito e n\u00e3o tocou o eixo, o tratamento com grupo experimental \u00e9 melhor, ou seja, mostrou resultados significativos. J\u00e1 o valor da coluna diferen\u00e7a de m\u00e9dias (MD), revela que o grupo experimental foi melhor 2,78 pontos numa escala de 0 a 100 nos modelos aleat\u00f3rios. Com rela\u00e7\u00e3o a heterogeneidade entre os estudos, I,14,17,18 apresentaram uma classifica\u00e7\u00e3o geral de alto risco de vi\u00e9s, dois foram classificados com algumas preocupa\u00e7\u00f5es,20 e tr\u00eas considerados de baixo risco,15,19 pela avalia\u00e7\u00e3o de qualidade aplicada.Os estudos inclu\u00eddos apresentaram bastante heterogeneidade metodol\u00f3gica. Cinco artigosAs principais limita\u00e7\u00f5es metodol\u00f3gicas encontradas nos estudos foram relativas \u00e0s informa\u00e7\u00f5es n\u00e3o contidas sobre a gera\u00e7\u00e3o de sequ\u00eancia aleat\u00f3ria, oculta\u00e7\u00e3o de aloca\u00e7\u00e3o e cegamento de participantes, conforme exposto na Como a revis\u00e3o utiliza desfechos provenientes de ensaios cl\u00ednicos randomizados, a avalia\u00e7\u00e3o da qualidade da evid\u00eancia foi iniciada com pontua\u00e7\u00e3o m\u00e1xima, sendo posteriormente rebaixada em alguns par\u00e2metros, conforme o  e est\u00edmulo muscular microel\u00e9trico (MENS) n\u00e3o apresentou resultados significativos com rela\u00e7\u00e3o ao desfecho de movimentos mandibulares. J\u00e1 ao comparar a estimula\u00e7\u00e3o el\u00e9trica nervosa transcut\u00e2nea (TENS) e o LBP, em um estudo mostrou-se efic\u00e1cia de ambas as terapias, havendo diferen\u00e7as entre os grupos apenas no efeito acumulativo; e no outro, n\u00e3o houve diferen\u00e7as significativas entre os grupos LBP e TENS, em todas as etapas.Os resultados evidenciaram que a compara\u00e7\u00e3o do laser com as interven\u00e7\u00f5es de toxina botul\u00ednica tipo A,18,19, percebeu-se que os resultados foram significativos e superiores para os grupos que receberam a interven\u00e7\u00e3o. No trabalho que comparou o laser com a TMO, identificou-se grandes resultados desta terapia de forma isolada, mas n\u00e3o foi combinada \u00e0 terapia de LBP, podendo ser uma poss\u00edvel alternativa para que se obtenham resultados mais significativos.Quando houve compara\u00e7\u00e3o entre duas modalidades de LBP diferentes ou com o grupo placeboVerificou-se que um importante aspecto a ser considerado diz respeito \u00e0 dose utilizada, pois alguns estudos utilizaram uma dose baixa, entre 1,5J \u2013 3J, que para os objetivos propostos, talvez n\u00e3o trouxesse signific\u00e2ncia, sendo necess\u00e1rio uma dose maior. Considerando tais resultados, percebeu-se uma grande inconsist\u00eancia entre os estudos inclu\u00eddos, bem como a presen\u00e7a de falhas metodol\u00f3gicas, fazendo com que cinco dos estudos ficassem com alto risco de vi\u00e9s, abaixando assim a qualidade da evid\u00eancia e a n\u00e3o confian\u00e7a dos mesmos.Tamb\u00e9m houve grande variabilidade no protocolo de laser utilizado em cada estudo. Com rela\u00e7\u00e3o ao n\u00famero de sess\u00f5es, os estudos mostraram que h\u00e1 um equil\u00edbrio entre 10 a 12 sess\u00f5es, como preconiza a literatura, pois \u00e9 considerado o n\u00famero de sess\u00f5es adequado para que se obtenham resultados significativos. Levando em considera\u00e7\u00e3o a periodicidade das sess\u00f5es, observou-se uma varia\u00e7\u00e3o entre uma vez por semana, todos os dias durante quatro semanas, cinco semanas ou quinzenalmente.2 a 105,0 J/cm2, a depender do equipamento que foi utilizado. Assim, os estudos revelam o quanto s\u00e3o heterog\u00eaneos, sendo necess\u00e1rio que, nos pr\u00f3ximos ensaios cl\u00ednicos com laser, sejam escolhidos protocolos mais homog\u00eaneos e com um maior rigor metodol\u00f3gico, para que os resultados possam ter uma evid\u00eancia mais confi\u00e1vel.Com rela\u00e7\u00e3o ao comprimento de onda, existiu uma varia\u00e7\u00e3o de 780nm a 904nm, identificando assim que todos os estudos utilizaram o comprimento de onda infravermelho. A maior dissemelhan\u00e7a entre os estudos foi quanto \u00e0 dose aplicada, que variou entre 1,5 J/cm-15, mostrando que o Brasil tem forte publica\u00e7\u00e3o na \u00e1rea da Fotobiomodula\u00e7\u00e3o e DTM, como tamb\u00e9m, tr\u00eas estudos integram o mesmo grupo de pesquisa-15. Quase todos ensaios cl\u00ednicos s\u00e3o de \u00e1reas como a Fisioterapia ou Odontologia e, apenas um artigo traz uma fonoaudi\u00f3loga entre os autores, o qual tamb\u00e9m \u00e9 o \u00fanico que analisa a fun\u00e7\u00e3o mastigat\u00f3ria. Isso pode ocorrer devido a essas ci\u00eancias utilizarem o laser h\u00e1 mais tempo e na Fonoaudiologia a regulamenta\u00e7\u00e3o de seu uso ocorreu apenas no ano de 2019, por meio da Resolu\u00e7\u00e3o de n\u00ba 541, associada a uma recente aplica\u00e7\u00e3o desse recurso na pr\u00e1tica cl\u00ednica.Dos 10 estudos, cinco s\u00e3o brasileirosTais aspectos demonstram que esses profissionais precisam executar mais pesquisas sobre fun\u00e7\u00e3o mastigat\u00f3ria e movimentos mandibulares, j\u00e1 que s\u00e3o fundamentais na terapia com DTM. Atualmente dispomos de achados cl\u00ednicos positivos, mas ainda necessitamos de maiores evid\u00eancias cient\u00edficas para recomendar a escolha terap\u00eautica e a tomada de decis\u00e3o pela utiliza\u00e7\u00e3o desse recurso em detrimento ou associado aos outros j\u00e1 dispon\u00edveis na \u00e1rea.. \u00c9 importante salientar que, na cl\u00ednica fonoaudiol\u00f3gica, essa tecnologia n\u00e3o deve ser utilizada para substituir terapias consistentes e de alta relev\u00e2ncia na \u00e1rea, mas sim como uma interven\u00e7\u00e3o coadjuvante e alternativa, a fim de promover uma acelera\u00e7\u00e3o no processo de tratamento. Assim, \u00e9 necess\u00e1ria uma interven\u00e7\u00e3o direcionada e individualizada, que envolva uma integra\u00e7\u00e3o entre as diversas abordagens envolvidas no cuidado aos indiv\u00edduos com DTM e considere os distintos aspectos fonoaudiol\u00f3gicos e odontol\u00f3gicos envolvidos na reabilita\u00e7\u00e3o dessa fun\u00e7\u00e3o.Considerando que o laser pode atuar estimulando ou inibindo a resposta do tecido, nos indiv\u00edduos com DTM, esse recurso pode favorecer o desenvolvimento das fun\u00e7\u00f5es alteradas, inclusive a mastiga\u00e7\u00e3o, que possui um impacto consider\u00e1vel nessa patologiaDiante do exposto, algumas implica\u00e7\u00f5es cl\u00ednicas decorrentes desse estudo se destacam. \u00c9 bastante evidente a necessidade da elabora\u00e7\u00e3o de protocolos de interven\u00e7\u00e3o, que tragam uma maior padroniza\u00e7\u00e3o de par\u00e2metros importantes, como a dosimetria, o n\u00famero e a periodicidade de sess\u00f5es, na busca por resultados terap\u00eauticos efetivos.Essa revis\u00e3o apresenta algumas contribui\u00e7\u00f5es ao apontar os principais par\u00e2metros considerados atualmente pela literatura cient\u00edfica da \u00e1rea e os resultados com eles obtidos. Tamb\u00e9m contribui ao evidenciar os efeitos obtidos com o laser comparados aos de outras interven\u00e7\u00f5es, facilitando assim a pr\u00e1tica cl\u00ednica dos fonoaudi\u00f3logos na \u00e1rea, sobre a escolha da melhor abordagem terap\u00eautica para o objetivo pretendido.Outro aspecto importante \u00e9 que a medida mais recorrentemente encontrada na literatura, seja como desfecho principal ou secund\u00e1rio, foi a amplitude de abertura da boca, sendo assim, verificou-se que a medida desse par\u00e2metro \u00e9 de fundamental import\u00e2ncia para a quantifica\u00e7\u00e3o dos resultados obtidos na interven\u00e7\u00e3o com o laser. Contudo, \u00e9 imprescind\u00edvel uma avalia\u00e7\u00e3o mais robusta, que considere crit\u00e9rios mais amplos na an\u00e1lise dos diversos movimentos mandibulares.Nesta revis\u00e3o sistem\u00e1tica, algumas limita\u00e7\u00f5es precisam ser apontadas. Foi encontrada uma consider\u00e1vel variabilidade na an\u00e1lise dos estudos inclu\u00eddos. Isso pode ocorrer devido \u00e0s caracter\u00edsticas dos estudos individuais, que s\u00e3o bem divergentes quanto \u00e0 metodologia aplicada . Dessa forma, mesmo que existam algunss efeitos positivos quanto a efic\u00e1cia do laser na DTM, os diversos par\u00e2metros metodol\u00f3gicos utilizados interferem nas conclus\u00f5es obtidas nos estudos individuais, que apresentam resultados distintos e conflitantes entre si.Al\u00e9m das diverg\u00eancias metodol\u00f3gicas encontradas entre os estudos, tamb\u00e9m foi verificada uma baixa qualidade da evid\u00eancia, com a presen\u00e7a de um vi\u00e9s consider\u00e1vel na maioria dos estudos. Destaca-se tamb\u00e9m os dados ausentes nos estudos e a dificuldade em conseguir as informa\u00e7\u00f5es para uma s\u00edntese quantitativa que inclu\u00edsse todos os resultados, permitindo uma an\u00e1lise mais ampla.Diante disso, neste estudo verificou-se que a fotobiomodula\u00e7\u00e3o com LBP n\u00e3o trouxe evid\u00eancias quanto ao efeito do LBP para o benef\u00edcio da fun\u00e7\u00e3o mastigat\u00f3ria, mas demonstrou os efeitos ben\u00e9ficos para o aumento da amplitude dos movimentos mandibulares. A terapia com LBP promoveu impactos positivos no aumento da amplitude de abertura da boca, com melhores resultados quando comparada \u00e0s outras interven\u00e7\u00f5es ou \u00e0 aus\u00eancia de tratamento, conforme demonstrado na metan\u00e1lise.Destaca-se a necessidade da elabora\u00e7\u00e3o de novos ensaios cl\u00ednicos, com protocolos mais homog\u00eaneos e com alta qualidade, para que novas abordagens cl\u00ednicas e evid\u00eancias cient\u00edficas surjam e possam ser replicadas, principalmente na \u00e1rea da Fonoaudiologia em que se apresentou uma escassez de estudos com \u00eanfase na fun\u00e7\u00e3o mastigat\u00f3ria.Tendo em vista que apenas um estudo abordou a fun\u00e7\u00e3o mastigat\u00f3ria, verificou-se que h\u00e1 uma escassez na literatura quanto \u00e0 an\u00e1lise dessa vari\u00e1vel. Portanto, n\u00e3o h\u00e1 informa\u00e7\u00f5es suficientes para realizar uma an\u00e1lise quanto aos efeitos da terapia de fotobiomodula\u00e7\u00e3o com LBP nessa fun\u00e7\u00e3o. Com rela\u00e7\u00e3o aos movimentos mandibulares, as pesquisas s\u00e3o muito vari\u00e1veis quanto aos par\u00e2metros metodol\u00f3gicos utilizados e desfechos pretendidos. Nos grupos de interven\u00e7\u00e3o, a Fotobiomodula\u00e7\u00e3o com LBP apresentou resultados significativos, evidenciados na s\u00edntese quantitativa do desfecho principal de amplitude de abertura da boca."}
+{"text": "Verify how demographic and socioeconomic variables on the in-noise speech recognition threshold (SRT) from the digits-in-noise test (DIN) in Brazilian Portuguese influence normal-hearing subjects.Cross-sectional, prospective study. The convenience sample had 151 normal-hearing subjects between 12 and 79 years (mean=34.66) who underwent pure tone audiometry and digits-in-noise test with white noise using a sequence of three numbers in diotic stimulus (in-phase) on the same day. The DIN was performed using a Motorola Z3 Play smartphone with internet access and in-ear headphones. In-noise digit speech recognition threshold (SRT) was analyzed for gender, age, educational levels, and socioeconomic status. We used the non-parametric version of the Kruskal-Wallis and Mann-Whitney U tests to compare independent samples adopting a significance level of 5%.The mean SRT was -8.47 dBNA (SD -3.89) with a median of -9.6 dBNA. The SRT was proportionally inverse to educational levels and socioeconomic status and more negative (better) with lower age groups. Gender did not influence the DIN SRT.Age, educational levels, and socioeconomic status influenced the DIN threshold. These variables must be considered when analyzing DIN performance in Brazilian Portuguese in normal-hearing subjects. In 2018, that estimation rose to 6.1%, corresponding to 466 million people living with auditory sensory deprivation. This estimate is that 700 million people will have disabling hearing loss. Besides, untreated hearing loss generates a high annual cost worldwide, ranging from around US$ 981 billion. Therefore, early detection and intervention are essential to lessening hearing loss impacts. Therefore, measures for hearing screening should be established at different stages of life, including neonates and infants, preschool-age children, and adults \u2014 especially older adults and other populations at greater risk due to exposure to noise, chemicals, and ototoxic medications.Hearing loss dramatically impacts people's lives, leading to changes in communication and learning that can cause social isolation, emotional problems, and low academic and professional performance must be validated for the appropriate populations that allow identifying hearing loss.Increasingly validated and reliable technologies need to be implemented to detect hearing loss as its prevalence grows. In addition, economic issues, easy-to-apply technologies, accessibility, and timeliness are essential. Therefore, hearing screening instruments.There is an exponential growth of mobile technologies transforming different aspects of society, including health care. It is a significant opportunity to make available several technical solutions. There are 346 million mobile devices in Brazil, 83% of which are cell phones, even though there is still inequality in distribution. It plays three-digit sequences (0-9) mixed with noise. The speech stimulus presentation level is fixed, and the masking noise level is adaptively increased or decreased until there is a signal/noise ratio in which individuals can correctly recognize 50% of the presented stimuli. That level is the speech recognition threshold (SRT),7.The digits-in-noise test (DIN) has become increasingly known among hearing screening procedures. The DIN was initially proposed in the Netherlands as an automated hearing screening using a landline phoneIn the DIN, groups of three digits are played diotically, that is, in both ears simultaneously with white noise. That is different from the dichotic digits test (DDT) used to assess central auditory processing in which two pairs of digits are presented simultaneously in both ears in a dichotic situation. Thus, the DIN and the DDT are distinct in stimulus presentation and purpose., making it suitable for populations with different language skills. Besides, it is similar to daily life hearing situations. Finally, as it is an automated procedure, users can perform it in minutes. The DIN has been translated into several languages such as English, Flemish, Finnish, Australian English, Turkish, South African English, Swedish, Chinese, and Greek.The DIN uses speech material (digits) with low linguistic demand in a closed set,8 administration in 2016 with a structure similar to the original proposal as these devices make it possible to provide users with a more user-friendly test. Additionally, the audio signal is broadband and digital, unlike a landline telephone whose bandwidth is approximately 300 to 3,400 Hz,8.It was adapted for mobile device.Screening methods that make it easier for populations to access information related to hearing health and reduce the demands for assistance in health care units have been the foundation for several pieces of research in both the academic environment and tech field. These methods can be used to identify hearing loss, reduce expenses, and facilitate monitoring and early detection, even in the DIN Portuguese version.Its application using smartphones' headphones compared to headphones traditionally attached to audiometers showed the same results which contributes to its wide use and widespread access to a simple screening instrument due to its low cost and high sensitivity. The DIN was recently translated and adapted into Brazilian Portuguese,12,13. The World Health Organization has indicated it for hearing screening due to its features, and it is available for download in app stores as \u201cHearWHO App.\u201dIt is a tool with great potential for hearing screening as it simulates everyday listening situations in an adaptive test.A scoping review compiled 39 studies which were selected out of 95 studies related to the \u201cdigit triplet test\u201d and \u201cdigits in noise.\u201d The authors discuss several variables between the studies, such as test language, speech and noise material, platform, procedural aspects, stimulation method, speech/noise adaptation, measurement procedure, aspects of validity, and reliability. They discovered that studies with the DIN in the last fifteen years have shown that the test is highly reliable and efficient to measure functional hearing loss and estimate hearing loss in different age groups and populations. A DIN study conducted in English in South Africa showed that English competence affected the auditory performance of subjects in 11 different languages.Different countries have intrinsic test changes, which means there might be a connection to social determinants of health (SDH). SDH express that individuals and population groups' living and working conditions are related to their health situation, including social, economic, cultural, ethnic/racial, psychological, and behavioral factors, which shows a connection between hearing and SDH. Studies performed in China and the United States have shown relationships between hearing loss and lower socioeconomic and educational levels,17. The World Health Organization's World Hearing Report (2021) also portrays that reality. A preliminary accuracy study in Brazil using the DIN found that factors external to the test and intrinsic to subjects, such as age, education, and socioeconomic status, may influence results did not find studies with those specific objectives, which shows limited literature on the impact of educational and socioeconomic statuses on the DIN SRT. As the DIN in Brazilian Portuguese is currently undergoing validation, it is essential to know its results against demographic and socioeconomic variables in normal-hearing subjects so that they can be exempt from the influence of type, degree, and configuration of hearing loss in hearing-impaired subjects, to whom the DIN is intended.The analysis of the influence of social determinants of health can contribute so that in the validation process of new tests, including hearing screening, these variables are considered at the cut-off points to adapt the test methodology to each country's social reality. Unfortunately, the scope reviewConsequently, this study aims to analyze the influence of demographic and socioeconomic variables on the DIN in Brazilian Portuguese on normal-hearing subjects.This prospective multi center cross-sectional study was approved by the Hospital Universit\u00e1rio Onofre Lopes's Human Research Ethics Committee (protocol No. 2525183). All participants or guardians signed an informed consent or assent form, and subjects between 12 and 18 years old signed the assent form.This study sample had 151 normal-hearing subjects between 12 and 79 years old (34.66\u00b116.17). The subjects were from the Brazilian states of Rio Grande do Norte and Paraiba and underwent pure-tone audiometry, tympanometry, and the digits-in-noise test subsequently on the same day. Subjects from Para\u00edba were recruited and assessed at the Hospital da Universidade Federal da Para\u00edba, and those from Rio Grande do Norte attended a hearing health service provider accredited to the Sistema Unico de Sa\u00fade (SUS) through convenience samples between September 2018 and March 2020. The teams performing the DIN and pure-tone audiometry in both centers were trained and followed the same collection procedures. They were both in a multi-center study between Universidade Federal do Rio Grande do Norte, Hospital da Universidade Federal da Para\u00edba, Faculdade de Odontologia da Universidade de S\u00e3o Paulo e University of Pretoria, and South African company hearX. The researchers recruited the subjects in the waiting room of the hearing health service provider.Study participants met the following inclusion criteria: Subjects aged 12 years or older who underwent pure-tone audiometry and could identify the graphic representation of the digits 0 to 9 with no motor or uncorrected visual impairment, as well as cognitive deficit or known neurological disorders. Additionally, they presented a four-tone average of up to 25 dB HL in the pure-tone audiometry in both ears and had no middle ear alterations confirmed by tympanometry with peak pressure between +100 to -100 daPA and compliance greater than 0.3 cc. Subjects were considered normal hearing according to this criterion.. The researchers first registered subjects in the test version of the DIN. In a non-acoustically treated quiet environment, all subjects were instructed to listen to three-digit sequences mixed with white noise played simultaneously and then click the numbers they would hear using the smartphone. If they did not hear any of the digits, they were instructed to assume a sequence of digits to proceed. After instructions and before starting the test, the subjects were informed that they could adjust the test volume according to the preliminary version of the application to ensure that they could hear the numbers clearly and comfortably. That was the only volume adjustment performed by the user as it also occurs in the final version of the application available in other languages. The device volume was fixed at its maximum level.A Motorola Z3 Play smartphone with internet access performed the test version of the DIN. That preliminary version of the application was developed for Brazilian research. Original smartphone in-ear headphones were used for the procedure with the original adapter connecting the headphones to the smartphone. A preliminary study showed no difference in in-noise digit speech recognition threshold (SRT) of the DIN between the in-ear headphones and the TDH-3910The test randomly showed 23 three-digit sequences (0-9) in white noise at 70 dB SPL in a fixed signal-to-noise ratio between -20 dB to 20 dB in diotic mode (in-phase). The sequences were initially presented at a signal/noise ratio of 0 dB and varied according to the patient's responses. The researcher did not interfere. The first three presentations of each stimulus were considered training and thus disregarded from the final result. The subjects were instructed to type the three-digit sequence that they had heard with the noise on the smartphone's virtual keyboard. The following speech signal and noise had a lower signal-to-noise ratio if they selected the correct sequence. However, if they selected the wrong sequence, the software would increase the signal-to-noise ratio the next time, with a dB variation in both cases. After the 23 sequences, the software generated the digit recognition threshold (SRT) in noise using the average signal-to-noise ratio between sequences 4 and 23. The final screen displayed a number representing the SRT value. In addition, the application would download a table with each subject's presentation's detailed results. This data was then tabulated in an Excel database. More negative DIN SRT values are expected in normal-hearing subjects, which means better performance in the test..Pure-tone audiometry was performed in a soundproof booth with an AD229e calibrated audiometer to determine the audiological status. Tested frequencies ranged from 250 Hz to 8,000 Hz in the airway and 500 Hz to 4,000 Hz in the bone pathway when patients had a minimal response in any of these frequencies at an intensity greater than 25 dB HL in the airway test. Those with four-tone mean auditory thresholds  up to 25 dB HL in both ears were classified as normal-hearingData were collected independently by the speech-language pathologists who performed the pure-tone audiometry and those who applied the DIN. As a result, the team only learned the results of each procedure during data tabulation.In addition to the audiological tests, all subjects orally answered a questionnaire to collect the following demographic variables: Age and gender, and the socioeconomic variables educational levels and socioeconomic status.The sample was subdivided into the following age groups: G1: 12-19, G2: 20-39, G3: 40-59, G4: 60-79 years old.Educational levels were split into three levels: \u201cLow\u201d for subjects who declared themselves illiterate or who had not completed elementary school, corresponding to 0-9 years of school time; \u201cAverage\u201d for subjects who completed elementary or high school, equivalent to 9-16 years of school time; and \u201cHigh\u201d for those with incomplete or complete higher education, totaling more than 16 years of school time. questionnaire was applied to assess socioeconomic status. The document is divided into two categories. The first includes which and how many \u201citems\u201d participants have at home, including bathrooms, computers, dishwashers, automobiles, microwave ovens, among others. The second category is the family's provider's educational level (school years) and access to public services (piped water supply and paved streets). Therefore, this study was divided into three socioeconomic statuses based on the analysis proposed by ABEP: \u201clow\u201d for subjects scoring 1-16 points; \u201cmedium\u201d for 17-28 points; \u201chigh\u201d for 29-100 points.The Associa\u00e7\u00e3o Brasileira de Empresas de Pesquisa (ABEP)The Kolmogorov-Smirnov test was used to check for distribution normality during data analysis. As normal distribution was not found, the non-parametric version of the Kruskal-Wallis and Mann-Whitney U tests were used to compare the independent variables  against the dependent variable, which was the DIN SRT value. A significance level of 5% was adopted.This study sample had 151 normal-hearing subjects between 12 and 79 years old (34.66\u00b116.17). The DIN SRT of the total sample of normal hearing subjects had a median of -9.6 dB, a minimum value of -13 dB and a maximum value of +1.8 dB of the DIN SRT.All variables but gender influenced the DIN SRT result. As for age groups, the youngest group (12-19 years old) had a significantly better DIN SRT only when compared to older adults (60-79 years old). On the other hand, adults between 20 and 39 years old had better DIN SRT when compared to adults between 40 and 59 years old and older adults over 60 years old.This study found that the DIN SRT in Brazilian Portuguese in normal-hearing subjects is related to educational level, socioeconomic status, and age group. Gender did not influence the DIN SRT. reported in normal-hearing subjects (-10.7 dB for both ears < 15 dB four-tone mean). However, it is similar to the cut-off value these authors found of -8.4 dB for the best ear or -8.9 dB for both ears with normal hearing (<15dB four-tone average).The average of -8.47 dB in the DIN SRT in diotic condition (in-phase) found in normal-hearing subjects in this study is higher than the average Potgieter et al.. On the other hand, people with better English skills or native speakers had the average DIN SRT at -10.4 and -10.2 dB, respectively.The expected results are similar to the average DIN SRT of subjects who do not speak English (-8.7 dB),21, as identified in this sample. However, due to the influence of socioeconomic and demographic variables, the SRT result was not similar to the findings in the full version of the test.The digit test assessment proved reliable in groups of normal-hearing subjects and people with hearing aids and cochlear implants. It is a tool for hearing screening and evaluating the rehabilitation process.The studied sample had 72.18% of female subjects, although this predominance over male subjects was not evidenced by the difference between the results of the DIN SRT between genders. This variable was not a predictor of DIN SRT results in a study with English SRT with varied English competencies and speakers of different languages in South Africa. A similar result was found in the study with DIN in Brazilian Portuguese with normal-hearing children without auditory processing disorders and with auditory processing disorder aged between 8 and 11 years. The SRT values for these two groups had means similar to those found in another study with a digits-in-noise test in Brazilian Portuguese. That may indicate the impact of the sociodemographic differences, something typical to the sample since these studies' populations come from the same region despite having different age groups.Subjects over 60 years old had worse diotic DIN SRT when compared to younger subjects (12-39 years old). That result is different from another study with SRT results similar to those of young people starting at 12 years old. Even though these are minor difficulties, they may pose a challenge and inconvenience for this age group when interacting with their smartphones. Researchers addressed the need to consider age when determining test results as their accuracy may differ based on the age group. These authors showed that age could be a significant predictor of the DIN SRT for hearing subjects with better ears MQ\u226425 dB HL.A retrospective study with 24,072 subjects found that age impacts DIN results. That may be due to older adults' decreased cognition and difficulty understanding explanations.Similar information can be found in a study that found decreased cognitive aspects and auditory processing skills with other in-noise speech recognition tasks as subjects aged. Additionally, other studies may consider a cognitive screening to identify how these potential changes may impact DIN results.Thus, considering age when determining the RDT result in normal-hearing subjects is essential as it may contribute to screening test accuracyAlthough most subjects in this study had high educational levels, subjects with higher education levels tend to have better speech understanding in noise with better SRT..Different researchers also realized that the difference in educational level is related to hearing difficulties for auditory processing activities. Among their hypotheses is the difference in the history of the older adults who had precarious access to education.Speech understanding in noise is also impaired in auditory processing activities due to a lower educational level. It is up to discussion whether that result is influenced by working memory in addition to auditory factors, although that feature is significant in other auditory processing skills but not in the speech-in-noise testSocioeconomic status considers education, occupation, and income; therefore, socioeconomic and educational level variables addressed in this study are directly related. The statistical analysis in this study shows that equivalence. There is a statistically significant difference between low, medium, and high groups for educational level and socioeconomic status. That is, the higher the socioeconomic status and educational level, the more negative the DIN SRT value.. Among the world population with hearing loss, there is a higher prevalence in low- and middle-income countries in addition to low health care service capacity. Thus, the prevalence of this disorder changes according to the region, and the socioeconomic component is one of its determining factors.Socioeconomic status is intrinsically related to health, so higher-income people are usually healthier than those with lower socioeconomic statuses.Socioeconomic and educational factors can be related to individuals' audiological status. For example, a study with 3379 people in the United States showed a direct correlation between socioeconomic status, educational level and hearing loss, showing that this impairment may be a factor or a product of socioeconomic status. In addition, research revealed associations between unemployment, age, education, gender, and hearing status. As for the DIN, individuals with normal hearing (confirmed through pure-tone audiometry) generally did not perform appropriately for their audiological status, has caused a worldwide concern given their excessive use of individual music devices used with loud volumes.Besides health promotion and prevention methods through digital technologies, professionals should always consider the influence of aging on the DIN, especially with older adults, due to their physical restrictions and difficulty in handling electronic devices. Still, the DIN is likely to target the younger population that, despite its lower prevalence of hearing lossTherefore, it would be ideal to consider the different factors studied in the DIN result, adopting different cut-off points according to the individual's socioeconomic status, educational level or age group.When analyzing factors that may have changed search results, the available test version used for testing digits in noise stands out. Its access through an online link made it impossible to use when there was no internet connection. As its response to touchscreens is still not fully deployed, the researcher needed to intervene sometimes to zoom out after users accidentally double-tapping their devices. User experience could be improved through the final app version.Different age groups, educational level and socioeconomic status characteristics, and other Northeastern Brazilian population features could also impact the results, which is why we suggest further studies in different Brazilian regions.Further studies must check the finished app version against its trial version. Besides, future research should consider analyzing demographic and socioeconomic variables studied at the test cut-off point to achieve better accuracy in the digits-in-noise test in Portuguese, considering population characteristics and favoring its large-scale application as a tool to identify hearing loss.The diotic digits-in-noise test in Brazilian Portuguese is associated with extrinsic variables, showing better responses in people between 20 and 39 years of age with high socioeconomic status and educational levels. Gender did not influence digit recognition in the DIN. .Em 1985, a Organiza\u00e7\u00e3o Mundial de Sa\u00fade estimava que 1% da popula\u00e7\u00e3o mundial possu\u00eda perda auditiva incapacitante. Em 2018, a estimativa subiu para 6,1%, o que corresponde a 466 milh\u00f5es de pessoas vivendo com priva\u00e7\u00e3o sensorial auditiva. A proje\u00e7\u00e3o dessa estimativa \u00e9 que at\u00e9 2050, 700 milh\u00f5es de pessoas tenham perda auditiva incapacitante. Al\u00e9m disso, perdas auditivas n\u00e3o tratadas geram no mundo todo um alto custo anual, numa faixa de 981 bilh\u00f5es de d\u00f3lares. A fim de diminuir os impactos da defici\u00eancia auditiva, a detec\u00e7\u00e3o e interven\u00e7\u00e3o precoce s\u00e3o necess\u00e1rias. Portanto, medidas para a triagem auditiva devem ser estabelecidas nos diferentes est\u00e1gios de vida, incluindo neonatos e beb\u00eas, crian\u00e7as em idade pr\u00e9-escolar, adultos - especialmente os mais velhos e outras popula\u00e7\u00f5es que apresentam maior risco em fun\u00e7\u00e3o de exposi\u00e7\u00e3o a ru\u00eddo, produtos qu\u00edmicos e medicamentos otot\u00f3xicos.A perda auditiva possui diversos impactos sobre a vida de uma pessoa, levando, de maneira geral, a altera\u00e7\u00f5es na comunica\u00e7\u00e3o e na aprendizagem e assim podendo conduzir ao isolamento social, problemas emocionais, baixo desempenho acad\u00eamico e/ou profissional validados para as popula\u00e7\u00f5es em que ser\u00e3o aplicados, permitindo a identifica\u00e7\u00e3o da perda auditiva.\u00c9 necess\u00e1ria uma implementa\u00e7\u00e3o de tecnologias cada vez mais v\u00e1lidas e confi\u00e1veis para detectar perdas auditivas na medida que a sua preval\u00eancia cresce. Quest\u00f5es econ\u00f4micas, tecnologias de f\u00e1cil aplica\u00e7\u00e3o, acessibilidade e rapidez s\u00e3o essenciais para isso. Portanto \u00e9 necess\u00e1rio a utiliza\u00e7\u00e3o de instrumentos de rastreio auditivo.H\u00e1 um crescimento exponencial das tecnologias m\u00f3veis que vem transformando diferentes aspectos da sociedade, incluindo a \u00e1rea da sa\u00fade. Isso representa uma importante oportunidade para dissemina\u00e7\u00e3o de variadas solu\u00e7\u00f5es desta natureza. No Brasil existem 346 milh\u00f5es de dispositivos m\u00f3veis, sendo 83% destes celulares, embora ainda exista desigualdade de distribui\u00e7\u00e3o. Neste teste, sequ\u00eancias de tr\u00eas d\u00edgitos (0 a 9) s\u00e3o apresentadas na presen\u00e7a de ru\u00eddo. O n\u00edvel de apresenta\u00e7\u00e3o do est\u00edmulo de fala \u00e9 fixo e o n\u00edvel do ru\u00eddo mascarante \u00e9 adaptativamente aumentado ou diminu\u00eddo, at\u00e9 que se obtenha a rela\u00e7\u00e3o sinal/ru\u00eddo em que o indiv\u00edduo conseguiu reconhecer corretamente 50% dos est\u00edmulos apresentados. Este n\u00edvel \u00e9 chamado limiar de reconhecimento de fala (LRF),7.Dentre os procedimentos para a triagem auditiva, o teste de d\u00edgitos no ru\u00eddo (TDR) vem ganhando notoriedade. O TDR foi proposto inicialmente na Holanda, como forma de triagem auditiva automatizada, por meio de telefone fixoDestaca-se que o TDR \u00e9 um teste no qual os trios de d\u00edgitos s\u00e3o apresentados dioticamente, isto \u00e9, nas duas orelhas simultaneamente com o ru\u00eddo branco, sendo diferente do Teste dic\u00f3tico de d\u00edgitos (TDD) utilizado na avalia\u00e7\u00e3o do processamento auditivo central no qual s\u00e3o apresentados dois pares de d\u00edgitos simultaneamente nas duas orelhas em situa\u00e7\u00e3o dic\u00f3tica. Desta forma, tanto na apresenta\u00e7\u00e3o dos est\u00edmulos quanto na sua finalidade o TDR e o TDD s\u00e3o distintos., fazendo com que seja adequado para popula\u00e7\u00f5es com distintas compet\u00eancias de linguagem. Al\u00e9m disso, o teste se aproxima de situa\u00e7\u00f5es de escuta reais. Finalmente, por se tratar de um procedimento automatizado, pode ser realizado em quest\u00f5es de minutos pelo pr\u00f3prio usu\u00e1rio. Este teste foi traduzido para diversos idiomas como ingl\u00eas, flamengo, finland\u00eas, australiano-ingl\u00eas, turco, ingl\u00eas sul-africano, sueco, chin\u00eas e grego.O TDR utiliza um material de fala (d\u00edgitos) com baixa demanda lingu\u00edstica e apresentado em conjunto fechado,8. com estrutura semelhante \u00e0 proposta \u00e0 original. O uso destes dispositivos possibilita fornecer ao usu\u00e1rio um teste mais amig\u00e1vel e, al\u00e9m disto, o sinal de \u00e1udio produzido \u00e9 de banda larga e qualidade digital, diferentemente do telefone fixo cuja largura de banda \u00e9 de aproximadamente 300 a 3400 Hz,8A partir de 2016, o TDR foi adaptado para administra\u00e7\u00e3o via dispositivos m\u00f3veis.M\u00e9todos de triagem que facilitam o acesso da popula\u00e7\u00e3o a informa\u00e7\u00f5es que se referem \u00e0 sa\u00fade auditiva e diminuem as demandas de atendimentos nas Unidades de Sa\u00fade t\u00eam sido base para diversas pesquisas no meio acad\u00eamico e na \u00e1rea tecnol\u00f3gica. Isso se deve ao fato de que esses m\u00e9todos podem ser usados como ferramentas na identifica\u00e7\u00e3o da perda auditiva, reduzindo gastos e facilitando o monitoramento e detec\u00e7\u00e3o precoce da mesmasmartphone em comparativo a fones que s\u00e3o tradicionalmente acoplados aos audi\u00f4metros apresentaram os mesmos resultados, inclusive na vers\u00e3o em Portugu\u00eas do TDR.Sua aplica\u00e7\u00e3o com uso de fones de ouvido do pr\u00f3prio , contribuindo para uma ampla utiliza\u00e7\u00e3o, permitindo, \u00e0 popula\u00e7\u00e3o, o acesso a um instrumento de triagem simples, por possuir baixo custo e alta sensibilidade. O TDR foi recentemente traduzido e vem sendo adaptado para o portugu\u00eas brasileiro,12,13. Por suas caracter\u00edsticas, \u00e9 indicado para rastreio auditivo pela Organiza\u00e7\u00e3o Mundial de Sa\u00fade e disponibilizado nas plataformas de download com o t\u00edtulo HearWHO App.\u00c9 uma ferramenta com alto potencial para triagem auditiva, pois simula situa\u00e7\u00f5es de escuta cotidiana em teste adaptativodigit triplet test\u201d e/ou \u201cdigits in noise\u201d. Os autores discutem sobre diversas vari\u00e1veis entre os estudos como o idioma do teste, o material de fala e ru\u00eddo utilizados, plataforma, aspectos procedimentais, m\u00e9todo de estimula\u00e7\u00e3o, adapta\u00e7\u00e3o de fala/ru\u00eddo, procedimento de medi\u00e7\u00e3o, aspectos de validade e confiabilidade. Os autores, acabam por ressaltar que os estudos com o TDR, nos \u00faltimos quinze anos, evidenciaram ser este um teste altamente confi\u00e1vel e eficiente para medir a perda da capacidade auditiva funcional, bem como para estimar a perda auditiva de pessoas em diferentes faixas-et\u00e1rias e popula\u00e7\u00f5es.Em uma revis\u00e3o de escopo, foi apresentada uma compila\u00e7\u00e3o de 39 estudos selecionados a partir da identifica\u00e7\u00e3o de 95 estudos relacionados ao \u201c. Dentro de estudo com TDR em ingl\u00eas na \u00c1frica do Sul, foi observada a influ\u00eancia do n\u00edvel de compet\u00eancia em ingl\u00eas no desempenho auditivo de sujeitos falantes de 11 diferentes l\u00ednguas.Ao redor do mundo, \u00e9 poss\u00edvel observar altera\u00e7\u00f5es intr\u00ednsecas do teste, evidenciando uma poss\u00edvel rela\u00e7\u00e3o com os Determinantes Sociais da Sa\u00fade (DSS). Os DSS expressam que as condi\u00e7\u00f5es de vida e trabalho de indiv\u00edduos e/ou grupos populacionais tem rela\u00e7\u00e3o com a sua situa\u00e7\u00e3o de sa\u00fade, podendo ser citados os fatores sociais, econ\u00f4micos, culturais, \u00e9tnicos/raciais, psicol\u00f3gicos e comportamentais, evidenciando as rela\u00e7\u00f5es entre audi\u00e7\u00e3o e DSS. Estudos realizados na China e nos Estados Unidos evidenciaram rela\u00e7\u00f5es da perda auditiva com menores n\u00edveis socioecon\u00f4micos e de escolaridade,17. O relat\u00f3rio mundial da audi\u00e7\u00e3o da Organiza\u00e7\u00e3o Mundial de Sa\u00fade (2021) tamb\u00e9m retrata esta realidade. Em estudo preliminar de acur\u00e1cia no Brasil utilizando o TDR foi observado poss\u00edvel influ\u00eancia de fatores externos ao teste e intr\u00ednsecos ao sujeito como idade, escolaridade e n\u00edvel socioecon\u00f4mico n\u00e3o foram evidenciados estudos que tivessem estes objetivos como foco de suas investiga\u00e7\u00f5es cient\u00edficas, o que acaba por evidenciar uma literatura restrita sobre o impacto do n\u00edvel de escolaridade e socioecon\u00f4mico no LRF do TDR. Como o TDR na l\u00edngua Portuguesa \u00e9 um teste em processo de valida\u00e7\u00e3o \u00e9 de suma import\u00e2ncia conhecer quais os seus resultados frente as vari\u00e1veis demogr\u00e1ficas e socioec\u00f4micas em normo-ouvintes para que possam estar isentas da influ\u00eancia do tipo, grau e configura\u00e7\u00e3o da perda auditiva nas pessoas com defici\u00eancia auditiva, para o qual o TDR se destina.A an\u00e1lise da influ\u00eancia dos determinantes sociais de sa\u00fade pode contribuir para que no processo de valida\u00e7\u00e3o de novos testes, inclusive de triagem auditiva, sejam consideradas, estas vari\u00e1veis nos pontos de corte dos testes, no intuito, de adequar a metodologia do teste a realidade social do Pa\u00eds no qual ela est\u00e1 sendo proposta. Infelizmente, na revis\u00e3o de escopoDiante do exposto, o objetivo deste estudo foi analisar a influ\u00eancia de vari\u00e1veis demogr\u00e1ficas e socioecon\u00f4micas no TDR em portugu\u00eas brasileiro de normo-ouvintes.Este estudo transversal, prospectivo e multic\u00eantrico foi aprovado pelo Comit\u00ea de \u00c9tica em Pesquisa do Hospital Universit\u00e1rio Onofre Lopes (n\u00ba 2525183). Todos os participantes ou respons\u00e1veis assinaram o Termo de Consentimento ou Assentimento Livre e Esclarecido (TCLE), e os sujeitos entre 12 a 18 anos assinaram o Termo de Assentimento.Hear X da \u00c1frica do Sul. Os sujeitos foram recrutados pelos pesquisadores na sala de espera do Servi\u00e7o de Sa\u00fade Auditiva.A amostra deste estudo foi composta por 151 sujeitos normo-ouvintes com idade entre 12 a 79 anos . Participaram deste estudo sujeitos do Rio Grande do Norte e da Para\u00edba, que realizaram audiometria tonal liminar, timpanometria e o teste de d\u00edgitos no ru\u00eddo em sequ\u00eancia no mesmo dia. Os sujeitos da Para\u00edba foram recrutados e avaliados no Hospital Universit\u00e1rio da Universidade Federal da Para\u00edba, enquanto os do Rio Grande do Norte compareceram a um Servi\u00e7o de Sa\u00fade Auditiva credenciado ao Sistema \u00danico de Sa\u00fade por meio de amostras de conveni\u00eancia entre setembro de 2018 e mar\u00e7o de 2020. As equipes envolvidas na aplica\u00e7\u00e3o do TDR e realiza\u00e7\u00e3o da audiometria tonal liminar em ambos os locais foram treinados e seguiram os mesmos procedimentos de coleta, estando envolvidos num estudo Multic\u00eantrico entre a a Universidade Federal do Rio Grande do Norte, Universidade Federal da Para\u00edba, Faculdade de Odontologia de Bauru da Universidade de S\u00e3o Paulo, Universidade de Pret\u00f3ria e empresa Participaram do estudo aqueles que se encaixavam no crit\u00e9rio de inclus\u00e3o: sujeitos com idade maior ou igual a 12 anos, que tivessem realizado audiometria tonal liminar, que pudessem identificar a representa\u00e7\u00e3o gr\u00e1fica dos d\u00edgitos de 0 a 9 e que n\u00e3o apresentassem alguma defici\u00eancia motora ou visual n\u00e3o corrigida, bem como d\u00e9ficit cognitivo ou dist\u00farbios neurol\u00f3gicos conhecidos, al\u00e9m de apresentar m\u00e9dia quadritonal at\u00e9 25 dB NA na audiometria tonal liminar bilateralmente, sem altera\u00e7\u00f5es de orelha m\u00e9dia confirmada pela presen\u00e7a de timpanometria com pico de press\u00e3o entre +100 a -100daPA e complac\u00eancia maior do que 0,3 cc. Este foi o crit\u00e9rio adotado para considerar os sujeitos como normo-ouvintes.smartphone Motorola Z3 play com acesso \u00e0 internet da vers\u00e3o teste do TDR. Esta vers\u00e3o foi desenvolvida para a realiza\u00e7\u00e3o das pesquisas no Brasil, sendo uma vers\u00e3o preliminar do aplicativo. Foram utilizados fones intra-auriculares originais do smartphone para o procedimento com adaptador original para conectar os fones ao celular. Estudo preliminar n\u00e3o evidenciou diferen\u00e7a limiar de reconhecimento de d\u00edgitos no ru\u00eddo (LRF) do TDR entre os fones intra-auriculares e o TDH-39. Os pesquisadores realizaram o registro inicial dos sujeitos na vers\u00e3o teste do TDR. Em ambiente silencioso, por\u00e9m n\u00e3o acusticamente tratado, todos os sujeitos foram orientados a escutarem sequ\u00eancias de tr\u00eas d\u00edgitos em meio a um ru\u00eddo branco apresentado simultaneamente e clicarem os n\u00fameros que ouviriam na tela do smartphone. Caso o sujeito n\u00e3o escutasse algum dos d\u00edgitos, era orientado a supor uma sequ\u00eancia de d\u00edgitos para dar sequ\u00eancia ao teste. Ap\u00f3s a instru\u00e7\u00e3o e antes do in\u00edcio do teste, os sujeitos eram informados que poderiam ajustar o volume do teste na op\u00e7\u00e3o pr\u00f3pria da vers\u00e3o preliminar do aplicativo, para garantir que escutassem os n\u00fameros de maneira clara e confort\u00e1vel. Esse foi o \u00fanico ajuste de volume, realizado pelo pr\u00f3prio usu\u00e1rio como tamb\u00e9m ocorre na vers\u00e3o final do aplicativo disponibilizada em outros idiomas, estando o volume do dispositivo fixo no m\u00e1ximo.Para a realiza\u00e7\u00e3o do TDR foi utilizado um inphase). As sequ\u00eancias foram apresentadas inicialmente numa rela\u00e7\u00e3o sinal/ru\u00eddo de 0dB e variaram conforme respostas do paciente sem interfer\u00eancia do pesquisador. As tr\u00eas primeiras apresenta\u00e7\u00f5es de cada est\u00edmulo foram desconsideradas do resultado final, atuando como momento de treinamento. Os sujeitos foram orientados a selecionar no teclado virtual do smartphone, a sequ\u00eancia de tr\u00eas d\u00edgitos que havia escutado junto ao ru\u00eddo. Em caso de acerto, o sinal de fala seguinte e o ru\u00eddo apresentavam uma rela\u00e7\u00e3o sinal ru\u00eddo menor. Contudo, caso o sujeito errasse a sequ\u00eancia, o software iria aumentar a rela\u00e7\u00e3o sinal ru\u00eddo na pr\u00f3xima sequ\u00eancia. Essa varia\u00e7\u00e3o foi de 2 decib\u00e9is em ambos os casos. Ap\u00f3s as 23 sequ\u00eancias, era gerado pelo software o limiar de reconhecimento de d\u00edgitos no ru\u00eddo (LRF) pela m\u00e9dia da rela\u00e7\u00e3o sinal ru\u00eddo entre as sequ\u00eancias 4 e 23. Na tela final era mostrado um n\u00famero, que representa o valor do LRF. Al\u00e9m disso, foi realizado o download em uma tabela, com os resultados detalhados de cada apresenta\u00e7\u00e3o por sujeito. Estas informa\u00e7\u00f5es foram tabuladas em banco de dados no Excel. Espera-se em normo-ouvintes valores do LRF do TDR mais negativos que significam melhor desempenho no teste.O teste envolveu apresenta\u00e7\u00e3o aleat\u00f3ria de 23 sequ\u00eancias de tr\u00eas d\u00edgitos (0-9) no ru\u00eddo branco a 70 dB SPL numa rela\u00e7\u00e3o sinal-ru\u00eddo fixada entre -20dB a 20dB de modo di\u00f3tico  at\u00e9 25 dB NA em ambas as orelhasOs dados foram coletados de forma independente, tanto pelos fonoaudi\u00f3logos que realizaram a audiometr\u00eda tonal liminar e como pelos que aplicaram o TDR. O resultado de cada procedimento foi conhecido pela equipe apenas na tabula\u00e7\u00e3o dos dados.Al\u00e9m dos testes audiol\u00f3gicos, todos os sujeitos responderam oralmente a um question\u00e1rio para a coleta das seguintes vari\u00e1veis demogr\u00e1ficas: idade e sexo; assim como as vari\u00e1veis socioecon\u00f4micas: escolaridade e n\u00edvel socioecon\u00f4mico.Em rela\u00e7\u00e3o a idade, a amostra foi subdividida nas seguintes faixas-et\u00e1rias: G1:12-19 anos, G2:20 a 39 anos, G3:40 a 59 anos e G4: 60 a 79 anos.A escolaridade foi categorizada em tr\u00eas n\u00edveis: baixa, para sujeitos que se declararam analfabetos ou tendo cursado o ensino fundamental incompleto, correspondendo ao tempo de 0 a 9 anos de escolaridade; m\u00e9dia, para sujeitos que cursaram do ensino fundamental completo ao ensino m\u00e9dio completo, equivalente a 9 a 16 anos de escolaridade, e escolaridade alta para aqueles que cursaram ensino superior incompleto ou completo, com mais de 16 anos de escolaridade.. O documento \u00e9 dividido em duas categorias de informa\u00e7\u00f5es. Na primeira o sujeito informa sobre os itens que possui em casa e suas respectivas quantidades; os itens incluem banheiro, microcomputador, m\u00e1quina de lavar lou\u00e7a, autom\u00f3vel, micro-ondas etc. A segunda categoria identifica o grau de instru\u00e7\u00e3o do chefe de fam\u00edlia (relativo \u00e0 escolaridade) e o acesso a servi\u00e7os p\u00fablicos (\u00e1gua encanada e rua pavimentada). A partir da an\u00e1lise proposta pela ABEP foi realizada a categoriza\u00e7\u00e3o, neste estudo, em tr\u00eas n\u00edveis socioecon\u00f4micos: baixo, com pontua\u00e7\u00e3o de 1 a 16 pontos; m\u00e9dio para sujeitos com pontua\u00e7\u00e3o de 17 a 28 pontos; alto para os sujeitos que pontuaram de 29 a 100 pontos.Quanto ao n\u00edvel socioecon\u00f4mico foi aplicado o question\u00e1rio da Associa\u00e7\u00e3o Brasileira de Empresas de Pesquisa (ABEP)Na an\u00e1lise dos dados foi verificada a normalidade da distribui\u00e7\u00e3o, aplicando do Teste de Kolmogorov-Smirnov. Ao n\u00e3o ser constatada distribui\u00e7\u00e3o normal, foram utilizados os testes n\u00e3o-param\u00e9tricos Kruskal-Wallis e Mann-Whitney na compara\u00e7\u00e3o entre as vari\u00e1veis independentes  em rela\u00e7\u00e3o a vari\u00e1vel dependente que foi o valor do LRF do TDR. Foi adotado o n\u00edvel de signific\u00e2ncia de 5%.A amostra deste estudo foi composta por 151 sujeitos normo-ouvintes com idade entre 12 a 79 anos . O LRF do TDR da amostra total de sujeitos normo-ouvintes teve a mediana de -9,6 dB, com valor m\u00ednimo -13 dB e o valor m\u00e1ximo de +1,8 dB do LRF do TDR.A Observa-se que todas as vari\u00e1veis, menos a vari\u00e1vel sexo, influenciaram no resultado do LRF do TDR. Em rela\u00e7\u00e3o \u00e0 faixa-et\u00e1ria, o grupo composto pelos mais jovens (12 a 19 anos) teve o LRF do TDR significativamente melhor apenas quando comparado aos dos idosos (60 a 79 anos). J\u00e1 os adultos entre 20 a 39 anos tiveram o LRF do TDR melhores quando comparados aos adultos entre 40 e 59 anos e aos idosos acima de 60 anos.Os resultados deste estudo demonstraram que o LRF do TDR em portugu\u00eas Brasileiro em sujeitos normo-ouvintes apresenta associa\u00e7\u00e3o com a escolaridade e n\u00edvel socioecon\u00f4mico, bem como em rela\u00e7\u00e3o \u00e0 faixa-et\u00e1ria. N\u00e3o houve evid\u00eancias de influ\u00eancias do sexo no LRF do TDR.inphase) encontrada entre os sujeitos normo-ouvintes deste estudo est\u00e1 maior do que a m\u00e9dia referida por Potgieter et al. tamb\u00e9m em sujeitos normo-ouvintes , por\u00e9m assemelha-se ao valor do ponto de corte encontrado por estes autores de -8,4 dB pela melhor orelha ou -8,9 dB para ambas as orelhas com audi\u00e7\u00e3o normal .A m\u00e9dia de -8,47 dB no LRF do TDR em condi\u00e7\u00e3o di\u00f3tica ,21, assim como identificado na presente amostra. Contudo, pela influ\u00eancia das vari\u00e1veis socioecon\u00f4micas e demogr\u00e1ficas, o resultado do LRF n\u00e3o foi semelhante aos achados da vers\u00e3o teste de forma integral.A avalia\u00e7\u00e3o do teste de d\u00edgitos se mostrou confi\u00e1vel em grupos normo-ouvintes, assim como em grupos usu\u00e1rios de aparelhos auditivos e de implante coclear, ressaltando n\u00e3o s\u00f3 a sua capacidade de ferramenta de rastreio auditivo como de avalia\u00e7\u00e3o do processo de reabilita\u00e7\u00e3o.A amostra estudada foi composta por 72,18% por sujeitos do sexo feminino, embora tenha tido esta predomin\u00e2ncia sobre os sujeitos do sexo masculino n\u00e3o foi evidenciada diferen\u00e7a entre os resultados do LRF do TDR entre os sexos. Esta vari\u00e1vel n\u00e3o se mostrou preditora dos resultados do LRF do TDR em estudo com o TDR em ingl\u00eas com diferentes compet\u00eancias no ingl\u00eas e falantes de outras l\u00ednguas da \u00c1frica do Sul. Achado semelhante a este estudo tamb\u00e9m foi evidenciado no estudo com o TDR em portugu\u00eas Brasileiro sendo utilizado com crian\u00e7as normo-ouvintes e sem transtornos do processamento auditivo e com transtorno do processamento auditivo entre 8 a 11 anos. Os valores do LRF destes dois grupos tiveram m\u00e9dias similares aos encontrados em outra pesquisa do Teste de d\u00edgitos no ru\u00eddo em portugu\u00eas brasileiro. Esses achados podem indicar o impacto das diferen\u00e7as sociodemogr\u00e1ficas pr\u00f3prias da amostra, j\u00e1 que apesar de terem faixas et\u00e1rias diferentes, esses estudos t\u00eam popula\u00e7\u00e3o origin\u00e1ria da mesma regi\u00e3o.Sujeitos com idade acima de 60 anos apresentaram LRF do TDR di\u00f3tico pior quando comparados aos mais jovens (12-39 anos). Este resultado difere de outro estudo que demonstrou resultados de LRF semelhantes aos de jovens a partir dos 12 anos de idade, na qual essas dificuldades, mesmo sendo m\u00ednimas, tornam-se um desafio e um transtorno na intera\u00e7\u00e3o da popula\u00e7\u00e3o dessa faixa et\u00e1ria com o smartphone. Pesquisadores abordaram sobre a necessidade de considerar a idade ao determinar o resultado do teste, pois a precis\u00e3o do resultado pode diferenciar dependendo da faixa et\u00e1ria. Esses autores evidenciaram que a idade pode ser um preditor significativo do LRF do TDR para ouvintes com melhor orelha MQ\u226425 dB NA.Um estudo retrospectivo com 24.072 sujeitos constatou que a idade \u00e9 um fator de influ\u00eancia nos resultados do TDR. Fator que pode ser explicado devido a diminui\u00e7\u00e3o da cogni\u00e7\u00e3o nos idosos e a dificuldade na compreens\u00e3o das explica\u00e7\u00f5es dadas.Informa\u00e7\u00f5es semelhantes a estas podem ser constatadas no estudo no qual se observou decl\u00ednio de aspectos cognitivos e da capacidade do processamento auditivo com outras tarefas de reconhecimento de fala no ru\u00eddo conforme o avan\u00e7o da idade. Al\u00e9m disso, \u00e9 poss\u00edvel que outros estudos considerem a aplica\u00e7\u00e3o de um rastreio cognitivo, para identificar o impacto dessas poss\u00edveis altera\u00e7\u00f5es no resultado do TDR.Desta forma, \u00e9 importante considerar a idade ao determinar o resultado do TDR em sujeitos normo-ouvintes, pois isso pode contribuir para a precis\u00e3o do resultado do teste de triagemApesar de uma predomin\u00e2ncia de sujeitos com escolaridade alta, foi poss\u00edvel observar que sujeitos com maior escolaridade tendem a ter melhor compreens\u00e3o de fala no ru\u00eddo, com melhores LRF..Outros pesquisadores tamb\u00e9m observaram que a diferen\u00e7a de escolaridade est\u00e1 associada a dificuldades auditivas para atividades de processamento auditivo. Entre as hip\u00f3teses levantadas est\u00e1 a diferen\u00e7a de hist\u00f3rico da popula\u00e7\u00e3o idosa que teve acesso prec\u00e1rio \u00e0 educa\u00e7\u00e3o.Dentre as atividades de processamento auditivo, a compreens\u00e3o de fala no ru\u00eddo tamb\u00e9m \u00e9 prejudicada com menor \u00edndice de escolaridade. Abre-se a discuss\u00e3o se h\u00e1 nesse resultado influ\u00eancia da mem\u00f3ria de trabalho al\u00e9m dos fatores auditivos, embora essa caracter\u00edstica tenha se mostrado significante em outras habilidades do processamento auditivo, mas n\u00e3o no teste de fala no ru\u00eddo. Portanto, as vari\u00e1veis socioecon\u00f4mica e de escolaridade abordadas neste estudo est\u00e3o diretamente relacionadas. \u00c9 poss\u00edvel observar essa equival\u00eancia na an\u00e1lise estat\u00edstica do estudo, em que h\u00e1 diferen\u00e7a estatisticamente significante entre os grupos baixos, m\u00e9dio e altos tanto na escolaridade quanto no n\u00edvel socioecon\u00f4mico.O n\u00edvel socioecon\u00f4mico \u00e9 um par\u00e2metro que leva em considera\u00e7\u00e3o escolaridade, ocupa\u00e7\u00e3o e rendaAssim, quanto mais elevado o n\u00edvel socioecon\u00f4mico e a escolaridade mais negativo o valor do LRF do TDR.. Corroborando com isso, constata-se que dentre a popula\u00e7\u00e3o mundial que apresenta perda auditiva, onde h\u00e1 maior preval\u00eancia em pa\u00edses de baixa e m\u00e9dia renda, ainda h\u00e1 baixa capacidade de atendimento dos servi\u00e7os de sa\u00fade, mostrando que a preval\u00eancia dessa enfermidade varia de acordo com a regi\u00e3o e que o componente socioecon\u00f4mico \u00e9 um dos fatores determinantes para o seu surgimento.O n\u00edvel socioecon\u00f4mico est\u00e1 intrinsecamente ligado \u00e0 sa\u00fade, de modo que aqueles com melhor poder aquisitivo normalmente s\u00e3o mais saud\u00e1veis do que aqueles com o n\u00edvel socioecon\u00f4mico mais baixo.Os fatores socioecon\u00f4micos e de escolaridade podem se relacionar com o status audiol\u00f3gico de um indiv\u00edduo. Um estudo realizado com 3379 pessoas nos Estados Unidos, mostrou que h\u00e1 correla\u00e7\u00e3o direta do n\u00edvel socioecon\u00f4mico e escolaridade com a perda de audi\u00e7\u00e3o, no qual essa defici\u00eancia pode ser um fator ou um produto da caracteriza\u00e7\u00e3o socioecon\u00f4mica do sujeito. Al\u00e9m disso, a pesquisa revelou associa\u00e7\u00f5es entre desemprego, idade, escolaridade, sexo e estado auditivo. No caso do TDR, a situa\u00e7\u00e3o que se encontrou foi que, aqueles indiv\u00edduos que possu\u00edam a audi\u00e7\u00e3o normal , de modo geral, n\u00e3o tiveram um desempenho adequado para seu status audiol\u00f3gico, mas que vem sendo a preocupa\u00e7\u00e3o mundial visto o uso excessivo de dispositivos individuais de m\u00fasica utilizados com intensidade excessiva.Concomitante \u00e0 utiliza\u00e7\u00e3o de m\u00e9todos de promo\u00e7\u00e3o e preven\u00e7\u00e3o \u00e0 sa\u00fade atrav\u00e9s de tecnologias digitais, embasar conhecimentos acerca da influ\u00eancia da idade no TDR, em principal na popula\u00e7\u00e3o idosa, deve ser constante devido \u00e0s restri\u00e7\u00f5es f\u00edsicas e a pr\u00f3pria dificuldade de manipula\u00e7\u00e3o do equipamento nessa popula\u00e7\u00e3o. Atrelado a isso, h\u00e1 a probabilidade do TDR ter como alvo a popula\u00e7\u00e3o mais jovem, onde a preval\u00eancia da perda auditiva ainda \u00e9 menorPortanto, o ideal seria considerar os diferentes fatores estudados no resultado do TDR, adotando-se diferentes pontos de cortes de acordo com os n\u00edveis socioecon\u00f4micos, de escolaridade ou de idade que o indiv\u00edduo se encontre.Ao analisar pontos que podem ter alterado o resultado da pesquisa, destaca-se a vers\u00e3o de teste disponibilizada utilizada para teste de d\u00edgitos no ru\u00eddo. Sendo o acesso deste a partir de um link da internet, inviabilizando sua realiza\u00e7\u00e3o sem rede de dados. Tendo uma resposta ao toque da tela ainda em desenvolvimento que, por vezes, necessitava de interven\u00e7\u00e3o do pesquisador para corre\u00e7\u00e3o de zoom que se ativou a um r\u00e1pido toque duplo do sujeito no dispositivo. A experi\u00eancia de uso para o sujeito poderia ser melhorada por meio da vers\u00e3o finalizada do aplicativo.Outras categoriza\u00e7\u00f5es de faixa-et\u00e1ria, escolaridade e n\u00edvel socioecon\u00f4mico poderiam alterar os resultados encontrados, assim como as caracter\u00edsticas da popula\u00e7\u00e3o do nordeste, sendo sugerida ainda a realiza\u00e7\u00e3o de outros estudos em outras regi\u00f5es brasileiras.Estudos posteriores devem ser conduzidos para estudar a vers\u00e3o finalizada do aplicativo em compara\u00e7\u00e3o com a vers\u00e3o teste. Al\u00e9m disso, devem ser realizadas futuras pesquisas que considerem a an\u00e1lise das vari\u00e1veis demogr\u00e1ficas e socioecon\u00f4micas estudadas no ponto de corte do teste, a fim de alcan\u00e7ar uma melhor acur\u00e1cia no teste de d\u00edgitos no ru\u00eddo em portugu\u00eas considerando as caracter\u00edsticas populacionais, e favorecendo sua aplica\u00e7\u00e3o em larga escala como instrumento de identifica\u00e7\u00e3o da perda auditiva.O teste de d\u00edgitos no ru\u00eddo di\u00f3tico no Portugu\u00eas Brasileiro tem associa\u00e7\u00e3o com vari\u00e1veis extr\u00ednsecas ao teste, apresentando melhores respostas entre 20 e 39 anos, com n\u00edvel socioecon\u00f4mico alto e escolaridade alta. N\u00e3o foi observada influ\u00eancia do sexo no reconhecimento dos d\u00edgitos do TDR."}
+{"text": "To map and describe the characteristics present in the publications of the CoDAS journal in the voice segment.The research was carried on the Scielo database using the descriptor voice.CoDAS publications in the field of voice.Specific data collected according to delineation, summarized by descriptive analysis and analyzed in narrative format.Studies published in 2019 and with cross-sectional delineation were more frequent. The most frequent result in the cross-sectional studies was the vocal self-assessment. Most intervention studies were of immediate single-session-only effect. The most frequent procedures in the validation studies were translation and transcultural adaptation.There was a gradual increase in the number of publications of voice studies, though these had heterogeneous characteristics. In this sense, the production of evidence through the publication of a scientific article is a way to transmit to the scientific and clinical community data on the development of new procedures, instruments, and interventions, as well as the analysis of risk factors and epidemiological reality in the various areas of Science. Since this resolution, the voice area has advanced even more as a recognized specialty in constant evolution. The strength and recognition of a profession or area are in most part based on the quality of the articles published in peer-reviewed journals. The Brazilian scientific production in the area of voice is vast, which contributes to and strengthens the practice. Historically, the first researches in the voice area, as well as in the health and speech sciences in general, dealt with the delineation of expert opinions and case series from clinical practice. These were the first scientific steps in a young field, but the conclusions of these studies could not yet be generalized. The practice was based on the learning acquired during the clinicians' training, and their questions were answered directly with recognized experts. Over time, research has been improving, and the focus has become the availability of evidence to improve clinical practice, as well as the implementation of evidence. Currently, the challenge for vocal clinicians is to choose the best scientific evidence to support their practice,4. These changes stemmed, in large part, from a movement called Evidence Based Practice (EBP), which seeks to ensure the quality of care of health professionals, including speech therapists, aiming at better decision making for each case. The EBP consists of three practices: 1) The clinician identifies a problem or doubt in their practice; 2) The researcher transforms this problem/doubt into a research question and develops a study to answer it based on evidence; 3) The clinician searches and selects the study, and applies the evidence to their clinical practice, from a critical analysis that takes into account their practice experience and patient perspectives. Thus, the execution of EBP does not depend only on researchers, but mainly on clinicians, who must act as integrators of science and clinic, critical evaluators of data, and executors in the application of evidence in their clinical cases. It can be said that the continuous development of Speech Pathology and the field of voice is directly linked to the practice of EBP, although EBP is still not frequent in the field of voice.In Brazil, voice is one of the phonoaudiological areas recognized as a specialty since 2006Communication Disorders, Audiology and Swallowing) an easy and short english abbreviation that includes the main areas of Speech Therapy. CoDAS is a journal that has been adapted to the needs of the phonoaudiological academy and clinic. Initially, it was called Pr\u00f3-Fono Revista de Atualiza\u00e7\u00e3o Cientifica (2005-2010). In 2010, it was renamed Jornal da Sociedade Brasileira de Fonoaudiologia (2010-2012). The articles published from 2010 onwards are available on the Scielo platform with open access. In its last restructuring in 2013, it was renamed CoDAS, with a centralized editorial as the only publication of the Brazilian Society of Speech Therapy. The journal is indexed by Web of Science, MEDLINE/PubMed, Scopus, PsycINFO, Scientific Electronic Library Online (SciELO), Linguistics and Language Behavior Abstracts (CSA), Literatura Latino-Americana e do Caribe em Ci\u00eancias da Sa\u00fade (LILACS), SociedadIberoamericana de Informaci\u00f3n Cient\u00edfica (SIIC Data Bases), and the Directory of Open Access Journals (DOAJ). Considering the importance of this journal for research and clinical practice in the area of voice, it is important to map the publications in this area that have been published in it. Such data will provide a general panorama (landscape) of the scope of the publications in regards to the designs, samples, outcomes and exercise prescription. It is believed that such data will contribute to identify what has been done in the country, map the advances, point out the limitations and needs of the area and help the speech therapist in the search for evidence towards a final goal that is to provide the best care for patients in the vocal clinic. Furthermore, the mapping done by a scope review can contribute to future directions in the area and the growth of science.Brazil currently h\u00e1s four speech therapy specialized magazines that contribute to EPB, one of them is CoDAS . To elaborate the research question we used the acronym PCC: Population - dysphonic and non-dysphonic individuals; Concept - sampling and methodological characteristics; Context - CoDAS magazine. Thus, the research question that supported its development was: What are the main sampling and methodological characteristics of studies with dysphonic and non-dysphonic individuals published in CoDAS?The present study has a scoping review design and followed the recommendations of The search was conducted in the Scielo database, using the descriptor \u201cvoice\u201d. Journal filters were applied, selecting only CoDAS, and publication period until December 2019. The search was performed in the month of August 2020.The inclusion criteria used to consider the studies for this review were: articles published in the journal CoDAS , period until December 2019, in the area of voice, with a population of dysphonic and non-dysphonic individuals. In June 2022 the article was updated with publications from January 2020 to December 2021. We excluded interdisciplinary studies in which the focus was not the area of voice (outcomes of other areas), and secondary studies (literature review).The procedures used to select the studies and apply the eligibility criteria were: reading the title; reading the abstract, and reading the full articles. The selection was performed by the main author between August and November 2020.; intervention; and instrument validation. The data extracted from the studies were:Data extraction and analysis was performed by two authors. In order to facilitate data extraction and analysis, the selected studies were separated into three groups, according to the design: observationalObservational : authors, year, country, institution, design, area, age group, gender, sample size, outcomes, self-assessment, perceptual-auditory assessment, acoustic analysis, aerodynamics.Intervention : authors, year, country, institution, design, area, age group, gender, sample size, number of sessions, session time, session frequency.Translation, cross-cultural adaptation, and validation of instruments: authors, year, country, institution, design, area, age group, gender, sample size, translation, and cross-cultural adaptation.The synthesis of the data was presented descriptively by means of tables and graphs with frequency analysis. Data analysis was performed in narrative format.-187.Publications in the area of voice were most frequent in the years 2019  and 2013 , as indicated in Most studies were cross-sectional , followed by quasi-experimental , translation, cross-cultural adaptation or validation studies , experimental  and before-and-after intervention .According to Regarding the 115 cross-sectional studies, In studies which analyzed the self-reported impact of a voice problem, that is, voice self-assessment (n=102), the most used instruments were the Vocal Symptoms Scale - VSS , Quality of Life in Voice - QLV  and the Vocal Disadvantage Index - VDI-10 . In the studies that performed JPA (n=78), the GRBASI scale  and self-generated scales  were most frequently used. In the 61 studies with acoustic analysis, traditional acoustic parameter extraction  and the phonation deviation diagram (POD)  were the most published. Finally, the few papers which did aerodynamic analysis (n=20) studied maximum phonatory time - TMF  and nasometry .It was observed that of the 37 intervention studies, 16 (43.2%) studied immediate effects, followed by those that did six  or twelve intervention sessions .The most frequent session time among those who reported the information was 60 minutes , and the absence of this information was predominant . Studies with a single session frequency  were the most frequent, followed by weekly frequency , as shown in ,185-187 based on evidence-based practice. In this practice, clinicians are faced with different results, and need to compare evidence that answers their questions and assists in decision making in search of the best results. However, this comparison is made difficult when analyzing research with different procedures or with several instruments used for the same purpose. The CoDAS journal occupies a prominent place in the national scenario of scientific research publications. In this sense, mapping procedures and analyzing their frequencies show trends, limitations, and can contribute to clinical practice, as well as to the development of other studies.Scientific research in Speech Therapy seeks to provide reliable evidence for the clinic. As for the year 2019, the journal was marked by improved indexing and internationalization of the journal.The results of the present scoping review showed that there was a non-linear upward curve of publications in the CoDAS journal in the last years analyzed, with a rise in the years 2013 and 2020. The higher number of publications in the year 2013 can be explained by changes in editorial strategies, such as the new name of the journal that began to be called CoDAS, the insertion of area editors, the greater participation of foreign colleagues and the professionalization of the editorial office. In addition, the year 2013 presented an improvement in the definition of the objectives of Brazilian studies in the designs of experiments, as well as the expansion of multicenter papersNational publications are the most frequent in CoDAS. Among the 11 international articles, the United States of America and Chile have published three, but it is worth remembering that only recently the journal has had international visibility with English as the mandatory language. The international articles are published both jointly between domestic and foreign institutions, and with only foreign authorship. It is believed that, even in the face of a journal that is still strong and recognized in Brazilian Speech Therapy publications, the increase in internationalization, such as the recent indexation of the journal in the Web of Science, will bring greater international visibility and reach, besides more growth and research data for the journal.. The UNIFESP counts on scientific initiation programs while still in the undergraduate course, and the improvement and specialization programs are linked to scientific production and publication. In the sequence, the results pointed to multicenter publications. This is a worldwide trend and a good indication for the journal, showing that researchers from institutes and universities have been coming together for the improvement of scientific development. The expansion of multicentric works can offer a more comprehensive national geographical representation, besides being fundamental for the development of large projects.The Centro de Estudos da Voz - CEV was the educational institution that published the most in CoDAS in the area of voice, followed by Universidade de Sao Paulo - USP, Universidade Federal de Sao Paulo - UNIFESP and the multicenter publications. CEV is a teaching and research institution in the area of human communication that completed 40 years in 2021, that offers a Specialization Course in Voice - CECEV, whose first graduating class was in 1993 . In 2021, CECEV had its 24th class, and all the students are encouraged and oriented to develop a monograph to conclude the course, to be presented in congresses and published. USP is a traditional public university in the area, which has three campuses with the Speech Therapy course, in S\u00e3o Paulo, Ribeir\u00e3o Preto, and Bauru. UNIFESP is one of the oldest universities in teaching and research, and is also recognized for its scientific effort in the area of voice. It is a public university that aims at developing interrelated teaching, research and extension activities, with emphasis on the specific field of health sciences,192. It is important to highlight that the design is directly related to the clinical question that is intended to be answered, and this type of study is more indicated for the description of characteristics, diagnostic accuracy and disease prevalence. Cross-sectional studies were followed by quasi-experimental studies, the most frequent type among intervention studies. Quasi-experimental studies are controlled interventions without sample randomization. The lack of randomization generates a risk of selection bias. Experimental studies, also known as randomized clinical trials, are considered high level of evidence studies and the gold standard for efficacy analysis of interventions, but only six publications with this design were observed. Although the quality of publications has increased in the last decade, being still in the process of growth and structural modifications, few researches published in specialized journals incorporated the proper methodology and answered the clinical questions satisfactorily, both in Brazilian journals and in international publications.Observational studies of the cross-sectional type, which are simple, fast, and easier to execute designs, were most commonly found in the review. They are research designs that are thought to be an excellent method for describing characteristics of a population. However, they are valid only for that particular place and time, and over time their findings can no longer be used for the clinicA balance was observed between studies of clinical voice and professional voice, however, still with greater frequency in the area of clinical voice, historically more present in the area of Voice. It is important to note that both subareas have been contemplated in CoDAS\u2019 publications journal, expanding the possibilities of searching for evidence for clinical vocal practice, professional voice training, and clinical voice therapy.. The elderly population has been gaining space not only in vocal clinic, but in all studies in the health area, by demographic changes and the search for vocal longevity and quality of life, although they are still few compared to adults,196.Most studies included adult participants (18-59 years), followed by the elderly (60-103 years) and children and adolescents (0-18 years). Adults also represent the majority of patients who seek vocal clinic. It is believed that pediatric dysphonia has fewer studies by the need for parental consent that do not necessarily want their children as a research subject. The occurrence of studies with children found in this review is in line with the literature,196. It is noteworthy here that some research did not report the age range of participants, although it is essential data for the applicability and interpretation of results.Children are the minority in seeking clinical care, although the prevalence data of childhood dysphonia is up to 38% of the pediatric population-199.Most studies included both genders in their analyses. This data is positive and relevant because the anatomical and physiological differences between the sexes lead to the need for specific studies and different interpretations, besides the different normality values for some evaluations. Self-evaluation brings data that cannot be obtained in the clinical evaluation carried out by the speech therapist and is used to quantify the perception of the subject about the influence of his or her voice on different daily activities. Total wellbeing does not include only the absence of disease, but also the individual's self-perception of his condition and the impacts on several aspects of his life-203.When considering only the cross-sectional studies, it is observed that the most frequent outcome was self-assessment, followed by JPA. These two assessments are part of the non-instrumental assessments that make up the multidimensional evaluation of voiceThe review showed that the most frequently used self-assessment instruments were the the Vocal Symptoms Scale - VSS, Quality of Life in Voice - QLV and the Vocal Disadvantage Index - VDI-10.,37,204 are widely used in day to day vocal clinic for being fast, easy to apply and also for presenting reliable psychometric properties, capable of classifying individuals with and without dysphonia. The VSS is one of the most robust instruments in the area of voice because of its psychometric properties and seeks to analyze the self-perception of vocal symptoms. The IDV-10, a reduced version of the IDV-30, is a quick, practical and reliable instrument to measure vocal handicap in individuals with voice problems. The QLV was the first instrument of vocal self-assessment to be validated for Brazilian Portuguese, widely applied in vocal clinic, which allows the analysis of the impact of a voice problem in the quality of life of dysphonic individuals.These instruments, all validated for Brazilian PortugueseAmerican Speech-Language-Hearing Association (ASHA) recommends the use of self-assessment protocols, but does not cite a specific one probably because the psychometric properties of the instruments are different between language validations and because the instruments have different objectives.When caring for a dysphonic patient, the . Most cross-sectional studies used the GRBASI scale. The GRBASI is a Japanese scale, based on ISSHIKI's work on hoarseness, used internationally. Initially conceived as GRBAS, in 1996 it had the addition of the instability factor I, by the authors Dejonckere, Remacle & Fresnel-Elbaz. It is noteworthy the large presence of JPA scales created by the researchers themselves. The use of non-validated scales and instruments generates a difficulty in the comparison with other studies, in the clinical application and in the reliability of the findings, since they have no proven validity, and the results cannot be reproduced.The JPA is considered the gold standard in vocal evaluation, capable of qualifying voice quality and quantifying the degree of deviation.The acoustic evaluation of the voice is one of the instrumental evaluations of the clinical speech therapist and appeared in 61 studies in the review. It is known that acoustic analysis quantifies the sound signal, making vocal analysis more objective. We reiterate that JPA is still the gold standard in vocal clinic and that acoustic analysis is complementary. The signs of dysphonic voices are type 2 and 3, and do not produce reliable measurements. In these cases, one can then opt for a descriptive analysis of the spectrographic tracing. Another option is to use multiparametric measurements that are more suitable for evaluations of dysphonic voices, offering more reliable and reliable results.In general, the acoustic analysis practiced in vocal clinic can be performed by extraction of acoustic parameters or by visual analysis of the spectrographic tracing. The review results show that traditional measures of automatic extraction of the fundamental frequency, noise measurements, and signal perturbations are more widely studied and published. This type of acoustic analysis, until recently, was what the Brazilian vocal clinic had as knowledge and available resource. However, currently, it is understood that in dysphonic individuals, this traditional analysis is not the best measure of evaluation, since the extraction of classical measures is performed in the time domain. Only one study that used this measure was included in this review. Such data indicate the need for greater investment in these measures, as well as in other multiparametric acoustic measures in Brazil.ASHA recommends the Cepstral Peak Proeminence (CPP) for acoustic analysis of the dysphonic individual, in conjunction with a rigorous clinical history and complete medical evaluation.Few studies were found that performed laryngeal imaging exams. In Brazil, laryngeal imaging exams are not part of the phonoaudiological procedures. However, this is a necessary procedure for laryngeal diagnosis, a requirement to be able to classify the type of dysphonia. The instrument recommended by the American Academy of Otolaryngology-Head and Neck Surgery is the laryngostroboscopy. Besides the measurements of maximum phonatory time, which help in the inference of physiological data such as glottal closure and tension during phonation, other aerodynamic measurements are hardly part of clinical vocal practice.Aerodynamic evaluation was studied in 20 articles included in the review. It is a clinical instrumental evaluation that allows noninvasive measurements of glottal parameters that make up the vocal production to help describe vocal behavior. As for aerodynamic evaluation, ASHA recommends obtaining measurements of mean airflow rate and mean subglottic pressure. There is also an orientation to collect fundamental frequency measures and sound pressure measures, which are acoustic measures, collected simultaneously with the aerodynamic ones,210.The most commonly used measure for aerodynamic assessment in the studies analyzed in this research was maximum phonation time, which is easy to obtain and non-invasive, widely used in clinical phonoaudiological practice.With regard to intervention data, studies that measured immediate effects were more frequent. In longitudinal interventions, 6-session and 12-session interventions were more frequent. The average time of sessions most used by the researchers was 60 minutes, with a weekly frequency. It is observed that the frequency of 6-12 sessions may come from the influence of American publications, since 6 sessions correspond to the number of sessions covered by the American health insurance.In Brazil, the SBF (Brazilian Society of Speech Therapy) and CFF  therapy beacons seek to guide the frequency, duration and amounts of voice therapy sessions for various conditions. The vocal alterations range from pediatric dysphonia to the rehabilitation of laryngectomized patients. There are recommendations for a number of sessions between eight and 24 sessions, 30 to 45 minutes each session, with weekly frequency of one to three times a week, varying according to the type of alteration and age of the patient states that Psychometrics is a group of techniques that enables the quantification of psychic phenomena. Among the options for instrument validation we highlight the rules of the Scientific Advisory Committee of the Medical Outcomes Trust-SAC, frequently used in national validation studies by the Classical Test Theory in the voice area. To be used, protocols need to be formally developed and psychometrically tested, thus ensuring evidence of validity, reliability, and fairness. Translation and cross-cultural adaptation is an initial part of validation. However, only translation and cross-cultural adaptation is not sufficient for an instrument to be considered applicable and valid in a language.Of the studies on psychometric properties of instruments, only five were validation studies, the most frequent being translation and cross-cultural adaptation of instruments into Brazilian Portuguese. ErthalRegardless of the design, some studies did not report essential data so that their findings could be interpreted and their evidence useful for practice, which is an important opportunity to improve the description of the experiments. There were studies that did not report the age range, the sex of the subjects studied, and the time and frequency of the sessions. In addition, some studies used scales created by the researchers, which do not allow comparison of their findings. The most frequent assessment instruments in aerodynamic measures, in acoustic measures, and in self-assessment are not the instruments recommended by ASHA. However, it should be noted that the year of study selection and ASHA publication is close, and it will be necessary to review this information again in the future.Therefore, it is necessary to reflect on the importance of a detailed and precise methodological description, as well as the standardization of procedures and measures for use in research. Evidence-based clinical practice is a necessity for the improvement of vocal clinic. However, it is necessary that some changes and standardization occur in research so that their findings are valid for clinical inference, and to be possible the implementation of evidence in practice.The results allow us to conclude that there was a gradual increase in the number of publications in the area of voice in the journal CoDAS. The procedures and characteristics of the publications were heterogeneous. Researchers in clinical and professional voice have a preference for more cross-sectional studies and with a sample of adults and of both sexes. Cross-sectional studies with self-assessment outcomes, experimental studies of immediate effect, and studies measuring psychometric properties that performed translation and cross-cultural adaptation were more frequent. There are uninformed data on relevant parameters for the applicability of the studies such as age range, sex, and temporal parameters of interventions, besides a high index of scales created by the researchers. , assim como na Fonoaudiologia.No mundo contempor\u00e2neo da \u00e1rea da sa\u00fade, a busca por conhecimento cient\u00edfico tomou lugar de destaque, com a finalidade principal de fomentar a pr\u00e1tica cl\u00ednica. Nesse sentido, a produ\u00e7\u00e3o da evid\u00eancia por meio da publica\u00e7\u00e3o de um artigo cient\u00edfico \u00e9 uma forma de transmitir \u00e0 comunidade cient\u00edfica e cl\u00ednica dados sobre o desenvolvimento de novos procedimentos, instrumentos e interven\u00e7\u00f5es, al\u00e9m da an\u00e1lise de fatores de risco e realidade epidemiol\u00f3gica, nas diversas \u00e1reas da ci\u00eancia. A partir dessa resolu\u00e7\u00e3o, a \u00e1rea de voz avan\u00e7ou ainda mais como especialidade reconhecida e em grande evolu\u00e7\u00e3o.No Brasil, a voz \u00e9 uma das \u00e1reas da Fonoaudiologia reconhecida como especialidade desde 2006A for\u00e7a e o reconhecimento de uma profiss\u00e3o ou \u00e1rea est\u00e3o em grande parte fundamentadas na qualidade dos artigos publicados em revistas com revis\u00e3o dos pares. A produ\u00e7\u00e3o cient\u00edfica brasileira na \u00e1rea de voz \u00e9 ampla, o que contribui e fortalece a pr\u00e1tica.,4.Historicamente, as primeiras pesquisas na \u00e1rea de voz, assim como nas ci\u00eancias da sa\u00fade e fonoaudiol\u00f3gicas de modo geral, abordavam delineamento de opini\u00f5es de especialistas e s\u00e9ries de casos da pr\u00e1tica cl\u00ednica. Tratava-se dos primeiros passos cient\u00edficos de uma \u00e1rea jovem, por\u00e9m, as conclus\u00f5es desses estudos n\u00e3o podiam, ainda, ser generaliz\u00e1veis. J\u00e1 a pr\u00e1tica baseava-se na aprendizagem adquirida durante a forma\u00e7\u00e3o dos cl\u00ednicos e as d\u00favidas destes profissionais eram tiradas diretamente com especialistas reconhecidos. No decorrer do tempo, as pesquisas foram se aprimorando, e o foco passou a ser a disponibilidade de evid\u00eancias para aprimorar a pr\u00e1tica cl\u00ednica, bem como a implementa\u00e7\u00e3o das evid\u00eancias. Atualmente, o desafio do cl\u00ednico vocal \u00e9 a escolha da melhor evid\u00eancia cient\u00edfica para embasar a sua pr\u00e1tica. A PBE consiste em tr\u00eas etapas: 1) O cl\u00ednico identifica um problema ou d\u00favida em sua pr\u00e1tica; 2) O pesquisador transforma esse problema/d\u00favida em pergunta de pesquisa e desenvolve um estudo para respond\u00ea-la com base em evid\u00eancias; 3) O cl\u00ednico busca e seleciona o estudo, e aplica as evid\u00eancias na sua pr\u00e1tica cl\u00ednica, a partir de uma an\u00e1lise cr\u00edtica que leva em considera\u00e7\u00e3o sua experi\u00eancia pr\u00e1tica e as perspectivas do paciente. Dessa forma, a execu\u00e7\u00e3o da PBE n\u00e3o depende somente dos pesquisadores, mas principalmente dos cl\u00ednicos que devem atuar como integradores da ci\u00eancia e da cl\u00ednica, avaliadores cr\u00edticos de dados, e executores na aplica\u00e7\u00e3o das evid\u00eancias em seus casos cl\u00ednicos. Pode-se dizer que o desenvolvimento cont\u00ednuo da Fonoaudiologia e da \u00e1rea de voz est\u00e1 diretamente ligado \u00e0 pr\u00e1tica da PBE, embora a PBE ainda n\u00e3o seja frequente na \u00e1rea de Voz.Tais mudan\u00e7as decorreram, em grande parte, de um movimento denominado de pr\u00e1tica baseada em evid\u00eancias (PBE), que busca assegurar a qualidade dos cuidados dos profissionais da sa\u00fade, incluindo os fonoaudi\u00f3logos, visando uma melhor tomada de decis\u00e3o frente a cada caso, sigla em ingl\u00eas para Dist\u00farbios da Comunica\u00e7\u00e3o, Audiologia e Degluti\u00e7\u00e3o, foi criado para ser curto e f\u00e1cil de ser lembrado, e considerou as \u00e1reas principais da Fonoaudiologia.O Brasil, atualmente, possui quatro revistas espec\u00edficas da Fonoaudiologia que contribuem para a PBE, e uma delas \u00e9 a CoDAS. O nome da revista CoDAS Web of Science, MEDLINE/PubMed, Scopus, PsycINFO, Scientific Electronic Library Online (SciELO), Linguistics and Language Behavior Abstracts (CSA), Literatura Latino-Americana e do Caribe em Ci\u00eancias da Sa\u00fade (LILACS), Sociedad Iberoamericana de Informaci\u00f3n Cient\u00edfica (SIIC Data Bases), e o Directory of Open Access Journals (DOAJ).A revista CoDAS \u00e9 um peri\u00f3dico que vem se adaptando \u00e0s necessidades da academia e da cl\u00ednica fonoaudiol\u00f3gica. Inicialmente, foi denominada Pr\u00f3-Fono Revista de Atualiza\u00e7\u00e3o Cient\u00edfica (2005-2010). Em 2010, passou a se chamar Jornal da Sociedade Brasileira de Fonoaudiologia (2010-2012). Os artigos publicados a partir de 2010 encontram-se dispon\u00edveis na plataforma Scielo com acesso aberto. Em sua \u00faltima reestrutura\u00e7\u00e3o em 2013, passou a ser chamada de CoDAS e com editorial centralizado como publica\u00e7\u00e3o \u00fanica da Sociedade Brasileira de Fonoaudiologia. A revista possui como fontes de indexa\u00e7\u00e3o a Considerando-se a import\u00e2ncia do peri\u00f3dico para a pesquisa e a cl\u00ednica na \u00e1rea de voz, torna-se relevante mapear as publica\u00e7\u00f5es da \u00e1rea nela realizadas. Tais dados fornecer\u00e3o um panorama geral sobre o escopo das publica\u00e7\u00f5es no que se refere aos delineamentos, amostras, desfechos e prescri\u00e7\u00e3o de exerc\u00edcios. Acredita-se que tais dados contribuir\u00e3o para identificar o que vem sendo realizado no pa\u00eds, mapear os avan\u00e7os, apontar as limita\u00e7\u00f5es e necessidades da \u00e1rea e auxiliar o fonoaudi\u00f3logo na busca da evid\u00eancia em prol de um objetivo final que \u00e9 fornecer o melhor atendimento para os pacientes da cl\u00ednica vocal. Al\u00e9m disso, o mapeamento realizado por uma revis\u00e3o de escopo pode contribuir para direcionamentos futuros na \u00e1rea e crescimento da ci\u00eancia.Dessa forma, o objetivo geral desta pesquisa foi mapear e descrever as caracter\u00edsticas das publica\u00e7\u00f5es da revista CoDAS na \u00e1rea de voz.Joanna Briggs Institute Manual for Evidence Synthesis for Scoping Reviews e do PRISMA-ScR. O protocolo da presente revis\u00e3o de escopo foi registrado na Open Science Framework (doi:10.17605/OSF.IO/VFWN7).O presente estudo tem delineamento de revis\u00e3o de escopo e seguiu as recomenda\u00e7\u00f5es da Para elaborar a pergunta de pesquisa foi utilizada a sigla PCC: Popula\u00e7\u00e3o - indiv\u00edduos disf\u00f4nicos e n\u00e3o disf\u00f4nicos; Conceito - caracter\u00edsticas amostrais e metodol\u00f3gicas; Contexto - revista CoDAS. Dessa forma, a pergunta de pesquisa que subsidiou seu desenvolvimento foi: Quais as principais caracter\u00edsticas amostrais e metodol\u00f3gicas dos estudos com indiv\u00edduos disf\u00f4nicos e n\u00e3o disf\u00f4nicos publicados na revista CoDAS?A busca foi realizada na base de dados Scielo, utilizando-se o descritor \u201cvoz\u201d. Foram aplicados os filtros de peri\u00f3dico selecionando-se apenas a CoDAS, e de per\u00edodo de publica\u00e7\u00e3o at\u00e9 dezembro de 2019. A busca foi realizada no m\u00eas de agosto de 2020.Os crit\u00e9rios de inclus\u00e3o utilizados para considerar os estudos para essa revis\u00e3o foram: artigos publicados no peri\u00f3dico CoDAS , per\u00edodo at\u00e9 dezembro de 2019, na \u00e1rea de voz, com popula\u00e7\u00e3o de indiv\u00edduos disf\u00f4nicos e n\u00e3o disf\u00f4nicos. Em junho de 2022 o artigo foi atualizado com as publica\u00e7\u00f5es de janeiro de 2020 a dezembro de 2021. Foram exclu\u00eddos os estudos interdisciplinares em que o foco n\u00e3o era a \u00e1rea de voz (desfechos de outras \u00e1reas), e os estudos secund\u00e1rios (revis\u00e3o de literatura).Os procedimentos utilizados para selecionar os estudos e aplicar os crit\u00e9rios de elegibilidade foram: leitura do t\u00edtulo; leitura do resumo e leitura na \u00edntegra dos artigos. A sele\u00e7\u00e3o foi realizada pelo autor principal entre agosto e novembro de 2020.; interven\u00e7\u00e3o; e, valida\u00e7\u00e3o de instrumentos. Os dados extra\u00eddos dos estudos foram:A extra\u00e7\u00e3o e an\u00e1lise dos dados foi realizada por dois autores. A fim de facilitar a extra\u00e7\u00e3o e an\u00e1lise dos dados, os estudos selecionados foram separados em tr\u00eas grupos, de acordo com o delineamento: observacionalObservacional : autores, ano, pa\u00eds, institui\u00e7\u00e3o, delineamento, \u00e1rea, faixa et\u00e1ria, sexo, c\u00e1lculo amostral, desfechos, autoavalia\u00e7\u00e3o, avalia\u00e7\u00e3o perceptivo-auditiva, an\u00e1lise ac\u00fastica, aerodin\u00e2mica;Interven\u00e7\u00e3o : autores, ano, pa\u00eds, institui\u00e7\u00e3o, delineamento, \u00e1rea, faixa et\u00e1ria, sexo, c\u00e1lculo amostral, n\u00famero de sess\u00f5es, tempo de sess\u00e3o, frequ\u00eancia de sess\u00e3o;Tradu\u00e7\u00e3o, adapta\u00e7\u00e3o transcultural e valida\u00e7\u00e3o de instrumentos: autores, ano, pa\u00eds, institui\u00e7\u00e3o, delineamento, \u00e1rea, faixa et\u00e1ria, sexo, c\u00e1lculo amostral, tradu\u00e7\u00e3o e adapta\u00e7\u00e3o transcultural.A s\u00edntese dos dados foi apresentada de forma descritiva por meio de tabelas e gr\u00e1ficos com an\u00e1lise de frequ\u00eancia. A an\u00e1lise de dados foi realizada no formato narrativo.-187.A As publica\u00e7\u00f5es na \u00e1rea de voz foram mais frequentes nos anos de 2019  e 2013 , como indica a A A maioria dos estudos apresentou delineamento transversal , seguido de quasi-experimental , estudos de tradu\u00e7\u00e3o, adapta\u00e7\u00e3o transcultural ou valida\u00e7\u00e3o , experimental  e interven\u00e7\u00e3o antes e ap\u00f3s .De acordo com a Com rela\u00e7\u00e3o aos 115 estudos transversais, a Nos estudos que analisaram o impacto autorreferido de um problema de voz, ou seja, a autoavalia\u00e7\u00e3o vocal (n=102), os instrumentos mais utilizados foram a Escala de Sintomas Vocais - ESV , Qualidade de Vida em Voz (QVV)  e o \u00cdndice de Desvantagem Vocal - IDV-10 . J\u00e1 nos estudos que realizaram JPA (n=78), a escala GRBASI  e as escalas criadas pelos pr\u00f3prios pesquisadores  foram mais frequentemente usadas. Nos 61 estudos com an\u00e1lise ac\u00fastica, a extra\u00e7\u00e3o de par\u00e2metros ac\u00fasticos tradicionais  e o diagrama de desvio fonat\u00f3rio (DDF)  foram os mais publicados. Por fim, os poucos trabalhos que fizeram a an\u00e1lise aerodin\u00e2mica (n=20) estudaram o tempo m\u00e1ximo fonat\u00f3rio - TMF  e a nasometria .Observou-se que dos 37 estudos de interven\u00e7\u00e3o, 16  estudaram os efeitos imediatos, seguidos pelos que fizeram seis  ou doze sess\u00f5es de interven\u00e7\u00e3o .O tempo de sess\u00e3o mais frequente dentre os que relataram a informa\u00e7\u00e3o foi de 60 minutos , sendo predominante a aus\u00eancia dessa informa\u00e7\u00e3o . Estudos cuja frequ\u00eancia de sess\u00e3o foi \u00fanica  foram os de maior ocorr\u00eancia, seguidos da frequ\u00eancia semanal , conforme mostra a A ,185-187 a partir da pr\u00e1tica baseada em evid\u00eancias. Nessa pr\u00e1tica, os cl\u00ednicos deparam-se com diferentes resultados, e precisam comparar evid\u00eancias que respondam \u00e0s suas perguntas e auxiliem na tomada de decis\u00e3o em busca dos melhores resultados. Por\u00e9m, essa compara\u00e7\u00e3o \u00e9 dificultada quando se analisa pesquisas com diferentes procedimentos ou com diversos instrumentos usados para uma mesma finalidade. A revista CoDAS ocupa um lugar de destaque no cen\u00e1rio nacional de publica\u00e7\u00f5es de pesquisas cient\u00edficas. Nesse sentido, mapear procedimentos e analisar suas frequ\u00eancias mostram tend\u00eancias, limita\u00e7\u00f5es, e podem contribuir para a pr\u00e1tica cl\u00ednica, bem como para o desenvolvimento de outros estudos.A pesquisa cient\u00edfica em Fonoaudiologia busca fornecer evid\u00eancias confi\u00e1veis para a cl\u00ednica. Quanto ao ano de 2019, a revista foi marcada pela melhoraria da indexa\u00e7\u00e3o e internacionaliza\u00e7\u00e3o do peri\u00f3dico.Os resultados da presente revis\u00e3o de escopo mostraram que houve uma curva ascendente n\u00e3o linear das publica\u00e7\u00f5es na revista CODAS nos \u00faltimos anos analisados, com uma ascens\u00e3o nos anos de 2013 e 2020. O maior n\u00famero de publica\u00e7\u00f5es no ano de 2013 pode ser explicado pelas mudan\u00e7as de estrat\u00e9gias editoriais, como o novo nome da revista que passou a ser denominada CoDAS, a inser\u00e7\u00e3o de editores de \u00e1rea, a maior participa\u00e7\u00e3o de colegas estrangeiros e a profissionaliza\u00e7\u00e3o da secretaria editorial. Al\u00e9m disso, o ano de 2013 apresentou uma melhoria na defini\u00e7\u00e3o dos objetivos dos estudos brasileiros nos desenhos dos experimentos, assim como a amplia\u00e7\u00e3o de trabalhos multic\u00eantricosWeb of Science, trar\u00e1 maior visibilidade internacional e alcance, al\u00e9m de mais dados de crescimento e pesquisas para a revista.As publica\u00e7\u00f5es nacionais s\u00e3o as mais frequentes na revista CoDAS. Dentre os 11 artigos internacionais, os Estados Unidos da Am\u00e9rica e o Chile publicaram tr\u00eas, mas vale lembrar que apenas recentemente a revista passou a ter visibilidade internacional com o ingl\u00eas como idioma obrigat\u00f3rio. Os artigos internacionais s\u00e3o tanto publicados em conjunto entre institui\u00e7\u00f5es nacionais e estrangeiras, como de autoria apenas estrangeira. Acredita-se que, mesmo diante de uma revista ainda forte e reconhecida nas publica\u00e7\u00f5es da Fonoaudiologia brasileira, o aumento da internacionaliza\u00e7\u00e3o, como a recente indexa\u00e7\u00e3o da revista na . A UNIFESP conta com programas de inicia\u00e7\u00e3o cient\u00edfica ainda na gradua\u00e7\u00e3o e os programas de aperfei\u00e7oamento e especializa\u00e7\u00e3o est\u00e3o vinculados \u00e0 produ\u00e7\u00e3o cient\u00edfica e publica\u00e7\u00e3o. Na sequ\u00eancia, os resultados apontaram para as publica\u00e7\u00f5es multic\u00eantricas. Trata-se de uma tend\u00eancia mundial e um bom indicativo para a revista, que mostra que os pesquisadores de institutos e universidades vem se unindo em prol da melhoria do desenvolvimento cient\u00edfico. A amplia\u00e7\u00e3o de trabalhos multic\u00eantricos pode oferecer uma representa\u00e7\u00e3o geogr\u00e1fica nacional mais abrangente, al\u00e9m deles serem fundamentais para o desenvolvimento de grandes projetos.O Centro de Estudos da Voz - CEV foi a institui\u00e7\u00e3o de ensino que mais publicou na CoDAs na \u00e1rea da voz, seguida pela Universidade de S\u00e3o Paulo - USP, Universidade Federal de S\u00e3o Paulo - UNIFESP e pelas publica\u00e7\u00f5es multic\u00eantricas. O CEV \u00e9 uma institui\u00e7\u00e3o de ensino e pesquisa na \u00e1rea de comunica\u00e7\u00e3o humana que completou 40 anos em 2021, que oferece um Curso de Especializa\u00e7\u00e3o em Voz - CECEV, cuja primeira turma formada foi em 1993 . O CECEV, em 2021, montou sua 24\u00aa turma e todos os alunos s\u00e3o incentivados e orientados a desenvolver monografia de conclus\u00e3o de curso para apresenta\u00e7\u00e3o em congressos e publica\u00e7\u00e3o. A USP \u00e9 uma universidade p\u00fablica tradicional na \u00e1rea, que possui tr\u00eas campus com o curso de Fonoaudiologia, em S\u00e3o Paulo, em Ribeir\u00e3o Preto, e em Bauru. A UNIFESP \u00e9 uma das universidades mais antigas no ensino e na pesquisa, e \u00e9 reconhecida tamb\u00e9m pelo esfor\u00e7o cient\u00edfico na \u00e1rea da voz. Trata-se de uma universidade p\u00fablica que tem o objetivo de desenvolver atividades inter-relacionadas de ensino, pesquisa e extens\u00e3o, com \u00eanfase no campo espec\u00edfico das ci\u00eancias da sa\u00fade,192. \u00c9 importante ressaltar que o delineamento est\u00e1 diretamente relacionado \u00e0 pergunta cl\u00ednica que se pretende responder, sendo que esse tipo de estudo \u00e9 mais indicado para descri\u00e7\u00e3o de caracter\u00edsticas, acur\u00e1cia diagn\u00f3stica e preval\u00eancia de doen\u00e7as.Os estudos observacionais do tipo transversais, que s\u00e3o delineamentos simples, r\u00e1pidos e de mais f\u00e1cil execu\u00e7\u00e3o foram mais comumente encontrados na revis\u00e3o. S\u00e3o delineamentos de pesquisa tidos como excelente m\u00e9todo para descrever caracter\u00edsticas de uma popula\u00e7\u00e3o. Contudo, s\u00e3o v\u00e1lidos apenas para aquele determinado local e momento e, com o passar do tempo, seus achados j\u00e1 n\u00e3o podem ser usados para a cl\u00ednica e padr\u00e3o-ouro para an\u00e1lise de efic\u00e1cia de interven\u00e7\u00f5es, por\u00e9m, foram observadas apenas seis publica\u00e7\u00f5es com esse delineamento. Apesar da qualidade das publica\u00e7\u00f5es ter aumentado no \u00faltimo dec\u00eanio, estando ainda no processo de crescimento e modifica\u00e7\u00f5es estruturais, poucas pesquisas publicadas em revistas especializadas incorporaram a metodologia adequada e respondem \u00e0s perguntas cl\u00ednicas satisfatoriamente, tanto nas revistas brasileiras quanto nas publica\u00e7\u00f5es internacionais.Os estudos transversais foram seguidos pelos quasi-experimentais, sendo o mais tipo mais frequente dentre os estudos de interven\u00e7\u00e3o. Estudos quasi-experimentais s\u00e3o interven\u00e7\u00f5es controladas, mas que n\u00e3o possuem randomiza\u00e7\u00e3o da amostra. A falta de randomiza\u00e7\u00e3o gera risco de vi\u00e9s de sele\u00e7\u00e3o. J\u00e1 os experimentais, tamb\u00e9m denominados de ensaios cl\u00ednicos randomizados, s\u00e3o considerados estudos de alto n\u00edvel de evid\u00eanciaObservou-se um equil\u00edbrio entre os estudos de voz cl\u00ednica e de voz profissional, por\u00e9m, ainda com maior frequ\u00eancia na \u00e1rea de voz cl\u00ednica, historicamente mais presente na \u00e1rea de Voz. \u00c9 importante ressaltar que ambas as sub\u00e1reas v\u00eam sendo contempladas nas publica\u00e7\u00f5es da revista CoDAS, ampliando as possibilidades de busca de evid\u00eancia para a pr\u00e1tica da cl\u00ednica vocal, no treinamento da voz profissional e na terapia da voz cl\u00ednica..A popula\u00e7\u00e3o de idosos vem ganhando espa\u00e7o n\u00e3o apenas na cl\u00ednica vocal, mas em todos os estudos da \u00e1rea da sa\u00fade, pelas mudan\u00e7as demogr\u00e1ficas e pela busca de longevidade vocal e qualidade de vida, apesar de ainda serem poucos em compara\u00e7\u00e3o aos adultos,196. As crian\u00e7as s\u00e3o minoria na procura de atendimento cl\u00ednico, apesar dos dados de preval\u00eancia da disfonia infantil ser de at\u00e9 38% da popula\u00e7\u00e3o pedi\u00e1trica. Acredita-se que a disfonia pedi\u00e1trica apresenta menos estudos pela necessidade de autoriza\u00e7\u00e3o dos pais que n\u00e3o necessariamente querem seus filhos como sujeito de pesquisa. A ocorr\u00eancia de estudos com crian\u00e7as encontrada nessa revis\u00e3o vai ao encontro da literatura,196. Cabe ressaltar aqui que algumas pesquisas n\u00e3o informaram a faixa et\u00e1ria dos participantes, embora sejam dados essenciais para a aplicabilidade e interpreta\u00e7\u00e3o dos resultados.A maioria dos estudos incluiu participantes adultos (18-59 anos), seguidos pelos idosos (60-103 anos) e pelas crian\u00e7as e adolescentes (0-18 anos). Os adultos tamb\u00e9m representam a maioria dos pacientes que buscam a cl\u00ednica vocal-199.A maior parte das pesquisas contemplou ambos os sexos em suas an\u00e1lises. Esse dado \u00e9 positivo e relevante porque as diferen\u00e7as anatomofisiol\u00f3gicas existentes entre os sexos levam \u00e0 necessidade de estudos espec\u00edficos e interpreta\u00e7\u00f5es diversas, al\u00e9m dos valores de normalidade diferentes para algumas avalia\u00e7\u00f5es. A autoavalia\u00e7\u00e3o traz dados que n\u00e3o podem ser obtidos na avalia\u00e7\u00e3o cl\u00ednica realizada pelo fonoaudi\u00f3logo e servem para quantificar a percep\u00e7\u00e3o do sujeito acerca da influ\u00eancia da sua voz nas diferentes atividades di\u00e1rias. O bem-estar total n\u00e3o contempla apenas a aus\u00eancia da doen\u00e7a, mas tamb\u00e9m a autopercep\u00e7\u00e3o do indiv\u00edduo em sua condi\u00e7\u00e3o e os impactos em diversos aspectos da sua vida-203.Ao considerar apenas os estudos transversais, observa-se que o desfecho mais frequente foi a autoavalia\u00e7\u00e3o, seguido do JPA. Essas duas avalia\u00e7\u00f5es fazem parte das avalia\u00e7\u00f5es n\u00e3o-instrumentais que comp\u00f5e a avalia\u00e7\u00e3o multidimensional da voz,37,204 s\u00e3o amplamente utilizados no dia a dia da cl\u00ednica vocal por serem r\u00e1pidos, de f\u00e1cil aplica\u00e7\u00e3o e ainda por apresentarem propriedades psicom\u00e9tricas confi\u00e1veis, capazes de classificar indiv\u00edduos com e sem disfonia. A ESV \u00e9 um dos instrumentos mais robustos na \u00e1rea da voz por suas propriedades psicom\u00e9tricas e busca analisar a autopercep\u00e7\u00e3o de sintomas vocais. O IDV-10, vers\u00e3o reduzida do IDV-30, \u00e9 um instrumento r\u00e1pido, pr\u00e1tico e confi\u00e1vel para mensurar a desvantagem vocal em indiv\u00edduos com problemas de voz. O QVV foi o primeiro instrumento de autoavalia\u00e7\u00e3o vocal a ser validado para o portugu\u00eas brasileiro, muito aplicado na cl\u00ednica vocal, que permite analisar o impacto de um problema de voz na qualidade de vida de indiv\u00edduos disf\u00f4nicos No atendimento de um paciente disf\u00f4nico, a American Speech-Language-Hearing Association (ASHA) recomenda o uso de protocolos de autoavalia\u00e7\u00e3o, mas n\u00e3o cita um espec\u00edfico provavelmente porque as propriedades psicom\u00e9tricas dos instrumentos s\u00e3o diferentes entre as valida\u00e7\u00f5es de cada l\u00edngua e porque os instrumentos possuem diferentes objetivos.A revis\u00e3o mostrou que os instrumentos de autoavalia\u00e7\u00e3o mais frequentemente utilizados foram a Escala de Sintomas Vocais (ESV), seguido pelo Qualidade de Vida em Voz (QVV) e pelo \u00cdndice de Desvantagem Vocal (IDV-10). Estes instrumentos, todos validados para o portugu\u00eas brasileiro. A maioria dos estudos transversais utilizou a escala GRBASI. A GRBASI \u00e9 uma escala japonesa, baseada nos trabalhos de ISSHIKI sobre rouquid\u00e3o, usada internacionalmente. Inicialmente concebida como GRBAS, em 1996 teve o acr\u00e9scimo do fator instabilidade I, pelos autores Dejonckere, Remacle & Fresnel-Elbaz. Ressalta-se a grande presen\u00e7a de escalas de JPA criadas pelos pr\u00f3prios pesquisadores. O uso de escalas e instrumentos n\u00e3o validados gera uma dificuldade na compara\u00e7\u00e3o com outros estudos, na aplica\u00e7\u00e3o cl\u00ednica e na confiabilidade dos achados, visto que n\u00e3o tem validade comprovada, e os resultados n\u00e3o podem ser reproduzidos.O JPA \u00e9 considerado padr\u00e3o-ouro na avalia\u00e7\u00e3o vocal, capaz de qualificar a qualidade da voz e quantificar o grau de desvio.A avalia\u00e7\u00e3o ac\u00fastica da voz \u00e9 uma das avalia\u00e7\u00f5es instrumentais do fonoaudi\u00f3logo cl\u00ednico vocal e apareceu em 61 estudos da revis\u00e3o. Sabe-se que a an\u00e1lise ac\u00fastica quantifica o sinal sonoro, tornando mais objetiva a an\u00e1lise vocal. Reiteramos que o JPA ainda \u00e9 padr\u00e3o-ouro na cl\u00ednica vocal e que a an\u00e1lise ac\u00fastica \u00e9 complementar. Os sinais de vozes disf\u00f4nicas s\u00e3o do tipo 2 e 3, e n\u00e3o produzem mensura\u00e7\u00f5es confi\u00e1veis. Nestes casos, pode-se, ent\u00e3o, optar por uma an\u00e1lise descritiva do tra\u00e7ado espectrogr\u00e1fico. Outra op\u00e7\u00e3o \u00e9 utilizar medidas multiparam\u00e9tricas que s\u00e3o mais indicadas para avalia\u00e7\u00f5es de vozes disf\u00f4nicas, oferecendo resultados mais fidedignos e confi\u00e1veis.De forma geral, a an\u00e1lise ac\u00fastica praticada na cl\u00ednica vocal pode ser realizada por meio da extra\u00e7\u00e3o de par\u00e2metros ac\u00fasticos ou por an\u00e1lise visual do tra\u00e7ado espectrogr\u00e1fico. Os resultados da revis\u00e3o demonstram que as medidas tradicionais de extra\u00e7\u00e3o autom\u00e1tica da frequ\u00eancia fundamental, medidas de ru\u00eddo e perturba\u00e7\u00f5es do sinal s\u00e3o mais estudadas e publicadas. Este tipo de an\u00e1lise ac\u00fastica, at\u00e9 h\u00e1 pouco tempo, era o que a cl\u00ednica vocal brasileira tinha como conhecimento e recurso dispon\u00edvel. Contudo, atualmente, entende-se que, em indiv\u00edduos disf\u00f4nicos, esta an\u00e1lise tradicional n\u00e3o \u00e9 a melhor medida de avalia\u00e7\u00e3o, visto que a extra\u00e7\u00e3o das medidas cl\u00e1ssicas \u00e9 realizada no dom\u00ednio do tempoCepstral Peak Proeminence (CPP) para a an\u00e1lise ac\u00fastica do indiv\u00edduo disf\u00f4nico. Apenas um estudo que utilizou essa medida foi inclu\u00eddo na presente revis\u00e3o. Tais dados indicam a necessidade de maiores investimentos nessas medidas, bem como em outras medidas ac\u00fasticas multiparam\u00e9tricas no Brasil.A ASHA recomenda o , em conjunto com um hist\u00f3rico cl\u00ednico rigoroso e a avalia\u00e7\u00e3o m\u00e9dica completa.Foram encontrados poucos estudos que fizeram exames de imagem da laringe. No Brasil, os exames de imagem de laringe n\u00e3o fazem parte dos procedimentos fonoaudiol\u00f3gicos. Contudo, trata-se de um procedimento necess\u00e1rio para o diagn\u00f3stico lar\u00edngeo, requisito para que seja poss\u00edvel classificar o tipo de disfonia. O instrumento recomendado pela Academia de Laringologia e Cirurgia de Cabe\u00e7a e Pesco\u00e7o dos Estados Unidos para a avalia\u00e7\u00e3o lar\u00edngea \u00e9 a laringoestroboscopia. Al\u00e9m das medidas de tempo m\u00e1ximo fonat\u00f3rio, que auxiliam na infer\u00eancia de dados fisiol\u00f3gicos como fechamento gl\u00f3tico e tens\u00e3o \u00e0 fona\u00e7\u00e3o, outras medidas aerodin\u00e2micas dificilmente fazem parte da pr\u00e1tica da cl\u00ednica vocal.A avalia\u00e7\u00e3o aerodin\u00e2mica foi estudada em 20 artigos inclu\u00eddos na revis\u00e3o. Ela \u00e9 uma avalia\u00e7\u00e3o cl\u00ednica instrumental que permite obter medidas n\u00e3o invasivas de par\u00e2metros gl\u00f3ticos que comp\u00f5em a produ\u00e7\u00e3o vocal para auxiliar na descri\u00e7\u00e3o do comportamento vocal. Com rela\u00e7\u00e3o a avalia\u00e7\u00e3o aerodin\u00e2mica, a ASHA orienta a obten\u00e7\u00e3o das medidas de taxa m\u00e9dia de fluxo de ar e press\u00e3o subgl\u00f3tica m\u00e9dia. H\u00e1, tamb\u00e9m, uma orienta\u00e7\u00e3o de coleta de medidas de frequ\u00eancia fundamental e medidas de press\u00e3o sonora, que s\u00e3o medidas ac\u00fasticas, coletadas simultaneamente as aerodin\u00e2micas,210.A medida mais utilizada para avalia\u00e7\u00e3o aerodin\u00e2mica nos estudos analisados nesta pesquisa foi de tempo m\u00e1ximo de fona\u00e7\u00e3o, de f\u00e1cil obten\u00e7\u00e3o e n\u00e3o invasiva, muito utilizada na pr\u00e1tica cl\u00ednica fonoaudiol\u00f3gica.Com rela\u00e7\u00e3o aos dados de interven\u00e7\u00e3o, foram mais frequentes os estudos que mensuraram efeitos imediatos. Nas interven\u00e7\u00f5es longitudinais, foram mais frequentes as de 6 sess\u00f5es e 12 sess\u00f5es. O tempo m\u00e9dio de sess\u00f5es mais utilizado pelos pesquisadores foi de 60 minutos, com frequ\u00eancia semanal. Observa-se que a frequ\u00eancia de 6-12 sess\u00f5es pode advir da influ\u00eancia das publica\u00e7\u00f5es americanas, pelo fato de que 6 sess\u00f5es correspondem ao n\u00famero de sess\u00f5es cobertas pelo seguro sa\u00fade americano.No Brasil, os balizadores de terapia da SBFa (Sociedade Brasileira de fonoaudiologia) e do CFF  procuram orientar a frequ\u00eancia, dura\u00e7\u00e3o e quantidades de sess\u00f5es de terapia de voz para diversos quadros. As altera\u00e7\u00f5es vocais v\u00e3o desde disfonia pedi\u00e1trica at\u00e9 a reabilita\u00e7\u00e3o de pacientes laringectomizados. H\u00e1 recomenda\u00e7\u00f5es de um n\u00famero de sess\u00f5es entre oito e 24 sess\u00f5es, 30 a 45 minutos cada sess\u00e3o, com frequ\u00eancia semanal de uma a tr\u00eas vezes na semana, variando em fun\u00e7\u00e3o do tipo de altera\u00e7\u00e3o e idade do paciente afirma que a Psicometria \u00e9 um grupo de t\u00e9cnicas que viabiliza a quantifica\u00e7\u00e3o de fen\u00f4menos ps\u00edquicos. Dentre as op\u00e7\u00f5es para a valida\u00e7\u00e3o de instrumentos destacamos as regras do Scientific Advisory Committee of the Medical Outcomes Trust-SAC, frequentemente utilizadas nos estudos nacionais de valida\u00e7\u00e3o por Teoria Cl\u00e1ssica dos Testes na \u00e1rea de voz. Para serem utilizados os protocolos precisam ser formalmente desenvolvidos e psicometricamente testados, garantindo assim evid\u00eancias de validade, confiabilidade e equidade. A tradu\u00e7\u00e3o e adapta\u00e7\u00e3o transcultural \u00e9 uma parte inicial da valida\u00e7\u00e3o. Por\u00e9m, apenas a tradu\u00e7\u00e3o e adapta\u00e7\u00e3o transcultural n\u00e3o \u00e9 suficiente para que um instrumento seja considerado aplic\u00e1vel e v\u00e1lido em uma l\u00edngua.Dos estudos de propriedades psicom\u00e9tricas de instrumentos, apenas cinco foram de valida\u00e7\u00e3o, sendo mais frequente a de tradu\u00e7\u00e3o e adapta\u00e7\u00e3o transcultural de instrumentos para o portugu\u00eas brasileiro. ErthalIndependentemente do delineamento, alguns estudos n\u00e3o informaram dados essenciais para que seus achados possam ser interpretados e suas evid\u00eancias \u00fateis para a pr\u00e1tica, sendo essa uma oportunidade importante para a melhoria na descri\u00e7\u00e3o dos experimentos. Foram encontrados estudos que n\u00e3o informaram a faixa et\u00e1ria, o sexo dos sujeitos pesquisados, e o tempo e frequ\u00eancia de sess\u00e3o. Al\u00e9m disso, houve estudos utilizaram escalas criadas pelos pesquisadores, que n\u00e3o permitem compara\u00e7\u00e3o dos seus achados. Os instrumentos mais frequentes de avalia\u00e7\u00e3o em medidas aerodin\u00e2micas, em medidas ac\u00fasticas e de autoavalia\u00e7\u00e3o n\u00e3o s\u00e3o os instrumentos recomendados pela ASHA. Por\u00e9m, cabe ressaltar que o ano de sele\u00e7\u00e3o dos estudos e de publica\u00e7\u00e3o da ASHA \u00e9 pr\u00f3ximo, sendo necess\u00e1rio que futuramente essa informa\u00e7\u00e3o seja novamente revisada.Diante disso, faz-se necess\u00e1ria uma reflex\u00e3o sobre a import\u00e2ncia de uma descri\u00e7\u00e3o metodol\u00f3gica detalhada e precisa, bem como da padroniza\u00e7\u00e3o de procedimentos e medidas para o uso na pesquisa. A pr\u00e1tica cl\u00ednica baseada em evid\u00eancias \u00e9 uma necessidade para o aprimoramento da cl\u00ednica vocal. Por\u00e9m, \u00e9 necess\u00e1rio que algumas mudan\u00e7as e padroniza\u00e7\u00f5es ocorram nas pesquisas para que seus achados sejam v\u00e1lidos para a infer\u00eancia cl\u00ednica, e para que seja poss\u00edvel a implementa\u00e7\u00e3o da evid\u00eancia na pr\u00e1tica.Os resultados permitem concluir que houve aumento gradual no n\u00famero de publica\u00e7\u00f5es na \u00e1rea de voz da revista CoDAS. Os procedimentos e caracter\u00edsticas das publica\u00e7\u00f5es foram heterog\u00eaneos. Os pesquisadores em voz cl\u00ednica e profissional t\u00eam por prefer\u00eancia mais estudos transversais e com uma amostra de adultos e de ambos os sexos. Foram mais frequentes os estudos transversais com desfechos de autoavalia\u00e7\u00e3o, estudos experimentais de efeito imediato, e estudos de mensura\u00e7\u00e3o de propriedades psicom\u00e9tricas que realizaram tradu\u00e7\u00e3o e adapta\u00e7\u00e3o transcultural. H\u00e1 dados n\u00e3o informados de par\u00e2metros relevantes para a aplicabilidade dos estudos como faixa et\u00e1ria, sexo e par\u00e2metros temporais de interven\u00e7\u00f5es, al\u00e9m de um alto \u00edndice de escalas criadas pelos pesquisadores."}
+{"text": "S\u00e3o motivospelos quais pais e/ou respons\u00e1veis n\u00e3o vacinaram ou est\u00e3o na d\u00favida em vacinaras crian\u00e7as e os adolescentes sob sua responsabilidade para preven\u00e7\u00e3o daCOVID-19: receio em raz\u00e3o de a vacina estar em fase experimental e medo dasrea\u00e7\u00f5es adversas e dos efeitos a longo prazo. J\u00e1 os motivos para aus\u00eancia deinten\u00e7\u00e3o de vacinar decorrem dos entendimentos dos participantes de que aCOVID-19 em crian\u00e7as n\u00e3o \u00e9 grave, os riscos da vacina\u00e7\u00e3o s\u00e3o maiores do que osbenef\u00edcios e o direito de escolha em n\u00e3o vacinar.Objetiva-se desvelar os motivos para hesita\u00e7\u00e3o vacinal de pais e/ou respons\u00e1veisde crian\u00e7as e adolescentes para preven\u00e7\u00e3o da COVID-19. Trata-se de um estudodescritivo, de abordagem qualitativa, que busca analisar as respostas dapergunta aberta \u201cpor que voc\u00ea n\u00e3o vai vacinar, n\u00e3o vacinou ou est\u00e1 na d\u00favida emvacinar as crian\u00e7as e os adolescentes sob sua responsabilidade para preven\u00e7\u00e3o daCOVID-19?\u201d. A pesquisa incluiu indiv\u00edduos adultos, brasileiros, residentes nopa\u00eds, respons\u00e1veis por crian\u00e7as e adolescentes menores de 18 anos. A coleta dedados aconteceu de forma eletr\u00f4nica entre os meses de novembro e dezembro de2021. As respostas foram organizadas e processadas com suporte do softwareIramuteq. O  Criada em 1796 por Edward Jenner, a vacina tem a capacidade de prevenir o retorno dedoen\u00e7as j\u00e1 erradicadas ou controladas e de diminuir consideravelmente a morteprecoce da popula\u00e7\u00e3o No Brasil, o Programa Nacional de Imuniza\u00e7\u00f5es (PNI), criado em 1973, apresenta-secomo uma pol\u00edtica capaz de impactar o perfil de morbimortalidade da popula\u00e7\u00e3obrasileira, repercutindo em mudan\u00e7as nos campos pol\u00edtico, epidemiol\u00f3gico e socialEm meio a tal cen\u00e1rio j\u00e1 consolidado, destaca-se, na atualidade, a COVID-19, que temmostrado qu\u00e3o vulner\u00e1vel \u00e9 a popula\u00e7\u00e3o humana diante de doen\u00e7as infecciosasemergentes, principalmente quando n\u00e3o existem tratamentos curativos e vacinas parapromover a preven\u00e7\u00e3o desse agravo A vacina\u00e7\u00e3o contra a COVID-19 no territ\u00f3rio brasileiro iniciou no dia 17 de janeirode 2021 com o uso de doses da vacina do laborat\u00f3rio Sinovac em parceria com oInstituto Butantan, que contemplou inicialmente os grupos de trabalhadores de sa\u00fade, idososresidentes em institui\u00e7\u00f5es de longa perman\u00eancia, indiv\u00edduos com mais de 18 anos deidade com defici\u00eancia, pessoas que viviam em resid\u00eancias inclusivas e povosind\u00edgenas Plano Nacional de Operacionaliza\u00e7\u00e3o da Vacina\u00e7\u00e3o contra aCOVID-19, at\u00e9 o dia 1\u00ba de fevereiro de 2022, o Brasil j\u00e1 fazia uso dequatro vacinas autorizadas pela Ag\u00eancia Nacional de Vigil\u00e2ncia Sanit\u00e1ria (Anvisa),duas delas com autoriza\u00e7\u00e3o para uso emergencial (Sinovac/Butantan e Janssen) e duascom registro definitivo (AstraZeneca/Fiocruz e Pfizer/Wyeth) Conforme o Nota T\u00e9cnica n\u00ba 02/2022, a qual destaca que paraesse grupo o Minist\u00e9rio da Sa\u00fade rotula como \u201cvacina\u00e7\u00e3o n\u00e3o obrigat\u00f3ria\u201d. Em 14 dejulho de 2022, a Anvisa aprovou a amplia\u00e7\u00e3o da vacina\u00e7\u00e3o de crian\u00e7as de 3 a 5 anoscontra a COVID-19 Por sua vez, crian\u00e7as e adolescentes na faixa et\u00e1ria de 12 a 17 anos tiveram suavacina\u00e7\u00e3o contra a COVID-19 iniciada no dia 15 de setembro de 2021 Sabe-se que a vacina\u00e7\u00e3o de crian\u00e7as \u00e9 capaz de proteg\u00ea-las da COVID-19 na formagrave, assim como das complica\u00e7\u00f5es de curto e longo prazo A recusa vacinal n\u00e3o \u00e9 um problema recente, ela surgiu no fim do s\u00e9culo XVII logoap\u00f3s a ocorr\u00eancia da var\u00edola. A palavra hesita\u00e7\u00e3o \u00e9 mais utilizada nos dias atuaispara nomear o processo de tomada de decis\u00e3o em que os indiv\u00edduos: s\u00e3o motivados pelafalta de confian\u00e7a nas vacinas, nos profissionais de sa\u00fade e na sua efic\u00e1cia; n\u00e3oapresentam entendimento sobre os riscos das doen\u00e7as imunopreven\u00edveis ou sobre aimport\u00e2ncia das vacinas; e/ou aqueles que por conveni\u00eancia utilizam os motivos defalta de acesso ou indisponibilidade da vacina nos servi\u00e7os de sa\u00fade para fortaleceros motivos para a recusa Outrossim, apesar de a vacina\u00e7\u00e3o contra a COVID-19 ter apresentado importantecontribui\u00e7\u00e3o para o controle da pandemia, protegendo a popula\u00e7\u00e3o do adoecimento eprincipalmente prevenindo as ocorr\u00eancias das formas mais graves da doen\u00e7a, ahesita\u00e7\u00e3o vacinal representa uma das principais barreiras para o progresso dessaa\u00e7\u00e3o. Dada a sua relev\u00e2ncia, ressalta-se, ainda, que a hesita\u00e7\u00e3o vacinal foiconsiderada pela Organiza\u00e7\u00e3o Mundial da Sa\u00fade (OMS) Destarte, este estudo objetiva desvelar os motivos para hesita\u00e7\u00e3o vacinal de paise/ou respons\u00e1veis de crian\u00e7as e adolescentes para preven\u00e7\u00e3o da COVID-19.Trata-se de estudo descritivo, de abordagem qualitativa, que incluiu indiv\u00edduosadultos, brasileiros, residentes no pa\u00eds, respons\u00e1veis por crian\u00e7as e adolescentesmenores de 18 anos.https://workspace.google.com/products/forms/). O formul\u00e1rio eracomposto por 35 quest\u00f5es, envolvendo dados demogr\u00e1ficos e quest\u00f5es sobre COVID-19 evacinas. Neste artigo, apresenta-se a an\u00e1lise da quest\u00e3o aberta, de resposta n\u00e3oobrigat\u00f3ria: por que voc\u00ea n\u00e3o vai vacinar, n\u00e3o vacinou ou est\u00e1 na d\u00favida em vacinaras crian\u00e7as e os adolescentes sob sua responsabilidade para preven\u00e7\u00e3o daCOVID-19?A coleta de dados aconteceu de forma eletr\u00f4nica entre os meses de novembro e dezembrode 2021, a partir de instrumento de pesquisa constru\u00eddo na plataforma Google Forms(https://www.iff.fiocruz.br/), Funda\u00e7\u00e3o Oswaldo Cruz (Fiocruz), com ot\u00edtulo Estudo VacinaKids, convidando para a participa\u00e7\u00e3o  e disponibilizando o link doformul\u00e1rio. Em uma estrat\u00e9gia de \u201cbola de neve\u201d, solicitou-se aos participantesconvidar amigos, propagando exponencialmente o link nas redessociais. Foi solicitado que respons\u00e1veis por crian\u00e7as e adolescentes menores de 18anos respondessem ao formul\u00e1rio, relatando sua pretens\u00e3o futura de vacina\u00e7\u00e3o contraa COVID-19 quando a vacina estivesse autorizada pela Anvisa para sua idade.O estudo foi divulgado na p\u00e1gina institucional de Internet do Instituto Nacional deSa\u00fade da Mulher, da Crian\u00e7a e do Adolescente Fernandes Figueira  e 13% (246) de pais que t\u00eam inten\u00e7\u00e3o de vacinar, mas que esbo\u00e7aram algumasd\u00favidas e considera\u00e7\u00f5es a respeito da vacina\u00e7\u00e3o de crian\u00e7as e adolescentes (Responderam ao inqu\u00e9rito escentes .http://www.iramuteq.org/), o qual processa an\u00e1lises lexicais dedados textuais ao fornecer contextos e classes por meio do julgamento da semelhan\u00e7ade seus vocabul\u00e1rios, de maneira a contribuir para a compreens\u00e3o do ambiente desentido das palavras e, logo, indicar elementos das representa\u00e7\u00f5es referentes aoobjeto estudado Tais respostas foram organizadas e processadas com suporte do software Iramuteq como m\u00e9todo de tratamentodos dados, o que possibilitou identificar a frequ\u00eancia de cada palavra e sua conex\u00e3ocom as outras, al\u00e9m de auxiliar na an\u00e1lise do A CHD constitui m\u00e9todo de tratamento de dados que visa obter classes de segmentos detexto que, ao mesmo tempo, apresentam vocabul\u00e1rio semelhante entre si e vocabul\u00e1riodiferente dos segmentos de texto das outras classes, a partir de uma an\u00e1liselexicogr\u00e1fica que permite contextualizar o vocabul\u00e1rio t\u00edpico de cada classe Ressalta-se que a interpreta\u00e7\u00e3o e a an\u00e1lise dos dados tiveram embasamento daliteratura atual sobre o objeto de estudo.O estudo seguiu os princ\u00edpios \u00e9ticos e legais que regem a pesquisa cient\u00edfica comseres humanos e foi aprovado pelo Comit\u00ea de \u00c9tica em Pesquisa do IFF/Fiocruz . Oquestion\u00e1rio foi preenchido somente ap\u00f3s concord\u00e2ncia com o consentimentoinformado.corpus textual composto pelas respostas dosparticipantes apresentou 64.472 ocorr\u00eancias de palavras e 4.928 formas distintas,com aproveitamento de texto de 92,09% na an\u00e1lise da CHD.Expuseram motivos de hesita\u00e7\u00e3o em vacinar crian\u00e7as e adolescentes sob suaresponsabilidade 1.896 sujeitos, o que corresponde a 12,2% do total de respondentesda pesquisa. O A an\u00e1lise lexicogr\u00e1fica agrupou os textos em duas reparti\u00e7\u00f5es e seis classes. A A reparti\u00e7\u00e3o 1 integrou um pouco menos da metade da percep\u00e7\u00e3o dos participantes e tr\u00eas classes que expressavam receios com a vacina\u00e7\u00e3o de crian\u00e7as eadolescentes, perpassando a impress\u00e3o de falta de mais estudos sobre seguran\u00e7a eefic\u00e1cia e o medo quanto a rea\u00e7\u00f5es adversas e efeitos de longo prazo.A classe \u201cA vacina ainda est\u00e1 em fase experimental\u201d  apresentou como palavrasmais significativas \u201cseguro\u201d, \u201cfalta\u201d e \u201cestudo\u201d. As respostas dessa classe revelama concep\u00e7\u00e3o de que s\u00e3o necess\u00e1rios mais estudos nas faixas et\u00e1rias das crian\u00e7as, oque gera sentimento de inseguran\u00e7a nos pais em rela\u00e7\u00e3o \u00e0 vacina\u00e7\u00e3o de seus filhos,conforme observado nas falas a seguir:Tenho medo de vacinar porque os estudos e testes ainda s\u00e3o muitorecentes\u201d .\u201cN\u00e3o vacinarei por tudo ainda ser incerto para as crian\u00e7as. Com mais estudose comprova\u00e7\u00f5es ficarei mais segura e tomarei minha decis\u00e3o\u201d .\u201cAs classes \u201cTenho medo de rea\u00e7\u00f5es adversas\u201d  e \u201cN\u00e3o sei quais s\u00e3o os efeitosa longo prazo\u201d  tamb\u00e9m revelaram motivos de d\u00favidas dos pais quanto avacinar seus filhos devido ao medo de poss\u00edveis efeitos que a vacina\u00e7\u00e3o contra aCOVID-19 poderia ocasionar em crian\u00e7as.Na classe \u201cTenho medo de rea\u00e7\u00f5es adversas\u201d, as palavras \u201crea\u00e7\u00e3o\u201d, \u201crelato\u201d, \u201cmenino\u201de \u201ccardiovascular\u201d tiveram destaque e revelaram inseguran\u00e7as espec\u00edficas quanto area\u00e7\u00f5es cardiovasculares devido a relatos que leram ou escutaram em alguma fonte,conforme demonstrado nas falas:Tenho medo de rea\u00e7\u00f5es adversas, principalmente eventoscardiovasculares\u201d .\u201cTenho medo de rea\u00e7\u00f5es adversas cardiovasculares graves epermanentes\u201d .\u201cTenho conhecimento de v\u00e1rios adolescentes com rea\u00e7\u00f5es adversas\u201d.\u201cTenho medo de rea\u00e7\u00f5es da vacina, em especial a Pfizer, em meninos, em raz\u00e3ode not\u00edcias que circulam sobre maiores chances de efeitos colaterais emmeninos\u201d .\u201cN\u00e3o vacinarei devido \u00e0 inseguran\u00e7a e ao medo de rea\u00e7\u00f5es adversas a longoprazo\u201d .\u201cAlguns participantes relataram o desejo de verificar primeiro como as crian\u00e7as doconv\u00edvio de seus filhos iriam reagir \u00e0 vacina\u00e7\u00e3o para, ap\u00f3s isso, tomar a decis\u00e3o devacinar suas crian\u00e7as:Gostaria de verificar quais rea\u00e7\u00f5es poss\u00edveis na comunidade queconvivo\u201d .\u201cNo que concerne \u00e0 classe \u201cN\u00e3o sei quais s\u00e3o os efeitos a longo prazo\u201d, ter EnsinoSuperior completo foi uma vari\u00e1vel significativa , com destaque paraos voc\u00e1bulos: \u201clongo\u201d, \u201cefeito\u201d, \u201cneurol\u00f3gico\u201d e \u201ctecnologia\u201d. Os discursosagrupados nessa classe revelam preocupa\u00e7\u00e3o com os efeitos de longo prazo davacina\u00e7\u00e3o contra a COVID-19, associados sobretudo ao fato de as crian\u00e7as aindaestarem em desenvolvimento fisiol\u00f3gico, conforme pode ser observado nas falas:Tenho medo de vacinar porque s\u00e3o vacinas novas (...). Beb\u00ease crian\u00e7as est\u00e3o em pleno desenvolvimento f\u00edsico neurol\u00f3gico, n\u00e3o existe l\u00f3gicaem usar vacinas novas com pouco estudo e que ningu\u00e9m tem como saber o que vaiacontecer a longo prazo\u201d .\u201cTenho receio do impacto que a vacina possa ter a longo prazo nodesenvolvimento neurol\u00f3gico dela\u201d .\u201cNessa classe, outro elemento muito enfatizado foi o medo das vacinas que utilizamtecnologias inovadoras em compara\u00e7\u00e3o \u00e0s vacinas at\u00e9 ent\u00e3o aplicadas em crian\u00e7as.Foram v\u00e1rios os relatos da hesita\u00e7\u00e3o vacinal relacionada exclusivamente aoimunizante produzido pela Pfizer, com destaque para respostas com termos t\u00e9cnicos, oque pode estar relacionado ao fato de a escolaridade dos respondentes ter sido umavari\u00e1vel significativa nessa classe. Tais elementos est\u00e3o exemplificados nas falas aseguir:Tenho medo de vacinar porque desconhe\u00e7o os efeitos a longo prazo de umavacina de RNA em c\u00e9lulas germinativas\u201d .\u201cN\u00e3o vou vacinar, por ora, pois as vacinas aprovadas para crian\u00e7as t\u00eamtecnologia de RNA para a qual n\u00e3o sabemos ainda as consequ\u00eancias a longoprazo\u201d .\u201cQuero outro tipo de vacina, diferente da Pfizer\u201d .\u201cN\u00e3o quero vacinar com a Pfizer\u201d .\u201cEnquanto a reparti\u00e7\u00e3o 1 apresentou um agrupamento de percep\u00e7\u00f5es relacionadas aoreceio quanto \u00e0 vacina\u00e7\u00e3o, na reparti\u00e7\u00e3o 2 foi poss\u00edvel observar respostas de totalnega\u00e7\u00e3o quanto \u00e0 vacina\u00e7\u00e3o em crian\u00e7as e adolescentes, apoiadas em diferentesargumentos, conforme pode se observar nas classes apresentadas a partir deagora.A classe \u201cCOVID-19 em crian\u00e7as n\u00e3o \u00e9 grave\u201d integrou 15,81% das falas dosrespondentes. Nela, duas vari\u00e1veis de caracteriza\u00e7\u00e3o dos sujeitos foram elucidadascomo significativas: o filho j\u00e1 ter tido COVID-19 ; e o pai ourespons\u00e1vel n\u00e3o ter se vacinado contra a COVID-19 . Destacaram-se osvoc\u00e1bulos \u201cgrave\u201d, \u201ccrian\u00e7a\u201d, \u201cchance\u201d e \u201crisco\u201d e a principal ideia sustentadanessa classe foi a concep\u00e7\u00e3o de que n\u00e3o \u00e9 necess\u00e1rio imunizar crian\u00e7as, j\u00e1 que n\u00e3oh\u00e1 chances de forma grave da doen\u00e7a nessas faixas et\u00e1rias, discurso que pode serobservado nas falas a seguir:Crian\u00e7as n\u00e3o desenvolvem a doen\u00e7a de forma grave. Quem ir\u00e1 seresponsabilizar pelos danos causados por esses produtos aprovados em car\u00e1terexperimental?\u201d .\u201cOs n\u00fameros da COVID-19, cont\u00e1gio em crian\u00e7as e desfechos n\u00e3o se mostramcr\u00edticos e aparentemente as crian\u00e7as respondem bem ao processo infeccioso e,portanto, aplicar uma vacina que n\u00e3o impede o cont\u00e1gio, tampouco os desfechosgraves, como tem ocorrido com adultos n\u00e3o faz sentido\u201d .\u201cCrian\u00e7as e adolescentes t\u00eam poucas chances de pegar COVID-19 e, caso peguem,a chance de ser grave \u00e9 infinitamente menor que o risco da vacina\u201d.\u201cDe forma semelhante a tal compreens\u00e3o acerca da vacina\u00e7\u00e3o em crian\u00e7as como algodesnecess\u00e1rio, a classe \u201cOs riscos s\u00e3o maiores que os benef\u00edcios\u201d  pautou-seem uma afirma\u00e7\u00e3o de que os riscos da vacina\u00e7\u00e3o em crian\u00e7as superariam os daCOVID-19, o que pode ser evidenciado no destaque dos voc\u00e1bulos \u201crisco\u201d, \u201cbaixo\u201d e\u201ccompensar\u201d e nos discursos a seguir:Estou vendo muitos relatos de efeitos colaterais que a m\u00eddia ou os \u00f3rg\u00e3osrespons\u00e1veis n\u00e3o est\u00e3o relatando e nem orientando devidamente a popula\u00e7\u00e3o. E n\u00e3osinto seguran\u00e7a nenhuma nessas vacinas, portanto, acho o risco de meus filhosterem COVID-19 grave muito baixo e acho o risco de efeito adverso da vacinamuito maior\u201d .\u201cN\u00e3o vou vacinar porque a taxa de letalidade em crian\u00e7as e adolescentes porCOVID-19 \u00e9 muito baixa e o risco de se usar imunizantes desenvolvidos em t\u00e3opouco tempo sem garantias de seguran\u00e7a, sobretudo no caso das vacinas gen\u00e9ticas,ainda \u00e9 desconhecido, ou seja, a rela\u00e7\u00e3o custo-benef\u00edcio n\u00e3o compensa\u201d.\u201cA classe \u201cTenho o direito de escolher n\u00e3o vacinar\u201d agrupou mais de 1/4 da percep\u00e7\u00e3odos respondentes, com destaque para as palavras \u201cquerer\u201d, \u201cop\u00e7\u00e3o\u201d, \u201cdireito\u201d e\u201ccobaia\u201d. Observaram-se nessa classe discursos enf\u00e1ticos de hesita\u00e7\u00e3o vacinal,apoiados em uma concep\u00e7\u00e3o de liberdade de escolha quanto ao ato de vacinar:N\u00e3o sou cobaia humana de vacina, tampouco meus filhos, essas vacinas n\u00e3oimunizam ningu\u00e9m e s\u00f3 causam danos\u201d .\u201cEssas vacinas s\u00e3o experimentais e n\u00e3o sabemos plenamente o que elas cont\u00eam,temos direitos pela nossa constitui\u00e7\u00e3o de optarmos pela nossa liberdade deescolha e de n\u00e3o arriscarmos a vida dos nossos filhos e netos\u201d .\u201cO m\u00ednimo que deveria ser ofertado ao cidad\u00e3o \u00e9 o direito de escolher serealmente quer ou n\u00e3o se vacinar, sem contar que os efeitos colaterais eadversidades n\u00e3o s\u00e3o responsabilidade das ind\u00fastrias, e sim dos governos quecompram esses projetos de vacina. Os profissionais da sa\u00fade se corromperam e seprostitu\u00edram, n\u00e3o t\u00eam mais valores e nem princ\u00edpio algum, nem mesmo empatia ousolidariedade com o pr\u00f3ximo\u201d .\u201cA compreens\u00e3o dos dados deste estudo demanda, inicialmente, o entendimento do cen\u00e1riopand\u00eamico no Brasil, que \u00e9 constitu\u00eddo pelo fortalecimento do movimento antivacina epelo negacionismo da pandemia e, consequentemente, pela presen\u00e7a de impactosnegativos na implementa\u00e7\u00e3o de a\u00e7\u00f5es para preven\u00e7\u00e3o e controle da infec\u00e7\u00e3o peloSARS-CoV-2 Transversalmente ao movimento antivacina e ao negacionismo da pandemia, h\u00e1 onegacionismo da ci\u00eancia, em que \u201cquem nega a gravidade da COVID-19 parte, muitasvezes, da nega\u00e7\u00e3o dos discursos cient\u00edficos\u201d, e, portanto, a desqualifica\u00e7\u00e3o doscientistas Posto isso, a reparti\u00e7\u00e3o 1 do dendrograma (\u201cReceios com a vacina\u00e7\u00e3o\u201d) desvela que46,74% dos participantes t\u00eam receio de vacinar seus filhos por diversosmotivos/concep\u00e7\u00f5es: falta de estudos sobre seguran\u00e7a e efic\u00e1cia da vacina e medo dasrea\u00e7\u00f5es adversas e dos efeitos de longo prazo. Al\u00e9m desses motivos identificados emnosso estudo, outros j\u00e1 foram pontuados: vacina nova, percep\u00e7\u00e3o de que a crian\u00e7a n\u00e3ocorre risco de contrair COVID-19, recusa geral da vacina, falta de informa\u00e7\u00f5esdispon\u00edveis/recomendadas sobre as vacinas Um estudo destaca que o desenvolvimento da vacina contra a COVID-19, que ocorreu emtempo recorde, com dura\u00e7\u00e3o de meses - consequ\u00eancia do alto investimento pelos pa\u00edses-, associado \u00e0 falta de conhecimento da popula\u00e7\u00e3o sobre o processo sistematizado erigoroso da produ\u00e7\u00e3o dos imunizantes, o uso inapropriado de termos epidemiol\u00f3gicos -e, por vezes, sem esclarecimentos \u00e0 popula\u00e7\u00e3o, a exemplo do termo efic\u00e1cia da vacina- e a socializa\u00e7\u00e3o de informa\u00e7\u00f5es incorretas e/ou falsas maximizaram os sentimentosde medo e inseguran\u00e7a Em coer\u00eancia com esses achados, uma pesquisa realizada em Teresina (Piau\u00ed), no ano de2020, em unidades b\u00e1sicas de sa\u00fade, demonstrou que os fatores decisivos para a n\u00e3ovacina\u00e7\u00e3o foram o descr\u00e9dito na celeridade do processo de fabrica\u00e7\u00e3o da vacina. Paraos autores, \u00e9 necess\u00e1ria a comunica\u00e7\u00e3o efetiva com a popula\u00e7\u00e3o, por meio decampanhas informativas relativas aos benef\u00edcios das vacinas aprovadas pela AnvisaDevido \u00e0 urg\u00eancia na produ\u00e7\u00e3o de vacinas para o enfrentamento do SARS-CoV-2,passou-se a adotar estrat\u00e9gia do uso emergencial dos imunizantes. Em 18 de janeirode 2021, a vacina contra a COVID-19 come\u00e7ou a ser aplicada no Brasil medianteaprova\u00e7\u00e3o emergencial do \u00f3rg\u00e3o regulador nacional, a Anvisa No tocante ao \u201cmedo das rea\u00e7\u00f5es adversas\u201d, uma revis\u00e3o sistem\u00e1tica da literaturaOutro ponto de discuss\u00e3o \u00e9 a hesita\u00e7\u00e3o vacinal pela inseguran\u00e7a quanto \u00e0s rea\u00e7\u00f5escardiovasculares p\u00f3s-vacina\u00e7\u00e3o, em especial \u00e0quelas relacionadas \u00e0s vacinas de mRNA.H\u00e1 evid\u00eancia de casos de mio/pericardite, especialmente ap\u00f3s a segunda dose davacina\u00e7\u00e3o. Contudo, s\u00e3o eventos raros e os benef\u00edcios superam os riscos das rea\u00e7\u00f5esassociadas ao imunizante No Brasil, os casos de eventos adversos p\u00f3s-vacina\u00e7\u00e3o da COVID-19 ocorridos na faixaet\u00e1ria de 5 a 18 anos registrados pelos sistema de vigil\u00e2ncia brasileiro no per\u00edodode 18 de janeiro de 2021 a 18 de junho de 2022 mostram que ap\u00f3s 37.205.093 doses devacinas contra COVID-19 foram registradas 17.449 notifica\u00e7\u00f5es de eventos adversos eapenas 546  de eventos adversos graves, sem nenhum \u00f3bito com rela\u00e7\u00e3o causalcom a vacina utilizada Ainda sobre as rea\u00e7\u00f5es p\u00f3s-vacina\u00e7\u00e3o, deve-se atentar que algumas condi\u00e7\u00f5esbiol\u00f3gicas, como a resposta imune robusta normal e esperada em grupos espec\u00edficos -crian\u00e7as e adolescentes, por exemplo -, e predisposi\u00e7\u00f5es gen\u00e9ticas expliquem apresen\u00e7a de rea\u00e7\u00f5es cardiovasculares em pessoas ap\u00f3s recebimento de imunizante Com rela\u00e7\u00e3o \u00e0s vacinas produzidas pela tecnologia de mRNA, categorizadas no grupo devacinas gen\u00e9ticas, a exemplo da Pfizer, o processo de produ\u00e7\u00e3o de anticorpos n\u00e3oocasiona altera\u00e7\u00f5es no organismo humano. A vacina tem parte do material gen\u00e9tico doSARS-CoV-2 e, ap\u00f3s sua administra\u00e7\u00e3o, sensibiliza nosso sistema imunol\u00f3gico paraprodu\u00e7\u00e3o de anticorpos, possibilitando uma boa resposta imune celular e humoral,Al\u00e9m disso, o emprego de vacinas gen\u00e9ticas n\u00e3o \u00e9 recente e sua utiliza\u00e7\u00e3o, h\u00e1 quase30 anos, n\u00e3o se restringiu \u00e0 preven\u00e7\u00e3o e ao tratamento de doen\u00e7as infecciosas, masalcan\u00e7ou o cen\u00e1rio oncol\u00f3gico. Elas apresentam bom perfil de seguran\u00e7a, podem serproduzidas em larga escala, t\u00eam baixo custo e induzem o organismo a produzir t\u00edtulosde anticorpos neutralizadores - capazes de bloquear a entrada do v\u00edrus nas c\u00e9lulas -maiores do que os presentes no soro humano, ap\u00f3s recupera\u00e7\u00e3o da infec\u00e7\u00e3o Outro resultado identificado neste estudo foi a concep\u00e7\u00e3o de que a \u201cCOVID-19 emcrian\u00e7as n\u00e3o \u00e9 grave\u201d. De fato, a doen\u00e7a nesse p\u00fablico ocorre, na maioria das vezes,com quadros assintom\u00e1ticos ou leves em compara\u00e7\u00e3o com adultos e idosos. Todavia,essa assertiva n\u00e3o denota afirmar que h\u00e1 inexist\u00eancia de casos graves e \u00f3bitos Estima-se que nos Estados Unidos 40 milh\u00f5es de crian\u00e7as est\u00e3o vulner\u00e1veis.Consequentemente, em caso de transmiss\u00e3o descontrolada entre esse grupo, pode-sevivenciar o cen\u00e1rio de v\u00e1rios \u00f3bitos e hospitaliza\u00e7\u00f5es Boletim Epidemiol\u00f3gico n\u00ba 123 doMinist\u00e9rio da Sa\u00fade Ainda, ressalta-se que, segundo o Na reparti\u00e7\u00e3o 2 (\u201cAus\u00eancia de inten\u00e7\u00e3o de vacinar\u201d), a classe \u201cOs riscos s\u00e3o maioresque os benef\u00edcios\u201d revela a manipula\u00e7\u00e3o das informa\u00e7\u00f5es a fim de subordinar um grupoda popula\u00e7\u00e3o para o n\u00e3o engajamento \u00e0 vacina\u00e7\u00e3o. Essa constata\u00e7\u00e3o \u00e9 pauta dediscuss\u00f5es em todos os pa\u00edses e a desinforma\u00e7\u00e3o, al\u00e9m de desencadear baixa ades\u00e3o \u00e0scampanhas, prolonga a pandemia, aumenta a suscetibilidade das crian\u00e7as \u00e0 infec\u00e7\u00e3opelo SARS-CoV-2 e potencializa o sofrimento emocional decorrente da COVID-19, asaber: separa\u00e7\u00e3o dos pais e amigos, hospitaliza\u00e7\u00f5es e distanciamento social No tocante ao resultado da classe \u201cTenho o direito de escolher n\u00e3o vacinar\u201d, asreflex\u00f5es devem ser pautadas nos princ\u00edpios \u00e9ticos do direito individual e coletivo.Dessa forma, a n\u00e3o ades\u00e3o \u00e0 vacina\u00e7\u00e3o causa impactos na esfera individual, quevariam entre adoecimento, hospitaliza\u00e7\u00e3o e \u00f3bito, mas sobretudo em \u00e2mbito coletivo,pois o sucesso da vacina\u00e7\u00e3o demanda a participa\u00e7\u00e3o de 80% da popula\u00e7\u00e3o Sabe-se que com a propaga\u00e7\u00e3o de falsas informa\u00e7\u00f5es e a nega\u00e7\u00e3o da pandemia,principalmente por chefes do Poder Executivo que polarizam a popula\u00e7\u00e3o no contextodas defini\u00e7\u00f5es estrat\u00e9gicas de preven\u00e7\u00e3o e controle da COVID-19 por benef\u00edciospr\u00f3prios e partid\u00e1rios, estimulam a sensa\u00e7\u00e3o de que o direito individual \u00e9 soberanoe, portanto, o direito de escolha configura uma a\u00e7\u00e3o de liberdade. \u00c9 precisoesclarecer que no combate ao SARS-CoV-2 a uniformidade \u00e9 princ\u00edpio mandat\u00f3rio.Afinal, a sa\u00fade \u00e9 direito individual e coletivo e dever do Estado, n\u00e3o subordinado agrupos espec\u00edficos.online e ao momento de coleta de dados, visto que, \u00e0 \u00e9poca, avacina\u00e7\u00e3o contra a COVID-19 ainda n\u00e3o havia sido iniciada no p\u00fablico infantil e,portanto, mapeou-se a inten\u00e7\u00e3o futura de vacina\u00e7\u00e3o. Al\u00e9m disso, a estrat\u00e9gia bola deneve acaba distribuindo o instrumento de coleta de dados para pessoas de um mesmoconv\u00edvio social, com poss\u00edvel n\u00edvel de cren\u00e7as em sa\u00fade similar. Os resultadosapresentados, portanto, devem ser analisados \u00e0 luz de tais limita\u00e7\u00f5es.Como limita\u00e7\u00e3o do estudo, destaca-se o poss\u00edvel vi\u00e9s de sele\u00e7\u00e3o da amostra,influenciado pelo acesso aos meios de divulga\u00e7\u00e3o do formul\u00e1rio no ambienteS\u00e3o motivos pelos quais pais e/ou respons\u00e1veis n\u00e3o vacinaram ou est\u00e3o na d\u00favida emvacinar as crian\u00e7as e os adolescentes sob sua responsabilidade para preven\u00e7\u00e3o daCOVID-19: receio da vacina\u00e7\u00e3o devido \u00e0 concep\u00e7\u00e3o de que a vacina est\u00e1 em faseexperimental e medo das rea\u00e7\u00f5es adversas e dos efeitos a longo prazo. Aoidentificarmos fatores que contribuem para a hesita\u00e7\u00e3o vacinal em crian\u00e7as, torna-seposs\u00edvel otimizar as estrat\u00e9gias para melhorar a aceita\u00e7\u00e3o da vacina\u00e7\u00e3o contra aCOVID-19 pelos respons\u00e1veis.J\u00e1 os motivos para aus\u00eancia de inten\u00e7\u00e3o de vacinar decorrem dos entendimentos dosparticipantes de que a COVID-19 em crian\u00e7as n\u00e3o \u00e9 grave, os riscos da vacina\u00e7\u00e3o s\u00e3omaiores do que os benef\u00edcios e o direito de escolha em n\u00e3o vacinar.Destarte, \u00e9 condi\u00e7\u00e3o indispens\u00e1vel o delineamento de iniciativas - e consolida\u00e7\u00e3o dasj\u00e1 existentes - que contribuam para a atenua\u00e7\u00e3o dos movimentos antivacina e para ofortalecimento da ci\u00eancia, bem como para a divulga\u00e7\u00e3o efetiva dos seus feitos \u00e0sa\u00fade da popula\u00e7\u00e3o."}
+{"text": "To analyze the consumption of drugs for Alzheimer\u2019s disease on the Brazilian private market and its geographical distribution from 2014 to 2020.National data from the Brazilian National System of Controlled Product Management were used, regarding sales of donepezil, galantamine, rivastigmine, and memantine from January 2014 to December 2020. Sales data were used as a proxy for drug consumption and expressed as defined daily dose/1,000 inhabitants/year at national, regional, federative unit and microregion levels.Drug consumption went from 5,000 defined daily doses/1,000 inhabitants, in 2014, to more than 16,000/1,000 inhabitants, in 2020, and all federative units showed positive variation. The Brazilian Northeast had the highest cumulative consumption in the period but displayed microregional disparities while the North region had the lowest consumption. Donepezil and memantine were the most consumed drugs, with the highest growth in consumption from 2014 to 2020.The consumption of medicines indicated to treat Alzheimer\u2019s disease tripled in Brazil between 2014 and 2020, which may relate to the increase in the prevalence of the disease in the country, greater access to health services, and inappropriate use. This challenges managers and healthcare providers due to population aging and the increased prevalence of chronic-degenerative diseases. The Brazilian population aged over 60 years represented 12.8% of all residents in 2012, increasing to 15.4% in 2018, representing over 30 million people. In 2018, this age group had the highest concentrations in the Brazilian Southeast (17.1%) and South (16.9%), but all major regions followed the trend of population aging 3 .Demographic transition is a population phenomenon in several countries 4 , a neurological condition with symptoms such as the deterioration of cognitive and behavioral capacity and impaired memory and language use, which greatly affects patients\u2019 quality of life 5 . The worldwide prevalence of dementia more than doubled from 1990 to 2016 and population aging configures a key factor in this growth 6 . Brazil stands out in this scenario with the second highest global estimate in relation to the age-standardized prevalence 6 . National studies still differ regarding the indicators of the disease in the country, hindering its reliable mapping 7 .The increase in life expectancy is related to the growing prevalence of chronic-degenerative diseases such as dementia 5 . AD is a neurodegenerative disease associated with the accumulation of two pathogenic proteins, amyloid \u03b2 peptide and tau protein, leading to neuronal dysfunction and loss and ultimately to the progression of cognitive impairment 8 .Alzheimer\u2019s disease (AD) is the leading cause of dementia, associated with 60\u201370% of cases 9 . The AChEi class includes donepezil, galantamine, and rivastigmine, and the latter class, only memantine. The Clinical Protocols and Therapeutic Guidelines (CPTG) for Alzheimer\u2019s Disease 9 include all these drugs, establishing treatment guidelines for the disease, which is offered by the C omponente Especializado de Assit\u00eancia Farmac\u00eautica . The acquisition on the National Health System (SUS) is conditioned to the delivery of specific documents and depends on their prior evaluation, which may exclude applicants 10 . Out-of-pocket acquisition can represent a source of access to medicines for these patients.This disease has no cure, and its pharmacological treatment is based on the use of acetylcholinesterase inhibitors (AChEi) and NMDA-type glutamate receptor antagonists to increase the supply of acetylcholine in synaptic clefts and reduce glutamatergic excitotoxicity, respectively Ag\u00eancia Nacional de Vigil\u00e2ncia Sanit\u00e1ria  12 . All due information is sent to the Sistema Nacional de Gerenciamento de Produtos Controlados  and these data are publicly accessible, according to the 2016 Brazilian Open Data Policy 13 .Ordinance No. 344, of May 12, 1998, regarding controlled substances, includes all indicated drugs to treat Alzheimer\u2019s disease; thus, their trade is subject to record keeping. Private pharmacies and drugstores currently conduct this process, periodically and electronically sending data to the This study aims to analyze the consumption profile of Alzheimer\u2019s drugs in Brazil using a publicly accessible database to evaluate trends in the consumption of these drugs in the private market.14 ) were used as a source of data on drug consumption. The used data came from spreadsheets downloaded from May to September 2021 in an CSV format, using Excel \u00ae (2016) and its integrated tool PowerQuery, which offers ETL functions  to process and then analyze broad databases 15 .This is a descriptive cross-sectional study. SNGPC dispensing records, made available by ANVISA  classifications and corresponding DDD were searched 17  were used, a unit of measurement employed to evaluate trends in the use of medicines and to compare population groups as it remains stable despite price fluctuations, packaging changes, or presentation rched 17 . DonepezInstituto Brasileiro de Geografia e Estat\u00edstica (Brazilian Institute of Geography and Statistics \u2013 IBGE) were considered, with a reference date of July 1 for each year 18 .Consumed amounts were estimated according to the DDD indicator per 1,000 inhabitants for each analyzed year, providing a population estimate of the use of these drugs. For this calculation, the population projections made available annually by the 19 .The formulas to calculate the indicators are shown below 20 .Annual consumption data for each active ingredient were obtained at the municipal level, identifying the respective unit of the federation or Federal District. For each evaluated year, information was aggregated into 558 microregions based on the compatibility of spatial scales. The territorial meshes relating municipalities and microregions were obtained according to the IBGE classification Consumption classes to analyze spatial distributions were defined by calculating the quartiles of the indicator, expressed in DDD/1,000 inhabitants  considering the entire period of analysis (2014 to 2020). Thus, four consumption ranges were specified : 0 to 103; 103 to 240; 240 to 466; and 466 to 491,376.21 (2021) was used to analyze the quantitative data and elaborate graphs and maps to determine consumption by period and place.R software Aggregate analysis    of all In 2014, the states of S\u00e3o Paulo , Rio de Janeiro , and Rio Grande do Sul  showed the highest consumption of AD medication, whereas Rio Grande do Sul , Rio Grande do Norte , and Pernambuco  did so in 2020. Rio Grande do Norte and Pernambuco showed significant variation in consumption in relation to the beginning of the historical series . These federative units showed the highest consumption of drugs for AD in 2020.The Northeast showed the highest cumulative consumption over the seven evaluated years  and the greatest variation in consumption between 2014 and 2020. The Brazilian Southeast features in second place, with 17,612 DDD/1,000 inhabitants from January 2014 to December 2020. The Brazilian North region had the lowest cumulative consumption in the country .We found a higher magnitude of donepezil and memantine consumption than that of other drugs   . MoreovMonthly analysis indicates that differences in the magnitude of consumption remained throughout the period, showing no seasonal or periodic trends   .Regarding spatial distribution, we analyzed the consumption of drugs in the Brazilian micro-regions. In 2014, it totaled 103 DDD/1,000 inhabitants in most of the country, with micro-regions without sales records, concentrated especially in the North region. In that year, the Southeast and South concentrated most of the consumption of the analyzed drugs as they contained all the microregions that consumed more than 466 DDD/1,000 inhabitants/year   . We fouThroughout the historical series, we can see that the magnitude of consumption rises in Brazil, especially on the South and Southeast, which showed a higher proportion of records in the upper range, above 466 DDD/1,000 inhabitants/year   .The Northeast showed the highest accumulated consumption of drugs in the national scenario, with micro-regional disparities: In 2020, the states of Rio Grande do Norte (10), Para\u00edba (8), and Pernambuco (6) concentrated the microregions that consumed more than 466 DDD/1,000 inhabitants, totaling only 37 (approximately 20%) among the 187 Northeastern microregions. Consumption decreases outside these areas and toward the local inland   .Regarding the Brazilian North, only one microregion in Rond\u00f4nia and another in Par\u00e1, consumed more than 466 DDD/1,000 inhabitants in 2020. The highlight of this region stems from the maintenance of areas with consumption voids, especially in the states of Amazonas and Par\u00e1   .22 .The consumption of drugs to treat AD increased by more than 200% from 2014 to 2020, representing an average growth rate of 21.56% per year. All federative units and major regions showed positive consumption variations. Similarly, pharmaceutical market data from other countries shows the growing demand for such drugs. Recent analysis of the international pharmaceutical market showed a 55.74% increase in the consumption of these drugs from 2008 to 2018, driven mainly by low- and middle-income countries such as Brazil 6 . In Brazil, estimates suggest that, in 1990, 472,667 people had dementia , rising to 1,702,402  in 2019 23 .Results of the 2016 Global Burden of Disease Study (GDB 2016) indicate a global growth of 117% in dementia cases (or 26.6 million people) from 1990 to 2016 24 . In line with these estimates, the demographic profile indicates a rapid growth of the population aged 65 years or older (which represented 7.6% of its population in 2010), reaching 38% of the total population in 2050 26 . Thus, the consumption profile we observed would tend to increase.We face the expectation of the worldwide growth in the prevalence of AD and other dementias. Projections for Brazil indicate that it will affect, on average, 5,666,116 people in 2050, an increase above 200% compared to 2019 The consumption increase we found can also relate to aspects such as greater access to health services and/or some level of inadequate use of the analyzed drugs. The absence of national data on the prevalence of dementia in Brazil is notable. Thus, this study suggests a possible increase in this prevalence that deserves investigation.27 . This improvement may be related to greater access to diagnostic services and the indication of treatment. Moreover, the expected trend of increasing prevalence of AD has already been reported for lower-middle-income countries 28 .A 2017 study showed improvements in the supply of health services in Brazil from 2000 to 2016, with greater access to primary care and services of medium and high complexity, including the provision of private supplementary services 29 . Diagnostic accuracy is important to prevent potential risks derived from medication use. Correctly assessing a picture of cognitive deterioration can optimize pharmacological therapy and reduce the occurrence of potential adverse events 30 .Diagnosis can offer challenges. Factors such as the symptomatic similarity between AD and other dementias and syndromes related to cognitive deterioration, can lead some patients, suffering from the latter, to be misdiagnosed and treated for AD 22 . Acetylcholinesterase inhibitors (AChEi) are the first line of treatment for mild to moderate AD, and donepezil is the only such drug indicated for all stages of the disease 9 . The recommendation (or indication) of donepezil for all stages of AD may be an important factor contributing to the greater magnitude of its consumption. Moreover, it is the oldest drug on the market for AD 31 , which may be associated with more consolidated prescribing habits.Regarding the analysis of national drug consumption, donepezil and memantine were more consumed than galantamine and rivastigmine since the beginning of the evaluated historical series, data corroborated in the literature 3 , which may contribute to this observation. The Brazilian Northeast showed a different situation. It had the highest cumulative consumption of our historical series but an irregular distribution, suggesting greater acquisition disparities.Regarding the analysis of microregional distribution, Southern and Southeastern microregions predominate in the range of higher consumption, showing a more uniform distribution throughout the territory. The Brazilian South and Southeast show the highest proportion of older adults in the country 33 .Access to health services can be understood under different aspects, including purchasing capacity and geographical accessibility. Purchasing capacity addresses the adequacy between the cost of using health services and the ability to pay individuals, whereas geographical accessibility refers to the distance between the desired service and the user and the means of transport and travel time 27 . According to the authors, residents of the South and Southeast had greater access to health services, despite marked social inequalities in the South. Moreover, the improvement of access over a five-year period was greater in these more socioeconomically developed regions 27 . More recently, a study on regional health inequalities evaluated the internalization of the development and supply of services in the Brazilian South and Southeast, whereas the Northeast, despite its socioeconomic development, shows a high concentration in a few areas of greater economic activity 34 , an aspect that may be related to our results.A 2006 study showed that these two factors strongly influence access to health services in Brazil 37 . Moreover, the acquisition of drugs in the private market may impair family incomes 38 or patients may be unable to acquire drugs 36 , compromising therapeutic results 39 .Other studies corroborate the relevance of purchasing capacity for the effective access to drugs both in private and public markets and access inequalities 32 . It was only on the 2017 edition of the CPTG that memantine and rivastigmine transdermal patches were added to the national guideline. Currently, all approved drugs  to treat AD feature in the 2022 National Relation of Essential Medicines 40 and are dispensed by CEAF according to guidelines established by the CPTG 9 .Acquisition in the private market may occur due to the absence of a drug in the public system Sistema de Gerenciamento da Tabela de Procedimento, Medicamentos e OPM  e no Sul , mas todas as grandes regi\u00f5es do pa\u00eds seguem a tend\u00eancia de envelhecimento populacional 3 .O processo de transi\u00e7\u00e3o demogr\u00e1fica \u00e9 um fen\u00f4meno populacional que ocorre em diversos pa\u00edses 4 , que s\u00e3o condi\u00e7\u00f5es neurol\u00f3gicas que se manifestam com sintomas como deteriora\u00e7\u00e3o da capacidade cognitiva e comportamental, preju\u00edzo de mem\u00f3ria e do uso da linguagem, com grande impacto na qualidade de vida dos portadores 5 . A preval\u00eancia mundial das dem\u00eancias mais do que dobrou entre 1990 e 2016, e o envelhecimento da popula\u00e7\u00e3o \u00e9 um fator-chave nesse crescimento 6 . O Brasil tem destaque nesse cen\u00e1rio, com a segunda maior estimativa mundial ao comparar a preval\u00eancia padronizada por idade 6 . Apesar disso, estudos nacionais ainda divergem em rela\u00e7\u00e3o aos indicadores da presen\u00e7a da doen\u00e7a no pa\u00eds, dificultando o mapeamento da condi\u00e7\u00e3o de forma fidedigna 7 .O aumento da expectativa de vida relaciona-se com o crescimento da preval\u00eancia de doen\u00e7as cr\u00f4nico-degenerativas, como as dem\u00eancias 5 . A DA \u00e9 uma doen\u00e7a neurodegenerativa associada ao ac\u00famulo de duas prote\u00ednas patog\u00eanicas, pept\u00eddeo \u03b2-amiloide e prote\u00edna tau, o que leva \u00e0 disfun\u00e7\u00e3o e perda neuronal, e em \u00faltima an\u00e1lise, \u00e0 progress\u00e3o do 8 .A doen\u00e7a de Alzheimer (DA) \u00e9 a principal causa de dem\u00eancia, e est\u00e1 associada a 60% a 70% dos casos 9 . Na classe dos iAChE est\u00e3o donepezila, galantamina e rivastigmina, e na segunda classe, apenas a memantina. Todos estes f\u00e1rmacos est\u00e3o inclu\u00eddos nos Protocolos Cl\u00ednicos e Diretrizes Terap\u00eauticas (PCDT) para a Doen\u00e7a de Alzheimer 9 , estabelecendo as linhas de cuidado para a doen\u00e7a, cujo tratamento \u00e9 ofertado por meio do Componente Especializado da Assist\u00eancia Farmac\u00eautica (CEAF). Esta dispensa\u00e7\u00e3o pelo SUS est\u00e1 condicionada \u00e0 entrega de documentos espec\u00edficos: sua libera\u00e7\u00e3o depende da avalia\u00e7\u00e3o pr\u00e9via destes documentos, n\u00e3o sendo aprovada para todos os solicitantes 10 . Neste sentido, a aquisi\u00e7\u00e3o no mercado privado pode representar uma fonte de acesso aos medicamentos para os pacientes recusados.Esta doen\u00e7a n\u00e3o tem cura e seu tratamento farmacol\u00f3gico se baseia na utiliza\u00e7\u00e3o de inibidores da enzima acetilcolinesterase (iAChE) e antagonistas do receptor de glutamato do tipo NMDA, buscando, respectivamente, aumentar a oferta de acetilcolina nas fendas sin\u00e1pticas e reduzir a excitotoxicidade glutamat\u00e9rgica 12 . Esta escritura\u00e7\u00e3o \u00e9 realizada no Sistema Nacional de Gerenciamento de Produtos Controlados (SNGPC), cujos dados s\u00e3o de acesso p\u00fablico, conforme a Pol\u00edtica de Dados Abertos do Governo Federal, institu\u00edda em 2016 13 .Todos os medicamentos indicados para o tratamento da DA est\u00e3o inclu\u00eddos na Portaria n\u00ba 344 de 12 de maio de 1998, desta forma, sua comercializa\u00e7\u00e3o est\u00e1 sujeita \u00e0 escritura\u00e7\u00e3o. Atualmente, este processo \u00e9 realizado por farm\u00e1cias e drogarias privadas, com o envio peri\u00f3dico dos dados \u00e0 Ag\u00eancia Nacional de Vigil\u00e2ncia Sanit\u00e1ria (Anvisa), por meio eletr\u00f4nico O objetivo deste trabalho foi analisar o perfil de consumo dos medicamentos para Alzheimer no Brasil, utilizando base de dados de acesso p\u00fablico, a fim de avaliar tend\u00eancias desse consumo no mercado privado.14 . Os dados utilizados neste trabalho s\u00e3o oriundos de planilhas baixadas entre maio e setembro de 2021, no formato CSV., utilizando-se o software Excel\u00ae (2016) e sua ferramenta integrada PowerQuery, que possibilita a execu\u00e7\u00e3o de fun\u00e7\u00f5es ETL  para o processamento e posterior an\u00e1lise de bases amplas de dados 15 .Trata-se de um estudo descritivo, de tipo ecol\u00f3gico. Como fonte de dados de consumo de medicamentos utilizaram-se os registros de dispensa\u00e7\u00e3o do SNGPC disponibilizados pela Anvisa por meio do Portal Brasileiro de Dados Abertos, na se\u00e7\u00e3o Venda de Medicamentos Controlados e Antimicrobianos \u2013 Medicamentos Industrializados Os medicamentos analisados neste trabalho foram todos aqueles comercializados no per\u00edodo de janeiro de 2014 a dezembro de 2020, que incluam os princ\u00edpios ativos autorizados para o tratamento da DA no pa\u00eds, a saber: rivastigmina, donepezila, galantamina e memantina, em todas as apresenta\u00e7\u00f5es dispon\u00edveis, incluindo associa\u00e7\u00f5es. Excetua-se desta an\u00e1lise a apresenta\u00e7\u00e3o de memantina de 10mg/g, pois n\u00e3o foi poss\u00edvel encontrar a bula de tal apresenta\u00e7\u00e3o para confirmar a dose por unidade farmac\u00eautica. Em uma an\u00e1lise explorat\u00f3ria dos dados foi poss\u00edvel observar que o percentual de venda desta apresenta\u00e7\u00e3o dentre as demais foi menor do que 0,1% anualmente. Sendo assim, considerou-se que a exclus\u00e3o desta apresenta\u00e7\u00e3o seria uma perda de pequena monta para o estudo.16 . Para encontrar a DDD de cada medicamento, foram consultadas suas classifica\u00e7\u00f5es ATC  e posteriormente a DDD correspondente 17 , unidade de medida usada para avaliar tend\u00eancias na utiliza\u00e7\u00e3o de medicamentos e \u00fateis para compara\u00e7\u00f5es entre grupos populacionais, por n\u00e3o variar devido a flutua\u00e7\u00f5es de pre\u00e7o, modifica\u00e7\u00f5es de embalagem ou apresenta\u00e7\u00e3o ente 17   . Neste 18 .A quantidade de medicamentos consumida foi calculada segundo o indicador DDD por 1.000 habitantes para cada ano analisado, fornecendo uma estimativa populacional do uso dos medicamentos. Para o c\u00e1lculo, foram consideradas as proje\u00e7\u00f5es populacionais disponibilizadas anualmente pelo Instituto Brasileiro de Geografia e Estat\u00edstica (IBGE), com data de refer\u00eancia em 1\u00ba de julho de cada ano 19 .Abaixo seguem as f\u00f3rmulas utilizadas para o c\u00e1lculo dos indicadores 20 .Os dados de consumo anual de cada princ\u00edpio ativo foram obtidos a n\u00edvel municipal, com a identifica\u00e7\u00e3o da respectiva unidade da federa\u00e7\u00e3o ou Distrito Federal. A cada ano avaliado, as informa\u00e7\u00f5es foram agregadas em 558 microrregi\u00f5es, a partir de uma compatibiliza\u00e7\u00e3o das escalas espaciais. As malhas territoriais que relacionam munic\u00edpio e microrregi\u00e3o foram obtidas segundo classifica\u00e7\u00e3o do IBGE As classes de consumo, para a an\u00e1lise da distribui\u00e7\u00e3o espacial, foram definidas a partir do c\u00e1lculo dos quartis do indicador expressado em DDD/1.000 habitantes  considerando todo o per\u00edodo de an\u00e1lise (2014 a 2020). Desta maneira, foram especificadas quatro faixas de consumo (em DDD/1.000 habitantes/ano): 0 a 103; 103 a 240; 240 a 466; 466 a 491.376.21 (2021) para a an\u00e1lise dos dados quantitativos e elabora\u00e7\u00e3o dos gr\u00e1ficos e dos mapas, a fim de determinar o consumo por per\u00edodo e local.Utilizou-se, tamb\u00e9m, o software R A an\u00e1lise agregada    de todoEm 2014, S\u00e3o Paulo (596 DDD/1.000 habitantes), Rio de Janeiro (494 DDD/1.000 habitantes) e Rio Grande do Sul (440 DDD/1.000 habitantes) foram os estados com maior consumo dos medicamentos. Em 2020, o Rio Grande do Sul seguiu em destaque (2.314 DDD/1.000 habitantes), junto ao Rio Grande do Norte (2.373 DDD/1.000 habitantes) e Pernambuco (1.442 DDD/1.000 habitantes). Ambos estados nordestinos apresentaram varia\u00e7\u00e3o expressiva do consumo em rela\u00e7\u00e3o ao in\u00edcio da s\u00e9rie hist\u00f3rica \u2013 1.144,49% e 586,67%, respectivamente \u2013 e foram as unidades federativas de maior consumo de medicamentos para DA em 2020.A regi\u00e3o Nordeste apresentou o maior consumo acumulado ao longo dos sete anos avaliados, com 22.561 DDD/1.000 habitantes dispensadas no per\u00edodo. A regi\u00e3o tamb\u00e9m foi a que apresentou maior varia\u00e7\u00e3o no consumo entre 2014 e 2020. Em segundo lugar, aparece a regi\u00e3o Sudeste, com 17.612 DDD/1.000 habitantes consumidas entre janeiro de 2014 e dezembro de 2020. A regi\u00e3o Norte tem o consumo acumulado mais baixo do pa\u00eds (5.830 DDD/1.000 habitantes).P\u00f4de-se verificar que o consumo de donepezila e memantina tem maior magnitude em compara\u00e7\u00e3o aos demais f\u00e1rmacos   . AdemaiA an\u00e1lise mensal ao longo da s\u00e9rie hist\u00f3rica indica que a diferen\u00e7a da magnitude do consumo se mant\u00e9m ao longo de todo o per\u00edodo analisado, n\u00e3o indicando tend\u00eancias relacionadas \u00e0 sazonalidade ou per\u00edodos espec\u00edficos   .Em rela\u00e7\u00e3o \u00e0 distribui\u00e7\u00e3o espacial, analisou-se o consumo dos medicamentos nas microrregi\u00f5es brasileiras. Em 2014, este consumo era de at\u00e9 103 DDD/1.000 habitantes na maior parte do pa\u00eds, havendo microrregi\u00f5es sem registro de vendas, concentradas majoritariamente na regi\u00e3o Norte. Naquele ano, o consumo dos medicamentos analisados concentrou-se nas regi\u00f5es Sudeste e Sul, onde localizaram-se todas as microrregi\u00f5es que consumiram mais de 466 DDD/1.000 habitantes/ano   . No SudAo longo da s\u00e9rie hist\u00f3rica, pode-se perceber que a magnitude do consumo se expande no pa\u00eds, com o destaque para as regi\u00f5es Sul e Sudeste, onde h\u00e1 maior propor\u00e7\u00e3o de registros na faixa superior, acima de 466 DDD/1.000 habitantes/ano   .A regi\u00e3o Nordeste, onde ocorreu o maior consumo acumulado de medicamentos no cen\u00e1rio nacional, exibe disparidades microrregionais: Em 2020, as microrregi\u00f5es que consumiram mais de 466 DDD/1.000 habitantes se concentraram nos estados de Rio Grande do Norte (10), Para\u00edba (8) e Pernambuco (6), e totalizam somente 37 (aproximadamente 20%) dentre as 187 microrregi\u00f5es nordestinas. Fora destas \u00e1reas, e em dire\u00e7\u00e3o ao interior da regi\u00e3o, o consumo se reduz   .Em rela\u00e7\u00e3o ao Norte do pa\u00eds, em 2020 encontra-se apenas uma microrregi\u00e3o com consumo superior a 466 DDD/1.000 habitantes, em Rond\u00f4nia, e outra localizada no Par\u00e1. O destaque da regi\u00e3o fica por conta da manuten\u00e7\u00e3o de \u00e1reas com vazios de consumo, localizados primariamente nos estados do Amazonas e Par\u00e1   .22 .O consumo dos medicamentos utilizados no tratamento da DA aumentou mais de 200% entre 2014 e 2020, representando uma taxa m\u00e9dia de crescimento de 21,56% ao ano. Todas as unidades federativas e Grandes Regi\u00f5es apresentaram varia\u00e7\u00e3o positiva no consumo. Similarmente, dados do mercado farmac\u00eautico de outros pa\u00edses mostram a crescente demanda por tais medicamentos. An\u00e1lise recente do mercado farmac\u00eautico internacional mostrou um aumento de 55,74% no consumo destes medicamentos entre 2008 e 2018, impulsionado principalmente por pa\u00edses de baixa e m\u00e9dia renda, como o Brasil 6 . No Brasil, estima-se que em 1990 havia 472.667 pessoas com dem\u00eancia , passando para 1.702.402  em 2019 23 .Resultados do Estudo de Carga Global de Doen\u00e7a de 2016 (GDB 2016) indicam crescimento de 117% nos casos de dem\u00eancia em n\u00edvel global - ou 26,6 milh\u00f5es de pessoas, comparando-se os anos de 1990 e 2016 24 . Em linha com essas estimativas, o perfil demogr\u00e1fico indica um r\u00e1pido crescimento da popula\u00e7\u00e3o com 65 anos ou mais, que representava 7,6% em 2010 e chegar\u00e1 a 38% do total de habitantes em 2050 26 . Neste sentido, o perfil de consumo observado no presente estudo tende a ser crescente.A perspectiva \u00e9 de crescimento mundial na preval\u00eancia da DA e outras dem\u00eancias. Proje\u00e7\u00f5es para o Brasil apontam que em 2050 haver\u00e1, em m\u00e9dia, 5.666.116 pessoas afetadas pela doen\u00e7a, mais de 200% de aumento em rela\u00e7\u00e3o a 2019 O aumento do consumo, observado no presente estudo, pode tamb\u00e9m ser analisado tendo em vista aspectos como maior acesso a servi\u00e7os de sa\u00fade, e/ou algum n\u00edvel de utiliza\u00e7\u00e3o inadequada dos medicamentos analisados. Cabe destacar que n\u00e3o existem dados nacionais sobre a preval\u00eancia de dem\u00eancias no pa\u00eds, neste sentido, o presente estudo traz uma perspectiva de poss\u00edvel aumento da preval\u00eancia que merece ser investigada.27 . Esta melhoria pode estar relacionada ao maior acesso a servi\u00e7os diagn\u00f3sticos e \u00e0 indica\u00e7\u00e3o de tratamento. Somando-se a isso, a tend\u00eancia esperada de aumento da preval\u00eancia da DA j\u00e1 reportada para pa\u00edses de renda m\u00e9dia-baixa 28 .Um estudo de 2017 apontou melhorias na oferta de servi\u00e7os de sa\u00fade no Brasil entre 2000 e 2016, com maior acesso a servi\u00e7os de aten\u00e7\u00e3o prim\u00e1ria, de m\u00e9dia e alta complexidade, incluindo oferta de servi\u00e7os na rede privada, de car\u00e1ter suplementar 29 .Acerca do diagn\u00f3stico, este pode apresentar desafios. Devido a fatores como a apresenta\u00e7\u00e3o sintomatol\u00f3gica da DA guardar semelhan\u00e7as com outros quadros demenciais e s\u00edndromes relacionadas \u00e0 deteriora\u00e7\u00e3o cognitiva, uma parcela de pacientes \u00e9 diagnosticada com DA e recebe o tratamento indicado para a doen\u00e7a, apesar de n\u00e3o a apresentar de fato 30 .A import\u00e2ncia da acur\u00e1cia diagn\u00f3stica em rela\u00e7\u00e3o ao uso dos medicamentos avaliados reside no fato de que essa utiliza\u00e7\u00e3o n\u00e3o \u00e9 isenta de riscos, e avaliar corretamente um 22 . Os inibidores da acetilcolinesterase (iAChE) comp\u00f5em a primeira linha de tratamento para quadros leves a moderados de DA, sendo a donepezila o \u00fanico f\u00e1rmaco desta classe indicado em todos os est\u00e1gios da doen\u00e7a 9 . A recomenda\u00e7\u00e3o (ou a indica\u00e7\u00e3o) da donepezila para todos os graus da DA pode ser um fator importante que contribui para a maior magnitude de seu consumo. Outro ponto a ser considerado \u00e9 que este \u00e9 o medicamento mais antigo no mercado, dentre os demais utilizados na DA 31 , o que pode estar associado a h\u00e1bitos de prescri\u00e7\u00e3o mais consolidados.Em rela\u00e7\u00e3o \u00e0 an\u00e1lise do consumo nacional por f\u00e1rmaco, donepezila e memantina t\u00eam consumo de maior magnitude frente a galantamina e rivastigmina desde o in\u00edcio da s\u00e9rie hist\u00f3rica avaliada, dados corroborados na literatura 3 , o que pode contribuir para esta observa\u00e7\u00e3o. Na regi\u00e3o Nordeste, observa-se uma situa\u00e7\u00e3o distinta. Esta regi\u00e3o apresentou o maior consumo acumulado da s\u00e9rie hist\u00f3rica avaliada, por\u00e9m a distribui\u00e7\u00e3o \u00e9 irregular na regi\u00e3o, sugerindo maiores disparidades em rela\u00e7\u00e3o \u00e0 aquisi\u00e7\u00e3o.Em rela\u00e7\u00e3o \u00e0 an\u00e1lise da distribui\u00e7\u00e3o microrregional, predominam na faixa de maior consumo microrregi\u00f5es localizadas no Sul e Sudeste do pa\u00eds, onde percebe-se distribui\u00e7\u00e3o mais uniforme ao longo do territ\u00f3rio. Sul e Sudeste s\u00e3o as regi\u00f5es com a maior propor\u00e7\u00e3o de idosos do pa\u00eds 33 .O acesso a servi\u00e7os de sa\u00fade pode ser entendido sob diferentes aspectos, entre eles capacidade aquisitiva e acessibilidade geogr\u00e1fica. A capacidade aquisitiva trata da adequa\u00e7\u00e3o entre o custo da utiliza\u00e7\u00e3o dos servi\u00e7os de sa\u00fade e a capacidade de pagamento dos indiv\u00edduos, enquanto a acessibilidade geogr\u00e1fica diz respeito \u00e0 dist\u00e2ncia entre o servi\u00e7o desejado e o usu\u00e1rio, assim como aos meios de transporte e o tempo de deslocamento 27 . Segundo os autores, residentes das regi\u00f5es Sul e Sudeste tiveram maior acesso a servi\u00e7os sanit\u00e1rios, apesar de marcadas desigualdades sociais na regi\u00e3o Sul. Some-se a isso a observa\u00e7\u00e3o de que a melhoria do acesso observada em um per\u00edodo de cinco anos foi maior nestas regi\u00f5es, mais socioeconomicamente desenvolvidas 27 . Mais recentemente, um trabalho acerca de desigualdades regionais na sa\u00fade avaliou a interioriza\u00e7\u00e3o do desenvolvimento e da oferta de servi\u00e7os no Sul e Sudeste, enquanto no Nordeste, apesar do desenvolvimento socioecon\u00f4mico ocorrido, observa-se alta concentra\u00e7\u00e3o em poucas \u00e1reas de maior atividade econ\u00f4mica 34 , aspecto que pode estar relacionado com os resultados deste trabalho.Um estudo publicado em 2006 mostrou que esses dois fatores influenciam fortemente o acesso a servi\u00e7os de sa\u00fade no Brasil 37 . Ainda, a aquisi\u00e7\u00e3o dos medicamentos na rede privada pode levar ao comprometimento da renda familiar 38 ou o paciente pode acabar por n\u00e3o adquirir o medicamento 36 , comprometendo resultados terap\u00eauticos 39 .Outros estudos corroboram a relev\u00e2ncia da capacidade aquisitiva para a efetiva\u00e7\u00e3o do acesso a medicamentos, tanto no mercado privado quanto no p\u00fablico e iniquidades neste acesso 32 . Neste sentido, foi apenas na edi\u00e7\u00e3o de 2017 do PCDT que ocorreu a incorpora\u00e7\u00e3o da memantina e da rivastigmina em sua apresenta\u00e7\u00e3o de adesivos transd\u00e9rmicos. Atualmente, todos os medicamentos \u2013 ainda que n\u00e3o todas as apresenta\u00e7\u00f5es \u2013 aprovados para o tratamento da DA est\u00e3o listados na Rela\u00e7\u00e3o Nacional de Medicamentos Essenciais 2022 40 , e s\u00e3o dispensados pelo CEAF, segundo linhas de cuidado estabelecidas nos PCDT 9 .A aquisi\u00e7\u00e3o na rede privada pode ocorrer pela aus\u00eancia do medicamento na rede p\u00fablica 41 , enquanto o processo s\u00f3 ocorreu para a memantina 10mg em agosto de 2019 42 . Esta sucess\u00e3o de fatos pode haver influenciado nas compras p\u00fablicas destes medicamentos e na manuten\u00e7\u00e3o do baixo consumo de rivastigmina no mercado privado e, por outro lado, uma poss\u00edvel redu\u00e7\u00e3o do consumo de memantina pode n\u00e3o ter sido observada devido ao per\u00edodo de an\u00e1lise do presente trabalho.Apesar da incorpora\u00e7\u00e3o ao SUS no mesmo momento, houve disparidades no processo administrativo necess\u00e1rio para efetivar as compras p\u00fablicas. As apresenta\u00e7\u00f5es de rivastigmina incorporadas \u2013 adesivo transd\u00e9rmico 9mg e 18mg \u2013 tiveram c\u00f3digo atribu\u00eddo no Sistema de Gerenciamento da proxy para o uso, e n\u00e3o foram considerados quaisquer eventos ocorridos ap\u00f3s a dispensa\u00e7\u00e3o; neste sentido, n\u00e3o retratam diretamente o uso pelos pacientes 43 . Ademais, o estudo limita-se ao mercado privado, n\u00e3o incluindo informa\u00e7\u00f5es acerca de aquisi\u00e7\u00f5es relativas ao mercado p\u00fablico ou dados de dispensa\u00e7\u00e3o nesse setor.Este trabalho possui limita\u00e7\u00f5es. Em primeiro lugar, tomaram-se os dados de venda como Outro ponto a ser salientado \u00e9 a possibilidade de corre\u00e7\u00f5es nos registros do SNGPC ao longo do tempo pelos estabelecimentos que o utilizam; isso deve ser considerado por quem pretende realizar este tipo de an\u00e1lise, levando em conta a possibilidade de modifica\u00e7\u00e3o. Somando-se a essas quest\u00f5es, a limita\u00e7\u00e3o acerca da incerteza quanto ao uso da rivastigmina, tamb\u00e9m aprovada para uso na dem\u00eancia, associada \u00e0 doen\u00e7a de Parkinson, ainda que n\u00e3o esteja inclu\u00edda nos PCDT desta condi\u00e7\u00e3o.Apesar das limita\u00e7\u00f5es supracitadas, os dados de venda de medicamentos podem fornecer dados importantes sobre o consumo de medicamentos. Os dados utilizados neste trabalho foram obtidos de base de dados aberta ao p\u00fablico, e sua utiliza\u00e7\u00e3o corrobora a import\u00e2ncia da transpar\u00eancia p\u00fablica em rela\u00e7\u00e3o ao uso de bases de dados secund\u00e1rios, abertas, para fins de pesquisa.O presente estudo traz resultados in\u00e9ditos, ao analisar dados nacionais sobre o consumo de medicamentos para a DA obtidos de base de dados de alcance nacional e acesso p\u00fablico, ampliando o conhecimento sobre a presen\u00e7a da doen\u00e7a no pa\u00eds. Os resultados apresentados podem ser \u00fateis para orientar a gest\u00e3o da assist\u00eancia farmac\u00eautica no pa\u00eds e demais pol\u00edticas p\u00fablicas de sa\u00fade, visando ao enfrentamento estrat\u00e9gico da DA no pa\u00eds.O consumo de medicamentos para o tratamento da DA triplicou no mercado privado brasileiro entre 2014 e 2020. O aumento ocorreu em todas as unidades federativas em propor\u00e7\u00f5es variadas. A regi\u00e3o Nordeste acumulou o maior consumo ao longo dos 7 anos, e foi tamb\u00e9m a regi\u00e3o com o maior aumento do consumo no per\u00edodo. Por\u00e9m, observou-se que, nessa regi\u00e3o, as disparidades microrregionais s\u00e3o mais frequentes do que nas regi\u00f5es Sul e Sudeste, denotando poss\u00edveis iniquidades no acesso \u00e0 sa\u00fade e medicamentos. Os resultados deste trabalho corroboram a crescente import\u00e2ncia epidemiol\u00f3gica da DA no pa\u00eds, e salientam a relev\u00e2ncia de preparar a estrutura de sa\u00fade para o aumento de preval\u00eancia desta doen\u00e7a e da demanda por tratamento. \u00c9 essencial que, por sua import\u00e2ncia epidemiol\u00f3gica, sejam realizados mais estudos acerca da doen\u00e7a no Brasil, fomentando pol\u00edticas p\u00fablicas e melhorias na gest\u00e3o do cuidado ao portador da DA."}
+{"text": "To identify the possible causes of low adherence to vaccination campaigns in Brazil, find and analyze campaigns regarding human papillomavirus (HPV) in Brazil and abroad, and apply quality tools to prepare proposals to increase vaccination coverage (VC) and prevent HPV in the country.This is a qualitative and deductive-hypothetical research. A narrative review of the literature  was the technique used to develop our method.Brazil had a 49.6% VC in 2019, unlike countries such as Australia (80.2% in 2017), Mexico (97.5% in 2019), and Peru (91% in 2019). This study found evidence of the use of social marketing strategies to engage communities as good practices in the vaccination campaigns of these countries.With the retrieved information, three quality tools  classified and quantified the causes of low VC in Brazil and enabled proposals that can direct its Ministry of Health to take more effective strategies to achieve the HPV VC goal recommended by the WHO. High-risk HPV causes 99% of cervical cancer cases, with type 16 being the most commonly variation detected in carcinoma  and among the four types of cancers that kill the most per year in Brazil   . The world endured 311,000 in 2018  . Among all types of cancer, cervical cancer is the only one that currently has an immunizer as preventive.Sexual contact constitutes the main transmission route for human papillomavirus (HPV). Among the more than 100 types of HPV in the medical literature, 50 affect the mucosa of the genital tract and at least 15 are classified as high risk, i.e., with carcinogenic potential  . These four types are prophylactic targets of the recombinant quadrivalent vaccine to prevent HPV \u2014 distributed by the National Immunization Program  of the Brazilian Unified Health System (Sistema \u00danico de Sa\u00fade\u2013 SUS) since 2014. Brazil has a vaccination coverage (VC) target of 80%, aligned with the World Health Organization (WHO). However, seven years after the beginning of the national vaccination campaign to prevent HPV (2014\u20132021), Ministry of Health (MH) data show that the country has failed to reach its goal  .HPV types 16 and 18 account for about 70% of cervical cancer cases; whereas types 6 and 11, for more than 90% of all genital warts  . Although the WHO recommends 80% vaccination coverage for target audiences in all countries, some have VCs below the recommended target, such as Ireland (73%) and Switzerland (58.9%). On the other hand, countries such as Australia, Mexico, and Peru have VCs above the WHO target  . In general, different communication channels and the literature show that these countries have used social marketing techniques in their vaccination campaigns to better engage their target audience.The health systems of several countries have adopted vaccination campaigns to prevent HPV following WHO goals and recommendations. Currently, 114 nations have included two or three doses in the vaccination schedule of their public health programs  . Kotler  highlights the impossibility of influencing people\u2019s behavior without considering the socioeconomic aspect. Social marketing also argues for the fundamental importance of the ability to generate inputs and tools to develop effective interventions, stressing that the focus lies on individuals, groups, or society\u2019s well-being. Social marketing can be applied based on Kotler\u2019s four \u201cP\u201d . The four \u201cP\u201d provide a sort of guide to the success of a social marketing strategy, which Nowak considers the heart of social marketing  . Therefore, it is inferred that countries with vaccination targets far below those recommended by the WHO  fail to use the benefits of social marketing, especially the four benefits that have direct link with the four \u201cP\u201d: offer of real benefits, costs, ease of access, and personalized messages.Social marketing consists of a set of initiatives with a social purpose whose main objective is to modify behavior and influence social issues by several approaches without focusing on the trade of goods or services  .Nevertheless, the social marketing from the vaccination campaigns of Australia, Mexico, and Peru can be considered as an opportunity to use quality tools to identify problems, causes, and possible solutions to improve VC in Brazil. Quality tools constitute instruments that aim to facilitate the various activities of a corporation to better manage its processes  and enables the quick identification of the root cause of problems to mitigate them.The Ishikawa diagram is such an instrument, a process management quality tool that requires the mapping of the delivery of products or services within defined parameters. Also known as cause and effect or fishbone diagram, the Ishikawa diagram is a visual tool that helps with problem analysis  .Another quality tool is the Pareto chart, which allows us to prioritize and address problems to quickly obtain significant results without the need to mitigate all causes at once. The Pareto chart is known as the 80-20 chart as it is based on the rule that 80% of results stem from 20% of actions taken. It enables to focus actions on 20% of the main problems to achieve 80% of results what, why, where, when, who, how,andhow much it costs .Finally, 5W2H is a simple technique that can guide people in situations and problems by generating an action plan for each problem. The tool has seven questions, creating a roadmap that can evaluate problems and their impact to offer solutions. The questions areThis literature review aimed to 1) identify the possible causes for Brazil failing to reach its goal of 80% immunization and 2) to list the main strategies and tactics of vaccination adherence campaigns toward the prevention of HPV in other countries to serve as good adherence practices in Brazil based on the social marketing approach. Finally, this study aimed to 3) apply quality tools to classify and quantify the causes of low VC and enable proposals that can guide the Brazilian Ministry of Health to take more effective strategies to achieve the VC goal recommended by the WHO.1) To identify the causes of insuf\ufb01cient VC in Brazil, a bibliographic and documentary research was adopted to collect information for our analyses on vaccination campaigns in Brazil and abroad using public domain websites. A narrative review of the medical literature was also carried out using keywords such as \u201chuman papillomavirus,\u201d \u201cvaccination,\u201d and \u201cHPV vaccination campaign\u201d in databases such as PubMed, Embase, Scopus, Bireme, and SciELO (Jan./2010\u2013Dec./2022).Sociedade Brasileira de Oncologia Cl\u00ednica\u2013 SBOC) website. The data were separated according to coverage for the first and second doses of the vaccine and a simple mean for all genders was calculated to assess overall coverage and evaluate it according to the goal recommended by the MH.To collect information and data on the Brazilian vaccination campaign (2014\u20132021), official data available on the \u201caccess to information\u201d tab on the MH website  were used. Public data available on the PNI portal (http://pni.datasus.gov.br/) were also included, as were complementary information on 2019, which was accessed via the Brazilian Society of Clinical Oncology  To find the main strategies and tactics of vaccination adherence campaigns carried out globally according to social marketing, it was necessary to collect VC data from other countries, obtained from the official report on indicators from the WHO   to better describe the information.Finally, 3) content analysis of all the organized material was performed to translate it into interpretative results using the Ishikawa diagram, Pareto chart, and 5W2H A 49.6% VC in Brazil was determined based on MH, PNI, and SBOC data . MH datTo calculate VC in girls, the considered period spanned from March 2014 to November 2020; whereas, for boys, from March 2015 to November 2020.Our bibliographical, documental, and medical literature review chose two real-life publications that applied questionnaires to guardians when they refused to vaccinate their children and adolescents. conducted a study in the municipality of Barretos (SP) with 1,574 girls aged from 10 to 16 years to evaluate acceptance responses and the VC of a three-dose HPV vaccine. At the end of the third dose, overall VC totaled 85%. To determine the delta of participants who failed to receive the third dose, the authors investigated their parents or guardians\u2019 reasons for refusing vaccination. Overall, 27.4% of responses indicated fear of adverse events; 20.2%, personal reasons; and 14.5%, that the girl refused to receive the vaccine. Other responses pointed to heterogeneous causes such as considering the vaccine unnecessary, distrust of its efficacy, unawareness, and pediatricians or gynecologists\u2019 discouragement of vaccination.In September 2010, Fregnani et al.  with healthcare providers investigated parents\u2019 rejection of the vaccine, finding that 90% of parents worried about its safety; 79% believed their children or adolescents were sexually inactive; and 63% thought their children would avoid contracting HPV-related diseases, thus evincing that lack of information impacts parents and guardians\u2019 decision regarding vaccination.A study conducted in Ohio Australia, England, Mexico, and Peru stood out among all the countries that achieved the WHO-established target of 80% VC in 2018. After documentary surveys, these countries offered information on their vaccination campaigns to prevent HPV. To offer references of good VC practices and the use of social marketing, this study chose informative materials from vaccination campaigns in Australia (considered a reference in vaccination to prevent HPV) and Mexico and Peru .Australia offers the vaccine free of charge to girls aged from 11 to 13 years. Despite the fees for boys, the vaccination is approved for all genders from the age of 9 years onward. Australia uses several materials and medical and informational communication aimed at the general population with messages of great impact on health, such as \u201cCervical Screening saves lives,\u201d \u201cDon\u2019t just sit there,\u201d and \u201cDon\u2019t be ashamed.\u201d This study also found the use of several communication channels, well-timed sequences, frequent dissemination, and information on HPV and the importance of complete vaccination to eradicate and prevent cervical cancer. Such pieces were broadcast on TV, radio, and digital and printed media from 2007 to 2010 and highlighted the strategy of translating and adapting these informative messages for immigrants, such as those from Saudi Arabia, China, and Vietnam. .As part of its vaccination program, Australia has created a national registry of women\u2019s health screenings that dialogues with registered participants via mail, with invitations for testing, reminders, or follow-up. It also created a website with information on HPV and vaccination, several types of communication channels such as an email, postal address, and a free telephone line so women can seek more information and ask questions about cervical cancer issues. It also holds periodic workshops and offers electronic messages (SMS and email) with information about its program, dates, and events. Thus, campaigns increased exams by 15% in 2007 in relation to 2006 and adherence in areas with areas with low examination rates by 21%. Moreover, they obtained an 80.2% third-dose VC in 2017, with a low incidence of nine new cases of cervical cancer for every 100,000 women  . By treating cervical cancer as a public health problem, the Mexican MH invested in prevention via free vaccination in schools (for girls aged from 9 to 12 years) and in health units for other ages. Teachers mobilize parents, inform them of the date of the vaccination, and request their authorization. The Mexican MH also houses a department dedicated to the health of children and adolescents aged from 10 to 19 years and healthcare providers follow protocol of care to this population that provides for the monitoring and mandatory updating of the vaccination card, including the HPV vaccine. Digital channels distribute vaccination campaign materials and make access to information available to the target audience to engage the community by social marketing.In Latin America, Mexico had a 97.5% VC for girls aged up to 15 years in 2019. A 2017 local study on the prevalence of HPV in Mexican women showed a 9% rate, of which 77% were type 56, i.e., high risk  . Moreover, the Peruvian MH campaign has gifts for girls who are vaccinated. Bracelets and USB sticks in the shape of a heart with the campaign phrase \u201cI got vaccinated. Get vaccinated too\u201d are distributed free of charge to girls who have been vaccinated. The information materials of this vaccination campaign use terms of consent and image resources with characteristics of the local culture and population (strong and striking colors and Peruvian citizens as models).Peru is another Latin American country that maintained 91% VC in 2019 and incorporated a nonavalent vaccine in its National Immunization Program. Girls aged from 9 to 13 years who are in the fifth grade of primary school are vaccinated in schools for free after their guardians\u2019 consent, who are contacted by government campaigns and schools. Vaccination is administered in three doses  following the Mexican vaccination schedule. Campaign materials employ accessible language and messages that show the probable outcome of the lack of vaccination, including \u201cA woman dies every five hours from cervical cancer in Peru\u201d This evidence and campaign examples enabled the comparison between the social marketing strategies and tactics in Australia, Mexico, and Peru and Brazil.The chosen quality tools offer different forms of analyzing results. The Ishikawa diagram  shows t that estimated each raised point on the X axis of our Pareto chart. After classifying the causes and quantifying their impact, it was possible to elaborate the results of a third quality tool to suggest proposals for increasing VC. The bars from the left to right in the Pareto chart show the problems that most impact adherence to Brazilian vaccination campaigns. The red line shows the cumulative percentage of their impact on vaccination campaigns. Thus, it is possible to observe that causes 1 and 2 have a 55% cumulative impact, suggesting that the focus applied to the first two causes could solve the main problems that impact adherence increase by 55%.The Ishikawa diagram evinces the unawareness of HPV and its vaccine, public hesitancy, difficulty of access, scope of promotion, healthcare providers\u2019 low engagement, and inefficient policies constitute the main causes of low adherence to the vaccination campaign in Brazil. This study used a Pareto graph to quantify such causes. It numerically shows which should be prioritized by action plans. To determine the degree of impact, this study used references from research  . They correctly identified their target audience, free products facilitated access for the population, and the environment of application and information to health (schools) and the promotion tactics reflected the need for objective communication and easy acceptance by the target audience in each country  . Moreover, campaign material customization included an accessible language to immigrants in these countries  without judging people by their creeds, tastes, and cultures.Australia, Mexico, and Peru showed good application and integration of Kotler\u2019s four conceptual \u201cP\u201d as the foundations of social marketing strategies  estimated a 34% difficulty of access, i.e., social marketing can increase vaccination adherence by 34%. This datum is corroborated by the 35% increase in coverage in Uruguay after it changed its vaccination strategy to schools.Regarding the quality tools with social impact, the mapping of the main causes is expected to enable the creation of plans for each of them and solve low adherence. Each cause significantly impacts the target audience\u2019s adherence to vaccination campaigns. Predicting this impact and taking assertive measures contributes to increasing population engagement, creating collective awareness, and raising VC. The Pareto graph also shows the percentage of isolated impact for each cause. A 2014 study on how social marketing impacted vaccination campaigns  . A study conducted in Mexico  estimated unawareness about the vaccine at about 16%. Daley et al.  state that healthcare providers\u2019 recommendations and prescriptions can increase adherence by 15%.The Australian survey evaluated promotion scope, which increased adherence up to 21%  .According to data from the Barretos study, about 8% of the target audience show vaccine hesitancy, leaving the rest of the impact on inefficient policies (6%) The consecutive stages of our bibliographic and documentary review, the determination of the actual VC (%) in Brazil, and the comparison of the use of social marketing strategies in campaigns in countries with high VCs was essential to apply quality tools that classified and quantified the causes of low VC in Brazil. Finally, the proposal for an action plan (detailed in the 5W2H tool) may serve to build a potential social document with proposals based on global good practices that can direct the Brazilian MH to follow more effective strategies to achieve the VC goal recommended by the WHO. . O HPV de alto risco \u00e9 respons\u00e1vel por 99% dos casos de c\u00e2ncer de colo de \u00fatero, sendo o tipo 16 o mais comum detectado no carcinoma, e est\u00e1 dentre os quatro tipos de c\u00e2nceres que mais matam por ano no Brasil (6.526 \u00f3bitos em 2019). No mundo, em 2018, foram 311 mil v\u00edtimas fatais. Dentre todos os tipos de c\u00e2ncer, o de colo de \u00fatero \u00e9 o \u00fanico que atualmente conta com um imunizante para preven\u00e7\u00e3o.A principal via de transmiss\u00e3o do papilomav\u00edrus humano (HPV) \u00e9 o contato sexual. Dentre os mais de 100 tipos de HPV reportados na literatura m\u00e9dica, 50 tipos acometem a mucosa do aparelho genital e pelo menos 15 s\u00e3o classificados como de alto risco, ou seja, com potencial carcinog\u00eanico. Esses quatro tipos s\u00e3o alvos profil\u00e1ticos da vacina quadrivalente recombinante para a preven\u00e7\u00e3o do HPV distribu\u00edda desde 2014 no Sistema \u00danico de Sa\u00fade (SUS) brasileiro por meio do Programa Nacional de Imuniza\u00e7\u00e3o (PNI) e tem meta de cobertura vacinal (CV) de 80%, alinhada \u00e0 Organiza\u00e7\u00e3o Mundial da Sa\u00fade (OMS). Entretanto, ap\u00f3s sete anos do in\u00edcio da campanha nacional de vacina\u00e7\u00e3o para preven\u00e7\u00e3o do HPV (2014\u20132021), os dados do Minist\u00e9rio da Sa\u00fade (MS) mostram que a meta n\u00e3o foi atingida no pa\u00eds.Os tipos de HPV 16 e 18 s\u00e3o respons\u00e1veis por cerca de 70% dos casos de c\u00e2ncer de colo do \u00fatero; os tipos 6 e 11 s\u00e3o respons\u00e1veis por mais de 90% dos casos de verrugas genitais. Embora a OMS preconize a cobertura de 80% de vacina\u00e7\u00e3o do p\u00fablico-alvo para todos os pa\u00edses, alguns deles apresentam CV abaixo da meta recomendada, como \u00e9 o caso de Irlanda, com 73% de cobertura, e Su\u00ed\u00e7a, com 58,9%. Em dire\u00e7\u00e3o oposta, pa\u00edses como Austr\u00e1lia, M\u00e9xico e Peru apresentam CV acima da meta recomendada pela OMS. No geral, \u00e9 poss\u00edvel observar em diferentes canais de comunica\u00e7\u00e3o e na literatura que tais pa\u00edses utilizaram em suas campanhas de vacina\u00e7\u00e3o t\u00e9cnicas de marketing social para melhor engajamento do p\u00fablico-alvo.Globalmente, campanhas de vacina\u00e7\u00e3o para preven\u00e7\u00e3o do HPV foram adotadas por diversos pa\u00edses em seus sistemas de sa\u00fade, seguindo as metas e recomenda\u00e7\u00f5es da OMS. Atualmente, 114 pa\u00edses inclu\u00edram no calend\u00e1rio vacinal duas ou tr\u00eas doses em seus programas de sa\u00fade p\u00fablica. O grande ponto defendido por Kotler, idealizador do marketing social, \u00e9 que n\u00e3o \u00e9 poss\u00edvel influenciar o comportamento das pessoas sem levar em considera\u00e7\u00e3o o aspecto socioecon\u00f4mico. Al\u00e9m disso, o marketing social defende que a capacidade de gerar insumos e ferramentas necess\u00e1rias para desenvolver interven\u00e7\u00f5es eficazes \u00e9 de fundamental import\u00e2ncia, deixando claro que o foco \u00e9 o bem-estar do indiv\u00edduo, grupo ou sociedade. A aplica\u00e7\u00e3o do marketing social pode ser feita com base nos quatro \u201cP\u201d defendidos por Kotler . Quando aplicados em conjunto, os quatro \u201cP\u201d fornecem uma esp\u00e9cie de guia para o sucesso de uma estrat\u00e9gia de marketing social e s\u00e3o considerados o cora\u00e7\u00e3o do marketing social por Nowak. Logo, infere-se que pa\u00edses com metas de vacina\u00e7\u00e3o muito abaixo da recomendada pela OMS, como o Brasil, por exemplo, n\u00e3o est\u00e3o utilizando os benef\u00edcios do marketing social. Dentre os benef\u00edcios, destacam-se quatro que t\u00eam liga\u00e7\u00e3o direta com os quatro \u201cP\u201d: a oferta de benef\u00edcios reais, custos, facilidade de acesso e mensagem personalizada.O marketing social \u00e9 um conjunto de iniciativas com finalidade sociais cujo objetivo principal \u00e9, atrav\u00e9s de diferentes abordagens, modificar o comportamento e influenciar quest\u00f5es sociais, sem foco na comercializa\u00e7\u00e3o de bens ou servi\u00e7os.Ainda assim, no contexto de marketing social aplicado por Austr\u00e1lia, M\u00e9xico e Peru em suas campanhas de vacina\u00e7\u00e3o, considera-se a oportunidade de utilizar ferramentas de qualidade que possam identificar problemas, causas e poss\u00edveis solu\u00e7\u00f5es para melhorar a CV no Brasil. As ferramentas de qualidade s\u00e3o instrumentos que visam facilitar diversas atividades de uma corpora\u00e7\u00e3o para melhor gest\u00e3o de seus processose permite realizar a identifica\u00e7\u00e3o r\u00e1pida da causa raiz dos problemas para mitig\u00e1-los.Um desses instrumentos \u00e9 o diagrama de Ishikawa, uma ferramenta de qualidade utilizada para gest\u00e3o de processos em que \u00e9 necess\u00e1rio mapear as entregas de produtos ou servi\u00e7os dentro de par\u00e2metros definidos. Tamb\u00e9m conhecido como causa e efeito ou diagrama de espinha de peixe, o diagrama de Ishikawa \u00e9 basicamente uma ferramenta visual que auxilia em an\u00e1lises de problemas.Outra ferramenta de qualidade \u00e9 o gr\u00e1fico de Pareto, que possibilita priorizar os problemas e atac\u00e1-los de forma a obter resultados significativos de forma r\u00e1pida, sem a necessidade de mitigar todas as causas de uma s\u00f3 vez. O gr\u00e1fico de Pareto \u00e9 conhecido como gr\u00e1fico 80-20, pois se baseia na regra que diz que 80% dos resultados adv\u00e9m de 20% das a\u00e7\u00f5es realizadas. Com isso \u00e9 poss\u00edvel focar as a\u00e7\u00f5es em 20% dos principais problemas para conseguir 80% de resultadoo qu\u00ea?, por qu\u00ea?, onde?, quando?, quem?, como?equanto custa?.Por fim, cita-se a ferramenta 5W2H, uma t\u00e9cnica simples que permite guiar as pessoas em situa\u00e7\u00f5es e problemas gerando um plano de a\u00e7\u00e3o para cada problema identificado. A ferramenta traz sete quest\u00f5es, criando um roteiro que permite entender o problema e seu impacto para saber como resolv\u00ea-lo. As perguntas s\u00e3o:A presente revis\u00e3o da literatura teve como objetivo 1) identificar as poss\u00edveis causas do n\u00e3o alcance da meta de 80% de imuniza\u00e7\u00e3o no Brasil. Em paralelo, buscou 2) listar as principais estrat\u00e9gias e t\u00e1ticas de campanhas de ades\u00e3o \u00e0 vacina\u00e7\u00e3o para preven\u00e7\u00e3o do HPV realizadas em outros pa\u00edses para servir como boas pr\u00e1ticas de ades\u00e3o no Brasil com base na abordagem do marketing social. Por fim, este trabalho objetivou 3) aplicar ferramentas de qualidade que classificaram e quantificaram as causas da baixa CV e, com isso, viabilizaram propostas que podem direcionar o MS do Brasil na tomada de estrat\u00e9gias mais eficazes a fim de atingir a meta de CV recomendada pela OMS.Para 1) identifica\u00e7\u00e3o das causas do n\u00e3o alcance da CV no Brasil, a pesquisa bibliogr\u00e1fica e documental foi o m\u00e9todo adotado na coleta das informa\u00e7\u00f5es para as an\u00e1lises sobre as campanhas de vacina\u00e7\u00e3o realizadas no Brasil e no mundo utilizando websites de dom\u00ednio p\u00fablico. Tamb\u00e9m foi realizada uma revis\u00e3o narrativa da literatura m\u00e9dica na qual foram usadas palavras-chave como \u201cpapilomav\u00edrus humano\u201d, \u201cvacina\u00e7\u00e3o\u201d e \u201ccampanha de vacina\u00e7\u00e3o HPV\u201d em bases de dados como PubMed, Embase, Scopus, Bireme e SciELO (jan./2010\u2013dez./2022).Para coleta das informa\u00e7\u00f5es e dados da campanha de vacina\u00e7\u00e3o no Brasil (2014\u20132021), foram utilizados dados oficiais dispon\u00edveis no site do MS , na aba \u201cacesso \u00e0 informa\u00e7\u00e3o\u201d. Tamb\u00e9m se inclu\u00edram dados p\u00fablicos dispon\u00edveis no portal PNI (http://pni.datasus.gov.br/) e informa\u00e7\u00f5es complementares de 2019, acessadas via website da Sociedade Brasileira de Oncologia Cl\u00ednica (SBOC). Os dados foram separados de acordo com a cobertura para a primeira e segunda dose da vacina, e foi calculada a m\u00e9dia simples para ambos os sexos para avaliar a cobertura geral e possibilitar a avalia\u00e7\u00e3o da cobertura em rela\u00e7\u00e3o \u00e0 meta preconizada pelo pr\u00f3prio MS.. Esses dados foram avaliados por meio de trabalhos publicados, sendo selecionados tr\u00eas pa\u00edses cujas informa\u00e7\u00f5es das campanhas de vacina\u00e7\u00e3o foram divulgadas e que conseguiram manter a meta preconizada pela OMS para efic\u00e1cia da imuniza\u00e7\u00e3o na inten\u00e7\u00e3o de erradicar o c\u00e2ncer, para fins de compara\u00e7\u00e3o. Com base nas informa\u00e7\u00f5es obtidas de CV e campanhas utilizadas, foi feita uma avalia\u00e7\u00e3o para tentar identificar os poss\u00edveis problemas na campanha de vacina\u00e7\u00e3o do HPV no Brasil. O marketing social utilizado pelo MS foi avaliado de acordo com a teoria preconizada e defendida por Philip Kotlere com estrat\u00e9gias utilizadas em trabalhos publicados.Para 2) identificar com base no marketing social as principais estrat\u00e9gias e t\u00e1ticas de campanhas de ades\u00e3o \u00e0 vacina\u00e7\u00e3o realizadas globalmente, foi necess\u00e1rio levantar os dados de CV de outros pa\u00edses, obtidos no relat\u00f3rio oficial de indicadores emitido pela OMS , para melhor exposi\u00e7\u00e3o das informa\u00e7\u00f5es.Por fim, 3) foi feita a an\u00e1lise de conte\u00fado de todo o material organizado para traduzi-lo em resultados interpretativos utilizando as ferramentas de qualidade diagrama de Ishikawa, gr\u00e1fico de Pareto e ferramenta 5W2HCom base nos dados fornecidos pelo MS, PNI e SBOC, determinou-se a CV de 49,6% no Brasil . Os dadPara c\u00e1lculo da CV em meninas, o per\u00edodo considerado foi de mar\u00e7o de 2014 a novembro de 2020. Para meninos, considerou-se o per\u00edodo de mar\u00e7o de 2015 a novembro de 2020.Na revis\u00e3o bibliogr\u00e1fica, documental e da literatura m\u00e9dica, foram selecionadas duas publica\u00e7\u00f5es de vida real que aplicaram question\u00e1rios aos respons\u00e1veis quando eles se recusavam vacinar as crian\u00e7as e adolescentes.iniciaram um estudo na cidade de Barretos (SP) envolvendo 1.574 meninas entre 10 e 16 anos de idade com o objetivo de avaliar a resposta de aceita\u00e7\u00e3o e a CV das tr\u00eas doses da vacina contra HPV. Ao final da 3\u00aa dose, a CV geral foi de 85%. Para determinar o delta de participantes que n\u00e3o completaram a 3\u00aa dose, investigaram-se junto aos seus pais ou respons\u00e1veis legais as raz\u00f5es pelas quais a vacina\u00e7\u00e3o foi recusada. No geral, 27,4% das respostas apontaram medo dos eventos adversos da vacina; 20,2% raz\u00f5es pessoais; e 14,5% afirmaram que a menina n\u00e3o desejava se vacinar. As demais respostas apontaram causas heterog\u00eaneas como a vacina n\u00e3o ser necess\u00e1ria, n\u00e3o confiar na efic\u00e1cia da vacina, n\u00e3o conhecer a vacina, e o desaconselhamento da vacina\u00e7\u00e3o pelo m\u00e9dico pediatra ou ginecologista.Em setembro de 2010, Fregnani et al.com profissionais de sa\u00fade investigou a percep\u00e7\u00e3o para a recusa dos pais em rela\u00e7\u00e3o \u00e0 vacina. A pesquisa apontou que 90% dos pais est\u00e3o preocupados com a seguran\u00e7a da vacina; 79% acreditam que a crian\u00e7a ou adolescente n\u00e3o \u00e9 sexualmente ativo; 63% acreditam que os filhos n\u00e3o ir\u00e3o contrair doen\u00e7as relacionadas ao HPV. Logo, evidencia-se que a falta de informa\u00e7\u00e3o impacta a decis\u00e3o dos pais e respons\u00e1veis em rela\u00e7\u00e3o \u00e0 vacina\u00e7\u00e3o.Um outro estudo realizado em OhioDe todos os pa\u00edses que em 2018 se mantiveram dentro da meta de 80% de CV estabelecida pela OMS e que, ap\u00f3s o levantamento documental, apresentavam informa\u00e7\u00f5es sobre as suas campanhas de vacina\u00e7\u00e3o para preven\u00e7\u00e3o do HPV, destacaram-se Austr\u00e1lia, Inglaterra, M\u00e9xico e Peru. Para fins referenciais de boas pr\u00e1ticas de CV e da utiliza\u00e7\u00e3o do marketing social, foram selecionados materiais informativos das campanhas de vacina\u00e7\u00e3o da Austr\u00e1lia (pa\u00eds considerado refer\u00eancia na vacina\u00e7\u00e3o para preven\u00e7\u00e3o do HPV) e de dois pa\u00edses latinos, M\u00e9xico e Peru (pa\u00edses que t\u00eam similaridades socioculturais e econ\u00f4micas com o Brasil).Na Austr\u00e1lia, a vacina \u00e9 administrada gratuitamente em meninas de 11 a 13 anos. Meninos n\u00e3o recebem a vacina gratuitamente, mas ela \u00e9 aprovada para ambos os sexos a partir dos 9 anos. A Austr\u00e1lia utiliza diferentes materiais e pe\u00e7as de comunica\u00e7\u00e3o m\u00e9dica e informativa direcionados \u00e0 popula\u00e7\u00e3o geral com mensagens de alto valor de impacto \u00e0 sa\u00fade, como \u201cO [exame] Papanicolau pode salvar sua vida\u201d, \u201cN\u00e3o fique s\u00f3 a\u00ed sentado\u201d, \u201cN\u00e3o fique com vergonha\u201d. Al\u00e9m disso, notou-se o uso de diversos canais de comunica\u00e7\u00e3o e sequ\u00eancia e frequ\u00eancia bem ritmadas na periodicidade da divulga\u00e7\u00e3o das mensagens e informa\u00e7\u00f5es sobre o HPV e a import\u00e2ncia da vacina\u00e7\u00e3o completa para sua erradica\u00e7\u00e3o e preven\u00e7\u00e3o do c\u00e2ncer de colo de \u00fatero. As pe\u00e7as foram veiculadas na TV, r\u00e1dio, m\u00eddia digital e material impresso durante os anos de 2007 a 2010, destacando-se a estrat\u00e9gia de traduzir e adaptar as mensagens informativas para imigrantes, como Ar\u00e1bia Saudita, China e Vietn\u00e3..Como parte do programa de vacina\u00e7\u00e3o, o governo criou um registro nacional de exames de sa\u00fade da mulher, cuja comunica\u00e7\u00e3o com as participantes registradas \u00e9 feita via correio postal, com cartas de convite para realiza\u00e7\u00e3o de exames, lembretes ou acompanhamento. Tamb\u00e9m foi criado um website com informa\u00e7\u00f5es sobre o HPV e vacina\u00e7\u00e3o, com diversos tipos de canais de comunica\u00e7\u00e3o como e-mail, endere\u00e7o postal e telefone para chamadas gratuitas, para as mulheres poderem buscar mais informa\u00e7\u00f5es e tirar d\u00favidas sobre qualquer quest\u00e3o relacionada ao c\u00e2ncer do colo de \u00fatero. Ainda h\u00e1 workshops peri\u00f3dicos e mensagens eletr\u00f4nicas (SMS e e-mail) com informa\u00e7\u00f5es sobre o programa, datas e eventos. Como resultado, as campanhas foram respons\u00e1veis pelo aumento de 15% de exames em 2007 em rela\u00e7\u00e3o ao ano anterior e, nas \u00e1reas em que a ades\u00e3o aos exames era baixa, houve aumento de 21%. Al\u00e9m disso, em 2017, a CV da 3\u00aa dose era de 80,2%, com uma incid\u00eancia baixa de nove novos casos de c\u00e2ncer de colo de \u00fatero para cada 100 mil mulheres. Ao tratar o c\u00e2ncer de colo do \u00fatero como problema de sa\u00fade p\u00fablica, o MS mexicano investiu na preven\u00e7\u00e3o por meio da vacina\u00e7\u00e3o gratuita feita nas escolas (para meninas de 9 a 12 anos) e nas unidades de sa\u00fade para as demais idades. Os pais s\u00e3o acionados por professores e informados sobre quando a vacina\u00e7\u00e3o ir\u00e1 ocorrer, mediante a sua autoriza\u00e7\u00e3o. Al\u00e9m disso, o MS mexicano abriga um departamento dedicado especificamente \u00e0 sa\u00fade de crian\u00e7as e adolescentes com idade entre 10 e 19 anos, cujo protocolo de atendimento dos profissionais de sa\u00fade a essa popula\u00e7\u00e3o prev\u00ea a observ\u00e2ncia e atualiza\u00e7\u00e3o obrigat\u00f3ria da carteira de vacina\u00e7\u00e3o, incluindo a vacina contra HPV. Materiais de campanha de vacina\u00e7\u00e3o s\u00e3o distribu\u00eddos e o acesso \u00e0 informa\u00e7\u00e3o \u00e9 disponibilizado ao p\u00fablico-alvo da vacina nos canais digitais, visando engajamento comunit\u00e1rio por meio do marketing social.No contexto da Am\u00e9rica Latina, em 2019, o M\u00e9xico apresentou uma CV de 97,5% para meninas at\u00e9 15 anos de idade. Em 2017, foi publicado um estudo local sobre a preval\u00eancia de HPV nas mulheres mexicanas e o resultado foi de 9%. O estudo tamb\u00e9m mostrou que 77% eram do tipo 56, de alto risco. Al\u00e9m disso, a campanha do MS do Peru conta com brindes para as meninas que s\u00e3o vacinadas. Pulseiras ependrivesno formato de cora\u00e7\u00e3o com a frase da campanha \u201cEu me vacinei. Vacine-se voc\u00ea tamb\u00e9m\u201d s\u00e3o distribu\u00eddos gratuitamente para as meninas que se vacinaram. Os materiais informativos das campanhas de vacina\u00e7\u00e3o utilizam termos de consentimento e recursos de imagens com caracter\u00edsticas da cultura e popula\u00e7\u00e3o local .O Peru \u00e9 outro pa\u00eds latino-americano que manteve 91% de CV em 2019. O pa\u00eds incorporou em seu PNI a vacina nonavalente. As meninas com idade entre 9 e 13 anos que est\u00e3o na 5\u00aa s\u00e9rie do prim\u00e1rio s\u00e3o vacinadas nas escolas de forma gratuita ap\u00f3s o consentimento dos respons\u00e1veis, que s\u00e3o alcan\u00e7ados por meio de campanhas do governo e pelas pr\u00f3prias escolas. A vacina\u00e7\u00e3o \u00e9 administrada em tr\u00eas doses  seguindo o esquema vacinal do M\u00e9xico. Em rela\u00e7\u00e3o aos materiais de campanha, observou-se o uso de linguagem de f\u00e1cil acesso e com mensagens que demonstram o prov\u00e1vel desfecho da falta de vacina\u00e7\u00e3o, como: \u201cUma mulher morre a cada cinco horas em decorr\u00eancia do c\u00e2ncer de colo do \u00fatero no Peru\u201dCom as evid\u00eancias e exemplos de suas campanhas, foi poss\u00edvel comparar as estrat\u00e9gias e t\u00e1ticas de marketing social utilizadas pela Austr\u00e1lia, M\u00e9xico e Peru em rela\u00e7\u00e3o ao Brasil. OAs ferramentas de qualidade escolhidas trazem diferentes formas de an\u00e1lise dos resultados. O diagrama de Ishikawa  mostra que trazem estimativas para cada ponto levantado no eixo X do gr\u00e1fico de Pareto elaborado. Com as causas classificadas e seu impacto quantificado, foi poss\u00edvel elaborar os resultados da terceira ferramenta de qualidade, utilizada para sugerir propostas de aumento da CV. No gr\u00e1fico de Pareto, as barras a partir da esquerda mostram os problemas que mais impactam a ades\u00e3o \u00e0 campanha de vacina\u00e7\u00e3o no Brasil. A linha vermelha mostra o percentual acumulado do impacto na campanha de vacina\u00e7\u00e3o. Dessa forma, \u00e9 poss\u00edvel observar que as causas 1 e 2 t\u00eam um impacto acumulado de 55%. Infere-se que o foco aplicado \u00e0s aten\u00e7\u00f5es nas duas primeiras causas poderia resolver os principais problemas que impactam em 55% o aumento da ades\u00e3o.Desconhecimento sobre o HPV e sobre a vacina, hesita\u00e7\u00e3o do p\u00fablico, baixo engajamento dos profissionais de sa\u00fade, dificuldade de acesso, alcance da promo\u00e7\u00e3o e pol\u00edticas deficientes s\u00e3o as principais causas da baixa ades\u00e3o \u00e0 campanha de vacina\u00e7\u00e3o no Brasil mostradas no diagrama de Ishikawa. Tais causas foram quantificadas utilizando o gr\u00e1fico de Pareto , que moO. O p\u00fablico foi corretamente identificado, o produto gratuito \u00e0 popula\u00e7\u00e3o facilitou o acesso, o ambiente de aplica\u00e7\u00e3o e informa\u00e7\u00e3o \u00e0 sa\u00fade (escolas) e as t\u00e1ticas de promo\u00e7\u00e3o refletiram a necessidade de comunica\u00e7\u00e3o objetiva e de f\u00e1cil aceita\u00e7\u00e3o pelo p\u00fablico-alvo de cada pa\u00eds. Al\u00e9m disso, observa-se a customiza\u00e7\u00e3o dos materiais de campanha para incluir tamb\u00e9m uma linguagem acess\u00edvel aos imigrantes que est\u00e3o estabelecidos em seus pa\u00edses, como o caso da Austr\u00e1lia, sem fazer acep\u00e7\u00e3o de pessoas pelos seus credos, gostos e culturas.Para Austr\u00e1lia, M\u00e9xico e Peru, observou-se a boa aplica\u00e7\u00e3o e a integra\u00e7\u00e3o dos quatro \u201cP\u201d conceituais definidos por Kotler como fundamentos das estrat\u00e9gias de marketing social, ou seja, a aplica\u00e7\u00e3o do marketing social pode aumentar em 34% a ades\u00e3o \u00e0 vacina\u00e7\u00e3o. Esse dado \u00e9 corroborado pelo aumento de 35% de cobertura atingido pelo Uruguai quando mudou a estrat\u00e9gia de vacina\u00e7\u00e3o para as escolas.Quanto \u00e0s ferramentas de qualidade com impacto social, espera-se que o mapeamento das principais causas possibilite a cria\u00e7\u00e3o de planos para cada uma delas com o objetivo de resolver o problema da baixa ades\u00e3o. Cada causa tem um impacto significativo na ades\u00e3o do p\u00fablico-alvo \u00e0 campanha de vacina\u00e7\u00e3o, de forma que prever esse impacto e tomar medidas assertivas contribui para o aumento do engajamento da popula\u00e7\u00e3o e cria\u00e7\u00e3o da conscientiza\u00e7\u00e3o coletiva, aumentando o CV. O gr\u00e1fico de Pareto mostra tamb\u00e9m o percentual de impacto isolado de cada causa. A dificuldade de acesso \u00e9 mensurada em 34% de acordo com o estudo publicado em 2014 que mostra o impacto do marketing social nas campanhas de vacina\u00e7\u00e3o. O desconhecimento sobre a vacina \u00e9 mensurado em aproximadamente 16% em um estudo realizado no M\u00e9xico. Daley et al.afirmam que a recomenda\u00e7\u00e3o e prescri\u00e7\u00e3o pelos profissionais de sa\u00fade pode aumentar a ades\u00e3o em 15%.O alcance da promo\u00e7\u00e3o \u00e9 mensurado no trabalho realizado pelo governo da Austr\u00e1lia, que conseguiu atingir um aumento de at\u00e9 21%.De acordo com os dados do estudo de Barretos, a hesita\u00e7\u00e3o em vacinar atinge cerca de 8% do p\u00fablico-alvo, deixando o restante do impacto em pol\u00edticas deficientes em 6%A realiza\u00e7\u00e3o de etapas consecutivas de revis\u00e3o bibliogr\u00e1fica e documental, seguida da determina\u00e7\u00e3o da real CV (%) no Brasil e da compara\u00e7\u00e3o do uso das estrat\u00e9gias de marketing social nas campanhas realizadas por pa\u00edses com alta CV, foi essencial para a aplica\u00e7\u00e3o de ferramentas de qualidade que classificaram e quantificaram as causas da baixa CV no Brasil. Por fim, a proposta do plano de a\u00e7\u00e3o pormenorizada na ferramenta 5W2H pode ser utilizada na constru\u00e7\u00e3o de um potencial documento social com propostas baseadas nas boas pr\u00e1ticas globais que podem direcionar o MS do Brasil a seguir estrat\u00e9gias mais eficazes para atingir a meta de CV recomendada pela OMS."}
+{"text": "Os objetivos foram avaliar o grau de implanta\u00e7\u00e3o do projeto Regula+ Brasil eanalisar em que medida as varia\u00e7\u00f5es da implanta\u00e7\u00e3o influenciam nos resultadosobservados no acesso a consultas especializadas em Recife, Pernambuco, Brasil.Trata-se de uma pesquisa avaliativa de an\u00e1lise de implanta\u00e7\u00e3o. Foram elaboradoso modelo l\u00f3gico e a matriz de an\u00e1lise e julgamento com os indicadores paraavalia\u00e7\u00e3o do grau de implanta\u00e7\u00e3o e de resultado do projeto, os quais foramsubmetidos ao consenso de especialistas. A coleta de dados se deu por meio dequestion\u00e1rio semiestruturado, aplicado com informantes-chave, e dadossecund\u00e1rios extra\u00eddos dos documentos oficiais do projeto e do Sistema Nacionalde Regula\u00e7\u00e3o (SISREG), referentes ao per\u00edodo de maio de 2020 a maio de 2021, osquais foram consolidados e comparados com valores definidos na matriz. O grau deimplanta\u00e7\u00e3o do projeto Regula+ Brasil em Recife foi considerado implantado, bem como as dimens\u00f5es Estrutura  e Processo . Entretanto,a maioria dos seus indicadores de efeito obtiveram desempenho insatisfat\u00f3rio.Quando confrontados, guardaram coer\u00eancia com gargalos observados em algunscomponentes e subcomponentes do projeto, como a atua\u00e7\u00e3o dos profissionais dasunidades b\u00e1sicas de sa\u00fade (UBS), apontada como incipiente, principalmente no quediz respeito ao acompanhamento das solicita\u00e7\u00f5es devolvidas. Os resultadossugerem que qualquer interven\u00e7\u00e3o em telessa\u00fade requer, para sua devidaimplanta\u00e7\u00e3o e para o alcance dos resultados esperados, adequa\u00e7\u00e3o das equipes edos processos de trabalho, pr\u00e1ticas de educa\u00e7\u00e3o permanente e processo cont\u00ednuode avalia\u00e7\u00e3o, ou ent\u00e3o se configurar\u00e1 em nova burocratiza\u00e7\u00e3o e barreira deacesso. A regula\u00e7\u00e3o em sa\u00fade busca alcan\u00e7ar os princ\u00edpios da universalidade, integralidade eequidade no Sistema \u00danico de Sa\u00fade (SUS) ,,A regula\u00e7\u00e3o do acesso \u00e0 assist\u00eancia, ou regula\u00e7\u00e3o assistencial, \u00e9 um importantemecanismo de gest\u00e3o entre oferta e demanda, canal de comunica\u00e7\u00e3o entre unidades desa\u00fade, na busca por equidade ,,,A insufici\u00eancia de recursos financeiros e de servi\u00e7os poderia ser apontada como oprincipal determinante para ocorr\u00eancia dessas filas, por\u00e9m fatores organizacionais egerenciais, como a baixa resolubilidade da aten\u00e7\u00e3o prim\u00e1ria \u00e0 sa\u00fade (APS),encaminhamentos inapropriados, marca\u00e7\u00f5es desnecess\u00e1rias para especialistas eproblemas na contrarrefer\u00eancia t\u00eam sido igualmente citados como aspectos limitadoresda regula\u00e7\u00e3o assistencial Em 2020, o Munic\u00edpio de Recife, Pernambuco, Brasil, aderiu ao projeto Regula+ Brasil,visando, por meio da telerregula\u00e7\u00e3o, qualificar o processo de regula\u00e7\u00e3o assistenciale reduzir as filas de espera para algumas especialidades, bem como oferecer suporteno manejo cl\u00ednico aos profissionais da APS por meio da telessa\u00fade Pesquisa avaliativa, de an\u00e1lise de implanta\u00e7\u00e3o, que relaciona a influ\u00eancia davaria\u00e7\u00e3o do grau de implanta\u00e7\u00e3o de uma interven\u00e7\u00e3o sobre os resultados observadosA interven\u00e7\u00e3o estudada foi o projeto Regula+ Brasil, desenvolvido no \u00e2mbito doPrograma de Apoio ao Desenvolvimento Institucional do SUS (PROADI-SUS). O PROADI-SUS\u00e9 uma alian\u00e7a entre Entidades de Sa\u00fade de Reconhecida Excel\u00eancia (ESRE) - hospitaisde refer\u00eancia no Brasil  - e o Minist\u00e9rio da Sa\u00fade, com os prop\u00f3sitos de apoiar eaprimorar o SUS por meio de projetos de capacita\u00e7\u00e3o de recursos humanos, pesquisa,avalia\u00e7\u00e3o e incorpora\u00e7\u00e3o de tecnologias, gest\u00e3o e assist\u00eancia especializada.O projeto atuou em duas frentes: a teleconsultoria, para apoiar os m\u00e9dicos dasunidades b\u00e1sicas de sa\u00fade (UBS), e a telerregula\u00e7\u00e3o, para orientar a regula\u00e7\u00e3o dasfilas para consultas na aten\u00e7\u00e3o secund\u00e1ria.Selecionou-se Recife como local de estudo, capital do Estado de Pernambuco, munic\u00edpioconsiderado como o segundo maior polo m\u00e9dico do Brasil, com 2.116 estabelecimentosde sa\u00fade, 1.820 da rede privada e 296 da p\u00fablica, 59 tipos de servi\u00e7osespecializados e mais de oito mil leitos hospitalares Este estudo toma como refer\u00eancia o per\u00edodo de maio de 2020 a maio de 2021, mesesestabelecidos no relat\u00f3rio final do projeto.As atividades regulat\u00f3rias do projeto iniciaram-se ap\u00f3s an\u00e1lise pr\u00e9via das filas edefini\u00e7\u00e3o das especialidades que seriam reguladas  16. ForaO estudo avaliativo foi composto por cinco etapas: (1) elabora\u00e7\u00e3o e valida\u00e7\u00e3o domodelo l\u00f3gico; (2) elabora\u00e7\u00e3o e valida\u00e7\u00e3o da matriz de an\u00e1lise e julgamento; (3)classifica\u00e7\u00e3o do grau de implanta\u00e7\u00e3o; (4) an\u00e1lise dos indicadores de efeitos; e(5) an\u00e1lise da influ\u00eancia do grau de implanta\u00e7\u00e3o sobre os efeitosobservados.Para descrever a interven\u00e7\u00e3o, elaborou-se uma vers\u00e3o inicial do modelo l\u00f3gico doRegula+ Brasil, utilizando como refer\u00eancia documentos oficiais e legisla\u00e7\u00f5es, emque foram definidos os componentes das dimens\u00f5es estrutura e processo Com base no modelo l\u00f3gico final, uma matriz de an\u00e1lise e julgamento foi elaboradae submetida \u00e0 consulta e valida\u00e7\u00e3o dos especialistas supracitados, sendoconclu\u00edda em duas rodadas, composta pelos componentes (e subcomponentes), pelasrespectivas pontua\u00e7\u00f5es e pelas fontes de dados para cada indicador .A sele\u00e7\u00e3o dos indicadores considerou como crit\u00e9rios de inclus\u00e3o a relev\u00e2ncia, adisponibilidade e a facilidade de coleta de dados, atribuindo-se para cada um opadr\u00e3o, a fonte de verifica\u00e7\u00e3o e os pontos de corte distribu\u00eddos de acordo com aimport\u00e2ncia e o peso de seus componentes. Para definir os padr\u00f5es, utilizaram-seaqueles estabelecidos nos documentos oficiais do pr\u00f3prio projeto. No caso dosindicadores propostos pelos pesquisadores, os padr\u00f5es foram definidos emconson\u00e2ncia com a realidade do munic\u00edpio.https://products.office.com/).A coleta de dados foi feita mediante a aplica\u00e7\u00e3o de question\u00e1rio semiestruturadoa sete informantes-chave ligados ao projeto no hospital de excel\u00eancia e noMinist\u00e9rio da Sa\u00fade e a gestores e m\u00e9dicos reguladores da central de regula\u00e7\u00e3oda SMS de Recife. Al\u00e9m das perguntas espec\u00edficas, elaboradas a partir da matriz,foram elencadas quest\u00f5es relacionadas ao contexto de implanta\u00e7\u00e3o do projeto, asquais puderam contribuir para o entendimento acerca dos achados sobre o grau deimplanta\u00e7\u00e3o. As respostas foram sistematizadas em uma matriz de an\u00e1lise, sendoidentificados padr\u00f5es ou temas que permitissem interpretar os dados, digitados econsolidados nos programas Microsoft Office Excel 2016 e Microsoft Office Word2016 , parcialmente implantado (50%-75%),incipiente (25%-50%) e n\u00e3o implantado (< 25%).dashboards) - e dos bancos de dados de fila e agendamentodo SISREG. Os indicadores de resultado foram submetidos \u00e0 an\u00e1lise dosespecialistas durante as rodadas de consulta.Para analisar os efeitos (resultados), foram considerados nove indicadores deresultado e suas metas, de acordo com o modelo l\u00f3gico, bem como aqueles j\u00e1previstos no escopo do projeto, obedecendo a crit\u00e9rios de validade, relev\u00e2ncia edisponibilidade de informa\u00e7\u00e3o .UtilizaEste estudo foi aprovado pelo Comit\u00ea de \u00c9tica em Pesquisa em Seres Humanos doInstituto de Medicina Integral Professor Fernando Figueira , e seguiu as recomenda\u00e7\u00f5es da Resolu\u00e7\u00e3o n\u00ba 466/2012, doConselho Nacional de Sa\u00fade e complementares.O grau de implanta\u00e7\u00e3o total do projeto Regula+ Brasil no Munic\u00edpio do Recife foiconsiderado implantado . Quanto \u00e0s dimens\u00f5es, a estrutura e o processotamb\u00e9m foram consideradas implantados  .Alguns indicadores de estrutura tiveram resultados negativos, tais como\u201cexist\u00eancia de fluxos e protocolos de encaminhamento/acesso\u201d, \u201cexist\u00eancia det\u00e9cnicos em regula\u00e7\u00e3o\u201d, \u201cexist\u00eancia de m\u00e9dicos reguladores no complexoregulador\u201d e \u201cexist\u00eancia de operadores do SISREG para administra\u00e7\u00e3o das demandasgeradas no sistema nas UBS\u201d. Os informantes-chave justificaram que a incoer\u00eanciados protocolos cl\u00ednicos e de acesso utilizados pela equipe do projeto em rela\u00e7\u00e3o\u00e0 realidade do munic\u00edpio e o baixo quantitativo de profissionais, tanto nacentral de regula\u00e7\u00e3o quanto nas UBS (operadores do SISREG), foram fatores queinfluenciaram nesse resultado.Na dimens\u00e3o processo, a maioria dos componentes foi considerada implantada, comdestaque para telerregula\u00e7\u00e3o , teleconsulta , gest\u00e3o do projeto e divulga\u00e7\u00e3o de conhecimento t\u00e9cnico e cient\u00edfico . A exce\u00e7\u00e3o foia teleconsultoria, definida como parcialmente implantada . Entretanto,quando analisados isoladamente, observa-se que nem todos os indicadores esubcomponentes dessa dimens\u00e3o apresentaram bons resultados.Com rela\u00e7\u00e3o \u00e0 telerregula\u00e7\u00e3o, apenas o subcomponente \u201cpapel dos profissionaistelerreguladores do projeto\u201d foi implantado (100%), enquanto o \u201cpapel dosprofissionais reguladores da central de regula\u00e7\u00e3o\u201d foi parcialmente implantado e o \u201cpapel dos profissionais das UBS\u201d foi incipiente .Na teleconsultoria, destaca-se o resultado do indicador \u201cgrau de ades\u00e3o dosprofissionais solicitantes \u00e0s teleconsultorias\u201d, avaliado pela maioria dosinformantes como muito baixo, e do \u201csolicita\u00e7\u00f5es reavaliadas ap\u00f3s devolu\u00e7\u00e3o paraAPS por consultoria (%)\u201d, que alcan\u00e7ou 1%. Com rela\u00e7\u00e3o ao componente\u201cteleconsulta\u201d, apesar de implantado, alguns informantes relataram baixa procurade usu\u00e1rios pelo servi\u00e7o.No componente \u201cgest\u00e3o do projeto\u201d, destacam-se os indicadores \u201cexist\u00eancia deworkshop com os profissionais da rede\u201d, \u201celabora\u00e7\u00e3o de relat\u00f3rios t\u00e9cnicos e/oude desempenho para acompanhamento dos indicadores do projeto\u201d e \u201catualiza\u00e7\u00e3omensal dos pain\u00e9is de monitoramento compartilhados com o complexo regulador\u201d -todos com pontua\u00e7\u00f5es abaixo do esperado. Mesma situa\u00e7\u00e3o no componente\u201cdivulga\u00e7\u00e3o de conhecimento t\u00e9cnico e cient\u00edfico\u201d, no qual o indicador\u201crealiza\u00e7\u00e3o de divulga\u00e7\u00e3o e compartilhamento das experi\u00eancias durante o per\u00edodode execu\u00e7\u00e3o do projeto\u201d tamb\u00e9m apresentou baixa pontua\u00e7\u00e3o.net promoter score (NPS) \u201d, que atingiu uma redu\u00e7\u00e3o de 26%; \u201credu\u00e7\u00e3o dotempo m\u00e9dio em dias de espera nos casos regulados em prioridade alta (%)\u201d, comredu\u00e7\u00e3o de 79%; e \u201cn\u00edvel de satisfa\u00e7\u00e3o dos usu\u00e1rios atendidos nasteleconsultas\u201d, com 90 re (NPS) .Em contrapartida, cinco indicadores n\u00e3o alcan\u00e7aram as metas preconizadas:\u201csolicita\u00e7\u00f5es aprovadas na primeira avalia\u00e7\u00e3o (%)\u201d ; \u201cagendamento decasos regulados priorit\u00e1rios (vermelho e amarelo) para atendimento especializado(%)\u201d (< 19%); \u201credu\u00e7\u00e3o de novos encaminhamentos na fila de espera (%)\u201d (>68%); \u201credu\u00e7\u00e3o do tempo m\u00e9dio em dias de espera nos casos regulados emprioridade m\u00e9dia e baixa (%)\u201d (> 130%); \u201credu\u00e7\u00e3o no n\u00famero de encaminhamentosem fila de espera (%)\u201d (> 14%) - os quais demonstraram coer\u00eancia com o graude implanta\u00e7\u00e3o obtido no componente \u201ctelerregula\u00e7\u00e3o\u201d, subcomponente \u201cpapel dosprofissionais das UBS\u201d.O indicador \u201cn\u00edvel de satisfa\u00e7\u00e3o dos profissionais atendidos nasteleconsultorias\u201d n\u00e3o p\u00f4de ser avaliado na pesquisa, visto que a equipe doprojeto n\u00e3o tinha esse dado exclusivamente para os profissionais domunic\u00edpio.Assim, uma an\u00e1lise global entre o grau de implanta\u00e7\u00e3o de estrutura e processo doprojeto Regula+ Brasil e o desempenho dos indicadores de efeito parecedemonstrar que a implanta\u00e7\u00e3o n\u00e3o influenciou no alcance dos resultados. Contudo,quando considerados os componentes, subcomponentes e indicadores, isoladamente,sobretudo da dimens\u00e3o processo, observa-se coer\u00eancia entre eles.O desempenho alcan\u00e7ado pelos indicadores \u201credu\u00e7\u00e3o do tempo m\u00e9dio em dias deespera para autoriza\u00e7\u00e3o dos casos enviados \u00e0s especialidades (%)\u201d e \u201credu\u00e7\u00e3o dotempo m\u00e9dio em dias de espera nos casos regulados em prioridade alta (%)\u201ddeve-se ao fato de estarem diretamente ligados \u00e0s atividades desenvolvidas pelosprofissionais telerreguladores do projeto e pelos reguladores da central deregula\u00e7\u00e3o do munic\u00edpio.Por outro lado, os indicadores \u201csolicita\u00e7\u00f5es aprovadas na primeira avalia\u00e7\u00e3o(%)\u201d, \u201cagendamento de casos regulados priorit\u00e1rios para atendimentoespecializado (%)\u201d, \u201credu\u00e7\u00e3o de novos encaminhamentos na fila de espera (%)\u201d,\u201credu\u00e7\u00e3o do tempo m\u00e9dio em dias de espera nos casos regulados em prioridadem\u00e9dia e baixa (%)\u201d e \u201credu\u00e7\u00e3o no n\u00famero de encaminhamentos em fila de espera(%)\u201d estariam sob maior influ\u00eancia da atua\u00e7\u00e3o dos profissionais das UBS, seja noacompanhamento e reenvio das solicita\u00e7\u00f5es devolvidas pelos profissionaistelerreguladores, na redu\u00e7\u00e3o e melhor qualifica\u00e7\u00e3o dos encaminhamentos \u00e0 aten\u00e7\u00e3oespecializada ou no acolhimento das demandas sens\u00edveis \u00e0 APS por meio do servi\u00e7ode teleconsultoria.Outro ponto diz respeito \u00e0 coer\u00eancia entre o grau de implanta\u00e7\u00e3o do subcomponente\u201cpapel dos profissionais das UBS\u201d e do componente \u201cteleconsultoria\u201d e odesempenho inadequado do indicador \u201cades\u00e3o profissionais da APS\u201d, avaliado comomuito baixo.A atua\u00e7\u00e3o dos profissionais das UBS, principalmente no que diz respeito aoacompanhamento das solicita\u00e7\u00f5es devolvidas pela equipe do projeto, foi apontadapelos informantes-chave como um dos grandes entraves \u00e0 obten\u00e7\u00e3o de melhoresresultados, especialmente pelo grande volume de solicita\u00e7\u00f5es devolvidas. Uma vezque tanto os profissionais telerreguladores do projeto quanto os reguladores dacentral de regula\u00e7\u00e3o dependiam do retorno das UBS para concluir o processo deregula\u00e7\u00e3o, a maior parte dessas solicita\u00e7\u00f5es ainda permaneciam retidas nosistema.Os indicadores utilizados neste estudo para avaliar a influ\u00eancia do grau deimplanta\u00e7\u00e3o sobre os resultados do projeto Regula+ Brasil no Munic\u00edpio de Recifeforneceram informa\u00e7\u00f5es importantes sobre a regula\u00e7\u00e3o assistencial. O grau deimplanta\u00e7\u00e3o total foi avaliado como implantado, assim como o grau de implanta\u00e7\u00e3o dasdimens\u00f5es estrutura e processo, por\u00e9m com diferentes n\u00edveis entre componentes esubcomponentes. O desempenho insatisfat\u00f3rio da maioria dos indicadores de efeitopareceu demonstrar que a implanta\u00e7\u00e3o do projeto n\u00e3o influenciou no alcance dosresultados esperados. Entretanto, faz-se necess\u00e1rio analisar essas rela\u00e7\u00f5es de formamais minuciosa, confrontando o grau de implanta\u00e7\u00e3o de componentes e subcomponentescom os efeitos.Para a telerregula\u00e7\u00e3o, a avalia\u00e7\u00e3o a partir de cada subcomponente possibilitou, al\u00e9mde uma vis\u00e3o mais clara sobre sua implanta\u00e7\u00e3o, identificar seu ponto de maiorfragilidade. Observou-se que o subcomponente \u201cpapel dos profissionais das UBS\u201d foin\u00e3o apenas o \u00fanico avaliado como n\u00e3o implantado, mas tamb\u00e9m parece ter sido o querepercutiu mais negativamente no alcance dos resultados.Um dos principais fatores que limitaram sua implanta\u00e7\u00e3o refere-se \u00e0 incipiente rotinanas UBS de acompanhamento e reenvio das solicita\u00e7\u00f5es devolvidas pelos profissionaisdo projeto por aus\u00eancia e/ou necessidade de complementa\u00e7\u00e3o de dados cl\u00ednicos. Dadoslevantados pela central de regula\u00e7\u00e3o de Recife Essa realidade pode ter limitado a finaliza\u00e7\u00e3o da a\u00e7\u00e3o regulat\u00f3ria de muitosencaminhamentos, n\u00e3o gerando o impacto pretendido, principalmente no que dizrespeito \u00e0 redu\u00e7\u00e3o das filas e do tempo de espera e \u00e0 maior qualifica\u00e7\u00e3o dassolicita\u00e7\u00f5es.,,A insuficiente transfer\u00eancia de informa\u00e7\u00f5es cl\u00ednicas, as falhas nos crit\u00e9rios deencaminhamento e as dificuldades no fluxo de informa\u00e7\u00f5es entre a APS e a regula\u00e7\u00e3os\u00e3o importantes obst\u00e1culos \u00e0 regula\u00e7\u00e3o e ao seu papel de colaboradora no processo decoordena\u00e7\u00e3o do cuidado, podendo retardar ou mesmo impedir o acesso dos usu\u00e1rios aosservi\u00e7os de sa\u00fade especializados ,,,,Com rela\u00e7\u00e3o ao componente \u201cteleconsultoria\u201d (servi\u00e7o de suporte \u00e0 regula\u00e7\u00e3o paragarantir maior resolutividade da APS), o projeto utilizou um canal 0800, o qual osprofissionais das UBS poderiam acionar para discuss\u00e3o de casos e/ou solicita\u00e7\u00f5essinalizadas como sens\u00edveis \u00e0 APS pela equipe do projeto e se encontravam devolvidasno SISREG. Contudo, apesar da disponibilidade de estrutura e profissionais para oservi\u00e7o, os resultados apresentados neste estudo identificaram baixa ades\u00e3o dosprofissionais das UBS, corroborando outros estudos Como exemplo de resultados alcan\u00e7ados pelo projeto em outras localidades,observaram-se redu\u00e7\u00e3o de fila e de tempo de espera para consultas priorit\u00e1rias emmais de 50% em Porto Alegre (Rio Grande do Sul) e Belo Horizonte (Minas Gerais),redu\u00e7\u00e3o de 40% no n\u00famero de novos encaminhamentos no Amazonas, al\u00e9m de aumento daqualifica\u00e7\u00e3o dos encaminhamentos no Distrito Federal ,,O componente \u201cteleconsulta\u201d, que n\u00e3o fazia parte do escopo inicial do projeto, foiinclu\u00eddo com o objetivo de reduzir o impacto da pandemia de COVID-19 no adiamento oucancelamento de consultas eletivas e, no per\u00edodo de maio de 2020 a setembro de 2020,622 teleconsultas foram realizadas Os protocolos cl\u00ednicos e de acesso utilizados pela equipe do projeto foram apontadospelos informantes como insuficientes, o que limitou a maior ades\u00e3o e a condu\u00e7\u00e3o doprojeto. Os protocolos s\u00e3o ferramentas de gest\u00e3o e de cuidado, pois tanto orientamas decis\u00f5es dos profissionais solicitantes quanto atuam como refer\u00eancias que modulama avalia\u00e7\u00e3o das solicita\u00e7\u00f5es pelos m\u00e9dicos reguladores ,,,,,,,,Devido \u00e0 pandemia, a \u201cexist\u00eancia de workshop com os profissionais da rede\u201d ocorreuquase seis meses depois do in\u00edcio das atividades do projeto. Apenas outro evento comos profissionais das UBS foi realizado, j\u00e1 na fase de encerramento, sendo apontadopelos informantes como fator que poderia ter auxiliado na maior divulga\u00e7\u00e3o e ades\u00e3odos profissionais. Esse achado corrobora outros estudos que citam aspectosorganizacionais como fatores relevantes para ado\u00e7\u00e3o e incorpora\u00e7\u00e3o da telessa\u00fadeA telemedicina desencadeia uma s\u00e9rie de altera\u00e7\u00f5es nas formas de coordena\u00e7\u00e3o,processos de trabalho e rela\u00e7\u00f5es de poder. Moehr et al. Estudo que analisou estrat\u00e9gias no processo de implementa\u00e7\u00e3o de uma solu\u00e7\u00e3o digitalobservou elevados n\u00edveis de coer\u00eancia e entusiasmo dos participantes ap\u00f3s aorganiza\u00e7\u00e3o de workshops, assim como a import\u00e2ncia de suporte durante aimplementa\u00e7\u00e3o, com a presen\u00e7a de pessoas que liderem o processo, que promovam autiliza\u00e7\u00e3o da telessa\u00fade e que motivem os participantes ,,,Tanto os relat\u00f3rios e pain\u00e9is de acompanhamento dos indicadores quanto o canal decomunica\u00e7\u00e3o entre a equipe do projeto e as UBS foram apontados como ferramentas quepoderiam ter sido melhor aproveitadas. A falta de cultura e capacidadeorganizacional para coletar, manejar e avaliar os dados em sa\u00fade inviabilizou osenormes ganhos que mecanismos de feedback podem produzir a a\u00e7\u00f5es complexas Al\u00e9m disso, envolver os diversos atores na escolha da solu\u00e7\u00e3o \u00e9 igualmente uma tarefaimportante. Segundo Bradford et al. ,,stakeholdersQuanto \u00e0 divulga\u00e7\u00e3o de conhecimento t\u00e9cnico e cient\u00edfico, mesmo com publica\u00e7\u00f5es sobreo tema Diante dos achados, compreende-se o comportamento dos profissionais de sa\u00fade comoelemento-chave para implanta\u00e7\u00e3o de interven\u00e7\u00f5es efetivas Como limita\u00e7\u00e3o deste estudo, devido \u00e0 escassez de indicadores e par\u00e2metros deavalia\u00e7\u00e3o nos documentos oficiais do projeto, principalmente para a dimens\u00e3oprocesso, tais valores de refer\u00eancia foram empiricamente derivados. No entanto, aosubmeter o modelo l\u00f3gico e a matriz de julgamento a um painel de especialistasinseridos em diferentes espa\u00e7os de envolvimento do projeto e ao confrontar fontes,buscou-se ampliar a validade dos instrumentos.Sabe-se que as dificuldades operacionais e as fragilidades dos mecanismos decoordena\u00e7\u00e3o do cuidado nas redes de aten\u00e7\u00e3o \u00e0 sa\u00fade t\u00eam apontado para a necessidadede ado\u00e7\u00e3o de novos arranjos para garantir um acesso mais equ\u00e2nime e integral aosusu\u00e1rios, fato que tem estimulado na \u00faltima d\u00e9cada a incorpora\u00e7\u00e3o de tecnologias,principalmente a partir da pandemia de COVID-19. No entanto, apesar das vantagens nouso dessas tecnologias no processo regulat\u00f3rio, ainda parecem existir barreiras \u00e0sua devida implanta\u00e7\u00e3o e, especialmente, \u00e0 obten\u00e7\u00e3o de resultados efetivos.,Os resultados deste estudo sugerem que deve haver certa cautela com a utiliza\u00e7\u00e3o detecnologias de apoio \u00e0 comunica\u00e7\u00e3o e \u00e0 informa\u00e7\u00e3o, sob pena de se configurar novaburocratiza\u00e7\u00e3o e novo obst\u00e1culo de acesso, quando o que se precisa \u00e9 uma regula\u00e7\u00e3oviva e centrada nas necessidades dos usu\u00e1rios mais do que em normas ou procedimentosNesse sentido, \u00e9 necess\u00e1rio fortalecer as equipes de regula\u00e7\u00e3o no que diz respeito aoquantitativo e \u00e0 capacidade t\u00e9cnica dos operadores do SISREG nas UBS paraadministra\u00e7\u00e3o das demandas. Al\u00e9m disso, a adequa\u00e7\u00e3o dos protocolos cl\u00ednicos e deencaminhamento \u00e0 realidade assistencial do munic\u00edpio \u00e9 fundamental, levando em contaa participa\u00e7\u00e3o conjunta de gestores e profissionais da regula\u00e7\u00e3o e aten\u00e7\u00e3ob\u00e1sica.Este estudo tamb\u00e9m apontou para a import\u00e2ncia de se estabelecer, desde o in\u00edcio daimplanta\u00e7\u00e3o do projeto, um processo de educa\u00e7\u00e3o continuada para maior envolvimentodos profissionais das UBS, tanto dos profissionais solicitantes quanto dosoperadores do SISREG - seja por meio de capacita\u00e7\u00f5es e/ou reuni\u00f5es peri\u00f3dicas com aequipe, abordando objetivos e operacionaliza\u00e7\u00e3o do projeto, divulga\u00e7\u00e3o dosinstrumentos (protocolos) e a import\u00e2ncia da atua\u00e7\u00e3o dos diferentes atores(responsabiliza\u00e7\u00e3o compartilhada), seja com a apresenta\u00e7\u00e3o dos resultados parciais edas dificuldades observadas. Estabelecer um canal de comunica\u00e7\u00e3o direto e permanentecom os profissionais da APS, com a escolha de atores-chave , para possibilitarmaior articula\u00e7\u00e3o entre as a\u00e7\u00f5es da equipe do projeto e das equipes de sa\u00fade dafam\u00edlia pode ser uma medida pertinente. Ademais, \u00e9 importante a atua\u00e7\u00e3o permanenteda central de regula\u00e7\u00e3o junto aos operadores do SISREG para continuidade doacompanhamento das demandas, identifica\u00e7\u00e3o de gargalos e aprimoramento dos processosde trabalho."}
+{"text": "Tendo em vista que as raz\u00f5es de mortalidadematerna, no Brasil, t\u00eam se mantido constantes apesar do compromisso firmadodurante a Assembleia Geral da Organiza\u00e7\u00e3o das Na\u00e7\u00f5es Unidas (ONU), em 2015, oobjetivo deste artigo \u00e9 propor um sistema nacional de vigil\u00e2ncia de nearmiss materno. Prop\u00f5e-se a inclus\u00e3o dos eventos nearmiss materno na Lista Nacional de Notifica\u00e7\u00e3o Compuls\u00f3ria deDoen\u00e7as, Agravos e Eventos de Sa\u00fade P\u00fablica, por meio da compatibiliza\u00e7\u00e3o doscrit\u00e9rios diagn\u00f3sticos de near miss materno, informados pelaOMS, com os c\u00f3digos da Classifica\u00e7\u00e3o Internacional de Doen\u00e7as (CID) paraidentifica\u00e7\u00e3o dos casos. Tendo em vista que a vigil\u00e2ncia em sa\u00fade se faz baseadaem diversas fontes de informa\u00e7\u00f5es, a notifica\u00e7\u00e3o poderia ser feita pelosprofissionais dos servi\u00e7os de sa\u00fade t\u00e3o logo fosse identificado um casoconfirmado ou suspeito. A partir do estudo dos fatores associados aos desfechos,espera-se a avalia\u00e7\u00e3o mais qualificada dos servi\u00e7os voltados \u00e0 assist\u00eanciaobst\u00e9trica e consequente implementa\u00e7\u00e3o de pol\u00edticas mais eficientes de preven\u00e7\u00e3on\u00e3o apenas do \u00f3bito materno, mas de eventos que podem tanto causar sequelasirrevers\u00edveis \u00e0 sa\u00fade da mulher quanto aumento do risco de \u00f3bito fetal eneonatal.A Organiza\u00e7\u00e3o Mundial da Sa\u00fade (OMS) recomenda a an\u00e1lise dos casos de morbidadematerna severa/ Ao longo das \u00faltimas tr\u00easd\u00e9cadas e das demais confer\u00eancias de popula\u00e7\u00e3o, esses esfor\u00e7os globais levaram \u00e0ado\u00e7\u00e3o de medidas mais eficientes para a promo\u00e7\u00e3o da sa\u00fade materna. A literaturaaponta que a redu\u00e7\u00e3o dos \u00f3bitos maternos \u00e9 resultado de melhorias nas pol\u00edticasp\u00fablicas com medidas para diminui\u00e7\u00e3o das iniquidades em sa\u00fade, especialmenteamplia\u00e7\u00e3o do acesso ao pr\u00e9-natal, qualifica\u00e7\u00e3o da assist\u00eancia ao parto e cuidadosp\u00f3s-parto ,Embora o Brasil tenha, na maior parte do per\u00edodo citado, se empenhado para garantirmelhorias na assist\u00eancia obst\u00e9trica e neonatal, como a ado\u00e7\u00e3o de um sistema nacionalde vigil\u00e2ncia de \u00f3bitos maternos e a implementa\u00e7\u00e3o de um programa nacional voltadoao pr\u00e9-natal e ao nascimento, a j\u00e1 extinta Rede Cegonha Portaria n\u00ba 1.119 de 2008 ,near miss materno nas investiga\u00e7\u00f5es relacionadas \u00e0 sa\u00fadematerna ,No Brasil, a near miss materno ocorre quando uma mulher, devido a complica\u00e7\u00f5esprovocadas ou agravadas por seu estado grav\u00eddico-puerperal, quase morre, n\u00e3oevoluindo para a morte em raz\u00e3o de interven\u00e7\u00f5es eficazes da equipe de assist\u00eancia \u00e0sa\u00fade ,near miss materno est\u00e3o associadas \u00e0possibilidade da an\u00e1lise da efic\u00e1cia e efetividade das interven\u00e7\u00f5es adotadas queimpediram o \u00f3bito materno, \u00e0 oportunidade de obter informa\u00e7\u00f5es sobre a assist\u00eancia eoutros fatores associados ao evento junto \u00e0 mulher que o experimentou, assim comopelo fato de a incid\u00eancia de near miss materno ser mais alta que ade \u00f3bito oportunizar informa\u00e7\u00f5es mais espec\u00edficas, principalmente em regi\u00f5es menospopulosas.O nearmiss materno a ser implementado com base na inclus\u00e3o desses eventos naLista de Agravos de Notifica\u00e7\u00e3o Compuls\u00f3ria e, visto que a vigil\u00e2ncia em sa\u00fade \u00e9feita por fontes de informa\u00e7\u00f5es diversas, discutir as poss\u00edveis bases utilizadaspela literatura. Neste trabalho, primeiramente apresentamos os crit\u00e9rios utilizadospara a padroniza\u00e7\u00e3o dos conceitos de morbidade materna grave e nearmiss materno, seguido da apresenta\u00e7\u00e3o das vantagens dos registros eavalia\u00e7\u00e3o desses eventos. Em seguida, apresentamos alguns exemplos de sistemas devigil\u00e2ncia de morbidade materna grave e near miss maternoregistrados no mundo e no Brasil. Por fim, sugerimos a implementa\u00e7\u00e3o de um sistemabrasileiro de vigil\u00e2ncia de near miss materno. O objetivo deste artigo \u00e9 propor um sistema de vigil\u00e2ncia nacional de near miss e o \u00f3bito maternoA sa\u00fade materna abrange as condi\u00e7\u00f5es de sa\u00fade da mulher durante a gesta\u00e7\u00e3o, o parto eo per\u00edodo puerperal. De acordo com Say et al. ,,near miss materno ,near miss materno, que explicaremos nos pr\u00f3ximospar\u00e1grafos. Conforme a OMS ,As complica\u00e7\u00f5es maternas graves s\u00e3o definidas como condi\u00e7\u00f5es potencialmenteamea\u00e7adoras \u00e0 vida e, ainda que o guia adote apenas cinco como crit\u00e9rios de inclus\u00e3oinicial - hemorragia p\u00f3s-parto grave, pr\u00e9-ecl\u00e2mpsia grave, ecl\u00e2mpsia, sepse/infec\u00e7\u00e3osist\u00eamica grave, rotura uterina -, elas abrangem outras condi\u00e7\u00f5es cl\u00ednicas, taiscomo gravidez ect\u00f3pica, descolamento prematuro de placenta, edema pulmonar e paradarespirat\u00f3ria near miss materno, por seu turno, ap\u00f3s ampla revis\u00e3o da literaturaespecializada em sa\u00fade materna pelo grupo de trabalho da OMS sobre mortalidadematerna e classifica\u00e7\u00f5es de morbidade, \u00e9 definido como uma mulher que quase morreu,mas sobreviveu a uma complica\u00e7\u00e3o que ocorreu durante a gravidez, parto ou dentro de42 dias ap\u00f3s o t\u00e9rmino da gravidez ,,near miss s\u00e3o aqueles associados \u00e0sdisfun\u00e7\u00f5es org\u00e2nicas apresentadas pela mulher e que foram provocadas ou agravadaspela gesta\u00e7\u00e3o, ou por intercorr\u00eancias durante e ap\u00f3s o parto. Nesse contexto, combase nos crit\u00e9rios diagn\u00f3sticos existentes na literatura ,,,,O near miss materno Para identificar as disfun\u00e7\u00f5es org\u00e2nicas capazes de levar uma parturiente ou pu\u00e9rperaa \u00f3bito, foram elencados 25 crit\u00e9rios, divididos em tr\u00eas grupos: cl\u00ednico,laboratorial e de manejo. Os crit\u00e9rios cl\u00ednicos s\u00e3o compostos por 11 condi\u00e7\u00f5es,entre elas, a falha de coagula\u00e7\u00e3o, o choque e a perda de consci\u00eancia superior ouigual a 12 horas. Os laboratoriais, compostos por oito crit\u00e9rios, incluem a presen\u00e7ade glicose e ceto\u00e1cidos na urina, a satura\u00e7\u00e3o de oxig\u00eanio abaixo de 90% por 60minutos ou mais e a trombocitopenia aguda. Por fim, os crit\u00e9rios baseados em manejoincluem, entre os seis estabelecidos, a di\u00e1lise para insufici\u00eancia renal aguda, ahisterectomia ap\u00f3s infec\u00e7\u00e3o ou hemorragia e a ressuscita\u00e7\u00e3o cardiopulmonar near miss e outras complica\u00e7\u00f5es maternas graves. Comrela\u00e7\u00e3o \u00e0 escala, isto \u00e9, obter um n\u00famero maior de eventos em compara\u00e7\u00e3o aos \u00f3bitosmaternos, a estrat\u00e9gia \u00e9 \u00fatil para ter maior robustez na an\u00e1lise, descobrirproblemas de assist\u00eancia rapidamente e inserir controles sociodemogr\u00e1ficos, tendo emvista que a maioria dos \u00f3bitos est\u00e1 relacionada \u00e0 fal\u00eancia de \u00f3rg\u00e3os ,,Uma vez definidos os conceitos, \u00e9 importante entender as vantagens dos registros eavalia\u00e7\u00e3o desses eventos, como destacado por alguns estudos que investigaram aincid\u00eancia de near miss materno para cada \u00f3bito materno associado \u00e0hemorragia; 58 casos de near miss por cada \u00f3bito materno associado\u00e0 ecl\u00e2mpsia, 92 casos de near miss materno por cada \u00f3bito associado\u00e0 sepse e 35 casos de near miss por cada \u00f3bito materno associado \u00e0trombose. Por exemplo, em um estudo que quantificou a incid\u00eancia de quatro das principaiscausas de morbimortalidade materna na Irlanda - hemorragia, dist\u00farbioshipertensivos, sepse e trombose -, Leitao et al. ,,near miss s\u00e3o similares aosde mortalidade materna, eles podem ser utilizados para fornecer informa\u00e7\u00f5es sobre ocuidado obst\u00e9trico, assim como para identificar obst\u00e1culos e melhores pr\u00e1ticasdiante de complica\u00e7\u00f5es agudas, permitindo que a\u00e7\u00f5es corretivas sejam colocadas empr\u00e1tica de forma pontual e que a prioridade seja dada aos casos mais urgentes ,near miss e \u00f3bitos maternosnear miss materno.Embora os \u00f3bitos maternos, por ser o desfecho mais grave associado \u00e0 sa\u00fade da m\u00e3e,recebam maior aten\u00e7\u00e3o, a vigil\u00e2ncia de outros eventos, capazes de causar sequelasirrevers\u00edveis \u00e0 sa\u00fade sexual e reprodutiva da mulher, \u00e9 incipiente ou, em muitospa\u00edses, negligenciada near missmaterno ,,Tendo em vista as dificuldades que alguns pa\u00edses enfrentam para alcan\u00e7ar as metasassumidas durante as Confer\u00eancias das Na\u00e7\u00f5es Unidas ocorridas nos \u00faltimos 30 anos,que estabeleceram que as mortes maternas globais n\u00e3o poder\u00e3o ultrapassar 70 mortespor 100 mil nascidos vivos at\u00e9 2030, a Organiza\u00e7\u00e3o das Na\u00e7\u00f5es Unidas (ONU) definiuestrat\u00e9gias para alcance dos compromissos assumidos pelos pa\u00edses signat\u00e1rios. No queconcerne \u00e0 sa\u00fade materna, destaca-se a necessidade de investimentos em interven\u00e7\u00f5esbaseadas em evid\u00eancias robustas capazes de proporcionar uma an\u00e1lise eficiente econfi\u00e1vel dos determinantes dos processos sa\u00fade-doen\u00e7a. Nesse contexto, ainda que o\u00f3bito seja evento sentinela para avalia\u00e7\u00e3o e monitoramento da qualidade daassist\u00eancia obst\u00e9trica, a OMS e a comunidade cient\u00edfica recomendam a implementa\u00e7\u00e3ode sistemas de vigil\u00e2ncia em morbidade materna grave e near miss com a ocorr\u00eancia de morteperinatal. Outras tentativas de se estabelecer investiga\u00e7\u00f5es de nearmiss com base em coletas de prontu\u00e1rio e formul\u00e1rios espec\u00edficos emhospital, como parte do protocolo de atendimento ou em auditorias, s\u00e3o relatadas nasrevis\u00f5es de Okusanya et al. ,Por meio da an\u00e1lise de prontu\u00e1rios de cuidado na unidade de terapia intensiva (UTI)obst\u00e9trica e pelo registro de atendimento hospitalar, em um estudo para o Suriname,Verschueren et al. Near Miss Materno(NMNMSS) foi criado em 2010 e utiliza os indicadores da OMS para o monitoramentomaterno e perinatal, com leves modifica\u00e7\u00f5es ,online localizada no Escrit\u00f3rio Nacional de Vigil\u00e2nciada Sa\u00fade Materno-Infantil da China (NOMCHS). Diante desse desenho, que coletainforma\u00e7\u00f5es no momento da entrada no hospital, \u00e9 poss\u00edvel calcular at\u00e9 mesmo amortalidade espec\u00edfica por causa tamb\u00e9m associada ao near miss,incluindo diferentes complica\u00e7\u00f5es e disfun\u00e7\u00f5es org\u00e2nicas Al\u00e9m de estudos pontuais, alguns pa\u00edses contam com Sistemas Nacionais de Vigil\u00e2nciaEpidemiol\u00f3gica de eventos graves associados \u00e0 gravidez, ao parto e ao puerp\u00e9rio. NaChina, o Sistema Nacional de Vigil\u00e2ncia de near miss materno O Reino Unido, que conta com um sistema de vigil\u00e2ncia de \u00f3bito materno desde a d\u00e9cadade 1950, instituiu o Sistema de Vigil\u00e2ncia Obst\u00e9trica do Reino Unido (UKOSS),cobrindo todas as unidades obst\u00e9tricas do pa\u00eds e permitindo a an\u00e1lise, seja emauditorias ou em outros tipos de estudos, de uma gama de eventos associados \u00e0gravidez, neles inclu\u00eddos o near miss materno, entre 2000 e 2012, sendo as raz\u00f5es maisaltas observadas nas regi\u00f5es Norte e Nordeste. Um estudo, que tamb\u00e9m utilizou osdados do SIH-SUS, identificou 766.249 casos de near miss maternoentre as 20.891.040 interna\u00e7\u00f5es por causas obst\u00e9tricas, registradas entre 2010 e2018 near missmaterno, a vigil\u00e2ncia cont\u00ednua dos casos pode contribuir n\u00e3o apenas para aconstru\u00e7\u00e3o e melhoria das pol\u00edticas voltadas \u00e0 redu\u00e7\u00e3o da morte materna, mas tamb\u00e9mpara entendimento e identifica\u00e7\u00e3o dos fatores associados ao n\u00famero de mulheres quecontinuam experimentando morbidade materna mesmo ap\u00f3s o avan\u00e7o da cobertura daassist\u00eancia profissional ao pr\u00e9-natal, ao parto e ao p\u00f3s-parto.No caso do Brasil, Carvalho et al. No Brasil, a cria\u00e7\u00e3o do Sistema de Vigil\u00e2ncia do \u00d3bito Materno ocorreu recentemente,em 2009, o que possibilitou acompanhar a evolu\u00e7\u00e3o desse indicador com mais seguran\u00e7asomente a partir dessa data. No entanto, Leal et al. Em momentos de crise sanit\u00e1ria e consequente sobrecarga dos servi\u00e7os de sa\u00fade, essesindicadores podem sofrer importantes efeitos. Durante a pandemia de COVID-19,estima-se que a RMM tenha alcan\u00e7ado cerca de 71,97 \u00f3bitos por 100 mil nascidos vivosem 2020 e 107 mortes maternas por 100 mil nascidos vivos em 2021 ,,,,,,near missmaterno quanto emerg\u00eancia em sua implementa\u00e7\u00e3o. Na pr\u00f3xima se\u00e7\u00e3o discutimos umaproposta para sua efetiva\u00e7\u00e3o.A literatura tem avan\u00e7ado nas an\u00e1lises de diversas fontes de informa\u00e7\u00f5es para mapearos fatores associados aos indicadores de sa\u00fade materna e se reconhece a import\u00e2nciada vigil\u00e2ncia do \u00f3bito materno, que j\u00e1 conta com um sistema obrigat\u00f3rio deinvestiga\u00e7\u00e3o em todo o territ\u00f3rio nacional. Uma vez que os processos de investiga\u00e7\u00e3oem sa\u00fade n\u00e3o s\u00e3o excludentes, mas complementares, dadas as experi\u00eancias dispon\u00edveisna literatura ,,A vigil\u00e2ncia em sa\u00fade \u00e9 uma importante ferramenta para planejamento e avalia\u00e7\u00e3o dasa\u00e7\u00f5es voltadas \u00e0 sa\u00fade da popula\u00e7\u00e3o, uma vez que fornece informa\u00e7\u00f5es coletadas emprocessos sistem\u00e1ticos e cont\u00ednuos acerca dos fatores determinantes e condicionantesde sa\u00fade individual ou coletiva ,No caso brasileiro, a base do sistema de vigil\u00e2ncia \u00e9 formada pela notifica\u00e7\u00e3ocompuls\u00f3ria de doen\u00e7as e agravos \u00e0 sa\u00fade, em que as informa\u00e7\u00f5es s\u00e3o registradas noSistema de Informa\u00e7\u00e3o de Agravos de Notifica\u00e7\u00e3o (SINAN). Al\u00e9m do SINAN, osprincipais sistemas de informa\u00e7\u00f5es utilizados para vigil\u00e2ncia em sa\u00fade s\u00e3o o Sistemade Informa\u00e7\u00e3o sobre Mortalidade (SIM), Sistema de Informa\u00e7\u00e3o sobre Nascidos Vivos(SINASC) e o SIH-SUS. Outras fontes de dados s\u00e3o registros hospitalares, inqu\u00e9ritosdomiciliares, investiga\u00e7\u00f5es de surto, estudos epidemiol\u00f3gicos e estudos conduzidospor seguimentos da sociedade civil, desde que permitam a identifica\u00e7\u00e3o imediata doproblema e seu enfrentamento de forma eficiente e em tempo oportuno near miss materno, a possibilidade\u00e9 que se aprenda tanto com as falhas da assist\u00eancia quanto com os acertos capazes deimpedir o desfecho grave, com a diferen\u00e7a de que as informa\u00e7\u00f5es complementares quen\u00e3o s\u00e3o poss\u00edveis de capta\u00e7\u00e3o por meio de dados institucionais podem ser obtidasjunto \u00e0 mulher.No contexto da sa\u00fade materna, ainda que a vigil\u00e2ncia de \u00f3bitos maternos desempenheimportante papel na investiga\u00e7\u00e3o dos fatores associados \u00e0s mortes de mulheres nociclo grav\u00eddico-puerperal, na corre\u00e7\u00e3o dos dados e no fornecimento de subs\u00eddios paraavalia\u00e7\u00e3o e melhoria da assist\u00eancia obst\u00e9trica, os resultados podem n\u00e3o serrepresentativos de toda a popula\u00e7\u00e3o, pois pode haver subnotifica\u00e7\u00e3o ou incompletude.Por outro lado, por mais que seja urgente a ado\u00e7\u00e3o de medidas eficientes que impe\u00e7ama morte de uma mulher, \u00e9 necess\u00e1rio que eventos maternos graves tamb\u00e9m sejamprevenidos dadas as poss\u00edveis sequelas f\u00edsicas e psicol\u00f3gicas infligidas \u00e0 mulher.Em s\u00edntese, a investiga\u00e7\u00e3o de um \u00f3bito materno possibilita interven\u00e7\u00f5es preventivasde novos \u00f3bitos, mas para a mulher que morre nada pode ser feito, mesmo que muitopossa ser apreendido. No caso do near miss materno considerando sua caracter\u00edstica preditiva do\u00f3bito materno. Tendo como pressuposto que uma mulher que experimenta um evento denear miss \u00e9 exatamente como aquela que morre, exceto pelodesfecho, as an\u00e1lises confirmaram os crit\u00e9rios estabelecidos com uma sensibilidadede 100% e especificidade de 92% ,,near miss materno por meio deauditorias hospitalares.Alguns estudos realizados no Brasil indicam direcionamentos poss\u00edveis para aimplementa\u00e7\u00e3o da vigil\u00e2ncia em morbidade materna. Entre julho de 2009 e junho de2010, um estudo transversal multic\u00eantrico foi realizado em 27 hospitais, das cincoregi\u00f5es do pa\u00eds, pela Rede Nacional de Vigil\u00e2ncia de Morbidade Materna Grave. Combase nas defini\u00e7\u00f5es recomendadas pela OMS near miss eoutras complica\u00e7\u00f5es maternas graves ,,,,near miss materno para todas as macrorregi\u00f5es doBrasil. Nakamura-Pereira et al. Outro caminho indicado pela literatura \u00e9 a utiliza\u00e7\u00e3o de dados secund\u00e1rios extra\u00eddosdo SIH-SUS. Ainda que sua fun\u00e7\u00e3o n\u00e3o seja de vigil\u00e2ncia, mas cont\u00e1bil-financeira, osistema oferece informa\u00e7\u00f5es sobre causas de interna\u00e7\u00e3o e procedimentos realizadosque podem ser utilizadas para identificar casos de nearmiss materno tanto pelo uso de dados prim\u00e1rios como de dadossecund\u00e1rios. Contudo, a literatura pontua algumas limita\u00e7\u00f5es. No caso de auditoriashospitalares, as investiga\u00e7\u00f5es demandam o empenho das equipes de sa\u00fade no registroadequado das informa\u00e7\u00f5es, sendo necess\u00e1rio, entretanto, assumir o pressuposto de queos protocolos de manejo e de assist\u00eancia s\u00e3o seguidos adequadamente, uma vez que h\u00e1crit\u00e9rios de interven\u00e7\u00e3o espec\u00edficos para identifica\u00e7\u00e3o dos casos. Al\u00e9m disso, asauditorias s\u00e3o mais dispendiosas quanto ao investimento financeiro e \u00e0disponibilidade de tempo Conforme explicitado, \u00e9 poss\u00edvel investigar as ocorr\u00eancias de near miss materno near miss materno, assim como j\u00e1 \u00e9 utilizado para avigil\u00e2ncia de outras morbidades.No que se refere ao SIH-SUS, por ser uma fonte secund\u00e1ria, o registro inadequado dasinforma\u00e7\u00f5es pode gerar resultados n\u00e3o condizentes com a realidade. Estudo realizadoem um hospital do Estado do Rio de Janeiro, por exemplo, mostrou baixa efici\u00eancia nacapta\u00e7\u00e3o dos casos de Portaria n\u00ba 1.271 de 2014 near miss materno se enquadra no conceito dedoen\u00e7a para os fins a que se destina a referida norma, a sugest\u00e3o deste presenteartigo \u00e9 que o evento seja inclu\u00eddo na Lista de Notifica\u00e7\u00e3o Compuls\u00f3ria para que,diante disso, seja obrigat\u00f3rio, via SINAN, o comunicado de casos suspeitos ouconfirmados. Quanto \u00e0 responsabilidade de toda a equipe profissional, destaca-se queo procedimento de notifica\u00e7\u00e3o pode ser executado pelos tr\u00eas n\u00edveis de aten\u00e7\u00e3o \u00e0sa\u00fade: prim\u00e1rio, secund\u00e1rio e terci\u00e1rio. A near miss materno no rol dedoen\u00e7as e agravos de import\u00e2ncia nacional \u00e9 a aus\u00eancia de c\u00f3digo espec\u00edfico na CID.No entanto, tendo em vista a exist\u00eancia de instrumento que j\u00e1 \u00e9 utilizado em algunsestados do pa\u00eds, considerando os crit\u00e9rios padronizados pela OMS, os casos podem seridentificados a partir da an\u00e1lise do quadro cl\u00ednico da mulher ainda no hospital, oupor meio das informa\u00e7\u00f5es constantes no sum\u00e1rio de alta hospitalar, durante aconsulta puerperal, por exemplo. Um poss\u00edvel entrave para a inclus\u00e3o do ,Com base em sistemas implementados em outros pa\u00edses, destacando-se os de vigil\u00e2nciachin\u00eas e do Reino Unido near miss materno, padronizado pela OMS, oaborto foi inclu\u00eddo na ferramenta de investiga\u00e7\u00e3o como causa subjacente aosdesfechos maternos graves ,Os abortos, ainda que sejam respons\u00e1veis por grande parte da morbidade materna, aindas\u00e3o subnotificados, possivelmente devido \u00e0 criminaliza\u00e7\u00e3o de sua pr\u00e1tica. Em muitoscasos, declarados como infec\u00e7\u00e3o puerperal, hemorragias ou sepses, a sua notifica\u00e7\u00e3oadequada possibilitaria tanto dimensionar a magnitude do n\u00famero de abortosinseguros, relacionados a um maior risco de morbimortalidade materna, assim comopermitiria a avalia\u00e7\u00e3o da qualidade da aten\u00e7\u00e3o \u00e0s suas complica\u00e7\u00f5es, mesmo entre osabortos espont\u00e2neos. Cumpre esclarecer que, tendo como base o Formul\u00e1rio Individualde Coleta de Dados para Lei n\u00ba 8.080 de 1990; Lei n\u00ba6.259 de 1975; e Constitui\u00e7\u00e3o Federal de 1988), asinvestiga\u00e7\u00f5es n\u00e3o se exaurem em uma \u00fanica fonte de informa\u00e7\u00e3o. Nesse contexto,considerada a potencialidade do SIH-SUS para identifica\u00e7\u00e3o de diversas morbidadesnear miss materno. Assim, como at\u00e9cnica de associa\u00e7\u00e3o dos c\u00f3digos da CID-10, adotada por Nakamura-Pereira et al.nearmiss materno \u00e0 vigil\u00e2ncia dos \u00f3bitos maternos transformando o sistemaexistente em um sistema de vigil\u00e2ncia de morbimortalidade materna ou, em outrapossibilidade, ao inclu\u00ed-lo na Lista de Agravos de Notifica\u00e7\u00e3o Compuls\u00f3ria,possibilitar que todos os casos sejam reportados e, assim, sejam utilizados n\u00e3oapenas para otimizar a vigil\u00e2ncia do \u00f3bito, mas possibilitar um amplo acesso aosinteressados no assunto, tanto no \u00e2mbito cient\u00edfico quanto no de utiliza\u00e7\u00e3o paramelhoria das pol\u00edticas voltadas \u00e0 sa\u00fade materna.Conforme discutido em Ayres et al. Com rela\u00e7\u00e3o \u00e0 viabilidade de sua implementa\u00e7\u00e3o, como os custos operacionais, fluxos,prazos e instrumentos, e a capacidade institucional de lev\u00e1-lo adiante, al\u00e9m daslimita\u00e7\u00f5es j\u00e1 expostas e os desafios ainda enfrentados pelo Sistema de Vigil\u00e2ncia de\u00d3bito, a cria\u00e7\u00e3o e execu\u00e7\u00e3o de um sistema complementar almeja a an\u00e1lise de umaequipe multidisciplinar do governo, da sociedade civil e de especialistas. Noentanto, o Brasil tem investido na melhoria dos sistemas de investiga\u00e7\u00e3o e daqualidade das notifica\u00e7\u00f5es, o que pode reduzir os custos com treinamento, manuten\u00e7\u00e3oe investimento em novas tecnologias. near miss materno, conforme discutido, ocorre quando uma mulherapresenta disfun\u00e7\u00f5es org\u00e2nicas provocadas ou agravadas pela gravidez, por eventosadversos durante o parto ou no puerp\u00e9rio, mas n\u00e3o evolui para \u00f3bito apesar dagravidade de seu quadro de sa\u00fade. Embora seja associado \u00e0 qualidade da assist\u00eanciahospitalar, uma vez que o \u00f3bito materno foi evitado, est\u00e1 associado a pioresdesfechos neonatais e sequelas irrevers\u00edveis \u00e0 sa\u00fade sexual e reprodutiva demulheres que o experimentam.O near miss e \u00e0 necessidade de implementa\u00e7\u00e3o de um sistema devigil\u00e2ncia cont\u00ednuo em adi\u00e7\u00e3o ao Sistema de Vigil\u00e2ncia de \u00d3bito Materno. A primeiradiz respeito ao fato de que \u00e9 ineg\u00e1vel que a assist\u00eancia obst\u00e9trica adequada previnea evolu\u00e7\u00e3o de gesta\u00e7\u00f5es com risco habitual ou com complica\u00e7\u00f5es com baixo risco demorte para desfechos maternos graves near miss, esses casos podem indicaros fatores associados tanto \u00e0 evolu\u00e7\u00e3o do quadro de sa\u00fade da mulher para umnear miss materno quanto \u00e0 evitabilidade do \u00f3bito. Nessecontexto, a investiga\u00e7\u00e3o pode fornecer ferramentas para criar protocolos deinterven\u00e7\u00e3o eficientes para replica\u00e7\u00e3o em casos semelhantes, assim como podemcontribuir para a adequa\u00e7\u00e3o de protocolos obsoletos ou n\u00e3o baseados em evid\u00eanciascient\u00edficas. Duas perspectivas podem ser discutidas no que diz respeito \u00e0 incid\u00eancia donear miss maternodiz respeito aos direitos sexuais e reprodutivos de toda mulher, que deve abrangeresfor\u00e7os m\u00e1ximos de uma experi\u00eancia gestacional e puerperal positiva. Ainda que amorte materna, assim como o \u00f3bito fetal e neonatal, sejam eventos maternos tr\u00e1gicos,a experimenta\u00e7\u00e3o de um near miss materno pode acarretar n\u00e3o apenassequelas f\u00edsicas, mas emocionais e psicol\u00f3gicas importantes. \u00c9 not\u00f3rio que asmedidas adotadas para redu\u00e7\u00e3o do \u00f3bito proporcionam, em consequ\u00eancia, melhoria daqualidade assistencial e redu\u00e7\u00e3o dos riscos maternos de modo geral. No entanto,mesmo em pa\u00edses em que as raz\u00f5es de morte materna s\u00e3o baixas, o nearmiss materno ainda \u00e9 uma preocupa\u00e7\u00e3o, uma vez que a sa\u00fade das m\u00e3es deveestar sob constante vigil\u00e2ncia, dada a complexidade do espectro de morbidade maternaque pode evoluir de uma gesta\u00e7\u00e3o sem complica\u00e7\u00f5es para um desfecho grave, caso agestante n\u00e3o seja monitorada de forma adequada por toda a gesta\u00e7\u00e3o, no parto e nopuerp\u00e9rio. A segunda perspectiva que se apreende dos casos de nearmiss materno pode contribuir para aperfei\u00e7oamento das pol\u00edticas eservi\u00e7os de sa\u00fade nas regi\u00f5es onde a RMM \u00e9 mais baixa, proporcionando cada vez maisa redu\u00e7\u00e3o de outros desfechos, como a morbidade materna grave e severa e a redu\u00e7\u00e3oda morbimortalidade fetal e neonatal. Afinal, em pa\u00edses citados neste artigo ,near miss materno pode contribuir para a elucida\u00e7\u00e3o de falhas eacertos na assist\u00eancia obst\u00e9trica, possibilitando, dessa forma, avalia\u00e7\u00e3o eadequa\u00e7\u00e3o, cada vez mais minuciosa, da pol\u00edtica e dos servi\u00e7os voltados \u00e0 sa\u00fadematerna.O Brasil, embora tenha avan\u00e7ado na melhoria de seus indicadores maternos, n\u00e3oconseguiu cumprir a meta assumida, durante a C\u00fapula do Mil\u00eanio, para redu\u00e7\u00e3o da RMMem 75% at\u00e9 2015 e tem mantido sua RMM, nos \u00faltimos anos, em cerca de 60 \u00f3bitosmaternos por 100 mil nascidos vivos, cerca de duas vezes o valor esperado para 2030,de acordo com compromisso assumido pelo ODS"}
+{"text": "Escala de Depress\u00e3o Geri\u00e1trica (GDS-15), tanto na linha debase como no seguimento, que n\u00e3o apresentavam depress\u00e3o no ano de 2008. Paracalcular as raz\u00f5es de incid\u00eancia bruta e ajustadas e intervalo de 95% deconfian\u00e7a, foi utilizada a regress\u00e3o de Poisson com ajuste robusto de vari\u00e2ncia,incluindo as vari\u00e1veis da linha de base. Empregou-se um modelo hier\u00e1rquico dequatro n\u00edveis de determina\u00e7\u00e3o. As vari\u00e1veis foram controladas para aquelas domesmo n\u00edvel ou dos n\u00edveis superiores, sendo estabelecido o valor de p \u2264 0,20para permanecer no modelo de an\u00e1lise. Observou-se que, em 2008, 523 idosos n\u00e3otinham depress\u00e3o e 92 haviam sido diagnosticados com a doen\u00e7a. Em 2016/2017, dos523 indiv\u00edduos sem depress\u00e3o na medida de linha de base, 10,3% apresentaramresultado positivo no rastreamento (casos incidentes), enquanto 89,7% dos idosospermaneceram livres do problema. Dos 92 idosos com depress\u00e3o em 2008, 32,6%continuaram referindo a sintomatologia depressiva no acompanhamento e 67,3%apresentaram remiss\u00e3o dos sintomas. Sair de casa uma ou nenhuma vez e apresentarincapacidades para o desenvolvimento de atividades funcionais e instrumentais davida di\u00e1ria se associaram com maior risco de apresentar rastreamento positivopara depress\u00e3o. Os resultados refor\u00e7am o car\u00e1ter multidimensional e din\u00e2mico dadepress\u00e3o, que alterna epis\u00f3dios curtos e longos, podendo se tornar recorrente ede curso cr\u00f4nico.Com o objetivo de avaliar a incid\u00eancia cumulativa de depress\u00e3o e seus fatoresassociados na popula\u00e7\u00e3o idosa, residente na zona urbana do Munic\u00edpio de Bag\u00e9,Rio Grande do Sul, Brasil, realizou-se um estudo de coorte, prospectivo, entre2008 e 2016/2017. A an\u00e1lise foi restrita a 615 idosos com informa\u00e7\u00f5es completasna  O estudo encontrou maior raz\u00e3o de preval\u00eancia (RP) entre os grupos populacionais com idades entre 40-49 anos , 50-59 anos  e 80 anos ou mais  em compara\u00e7\u00e3o ao grupo de refer\u00eancia (18-29 anos) De acordo com a Organiza\u00e7\u00e3o Mundial da Sa\u00fade (OMS), a depress\u00e3o atinge 4,8% da popula\u00e7\u00e3o mundial, acometendo 5,8%  dos brasileiros odds ratio - OR = 3,30; IC95%: 1,20-5,40). Bojorquez-Chapela et al. Os determinantes da incid\u00eancia de depress\u00e3o em idosos incluem aspectos sociais, comportamentais, culturais, ambientais, econ\u00f4micos, pol\u00edticos, familiares e de sa\u00fade. Estudos de coorte desenvolvidos por Gureje et al. ,,No Brasil, pouco se sabe sobre a incid\u00eancia de depress\u00e3o entre a popula\u00e7\u00e3o idosa, particularmente de seus determinantes e de suas consequ\u00eancias para a sa\u00fade. Foram encontrados dois estudos brasileiros longitudinais e de base populacional que abordaram essa tem\u00e1tica Sa\u00fade do Idoso Ga\u00facho de Bag\u00e9 (SIGA-Bag\u00e9), realizado com idosos de 60 anos ou mais, residentes na \u00e1rea de abrang\u00eancia dos servi\u00e7os de aten\u00e7\u00e3o b\u00e1sica \u00e0 sa\u00fade da zona urbana do munic\u00edpio.Estudo de coorte, prospectivo, de base populacional, intitulado 2. O munic\u00edpio est\u00e1 situado a pouco mais de 350km de Porto Alegre , faz fronteira com o Uruguai ao sul e sua principal base econ\u00f4mica \u00e9 a atividade agropecu\u00e1ria. O \u00cdndice de Desenvolvimento Humano Municipal (IDH-M) em 2010 era de 0,740 e o produto interno bruto (PIB) era de R$ 21.930,00 per capita/ano em 2016. A escolha do munic\u00edpio como local de estudo em 2008 considerou a taxa de cobertura da Estrat\u00e9gia Sa\u00fade da Fam\u00edlia (ESF) (51%), que era a maior entre os munic\u00edpios com mais de 100 mil habitantes do Estado do Rio Grande do Sul. Al\u00e9m disso, a propor\u00e7\u00e3o de indiv\u00edduos com 60 anos ou mais (12%) era superior em compara\u00e7\u00e3o ao pa\u00eds (10%) Bag\u00e9 localiza-se no extremo sul do Brasil, tinha uma popula\u00e7\u00e3o estimada em 120.943 habitantes em 2018 e densidade demogr\u00e1fica de 28,52 habitantes/kmNo estudo de linha de base (ELB) em 2008, a amostra de 1.713 idosos foi localizada por busca sistem\u00e1tica nas \u00e1reas de abrang\u00eancia das 20 unidades b\u00e1sicas de sa\u00fade (UBS) da zona urbana. Todos os moradores com 60 anos ou mais residentes nos domic\u00edlios selecionados foram convidados a participar, dos quais 1.593 (93%) foram entrevistados. Os idosos foram selecionados, sorteando diferentes pontos de partida com pulo sistem\u00e1tico de cinco domic\u00edlios entre as resid\u00eancias, a fim de garantir a equiprobabilidade e a distribui\u00e7\u00e3o da amostra no territ\u00f3rio, estimando-se a presen\u00e7a de um idoso a cada tr\u00eas domic\u00edlios. Os dados foram coletados por meio de um question\u00e1rio estruturado com perguntas pr\u00e9-codificadas ap\u00f3s um estudo piloto. Informa\u00e7\u00f5es detalhadas sobre a metodologia do ELB foram descritas por Thum\u00e9 et al. Escala de Depress\u00e3o Geri\u00e1trica  em 2008 e 2016/2017, na vers\u00e3o reduzida de Yesavage et al. Para o desfecho, foi utilizada a Estudo Longitudinal Dinamarqu\u00eas sobre o Comportamento na Sa\u00fade, do ingl\u00eas Danish Longitudinal Health Behavior Study) As vari\u00e1veis independentes foram obtidas em 2008 e compreenderam as seguintes caracter\u00edsticas: (a) sociodemogr\u00e1ficas: sexo , idade , cor da pele , situa\u00e7\u00e3o conjugal , anos completos de estudo , classifica\u00e7\u00e3o econ\u00f4mica pela Associa\u00e7\u00e3o Brasileira de Empresas de Pesquisas (ABEP) 2018 , trabalho no \u00faltimo m\u00eas  e aposentadoria ; (b) comportamentais: saiu de casa nos \u00faltimos 30 dias , tabagismo  e consumo de bebida alco\u00f3lica nos \u00faltimos 30 dias ; (c) rede de apoio social .Para a an\u00e1lise descritiva, foram calculados as incid\u00eancias e seus respectivos IC95%. Os riscos relativos (RR), express\u00e3o das raz\u00f5es de incid\u00eancia, brutos e ajustados e o IC95% foram calculados por meio da regress\u00e3o de Poisson Resolu\u00e7\u00e3o n\u00ba 466/2012. Os princ\u00edpios \u00e9ticos foram assegurados a partir da assinatura do Termo de Consentimento Livre e Esclarecido pelos participantes.O projeto foi aprovado pelo Comit\u00ea de \u00c9tica em Pesquisa da Faculdade de Medicina da Universidade Federal de Pelotas, em 29 de maio de 2014 (parecer n\u00ba 678.664), seguindo os preceitos da No ELB, foram entrevistados 1.593 idosos (propor\u00e7\u00e3o de resposta de 93%). No acompanhamento realizado em 2016/2017, 1.314 idosos  foram localizados, dos quais 735  foram entrevistados novamente e 579  foram a \u00f3bito, confirmado pelo Sistema de Informa\u00e7\u00e3o sobre Mortalidade (SIM), at\u00e9 agosto de 2017. Entre os 279  indiv\u00edduos que n\u00e3o foram acompanhados, 81 (29%) foram recusas e 198 (71%) foram perdas, principalmente por n\u00e3o localiza\u00e7\u00e3o do endere\u00e7o, mudan\u00e7a para outros munic\u00edpios e institucionaliza\u00e7\u00e3o.Nas duas avalia\u00e7\u00f5es, houve predom\u00ednio de indiv\u00edduos do sexo feminino, de cor branca, com 1-7 anos de escolaridade, que n\u00e3o trabalharam no \u00faltimo m\u00eas, aposentados, que sa\u00edram de casa duas vezes por semana ou mais, fumante/ex-fumante e que n\u00e3o consumiam bebida alco\u00f3lica, com diagn\u00f3stico m\u00e9dico de duas ou mais morbidades, sem incapacidade para a realiza\u00e7\u00e3o de atividades b\u00e1sicas e instrumentais da vida di\u00e1ria .No acompanhamento, observou-se mudan\u00e7a significativa na propor\u00e7\u00e3o da categoria predominante em rela\u00e7\u00e3o ao ELB para as vari\u00e1veis idade, situa\u00e7\u00e3o conjugal e classe econ\u00f4mica. O predom\u00ednio de indiv\u00edduos com menos de 75 anos deu lugar ao de idosos com 75 anos ou mais; o de casados e com companheiro, ao de solteiros, separados ou vi\u00favos; o de idosos de classe econ\u00f4mica C, ao de pertencentes \u00e0s classes D/E .A an\u00e1lise de incid\u00eancia cumulativa deste estudo foi restrita a 615 idosos com informa\u00e7\u00f5es completas na escala GDS-15, tanto na linha de base como no seguimento, que n\u00e3o apresentavam depress\u00e3o no ano de 2008. Para esses idosos, observou-se a forma\u00e7\u00e3o de dois grupos de evolu\u00e7\u00e3o entre as medidas da escala. O primeiro grupo reuniu 523 idosos que apresentaram resultado negativo no rastreamento de sintomas depressivos em 2008, dos quais 54  apresentaram resultado positivo no rastreamento de 2016/2017 (casos incidentes). O segundo grupo incluiu os 92 indiv\u00edduos que foram rastreados com depress\u00e3o em 2008, dos quais 30  continuaram com sintomatologia depressiva e 62  exibiram remiss\u00e3o dos sintomas , observaNa an\u00e1lise ajustada, mantiveram-se associadas ao desfecho as vari\u00e1veis incapacidade funcional e sair de casa. A incid\u00eancia de depress\u00e3o entre idosos com incapacidade para atividades b\u00e1sicas e instrumentais da vida di\u00e1ria foi de 45,1%, com risco 5,18  vezes maior se comparado com idosos que n\u00e3o foram rastreados com incapacidade . A incid\u00eancia de depress\u00e3o entre os idosos que sa\u00edram de casa uma ou nenhuma vez na semana foi de 18,2%, com risco 1,83  vez maior em rela\u00e7\u00e3o \u00e0queles que sa\u00edram de casa duas vezes ou mais por semana no m\u00eas que antecedeu a entrevista  .Center for Epidemiological Studies - Depression (CES-D), Batistone et al. A incid\u00eancia cumulativa de depress\u00e3o na coorte de idosos do estudo SIGA-Bag\u00e9, no per\u00edodo de oito anos de acompanhamento, foi de 10,3%. No M\u00e9xico, com a escala GDS-15, Bojorquez-Chapela et al. ,Os resultados relacionados \u00e0 baixa incid\u00eancia e \u00e0 alta taxa de remiss\u00e3o entre quem foi diagnosticado com depress\u00e3o no ELB refor\u00e7am o car\u00e1ter multidimensional e din\u00e2mico da doen\u00e7a, que alterna epis\u00f3dios curtos e longos ,A maior restri\u00e7\u00e3o no n\u00famero de vezes que o idoso saiu de casa esteve associada ao risco de depress\u00e3o ap\u00f3s a an\u00e1lise ajustada, evidenciando que os idosos que n\u00e3o saem de casa, ou saem pouco, s\u00e3o mais propensos ao isolamento, \u00e0 solid\u00e3o, \u00e0 baixa autoestima, eventualmente associados a problemas de sa\u00fade e incapacidades, contribuindo para a ocorr\u00eancia de sintomas de depress\u00e3o As incapacidades funcionais para atividades b\u00e1sicas e instrumentais da vida implicam restri\u00e7\u00f5es f\u00edsicas e mentais para os idosos, relacionadas a mobilidade, alimenta\u00e7\u00e3o, vontade de se vestir e sair de casa para fazer compras ou pagar contas. Essa perda de autonomia afeta a qualidade de vida e pode aumentar o risco de depress\u00e3o. Nos estudos de Michikawa et al. Cadernos de Aten\u00e7\u00e3o \u00e0 Sa\u00fade do Idoso,A avalia\u00e7\u00e3o criteriosa da incid\u00eancia de depress\u00e3o na popula\u00e7\u00e3o idosa \u00e9 um dos destaques do estudo. As taxas de incid\u00eancia e remiss\u00e3o encontradas s\u00e3o representativas da popula\u00e7\u00e3o idosa moradora da zona urbana do Munic\u00edpio de Bag\u00e9. O instrumento utilizado para rastrear a sintomatologia depressiva em idosos tem alta sensibilidade e especificidade de acordo com os crit\u00e9rios da CID-10 e \u00e9 recomendado pelo Minist\u00e9rio da Sa\u00fade nos ,,,,Uma das limita\u00e7\u00f5es do estudo para avaliar a ocorr\u00eancia de depress\u00e3o foi o intervalo de oito a nove anos entre as duas medidas. A incid\u00eancia observada foi, em geral, menor do que a relatada na literatura nacional e internacional que utiliza o mesmo instrumento, n\u00e3o apenas por diferen\u00e7as demogr\u00e1ficas e de contexto social, mas tamb\u00e9m porque epis\u00f3dios depressivos de curta dura\u00e7\u00e3o podem ter sido sub-representados. Al\u00e9m disso, o estudo teve 54% de taxa de n\u00e3o respondentes , o que reduziu o poder estat\u00edstico das an\u00e1lises e afetou a capacidade de identificar associa\u00e7\u00f5es significativas com depress\u00e3o de vari\u00e1veis comumente associadas em outros estudos, como sexo ,A incid\u00eancia cumulativa de depress\u00e3o na coorte de idosos do estudo SIGA-Bag\u00e9 em um per\u00edodo de oito anos de acompanhamento foi de 10,3%. Apresentar incapacidade funcional para as atividades b\u00e1sicas e instrumentais da vida di\u00e1ria e sair de casa uma ou nenhuma vez na semana se associou com maior risco de depress\u00e3o. Sugere-se o fortalecimento de pol\u00edticas sociais e de aten\u00e7\u00e3o \u00e0 sa\u00fade, em ambientes comunit\u00e1rios seguros com infraestrutura adequada para a popula\u00e7\u00e3o idosa, para a promo\u00e7\u00e3o da qualidade de vida e do envelhecimento saud\u00e1vel. Al\u00e9m disso, uma avalia\u00e7\u00e3o mais abrangente e qualificada da pessoa idosa na aten\u00e7\u00e3o prim\u00e1ria \u00e0 sa\u00fade e o incentivo \u00e0 cria\u00e7\u00e3o de grupos de conviv\u00eancia permitem o controle da depress\u00e3o entre os idosos, a preserva\u00e7\u00e3o da sua sa\u00fade f\u00edsica e mental, al\u00e9m de mudan\u00e7as de h\u00e1bitos e atitudes que podem diminuir o risco de incapacidade, afastar o idoso da solid\u00e3o e do isolamento social, promovendo a integra\u00e7\u00e3o, aumentando a autoestima e melhorando o relacionamento com familiares e amigos"}
+{"text": "O artigo tem por objetivo analisar recomenda\u00e7\u00f5es de sa\u00fade p\u00fablica da Organiza\u00e7\u00e3oMundial da Sa\u00fade e das manifesta\u00e7\u00f5es de seu Diretor-geral durante a epidemia devar\u00edola dos macacos endere\u00e7adas a homens que fazem sexo com homens (HSH) \u00e0 luzda microagress\u00e3o como categoria de an\u00e1lise. Questiona-se o potencialestigmatizador de divulga\u00e7\u00e3o estat\u00edstica, para p\u00fablico amplo, de que 98% dosinfectados estavam entre HSH, bem como a utiliza\u00e7\u00e3o da pr\u00f3pria categoria HSH eda sugest\u00e3o de abstin\u00eancia sexual parcial ou total como forma de interromper adissemina\u00e7\u00e3o viral. Sugere-se como alternativas capazes de, simultaneamente,garantir pol\u00edticas de preven\u00e7\u00e3o de doen\u00e7as sem estigmatizar grupos vulner\u00e1veis,especialmente a popula\u00e7\u00e3o LGBTQIA+: (i) diferenciar as divulga\u00e7\u00f5es voltadas aop\u00fablico geral das destinadas \u00e0s popula\u00e7\u00f5es predominantemente contaminadas esujeitas a maior grau de vulnerabilidade social; (ii) superar a utiliza\u00e7\u00e3o daexpress\u00e3o HSH para, nas comunica\u00e7\u00f5es destinadas \u00e0 ampla audi\u00eancia, utilizar aexpress\u00e3o SGD (popula\u00e7\u00e3o sexo e g\u00eanero diversa), mantendo-se o procedimento deregistrar, nas pesquisas cient\u00edficas e nos formul\u00e1rios de atendimento, aidentidade de g\u00eanero e a orienta\u00e7\u00e3o sexual por autodeclara\u00e7\u00e3o dos pacientes;(iii) evitar mensagens que abordem a sexualidade de modo negativo, reforcem umaviv\u00eancia sexual majorit\u00e1ria e gerem uma responsabiliza\u00e7\u00e3o socialmente punitivado infectado, excluindo, pois, das recomenda\u00e7\u00f5es voltadas ao p\u00fablico amplo asugest\u00e3o de abstin\u00eancia sexual parcial, relativa \u00e0 redu\u00e7\u00e3o do n\u00famero deparceiros, ou de abstin\u00eancia sexual total, exceto para os casos de pessoas nafase ativa da infec\u00e7\u00e3o ou no per\u00edodo imediato \u00e0 recupera\u00e7\u00e3o. Quantoao \u00faltimo grupo, que interessa a este artigo, identificaram-se alguns temas queservem como aglutinadores para a compreens\u00e3o das microagress\u00f5es relativas \u00e0orienta\u00e7\u00e3o sexual e \u00e0 identidade de g\u00eanero A microagress\u00e3o n\u00e3o \u00e9 uma experi\u00eancia menor de discrimina\u00e7\u00e3o. No decorrer dos anos,rea\u00e7\u00f5es conservadoras tentaram vincul\u00e1-la ao suposto patrulhamento social motivadopela linguagem politicamente correta, justific\u00e1-la em nome da liberdade demanifesta\u00e7\u00e3o de pensamento, desacredit\u00e1-la ao apontarem a dificuldade de mensura\u00e7\u00e3odos danos ps\u00edquicos por ela causados ou deslegitim\u00e1-la por supostamente fomentar umacultura da vitimiza\u00e7\u00e3o, cuja consequ\u00eancia seria a fragiliza\u00e7\u00e3o dos jovens diante dosdesafios da vida adulta. Por tais motivos, j\u00e1 se cogitou substituir a terminologiamicroagress\u00f5es por atos sutis de exclus\u00e3o, a fim de se tirar o foco do radical\u201cmicro\u201d como algo insignificante e deixar ainda mais claro que tal linguagemexcludente \u00e9 performativa. Afinal, em vez de se restringir ao campo das palavras,ela n\u00e3o s\u00f3 fomenta como se converte em atos concretos de subcidadaniza\u00e7\u00e3o ou, nolimite, de exclus\u00e3o de pessoas vulnerabilizadas e estigmatizadas monkeypox\u201d, especialmente em rela\u00e7\u00e3o a HSH, \u00e9 de que nessecaso as recomenda\u00e7\u00f5es em sa\u00fade p\u00fablica destinadas \u00e0 popula\u00e7\u00e3o LGBTQIA+ apresentavamelementos de natureza microagressiva. Com isso, podem ter sido criados contextosinadequados de constrangimento, com potenciais consequ\u00eancias psicossociais \u00e0 pessoacuja sa\u00fade se buscava inicialmente proteger. Os objetivos que se pretende alcan\u00e7arcom este texto s\u00e3o apontar como tais microagress\u00f5es correspondem a express\u00f5esconsolidadas nos programas de sa\u00fade p\u00fablica e propor alternativas capazes de,simultaneamente, garantir pol\u00edticas de preven\u00e7\u00e3o de doen\u00e7as sem estigmatizar gruposvulnerabilizados. Para tanto, vale-se da perspectiva das Ci\u00eancias Sociais em Sa\u00fade,a fim de desvelar processos hegem\u00f4nicos heterocisnormativos que dificultam \u00e0spopula\u00e7\u00f5es LGBTQIA+ o exerc\u00edcio do direito \u00e0 sexualidade e \u00e0 sa\u00fade sexual.A hip\u00f3tese deste ensaio, considerando a rea\u00e7\u00e3o imediata da comunidade cient\u00edfica,preocupada com a atua\u00e7\u00e3o potencialmente estigmatizadora da OMS no caso\u201c,monkeypox\u201d pormpox, resguardando um per\u00edodo de transi\u00e7\u00e3o de um ano em que ambos os significantesser\u00e3o admitidos Em 1958, a var\u00edola dos macacos foi identificada pela primeira vez: macacospertencentes ao Instituto Statens Serum, um centro de pesquisas sobre doen\u00e7asinfecciosas localizado em Copenhague (Dinamarca), foram diagnosticados com umadoen\u00e7a viral in\u00e9dita semelhante \u00e0 var\u00edola comum chemsex). O marcador \u00e9tnico-racial \u00e9 oportuno para demonstrarum dos vieses do estudo. Afinal, o dado de que 75% dos infectados eramautodeclarados brancos e s\u00f3 5% autodeclarados negros n\u00e3o pode ser separado dorecorte geogr\u00e1fico da origem dos casos analisados. Os pesquisadores foramtransparentes ao indicar a origem majoritariamente europeia dos casos, a delimita\u00e7\u00e3oestrita entre os pa\u00edses das Am\u00e9ricas  e a inexist\u00eancia de dados relativos a pa\u00edses africanos. Ainda assim, \u00e9surpreendente que as imagens das les\u00f5es cut\u00e2neas presentes no estudo apresentem demodo parit\u00e1rio homens brancos e negros. Embora isso possa ser estrat\u00e9gico para seevitar uma vincula\u00e7\u00e3o imag\u00e9tica imediata entre a patologia e o marcador\u00e9tnico-racial, tal escolha parece dissonante em rela\u00e7\u00e3o \u00e0 intencionalidade dorecorte proposto.Diante do surto crescente, em junho de 2022, um grupo de pesquisadores vinculados aoSHARE , sediado em Londres (Reino Unido), aque se juntaram pares de outros continentes com o objetivo de se ampliar omapeamento global dos casos reportados, analisaram um total de 528 casos comprovadosde infec\u00e7\u00e3o humana, distribu\u00eddos em 16 pa\u00edses. O estudo Um outro vi\u00e9s que n\u00e3o pode ser desconsiderado e que pode ter interferido no altopercentual relatado entre HSH refere-se \u00e0s cl\u00ednicas nas quais a infec\u00e7\u00e3o foiconfirmada por meio de plataformas PCR (rea\u00e7\u00e3o em cadeia da polimerase), crit\u00e9rioutilizado pelos pesquisadores para confiabilidade de diagn\u00f3sticos dos casosestudados. Mais da metade deles tiveram origem em cl\u00ednicas especializadas emtratamentos de HIV/aids (29%) e de sa\u00fade sexual (23%). Combinados com o perfil dospacientes - 41% de pessoas vivendo com HIV e 33% de usu\u00e1rios de profilaxiapr\u00e9-exposi\u00e7\u00e3o ao HIV (PrEP) -, praticamente tr\u00eas quartos dos casos reportados s\u00e3o depacientes que mant\u00eam uma pr\u00e1tica de acompanhamento m\u00e9dico-hospitalar regular,portanto, mais sujeitos a uma identifica\u00e7\u00e3o r\u00e1pida da mpox De duas, uma: se o vi\u00e9s apresentado pode ter majorado sobremaneira o percentual deocorr\u00eancia da var\u00edola dos macacos entre HSH em rela\u00e7\u00e3o ao total de casos reportados,seja em raz\u00e3o de os locais que disponibilizaram os dados realizarem acompanhamentocontinuado de v\u00e1rias pessoas com esse perfil ou devido \u00e0 subnotifica\u00e7\u00e3o entrepessoas heterossexuais n\u00e3o habituadas a procurar o sistema de sa\u00fade com a mesmaregularidade, a divulga\u00e7\u00e3o de tal estat\u00edstica pela OMS deveria ter sido evitada paran\u00e3o minorar a import\u00e2ncia da profilaxia entre a popula\u00e7\u00e3o geral. No Brasil, porexemplo, mesmo considerando os mais de 30 anos da pandemia de HIV/aids, bem como osdados oficiais recentes de que homens heterossexuais respondem por 49% dos casos,enquanto os homossexuais representam 38% deles, o diagn\u00f3stico para os primeirosainda \u00e9 recebido como algo inesperado e surpreendente. Essa surpresa decorre doimagin\u00e1rio social que relacionou determinadas infec\u00e7\u00f5es a, sucessivamente, grupos derisco, comportamentos de risco e popula\u00e7\u00f5es-chave Desse modo, como conclus\u00e3o parcial, os \u00f3rg\u00e3os internacionais e estatais respons\u00e1veispelas recomenda\u00e7\u00f5es em sa\u00fade p\u00fablica relativas a ISTs que sejam majoritariamentereportadas pelas popula\u00e7\u00f5es LGBTQIA+ deveriam se pautar por duas condutas: quanto aop\u00fablico geral, manter apenas as divulga\u00e7\u00f5es relacionadas aos sintomas, \u00e0s formas decont\u00e1gio e de profilaxia; e com rela\u00e7\u00e3o \u00e0s popula\u00e7\u00f5es predominantemente contaminadase sujeitas a maior grau de vulnerabilidade social, realizar divulga\u00e7\u00f5es espec\u00edficase focais. Tais divulga\u00e7\u00f5es diferenciadas seriam feitas diretamente nos locaisusualmente frequentados para a pr\u00e1tica de sexo casual e nos servi\u00e7os ambulatoriaisde atendimento a ISTs, virtualmente nos aplicativos de relacionamento maisutilizados, a exemplo da parceria acordada entre o Grindr e a Ag\u00eancia de Seguran\u00e7aSanit\u00e1ria do Reino Unido (UKHSA) para envio de alertas sobre a var\u00edola dos macacosaos seus usu\u00e1rios ,,,,A question\u00e1vel divulga\u00e7\u00e3o ampla do percentual elevado de contamina\u00e7\u00e3o por MPXV entrepessoas sujeitas \u00e0 estigmatiza\u00e7\u00e3o social n\u00e3o foi a \u00fanica microagress\u00e3o feita porGhebreyesus. A utiliza\u00e7\u00e3o da categoria HSH pelo Diretor-geral da OMS na j\u00e1mencionada coletiva virtual de imprensa o sexo ao nascimento  ou a atualidentidade de g\u00eanero \u201d Com o passar dos anos, por\u00e9m, dois movimentos aconteceram: um, no \u00e2mbito das Ci\u00eanciasda Sa\u00fade; outro, no campo social. Nas Ci\u00eancias da Sa\u00fade, a emerg\u00eancia do conceito devulnerabilidade, originariamente surgido no campo do direito internacional dosdireitos humanos cruising,celebra\u00e7\u00f5es do orgulho (pride events) e chemsex,que se distanciam do padr\u00e3o heteronormativo, e (iii) uma presun\u00e7\u00e3o de uniformidadeentre pessoas dissidentes de sexualidade e de g\u00eanero, generalizando condutas que, emuma subcultura pr\u00f3pria, podem dizer respeito apenas a performances determinadas eprovis\u00f3rias. A utiliza\u00e7\u00e3o de uma categoria desvinculada das identidades sociaisgera, ainda, (iv) uma dificuldade de endere\u00e7amento dos alertas preventivosveiculados pelos \u00f3rg\u00e3os de sa\u00fade, na medida em que as pessoas destinat\u00e1rias de taismensagens dificilmente com elas se identificam. Um exemplo disso \u00e9 que, nos EstadosUnidos, embora pesquisadores pretendessem que HSH servisse para incluir homens gaynegros nas pesquisas epidemiol\u00f3gicas, essa categoria n\u00e3o gera reconhecimentosuficiente entre tais destinat\u00e1rios. Homens gays negros ou se aproximam dasidentidades cl\u00e1ssicas vinculadas aos homens brancos  ou seautoidentificam por meio de categorias pr\u00f3prias, comosame-gender-loving (SGL) ou down low (DL),top-down, ao menos entre os pesquisadores que autilizam, tornando-a, pois, ou incapaz de funcionar como um mero descritor decomportamento ou impositiva em rela\u00e7\u00e3o a outras identidades surgidas nos pr\u00f3prioscoletivos vulnerabilizados partnered masturbation) ,A essa primeira cr\u00edtica endere\u00e7ada \u00e0 categoria HSH, somam-se outras: (i) o focorestrito ao comportamento pode gerar tanto uma hipersexualiza\u00e7\u00e3o sexual minority men ou SMM), j\u00e1 utilizada em algumas pesquisascient\u00edficas sexual and gender diversepopulation ou SGD), que considera a multiplicidade de pessoas comidentidades, experi\u00eancias de vida e de opress\u00e3o interseccionadas ,,A supera\u00e7\u00e3o da categoria HSH \u00e9, por vezes, associada \u00e0 proposta de terminologias maisinclusivas. Uma dessas sugest\u00f5es seria \u201chomens de minorias sexuais\u201d  em junho de 2022. DonWeiss, epidemiologista e Diretor do Escrit\u00f3rio de Doen\u00e7as Transmiss\u00edveis, ap\u00f3scriticar a chefia do departamento por n\u00e3o recomendar a abstin\u00eancia para HSH, acabouvindo a p\u00fablico esclarecer, inclusive em audi\u00eancia p\u00fablica do Comit\u00ea de Sa\u00fadevinculado ao Conselho Municipal de Nova Iorque labeling,,,Com rela\u00e7\u00e3o \u00e0 estigmatiza\u00e7\u00e3o, h\u00e1 sempre o risco de que infec\u00e7\u00f5es transmiss\u00edveisvenham acompanhadas de discursos baseados na patologiza\u00e7\u00e3o do outro, supostamenteconsiderado anormal, e no refor\u00e7o do par\u00e2metro normativo da pretensa normalidade doemissor do discurso. No caso da var\u00edola dos macacos, ela reativou tr\u00eas tipos deestigmas que, em geral, aglutinam os processos de abstinence, be faithful, correct and consistent condomuse) - permitiu que grupos conservadores e religiosos dos EstadosUnidos tratassem do tema das ISTs, sobretudo entre jovens e adolescentes, ao mesmotempo que difundiam seus valores morais. Programas que defendiam a abstin\u00eancia como\u00fanico m\u00e9todo v\u00e1lido at\u00e9 o casamento surgiram no governo de Ronald Reagan, alcan\u00e7aramseu \u00e1pice no governo de George W. Bush e s\u00f3 foram extintos no governo de BarackObama. Ali\u00e1s, o Plano de Emerg\u00eancia do Presidente dos Estados Unidos para o Al\u00edvioda Aids (The United States President\u2019s Emergency Plan for AIDSRelief ou PEPFAR), quando criado em 2003 por George W. Bush, vinculavao financiamento de projetos \u00e0 ado\u00e7\u00e3o da abordagem ABC. Essa abordagem, por vezes,era estrategicamente parcial, j\u00e1 que inclu\u00eda mensagens sobre abstin\u00eancia efidelidade para adolescentes menores de 14 anos, sem que, no entanto, fossemdistribu\u00eddos preservativos A chamada abordagem ABC - que, em ingl\u00eas, refere-se ao trip\u00e9 abstin\u00eancia, fidelidadee camisinha  diferenciar as divulga\u00e7\u00f5es endere\u00e7adas ao p\u00fablico geral, focadas nascaracter\u00edsticas epidemiol\u00f3gicas da infec\u00e7\u00e3o, das destinadas \u00e0s popula\u00e7\u00f5espredominantemente contaminadas e sujeitas a um maior grau de vulnerabilidade social,para as quais devem ser dadas informa\u00e7\u00f5es espec\u00edficas, observando a diversidade deperfil dos infectados, focando nos locais usualmente frequentados para a pr\u00e1tica desexo casual, nos aplicativos de relacionamento e nos servi\u00e7os ambulatoriais deatendimento a ISTs, aliando-se \u00e0s associa\u00e7\u00f5es e organiza\u00e7\u00f5es n\u00e3o governamentais quemantenham com tais popula\u00e7\u00f5es um contato mais amig\u00e1vel e menos disciplinar que os\u00f3rg\u00e3os estatais; (ii) superar a utiliza\u00e7\u00e3o da express\u00e3o HSH para, nas comunica\u00e7\u00f5esdestinadas \u00e0 ampla audi\u00eancia, utilizar a express\u00e3o SGD, mantendo-se o procedimentode registrar, nas pesquisas cient\u00edficas e nos formul\u00e1rios de atendimento, tanto aidentidade de g\u00eanero quanto a orienta\u00e7\u00e3o sexual por autodeclara\u00e7\u00e3o dos pacientes;(iii) evitar mensagens que abordem a sexualidade de modo negativo, reforcem umaviv\u00eancia sexual majorit\u00e1ria ou, ainda, gerem uma responsabiliza\u00e7\u00e3o socialmentepunitiva do infectado, excluindo, pois, das recomenda\u00e7\u00f5es irrestritas, voltada parao p\u00fablico amplo, a sugest\u00e3o de abstin\u00eancia sexual parcial, relativa \u00e0 redu\u00e7\u00e3o don\u00famero de parceiros, ou de abstin\u00eancia sexual total, exceto para os casos de pessoasna fase ativa da infec\u00e7\u00e3o ou no per\u00edodo imediato \u00e0 recupera\u00e7\u00e3o.o direito ao padr\u00e3o mais alto alcan\u00e7\u00e1vel de sa\u00fade f\u00edsica e mental, semdiscrimina\u00e7\u00e3o por motivo de orienta\u00e7\u00e3o sexual ou identidade de g\u00eanero\u201d,previsto no Princ\u00edpio 17 de Yogyakarta e elaborado por especialistas em direitoshumanos de diversos pa\u00edses reunidos na Indon\u00e9sia em 2006 Constitui\u00e7\u00e3o Federal brasileira de 1988 O aperfei\u00e7oamento das recomenda\u00e7\u00f5es p\u00fablicas de sa\u00fade, desse modo, n\u00e3o s\u00f3 respeitaria\u201c"}
+{"text": "To investigate evidence of construct validity for a Phonological Assessment Instrument for Brazilian Portuguese, based on the diagnostic data generated by its application from contrastive analysis and speech severity.The sample consisted of 176 children, aged between five to nine years old. They were evaluated with the Phonological Assessment Instrument and then classified as having Speech Sound Disorder or in typical phonological development, comparing these results to the criteria described for the disorder in the DSM-5. The search for evidence of construct validity relied on the agreement between the two assessment methods while applying the Kappa Coefficient. To differentiate between groups, Student's t-test was used for independent samples. We sought to investigate the instrument indexes using the Receiver Operating Characteristic Curve statistics to obtain values for area, cut-off point, sensitivity, specificity, accuracy, and positive and negative predictive value.The instrument showed agreement and significant differentiation between the classifications. As for the performance parameters, it shows a cut-off point for diagnosis with results equal to or greater than 96.17%, an excellent area under the curve, as well as satisfactory percentages for the other analyses investigated.The data indicated evidence for the construct validity of the Phonological Assessment Instrument, presenting a useful and valid contribution to the arsenal of clinical assessment and research involving the diagnosis of Speech Sound Disorder and, with its accuracy result, contributed to the properties of performance of instruments used in Speech, Language and Hearing Sciences. This disorder does not have a defined etiology, however, it affects the phonological level of language organization, presenting performance difficulties concerning phonemes and/or syllabic structures of the language being acquired. The criteria for clinical diagnosis referred to in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) include (a) persistent difficulty in speech production; (b) age greater than four years; (c) auditory thresholds within normal limits; (d) absence of neurological alterations or evident organic causes; (e) normal intellectual abilities; (f) speech understanding ability; and, (g) expressive language without alterations regarding lexicon and syntax.Phonological Disorder (PD). In this sense, through the observation of the variability of production, it becomes possible to analyze the phonemes that have already been acquired, those that have not been, and those that are in the acquisition process.The set of signs listed enables the clinical diagnosis of PD, highlighting the speech assessment, which allows the detailing of the linguistic organization and the understanding of the child's phonetic and phonological acquisition by the speech therapist. Thus, it is necessary that the instruments for such assessments go through psychometric studies carried out with speakers of the mother tongue to measure their skills and parameters.In speech evaluation, the analysis of the phonological system is recommended by verifying the production of sounds and comparing them with the expected patterns of the target language,5. There are instruments established in clinical use  that are widely used by professionals in the area. They help in the diagnostic and speech therapy process, in addition to providing parameters for several studies. However, despite such prestigious instruments and the development of new tests-10, there are still gaps in the development of a tool as a scientifically proven gold standard in the field of oral language in Brazilian Portuguese (BP). As a result, accurate diagnostic identification is hampered, hindering the evolution of both clinical activity and scientific knowledge on the subject.Currently, the literature on assessment measures has been advancing within Brazilian speech therapy,11,12. Reliability is a test\u2019s ability to consistently reproduce its result, indicating aspects of coherence, stability, and accuracy. Validity concerns the aspect of the measure being coherent with the competence that is intended to be evaluated, that is, measuring what it is proposed to measure,13. In this sense, it is possible to make an analogy that reliability responds to the percentage of correct answers- if something is correct and what is its intensity, while validity responds to the reality of the measurement- if something is true and how it was based.Studies on psychometrics are unanimous in considering reliability and validity as the main parameters for instrument legitimacy.In order to determine validity, we can separate it into two of its concepts: content validity and construct validity. The first evaluates the degree to which the content of an instrument adequately reflects its objective, that is, how much the sample of items represents the domain of the content. For such validation, the material must be analyzed by expert judges in the area. The second, the focus of this study, verifies whether the test set represents the elaborated theoretical construct, analyzing through the instrument itself whether the observed behaviors measure the desired latent trait. Thus, the present study aimed to investigate evidence of construct validity for a Phonological Assessment Instrument for BP, based on diagnostic data generated by its application based on contrastive analysis and the degree of speech severity.Considering these parameters, to understand the construct it is necessary to understand the process that is constituted as the cause of its behavior. The construct of a test is assumed to be true since it allows measuring the action that manifests a latent trait of the mental processThe research corresponds to an observational, cross-sectional, controlled, descriptive, and quantitative study, whose data were used for the construct validity of the Phonological Assessment Instrument (IAF). This study was approved by the Research Ethics Committee of a federal university under number 5.045.533.. To determine a Kappa coefficient of 0.80, indicating substantial agreement, and for a significance of 5% and power of 80%, the result was a minimum of 165 children for the representative sample.The sample size was calculated considering 25% of PD, according to the estimated prevalence of the diagnosis for the child populationcorpus of this study consists of data from 176 children, between five and nine years old, from a public school in the city of Porto Alegre, selected from a data bank with 219 evaluations. Data from children who had auditory, lexical, and syntactic alterations in relation to expressive language, evident neurological and/or organic, intellectual and/or cognitive alterations, language comprehension and school difficulties, history of neuropsychomotor delay, and/or intercurrences in pregnancy or childbirth. Those with characteristics of typical phonological development and those diagnosed with PD were included. Such categorization was obtained from the results of language assessments carried out with the entire corpus, as well as reports in interviews with those responsible. All parents or guardians signed a Free and Informed Consent Term and Authorization for Audio Use; and, in the case of children over 7 years old, they also signed a Term of Assent.The  is a software designed to evaluate the child's speech sound system efficiently, thoroughly, and optimally. The instrument was elaborated with 123 words, belonging to children's vocabulary, extracted from popular children's stories, easily represented in an image or photo, and of the noun type, with an image corresponding to each lexical item. The items were carefully selected so that the words included all consonant phonemes in all syllabic positions in BP, with five occurrences of each phoneme and syllabic position, totaling 235 phonemic possibilities. The collection of the child's speech should occur from the naming of each of the images, by observing the illustrations or photographs, which takes approximately 10 minutes for the application. The evaluator must record the audio of the speech collection, and later, listen and observe the children's elicitations and register the information to the software. This process takes between 10 and 30 minutes, depending on the evaluator's practice and skill. After inserting data referring to the production of each target phoneme in the instrument, the results are automatically generated. They are expressed in descriptive and quantitative reports by the degree of speech severity , contrastive analysis, phonological processes, and change in distinctive features.The IAF with the search for quantitative evidence of agreement. However, studies on the subject point to the absence of an oral language assessment instrument considered the gold standard in BP, hindering the possibility of comparative calculations,11. From this, the choice was made to use the reference described in the criteria for Speech Disorder in the DSM-5, circumventing this impediment with the justification of being the manual that not only helps in the diagnosis of PD, but how it was prepared to be the standard resource in the definition of disorders that affect the mind and emotions,16.The assessment of how the measured variables represent the instrument's construct requires a qualitative theoretical analysis. Applied to this study, the convergent analysis aims to ascertain whether the instrument has a high degree of agreement compared to another with the same outcome, that is, whether the diagnosis obtained with the IAF agrees with the reference described in the criteria for Speech Disorder of the DSM-5. As for the discriminant ratio, which evaluates the ability to distinguish compared to different target populations; in this case, if the group with typical phonological development obtained by the IAF is the same as those who do not fulfill the criteria determined by the DSM-5-11.An evaluation includes the use of convergent and discriminant relationshipsSpeech collections (n = 179) in audio format were analyzed using the IAF software by three evaluators - undergraduate students in speech therapy and trained in phonetic analysis. These were blinded in relation to the sample. In case of disagreement, a consensus was sought among the evaluators and, finally, a fourth evaluation was performed by a specialized speech therapist., and; the degree of speech severity, according to the calculation of Percentage of Correct Consonants - Revised (PCC-R), which considers the percentage of correct productions without considering articulatory distortions as errors. In the analysis using the DSM-5 framework, the diagnostic criteria for Speech Disorder were fulfilled based on information from the language assessments already considered in the sample selection for this research study. Finally, each of the instruments resulted in a diagnosis, associating 0= 'Typical Phonological Development', 1= 'Phonological Disorder'.The final result of the diagnosis of PD for each of the children was organized in spreadsheets. For the IAF analysis, the following were considered: contrastive analysis, with acquisition definition value>75%The results were presented through frequencies and percentages. For the statistical analysis, the SPSS software version 28 for Windows was used. was applied to measure the agreement between the two assessment methods (IAF and DSM-5) for the diagnosis of PD since it corrects the value for the frequency with which they may agree by chance. An investigation was also carried out using Student's t-test for independent samples, to verify whether the IAF results differed between the classifications according to the DSM-5.Cohen's Kappa Coefficient,13,20, using the area under the curve (AUC) indicators, and the cut-off point, according to the index of Youden, with values obtained through the graduation of scores from the degree of severity (PCC-R). For general comparisons of test performance, sensitivity, specificity, and accuracy values of the instrument were highlighted. To substantiate its clinical applicability, the calculation of the positive predictive value (PPV) was used as an analysis for convergent validity, as well as the negative predictive value (NPV) used for divergent validity. Estimates of Cohen's Kappa coefficient, sensitivity, specificity, and AUC are presented with a 95% confidence interval (95% CI).To describe its classification performance, the most recommended analytical method is the Receiver Operating Characteristic Curve (ROC).The search for evidence for the construct validity of this study consisted of two analyses: agreement and difference between the results and assessment of the instrument's indexes. The general degree of agreement in the diagnosis classification between the two methods resulted in a coefficient of 0.759 . This value is described as a moderate level (0.6\u2264 Kappa \u22650.79), interpreted as adequate for confidence in the results criteria, performed with Student's t-test for independent samples. The results reveal that the average of the group with typical phonological development was higher than the group with a diagnosis of PD. This shows that the IAF scores differentiate children with alterations in the phonological system from those who do not. It is noteworthy that the high variability in the standard deviation value found for the diagnosis of PD may represent the difference in the children's phonological system profiles. There may be many phonemes not yet acquired (severe degree of PD) or few phonemes not yet acquired(medium-grade PD).As for the evidence for the evaluation of the IAF performance parameters, the ROC Curve analysis was used . The cut.Regarding the size of the effect of the ROC Curve, shown in  (gold standard reference), in the center the categorizations are indicated in a crossed manner, allowing the visualization of the diagnoses for PD and for typical phonological development determined by the standard, including their proportion by the IAF.Based on the aforementioned cutoff value, the results are shown in The data presented in The VPP and NPV analyses describe the proportion of correct IAF conclusions within each classification in an unknown population. Such results are evidence for convergent and discriminant validity, respectively. The convergent predicts the proportion of true PD diagnoses determined by the IAF, while the discriminant verifies the proportion of true cases of typical phonological development. Thus, the IAF presents predictive values that confirm sensitivity and specificity .Regarding accuracy, which is the probability that the test provides correct conclusions regardless of the diagnostic category, the IAF has a significant index, as seen in . Thus, the theoretical and technical foundations assume the construct of the instrument as true and adequate, since the ability to measure the latent trait of phonological acquisition and systematization is explored from the speech behavior,14. This study presents evidence for the construct validity of the IAF, which confirms adequate indicators for its use as an instrument in the phonological assessment of children.The development of speech sounds represents the phonological domain in the mental process of language acquisition. It is necessary to evaluate the precision in the production of these sounds for an investigation of the organization of phonemes defines criteria and allows an analysis that refers only to the observation of the flow of speech and the indication of whether or not there are alterations in the sounds and/or syllables spoken. On the other hand, the instrumental measure with the collection of isolated words complements this process,22. It details the phonological profile in a more agile, systematic, detailed, and precise way, guaranteeing significant clinical data for the treatment and evolution. In the presentation of the results in Construct validity, in addition to the theoretical basis, also requires empirical confirmation. The exclusive use of the DSM-5) and it was concluded that, even as complementary tools, when applied separately, they still present a good correlation. The level at which the IAF is related to the results of the DSM-5 is within the standards established as acceptable, both for health care and for clinical research. This means that the test set represents consistency in its application, confirming that one of the objectives was satisfactorily achieved.In this sense, it is important to assess the classification agreement between the two methods , evaluated the sensitivity and specificity parameters of the Terdaf instrument.The sensitivity and specificity indexes, observed in ,24 and with other languages,26. Furthermore, these studies conclude that there is no significant difference when the age variable applied to picture naming tests is evaluated. For this reason, the IAF data were not designed to separate participants based on such criteria.The discriminant validity was defined with the negative predictive value and stands out, pointing out that the instrument well identifies the population that does not have the diagnosis, that is, with typical phonological development. This finding is homogeneous in descriptions of the test properties, both in studies carried out with BP speakers,13. The relevance of the findings of the present research study is emphasized since the measure is significant for the IAF and adds the performance properties of the instruments used in the area. This, therefore, demonstrates that the instrument is a useful and valid contribution to the arsenal of clinical and research evaluation involving the diagnosis of PD.Regarding the accuracy analysis, recent reviews on the subject indicate that no phonological assessment test investigates such data and that they are necessary to verify the overall quality of the instrument's measurement. Therefore, it is recommended that studies addressing the consequences of the test apply it to samples with regional variability, types of schools, and age groups. Furthermore, the IAF provides support for future studies to explore comparisons between it and other phonological assessment tests.Finally, it is highlighted that the instrument is structured for BP speakers in general; however, the data used are exclusively with the phonological profile of children from a single public school in the city of Porto Alegre/RS. Just as it should be noted that the IAF software was developed to assess any age group. However, this validation is constituted by a sample of children aged from five years old, which respects the period of stabilization of the phonological acquisition and the criteria for the diagnosis of PD described in the DSM-5The set of data found indicates good evidence for the construct validity of the Phonological Assessment Instrument - IAF. In addition, it demonstrates being able to achieve objective, systematic, and relevant results both in the evaluation and in the analysis. This study fulfills a stage of instrument construct validation. It should be noted that all other steps for the psychometric process of the IAF are being carried out and disseminated in parallel, including the establishment of standards of reliability with safety.  \u00e9 uma desordem lingu\u00edstica que se manifesta por um desvio na capacidade fonol\u00f3gica de determinada crian\u00e7a em compara\u00e7\u00e3o ao esperado para aquela faixa et\u00e1ria. Esse transtorno n\u00e3o possui etiologia definida, contudo, afeta o n\u00edvel fonol\u00f3gico da organiza\u00e7\u00e3o da linguagem, apresentando dificuldade de desempenho com rela\u00e7\u00e3o aos fonemas e/ou estruturas sil\u00e1bicas da l\u00edngua em aquisi\u00e7\u00e3o. Os crit\u00e9rios para o diagn\u00f3stico cl\u00ednico referidos no Manual Diagn\u00f3stico e Estat\u00edstico de Transtornos Mentais (DSM-5) englobam: (a) dificuldade persistente para produ\u00e7\u00e3o de fala; (b) idade superior a quatro anos; (c) limiares auditivos dentro dos padr\u00f5es de normalidade; (d) aus\u00eancia de altera\u00e7\u00f5es neurol\u00f3gicas ou causas org\u00e2nicas evidentes; (e) habilidades intelectuais normais; (f) capacidade de compreens\u00e3o da fala; e, (g) linguagem expressiva sem altera\u00e7\u00f5es com rela\u00e7\u00e3o ao l\u00e9xico e \u00e0 sintaxe.O Transtorno Fonol\u00f3gico (TF). Nesse sentido, atrav\u00e9s da observa\u00e7\u00e3o da variabilidade de produ\u00e7\u00e3o, torna-se poss\u00edvel analisar os fonemas que j\u00e1 foram adquiridos, os que n\u00e3o foram, e, os que est\u00e3o em processo de aquisi\u00e7\u00e3o.O conjunto de sinais listados viabiliza o diagn\u00f3stico cl\u00ednico de TF, destacando a avalia\u00e7\u00e3o de fala, que permite o detalhamento da organiza\u00e7\u00e3o lingu\u00edstica e a compreens\u00e3o da aquisi\u00e7\u00e3o fon\u00e9tica e fonol\u00f3gica da crian\u00e7a pelo fonoaudi\u00f3logo. Dessa forma, faz-se necess\u00e1rio que os instrumentos para tais avalia\u00e7\u00f5es passem por estudos psicom\u00e9tricos realizados com falantes da l\u00edngua materna para mensurar suas compet\u00eancias e par\u00e2metros.Na avalia\u00e7\u00e3o da fala preconiza-se a an\u00e1lise do sistema fonol\u00f3gico por meio da verifica\u00e7\u00e3o da produ\u00e7\u00e3o dos sons e da compara\u00e7\u00e3o com os padr\u00f5es esperados da l\u00edngua alvo,5. Existem instrumentos consagrados no uso cl\u00ednico  muito utilizados pelos profissionais da \u00e1rea que auxiliam no processo diagn\u00f3stico e fonoterap\u00eautico, al\u00e9m de fornecerem par\u00e2metros para diversos estudos. No entanto, apesar de tais instrumentos prestigiados e embora exista o desenvolvimentos de novos testes-10, ainda h\u00e1 lacunas na elabora\u00e7\u00e3o de uma ferramenta como padr\u00e3o-ouro cientificamente comprovada na \u00e1rea da linguagem oral em Portugu\u00eas Brasileiro (PB). Por causa disso, tem-se preju\u00edzos na identifica\u00e7\u00e3o diagn\u00f3stica precisa, dificultando a evolu\u00e7\u00e3o tanto da atividade cl\u00ednica, quanto do conhecimento cient\u00edfico sobre o tema.Atualmente, a literatura sobre medidas de avalia\u00e7\u00e3o vem avan\u00e7ando dentro da fonoaudiologia brasileira,11,12. A fidedignidade \u00e9 a capacidade de um teste em reproduzir seu resultado de forma consistente, indicando aspectos sobre a coer\u00eancia, estabilidade e precis\u00e3o. A validade diz respeito ao aspecto da medida ser coerente com a compet\u00eancia que se almeja avaliar, ou seja, medir o que se prop\u00f5e a medir,13. Nesse sentido, \u00e9 poss\u00edvel fazer uma analogia de que a fidedignidade responde ao percentual de acertos, se algo est\u00e1 correto e qual sua intensidade, enquanto a validade responde \u00e0 realidade da medida, se algo \u00e9 verdadeiro e como foi fundamentado.Os estudos sobre psicometria s\u00e3o un\u00e2nimes em considerar a fidedignidade e a validade como principais par\u00e2metros para a legitimidade de instrumentos.A fim de determinar a validade, podemos separ\u00e1-la em dois de seus conceitos: validade de conte\u00fado e de construto. A primeira avalia o grau em que o conte\u00fado de um instrumento reflete adequadamente o objetivo dele, isto \u00e9, o quanto a amostra de itens de fato representa o dom\u00ednio do conte\u00fado; para tal valida\u00e7\u00e3o \u00e9 necess\u00e1rio que o material seja analisado por ju\u00edzes especialistas na \u00e1rea. J\u00e1 a segunda, foco deste estudo, verifica se o conjunto do teste representa o construto te\u00f3rico elaborado, analisando pelo pr\u00f3prio instrumento se os comportamentos observados medem o tra\u00e7o latente almejado. Assim, o presente estudo teve como objetivo investigar evid\u00eancias de validade de construto para um Instrumento de Avalia\u00e7\u00e3o Fonol\u00f3gica para o PB, baseadas nos dados de diagn\u00f3stico gerados por sua pr\u00f3pria aplica\u00e7\u00e3o a partir da an\u00e1lise contrastiva e do grau de severidade de fala.Considerando esses par\u00e2metros, para compreender o construto se faz necess\u00e1rio entender o processo que \u00e9 constitu\u00eddo como a causa do seu comportamento. O construto de um teste se assume verdadeiro uma vez que permite mensurar a a\u00e7\u00e3o que manifesta um tra\u00e7o latente do processo mentalA pesquisa corresponde a um estudo observacional, transversal controlado, descritivo e quantitativo, cujos dados foram utilizados para a validade de construto do Instrumento de Avalia\u00e7\u00e3o Fonol\u00f3gica (IAF). Este trabalho foi aprovado pelo Comit\u00ea de \u00c9tica em Pesquisa (CEP) da Universidade Federal de Ci\u00eancias da Sa\u00fade de Porto Alegre (UFCSPA) sob parecer n\u00famero 5.045.533.. Para determinar um coeficiente Kappa de 0,80, indicando boa concord\u00e2ncia e para signific\u00e2ncia de 5% e poder de 80%, o resultado foi de minimamente 165 crian\u00e7as para a amostra representativa.O tamanho amostral foi calculado considerando 25% de TF, conforme estimativa de preval\u00eancia do diagn\u00f3stico para a popula\u00e7\u00e3o infantilcorpus deste estudo \u00e9 constitu\u00eddo por dados de 176 crian\u00e7as, entre cinco anos at\u00e9 nove anos de idade, de uma escola p\u00fablica da cidade de Porto Alegre, selecionadas de um banco com 219 avalia\u00e7\u00f5es. Foram exclu\u00eddos os dados de crian\u00e7as que possu\u00edam altera\u00e7\u00f5es auditivas, lexicais e sint\u00e1ticas com rela\u00e7\u00e3o \u00e0 linguagem expressiva, neurol\u00f3gicas e/ou org\u00e2nicas evidentes, intelectuais e/ou cognitivas, dificuldades compreensivas de linguagem, escolares, hist\u00f3rico de atraso neuropsicomotor e/ou de intercorr\u00eancias em gravidez ou parto. Foram inclu\u00eddos aqueles com caracter\u00edsticas de desenvolvimento fonol\u00f3gico t\u00edpico e os com diagn\u00f3stico de TF. Tal categoriza\u00e7\u00e3o foi obtida a partir dos resultados das avalia\u00e7\u00f5es de linguagem realizadas com todo o corpus, assim como dos relatos em entrevista de com os respons\u00e1veis. Todos os pais ou os respons\u00e1veis assinaram Termo de Consentimento Livre e Esclarecido (TCLE) e Autoriza\u00e7\u00e3o para Uso de \u00c1udio; e, no caso de crian\u00e7as acima de 7 anos, essas tamb\u00e9m assinaram Termo de Assentimento.O  \u00e9 um software delineado para avaliar o sistema de sons da fala infantil de forma eficiente, minuciosa e otimizada. O instrumento foi elaborado com 123 palavras, pertencem ao vocabul\u00e1rio infantil, extra\u00eddas de hist\u00f3rias infantis populares, facilmente representadas em imagem ou foto e s\u00e3o do tipo substantivo, com uma imagem correspondente a cada item lexical. Os itens foram criteriosamente selecionados de forma que as palavras contemplassem todos os fonemas consonantais em todas as posi\u00e7\u00f5es sil\u00e1bicas do PB, com cinco ocorr\u00eancias de cada fonema e posi\u00e7\u00e3o sil\u00e1bica, totalizando 235 possibilidades fon\u00eamicas. A coleta da fala da crian\u00e7a deve ocorrer a partir da nomea\u00e7\u00e3o de cada uma das imagens, pela observa\u00e7\u00e3o das ilustra\u00e7\u00f5es ou fotografias, que leva aproximadamente 10 minutos para a aplica\u00e7\u00e3o. O avaliador deve gravar o \u00e1udio da coleta de fala, e posteriormente, ouvir e observar as elicita\u00e7\u00f5es das crian\u00e7as e registrar as informa\u00e7\u00f5es no software. Tal processo leva em torno de 10 a 30 minutos, dependendo da pr\u00e1tica e habilidade do avaliador. Ap\u00f3s a inser\u00e7\u00e3o dos dados referentes \u00e0 produ\u00e7\u00e3o de cada fonema alvo no instrumento, os resultados s\u00e3o gerados automaticamente e expressos em relat\u00f3rios descritivos e quantitativos por: grau de severidade de fala , an\u00e1lise contrastiva, processos fonol\u00f3gicos e mudan\u00e7a de tra\u00e7os distintivos.O IAF com a busca por evid\u00eancias quantitativas de concord\u00e2ncia. No entanto, os estudos sobre o assunto apontam para a aus\u00eancia de um instrumento de avalia\u00e7\u00e3o de linguagem oral considerado como padr\u00e3o-ouro em PB, dificultando a possibilidade de c\u00e1lculos comparativos,11. A partir disso, a escolha foi pelo uso do referencial descrito nos crit\u00e9rios para Transtorno de Fala do DSM-5, contornando esse impeditivo com a justificativa de ser o manual que n\u00e3o s\u00f3 auxilia no diagn\u00f3stico de TF, mas como foi elaborado para ser o recurso padr\u00e3o na defini\u00e7\u00e3o de transtornos que afetem a mente e as emo\u00e7\u00f5es,16.A avalia\u00e7\u00e3o de como as vari\u00e1veis medidas representam o construto do instrumento exige uma an\u00e1lise te\u00f3rica qualitativa. Aplicada a este estudo, a an\u00e1lise convergente visa averiguar se o instrumento possui uma elevada concord\u00e2ncia comparado com outro de mesmo desfecho, isto \u00e9, se o diagn\u00f3stico obtido com o IAF concorda com o referencial descrito nos crit\u00e9rios para Transtorno de Fala do DSM-5. J\u00e1 a rela\u00e7\u00e3o discriminante que avalia a capacidade de distin\u00e7\u00e3o comparada a diferentes popula\u00e7\u00f5es-alvo; neste caso, se o grupo com desenvolvimento fonol\u00f3gico t\u00edpico obtido pelo IAF \u00e9 o mesmo dos que n\u00e3o preenchem os crit\u00e9rios determinados pelo DSM-5-11.Assim como tal avalia\u00e7\u00e3o inclui o uso das rela\u00e7\u00f5es convergente e discriminantesoftware do IAF por tr\u00eas avaliadoras - graduandas em fonoaudiologia e treinadas para an\u00e1lise fon\u00e9tica. Essas foram cegadas em rela\u00e7\u00e3o \u00e0 amostra. Em caso de discord\u00e2ncia, buscou-se o consenso entre as avaliadoras e, por fim, uma quarta avalia\u00e7\u00e3o foi realizada por uma fonoaudi\u00f3loga especializada.As coletas de fala (n = 179) em formato de \u00e1udio foram analisadas com a utiliza\u00e7\u00e3o do , e; o grau de severidade de fala, conforme o c\u00e1lculo de Percentual de Consoantes Corretas - Revisado (PCC-R), que considera a porcentagem de produ\u00e7\u00f5es corretas sem contabilizar distor\u00e7\u00f5es articulat\u00f3rias como erro. J\u00e1 na an\u00e1lise pelo referencial DSM-5, os crit\u00e9rios do diagn\u00f3stico para Transtorno de Fala foram preenchidos a partir das informa\u00e7\u00f5es das avalia\u00e7\u00f5es de linguagem j\u00e1 consideradas na sele\u00e7\u00e3o da amostra desta pesquisa. Por fim, cada um dos instrumentos resultou em um diagn\u00f3stico, relacionando 0= \u2018Desenvolvimento Fonol\u00f3gico T\u00edpico\u2019, 1= \u2018Transtorno Fonol\u00f3gico\u2019.O resultado final do diagn\u00f3stico de TF de cada uma das crian\u00e7as foi organizado em planilhas. Para a an\u00e1lise do IAF foram consideradas: a an\u00e1lise contrastiva, com valor de defini\u00e7\u00e3o de aquisi\u00e7\u00e3o>75%software SPSS vers\u00e3o 28 para Windows.Os resultados foram apresentados atrav\u00e9s de frequ\u00eancias e percentuais. Para a an\u00e1lise estat\u00edstica foi utilizado o  para mensurar a concord\u00e2ncia entre os dois m\u00e9todos de avalia\u00e7\u00e3o (IAF e DSM-5) de diagn\u00f3stico de TF, uma vez que corrige o valor pela frequ\u00eancia com que podem concordar pelo acaso. Realizou-se, tamb\u00e9m, uma investiga\u00e7\u00e3o atrav\u00e9s do teste t de Student para amostras independentes, com o intuito de verificar se os resultados do IAF diferenciavam entre as classifica\u00e7\u00f5es de acordo com o DSM-5.Foi aplicado o Coeficiente Kappa de Cohen,13,20, usando os indicadores de \u00e1rea sob a curva (AUC), e ponto de corte, segundo o \u00edndice de Youden, com valores obtidos atrav\u00e9s da gradua\u00e7\u00e3o de escores do grau de severidade (PCC-R). Para compara\u00e7\u00f5es gerais do desempenho do teste, foram destacados os valores de sensibilidade, especificidade e acur\u00e1cia do instrumento. Para fundamenta\u00e7\u00e3o da sua aplicabilidade cl\u00ednica, o c\u00e1lculo de valor preditivo positivo (VPP) foi utilizado como an\u00e1lise para validade convergente, tal como o de valor preditivo negativo (VPN) usado para validade divergente. As estimativas do coeficiente Kappa de Cohen, sensibilidade, especificidade e a AUC foram apresentadas com intervalo de confian\u00e7a de 95% (IC95%).Para descrever seu desempenho classificat\u00f3rio, o m\u00e9todo anal\u00edtico mais recomendado \u00e9 a Curva de Receiver Operating Characteristic (ROC).A busca por evid\u00eancias para validade de construto deste trabalho foi constitu\u00edda por duas an\u00e1lises: concord\u00e2ncia e diferen\u00e7a entre os resultados e avalia\u00e7\u00e3o dos \u00edndices do instrumento. O grau geral de concord\u00e2ncia na classifica\u00e7\u00e3o do diagn\u00f3stico entre os dois m\u00e9todos obteve como resultado o coeficiente de 0,759 . Esse valor \u00e9 descrito como n\u00edvel moderado , interpretado como adequado para confian\u00e7a nos resultados, realizados com o teste t de Student para amostras independentes. Os resultados revelam que a m\u00e9dia do grupo com desenvolvimento fonol\u00f3gico t\u00edpico foi superior ao grupo com diagn\u00f3stico de TF. Isso evidencia que os escores do IAF diferenciam crian\u00e7as com altera\u00e7\u00f5es no sistema fonol\u00f3gico daquelas que n\u00e3o as apresentam. Vale ressaltar que a alta variabilidade no valor de desvio-padr\u00e3o encontrada para o diagn\u00f3stico de TF pode representar a diferen\u00e7a nos perfis de sistema fonol\u00f3gicos das crian\u00e7as, nos quais pode haver muitos fonemas ainda n\u00e3o adquiridos (TF de grau severo) ou poucos fonemas ainda n\u00e3o adquiridos (TF de grau m\u00e9dio).A Quanto \u00e0s evid\u00eancias para a avalia\u00e7\u00e3o dos par\u00e2metros de desempenho do IAF, utilizou-se a an\u00e1lise pela Curva ROC . O ponto.Em rela\u00e7\u00e3o \u00e0 dimens\u00e3o do efeito da Curva ROC, exibida na  , no centro s\u00e3o apontadas as categoriza\u00e7\u00f5es de forma cruzada, permitindo a visualiza\u00e7\u00e3o dos diagn\u00f3sticos para TF e para desenvolvimento fonol\u00f3gico t\u00edpico determinados pelo padr\u00e3o, incluindo a propor\u00e7\u00e3o dos mesmos pelo IAF.A partir do valor de ponto de corte supracitado s\u00e3o exibidos os resultados no Os dados apresentados no As an\u00e1lises de VPP e VPN descrevem a propor\u00e7\u00e3o de conclus\u00f5es corretas do IAF dentro de cada classifica\u00e7\u00e3o em uma popula\u00e7\u00e3o desconhecida. Tais resultados s\u00e3o evid\u00eancias para as validades convergente e discriminante, respectivamente. A convergente prev\u00ea a propor\u00e7\u00e3o de verdadeiros diagn\u00f3sticos de TF determinados pelo IAF, enquanto a discriminante verifica a propor\u00e7\u00e3o de verdadeiros quadros de desenvolvimento fonol\u00f3gico t\u00edpico. Dessa forma, o IAF apresenta valores preditivos que confirmam sensibilidade e especificidade .Em rela\u00e7\u00e3o \u00e0 acur\u00e1cia, que \u00e9 a probabilidade de o teste fornecer conclus\u00f5es corretas seja qual for a categoria diagn\u00f3stica, o IAF apresenta um \u00edndice significativo, como visto na . Assim, as fundamenta\u00e7\u00f5es te\u00f3ricas e t\u00e9cnicas assumem o construto do instrumento como verdadeiro e adequado, uma vez que a partir do comportamento da fala explora-se a capacidade de mensurar o tra\u00e7o latente da aquisi\u00e7\u00e3o e sistematiza\u00e7\u00e3o fonol\u00f3gica,14. Esta pesquisa apresenta as evid\u00eancias para a validade de construto do IAF, que confirma indicadores adequados para a sua utiliza\u00e7\u00e3o como instrumento na avalia\u00e7\u00e3o fonol\u00f3gica em crian\u00e7as.O desenvolvimento dos sons da fala representa o dom\u00ednio fonol\u00f3gico no processo mental de aquisi\u00e7\u00e3o de linguagem. Faz-se necess\u00e1rio avaliar a precis\u00e3o na produ\u00e7\u00e3o desses sons para uma investiga\u00e7\u00e3o da organiza\u00e7\u00e3o dos fonemas define crit\u00e9rios e permite uma an\u00e1lise do que se refere apenas \u00e0 observa\u00e7\u00e3o do fluxo de fala e a indica\u00e7\u00e3o se h\u00e1 ou n\u00e3o altera\u00e7\u00f5es nos sons e/ou s\u00edlabas faladas. Por outro lado, a medida instrumental com a coleta de palavras isoladas complementa esse processo,22, pois detalha o perfil fonol\u00f3gico de forma mais \u00e1gil, sistem\u00e1tica, minuciosa e precisa, garantindo dados cl\u00ednicos significativos para o tratamento e o guia da evolu\u00e7\u00e3o. Na apresenta\u00e7\u00e3o dos resultados do A validade de construto, al\u00e9m do embasamento te\u00f3rico, tamb\u00e9m requer confirma\u00e7\u00f5es emp\u00edricas. O uso exclusivo do DSM-5) e concluiu-se que, mesmo como ferramentas complementares, quando aplicadas separadamente, ainda assim apresentam boa correla\u00e7\u00e3o. O n\u00edvel em que o IAF relaciona-se com os resultados do DSM-5 se encontra dentro dos padr\u00f5es estabelecidos como aceit\u00e1veis, tanto para a assist\u00eancia \u00e0 sa\u00fade, como para a pesquisa cl\u00ednica. Isso significa que o conjunto do teste representa consist\u00eancia em sua aplica\u00e7\u00e3o, confirmando que um dos objetivos foi alcan\u00e7ado de modo satisfat\u00f3rio.Nesse sentido, \u00e9 importante avaliar a concord\u00e2ncia da classifica\u00e7\u00e3o entre os dois m\u00e9todos , avaliou os par\u00e2metros de sensibilidade e especificidade do instrumento Terdaf.Os \u00edndices de sensibilidade e especificidade, observados na ,24 quanto com outras l\u00ednguas,26. Ademais, esses estudos concluem que n\u00e3o h\u00e1 diferen\u00e7a significativa quando \u00e9 avaliada a vari\u00e1vel de idade aplicada \u00e0s provas de nomea\u00e7\u00e3o de figuras; por esse motivo, os dados do IAF n\u00e3o foram delineados para separa\u00e7\u00e3o dos participantes a partir de tais crit\u00e9rios.A validade discriminante foi definida com o valor preditivo negativo e se destaca, apontando que o instrumento identifica bem a popula\u00e7\u00e3o que n\u00e3o possui o diagn\u00f3stico, ou seja, com desenvolvimento fonol\u00f3gico t\u00edpico. Esse achado \u00e9 homog\u00eaneo em descri\u00e7\u00f5es das propriedades dos testes, tanto em estudos realizados em falantes de PB,13. Ressalta-se a relev\u00e2ncia dos achados da presente pesquisa, uma vez que a medida \u00e9 evidentemente significativa para o IAF e acrescenta as propriedades de desempenho dos instrumentos utilizados na \u00e1rea. Isso, portanto, demonstra que o instrumento \u00e9 uma contribui\u00e7\u00e3o \u00fatil e v\u00e1lida ao arsenal de avalia\u00e7\u00e3o cl\u00ednica e de pesquisa envolvendo diagn\u00f3stico de TF.Em rela\u00e7\u00e3o \u00e0 an\u00e1lise sobre acur\u00e1cia, as revis\u00f5es recentes na tem\u00e1tica indicam que nenhum teste de avalia\u00e7\u00e3o fonol\u00f3gica investiga tais dados e que eles s\u00e3o necess\u00e1rios para verificar a qualidade geral da medida do instrumentosoftware do IAF foi desenvolvido para avaliar qualquer faixa et\u00e1ria; contudo esta valida\u00e7\u00e3o \u00e9 constitu\u00edda por uma amostra de crian\u00e7as com idade a partir de cinco anos, o que respeita o per\u00edodo de estabiliza\u00e7\u00e3o da aquisi\u00e7\u00e3o fonol\u00f3gica e os crit\u00e9rios para o diagn\u00f3stico de TF descritos no DSM-5. Recomenda-se, ent\u00e3o, que pesquisas abordando as consequ\u00eancias do teste o apliquem em amostras com variabilidade regional, tipos de escola e faixa et\u00e1ria. Ademais, o IAF apresenta sustenta\u00e7\u00e3o para que pr\u00f3ximos estudos explorem compara\u00e7\u00f5es entre ele e outros testes de avalia\u00e7\u00e3o fonol\u00f3gicas.Por fim, destaca-se que o instrumento \u00e9 estruturado para falantes de PB em geral; no entanto, os dados utilizados s\u00e3o exclusivamente com o perfil fonol\u00f3gico de crian\u00e7as de uma \u00fanica escola p\u00fablica do munic\u00edpio de Porto Alegre/RS. Assim como cabe ressaltar que o O conjunto de dados encontrados indica boas evid\u00eancias para validade de construto do Instrumento de Avalia\u00e7\u00e3o Fonol\u00f3gica - IAF. Al\u00e9m disso, demonstra alcan\u00e7ar resultados objetivos, sistem\u00e1ticos e relevantes tanto na avalia\u00e7\u00e3o, quanto na an\u00e1lise. Este estudo cumpre uma etapa da valida\u00e7\u00e3o de construto do instrumento. Salienta-se que todas as demais etapas para o processo psicom\u00e9trico do IAF est\u00e3o sendo paralelamente realizadas e divulgadas, inclusive com o estabelecimento dos padr\u00f5es de fidedignidade com seguran\u00e7a."}
+{"text": "Twenty-nine speech-language pathologists of both sexes participated. Data were analyzed using descriptive statistics.all participants knew the theoretical foundations of PBM, and among them, 28 (96.6%) knew its use specifically in the voice area; twenty-five respondents (86.2%) had a device to perform the irradiation, and all of them used it routinely in their clinical practice in voice. The majority  participated in a PBM training course, including specific approaches to the voice area. Participants stated that PBM is a resource that can be used in the area of \u200b\u200bvoice to improve performance in sung  and spoken , in addition to its application in cases of inflammatory processes in the vocal folds . As for dosimetry parameters, the most used wavelength was 808 - 830nm  and 660/808nm simultaneously , with a dose of 3-5 J per point for the patients with inflammatory processes in the vocal folds  and 6-9 J  per point for patients whose objective was improvement/conditioning.the study participants demonstrated knowledge and training in PBM and its applicability to the voice area. It involves three main components,4: a treatment target (the function of the patient aimed to be changed with the ingredient); an ingredient ; and the action mechanism (understanding of how the ingredient will change the target).Vocal therapy generally aims to reduce the patient\u2019s symptoms and limitations and improve vocal functioning for everyday voice use situations,4. The action mechanism of volitive ones necessarily includes learning new behaviors related to voice use. On the other hand, non-volitive ingredients do not require patients to have any specific action  or learn any new vocal behavior .Vocal therapy ingredients can be classified as volitive and non-volitive,4. Thus, photobiomodulation (PBM), considering the taxonomy proposed by Van Stan et al., can be considered a non-volitive device (as it does not require any specific action of the patient) meant to optimize treatment results. PBM refers to the capacity of light to induce biological processes in cells, including anti-inflammatory and analgesic effects, decreased edema, tissue recovery, and improved muscle performance,7.In vocal therapy, ingredients may include the use of technological devices as a complementary strategy to change predefined targets and reach the expected therapy results-10. The body of evidence is not enough yet to support recommending PBM to dysphonic patients or vocally healthy occupational voice users who wish to improve their vocal performance. There has been an effort in the last years, though incipient, to research PBM use on the voice,12.PBM has been used in the field of voice for its anti-inflammatory, analgesic, and cell activity-modulating properties. Hypothetically, these properties can help decrease inflammatory processes commonly present in laryngeal lesions and improve muscle performance. However, such effects are so far only hypothetical, by analogy to its effects on other body tissues unrelated to the larynx,13. In 2021, the Federal SLH Council (CFFa) regulated PBM use for SLH therapists to use as a therapy resource. Its states that they can use PBM therapy as a therapy resource associated with conventional SLH clinical procedures. Moreover, the treatment can be used directly and/or indirectly, adapted or transdermic for systemic intervention.Nevertheless, PBM has proved to effectively treat various other health conditions in dentistry, dermatology, physical therapy, otorhinolaryngology, and speech-language-hearing (SLH) therapyTherefore, considering the possible potential of PBM to optimize SLH intervention results in dysphonic patients and vocally healthy individuals, the scarcity of studies supporting external evidence of PBM use in the voice, and the need for understanding the current use of this type of device in vocal clinical practice, this research aimed to investigate the opinion of Brazilian SLH therapists on the training, procedures, and parameters used to apply PBM in vocal clinical practice. It is expected that the study results will help develop clinical references for PBM use in vocal clinical practice and provide insight for future research.This quantitative, cross-sectional, observational study was approved by the Human Research Ethics Committee of the originating institution\u2019s Department of Health Sciences, under evaluation report no. 3.998.709. All study volunteers read and signed an informed consent form, agreeing to participate in the research.Participants were recruited by displaying posters with information and sending a link to access the research via social media of the laboratory where this investigation was carried out. These media have followers in different parts of the country, specifically interested in the area of voice, which helps reach the target public of the research.The eligibility criteria were as follows: being a professional with a degree in SLH Sciences, working in Brazil in the area of voice. Thus, the convenience sample comprised 29 SLH therapists of both sexes.The research was conducted via a web survey hosted in Google Forms. Three SLH therapists experienced in applying PBM to the voice were initially interviewed to discuss the main points to be approached to reach the research objectives. These SLH therapists met the following eligibility criteria: being an SLH therapist specialized in voice, with more than 10 years of experience in the area of voice; having participated in theoretical-practical PBM use training, including its applications in the area of voice; having at least 2 years of experience applying PBM to rehabilitate dysphonic patients or train occupational voice users; being specialized in voice. The three selected professionals worked predominantly in clinics and did not teach at any public or private university. A questionnaire was developed based on the interview content, as shown in Then the link to access the questionnaire was made available on the social media of the laboratory where this research was carried out, as previously described. Data were collected between July and August 2020. The questionnaire had items on the SLH therapists\u2019 sociodemographic profile, training, professional practice, and knowledge of PBM principles and use in the area of voice. Before answering the questions, participants had access to a text explaining the research, then read the informed consent form, and if they agreed with it, proceeded with the answers.Data were organized and categorized into Microsoft Excel spreadsheets and then analyzed with descriptive statistics.The web survey had 29 participating SLH therapists, whose information is available in All research participants knew the PBM theoretical framework; 28 (96.6%) of them were familiar with its use specifically in the area of voice; 25 (86.2%) had their own device, and all of them normally used it in their voice clinical practice .Only three (10.3%) of the participants learned about PBM in their undergraduate studies; most of them  learned about it in their postgraduate studies. Of the total sample, 28 (96.6%) took PBM training courses directed to voice clinical use; 26 (89.7%) had access to the bibliography on PBM use in SLH therapy or health; only 17 (58.6%) have/had access to the bibliography on PBM use in the voice; and 27 (93.1%) had access to CFFa recommendations on the topic.All participants stated that PBM is a therapeutic resource indicated to the area of voice, and 27 (93.1%) of them said that SLH therapists specialized in voice can use it.It was also found that all research participants use point contact irradiation and that 23 (79.4%) apply the laser on the lamina of the thyroid cartilage, bilaterally. Lastly, 16 (55.2%) participants stated using systemic laser therapy (ILIB) in the area of voice.As for purpose, 21 (72.4%) SLH therapists use PBM to improve/train singing voices; 23 (79.3%) use it in individuals with vocal fold inflammatory processes; 24 (82.8%) use it to improve vocal performance in speech; 25 (86.2%) use it to improve vocal performance in singing; 19 (65.5%) use it to improve/train the voice in speech; 15 (51.7%) use it in cases of behavioral dysphonia without lesions; 13 (44.8%) use it in cases of behavioral dysphonia with lesions; nine (31.0%) use it in cases of organic neurological dysphonia; and eight (27.6%) use it in cases of sequelae of head and neck cancer .PBM is used by 19 (65.5%) participants before doing vocal exercises; 11 (37.9%) use 808-803 nm wavelengths; and another 11 (37.9%) use 660 and 808 nm simultaneously .Most participants use two points per laser application; 15 (51.7%) use 3-5 J doses for patients in vocal fold inflammatory processes , and 13 .This study analyzed Brazilian SLH therapists\u2019 knowledge and use of PBM in voice clinical practice. Most study participants were SLH therapists who specialized in voice but did not teach undergraduate or postgraduate courses. They reported knowing PBM principles and use in the area of voice. Moreover, most of them owned PBM equipment and normally used it in their clinical practice in the area of voice. This reinforces SLH therapists\u2019 general interest in using new technology (such as PBM) in the therapeutic process, which involves learning the principles of these tools,15. In both contexts, PBM is believed to modulate inflammation, maximize muscle performance, and, therefore, potentialize the effects of therapy or vocal training.PBM has been used as one of the strategies complementary to vocal therapy to either rehabilitate dysphonic individuals or improve/train occupational voice users. PBM use in dysphonic individuals is justified, as most phonotraumatic lesions have vocal fold edemas and inflammatory processes. As for occupational voice users with no laryngeal changes, PBM use is grounded on the possibility of optimizing the muscle energy mechanism associated with voice production, thus improving muscle performance, and decreasing the recovery time after using the voice in their occupation,12. However, the findings in these studies,12 may not reflect the expected action mechanisms and effects, hypothesized by inference based on findings in other body tissues.PBM use in voice is incipient and grounded on translational premises from other areas and application in other body tissues. Hence, based on translational inference, PBM effects are expected to benefit vocal performance and modulate inflammatory processes with metabolic and photochemical actions in the mitochondria. Concerning the voice, improvements were verified in acoustic and aerodynamic measures and self-perceived vocal effort after using PBM. Thus, such content is approached in extension and postgraduate specialization courses, which are part of SLH therapists\u2019 continuing education.Most SLH therapists learned about PBM in postgraduate courses and/or extension training courses. It must be considered that PBM has been incorporated into SLH therapists\u2019 clinical practice in the last years and that content on using technological resources complementary to conventional therapy is not necessarily among the primary objectives of the initial training of generalist professionals in their undergraduate studies.CFFa states that SLH therapists can only use PBM as a therapeutic resource when specifically and adequately trained for it and are subject to legal responsibility in cases of malpractice, negligence, or recklessness. Adequate training generally has a minimum course load, obligatory content, practical training, and supervision to reinforce skills and competencies related to applying the technology. It includes a systematic and personalized approach to gathering information, formulating hypotheses, and selecting strategies. It is a complex process that requires professionals to have a well-established mindset. Thus, teaching tools must introduce students not only to knowledge but also training with scripts that make decision-making easier.Clinical thinking is a continuous process of making decisions throughout treatment. It is recommended that initial basic training to use PBM be theoretical-practical, with a minimum 20-hour course load, also suggesting continuing education and in-depth training to use the resource. They also recommend minimum competencies SLH therapists must have by the end of their training.Therefore, PBM training in the area of voice involves not only general knowledge about PBM but also practical training and specific previous experience in the specialty. Clinical thinking to apply PBM to patients in voice clinical practice must involve deep knowledge of biological, etiological, and physiopathological aspects, and the main manifestations related to the condition being treated. Hence, training must include such knowledge, exposure to clinical cases, and practical training, preferably supervised. Training and supervision help consolidate knowledge for decision-making in each new clinical case, with studies,18 whose designs do not allow generalization and direct inferences for this field of practice.Participants in this research reported having access to the bibliography on PBM use, though limited to the specific material in the area of voice. Specific literature in the area applied to cases of dysphonia and occupational voice use is still scarce. Due to the few studies on the effectiveness of PBM to treat dysphonic individuals, regulating it is necessary to legitimate and guide its exploratory use with a minimal assurance of not harming patients.Many participating SLH therapists had access to the CFFa recommendations on using low-level lasers in their profession. CFFa regulated PBM use as a therapeutic resource for SLH therapists in different areas. According to the resolution, they can use PBM therapy as a therapeutic resource associated with conventional SLH clinical procedures, directly (when applied to the specific region or location for its biostimulation) and/or indirectly  and dysphonia as a sequela of head and neck cancer . Concerning specifically the latter, though reported by fewer respondents, it is important to point out the relationship between risk, safety, and benefit to the patient in the clinical procedure.. In these cases, PBM can benefit the management of toxicities related to cancer treatment. On the other hand, there is not enough evidence available on PBM\u2019s effect on malignant cell protection or increased tumoral growth. Thus, professionals must communicate with patients about the potential PBM risks and benefits.Red and infrared PBM has proved to be safe and effective to manage the side effects of adjuvant cancer treatment. In general, SLH therapists are recommended to judiciously evaluate PBM use to rehabilitate patients with sequelae of head and neck cancer. Furthermore, irradiation should be avoided in areas with neoplastic processes, as the literature available has no evidence of PBM effects on tumoral proliferation.In the area of voice, particularly regarding oncological contexts, PBM can be used to treat sequelae of head and neck cancer by managing symptoms in terms of reducing mucositis, xerostomia, lymphoedema, and trismus, and improving extrinsic laryngeal, tongue, and soft palate muscle performance.Participants reported that PBM is a therapeutic resource that can be indicated for use in the area of voice and that SLH therapists specialized in voice can use this practice. Despite the limited external evidence for the area, clinicians\u2019 experience and patients\u2019 preference for using such devices and the advances and discussions in the area justify the growing use of this technological resource complementary to traditional therapy. Moreover, the larynx has anatomical and histological specificities, such as the barriers  for the light to reach the laryngeal intrinsic muscles and the various vocal fold layers. Thus, it is hypothesized that point contact is the most adequate technique for this region,22.Concerning parameters to apply PBM in the area of voice, all SLH therapists use point contact irradiation in the laryngeal region. This seems to be the most adequate irradiation technique for this region, as it ensures greater light penetrability, greater precision of the irradiated energy, and low light reflection. Some studies that used electrostimulation on the voice applied it on the lamina of the thyroid cartilage bilaterally, as it is appropriate for being nearer the vocal folds and the recurrent nerve, ensuring the stimulation of the laryngeal intrinsic muscles and vocal ligament, providing effective stimulation. Besides this application point reported by most SLH therapists in this research, PBM can also address the voice by applying it to the submandibular region, thus irradiating the suprahyoid extrinsic muscles, and the intraoral region, specifically the soft palate,24.Participating SLH therapists reported applying PBM on the lamina of the thyroid cartilage bilaterally. The vocal folds are located inside the thyroid cartilage, and one of their insertion points is on this cartilage. Hence, applying it to the thyroid cartilage aims to reach the trilaminar structure of the vocal folds.Most SLH therapists use PBM before doing vocal exercises. This use is probably justified by the need for precise irradiation on the adequate point and location. In general, vocal exercises that activate the glottal source or displace the articulators also move the laryngeal structure and may displace the predefined anatomical point  and limit the expected effects. On the other hand, when the goal is related to training strength and obtaining long-term (chronic) effects, irradiation must be made immediately before each exercise session. When the goal is a chronic effect associated with resistance training, irradiation must occur mediately before and immediately after each exercise session. In cases whose goal is tissue inflammation modulation, irradiation must also occur before exercises that recruit or manipulate the tissue inflammation area,26. Thus, despite the lack of specific studies on the moment of irradiation to rehabilitate dysphonic patients or train occupational voice users, the evidence available leads to infer the indication of PBM use before the functional activity  or vocal exercise.It is also indicated that irradiation be made 5 minutes to 6 hours before the activity when aiming at an acute effect, focusing on a single event,11.The 808-830 nm wavelength was the most reported by responding SLH therapists to apply in the area of voice. This wavelength corresponds to infrared light, which has a greater interaction with deeper tissue layers. Hence, infrared light is seemingly more adequate to overcome anatomical and histological barriers and reach the vocal folds,27. The energy corresponds to the equipment\u2019s power multiplied by the irradiation time, resulting in a value in Joules. Obviously, calculating the dose of irradiated light that effectively reaches the tissue, involves other parameters, so the irradiated energy has been commonly used to describe doses in SLH clinical practice. Even though 3-5 J per point was the most reported, there was a dispersion of the participants\u2019 answers. This reinforces that PBM dosimetry is an important aspect to be discussed in the area, given the possibility of overdosage or underdosage, for example.The dose of 3-5 J per point was the most reported by the respondents to apply in patients with vocal fold inflammation processes. The concept of PBM dose is directly related to the power of the equipment and the energy used at a point during the therapy session,26. This dose is indicated to modulate the potential of the mitochondrial membrane of neurons, decreasing ATP generation, blocking sensory innervation, stimulating mitochondrial homeostasis, accelerating tissue healing, easing pain, and decreasing edema.The indicated dose in oral-motor control is 3-4 J to provide analgesia in therapy and modulate inflammation in cases of temporomandibular disorder,29. Higher doses stimulate bioenergetic pathways of the muscle fiber and the modulation of enzymes and oxygen-reactive species, which produces larger and more functional mitochondria, increasing oxygen consumption, and reducing muscle fatigue,30.Most SLH therapists reported using 6-9 J to improve/train voices. There is a general tendency to use higher doses to improve muscle performance. Hence, given the neck dimensions and the said variables, consensus and future studies may verify the need for irradiation at more points in vocal clinical practice. It is essential to apply it on the whole extension of the target region or muscles to achieve biomodulation.SLH therapists reported irradiating two points in the laryngeal region in cases of dysphonia and vocal improvement. The number of points depends on variables such as muscle length, the place of irradiation, the amount of fat tissue, and so onMore than half of the SLH therapists  reported using ILIB in the area of voice. It consists of transdermic intravascular irradiation of a light beam in the radial artery. Such irradiation aims at the bloodstream to stimulate action in the whole organism. ILIB has potential generalized analgesic, spasmolytic, and sedative effects in almost all systems. However, there are yet no clinical studies supporting its use in patients with voice complaints or who seek vocal improvement.PBM has been generally used in association with conventional vocal therapy to either rehabilitate dysphonic individuals or train vocal conditioning in speech or singing among occupational voice users. Data in this study portray this tool\u2019s current use in vocal clinical practice and raise hypotheses of the possible justifications for its use in this context. Given the lack of robust external evidence, the specialists\u2019 opinions may be a first step to understanding how a new tool is used.Furthermore, the survey present in this manuscript may be a reference for experimental research and randomized clinical trials to verify the hypotheses related to PBM effects on dysphonic and vocally healthy individuals.This exploratory study contributed to a cross-sectional understanding of specialists\u2019 perception and use of PBM in their practice. It also has historical usefulness for future comparisons. The convenience sample may be representative of the reality investigated in a cross-section. A possible limitation of this study is the number of participants. Data were collected in 2020, the most critical part of the COVID-19 pandemic, which may have influenced the little adherence of participants. Moreover, future inquiries to this population may include questions on training duration and mandatory content to use PBM in vocal clinical practice.All participating SLH therapists reported knowing PBM precepts and use in the area of voice. Most respondents learned about PBM in their postgraduate studies. SLH therapists in the area of voice reported generally using point contact irradiation in the laryngeal region, applying PBM before vocal exercises, and using 808-830 nm wavelengths. Respondents used 3-5 J doses in patients with vocal fold inflammatory processes and 6-9 J doses in clients that aimed to improve/train their voices. -4. A terapia vocal envolve tr\u00eas componentes principais,4: um alvo do tratamento, ou seja, a fun\u00e7\u00e3o do paciente que se deseja modificar pelo ingrediente; um ingrediente, que se refere \u00e0 a\u00e7\u00e3o do cl\u00ednico, uso de dispositivos, modelagem, uso de palavras e comandos, manipula\u00e7\u00f5es realizadas com o paciente durante o tratamento de reabilita\u00e7\u00e3o vocal, al\u00e9m dos elementos da metaterapia, todos voltados para modificar o alvo pr\u00e9-definido; e o mecanismo de a\u00e7\u00e3o, ou seja, a compreens\u00e3o sobre como o ingrediente ir\u00e1 modificar o alvo.De modo geral, o objetivo da terapia vocal \u00e9 reduzir os sintomas apresentados pelo paciente, reduzir sua limita\u00e7\u00e3o e melhorar a sua funcionalidade vocal para as situa\u00e7\u00f5es cotidianas de uso da voz,4. Em seu mecanismo de a\u00e7\u00e3o, os ingredientes volitivos incluem, necessariamente, a aprendizagem de novos comportamentos relacionados ao uso da voz. Por outro lado, ingredientes n\u00e3o volitivos n\u00e3o demandam uma a\u00e7\u00e3o espec\u00edfica do paciente  e a aprendizagem de um novo comportamento vocal .Os ingredientes da terapia vocal podem ser classificados em volitivos e n\u00e3o volitivos,4. Nesse sentido, a fotobiomodula\u00e7\u00e3o (FBM), considerando a taxonomia proposta por Van Stan et al., pode ser considerado um dispositivo n\u00e3o volitivo (visto que o seu uso n\u00e3o demanda uma a\u00e7\u00e3o espec\u00edfica do paciente), utilizado para otimiza\u00e7\u00e3o dos resultados do tratamento. A FBM consiste na capacidade da luz de induzir processos biol\u00f3gicos no n\u00edvel celular, incluindo efeitos anti-inflamat\u00f3rios, analg\u00e9sicos, diminui\u00e7\u00e3o de edema, repara\u00e7\u00e3o tecidual e melhora no desempenho muscular,7.Na terapia vocal, os ingredientes podem envolver a utiliza\u00e7\u00e3o de dispositivos tecnol\u00f3gicos como estrat\u00e9gia complementar modificar os alvos pr\u00e9-definidos e alcan\u00e7ar os resultados terap\u00eauticos esperados-10. Ainda n\u00e3o existe corpo de evid\u00eancia suficiente que suporte a recomenda\u00e7\u00e3o da FBM em pacientes disf\u00f4nicos ou profissionais da voz vocalmente saud\u00e1veis que desejem melhorar seu desempenho vocal. Nos \u00faltimos anos, observa-se um esfor\u00e7o para realiza\u00e7\u00e3o de pesquisas com o uso da FBM em voz,12, embora ainda incipientes.Na \u00e1rea de Voz, a FBM tem sido utilizada por suas propriedades anti-inflamat\u00f3rias, analg\u00e9sica e moduladora da atividade celular. Hipoteticamente, tais propriedades podem contribuir para diminui\u00e7\u00e3o do processo inflamat\u00f3rio, comumente presente nas les\u00f5es lar\u00edngeas, e melhorar o desempenho muscular dos pacientes. No entanto, at\u00e9 o momento, os efeitos s\u00e3o hipot\u00e9ticos, por analogia aos efeitos sobre outros tecidos corporais n\u00e3o relacionados \u00e0 laringe,13. Em 2021, o Conselho Federal de Fonoaudiologia (CFFa) normatizou o uso da FBM como recurso terap\u00eautico a ser utilizado por fonoaudi\u00f3logos. De acordo com essa resolu\u00e7\u00e3o, o fonoaudi\u00f3logo poder\u00e1 utilizar a terapia por FBM como recurso terap\u00eautico associado aos procedimentos cl\u00ednicos fonoaudiol\u00f3gicos convencionais. Al\u00e9m disso, o tratamento poder\u00e1 ser aplicado nas modalidades direta e/ou indireta, adaptada ou transd\u00e9rmica para interven\u00e7\u00e3o sist\u00eamica.Por outro lado, a FBM tem se mostrado eficaz no tratamento de v\u00e1rias outras condi\u00e7\u00f5es de sa\u00fade em \u00e1reas da odontologia, dermatologia, fisioterapia, otorrinolaringologia e fonoaudiologiainsights para realiza\u00e7\u00e3o de pesquisas futuras.Sendo assim, considerando-se o poss\u00edvel potencial da FBM para otimizar os resultados da interven\u00e7\u00e3o fonoaudiol\u00f3gica com pacientes disf\u00f4nicos e com indiv\u00edduos vocalmente saud\u00e1veis, a escassez de estudos que suportem a evid\u00eancia externa quanto ao uso da FBM na \u00e1rea de voz e a necessidade de compreender o uso corrente desse tipo de dispositivo na cl\u00ednica vocal, o objetivo desta pesquisa foi investigar a opini\u00e3o de fonoaudi\u00f3logos brasileiros sobre a forma\u00e7\u00e3o, atua\u00e7\u00e3o e par\u00e2metros utilizados para aplica\u00e7\u00e3o da fotobiomodula\u00e7\u00e3o (FBM) na cl\u00ednica vocal. A partir dos resultados deste estudo, espera-se contribuir para o desenvolvimento de balizadores cl\u00ednicos para uso da FBM na cl\u00ednica vocal e fornecer Trata-se de um estudo observacional, transversal e quantitativo, aprovado pelo Comit\u00ea de \u00c9tica em Pesquisa com Seres Humanos do Centro de Ci\u00eancias da Sa\u00fade da Institui\u00e7\u00e3o de origem, com o parecer de n\u00famero 3.998.709. Todos os volunt\u00e1rios do estudo tiveram acesso e assinaram o Termo de Consentimento Livre e Esclarecido (TCLE), concordando em participar da pesquisa.banner com as informa\u00e7\u00f5es e link de acesso para a pesquisa foi divulgado nas m\u00eddias sociais do Laborat\u00f3rio onde foi realizada esta investiga\u00e7\u00e3o. Tais m\u00eddias possuem seguidores de diferentes regi\u00f5es do pa\u00eds com foco de interesse espec\u00edfico na \u00e1rea de voz, o que favorece a capta\u00e7\u00e3o da popula\u00e7\u00e3o-alvo da pesquisa.Para o recrutamento dos participantes, um Foram estabelecidos os seguintes crit\u00e9rios de elegibilidade: ser profissional graduado em Fonoaudiologia, atuante na \u00e1rea de Voz no Brasil. Dessa forma, foi constitu\u00edda uma amostra por conveni\u00eancia de 29 fonoaudi\u00f3logos, de ambos os sexos.websurvey hospedada na plataforma digital Google Forms. Inicialmente, foi realizada uma entrevista inicial com tr\u00eas fonoaudi\u00f3logos experientes na aplica\u00e7\u00e3o da FBM em Voz, discutindo os principais pontos que deveriam ser abordados para atingir os objetivos da presente pesquisa. Tais fonoaudi\u00f3logos cumpriram os seguintes crit\u00e9rios de elegibilidade: fonoaudi\u00f3logo especialista em voz com mais de 10 anos de atua\u00e7\u00e3o na \u00e1rea de Voz; ter participado de treinamento te\u00f3rico-pr\u00e1tico sobre o uso da FBM, incluindo suas aplica\u00e7\u00f5es na \u00e1rea de Voz; ter experi\u00eancia m\u00ednima de dois anos na aplica\u00e7\u00e3o da FBM no processo de reabilita\u00e7\u00e3o de pacientes disf\u00f4nicos ou no treinamento de profissionais da voz; ser especialista em Voz. Os tr\u00eas profissionais selecionados tinham atividade predominantemente cl\u00ednica, sem v\u00ednculo de doc\u00eancia em universidades p\u00fablicas ou privadas. A partir do conte\u00fado da entrevista foi elaborado o question\u00e1rio que pode ser conferido no A pesquisa foi realizada por meio de uma link de acesso ao question\u00e1rio foi divulgado nas redes sociais do Laborat\u00f3rio onde foi realizada esta pesquisa, conforme descrito anteriormente. A coleta de dados foi realizada no per\u00edodo entre julho e agosto de 2020. O question\u00e1rio continha itens sobre o perfil sociodemogr\u00e1fico dos fonoaudi\u00f3logos, dados de forma\u00e7\u00e3o, atua\u00e7\u00e3o profissional e sobre os conhecimentos relacionados aos princ\u00edpios e uso da FBM na \u00e1rea de voz. Antes de responder \u00e0s quest\u00f5es, os participantes tiveram acesso ao texto explicativo sobre a pesquisa, procederam com a leitura do TCLE e, caso estivessem de acordo, prosseguiam com as respostas.Na sequ\u00eancia, o Os dados foram organizados e categorizados em planilhas do Microsoft Excel. Para an\u00e1lise dos dados, foi realizada an\u00e1lise estat\u00edstica descritiva.websurvey 29 fonoaudi\u00f3logos, cujas informa\u00e7\u00f5es podem ser conferidas na Participaram da Todos os participantes da pesquisa conheciam os fundamentos te\u00f3ricos da FBM. Entre eles, 28  conheciam sua utiliza\u00e7\u00e3o especificamente na \u00e1rea de voz; 25  possu\u00edam aparelho particular e todos costumavam utiliz\u00e1-lo em sua pr\u00e1tica cl\u00ednica em voz .De todos os participantes, apenas tr\u00eas  adquiriram conhecimentos sobre FBM na gradua\u00e7\u00e3o; a maioria obteve tal conhecimento na p\u00f3s-gradua\u00e7\u00e3o . Do total da amostra, 28  fizeram curso de capacita\u00e7\u00e3o em FBM com direcionadores cl\u00ednicos para voz; 26  tiveram acesso a alguma bibliografia relacionada a \u00e1rea da FBM em fonoaudiologia ou em sa\u00fade; somente 17  t\u00eam/tiveram acesso a alguma bibliografia relacionada a \u00e1rea de FBM na voz; e 27  tiveram acesso \u00e0s recomenda\u00e7\u00f5es do CFFa sobre o tema.Todos os participantes afirmaram que a FBM \u00e9 um recurso terap\u00eautico indicado para a \u00e1rea de voz, e 27  deles referiram que o fonoaudi\u00f3logo especialista em voz pode atuar com esse recurso.Foi observado tamb\u00e9m que todos os participantes da pesquisa utilizam o m\u00e9todo de irradia\u00e7\u00e3o pelo contato pontual e que 23  fazem a aplica\u00e7\u00e3o do laser na l\u00e2mina da cartilagem tire\u00f3idea, bilateralmente. Por fim, 16  participantes afirmaram utilizar a laserterapia sist\u00eamica (ILIB) para a \u00e1rea da voz.Em rela\u00e7\u00e3o \u00e0 utiliza\u00e7\u00e3o da FBM pelos fonoaudi\u00f3logos, observou-se que 21  para aperfei\u00e7oamento/condicionamento de voz (cantada); 23  utilizam em indiv\u00edduos com processos inflamat\u00f3rios nas PPVV; 24  utilizam para melhorar a performance vocal  e 25  para melhorar a performance vocal (voz cantada); 19  para aperfei\u00e7oamento/condicionamento de voz ; 15  a utilizam em casos de disfonia comportamental sem les\u00e3o; 13  utilizam em casos de disfonia comportamental com les\u00e3o; nove  em casos de disfonia por causas org\u00e2nicas neurol\u00f3gicas; oito  em casos de sequela de CCP; .Do total de participantes, 19  fazem uso da FBM antes da execu\u00e7\u00e3o do exerc\u00edcio vocal; 11  utilizam comprimentos de onda 808-803nm e outros 11  utilizam 660 e 808nm simultaneamente .A maioria dos participantes utiliza dois pontos por aplica\u00e7\u00e3o do laser; 15  deles utilizam a dose de 3-5 J para pacientes com processos inflamat\u00f3rios nas pregas vocais , e 13 4..Este estudo analisou o conhecimento e o uso da FBM na cl\u00ednica vocal por fonoaudi\u00f3logos brasileiros. A maioria dos participantes do estudo foi composta por fonoaudi\u00f3logos especialistas em voz e que n\u00e3o lecionam em cursos de gradua\u00e7\u00e3o e de p\u00f3s-gradua\u00e7\u00e3o. Os participantes responderam que conhecem os princ\u00edpios da FBM e da sua utiliza\u00e7\u00e3o na \u00e1rea de voz. Al\u00e9m disso, a maioria possui um aparelho de FBM e costuma utiliz\u00e1-lo em sua pr\u00e1tica cl\u00ednica na \u00e1rea de voz. Tal fato refor\u00e7a o interesse do fonoaudi\u00f3logo, de maneira geral, pelo uso de novas tecnologias como a FBM no processo terap\u00eautico, o que envolve a busca pela compreens\u00e3o dos princ\u00edpios de tais ferramentas,15. Nesses dois contextos, a FBM atuaria no sentido de modular a inflama\u00e7\u00e3o, maximizar o desempenho muscular e, assim, potencializar o efeito da terapia ou treinamento vocal.A FBM tem sido utilizada como uma das estrat\u00e9gias complementares \u00e0 terapia vocal, seja para reabilita\u00e7\u00e3o de indiv\u00edduos disf\u00f4nicos ou para treinamento/condicionamento de profissionais da voz. A justificativa para o uso da FBM em indiv\u00edduos disf\u00f4nicos \u00e9 de que a maioria das les\u00f5es fonotraum\u00e1ticas envolvem a presen\u00e7a de edema e processos inflamat\u00f3rios nas pregas vocais. No contexto de profissionais da voz sem altera\u00e7\u00e3o lar\u00edngea, a aplica\u00e7\u00e3o da FBM est\u00e1 fundamentada na possibilidade de otimizar o mecanismo energ\u00e9tico muscular associado \u00e0 produ\u00e7\u00e3o vocal, melhorando o desempenho muscular e reduzindo o tempo de recupera\u00e7\u00e3o ap\u00f3s o uso profissional da voz,12. No entanto, deve-se ressaltar que os achados dos estudos citados,12 podem n\u00e3o traduzir, de fato, os mecanismos de a\u00e7\u00e3o e efeitos esperados que s\u00e3o hipotetizados por ila\u00e7\u00e3o a achados em outros tecidos corporais.O uso da FBM em voz \u00e9 incipiente e sustentado por premissas translacionais de outras \u00e1reas e com aplica\u00e7\u00f5es em outros tecidos corporais. Nesse sentido, por infer\u00eancia translacional, espera-se que os efeitos da FBM podem beneficiar o desempenho vocal e modular os processos inflamat\u00f3rios com a\u00e7\u00f5es metab\u00f3licas e fotoqu\u00edmicas em n\u00edvel mitocondrial. Na \u00e1rea de voz, observou-se melhora nas medidas ac\u00fasticas, aerodin\u00e2micas e na autopercep\u00e7\u00e3o do esfor\u00e7o vocal ap\u00f3s o uso da FBM. Dessa forma, tais conte\u00fados passam a ser abordados em cursos livres e em cursos de p\u00f3s-gradua\u00e7\u00e3o lato sensu, fazendo parte da educa\u00e7\u00e3o continuada do fonoaudi\u00f3logo.A maioria dos fonoaudi\u00f3logos adquiriu conhecimentos em FBM em cursos de p\u00f3s-gradua\u00e7\u00e3o e/ou em cursos livres de capacita\u00e7\u00e3o. Deve-se considerar que a FBM tem sido incorporada na pr\u00e1tica cl\u00ednica de fonoaudi\u00f3logos nos \u00faltimos anos e que, os conte\u00fados voltados ao uso de recursos tecnol\u00f3gicos complementares \u00e0 terapia convencional, n\u00e3o est\u00e3o, necessariamente, entre os objetivos prim\u00e1rios da forma\u00e7\u00e3o inicial de um profissional generalista ao t\u00e9rmino da gradua\u00e7\u00e3o.O CFFa preconiza que o fonoaudi\u00f3logo s\u00f3 poder\u00e1 utilizar o recurso terap\u00eautico de FBM quando possuir capacita\u00e7\u00e3o espec\u00edfica e adequada, estando sujeito \u00e0 responsabilidade legal em casos de imper\u00edcia, neglig\u00eancia e imprud\u00eancia. De maneira geral, uma capacita\u00e7\u00e3o adequada deve envolver carga hor\u00e1ria m\u00ednima, conte\u00fados obrigat\u00f3rios, assim como treinamento e supervis\u00e3o para fortalecer as habilidades e compet\u00eancias relacionadas \u00e0 aplica\u00e7\u00e3o de uma tecnologia. Ele inclui uma abordagem sistem\u00e1tica e personalizada de coleta de informa\u00e7\u00f5es, formula\u00e7\u00e3o de hip\u00f3teses e sele\u00e7\u00e3o de estrat\u00e9gias. Ele \u00e9 um processo complexo e exige que os esquemas mentais estejam sedimentados no profissional. Dessa forma, as ferramentas de ensino devem possibilitar n\u00e3o somente a exposi\u00e7\u00e3o do aprendiz ao conhecimento, mas o treinamento em scripts que facilitem a tomada de decis\u00e3o.O racioc\u00ednio cl\u00ednico \u00e9 um processo cont\u00ednuo de tomada de decis\u00e3o ao longo de um atendimento. Recomenda-se que a forma\u00e7\u00e3o b\u00e1sica inicial para uso da FBM seja te\u00f3rico-pr\u00e1tica, com carga-hor\u00e1ria m\u00ednima de 20h, com sugest\u00e3o de educa\u00e7\u00e3o continuada e necessidade de aprofundamento quanto ao uso desse recurso. Al\u00e9m disso, recomenda compet\u00eancias m\u00ednimas que o fonoaudi\u00f3logo dever\u00e1 apresentar ao final da forma\u00e7\u00e3o.Nesse sentido, a capacita\u00e7\u00e3o em FBM para a \u00e1rea de voz envolve n\u00e3o somente o conhecimento geral sobre FBM, mas a forma\u00e7\u00e3o e experi\u00eancia pr\u00e9via espec\u00edfica da especialidade. O racioc\u00ednio cl\u00ednico para a aplica\u00e7\u00e3o da FBM em pacientes na cl\u00ednica vocal deve envolver um profundo conhecimento dos aspectos biol\u00f3gicos, etiol\u00f3gicos, fisiopatol\u00f3gicos e das principais manifesta\u00e7\u00f5es envolvidas com a condi\u00e7\u00e3o tratada. Sendo assim, a capacita\u00e7\u00e3o deveria envolver tal conhecimento, a exposi\u00e7\u00e3o aos casos cl\u00ednicos e o treinamento pr\u00e1tico, preferencialmente, sob supervis\u00e3o. O treinamento e a supervis\u00e3o s\u00e3o facilitadores para que esse conhecimento seja encapsulado para a tomada de decis\u00e3o a cada novo caso cl\u00ednico, com estudos,18 cujo delineamento n\u00e3o permite generaliza\u00e7\u00f5es e infer\u00eancias diretas para esses campos de atua\u00e7\u00e3o.Os participantes desta pesquisa referiram ter acesso \u00e0 material bibliogr\u00e1fico relacionado ao uso da FBM, embora com acesso restrito a materiais espec\u00edficos na \u00e1rea de voz. Ressalta-se que a literatura espec\u00edfica da \u00e1rea aplicada aos casos de disfonia e voz profissional ainda \u00e9 escassa. Considerando-se a escassez de estudos sobre a efetividade da FBM no tratamento de indiv\u00edduos disf\u00f4nicos, a regulamenta\u00e7\u00e3o \u00e9 necess\u00e1ria para legitimar e nortear o uso em car\u00e1ter explorat\u00f3rio, com a m\u00ednima garantia de n\u00e3o malefic\u00eancia ao paciente.Dos fonoaudi\u00f3logos participantes, grande parte teve acesso \u00e0s recomenda\u00e7\u00f5es do CFFa sobre a utiliza\u00e7\u00e3o do laser de baixa pot\u00eancia na profiss\u00e3o. O CFFa normatizou o uso da FBM como recurso terap\u00eautico a ser utilizado por fonoaudi\u00f3logos em diferentes \u00e1reas. De acordo com a resolu\u00e7\u00e3o, o fonoaudi\u00f3logo poder\u00e1 utilizar a terapia por FBM como recurso terap\u00eautico associado aos procedimentos cl\u00ednicos fonoaudiol\u00f3gicos convencionais, aplicado nas modalidades direta quando aplicado na regi\u00e3o ou local espec\u00edfico para promover a bioestimula\u00e7\u00e3o e/ou indireta com a aplica\u00e7\u00e3o do ILIB, adaptada ou transd\u00e9rmica para interven\u00e7\u00e3o sist\u00eamica,12.Quanto \u00e0 utiliza\u00e7\u00e3o da FBM pelos fonoaudi\u00f3logos na \u00e1rea de voz, a maioria utiliza em indiv\u00edduos cujo objetivo \u00e9 o aperfei\u00e7oamento/condicionamento da voz falada e cantada, assim como em pacientes com processos inflamat\u00f3rios nas pregas vocais. A justificativa para o uso em profissionais da voz sem altera\u00e7\u00e3o vocal pode estar associada ao efeito da FBM em modular os processos metab\u00f3licos em n\u00edvel mitocondrial, refletindo em maior resist\u00eancia \u00e0 fadiga e menor tempo de recupera\u00e7\u00e3o ap\u00f3s o uso intensivo.O princ\u00edpio para utiliza\u00e7\u00e3o da FBM em pacientes com les\u00f5es inflamat\u00f3rias nas pregas vocais pode estar associado ao efeito da FBM sobre as enzimas celulares e por alterar o estado redox, aumentando o mecanismo da cadeia oxidativa em n\u00edvel mitocondrial. Dessa forma, espera-se que haja aumento na microcircula\u00e7\u00e3o, melhora a drenagem linf\u00e1tica, aumenta a prolifera\u00e7\u00e3o e mobilidade das c\u00e9lulas epiteliais, acelera\u00e7\u00e3o da s\u00edntese de col\u00e1geno, redu\u00e7\u00e3o da resposta inflamat\u00f3ria e a cicatriza\u00e7\u00e3o do tecido de forma efetiva. Todos esses fatores contribuiriam para uma recupera\u00e7\u00e3o vocal mais eficiente e r\u00e1pidaUm menor percentual de fonoaudi\u00f3logos referiu utilizar a FBM em disfonias de causa neurol\u00f3gica  e nas disfonias por sequela de c\u00e2ncer de cabe\u00e7a e pesco\u00e7o . Especificamente quanto ao \u00faltimo caso, embora referido por um n\u00famero menor de respondentes, deve-se comentar acerca das rela\u00e7\u00f5es entre risco, seguran\u00e7a e benef\u00edcios da a\u00e7\u00e3o cl\u00ednica sobre o paciente.. Nesses casos, a FBM pode ser uma abordagem que beneficia no manejo das toxicidades relacionadas ao tratamento do c\u00e2ncer. Por outro lado, ainda n\u00e3o h\u00e1 evid\u00eancia dispon\u00edvel suficiente quanto ao efeito da FBM na prote\u00e7\u00e3o celular maligna ou no aumento do crescimento tumoral. Nesse sentido, \u00e9 mandat\u00f3rio que os profissionais comuniquem os pacientes sobre os potenciais riscos e benef\u00edcios relacionados \u00e0 FBM.A FBM (no espectro vermelho ou infravermelho) demonstrou ser segura e efetiva para o manejo dos efeitos colaterais relacionados ao tratamento adjuvante do c\u00e2ncer. De maneira geral, recomenda-se que o fonoaudi\u00f3logo avalie criteriosamente o uso da FBM na reabilita\u00e7\u00e3o de pacientes com sequelas de c\u00e2ncer de cabe\u00e7a e pesco\u00e7o. Al\u00e9m disso, deve evitar a irradia\u00e7\u00e3o sobre \u00e1reas com processos neopl\u00e1sicos, considerando-se que, na literatura dispon\u00edvel, n\u00e3o h\u00e1 evid\u00eancia sobre os efeitos da FBM na prolifera\u00e7\u00e3o tumoral.Na \u00e1rea de voz, especificamente no contexto oncol\u00f3gico, a FBM pode vir a ser utilizada no tratamento das sequelas de c\u00e2ncer de cabe\u00e7a e pesco\u00e7o para o manejo de sintomas relacionadas aos alvos terap\u00eauticos de: redu\u00e7\u00e3o da mucosite, redu\u00e7\u00e3o da xerostomia, redu\u00e7\u00e3o do linfedema, redu\u00e7\u00e3o do trismo, melhora no desempenho da musculatura extr\u00ednseca da laringe, melhora no desempenho da musculatura da l\u00edngua e do palato mole.Os participantes referiram que a FBM \u00e9 um recurso terap\u00eautico que pode ser indicado para utiliza\u00e7\u00e3o na \u00e1rea de voz e que os fonoaudi\u00f3logos especialistas em voz podem atuar com essa pr\u00e1tica. Mesmo com evid\u00eancias externas limitadas para a \u00e1rea, a experi\u00eancia dos cl\u00ednicos e a prefer\u00eancia dos pacientes pela utiliza\u00e7\u00e3o desses dispositivos, como tamb\u00e9m avan\u00e7os e discuss\u00f5es na \u00e1rea, tem justificado o uso crescente desse recurso tecnol\u00f3gico complementar \u00e0 terapia tradicional. Al\u00e9m disso, a laringe tem especificidades anat\u00f4micas e histol\u00f3gicas, tais como as barreiras  at\u00e9 que a luz alcance os m\u00fasculos intr\u00ednsecos da laringe e as diferentes camadas das pregas vocais. Dessa forma, hipotetiza-se que a t\u00e9cnica pontual por contato seria mais adequada para utiliza\u00e7\u00e3o nessa regi\u00e3o,22.Quando questionados sobre os balizadores de aplica\u00e7\u00e3o da FBM na \u00e1rea de voz, todos os fonoaudi\u00f3logos utilizam a t\u00e9cnica de irradia\u00e7\u00e3o por contato pontual em regi\u00e3o lar\u00edngea. A t\u00e9cnica pontual por contato parece ser mais adequada para a irradia\u00e7\u00e3o na regi\u00e3o lar\u00edngea, uma vez que permite uma maior penetrabilidade da luz, maior precis\u00e3o da energia irradiada e baixa reflex\u00e3o da luz. Alguns estudos que utilizaram a eletroestimula\u00e7\u00e3o na voz aplicaram esta t\u00e9cnica nas l\u00e2minas da cartilagem tire\u00f3idea bilateralmente por ser uma localiza\u00e7\u00e3o oportuna, por ser mais pr\u00f3xima das pregas vocais e do nervo recorrente, garantindo uma estimula\u00e7\u00e3o na musculatura intr\u00ednseca da laringe, ligamento vocal propiciando uma estimula\u00e7\u00e3o efetiva. Al\u00e9m desse ponto de aplica\u00e7\u00e3o referido pela maioria dos fonoaudi\u00f3logos nesta pesquisa, a FBM tamb\u00e9m pode ser aplicada em voz na regi\u00e3o submandibular, para irradia\u00e7\u00e3o dos m\u00fasculos extr\u00ednsecos supra-hioideos e na regi\u00e3o intraoral, especificamente, no palato mole,24.Os fonoaudi\u00f3logos participantes referiram aplicar a FBM na l\u00e2mina da cartilagem tire\u00f3idea bilateralmente. As pregas vocais situam-se no interior da cartilagem tire\u00f3ide, tendo um de seus pontos de inser\u00e7\u00e3o nessa cartilagem. Dessa forma, a aplica\u00e7\u00e3o na cartilagem tire\u00f3ide tem por objetivo alcan\u00e7ar a estrutura trilaminar das pregas vocais.A maioria dos fonoaudi\u00f3logos utilizam a FBM antes da execu\u00e7\u00e3o dos exerc\u00edcios vocais. A prov\u00e1vel justificativa para esse uso pode estar relacionada \u00e0 necessidade de precis\u00e3o da irradia\u00e7\u00e3o, no ponto e local adequado. De maneira geral, a execu\u00e7\u00e3o dos exerc\u00edcios vocais com ativa\u00e7\u00e3o da fonte gl\u00f3tica ou deslocamento dos articuladores movimenta o arcabou\u00e7o lar\u00edngeo e pode deslocar o ponto anat\u00f4mico pr\u00e9-definido  e limitar o alcance dos efeitos esperados. Por outro lado, quando o objetivo est\u00e1 relacionado ao treinamento de for\u00e7a e ao efeito de longo prazo (cr\u00f4nico), a irradia\u00e7\u00e3o deve ser realizada imediatamente antes de cada sess\u00e3o de exerc\u00edcio. Nos casos que o objetivo \u00e9 o efeito cr\u00f4nico associado ao treinamento de resist\u00eancia, a indica\u00e7\u00e3o \u00e9 que a irradia\u00e7\u00e3o deva ocorrer imediatamente antes e imediatamente ap\u00f3s cada sess\u00e3o de exerc\u00edcio. Para os casos em que o objetivo \u00e9 a modula\u00e7\u00e3o da inflama\u00e7\u00e3o tecidual, a irradia\u00e7\u00e3o tamb\u00e9m \u00e9 recomendada antes da execu\u00e7\u00e3o de um exerc\u00edcio que envolva o recrutamento ou manipula\u00e7\u00e3o da \u00e1rea com inflama\u00e7\u00e3o tecidual,26. Sendo assim, embora n\u00e3o haja estudos espec\u00edficos quanto ao momento da irradia\u00e7\u00e3o na reabilita\u00e7\u00e3o de disf\u00f4nicos ou treinamento de vozes profissionais, por ila\u00e7\u00e3o, a evid\u00eancia dispon\u00edvel suporta a indica\u00e7\u00e3o do uso da FBM antes da atividade funcional  ou do exerc\u00edcio vocal.Al\u00e9m disso, h\u00e1 indica\u00e7\u00e3o para que a irradia\u00e7\u00e3o seja realizada entre cinco minutos a seis horas antes da atividade, quando o objetivo \u00e9 um efeito agudo, focado em um evento \u00fanico,11.O comprimento de onda 808-830nm foi o mais referido pelos fonoaudi\u00f3logos respondentes para aplica\u00e7\u00e3o na \u00e1rea de voz. Tal comprimento corresponde \u00e0 luz infravermelha, que possui maior intera\u00e7\u00e3o com camadas de tecido mais profundas. Dessa forma, a luz infravermelha parece ser mais adequada para ultrapassar as barreiras anat\u00f4micas e histol\u00f3gicas para atingir o n\u00edvel das pregas vocais,27. Dessa forma, a energia corresponde \u00e0 multiplica\u00e7\u00e3o da pot\u00eancia do equipamento pelo tempo de irradia\u00e7\u00e3o, resultando em um valor dado em Joules. Obviamente, o c\u00e1lculo da dose efetiva de luz irradiada que \u00e9 entregue ao tecido envolva outros par\u00e2metros, de modo que a energia irradiada tem sido utilizada comumente para a descri\u00e7\u00e3o da dose na cl\u00ednica fonoaudiol\u00f3gica. Embora 3-5 J por ponto tenha sido o valor mais referido, observou-se que h\u00e1 uma dispers\u00e3o nas respostas dos participantes. Tal fato refor\u00e7a que a dosimetria da FBM \u00e9 um dos aspectos importantes a ser discutido na \u00e1rea, considerando a possibilidade de super ou subdosagem, por exemplo.A dose de 3-5 J por ponto foi a mais referida pelos respondentes para a aplica\u00e7\u00e3o em pacientes com processos inflamat\u00f3rios nas pregas vocais. O conceito de dose em FBM est\u00e1 diretamente relacionado \u00e0 pot\u00eancia do equipamento utilizado e \u00e0 energia que ser\u00e1 utilizada em um ponto durante a sess\u00e3o de terapia,26. Essa dose \u00e9 preconizada para modular o potencial da membrana mitocondrial nos neur\u00f4nios, levando \u00e0 diminui\u00e7\u00e3o da gera\u00e7\u00e3o de ATP, bloqueio da inerva\u00e7\u00e3o sensorial, est\u00edmulo da homeostase mitocondrial, acelera\u00e7\u00e3o da cicatriza\u00e7\u00e3o tecidual e redu\u00e7\u00e3o da dor e edema.Na \u00e1rea de motricidade orofacial h\u00e1 uma indica\u00e7\u00e3o para o uso de doses de 3-4 J associado ao objetivo terap\u00eautico de analgesia e modula\u00e7\u00e3o da inflama\u00e7\u00e3o em casos de disfun\u00e7\u00e3o temporomandibular,29. A dosagem mais alta estimula as vias bioenerg\u00e9ticas das fibras musculares, a modula\u00e7\u00e3o enzim\u00e1tica e a modula\u00e7\u00e3o de esp\u00e9cies reativas de oxig\u00eanio, o que produz mitoc\u00f4ndrias maiores e mais funcionais, aumentando o consumo de oxig\u00eanio e reduzindo a fadiga muscular,30.A maioria dos fonoaudi\u00f3logos referiram utilizar a dosagem de 6-9 Joules para os casos de aperfei\u00e7oamento/condicionamento vocal. De maneira geral, observa-se uma tend\u00eancia ao uso de doses mais altas quando o objetivo est\u00e1 associado \u00e0 melhora do desempenho muscular. Sendo assim, considerando as dimens\u00f5es do pesco\u00e7o e as vari\u00e1veis citadas, consensos e estudos futuros podem verificar a necessidade de irradia\u00e7\u00e3o em mais pontos quando a aplica\u00e7\u00e3o for realizada na cl\u00ednica vocal. A aplica\u00e7\u00e3o em toda a extens\u00e3o da regi\u00e3o alvo ou musculatura que se deseja alcan\u00e7ar \u00e9 essencial para se obter um efeito biomodulador.Os fonoaudi\u00f3logos referiram irradiar dois pontos na regi\u00e3o lar\u00edngea nos casos de disfonia e aperfei\u00e7oamento vocal. A quantidade de pontos depende de vari\u00e1veis tais como, a extens\u00e3o do m\u00fasculo, o local de irradia\u00e7\u00e3o, a quantidade de tecido adiposo, entre outrosMais da metade dos fonoaudi\u00f3logos  referiram utilizar o ILIB na \u00e1rea de voz, essa t\u00e9cnica consiste na irradia\u00e7\u00e3o intravascular do sangue, que \u00e9 feita transdermicamente, por meio de um feixe luminoso na art\u00e9ria radial. O objetivo \u00e9 irradiar a corrente sangu\u00ednea e, com isso estimular a a\u00e7\u00e3o do organismo como um todo. O ILIB tem potenciais efeitos analg\u00e9sicos, espasmol\u00edticos e sedativos generalizados em quase todos os sistemas. No entanto, ainda n\u00e3o existem estudos cl\u00ednicos que d\u00eaem suporte \u00e0 utiliza\u00e7\u00e3o da t\u00e9cnica ILIB em pacientes com queixa de problema de voz ou para aperfei\u00e7oamento vocal.De maneira geral a FBM tem sido utilizada associada \u00e0 terapia vocal convencional, seja na reabilita\u00e7\u00e3o de indiv\u00edduos disf\u00f4nicos ou treinamento para condicionamento vocal de profissionais da voz falada ou cantada. As informa\u00e7\u00f5es do presente estudo permitem ter uma vis\u00e3o acerca do uso atual dessa ferramenta na cl\u00ednica vocal, assim como hipotetizar sobre as poss\u00edveis justificativas do seu uso nesse contexto. Na aus\u00eancia de evid\u00eancias externas robustas, a opini\u00e3o dos especialistas pode ser um primeiro passo para compreender o uso de uma nova ferramenta.Al\u00e9m disso, o levantamento apresentado neste manuscrito pode servir de base para a realiza\u00e7\u00e3o de pesquisas experimentais e ensaios cl\u00ednicos randomizados para verificar as hip\u00f3teses relacionadas aos efeitos da FBM em indiv\u00edduos disf\u00f4nicos e vocalmente saud\u00e1veis.Esse estudo tem um car\u00e1ter explorat\u00f3rio, contribuindo para a compreens\u00e3o transversal sobre como os especialistas t\u00eam compreendido e utilizado a FBM em sua pr\u00e1tica. Al\u00e9m disso, tem a sua utilidade hist\u00f3rica, por permitir compara\u00e7\u00f5es no futuro. Sendo assim, a amostra por conveni\u00eancia recrutada pode ser representativa da realidade investigada em um recorte transversal. Uma das poss\u00edveis limita\u00e7\u00f5es do presente estudo pode ser o n\u00famero de participantes. A coleta de dados aconteceu no ano de 2020, em meio \u00e0 pandemia pela COVID-19 no seu momento mais cr\u00edtico. Tal fato pode ter influenciado para a reduzida ades\u00e3o dos participantes. Al\u00e9m disso, inqu\u00e9ritos futuros com essa popula\u00e7\u00e3o podem incluir entre as suas quest\u00f5es a dura\u00e7\u00e3o e o conte\u00fado obrigat\u00f3rio na capacita\u00e7\u00e3o para o uso da FBM na cl\u00ednica vocal.Todos os fonoaudi\u00f3logos participantes relataram conhecer os preceitos da FBM, bem como a sua utiliza\u00e7\u00e3o na \u00e1rea de Voz. A maioria dos respondentes adquiriu conhecimentos sobre a FBM em uma p\u00f3s-gradua\u00e7\u00e3o. Na \u00e1rea de Voz, os fonoaudi\u00f3logos referiram que, de maneira geral, utilizavam o m\u00e9todo de irradia\u00e7\u00e3o por contato pontual em regi\u00e3o lar\u00edngea, com aplica\u00e7\u00e3o da FBM antes da execu\u00e7\u00e3o dos exerc\u00edcios vocais e com o comprimento de onda 808-830nm. Os respondentes utilizavam uma dose de 3-5 Joules para os casos de pacientes com processos inflamat\u00f3rios nas pregas vocais, e 6-9 Joules como par\u00e2metros dosim\u00e9tricos para clientes cujo objetivo \u00e9 o aperfei\u00e7oamento/condicionamento vocal."}
+{"text": "To develop and present an instrument to evaluate and monitor the quality of medical residency programs in residencies in family and community medicine (FCM) based on preceptors and residents, considering the insertion of the health network program. The instrument was developed in three stages: 1) interview with the preceptors of FCM; 2) literature review; and 3) production, adequacy, and approval of the evaluation instrument by renowned professionals of the Brazilian FCM. The third stage included 9 people and used the Delphi technique with 80% agreement. For the qualitative results, Bardin\u2019s Content Analysis was used. In all, there were five evaluation cycles to adapt the proposed recommendations, with the elimination of one item and weighting, with a results analysis methodology of 10 resulting items, reaching an expected matrix for organizing residency programs in the health network, divided into 3 domains: Organization of the Unit, Human Resources, and Preceptor-resident relationship. An instrument for evaluating and monitoring residency programs in family and community medicine can be a tool to facilitate program managers and allow evaluation and monitoring, continuously qualifying them. Some authors report that it began in the United States with medical and surgical clinics in the late 19th century. In Brazil, it is legally considered a postgraduate course, a specialization modality, focused on in-service training, existing since 19441, showing a small expansion of vacancies until 2013 compared to the following period (2013\u20132021)2. As of Law 12,871/13, known as the Mais M\u00e9dicos Law, the number of vacancies occupied increased from 206 in 2011 to more than 2,282 (an increase of 11.7 times), data from October 2021. The state of S\u00e3o Paulo had 62 medical residency programs (MRP) in MFC registered, with 37 programs with residents , corresponding to 17.8% of the MFC residents in Brazil, being the state with the highest number3 in 2021. The data for 2021 were obtained from the Law on Access to Information4.Residencies in Family and Community Medicine (FCM) began in 19763for more than 43,000 Family Health teams5. This discrepancy intensifies when observing their distribution, as they are mostly present in the South and Southeast, corresponding to 71.4% of specialists in Brazil and 46% of family health units5.As much as the Family Health Strategy (FHS) is based on the presence of a FCM specialist as a medical professional, the country has approximately 7,000 FCM professionals3. To calculate the ideal ratio, it is possible to infer that each family and community doctor is responsible for 4,000 people6, that is, the country would need a ratio of 25 family and community doctors per 100,000 inhabitants. Thus, considering that in 2020, approximately 1,500 new specialists were trained in residency, maintaining the current volume of vacancies occupied, the country would only reach the number of specialists needed after two decades, without considering losses over time.Amap\u00e1, Bahia, Maranh\u00e3o, and Piau\u00ed have less than 1.1 specialists per 100,000 inhabitants, whereas Acre, Distrito Federal, Rio Grande do Sul, and Santa Catarina have between 4.9 and 8.7 specialists per 100,000 inhabitants7.Given the scarcity and concentration of specialists, training depends on preceptors from other areas of activity, who are legally qualified for such a role, according to the specific legislation of the MRP-FCM, unlike other areas, which require expertise in the area of training as a prerequisite for the functionThis probably implies great variability in training conditions. In addition to this situation, there is also a lack of information and standards for minimum conditions of a physical structure and adequate inputs to guarantee training. With this, the programs need guidelines for opening and expanding vacancies in an orderly manner and capable of supplying training, considering the uniqueness of FCM, which operates predominantly in the FHS/Primary Health Care (PHC).8. Donabedian11 reinforces that the evaluation process requires continuous monitoring of the health service, seeking to detect and correct departures from standards, being able to evaluate structures, processes and results obtained. In view of these factors, this study proposed a matrix for evaluating and monitoring residency programs in FCM in Brazil, with a focus on PHC.For this, it is necessary to understand the service itself and evaluate it. This act involves issuing a value judgment based on a predetermined standard or an ideal reference, looking for flaws and correcting themThis is an evaluative, descriptive, and exploratory methodology study, starting in 2018 to 2021. It consists of quantitative and qualitative research, using an electronic form to obtain responses from participants and a literature review for complementation and characterization of the instrument presented at the end.This study developed a matrix instrument to define the training conditions offered by medical residency programs in FCM based on the PHC structure. The construction was divided into three stages of development, starting with understanding the preceptor\u2019s reality and ending with the proposition of an evaluative instrument with the possibility of nationwide application.12, which listed the strengths, opportunities, weaknesses, and threats (SOWT) that 67 preceptors perceive in their work and in the MRP-FCM.In the first stage, 132 FCM preceptors from the state of S\u00e3o Paulo were invited from February to November 2018, applying a Google Forms, with open and closed questions. All professionals were invited via e-mail to understand the professional\u2019s characteristics and the work they perform. The complete results have been reported in a specific article12. The framework constructed allowed obtaining responses that could be evaluated in PHC, generating a matrix of recommendations on FCM residency programs, completing the second stage of the matrix to be validated nationally.With the answers obtained, the second stage began with a review of national and international literature, resolutions and ordinances on medical residency in general and FCM, comparing the literature with the preceptors\u2019 perception, superimposing SWOT with the Donabedian triad13. The presidents of all active FCM state associations and the president of the Brazilian Society of Family and Community Medicine were invited to participate, comprising 24 people. These were chosen by the authors considering their regional diversity and national representativeness. The president of the S\u00e3o Paulo state association was excluded for being the project\u2019s author.The third stage peer-validated the document, ensuring quality homogeneity, with the possibility of use in all regions. For that purpose, the instrument was presented to a group of FCM experts, using the Delphi methodThe Delphi questionnaire had the same structure for all questions: Description of the evaluated item, questions about the pertinence and permanence of the item in the final questionnaire (yes and no), 0-10 Likert scales about the relevance of the item and what score or value this item should receive in the program evaluation (0 to 10). Open questions about wording suggestions and comments on the score and topic in question were also included in all items to improve the item. For the items to be maintained, a consensus among the judges had to be reached, the cut-off value for maintenance was 80%, with lower values for non-approval of the item.For open questions, with text suggestion and verification sources, Bardin\u2019s Analysis was used, allowing to adjust the writing, justify exclusions, and merge items if necessary.Both surveys, with both the preceptor and the judges, were approved by the Research Ethics Committees, under protocols CAAE 78853317.0.0000.5411 and 30805420.5.0000.5440.At the end of the discussion cycles, the recommendations were reassessed by the authors, organized, and compared with current legislation.Phase 1 responses showed that 70% of respondents were FCM specialists and more than 90% had some specific training in preceptorship. Although 62% (42 people) considered themselves quite satisfied with their performance, 27 people reported great difficulty at work.The rewards most frequently reported by preceptors were: qualification in the area, keeping up-to-date, personal qualification, and participating in a transformation process. The challenges were: excessive demand versus difficulty in teaching time, undervaluation of the specialty, difficulty in the relationship with local management and difficulty in the teaching process, insufficient physical space for education, and difficulty in organizing the unit\u2019s agenda.By associating the preceptor\u2019s point of view with the national and international literature on medical residency and on the specific area, a matrix of recommendations for FCM residency programs (stage 2) was produced. It was presented to the judges for continuing the construction process. Altogether, it took five evaluation cycles among the judges to obtain at least 80% agreement, with nine participants. The questionnaire started with 12 items and ended with 11 items, with the elimination of the question about the obligation for the preceptor to have a period of assistance exclusively before starting the trainer role, justified by the country having a low number of specialized professionals . The FigThe instrument was divided into Unit Organization , Human R15.The results of the work show that most of the preceptors in the state of S\u00e3o Paulo are specialists in the area and trained for the position of educators. Their main difficulties in exercising the position are related to organizing the agenda, the unit and the relationship with municipal managers, who often have different objectives in relation to the function of medical residency, seeing the resident as a team doctor and not a doctor in training. Similar data were perceived in other works on residency in FCM16. Thus, the instrument includes the structure and training processes, adapted from Donabedian\u2019s triad and the preceptors\u2019 experience12.From the preceptors\u2019 words and the current legislation, recommendations are proposed applicable to medical residency programs in Family and Community Medicine, which are validated by judges, resulting in a matrix with 11 items, organized into 3 cores: unit organization, humans resource, and preceptor-resident relationship. This makes it possible to observe training from a more realistic perspective compared to what is currently done, as carried out by multidisciplinary residency in health17, with educational training in PHC also unique, as demonstrated in other studies19.When observing the instrument, the first evaluated group (A1 to A3) are the unit\u2019s physical and organizational resources, of which physical space, the possibility of developing the expected competencies in the residency, and the organization of the unit are evaluated, aspects that directly influence resident training. Unlike hospital residencies, in which the service structure is a rotating one, PHC is characterized by being solution-oriented, close to individuals (accessible), with a community focus and a multidisciplinary team21, being corroborated by the judges as points to be observed in the program. This is a critical point that demonstrates the need for dialogue between teaching and assistance.The above points were listed as challenges by the preceptors in the state of S\u00e3o Paulo in working on the residency and coincide with those found in previous research22.When evaluating domain A, the three components converge to two essential points: population size and physical structure of the residency unit/program, since they delimit the appointment schedule, health unit activities, and teaching-learning scenarios and methodologies, in addition to the health and residency financing itself. Thus, the adaptation of learning scenarios interferes with the organization of municipal health departments due to the needs of population coverage, health financing, adequacy of physical space and health teams, including the legislation that governs such aspects 23. However, the presence of these challenges demonstrates that it is necessary to improve the dialogue and definition of work processes between residency and municipal management, as other works have already demonstrated that the objectives are different15, making it difficult for the MRP-FCM to achieve its objectives: education based on quality service and training model.The adequate population size per team in \u201cschool-units\u201d is suggested since 2015 as a maximum of 3,000 people, in addition to moments of permanent education for both the preceptor and the resident and what would be their functions in the unitTherefore, component A of the recommendations is mandatory, since it is necessary to observe the unit and how it is integrated into the municipality, from the population covered to the work process of resident training.24.It is known that from the genesis of legislation to its effective implementation, several steps are necessary with constant monitoring to adapt the structure and process. Thus, the presented matrix can be a strategy to achieve this objective, as carried out in the urgency and emergency network26.Another learning scenario that can be inserted in training is the simulation labs. By its nature, FCM requires simulations involving the behavioral domain (such as those developed with actors) and technical skills (such as placement of an intrauterine device), being a new learning strategy to be acquired by preceptors and a new scenario for residencyIn the second group of questions (B1 to B4), involved in the Human Resources domain, two items had a high acceptance value by the judges: if the preceptor is a specialist in FCM (B1) and if the preceptor receives a differentiated value in their salary (B4).27. Despite the judges\u2019 desire for specialists in the field to train residents, the national policy for medical residency in FCM allows the activity of professionals from other areas as preceptors23, possibly because of the low number of specialists. With this, it is mandatory to assess whether the residency preceptors are specialists in the field or if they have the competence to exercise the position, which is contemplated by the instrument developed.In 2020, there were 7,149 specialist professionals in the field, with an increase of 3,127 professionals in the last 5 years22. However, although studies show that preceptors do not routinely receive scholarships28, there is already evidence that this is not the main motivation for professionals to exercise this function28. Furthermore, the use of any financial incentive must be coupled with production indicators for it to be an effective inducing policy. However, the judges did not specify the reason for their choice, which prevents an assertive conclusion on the topic and could be an opportunity to improve the instrument in future versions.The second item that received maximum weighting was scholarship supplementation to be a preceptor (B4). This is an item that the Ministry of Health has encouraged since 2019, with remuneration for the municipality and the preceptor29. When observing the preceptor, many do not clearly and homogeneously define the FCM specialty28. Thus, it is mandatory that the program systematically present the specialty to all those involved, ensuring adequate knowledge of the field (items B2 and B3).The other items in group B address the aspect of education through work, permanent education and continuing education, being professional qualification health policies30. Finally, training as an educator provides preceptors with a greater quantity and quality of educational and care tools25(B2).Furthermore, considering Permanent Education as a health policy, its presence in the residency is essential31.The third evaluation domain (C1 and C2) required the most evaluation cycles by the judges, as it aimed to reach a consensus on the number of students per preceptor, a value already determined by the National Commission for Medical Residency, with 6 residents per preceptor 40 hours28.Despite this predetermined number, the programs vary greatly, with proportions ranging from 1 to 9 residents per preceptor in the state of S\u00e3o Paulo. In addition to residents, 67% of preceptors are responsible for undergraduates and other non-medical areas, increasing the number of trainees per professional28. Although a lower resident-to-preceptor ratio is likely to be adequate, until the desired number of preceptors is reached, this item will continue to differ across programs. The repeated use of the instrument may provide data on the evolution of this indicator (preceptor/resident ratio) and its comparison between the regions, allowing intervention with the responsible instances for the continuous improvement of the programs.Such data correspond to significantly higher numbers as compared to programs abroadAlso in this domain, the number of students per preceptor is presented, resulting from the sum of FCM residents and students from other instances (undergraduate and multidisciplinary residency). It is important to observe this number because the more students who are under the tutelage of the preceptor, the less time dedicated to the residency and to the student.32.Finally, the item excluded from the initial questionnaire, following the judges\u2019 advice, was \u201cHiring professionals already with a minimum period of assistance prior to preceptorship work (\u201cflight hours\u201d)\u201d, with at least 3 years of experience before preceptorship as the source of verification, as described for residency in Portugal28.The justification is that the country still does not have a sufficient number of specialist professionals in the field to adequately provide assistance, teaching, management and preceptorship. Thus, it is necessary for the recent residency graduate to already take on a team to train new residents, which actually happens in practice33.As limitations of this study, we can point out that the instrument was developed using as a basis only preceptors from the state of S\u00e3o Paulo, which is the state with the highest number of FCM programs implemented in stage 1. Stages 2 and 3 were nationwide in scope. It will still be necessary to validate the instrument in other federation states with different realities. It is also important to emphasize that any evaluation process should not be based on just one tool, but a set of toolsThis work proposes an evaluative instrument of structures and processes for FCM residency programs divided into three domains: Unit Organization, Human Resources and Preceptor-Resident Relationship. Such an instrument, when properly validated, may allow the continuous evaluation of programs to ensure the implementation of public policies that govern FCM residency. 1.A resid\u00eancia m\u00e9dica \u00e9 considerada a melhor estrat\u00e9gia para forma\u00e7\u00e3o de novos especialistas m\u00e9dicos, considerada uma forma\u00e7\u00e3o ap\u00f3s a gradua\u00e7\u00e3o. Alguns autores relatam que teve in\u00edcio nos Estados Unidos com as cl\u00ednicas m\u00e9dica e cir\u00fargica, no final do s\u00e9culo XIX. No Brasil, ela \u00e9 considerada legalmente como curso de p\u00f3s-gradua\u00e7\u00e3o, modalidade de especializa\u00e7\u00e3o, com foco no treinamento em servi\u00e7o, existindo desde 19441 e apresentaram uma expans\u00e3o pequena de vagas at\u00e9 2013 em compara\u00e7\u00e3o com o per\u00edodo seguinte (2013\u20132021)2. A partir da Lei 12.871/2013, conhecida como Lei Mais M\u00e9dicos, o n\u00famero de vagas ocupadas passou de 206 em 2011 para mais de 2.282  \u2013 dados de outubro de 2021. O estado de S\u00e3o Paulo possu\u00eda 62 programas de resid\u00eancia m\u00e9dica (PRM) em MFC cadastrados, com 37 programas com residentes , correspondendo a 17,8% dos residentes em MFC do Brasil, sendo o estado com maior n\u00famero3 no ano de 2021. Os dados do ano de 2021 foram obtidos a partir da Lei de Acesso \u00e0 Informa\u00e7\u00e3o4.As resid\u00eancias em medicina de fam\u00edlia e comunidade (MFC) iniciaram em 19763 para mais de 43 mil equipes de Sa\u00fade da Fam\u00edlia no pa\u00eds5. Essa discrep\u00e2ncia se intensifica quando observada a distribui\u00e7\u00e3o desses profissionais, presentes em sua maioria no Sul e Sudeste, correspondendo a 71,4% dos especialistas do Brasil e 46% das unidades de sa\u00fade da fam\u00edlia5.Por mais que a Estrat\u00e9gia Sa\u00fade da Fam\u00edlia (ESF) esteja pautada na presen\u00e7a do especialista em MFC como profissional m\u00e9dico, h\u00e1 aproximadamente 7 mil profissionais de MFC3. Para fazer o c\u00e1lculo da rela\u00e7\u00e3o ideal, \u00e9 poss\u00edvel inferir que cada m\u00e9dico de fam\u00edlia e comunidade \u00e9 respons\u00e1vel por 4 mil pessoas6, ou seja, o pa\u00eds necessitaria da rela\u00e7\u00e3o de 25 m\u00e9dicos de fam\u00edlia e comunidade por 100 mil habitantes. Assim, considerando que no ano de 2020 foram formados aproximadamente 1.500 novos especialistas pela resid\u00eancia, mantendo o atual volume de vagas ocupadas, o pa\u00eds s\u00f3 atingiria o n\u00famero de especialistas necess\u00e1rios ap\u00f3s duas d\u00e9cadas, sem considerar perdas ao longo do tempo.Amap\u00e1, Bahia, Maranh\u00e3o e Piau\u00ed apresentam menos de 1,1 especialista em MFC por 100 mil habitantes, enquanto Acre, Distrito Federal, Rio Grande do Sul e Santa Catarina t\u00eam entre 4,9 e 8,7 especialistas por 100 mil habitantes7.Perante a escassez e concentra\u00e7\u00e3o de especialistas, a forma\u00e7\u00e3o depende de preceptores de outras \u00e1reas de atua\u00e7\u00e3o, os quais s\u00e3o legalmente habilitados para tal papel, segundo a legisla\u00e7\u00e3o espec\u00edfica dos PRM-MFC, diferentemente de outras \u00e1reas, que exigem especialidade na \u00e1rea de forma\u00e7\u00e3o como pr\u00e9-requisito para a fun\u00e7\u00e3oIsso provavelmente implica grande variabilidade nas condi\u00e7\u00f5es de forma\u00e7\u00e3o. Soma-se a essa situa\u00e7\u00e3o a exist\u00eancia de informa\u00e7\u00f5es e padr\u00f5es para condi\u00e7\u00f5es m\u00ednimas de uma estrutura f\u00edsica e insumos adequados para garantir a forma\u00e7\u00e3o. Com isso, os programas necessitam de diretrizes para a abertura e expans\u00e3o de vagas de forma ordenada e capaz de suprir a forma\u00e7\u00e3o, considerando a singularidade da MFC, que atua predominantemente na ESF/aten\u00e7\u00e3o prim\u00e1ria \u00e0 sa\u00fade (APS).8. Donabedian11 refor\u00e7a que o processo de avaliar exige um monitoramento cont\u00ednuo do servi\u00e7o de sa\u00fade, buscando detectar e corrigir desvios de padr\u00f5es, e pode avaliar estruturas, processos e resultados obtidos. Diante desses fatores, este estudo prop\u00f4s uma matriz para avalia\u00e7\u00e3o e monitoramento dos PRM-MFC no Brasil, com enfoque na APS.Para tal, \u00e9 necess\u00e1rio compreender o pr\u00f3prio servi\u00e7o e avali\u00e1-lo. Esse ato consiste em emitir um ju\u00edzo de valor a partir de um padr\u00e3o predeterminado ou um referencial ideal, buscando falhas e corrigindo-asTrata-se de um estudo de metodologia avaliativa, descritiva e explorat\u00f3rio iniciado em 2018 e constitu\u00eddo de pesquisa quantitativa e qualitativa, com uso de formul\u00e1rio eletr\u00f4nico para obten\u00e7\u00e3o de respostas dos participantes e revis\u00e3o de literatura para complementa\u00e7\u00e3o e caracteriza\u00e7\u00e3o do instrumento apresentado ao final.Este estudo desenvolveu um instrumento matriz para definir as condi\u00e7\u00f5es de forma\u00e7\u00e3o ofertadas pelos PRM-MFC com base na estrutura da APS. A constru\u00e7\u00e3o foi dividida em tr\u00eas est\u00e1gios de desenvolvimento, buscando inicialmente compreender a realidade na perspectiva do preceptor e finalizando com a proposi\u00e7\u00e3o de um instrumento avaliativo com possibilidade de aplica\u00e7\u00e3o em \u00e2mbito nacional.12, no qual foram enumeradas as for\u00e7as, oportunidades, fraquezas e amea\u00e7as (FOFA) que 67 preceptores percebem em seu trabalho e nos PRM-MFC.No primeiro est\u00e1gio, foram convidados 132 preceptores em MFC do estado de S\u00e3o Paulo, entre fevereiro e novembro de 2018, aplicando-se um formul\u00e1rio do Google com quest\u00f5es abertas e fechadas. Todos os profissionais foram convidados via correio eletr\u00f4nico, com o objetivo de compreender caracter\u00edsticas do participante e do trabalho que realiza. Os resultados completos est\u00e3o em artigo espec\u00edfico12. O quadro constru\u00eddo permitiu obter as respostas pass\u00edveis de avalia\u00e7\u00e3o na APS e gerar uma matriz de recomenda\u00e7\u00f5es sobre PRM-MFC, finalizando o segundo est\u00e1gio da matriz a ser validada nacionalmente.Com as respostas obtidas, o segundo est\u00e1gio iniciou com a revis\u00e3o de literatura nacional e internacional, resolu\u00e7\u00f5es e portarias sobre resid\u00eancia m\u00e9dica em geral e de MFC, comparando a literatura com a percep\u00e7\u00e3o dos preceptores e sobrepondo a FOFA com a tr\u00edade de Donabedian13. Foram convidados a participar os presidentes de todas as associa\u00e7\u00f5es estaduais ativas de MFC e o presidente da Sociedade Brasileira de Medicina de Fam\u00edlia e Comunidade, contemplando 24 pessoas. Eles foram escolhidos pelos autores considerando sua diversidade regional e representatividade nacional. O presidente da estadual paulista foi exclu\u00eddo por ser o autor do projeto.O terceiro est\u00e1gio validou por pares o documento, garantindo a homogeneidade de qualidade, com possibilidade de uso em todas as regi\u00f5es. Para tanto o instrumento foi apresentado a um grupo de ju\u00edzes especialistas em MFC, utilizando-se o m\u00e9todo DelphiO question\u00e1rio Delphi possu\u00eda estrutura igual para todas as quest\u00f5es: descri\u00e7\u00e3o do item avaliado, perguntas sobre a pertin\u00eancia e perman\u00eancia do item no question\u00e1rio final (sim e n\u00e3o), escalas Likert de 0 a 10 sobre a relev\u00e2ncia do item e que nota ou valor esse item deveria receber na avalia\u00e7\u00e3o do programa (0 a 10). Tamb\u00e9m foram inseridas perguntas abertas sobre sugest\u00f5es de escrita, coment\u00e1rios sobre a nota e sobre o tema em quest\u00e3o em todos os itens para aperfei\u00e7o\u00e1-los. Para manuten\u00e7\u00e3o dos itens, deveria haver consenso entre os ju\u00edzes, sendo considerado o valor de corte de 80%, valores menores acarretariam a n\u00e3o aprova\u00e7\u00e3o do item.Para as quest\u00f5es abertas, com sugest\u00e3o do texto e fontes de verifica\u00e7\u00e3o, foi utilizada a an\u00e1lise de Bardin, permitindo adequar a escrita, justificar elimina\u00e7\u00f5es e fundir itens, se necess\u00e1rio.Ambas as pesquisas, tanto com preceptores, quanto com os ju\u00edzes, foram aprovadas por comit\u00eas de \u00e9tica em pesquisa, sob os protocolos CAAE 78853317.0.0000.5411 e 30805420.5.0000.5440.Ao final dos ciclos de discuss\u00e3o, as recomenda\u00e7\u00f5es foram reavaliadas pelos autores, organizadas e cotejadas com a legisla\u00e7\u00e3o vigente.As respostas da fase 1 demonstraram que 70% dos entrevistados eram especialistas em MFC e mais de 90% tinham alguma forma\u00e7\u00e3o espec\u00edfica em preceptoria. Embora 62% (42 indiv\u00edduos) tenham se considerado bastante satisfeitos com sua atua\u00e7\u00e3o, 27 pessoas relataram grande dificuldade no trabalho.versus dificuldade no tempo de ensino, subvaloriza\u00e7\u00e3o da especialidade, dificuldade na rela\u00e7\u00e3o com a gest\u00e3o local e dificuldade no processo de ensino, espa\u00e7o f\u00edsico insuficiente para educa\u00e7\u00e3o e dificuldade na organiza\u00e7\u00e3o da agenda da unidade.As recompensas apresentadas pelos preceptores com maior frequ\u00eancia s\u00e3o: qualifica\u00e7\u00e3o na \u00e1rea, atualiza\u00e7\u00e3o, qualifica\u00e7\u00e3o pessoal e participa\u00e7\u00e3o em um processo de transforma\u00e7\u00e3o. Os desafios foram: demanda excessiva Associando a vis\u00e3o do preceptor com a literatura nacional e internacional sobre resid\u00eancia m\u00e9dica e na \u00e1rea em espec\u00edfico, foi produzida a matriz de recomenda\u00e7\u00f5es a PRM-MFC (est\u00e1gio 2). Ela foi apresentada aos ju\u00edzes para a continuidade do processo de constru\u00e7\u00e3o. Ao todo, foram necess\u00e1rios cinco ciclos de avalia\u00e7\u00e3o entre os ju\u00edzes at\u00e9 obter a concord\u00e2ncia de pelo menos 80%, com nove participantes. O question\u00e1rio tinha inicialmente 12 itens e foi finalizado com 11, com a elimina\u00e7\u00e3o da quest\u00e3o sobre a obrigatoriedade de o preceptor ter um per\u00edodo de assist\u00eancia exclusiva antes de iniciar o papel de formador, o que se justificou pelo pa\u00eds ter baixo n\u00famero de profissionais especialistas . O proceO instrumento foi dividido em organiza\u00e7\u00e3o da unidade , recurso15.Os resultados do trabalho demonstram que em sua maioria os preceptores do estado de S\u00e3o Paulo s\u00e3o especialistas na \u00e1rea e t\u00eam forma\u00e7\u00e3o para o cargo de educadores. Suas principais dificuldades em exercer o cargo est\u00e3o relacionadas \u00e0 organiza\u00e7\u00e3o da agenda e da unidade, bem como \u00e0 rela\u00e7\u00e3o com os gestores municipais. Estes muitas vezes t\u00eam objetivos diferentes em rela\u00e7\u00e3o \u00e0 fun\u00e7\u00e3o da resid\u00eancia m\u00e9dica, observando o residente como um m\u00e9dico da equipe e n\u00e3o um m\u00e9dico em forma\u00e7\u00e3o. Dados semelhantes foram percebidos em outros trabalhos sobre resid\u00eancia em MFC16. Assim, o instrumento contempla a estrutura e processos de forma\u00e7\u00e3o, adaptados da tr\u00edade de Donabedian, e a viv\u00eancia dos preceptores12.Considerando a fala dos preceptores e a legisla\u00e7\u00e3o atual, prop\u00f5em-se recomenda\u00e7\u00f5es aplic\u00e1veis aos PRM-MFC que foram validadas por ju\u00edzes, resultando em uma matriz com 11 itens, organizados em tr\u00eas n\u00facleos: organiza\u00e7\u00e3o da unidade, recursos humanos e rela\u00e7\u00e3o preceptor-residente. Isso permite observar a forma\u00e7\u00e3o com uma \u00f3ptica mais real\u00edstica em compara\u00e7\u00e3o ao que \u00e9 realizado atualmente, como o que ocorre na resid\u00eancia multiprofissional em sa\u00fade17, sendo a forma\u00e7\u00e3o educacional na APS tamb\u00e9m singular, como demonstrado em outros trabalhos19.Quando observado o instrumento, o primeiro grupo avaliado (A1 a A3) contempla os recursos f\u00edsicos e organizativos da unidade, dos quais s\u00e3o avaliados o espa\u00e7o f\u00edsico, a possibilidade de desenvolver as compet\u00eancias esperadas na resid\u00eancia e a organiza\u00e7\u00e3o da unidade, aspectos que influenciam diretamente a forma\u00e7\u00e3o do residente. Diferentemente de resid\u00eancias hospitalares, em que a estrutura do servi\u00e7o \u00e9 de rotatividade, a APS tem como caracter\u00edsticas ser resolutiva, pr\u00f3xima dos indiv\u00edduos (acess\u00edvel), com enfoque comunit\u00e1rio e em equipe multirpofissional21, sendo corroborados pelos ju\u00edzes como pontos a serem observados no programa. Esse \u00e9 um ponto cr\u00edtico que demonstra a necessidade da interlocu\u00e7\u00e3o ensino-assist\u00eancia.Esses pontos foram elencados pelos preceptores do estado de S\u00e3o Paulo como desafios de atuar na resid\u00eancia e coincidem com os achados de pesquisas anteriores22.Quando avaliado o dom\u00ednio A, os tr\u00eas componentes convergem para dois pontos essenciais: tamanho populacional e estrutura f\u00edsica da unidade/programa de resid\u00eancia, pois delimitam a agenda de consultas, atividades da unidade de sa\u00fade e cen\u00e1rios e metodologias de ensino-aprendizagem, al\u00e9m do pr\u00f3prio financiamento da sa\u00fade e da resid\u00eancia. Assim, a adequa\u00e7\u00e3o de cen\u00e1rios de aprendizagem se interp\u00f5e com a pr\u00f3pria organiza\u00e7\u00e3o das secretarias municipais de sa\u00fade pelas necessidades de cobertura populacional, financiamento em sa\u00fade, adequa\u00e7\u00e3o de espa\u00e7o f\u00edsico e equipes de sa\u00fade, inclusive pela legisla\u00e7\u00e3o que rege tais aspectos23. Contudo, a presen\u00e7a desses desafios demonstra que \u00e9 preciso aprimorar a interlocu\u00e7\u00e3o e defini\u00e7\u00e3o de processos de trabalho entre a resid\u00eancia e a gest\u00e3o municipal, pois j\u00e1 foi demonstrado por outros trabalhos que os objetivos s\u00e3o diferentes15, dificultando que o PRM-MFC atinja seu objetivo: educa\u00e7\u00e3o baseada no servi\u00e7o de qualidade e modelo formativo.O tamanho populacional adequado por equipe em \u201cunidades-escola\u201d sugerido desde 2015 \u00e9 o m\u00e1ximo de 3 mil pessoas. Al\u00e9m disso, recomendam-se momentos de educa\u00e7\u00e3o permanente para o preceptor e para o residente e a delimita\u00e7\u00e3o de suas fun\u00e7\u00f5es na unidadeSendo assim, o componente A das recomenda\u00e7\u00f5es \u00e9 mandat\u00f3rio, pois \u00e9 preciso observar a unidade e como ela est\u00e1 inserida no munic\u00edpio, desde a popula\u00e7\u00e3o coberta at\u00e9 o processo de trabalho da forma\u00e7\u00e3o do residente.24.\u00c9 conhecido que desde a g\u00eanese de uma legisla\u00e7\u00e3o at\u00e9 sua efetiva implementa\u00e7\u00e3o v\u00e1rias etapas s\u00e3o necess\u00e1rias com monitoriza\u00e7\u00e3o constante para adequar a estrutura e processo. Assim, a matriz apresentada pode ser uma estrat\u00e9gia para atingir esse objetivo, como realizado na rede de urg\u00eancias e emerg\u00eancias26.Outro cen\u00e1rio de aprendizagem que pode ser inserido na forma\u00e7\u00e3o s\u00e3o os laborat\u00f3rios de simula\u00e7\u00e3o. Por sua natureza, a MFC necessita de simula\u00e7\u00f5es que envolvam o dom\u00ednio comportamental (como aquelas desenvolvidas com atores) e habilidades t\u00e9cnicas (como coloca\u00e7\u00e3o de dispositivo intrauterino), sendo uma nova estrat\u00e9gia de aprendizagem a ser adquirida pelos preceptores e novo cen\u00e1rio para a resid\u00eanciaNo segundo grupo de quest\u00f5es (B1 a B4), envolvido no dom\u00ednio recursos humanos, dois itens apresentaram alto valor de aceita\u00e7\u00e3o pelos ju\u00edzes: o preceptor \u00e9 especialista em MFC (B1) e o preceptor recebe um valor diferenciado em seu sal\u00e1rio (B4).27. Apesar de os ju\u00edzes apontarem o desejo de que haja especialistas na \u00e1rea para a forma\u00e7\u00e3o de residentes, a pol\u00edtica nacional de resid\u00eancia m\u00e9dica em MFC permite a atividade de profissionais de outras \u00e1reas como preceptores23, uma justificativa pode ser o baixo n\u00famero de especialistas. Com isso, \u00e9 mandat\u00f3rio avaliar se os preceptores da resid\u00eancia s\u00e3o especialistas na \u00e1rea ou t\u00eam compet\u00eancia para exercer o cargo, o que est\u00e1 contemplado pelo instrumento desenvolvido.No ano de 2020 existiam 7.149 profissionais especialistas na \u00e1rea, ocorrendo um aumento de 3.127 profissionais nos \u00faltimos 5 anos22. No entanto, apesar de estudos demonstrarem que o preceptor n\u00e3o recebe bolsa rotineiramente28, j\u00e1 h\u00e1 evid\u00eancias de que essa n\u00e3o \u00e9 a principal motiva\u00e7\u00e3o para que os profissionais exer\u00e7am essa fun\u00e7\u00e3o28. Ademais, a utiliza\u00e7\u00e3o de qualquer incentivo financeiro deve estar relacionada a indicadores de produ\u00e7\u00e3o para que seja uma pol\u00edtica indutora efetiva. Entretanto, os ju\u00edzes n\u00e3o especificaram o motivo de sua escolha, o que impede uma conclus\u00e3o assertiva sobre o tema e poderia ser uma oportunidade de aprimoramento do instrumento em vers\u00f5es futuras.O segundo item que recebeu pondera\u00e7\u00e3o m\u00e1xima foi a complementa\u00e7\u00e3o de bolsa para ser preceptor (B4), algo que o Minist\u00e9rio da Sa\u00fade incentiva desde 2019, com a remunera\u00e7\u00e3o para o munic\u00edpio e para o preceptor29. Quando aos preceptores, muitos n\u00e3o definem de forma clara e homog\u00eanea a especialidade MFC28. Assim, \u00e9 mandat\u00f3rio que o programa apresente sistematicamente a especialidade a todos os envolvidos, garantindo adequado conhecimento da \u00e1rea (itens B2 e B3).Os outros itens do grupo B visam o aspecto de educa\u00e7\u00e3o pelo trabalho, educa\u00e7\u00e3o permanente e educa\u00e7\u00e3o continuada, sendo pol\u00edticas de sa\u00fade de qualifica\u00e7\u00e3o profissional30. Por fim, a forma\u00e7\u00e3o como educador possibilita ao preceptor maior quantidade e qualidade de ferramentas educacionais e assistenciais25 (B2).Al\u00e9m disso, considerando a educa\u00e7\u00e3o permanente como pol\u00edtica de sa\u00fade, sua presen\u00e7a na resid\u00eancia \u00e9 fundamental31.O terceiro dom\u00ednio (C1 e C2) foi o que mais exigiu ciclos de avalia\u00e7\u00e3o pelos ju\u00edzes, pois visou atingir um consenso do n\u00famero de educandos por preceptor, valor j\u00e1 determinado pela Comiss\u00e3o Nacional de Resid\u00eancia M\u00e9dica, sendo seis residentes por preceptor com carga de 40 horas28.Apesar desse n\u00famero predeterminado, os programas apresentam uma grande varia\u00e7\u00e3o, com propor\u00e7\u00f5es que abrangem entre um e nove residentes por preceptor no estado de S\u00e3o Paulo. Al\u00e9m dos residentes, 67% dos preceptores s\u00e3o respons\u00e1veis por graduandos e outras \u00e1reas n\u00e3o m\u00e9dicas, aumentando o n\u00famero de formandos por profissional28. Apesar de uma propor\u00e7\u00e3o menor entre residentes por preceptor provavelmente ser adequada, at\u00e9 que se atinja um n\u00famero desejado de preceptores, esse item continuar\u00e1 a ser divergente entre os programas. A utiliza\u00e7\u00e3o repetida do instrumento poder\u00e1 prover dados sobre a evolu\u00e7\u00e3o desse indicador (rela\u00e7\u00e3o preceptor-residente) e sua compara\u00e7\u00e3o entre as regionais, permitindo interven\u00e7\u00e3o nas inst\u00e2ncias respons\u00e1veis para aprimoramento cont\u00ednuo dos programas.Tais dados correspondem a n\u00fameros expressivamente superiores quando comparados a programas do exteriorTamb\u00e9m nesse dom\u00ednio \u00e9 apresentado o n\u00famero de educandos por preceptor, resultado da soma de residentes de MFC e alunos de outras inst\u00e2ncias (gradua\u00e7\u00e3o e resid\u00eancia multidisciplinar). \u00c9 importante observar esse n\u00famero porque quanto mais educandos estiverem sob a tutela do preceptor, menor pode ser o tempo dedicado \u00e0 resid\u00eancia e ao graduando.32.Por fim, o item exclu\u00eddo do question\u00e1rio inicial por orienta\u00e7\u00e3o dos ju\u00edzes foi \u201cContrata\u00e7\u00e3o de profissionais j\u00e1 com um per\u00edodo m\u00ednimo de assist\u00eancia pr\u00e9via ao trabalho de preceptoria (\u201choras de voo\u201d)\u201d, sendo a fonte de verifica\u00e7\u00e3o de pelo menos tr\u00eas anos de atua\u00e7\u00e3o antes da preceptoria, como descrito para a resid\u00eancia em Portugal28.A justificativa \u00e9 que o pa\u00eds ainda n\u00e3o possui um n\u00famero suficiente de profissionais especialistas na \u00e1rea para ter assist\u00eancia, doc\u00eancia, gest\u00e3o e preceptoria de forma adequada. Assim, \u00e9 necess\u00e1rio que o rec\u00e9m-formado da resid\u00eancia j\u00e1 assuma uma equipe para formar novos residentes, o que realmente ocorre na pr\u00e1tica33.Como limita\u00e7\u00f5es do estudo podemos apontar que o instrumento foi desenvolvido utilizando como base apenas os preceptores de S\u00e3o Paulo, que \u00e9 o estado com maior n\u00famero de programas de MFC implantados na etapa 1. J\u00e1 as etapas 2 e 3 tiveram abrang\u00eancia nacional. Ainda ser\u00e1 necess\u00e1rio validar o instrumento em outras unidades da federa\u00e7\u00e3o com realidades distintas. Tamb\u00e9m \u00e9 importante ressaltar que qualquer processo de avalia\u00e7\u00e3o n\u00e3o deve usar apenas uma ferramenta, mas um conjuntoEste trabalho prop\u00f5e um instrumento avaliativo de estruturas e processos para PRM-MFC dividido em tr\u00eas dom\u00ednios: organiza\u00e7\u00e3o da unidade, recursos humanos e rela\u00e7\u00e3o preceptor-residente. Tal instrumento, quando adequadamente validado, poder\u00e1 permitir a avalia\u00e7\u00e3o cont\u00ednua dos programas para garantir a implementa\u00e7\u00e3o das pol\u00edticas p\u00fablicas que regimentam a resid\u00eancia de MFC."}
+{"text": "A transla\u00e7\u00e3o do conhecimento (TC) tem como prop\u00f3sito a utiliza\u00e7\u00e3o pr\u00e1tica dosresultados de pesquisas cient\u00edficas e o monitoramento dos benef\u00edcios causados \u00e0sa\u00fade da popula\u00e7\u00e3o. Na \u00e1rea de sa\u00fade, o governo e, principalmente, a sociedadeesperam que os investimentos em pesquisas obtenham resultados que v\u00e3o al\u00e9m daprodu\u00e7\u00e3o e da publica\u00e7\u00e3o do conhecimento, e provoquem solu\u00e7\u00f5es como pol\u00edticasp\u00fablicas, sistemas, produtos e tecnologias para beneficiar a sa\u00fade da popula\u00e7\u00e3o.Contudo, verifica-se ainda a necessidade de superar diversos desafios paraeliminar as lacunas existentes entre a investiga\u00e7\u00e3o e a aplica\u00e7\u00e3o. O objetivodeste estudo \u00e9 propor estrat\u00e9gias, com base na identifica\u00e7\u00e3o de barreiras efatores facilitadores de um instituto de ci\u00eancia e tecnologia (ICT) em sa\u00fade,para fomentar o processo de transforma\u00e7\u00e3o do conhecimento cient\u00edfico, gerado naspesquisas, em a\u00e7\u00f5es e produtos que contribuam para a melhoria da sa\u00fade dapopula\u00e7\u00e3o. Os relatos das entrevistas, realizadas com 16 pesquisadores,permitiram a identifica\u00e7\u00e3o de 10 categorias de barreiras, tendo destaque:\u201cfinanciamento em ci\u00eancia, tecnologia e informa\u00e7\u00e3o (CT&I) limitado\u201d e \u201capoiot\u00e9cnico insuficiente para a transla\u00e7\u00e3o do conhecimento\u201d. \u201cInfraestrutura e apoioinstitucional\u201d foi a categoria de fatores facilitadores mais citada pelosparticipantes. Por fim, foi desenvolvido o artefato \u201cestrat\u00e9gias e abordagenspara supera\u00e7\u00e3o de barreiras \u00e0 implementa\u00e7\u00e3o de resultados de pesquisa\u201d. Entre asestrat\u00e9gias, sugere-se a inclus\u00e3o de uma disciplina de TC nos programas dep\u00f3s-gradua\u00e7\u00e3o  Esse n\u00famero leva o pa\u00eds aocupar a 13\u00aa posi\u00e7\u00e3o na produ\u00e7\u00e3o de publica\u00e7\u00f5es cient\u00edficas, sendo a \u00e1rea deCi\u00eancias da Sa\u00fade seu principal campo de estudo, representando 33% das publica\u00e7\u00f5esEm 2008, Montagner Nos pa\u00edses desenvolvidos, as organiza\u00e7\u00f5es de sa\u00fade est\u00e3o sendo incentivadas aimplementar pr\u00e1ticas inovadoras baseadas em evid\u00eancias cient\u00edficas knowledge translation, adotadas pela OMS epor outros pa\u00edses e institui\u00e7\u00f5es Buscando superar as dificuldades da trajet\u00f3ria entre o conhecimento produzido naspesquisas e sua aplica\u00e7\u00e3o, surgem as teorias da transla\u00e7\u00e3o do conhecimento, termooriginado no Canad\u00e1 como Um n\u00famero significativo de barreiras a serem ultrapassadas nesse processo \u00e9 descritopor diversos autores encontrados na literatura sobre o tema. Dobbins et al. Haines et al. Nutley et al. Em estudo realizado por Mahendradhata & Kalbarczyk Oelke et al. Somada aos desafios j\u00e1 apresentados, a fragmenta\u00e7\u00e3o do conhecimento produzido em umaquantidade de pesquisas cada vez mais crescente, o custo de decis\u00f5es inadequadas e alentid\u00e3o no processo de transforma\u00e7\u00e3o do conhecimento em pr\u00e1tica tornam a TC umcampo primordial para a sa\u00fade p\u00fablica A identifica\u00e7\u00e3o dos fatores que impactaram e que continuam impactando, de formapositiva ou negativa, a TC gerada nas pesquisas realizadas em um instituto deci\u00eancia e tecnologia (ICT) em sa\u00fade, pertencente \u00e0 estrutura organizacional de umafunda\u00e7\u00e3o ligada ao Minist\u00e9rio da Sa\u00fade, contribuir\u00e1 para responder \u00e0 quest\u00e3o departida deste estudo: como ampliar a capacidade do ICT de transformar osconhecimentos gerados em pr\u00e1ticas inovadoras que possam beneficiar a sa\u00fade dapopula\u00e7\u00e3o brasileira. Andrade & Pereira Diante do exposto, o objetivo geral deste estudo foi, portanto, propor estrat\u00e9gias,com base na identifica\u00e7\u00e3o de barreiras e facilitadores de um ICT em sa\u00fade, parafomentar o processo de transforma\u00e7\u00e3o do conhecimento cient\u00edfico, gerado naspesquisas, em a\u00e7\u00f5es e produtos que contribuam para a melhoria da sa\u00fade dapopula\u00e7\u00e3o.Design Science Research(DSR), que tem como finalidade a constru\u00e7\u00e3o de artefatos inovadores que se traduzamem benef\u00edcios para as organiza\u00e7\u00f5es Neste estudo, foi utilizada a abordagem ,,,,,,,,,,,A abordagem DSR tem diferentes etapas, iniciando com a identifica\u00e7\u00e3o econscientiza\u00e7\u00e3o do problema; proposi\u00e7\u00e3o de artefatos para resolver o problemaespec\u00edfico; projeto e desenvolvimento do artefato; avalia\u00e7\u00e3o; e contemplando,inclusive, a comunica\u00e7\u00e3o dos resultados ,,,Esta investiga\u00e7\u00e3o enquadra-se como uma pesquisa qualitativa do tipo estudo de caso,que responde \u00e0s perguntas sobre \u201ccomo\u201d e \u201cpor que\u201d, a partir de um problema depesquisa Em um universo de 47 servidores em atividade de pesquisa no ICT, 25 integraram apopula\u00e7\u00e3o deste estudo, pois atenderam a pelo menos um dos dois crit\u00e9rios deinclus\u00e3o descritos a seguir: crit\u00e9rio 1 - pesquisadores que recebem bolsa deprodutividade do Conselho Nacional de Desenvolvimento Cient\u00edfico e Tecnol\u00f3gico(CNPq); e crit\u00e9rio 2 - pesquisadores que est\u00e3o desempenhando a fun\u00e7\u00e3o de l\u00edderde laborat\u00f3rio de pesquisa.Dessa popula\u00e7\u00e3o, 15 pesquisadores participaram do estudo e assinaram o Termo deConsentimento Livre e Esclarecido (projeto aprovado pelo Comit\u00ea de \u00c9tica emPesquisa do SENAI CIMATEC - parecer n\u00ba 5.096.148). Esses indiv\u00edduos t\u00eam,majoritariamente, forma\u00e7\u00e3o em Medicina, correspondendo a 47% da popula\u00e7\u00e3o. Ospesquisadores com forma\u00e7\u00e3o em Ci\u00eancias Biol\u00f3gicas (20%) e Farm\u00e1cia (20%) tamb\u00e9mse destacam na representatividade e, junto aos formados em Medicina, compreendem87% dos servidores em atividade de pesquisa aptos a participarem deste estudo.Destaca-se que a participa\u00e7\u00e3o na pesquisa foi volunt\u00e1ria e confidencial,respeitando todas as diretrizes e normativas vigentes sobre a realiza\u00e7\u00e3o depesquisas com seres humanos no Brasil.O roteiro de entrevista foi inspirado no modelo proposto na estrutura consolidadapara pesquisa de implementa\u00e7\u00e3o, desenvolvida por Damschroder et al. Neste estudo, o DI representa a busca por informa\u00e7\u00f5es relativas \u00e0sespecificidades de cada pesquisa finalizada que teve seus resultadosefetivamente aplicados em benef\u00edcio da popula\u00e7\u00e3o, bem como daquelas que, apesarde terem gerado conhecimento com potencial de causar impacto positivo imediatona sa\u00fade da popula\u00e7\u00e3o, deixaram de ser implementadas (exemplo de quest\u00e3o: Houvetentativa de implementa\u00e7\u00e3o dos resultados obtidos nesta pesquisa? Descreva asdificuldades que impediram a implementa\u00e7\u00e3o). O DII concentra-se no cen\u00e1riointerno do ICT estudado ;enquanto o cen\u00e1rio externo do ICT \u00e9 tratado no DIII . \u00c9 importante comentar que houve um estudopiloto do roteiro de entrevista, antes da coleta de dados para esta pesquisa,buscando verificar a clareza das perguntas e encadeamento do roteiro,propiciando a experi\u00eancia da primeira autora nessa t\u00e9cnica de coleta dedados.Utilizando as t\u00e9cnicas recomendadas no modelo de an\u00e1lise de conte\u00fado de BardinO processo de categoriza\u00e7\u00e3o dos determinantes contextuais, que foram citadospelos pesquisadores como fatores que influenciam, positiva ou negativamente, aimplementa\u00e7\u00e3o dos resultados de pesquisas, exigiu um esfor\u00e7o de abstra\u00e7\u00e3o apartir de fatos da realidade estudada que s\u00e3o \u00fanicos em si. Isto \u00e9, muitos fatosespec\u00edficos e individuais foram agrupados e transformados em um n\u00famero reduzidode conceitos. Foram definidas categorias referentes aos desafios (barreiras) queprecisam ser ultrapassados na implementa\u00e7\u00e3o de resultados de pesquisa; fatoresfacilitadores utilizados pelos servidores em atividade de pesquisa entrevistadosnesse processo e que poder\u00e3o ser potencializados; estrat\u00e9gias encontradas esugeridas por esse p\u00fablico para serem utilizadas em maior escala no ICT. Assim,a categoriza\u00e7\u00e3o dos determinantes contextuais (barreiras e facilitadores) foiuma etapa fundamental na constru\u00e7\u00e3o das estrat\u00e9gias propostas ao final desteestudo.Os determinantes contextuais identificados e apresentados nas ,,,,,,,,,,Os relatos das entrevistas permitiram a identifica\u00e7\u00e3o das categorias de barreirasapresentadas na Adicionalmente, foram relatadas dificuldades decorrentes do desconhecimento dasregulamenta\u00e7\u00f5es e requisitos definidos e da demora no processo de an\u00e1lise dademanda, realizado pelos \u00f3rg\u00e3os reguladores. A inexist\u00eancia de uma inst\u00e2ncia com amiss\u00e3o de prestar apoio t\u00e9cnico especializado aos pesquisadores do ICT nasatividades necess\u00e1rias \u00e0 implementa\u00e7\u00e3o dos resultados das pesquisas foi constatadacomo um grande desafio. O suporte \u00e0 pesquisa \u00e9 essencial, visto que libera opesquisador da parte burocr\u00e1tica dos seus projetos, conforme salientado pelosentrevistados, e o tempo efetivamente gasto para realizar pesquisa, analisar osdados e publicar os resultados \u00e9 bastante reduzido. De acordo com Siewert Junior& Parisotto Curr\u00edculo Lattes seu principal instrumentoindicador de produtividade. O equil\u00edbrio entre a produ\u00e7\u00e3o e a recep\u00e7\u00e3o doconhecimento gerado foi perdido. Nesse sentido, considerando o foco da TC, \u00e9necess\u00e1rio que a interse\u00e7\u00e3o entre produ\u00e7\u00e3o, aceita\u00e7\u00e3o e aplica\u00e7\u00e3o do novoconhecimento se torne cada vez mais integrada.A categoria de barreira intitulada, neste estudo, como \u201cprodutivismo acad\u00eamico\u201d \u00e9caracterizada pelo autor Waters A Fundamentando-se em modelos te\u00f3ricos de TC, este estudo buscou construir uma proposta- aplic\u00e1vel ao contexto de uma institui\u00e7\u00e3o p\u00fablica de pesquisa no Brasil - que,combinando estrat\u00e9gias de governan\u00e7a e aplica\u00e7\u00e3o do conhecimento, resulta num modelopr\u00e1tico para favorecer a inova\u00e7\u00e3o em sa\u00fade. Os caminhos propostos nesta pesquisapretendem aumentar a capacidade institucional de identifica\u00e7\u00e3o e alinhamento \u00e0sreais necessidades do sistema de sa\u00fade, facilitando a obten\u00e7\u00e3o de resultadospr\u00e1ticos decorrentes dos investimentos voltados \u00e0 gera\u00e7\u00e3o de conhecimento cient\u00edficopara solu\u00e7\u00e3o de problemas de sa\u00fade da popula\u00e7\u00e3o. Com base nos dados coletados eanalisados, foram desenvolvidas propostas de estrat\u00e9gias e abordagens para tratar osdeterminantes contextuais. O ,integrated de Lavis et al. As estrat\u00e9gias propostas buscam contribuir para a supera\u00e7\u00e3o das dificuldades efortalecimento dos fatores facilitadores, e encontram fundamenta\u00e7\u00e3o em Powell et al.Ainda que essas estrat\u00e9gias tenham sido propostas por uma amostra restrita depesquisadores de um ICT, suas recomenda\u00e7\u00f5es, vindas de profissionais experientes,favorecem a identifica\u00e7\u00e3o de informa\u00e7\u00f5es referentes ao problema e ao contexto em queele se encontra, ampliando a conscientiza\u00e7\u00e3o do que pode ser feito para umaresolu\u00e7\u00e3o mais efetiva. Essas sugest\u00f5es possibilitam implica\u00e7\u00f5es pr\u00e1ticas para odesenvolvimento dos artefatos e implementa\u00e7\u00e3o de inova\u00e7\u00f5es. Mesmo que outros estudossejam necess\u00e1rios para o desenvolvimento e aprimoramento dos artefatos, inclusivecom amostras ampliadas, os resultados aqui levantados s\u00e3o estruturantes efundamentais para as pr\u00f3ximas etapas da DSR, at\u00e9 que seja poss\u00edvel alcan\u00e7ar a metafinal: fomentar a transforma\u00e7\u00e3o do conhecimento cient\u00edfico gerado nas pesquisas ema\u00e7\u00f5es e produtos que contribuam para a melhoria da sa\u00fade populacional.A identifica\u00e7\u00e3o das barreiras que, na vis\u00e3o dos pesquisadores, impedem aimplementa\u00e7\u00e3o do conhecimento resultante das pesquisas viabilizou a proposi\u00e7\u00e3o deestrat\u00e9gias para diminuir a lacuna entre a cria\u00e7\u00e3o do conhecimento e a sua aplica\u00e7\u00e3opr\u00e1tica. Os fatores facilitadores tamb\u00e9m foram importantes para o aprimoramentodessas estrat\u00e9gias. Os resultados contribu\u00edram para ampliar a capacidade do ICT detransformar os conhecimentos gerados em pr\u00e1ticas inovadoras que beneficiem a sa\u00fadeda popula\u00e7\u00e3o brasileiraA disponibiliza\u00e7\u00e3o de uma inst\u00e2ncia organizacional dotada de vis\u00e3o estrat\u00e9gica evoltada ao apoio t\u00e9cnico especializado em inova\u00e7\u00e3o \u00e9 uma estrat\u00e9gia indispens\u00e1velpara o aumento da contribui\u00e7\u00e3o dos institutos de pesquisa para a sa\u00fade. Essainst\u00e2ncia, que dever\u00e1 dispor de integrantes com as compet\u00eancias requeridas noprocesso de implementa\u00e7\u00e3o de resultados de pesquisa, permitir\u00e1 a libera\u00e7\u00e3o dospesquisadores de fun\u00e7\u00f5es burocr\u00e1ticas e pol\u00edticas, possibilitando que essesprofissionais dediquem mais tempo ao processo de cria\u00e7\u00e3o de conhecimento.Sendo assim, recomenda-se a implanta\u00e7\u00e3o de um curso de forma\u00e7\u00e3o em TC voltado aop\u00fablico interno e externo do ICT, seja ele produtor ou consumidor de conhecimentocient\u00edfico, com o objetivo de formar profissionais para atuarem nos processosinerentes \u00e0 convers\u00e3o dos conhecimentos produzidos em inova\u00e7\u00e3o. No sentido dedesenvolver a cultura da TC, sugere-se, ainda, a inclus\u00e3o de um componentecurricular nos programas de p\u00f3s-gradua\u00e7\u00e3o oferecidos pelo ICT, fortalecendo afamiliaridade dos discentes e docentes com o tema j\u00e1 no processo de forma\u00e7\u00e3ocient\u00edfica.A cria\u00e7\u00e3o de indicadores que demonstrem a capacidade de aplica\u00e7\u00e3o das evid\u00eanciasadquiridas nas investiga\u00e7\u00f5es pode fortalecer o potencial de inova\u00e7\u00e3o dospesquisadores, universidades e institui\u00e7\u00f5es de pesquisa, servindo como passo inicialpara que seja revisto o modelo de avalia\u00e7\u00e3o da ci\u00eancia, atualmente baseadofundamentalmente em dados bibliom\u00e9tricos, que incentivam o produtivismo acad\u00eamico.Este estudo de caso tamb\u00e9m demonstra que as caracter\u00edsticas dos resultados depesquisa e o contexto interno do ICT afetam a ado\u00e7\u00e3o do processo de TCindependentemente das restri\u00e7\u00f5es de recursos financeiros, em vista da diversidade dedesafios apresentados.Apesar de contar com uma amostra expressiva de 60% da popula\u00e7\u00e3o convidada paraparticipar da entrevista, o fato de o estudo ter sido realizado em um \u00fanico contextopode ser considerado como uma limita\u00e7\u00e3o. Ampliar o n\u00famero de contextos estudados e,consequentemente, a amostra \u00e9 recomendado. Sendo assim, pesquisas futuras poderiamexpandir os crit\u00e9rios de inclus\u00e3o da amostra de pesquisadores, n\u00e3o restringindoapenas a bolsista de produtividade ou l\u00edderes de laborat\u00f3rio. A categoriza\u00e7\u00e3orealizada aqui pode ser usada com amostra ampliada, a fim de verificar se essesresultados se confirmam na percep\u00e7\u00e3o de diferentes pesquisadores e de outros ICT ouse novas estrat\u00e9gias podem ser adicionadas para o fomento da TC. Sugere-se, por fim,que sejam realizados estudos com o objetivo de conhecer o encaminhamento dado pelasag\u00eancias de fomento aos conhecimentos produzidos nas pesquisas que financiam.Por fim, grupos focais confirmat\u00f3rios s\u00e3o bem recomendados na abordagem DSR e podemser aplicados para an\u00e1lise da utilidade e replicabilidade dos artefatos(estrat\u00e9gias) em outras institui\u00e7\u00f5es. Al\u00e9m disso, como os artefatos aqui propostosn\u00e3o foram ainda implementados, destaca-se a continuidade deste estudo, avan\u00e7ando nodesenvolvimento e aplica\u00e7\u00e3o das estrat\u00e9gias, seguindo, desse modo, com as demaisetapas da DSR."}
+{"text": "To analyze the correlation between the results obtained on the SEAL and the Bayley III Scale and compare babies with and without delay in language acquisition at 24 months concerning the performance obtained by them and their mothers on the SEAL from 3 to 24 months.The SEAL collection consists of 15-minute footages of 45 babies aged from 3 to 24 months old in interaction with their mothers, who were assessed by two trained speech therapists for the use of the SEAL. At 24 months, the 45 babies were assessed using the Bayley III Scale and the item language was selected to classify them with and without delay. These results were statistically analyzed through a Pearson\u2019s correlation test and a Fisher's exact test.In average, eighteen signs of typical development as we obtained, while a mean of 12 delay signs were found. By comparing the presence and absence of signs between the groups with and without delay in language acquisition, eight signs from the baby and one from the mother differed statistically in the sample. The analysis using the SEAL for cases of delay showed that the maternal factor was as important as the infant factor to understand the babies\u2019 language functioning.There was a significant correlation between the SEAL performance from 3 to 24 months and the language outcome at 24 months assessed by the Bayley III Scale in this sample. The Bayley III Scale in a study on cross-cultural adaptation and psychometric properties, the Brazilian version of the Bayley III scale showed a highly convergent validity, as well as good internal consistency and homogeneity of items for children aged 12 to 42 months, thus corroborating its effectiveness for research purposes.According to Madaschi et al.Although this scale has diagnostic value for the grammatical domain, it involves some application time (one to two sessions) and depends on the collaboration of the child, as well as on specialized training by the examiner and acquisition of high-cost materials in the context of the common reality of Brazilian professionals. Furthermore, it does not investigate the adult's participation in the language acquisition process.Sinais Enunciativos de Aquisi\u00e7\u00e3o da Linguagem (SEAL)]-14 tool was preliminarily validated to provide an instrument to address the adult-child dialogue so that it could be easily applied in the process of language acquisition follow-up, based on the contributions of clinical studies from the enunciative perspective-18 and the enunciative study of language acquisition. The ESLA signs consider the semiotic level  and the language semantization process. This process is related to the subject's appropriation of their linguistic knowledge (semiotic level) in the dialogue support, which allows for identifying the emergence and support of a place of enunciation for the baby-19.The Enunciative Signs of Language Acquisition . In this condition, the suspected cases according to the ESLA would be referred to a diagnostic test through the Bayley Scale III or other diagnostic scales for language and development,22. The number of mother-baby dyads participating in the ESLA investigation in all age groups was much higher (101) than in the group that attended the two assessment meetings for the Bayley Scale III (45). This sample loss suggests that the adherence to the more time-consuming test  by users demands a change of culture and an improvement in the access to the health service, which is not expected to change on a short-term perspective.In this research, the ESLA was assigned by filming during childcare follow-up sessions, although it may be analyzed by a qualified professional by observing the mother-baby interaction in an outpatient clinic, which would be less expensive in terms of time and cost for insertion in the Universal Health System [in Portuguese In contrast, the comparison between the group with and without delay allowed us to establish an average of 18 enunciative signs out of 24 assessed as the absence of risk in the ESLA. These data suggest the need to continue investigating the ESLA in terms of establishing criteria per age group and in the total test, which was not possible from the small sample obtained in this research.. Among the signs that statistically differed when comparing infants with and without delay, signs 9, 10, 21, 22, and 23 showed the ability of infants without language delay to occupy their place in enunciation with increasingly complex vocalization and speech . In turn, babies without these signs may show a potential delay in language acquisition..Sign 16 is related to the use of gestures as a form of communication, which is predicted by language acquisition studies that claim some continuity and synchrony between verbal skills and baby gestures in the language acquisition process. It is also related to an adult's willingness to help the child speaking, assessed in sign 24. Therefore, it is important to observe the strength of both signs simultaneously in the sample studied.Sign 17 is related to the baby's ability to anchor themselves in the mother's speech to improve what they say, a strategy identified by Silva, who found that babies in psychological suffering and facing difficulties in the separation process and operation of the paternal function showed difficulty in speaking with distinct interlocutors.In addition to those already mentioned, sign 18, related to the amplitude of interlocutors, was fundamental to assess not only the disjunction in terms of the enunciative acquisition relation but also of the mother-baby separation process. Such a scenario was observed by Flores and Souza. These results suggest the need for continuous studies on validation criteria.The lack of distinctive sign when comparing the two groups in the first age group (zero to six months) indicates the need for further investigations and improving the instrument. Likewise, the factor analysis showed three signs at this phase that were related to a child factor and a maternal factor in a larger sample of subjects at the same phase. These data allow us to observe that, in most cases, the maternal factor contributed to the emergence and understanding of language functioning in cases of delayed language acquisition. In other words, the way the adult carries out enunciative support must be considered in the assessment and intervention for delayed language acquisition,18.-19 have evidenced that both language acquisition and clinical practice with young children should invest in the analysis of the mother-baby dialogue to propose a hypothesis of language functioning that allows proposing intervention lines. This language operating hypothesis foresees the relation I (child) - YOU (adult) in the understanding of the suffering arising from language delay or disorder. Based on this theoretical perspective and our results, the ESLA is a promising tool for assessing such a factor, was as it was revealed in 16 out of 20 cases assessed as language delay by the Bayley III Scale. It is important highlighting that children with extremely low values on the Bayley III Scale were the same ones who received lower ESLA values.Several studies in the enunciative field,18.Considering the numerical limitation of our sample, the results suggest the need to continue investigating the language of infants and young children using ESLA since it is an effective way to monitor language acquisition in childcare and propose interventions in time to prevent the crystallization of language symptomsSuch a scenario requires to establish criteria for the test in larger samples. Ours is a clinical study of a smaller proportion, which included babies who attended the assessment using the Bayley Scale III at the end of the research, at two years of age, a number much smaller than should be desired. ESLA assessments have no diagnostic purposes since the baby is undergoing the process of linguistic constitution, rather they seek to offer timely interventions to favor the convergence between family members and the baby or small child. In this context, facilitating the maternal factor, an important element in the factorial studies, is a way of strengthening the convergence and linguistic synchrony between the mother (or her substitute) and the baby. This shows that the field of speech therapy could benefit from studies centered on dialogue as the analysis focus in research on language acquisition since children's abilities to occupy their place of enunciation are as relevant in the acquisition process as the adult's support of an enunciative place.Our findings allow us to suggest a significant correlation between the performance in the ESLA between 3 and 24 months and the language outcome at 24 months assessed by the Bayley Scale III. The comparison between babies with and without delay in language acquisition allowed us to establish averages of signs in the ESLA. Additionally, some signs from the baby and one from the mother showed statistical differences when comparing the two groups of the sample studied as to their presence and absence, especially from the second age group studied.These data allow us to conclude that the ESLA has some potential as a screening test and should be investigated in larger samples since it involves a short application time requiring only to observe the mother-baby interaction during the first and second years of life in a context of spontaneous play with materials that are accessible to examiners and families. , considerada padr\u00e3o-ouro para avalia\u00e7\u00e3o do desenvolvimento infantil, amplamente utilizada pela comunidade cient\u00edfica-10 por diferenciar a comunica\u00e7\u00e3o receptiva (49 itens) da expressiva (48 itens) no dom\u00ednio gramatical infantil.A aquisi\u00e7\u00e3o da linguagem infantil deve ser avaliada nos primeiros anos de vida do beb\u00ea, desde que haja um acompanhamento especializado na puericultura que contemple uma an\u00e1lise deste aspecto do desenvolvimento. Um dos instrumentos que permite uma avalia\u00e7\u00e3o nos dois primeiros anos de vida \u00e9 a Escala Bayley III sobre a adapta\u00e7\u00e3o transcultural e propriedades psicom\u00e9tricas, a vers\u00e3o brasileira da escala Bayley III apresentou alta validade convergente e boa consist\u00eancia interna e homogeneidade de itens para crian\u00e7as de 12 a 42 meses, corroborando sua efetividade para fins de pesquisas.Na pesquisa de Madaschi et al.Embora possua valor diagn\u00f3stico para o dom\u00ednio gramatical, a referida escala demanda tempo de aplica\u00e7\u00e3o (de uma a duas sess\u00f5es) e depende da colabora\u00e7\u00e3o da crian\u00e7a, bem como forma\u00e7\u00e3o especializada do examinador e aquisi\u00e7\u00e3o de materiais de alto custo, ao considerar a realidade habitual dos profissionais no Brasil. Al\u00e9m disso, n\u00e3o investiga a participa\u00e7\u00e3o do adulto no processo de aquisi\u00e7\u00e3o da linguagem.-14, que consideraram as contribui\u00e7\u00f5es de estudos cl\u00ednicos na perspectiva enunciativa-18 e estudo enunciativo de aquisi\u00e7\u00e3o da linguagem. Os sinais do SEAL consideram o n\u00edvel semi\u00f3tico  e o processo de semantiza\u00e7\u00e3o da l\u00edngua. Esse processo relaciona-se \u00e0 apropria\u00e7\u00e3o que o sujeito faz de seu conhecimento lingu\u00edstico (n\u00edvel semi\u00f3tico) na sustenta\u00e7\u00e3o do di\u00e1logo, que permite que se identifique a emerg\u00eancia e sustenta\u00e7\u00e3o de um lugar de enuncia\u00e7\u00e3o para o beb\u00ea-19.Com o prop\u00f3sito de oferecer um instrumento que abordasse o di\u00e1logo adulto-crian\u00e7a e de f\u00e1cil aplica\u00e7\u00e3o no processo de acompanhamento da aquisi\u00e7\u00e3o da linguagem, foram validados preliminarmente os Sinais Enunciativos de Aquisi\u00e7\u00e3o da Linguagem - SEAL,18. Os sinais do SEAL captam se o processo de aquisi\u00e7\u00e3o da linguagem est\u00e1 transcorrendo dentro do esperado ou se apresenta algum impedimento por meio de um paradigma indici\u00e1rio, ou seja, se os sinais est\u00e3o presentes possivelmente o processo est\u00e1 a contento, se ausentes, a crian\u00e7a e seus familiares devem ser acompanhados em consultas de menor intervalo de tempo para verificar o progresso em linguagem e estabelecer uma eventual demanda por interven\u00e7\u00e3o oportuna. Os estudos do SEAL indicam um fator infantil e um fator materno no funcionamento de linguagem entre o beb\u00ea e sua m\u00e3e, que contribuem na compreens\u00e3o de obst\u00e1culos \u00e0 aquisi\u00e7\u00e3o da linguagem-14, demonstrando que \u00e9 poss\u00edvel realizar interven\u00e7\u00f5es oportunas para revert\u00ea-los a partir de uma escuta sens\u00edvel da fam\u00edlia. O SEAL n\u00e3o tem objetivo diagn\u00f3stico, mas de acompanhamento da aquisi\u00e7\u00e3o da linguagem.Nessa perspectiva, s\u00e3o importantes as potencialidades da crian\u00e7a  e a sustenta\u00e7\u00e3o enunciativa que o adulto oferece-19, e as evid\u00eancias cient\u00edficas obtidas com a Escala Bayley III-11, esta pesquisa analisa a correla\u00e7\u00e3o entre os resultados obtidos pelo SEAL e a Escala Bayley III, e compara beb\u00eas com e sem atraso na aquisi\u00e7\u00e3o da linguagem aos 24 meses, em rela\u00e7\u00e3o ao desempenho obtido por ele e sua m\u00e3e no SEAL dos 3 aos 24 meses.Assim, considerando os resultados obtidos de estudos anteriores sobre o dom\u00ednio gramatical e processo de semantiza\u00e7\u00e3o da l\u00edngua para analisar as condi\u00e7\u00f5es da crian\u00e7a na ocupa\u00e7\u00e3o do lugar de enuncia\u00e7\u00e3o e o do adulto na sustenta\u00e7\u00e3o desse lugar.Trata-se de um estudo quantitativo, longitudinal e prospectivo, aprovado pelo Comit\u00ea de \u00c9tica em Pesquisa de uma institui\u00e7\u00e3o de ensino em cidade de porte m\u00e9dio do Rio Grande do Sul, sob n\u00famero de CAAE: 28586914.0.0000.5346. O estudo respeita as normas e diretrizes regulamentadoras para pesquisa com seres humanos que est\u00e3o na Resolu\u00e7\u00e3o 466/12 do Conselho Nacional de Sa\u00fade, prevendo a confidencialidade dos dados, garantindo sigilo e privacidade da identidade dos sujeitos, por meio da assinatura do Termo de Confidencialidade e do esclarecimento dos objetivos e procedimentos \u00e0s fam\u00edlias que assinaram o TCL (Termo de Consentimento Livre e Esclarecido) ap\u00f3s terem aceitado participar da pesquisa. Os respons\u00e1veis pelos beb\u00eas responderam \u00e0 entrevista sobre dados sociodemogr\u00e1ficos, obst\u00e9tricos e psicossociais adaptados na vers\u00e3o original de Schwengber e PiccininiA amostra inicial na avalia\u00e7\u00e3o do SEAL foi de 101 beb\u00eas, mas destes apenas 45 crian\u00e7as, 19 nascidas a termo e 26 pr\u00e9-termo, acompanhadas pelo SEAL de 3 a 24 meses, foram avaliadas aos 24 meses pela Escala Bayley III. Nesta pesquisa ser\u00e1 analisado o item linguagem. Os demais aspectos do desenvolvimento foram analisados a partir da Escala Bayley III por outros profissionais participantes da pesquisa maior. Para os beb\u00eas nascidos prematuros considerou-se a idade corrigida na avalia\u00e7\u00e3o. Os beb\u00eas e seus familiares foram convidados a participar da pesquisa no seguimento de prematuros de um hospital universit\u00e1rio e no teste do Pezinho em uma Unidade B\u00e1sica de Sa\u00fade pr\u00f3xima ao local. Como crit\u00e9rios de inclus\u00e3o buscou-se beb\u00eas sem limita\u00e7\u00f5es biol\u00f3gicas como les\u00f5es neurol\u00f3gicas ou s\u00edndromes, bem como d\u00e9ficits sensoriais . Esses aspectos foram avaliados pelos pediatras, pela equipe de pesquisa que constou de fonoaudi\u00f3logos, psic\u00f3logos, fisioterapeutas e terapeutas ocupacionais. Em caso d\u00favida foram retirados da pesquisa e encaminhados para o neuropediatra ou geneticista.Para an\u00e1lise de linguagem pelo SEAL foi realizada uma filmagem da intera\u00e7\u00e3o da m\u00e3e ou quem desempenhava essa fun\u00e7\u00e3o para o beb\u00ea, que ocorreu de diferentes modos nas etapas do estudo. A filmagem foi realizada por dois \u00e2ngulos: frontal e lateral, com tempo de 15 minutos, a depender da idade do beb\u00ea e demais aspectos a serem analisados. Os beb\u00eas foram posicionados em um beb\u00ea conforto ou sentados em tapete de EVA para interagir com suas m\u00e3es, em ambiente iluminado e confort\u00e1vel em termos de temperatura. Deveriam estar em bom estado de vig\u00edlia, bem alimentados e higienizados. A filmagem foi realizada com duas filmadoras JVC Everio GZ-MG 630 colocadas em duas posi\u00e7\u00f5es: h\u00e1 dois metros da m\u00e3e e do beb\u00ea, pegando a m\u00e3e posicionada de costas para filmadora e o beb\u00ea de frente, e outra colocada h\u00e1 um metro, pegando a intera\u00e7\u00e3o face a face da m\u00e3e com o beb\u00ea em \u00e2ngulo lateral.Houve uma padroniza\u00e7\u00e3o de posturas em que a crian\u00e7a foi observada na intera\u00e7\u00e3o com sua m\u00e3e. Os beb\u00eas eram nascidos a termo e prematuros tardios. No caso deste grupo considerou-se a idade corrigida.-14 foram:As faixas et\u00e1rias em que os beb\u00eas foram filmados para an\u00e1lise do SEAL de acordo com os quatro instrumentos semestrais criadosFase 1 - 3 meses e 1 dia a 4 meses e 29 dias - O beb\u00ea sentado no beb\u00ea conforto (9 minutos). A m\u00e3e foi instru\u00edda a cantar (3 minutos) (ambienta\u00e7\u00e3o), conversar com o beb\u00ea (3 minutos) e oferecer um objeto -ex- um cachorro de borracha sem barulho (3 minutos).Fase 2- 8 meses e 1 dia a 9 meses e 29 dias - A m\u00e3e e beb\u00ea sentados no tapete EVA, foram filmados na intera\u00e7\u00e3o, com a solicita\u00e7\u00e3o de a m\u00e3e cantar para o beb\u00ea por 3 minutos, conversar por mais 6 minutos e a brincar com um objeto (o cachorro de borracha) oferecido pelo examinador (6 minutos). Se o beb\u00ea n\u00e3o tivesse ainda dom\u00ednio de tronco poderia utilizar beb\u00ea conforto.Fase 3 - 17 meses e um dia a 18 meses e 29 dias e Fase 4 - 23 meses e um dia a 24 meses e 29 dias - Nestas fases o beb\u00ea foi observado em atividade livre com a m\u00e3e com uma caixa de brinquedos tem\u00e1ticos  e observou-se o brincar e a intera\u00e7\u00e3o lingu\u00edstica entre m\u00e3e e beb\u00ea. A m\u00e3e foi orientada a permanecer sobre o tapete com o beb\u00ea durante a filmagem. Nos primeiros 10 minutos foi filmada a intera\u00e7\u00e3o da m\u00e3e com o beb\u00ea e nos \u00faltimos 5 minutos o examinador participou da intera\u00e7\u00e3o para observar alguns sinais que abrangiam o di\u00e1logo com distintos interlocutores.Os v\u00eddeos foram assistidos por duas fonoaudi\u00f3logas habilitadas que atribu\u00edram os sinais dos instrumentos do SEAL aos beb\u00eas, o que permitiu verificar uma concord\u00e2ncia entre ambas 95 e 100%. Para a an\u00e1lise aqui apresentada foram considerados os valores atribu\u00eddos pela pesquisadora principal, primeira autora deste artigo.Na ,11 por uma profissional habilitada para esta avalia\u00e7\u00e3o, sendo considerada nesta pesquisa a subescala de linguagem (comunica\u00e7\u00e3o receptiva e comunica\u00e7\u00e3o expressiva). Inicialmente foi encontrado o ponto de partida no teste de cada beb\u00ea, com base na sua idade. A avalia\u00e7\u00e3o teve in\u00edcio assim que o beb\u00ea pontuou consecutivamente as tr\u00eas primeiras quest\u00f5es (ponto base), e terminou com cinco erros seguidos.Todos os sujeitos tamb\u00e9m foram avaliados na fase 4 (faixa et\u00e1ria de 24 meses) por meio da Escala Bayley IIIsoftware STATISTICA 9.1. Para este estudo, considerou-se o n\u00edvel de signific\u00e2ncia p \u2264 0,05. Foram utilizados os testes de correla\u00e7\u00e3o de Pearson e exato de Fisher.Para a an\u00e1lise estat\u00edstica utilizou-se um banco de dados em Excel em que foram organizados os dados de linguagem obtidos para presen\u00e7a e aus\u00eancia de sinais do SEAL em cada faixa et\u00e1ria e total, bem como tamb\u00e9m os escores do Bayley III obtidos para 24 meses. Os resultados foram analisados estatisticamente no Pearson de 0,718 e um p_valor de 0,001, indicando signific\u00e2ncia estat\u00edstica . Isso permite concluir que quanto maior a pontua\u00e7\u00e3o do SEAL, maior a pontua\u00e7\u00e3o no Bayley III.Foram analisados 45 beb\u00eas, foi verificada a correla\u00e7\u00e3o entre o n\u00famero total de sinais do SEAL obtido por meio dos quatro instrumentos semestrais e os resultados de linguagem obtidos por meio da Escala Bayley III aos 24 meses. Os resultados pontuaram uma correla\u00e7\u00e3o Na an\u00e1lise comparativa entre crian\u00e7as com atraso de linguagem e sem atraso de linguagem por meio dos resultados obtidos na avalia\u00e7\u00e3o de linguagem na Escala Bayley III aos 24 meses, foi poss\u00edvel identificar o n\u00famero m\u00e9dio de sinais enunciativos de aquisi\u00e7\u00e3o da linguagem de cada grupo, conforme indicado na Observou-se que, em m\u00e9dia, os beb\u00eas sem atraso na aquisi\u00e7\u00e3o da linguagem apresentaram 18 sinais presentes, e que os beb\u00eas com atraso, 12 sinais, fato que se refletiu na diferen\u00e7a entre ambos grupos quando comparados a aus\u00eancia e presen\u00e7a de cada sinal como se observa na Os sinais 9, 10, 16, 17, 18, 21, 22 e 23, referentes a aspectos enunciativos do beb\u00ea, e o sinal 24, relativo \u00e0 posi\u00e7\u00e3o materna na \u00faltima faixa et\u00e1ria, diferenciaram o grupo com atraso na aquisi\u00e7\u00e3o da linguagem do grupo sem atraso na compara\u00e7\u00e3o estat\u00edstica da amostra. Os beb\u00eas com desenvolvimento t\u00edpico tiveram maior presen\u00e7a desses sinais do que os beb\u00eas com atraso.A an\u00e1lise descritiva dos dados das 20 crian\u00e7as que apresentaram altera\u00e7\u00e3o de linguagem pela Escala Bayley III, aos 24 meses, est\u00e1 descrita na Observou-se que as crian\u00e7as com altera\u00e7\u00f5es pelo SEAL tiveram pontua\u00e7\u00e3o lim\u00edtrofe, baixa ou muito baixa pela Escala Bayley III. As crian\u00e7as que desenvolveram o atraso na avalia\u00e7\u00e3o pela Escala Bayley III aos 24 meses, apresentaram altera\u00e7\u00f5es em sinais da crian\u00e7a (fator infantil) e nos sinais relativos \u00e0 atividade materna de sustenta\u00e7\u00e3o do di\u00e1logo (fator materno). Ainda, deste grupo de 20 crian\u00e7as com altera\u00e7\u00e3o pela Escala Bayley III, quatro n\u00e3o obtiveram risco no SEAL, de acordo com o n\u00famero m\u00e9dio de sinais , bem comOutro aspecto relevante na A correla\u00e7\u00e3o positiva entre casos com atraso de linguagem avaliados pela Escala Bayley III e casos de risco pelo SEAL permite afirmar que este teste foi efetivo como teste de triagem na amostra estudada. Na ,22. Cabe destacar que o n\u00famero de d\u00edades m\u00e3e-beb\u00ea participantes na investiga\u00e7\u00e3o do SEAL em todas as faixas et\u00e1rias foi muito superior (101) ao grupo que compareceu aos dois encontros de avalia\u00e7\u00e3o da Escala Bayley III (45). Essa perda amostral sugere que a ades\u00e3o ao realizar o teste mais demorado  por parte dos usu\u00e1rios demanda uma mudan\u00e7a de cultura e melhoria no acesso ao servi\u00e7o de sa\u00fade, algo que n\u00e3o se vislumbra mudar em uma perspectiva de curto prazo.Nesta pesquisa, o SEAL foi atribu\u00eddo por filmagens, em acompanhamentos de puericultura, embora possa ser analisado pelo profissional habilitado em sua forma\u00e7\u00e3o, durante uma observa\u00e7\u00e3o da intera\u00e7\u00e3o m\u00e3e-beb\u00ea em ambulat\u00f3rio, o que seria menos dispendioso em termos de tempo e custo para inser\u00e7\u00e3o no SUS. Nesta condi\u00e7\u00e3o, os casos suspeitos pelo SEAL seriam enviados para um teste diagn\u00f3stico com a Escala Bayley III ou outras escalas diagn\u00f3sticas em linguagem e desenvolvimentoJ\u00e1 a compara\u00e7\u00e3o realizada entre o grupo com atraso e sem atraso permitiu estabelecer uma m\u00e9dia de 18 sinais enunciativos, entre os 24 avaliados, como aus\u00eancia de risco. Esse dado sugere a necessidade de dar continuidade na investiga\u00e7\u00e3o do SEAL em termos de estabelecimento de crit\u00e9rios por faixa et\u00e1ria e no total do teste, o que n\u00e3o foi poss\u00edvel com a pequena amostra obtida nesta pesquisa.. Entre os sinais que diferiram estatisticamente na compara\u00e7\u00e3o entre beb\u00eas com atraso e sem atraso, os Sinais 9, 10, 21, 22 e 23 evidenciam habilidades de o beb\u00ea sem atraso na linguagem de ocupar seu lugar de enuncia\u00e7\u00e3o com vocaliza\u00e7\u00e3o e fala crescentemente mais complexas . J\u00e1 beb\u00eas sem esses sinais pode evidenciar o poss\u00edvel atraso na aquisi\u00e7\u00e3o da linguagem.Na .O sinal 16 se relaciona, por outro lado, ao uso da gestualidade como forma de comunica\u00e7\u00e3o, o que \u00e9 previsto por estudos de aquisi\u00e7\u00e3o da linguagem que afirmam haver uma continuidade e sincronia entre habilidades verbais e gestualidade do beb\u00ea no processo de aquisi\u00e7\u00e3o da linguagem. Ela tamb\u00e9m est\u00e1 relacionada a uma disposi\u00e7\u00e3o do adulto em socorrer a crian\u00e7a em seu dizer, avaliada no sinal 24. Portanto, \u00e9 importante observar a for\u00e7a de ambos sinais simultaneamente na amostra estudada.O sinal 17 relaciona-se \u00e0 capacidade de o beb\u00ea se ancorar na fala da m\u00e3e para aprimorar o seu dizer, uma estrat\u00e9gia identificada por Silva, em que beb\u00eas em sofrimento ps\u00edquico e dificuldades no processo de separa\u00e7\u00e3o e opera\u00e7\u00e3o da fun\u00e7\u00e3o paterna, evidenciaram dificuldade de falar com distintos interlocutores.Al\u00e9m deles, o sinal 18 que se relaciona \u00e0 amplitude de interlocutores, \u00e9 fundamental na avalia\u00e7\u00e3o n\u00e3o s\u00f3 da disjun\u00e7\u00e3o em termos de rela\u00e7\u00e3o enunciativa de aquisi\u00e7\u00e3o, mas tamb\u00e9m do processo de separa\u00e7\u00e3o m\u00e3e-beb\u00ea, como visto no estudo de Flores e Souza. Esses resultados indicam a necessidade de continuar os estudos de valida\u00e7\u00e3o de crit\u00e9rio.O fato de nenhum sinal ter sido distintivo na compara\u00e7\u00e3o entre ambos grupos na primeira faixa et\u00e1ria (zero a seis meses) indica a necessidade de continuar investigando e aprimorando o instrumento, visto que a an\u00e1lise fatorial demonstrou tr\u00eas sinais nessa fase relativos a um fator infantil e um materno em uma amostra maior de sujeitos nesta fase. Esse dado permite observar que, na maior parte dos casos, houve a contribui\u00e7\u00e3o do fator materno para a emerg\u00eancia e compreens\u00e3o do funcionamento de linguagem nos casos de atraso na aquisi\u00e7\u00e3o da linguagem, ou seja, a forma como o adulto realiza a sustenta\u00e7\u00e3o enunciativa \u00e9 um aspecto que deve ser considerado na avalia\u00e7\u00e3o e interven\u00e7\u00e3o junto aos atrasos de aquisi\u00e7\u00e3o da linguagem,18.Nos dados observados na -19 t\u00eam evidenciado que tanto a aquisi\u00e7\u00e3o da linguagem, quanto a cl\u00ednica com crian\u00e7as pequenas, devem investir na an\u00e1lise do di\u00e1logo m\u00e3e-beb\u00ea para propor uma hip\u00f3tese de funcionamento de linguagem que permita propor linhas de interven\u00e7\u00e3o. Essa hip\u00f3tese de funcionamento de linguagem prev\u00ea a rela\u00e7\u00e3o EU (crian\u00e7a) - TU (adulto) no entendimento do sofrimento advindo do atraso ou dist\u00farbio de linguagem. A partir dessa perspectiva te\u00f3rica e dos resultados observados nesta pesquisa, observou-se que o SEAL \u00e9 promissor por avaliar tal fator cuja import\u00e2ncia foi identificada na presen\u00e7a do mesmo em 16 dos 20 casos avaliados como atraso de linguagem pela Escala Bayley III. Destaca-se a import\u00e2ncia de que crian\u00e7as com valores extremamente baixos pela Escala Bayley III tamb\u00e9m foram as com menores valores no SEAL.Diversos estudos do campo enunciativo,18.Considerando a limita\u00e7\u00e3o num\u00e9rica da amostra deste estudo, os resultados encontrados sugerem a necessidade de continuar investigando a linguagem de beb\u00eas e crian\u00e7as pequenas com o SEAL, pois real\u00e7a um modo efetivo de acompanhar a aquisi\u00e7\u00e3o da linguagem na puericultura e propor interven\u00e7\u00f5es a tempo de impedir a cristaliza\u00e7\u00e3o de sintomas de linguagem-15. Isso evidencia que a Fonoaudiologia poderia se beneficiar de estudos que tomem o di\u00e1logo como foco da an\u00e1lise nas pesquisas de aquisi\u00e7\u00e3o da linguagem, pois as habilidades infantis para ocupar seu lugar de enuncia\u00e7\u00e3o s\u00e3o t\u00e3o relevantes no processo de aquisi\u00e7\u00e3o, quanto a sustenta\u00e7\u00e3o que o adulto faz de um lugar de enuncia\u00e7\u00e3o.Para tanto, ser\u00e1 necess\u00e1rio estabelecer crit\u00e9rios para o teste em amostras maiores, visto que este foi um estudo cl\u00ednico, de menor propor\u00e7\u00e3o, com os beb\u00eas que compareceram \u00e0 avalia\u00e7\u00e3o realizada com a Escala Bayley III no desfecho da pesquisa aos dois anos, n\u00famero muito inferior ao desejado. As avalia\u00e7\u00f5es com o SEAL n\u00e3o possuem fins diagn\u00f3sticos, uma vez que o beb\u00ea est\u00e1 em processo de constitui\u00e7\u00e3o lingu\u00edstica, mas buscam oferecer interven\u00e7\u00f5es oportunas que possam favorecer um encontro entre os familiares e o beb\u00ea ou crian\u00e7a pequena, pois facilitar o fator materno, que se apresentou importante nos estudos fatoriais, \u00e9 uma forma de fortalecer o encontro e sincronia lingu\u00edstica entre a m\u00e3e (ou sua substituta) e o beb\u00ea\u00c9 poss\u00edvel concluir que houve correla\u00e7\u00e3o significativa entre o desempenho no SEAL entre 3 e 24 meses e o desfecho de linguagem aos 24 meses avaliado pela Escala Bayley III. A compara\u00e7\u00e3o entre beb\u00eas com e sem atraso na aquisi\u00e7\u00e3o da linguagem permitiu estabelecer m\u00e9dias de sinais no SEAL e em alguns sinais do beb\u00ea e um da m\u00e3e apresentaram diferen\u00e7as estat\u00edsticas na compara\u00e7\u00e3o dos dois grupos da amostra estudada quanto a sua presen\u00e7a e aus\u00eancia, sobretudo a partir da segunda faixa et\u00e1ria estudada.Tais dados permitem afirmar que o SEAL tem potencial como teste de triagem e deve ser investigado em amostras maiores, pois \u00e9 r\u00e1pido e exige apenas a observa\u00e7\u00e3o da intera\u00e7\u00e3o m\u00e3e-beb\u00ea no primeiro e segundo anos de vida, em meio a uma brincadeira naturalista com materiais acess\u00edveis aos examinadores e \u00e0s fam\u00edlias."}
+{"text": "To present evidence of intra- and inter-rater reliability and internal consistency of the Phonological Assessment Instrument scores, so that it can be considered reliable and valid for use in clinical practice.179 audio recordings of the instrument's speech samples were analyzed. The collection was carried out from its application in the period of 5 months in children aged from five to eight years and 11 months. Three expert judges transcribed the speech production of each child into the software, which generated performance reports. The speech data of each child were compared between these evaluators, who were trained and experienced in phonetic transcription, to verify the agreement of the instrument scores. For the reliability analysis, the internal consistency was verified using Cronbach's Alpha and the intra and inter-rater reliability using the Intraclass Correlation Coefficient.The Phonological Assessment Instrument showed evidence of high internal consistency, with scores indicating excellent reliability for the assessment of Brazilian Portuguese phonemes, as well as adequate agreement among the judges regarding the instrument scores.The instrument presented robust evidence of reliability, being a reliable and safe option to be used in Brazilian research and clinical practice to evaluate the phonological system of Brazilian children. Consonants can occupy different positions in Brazilian Portuguese (BP), namely: Simple Onset, which marks the consonant that fills the beginning of the syllable and can be initial (ISO) when it is at the beginning of the word, or medial (MSO) when it is in the middle of the word; Complex Onset, also being classified as initial (ICO) or medial (MCO), which indicates the junction of a lateral or non-lateral liquid (/l/ or /r/) with another consonant at the beginning of the syllable. it should be noted that there are restrictions on the consonants that can occupy the referred position, as for ICO in conjunction with /l/, only the phonemes /p/, /b/, /k/, /g/, and /f/ can appear in the first position, while in conjunction with /r/, it would be all plosive phonemes and /f/; In MCO, in conjunction with /l/, only the phonemes /p/, /b can appear /, /t/, /k/, /g/ and /f/, and in conjunction with /r/, would be all plosive phonemes, and labial fricatives; in Coda, which marks the consonant that is at the end of the syllable, which can be in the middle of the word indicated as medial (MC) or final (FC) when it is at the end of the last syllable ,2. To verify whether or not a given phoneme was acquired, it is necessary to analyze the correct production frequency of sounds in each syllabic position since the same phoneme can occupy different positions and structures. They may have indicators of 75% or more to demonstrate that the phoneme is acquired in that particular syllabic context and 75% to 50% for the phoneme that is in the acquisition process, and below 50% for the non-acquired phoneme.The typical phonological development occurs from a pattern in the order of phonemes domain, which needs to be stabilized until approximately five years and six months of age in all syllabic positions. This condition, called Phonological Disorder (PD), is idiopathic and characterized by a set of signs, namely: having persistent difficulty in speech production; age over four years; present consonant changes or omissions in speech; having auditory thresholds within normal limits; having normal intellectual abilities; no changes in lexicon and syntax concerning expressive language; absence of neurological alterations or evident organic causes and having the ability to understand speech,5,. Thus, it is essential to confirm these criteria and carry out an effective phonological assessment, since only this will describe in detail the changes in the child's speech and in what phase of acquisition each phoneme is located. It should be noted that in this study the expression Phonological Disorder is used considering the same as ASHA (American Speech-Language-Hearing Association), which considers it as a Speech Sound Disorder, and that the DSM-5 refers to as Speech Disorder. However, the term Phonological Disorder was chosen because both in ASHA and DSM-5, it is exposed in a general way, encompassing both articulation and phonological disorders in the same denomination, and this study specifically refers to PD.When there is no complete acquisition of the phonological system within the expected period, the child presents omissions and/or substitutions of phonemes, mainly in consonants, which may cause speech unintelligibility-10, with the highest value found being approximately 25% of the child population aged between six and 12 years. This fact generates a lot of demand for speech-language pathology evaluation and treatment. There are some tests to help in the evaluation and diagnosis. Among those available and most used in Brazil: the Child's Phonological Assessment (AFC) and the child language test ABFW-Children's Language Test-Phonology. Such instruments demand considerable time for application and analysis, requiring training and prior specific knowledge of the applicator so that a correct assessment can be made, in addition to requiring detailed technical care, since the analysis is done manually. In addition, these instruments do not have psychometric indicators of validity and reliability, which can impair the safety of clinical evidence to draw an accurate diagnosis, adequate conduct, and correct intervention planning. There are other speech assessment instruments, but little publicized and/or not available for use, such as the Phonological Assessment Instrument (INFONO) and the Speech Assessment Instrument for Acoustic Analysis (IAFAC).The prevalence of PD in Brazil varies.A test is valid when it measures what it purports to measure. In this sense, it needs to go through validation steps. This process includes construct validity, which refers to the direct way of verifying the hypothesis of the legitimacy of the behavioral representation of the items; content validity, which consists of verifying whether the test constitutes a representative sample of a finite universe of behaviors; and response-process validity, which concerns the degree of effectiveness that the test has in predicting a specific performance of a subject. Therefore, the same test needs to be stable and consistent to reproduce an equivalent result from different examiners or from the same evaluator at different times. In this sense, there are three ways to verify reliability: through internal consistency, inter-rater reliability, and intra-rater reliability. The first seeks to verify whether all subparts of the instrument measure the same characteristic, that is, whether the responses to the test are consistent. The second involves the independent participation of two or more evaluators who will complete the instrument, and later it is verified if there was equivalence in the score obtained between them. On the other hand, intra-evaluator reliability indicates that the same judge should fill in the instrument data and perform the analysis at two different times, independently of the first application, to verify whether the result remains stable and consistent over time,19.In addition, an instrument needs to bring evidence of reliability for it to be considered reliableDue to the lack of specific criteria in the usual phonological assessment instruments in Brazil, Prof. Dr. Let\u00edcia Pacheco Ribas created the Phonological Assessment Instrument (IAF) in 2007, which aims to quantify and qualify what the child is presenting in their phonological system. The IAF is a computerized instrument, made up of 123 words with an image corresponding to each lexical item, which arose from the need to evaluate speech based on a practical, quick-to-apply protocol that could analyze children's phonological system more carefully and efficiently. Given the above, this study aimed to present evidence of intra- and inter-rater reliability, and internal consistency, of the Phonological Assessment Instrument scores, so that it can be considered reliable and valid for use in clinical practice.This research corresponds to an observational, cross-sectional, controlled, descriptive, and quantitative study, whose data were used to verify the evidence of the reliability of the IAF. The study was approved by the Research Ethics Committee of a federal university under number 5.045.533. , the study of the necessary sample size was carried out. It was calculated to be 25%, according to the maximum estimate of the prevalence of the diagnosis of PD for the child population. To determine a Kappa coefficient of 0.80, which indicates good agreement, and for a significance of 5% and power of 80%, the result was data from at least 165 children for a representative sample.After carrying out the content validity stages with the expert judges and the response-process validityTo carry out the reliability analysis, the audios of the IAF speech recordings were used, previously collected for a research study on the validity of the response-process, applied to a group of children aged between five years and eight years and 11 months. This collection process occurred in the period from August to December, from a public school in Porto Alegre, selected from a database with 219 evaluations. Forty children who had evident organic causes, hearing, neurological, and/or cognitive alterations, school difficulties, history of neuro psychomotor delay, and/or intercurrences during pregnancy or childbirth were excluded. These exclusions we based on the analysis of the anamnesis responses and the preliminary assessments carried out in the previous study that verified the validity of response-process.Information from participants with characteristics of typical phonological development or with PD was included, totaling 179 children for the study. The information was checked through a previous assessment and reports in interviews with those responsible. All parents or guardians signed the Free and Informed Consent Term and the Authorization for the use of Audio, and in the case of children over seven years old, they also signed the Term of Assent. is a software designed to evaluate the child's speech sound system efficiently, thoroughly, and optimally. The instrument consists of 123 words belonging to children's vocabulary, extracted from popular children's stories, easily represented in an image or photo, and are of the noun type, with an image corresponding to each lexical item. The items were carefully selected so that they included all consonant phonemes in all syllabic positions in Brazilian Portuguese (BP), with five occurrences of each phoneme and syllabic position, totaling 235 phonemic possibilities. The collection of the child's speech should occur by naming each of the images, by observing the illustrations or photographs, which takes approximately ten minutes for the application. The evaluator must record the audio of the speech collection, and later, listen and observe the children's elicitations and register the information to the software. This process takes around 15 to 30 minutes, depending on the evaluator's practice and skill. After entering the data into the instrument, the results are automatically generated and expressed in descriptive and qualitative reports by the degree of speech severity, contrastive analysis, phonological processes, and change in distinctive features.IAFThe analysis of internal consistency and inter-rater reliability was performed based on the judgment of three expert judges with training and experience in phonetic transcription. They were presented with the audio of the speech collections of the 179 children, blinded, and asked to mark the phonetic correspondence of each target in the software. Based on the transcript, the instrument generated all reports. The data of each child were compared between the judges to verify the degree of agreement of the IAF scores.,19 in order not to have a change in the child's development. In this study, it was decided to carry out the analysis over a longer period, since it is done from audio already recorded and, therefore, would not have alteration in the individual's phonological system. In addition, a longer listening time for the audio recordings could decrease the possibility of remembering phonological exchanges performed by the children, with the reassessment being independent and without bias from the first analysis made by the evaluators.For the intra-evaluator reliability analysis, the same evaluators analyzed again the same audio samples from the speech collections of the original application. This occurred independently from the first analysis and the results were compared individually. That is, it was verified whether the results of the first and second analyses were equivalent between the same evaluator. This stage was carried out with the audio of 18 children (approximately 10% of the sample), randomly drawn, and evaluated by the same evaluators three months after the first analysis. Research and validation studies suggest performing the second analysis between seven and 14 days after the first assessment. As for the contrastive analysis, in both analyses, the percentage of correct answers for each phoneme was verified for each child. For the internal consistency analysis, the data were generated from the cross-judgment of the evaluators, who classified the phonemes into three categories for the application of the statistical calculation , and analyzed the frequency of correct production of the sounds for each child. The phonological processes were organized as having or not having the presence of each process.The data used in the inter and intra-rater reliability for the analysis of the degree of severity were obtained from the Percentage of Correct Consonants - RevisedFor this study, reports on the degree of speech severity, contrastive analysis, and phonological processes were used. The results of the distinctive features were not presented, since such data are contemplated in the report of the phonological processes, as they are the same object analyzed by different theoretical perspectives, and that result in the same findings.The results of the reliability analysis stage were approached quantitatively. Analyses were performed using SPSS software, version 28 for Windows.. It measures the degree of covariance between the items of a scale and allows analysis of the consistency of the instrument, calculating the correlation that exists between each test item and the rest of the items or the total of the items. Values range from 0 to 1, with values greater than 0.7 considered ideal, suggesting adequate reliability. For values greater than 0.90, it is assumed that there is redundancy or duplication, indicating that several items are measuring the same element of the construct, requiring the elimination of these redundant items.To verify the internal consistency, Cronbach's Alpha coefficient was calculated, which is the most used measure to assess reliability.To compare the average of the total number of phonological processes and to evaluate the judges' compliance with the results of the contrastive analysis and the degree of speech severity, the Intraclass Correlation Coefficient (ICC) was performed. It is suitable for measuring the correlation of ratings between two or more raters when there is a quantitative variable. Values range from 0 to 1. The closer to 1, the greater the agreement between raters. If less than 0.5, the agreement is weak. Between 0.5-0.75, it is moderate. Between 0.75-0.9, the agreement is good. If greater than 0.9, the agreement is excellentTo assess the agreement of the judges, that is, to measure the degree of conformity of the assessments between two different moments, in the results of the degree of speech severity and the contrastive analysis, the ICC was used. The values adopted as a criterion are the same as those referred to for inter-rater reliability.Evidence of reliability was verified from the results collected by the IAF. To verify the instrument's internal consistency, the results were analyzed using Cronbach's Alpha coefficient for each phoneme in each syllabic position in Brazilian Portuguese (BP). The instrument had a coefficient of 0.88, indicating high internal consistency (above 0.7), showing excellent reliability of the scores that assess BP phonemes.As for the evidence of inter-rater reliability of the contrastive analysis, There was moderate agreement only on /b/ in ISO and MSO; /t/ in ISO and MSO; /v/ in ISO and MSO; /s/ in ISO; /z/ in ISO; /n/ in ISO; and /\u0272/ in MSO. In most of the phonemes in which agreement was considered weak, there was an indication of a highly homogeneous sample.Regarding the intra-rater reliability of the contrastive analysis, Agreement between evaluators was considered excellent, with values above 0.9 for most phonemes. There were several phonemes with agreement classified as good, with values between 0.75 and 0.90, indicating adequate reliability among the judges. Evaluator A had agreement considered excellent or good in all listed phonemes. Evaluator B had the phoneme /g/ in ISO considered moderate, with values between 0.50 to 0.75, in addition to having the phonemes /v/ in ISO and /n/ in ISO classified as weak, with lower values to 0.50. Evaluator C had agreement considered moderate for the phonemes /\u028e/ in MSO and /l/ in MC, and agreement considered weak for the phoneme /z/ in ISO.. However, to be considered reliable, it is necessary to go through precise measurement steps, namely: validity and reliability-19. Given the objective of this study and its results, the IAF proved to be a pertinent and appropriate instrument to analyze the phonological system of BP-speaking children in detail, in addition to determining the degree of PD severity, having adequate indicators, and satisfactory reliability.There is a recognized relevance in the use of speech evaluation instruments for speech therapy clinical practice, which assesses phonology; and the speech discrimination task with pseudowords, created to assess the auditory discrimination ability of speech sounds. Both obtained results above 0.70, having indicators considered appropriate. In a protocol constructed to assess the oral language comprehension of children aged between two and six years old, the internal consistency ranged from 0.60 to 0.70, classified as moderate. As for a study on the internal consistency of the task of evaluating syntactic competencies , Cronbach's Alpha ranged from 0.00 to 0.47, being insufficient to validate the reliability of the instrument.Regarding the evidence of the reliability of the IAF, the internal consistency proved to be excellent, since it was above the indicator considered minimally ideal (0.70), indicating a strong reliability. This result shows the absence of redundancy or duplication in the instrument's items. Other national speech-language assessment instruments also used Cronbach's Alpha to analyze internal consistency: the Phonological Assessment Instrument (INFONO), which analyzed the validation procedures used by speech therapy instruments for the assessment of oral language, published in national journals, it was evident that only five instruments, out of a total of 21, carried out reliability analyses based on internal consistency. Such results demonstrate the scarcity of validated instruments in relation to reliability, preventing the accuracy of precise data in the evaluation of speech therapy clinical practice.In a systematic review study, the sample calculation for defining the sample size was presented in only one study out of the 21 included in the systematic review, proving a significant limitation in the validation studies of speech tests. The IAF, on the other hand, demonstrates both the internal consistency indicators and the sample calculation and can be considered a reliable instrument for use in clinical practice and research.In the study mentioned. Thus, an instrument created to evaluate the phonological system needs to analyze all the phonemes in all the syllable positions of its target language, in order to make a correct judgment about the presence or absence of a diagnosis of PD. This structure is advocated in the IAF to enable a thorough analysis of the child's phonological profile and is rarely found in other language assessment tests. Following this same parameter, only the Fuzzy Linguistic Model, designed to classify the severity of PD, and the aforementioned INFONO were found. Thus, an instrument created to evaluate the phonological system needs to analyze all the phonemes in all the syllable positions of its target language, in order to make a correct judgment about the presence or absence of a diagnosis of PD.The instruments need to go through stages of validity and reliability to measure what they are intended to measure and for the results to represent the analyzed construct, so as not to compromise the accuracy of the assessment and diagnosis,29, but for an instrument to be able to add this analysis, it needs to be able to assess all the phonemic possibilities in all the syllable positions in a quali-quantitative manner. The IAF has this attribute, providing detailed information on the phonemes and all their possibilities of occurrence, being an adequate instrument to include the observation of the phonological processes.Identifying the types of phonological processes and the substitutions that the child performs is information that collaborates with the phonological assessment. It does not explain, in a detailed and judicious way, the organization of the phonological system and its functioning in relation to each phoneme in each syllable position of BP, because only in this way is it feasible and appropriate to outline the therapeutic approach. Therefore, the analysis of the use of phonological processes is additional data for the evaluation, but not fundamental, since the verification of the contrastive analysis provides the guiding and primordial aspects to know the functioning of the phonological system of an individual.Regarding the means of inter-rater agreement for phonological processes, the results indicated adequate reliability for this analysis. However, it should be noted that despite being complementary data to outline the choice of therapy model, the analysis of phonological processes is neither essential nor necessary also followed the same steps to verify the evidence of reliability, as well as another national research study. In both steps, the IAF indicators presented in the current study for the analysis of the degree of severity were considered excellent, demonstrating that it is reliable data for its use in evaluations and diagnoses in clinical practice.In addition to internal consistency, inter-rater and intra-rater reliability were performed to test the reliability of the instrument. An international study designed to assess speech production in Turkish childrenThe two steps for the contrastive analysis of the IAF were also carried out, in which it was observed that most of the phonemes presented reliability between excellent and good. However, both stages had some phonemes with moderate and weak indicators . Regardi. Disagreements in the inter-rater reliability of the contrastive analysis may have occurred due to the hearing ability and the raters' parameters. This can be verified in the intra-rater reliability, since rater B and C, even having most of the phonemes with excellent reliability, had some phonemes with moderate and weak indicators, while rater A had only good and excellent indicators , sendo: Onset Simples, que marca a consoante que preenche o in\u00edcio da s\u00edlaba, podendo ser inicial (OSI) quando est\u00e1 no in\u00edcio da palavra, ou medial (OSM), quando est\u00e1 no meio da palavra; Onset Complexo, tamb\u00e9m sendo classificada em inicial (OCI) ou medial (OCM), que indica a jun\u00e7\u00e3o de uma l\u00edquida lateral ou n\u00e3o lateral (/l/ ou /r/) com outra consoante no in\u00edcio da s\u00edlaba ; em Coda, a qual marca a consoante que est\u00e1 no final da s\u00edlaba, que pode ser no meio da palavra apontada como medial (CM) ou final (CF) quando estiver no final da \u00faltima s\u00edlaba ,2. Para verificar se um determinado fonema foi ou n\u00e3o adquirido, necessita-se analisar a frequ\u00eancia de produ\u00e7\u00e3o correta dos sons em cada posi\u00e7\u00e3o sil\u00e1bica (visto que um mesmo fonema pode ocupar diferentes posi\u00e7\u00f5es e estruturas), tendo indicadores de 75% ou mais para demonstrar que o fonema est\u00e1 adquirido naquele determinado contexto sil\u00e1bico, 75% a 50% para o fonema que est\u00e1 em processo de aquisi\u00e7\u00e3o, e abaixo de 50% para fonema n\u00e3o adquirido.O desenvolvimento fonol\u00f3gico t\u00edpico ocorre a partir de um padr\u00e3o na ordem de dom\u00ednio dos fonemas, que precisa estar estabilizado at\u00e9 aproximadamente cinco anos e seis meses de idade em todas as posi\u00e7\u00f5es sil\u00e1bicas. Tal condi\u00e7\u00e3o, denominada Transtorno Fonol\u00f3gico (TF), \u00e9 idiop\u00e1tica e caracterizada por um conjunto de sinais, sendo eles: ter dificuldade persistente para produ\u00e7\u00e3o de fala; idade superior a quatro anos; apresentar trocas ou omiss\u00f5es consonantais na fala; ter limiares auditivos dentro dos padr\u00f5es de normalidade; ter habilidades intelectuais normais; sem altera\u00e7\u00f5es no l\u00e9xico e na sintaxe com rela\u00e7\u00e3o \u00e0 linguagem expressiva; aus\u00eancia de altera\u00e7\u00f5es neurol\u00f3gicas ou causas org\u00e2nicas evidentes e ter capacidade de compreens\u00e3o da fala,5. Dessa forma, faz-se indispens\u00e1vel a confirma\u00e7\u00e3o desses crit\u00e9rios e a realiza\u00e7\u00e3o de uma efetiva avalia\u00e7\u00e3o fonol\u00f3gica, j\u00e1 que somente esta descrever\u00e1 detalhadamente as trocas na fala da crian\u00e7a e em que fase de aquisi\u00e7\u00e3o cada fonema se encontra. Cabe salientar que neste trabalho se utiliza a express\u00e3o Transtorno Fonol\u00f3gico considerando o mesmo que a ASHA (American Speech-Language-Hearing Association), considera como Transtorno dos Sons da Fala e que o DSM-5 refere de Transtorno da Fala. Por\u00e9m, opta-se por Transtorno Fonol\u00f3gico, pois tanto na ASHA quanto no DSM-5, ele \u00e9 exposto de forma geral, englobando tanto os transtornos de articula\u00e7\u00e3o quanto fonol\u00f3gico na mesma denomina\u00e7\u00e3o, e refere-se neste estudo especificamente o TF.Quando n\u00e3o h\u00e1 aquisi\u00e7\u00e3o integral do sistema fonol\u00f3gico no per\u00edodo esperado, a crian\u00e7a apresenta omiss\u00f5es e/ou substitui\u00e7\u00f5es de fonemas, principalmente nas consoantes, podendo ocasionar ininteligibilidade de fala-10, sendo que o valor mais alto encontrado foi de aproximadamente 25% da popula\u00e7\u00e3o infantil entre seis a 12 anos. Esse fato gera muita demanda pela avalia\u00e7\u00e3o e tratamento fonoaudiol\u00f3gico, e por conta disso, existem alguns testes para auxiliar na avalia\u00e7\u00e3o e diagn\u00f3stico, sendo, entre os dispon\u00edveis, conhecidos e mais utilizados no Brasil: a Avalia\u00e7\u00e3o Fonol\u00f3gica da Crian\u00e7a (AFC) e o teste de linguagem infantil ABFW-Teste de Linguagem Infantil-Fonologia. Tais instrumentos demandam um consider\u00e1vel tempo para aplica\u00e7\u00e3o e an\u00e1lise, necessitando de treinamento e conhecimento espec\u00edfico pr\u00e9vio do aplicador para que seja feita uma avalia\u00e7\u00e3o correta, al\u00e9m de precisar de um cuidado t\u00e9cnico minucioso, visto que a an\u00e1lise \u00e9 feita manualmente. Al\u00e9m disso, os referidos instrumentos n\u00e3o possuem indicadores psicom\u00e9tricos de validade e de fidedignidade, o que pode prejudicar a seguran\u00e7a das evid\u00eancias cl\u00ednicas para tra\u00e7ar um diagn\u00f3stico preciso, uma conduta adequada e um planejamento de interven\u00e7\u00e3o correto. Existem outros instrumentos de avalia\u00e7\u00e3o de fala, mas pouco divulgados e/ou n\u00e3o dispon\u00edveis para uso, como o Instrumento de Avalia\u00e7\u00e3o Fonol\u00f3gica (INFONO) e o Instrumento de Avalia\u00e7\u00e3o de Fala para An\u00e1lise Ac\u00fastica (IAFAC).A preval\u00eancia de TF no Brasil \u00e9 variada.Um teste \u00e9 v\u00e1lido quando, de fato, mede o que se prop\u00f5e a medir. Nesse sentido, necessita passar por etapas de valida\u00e7\u00e3o. Esse processo abrange: a validade de construto, que se refere \u00e0 maneira direta de verificar a hip\u00f3tese da legitimidade da representa\u00e7\u00e3o comportamental dos itens; a validade de conte\u00fado, que consiste em verificar se o teste constitui uma amostra representativa de um universo finito de comportamentos; e a validade de processo-resposta, que diz respeito ao grau de efic\u00e1cia que o teste tem em predizer um desempenho espec\u00edfico de um sujeito. Sendo assim, um mesmo teste precisa ser est\u00e1vel e consistente para reproduzir um resultado equivalente a partir de examinadores diferentes ou de um mesmo avaliador em momentos distintos. Nesse sentido, h\u00e1 tr\u00eas maneiras de verificar a fidedignidade: pela consist\u00eancia interna, pela confiabilidade interavaliadores e pela confiabilidade intra-avaliador. A primeira busca verificar se todas as subpartes do instrumento medem a mesma caracter\u00edstica, ou seja, se as respostas ao teste s\u00e3o consistentes. J\u00e1 a segunda envolve a participa\u00e7\u00e3o independente de dois ou mais avaliadores, os quais preencher\u00e3o o instrumento e, posteriormente, \u00e9 verificado se houve equival\u00eancia na pontua\u00e7\u00e3o obtida entre eles. Por outro lado, a confiabilidade intra-avaliador indica que o mesmo juiz dever\u00e1 preencher os dados do instrumento e realizar a an\u00e1lise em dois momentos distintos, de forma independente da primeira aplica\u00e7\u00e3o, para verificar se o resultado permanece est\u00e1vel e consistente ao longo do tempo,19.Al\u00e9m disso, um instrumento precisa trazer evid\u00eancias de fidedignidade para que seja considerado confi\u00e1velDevido \u00e0 falta de crit\u00e9rios espec\u00edficos nos instrumentos usuais de avalia\u00e7\u00e3o fonol\u00f3gica no Brasil, foi elaborado em 2007 por Prof\u00aa Dr\u00aa Let\u00edcia Pacheco Ribas o Instrumento de Avalia\u00e7\u00e3o Fonol\u00f3gica (IAF), que visa quantificar e qualificar o que a crian\u00e7a est\u00e1 apresentando em seu sistema fonol\u00f3gico. O IAF \u00e9 um instrumento computadorizado, formado por 123 palavras com uma imagem correspondendo cada item lexical, que surgiu pela necessidade de avaliar a fala a partir de um protocolo pr\u00e1tico, de r\u00e1pida aplica\u00e7\u00e3o e que pudesse analisar de forma mais criteriosa e eficiente o sistema fonol\u00f3gico infantil. Tendo em vista o supracitado, este estudo teve o objetivo de apresentar evid\u00eancias de fidedignidade intra e interavaliadores, e de consist\u00eancia interna, dos escores do Instrumento de Avalia\u00e7\u00e3o Fonol\u00f3gica, a fim de que possa ser considerado fidedigno e v\u00e1lido para a utiliza\u00e7\u00e3o na pr\u00e1tica cl\u00ednica.Esta pesquisa corresponde a um estudo observacional, transversal controlado, descritivo e quantitativo, cujos dados foram utilizados para verificar a evid\u00eancia de fidedignidade do IAF. O estudo foi aprovado pelo Comit\u00ea de \u00c9tica em Pesquisa (CEP) de uma universidade federal sob parecer n\u00famero 5.045.533. , foi realizado o estudo do tamanho amostral necess\u00e1rio, calculado com 25%, conforme estimativa m\u00e1xima de preval\u00eancia do diagn\u00f3stico de TF para a popula\u00e7\u00e3o infantil. Para determinar um coeficiente Kappa de 0,80, que indica boa concord\u00e2ncia, e para signific\u00e2ncia de 5% e poder de 80%, o resultado foi de, minimamente, dados de 165 crian\u00e7as para uma amostra representativa.Ap\u00f3s serem realizadas as etapas de validade de conte\u00fado com os ju\u00edzes especialistas e a validade de processo-respostaPara realizar a an\u00e1lise da fidedignidade, foram utilizados os \u00e1udios dos registros de fala do IAF, previamente coletados para uma pesquisa sobre a validade de processo-resposta, aplicados em um grupo de crian\u00e7as, entre cinco anos e oito anos e 11 meses, no per\u00edodo de agosto a dezembro, de uma escola p\u00fablica de Porto Alegre, selecionadas de um banco de dados com 219 avalia\u00e7\u00f5es. Foram exclu\u00eddas 40 crian\u00e7as que possu\u00edam causas org\u00e2nicas evidentes, altera\u00e7\u00f5es auditivas, neurol\u00f3gicas e/ou cognitivas, dificuldades escolares, hist\u00f3rico de atraso neuropsicomotor e/ou de intercorr\u00eancias em gravidez ou parto, a partir da an\u00e1lise das respostas da anamnese e das avalia\u00e7\u00f5es realizadas preliminarmente no estudo anterior que verificou a validade de processo-resposta.Foram inclu\u00eddas as informa\u00e7\u00f5es dos participantes com caracter\u00edsticas de desenvolvimento fonol\u00f3gico t\u00edpico ou com TF, totalizando 179 crian\u00e7as para o estudo. As informa\u00e7\u00f5es foram conferidas por meio de avalia\u00e7\u00e3o pr\u00e9via e relatos em entrevista com os respons\u00e1veis. Todos os pais ou respons\u00e1veis assinaram o Termo de Consentimento Livre e Esclarecido e a Autoriza\u00e7\u00e3o para uso de \u00c1udio, e no caso de crian\u00e7as acima de sete anos, essas tamb\u00e9m assinaram o Termo de Assentimento. \u00e9 um software delineado para avaliar o sistema de sons da fala infantil de forma eficiente, minuciosa e otimizada. O instrumento \u00e9 formado por 123 palavras pertencentes ao vocabul\u00e1rio infantil, extra\u00eddas de hist\u00f3rias infantis populares, facilmente representadas em imagem ou foto e s\u00e3o do tipo substantivo, com uma imagem correspondente a cada item lexical. Os itens foram criteriosamente selecionados de forma com que contemplassem todos os fonemas consonantais em todas as posi\u00e7\u00f5es sil\u00e1bicas do PB, com cinco ocorr\u00eancias de cada fonema e posi\u00e7\u00e3o sil\u00e1bica, totalizando 235 possibilidades fon\u00eamicas. A coleta da fala da crian\u00e7a deve ocorrer a partir da nomea\u00e7\u00e3o de cada uma das imagens, pela observa\u00e7\u00e3o das ilustra\u00e7\u00f5es ou fotografias, que leva aproximadamente dez minutos para a aplica\u00e7\u00e3o. O avaliador deve gravar o \u00e1udio da coleta de fala, e posteriormente, ouvir e observar as elicita\u00e7\u00f5es das crian\u00e7as e registrar as informa\u00e7\u00f5es ao software. Tal processo leva em torno de 15 a 30 minutos, dependendo da pr\u00e1tica e habilidade do avaliador. Ap\u00f3s a inser\u00e7\u00e3o dos dados no instrumento, os resultados s\u00e3o gerados automaticamente e expressos em relat\u00f3rios descritivos e qualitativos por grau de severidade de fala, an\u00e1lise contrastiva, processos fonol\u00f3gicos e mudan\u00e7a de tra\u00e7os distintivos.O IAFsoftware da correspond\u00eancia fon\u00e9tica de cada alvo. Com base na transcri\u00e7\u00e3o, o instrumento gerou todos os relat\u00f3rios. Os dados de cada crian\u00e7a foram comparados entre os ju\u00edzes para verificar o grau de concord\u00e2ncia dos escores do IAF.A an\u00e1lise da consist\u00eancia interna e da confiabilidade interavaliadores foi realizada a partir do julgamento de tr\u00eas ju\u00edzes especialistas com treinamento e experi\u00eancia em transcri\u00e7\u00e3o fon\u00e9tica. A estes, foram apresentados os \u00e1udios das coletas de fala das 179 crian\u00e7as, de forma cega, e solicitado que fizessem a marca\u00e7\u00e3o no ,19 para n\u00e3o ter mudan\u00e7a no desenvolvimento da crian\u00e7a. Neste estudo, optou-se por realizar a an\u00e1lise em um tempo superior, visto que ela \u00e9 feita a partir de um \u00e1udio j\u00e1 gravado e, dessa forma, n\u00e3o teria altera\u00e7\u00e3o no sistema fonol\u00f3gico do indiv\u00edduo. Al\u00e9m disso, um tempo maior de oitiva dos \u00e1udios poderia diminuir a possibilidade de lembran\u00e7a de trocas fonol\u00f3gicas realizadas pelas crian\u00e7as, sendo a reavalia\u00e7\u00e3o totalmente independente e sem vi\u00e9s da primeira an\u00e1lise feita pelos avaliadores.Para a an\u00e1lise da confiabilidade intra-avaliadores, os mesmos avaliadores analisaram novamente os mesmos \u00e1udios das amostras das coletas de fala da aplica\u00e7\u00e3o original, de forma independente da primeira an\u00e1lise, e os resultados foram comparados de forma individual, ou seja, conferiu-se se os resultados da primeira e da segunda an\u00e1lise foram equivalentes entre o mesmo avaliador. Esta etapa foi realizada com \u00e1udios de 18 crian\u00e7as (aproximadamente 10% da amostra), sorteados aleatoriamente e avaliados pelos mesmos avaliadores tr\u00eas meses ap\u00f3s a primeira an\u00e1lise. Pesquisas e estudos sobre valida\u00e7\u00e3o sugerem realizar a segunda an\u00e1lise entre sete a 14 dias da primeira avalia\u00e7\u00e3o. J\u00e1 para a an\u00e1lise contrastiva, em ambas as an\u00e1lises, foi verificada a porcentagem de acertos de cada fonema, para cada crian\u00e7a. Para a an\u00e1lise da consist\u00eancia interna, os dados foram gerados a partir do julgamento cruzado dos avaliadores, os quais classificaram os fonemas em tr\u00eas categorias para a aplica\u00e7\u00e3o do c\u00e1lculo estat\u00edstico , e analisaram a frequ\u00eancia de produ\u00e7\u00e3o correta dos sons de cada crian\u00e7a. Os processos fonol\u00f3gicos foram organizados como tendo ou n\u00e3o a presen\u00e7a de cada processo.Os dados utilizados na confiabilidade inter e intra-avaliador para as an\u00e1lises do grau de severidade foram obtidos a partir do Percentual de Consoantes Corretas- RevisadoPara este estudo, foram utilizados os relat\u00f3rios do grau de severidade de fala, da an\u00e1lise contrastiva e dos processos fonol\u00f3gicos. Os resultados dos tra\u00e7os distintivos n\u00e3o foram apresentados, j\u00e1 que tais dados est\u00e3o contemplados no relat\u00f3rio dos processos fonol\u00f3gicos, pois s\u00e3o o mesmo objeto analisados por perspectivas te\u00f3ricas diferentes, e que resultam nos mesmos achados.software SPSS, vers\u00e3o 28 para Windows.Os resultados da etapa da an\u00e1lise da fidedignidade foram abordados de modo quantitativo. As an\u00e1lises foram realizadas no Alpha de Cronbach, que \u00e9 a medida mais utilizada para avaliar a confiabilidade. Ela mede o grau de covari\u00e2ncia entre os itens de uma escala e permite analisar a consist\u00eancia do instrumento, calculando a correla\u00e7\u00e3o que existe entre cada item do teste e o restante dos itens ou o total dos itens. Os valores variam de 0 a 1, sendo que valores superiores a 0,7 s\u00e3o considerados ideais, sugerindo uma adequada fidedignidade. J\u00e1 para valores superiores a 0,90, assume-se que h\u00e1 redund\u00e2ncia ou duplica\u00e7\u00e3o, indicando que v\u00e1rios itens est\u00e3o medindo o mesmo elemento do construto, sendo necess\u00e1ria uma elimina\u00e7\u00e3o desses itens redundantes.Para verificar a consist\u00eancia interna foi realizado o c\u00e1lculo do coeficiente .Para comparar a m\u00e9dia da quantidade total de processos fonol\u00f3gicos e avaliar a conformidade dos ju\u00edzes nos resultados da an\u00e1lise contrastiva e do grau de severidade de fala, foi executado o Coeficiente de Correla\u00e7\u00e3o Intraclasse (ICC). Ele \u00e9 apropriado para medir a correla\u00e7\u00e3o das avalia\u00e7\u00f5es entre dois ou mais avaliadores quando h\u00e1 uma vari\u00e1vel quantitativa. Os valores variam de 0 a 1. Quanto mais pr\u00f3ximo de 1, maior a concord\u00e2ncia entre os avaliadores. Se menor que 0,5, a concord\u00e2ncia \u00e9 fraca. Entre 0,5-0,75, \u00e9 moderada. Entre 0,75-0,9, a concord\u00e2ncia \u00e9 boa. Se maior que 0,9, a concord\u00e2ncia \u00e9 excelentePara avaliar a concord\u00e2ncia dos ju\u00edzes, ou seja, medir o grau de conformidade das avalia\u00e7\u00f5es entre dois momentos distintos, nos resultados do grau de severidade de fala e da an\u00e1lise contrastiva, foi utilizado o ICC. Os valores adotados como crit\u00e9rio s\u00e3o os mesmos referidos da confiabilidade interavaliadores.Alpha de Cronbach para cada fonema em cada posi\u00e7\u00e3o sil\u00e1bica do Portugu\u00eas Brasileiro (PB). O instrumento teve um coeficiente de 0,88, indicando alta consist\u00eancia interna , evidenciando uma excelente fidedignidade dos escores que avaliam os fonemas do PB.As evid\u00eancias de fidedignidade foram verificadas a partir dos resultados coletados pelo IAF. Para verificar a consist\u00eancia interna do instrumento, os resultados foram analisados pelo coeficiente A Quanto \u00e0s evid\u00eancias de fidedignidade interavaliadores da an\u00e1lise contrastiva, a Houve concord\u00e2ncia moderada apenas em /b/ em OSI e OSM; /t/ em OSI e OSM; /v/ em OSI e OSM; /s/ em OSI; /z/ em OSI; /n/ em OSI; e /\u0272/ em OSM. Na maioria dos fonemas em que se obteve concord\u00e2ncia considerada fraca, houve indicativo de amostra altamente homog\u00eanea.A Em rela\u00e7\u00e3o \u00e0 fidedignidade intra-avaliador da an\u00e1lise contrastiva, a A concord\u00e2ncia entre os avaliadores foi considerada excelente, com valores acima de 0,9 para a maioria dos fonemas. Houve v\u00e1rios fonemas com concord\u00e2ncia classificada como boa, com valores entre 0,75 a 0,90, indicando uma adequada confiabilidade entre os ju\u00edzes. O avaliador A teve concord\u00e2ncia considerada como excelente ou boa em todos os fonemas elencados. O avaliador B teve o fonema /g/ em OSI considerado como moderado, com valores entre 0,50 a 0,75, al\u00e9m de ter tido os fonemas /v/ em OSI e /n/ em OSI classificados como fracos, com valores inferiores a 0,50. O avaliador C teve concord\u00e2ncia considerada moderada para os fonemas /\u028e/ em OSM e o /l/ em CM, e concord\u00e2ncia considerada fraca para o fonema /z/ em OSI., por\u00e9m, para que seja considerado confi\u00e1vel, \u00e9 necess\u00e1rio passar por etapas de mensura\u00e7\u00e3o precisas, sendo elas: validade e fidedignidade-19. Tendo em vista o objetivo deste estudo e seus resultados, o IAF mostrou-se como um pertinente e apropriado instrumento para analisar o sistema fonol\u00f3gico das crian\u00e7as falantes de PB de forma detalhada, al\u00e9m de determinar o grau de severidade de TF, tendo indicadores adequados e satisfat\u00f3rios de fidedignidade.H\u00e1 uma reconhecida relev\u00e2ncia da utiliza\u00e7\u00e3o de instrumentos de avalia\u00e7\u00e3o de fala para a pr\u00e1tica cl\u00ednica fonoaudiol\u00f3gicaAlpha de Cronbach para analisar a consist\u00eancia interna: o Instrumento de Avalia\u00e7\u00e3o Fonol\u00f3gica (INFONO), que faz a avalia\u00e7\u00e3o da fonologia; e a tarefa de discrimina\u00e7\u00e3o de fala com pseudopalavras, criada para avaliar a habilidade de discrimina\u00e7\u00e3o auditiva de sons da fala. Ambos obtiveram resultados acima de 0,70, tendo indicadores considerados apropriados. Em um protocolo constru\u00eddo para avaliar a compreens\u00e3o de linguagem oral de crian\u00e7as de dois a seis anos, a consist\u00eancia interna variou de 0,60 e 0,70, classificada como moderada. J\u00e1 para um estudo sobre a consist\u00eancia interna da tarefa de avalia\u00e7\u00e3o de compet\u00eancias sint\u00e1ticas, o Alpha de Cronbach variou de 0,00 a 0,47, sendo insuficiente para validar a fidedignidade do instrumento.Em rela\u00e7\u00e3o \u00e0s evid\u00eancias de fidedignidade do IAF, a consist\u00eancia interna mostrou-se excelente, uma vez que ficou acima do indicador considerado minimamente ideal , indicando uma forte confiabilidade. Tal resultado evidencia aus\u00eancia de redund\u00e2ncia ou duplica\u00e7\u00e3o nos itens do instrumento. Outros instrumentos nacionais de avalia\u00e7\u00e3o fonoaudiol\u00f3gica tamb\u00e9m utilizaram o , que analisou os procedimentos de valida\u00e7\u00e3o utilizados por instrumentos fonoaudiol\u00f3gicos de avalia\u00e7\u00e3o de linguagem oral, publicados em peri\u00f3dicos nacionais, ficou evidente que apenas cinco instrumentos, num total de 21, realizaram an\u00e1lises de fidedignidade pela consist\u00eancia interna. Tais resultados demonstram a escassez de instrumentos validados em rela\u00e7\u00e3o \u00e0 confiabilidade, impedindo a exatid\u00e3o de dados precisos na avalia\u00e7\u00e3o na pr\u00e1tica cl\u00ednica fonoaudiol\u00f3gica.Em um estudo de revis\u00e3o sistem\u00e1tica, o c\u00e1lculo amostral para defini\u00e7\u00e3o do tamanho da amostra foi apresentado em apenas um estudo dos 21 inclu\u00eddos na revis\u00e3o sistem\u00e1tica, comprovando uma expressiva limita\u00e7\u00e3o nos estudos de valida\u00e7\u00e3o de testes de fala. O IAF, por outro lado, demonstra tanto os indicadores de consist\u00eancia interna, quanto o c\u00e1lculo amostral, podendo ser considerado um instrumento confi\u00e1vel para a utiliza\u00e7\u00e3o na pr\u00e1tica cl\u00ednica e em pesquisas.No estudo referido. Desta forma, um instrumento criado para avaliar o sistema fonol\u00f3gico precisa analisar todos os fonemas em todas as posi\u00e7\u00f5es sil\u00e1bicas da sua l\u00edngua alvo, para que se fa\u00e7a um correto julgamento sobre a presen\u00e7a ou aus\u00eancia de diagn\u00f3stico de TF. Essa estrutura \u00e9 preconizada no IAF para possibilitar uma an\u00e1lise minuciosa do perfil fonol\u00f3gico da crian\u00e7a, e pouco encontrado em outros testes de avalia\u00e7\u00e3o da linguagem. Seguindo esse mesmo par\u00e2metro, foram encontrados apenas o Modelo Lingu\u00edstico Fuzzy, elaborado para classificar a gravidade do TF, e o j\u00e1 mencionado INFONO.Os instrumentos necessitam passar por etapas de validade e fidedignidade para mensurar o que se prop\u00f5e a medir e para que os resultados representem o construto analisado, para que n\u00e3o comprometa a precis\u00e3o da avalia\u00e7\u00e3o e do diagn\u00f3stico,29, mas para que um instrumento possa adicionar essa an\u00e1lise, necessita ter a capacidade de avaliar todas as possibilidades fon\u00eamicas em todas as posi\u00e7\u00f5es sil\u00e1bicas de modo quali-quantitativo. O IAF disp\u00f5e desse atributo, proporcionando informa\u00e7\u00f5es detalhadas sobre os fonemas e todas as suas possibilidades de ocorr\u00eancia, sendo um instrumento adequado para incluir a observa\u00e7\u00e3o dos processos fonol\u00f3gicos.Identificar os tipos de processos fonol\u00f3gicos e as substitui\u00e7\u00f5es que a crian\u00e7a realiza \u00e9 uma informa\u00e7\u00e3o que colabora com a avalia\u00e7\u00e3o fonol\u00f3gica, uma vez que n\u00e3o explica, de forma detalhada e criteriosa, a organiza\u00e7\u00e3o do sistema fonol\u00f3gico e seu funcionamento com rela\u00e7\u00e3o a cada fonema em cada posi\u00e7\u00e3o sil\u00e1bica do PB, pois apenas dessa forma \u00e9 fact\u00edvel e adequado delinear a conduta terap\u00eautica. Portanto, a an\u00e1lise do uso de processos fonol\u00f3gicos \u00e9 um dado adicional para a avalia\u00e7\u00e3o, mas n\u00e3o fundamental, uma vez que a verifica\u00e7\u00e3o da an\u00e1lise contrastiva fornece os aspectos norteadores e primordiais para saber o funcionamento do sistema fonol\u00f3gico de um indiv\u00edduo.Em rela\u00e7\u00e3o \u00e0s m\u00e9dias da concord\u00e2ncia interavaliadores para processos fonol\u00f3gicos, os resultados indicaram uma fidedignidade adequada para essa an\u00e1lise. No entanto, cabe ressaltar que, apesar de ser um dado complementar para tra\u00e7ar a escolha do modelo de terapia, a an\u00e1lise dos processos fonol\u00f3gicos n\u00e3o \u00e9 primordial, nem necess\u00e1ria tamb\u00e9m seguiu as mesmas etapas para verificar as evid\u00eancias de fidedignidade, assim como outra pesquisa nacional.Em ambas as etapas, os indicadores do IAF apresentados no presente estudo para a an\u00e1lise do grau de severidade foram considerados excelentes, demonstrando que \u00e9 um dado confi\u00e1vel para sua utiliza\u00e7\u00e3o nas avalia\u00e7\u00f5es e diagn\u00f3sticos na pr\u00e1tica cl\u00ednica.Al\u00e9m da consist\u00eancia interna, foi realizada a confiabilidade interavaliadores e intra-avaliador para testar a fidedignidade do instrumento. Um estudo internacional elaborado para avaliar a produ\u00e7\u00e3o de fala em crian\u00e7as turcasTamb\u00e9m foram realizadas as duas etapas para a an\u00e1lise contrastiva do IAF, na qual se observou que a maioria dos fonemas apresentou confiabilidades entre excelentes e boas. No entanto, ambas as etapas tiveram alguns fonemas com indicadores moderados e fracos . Em rela. As discord\u00e2ncias na confiabilidade interavaliadores da an\u00e1lise contrastiva podem ter ocorrido por conta da habilidade de oitiva e par\u00e2metros pr\u00f3prios dos avaliadores. Isso pode ser verificado na confiabilidade intra-avaliador, uma vez que o avaliador B e C, mesmo tendo a maioria dos fonemas com fidedignidade excelente, tiveram alguns fonemas com indicadores moderados e fracos, enquanto o avaliador A teve apenas indicadores bons e excelentes ( tamb\u00e9m teve indicadores variados entre os ju\u00edzes, os quais afetaram os indicadores de concord\u00e2ncias com vistas \u00e0 confiabilidade. Por\u00e9m, conv\u00e9m mencionar que os altos valores de ICC para a confiabilidade inter e intra-avaliadores do IAF na maioria dos fonemas apontam que h\u00e1 \u00f3tima concord\u00e2ncia entre os ju\u00edzes ( em que cada crian\u00e7a se encontra, em cada posi\u00e7\u00e3o sil\u00e1bica, facilitando a avalia\u00e7\u00e3o e diagn\u00f3stico, como tamb\u00e9m o planejamento terap\u00eautico e evolu\u00e7\u00e3o individual.Al\u00e9m disso, conv\u00e9m mencionar que a fidedignidade de um instrumento pode ser influenciada pela experi\u00eancia e pelos crit\u00e9rios individuais de cada avaliadorcelentes . Da mesms ju\u00edzes . Assim,  s\u00e3o o AFCe o ABFW, como j\u00e1 mencionado anteriormente, que s\u00e3o muito importantes como ferramentas para o processo diagn\u00f3stico dos fonoaudi\u00f3logos brasileiros. No entanto, apesar de tal import\u00e2ncia, eles ainda n\u00e3o disp\u00f5em de estudos psicom\u00e9tricos de validade e de fidedignidade, o que poderia afetar a seguran\u00e7a de uso das medidas desses instrumentos. Desse modo, este estudo \u00e9 pertinente para o avan\u00e7o da fonoaudiologia, visto que o IAF torna-se uma op\u00e7\u00e3o v\u00e1lida e qualificada para se utilizar em avalia\u00e7\u00f5es de crian\u00e7as com suspeita de TF e/ou com altera\u00e7\u00f5es no sistema fonol\u00f3gico, al\u00e9m de ser um instrumento que possibilita uma an\u00e1lise criteriosa e minuciosa de forma r\u00e1pida, uma vez que o software produz rapidamente um relat\u00f3rio de desempenho.Os instrumentos de avalia\u00e7\u00e3o da fonologia do PB mais aplicados e difundidos atualmente no pa\u00edsO IAF foi elaborado visando contribuir com a pr\u00e1tica cl\u00ednica, auxiliando na avalia\u00e7\u00e3o da fonologia de crian\u00e7as e apresentou \u00f3timos resultados de fidedignidade. Apesar disso, este estudo possui algumas limita\u00e7\u00f5es, como: ser estruturado para falantes do PB em geral, mas os dados serem exclusivos de falantes de apenas uma amostra de uma escola p\u00fablica do Rio Grande do Sul, podendo ser um obst\u00e1culo \u00e0 generaliza\u00e7\u00e3o; n\u00e3o ter feito uso de \u00edndices padronizados para calibrar a avalia\u00e7\u00e3o de oitiva, permitindo crit\u00e9rios pr\u00f3prios dos avaliadores; e n\u00e3o apresentar coeficientes de fidedignidade por cada faixa et\u00e1ria, g\u00eanero e tipo de escola, uma vez que a variabilidade da amostra \u00e9 composta apenas por estudantes oriundos do ensino p\u00fablico.software do IAF foi desenvolvido para avaliar qualquer faixa et\u00e1ria, por\u00e9m, ele foi validado para crian\u00e7as com idade superior a cinco anos, respeitando o per\u00edodo de estabiliza\u00e7\u00e3o da aquisi\u00e7\u00e3o fonol\u00f3gica e o conjunto de sinais que caracterizam o TF, al\u00e9m da idade da amostra.O presente estudo demonstrou que o IAF \u00e9 um instrumento confi\u00e1vel para a utiliza\u00e7\u00e3o e aplicabilidade, trazendo evid\u00eancias de fidedignidade dos escores, por\u00e9m, outros estudos dever\u00e3o ser realizados em busca de outras evid\u00eancias de validade, como a etapa de consequ\u00eancias do teste, a normatiza\u00e7\u00e3o, a padroniza\u00e7\u00e3o e a an\u00e1lise de itens. Cabe ressaltar que o O IAF apresentou evid\u00eancias robustas de fidedignidade, demonstrando bons escores de consist\u00eancia interna, o que aponta uma excelente confiabilidade dos itens do instrumento, al\u00e9m da confiabilidade inter e intra-avaliador. Desta forma, houve uma adequada concord\u00e2ncia entre os resultados fornecidos pelo IAF, tanto em aplica\u00e7\u00e3o por diferentes avaliadores, quanto por aplica\u00e7\u00e3o individual em momentos distintos. Por ser um estudo que seguiu par\u00e2metros psicom\u00e9tricos de valida\u00e7\u00e3o, as evid\u00eancias apresentadas demonstram a qualidade do instrumento e fortalecem a seguran\u00e7a do uso de suas medidas. Conclui-se que o IAF \u00e9 uma op\u00e7\u00e3o confi\u00e1vel e segura para ser utilizado em pesquisas brasileiras e na pr\u00e1tica cl\u00ednica para a avalia\u00e7\u00e3o do sistema fonol\u00f3gico de crian\u00e7as."}
+{"text": "Regress\u00e3olog\u00edstica foi empregada para estimar raz\u00f5es de chances com intervalos de 95% deconfian\u00e7a. Foram analisadas 1.115 notas t\u00e9cnicas das a\u00e7\u00f5es demandantes de CBD,das quais 54,7% dos pacientes eram do sexo masculino, com idade m\u00e9dia de 18,4anos, em sua maioria da Regi\u00e3o Sul do pa\u00eds , e 49,6% buscavam tratamentopara epilepsia. Das a\u00e7\u00f5es com pareceres favor\u00e1veis, 28,8% n\u00e3o tinham evid\u00eanciascient\u00edficas, 26,5% pleitearam produtos sem registro na Ag\u00eancia Nacional deVigil\u00e2ncia Sanit\u00e1ria e 25,3% dos que tinham registro n\u00e3o estavam em conformidadecom a indica\u00e7\u00e3o terap\u00eautica. Os pacientes da Regi\u00e3o Nordeste tiveram a chance deparecer favor\u00e1vel aumentada em 3 vezes; e os que tinham diagn\u00f3stico deepilepsia, em 2,3 vezes. Os pareceres t\u00e9cnicos que deram suporte aos magistradospara as decis\u00f5es judiciais das demandas de pacientes por produtos \u00e0 base decanabidiol no Brasil estavam, em sua maioria, em conformidade com evid\u00eanciascient\u00edficas, denotando a import\u00e2ncia dos NatJus na qualifica\u00e7\u00e3o do acesso aprodutos medicinais no pa\u00eds.Este estudo analisou as a\u00e7\u00f5es judiciais de pacientes que solicitaram ao Sistema\u00danico de Sa\u00fade produtos \u00e0 base de canabidiol (CBD) durante o per\u00edodo de 2019 a2022, descrevendo caracter\u00edsticas sociodemogr\u00e1ficas, cl\u00ednicas e jur\u00eddicas.Trata-se de um estudo transversal composto pela avalia\u00e7\u00e3o das notas t\u00e9cnicasemitidas pelos N\u00facleos de Apoio T\u00e9cnico do Judici\u00e1rio (NatJus), que embasaram asdecis\u00f5es judiciais. Os dados foram obtidos do sistema e-NatJus, do Minist\u00e9rio daJusti\u00e7a, utilizando t\u00e9cnicas de  Cannabis sativa ou obtido sinteticamente. Os produtos \u00e0 base deCBD t\u00eam sido utilizados para o tratamento de diferentes condi\u00e7\u00f5es cl\u00ednicas.Formula\u00e7\u00f5es de diferentes origens, concentra\u00e7\u00f5es e grau de pureza podem serencontradas no mercado, muitas delas sem aprova\u00e7\u00e3o por \u00f3rg\u00e3os reguladores, o queaumenta os riscos potenciais de ocorr\u00eancia de eventos adversos \u00e0 sa\u00fade humana O canabidiol (CBD) \u00e9 um fitocanabinoide, que pode ser extra\u00eddo da planta,As evid\u00eancias cient\u00edficas sobre a efetividade desses produtos s\u00e3o escassas.Entretanto, a garantia do acesso ao tratamento de enfermidades com CBD tem ocorridoespecialmente pela via judicial, em alguns casos mesmo sem aprova\u00e7\u00e3o regulat\u00f3ria,,,,,Devido aos seus efeitos terap\u00eauticos promissores, o CBD, um composto terpenofen\u00f3licode 21 carbonos, \u00e9 um dos canabinoides mais estudados atualmente. Esse composto n\u00e3opsicoativo, diferentemente do delta-9-tetraidrocanabinol (\u03949-THC), tem alegadaspropriedades anti-inflamat\u00f3rias, analg\u00e9sicas, ansiol\u00edticas e antitumorais. Al\u00e9mdisso, existem relatos de uso para o tratamento de pacientes com transtorno de humore epilepsia ,,,,Com exce\u00e7\u00e3o dos estudos que avaliam o tratamento da epilepsia, as demais pesquisaspublicadas geralmente apresentam baixa qualidade metodol\u00f3gica e fraca evid\u00eanciacient\u00edfica. Apesar disso, os produtos \u00e0 base de CBD est\u00e3o sendo utilizados notratamento de v\u00e1rias condi\u00e7\u00f5es cl\u00ednicas ,O uso de produtos \u00e0 base de CBD \u00e9 atualmente aprovado pela Ag\u00eancia de Alimentos eMedicamentos dos Estados Unidos (Food and Drug Administration - FDA), pela Ag\u00eanciade Sa\u00fade do Canad\u00e1  e pela Ag\u00eancia Europeia de Medicamentos (EuropeanMedicines Agency - EMA). A aprova\u00e7\u00e3o \u00e9 espec\u00edfica para determinadas indica\u00e7\u00f5esterap\u00eauticas, em alguns casos, enquanto em outros a escolha da indica\u00e7\u00e3o pode seruma decis\u00e3o m\u00e9dica. Apesar da aprova\u00e7\u00e3o, a falta de padroniza\u00e7\u00e3o e regulamenta\u00e7\u00e3olevanta preocupa\u00e7\u00f5es sobre a composi\u00e7\u00e3o desses produtos Resolu\u00e7\u00e3o da Diretoria Colegiada(RDC) n\u00ba 3, de 26 de janeiro de 2015 C. sativa. Dez produtos \u00e0base de CBD e oito \u00e0 base de extratos de C. sativa t\u00eam registroativo na Anvisa ,No Brasil, em 2015, a Ag\u00eancia Nacional de Vigil\u00e2ncia Sanit\u00e1ria (Anvisa) excluiu o CBDda lista de subst\u00e2ncias proibidas, incluindo-o na lista de subst\u00e2ncias sujeitas acontrole especial por meio da ,As recentes altera\u00e7\u00f5es nas normas regulat\u00f3rias no que tange aos produtos \u00e0 base deCBD permitem maior acesso pelos pacientes, inclusive pelas vias judiciais. Asdemandas por esses produtos se juntam \u00e0s demais, relacionadas aos bens e servi\u00e7os desa\u00fade que o Estado \u00e9 obrigado a fornecer por ordem judicial. Esse fen\u00f4meno,conhecido como judicializa\u00e7\u00e3o da sa\u00fade, tem gerado desafios e exigido dos PoderesExecutivo e Judici\u00e1rio a cria\u00e7\u00e3o de estrat\u00e9gias institucionais, como c\u00e2marast\u00e9cnicas e secretarias espec\u00edficas para reduzir as distor\u00e7\u00f5es sociais, econ\u00f4micas epol\u00edticas linkhttps://www.cnj.jus.br/e-natjus/Com o objetivo de capacitar os profissionais de sa\u00fade que comp\u00f5em os N\u00facleos de ApoioT\u00e9cnico do Poder Judici\u00e1rio (NatJus), o Conselho Nacional de Justi\u00e7a (CNJ) e oMinist\u00e9rio da Sa\u00fade mant\u00eam coopera\u00e7\u00e3o para proporcionar aos magistrados dosTribunais de Justi\u00e7a dos Estados e Tribunais Regionais Federais (TRF) subs\u00eddiost\u00e9cnicos para a tomada de decis\u00e3o com base em evid\u00eancias cient\u00edficas. Assim, foicriado o Banco Nacional de Pareceres (Sistema e-NatJus) para abrigar os parecerest\u00e9cnico-cient\u00edficos e notas t\u00e9cnicas elaboradas pelos NatJus e pelos N\u00facleos deAvalia\u00e7\u00e3o de Tecnologias em Sa\u00fade (Nats). Esse sistema \u00e9 aberto e pode ser acessadopelo Considerando a necessidade de promover a discuss\u00e3o sobre o acesso de pacientes aosprodutos \u00e0 base do CBD, e de avaliar as a\u00e7\u00f5es judiciais existentes, este estudo temcomo objetivo analisar as demandas judiciais movidas contra o Sistema \u00danico de Sa\u00fade(SUS) e avaliadas pelos NatJus durante o per\u00edodo de 2019 a 2022.Trata-se de um estudo transversal, proveniente de pesquisa documental, composto portodas as notas t\u00e9cnicas das a\u00e7\u00f5es judiciais demandantes de produtos \u00e0 base de CBDsubmetidos ao Minist\u00e9rio da Justi\u00e7a do Brasil entre dezembro de 2019 e junho de2022.A nota t\u00e9cnica \u00e9 um documento de car\u00e1ter cient\u00edfico, elaborado pela equipe t\u00e9cnicados NatJus, que se prop\u00f5e a responder, de modo preliminar, as quest\u00f5es cl\u00ednicassobre os potenciais efeitos de uma tecnologia para uma condi\u00e7\u00e3o de sa\u00fade vivenciadapor um indiv\u00edduo. Ela \u00e9 produzida por solicita\u00e7\u00e3o de um juiz para auxiliar na tomadade decis\u00e3o judicial em um caso espec\u00edfico web scraping, desenvolvidas na linguagem de programa\u00e7\u00e3o Python(https://www.python.org/). De maneira resumida, webscraping \u00e9 um procedimento utilizado para extrair conte\u00fado daweb no qual um agente de software, tamb\u00e9m conhecido como rob\u00f4web (scraper), imita a intera\u00e7\u00e3o entre humanose servidores web em uma navega\u00e7\u00e3o convencional na Internet,extraindo e combinando conte\u00fados de interesse de forma sistem\u00e1tica Os dados foram coletados do sistema e-NatJus de forma automatizada, usando t\u00e9cnicasde https://www.cnj.jus.br/e-natjus/pesquisaPublica.php) foram extra\u00eddoscom base em algoritmo desenvolvido pelo nosso grupo de pesquisa, os quais inclu\u00edramtodas as notas t\u00e9cnicas e suas respectivas URL para download. Aescolha do termo \u201ccanabidiol\u201d se deu a partir de alguns testes iniciais paraverificar a obten\u00e7\u00e3o de maior n\u00famero de notas t\u00e9cnicas registradas no sistemae-NatJus.A extra\u00e7\u00e3o das vari\u00e1veis de interesse foi realizada em tr\u00eas etapas. Na primeira, osresultados obtidos da pesquisa feita com o termo \u201ccanabidiol\u201d no sistema e-NatJus para fins de tratamento e an\u00e1liseestat\u00edstica.Na segunda etapa, todas as URL listadas foram consideradas, seus conte\u00fados forambaixados e salvos em disco local no formato de origem PDF peloForam estudadas as caracter\u00edsticas dos pacientes, segundo as categorias das seguintesvari\u00e1veis: (i) sociodemogr\u00e1ficas ; e (ii)diagn\u00f3sticos m\u00e9dicos por c\u00f3digo da Classifica\u00e7\u00e3o Internacional de Doen\u00e7as - 10\u00aarevis\u00e3o (CID-10). As vari\u00e1veis utilizadas para a caracteriza\u00e7\u00e3o dos pareceres foram:(i) presen\u00e7a ou n\u00e3o de evid\u00eancias cient\u00edficas; (ii) registro sanit\u00e1rio do produto naAnvisa; (iii) indica\u00e7\u00e3o de uso conforme o registro sanit\u00e1rio; e (iv) avalia\u00e7\u00e3o erecomenda\u00e7\u00e3o pela Comiss\u00e3o Nacional de Incorpora\u00e7\u00e3o de Tecnologias no SUS (Conitec).Foram utilizadas as vari\u00e1veis conforme registro feito nas notas t\u00e9cnicas oriundas dosistema e-NatJus.http://www.r-project.org). As vari\u00e1veis categ\u00f3ricas foramapresentadas em frequ\u00eancias absolutas e relativas; e as vari\u00e1veis quantitativas, emvalores m\u00e9dios, medianas e desvios padr\u00e3o.A an\u00e1lise estat\u00edstica foi realizada com aux\u00edlio do software R, vers\u00e3o 4.0.3 parainvestigar a associa\u00e7\u00e3o entre as vari\u00e1veis de interesse com o desfecho \u201cparecerfavor\u00e1vel para atendimento \u00e0 demanda judicial\u201d.O estudo foi aprovado pelo Comit\u00ea de \u00c9tica em Pesquisa da Funda\u00e7\u00e3o de Ensino ePesquisa em Ci\u00eancias da Sa\u00fade da Secretaria de Estado da Sa\u00fade do Distrito Federal.Foram analisadas todas as 1.115 notas t\u00e9cnicas das a\u00e7\u00f5es judiciais demandantes deprodutos \u00e0 base de CBD emitidas pelos NatJus. No ano de 2019, foram inseridas apenas11 notas t\u00e9cnicas no sistema e-NatJus, valor que foi aumentando progressivamente nosanos seguintes, chegando a 420 at\u00e9 o fim do primeiro semestre de 2022, como mostra aA As epilepsias figuraram entre os diagn\u00f3sticos mais demandados , seguidos pelostranstornos globais do desenvolvimento (CID-10 F84) . Entre os demaisdiagn\u00f3sticos de epilepsia, a epilepsia n\u00e3o especificada (CID-10 G40.9)  eoutras epilepsias e s\u00edndromes epil\u00e9pticas generalizadas (CID-10 G40.4)  foramas mais frequentes .A Dos pareceres das a\u00e7\u00f5es que n\u00e3o apresentaram evid\u00eancias cient\u00edficas, 28,8% foramainda assim favor\u00e1veis ao acesso. Das solicita\u00e7\u00f5es de produtos \u00e0 base de CBD semregistro na Anvisa, 26,5% foram deferidas. Mesmo pleiteando o uso fora dasindica\u00e7\u00f5es, 25,3% das a\u00e7\u00f5es tiveram parecer favor\u00e1vel quando o produto tinharegistro na Anvisa .A Os dados obtidos no sistema e-NatJus n\u00e3o permitiram tra\u00e7ar um perfil mais preciso dospacientes que demandaram o CBD, caracterizando, assim, uma limita\u00e7\u00e3o deste estudo.Em pesquisa recente que avaliou a\u00e7\u00f5es judiciais de solicita\u00e7\u00e3o de medicamentos, osautores relatam que, mesmo ap\u00f3s mais de duas d\u00e9cadas da exist\u00eancia do fen\u00f4meno dejudicializa\u00e7\u00e3o no Brasil, ainda h\u00e1 dificuldade para tra\u00e7ar um perfil nacional dasdemandas e dos demandantes. Os autores avaliam, ainda, que dados de estudos locais,realizados em sua maioria nas regi\u00f5es Sul e Sudeste do pa\u00eds, n\u00e3o permitemextrapola\u00e7\u00f5es, principalmente para as realidades socioecon\u00f4micas profundamentedistintas, como as observadas nas regi\u00f5es Norte e Nordeste ,,A maior parte das a\u00e7\u00f5es judiciais teve origem na Regi\u00e3o Sul do pa\u00eds; e a menor, naRegi\u00e3o Norte. Essa rela\u00e7\u00e3o pode ter sido influenciada pela diferen\u00e7a socioecon\u00f4micadas popula\u00e7\u00f5es dessas duas regi\u00f5es e pelos n\u00edveis de acesso \u00e0 informa\u00e7\u00e3o e aosservi\u00e7os de sa\u00fade. Ao avaliar os fatores associados aos servi\u00e7os de sa\u00fade, estudorecente concluiu que a popula\u00e7\u00e3o da Regi\u00e3o Norte apresenta maior precariza\u00e7\u00e3o noacesso e que o n\u00edvel de acesso da Regi\u00e3o Sul se aproxima ao da Regi\u00e3o Sudeste ,,,,,,,,,,,As condi\u00e7\u00f5es de epilepsias figuraram entre os diagn\u00f3sticos que mais demandaram acessoao produto, seguidas pelos transtornos globais do desenvolvimento (CID-10 F84).Entre os diagn\u00f3sticos de epilepsias classificadas, a epilepsia n\u00e3o especificada(CID-10 G40.9), outras epilepsias e s\u00edndromes epil\u00e9pticas generalizadas (CID-10G40.4) foram as mais frequentes. A preval\u00eancia desses diagn\u00f3sticos pode serexplicada pelo fato de v\u00e1rios estudos terem evidenciado efic\u00e1cia e seguran\u00e7a do usodo CBD no tratamento dessa doen\u00e7a e do transtorno do espectro autista, apesar deainda serem necess\u00e1rios ensaios cl\u00ednicos randomizados, cegos e controlados paraesclarecer os efeitos do CBD ,A maioria das solicita\u00e7\u00f5es apresentou evid\u00eancia cient\u00edfica para o tratamentoindicado, entretanto, somente 1/3 destas tiveram pareceres favor\u00e1veis para o acessoao CBD. Dos pareceres sem evid\u00eancias cient\u00edficas, 28,8% foram mesmo assim favor\u00e1veisao acesso por ordem judicial. Percebe-se que a falta de evid\u00eancia cient\u00edfica n\u00e3o foifator preponderante para pareceres favor\u00e1veis ao acesso, podendo a prescri\u00e7\u00e3o m\u00e9dicater prevalecido como documento suficiente para atendimento \u00e0 demanda judicial.Apesar da busca incessante por evid\u00eancia cient\u00edfica que embase a prescri\u00e7\u00e3o do CBD esua disponibiliza\u00e7\u00e3o pelo SUS, sua efic\u00e1cia comprovada permanece restrita \u00e0scondi\u00e7\u00f5es de epilepsias pedi\u00e1tricas resistentes a tratamentos com medicamentosconvencionais Lei n\u00ba 6.360/1976Lei n\u00ba 13.411/2016,,Os achados evidenciam uma defici\u00eancia de rigor cient\u00edfico nas discuss\u00f5es para asdecis\u00f5es judiciais para acesso ao CBD por gravitarem em torno de pretensos direitosn\u00e3o reconhecidos por tratamentos e produtos sem registros na Anvisa. Apesar daoff-label (fora das indica\u00e7\u00f5es dos produtos \u00e0 base de CBDregistrados na ag\u00eancia) podem estimular a divulga\u00e7\u00e3o do CBD como uma panaceia parauma ampla gama de problemas de sa\u00fade e tentativa de comercializa\u00e7\u00e3o para outrosfins, como diet\u00e9tico e de bem-estar O estudo demonstrou a emiss\u00e3o de pareceres favor\u00e1veis para o acesso ao CBD por viajudicial, mesmo quando a prescri\u00e7\u00e3o estava fora das indica\u00e7\u00f5es terap\u00eauticas conformeo registro do produto na Anvisa. A prescri\u00e7\u00e3o e a concess\u00e3o judicial para usoDas a\u00e7\u00f5es judiciais, 29% pleiteavam produtos j\u00e1 avaliados pela Conitec, entretanto,apenas 7,4% deles tinham sido recomendados para incorpora\u00e7\u00e3o ao SUS. Das a\u00e7\u00f5es quedemandaram produtos recomendados pela Conitec, 58,3% tiveram pareceres favor\u00e1veis aoacesso.,A incorpora\u00e7\u00e3o ao SUS de produtos para a sa\u00fade deve ser baseada em evid\u00eanciascient\u00edficas de efic\u00e1cia e seguran\u00e7a, al\u00e9m de avalia\u00e7\u00e3o econ\u00f4mica e de impactoor\u00e7ament\u00e1rio, produzidas por estudos de avalia\u00e7\u00e3o de tecnologia em sa\u00fade (ATS). Ap\u00f3san\u00e1lises desses estudos, cabe \u00e0 Conitec tomar a decis\u00e3o sobre a incorpora\u00e7\u00e3o.Percebe-se nesse contexto a import\u00e2ncia do alinhamento das tomadas de decis\u00f5es entreo Poder Judici\u00e1rio e a Conitec, no sentido de garantir a disponibiliza\u00e7\u00e3o \u00e0popula\u00e7\u00e3o de medicamentos e produtos como o CBD, demandados judicialmente O estudo demonstrou que a chance de um parecer ter sido deferido foi 3,0 vezes maiorem a\u00e7\u00f5es judiciais da Regi\u00e3o Nordeste do que da Regi\u00e3o Centro-oeste; 2,3 vezes maiorpara pacientes com diagn\u00f3stico de epilepsias n\u00e3o classificadas (CID-10 G40) do quepara aqueles com diagn\u00f3stico de transtornos globais do desenvolvimento (CID-10 F84);2,4, 4,8 e 2,0 vezes maiores que aqueles com diagn\u00f3stico de outras epilepsias es\u00edndromes epil\u00e9pticas generalizadas (CID-10 G40.4), s\u00edndromes epil\u00e9pticas especiais(CID-10 G40.5) e paralisia cerebral (CID-10 G80); 35% maior quando havia evid\u00eanciacient\u00edfica; 97% maior quando o produto era registrado na Anvisa; e 3,3 vezes maiorse a indica\u00e7\u00e3o terap\u00eautica estivesse em conformidade com o registro. Por outro lado,produtos \u00e0 base de CBD j\u00e1 submetidos \u00e0 avalia\u00e7\u00e3o da Conitec tiveram a chance de umparecer favor\u00e1vel reduzida em 42%.A prescri\u00e7\u00e3o de produtos \u00e0 base de CBD, mesmo na aus\u00eancia de evid\u00eancias cient\u00edficasrobustas, pode estar refletindo decis\u00f5es cl\u00ednicas que consideram prioritariamente osanseios do paciente e a concep\u00e7\u00e3o do m\u00e9dico de estar proporcionando um \u201cbenef\u00edcio\u201dpara o indiv\u00edduo. Tal fato pode tamb\u00e9m refletir negativamente sobre a abordagemsocial do uso do CBD, aprofundando vieses ideol\u00f3gicos e discursos de cunhopreconceituoso. Estimular a realiza\u00e7\u00e3o de estudos de consider\u00e1vel robustez, queavaliem os promissores efeitos ben\u00e9ficos do CBD em diferentes condi\u00e7\u00f5es cl\u00ednicas,seria uma importante estrat\u00e9gia para oferecer maiores garantias de resultadospositivos durante seu uso.,,,,,,As maiores chances para se terem pareceres favor\u00e1veis para demandas com diagn\u00f3sticode epilepsias e com indica\u00e7\u00e3o terap\u00eautica, de acordo com o registro dos produtos \u00e0base de CBD na Anvisa, demonstram que os pareceres e as decis\u00f5es judiciais podemestar de acordo com os estudos que evidenciam o uso de CBD para o tratamento deepilepsias de dif\u00edcil tratamento com as terapias convencionais A impossibilidade de captura de dados nas notas t\u00e9cnicas emitidas pelos NatJus, comoo tipo de advocacia, se p\u00fablica ou privada, e a qual estabelecimento de sa\u00fade oprofissional que emitiu o relat\u00f3rio m\u00e9dico estaria vinculado, pode ter sido fator delimita\u00e7\u00e3o do estudo. Outra importante limita\u00e7\u00e3o foi a quase inexist\u00eancia depesquisas abordando a judicializa\u00e7\u00e3o de produtos \u00e0 base de CBD, para efeito decompara\u00e7\u00e3o.Os achados deste estudo podem contribuir para o aprimoramento t\u00e9cnico dos diferentesatores com poder decis\u00f3rio envolvidos no processo de judicializa\u00e7\u00e3o , garantindo, assim, o acesso de pacientesdemandantes de produtos \u00e0 base de CBD com efic\u00e1cia e seguran\u00e7a evidenciadas paratratamento de suas condi\u00e7\u00f5es cl\u00ednicas. O estudo pode tamb\u00e9m possibilitar umareflex\u00e3o, sem vi\u00e9s ideol\u00f3gico, sobre a possibilidade de padroniza\u00e7\u00e3o no SUS dosprodutos \u00e0 base de CBD, inicialmente para epilepsias de dif\u00edcil tratamento.Conclui-se que os pareceres t\u00e9cnicos que deram suporte aos magistrados para asdecis\u00f5es judiciais das demandas de pacientes por produtos \u00e0 base de CBD no Brasilestavam, em sua maioria, em conformidade com evid\u00eancias cient\u00edficas, denotando aimport\u00e2ncia dos NatJus na qualifica\u00e7\u00e3o do acesso a produtos medicinais no pa\u00eds poressa via. No entanto, a falta de evid\u00eancia cient\u00edfica e o uso fora da indica\u00e7\u00e3oterap\u00eautica, quando registrados na Anvisa, n\u00e3o foram fatores preponderantes para aemiss\u00e3o de pareceres t\u00e9cnicos favor\u00e1veis ao acesso de produtos \u00e0 base de CBD."}
+{"text": "Pesquisa Especial de Tabagismoconduzida em 2008 e da Pesquisa Nacional de Sa\u00fade conduzida em2013 e 2019. Modelo linear generalizado foi usado para calcular as diferen\u00e7as napropor\u00e7\u00e3o de compra de cigarros avulsos entre os anos das pesquisas, ajustadaspor vari\u00e1veis sociodemogr\u00e1ficas e de comportamento de fumar. Considerando 2013como ano de refer\u00eancia, as diferen\u00e7as relativas entre as propor\u00e7\u00f5es foram,respectivamente, -15,3%  na compara\u00e7\u00e3o com 2008, e+13,3  na compara\u00e7\u00e3o com 2019. Cerca de 20% dosjovens adultos fumantes relataram comprar cigarro avulso em 2019 e a diferen\u00e7ana propor\u00e7\u00e3o de compra de cigarro avulso entre indiv\u00edduos de 18 a 24 anos eaqueles mais velhos provavelmente aumentou entre 2013 e 2019 . H\u00e1 motivos de preocupa\u00e7\u00e3o, pois o fortalecimento dapol\u00edtica tribut\u00e1ria entre 2008 e 2013 foi acompanhado de um aumento na propor\u00e7\u00e3ode compra de cigarros avulsos. Apesar da queda do pre\u00e7o real do ma\u00e7o de cigarrosa partir de 2017, um contexto de baixa efetividade de implementa\u00e7\u00e3o de outrasmedidas antitabagismo acentuou provavelmente a diferen\u00e7a da propor\u00e7\u00e3o de comprade cigarros avulsos entre jovens e adultos. A presen\u00e7a permanente do cigarroavulso como modalidade de aquisi\u00e7\u00e3o contribui para que subgrupos populacionaismais vulner\u00e1veis do ponto de vista econ\u00f4mico se tornem e/ou permane\u00e7amdependentes do comportamento de fumar.No Brasil, a venda de cigarros \u00e9 permitida apenas em embalagens fechadas com 20unidades. Avaliou-se a evolu\u00e7\u00e3o ao longo do tempo da propor\u00e7\u00e3o de fumantesadultos que adquiriram cigarros industrializados avulsos na \u00faltima compra.Utilizaram-se os dados da  A pol\u00edtica de controle do tabaco do Brasil \u00e9 norteada pelos objetivos, princ\u00edpios eobriga\u00e7\u00f5es presentes na Conven\u00e7\u00e3o-Quadro para o Controle do Tabaco (CQCT), primeirotratado internacional de sa\u00fade p\u00fablica negociado sob a coordena\u00e7\u00e3o da Organiza\u00e7\u00e3oMundial da Sa\u00fade (OMS) e ratificado pelo pa\u00eds em 2005 ,,,,Entre uma s\u00e9rie de medidas relativas \u00e0 redu\u00e7\u00e3o da demanda de tabaco, aquelarelacionada ao aumento de pre\u00e7os e impostos \u00e9 considerada a mais eficaz para quediversos segmentos da popula\u00e7\u00e3o, em particular os jovens que n\u00e3o t\u00eam tantos recursosfinanceiros, reduzam/cessem o consumo de tabaco (Artigo 6/CQCT) ,,J\u00e1 a utiliza\u00e7\u00e3o das embalagens dos produtos derivados do tabaco \u00e9 tamb\u00e9m umaimportante medida para comunicar \u00e0 popula\u00e7\u00e3o os reais efeitos negativos do tabagismo(Artigo 11/CQCT) 1, o Brasil conta com um sistema demonitoramento da epidemia do tabagismo composto por uma s\u00e9rie de perguntas sobre ocomportamento de fumar inseridas em pesquisas peri\u00f3dicas nacionais realizadas tantona popula\u00e7\u00e3o jovem quanto na adulta ,,versus10,5% em 2013) ,,,,,,,,,Tal como preconizado no Artigo 20/CQCT ,O objetivo deste estudo foi, portanto, avaliar a evolu\u00e7\u00e3o ao longo do tempo dapropor\u00e7\u00e3o de compra de cigarro avulso pelo fumante, estratificada por vari\u00e1veissociodemogr\u00e1ficas e de comportamento de fumar. At\u00e9 onde os autores sabem, n\u00e3o existenenhum estudo que tenha analisado, a partir de inqu\u00e9ritos nacionais seriados, o temado cumprimento/descumprimento do conjunto de legisla\u00e7\u00f5es que pro\u00edbem a venda decigarros avulsos, i.e., que pro\u00edbem a venda de cigarros fora das embalagens Pesquisa Especial de Tabagismo (PETab) conduzida em 2008 comoum suplemento da Pesquisa Nacional por Amostra de Domic\u00edlios (PNAD)Pesquisa Nacional de Sa\u00fade (PNS), conduzida em 2013 e 2019,,,Este artigo utiliza os dados sociodemogr\u00e1ficos e de comportamento de fumar daversus \u201csim\u201d). Vale a pena assinalar que os indiv\u00edduos quecompraram cigarros para uso pr\u00f3prio tamb\u00e9m forneceram a informa\u00e7\u00e3o em rela\u00e7\u00e3o \u00e0quantidade adquirida em termos, respectivamente, de cigarros avulsos . Sendo assim, indiv\u00edduos queafirmaram ter comprado \u201ccigarros\u201d na \u00faltima compra em n\u00famero igual ou superior am\u00faltiplos de 20 foram reclassificados como compradores de \u201cma\u00e7o ou pacote\u201d ,A pergunta que definiu a compra de cigarro avulso pelo fumante tanto na PETab quantonas edi\u00e7\u00f5es da PNS foi a seguinte: \u201cNa \u00faltima vez em que o(a) Sr(a) comprou cigarrospara uso pr\u00f3prio, quantos cigarros comprou?\u201d, sendo que as op\u00e7\u00f5es de resposta eram\u201ccigarros\u201d, \u201cma\u00e7os\u201d, \u201cpacotes\u201d e \u201cnunca comprei cigarros para uso pr\u00f3prio\u201d. Essapergunta foi feita apenas para aqueles indiv\u00edduos que afirmaram fumar, atualmente,cigarros industrializados. Ap\u00f3s excluir os fumantes que afirmaram nunca ter compradocigarros para uso pr\u00f3prio, aqueles que compraram por \u201cma\u00e7o\u201d ou \u201cpacote\u201d foramagrupados de forma a criar a vari\u00e1vel dicot\u00f4mica \u201ccompra de cigarro avulso\u201d escolaridade, classificada como Ensino Fundamental completo ou maisversus Ensino Fundamental incompleto; (4) regi\u00e3o de resid\u00eancia,agrupada entre Norte  e Nordeste versus Centro-oeste , Sudeste  e Sul , a partir tamb\u00e9m de an\u00e1lise preliminardos bancos de dados; (5) frequ\u00eancia de consumo de cigarros, definida a partir dapergunta \u201cAtualmente, o(a) Sr(a) fuma algum produto do tabaco?\u201d e classificada combase nas respostas \u201csim, diariamente\u201d ou \u201csim, ocasionalmente\u201d. Al\u00e9m disso,indiv\u00edduos que fumam cigarros industrializados ilegais (versuslegais) foram separados a partir de metodologia baseada no crit\u00e9rio do nomeautorreportado da marca de cigarros da \u00faltima compra (informa\u00e7\u00e3o dispon\u00edvel apenaspara o ano de 2019) ,As an\u00e1lises do artigo foram restritas, portanto, aos fumantes de cigarrosindustrializados com 18 anos de idade ou mais que em algum momento da vida j\u00e1compraram seus pr\u00f3prios cigarros. Informa\u00e7\u00f5es sociodemogr\u00e1ficas e de comportamentode fumar amplamente descritas na literatura como relacionadas ao uso de cigarrosavulsos versus 2013 e 2013versus 2019).Inicialmente, calculou-se, para os anos das pesquisas , adistribui\u00e7\u00e3o dos fumantes de cigarros industrializados estratificada pelas vari\u00e1veissociodemogr\u00e1ficas e de comportamento de fumar. Para essa an\u00e1lise estat\u00edsticadescritiva, o teste qui-quadrado foi utilizado para comparar as correspondentespropor\u00e7\u00f5es entre os anos das pesquisas  da compra de cigarro avulso Ademais, foram estimados, para cada ano de pesquisa, os n\u00fameros totais de fumantes decigarros avulsos e o n\u00famero total de cigarros avulsos comprados, estratificadospelas vari\u00e1veis sociodemogr\u00e1ficas e de comportamento de fumar. Para estimar o n\u00famerototal de cigarros avulsos comprados por ano, foi necess\u00e1rio ponderar pela informa\u00e7\u00e3orelativa ao consumo m\u00e9dio di\u00e1rio de cigarros dos fumantes, cuja \u00faltima compracorrespondeu a uma aquisi\u00e7\u00e3o de cigarro avulso, multiplicada por 365,25. Para tal,utilizou-se a resposta \u00e0 pergunta \u201cEm m\u00e9dia, quantos cigarros industrializados o(a)Sr(a) fuma por dia ou por semana atualmente?\u201d. O consumo m\u00e9dio di\u00e1rio de cigarrospara aqueles que responderam \u201cpor semana\u201d foi calculado dividindo a informa\u00e7\u00e3ofornecida por 7.status de compra decigarro ilegal (assim como as respectivas diferen\u00e7as brutas absoluta e relativa) eos n\u00fameros totais de fumantes e de cigarros avulsos comprados.Finalmente, apenas para o ano de 2019, foram estimadas tamb\u00e9m a propor\u00e7\u00e3o de consumode cigarro ilegal entre os fumantes de cigarro industrializado, a propor\u00e7\u00e3o decompra de cigarro avulso estratificada por https://www.stata.com), considerando o desenho amostral complexo daspesquisas.Todas as an\u00e1lises foram realizadas com o programa estat\u00edstico Stata, vers\u00e3o 15.0. Vale a pena assinalar que, em 2019, n\u00e3o foram encontradasdiferen\u00e7as absolutas ou relativas na propor\u00e7\u00e3o de compra de cigarros avulsos segundostatus de compra de cigarro ilegal.Os dados brutos apresentados na versus suas respectivas categorias decompara\u00e7\u00e3o). As diferen\u00e7as absoluta e relativa ajustadas entre homens e mulheres n\u00e3oforam estatisticamente significativas. As diferen\u00e7as ajustadas entre os anos dapesquisa 2013 e 2008, e entre os indiv\u00edduos de \u201calta\u201d e \u201cbaixa\u201d escolaridade,permaneceram estatisticamente significativas apenas na escala relativa . \u00c9 importante mencionar que, embora as diferen\u00e7as absolutae relativa entre os anos de pesquisa 2013 e 2019 sugiram um aumento na propor\u00e7\u00e3o decompra de cigarros avulsos, elas n\u00e3o foram estatisticamente significativas .Ainda, a versus 2013) . Al\u00e9m disso, as diferen\u00e7as absolutas erelativas na propor\u00e7\u00e3o de compra de cigarros avulsos entre os jovens adultos eindiv\u00edduos com mais de 24 anos sugerem um aumento entre 2013 e 2019 .Todas as diferen\u00e7as entre as categorias das vari\u00e1veis sociodemogr\u00e1ficas e decomportamento de fumar foram homog\u00eaneas segundo os anos de pesquisa . Mesmo assim, os resultados encontradossugerem que a reforma tribut\u00e1ria que entrou em vigor em 2012 ,versus 89,6%) O crescimento do consumo de cigarros de origem ilegal observado no Brasil ap\u00f3s areforma tribut\u00e1ria de 2011 ,,,,,,,,,O caminho para tentar adquirir cigarro avulso no pa\u00eds  reflete, ainda, uma s\u00e9rie de eventos oriundos da baixa efetividade naimplementa\u00e7\u00e3o de algumas pol\u00edticas antitabaco existentes no Brasil voltadas areduzir a inicia\u00e7\u00e3o e/ou estimular a cessa\u00e7\u00e3o dessa pr\u00e1tica, como: (i) a presen\u00e7a decigarros com aromas e sabores no mercado brasileiro, muito atrativos particularmentepara adolescentes e jovens adultos. Tal situa\u00e7\u00e3o acontece apesar de existir umaresolu\u00e7\u00e3o da Anvisa de 2012 que a impediria ,,,,Ademais, nos \u00faltimos anos, tem-se observado no pa\u00eds o aumento do consumo de outrosprodutos derivados do tabaco pelos jovens brasileiros, como o cigarro de palha e onarguil\u00e9 ,,,,,,,Diante do cen\u00e1rio atual da pol\u00edtica antitabagismo, provavelmente n\u00e3o por acaso, cercade um em cada cinco jovens adultos fumantes de cigarro industrializado relatou teradquirido cigarro avulso na sua \u00faltima compra em 2019, o que representou 360 milindiv\u00edduos entre 18 e 24 anos no Brasil. Tal achado \u00e9 extremamente preocupante econtribui para que a ind\u00fastria do tabaco seja bem-sucedida na sua estrat\u00e9gia demarketing voltada a substituir uma parte dos seus consumidores atuais, os quais ir\u00e3oinevitavelmente falecer ,,,Global Youth TobaccoSurvey, que comp\u00f5e o sistema de monitoramento da epidemia do tabagismoproposto pela OMS nos pa\u00edses, coletados entre 2010 e 2018, percebemos que apropor\u00e7\u00e3o foi bem superior \u00e0 observada entre o restante dos pa\u00edses da regi\u00e3o dasAm\u00e9ricas  ou \u00e0 m\u00e9dia mundial  ,Existem poucos estudos internacionais que tenham estimado a propor\u00e7\u00e3o de compra decigarros avulsos na popula\u00e7\u00e3o adulta de outros pa\u00edses ,,,,Embora as an\u00e1lises do artigo sejam baseadas em pesquisas de representatividadenacional, os resultados podem estar sujeitos a vi\u00e9s de informa\u00e7\u00e3o: (i) a informa\u00e7\u00e3oautorreferida sobre a quantidade de cigarros adquirida na \u00faltima compra pode tersido subestimada devido \u00e0 redu\u00e7\u00e3o da aceita\u00e7\u00e3o do comportamento de fumar nasociedade A an\u00e1lise in\u00e9dita da propor\u00e7\u00e3o de compra de cigarro avulso entre adultos no Brasilentre 2008 e 2019 reflete a import\u00e2ncia de se buscar uma sinergia na implementa\u00e7\u00e3oefetiva das medidas voltadas para a redu\u00e7\u00e3o da inicia\u00e7\u00e3o e para o est\u00edmulo \u00e0cessa\u00e7\u00e3o do fumo no pa\u00eds. H\u00e1 motivo de preocupa\u00e7\u00e3o quando percebemos que ofortalecimento da pol\u00edtica tribut\u00e1ria entre 2008 e 2013 foi acompanhado de umaumento na propor\u00e7\u00e3o de compra de cigarros avulsos. A preocupa\u00e7\u00e3o continua quandoconstatamos que, apesar da queda do pre\u00e7o real do ma\u00e7o de cigarros a partir de 2017,um contexto favor\u00e1vel de impunidade e ilegalidade, aliado \u00e0 baixa efetividade demedidas voltadas para redu\u00e7\u00e3o da demanda e oferta dos produtos derivados do tabaco,levou provavelmente a um aumento na diferen\u00e7a da propor\u00e7\u00e3o de compra de cigarrosavulsos entre jovens e adultos. A presen\u00e7a permanente do cigarro avulso comomodalidade de aquisi\u00e7\u00e3o poss\u00edvel contribui para que subgrupos populacionais maisvulner\u00e1veis do ponto de vista econ\u00f4mico se tornem e/ou permane\u00e7am dependentes docomportamento de fumar e, consequentemente, sofram/venham a sofrer com os problemasde sa\u00fade a ele associados."}
+{"text": "A Rede de Cuidados \u00e0 Pessoa com Defici\u00eancia (RCPCD) foi implantada em 2012 comodesdobramento das a\u00e7\u00f5es do Plano Viver sem Limite, sendo objeto de pesquisasrecentes, entretanto, n\u00e3o foram encontrados estudos de avalia\u00e7\u00e3o do grau deimplanta\u00e7\u00e3o dessa rede. O objetivo deste artigo foi avaliar o grau deimplanta\u00e7\u00e3o da RCPCD em oito estados nas cinco regi\u00f5es geogr\u00e1ficas brasileiras.Realizou-se estudo de casos m\u00faltiplos mediante pesquisa avaliativa do grau deimplanta\u00e7\u00e3o da RCPCD nos estados/casos: Amazonas, Bahia, Esp\u00edrito Santo, MatoGrosso do Sul, Minas Gerais, Para\u00edba, Rio Grande do Sul e S\u00e3o Paulo. Para tanto,desenvolveu-se um modelo l\u00f3gico da pol\u00edtica e uma matriz de medidas. O grau deimplanta\u00e7\u00e3o de sete estados foi classificado como moderado, somente o Amazonasobteve grau de implanta\u00e7\u00e3o incipiente. Foram identificadas diferen\u00e7asimportantes na avalia\u00e7\u00e3o de cada fase desse processo, as fases de diagn\u00f3sticoregional e ades\u00e3o \u00e0 rede obtiveram grau de implanta\u00e7\u00e3o de moderado a avan\u00e7ado namaioria dos estados. Na fase da contratualiza\u00e7\u00e3o dos servi\u00e7os, nenhum estadoalcan\u00e7ou o grau avan\u00e7ado de implanta\u00e7\u00e3o e a fase de acompanhamento emonitoramento da RCPCD basicamente n\u00e3o ocorreu em todos os estados. A matriz demedidas permite avaliar o grau de implanta\u00e7\u00e3o da RCPCD. Ainda, o reconhecimentodos resultados do grau de implanta\u00e7\u00e3o pelos grupos condutores e \u00e1reas t\u00e9cnicasestaduais referendou o uso desse instrumento. Salienta-se a necessidade de a\u00e7\u00f5espara o aprimoramento dessa implanta\u00e7\u00e3o, tais como: fortalecer a regionaliza\u00e7\u00e3o,instituir grupos condutores regionais, garantir mecanismos de contratualiza\u00e7\u00e3o edefinir crit\u00e9rios para certifica\u00e7\u00e3o dos pontos de aten\u00e7\u00e3o. Constitui\u00e7\u00e3o Federal de 1988,que determinou ser dever do Estado o cuidado a sa\u00fade, educa\u00e7\u00e3o, emprego e prote\u00e7\u00e3osocial \u00e0s pessoas com defici\u00eancia, seguido da institui\u00e7\u00e3o do Sistema \u00danico de Sa\u00fade(SUS) em 1990, que tem como princ\u00edpios universalidade, integralidade e equidade. Emseguida, surgiram diversas a\u00e7\u00f5es relacionadas \u00e0 pessoa com defici\u00eancia na forma deleis complementares, de forma fragmentada, desarticulada e centrada na aten\u00e7\u00e3oespecializada ,O Estado brasileiro, ao longo de sua hist\u00f3ria, apresentou insufici\u00eancia na garantiados direitos das pessoas com defici\u00eancia. Dessa forma, a filantropia assumiu oprotagonismo ao assegurar, parcialmente, a\u00e7\u00f5es de sa\u00fade, reabilita\u00e7\u00e3o e no campoeducacional Outro marco importante na garantia dos direitos das pessoas com defici\u00eancia foi aassinatura e ratifica\u00e7\u00e3o, em 2007, da Conven\u00e7\u00e3o Internacional sobre os Direitos dasPessoas com Defici\u00eancia no Brasil, que adquiriu status de emenda constitucional. Aentrada dessa tem\u00e1tica na agenda das pol\u00edticas p\u00fablicas brasileiras foi um dosfatores que contribu\u00edram para que, em 2011, fosse institu\u00eddo o Plano Nacional dosDireitos das Pessoas com Defici\u00eancia - Viver sem Limite, estruturado em quatroeixos: acesso \u00e0 sa\u00fade, educa\u00e7\u00e3o, inclus\u00e3o social e acessibilidade. Esse planoteve a participa\u00e7\u00e3o, em sua concep\u00e7\u00e3o, de 15 minist\u00e9rios, do Conselho Nacional dosDireitos da Pessoa com Defici\u00eancia (Conade) e da sociedade civil, definindo umaindu\u00e7\u00e3o financeira importante no pa\u00eds Portaria n\u00ba 793Portaria deConsolida\u00e7\u00e3o n\u00ba 03/2017 Como desdobramento das a\u00e7\u00f5es do eixo de acesso \u00e0 sa\u00fade, foi publicada, em 2012, aRecentemente, observa-se um crescente interesse de pesquisas avaliativas na RCPCD.Dubow et al. Pesquisas nas bases SciELO e MEDLINE n\u00e3o evidenciaram estudos de avalia\u00e7\u00e3o do grau deimplanta\u00e7\u00e3o da RCPCD no Brasil. Muitas vezes, a pol\u00edtica implementada n\u00e3ocorresponde exatamente ao que foi formulado, sofrendo altera\u00e7\u00f5es por parte dosagentes implementadores pela necessidade de adequar a pol\u00edtica \u00e0s suas realidadesAvalia\u00e7\u00e3o da Rede de Cuidados Integral\u00e0 Pessoa com Defici\u00eancia no SUS - Redecin Brasil, contemplado comfinanciamento na chamada CNPq/MS/SCTIE/DECIT/SAS/DAPES/CGSPD n\u00ba 35/2018. Seupercurso metodol\u00f3gico foi objeto de uma publica\u00e7\u00e3o espec\u00edfica Este estudo faz parte da pesquisa Trata-se de uma pesquisa de casos m\u00faltiplos, em que foi realizada avalia\u00e7\u00e3o dograu de implanta\u00e7\u00e3o da RCPCD em oito estados (casos), situados nas cinco regi\u00f5esgeogr\u00e1ficas brasileiras, selecionados a partir da representa\u00e7\u00e3o dospesquisadores envolvidos na proposta nesses estados: Amazonas, Bahia, Esp\u00edritoSanto, Mato Grosso do Sul, Minas Gerais, Para\u00edba, Rio Grande do Sul e S\u00e3oPaulo.O tipo de estudo proposto visa estabelecer em que medida uma interven\u00e7\u00e3o/pol\u00edticaest\u00e1 sendo implantada da forma como foi planejada. O artigo foi estruturado emcinco etapas A avalia\u00e7\u00e3o da situa\u00e7\u00e3o inicial ocorreu mediante a an\u00e1lise dos documentosreferentes \u00e0 pol\u00edtica de sa\u00fade da pessoa com defici\u00eancia, que culminaram com ainstitui\u00e7\u00e3o da RCPCD e subsidiaram a elabora\u00e7\u00e3o do modelo l\u00f3gico.A utiliza\u00e7\u00e3o de modelos te\u00f3ricos na pesquisa avaliativa parte da premissa de quetoda a\u00e7\u00e3o tem uma teoria subjacente a suas opera\u00e7\u00f5es, uma teoria da a\u00e7\u00e3o.Resgatar essa teoria proporciona maior clareza sobre o objeto avaliado Portaria n\u00ba 4.279, de 30 de dezembro de 2010 Portaria n\u00ba 793/2012O modelo l\u00f3gico foi elaborado por seis pesquisadores do projeto Redecin (grupo A)e avaliado por uma pesquisadora com expertise na constru\u00e7\u00e3o de modelos l\u00f3gicos.Baseou-se nas fases e nos atributos extra\u00eddos de duas portarias do Minist\u00e9rio daSa\u00fade: a O modelo l\u00f3gico proposto  foiestrPortaria n\u00ba 793/2012.A imagem-objetivo do processo de implanta\u00e7\u00e3o da RCPCD segue as quatro fasesprevistas na A fase I do processo da operacionaliza\u00e7\u00e3o da implanta\u00e7\u00e3o da RCPCD consiste no\u201cdiagn\u00f3stico e desenho regional da rede\u201d, estruturado em quatro a\u00e7\u00f5es:apresenta\u00e7\u00e3o da RCPCD; realiza\u00e7\u00e3o do diagn\u00f3stico e situa\u00e7\u00e3o de sa\u00fade,considerando as necessidades das pessoas com defici\u00eancia; programa\u00e7\u00e3o do desenhoregional da rede, planejando os cuidados a serem ofertados para os usu\u00e1riosnessa condi\u00e7\u00e3o; e elabora\u00e7\u00e3o dos planos de a\u00e7\u00e3o regionais e municipais. Umdiagn\u00f3stico preciso da situa\u00e7\u00e3o de sa\u00fade depende de sistemas de informa\u00e7\u00e3o emsa\u00fade claros, alimentados de forma cont\u00ednua e organizados em indicadores,par\u00e2metros, pain\u00e9is e observat\u00f3rios Al\u00e9m do diagn\u00f3stico, o desenho da rede tamb\u00e9m \u00e9 importante para mapeamento dasdemandas e dos avan\u00e7os no processo de implanta\u00e7\u00e3o da RCPCD. Uma rede bemdesenhada colabora para reduzir os custos, melhorar a cobertura dos vaziosassistenciais e a aten\u00e7\u00e3o prestada Portaria n\u00ba4.279/2010 define que as redes de aten\u00e7\u00e3o devem ter um sistema degovernan\u00e7a \u00fanico, com o prop\u00f3sito de criar miss\u00e3o, vis\u00e3o e estrat\u00e9gias nasorganiza\u00e7\u00f5es que comp\u00f5em a regi\u00e3o de sa\u00fade, organizado em governan\u00e7ainstitucional, gerencial e de financiamento. A governan\u00e7a institucional incluiComiss\u00f5es Intergestoras Regionais (CIR), CIB e Comiss\u00e3o Intergestora Tripartite(CIT), al\u00e9m do Contrato Organizativo de A\u00e7\u00e3o P\u00fablica (COAP) como importanteinstrumento para governan\u00e7a sist\u00eamica do SUS. Os grupos condutores fazem parteda governan\u00e7a gerencial das redes e a governan\u00e7a financeira \u00e9 determinada pelosplanos de a\u00e7\u00e3o regionais A ades\u00e3o \u00e0 RCPCD, segunda fase do processo de implanta\u00e7\u00e3o, compreende ainstitui\u00e7\u00e3o do grupo condutor estadual e a pactua\u00e7\u00e3o e homologa\u00e7\u00e3o da regi\u00e3oinicial de implementa\u00e7\u00e3o da rede na Comiss\u00e3o Intergestores Bipartite (CIB). Essafase remete aos espa\u00e7os de governan\u00e7a da rede. A ,,A terceira fase corresponde \u00e0 contratualiza\u00e7\u00e3o dos pontos de aten\u00e7\u00e3o da RCPCD.Trata-se de uma estrat\u00e9gia de coordena\u00e7\u00e3o administrativa, baseada na coopera\u00e7\u00e3o,que estabelece novas bases de relacionamento na gest\u00e3o p\u00fablica, maior efic\u00e1cia eefici\u00eancia no desempenho dos agentes p\u00fablicos e seus parceiros, al\u00e9m de maiorefetividade dos resultados. \u00c9 um modo de pactua\u00e7\u00e3o da demanda quantitativa equalitativa com defini\u00e7\u00e3o clara de responsabilidades, objetivos de desempenho,resultando em um compromisso entre ambas as partes A contratualiza\u00e7\u00e3o deve ocorrer no \u00e2mbito da regi\u00e3o de sa\u00fade, seguindo crit\u00e9riosde adscri\u00e7\u00e3o da popula\u00e7\u00e3o estratificada por grau de risco e abordando osdiversos estabelecimentos de sa\u00fade A \u00faltima fase da operacionaliza\u00e7\u00e3o da implanta\u00e7\u00e3o da RCPCD \u00e9 a implanta\u00e7\u00e3o e oacompanhamento pelo grupo condutor estadual da RCPCD. Os grupos condutores s\u00e3orespons\u00e1veis pelo acompanhamento da implementa\u00e7\u00e3o da rede e pelas articula\u00e7\u00f5escom os atores envolvidos, p\u00fablicos ou privados O acompanhamento da RCPCD envolve o monitoramento rotineiro, sistem\u00e1tico econt\u00ednuo do processo de implanta\u00e7\u00e3o dos indicadores de sa\u00fade visando obterinforma\u00e7\u00f5es relevantes para subsidiar tomada de decis\u00f5es. No monitoramento,verifica-se a realiza\u00e7\u00e3o das atividades para implanta\u00e7\u00e3o da RCPCD. J\u00e1 aavalia\u00e7\u00e3o verifica valores e m\u00e9ritos de programas e pol\u00edticas, ampliando acompreens\u00e3o da rede Portaria n\u00ba 793/2012O grupo A definiu os crit\u00e9rios para cada uma das fases da implanta\u00e7\u00e3o, conformeestabelecido na Ap\u00f3s esse consenso, a vers\u00e3o final da matriz de medidas foi disponibilizada paraa aplica\u00e7\u00e3o, contendo quatro dimens\u00f5es com duas subdimens\u00f5es cada, totalizandooito subdimens\u00f5es com seus crit\u00e9rios e uma pontua\u00e7\u00e3o total m\u00e1xima de 240 pontos,conforme A matriz foi aplicada em cada estado pelo grupo local de pesquisadores epreenchida a partir de informa\u00e7\u00f5es coletadas em an\u00e1lise documental  e por meio de 23 entrevistas com membros dogrupo condutor estadual e/ou coordenadores da \u00e1rea t\u00e9cnica da pessoa comdefici\u00eancia. Posteriormente, constituiu-se, entre os pesquisadores, um comit\u00ea detr\u00eas avaliadores, que realizou discuss\u00e3o e alinhamento com os representantes damatriz aplicada em cada estado. Ap\u00f3s esse alinhamento, os representantesrespons\u00e1veis pela aplica\u00e7\u00e3o da matriz de medidas em cada estado apresentaram oresultado da avalia\u00e7\u00e3o ao grupo condutor estadual da RCPCD como forma dediscutir e referendar a pontua\u00e7\u00e3o atribu\u00edda e ter a garantia de que todas asfontes de informa\u00e7\u00f5es dispon\u00edveis foram consideradas na avalia\u00e7\u00e3o.Pesquisa Nacional deSa\u00fade (PNS) de 2013 Os oito estados apresentam perfis diferentes em v\u00e1rios aspectos. H\u00e1 estadospopulosos, como S\u00e3o Paulo e Minas Gerais, e alguns com menos de 5 milh\u00f5es dehabitantes, como Amazonas, Esp\u00edrito Santo, Para\u00edba e Mato Grosso do Sul. RioGrande do Sul e Bahia foram os estados com maior porcentagem de pessoas comdefici\u00eancia, 9,8% e 6,3%, respectivamente, enquanto Esp\u00edrito Santo foi o estadocom menor porcentagem , segundo a O desenho regional de organiza\u00e7\u00e3o da RCPCD foi diferente entre os estados: quatroem macrorregi\u00f5es de sa\u00fade e quatro em regi\u00f5es de sa\u00fade. Com rela\u00e7\u00e3o aos planosde a\u00e7\u00e3o da RCPCD, tr\u00eas estados constru\u00edram os planos de a\u00e7\u00e3o regionais  e cinco estados optaram pela constru\u00e7\u00e3o deum plano de a\u00e7\u00e3o estadual , contemplando as regi\u00f5es/macrorregi\u00f5es de sa\u00fade .O grau de implanta\u00e7\u00e3o foi classificado como intermedi\u00e1rio  em sete estados, sendo os maiores percentuais alcan\u00e7ados por S\u00e3o Paulo,Mato Grosso do Sul e Rio Grande do Sul. Apenas o Estado do Amazonas ficou nacategoria \u201cincipiente\u201d . H\u00e1 diferen\u00e7as importantes a respeito dasdimens\u00f5es entre os estados. A dimens\u00e3o \u201cades\u00e3o \u00e0 rede\u201d teve pontua\u00e7\u00e3o m\u00e1xima(100%) para Minas Gerais, S\u00e3o Paulo, Mato Grosso do Sul e Bahia, enquanto adimens\u00e3o \u201cdiagn\u00f3stico e desenho regional da RCPCD\u201d teve desempenho variado naimplanta\u00e7\u00e3o . A \u201ccontratualiza\u00e7\u00e3o dos pontos de aten\u00e7\u00e3o\u201d teveclassifica\u00e7\u00e3o entre incipiente e intermedi\u00e1ria, com distin\u00e7\u00e3o positiva paraMinas Gerais e negativa para Amazonas. J\u00e1 a dimens\u00e3o \u201cimplanta\u00e7\u00e3o eacompanhamento pelo grupo condutor estadual\u201d de forma mais sistem\u00e1ticapraticamente n\u00e3o ocorreu, com exce\u00e7\u00e3o do Rio Grande do Sul, que apresentouimplanta\u00e7\u00e3o avan\u00e7ada  e 3.Analisando os escores obtidos nas subdimens\u00f5es, verifica-se que, com rela\u00e7\u00e3o ao\u201cdiagn\u00f3stico da situa\u00e7\u00e3o de sa\u00fade\u201d e ao \u201cdesenho da rede e elabora\u00e7\u00e3o dos planosde a\u00e7\u00e3o\u201d, que pertencem \u00e0 dimens\u00e3o \u201cdiagn\u00f3stico e desenho regional da RCPCD\u201d,mais da metade dos estados obtiveram minimamente a classifica\u00e7\u00e3o de implanta\u00e7\u00e3ointermedi\u00e1ria, com mediana  da porcentagem dapontua\u00e7\u00e3o de 64,6%  e 67,5% , respectivamente. Na dimens\u00e3o \u201cades\u00e3o \u00e0RCPCD\u201d, todos os estados atingiram a classifica\u00e7\u00e3o de implanta\u00e7\u00e3o avan\u00e7ada nasubdimens\u00e3o \u201cinstitui\u00e7\u00e3o do grupo condutor\u201d e metade dos estados alcan\u00e7aram talclassifica\u00e7\u00e3o na subdimens\u00e3o \u201cpactua\u00e7\u00e3o e homologa\u00e7\u00e3o na CIB\u201d, com mediana dasporcentagens de 100%  e 83,3% (50), respectivamente, evidenciando que essadimens\u00e3o teve maior ades\u00e3o dos estados participantes.Na dimens\u00e3o \u201ccontratualiza\u00e7\u00e3o dos pontos de aten\u00e7\u00e3o\u201d, mais da metade dos estadosatingiram pelo menos a classifica\u00e7\u00e3o de implanta\u00e7\u00e3o intermedi\u00e1ria na subdimens\u00e3o\u201ccontratualiza\u00e7\u00e3o\u201d, com mediana (IIQ) da porcentagem de 66,7% . Quasetodos, \u00e0 exce\u00e7\u00e3o do Estado do Rio Grande do Sul, obtiveram a classifica\u00e7\u00e3o \u201cn\u00e3oimplantado\u201d na subdimens\u00e3o \u201cdesenho da rede e grupos condutores municipais\u201d, commediana (IIQ) da porcentagem de 0,0% . Na dimens\u00e3o \u201cimplanta\u00e7\u00e3o eacompanhamento pelo grupo condutor\u201d, mais da metade dos estados obtiveramimplanta\u00e7\u00e3o incipiente na subdimens\u00e3o \u201cdiretrizes cl\u00ednicas e protocolos\u201d, commediana (IIQ) da porcentagem da pontua\u00e7\u00e3o atingida de 37,5% . Mais dametade dos estados apresentaram a classifica\u00e7\u00e3o n\u00e3o implantada na subdimens\u00e3o\u201cacompanhamento da RCPCD\u201d, com mediana (IIQ) da porcentagem de 14,1% ,tendo divergido somente o Estado do Rio Grande do Sul, que alcan\u00e7ou aclassifica\u00e7\u00e3o de implanta\u00e7\u00e3o avan\u00e7ada nessas duas subdimens\u00f5es. Esses resultadosevidenciam que as subdimens\u00f5es das dimens\u00f5es III e IV foram as que os estadosencontraram maiores dificuldades em implantar.A maioria dos estados elaborou o plano de a\u00e7\u00e3o estadual, sem cumprir a etapa deelabora\u00e7\u00e3o dos planos de a\u00e7\u00e3o regionais, que deveria anteceder o plano estadual, emuma l\u00f3gica ascendente. A perspectiva das RAS \u00e9 orientada pela regionaliza\u00e7\u00e3o. Aregi\u00e3o de sa\u00fade \u00e9 um dos fundamentos e elementos constitutivos, primordial naorganiza\u00e7\u00e3o das redes. Assumindo como um dos seus objetivos responder positivamente\u00e0s necessidades de sa\u00fade de determinada popula\u00e7\u00e3o, a constru\u00e7\u00e3o das RAS exige adivis\u00e3o territorial adequada por meio da consolida\u00e7\u00e3o das regi\u00f5es de sa\u00fade A preval\u00eancia de pessoas com defici\u00eancia e o IDH dos estados parecem n\u00e3o terimpactado no resultado da implanta\u00e7\u00e3o da RCPCD, o que pode ter comprometido adefini\u00e7\u00e3o de a\u00e7\u00f5es e a pactua\u00e7\u00e3o dos servi\u00e7os necess\u00e1rios para esse p\u00fablico.A avalia\u00e7\u00e3o de implanta\u00e7\u00e3o da RCPCD dos oito estados investigados aponta queprevaleceu o grau intermedi\u00e1rio em rela\u00e7\u00e3o \u00e0 imagem-objetivo delineada, ou seja, osestados conseguiram implantar, mas nenhum cumpriu todo o processo proposto pelaportaria. O Amazonas, \u00fanico estado com implanta\u00e7\u00e3o incipiente, passou por sucessivastrocas na gest\u00e3o estadual durante o per\u00edodo estudado, com consequentes interrup\u00e7\u00f5esno processo de implanta\u00e7\u00e3o, o que provavelmente influenciou o resultado.com oprop\u00f3sito de criar uma miss\u00e3o, vis\u00e3o e estrat\u00e9gias nas organiza\u00e7\u00f5es que comp\u00f5ema regi\u00e3o de sa\u00fade; definir objetivos e metas que devam ser cumpridos no curto,m\u00e9dio e longo prazo; articular as pol\u00edticas institucionais; e desenvolver acapacidade de gest\u00e3o necess\u00e1ria para planejar, monitorar e avaliar o desempenhodos gerentes e das organiza\u00e7\u00f5es\u201d Entre as fases previstas para a operacionaliza\u00e7\u00e3o, a que se mostrou mais efetiva foia \u201cades\u00e3o \u00e0 rede\u201d, com a institui\u00e7\u00e3o do grupo condutor e pactua\u00e7\u00e3o e homologa\u00e7\u00e3o naCIB. Tal fase \u00e9 imprescind\u00edvel para a governan\u00e7a da rede: \u201c(...) A institui\u00e7\u00e3o do grupo condutor traduz a governan\u00e7a gerencial da RCPCD. A pactua\u00e7\u00e3o ehomologa\u00e7\u00e3o na CIB, reconhecida como uma inst\u00e2ncia gestora institucional, \u00e9 parte dagovernan\u00e7a sist\u00eamica do SUS Portaria n\u00ba 793/2012 prever a institui\u00e7\u00e3o do grupocondutor na segunda fase do processo de implanta\u00e7\u00e3o, observou-se em todos os estadosque eles foram constitu\u00eddos na fase inicial do processo e tiveram um protagonismoimportante na elabora\u00e7\u00e3o dos planos de a\u00e7\u00e3o A despeito de a Embora a constru\u00e7\u00e3o do \u201cdiagn\u00f3stico e desenho regional da rede\u201d tenha obtidoimplanta\u00e7\u00e3o intermedi\u00e1ria, apresenta fragilidades, contrariando a l\u00f3gica da ofertade servi\u00e7os em redes. H\u00e1 dificuldades no uso das informa\u00e7\u00f5es acerca da situa\u00e7\u00e3o desa\u00fade para o planejamento das a\u00e7\u00f5es, muitas vezes pela indisponibilidade dedetalhamento dos indicadores e pela aus\u00eancia de uma cultura de sua an\u00e1lise paratomada de decis\u00f5es Referente \u00e0 terceira fase da implanta\u00e7\u00e3o, alguns estados avan\u00e7aram nacontratualiza\u00e7\u00e3o, enquanto outros tiveram desempenho incipiente. As limita\u00e7\u00f5esidentificadas no \u201cdesenho regional da rede\u201d, restringindo-o aos servi\u00e7osespecializados, agravam-se nessa fase, com lacunas relacionadas \u00e0 contratualiza\u00e7\u00e3odesses servi\u00e7os, al\u00e9m dos servi\u00e7os nos demais pontos da rede. A RCPCD se caracterizaa partir do servi\u00e7o especializado, comprovado pelo aporte financeiro realizado pelaUni\u00e3o e considerando que os demais pontos de aten\u00e7\u00e3o n\u00e3o s\u00e3o espec\u00edficos para aspessoas com defici\u00eancia.Essa fragilidade na contratualiza\u00e7\u00e3o pode impactar o funcionamento da RCPCD,impossibilitando que as regi\u00f5es de sa\u00fade garantam o acesso das pessoas comdefici\u00eancia aos servi\u00e7os dos quais necessitam. A negocia\u00e7\u00e3o contratual \u00e9 relevantepara o alcance da equidade regional, proporcionando o estabelecimento de la\u00e7os decolabora\u00e7\u00e3o entre poder p\u00fablico e agentes sociais, de forma consensual e em umaperspectiva de solidariedade sist\u00eamica, regionalizada, visando \u00e0 integralidade daaten\u00e7\u00e3o \u00e0 sa\u00fade Tal estrat\u00e9gia \u00e9 de particular import\u00e2ncia para os munic\u00edpios de pequeno porte, queconstituem cerca de 70% na realidade brasileira Mesmo nos estados que avan\u00e7aram na contratualiza\u00e7\u00e3o dos pontos de aten\u00e7\u00e3o, n\u00e3o foramencontradas, nos documentos analisados da maioria deles, as formas decontratualiza\u00e7\u00e3o. Particularmente, n\u00e3o foi identificado o instrumento legal derefor\u00e7o para a governan\u00e7a sist\u00eamica da rede, o COAP, sendo \u00fanica exce\u00e7\u00e3o o Estado doRio Grande do Sul, em que se identificou a presen\u00e7a desses contratos em algunsmunic\u00edpios. O COAP atua como um mecanismo de fortalecimento e concretiza\u00e7\u00e3o dagovernan\u00e7a regional do SUS e permite a integra\u00e7\u00e3o das atividades e dos servi\u00e7os,garantindo o atendimento \u00e0s necessidades de sa\u00fade.5. Essa indefini\u00e7\u00e3o em rela\u00e7\u00e3o ao acompanhamento e\u00e0 avalia\u00e7\u00e3o na fase de contratualiza\u00e7\u00e3o parece ter impactado a realiza\u00e7\u00e3o dessasa\u00e7\u00f5es pelos grupos condutores, o que resultou no baixo desempenho dos estados nafase IV da implanta\u00e7\u00e3o.Outro aspecto a ser considerado \u00e9 que a contratualiza\u00e7\u00e3o deve resultar na fixa\u00e7\u00e3o decrit\u00e9rios e instrumentos de acompanhamento e avalia\u00e7\u00e3o de resultados, metas eindicadores definidos Com rela\u00e7\u00e3o \u00e0 institui\u00e7\u00e3o do grupo condutor municipal, nenhum dos estados cumpriuesse quesito. Essa lacuna tamb\u00e9m vem sendo identificada em outras redes tem\u00e1ticas,conforme verificou-se em um estudo sobre a Rede Cegonha, que encontrou grupocondutor municipal formalizado somente em um dos quatro munic\u00edpios estudados A dimens\u00e3o 4 de \u201cimplanta\u00e7\u00e3o e acompanhamento pelo grupo condutor estadual\u201d,correspondendo ao monitoramento e \u00e0 avalia\u00e7\u00e3o das a\u00e7\u00f5es, foi incipiente nos estados,com exce\u00e7\u00e3o do Rio Grande do Sul, que teve como uma subdimens\u00e3o a implementa\u00e7\u00e3o dediretrizes cl\u00ednicas e protocolos para a aten\u00e7\u00e3o \u00e0 pessoa com defici\u00eancia. Embora oMinist\u00e9rio da Sa\u00fade tenha publicado 14 diretrizes cl\u00ednicas e protocolos direcionadospara a RCPCD entre 2012 e 2014, poucos estados as implementaram. Al\u00e9m de n\u00e3oimplement\u00e1-las, os estados tamb\u00e9m n\u00e3o estabelecerem outras. As diretrizesterap\u00eauticas e os protocolos cl\u00ednicos prop\u00f5em crit\u00e9rios baseados em evid\u00eancia para odiagn\u00f3stico da doen\u00e7a ou do agravo \u00e0 sa\u00fade, manejo terap\u00eautico, mecanismos decontrole e acompanhamento dos resultados terap\u00eauticos A indefini\u00e7\u00e3o de instrumentos e crit\u00e9rios de acompanhamento, metas e indicadoresverificada na contratualiza\u00e7\u00e3o, somada \u00e0 n\u00e3o implementa\u00e7\u00e3o de diretrizes cl\u00ednicas,possivelmente contribuiu para a n\u00e3o implanta\u00e7\u00e3o dessas a\u00e7\u00f5es.Portaria n\u00ba 793/2012. A pr\u00f3pria Secretaria de Aten\u00e7\u00e3o \u00e0 Sa\u00fadedo Minist\u00e9rio da Sa\u00fade reconhece o desafio de monitoramento e avalia\u00e7\u00e3o dosresultados com apropriados sistemas de informa\u00e7\u00e3o Preveem-se, nessa fase, a\u00e7\u00f5es de \u201cacompanhamento e monitoramento da RCPCD\u201d pelo grupocondutor. Durante o per\u00edodo analisado, constatou-se que os grupos condutoreslideraram o processo de constru\u00e7\u00e3o dos planos de a\u00e7\u00e3o, mas n\u00e3o cumpriram com asatribui\u00e7\u00f5es de monitoramento e avalia\u00e7\u00e3o que lhes foram designadas pelaEmbora as redes tem\u00e1ticas de aten\u00e7\u00e3o \u00e0 sa\u00fade tenham uma l\u00f3gica comum na conforma\u00e7\u00e3odas portarias que as instituem, incluindo as fases para implementa\u00e7\u00e3o e as etapasnecess\u00e1rias para o cumprimento de cada fase, no tocante ao monitoramento e \u00e0avalia\u00e7\u00e3o, observa-se aus\u00eancia de indicadores de desempenho da RCPCD, diferentementede outras redes, conforme consta no Sistema de Informa\u00e7\u00e3o da Aten\u00e7\u00e3o B\u00e1sica e noPrograma de Monitoramento e Avalia\u00e7\u00e3o da Qualidade Nas portarias que instituem a Rede Cegonha, a Rede de Aten\u00e7\u00e3o \u00e0s Urg\u00eancias eEmerg\u00eancias e a Rede de Aten\u00e7\u00e3o Psicossocial, est\u00e3o previstos indicadores dedesempenho, com defini\u00e7\u00e3o das a\u00e7\u00f5es para qualifica\u00e7\u00e3o dos componentes da rede e suacertifica\u00e7\u00e3o, avalia\u00e7\u00e3o do cumprimento das metas e a\u00e7\u00f5es ,Apesar das tentativas de institucionaliza\u00e7\u00e3o da avalia\u00e7\u00e3o no SUS, o processo ainda \u00e9incipiente. A inser\u00e7\u00e3o da avalia\u00e7\u00e3o na rotina dos servi\u00e7os somente se dar\u00e1 por meioda implanta\u00e7\u00e3o de uma cultura avaliativa, explicitando a perspectiva \u00fatil daavalia\u00e7\u00e3o, que possibilite a inclus\u00e3o/interfer\u00eancia dos diferentes gruposenvolvidos, incluindo profissionais, usu\u00e1rios, gestores e prestadores,potencializando e renovando a avalia\u00e7\u00e3o no cotidiano Assim, consideramos que o processo de operacionaliza\u00e7\u00e3o da implanta\u00e7\u00e3o da RCPCD seconcretizou nos estados analisados, mesmo com as diferentes condi\u00e7\u00f5es e escolhas doprocesso da condu\u00e7\u00e3o de cada fase. Os resultados deste estudo podem contribuir parasubsidiar os estados participantes a compreender em que medida a RCPCD foiimplantada da forma como foi planejada Portaria n\u00ba 793/2012. Dessa forma, n\u00e3o foram consideradas asa\u00e7\u00f5es e estrat\u00e9gias preconizadas para implanta\u00e7\u00e3o de cada componente da rede. Outralimita\u00e7\u00e3o \u00e9 a aus\u00eancia de representa\u00e7\u00e3o da sociedade civil entre os entrevistadospara a compreens\u00e3o do processo de implanta\u00e7\u00e3o da pol\u00edtica na perspectiva dessesoutros atores. Por fim, foram estudados apenas oito estados do Brasil, com pelomenos um de cada regi\u00e3o do pa\u00eds.Reconhece-se como limita\u00e7\u00e3o do estudo o modelo l\u00f3gico ter sido constru\u00eddo baseado nosmarcos legais da implanta\u00e7\u00e3o da RCPCD com as fases de operacionaliza\u00e7\u00e3o listadas naPortaria n\u00ba 793/2012 e a Portariade Consolida\u00e7\u00e3o n\u00ba 03/2017. O reconhecimento dos resultados do grau deimplanta\u00e7\u00e3o pelos grupos condutores e representantes da \u00e1rea t\u00e9cnica estadualreferendou o uso da matriz e favoreceu maior aplicabilidade com potencial para usona realidade local pela governan\u00e7a da RCPCD.A matriz de medidas permitiu avaliar o grau de implanta\u00e7\u00e3o da RCPCD em conson\u00e2nciacom o que estabelecem a Os resultados das avalia\u00e7\u00f5es do grau de implanta\u00e7\u00e3o revelaram discrep\u00e2ncias entre osestados, sobretudo no Amazonas, que apresentou grau de implanta\u00e7\u00e3o incipiente emrela\u00e7\u00e3o aos demais, os quais obtiveram grau intermedi\u00e1rio, entretanto, comdiferen\u00e7as importantes na avalia\u00e7\u00e3o de cada fase desse processo.Com rela\u00e7\u00e3o \u00e0s fases de operacionaliza\u00e7\u00e3o, a ades\u00e3o \u00e0 rede foi um componente bemimplantado na maioria dos estados, o que eleva a pontua\u00e7\u00e3o geral da avalia\u00e7\u00e3o,por\u00e9m, como se trata de uma fase mais deliberativa, n\u00e3o necessariamente reflete deforma positiva nas demais fases.Essa matriz pode ser utilizada para avaliar a operacionaliza\u00e7\u00e3o da RCPCD nos demaisestados da federa\u00e7\u00e3o ou nas regi\u00f5es de sa\u00fade. Entretanto, faz-se necess\u00e1rio procederaos rearranjos para as especificidades de cada contexto no que diz respeito \u00e0sevid\u00eancias a serem consideradas para a an\u00e1lise.Uma vez que a rotatividade dos atores que conduzem o processo de implanta\u00e7\u00e3o da RCPCDimplicou descontinuidade do processo, conforme verificou-se nos estados analisadosem rela\u00e7\u00e3o aos membros dos grupos condutores estaduais, estudos futuros deveminvestigar de forma mais aprofundada essa rela\u00e7\u00e3o.Algumas recomenda\u00e7\u00f5es se fazem necess\u00e1rias para aprimorar a implanta\u00e7\u00e3o da RCPCD nosestados: fortalecer a regionaliza\u00e7\u00e3o, garantindo mais protagonismo para as regi\u00f5esde sa\u00fade em todo o processo; instituir grupos condutores regionais a fim deassegurar a capilaridade dos atores na rede; garantir mecanismos de contratualiza\u00e7\u00e3ocom defini\u00e7\u00e3o de crit\u00e9rios, indicadores para avalia\u00e7\u00e3o e monitoramento das a\u00e7\u00f5es daRCPCD; e estabelecer normas para certifica\u00e7\u00e3o dos pontos de aten\u00e7\u00e3o.Novos estudos de avalia\u00e7\u00e3o da RCPCD que utilizem modelo l\u00f3gico para cada um dosn\u00edveis de aten\u00e7\u00e3o e suas respectivas atribui\u00e7\u00f5es no processo de implanta\u00e7\u00e3o, bemcomo pesquisas que incorporem a representa\u00e7\u00e3o do segmento da sociedade civilorganizada entre os atores entrevistados, podem contribuir para a compreens\u00e3o doprocesso de implanta\u00e7\u00e3o da pol\u00edtica."}
+{"text": "Hura crepitans L.), realizada em Santar\u00e9m, Par\u00e1, em 1847, por um ind\u00edgena chamado Antonio Vieira dos Passos. A experi\u00eancia passou a ser realizada nas demais prov\u00edncias do Brasil e tamb\u00e9m no exterior. Por essa raz\u00e3o, o artigo estabelece rela\u00e7\u00f5es com pr\u00e1ticas m\u00e9dicas realizadas em outras partes do pa\u00eds, tendo como foco o di\u00e1logo entre a medicina oficial e a medicina ind\u00edgena. A an\u00e1lise de mat\u00e9rias de jornais e documentos oficiais revelou que os saberes ind\u00edgenas sobre o uso de plantas medicinais eram amplamente reconhecidos e utilizados pelos m\u00e9dicos com a inten\u00e7\u00e3o de incorpor\u00e1-los em seu repert\u00f3rio terap\u00eautico.O artigo analisa uma experi\u00eancia de cura da lepra com assacu ( Ap\u00f3s assinar declara\u00e7\u00e3o assumindo para si a responsabilidade, o leproso introduziu a m\u00e3o direita na gaiola em que se encontrava o animal, que n\u00e3o tardou a picar seu dedo.Quando viu sua pele coberta de tub\u00e9rculos, dedos das m\u00e3os atrofiados e rosto deformado, Marianno Jos\u00e9 Machado, de 50 anos de idade, passou a residir no Hospital dos L\u00e1zaros do Rio de Janeiro. O estigma 1 que acoMat\u00e9ria publicada dez anos depois informava que Marianno decidiu se submeter a essa experi\u00eancia \u201capesar dos prudentes conselhos de muitos m\u00e9dicos que duvidavam do bom processo desse perigoso meio\u201d . O certo \u00e9 que ningu\u00e9m tentou proibir a experi\u00eancia, e Marianno, \u201cat\u00e9 a meia noite, sofreu cruelmente\u201d. Os poucos rem\u00e9dios que lhe foram ministrados pelos m\u00e9dicos presentes em nada diminu\u00edram seu sofrimento, e a mat\u00e9ria revela a postura de passiva contempla\u00e7\u00e3o da plateia, desde a picada da cobra, \u00e0s 11h50 da manh\u00e3 do dia 4 de setembro de 1838, at\u00e9 11h30 do dia seguinte, quando Marianno \u201cdeu alma a Deus\u201d. Movidos pela curiosidade cient\u00edfica e indiferentes \u00e0 situa\u00e7\u00e3o do doente, os assistentes registraram, minuto a minuto, as rea\u00e7\u00f5es do leproso, o que indica que ele era instado a relatar tudo o que sentia: o sangue escorrendo na regi\u00e3o picada, o incha\u00e7o da m\u00e3o, frio, altera\u00e7\u00e3o da vista, formigamento no rosto, ansiedade, fechamento da garganta, dores no peito, pulsa\u00e7\u00e3o irregular, at\u00e9 o momento em que faleceu . O m\u00e9dico franc\u00eas Xavier Experi\u00eancias menos tr\u00e1gicas de cura da lepra eram realizadas por todo o Brasil ao longo do s\u00e9culo XIX, e os jornais da \u00e9poca frequentemente anunciavam supostas curas da doen\u00e7a, tanto no Brasil como no exterior. Em 1844, anunciava-se a cura da \u201chorr\u00edvel mol\u00e9stia da elefancia\u201d, que teria sido descoberta por uma portuguesa na cidade do Porto, Portugal . Em 1848, ganhou not\u00edcia a descoberta de um \u201cmeio de curar radicalmente a morfeia, com ervas e outros espec\u00edficos\u201d na vila de Itapetininga, S\u00e3o Paulo . O descobridor era um franc\u00eas chamado Charles Pierre Et\u00e9ch\u00e9ion, que, desde 1847, fazia experi\u00eancias de cura da lepra utilizando-se do guano, material constitu\u00eddo das fezes de aves e morcegos . Em 1859Treze de Maio, em 1840, aponta para o imagin\u00e1rio da \u00e9poca em torno da doen\u00e7a, o crescimento de casos de lepra na prov\u00edncia do Par\u00e1 e a esperan\u00e7a que esse tipo de not\u00edcia gerava:Mat\u00e9ria publicada no jornal N\u00e3o h\u00e1 pessoa que n\u00e3o conhe\u00e7a o terr\u00edvel e progressivo flagelo, que de dia em dia se vai tornando mais amea\u00e7ador para a nossa prov\u00edncia: a elefant\u00edase! N\u00f3s todos sentimos a urgente necessidade que h\u00e1 de tomarmos as mais s\u00e9rias provid\u00eancias e cautelas, para que um semelhante mal n\u00e3o se derrame pela popula\u00e7\u00e3o, se generalize e afinal s\u00f3 tenhamos de recriminar nossa apatia .A lepra era, ent\u00e3o, vista como um \u201cterr\u00edvel flagelo\u201d, amea\u00e7a para a vida em sociedade, mal a ser extirpado da prov\u00edncia ou, pelo menos, posto sob controle. Para isso, o articulista defendia que o governo provincial constru\u00edsse um lazareto em lugar afastado e promovesse o envio anual de leprosos para a prov\u00edncia de Goi\u00e1s, \u201ca fim de usarem das Caldas\u201d . As \u00e1guas de Caldas Novas, em Goi\u00e1s, assim como as de Po\u00e7os de Caldas, no sul de Minas, eram consideradas auxiliares eficientes na cura de doen\u00e7as como lepra, s\u00edfilis e mol\u00e9stias ven\u00e9reas em geral. Muitas pessoas desenganadas com os recursos ordin\u00e1rios poss\u00edveis nas vilas e cidades nutriam esperan\u00e7a no poder daquelas \u00e1guas tidas como virtuosas . A doen\u00e7Treze de Maio a not\u00edcia de que, em Santar\u00e9m, havia sido descoberto um rem\u00e9dio para a cura da lepra.3 Ao procurar informa\u00e7\u00f5es sobre o fato, o vice-presidente da prov\u00edncia, Jo\u00e3o Maria de Moraes, soube que certo Jos\u00e9 Joaquim de Souza Gomes, de longa data conhecido como leproso, teria aparecido curado depois de tratado com aplica\u00e7\u00f5es de assacu (Hura crepitans L.) por um ind\u00edgena chamado Antonio Vieira dos Passos . Passos n\u00e3o se intimidou diante do cirurgi\u00e3o:Afirma com regularidade que n\u00e3o teme curar qualquer morf\u00e9tico sob as vistas de m\u00e9dicos. N\u00e3o deixa, por\u00e9m, de exprimir-se assim: que quem tem de morrer da mol\u00e9stia sempre morre, qui\u00e7\u00e1 querendo dizer que assim como outras mol\u00e9stias, que t\u00eam rem\u00e9dios conhecidos, nem sempre com eles se curam, tamb\u00e9m n\u00e3o \u00e9 infal\u00edvel o seu rem\u00e9dio da morfeia. Diz ele que nem todos os rem\u00e9dios que aplica tem declarado. Todavia, parece que todos ou o essencial, possui o cirurgi\u00e3o Rebello .O relato \u00e9 importante porque, ainda que de modo indireto, revela a fala do \u00edndio Passos, sua seguran\u00e7a na defesa do m\u00e9todo utilizado para a cura da lepra e a leitura comparada que ele fazia entre sua pr\u00e1tica de cura e a da medicina oficial, ambas fal\u00edveis ou incapazes de curar em todos os casos. Ao mesmo tempo, o relato sugere que Passos se esfor\u00e7ava em guardar para si certo controle do uso dos medicamentos que utilizava, n\u00e3o declarando todos de que fazia uso. Quatro meses depois de iniciada a experi\u00eancia em Santar\u00e9m, o cirurgi\u00e3o informava que os doentes apresentavam sens\u00edveis melhoras e que havia esperan\u00e7a de cur\u00e1-los completamente com mais tr\u00eas meses de tratamento.V\u00e1rios jornais publicaram o receitu\u00e1rio utilizado pelo \u00edndio Passos:O Sr. Rebello diz que a forma por que ele emprega o assacu no curativo dos morf\u00e9ticos em Santar\u00e9m \u00e9 a de que serviu Souza Gomes no tratamento da sua mol\u00e9stia e que somente a aperfei\u00e7oou e a adaptou \u00e0s regras da Ci\u00eancia M\u00e9dica. A forma \u00e9 assentada no uso di\u00e1rio de p\u00edlulas feitas do suco inspissado (que tem recebido o nome de extrato); no uso da mistura composta de meia libra de cozimento forte da casca e de dez a vinte gotas do suco ; o enfermo \u00e9 obrigado a beber de uma s\u00f3 vez toda a por\u00e7\u00e3o da mistura com o fim de fazer-se vomitar e assim \u00e9 por que os doentes vomitam para mais de seis vezes. Desse meio \u00e9 repetido o uso de oito em oito dias. No uso de banhos gerais preparados pelo cozimento saturado da casca e repetidos de dias a dias; e no uso de um cozimento emoliente para bebida ordin\u00e1ria .Note-se que o cirurgi\u00e3o Rebello procurava distinguir seu procedimento daquele que era utilizado pelo \u00edndio Passos, afirmando que \u201caperfei\u00e7oou\u201d e \u201cadaptou\u201d o m\u00e9todo \u201c\u00e0s regras da Ci\u00eancia M\u00e9dica\u201d. Essa roupagem cient\u00edfica visava conferir mais credibilidade e legitimidade ao tratamento experimental.Di\u00e1rio do Rio de Janeiro informava o recebimento de carta oriunda de Santar\u00e9m, a qual dizia que \u201cparece que com um veneno denominado assacu e que produz o Par\u00e1, aplicado em vomit\u00f3rio e em purgante de um modo ensinado por um \u00edndio dos Parintins, se cura perfeitamente a morfeia\u201d . Essa foi a \u00fanica publica\u00e7\u00e3o sobre o caso em que encontrei refer\u00eancia ao poss\u00edvel pertencimento \u00e9tnico de Antonio Vieira dos Passos. No s\u00e9culo XVII, mission\u00e1rios jesu\u00edtas fundaram a miss\u00e3o de Tupinambaranas, origem remota da atual cidade de Parintins. Em 1803, \u00edndios mau\u00e9 e munduruku foram reunidos no local. Parintins, nome oficializado em 1880, seria uma refer\u00eancia aos parintintins que habitavam a regi\u00e3o. Em 1832, Ayapana triplinervis (M. Vahl) R.M.King e H. Rob.), revelada por uma mulher ind\u00edgena de nome e etnia desconhecidos, mas que se tornou conhecida como a \u201cerva-do-ouvidor\u201d, em refer\u00eancia \u00e0 autoridade de Bel\u00e9m cujo \u00fanico m\u00e9rito foi enviar a planta para Lisboa, com a indica\u00e7\u00e3o de suas virtudes terap\u00eauticas . A ayapana \u00e9 eficiente no tratamento de desordens gastrointestinais, afec\u00e7\u00f5es da boca, febre, verminoses, al\u00e9m de ser utilizada como sudor\u00edfero e ant\u00eddoto para mordeduras de cobras.Mat\u00e9ria publicada no jornal Natureza, doen\u00e7as, medicina e rem\u00e9dios dos \u00edndios brasileiros . Ao destacar a \u201cmagnific\u00eancia de sua vegeta\u00e7\u00e3o\u201d, o articulista refor\u00e7a a ideia de uma \u201csabedoria natural\u201d dos \u00edndios, vistos, eles pr\u00f3prios, como parte da natureza, segundo a concep\u00e7\u00e3o do \u201c\u00edndio ecol\u00f3gico\u201d .Dicion\u00e1rio de palavras brasileiras de origem ind\u00edgena, significa \u201ccaboclo\u201d, \u201cfilho de \u00edndio com negro\u201d, \u201cmesti\u00e7o de branco e \u00edndio\u201d ,6 marapuama  e o assacu . Observa-se, ent\u00e3o, que o assacu era utilizado em experi\u00eancias de cura da lepra por curandeiros antes do \u00edndio Passos.Em 1840, Jo\u00e3o Antonio de Miranda, presidente da prov\u00edncia do Par\u00e1, convocou alguns m\u00e9dicos para dar parecer acerca de um grupo de pessoas apresentadas como curadas da lepra pelo cirurgi\u00e3o da Armada, Marcelo Domingues Barbosa. Os m\u00e9dicos Camillo Jos\u00e9 do Valle Guimar\u00e3es, Francisco da Silva Castro, Jos\u00e9 Cust\u00f3dio da Fonseca Paes e Alexandre da Costa Ara\u00fajo trataram de desqualificar o curandeiro, classificando-o como charlat\u00e3o e dizendo que alguns dos quais se diziam curados da lepra nunca foram leprosos. Diziam, ainda, que ele fazia uso particular de rem\u00e9dios conhecidos da medicina, juntamente com \u201cextravagantes composi\u00e7\u00f5es\u201d que inclu\u00edam as plantas chamadas de murur\u00e9 , \u201cm\u00e9dicos e curandeiros nunca estiveram muito distanciados uns dos outros, antes da segunda metade do s\u00e9culo XIX\u201d. Plantas mal estudadas ou desconhecidas pela medicina oficial eram amplamente utilizadas em experi\u00eancias de cura das mais diversas doen\u00e7as. A respeito das pr\u00e1ticas terap\u00eauticas utilizadas por Ant\u00f4nio Corr\u00eaa de Lacerda e Francisco da Silva Castro, Em outubro de 1847, Jos\u00e9 de Souza Gomes, o morador de Santar\u00e9m que se dizia curado da lepra gra\u00e7as ao tratamento do \u00edndio Antonio Vieira Passos, chegou a Bel\u00e9m, onde foi examinado no Pal\u00e1cio do Governo por uma junta m\u00e9dica composta pelos doutores Camillo Jos\u00e9 do Valle Guimar\u00e3es, Jos\u00e9 da Gama Malcher e Joaquim Frutuoso Guimar\u00e3es. No relat\u00f3rio apresentado \u00e0 presid\u00eancia da prov\u00edncia, constam algumas informa\u00e7\u00f5es que nos permitem conhecer um pouco de sua biografia. Diziam os m\u00e9dicos que Jos\u00e9 de Souza Gomes era filho de Antonio de Souza Gomes, nascido em Bel\u00e9m do Par\u00e1 e que estava com 33 anos. Era solteiro, \u201cmameluco, de temperamento linf\u00e1tico, de constitui\u00e7\u00e3o relativa a este temperamento; tem sido desregrado em seu modo de viver; teve bexigas e a mol\u00e9stia sifil\u00edtica\u201d . Tr\u00eas anos antes, havia sido internado no Hospital de Caridade, em Bel\u00e9m, a fim de se tratar de uma doen\u00e7a de pele que ele desconhecia que fosse lepra, sendo orientado pelo doutor Jos\u00e9 da Gama Malcher a se recolher no lepros\u00e1rio do Tucunduba. Insatisfeito com essa determina\u00e7\u00e3o, Gomes fugiu do Hospital da Caridade e se retirou para o interior da prov\u00edncia \u201cem procura da morte\u201d, diziam os m\u00e9dicos. Ocorreu queali um sujeito lhe propusera a cura da sua enfermidade por meio do assacu; desgostoso o paciente do hediondo estado em que se via aceitou a oferta da cura; duvidoso, por\u00e9m, do que se lhe prometia, esperava que este meio, como veneno, encurtasse os dias da sua vida, esperan\u00e7a que ele tinha como lenitivo aos seus males; contudo, n\u00e3o sucedeu assim, o acaso lhe deparou este rem\u00e9dio que modificou a sua enfermidade a ponto que o tem conduzido a poder voltar para o gr\u00eamio da sociedade, de onde fora sequestrado .Em seguida, os m\u00e9dicos trataram de apresentar o quadro em que Gomes se encontrava quando foi examinado pelo doutor Malcher no Hospital da Caridade, antes de sua fuga para o interior da prov\u00edncia. Os m\u00e9dicos descreveram sintomas t\u00edpicos de uma pessoa acometida pela lepra, tais como h\u00e1lito f\u00e9tido, a voz rouca, o rosto inchado, fosco e rugoso e que \u201ccausava repugn\u00e2ncia pela deformidade de suas fei\u00e7\u00f5es\u201d, as pernas inchadas, dedos das m\u00e3os deformados . A descri\u00e7\u00e3o dos sintomas da lepra contribu\u00eda para refor\u00e7ar o estigma em torno da doen\u00e7a e, especialmente, do doente. Gomes foi posto nu e observado minuciosamente pela junta m\u00e9dica em um intervalo de pouco mais de dois meses. Os m\u00e9dicos chegaram \u00e0 conclus\u00e3o de que \u201ca mudan\u00e7a que apresentam a face, o tronco e os membros tor\u00e1cicos que se achavam atacados da lepra tuberculosa \u00e9 agrad\u00e1vel aos olhos do m\u00e9dico, porque ela d\u00e1 toda a esperan\u00e7a de que, se o enfermo Souza Gomes insistir no uso dos meios de que tem tirado proveito, h\u00e1 de chegar ao completo restabelecimento da sua sa\u00fade\u201d .7Em outubro de 1848, o \u00edndio Passos chegou \u00e0 capital paraense, sendo recebido pelo presidente da prov\u00edncia, o chefe de pol\u00edcia, um m\u00e9dico da C\u00e2mara e outro da Santa Casa. O presidente Jer\u00f4nimo Francisco Coelho tentou, ent\u00e3o, convenc\u00ea-lo a declarar o processo de fabrica\u00e7\u00e3o e uso do assacu, prometendo remuner\u00e1-lo, ao que o \u00edndio Passos acedeu, embora continuasse \u201cna suposi\u00e7\u00e3o de que lhe querem arrebatar um segredo, de que ele se julga o deposit\u00e1rio, e de que vai fazendo aplica\u00e7\u00e3o emp\u00edrica\u201d , p.96. DDepois disso, o presidente da prov\u00edncia autorizou o estabelecimento de uma enfermaria exclusivamente para realizar experi\u00eancias com o assacu junto aos leprosos do Tucunduba , p.60. DA primeira dificuldade foi encontrar local adequado para instalar o \u201clazareto experimental\u201d onde seis leprosos escolhidos no Tucunduba seriam submetidos a tais experi\u00eancias. Dizia Jos\u00e9 Pio de Ara\u00fajo Nobre, provedor da Santa Casa, que \u201cn\u00e3o nos tem sido poss\u00edvel conseguir, porque ningu\u00e9m as quer alugar para semelhante fim\u201d , fato que refor\u00e7a o estigma a que estavam sujeitos os doentes de lepra nesse per\u00edodo. Por essa raz\u00e3o, a Santa Casa acabou utilizando pr\u00e9dio do governo, situado na chamada rua do Atalaia, atual travessa Joaquim T\u00e1vora, em Bel\u00e9m. Depois das obras de adapta\u00e7\u00e3o, o provedor informou ao presidente da prov\u00edncia que o local estava pronto para receber \u201cos l\u00e1zaros que v\u00e3o entrar no curativo do Assacu, pelo m\u00e9todo do \u00cdndio Passos\u201d .8 O processo de nomea\u00e7\u00e3o e descri\u00e7\u00e3o da lepra na primeira metade do s\u00e9culo XIX era complexo e sutil, sujeito a erros e falsas interpreta\u00e7\u00f5es, quest\u00f5es que \u201cserviram para obscurecer e confundir o diagn\u00f3stico da lepra, e, ao mesmo tempo, serviram para agravar a j\u00e1 carregada resson\u00e2ncia simb\u00f3lica da doen\u00e7a, bem como a for\u00e7a correspondente e o poder de suas in\u00fameras representa\u00e7\u00f5es\u201d . A preocupa\u00e7\u00e3o em escolher \u201c4 enfermos perfeitamente caracterizados como leprosos\u201d estava ligada \u00e0s incertezas que acompanhavam o diagn\u00f3stico da lepra naquele per\u00edodo.nta\u00e7\u00f5es\u201d , p.15. Dnta\u00e7\u00f5es\u201d , p.54-55nta\u00e7\u00f5es\u201d , p.167. nta\u00e7\u00f5es\u201d , p.96. SCorreio Mercantil, da Bahia, publicou mat\u00e9ria revelando os nomes de quatro dos leprosos que haviam sido submetidos \u00e0s experi\u00eancias com o assacu pela Santa Casa de Miseric\u00f3rdia do Par\u00e1. Foram eles: \u201cAntonio Hil\u00e1rio Martins, branco, solteiro, nascido em Monte Alegre\u201d, que \u201ctem o rosto inchado, fusco, rugoso e causa repugn\u00e2ncia pela deformidade de suas fei\u00e7\u00f5es\u201d; Raymundo Gon\u00e7alves da Cunha, \u201cbranco, solteiro, nascido nesta cidade, filho de Jos\u00e9 da Cunha de Assun\u00e7\u00e3o\u201d; \u201cDomingos Manoel, preto, crioulo e escravo de Jo\u00e3o Henrique da Silva Lavareda, filho de Catarina Maria do Esp\u00edrito Santo e de pai inc\u00f3gnito\u201d e \u201cMaria do Ros\u00e1rio, preta nascida na freguesia do Acar\u00e1, escrava de Manoel Henrique Dias, filha de Michelle Francisca e de pai inc\u00f3gnito\u201d . Al\u00e9m dos nomes dos pacientes, os jornais costumavam publicar a descri\u00e7\u00e3o das doen\u00e7as pr\u00e9vias dos doentes, o que constitu\u00eda mais um meio de estigmatiza\u00e7\u00e3o que atingia a vida de popula\u00e7\u00f5es pobres, fossem elas livres, libertas ou escravas.O 9 O m\u00e9dico se mostrou esperan\u00e7oso diante do quadro manifestado pelos doentes ap\u00f3s o in\u00edcio do tratamento e parecia querer reivindicar para si todo o protagonismo da suposta cura:O doutor Jos\u00e9 da Gama Malcher assim relatou os efeitos que o uso do assacu causou nos quatro leprosos: \u201clogo depois que o tomaram sentiram abalo geral acompanhado de estremecimento ligeiro, sensa\u00e7\u00e3o de frio nas extremidades, calor estendendo-se ao peito e ao rosto\u201d , \u201calguma ansiedade e vontade de vomitar\u201d (p.2). Cada paciente vomitou entre 10 e 15 vezes. Alguns deles lan\u00e7aram sangue pelo nariz, tiveram evacua\u00e7\u00f5es com sangue negro e sensa\u00e7\u00e3o de que estavam sendo picados por formigas.Pelo que tenho expendido, parece-me que n\u00e3o serei leviano em esperar que, se progredirem as melhoras, os quatro infelizes poder\u00e3o ficar habilitados para de novo pertencer \u00e0 sociedade, de onde viviam proscritos. E, se tal consigo, que gl\u00f3ria para a minha prov\u00edncia! Quantos benef\u00edcios para a humanidade! E, que triunfo para a medicina! .Anais de Medicina Brasiliense informava queOutros m\u00e9dicos procuraram ganhar notoriedade apresentando f\u00f3rmulas espec\u00edficas para o uso do assacu. Mat\u00e9ria dos o sr. cirurgi\u00e3o-mor Francisco de Paula Cavalcanti de Albuquerque (do Par\u00e1) acaba de comunicar a esta reda\u00e7\u00e3o que, segundo um processo seu, tem ele preparado um extrato do leite de assacu, de que tem tirado grande vantagem, aplicando-o em seis doentes morf\u00e9ticos, que se est\u00e3o tratando em seu lazareto particular .Express\u00f5es como \u201cse tal consigo\u201d ou \u201csegundo um processo seu\u201d, referindo-se \u00e0s experi\u00eancias de m\u00e9dicos com o assacu, invisibilizavam o protagonismo do \u00edndio Antonio Vieira dos Passos.O Brasil, do Rio de Janeiro: \u201cN\u00e3o chega do Par\u00e1 barco que n\u00e3o traga not\u00edcias do assacu\u201d . O governo imperial solicitou \u00e0 Imperial Academia de Medicina que fizesse experi\u00eancias a fim de confirmar a efic\u00e1cia do assacu para a cura da lepra .Houve, tamb\u00e9m, quem procurasse lucrar com a suposta cura da lepra. Mat\u00e9ria publicada no jornal Anais de Medicina Brasiliense .As experi\u00eancias com o assacu colocaram alguns personagens do Par\u00e1 em evid\u00eancia, especialmente porque muitos m\u00e9dicos paraenses enviaram cartas para pessoas e institui\u00e7\u00f5es de outras partes do Brasil, informando sobre a suposta cura da lepra. Os doutores Camillo do Valle, Gama Malcher e Joaquim Frutuoso Pereira Guimar\u00e3es se tornaram s\u00f3cios correspondentes da Academia Imperial de Medicina . Francisco da Silva Castro, juntamente com Guimar\u00e3es, tornou-se colaborador dos Quanto mais as experi\u00eancias se espalhavam, mais ansiedade geravam em torno do veredito final da efic\u00e1cia do assacu para a cura da lepra: \u201co assacu \u00e9 como uma teia de aranha suspensa no vago das experi\u00eancias terap\u00eauticas no Rio de Janeiro. Aguardam-se as suas virtudes miraculosas contra a lepra, como se aguardou a verifica\u00e7\u00e3o dos efeitos do guano contra essa mol\u00e9stia e, todavia, o guano falhou\u201d . Outra mat\u00e9ria dizia: \u201cTodos aguardam com impaci\u00eancia o resultado das experi\u00eancias feitas nos hospitais do Rio de Janeiro, Bahia e Pernambuco\u201d .Tal foi a repercuss\u00e3o da experi\u00eancia do \u00edndio Passos que ensaios de cura da lepra com o assacu foram feitos no Hospital de S\u00e3o L\u00e1zaro, em Lisboa, Portugal, com 13 doentes, concluindo os m\u00e9dicos que a subst\u00e2ncia poderia auxiliar na melhora, embora n\u00e3o tivesse poder de cura .Formul\u00e1rio e guia m\u00e9dico  da Concei\u00e7\u00e3o, idade setenta anos, casada com Antonio Vieira dos Passos, sem testamento, ficando de seu matrim\u00f4nio cinco filhos .Se era o mesmo Antonio Vieira dos Passos, ele teria casado com Francisca da Concei\u00e7\u00e3o e tido cinco filhos, residindo no igarap\u00e9 do Muratuba. Vila Franca, lugar de onde Francisco Vieira dos Passos era natural, \u00e9 um lugar pr\u00f3ximo a Santar\u00e9m, onde o \u00edndio Passos foi preso.status social, reservado a grupos marginalizados da sociedade, como os escravos, os libertos, os pobres e as mulheres\u201d  e a submiss\u00e3o a todo tipo de experi\u00eancias nos chamados \u201clazaretos experimentais\u201d. Mas n\u00e3o apenas isso. Como vimos, alguns deles fugiam ou se recusavam a ser submetidos a essas experi\u00eancias. E os que viviam nos lepros\u00e1rios n\u00e3o compactuavam com a vis\u00e3o desses locais como \u201ccemit\u00e9rios dos vivos\u201d .Psychotria ipecacuanha (Brot.) [Stokes]), utilizada em rem\u00e9dios contra tosse e xaropes para indu\u00e7\u00e3o de v\u00f4mito, da ayapana (Ayapana triplinervis [Vahl] R.M. King e H. Rob.) utilizada como t\u00f4nico, digestivo e antidiarreico, cite-se o exemplo da quinina, subst\u00e2ncia extra\u00edda da casca da quina ou cinchona, descoberta pelos ind\u00edgenas do Peru e utilizada na cura de febres. Pertencente ao g\u00eanero Cinchona, da fam\u00edlia Rubiaceae, a quinina passou a ser utilizada pela medicina ocidental no tratamento da mal\u00e1ria e, segundo Carapa guianensis [Aublet]), amplamente utilizada na Amaz\u00f4nia como analg\u00e9sico, antibacteriano, anti-inflamat\u00f3rio, antif\u00fangico, antial\u00e9rgico, antimal\u00e1rico, al\u00e9m de se mostrar eficaz contra feridas, hematomas, \u00falceras de herpes, reumatismo e infec\u00e7\u00f5es de ouvido  e tantas outras. Recuperar essas experi\u00eancias \u00e9, tamb\u00e9m, um modo de registrar o protagonismo ind\u00edgena na hist\u00f3ria do Brasil e na hist\u00f3ria da medicina.Se a experi\u00eancia com o assacu n\u00e3o teve como resultado a esperada cura da lepra, o uso medicinal que os \u00edndios faziam de muitas outras plantas foi incorporado pela medicina oficial, a exemplo da ipecacuanha, da ayapana, da copa\u00edba . In fact, no one attempted to stop the experiment, and Marianno \u201csuffered cruelly until midnight.\u201d The few medications administered by the doctors present did nothing to alleviate his suffering, and the report reveals the passive, observational stance of those who watched from the snakebite at 11:50 in the morning of September 4, 1838 until 11:30 the next morning, when Marianno \u201cgave up his soul to God.\u201d Driven by scientific curiosity and indifferent to the patient\u2019s suffering, the observers made a minute-by-minute report of his reactions, indicating that he was encouraged to share everything he felt: the blood gushing from the bite wound, the swelling in his hand, chills, vision changes, tingling face, anxiety, throat swelling, chest pain, irregular heartbeat, until the moment he died . In 1844, the French Doctor Xavier A report ten years afterward reported that Marianno decided to subject himself to this experiment \u201cdespite the prudent counsel of many physicians who doubted whether this dangerous method could be successful\u201dLess tragic experiments to cure leprosy were conducted throughout Brazil during the nineteenth century, and contemporary newspapers often announced supposed cures for the disease, in Brazil as well as abroad. A cure for the \u201chorrible disease of leprosy\u201d discovered by a Portuguese woman in the city of Porto was announced in 1844 . In 1848, the discovery of a \u201cradical cure for leprosy using herbs and other items\u201d was reported in the village of Itapetininga, S\u00e3o Paulo . This discovery was made by a Frenchman named Charles Pierre Et\u00e9ch\u00e9ion, who since 1847 had experimented with cures for leprosy that involved guano, the feces of birds and bats . In 1859Treze de Maio newspaper depicts public perception of the disease at that time, growing numbers of leprosy cases in the province of Par\u00e1, and the hope that such reporting generated:An 1840 article in the No one is unfamiliar with the terrible and progressive scourge that day by day becomes a greater threat to our province: leprosy! We all feel the urgent need to take more serious measures and cautions so that this same evil does not spread throughout the population, become widespread, and ultimately we will only have our own apathy to blame .morfeia, gafa, elefant\u00edase dos gregos, elefancia, mal de l\u00e1zaro, mal da pele, and mal do sangue. It was synonymous with everything considered repugnant that could corrupt morality, destroy social life, and topple the natural order of things.Leprosy was consequently seen as a \u201cterrible scourge,\u201d a threat to society, an evil to be driven out of the province or at least brought under control. To do this, the author maintained that the provincial government should build a leper\u2019s hospital in some far-off place and take measures to send lepers to Goi\u00e1s Province \u201cin order to use the Caldas\u201d . The hot springs at Caldas Novas, in Goi\u00e1s, as well as those at Po\u00e7os de Caldas in southern Minas Gerais, were considered effective aids in curing diseases like leprosy, syphilis, and venereal diseases in general. Many people who were disillusioned with the ordinary resources they could obtain in the villages and cities placed their hopes in the healing power of these waters . The disTreze de Maio newspaper in Bel\u00e9m, Par\u00e1 learned that a cure for leprosy had been found.4 In investigating this event, provincial vice-president Jo\u00e3o Maria de Moraes learned that a certain Jos\u00e9 Joaquim de Souza Gomes, long known to have leprosy, appeared to be cured of the disease after applications of assacu (Hura crepitans L.) by an Indian named Antonio Vieira dos Passos . Passos was not intimidated:He regularly states that he is not afraid to cure any leper while supervised by physicians. But he does not hesitate to say: whoever has to die of this disease always dies, perhaps meaning that just as other diseases with known remedies are not always cured by them, his cure for leprosy is also not infallible. He says he has not declared all the remedies he applies. But it seems that the surgeon Rebello has all of them, or [at least] the essential ones .This report is important, since it reveals  Passos\u2019s secure defense of the method he used to cure leprosy and the comparative reading he made between his healing practice and official medicine, both fallible or unable to cure every single case. The report also suggests that Passos took pains to maintain a certain control over the medications he used for himself, not reporting all of them. Four months after the experiment in Santar\u00e9m began, the surgeon reported that the patients had noticeably improved and there was hope they might be cured after another three months of treatment.Various newspapers published the recipe used by Passos:Mr. Rebello said that the way he uses assacu to cure lepers in Santar\u00e9m is what was used by Souza Gomes to treat this disease and that he only perfected and adapted it to the rules of Medical Science. It is based on daily use of pills made of the condensed sap (referred to as the extract); on using a mixture composed of half a pound of strong cooked bark and ten to twenty drops of the juice (known as the emetic); the patient must drink the entire mixture all at once to make himself vomit, and patients consequently vomit more than six times. This is repeated daily for eight days. The use of overall baths prepared by the saturated cooking of the bark, repeated for days, and the use of a cooked emollient for everyday drinking .Note that Rebello, the surgeon, tried to differentiate his procedure from the one used by Passos, stating that he \u201cperfected\u201d and \u201cadapted\u201d the method \u201cto the rules of Medical Science.\u201d This scientific clothing was intended to lend this experimental treatment greater credibility and legitimacy.Di\u00e1rio do Rio de Janeiro newspaper reported receiving a letter from Santar\u00e9m stating that \u201cit appears that a poison named assacu produced in Par\u00e1, when applied as an emetic and purgative as taught by a Parintins Indian, completely cures leprosy\u201d . This was the only publication on this case with a reference to the potential ethnic background of Antonio Vieira dos Passos. In the seventeenth century, Jesuit missionaries founded a mission in Tupinambaranas, far from the current city of Parintins. In 1803, Mau\u00e9 and Munduruku Indigenous peoples were brought together there. Parintins became its official name in 1880, a reference to the Parintintins who had lived in the region. In 1832, Ayapana triplinervis (M. Vahl) R.M. King & H. Rob.) revealed by an Indigenous woman of unknown name and ethnicity which nevertheless became known as erva-do-ouvidor [ombudsman\u2019s herb] in a reference to a bureaucrat in Bel\u00e9m known only for sending this plant to Lisbon and recommending its therapeutic properties . Ayapana is an effective treatment for gastrointestinal disorders, mouth ailments, fever, and parasites, and is also used as a diaphoretic and antidote for snakebite.An article published in the Natureza, doen\u00e7as, medicina e rem\u00e9dios dos \u00edndios brasileiros  . By highlighting the \u201cmagnificence of its vegetation,\u201d the writer reinforces the idea of some \u201cnatural wisdom\u201d held by the Indians, who themselves are seen as part of nature, according to the notion of the \u201cecological Indian\u201d .According to a publication in the  Indian\u201d . In any  Indian\u201d , p.131 spardo7 Antonio Vieira dos Passos,\u201d who confirmed he had cured Jos\u00e9 Joaquim de Souza Gomes:In this way, we can understand the doctors\u2019 curiosity about the discovery of the Indian Passos\u2019s supposed cure for leprosy. In a statement sent to the Par\u00e1 provincial president Herculano Ferreira Pena, a Santar\u00e9m district court judge named Jo\u00e3o Baptista Gon\u00e7alves Campos described his encounter with \u201cthe curibocolo in Juruti Parish named Manoel Joaquim, who was also in the work gang, but has since died .He further declared that he was able to completely cure a Tapuyo [Indian] named Theod\u00f3zio, a member of the Faro work gang who had been miserably wounded by leprosy but today carries out his work clearing brush in that village. [And] that he learned this cure from an old curibocolo in Juriti Parish\u201d reveals that the use of assacu to treat leprosy went back even farther among the Indians. Curibocolo is a corruption of curiboca or caraiboca, a term which according to the Dicion\u00e1rio de palavras brasileiras de origem ind\u00edgena means caboclo, \u201can Indian/Black child\u201d or \u201cwhite/Indian mix\u201d ,8 marapuama , and assacu . This illustrates that Passos was not the first healer to use assacu to cure leprosy.In 1840, president of Par\u00e1 Jo\u00e3o Antonio de Miranda invited a group of physicians to evaluate a group of people presented as healers of leprosy by the Armada\u2019s surgeon, Marcelo Domingues Barbosa. Doctors Camillo Jos\u00e9 do Valle Guimar\u00e3es, Francisco da Silva Castro, Jos\u00e9 Cust\u00f3dio da Fonseca Paes, and Alexandre da Costa Ara\u00fajo moved to disqualify the healer, considering him a quack and saying that some of the people he claimed to have cured of leprosy in fact never had the disease. They also claimed that he used known medical remedies in a peculiar manner, together with \u201cextravagant compounds\u201d that included plants known as murur\u00e9 , \u201cdoctors and healers were never very far from each other prior to the second half of the nineteenth century.\u201d Plants that were unknown or had not been studied in detail by official medicine were widely used in experiments to cure a wide array of diseases. As for the therapeutic practices used by Ant\u00f4nio Corr\u00eaa de Lacerda and Francisco da Silva Castro, In October 1847, Jos\u00e9 de Souza Gomes (who lived in Santar\u00e9m and claimed to have been cured of leprosy by the Indian Antonio Vieira Passos) traveled to Bel\u00e9m, where he was examined at the Governor\u2019s Palace by a medical board comprised of Doctors Camillo Jos\u00e9 do Valle Guimar\u00e3es, Jos\u00e9 da Gama Malcher, and Joaquim Frutuoso Guimar\u00e3es. Their report to the president of the province contains some details that give us an idea of his background. The doctors stated that Jos\u00e9 de Souza Gomes was the son of Antonio de Souza Gomes, had been born in Bel\u00e9m, Par\u00e1, and was 33 years old. He was single, \u201cmixed race, with a lymphatic temperament, with the constitution related to this temperament, had had an unrestrained lifestyle; had boils and syphilitic disease\u201d . Three years earlier, he had been hospitalized in Bel\u00e9m at the Charity Hospital to treat a skin disease he did not know was leprosy, and was directed by the physician Jos\u00e9 da Gama Malcher to enter the leper asylum in Tucunduba. Displeased with this directive, Gomes fled the hospital to the interior of the province \u201cin search of death,\u201d according to the doctors. Then,there an individual suggested he could cure his disease using assacu; the patient, miserable because of his awful state, accepted this offer of a cure, but doubted what was promised, and hoped that this method, like a poison, would shorten his days, a belief that soothed him in the face of his troubles; but this was not what happened, in fact this remedy affected his illness such that he was able to return to society, from which he had been cut off .Next, the doctors discussed Gomes\u2019s condition when he was first examined by Malcher at the Charity Hospital, before he had fled to the interior. The doctors described symptoms typically seen in people with leprosy, such as foul breath, raspy voice, a swollen, dull, wrinkled face that \u201cwas repugnant because of its deformed features,\u201d swollen legs and deformed fingers . This description of leprosy symptoms helped reinforce the stigma around this disease, and especially around the people affected by it. Gomes was stripped naked and scrupulously examined by the team of doctors just over two months later. They concluded that \u201cthe changes seen in the face, trunk, and arms that previously were attacked by tuberculous leprosy are pleasing to the eyes of the physician, since they offer complete hope that if the patient Souza Gomes diligently uses the methods that have been proven, his health may be completely restored\u201d .9In October 1848, Passos the Indian healer came to Bel\u00e9m and was received by the president of the province, the chief of police, a city doctor, and another from the Santa Casa hospital. The president, Jer\u00f4nimo Francisco Coelho, attempted to persuade him to describe how he produced and used assacu and promised payment in return. Passos assented, but continued \u201con the assumption that a secret was being taken from him, [a secret] he considered himself to be the owner of and which he applied empirically\u201d , p.96. SThe president of the province subsequently authorized the establishment of a ward exclusively to test assacu on the lepers in the Tucunduba asylum , p.60. SThe first challenge was to find a place suitable for establishing an \u201cexperimental leper hospital\u201d where six patients with the disease chosen from Tucunduba would be subjected to these experiments. Jos\u00e9 Pio de Ara\u00fajo Nobre of Santa Casa said that \u201cwe have been unable to [find a location], because no one wishes to rent for such a purpose\u201d , further reinforcement of the stigma that people with leprosy faced during this period. Santa Casa ultimately used a government building in Bel\u00e9m on what was once known as Rua do Atalaia (currently Travessa Joaquim T\u00e1vora). After adaptations were made, Nobre told the president of the province that the space was ready to receive \u201cthe lepers who will undergo the Assacu cure according to the method of the Indian Passos\u201d .10 The process of naming and describing leprosy during the first half of the nineteenth century was complex and subtle, subject to errors and misinterpretation, issues that \u201cserved to obscure and confuse diagnoses of leprosy, and, at the same time, they served to compound the already charged symbolic resonance of the disease and the corresponding force and power of its myriad representations\u201d . The concern with choosing patients \u201cwith all the characteristics of leprosy\u201d reflected the uncertainties involved in diagnosing leprosy at that time.tations\u201d , p.15. Htations\u201d , p.54-55tations\u201d , p.167. tations\u201d , p.96. TCorreio Mercantil newspaper in Bahia published an article listing the names of four people with leprosy who had been part of the experiments involving assacu at Santa Casa de Miseric\u00f3rdia in Par\u00e1. They were: \u201cAntonio Hil\u00e1rio Martins, white, single, born in Monte Alegre,\u201d who \u201chas a swollen, opaque, wrinkled face that is repugnant because of the deformity of its features;\u201d Raymundo Gon\u00e7alves da Cunha, \u201cwhite, single, born in this city, son of Jos\u00e9 da Cunha de Assun\u00e7\u00e3o;\u201d \u201cDomingos Manoel, Black, Creole and slave of Jo\u00e3o Henrique da Silva Lavareda, son of Catarina Maria do Esp\u00edrito Santo and unknown father\u201d and \u201cMaria do Ros\u00e1rio, Black woman born in Acar\u00e1 parish, slave of Manoel Henrique Dias, daughter of Michelle Francisca and unknown father\u201d . Besides their names, the newspapers often published descriptions of diseases these patients had previously, in yet another form of stigmatization that affected the lives of the poor, whether freeborn, freed, or slaves.The 11 The doctor expressed optimism in response to their appearance at the start of treatment, as well as interest in claiming credit for the supposed cure:Doctor Jos\u00e9 da Gama Malcher described the effects caused by assacu in the four patients with leprosy as follows: \u201cSoon after taking it they felt general malaise, along with mild tremor, cold extremities, and heat extending from the chest to the face\u201d , \u201csome anxiety and desire to vomit\u201d (p.2). Each patient vomited between 10 and 15 times. Some experienced nosebleeds, defecated black blood, and felt as if they were being stung by ants.As I have established, I do not think I am being rash in hoping that if the improvements continue, the four unfortunate [patients] may be able to once again belong to society, from which they were excluded. And if I can do this, what glory for my province! How many benefits for humankind! And what a triumph for medicine! .Anais de Medicina Brasiliense reported thatOther physicians sought fame by presenting specific formulas for utilizing assacu. An article in the the master surgeon Mr. Francisco de Paula Cavalcanti de Albuquerque (of Par\u00e1) has just communicated to our editors that through a process of his he has prepared an extract of the milk of assacu, which has proven very valuable when applied to six lepers who are receiving treatment in a private leper hospital .Expressions like \u201cif I can do this\u201d and \u201cthrough a process of his,\u201d in reference to the doctors\u2019 experiments with assacu, erase the role of the Indian Antonio Vieira dos Passos.O Brasil newspaper of Rio de Janeiro stated: \u201cNo boats arrive from Par\u00e1 that do not bear news of assacu\u201d . The imperial government requested that the Imperial Academy of Medicine conduct experiments to confirm whether assacu effectively cured leprosy .But others sought to make money off this supposed cure. Another article in the Anais de Medicina Brasiliense .The experiments with assacu called attention to some people in Par\u00e1, especially because many physicians in that state corresponded with people and institutions in other areas of the country to report the supposed leprosy cure. The physicians Camillo do Valle, Gama Malcher, and Joaquim Frutuoso Pereira Guimar\u00e3es became corresponding members of the Imperial Academy of Medicine . Francisco da Silva Castro, along with Guimar\u00e3es, joined the contributors to the As the experiments spread, they generated increasing anxiety about their findings: \u201cassacu is like a spiderweb hanging in the gap of therapeutic experiments in Rio de Janeiro. Miraculous effects against leprosy are expected, as they were expected from guano against this disease, although guano failed\u201d . Another article stated: \u201cWe all impatiently await the outcome of the experiments conducted at the hospitals in Rio de Janeiro, Bahia, and Pernambuco\u201d .The repercussions of Passos\u2019s experiment were so broad that additional tests of the assacu cure for leprosy involving 13 patients were conducted at the S\u00e3o L\u00e1zaro Hospital in Lisbon; the doctors concluded that this substance could help improve their condition but did not have the power to cure the disease .Formul\u00e1rio e guia m\u00e9dico [Prescription Vademecum and Medical Guide]  da Concei\u00e7\u00e3o, seventy years of age and married to Antonio Vieira dos Passos, died without a will, leaving five children from this marriage .On the twentieth of may in 1883 Francisco Vieira dos Passos, resident in the Muratuba If this was the same Antonio Vieira dos Passos, he married Francisca da Concei\u00e7\u00e3o and had five children who lived in Muratuba. Vila Franca, where Francisco Vieira dos Passos was born, is near Santar\u00e9m, where Passos was imprisoned.Passos the Indian\u2019s experience shows that the search for a cure for leprosy was not restricted to the field of official medicine. In various parts of the world, healers, shamans, and others classified as quacks conducted their own experiments to cure this disease. I was, by the way, unable to find any document decrying Antonio Vieira dos Passos as a quack or a charlatan, which may be explained by the respect that physicians tended to have for Indigenous medicine and the initial success of the experiment involving assacu. The varied work of healers was associated with \u201cmanual labor, low social status, reserved for groups on the margins of society such as slaves, freed men and women, the poor, and women\u201d , p.25. TLepers were left with stigma, the pain of being excluded from social life , and all types of trials in \u201cexperimental leper hospitals.\u201d But that wasn\u2019t all; as we have seen, some were able to escape or refused to take part in these tests. And those who lived in the leper hospitals and centers did not agree with the vision of these places as \u201ccemeteries for the living\u201d .Psychotria ipecacuanha (Brot.) [Stokes]), used in cough remedies and in a syrup to induce vomiting, and the tonic, digestive, and anti-diarrheic ayapana (Ayapana triplinervis [Vahl] R.M. King & H. Rob.), there is also quinine, a substance extracted from the bark of the quina or cinchona tree, discovered by the native people of Peru and used to cure fevers. Quina is a member of the genus Cinchona, family Rubiaceae, and was integrated into western medicine to treat malaria; according to Carapa guianensis [Aublet]), which is widely used in Amazonia as an analgesic, antibacterial, anti-inflammatory, antifungal, and antiallergic and has also been proven effective against wounds, hematomas, rheumatism, and ear infections , the authorities of Par\u00e1 province set out to learn the \u201cmethod of the Indian Passos,\u201d a representative of people who  tended to be defined in the reports penned by the presidents of the province as lazy and the embodiment of the last stages of human degeneration . While PThe experiments begun by the Indian Passos in Santar\u00e9m around 1847 spread around the world, in a circle which in a way closed with Chernoviz\u2019s declaration that assacu\u2019s reputation as a \u201cremedy for leprosy\u201d had reached its end. In this case, we can note that \u201ca world examined through the lens of the history of leprosy shows complex convergences of national histories, international, governmental and medical politics\u201d , p.2. StStudies on the history of medicine in nineteenth-century Brazil are essential to recover and reveal the active roles played by Indigenous people in the process of creating and institutionalizing medicine in the country. Besides the labor they provided, Indians in Brazil played a notable role in solidifying western knowledge in fields including botany, agronomy, and medicine. Throughout the nineteenth century, Indigenous knowledge about medicinal plants was widely recognized and utilized by physicians who wanted to incorporate them into their therapeutic repertoire. Assacu was abandoned as a treatment for leprosy, but continued to be used for other purposes. For example, in 1932 Paul Copaifera langsdorffii Desf.), and many others. Recovering these experiments is also a way of recording Indigenous participation in the history of Brazil as well as the history of medicine.While assacu did not produce the desired results in curing leprosy, medicinal uses of many other plants among Indians became part of official medicine, as in the cases of ipecac, ayapana, copa\u00edba ("}
+{"text": "Considering the published evidence on the impact of recent economic crises and the implementation of fiscal austerity policies in Brazil on various health indicators, this study aims to analyze how the trend and socio-spatial inequality of infant mortality behaved in the municipality of S\u00e3o Paulo from 2006 to 2019.This is an ecological study with a temporal trend analysis that was developed in municipality of S\u00e3o Paulo, using three residence area strata differentiated according to their social vulnerability following the 2010 S\u00e3o Paulo Social Vulnerability Index. Infant mortality rate, as well as neonatal, and post-neonatal mortality rates, were calculated for each social vulnerability stratum, each year in the period, and for the first and last three triennia. Temporal trends were analyzed by the Prais-Winsten regression model and inequality magnitude, by rate ratios.We found a decline in infant mortality rate and its components from 2006 to 2015, greater in the stratum with low social vulnerability and in the post-neonatal period when compared to the neonatal one. This decline ended in 2015, stagnating in the next period (2016\u20132019). Our analysis of infant mortality inequality across social vulnerability stratum showed a significant increase from the initial to the final triennia in the analyzed period; rate ratios increased from 1.36 to 1.48 in the high stratum , and from 1.19 to 1.32 between the medium and low social vulnerability strata.The observed stagnation of infant mortality rate decline in 2015 and the increase in socio-spatial inequality point to the urgent need to reformulate current public policies to reverse this situation and reduce inequalities in the risk of infant death. This panorama also occurred in the Americas, whose IMR fell by 55% from 1995 to 2017, but with great variation between countries 2 .Data from the World Health Organization show that infant mortality rates (IMR) declined by about 50% from 2000 to 2018, but unequally across regions and countries 3 and infant mortality in several countries of the world 6 .The literature has shown that accelerated income concentration, economic crises, and fiscal austerity policies have negatively affected several health indicators 7 . Regarding infant mortality, a Brazilian study found, in 2016 and 2017, a deceleration of the downward trend observed up to 2015 8 and two other studies found an increase in IMR in 2016, after the decline up to 2015 10 . 2016 deepened the economic and political crisis in Brazil, unevenly affecting its overall population and that of the municipality of S\u00e3o Paulo (MSP), increasing unemployment rates and decreasing income, especially among the most vulnerable population 11 .In Brazil, these same processes have also worsened the trends of some health indicators , increasing social inequality among social segments of these populations 13 ) and the absence of recent studies on the trend of rates and social inequalities of this indicator in MSP, our study aims to analyze rate trend and the magnitude of socio-spatial inequalities of infant mortality in this municipality from 2006 to 2019.In view of this situation and considering the relevance of IMR  began to feedback records of the Ministry of Health database, incorporating the events that occurred in other municipalities into its municipal database.Sistema de Informa\u00e7\u00e3o de Mortalidade  and that on Sistema de Informa\u00e7\u00f5es sobre Nascidos Vivos (SINASC \u2013 Live Birth Information System). The population residing in MSP was obtained from the SMS-SP TabNet, with projections by the SEADE Foundation based on data from the 2010 Census 14 .Our databases come from the 15 .Socio-spatial inequalities were analyzed based on the S\u00e3o Paulo Social Vulnerability Index (SPSVI) by the SEADE Foundation, which used socioeconomic and demographic indicators to classify the census tracts of the municipalities in the state of S\u00e3o Paulo into six social vulnerability groups: lowest, very low, low, medium, high, and very high. This indicator enables the identification and spatial location of the areas housing the segments exposed to different degrees of social vulnerability To classify the MSP Social Vulnerability Strata, each of its 96 Administrative Districts (AD) received a vulnerability score based on the percentage of census tracts classified in each SPSVI group. Then, AD were ordered from lowest to highest according to these scores and classified into three social vulnerability strata    , contaiIMR (< 1 year of age) and neonatal (0\u201327 days) and post-neonatal (28 days to < 1 year) mortality rates per 1,000 live births (LB) were calculated for the three social vulnerability strata for each year in the studied period (2006 to 2019).16 .The Prais-Winsten regression model was used to analyze trends. Infant, neonatal, and post-neonatal mortality trends were analyzed for the whole period (2006\u20132019) and separately from 2006 to 2015 and from 2016 to 2019 since we found the lowest IMR in 2015. For the time series, the rate logarithm was considered as the dependent variable and the years in the historical series as the independent variable. Serial autocorrelation was checked using the Durbin-Watson test, whereas rate annual percentage variation (APV), regression coefficients (\u03b2), respective 95% confidence intervals (95%CI), and p-values (p) were calculated considering a 95% significance level To analyze the magnitude of infant mortality inequality, the extreme years in the series were grouped into three-year periods (2006\u20132008 and 2017\u20132019) and the rate ratios (RT) between high and medium social vulnerability areas were calculated in relation to those with low vulnerability and used as a reference category. This procedure was performed to provide greater rate stability for our analyses.To evaluate whether the RT between the areas with high and medium social vulnerability, compared to those with low vulnerability, differed between the first and the last triennium, the right-tailed Student\u2019s t-test was used for independent samples. A p-value < 0.05 was considered for statistical decision-making.\u00ae .Data tabulation, descriptive analysis, and graphs were performed in TabWin  and Microsoft Office Excel 2010. All analyses were carried out using Stata 15.0 17 .In this study, databases of deaths and live births without identification available electronically and aggregated by the SMS-SP were used, thus dispensing with submitting this study to the Research Ethics Committee. This research was conducted in accordance with the Resolution of the National Health Council no. 466 of December 12, 2012 MSP suffered 27,808 deaths in children under 1 year of age and had 2,394,375 LB, from 2006 to 2019. We observed that about 65% of infant deaths occurred in the neonatal component for all strata of social vulnerability in the first and last analyzed triennia   .Our analysis of the IMR trend for the whole period    shows aWhen we analyzed infant and neonatal and post-neonatal mortality trends according to social vulnerability strata, we observed that the rates for IMR and its components significantly decreased from 2006 to 2015 in the three strata (p < 0.05). However, the second period (2016 to 2019) showed a stagnant downward trend in the high vulnerability stratum as it significantly declined , except for post-neonatal mortality. However, regarding comparing trends between social vulnerability strata showed no significant differences in all analyzed periods for both IMR and neonatal and post-neonatal mortality   .By comparing inequalities in infant mortality and its components between the first and last triennia in the studied period, we observed that, according to RT, infant mortality showed increased inequality and risk of dying in the stratum of high social vulnerability in relation to that of low vulnerability, increasing from 36% in the first triennium to 48% in the last triennium (p = 0.041). In the stratum of medium social vulnerability, the increased risk of dying in the first year of life increased from 19% to 32% (p = 0.007), when compared to the stratum of low social vulnerability. The increases in social inequalities between the two triennia for neonatal and post-neonatal rates failed to reach statistical significance, except for that between the middle and low social vulnerability strata, which increased from 22% to 48% (p = 0.029)   .Results show a significant drop in infant, neonatal, and post-neonatal mortality rates in MSP, ending in 2015. In the decline period (2006 to 2015), the three IMR strata and post-neonatal rates  showed a significant reduction. Another important result in this study refers to a significant increase in the social inequality for infant mortality in MSP between the first (2006\u20132008) and last triennium (2017\u20132019) in the analyzed period.8 found significant declines in childhood mortality of \u22123.95% a year from 2001 to 2010 and of \u22122.35% from 2011 to 2015 and a stabilizing trend from 2016 to 2017 with an insignificant decline of \u22120.07%. Ferreira et al. 10 analyzed IMR in clusters of Brazilian municipalities from 2007 to 2016 and observed a decrease in this indicator from 2007  to 2015 , with a slight increase in 2016 , with higher concentrations of infant mortality in the Brazilian North and Northeast. Szwarcwald et al. 9 found a declining trend in infant mortality from 1990 (47.1) to 2015  but a 3.7% increase in 2016, when compared to 2015, from 10.9 to 11.3 deaths/1,000 LB.Studies conducted in Brazil have also observed recent changes in the trend of infant and childhood mortality. Marinho et al. Since we analyzed longer periods than these studies, we found a slight increase in IMR in relation to 2015 and that rates maintained similar values from 2016 to 2019 , although higher than that in 2015.18 , hitting the population unevenly with increased unemployment and misery rates, preserving the earnings of the richest and penalizing the most vulnerable population 19 .In this and the aforementioned studies, 2016 had a greater or interrupted IMR decline. That year witnessed a worsened economic crisis and a serious political crisis in Brazil that culminated in the impeachment of its president and the immediate implementation of fiscal austerity measures, including the approval of Constitutional Amendment no. 95/2016 (Spending Ceiling), which reduced budget spending and broadly compromised the health and social protection systems 19 , and decreased IMR. This study found that the greatest decrease in post-neonatal mortality occurred from 2006 to 2015. Most post-neonatal deaths stem from preventable causes that dispense with high-cost health technologies. We can infer that the expansion of access to primary health care certainly contributed to decreasing IMR in the municipality, but that it insufficiently reduced social inequalities even in that period 20 .In Brazil, the impact of the economic crisis was evinced from 2014 onward, after a period of expansion from 2004 to 2013, which improved income distribution, reduced poverty Social protection measures and increased health spending could mitigate the effects of economic crises on the population\u2019s health and the mortality of children under one year of age but fiscal austerity policies act in the opposite direction, preventing the application of these protection measures. This context must have expanded the inequalities we observed in infant mortality rates.favelas in relation to the total number of dwellings was higher than 10% in 25 of 96 MSP DA 11 in 2020. Moreover, the district of Pinheiros, in Western S\u00e3o Paulo, had a Municipal Human Development Index (MHDI 2010) of 0.942, which was only 0.680 at Parelheiros, at the southern end of city 21 .MSP, one of the main Latin American economic centers, shows a scenario of great social inequality, which can be represented in several ways. To illustrate this inequality, the proportion of households in per capita of MSP increased by 118% from 2006 to 2015, the observed growth of this indicator in the same period was only 10% 22 , concomitant to the stagnation of the decline in infant mortality and increase in social inequality.Another important aspect refers to the fact that while the gross domestic product 23 . This expansion, however, neither maintained the decline in IMR in recent years nor prevented the expansion of inequality in infant deaths between the most and least vulnerable areas of the municipality.Note that the municipality has a capillary public primary health care network that has grown over the years. From 434 basic health units operating in 2010, MSP had 468 in 2019 and an increase in the number of Family Health Strategy teams, from 928 in 2010 to 1,343 in 2019, with a higher concentration of basic health units and Family Health Strategy teams in the most peripheral areas of the municipality 24 . We should also highlight that, given that the observed rates are already low and inequalities rather small, our option to compare the initial and final triennium of the series proved to be correct since it managed to find the increase in inequality in infant mortality.This study has some limitations inherent to its use of secondary databases and the impossibility of analyzing a longer series since the SMS-SP had no complete databases prior to 2006. The analysis of our results should consider its ecological design, which bases its definition of social vulnerability strata on data from residence areas rather than on an individual basis, which could produce different results. However, this approach can identify areas that need differentiated strategies of actions and signal the need to redirect resources for intervention The period we analyzed is more recent than that in the literature, enabling us to evince the maintenance of IMR values and the increase in their social inequality. Another aspect we should mention is our use of reliable databases since the SMS-SP maintains a program to improve data quality in Certificates of Live Births and Deaths, reducing incompleteness and inconsistencies.26 and mitigate the effects of income concentration and poverty on infant mortality 27 as these determinants seem to have important implications for reducing infant mortality, as per a systematic review by Bugelli et al. 32This study fills an important knowledge gap since we found no recent research in the literature that analyzed the trend and inequality of infant mortality in MSP. Our results show an unfavorable epidemiological scenario since current public policies have failed to continue decreasing infant deaths in the city and have enabled the increase in the socio-spatial inequality of infant mortality. Thus, in addition to directing efforts to expand social security policies, basic sanitation, education, and access to health, including protection measures involving women  and monitoring children during their first year of life, it is also necessary to maintain income transfer programs since they can both reduce IMR and inequality Results also show the need for continuously monitoring the trend and size of prevalent social inequalities and adopting and reinforcing intervention measures especially directed to the population in areas of medium and high social vulnerability within the perspective of subsidizing policies to advance health equity.Further studies are needed to develop the understanding of the determinants on the scene and how they interact in a municipality with the characteristics of S\u00e3o Paulo. 1 . Esse panorama tamb\u00e9m foi observado na Regi\u00e3o das Am\u00e9ricas, onde a TMI caiu 55%, entre 1995 e 2017, mas com grande varia\u00e7\u00e3o nos valores das taxas entre os pa\u00edses 2 .Dados da Organiza\u00e7\u00e3o Mundial da Sa\u00fade (OMS) mostram que a taxa de mortalidade infantil (TMI) apresentou decl\u00ednio de aproximadamente 50%, no per\u00edodo de 2000 a 2018, por\u00e9m com profunda desigualdade entre regi\u00f5es e pa\u00edses 3 e na mortalidade infantil, como observado em diversos pa\u00edses do mundo 4 .A literatura tem evidenciado que o processo de acelera\u00e7\u00e3o da concentra\u00e7\u00e3o de renda, a crise econ\u00f4mica e as pol\u00edticas de austeridade fiscal implementadas t\u00eam provocado reflexos negativos em v\u00e1rios indicadores de sa\u00fade 7 . No que se refere \u00e0 mortalidade infantil, um estudo brasileiro detectou, em 2016 e 2017, desacelera\u00e7\u00e3o da tend\u00eancia de queda que vinha sendo observada at\u00e9 2015 8 e outros dois estudos observaram aumento da TMI em 2016, ap\u00f3s o decl\u00ednio verificado at\u00e9 2015 10 . Em 2016, registrou-se um aprofundamento da crise econ\u00f4mica e pol\u00edtica no Brasil, que atingiu de forma desigual a popula\u00e7\u00e3o do pa\u00eds e afetou os moradores do munic\u00edpio de S\u00e3o Paulo (MSP), com eleva\u00e7\u00e3o da taxa de desemprego e queda da renda, principalmente entre os mais vulnerabilizados 11 .No Brasil, esses mesmos processos tamb\u00e9m levaram \u00e0 tend\u00eancia de piora de alguns indicadores de sa\u00fade , com amplia\u00e7\u00e3o da desigualdade social entre segmentos sociais da popula\u00e7\u00e3o 13 , e como n\u00e3o foram encontrados estudos recentes que tivessem avaliado a tend\u00eancia das taxas e das desigualdades sociais desse indicador no MSP, o objetivo deste estudo foi analisar a tend\u00eancia das taxas e da magnitude das desigualdades socioespaciais da mortalidade infantil nesse munic\u00edpio, considerando o per\u00edodo de 2006 a 2019.Diante dessa conjuntura e considerando a relev\u00e2ncia da TMI, indicador sens\u00edvel para avaliar as condi\u00e7\u00f5es de vida e sa\u00fade de uma localidade Trata-se de um estudo ecol\u00f3gico com delineamento de s\u00e9ries temporais que utiliza dados de \u00f3bitos em menores de 1 ano e de nascidos vivos (NV) do MSP, ocorridos em \u00e1reas com diferentes n\u00edveis de vulnerabilidade social, entre 2006 e 2019.Os dados dos \u00f3bitos e os de nascidos vivos foram coletados por local de resid\u00eancia e corresponderam ao per\u00edodo entre 1\u00ba de janeiro de 2006 e 31 de dezembro de 2019, sendo 2019 considerado o ano mais recente com dados consolidados dispon\u00edveis. Optou-se por utilizar 2006 como ano de in\u00edcio da s\u00e9rie porque foi somente a partir desse ano que a Secretaria Municipal de Sa\u00fade de S\u00e3o Paulo (SMS-SP) passou a realizar o procedimento de retroalimenta\u00e7\u00e3o dos registros da base de dados consolidada pelo Minist\u00e9rio da Sa\u00fade, incorporando na base municipal aqueles que ocorreram em outros munic\u00edpios.14 .As bases de dados s\u00e3o provenientes dos Sistemas de Informa\u00e7\u00f5es sobre Mortalidade (SIM) e sobre Nascidos Vivos (Sinasc). A popula\u00e7\u00e3o de residentes no MSP foi obtida do TabNet da SMS-SP, com proje\u00e7\u00f5es realizadas pela Funda\u00e7\u00e3o Seade, a partir dos dados do censo de 2010 15 .As an\u00e1lises de desigualdades socioespaciais foram realizadas com base no \u00cdndice Paulista de Vulnerabilidade Social (IPVS), desenvolvido pela Funda\u00e7\u00e3o Seade, que utilizou indicadores socioecon\u00f4micos e demogr\u00e1ficos para classificar os setores censit\u00e1rios dos munic\u00edpios do estado de S\u00e3o Paulo em seis grupos de vulnerabilidade social: baix\u00edssima, muito baixa, baixa, m\u00e9dia, alta e muito alta. Esse indicador permite identificar e localizar espacialmente as \u00e1reas que abrigam os segmentos expostos a diferentes graus de vulnerabilidade social Para classificar os estratos de vulnerabilidade social do MSP, cada um dos 96 distritos administrativos (DA) do munic\u00edpio recebeu um escore de vulnerabilidade, baseado no percentual de setores censit\u00e1rios classificados em cada grupo do IPVS. Em seguida, os DA foram ordenados segundo esses escores, do menor para o maior, e foram classificados em tr\u00eas estratos de vulnerabilidade social    , contenForam calculadas as TMI (< 1 ano de idade) e as taxas de mortalidade dos componentes neonatal (0\u201327 dias) e p\u00f3s-neonatal (28 dias a < 1 ano) por 1.000 nascidos vivos, para os tr\u00eas estratos de vulnerabilidade social e para cada ano do per\u00edodo estudado (2006 a 2019).16 .Para an\u00e1lises de tend\u00eancia, foi utilizado o modelo de regress\u00e3o de Prais-Winsten. As an\u00e1lises de tend\u00eancia da mortalidade infantil, neonatal e p\u00f3s-neonatal foram feitas para o per\u00edodo todo (2006\u20132019) e separadamente para os per\u00edodos de 2006 a 2015 e de 2016 a 2019, devido \u00e0 observa\u00e7\u00e3o de que o menor valor da TMI havia ocorrido em 2015. Para as s\u00e9ries temporais, considerou-se como vari\u00e1vel dependente o logaritmo das taxas; e como vari\u00e1vel independente, os anos da s\u00e9rie hist\u00f3rica. Investigou-se a exist\u00eancia de autocorrela\u00e7\u00e3o serial por meio do teste de Durbin-Watson e foram calculados a varia\u00e7\u00e3o percentual anual (VPA) das taxas, o coeficiente de regress\u00e3o (\u03b2) e o respectivo intervalo de confian\u00e7a de 95% (IC95%) e o valor de p, considerando um n\u00edvel de signific\u00e2ncia de 95% Para analisar a magnitude da desigualdade na mortalidade infantil, os anos extremos da s\u00e9rie foram agrupados em tri\u00eanios (2006\u20132008 e 2017\u20132019) e calculadas as raz\u00f5es de taxas (RT) entre as \u00e1reas de alta e de m\u00e9dia vulnerabilidade social em rela\u00e7\u00e3o \u00e0s de baixa vulnerabilidade, sendo essa a categoria de refer\u00eancia. Tal procedimento foi realizado para proporcionar maior estabilidade das taxas para as an\u00e1lises.Para verificar se as RT entre as \u00e1reas de alta e de m\u00e9dia vulnerabilidade social diferiram entre o primeiro e o \u00faltimo tri\u00eanio em compara\u00e7\u00e3o \u00e0s de baixa, utilizou-se o teste t de Student, monocaudal \u00e0 direita, para amostras independentes. Para tomada de decis\u00e3o estat\u00edstica, foi considerado o valor de p < 0,05.A tabula\u00e7\u00e3o dos dados, a an\u00e1lise descritiva e os gr\u00e1ficos foram feitos nos programas TabWin (tabulador para Windows), desenvolvido pelo DATASUS, e Microsoft Office Excel 2010. Todas as an\u00e1lises foram realizadas com o programa Stata 15.0 .17 .Neste estudo, foram utilizadas bases de dados de \u00f3bitos e de nascidos vivos sem identifica\u00e7\u00e3o, disponibilizadas por meio eletr\u00f4nico e de forma agregada pela SMS-SP. Portanto, n\u00e3o houve necessidade de submiss\u00e3o ao Comit\u00ea de \u00c9tica em Pesquisa. O estudo foi realizado em conformidade com a Resolu\u00e7\u00e3o do Conselho Nacional de Sa\u00fade n\u00ba 466, de 12 de dezembro de 2012 No MSP, no per\u00edodo de 2006 a 2019, ocorreram 27.808 \u00f3bitos em menores de 1 ano e 2.394.375 em nascidos vivos. Observa-se na Quanto \u00e0 distribui\u00e7\u00e3o dos \u00f3bitos infantis, observa-se que cerca de 65% deles ocorreram no componente neonatal, em todos os estratos de vulnerabilidade social, no primeiro e no \u00faltimo tri\u00eanio analisado   .A an\u00e1lise da tend\u00eancia da TMI, considerando o per\u00edodo todo   , revelaAo analisar a tend\u00eancia da mortalidade infantil e dos componentes neonatal e p\u00f3s-neonatal, segundo estrato de vulnerabilidade social, observa-se que no per\u00edodo de 2006 a 2015, a redu\u00e7\u00e3o das taxas ocorreu de forma significativa para os tr\u00eas estratos nas TMI e seus componentes . Entretanto, no segundo per\u00edodo (2016 a 2019), observou-se estagna\u00e7\u00e3o da tend\u00eancia de queda, exceto para a mortalidade p\u00f3s-neonatal, no estrato de alta vulnerabilidade, que apresentou decl\u00ednio significativo . Todavia, no que se refere \u00e0 compara\u00e7\u00e3o das tend\u00eancias entre os estratos de vulnerabilidade social, n\u00e3o foram verificadas diferen\u00e7as significativas em todos os per\u00edodos analisados, tanto para a TMI quanto para a mortalidade neonatal e p\u00f3s-neonatal   .Comparando as desigualdades na mortalidade infantil e componentes, entre o primeiro e o \u00faltimo tri\u00eanio do per\u00edodo estudado, observou-se que, segundo as RT, a mortalidade infantil apresentou aumento da desigualdade. O risco de morrer no estrato de alta vulnerabilidade social aumentou de 36% no primeiro tri\u00eanio para 48% no \u00faltimo tri\u00eanio  em compara\u00e7\u00e3o ao de baixa vulnerabilidade. No estrato de m\u00e9dia vulnerabilidade social, o aumento do risco de morrer no primeiro ano de vida passou de 19% para 32% , quando comparado ao estrato de baixa vulnerabilidade social. Os aumentos das desigualdades sociais entre os dois tri\u00eanios, nos componentes neonatal e p\u00f3s-neonatal, n\u00e3o atingiram signific\u00e2ncia estat\u00edstica, com exce\u00e7\u00e3o da desigualdade entre o estrato de m\u00e9dia e o de baixa vulnerabilidade social, que passou de 22% para 48%    .Os resultados deste estudo revelaram que a queda significativa que vinha sendo observada no MSP nas TMI, neonatal e p\u00f3s-neonatal foi interrompida em 2015. No per\u00edodo de decl\u00ednio (2006 a 2015), a redu\u00e7\u00e3o das taxas ocorreu de forma significativa para os tr\u00eas estratos nas TMI e no componente p\u00f3s-neonatal em compara\u00e7\u00e3o ao neonatal. Outro resultado importante do estudo foi a detec\u00e7\u00e3o de aumento significativo da desigualdade social da mortalidade infantil no MSP entre o primeiro (2006\u20132008) e \u00faltimo tri\u00eanio (2017\u20132019) do per\u00edodo analisado.8 verificaram decl\u00ednios significativos da mortalidade na inf\u00e2ncia de -3,95% ao ano entre 2001 e 2010 e de -2,35% entre 2011 e 2015, al\u00e9m de tend\u00eancia de estabiliza\u00e7\u00e3o entre 2016 e 2017, com decl\u00ednio n\u00e3o significativo de -0,07%. Ferreira et al. 10 analisaram a TMI em agrupamentos de munic\u00edpios brasileiros, no per\u00edodo de 2007 a 2016, e observaram queda desse indicador, entre 2007  e 2015 , com discreto aumento em 2016  e maiores concentra\u00e7\u00f5es da mortalidade infantil nas regi\u00f5es Norte e Nordeste do pa\u00eds. Szwarcwald et al. 9 constataram tend\u00eancia de decl\u00ednio da mortalidade infantil entre os anos de 1990  e 2015 , por\u00e9m com aumento de 3,7% em 2016 em rela\u00e7\u00e3o a 2015, passando de 10,9 para 11,3 \u00f3bitos/1.000 nascidos vivos.Estudos realizados no Brasil tamb\u00e9m observaram mudan\u00e7as recentes na tend\u00eancia da mortalidade infantil e na inf\u00e2ncia. Marinho et al. Tendo em vista que neste estudo a an\u00e1lise avan\u00e7ou por mais tempo do que nas pesquisas mencionadas, foi poss\u00edvel observar um discreto aumento no valor da TMI em rela\u00e7\u00e3o a 2015 e identificar que as taxas mantiveram valores similares entre 2016 e 2019 , por\u00e9m superiores ao observado em 2015.impeachment da presidente e a imediata implementa\u00e7\u00e3o de medidas de austeridade fiscal. Estas inclu\u00edram a aprova\u00e7\u00e3o da Emenda Constitucional n o 95/2016 (teto de gastos), que reduziu os gastos or\u00e7ament\u00e1rios, comprometendo amplamente o sistema de sa\u00fade e o sistema de prote\u00e7\u00e3o social 18 . Com isso, a popula\u00e7\u00e3o foi atingida de forma desigual, com aumento das taxas de desemprego e da mis\u00e9ria, preservando os ganhos dos mais ricos e penalizando a popula\u00e7\u00e3o mais vulner\u00e1vel 19 .Neste estudo e nas pesquisas citadas, 2016 foi o ano que marcou aumento ou interrup\u00e7\u00e3o do decl\u00ednio da TMI, momento em que ocorria no Brasil um agravamento da crise econ\u00f4mica e pol\u00edtica que culminou com o 19 e no qual a TMI vinha declinando. Neste estudo, constatou-se que, entre 2006 e 2015, a maior queda foi observada no per\u00edodo p\u00f3s-neonatal. Grande parte dos \u00f3bitos do componente p\u00f3s-neonatal se constituem por causas evit\u00e1veis e n\u00e3o dependem de tecnologias em sa\u00fade de alto custo. Pode-se inferir que a amplia\u00e7\u00e3o do acesso \u00e0 aten\u00e7\u00e3o prim\u00e1ria \u00e0 sa\u00fade certamente contribuiu para o decl\u00ednio da TMI no munic\u00edpio, mas, mesmo no per\u00edodo de queda, ela n\u00e3o foi suficiente para reduzir as desigualdades sociais 20 .No Brasil, o impacto da crise econ\u00f4mica foi evidenciado a partir de 2014, ap\u00f3s um per\u00edodo de expans\u00e3o econ\u00f4mica, entre 2004 e 2013, em que houve maior distribui\u00e7\u00e3o de renda e redu\u00e7\u00e3o da pobreza A ado\u00e7\u00e3o de medidas de prote\u00e7\u00e3o social e o aumento dos gastos com sa\u00fade poderiam abrandar os efeitos das crises econ\u00f4micas na sa\u00fade da popula\u00e7\u00e3o e na mortalidade de menores de 1 ano, mas a implementa\u00e7\u00e3o de pol\u00edticas de austeridade fiscal atua em sentido contr\u00e1rio, impedindo a aplica\u00e7\u00e3o dessas medidas de prote\u00e7\u00e3o. Esse contexto deve ter favorecido a amplia\u00e7\u00e3o das desigualdades que foram observadas na TMI.11 e o \u00cdndice de Desenvolvimento Humano Municipal (IDHM), em 2010, atingiu 0,942 no distrito de Pinheiros, na zona oeste, e apenas 0,680 em Parelheiros, no extremo sul da cidade 21 .O MSP, um dos principais centros econ\u00f4micos da Am\u00e9rica Latina, apresenta um cen\u00e1rio de grande desigualdade social, que pode ser dimensionado de diversas formas. Para ilustrar esse contexto, pode-se verificar, por exemplo, as condi\u00e7\u00f5es de habita\u00e7\u00e3o na cidade. Em 2020, a propor\u00e7\u00e3o de domic\u00edlios em favelas em rela\u00e7\u00e3o ao total de habita\u00e7\u00f5es foi superior a 10% em 25 dos 96 DA per capita do munic\u00edpio aumentou 118% entre 2006 e 2015, o crescimento observado desse indicador entre 2016 e 2019 foi de apenas 10% 22 , justamente o per\u00edodo de estancamento do decl\u00ednio da mortalidade infantil e aumento da desigualdade social.Outro aspecto importante a ser ressaltado \u00e9 que enquanto o Produto Interno Bruto (PIB) 23 . Essa amplia\u00e7\u00e3o, entretanto, n\u00e3o possibilitou a manuten\u00e7\u00e3o do decl\u00ednio da TMI nos \u00faltimos anos, nem impediu a amplia\u00e7\u00e3o da desigualdade nas mortes infantis entre as \u00e1reas mais e menos vulner\u00e1veis do munic\u00edpio.Cabe destacar que o munic\u00edpio disp\u00f5e de uma rede p\u00fablica da aten\u00e7\u00e3o prim\u00e1ria \u00e0 sa\u00fade capilarizada, que vem sendo ampliada ao longo dos anos. De 434 unidades b\u00e1sicas de sa\u00fade funcionando em 2010, o MSP passou a ter 468 em 2019, al\u00e9m de ampliar o n\u00famero de equipes da Estrat\u00e9gia de Sa\u00fade da Fam\u00edlia, que passou de 928 em 2010 para 1.343 em 2019, com maior concentra\u00e7\u00e3o de unidades b\u00e1sicas de sa\u00fade e de equipes de Estrat\u00e9gia de Sa\u00fade da Fam\u00edlia nas \u00e1reas mais perif\u00e9ricas do munic\u00edpio 24 . Outro aspecto a ser evidenciado \u00e9 que, visto que as taxas observadas j\u00e1 s\u00e3o baixas e as desigualdades n\u00e3o s\u00e3o t\u00e3o expressivas, a op\u00e7\u00e3o por comparar os tri\u00eanios inicial e final da s\u00e9rie mostrou-se acertada, pois foi poss\u00edvel identificar o aumento da desigualdade na mortalidade infantil.O estudo apresenta algumas limita\u00e7\u00f5es, tanto inerentes ao uso de base de dados secund\u00e1rias quanto ao fato de n\u00e3o ter sido poss\u00edvel analisar uma s\u00e9rie mais longa, uma vez que a SMS-SP n\u00e3o dispunha de bases completas anteriores ao ano de 2006. A an\u00e1lise dos resultados deve considerar que se trata de um estudo ecol\u00f3gico, no qual a defini\u00e7\u00e3o dos estratos de vulnerabilidade social baseou-se em dados de \u00e1rea de resid\u00eancia, e n\u00e3o de base individual, que poderiam produzir resultados diferentes. Por\u00e9m, essa abordagem permite identificar \u00e1reas que precisam de estrat\u00e9gias diferenciadas de a\u00e7\u00f5es e sinalizar a necessidade de redirecionamento de recursos para interven\u00e7\u00e3o O per\u00edodo analisado neste estudo avan\u00e7ou em anos mais recentes em rela\u00e7\u00e3o \u00e0 literatura, permitindo evidenciar a manuten\u00e7\u00e3o dos valores da TMI e o aumento da desigualdade social no indicador. Outro aspecto a ser mencionado \u00e9 a utiliza\u00e7\u00e3o de bases de dados confi\u00e1veis neste estudo, uma vez que a SMS-SP mant\u00e9m um programa de aprimoramento da qualidade dos dados que constam nas declara\u00e7\u00f5es de nascidos vivos e de \u00f3bitos, reduzindo incompletudes e inconsist\u00eancias.26 . Ainda, \u00e9 preciso mitigar os efeitos da concentra\u00e7\u00e3o de renda e da pobreza sobre a mortalidade infantil 27 , j\u00e1 que todos esses determinantes parecem ter implica\u00e7\u00f5es importantes na redu\u00e7\u00e3o da mortalidade infantil, conforme evidenciado em revis\u00e3o sistem\u00e1tica realizada por Bugelli et al. 32Este estudo supre uma lacuna importante do conhecimento, visto que n\u00e3o foram identificadas pesquisas recentes na literatura que tenham analisado a tend\u00eancia e a desigualdade da mortalidade infantil no MSP. Os resultados desta an\u00e1lise revelam um cen\u00e1rio epidemiol\u00f3gico desfavor\u00e1vel, tendo em vista que as pol\u00edticas p\u00fablicas vigentes n\u00e3o est\u00e3o conseguindo manter o decl\u00ednio das mortes infantis no munic\u00edpio e est\u00e3o possibilitando o aumento da desigualdade socioespacial da mortalidade infantil. Sendo assim, al\u00e9m de direcionar esfor\u00e7os para expandir as pol\u00edticas de seguridade social, de saneamento b\u00e1sico, de educa\u00e7\u00e3o e de acesso \u00e0 sa\u00fade, incluindo a\u00e7\u00f5es de prote\u00e7\u00e3o que envolvem as mulheres  e acompanhamento da crian\u00e7a durante o primeiro ano de vida, tamb\u00e9m \u00e9 necess\u00e1rio manter os programas de transfer\u00eancia de renda, j\u00e1 reconhecidos como medidas que contribuem tanto para a redu\u00e7\u00e3o da TMI quanto para a diminui\u00e7\u00e3o da sua desigualdade Os resultados deste estudo revelam tamb\u00e9m a necessidade de monitoramento cont\u00ednuo da tend\u00eancia e da magnitude das desigualdades sociais prevalentes, al\u00e9m da import\u00e2ncia da ado\u00e7\u00e3o e do refor\u00e7o de medidas de interven\u00e7\u00e3o direcionadas especialmente \u00e0 popula\u00e7\u00e3o que vive em \u00e1reas de m\u00e9dia e alta vulnerabilidade social, na perspectiva de subsidiar pol\u00edticas que visem avan\u00e7os na equidade em sa\u00fade.Novos estudos s\u00e3o necess\u00e1rios para aprofundar a compreens\u00e3o dos determinantes que est\u00e3o em cena e como eles interagem em um munic\u00edpio com as caracter\u00edsticas de S\u00e3o Paulo."}
+{"text": "Pesquisa Nacional de Sa\u00fade doEscolar (PeNSE) em suas quatro edi\u00e7\u00f5es - 2009, 2012, 2015 e 2019.Foram usados dados dos escolares (13-17 anos) participantes das quatro edi\u00e7\u00f5esda PeNSE (n = 392.922). Descrevemos o percentual de ativos, a m\u00e9dia e valorespercentuais da atividade f\u00edsica de intensidade moderada \u00e0 vigorosa emminutos/semana. A regress\u00e3o de Poisson foi ajustada para sexo, idade, cor dapele, escore de bens e comportamento sedent\u00e1rio (\u2265 2 horas/dia para assistir TVe \u2265 3 horas/dia de tempo sentado). Como limita\u00e7\u00e3o, a amostra da PeNSE/2009refere-se apenas \u00e0s capitais brasileiras. O percentual de ativos reduziu de43,1% em 2009 para 18,2% em 2019. A m\u00e9dia em atividade f\u00edsica de intensidademoderada \u00e0 vigorosa da PeNSE/2009  reduziu 50% em 2019. Na educa\u00e7\u00e3o f\u00edsica, a m\u00e9dia semanal ematividade f\u00edsica de intensidade moderada \u00e0 vigorosa das meninas foi menor que 50minutos, ao passo que a dos meninos foi maior que 60 minutos, nas quatro edi\u00e7\u00f5esda PeNSE. Ainda, 22,7% das meninas relataram (PeNSE/2019) n\u00e3o ter tido aulas deeduca\u00e7\u00e3o f\u00edsica, enquanto o mesmo \u00e9 relatado por 19,7% dos meninos. Ocomportamento sedent\u00e1rio sofreu redu\u00e7\u00e3o no h\u00e1bito de assistir TV, por\u00e9m o temposentado aumentou de 50,1%  para 54%  entre aPeNSE/2009 e a PeNSE/2019. Como consequ\u00eancia da queda nos n\u00edveis de atividadef\u00edsica, s\u00e3o necess\u00e1rias pol\u00edticas p\u00fablicas que promovam a atividade f\u00edsica, comoaumentar as aulas de educa\u00e7\u00e3o f\u00edsica na escola para, no m\u00ednimo, tr\u00eas vezes porsemana.O objetivo do estudo foi analisar a tend\u00eancia de atividade f\u00edsica dos escolaresbrasileiros e as associa\u00e7\u00f5es com vari\u00e1veis demogr\u00e1ficas, socioecon\u00f4micas ecomportamentais, por meio da  Cercade um quarto dos brasileiros tem pelo menos uma DCNT Pesquisa Nacional de Sa\u00fade doEscolar (PeNSE) ,Em 2016, 28% dos adultos (18+ anos) n\u00e3o atenderam \u00e0s recomenda\u00e7\u00f5es da OMS paraatividade f\u00edsica, ou seja, n\u00e3o cumpriram de 150 a 300 minutos por semana deatividade f\u00edsica com intensidade moderada \u00e0 vigorosa. A preval\u00eancia de inatividadef\u00edsica \u00e9 mais do que o dobro em pa\u00edses de alta renda em rela\u00e7\u00e3o aos de m\u00e9dia e baixarendas, as mulheres s\u00e3o menos ativas na maioria dos pa\u00edses membro da OMS e, nos\u00faltimos 15 anos, os n\u00edveis de inatividade f\u00edsica n\u00e3o diminu\u00edram Health Behaviour School-basedChildren  em mais de40 pa\u00edses europeus, o Global School-based Student Health Survey da OMS e o Youth RiskBehavior Surveillance System  do Centro de Controle e Preven\u00e7\u00e3o de Doen\u00e7as dosEstados Unidos (CDC). H\u00e1 um alerta nesses estudos em rela\u00e7\u00e3o \u00e0 atividade f\u00edsica dosadolescentes, pois a grande maioria dos jovens n\u00e3o est\u00e1 atingindo as recomenda\u00e7\u00f5espara atividade f\u00edsica semanal, como explicitam o HBSC/2016 (82%) Enquanto isso, o Brasil caminha lentamente no monitoramento e vigil\u00e2ncia da sa\u00fade dosadolescentes. Observa-se que estudos semelhantes em outros pa\u00edses s\u00e3o realizados h\u00e1mais de quatro d\u00e9cadas, como o transnacional ,Em n\u00edvel mundial, as aferi\u00e7\u00f5es da atividade f\u00edsica em adolescentes t\u00eam como base oponto de corte para atividade f\u00edsica recomendado pela OMS Assim, o acompanhamento do n\u00edvel de atividade f\u00edsica dos adolescentes insere-se navigil\u00e2ncia em sa\u00fade do Minist\u00e9rio da Sa\u00fade, ou seja, na necessidade de identificar eacompanhar os principais indicadores de sa\u00fade e a probabilidade de o adultodesenvolver alguma DCNT, pois a pr\u00e1tica de atividade f\u00edsica nessa faixa et\u00e1ria \u00e9preditora do comportamento fisicamente ativo ou inativo na idade adulta Nesse cen\u00e1rio, a relev\u00e2ncia e a an\u00e1lise dos dados da PeNSE permitir\u00e3o compreender atend\u00eancia da atividade f\u00edsica entre adolescentes na \u00faltima d\u00e9cada, projetar ofuturo, elencar a\u00e7\u00f5es necess\u00e1rias para reduzir o desenvolvimento precoce dos fatoresde risco e o subsequente surgimento de DCNT. Portanto, nosso objetivo \u00e9 analisar atend\u00eancia de atividade f\u00edsica dos escolares brasileiros e as associa\u00e7\u00f5es comvari\u00e1veis demogr\u00e1ficas, socioecon\u00f4micas e comportamentais por meio da PeNSE em suasquatro edi\u00e7\u00f5es - 2009, 2012, 2015 e 2019.Esta \u00e9 uma pesquisa epidemiol\u00f3gica, transversal, de base escolar e composta poran\u00e1lises ecol\u00f3gicas A popula\u00e7\u00e3o-alvo da PeNSE s\u00e3o adolescentes, de ambos os sexos, matriculados efrequentes nos Ensinos Fundamental e M\u00e9dio de escolas p\u00fablicas e privadassituadas nas zonas urbanas e rurais de todo o territ\u00f3rio brasileiro. A s\u00e9rie e aidade foram definidas por estarem relacionadas, respectivamente, com o m\u00ednimo deescolariza\u00e7\u00e3o e a fase em que os indiv\u00edduos j\u00e1 t\u00eam autonomia necess\u00e1ria,preconizada pela OMS, para responder a um question\u00e1rio autoaplic\u00e1vel.Na primeira edi\u00e7\u00e3o da PeNSE (2009), a coleta de dados foi restrita \u00e0s 27 capitaisbrasileiras, com N = 618.553 e uma amostra de 61.434 escolares. Em 2012, foimantida a coleta de dados nas capitais e foram inclu\u00eddas cidades do interior,agrupadas em cada uma das cinco grandes regi\u00f5es pol\u00edtico-administrativas do pa\u00eds, elevando a popula\u00e7\u00e3o-alvo (N =3.153.314) e obtendo amostra de 106.480 escolares.Em 2015, o plano amostral sofreu adapta\u00e7\u00f5es e foram desenvolvidas duas amostras.Neste estudo, utilizamos a amostra 1, composta pelas 27 capitais e pelosmunic\u00edpios do interior, agrupados por Unidades da Federa\u00e7\u00e3o e abrangendo todo oterrit\u00f3rio brasileiro. Assim, foram criados 53 estratos geogr\u00e1ficos, com apopula\u00e7\u00e3o-alvo estimada em 2.630.835 de escolares e a amostra final com 100.110escolares.Finalmente, em 2019, a partir da popula\u00e7\u00e3o-alvo, estimada em 11.851.941 deescolares na faixa et\u00e1ria de 13 a 17 anos, matriculados do 7\u00ba ao 9\u00ba do EnsinoFundamental e do 1\u00ba ao 3\u00ba ano do Ensino M\u00e9dio, a amostra totalizou 124.898escolares.A amostra deste estudo \u00e9 o conjunto das quatro edi\u00e7\u00f5es da PeNSE, cujas amostrasforam aleat\u00f3rias, probabil\u00edsticas, estratificadas e dimensionadas para estimarpar\u00e2metros populacionais , representativas paraterem validade interna, externa e signific\u00e2ncia estat\u00edstica. A amostra foi aestimativa da propor\u00e7\u00e3o populacional, calculada para fornecer estimativas depropor\u00e7\u00f5es de algumas caracter\u00edsticas de interesse, em cada um dos estratosgeogr\u00e1ficos, utilizando-se erro amostral m\u00e1ximo de 3%, n\u00edvel de 95% deconfian\u00e7a, preval\u00eancia de 50%, pois para propor\u00e7\u00f5es desse valor a vari\u00e2ncia dosestimadores amostrais \u00e9 m\u00e1xima.Assim, este estudo \u00e9 baseado em dados p\u00fablicos e os projetos originais foramsubmetidos e aprovados pela Comiss\u00e3o Nacional de \u00c9tica em Pesquisa (CONEP).Nossa amostra \u00e9 composta por 392.922 escolares, de ambos os sexos, da faixaet\u00e1ria de 13 a 17 anos e oriundos da PeNSE/2009 (n = 61.434), PeNSE/2012 (n =106.480), PeNSE/2015 (n = 100.110) e PeNSE/2019 (n = 124.898).Desde 2009, o Minist\u00e9rio da Sa\u00fade, sob a lideran\u00e7a da Secretaria de Vigil\u00e2ncia emSa\u00fade, tem realizado a PeNSE, em parceria com o IBGE e o Instituto Nacional deEstudos e Pesquisas Educacionais An\u00edsio Teixeira (INEP) do Minist\u00e9rio daEduca\u00e7\u00e3o, al\u00e9m do suporte das Secretarias Estaduais e Municipais de Sa\u00fade e deEduca\u00e7\u00e3o dos estados e munic\u00edpios brasileiros. Nesse per\u00edodo, por meio deestudos epidemiol\u00f3gicos transversais, de base escolar, quatro edi\u00e7\u00f5es da PeNSE coletaram dados de adolescentes dos EnsinosFundamental e M\u00e9dio de escolas p\u00fablicas e privadas.A vari\u00e1vel dependente foi a atividade f\u00edsica acumulada. Esse desfecho foi obtidopor autorrelato, utilizando informa\u00e7\u00f5es de tr\u00eas dom\u00ednios: deslocamentoscasa-escola-casa, atividade f\u00edsica nas aulas de educa\u00e7\u00e3o f\u00edsica e atividadef\u00edsica de lazer - consideram-se as atividades realizadas na escola, masdistintas da aula regular de educa\u00e7\u00e3o f\u00edsica e atividades f\u00edsicas diversasrealizadas em outros espa\u00e7os . Com essasinforma\u00e7\u00f5es, foi realizada a multiplica\u00e7\u00e3o da frequ\u00eancia (dias) pela dura\u00e7\u00e3o(tempo de pr\u00e1tica di\u00e1ria) da atividade f\u00edsica em cada dom\u00ednio, seguida pela somados produtos de cada dom\u00ednio, resultando na atividade f\u00edsica acumulada.,,,Posteriormente, a atividade f\u00edsica acumulada foi dicotomizada em atingir (\u2265 300minutos/semana) e n\u00e3o atingir (< 300 minutos/semana) as recomenda\u00e7\u00f5es paraatividade f\u00edsica. A categoria \u201catingir\u201d foi denominada \u201cpercentual de ativosfisicamente\u201d e teve seu intervalo de 95% de confian\u00e7a (IC95%) reportado paracada edi\u00e7\u00e3o da PeNSE, distribui\u00e7\u00e3o geogr\u00e1fica  eestratificado por sexo, idade e escore de bens . DestacaAs vari\u00e1veis independentes s\u00e3o demogr\u00e1ficas , socioecon\u00f4micas(escore de posse de bens e servi\u00e7os) e comportamentais (comportamento sedent\u00e1riorelacionado ao tempo assistindo televis\u00e3o e relacionado ao tempo sentado). Comrela\u00e7\u00e3o ao tempo assistindo televis\u00e3o, foi considerado excessivo o tempo \u2265 2horas por dia; e quanto ao tempo sentado, \u2265 3 horas por dia. A idade inclu\u00eddafoi limitada \u00e0 faixa et\u00e1ria de 13 a 17 anos e o sexo restringiu-se \u00e0determina\u00e7\u00e3o biol\u00f3gica, masculino ou feminino. Como de praxe, a determina\u00e7\u00e3o daetnia/cor da pele foi autodeclarada e seguiu as categorias propostas pelo IBGE.notebook , acesso \u00e0 Internet em casa  e ter banheiro completo na resid\u00eancia . O escorefoi contabilizado como a soma dos itens, sendo \u201c0\u201d um indiv\u00edduo que n\u00e3o temnenhum dos itens e \u201c4\u201d o indiv\u00edduo que tem todos os itens.Partiu-se das quest\u00f5es sobre bens e servi\u00e7os, inclu\u00eddas na PeNSE, para gerar umescore de bens e servi\u00e7os, conforme relat\u00f3rio do IBGE. Para o escore, foramconsideradas as vari\u00e1veis de posse de celular , computador ouMaterialSuplementarhttps://cadernos.ensp.fiocruz.br/static//arquivo/suppl-e00063423_6796.pdf)das vari\u00e1veis utilizadas nas quatro edi\u00e7\u00f5es da PeNSE .A atividade f\u00edsica foi utilizada para verificar a diferen\u00e7a entre os inqu\u00e9ritose descrita por meio de: (i) percentual de ativos fisicamente e seus respectivosIC95%, conforme a distribui\u00e7\u00e3o geogr\u00e1fica ,considerando sexo, idade e escore de bens e servi\u00e7os  m\u00e9servi\u00e7os ; e (iii)servi\u00e7os .Realizamos a regress\u00e3o de Poisson  para comhttps://www.stata.com), oefeito do delineamento amostral, utilizado pelo IBGE, para a obten\u00e7\u00e3o de todasas estat\u00edsticas descritivas e de associa\u00e7\u00e3o, considerando IC95% e valor de p \u22640,05 como resultados estatisticamente significantes Como consequ\u00eancia da sele\u00e7\u00e3o da amostra em conglomerado, inclu\u00edmos no softwareestat\u00edstico Stata, vers\u00e3o 16 ; PeNSE/2012 (registro n\u00ba 16.805);PeNSE/2015 (registro n\u00ba 1.006.467); e PeNSE/2019 (parecer n\u00ba 3.249.268).Material Suplementarhttps://cadernos.ensp.fiocruz.br/static//arquivo/suppl-e00063423_6796.pdf).Foram utilizados dados de 392.922 adolescentes, na faixa et\u00e1ria de 13 a 17 anos, amaioria sendo do sexo feminino e pardos. A descri\u00e7\u00e3o das caracter\u00edsticassociodemogr\u00e1ficas e comportamentais constam no Material Suplementar na PeNSE/2012 e houve uma queda abrupta para 18%  naPeNSE/2019. A flutua\u00e7\u00e3o foi semelhante nos munic\u00edpios do interior: de 30,4%  na PeNSE/2012 para 17,9%  na PeNSE/2019. A tend\u00eancia dereduzir o percentual de ativos fisicamente com flutua\u00e7\u00e3o descendente tamb\u00e9m foiobservada nas capitais: de 43,1%  na PeNSE/2009 para 18,2%  na PeNSE/2019 .A flutua\u00e7\u00e3o observada no percentual de ativos fisicamente tamb\u00e9m ocorreu na m\u00e9dia ematividade f\u00edsica: (i) no Brasil, de 232,4 minutos/semana  naPeNSE/2012 para 159,2 minutos/semana  na PeNSE/2019; (ii) nosmunic\u00edpios do interior, de 227,7 minutos/semana  para 158,2minutos/semana ; e (iii) nas capitais, de 318,4 minutos/semana para 162,7 minutos/semana . Nas capitais,ao longo de dez anos, a redu\u00e7\u00e3o foi de 50% na m\u00e9dia em atividade f\u00edsica , represePor sexo, as meninas tiveram um percentual de ativos fisicamente menor em rela\u00e7\u00e3o aosmeninos em todas as edi\u00e7\u00f5es, estatisticamente significante para Brasil, capitais einterior e entre inqu\u00e9ritos . ElastaO escore socioecon\u00f4mico revela que s\u00e3o fisicamente ativos, com diferen\u00e7aestatisticamente significante, aqueles que t\u00eam todos os bens do escore, sendo que em2012 e 2015 essa diferen\u00e7a ocorreu de forma progressiva nos quatro n\u00edveis de posse. N\u00e3o houQuando comparamos o percentual de ativos fisicamente por meio do IC95% entremunic\u00edpios das capitais e do interior, encontramos diferen\u00e7a estatisticamentesignificativa nas PeNSE/2012 e PeNSE/2015. Nas capitais e no interior, h\u00e1 diferen\u00e7aestat\u00edstica entre os inqu\u00e9ritos .Nossas an\u00e1lises revelam que a varia\u00e7\u00e3o no deslocamento, aferida pela mediana, foi de15 minutos entre 2009 e 2019. Por\u00e9m, 90% (P90) dos adolescentes em 2009 n\u00e3o atingiamas recomenda\u00e7\u00f5es de atividade f\u00edsica de intensidade moderada \u00e0 vigorosa nessedom\u00ednio, mas eram mais ativos (250 minutos/semana) do que foram os de 2019 (108minutos/semana), conforme A mudan\u00e7a no comportamento sedent\u00e1rio foi estatisticamente significativa nosacompanhados por meio do tempo assistindo televis\u00e3o e tempo sentado. Assistir TV pormais de duas horas por dia foi informado por 79,8%  em 2009 e por46%  em 2019, revelando uma redu\u00e7\u00e3o de 50%. Ter o h\u00e1bito de ficarsentado (tempo sentado) por mais de tr\u00eas horas saltou de 50,1%  em2009 para 54%  em 2019.,Com rela\u00e7\u00e3o ao Brasil, houve redu\u00e7\u00e3o do percentual de ativos fisicamente  no per\u00edodo de 2012 a 2019 , aproximTais redu\u00e7\u00f5es s\u00e3o refor\u00e7adas com a quest\u00e3o de n\u00e3o ter tido aula de educa\u00e7\u00e3o f\u00edsica na\u00faltima semana, pois essa afirma\u00e7\u00e3o esteve mais presente no autorrelato de meninos e meninas . Concomitantemente, ter tido tr\u00eas ou mais aulas foi menosrelatado por meninos  e meninas  .,,,,,,Um dos caminhos a seguir \u00e9, indubitavelmente, promover a atividade f\u00edsica nocotidiano das pessoas, sobretudo de crian\u00e7as e adolescentes, sendo uma formaeficiente para enfrentar a pandemia da inatividade f\u00edsica ,,,,,Nesse contexto, a escola pode contribuir para elevar o percentual de ativosfisicamente e reduzir a inatividade f\u00edsica. Tal assertiva encontra respaldo nosbenef\u00edcios gerados pela atividade f\u00edsica na vida dos indiv\u00edduos, que incluemmelhoria dos resultados acad\u00eamicos Infelizmente, nos \u00faltimos seis anos, o Brasil foi na contram\u00e3o do mundo, reduzindo apr\u00e1tica de educa\u00e7\u00e3o f\u00edsica escolar a uma aula por semana em muitas redes de ensino.Isso afeta a quantidade de est\u00edmulos aos quais os adolescentes est\u00e3o expostos e osafasta da pr\u00e1tica de atividade f\u00edsica fora da escola. Ou seja, a educa\u00e7\u00e3o f\u00edsicaescolar n\u00e3o tem o objetivo de tornar os adolescentes exaustivamente ativos durante aaula, mas sim exp\u00f4-los \u00e0 cultura corporal do movimento e, nesse cen\u00e1rio, incentivara realiza\u00e7\u00e3o de atividades f\u00edsicas em outros contextos.,Por\u00e9m, \u00e9 necess\u00e1rio reverter o n\u00famero total de aulas semanais ofertadas - apenas11,3% (PeNSE/2015) Nossa an\u00e1lise mostra que h\u00e1, na educa\u00e7\u00e3o f\u00edsica escolar, diferen\u00e7a estatisticamentesignificante entre a PeNSE/2009  e aPeNSE/2019 . A an\u00e1lise tamb\u00e9m reportadiferen\u00e7a na participa\u00e7\u00e3o das meninas nas aulas desse componente curricular, queest\u00e3o, aproximadamente, 20 minutos aqu\u00e9m da pr\u00e1tica realizada pelos meninos em todosos inqu\u00e9ritos no Brasil, nas capitais e no interior - em percentual de ativosfisicamente , em m\u00e9diA atividade f\u00edsica mostra uma grande varia\u00e7\u00e3o no dom\u00ednio do lazer. Entre 2012 e 2019,em m\u00e9dia, houve aumento de 15,1 minutos/semana nas capitais e 9,9 minutos/semana nointerior entre as meninas, enquanto os meninos tiveram incremento de 4,3minutos/semana nas capitais e 7,4 minutos/semana no interior . EntretaSabe-se que o lazer envolve a exist\u00eancia de pra\u00e7as e parques pr\u00f3ximos da resid\u00eancia,instala\u00e7\u00f5es adequadas e condi\u00e7\u00f5es seguras para deslocamento , mas o que justifica a atividade f\u00edsica das meninas, na educa\u00e7\u00e3o f\u00edsicaescolar, ser cerca de 21 minutos/semana mais breve do que a dos meninos? A educa\u00e7\u00e3of\u00edsica escolar n\u00e3o \u00e9 um lugar democr\u00e1tico, inclusivo, acess\u00edvel a todos, partilhadoe, principalmente, pedagogicamente orientado?Se considerarmos que todas as aulas foram ministradas, que as 28 semanas letivas naeduca\u00e7\u00e3o brasileira transcorreram normalmente, a diferen\u00e7a encontrada representaque, de 13 a 17 anos, as meninas perderam, em m\u00e9dia, 49 horas de aulas de educa\u00e7\u00e3of\u00edsica - exatamente no per\u00edodo em que poderiam ter uma aula sobre e com o movimentocorporal igual a de seus pares, desenvolver habilidades motoras e adquirirconhecimento e h\u00e1bito da atividade f\u00edsica para toda a vida.Marramarco N\u00e3o \u00e9 de nosso interesse dissertar sobre a puberdade e as altera\u00e7\u00f5es t\u00edpicas dessaetapa da vida dos indiv\u00edduos. Entretanto, alguns aspectos precisam ser elencados, j\u00e1que, nas aulas de educa\u00e7\u00e3o f\u00edsica, a exclus\u00e3o se d\u00e1 pelo grau de habilidade e for\u00e7ados participantes. A for\u00e7a come\u00e7a a se diferenciar na puberdade, que pode ocorrerentre 8 e 13 anos de idade nas meninas.A habilidade motora fundamental inclui as capacidades motoras b\u00e1sicas , necess\u00e1rias para tarefas espec\u00edficas do movimento, eprecisa ser lapidada para promover o desenvolvimento motor. Experimentar-semotoramente fornece uma abund\u00e2ncia de informa\u00e7\u00f5es e percep\u00e7\u00f5es sobre si mesma esobre o mundo que a cerca, contribuindo para que a crian\u00e7a se desenvolva cognitiva efisicamente, progrida sequencialmente de um est\u00e1gio a outro, influenciada peloamadurecimento e pelo conhecimento. N\u00e3o se trata exclusivamente da matura\u00e7\u00e3o, massim de oportunidades de pr\u00e1tica, encorajamento e instru\u00e7\u00f5es, que s\u00e3o cruciais para odesenvolvimento de padr\u00f5es maduros de movimentos fundamentais Encontramos respaldo em estudo desenvolvido por Kremer et al. Contudo, estudo realizado por Ferrari et al. Assim, \u00e9 importante fortalecer o sistema de monitoramento da atividade f\u00edsica dosadolescentes, que representa uma forma eficaz de analisar os efeitos de diferentesest\u00edmulos, resultantes dos exerc\u00edcios f\u00edsicos  Adolescentes fisicamente ativos aumentam a probabilidade de serem adultos ativos,contribuindo para o balan\u00e7o energ\u00e9tico (consumo e gasto), reduzem a probabilidade dedesenvolver obesidade e doen\u00e7as relacionadas \u00e0 obesidade na fase adulta e, o maisimportante, equilibram o balan\u00e7o energ\u00e9tico durante a adolesc\u00eancia, pois est\u00e3oprotagonizando a preven\u00e7\u00e3o e a profilaxia da obesidade e de doen\u00e7as relacionadasnessa fase do ciclo vital.Com rela\u00e7\u00e3o ao comportamento sedent\u00e1rio, sabe-se que h\u00e1 pouco mais de 20 anos ele foireconhecido como problema de sa\u00fade p\u00fablica e, ao mesmo tempo, \u00e9 um modulador dastaxas de preval\u00eancia das DCNT. Isso ocorre porque o comportamento sedent\u00e1rioinfluencia a redu\u00e7\u00e3o do percentual de ativos fisicamente, somado \u00e0 facilidade que osindiv\u00edduos t\u00eam de usufruir das benesses das novas tecnologias , ao mesmo tempo que as formas detrabalho, baseadas na for\u00e7a f\u00edsica, foram abrandadas com as revolu\u00e7\u00f5es industrial etecnol\u00f3gica, sendo substitu\u00eddas pelo maior tempo despendido em trabalho intelectual- normalmente, tempo sentado.A maneira como se mensura o comportamento sedent\u00e1rio ainda precisa evoluir para quese possa afirmar com exatid\u00e3o se a\u00e7\u00f5es caracterizadas como sedent\u00e1rias contribuem oun\u00e3o para que os indiv\u00edduos usufruam das benesses que a sociedade conquistou ao longodos \u00faltimos s\u00e9culos sem se expor \u00e0s DCNT. \u00c9 especialmente importante entender que h\u00e1videogames que exigem a execu\u00e7\u00e3o de movimentos pelo praticante, portanto, reduzindoo impacto de uma atividade que \u00e9 considerada prejudicial \u00e0 sa\u00fade dos indiv\u00edduos e,qui\u00e7\u00e1, revertendo os efeitos delet\u00e9rios do tempo adicional sentado.Considera-se como limita\u00e7\u00e3o neste estudo a an\u00e1lise da PeNSE/2009, pois refere-seexclusivamente \u00e0s 27 capitais brasileiras, sem aferi\u00e7\u00e3o da atividade f\u00edsica e demaiscondi\u00e7\u00f5es de sa\u00fade dos adolescentes no interior. Assim, a tend\u00eancia temporal dascapitais inclui as quatro edi\u00e7\u00f5es da PeNSE , mas o interiordo Brasil est\u00e1 restrito \u00e0s edi\u00e7\u00f5es de 2012, 2015 e 2019. Consequentemente, a an\u00e1lisede Brasil tamb\u00e9m exclui a PeNSE/2009.Em nossos achados, dois aspectos merecem aten\u00e7\u00e3o redobrada dos gestores do Minist\u00e9rioda Sa\u00fade e das Secretarias Estaduais e Municipais de Sa\u00fade: a queda abrupta dapreval\u00eancia de atividade f\u00edsica e o resultado da inequidade entre os sexos nopercentual de ativos fisicamente.Primeiro, a m\u00e9dia em atividade f\u00edsica regrediu de 318,4 minutos/semana (2009) para159,2 minutos/semana, queda de aproximadamente 50% em dez anos, e o Brasil est\u00e1 non\u00edvel de pa\u00edses considerados desenvolvidos, como demonstrado no resultado do HBSC.Por\u00e9m, tal processo foi progressivo e os gestores p\u00fablicos tiveram oportunidades derever as a\u00e7\u00f5es de promo\u00e7\u00e3o da atividade f\u00edsica em 2012  ou em2015 , pois uma parcela significativa j\u00e1 n\u00e3o estava cumprindoas recomenda\u00e7\u00f5es de 300 minutos/semana em atividade f\u00edsica de intensidade moderada \u00e0vigorosa. O segundo aspecto \u00e9 o resultado entre sexos nas aulas de educa\u00e7\u00e3o f\u00edsica,pois as meninas est\u00e3o, em m\u00e9dia, 21 minutos/semana aqu\u00e9m do tempo de pr\u00e1tica dosmeninos nesse dom\u00ednio.\u00c9 imprescind\u00edvel que o n\u00famero de aulas seja ampliado para, no m\u00ednimo, tr\u00eas vezes nasemana, e que os escolares sejam estimulados \u00e0 pr\u00e1tica de atividade f\u00edsica fora doambiente escolar. Al\u00e9m disso, mudan\u00e7as metodol\u00f3gicas, didaticamente conscientes epedagogicamente igualit\u00e1rias, devem ser conduzidas, pois parece inaceit\u00e1velquerermos promover a intera\u00e7\u00e3o entre meninas e meninos se elas s\u00e3o preteridas nasaulas de educa\u00e7\u00e3o f\u00edsica, muito provavelmente em raz\u00e3o das habilidades motoras dosmeninos, que s\u00e3o, em nossa sociedade, estimulados ao esporte, \u00e0 aventura, ao l\u00fadicoem ambientes abertos, enquanto as meninas fantasiam a vida de donas do lar.Ampliamos a lacuna no desenvolvimento motor ao considerarmos que todas as quest\u00f5esculturais desaparecem quando meninas e meninos se juntam na quadra/p\u00e1tio/gin\u00e1sio daescola e n\u00e3o percebemos que tr\u00eas horas por semana n\u00e3o impedir\u00e3o o desenvolvimentosocial e afetivo dos adolescentes. Portanto, \u00e9 prov\u00e1vel que a solu\u00e7\u00e3o seja separaras turmas por sexo e permitir que as meninas se apropriem da cultura corporal domovimento e desenvolvam habilidades motoras que lhes t\u00eam sido negadas ao longo dosanos."}
+{"text": "Diversos processos que permeiam a assist\u00eancia \u00e0 sa\u00fade, incluindo a reabilita\u00e7\u00e3o,precisam de brevidade para ser iniciados ou n\u00e3o podem ser interrompidos. Sendoassim, estes passaram por importantes adapta\u00e7\u00f5es durante a pandemia de COVID-19.Por\u00e9m, n\u00e3o se sabe ao certo como os equipamentos de sa\u00fade adaptaram suasestrat\u00e9gias e quais foram os resultados. O estudo investigou como osatendimentos em reabilita\u00e7\u00e3o foram afetados durante a pandemia e quais foram asestrat\u00e9gias para a manuten\u00e7\u00e3o dos servi\u00e7os prestados. Entre junho de 2020 efevereiro de 2021, realizaram-se 17 entrevistas semiestruturadas comprofissionais de sa\u00fade da \u00e1rea da reabilita\u00e7\u00e3o do Sistema \u00danico de Sa\u00fade (SUS),que atuam em um dos tr\u00eas n\u00edveis de aten\u00e7\u00e3o, nas cidades de Santos e S\u00e3o Paulo,Estado de S\u00e3o Paulo, Brasil. Os discursos foram gravados, transcritos eanalisados por meio da an\u00e1lise de conte\u00fado. Os profissionais relataram mudan\u00e7asorganizacionais em seus servi\u00e7os, com a interrup\u00e7\u00e3o inicial dos atendimentos e,posteriormente, com a ado\u00e7\u00e3o de novos protocolos sanit\u00e1rios e o retornogradativo dos atendimentos presenciais e/ou a dist\u00e2ncia. As condi\u00e7\u00f5es detrabalho foram diretamente impactadas, pois houve necessidade dedimensionamento, capacita\u00e7\u00e3o, amplia\u00e7\u00e3o de carga hor\u00e1ria, al\u00e9m da sobrecarga detrabalho e do esgotamento f\u00edsico e mental dos profissionais. A pandemiadeterminou uma s\u00e9rie de mudan\u00e7as nos servi\u00e7os de sa\u00fade, por vezes descont\u00ednuas,com a suspens\u00e3o de in\u00fameros servi\u00e7os e atendimentos. Alguns atendimentospresenciais foram mantidos, apenas para os pacientes que apresentavam risco deagravo em curto prazo. Medidas sanit\u00e1rias preventivas e estrat\u00e9gias decontinuidade dos atendimentos foram adotadas. A velocidade epotencialidade na contamina\u00e7\u00e3o, aliadas \u00e0 falta de compreens\u00e3o inicial sobre oSARS-CoV-2, adicionaram mais complexidade e incertezas \u00e0s estrat\u00e9gias de como lidarcom a doen\u00e7a, intensificando os desafios \u00e0 aten\u00e7\u00e3o em sa\u00fade e \u00e0 prote\u00e7\u00e3o social daspessoas com defici\u00eancia (PcD) A assist\u00eancia \u00e0 sa\u00fade - especialmente alguns cuidados, como os de reabilita\u00e7\u00e3o, comprocessos que precisam ser iniciados imediatamente ou que n\u00e3o podem serinterrompidos - passou por importantes adapta\u00e7\u00f5es. O que antes era realizado deforma presencial precisou ser adaptado em raz\u00e3o do isolamento social. As tecnologiasdigitais de informa\u00e7\u00e3o e comunica\u00e7\u00e3o (TDIC) se mostraram uma possibilidade decontinuidade.,,,,,A abrang\u00eancia e flexibilidade das TDIC ofereceram solu\u00e7\u00f5es inovadoras para apresta\u00e7\u00e3o de servi\u00e7os de sa\u00fade com a realiza\u00e7\u00e3o de atendimentos remotos no contextoda pandemia. Os gestores, por sua vez, se depararam com desafios multifacetados,como o desencontro de informa\u00e7\u00f5es, provocado pelas mudan\u00e7as di\u00e1rias de cen\u00e1rios,concomitante \u00e0 necessidade de continuidade dos atendimentos, com aten\u00e7\u00e3o para aseguran\u00e7a de pacientes e dos profissionais Os termos telessa\u00fade, teleconsultoria, teleorienta\u00e7\u00e3o, teleconsulta, telediagn\u00f3stico,telemonitoramento, teleinterconsulta e teleduca\u00e7\u00e3o ganharam novas discuss\u00f5es ediretrizes, exigindo rapidez na tomada de decis\u00f5es, com necessidade de diversasadequa\u00e7\u00f5es dos servi\u00e7os de sa\u00fade em um cen\u00e1rio de desequil\u00edbrio entre o avan\u00e7o dadoen\u00e7a, que se deu de forma exponencial, e a capacidade de resposta dasorganiza\u00e7\u00f5es, que, por vezes, ocorreu em escala aritm\u00e9tica ,,,,Cada espa\u00e7o social se mostrou relativamente adepto \u00e0s mudan\u00e7as e foi afetado dediferentes maneiras. Desafios e descobertas foram compartilhados pelas equipesmultidisciplinares, independentemente do n\u00edvel de aten\u00e7\u00e3o \u00e0 sa\u00fade a que pertenciam.Alternativas que pareciam tempor\u00e1rias e breves, para manuten\u00e7\u00e3o das interven\u00e7\u00f5es, seconverteram em novas modalidades de atua\u00e7\u00e3o diante das necessidades de sa\u00fade dosusu\u00e1rios, sendo implementadas para minimizar riscos adicionais \u00e0 sa\u00fade, j\u00e1 muitofragilizada em alguns casos, sem prejudicar a continuidade dos tratamentos Algumas das adapta\u00e7\u00f5es sociais propostas durante a pandemia j\u00e1 eram parte dasreivindica\u00e7\u00f5es das PcD sobre como a sociedade poderia melhor acolher as diversidadeshumanas. A possibilidade de trabalho remoto, adapta\u00e7\u00f5es nos locais de trabalho,oferta de servi\u00e7os domiciliares, amplia\u00e7\u00e3o de pol\u00edticas sociais, formas inclusivasde comunica\u00e7\u00e3o, qualifica\u00e7\u00e3o das informa\u00e7\u00f5es e presta\u00e7\u00e3o de servi\u00e7os, no cotidianodas sociedades no p\u00f3s-pandemia, promovem o exerc\u00edcio pleno e equitativo dos direitoshumanos e liberdades fundamentais das PcD e de outras popula\u00e7\u00f5es vulner\u00e1veis ,,Nessa nova forma de conduzir os tratamentos e produzir cuidado, servi\u00e7os de sa\u00fade portodo o mundo est\u00e3o se reestruturando pelo risco de desorganiza\u00e7\u00e3o dos sistemas desa\u00fade. Desde o in\u00edcio da pandemia, registraram-se quedas brutais nos n\u00fameros deconsultas, exames e cirurgias e, consequentemente, aumento de mortes por outrasenfermidades que n\u00e3o a COVID-19, como doen\u00e7as cardiovasculares, c\u00e2ncer e outrasdoen\u00e7as infecciosas. A falta de atendimento, somada ao receio da popula\u00e7\u00e3o de seexpor \u00e0 contamina\u00e7\u00e3o pelo v\u00edrus, al\u00e9m das recomenda\u00e7\u00f5es dos \u00f3rg\u00e3os de sa\u00fade desuspender os procedimentos eletivos, levou ao aumento da preocupa\u00e7\u00e3o em rela\u00e7\u00e3o aosdiagn\u00f3sticos prim\u00e1rios e acompanhamentos A Organiza\u00e7\u00e3o Europeia para as Doen\u00e7as Raras (EURORDIS) ,Nos sistemas p\u00fablicos de sa\u00fade, essa tend\u00eancia convoca a introdu\u00e7\u00e3o de estrat\u00e9gias degest\u00e3o da cl\u00ednica e de novos modelos de aten\u00e7\u00e3o \u00e0 sa\u00fade baseados em evid\u00eancias,especialmente os modelos inovadores de aten\u00e7\u00e3o \u00e0s condi\u00e7\u00f5es cr\u00f4nicas Portaria n\u00ba793/2012 do Minist\u00e9rio da Sa\u00fade A configura\u00e7\u00e3o do desenho regional da Rede de Cuidados \u00e0 Pessoa com Defici\u00eancia(RCPcD) no estado, na l\u00f3gica da Rede de Aten\u00e7\u00e3o \u00e0 Sa\u00fade (RAS), permite que as redesorganizadas contemplem os pontos de aten\u00e7\u00e3o previstos na Com a relev\u00e2ncia do cuidado de reabilita\u00e7\u00e3o e o contexto da pandemia, \u00e9 importanteinvestigar como os diferentes servi\u00e7os de sa\u00fade adaptaram suas estrat\u00e9gias e osresultados que v\u00eam colhendo de suas a\u00e7\u00f5es. Assim, este estudo apresenta uma an\u00e1lisesobre como os atendimentos realizados por profissionais que atuam na \u00e1rea dareabilita\u00e7\u00e3o, nos tr\u00eas n\u00edveis de aten\u00e7\u00e3o \u00e0 sa\u00fade no Sistema \u00danico de Sa\u00fade (SUS),foram afetados durante a pandemia e quais foram as estrat\u00e9gias utilizadas para amanuten\u00e7\u00e3o dos servi\u00e7os prestados durante esse per\u00edodo.Fortalecendo a Inclus\u00e3o de Pessoas comDefici\u00eancia no Sistema de Sa\u00fade no Brasil: Explorando o Acesso das Pessoas comDefici\u00eancia aos Servi\u00e7os de Sa\u00fade nos Munic\u00edpios de Santos e S\u00e3o Paulo,que tem por objetivo avaliar o acesso das PcD ao SUS nessas localidades, a partirdos relatos das experi\u00eancias de gestores, profissionais de sa\u00fade e PcD.Este estudo \u00e9 parte da pesquisa Para responder \u00e0s quest\u00f5es deste estudo, optou-se pela pesquisa de abordagemqualitativa, com olhar para quest\u00f5es centradas na interpreta\u00e7\u00e3o e na explica\u00e7\u00e3o dadin\u00e2mica das rela\u00e7\u00f5es sociais Neste estudo, foi utilizado um roteiro semiestruturado no qual havia uma sess\u00e3oespec\u00edfica sobre a pandemia, com cinco quest\u00f5es: (a) como os servi\u00e7os na sua unidadeforam afetados pela pandemia?; quais atividades foram mantidas?; (b) como foramrealizados os atendimentos a dist\u00e2ncia?; (c) alguns pacientes/usu\u00e1rios foramconvocados para atendimentos presenciais?; (d) que estrat\u00e9gias foram adotadas comomedidas de precau\u00e7\u00e3o na unidade?; e (e) foi dado apoio para outra unidade? Caso sim,de que forma?As pesquisadoras entraram em contato com os respons\u00e1veis pelas unidades de sa\u00fade dosmunic\u00edpios de S\u00e3o Paulo e Santos (Estado de S\u00e3o Paulo), incluindo unidades b\u00e1sicasde sa\u00fade (UBS), n\u00facleos de apoio \u00e0 sa\u00fade da fam\u00edlia (NASF), CER e hospitais. Seisdeles demonstraram interesse em participar da pesquisa, sendo dois de cada n\u00edvel deaten\u00e7\u00e3o. A ger\u00eancia forneceu uma lista com o nome dos profissionais e seus contatospara que eles tamb\u00e9m fossem convidados a participar. Aqueles que se mostraramdispon\u00edveis foram entrevistados a dist\u00e2ncia, entre junho de 2020 e fevereiro de2021, sendo suas falas gravadas, transcritas e analisadas.A amostra foi composta por 17 participantes, dois m\u00e9dicos(as), dois terapeutasocupacionais, tr\u00eas fonoaudi\u00f3logos(as), tr\u00eas psic\u00f3logos(as), dois enfermeiros(as),um(a) assistente social, quatro fisioterapeutas, dos tr\u00eas n\u00edveis de aten\u00e7\u00e3o, de tr\u00easunidades de Santos e outras tr\u00eas de S\u00e3o Paulo .brainstorme criado um codebook com seis subcategorias, agrupadas em duasprincipais categorias, que nortearam toda a an\u00e1lise de dados  e da Secretaria Municipal de Sa\u00fade deS\u00e3o Paulo . Os participantesassinaram o Termo de Consentimento Livre e Esclarecido, que apresentava os objetivose detalhamentos da pesquisa, bem como assegurava a confidencialidade.Respeitando a codebook, em duasgrandes categorias identificadas - servi\u00e7os e atendimentos e estrat\u00e9gias -,resultando em seis subcategorias, que ser\u00e3o detalhadas a seguir.Em nossa amostra, a maioria dos profissionais que atuam na reabilita\u00e7\u00e3o s\u00e3o mulheres,com idade entre 29 e 65 anos, com ampla experi\u00eancia na \u00e1rea e est\u00e3o concentrados nosCERs. A an\u00e1lise foi desenvolvida a partir do Portaria n\u00ba 245/2020Eu j\u00e1 fuiafastando aqueles pacientes que era poss\u00edvel de voc\u00ea dar alta. Eu fui dandoalta. Aqueles pacientes que eram de grupos de risco e ofereciam menos,\u00e9 (...) menos problemas de uma tonifica\u00e7\u00e3o de les\u00e3o, euoptei por afastar\u201d. Sua fala expressa a forma como muitosprofissionais atuaram na reabilita\u00e7\u00e3o nesse cen\u00e1rio: mensuravam o risco de perdafuncional com a interrup\u00e7\u00e3o dos cuidados versus o risco de desenvolvimento dequadros mais graves de COVID-19, como no caso de pacientes fr\u00e1geis,imunossuprimidos e obesos.Com a pandemia de COVID-19, a rotina na sa\u00fade passou por mudan\u00e7as significativas.Os profissionais relataram que as orienta\u00e7\u00f5es partiram do Minist\u00e9rio da Sa\u00fade edas institui\u00e7\u00f5es. Embora a faceshield, \u00f3culos de prote\u00e7\u00e3o, jaleco permanente, avental descart\u00e1vel,roupa privativa etc. Ocorreram altera\u00e7\u00f5es na forma dos atendimentos, com acria\u00e7\u00e3o de protocolos baseados no momento singular da pandemia. Considerando queparte significativa das pessoas que requerem reabilita\u00e7\u00e3o s\u00e3o mais vulner\u00e1veis,pacientes fr\u00e1geis, idosos, imunossuprimidos e com diversas comorbidades ,,Com o aumento da demanda de pacientes sintom\u00e1ticos nos primeiros meses, asunidades de sa\u00fade promoveram treinamentos para uso dos equipamentos de prote\u00e7\u00e3oindividual (EPI), como touca, m\u00e1scara descart\u00e1vel ou Os profissionais relatam que adotaram cuidados espec\u00edficos para atender ospacientes, visando a menor exposi\u00e7\u00e3o poss\u00edvel ao risco. Uma das alternativas foideix\u00e1-los decidir se gostariam ou acreditavam ser necess\u00e1rio comparecer \u00e0unidade de sa\u00fade, sem impor o atendimento presencial. Quando poss\u00edvel, asdecis\u00f5es foram compartilhadas e tomadas em consenso, ap\u00f3s o di\u00e1logo entreprofissionais, pacientes e/ou familiares.Tivemos que reduzir muitoo n\u00famero de pacientes por hor\u00e1rio e a quantidade de pacientes por sala (deum a dois s\u00f3), dependendo do tamanho da sala\u201d. Uma enfermeiraacrescentou: \u201cNaquele hor\u00e1rio que voc\u00ea atendia tr\u00eas, passou a atenderum. Ent\u00e3o, querendo ou n\u00e3o, impactou. E o que acontece? O que fazia comtr\u00eas, agora faz com um de cada vez. Sem o [atendimento]grupal, voc\u00ea meio que breca a sua fila da demanda, ent\u00e3o come\u00e7a aacumular\u201d.Houve redu\u00e7\u00e3o do n\u00famero de pacientes por hor\u00e1rio e por sala, bem como dosprofissionais atuantes. Para evitar aglomera\u00e7\u00f5es, as atividades em grupo foramcanceladas. Caso os pacientes n\u00e3o tivessem m\u00e1scaras, alguns servi\u00e7os asforneciam. Avisos e cartazes com orienta\u00e7\u00f5es foram espalhados pelas unidades.Uma terapeuta ocupacional de um CER relatou: \u201cOs pacientes encaminhados para o CER pelo programa IntegraSUS Nos atendimentos \u00e0s crian\u00e7as, os profissionais relataram que convocavam osrespons\u00e1veis, e a crian\u00e7a comparecia apenas nos casos mais graves. O atendimentointerdisciplinar, composto por profissionais atuando simultaneamente, passou aser realizado por uma equipe reduzida. Al\u00e9m disso, restringiu-se a quantidade deacompanhantes. Anteriormente \u00e0 consulta presencial na unidade, eram realizadasliga\u00e7\u00f5es telef\u00f4nicas, com o intuito de fazer uma triagem quanto \u00e0 presen\u00e7a desintomas de COVID-19 em pacientes e/ou familiares.,Nas unidades, profissionais aferiam a temperatura e orientavam quanto \u00e0 higienedas m\u00e3os e ao uso de m\u00e1scaras. Os atendimentos ficaram mais espa\u00e7ados,individuais e com as medidas de higieniza\u00e7\u00e3o entre eles, tanto de material,ambiente, quanto dos EPIs, com descarte de parte deles. Para tanto, foramdesenvolvidos alguns manuais de orienta\u00e7\u00e3o e os profissionais de sa\u00fade adotaramas pr\u00e1ticas recomendadas para evitar o cont\u00e1gio Servi\u00e7os que continuaram a ser prestados, como vacina\u00e7\u00e3o e curativos, tinhamn\u00famero reduzido de pacientes e controle focado nas demandas. Os profissionaisrelataram ter utilizado muitas salas de isolamento, pois, em caso de suspeita, opaciente ficava isolado. Essa estrat\u00e9gia sobrecarregava a estrutura das unidadese foi considerada a maior mudan\u00e7a por ser incomum nos contextos avaliados. Odistanciamento e o isolamento social e suas consequ\u00eancias s\u00e3o pouco estudadospor ser medidas emergenciais, o que torna seus efeitos desconhecidos Decreto n\u00ba 64.881/2020Antes das consultas, os profissionais verificavam a possibilidade de o pacientecomparecer sozinho ou com apenas um acompanhante para assegurar o distanciamentona recep\u00e7\u00e3o. Nas salas de espera, havia orienta\u00e7\u00e3o para os pacientes se sentaremem cadeiras intercaladas, com o objetivo de evitar aproxima\u00e7\u00e3o e poss\u00edveiscont\u00e1gios, seguindo as orienta\u00e7\u00f5es estaduais sobre o distanciamento social,conforme o Segundo os entrevistados, na terapia ocupacional e na fisioterapia odistanciamento social foi mais dif\u00edcil, pois muitas vezes eles precisavamorientar o posicionamento ou manipular o paciente. Esse ponto tamb\u00e9m foirelatado pelos m\u00e9dicos, tendo em vista a necessidade do exame f\u00edsico.Os pacientes que precisavam receber seus aparelhos auditivos receberam liga\u00e7\u00f5esque verificavam a possibilidade de seu comparecimento ao CER e explicavam que aunidade estava com atendimentos reduzidos e agendados de acordo com adisponibilidade e o interesse do paciente. A maioria preferiu receberpresencialmente os aparelhos e foi orientada a ir, preferencialmente, comve\u00edculo pr\u00f3prio ou n\u00e3o coletivo, com apenas um acompanhante, principalmenteporque o p\u00fablico majorit\u00e1rio era de idosos. Embora essa orienta\u00e7\u00e3o expresse apreocupa\u00e7\u00e3o com o risco imposto pela exposi\u00e7\u00e3o ao v\u00edrus, ela desconsidera quemuitas pessoas, incluindo boa parte das PcD, que j\u00e1 estavam em vulnerabilidadesocial sofreram profundos agravos durante a pandemia Houve, ainda, situa\u00e7\u00f5es polarizadas nos servi\u00e7os de sa\u00fade. Um hospital em Santosfuncionou como hospital de campanha, com uma unidade de terapia intensiva (UTI)para pacientes com COVID-19. Um dos profissionais relatou que um CER em S\u00e3oPaulo foi dedicado exclusivamente aos pacientes de reabilita\u00e7\u00e3o e era chamado deunidade limpa, pois n\u00e3o atendia de forma alguma pacientes com sintomas deCOVID-19. As medidas sanit\u00e1rias preventivas estiveram entre os assuntospriorit\u00e1rios durante as entrevistas, sendo mencionadas por todos osparticipantes.,,tanto para as crian\u00e7asquanto para os adultos a gente tem evitado. Os atendimentos que aconteciam\u00e0s vezes de um paciente junto com outro, em dupla, ou \u00e0s vezes em grupos,todos esses tipos de atendimentos foram todos suspensos\u201d.A primeira medida implementada foi cancelar a maior parte dos atendimentos,principalmente da popula\u00e7\u00e3o considerada vulner\u00e1vel  Os atendimentos da aten\u00e7\u00e3o b\u00e1sica foram suspensos e hipertensos e diab\u00e9ticos j\u00e1n\u00e3o tinham mais suas consultas garantidas. As visitas domiciliares tamb\u00e9m foramsuspensas, afetando a vigil\u00e2ncia dos agentes comunit\u00e1rios de sa\u00fade (ACS) poralguns meses. Ainda assim, o fornecimento das medica\u00e7\u00f5es de uso cont\u00ednuo foimantido. Nos hospitais, foram interrompidos os atendimentos a pacientes comindica\u00e7\u00e3o de cirurgias eletivas.No in\u00edcio da pandemia, os servi\u00e7os de plant\u00e3o no CER para manuten\u00e7\u00e3o de aparelhosauditivos foram suspensos e os exames foram desmarcados e voltaram a serrealizados ap\u00f3s um tempo e com adapta\u00e7\u00f5es (agendamento e restri\u00e7\u00e3o na quantidadede pacientes) para manter o cuidado e controle das pessoas no acesso \u00e0s unidadesde reabilita\u00e7\u00e3o, seguindo as normas estabelecidas do distanciamento social parapopula\u00e7\u00f5es vulner\u00e1veis, incluindo as PcD mantivemos uma atividade, assim,mais da basal, daqueles que realmente, assim, aconteceria algum, enfim,algum preju\u00edzo na recupera\u00e7\u00e3o dele\u201d.Durante a pandemia, os profissionais relataram que as unidades mantiveram algunsatendimentos sem interrup\u00e7\u00e3o. Com v\u00e1rias adapta\u00e7\u00f5es, os atendimentos presenciaisforam mantidos para os pacientes que apresentavam risco de agravo em curtoper\u00edodo, como p\u00f3s-operat\u00f3rios ortop\u00e9dicos; com afec\u00e7\u00f5es neurol\u00f3gicas agudas,como quadros recentes de acidente vascular cerebral p\u00f3s-alta hospitalar;p\u00f3s-cir\u00fargicos, como sequelas de traumas; assim como quadros osteomioarticularesagudos com demandas de reabilita\u00e7\u00e3o. Os casos que apresentavam necessidades maisurgentes n\u00e3o deixaram de ser atendidos, visando minimizar as sequelas, comoexplicou uma fisioterapeuta do CER: \u201cmantivemos o atendimento do hospital normalmente (...)como parar de atender, principalmente maternidade? A gente manteve oservi\u00e7o de sa\u00fade\u201d. Uma fisioterapeuta do CER acrescentou:\u201ca gente monitorou com um pouco mais afinco os beb\u00eas de risco, agente tem grupos grandes de beb\u00eas de risco em rela\u00e7\u00e3o ao desenvolvimento,porque pra eles um, dois meses faria muita diferen\u00e7a\u201d.Foram mantidos atendimentos a rec\u00e9m-nascidos de risco, crian\u00e7as com at\u00e9 dois anose pr\u00e9-natal, vacina\u00e7\u00e3o, curativos, consultas de emerg\u00eancia, com quantidadedi\u00e1ria limitada, por\u00e9m o foco dos atendimentos era o cuidado a pacientes comsintomas de COVID-19. Uma fisioterapeuta de um hospital afirmou:\u201ca gente mandou para as m\u00e3es umas cartilhasde desenvolvimento motor pra tentar estimular em casa com algumasatividades, a gente foi enviando essas cartilhas e algumas instru\u00e7\u00f5es praelas tentarem fazer em casa e tirando as d\u00favidas sempre portelefone\u201d.Para a continuidade dos servi\u00e7os e atendimentos que precisaram ser mantidos porsua import\u00e2ncia e para a retomada daqueles que precisaram ser cancelados, asunidades implementaram estrat\u00e9gias que foram estabelecidas por normasgovernamentais ou definidas de acordo com as especificidades de cada local.Entre as estrat\u00e9gias citadas pelos profissionais est\u00e3o v\u00e1rias mudan\u00e7as na formade atendimento. As equipes formaram turmas de interven\u00e7\u00e3o, passando a trabalharem plant\u00f5es e a fazer monitoramento por telefone, e-mail ou alguma forma decontato para que os profissionais pudessem fornecer orienta\u00e7\u00f5es e estimular apr\u00e1tica de atividades, como no caso de fam\u00edlias com crian\u00e7a com autismo oudefici\u00eancia intelectual, colocando-se \u00e0 disposi\u00e7\u00e3o para tirar d\u00favidas. Comorelatou uma fisioterapeuta: \u201cQuando houve uma flexibiliza\u00e7\u00e3o, os profissionais convocaram os pacientes queapresentavam urg\u00eancia e contataram os pais para avaliar a evolu\u00e7\u00e3o das crian\u00e7asdurante o per\u00edodo de monitoramento a dist\u00e2ncia para elaborar interven\u00e7\u00f5es paraos casos com maior demanda de cuidado. Os atendimentos n\u00e3o eram semanais comoantes, e sim espa\u00e7ados, com um intervalo maior de tempo, permitindo que asfam\u00edlias expressassem sentimentos de seguran\u00e7a para comparecer ou n\u00e3o \u00e0sunidades. Os casos que n\u00e3o apresentavam urg\u00eancia permaneceram notelemonitoramento.No retorno gradual dos atendimentos, estes come\u00e7aram a ser realizadosindividualmente, sem previs\u00e3o para retorno dos grupos. No caso das visitasdomiciliares, a equipe n\u00e3o deixou de atuar, por\u00e9m n\u00e3o entrava nas casas. Nasunidades que permitiam o acesso sem encaminhamento e ofereciam plant\u00e3o paramanuten\u00e7\u00e3o de aparelhos auditivos, os servi\u00e7os passaram a ser agendados eplanejados para evitar aglomera\u00e7\u00e3o. Uma profissional que atua no CER de Santosreferiu que, antes da pandemia, n\u00e3o havia fila de espera por atendimento e,durante a pandemia, a fila voltou a crescer.os atendimentos, elesforam passados pra teleatendimento, pra monitoramento via telefone. Depoisde um tempo, n\u00e9, do in\u00edcio da pandemia chegaram algumas webcams, ent\u00e3o,alguns profissionais da unidade come\u00e7aram a fazer atendimentos porv\u00eddeo\u201d.No in\u00edcio da pandemia, o telemonitoramento enfrentava dificuldades dedisponibilidade de recursos e do registro do faturamento do atendimento peloMinist\u00e9rio da Sa\u00fade. Embora n\u00e3o houvesse um protocolo estruturado comorienta\u00e7\u00f5es e equipamentos suficientes para a pr\u00e1tica do teleatendimento, osprofissionais passaram a contatar cada fam\u00edlia e verificar como cada umaconseguia se adaptar. Uma psic\u00f3loga relatou: \u201conline, por e-mail e/ou por telefone. Em algumasunidades, desde o primeiro m\u00eas da pandemia, foram realizados monitoramentos viatelefone, semanalmente ou mensalmente, de todos os pacientes e, se houvessenecessidade, havia convoca\u00e7\u00e3o para um atendimento presencial. As fam\u00edlias sesentiram acolhidas, em especial os pais de crian\u00e7as em reabilita\u00e7\u00e3o, porpermanecerem em contato com os profissionais.O teleatendimento foi o principal meio de comunica\u00e7\u00e3o para pacientes dareabilita\u00e7\u00e3o infantil. Os profissionais relatam que passavam orienta\u00e7\u00f5es eatividades o atendimentoa dist\u00e2ncia foi feito, mais limitado e era dif\u00edcil, n\u00e3o era uma consultaagendada, n\u00e3o foi uma coisa t\u00e3o bem estruturada assim. A gente enfrentaalguns tipos de desafios na telemedicina por conta das pessoas que est\u00e3o dooutro lado da linha, que elas n\u00e3o conhecem o servi\u00e7o, n\u00e3o est\u00e3o estruturadasa utilizar\u201d.Quando os atendimentos foram liberados para o retorno presencial, o(a) assistentesocial ligava para os pacientes para verificar os motivos de sua aus\u00eancia nasconsultas. Durante o per\u00edodo da pandemia, os pacientes n\u00e3o foram desligados porfalta, os profissionais buscavam compreender a situa\u00e7\u00e3o de cada um antes detomar qualquer decis\u00e3o. Entre os desafios mais comuns citados, na tentativa decontato com os pacientes, estava a limita\u00e7\u00e3o dos pacientes em rela\u00e7\u00e3o \u00e0s TDIC ea desatualiza\u00e7\u00e3o dos n\u00fameros de telefone. Sobre as dificuldades enfrentadas noteleatendimento, um m\u00e9dico compartilhou sua experi\u00eancia: \u201cO telemonitoramento foi eficiente para alguns grupos espec\u00edficos, como osacamados e os de menor complexidade - hipertensos, diab\u00e9ticos e os inscritos noBolsa Fam\u00edlia -, pois os profissionais conseguiam monitorar o acesso \u00e0 medica\u00e7\u00e3oe o estado de sa\u00fade do paciente e dos familiares/cuidadores. Foram criadosgrupos no aplicativo WhatsApp para transmitir orienta\u00e7\u00f5es e v\u00eddeos educativossobre a pandemia e sobre medidas educativas para demandas frequentes decuidado.Em Santos, uma das unidades funcionou como hospital de campanha, como j\u00e1mencionado. Profissionais da enfermagem foram deslocados para fazer testes deCOVID-19 em unidades abertas e para atender os casos de contamina\u00e7\u00e3o. Algumasunidades receberam doa\u00e7\u00f5es de m\u00e1scaras e \u00e1lcool em gel, o que contribuiu para aredu\u00e7\u00e3o da contamina\u00e7\u00e3o e seguran\u00e7a dos pacientes. O CER de Santos passava porreforma quando a pandemia se instalou, resultando na transfer\u00eancia deprofissionais e pacientes para outras unidades.em rela\u00e7\u00e3o ao trabalho de psic\u00f3logo, a gente teve uma mudan\u00e7atamb\u00e9m nesses meses de que foi feito o suporte ao colaborador. Suporteemocional. Ent\u00e3o eu fui deslocado tamb\u00e9m para uma outra unidade, al\u00e9m da queeu j\u00e1 atendo, pra poder fazer o atendimento de acolhimento e um trabalhoterap\u00eautico com os colaboradores\u201d.Uma UBS em S\u00e3o Paulo instaurou uma equipe m\u00f3vel multidisciplinar para apoiar osprofissionais da linha de frente. Um dia em cada unidade, eram promovidosexerc\u00edcios de alongamento, t\u00e9cnicas de relaxamento, momentos de conversas. Al\u00e9mdisso, a equipe ajudou na confec\u00e7\u00e3o de m\u00e1scaras para doa\u00e7\u00e3o e na organiza\u00e7\u00e3o defilas. Sobre sua experi\u00eancia durante o per\u00edodo da pandemia, um psic\u00f3logorelatou: \u201catendimentos cancelados\u201d, que foi destaque em\u201cmedidas sanit\u00e1rias preventivas\u201d e \u201cservi\u00e7os eatendimentos interrompidos\u201d. O controle do fluxo nas unidadesapareceu como \u201cmedidas sanit\u00e1rias preventivas\u201d e\u201cestrat\u00e9gias de continuidade do atendimento\u201d.Alguns aspectos foram abordados em mais de uma das subcategorias, como\u201cAs medidas sanit\u00e1rias preventivas e as estrat\u00e9gias de continuidade do atendimentoforam essenciais para o cuidado com os pacientes para que houvesse menorexposi\u00e7\u00e3o ao cont\u00e1gio e redu\u00e7\u00e3o nos preju\u00edzos \u00e0 sa\u00fade da popula\u00e7\u00e3o. O SUS esteveno centro da pandemia de COVID-19, com seus profissionais atuando nas frentes depreven\u00e7\u00e3o, diagn\u00f3stico, tratamento e reabilita\u00e7\u00e3o N\u00e3o foi exclusividade do Brasil cancelar servi\u00e7os de sa\u00fade e manter apenas osatendimentos essenciais. Pa\u00edses da Europa suspenderam interna\u00e7\u00f5es parareabilita\u00e7\u00e3o, autorizaram alta precoce e diminu\u00edram as atividades assistenciais.Na It\u00e1lia, B\u00e9lgica e Reino Unido, o cancelamento das atividades ambulatoriaisatingiu 87%, resultando em milh\u00f5es de pacientes, incluindo PcD, prejudicados.Mais gravemente, as PcD corriam risco de ser dispensadas dos cuidadospriorit\u00e1rios em meio a uma pandemia, em uma situa\u00e7\u00e3o contingencial, explicitandoa inequidade de acesso A falta de coordena\u00e7\u00e3o de cuidados dos servi\u00e7os territorializados e o di\u00e1logolimitado entre os servi\u00e7os especializados e os de aten\u00e7\u00e3o b\u00e1sica no per\u00edodo dapandemia evidenciaram um vazio assistencial no que tange aos cuidados cr\u00f4nicosdas PcD, uma popula\u00e7\u00e3o negligenciada, mesmo antes da pandemia ,O teleatendimento se destacou por ser eficaz e seguro para a comunica\u00e7\u00e3o entreprofissionais e pacientes, podendo ainda ser combinado com a modalidadepresencial. A pandemia imp\u00f4s o desafio da implementa\u00e7\u00e3o da telemedicina noatendimento aos pacientes que, no caso das PcD, vivenciam a invisibiliza\u00e7\u00e3o, oconfinamento ao longo do tempo e uma rotina de necessidades de cuidado em sa\u00fade,Durante a pandemia, a sa\u00fade f\u00edsica e mental dos profissionais de sa\u00fade foiprejudicada devido a sobrecarga de trabalho, riscos de infec\u00e7\u00e3o, redistribui\u00e7\u00e3oconstante e inesperada para novas fun\u00e7\u00f5es, restri\u00e7\u00f5es generalizadas, avalia\u00e7\u00f5esfrequentes de desempenho e preocupa\u00e7\u00f5es com seu bem-estar e de seus familiares.Com isso, epis\u00f3dios de esgotamento, ansiedade e depress\u00e3o entre os profissionaisde sa\u00fade nesse per\u00edodo aumentaram significativamente n\u00f3s, funcion\u00e1rios da sa\u00fade, fomos impedidosinclusive de tirar f\u00e9rias, licen\u00e7as, enfim, a sa\u00fade continuoutrabalhando\u201d. Os profissionais lidaram com uma situa\u00e7\u00e3odesconhecida e aprenderam com a pr\u00e1tica. \u00c0 medida que protocolos e estrat\u00e9giaseram elaborados, eles atuavam de forma intensa e cont\u00ednua. Os profissionaisdescreveram o per\u00edodo como emocionalmente desgastante, relatando medo eang\u00fastia, e destacaram a import\u00e2ncia do apoio da equipe. Uma fonoaudi\u00f3logacompartilhou: \u201cno come\u00e7o foi um pouco assustador, deu umadesestabilizada\u201d. Alguns profissionais faziam parte de gruposvulner\u00e1veis e passaram a trabalhar de forma remota, j\u00e1 outros precisaram serafastados ao apresentarem sintomas de COVID-19. O medo da infec\u00e7\u00e3o, a escassezde EPIs e o excesso de trabalho impactaram de forma negativa a sa\u00fade f\u00edsica emental dos profissionais de sa\u00fade, especialmente daqueles que atuaram na linhade frente no combate \u00e0 pandemia de COVID-19 Os profissionais relatam que n\u00e3o existiu interrup\u00e7\u00e3o nos servi\u00e7os de sa\u00fade(apenas adequa\u00e7\u00e3o e diversifica\u00e7\u00e3o das atividades) e, como o n\u00famero decontaminados aumentava a cada dia, houve a intensifica\u00e7\u00e3o do trabalho e anecessidade de adapta\u00e7\u00f5es de forma din\u00e2mica. Sobre o trabalho intenso, umafonoaudi\u00f3loga relatou: \u201cConven\u00e7\u00e3o sobre os Direitos das Pessoas comDefici\u00eanciaA Organiza\u00e7\u00e3o Mundial da Sa\u00fade (OMS) apresentou recomenda\u00e7\u00f5es espec\u00edficas depreven\u00e7\u00e3o, controle, assist\u00eancia e prote\u00e7\u00e3o social para as PcD que tiveram suavulnerabilidade ampliada durante a pandemia. Mesmo em pa\u00edses que adotaram aNossos resultados contribuem para a compreens\u00e3o de como ocorreram os atendimentos dereabilita\u00e7\u00e3o para PcD em todos os n\u00edveis de cuidado durante a pandemia de COVID-19.Uma das primeiras a\u00e7\u00f5es foi suspender a maior parte dos atendimentos, principalmentepara a popula\u00e7\u00e3o considerada mais vulner\u00e1vel. Com v\u00e1rias adapta\u00e7\u00f5es, algunsatendimentos presenciais foram mantidos, apenas para os pacientes que apresentavamrisco de agravo em curto prazo, visando minimizar as perdas funcionais e sequelas.Algumas das medidas sanit\u00e1rias preventivas inclu\u00edram uso de EPIs, distanciamentosocial, triagem de sinais e sintomas e o intervalo mais longo entre os atendimentos.Para n\u00e3o provocar aglomera\u00e7\u00e3o, as atividades grupais foram canceladas. Outras a\u00e7\u00f5esforam o aumento de monitoramento por telefone e o uso das TDIC. Para osprofissionais de sa\u00fade, o per\u00edodo da pandemia foi f\u00edsica e emocionalmentedesgastante, com relatos de sentimentos de medo e ang\u00fastia. Com rela\u00e7\u00e3o \u00e0articula\u00e7\u00e3o da rede, ocorreu o deslocamento de profissionais para outras unidades,apoiando a realiza\u00e7\u00e3o de testes de COVID-19 e o cuidado \u00e0s pessoas afetadas pelov\u00edrus.Existem pontos fortes e limita\u00e7\u00f5es neste estudo, que devem ser considerados nainterpreta\u00e7\u00e3o dos achados. A amostra por conveni\u00eancia n\u00e3o reflete, em suatotalidade, a classe dos profissionais de reabilita\u00e7\u00e3o. O question\u00e1rio n\u00e3o eraespec\u00edfico sobre a COVID-19, mas sim uma sess\u00e3o de um question\u00e1rio mais amplo, oque dificultou o aprofundamento em alguns assuntos. As entrevistas foramrealizadas durante um per\u00edodo em que as equipes estavam sobrecarregadas devido \u00e0pandemia. Por isso algumas entrevistas foram mais curtas do que o esperado, emraz\u00e3o da falta de disponibilidade. Embora medidas tenham sido implementadas natentativa de reduzir o vi\u00e9s, como sugerir durante o agendamento que asentrevistas fossem feitas fora do ambiente de trabalho, algumas ocorreramdurante os intervalos dos profissionais, enquanto estavam em seus locais detrabalho.Para estudos futuros, sugerimos que a singularidade da viv\u00eancia da defici\u00eanciadurante o per\u00edodo de COVID-19 seja investigada com mais profundidade, juntamente\u00e0s PcD, bem como as repercuss\u00f5es na assist\u00eancia \u00e0 sa\u00fade, com o objetivo defomentar estrat\u00e9gias necess\u00e1rias de aten\u00e7\u00e3o \u00e0 sa\u00fade, potencializando, assim, ocuidado continuado e integrado."}
+{"text": "To verify the effectiveness, efficiency, and satisfaction in the usability test of the tinnitus assessment application.This is a descriptive usability test study that assessed the satisfaction, effectiveness, and efficiency of the application. The test was carried out virtually via Google Forms. First, the participants received instructions on how to access and use Avazum, through texts and illustrative images. Afterward, the users used the application, observing its functions and usability. Next, the participants answered the usability questionnaire. Statistical analysis was performed using the Statistical Package for the Social Sciences, version 21.0, to perform descriptive analysis such as frequency, percentages of data in the System Usability Questionnaire (SUS), and analysis in the Net Promoter Score (NPS).Thus, the overall mean SUS score was consistent with satisfactory usability, which implies that the application does not present serious usability problems. Also, the overall NPS percentage indicated very good user satisfaction, with a good percentage of promoting users. As far as effectiveness is concerned, it was found that Avazum reached its goals, besides being efficient, as it uses clear language and is comfortably used.Avazum obtained very good satisfaction from users, in addition to achieving its goals. It proved to be effective, has clear language, and is comfortably used, adducing efficiency in the multidisciplinary evaluation of tinnitus. Technology became a great ally in the field of health, with advances in procedures, techniques, healing, innovation in health education, healthcare, and so forth. The quick development and generalized use of mobile technology have been expanding opportunities for health activities, ushering in a new era - that of mobile health .The scientific revolution has brought to society a wider look at how to deal with the world, providing advances in all areas. Technology is a result of modern science, combining techniques and methods to develop it and make it as powerful and useful as it is today.Technological innovations are becoming one of the main allies in all areas of speech-language-hearing therapy, including health processes, products, and services. Currently, various applications and pieces of software are being developed to innovate therapy, assessment, health education, and so on. Concerning tinnitus, various applications are currently available to help its treatment, such as sound therapy and cognitive behavioral therapy. Applications with greater availability on platforms are those focused on therapy, but few of them have functions aimed at multidisciplinary assessments, with differential referral functions. Moreover, most applications did not undergo usability testsAvazum is an application developed to help in the initial assessment of tinnitus, helping screen and refer users to the necessary professionals, providing detailed assessment according to the need in each case, and hints and instructions on tinnitus care. The application has three main interfaces, namely: the registry screen, the assessment screens, and the screen with results, referrals, hints, and guidance. It was developed by an interdisciplinary team, involving speech-language-hearing therapists, programmers, and designers, members of two research groups on health technology innovation, and a study and research group on tinnitus of the Federal University of Paraiba. The application has undergone all development phases, and its usability test is conducted in this study.A usability test is a method to verify interface functioning in a digital platform. It is used in websites, applications, and other tools, leading real users to do certain tasks. After its development, its usability and main difficulties are analyzed. Usability tests record the best results for future updates, minimizing the costs of technical support to users, increasing sales, and predicting new products with fewer usability problems..The usability test is an indispensable requirement to develop technological innovation products, as it analyzes the necessary information to detect occasional usability problems and, consequently, furnishes tools to deliver a quality product to usersEvidence-based health practices are essential to provide excellent services with proven results. When developing innovative products in this area, it is essential to understand the needs of users to meet the desired experience with objectivity and quality in the target functions.Hence, this study aimed to verify the effectiveness, efficiency, and satisfaction of the usability test of the tinnitus assessment application.The application initially has a user registry screen with an e-mail and password for their login. After registering, users are directed to interactive assessment screens, with all aspects related to the symptoms - e.g., how it began, type and sound characterization and location - and audio-visual resources. Later, they are directed to sessions on the habits that worsen or improve tinnitus perception, measuring discomfort with a visual analog scale. After finishing all assessment stages, users have access to the results, indicating possible symptoms and associated causes. It also indicates professionals according to each case\u2019s specificities, based on referral descriptors, relating the symptoms with specific professionals in each area, including speech-language-hearing therapists, otorhinolaryngologists, psychologists, physical therapists, and nutritionists. In the end, it provides hints and guidance on tinnitus care related to physical and mental health. The application\u2019s registry number in INPI is BR512020001425-9. Further details on the application will be provided in another study entitled \u201cDeveloping Avazum: An interactive tinnitus assessment application\u201d, yet to be published.This is a descriptive study of the usability test of a tinnitus assessment application (Avazum).The instruments used in the usability research addressed the application\u2019s satisfaction, efficiency, and effectiveness (Annex A). Satisfaction was assessed with an empirical method, using the System Usability Questionnaire (SUS) and Net Promoter Score (NPS), while its efficiency and effectiveness were assessed with an analytical method, considering heuristic principles for the application.EffectivenessThe assessment aimed at collecting information on meeting the users\u2019 objectives and the product\u2019s capacity to do that for which it was designed. Hence, it approaches the assessment, guidance, and referral of tinnitus patients. Efficiency and effectiveness responses are observed based on the presence or absence of problems to be solved. If the user perceives a problem, they indicate its severity on an importance scale: (0) not important, (1) layout/appearance problems, (2) simple problems, (3) severe problems, and (4) catastrophic problems. After responding on the scale, they can suggest solutions.EfficiencyEfficiency analysis aims at the application browsability, considering the amount of effort required from users to reach the product\u2019s goals. Hence, its approaches the visibility of elements in the application, language use, and information to do the tasks. The following questionnaire items were assessed: \u201cAre the instructions enough to do the application\u2019s tasks?\u201d; \u201cIs the usage information clear and does it help pass to other application phases?\u201d; \u201cDid you feel any discomfort in using the application?\u201d. Users had three answer options for each item: \u201cyes\u201d; \u201cpartly\u201d, and \u201cno\u201d. After the collection, data were descriptively analyzed.Satisfaction.Methods that measure user satisfaction with questionnaires help widely assess various types of products and systems. SUS, developed by John Brooke in 1996, is a much-known and used usability numerical scale that assesses the effectiveness, efficiency, and satisfaction of software, products, services, websites, and other types of interfaces. SUS is widely used for balancing scientific accuracy and objectivity in 10 questions. Agreement levels in the questionnaire are recorded with a 5-point Likert scale with the following 10 agreement/disagreement indications: I strongly/totally disagree (1), I disagree (2), neutral (3) I agree (4), and I strongly or totally agree (5).Data collected with SUS analyzed the responses to the 10 questions in two sets of independent data addressing two factors - Usability (eight questions) and Apprehensibility (2 questions).Odd alternatives  in the questionnaires are positively written about the product, while even ones  are negative. Some terms can be adapted to the context, users, and product being assessed. After indicating each question\u2019s agreement level, the final SUS score is obtained as follows: in odd items, 1 is subtracted from the user\u2019s score, and in odd ones, 5 is subtracted from their response. Then, the values of the 10 questions are added and multiplied by 2.5, reaching a score that can range from 0 to 100. The assessment considers the whole questionnaire, rather than individual items, representing a compound measure of the overall system capacity.The author of the method does not indicate precisely what the scores represent in terms of system usability quality. However, studies conducted in different applications indicate that the mean SUS score is around 70 points and that results below this value represent serious usability problems. Other studies conducted with SUS consider this mean as a satisfactory usability indexNPS assessment is based on the following question: \u201cHow much would you recommend this application to someone?\u201d. The answer to this question is indicated on a scale ranging from 0 to 10. Response-based calculations and analyses are divided into three categories: Promotors, for respondents who score 9 or 10, are satisfied and encourage people to use the application; Neutral, for those who score 7 or 8 and do not help or hinder making the application known; and Detractors, for those who score 0 to 6 as a sign of their dissatisfaction. The overall satisfaction is calculated by subtracting the percentage of promoters from the percentage of detractors. Excellent NPS results are those from 75 to 100%; very good, from 50 to 74%; average, from 0 to 49; poor from -100 to -1.The study population comprised tinnitus patients attended at the Tinnitus Outreach Project of the Speech-Language-Hearing Sciences program at the Federal University of Paraiba. The sample size was calculated with G*Power software, resulting in 47 patients to make up the virtual project guidance group, although the final sample had 48 patients - 62.5% (30) were women, and 37.5% (18) were men. Their ages ranged from 25 to 65 years, with a mean age of 43.5 years and a standard deviation of 11.8. Regarding educational attainment, 8.33% (4) never went to school; 20.8% (10) and not finished elementary school; 20.8% (10) had not finished high school; 22.91% (11) were high school graduates, and 25% (12) had a bachelor\u2019s degree.As for participation criteria, the study included all tinnitus patients who attended the Tinnitus Outreach Project of the Speech-Language-Hearing Sciences program at the Federal University of Paraiba who had access to their own or a relative\u2019s mobile phone with an Android operating system.The research was conducted online between October and December 2021. The usability test had three main stages: first, users used the product being tested; then, they answered the usability questionnaire on their satisfaction, effectiveness, and efficiency regarding the product; lastly, the researchers analyzed the results.Thus, the research began by inviting volunteer participants, to whom the procedures were explained. Those who agreed to participate in the research signed an informed consent form, which was sent online via Google Forms. After this stage, participants received instructions to access and use Avazum. Then, they used the application and its functions  and received necessary referrals, hints, and guidance on tinnitus care. Lastly, participants answered the usability questionnaire to collect data. The stages are listed separately below.Inviting volunteer participants.Signing the informed consent form.Sending instructions to access and use the application, with explanatory images and texts.Users used the Avazum application.Participants answered the usability questionnaire in Google Forms.Researchers analyzed the results.Data were tabulated in 2019 Microsoft Excel (16.0) for quantitative analysis. The Statistical Package for the Social Sciences (SPSS), version 21.0.4.7, was used for the descriptive analysis, addressing frequency, percentages, and SUS score analysis.This project was submitted to and approved by the Research Ethics Committee of the Department of Health Sciences of the Federal University of Paraiba, under evaluation report number 4.297.792. Informed consent was obtained from all participants. All procedures complied with the guidelines and parameters of the agencies that regulate health ethics norms.Avazum was analyzed regarding its efficiency and effectiveness and participating user satisfaction. They analyzed aspects such as visibility of elements in the application, language use, information to do the tasks, assessments, guidance, and referrals of tinnitus patients. The results are presented below.This item analyzed 10 SUS questions and the NPS assessment, in which users scored their level of recommendation of the application, ranging from 0 to 10. The overall SUS score was 78.28, considered a good score that demonstrates the absence of severe usability problems. Most users reported they would like to use the application often and could easily use it, denying the need for support to use the Avazum functions well - despite the presence of older participants and people with low educational attainment in the sample. These results can be seen in detail in Concerning the key satisfaction points, participants were satisfied and encouraged others to use the application. Thus, the NPS scale and SUS score verified good user satisfaction regarding Avazum. The overall NPS percentage was 58%, indicating that NPS was very good - i.e., there was a higher satisfaction rate. Values are shown in detail in Users understood well the tasks, instructions, and language in the application. They followed all tasks and described their tinnitus using the application. The hints and guidance provided in Avazum proved to be relevant/interesting to their realities. As for referrals to professionals. They were disappointed with the lack of clarity. Therefore, referrals must be clearer, and the list of professionals must be more complete. The list of professionals was updated based on a master\u2019s research on the \u201cprofile of professionals specialized in treating tinnitus patients in Brazil\u201d and will be added to the application in its next update. Concerning application efficiency, the assessments were sufficient for the key application goals, and the information on the screens was clear - thus, browsing Avazum was comfortable. Thus, after analyzing the SUS score, its mean proved to be satisfactory, which indicates that the application has no severe usability problems and a good percentage of promoting users, who scored 9 and 10 in NPS satisfaction. The overall NPS percentage showed that the user satisfaction is very good. Moreover, the data descriptive analysis showed that Avazum effectively reached its goals, assessing tinnitus, making referrals, and providing hints and guidance to users. It is also efficient, as its language is clear, and its use is comfortable. However, the effectiveness item that assessed referrals was flawed regarding its ease of use and instruction on access.. The main focus of the usability test is the users\u2019 needs, aiming to provide them with an excellent experience. Thus, the essential focus of usability evidently is the ease of use when interacting with the product.Usability is an important aspect of the quality of products and systems. It is a concept widely used in product development, aiming to observe people using the product, based on the interaction between the human, the task, and the product. A growing number of companies are recognizing not only the importance of usability in the design process but also its potential to ensure advantages in the market. Given such importance, the topic has been addressed in various studies by researchers and specialists. Methods that measure user satisfaction with questionnaires contribute to a comprehensive assessment of various types of products and systems.Usability tests count on tools and questionnaires to verify the effectiveness, efficiency, and satisfaction with the tested product. According to ISO 9241:11 (1998), effectiveness is normally assessed by the number of stages the user successfully completed, efficiency focuses on the time users append to reach the goals, and satisfaction is assessed with protocols. User satisfaction is directly related to the levels of comfort and enjoyment in using the product.Usability is a key tool to develop health technology innovation tools. Hence, this stage must be carefully carried out, focusing on real users. A study aimed to verify the methodology of usability tests regarding health applications and showed that 75.9% of them were tested in real users, such as patients and professionals, whereas only 6% were tested in specialized professionals. It also demonstrated that most tests used quantitative and qualitative questionnairesSUS score ranges from 0 to 100, although the questionnaire validation study does not provide details of what each score represents regarding a product\u2019s usability. However, the study by Zorzal (2009) demonstrates that adequate scores range from 70 to 100, below which, the product may have serious usability problems. Hence, mean scores above 70 are satisfactory, showing that Avazum did not have major usability problems..Satisfaction was also analyzed based on NPS, which is widely used to verify clients\u2019 satisfaction with products, services, attention, and so on. When the percentage of promoting clients/users is greater than that of detractors, the product is more likely to be indicated by people who use it. As for neutrals or passive clients, they are not dissatisfied but are unlikely to indicate it to other people. A total NPS score above 50% shows a very good satisfaction with the product, whereas, below 49%, the satisfaction was not good.To obtain high usability, an application must have adequate effectiveness and efficiency levels. Characteristics such as good menu accessibility, common functions in the screens, fonts and sizes that favor reading even among users with difficulties, and simple tasks that make the next step clear are important to efficiency assessment. Hence, an application with clear language, enough instructions to do tasks, and clear information to pass to other screens is efficient regarding its functions.Effective products and services can reach their goals and meet users\u2019 real needs. The activities in the final version of mobile applications must be functional, considering whether it has enough functions. Usability tests must analyze their efficiency considering each item and the functions that did not meet the users\u2019 needs.A study assessed 66 applications available to people with diabetes, using a 5-point Likert scale. The results showed mean answers between 3 and 4, indicating that applications had moderate to good usability, especially the ones that were easy to use and had clear languageAs a limitation of the study, it is important to mention that Avazum is not yet available in the iOS system. Hence, the usability test could not include patients who use this mobile system. The next steps will include the application for the iOS system, translating and adapting it to other languages, and conducting further tests encompassing the updates.Users understood all tasks and described their tinnitus using the application, thus demonstrating that Avazum was effective regarding its goals. Also, the application functions are well integrated, clearly arranged, and comfortable to use, proving to efficiently do its functions. Moreover, Avazum users presented a good satisfaction index. It is a promising application to help assess tinnitus, refer users, and promote health through its instructions. . No campo da sa\u00fade, a tecnologia tornou-se uma grande aliada com avan\u00e7os em procedimentos, em t\u00e9cnicas, curas, inova\u00e7\u00e3o em educa\u00e7\u00e3o em sa\u00fade, atendimentos e dentre outros. O r\u00e1pido desenvolvimento e uso generalizado de tecnologias m\u00f3veis v\u00eam expandindo novas oportunidades de atividades em sa\u00fade, uma nova era se faz presente, a mobile health , mais conhecida como sa\u00fade m\u00f3vel.A revolu\u00e7\u00e3o cient\u00edfica vem trazendo \u00e0 sociedade um olhar mais amplo ao lidar com o mundo, proporcionando avan\u00e7os em todas as \u00e1reas, considerando que a tecnologia \u00e9 um fruto da ci\u00eancia moderna que uniu t\u00e9cnicas e m\u00e9todos para desenvolv\u00ea-la e fazer dela a pot\u00eancia e instrumento que \u00e9 hojesoftwares est\u00e3o sendo desenvolvidos para inova\u00e7\u00f5es na execu\u00e7\u00e3o de terapias, avalia\u00e7\u00e3o, educa\u00e7\u00e3o em sa\u00fade e dentre outros. No que se refere ao zumbido, hoje est\u00e3o dispon\u00edveis uma diversidade de aplicativos que auxiliam no tratamento, como terapia sonora e terapia cognitivo comportamental. Os aplicativos com maiores leques de disponibilidades nas plataformas s\u00e3o os com \u00eanfase em terapia, poucos tem fun\u00e7\u00f5es voltadas para avalia\u00e7\u00e3o multidisciplinar que cont\u00e9m fun\u00e7\u00f5es de encaminhamento diferencial. \u00c9 importante mencionar que a maior parte dos aplicativos n\u00e3o realizou o teste de usabilidade.Na Fonoaudiologia, a inova\u00e7\u00e3o tecnol\u00f3gica est\u00e1 se tornando umas das principais aliadas em todas suas \u00e1reas de atua\u00e7\u00e3o, seja em processos, produtos ou servi\u00e7os em sa\u00fade. Atualmente, v\u00e1rios aplicativos e Nesse sentido, O Avazum \u00e9 um aplicativo desenvolvido para auxiliar na avalia\u00e7\u00e3o inicial do zumbido, ajudando na triagem e encaminhamento dos usu\u00e1rios para os profissionais necess\u00e1rios, realizando uma avalia\u00e7\u00e3o detalhada, segundo a necessidade de cada caso, al\u00e9m de disponibilizar dicas e orienta\u00e7\u00f5es sobre os cuidados com o zumbido. O aplicativo apresenta tr\u00eas interfaces principais, a tela de cadastro, as telas para avalia\u00e7\u00e3o propriamente dita e as telas de resultados, encaminhamentos, dicas e orienta\u00e7\u00f5es. Foi desenvolvido por uma equipe interdisciplinar entre Fonoaudi\u00f3logos, Programador e Designers, membros de dois grupos de pesquisa em inova\u00e7\u00e3o tecnol\u00f3gica em sa\u00fade e grupo de estudo e pesquisa em zumbido da Universidade Federal da Para\u00edba. O aplicativo j\u00e1 passou por todas as fases de desenvolvimento, sendo realizado o teste de usabilidade no presente estudo.Teste de usabilidade \u00e9 um m\u00e9todo de verifica\u00e7\u00e3o de funcionalidades da interface de uma plataforma digital. \u00c9 empregado em websites, aplica\u00e7\u00f5es e outras ferramentas, levando usu\u00e1rios reais \u00e0 execu\u00e7\u00e3o de determinadas tarefas. Ap\u00f3s seu desenvolvimento, \u00e9 realizada uma an\u00e1lise de usabilidade e das principais dificuldades. Por meio de testes de usabilidade, pode-se registrar os melhores resultados obtidos para futuras atualiza\u00e7\u00f5es levando \u00e0 minimiza\u00e7\u00e3o do custo do servi\u00e7o de suporte aos usu\u00e1rios, crescimento de vendas e prever o lan\u00e7amento de produtos com menos problemas de usabilidade..O teste de usabilidade \u00e9 um quesito imprescind\u00edvel no desenvolvimento de um produto com inova\u00e7\u00e3o tecnol\u00f3gica, pois analisa as informa\u00e7\u00f5es necess\u00e1rias para detectar eventuais problemas de usabilidade e consequentemente, fornece ferramentas para entregar um produto com qualidade para os usu\u00e1riosNa \u00e1rea da sa\u00fade, a pr\u00e1tica baseada em evid\u00eancia \u00e9 essencial para oferecer um servi\u00e7o de excel\u00eancia com resultados comprovados. Ao desenvolver um produto de inova\u00e7\u00e3o para essa \u00e1rea, \u00e9 imprescind\u00edvel buscar a compreens\u00e3o das necessidades do usu\u00e1rio para que se possa atender com objetividade e qualidade a experi\u00eancia desejada na realiza\u00e7\u00e3o das fun\u00e7\u00f5es alvo.Dessa forma, o objetivo deste estudo \u00e9 verificar a efetividade, efici\u00eancia e satisfa\u00e7\u00e3o no teste de usabilidade para o aplicativo de avalia\u00e7\u00e3o do zumbido.login. Ap\u00f3s o cadastro, os usu\u00e1rios ser\u00e3o direcionados para as telas de avalia\u00e7\u00e3o, com todos os aspectos relacionados ao sintoma, como ocorreu seu in\u00edcio, caracteriza\u00e7\u00e3o do tipo de som e localiza\u00e7\u00e3o de forma interativa, com recursos \u00e1udios visuais. Posteriormente, ter\u00e3o as sess\u00f5es sobre os h\u00e1bitos que pioram ou melhoram a percep\u00e7\u00e3o do zumbido, e mensura\u00e7\u00e3o do inc\u00f4modo com o aux\u00edlio da Escala Visual Anal\u00f3gica. Ap\u00f3s todas as etapas de avalia\u00e7\u00e3o conclu\u00eddas, os usu\u00e1rios ter\u00e3o acesso ao resultado, indicando os poss\u00edveis sintomas e causas associadas. Al\u00e9m, da indica\u00e7\u00e3o para os profissionais de acordo com as especificidades de cada caso avaliado, baseados nos descritores de encaminhamento, relacionando os sintomas descritos com os profissionais espec\u00edficos de cada \u00e1rea. Os profissionais que est\u00e3o inseridos s\u00e3o: Fonoaudi\u00f3logo, Otorrinolaringologista, Psic\u00f3logo, Fisioterapeuta e Nutricionista. Ao final, ficar\u00e3o disponibilizados dicas e orienta\u00e7\u00f5es sobre os cuidados do o zumbido, relacionados com sa\u00fade f\u00edsica e mental. O n\u00famero de registro do aplicativo no INPI \u00e9 BR512020001425-9. Mais detalhes sobre o aplicativo ficar\u00e3o dispon\u00edveis em um outro estudo intitulado \u201cDesenvolvendo o Avazum: Aplicativo de avalia\u00e7\u00e3o interativa do zumbido\u201d no qual ser\u00e1 publicado.O aplicativo cont\u00e9m inicialmente uma tela de cadastro do usu\u00e1rio com e-mail e senha para realizar o Estudo descritivo de teste de usabilidade do Aplicativo de Avalia\u00e7\u00e3o do Zumbido (Avazum).System Usability Questionnaire - SUS e do Net Promoter Score - NPS e as dimens\u00f5es de efici\u00eancia e efic\u00e1cia de uso, por m\u00e9todo anal\u00edtico, considerando princ\u00edpios heur\u00edsticos para o aplicativo.Os instrumentos utilizados para pesquisa de usabilidade contemplaram as dimens\u00f5es de satisfa\u00e7\u00e3o, efici\u00eancia e efetividade do aplicativo (Anexo A), sendo a satisfa\u00e7\u00e3o avaliada por m\u00e9todo emp\u00edrico, atrav\u00e9s do question\u00e1rio de usabilidade EfetividadeA avalia\u00e7\u00e3o foi direcionada \u00e0 coleta de informa\u00e7\u00f5es sobre o alcance dos objetivos por parte dos usu\u00e1rios e a capacidade do produto para fazer o que se prop\u00f5e. Nesse prop\u00f3sito, s\u00e3o abordados os aspectos de avalia\u00e7\u00e3o, orienta\u00e7\u00f5es e encaminhamentos de pacientes com zumbido. Nas dimens\u00f5es de efici\u00eancia e efetividade, as respostas s\u00e3o observadas a partir da presen\u00e7a ou aus\u00eancia de problem\u00e1ticas a serem solucionadas. No caso de apontamento afirmativo para o problema, o usu\u00e1rio apontar\u00e1 a severidade na escala de import\u00e2ncia: (0) sem import\u00e2ncia, (1) problema cosm\u00e9tico/apar\u00eancia, (2) problema simples, (3) problema grave e (4) problema catastr\u00f3fico. Ap\u00f3s responder na escala, realizar\u00e1 a sugest\u00e3o de corre\u00e7\u00e3o.Efici\u00eanciaNa efici\u00eancia, a an\u00e1lise \u00e9 direcionada \u00e0 navegabilidade do aplicativo, considerando a quantidade de esfor\u00e7o exigida dos usu\u00e1rios para atingir os objetivos propostos pelo produto. Nesse intuito, s\u00e3o abordados a visibilidade dos elementos do aplicativo, utiliza\u00e7\u00e3o da linguagem, informa\u00e7\u00f5es para realiza\u00e7\u00e3o das tarefas. Os itens do question\u00e1rio que foram avaliados na efici\u00eancia foram \u201cOs enunciados s\u00e3o suficientes para realiza\u00e7\u00e3o das tarefas propostas no aplicativo?\u201d; As informa\u00e7\u00f5es de uso s\u00e3o claras e possibilitam a passagem de fases no aplicativo?\u201d; \u201cVoc\u00ea sentiu algum desconforto na utiliza\u00e7\u00e3o do aplicativo?\u201d. Para cada item os usu\u00e1rios tinham tr\u00eas op\u00e7\u00f5es \u201csim\u201d; \u201cem parte\u201d e \u201cn\u00e3o\u201d. Ap\u00f3s a coleta, foi realizada a an\u00e1lise descritiva dos dados.Satisfa\u00e7\u00e3oSystem Usability Scale, por John Brooke em 1986, \u00e9 uma escala num\u00e9rica de usabilidade que efetividade, efici\u00eancia e satisfa\u00e7\u00e3o de 10 software, produtos, servi\u00e7os, websites e outros tipos de interface. O SUS \u00e9 bastante utilizado por ter um equil\u00edbrio em ser cientificamente apurado e objetivo, consiste em 10 perguntas.M\u00e9todos que permitem medir a satisfa\u00e7\u00e3o dos usu\u00e1rios por meio de question\u00e1rios contribuem para uma avalia\u00e7\u00e3o ampla para v\u00e1rios tipos de produtos e sistemas. Um question\u00e1rio conhecido e muito utilizado \u00e9 o SUS- System Usability Questionnaire - SUS foram verificados a partir das respostas das dez declara\u00e7\u00f5es em dois conjuntos de dados independentes atrav\u00e9s de dois fatores - Usabilidade (8 quest\u00f5es) e Apreensibilidade (2 quest\u00f5es). Para o registro dos n\u00edveis de concord\u00e2ncia, o question\u00e1rio utiliza uma escala de Likert de 5 pontos com as seguintes 10 indica\u00e7\u00f5es de concord\u00e2ncia/discord\u00e2ncia: discordo fortemente ou totalmente (1), discordo (2), uma de neutralidade (3) e duas de concord\u00e2ncia: concordo (4) e concordo fortemente ou totalmente (5).A an\u00e1lise dos dados coletados com o question\u00e1rio de usabilidade .As alternativas \u00edmpares do question\u00e1rio s\u00e3o redigidas de forma positiva sobre o produto avaliado, ou seja, os itens 1,3,5,7 e 9, enquanto os pares de forma negativa, itens 2,4,6,8 e 10. Tendo a possibilidade de alguns termos usados serem adaptados ao contexto, usu\u00e1rio e produto avaliado. Para obter o score final do SUS, ap\u00f3s a indica\u00e7\u00e3o dos n\u00edveis de concord\u00e2ncia de cada quest\u00e3o, para as respostas \u00edmpares, subtrai-se 1 da pontua\u00e7\u00e3o que o usu\u00e1rio respondeu, para as respostas pares subtrai-se 5. Em seguida, os valores obtidos para as dez perguntas ser\u00e3o somados e multiplicados por 2,5, essa pontua\u00e7\u00e3o pode ir de 0 a 100, representando uma medida composta da capacidade geral do sistema, sendo a avalia\u00e7\u00e3o em conjunto, n\u00e3o por itens individuais.O autor do m\u00e9todo n\u00e3o apresenta precisamente o que a pontua\u00e7\u00e3o obtida pode representar em termos de qualidade da usabilidade do sistema avaliado, contudo, estudos realizados em diferentes aplica\u00e7\u00f5es indicam que a m\u00e9dia do SUS gira em torno de 70 pontos, e que resultados abaixo desse valor representam problemas s\u00e9rios de usabilidadePara o NPS, a avalia\u00e7\u00e3o \u00e9 baseada na pergunta: O quanto voc\u00ea recomendaria este aplicativo para algu\u00e9m? A resposta para pergunta ser\u00e1 evidenciada em escala de 0 a 10. O c\u00e1lculo e an\u00e1lise com base na resposta s\u00e3o divididos em tr\u00eas categorias: Promotores, para os respondentes que d\u00e3o as notas 9 ou 10, est\u00e3o satisfeitos e incentivam pessoas ao uso do aplicativo; Neutros para os respondentes que d\u00e3o as notas 7 ou 8, n\u00e3o ajudam a divulgar o aplicativo, mas n\u00e3o atrapalham; e Detratores, para os respondentes que d\u00e3o as notas de 0 a 6, como evid\u00eancia de insatisfa\u00e7\u00e3o. O c\u00e1lculo para verificar a satisfa\u00e7\u00e3o geral \u00e9 realizado pela subtra\u00e7\u00e3o da porcentagem dos promotores pela porcentagem de detratores. Resultado de 75 a 100% \u00e9 considerado NPS excelente; 50 a 74%-NPS muito bom; 0 a 49- NPS razo\u00e1vel; -100 a -1 NPS ruim.A popula\u00e7\u00e3o do estudo foi composta por pacientes com zumbido atendidos no Projeto de Extens\u00e3o de Zumbido, do curso de Fonoaudiologia da Universidade Federal da Para\u00edba. Foi realizado o c\u00e1lculo amostral pelo o software G*Power no qual resultou em 47 pacientes, que comp\u00f5em o grupo virtual de orienta\u00e7\u00e3o do projeto, por\u00e9m a amostra final foi composta por 48 pacientes ao total. Dentre os 48 pacientes, 62,5% (30) foram mulheres e 37,5% (18) homens. As idades dos participantes da pesquisa foram de 25 a 65 anos, com idade m\u00e9dia de 43,5 anos e desvio padr\u00e3o de 11,8. Com rela\u00e7\u00e3o \u00e0 escolaridade, 8,33% (4) nunca foram \u00e0 escola; 20,8% (10) ensino fundamental incompleto; 20,8% (10) ensino m\u00e9dio incompleto; 22,91% (11) ensino m\u00e9dio completo e 25% (12) ensino superior completo.android.No que se refere aos crit\u00e9rios de participa\u00e7\u00e3o, foram inclu\u00eddos todos os pacientes que possu\u00edam zumbido, eram atendidos no Projeto de Extens\u00e3o de Zumbido, do curso de Fonoaudiologia da Universidade Federal da Para\u00edba e que tinham acesso ao um celular de uso pr\u00f3prio ou de algum familiar com sistema A pesquisa foi realizada de forma virtual no per\u00edodo de outubro a dezembro de 2021. O teste de usabilidade foi realizado em 3 etapas principais: primeiro os usu\u00e1rios utilizaram o produto alvo do teste; em seguida responderam aos question\u00e1rios de usabilidade sobre a sua satisfa\u00e7\u00e3o, efic\u00e1cia e efici\u00eancia do produto testado; e por \u00faltimo, realizou-se a an\u00e1lise dos resultados pelos pesquisadores.Google Forms. Cumprida essa etapa, os participantes receberam as instru\u00e7\u00f5es de acesso e uso do Avazum, e em seguida, fizeram uso do aplicativo e suas fun\u00e7\u00f5es, ou seja, realizaram a avalia\u00e7\u00e3o do zumbido, al\u00e9m de receberem os encaminhamentos necess\u00e1rios, dicas e orienta\u00e7\u00f5es sobre os cuidados do zumbido. Por \u00faltimo, os participantes responderam o question\u00e1rio de usabilidade para a coleta de dados. Abaixo est\u00e3o listadas as etapas separadamente.Sendo assim, a seguinte pesquisa teve in\u00edcio com o convite para a participa\u00e7\u00e3o volunt\u00e1ria com explica\u00e7\u00e3o dos seus procedimentos, ap\u00f3s o aceite para participa\u00e7\u00e3o da pesquisa e assinatura do Termo de Consentimento Livre e Esclarecido- TCLE, o qual foi enviado virtualmente como um formul\u00e1rio do 1.Convite para participa\u00e7\u00e3o volunt\u00e1ria;2.Assinatura do TCLE;Envio das instru\u00e7\u00f5es de acesso e uso do aplicativo atrav\u00e9s de imagens e textos explicativos;Os usu\u00e1rios fizeram o uso do aplicativo Avazum;Os participantes responderam os question\u00e1rios de usabilidade atrav\u00e9s do google forms;An\u00e1lise dos resultados pelos pesquisadores.Statistics Package for the Social Sciences (SPSS) vers\u00e3o 21.0. 4.7 para realizar a an\u00e1lise descritiva como frequ\u00eancia, percentagens, al\u00e9m de an\u00e1lise do escore do SUS.Os dados foram tabulados no programa Microsoft Excel 2019 (16.0), o tipo de an\u00e1lise dos dados foi realizado de forma quantitativa. Foi utilizado o software Este projeto foi submetido e aprovado pelo Comit\u00ea de \u00c9tica em Pesquisa do Centro de Ci\u00eancias da Sa\u00fade da Universidade Federal da Para\u00edba, com n\u00famero do parecer de aprova\u00e7\u00e3o 4.297.792. Consentimento informado foi obtido de todos os participantes. Todos os procedimentos ocorreram de acordo com as diretrizes e balizamentos dos \u00f3rg\u00e3os que regem as normativas \u00e9ticas em sa\u00fade.O Avazum foi analisado nos aspectos de efici\u00eancia, efetividade e satisfa\u00e7\u00e3o dos usu\u00e1rios participantes. Os pontos analisados foram desde visibilidade dos elementos do aplicativo, utiliza\u00e7\u00e3o da linguagem, informa\u00e7\u00f5es para realiza\u00e7\u00e3o das tarefas, como tamb\u00e9m, aspectos de avalia\u00e7\u00e3o, orienta\u00e7\u00f5es e encaminhamentos de pacientes com zumbido. Sendo assim, os resultados ser\u00e3o apresentados abaixo.Nesse quesito foram analisadas 10 declara\u00e7\u00f5es do question\u00e1rio SUS, al\u00e9m da avalia\u00e7\u00e3o do NPS, no qual os usu\u00e1rios deram a nota de recomenda\u00e7\u00e3o dos aplicativos, variando de 0 a 10. A m\u00e9dia geral do score do SUS foi 78,28, evidenciando que n\u00e3o h\u00e1 problemas graves de usabilidade, sendo considerado um escore bom. A maior parte dos usu\u00e1rios evidenciaram que gostariam de utilizar o aplicativo com frequ\u00eancia e demonstraram facilidade em utiliz\u00e1-lo, negando que precisariam de apoio para utilizar bem as fun\u00e7\u00f5es do Avazum, mesmo havendo participantes idosos e com baixa escolaridade na amostra. \u00c9 poss\u00edvel observar esses resultados detalhadamente nas Em rela\u00e7\u00e3o ao ponto chave da satisfa\u00e7\u00e3o, os participantes demonstraram satisfeitos e incentivadores ao uso do aplicativo. Dessa forma, foi poss\u00edvel constatar que houve uma boa satisfa\u00e7\u00e3o dos usu\u00e1rios com o uso do Avazum, atrav\u00e9s da escala do NPS e score do SUS. Ap\u00f3s realizar o c\u00e1lculo para obter a porcentagem geral do NPS, o resultado foi de 58%, indicando que o NPS foi muito bom, ou seja, houve maiores \u00edndices de satisfa\u00e7\u00e3o. Os valores detalhados podem ser observados no gr\u00e1fico abaixo representado na app. Nas Foi poss\u00edvel observar que houve boa compreens\u00e3o dos usu\u00e1rios no que se refere \u00e0s tarefas e orienta\u00e7\u00f5es apresentadas pelo aplicativo e a linguagem utilizada. Demonstraram compreender todas as tarefas e conseguiram descrever o zumbido utilizando o aplicativo. Com rela\u00e7\u00e3o \u00e0s dicas e orienta\u00e7\u00f5es oferecidas no Avazum, demonstraram ser relevantes/interessantes para suas realidades. Ao serem questionados sobre os encaminhamentos para os profissionais, houve desapontamentos sobre a clareza dos direcionamentos. Sendo assim, os encaminhamentos precisam ser mais claros e a lista dos profissionais ser mais completa. \u00c9 importante mencionar que a lista dos profissionais foi atualizada com base em uma pesquisa de mestrado sobre \u201cPerfil dos Profissionais Especializados no Atendimento em Pacientes com Zumbido no Brasil\u201d ser\u00e1 adicionada na pr\u00f3xima atualiza\u00e7\u00e3o do app, al\u00e9m das informa\u00e7\u00f5es sobre as telas serem apresentadas com clareza, consequentemente, apresentando conforto ao navegar no Avazum. Na No que diz respeito \u00e0 efici\u00eancia do aplicativo, foi poss\u00edvel observar que as avalia\u00e7\u00f5es foram suficientes para os objetivos chaves do Dessa forma, ap\u00f3s a realiza\u00e7\u00e3o da an\u00e1lise realizada do escore do question\u00e1rio SUS, a m\u00e9dia encontrada \u00e9 condizente com uma m\u00e9dia de score satisfat\u00f3ria, o que implica dizer que o aplicativo n\u00e3o apresenta graves problemas de usabilidade, al\u00e9m de um bom percentual de usu\u00e1rios promotores, ou seja, deram notas 9 e 10 para satisfa\u00e7\u00e3o no NPS. A porcentagem geral do NPS mostrou que a satisfa\u00e7\u00e3o dos usu\u00e1rios \u00e9 muito boa, j\u00e1 em rela\u00e7\u00e3o \u00e0 efetividade, ap\u00f3s a an\u00e1lise descritiva dos dados, foi poss\u00edvel observar que o Avazum atinge os objetivos propostos, consegue realizar avalia\u00e7\u00e3o do zumbido, os encaminhamentos e oferecer dicas e orienta\u00e7\u00f5es aos usu\u00e1rios. Al\u00e9m de ser eficiente, pois apresenta uma linguagem clara e confortabilidade durante o uso. \u00c9 importante mencionar que o item avaliado na efic\u00e1cia referente aos encaminhamentos dos usu\u00e1rios, apresentou um d\u00e9ficit sobre a facilidade e direcionamento do acesso.. O teste de usabilidade tem foco principal nas necessidades dos usu\u00e1rios, concentrando-se em trazer uma excelente experi\u00eancia para os mesmos. Dessa forma, fica evidente que o foco fundamental da usabilidade continua sendo a facilidade de uso quando interage com o produto.A usabilidade \u00e9 um quesito importante para a qualidade de produtos e sistemas. Consiste em um conceito amplamente utilizado no desenvolvimento de produtos, tem como objetivo principal observar as pessoas usando um produto, a partir da intera\u00e7\u00e3o humano, tarefa e produto. Um n\u00famero crescente de empresas est\u00e1 reconhecendo n\u00e3o s\u00f3 a import\u00e2ncia da usabilidade no processo de design, mas tamb\u00e9m o seu potencial para garantir vantagens no mercado. Devido a esta import\u00e2ncia, o tema tem sido alvo de v\u00e1rios estudos propostos por pesquisadores e especialistas. M\u00e9todos que permitem medir a satisfa\u00e7\u00e3o dos usu\u00e1rios por meio de question\u00e1rios contribuem para uma avalia\u00e7\u00e3o ampla para v\u00e1rios tipos de produtos e sistemas.Os testes de usabilidade s\u00e3o realizados com aux\u00edlio de ferramentas e question\u00e1rios para verificar a efetividade, efici\u00eancia e satisfa\u00e7\u00e3o com o produto testado. Segundo a ISO9241:11 (1998), a efetividade normalmente \u00e9 avaliada pela quantidade de etapas que o usu\u00e1rio conseguiu completar com sucesso, a efici\u00eancia tem foco no tempo gasto para cumprir os objetivos, j\u00e1 a satisfa\u00e7\u00e3o \u00e9 avaliada por meio de protocolos. A satisfa\u00e7\u00e3o dos usu\u00e1rios tem rela\u00e7\u00e3o direta com os n\u00edveis de conforto ao usar o produto, como tamb\u00e9m o quanto gostou da utiliza\u00e7\u00e3o da ferramenta em quest\u00e3o.A usabilidade \u00e9 ferramenta chave para o desenvolvimento de produtos de inova\u00e7\u00e3o tecnol\u00f3gica em sa\u00fade, uma etapa que deve ser realizada com muita aten\u00e7\u00e3o e direcionada para usu\u00e1rios reais. Em um estudo direcionado para verificar a metodologia dos testes de usabilidade nos aplicativos em sa\u00fade, mostrou que 75,9% foram testados em usu\u00e1rios reais, como pacientes e profissionais e apenas 6% testados com profissionais especializados. Al\u00e9m de evidenciar que a maior parte dos testes foram realizados com question\u00e1rios de forma quantitativa e qualitativaO escore do question\u00e1rio SUS varia de 0 a 100, n\u00e3o h\u00e1 detalhes no estudo de valida\u00e7\u00e3o do question\u00e1rio, sobre o que cada escore pode representar em rela\u00e7\u00e3o \u00e0 usabilidade de um produto. Por\u00e9m, o estudo de Zorzal (2009) evidencia que um score adequado varia de 70 a 100, abaixo disso o produto pode apresentar problemas s\u00e9rios de usabilidade, sendo assim, a m\u00e9dia do escore a partir de 70 \u00e9 satisfat\u00f3ria. Mostrando assim, que o Avazum n\u00e3o apresentou grandes problemas de usabilidade..Outro quesito analisado foi \u00e0 satisfa\u00e7\u00e3o a partir da Net promoter score- NPS, muito utilizado para medir a satisfa\u00e7\u00e3o dos clientes sobre produtos, servi\u00e7os, atendimentos e dentre outros. Quando a porcentagem dos clientes/usu\u00e1rios promotores \u00e9 maior que os detratores, o produto tem mais chance de ser indicado pelas pessoas que o utilizaram, j\u00e1 os neutros ou passivos, n\u00e3o est\u00e3o insatisfeitos, mas provavelmente n\u00e3o indicar\u00e3o para outras pessoas. Um score total a partir de 50% no NPS mostra que tiveram uma satisfa\u00e7\u00e3o muito boa com o produto utilizado, mas abaixo de 49% n\u00e3o houve uma satisfa\u00e7\u00e3o boa.Para obter uma usabilidade alta de um aplicativo, \u00e9 necess\u00e1rio que haja n\u00edveis de efetividade e efici\u00eancia adequados para o que \u00e9 proposto. Caracter\u00edsticas como boa acessibilidade dos menus e fun\u00e7\u00f5es comuns nas telas, fontes e tamanho que favorecem a leitura mesmo para aquele usu\u00e1rio com dificuldade, tarefas simples de serem executadas, deixando claro o pr\u00f3ximo passo, s\u00e3o importantes na avalia\u00e7\u00e3o da efici\u00eancia. Sendo assim, um aplicativo com linguagem clara, enunciados suficientes para realiza\u00e7\u00e3o das tarefas e informa\u00e7\u00f5es claras para passagem de telas, \u00e9 eficiente para as fun\u00e7\u00f5es propostas.Um produto ou servi\u00e7o eficaz \u00e9 aquele que consegue cumprir com os objetivos propostos, atende as necessidades reais dos usu\u00e1rios. Com rela\u00e7\u00e3o a aplicativos m\u00f3veis, \u00e9 de extrema import\u00e2ncia que o produto final consiga atingir as atividades propostas, levando em considera\u00e7\u00e3o se as fun\u00e7\u00f5es foram suficientes. Ao realizar um teste de usabilidade, deve analisar a efic\u00e1cia levando em considera\u00e7\u00e3o cada item apresentado, observando a presen\u00e7a de fun\u00e7\u00f5es que n\u00e3o supriu as necessidades dos usu\u00e1rioslikert de 5 pontos. Como resultado obteve-se a m\u00e9dia de respostas entre 3 e 4, indicando que os aplicativos avaliados tiveram uma usabilidade moderada a boa, principalmente os que tinham grande facilidade de uso e linguagem clara.Foram avaliados 66 aplicativos dispon\u00edveis para pessoas com diabetes, utilizando a escala de Como limita\u00e7\u00e3o do estudo, \u00e9 importante mencionar que o Avazum ainda n\u00e3o est\u00e1 dispon\u00edvel para sistema iOS, sendo assim, n\u00e3o foi poss\u00edvel realizar o teste de usabilidade em pacientes que utilizam esse sistema para celular. Os pr\u00f3ximos passos ser\u00e3o a expans\u00e3o para o sistema iOS, tradu\u00e7\u00e3o e adapta\u00e7\u00e3o para outros idiomas, como tamb\u00e9m a realiza\u00e7\u00e3o de novos testes para as atualiza\u00e7\u00f5es feitas.Dessa forma, foi poss\u00edvel observar que os usu\u00e1rios demonstraram compreender todas as tarefas e conseguiram descrever o zumbido utilizando o aplicativo, evidenciando assim, que o Avazum mostrou efetivo para os objetivos propostos. Como tamb\u00e9m, as fun\u00e7\u00f5es do aplicativo est\u00e3o bem integradas, dispostas com clareza e com confortabilidade de uso, mostrando-se eficiente ao realizar as fun\u00e7\u00f5es do app, al\u00e9m de bom \u00edndice de satisfa\u00e7\u00e3o dos usu\u00e1rios ao utilizar o Avazum. Sendo um aplicativo promissor para auxiliar na avalia\u00e7\u00e3o do zumbido, encaminhamentos dos usu\u00e1rios e promover sa\u00fade atrav\u00e9s das orienta\u00e7\u00f5es."}
+{"text": "Uma hist\u00f3ria das leishmanioses no Novo Mundo, fruto de parceria entre as editoras Garamond e Fiocruz. Com narrativa densa e envolvente, o pesquisador Jaime Larry Benchimol, titular da Casa de Oswaldo Cruz/Fiocruz, e Cl\u00e1udio de Oliveira Peixoto, analista em gest\u00e3o de sa\u00fade do Instituto Le\u00f4nidas e Maria Deane/Fiocruz-AM e doutorando do Programa de P\u00f3s-gradua\u00e7\u00e3o em Sa\u00fade Global e Sustentabilidade da Universidade de S\u00e3o Paulo, transportam-nos para a Amaz\u00f4nia, revelando as fascinantes e espec\u00edficas maneiras pelas quais as pesquisas realizadas na regi\u00e3o contribu\u00edram para a constru\u00e7\u00e3o de conhecimentos sobre as leishmanioses em escala global entre 1960 e os primeiros anos do s\u00e9culo XXI.Em dezembro de 2022 foi lan\u00e7ado o segundo volume da trilogia Com pref\u00e1cio assinado pelo historiador das ci\u00eancias Nelson Sanjad e oito cap\u00edtulos, os autores n\u00e3o se limitaram \u00e0 an\u00e1lise do objeto central da obra, isto \u00e9, a hist\u00f3ria das leishmanioses, mas tamb\u00e9m lan\u00e7aram luz sobre pesquisas desenvolvidas acerca de v\u00e1rias enfermidades como mal\u00e1ria, filariose, tripanossom\u00edases, arboviroses, entre outras. Al\u00e9m disso, as trajet\u00f3rias profissionais dos cientistas e de suas respectivas institui\u00e7\u00f5es s\u00e3o pontos fortes do trabalho. Os personagens abordados no livro t\u00eam um papel importante nessa hist\u00f3ria, e a obra apresenta uma vis\u00e3o ampla e din\u00e2mica da pesquisa cient\u00edfica na \u00e1rea de doen\u00e7as tropicais.No primeiro volume, Benchimol e Jogas Junior (2020) demonstraram que, na primeira metade do s\u00e9culo XX, a rede global de pesquisas sobre as leishmanioses foi orquestrada pela Soci\u00e9t\u00e9 de Pathologie Exotique e por seu fundador e primeiro presidente, Alphonse Laveran, sendo os m\u00e9dicos sul-americanos personagens essenciais na caracteriza\u00e7\u00e3o das leishmanioses do Novo Mundo como doen\u00e7a humana singular e pr\u00f3pria dessa regi\u00e3o. No novo volume, \u00e9 dada aten\u00e7\u00e3o especial ao papel desempenhado pela London School of Hygiene and Tropical Medicine e pelo parasitologista brit\u00e2nico Percy Cyril Claude Garnham na constru\u00e7\u00e3o de uma nova rede centrada em nova abordagem, menos antropoc\u00eantrica e com maior interesse pelas zoonoses. Essa rede tornava-se cada vez mais densa e polic\u00eantrica  \u00e0 medida que grandes projetos de infraestrutura adentravam territ\u00f3rios inabitados e/ou regi\u00f5es interioranas, alterando drasticamente o ambiente e criando, assim, condi\u00e7\u00f5es prop\u00edcias \u00e0 circula\u00e7\u00e3o de pat\u00f3genos \u2013 antes limitados aos animais vetores silvestres \u2013 nos ambientes modificados pelo homem, um novo hospedeiro vertebrado.O in\u00edcio da narrativa se estrutura em torno da cria\u00e7\u00e3o da Wellcome Parasitology Unit no \u00e2mbito do Instituto Evandro Chagas, em Bel\u00e9m do Par\u00e1, e da chegada de Ralph Lainson e Jeffrey Shaw, ambos disc\u00edpulos de Garnham, para comand\u00e1-la. Essa unidade de pesquisa, financiada pelo Wellcome Trust, tinha como objetivo prim\u00e1rio o estudo de poss\u00edveis hospedeiros silvestres dos parasitos respons\u00e1veis pelas m\u00faltiplas formas cl\u00ednicas da leishmaniose tegumentar americana em animais existentes na vasta fauna das florestas tropicais; em especial, na amaz\u00f4nica. Merece men\u00e7\u00e3o a envolvente digress\u00e3o hist\u00f3rica feita por Benchimol sobre a hist\u00f3ria da fus\u00e3o da Wellcome Foundation e do Wellcome Trust, a fim de dar aos leitores uma ideia sobre o papel dessa organiza\u00e7\u00e3o no mercado global de f\u00e1rmacos e no financiamento das ci\u00eancias da vida e da sa\u00fade em v\u00e1rias partes do mundo, inclusive no Brasil.Leishmania braziliensis como \u00fanico agente etiol\u00f3gico das diferentes formas da leishmaniose tegumentar americana. Um conceito sedimentado na d\u00e9cada de 1930, como mostram Benchimol e Jogas Junior (2020).Como \u00e9 demonstrado por Benchimol e Peixoto, apesar de algumas desaven\u00e7as no cotidiano do Instituto Evandro Chagas, as prof\u00edcuas prospec\u00e7\u00f5es e pesquisas l\u00e1 desenvolvidas produziram significativas mudan\u00e7as na maneira pela qual eram compreendidas as leishmanioses e outras doen\u00e7as parasit\u00e1rias na regi\u00e3o amaz\u00f4nica, sobretudo a partir da d\u00e9cada de 1970, quando os parasitologistas brit\u00e2nicos, em colabora\u00e7\u00e3o com pesquisadores da regi\u00e3o, como o parasitologista Orlando Rodrigues da Costa e os entomologistas Reynaldo Goubert Damasceno e Habib Fraiha Neto, demonstraram que eram muito mais diversificadas do que se pensava as popula\u00e7\u00f5es de parasitos, vetores e hospedeiros das leishmanioses, um complexo de doen\u00e7as diferentes cl\u00ednica e epidemiologicamente. Assim, desbancaram de vez a j\u00e1 abalada soberania da expertise local por pesquisadores ligados \u00e0 tradi\u00e7\u00e3o parasitol\u00f3gica brasileira como os paraenses Heitor Vieira Dourado e Carlos Borborema, fundadores da Cl\u00ednica de Mol\u00e9stias Tropicais, embri\u00e3o da atual Funda\u00e7\u00e3o de Medicina Tropical Doutor Heitor Vieira Dourado, e estrangeiros associados a institui\u00e7\u00f5es amazonenses, como Jorge Ramon Arias e Toby Barret no Instituto Nacional de Pesquisas da Amaz\u00f4nia. Esses e outros cientistas desempenharam pap\u00e9is relevantes n\u00e3o apenas no enfrentamento dos surtos epid\u00eamicos ensejados pelos projetos de desenvolvimento, que deveriam trazer moderniza\u00e7\u00e3o \u00e0 regi\u00e3o, como tamb\u00e9m na descri\u00e7\u00e3o de novas esp\u00e9cies de parasitos e vetores das Leishmania e de outros parasitos. Produziram ou propuseram esses pesquisadores inova\u00e7\u00f5es no tocante a preven\u00e7\u00e3o, tratamento e controle por meio da aplica\u00e7\u00e3o de nov\u00edssimas t\u00e9cnicas biomoleculares que foram essenciais para o conhecimento da epidemiologia, da ecologia e dos fatores de risco das leishmanioses na Amaz\u00f4nia.O livro, portanto, apresenta uma perspectiva din\u00e2mica sobre a pesquisa cient\u00edfica na regi\u00e3o amaz\u00f4nica e as complexas intera\u00e7\u00f5es entre sa\u00fade p\u00fablica, desenvolvimento econ\u00f4mico e transforma\u00e7\u00f5es socioambientais. Configura-se como excelente oportunidade n\u00e3o apenas para aqueles que querem conhecer melhor a hist\u00f3ria das leishmanioses na regi\u00e3o Norte do pa\u00eds, mas tamb\u00e9m para quem deseja compreender o cotidiano e as din\u00e2micas de pesquisas nas institui\u00e7\u00f5es amaz\u00f4nicas, assim como as redes e os contatos por elas estabelecidos com centros de pesquisas cong\u00eaneres em outras regi\u00f5es do Brasil e do exterior. Afinal, como Jaime Benchimol sempre gostou de frisar, a hist\u00f3ria de uma doen\u00e7a nunca \u00e9 apenas a hist\u00f3ria s\u00f3 de uma doen\u00e7a."}
+{"text": "Because of the importance of communication to their thorough development, it is essential to have SLH therapists in primary healthcare (PHC), as they are the main rehabilitation professionals providing such care. Communication disorders interfere directly with various contexts in life, including physical, sensory, psychological, and social ones.SLH therapists\u2019 work in PHC is a recent construction full of challenges. It is mainly based on the principles of the Unified Health System (SUS), aiming to provide the whole population with greater care in the areas of voice, language, hearing, and oral-motor control, improving their quality of life.SLH therapists are responsible along with the multidisciplinary PHC team for various activities, such as situational and institutional diagnoses, support, home visits, individual and/or group treatment, health campaigns, permanent education for the teams, and conducting and publishing research.Language is one of the areas addressed by SLH therapy, with an essential role in perceptual organization, information reception and structuring, and social interaction. Moreover, hearing is a prerequisite to acquiring and developing language, so hearing loss is one of the main disorders that interfere with language and speech development, as hearing and language are correlated and interdependent functions.In 2008, the Ministry of Health Regulation no. 154 created the Extended Center for Family Health and Basic Care  to meet these needs and provide comprehensive healthcare, aiming to broaden PHC coverage and scope of activity. Their teams have professionals from different fields of knowledge, who are expected to work in cooperation, support the Family Health Teams, and share practices and knowledge about health in the regions under their responsibility.The work of NASF-AB must be guided by the theoretical-methodological framework of team cooperation. Such support is an innovative means of producing health, incorporating interdisciplinary practices, and ensuring comprehensive attention throughout the health system. SLH therapy provided through home visits is an important tool to promote the population\u2019s health.Home visits are unique care opportunities, aiming to promote health in the community in a setting other than the health unit. It uses light technology, ensuring more humanized and supportive care, and building rapport between professionals, users, the family, and the community.The Ministry of Health uses development milestones as references to follow up on children in neonatal consultations - whose periodicity in health units, involving weight and length control, justifies including hearing and language development follow-up. Another possibility is to apply such instruments in home visits.The Ministry of Health has indicated the following milestones involving hearing and language behaviors: reacting to sounds, emitting sounds, locating sounds, emitting sounds, emitting sounds, laughing aloud, duplicating syllables, producing \u201cjargons\u201d, speaking one word, speaking three words, and speaking 2-word sentences.Community health agents (CHA) are the target public of NASF-AB team cooperation. They can provide base support to children\u2019s hearing loss and language changes prevention, diagnosis, and intervention. These professionals are the link between SUS and the community, identifying risks or problems that might interfere with hearing and language development, thus referring them when necessaryCHA training provides a broader knowledge of SLH therapy and team cooperation through home visits regarding hearing and language development in early childhood, reaching the scientific community, health professionals, administrators, and the population that uses SLH therapy at SUS.Given the above, this article aimed to analyze CHA\u2019s knowledge of hearing and language development milestones in early childhood, in the context of home visits, before and after team cooperation workshops. The perspective is to contribute to scientific advances on the said issue, considering the few such studies in the scientific literature.This study was approved by the Research Ethics Committee of the Department of Health Sciences at the Federal University of Pernambuco, under evaluation report no. 4.147.895..Qualitative and quantitative approaches were used in this action survey, which is a type of empirical social survey conceived and carried out in close association with an action or the solution to a public problem. In it, researchers and participants who represent the situation or problem are mutually cooperative or participativeThis study approached the region covered by the Family Health Unit of Vila Uni\u00e3o, in Health District IV of the municipality of Recife, Pernambuco, Brazil. The unit has four Family Health Teams.Eighteen CHAs participated in the quantitative stage of the research, while four CHAs participated in its second  stage, with the volunteer participation of one CHA from each team. The second stage only had four participants because it was conducted during the pandemic. They were recruited by invitation to participate in the research.Participants were informed of the study objectives and data collection procedures both verbally and in writing and had their questions answered. Those who agreed to participate signed an informed consent form.The inclusion criteria were as follows: having worked for more than 1 year as CHA in the Family Health Unit approached in the study, being interested in and available to participate in the research. CHAs who were on a leave of absence or vacation during data collection were excluded.Data were collected in three phases: Situational diagnosis; Action; and Action assessment. Initially, the situational diagnosis was conducted through a structured interview form to gather data on the research participants\u2019 knowledge, attitudes, and practices (KAP) regarding hearing and language development milestones in early childhood.The data collection instrument was developed by the researchers, using references for each dimension in the KAP method, as follows: :25.Knowledge refers to recalling specific facts (in the education system to which the person belongs) or skills to solve specific problems or define concepts based on the understanding they have acquired on a given topic or event. Attitude means having relatively unceasing opinions, willingness, beliefs, feelings, and affectivity about things, situations, or people. It is related to the affective dominion and portrays the emotional dimension. Practice is the decision to do an action. It is related to the cognitive and psychomotor domains and reinforces the social dimensionThe form had two sections. The first one comprised sociodemographic and professional variables, and the second one had the KAP variables.A focus group with participating CHAs was also conducted before and after the workshop, at the Family Health Unit in Vila Uni\u00e3o..Focus groups are interviews with few participants on a specific topic, emphasizing the attention to various opinions. Each person is encouraged to share their ideas and listen and respond to those of the other ones, aiming at people\u2019s synergy, rather than consensus. Focus-group research is also centered on discussion, more in-depth information thanks to group interaction and influence, low cost, easy-to-understand methods and results, noticeable differences and contradictions in opinions between participants, and quick resultsThe group was facilitated by a moderator, while another person took notes of the statements. The group\u2019s responses were recorded and later transcribed.Participants were asked guiding questions, organized into four analysis themes. If the group did not respond satisfactorily, auxiliary questions were asked.Interviewees were identified as CHA and the interview number to ensure their anonymity. For instance, the first CHA to be interviewed was identified as CHA 1, the second one as CHA 2, and so forth.The action in this research was developed in a team cooperation workshop lasting about 4 hours, encouraging CHAs\u2019 autonomy to construct knowledge. It included a lecture and discussions about hearing and language development milestones and the CHAs\u2019 procedures in home visits after identifying these milestones. The program included team-building activities to both relax and involve participants in the pedagogical approach, encouraging their participation and reflection on the central workshop theme .Data collection finished with a new focus group after the workshop, carried out at the Family Health Unit in Vila Uni\u00e3o. It followed the same model as the first one, using the same guiding questions, and adding other ones on the process experienced in the workshop.. It had the following stages: skimming the transcriptions to understand general content and organize data; identifying categories and subcategories to analyze the subjects\u2019 statements; describing results; and interpreting results . The KAP questionnaire was analyzed with descriptive statistics (distribution of absolute and relative frequencies). All data were tabulated and calculated in 2007 Microsoft Excel.Qualitative data were submitted to content analysis, as proposed by BardinAltogether, 18 CHAs participated in the research, all of them females. The predominating age range was from 41 to 50 years (88.9%). Most of them had finished high school (72.2%), and about 88.9% had been working in this position for 9 or more years .The assessment of the CHAs\u2019 KAP regarding hearing and language development milestones in early childhood showed their knowledge of the topic was fragile, and their practices were not based on evidence .Four of the participating CHAs also took part in the second  phase of the research. Statement content analysis about early childhood before the team cooperation workshop identified fragile knowledge of the topic . They reAfter participating in the workshop, they continued to associate age with early childhood, but they gave more assertive statements on following up on children from 0 to 5 years old, as early as pregnancy.They identified the vaccination cards as a main reference, although they had fragmented knowledge of what they received mainly in the context of health.They also reported instructing families in the region they covered as part of actions aimed at them and early childhood.After participating in the workshop, statements about instructions were accompanied by their observation of speech and hearing, leading to referrals.(CHA 2).Listening to the parents, observing, instructing, and providing referrals, which in our case is to schedule a visit to professionals in the health unit Concerning the type of instruction they gave, they reported the vaccination card, neonatal care, and diet. After the workshop, the statements had similar content, adding statements on development milestones available in the personal child health record for CHAs to instruct the families.BEFORE:(CHA 1).Well... first, we have to instruct them about breastfeeding, right? The importance of breastfeeding and all; we instruct them to go to the unit regularly when they have a neonatal care appointment to follow up on the child\u2019s development and instruct about baby bottles, pacifiers, and such. We also check the vaccination card to see if it\u2019s all up to date AFTER:(CHA 1).We have to instruct them, right? Always instruct the parents to check the vaccination card often and the child\u2019s development and growth, right? We have to instruct them and refer the children if we identify any\u2026 what is it called? Some sign, right? In the child, in their speech or hearing The CHAs\u2019 responses did not refer to their knowledge about hearing development milestones. However, after participating in the workshop, they speak about identifying sounds and locating sounds as hearing milestones.BEFORE:(CHA 3).No, I don\u2019t remember AFTER:(CHA 3).Two of them are locating sounds and identifying sounds Their statements also lack questions on hearing during home visits, as CHAs reported asking more about language. The families likewise did not ask about hearing. The questions are always related to language.After participating in the workshop, CHAs reported asking during home visits the mother\u2019s perception of the child\u2019s reactions and responses when they heard louder sounds or whether any sound startled them.BEFORE:(CHA 1).Usually, I ask, we ask more about speech, right? Sometimes we ask if any noise or loud sound startles the child, but we usually ask more if the child is speaking or walking AFTER:(CHA 2).We ask the mother how the child\u2019s doing. We ask the parents if the child gives any sign that they\u2019re hearing when they clap their hands, if the child reacts when something falls on the floor, how\u2019s their expression when someone\u2019s talking, their eyes, and how they move their head. We ask parents to draw some conclusions The CHAs also reported not knowing about language development milestones. Once again, the statements revealed flaws in their knowledge of the topic. After participating in the workshop, they spoke about some language milestones, showing that they had then acquired such knowledge.BEFORE:(CHA 4).Saying papa, pepe, dada, want, you know? We also pay attention to see if they\u2019ll have any progress or continue like that, or even only point at things AFTER:(CHA 3).They\u2019re eight milestones, like\u2026 what are they, again? Emitting sounds, emitting sounds and laughing aloud, speaking one word, speaking duplicated words; by five years old, they already speak sentences, complete sentences we can understand They said they did not always ask about language during home visits, and when they did, the questions were asked according to the child\u2019s age. After participating in the workshop, they referred to questions on whether the child emitted sound and spoke words.BEFORE:(CHA 1).To be honest, not me. No, I never asked that AFTER:(CHA 2).The mother or another adult responsible for the child, right? I\u2019ll come up with a name! Mary, is your child emitting sounds? What type of sounds? Can they say mama, papa? They reported that many parents ask questions, while others do not, and that questions come up mostly when they identify something in their children.(CHA 3).In my area, it depends; some families ask questions, right? \u2018Ana, see, he\u2019s such and such years old, he\u2019s already learning dirty language\u2019. Other families do not even so; they think it\u2019s normal not to speak. Not all of them ask, just some do. And I think the ones that ask know a little bit more, they are the ones who want more information Concerning the CHAs\u2019 procedure when they found a child who had not reached development milestones, they reported referring them to the team\u2019s nurse or physician, and that they scheduled appointments for the physician to assess that child and then refer them to the NASF-AB team. Moreover, the CHAs do not have any educational project on the topic in the unit.After the workshop, the CHAs reported first instructing families and then referring cases to their team\u2019s nurse or physician and then to the NASF-AB team.BEFORE:(CHA 2).We refer them to the nurse or physician, and they get in touch with NASF AFTER:(CHA 1).I present the case to my physician or nurse, right? Then, when they meet with the NASF team, we mention the case again and follow up on the process, you know? We always go to their house to check the child\u2019s development and growth, right? Assessments before and after the workshop revealed differences in the CHAs\u2019 knowledge of hearing and language development milestones. All CHAs stated that the experience contributed to their learning, further enriching home visit practices with the population in their first years of life. An aspect that stood out was the lack of difference in analysis categories on hearing and language development before and after the workshop.,16.All CHAs participating in the study were females, above 41 years old, having finished high school, and working in the position for more than 9 years. The predominance of females was verified in similar study results, in which females were prevalent, in the age range above 40 yearsConcerning the CHAs\u2019 KAP about hearing and language development milestones in early childhood, there were some flaws in their knowledge, and their practices were not based on evidence. CHAs must have conceptual and attitudinal skills regarding human communication health.. Thus, they need to be equipped to increase their potential of providing education, promotion, and prevention in human communication.It has been observed that CHAs have great knowledge, but they also need training regarding SLH issuesThe findings reveal that the team cooperation process with CHAs is essential to ensure that they have more qualified and engaged practice with service users and their needs. PHC must encourage their teams to share knowledge, prevent and promote health, and improve professionally to ensure comprehensive care to the population..Corroborating the perspective that team cooperation is essential to CHAs, a study stated that team cooperation leads to changes in the professionals\u2019 understanding and practice, as well as organizational changes in the Family Health Units and their relationship with the service network, thus demonstrating that team cooperation is an effective intervention toolBefore participating in the team cooperation workshop, the CHAs\u2019 knowledge of early childhood had a fragilized perspective of concepts acquired mainly in the context of health. It must be highlighted that early childhood does not refer to a date, but a comprehensive and specific development process people undergo at a certain time of their lives.. Therefore, CHAs\u2019 everyday practice must reflect their knowledge of the said Policy, as it guides child healthcare practices.Corroborating this aspect, the National Policy for Comprehensive Child Healthcare stated that early childhood is the part of life from 0 to 5 years old, or until turning 6 years old. Hence, to ensure that this stage is healthy, their development must be followed up with actions on all attention levels - promotion, protection, appointments, early detection, and rehabilitation of changes that may have consequences in their future livesThese aspects were verified in the CHAs\u2019 statements. These answers varied when asked about hearing, language, and following up on children and their families in home visits. Specifically, they seldom asked about hearing and more often asked about speech issues.. The study also points out that CHAs are responsible for following up on children\u2019s health in home visits, based on the personal child health record, which makes it possible to verify in detail their hearing and language development.Scientific contributions have referred to CHAs\u2019 reports on their approach in home visits regarding speech development, learning difficulties, and attention and concentration difficultiesHence, it is necessary to rethink the priority and importance teams give to this topic, how and how often it is brought up in discussions, the team cooperation methods involving CHAs, and the responsibilities they must carry out based on such team dialogue. CHAs are a unique category, as they are inserted in and belong to the community, having direct contact with the families. In this sense, their core information was expected to be more consistent.. Moreover, there is a reported lack of clarity on the part of the teams regarding CHAs\u2019 main responsibilities, reallocating them to other activities that require their time and hinder them from making home visits, as recommended, not to mention that some cases require even more visits.On the other hand, it is important to avoid blaming these professionals, as much is demanded from them. Corroborating this perspective, a study presented CHAs\u2019 reported overwork as a difficulty to their home visits, which may help justify their difficulty carrying out their duties effectively in the aspects analyzed in this study. Despite the fragilities - overwork, deviated functions, and lack of training -, CHAs provide guidance as they have contact with children and notice the possibility of interventions. However, there is scarce prevention based on previously informing the children\u2019s mothers.The responsibilities given to CHAs must also be reviewed to better define their role and dimension their actions, according to available resources, particularly avoiding deviating them from their functions. Thus, horizontalized teamwork integrating its various members reflects positively on the CHAs\u2019 work.It was also identified how CHAs refer cases to their health team and then to the NASF-AB team. This shows a fragility in the work organization between CHAs and Family Health Teams, as team discussions about cases were not reported. A study indicates that the work organization of Family Health Teams must be reviewed to provide CHAs with more room for dialogue with other team membersOne of the limitations of this study was the difference in the number of CHAs participating in the KAP questionnaire and focus groups. Moreover, there is little scientific literature on the topic, addressing the knowledge of CHAs in the team cooperation process to identify hearing and language development milestones in early childhood, in the context of home visits.It is essential to conduct further research on this topic to follow up on hearing and language development in early childhood. Thus, new studies should be conducted to equip increasingly more CHAs regarding development milestones.The results of this study allow for inferences on the CHAs\u2019 fragile knowledge about hearing and language development milestones in early childhood. Such knowledge, however, increased after the workshop. One aspect to highlight is that CHAs did not feel trained to instruct about hearing and language milestones. On the other hand, it verified the need to update professionals on the topic, thus stating the importance of team cooperation to these professionals.It is necessary to debate the CHAs\u2019 knowledge to identify hearing and language development milestones in early childhood, as they have privileged contact with the population and can perceive possible hindrances to children\u2019s hearing and speech development in their earliest years. .A Fonoaudiologia tem como seu principal instrumento de trabalho a comunica\u00e7\u00e3o humana. Esta por sua vez \u00e9 fundamental para o pleno desenvolvimento das pessoas. Considerando a import\u00e2ncia da comunica\u00e7\u00e3o para o desenvolvimento integral do indiv\u00edduo, o fonoaudi\u00f3logo \u00e9 um profissional imprescind\u00edvel na Aten\u00e7\u00e3o B\u00e1sica \u00e0 sa\u00fade, sendo ele o principal profissional reabilitador para prestar este cuidado. Na exist\u00eancia de dist\u00farbios na comunica\u00e7\u00e3o, h\u00e1 interfer\u00eancia diretamente em diversos \u00e2mbitos da vida das pessoas, sejam eles f\u00edsicos, sensoriais, psicol\u00f3gicos e sociais.Sendo assim a atua\u00e7\u00e3o do fonoaudi\u00f3logo na Aten\u00e7\u00e3o Prim\u00e1ria \u00e0 Sa\u00fade (APS) \u00e9 uma constru\u00e7\u00e3o recente e cheia de desafios. Essa atua\u00e7\u00e3o baseia-se primeiramente nos princ\u00edpios do Sistema \u00danico de Sa\u00fade (SUS), que visa oferecer a toda popula\u00e7\u00e3o um cuidado maior com as \u00e1reas da voz, linguagem, audi\u00e7\u00e3o e motricidade orofacial, favorecendo uma melhor qualidade de vida.Na APS cabe ao fonoaudi\u00f3logo junto \u00e0 equipe multidisciplinar, realizar diversas atividades, algumas s\u00e3o: diagn\u00f3stico situacional e institucional; acolhimento; visitas domiciliares; atendimentos individualmente e/ou em grupos; atua\u00e7\u00e3o em campanhas de sa\u00fade; educa\u00e7\u00e3o permanente das equipes, bem como a realiza\u00e7\u00e3o e divulga\u00e7\u00e3o de pesquisas.A linguagem \u00e9 uma das \u00e1reas de atua\u00e7\u00e3o da fonoaudiologia, no qual o seu papel \u00e9 fundamental na organiza\u00e7\u00e3o perceptual, na recep\u00e7\u00e3o e estrutura\u00e7\u00e3o das informa\u00e7\u00f5es e intera\u00e7\u00f5es sociais. Al\u00e9m disso, temos a audi\u00e7\u00e3o constituindo-se como um pr\u00e9-requisito para a aquisi\u00e7\u00e3o e desenvolvimento da linguagem. Tendo como um dos principais dist\u00farbios que pode interferir no desenvolvimento da linguagem e da fala, a defici\u00eancia auditiva. Onde a audi\u00e7\u00e3o e a linguagem s\u00e3o fun\u00e7\u00f5es correlacionadas e interdependentes.Com o intuito de solucionar essas demandas e alcan\u00e7ar a aten\u00e7\u00e3o integral \u00e0 sa\u00fade, o N\u00facleo Ampliado de Sa\u00fade da Fam\u00edlia e Aten\u00e7\u00e3o B\u00e1sica (Nasf-AB), foi criado em 2008, pela portaria 154 do Minist\u00e9rio da Sa\u00fade (MS), objetivando ampliar a abrang\u00eancia e o escopo das a\u00e7\u00f5es de aten\u00e7\u00e3o b\u00e1sica. Suas equipes s\u00e3o compostas por profissionais de diferentes \u00e1reas de conhecimento, que devem atuar de forma integrada, apoiando as Equipes de Sa\u00fade da Fam\u00edlia (EqSF), compartilhando as pr\u00e1ticas e saberes em sa\u00fade nos territ\u00f3rios sob responsabilidade destas equipes.O Nasf-AB deve ter seu trabalho orientado pelo referencial te\u00f3rico-metodol\u00f3gico do apoio matricial. Uma vez que este apoio proporciona a produ\u00e7\u00e3o de sa\u00fade de maneira inovadora com a incorpora\u00e7\u00e3o da pr\u00e1tica interdisciplinar, garantindo a integralidade da aten\u00e7\u00e3o em todo o sistema de sa\u00fade. A atua\u00e7\u00e3o da fonoaudiologia atrav\u00e9s de visitas domiciliares apresenta-se como uma importante ferramenta de promo\u00e7\u00e3o \u00e0 sa\u00fade da popula\u00e7\u00e3o.A visita domiciliar \u00e9 uma oportunidade diferente de cuidado que visa promover sa\u00fade \u00e0 comunidade, desenvolve-se em um espa\u00e7o externo \u00e0 unidade de sa\u00fade. Caracteriza-se por fazer uso de uma tecnologia leve, permitindo o cuidado de forma mais humana, acolhedora, estabelecendo la\u00e7os de confian\u00e7a entre profissionais e usu\u00e1rios, a fam\u00edlia e a comunidade.O MS utiliza marcos do desenvolvimento como referencial para o acompanhamento das crian\u00e7as durante as consultas de puericultura. Considerando a periodicidade deste acompanhamento realizado na unidade de sa\u00fade, no qual envolve o controle de peso e a estatura, o acompanhamento do desenvolvimento auditivo e de linguagem podem ser inclu\u00eddos nestas consultas, ou ainda, durante as visitas domiciliares pode aplicar estes instrumentos.Os marcos sugeridos pelo MS que envolvem os comportamentos auditivos e da linguagem s\u00e3o: reage ao som, emite sons, localiza o som, emite sons, emite sons, ri alto, duplica s\u00edlabas, produz \u201cjarg\u00e3o\u201d, fala uma palavra, fala 3 palavras, fala frases com 2 palavras.Os Agentes Comunit\u00e1rios de Sa\u00fade (ACS) s\u00e3o o p\u00fablico-alvo para as a\u00e7\u00f5es de apoio matricial do Nasf-AB. Eles podem fornecer um apoio basilar \u00e0 preven\u00e7\u00e3o, diagn\u00f3stico e interven\u00e7\u00e3o na defici\u00eancia auditiva e nas altera\u00e7\u00f5es de linguagem da crian\u00e7a. Estes profissionais s\u00e3o o v\u00ednculo entre o SUS e a comunidade. Atuando como os identificadores e encaminhadores (quando necess\u00e1rio) de riscos ou problemas que possam interferir no desenvolvimento auditivo e de linguagemA forma\u00e7\u00e3o dos ACS promove um conhecimento mais amplo acerca da atua\u00e7\u00e3o da fonoaudiologia no apoio matricial sobre o desenvolvimento auditivo e de linguagem na primeira inf\u00e2ncia, no contexto da visita domiciliar, tanto para a comunidade cient\u00edfica, para os profissionais dos servi\u00e7os de sa\u00fade, gestores e popula\u00e7\u00e3o usu\u00e1ria da Fonoaudiologia no SUS.Diante do exposto, este artigo objetivou analisar o conhecimento dos ACS sobre os marcos do desenvolvimento auditivo e de linguagem na primeira inf\u00e2ncia, no contexto da visita domiciliar, antes e ap\u00f3s a oficina de apoio matricial. A perspectiva \u00e9 colaborar com o avan\u00e7o cient\u00edfico sobre a problem\u00e1tica acima exposta, tendo em vista a escassez de estudos na literatura cient\u00edfica.O presente estudo foi aprovado pelo Comit\u00ea de \u00c9tica em Pesquisas do Centro de Ci\u00eancias da Sa\u00fade da Universidade Federal de Pernambuco, sob o n\u00famero do Parecer: 4.147.895..Foram conduzidas abordagens metodol\u00f3gicas qualitativa e quantitativa, com desenho do tipo pesquisa-a\u00e7\u00e3o. Sendo a pesquisa-a\u00e7\u00e3o um tipo de pesquisa social com base emp\u00edrica que \u00e9 concebida e realizada em estreita associa\u00e7\u00e3o com uma a\u00e7\u00e3o ou a resolu\u00e7\u00e3o de um problema coletivo e no qual os pesquisadores e os participantes representativos da situa\u00e7\u00e3o ou do problema est\u00e3o envolvidos de modo cooperativo ou participativoA \u00e1rea do presente estudo refere-se ao territ\u00f3rio coberto pela Unidade de Sa\u00fade da Fam\u00edlia de Vila Uni\u00e3o, localizada no Distrito Sanit\u00e1rio IV do munic\u00edpio do Recife - PE. A unidade possui quatro Equipes de Sa\u00fade da Fam\u00edlia.Participaram da etapa quantitativa da pesquisa 18 ACS. E quatro agentes participaram da segunda etapa qualitativa da pesquisa, onde voluntariamente uma ACS de cada equipe se disp\u00f4s a participar. Essa segunda etapa teve a participa\u00e7\u00e3o de apenas quatro, pois o estudo foi realizado em um momento de pandemia. As participantes foram recrutadas, a partir do convite para a participa\u00e7\u00e3o na pesquisa.As participantes foram informadas e esclarecidas verbalmente e por escrito sobre os objetivos do estudo e procedimentos da coleta de dados do trabalho. Aquelas que concordaram em participar assinaram o Termo de Consentimento Livre e Esclarecido.Crit\u00e9rios de inclus\u00e3o: atuar h\u00e1 mais de um ano na fun\u00e7\u00e3o de ACS na USF selecionada para o estudo, ter interesse e disponibilidade para participar da pesquisa. Foram exclu\u00eddas as ACS que estavam de licen\u00e7a ou f\u00e9rias no per\u00edodo da coleta de dados.A coleta dos dados ocorreu em tr\u00eas fases: Diagn\u00f3stico situacional; A\u00e7\u00e3o; e Avalia\u00e7\u00e3o da a\u00e7\u00e3o. Inicialmente foi realizado o diagn\u00f3stico situacional, atrav\u00e9s de um formul\u00e1rio de entrevista do tipo estruturado para obter dados a respeito dos Conhecimentos, Atitudes e Pr\u00e1ticas (CAP) das participantes da pesquisa referente aos marcos do desenvolvimento auditivo e de linguagem na primeira inf\u00e2ncia.O instrumento de coleta de dados foi constru\u00eddo pelas pesquisadoras. Foram consideradas refer\u00eancias para cada uma das dimens\u00f5es do m\u00e9todo CAP, os seguintes aspectos: :25.Conhecimento - refere-se a relembrar fatos espec\u00edficos  ou a habilidade para resolver os problemas de forma espec\u00edfica ou saber definir conceitos de acordo com a compreens\u00e3o adquirida sobre uma determinada tem\u00e1tica ou evento. Atitude - \u00e9 ter opini\u00e3o, predisposi\u00e7\u00e3o, cren\u00e7a, sentimento, afetividade, relativamente incessantes, acerca de algo, de uma situa\u00e7\u00e3o ou de pessoas. Est\u00e1 relacionado com o dom\u00ednio afetivo, retrata a dimens\u00e3o emocional. Pr\u00e1tica - \u00e9 a delibera\u00e7\u00e3o para realizar uma a\u00e7\u00e3o. Est\u00e1 relacionado aos dom\u00ednios cognitivo e psicomotor, refor\u00e7a uma dimens\u00e3o socialO formul\u00e1rio foi constitu\u00eddo de dois blocos de vari\u00e1veis. O primeiro, composto por vari\u00e1veis sociodemogr\u00e1ficas e profissionais e, o segundo bloco por vari\u00e1veis referentes aos Conhecimentos, Atitudes e Pr\u00e1tica.Tamb\u00e9m foi realizado um grupo focal com as ACS participantes do estudo, conduzido no espa\u00e7o da USF Vila Uni\u00e3o, antes e ap\u00f3s a oficina..O grupo focal \u00e9 uma entrevista com um pequeno n\u00famero de pessoas sobre um t\u00f3pico espec\u00edfico que enfatiza a aten\u00e7\u00e3o por diferentes opini\u00f5es. Cada pessoa \u00e9 estimulada a apresentar suas ideias e a ouvir e responder as outras, sendo assim o grupo focal tem como objetivo a sinergia entre as pessoas e n\u00e3o o consenso. A pesquisa do tipo grupo focal tamb\u00e9m proporciona centraliza\u00e7\u00e3o da discuss\u00e3o; informa\u00e7\u00f5es em maior profundidade por conta da intera\u00e7\u00e3o e influ\u00eancia do grupo; custos reduzidos; t\u00e9cnica e resultados facilmente entendidos; evidencia as diferen\u00e7as de opini\u00f5es e contradi\u00e7\u00f5es entre os participantes; possibilita resultados r\u00e1pidosO grupo foi conduzido por um moderador e um respons\u00e1vel pelo registro das falas. As respostas dadas pelo grupo foram gravadas e posteriormente transcritas.Foram dirigidas \u00e0s participantes perguntas orientadoras, organizadas a partir de quatro eixos de an\u00e1lise. Caso o grupo n\u00e3o respondesse satisfatoriamente, seriam dirigidas as perguntas auxiliares.Para assegurar o anonimato, as entrevistadas foram identificadas pela sigla ACS e pelo n\u00famero da entrevista. Para exemplificar: a primeira Agente Comunit\u00e1ria de Sa\u00fade entrevistada foi identificada como (ACS1), a segunda como (ACS2) e assim sucessivamente.A a\u00e7\u00e3o da presente pesquisa foi desenvolvida por meio de uma oficina de apoio matricial, com est\u00edmulo \u00e0 autonomia na constru\u00e7\u00e3o do saber pelos ACS, com carga hor\u00e1ria m\u00e9dia de quatro horas. A oficina foi realizada a partir de uma explana\u00e7\u00e3o e discuss\u00e3o sobre os marcos de desenvolvimento da audi\u00e7\u00e3o e linguagem e a conduta do ACS na visita domiciliar ap\u00f3s a identifica\u00e7\u00e3o desses marcos. As atividades foram programadas atrav\u00e9s de din\u00e2micas com intuito de descontrair e, ao mesmo tempo, envolver as integrantes com a proposta pedag\u00f3gica, incentivando a participa\u00e7\u00e3o e, de antem\u00e3o, a reflex\u00e3o do tema central da oficina .A coleta dos dados foi finalizada com a realiza\u00e7\u00e3o de um novo grupo focal, conduzido no espa\u00e7o da USF Vila Uni\u00e3o, ap\u00f3s a oficina, nos mesmos moldes do primeiro grupo focal, onde foram realizadas as mesmas perguntas orientadoras, acrescidas de perguntas referentes ao processo vivenciado na oficina.. A an\u00e1lise foi desenvolvida atrav\u00e9s das seguintes etapas: leitura flutuante das transcri\u00e7\u00f5es para compreender o todo e organizar os dados; identifica\u00e7\u00e3o de categorias e subcategorias de an\u00e1lise nas falas dos sujeitos; descri\u00e7\u00e3o dos resultados; e interpreta\u00e7\u00e3o dos resultados (questionamento da rela\u00e7\u00e3o entre as categorias e subcategorias de an\u00e1lise e os objetivos propostos pelo estudo). Para a an\u00e1lise do question\u00e1rio CAP se fez uso da estat\u00edstica descritiva (distribui\u00e7\u00e3o de frequ\u00eancia absoluta e relativa). Onde todos os dados foram digitados e calculados atrav\u00e9s do programa Microsoft Excel, vers\u00e3o 2007.Os dados qualitativos foram analisados atrav\u00e9s da an\u00e1lise de conte\u00fado, segundo BardinParticiparam da pesquisa 18 ACS, todas do sexo feminino. A faixa et\u00e1ria predominante foi de 41 a 50 anos de idade . Em rela\u00e7\u00e3o \u00e0 escolaridade, a maioria afirmou possuir ensino m\u00e9dio completo . Cerca de 88,9% atua na fun\u00e7\u00e3o h\u00e1 nove anos ou mais .A avalia\u00e7\u00e3o dos conhecimentos, atitudes e pr\u00e1ticas das agentes comunit\u00e1rias de sa\u00fade sobre os marcos do desenvolvimento auditivo e de linguagem na primeira inf\u00e2ncia demonstrou certa fragilidade de conhecimento sobre o tema, assim como uma pr\u00e1tica sem embasamento .conhecimento das ACS sobre a primeira inf\u00e2ncia, antes da participa\u00e7\u00e3o na oficina de apoio matricial, foi identificada fragilidade nas falas sobre a tem\u00e1tica .Ouvir os respons\u00e1veis, observar, orientar e fazer o encaminhamento. Que no caso \u00e9 o agendamento para os profissionais na unidade de sa\u00fade ao tipo de orienta\u00e7\u00e3o que seria dada, relatam o cart\u00e3o de vacina, puericultura, amamenta\u00e7\u00e3o e alimenta\u00e7\u00e3o como sendo algumas das orienta\u00e7\u00f5es. Ap\u00f3s a oficina, as falas permanecem com o mesmo sentido com acr\u00e9scimo dos marcos do desenvolvimento que est\u00e3o dispon\u00edveis na caderneta de sa\u00fade da crian\u00e7a para que as ACS orientem as fam\u00edlias.J\u00e1 no que diz respeito ANTES:(ACS 1).\u00c9... primeiro lugar \u00e9 orientar sobre a amamenta\u00e7\u00e3o n\u00e9? A import\u00e2ncia da amamenta\u00e7\u00e3o tudinho e orientar a vir frequentemente quando tiver marcada a puericultura para acompanhar o desenvolvimento da crian\u00e7a e orientar a mamadeira, chupeta essas coisas. E ver o cart\u00e3o de vacina sempre pra ver se a vacina t\u00e1 em dia AP\u00d3S:(ACS 1).\u00c9 orientar n\u00e9? Sempre t\u00e1 orientando os pais pra que sempre veja a caderneta da vacina onde tem o desenvolvimento e crescimento da crian\u00e7a n\u00e9? A gente tem que orientar eles e tamb\u00e9m encaminhar eles se a gente identificar algum, como \u00e9 que se diz? Algum sinal n\u00e9? Na crian\u00e7a, na fala, na audi\u00e7\u00e3o conhecimento com rela\u00e7\u00e3o aos marcos do desenvolvimento auditivo n\u00e3o apareceu nas respostas das agentes. Ap\u00f3s a participa\u00e7\u00e3o na oficina esses marcos aparecem na fala das agentes onde elas citam a identifica\u00e7\u00e3o do som e a localiza\u00e7\u00e3o do som como sendo marcos auditivos.O ANTES:(ACS 3).eu num lembro n\u00e3o AP\u00d3S:(ACS 3).S\u00e3o localizar o som e identificar o som perguntas sobre a audi\u00e7\u00e3o na visita domiciliar, onde as agentes relatam direcionar mais perguntas relacionadas \u00e0 linguagem. Assim como tamb\u00e9m n\u00e3o h\u00e1 por parte das fam\u00edlias perguntas direcionadas para quest\u00f5es de audi\u00e7\u00e3o. Sempre h\u00e1 exist\u00eancia de perguntas relacionadas \u00e0 linguagem.Percebe-se tamb\u00e9m na fala das agentes a inexist\u00eancia de Ap\u00f3s a participa\u00e7\u00e3o na oficina, as ACS direcionam em seus discursos perguntas para a visita domiciliar direcionadas \u00e0 percep\u00e7\u00e3o da m\u00e3e sobre rea\u00e7\u00f5es e respostas da crian\u00e7a quando escuta um barulho mais alto, ou se a crian\u00e7a se assusta ao escutar algum barulho.ANTES:(ACS 1).Geralmente eu pergunto mais a gente pergunta mais da fala n\u00e9? Ai as vezes \u00e9 que assim a gente pergunta se a crian\u00e7a se assusta com barulho, som alto, mas geralmente mesmo a gente pergunta mais na fala e no andar da crian\u00e7a AP\u00d3S:(ACS 2).Perguntar \u00e0 m\u00e3e, perguntar como \u00e9 que t\u00e1 n\u00e9? \u00c9. Perguntar aos respons\u00e1veis se quando bate palma a crian\u00e7a de algum sinal de que est\u00e1 ouvindo, se quando cai alguma coisa se a crian\u00e7a tem alguma rea\u00e7\u00e3o, se quando algu\u00e9m t\u00e1 falando como \u00e9 que fica a express\u00e3o dela n\u00e9, os olhos, o jeitinho da cabe\u00e7a, perguntando aos respons\u00e1veis pra poder da\u00ed tirar algumas conclus\u00f5es marcos de desenvolvimento da linguagem as ACS trouxeram em seus relatos a inexist\u00eancia de conhecimento perante os marcos. Mostrando mais uma vez, fragilidade de conhecimento sobre a tem\u00e1tica. Ap\u00f3s a participa\u00e7\u00e3o na oficina elas trazem em suas falas alguns marcos de linguagem. Demonstrando assim que conseguiram abranger o conhecimento sobre os marcos de linguagem durante a oficina.J\u00e1 com rela\u00e7\u00e3o aos ANTES:(ACS 4) .A linguagem papa, pepe, dada, querquer n\u00e9? E a gente vai observando se vai evoluir ou se ele vai ficar s\u00f3 nisso ou ent\u00e3o s\u00f3 apontar AP\u00d3S:(ACS 3) .S\u00e3o 8 marcos, tem como \u00e9 que se diz? Emitir sons, emite sons e ri alto, \u00e9 falar uma palavra, falar com duplica\u00e7\u00e3o de palavras, aos 5 anos ela j\u00e1 fala frases, ela j\u00e1 fala frases completas que voc\u00ea j\u00e1 entende perguntas sobre a linguagem durante suas visitas domiciliares e quando fazem direcionam as perguntas de acordo com a idade da crian\u00e7a. J\u00e1 ap\u00f3s a participa\u00e7\u00e3o na oficina, trazem em suas falas perguntas direcionadas \u00e0 emiss\u00e3o de sons e elabora\u00e7\u00e3o de palavras pela crian\u00e7a.Relatam ainda que nem sempre costumam fazer ANTES:(ACS 1).Eu pra ser sincera n\u00e3o. Nunca perguntei n\u00e3o AP\u00d3S:(ACS 2).M\u00e3e o respons\u00e1vel n\u00e9. Vou dar um nome! Maria a sua crian\u00e7a j\u00e1 est\u00e1 emitindo sons, que tipo de som? J\u00e1 consegue dizer mama, papa? questionamentos por parte dos familiares, elas relatam que muitos pais questionam, j\u00e1 outros n\u00e3o. As perguntas surgem mais quando os pais identificam algo em seus filhos.J\u00e1 com rela\u00e7\u00e3o aos (ACS 3).Na minha \u00e1rea \u00e9 muito relativo tem fam\u00edlia que pergunta n\u00e9? Ana oia ele j\u00e1 t\u00e1 com tantos meses j\u00e1 fala bobagem. Outros nem assim, acha que \u00e9 normal mesmo num falar, mas num \u00e9 todas que pergunta n\u00e3o, s\u00e3o algumas. E eu acho que \u00e9 as que tem um pouquinho mais de conhecimento, na verdade s\u00e3o essas que tentam buscar mais informa\u00e7\u00f5es conduta das agentes perante aos casos que possam surgir no caso de uma crian\u00e7a n\u00e3o atingir algum marco do desenvolvimento, foi relatado o repasse do caso para enfermeira ou m\u00e9dica de sua equipe, relataram ainda que marcam consulta m\u00e9dica para que aquela crian\u00e7a seja avaliada pela m\u00e9dica e depois disso o caso seja ent\u00e3o repassado para a equipe Nasf-AB. Percebe-se tamb\u00e9m, que as ACS n\u00e3o realizam nenhum trabalho educativo na unidade sobre a tem\u00e1tica.No que diz respeito \u00e0 Ap\u00f3s a oficina, as agentes relataram como conduta a realiza\u00e7\u00e3o no primeiro momento de orienta\u00e7\u00f5es para as fam\u00edlias, e encaminhamento do caso para sua equipe de sa\u00fade, se referindo \u00e0 m\u00e9dica ou \u00e0 enfermeira, e ap\u00f3s isso repassar para a equipe Nasf-AB.ANTES:(ACS 2).Passar pra enfermeira ou pra m\u00e9dica que elas entram em contato com o Nasf AP\u00d3S:(ACS 1).Eu trago o caso assim pra minha m\u00e9dica ou minha enfermeira n\u00e9? Pra elas, pra depois quando tiver a reuni\u00e3o com o pessoal do Nasf a gente passar novamente o caso e a gente ficar acompanhando n\u00e9? Ficar sempre indo na casa, vendo como \u00e9 que t\u00e1 o desenvolvimento e crescimento dessa crian\u00e7a n\u00e9? Nas avalia\u00e7\u00f5es pr\u00e9 e p\u00f3s-oficina, observaram-se diferen\u00e7as quanto ao conhecimento das ACS referente aos marcos do desenvolvimento auditivo e de linguagem. Todas as ACS afirmam que a experi\u00eancia contribuiu para o seu aprendizado, enriquecendo ainda mais a pr\u00e1tica da visita domiciliar junto \u00e0 popula\u00e7\u00e3o nos primeiros anos de vida. Um dos grandes aspectos de destaque foi o diferencial das categorias de an\u00e1lise sobre os marcos do desenvolvimento auditivo e de linguagem, no qual houve inexist\u00eancia antes da oficina e relato ap\u00f3s.,16.A totalidade das ACS participantes do estudo foi do sexo feminino, possui mais de 41 anos de idade, ensino m\u00e9dio completo, e exerce a fun\u00e7\u00e3o h\u00e1 mais de nove anos. A predomin\u00e2ncia do sexo feminino foi verificada em resultados semelhantes obtidos atrav\u00e9s de alguns estudos, pelos quais, o sexo feminino era prevalente e a faixa et\u00e1ria era entre 40 anos ou maisQuanto aos conhecimentos, atitudes e pr\u00e1ticas das agentes comunit\u00e1rias de sa\u00fade sobre os marcos do desenvolvimento auditivo e de linguagem na primeira inf\u00e2ncia, houve demonstra\u00e7\u00e3o de certa fragilidade no conhecimento sobre o tema, assim como pr\u00e1tica sem embasamento. Se faz necess\u00e1rio que o ACS tenha habilidades conceituais e atitudinais com rela\u00e7\u00e3o \u00e0 sa\u00fade da comunica\u00e7\u00e3o humana.. Portanto, h\u00e1 necessidade de realizar capacita\u00e7\u00f5es para esses profissionais, a fim de que se tornem agentes potenciais no que diz respeito a educa\u00e7\u00e3o, promo\u00e7\u00e3o e preven\u00e7\u00e3o na sa\u00fade da comunica\u00e7\u00e3o humana.Nesse sentido, observa-se que h\u00e1 muito conhecimento por parte dos ACS, por\u00e9m esta classe de trabalhadores necessita de capacita\u00e7\u00f5es inclusive da \u00e1rea fonoaudiol\u00f3gicaOs achados revelam que o processo de apoio matricial junto aos ACS \u00e9 fundamental para garantir uma atua\u00e7\u00e3o mais qualificada e engajada destes profissionais com os usu\u00e1rios do servi\u00e7o e suas demandas. O compartilhamento de saberes, a preven\u00e7\u00e3o, a promo\u00e7\u00e3o da sa\u00fade e o aprimoramento profissional de suas equipes s\u00e3o elementos que devem ser promovidos na APS, com o intuito de garantir um atendimento integral \u00e0 popula\u00e7\u00e3o..Corroborando com a perspectiva de que o apoio matricial \u00e9 fundamental aos ACS, um estudo afirma que atrav\u00e9s do apoio matricial h\u00e1 mudan\u00e7as na compreens\u00e3o e pr\u00e1tica dos profissionais, assim como mudan\u00e7as organizacionais na USF e em sua rela\u00e7\u00e3o com a rede de servi\u00e7os, evidenciando assim que o apoio matricial \u00e9 uma ferramenta de interven\u00e7\u00e3o efetivaAntes de participarem da oficina de apoio matricial, o conhecimento das ACS sobre a primeira inf\u00e2ncia trazia consigo uma perspectiva fragilizada dos conhecimentos repassados no \u00e2mbito da sa\u00fade, majoritariamente. Reitera-se que a primeira inf\u00e2ncia n\u00e3o \u00e9 uma data, mas faz parte de todo um processo espec\u00edfico de desenvolvimento que o indiv\u00edduo passa num determinado per\u00edodo da vida.. Nesse contexto, ent\u00e3o, se faz necess\u00e1rio, na pr\u00e1tica cotidiana das ACS, o conhecimento sobre a PNAISC, uma vez que ela \u00e9 orientadora das pr\u00e1ticas de aten\u00e7\u00e3o \u00e0 sa\u00fade da crian\u00e7a.Corroborando com esse aspecto, a PNAISC afirma que a primeira inf\u00e2ncia \u00e9 o per\u00edodo de vida entre zero e cinco anos ou at\u00e9 completar os seis anos. No sentido de garantir que essa etapa seja vivida de forma saud\u00e1vel, preconiza-se o acompanhamento do desenvolvimento da crian\u00e7a com a\u00e7\u00f5es que perpassam todos os n\u00edveis de aten\u00e7\u00e3o: promo\u00e7\u00e3o, prote\u00e7\u00e3o, atendimento, detec\u00e7\u00e3o precoce e reabilita\u00e7\u00e3o de altera\u00e7\u00f5es que podem repercutir na sua vida futuraDesse modo, observam-se esses aspectos nas falas das ACS. Quando questionadas sobre a realiza\u00e7\u00e3o de acompanhamento das crian\u00e7as e suas respectivas fam\u00edlias atrav\u00e9s da visita domiciliar, bem como nas perguntas sobre a audi\u00e7\u00e3o e linguagem, houve uma varia\u00e7\u00e3o de respostas. Especificamente, percebeu-se a aus\u00eancia de perguntas sobre audi\u00e7\u00e3o e a maior frequ\u00eancia da exist\u00eancia de questionamentos sobre fala.. O estudo aponta ainda que os agentes t\u00eam a responsabilidade de, em suas visitas domiciliares, fazer o acompanhamento da sa\u00fade da crian\u00e7a e, para isso, devem utilizar como instrumento de base a Caderneta de sa\u00fade da crian\u00e7a, a qual possibilita o acompanhamento detalhado do desenvolvimento da audi\u00e7\u00e3o e da linguagem.A respeito desse aspecto, h\u00e1 contribui\u00e7\u00e3o cient\u00edfica que aponta o relato dos ACS sobre a abordagem em suas visitas das tem\u00e1ticas: o desenvolvimento da fala, dificuldades de aprendizagem e dificuldades de aten\u00e7\u00e3o e concentra\u00e7\u00e3oAssim, \u00e9 necess\u00e1rio repensar sobre as prioridades e import\u00e2ncias que as equipes d\u00e3o a esse tema, a frequ\u00eancia e as formas pelas quais esse assunto \u00e9 posto em debate, os m\u00e9todos de matriciamento junto aos ACS\u2019s e atribui\u00e7\u00f5es que devem ser exercidas a partir desse di\u00e1logo nas equipes. Ressalta-se que os ACS s\u00e3o uma categoria singular pela sua inser\u00e7\u00e3o e perten\u00e7a \u00e0 comunidade, de modo a ter um contato direto com as fam\u00edlias, e, nesse sentido, esperou-se um n\u00facleo mais consistente de informa\u00e7\u00f5es por parte da categoria.. Al\u00e9m disso, sinaliza-se a falta de clareza das equipes quanto \u00e0s principais atribui\u00e7\u00f5es dos ACS, deslocando-os para outras atividades que demandam tempo e dificultam o cumprimento das visitas domiciliares conforme o preconizado, ou at\u00e9 em maior frequ\u00eancia, em caso de necessidade.Por outro lado, na tentativa de distanciamento de poss\u00edveis culpabiliza\u00e7\u00e3o sobre esses profissionais, ressalta-se o excesso de demandas a que esses trabalhadores s\u00e3o submetidos. Corroborando com essa perspectiva, um estudo evidenciou que a sobrecarga de trabalho \u00e9 relatada pelos agentes como uma dificuldade para realizar visitas domiciliares, o que pode auxiliar na tentativa de buscar justificativas para a dificuldade desses profissionais exercerem de modo efetivo sua fun\u00e7\u00e3o nos quesitos analisados neste trabalho. Apesar das fragilidades - sobrecarga de trabalho, desvio de fun\u00e7\u00f5es e falta de capacita\u00e7\u00e3o - as agentes, ao terem contato com as crian\u00e7as e perceberem uma poss\u00edvel interven\u00e7\u00e3o, desenvolvem orienta\u00e7\u00f5es. No entanto, a preven\u00e7\u00e3o a partir de informa\u00e7\u00f5es passadas previamente \u00e0s m\u00e3es das crian\u00e7as \u00e9 escassa.Tamb\u00e9m nessa perspectiva, a prescri\u00e7\u00e3o das atribui\u00e7\u00f5es dos ACS precisa ser revista para uma melhor defini\u00e7\u00e3o do papel desse trabalhador e dimensionamento de suas a\u00e7\u00f5es, de acordo com os recursos disponibilizados, evitando, sobretudo, o desvio de fun\u00e7\u00f5es. De fato, quando o trabalho em equipe ocorre de forma mais horizontalizada, com integra\u00e7\u00e3o entre seus membros, isso se reflete, positivamente, no trabalho do ACS.Outra quest\u00e3o identificada foi a forma como os ACS repassam os casos para sua equipe de sa\u00fade e, em seguida, para a equipe Nasf-AB. Demonstra-se, dessa maneira, uma fragilidade na organiza\u00e7\u00e3o do trabalho entre os agentes e as equipes da ESF, haja vista o n\u00e3o relato da discuss\u00e3o do caso em equipe. Um estudo indica que a organiza\u00e7\u00e3o do trabalho das equipes da ESF deve ser revista de forma a permitir que o ACS tenha um espa\u00e7o de di\u00e1logo fortalecido com os demais integrantes da equipeIdentificou-se como limita\u00e7\u00e3o do presente estudo a diferen\u00e7a no quantitativo de ACS que participou do question\u00e1rio CAP e dos grupos focais. Constatou-se tamb\u00e9m escassez de literatura cient\u00edfica nessa tem\u00e1tica sobre o conhecimento dos agentes comunit\u00e1rios de sa\u00fade no processo de apoio matricial sobre a identifica\u00e7\u00e3o dos marcos do desenvolvimento auditivo e de linguagem na primeira inf\u00e2ncia no contexto da visita domiciliar.A continuidade de pesquisas abordando essa tem\u00e1tica \u00e9 essencial para o acompanhamento do desenvolvimento auditivo e de linguagem na primeira inf\u00e2ncia. Desta forma, sugere-se que novos estudos sejam realizados, com o objetivo de capacitar cada vez mais agentes comunit\u00e1rios de sa\u00fade no que diz respeito aos marcos de desenvolvimento.Os resultados obtidos com este estudo permitem inferir a fragilidade no conhecimento sobre os marcos do desenvolvimento auditivo e de linguagem na primeira inf\u00e2ncia por parte das ACS. J\u00e1 no p\u00f3s-oficina o conhecimento foi ampliado. Uma quest\u00e3o a ser destacada \u00e9 o fato de que as agentes n\u00e3o se sentiam capacitadas para a realiza\u00e7\u00e3o de orienta\u00e7\u00f5es sobre os marcos auditivos e de linguagem. Contudo, foi apontada a necessidade de atualizar os profissionais sobre o tema, afirmando assim a import\u00e2ncia do apoio matricial para esses profissionais.O debate sobre o conhecimento dos ACS a respeito da identifica\u00e7\u00e3o dos marcos de desenvolvimento auditivo e de linguagem na primeira inf\u00e2ncia \u00e9 necess\u00e1rio, devido ao fato de que esses profissionais possuem um contato privilegiado com a popula\u00e7\u00e3o, conseguindo perceber os poss\u00edveis entraves que permeiam o desenvolvimento da audi\u00e7\u00e3o e da fala apresentados pelas crian\u00e7as nos anos iniciais de sua trajet\u00f3ria de vida."}
+{"text": "To identify the effects of prophylactic, non-pharmacological measures on the progression of dysphagia in patients with head and neck cancer undergoing radiotherapy.The search was performed in Medline (via PubMed), Scopus, and Embase databases, as well as in the gray literature.Randomized clinical trials were included, with adult patients (\u2265 18 years old) and diagnosed with head and neck cancer, treated with radiotherapy (with or without surgery and chemotherapy), and submitted to non-pharmacological protocols for the prevention of dysphagia.The risk of bias was assessed using the PEDRO scale and the overall quality of evidence was assessed using the GRADE instrument.Four studies were considered eligible, and of these, two were included in the meta-analysis. The result favored the intervention group, with a mean difference of 1.27 [95% CI: 0.74 to 1.80]. There was low heterogeneity and the mean score for risk of bias was 7.5 out of 11 points. The lack of detail in the care with selection, performance, detection, attrition, and reporting biases contributed to the judgment of the quality of the evidence, considered low.Prophylactic measures to contain dysphagia can promote important benefits on the oral intake of patients with head and neck cancer when compared to those who did not undergo such a therapeutic measure during radiotherapy. This disorder causes oral nutrition limitation and damage to the nutritional state, increasing the risk of recurrent aspiration pneumonia. Due to the role of oral nutrition in the functionality and quality of life, it is fundamental to detect early alterations indicating the onset of dysphagia to soften the impact of the disorder on the cancer treatment course.Dysphagia is a common alteration in patients with head and neck cancer (HNC).It is known that patients with HNC who are subjected to radiotherapy (RT) may have their swallowing function more damaged than those who are only subjected to surgical intervention. The adverse effects caused by radiation, like mucositis, xerostomia, pain, skin reactions, and swelling, combined with tissue fibrosis, contribute to swallowing deterioration,6. In these cases, it is common to resort to alternative nutrition routes during the treatment; however, it is known that despite being necessary, an artificial diet can be insufficient to maintain the nutritional state and may also act negatively on the evolution of dysphagia-9.In general, the whole skeletal muscle is affected by the poor nutritional state caused by the reduction in swallowing capacity. In such a process, the muscle involved in the swallowing process loses performance and the clinical condition worsens,6. The skeletal muscles start to show evidence of atrophy by disuse only a few hours after immobilization,10.Due to the adverse effects that appear throughout the treatment, the individuals may have their oral food intake either limited or interrupted, and such disuse of the muscle involved in swallowing can stimulate the remodeling of the muscles and possibly potentialize fibrosis and radio-induced swelling,11.Dysphagia recovery associated with HNC involves multiple approaches, especially in patients treated with radiotherapy due to the long-term effects induced by ionizing radiation (tissue fibrosis). Over the past few years, the effect of different prophylaxis models on dysphagia has been investigated in the context of antineoplastic treatment to identify the ideal moment to start an intervention,6.These are some important measures since RT, despite its desired antitumor effects, promotes cumulative effects in molecular routes of the skeletal muscle, which implies changes in the muscle configuration with mutation of both the type and size of the muscle fibers, an increase of local fatty tissue, and redistribution of fibers in the muscle.Even though these preventive measures have been investigated and sometimes applied, a consensus is yet to be reached regarding the effect of prophylactic measures on the degree of dysphagia. Therefore, this systematic review study aimed to assess the effect of prophylactic interventions on the progression of dysphagia associated with HNC in patients subjected to radiotherapy to guide and favor the decision-making process in the early clinical managementThis study aimed to identify the effect of non-pharmacological prophylactic measures on the progression of dysphagia in patients with head and neck cancer who are subjected to radiotherapy.. The review is described according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA Statement) according to the checklist in the Supplementary Material. This research was also registered in the International Prospective Register of Systematic Reviews (PROSPERO) identified as CRD42021226726, using the PICO  strategy,16.This study is based on the recommendations of the Cochrane HandbookWe included only randomized clinical tests whose at least one arm analyzed the prophylactic effect of non-pharmacological interventions on dysphagia by comparing the results with a control group. The sample includes adult patients with a diagnosis of HNC and indication of radiotherapy, associated or not with chemotherapy and surgery, with or without dysphagia at the beginning of the study.We considered the following primary outcome: progression of dysphagia degree assessed by the difference between the initial and final assessments. There were no restrictions regarding the dysphagia measurement method or instrument since the results were normalized through the difference between the initial and final degrees of the dysphagia state. The secondary outcome considered the analysis of the nutritional profile and the presence of alternative nutrition routes.As for the intervention of interest, there was no restriction or referring to either one or another prophylactic measure of prevention or progression (worsening) of dysphagia. The techniques of specific prophylaxis were not compared, only their effects were measured regarding the usual care  or regarding a placebo or sham treatments.We excluded studies without any non-pharmacological intervention for the prevention of dysphagia and/or speech therapy assessment.Our search was performed on the following main databases: Medline (via PubMed), Scopus, and Embase, in addition to the gray literature on the Clinical Trial, WHO International Clinical Trials Registry Platform, REBEC, OpenGrey, as well as abstracts of potentially relevant congresses over the past five years. A manual search for papers was also conducted by screening the references of the papers included in this systematic review. We started the selection process of the studies right after the last search (December 2020).There was no restriction of languages or publication dates for the studies on the databases and in the gray literature. We used several morphological variations and synonym terms related to the following words: \u201cHead and neck neoplasms\u201d, \u201cDeglutition disorders\u201d, \u201cDysphagia\u201d, \u201cSwallowing disorders\u201d, \u201cPrevention\u201d, \u201cProphylactic\u201d, \u201cRandomized controlled trial\u201d, \u201crandomized\u201d, \u201ccontrolled\u201d, and \u201ctrial\u201d. The full search strategy for each bibliographic base is described in the Supplementary Material.After excluding the repeated papers, two reviewers (AGB and NSF) assessed the titles and abstracts independently. The papers were selected based on the eligibility criteria using the software of bibliographical management (Mendeley). At this step, any disagreements were analyzed by a third reviewer (FEM).After the exclusion based on the titles and abstracts, the full texts were read by the two reviewers for the final decision of either including or excluding the paper. Any disagreements were resolved by a third reviewer (FEM).Data extraction was performed by two authors (AGB and NSF) using a standard form for the following information: study design, first author, year of publication, location, sampling size, clinical characteristics of the volunteers, detailed description of the interventions implemented, control groups, and pre-and post-treatment values for the results generated from the different dysphagia assessment scales, both for the control group and the intervention group.All information was organized and stored in a file on the Excel software, and the disagreements between the authors were resolved by consensus with the third reviewer, who performed the data checking., and the final evaluations were discussed and defined combined with all authors. To score the criteria of the scale, the information must be clear and objective, otherwise, the score is considered null. Two independent reviewers (EDP and VBM) assessed the risk of bias ,22. For each outcome, the quality of evidence is initially considered \u2018high\u2019 and subsequently can be lower graded to the levels of \u2018moderate\u2019, \u2018low\u2019, or \u2018very low\u2019 quality, depending on the assessment of the following five criteria: risk of bias in the individual studies, indirect evidence, heterogeneity, imprecision, and risk of bias in the publication. The quality of evidence was individually evaluated in two ways: a) for the body of evidence composed only of studies included in the meta-analysis and b) for the body of evidence included in this systematic review, composed of the entirety of the narratively synthesized individual studies.The global quality of evidence was assessed based on the GRADE approachThe bias of publication was assessed through linear regression of the estimates of the intervention effect by its reverse variance using the Egger test and a Funnel Plot chart.,20 were statistically collected from a meta-analysis. The analysis followed the reverse method of variances and estimator of Der Simonian and Laird for \u03c42 in a model of random effects, which allows for statistically incorporating the variability between studies into the estimate of the final effect. For continuous outcomes, we used the data of the post-treatment means of each group to calculate the effect size (Cohen D) from a mean weighted difference (MWD).According to . All analyses were performed on the RStudio software (version 1.3.1093) using the \u2018meta\u2019 package in the R language (version 4.0.3).The results of studies that did not report the data as mean and standard deviation (SD) in the metanalyses were included by converting the data from median to mean according to the Hozo method2I statistical and the 2\u03c7 test. The statistical heterogeneity was interpreted according to the most recent guidelines . Heterogeneity is classified based on the 2I values as follows: up to 40% is a trivial effect, from 30 to 60% is moderate, from 50 to 90% is substantial, and from 75% to 100% is considerable heterogeneity.The statistical heterogeneity was quantitatively assessed using the Our search strategy resulted in 312 studies . Four st,18-20.The sample included 165 volunteers , predomi. This is important information since RT-induced dysphagia tends to be more severe, and sometimes chronic, in elderly individuals.The distribution of the participant's age (57.6 \u00b1 8.2 years old) was close to the usual occurrence of HNC in the age group of 60-75 years carried out a study with volunteers randomized in three arms, but only the \u201cPharyngocise\u201d (intervention) and usual care (control) groups were considered in the analysis. Messing et al., Mortensen et al., and Kotz et al. distributed their volunteers into only two arms (intervention and control). Three studies,18,20 applied scales for the assessment of oral intake, and two tests,19 used videofluoroscopy.Carnaby-Mann et al.,18-20 or intensity-modulated RT (IMRT),18,19. The IMRT is known to preserve the regions close to the tumor, reducing the radiation effects on the stomatognathic functions. Radio-induced fibrosis is one of the main undesirable effects of RT and can become chronic in the absence of early intervention. In addition, throughout the RT treatment, the irradiated muscle is modified regarding the distribution of type of fiber, and the predominance is altered to type-I muscle fibers, which lowers the speed of contraction and may slow the swallowing movement and delay the pharyngeal response, which, combined, worsen the risk of aspiration.All patients were treated with conventional RT. Either individually or combined, these effects affect the swallowing process leading to significant systemic repercussions that can negatively influence the adherence to the cancer treatment, which, in turn, requires the deployment of multidisciplinary prophylactic interventions,29.In addition to the muscle alterations, depending on the irradiated region, RT may promote different degrees of alteration in sensitivity, taste, salivary flow, and laryngeal swelling: diet supervision and safe nutrition , individualized dietary counseling, and reference to a specialized speech therapist to assess the swallowing and treatment of dysphagic symptoms if persisting after the treatment completion.The intervention protocols of the studies included herein are composed of different techniques of exercises and associated swallowing maneuvers, mostly an adaptation of food consistency. For the volunteers in the control group, the usual care implemented in the patient care routines was preserved by the speech therapy service of the hospital. Still, perhaps because at this phase of the treatment, the strong catabolic predominance affects all patients indiscriminately regardless of any stomatognathic alterations that can appear early. In contrast, the finding of equivalent nutritional conditions reveals, indirectly, that nutritional care is extremely relevant for the maintenance of functional capacity.We found no significant change in the nutritional state between the groups by the end of the interventions . Such reEven so, the mean difference between the groups by the end of the third month of tracking, assessed through the random effect, reveals that the prophylactic measures significantly increase the FOIS  score, indicating that the intervention affected the oral intake. The values of mean weighted difference and effect size were 1.27 [IC95%: 0.74 to 1.80] and 3.17 (Cohen D), respectively, in favor of the intervention. However, despite such an expressive effect size, it is worth highlighting that this analysis counted only 33 volunteers in each arm (intervention/control). The low sampling number and the inclusion of only two studies do not invalidate the analysis but imply some caution at the moment of interpreting and transposing the results to daily clinical practice. It is also worth emphasizing the low heterogeneity among the studies ; however, evidence suggests that maintaining oral nutrition and practicing swallowing exercises throughout the cancer treatment have a positive impact both on diet consistency and the swallowing physiology, quality of life, and reduction in the use of alternative nutrition routines. Apparently, swallowing exercises reduce the impairment by radio-induced fibrosis, preserving the function of the muscles involved in the stomatognathic functions and contributing to preserving the capacities of mouth opening, chewing, and swallowing food.According to Starmer (2014),11,12. The severity of such an impairment can be closely linked to the early interruption of oral nutrition since the maintenance of this via  provides a lower impact on the muscle involved and increases the possibility of recovery of the muscle homeostasis after the treatment,11.Atrophy by disuse emerges early and manifests as greater fatigue, and lower strength, in addition to damaged amplitude of movements and motor control reinforce the importance of multi-professional actions in the clinical decision-making process to ensure the referring to early patient care. Knowing the complications resulting from the HNC treatment is fundamental to anticipating the intervention of speech therapy since it allows, to some extent, minimizing the harmful effects caused by the antineoplastic treatment on swallowing. The data of this meta-analysis reinforce such a recommendation and can contribute to the progress of multi-professional patient care qualification in this clinical scenario.De Felice et al.,35.The preventive measures adopted to prevent the progression of dysphagia throughout the HNC treatment impose the patients with a series of indispensable physical and behavioral adaptations to face the clinical condition involved. Therefore, the multi-professional team has an important role when assessing and identifying the symptoms inherent to the treatment by planning and reinforcing the stimuli of adherence to actions aimed at the care entiretyDespite the prophylactic intervention has been suggested to benefit swallowing through exercises, it is not possible to state that all patients will preserve or recover their swallowing functionality. It is expected that at least one in 2.15 patients reaches positive results (NNT 2.15) in the effect size analysis., important confounding factors for the analysis of results. In turn, such results cannot be assumed as definitive, but rather partial data given the limitations described.There was an 81% probability of superiority in the FOIS for the volunteers who practiced the swallowing exercises. In general, the FOIS values for 89% of the volunteers in the intervention group were higher than the mean of the control group. Even so, the limitations of sample size, high loss percentage, discrepancy among the therapeutical programs, and low adherence to the exercises are, according to Lazarus et al..Apparently, adherent patients have greater chances of achieving benefits that are closer to the superior values of the confidence interval. Thereby, it is reasonable to assume that prophylactic exercises should be encouraged as much as possible since there was no report of undesirable effects or events that could have compromised the RT continuity. These results must be considered with caution, but at the same time, should stimulate further studies. However, we found no evidence indicating any benefit to the patients allocated in the control groups. Thus, the low risk involved in the swallowing exercises and the good probability of benefits justify the prophylactic use of such techniques to manage and control the progression of dysphagia associated with HNC. In addition, other important outcomes should be studied, such as pain , and the effectiveness of cough; in addition, other protection maneuvers of lower airways should be included in further studies. Likewise, there is some evidence that electrostimulation, in association with exercises, favors the maintenance of muscle function, conservation, and/or recovery of the salivary flow, in addition to reducing laryngeal swelling-40.Even though this review is focused on the analysis of the prophylactic effect of swallowing exercise protocols on the progression of dysphagia, it is worth highlighting the valuable contribution of other associated techniques. Laser therapy, for example, is indicated to prevent or treat mucositis and can improve the swallowing pattern by reducing odynophagia during nutritionIt is still not possible to determine the ideal moment to start the prophylactic intervention or the most efficient therapeutic strategies. Further studies should clarify issues concerning the number of sessions, weekly frequency, intervention duration, types of exercises, muscle overload intensity, number of repetitions/series, and other components that constitute a complete recovery program. So far, it is known that a certain benefit is provided, which justifies further efforts to enlarge and deepen the evidence. refer to the blinding of the evaluators, blinding of the participants, and absence of information concerning the protocols used in the clinical practice  summarizes the evaluations performed for the body of evidence present in the meta-analysis and the narrative description of the systematic review. The quality of evidence was evaluated as low due to the risk of bias in the individual studies and the issues related to the imprecision of results. Based on the evidence presented, it is reasonable to assume that patients with HNC can experience some positive effects on oral intake through prophylactic swallowing exercises compared with those who are not subjected to this therapeutic measure throughout radiotherapy. However, the low quality of evidence and the limited details on the actions implemented in the patient care protocols justify further studies. . Esta disfun\u00e7\u00e3o causa limita\u00e7\u00e3o na alimenta\u00e7\u00e3o por via oral e preju\u00edzo no estado nutricional aumentando o risco de pneumonias aspirativas recorrentes. Devido ao papel que a alimenta\u00e7\u00e3o por via oral representa na funcionalidade e qualidade de vida dos indiv\u00edduos, \u00e9 fundamental detectar precocemente as altera\u00e7\u00f5es que sinalizam o in\u00edcio da disfagia, visando minimizar o impacto que este dist\u00farbio promove no curso do tratamento oncol\u00f3gico.A disfagia \u00e9 uma altera\u00e7\u00e3o comum nos pacientes com c\u00e2ncer de cabe\u00e7a e pesco\u00e7o (CCP).Sabe-se que pacientes com CCP submetidos \u00e0 radioterapia (RT) podem apresentar maior preju\u00edzo na degluti\u00e7\u00e3o quando comparados \u00e0queles que realizam apenas interven\u00e7\u00e3o cir\u00fargica. Os efeitos adversos provocados pela radia\u00e7\u00e3o como mucosite, xerostomia, dor, rea\u00e7\u00f5es cut\u00e2neas e edema, aliados \u00e0 fibrose tecidual, contribuem para o decl\u00ednio na degluti\u00e7\u00e3o,6. \u00c9 comum, nestes casos, a utiliza\u00e7\u00e3o de vias alternativas para alimenta\u00e7\u00e3o durante o tratamento, no entanto sabe-se que, embora necess\u00e1ria, a alimenta\u00e7\u00e3o artificial pode ser insuficiente para manter o estado nutricional e pode ainda agir negativamente sobre a evolu\u00e7\u00e3o da disfagia-9.De um modo geral toda a musculatura esquel\u00e9tica \u00e9 afetada pelo prec\u00e1rio estado nutricional promovido pela redu\u00e7\u00e3o da capacidade de engolir, e nesse processo a pr\u00f3pria musculatura envolvida no processo de degluti\u00e7\u00e3o perde performance agravando o quadro cl\u00ednico,6. Os m\u00fasculos esquel\u00e9ticos j\u00e1 come\u00e7am a mostrar evid\u00eancias de atrofia por desuso apenas algumas horas ap\u00f3s a imobiliza\u00e7\u00e3o,10.Devido aos efeitos adversos que iniciam durante o tratamento, os indiv\u00edduos podem apresentar limita\u00e7\u00e3o ou interrup\u00e7\u00e3o da ingesta de alimentos por via oral e esse desuso da musculatura envolvida na degluti\u00e7\u00e3o pode estimular a remodela\u00e7\u00e3o dos m\u00fasculos e possivelmente exacerbar a fibrose e o edema radioinduzido,11.A reabilita\u00e7\u00e3o da disfagia associada ao CCP, envolve m\u00faltiplas abordagens principalmente nos pacientes tratados com radioterapia, em fun\u00e7\u00e3o dos efeitos de longo prazo induzidos pela radia\u00e7\u00e3o ionizante . Nos \u00faltimos anos, tem-se investigado o efeito de diferentes modelos de profilaxia da disfagia ao longo do tratamento antineopl\u00e1sico com o objetivo de identificar o momento ideal para iniciar a interven\u00e7\u00e3o,6.Tais medidas s\u00e3o importantes pois a RT, apesar dos efeitos antitumorais desejados, promove efeitos cumulativos em vias moleculares da musculatura esquel\u00e9tica o que implica em mudan\u00e7a na configura\u00e7\u00e3o muscular com muta\u00e7\u00e3o do tipo e tamanho das fibras musculares, aumento de tecido adiposo local e redistribui\u00e7\u00e3o de fibras dentro do m\u00fasculo.Embora essas medidas preventivas estejam sendo investigadas e por vezes utilizadas, ainda n\u00e3o existe um consenso quanto ao efeito de medidas profil\u00e1ticas sobre o grau da disfagia. Nesse sentido, este estudo de revis\u00e3o sistem\u00e1tica da literatura visou avaliar o efeito de interven\u00e7\u00f5es profil\u00e1ticas na progress\u00e3o da disfagia associada ao CCP de pacientes submetidos \u00e0 radioterapia no intuito de direcionar e auxiliar a tomada de decis\u00e3o no manejo cl\u00ednico precoceO objetivo deste estudo foi identificar o efeito de medidas profil\u00e1ticas, n\u00e3o farmacol\u00f3gicas, sobre a progress\u00e3o da disfagia de pacientes com c\u00e2ncer de cabe\u00e7a e pesco\u00e7o submetidos \u00e0 radioterapia.Cochrane Handbook. A revis\u00e3o foi descrita de acordo com o Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA Statement) conforme checklist que consta no Material Suplementar. Posteriormente, foi registrada no International Prospective Register of Systematic Reviews (PROSPERO), com a seguinte identifica\u00e7\u00e3o: CRD42021226726 e utilizou-se a estrat\u00e9gia PICO ,16.O estudo est\u00e1 baseado nas recomenda\u00e7\u00f5es preconizadas pelo Foram inclu\u00eddos apenas ensaios cl\u00ednicos randomizados que analisaram em um bra\u00e7o do estudo o efeito profil\u00e1tico de interven\u00e7\u00f5es n\u00e3o farmacol\u00f3gicas sobre a disfagia comparando os resultados a um grupo controle. A amostra se deu por pacientes adultos com diagn\u00f3stico de CCP e indica\u00e7\u00e3o de radioterapia, associados ou n\u00e3o a quimioterapia e cirurgia, com ou sem disfagia no in\u00edcio do estudo.Foi considerado desfecho prim\u00e1rio: progress\u00e3o do grau da disfagia, avaliada pela diferen\u00e7a entre a avalia\u00e7\u00e3o inicial e final; n\u00e3o houveram restri\u00e7\u00f5es quanto ao m\u00e9todo ou instrumento de mensura\u00e7\u00e3o da disfagia, pois os resultados foram normalizados atrav\u00e9s da diferen\u00e7a entre a gradua\u00e7\u00e3o inicial e final do estado de disfagia. Como desfecho secund\u00e1rio considerou-se a an\u00e1lise do perfil nutricional e presen\u00e7a de via alternativa para alimenta\u00e7\u00e3o.Quanto a interven\u00e7\u00e3o de interesse, n\u00e3o houve restri\u00e7\u00e3o ou direcionamento para uma ou outra medida profil\u00e1tica de preven\u00e7\u00e3o ou progress\u00e3o (agravo) da disfagia. N\u00e3o houve compara\u00e7\u00e3o entre t\u00e9cnicas de profilaxia espec\u00edficas, apenas a medida do efeito em rela\u00e7\u00e3o aos cuidados usuais  ou em rela\u00e7\u00e3o \u00e0 tratamento placebo ou sham.Foram exclu\u00eddos estudos que n\u00e3o envolvessem interven\u00e7\u00e3o n\u00e3o farmacol\u00f3gica para preven\u00e7\u00e3o da disfagia e/ou que n\u00e3o envolvessem avalia\u00e7\u00e3o fonoaudiol\u00f3gica.A busca foi realizada nas principais bases de dados: Medline (via PubMed), Scopus e Embase, assim como na literatura cinzenta por meio do Clinical Trial, WHO International Clinical Trials Registry Platform, REBEC OpenGrey e resumos de congressos potencialmente relevantes nos \u00faltimos 5 anos. A busca manual por artigos tamb\u00e9m foi realizada por uma triagem das refer\u00eancias dos artigos inclu\u00eddos na presente revis\u00e3o sistem\u00e1tica. O processo da sele\u00e7\u00e3o dos estudos iniciou logo ap\u00f3s a \u00faltima busca (dezembro de 2020)Head and neck neoplasms\u201d, \u201cDeglutition disorders\u201d, \u201cDysphagia\u201d, \u201cSwallowing disorders\u201d, \u201cPrevention\u201d, \u201cProphylactic\u201d, \u201cRandomized controlled trial\u201d, \u201crandomized\u201d, \u201ccontrolled\u201d e \u201ctrial\u201d. A estrat\u00e9gia de busca completa para cada base bibliogr\u00e1fica est\u00e1 descrita no Material Suplementar.N\u00e3o houve restri\u00e7\u00e3o de idiomas ou data de publica\u00e7\u00e3o dos estudos das bases de dados e da literatura cinzenta. Foram utilizadas diversas varia\u00e7\u00f5es morfol\u00f3gicas e termos sin\u00f4nimos relacionados \u00e0s seguintes palavras: \u201cAp\u00f3s exclus\u00e3o de artigos em duplicata, dois revisores (AGB e NSF) avaliaram de forma independente os t\u00edtulos e resumos obtidos. Os artigos foram selecionados com base nos crit\u00e9rios de elegibilidade em um software de gerenciamento bibliogr\u00e1fico (Mendeley). Nessa etapa, as discord\u00e2ncias foram analisadas por um terceiro revisor (FEM).Ap\u00f3s a exclus\u00e3o realizada com base nos t\u00edtulos e resumos, os textos completos foram lidos, pelos dois revisores, para a decis\u00e3o final de inclus\u00e3o ou exclus\u00e3o, resolvendo qualquer discord\u00e2ncia por intermedia\u00e7\u00e3o do terceiro revisor (FEM).A extra\u00e7\u00e3o de dados foi realizada por dois autores (AGB e NSF), atrav\u00e9s de um formul\u00e1rio padronizado com as seguintes informa\u00e7\u00f5es: delineamento do estudo, primeiro autor, ano de publica\u00e7\u00e3o, local onde o estudo foi conduzido, tamanho amostral, caracter\u00edsticas cl\u00ednicas dos volunt\u00e1rios, descri\u00e7\u00e3o detalhada das interven\u00e7\u00f5es implementadas no grupo interven\u00e7\u00e3o e controle, e os valores pr\u00e9 e p\u00f3s-tratamento para os resultados obtidos nas diferentes escalas de avalia\u00e7\u00e3o da disfagia, tanto para grupo controle quanto para grupo interven\u00e7\u00e3o.Todas as informa\u00e7\u00f5es foram organizadas e armazenadas no software Excel, e as discord\u00e2ncias entre os autores foram resolvidas por consenso com o terceiro revisor, que realizou a checagem de dados., sendo que os julgamentos finais foram discutidos e definidos em conjunto com todos os autores. Para pontuar nos crit\u00e9rios da escala, as informa\u00e7\u00f5es deveriam ser claras e objetivas, caso contr\u00e1rio a pontua\u00e7\u00e3o seria considerada nula, os resultados est\u00e3o expressos no Dois revisores independentes (EDP e VBM) avaliaram o risco de vi\u00e9s ,22. Para cada desfecho, a qualidade da evid\u00eancia \u00e9 inicialmente considerada \u2018alta\u2019 e subsequentemente pode ser graduada para baixo aos n\u00edveis \u2018moderada\u2019, \u2018baixa\u2019 ou \u2018muito baixa\u2019 qualidade, a depender da avalia\u00e7\u00e3o de cinco crit\u00e9rios: risco de vi\u00e9s dos estudos individuais, evid\u00eancia indireta, heterogeneidade, imprecis\u00e3o e risco de vi\u00e9s de publica\u00e7\u00e3o. A qualidade da evid\u00eancia foi separadamente julgada de duas formas: a) para o corpo de evid\u00eancia composto apenas pelos estudos inclu\u00eddos na metan\u00e1lise; e b) para o corpo de evid\u00eancia inclu\u00eddo na presente revis\u00e3o sistem\u00e1tica, composto pela totalidade de estudos individuais narrativamente sintetizados.A qualidade global da evid\u00eancia foi avaliada com base na abordagem GRADEPara avalia\u00e7\u00e3o do vi\u00e9s de publica\u00e7\u00e3o foi utilizada regress\u00e3o linear das estimativas do efeito da interven\u00e7\u00e3o por sua vari\u00e2ncia inversa por meio do Egger test e do gr\u00e1fico Funnel Plot.,20 foram estatisticamente compilados em uma meta-an\u00e1lise. A an\u00e1lise foi conduzida utilizando o m\u00e9todo do inverso das vari\u00e2ncias e estimador de Der Simonian and Laird para \u03c42 em modelo de efeitos rand\u00f4micos, o que permite incorporar estatisticamente a variabilidade entre estudos na estimativa de efeito final. Para desfechos cont\u00ednuos, foram utilizados os dados das m\u00e9dias p\u00f3s-tratamento de cada grupo para c\u00e1lculo do tamanho de efeito (Cohen D) a partir da diferen\u00e7a m\u00e9dia ponderada (DMP).Conforme descrito na . Todas as an\u00e1lises foram conduzidas no software RStudio (vers\u00e3o 1.3.1093) com o pacote \u2018meta\u2019 na linguagem R (vers\u00e3o 4.0.3).Para inclus\u00e3o de resultados dos estudos que n\u00e3o relataram os dados em m\u00e9dia e desvio padr\u00e3o (DP) nas meta-an\u00e1lises, a convers\u00e3o de dados de mediana para m\u00e9dia foi realizada pelo m\u00e9todo de Hozo2I e o teste de 2\u03c7 . A interpreta\u00e7\u00e3o da heterogeneidade estat\u00edstica seguiu as orienta\u00e7\u00f5es mais recentes , onde 2I at\u00e9 40% representa heterogeneidade de efeito trivial de 30 a 60% representa heterogeneidade moderada; de 50 a 90% representa heterogeneidade substancial e de 75% a 100% apresenta heterogeneidade consider\u00e1vel.A heterogeneidade estat\u00edstica foi avaliada quantitativamente utilizando a estat\u00edstica A estrat\u00e9gia de busca resultou em 312 estudos , que ap\u00f3,18-20.A amostra incluiu 165 volunt\u00e1rios , sendo q. Esse \u00e9 um dado importante, pois a disfagia induzida pela RT tende a ser mais grave, e por vezes cr\u00f4nica, em indiv\u00edduos idosos.A distribui\u00e7\u00e3o da idade dos participantes  ficou pr\u00f3xima da incid\u00eancia de CCP que comumente ocorre na faixa et\u00e1ria de 60-75 anos os volunt\u00e1rios foram randomizados em tr\u00eas bra\u00e7os, mas apenas os grupos \u201cPharyngocise\u201d (interven\u00e7\u00e3o) e de cuidados usuais (controle) foram considerados na an\u00e1lise. Nos estudos de Messing et al., Mortensen et al. e Kotz et al., a distribui\u00e7\u00e3o dos volunt\u00e1rios foi realizada em apenas dois bra\u00e7os (interven\u00e7\u00e3o e controle). Tr\u00eas estudos,18,20 aplicaram escalas para avalia\u00e7\u00e3o da ingest\u00e3o oral e dois ensaios,19 utilizaram a videofluoroscopia.No estudo realizado por Carnaby-Mann et al.,18-20 ou RT de intensidade modulada (IMRT),18,19. Sabe-se que a IMRT preserva as regi\u00f5es pr\u00f3ximas ao tumor, reduzindo os efeitos da radia\u00e7\u00e3o sobre as fun\u00e7\u00f5es estomatogn\u00e1ticas. A fibrose radioinduzida \u00e9 um dos principais efeitos indesej\u00e1veis da RT, e pode tornar-se cr\u00f4nica na aus\u00eancia de interven\u00e7\u00e3o precoce. Al\u00e9m disso, ao longo do tratamento com RT, a musculatura irradiada sofre modifica\u00e7\u00e3o na distribui\u00e7\u00e3o do tipo de fibra alterando o predom\u00ednio para fibras musculares do tipo I, o que reduz a velocidade de contra\u00e7\u00e3o podendo gerar lentid\u00e3o do movimento de degluti\u00e7\u00e3o e atraso da resposta far\u00edngea, que em conjunto agravam o risco de aspira\u00e7\u00e3o.Todos os pacientes foram tratados com RT convencional. Separadamente ou em conjunto estes efeitos afetam o processo de degluti\u00e7\u00e3o levando \u00e0 repercuss\u00f5es sist\u00eamicas significativas, capazes de influenciar negativamente na ades\u00e3o ao tratamento oncol\u00f3gico, o qu\u00ea, por sua vez, torna necess\u00e1rio a implementa\u00e7\u00e3o de interven\u00e7\u00f5es multidisciplinares profil\u00e1ticas,29.Adicionalmente \u00e0s altera\u00e7\u00f5es musculares, a RT, dependendo da regi\u00e3o irradiada, pode promover diferentes graus de altera\u00e7\u00e3o da sensibilidade, paladar, fluxo salivar e edema lar\u00edngeo, aconselhamento diet\u00e9tico individualizado e encaminhamento a um fonoaudi\u00f3logo especializado para avalia\u00e7\u00e3o da degluti\u00e7\u00e3o e tratamento de sintomas disf\u00e1gicos, se estivessem presentes ap\u00f3s a conclus\u00e3o do tratamento.Os protocolos de interven\u00e7\u00e3o, dos estudos inclu\u00eddos nesta revis\u00e3o, foram compostos por diferentes t\u00e9cnicas de exerc\u00edcios e manobras de degluti\u00e7\u00e3o associadas, em sua maioria, a adapta\u00e7\u00e3o de consist\u00eancia alimentar. Para os volunt\u00e1rios do grupo controle, foram mantidos os cuidados usuais implementados nas rotinas assistenciais como: supervis\u00e3o para alimenta\u00e7\u00e3o e cuidados para alimenta\u00e7\u00e3o segura  pelo servi\u00e7o de fonoaudiologia do hospital ou talvez porque nessa fase do tratamento, o forte predom\u00ednio catab\u00f3lico afete indiscriminadamente todos os pacientes a despeito de quaisquer altera\u00e7\u00f5es estomatogn\u00e1ticas que precocemente possam ocorrer. Por outro lado, a constata\u00e7\u00e3o de condi\u00e7\u00f5es nutricionais equivalentes revela, de forma indireta, a import\u00e2ncia dos cuidados nutricionais t\u00e3o importantes para a manuten\u00e7\u00e3o da capacidade funcional.N\u00e3o foi identificada mudan\u00e7a significativa no estado nutricional entre os grupos ao final das interven\u00e7\u00f5es . Estes r, evid\u00eancias sugerem que manter a dieta por via oral e praticar exerc\u00edcios de degluti\u00e7\u00e3o durante o tratamento oncol\u00f3gico t\u00eam impacto positivo tanto sobre a consist\u00eancia da dieta quanto na fisiologia da degluti\u00e7\u00e3o, qualidade de vida e redu\u00e7\u00e3o do uso de vias alternativas de alimenta\u00e7\u00e3o. Aparentemente, os exerc\u00edcios de degluti\u00e7\u00e3o reduzem o comprometimento por fibrose radioinduzida, preservando a fun\u00e7\u00e3o dos m\u00fasculos envolvidos nas fun\u00e7\u00f5es estomatogn\u00e1ticas e contribuindo para a manuten\u00e7\u00e3o da capacidade de abertura da boca, mastiga\u00e7\u00e3o e degluti\u00e7\u00e3o dos alimentos.Ainda assim, a m\u00e9dia da diferen\u00e7a entre os grupos ao final do terceiro m\u00eas de seguimento, avaliada atrav\u00e9s do efeito rand\u00f4mico, mostra que as medidas profil\u00e1ticas aumentam significativamente a pontua\u00e7\u00e3o na escala FOIS  o que significa dizer que houve efeito da interven\u00e7\u00e3o sobre a ingesta oral. A m\u00e9dia da diferen\u00e7a ponderada foi de 1,27  e o tamanho do efeito foi de 3,17 (Cohen D) \u00e0 favor da interven\u00e7\u00e3o. Contudo, embora o tamanho do efeito tenha sido expressivo, cabe salientar que esta an\u00e1lise contou com apenas 33 volunt\u00e1rios em cada bra\u00e7o (interven\u00e7\u00e3o/controle). O baixo n\u00famero amostral e a inclus\u00e3o de apenas dois estudos n\u00e3o inviabilizam a an\u00e1lise, mas requer cautela no momento de interpretar e transpor os resultados para a pr\u00e1tica cl\u00ednica di\u00e1ria. \u00c9 importante ressaltar tamb\u00e9m que houve baixa heterogeneidade entre os estudos , mas ain,11,12. A gravidade do comprometimento pode estar intimamente ligada a interrup\u00e7\u00e3o precoce da alimenta\u00e7\u00e3o por via oral, pois com a manuten\u00e7\u00e3o desta via (ou treinamento envolvendo a degluti\u00e7\u00e3o) menor ser\u00e1 o impacto na musculatura envolvida e maior ser\u00e1 a possibilidade de recupera\u00e7\u00e3o da homeostase muscular ap\u00f3s o tratamento,11.A atrofia por desuso, que surge precocemente, se manifesta com aumento da fadiga, redu\u00e7\u00e3o da for\u00e7a, preju\u00edzo na amplitude dos movimentos e no controle motor refor\u00e7am a import\u00e2ncia da atua\u00e7\u00e3o multiprofissional na tomada de decis\u00e3o cl\u00ednica que garanta o direcionamento assistencial precoce. Conhecer as complica\u00e7\u00f5es decorrentes do tratamento do CCP \u00e9 fundamental para a antecipa\u00e7\u00e3o da interven\u00e7\u00e3o fonoaudiol\u00f3gica, pois \u00e9 poss\u00edvel, em certa medida, minimizar os efeitos delet\u00e9rios que o tratamento antineopl\u00e1sico promove sobre a degluti\u00e7\u00e3o. Os dados desta metan\u00e1lise refor\u00e7am essa recomenda\u00e7\u00e3o e podem contribuir para o progresso da qualifica\u00e7\u00e3o assistencial multiprofissional neste cen\u00e1rio cl\u00ednico.De Felice et al.,35.As medidas preventivas adotadas para conter a progress\u00e3o da disfagia ao longo do tratamento do CCP, exigem dos pacientes uma s\u00e9rie de adapta\u00e7\u00f5es f\u00edsicas e comportamentais imprescind\u00edveis para o enfrentamento que esta condi\u00e7\u00e3o cl\u00ednica imp\u00f5e. Nesse sentido, a equipe multiprofissional assume papel importante, avaliando e identificando os sintomas inerentes ao tratamento, para planejar e refor\u00e7ar os est\u00edmulos de ades\u00e3o \u00e0s condutas pertinentes visando a integralidade do cuidadoEmbora tenha sido identificado benef\u00edcio na interven\u00e7\u00e3o profil\u00e1tica para a degluti\u00e7\u00e3o por meio de exerc\u00edcios, n\u00e3o se pode afirmar que todos os pacientes ir\u00e3o manter ou recuperar a funcionalidade da degluti\u00e7\u00e3o. Na an\u00e1lise do tamanho do efeito espera-se que um paciente em cada 2.15 possa ter resultados positivos (NNT 2.15)., \u00e9 um importante fator confundidor para a an\u00e1lise dos resultados, esses resultados n\u00e3o podem ser assumidos como definitivos e sim como dados parciais dadas as limita\u00e7\u00f5es descritas.A probabilidade de superioridade na escala FOIS foi de 81% para os volunt\u00e1rios que praticaram os exerc\u00edcios de degluti\u00e7\u00e3o. De um modo geral 89% dos volunt\u00e1rios do grupo interven\u00e7\u00e3o apresentaram valores na escala FOIS superiores \u00e0 m\u00e9dia do grupo controle. Ainda assim, em fun\u00e7\u00e3o das limita\u00e7\u00f5es de tamanho amostra, elevado percentual de perda, discrep\u00e2ncia considerada entre programas terap\u00eauticos e baixa ades\u00e3o aos exerc\u00edcios institu\u00eddos que, segundo Lazarus, et al. (2014).Ao que tudo indica, pacientes aderentes t\u00eam mais chances de alcan\u00e7ar benef\u00edcios pr\u00f3ximos aos valores superiores do intervalo de confian\u00e7a. Sendo assim, \u00e9 razo\u00e1vel assumir que os exerc\u00edcios profil\u00e1ticos devem ser encorajados ao m\u00e1ximo, pois n\u00e3o houve relato de efeitos indesejados ou eventos que tenham comprometido a continuidade da RT. Esses resultados devem ser considerados com cautela, mas ao mesmo tempo, devem servir de est\u00edmulo para novos estudos. No entanto, n\u00e3o encontramos ind\u00edcios que sinalizem qualquer benef\u00edcio aos pacientes alocados nos grupos controles. Sendo assim, o baixo risco envolvido com o emprego dos exerc\u00edcios de degluti\u00e7\u00e3o e a boa probabilidade de benef\u00edcios justificam o uso profil\u00e1tico destas t\u00e9cnicas para o manejo e controle da progress\u00e3o da disfagia associada ao CCP. Al\u00e9m disso, outros desfechos importantes poderiam ser estudados, como por exemplo dor , efetividade da tosse e demais manobras de prote\u00e7\u00e3o de vias a\u00e9reas inferiores poderiam ser inclu\u00eddos em estudos futuros. Do mesmo modo, existem evid\u00eancias de que a eletroestimula\u00e7\u00e3o, se utilizada associada aos exerc\u00edcios, auxilia na manuten\u00e7\u00e3o da fun\u00e7\u00e3o muscular, preserva\u00e7\u00e3o e/ou recupera\u00e7\u00e3o do fluxo salivar e redu\u00e7\u00e3o do edema lar\u00edngeo-40.Embora essa revis\u00e3o tenha centralizado a an\u00e1lise no efeito profil\u00e1tico de protocolos de exerc\u00edcios de degluti\u00e7\u00e3o sobre a progress\u00e3o da disfagia, \u00e9 v\u00e1lido ressaltar a valiosa contribui\u00e7\u00e3o que outras t\u00e9cnicas podem gerar quando associadas. A laserterapia, por exemplo, \u00e9 indicada para a preven\u00e7\u00e3o ou para o tratamento da mucosite e pode melhorar o padr\u00e3o de degluti\u00e7\u00e3o, visto que reduz a odinofagia durante a alimenta\u00e7\u00e3oAinda n\u00e3o \u00e9 poss\u00edvel afirmar qual o momento ideal para iniciar a interven\u00e7\u00e3o profil\u00e1tica, nem quais as estrat\u00e9gias terap\u00eauticas s\u00e3o mais eficazes. Mais estudos dever\u00e3o elucidar quest\u00f5es referentes ao n\u00famero de sess\u00f5es, frequ\u00eancia semanal, dura\u00e7\u00e3o da interven\u00e7\u00e3o, tipos de exerc\u00edcios, intensidade de sobrecarga muscular, n\u00famero de repeti\u00e7\u00f5es/s\u00e9ries e demais componentes que constituem um programa completo de reabilita\u00e7\u00e3o. Por ora sabemos que existe certo benef\u00edcio e isso justifica empreender mais esfor\u00e7o na amplia\u00e7\u00e3o e aprofundamento das evid\u00eancias., referem-se ao cegamento dos avaliadores, cegamento dos participantes e aus\u00eancia de informa\u00e7\u00f5es referentes aos protocolos utilizados na pr\u00e1tica cl\u00ednica  resume os julgamentos realizados para o corpo de evid\u00eancia presente na metan\u00e1lise e na descri\u00e7\u00e3o narrativa da revis\u00e3o sistem\u00e1tica. A qualidade da evid\u00eancia foi julgada como baixa em fun\u00e7\u00e3o do risco de vi\u00e9s nos estudos individuais e tamb\u00e9m pelas quest\u00f5es relacionadas \u00e0 imprecis\u00e3o dos resultados. As justificativas para cada julgamento constam em maiores detalhes no Com base nas evid\u00eancias apresentadas, \u00e9 admiss\u00edvel supor que pacientes com CCP podem apresentar efeito positivo sobre a ingesta oral ao realizar exerc\u00edcios profil\u00e1ticos de degluti\u00e7\u00e3o quando comparados aqueles que n\u00e3o realizaram tal medida terap\u00eautica ao longo da radioterapia. No entanto, a baixa qualidade da evid\u00eancia e o restrito detalhamento das condutas utilizadas nos protocolos assistenciais, justificam a execu\u00e7\u00e3o de novos estudos."}
+{"text": "To examine the perceptions of adolescent students from a public school, of both sexes, living in a peripheral region of the city of S\u00e3o Paulo, Brazil, in relation to the covid-19 pandemic, with a special focus on their experiences regarding education and sociability. This study is part of the Global Early Adolescent Study. Seven face-to-face focus groups were conducted with adolescents between 13 and 16 years old (19 girls and 15 boys) in 2021. The experience of remote teaching was frustrating for the adolescents, without the daily and personalized monitoring of the teacher(s). In addition to the difficult or impossible access to devices and the lack of support from schools, there is also the domestic environment, which made the schooling process more difficult, especially for girls, who were forced to take on more household and family care tasks. The closed school blocked an important space for socialization and forced family interaction, generating conflicts and stress in the home environment. The abrupt rupture brought feelings of fear, uncertainty, anguish and loneliness. The iterative evocation of the words \u201cstuck\u201d, \u201calone\u201d and \u201cloneliness\u201d and the phrase \u201cthere was no one to talk to\u201d shows how most of the adolescents experienced the period of distancing. The pandemic aggravated the objective and subjective conditions of preexisting feelings, such as \u201cnot knowing the future\u201d and the prospects of a life project. It has been documented how pandemic control measures implemented in a fragmented way and without support for the most impoverished families have negative effects on other spheres of life, in particular for poor young people. The school is a privileged territory to propose/construct actions that help adolescents to deal with problems aggravated in/by the pandemic. The covid-19 pandemic was especially devastating for impoverished urban communities living in high-density areas, with limited access to such resources as public services, region/neighborhood infrastructure, and disposable income to sustain lockdowns  related to contagion and illnessThe closing of schools was one of the first non-pharmacological measures adopted in the face of the covid-19 pandemic \u2013 and the longest lasting one \u2013, having a major negative effect on the learning process. The return to face-to-face activities in schools was marked by several protocols with different intervention measures. Our understanding of how adolescents from different contexts  have experienced and are still facing ruptures in educational, family and social terms requires in-depth and transversal analysis.4, mainly due to the deleterious effects of the suspension of face-to-face classes and closure of schools on the health and well-being of children, adolescents and young people7.Unlike adults, who are more subject to severe forms of the disease, adolescents seem to be more affected in terms of psychosocial health and emotional well-being9.The social and economic crisis generated by the pandemic exacerbates social inequalities, which tend to worsen/degrade the living conditions of those living in poor communities, altering their educational aspirations, health and well-being. Understanding the individual, relational, family and social effects, in the short, medium and long term, associated with the pandemic context, on the trajectories of adolescents from poor urban communities is one of the objectives of the international multicenter Global Early Adolescent Study (Geas), conducted in eleven countries from different continents, including BrazilThis article is part of this initiative, by analyzing the results of the first phase of the research \u201cCovid-19 pandemic and adolescents: challenges faced from physical and social distancing measures\u201d. Here, the perceptions of adolescents of both sexes living in a peripheral region of the city of S\u00e3o Paulo (SP - Brazil) are examined in relation to the covid-19 pandemic, with a special focus on their experiences regarding education and sociability. It is argued here that the school is also an important space for diverse learning and sociability, as well as a privileged territory for interventions of a structural and collective nature to face social and health inequalities, deepened by the pandemic.This article presents the results produced in the first round of the qualitative stage of the Geas-covid study in Brazil. Focus groups (FG) were conducted in September 2021, on the premises of a public school located in an impoverished area in the far east of the city of S\u00e3o Paulo \u2013 a region where the Geas study has been developing since 2018. That is a location which, until the early 1980s, corresponded to a more ruralized area with low real estate value. The fast and disorganized growth is observed in the cluster of slums in the territorial expansion of the neighborhood; there are popular housing complexes (new or old), large two-floor houses in more wooded areas, villas with houses without external cladding and even wooden shacks.Seven mixed FGs were carried out, with students between 13 and 16 years old. In total, we had 34 participants; of these, 19 were girls and 15 were boys \u2013 an average of 5 adolescents in each FG. The FGs were held in a meeting room provided by the school\u2019s coordination. A quiet space, with a large and long table, accompanied by padded chairs, ensured both comfort and privacy and secrecy of conversations. The 7 FG were conducted by the same moderator, accompanied by an observer, who was responsible for recording comments and non-verbal communications. All sessions were recorded, fully transcribed and lasted an average of 50 minutes. Each FG had participants from different classes, but all were enrolled in the same grade; we also sought to establish gender parity in each session. Students from the eighth and ninth years of elementary school II and the first year of high school participated, in order to meet the age criteria established by the general coordination for this component of the study.The engagement of the adolescents took place through an invitation and presentation of the research in the classrooms and through mobilization among peers. Research information  was disseminated to parents and students via the school\u2019s institutional WhatsApp. Contacts for the guardians\u2019 consent were mediated by the school coordination. The presentation \u2013 and invitation \u2013 of the research was made by the moderator and the observer in the classrooms, the day before and again on the day of each FG. Adolescents clarified group and individual doubts about the research, and confirmed their participation before the start of each FG in writing.Although initially planned to take place in an online format, the FGs were conducted face-to-face. The impossibility of counting on the adherence of adolescents in the empirical stage of the research in remote mode signaled the structural and logistical difficulties for digital communication with residents of impoverished areas of the city, one of the dimensions that greatly affected the adolescent context.The first round of discussion focused on issues related to adolescents\u2019 experiences of physical and social distancing. The FG script privileged themes such as routine changes, prevention practices adopted against the covid-19 virus, school context, sociability and maintenance of friendship relationships, intra-family dynamics instituted and/or stressed by the context of the pandemic and the impact of covid-19 on the adolescents\u2019 health and well-being. This roadmap was prepared having as its central axis the elements common to the other countries participating in the Geas study.10was adopted, which conceives the narrative as an expression of a network of relationships in which the individual is included. This type of analysis allows understanding the individuals\u2019 world view \u2013 understood as the content of their action \u2013 and the context in which it is produced. Through and in the discourse, one can apprehend the social, cultural and symbolic dimensions that are expressed in it and that explain the way in which the members of the community that reproduce it relate, behave and act.Thematic analysis of the results was done in order to understand the adolescents\u2019 perceptions and experiences of the pandemic. The theoretical perspective proposed by FiorinThe project was approved by the Research Ethics Committee of the Faculty of Public Health of the University of S\u00e3o Paulo (number CAAE 31664720.8.0000.5421). The ethical issues established in Resolution 510/2016, of the National Health Council, were considered throughout the conduct of the study: information about the investigation was previously provided to the participants, and the confidentiality of the conversations and anonymity of all with the use of fictitious names was ensured. Phrases or expressions between quotation marks are fragments of youth narratives, placed here as a way of explaining or exemplifying some dimension under analysis. All names used in this article are fictitious.11.One of the first safety and prevention measures for infections by the covid-19 virus was the establishment of physical and social distancing, which implied restriction and/or interruption of face-to-face activities in various spaces. On March 17, 2020, the Ministry of Education authorized the holding of remote/online classes in all teaching units, from basic to higher education12.Emergency remote teaching (ERE) is an approximation of distance learning (EAD). In ERE, schools could resort to any technological means  that made communication viable and ensured the continuity of teaching. Until then, the distance learning mode and the information and communication technologies (ICT) occupied a marginal space and role in the national educational system. There was a shortage of investment in technological and continuing education apparatus for teachers to use virtual environments for teachingIn 2020, the Department of Education of the State of S\u00e3o Paulo (SEDUC-SP) launched the S\u00e3o Paulo Education Media Center (CMSP), which objective was to ensure the maintenance of classes, without major damage to the school calendar, in the period of social confinement. The CMSP brings together a virtual learning space available in the form of an application for mobile devices such as cell phones and tablets, as well as a television transmission system on open channels for the state of S\u00e3o Paulo. Students would be able to access their respective classes and activities and interact live with each other and with teachers through the app. Those who did not have a mobile device could watch the classes of all subjects directly on television at specific times. Thus, both accesses have synchronous and asynchronous classes taught by public school teachers.The research participants considered the experience of remote teaching, including the Media Center, to be quite frustrating and precarious: there were constant and emphatic criticisms of the disconnection between the contents and the lack of interaction between teachers and students in this application. Mostly, they considered studying as the biggest challenge of the pandemic period (even more than surviving). Also, the transfer of the teaching-learning context to the domestic scope weighed more than the disconnection between teacher and student.13. Some students reported not being able to study because they did not have access to the internet and/or a cell phone \u2013 \u201cI couldn\u2019t study, they passed me out of pity\u201d . These barriers to good study conditions were not sufficiently mitigated by the education network, without the necessary investment to purchase computers, laptops and the installation of compatible broadband. Even though the school remained open for some periods, adolescents who attended online classes reported difficulties in attending them because there was not enough equipment (computers and laptops) or an adequate internet network (Wi-Fi) to meet the demands in the first year of the pandemic (year 2020).Remote teaching exposed and intensified social inequalities associated with exclusion or digital literacy that affect economically disadvantaged segments, such as the lack of technological devices like computers, tablets or smartphones with adequate processors and memory and precarious (or non-existent) access to the internetThe centralization of online education in app\u2019s made student duties more flexible: it blurred, for example, obligations with meeting deadlines for delivering work, fundamental for the constitution of a discipline in study and the effectiveness of the practice of studying. Equally problematic were the generic contents, distanced from the students\u2019 knowledge and objectively devoid of context, offered in classes promoted by the state department of education. Standardized teaching brought them added difficulty, as it was not compatible with their learning level. The students also pointed out differences in language and content in relation to the usual communication and themes presented by their teachers as barriers to learning. According to the reports, there is a clear confusion regarding the activities and the various digital communication tools and platforms that have been used throughout the pandemic \u201cconfinement\u201d.Another aspect was the impossibility for the teachers to follow the development of the students, since they did not have access to the activities carried out in the Media Center. The conduct of distance learning by the government was considered \u201cvery bad\u201d, since there was no gradual development of aspects, elements and contexts related to the themes under study, as done by the school teachers. In online classes:\u201cthey go straight to the point\u2026 they just want the result\u2026 ask here and want me to answer there. They are doing as if we had studied it before. There was no recap in the next class like there is at school. Interlocution in the classroom allows the teacher to realize that the student did not understand, one goes back to the previous content, until they understand\u201d .15. Having to \u201ctake care of the brother, take care of the house\u201d brought difficulties in concentrating on studies, with delays in schoolwork and even more \u201cdiscouragement\u201d with the context experienced. This enlargement of responsibilities for taking care of younger siblings and cleaning the house for girls signals the permanence of the traditional sexual division of domestic work. In general, boys had fewer tasks, such as \u201cwashing dishes and sweeping\u201d; they took up cleaning only when they were home alone or when they were the eldest child with younger siblings. This fact is highlighted by the way some boys referred to the tasks, describing them as a \u201cfavor\u201d asked by the mother, not a consolidated obligation.Being at home full time seems to have amplified the adolescents\u2019 household tasks, making the schooling process more difficult, especially for girls16. Before the pandemic, Sara used to get together with her friends to go to the neighborhood square \u201cto have an ice cream\u201d, \u201cand today you can\u2019t anymore, there\u2019s this distance. If you are like this [close] they say \u2018oh, the distance!\u2019, \u2018you are very close to each other!\u2019. So this sucks. We want to hug a friend. We don\u2019t like hugging our family at home\u2026\u201d .The suspension of face-to-face teaching brought the teenagers an interruption of social relationships and important bonds experienced in the school environment: the school is a territory of protection, food and sociability18, but face-to-face contact creates a network of affection, hugs and conversations that online contact does not allow. Friends are a significant support among young people, in a constitutive process of this phase of life in which the separation from the family nucleus is intensified and the peer group gets closer together19. Coping with the separation was \u201cvery hard\u201d, as it happened precisely at a time in the course of life when adolescents are eager to find autonomy and identity20. Although they could use social networks \u2013 Instagram, WhatsApp, Facebook \u2013 to communicate virtually with friends, the \u201cpreference to talk in person\u201d was the keynote of the discourses, justified by the need for \u201cphysical contact\u201d or by the \u201clittle patience\u201d for the virtual communication, as expressed in the statement \u201cI have no patience for WhatsApp\u201d .Social networks played a key role in maintaining socialization between peers22.Young people began to spend more time with family members, who also had their routine interrupted due to enforced health rules, especially in the first year of the pandemic. Many fathers and mothers had their jobs changed, either because they started to work remotely, or because they became unemployed. Spending more time with family members was identified as a generator of conflicts, stress and violence in the family environment, which has implications for the well-being and health of adolescents19. This rupture, occurring abruptly, brought feelings of fear, uncertainty, anguish, loneliness \u2013 very frequent terms in their narratives. \u201cThe pandemic pushed people away, it generated loneliness and emptiness because I was trapped, so there was a strange, dark, heavy atmosphere. And we end up feeling bad\u201d . In another FG, some of the participants report the centrality of feelings of uncertainty and fear:The period of adolescence is marked by many changes and also experimentations. The context of the covid-19 health crisis generated barriers to socialization and self-building for adolescentsModerator: How do you think the pandemic contributed to this anxiety crisis?Yara (15): Not seeing if this will end, not knowing if one day it will end, if one day we will stop wearing a mask.Simone (16): Not knowing the future.Yara (15): Now that I\u2019ve had the vaccine, I\u2019m feeling calmer, but before that I was like: \u201cMy God, is there going to be a vaccine? Will the world end? Is everyone going to die?\u201dRenata (15): Yeah, \u201cwill I get covid? I wonder if\u2026 I wonder what\u2026?\u201dYara (15): \u201cWill I die if I get covid?\u201dRenata (15): No, it wasn\u2019t even me getting [the] covid; like, my mother... My mother has asthma, she has... she has everything, right? And then, \u201cwhat if I pass it on to my mother? will she die?\u201d Because if I get it, okay, but what about my mother? My father? My brother? My grandma?23. Even when family relationships are not marked by conflicts, these do not usually make up for the absence of friends, as friendship involves common affinity, interests and styles.The iterative evocation of the words \u201cstuck\u201d, \u201calone\u201d and \u201cloneliness\u201d and the phrase \u201cthere was no one to talk to\u201d sets the tone for how most adolescents experienced the period of physical and social distancing. The condition of being alone is an unintentional result of long-term containment measures, making the group vulnerable and increasing the risk of developing mental health problems25. The old school routine or with activities outside the home was replaced by one in which \u201cboredom\u201d and \u201cdiscouragement\u201d prevailed. Recurrent reports among adolescents include: \u201cI only slept and ate\u201d, \u201cwatched TV\u201d, \u201cplayed on my cell phone\u201d, \u201cplayed games\u201d, in addition to increasing household chores. Perceived changes also relate to lower productivity, increased sedentary lifestyle, adoption of eating habits that are less favorable to health and a disrupted sleep routine26. Research carried out with students in the ninth year of the fundamental level, enrolled in teaching units in the Metropolitan Region of S\u00e3o Paulo, recorded the time of exposure to screens, sleep inversion and being female as elements associated with symptoms of depression and anxiety among study participants26.Authors argue about the need for special attention to the shocks resulting from physical-social distancing and the suspension of face-to-face activities for adolescents7related to family problems  are present in the narratives. Leaving school means leaving friends, contact, presence, support from schoolmates. Classmates constitute a network of solidarity that provides continuous emotional and affective support. The \u201cgroup\u201d is able to perceive days of sadness and hopelessness and tries to make the partner happy with conversations and games. This bond strengthens as they get to know each other by advancing through the school years together. Moments of mutual help operate as a space for promoting care and freedom of positioning; they have educational relevance by stimulating social skills and meaning-making about their beliefs, aspirations, fears, anxieties \u2013 feelings closely related to the construction of identity27.At this point, it is important to locate the centrality of the school as a space for sociability and the making of affective and emotional bonds between friends. Issues of psychosocial suffering2. The frequent narratives about psychosocial distress seem to reiterate the argument of Najar and Castro29who, recovering another author, Frank Furedi, talk about the psychologization of everyday life and a greater sense of existential insecurity as some of the elements of a certain \u201ccultural script\u201d that would be influencing the reactions to covid-19. For these authors, \u201cthe way a social group responds to a threat, such as a pandemic, is mediated by the perception of the threat, its sense of existential security and the ability to make sense of unpredictable experiences\u201d (p. 145).Keeping adversities to oneself can exacerbate disillusionment, suicidal ideation, depression symptoms and the very feeling of loneliness \u2013 dimensions present in the speeches of FG participants and in other moments of interaction, including pre-pandemic, made between study researchers and students from the same school30, as the \u201cgreatest psychological experiment in the world\u201d,,placing in question the human capacity to find some meaning in the midst of so much suffering and challenges, individual and collective.The state of social contingency introduced by the pandemic aggravated the pre-existing conditions of feelings of anxiety. The uncertainties, the \u201cnot knowing the future\u201d, break with perspectives of life project. \u201cFear\u201d, added to excessive \u201cworry\u201d, and being \u201calone\u201d are constants experienced and reported by adolescents. The girls offered more detailed reports about these feelings, while the boys restricted themselves to expressing \u201canger\u201d and \u201chatred\u201d for the disruption of their school routine and interaction with friends. Similar reports and situations are found in other studies with adolescents and young people: being \u201cconfined\u201d imposed by the pandemic was described by the participants of this study, as well as in the study by Lima24.Confined to a home space and with no leisure activities, some of the adolescents reported that they slept to pass the time and avoid boredom. They also stated that they became \u201cmore nervous\u201d during the pandemic and that they gained weight \u2013 \u201cI gained about 10 kg in the quarantine\u201d ; \u201cI gained 11 kg\u201d . The lack of entertainment options at home, combined with the decrease in physical activity, increased sedentary lifestyle, \u201cstress\u201d and \u201canxiety\u201d, helps to understand the weight gain reported by girlsSome boys have similar reports to those of girls, such as sleeping or staying in their room playing all day. However, there are those who repeatedly break the period of physical distancing to be with close friends and classmates (neighbors) or girlfriends/lovers, emphasizing that they did so when there was a reduction in the number of cases of infection and deaths. It should be noted that non-pharmacological measures were often adhered to by young people due to their mothers\u2019 demand and vigilance. However, those whose mothers remained in face-to-face work did not strictly comply with the period of distancing: the eagerness for socializing meant that there was an escape from isolation.31.Also, the youth narrative associates constant fear and insecurity about the disease and death of family members with feelings of depression and anxiety. This type of association is pointed out by the specific literature on mental health: studies indicate that adolescents who had parents in jobs considered essential, or who were unable to maintain physical distance, had more symptoms of psychological distress. Similarly, adolescents who lived in families with vulnerable economic conditions had higher rates of stress30. Physical distancing measures brought added concerns to adolescents, whose stage of life is marked by the centrality of the group and potentialization of the gregarious feeling among peers14. This has been considered an important trigger for the emergence of problems related to psychosocial suffering, enhanced by situations of individual, social and programmatic vulnerability of adolescents in the face of the chaotic pandemic scenario7.The convergence of the deleterious effects resulting from the ongoing pandemic has negative repercussions in different spheres of life, with emphasis on aspects associated with psychosocial sufferingMeasures of physical and social distancing and the shutting down of schools harmed the process of schooling and socialization of young people, as well as limited important opportunities for peer interaction, with an impact on the adolescents\u2019 development of identity, autonomy and independence and on maintaining physical and psychosocial health. This study documents how measures to control the pandemic, implemented in a fragmented way and without support for the most impoverished families, have negative effects on other spheres of life, in particular for poor young people.This research shows the implications and weaknesses of adolescents living in a peripheral and very vulnerable region in a large Latin American metropolis. The social context proved to be decisive for this group\u2019s experience of the covid-19 pandemic, from intermittent adherence to non-pharmacological prevention measures to the very impossibility of carrying out social distancing, since many had family members who were working in services considered essential, with the need to use crowded public transport in the most acute phase of the pandemic.32.Adolescents reported feelings of depression and anxiety, generated by the anguish and fear caused by the covid-19 pandemic. Many spoke about their relationship with their friends and the support network they represent. Direct health effects, such as physical inactivity and weight gain, were mentioned. However, it is still too early to fully understand the effects of the pandemic and the long-term implications of the disease control and prevention strategies adopted in Brazil, a country that is among those with the most cases and deaths from covid-19 in the world33. The school is shown as a territory of sociability, support and refuge to deal with family and personal problems, as well as a scenario for identifying abuse and negligence. Apparently, it is also a privileged place to propose/build actions that help these teenagers to deal with the wounds left by the pandemic. \u201cIn peripheral areas, both vulnerabilities and opportunities have, to a large extent, territorial bases\u201d26. Even though we believe in the resilience and plasticity of children and young people, this research indicates that the road to recover youth teaching and sociability will be long and deserves increased attention34. This scenario demands efforts, especially in terms of public policy propositions to face the various social inequalities  exacerbated by the pandemic, as well as in relation to the possibilities of recovery33, considering the local dynamics of the pandemic.The UN points out that countries must ensure safe access to high-quality education in schools during emergencies with the same attention given to health services 1.Passados dois anos desde o primeiro caso de infec\u00e7\u00e3o por covid-19 no Brasil, ainda h\u00e1 muitas lacunas a serem preenchidas pelo conhecimento cient\u00edfico, sobretudo no que concerne \u00e0s diversas rupturas experimentadas por diferentes gera\u00e7\u00f5es, g\u00eaneros e segmentos sociais. A pandemia de covid-19 foi especialmente devastadora para as comunidades urbanas empobrecidas habitantes de \u00e1reas de alta densidade populacional, com acesso limitado a recursos como servi\u00e7os p\u00fablicos, infraestrutura da regi\u00e3o/bairro e renda dispon\u00edvel para sustentar bloqueios  relacionados ao cont\u00e1gio e ao adoecimentoO fechamento das escolas foi uma das primeiras medidas n\u00e3o farmacol\u00f3gicas adotadas no enfrentamento da pandemia de covid-19 \u2013 e a mais duradoura \u2013, tendo como efeito importante preju\u00edzo no processo de aprendizado. O retorno \u00e0s atividades presenciais nas escolas tem sido marcado por diversos protocolos com distintas medidas de interven\u00e7\u00e3o. Nosso entendimento sobre como as/os adolescentes de diferentes contextos  experimentaram e ainda t\u00eam enfrentado as rupturas em termos educacionais, familiares e sociais necessita de an\u00e1lises aprofundadas e transversalizadas.4, principalmente por conta dos efeitos delet\u00e9rios da suspens\u00e3o das aulas presenciais e do fechamento das escolas sobre a sa\u00fade e bem-estar de crian\u00e7as, adolescentes e jovens7.Diferentemente dos adultos, mais sujeitos a formas graves da doen\u00e7a, as/os adolescentes parecem afetar-se mais em termos de sa\u00fade psicossocial e do bem-estar emocionalGlobal Early Adolescent Study (Geas), conduzido em onze pa\u00edses de v\u00e1rios continentes, incluindo o Brasil9.A crise social e econ\u00f4mica gerada pela pandemia recrudesce desigualdades sociais, que tendem a piorar/degradar as condi\u00e7\u00f5es de vida daqueles que vivem em comunidades pobres, alterando suas aspira\u00e7\u00f5es educacionais, sua sa\u00fade e seu bem-estar. Compreender os efeitos individuais, relacionais, familiares e sociais, em curto, m\u00e9dio e longo prazo, associados ao contexto pand\u00eamico, nas trajet\u00f3rias de adolescentes de comunidades urbanas pobres \u00e9 um dos objetivos do estudo multic\u00eantrico internacional Este artigo surge como parte dessa iniciativa, ao analisar os resultados da primeira fase da pesquisa \u201cPandemia covid-19 e os/as adolescentes: desafios enfrentados a partir das medidas de distanciamento f\u00edsico-social\u201d. Aqui, s\u00e3o examinadas as percep\u00e7\u00f5es de adolescentes, de ambos os sexos, moradores de uma regi\u00e3o perif\u00e9rica da cidade de S\u00e3o Paulo (SP \u2013 Brasil), em rela\u00e7\u00e3o \u00e0 pandemia de covid-19, com especial enfoque em suas experi\u00eancias quanto \u00e0 educa\u00e7\u00e3o e sociabilidade. Argumenta-se aqui que a escola \u00e9, igualmente, espa\u00e7o importante de aprendizagens diversas e de sociabilidade, bem como territ\u00f3rio privilegiado para interven\u00e7\u00f5es de car\u00e1ter estrutural e coletivo de enfrentamento \u00e0s desigualdades sociais e em sa\u00fade, aprofundadas pela pandemia.Este artigo apresenta os resultados produzidos na primeira rodada da etapa qualitativa do estudo Geas-covid no Brasil. Foram conduzidos grupos focais (GF) em setembro de 2021, nas depend\u00eancias de uma escola p\u00fablica localizada numa \u00e1rea empobrecida do extremo leste da cidade de S\u00e3o Paulo \u2013 regi\u00e3o em que o estudo Geas vem se desenvolvendo desde 2018. Trata-se de uma localidade que, at\u00e9 o princ\u00edpio da d\u00e9cada de 1980, correspondia a uma \u00e1rea mais ruralizada e com baixo valor imobili\u00e1rio. O crescimento r\u00e1pido e desordenado \u00e9 observado no aglomerado de favelas na expans\u00e3o territorial do bairro; h\u00e1 conjuntos habitacionais populares (novos ou antigos), grandes sobrados em \u00e1reas mais arborizadas, vilas com casas sem revestimento externo e at\u00e9 barracos de madeira.Foram realizados sete GF mistos, com estudantes entre 13 e 16 anos. No total, tivemos 34 participantes; destes, 19 eram meninas e 15, meninos \u2013 uma m\u00e9dia de 5 adolescentes em cada GF. Os GF foram realizados em uma sala de reuni\u00f5es cedida pela coordena\u00e7\u00e3o da escola. Espa\u00e7o silencioso, com uma mesa grande e comprida, acompanhada de cadeiras acolchoadas, garantiu tanto o conforto, quanto a privacidade e o sigilo das conversas. Os 7 GF foram conduzidos por uma mesma moderadora, acompanhada de uma observadora, que foi respons\u00e1vel pelo registro de coment\u00e1rios e comunica\u00e7\u00f5es n\u00e3o verbais. Todas as sess\u00f5es foram gravadas, integralmente transcritas e tiveram dura\u00e7\u00e3o m\u00e9dia de 50 minutos. Cada GF contou com participantes de diferentes turmas, por\u00e9m todos/as eram matriculados na mesma s\u00e9rie; procurou-se ainda estabelecer uma paridade de g\u00eanero em cada sess\u00e3o. Participaram alunas/os do oitavo e nono anos do ensino fundamental II e do primeiro ano do ensino m\u00e9dio, de forma a atender o crit\u00e9rio et\u00e1rio estabelecido pela coordena\u00e7\u00e3o geral para esse componente do estudo.O engajamento dos/as adolescentes deu-se mediante convite e apresenta\u00e7\u00e3o da pesquisa nas salas de aula e por meio da mobiliza\u00e7\u00e3o entre pares. Procedeu-se \u00e0 divulga\u00e7\u00e3o de informa\u00e7\u00f5es da pesquisa  junto a pais e estudantes, via WhatsApp institucional da escola. Os contatos para o consentimento de respons\u00e1veis foram mediados pela coordena\u00e7\u00e3o da escola. Foi feita a apresenta\u00e7\u00e3o \u2013 e convite \u2013 da pesquisa pela moderadora e pela observadora nas salas de aula, um dia antes e novamente no dia de realiza\u00e7\u00e3o de cada GF. As/os adolescentes tiraram d\u00favidas em grupo e individualmente sobre a pesquisa, e confirmaram sua participa\u00e7\u00e3o antes do in\u00edcio de cada GF por escrito.online, os GF foram conduzidos de forma presencial. A impossibilidade de contar com a ades\u00e3o das/os adolescentes na etapa emp\u00edrica da pesquisa em modalidade remota sinalizou as dificuldades estruturais e de log\u00edstica para comunica\u00e7\u00e3o digital com moradores de \u00e1reas empobrecidas da cidade, uma das dimens\u00f5es que afetou sobremaneira o contexto adolescente.Embora inicialmente previstos para ocorrer no formato A primeira rodada de discuss\u00e3o concentrou-se em quest\u00f5es relacionadas \u00e0s experi\u00eancias do distanciamento f\u00edsico-social das/os adolescentes. O roteiro dos GF privilegiou temas como mudan\u00e7as de rotina, pr\u00e1ticas de preven\u00e7\u00e3o adotadas contra o v\u00edrus da covid-19, contexto escolar, sociabilidade e manuten\u00e7\u00e3o de relacionamentos de amizade, din\u00e2micas intrafamiliares institu\u00eddas e/ou tensionadas pelo contexto da pandemia e impacto da covid-19 na sa\u00fade e no bem-estar das/os adolescentes. Tal roteiro foi elaborado tendo como eixo central os elementos comuns aos demais pa\u00edses participantes do estudo Geas.10, que concebe a narrativa como express\u00e3o de uma rede de rela\u00e7\u00f5es na qual o indiv\u00edduo est\u00e1 inserido. Este tipo de an\u00e1lise permite a compreens\u00e3o da vis\u00e3o de mundo dos indiv\u00edduos \u2013 entendida como o conte\u00fado de sua a\u00e7\u00e3o \u2013 e do contexto em que \u00e9 produzida. Por meio do e no discurso, pode-se apreender as dimens\u00f5es sociais, culturais e simb\u00f3licas que nele se expressam e que explicam a forma pela qual os membros da comunidade que o reproduzem se relacionam, comportam-se e agem.Com o fito de compreender as percep\u00e7\u00f5es e experi\u00eancias da pandemia vividas pelas/os adolescentes, optou-se pelo procedimento de an\u00e1lise tem\u00e1tica dos resultados. Adotou-se a perspectiva te\u00f3rica proposta por FiorinO projeto foi aprovado pelo Comit\u00ea de \u00c9tica em Pesquisa da Faculdade de Sa\u00fade P\u00fablica da Universidade de S\u00e3o Paulo (n\u00famero CAAE 31664720.8.0000.5421). As quest\u00f5es \u00e9ticas estabelecidas na Resolu\u00e7\u00e3o 510/2016, do Conselho Nacional de Sa\u00fade, foram consideradas durante toda a condu\u00e7\u00e3o do estudo: forneceu-se previamente informa\u00e7\u00f5es acerca da investiga\u00e7\u00e3o aos participantes e assegurou-se o sigilo das conversas e anonimato de todos/as com o uso de nomes fict\u00edcios. Frases ou express\u00f5es entre aspas s\u00e3o fragmentos das narrativas juvenis, colocados aqui como forma de explicitar ou exemplificar alguma dimens\u00e3o em an\u00e1lise. Todos os nomes utilizados neste artigo s\u00e3o fict\u00edcios.11.Uma das primeiras medidas de seguran\u00e7a e de preven\u00e7\u00e3o das infec\u00e7\u00f5es pelo v\u00edrus da covid-19 foi o estabelecimento do distanciamento f\u00edsico-social, que implicou restri\u00e7\u00e3o e/ou interrup\u00e7\u00e3o de atividades presenciais em diversos espa\u00e7os. Em 17 de mar\u00e7o de 2020, o Minist\u00e9rio da Educa\u00e7\u00e3o autorizou a execu\u00e7\u00e3o de aulas remotas/online em todas as unidades de ensino, desde a educa\u00e7\u00e3o b\u00e1sica ao ensino superior12.O ensino remoto emergencial (ERE) \u00e9 uma aproxima\u00e7\u00e3o do ensino \u00e0 dist\u00e2ncia (EAD). No ERE, as escolas poderiam recorrer a qualquer meio tecnol\u00f3gico  que tornasse vi\u00e1vel a comunica\u00e7\u00e3o e garantisse a continuidade do ensino. At\u00e9 ent\u00e3o, a modalidade EAD e as tecnologias da informa\u00e7\u00e3o e comunica\u00e7\u00e3o (TCI) ocupavam espa\u00e7o e fun\u00e7\u00e3o marginal no sistema educacional nacional. Havia escassez de investimento no aparato tecnol\u00f3gico e de forma\u00e7\u00e3o continuada para docentes utilizarem os ambientes virtuais para ensinotablets, al\u00e9m de um sistema de transmiss\u00e3o por televis\u00e3o em canais abertos para o estado de S\u00e3o Paulo. As/Os estudantes teriam a possibilidade de acessar suas respectivas aulas e atividades e interagirem ao vivo entre si e com professoras/es por meio do aplicativo. Aquelas/Aqueles que n\u00e3o possu\u00edssem um dispositivo m\u00f3vel poderiam assistir as aulas de todas as disciplinas diretamente pela televis\u00e3o nos hor\u00e1rios espec\u00edficos. Assim, ambos os acessos disp\u00f5em de aulas s\u00edncronas e ass\u00edncronas ministradas por professoras/es da rede p\u00fablica.Em 2020, a Secretaria de Educa\u00e7\u00e3o do Estado de S\u00e3o Paulo (SEDUC-SP) lan\u00e7ou o Centro de M\u00eddias da Educa\u00e7\u00e3o de S\u00e3o Paulo (CMSP), cujo objetivo era assegurar a manuten\u00e7\u00e3o das aulas, sem grande preju\u00edzo ao calend\u00e1rio letivo, no per\u00edodo de confinamento social. O CMSP re\u00fane um espa\u00e7o de aprendizagem virtual disponibilizado no formato de aplicativo para dispositivos m\u00f3veis como celulares e As/os participantes da pesquisa consideraram a experi\u00eancia do ensino remoto, incluindo o Centro de M\u00eddias, bastante frustrante e prec\u00e1ria: foram constantes e enf\u00e1ticas as cr\u00edticas \u00e0 desconex\u00e3o entre os conte\u00fados e \u00e0 falta de intera\u00e7\u00e3o entre professoras/es e estudantes neste aplicativo. Majoritariamente, consideraram estudar como o maior desafio do per\u00edodo pand\u00eamico (mais at\u00e9 do que sobreviver). Ainda, mais do que a desconex\u00e3o entre professor/a-aluno/a, pesou a transfer\u00eancia do contexto de ensino-aprendizagem para o \u00e2mbito dom\u00e9stico.tablet ou smartphones com processador e mem\u00f3ria adequados e o acesso prec\u00e1rio (ou inexistente) \u00e0 internet13. Algumas/alguns estudantes relataram n\u00e3o ter conseguido estudar por n\u00e3o possu\u00edrem acesso \u00e0 internet e/ou aparelho celular \u2013 \u201cn\u00e3o consegui estudar, me passaram por d\u00f3\u201d . Essas barreiras \u00e0s boas condi\u00e7\u00f5es de estudo n\u00e3o foram suficientemente atenuadas pela rede de ensino, sem investimento necess\u00e1rio para compra de computadores, notebooks e instala\u00e7\u00e3o de banda larga compat\u00edvel. Ainda que a escola tenha permanecido aberta em alguns per\u00edodos, adolescentes que a frequentaram para acompanhar as aulas online relataram dificuldades em assistir a estas por n\u00e3o existirem equipamentos suficientes (computadores e notebooks) nem rede de internet (Wi-Fi) adequada para atender \u00e0s demandas no primeiro ano da pandemia (ano de 2020).O ensino remoto exp\u00f4s e intensificou desigualdades sociais associadas \u00e0 exclus\u00e3o ou letramento digital que afetam segmentos mais desfavorecidos economicamente, a exemplo da falta de dispositivos tecnol\u00f3gicos como computador, A centraliza\u00e7\u00e3o da educa\u00e7\u00e3o online nos aplicativos flexibilizou os deveres estudantis: esfumou, por exemplo, obriga\u00e7\u00f5es com o cumprimento de prazos de entrega de trabalhos, fundamental para a constitui\u00e7\u00e3o de uma disciplina no estudo e da efetiva\u00e7\u00e3o da pr\u00e1tica do estudar. Mostraram-se igualmente problem\u00e1ticos os conte\u00fados gen\u00e9ricos, distanciados dos conhecimentos das/os estudantes e objetivamente desprovidos de contextualiza\u00e7\u00e3o, oferecidos nas aulas promovidas pela secretaria estadual de educa\u00e7\u00e3o. O ensino padronizado trouxe-lhes dificuldade acrescida, por n\u00e3o estar compatibilizado com o n\u00edvel de aprendizagem delas/es. As/Os estudantes tamb\u00e9m apontaram diferen\u00e7as de linguagem e conte\u00fado em rela\u00e7\u00e3o \u00e0 habitual comunica\u00e7\u00e3o e temas apresentados por suas/seus professoras/es enquanto barreiras ao aprendizado. Conforme os relatos, fica patente uma confus\u00e3o quanto \u00e0s atividades e \u00e0s v\u00e1rias ferramentas e plataformas de comunica\u00e7\u00e3o digital que foram sendo empregadas ao longo do \u201cconfinamento\u201d pand\u00eamico.online:Outro aspecto era a impossibilidade de as/os professoras/es acompanharem o desenvolvimento das/os alunas/os, visto que n\u00e3o tinham acesso \u00e0s atividades feitas no Centro de M\u00eddias. A condu\u00e7\u00e3o do ensino \u00e0 dist\u00e2ncia pelo governo foi considerada \u201cmuito ruim\u201d, j\u00e1 que n\u00e3o havia um desenvolvimento paulatino de aspectos, elementos e contextos relacionados aos temas em estudo, como feito pelas/os professoras/es da escola. Nas aulas \u201cv\u00e3o direto ao ponto\u2026 eles querem \u00e9 logo o resultado\u2026 pergunta aqui e quer que responda ali. Eles est\u00e3o fazendo como se n\u00f3s tiv\u00e9ssemos estudado antes. N\u00e3o havia uma recapitula\u00e7\u00e3o na aula seguinte como acontece na escola. A interlocu\u00e7\u00e3o em sala propicia ao professor perceber que a/o aluna/o n\u00e3o entendeu, volta o conte\u00fado anterior, at\u00e9 eles entenderem\u201d .15. Ter que \u201ccuidar do irm\u00e3o, cuidar da casa\u201d trouxe dificuldades de concentra\u00e7\u00e3o nos estudos, com atrasos nas tarefas escolares e ainda mais \u201cdes\u00e2nimo\u201d com o contexto vivido. Esse alargamento das responsabilidades de cuidar dos irm\u00e3os menores e da arruma\u00e7\u00e3o da casa para as garotas assinala a perman\u00eancia da tradicional divis\u00e3o sexual do trabalho dom\u00e9stico. Em geral, os rapazes possu\u00edam menos tarefas, como \u201clavar a lou\u00e7a e varrer\u201d; eles assumiam a limpeza apenas quando ficavam sozinhos em casa ou quando eram o filho mais velho com irm\u00e3os pequenos. Este fato \u00e9 real\u00e7ado pela forma como alguns garotos se referiram \u00e0s tarefas, descrevendo-as como um \u201cfavor\u201d pedido pela m\u00e3e, n\u00e3o uma obriga\u00e7\u00e3o consolidada.Estar em casa em tempo integral parece ter amplificado as atribui\u00e7\u00f5es dom\u00e9sticas das/os adolescentes, dificultando o processo de escolariza\u00e7\u00e3o, sobretudo para as meninas16. Antes da pandemia, Sara reunia-se com as/os amigas/os para ir at\u00e9 a pracinha do bairro \u201ctomar um sorvete\u201d, \u201ce hoje n\u00e3o pode mais, tem essa dist\u00e2ncia assim. Se voc\u00ea [es]tiver assim [pr\u00f3ximo] j\u00e1 falam \u2018\u00f3, o distanciamento!\u2019, \u2018t\u00e1 muito perto um do outro!\u2019. Ent\u00e3o isso \u00e9 chato. A gente quer abra\u00e7ar o amigo. A gente n\u00e3o gosta de ficar abra\u00e7ando nossa fam\u00edlia dentro de casa n\u00e3o\u2026\u201d .A suspens\u00e3o do ensino presencial trouxe para as/os adolescentes uma interrup\u00e7\u00e3o das rela\u00e7\u00f5es sociais e v\u00ednculos importantes vivenciados no ambiente escolar: a escola \u00e9 um territ\u00f3rio de prote\u00e7\u00e3o, alimenta\u00e7\u00e3o e sociabilidade18, mas o conv\u00edvio presencial cria uma rede de afetos, abra\u00e7os e conversas que o online n\u00e3o permite. As/os amigas/os constituem um significativo suporte entre as/os jovens, num processo constitutivo dessa fase da vida em que se intensifica o afastamento dos n\u00facleos familiares e h\u00e1 maior aproxima\u00e7\u00e3o do grupo de pares19. O enfrentamento do apartar foi \u201cbem dif\u00edcil\u201d, pois se deu justamente em um momento do curso da vida em que as/os adolescentes possuem avidez quanto ao encontro de autonomia e identidade20. Embora pudessem utilizar as redes sociais \u2013 Instagram, WhatsApp, Facebook \u2013 para se comunicar virtualmente com amigas/os, o \u201cpreferir falar pessoalmente\u201d era a t\u00f4nica dos discursos, justificado pela necessidade de \u201ccontato f\u00edsico\u201d ou pela \u201cpouca paci\u00eancia\u201d para a comunica\u00e7\u00e3o virtual, como expresso na fala \u201ceu n\u00e3o tenho paci\u00eancia pro WhatsApp\u201d .As redes sociais tiveram um papel fundamental para manter a socializa\u00e7\u00e3o entre os pares22.As/Os jovens passaram a conviver mais com familiares, que tamb\u00e9m tiveram sua rotina interrompida por conta das regras sanit\u00e1rias impingidas, sobretudo, no primeiro ano da pandemia. Muitos pais e m\u00e3es tiveram seus trabalhos alterados, seja porque passaram a trabalhar de forma remota, seja porque ficaram desempregados. O maior tempo de conv\u00edvio com familiares foi identificado como gerador de conflitos, de estresse e de viol\u00eancias no ambiente familiar, o que tem implica\u00e7\u00f5es na rela\u00e7\u00e3o de bem-estar e sa\u00fade das/os adolescentes19. Essa ruptura, ocorrendo de modo abrupto, trouxe sentimentos de medo, incertezas, ang\u00fastia, solid\u00e3o \u2013 termos muito frequentes nas narrativas delas/es. \u201cA pandemia afastou as pessoas, gerou solid\u00e3o e vazio porque ficava presa, ent\u00e3o ficava um clima mais estranho, escuro, pesado. E a gente acaba ficando mal\u201d . Em outro GF, algumas das participantes relatam a centralidade de sentimentos de incerteza e medo:O per\u00edodo da adolesc\u00eancia \u00e9 marcado por muitas mudan\u00e7as e tamb\u00e9m experimenta\u00e7\u00f5es. O contexto da crise sanit\u00e1ria da covid-19 gerou barreiras de socializa\u00e7\u00e3o e constru\u00e7\u00e3o de si para as/os adolescentesModeradora: Como \u00e9 que voc\u00ea acha que a pandemia colaborou nessa crise de ansiedade?Yara (15): N\u00e3o ver se vai acabar isso, n\u00e3o saber se um dia vai acabar, se um dia a gente vai parar de usar m\u00e1scara.Simone (16): N\u00e3o saber o futuro.Yara (15): Agora que eu tomei a vacina j\u00e1 t\u00f4 mais de boa, mas antes eu ficava tipo: \u201cmeu Deus ser\u00e1 que vai ter vacina? Ser\u00e1 que o mundo vai acabar? Vai todo mundo morrer?\u201dRenata (15): \u00c9, \u201cser\u00e1 que eu vou pegar covid? Ser\u00e1 que\u2026 n\u00e3o sei o qu\u00ea\u2026?\u201dYara (15): \u201cSer\u00e1 que se eu pegar covid eu vou morrer?\u201dRenata (15): N\u00e3o, n\u00e3o era nem comigo pegar [a] covid; tipo, minha m\u00e3e\u2026 Minha m\u00e3e tem asma, tem... tem tudo n\u00e9? E a\u00ed, \u201ce se eu passar para minha m\u00e3e? Ela vai morrer?\u201d Porque eu pegar, beleza, mas a\u00ed minha m\u00e3e? Meu pai? Meu irm\u00e3o? Minha v\u00f3?23. Mesmo quando as rela\u00e7\u00f5es familiares n\u00e3o s\u00e3o marcadas por conflitos, estas n\u00e3o costumam suprir a aus\u00eancia dos amigos, pois amizade envolve afinidade, interesses e estilos comuns.A evoca\u00e7\u00e3o iterativa das palavras \u201cpresa/o\u201d, \u201csozinha/o\u201d e \u201csolid\u00e3o\u201d e da frase \u201cn\u00e3o teve ningu\u00e9m pra conversar\u201d d\u00e1 o tom da forma como grande parte das/os adolescentes experienciou o per\u00edodo de distanciamento f\u00edsico-social. A condi\u00e7\u00e3o de estar sozinha/o \u00e9 uma resultante n\u00e3o intencional das medidas de conten\u00e7\u00e3o em per\u00edodo prolongado, vulnerabilizando o grupo e aumentando o risco de desenvolvimento de problemas de sa\u00fade mental25. A antiga rotina escolar ou com atividades fora de casa foi substitu\u00edda por uma em que o \u201ct\u00e9dio\u201d e o \u201cdes\u00e2nimo\u201d predominaram. Relatos recorrentes entre as/os adolescentes incluem: \u201ceu s\u00f3 dormia e comia\u201d, \u201cvia TV\u201d, \u201cmexia no celular\u201d, \u201cjogava\u201d, al\u00e9m do aumento das tarefas dom\u00e9sticas. As mudan\u00e7as percebidas tamb\u00e9m dizem respeito \u00e0 menor produtividade, aumento do sedentarismo, ado\u00e7\u00e3o de h\u00e1bitos alimentares menos favor\u00e1veis \u00e0 sa\u00fade e rotina de sono desregulada26. Pesquisa realizada junto a escolares do nono ano do n\u00edvel fundamental, matriculadas/os em unidades de ensino da Regi\u00e3o Metropolitana de S\u00e3o Paulo, registrou o tempo de exposi\u00e7\u00e3o \u00e0s telas, a invers\u00e3o do sono e ser do sexo feminino como elementos associados a sintomas de depress\u00e3o e ansiedade entre as/os participantes do estudo26.Autores argumentam acerca da necessidade de aten\u00e7\u00e3o especial aos abalos resultantes do distanciamento f\u00edsico-social e da suspens\u00e3o de atividades presenciais para as/os adolescentes7 relacionadas aos problemas familiares  est\u00e3o presentes nas narrativas. O afastamento da escola significa o afastamento de amigas/os, do contato, da presen\u00e7a, do apoio de colegas. Companheiras/os de turma consubstanciam uma rede de solidariedade que fornece cont\u00ednuo apoio emocional e afetivo. A \u201cturma\u201d \u00e9 capaz de perceber dias de tristeza e desesperan\u00e7a e tenta alegrar o/a companheiro/a com conversas e brincadeiras. Esse la\u00e7o se fortalece \u00e0 medida que v\u00e3o se conhecendo no avan\u00e7ar dos anos escolares juntos. Os momentos de interajuda operam como espa\u00e7o de promo\u00e7\u00e3o de cuidado e liberdade de posicionamento; t\u00eam relev\u00e2ncia educativa ao estimular habilidades sociais e a constru\u00e7\u00e3o de sentidos acerca de suas cren\u00e7as, aspira\u00e7\u00f5es, medos, ansiedades \u2013 sentimentos estreitamente relacionados \u00e0 constru\u00e7\u00e3o da identidade27.Nesse ponto, importa localizar a centralidade da escola como espa\u00e7o de sociabilidade e de constru\u00e7\u00e3o de v\u00ednculos afetivos e emocionais entre amigos. Quest\u00f5es de sofrimento psicossocial28. As frequentes narrativas sobre sofrimento psicossocial parecem reiterar o argumento de Najar e Castro29 que, recuperando um outro autor, Frank Furedi, falam sobre a psicologiza\u00e7\u00e3o da vida cotidiana e um maior senso de inseguran\u00e7a existencial como alguns dos elementos de um certo \u201cscript cultural\u201d que estaria influenciando as rea\u00e7\u00f5es \u00e0 covid-19. Para estes autores, \u201ca maneira como um grupo social responde a uma amea\u00e7a, tal como uma pandemia, \u00e9 mediada pela percep\u00e7\u00e3o da amea\u00e7a, seu senso de seguran\u00e7a existencial e a capacidade de dar sentido \u00e0s experi\u00eancias imprevis\u00edveis\u201d (p. 145).Guardar para si as adversidades pode exacerbar a desilus\u00e3o, idea\u00e7\u00f5es suicidas, sintomas de depress\u00e3o e a pr\u00f3pria sensa\u00e7\u00e3o de solid\u00e3o \u2013 dimens\u00f5es presentes nos discursos das/os participantes dos GF e em outros momentos de intera\u00e7\u00e3o, inclusive pr\u00e9-pandemia, feitos entre pesquisadoras do estudo e alunas/os desta mesma escola30, como o \u201cmaior experimento psicol\u00f3gico do mundo\u201d, colocando em xeque a capacidade humana de encontrar algum sentido em meio a tanto sofrimento e desafios, individuais e coletivos.O estado de conting\u00eancia social instaurado pela pandemia agravou as condi\u00e7\u00f5es do sentimento de ansiedade preexistentes. As incertezas, o \u201cn\u00e3o saber o futuro\u201d, rompem com perspectivas de projeto de vida. O \u201cmedo\u201d, somado \u00e0 \u201cpreocupa\u00e7\u00e3o\u201d excessiva, e o ficar \u201csozinho/a\u201d s\u00e3o constantes vivenciadas e relatadas pelas/os adolescentes. As jovens ofereceram relatos mais pormenorizados acerca desses sentimentos, enquanto os garotos restringiram-se a expressar \u201craiva\u201d e \u201c\u00f3dio\u201d pela desestrutura\u00e7\u00e3o de sua rotina escolar e intera\u00e7\u00e3o com os amigos. Relatos e situa\u00e7\u00f5es semelhantes s\u00e3o encontrados em outros estudos com adolescentes e jovens: o estar \u201cconfinado\u201d imposto pela pandemia foi descrito pelos/as participantes deste estudo, bem como no estudo de Lima24.Inseridas em um espa\u00e7o domiciliar e com aus\u00eancia de atividades de lazer, algumas das adolescentes relataram que dormiam para passar o tempo e evitar o t\u00e9dio. Afirmaram ainda que ficaram \u201cmais nervosas\u201d durante a pandemia e que engordaram \u2013 \u201cGanhei uns 10 kg na quarentena\u201d ; \u201cEu ganhei 11 kg\u201d . A car\u00eancia de op\u00e7\u00f5es de distra\u00e7\u00e3o dentro de casa, aliada ao decr\u00e9scimo de atividades f\u00edsicas, ao aumento do sedentarismo, ao \u201cestresse\u201d e \u00e0 \u201cansiedade\u201d, ajuda a compreender o aumento de peso referido pelas meninasAlguns rapazes possuem relatos semelhantes aos das garotas, como dormir ou ficar no quarto jogando o dia todo. No entanto, h\u00e1 aqueles que explicitaram repetidas quebras do per\u00edodo de distanciamento f\u00edsico para estar com amigos e colegas pr\u00f3ximos (vizinhos) ou namoradas/ficantes, ressaltando que o fizeram quando houve redu\u00e7\u00e3o no n\u00famero de casos de infec\u00e7\u00e3o e de mortes. Cabe pontuar que as medidas n\u00e3o farmacol\u00f3gicas, muitas vezes, tiveram ades\u00e3o por parte das/os jovens pela exig\u00eancia e vigil\u00e2ncia das m\u00e3es. Todavia, aquelas/es cujas m\u00e3es permaneceram em trabalho presencial n\u00e3o cumpriram \u00e0 risca o per\u00edodo de distanciamento: a \u00e2nsia pelo conv\u00edvio fez com que houvesse escape do isolamento.31.Ainda, a narrativa juvenil associa o medo constante e a inseguran\u00e7a sobre o adoecimento e morte dos familiares a sentimentos de depress\u00e3o e ansiedade. Esse tipo de associa\u00e7\u00e3o \u00e9 apontado pela literatura espec\u00edfica sobre sa\u00fade mental: estudos indicam que adolescentes que tiveram pais em trabalhos considerados essenciais, ou que n\u00e3o puderam fazer o distanciamento f\u00edsico, tiveram mais sintomas de sofrimento ps\u00edquico. Similarmente, adolescentes que viviam em fam\u00edlia com condi\u00e7\u00f5es econ\u00f4micas vulner\u00e1veis apresentaram maiores taxas de estresse30. As medidas de distanciamento f\u00edsico trouxeram preocupa\u00e7\u00f5es acrescidas \u00e0s/aos adolescentes, cuja fase da vida \u00e9 marcada pela centralidade do grupo e potencializa\u00e7\u00e3o do sentimento greg\u00e1rio entre pares14. Esse tem sido considerado importante estopim para o surgimento de problemas relacionados ao sofrimento psicossocial, potencializado pelas situa\u00e7\u00f5es de vulnerabilidade individual, social e program\u00e1tica das/os adolescentes frente ao ca\u00f3tico cen\u00e1rio pand\u00eamico7.A converg\u00eancia dos efeitos delet\u00e9rios decorrentes da pandemia em curso tem repercuss\u00f5es negativas em diversas esferas da vida, tendo relevo os aspectos associados ao sofrimento psicossocialAs medidas de distanciamento f\u00edsico-social e o fechamento das escolas trouxeram preju\u00edzos ao processo de escolariza\u00e7\u00e3o e socializa\u00e7\u00e3o das/os jovens, bem como limitaram importantes oportunidades do conv\u00edvio entre pares, com impacto tanto no desenvolvimento de identidade, autonomia e independ\u00eancia das/os adolescentes quanto na manuten\u00e7\u00e3o da sa\u00fade f\u00edsica e psicossocial. Este estudo documenta como medidas de controle da pandemia, implementadas de forma fragmentada e sem suporte \u00e0s fam\u00edlias mais empobrecidas, t\u00eam efeitos negativos em outras esferas da vida, em particular para jovens pobres.Esta pesquisa mostra as implica\u00e7\u00f5es e fragilidades das/os adolescentes moradores de uma regi\u00e3o perif\u00e9rica e muito vulner\u00e1vel em uma grande metr\u00f3pole latino-americana. O contexto social mostrou-se determinante para a experi\u00eancia desse grupo de viver a pandemia de covid-19, desde a ades\u00e3o intermitente \u00e0s medidas n\u00e3o farmacol\u00f3gicas de preven\u00e7\u00e3o at\u00e9 a pr\u00f3pria impossibilidade de executar o distanciamento social, uma vez que muitos tinham familiares que estavam trabalhando em servi\u00e7os considerados essenciais, com necessidade do uso de transportes p\u00fablicos lotados na fase mais aguda da pandemia.32.As/os adolescentes relataram sentimentos de depress\u00e3o e ansiedade, gerados pela ang\u00fastia e medo provocados pela pandemia da covid-19. Muitos falaram da rela\u00e7\u00e3o com as/os amigas/os e da rede de apoio que elas/es representam. Efeitos diretos na sa\u00fade, como sedentarismo e aumento de peso, foram mencionados. Entretanto, ainda \u00e9 cedo para compreender integralmente os efeitos da pandemia e as implica\u00e7\u00f5es a longo prazo das estrat\u00e9gias de controle e preven\u00e7\u00e3o da doen\u00e7a adotadas no Brasil, pa\u00eds que figura dentre os que tiveram mais casos e \u00f3bitos por covid-19 no mundo33. A escola se mostra como territ\u00f3rio de sociabilidade, de apoio e de ref\u00fagio para lidar com os problemas de ordem familiar e pessoais, al\u00e9m de cen\u00e1rio de identifica\u00e7\u00e3o de abusos e neglig\u00eancias. Ao que parece, \u00e9 tamb\u00e9m ali um lugar privilegiado para se propor/construir a\u00e7\u00f5es que auxiliem estas/es adolescentes a lidar com as feridas deixadas pela pandemia. \u201cNas \u00e1reas perif\u00e9ricas, tanto vulnerabilidades quanto oportunidades t\u00eam, em grande medida, bases territoriais\u201d26. Ainda que acreditemos na resili\u00eancia e plasticidade de crian\u00e7as e jovens, esta pesquisa indica que o caminho para a recupera\u00e7\u00e3o do ensino e da sociabilidade juvenis ser\u00e1 longo e merece aten\u00e7\u00e3o redobrada34. Este cen\u00e1rio demanda esfor\u00e7os, sobretudo em termos de proposi\u00e7\u00f5es de pol\u00edticas p\u00fablicas para o enfrentamento das diversas desigualdades sociais  acirradas pela pandemia, bem como em rela\u00e7\u00e3o \u00e0s possibilidades de recupera\u00e7\u00e3o (recovery)33, considerando a din\u00e2mica local da pandemia.A ONU assinala que os pa\u00edses devem assegurar o acesso seguro \u00e0 educa\u00e7\u00e3o de alta qualidade nas escolas durante emerg\u00eancias com a mesma aten\u00e7\u00e3o destinada aos servi\u00e7os de sa\u00fade"}
+{"text": "Isto causou uma melhoria cont\u00ednua das t\u00e9cnicas perioperat\u00f3rias, dos dispositivos, e dos resultados.Algumas caracter\u00edsticas propiciaram o grande desenvolvimento da cirurgia cardiovascular, dentre elas a criatividade para o desenvolvimento de t\u00e9cnicas e dispositivos e principalmente muita coragem. Assim, ela teve uma evolu\u00e7\u00e3o fant\u00e1stica, movida pelo impacto que causaria na qualidade de vida dos pacientes, tornando-se rapidamente um dos procedimentos mais realizados no mundo. A partir da an\u00e1lise destes registros surgiram algumas necessidades a serem resolvidas. Esta foi a \u00e9poca em que escores de predi\u00e7\u00e3o de risco de mortalidade foram introduzidos, com a finalidade de ajustar e entender melhor os resultados. A partir disto, e para conseguir a melhoria cont\u00ednua, a implementa\u00e7\u00e3o de programas de qualidade se tornou uma necessidade. Outro passo importante foi tamb\u00e9m a iniciativa de tornar p\u00fablicos os resultados dos hospitais, introduzindo o conceito da transpar\u00eancia.Isto pode explicar a melhora dos desfechos, mesmo quando os procedimentos se tornaram mais complexos e em pacientes cada vez mais graves. Isto passou a se tornar um problema para as fontes pagadoras, p\u00fablicas ou privadas, onde otimizar se tornaria a \u00fanica alternativa, principalmente em um ecossistema onde hospitais e funcion\u00e1rios, na sua grande maioria, s\u00e3o ressarcidos por meio de modelos de pagamento por servi\u00e7o (fee for service). Isto remete a uma reflex\u00e3o de um modelo que privilegia o conceito de que quanto mais interven\u00e7\u00f5es ou mais tempo no hospital melhor, em um sistema que n\u00e3o necessariamente premia o melhor resultado. Assim hospitais com menos complica\u00e7\u00f5es poderiam ter menor ressarcimento e vice-versa. Portanto a sobreviv\u00eancia deste modelo, mesmo com pr\u00e1ticas adequadas, passou a ser questionada.Entretanto outras vari\u00e1veis entraram em cena, pois com o aumento da expectativa de vida, a indica\u00e7\u00e3o de cirurgia se tornou mais frequente em pacientes idosos e fr\u00e1geis onde h\u00e1 um aumento da taxa de complica\u00e7\u00f5es, com um aumento dos tempos de interna\u00e7\u00e3o e consequentemente dos custos. Na maior parte das vezes estes modelos s\u00e3o caracterizados por uma das alternativas a seguir: 1- redu\u00e7\u00e3o dos gastos, sem perder a qualidade do atendimento; 2- melhorar a qualidade sem aumentar os gastos; ou, idealmente, 3- melhorar a qualidade e reduzir os gastos. Em alguns destes modelos, as cirurgias cardiovasculares s\u00e3o apenas um item dentro de um pacote de ressarcimento j\u00e1 atribu\u00eddo ao respectivo grupo de diagn\u00f3sticos relacionados (GDR). Portanto, os esfor\u00e7os para diminuir complica\u00e7\u00f5es e tempos de interna\u00e7\u00e3o, ap\u00f3s uma cirurgia cardiovascular, ajudariam na redu\u00e7\u00e3o dos gastos do hospital. Dentre os v\u00e1rios modelos, h\u00e1 aqueles que se adaptam melhor \u00e0 determinadas situa\u00e7\u00f5es, mas independentemente disto, sabemos que gerar valor em sa\u00fade, sempre foca nos melhores resultados para os pacientes, e \u00e9 a\u00ed onde os cirurgi\u00f5es cardiovasculares podem ter um impacto significativo.Existem na atualidade mais de 50 modelos de pagamento, baseados em valor, que podem ser escolhidos pela fonte pagadora, j\u00e1 que variam em fun\u00e7\u00e3o dos riscos e dos tipos de reembolso. Por meio de equipes bem treinadas se conseguiu implementar protocolos, otimizar processos, levando a menos complica\u00e7\u00f5es e, consequentemente, menor custo. Dentro disto, o que mais chamou a aten\u00e7\u00e3o foram os hospitais que ofereciam cirurgias card\u00edacas a custo baixo e com \u00f3timos resultados. Pouco mais longe foi o plano de sa\u00fade Geisinger quando anunciou \u201ccirurgia card\u00edaca com garantia ou seu dinheiro de volta\u201d. Exemplos mais recentes, como o modelo do cuidado perfeito \u201cPerfect Care\u201d mostrou redu\u00e7\u00e3o de 37% do custo, mantendo a qualidade do atendimento, quanto mais ader\u00eancia \u00e0s m\u00e9tricas de gera\u00e7\u00e3o de valor. Na Am\u00e9rica Latina, exemplos iniciais de gera\u00e7\u00e3o de valor em cirurgia cardiovascular mostraram uma redu\u00e7\u00e3o da mortalidade, ap\u00f3s o estabelecimento de m\u00e9tricas e a forma\u00e7\u00e3o de n\u00facleos de exc\u00ealencia e, por outro lado, uma diminui\u00e7\u00e3o significativa dos tempos de interna\u00e7\u00e3o de forma segura e efetiva.Mais recentemente exemplos de bons resultados cir\u00fargicos, com custo baixo, come\u00e7aram a serem divulgados.Enhanced Recovery After Surgery) para cirurgia card\u00edaca publicada em 2019, consolidou um novo conceito que se fortificou ap\u00f3s a chegada da COVID-19. Trata-se de protocolos perioperat\u00f3rios, multiprofissionais e baseados em evid\u00eancia, que buscaram melhorar resultados e diminuir os custos por meio da forma\u00e7\u00e3o de uma linha de cuidado. Para isto acontecer em grande escala existiu a necessidade da implementa\u00e7\u00e3o de bancos de dados, de educa\u00e7\u00e3o e treinamento de equipes, com foco nestes princ\u00edpios de melhoria cont\u00ednua. Al\u00e9m disto \u00e9 importante que estas a\u00e7\u00f5es tenham suporte de outras medidas como s\u00e3o as portarias nacionais do Medicare e Medicaid nos Estados Unidos que at\u00e9 2030 se prop\u00f5em a colocar todos seus pacientes em linhas de cuidados baseadas em valor. Mais recentemente o Minist\u00e9rio da Sa\u00fade do Brasil estabeleceu mudan\u00e7as para um ressarcimento por resultados, atrav\u00e9s da portaria do QualiSUS-Cardio, introduzindo categorias baseadas em volume, mortalidade, tempo de interna\u00e7\u00e3o e taxa de reinterna\u00e7\u00e3o, o que cria um cen\u00e1rio promissor dentro destes princ\u00edpios. Com certeza outras a\u00e7\u00f5es dever\u00e3o se seguir, para refor\u00e7ar este modelo de ressarcimento. Entretanto este modelo pode vir a criar distor\u00e7\u00f5es, que precisam ser bem equacionadas, pois pacientes de alto risco podem passar a ser recusados por alguns centros e encaminhados para outros servi\u00e7os.Dentro disto, a diretriz do ERAS . Therefore, efforts to reduce complications and length of stay after cardiovascular surgery would help reduce hospital costs. Among the models, some adapt better to certain situations, but regardless of this, we know that value creation in health always focuses on the best results for patients, and that is where cardiovascular surgeons can have a significant impact.There are currently more than 50 value-based payment models, which can be chosen by the payment source, as they vary according to the risks and types of reimbursement.With well-trained teams, it was possible to implement protocols and optimize processes, leading to fewer complications and, consequently, lower costs. What most drew attention were hospitals that performed heart surgeries at low cost and with excellent results.Geisinger Health System, a hospital group in the United States, went further when it announced \u201cheart surgery guaranteed or your money back,\u201d a 90-day warranty for elective coronary artery bypass surgery (CABG).More recent examples, such as the Perfect Care approach, showed a 37% cost reduction, maintaining the quality of care when adherence to value creation metrics was higher.In Latin America, initial examples of value creation in cardiovascular surgery showed a reduction in mortality after establishing metrics and forming centers of excellenceand, simultaneously, a significant decrease in the length of hospital stay in a safe and effective way.More recently, some examples of good surgical results at a low cost have begun to be announced.consolidated a new concept strengthened after the COVID-19 outbreak.These perioperative, multidisciplinary, and evidence-based protocols sought to improve results and reduce costs by creating a line of care. For this to happen on a large scale, databases, education, and team training focusing on continuous improvement principles must be implemented. In addition, these actions must be supported by other measures, such as the Medicare and Medicaid ordinances in the United States, which by 2030 propose to have all their patients in value-based lines of care.More recently, the Brazilian Ministry of Health established changes to reimbursement based on results through the QualiSUS-Cardio ordinance, introducing categories based on surgical volume, mortality, length of stay, and readmission rate,which creates a promising scenario within these principles. Other actions will certainly come to reinforce this reimbursement model. However, this model may create distortion, which needs to be corrected, as high-risk patients may be referred to other institutions.The Enhanced Recovery After Surgery (ERAS) guideline for cardiac surgery, published in 2019,In future propositions, this ordinance could consider performance categories for each risk stratum and not in general. As a principle, the ideal risk score should include local characteristics. In S\u00e3o Paulo state, we have the SPScore, an artificial intelligence-generated risk index that could help with a more appropriate reimbursement to payment sources in our scenario.Thus, results need to be adjusted and prepared to be revealed in a public and transparent way. Risk adjustment is essential, as we identified that the cost of care for low-, medium- and high-risk patients were significantly disproportionate due to differences between morbidity and mortality rates in different risk groups.In Brazil, to keep up with these changes, a line of research at the Department of Cardiopneumology of the University of S\u00e3o Paulo Medical School began in 2012 to stratify and improve results in patients referred for cardiovascular surgery. Undergraduate and graduate students research and publish topics on implementing large databases, constructing artificial intelligence-generated risk scores, identifying cost-effective strategies in risk groups, and process optimization, among others. Projects for training non-technical skills and surgical coaching for the teams, as well as the dissemination of improvement programs in centers in the country and Latin America, are still under development. Initial national strategies, such as payment by results, encourage the search for quality of care, but this will only be scaled with the support of a large database and specialists trained in value creation metrics. We seek to collaborate with the new health system by developing processes, training, and qualifying teams to apply the principles of continuous improvement, in the patient care flow, for cardiovascular surgery."}
+{"text": "To verify the occurrence of abnormal auditory evoked potentials (AEP) tests in adult smokers.Systematic review of the literature according to the PRISMA guidelines, to answer the question: \u201cAre there any changes in the AEP results in adult smokers?\u201d, PECOS strategy. Research carried out on PubMed, Embase, CINAHL, LIVIVO, Scopus, Web of Science, LILACS and Scielo databases. Additional search of gray literature: Google Scholar and ProQuest hand searching of reference lists of the included studies.Cross-sectional studies were selected, without restriction on the year of publication and language.First, the titles and abstracts of all the studies were analyzed, followed by the full reading of the eligible studies.898 articles were collected, after the duplicate studies were removed and after blind analysis by three researchers, 8 studies of the observational type were selected. Most studies have found an association between active smoking and changes in electrophysiological tests.Normal hearing adult smokers present alterations in short and long AEP. In the auditory brainstem response, the main altered components were the increase in waves latencies of I and III and in the interpeaks I - III and III - V, as well as a decrease in the amplitude of the waves. In Mismatch Negativity, there was a significant increase in wave amplitude and latency. In the long latency potential, P300, there was an increase in latencies and decreased amplitudes in the components N1 (in Fz) and P3. Also, as any type of hearing impairment can lead to a worsening of the individual's quality of life, many authors have explored the association between tobacco use and its effect on hearing over the years.Therefore, the auditory system can be exposed to harmful influences from this adverse event and, when it comes to ototoxicity, its effects can be transient or permanent, depending on which structures were affected or the characteristics of the exposure.A recent 8-year cohort study verified the prospective association of tobacco use, intensity, and smoking cessation with the risk of hearing loss, which included 50,195 participants, aged between 20 and 64 years and without hearing loss at the beginning of the study. Pure-tone threshold audiometry was performed annually, and during monitoring, 3,532 individuals developed high-frequency hearing loss and 1,575 developed low-frequency hearing loss. The conclusion was that smoking is associated with an increased risk of hearing loss, especially at high frequencies, in a dose-response manner. The excessive risk of hearing loss associated with smoking disappeared in a relatively short period after smoking cessation.In addition to the occurrence of sensorineural hearing loss at high frequencies, a study also observed the presence of a high number of smokers with tube dysfunction, which increases the incidence of middle ear diseases, as it brings nonspecific symptoms characterized by ear fullness and difficulty equalizing the middle ear,7. It is also known that the degeneration of the function of the nervous system happens mostly in a rostrocaudal manner, that is, it starts with the cortex, passing through the subcortical regions until reaching the brainstem. Thus, the investigation of the nicotine effect on the central auditory nervous system (CANS) has also been investigated by means of the auditory evoked potential (AEP).Furthermore, nicotine can be transported to receptors in the central nervous system and may involve both peripheral and central auditory structures.The AEP is a set of methods that evaluate the electrobiological activity along the auditory system, from the inner ear to the cerebral cortex. Thus, the application of these tests allows the investigation of hearing neurophysiological conditions. The middle-latency auditory evoked potential, which appears approximately 80 ms after stimulation, originates in the primary auditory cortex - more specifically from the nuclei and auditory pathways to the level of the thalamus-cortical region and primary auditory cortex; finally, the long-latency auditory evoked potential, which appears around 100 to 700 ms after stimulation, reflecting activities of the auditory pathway in the regions of the thalamus and auditory cortex, providing information about the CANS functioning.The AEPs can be divided into three types. The brainstem auditory evoked potential (BAEP), considered a short-latency potential, stands out; it appears in an interval of approximately 10 ms after stimulation, which allows the neurophysiological analysis of the auditory pathway, from the inner ear to the high brainstem,13,14.Thus, sensorineural hearing loss at high frequencies of cochlear origin compromises the morphology of AEP waves, as well as retrocochlear disorders. In this sense, studies indicate that there are alterations in the parameters of AEP test records in smokers when compared to non-smokers, such as increased latencies and decreased response amplitudes, even in the absence of increased auditory thresholds, and these findings may somehow influence the correct processing of acoustic informationSeveral anatomical sites, responsible for producing the neuroelectric activity of the auditory pathway in response to acoustic stimulation, may behave differently in smokers, which makes it necessary to assess what evidence is available in the literature that proves the existence or not of that association.,7,13,14.In view of the above, studies have pointed to the need to carry out additional tests for basic audiological assessment in order to investigate the extent of the injury caused by constant tobacco exposure, helping in a better understanding of the alterations found, besides detailing the types of alterations that smoking causes to the CANS,7,13,14.Thus, the AEPs analysis proves to be useful in the differential diagnosis of sensorineural hearing loss, bringing important pieces of information that can indicate objectively if the lesion is located at the cochlear and/or retrocochlear level, as well as showing early changes in the sites that generate the neural response, before changes are detected in the basic audiological assessmentThis study aimed to verify the occurrence of abnormal auditory evoked potentials (AEP) tests in adult smokers with normal hearing, through a systematic review of the literature..This systematic review followed the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-analyses - PRISMAObservational studies on adult smokers (aged 18 years and under 60 years) were considered eligible for this systematic review, which aimed to assess the integrity of the auditory pathway by means of the AEP test. There was no restriction on the study publication date. The following studies were excluded: (1) review articles, letters, case studies, and event abstracts; (2) studies on smokers associated with other diseases; (3) studies that included individuals younger than 18 years old or older than 60 years old; (4) studies carried out with smokers with hearing alterations prior to addiction; (5) studies without a control group; (6) studies without the full version available.  was used to formulate the guiding question. Thus, in this literature review, PECOS stands for P - population (adults), E - exposure to tobacco; C - tobacco non-exposed adults; O - any change in auditory evoked potential tests, and S - design of included, observational cross-sectional studies (S).The following guiding question was used to conduct the study: \u201cAre there any changes in the AEP results in adult smokers?\u201d The PECOS approach. EndNote Web\u00ae, reference manager software, was used to collect references and delete duplicates. The collection date on the databases was held on March 24, 2021. Studies that answered the research question were selected, without restriction on publication date and language.Individual electronic search strategies were developed, using the combination of the following descriptors in Portuguese and English, respectively: \u201cFumantes,\u201d \u201cPotenciais Evocados Auditivos,\u201d \u201cEletrofisiologia,\u201d, \u201cNervo Coclear,\u201d \u201cSmokers\u201d, \u201cAuditory Evoked Potentials,\u201d \u201cElectrophysiology,\u201d \u201cCochlear Nerve.\u201d In order to encompass certain thematic axes, the Boolean operators \u201cOR\u201d and \u201cAND\u201d were used, according to MESH/DECS, for each of the following databases: PubMed, Embase, CINAHL, LIVIVO, Scopus, Web of Science, LILACS, and Scielo. Additional search of gray literature was made by accessing Google Scholar and ProQuest. Moreover, hand searching of reference lists of the included studies was conducted, as recommended by Greenhalgh and Peacock (2005)The selection stage had two phases. In phase one, the titles and abstracts of all identified database citations were screened by two reviewers independently. Studies that did not meet the eligibility criteria were excluded. In phase two, the same two reviewers applied the eligibility criteria to the full text of the studies. A third reviewer was consulted in case of disagreement that was not resolved by a consensus discussion between the two reviewers.Two authors collected the necessary information from the selected studies. A third author confirmed the veracity of the information collected by checking the full text of the articles against the information selected by the first two authors. Any controversies in this process were discussed and a consensus was established. The data extracted from the studies were: characteristics of the studies , characteristics of the population , characteristic of exposure (smoking characterization), and characteristics of the outcome .. The first and second authors performed this assessment independently. Any disagreements that arose were resolved with the third author\u2019s help.The risk of bias assessment of the selected studies was evaluated using the JBI Critical Appraisal Checklist for Studies Reporting Prevalence Data. Regarding the percentage of \u201cYes\u201d of each analyzed study, classification was as follows: high risk of bias (> 49%), moderate high risk of bias (50 to 69%), or low high risk of bias (> 70%).For each domain of the tool, one of the following responses was assigned: \u201cYes,\u201d \u201cNo,\u201d \u201cUnclear\u201d or \u201cNot Applicable\u201dThe first phase of the selection process resulted in 898 citations on electronic databases. After removing duplicates, a total of 537 were evaluated. After reading the titles and abstracts, 47 references were selected to be screened by full-text reading, which resulted in the inclusion of eight studies for qualitative and quantitative evaluation. A new article was added after hand searching of the reference list of articles included. Both selection and exclusion processes are shown in 19 to 137. Regarding the country of origin of the studies, one was from Brazil, two were from Turkey,21, two were from India,22, two were from Egypt,23, and one from Germany. Due to the nature of the guiding question, all included studies used convenience samples. A summary of the characteristics of the eight included studies can be found in ,14,22, four performed P300-21,23, and one performed Mismatch Negativity (MMN) and P300.The articles included had been published in different scientific journals . The number of smokers included in the studies ranged from 10, one study was classified as having a moderate risk of bias, and seven as having a low risk of bias, according to the number of responses \u201cyes\u201d for the eight questions in the tool adopted for quality assessment.In the analysis of the methodological quality of the studies included, evaluated according to the JBI Critical Appraisal Checklist for Studies Reporting Prevalence Data,14,22, significant increase in wave amplitude and latency of MMN in the group of smokers, and also an increase in latencies and lower amplitude in the group of smokers in P300-21,23.The studies evaluated in this review present data that imply damage in the conductivity of the neural impulse along the auditory pathway in smokers. Of eight studies reviewed - observational studies -, one evidenced the relationship between smoking and the significant increase in the latencies of waves I and III and in the interpeaks I-III and III-V, as well as a decrease in the amplitudes of the BAEP waves,25. Nicotinic acetylcholine receptors are widely distributed in the auditory pathways, and it is very plausible that the nicotine absorbed by smoking can influence this pathway, consequently causing conductive, mixed, sensorineural and/or central hearing loss,25.Smoking is the main nicotine release way, as each cigarette contains about 9-13 mg nicotine, which is rapidly absorbed and transported by the bloodstream to receptors in the central nervous system. Hence the importance of investigating the effects of smoking by recording the AEP, both in the peripheral and central portions, prior to alterations in the basic audiological assessment.The degeneration of the function of the nervous system is often processed by the organism in a rostrocaudal manner. Thus, it starts with the cortex, passes through the subcortical regions, and then reaches the brainstem. This reduction causes changes in endocochlear potentials, cochlear microphonics and eighth nerve potentials, and nicotine central effects may be due to the alteration in the efferent neural discharge through the olivocochlear system that leads to the modulation of the response of the cochlear hair cells.When studying AEP findings in smokers, changes were found in several parameters analyzed, and the possible reason for changes in latency and amplitude of the studied components is due to the reduction in cochlear blood flow induced by nicotine,14,22, there was a significant increase in the absolute latency of waves I,14,22 and III,22 and a significant increase in the interpeaks I-III and III-V. Such findings show alteration in the synchrony of the neural element in the sites that generate the response of this potential, in a diffuse manner, evidenced by the delay in the response generation.In the studies that performed BAEP,28. In other words, one of the stimuli is often presented, while the other occurs rarely and randomly. This vertex-positive potential and approximate latency of 300 ms appears once the individual processes a signal at a cognitive level, thus being an execution strategy of the central nervous system manifested electrophysiologically,28.The P300 is an endogenous auditory evoked potential, and it is identified as the result of an internal cognitive event generated in an active and voluntary manner during the performance of a specific discriminatory task between two different sound stimuli,28. In order for the results to be generated, there is joint and integrate activation of the inferior parietal lobe with the medial and lateral prefrontal areas in attention processes, the heteromodal, paralimbic and hippocampus areas in memory processes, and also the auditory cortex involved in discrimination processes and linguistic auditory association-29.It is known that the brain regions responsible for attention, discrimination, integration, and memory skills, such as the hippocampus, auditory cortex and frontal cortex, are the areas that stand out during the generation of the P300-29. Studies suggest that the more significant the frequency difference between the frequent and the rare stimuli is, the more increased the amplitude of the P300, due to the greater ease of detecting the difference between them-29. As it is presented by four out of five articles that used this type of AEP, there was a decrease in the amplitude of response in the group of smokers,19,21,23, and only one showed absence of significant differences between the values averages between components N1, P2, N2 and P3. There was divergence between the observed latency relationship, since part of the studies reported increased latency and specifically increased N1 (in FZ) for the group of smokers, and results were also found in which no significant difference values were obtained between latencies,20, which shows the need for further studies with this type of potential.To record and analyze the results of this test, parameters such as latency and wave amplitude are considered essential. Unlike the P300 test, the MMN does not require the patient\u2019s attention, thus it is capable of providing information about the physiological bases for auditory discrimination without requiring the subject\u2019s speech production.The MMN test is an endogenous auditory evoked potential, which indicates responses to two stimuli, one of which is a rare stimulus and the other a frequent stimulus, which occur bilaterally in the auditory cortex,31. Pieces of Research have used the MMN to assess different aspects such as, among other factors, attention and hyperactivity disorder, detection of articulation disorders, and auditory behavior in alcohol or cigarette users,31.The MMN can be applied as a neural indicator of early auditory variations, often being used in order to observe disorders involving auditory cognition, and its main generators are found in the auditory cortex and receives contributions from the frontal cortex, thalamus, and hippocampus-33.The analysis of the MMN is carried out by observing the latency and amplitude of the wave and clinical alterations can be questioned when verifying an increase in latencies or a decrease in amplitudes, where latency informs the course time of the processing activity, while the wave amplitude demonstrates the extent of neural allocation involved in cognitive processes. Thus, research has been carried out with the use of the MMN to prove the effects caused by tobacco use on the auditory cortex. One of these studies selected in this review pointed to a significant increase in wave amplitude and MMN latency in smokers, suggesting that smokers may present delay in information processing, just as chronic smoking can produce cognitive dysfunction.As previously described, nicotine triggers the activation of different receptors that can cause negative effects on the cortex, even compromising cognitionFinally, based on the data collected and analyzed in this review, there was a predominance of alterations in the AEPs - whether BAEP, P300 or MMN - in smokers without impairment of hearing acuity. The need for more primary studies on this subject is highlighted, especially with performance of the three types of potential in the same study for a better understanding of the clinical implications observed in the same sample unit.Some limitations can be pointed out in this systematic review, such as: small sample size; lack of studies that applied all AEPs in the same case; convenience samples in all included studies; some studies had only a single sex, and population heterogeneity. Therefore, the results should be analyzed with caution.The results presented by this review show that normal-hearing adult smokers present alterations in the short- and long-latency AEP tests. In the BAEP, the main altered components were the increase in the latencies of waves I and III and in the interpeaks I-III and III-V, as well as a decrease in the amplitude of the waves. In the MMN, there was a significant increase in wave amplitude and latency. In the long latency potential, P300, there was an increase in latencies and a reduction in amplitudes in components N1 (in Fz) and P3. ,2.O consumo de tabaco \u00e9 considerado como um dos fatores de risco que mais provocam a morbimortalidade em todo o mundo e sabe-se que o seu consumo \u00e9 o principal meio de libera\u00e7\u00e3o de nicotina, que \u00e9 altamente absorvida na corrente sangu\u00ednea, podendo comprometer diferentes estruturas do organismo, provocando diversos efeitos nocivos, como doen\u00e7as card\u00edacas, acidente vascular cerebral, doen\u00e7a pulmonar obstrutiva cr\u00f4nica, al\u00e9m de c\u00e2nceres, comprometimento cognitivo dentre outras-3.O tabaco tamb\u00e9m provoca diminui\u00e7\u00e3o da oxigena\u00e7\u00e3o celular, bloqueio vascular, mudan\u00e7as na viscosidade sangu\u00ednea, forma\u00e7\u00e3o de placa ateroscler\u00f3tica e diminui\u00e7\u00e3o do aporte de oxig\u00eanio, que pode levar a um preju\u00edzo no suprimento sangu\u00edneo, inclusive, das vias auditivas. E tamb\u00e9m como qualquer tipo de comprometimento auditivo pode levar a uma piora da qualidade de vida do indiv\u00edduo, muitos autores t\u00eam explorado a associa\u00e7\u00e3o entre o uso do tabaco e seu efeito na audi\u00e7\u00e3o, ao longo dos anos.Sendo assim, o sistema auditivo pode sofrer influ\u00eancias danosas deste evento adverso e, se tratando da ototoxicidade, seus efeitos podem ser transit\u00f3rios ou permanentes, a depender de quais estruturas foram acometidas ou ent\u00e3o das caracter\u00edsticas da exposi\u00e7\u00e3o.Um estudo recente verificou a associa\u00e7\u00e3o prospectiva do tabagismo, a intensidade e a cessa\u00e7\u00e3o do v\u00edcio com o risco de perda auditiva, em um delineamento de coorte, por oito anos, que incluiu 50.195 participantes, com idade entre 20 e 64 anos e sem perda auditiva no in\u00edcio do estudo. A audiometria tonal liminar foi feita anualmente e durante o acompanhamento, 3.532 indiv\u00edduos desenvolveram perda auditiva nas altas frequ\u00eancias e 1.575 desenvolveram perda de audi\u00e7\u00e3o nas baixas frequ\u00eancias. Conclu\u00edram que o tabagismo est\u00e1 associado a um risco aumentado de perda auditiva, especialmente nas altas frequ\u00eancias, de forma dose-resposta. O risco excessivo de perda auditiva, associado ao tabagismo, desapareceu em um per\u00edodo relativamente curto ap\u00f3s a cessa\u00e7\u00e3o do v\u00edcio.Al\u00e9m da ocorr\u00eancia de perda auditiva sensorioneural nas altas frequ\u00eancias, um estudo tamb\u00e9m observou a presen\u00e7a de um elevado n\u00famero de fumantes com disfun\u00e7\u00e3o tub\u00e1ria, que aumentam a incid\u00eancia de doen\u00e7as da orelha m\u00e9dia, por trazer sintomas inespec\u00edficos caracterizados por plenitude auricular e dificuldade de equaliza\u00e7\u00e3o da orelha m\u00e9dia,7. Al\u00e9m do mais, sabe-se que a degrada\u00e7\u00e3o da fun\u00e7\u00e3o do sistema nervoso, em sua maioria, acontece de forma rostrocaudal, ou seja, inicia-se pelo c\u00f3rtex, passando pelas regi\u00f5es subcorticais at\u00e9 atingir o tronco encef\u00e1lico. Assim, a investiga\u00e7\u00e3o do efeito da nicotina sobre o sistema nervoso auditivo central (SNAC) tem sido tamb\u00e9m investigado atrav\u00e9s do potencial evocado auditivo (PEA).E ainda, a nicotina pode ser transportada aos receptores do sistema nervoso central podendo envolver tanto estruturas auditivas perif\u00e9ricas como centrais.O PEA trata-se de um conjunto de m\u00e9todos que avaliam a atividade eletrobiol\u00f3gica, ao longo do sistema auditivo, desde orelha interna ao c\u00f3rtex cerebral. Dessa forma, a aplica\u00e7\u00e3o destes testes permite investigar condi\u00e7\u00f5es neurofisiol\u00f3gicas da audi\u00e7\u00e3o. O potencial evocado auditivo de m\u00e9dia lat\u00eancia que surge em aproximadamente 80 ms ap\u00f3s a estimula\u00e7\u00e3o, originando-se em \u00e1reas prim\u00e1rias do c\u00f3rtex auditivo, mais especificamente dos n\u00facleos e vias auditivas existentes at\u00e9 no n\u00edvel da regi\u00e3o t\u00e1lamo-cortical e c\u00f3rtex auditivo prim\u00e1rio, por fim o potencial evocado auditivo de longa lat\u00eancia que surge por volta de 100 a 700 ms ap\u00f3s a estimula\u00e7\u00e3o, refletindo atividades da via auditiva nas regi\u00f5es do t\u00e1lamo e c\u00f3rtex auditivo, fornecendo informa\u00e7\u00f5es sobre o funcionamento do sistema nervoso auditivo central (SNAC).Dentres os PEAs destaca-se: o potencial evocado auditivo de tronco encef\u00e1lico (PEATE) considerado um potencial de curta lat\u00eancia, que surge em um intervalo de aproximadamente 10 ms, o mesmo permite a an\u00e1lise neurofisiol\u00f3gica da via auditiva, desde a orelha interna at\u00e9 o tronco encef\u00e1lico alto,13,14.Desta forma, perdas auditivas sensorioneurais nas altas frequ\u00eancias de origem coclear comprometem a morfologia das ondas dos PEAs, assim como disfun\u00e7\u00f5es retrococleares. Neste sentido, estudos apontam que h\u00e1 altera\u00e7\u00e3o nos par\u00e2metros de registros de exames de PEA, tais como aumento das lat\u00eancias e diminui\u00e7\u00e3o das amplitudes das respostas, em fumantes quando comparados aos n\u00e3o fumantes, mesmo na aus\u00eancia da eleva\u00e7\u00e3o dos limiares auditivos, sendo que esses achados podem influenciar, de alguma maneira, o correto processamento da informa\u00e7\u00e3o ac\u00fastica\u00c9 prov\u00e1vel que diversos s\u00edtios anat\u00f4micos, respons\u00e1veis pela produ\u00e7\u00e3o da atividade neuroel\u00e9trica da via auditiva, em resposta a uma estimula\u00e7\u00e3o ac\u00fastica, se comporte de forma diferente em fumantes, o que torna necess\u00e1rio avaliar quais s\u00e3o as evid\u00eancias dispon\u00edveis na literatura que comprovem a exist\u00eancia ou n\u00e3o dessa associa\u00e7\u00e3o.,7,13,14.Diante do exposto acima, estudos t\u00eam apontado a necessidade de se realizar testes complementares a avalia\u00e7\u00e3o audiol\u00f3gica b\u00e1sica a fim de se investigar a extens\u00e3o da les\u00e3o ocasionada pela exposi\u00e7\u00e3o constante ao tabaco e auxiliar no melhor entendimento das altera\u00e7\u00f5es encontradas, al\u00e9m de detalhar os tipos de altera\u00e7\u00f5es que o fumo ocasiona ao SNAC,7,13,14.Assim, a investiga\u00e7\u00e3o dos PEAs se mostra \u00fatil no diagn\u00f3stico diferencial da perda auditiva sensorioneural trazendo informa\u00e7\u00f5es importantes que podem objetivamente indicar se a les\u00e3o est\u00e1 situada em n\u00edvel coclear e/ou retrococlear, bem como mostrar altera\u00e7\u00e3o precoce nos s\u00edtios geradores da resposta neural, antes de se detectar mudan\u00e7as na avalia\u00e7\u00e3o audiol\u00f3gica b\u00e1sicaDesse modo, o objetivo do presente estudo foi verificar a ocorr\u00eancia de altera\u00e7\u00f5es nos exames de PEA em adultos fumantes normo-ouvintes, por meio de uma revis\u00e3o sistem\u00e1tica da literatura.Preferred Reporting Items for Systematic Reviews and Meta-analyses - PRISMA.Esta revis\u00e3o sistem\u00e1tica seguiu as recomenda\u00e7\u00f5es do Foram considerados eleg\u00edveis para essa revis\u00e3o sistem\u00e1tica estudos observacionais realizados em adultos  tabagistas, que tiveram como objetivo avaliar a integridade da via auditiva por meio do exame de PEA. N\u00e3o houve restri\u00e7\u00e3o do tempo de publica\u00e7\u00e3o dos estudos. Foram exclu\u00eddos os seguintes estudos: (1) artigos de revis\u00e3o, cartas, estudos de caso e resumos para eventos; (2) estudos realizados em fumantes associados com outras doen\u00e7as; (3) estudos que inclu\u00edram indiv\u00edduos com idade inferior a 18 anos ou maiores de 60 anos; (4) estudos realizados em fumantes com altera\u00e7\u00f5es auditivas pr\u00e9vias ao v\u00edcio; (5) estudos sem grupo controle; (6) estudos que n\u00e3o tinham a vers\u00e3o na \u00edntegra dispon\u00edvel. . Assim, o acr\u00f4nimo (P) consiste em popula\u00e7\u00e3o (adultos), (E) consiste na exposi\u00e7\u00e3o ao tabaco, (O) consiste em qualquer altera\u00e7\u00e3o nos exames de potenciais evocados auditivos, (C) adultos sem exposi\u00e7\u00e3o ao tabaco e (S) consiste no desenho de estudos inclu\u00eddos, observacionais - transversais.Para a condu\u00e7\u00e3o do estudo foi utilizada a seguinte pergunta norteadora: \u201cH\u00e1 altera\u00e7\u00f5es nos resultados do exame de potenciais evocados auditivos em adultos fumantes?\u201d. Esta pergunta foi organizada no formato PECOSSmokers\u201d, \u201cAuditory Evoked Potentials\u201d, \u201cElectrophysiology\u201d, \u201cCochlear Nerve\u201d. Para contemplar os determinados eixos tem\u00e1ticos, foram utilizados os operadores booleanos \u201cOR\u201d e \u201cAND\u201d, de acordo com MESH/DECS, para cada uma das seguintes bases de dados: PubMed, Embase, CINAHL, LIVIVO, Scopus, Web of Science, LILACS, Scielo. Uma pesquisa adicional da literatura cinzenta foi realizada acessando o Google Scholar e ProQuest. Al\u00e9m disso, foram realizadas buscas manuais das refer\u00eancias dos estudos inclu\u00eddos, conforme recomendado por Greenhalgh e Peacock. Um software gerenciador de refer\u00eancia (EndNote Web\u00ae) foi usado para coletar as refer\u00eancias e excluir as duplicatas. A data de coleta nas bases foi realizada no dia 24 de mar\u00e7o de 2021. Foram selecionados os estudos que responderam a pergunta de pesquisa, sem restri\u00e7\u00e3o da data de publica\u00e7\u00e3o e idioma.Foram desenvolvidas estrat\u00e9gias de busca eletr\u00f4nica individual, sendo utilizada a combina\u00e7\u00e3o dos seguintes descritores em portugu\u00eas e em ingl\u00eas, respectivamente: \u201cFumantes\u201d, \u201cPotenciais Evocados Auditivos\u201d, \u201cEletrofisiologia\u201d, \u201cNervo Coclear\u201d, \u201cA etapa de sele\u00e7\u00e3o foi realizada em duas fases. Na fase um, os t\u00edtulos e resumos de todas as cita\u00e7\u00f5es do banco de dados identificadas foram selecionados de forma independente por dois revisores. Os estudos que n\u00e3o preencheram os crit\u00e9rios de elegibilidade foram exclu\u00eddos. Na fase dois, os mesmos dois revisores aplicaram os crit\u00e9rios de elegibilidade ao texto completo dos estudos. Um terceiro revisor foi consultado em caso de desacordo que n\u00e3o tenha sido resolvido por uma discuss\u00e3o de consenso entre os dois revisores.Dois autores coletaram as informa\u00e7\u00f5es necess\u00e1rias dos estudos selecionados. Um terceiro autor confirmou a veracidade das informa\u00e7\u00f5es coletadas por meio da confer\u00eancia do texto completo dos artigos com as informa\u00e7\u00f5es selecionadas pelos dois primeiros autores. Quaisquer controv\u00e9rsias, neste processo, foram discutidas e estabelecido um consenso. Os dados extra\u00eddos dos estudos foram: caracter\u00edsticas dos estudos , caracter\u00edsticas da popula\u00e7\u00e3o , caracter\u00edstica de exposi\u00e7\u00e3o (caracteriza\u00e7\u00e3o do tabagismo) e caracter\u00edsticas do desfecho .JBI Critical Appraisal Checklist for Studies Reporting Prevalence Data. O primeiro e o segundo autores realizaram esta avalia\u00e7\u00e3o de forma independente. Quaisquer discord\u00e2ncias surgidas foram resolvidas com a ajuda do terceiro autor.A avalia\u00e7\u00e3o do risco de vi\u00e9s dos estudos selecionados foi avaliada pelo Yes\u201d, \u201cNo\u201d, \u201cUnclear\u201d ou \u201cNot Applicable\u201d. Para a porcentagem de \u201cYes\u201d de cada estudo analisado, foi considerado com risco alto de vi\u00e9s (> 49%) ou moderado (50 a 69%) ou baixo (> 70%).Para cada dom\u00ednio da ferramenta foi atribu\u00edda uma das seguintes respostas: \u201cA primeira fase do processo de sele\u00e7\u00e3o resultou em 898 cita\u00e7\u00f5es nas bases de dados eletr\u00f4nicas. Ap\u00f3s a remo\u00e7\u00e3o de duplicados, um total de 537 foi avaliado. Ap\u00f3s a leitura de t\u00edtulos e resumos, 47 refer\u00eancias foram selecionadas para serem triadas por meio da leitura do texto na \u00edntegra, o que resultou na inclus\u00e3o de oito estudos para avalia\u00e7\u00e3o qualitativa e quantitativa. Foi adicionado um artigo novo ap\u00f3s a pesquisa na lista de refer\u00eancias dos artigos inclu\u00eddos. Tanto a sele\u00e7\u00e3o quanto os processos de exclus\u00e3o s\u00e3o apresentados na 19 a 137. Em rela\u00e7\u00e3o ao pa\u00eds de origem dos estudos, um foi do Brasil, dois foram da Turquia,21, dois foram da \u00cdndia,22, dois foram do Egito,23 e um da Alemanha. Devido a natureza da pergunta norteadora, todos os estudos inclu\u00eddos usaram amostras de conveni\u00eancia. A s\u00edntese das caracter\u00edsticas dos oito estudos inclu\u00eddos pode ser encontrada no ,14,22, quatro realizaram o P300-21,23 e um o MMN e o P300.Os artigos inclu\u00eddos foram publicados em diferentes revistas cient\u00edficas . O n\u00famero de fumantes inclu\u00eddos nos estudos variou de 10JBI Critical Appraisal Checklist for Studies Reporting Prevalence Data, um estudo foi classificado como tendo moderado risco de vi\u00e9s, e sete com baixo risco de vi\u00e9s, de acordo com o n\u00famero de respostas \u201csim\u201d para as oito perguntas na ferramenta adotada para a avalia\u00e7\u00e3o da qualidade.Na an\u00e1lise da qualidade metodol\u00f3gica dos estudos inclu\u00eddos, avaliado de acordo com ,14,22, aumento significativo da amplitude da onda e da lat\u00eancia do Mismatch Negativity (MMN) no grupo de fumantes e ainda, aumento das lat\u00eancias e amplitude menores no grupo de fumantes no exame P300-21,23.Os estudos avaliados nesta revis\u00e3o mostram dados que implicam em preju\u00edzos na condutividade do impulso neural ao longo da via auditiva em indiv\u00edduos fumantes. A partir de oito trabalhos revisados, sendo estes com tipo de estudo observacional, evidenciou-se a rela\u00e7\u00e3o entre o tabagismo com o aumento significativo das lat\u00eancias das ondas I e III e nos interpicos I - III e III - V, bem como diminui\u00e7\u00e3o das amplitudes das ondas do potencial evocado auditivo de tronco encef\u00e1lico (PEATE),25. Os receptores nicot\u00ednicos de acetilcolina t\u00eam ampla distribui\u00e7\u00e3o nas vias auditivas, o que \u00e9 muito prov\u00e1vel que a nicotina absorvida pelo fumo possa exercer influ\u00eancia nesta via, e consequentemente provocar perdas auditivas de natureza condutiva, mista, sensorioneural e/ou central,25.O tabagismo \u00e9 o principal sistema de libera\u00e7\u00e3o da nicotina, pois cada cigarro cont\u00e9m cerca de 9-13 mg de nicotina que \u00e9 rapidamente absorvida e transportada pela corrente sangu\u00ednea aos receptores no sistema nervoso central. Da\u00ed a import\u00e2ncia da investiga\u00e7\u00e3o dos efeitos do tabagismo por meio do registro dos PEA, tanto na por\u00e7\u00e3o perif\u00e9rica como central, previamente a altera\u00e7\u00f5es na avalia\u00e7\u00e3o audiol\u00f3gica b\u00e1sica.A deteriora\u00e7\u00e3o da fun\u00e7\u00e3o do sistema nervoso central muitas vezes \u00e9 processada pelo organismo de forma rostro-caudal. Sendo assim, inicia-se pelo c\u00f3rtex, passa pelas regi\u00f5es subcorticais quando ent\u00e3o atinge o tronco encef\u00e1lico. Esta redu\u00e7\u00e3o causa mudan\u00e7as nos potenciais endococleares, no microfonismo coclear e nos potenciais do oitavo nervo e \u00e9 poss\u00edvel tamb\u00e9m que os efeitos centrais da nicotina s\u00e3o em decorr\u00eancia da altera\u00e7\u00e3o na descarga neural eferente atrav\u00e9s da sistema olivococlear que leva \u00e0 modula\u00e7\u00e3o da resposta das c\u00e9lulas ciliadas da c\u00f3clea.Ao estudar os achados dos PEA em fumantes encontram-se mudan\u00e7as em diversos par\u00e2metros analisados e a poss\u00edvel raz\u00e3o para as altera\u00e7\u00f5es na lat\u00eancia e nas amplitudes dos componentes estudados se deve ao fato da redu\u00e7\u00e3o do fluxo sangu\u00edneo coclear induzida pela nicotina,14,22, observou-se aumento significativo da lat\u00eancia absoluta das ondas I,14,22 e III,22 e aumento significativo do interpico I - III e III - V. Tais achados mostram altera\u00e7\u00e3o na sincronia do elemento neural nos s\u00edtios geradores da resposta deste potencial, de forma difusa, evidenciado pelo atraso na forma\u00e7\u00e3o da resposta.Para os estudos que realizaram o PEATE,28. Ou seja, um dos est\u00edmulos \u00e9 apresentado de forma frequente, enquanto que o outro ocorre raramente e de forma aleat\u00f3ria. Este potencial de v\u00e9rtex-positivo e lat\u00eancia aproximada de 300 ms aparece uma vez que o indiv\u00edduo processe um sinal em n\u00edvel cognitivo, sendo assim uma estrat\u00e9gia de execu\u00e7\u00e3o do sistema nervoso central manifestada eletrofisiologicamente,28.O P300 \u00e9 um potencial evocado auditivo end\u00f3geno, sendo designado como o resultado de um evento cognitivo interno gerado de forma ativa e volunt\u00e1ria durante o desempenho de uma tarefa discriminat\u00f3ria espec\u00edfica entre dois est\u00edmulos sonoros diferentes entre si,28. Para que os resultados sejam gerados, s\u00e3o ativadas de forma conjunta e integrada o lobo parietal inferior com \u00e1reas pr\u00e9 frontais medial e lateral nos processos de aten\u00e7\u00e3o, das \u00e1reas paral\u00edmbicas heteromodais e do hipocampo nos processos de mem\u00f3ria e, ainda, o c\u00f3rtex auditivo envolvidos nos processos de discrimina\u00e7\u00e3o e associa\u00e7\u00e3o auditivo lingu\u00edstica-29.Sabe-se que as regi\u00f5es cerebrais respons\u00e1veis pelas habilidades de aten\u00e7\u00e3o, discrimina\u00e7\u00e3o, integra\u00e7\u00e3o e mem\u00f3ria, como por exemplo o hipocampo, c\u00f3rtex auditivo e o c\u00f3rtex frontal, s\u00e3o as \u00e1reas que se sobressaem durante a gera\u00e7\u00e3o do P300-29. Estudos sugerem que a amplitude do P300 aumenta quanto mais significativa for a diferen\u00e7a de frequ\u00eancia entre o est\u00edmulo frequente e o raro, devido a maior facilidade de detec\u00e7\u00e3o da diferen\u00e7a entre eles-29. As pesquisas selecionadas evidenciam que se tratando de sujeitos fumantes, quatro dos cinco artigos que utilizaram este tipo de PEA, houve diminui\u00e7\u00e3o da amplitude de resposta no grupo de fumantes,19,21,23, apenas um deles evidenciou aus\u00eancia de diferen\u00e7as significativas entre os valores m\u00e9dios entre os componentes N1, P2, N2 e P3. Houve diverg\u00eancia entre a rela\u00e7\u00e3o das lat\u00eancias observadas, uma vez que parte dos estudos referiu aumento da lat\u00eancia e especificamente aumento de N1 (em FZ) para o grupo de fumantes, tamb\u00e9m foram encontrados resultados em que n\u00e3o foram obtidos valores de diferen\u00e7a significativa entre as lat\u00eancias,20, o que mostra a necessidade de mais estudos com este tipo de potencial.Para registro e an\u00e1lise dos resultados deste teste, par\u00e2metros como lat\u00eancia e amplitude de onda s\u00e3o considerados fundamentais. Diferente do teste P300, o MMN n\u00e3o requer a aten\u00e7\u00e3o do paciente, sendo assim capaz de fornecer informa\u00e7\u00f5es sobre as bases fisiol\u00f3gicoas para a discrimina\u00e7\u00e3o auditiva, sem requerer a produ\u00e7\u00e3o da fala do sujeito.O teste Mismatch Negativity (MMN) \u00e9 um potencial evocado auditivo end\u00f3geno, que indica respostas de dois est\u00edmulos, sendo um deles o est\u00edmulo raro e o outro, um est\u00edmulo frequente, os quais ocorrem bilateralmente no c\u00f3rtex auditivo,31. Pesquisas t\u00eam utilizado o MMN para avaliar diferentes aspectos como: transtorno de aten\u00e7\u00e3o e hiperatividade, detec\u00e7\u00e3o de dist\u00farbios articulat\u00f3rios, comportamento auditivo em usu\u00e1rios de \u00e1lcool ou cigarro entre outros fatores,31.O MMN pode ser aplicado como um indicador neural de varia\u00e7\u00f5es auditivas precoces, sendo muitas vezes, aplicado a fim de se observar transtornos envolvendo a cogni\u00e7\u00e3o auditiva, e seus principais geradores encontram-se no c\u00f3rtex auditivo e recebe contribui\u00e7\u00f5es do c\u00f3rtex frontal, t\u00e1lamo e hipocampo-33.A an\u00e1lise do MMN \u00e9 realizada atrav\u00e9s da observa\u00e7\u00e3o da lat\u00eancia e amplitude da onda e ao se verificar aumento das lat\u00eancias ou diminui\u00e7\u00e3o das amplitudes, altera\u00e7\u00f5es cl\u00ednicas podem ser questionadas, sendo que a lat\u00eancia informa o tempo de curso da atividade do processamento, enquanto que a amplitude da onda demonstra a extens\u00e3o da aloca\u00e7\u00e3o neural envolvida nos processos cognitivos. Dessa forma, pesquisas t\u00eam sido feitas com o uso do MMN para comprovar os efeitos provocados pelo uso do tabaco no c\u00f3rtex auditivo. Um desses estudos selecionados na presente revis\u00e3o, apontou aumento significativo da amplitude da onda e da lat\u00eancia do MMN nos fumantes, sugerindo que sujeitos fumantes possam apresentar atraso no processamento da informa\u00e7\u00e3o, assim como o tabagismo cr\u00f4nico pode produzir disfun\u00e7\u00e3o cognitiva.Como descrito anteriormente, a nicotina provoca a ativa\u00e7\u00e3o de diferentes receptores que podem ocasionar efeitos negativos ao c\u00f3rtex comprometendo at\u00e9 mesmo a cogni\u00e7\u00e3oPor fim, a partir dos dados coletados e analisados nesta revis\u00e3o, houve predom\u00ednio de altera\u00e7\u00f5es em qualquer um dos PEA, seja PEATE, P300 ou MMN, em indiv\u00edduos fumantes sem preju\u00edzo da acuidade auditiva. Destaca-se a necessidade de mais estudos prim\u00e1rios sobre este assunto, principalmente na realiza\u00e7\u00e3o dos tr\u00eas tipos de potencial num mesmo estudo para melhor entendimento das implica\u00e7\u00f5es cl\u00ednicas observadas numa mesma unidade amostral.Algumas limita\u00e7\u00f5es podem ser apontadas nesta revis\u00e3o sistem\u00e1tica, como o pequeno n\u00famero da amostra dos estudos inclu\u00eddos, n\u00e3o foi encontrado estudos que aplicassem todos os PEAs na mesma casu\u00edstica, todos os estudos inclu\u00eddos foram conduzidos com amostras de conveni\u00eancia, alguns eram restritos a um \u00fanico sexo, e a heterogeneidade da popula\u00e7\u00e3o deve ser considerada, portanto, os resultados devem ser analisados com cautela.Os resultados apresentados por esta pesquisa evidenciam que adultos fumantes normo-ouvintes apresentam altera\u00e7\u00f5es nos exames de PEA de curta e longa lat\u00eancia. No PEATE, os principais componentes alterados foram o aumento das lat\u00eancias das ondas I e III e nos interpicos I - III e III - V, bem como diminui\u00e7\u00e3o da amplitude das ondas. No MMN, houve aumento significativo da amplitude da onda e da lat\u00eancia. No potencial de longa lat\u00eancia, P300, houve aumento das lat\u00eancias e redu\u00e7\u00e3o das amplitudes nos componentes N1 (em Fz) e P3."}
+{"text": "M\u00e9todos para Evidenciar a Infec\u00e7\u00e3o pelo Agente Etiol\u00f3gico 51 6.2.8. Estudo Eletrofisiol\u00f3gico Intracard\u00edaco51 6.2.9. Teste Ergom\u00e9trico e Teste Cardiopulmonar51 6.2.10. Cateterismo Card\u00edaco51 7. Estratifica\u00e7\u00e3o de Risco e Progn\u00f3stico 52 8. Condutas Terap\u00eauticas na Forma Indeterminada da Doen\u00e7a de Chagas 57 9. Tratamento Etiol\u00f3gico da Doen\u00e7a de Chagas 599.1. Introdu\u00e7\u00e3o 599.2. F\u00e1rmacos e Administra\u00e7\u00e3o 60 9.3. Tratamento Etiol\u00f3gico de Indiv\u00edduos com Doen\u00e7a de Chagas 62 9.4. Infec\u00e7\u00e3o Aguda 649.5. Infec\u00e7\u00e3o Cong\u00eanita 64 9.6. Crian\u00e7as e Adolescentes com Infec\u00e7\u00e3o Cr\u00f4nica 65  9.7. Mulheres em Idade F\u00e9rtil com Infec\u00e7\u00e3o Cr\u00f4nica 65 9.8. Adultos em Geral com Infec\u00e7\u00e3o Cr\u00f4nica 659.9. Reativa\u00e7\u00e3o da Doen\u00e7a de Chagas 679.10. Infec\u00e7\u00e3o Acidental 68 9.11. Avalia\u00e7\u00e3o de Cura da Doen\u00e7a de Chagas P\u00f3s-Tratamento Etiol\u00f3gico 68 9.11.1. Onde Realizar Tratamento da Pessoa Acometida68  10. Condutas Terap\u00eauticas na Disfun\u00e7\u00e3o Ventricular e Insufici\u00eancia Card\u00edaca 69 10.1. Recursos Farmacol\u00f3gicos 6910.1.1. Classifica\u00e7\u00e3o da Insufici\u00eancia Card\u00edaca69 10.1.2. Dose M\u00e1xima de Medica\u00e7\u00f5es70 10.1.3. O Paciente Contempor\u00e2neo70 10.1.4. Revis\u00e3o da Literatura70 10.1.5. Terapia Farmacol\u00f3gica70 10.1.5.1. Diur\u00e9ticos70 10.1.5.2. Inibidores do Sistema Renina-Angiotensina-Aldosterona71 10.1.5.3. Betabloqueadores71 10.1.5.4. Espironolactona72 10.1.5.5. Ivabradina72 10.1.5.6. Digoxina72 10.1.5.7. Sacubitril-Valsartana72 10.1.5.8. Inibidores do Cotransportador de S\u00f3dio e Glicose do Tipo 273 10.2. Recursos N\u00e3o Farmacol\u00f3gicos 7510.2.1. Transplante Cardiaco75 10.2.1.1. Estrat\u00e9gias de Imunossupress\u00e3o75 10.2.1.2. Terapia de Indu\u00e7\u00e3o75 10.2.1.3. Terapia de Manuten\u00e7\u00e3o76 10.2.2. Diagn\u00f3stico e Tratamento da Rejei\u00e7\u00e3o78 10.2.3. Diagn\u00f3stico e Tratamento da Reativa\u00e7\u00e3o da Infec\u00e7\u00e3o pelo T. cruzi78 10.2.3.1. Apresenta\u00e7\u00e3o Cl\u00ednica78 10.2.3.2. Diagn\u00f3stico Parasitol\u00f3gico da Reativa\u00e7\u00e3o79 10.2.3.3. Tratamento Etiol\u00f3gico da Reativa\u00e7\u00e3o79 10.2.3.4. Complica\u00e7\u00f5es P\u00f3s-Transplante Card\u00edaco e Sobreviv\u00eancia79 10.2.4. Assist\u00eancia Circulat\u00f3ria Mec\u00e2nica79  11. Condutas Terap\u00eauticas nas Arritmias Card\u00edacas 81 11.1. Recursos Farmacol\u00f3gicos 8111.1.1. Introdu\u00e7\u00e3o81 11.1.2. Preven\u00e7\u00e3o da Morte S\u00fabita com F\u00e1rmacos N\u00e3o Antiarr\u00edtmicos81 11.1.3. Arritmias Ventriculares em Cardiopatias de Outras Etiologias82 11.1.4. Amiodarona em Pacientes com Cardiopatias de Outras Etiologias: Preven\u00e7\u00e3o Prim\u00e1ria82 11.1.5. Amiodarona em Pacientes com Cardiopatias de Outras Etiologias: Preven\u00e7\u00e3o Secund\u00e1ria84 11.1.6. Arritmias Ventriculares em Pacientes com Cardiomiopatia Cr\u00f4nica da Doen\u00e7a de Chagas: Caracter\u00edsticas e Tratamento85 11.1.6.1. Extrass\u00edstoles Ventriculares85 11.1.6.2. Taquicardia Ventricular N\u00e3o Sustentada85 11.1.6.3. Taquicardia Ventricular Sustentada e Fibrila\u00e7\u00e3o Ventricular86 11.1.7. Cuidados Durante Utiliza\u00e7\u00e3o de Amiodarona87 11.1.8. Preven\u00e7\u00e3o de Choques El\u00e9tricos Recorrentes em Pacientes Tratados com Cardioversor-Desfibrilador Implant\u00e1vel88 11.1.9. Tratamento Medicamentoso da Fibrila\u00e7\u00e3o Atrial na Cardiomiopatia Cr\u00f4nica da Doen\u00e7a de Chagas88 11.1.10. Tratamento na Sala de Emerg\u00eancia90 11.1.11. Tratamento Ambulatorial90 11.1.11.1. Revers\u00e3o para Ritmo Sinusal90 11.1.11.2. Controle da Frequ\u00eancia Card\u00edaca90  11.2. Marca-passo, Cardioversor-Desfibrilador e Ressincronizador 90 11.2.1. Marca-passo Card\u00edaco Artificial90 11.2.2. Cardioversor-Desfibrilador Implant\u00e1vel na CCDC91 11.2.2.1. Preven\u00e7\u00e3o Prim\u00e1ria de Morte S\u00fabita Card\u00edaca91 11.2.2.2. Preven\u00e7\u00e3o Secund\u00e1ria de Morte S\u00fabita Card\u00edaca93 11.2.3. Terapia de Ressincroniza\u00e7\u00e3o Card\u00edaca94 11.3. M\u00e9todos de Abla\u00e7\u00e3o 9611.3.1. Taquicardia Ventricular Sustentada: Apresenta\u00e7\u00e3o Cl\u00ednica, Mecanismos Eletrofisiol\u00f3gicos e Localiza\u00e7\u00f5es96 11.3.2. Avalia\u00e7\u00e3o Cl\u00ednica e Laboratorial Antes da Abla\u00e7\u00e3o97 11.3.3. T\u00e9cnicas de Mapeamento das Taquicardias Ventriculares97 11.3.4. Desfechos e Complica\u00e7\u00f5es Durante o Procedimento de Abla\u00e7\u00e3o da Taquicardia Ventricular98 11.3.5. Resultados da Abla\u00e7\u00e3o e Seguimento dos Pacientes98  12. Condutas para Preven\u00e7\u00e3o e Tratamento de Complica\u00e7\u00f5es Tromboemb\u00f3licas 99 12.1. Introdu\u00e7\u00e3o 9912.2. Epidemiologia dos Eventos Tromboemb\u00f3licos 9912.3. Fatores de Risco e Mortalidade 99 12.4. Avalia\u00e7\u00e3o de Risco de Acidente Vascular Cerebral 101  12.5. Quadro Cl\u00ednico e Investiga\u00e7\u00e3o Diagn\u00f3stica do Acidente Vascular Cerebral Isqu\u00eamico na Doen\u00e7a de Chagas 101  12.6. Tratamento do Acidente Vascular Cerebral Isqu\u00eamico na Doen\u00e7a de Chagas 103  12.7. Preven\u00e7\u00e3o de Eventos Cardioemb\u00f3licos na Doen\u00e7a de Chagas 104  13. Condutas em Subgrupos Especiais e Abordagem de Problemas Relativos a Gravidez, Atividade F\u00edsica, Risco Cir\u00fargico, Anestesia Geral e COVID-19 106 13.1. Coinfec\u00e7\u00e3o T. cruzi-HIV 106 13.2. Soropositividade em Doadores Potenciais nos Bancos de Sangue 107 13.3. Atividade F\u00edsica 10713.4. Gestantes 10813.5. Rec\u00e9m-natos 10913.6. Risco Cir\u00fargico e Anestesiol\u00f3gico 110 13.7. Doen\u00e7a de Chagas e Infec\u00e7\u00e3o por Coronav\u00edrus 111  13.8. Transplante N\u00e3o Card\u00edaco e Terapia Imunossupressora 111 13.8.1. Doador com Doen\u00e7a de Chagas e Receptor sem Doen\u00e7a de Chagas112 13.8.2. Receptor com Doen\u00e7a de Chagas112 13.8.3. Doen\u00e7as Autoimunes113 13.9. Doen\u00e7a de Chagas e Senesc\u00eancia 113 14. Recomenda\u00e7\u00f5es para Constitui\u00e7\u00e3o de Servi\u00e7os Estruturados para Acompanhamento de Pessoas Com Cardiomiopatia Cr\u00f4nica da Doen\u00e7a de Chagas 114  14.1. Atribui\u00e7\u00f5es dos Servi\u00e7os Estruturados para Acompanhamento de Pessoas com Cardiomiopatia Cr\u00f4nica da Doen\u00e7a de Chagas 115  14.2. Benef\u00edcios Esperados dos Servi\u00e7os Estruturados para Acompanhamento de Pessoas com Cardiomiopatia Cr\u00f4nica da Doen\u00e7a de Chagas 116  15. Defini\u00e7\u00e3o de Cardiopatia Grave e Avalia\u00e7\u00e3o M\u00e9dico-Trabalhista 116 15.1. Introdu\u00e7\u00e3o 11615.2. Conceito e \u00c2mbito 117 15.3. Escore Capaz de Predizer o Risco de \u00d3bito em Pacientes com Cardiomiopatia Cr\u00f4nica da Doen\u00e7a de Chagas 117 15.4. Aspectos Cl\u00ednicos 11715.5. Fun\u00e7\u00e3o Pericial 11815.6. Conclus\u00e3o 118Agradecimentos 118Refer\u00eancias 119Arquivos Brasileiros de Cardiologia,  a atual n\u00e3o mais seria \u201clatino-americana\u201d, mas passaria a contar essencialmente \u201capenas\u201d com contingente expressivo de colaboradores nacionais. A pl\u00eaiade ilustre de investigadores ativos no contexto, que ent\u00e3o convocamos, seria representativa de uma equipe ainda mais dilatada de profissionais dos mais diversificados pontos do pa\u00eds, que se envolvem e contribuem diretamente para o avan\u00e7o no combate \u00e0 DC, e passou a responder integralmente pela autoria desta diretriz, conforme explicitado abaixo.  Em 2021, por iniciativa de seu ent\u00e3o presidente, Dr. Marcelo Queiroga Cartaxo Lopes, a Sociedade Brasileira de Cardiologia (SBC) nos comissionou para a coordena\u00e7\u00e3o dos trabalhos, visando \u00e0 elabora\u00e7\u00e3o da nova diretriz relativa \u00e0 doen\u00e7a de Chagas (DC). Justificava-se a empreitada, uma vez que, desde 2011, a SBC n\u00e3o se responsabilizava diretamente por uma diretriz no contexto. Diversamente daquela, publicada h\u00e1 mais de uma d\u00e9cada nos resolveu-se limitar o escopo da atual, para focalizar \u201csomente\u201d os aspectos relacionados com o diagn\u00f3stico e o tratamento da manifesta\u00e7\u00e3o mais frequente e grave, a cardiopatia da doen\u00e7a de Chagas (CDC).  Al\u00e9m disso, considerando que em 2015 hav\u00edamos colaborado extensamente com a edi\u00e7\u00e3o pela Sociedade Brasileira de Medicina Tropical de outra diretriz sobre o contexto geral da DC,  discrep\u00e2ncias entre eles no que diz respeito, principalmente, \u00e0s for\u00e7as de recomenda\u00e7\u00f5es e n\u00edveis de evid\u00eancias relacionados aos diversos tipos de tratamentos, assim como o surgimento de novas evid\u00eancias cient\u00edficas, corroboram o entendimento de que as diretrizes precisam ser periodicamente revistas e atualizadas.  Apesar de existir enorme gama de documentos que aborda esse tema em seus variados aspectos , 1-2 Esta diretriz, \u00e0 parte seu arcabou\u00e7o habitual naturalmente voltado para formula\u00e7\u00e3o de normas de conduta e evid\u00eancias cient\u00edficas que a embasam quanto aos in\u00fameros aspectos de diagn\u00f3stico e tratamento da CDC, reveste-se de algumas caracter\u00edsticas que o contexto temporal durante o qual foi elaborada lhe emprestou. De fato, vivia-se a angustiante circunst\u00e2ncia de, em muitos pacientes, \u00e0 CDC, entidade nosol\u00f3gica marcantemente inflamat\u00f3ria, somar-se o agravo da pandemia da doen\u00e7a causada pelo novo coronav\u00edrus (COVID-19), tamb\u00e9m com seu inerente componente de inflama\u00e7\u00e3o. Ent\u00e3o, a coletividade cient\u00edfica, tanto em \u00e2mbito mundial como, em especial, no Brasil, teve que se arrostar com pelo menos tr\u00eas grandes obst\u00e1culos para controlar a pandemia: primeiro, trata-se de v\u00edrus especial, com comportamento bastante peculiar quanto ao ataque aos \u00f3rg\u00e3os do hospedeiro individual; segundo, havia dificuldades inerentes e imprevis\u00edveis quanto ao seu comportamento em termos epidemiol\u00f3gicos; terceiro, nossa indig\u00eancia nacional, quando se constata que para se dominar a pandemia, as medidas adequadas esbarram em fatos b\u00e1sicos, como as muito prec\u00e1rias condi\u00e7\u00f5es sanit\u00e1rias de 30-40% de nossa popula\u00e7\u00e3o, carente de esgoto, \u00e1gua encanada e habita\u00e7\u00e3o minimamente condizente.  Ao conjunto desses desafios e obst\u00e1culos, a comunidade cient\u00edfica nacional respondeu com not\u00e1vel presteza e efici\u00eancia, como exemplificado pelo desenvolvimento e aplica\u00e7\u00e3o, em larga escala, de vacinas contra a COVID-19. Conv\u00e9m destacar que o dif\u00edcil cen\u00e1rio que se enfrentava para ampliar a prote\u00e7\u00e3o contra o cont\u00e1gio e implementar a vacina\u00e7\u00e3o populacional era reminiscente das guerras que travamos durante o s\u00e9culo XX contra as perniciosas influ\u00eancias industriais, as quais, durante tanto tempo e t\u00e3o renitentemente, tentavam ocultar os malef\u00edcios do tabagismo.  De realce, alguns aspectos da concomit\u00e2ncia das duas infec\u00e7\u00f5es - peloTrypanosoma cruzi(T. cruzi)e pelo coronav\u00edrus - no mesmo indiv\u00edduo foram adequadamente focados em t\u00f3picos espec\u00edficos desta diretriz.  Posturas negacionistas e dissemina\u00e7\u00e3o de falsos conceitos, inclusive por elementos de parte da coletividade m\u00e9dica, representaram \u00f3bice incremental ao desempenho da Ci\u00eancia e da Medicina no combate \u00e0 pandemia.  Neste ponto, \u00e9 inafast\u00e1vel a lembran\u00e7a de que as conquistas sanit\u00e1rias no combate \u00e0 pandemia deste s\u00e9culo XXI, angariadas pela comunidade cient\u00edfica, t\u00e3o bem representada pela FIOCRUZ, como herdeira hist\u00f3rica de seu primeiro e inexced\u00edvel ep\u00edgono, o pr\u00f3prio Oswaldo Cruz, sejam reminiscentes de seu \u00eaxito com as campanhas de vacina\u00e7\u00e3o contra a febre amarela, no in\u00edcio do s\u00e9culo XX. Mas tamb\u00e9m \u00e9 oportuno tra\u00e7ar-se um paralelo entre a atual e admir\u00e1vel conjuntura vivificada pela comunidade cient\u00edfica e m\u00e9dica no combate \u00e0 pandemia de COVID-19 e o dif\u00edcil contexto vivido por Carlos Chagas e seu mentor Oswaldo Cruz, durante as primeiras d\u00e9cadas do s\u00e9culo XX.  \u00c0 semelhan\u00e7a do negacionismo que enfrentamos atualmente, o grande brasileiro, a despeito de sua cientificamente \u00e9pica descoberta, teve que confrontar o niilismo e a incompreens\u00e3o com que parte consider\u00e1vel da comunidade m\u00e9dica de ent\u00e3o recebia o feito singular de Carlos Chagas na hist\u00f3ria da Medicina, nas palavras do professor Jo\u00e3o Carlos Pinto Dias, filho de seu colaborador direto, Emmanuel Dias, e tamb\u00e9m participante desta diretriz. E, talvez, o desaparecimento precoce de Carlos Chagas, por morte s\u00fabita, tenha sido deflagrado por gatilho emocional, consequente \u00e0 agress\u00e3o obscurantista.  Como assinalamos em outra divulga\u00e7\u00e3o, \u201c\u00c9 tamb\u00e9m plaus\u00edvel que sua grande perspic\u00e1cia human\u00edstica lhe tenha propiciado a antevis\u00e3o do tragicamente real significado social da mol\u00e9stia que revelara ao mundo, por afligir literalmente milh\u00f5es de indiv\u00edduos desvalidos em vastas \u00e1reas do territ\u00f3rio brasileiro. Em acerbo contraste com o negacionismo de parte da comunidade acad\u00eamica em aceitar a pr\u00f3pria exist\u00eancia da nova entidade m\u00f3rbida, possivelmente Carlos Chagas pressentisse o car\u00e1ter de trag\u00e9dia nacional que se desvendava a partir de sua descoberta e que se desenrola em m\u00faltiplos atos e cap\u00edtulos deplor\u00e1veis socialmente at\u00e9 hoje\u201d.  Nunca ser\u00e1 demasiado glorificar a mem\u00f3ria de Carlos Chagas. No dizer inspirado de Alejandro Hasslocher-Moreno, outro colaborador desta diretriz, \u201cCarlos Chagas foi o m\u00e9dico e o cientista certo, na hora certa, no lugar certo. As circunst\u00e2ncias que envolveram a descoberta da doen\u00e7a tiveram como protagonista um indiv\u00edduo amplamente preparado para enfrentar um desafio conhecido e, ao mesmo tempo, descobrir um desconhecido. No contexto biom\u00e9dico, a ci\u00eancia brasileira ganhou um grande impulso ap\u00f3s a descoberta da DC, passando a ter reconhecimento internacional, um dos principais legados de Carlos Chagas para a ci\u00eancia e para a medicina brasileira\u201d.  Nesse sentido e quando se revisitam e elaboram diretrizes, torna-se plenamente justific\u00e1vel reconhecer a excepcional contribui\u00e7\u00e3o dos m\u00e9dicos e cientistas em\u00e9ritos que nos deixaram justo quando se publicava a de 2011, e agora, quando finalizamos a de 2022. Entre tantos outros, cujos nomes aqui omitimos por raz\u00e3o de espa\u00e7o, queremos reverenciar a mem\u00f3ria ilustre dos Professores Joaquim Romeu Can\u00e7ado 1913-2011 (Belo Horizonte), Alu\u00edzio Rosa Prata 1920-2011 (Uberaba), desaparecidos h\u00e1 j\u00e1 uma d\u00e9cada, e de Zilton Ara\u00fajo Andrade 1924-2020 , Jos\u00e9 Rodrigues Coura 1927-2021 (Rio de Janeiro) e Anis Rassi 1929-2021 (Goi\u00e2nia), que mais recentemente nos legaram a continuidade de seus trabalhos com a DC. A esses luminares devotamos, por ocasi\u00e3o e lembran\u00e7a de seu passamento, nossa gratid\u00e3o e o reconhecimento por permitirem, com sua influ\u00eancia nesta diretriz, nos mantermos na senda luminosamente cient\u00edfica tra\u00e7ada por Carlos Chagas.  Os autores, colaboradores e coordenadores em geral deste documento t\u00eam plena consci\u00eancia de que, nesta fase de percep\u00e7\u00e3o intensificada quanto a ser a DC ainda negligenciada, imp\u00f5e-se a premente necessidade de resgatar os indiv\u00edduos por ela afligidos de suas miser\u00e1veis condi\u00e7\u00f5es humanas e suas deplor\u00e1veis implica\u00e7\u00f5es m\u00e9dico-sociais. Nesse sentido, deve-se envidar todo esfor\u00e7o para minimizar o estigma que a acompanha, a come\u00e7ar pela aboli\u00e7\u00e3o do termo \u201cchag\u00e1sico\u201d, eliminado desta diretriz, a partir da compreens\u00e3o recente de que em vez de constituir um ep\u00f4nimo fiel \u00e0 trajet\u00f3ria hist\u00f3rica do grande cientista brasileiro, em alguns pacientes, o termo soa como indicando que em seu cora\u00e7\u00e3o existe uma verdadeira e dolorosa \u201cchaga\u201d incur\u00e1vel.  Perpassa tamb\u00e9m pelo esp\u00edrito dos envolvidos na elabora\u00e7\u00e3o da diretriz a clara no\u00e7\u00e3o de que nossa responsabilidade se incrementou sobremaneira nos \u00faltimos tempos. Porquanto, al\u00e9m de dirigir-se precipuamente aos profissionais m\u00e9dicos e param\u00e9dicos, os princ\u00edpios aqui exarados devem ser \u00fateis para nortear a atua\u00e7\u00e3o de gestores e \u00f3rg\u00e3os incumbidos de prover condi\u00e7\u00f5es adequadas de sa\u00fade p\u00fablica em \u00e2mbito nacional. E, por \u00faltimo, mas n\u00e3o menos significativo, existe o factual moderno de serem os pr\u00f3prios indiv\u00edduos infelicitados pela doen\u00e7a muito mais carentes hoje do que antigamente em termos de orienta\u00e7\u00f5es seguras por parte dos profissionais que os atendem; de fato, com a democratiza\u00e7\u00e3o inerente ao provimento de recursos inform\u00e1ticos pela web, cresceu paralelamente o contingente dos indiv\u00edduos com a doen\u00e7a, que elicitam dos profissionais melhores instru\u00e7\u00f5es sobre como gerenciar e minorar o drama acarretado por sua triste condi\u00e7\u00e3o m\u00f3rbida.  Devemos aproveitar a introdu\u00e7\u00e3o desta nova diretriz como uma oportunidade para descrever o processo que culminou com este documento. Logo de in\u00edcio, notamos que um cronograma inicialmente planejado para t\u00e9rmino em alguns meses n\u00e3o correspondia \u00e0 nossa ambi\u00e7\u00e3o de construir um documento reflexivo, cientificamente profundo e de implica\u00e7\u00f5es cl\u00ednicas e populacionais consistentes.  O ponto de partida ocorreu em reuni\u00e3o onde os coordenadores gerais discutiram os princ\u00edpios cient\u00edficos a nortear a confec\u00e7\u00e3o dos cap\u00edtulos, introduzindo a ideia de que o conhecimento dos especialistas seria essencial para interpreta\u00e7\u00e3o e julgamento da aplicabilidade das evid\u00eancias, mas n\u00e3o para fomentar opini\u00f5es baseadas em prefer\u00eancias pessoais. Discord\u00e2ncias seriam resolvidas com aprofundamento da an\u00e1lise das evid\u00eancias, mas n\u00e3o por vota\u00e7\u00e3o baseada em maioria. Naquele momento, foi plantada a semente para uma diretriz que teve a coragem de desafiar nossas pr\u00f3prias intui\u00e7\u00f5es e reconhecer que, muitas vezes, a verdade contraria nossas expectativas, sendo necess\u00e1rio o cultivo da d\u00favida que, muitas vezes, contrasta com a eloqu\u00eancia de um grupo de formadores de opini\u00e3o em suas respectivas \u00e1reas. Assim foi plantada a semente para uma diretriz constru\u00edda sob a forma de debates intensos, abras\u00e3o criativa e aprendizado de todos, totalizando 7 reuni\u00f5es virtuais e cerca de 28 horas de debates. Esse processo poder\u00e1 ser percebido nas entrelinhas do documento final assim engendrado. outcome- \u201cO\u201d).  E esperamos ter sido poss\u00edvel escoimar, pelo menos em grande parte, as recomenda\u00e7\u00f5es e as an\u00e1lises das evid\u00eancias que as embasam de vieses e outros desvios de conduta identific\u00e1veis em alguns contextos anteriores. Temos a convic\u00e7\u00e3o de que, infelizmente, o pr\u00f3prio paradigma da MEE encontra-se atualmente abusado e distorcido, paradoxalmente em meio \u00e0 exponencial multiplica\u00e7\u00e3o de pesquisas e conhecimentos assim gerados e divulgados sem controle proporcional por entidades que deveriam supervisionar todo o processo de avan\u00e7os nessa \u00e1rea t\u00e3o nobre da atividade humana. Um exemplo dessas distor\u00e7\u00f5es, felizmente n\u00e3o observado no contexto da DC, mas muito n\u00edtido em algumas \u00e1reas da Medicina, consiste na profus\u00e3o de meta-an\u00e1lises inadequadas, contradit\u00f3rias, perfunct\u00f3rias ou redundantes, resultando em prov\u00e1vel forma de \u201cfake news\u201d, como aventado h\u00e1 algum tempo.  Desde sua concep\u00e7\u00e3o at\u00e9 o \u00faltimo conceito exarado nesta diretriz, intentou-se sempre seguir os mais leg\u00edtimos e \u00ednclitos princ\u00edpios do cl\u00e1ssico paradigma da Medicina Embasada em Evid\u00eancias (MEE). Mesmo n\u00e3o tendo sido poss\u00edvel a realiza\u00e7\u00e3o geral exaustiva de revis\u00f5es sistem\u00e1ticas da literatura, em alguns contextos mais pol\u00eamicos recorreu-se ao m\u00e9todo de analisar as evid\u00eancias que deveriam responder \u00e0 chamada quest\u00e3o PICO, que engloba as caracter\u00edsticas atinentes \u00e0 popula\u00e7\u00e3o (\u201dP\u201d), \u00e0 interven\u00e7\u00e3o (\u201cI\u201d), ao controle comparador (\u201cC\u201d), e ao desfecho , relativamente \u00e0 constru\u00e7\u00e3o do conhecimento de causalidade, e a pragm\u00e1tica, que influencia o processo de decis\u00e3o . Na primeira fun\u00e7\u00e3o, evid\u00eancias de car\u00e1ter \u201cexplorat\u00f3rio\u201d, de qualidade satisfat\u00f3ria, t\u00eam valor em sugerir os caminhos da ci\u00eancia. Na segunda fun\u00e7\u00e3o, a de influenciar decis\u00f5es, a utiliza\u00e7\u00e3o de evid\u00eancias com alto risco de vi\u00e9s ou imprecis\u00e3o estat\u00edstica serve mais para justificar o desejo de agir do que para aumentar a probabilidade de a a\u00e7\u00e3o representar a melhor escolha para o paciente ou a popula\u00e7\u00e3o. \u00c9 o desejo intuitivo buscando justificativa cient\u00edfica.  A for\u00e7a de recomenda\u00e7\u00e3o est\u00e1 geralmente ligada ao n\u00edvel de evid\u00eancia. Para esta diretriz, resolvemos adotar uma classifica\u00e7\u00e3o simples, baseada no sistema GRADE ,  mas com algumas modifica\u00e7\u00f5es, agrupando os estudos em apenas 3 n\u00edveis de evid\u00eancias , de onde derivam 2 graus de recomenda\u00e7\u00f5es . O ponto de partida na avalia\u00e7\u00e3o da qualidade da evid\u00eancia deve ser o tipo de delineamento de pesquisa utilizado. Evid\u00eancias provenientes de estudos anal\u00edticos experimentais, como os ensaios cl\u00ednicos randomizados (ECR), e de revis\u00f5es sistem\u00e1ticas com meta-an\u00e1lises desses estudos est\u00e3o menos propensas a vieses e, consequentemente, s\u00e3o consideradas de melhor qualidade, ou seja, de alto n\u00edvel (A). Por outro lado, evid\u00eancias provenientes de estudos anal\u00edticos observacionais  s\u00e3o consideradas de n\u00edvel moderado (B) e aquelas oriundas de estudos observacionais descritivos (sem grupo comparativo), como as s\u00e9ries de casos, de qualidade inferior ou n\u00edvel baixo (C).  As diretrizes, de modo geral, fazem recomenda\u00e7\u00f5es cl\u00ednicas baseadas na qualidade das evid\u00eancias encontradas, ap\u00f3s processo de busca pormenorizada. V\u00e1rios sistemas t\u00eam sido propostos para classificar as evid\u00eancias e tamb\u00e9m para categorizar a \u201cfor\u00e7a\u201d da recomenda\u00e7\u00e3o cl\u00ednica, como o GRADE, CEBM, SIGN, NZGG, SORT, USPSTF, ACCF/AHA/ESC, ACCP, IDSA e NICE.  Uma das solu\u00e7\u00f5es para essa quest\u00e3o est\u00e1 no reconhecimento do valor de evid\u00eancias indiretas, a partir de resultados de ECR realizados em outras cardiopatias, e no entendimento da diferen\u00e7a entre amostra representativa e amostra generaliz\u00e1vel.  No caso espec\u00edfico da CDC, devido \u00e0 constata\u00e7\u00e3o de que n\u00e3o se disp\u00f5e, habitualmente, de evid\u00eancias de qualidade por meio de ECR ou, em algumas situa\u00e7\u00f5es, nem mesmo por meio de estudos observacionais com resultados substanciais para gerar recomenda\u00e7\u00f5es avalizadas, existe uma tend\u00eancia natural de se recorrer \u00e0 livre \u201copini\u00e3o de especialistas\u201d ou \u201cconsenso\u201d, palavras abstratas de significado e consequ\u00eancias incertas, que n\u00e3o devem ser formalmente caracterizadas como evid\u00eancias.  Em estudos observacionais descritivos, \u00e9 essencial a representatividade da amostra. Por exemplo, se o intuito \u00e9 descrever o progn\u00f3stico de um paciente com insufici\u00eancia card\u00edaca (IC), o que \u00e9 observado em cardiomiopatia isqu\u00eamica (CMI) pode n\u00e3o ser aplic\u00e1vel \u00e0 CDC. Por outro lado, em estudos anal\u00edticos, observacionais ou experimentais , uma amostra n\u00e3o representativa pode vir a ser generaliz\u00e1vel. Para que a generaliza\u00e7\u00e3o se justifique, \u00e9 necess\u00e1rio aus\u00eancia de intera\u00e7\u00e3o (modifica\u00e7\u00e3o de efeito) entre as diferen\u00e7as das popula\u00e7\u00f5es e o efeito de um fator de risco ou conduta m\u00e9dica.  Como intera\u00e7\u00e3o biol\u00f3gica \u00e9 um fen\u00f4meno raro, normalmente amostras n\u00e3o representativas geram conceitos generaliz\u00e1veis para diferentes tipos de pacientes. Isso justifica boa parte das recomenda\u00e7\u00f5es para idosos ou crian\u00e7as, subgrupos em geral n\u00e3o representados adequadamente no \u00e2mbito de ECR. Prescrever, por exemplo, inibidor da enzima de convers\u00e3o da angiotensina (IECA) para um paciente com CDC e fra\u00e7\u00e3o de eje\u00e7\u00e3o ventricular esquerda (FEVE) reduzida n\u00e3o \u00e9 uma conduta baseada em vontade ou uso de evid\u00eancia de baixa qualidade nesse tipo de popula\u00e7\u00e3o. \u00c9 uma conduta baseada em evid\u00eancia de alta qualidade em outras doen\u00e7as cursando com IC, alinhada \u00e0 percep\u00e7\u00e3o de que \u201cmodifica\u00e7\u00e3o de efeito\u201d pela etiologia da cardiomiopatia (intera\u00e7\u00e3o) \u00e9 improv\u00e1vel. Assim se constr\u00f3i o conhecimento cient\u00edfico. Por exemplo, a teoria que embasa o conhecimento de que a velocidade da luz \u00e9 constante n\u00e3o derivou da medida desse par\u00e2metro em todos os ambientes e circunst\u00e2ncias. Apenas algumas medidas, em linha com a no\u00e7\u00e3o de baixa probabilidade de intera\u00e7\u00e3o entre o ambiente e a velocidade da luz, permitem generalizar que essa velocidade seja, de fato, constante.  No exerc\u00edcio da generaliza\u00e7\u00e3o, devemos nos questionar se h\u00e1 caracter\u00edstica na popula\u00e7\u00e3o de interesse que mudaria o resultado do estudo. Por exemplo, h\u00e1 alguma caracter\u00edstica do paciente com CDC com alto potencial de modificar o efeito (intera\u00e7\u00e3o) ben\u00e9fico da terapia vasodilatadora, comprovado em CMI ou em cardiomiopatia dilatada (CMD)? Provavelmente n\u00e3o.  Na aus\u00eancia de evid\u00eancias experimentais diretas, ou seja, aquelas obtidas a partir de resultados de ECR realizados na CDC (n\u00edvel A), e de evid\u00eancias indiretas, obtidas por extrapola\u00e7\u00e3o de resultados de ECR realizados em outras cardiopatias (n\u00edvel B), optamos tamb\u00e9m por valorizar resultados obtidos a partir de estudos observacionais anal\u00edticos (n\u00edvel B) ou de estudos observacionais descritivos (n\u00edvel C), ambos realizados na CDC, e ainda adotamos o princ\u00edpio da plausibilidade extrema e o princ\u00edpio da assimetria como n\u00edveis C de evid\u00eancias. equipoise, as decis\u00f5es n\u00e3o derivam de dados experimentais, mas de dados naturais. Existem situa\u00e7\u00f5es que n\u00e3o requerem \u201cjulgamento\u201d  e seria anti\u00e9tico realizar um experimento com grupo controle. Um dos exemplos \u00e9 o uso de diur\u00e9tico em IC com congest\u00e3o pronunciada, cujo benef\u00edcio nunca foi especificamente mensurado por ensaio cl\u00ednico placebo-controlado, devido ao seu car\u00e1ter quase determin\u00edstico. Se o fosse, ter\u00edamos um n\u00famero necess\u00e1rio a tratar (NNT) de 1 para melhora de sintomas e possivelmente um NNT tamb\u00e9m muito relevante para redu\u00e7\u00e3o de mortalidade.  Vale lembrar que decis\u00f5es que dispensam evid\u00eancias emp\u00edricas s\u00e3o comuns em Medicina. Na aus\u00eancia essencial de Essa \u00e9 outra circunst\u00e2ncia onde o n\u00edvel de evid\u00eancia C deve ser aplicado: aus\u00eancia de evid\u00eancia experimental, mas forte evid\u00eancia natural. Isso deve ser enfaticamente diferenciado do paradigma da vontade, contido no \u201cconsenso\u201d, pois as evid\u00eancias a respeito do uso de paraquedas n\u00e3o requerem consenso. S\u00e3o indiscut\u00edveis.  A incompreens\u00e3o dessa afirma\u00e7\u00e3o pela comunidade m\u00e9dica posiciona o diur\u00e9tico em um n\u00edvel inferior de benef\u00edcio devido \u00e0 falta de comprova\u00e7\u00e3o experimental de redu\u00e7\u00e3o de mortalidade. Sendo assim, na presen\u00e7a de IC com congest\u00e3o sist\u00eamica e/ou pulmonar, a prescri\u00e7\u00e3o (criteriosa) de diur\u00e9tico deve ser considerada embasada em evid\u00eancia essencial, o que leva \u00e0 sua forte recomenda\u00e7\u00e3o. Para situa\u00e7\u00f5es desse tipo, costuma-se utilizar a met\u00e1fora do paraquedas como estrat\u00e9gia para reduzir mortalidade de pessoas em queda livre.  Outro princ\u00edpio que ser\u00e1 utilizado como n\u00edvel C de evid\u00eancia \u00e9 o da assimetria de efeito, que pode ser aplicado em situa\u00e7\u00f5es em que, apesar de n\u00e3o existir ainda comprova\u00e7\u00e3o de efic\u00e1cia de determinada interven\u00e7\u00e3o, h\u00e1 grande assimetria entre a magnitude de um potencial benef\u00edcio e a magnitude de um eventual malef\u00edcio, em prol do primeiro, como, por exemplo, uso de m\u00e1scaras no controle da COVID-19 e tratamento etiol\u00f3gico em adultos com a forma indeterminada da DC (FIDC).  Uma vez resolvidas as situa\u00e7\u00f5es de plausibilidade extrema e assimetria (n\u00edvel C), devemos partir para resolver as indica\u00e7\u00f5es baseadas em n\u00edvel B de evid\u00eancias. Esse n\u00edvel n\u00e3o deve ser representado por evid\u00eancia de qualidade duvidosa. A qualidade da evid\u00eancia deve ser de baixo risco de vi\u00e9s e alta precis\u00e3o, estando aqui representadas as evid\u00eancias indiretas de alto n\u00edvel e as diretas de qualidade satisfat\u00f3ria. versusrisco (dano/preju\u00edzo), da d\u00favida quanto \u00e0 factibilidade (efetividade) ou at\u00e9 mesmo sobre quest\u00f5es de custo-efetividade (impacto no sistema de sa\u00fade).  Enquanto a classifica\u00e7\u00e3o do n\u00edvel de evid\u00eancia faz parte da dimens\u00e3o cient\u00edfica, a for\u00e7a de recomenda\u00e7\u00e3o envolve e traduz mais a dimens\u00e3o do pensamento cl\u00ednico: da probabilidade individual de benef\u00edcio (tamanho de efeito) Assim, fazendo um paralelo com o sistema de classifica\u00e7\u00e3o adotado pelo ACC/AHA, denominaremos o grau de recomenda\u00e7\u00e3o I e, na maioria das vezes, tamb\u00e9m o grau de recomenda\u00e7\u00e3o IIa, como \u201cfortes\u201d, devendo ser aplicados \u00e0quelas situa\u00e7\u00f5es em que h\u00e1 pouca ou nenhuma d\u00favida quanto ao processo de \u201cprescri\u00e7\u00e3o\u201d, que se torna quase uma regra, salvo contraindica\u00e7\u00f5es espec\u00edficas. Por exemplo, prescrever tratamento etiol\u00f3gico em casos de reativa\u00e7\u00e3o da DC (RDC). Por outro lado, ser\u00e1 considerado recomenda\u00e7\u00e3o \u201cponderada\u201d ou \u201ccondicional\u201d o grau IIb , cuja decis\u00e3o depende de uma an\u00e1lise cl\u00ednica individualizada em sua magnitude de benef\u00edcio e risco, valores e prefer\u00eancias do paciente (decis\u00e3o compartilhada) e de aspectos atinentes ao sistema de sa\u00fade .  Em paralelo \u00e0 organiza\u00e7\u00e3o do pensamento cient\u00edfico aplicado \u00e0 recomenda\u00e7\u00e3o sobre conduta terap\u00eautica, tema que predomina em qualquer diretriz, devemos ampliar a discuss\u00e3o para recomenda\u00e7\u00e3o de testes diagn\u00f3sticos, visto que tamb\u00e9m temos cap\u00edtulos que abordam essas dimens\u00f5es da decis\u00e3o m\u00e9dica.  Para o contexto do diagn\u00f3stico, o conceito cient\u00edfico a alicer\u00e7ar o n\u00edvel de evid\u00eancia n\u00e3o \u00e9 o de efic\u00e1cia, como ocorre em tratamento. Aqui se trata do conceito de acur\u00e1cia, a capacidade de discriminar entre doentes (sensibilidade) e saud\u00e1veis (especificidade). Portanto, a quest\u00e3o n\u00e3o \u00e9 a de prova conceitual de causalidade, nem da necessidade de estudos experimentais randomizados para minimiza\u00e7\u00e3o de fatores de confus\u00e3o. A necessidade \u00e9 de demonstra\u00e7\u00e3o de acur\u00e1cia suficiente para que a nova informa\u00e7\u00e3o trazida pelo exame solicitado incremente de forma significativa a probabilidade diagn\u00f3stica pr\u00e9-teste, dentro de uma estrutura de pensamento bayesiano.  Nesse caso, o melhor n\u00edvel de evid\u00eancia para acur\u00e1cia diagn\u00f3stica deriva de estudos transversais, com metodologia adequada de sele\u00e7\u00e3o de pacientes, execu\u00e7\u00e3o e leitura dos exames pr\u00e9-definidos e realizados de forma a reduzir erros sistem\u00e1ticos. Deve-se salientar que estudos de acur\u00e1cia diagn\u00f3stica s\u00e3o muito sens\u00edveis a vieses provocados por observa\u00e7\u00f5es retrospectivas de bancos de dados .  Portanto, a qualidade da evid\u00eancia \u00e9 essencial, evitando-se a recomenda\u00e7\u00e3o baseada em informa\u00e7\u00f5es preliminares. Sendo assim, \u00e0 semelhan\u00e7a do utilizado para tratamento, a atual diretriz classifica como n\u00edvel de evid\u00eancia diagn\u00f3stica A e B aquelas com precis\u00e3o satisfat\u00f3ria e baixo risco de vi\u00e9s, sendo que o n\u00edvel B se refere \u00e0 evid\u00eancia indireta com alto potencial de generaliza\u00e7\u00e3o ou \u00e0 evid\u00eancia direta de qualidade satisfat\u00f3ria. O n\u00edvel de evid\u00eancia C fica reservado para situa\u00e7\u00f5es que n\u00e3o requerem evid\u00eancia emp\u00edrica, situa\u00e7\u00f5es incontroversas. Por exemplo, acur\u00e1cia do eletrocardiograma (ECG) para definir o ritmo card\u00edaco de base.  Quanto \u00e0 for\u00e7a de recomenda\u00e7\u00e3o, essa tem na acur\u00e1cia observada uma condi\u00e7\u00e3o necess\u00e1ria, por\u00e9m n\u00e3o suficiente. Um exame acurado n\u00e3o \u00e9, obrigatoriamente, de forte indica\u00e7\u00e3o. Para tanto, tr\u00eas condi\u00e7\u00f5es s\u00e3o essenciais: primeiro, o diagn\u00f3stico deve ter utilidade cl\u00ednica, ou seja, implicar em condutas que, em sucess\u00e3o, beneficiem o paciente; segundo, a informa\u00e7\u00e3o adicional do teste deve ser necess\u00e1ria e suficiente para incrementar uma probabilidade pr\u00e9-teste diagn\u00f3stica antes indefinida; e terceiro, op\u00e7\u00f5es menos complexas, menos invasivas, de menor risco, ou menos custosas devem estar ausentes. Por exemplo, embora a resson\u00e2ncia magn\u00e9tica card\u00edaca (RMC) seja um teste de melhor acur\u00e1cia para avalia\u00e7\u00e3o de fun\u00e7\u00e3o sist\u00f3lica, ela n\u00e3o \u00e9 fortemente recomendada, pois, na grande maioria das vezes, a acur\u00e1cia do ecocardiograma (ECO) j\u00e1 \u00e9 suficiente e o m\u00e9todo encontra-se largamente dispon\u00edvel, ao contr\u00e1rio da RMC. equipoiseentre as consequ\u00eancias intencionais do diagn\u00f3stico precoce e a probabilidade de dano. Nessas circunst\u00e2ncias mais duvidosas, prop\u00f5e-se a realiza\u00e7\u00e3o de exames diagn\u00f3sticos por meio de ECR para concretiza\u00e7\u00e3o do esfor\u00e7o diagn\u00f3stico.  Essa an\u00e1lise da necessidade e do impacto de um determinado teste diagn\u00f3stico \u00e9 o que norteia sua for\u00e7a de recomenda\u00e7\u00e3o e, em boa parte das vezes, tem sua defini\u00e7\u00e3o baseada em racionalidade cl\u00ednica. Por exemplo, no caso de paciente sintom\u00e1tico, a descoberta de um problema definido \u00e9 de \u00f3bvia utilidade, se houver uma solu\u00e7\u00e3o espec\u00edfica. A utilidade diagn\u00f3stica fica mais duvidosa, no entanto, no caso de rastreamentos, em que h\u00e1 forte Finalmente, destacamos que o racional descrito para diagn\u00f3stico tamb\u00e9m se aplica, de forma an\u00e1loga, \u00e0 defini\u00e7\u00e3o do n\u00edvel de evid\u00eancia e for\u00e7a de recomenda\u00e7\u00e3o para marcadores e modelos progn\u00f3sticos. T. cruzie que integra o grupo de doen\u00e7as tropicais negligenciadas (DTN) da Organiza\u00e7\u00e3o Mundial da Sa\u00fade (OMS).  Descoberta por Carlos Ribeiro Justiniano Chagas em 1909,  segue no s\u00e9culo XXI acometendo principalmente pessoas com maior vulnerabilidade social, podendo gerar graves impactos f\u00edsicos , psicol\u00f3gicos (como medo e estigma) e socioecon\u00f4micos tamb\u00e9m muito ominosos, com reflexos diretos e indiretos na qualidade de vida.  A DC (tripanossom\u00edase americana) \u00e9 entidade m\u00f3rbida transmiss\u00edvel, potencialmente fatal, causada pelo protozo\u00e1rio parasitaT. cruzi\u00e0 esp\u00e9cie humana.  Fatores pol\u00edtico-institucionais, econ\u00f4micos, ambientais  e sociais  inserem-se igualmente como elementos centrais na determina\u00e7\u00e3o do impacto global da transmiss\u00e3o deT. cruzi, esp\u00e9cies do vetor e reservat\u00f3rios do agente etiol\u00f3gico,  em uma perspectiva de Sa\u00fade \u00danica -One Health.  Para an\u00e1lise mais aprofundada sobre a DC, torna-se fundamental a identifica\u00e7\u00e3o de cen\u00e1rios epidemiol\u00f3gicos e sua din\u00e2mica de transmiss\u00e3o, envolvendo desde pessoas infectadas ou sob risco de infec\u00e7\u00e3o at\u00e9 diferentes \u201ccepas\u201d deT. cruzi\u00e9 parasito hemoflagelado, transmitido principalmente pelo contato com dejetos de diferentes esp\u00e9cies da ordemHemiptera, fam\u00edliaReduviidae, subfam\u00edliaTriatominae, cujo habitat se estende da Argentina e Chile at\u00e9 a metade sul dos Estados Unidos da Am\u00e9rica (EUA), contaminadas ao sugarem o sangue de pessoas ou animais infectados. T. cruzi; 4- transplantes de \u00f3rg\u00e3os s\u00f3lidos a partir de doadores infectados; e 5- acidentes com materiais biol\u00f3gicos, particularmente em laborat\u00f3rios, al\u00e9m de compartilhamento de agulhas/seringas contaminadas por pessoas em uso de drogas il\u00edcitas.  Nessa perspectiva, as a\u00e7\u00f5es de preven\u00e7\u00e3o e controle da DC est\u00e3o diretamente relacionadas \u00e0s modalidades de transmiss\u00e3o deT. cruzi.  A transmiss\u00e3o tamb\u00e9m pode ocorrer pelos meios a seguir mencionados: 1- ingest\u00e3o de alimentos ou bebidas contaminados com triatom\u00edneos ou seus dejetos; 2- via transplacent\u00e1ria, da m\u00e3e infectada para seu feto ou rec\u00e9m-nascido durante a gesta\u00e7\u00e3o ou o parto; 3- transfus\u00e3o de sangue ou hemocomponentes de pessoas candidatas \u00e0 doa\u00e7\u00e3o, infectadas por Caso n\u00e3o seja adequadamente tratada, a infec\u00e7\u00e3o porT. cruzipode seguir por toda a vida.  Estima-se que 30-40% das pessoas infectadas n\u00e3o tratadas desenvolvem s\u00edndromes cl\u00ednicas graves na fase cr\u00f4nica, \u00e0s vezes fatais, ao longo de suas vidas. Essas les\u00f5es est\u00e3o associadas a acometimento de \u00f3rg\u00e3os-alvo, levando a manifesta\u00e7\u00f5es card\u00edacas, digestivas, neurol\u00f3gicas ou mistas, que podem exigir tratamento etiol\u00f3gico.  Esse aspecto refor\u00e7a a import\u00e2ncia do diagn\u00f3stico oportuno, em ciclos de vida ainda iniciais, particularmente em pessoas oriundas de comunidades em condi\u00e7\u00e3o de pobreza e vulnerabilidade social.  A DC \u00e9 multissist\u00eamica e sua hist\u00f3ria natural \u00e9 caracterizada por uma fase aguda, que pode durar at\u00e9 algumas semanas ou meses, geralmente com express\u00e3o cl\u00ednica leve ou assintom\u00e1tica, e uma fase cr\u00f4nica.  Uma propor\u00e7\u00e3o substancial da carga econ\u00f4mica \u00e9 consequente \u00e0 perda de produtividade pela morbimortalidade precoce induzida, particularmente, pela cardiomiopatia cr\u00f4nica.  Globalmente, a carga anual \u00e9 de US$ 627,46 milh\u00f5es em custos de sa\u00fade, com valor l\u00edquido global atual de US$ 24,73 bilh\u00f5es . Os custos globais alcan\u00e7am n\u00edveis de US$ 7,19 bilh\u00f5es por ano e de US$188 bilh\u00f5es ao longo da vida. Ressalta-se que aproximadamente 10% desses custos associam-se a \u00e1reas onde a DC n\u00e3o \u00e9 end\u00eamica, como EUA e Canad\u00e1.  Assim, superar as barreiras de acesso a diagn\u00f3stico e tratamento com a adequada implementa\u00e7\u00e3o da aten\u00e7\u00e3o integral \u00e0s pessoas com DC reduziria a ocorr\u00eancia de complica\u00e7\u00f5es cr\u00f4nicas e os custos associados aos sistemas nacionais de sa\u00fade , com impacto ben\u00e9fico para toda a sociedade.  A carga econ\u00f4mica gerada pela DC nos sistemas nacionais de sa\u00fade e para a sociedade \u00e9 expressiva, igualando-se ou superando a de outras doen\u00e7as, como infec\u00e7\u00e3o por rotav\u00edrus ou c\u00e2ncer de colo de \u00fatero, mesmo em \u00e1reas n\u00e3o end\u00eamicas.  Pol\u00edticas mais abrangentes, que reconhe\u00e7am as diferentes dimens\u00f5es de determina\u00e7\u00e3o social, s\u00e3o fundamentais para redu\u00e7\u00e3o dessa carga, demandando o envolvimento de outras \u00e1reas que ultrapassem o setor sa\u00fade.  A agenda trazida pelos Objetivos de Desenvolvimento Sustent\u00e1vel (ODS) integra a DC em seu terceiro objetivo: \u201cassegurar uma vida saud\u00e1vel e promover o bem-estar para todos, em todas as idades\u201d, na meta de \u201cacabar com as epidemias de AIDS, tuberculose, mal\u00e1ria e doen\u00e7as tropicais negligenciadas, e combater a hepatite, doen\u00e7as transmitidas pela \u00e1gua e outras doen\u00e7as transmiss\u00edveis\u201d at\u00e9 2030.  Nessa perspectiva, uma avalia\u00e7\u00e3o econ\u00f4mica abrangente relativa a medidas destinadas \u00e0 amplia\u00e7\u00e3o do acesso ao diagn\u00f3stico e tratamento da doen\u00e7a indicou a import\u00e2ncia da triagem sorol\u00f3gica de candidatos (as) \u00e0 doa\u00e7\u00e3o de sangue e de gestantes, como estrat\u00e9gias de sa\u00fade p\u00fablica com melhor custo-efetividade.  H\u00e1 evid\u00eancias contundentes de que o diagn\u00f3stico e o tratamento etiol\u00f3gico adequado da DC resultam em muitos benef\u00edcios, incluindo a preven\u00e7\u00e3o da transmiss\u00e3o cong\u00eanita futura em m\u00e3es tratadas, cura sorol\u00f3gica em beb\u00eas e crian\u00e7as e redu\u00e7\u00e3o da progress\u00e3o para formas cl\u00ednicas avan\u00e7adas da doen\u00e7a nas pessoas aguda e cronicamente infectadas.  No entanto, uma vez que a doen\u00e7a tenha progredido para uma fase cl\u00ednica mais avan\u00e7ada, com comprometimento card\u00edaco grave, o tratamento etiol\u00f3gico n\u00e3o parece trazer benef\u00edcios cl\u00ednicos.  Esse fato refor\u00e7a a necessidade de potencializar o desenvolvimento de m\u00e9todos diagn\u00f3sticos mais aprimorados nos cen\u00e1rios locais dos servi\u00e7os de sa\u00fade para garantia de acesso a tratamento precoce, seguro e eficaz.  Apesar da alta carga de morbimortalidade da DC e dos elevados custos para os sistemas nacionais de sa\u00fade e, sobretudo, para a sociedade, registra-se que 70-90% das pessoas com a doen\u00e7a desconhecem o seu diagn\u00f3stico e somente 1% recebe, efetivamente, o tratamento etiol\u00f3gico adequado no s\u00e9culo XXI.  Essas barreiras incluem: incompletude e inconsist\u00eancia de dados sobre a doen\u00e7a; limita\u00e7\u00e3o de a\u00e7\u00f5es integradas de vigil\u00e2ncia, controle e cuidado na rede de Aten\u00e7\u00e3o Prim\u00e1ria \u00e0 Sa\u00fade (APS); dist\u00e2ncia geogr\u00e1fica aos servi\u00e7os de sa\u00fade, fluxograma e processo de diagn\u00f3stico muitas vezes complicados (sistemas de refer\u00eancia e contrarrefer\u00eancia), demorados e com custos elevados; limitada integra\u00e7\u00e3o de pol\u00edticas e a\u00e7\u00f5es para sa\u00fade reprodutiva, materna, neonatal e infantil; impacto desproporcional da doen\u00e7a em popula\u00e7\u00f5es mais vulner\u00e1veis; conhecimento limitado sobre a doen\u00e7a, tanto na popula\u00e7\u00e3o em geral quanto entre profissionais de sa\u00fade; limitado interesse da m\u00eddia e da ind\u00fastria farmac\u00eautica; reduzidas iniciativas de educa\u00e7\u00e3o em sa\u00fade; disponibilidade limitada de ferramentas e materiais nos centros de sa\u00fade; medo; estigma e discrimina\u00e7\u00e3o contra pessoas acometidas; baixa capacidade de mobiliza\u00e7\u00e3o social e protagonismo pol\u00edtico limitado das pessoas com maior risco.  Al\u00e9m dos complexos desafios pol\u00edticos, geogr\u00e1ficos, socioecon\u00f4micos, culturais, tecnol\u00f3gicos e jur\u00eddicos inerentes aos territ\u00f3rios de maior endemicidade para a DC, reconhece-se a persist\u00eancia de barreiras que limitam o acesso a diagn\u00f3stico, tratamento e cuidado longitudinal.  Ademais, h\u00e1 ainda clara necessidade de superar barreiras de acesso relacionadas ao tratamento etiol\u00f3gico, limitado a dois medicamentos eficazes apenas - benznidazol e nifurtimox - que requerem per\u00edodos de administra\u00e7\u00e3o relativamente longos e que podem estar associados a rea\u00e7\u00f5es adversas que podem complexificar o tratamento, demandando monitoramento cl\u00ednico e laboratorial.  Deve-se frisar tamb\u00e9m que os medicamentos para tratamento etiol\u00f3gico t\u00eam limita\u00e7\u00e3o de uso em mulheres durante a gesta\u00e7\u00e3o ou em casos de est\u00e1gio avan\u00e7ado da doen\u00e7a com comprometimento card\u00edaco ou cardiodigestivo.  Entretanto, em gestantes, diante de quadro cl\u00ednico agudo e grave de DC ,  a decis\u00e3o desse dilema \u00e9tico relativo ao tratamento etiol\u00f3gico, no contexto da gravidez, imp\u00f5e-se.  Ressalta-se que o limitado conhecimento dos profissionais de sa\u00fade sobre a DC representa um dos fatores cr\u00edticos para que os sistemas nacionais de sa\u00fade possam garantir amplo acesso a diagn\u00f3stico e tratamento adequados.  Al\u00e9m disso, a OMS, em seu documento-guia para DTN, identificou tr\u00eas a\u00e7\u00f5es estrat\u00e9gicas para alcan\u00e7ar a elimina\u00e7\u00e3o da doen\u00e7a: a\u00e7\u00e3o 1 \u2013 advogar junto a institui\u00e7\u00f5es/\u00f3rg\u00e3os p\u00fablicos que executam a\u00e7\u00f5es de preven\u00e7\u00e3o e controle dos pa\u00edses (minist\u00e9rios da sa\u00fade) para que reconhe\u00e7am a DC como problema de sa\u00fade p\u00fablica e estabele\u00e7am pol\u00edticas e a\u00e7\u00f5es de preven\u00e7\u00e3o, controle, aten\u00e7\u00e3o e vigil\u00e2ncia eficazes em todos os territ\u00f3rios end\u00eamicos; a\u00e7\u00e3o 2 \u2013 qualificar a aten\u00e7\u00e3o m\u00e9dica, desde educa\u00e7\u00e3o permanente em servi\u00e7o at\u00e9 a integra\u00e7\u00e3o das a\u00e7\u00f5es em toda a rede de aten\u00e7\u00e3o; e a\u00e7\u00e3o 3 \u2013 garantir que os pa\u00edses onde a transmiss\u00e3o vetorial domiciliar/peridomiciliar ainda \u00e9 registrada possam cumprir com os protocolos de preven\u00e7\u00e3o, controle e vigil\u00e2ncia.  Como forma de enfrentamento, no dia 24 de maio de 2019, durante a 72\u00aa sess\u00e3o da Assembleia Mundial da Sa\u00fade, foi institu\u00eddo o Dia Mundial da Doen\u00e7a de Chagas, em uma das 11 campanhas globais de sa\u00fade p\u00fablica da OMS.  Esses movimentos unem-se inclusive em um F\u00f3rum Social mais amplo para enfrentamento de DTN no Brasil.  Al\u00e9m disso, esses movimentos para DC comp\u00f5em uma federa\u00e7\u00e3o internacional  representativa de pa\u00edses end\u00eamicos e n\u00e3o end\u00eamicos.  Ressalta-se nesse enfrentamento a crescente participa\u00e7\u00e3o social, com engajamento e protagonismo de movimentos sociais em DC globalmente, com mobiliza\u00e7\u00e3o articulada a outros movimentos voltados para DTN, visando a garantia de direitos fundamentais como o de acesso \u00e0 sa\u00fade. T. cruzi. H\u00e1 relativa dificuldade no estabelecimento de estimativas mais precisas dentro do contexto de uma DTN, o que traz incertezas. Entretanto, as estimativas atualmente dispon\u00edveis t\u00eam sido fundamentais para subsidiar agendas para controle da doen\u00e7a. A OMS estima que 6 a 7 milh\u00f5es de pessoas em todo o mundo estejam infectadas, a maioria na Am\u00e9rica Latina, traduzindo uma redu\u00e7\u00e3o de aproximadamente 65% em compara\u00e7\u00e3o a 1980 (17 milh\u00f5es).  A DC no s\u00e9culo XXI mant\u00e9m padr\u00e3o epidemiol\u00f3gico de endemicidade em 21 pa\u00edses da regi\u00e3o da Am\u00e9rica Latina, com aproximadamente 70 milh\u00f5es de pessoas sob risco de exposi\u00e7\u00e3o \u00e0 infec\u00e7\u00e3o por O Cerca de 63% desses casos est\u00e3o em pa\u00edses da Iniciativa de Pa\u00edses do Cone Sul, com destaque para Argentina , Brasil , M\u00e9xico (880 mil) e Bol\u00edvia (610 mil).  A subnotifica\u00e7\u00e3o de casos e o n\u00e3o registro de \u00f3bitos por DC tamb\u00e9m representam cr\u00edticos obst\u00e1culos, pois impedem a ado\u00e7\u00e3o de medidas de controle mais ajustadas \u00e0s realidades locais, a partir da vigil\u00e2ncia epidemiol\u00f3gica.  Entretanto, esses dados globais divergem das estimativas individualizadas em v\u00e1rios pa\u00edses, o que dificulta o estabelecimento exato da preval\u00eancia da doen\u00e7a nas Am\u00e9ricas. T. cruzi.  A consecu\u00e7\u00e3o de metas pactuadas de elimina\u00e7\u00e3o da transmiss\u00e3o vetorial pela principal esp\u00e9cie (Triatoma infestans) e por transfus\u00f5es de sangue foi alcan\u00e7ada por v\u00e1rios pa\u00edses a partir de iniciativas desde a d\u00e9cada de 1990, com significativa redu\u00e7\u00e3o do n\u00famero de casos novos, persistindo, entretanto, algumas \u00e1reas cr\u00edticas de transmiss\u00e3o na atualidade.  N\u00e3o obstante essa dificuldade, a expressiva redu\u00e7\u00e3o da preval\u00eancia global est\u00e1 associada ao desenvolvimento de iniciativas regionais, coordenadas com o objetivo de interromper a transmiss\u00e3o de Acresce que, na maioria das \u00e1reas onde foi alcan\u00e7ada a interrup\u00e7\u00e3o vetorial ou redu\u00e7\u00e3o da transmiss\u00e3o, ocorre um processo de envelhecimento da popula\u00e7\u00e3o acometida, ampliando a carga de morbimortalidade pela coexist\u00eancia com doen\u00e7as cr\u00f4nico-degenerativas, em grande parte cardiovasculares.  Na popula\u00e7\u00e3o mais idosa, a CDC mant\u00e9m-se como forte fator preditor de maior risco para morte.  Os atuais desafios s\u00e3o ainda muito vultosos. Apenas cerca de 10%-30% das pessoas acometidas por DC sabem do seu diagn\u00f3stico, o que contribui para que somente 1% daquelas que necessitam de tratamento etiol\u00f3gico tenha acesso de fato, mantendo o elevado impacto de morbimortalidade e de custo social, com limita\u00e7\u00e3o da qualidade de vida.  Em rela\u00e7\u00e3o \u00e0 mortalidade espec\u00edfica, tamb\u00e9m tem sido verificada significativa redu\u00e7\u00e3o, considerando-se o registro de mais de 45 mil mortes anuais nos anos 1980. No entanto, a mortalidade mant\u00e9m-se em patamares elevados,  o que contribui para sustentar a DC como problema de sa\u00fade p\u00fablica.  Apesar da significativa redu\u00e7\u00e3o registrada na preval\u00eancia, aproximadamente 10 a 15 mil mortes relacionadas \u00e0 DC ainda s\u00e3o registradas a cada ano.  Para al\u00e9m das \u00e1reas classicamente end\u00eamicas da Am\u00e9rica Latina, a DC tem sido progressivamente registrada em pa\u00edses n\u00e3o end\u00eamicos , em virtude de movimentos migrat\u00f3rios associados a crises pol\u00edtico-institucionais, sanit\u00e1rias, ambientais e econ\u00f4micas nos pa\u00edses de origem.  Essas estimativas globais s\u00e3o corroboradas por dados recentes oriundos, por exemplo, de um pa\u00eds como a Espanha, onde a doen\u00e7a n\u00e3o \u00e9 end\u00eamica, mas h\u00e1 pesquisa ativa e foco em medidas de sa\u00fade p\u00fablica para controle. Nesse pa\u00eds, estimou-se que, para 2018, mais de 55 mil dos quase 2,6 milh\u00f5es de migrantes origin\u00e1rios de pa\u00edses end\u00eamicos (54% da Bol\u00edvia) vivam com a DC, uma preval\u00eancia estimada de 2,1%. Aproximadamente 70% das pessoas migrantes n\u00e3o tinham o diagn\u00f3stico estabelecido e a maioria n\u00e3o foi tratada, 83% maiores de 15 anos de idade e 60% crian\u00e7as.  Destaque-se ainda que oT. cruzitamb\u00e9m pode atuar como microrganismo oportunista em pessoas com outras patologias associadas a imunossupress\u00e3o, desencadeando s\u00edndromes cl\u00ednicas potencialmente fatais pela RDC.  Essas popula\u00e7\u00f5es tamb\u00e9m apresentam condi\u00e7\u00f5es muito prec\u00e1rias de vida, com alta vulnerabilidade social por restri\u00e7\u00f5es sociais e econ\u00f4micas que complicam o acesso \u00e0 aten\u00e7\u00e3o \u00e0 sa\u00fade, inclusive pela baixa experi\u00eancia profissional no setor espec\u00edfico de sa\u00fade. T. cruzitem sido cada vez mais reconhecida. Embora a DC raramente seja definida como um problema de sa\u00fade p\u00fablica em pa\u00edses n\u00e3o end\u00eamicos, muitos hemocentros t\u00eam implementado nos \u00faltimos 10 anos medidas para mitigar o risco relativo \u00e0 seguran\u00e7a sangu\u00ednea com base no reconhecimento de fatores de risco epidemiol\u00f3gico associados a imigrantes latino-americanos e na ado\u00e7\u00e3o de testes sorol\u00f3gicos de triagem.  Nesses novos contextos n\u00e3o end\u00eamicos, a possibilidade de transmiss\u00e3o transfusional de Estima-se, em regi\u00f5es end\u00eamicas, que 1,12 milh\u00e3o de mulheres em idade reprodutiva estejam infectadas  e que a taxa m\u00e9dia de transmiss\u00e3o cong\u00eanita estimada seja de cerca de 5%, principalmente em \u00e1reas end\u00eamicas de alto risco.  Como o acesso ao diagn\u00f3stico da infec\u00e7\u00e3o porT. cruziem m\u00e3es ou crian\u00e7as rec\u00e9m-nascidas \u00e9 limitado na maioria das \u00e1reas end\u00eamicas, a preval\u00eancia em mulheres gr\u00e1vidas e rec\u00e9m-nascidos pode estar subestimada.  Mesmo com essas limita\u00e7\u00f5es, a incid\u00eancia estimada \u00e9 de 8.000 a 15.000 casos de transmiss\u00e3o cong\u00eanita por ano na Am\u00e9rica Latina.  Por outro lado, essa modalidade de transmiss\u00e3o tem representado um papel central como principal modo de manuten\u00e7\u00e3o deT. cruziem \u00e1reas n\u00e3o end\u00eamicas.  Assim, a ocorr\u00eancia de infec\u00e7\u00e3o cong\u00eanita pode sustentar a transmiss\u00e3o deT. cruziindefinidamente, mesmo em pa\u00edses sem a modalidade vetorial cl\u00e1ssica.  Em contextos end\u00eamicos, o controle de outros modos de transmiss\u00e3o  coloca em perspectiva de realce a cong\u00eanita, respons\u00e1vel por quase um ter\u00e7o das novas infec\u00e7\u00f5es em 2010.  Al\u00e9m disso, o diagn\u00f3stico da infec\u00e7\u00e3o porT. cruziem gr\u00e1vidas durante o pr\u00e9-natal, oportunizando o rastreamento precoce de infec\u00e7\u00e3o no rec\u00e9m-nascido, e o diagn\u00f3stico da infec\u00e7\u00e3o em crian\u00e7as nascidas de m\u00e3es infectadas, possibilitando a implementa\u00e7\u00e3o de tratamento etiol\u00f3gico, seriam medidas altamente eficazes e seguras.  Para que seja alcan\u00e7ada a preven\u00e7\u00e3o da transmiss\u00e3o cong\u00eanita em \u00e1reas end\u00eamicas, \u00e9 fundamental garantir acesso a diagn\u00f3stico e tratamento etiol\u00f3gico de meninas e mulheres em idade f\u00e9rtil antes da gravidez.  tendo papel relevante na gera\u00e7\u00e3o de casos agudos na Amaz\u00f4nia brasileira e na Venezuela.  Nesses cen\u00e1rios, verifica-se maior mortalidade durante a fase aguda, quando se compara ao que ocorre em casos agudos causados por transmiss\u00e3o vetorial cl\u00e1ssica.  A DC aguda transmitida por via oral tem letalidade consider\u00e1vel ao longo do primeiro ano ap\u00f3s a infec\u00e7\u00e3o,  como discutido em outro cap\u00edtulo desta diretriz.  A transmiss\u00e3o oral, por sua vez, tem sido registrada particularmente na regi\u00e3o amaz\u00f4nica e nos Andes subtropicais,  Como pa\u00eds de dimens\u00f5es continentais, vem passando ao longo deste s\u00e9culo por transforma\u00e7\u00f5es demogr\u00e1ficas, sociais, econ\u00f4micas e ambientais, sem que se consigam superar as cr\u00edticas desigualdades socioecon\u00f4micas e regionais.  \u00c9 inequ\u00edvoca a import\u00e2ncia de se sustentar no s\u00e9culo XXI a vigil\u00e2ncia e o controle da DC em todas as suas fases cl\u00ednicas evolutivas, considerando-se como crit\u00e9rios a magnitude, o potencial de dissemina\u00e7\u00e3o, a transcend\u00eancia, a vulnerabilidade e os compromissos internacionais do Brasil.  Por outro lado, o pa\u00eds possui o Sistema \u00danico de Sa\u00fade (SUS), de car\u00e1ter p\u00fablico, universal e de base democr\u00e1tica, que deve avan\u00e7ar em constante aprimoramento de sua qualidade, com a finalidade de estabelecer a garantia ao direito \u00e0 sa\u00fade para todas as pessoas, o qual foi consagrado na Constitui\u00e7\u00e3o Federal de 1988.  Tendo em vista a extens\u00e3o e diversidade do territ\u00f3rio do pa\u00eds, com implica\u00e7\u00f5es nas din\u00e2micas ecol\u00f3gica, demogr\u00e1fica, social e econ\u00f4mica das regi\u00f5es, verificam-se m\u00faltiplos cen\u00e1rios cl\u00ednicos, epidemiol\u00f3gicos e operacionais para o controle da doen\u00e7a.  Nesse contexto, a DC mant\u00e9m-se como a DTN com maior carga de morbimortalidade, particularmente entre homens idosos e residentes no passado em importantes \u00e1reas end\u00eamicas para transmiss\u00e3o vetorial.  mas preocupa o cen\u00e1rio atual de fragiliza\u00e7\u00e3o das opera\u00e7\u00f5es da vigil\u00e2ncia entomol\u00f3gica nos munic\u00edpios end\u00eamicos do pa\u00eds. A \u201cCertifica\u00e7\u00e3o da Interrup\u00e7\u00e3o da Transmiss\u00e3o da Doen\u00e7a de Chagas pelo principal vetor domiciliado,T. infestans\u201d, foi concedida em 2006 pela Organiza\u00e7\u00e3o Panamericana da Sa\u00fade (OPAS), dentro da Iniciativa dos Pa\u00edses do Cone Sul.  A despeito dos avan\u00e7os, o risco de transmiss\u00e3o vetorial da DC persiste e tem sido avaliado sob diferentes perspectivas, em decorr\u00eancia de diversos fatores, entre os quais a exist\u00eancia de esp\u00e9cies de triatom\u00edneos aut\u00f3ctones com elevado potencial de coloniza\u00e7\u00e3o, a presen\u00e7a de reservat\u00f3rios silvestres e dom\u00e9sticos deT. cruzi, a aproxima\u00e7\u00e3o cada vez mais frequente das popula\u00e7\u00f5es humanas a esses ambientes, al\u00e9m de persist\u00eancia de focos residuais deT. infestans, mesmo em \u00e1reas espec\u00edficas do estado da Bahia, e a limita\u00e7\u00e3o das a\u00e7\u00f5es de vigil\u00e2ncia entomol\u00f3gica.  O controle vetorial em \u00e1reas end\u00eamicas teve impacto consider\u00e1vel tamb\u00e9m em rela\u00e7\u00e3o \u00e0s transmiss\u00f5es transfusional e cong\u00eanita, T. cruzi, passando para 1.900.000  em 2000.  As estimativas mais recentes da OMS indicam infec\u00e7\u00e3o em 2010 de 1.156.821 pessoas porT. cruzi.  Entretanto, a limita\u00e7\u00e3o de estudos de base populacional dificulta avalia\u00e7\u00f5es mais realistas da magnitude da DC no pa\u00eds.  Assim, alguns estudos com base em revis\u00f5es sistem\u00e1ticas e meta-an\u00e1lises de dados dispon\u00edveis no Brasil estimaram o n\u00famero de pessoas infectadas variando de 1,9 a 4,6 milh\u00f5es, provavelmente cifras mais pr\u00f3ximas atualmente \u00e0 varia\u00e7\u00e3o de 1,0% a 2,4% da popula\u00e7\u00e3o.  Com base nessas propor\u00e7\u00f5es, estimou-se para 2020 entre 1.365.585 e 3.213.142 o n\u00famero de brasileiros infectados porT. cruzi, sendo 136.559 a 321.314 pessoas com a forma cr\u00f4nica digestiva e 409.676 a 963.943 com a forma cr\u00f4nica card\u00edaca. Por outro lado, a popula\u00e7\u00e3o estimada com infec\u00e7\u00e3o porT. cruzina FIDC variou de 819.350 a 1.927.885 pessoas.  OT. cruzie o n\u00famero de casos com DC na fase cr\u00f4nica com formas card\u00edaca e digestiva no Brasil de 2020 a 2055.  No Brasil, em 1980-1985, a estimativa era de 6.180.000  pessoas infectadas porT. cruziem gestantes de 1,1% (34.629 mulheres), com m\u00e9dia de 589 crian\u00e7as nascendo com infec\u00e7\u00e3o cong\u00eanita ,  semelhante \u00e0s estimativas da OMS (571 casos).  A taxa de transmiss\u00e3o cong\u00eanita \u00e9 menor  quando comparada \u00e0 m\u00e9dia de 5% verificada em outros pa\u00edses do Cone Sul, como Argentina, Paraguai e Bol\u00edvia. Esses achados sugerem que a presen\u00e7a de TcII se associa a menor transmiss\u00e3o quando comparada a TcV, que predomina na regi\u00e3o Sul do Brasil e naqueles pa\u00edses.  Estimou-se para o pa\u00eds, em 2010, preval\u00eancia de infec\u00e7\u00e3o por J\u00e1 em 2020, foram confirmados 146 casos, principalmente na regi\u00e3o Norte, com letalidade de 2% (3/146 - todos os \u00f3bitos no estado do Par\u00e1). A forma de transmiss\u00e3o mais frequentemente notificada no pa\u00eds nos \u00faltimos 15 anos em casos de DC aguda tem sido a via oral,  fato revelador de limita\u00e7\u00f5es operacionais do processo de vigil\u00e2ncia no pa\u00eds, que t\u00eam induzido mudan\u00e7as do perfil epidemiol\u00f3gico da doen\u00e7a na \u00faltima d\u00e9cada.  Com base nos dados do Sistema de Informa\u00e7\u00e3o de Agravos de Notifica\u00e7\u00e3o (SINAN), a ocorr\u00eancia de casos de DC aguda tem sido alvo da vigil\u00e2ncia epidemiol\u00f3gica, segundo a defini\u00e7\u00e3o de \u201ccaso\u201d do Minist\u00e9rio da Sa\u00fade do Brasil. Entre 2007 e 2019, foram confirmados 3.060 casos de DC aguda (m\u00e9dia de 222 casos/ano) em 219 munic\u00edpios.  As diferen\u00e7as que t\u00eam sido observadas entre as regi\u00f5es, em especial com maior carga no Centro-Oeste e Sudeste, indicam iniquidades socioecon\u00f4micas e o padr\u00e3o diferencial de acesso aos servi\u00e7os de sa\u00fade no SUS.  Registra-se que a regi\u00e3o Sul tamb\u00e9m apresenta redu\u00e7\u00e3o da tend\u00eancia de mortalidade, mas com aumento na regi\u00e3o Norte, enquanto a regi\u00e3o Nordeste n\u00e3o tem tend\u00eancia definida.  A carga da mortalidade relacionada \u00e0 DC no Brasil persiste em n\u00edveis significativamente elevados, a despeito das a\u00e7\u00f5es de controle empreendidas. A mortalidade \u00e9 reconhecidamente mais expressiva para idades de 50 a 64 anos e coortes mais idosas, provavelmente relacionada aos efeitos do per\u00edodo de intensifica\u00e7\u00e3o de a\u00e7\u00f5es de controle vetorial, al\u00e9m de mudan\u00e7as demogr\u00e1ficas.  Al\u00e9m da prov\u00e1vel subnotifica\u00e7\u00e3o de casos n\u00e3o associados \u00e0 transmiss\u00e3o vetorial domiciliar, essa regi\u00e3o obteve pouco impacto resultante das a\u00e7\u00f5es sistem\u00e1ticas de controle triatom\u00ednico. Esse fato justifica-se uma vez que o ciclo local de transmiss\u00e3o deT. cruzin\u00e3o envolve vetores com capacidade de domicilia\u00e7\u00e3o, mas se sustenta em um ciclo enzo\u00f3tico, com vetores silvestres, implicados nos casos associados \u00e0 transmiss\u00e3o oral ou vetorial extradomiciliar.  \u00c9 razo\u00e1vel estimar, portanto, que o ac\u00famulo de centenas ou mesmo milhares de casos de infec\u00e7\u00e3o porT. cruziao longo do tempo, na regi\u00e3o amaz\u00f4nica, possa estar contribuindo para esse padr\u00e3o epidemiol\u00f3gico espec\u00edfico.  Destaca-se de novo que \u00e9 justamente a regi\u00e3o Norte que concentra a grande maioria dos casos novos notificados no pa\u00eds.  particularmente com o envelhecimento da popula\u00e7\u00e3o acometida.  A an\u00e1lise global para o per\u00edodo de 2030 a 2034 indica decl\u00ednio progressivo na mortalidade (mais de 75% em compara\u00e7\u00e3o a 2010-2014), principalmente entre os mais jovens, variando de 86%, na faixa et\u00e1ria entre 20 e 24 anos, a 50% naqueles com 80 anos ou mais.  Registra-se ainda o significativo impacto com a redu\u00e7\u00e3o da qualidade de vida das pessoas com a doen\u00e7a e de suas fam\u00edlias.  A DC segue tendo forte impacto na Previd\u00eancia Social e nos Servi\u00e7os do Instituto Nacional do Seguro Social (INSS) nos estados brasileiros com maior preval\u00eancia,  O documento da OPAS \u201cCuidados cr\u00f4nicos para doen\u00e7as infecciosas negligenciadas: hansen\u00edase, filariose linf\u00e1tica, tracoma e doen\u00e7a de Chagas \u2013 Um guia para manejo da morbidade e preven\u00e7\u00e3o de incapacidade para servi\u00e7os de aten\u00e7\u00e3o prim\u00e1ria \u00e0 sa\u00fade\u201d \u00e9 um verdadeiro marco, pois assinala v\u00e1rios aspectos fundamentais no cuidado de pessoas acometidas por DC, com vistas a instrumentalizar as equipes de APS e refor\u00e7ar a import\u00e2ncia da integra\u00e7\u00e3o com as a\u00e7\u00f5es de vigil\u00e2ncia.  A integra\u00e7\u00e3o das a\u00e7\u00f5es de aten\u00e7\u00e3o, vigil\u00e2ncia e controle da DC na APS tem sido disposta como fundamental e estrat\u00e9gica para a redu\u00e7\u00e3o da carga de morbimortalidade, sobretudo em territ\u00f3rios end\u00eamicos, para se ampliar acesso a diagn\u00f3stico e tratamento etiol\u00f3gico.  A vigil\u00e2ncia epidemiol\u00f3gica da DC engloba a\u00e7\u00f5es necessariamente integradas, que envolvem a abordagem de casos humanos, vetores e reservat\u00f3rios, com interface estreita com a rede de aten\u00e7\u00e3o \u00e0 sa\u00fade e especial realce para o papel da APS. T. cruzina popula\u00e7\u00e3o humana, por meio de programas de rastreamento na APS, inqu\u00e9ritos sorol\u00f3gicos peri\u00f3dicos em popula\u00e7\u00f5es estrat\u00e9gicas e an\u00e1lise do processo de triagem de candidatos \u00e0 doa\u00e7\u00e3o de sangue em hemocentros; 4) monitorar o perfil de morbimortalidade da DC, delineando a\u00e7\u00f5es para fortalecimento da rede de aten\u00e7\u00e3o \u00e0 sa\u00fade \u00e0s pessoas infectadas; 5) manter eliminada a transmiss\u00e3o vetorial porT. infestanse sob monitoramento/controle as outras esp\u00e9cies importantes; e 6) integrar a\u00e7\u00f5es de vigil\u00e2ncia sanit\u00e1ria, ambiental, de vetores e reservat\u00f3rios \u00e0s a\u00e7\u00f5es de vigil\u00e2ncia epidemiol\u00f3gica.  As a\u00e7\u00f5es de vigil\u00e2ncia epidemiol\u00f3gica da DC no Brasil t\u00eam os seguintes objetivos principais: 1) detectar precocemente casos de DC aguda para tratamento etiol\u00f3gico adequado, bem como para aplica\u00e7\u00e3o de medidas de preven\u00e7\u00e3o de ocorr\u00eancia de novos casos; 2) proceder \u00e0 investiga\u00e7\u00e3o epidemiol\u00f3gica de todos os casos agudos, visando identificar a forma de transmiss\u00e3o e adotar medidas adequadas de controle; 3) monitorar a infec\u00e7\u00e3o por At\u00e9 maio de 2020, quando foi institu\u00edda a inclus\u00e3o da fase cr\u00f4nica da DC tamb\u00e9m como evento de interesse para fins de vigil\u00e2ncia epidemiol\u00f3gica, por meio da notifica\u00e7\u00e3o compuls\u00f3ria de casos , somente a tradicional vigil\u00e2ncia de casos na fase aguda era realizada e estava inclu\u00edda na Lista Nacional de Doen\u00e7as de Notifica\u00e7\u00e3o Compuls\u00f3ria e Imediata.  Essa amplia\u00e7\u00e3o no escopo da vigil\u00e2ncia configura a\u00e7\u00e3o de grande import\u00e2ncia para o pa\u00eds no sentido de se alcan\u00e7ar o reconhecimento nacional de padr\u00f5es de ocorr\u00eancia da doen\u00e7a e pode ser seguida por outros pa\u00edses end\u00eamicos. H\u00e1 uma expectativa de que esse novo processo de vigil\u00e2ncia epidemiol\u00f3gica no Brasil esteja implantado em todo o territ\u00f3rio a partir de 2022.  Os dados dispon\u00edveis relativos \u00e0 vigil\u00e2ncia epidemiol\u00f3gica de casos humanos n\u00e3o permitem estimar a magnitude nosol\u00f3gica da tripanossom\u00edase americana. Estima-se que somente 10-20% dos casos de DC aguda sejam de fato notificados. T. cruzi.  Com vistas a elaborar um modelo de prioriza\u00e7\u00e3o de munic\u00edpios para vigil\u00e2ncia da DC cr\u00f4nica, uma equipe do Minist\u00e9rio da Sa\u00fade realizou an\u00e1lise multicrit\u00e9rio preliminar baseada em tr\u00eas \u00edndices constru\u00eddos a partir dos seguintes indicadores: (a) epidemiol\u00f3gicos, diretamente relacionados \u00e0 DC cr\u00f4nica; (b) decorrentes da evolu\u00e7\u00e3o da DC cr\u00f4nica; e (c) relacionados ao acesso aos servi\u00e7os de sa\u00fade. O modelo definido como o mais adequado era composto por 1.345 munic\u00edpios de m\u00e9dia prioridade, 1.003 de alta e 601 de muito alta prioridade para DC cr\u00f4nica, principalmente no Sudeste e Nordeste do pa\u00eds.  Mais recentemente, para o reconhecimento da magnitude da DC cr\u00f4nica no pa\u00eds, tem sido discutida a import\u00e2ncia de se rearticular e integrar as a\u00e7\u00f5es de vigil\u00e2ncia em sa\u00fade, buscando o desenvolvimento de uma ampla rede hierarquizada de servi\u00e7os de sa\u00fade nos v\u00e1rios territ\u00f3rios geogr\u00e1ficos, para garantir acesso a milh\u00f5es de pessoas infectadas por Para tanto, foram desenvolvidos tr\u00eas sub\u00edndices a partir dos tr\u00eas indicadores integrados na an\u00e1lise anterior.  O valor do \u00edndice pode variar no intervalo entre 0 e 1, sendo que quanto mais pr\u00f3ximo do valor \u20181\u2019, maior a vulnerabilidade para DC cr\u00f4nica  ou s\u00edndrome da imunodefici\u00eancia adquirida (AIDS) tenha, \u00e0 disposi\u00e7\u00e3o, a solicita\u00e7\u00e3o de teste de anticorpos anti- O car\u00e1ter pand\u00eamico foi amplificado em pouco tempo por sua alta infectividade, mesmo em fases assintom\u00e1ticas da doen\u00e7a, fato que levou \u00e0 sua r\u00e1pida dissemina\u00e7\u00e3o.  A emerg\u00eancia da COVID-19, causada pelo coronav\u00edrus da s\u00edndrome respirat\u00f3ria aguda grave 2 (SARS-CoV-2), trouxe desafios cr\u00edticos e sem precedentes globalmente para os sistemas nacionais de sa\u00fade e para a humanidade em geral.  que j\u00e1 carregam uma carga de morbimortalidade consider\u00e1vel para DTN. Dessa forma, a an\u00e1lise do atual contexto de DTN oferece possibilidades relevantes para abordar lacunas do controle da COVID-19, pois representa referencial importante para o progresso na resposta \u00e0s necessidades das popula\u00e7\u00f5es mais vulner\u00e1veis. O sucesso na resposta ao controle da COVID-19, sem estar acompanhado por redu\u00e7\u00e3o da carga de DTN, sinaliza falhas na sustentabilidade dos sistemas nacionais de sa\u00fade para manter esse controle.  \u00c0 medida que a pandemia global da COVID-19 avan\u00e7a, impacta desproporcionalmente cada vez mais as popula\u00e7\u00f5es com elevada vulnerabilidade social,  De fato, a maior preval\u00eancia de comorbidades parece estar relacionada a um pior progn\u00f3stico na coinfec\u00e7\u00e3o.  Desde o surgimento da pandemia causada pelo SARS-CoV-2, o envolvimento cardiovascular tem sido identificado como complica\u00e7\u00e3o frequente da COVID-19.  Entretanto, h\u00e1 ainda poucas evid\u00eancias sobre os efeitos da COVID-19 em pessoas acometidas pela DC.  Alguns estudos indicam que a COVID-19 pode trazer novos desafios relativos \u00e0 garantia de acesso \u00e0 aten\u00e7\u00e3o integral  a essas pessoas, bem como ao necess\u00e1rio desenvolvimento de novas pesquisas no futuro para an\u00e1lise das implica\u00e7\u00f5es da coinfec\u00e7\u00e3o com SARS-CoV-2.  A concomit\u00e2ncia de DC \u00e9 particularmente preocupante por causar, potencialmente, complica\u00e7\u00f5es card\u00edacas, gastrointestinais, neurol\u00f3gicas e outras, ampliando a suscetibilidade \u00e0 COVID-19.  Entretanto, ressalta-se a import\u00e2ncia de se considerarem as diversas formas cl\u00ednicas da doen\u00e7a e os mecanismos fisiopatol\u00f3gicos espec\u00edficos a elas associados.  Assim, n\u00e3o obstante alguma similaridade quanto \u00e0 fisiopatologia, que envolve risco elevado de tromboembolismo na COVID-19 e na cardiomiopatia cr\u00f4nica da doen\u00e7a de Chagas (CCDC), demanda-se cautela quanto \u00e0 recomenda\u00e7\u00e3o de tratamento imediato da DC com f\u00e1rmacos anticoagulantes, restringindo-se o benef\u00edcio potencial dessa conduta a cen\u00e1rios cl\u00ednicos em que uma adequada rela\u00e7\u00e3o de riscos de hemorragiaversustrombose seja individualizadamente favor\u00e1vel ao uso desses f\u00e1rmacos. Tais princ\u00edpios s\u00e3o discutidos de forma pertinente em outro cap\u00edtulo desta diretriz.  Em adi\u00e7\u00e3o, verifica-se que as duas doen\u00e7as apresentam semelhan\u00e7as relativas \u00e0 suscetibilidade e aos fatores de risco, padr\u00f5es moleculares associados ao pat\u00f3geno, reconhecimento de glicosaminoglicanos, processo de inflama\u00e7\u00e3o, hipercoagulabilidade vascular, microtrombose e endoteliopatia, podendo, assim, requerer tratamentos com princ\u00edpios semelhantes.  Embora mais de 80% dos casos de COVID-19 sejam leves ou assintom\u00e1ticos, casos graves t\u00eam sido mais frequentes entre pessoas idosas e com comorbidades, enquanto que, para a DC, pessoas idosas com cardiomiopatia cr\u00f4nica apresentam maior risco de morte, justificado, em parte, pela associa\u00e7\u00e3o com idade ou outras condi\u00e7\u00f5es cr\u00f4nicas, mas tamb\u00e9m pela condi\u00e7\u00e3o de pobreza social.  Alguns estudos t\u00eam apontado para altos n\u00edveis de comorbidades em casos com DC associada a formas graves de COVID-19. \u00c9 importante ressaltar que essas comorbidades tamb\u00e9m refletem a idade mais avan\u00e7ada das popula\u00e7\u00f5es que s\u00e3o especialmente impactadas pela DC e pela COVID-19.  Embora a coinfec\u00e7\u00e3o possa estar associada a maior risco potencial de complica\u00e7\u00f5es, com pior progn\u00f3stico cl\u00ednico, achados de um estudo multic\u00eantrico prospectivo com 37 hospitais em 17 munic\u00edpios de 5 estados brasileiros  indicam n\u00e3o ter havido diferen\u00e7as significativas na apresenta\u00e7\u00e3o cl\u00ednica e nos desfechos de casos com DC em compara\u00e7\u00e3o a controles, a despeito da evid\u00eancia no in\u00edcio do estudo de maior frequ\u00eancia de IC cr\u00f4nica e fibrila\u00e7\u00e3o atrial (FA). Al\u00e9m disso, nesse estudo foi observado n\u00edvel mais baixo de prote\u00edna C reativa entre participantes com DC.  O significativo aumento da pobreza extrema globalmente na \u00faltima d\u00e9cada traz consigo a amea\u00e7a de tornar o acesso \u00e0 sa\u00fade ainda mais cr\u00edtico para pessoas acometidas por DC.  A maior vulnerabilidade social de pessoas acometidas por DC em contexto de pobreza pode ser ainda mais ampliada com a COVID-19, por seus impactos pol\u00edtico-econ\u00f4micos.  Por outro lado, pessoas acometidas pela DC podem ter receio de procurar atendimento por medo de exposi\u00e7\u00e3o \u00e0 COVID-19, retardando a busca de solu\u00e7\u00e3o para complica\u00e7\u00f5es relacionadas \u00e0 doen\u00e7a e ampliando a carga emocional da doen\u00e7a pelas preocupa\u00e7\u00f5es associadas. Acresce-se o cen\u00e1rio de enfraquecimento, desestrutura\u00e7\u00e3o e sobrecarga dos sistemas nacionais de sa\u00fade.  Por outro lado, a desigualdade na express\u00e3o da COVID-19 no pa\u00eds tem sido demarcada, por exemplo, pelo excesso de mortalidade entre negros/pardos em todas as faixas et\u00e1rias dessa popula\u00e7\u00e3o.  Essas disparidades raciais podem ser justificadas por condi\u00e7\u00f5es socioecon\u00f4micas historicamente determinadas, que muitas vezes definem quem \u00e9 capaz de se manter em distanciamento social e evitar a exposi\u00e7\u00e3o ao SARS-CoV-2.  O Brasil \u00e9 um dos pa\u00edses com maior carga de morbimortalidade por COVID-19 e tem se destacado negativamente no cen\u00e1rio internacional pela falta de coordena\u00e7\u00e3o e lideran\u00e7a das a\u00e7\u00f5es de vigil\u00e2ncia e controle da COVID-19.  Verificou-se ainda forte gradiente para o risco de morte por COVID-19 durante os est\u00e1gios iniciais da pandemia, ampliando a vulnerabilidade de \u00e1reas perif\u00e9ricas, onde se encontram comunidades mais vulner\u00e1veis, colocando em risco a capacidade de resposta do sistema de sa\u00fade e aumentando as desigualdades em aten\u00e7\u00e3o \u00e0 sa\u00fade.  A despeito dessas orienta\u00e7\u00f5es, a possibilidade de ocorr\u00eancia de impacto da pandemia por COVID-19 frente ao perfil de morbimortalidade e \u00e0s a\u00e7\u00f5es de vigil\u00e2ncia da doen\u00e7a no pa\u00eds foi levantada como hip\u00f3tese em Boletim Epidemiol\u00f3gico espec\u00edfico do Minist\u00e9rio da Sa\u00fade.  Por interm\u00e9dio da nota informativa n\u00ba 9 de 2020 (CGZV/DEIDT/SVS/MS) foram estabelecidas no Brasil recomenda\u00e7\u00f5es do Minist\u00e9rio da Sa\u00fade para adequa\u00e7\u00f5es das a\u00e7\u00f5es de vigil\u00e2ncia e aten\u00e7\u00e3o \u00e0s pessoas acometidas por DC frente \u00e0 situa\u00e7\u00e3o epidemiol\u00f3gica da COVID-19.  Nesse documento, s\u00e3o trazidas evid\u00eancias que apontam as doen\u00e7as cardiovasculares como fatores de risco cr\u00edticos para maior gravidade da s\u00edndrome cl\u00ednica associada \u00e0 COVID-19. Com base nesses aspectos, ressalta-se o fato de que as pessoas acometidas por DC devam ser consideradas tamb\u00e9m como popula\u00e7\u00e3o com maior risco para pior evolu\u00e7\u00e3o cl\u00ednica da COVID-19, demandando maior cuidado e aten\u00e7\u00e3o pelo SUS no contexto pand\u00eamico.  Naquele mesmo per\u00edodo, foram registrados 125.691 \u00f3bitos por COVID-19, dos quais em 207  havia men\u00e7\u00e3o \u00e0 DC como condi\u00e7\u00e3o que contribuiu para a morte (parte II da Declara\u00e7\u00e3o de \u00d3bito), com maior propor\u00e7\u00e3o nas regi\u00f5es Sudeste e Nordeste. A maioria desses \u00f3bitos ocorreu em pessoas do sexo feminino , de ra\u00e7a/cor parda , com m\u00e9dia de 74 anos de idade  e faixa et\u00e1ria acima de 75 anos .  Ainda em car\u00e1ter preliminar, considerando-se o per\u00edodo de mar\u00e7o a agosto de 2020, aquele boletim epidemiol\u00f3gico indica que foram registrados no pa\u00eds 1.746 \u00f3bitos em que a DC foi inserida como causa b\u00e1sica , dos quais 29 mencionam a COVID-19 ou S\u00edndrome Respirat\u00f3ria Aguda Grave como condi\u00e7\u00e3o que agravou ou contribuiu direta ou indiretamente na cadeia causal do \u00f3bito (partes I e II da Declara\u00e7\u00e3o de \u00d3bito), com maior propor\u00e7\u00e3o nas regi\u00f5es Sudeste e Nordeste. T. cruzie SARS-CoV-2 como importante bin\u00f4mio causal n\u00e3o investigado de morte em regi\u00f5es end\u00eamicas para a DC.  Existem hip\u00f3teses que apontam a coinfec\u00e7\u00e3o A an\u00e1lise de tend\u00eancia temporal regionalizada no pa\u00eds, de 2009 a 2019, revela propens\u00e3o a redu\u00e7\u00e3o estatisticamente significativa quanto ao coeficiente de mortalidade espec\u00edfica pela doen\u00e7a. Entretanto, verificou-se tend\u00eancia de aumento do coeficiente de incid\u00eancia de casos na fase aguda, estatisticamente significativa para a regi\u00e3o Norte; contudo, em 2020, o n\u00famero de casos registrados foi inferior ao previsto.  Esse cen\u00e1rio de redu\u00e7\u00e3o tamb\u00e9m foi verificado em rela\u00e7\u00e3o ao tratamento, avaliado por meio da redu\u00e7\u00e3o da distribui\u00e7\u00e3o do benznidazol, e tamb\u00e9m pela avalia\u00e7\u00e3o da vigil\u00e2ncia entomol\u00f3gica junto a coordena\u00e7\u00f5es estaduais,  indicando poss\u00edvel redu\u00e7\u00e3o da sensibilidade da rede de aten\u00e7\u00e3o e vigil\u00e2ncia em sa\u00fade, provavelmente relacionada ao direcionamento de esfor\u00e7os municipais e estaduais para o enfrentamento da pandemia por COVID-19.  Em termos de diagn\u00f3stico, verificou-se redu\u00e7\u00e3o de 24% no n\u00famero de requisi\u00e7\u00f5es de exames laboratoriais para diagn\u00f3stico da DC que foram processadas nesse per\u00edodo de 2020, em compara\u00e7\u00e3o com a m\u00e9dia verificada de 2017 a 2019.  os relatos e informes de representantes estaduais indicam que em muitos territ\u00f3rios n\u00e3o foi poss\u00edvel realizar, mesmo que parcialmente, as atividades de controle previstas para o ano de 2020.  Mesmo com as orienta\u00e7\u00f5es acerca da necessidade de readapta\u00e7\u00e3o das atividades de vigil\u00e2ncia entomol\u00f3gica no contexto da COVID-19,  isso poder\u00e1 ser ainda mais ominoso no contexto daquelas j\u00e1 afligidas pela CCDC ao se infectarem pelo SARS-CoV-2.  Finalmente, como h\u00e1 evid\u00eancias recentes de que persistam a longo prazo sequelas cardiovasculares em pessoas acometidas pela COVID-19,  como por aqueles onde a DC ainda \u00e9 end\u00eamica,  indigitam a premente necessidade de se adotarem pol\u00edticas abrangentes em termos de sa\u00fade p\u00fablica para controle eficaz da transmiss\u00e3o inter-humanos da infec\u00e7\u00e3o peloT. cruzie se alcan\u00e7ar um n\u00edvel otimizado de atendimento aos indiv\u00edduos j\u00e1 infectados, com foco em oportuniza\u00e7\u00e3o tanto diagn\u00f3stica como terap\u00eautica.  Publica\u00e7\u00f5es recentes, tanto por investigadores e gestores de pa\u00edses n\u00e3o end\u00eamicos T. cruzie por rea\u00e7\u00e3o imune adversa \u00e0 persist\u00eancia parasit\u00e1ria.  A patog\u00eanese da CCDC ainda \u00e9 objeto de intenso debate. Enquanto na fase aguda da DC o intenso parasitismo tissular foi sempre reconhecido como mecanismo essencial, na fase cr\u00f4nica isso n\u00e3o ocorreu e outras hip\u00f3teses patogen\u00e9ticas predominaram durante a segunda metade do s\u00e9culo XX. Foi somente a partir dos anos 2000 que se consolidou a no\u00e7\u00e3o de que a persist\u00eancia parasit\u00e1ria no mioc\u00e1rdio seja o mecanismo primordial tamb\u00e9m para que se instale a CCDC. Isso resgatou o conceito da DC como verdadeira entidade infecciosa e da CCDC como causada por processo inflamat\u00f3rio focal de baixa intensidade, por\u00e9m virtualmente incessante. A agress\u00e3o tissular, causando necrose e fibrose reativa e reparativa, por sua vez, \u00e9 diretamente estimulada pelo Entre outras no\u00e7\u00f5es, deve-se reconhecer que o progn\u00f3stico da CCDC \u00e9 em geral mais ominoso do que o das cardiomiopatias n\u00e3o inflamat\u00f3rias. A identifica\u00e7\u00e3o dos fatores progn\u00f3sticos e dos alvos terap\u00eauticos \u00e9 criticamente dependente desse conhecimento. A lise direta das c\u00e9lulas infectadas \u00e9 relevante principalmente durante a fase aguda da infec\u00e7\u00e3o, quando os parasitas intracelulares s\u00e3o abundantes e a miocardite costuma ser difusa e intensa. J\u00e1 os indiv\u00edduos cronicamente infectados apresentam progress\u00e3o nitidamente diferencial da doen\u00e7a. D\u00e9cadas ap\u00f3s a infec\u00e7\u00e3o, cerca de 60% dos indiv\u00edduos infectados permanecem livres de manifesta\u00e7\u00f5es cl\u00ednicas da doen\u00e7a por toda a vida (est\u00e1gio A - FIDC), 10% desenvolvem doen\u00e7a gastrointestinal e 30% desenvolvem CCDC, que pode apresentar est\u00e1gios B1/B2 (cardiomiopatia menos avan\u00e7ada) ou C/D (cardiopatia grave), conforme ser\u00e1 visto em outro cap\u00edtulo desta diretriz. feedbackpositivo, potencializando os danos inflamat\u00f3rios e mitocondriais, como discutido a seguir.  As principais hip\u00f3teses patog\u00eanicas propostas para explicar o in\u00edcio e a progress\u00e3o da CCDC incluem: 1) danos diretos aos tecidos induzidos por parasitas; 2) danos indiretos inflamat\u00f3rios/imunol\u00f3gicos aos tecidos; 3) dist\u00farbios neurog\u00eanicos; 4) dist\u00farbios microvasculares. A hip\u00f3tese neurog\u00eanica foi embasada na deple\u00e7\u00e3o neuronal intracard\u00edaca e na consequente disautonomia, mas h\u00e1 obst\u00e1culos incontorn\u00e1veis para a postulada cardiopatia \u201cparassimpaticopriva\u201d. As evid\u00eancias em modelos experimentais e na doen\u00e7a humana indicam que os infiltrados inflamat\u00f3rios s\u00e3o os principais causadores de dano ao tecido card\u00edaco. Mas, tamb\u00e9m, evid\u00eancias mais recentes mostram que a suscetibilidade gen\u00e9tica e os danos mitocondriais s\u00e3o partes importantes da patog\u00eanese da CCDC. Foram relatadas les\u00f5es microcirculat\u00f3rias card\u00edacas na CCDC, mas a isquemia microvascular pode ser consequ\u00eancia da a\u00e7\u00e3o de mediadores inflamat\u00f3rios e constituir mecanismo deT. cruziespec\u00edficos que controlam parcialmente o parasitismo, estabelecendo infec\u00e7\u00e3o persistente embora de baixo grau.  Na fase aguda da infec\u00e7\u00e3o, que tem sido investigada mais detalhadamente em modelos murinos, a parasitemia e o parasitismo intenso dos tecidos desencadeiam forte resposta imunol\u00f3gica. Ocorre inicialmente resposta imune inata, logo seguida pela que depende de linf\u00f3citos T citot\u00f3xicos e linf\u00f3citos T produzindo citocinas inflamat\u00f3rias como interferon-gama (IFN-\u03b3) e fator de necrose tumoral alfa (TNF-\u03b1), juntamente com anticorpos anti-T. cruzimostram graus distintos de gravidade de CCDC, caracterizados por altera\u00e7\u00f5es eletrocardiogr\u00e1ficas e ecocardiogr\u00e1ficas, associadas a variados n\u00edveis s\u00e9ricos de TNF-\u03b1 e \u00f3xido n\u00edtrico, sugerindo que varia\u00e7\u00f5es na gen\u00e9tica do hospedeiro possam condicionar a gravidade da doen\u00e7a cr\u00f4nica.  Observa-se que diferentes linhagens de camundongos infectados com a mesma linhagem de Prop\u00f5e-se existir rela\u00e7\u00e3o entre a intensidade da fase aguda e a gravidade da fase cr\u00f4nica da infec\u00e7\u00e3o porT. cruzi. Pacientes com CCDC apresentam miocardite difusa  com fibrose e hipertrofia. A miocardite \u00e9 devida tanto aos linf\u00f3citosT. cruziespec\u00edficos como aos linf\u00f3citos T autoimunes, que produzem grandes quantidades de IFN-\u03b3 e TNF-\u03b1. IFN-\u03b3 desempenha papel patog\u00eanico central na CCDC ao induzir danos celulares por v\u00e1rios mecanismos, enquanto outros mediadores inflamat\u00f3rios tamb\u00e9m atuam relevantemente.  A estimula\u00e7\u00e3o parasit\u00e1ria persistente induz produ\u00e7\u00e3o sist\u00eamica de IFN-\u03b3 e TNF-\u03b1 em indiv\u00edduos com DC cr\u00f4nica, que \u00e9 particularmente intensa naqueles com CCDC em compara\u00e7\u00e3o aos que apresentam a FIDC.  Foram observados efeitos imunol\u00f3gicos sist\u00eamicos significativos no sangue perif\u00e9rico de pacientes com DC cr\u00f4nica, que est\u00e3o associados com as distintas formas cl\u00ednicas. \u00c9 importante notar que diferen\u00e7as qualitativas s\u00e3o claramente observadas nas respostas celulares sist\u00eamicas de pacientes com formas cl\u00ednicas indeterminada e card\u00edaca. Essas diferen\u00e7as est\u00e3o sob a influ\u00eancia de uma rede imunorreguladora de citocinas, que orquestra a resposta imunol\u00f3gica. Enquanto os indiv\u00edduos com a FIDC apresentam perfil imunorregulat\u00f3rio equilibrado e modulado pela produ\u00e7\u00e3o de interleucina (IL)-10,  os pacientes com CCDC apresentam frequ\u00eancia aumentada de CD4+ e CD4-CD8- c\u00e9lulas T produtoras de IFN-\u03b3, assim como de n\u00edveis aumentados de TNF-\u03b1 circulantes no sangue perif\u00e9rico.  Recente revis\u00e3o sobre altera\u00e7\u00f5es imunol\u00f3gicas sist\u00eamicas e espec\u00edficas do cora\u00e7\u00e3o revelou que os pacientes com CCDC apresentam caracter\u00edstico perfil inflamat\u00f3rio de citocinas.  Por outro lado, os pacientes com CCDC apresentam frequ\u00eancias reduzidas de c\u00e9lulas T Th17 circulantes  e de mon\u00f3citos produtores de IL-10,  c\u00e9lulas T reguladoras CD4+CD25+ (Tregs),  bem como n\u00edveis reduzidos de Ebi/IL-27p28  em compara\u00e7\u00e3o a indiv\u00edduos com a FIDC , corroborando o papel patog\u00eanico das c\u00e9lulas T produtoras de IFN-\u03b3. Em contrapartida, a express\u00e3o de RNAm do GATA3, ROR\u03b3T e FoxP3, subconjunto de c\u00e9lulas T que define fatores de transcri\u00e7\u00e3o das popula\u00e7\u00f5es Th1-antagonizante Th2, Th17 e Treg, juntamente com suas assinaturas de citocinas IL-4, IL-13, IL-17, IL-10 e marcadores moleculares (FoxP3 e CTLA4), era baixa ou indetect\u00e1vel.  e as mesmas c\u00e9lulas foram identificadas no tecido card\u00edaco de pacientes com CCDC, juntamente com seus ligantes de quimiocinas . CCL5 e CXCL9 foram as quimiocinas mais expressas e a intensidade da inflama\u00e7\u00e3o mioc\u00e1rdica foi positivamente correlacionada com a express\u00e3o do RNAm de CXCL9.  As c\u00e9lulas T Th1 CCR5+ CXCR3+ produtoras de IFN-\u03b3 s\u00e3o mais abundantes em pacientes com CCDC do que naqueles com a FIDC, T. cruzi, CCL3, CCL4 e CCL5, agindo via CCR1 ou CCR5, controlam a migra\u00e7\u00e3o das c\u00e9lulas T e macr\u00f3fagos para o tecido card\u00edaco, levando \u00e0 les\u00e3o cardiomiocit\u00e1ria, anomalias de condu\u00e7\u00e3o e disfun\u00e7\u00e3o ventricular.  Em conjunto, isso sugere que as quimiocinas quimioatrativas Th1 produzidas localmente desempenhem papel significativo no ac\u00famulo seletivo de c\u00e9lulas T Th1 no cora\u00e7\u00e3o com CCDC. Al\u00e9m disso, indica essencialmente n\u00e3o haver regula\u00e7\u00e3o por c\u00e9lulas T ou citocinas reguladoras no mioc\u00e1rdio infiltrado por Th1 de pacientes com CCDC.  Em modelos animais de CCDC, nas fases aguda e cr\u00f4nica da infec\u00e7\u00e3o pelo Por sofrer pouca regula\u00e7\u00e3o, isso poderia explicar a destrutividade do infiltrado inflamat\u00f3rio, muito provavelmente devido aos danos colaterais excessivos causados pelas c\u00e9lulas T produtoras de IFN-\u03b3. Acredita-se que a a\u00e7\u00e3o n\u00e3o antag\u00f4nica ao IFN-\u03b3 no paciente com CCDC esteja ligada ao fato de que as c\u00e9lulas T produtoras de IL10, Ebi/IL27R e reguladoras, todas capazes de suprimir a produ\u00e7\u00e3o do IFN-\u03b3 e/ou a diferencia\u00e7\u00e3o das c\u00e9lulas T Th1, encontram-se diminu\u00eddas. et al. foram os primeiros a implicar disfun\u00e7\u00e3o mitocondrial mioc\u00e1rdica e estresse oxidativo na patog\u00eanese da CCDC em modelos murinos.  A not\u00e1vel semelhan\u00e7a entre os dist\u00farbios card\u00edacos, digestivos e auton\u00f4micos nas mitocondriopatias ,  bem como o amplo espectro cl\u00ednico da DC sintom\u00e1tica,  sugerem que a patog\u00eanese da CCDC possa ter como componente fundamental a disfun\u00e7\u00e3o mitocondrial.  Wan e do DNA mitocondrial,  assim como outras observa\u00e7\u00f5es (n\u00e3o publicadas) e produ\u00e7\u00e3oin vivode adenosina trifosfato (ATP),  foram descritas no mioc\u00e1rdio do paciente com CCDC.  De fato, o mioc\u00e1rdio na CCDC apresenta sinais de redu\u00e7\u00e3o da atividade mitocondrial e da produ\u00e7\u00e3o de energia. Redu\u00e7\u00e3o do RNA ribossomal mitocondrial  o que poderia contribuir para o pior progn\u00f3stico associado \u00e0 CCDC. A descoberta da associa\u00e7\u00e3o de CCDC com variantes raras de genes mitocondriais, descritas com mais detalhes abaixo neste cap\u00edtulo, corrobora o papel da disfun\u00e7\u00e3o mitocondrial no dano mioc\u00e1rdico do paciente com CCDC e pode ser um mecanismo para perpetua\u00e7\u00e3o da inflama\u00e7\u00e3o e dano cardiomiocit\u00e1rio.  Os n\u00edveis mioc\u00e1rdicos e a atividade das enzimas do metabolismo energ\u00e9tico mitocondrial ATP-sintase e creatina-quinase s\u00e3o ainda mais baixos do que em outras cardiomiopatias,  e na infec\u00e7\u00e3o murina aguda porT. cruzi.  Estudos recentes mostraram a modula\u00e7\u00e3o da express\u00e3o de alguns microRNAs (miRNAs), mol\u00e9culas que controlam especificamente a tradu\u00e7\u00e3o do RNAm, no tecido card\u00edaco de pacientes com CCDC T. cruzigeneticamente deficientes em microRNA-155 tamb\u00e9m apoiam a rela\u00e7\u00e3o do miRNA com o controle da infec\u00e7\u00e3o e a produ\u00e7\u00e3o de citocinas inflamat\u00f3rias.  As descobertas em camundongos infectados com sugeriu a participa\u00e7\u00e3o de fatores gen\u00e9ticos na progress\u00e3o diferencial da doen\u00e7a. Os pacientes com CCDC apresentam resposta inflamat\u00f3ria mais intensa do que aqueles com FIDC, que parecem ter resposta imunol\u00f3gica mais bem regulada.  A verifica\u00e7\u00e3o de que apenas cerca de 30% dos pacientes com DC desenvolvem a cardiomiopatia cr\u00f4nica, bem como a agrega\u00e7\u00e3o familiar de casos de CCDC,  Dada a import\u00e2ncia dos mecanismos inflamat\u00f3rios na patog\u00eanese da CCDC, muitos estudos focaram nos polimorfismos \u201ccomuns\u201d ou frequentes nos genes relacionados \u00e0s respostas inflamat\u00f3rias e imunol\u00f3gicas, que assim acarretariam importantes varia\u00e7\u00f5es na express\u00e3o de citocinas inflamat\u00f3rias e quimiocinas envolvidas na patog\u00eanese da doen\u00e7a. Cada polimorfismo comum ou frequente \u00e9 tipicamente respons\u00e1vel por pequenos efeitos fenot\u00edpicos (cerca de 10% da popula\u00e7\u00e3o/fen\u00f3tipo).  Desses, SNP em 8 genes foram associadas com a gravidade da CCDC: SNP nos genes IL17a, IL18, IL27b/Ebi3, CCR2, CXCL9, CXCL10 e MICA foram mais frequentes entre os pacientes CCDC com disfun\u00e7\u00e3o ventricular esquerda significativa (FEVE < 40%) em compara\u00e7\u00e3o aos demais pacientes com CCDC.  Revis\u00e3o recente revelou 145 estudos de associa\u00e7\u00e3o abordando polimorfismos candidatos em 76 genes, encontrando 62 polimorfismos de nucleot\u00eddeos simples (SNP) de 44 genes a serem associados ao fen\u00f3tipo da CCDC. Genome Wide Association Study), comparando CCDC e FIDC, um em 2013  envolvendo 600 pacientes com DC e outro em 2021 envolvendo 3413 indiv\u00edduos;  apenas esse \u00faltimo revelou uma \u00fanica variante significativa para todo o genoma (p < 10 -8 ) perto do gene SAC3D1.  Foram realizados dois estudos de associa\u00e7\u00e3o do genoma utilizando a t\u00e9cnica GWAS  ocorreu em genes mitocondriais ou relacionados \u00e0 inflama\u00e7\u00e3o e todas as fam\u00edlias estudadas apresentaram pelo menos um gene de variante associada \u00e0 CCDC pertencente a essas vias. Os resultados desse estudo indicaram que a contribui\u00e7\u00e3o gen\u00e9tica para causar CCDC \u00e9 polig\u00eanica e mediada por diversas variantes raras em genes que diferem entre fam\u00edlias, mas que est\u00e3o relacionados com altera\u00e7\u00f5es em mitoc\u00f4ndrias e com inflama\u00e7\u00e3o.  Estudo recente abordou o papel de variantes gen\u00e9ticas raras na progress\u00e3o para CCDC em fam\u00edlias nucleares com m\u00faltiplos casos de DC usando sequenciamento de exomas inteiros.  Os resultados implicam que a disfun\u00e7\u00e3o e inflama\u00e7\u00e3o mitocondrial, processos-chave na fisiopatologia da CCDC, sejam, pelo menos em parte, determinados geneticamente. Isso pode ser dependente de mecanismo de dupla agress\u00e3o. Dessa forma, o IFN-\u03b3 e citocinas pr\u00f3-inflamat\u00f3rias induzidas por infec\u00e7\u00e3o cr\u00f4nica desencadeariam disfun\u00e7\u00e3o mitocondrial e doen\u00e7a cl\u00ednica em pacientes com variantes que causam comprometimento subcl\u00ednico da fun\u00e7\u00e3o mitocondrial em \u00f3rg\u00e3os de alta demanda metab\u00f3lica, como cora\u00e7\u00e3o e c\u00e9lulas neuronais ganglionares mioent\u00e9ricas. Les\u00e3o mitocondrial pode constituir mecanismo de perpetua\u00e7\u00e3o de altera\u00e7\u00f5es inflamat\u00f3rias tissulares visto que h\u00e1 libera\u00e7\u00e3o de componentes internos por mitoc\u00f4ndrias danificadas pela resposta imune inata. A H\u00e1 evid\u00eancias crescentes, no campo tanto cl\u00ednico como experimental, da participa\u00e7\u00e3o das anormalidades microvasculares coron\u00e1rias como mecanismo patog\u00eanico da CCDC. V\u00e1rios estudos indicam que a les\u00e3o mioc\u00e1rdica possa ser consequente a altera\u00e7\u00f5es microvasculares, fundamentalmente associadas a inflama\u00e7\u00e3o e que levam a isquemia e necrose mioc\u00e1rdica, com eventual fibrose reparadora.  Al\u00e9m disso, as fibras mioc\u00e1rdicas nas proximidades das les\u00f5es vasculares apresentavam necrose miocitol\u00edtica, uma les\u00e3o celular intimamente relacionada a isquemia mioc\u00e1rdica.  A primeira evid\u00eancia de que dist\u00farbios da microcircula\u00e7\u00e3o coron\u00e1ria possam participar dos mecanismos de les\u00e3o mioc\u00e1rdica na DC em humanos foi obtida em estudos necrosc\u00f3picos descrevendo altera\u00e7\u00f5es vasculares intensas, com hiperprolifera\u00e7\u00e3o intimal, espessamento parietal e obstru\u00e7\u00e3o de pequenas arter\u00edolas coron\u00e1rias intramurais em cora\u00e7\u00f5es de pacientes com CCDC. et al. descreveram altera\u00e7\u00f5es estruturais intensas da microcircula\u00e7\u00e3o coron\u00e1ria com dilata\u00e7\u00e3o vascular e rarefa\u00e7\u00e3o em cora\u00e7\u00f5es de pacientes com CCDC, que eram diversas das geralmente observadas em pacientes com CMD idiop\u00e1tica.  Em estudo mais recente, Higuchi Assim, as observa\u00e7\u00f5es necrosc\u00f3picas sugerem fortemente a participa\u00e7\u00e3o da isquemia microvascular na g\u00eanese dos focos inflamat\u00f3rios e da miocit\u00f3lise, que levam a fibrose reparadora e que s\u00e3o as caracter\u00edsticas histopatol\u00f3gicas fundamentais da CCDC.  V\u00e1rios estudos tamb\u00e9m mostraram que os defeitos de perfus\u00e3o mioc\u00e1rdica estavam topograficamente relacionados ao comprometimento do movimento da parede regional do VE, ocorrendo em pacientes em fases iniciais da CCDC e sem outras evid\u00eancias de envolvimento card\u00edaco,  sugerindo que a isquemia microvascular seja dist\u00farbio precoce na evolu\u00e7\u00e3o da doen\u00e7a, precedendo a disfun\u00e7\u00e3o ventricular regional e possivelmente relacionado \u00e0 indu\u00e7\u00e3o de hiberna\u00e7\u00e3o ou atordoamento mioc\u00e1rdico. Resultados similares foram obtidos por estudos com doppler-ecocardiografia, mostrando diminui\u00e7\u00e3o da reserva vasodilatadora coron\u00e1ria, um \u00edndice de disfun\u00e7\u00e3o microvascular, em pacientes com FIDC quando comparados a controles normais.  No cen\u00e1rio cl\u00ednico, estudos utilizando cintilografia de perfus\u00e3o mioc\u00e1rdica mostraram elevada preval\u00eancia (30% a 50%) de defeitos perfusionais em pacientes com CCDC e art\u00e9rias coron\u00e1rias angiograficamente normais, sugerindo fortemente a presen\u00e7a de disfun\u00e7\u00e3o microvascular coron\u00e1ria.  Tamb\u00e9m os resultados de estudo retrospectivo longitudinal utilizando cintilografia de perfus\u00e3o mioc\u00e1rdica em pacientes com CCDC mostraram que a isquemia microvascular est\u00e1 topograficamente relacionada com \u00e1reas que, em \u00faltima inst\u00e2ncia, desenvolvem fibrose mioc\u00e1rdica durante a progress\u00e3o da doen\u00e7a. Esses resultados corroboram a hip\u00f3tese de que a isquemia microvascular possa estar diretamente envolvida no mecanismo que leva \u00e0 fibrose regional e \u00e0 progress\u00e3o da disfun\u00e7\u00e3o sist\u00f3lica do VE na CCDC. T. cruzimostraram estreita rela\u00e7\u00e3o topogr\u00e1fica entre defeitos de perfus\u00e3o mioc\u00e1rdica em repouso, utilizando cintilografia de perfus\u00e3o mioc\u00e1rdica de alta resolu\u00e7\u00e3oin vivo, com inflama\u00e7\u00e3o histologicamente verificada e disfun\u00e7\u00e3o sist\u00f3lica ventricular esquerda regional/global.  Al\u00e9m disso, a tomografia computadorizada por emiss\u00e3o de p\u00f3sitrons (PET/TC) com  F-fluordesoxiglicose (  F-FDG) confirmou que as regi\u00f5es com hipoperfus\u00e3o mioc\u00e1rdica em repouso correspondiam \u00e0s \u00e1reas com mioc\u00e1rdio vi\u00e1vel e inflama\u00e7\u00e3o em outra investiga\u00e7\u00e3o nesse modelo experimental.  Estudos mais recentes em modelo experimental de hamsters s\u00edrios cronicamente infectados porT. cruzimostrou que o uso prolongado do dipiridamol, um agente vasodilatador da microcircula\u00e7\u00e3o coron\u00e1ria, estava associado \u00e0 redu\u00e7\u00e3o significativa dos defeitos de perfus\u00e3o mioc\u00e1rdica de repouso, apoiando indiretamente a presen\u00e7a de mioc\u00e1rdio vi\u00e1vel, mas hipoperfundido, causado pela disfun\u00e7\u00e3o da microcircula\u00e7\u00e3o coron\u00e1ria na CCDC experimental.  Ainda outro estudo recente no mesmo modelo de hamsters cronicamente infectados pelo 2. Les\u00f5es endoteliais causadas diretamente pela agress\u00e3o parasit\u00e1ria;  3. Altera\u00e7\u00f5es funcionais e estruturais induzidas por subst\u00e2ncias secretadas pelo infiltrado inflamat\u00f3rio no tecido mioc\u00e1rdico pr\u00f3ximo aos microvasos coron\u00e1rios, principalmente endotelina e citocinas. Esse mecanismo tardio \u00e9 ainda apoiado por estudos que evidenciam que as altera\u00e7\u00f5es da inflama\u00e7\u00e3o mioc\u00e1rdica est\u00e3o associadas \u00e0 ocorr\u00eancia deplugsplaquet\u00e1rios, \u00e0 prolifera\u00e7\u00e3o obstrutiva da \u00edntima vascular e a espasmo microarteriolar.  Os mecanismos potencialmente envolvidos na g\u00eanese de disfun\u00e7\u00e3o microvascular coronariana na CCDC s\u00e3o: 1. Altera\u00e7\u00f5es funcionais na \u00e1rvore coron\u00e1ria, com aumento da vasorreatividade e espasmo dos pequenos ramos arteriais intramurais;  Essas descobertas foram corroboradas por estudos em animais experimentalmente infectados com oT. cruzi, que demonstraram parasitismo neuronal card\u00edaco associado com periganglionite e anormalidades degenerativas em c\u00e9lulas de Schwann e fibras nervosas.  Importante enfatizar que essa despopula\u00e7\u00e3o neural tamb\u00e9m acomete os g\u00e2nglios intramurais de v\u00e1rios \u00f3rg\u00e3os do sistema digest\u00f3rio, entre os quais avultam o es\u00f4fago e o c\u00f3lon, sendo esse fato claramente incriminado na fisiopatologia do megaes\u00f4fago e do megac\u00f3lon da DC.  A denerva\u00e7\u00e3o auton\u00f4mica card\u00edaca \u00e9 caracter\u00edstica proeminente da CCDC e foi descrita pela primeira vez em estudos de aut\u00f3psia em humanos mostrando intenso despovoamento neuronal intramural, superior ao observado em qualquer outra doen\u00e7a cardiovascular.  H\u00e1 tamb\u00e9m ind\u00edcios de que o dano pode prosseguir na fase cr\u00f4nica devido a inflama\u00e7\u00e3o localizada.  Postulou-se que a despopula\u00e7\u00e3o neuronal na CCDC ocorra durante a fase aguda da infec\u00e7\u00e3o, secund\u00e1ria ao parasitismo direto dos neur\u00f4nios, degenera\u00e7\u00e3o causada pela inflama\u00e7\u00e3o periganglionar e rea\u00e7\u00e3o autoimune antineuronal.  Pacientes com CCDC apresentam priva\u00e7\u00e3o da a\u00e7\u00e3o inibit\u00f3ria t\u00f4nica do sistema parassimp\u00e1tico no n\u00f3 sinusal e falta do mecanismo vagalmente mediado para responder com bradicardia r\u00e1pida ou taquicardia a mudan\u00e7as transit\u00f3rias na press\u00e3o sangu\u00ednea ou no retorno venoso.  A disautonomia em pacientes com CCDC pode ser detectada antes do desenvolvimento da disfun\u00e7\u00e3o ventricular, bem como em est\u00e1gio precoce da fase cr\u00f4nica e mesmo nas formas indeterminada e digestiva da DC.  Diversas anormalidades funcionais do controle auton\u00f4mico reflexo da frequ\u00eancia card\u00edaca (FC) em pacientes com CCDC foram descritas como consequ\u00eancia da denerva\u00e7\u00e3o auton\u00f4mica card\u00edaca anatomicamente detectada.  I-MIBG) foi empregada em pacientes com CD para fornecer informa\u00e7\u00f5es precisas sobre a integridade das fibras nervosas simp\u00e1ticas na intimidade do mioc\u00e1rdio ventricular esquerdo.  Nesse estudo, 37 pacientes foram investigados com imageamento por  I-MIBG e os resultados foram correlacionados com a perfus\u00e3o mioc\u00e1rdica e a perda regional de mobilidade parietal do VE. Defeitos de capta\u00e7\u00e3o de  I-MIBG foram observados na maioria dos pacientes: em 33% daqueles sem evid\u00eancia de cardiopatia ao ECG e ECO e em 77% daqueles com dist\u00farbio regional da movimenta\u00e7\u00e3o parietal ventricular. Al\u00e9m disso, os pacientes com disfun\u00e7\u00f5es ventriculares mais graves tinham tamb\u00e9m maior preval\u00eancia de defeitos de capta\u00e7\u00e3o do  I-MIBG (92%). Notavelmente, havia n\u00edtida correla\u00e7\u00e3o topogr\u00e1fica entre \u00e1reas de denerva\u00e7\u00e3o simp\u00e1tica mioc\u00e1rdica, defeitos de perfus\u00e3o mioc\u00e1rdica e anormalidades parietais segmentares do VE.  Mais recentemente, a cintilografia mioc\u00e1rdica com meta-iodo-benzil-guanidina marcado com iodo-123  e derrame peric\u00e1rdico. Tais altera\u00e7\u00f5es costumam ser autolimitadas em curso de poucas semanas, n\u00e3o causando, em geral, sequelas clinicamente manifestas.  A fisiopatologia essencial da CDC pode ser assim resumidamente descrita: na fase aguda, a grande maioria dos indiv\u00edduos infectados peloT. cruziprovoca, direta ou indiretamente, no tecido especializado de condu\u00e7\u00e3o, no mioc\u00e1rdio contr\u00e1til e no sistema auton\u00f4mico intramural.  J\u00e1 o dano card\u00edaco na CCDC resulta das altera\u00e7\u00f5es fundamentais  que o O frequente comprometimento do n\u00f3 sinusal, do n\u00f3 atrioventricular e do feixe de His, por altera\u00e7\u00f5es inflamat\u00f3rias, degenerativas e fibr\u00f3ticas, leva \u00e0 disfun\u00e7\u00e3o sinusal e a bloqueios variados atrioventriculares e intraventriculares. Por serem estruturas mais individualizadas, o ramo direito e o fasc\u00edculo anterior-superior esquerdo s\u00e3o mais vulner\u00e1veis e mais frequentemente lesados. Focos inflamat\u00f3rios e \u00e1reas de fibrose no mioc\u00e1rdio ventricular, especialmente em regi\u00f5es apical, posterior-lateral e inferior-basal, podem produzir altera\u00e7\u00f5es eletrofisiol\u00f3gicas e favorecer o aparecimento de reentrada, principal mecanismo eletrofisiol\u00f3gico das taquiarritmias ventriculares malignas, que acarretam morte s\u00fabita mesmo em pacientes sem IC pregressa e sem grave disfun\u00e7\u00e3o sist\u00f3lica de VE.  Outra consequ\u00eancia bastante comum das les\u00f5es mioc\u00e1rdicas \u00e9 a disfun\u00e7\u00e3o biventricular, caracter\u00edstica da CCDC. Inicialmente, h\u00e1 comprometimento regional, assemelhando-se ao que ocorre na cardiopatia por obstru\u00e7\u00e3o coron\u00e1ria, mas, paulatinamente, verifica-se dilata\u00e7\u00e3o e hipocinesia generalizada, em geral de ambos os ventr\u00edculos, conferindo padr\u00e3o hemodin\u00e2mico de CMD \u00e0 CCDC. Em fases mais avan\u00e7adas da hist\u00f3ria natural, observa-se dilata\u00e7\u00e3o card\u00edaca global e not\u00e1vel aumento da massa do cora\u00e7\u00e3o, o que se deve \u00e0 combina\u00e7\u00e3o de hipertrofia mioc\u00e1rdica e fibrose em graus vari\u00e1veis de paciente a paciente.  Desde as fases mais precoces, dissinergias ou aneurismas ventriculares predisp\u00f5em a complica\u00e7\u00f5es tromboemb\u00f3licas. Em est\u00e1gios avan\u00e7ados, a dilata\u00e7\u00e3o global, a estase venosa e a FA s\u00e3o fatores adicionais que propiciam a forma\u00e7\u00e3o de trombos e a consequente emboliza\u00e7\u00e3o pulmonar e sist\u00eamica, como no sistema nervoso central, onde provocam o acidente vascular cerebral (AVC). Esse aspecto confere \u00e0 CCDC, al\u00e9m das predominantes caracter\u00edsticas de provocar arritmias malignas e IC refrat\u00e1ria, a de ser precipuamente embolizante tanto no circuito pulmonar como em diversos \u00f3rg\u00e3os sist\u00eamicos, com infartos renais, espl\u00eanicos, mesent\u00e9ricos ou nas art\u00e9rias de membros, por exemplo.  Tais caracter\u00edsticas da fisiopatologia pr\u00f3pria da CCDC podem ser entendidas, em grande parte, como consequentes a importantes mecanismos patog\u00eanicos, como os abordados no cap\u00edtulo espec\u00edfico da patog\u00eanese, e com \u00eanfase adicional nos aspectos descritos a seguir. T. cruzi, tem sua hist\u00f3ria natural dividida em fases aguda e cr\u00f4nica.  A fase aguda \u00e9 usualmente oligossintom\u00e1tica e com sintomas inespec\u00edficos, mas pode cursar com sintomas mais expressivos em cerca de 5-10% dos casos, quando h\u00e1 intensa parasitemia,  acompanhada por febre e les\u00e3o no local de inocula\u00e7\u00e3o do pat\u00f3geno, e se complicar por meningoencefalite, miocardite, entre outras manifesta\u00e7\u00f5es.  A DC, mol\u00e9stia infecto-parasit\u00e1ria causada pelo protozo\u00e1rio O restante dos pacientes cronicamente infectados desenvolve as formas determinadas, com acometimento card\u00edaco e/ou digestivo.  Cerca de quatro a oito semanas ap\u00f3s a infec\u00e7\u00e3o, quando a parasitemia cai para n\u00edveis indetect\u00e1veis e os sintomas da fase aguda desaparecem, surge a fase cr\u00f4nica, que costuma durar v\u00e1rias d\u00e9cadas. Na fase cr\u00f4nica, cerca de 60-70% dos indiv\u00edduos n\u00e3o apresentam sintomas e os exames complementares de rotina, relacionados ao cora\u00e7\u00e3o e ao aparelho digestivo, n\u00e3o demonstram altera\u00e7\u00f5es. Quando isso ocorre, configura-se para tais indiv\u00edduos a FIDC. pelo T. cruziem si), desempenham papel fundamental no processo.  Desde a fase aguda, a DC tem fisiopatologia multifatorial e os mecanismos imunol\u00f3gicos, associados aos inflamat\u00f3rios prim\u00e1rios , que v\u00e3o desencadear intensa resposta inflamat\u00f3ria visando a controlar a parasitemia. A ativa\u00e7\u00e3o da imunidade inata gera intensa secre\u00e7\u00e3o de citocinas pr\u00f3-inflamat\u00f3rias, como o TNF-\u03b1, IFN-\u03b3 e diversas interleucinas, em especial IL-10.  Essa intensa resposta inflamat\u00f3ria pela ativa\u00e7\u00e3o das c\u00e9lulas de imunidade inata e produ\u00e7\u00e3o de mediadores pr\u00f3-inflamat\u00f3rios, apesar de ser decisiva para controlar a infec\u00e7\u00e3o, contribui para provocar les\u00e3o direta dos cardiomi\u00f3citos - tamb\u00e9m agredidos pelo usualmente consp\u00edcuo parasitismo tissular. Esse conjunto fisiopatol\u00f3gico configura a t\u00edpica miocardite difusa da fase aguda da DC, que, na maioria dos casos, tem curso benigno e autolimitado.  Na fase aguda, ocorre exposi\u00e7\u00e3o das mol\u00e9culas de superf\u00edcie doT. cruzidesencadeiam a resposta imune humoral e celular, com ativa\u00e7\u00e3o dos linf\u00f3citos B e T. Inicia-se, assim, a fase cr\u00f4nica na grande maioria dos pacientes que n\u00e3o conseguiram a elimina\u00e7\u00e3o total do parasita nessa janela de oportunidade da fase aguda.  Ap\u00f3s a fase de intensa atividade inflamat\u00f3ria, ocasionando redu\u00e7\u00e3o da parasitemia e do parasitismo tissular, os macr\u00f3fagos e as c\u00e9lulas dendr\u00edticas que fagocitaram o e o reconhecimento cruzado por c\u00e9lulas T CD4+ de ant\u00edgenos doT. cruzie de sequ\u00eancias de amino\u00e1cidos existentes na miosina card\u00edaca constituem aspectos importantes envolvidos na fisiopatologia da disfun\u00e7\u00e3o mioc\u00e1rdica durante a fase cr\u00f4nica.  A presen\u00e7a do DNA do parasita no mioc\u00e1rdio T.cruzide rea\u00e7\u00e3o cruzada com o cora\u00e7\u00e3o aos linf\u00f3citos T CD4+, que migram para o cora\u00e7\u00e3o produzindo citocinas inflamat\u00f3rias que levam a maior recrutamento e ativa\u00e7\u00e3o de c\u00e9lulas do sistema imune, desencadeando rea\u00e7\u00e3o de hipersensibilidade tardia. Dentre essas citocinas no infiltrado inflamat\u00f3rio, TNF-\u03b1 e IFN-\u03b3 est\u00e3o notadamente aumentados nos pacientes com CCDC.  Quanto \u00e0 resposta imune celular, demonstrou-se que macr\u00f3fagos infectados apresentam ant\u00edgenos de Estudo recente comparou diretamente a subpopula\u00e7\u00e3o linfocit\u00e1ria-T em indiv\u00edduos com CCDC e com CMD idiop\u00e1tica, evidenciando diferen\u00e7a n\u00edtida quanto ao perfil imunorregulador e maior ativa\u00e7\u00e3o imunol\u00f3gica na CCDC, apesar de serem duas condi\u00e7\u00f5es com caracter\u00edsticas hemodin\u00e2micas similares.  Diversos s\u00e3o os fatores implicados na etiopatogenia da DC no cora\u00e7\u00e3o, mas, independentemente dos mecanismos primordiais de agress\u00e3o tissular, a via final comum \u00e9 constitu\u00edda pelo intenso infiltrado inflamat\u00f3rio e a fibrose mioc\u00e1rdica reativa e reparativa. A desorganiza\u00e7\u00e3o estrutural, geom\u00e9trica e funcional do cora\u00e7\u00e3o \u00e9 resultado essencial da necrose mioc\u00e1rdica e consequente reposi\u00e7\u00e3o por tecido fibr\u00f3tico, agredindo o conte\u00fado perivascular e intersticial, importantes marcadores histopatol\u00f3gicos na DC.  Tais altera\u00e7\u00f5es s\u00e3o suficientes para causar dilata\u00e7\u00e3o e consequente disfun\u00e7\u00e3o contr\u00e1til biventricular, sendo a fibrose mioc\u00e1rdica de grau muito mais intenso quando comparada \u00e0 de outras cardiomiopatias. Mecanismos complexos, como descritos, ativam cascata de resposta celular e molecular, intensificando a resposta inflamat\u00f3ria, o estresse oxidativo e a perda progressiva de cardiomi\u00f3citos por necrose e/ou apoptose, al\u00e9m de promover a sobrecarga e ulterior disfun\u00e7\u00e3o do mioc\u00e1rdio remanescente.  Relatou-se que tais altera\u00e7\u00f5es s\u00e3o mais consp\u00edcuas em pacientes com a DC, comparativamente ao que ocorre, em menor grau, em outras cardiomiopatias.  Todavia, a despeito de constitu\u00edrem aspecto dos mais marcantes na fisiopatologia da DC, o real papel etiopatog\u00eanico dessas altera\u00e7\u00f5es, inclusive as descritas no plexo intertruncal card\u00edaco, permanece imerso em incertezas.  Altera\u00e7\u00f5es anatomopatol\u00f3gicas e funcionais do sistema nervoso auton\u00f4mico foram descritas  em humanos e animais de experimenta\u00e7\u00e3o. T. cruzi, altera\u00e7\u00f5es como ganglionite, periganglionite, neurite e perineurite acarretam redu\u00e7\u00e3o acentuada da densidade ganglionar e despovoamento neural em modelos animais experimentais  e em pacientes com a DC.  Postula-se, com base em estudos de modelos experimentais, que essas altera\u00e7\u00f5es anatomopatol\u00f3gicas no plexo intertruncal do cora\u00e7\u00e3o ocorram predominantemente durante a fase aguda da infec\u00e7\u00e3o,  mas que continuem na fase cr\u00f4nica,  mesmo que com menor intensidade. Tais altera\u00e7\u00f5es decorrem de 4 fatores, atuando isoladamente ou em combina\u00e7\u00e3o: parasitismo direto de neur\u00f4nios,  intenso processo inflamat\u00f3rio periganglionar,  rea\u00e7\u00e3o antineural autoimune  e disfun\u00e7\u00e3o microvascular periganglionar.  Diretamente dependentes da infec\u00e7\u00e3o pelo Al\u00e9m disso, reinerva\u00e7\u00e3o simp\u00e1tica foi relatada em humanos durante a fase cr\u00f4nica da DC ap\u00f3s procedimentos como transplante card\u00edaco (TC)  e terapia com c\u00e9lulas-tronco.  A agress\u00e3o \u00e0s estruturas auton\u00f4micas pode ser parcialmente compensada, pois os neur\u00f4nios auton\u00f4micos mant\u00eam, dentro de limites, certa capacidade de recupera\u00e7\u00e3o funcional.  V\u00e1rios testes fisiol\u00f3gicos e farmacol\u00f3gicos evidenciam respostas funcionais anormais, coerentes com essa hip\u00f3tese fisiopatol\u00f3gica.  No entanto, a restaura\u00e7\u00e3o das jun\u00e7\u00f5es neuroefetoras funcionais, devido \u00e0 regenera\u00e7\u00e3o axonal durante a fase cr\u00f4nica, \u00e9 desorganizada, aleat\u00f3ria e incompleta. A inerva\u00e7\u00e3o parassimp\u00e1tica apresenta comportamento an\u00e1logo: ocorre destrui\u00e7\u00e3o acentuada das fibras nervosas, com diminui\u00e7\u00e3o dos n\u00edveis de acetilcolina card\u00edaca durante a fase aguda, seguida de funcional restabelecimento de forma desorganizada, aleat\u00f3ria e incompleta durante a fase cr\u00f4nica.  avan\u00e7ou-se inicialmente a teoria de que no cora\u00e7\u00e3o se instalaria uma cardiopatia \u201cparassimpaticopriva\u201d ou, em outros termos, haveria uma verdadeira \u201ccardioneuropatia induzida por excesso relativo n\u00e3o antagonizado de catecolaminas\u201d.  De acordo com essa teoria fisiopatol\u00f3gica, o cora\u00e7\u00e3o, desprotegido pela aus\u00eancia do efeito moderador parassimp\u00e1tico, estaria sujeito ao estresse de intensa estimula\u00e7\u00e3o t\u00f3xica do sistema adren\u00e9rgico.  Como a despopula\u00e7\u00e3o neuronal ocorre predominantemente em g\u00e2nglios intramurais parassimp\u00e1ticos do cora\u00e7\u00e3o e tamb\u00e9m dos plexos mient\u00e9ricos,  Entretanto, v\u00e1rias evid\u00eancias dificultam a comprova\u00e7\u00e3o de que uma \u201ccardioneuropatia induzida por catecolaminas\u201d contribua de forma decisiva para a patog\u00eanese na forma card\u00edaca da DC. Por outro lado, \u00e9 virtualmente imposs\u00edvel descartar a possibilidade de que esse mecanismo n\u00e3o esteja envolvido no processo. Mais importante ainda, haveria ind\u00edcios de que a via vagal-colin\u00e9rgica desempenha papel fundamental direto na preven\u00e7\u00e3o do envolvimento card\u00edaco que ocorre na DC.  Al\u00e9m disso, no n\u00edvel mioc\u00e1rdico, a denerva\u00e7\u00e3o simp\u00e1tica tamb\u00e9m \u00e9 descrita em estudos de cintilografia card\u00edaca com I-MIBG.  Os dist\u00farbios de capta\u00e7\u00e3o deste radiotra\u00e7ador, que reflete a integridade adren\u00e9rgica nesse n\u00edvel ventricular, tendem a recrudescer \u00e0 medida que a doen\u00e7a progride.  Tais investiga\u00e7\u00f5es evidenciam forte associa\u00e7\u00e3o entre \u00e1reas de denerva\u00e7\u00e3o simp\u00e1tica, altera\u00e7\u00f5es da mobilidade parietal e hipoperfus\u00e3o mioc\u00e1rdica em muitos pacientes, contribuindo para a instala\u00e7\u00e3o de arritmias potencialmente fatais. Em conjunto, esses estudos em humanos e em modelo experimental de infec\u00e7\u00e3o peloT. cruzino hamster s\u00edrio sugerem que a denerva\u00e7\u00e3o auton\u00f4mica simp\u00e1tica e a disfun\u00e7\u00e3o microvascular estejam intimamente relacionadas e atuantes nos est\u00e1gios iniciais da CCDC.  Entre as dificuldades antepostas \u00e0 teoria \u201cparassimpaticopriva\u201d inclui-se a constata\u00e7\u00e3o de que, embora a disfun\u00e7\u00e3o vagal seja predominante, h\u00e1 concomitante atenua\u00e7\u00e3o da regula\u00e7\u00e3o adren\u00e9rgica do cronotropismo card\u00edaco mediado pelo n\u00f3 sinusal.  Assim, observou-se atenua\u00e7\u00e3o da citotoxicidade de linf\u00f3citos T pela estimula\u00e7\u00e3o colin\u00e9rgico-muscar\u00ednica, postulando-se vias de sinais aferentes e eferentes que comporiam um arco, o reflexo \u201cneuroimune\u201d ou \u201cinflamat\u00f3rio\u201d.  Aspectos adicionais relacionados com a complexa fisiopatologia disauton\u00f4mica observada na DC envolvem a chamada via anti-inflamat\u00f3ria colin\u00e9rgica. A base conceitual aqui envolvida reside em evid\u00eancias de que o processo inflamat\u00f3rio instalado na DC influencia e \u00e9 influenciado pelo equil\u00edbrio auton\u00f4mico mediado pelo sistema imunol\u00f3gico.  No contexto da DC, levanta-se a hip\u00f3tese de que a depress\u00e3o do t\u00f4nus parassimp\u00e1tico card\u00edaco poderia contribuir para exacerbar a inflama\u00e7\u00e3o durante a fase cr\u00f4nica, uma concep\u00e7\u00e3o fisiopatol\u00f3gica que remonta aos prim\u00f3rdios das investiga\u00e7\u00f5es sobre a DC.  De acordo com essa vis\u00e3o conceitual, os sistemas nervoso e imunol\u00f3gico comunicam-se de forma bidirecional usando essa intera\u00e7\u00e3o como mediadora de citocinas e neurotransmissores comuns a ambos. A via eferente do sistema nervoso central atuaria no sistema imunol\u00f3gico atrav\u00e9s de seu componente parassimp\u00e1tico, compondo a chamada via anti-inflamat\u00f3ria colin\u00e9rgica. O sistema parassimp\u00e1tico inerva os \u00f3rg\u00e3os do sistema imunol\u00f3gico e seu mediador, a acetilcolina, atua sobre as c\u00e9lulas do mesmo, especialmente em macr\u00f3fagos, por meio da ativa\u00e7\u00e3o do receptor de acetilcolina.  Postula-se que tais anticorpos sejam resultantes do mimetismo antig\u00eanico ,  sendo plaus\u00edvel conceber que tais dist\u00farbios mediados por autoanticorpos circulantes possam conferir caracter\u00edsticas particulares \u00e0 disautonomia da DC, entre as outras afec\u00e7\u00f5es neuronais.  Os mecanismos que induzem disfun\u00e7\u00e3o auton\u00f4mica na DC incluem produ\u00e7\u00e3o de autoanticorpos circulantes . conundrum\u201d de porque aproximadamente 30% dos indiv\u00edduos infectados desenvolvem a CCDC, enquanto o restante permanece assintom\u00e1tico e sem manifesta\u00e7\u00f5es cl\u00ednicas por toda a vida.  O desenvolvimento de uma doen\u00e7a infecciosa \u00e9 usualmente fen\u00f4meno complexo relacionado a v\u00e1rios fatores ambientais, do pat\u00f3geno infectante e do hospedeiro. Assim, a avalia\u00e7\u00e3o das caracter\u00edsticas gen\u00e9ticas do hospedeiro e do pat\u00f3geno poder\u00e1 contribuir decisivamente para que se decifre o \u201cT. cruzireconhece sete unidades discretas de tipagem (DTU), TcI-TcVI e Tcbat.  Essa diversidade gen\u00e9tica constitui, em ess\u00eancia, alvo potencial de inova\u00e7\u00f5es a serem conseguidas com novos f\u00e1rmacos tripanocidas.  A diversidade gen\u00e9tica doin vitroevidenciou que, a despeito de existirem ind\u00edcios preliminares de relevantes diferen\u00e7as na sensibilidade do parasito ao tratamento etiol\u00f3gico, h\u00e1 consider\u00e1vel heterogeneidade de resultados, mesmo considerando-se apenas estudos relativos \u00e0 sensibilidade das diversas DTU doT. cruzia um \u00fanico tripanocida, o benznidazol, impossibilitando a identifica\u00e7\u00e3o precisa de cepas parasit\u00e1rias mais e menos sens\u00edveis ao tratamento.  Recentes pesquisas indicam que as cepas do parasita detectadas em pacientes, independentemente da apresenta\u00e7\u00e3o cl\u00ednica, refletem as principais DTU circulantes nos ciclos de transmiss\u00e3o dom\u00e9stica de uma determinada regi\u00e3o. Recente revis\u00e3o sistem\u00e1tica e meta-an\u00e1lise de investiga\u00e7\u00f5esT. cruzie da distribui\u00e7\u00e3o geogr\u00e1fica diferencial das DTU em humanos, verificam-se varia\u00e7\u00f5es regionais na sensibilidade dos testes sorol\u00f3gicos, acarretando potenciais implica\u00e7\u00f5es na resposta \u00e0s op\u00e7\u00f5es de tratamento parasiticida.  Em v\u00e1rios estudos de micro surtos com parasitos transmitidos oralmente, cepas silvestres est\u00e3o implicadas. Como consequ\u00eancia das diferen\u00e7as genot\u00edpicas e fenot\u00edpicas das cepas de Tais caracter\u00edsticas genot\u00edpicas foram recentemente sumarizadas para aclarar suas potenciais associa\u00e7\u00f5es com manifesta\u00e7\u00f5es cl\u00ednicas da DC, ressaltando-se que persistem significativas incertezas de conhecimento e relevantes desafios nessas linhas de pesquisa.  De forma similar, estudos de polimorfismo gen\u00e9tico focalizam caracter\u00edsticas do hospedeiro que influenciam no desenvolvimento e na gravidade das apresenta\u00e7\u00f5es cl\u00ednicas. Nesse contexto, os SNP s\u00e3o definidos quando pelo menos dois nucleot\u00eddeos alternativos ocorrem no genoma em frequ\u00eancias apreci\u00e1veis . Os SNP exibem heran\u00e7a mendeliana e s\u00e3o usados como marcadores gen\u00e9ticos. T. cruzi. O polimorfismo do TNF figura entre os mais estudados na DC. No Brasil, relatou-se redu\u00e7\u00e3o de sobrevida de pacientes em que se encontrava o alelo TNF-308A ou do microssat\u00e9lite TNFa2,  mas n\u00e3o se comprovou associa\u00e7\u00e3o entre o polimorfismo do TNF-308 e as apresenta\u00e7\u00f5es cl\u00ednicas da DC.  De maneira an\u00e1loga, outra investiga\u00e7\u00e3o em pacientes peruanos, comparando aqueles com DCversusindiv\u00edduos controles sem infec\u00e7\u00e3o peloT. cruzi, n\u00e3o evidenciou maior associa\u00e7\u00e3o dos polimorfismo -308, -244 e -238 com a DC.  Diversas pesquisas foram desenvolvidas avaliando o polimorfismo gen\u00e9tico humano e incluindo correla\u00e7\u00f5es com elementos da resposta imune, adaptativa e de regula\u00e7\u00e3o, durante a infec\u00e7\u00e3o pelo Em contraposi\u00e7\u00e3o ao descrito para mediadores relacionados ao perfil imunol\u00f3gico, avalia\u00e7\u00e3o gen\u00e9tica relacionada ao sistema da enzima de convers\u00e3o da angiotensina evidencia algumas discord\u00e2ncias, mas o gen\u00f3tipo DD tem sido associado com maior risco de IC e mortalidade na doen\u00e7a mioc\u00e1rdica de etiologia isqu\u00eamica.  J\u00e1 em duas popula\u00e7\u00f5es distintas com DC, incluindo uma brasileira, n\u00e3o foram observadas associa\u00e7\u00f5es v\u00e1lidas quanto a esses polimorfismos.  No entanto, em outra popula\u00e7\u00e3o do nordeste brasileiro, relatou-se maior preval\u00eancia do polimorfismo I/D em pacientes com IC em compara\u00e7\u00e3o a pacientes com DC assintom\u00e1ticos.  Essas discrep\u00e2ncias podem dever-se a que fen\u00f3tipos finais sejam vistos na depend\u00eancia de fatores ambientais,  tornando necess\u00e1rias grandes amostras para se demonstrar efeitos dos genes envolvidos em tra\u00e7os complexos, como as vigentes em s\u00edndromes cl\u00ednicas complicadas, como a IC de etiologia da DC.  Em outro estudo de coorte, na IC por cardiomiopatia idiop\u00e1tica, demonstrou-se que o gen\u00f3tipo DD mantinha-se como preditor de mortalidade.  Mas recente meta-an\u00e1lise revelou a associa\u00e7\u00e3o do genoma com o desenvolvimento de CCDC em posi\u00e7\u00e3o rs2458298, pr\u00f3ximo ao gene SAC3D1, e indigitou-se a variabilidade gen\u00e9tica do hospedeiro como fator de suscetibilidade ao desenvolvimento da CCDC ap\u00f3s a infec\u00e7\u00e3o peloT. cruzi.  Estudos mais recentes focalizando aspectos gen\u00e9ticos e utilizando a tecnologia GWAS j\u00e1 envolvem amostras de grande amplitude e podem gerar informa\u00e7\u00f5es mais consistentes e relevantes. Por exemplo, anteriormente, n\u00e3o foram os SNP altamente associados com a CCDC. T. cruzi,com potenciais implica\u00e7\u00f5es fisiopatol\u00f3gicas e terap\u00eauticas.  Na fase aguda da infec\u00e7\u00e3o, a ades\u00e3o e a penetra\u00e7\u00e3o do parasito nas c\u00e9lulas do hospedeiro ocorrem por meio de lecitinas que se ligam a res\u00edduos de carboidratos existentes na membrana da c\u00e9lula hospedeira, principalmente o \u00e1cido si\u00e1lico. Revis\u00e3o recente sobre fam\u00edlia de prote\u00ednas humanas ligantes de galactos\u00eddeos, denominadas galectinas, advoga por sua atua\u00e7\u00e3o significante na imunomodula\u00e7\u00e3o inata e adaptativa \u00e0 infec\u00e7\u00e3o pelo Formas tripomastigotas transformam-se no interior das c\u00e9lulas do hospedeiro em formas amastigotas, mas, enquanto as c\u00e9lulas parasitadas se mant\u00eam \u00edntegras, n\u00e3o se observa rea\u00e7\u00e3o inflamat\u00f3ria local. Quando a c\u00e9lula parasitada se rompe, h\u00e1 libera\u00e7\u00e3o das formas epi, tripo e amastigotas do parasito, \u00edntegras ou degeneradas, bem como de componentes celulares que atuam como imun\u00f3genos  no meio extracelular, estimulando a presen\u00e7a de mediadores inflamat\u00f3rios, que causam vasodilata\u00e7\u00e3o e aumento da permeabilidade vascular, fatores tipicamente implicados na exacerba\u00e7\u00e3o do processo inflamat\u00f3rio. in vitro, linf\u00f3citos sensibilizados aoT. cruzit\u00eam a\u00e7\u00e3o citot\u00f3xica contra miocardi\u00f3citos; (2) o infiltrado inflamat\u00f3rio mononuclear e a eventual forma\u00e7\u00e3o de granulomas sugerem poss\u00edvel rea\u00e7\u00e3o de hipersensibilidade tardia.  Na fase aguda inicial, a inflama\u00e7\u00e3o \u00e9 focal e associada topograficamente ao parasitismo intenso, podendo confluir e tornar-se difusa. Em contraste, na fase cr\u00f4nica, a situa\u00e7\u00e3o \u00e9 mais obscura e complexa, pois embora se verifique rea\u00e7\u00e3o inflamat\u00f3ria ativa, o parasitismo \u00e9 escasso e n\u00e3o explica completamente os focos inflamat\u00f3rios. Por isso, tem-se aventado a hip\u00f3tese de hipersensibilidade tardia e de autoimunidade na manuten\u00e7\u00e3o da inflama\u00e7\u00e3o e das les\u00f5es na fase cr\u00f4nica da doen\u00e7a, explicada por: (1) mol\u00e9culas do parasito e de miocardi\u00f3citos t\u00eam alguma semelhan\u00e7a estrutural, o que poderia explicar propriedades antig\u00eanicas comuns e rea\u00e7\u00e3o imunit\u00e1ria cruzada: Esses aspectos mais controversos da fisiopatologia das les\u00f5es inflamat\u00f3rias da fase cr\u00f4nica da cardiomiopatia da DC foram parcialmente esclarecidos por estudos recentes usando testes mais sens\u00edveis para detec\u00e7\u00e3o do parasito. Esses testes sugerem que, mesmo escassa, a persist\u00eancia parasit\u00e1ria nos tecidos \u00e9 fonte cont\u00ednua de ant\u00edgenos, que podem mediar resposta inflamat\u00f3ria de baixo grau, mas virtualmente incessante. T. cruzinos focos inflamat\u00f3rios em praticamente todos os casos estudados. Al\u00e9m disso, o ac\u00famulo de linf\u00f3citos T CD8+, que predominam na miocardite cr\u00f4nica, correlaciona-se com a presen\u00e7a focal de ant\u00edgenos parasit\u00e1rios. \u00c9 poss\u00edvel que, al\u00e9m de tripanossomas degenerados, a ruptura celular promova libera\u00e7\u00e3o de microrganismos que estariam no citoplasma dos parasitas. Essa hip\u00f3tese vem da observa\u00e7\u00e3o de que bi\u00f3psias endomioc\u00e1rdicas de pacientes com CCDC evidenciaram micropart\u00edculas e nanoves\u00edculas el\u00e9tron-lucentes contendo DNA de arqueias - microrganismos mais antigos da natureza, que podem parasitar tripanossomos - na regi\u00e3o dos focos inflamat\u00f3rios.  T\u00e9cnicas de biologia molecular, como a rea\u00e7\u00e3o em cadeia da polimerase (PCR), aplicadas em fragmentos mioc\u00e1rdicos de pacientes com a CCDC, mostram DNA do Arqueias, numerosas no soro de pacientes com IC por DC, associam-se a inflama\u00e7\u00e3o, pois captam prote\u00ednas do interst\u00edcio e geram resposta imune com linf\u00f3citos T CD8+, sem resposta de c\u00e9lulas T CD4+. J\u00e1 arqueias lip\u00eddicas est\u00e3o aumentadas na FIDC, assim como exossomos protetores que captam AMZ1  do meio externo, impedindo a ativa\u00e7\u00e3o das enzimas e protegendo contra a degrada\u00e7\u00e3o do col\u00e1geno e a inflama\u00e7\u00e3o. Assim, por essa hip\u00f3tese, arqueias poderiam ter papel fundamental no surgimento de inflama\u00e7\u00e3o mioc\u00e1rdica e dilata\u00e7\u00e3o da microcircula\u00e7\u00e3o. T. cruzitenha inclusive certo tropismo para o tecido adiposo e que esse fato possa constituir outro elo fisiopatol\u00f3gico da extensa al\u00e7a de altera\u00e7\u00f5es inflamat\u00f3rias presentes na fase cr\u00f4nica, eventualmente pass\u00edvel de explora\u00e7\u00e3o como alvo terap\u00eautico.  Ainda do ponto de vista da histopatologia da DC, pesquisas antigas evidenciaram que a infec\u00e7\u00e3o pelo Diversas manifesta\u00e7\u00f5es cl\u00ednicas em pacientes com a CCDC mimetizam as que ocorrem em doentes afetados por doen\u00e7a obstrutiva coron\u00e1ria. Assim, constata-se que cerca de 30-40% deles exibem precordialgia, embora usualmente at\u00edpica por n\u00e3o guardar rela\u00e7\u00e3o n\u00edtida com o esfor\u00e7o f\u00edsico e ter dura\u00e7\u00e3o muito vari\u00e1vel, por longos per\u00edodos sintom\u00e1ticos. O ECG desses pacientes, com frequ\u00eancia, exibe altera\u00e7\u00f5es de ST-T, al\u00e9m de \u00e1reas de inatividade el\u00e9trica, simulando altera\u00e7\u00f5es comumente devidas a isquemia e/ou infarto do mioc\u00e1rdio. Ainda mais caracteristicamente, os pacientes com CCDC com frequ\u00eancia apresentam altera\u00e7\u00f5es de mobilidade parietal ventricular semelhantes \u00e0s que decorrem de necrose e infarto associado a obstru\u00e7\u00f5es coron\u00e1rias. Finalmente, variados dist\u00farbios perfusionais mioc\u00e1rdicos s\u00e3o descritos em pacientes em diversas fases da hist\u00f3ria natural da CCDC.  Em conjunto, essas altera\u00e7\u00f5es fisiopatol\u00f3gicas s\u00e3o atribu\u00eddas a anormalidades estruturais e de regula\u00e7\u00e3o coron\u00e1ria em n\u00edvel microvascular. Histologicamente, descreve-se vasodilata\u00e7\u00e3o extrema, n\u00e3o vista em outras CMD, com redu\u00e7\u00e3o da press\u00e3o de perfus\u00e3o distal, miocit\u00f3lise e isquemia em regi\u00f5es lim\u00edtrofes de dupla irriga\u00e7\u00e3o coronariana , postuladas como mais suscet\u00edveis a isquemia.  Admite-se que tais les\u00f5es isqu\u00eamicas possam contribuir para a instala\u00e7\u00e3o de \u00e1reas acin\u00e9ticas e aneurismas ventriculares, como no adelga\u00e7amento da ponta e na fibrose t\u00edpica inferolateral frequentemente detectada como origem de taquicardia ventricular sustentada (TVS).  Todavia, todas essas altera\u00e7\u00f5es estruturais e funcionais s\u00e3o encontradas na presen\u00e7a de coron\u00e1rias subepic\u00e1rdicas angiograficamente normais e sem aterosclerose precocemente detect\u00e1vel por angiotomografia.  Consequ\u00eancia comum desses dist\u00farbios microcirculat\u00f3rios \u00e9 a fibrose, que se desenvolve lenta e progressivamente, com deposi\u00e7\u00e3o de fibronectina, laminina e col\u00e1geno no interst\u00edcio, levando \u00e0 expans\u00e3o e distens\u00e3o da matriz extracelular e contribuindo para perda progressiva da atividade contr\u00e1til do mioc\u00e1rdio e aparecimento de arritmias card\u00edacas. N\u00e3o h\u00e1 outra miocardite humana em que a fibrose se desenvolva de forma t\u00e3o intensa e com caracter\u00edsticas t\u00e3o peculiares como na CCDC. T. cruziou mesmo da CCDC. O pr\u00f3prio ciclo vital do parasito, mediante novos conhecimentos de sua intera\u00e7\u00e3o com o hospedeiro humano, e o vetor como hospedeiro intermedi\u00e1rio, com suas caracter\u00edsticas gen\u00e9ticas melhor compreendidas, poder\u00e3o ser revisitados com vistas a possibilidades terap\u00eauticas de efeito tripanocida.  Diversas investiga\u00e7\u00f5es recentes focalizaram variadas altera\u00e7\u00f5es fisiopatol\u00f3gicas, com potencial de constituir alvos terap\u00eauticos para se influenciar favoravelmente a hist\u00f3ria natural da infec\u00e7\u00e3o pelo Assim, ap\u00f3s estudo pr\u00e9-cl\u00ednico, evidenciando redu\u00e7\u00e3o de fibrose com inibidor do fator TGF-beta,  o antagonismo dessa citocina passa a representar um importante alvo terap\u00eautico nesse contexto.  Mas \u00e9 sobre a possibilidade de modula\u00e7\u00e3o da resposta inflamat\u00f3ria que residem as perspectivas mais recentemente divisadas. Por exemplo, h\u00e1 demonstra\u00e7\u00e3o de que, nas formas indeterminada e cardiomiop\u00e1tica da DC, existem mecanismos diversificados de ativa\u00e7\u00e3o inflamat\u00f3ria da IL-1Beta.  Uma vis\u00e3o aprofundada sobre v\u00e1rios aspectos hipoteticamente ligados a m\u00faltiplas estrat\u00e9gias visando controlar o parasito e suas consequ\u00eancias inflamat\u00f3rias para se melhorar o progn\u00f3stico de indiv\u00edduos infectados foi recentemente divulgada.  Ademais, h\u00e1 evid\u00eancias de que as formas cl\u00ednicas da DC (indeterminada e cardiomiop\u00e1tica) envolvam diferentes subpopula\u00e7\u00f5es de c\u00e9lulas de mem\u00f3ria imunol\u00f3gica CD4- e CD8- e abram a perspectiva de nova estrat\u00e9gia anti-inflamat\u00f3ria para controle da DC no cora\u00e7\u00e3o.  Estudo pioneiro randomizado em pequena amostra de 37 pacientes com CCDC reportou que a terapia com o fator estimulador de col\u00f4nias de granul\u00f3citos (G-CSF), usada em aplica\u00e7\u00f5es cl\u00ednicas como suporte para quimioterapia e transplante de medula \u00f3ssea, visando controlar outros contextos de doen\u00e7as, e tamb\u00e9m com resultados promissores em camundongos infectados peloT. cruzi, apresenta boa tolerabilidade ao tratamento durante 1 ano, sugerindo a possibilidade de pesquisas mais extensas a serem realizadas com esse fator G-CSF em humanos com CCDC.  Em outra linha de pesquisa sobre f\u00e1rmacos naturais dotados de potente atividade anti-inflamat\u00f3ria e antioxidante, como o curcumin e o resveratrol, resultados em animais de experimenta\u00e7\u00e3o foram revistos e encorajam futuras iniciativas em humanos. T. cruzi, com a perspectiva de obter biomarcadores preditores de risco de desenvolvimento de CCDC e eventualmente servir para se monitorar a evolu\u00e7\u00e3o e as interven\u00e7\u00f5es terap\u00eauticas nesse contexto.  Finalmente, o enfoque sobre o polimorfismo gen\u00e9tico, que regula fisiopatologicamente n\u00edveis de fatores pr\u00f3- e anti-inflamat\u00f3rios (como exemplificado por IL-10), tem sido recentemente revisitado mediante meta-an\u00e1lise de v\u00e1rios estudos em diversas subpopula\u00e7\u00f5es de indiv\u00edduos infectados peloT. cruzi.  A miocardite aguda da DC tem incid\u00eancia vari\u00e1vel decorrente da carga e cepa parasit\u00e1ria, do hospedeiro e da via de infec\u00e7\u00e3o . Dependendo da ferramenta utilizada para o diagn\u00f3stico, a detec\u00e7\u00e3o de miocardite pode variar de 40% a 100% na fase aguda da infec\u00e7\u00e3o pelo H\u00e1 les\u00f5es inflamat\u00f3rias no mioc\u00e1rdio, endoc\u00e1rdio, peric\u00e1rdio e sistema nervoso aut\u00f4nomo intramural do cora\u00e7\u00e3o e de v\u00e1rios outros \u00f3rg\u00e3os, \u00e0 semelhan\u00e7a do verificado em miocardites virais. Nas colora\u00e7\u00f5es com hematoxilina-eosina e Giemsa, podem-se evidenciar, com certa facilidade, formas amastigotas do parasito.  Conforme amplamente discutido no cap\u00edtulo sobre a patog\u00eanese da DC, a anatomopatologia na fase aguda est\u00e1 diretamente relacionada ao parasitismo das c\u00e9lulas card\u00edacas, \u00e0 rea\u00e7\u00e3o inflamat\u00f3ria imediatamente suscitada pelo processo infeccioso e \u00e0 perturba\u00e7\u00e3o microcirculat\u00f3ria consequente.  De caracter\u00edstico, podem-se encontrar pequenos n\u00f3dulos enfileirados com aspecto de contas de ros\u00e1rio, aos quais se denomina epicardite moniliforme. Conquanto ocorra verdadeira pancardite, frequentemente h\u00e1 preserva\u00e7\u00e3o das valvas card\u00edacas, estruturas tipicamente avasculares. As les\u00f5es card\u00edacas t\u00eam intensidade bastante influenciada pela via de infec\u00e7\u00e3o , podendo cursar, na maioria dos casos, de forma muito benigna, virtualmente oligossintom\u00e1tica, ou, ao contr\u00e1rio, muito grave, acarretando inclusive a morte do paciente. T. cruziap\u00f3s transmiss\u00e3o oral , verificando-se com muita frequ\u00eancia aspectos subcl\u00ednicos. A inflama\u00e7\u00e3o aguda pode ter in\u00edcio pouco antes do desaparecimento da febre, o que ocorre em m\u00e9dia cerca de 15 a 20 dias do in\u00edcio da doen\u00e7a.  Os aspectos cl\u00ednicos t\u00eam sido mais focados recentemente no que respeita \u00e0 miocardite provocada pelo Comumente, encontra-se taquicardia e, nos casos mais graves, sintomas e sinais de IC aguda em que alguns pacientes apresentam o perfil hemodin\u00e2mico C (m\u00e1 perfus\u00e3o tissular e congest\u00e3o pulmonar e/ou sist\u00eamica).  No ECG, registram-se altera\u00e7\u00f5es inespec\u00edficas da repolariza\u00e7\u00e3o ventricular, complexos QRS de baixa voltagem, extrass\u00edstoles supra ou ventriculares, podendo inclusive ocorrer supradesnivelamento mantido do segmento ST. Os dist\u00farbios de condu\u00e7\u00e3o atrioventricular ou mesmo intraventricular, comuns na fase cr\u00f4nica, s\u00e3o menos frequentes na miocardite da fase aguda.  Alguns pacientes, \u00e0 semelhan\u00e7a do que ocorre nas miocardites virais, podem manifestar sintomas de dor precordial, dispneia e palpita\u00e7\u00f5es, \u00e0s vezes simulando quadros de doen\u00e7a arterial coron\u00e1ria.  O ECO detecta frequentemente derrame peric\u00e1rdico de propor\u00e7\u00f5es vari\u00e1veis, com hipocontratilidade difusa de ambos os ventr\u00edculos, sendo um apan\u00e1gio dos casos de miocardite mais graves. T. cruzi.  Em estudo envolvendo 126 indiv\u00edduos com idade < 18 anos, nos quais a forma aguda foi diagnosticada em sua maioria  ap\u00f3s transmiss\u00e3o oral e seguidos por 10,9 anos, a evolu\u00e7\u00e3o foi considerada benigna, embora 2,4% tivessem persistido com altera\u00e7\u00f5es card\u00edacas.  A hip\u00f3tese mais aceita para evolu\u00e7\u00e3o fatal em porcentagem mais significativa de pacientes em que a transmiss\u00e3o foi por via oral deve-se a que um grande in\u00f3culo, com elevada carga parasit\u00e1ria ingerida, ocorreu, al\u00e9m de facilitada pela intensa penetra\u00e7\u00e3o do parasita atrav\u00e9s da mucosa gastrointestinal, muito perme\u00e1vel aoT. cruzipode ser fatal .  A hist\u00f3ria natural da fase aguda da DC causada por transmiss\u00e3o vetorial cl\u00e1ssica (dejetos do inseto hemat\u00f3fago) inclui elevada fra\u00e7\u00e3o de indiv\u00edduos cuja infec\u00e7\u00e3o n\u00e3o \u00e9 sequer diagnosticada por serem assintom\u00e1ticos ou oligossintom\u00e1ticos e que evoluem para remiss\u00e3o praticamente espont\u00e2nea dos escassos sintomas. Em reduzida propor\u00e7\u00e3o dos casos, a infec\u00e7\u00e3o aguda pelo \u00e9 menos esclarecida do que a registrada em micro surtos recentemente verificados ap\u00f3s transmiss\u00e3o oral. Entretanto, \u00e9 patente que casos mais sintom\u00e1ticos se associam a desfechos desfavor\u00e1veis pela \u00f3bvia raz\u00e3o de ocorrerem em condi\u00e7\u00f5es de miocardite aguda mais intensa.  Todavia, de forma geral, a grande maioria dos indiv\u00edduos agudamente infectados peloT. cruzievoluem para a fase cr\u00f4nica e s\u00e3o caracterizados como tendo inicialmente a FIDC.  A hist\u00f3ria natural da miocardite da fase aguda causada por transmiss\u00e3o vetorial cl\u00e1ssica  A hist\u00f3ria natural da miocardite aguda da DC e da FIDC ainda apresenta aspectos obscuros e controversos. Alguns estudos avaliaram de forma adequada essa evolu\u00e7\u00e3o. Entretanto, diversas influ\u00eancias podem enviesar os resultados, tais como, faixa et\u00e1ria da popula\u00e7\u00e3o acometida, via de transmiss\u00e3o, carga e cepa parasit\u00e1ria, tempo de acompanhamento, al\u00e9m do tratamento etiol\u00f3gico pregresso, o que, ali\u00e1s, tem o potencial de descaracterizar completamente - em sentido ben\u00e9fico - a hist\u00f3ria natural.  Em estudo transversal realizado no munic\u00edpio de Bambu\u00ed (MG), nas d\u00e9cadas de 1940-1950, a partir de fase aguda da DC diagnosticada ap\u00f3s transmiss\u00e3o vetorial cl\u00e1ssica, foi descrita 8,3% de letalidade na fase aguda de crian\u00e7as < 10 anos. De 130 indiv\u00edduos acompanhados entre 1 e 3 anos ap\u00f3s a fase aguda, 71,5% n\u00e3o apresentaram altera\u00e7\u00f5es no ECG e 30% tinham a \u00e1rea card\u00edaca normal. Ap\u00f3s 3 a 5 anos, esses n\u00fameros foram, respectivamente, 65,7% e 87,5%. Deve-se lembrar que essa amostra populacional era basicamente composta de crian\u00e7as em \u00e9poca p\u00f3s-segunda guerra mundial e que n\u00e3o receberam tratamento etiol\u00f3gico. ln scale] = 0,4946). J\u00e1 nos indiv\u00edduos acompanhados a partir da FIDC, esse risco foi de 1,9% .  Em outro enfoque, mais recente, sobre hist\u00f3ria natural da DC, em dois grupos distintos de pacientes, o primeiro acompanhado desde o diagn\u00f3stico da fase aguda e o segundo, a partir da FIDC, avaliou-se o risco de desenvolvimento de cardiomiopatia cr\u00f4nica, por meio de revis\u00e3o sistem\u00e1tica e meta-an\u00e1lise de 32 estudos. Considerou-se como diagn\u00f3stico de cardiomiopatia cr\u00f4nica o aparecimento de arritmias ou altera\u00e7\u00f5es no ECG, evid\u00eancias de anormalidades na contra\u00e7\u00e3o ventricular ao ECO ou mortalidade associada com a DC. Ap\u00f3s a fase aguda, o risco estimado anual de evoluir para cardiopatia cr\u00f4nica foi elevado, de 4,6% , sendo as mortes entre eles muito raras e provavelmente n\u00e3o mais frequentes que as ocorrendo em grupos de indiv\u00edduos pareados por sexo e idade sem infec\u00e7\u00e3o peloT. cruzi.  Ap\u00f3s a fase aguda, os indiv\u00edduos infectados pelo Embora muitos indiv\u00edduos possam permanecer indefinidamente com a FIDC, observa-se em outros que, algumas d\u00e9cadas ap\u00f3s a infec\u00e7\u00e3o aguda, a DC torna-se clinicamente evidente por acometimento espec\u00edfico de \u00f3rg\u00e3os, principalmente cora\u00e7\u00e3o, es\u00f4fago e c\u00f3lon, caracterizando as formas cl\u00ednicas cr\u00f4nicas determinadas: card\u00edaca, digestiva ou mista (cardiodigestiva).  No Brasil, estima-se que cerca de 20% a 30% dos pacientes desenvolvem a forma card\u00edaca, de 5% a 8%, esofagopatia, e de 4% a 6%, colopatia. Com o envelhecimento da popula\u00e7\u00e3o, parcela maior dos infectados tende a evoluir para a forma card\u00edaca, embora o reconhecimento da real preval\u00eancia fique prejudicado pela coexist\u00eancia de outras doen\u00e7as cardiovasculares t\u00edpicas da senesc\u00eancia.  H\u00e1 significativas diferen\u00e7as geogr\u00e1ficas nas manifesta\u00e7\u00f5es cl\u00ednicas da DC em diversas regi\u00f5es da Am\u00e9rica Latina e s\u00edndromes digestivas s\u00e3o menos comumente relatadas fora do Brasil. Do ponto de vista epidemiol\u00f3gico e cl\u00ednico, a cardiomiopatia cr\u00f4nica \u00e9 a forma mais importante da DC em decorr\u00eancia de suas elevadas morbidade e mortalidade associadas e consequente impacto m\u00e9dico e social.  Estudos epidemiol\u00f3gicos em \u00e1reas end\u00eamicas, observa\u00e7\u00f5es em doadores de sangue e resultado de meta-an\u00e1lise, ap\u00f3s revis\u00e3o sistem\u00e1tica, mostraram que cerca de 2% dos pacientes evoluem, a cada ano, a partir da FIDC para uma forma cl\u00ednica da doen\u00e7a. T. cruzina \u201caus\u00eancia de qualquer das s\u00edndromes cl\u00ednicas predominantes\u201d da doen\u00e7a.  O seu potencial evolutivo foi descrito originalmente por Eurico Villela e Carlos Chagas em 1923  e ressaltado, na d\u00e9cada de 1950, por Laranja et al.,  que definiram como FIDC o per\u00edodo assintom\u00e1tico de cerca de 10 a 30 anos entre o fim da fase aguda e o estabelecimento tardio da cardiopatia da infec\u00e7\u00e3o cr\u00f4nica.  O termo \u201cforma indeterminada\u201d foi utilizado, pela primeira vez, por Carlos Chagas, em 1916, para designar a infec\u00e7\u00e3o pelo Desde ent\u00e3o, diversos autores utilizaram diferentes termos para se referir a esse est\u00e1gio da doen\u00e7a, incluindo forma latente, assintom\u00e1tica, subcl\u00ednica, laboratorial ou de \u201ccard\u00edacos potenciais\u201d, sem padroniza\u00e7\u00e3o estrita dos crit\u00e9rios diagn\u00f3sticos e levando a interpreta\u00e7\u00f5es diferentes e at\u00e9 conflitantes sobre o real significado da FIDC.  O consenso ressaltou que a exist\u00eancia de altera\u00e7\u00f5es \u00e0 proped\u00eautica mais sofisticada n\u00e3o invalida o conceito acima exposto, refor\u00e7ando o bom progn\u00f3stico dos casos em m\u00e9dio prazo, como confirmado pelo seguimento cl\u00ednico e pelo ECG e ECO.  Foi nesse contexto que um grupo de especialistas reunidos em Arax\u00e1, Minas Gerais, em 1984, elaborou um documento consensual reafirmando a validade do conceito da FIDC, bem como definindo os crit\u00e9rios diagn\u00f3sticos objetivos citados acima.  e at\u00e9 mesmo a aboli\u00e7\u00e3o do termo, substituindo-o por \u201cDC cr\u00f4nica sem patologia demonstrada\u201d, quando n\u00e3o apenas o ECG convencional e a radiografia de t\u00f3rax, mas tamb\u00e9m o ecodopplercardiograma, Holter e teste ergom\u00e9trico, realizados de rotina, apresentassem resultados normais.  Entretanto, o conceito cl\u00e1ssico de FIDC tem sido reafirmado em diretrizes nacionais e internacionais.  Existem cr\u00edticas e sugest\u00f5es de modifica\u00e7\u00e3o do conceito de FIDC, como a substitui\u00e7\u00e3o da normalidade \u00e0 radiografia de t\u00f3rax pelo ECO normal para a defini\u00e7\u00e3o da presen\u00e7a da FIDC  Deve-se ressaltar n\u00e3o ser habitual na pr\u00e1tica cl\u00ednica e em estudos epidemiol\u00f3gicos que se avalie rotineiramente os pacientes com DC, ECG e radiografia de t\u00f3rax normais e sem manifesta\u00e7\u00f5es digestivas, por meio da proped\u00eautica radiol\u00f3gica do trato gastrointestinal, o que tem levado ao conceito operacional de \u201cDC cr\u00f4nica sem cardiopatia aparente\u201d, visto que a defini\u00e7\u00e3o cl\u00e1ssica de FIDC requer a explora\u00e7\u00e3o radiol\u00f3gica de es\u00f4fago e c\u00f3lon.  Al\u00e9m disso, m\u00e9todos invasivos, como a bi\u00f3psia endomioc\u00e1rdica, mostraram altera\u00e7\u00f5es histol\u00f3gicas em pacientes com FIDC, em substancial porcentagem de casos, mas de baixa intensidade. Entre 33 pacientes com essa forma da doen\u00e7a submetidos \u00e0 bi\u00f3psia endomioc\u00e1rdica, 60% mostraram altera\u00e7\u00f5es degenerativas, altera\u00e7\u00e3o no volume de fibras, edema intersticial, infiltrado inflamat\u00f3rio e fibrose em pequenas quantidades.  \u00c0 medida que os m\u00e9todos de investiga\u00e7\u00e3o utilizados se tornaram mais sofisticados, v\u00e1rias altera\u00e7\u00f5es, geralmente discretas e sem implica\u00e7\u00f5es progn\u00f3sticas, puderam ser detectadas nesses indiv\u00edduos, como relatado em estudos com ecodopplercardiograma, ventriculografia radioisot\u00f3pica, teste ergom\u00e9trico, ergoespirometria, provas auton\u00f4micas e ECG din\u00e2mico.  M\u00e9todos ecocardiogr\u00e1ficos mais sens\u00edveis, como o Doppler tecidual  e a deforma\u00e7\u00e3o (strain)mioc\u00e1rdica longitudinal global (GLS)  medida comspeckle tracking echocardiography(STE), tamb\u00e9m se mostraram alterados em pacientes na FIDC. Todavia, tais estudos ainda n\u00e3o tiveram seguimento suficiente para definir se os pacientes com tais altera\u00e7\u00f5es sutis evoluiriam de forma diferenciada e, eventualmente, com disfun\u00e7\u00e3o ventricular.  Atualmente, a RMC fornece os mesmos dados, com a vantagem de ser m\u00e9todo n\u00e3o invasivo.  Os seguintes desfechos card\u00edacos prim\u00e1rios foram considerados nessa revis\u00e3o sistem\u00e1tica: (1) desenvolvimento de sintomas em geral ou de IC em espec\u00edfico; (2) desenvolvimento de cardiomiopatia estrutural ou arritmias card\u00edacas, conforme observado em resultados anormais por ECG ou ecocardiografia; e (3) presen\u00e7a de complica\u00e7\u00f5es decorrentes de cardiomiopatia grave, incluindo morte s\u00fabita, mortalidade associada a IC avan\u00e7ada, embolia pulmonar ou AVC. Vinte e tr\u00eas estudos apresentaram resultados observacionais longitudinais para pacientes com a FIDC. A maioria foi de coortes prospectivas e conduzidas no Brasil ou na Argentina entre 1960 e 2005. Nos estudos que inclu\u00edram dados de idade, as m\u00e9dias et\u00e1rias variaram de 10 anos a 44 anos, com m\u00e9dia geral de 31 anos. A dura\u00e7\u00e3o m\u00e9dia do acompanhamento foi de 8,5 anos (varia\u00e7\u00e3o de 3 anos a 18 anos). O estudo concluiu que a taxa anual estimada combinada de desenvolvimento de CCDC foi de 1,9% . A probabilidade cumulativa do aparecimento de evid\u00eancias de cardiomiopatia foi de aproximadamente 17% em 10 anos e 31% em 20 anos.  O risco de desenvolvimento de cardiomiopatia cr\u00f4nica tem sido avaliado em estudos de coorte nos \u00faltimos 60 anos, que foram congregados em revis\u00e3o sistem\u00e1tica e meta-an\u00e1lise recente.  os autores n\u00e3o encontraram diferen\u00e7as quanto \u00e0 taxa de evolu\u00e7\u00e3o com base no ano das investiga\u00e7\u00f5es (anteriores ou posteriores a 1985), no tamanho do estudo (> ou < 200 participantes), na idade m\u00e9dia dos participantes (< ou > 32 anos) ou no sexo predominante. Entretanto, nos estudos origin\u00e1rios do Brasil, os participantes tiveram uma taxa anual significativamente maior de desenvolvimento de cardiomiopatia  em compara\u00e7\u00e3o com estudos de pacientes de outros pa\u00edses da Am\u00e9rica do Sul , mais uma vez ressaltando a import\u00e2ncia de diferen\u00e7as regionais no curso da doen\u00e7a.  Embora a taxa de evolu\u00e7\u00e3o para cardiomiopatia seja assim estimada, ainda persistem muitas d\u00favidas sobre os mecanismos envolvidos na progress\u00e3o da doen\u00e7a. Na mesma revis\u00e3o sistem\u00e1tica citada acima,  De import\u00e2ncia cl\u00ednica, os autores relataram que o subgrupo de participantes que recebeu tratamento antiparasit\u00e1rio teve uma estimativa de taxa anual combinada significativamente menor de desenvolvimento de cardiomiopatia  em compara\u00e7\u00e3o com o subgrupo que n\u00e3o recebeu tratamento etiol\u00f3gico .  mostrou-se, em modelo murino de infec\u00e7\u00e3o peloT. cruzi, que a persist\u00eancia do parasita se correlaciona com a presen\u00e7a de doen\u00e7a card\u00edaca e que a elimina\u00e7\u00e3o dos parasitas dos tecidos foi associada \u00e0 melhora da inflama\u00e7\u00e3o.  Tais resultados s\u00e3o coerentes com a no\u00e7\u00e3o fisiopatol\u00f3gica geral de que existam, na verdade, evid\u00eancias substanciais de que a persist\u00eancia (carga) do parasita seja fator primordial para a progress\u00e3o da FIDC para a CCDC. Em estudo referencial,  A presen\u00e7a de parasitemia correlaciona-se significativamente com marcadores conhecidos de progress\u00e3o da doen\u00e7a, como prolongamento do QRS, FEVE reduzida e n\u00edveis mais elevados de troponina e da por\u00e7\u00e3o N-terminal do pr\u00f3-horm\u00f4nio do pept\u00eddeo natriur\u00e9tico do tipo B (NT-proBNP).  Estudos subsequentes demonstraram que a extens\u00e3o da inflama\u00e7\u00e3o e da fibrose e a gravidade da doen\u00e7a estavam associadas \u00e0 persist\u00eancia do DNA do parasita em les\u00f5es card\u00edacas observadas em pacientes com a DC.  Resultados adicionais da coorte NIH-REDS2, com seguimento m\u00e9dio de 8,7 anos da coorte original,  mostraram que a incid\u00eancia de cardiomiopatia em doadores de sangue soropositivos paraT. cruzifoi de 13,8  eventos/1000 aa  em compara\u00e7\u00e3o com 4,6  eventos/1000 aa  em controles soronegativos, com uma diferen\u00e7a de incid\u00eancia absoluta associada \u00e0 infec\u00e7\u00e3o porT. cruzide 9,2  eventos/1000 aa. O n\u00edvel de anticorpos anti-T. cruzino in\u00edcio do estudo, uma medida indireta da carga parasit\u00e1ria, foi associado ao desenvolvimento de cardiomiopatia, com raz\u00e3o de chances ajustada de 1,4  por unidade de aumento no n\u00edvel de anticorpo.  Em coorte de 1.813 pacientes com CCDC, aqueles previamente tratados com benznidazol apresentaram parasitemia significativamente reduzida, menor preval\u00eancia de marcadores de cardiomiopatia grave e menor mortalidade ap\u00f3s 2 anos de acompanhamento. et al.,  mostrando que o tratamento com benznidazol, em compara\u00e7\u00e3o com aus\u00eancia de tratamento etiol\u00f3gico, foi associado \u00e0 redu\u00e7\u00e3o da progress\u00e3o da DC e aumento da soroconvers\u00e3o negativa. Outros estudos observacionais mostraram resultados semelhantes.  A import\u00e2ncia da persist\u00eancia do parasita no desenvolvimento da CCDC tamb\u00e9m \u00e9 corroborada por extenso ensaio cl\u00ednico n\u00e3o randomizado relatado por Viotti Tais resultados t\u00eam sido objeto de discuss\u00f5es e interpreta\u00e7\u00f5es distintas e complementares  e a quest\u00e3o da import\u00e2ncia da persist\u00eancia do parasita nos pacientes com cardiopatia estabelecida continua controversa, conforme exposto em detalhes no cap\u00edtulo de tratamento etiol\u00f3gico desta diretriz.  Por outro lado, existem evid\u00eancias de que, uma vez estabelecida a cardiopatia, o parasitismo tecidual possa ter menor import\u00e2ncia no curso cl\u00ednico da doen\u00e7a, predominando os danos imunol\u00f3gicos aos tecidos. De acordo com essa possibilidade hipot\u00e9tica, uma vez estabelecida a cardiopatia, ao se eliminar o fator parasit\u00e1rio tissular, n\u00e3o haveria mais chance de revers\u00e3o em benef\u00edcio de hist\u00f3ria natural menos ominosa, porquanto les\u00f5es irrevers\u00edveis j\u00e1 estariam instaladas. Assim, o estudo BENEFIT, prospectivo, multic\u00eantrico e randomizado, envolvendo 2.854 pacientes com CCDC que receberam benznidazol ou placebo por at\u00e9 80 dias e foram acompanhados por uma m\u00e9dia de 5,4 anos, mostrou que o uso do tripanomicida reduziu a parasitemia nos pacientes tratados, mas n\u00e3o influenciou significativamente a deteriora\u00e7\u00e3o cl\u00ednica card\u00edaca em rela\u00e7\u00e3o ao grupo controle.  Os sintomas mais importantes s\u00e3o: dispneia aos esfor\u00e7os, fadiga, palpita\u00e7\u00f5es, tontura, s\u00edncope, dor tor\u00e1cica  e edema de membros inferiores.  A CCDC apresenta hist\u00f3ria natural caracteristicamente lenta e progressiva, embora ocasionalmente possa ter evolu\u00e7\u00e3o mais abrupta. Suas manifesta\u00e7\u00f5es cl\u00ednicas variam desde quadros assintom\u00e1ticos (cardiopatia \u201csilenciosa\u2019\u2019) at\u00e9 apresenta\u00e7\u00f5es graves, com IC refrat\u00e1ria, dist\u00farbios do ritmo e fen\u00f4menos tromboemb\u00f3licos, as tr\u00eas s\u00edndromes cl\u00ednicas principais.  O exame f\u00edsico geralmente demonstra uma ou mais altera\u00e7\u00f5es: sopro sist\u00f3lico de regurgita\u00e7\u00e3o mitral e/ou tric\u00faspide; desdobramento da segunda bulha card\u00edaca, geralmente associado a bloqueio de ramo direito (BRD); impulso apical difuso e deslocado no t\u00f3rax; e arritmia, sendo as extrass\u00edstoles a forma mais comum. 5.2.4.1. Altera\u00e7\u00f5es em Exames Subsidi\u00e1rios A aus\u00eancia de altera\u00e7\u00f5es eletrocardiogr\u00e1ficas, todavia, n\u00e3o \u00e9 indicador fidedigno absoluto da aus\u00eancia de acometimento card\u00edaco.  O BRD \u00e9 a anormalidade eletrocardiogr\u00e1fica mais comum, isoladamente ou em associa\u00e7\u00e3o com outras altera\u00e7\u00f5es.  \u00c9 mais tipicamente associado com bloqueio divisional anterossuperior esquerdo (BDASE) e extrass\u00edstoles ventriculares (EV). A dura\u00e7\u00e3o do QRS est\u00e1 diretamente relacionada ao tamanho do VE e inversamente relacionada com a FEVE.  A dura\u00e7\u00e3o do QRS > 120ms e o intervalo QT > 440ms t\u00eam acur\u00e1cia moderada em predizer FEVE reduzida em pacientes com DC.  O ECG na DC tem fundamental valor diagn\u00f3stico e progn\u00f3stico.  A combina\u00e7\u00e3o de dist\u00farbios de condu\u00e7\u00e3o intraventricular com extrass\u00edstoles ou com bradicardia sinusal associa-se tanto \u00e0 redu\u00e7\u00e3o da FEVE quanto ao aumento do volume do VE.  Deve-se ainda reconhecer que altera\u00e7\u00f5es eletrocardiogr\u00e1ficas causadas pela DC tendem, em indiv\u00edduos mais longevos, a somar-se \u00e0quelas ocasionadas pelo pr\u00f3prio processo inerente ao envelhecimento biol\u00f3gico.  Apresenta\u00e7\u00e3o mais detalhada das altera\u00e7\u00f5es de ECG que configuram CCDC e das que n\u00e3o s\u00e3o consideradas suficientes para firmar esse diagn\u00f3stico encontra-se em outros cap\u00edtulos desta diretriz.  As anormalidades no ECG mais frequentemente associadas \u00e0 redu\u00e7\u00e3o da FEVE na DC s\u00e3o as extrass\u00edstoles supraventriculares e ventriculares frequentes, FA, bloqueios intraventriculares, ondas Q patol\u00f3gicas e altera\u00e7\u00f5es de ST-T.  H\u00e1 baixa correla\u00e7\u00e3o entre o aumento da silhueta card\u00edaca \u00e0 radiografia de t\u00f3rax e o grau de disfun\u00e7\u00e3o ventricular sist\u00f3lica.  Por outro lado, a cardiomegalia detectada por \u00edndice cardiotor\u00e1cico (ICT) > 0.5 \u00e0 radiografia tem melhor correla\u00e7\u00e3o com o aumento do di\u00e2metro diast\u00f3lico do VE (DDVE) e sugere a presen\u00e7a de disfun\u00e7\u00e3o ventricular esquerda sist\u00f3lica.  A radiografia de t\u00f3rax \u00e9 importante exame complementar no diagn\u00f3stico dos pacientes com CCDC, possibilitando n\u00e3o somente avaliar-se o aumento das c\u00e2maras card\u00edacas como, em especial, o grau de congest\u00e3o pulmonar, altera\u00e7\u00e3o n\u00e3o percept\u00edvel pela ecocardiografia habitual.  De forma geral, na CCDC, as altera\u00e7\u00f5es radiol\u00f3gicas s\u00e3o semelhantes \u00e0s detectadas em outras CMD. Por\u00e9m, uma particularidade interessante refere-se a um fato consp\u00edcuo descrito por cl\u00ednicos h\u00e1 v\u00e1rias d\u00e9cadas: em muitos pacientes com evidente congest\u00e3o sist\u00eamica, incluindo ascite, hepatomegalia e anasarca, h\u00e1 n\u00edtida despropor\u00e7\u00e3o entre o grau avan\u00e7ado de cardiomegalia e a pouco intensa congest\u00e3o pulmonar.  O ECO \u00e9 o exame n\u00e3o invasivo mais utilizado na avalia\u00e7\u00e3o da fun\u00e7\u00e3o card\u00edaca por ser altamente dispon\u00edvel e confi\u00e1vel em sua obten\u00e7\u00e3o e interpreta\u00e7\u00e3o, al\u00e9m de ter custo relativamente baixo. O ECO permite determinar o estado evolutivo e as altera\u00e7\u00f5es mais sutis do comprometimento card\u00edaco, especialmente em fases menos avan\u00e7adas da cardiomiopatia. Particularidade muito expressiva nessa cardiomiopatia, verifica-se que at\u00e9 13% dos pacientes com CCDC no est\u00e1gio B (ver grada\u00e7\u00e3o da IC mais adiante) apresentam caracter\u00edstico d\u00e9ficit segmentar, apesar de fun\u00e7\u00e3o sist\u00f3lica biventricular global preservada.  \u00c9 relevante observar que tais altera\u00e7\u00f5es isoladas de mobilidade segmentar do VE evidenciam n\u00edtida conota\u00e7\u00e3o de mau progn\u00f3stico, como verificado em estudos seriados com ecocardiografia.  O ECO transtor\u00e1cico tornou-se, h\u00e1 d\u00e9cadas, importante instrumento no diagn\u00f3stico e acompanhamento dos pacientes com DC em suas diversas formas.  Dentre os v\u00e1rios par\u00e2metros analisados, os mais importantes s\u00e3o: FEVE, di\u00e2metro do \u00e1trio esquerdo, volume do \u00e1trio esquerdo, di\u00e2metros sist\u00f3lico e diast\u00f3lico do VE, fun\u00e7\u00e3o diast\u00f3lica, fun\u00e7\u00e3o sist\u00f3lica do ventr\u00edculo direito (VD), contratilidade global e segmentar do VE, contratilidade global do VD e presen\u00e7a de aneurisma vorticilar ou de ponta do VE.  A despeito dessa no\u00e7\u00e3o fisiopatol\u00f3gica, h\u00e1 evid\u00eancia derivada de estudos empregando outros m\u00e9todos - como a ventriculografia radionuclear, a RMC e a pr\u00f3pria ecocardiografia mais especializada - de que alguns pacientes com a CCDC apresentam precocemente importantes altera\u00e7\u00f5es morfofuncionais isoladas do VD.  Nessas condi\u00e7\u00f5es, na aus\u00eancia de concomitante envolvimento patol\u00f3gico do VE e enquanto a imped\u00e2ncia do circuito pulmonar se mantiver reduzida, a disfun\u00e7\u00e3o da c\u00e2mara ventricular direita deve passar sem repercuss\u00e3o percept\u00edvel, uma vez que avis-a-tergoventricular esquerda \u00e9 suficiente para a manuten\u00e7\u00e3o de fluxo e de resist\u00eancia vascular pulmonar normais, conforme aventado em publica\u00e7\u00e3o seminal sobre o tema.  O estudo ecocardiogr\u00e1fico do VD \u00e9 de mais dif\u00edcil realiza\u00e7\u00e3o por \u00f3bices t\u00e9cnicos inerentes tanto \u00e0 pr\u00f3pria c\u00e2mara ventricular como \u00e0 ess\u00eancia do m\u00e9todo ultrassonogr\u00e1fico. Em parte, por isso, h\u00e1 percep\u00e7\u00e3o de que a disfun\u00e7\u00e3o do VD seja mais evidente quando h\u00e1 envolvimento concomitante e significativo do VE.  Finalmente, quando aparece na hist\u00f3ria natural da doen\u00e7a, a disfun\u00e7\u00e3o sist\u00f3lica ventricular direita clinicamente manifesta agrega significativo fator negativo ao progn\u00f3stico de pacientes com a CCDC. 5.2.4.2. Arritmias Card\u00edacasT. cruziapresentam EV. Quando tais pacientes com altera\u00e7\u00f5es no ECG em repouso e IC manifesta s\u00e3o estudados atrav\u00e9s da eletrocardiografia din\u00e2mica, praticamente todos (99%) apresentam EV, sendo que, em 87% deles, elas s\u00e3o multiformes ou se apresentam como formas repetitivas (pareadas) ou mesmo como taquicardia ventricular n\u00e3o sustentada (TVNS), ou seja, tr\u00eas ou mais ectopias ventriculares sucessivas, com dura\u00e7\u00e3o inferior a 30 segundos.  Arritmia card\u00edaca \u00e9 manifesta\u00e7\u00e3o extremamente comum na CCDC, sendo a atividade ect\u00f3pica ventricular a predominante desde as fases iniciais de sua hist\u00f3ria natural. Assim, globalmente se constata que 15% a 55% dos indiv\u00edduos com sorologia positiva para o O acometimento do n\u00f3 sinusal e do sistema de condu\u00e7\u00e3o atrioventricular tamb\u00e9m \u00e9 muito frequente nos pacientes com CCDC. A disfun\u00e7\u00e3o do n\u00f3 sinusal pode se manifestar como bradicardia ou mesmo parada sinusal, bloqueio sinoatrial de segundo grau, ritmo juncional e ritmo idioventricular acelerado. O bloqueio atrioventricular (BAV) de 1\u00b0 grau constitui um dos dist\u00farbios de condu\u00e7\u00e3o atrioventricular mais encontrados, podendo ser transit\u00f3rio ou fixo. O BAV de 2\u00b0 grau \u00e9 menos frequente, podendo ser do tipo Mobitz I (Wenckebach), Mobitz II ou de grau avan\u00e7ado. O BAV de 3\u00b0 grau ou total (BAVT) pode ocorrer em 10% dos pacientes, sendo mais frequente do que em qualquer outra cardiopatia adquirida. Fibrila\u00e7\u00e3o atrial tende a ser manifesta\u00e7\u00e3o mais tardia, geralmente associada a graus mais avan\u00e7ados de disfun\u00e7\u00e3o sist\u00f3lica e dilata\u00e7\u00e3o ventricular.  A morte s\u00fabita costuma ser precipitada por exerc\u00edcios f\u00edsicos e pode ser associada a TVS ou fibrila\u00e7\u00e3o ventricular (FV) e, menos frequentemente, assistolia ou BAVT. Cerca de 40% a 50% dos casos de morte s\u00fabita s\u00e3o assintom\u00e1ticos antes do epis\u00f3dio fatal, por\u00e9m, na maioria dos pacientes, h\u00e1 concomit\u00e2ncia de comprometimento grave da fun\u00e7\u00e3o sist\u00f3lica ventricular e do sistema de condu\u00e7\u00e3o. A gravidade das arritmias ventriculares tende a se correlacionar com o grau de disfun\u00e7\u00e3o ventricular. Entretanto, diversamente do que ocorre em outras doen\u00e7as, n\u00e3o \u00e9 incomum que pacientes com CCDC e arritmias ventriculares malignas apresentem fun\u00e7\u00e3o ventricular esquerda global relativamente preservada .  Epis\u00f3dios de arritmias ventriculares malignas s\u00e3o muito mais frequentes em pacientes com CCDC do que naqueles com outras formas de cardiopatia (como a decorrente de doen\u00e7a coron\u00e1ria ou CMD de outras etiologias).  As arritmias podem ser assintom\u00e1ticas ou causar palpita\u00e7\u00f5es, tonturas, dispneia, fraqueza, pr\u00e9-s\u00edncope, s\u00edncope ou parada card\u00edaca. A morte s\u00fabita \u00e9 respons\u00e1vel por 50% a 65% dos \u00f3bitos por DC. 5.2.4.3. S\u00edndrome de Insufici\u00eancia Card\u00edaca Essa manifesta\u00e7\u00e3o tamb\u00e9m aparece em muitos pacientes durante a hist\u00f3ria natural da CCDC, usualmente com evid\u00eancias de disfun\u00e7\u00e3o biventricular, incluindo sintomas precoces como dispneia, fatigabilidade, edema de membros inferiores e dor tor\u00e1cica at\u00edpica. A disfun\u00e7\u00e3o diast\u00f3lica pode ser observada precocemente na hist\u00f3ria natural da CCDC, na aus\u00eancia de disfun\u00e7\u00e3o sist\u00f3lica regional ou global do VE, e pode ser explicada por certo grau de fibrose difusa dessa c\u00e2mara.  Conforme apontado acima, em alguns pacientes, a IC direita pode ser mais proeminente do que a IC esquerda, mas a disfun\u00e7\u00e3o do VD, quando clinicamente manifesta, em geral est\u00e1 associada \u00e0 disfun\u00e7\u00e3o ventricular esquerda em est\u00e1gio avan\u00e7ado da CCDC.  A classifica\u00e7\u00e3o da IC de acordo com a FEVE \u00e9 mostrada na Uma classifica\u00e7\u00e3o para IC de etiologia da DC, considerando-se a presen\u00e7a ou n\u00e3o de defeitos funcionais e/ou estruturais em geral e a fun\u00e7\u00e3o sist\u00f3lica ventricular esquerda, em especial, mostra-se \u00fatil quando aplicada \u00e0 CCDC, ap\u00f3s discretas modifica\u00e7\u00f5es a partir das diretrizes de 2011 da SBC, permitindo a identifica\u00e7\u00e3o de subgrupos ou est\u00e1gios evolutivos distintos do ponto de vista progn\u00f3stico e terap\u00eautico. 5.2.4.4. S\u00edndrome Tromboemb\u00f3lica Sist\u00eamica e Pulmonar Do ponto de vista cl\u00ednico, predominam os fen\u00f4menos tromboemb\u00f3licos que atingem o c\u00e9rebro, seguidos por embolia para outros \u00f3rg\u00e3os sist\u00eamicos e membros e por embolia pulmonar diagnosticada em vida. O AVC pode ser a primeira e devastadora manifesta\u00e7\u00e3o da doen\u00e7a.  Essa s\u00edndrome tamb\u00e9m \u00e9 bastante comum na CCDC e fen\u00f4menos tromboemb\u00f3licos venosos e arteriais constituem a terceira causa de morte.  Para a s\u00edndrome tromboemb\u00f3lica ser t\u00e3o frequente na CCDC concorrem diversos fatores que podem ser variavelmente predominantes de acordo com a fase da hist\u00f3ria natural da doen\u00e7a. Assim, o aneurisma apical embolig\u00eanico pode ser altera\u00e7\u00e3o precoce na CCDC, mas, muito mais comumente, tromboses em veias sist\u00eamicas com potencial de causar embolia pulmonar s\u00e3o complica\u00e7\u00f5es da IC, quando o d\u00e9bito card\u00edaco e o retorno venoso est\u00e3o prejudicados. De forma an\u00e1loga, nessa condi\u00e7\u00e3o de IC, a dilata\u00e7\u00e3o de c\u00e2maras favorece a trombose parietal em \u00e1trios e ventr\u00edculos, provocando embolias sist\u00eamicas e/ou pulmonares. A FA tamb\u00e9m \u00e9 mais frequente em casos avan\u00e7ados de CCDC e concorre para aumentar o risco de complica\u00e7\u00f5es tromboemb\u00f3licas.  A incid\u00eancia de AVC em pacientes com DC conhecida varia de 0,56 a 2,67 por 100 pessoas-ano.  A CCDC deve, portanto, ser regularmente inclu\u00edda no diagn\u00f3stico diferencial do AVC na Am\u00e9rica Latina.  Disfun\u00e7\u00e3o sist\u00f3lica ventricular, aumento do volume do \u00e1trio esquerdo, aneurisma apical, trombose cavit\u00e1ria mural e arritmias, como a FA, parecem ser importantes fatores de risco na g\u00eanese do AVC de etiologia da DC, caracteristicamente de natureza cardioemb\u00f3lica.  De fato, em 50-70% dos pacientes, o AVC se manifesta com s\u00edndrome de circula\u00e7\u00e3o anterior parcial, que inclui dois dos tr\u00eas sinais: d\u00e9ficit motor ou sensorial envolvendo face, bra\u00e7o e perna; hemianopsia hom\u00f4nima; e disfun\u00e7\u00e3o cerebral superior, expressa por afasia ou d\u00e9ficit visuoespacial. Com menos frequ\u00eancia, os pacientes apresentar\u00e3o uma s\u00edndrome lacunar ou de circula\u00e7\u00e3o posterior.  A DC \u00e9 uma das principais causas de AVC na Am\u00e9rica Latina, com essa etiologia representando at\u00e9 20% dessa complica\u00e7\u00e3o em \u00e1reas end\u00eamicas. IPEC-FIOCRUZ)para AVC foi desenvolvido em estudo observacional prospectivo de 1.043 pacientes.  Conforme discutido em cap\u00edtulo espec\u00edfico desta diretriz sobre complica\u00e7\u00f5es tromboemb\u00f3licas na DC, h\u00e1 presentemente necessidade de o escore ser revisitado para atender a considera\u00e7\u00f5es cient\u00edficas mais atualizadas.  Um escore de risco , hemaglutina\u00e7\u00e3o indireta (HAI), ensaio imunoenzim\u00e1tico (ELISA), dentre os convencionais, e, nos \u00faltimos anos, testes n\u00e3o convencionais, como quimioluminesc\u00eancia magn\u00e9tica (CMIA) e eletroquimioluminesc\u00eancia (ECLIA) em plataforma automatizada, assim como testes r\u00e1pidos. Todos esses testes podem utilizar, como ant\u00edgenos, produtos n\u00e3o purificados ou purificados .  Dois testes positivos (reagentes) indicam que o paciente \u00e9 soropositivo, ou seja, que o paciente apresenta anticorpos anti-T. cruzipor duas metodologias diferentes, o que significa que \u00e9 infectado peloT. cruzi. Quando o resultado do exame \u00e9 n\u00e3o reagente (concordante por dois testes de princ\u00edpios diferentes), a sorologia \u00e9 negativa; nesses casos, em geral n\u00e3o h\u00e1 antecedentes epidemiol\u00f3gicos e as altera\u00e7\u00f5es cl\u00ednicas, se existentes, podem ser explicadas por outras causas, diferentes da infec\u00e7\u00e3o peloT. cruzi. Em uma terceira possibilidade, que n\u00e3o \u00e9 habitual (< 5% dos casos), o resultado n\u00e3o \u00e9 concordante, ou seja, um teste fornece resultado reagente e o outro teste resultado n\u00e3o reagente ( A combina\u00e7\u00e3o do resultado dos dois testes permite classificar o soro do paciente como positivo (dois testes reagentes) ou negativo (dois testes n\u00e3o reagentes). Trata-se de resultados concordantes entre os dois testes realizados. eagente .  Finalmente, existe ainda a possibilidade de que um dos testes apresente resultado indeterminado, ou seja, situe-se numa faixa estreita entre o considerado negativo e positivo. Trata-se de resultado na regi\u00e3o chamada \u201ccinza\u201d, observado, por exemplo, na transfer\u00eancia passiva de anticorpos maternos de m\u00e3e infectada para seu filho. A queda progressiva da concentra\u00e7\u00e3o de anticorpos maternos no rec\u00e9m-nascido n\u00e3o infectado, em torno do 3\u00ba m\u00eas de idade, pode corresponder a essa regi\u00e3o cinza, com resultado indeterminado.  Nessas raras eventualidades de discord\u00e2ncia, o m\u00e9dico, ap\u00f3s avaliar os dados epidemiol\u00f3gicos e cl\u00ednicos, pode adotar as seguintes atitudes: avaliar se o paciente foi submetido a tratamento espec\u00edfico anteriormente; e verificar se houve antecedentes de leishmaniose tegumentar ou de outras doen\u00e7as, em particular, as autoimunes. Nesses casos, deve-se solicitar nova coleta de sangue. Com frequ\u00eancia, o resultado discordante torna-se concordante na nova amostra. Se o resultado indeterminado persistir, deve-se encaminhar o paciente para um servi\u00e7o/laborat\u00f3rio especializado, onde outras t\u00e9cnicas ser\u00e3o realizadas, at\u00e9 se chegar a uma conclus\u00e3o final. Na excepcional eventualidade de que mesmo o laborat\u00f3rio de refer\u00eancia n\u00e3o consiga precisar se o indiv\u00edduo \u00e9 infectado ou n\u00e3o, pode-se recorrer a exames parasitol\u00f3gicos (vide abaixo). Nesses casos deve-se fazer avalia\u00e7\u00e3o cl\u00ednica com ECG. No entanto, ainda que tenha um EGC normal, o paciente com sorologia inconclusiva dever\u00e1 ser orientado a n\u00e3o doar sangue. 6.1.4.1. Resultados Sorol\u00f3gicos Inconclusivos Como j\u00e1 apontado, resultados sorol\u00f3gicos inconclusivos n\u00e3o s\u00e3o habituais (< 5%) e frequentemente est\u00e3o associados \u00e0 presen\u00e7a de outras doen\u00e7as, em particular leishmaniose visceral ou tegumentar, l\u00fapus eritematoso disseminado, hepatopatias cr\u00f4nicas, em geral com aumento de gamaglobulina. S\u00e3o as chamadas rea\u00e7\u00f5es cruzadas. Assim, devem-se investigar outras causas e questionar se o paciente recebeu tratamento com benznidazol no passado. Caso isso se comprove, poderia indicar que a concentra\u00e7\u00e3o de anticorpos do indiv\u00edduo diminuiu como consequ\u00eancia do tratamento e o resultado da sorologia tornou-se indeterminado. 6.1.4.2. Resultado Laboratorial N\u00e3o Corresponde ao Esperado Clinicamente Como j\u00e1 referido, devem ser solicitados dois testes sorol\u00f3gicos de princ\u00edpios diferentes, de prefer\u00eancia incluindo os t\u00edtulos obtidos, indicando a concentra\u00e7\u00e3o de anticorpos. Quase sempre ambos os resultados s\u00e3o positivos ou negativos. Raras vezes os resultados dos dois testes empregados s\u00e3o discordantes e podem se apresentar em algumas combina\u00e7\u00f5es: um negativo e outro positivo ou um positivo e outro indeterminado. Nessas situa\u00e7\u00f5es, deve-se solicitar nova coleta de sangue, empregando as mesmas t\u00e9cnicas e, se poss\u00edvel, uma terceira t\u00e9cnica . Em geral, com esse procedimento, \u00e9 poss\u00edvel obter um resultado conclusivo. T. cruzi, por\u00e9m os testes sorol\u00f3gicos solicitados s\u00e3o negativos. Pode-se recorrer a um laborat\u00f3rio de refer\u00eancia  para nova coleta de sangue e execu\u00e7\u00e3o de outros testes. Na experi\u00eancia desses laborat\u00f3rios, quando o resultado \u00e9 totalmente negativo em tr\u00eas testes de princ\u00edpios diferentes, em geral n\u00e3o se trata de infec\u00e7\u00e3o peloT. cruzi. Assim, existem casos de BRD por outras causas, sendo relativamente frequente encontrar fam\u00edlias em que alguns dos membros n\u00e3o s\u00e3o infectados peloT. cruzi, o que leva \u00e0 hip\u00f3tese de resist\u00eancia natural \u00e0 doen\u00e7a, reconhecida em outras infec\u00e7\u00f5es como hansen\u00edase e tuberculose. Tamb\u00e9m pode se tratar de um caso de cura espont\u00e2nea, raro, por\u00e9m poss\u00edvel. H\u00e1 relatos na literatura de casos excepcionais de infec\u00e7\u00e3o peloT. cruzisem a presen\u00e7a de anticorpos no soro dos pacientes.  Se houver essa suspeita, devem ser solicitados testes parasitol\u00f3gicos para esclarecer a d\u00favida.  Interfer\u00eancias de diversas origens podem dar lugar a um resultado falso reagente que n\u00e3o se confirma pelos outros dois testes, negativos. Em outros casos, um teste pode ser n\u00e3o reagente e o mesmo soro reagente pelos outros dois testes. Os dados cl\u00ednicos e os antecedentes epidemiol\u00f3gicos em geral permitem chegar ao diagn\u00f3stico. Em outras circunst\u00e2ncias, os dados cl\u00ednicos e epidemiol\u00f3gicos apontam para infec\u00e7\u00e3o por6.1.4.3. Parasitemia Embora a maioria dos pacientes cr\u00f4nicos apresente baixa carga parasit\u00e1ria no sangue perif\u00e9rico, cerca de 20% deles podem apresentar elevada parasitemia, detectada por testes de multiplica\u00e7\u00e3o  seriados. Nos casos de RDC por imunossupress\u00e3o (HIV e outros), a maioria dos pacientes vai apresentar elevada parasitemia. Deve-se lembrar que \u201creativa\u00e7\u00e3o\u201d significa que o indiv\u00edduo, do ponto de vista laboratorial, est\u00e1 na fase aguda, que \u00e9 definida pela presen\u00e7a de parasitos no sangue perif\u00e9rico por exame direto, s\u00f3 observ\u00e1vel, no contexto da hist\u00f3ria natural da infec\u00e7\u00e3o, em curto per\u00edodo da fase aguda inicial e durante a pr\u00f3pria reativa\u00e7\u00e3o a partir de fase cr\u00f4nica. Ressalte-se que a defini\u00e7\u00e3o laboratorial de fase aguda \u00e9 dada pela verifica\u00e7\u00e3o de parasitos vi\u00e1veis no sangue perif\u00e9rico. 6.1.4.4. Sorologia Negativa em Pacientes na Fase Cr\u00f4nica Embora poss\u00edvel, \u00e9 excepcional e foi observada em pacientes na Bol\u00edvia. 6.1.4.5. Cura Espont\u00e2neaet al.,  ap\u00f3s coletar sangue de pacientes infectados na Am\u00e9rica Central anos ap\u00f3s a respectiva fase aguda, que foi devidamente registrada com testes parasitol\u00f3gicos diretos positivos, durante a \u00e9poca em que n\u00e3o existia tratamento espec\u00edfico. A raridade desse fen\u00f4meno foi comprovada quando, posteriormente, relatou-se em estudo com 110 indiv\u00edduos na fase cr\u00f4nica da doen\u00e7a, seguidos por mais de 10 anos, que nenhum deles apresentou titula\u00e7\u00e3o posterior menor do que a inicial.  Ainda assim, tem-se observado esse fen\u00f4meno com ocorr\u00eancia < 1%, ou seja, \u00e9 poss\u00edvel, por\u00e9m muito raro; habitualmente, a segunda coleta de amostra sempre apresenta algum n\u00edvel de anticorpos por algumas das t\u00e9cnicas empregadas, isso \u00e9, n\u00e3o h\u00e1 negativa\u00e7\u00e3o total. Se houver, outras hip\u00f3teses devem ser avaliadas, dentre as quais a mais prov\u00e1vel se deve \u00e0s diferen\u00e7as entre testes de proced\u00eancias distintas.  A cura espont\u00e2nea da DC foi relatada por Zeled\u00f3n6.1.4.6. Diagn\u00f3stico de Fase Aguda Excepcional no Brasil nos dias de hoje, \u00e9 praticamente limitada a casos de transmiss\u00e3o pela via oral, em particular na regi\u00e3o amaz\u00f4nica (aproximadamente 350 casos por ano), por meio de alimentos contaminados com triatom\u00edneos infectados ou por suas fezes. A transmiss\u00e3o oral representa atualmente a principal causa da doen\u00e7a aguda em v\u00e1rios pa\u00edses sul-americanos.  Em contexto geral, a DC aguda pode ser causada por triatom\u00edneos , transmiss\u00e3o transfusional ou transplante de \u00f3rg\u00e3os s\u00f3lidos, vertical ou cong\u00eanita e por acidente de laborat\u00f3rio. A RDC em indiv\u00edduo imunossuprimido natural ou iatrogenicamente tamb\u00e9m \u00e9 considerada como fase aguda. Nesses casos, o diagn\u00f3stico laboratorial \u00e9 realizado pela pesquisa direta do parasito com utiliza\u00e7\u00e3o dos m\u00e9todos parasitol\u00f3gicos que podem incluir a PCR. 6.1.4.7. Servi\u00e7os de Hemoterapia O objetivo desses servi\u00e7os \u00e9 oferecer sangue de qualidade e, para tal, devem utilizar testes de elevada sensibilidade, capazes de detectar > 99% das amostras infectadas. Por\u00e9m, esse racioc\u00ednio n\u00e3o se aplica ao diagn\u00f3stico da doen\u00e7a. Como consequ\u00eancia do zelo necess\u00e1rio para obter sangue sem agentes infecciosos, a especificidade pode ser menor (98%), acarretando exclus\u00e3o do sangue, por\u00e9m n\u00e3o significando automaticamente que esse doador em particular esteja infectado. Com frequ\u00eancia, lida-se com um indiv\u00edduo que, ao doar sangue, \u00e9 notificado da sua condi\u00e7\u00e3o de possivelmente infectado. Nessas circunst\u00e2ncias, \u00e9 obrigat\u00f3rio solicitar os dois testes sorol\u00f3gicos de princ\u00edpios diferentes, como j\u00e1 abordado. Embora na casu\u00edstica de servi\u00e7os de refer\u00eancia, entre 70% e 80% dos doadores exclu\u00eddos sejam efetivamente infectados, uma propor\u00e7\u00e3o significativa (20% a 30%) desses indiv\u00edduos n\u00e3o ter\u00e1 confirma\u00e7\u00e3o de DC, refor\u00e7ando a necessidade de nova coleta e solicita\u00e7\u00e3o de dois testes sorol\u00f3gicos. 6.1.4.8. Transmiss\u00e3o Cong\u00eanitaT. cruziem regi\u00f5es livres do vetor, assim como em muitas \u00e1reas end\u00eamicas.  A taxa de preval\u00eancia deste tipo de transmiss\u00e3o no Brasil \u00e9 de 1,7%, um dos menores \u00edndices comparado a outros pa\u00edses sul-americanos.  \u00c9 importante considerar que beb\u00eas nascidos de mulheres com infec\u00e7\u00e3o cr\u00f4nica porT. cruzi,apresentando sinais cl\u00ednicos sugestivos de DC aguda, devem ser submetidos aos testes de diagn\u00f3stico para infec\u00e7\u00e3o o mais r\u00e1pido poss\u00edvel. O diagn\u00f3stico precoce da DC cong\u00eanita \u00e9 de enorme import\u00e2ncia, considerando que o tratamento tripanossomicida dos rec\u00e9m-nascidos infectados, no primeiro ano de vida, apresenta 100% de cura.  A transmiss\u00e3o vertical  representa a principal via de transmiss\u00e3o doT. cruzie n\u00e3o tendo ocorrido infec\u00e7\u00e3o fetal. Assim, para se detectar a transmiss\u00e3o cong\u00eanita, recomenda-se, preferencialmente, o diagn\u00f3stico parasitol\u00f3gico no sangue do cord\u00e3o ou do rec\u00e9m-nascido nas primeiras 72 horas. Alternativamente, o diagn\u00f3stico poder\u00e1 ser firmado, na aus\u00eancia de sintomas e sinais de infec\u00e7\u00e3o, durante os primeiros meses de vida por meio de m\u00e9todos parasitol\u00f3gicos diretos , com avalia\u00e7\u00e3o de duas ou tr\u00eas amostras para amplia\u00e7\u00e3o da sensibilidade.  Os beb\u00eas negativos no teste parasitol\u00f3gico inicial devem ser testados por sorologia entre 9 e 12 meses de idade, quando os anticorpos maternos ter\u00e3o desaparecido. A persist\u00eancia de t\u00edtulos inalterados de anticorpos anti-T. cruziem crian\u00e7as a partir de 9 meses de idade \u00e9 indicativa de infec\u00e7\u00e3o cong\u00eanita e, em contrapartida, a aus\u00eancia desses anticorpos nesse momento afasta a possibilidade de infec\u00e7\u00e3o na crian\u00e7a.  Mas, \u00e9 necess\u00e1rio levar em considera\u00e7\u00e3o a possibilidade da passagem de anticorpos (IgG) entre a m\u00e3e e o feto por via transplacent\u00e1ria durante a gesta\u00e7\u00e3o, sendo a m\u00e3e infectada com6.1.4.9. Sorologia no Indiv\u00edduo Infectado, mas Tratado com Quimioter\u00e1picos Foi verificado tamb\u00e9m, em propor\u00e7\u00e3o menor (25%), nos pacientes tratados na fase cr\u00f4nica tardia, que essa negativa\u00e7\u00e3o s\u00f3 ocorreu ap\u00f3s d\u00e9cadas da realiza\u00e7\u00e3o do tratamento. Trata-se de quest\u00e3o de tempo relacionada ao per\u00edodo de conv\u00edvio do parasito com o paciente .  A an\u00e1lise de cura deve ser baseada na negativa\u00e7\u00e3o das provas sorol\u00f3gicas ou at\u00e9 mesmo na diminui\u00e7\u00e3o (desde que expressiva) da concentra\u00e7\u00e3o dos anticorpos, preferencialmente com testes diagn\u00f3sticos que utilizem ant\u00edgenos n\u00e3o purificados.  O seguimento de pacientes por meio de exames laboratoriais ap\u00f3s o tratamento espec\u00edfico da infec\u00e7\u00e3o ser\u00e1 abordado mais detalhadamente no cap\u00edtulo referente \u00e0 quimioterapia da doen\u00e7a em geral. Aqui, para quem procura subs\u00eddios para a exclus\u00e3o ou confirma\u00e7\u00e3o diagn\u00f3stica, registre-se que se trata de assunto muito sens\u00edvel e complexo a ser resumido a alguns princ\u00edpios. Assim, segundo J. R. Can\u00e7ado, \u201c\u00e9 \u00f3bvio que se o infectado tem anticorpos e parasitos, para se considerar que est\u00e1 curado (ap\u00f3s quimioterapia), ambos teriam que desaparecer\u201d. Essa m\u00e1xima aplica-se aos tratados na fase aguda (70% de cura) em per\u00edodos de meses. Tamb\u00e9m foi demonstrada em crian\u00e7as que receberam o tratamento tripanossomicida j\u00e1 em fase cr\u00f4nica, mas recente, comprovando negativa\u00e7\u00e3o da sorologia (ELISA com ant\u00edgenos recombinantes) em 58% a 62% dos casos, ap\u00f3s 3 a 4 anos de seguimento. 6.1.4.10. Testes Sorol\u00f3gicos R\u00e1pidos Os testes de diagn\u00f3stico r\u00e1pido, em geral, s\u00e3o de f\u00e1cil manipula\u00e7\u00e3o e dispensam realiza\u00e7\u00e3o em laborat\u00f3rios de refer\u00eancia para diagn\u00f3stico especializado, em rela\u00e7\u00e3o \u00e0s t\u00e9cnicas sorol\u00f3gicas cl\u00e1ssicas. Existem diversos tipos dispon\u00edveis para diagn\u00f3stico da DC. Muitos deles podem ser realizados com soro ou com sangue perif\u00e9rico e podem ser armazenados em temperatura ambiente por longo per\u00edodo de tempo. Seu uso \u00e9 indicado em \u00e1reas end\u00eamicas, principalmente em pesquisa de campo (inqu\u00e9ritos soroepidemiol\u00f3gicos), por contribuir para aumentar o acesso ao diagn\u00f3stico em localidades de dif\u00edcil cobertura. No entanto, apesar de serem utilizados para essa finalidade, os testes r\u00e1pidos para DC n\u00e3o s\u00e3o comumente recomendados como m\u00e9todo de diagn\u00f3stico independente pela OMS, devido \u00e0 baixa sensibilidade. 6.1.4.11. Testes Parasitol\u00f3gicos Devem ser solicitados em situa\u00e7\u00f5es especiais e n\u00e3o de rotina. Existem v\u00e1rios tipos de testes parasitol\u00f3gicos utilizados na fase cr\u00f4nica da DC, que, devido \u00e0 baixa parasitemia, t\u00eam como objetivo promover a multiplica\u00e7\u00e3o daqueles poucos parasitos existentes, por meio de hemocultura, xenodiagn\u00f3stico, inocula\u00e7\u00e3o em animais de experimenta\u00e7\u00e3o ou a identifica\u00e7\u00e3o de \u00e1cidos nucleicos  espec\u00edficos a esse protozo\u00e1rio. in house\u201d, que demandam condi\u00e7\u00f5es especiais , assim como pessoal altamente qualificado. Em geral, s\u00e3o realizados apenas em centros especializados de pesquisa. A hemocultura e o xenodiagn\u00f3stico aplicados na fase cr\u00f4nica apresentam sensibilidades baixas e vari\u00e1veis (cerca de 20%) e, quando repetidos, a probabilidade de detec\u00e7\u00e3o pode ser aumentada, atingindo at\u00e9 60% de sensibilidade.  Para alguns pacientes com parasitemias muito reduzidas, at\u00e9 mesmo exames sucessivos apresentar\u00e3o, persistentemente, resultados negativos.  A multiplica\u00e7\u00e3o de parasitos pode levar v\u00e1rias semanas e, portanto, o resultado pode demorar. S\u00e3o t\u00e9cnicas \u201c No caso do m\u00e9todo empregando PCR, a identifica\u00e7\u00e3o de parte do material gen\u00e9tico do parasito demanda menos tempo (horas), por\u00e9m tamb\u00e9m exige reagentes e condi\u00e7\u00f5es t\u00e9cnicas especiais. Pela sua import\u00e2ncia, a t\u00e9cnica de PCR ser\u00e1 enfatizada a seguir. 6.1.4.11.1. Indica\u00e7\u00f5es de Testes Parasitol\u00f3gicos, em Particular, Rea\u00e7\u00e3o em Cadeia da Polimerase A PCR tem sido valorizada para avalia\u00e7\u00e3o e monitoramento de pacientes, quando um resultado positivo de detec\u00e7\u00e3o de material gen\u00e9tico do parasito, ao final do tratamento tripanocida, indica falha terap\u00eautica.  Em contraste, no p\u00f3s-tratamento, um resultado negativo de PCR n\u00e3o \u00e9 indicativo de cura da infec\u00e7\u00e3o. Cumpre tamb\u00e9m destacar que a convers\u00e3o sorol\u00f3gica negativa em pacientes cr\u00f4nicos tratados que apresentam resposta favor\u00e1vel ao tratamento pode levar muitos anos.  A PCR pode indicar antecipadamente uma resposta de falha terap\u00eautica, demonstrando resist\u00eancia ao tratamento tripanocida, ou seja, inefic\u00e1cia do esquema terap\u00eautico.  Entre as principais, encontra-se o seguimento de pacientes tratados com benznidazol ou outros quimioter\u00e1picos. M\u00e9todos de diagn\u00f3stico acurados e marcadores fidedignos de resposta ao tratamento parasiticida s\u00e3o prioridades na pesquisa e desenvolvimento de recursos em geral para aplica\u00e7\u00e3o em DC.  Nos casos de imunossupress\u00e3o resultantes de TC, a exclus\u00e3o do processo de rejei\u00e7\u00e3o e detec\u00e7\u00e3o da RDC podem ser efetivadas precocemente por meio de PCR realizada em amostras de sangue perif\u00e9rico e de bi\u00f3psia endomioc\u00e1rdica.  Em casos de RDC, a PCR tamb\u00e9m \u00e9 de utilidade, permitindo detec\u00e7\u00e3o precoce da mesma. O monitoramento de RDC em indiv\u00edduos imunossuprimidos \u00e9 \u00e1rea de crescente interesse. A RDC em pacientes infectados na fase cr\u00f4nica que adquiriram HIV ou durante terapias imunossupressoras, ap\u00f3s transplante de \u00f3rg\u00e3os, doen\u00e7as autoimunes ou c\u00e2ncer, geralmente induz aumento da parasitemia, caracterizando DC aguda. 6.1.4.11.2. Interpreta\u00e7\u00e3o de Resultados de Testes Parasitol\u00f3gicosT. cruzinem que tenha sido curado da infec\u00e7\u00e3o.  Os testes parasitol\u00f3gicos, por defini\u00e7\u00e3o, s\u00f3 t\u00eam valor se forem positivos, ou seja, por crescimento num\u00e9rico dos parasitos ou pela demonstra\u00e7\u00e3o de estruturas amplificadas do parasito (PCR). Um teste negativo, em si, n\u00e3o tem valor, pois o resultado s\u00f3 \u00e9 v\u00e1lido para aquela amostra no dia da coleta. \u00c9 poss\u00edvel que nova amostra, coletada em outro dia, seja positiva. Ou seja, um teste parasitol\u00f3gico negativo n\u00e3o significa que o indiv\u00edduo n\u00e3o esteja infectado pelo6.1.4.12. Rea\u00e7\u00e3o em Cadeia da Polimerase A partir dos anos 1990, a PCR passou a ser utilizada como m\u00e9todo molecular de apoio para o diagn\u00f3stico de pacientes na fase cr\u00f4nica da DC, devido \u00e0 sua maior sensibilidade em rela\u00e7\u00e3o aos testes de multiplica\u00e7\u00e3o de parasitos (hemocultura e xenodiagn\u00f3stico), al\u00e9m de demonstrar elevado potencial de aplica\u00e7\u00e3o no monitoramento de quimioterapia tripanocida.  V\u00e1rios estudos t\u00eam demonstrado resultados positivos por PCR em 40% a 70% dos pacientes cr\u00f4nicos diagnosticados previamente por sorologia convencional. Essa variabilidade na positividade \u00e9 dependente de in\u00fameros fatores, como o grau de parasitemia, volume de sangue coletado e da amostra de sangue para isolamento de DNA, m\u00e9todo de purifica\u00e7\u00e3o do DNA, regi\u00e3o-alvo a ser amplificada, caracter\u00edsticas das popula\u00e7\u00f5es de estudo e ainda a elevada diversifica\u00e7\u00e3o gen\u00e9tica, observada entre as DTU do parasito.  Nesse contexto, para esses pacientes, os m\u00e9todos de detec\u00e7\u00e3o com base molecular apresentam um valor diagn\u00f3stico limitado, por sensibilidade significativamente mais baixa do que os testes baseados em sorologia.  Diferentes combina\u00e7\u00f5es de alvos moleculares, conjuntos de iniciadores da rea\u00e7\u00e3o, m\u00e9todos de extra\u00e7\u00e3o e plataformas de amplifica\u00e7\u00e3o de DNA t\u00eam sido usadas para avaliar a acur\u00e1cia do m\u00e9todo em amostras de sangue perif\u00e9rico de pacientes com DC cr\u00f4nica; em geral, a sensibilidade alcan\u00e7ada para fins de diagn\u00f3stico \u00e9 mais baixa, comparada aos testes sorol\u00f3gicos.  Por outro lado, no caso de amostras positivas, a PCR possibilita a caracteriza\u00e7\u00e3o das DTU infectantes doT. cruzidiretamente do sangue do paciente, n\u00e3o sendo necess\u00e1rio o isolamento pr\u00e9vio do parasito.  Ressalte-se que a positividade da PCR confirma a presen\u00e7a do parasito em uma determinada amostra; por\u00e9m, devido \u00e0 escassez e intermit\u00eancia da circula\u00e7\u00e3o dos parasitos, caracter\u00edsticas da fase cr\u00f4nica, um resultado de PCR negativo n\u00e3o exclui a infec\u00e7\u00e3o. T. cruzi,recomenda-se o uso de sequ\u00eancias conservadas do DNA (presentes em todas as linhagens gen\u00e9ticas do parasito), que sejam exclusivas deT. cruzi(especificidade), e que essas sequ\u00eancias sejam representadas em m\u00faltiplas c\u00f3pias no genoma (maior sensibilidade). Os alvos mais frequentemente usados na PCR convencional  t\u00eam sido o DNA do cinetoplasto ou kDNA  e as unidades de repeti\u00e7\u00e3o (DNA sat\u00e9lite) presentes no genoma nuclear.  Para a sele\u00e7\u00e3o do alvo molecular de detec\u00e7\u00e3o do material gen\u00e9tico deT. cruzi, comparadas aos minic\u00edrculos do kDNA.  A PCR em tempo real ou quantitativa (qPCR) possibilita determinar a carga parasit\u00e1ria pela quantifica\u00e7\u00e3o de sequ\u00eancias de DNA espec\u00edficas. Para os ensaios de quantifica\u00e7\u00e3o, as sequ\u00eancias de DNA sat\u00e9lite s\u00e3o preferencialmente usadas, devido \u00e0 menor variabilidade no n\u00famero de c\u00f3pias entre as diferentes linhagens gen\u00e9ticas de6.1.4.13. Procedimentos Operacionais para Uso da PCR Coleta de sangue: em geral s\u00e3o coletados 10mL de sangue perif\u00e9rico (m\u00ednimo de 5mL) em tubos com EDTA . O sangue \u00e9 imediatamente transferido para tubo contendo o mesmo volume (1:1) de uma solu\u00e7\u00e3o de lise e preserva\u00e7\u00e3o da amostra, a solu\u00e7\u00e3o de 6M guanidina-HCl contendo 0,2M EDTA .  Processamento da amostra: o sangue em guanidina passa por fervura em banho-maria , a fim de promover uma distribui\u00e7\u00e3o homog\u00eanea das sequ\u00eancias de DNA-alvo do parasita, possibilitando a extra\u00e7\u00e3o de DNA de um volume menor da amostra (300 \u00b5L). O material fervido permanece \u00e0 temperatura ambiente por 48 a 72 horas e pode ser submetido \u00e0 extra\u00e7\u00e3o de DNA. O restante do material \u00e9 armazenado em geladeira ou c\u00e2mara fria, sem jamais congelar.  Duas r\u00e9plicas de 300 \u00b5L cada s\u00e3o submetidas \u00e0 extra\u00e7\u00e3o de DNA utilizando kits comerciais baseados na purifica\u00e7\u00e3o por minicolunas de s\u00edlica, seguindo as recomenda\u00e7\u00f5es do fabricante. in house\u201d pelos laborat\u00f3rios, geralmente com base no descrito no consenso internacional.  Os protocolos para PCR seguem aqueles padronizados \u201c Para a PCR qualitativa, o resultado do teste se d\u00e1 pela visualiza\u00e7\u00e3o do produto amplificado (do kDNA ou DNA-sat\u00e9lite) a partir da eletroforese em gel de agarose corado com agentes fluorescentes que se intercalam no DNA.  e exigem a inclus\u00e3o, em cada ensaio, de amostras-padr\u00e3o com concentra\u00e7\u00f5es preestabelecidas de parasitos , que servem como amostras calibradoras para a quantifica\u00e7\u00e3o absoluta deT. cruzi. Os resultados gerados pela qPCR s\u00e3o visualizados, em tempo real, na forma de gr\u00e1ficos emitidos pelo pr\u00f3prio equipamento, sem haver a necessidade de corrida eletrofor\u00e9tica.  Para a qPCR, os protocolos tamb\u00e9m seguem o consenso internacional T. cruzi) e negativo (DNA extra\u00eddo de sangue sabidamente n\u00e3o infectado e um tubo contendo \u00e1gua ultrapura sem DNA) \u00e9 fortemente recomendada.  A utiliza\u00e7\u00e3o de controles positivo  para a realiza\u00e7\u00e3o de novo teste de PCR dirigido para algum gene humano . Isso representa um passo decisivo para excluir resultados falso-negativos devido \u00e0 presen\u00e7a de agentes inibidores nas amostras de sangue ou pela perda ou m\u00e1 qualidade do DNA extra\u00eddo.  Foi disponibilizado, recentemente, conjunto diagn\u00f3stico (kit) para PCR produzido pela FIOCRUZ (Bio-Manguinhos) e aprovado pelas autoridades sanit\u00e1rias, que facilitar\u00e1 o seu emprego no Laborat\u00f3rio Central de Sa\u00fade P\u00fablica (LACEN).  A Assim, altera\u00e7\u00f5es eletrocardiogr\u00e1ficas bem definidas no indiv\u00edduo infectado indicam a presen\u00e7a de cardiomiopatia.  As altera\u00e7\u00f5es mais frequentes e definidas s\u00e3o retardos da condu\u00e7\u00e3o atrioventricular, da condu\u00e7\u00e3o no ramo direito e no fasc\u00edculo anterossuperior, altera\u00e7\u00f5es da repolariza\u00e7\u00e3o ventricular e ectopias ventriculares. Praticamente todas as anormalidades eletrocardiogr\u00e1ficas podem ser encontradas na DC, com predom\u00ednio de altera\u00e7\u00f5es na forma\u00e7\u00e3o e condu\u00e7\u00e3o da atividade el\u00e9trica card\u00edaca.  O ECG \u00e9 o exame cardiovascular inicial mais importante para avalia\u00e7\u00e3o de pacientes com DC, permitindo a classifica\u00e7\u00e3o da forma cl\u00ednica da doen\u00e7a.  O BRD est\u00e1 frequentemente associado ao BDASE, a mais comumente encontrada combina\u00e7\u00e3o na CCDC. O bloqueio do ramo esquerdo (BRE) \u00e9 raro e apresenta pior progn\u00f3stico.  O BRD, completo ou incompleto, \u00e9 o dist\u00farbio de condu\u00e7\u00e3o mais comum na DC, sendo encontrado em 10% a 50% dos pacientes infectados, dependendo das caracter\u00edsticas da amostra estudada.  Os BAV s\u00e3o tamb\u00e9m comuns, apresentam-se de graus variados e podem ser a primeira manifesta\u00e7\u00e3o da doen\u00e7a. Os BAV avan\u00e7ados s\u00e3o decorrentes de les\u00f5es extensas do n\u00f3 atrioventricular e sistema de His-Purkinje, podem evoluir com quadros sincopais e necessidade de implante de MP artificial definitivo e predisp\u00f5em a morte s\u00fabita por assistolia.  A disfun\u00e7\u00e3o do n\u00f3 sinusal frequentemente se expressa por bradicardia e pode ocasionar epis\u00f3dios de bloqueio sinoatrial e paradas sinusais. Quando a disfun\u00e7\u00e3o dessa estrutura \u00e9 acompanhada por sintomas de hipofluxo cerebral, caracteriza-se a doen\u00e7a do n\u00f3 sinusal, que, em alguns pacientes, tipicamente alterna a bradicardia com epis\u00f3dios de taquicardia.  Em geral, a FA est\u00e1 associada a dano mioc\u00e1rdico mais pronunciado e extenso, envolvimento difuso do sistema de condu\u00e7\u00e3o, arritmias ventriculares e AVC.  A FA na CCDC constitui altera\u00e7\u00e3o mais tardia, encontrada em at\u00e9 5% dos tra\u00e7ados eletrocardiogr\u00e1ficos.  As arritmias ventriculares, como as EV polim\u00f3rficas e a taquicardia ventricular (TV), s\u00e3o preditoras de s\u00edncopes e de morte s\u00fabita card\u00edaca por FV. Ondas Q patol\u00f3gicas ou perda de progress\u00e3o de ondas R de V1 a V3-V4 traduzem \u00e1reas el\u00e9tricas inativas e s\u00e3o decorrentes de fibrose mioc\u00e1rdica. J\u00e1 os transtornos difusos da condu\u00e7\u00e3o e a baixa voltagem de QRS geralmente est\u00e3o associados a disfun\u00e7\u00e3o ventricular acentuada.  A associa\u00e7\u00e3o de duas ou mais anormalidades no mesmo tra\u00e7ado eletrocardiogr\u00e1fico constitui uma das caracter\u00edsticas de cardiopatia grave. A mais frequente \u00e9 a presen\u00e7a de dist\u00farbios de condu\u00e7\u00e3o associados a arritmias ventriculares. A coexist\u00eancia de ondas Q patol\u00f3gicas tamb\u00e9m indica comprometimento mais significativo da fun\u00e7\u00e3o ventricular. Dessa forma, quanto maior for o n\u00famero de altera\u00e7\u00f5es eletrocardiogr\u00e1ficas apresentadas pelo paciente, pior ser\u00e1 seu progn\u00f3stico.  Com o atual controle mais abrangente da transmiss\u00e3o vetorial e o envelhecimento da popula\u00e7\u00e3o infectada peloT. cruzi, doen\u00e7as cr\u00f4nicas, como a cardiopatia hipertensiva e a cardiopatia isqu\u00eamica, podem coexistir com a CCDC e anormalidades t\u00edpicas dessas condi\u00e7\u00f5es podem se sobrepor \u00e0s t\u00edpicas da DC.  Al\u00e9m disso, embora existam anormalidades t\u00edpicas na CCDC, nenhuma delas \u00e9 espec\u00edfica para essa etiologia, tampouco aparece em todos os casos.  Os tradicionais estudos epidemiol\u00f3gicos, avaliando as altera\u00e7\u00f5es eletrocardiogr\u00e1ficas na DC, foram realizados no contexto predominante de infectados por transmiss\u00e3o vetorial cl\u00e1ssica, incluindo indiv\u00edduos mais jovens.  Corroborando a conota\u00e7\u00e3o apontada acima sobre o efeito progn\u00f3stico das anormalidades eletrocardiogr\u00e1ficas, recentes investiga\u00e7\u00f5es por grupos independentes de pesquisadores destacam a potencial contribui\u00e7\u00e3o da an\u00e1lise de altera\u00e7\u00f5es no ECG, inclusive usando recursos de intelig\u00eancia artificial e aprendizado de m\u00e1quina, para se prever a detec\u00e7\u00e3o de disfun\u00e7\u00e3o ventricular e fibrose mioc\u00e1rdica, dois prognosticadores fundamentais na DC.  Para pacientes com sintomas sugestivos de arritmias card\u00edacas, como palpita\u00e7\u00f5es, lipotimia, s\u00edncope e morte s\u00fabita recuperada, um ECG de repouso \u00e9 obrigat\u00f3rio antes da realiza\u00e7\u00e3o de novos testes, como Holter, ECG de estresse ou estudo eletrofisiol\u00f3gico (EEF) intracard\u00edaco.  O ECG deve ser realizado quando se suspeita ou se confirma o diagn\u00f3stico da DC, devendo ser repetido regularmente para se avaliar o aparecimento ou evolu\u00e7\u00e3o de anormalidades. Nos indiv\u00edduos com ECG normal, novas altera\u00e7\u00f5es indicam progress\u00e3o para a forma card\u00edaca, o que implica na realiza\u00e7\u00e3o de exames adicionais.  Estudo recente demonstrou que a presen\u00e7a de cardiomegalia pelo ICT \u00e9 adequadamente identificada pelo aumento do DDVE, medido pela ecocardiografia.  A radiografia de t\u00f3rax, dada sua ampla disponibilidade, \u00e9 um dos exames utilizados no diagn\u00f3stico de comprometimento cardiovascular e, principalmente, na avalia\u00e7\u00e3o de congest\u00e3o pulmonar. Mesmo em pacientes sintom\u00e1ticos, \u00e9 comum encontrar-se aumento de \u00e1rea card\u00edaca com campos pulmonares pouco congestos. Os sinais de aumento do VD em proje\u00e7\u00f5es p\u00f3stero-anterior e perfil tamb\u00e9m s\u00e3o comuns e significativos, assim como pode haver sinais de derrame pleural \u00e0 direita, secund\u00e1rios \u00e0 congest\u00e3o sist\u00eamica. O aumento do ICT \u00e9 fator preditor independente de morte em indiv\u00edduos com CCDC.  Os sinais ecocardiogr\u00e1ficos podem variar desde altera\u00e7\u00f5es localizadas de contra\u00e7\u00e3o segmentar nos est\u00e1gios iniciais da cardiopatia at\u00e9 dilata\u00e7\u00e3o importante das c\u00e2maras card\u00edacas com disfun\u00e7\u00e3o biventricular nos est\u00e1gios mais avan\u00e7ados. A presen\u00e7a e a gravidade das altera\u00e7\u00f5es ao ECO, associadas aos dados cl\u00ednicos, s\u00e3o crit\u00e9rios empregados para a classifica\u00e7\u00e3o da DC em est\u00e1gios de A a D, com valor progn\u00f3stico intr\u00ednseco, como exposto em outro cap\u00edtulo desta diretriz.  O ECO \u00e9 o exame de imagem mais utilizado na avalia\u00e7\u00e3o inicial e no seguimento de pacientes com DC. 6.2.3.1. Fun\u00e7\u00e3o Sist\u00f3lica do Ventr\u00edculo Esquerdo Em raz\u00e3o da presen\u00e7a de altera\u00e7\u00f5es geom\u00e9tricas e segmentares, o modo M n\u00e3o \u00e9 recomendado para a avalia\u00e7\u00e3o das dimens\u00f5es e da fun\u00e7\u00e3o sist\u00f3lica do VE. Essa an\u00e1lise deve ser realizada preferencialmente pelo modo bidimensional, por meio da estimativa de volumes, com o m\u00e9todo biplanar (Simpson). Assim como em outras cardiomiopatias, a ecocardiografia tridimensional \u00e9 superior \u00e0 bidimensional para a avalia\u00e7\u00e3o dos volumes e da fra\u00e7\u00e3o de eje\u00e7\u00e3o, principalmente quando h\u00e1 suspeita de encurtamento da imagem apical do VE ou quando h\u00e1 anormalidades na contra\u00e7\u00e3o segmentar com distor\u00e7\u00e3o da geometria, como nos aneurismas frequentemente visibilizados com o m\u00e9todo.  A CMD da DC caracteriza-se pelo aumento ventricular esquerdo e por hipocinesia segmentar e/ou difusa, sendo a disfun\u00e7\u00e3o sist\u00f3lica dessa c\u00e2mara o mais importante preditor de morte.  O valor progn\u00f3stico dessas altera\u00e7\u00f5es regionais precoces em pacientes na FIDC ainda n\u00e3o est\u00e1 definido. Estudo recente, incluindo 144 pacientes com DC, por\u00e9m sem evid\u00eancias de acometimento card\u00edaco, mostrou que ostrainradial avaliado pelo STE foi preditor de desenvolvimento de cardiomiopatia.  Em pacientes com FEVE reduzida e CCDC ou CMD idiop\u00e1tica, o GLS reduzido foi preditor de desfechos combinados independentemente da FEVE.  A ecocardiografia com rastreamento de pontos, ou STE, permite o diagn\u00f3stico precoce de disfun\u00e7\u00e3o sist\u00f3lica pela avalia\u00e7\u00e3o da deforma\u00e7\u00e3o mioc\u00e1rdica em pacientes com DC. A deforma\u00e7\u00e3o sist\u00f3lica nos eixos longitudinal, radial e circunferencial j\u00e1 foi avaliada em pacientes com FIDC ou com cardiopatia em v\u00e1rios estudos. Os resultados mais consistentes avaliaram o GLS, assim como em outras cardiomiopatias n\u00e3o isqu\u00eamicas. Mesmo em pacientes nos est\u00e1gios mais precoces da cardiopatia, como aqueles com fra\u00e7\u00e3o de eje\u00e7\u00e3o preservada (est\u00e1gio B1) ou ainda aqueles com a FIDC (est\u00e1gio A), altera\u00e7\u00f5es regionais na deforma\u00e7\u00e3o mioc\u00e1rdica s\u00e3o observadas. Nos pacientes com a FIDC, as altera\u00e7\u00f5es regionais descritas pela STE ocorrem principalmente em segmentos inferiores e \u00ednfero-laterais de VE. 6.2.3.2. Altera\u00e7\u00f5es Segmentares da Contratilidade Ventricular Em pacientes com CCDC, o \u00edndice de escore de mobilidade segmentar alterado em repouso (> 1) foi capaz de identificar aqueles com maior risco para desfechos clinicamente relevantes, inclusive mortalidade global, apesar de fun\u00e7\u00e3o ventricular global inicialmente preservada.  As altera\u00e7\u00f5es segmentares s\u00e3o encontradas mais frequentemente nas paredes inferior e inferolateral, al\u00e9m de nos segmentos apicais. O padr\u00e3o regional de acometimento, n\u00e3o relacionado ao territ\u00f3rio coronariano, \u00e9 caracter\u00edstica dessa cardiomiopatia.  As altera\u00e7\u00f5es segmentares podem estar presentes em 10% dos pacientes no est\u00e1gio inicial da doen\u00e7a e em at\u00e9 50% quando h\u00e1 dilata\u00e7\u00e3o e disfun\u00e7\u00e3o sist\u00f3lica. Essas altera\u00e7\u00f5es regionais de mobilidade parietal, quando incipientes, identificam indiv\u00edduos sob risco de evolu\u00e7\u00e3o para disfun\u00e7\u00e3o ventricular global e surgimento de arritmias.  A preval\u00eancia m\u00e9dia de aneurisma apical nas diferentes s\u00e9ries ecocardiogr\u00e1ficas foi de 8,5%  em pacientes assintom\u00e1ticos ou com cardiopatia leve e de at\u00e9 55% (variando de 47% a 64%) em pacientes com moderada a importante disfun\u00e7\u00e3o sist\u00f3lica de VE.  Os aneurismas n\u00e3o s\u00e3o limitados ao \u00e1pice ou \u00e0 parede inferolateral, podendo ser encontrados no septo, na parede \u00e2ntero-lateral e no VD.  Trombos intraventriculares podem estar associados a esses aneurismas e s\u00e3o considerados fator de risco importante para eventos emb\u00f3licos.  Os aneurismas ventriculares apresentam-se de forma vari\u00e1vel, desde tamanho diminuto, com conforma\u00e7\u00e3o digitiforme (em \u201cdedo de luva\u201d), at\u00e9 grandes aneurismas apicais (\u201csaculares\u201d), que podem ser dif\u00edceis de diferenciar dos encontrados na cardiopatia isqu\u00eamica.  Apesar de o exame ecocardiogr\u00e1fico transtor\u00e1cico em repouso ser de fundamental import\u00e2ncia na avalia\u00e7\u00e3o da CCDC, pois permite identificar altera\u00e7\u00f5es segmentares, principalmente os aneurismas apicais, sua execu\u00e7\u00e3o pode ser tecnicamente desafiadora. O uso de inspira\u00e7\u00e3o profunda e de incid\u00eancias ecocardiogr\u00e1ficas n\u00e3o convencionais, como corte intermedi\u00e1rio entre apical de 4 e 2 c\u00e2maras, com angula\u00e7\u00e3o posterior do transdutor, pode ser necess\u00e1rio, assim como o uso complementar de imageamento com contraste ultrassonogr\u00e1fico. 6.2.3.3. Fun\u00e7\u00e3o Diast\u00f3lica do Ventr\u00edculo Esquerdo A an\u00e1lise da fun\u00e7\u00e3o diast\u00f3lica pode ser desafiadora, por fatores de confundimento, em raz\u00e3o da presen\u00e7a eventual de FA e de MP em c\u00e2maras direitas. O aumento gradual da rela\u00e7\u00e3o E/e\u2019 ocorre a partir da FIDC e um valor maior que 15 \u00e9 preditor de pior desfecho em pacientes com disfun\u00e7\u00e3o sist\u00f3lica apenas discreta a moderada.  H\u00e1 evid\u00eancias de que a rela\u00e7\u00e3o E/e\u2019 se correlaciona, de forma independente, com os n\u00edveis sangu\u00edneos de pept\u00eddeo natriur\u00e9tico do tipo B (BNP).  A altera\u00e7\u00e3o do relaxamento mioc\u00e1rdico \u00e9 a primeira a surgir, podendo estar presente mesmo em pacientes com a FIDC. Com a progress\u00e3o da cardiomiopatia, a disfun\u00e7\u00e3o diast\u00f3lica pode agravar-se e apresentar padr\u00e3o restritivo t\u00edpico.  O volume do \u00e1trio esquerdo correlaciona-se, de forma independente, com a mortalidade.  A fun\u00e7\u00e3o atrial esquerda na CCDC est\u00e1 mais comprometida do que em outras etiologias, como na CMD idiop\u00e1tica, provavelmente devido a um acometimento miop\u00e1tico atrial intr\u00ednseco associado.  Quando avaliada pelostrain, a fun\u00e7\u00e3o atrial esquerda tamb\u00e9m se mostrou preditor independente de eventos cl\u00ednicos em pacientes com a DC.  De forma semelhante, \u00edndices de disfun\u00e7\u00e3o do \u00e1trio esquerdo avaliados pela ecocardiografia tridimensional e pelostrainforam preditores independentes para o surgimento de FA de in\u00edcio recente no seguimento desses pacientes.  A disfun\u00e7\u00e3o diast\u00f3lica contribui decisivamente para o remodelamento atrial, que pode ter seu volume aumentado em qualquer est\u00e1gio da CCDC. 6.2.3.4. Avalia\u00e7\u00e3o do Ventr\u00edculo Direito o comprometimento do VD pode, mais raramente, ocorrer de forma prim\u00e1ria e prematuramente em rela\u00e7\u00e3o ao acometimento do VE.  A disfun\u00e7\u00e3o sist\u00f3lica de VD, avaliada por meio de par\u00e2metros ecocardiogr\u00e1ficos convencionais, como o \u00edndice de Tei, foi preditor independente de mau progn\u00f3stico na CCDC.  O estudo da fun\u00e7\u00e3o sist\u00f3lica de VD pela t\u00e9cnica de STE, em especial na parede livre da c\u00e2mara, apresentou acur\u00e1cia satisfat\u00f3ria, correlacionando-se com outros m\u00e9todos, como a RMC.  A ecocardiografia tridimensional tamb\u00e9m constitui ferramenta promissora na avalia\u00e7\u00e3o da fun\u00e7\u00e3o sist\u00f3lica do VD.  A avalia\u00e7\u00e3o de VD pela ecocardiografia convencional, usando proje\u00e7\u00f5es dedicadas, permite a quantifica\u00e7\u00e3o de suas dimens\u00f5es, volumes (ECO 3D) e fun\u00e7\u00e3o contr\u00e1til, e deve ser realizada em todos os pacientes com CCDC. Embora frequentemente associado \u00e0 disfun\u00e7\u00e3o de VE, 6.2.3.5. Ecocardiograma sob Estresse Embora o exame farmacol\u00f3gico use comumente a dobutamina, provida de potencial arritmog\u00eanico, evidenciou-se seguran\u00e7a do m\u00e9todo na CCDC, sendo o \u00edndice de contra\u00e7\u00e3o segmentar alterado em repouso um preditor independente para o surgimento de arritmias durante o exame.  O ECO sob estresse farmacol\u00f3gico  pode demonstrar a presen\u00e7a de reserva contr\u00e1til bif\u00e1sica nesses pacientes, que tipicamente apresentam coron\u00e1rias subepic\u00e1rdicas sem obstru\u00e7\u00f5es.  Embora a RMC n\u00e3o seja exame de avalia\u00e7\u00e3o inicial da DC, o m\u00e9todo tem se mostrado \u00fatil no diagn\u00f3stico e estratifica\u00e7\u00e3o de risco da CCDC. Pacientes em investiga\u00e7\u00e3o de cardiomiopatia e sem suspeita espec\u00edfica de DC e que n\u00e3o vivem em \u00e1rea end\u00eamica frequentemente n\u00e3o s\u00e3o submetidos a testes sorol\u00f3gicos para DC. Nesses casos, um padr\u00e3o de disfun\u00e7\u00e3o sist\u00f3lica global ou regional t\u00edpico, associado a padr\u00e3o e localiza\u00e7\u00e3o espec\u00edfica da fibrose mioc\u00e1rdica pela RMC, pode levantar a suspeita e indicar a necessidade de se desencadear o teste sorol\u00f3gico espec\u00edfico.  A RMC pode ainda ser \u00fatil para detectar envolvimento mioc\u00e1rdico precoce na DC, principalmente na FIDC, quando, em geral, todos os outros exames s\u00e3o normais.  Al\u00e9m disso, a RMC \u00e9 capaz de estimar o progn\u00f3stico. A quantidade de fibrose mioc\u00e1rdica correlaciona-se fortemente com marcadores de gravidade da doen\u00e7a, arritmias ventriculares, eventos cardiovasculares graves e mesmo morte.  \u00c0 RMC, novas ferramentas n\u00e3o invasivas podem identificar atividade inflamat\u00f3ria mioc\u00e1rdica (edema e hiperemia mioc\u00e1rdica) em est\u00e1gio inicial antes do desenvolvimento de les\u00f5es irrevers\u00edveis, como necrose e fibrose, e eventualmente auxiliar na estratifica\u00e7\u00e3o de risco e, qui\u00e7\u00e1, na decis\u00e3o terap\u00eautica.  O imageamento por RMC provou ainda ser \u00fatil para detectar trombos intracard\u00edacos em pacientes selecionados, especialmente aqueles com imagens ecocardiogr\u00e1ficas limitadas e sem indica\u00e7\u00e3o de angiocardiografia invasiva.  Esse potencial progn\u00f3stico da RMC na CCDC muito provavelmente depender\u00e1 de confirma\u00e7\u00e3o por estudos em andamento e dever\u00e1 corroborar a amplifica\u00e7\u00e3o dos m\u00e9todos de estratifica\u00e7\u00e3o de risco j\u00e1 empregados.  Investiga\u00e7\u00f5es recentes indicam ter a RMC bom potencial para avaliar o progn\u00f3stico de pacientes com CCDC, independentemente do j\u00e1 provido pelo escore de RASSI, talvez permitindo a reestratifica\u00e7\u00e3o daqueles com risco baixo ou intermedi\u00e1rio de morte. steady-state free precession), imagens ponderadas em T2 e/ou mapa T2 para avalia\u00e7\u00e3o de edema mioc\u00e1rdico e obrigatoriamente o emprego de gadol\u00ednio para detectar pelo realce tardio mioc\u00e1rdico a fibrose mioc\u00e1rdica regional macrosc\u00f3pica. \u00c9 ainda oportuno que seja inclu\u00edda a t\u00e9cnica de mapa T1 mioc\u00e1rdico pr\u00e9 (nativo) e p\u00f3s-contraste para c\u00e1lculo do volume extracelular do mioc\u00e1rdio, que \u00e9 uma medida de fibrose intersticial e difusa, que pode estar presente nessa cardiomiopatia, mesmo em regi\u00f5es mioc\u00e1rdicas sem realce tardio evidente. O realce global ponderado em T1 antes e depois do contraste  ou o realce precoce com gadol\u00ednio pode ser \u00fatil para a detec\u00e7\u00e3o de hiperemia/inflama\u00e7\u00e3o. A aquisi\u00e7\u00e3o de realce tardio com um tempo de invers\u00e3o longo (~ 600ms) tamb\u00e9m deve ser usada, especificamente na suspeita de trombo intracavit\u00e1rio, para aumentar a sensibilidade de sua detec\u00e7\u00e3o.  O exame de RMC deve incluir avalia\u00e7\u00e3o da fun\u00e7\u00e3o sist\u00f3lica biventricular por t\u00e9cnicas de SSFP  s\u00e3o as t\u00e9cnicas utilizadas.  Merece relato o exemplo cl\u00e1ssico de CCDC pela RMC, que envolve os segmentos \u00ednfero-laterais basais e m\u00e9dio e o \u00e1pice do VE, com altera\u00e7\u00f5es contr\u00e1teis t\u00edpicas pela cine-resson\u00e2ncia e fibrose mioc\u00e1rdica de padr\u00e3o e distribui\u00e7\u00e3o caracter\u00edsticos pelo realce tardio. Um aneurisma apical t\u00edpico de VE com morfologia \u201cdedo em luva\u201d pode ser claramente visto nas imagens de cine-resson\u00e2ncia e no realce tardio. American Heart Associationrecomendou a RMC em pacientes selecionados com cardiopatia para avaliar a extens\u00e3o da fibrose e at\u00e9 mesmo exames seriados de RMC para indiv\u00edduos com arritmias ventriculares complexas, especialmente TVNS.  Recente posicionamento cient\u00edfico sobre DC daEuropean Association of Cardiovascular Imaginge do Departamento de Imagem Cardiovascular da SBC, foi recomendado que a RMC deva ser indicada em pacientes selecionados com arritmias ventriculares graves para quantificar a extens\u00e3o da fibrose mioc\u00e1rdica e avaliar o risco de morte s\u00fabita com potencial impacto na indica\u00e7\u00e3o de implante de cardioversor-desfibrilador implant\u00e1vel (CDI). Ainda, a RMC deveria ser indicada para avalia\u00e7\u00e3o da FEVE quando a ecocardiografia b\u00e1sica for considerada insatisfat\u00f3ria e n\u00e3o estiver dispon\u00edvel a ecocardiografia com contraste ou a tridimensional.  Em outro documento de consenso sobre imageamento em DC da \u00c9 modalidade de imageamento n\u00e3o invasiva, mas que requer uso de radia\u00e7\u00e3o. No caso da DC, o exame pode ser utilizado para a an\u00e1lise da fun\u00e7\u00e3o biventricular como alternativa \u00e0 RMC e para analisar a perfus\u00e3o mioc\u00e1rdica diante da suspeita de coronariopatia em n\u00edvel subepic\u00e1rdico ou microvascular, al\u00e9m de para avaliar a inerva\u00e7\u00e3o card\u00edaca simp\u00e1tica. 6.2.5.1. Ventriculografia Radioisot\u00f3pica A medicina nuclear \u00e9 op\u00e7\u00e3o para a an\u00e1lise da fun\u00e7\u00e3o sist\u00f3lica de ambos os ventr\u00edculos, em especial nos pacientes que mostram impedimento ou contraindica\u00e7\u00e3o \u00e0 realiza\u00e7\u00e3o de RMC e nos raros casos em que a ecocardiografia se mostra inexequ\u00edvel tecnicamente. Poderia ser considerado o m\u00e9todo padr\u00e3o-ouro para mensura\u00e7\u00e3o da fra\u00e7\u00e3o de eje\u00e7\u00e3o de ambos os ventr\u00edculos por permitir amostragem integrada de muitos ciclos card\u00edacos, assim minimizando a variabilidade ocasional que limita, em algumas circunst\u00e2ncias, a confiabilidade de m\u00e9todos que analisam apenas poucos ciclos, e para determina\u00e7\u00e3o dos volumes diast\u00f3lico e sist\u00f3lico, sem recorrer a pressupostos de ordem geom\u00e9trica. Tamb\u00e9m fornece informa\u00e7\u00f5es relacionadas \u00e0 contratilidade regional e \u00e0 presen\u00e7a de aneurismas ventriculares, t\u00e3o caracter\u00edsticos dessa entidade.  A avalia\u00e7\u00e3o da fun\u00e7\u00e3o diast\u00f3lica, cuja altera\u00e7\u00e3o pode ser uma das manifesta\u00e7\u00f5es mais precoces na DC, \u00e9 feita, mas com limita\u00e7\u00f5es, pela ventriculografia radioisot\u00f3pica. Por outro lado, a disfun\u00e7\u00e3o ventricular direita, que tamb\u00e9m pode ser um sinal precoce dessa cardiopatia, pode ser avaliada com precis\u00e3o por meio das t\u00e9cnicas de medicina nuclear, mas seu emprego em pacientes com CCDC ainda \u00e9 limitado logisticamente. 6.2.5.2. Perfus\u00e3o Mioc\u00e1rdica A preval\u00eancia de doen\u00e7a coron\u00e1ria obstrutiva n\u00e3o costuma ser elevada em pacientes com CCDC, mesmo quando apresentam dor precordial. Por outro lado, h\u00e1 relatos independentes, por v\u00e1rios investigadores, de que ocorra disfun\u00e7\u00e3o da microcircula\u00e7\u00e3o coron\u00e1ria nesses pacientes e a presen\u00e7a de defeitos de perfus\u00e3o tem valor progn\u00f3stico, pois pode preceder o desenvolvimento de disfun\u00e7\u00e3o contr\u00e1til mioc\u00e1rdica. SPECT-CT) \u00e9 eficaz para detectar dist\u00farbios da irriga\u00e7\u00e3o no m\u00fasculo card\u00edaco, mesmo diante da aus\u00eancia de les\u00f5es nas art\u00e9rias coron\u00e1rias epic\u00e1rdicas.  A exist\u00eancia de altera\u00e7\u00f5es cintilogr\u00e1ficas em pacientes com CCDC pode traduzir o mecanismo inflamat\u00f3rio pelo qual, ao menos em parte, h\u00e1 destrui\u00e7\u00e3o de m\u00fasculo card\u00edaco nessa entidade e sua substitui\u00e7\u00e3o por tecido fibr\u00f3tico. A cintilografia mioc\u00e1rdica de perfus\u00e3o baseada em tomografia computadorizada empregando radiotra\u00e7adores emissores de f\u00f3tons singulares ,  A detec\u00e7\u00e3o de arritmias card\u00edacas pelo Holter ou durante teste ergom\u00e9trico \u00e9 parte essencial da avalia\u00e7\u00e3o rotineira de pacientes com CCDC, possibilitando diagnosticar disfun\u00e7\u00e3o do n\u00f3 sinusal, dist\u00farbios na condu\u00e7\u00e3o atrioventricular, ectopias e taquiarritmias supraventriculares, ectopias ventriculares e TVNS ou TVS.  Estudo avaliando a ocorr\u00eancia das ectopias ventriculares pelo Holter em pacientes com CCDC evidenciou que o comportamento aparentemente aleat\u00f3rio dessa arritmia em grava\u00e7\u00f5es de 24 horas deixa de existir quando se analisam per\u00edodos mais longos, de 7 dias, sugerindo que grava\u00e7\u00f5es mais longas de Holter seriam mais adequadas nesse contexto.  No escore de RASSI, a identifica\u00e7\u00e3o de TVNS ao Holter soma 3 pontos de um total de 18 ou 20 pontos poss\u00edveis . Al\u00e9m da estratifica\u00e7\u00e3o de risco, o Holter permite a avalia\u00e7\u00e3o de sintomas como palpita\u00e7\u00f5es, lipotimias e s\u00edncopes, frequentes nesses pacientes e, em muitos casos, decorrentes das diversas formas de arritmia encontradas.  A presen\u00e7a de TVNS no Holter \u00e9 preditor independente de mortalidade geral em pacientes com CCDC.  H\u00e1 disfun\u00e7\u00e3o parassimp\u00e1tica predominante, mas tamb\u00e9m acometimento simp\u00e1tico (menor intensidade),  e ind\u00edcios preliminares, em estudo retrospectivo, de que tais altera\u00e7\u00f5es, refletindo-se em diversos par\u00e2metros de VFC, possam sinalizar risco de morte s\u00fabita.  A VFC avaliada durante registros curtos de Holter e com emprego de t\u00e9cnica de aprendizado de m\u00e1quina tamb\u00e9m mostrou capacidade de predi\u00e7\u00e3o de altera\u00e7\u00f5es ecocardiogr\u00e1ficas  e p\u00f4de ser correlacionada ao escore de RASSI, o mais avalizado prognosticador do risco de mortalidade, em cardiomiopatas com ou sem envolvimento digestivo associado.  O Holter tamb\u00e9m possibilita a avalia\u00e7\u00e3o do sistema nervoso aut\u00f4nomo por meio de an\u00e1lise da variabilidade da frequ\u00eancia card\u00edaca (VFC). V\u00e1rios estudos demonstraram altera\u00e7\u00f5es auton\u00f4micas em diferentes est\u00e1gios e formas da DC.  O EEF permite tamb\u00e9m avaliar o n\u00f3 sinusal e a condu\u00e7\u00e3o atrioventricular, al\u00e9m de definir com precis\u00e3o se o dist\u00farbio dromotr\u00f3pico localiza-se no n\u00f3 atrioventricular, no feixe de His ou \u00e9 infra-hissiano. A frequente ocorr\u00eancia parox\u00edstica de BAVT pelo acometimento do sistema His-Purkinje, consequente ao seu conhecido comportamento de condu\u00e7\u00e3o na forma \u201ctudo ou nada\u201d , faz com que, em determinados casos, apenas a investiga\u00e7\u00e3o invasiva com EEF permita o diagn\u00f3stico preciso e o tratamento adequado do paciente.  Na CCDC ocorrem substratos arritmog\u00eanicos reentrantes relacionados \u00e0s \u00e1reas de fibrose e o EEF permite a indu\u00e7\u00e3o de TVS ou mesmo FV que, em alguns contextos, passam a ter conota\u00e7\u00e3o progn\u00f3stica.  No entanto, a aplicabilidade cl\u00ednica geral dos testes de exerc\u00edcio n\u00e3o est\u00e1 bem estabelecida, embora o cardiopulmonar, com medida direta do consumo de oxig\u00eanio (VO 2 m\u00e1ximo), possa ser considerado o padr\u00e3o-ouro para avalia\u00e7\u00e3o da capacidade funcional e efic\u00e1cia dos programas de reabilita\u00e7\u00e3o.  O teste de esfor\u00e7o m\u00e1ximo convencional e o de avalia\u00e7\u00e3o cardiopulmonar podem detectar altera\u00e7\u00f5es importantes, incluindo arritmias ventriculares induzidas pelo exerc\u00edcio e incompet\u00eancia cronotr\u00f3pica.  Como essas arritmias tamb\u00e9m ocorrem em pacientes sem cardiopatia aparente, o teste de exerc\u00edcio m\u00e1ximo convencional \u00e9 clinicamente relevante para estratifica\u00e7\u00e3o de risco na popula\u00e7\u00e3o com DC, especialmente para orienta\u00e7\u00f5es trabalhistas.  Arritmias ventriculares induzidas pelo esfor\u00e7o constituem um marcador de risco de morte cardiovascular em pacientes com DC. 2 pico \u00e9 crit\u00e9rio importante para o TC em pacientes com formas avan\u00e7adas de cardiopatia. Entretanto, seu valor progn\u00f3stico deve ser mais bem compreendido no contexto de estrat\u00e9gias preventivas, estratifica\u00e7\u00e3o de risco e diagn\u00f3stico precoce. Al\u00e9m disso, \u00e9 necess\u00e1rio estabelecer pontos de corte para serem empregados especificamente na CCDC.  Poucos estudos verificaram a efic\u00e1cia das vari\u00e1veis avaliadas por meio dos testes de exerc\u00edcio na predi\u00e7\u00e3o de sobrevida dos pacientes com CCDC. O VO  Conforme apontado acima, pacientes com CCDC frequentemente apresentam dor tor\u00e1cica at\u00edpica e anormalidades eletrocardiogr\u00e1ficas, como altera\u00e7\u00f5es no segmento ST e ondas Q patol\u00f3gicas, al\u00e9m de dist\u00farbios regionais de contratilidade e de perfus\u00e3o mioc\u00e1rdica que mimetizam doen\u00e7a coron\u00e1ria ateroscler\u00f3tica. Na maioria desses casos, a avalia\u00e7\u00e3o das coron\u00e1rias epic\u00e1rdicas demonstra aus\u00eancia de doen\u00e7a ateroscler\u00f3tica obstrutiva subepic\u00e1rdica, atribuindo-se essas altera\u00e7\u00f5es \u00e0 disfun\u00e7\u00e3o microvascular coronariana.  Al\u00e9m disso, esses investigadores relataram melhora sintom\u00e1tica e da perfus\u00e3o mioc\u00e1rdica quando os pacientes com CCDC foram tratados com inibidor plaquet\u00e1rio e vasodilatador microvascular, a primeira demonstra\u00e7\u00e3o de benef\u00edcio alcan\u00e7ado nesse contexto.  Estudos recentes evidenciaram que a disfun\u00e7\u00e3o ventricular associada \u00e0 doen\u00e7a microvascular de etiologia da DC \u00e9 mais proeminente do que a verificada quando esse dist\u00farbio microcirculat\u00f3rio decorre de outras etiologias.  O cateterismo card\u00edaco tamb\u00e9m pode ser realizado em pacientes candidatos a TC por IC avan\u00e7ada para avaliar a resist\u00eancia vascular pulmonar. Al\u00e9m disso, possibilita a bi\u00f3psia endomioc\u00e1rdica p\u00f3s-transplante, quando a diferencia\u00e7\u00e3o de rejei\u00e7\u00e3oversusreativa\u00e7\u00e3o da infec\u00e7\u00e3o porT. cruzise torna mandat\u00f3ria em alguns pacientes.  O cateterismo card\u00edaco pode ser empregado, portanto, quando pacientes com m\u00e9dia ou alta probabilidade de doen\u00e7a arterial coronariana obstrutiva apresentam dor anginosa t\u00edpica e/ou m\u00faltiplos fatores de risco para doen\u00e7a ateroscler\u00f3tica ou t\u00eam grande \u00e1rea isqu\u00eamica demonstrada em exames n\u00e3o invasivos. Durante o estudo hemodin\u00e2mico, a ventriculografia de contraste radiol\u00f3gico, por sua elevada resolu\u00e7\u00e3o temporal e espacial, pode indigitar pequenos aneurismas apicais e/ou outras altera\u00e7\u00f5es segmentares na contra\u00e7\u00e3o ventricular, que poderiam n\u00e3o ser detectadas por outros m\u00e9todos de imageamento.  Em outra com 52 estudos incluindo somente pacientes com cardiopatia manifesta, revelaram-se taxa anual m\u00e9dia de mortalidade de 7,9% , mas com ampla heterogeneidade de resultados, e taxas individuais variando entre 0,5% e 38,3%/ano, dependendo das caracter\u00edsticas de base da popula\u00e7\u00e3o inclu\u00edda em cada estudo.   ou que tinham a FIDC . tudo.    Nas \u00faltimas d\u00e9cadas, v\u00e1rios fatores de risco para morbimortalidade foram identificados para quantificar a gravidade da CCDC, avaliar seu progn\u00f3stico e, eventualmente, sugerir estrat\u00e9gias terap\u00eauticas mais adequadas. Infelizmente, quando consideradas isoladamente, vari\u00e1veis associadas a um pior progn\u00f3stico em geral apresentam baixo valor preditivo positivo, limitando seu uso. Assim, passou-se a investigar modelos progn\u00f3sticos constru\u00eddos a partir de combina\u00e7\u00f5es variadas de par\u00e2metros demogr\u00e1ficos, cl\u00ednicos e laboratoriais.  Para ser aplicado na pr\u00e1tica cl\u00ednica, o modelo de estratifica\u00e7\u00e3o de risco deve ser simples e utilizar vari\u00e1veis bem definidas, de f\u00e1cil acesso e em n\u00famero n\u00e3o excessivo, al\u00e9m de apresentar poder discriminat\u00f3rio (estat\u00edstica C) satisfat\u00f3rio. Mais importante ainda, deve ser validado por investigadores de outros centros  e em per\u00edodos posteriores  e, se poss\u00edvel, capaz de predizer outros desfechos diferentes daquele para o qual foi desenvolvido e em diferentes cen\u00e1rios .  Vale ressaltar que modelos progn\u00f3sticos sem valida\u00e7\u00e3o externa, mesmo que desenvolvidos de maneira adequada, s\u00e3o considerados de pouca utilidade e n\u00edvel baixo de sustenta\u00e7\u00e3o por evid\u00eancias, n\u00e3o sendo recomendados para uso na pr\u00e1tica di\u00e1ria. Geralmente, o modelo progn\u00f3stico tem melhor desempenho no conjunto de dados que deu origem ao modelo do que com os novos dados em an\u00e1lises de valida\u00e7\u00e3o. et al.  desenvolveram e validaram um escore de risco para predizer morte por todas as causas na CCDC. Na coorte original envolvendo 424 pacientes ambulatoriais seguidos em m\u00e9dia por 7,9 anos, a mortalidade total foi de 31% (130/424), sendo 87% (113/130) do total de \u00f3bitos por causas cardiovasculares e 62% (81/130) devidos a morte s\u00fabita card\u00edaca. Na coorte de valida\u00e7\u00e3o externa (153 pacientes), a taxa de mortalidade total foi de 23% (35/153) durante seguimento m\u00e9dio de 7,7 anos, com a maioria dos \u00f3bitos (57%) tamb\u00e9m ocorrendo subitamente.  Em 2006, Rassi Jr A an\u00e1lise multivariada identificou seis preditores independentes de mortalidade, sendo atribu\u00eddos a cada um deles pontos correspondentes \u00e0 sua for\u00e7a de associa\u00e7\u00e3o com o desfecho em quest\u00e3o  a partir de valores baseados no coeficiente beta de regress\u00e3o do modelo de Cox . Com ba permite substituir a medida do ICT \u00e0 radiografia de t\u00f3rax pela medida do DDVE ao ECO, uma vez que foi observada, subsequentemente, boa correla\u00e7\u00e3o entre ICT > 0,50 e DDVE > 60 mm;  dispensa o uso de f\u00f3rmulas ou calculadoras por se tratar de escore de memoriza\u00e7\u00e3o numericamente simples e fact\u00edvel; \u00e9 capaz de predizer as tr\u00eas principais causas de \u00f3bitos: total, cardiovascular e s\u00fabito;  e, por fim, foi validado externamente em quatro coortes distintas, em momentos diferentes e por pesquisadores independentes.  Deve-se enfatizar que em duas dessas coortes,  o desfecho avaliado foi diferente daquele contemplado na publica\u00e7\u00e3o original  e, mesmo assim, o escore de RASSI mostrou resultados bastante reprodut\u00edveis  e que fazem parte da investiga\u00e7\u00e3o inicial obrigat\u00f3ria de pacientes com CCDC; avalia a fun\u00e7\u00e3o ventricular esquerda de maneira subjetiva, dispensando a medida da fra\u00e7\u00e3o de eje\u00e7\u00e3o pelo m\u00e9todo de Simpson e valoriza as altera\u00e7\u00f5es tanto globais quanto segmentares da contratilidade mioc\u00e1rdica, essas \u00faltimas recentemente corroboradas como importantes preditores independentes de risco de eventos cardiovasculares por meio de an\u00e1lise criteriosa do banco de dados do estudo BENEFIT; ut\u00edveis .  com a presen\u00e7a e extens\u00e3o da fibrose mioc\u00e1rdica \u00e0 RMC detectada pela t\u00e9cnica do realce tardio  ou do mapeamento T1,  essa \u00faltima avaliando o componente intersticial da fibrose mioc\u00e1rdica, e ainda com a indu\u00e7\u00e3o de taquiarritmias ventriculares sustentadas ao EEF.  A robustez do escore de RASSI, particularmente no que diz respeito \u00e0 acur\u00e1cia de sua estratifica\u00e7\u00e3o em subgrupos de risco, \u00e9 respaldada por resultados de investiga\u00e7\u00f5es recentes em diferentes contextos, demonstrando, por exemplo, haver forte correla\u00e7\u00e3o positiva dos n\u00edveis de risco com o grau de disautonomia card\u00edaca,  Em outro estudo, avaliando pacientes que realizaram teste cardiopulmonar de esfor\u00e7o, a adi\u00e7\u00e3o do escore de RASSI ao limiar anaer\u00f3bio aumentou a \u00e1rea sob a curva ROC de 0,706 para 0,800, tendo \u00f3bito por todas as causas como desfecho prim\u00e1rio \u00e0 an\u00e1lise de regress\u00e3o log\u00edstica.  Ao se investigarem a preval\u00eancia e o valor progn\u00f3stico da dissincronia ventricular ao ECO e do escore de RASSI em pacientes com CCDC, tendo como desfecho a combina\u00e7\u00e3o de morte total e hospitaliza\u00e7\u00e3o, apenas o escore de RASSI foi capaz de predizer os eventos combinados em an\u00e1lise multivariada . 2 aumentada  e o escore de RASSI  estiveram associados a maior mortalidade em an\u00e1lise multivariada ap\u00f3s seguimento m\u00e9dio de 32 meses.  Em pacientes com IC e FEVE < 45%, ao se avaliar o valor progn\u00f3stico de vari\u00e1veis obtidas no teste cardiopulmonar de esfor\u00e7o juntamente com outras vari\u00e1veis, apenas a inclina\u00e7\u00e3o VE/VCO  que utilizou an\u00e1lise multivariada para melhor avalia\u00e7\u00e3o do progn\u00f3stico na CCDC, englobando aproximadamente 4.300 pacientes, um enfoque mais detalhado dessas vari\u00e1veis demonstrou que os preditores mais consistentes e relevantes de mortalidade total, morte s\u00fabita card\u00edaca ou morte cardiovascular foram classe funcional III ou IV daNew York Heart Association(NYHA), cardiomegalia na radiografia de t\u00f3rax, disfun\u00e7\u00e3o ventricular esquerda avaliada por ECO ou cineventriculografia, al\u00e9m de TVNS ao Holter de 24 horas. Utilizando essas quatro vari\u00e1veis de forma integrada, \u00e9 poss\u00edvel elaborar um algoritmo capaz de estratificar o risco de \u00f3bito de pacientes com DC de maneira simplificada e l\u00f3gica por meio de par\u00e2metros cl\u00ednicos e m\u00e9todos complementares dispon\u00edveis na maioria dos servi\u00e7os de atendimento cardiol\u00f3gico em nosso meio ( Em revis\u00e3o sistem\u00e1tica de 12 estudos (1985 a 2006), so meio . per se, identifica casos de alto risco, uma vez que praticamente todos esses pacientes apresentam disfun\u00e7\u00e3o ventricular sist\u00f3lica ao ECO e TVNS ao Holter. J\u00e1 a combina\u00e7\u00e3o de disfun\u00e7\u00e3o ventricular com TVNS, independentemente da classe funcional, identifica grupo com risco cerca de 15 vezes maior quando comparado a pacientes nos quais essas duas anormalidades est\u00e3o ausentes.  A presen\u00e7a de classe funcional III ou IV da NYHA, espera sanar tal defici\u00eancia.  Apesar de o escore de RASSI apresentar base te\u00f3rica solidamente estabelecida na literatura como preditor independente de eventos fatais, validado externamente em m\u00faltiplos estudos, o mesmo ainda \u00e9 pouco utilizado no dia a dia. Talvez um dos motivos poss\u00edveis seja a baixa disponibilidade no SUS brasileiro, fora do ambiente dos hospitais universit\u00e1rios, dos m\u00e9todos diagn\u00f3sticos simples usados no c\u00e1lculo do escore, como o ECO e o Holter de 24 horas. Esta diretriz, conforme exposto em outros cap\u00edtulos, ao recomendar fortemente a aplica\u00e7\u00e3o do escore como principal m\u00e9todo de estratifica\u00e7\u00e3o de risco em todos os pacientes t\u00e3o logo se confirme o diagn\u00f3stico da cardiomiopatia, a exemplo do que j\u00e1 estabelecem outros consensos de sociedades internacionais, CHronic use of Amiodarone aGAinSt Implantable Cardioverter-defibrillator), comparando amiodaronaversusdesfibrilador na redu\u00e7\u00e3o de mortalidade total como estrat\u00e9gia de preven\u00e7\u00e3o prim\u00e1ria, tendo como crit\u00e9rios de inclus\u00e3o a presen\u00e7a de pelo menos um epis\u00f3dio de TVNS ao Holter de 24 horas e escore de RASSI \u2265 10 pontos.  Al\u00e9m disso, apesar de projetar o risco de \u00f3bito a longo prazo em condi\u00e7\u00f5es de progn\u00f3stico bastante heterog\u00eaneo, a utilidade do escore de RASSI em guiar a conduta cl\u00ednica e terap\u00eautica subsequente ainda resta por ser determinada. \u00c9 razo\u00e1vel considerar que a valiosa informa\u00e7\u00e3o do risco, assim providenciada pelo escore para pacientes e seus m\u00e9dicos, poder\u00e1 orientar estrat\u00e9gias de acompanhamento e, possivelmente, de tratamento. Vale ressaltar que se encontra em fase de conclus\u00e3o o ECR multic\u00eantrico brasileiro CHAGASICS  possam se submeter a revis\u00f5es cl\u00ednicas anuais, ao passo que os de risco intermedi\u00e1rio ou alto devam fazer revis\u00f5es mais ami\u00fade (a cada 3 ou 6 meses).  disfun\u00e7\u00e3o sist\u00f3lica do VD (\u00edndice de Tei),  disfun\u00e7\u00e3o diast\u00f3lica do VE (rela\u00e7\u00e3o E/e\u2019),  aumento de volume do \u00e1trio esquerdo,  altera\u00e7\u00f5es nos \u00edndices de deforma\u00e7\u00e3o mioc\u00e1rdica,  disfun\u00e7\u00e3o parassimp\u00e1tica e simp\u00e1tica,  altera\u00e7\u00f5es espec\u00edficas no ECG,  variabilidade da amplitude da onda T,  desvio do eixo da onda T,  dispers\u00e3o do intervalo QT,  altera\u00e7\u00f5es no ECG de alta resolu\u00e7\u00e3o ,  diminui\u00e7\u00e3o da VFC,  aumento da dura\u00e7\u00e3o do complexo QRS,  diminui\u00e7\u00e3o do VO 2 pico,  diminui\u00e7\u00e3o do tempo de exerc\u00edcio  e aumento dos valores plasm\u00e1ticos dos pept\u00eddeos natriur\u00e9ticos tipo B (BNP e NT-proBNP)  entre outros.  Tais fatores e vari\u00e1veis, quando analisados por meio de modelos multivariados ou transformados em escores de risco, associam-se a pior progn\u00f3stico. Al\u00e9m disso, contribuem para trazer informa\u00e7\u00f5es sobre os mecanismos relacionados \u00e0 progress\u00e3o da doen\u00e7a e desvendar aspectos menos explorados da sua complexa prognostica\u00e7\u00e3o.  Outros estudos acerca do progn\u00f3stico na CCDC focaram diferentes marcadores de risco, como redu\u00e7\u00e3o da FEVE,  As seguintes limita\u00e7\u00f5es afetam sua aplicabilidade: uso de vari\u00e1veis de mensura\u00e7\u00e3o dif\u00edcil ou trabalhosa, n\u00e3o padronizadas e de baixa reprodutibilidade, muitas vezes extra\u00eddas de exames complementares de acesso restrito ou n\u00e3o dispon\u00edveis na pr\u00e1tica comum; inclus\u00e3o de n\u00famero inadequadamente reduzido de pacientes ou de desfechos; n\u00e3o inclus\u00e3o de todas as vari\u00e1veis reconhecidamente associadas a um pior progn\u00f3stico na maioria desses modelos (aquelas 4 citadas anteriormente); e, particularmente, aus\u00eancia de valida\u00e7\u00e3o externa.  Entretanto, os estudos acima s\u00e3o bastante heterog\u00eaneos, sendo imperativo reconhecer limita\u00e7\u00f5es a essas abordagens.  Infelizmente, parece haver n\u00famero crescente de publica\u00e7\u00f5es tentando desenvolver novos modelos de risco em vez de validar ou aperfei\u00e7oar modelos existentes.  Assim, os escores propostos n\u00e3o est\u00e3o prontos para serem utilizados na assist\u00eancia m\u00e9dica de rotina, j\u00e1 que, na quase totalidade dos estudos, carece-se de valida\u00e7\u00e3o externa e independente.  e desenvolveu um escore simplificado para uso em regi\u00f5es end\u00eamicas sem acesso \u00e0 proped\u00eautica cardiol\u00f3gica al\u00e9m do ECG. O escore incluiu dados cl\u00ednicos e eletrocardiogr\u00e1ficos, al\u00e9m da dosagem do NT-proBNP, para a predi\u00e7\u00e3o do risco de morte em 2 anos em pacientes com CCDC.  Cinco preditores independentes de \u00f3bito foram identificados, dando-se pontos aos mesmos, da seguinte forma: idade (10 pontos por d\u00e9cada); classe funcional da NYHA superior a I (15 pontos); FC \u2265 80 batimentos/min (20 pontos); dura\u00e7\u00e3o do QRS \u2265 150ms (15 pontos); e NT-proBNP anormal ajustado pela idade (55 pontos). Os pacientes foram ent\u00e3o classificados em tr\u00eas categorias de risco . A valida\u00e7\u00e3o externa foi realizada aplicando-se o escore a outra popula\u00e7\u00e3o independente com DC. Ap\u00f3s 2 anos de seguimento, na coorte de desenvolvimento, 110 pacientes morreram, com uma taxa de mortalidade global de 3,5 mortes por 100 pessoas-ano. As taxas de mortalidade observadas nos grupos de risco baixo, intermedi\u00e1rio e alto foram 0%, 3,6% e 32,7%, respectivamente, na coorte de deriva\u00e7\u00e3o e 3,2%, 8,7% e 19,1%, respectivamente, na coorte de valida\u00e7\u00e3o. A discrimina\u00e7\u00e3o do escore foi boa na coorte de desenvolvimento  e na coorte de valida\u00e7\u00e3o .  As principais limita\u00e7\u00f5es do escore s\u00e3o a utiliza\u00e7\u00e3o da dosagem de NT-proBNP, que n\u00e3o \u00e9 habitualmente dispon\u00edvel na APS, e a aus\u00eancia de valida\u00e7\u00e3o externa independente e extensiva, como j\u00e1 foi realizado para o escore de RASSI.  Um estudo recente utilizou os dados da coorte NIH SaMi-Trop  ou a quantifica\u00e7\u00e3o  de fibrose mioc\u00e1rdica pela t\u00e9cnica do realce tardio na RMC, seja como vari\u00e1vel cont\u00ednua  ou como vari\u00e1vel dicot\u00f4mica , mostrou ser um importante preditor de risco para eventos cardiovasculares graves, como morte total, morte cardiovascular e ocorr\u00eancia de taquiarritmias ventriculares sustentadas, independentemente da fun\u00e7\u00e3o ventricular e do escore de RASSI. Vale destacar que um dos estudos  possibilitou a compara\u00e7\u00e3o direta entre o valor progn\u00f3stico da quantidade de fibrose mioc\u00e1rdica e o escore de RASSI.  Em dois outros estudos, a simples identifica\u00e7\u00e3o versusHR: 1,33; IC 95%: 0,68-2,61; p = 0,406). Expressas como vari\u00e1veis cont\u00ednuas (escore de RASSI em pontos e fibrose mioc\u00e1rdica em gramas), ambas foram preditoras de risco, mas com maior relev\u00e2ncia para o escore de RASSI , ou seja, para cada ponto adicional no escore de RASSI, o risco de \u00f3bito aumenta em 23%, enquanto para cada 1 grama adicional de fibrose mioc\u00e1rdica, esse aumento \u00e9 de apenas 2%. A massa de fibrose, como vari\u00e1vel dicot\u00f4mica, apresentou estat\u00edstica C de 0,709  na predi\u00e7\u00e3o de \u00f3bito por qualquer causa, ao passo que, para o escore de RASSI, esse valor n\u00e3o foi informado.  Utilizando mortalidade total como desfecho final (considerado desfecho secund\u00e1rio), ap\u00f3s seguimento mediano de 5,4 anos, o poder de associa\u00e7\u00e3o pelo escore de RASSI foi mais marcante do que o da fibrose mioc\u00e1rdica. Expressas como vari\u00e1veis categ\u00f3ricas , apenas o escore de RASSI esteve associado a pior progn\u00f3stico , o passo l\u00f3gico seguinte ser\u00e1 testar se o m\u00e9todo \u00e9 capaz de melhorar o desempenho de modelos de estratifica\u00e7\u00e3o de risco j\u00e1 existentes por meio de novas t\u00e9cnicas estat\u00edsticas, como a Tabela de reclassifica\u00e7\u00e3o, o \u00edndice de reclassifica\u00e7\u00e3o l\u00edquida (NRI) e a melhora da discrimina\u00e7\u00e3o integrada (IDI).  ao final de 10 anos ter\u00edamos 61 \u00f3bitos no grupo de baixo risco, 84 \u00f3bitos no grupo intermedi\u00e1rio e 168 \u00f3bitos no grupo de alto risco. Assim, de um total de 313 \u00f3bitos durante os 10 anos de seguimento, apesar de a maioria (168 ou 54%) ocorrer no grupo de alto risco (o que \u00e9 desej\u00e1vel em termos de estratifica\u00e7\u00e3o de risco), ainda ter\u00edamos 145 \u00f3bitos nos grupos de risco baixo e intermedi\u00e1rio. Para que um novo preditor de risco prove sua utilidade cl\u00ednica, o ideal \u00e9 que, uma vez adicionado ao escore de RASSI, ele seja capaz de identificar corretamente os pacientes de risco baixo e intermedi\u00e1rio que ir\u00e3o a \u00f3bito ou, menos provavelmente, aqueles de alto risco que ir\u00e3o sobreviver. Talvez a fibrose mioc\u00e1rdica seja esse marcador, uma hip\u00f3tese ainda a ser testada.  De acordo com a preval\u00eancia dos grupos de risco no escore de RASSI, sabe-se que, se o mesmo for aplicado a 1.000 pacientes com cardiomiopatia, 610 ser\u00e3o classificados como de baixo risco para \u00f3bito total, 190 como de risco intermedi\u00e1rio e 200 como de alto risco. Com taxas de \u00f3bito de 10%, 44% e 84% em 10 anos, respectivamente, para os tr\u00eas subgrupos,  Ademais, n\u00e3o h\u00e1 na literatura dados informando se a mudan\u00e7a na pontua\u00e7\u00e3o do escore de RASSI (particularmente com diminui\u00e7\u00e3o no n\u00famero de pontos) \u00e9 capaz de avaliar e monitorar a efic\u00e1cia de determinado tratamento e de melhorar o progn\u00f3stico dos pacientes. No entanto, como o escore integra seis vari\u00e1veis, atribuindo-se de 0 a 20 pontos ao conjunto, e duas delas possuem maior chance de sofrer altera\u00e7\u00f5es , essa \u00e9 outra investiga\u00e7\u00e3o atraente a ser considerada. a priori, risco de \u00f3bito elevado, bem como pacientes com doen\u00e7a isqu\u00eamica, hipertensiva ou valvular associada, para evitar confus\u00e3o com \u00f3bitos n\u00e3o relacionados \u00e0 CCDC, foram exclu\u00eddos do c\u00e1lculo e padroniza\u00e7\u00e3o do escore de RASSI.  Por fim, deve-se enfatizar que pacientes com idade > 70 anos, MP card\u00edaco artificial, TVS ou FV (documentadas), por apresentarem, Durante seguimento m\u00e9dio de 36 meses, apenas 1 dos 72 pacientes apresentou TVS espont\u00e2nea.  O valor progn\u00f3stico do EEF em pacientes com CCDC ainda n\u00e3o est\u00e1 bem estabelecido. No tocante \u00e0 preven\u00e7\u00e3o prim\u00e1ria de morte s\u00fabita, os dados dispon\u00edveis sugerem que o EEF n\u00e3o tenha utilidade progn\u00f3stica em pacientes com EV isoladas ou TVNS, desde que a fun\u00e7\u00e3o sist\u00f3lica de VE seja normal. Em estudo incluindo 72 pacientes com fun\u00e7\u00e3o de VE preservada  e 400 a 1.200 EV/hora ao Holter (35% com TVNS), a estimula\u00e7\u00e3o ventricular programada n\u00e3o induziu TVS em nenhum dos pacientes.  avaliou o valor progn\u00f3stico da indu\u00e7\u00e3o de TVS em resposta \u00e0 estimula\u00e7\u00e3o ventricular programada em 78 pacientes com TVNS ao Holter  e sem hist\u00f3ria cl\u00ednica de arritmias sustentadas. TVS monom\u00f3rfica foi induzida em 25 pacientes (32%), todos tratados com f\u00e1rmacos antiarr\u00edtmicos da classe III, a maioria com amiodarona, e apenas um com sotalol. Ap\u00f3s acompanhamento m\u00e9dio de 56 meses, as probabilidades de ocorr\u00eancia de morte card\u00edaca e de eventos combinados  foram 2,2 e 2,6 vezes maiores , respectivamente, nos pacientes indut\u00edveis em compara\u00e7\u00e3o aos n\u00e3o indut\u00edveis. Por outro lado, a indu\u00e7\u00e3o de TV polim\u00f3rfica ou de FV n\u00e3o teve significado progn\u00f3stico, tratando-se, provavelmente, de resposta ventricular inespec\u00edfica ao teste.  Posteriormente, outro estudo  Quanto \u00e0 preven\u00e7\u00e3o secund\u00e1ria (pacientes com arritmias ventriculares sustentadas documentadas ou com morte s\u00fabita ressuscitada), alguns autores avaliaram a import\u00e2ncia do EEF na estratifica\u00e7\u00e3o de risco e escolha da terapia antiarr\u00edtmica, mas os dados dispon\u00edveis s\u00e3o limitados.  incluiu 115 pacientes apresentando TV sintom\u00e1tica , dos quais, 78 com TVS espont\u00e2nea e 37 com TVNS espont\u00e2nea e TVS induzida ao EEF. Ap\u00f3s impregna\u00e7\u00e3o com antiarr\u00edtmicos da classe III de Vaughan-Williams , os pacientes foram divididos em tr\u00eas grupos, com base em suas respostas aos testes eletrofisiol\u00f3gicos. Os pacientes do grupo 1 n\u00e3o tinham TVS indut\u00edvel, aqueles do grupo 2 tinham TVS indut\u00edvel bem tolerada e aqueles do grupo 3 tinham TVS indut\u00edvel, hemodinamicamente inst\u00e1vel. Ap\u00f3s seguimento m\u00e9dio de 52 meses, a taxa de mortalidade total foi significativamente maior no grupo 3 em compara\u00e7\u00e3o com os grupos 1 e 2 .  O maior estudo de natureza observacional  Com base nesses resultados, embora o EEF seja capaz de identificar pacientes com maior risco de \u00f3bito ou que n\u00e3o respondem bem ao tratamento com f\u00e1rmacos antiarr\u00edtmicos, seu papel em guiar outros tipos de terapias, como, por exemplo, o implante de um CDI, permanece indefinido, o que torna o m\u00e9todo de pouca utilidade para esse fim.  sendo depois classicamente ratificado, em 1985,  para definir a situa\u00e7\u00e3o de um indiv\u00edduo cronicamente infectado peloT. cruzimas assintom\u00e1tico, com exame f\u00edsico normal e sem altera\u00e7\u00f5es na radiografia de t\u00f3rax, no ECG convencional e nos exames radiol\u00f3gicos contrastados de es\u00f4fago e c\u00f3lon.  A FIDC constitui per\u00edodo latente que, em geral, se inicia logo ap\u00f3s o t\u00e9rmino da fase aguda, podendo permanecer indefinidamente, ou seja, por toda a exist\u00eancia do indiv\u00edduo. Esse est\u00e1gio da DC foi reconhecido desde os estudos primordiais por Carlos Chagas,  Nessa situa\u00e7\u00e3o, orienta-se o uso do termo \u201csem cardiopatia aparente\u201d para esses pacientes em espec\u00edfico. Da mesma forma, essa denomina\u00e7\u00e3o cl\u00e1ssica n\u00e3o se aplica a pacientes assintom\u00e1ticos em rela\u00e7\u00e3o ao sistema digest\u00f3rio, por\u00e9m sem avalia\u00e7\u00e3o de es\u00f4fago e c\u00f3lon por exames contrastados.  A cl\u00e1ssica defini\u00e7\u00e3o de FIDC n\u00e3o considera indiv\u00edduos com altera\u00e7\u00f5es eletrocardiogr\u00e1ficas \u201cinespec\u00edficas\u201d, ou seja, n\u00e3o definidoras de CCDC.  Por exemplo, mesmo a baixa voltagem do complexo QRS no plano frontal, que conota mau progn\u00f3stico pelo escore de RASSI, \u00e9 tamb\u00e9m detect\u00e1vel em indiv\u00edduos enfisematosos ou obesos m\u00f3rbidos ; aspectos gen\u00e9ticos do hospedeiro; gravidade da infec\u00e7\u00e3o aguda inicial relacionada com a via de transmiss\u00e3o; exposi\u00e7\u00e3o \u00e0 reinfec\u00e7\u00e3o pelo parasito em \u00e1reas com transmiss\u00e3o vetorial sustentada; estado nutricional e presen\u00e7a de comorbidades; contexto social; qualidade de vida dos indiv\u00edduos com DC; e aus\u00eancia de tratamento antiparasit\u00e1rio.  Infelizmente, a despeito de d\u00e9cadas de pesquisa, ainda n\u00e3o est\u00e3o totalmente esclarecidos os fatores que levam cerca de 30% dos indiv\u00edduos na FIDC a desenvolverem a CCDC.  sendo a pr\u00f3pria mortalidade superpon\u00edvel \u00e0 da popula\u00e7\u00e3o geral n\u00e3o infectada, enquanto o ECG for normal.  O indiv\u00edduo com a FIDC pode permanecer por muitas d\u00e9cadas nessa condi\u00e7\u00e3o,  sendo que a realiza\u00e7\u00e3o anual ou mesmo bianual do ECG, de maneira seriada, pode detectar a evolu\u00e7\u00e3o para CCDC.  A despeito do pouco conhecimento sobre a hist\u00f3ria natural da DC, \u00e9 importante enfatizar que a FIDC tem geralmente bom progn\u00f3stico,  As taxas anuais de progress\u00e3o para CCDC, a partir da FIDC, variam de 0,3% a 10,3%, com m\u00e9dia de 1,9%.  Na FIDC, a presen\u00e7a de ECO alterado por dissinergias regionais, mesmo em vig\u00eancia de fun\u00e7\u00e3o ventricular sist\u00f3lica global preservada, pode significar risco para eventos cl\u00ednicos, como BAVT, AVC, taquiarritmias ventriculares e/ou IC, traduzindo pior progn\u00f3stico quando comparado a indiv\u00edduos na FIDC com ECO normal.  Altera\u00e7\u00f5es eletrocardiogr\u00e1ficas podem surgir no seguimento, em porcentagens vari\u00e1veis, por\u00e9m sem correspondente direto com a FEVE, que costuma permanecer inalterada. T. cruzina mesma faixa et\u00e1ria.  A incid\u00eancia anual de morte s\u00fabita entre os indiv\u00edduos com DC e ECG normal \u00e9 baixa e se assemelha \u00e0 da popula\u00e7\u00e3o sem DC,  sendo essa uma complica\u00e7\u00e3o rara, que incide de igual forma na popula\u00e7\u00e3o geral e, portanto, sua causa n\u00e3o deve ser atribu\u00edda \u00e0 DC.  O bom progn\u00f3stico dos pacientes com a FIDC foi relatado em v\u00e1rios estudos longitudinais, concluindo que as taxas de mortalidade s\u00e3o similares entre indiv\u00edduos com a FIDC e controles n\u00e3o infectados pelo sendo que pacientes adultos jovens tratados etiologicamente progridem menos para CCDC, em compara\u00e7\u00e3o aos n\u00e3o tratados.  Em rela\u00e7\u00e3o ao tratamento com medicamentos tripanocidas na fase cr\u00f4nica da DC, a FIDC constitui uma das principais indica\u00e7\u00f5es,  No caso particular de paciente com ECG normal e ECO evidenciando altera\u00e7\u00f5es segmentares da contra\u00e7\u00e3o ventricular, esse indiv\u00edduo deve receber a mesma abordagem proped\u00eautica daquele que apresenta ECG definidor de CCDC.  O seguimento de indiv\u00edduos com FIDC deve ser mantido em n\u00edvel de APS, sendo recomendada a realiza\u00e7\u00e3o anual ou bianual do ECG, uma vez que algumas altera\u00e7\u00f5es eletrocardiogr\u00e1ficas t\u00eam car\u00e1ter evolutivo e s\u00e3o priorit\u00e1rias como definidoras de CCDC.  A quest\u00e3o da rela\u00e7\u00e3o entre envelhecimento e comorbidades nos pacientes com FIDC parece ser independente da pr\u00f3pria presen\u00e7a de DC.  Por\u00e9m, pacientes idosos com a FIDC constituem grupo populacional particularmente vulner\u00e1vel em rela\u00e7\u00e3o aos efeitos prejudiciais de doen\u00e7as cr\u00f4nicas degenerativas.  Entre as comorbidades cardiovasculares, predomina a hipertens\u00e3o arterial sist\u00eamica (HAS) e, menos frequentemente, a doen\u00e7a arterial coronariana.  O monitoramento e o tratamento dessas comorbidades, associadas a dislipidemia e diabetesmellitus, devem ser feitos de forma individualizada. O controle desses agravos \u00e9 fundamental na preven\u00e7\u00e3o secund\u00e1ria da CCDC.  Pacientes com FIDC podem apresentar comorbidades que s\u00e3o mais frequentes \u00e0 medida que essa popula\u00e7\u00e3o envelhece. T. cruzi(comprovado por pelo menos duas sorologias positivas com t\u00e9cnicas laboratoriais distintas) deve ser, a princ\u00edpio, conservadora, com objetivo de caracterizar-se a FIDC e estabelecerem-se as seguintes recomenda\u00e7\u00f5es: 1) Na aus\u00eancia de sintomas cardiovasculares e digestivos  e sendo o exame f\u00edsico e o ECG (de prefer\u00eancia com registro de 30seg em deriva\u00e7\u00e3o \u00fanica) normais, n\u00e3o h\u00e1 necessidade de exames adicionais, dispensando-se os exames radiol\u00f3gicos de t\u00f3rax, es\u00f4fago e c\u00f3lon; 2) Devem-se repetir a anamnese dirigida, o exame f\u00edsico e o ECG anualmente ou bianualmente; 3) N\u00e3o deve ser institu\u00edda restri\u00e7\u00e3o para exerc\u00edcios f\u00edsicos (mesmo competitivos); 4) N\u00e3o se deve implementar restri\u00e7\u00e3o profissional, inclusive para condu\u00e7\u00e3o de ve\u00edculos coletivos; e 5) O apoio psicol\u00f3gico \u00e9 indispens\u00e1vel, explicitando-se as no\u00e7\u00f5es progn\u00f3sticas favor\u00e1veis, que norteiam essas condutas m\u00e9dicas mais conservadoras.  A conduta m\u00e9dica geral frente a indiv\u00edduo cronicamente infectado pelo A realiza\u00e7\u00e3o anual ou bianual de ECG em pacientes com FIDC tem recomenda\u00e7\u00e3o forte, com n\u00edvel de evid\u00eancia B. Reiterando o exposto em cap\u00edtulo espec\u00edfico da diretriz, o tratamento tripanocida com benznidazol deve ser oferecido, como recomenda\u00e7\u00e3o forte, n\u00edvel de evid\u00eancia B, aos indiv\u00edduos cursando com a FIDC at\u00e9 os 50 anos de idade. T. cruzipersiste como um desafio cr\u00edtico ao se analisarem os avan\u00e7os ao longo dos \u00faltimos 50 anos.  \u00c9 inequ\u00edvoca a import\u00e2ncia da realiza\u00e7\u00e3o dessa modalidade de tratamento da DC para tanto as pessoas acometidas, quanto, de modo mais amplo, suas fam\u00edlias e comunidades. Trata-se de quest\u00e3o central para os sistemas nacionais de sa\u00fade e barreiras devem ser superadas para que todos os pacientes possam ter acesso a diagn\u00f3stico e tratamento adequados.  Esse dilema \u00e9tico depende da atua\u00e7\u00e3o mais proativa de gestores, profissionais de sa\u00fade , movimentos sociais e todas as demais pessoas interessadas.  Assegurar acesso a tratamento etiol\u00f3gico antiparasit\u00e1rio (tripanocida) eficaz, eficiente e seguro para a infec\u00e7\u00e3o por Apesar dos avan\u00e7os, esses ainda t\u00eam sido insuficientes para uma resposta consistente em sa\u00fade p\u00fablica, com vista ao controle da doen\u00e7a na rede de servi\u00e7os locais de sa\u00fade nos diversos pa\u00edses.  Em muitos cen\u00e1rios locorregionais, m\u00e9todos para diagn\u00f3stico complementar e medicamentos para tratamento n\u00e3o est\u00e3o dispon\u00edveis e as popula\u00e7\u00f5es locais n\u00e3o est\u00e3o suficientemente informadas de sua factibilidade.  A DC insere-se no extenso grupo de DTN, em que falhas cr\u00edticas da ci\u00eancia, do ambiente mercadol\u00f3gico e da sa\u00fade p\u00fablica, tornam esse desafio ainda maior.  Em linhas gerais, h\u00e1 evid\u00eancias contundentes de que ambos s\u00e3o efetivos em reduzir a dura\u00e7\u00e3o e a gravidade cl\u00ednica da doen\u00e7a, ao possibilitarem a elimina\u00e7\u00e3o de parasitos quando do tratamento precoce na hist\u00f3ria natural da doen\u00e7a,  com ganhos potenciais em termos da qualidade de vida mediante preven\u00e7\u00e3o de eventuais limita\u00e7\u00f5es de capacidade f\u00edsica.  Nessas \u00faltimas cinco d\u00e9cadas, ainda se registra gritante limita\u00e7\u00e3o de op\u00e7\u00f5es para tratamento etiol\u00f3gico, havendo disponibilidade apenas de dois medicamentos comprovadamente eficazes, o benznidazol (1971) e o nifurtimox (1965).  Entretanto, os estudos dispon\u00edveis at\u00e9 o momento n\u00e3o permitem recomendar esquemas terap\u00eauticos diferentes dos classicamente estabelecidos. Ressalte-se que, na realidade brasileira do SUS, o benznidazol representa o f\u00e1rmaco mais dispon\u00edvel e utilizado, ainda com limitada operacionaliza\u00e7\u00e3o frente \u00e0 demanda esperada.  Em geral, o benznidazol ainda \u00e9 o mais eficaz tripanocida, com sistem\u00e1tica comprova\u00e7\u00e3o em ensaios cl\u00ednicos que o utilizaram como comparador para avalia\u00e7\u00e3o de novos f\u00e1rmacos. Entretanto, ainda h\u00e1 cr\u00edticas lacunas para o desenvolvimento de novas op\u00e7\u00f5es terap\u00eauticas com menor toxicidade, visando a melhorar o perfil de seguran\u00e7a e o acesso ao tratamento. Reconhece-se o car\u00e1ter estrat\u00e9gico de desenvolvimento de novos estudos para avaliar n\u00e3o apenas o uso de terapias combinadas, mas tamb\u00e9m de esquemas mais curtos temporalmente, com doses fixas e menores, em conson\u00e2ncia com a busca de melhores e mais confi\u00e1veis par\u00e2metros cl\u00ednicos e biomarcadores laboratoriais, para se avaliar a efic\u00e1cia do tratamento.  e traz, como benef\u00edcios potenciais para a pessoa acometida, a redu\u00e7\u00e3o da parasitemia, com impacto positivo na evolu\u00e7\u00e3o cl\u00ednica, como o impedimento da progress\u00e3o para a forma card\u00edaca, a redu\u00e7\u00e3o de complica\u00e7\u00f5es cl\u00ednicas nas duas fases da doen\u00e7a e o aumento da expectativa de vida, al\u00e9m da melhora da capacidade f\u00edsica e da qualidade vital.  O tratamento etiol\u00f3gico adequado \u00e9 reconhecidamente custo-efetivo  e de que a oferta desses medicamentos seja cont\u00ednua, fato ainda limitado pelo n\u00famero restrito de seus fornecedores e a baixa demanda pelos produtos nos pr\u00f3prios sistemas locais de sa\u00fade.  Torna-se, portanto, fundamental evitar oportunidades perdidas para o estabelecimento de diagn\u00f3stico e tratamento. Tendo em vista estar relacionada \u00e0 pobreza e a contextos de grande vulnerabilidade social, reconhece-se tamb\u00e9m que a aten\u00e7\u00e3o integral \u00e0s pessoas com DC potencialmente reduzir\u00e1 inequidades em sa\u00fade, em particular nos territ\u00f3rios end\u00eamicos.  Reconhece-se que, entre os principais desafios, insere-se a necessidade de que o tratamento etiol\u00f3gico esteja dispon\u00edvel e implementado nos sistemas locais de sa\u00fade  Os documentos referenciais apresentados a seguir estiveram fundamentados, em maior ou menor grau, nos procedimentos metodol\u00f3gicos do sistema GRADE,  adaptado para fins espec\u00edficos destas diretrizes (ver cap\u00edtulo relacionado).  Este cap\u00edtulo espec\u00edfico sobre tratamento etiol\u00f3gico fundamenta-se na an\u00e1lise de consensos, protocolos cl\u00ednicos e diretrizes terap\u00eauticas, que foram escritos e atualizados em diferentes contextos recentes. Representam estrat\u00e9gias relevantes que visam a contribuir com a amplia\u00e7\u00e3o do acesso a diagn\u00f3stico e tratamento, com base no apoio consubstanciado a decis\u00f5es cl\u00ednicas. Gu\u00eda para el diagn\u00f3stico y el tratamiento de la enfermedad de Chagas / Guidelines for the diagnosis and treatment of Chagas disease), publicado em 2019 pela OPAS/OMS.  Considerou-se ainda na revis\u00e3o, a I Diretriz Latino-Americana para o Diagn\u00f3stico e Tratamento da Cardiopatia Chag\u00e1sica, de 2011, coordenada pela SBC.  Entre as diretrizes cl\u00ednicas regionais, incluiu-se a an\u00e1lise do guia para diagn\u00f3stico e tratamento da DC  em DC, conduzido pela Comiss\u00e3o Nacional de Incorpora\u00e7\u00e3o de Tecnologias no SUS (CONITEC), da Secretaria de Ci\u00eancia, Tecnologia e Insumos Estrat\u00e9gicos do Minist\u00e9rio da Sa\u00fade.  na sequ\u00eancia do Consenso Brasileiro em DC de 2005.  Adicionalmente, foi analisado o 2\u00ba Consenso Brasileiro em DC de 2015, um importante marco referencial, coordenado pela Secretaria de Vigil\u00e2ncia em Sa\u00fade do Minist\u00e9rio da Sa\u00fade em parceria com a Sociedade Brasileira de Medicina Tropical,  H\u00e1 pesquisas cl\u00ednicas que inclu\u00edram outros f\u00e1rmacos sem efic\u00e1cia comprovada, por exemplo, alopurinol e antif\u00fangicos az\u00f3licos (por reposicionamento de mol\u00e9culas),  n\u00e3o fazendo, entretanto, parte do escopo da presente diretriz.  Dois compostos antiparasit\u00e1rios nitro-heteroc\u00edclicos est\u00e3o dispon\u00edveis, com efic\u00e1cia estabelecida para o tratamento etiol\u00f3gico da DC: benznidazol, um agente derivado nitroimidaz\u00f3lico, e o nifurtimox, um composto nitrofur\u00e2nico. T. cruzi, mas sem evid\u00eancia de dano em \u00f3rg\u00e3o-alvo, e tiveram resultados limitados apenas a aspectos parasitol\u00f3gicos por meio da avalia\u00e7\u00e3o via qPCR de longo prazo (12 meses).  Apesar dos resultados desapontadores com os novos f\u00e1rmacos, os estudos comparativos refor\u00e7aram o papel relevante do benznidazol no tratamento da doen\u00e7a.  Nesse sentido, estudos t\u00eam sido conduzidos nos \u00faltimos 7 anos para avalia\u00e7\u00e3o da efic\u00e1cia e seguran\u00e7a de monoterapia ou terapias em combina\u00e7\u00e3o de benznidazol com outros agentes, como posaconazol ou fosravuconazol. Tais pesquisas foram conduzidas em indiv\u00edduos infectados com Revis\u00e3o recente identificou 109 estudos epidemiol\u00f3gicos publicados ap\u00f3s 1997 sobre tratamento etiol\u00f3gico da DC (31 observacionais e 78 de interven\u00e7\u00e3o), incluindo 23.116 indiv\u00edduos, com grande heterogeneidade n\u00e3o apenas do manejo cl\u00ednico para tratamento etiol\u00f3gico, assim como no delineamento e na condu\u00e7\u00e3o dos estudos, o que limita as evid\u00eancias dispon\u00edveis.  Em grande parte, as evid\u00eancias em DC devem ser aduzidas por serem fundamentadas em tratamento focado na infec\u00e7\u00e3o porT. cruzi. Diante da comprova\u00e7\u00e3o da a\u00e7\u00e3o tripanocida, na aus\u00eancia de estudos experimentais aleatorizados utilizando desfechos cl\u00ednicos relevantes, evid\u00eancias por meio de estudos menos robustos, observacionais e de boa qualidade devem ser consideradas.  Em linhas gerais, o grau de recomenda\u00e7\u00e3o \u2018ponderado\u2019 ou \u2018condicional\u2019 estabelecido pela OPAS para o uso de benznidazol e nifurtimox, principalmente em casos com DC cr\u00f4nica, justifica-se pelo limitado n\u00edvel de certeza do corpo de evid\u00eancias sobre resultados de efic\u00e1cia, oriundos da escassez de ECR nessa \u00e1rea.  Ademais, dentro do princ\u00edpio da assimetria, a magnitude de um eventual dano do tratamento, caso ocorra, \u00e9 significativamente menor do que o benef\u00edcio associado, particularmente com seguimento qualificado. Portanto, justifica-se o tratamento etiol\u00f3gico para DC em n\u00famero consider\u00e1vel dos casos.  Na perspectiva dos gestores, o tratamento com benznidazol, portanto, pode ser adotado como pol\u00edtica de sa\u00fade em contextos espec\u00edficos, levando em considera\u00e7\u00e3o o balan\u00e7o entre benef\u00edcios e riscos e prioridades em sa\u00fade. Para profissionais de sa\u00fade, h\u00e1 a possibilidade de diferentes escolhas para a tomada de decis\u00e3o, que deve ser sempre compartilhada e informada em rela\u00e7\u00e3o \u00e0s pessoas acometidas pela doen\u00e7a. Por fim, a maioria das pessoas acometidas, quando bem-informadas, teria elevada probabilidade de desejar receber a interven\u00e7\u00e3o.  O uso do nifurtimox no Brasil \u00e9 recomendado nos casos em que o benznidazol n\u00e3o foi tolerado, como na ocorr\u00eancia de eventos adversos graves, e em algumas outras circunst\u00e2ncias mais particularizadas e espec\u00edficas.  O benznidazol representa a primeira op\u00e7\u00e3o no contexto brasileiro, devido n\u00e3o apenas \u00e0 maior experi\u00eancia de uso, mas tamb\u00e9m ao perfil de eventos adversos e \u00e0 disponibilidade, particularmente de apresenta\u00e7\u00f5es pedi\u00e1tricas.  De forma an\u00e1loga, a indica\u00e7\u00e3o em casos com outras afec\u00e7\u00f5es graves  deve ser avaliada criteriosamente de modo individualizado, de acordo com a gravidade cl\u00ednica.  Em geral, o tratamento etiol\u00f3gico com quaisquer dos medicamentos anteriores n\u00e3o deve ser institu\u00eddo de modo rotineiro e indiscriminado em mulheres em idade f\u00e9rtil que n\u00e3o estejam em uso regular de m\u00e9todo anticoncepcional reconhecidamente eficaz.  No Brasil, somente as apresenta\u00e7\u00f5es de 100mg e 12,5mg est\u00e3o dispon\u00edveis na rede do SUS.  O benznidazol foi aprovado em 2017 pela Ag\u00eancia Norte-Americana de Alimentos e Medicamentos (FDA) para tratamento da infec\u00e7\u00e3o porT. cruzi, fato que n\u00e3o foi suficiente para garantir o pleno acesso de pacientes ao medicamento naquele pa\u00eds.  O benznidazol encontra-se dispon\u00edvel como comprimidos de 100 mg e 50 mg (adultos) e de 12,5mg e 50mg (crian\u00e7as). A absor\u00e7\u00e3o ocorre atrav\u00e9s do trato gastrointestinal, enquanto a excre\u00e7\u00e3o \u00e9 predominantemente renal, com meia vida de 12 horas.  Por outro lado, a distribui\u00e7\u00e3o do benznidazol 12,5 mg \u00e9 centralizada no Minist\u00e9rio da Sa\u00fade, considerando o limitado registro de casos pedi\u00e1tricos no pa\u00eds.  O Minist\u00e9rio da Sa\u00fade brasileiro adquire o benznidazol 100mg e o distribui \u00e0s Secretarias Estaduais de Sa\u00fade mediante solicita\u00e7\u00e3o no Sistema de Informa\u00e7\u00e3o de Insumos Estrat\u00e9gicos. O fluxo de distribui\u00e7\u00e3o para regionais de sa\u00fade e/ou munic\u00edpios \u00e9 estabelecido por cada secretaria, integrando a\u00e7\u00f5es da Assist\u00eancia Farmac\u00eautica, Vigil\u00e2ncia Epidemiol\u00f3gica e Aten\u00e7\u00e3o B\u00e1sica.  Em adultos com DC cr\u00f4nica, o benznidazol \u00e9 utilizado por via oral na dose de 5mg/kg/dia dividida em duas ou tr\u00eas tomadas, durante 60 dias, com dose m\u00e1xima recomendada de 300mg/dia. Para casos de DC aguda, essa dose pode ser de at\u00e9 10mg/kg/dia. Pessoas com peso acima de 60kg podem estender o esquema terap\u00eautico para que se alcance a dose-alvo ideal, mantendo-se 300 mg como limite di\u00e1rio, com vistas a prevenir a ocorr\u00eancia de eventos adversos.  Pode-se utilizar o esquema de 300mg de benznidazol pelo n\u00famero de dias equivalente ao peso da pessoa, limitado ao total de 80 dias, mesmo que a pessoa possua mais de 80kg.  Esse esquema posol\u00f3gico, que parece ser melhor tolerado, foi proposto originalmente pelo Professor Anis Rassi (in memoriam) e adotado posteriormente na segunda metade da investiga\u00e7\u00e3o com os cerca de 1.500 indiv\u00edduos arrolados no estudo BENEFIT, publicado em 2015.  Reconhece-se que o processo de defini\u00e7\u00e3o da dose apropriada de benznidazol para garantir efic\u00e1cia e tolerabilidade foi estabelecido por uma abordagem de tentativa e erro.  H\u00e1 a possibilidade de uso da formula\u00e7\u00e3o pedi\u00e1trica de 12,5mg em comprimidos sol\u00faveis, tendo a vantagem de poder ser utilizada para tratar desde rec\u00e9m-nascidos at\u00e9 crian\u00e7as de 2 anos de idade.  A principal vantagem do comprimido de 50mg (n\u00e3o dispon\u00edvel no Brasil) \u00e9 poder utiliz\u00e1-lo para tratar o restante da popula\u00e7\u00e3o pedi\u00e1trica, incluindo adolescentes e adultos jovens.  Em crian\u00e7as, a dose utilizada pode variar de 5 a 10mg/kg/dia, dividida em duas tomadas di\u00e1rias por 60 dias, com dose m\u00e1xima de 300 mg/dia. Quando a dose di\u00e1ria ultrapassar os 300mg, recomenda-se estender o tempo de tratamento at\u00e9 alcan\u00e7ar a dose total calculada para 60 dias.  STOP-CHAGAS  e E1224,  que n\u00e3o demonstraram efeito parasitol\u00f3gico de longo prazo com posaconazol ou fosravuconazol isoladamente, descreveram evid\u00eancia superior a 85% de depura\u00e7\u00e3o parasitol\u00f3gica precoce (PCR negativo) ap\u00f3s 2 a 4 semanas de tratamento com benznidazol isoladamente ou associado a posaconazol ou fosravuconazol, efeito que foi sustentado durante o seguimento de 12 meses.  Mais recentemente, os ensaios cl\u00ednicos randomizados CHAGASAZOL,  Como resultados, evidenciou-se que o benznidazol induziu resposta antiparasit\u00e1ria eficaz (variando de 83% a 89%), independentemente da dura\u00e7\u00e3o do tratamento (2 ou 4 semanas), dose di\u00e1ria (150 mg ou 300 mg) ou de combina\u00e7\u00e3o com fosravuconazol, tendo sido bem tolerado (3% de eventos adversos graves) em adultos com doen\u00e7a cr\u00f4nica.  Mesmo n\u00e3o sendo \u201cdefinitivo\u201d, esse estudo sugere o uso do benznidazol como padr\u00e3o de tratamento e ressalta a necessidade de se avan\u00e7ar em novos estudos para utiliza\u00e7\u00e3o de esquemas encurtados ou com doses reduzidas de benznidazol.  Posteriormente, foi publicado o ensaio cl\u00ednico BENDITA, um estudo cl\u00ednico duplo-cego, duplo simulado, de fase 2, multic\u00eantrico e randomizado conduzido na Bol\u00edvia, que incluiu pessoas com 18 anos a 50 anos de idade com a FIDC.  Entretanto, h\u00e1 ainda a necessidade de se disponibilizar evid\u00eancias mais contundentes para a futura ado\u00e7\u00e3o de um esquema terap\u00eautico encurtado. Nesse sentido, est\u00e3o em curso outros ensaios cl\u00ednicos, como por exemplo: estudo BETTY - um ECR de n\u00e3o inferioridade do tratamento com benznidazol em curto prazo para reduzir a carga parasit\u00e1ria deT. cruzi,em mulheres em idade reprodutiva;  o estudo MULTIBENZ \u2013 um ECR multic\u00eantrico de n\u00e3o inferioridade de fase II, para avalia\u00e7\u00e3o de efic\u00e1cia e seguran\u00e7a de diferentes doses de benznidazol para tratamento da DC em fase cr\u00f4nica em adultos;  e o estudo TESEO - um ensaio cl\u00ednico aberto, randomizado, prospectivo, de fase 2, para avalia\u00e7\u00e3o de seguran\u00e7a e efic\u00e1cia de novos esquemas terap\u00eauticos com benznidazol e nifurtimox, em adultos na fase cr\u00f4nica da DC, al\u00e9m de ampla avalia\u00e7\u00e3o com biomarcadores.  Esses achados ampliam as evid\u00eancias de que o uso do benznidazol, nesses novos esquemas, poderia ampliar o acesso ao tratamento etiol\u00f3gico, assim como assegurar sua maior tolerabilidade.  A incid\u00eancia m\u00e9dia de eventos adversos associados ao uso de benznidazol \u00e9 de cerca de 50%, sendo que manifesta\u00e7\u00f5es cut\u00e2neas, sintomas gastrointestinais e dist\u00farbios do sistema nervoso t\u00eam representado as raz\u00f5es mais comuns para interrup\u00e7\u00e3o do tratamento.  O benznidazol tem sua efic\u00e1cia demonstrada por v\u00e1rios estudos, mas tem limita\u00e7\u00f5es relacionadas \u00e0 tolerabilidade, por sua relativamente elevada toxicidade, que pode levar \u00e0 interrup\u00e7\u00e3o do tratamento antiparasit\u00e1rio em cerca de 10-25% dos casos. rash(30%), e geralmente n\u00e3o demandam a interrup\u00e7\u00e3o do tratamento por sua baixa intensidade.  A dermatite inicia-se j\u00e1 no final da primeira semana de tratamento, apresentando boa resposta ao tratamento com anti-histam\u00ednicos ou com pequenas doses orais de corticosteroides.  Podem ocorrer ainda intoler\u00e2ncia gastrointestinal (13%), com n\u00e1useas, v\u00f4mitos e diarreia, parestesias (10%) e artralgias (8%).  A frequ\u00eancia observada de eventos adversos ao benznidazol foi de 20,2% em crian\u00e7as e adolescentes com DC na fase aguda, a partir de casu\u00edsticas amaz\u00f4nicas em focos de maior ocorr\u00eancia de casos. Nesses relatos, as altera\u00e7\u00f5es dermatol\u00f3gicas  foram as principais (72%), seguidas por alopecia (3%), dist\u00farbios gastrointestinais (2%) e ins\u00f4nia (2%).  Os eventos adversos dermatol\u00f3gicos s\u00e3o os mais frequentes, particularmente dermatite urticariforme (45%) e A ocorr\u00eancia de polineuropatia perif\u00e9rica com parestesias e dor em membros inferiores \u00e9 mais comum em adultos e, em geral, inicia-se ao final do tratamento de 60 dias (particularmente ap\u00f3s 50 dias), podendo ter importante impacto sobre a funcionalidade e qualidade de vida, j\u00e1 que pode permanecer por alguns meses, mesmo ap\u00f3s a interrup\u00e7\u00e3o do tratamento e n\u00e3o responde bem a tratamento com anti-inflamat\u00f3rios e polivitam\u00ednicos. J\u00e1 a ocorr\u00eancia de febre, adenomegalia e dor em orofaringe \u00e9 sugestiva de depress\u00e3o precoce da medula \u00f3ssea e agranulocitose, um dos efeitos mais graves, apesar de raro, do benznidazol. Nesses casos, h\u00e1 desenvolvimento de leucopenia significativa \u00e0s custas de segmentados (neutropenia febril), indicando a necessidade de interrup\u00e7\u00e3o imediata e proscri\u00e7\u00e3o definitiva do f\u00e1rmaco. Por esse efeito, est\u00e1 indicada a realiza\u00e7\u00e3o rotineira de hemograma 3 semanas ap\u00f3s o in\u00edcio do tratamento.  O sucesso alcan\u00e7ado foi associado ao monitoramento pr\u00f3ximo dos casos, o que fortaleceu a vigil\u00e2ncia, mas tamb\u00e9m ao aconselhamento com informa\u00e7\u00e3o qualificada e identifica\u00e7\u00e3o oportuna de eventos adversos e seu manejo, que levou \u00e0 menor taxa de abandono,  refor\u00e7ando a import\u00e2ncia da longitudinalidade do cuidado.  Em s\u00edntese, a despeito dos aspectos anteriormente mencionados, ressalta-se que o tratamento etiol\u00f3gico com benznidazol pode ser conduzido com seguran\u00e7a no contexto da APS. Protocolo da organiza\u00e7\u00e3o M\u00e9dicos sem Fronteiras demonstrou resultados consistentes, pois at\u00e9 89,8% das pessoas tratadas conclu\u00edram o tratamento, apesar de que 56,0% tivessem desenvolvido algum evento adverso.  Ressalta-se que, para al\u00e9m do tratamento etiol\u00f3gico, considerando o car\u00e1ter cr\u00f4nico da DC, o acompanhamento farmacoterap\u00eautico tamb\u00e9m possibilita o reconhecimento de eventos associados a outros medicamentos utilizados no manejo dos casos, al\u00e9m de melhorar a ades\u00e3o e a qualidade de vida.  No contexto da assist\u00eancia farmac\u00eautica, recomenda-se o protocolo de dispensa\u00e7\u00e3o de benznidazol em intervalos de aproximadamente 7 dias, o que pode ampliar a seguran\u00e7a do uso por possibilitar um seguimento mais pr\u00f3ximo e qualificado, com detec\u00e7\u00e3o e registro mais oportunos de eventos adversos associados.  Em 2020, obteve aprova\u00e7\u00e3o da FDA/EUA para uso no tratamento da DC em crian\u00e7as com menos de 18 anos de idade,  abrindo oportunidade para ampliar acesso diante das evid\u00eancias dispon\u00edveis.  Nos casos em que for registrada intoler\u00e2ncia ao benznidazol, o nifurtimox poder\u00e1 ser recomendado. Encontra-se dispon\u00edvel em comprimidos de 120mg (adultos) e de 30mg (crian\u00e7as).  O nifurtimox n\u00e3o \u00e9 disponibilizado pelo mercado farmac\u00eautico do Brasil e o seu fornecimento tem sido regulado por meio de protocolo padronizado pela Secretaria de Vigil\u00e2ncia em Sa\u00fade do Minist\u00e9rio da Sa\u00fade via OPAS, mediante demanda espec\u00edfica, em geral relacionada \u00e0 suspeita ou confirma\u00e7\u00e3o de resist\u00eancia ou intoler\u00e2ncia ao benznidazol.  A absor\u00e7\u00e3o do f\u00e1rmaco \u00e9 gastrointestinal, com metaboliza\u00e7\u00e3o hep\u00e1tica via citocromo P450 e elimina\u00e7\u00e3o preferencial por via renal.  O estudo CHICO, um ensaio cl\u00ednico prospectivo, controlado para avaliar a efic\u00e1cia e seguran\u00e7a de uma nova formula\u00e7\u00e3o pedi\u00e1trica de nifurtimox em crian\u00e7as com idades entre 0 e 17 anos com DC ap\u00f3s 1 ano de tratamento, reiterou que o esquema de tratamento por 60 dias foi mais eficaz do que a mesma dosagem por 30 dias.  Em adultos, \u00e9 utilizado na dose de 10mg/kg/dia por via oral, em tr\u00eas tomadas di\u00e1rias, durante 60 dias. J\u00e1 em crian\u00e7as, a dose preconizada \u00e9 de 15 mg/kg/dia por via oral, tamb\u00e9m em tr\u00eas tomadas di\u00e1rias, durante 60 dias.  Nos EUA, verificou-se que, na an\u00e1lise de 243 casos que iniciaram o tratamento, 222  relataram pelo menos um evento adverso . Os eventos adversos relatados inclu\u00edram as seguintes categorias: gastrointestinal , neurol\u00f3gica  e constitucionais , sendo que os mais comumente relatados foram n\u00e1usea , anorexia , perda de peso , cefaleia  e dor abdominal . Pelo menos 90% dos pacientes de todas as faixas et\u00e1rias do estudo  relataram eventos adversos.  De 1.042 eventos adversos com dados quanto \u00e0 gravidade dispon\u00edveis, 680  foram leves, 254  moderados e 108  graves. Os eventos adversos graves mais frequentes foram: depress\u00e3o , neuropatia perif\u00e9rica , parestesia  e tontura/vertigem . A propor\u00e7\u00e3o de pessoas com pelo menos um evento adverso grave foi maior entre os casos com mais de 50 anos  comparativamente \u00e0 queles de 18 a 50 anos .  Para o nifurtimox, a frequ\u00eancia m\u00e9dia de eventos adversos \u00e9 de aproximadamente 85%, sendo os mais frequentes a intoler\u00e2ncia gastrointestinal, como anorexia e perda de peso (60%), eventos reumatol\u00f3gicos, como artralgias (35%), e acometimento dermatol\u00f3gico (15%).  Nesse sentido, os eventos adversos e a toxicidade do nifurtimox destacam-se pela menor toler\u00e2ncia digestiva, refletida em anorexia, n\u00e1useas e v\u00f4mitos, com perda de peso e dist\u00farbios psiqui\u00e1tricos mais frequentes em adultos.  Em seu guia de 2019, a OPAS considerou n\u00e3o haver diferen\u00e7as substanciais, com base na an\u00e1lise comparativa de efeitos adversos, entre os dois f\u00e1rmacos por meio das evid\u00eancias analisadas e da experi\u00eancia do seu painel t\u00e9cnico. Entretanto, foram reconhecidos perfis espec\u00edficos de eventos adversos predominantes, nifurtimox principalmente associado a perda de peso e efeitos adversos psiqui\u00e1tricos, e benznidazol a rea\u00e7\u00f5es cut\u00e2neas e neurol\u00f3gicas.  O Para ambos os antiparasit\u00e1rios, torna-se fundamental garantir o monitoramento cl\u00ednico do uso para avalia\u00e7\u00e3o e manejo oportuno desses eventos adversos, com \u00eanfase em sua tolerabilidade.  J\u00e1 em contextos com predomin\u00e2ncia da transmiss\u00e3o por via oral (surtos ou microepidemias familiares), em 75% a 100% dos casos, verifica-se s\u00edndrome cl\u00ednica leve, como no caso de crian\u00e7as, ou adoecimento evidente de s\u00edndrome febril prolongada.  Como j\u00e1 expresso em outro cap\u00edtulo desta diretriz, na hist\u00f3ria natural da DC, a maioria dos indiv\u00edduos com infec\u00e7\u00e3o estabelecida permanece assintom\u00e1tica ao longo de toda a vida. Na fase aguda, 90% dos casos por transmiss\u00e3o cl\u00e1ssica vetorial evoluem de forma assintom\u00e1tica ou oligossintom\u00e1tica, sendo que, dos 10% que apresentam alguma evid\u00eancia de s\u00edndrome cl\u00ednica, menos da metade evolui com formas mais graves ou \u00f3bito. T. cruzina fase aguda dependem exclusivamente da presen\u00e7a do parasito, enquanto na fase cr\u00f4nica essas les\u00f5es s\u00e3o parcialmente explicadas pela persist\u00eancia parasit\u00e1ria tissular e pelo grau de resposta imunol\u00f3gica ao parasito.  \u00c9 oportuno salientar que as les\u00f5es org\u00e2nicas derivadas da infec\u00e7\u00e3o por Na fase cr\u00f4nica, aproximadamente 60-70% dos casos permanecem assintom\u00e1ticos enquanto 30-40% progridem para as formas cl\u00ednicas da doen\u00e7a, em geral ap\u00f3s v\u00e1rios anos,  com algumas complica\u00e7\u00f5es potencialmente graves, em particular aquelas de natureza cardiovascular, associadas a elevada carga de morbimortalidade.  O tratamento, quando indicado na fase cr\u00f4nica, tem como objetivo reduzir os n\u00edveis de parasitemia, prevenir o surgimento ou a progress\u00e3o de les\u00f5es em \u00f3rg\u00e3os-alvo, al\u00e9m de evitar a transmiss\u00e3o.  A fase cr\u00f4nica da DC inclui a forma indeterminada (assintom\u00e1tica) e as formas card\u00edaca, digestiva e cardiodigestiva. T. cruzia medicamentos antiparasit\u00e1rios.  Esses aspectos refor\u00e7am a import\u00e2ncia do seguimento de todos os casos, independentemente do local onde estejam sendo tratados na rede de servi\u00e7os de sa\u00fade.  A resposta comprovada em termos parasitol\u00f3gicos ao tratamento etiol\u00f3gico \u00e9 vari\u00e1vel e est\u00e1 na depend\u00eancia de fatores que incluem: idade do caso no diagn\u00f3stico; fase e tempo de dura\u00e7\u00e3o da doen\u00e7a; exames complementares utilizados para avalia\u00e7\u00e3o de efic\u00e1cia terap\u00eautica; tempo de seguimento ap\u00f3s o tratamento; condi\u00e7\u00f5es associadas; e susceptibilidade de diferentes linhagens (TcI a TcVI) de O tratamento etiol\u00f3gico da pessoa acometida pela DC deve, portanto, ser conduzido considerando-se o perfil do caso e a forma cl\u00ednica da doen\u00e7a, conforme demonstrado no Esse tratamento deve ser realizado o mais precocemente poss\u00edvel ap\u00f3s o diagn\u00f3stico da infec\u00e7\u00e3o, independentemente do modo de transmiss\u00e3o doT. cruzi, tendo em vista os benef\u00edcios potenciais.  O tratamento etiol\u00f3gico para todos os casos  na fase aguda da DC tem grau de recomenda\u00e7\u00e3o \u2018forte\u2019, mesmo com n\u00edvel de evid\u00eancia B, de moderada qualidade em termos do benef\u00edcio do efeito tripanocida.  Tendo em vista que o contexto da DC aguda n\u00e3o tratada pode associar-se a mortalidade de at\u00e9 5% entre os casos diagnosticados  e ainda a potencial evolu\u00e7\u00e3o para a fase cr\u00f4nica da doen\u00e7a em todos os casos, considera-se que os benef\u00edcios potenciais s\u00e3o muito superiores em rela\u00e7\u00e3o aos eventos adversos, em sua maioria leves.  Nessa fase, a despeito da evid\u00eancia cient\u00edfica em n\u00edvel moderado e da limita\u00e7\u00e3o da certeza quanto a desfechos cl\u00ednicos da doen\u00e7a, o tratamento apresenta elevada efic\u00e1cia, aumenta a probabilidade de negativa\u00e7\u00e3o sorol\u00f3gica e/ou da parasitemia, al\u00e9m de melhorar a s\u00edndrome cl\u00ednica potencialmente grave da fase aguda e, consequentemente, a princ\u00edpio, prevenir a progress\u00e3o para a forma cr\u00f4nica manifesta da doen\u00e7a pela redu\u00e7\u00e3o de danos em \u00f3rg\u00e3os espec\u00edficos.  Nesse sentido, mesmo em casos assintom\u00e1ticos ou na impossibilidade de confirma\u00e7\u00e3o diagn\u00f3stica, mas com suspeita persistente , o tratamento emp\u00edrico pode ser considerado.  Reconhece-se, portanto, que a interven\u00e7\u00e3o deve ser adotada por gestores da sa\u00fade como pol\u00edtica de sa\u00fade na maioria das situa\u00e7\u00f5es, considerando-se inclusive que a grande maioria dos profissionais de sa\u00fade concorda com a recomenda\u00e7\u00e3o desse tratamento e que a maioria das pessoas acometidas, quando bem-informadas, deseja realizar a interven\u00e7\u00e3o.  Al\u00e9m disso, mesmo com n\u00edvel C de evid\u00eancia, justifica-se essa indica\u00e7\u00e3o pelo elevado risco associado (20-70%) de transmiss\u00e3o cong\u00eanita, com potencial impacto na sa\u00fade de neonatos afetados, considerando-se ainda que os raros relatos de tratamento etiol\u00f3gico durante a gesta\u00e7\u00e3o estariam associados \u00e0s poucas evid\u00eancias relatadas de malforma\u00e7\u00f5es.  No caso de gestantes  com s\u00edndrome cl\u00ednica aguda grave relacionada a miocardite ou a meningoencefalite, o tratamento antiparasit\u00e1rio deve ser indicado independentemente da idade gestacional, em virtude da elevada morbimortalidade materna.  Por outro lado, gestantes na fase aguda sem evid\u00eancias de gravidade cl\u00ednica devem aguardar, idealmente, o segundo trimestre da gesta\u00e7\u00e3o para realizar tratamento etiol\u00f3gico. Apesar do benef\u00edcio potencial de redu\u00e7\u00e3o da DC neonatal, n\u00e3o existe certeza sobre a eventual ocorr\u00eancia de mortalidade perinatal ou de malforma\u00e7\u00f5es fetais. Dessa forma, recomenda-se sempre realizar aconselhamento acerca dos riscos e benef\u00edcios da abordagem, com compartilhamento da decis\u00e3o, sendo justific\u00e1vel o n\u00e3o tratamento em alguns casos.  Assim como os casos de infec\u00e7\u00e3o aguda, pessoas diagnosticadas com DC por transmiss\u00e3o cong\u00eanita tamb\u00e9m devem receber o tratamento etiol\u00f3gico. Nesses casos, o grau de recomenda\u00e7\u00e3o tamb\u00e9m \u00e9 considerado \u2018forte\u2019, independentemente de o diagn\u00f3stico ter sido estabelecido por meio de m\u00e9todos parasitol\u00f3gicos, ainda nas primeiras semanas, ou por testes sorol\u00f3gicos convencionais, 9 meses ap\u00f3s o nascimento.  Essa forte recomenda\u00e7\u00e3o, a despeito da moderada qualidade das evid\u00eancias dispon\u00edveis (n\u00edvel B) favor\u00e1veis ao tratamento tripanocida, \u00e9 fundamentada nos benef\u00edcios previs\u00edveis no contexto de uma situa\u00e7\u00e3o cl\u00ednica potencialmente grave, assim como na maior probabilidade de cura concreta da infec\u00e7\u00e3o. T. cruzie a express\u00e3o do est\u00e1gio cl\u00ednico da doen\u00e7a.  Esses aspectos ser\u00e3o detalhados nas se\u00e7\u00f5es a seguir. Reitera-se que diante das atuais evid\u00eancias para DC e da relev\u00e2ncia para a vigil\u00e2ncia epidemiol\u00f3gica dos casos cr\u00f4nicos no pa\u00eds, torna-se estrat\u00e9gico ampliar o acesso a sa\u00fade e o desenvolvimento de aten\u00e7\u00e3o integral para al\u00e9m do tratamento etiol\u00f3gico, devendo-se atentar para a possibilidade de transmiss\u00e3o de m\u00e3e para filho.  O tratamento etiol\u00f3gico da pessoa acometida na fase cr\u00f4nica com suspeita de transmiss\u00e3o cong\u00eanita deve ser realizado, considerando-se a idade atual, o momento da infec\u00e7\u00e3o por Para essa conduta ressaltam-se os benef\u00edcios potenciais em contexto epidemiol\u00f3gico de maior gravidade, al\u00e9m da possibilidade de influenciar, com o tratamento, desfechos como negativa\u00e7\u00e3o da sorologia e da parasitemia.  Para essa popula\u00e7\u00e3o, o grau de recomenda\u00e7\u00e3o do tratamento etiol\u00f3gico \u00e9 considerado \u2018forte\u2019, com n\u00edvel de evid\u00eancia B.  A fundamenta\u00e7\u00e3o para essa decis\u00e3o remete-se a benef\u00edcios significativos em termos da redu\u00e7\u00e3o de danos em \u00f3rg\u00e3os espec\u00edficos, sem aumento do risco de efeitos adversos diante da melhor toler\u00e2ncia aos antiparasit\u00e1rios nesses grupos et\u00e1rios.  O tratamento antiparasit\u00e1rio est\u00e1 indicado a todas as crian\u00e7as (12 anos de idade ou menos) e adolescentes (13 a 18 anos idade) com diagn\u00f3stico de FIDC, considerando-se a maior probabilidade de negativa\u00e7\u00e3o sorol\u00f3gica, traduzindo, assim, adequa\u00e7\u00e3o da resposta \u00e0 terap\u00eautica.  Coortes de seguimento de longo prazo utilizando m\u00e9todos sorol\u00f3gicos convencionais, como controle de cura com per\u00edodo m\u00e9dio de seguimento superior a 10 anos para cada caso, e realizados em contextos reais amaz\u00f4nicos revelaram o sucesso do tratamento etiol\u00f3gico nessa popula\u00e7\u00e3o. Nessas coortes, considerou-se que o tratamento provocou m\u00ednimas complica\u00e7\u00f5es com potencial de cronicidade, a despeito da persist\u00eancia de sorologias reagentes.  A maior expectativa de vida dessa popula\u00e7\u00e3o tamb\u00e9m justifica a maior probabilidade de que o tratamento apresente melhor efetividade em crian\u00e7as quando comparadas a adultos.  O uso de nifurtimox pode ser considerado ainda como alternativa v\u00e1lida, particularmente em casos envolvendo crian\u00e7as, adolescentes e adultos jovens com infec\u00e7\u00e3o recente e na vig\u00eancia de intoler\u00e2ncia ao benznidazol.  Entretanto, as evid\u00eancias relativas \u00e0 preven\u00e7\u00e3o de manifesta\u00e7\u00f5es cl\u00ednicas da doen\u00e7a com uso de benznidazol seguem limitadas pelo curto per\u00edodo de seguimento dos estudos, sendo ainda mais reduzidas para o nifurtimox, que deve seguir como alternativa terap\u00eautica. T. cruzi,considera-se como \u2018forte\u2019 o grau de recomenda\u00e7\u00e3o de tratamento etiol\u00f3gico com benznidazol, inclusive pelo benef\u00edcio adicional dessa conduta ligado a seu car\u00e1ter estrat\u00e9gico para controle da transmiss\u00e3o cong\u00eanita da DC.  Ressalta-se que, para mulheres em idade f\u00e9rtil (15 a 49 anos) com infec\u00e7\u00e3o cr\u00f4nica por Assim, mesmo com um n\u00edvel de evid\u00eancia B, com certeza moderada quando da an\u00e1lise da rela\u00e7\u00e3o de benef\u00edcios e riscos, estabeleceu-se como \u2018forte\u2019 o grau de recomenda\u00e7\u00e3o de tratamento.  Deve-se recomendar ainda que essas mulheres utilizem m\u00e9todos anticoncepcionais eficazes de modo sistem\u00e1tico e correto durante todo o per\u00edodo do tratamento tripanocida, descartando-se gravidez antes do in\u00edcio do tratamento.  Essas popula\u00e7\u00f5es devem ainda ser sistematicamente aconselhadas e avaliadas em \u00e1reas end\u00eamicas quanto \u00e0 possibilidade da presen\u00e7a de triatom\u00edneos, que devem ser eliminados do domic\u00edlio (intra e peridomic\u00edlio) para prevenir reinfec\u00e7\u00e3o.  O tratamento antiparasit\u00e1rio diminui significativamente a probabilidade de ocorr\u00eancia da transmiss\u00e3o cong\u00eanita, sem observa\u00e7\u00e3o de eventos adversos fetais ou neonatais.  No entanto, gestantes com quadro cl\u00ednico agudo e grave de DC, expresso por miocardite ou meningoencefalite, ou ainda na fase aguda, mesmo n\u00e3o grave da doen\u00e7a diagnosticada no primeiro trimestre, devem passar por avalia\u00e7\u00e3o criteriosa e decis\u00e3o compartilhada, individualizada caso a caso, quanto \u00e0 possibilidade de tratamento etiol\u00f3gico, em conson\u00e2ncia com o que foi previamente discutido.  Caso ocorra a gravidez, n\u00e3o se recomenda o tratamento da gestante com DC cursando na fase cr\u00f4nica, tendo em vista que o risco de transmiss\u00e3o cong\u00eanita \u00e9 baixo, em torno de 1,5% a 2% no Brasil.  Na Amaz\u00f4nia brasileira, onde predominam infec\u00e7\u00f5es agudas, h\u00e1 registro de transmiss\u00e3o vertical por desconhecimento da gravidez em contextos de surto ou microepidemia familiar, com alguns relatos bem documentados de infec\u00e7\u00e3o cong\u00eanita mesmo ap\u00f3s in\u00edcio de tratamento materno com benznidazol. T. cruzi, a serem avaliadas ao longo de quatro anos de desenvolvimento. Entre outros relevantes aspectos, incluiu-se nesse cons\u00f3rcio internacional o objetivo de testar, em estudo controlado rand\u00f4mico, se um regime terap\u00eautico tripanocida com benznidazol menos prolongado (duas semanas) \u00e9 pelo menos t\u00e3o eficaz quanto o habitual e se tem menos efeitos colaterais (de 60 dias).  Finalmente, deve-se registrar a importante iniciativa internacional sob o acr\u00f4nimo \u2018CUIDA Chagas\u2019, \u00e0 qual aderiu o Minist\u00e9rio da Sa\u00fade do Brasil, envolvendo tamb\u00e9m Bol\u00edvia, Col\u00f4mbia e Paraguai, al\u00e9m de cinco estados brasileiros . Com in\u00edcio em 2022, o projeto inclui medidas e modelos de implementa\u00e7\u00e3o diagn\u00f3stica e terap\u00eautica para eventual elimina\u00e7\u00e3o da transmiss\u00e3o vertical da DC entre mulheres em idade f\u00e9rtil, cronicamente infectadas por Essa recomenda\u00e7\u00e3o assume assim um n\u00edvel condicional a depender do caso em an\u00e1lise, tendo em vista a limitada evid\u00eancia dispon\u00edvel para algumas popula\u00e7\u00f5es,  reconhecendo-se, entretanto, nesses casos, aspectos relativos ao princ\u00edpio da assimetria . Dessa forma, em linhas gerais, essa decis\u00e3o deve ser compartilhada entre o profissional m\u00e9dico e a equipe de sa\u00fade, a pessoa acometida e sua fam\u00edlia, a depender do momento de infec\u00e7\u00e3o, da idade e das condi\u00e7\u00f5es cl\u00ednicas.  O potencial de benef\u00edcio do tratamento etiol\u00f3gico para todo adulto com infec\u00e7\u00e3o cr\u00f4nica por DC n\u00e3o \u00e9 sustentado por evid\u00eancias suficientes que possam embasar uma recomenda\u00e7\u00e3o forte com n\u00edvel elevado de evid\u00eancia para essa indica\u00e7\u00e3o, genericamente, para quaisquer situa\u00e7\u00f5es cl\u00ednico-epidemiol\u00f3gicas.  Em geral, reitera-se que, como discutido para adolescentes, para adultos em qualquer idade com infec\u00e7\u00e3o recentemente adquirida, a despeito do modo de transmiss\u00e3o, o grau de recomenda\u00e7\u00e3o do tratamento \u00e9 considerado \u2018forte\u2019, com n\u00edvel de evid\u00eancia B.  Ressalta-se que as diretrizes de pr\u00e1tica cl\u00ednica da OPAS publicadas em 2018 n\u00e3o adotaram essa estratifica\u00e7\u00e3o et\u00e1ria, trazendo em perspectiva as perguntas: \u2018Qual \u00e9 a interven\u00e7\u00e3o terap\u00eautica mais segura e eficaz para doentes adultos com infec\u00e7\u00e3o cr\u00f4nica por T. cruzi e [sem/com] les\u00f5es de \u00f3rg\u00e3os espec\u00edficos?\u2019. Para os casos na forma cr\u00f4nica indeterminada, o tratamento etiol\u00f3gico foi estabelecido como \u2018condicional\u2019 com n\u00edvel de evid\u00eancia \u2018fraco\u2019, enquanto, para os casos com les\u00e3o de \u00f3rg\u00e3os, o tratamento n\u00e3o foi recomendado, com n\u00edvel de evid\u00eancia moderado. Os procedimentos metodol\u00f3gicos das diretrizes da OPAS foram desenvolvidos a partir de revis\u00f5es sistem\u00e1ticas e estudos prim\u00e1rios publicados at\u00e9 agosto de 2017  e por meio de pesquisas manuais com an\u00e1lise pelo GRADE.  Tendo em vista a estratifica\u00e7\u00e3o definida no delineamento em parte significativa dos estudos consistentes para avalia\u00e7\u00e3o do tratamento etiol\u00f3gico, optou-se neste documento por estabelecer como par\u00e2metro de corte a idade de 50 anos, assim como em outros documentos referenciais nacionais e internacionais. T. cruzi.  Conforme apresentado a seguir, desde 2017, foram publicados novos estudos que agregaram evid\u00eancias \u00e0s j\u00e1 dispon\u00edveis, o que demarcou o estabelecimento das recomenda\u00e7\u00f5es constantes no presente documento, ampliando a oportunidade de acesso a tratamento da infec\u00e7\u00e3o por Trata-se de recomenda\u00e7\u00e3o forte com n\u00edvel de evid\u00eancia B, tendo em vista estudos mais recentes reconhecendo que o tratamento etiol\u00f3gico pode reduzir o risco de desenvolvimento da doen\u00e7a card\u00edaca a longo prazo,  mesmo sem uma clara evid\u00eancia sobre o impacto na mortalidade.  A probabilidade de se obter parasitemia negativa em curto prazo \u00e9 maior, enquanto a de sorologia n\u00e3o reagente \u00e9 evidenciada apenas em longo prazo.  Por outro lado, o tratamento est\u00e1 potencialmente associado a risco consider\u00e1vel de eventos adversos, que, embora na maioria sejam considerados leves e minimizados por meio de monitoramento qualificado,  em alguns casos s\u00e3o suficientemente graves para acarretar interrup\u00e7\u00e3o terap\u00eautica.  Em adultos at\u00e9 50 anos de idade com a forma cr\u00f4nica indeterminada, o tratamento \u00e9 recomendado, considerando-se que as vantagens de sua realiza\u00e7\u00e3o parecem superar as desvantagens e que h\u00e1 benef\u00edcio mais evidente quanto \u00e0 preven\u00e7\u00e3o de doen\u00e7a card\u00edaca.  Considera-se ainda que para pessoas com 50 anos de idade ou mais e DC em fase cr\u00f4nica, o benef\u00edcio do tratamento etiol\u00f3gico na FIDC associa-se a grau de incerteza maior, o que leva a uma recomenda\u00e7\u00e3o condicional (ou ponderada) do tratamento etiol\u00f3gico com n\u00edvel de evid\u00eancia C.  Em geral, essas perspectivas trazem a possibilidade de recomenda\u00e7\u00e3o condicional de tratamento etiol\u00f3gico nessa popula\u00e7\u00e3o.  Como apresentado anteriormente, o fator idade para tratamento etiol\u00f3gico deve ser relativizado, considerando-se particularmente para pessoas com infec\u00e7\u00e3o recente  ou que tiveram sua infec\u00e7\u00e3o durante a vida adulta sem comorbidades e dentro de um processo claro na sociedade brasileira de transi\u00e7\u00e3o demogr\u00e1fica com maior expectativa de vida.  Entende-se por CCDC em fases pouco avan\u00e7adas (iniciais) a daqueles casos apenas com altera\u00e7\u00f5es no ECG , mas fun\u00e7\u00e3o ventricular sist\u00f3lica global preservada ou levemente reduzida (FEVE superior a 40%), est\u00e1gios B1 e B2 de IC e sem arritmias graves.  Nos casos de adultos com formas cr\u00f4nicas determinadas em fases iniciais n\u00e3o avan\u00e7adas (card\u00edaca e digestiva), a decis\u00e3o para indicar o tratamento etiol\u00f3gico tamb\u00e9m deve ser compartilhada, com aconselhamento sobre os potenciais benef\u00edcios e riscos, podendo-se, assim, oferecer a possibilidade de tratamento, sendo tratar com benznidazol ou n\u00e3o tratar alternativas v\u00e1lidas, caso n\u00e3o haja contraindica\u00e7\u00f5es. A recomenda\u00e7\u00e3o do tratamento etiol\u00f3gico nesses casos \u00e9 condicional ou ponderada, com n\u00edvel de evid\u00eancia C.  pois o objetivo do tratamento \u00e9 a preven\u00e7\u00e3o das les\u00f5es card\u00edacas. Nos casos com altera\u00e7\u00f5es digestivas instaladas e mesmo naqueles sem a forma digestiva, n\u00e3o existem evid\u00eancias indicando benef\u00edcio da ado\u00e7\u00e3o do tratamento antiparasit\u00e1rio em prevenir ou retardar o aparecimento ou a progress\u00e3o do megaes\u00f4fago e do megacolo.  Alguns pacientes com megaes\u00f4fago podem ter a efic\u00e1cia do tratamento com benznidazol comprometida por interfer\u00eancia com a ingest\u00e3o ou absor\u00e7\u00e3o do f\u00e1rmaco.  Apesar de o diagn\u00f3stico da forma cr\u00f4nica digestiva n\u00e3o representar contraindica\u00e7\u00e3o para o tratamento etiol\u00f3gico, recomenda-se realizar reabilita\u00e7\u00e3o cl\u00ednica, dilata\u00e7\u00e3o ou corre\u00e7\u00e3o cir\u00fargica do megaes\u00f4fago previamente \u00e0 ado\u00e7\u00e3o do tratamento etiol\u00f3gico, com a finalidade de garantir o tr\u00e2nsito do medicamento e sua absor\u00e7\u00e3o.  Ao se optar pelo tratamento etiol\u00f3gico, esse pode ser considerado independentemente do diagn\u00f3stico da forma cr\u00f4nica digestiva isolada ou em associa\u00e7\u00e3o, isso \u00e9, com doen\u00e7a cardiodigestiva,  Dessa forma, o tratamento antiparasit\u00e1rio n\u00e3o deve ser recomendado para pessoas com les\u00e3o org\u00e2nica avan\u00e7ada (formas card\u00edacas em est\u00e1gios C e D) ou muito idosas.  Nesses casos, o tratamento etiol\u00f3gico n\u00e3o muda a hist\u00f3ria natural da doen\u00e7a, pode estar associado a risco aumentado de eventos adversos graves, al\u00e9m de induzir custos diretos e indiretos para as pessoas acometidas e suas fam\u00edlias, ampliando-se, dessa forma, sua vulnerabilidade social.  Quando j\u00e1 h\u00e1 cardiomiopatia cr\u00f4nica instalada, em geral n\u00e3o h\u00e1 evid\u00eancias que sustentem a possibilidade de o tratamento etiol\u00f3gico impactar significativamente a evolu\u00e7\u00e3o para morte ou a progress\u00e3o da doen\u00e7a card\u00edaca, mesmo aumentando-se a probabilidade de negativa\u00e7\u00e3o da parasitemia, avaliada por PCR.  Portanto, todos os esfor\u00e7os devem ser envidados para diagn\u00f3stico e tratamento etiol\u00f3gico oportuno de casos de DC com o objetivo de prevenir a progress\u00e3o da doen\u00e7a. Ressalta-se que o risco anual de mortalidade na CCDC \u00e9 consider\u00e1vel  e associado principalmente a causas atribu\u00edveis cardiovasculares, em especial quando da vig\u00eancia de baixa FEVE e classificados como est\u00e1gios C e C/D.  A indica\u00e7\u00e3o do tratamento etiol\u00f3gico tamb\u00e9m teria recomenda\u00e7\u00e3o \u2018condicional\u2019 e com n\u00edvel de evid\u00eancia C.  Situa\u00e7\u00e3o especial \u00e9 a de pessoas com megaes\u00f4fago grave, impedindo a adequada absor\u00e7\u00e3o do agente tripanocida. Em tais situa\u00e7\u00f5es cl\u00ednicas, sem cardiopatia manifesta ou com cardiopatia pouco avan\u00e7ada, em que o tratamento etiol\u00f3gico objetiva prevenir a progress\u00e3o da doen\u00e7a cardiovascular, esse pode ser indicado ap\u00f3s o tratamento cir\u00fargico do megaes\u00f4fago.  Tampouco ocorreu benef\u00edcio, comparativamente ao placebo, sobre a disfun\u00e7\u00e3o ventricular regional, altera\u00e7\u00e3o precoce e frequentemente detectada em tais indiv\u00edduos e dotada de real conota\u00e7\u00e3o de mau progn\u00f3stico.  N\u00e3o obstante essa concep\u00e7\u00e3o essencial, torna-se oportuno registrar que a an\u00e1lise meticulosa dos resultados obtidos com o ensaio cl\u00ednico BENEFIT, o mais extenso ECR sobre terap\u00eautica tripanocida em pacientes com CCDC (a maioria n\u00e3o avan\u00e7ada), permitiu identificar alguns aspectos relevantes a real\u00e7ar. De fato, na popula\u00e7\u00e3o como um todo, envolvendo pacientes de cinco pa\u00edses da Am\u00e9rica Latina , o tratamento etiol\u00f3gico com benznidazol n\u00e3o logrou impactar favoravelmente a evolu\u00e7\u00e3o dos pacientes quanto a mortalidade e outros desfechos graves da cardiomiopatia.  Por exemplo, comparativamente ao grupo tratado com placebo, no grupo do tratamento tripanocida com o benznidazol, verificou-se redu\u00e7\u00e3o estatisticamente significante da taxa de hospitaliza\u00e7\u00f5es por causas cardiovasculares, aspecto bastante real\u00e7ado em muitos estudos envolvendo pacientes com IC, mas que sequer foi discutido na an\u00e1lise prim\u00e1ria do estudo BENEFIT.  Entretanto, a an\u00e1lise global dos resultados tornou-se pass\u00edvel de cr\u00edticas e, muito provavelmente, impediu a devida aprecia\u00e7\u00e3o de alguns desacertos metodol\u00f3gicos com relevantes implica\u00e7\u00f5es potenciais para a aplicabilidade dos resultados da investiga\u00e7\u00e3o.  Em contraste, an\u00e1lisepost-hocdos resultados desse estudo evidenciou a possibilidade de que o efeito do tratamento etiol\u00f3gico nos pacientes brasileiros  possa ter sido positivo, particularmente quando se confrontam os resultados obtidos no subgrupo arrolado no Brasil com os observados nos quatro demais pa\u00edses em que a pesquisa foi realizada.  Entre outros aspectos merecedores de aprecia\u00e7\u00e3o cr\u00edtica, deve-se considerar que a an\u00e1lise de subgrupos inicialmente realizada no \u00e2mbito do estudo BENEFIT foi arbitr\u00e1ria, n\u00e3o pr\u00e9-especificada e n\u00e3o obedeceu a crit\u00e9rios defens\u00e1veis, podendo ter sido inadequadamente enviesada. T. cruzie ao nifurtimox. Em realidade, h\u00e1 raz\u00f5es cient\u00edficas para que o tratamento de pacientes baseado em f\u00e1rmacos tripanocidas  seja lastreado em considera\u00e7\u00e3o tanto da diversidade gen\u00f4mica parasit\u00e1ria  como da complexa intera\u00e7\u00e3o das diversas linhagens do parasito com o hospedeiro humano, que resultam em formas variadas de express\u00e3o cl\u00ednica.  Destaque-se que essa possibilidade deve ser encarada somente como geratriz de uma hip\u00f3tese e com certeza mereceria estudo subsequente especificamente para comprov\u00e1-la ou n\u00e3o. De toda forma, a hip\u00f3tese corol\u00e1rio dessa interpreta\u00e7\u00e3o, de que esse tratamento parasiticida seja mais eficaz quando aplicado em brasileiros j\u00e1 com a CCDC, \u00e9 biologicamente plaus\u00edvel e pode estar embasada na predomin\u00e2ncia do gen\u00f3tipo parasit\u00e1rio TcII que se verifica no Brasil, que pode ser mais sens\u00edvel ao tratamento com o benznidazol comparativamente a outras cepas de Com base em todas essas considera\u00e7\u00f5es, abre-se a perspectiva de que no Brasil o grau de recomenda\u00e7\u00e3o condicional de se oferecer o tratamento etiol\u00f3gico a indiv\u00edduos j\u00e1 com CCDC n\u00e3o avan\u00e7ada seja ponderada com mais \u00eanfase no potencial benef\u00edcio do que o que ocorreria em outros pa\u00edses. Finalmente, ressalte-se a expressiva gravidade da DC e a necessidade de diagn\u00f3stico e aten\u00e7\u00e3o integral \u00e0 pessoa com cardiopatia de modo oportuno e com base em manejo cl\u00ednico qualificado.  Al\u00e9m disso, considerando-se as atuais evid\u00eancias sobre o tratamento etiol\u00f3gico da doen\u00e7a bem como a relev\u00e2ncia da vigil\u00e2ncia epidemiol\u00f3gica, a notifica\u00e7\u00e3o compuls\u00f3ria de casos cr\u00f4nicos de DC deve ser implementada, o que possibilitaria ampliar o acesso ao diagn\u00f3stico e tratamento a mais pessoas acometidas. T. cruzi, caracterizada pelo aumento da parasitemia (semelhante \u00e0 doen\u00e7a na fase aguda) e pela incapacidade de o sistema imune controlar a infec\u00e7\u00e3o, em geral associada \u00e0 imunossupress\u00e3o farmacologicamente induzida \u2013 transplantes, tratamentos imunossupressores \u2013 ou \u00e0 coinfec\u00e7\u00e3o com HIV.  A RDC consiste na agudiza\u00e7\u00e3o da infec\u00e7\u00e3o cr\u00f4nica por A preval\u00eancia observada de RDC com base na parasitemia em pessoas com DC e imunossupress\u00e3o, sem profilaxia com tripanocida, foi aproximadamente 28%, sendo: 1,8% em transplante de f\u00edgado, 23,3% em transplante de medula \u00f3ssea, 27,3% em transplante de rim, 30,9% em transplante de cora\u00e7\u00e3o e 39,6% na infec\u00e7\u00e3o por HIV/AIDS.  A RDC est\u00e1 associada a elevada morbimortalidade em virtude da infec\u00e7\u00e3o no sistema nervoso central e da miocardite, impactando criticamente tamb\u00e9m a qualidade de vida.  Apesar do n\u00edvel de evid\u00eancia moderado (B), a recomenda\u00e7\u00e3o \u00e9 classificada como forte, pois os medicamentos antiparasit\u00e1rios podem apresentar benef\u00edcios potenciais na preven\u00e7\u00e3o da ocorr\u00eancia de reativa\u00e7\u00f5es e suas consequ\u00eancias, assim como no seu controle e mesmo quanto \u00e0 sua recorr\u00eancia.  Caso ocorra reativa\u00e7\u00e3o, deve-se iniciar o tratamento etiol\u00f3gico indicado para a fase aguda da DC. statusimunol\u00f3gico, em virtude do risco aumentado de ocorr\u00eancia de s\u00edndrome inflamat\u00f3ria de reconstitui\u00e7\u00e3o imune.  Na infec\u00e7\u00e3o por HIV, na vig\u00eancia de DC cr\u00f4nica sem reativa\u00e7\u00e3o e sem tratamento etiol\u00f3gico pr\u00e9vio, o tratamento deve ser realizado preferencialmente com benznidazol, avaliando-se o N\u00e3o h\u00e1 evid\u00eancia consistente para recomendar profilaxia secund\u00e1ria em casos submetidos a transplantes, mas pode ser indicada em casos selecionados, particularmente naqueles com maior grau de imunossupress\u00e3o.  Para os casos com transplantes e RDC, o tratamento tamb\u00e9m est\u00e1 indicado com a mesma posologia utilizada para os casos n\u00e3o relacionados a transplantes, sendo o benznidazol a alternativa preferencial pelo melhor perfil de eventos adversos e maior experi\u00eancia com utiliza\u00e7\u00e3o no pa\u00eds.  De modo geral, o tratamento etiol\u00f3gico pode contribuir para a preven\u00e7\u00e3o de complica\u00e7\u00f5es cl\u00ednicas (a exemplo da cardiopatia), devendo ser considerado com as mesmas recomenda\u00e7\u00f5es e n\u00edveis de evid\u00eancia utilizados em outras situa\u00e7\u00f5es relativas \u00e0 DC cr\u00f4nica em pessoas sem imunossupress\u00e3o.  Ressalta-se que os epis\u00f3dios de RDC podem ocorrer de forma repetitiva, devendo ser tratados quando documentados, o que justifica o monitoramento parasitol\u00f3gico regular enquanto estiver mantida a condi\u00e7\u00e3o de imunossupress\u00e3o.  Tanto para pessoas infectadas por HIV quanto com transplantes, a qPCR pode contribuir no monitoramento cl\u00ednico; entretanto, sua recomenda\u00e7\u00e3o de rotina ainda est\u00e1 por ser definida. T. cruzie risco elevado para transmiss\u00e3o da doen\u00e7a, como instrumentos perfurocortantes ou por contato com mucosas ou pele com solu\u00e7\u00e3o de continuidade ou manipula\u00e7\u00e3o de material biol\u00f3gico com parasitos vivos , deve-se indicar a profilaxia prim\u00e1ria, iniciando-se com benznidazol na dose de 7 a 10mg/kg imediatamente ap\u00f3s o acidente e mantendo-o por 10 dias.  Trata-se de uma conduta com recomenda\u00e7\u00e3o forte, apesar do limitado n\u00edvel de evid\u00eancia (C), mas que considera o princ\u00edpio de assimetria.  Em acidentes com material biol\u00f3gico contaminado com Em caso de os exames sorol\u00f3gicos serem reagentes, o tratamento antiparasit\u00e1rio convencional dever\u00e1 ser realizado como descrito previamente para a fase aguda. Em situa\u00e7\u00f5es de risco m\u00ednimo, como apenas contato superficial com sangue de casos com a DC em fase cr\u00f4nica, a profilaxia medicamentosa n\u00e3o est\u00e1 indicada, recomendando-se a realiza\u00e7\u00e3o de exames sorol\u00f3gicos imediatamente ap\u00f3s e no 20\u00ba, 40\u00ba e 60\u00ba dias ap\u00f3s o acidente.  Havendo soroconvers\u00e3o, o tratamento convencional para a fase aguda da DC dever\u00e1 ser institu\u00eddo e o monitoramento p\u00f3s-terap\u00eautico deve ser realizado como preconizado para a fase aguda. Se a sorologia permanecer positiva ap\u00f3s o tratamento, deve-se procurar documentar poss\u00edvel falha terap\u00eautica para um novo tratamento com benznidazol ou nifurtimox.  Devem ser realizados exames sorol\u00f3gicos antes de se iniciar o tratamento e no 20\u00ba, 40\u00ba e 60\u00ba dias p\u00f3s-tratamento para monitoramento de eventual soroconvers\u00e3o.  A garantia de acesso ao tratamento \u00e9 fundamental, tendo uma fun\u00e7\u00e3o social clara dado o car\u00e1ter de neglig\u00eancia relacionado \u00e0s pessoas acometidas pela doen\u00e7a. Muitas das vezes, argumentos associados a eventos adversos e n\u00e3o estabelecimento de cura s\u00e3o utilizados como justificativa para o n\u00e3o tratamento no SUS. Como condi\u00e7\u00e3o cr\u00f4nica, a DC demanda a necessidade de uma aten\u00e7\u00e3o integral e longitudinal a todas as pessoas acometidas.  Em uma doen\u00e7a em que existem apenas duas op\u00e7\u00f5es terap\u00eauticas com indica\u00e7\u00f5es consistentes para uso, n\u00e3o h\u00e1 evid\u00eancias dispon\u00edveis sobre m\u00e9todos complementares para avaliar, no contexto da rotina dos servi\u00e7os de sa\u00fade, o efeito do tratamento etiol\u00f3gico na elimina\u00e7\u00e3o do parasito, particularmente na fase cr\u00f4nica.  N\u00e3o existe m\u00e9todo complementar para confirmar a evolu\u00e7\u00e3o para cura (que seria considerado padr\u00e3o-ouro), o que torna os testes sorol\u00f3gicos e os testes moleculares, mesmo com todas as limita\u00e7\u00f5es t\u00e9cnicas, m\u00e9todos potencialmente dispon\u00edveis e \u00fateis para avaliar a resposta ao tratamento antiparasit\u00e1rio na fase cr\u00f4nica.  A qualidade das evid\u00eancias que sustentam o uso de negativa\u00e7\u00e3o sorol\u00f3gica como substituto para desfechos clinicamente relevantes \u00e9 \u2018baixa\u2019 ou \u2018muito baixa\u2019, representando, na realidade, um desfecho indireto.  Neste sentido, n\u00e3o existem evid\u00eancias relativas \u00e0 necessidade de seguimento com controle sorol\u00f3gico p\u00f3s-tratamento ou retratamento ap\u00f3s curso terap\u00eautico completo.  e ser alcan\u00e7ada por apenas aproximadamente 1/3 dos casos, na depend\u00eancia de diferentes fatores como idade no momento do tratamento, tempo entre o tratamento e o acompanhamento e \u00e1rea em que ocorreu a infec\u00e7\u00e3o.  Para crian\u00e7as e adolescentes, a negativa\u00e7\u00e3o sorol\u00f3gica pode ocorrer dentro de cinco anos em 3/4 dos casos.  An\u00e1lises em crian\u00e7as e adolescentes no contexto amaz\u00f4nico com DC aguda indicam persist\u00eancia de sorologias reagentes em quase 55% dos casos, em um per\u00edodo m\u00e9dio de seguimento de cada caso por aproximadamente 11 anos ap\u00f3s tratamento, al\u00e9m de propor\u00e7\u00e3o de 17% de casos com respostas sustentadas de negativa\u00e7\u00e3o sorol\u00f3gica.  Al\u00e9m disto, a negativa\u00e7\u00e3o sorol\u00f3gica p\u00f3s-tratamento em adultos pode ser muito lenta e levar mais de duas d\u00e9cadas para se efetivar,  e n\u00e3o h\u00e1 disponibilidade de m\u00e9todos validados e pactuados no SUS, restringindo sua aplicabilidade a atividades de pesquisa.  Reconhece-se, entretanto, que a PCR sendo positiva ainda nos primeiros 24 meses ap\u00f3s o tratamento indica possibilidade de falha terap\u00eautica.  Apesar de alguns estudos sugerirem o uso da PCR para monitoramento e controle da resposta terap\u00eautica, a sensibilidade da t\u00e9cnica \u00e9 vari\u00e1vel  Os percentuais de cura verificados por diversos estudos ap\u00f3s o tratamento antiparasit\u00e1rio da DC apresentam diverg\u00eancias, mas mesmo assim, reconhece-se a import\u00e2ncia do tratamento etiol\u00f3gico tanto na fase aguda quanto em algumas formas cl\u00ednicas da doen\u00e7a cr\u00f4nica.  o que torna inquestion\u00e1vel a utilidade do tratamento etiol\u00f3gico da DC em parte consider\u00e1vel das situa\u00e7\u00f5es cl\u00ednicas, independentemente da demonstra\u00e7\u00e3o de cura, \u00e0 exce\u00e7\u00e3o da DC aguda. Portanto, para a fase cr\u00f4nica da DC, a defini\u00e7\u00e3o de crit\u00e9rio para cura perde o sentido pr\u00e1tico e contribui sobremaneira como forte barreira para o acesso.  Al\u00e9m disto, mesmo com todas as limita\u00e7\u00f5es j\u00e1 mencionadas da terap\u00eautica antiparasit\u00e1ria vigente, pode-se alcan\u00e7ar a supress\u00e3o da parasitemia em muitos cen\u00e1rios,  como tem sido verificado em pa\u00edses n\u00e3o end\u00eamicos.  Para al\u00e9m da lideran\u00e7a t\u00e9cnico-cient\u00edfica sobre a DC, o Brasil tem um grande diferencial em rela\u00e7\u00e3o \u00e0 maioria dos pa\u00edses end\u00eamicos para DC: a exist\u00eancia do SUS, de car\u00e1ter p\u00fablico, universal e de base democr\u00e1tica, dentro dos referenciais de direito \u00e0 sa\u00fade da Constitui\u00e7\u00e3o Federal de 1988. Amplia-se, assim, a possibilidade de garantia de acesso a diagn\u00f3stico e tratamento da DC no pa\u00eds,  com benef\u00edcios cl\u00ednicos demonstrados a curto, m\u00e9dio e longo prazos, n\u00e3o se tem conseguido implementar de modo consistente o diagn\u00f3stico e o tratamento, nem a vigil\u00e2ncia de casos de DC cr\u00f4nica no territ\u00f3rio nacional.  Quest\u00f5es como centraliza\u00e7\u00e3o das a\u00e7\u00f5es de aten\u00e7\u00e3o, vigil\u00e2ncia e controle da DC contribuem para essa situa\u00e7\u00e3o. Portanto, uma vis\u00e3o global unificada sobre o atual est\u00e1gio de desenvolvimento de iniciativas para controle da DC no Brasil, apesar de reconhecer as conquistas alcan\u00e7adas ao longo desses quase 120 anos, indigita a premente necessidade de implementa\u00e7\u00e3o e integra\u00e7\u00e3o das medidas englobadas no PCDT com vigil\u00e2ncia sustentada da DC e ades\u00e3o a diretrizes nacionais e internacionais.  Entretanto, apesar de um contexto favor\u00e1vel e dos referenciais dispon\u00edveis a partir de portarias, diretrizes, consensos e do pr\u00f3prio PCDT, T. cruzi\u00e9 fact\u00edvel, seguro e operacionalmente vi\u00e1vel na APS.  Reconhece-se a possibilidade de que a rede de APS assuma a condu\u00e7\u00e3o de casos com DC na fase aguda n\u00e3o grave, com a FIDC, ou mesmo com formas cr\u00f4nicas  na vig\u00eancia de doen\u00e7a est\u00e1vel e n\u00e3o grave, bem como de gestantes com DC em fase cr\u00f4nica sem comorbidades.  H\u00e1 ainda evid\u00eancias de que m\u00e9dicos de fam\u00edlia e comunidade e suas equipes, conhecendo as particularidades dos medicamentos e da doen\u00e7a, podem manejar clinicamente os casos.  Devem-se considerar as especificidades da rede de aten\u00e7\u00e3o do SUS, reconhecendo-se, entretanto, que o tratamento etiol\u00f3gico da infec\u00e7\u00e3o por Dependendo da gravidade das condi\u00e7\u00f5es cl\u00ednicas de cada caso, principalmente na vig\u00eancia de fase aguda ou RDC, assim como de formas cr\u00f4nicas descompensadas, pode haver a necessidade de apoio matricial para o plano de cuidado ou de efetiva\u00e7\u00e3o do encaminhamento para unidades de sa\u00fade mais especializadas ou de refer\u00eancia, ou at\u00e9 mesmo de interna\u00e7\u00e3o hospitalar, em condi\u00e7\u00f5es esporadicamente configuradas. T. cruziem diferentes contextos da DC, segundo for\u00e7a de recomenda\u00e7\u00e3o e n\u00edvel de evid\u00eancia, com base nos referenciais do sistema GRADE.  AT. cruzi.  As conclus\u00f5es essenciais dessa publica\u00e7\u00e3o s\u00e3o de molde a ter coer\u00eancia com as recomenda\u00e7\u00f5es aqui exaradas na Diretriz Brasileira. Entretanto, reitera-se que, no atual momento, para al\u00e9m da busca de evid\u00eancias cient\u00edficas mais robustas, todos os esfor\u00e7os devem ser envidados para a garantia de acesso a diagn\u00f3stico e tratamento etiol\u00f3gico da DC nos sistemas nacionais de sa\u00fade.  Vale finalmente ressaltar que, quando da elabora\u00e7\u00e3o final do presente cap\u00edtulo, publicou-se atualiza\u00e7\u00e3o de antiga revis\u00e3o sistem\u00e1tica e respectiva meta-an\u00e1lise relativamente a estudos de tratamento etiol\u00f3gico com benznidazol para pessoas com infec\u00e7\u00e3o por Nossas recomenda\u00e7\u00f5es priorizam pacientes com FEVE reduzida, visto que a maioria das condutas farmacol\u00f3gicas foram validadas nesse cen\u00e1rio. Nesse contexto, devemos compreender a diferen\u00e7a entre crit\u00e9rios de inclus\u00e3o de um estudo cient\u00edfico e indica\u00e7\u00e3o cl\u00ednica. Estudos primam por selecionar pacientes com menor FEVE (< 35% ou < 40%) a fim de otimizar a incid\u00eancia do desfecho de interesse, aumentando-se o poder estat\u00edstico. Pelo fato de a magnitude do efeito absoluto (NNT) ser mais relevante em pacientes de maior risco  e n\u00e3o se identificar motivo plaus\u00edvel para a ocorr\u00eancia de intera\u00e7\u00e3o qualitativa (desaparecimento do efeito) quando um determinado ponto de corte de FEVE \u00e9 ultrapassado, optamos por generalizar nossas recomenda\u00e7\u00f5es para o uso dos principais f\u00e1rmacos destinados ao tratamento da IC em pacientes com FEVE < 55%, evitando excesso de categoriza\u00e7\u00e3o. continuumde rela\u00e7\u00e3o (e que \u00e9 inversa) entre FEVE e benef\u00edcio terap\u00eautico, de tal forma que, quanto menor for o valor da FEVE, maior ser\u00e1 o benef\u00edcio absoluto da terapia proposta. Para fins de simplifica\u00e7\u00e3o, recomenda\u00e7\u00f5es fortes para FEVE \u2264 40% se tornar\u00e3o ponderadas para FEVE entre 41% e 54%. Julgamos tamb\u00e9m que h\u00e1 maior possibilidade de modifica\u00e7\u00e3o de efeito em pacientes com altera\u00e7\u00f5es de contratilidade segmentar, por\u00e9m sem disfun\u00e7\u00e3o ventricular global, os quais se encaixam no est\u00e1gio B de IC. Durante a elabora\u00e7\u00e3o desta diretriz, predominou a no\u00e7\u00e3o de que evid\u00eancias para esses pacientes t\u00eam import\u00e2ncia na dimens\u00e3o cient\u00edfica, mas ainda s\u00e3o insuficientes para promover qualquer recomenda\u00e7\u00e3o.  No entanto, deve-se considerar que existe umversusdose ponderada) e se aquela supera consequ\u00eancias n\u00e3o intencionais. Terceiro, tolerabilidade e efeitos adversos s\u00e3o subestimados em ECR de efic\u00e1cia, pois, usualmente, s\u00e3o selecionados candidatos ideais para o tratamento em quest\u00e3o e as condutas s\u00e3o mais bem controladas. Portanto, n\u00e3o transformamos efic\u00e1cia em efetividade com padroniza\u00e7\u00e3o do m\u00e1ximo. O incremento de efetividade decorrer\u00e1 de judiciosa individualiza\u00e7\u00e3o.  Esta diretriz n\u00e3o respalda a obstina\u00e7\u00e3o por se atingir a dose m\u00e1xima das medica\u00e7\u00f5es em detrimento da polifarm\u00e1cia, preferindo enfatizar a individualiza\u00e7\u00e3o da melhor dose de cada f\u00e1rmaco para cada paciente. A racionalidade dessa posi\u00e7\u00e3o baseia-se em algumas justificativas. A dose proposta ou mesmo aquela atingida pelos pacientes nos ensaios cl\u00ednicos faz parte de uma estrat\u00e9gia cient\u00edfica, com objetivo de gerar contraste entre grupos e testar hip\u00f3teses conceituais. Uma vez demonstrado o conceito, esse deve ser aplicado de forma individualizada, ponderando benef\u00edcios e danos. Assim, a escolha da dose de um medicamento diz mais respeito \u00e0 dimens\u00e3o do racioc\u00ednio cl\u00ednico do que da evid\u00eancia. Segundo, n\u00e3o h\u00e1 dados cient\u00edficos convincentes sobre a magnitude de efeito incremental relacionado \u00e0 dose m\u00e1xima , observou-se m\u00e9dia de idade de 65 anos, com \u00edndice de massa corporal m\u00e9dio de 27,4kg/m  Uma pior trajet\u00f3ria cl\u00ednica, do ponto de vista meramente estat\u00edstico, sugere maior benef\u00edcio absoluto de tratamentos com n\u00edvel B de evid\u00eancia se comparados \u00e0s popula\u00e7\u00f5es-alvo dos estudos, n\u00e3o devendo implicar em viola\u00e7\u00e3o do princ\u00edpio da evid\u00eancia indireta, ou seja, por extrapola\u00e7\u00e3o.  incorpora-se em iniciativa abrangente de pesquisas translacionais destinadas a explorar, em car\u00e1ter experimental e tamb\u00e9m cl\u00ednico, hip\u00f3teses de potencial benef\u00edcio com suplementa\u00e7\u00e3o de nutrientes, como sel\u00eanio, e antagonismo de fatores inflamat\u00f3rios para modificar a evolu\u00e7\u00e3o da CCDC.  Talvez o m\u00e9rito primordial dessas investiga\u00e7\u00f5es incipientes resida no apelo de sua hip\u00f3tese fortemente embasada, fisiopatologicamente, no car\u00e1ter inflamat\u00f3rio da CCDC e somente a pesquisa dirigida poder\u00e1 responder no futuro quanto ao \u00eaxito dessas interven\u00e7\u00f5es.  \u00c9 oportuno mencionar que o estudo da FIOCRUZ acima citado Medical Subject Headings(MESH): \u201cbeta-blockers, spironolactone, sacubitril-valsartan, ivabradine, sodium-glucose transporter 2 inhibitors\u201d, \u201cheart failure\u201d ou \u201cChagas disease\u201d, com limite para tipo de publica\u00e7\u00e3o . As bases de dados MedLine/PubMed, Lilacs, Web of Science e EMBASE foram usadas como fonte de busca.  Para cada f\u00e1rmaco ou classe de f\u00e1rmacos utilizados no tratamento da IC, foi realizada uma revis\u00e3o sistem\u00e1tica da literatura at\u00e9 22/08/2021, visando responder \u00e0 seguinte quest\u00e3o PICO da medicina embasada em evid\u00eancia: \u201cEsses f\u00e1rmacos s\u00e3o eficazes ou efetivos para al\u00edvio de sintomas e/ou redu\u00e7\u00e3o de mortalidade em pacientes sintom\u00e1ticos com IC sist\u00f3lica secund\u00e1ria \u00e0 CCDC, com perfil de seguran\u00e7a similar \u00e0quele para as outras etiologias da s\u00edndrome?\u201d. Foram utilizados os seguintes termos padr\u00e3o ou10.1.5.1. Diur\u00e9ticosversusplacebo pode gerar a equivocada impress\u00e3o de que, diferentemente de betabloqueadores ou IECA, diur\u00e9ticos de al\u00e7a n\u00e3o reduzem a mortalidade. Essa vis\u00e3o ressente-se da percep\u00e7\u00e3o de que a car\u00eancia desses estudos se deva justamente \u00e0 aus\u00eancia deequipoisepara o tipo de paciente em que se validou benef\u00edcio progn\u00f3stico com as demais terapias. Ou seja, na IC, a administra\u00e7\u00e3o de diur\u00e9tico constitui terapia de plausibilidade extrema, o que corresponde ao paradigma do paraquedas,  representando justificativa desta diretriz para o n\u00edvel de evid\u00eancia C em indica\u00e7\u00e3o farmacol\u00f3gica. Assim, recomendamos fortemente terapia com intuito diur\u00e9tico para IC com moderada a importante redu\u00e7\u00e3o de fra\u00e7\u00e3o de eje\u00e7\u00e3o e para casos com redu\u00e7\u00e3o leve da fra\u00e7\u00e3o de eje\u00e7\u00e3o.  A terapia promotora de diurese na IC \u00e9 incompreendida em sua magnitude de efeito. A aus\u00eancia de ECR que compare diur\u00e9tico10.1.5.2. Inibidores do Sistema Renina-Angiotensina-Aldosterona Al\u00e9m disso, esses f\u00e1rmacos podem ser substitu\u00eddos pelos bloqueadores de receptores da angiotensina II (BRA) em casos de m\u00e1 tolerabilidade.  Entretanto, na IC da CCDC, n\u00e3o h\u00e1 evid\u00eancias diretas de benef\u00edcio por meio de ECR realizados especificamente nessa popula\u00e7\u00e3o. Sendo assim, julgamos que a evid\u00eancia a respeito do uso de IECA na CCDC \u00e9 indireta, proveniente de estudos de \u00f3tima qualidade que testaram a efic\u00e1cia desse tratamento nos tipos mais comuns de miocardiopatia  (n\u00edvel B). Acompanhando o racional de que fra\u00e7\u00e3o de eje\u00e7\u00e3o \u00e9 umcontinuumprogn\u00f3stico , quanto maior o grau de disfun\u00e7\u00e3o ventricular, maior o benef\u00edcio absoluto. Portanto, a recomenda\u00e7\u00e3o \u00e9 definida como forte para pacientes com IC e FEVE \u2264 40% e ponderada para pacientes com IC e FE levemente reduzida (ICFElr).  Est\u00e1 cabalmente demonstrado, por in\u00fameros ensaios cl\u00ednicos de qualidade, que em pacientes com IC e FEVE reduzida, diversos IECA reduzem desfechos relevantes de morbimortalidade.  Esses pacientes frequentemente cursam com press\u00e3o arterial sist\u00f3lica diminu\u00edda, podendo se tornar sintom\u00e1ticos com a introdu\u00e7\u00e3o dos IECA ou BRA que, por sua vez, devem ser titulados de forma gradual, buscando-se diminuir as doses dos diur\u00e9ticos, quando o paciente n\u00e3o mais apresentar edema.  Estudos com n\u00famero bastante reduzido de pacientes, avaliando captopril e enalapril na IC da CCDC, evidenciaram diminui\u00e7\u00e3o da ativa\u00e7\u00e3o neuro-humoral simp\u00e1tica e dos n\u00edveis de angiotensina plasm\u00e1tica, al\u00e9m de melhora da disfun\u00e7\u00e3o diast\u00f3lica e do remodelamento ventricular.  Vale destacar que, nas \u00faltimas d\u00e9cadas, as diretrizes internacionais t\u00eam enfatizado a busca da dose-alvo terap\u00eautica de IECA ou BRA nos pacientes com IC e fra\u00e7\u00e3o de eje\u00e7\u00e3o reduzida (ICFEr), algo que pode ser elusivo e consistir em limita\u00e7\u00e3o para a pr\u00e1tica cl\u00ednica, considerando-se que os pacientes com CCDC est\u00e3o mais propensos a apresentar hipotens\u00e3o arterial sintom\u00e1tica. Portanto, aqui devemos buscar a melhor dose tolerada e particularmente proceder \u00e0 titula\u00e7\u00e3o lenta nesse grupo particular de pacientes sujeitos a dificuldades posol\u00f3gicas. 10.1.5.3. Betabloqueadores Na ocasi\u00e3o, um paciente recebeu alprenolol 50 mg duas vezes ao dia e os demais receberam practolol, nas doses que variaram entre 50 mg e 400 mg, duas vezes ao dia. Os autores observaram melhora cl\u00ednica, redu\u00e7\u00e3o da cardiomegalia e melhora da fun\u00e7\u00e3o ventricular avaliada pelo fonocardiograma, ECO, apexcardiograma e pela curva do pulso carot\u00eddeo. Apesar dos resultados promissores reportados pelo grupo sueco, s\u00f3 na d\u00e9cada de 90 os betabloqueadores foram adequadamente investigados na IC.  As primeiras experi\u00eancias usando betabloqueadores para tratamento de pacientes com IC datam da d\u00e9cada de 70, quando alguns pesquisadores investigaram o efeito do f\u00e1rmaco em sete pacientes com cardiomiopatia, IC avan\u00e7ada e taquicardia. U.S. Carvedilol Heart Failure Study,  que randomizou 1.094 pacientes para carvedilol ou placebo e demonstrou redu\u00e7\u00e3o de mortalidade.  O estudo seminal que sugeriu benef\u00edcio do betabloqueador em ICFEr foi o envolvendo 10 ensaios cl\u00ednicos e 18.254 pacientes com IC e FEVE reduzida, os betabloqueadores reduziram a mortalidade global em 27%.  Ao longo desses \u00faltimos 25 anos de investiga\u00e7\u00e3o cl\u00ednica, os betabloqueadores se consolidaram no tratamento da IC. Em meta-an\u00e1lise  Imp\u00f5e-se, portanto, vigil\u00e2ncia quanto \u00e0 piora, aparecimento de bradicardia, bloqueio card\u00edaco e hipotens\u00e3o, em especial nas primeiras semanas de ajuste do tratamento.  No aspecto pr\u00e1tico, \u00e9 importante destacar que os pacientes com ICFEr podem piorar na fase inicial do uso do medicamento.  No contexto da IC, esse fato \u00e9 especialmente importante, pois os pacientes com CCDC s\u00e3o mais suscept\u00edveis \u00e0 ocorr\u00eancia dessas manifesta\u00e7\u00f5es adversas quando em uso de betabloqueadores. Ainda que a CCDC n\u00e3o tenha sido inclu\u00edda nos grandes estudos multic\u00eantricos que investigaram betabloqueador e mortalidade e que haja peculiaridades da s\u00edndrome com essa etiologia, que \u00e9 associada com not\u00f3ria desregula\u00e7\u00e3o do sistema nervoso auton\u00f4mico, como revisto em outros cap\u00edtulos desta diretriz, n\u00e3o h\u00e1 plausibilidade biol\u00f3gica em se questionar o benef\u00edcio do bloqueio beta-adren\u00e9rgico no tratamento da ICFEr de etiologia da CCDC.  comparou os que estavam em uso de betabloqueador com aqueles que n\u00e3o faziam uso do medicamento. Apesar da limita\u00e7\u00e3o inerente ao pequeno tamanho amostral para compara\u00e7\u00f5es diretas, segundo os autores, os resultados sugerem efeitos ben\u00e9ficos dos betabloqueadores relacionados ao aumento de sobrevida . Deve-se salientar que nesse estudo o uso de betabloqueador n\u00e3o foi randomizado, havendo alto risco de vi\u00e9s de confus\u00e3o por indica\u00e7\u00e3o.  An\u00e1lise de pequeno grupo de pacientes (n = 68) com IC de etiologia da DC do estudo REMADHE continuumprogn\u00f3stico (ao inv\u00e9s de uma dicotomiza\u00e7\u00e3o), disfun\u00e7\u00f5es sist\u00f3licas de maior gravidade tendem a ser associadas a maior benef\u00edcio absoluto. Portanto, a recomenda\u00e7\u00e3o \u00e9 definida como forte para pacientes com IC e FEVE \u2264 40% e ponderada para pacientes com ICFElr.  Sendo assim, julgamos que a evid\u00eancia a respeito do uso de betabloqueador para pacientes com ICFEr de etiologia da DC \u00e9 indireta, proveniente de estudos de \u00f3tima qualidade que testaram a efic\u00e1cia desse tratamento nos tipos mais comuns de miocardiopatia (n\u00edvel B). Acompanhando o racional de que fra\u00e7\u00e3o de eje\u00e7\u00e3o \u00e9 umversusgravidade da IC (favorece betabloqueador). Esse \u00e9 um momento raro em que a diretriz reconhece a limita\u00e7\u00e3o de recomenda\u00e7\u00f5es est\u00e1ticas e abre espa\u00e7o para o dinamismo do pensamento m\u00e9dico baseado em racionalidade e em lastro de evid\u00eancias .  Um caso especial ocorre na presen\u00e7a de arritmia ventricular grave que requer considerar-se a prescri\u00e7\u00e3o de amiodarona. Eventualmente torna-se inadequada a associa\u00e7\u00e3o de betabloqueador e amiodarona devido \u00e0 bradicardia e/ou prolongamento do intervalo QT. Consideramos que nesse contexto n\u00e3o existe comprova\u00e7\u00e3o de que betabloqueador deva ser o medicamento priorit\u00e1rio. \u00c9 o caso de se flexibilizar a decis\u00e3o pelo julgamento cl\u00ednico, cabendo ao m\u00e9dico decidir pelo medicamento inicial a ser prescrito, com base na gravidade da arritmia (favorece amiodarona)10.1.5.4. Espironolactona Espironolactona \u00e9 o antagonista preferencial do receptor de mineralocorticoide, s\u00edtio principal de liga\u00e7\u00e3o da aldosterona e respons\u00e1vel por suas a\u00e7\u00f5es fisiol\u00f3gicas e com envolvimento direto no tocante \u00e0 fisiopatologia da IC. clearancede creatinina < 30mL/min/1,73m  , ou n\u00edvel de pot\u00e1ssio s\u00e9rico > 5,0mEq/L.  De maneira geral, a espironolactona \u00e9 indicada para todos os pacientes com IC sintom\u00e1ticos e com FEVE \u2264 35%, a despeito do uso concomitante ou n\u00e3o dos IECA, BRA ou betabloqueadores, excetuando-se aqueles pacientes com creatinina s\u00e9rica > 2,5mg/dL ou O estudo foi interrompido precocemente ap\u00f3s 24 meses, com n\u00famero de desfechos satisfat\u00f3rios para indicar precis\u00e3o e com a an\u00e1lise interina prevista demonstrando 35% de redu\u00e7\u00e3o relativa do risco de morte.  O estudo que respalda essa indica\u00e7\u00e3o respondeu pelo acr\u00f4nimo RALES, randomizado, duplo-cego, placebo-controlado, publicado em 1999, e testou se o uso de espironolactona, em dose variando de 25mg a 50mg, seria superior ao placebo na ICFEr (\u2264 35%) e classe funcional III-IV, em uso concomitante de IECA e furosemida.  Portanto, respeitar os crit\u00e9rios de contraindica\u00e7\u00e3o para uso da espironolactona e vigil\u00e2ncia judiciosa s\u00e3o essenciais na condu\u00e7\u00e3o cl\u00ednica de pacientes em uso desse f\u00e1rmaco.  Ressalte-se que pacientes com creatinina > 2,5mg/dL foram exclu\u00eddos e a incid\u00eancia de hipercalemia foi m\u00ednima nos dois grupos. Esse fato deve ser destacado, visto que estudo canadense de vigil\u00e2ncia epidemiol\u00f3gica relatou que a taxa de prescri\u00e7\u00e3o da espironolactona elevou-se substancialmente ap\u00f3s a publica\u00e7\u00e3o do estudo RALES e foi acompanhada de aumento na taxa de morbimortalidade associada \u00e0 hipercalemia.  Ainda que a CCDC tenha sido minimamente representada no estudo RALES , n\u00e3o h\u00e1 plausibilidade biol\u00f3gica para se questionar o benef\u00edcio potencial do bloqueio da aldosterona quanto \u00e0 progress\u00e3o da ICFEr tamb\u00e9m nessa entidade nosol\u00f3gica. Portanto, consideramos uma boa aplica\u00e7\u00e3o do n\u00edvel de evid\u00eancia B . Quanto \u00e0 recomenda\u00e7\u00e3o, guardadas as devidas indica\u00e7\u00f5es e contraindica\u00e7\u00f5es, consideramos deva ser forte para os pacientes com CCDC sintom\u00e1tica, FEVE \u2264 40%, creatinina \u2264 2,5mg/dL e pot\u00e1ssio s\u00e9rico \u2264 5,0mEq/dL e ponderada para pacientes com ICFElr. 10.1.5.5. Ivabradina A ivabradina \u00e9 um bloqueador seletivo da corrente If (canais funny) e, portanto, inibidor da atividade de MP no n\u00f3 sinusal, resultando em redu\u00e7\u00e3o seletiva da FC sem alterar par\u00e2metros hemodin\u00e2micos, como press\u00e3o arterial ou contratilidade mioc\u00e1rdica, e sem interferir na condu\u00e7\u00e3o el\u00e9trica intracard\u00edaca.  Nesse ECR, duplo-cego, placebo-controlado, publicado em 2010, a ivabradina foi testada na dose m\u00e1xima de 7,5mg 2 vezes ao dia em pacientes com IC (FEVE \u2264 35%), ritmo sinusal e FC> 70bpm, a despeito do uso de betabloqueadores quando tolerados. Relatou-se redu\u00e7\u00e3o relativa do risco de hospitaliza\u00e7\u00e3o de 26% e mortalidade por IC tamb\u00e9m de 26%.  Na IC, o estudo que respalda o uso da ivabradina responde pelo acr\u00f4nimo SHIFT.  por an\u00e1lisepost-hoc, avaliou-se desempenho de 38 pacientes com IC de etiologia da DC. Nessa subamostra, 20 pacientes tinham sido alocados para o grupo ivabradina e 18 para o grupo placebo. Apesar de os pacientes com CCDC apresentarem pior progn\u00f3stico em geral, com maior preval\u00eancia de BRD, menor n\u00edvel de press\u00e3o arterial, maior taxa de uso de diur\u00e9ticos, espironolactona, digoxina e menor taxa de uso de IECA/BRA ou betabloqueadores, comparativamente \u00e0 popula\u00e7\u00e3o geral do estudo SHIFT, a ivabradina n\u00e3o foi associada a maior preval\u00eancia de bradicardia grave, BAV, hipotens\u00e3o ou s\u00edncope. Ademais, relatou-se que a ivabradina foi eficaz em reduzir a FC desses pacientes e melhorar a classe funcional da IC.  Em subestudo do SHIFT,  A tradu\u00e7\u00e3o das evid\u00eancias para recomenda\u00e7\u00e3o terap\u00eautica n\u00e3o deve ser baseada em trabalhos explorat\u00f3rios. \u00c9 bastante claro que a etiologia da CCDC n\u00e3o foi bem representada no estudo SHIFT. Por outro lado, generaliza\u00e7\u00e3o n\u00e3o depende apenas de representatividade e n\u00e3o reconhecemos qualquer prov\u00e1vel mecanismo de intera\u00e7\u00e3o que nos fa\u00e7a suspeitar que a etiologia da CCDC modifique o efeito da terapia com ivabradina, a ponto de perda da efic\u00e1cia demonstrada no conjunto geral dos pacientes inclu\u00eddos no SHIFT. Por esse motivo, definimos que h\u00e1 n\u00edvel de evid\u00eancia B, o que representa evid\u00eancia indireta de boa qualidade para uso de ivabradina em pacientes com CCDC e IC. Quanto \u00e0 for\u00e7a de recomenda\u00e7\u00e3o, essa deve ser ponderada, pois depende da percep\u00e7\u00e3o de que a FC esteja elevada na impossibilidade de aumento da dose do betabloqueador. Dada essa especificidade, optamos por n\u00e3o estender a indica\u00e7\u00e3o para pacientes com FEVE superior a 40%. 10.1.5.6. Digoxina Na pr\u00e1tica cl\u00ednica, o medicamento pode ser indicado para pacientes em classe funcional III e IV da NYHA, a despeito do tratamento medicamentoso otimizado com os outros f\u00e1rmacos, e especialmente quando h\u00e1 FA com elevada resposta ventricular.  Ao revisar a literatura, n\u00e3o identificamos nenhum estudo avaliando a seguran\u00e7a e efic\u00e1cia do medicamento nesse contexto espec\u00edfico. Portanto, utilizaremos evid\u00eancia cient\u00edfica indireta de que a digoxina mostrou efeito para melhora sintom\u00e1tica e redu\u00e7\u00e3o de interna\u00e7\u00f5es hospitalares.  Com o digital, h\u00e1 bastante proximidade entre a dose terap\u00eautica e a t\u00f3xica, elevando-se o potencial de efeitos adversos, devido ao acometimento do sistema excito-condutor, e ocasionando bradiarritmias, BAV e outras manifesta\u00e7\u00f5es cl\u00ednicas gerais. 10.1.5.7. Sacubitril-Valsartana que a comparou com enalapril. Embora esse possa ser considerado um estudo preciso e com baixo risco de vi\u00e9s, demonstrando redu\u00e7\u00e3o relativa do risco de 20% com a associa\u00e7\u00e3o medicamentosa para o desfecho combinado prim\u00e1rio de hospitaliza\u00e7\u00e3o por IC e morte cardiovascular, houve margem para questionamento cient\u00edfico de sua concep\u00e7\u00e3o conceitual.  Com comparador heterodoxo, a rigor, o estudo n\u00e3o foi capaz de esclarecer se o benef\u00edcio encontrado deveu-se \u00e0 mol\u00e9cula inovadora (sacubitril) ou se decorreu de diferen\u00e7a inadequada quanto \u00e0s doses dos inibidores tradicionais do sistema da angiotensina . Outro aspecto a ressaltar, a exist\u00eancia de uma faserun-inem estudo de fase III, que superestima a aplicabilidade do tratamento, pois seleciona previamente os pacientes que toleram a terapia vasodilatadora mais intensa.  Sacubitril-valsartana \u00e9 uma combina\u00e7\u00e3o medicamentosa composta por um f\u00e1rmaco inibidor da neprilisina , o sacubitril, em associa\u00e7\u00e3o com um tradicional bloqueador da angiotensina II tipo-1, a valsartana. O principal estudo para valida\u00e7\u00e3o cient\u00edfica dessa combina\u00e7\u00e3o medicamentosa foi o PARADIGM-HF, guidelinese diretrizes de IC. No Brasil, o uso da sacubitril-valsartana foi aprovado em maio de 2017 pela ANVISA  e, em agosto de 2019, incorporado ao SUS.  A partir da publica\u00e7\u00e3o do estudo PARADIGM-HF, passou a existir percep\u00e7\u00e3o por parte de muitos cardiologistas de que a combina\u00e7\u00e3o sacubitril-valsartana tenha efic\u00e1cia superior \u00e0 vasodilata\u00e7\u00e3o tradicional com IECA, o que tem influenciado recomenda\u00e7\u00f5es de de pacientes com IC e FEVE \u2265 45%, e no estudo de IC complicando o infarto agudo do mioc\u00e1rdio que correspondeu ao acr\u00f4nimo PARADISE-MI.  Em ambos os cen\u00e1rios, os resultados n\u00e3o foram capazes de rejeitar a hip\u00f3tese nula configurada nas suas an\u00e1lises prim\u00e1rias. Vale ressaltar que o estudo PARADISE-MI foi o \u00fanico que comparou o sacubitril-valsartana com dose adequada de IECA, no caso 10 mg/dia de ramipril.  H\u00e1 tamb\u00e9m ind\u00edcios de que, diversamente do benef\u00edcio homogeneamente verificado com in\u00fameros inibidores do sistema da angiotensina-II estudados, a combina\u00e7\u00e3o sacubitril-valsartana n\u00e3o se mostrou superior em outros contextos. Assim foi no estudo PARAGON-HF,  Portanto, julgamos inadequada uma indica\u00e7\u00e3o baseada na expectativa de que essa combina\u00e7\u00e3o medicamentosa traga superioridade \u00e0 terapia tradicional. Por outro lado, n\u00e3o h\u00e1 ind\u00edcios de que essa terapia seja prejudicial, fazendo desse tratamento uma alternativa terap\u00eautica v\u00e1lida, caso o m\u00e9dico deseje modificar um tratamento-padr\u00e3o por motivo cl\u00ednico ou log\u00edstico. \u00c9 importante salientar que o relat\u00f3rio que respaldou a incorpora\u00e7\u00e3o do sacubitril-valsartana no SUS estimou raz\u00e3o de custo-efetividade incremental de R$ 22.769 por ano de vida ganho com qualidade.  Quanto \u00e0 indica\u00e7\u00e3o de uso em pacientes com IC causada pela CCDC, al\u00e9m da t\u00e9cnica de revis\u00e3o da literatura mencionada anteriormente, utilizou-se tamb\u00e9m a ferramenta do google acad\u00eamico para buscar na literatura cinzenta alguma refer\u00eancia que pudesse trazer luz \u00e0 quest\u00e3o de interesse aqui tratada e avaliamos os anais de congressos em busca dessa informa\u00e7\u00e3o.  Assim, relatou-se s\u00e9rie de pacientes com CCDC tratados com sacubitril-valsartana em hospital de refer\u00eancia para essa doen\u00e7a no Brasil, referindo-se, ap\u00f3s 6 meses, melhora sintom\u00e1tica desses indiv\u00edduos.  os autores verificaram que at\u00e9 44% dos pacientes desse registro unic\u00eantrico apresentavam os principais crit\u00e9rios de exclus\u00e3o do PARADIGM-HF. Observaram ainda que n\u00edveis press\u00f3ricos mais baixos, comuns na CCDC, poderiam ter levado \u00e0 subutiliza\u00e7\u00e3o de alguns medicamentos nesse contexto.  Em estudo prospectivo e observacional de 136 pacientes consecutivos com IC em \u00fanico centro hospitalar universit\u00e1rio, incluindo as etiologias CMI, CCDC e cardiomiopatia idiop\u00e1tica,  Outro estudo avaliou a propor\u00e7\u00e3o de pacientes com CCDC randomizados em dois ensaios cl\u00ednicos recentes (PARADIGM-HF e ATMOSPHERE), reportando que apenas 7,6% dos pacientes randomizados na Am\u00e9rica Latina tinham essa etiologia. post-hocdo PARADIGM-HF sugeriu que o sacubitril-valsartana, em compara\u00e7\u00e3o com o enalapril, poderia levar a redu\u00e7\u00e3o semelhante ou at\u00e9 maior (37%) de morte e hospitaliza\u00e7\u00e3o em pacientes com CCDC, comparativamente \u00e0queles sem essa etiologia de IC, apesar de aus\u00eancia de signific\u00e2ncia estat\u00edstica e imprecis\u00e3o de estimativa de efeito.  Sob o acr\u00f4nimo PARACHUTE , est\u00e1 em andamento estudo exclusivo de pacientes com IC de etiologia da CCDC. Infelizmente, como no pr\u00f3prio PARADIGM,  os comparadores n\u00e3o s\u00e3o os ortodoxos e o efeito de sacubitril associado \u00e0 dose maximizada de valsartana ser\u00e1 cotejado ao do enalapril em dose n\u00e3o m\u00e1xima, de 20 mg diariamente.  An\u00e1lise de subgrupo Em s\u00edntese, fica claro que os pacientes com CCDC n\u00e3o foram bem representados nos estudos do sacubitril-valsartana. Ent\u00e3o, embora tenhamos trazido algumas evid\u00eancias a respeito da utiliza\u00e7\u00e3o da terapia em quest\u00e3o em pacientes com IC causada pela CCDC, elas n\u00e3o nos servem para induzir recomenda\u00e7\u00e3o, pois s\u00e3o de car\u00e1ter explorat\u00f3rio. Por\u00e9m servem para exemplificar o princ\u00edpio da evid\u00eancia indireta: generaliza\u00e7\u00e3o n\u00e3o depende apenas de representatividade e n\u00e3o reconhecemos nenhum prov\u00e1vel mecanismo de intera\u00e7\u00e3o que nos fa\u00e7a suspeitar que a etiologia da cardiopatia modifique o efeito dessa terapia. Por esse motivo, definimos que h\u00e1 n\u00edvel de evid\u00eancia B para o paciente com ICFEr e CCDC, no sentido de que o tratamento com a combina\u00e7\u00e3o sacubitril-valsartana seja alternativa poss\u00edvel, por\u00e9m n\u00e3o uma inova\u00e7\u00e3o superior ao tratamento tradicional. Quanto \u00e0 recomenda\u00e7\u00e3o, essa n\u00e3o \u00e9 a de se preferir esse tratamento, mas apenas consider\u00e1-lo como alternativa quando o julgamento cl\u00ednico sugere a necessidade de mudan\u00e7a terap\u00eautica (recomenda\u00e7\u00e3o ponderada). Tamb\u00e9m n\u00e3o estendemos essa indica\u00e7\u00e3o para paciente com FEVE > 40%. 10.1.5.8. Inibidores do Cotransportador de S\u00f3dio e Glicose do Tipo 2 Nos \u00faltimos anos, essa classe de medicamentos suscitou muito entusiasmo na comunidade cient\u00edfica a partir de demonstra\u00e7\u00f5es de benef\u00edcio incremental ao tratamento tradicional, em termos de melhora do progn\u00f3stico da IC e da disfun\u00e7\u00e3o renal. Neste cap\u00edtulo, revisaremos se o n\u00edvel de evid\u00eancias \u00e9 proporcional ao entusiasmo e traduziremos para a tomada de decis\u00e3o no contexto da IC da CCDC. mellitusdo tipo 2. O SGLT2 age fisiologicamente no t\u00fabulo contornado proximal e responde por 90% da reabsor\u00e7\u00e3o da glicose filtrada no glom\u00e9rulo. Os inibidores de SGLT2 promovem excre\u00e7\u00e3o renal de glicose, sendo esse o mecanismo de seu efeito redutor de glicemia.  Duas observa\u00e7\u00f5es iniciais foram percebidas quanto a efeitos intermedi\u00e1rios: primeiro, a efic\u00e1cia desses inibidores como redutores de glicemia em diab\u00e9ticos \u00e9 modesta, com redu\u00e7\u00f5es m\u00e9dias de hemoglobina glicada variando entre 0,4% e 1,1%, em compara\u00e7\u00e3o ao placebo;  segundo, promovem consistente redu\u00e7\u00e3o de peso, quando comparados a outros antidiab\u00e9ticos.  Os inibidores do cotransportador de s\u00f3dio e glicose do tipo 2 (SGLT2) s\u00e3o medicamentos originalmente testados para tratamento de hiperglicemia em pacientes com diabetes Diversamente do mais tradicional, a estrat\u00e9gia inicial dos produtores industriais dessa classe de medicamentos foi a de avaliar sua seguran\u00e7a em diab\u00e9ticos, focando em desfechos macrovasculares  e utilizando abordagem contraintuitiva de testar n\u00e3o inferioridade relativamente ao placebo. Embora contraintuitiva, o desvio da hip\u00f3tese nula para um valor diferente de zero \u00e9 m\u00e9todo adequado para testar seguran\u00e7a, visto que um intervalo de toler\u00e2ncia para efeito adverso pode se justificar com base em um benef\u00edcio demonstrado.  o que cientificamente tem validade. Por outro lado, restava a quest\u00e3o cl\u00ednica: na aus\u00eancia de um benef\u00edcio incremental constatado, apenas a demonstra\u00e7\u00e3o de seguran\u00e7a n\u00e3o seria justificativa para recomendar a adi\u00e7\u00e3o desse tratamento para pacientes diab\u00e9ticos?  A n\u00e3o inferioridade em compara\u00e7\u00e3o ao placebo (seguran\u00e7a) foi confirmada por diversos estudos dessa classe de f\u00e1rmacos,  onde compuseram desfecho de efic\u00e1cia prim\u00e1rio, caso a hip\u00f3tese de n\u00e3o inferioridade para eventos graves fosse demonstrada. Vale salientar que inibidores de SGLT2 promovem natriurese, diurese osm\u00f3tica (pela glicos\u00faria) e perda de peso, mecanismos que aumentam a probabilidadea priorido benef\u00edcio demonstrado. A partir desses resultados, investiu-se no teste da hip\u00f3tese de que esses inibidores de SGLT2 melhorem o progn\u00f3stico em pacientes com ICFEr.  Foi ent\u00e3o que se percebeu que desfechos relacionados a IC aparentavam redu\u00e7\u00e3o nos grupos tratados. Esses foram desfechos secund\u00e1rios dos estudos, exceto para o ensaio cl\u00ednico DECLARE\u2013TIMI 58, mellitustipo 2. Os estudos DAPA-HF  e EMPEROR-Reduced  avaliaram o efeito de dapagliflozina e empagliflozina, respectivamente, na incid\u00eancia de desfecho combinado de morte por causa cardiovascular e interna\u00e7\u00e3o por IC, em compara\u00e7\u00e3o ao placebo, nos pacientes com ICFEr. O primeiro a ser publicado, o estudo DAPA-HF, incluiu 4.744 pacientes com IC e FEVE \u2264 40%, em classe funcional II a IV (NYHA), j\u00e1 em uso de terapia farmacol\u00f3gica otimizada, e eleva\u00e7\u00e3o dos n\u00edveis de NT-proBNP. Diabetesmellitusestava presente em 42% da amostra e 99% dos casos estavam em classe funcional II ou III na randomiza\u00e7\u00e3o. A etiologia da IC foi n\u00e3o isqu\u00eamica em 44% dos casos, sem men\u00e7\u00e3o a DC, embora esse tenha sido um ensaio cl\u00ednico multicontinental, no qual cerca de 17% dos participantes foram recrutados em centros da Am\u00e9rica Latina.  Assim, os ensaios cl\u00ednicos com inibidores de SGLT2 voltaram-se para pacientes com IC sintom\u00e1tica, independentemente da presen\u00e7a de diabetesversus502 eventos, respectivamente; HR 0,74; IC 95%: 0,65-0,85). O benef\u00edcio foi observado em ambos os componentes do desfecho prim\u00e1rio, bem como mostrou-se consistente nas an\u00e1lises pr\u00e9-especificadas em diferentes subgrupos, inclusive conforme a presen\u00e7a ou n\u00e3o de diabetesmellitustipo 2.  Observou-se tamb\u00e9m redu\u00e7\u00e3o no risco de morte por todas as causas no grupo tratado com dapagliflozinaversuso grupo placebo .  Os pacientes foram randomicamente alocados para uso de dapagliflozina 10 mg/dia ou placebo, em raz\u00e3o 1:1. Ap\u00f3s seguimento mediano de 18 meses, dapagliflozina associou-se a redu\u00e7\u00e3o do risco para o desfecho prim\u00e1rio, que inclu\u00eda morte de causa cardiovascular e interna\u00e7\u00e3o por IC , quanto ao benef\u00edcio da dapagliflozina sobre o desfecho prim\u00e1rio e n\u00e3o encontrou modifica\u00e7\u00e3o de efeito.  constitu\u00edram crit\u00e9rios de exclus\u00e3o para participa\u00e7\u00e3o no estudo.  O perfil de seguran\u00e7a da dapagliflozina foi satisfat\u00f3rio, com baixa incid\u00eancia de eventos adversos s\u00e9rios. \u00c9 importante salientar, por\u00e9m, que, na avalia\u00e7\u00e3o de elegibilidade do DAPA-HF, press\u00e3o arterial sist\u00f3lica < 95mmHg e taxa de filtra\u00e7\u00e3o glomerular < 30mL/min/1,73m  investigou o efeito da empagliflozina, comparada a placebo, em amostra de pacientes com ICFEr (\u2264 40%) em terapia m\u00e9dica otimizada, e definiu perfil de elegibilidade e desfecho prim\u00e1rio semelhantes aos do ensaio DAPA-HF. No entanto, os 3.730 participantes do estudo (50% com diabetesmellitustipo 2) apresentaram valores m\u00e9dios mais altos de pept\u00eddeos atriais natriur\u00e9ticos e m\u00e9dia de FEVE mais baixa, em rela\u00e7\u00e3o \u00e0 amostra do estudo da dapagliflozina. Novamente, a DC n\u00e3o foi representada como etiologia da IC, ainda que 34% dos participantes do estudo tivessem sido recrutados em pa\u00edses da Am\u00e9rica Latina. Ap\u00f3s mediana de seguimento de 16 meses, empagliflozina reduziu em 25% o risco combinado de interna\u00e7\u00e3o por IC e morte cardiovascular em rela\u00e7\u00e3o ao placebo , por\u00e9m, diferentemente do DAPA-HF, esse benef\u00edcio pareceu decorrer basicamente da redu\u00e7\u00e3o de interna\u00e7\u00f5es por IC. Nas an\u00e1lises de subgrupo pr\u00e9-especificadas, o efeito da empagliflozina para o desfecho prim\u00e1rio manteve-se consistente.  O estudo correspondente ao acr\u00f4nimo EMPEROR-Reduced, publicado em 2020,  Assim como observado no DAPA-HF, no EMPEROR-Reduced, pacientes em uso do inibidor de SGLT2 evolu\u00edram com menores valores de press\u00e3o arterial sist\u00f3lica, peso corporal e NT-proBNP ap\u00f3s um ano de seguimento, em compara\u00e7\u00e3o aos valores basais.  estendeu a investiga\u00e7\u00e3o com empagliflozina para pacientes com ICFElr (> 40%). A redu\u00e7\u00e3o relativa do risco de eventos foi semelhante \u00e0quela verificada nos pacientes com FEVE \u2264 40%, o que \u00e9 esperado, pois um limite arbitr\u00e1rio de fra\u00e7\u00e3o de eje\u00e7\u00e3o n\u00e3o define duas doen\u00e7as diferentes. Cabe enfatizar que pacientes com ICFElr possuem melhor progn\u00f3stico, o que naturalmente reduz a magnitude absoluta do benef\u00edcio: NNT de 19 nos dois primeiros estudos com FEVE < 40% e NNT de 30 no EMPEROR-Preserved trial.  Mais recentemente, o EMPEROR-Preserved trial  Esses estudos possuem precis\u00e3o estat\u00edstica satisfat\u00f3ria e baixo risco de vi\u00e9s, parecendo, portanto, adequado afirmar que existe efeito de benef\u00edcio, cuja magnitude representada por 25% de redu\u00e7\u00e3o relativa do risco se situa no n\u00edvel  da maioria das terapias reconhecidas em IC. Portanto, do ponto de vista pragm\u00e1tico, esses f\u00e1rmacos s\u00e3o seguros e moderadamente ben\u00e9ficos.  Quanto \u00e0 custo-efetividade, recente incorpora\u00e7\u00e3o da dapagliflozina no SUS baseou-se em relat\u00f3rio da CONITEC que apresenta modelo econ\u00f4mico com raz\u00e3o de custo-efetividade incremental da ordem de R$ 9.296 por ano de vida salva com qualidade e situa-se dentro de uma defini\u00e7\u00e3o aceit\u00e1vel para efici\u00eancia versuso quanto deve-se especificamente \u00e0 inova\u00e7\u00e3o da mol\u00e9cula? H\u00e1 descri\u00e7\u00e3o de efeitos favor\u00e1veis dessas medica\u00e7\u00f5es em desfechos intermedi\u00e1rios, de ordem metab\u00f3lica e neuro-humorais, como aumento de n\u00edveis circulantes de subst\u00e2ncias vasodilatadoras e redu\u00e7\u00e3o dos n\u00edveis de vasoconstritores. Todavia, os ensaios cl\u00ednicos n\u00e3o focalizaram a pertinente prova de conceito de que s\u00e3o esses os efeitos que medeiam o benef\u00edcio cl\u00ednico no contexto. Nenhum deles gerou um contrafactual (segundo grupo controle) baseado na terapia diur\u00e9tica para responder \u00e0 quest\u00e3o: se um paciente que n\u00e3o recebesse o f\u00e1rmaco inovador tivesse tido um mesmo n\u00edvel de melhora da diurese, o seu desfecho seria diferente? Essa pergunta tamb\u00e9m poderia ser explorada por an\u00e1lise de media\u00e7\u00e3o , utilizando-se dados dos ensaios cl\u00ednicos e de uma vari\u00e1vel mediadora p\u00f3s-randomiza\u00e7\u00e3o que representasse o efeito na diurese. N\u00e3o detectamos na literatura esse tipo de abordagem.  No entanto, resta uma quest\u00e3o conceitual: o quanto do benef\u00edcio desses f\u00e1rmacos deriva do aprimoramento da terapia diur\u00e9tica Finalmente, como traduzir nossa interpreta\u00e7\u00e3o das evid\u00eancias para recomenda\u00e7\u00e3o de terap\u00eautica com gliflozinas em indiv\u00edduos com IC de etiologia da DC? De novo, essa n\u00e3o foi uma subpopula\u00e7\u00e3o representada nos ensaios cl\u00ednicos. Consoante o j\u00e1 exposto para outros contextos, generaliza\u00e7\u00e3o n\u00e3o depende apenas de representatividade e n\u00e3o reconhecemos um prov\u00e1vel mecanismo de intera\u00e7\u00e3o que nos fa\u00e7a suspeitar que a etiologia da CCDC modifique o efeito dessa terapia a ponto de perda da efic\u00e1cia demonstrada. Por esse motivo, definimos que h\u00e1 n\u00edvel de evid\u00eancia B para a IC causada pela CCDC, ou seja, ela \u00e9 indireta e de boa qualidade. Quanto \u00e0 for\u00e7a de recomenda\u00e7\u00e3o, na aus\u00eancia do contrafactual de que o benef\u00edcio exista al\u00e9m do efeito diur\u00e9tico, optamos por uma recomenda\u00e7\u00e3o ponderada para pacientes com IC cursando com FE reduzida, devendo a justificativa para esta nova prescri\u00e7\u00e3o ser mediada por um quadro cl\u00ednico que sugira necessidade de incremento terap\u00eautico.  As recomenda\u00e7\u00f5es para o tratamento farmacol\u00f3gico da IC na CCDC est\u00e3o expressas na Apesar dos avan\u00e7os observados no tratamento medicamentoso, nos cuidados de terapia intensiva e nas estrat\u00e9gias cir\u00fargicas, inclusive com uso de dispositivos card\u00edacos implant\u00e1veis para tratamento da IC, essa s\u00edndrome cl\u00ednica ainda persiste com elevada morbidade e mortalidade e consider\u00e1vel impacto econ\u00f4mico sobre o sistema de sa\u00fade, principalmente em suas fases mais avan\u00e7adas.  Portanto, o tratamento com TC na CCDC avan\u00e7ada \u00e9 considerado uma recomenda\u00e7\u00e3o forte, com n\u00edvel de evid\u00eancia B, \u00e0 semelhan\u00e7a do que ocorre em outras doen\u00e7as card\u00edacas com indica\u00e7\u00f5es cl\u00e1ssicas, desde que, obviamente, n\u00e3o haja contraindica\u00e7\u00f5es ao procedimento e que se considerem algumas peculiaridades, tais como, condi\u00e7\u00f5es socioecon\u00f4micas desfavor\u00e1veis e presen\u00e7a de megac\u00f3lon e/ou megaes\u00f4fago, que podem aumentar os riscos de complica\u00e7\u00f5es no p\u00f3s-operat\u00f3rio e comprometer o resultado do TC.  O TC ainda \u00e9 reconhecido como a melhor forma de tratamento para a IC refrat\u00e1ria, com influ\u00eancia evidente no aumento de sobrevida e melhora da qualidade de vida dos pacientes, especialmente na CCDC, que t\u00eam progn\u00f3stico mais reservado quando comparada \u00e0s outras etiologias. 10.2.1.1. Estrat\u00e9gias de Imunossupress\u00e3o Os regimes imunossupressores institu\u00eddos ap\u00f3s o TC podem ser classificados como de indu\u00e7\u00e3o e de manuten\u00e7\u00e3o e independem da etiologia da IC que resultou na indica\u00e7\u00e3o do TC. Os regimes de indu\u00e7\u00e3o propiciam intensa supress\u00e3o imunol\u00f3gica p\u00f3s-operat\u00f3ria precoce, enquanto os regimes de manuten\u00e7\u00e3o s\u00e3o usados ao longo da vida do paciente para prevenir a rejei\u00e7\u00e3o. 10.2.1.2. Terapia de Indu\u00e7\u00e3o S\u00e3o considerados de alto risco de rejei\u00e7\u00e3o fatal, podendo, portanto, beneficiar-se da terapia de indu\u00e7\u00e3o os pacientes com altos t\u00edtulos de anticorpos anti-HLA no painel imunol\u00f3gico (PRA = panel reactive antibody > 10%), sendo considerados mais vulner\u00e1veis: mulheres jovens com hist\u00f3ria pr\u00e9via de gravidez, pacientes com transfus\u00f5es pregressas m\u00faltiplas e usu\u00e1rios de suporte circulat\u00f3rio mec\u00e2nico. Os principais agentes indutores s\u00e3o as imunoglobulinas antitim\u00f3citos policlonais  e os inibidores dos receptores de IL-2, os quais t\u00eam baixa imunogenicidade, como o daclizumabe e basiliximabe.  A terapia de indu\u00e7\u00e3o no paciente transplantado consiste no tratamento imunossupressor de forma intensa, durante o transplante ou no p\u00f3s-operat\u00f3rio imediato, sendo utilizada em pacientes de alto risco para rejei\u00e7\u00e3o na tentativa de reduzir o risco agudo desse evento ou de retardar o uso de doses maiores de inibidores da calcineurina, minimizando o dano renal, particularmente em pacientes com fun\u00e7\u00e3o renal comprometida. T. cruzi. A terapia de indu\u00e7\u00e3o ainda \u00e9 controversa e, apesar de ser utilizada em 50% dos receptores card\u00edacos em geral, n\u00e3o foram realizados, at\u00e9 o momento, grandes ECR demonstrando o benef\u00edcio da terapia de indu\u00e7\u00e3oversusnenhuma terapia de indu\u00e7\u00e3o.  N\u00e3o existem dados dispon\u00edveis acerca de seus efeitos no receptor com CCDC.  Embora esses agentes possam reduzir o risco de rejei\u00e7\u00e3o precoce e/ou minimizar o dano renal, est\u00e3o associados a risco aumentado de infec\u00e7\u00e3o e, portanto, t\u00eam potencial para reativar a infec\u00e7\u00e3o pelo10.2.1.3. Terapia de Manuten\u00e7\u00e3o A terapia imunossupressora b\u00e1sica de manuten\u00e7\u00e3o nos pacientes transplantados card\u00edacos, em geral, inclui necessariamente um agente inibidor de calcineurina, qual seja a ciclosporina A ou o tacrolimus. Esses agentes devem ser associados ao micofenolato de mofetil (MMF) ou micofenolato s\u00f3dico ou azatioprina ou rapamicina ou everolimus. A prednisona tamb\u00e9m \u00e9 associada a esse esquema-padr\u00e3o, sendo que, na maioria dos pacientes, pode e deve ser suspensa cerca de 6 meses ap\u00f3s o transplante, na aus\u00eancia de rejei\u00e7\u00e3o. T.cruzi.  N\u00e3o existem estudos comparando os v\u00e1rios esquemas de imunossupress\u00e3o nos pacientes com CCDC; entretanto, um maior n\u00famero de reativa\u00e7\u00f5es foi diagnosticado com uso de MMFversusazatioprina.  Portanto, estrat\u00e9gias para alterar a imunossupress\u00e3o, como a substitui\u00e7\u00e3o do MMF pela azatioprina ou a redu\u00e7\u00e3o da dose do MMF, t\u00eam sido propostas, mas essas estrat\u00e9gias n\u00e3o foram testadas em ECR.  No contexto da CCDC, a terapia imunossupressora de indu\u00e7\u00e3o e/ou de manuten\u00e7\u00e3o pode reativar a infec\u00e7\u00e3o pelo Uma redu\u00e7\u00e3o precoce dos agentes imunossupressores, especialmente corticosteroides, \u00e9 recomendada para prevenir a RDC, mas essa abordagem pode facilitar os epis\u00f3dios de rejei\u00e7\u00e3o. Sendo assim, seria recomend\u00e1vel que o paciente com CCDC receba a terapia imunossupressora com a menor intensidade poss\u00edvel, desde que n\u00e3o tenha rejei\u00e7\u00e3o.  A A rejei\u00e7\u00e3o \u00e9 classificada em hiperaguda, mediada por anticorpos, e rejei\u00e7\u00e3o celular aguda, que representa a forma mais prevalente de rejei\u00e7\u00e3o. Histologicamente, \u00e9 definida por infiltrados inflamat\u00f3rios, em que tipicamente predominam linf\u00f3citos, e les\u00e3o associada aos mi\u00f3citos. AInternational Society for Heart & Lung Transplantation(ISHLT) revisou as categorias de rejei\u00e7\u00e3o celular aguda (R) como segue: 0R (sem rejei\u00e7\u00e3o), 1R (leve), 2R (moderado) ou 3R (grave).  A incid\u00eancia de rejei\u00e7\u00e3o com necessidade de tratamento vem se reduzindo progressivamente ao longo dos anos, acometendo apenas 12,6% dos receptores no primeiro ano ap\u00f3s o TC na atualidade.  A frequ\u00eancia de rejei\u00e7\u00e3o hiperaguda e rejei\u00e7\u00e3o mediada por anticorpos ap\u00f3s TC devido \u00e0 DC ainda n\u00e3o foi relatada.  A rejei\u00e7\u00e3o hiperaguda constitui evento pouco comum, \u00e9 mediada por anticorpos pr\u00e9-formados nos receptores e se manifesta como uma fal\u00eancia grave do enxerto dentro de minutos ou poucas horas ap\u00f3s o procedimento de TC.  A rejei\u00e7\u00e3o celular aguda ocorre em 10% a 14% dos receptores com CCDC e n\u00e3o h\u00e1 diferen\u00e7a na incid\u00eancia de epis\u00f3dios de rejei\u00e7\u00e3o celular aguda (grau 2R ou 3R) entre receptores de TC com ou sem DC. T. cruzino cora\u00e7\u00e3o transplantado, o que torna o diagn\u00f3stico diferencial entre rejei\u00e7\u00e3o e RDC um grande desafio.  A bi\u00f3psia endomioc\u00e1rdica ainda constitui o m\u00e9todo-padr\u00e3o para o diagn\u00f3stico de rejei\u00e7\u00e3o, sendo a frequ\u00eancia das bi\u00f3psias vari\u00e1vel conforme o protocolo do centro de transplante. Pode ocorrer miocardite secund\u00e1ria \u00e0 reativa\u00e7\u00e3o da infec\u00e7\u00e3o pelo A presen\u00e7a de ninhos de amastigotas deT. cruzicom infiltrados mononucleares inflamat\u00f3rios nos fragmentos de bi\u00f3psia endomioc\u00e1rdica n\u00e3o exclui rejei\u00e7\u00e3o concomitante do enxerto, pois as duas condi\u00e7\u00f5es podem ocorrer simultaneamente.  A defini\u00e7\u00e3o de uma dessas duas condi\u00e7\u00f5es ainda \u00e9 dif\u00edcil se parasitas n\u00e3o forem encontrados nos fragmentos de bi\u00f3psia. De acordo com as t\u00e9cnicas de colora\u00e7\u00e3o histopatol\u00f3gica de rotina, se os parasitas n\u00e3o forem vistos, as caracter\u00edsticas histopatol\u00f3gicas inflamat\u00f3rias encontradas na rejei\u00e7\u00e3o (grau 2R ou 3R) ou na RDC s\u00e3o bastante semelhantes. Assim, a detec\u00e7\u00e3o de infiltrado mononuclear inflamat\u00f3rio nas l\u00e2minas de bi\u00f3psia endomioc\u00e1rdica n\u00e3o \u00e9 suficiente para descartar o diagn\u00f3stico de RDC e representa um dilema m\u00e9dico, pois o tratamento imunossupressor agressivo para abortar a rejei\u00e7\u00e3o pode facilitar e intensificar a RDC.  A rejei\u00e7\u00e3o constitui um fator de risco para a RDC, sendo que mais de 85% dos pacientes apresentam pelo menos um epis\u00f3dio de rejei\u00e7\u00e3o antes de ocorrer a reativa\u00e7\u00e3o.  A terapia de rejei\u00e7\u00e3o em transplantados com e sem DC \u00e9 semelhante. Em geral, o grau leve de rejei\u00e7\u00e3o (1R), na aus\u00eancia de comprometimento cl\u00ednico ou hemodin\u00e2mico, n\u00e3o requer interven\u00e7\u00e3o adicional. No entanto, graus mais elevados (\u2265 2R) requerem terapia imunossupressora suplementar agressiva. 10.2.3.1. Apresenta\u00e7\u00e3o Cl\u00ednicaT. cruzi, cuja incid\u00eancia ap\u00f3s TC varia de 19,6% a 90%.  Considerando a morbidade e a mortalidade potencial, o diagn\u00f3stico e manejo apropriado da RDC no contexto de transplante de \u00f3rg\u00e3os \u00e9 extremamente importante.  A terapia imunossupressora institu\u00edda aumenta o risco de reativa\u00e7\u00e3o da infec\u00e7\u00e3o pelo O diagn\u00f3stico da reativa\u00e7\u00e3o baseia-se em sinais e sintomas cl\u00ednicos e na presen\u00e7a de parasitos em sangue, l\u00edquor e outros fluidos, medula \u00f3ssea ou tecidos.  Portanto, esse procedimento deve ser realizado dentro de um protocolo cl\u00ednico e laboratorial estruturado para monitorar a reativa\u00e7\u00e3o da infec\u00e7\u00e3o e seu subsequente tratamento. T. cruziprontamente. A reativa\u00e7\u00e3o cl\u00ednica tem manifesta\u00e7\u00f5es card\u00edacas e extracard\u00edacas incluindo: miocardite, disfun\u00e7\u00e3o ventricular, arritmias, bloqueios atrioventriculares/intraventriculares novos no ECG, les\u00f5es cut\u00e2neas , febre, acometimento de medula \u00f3ssea ou manifesta\u00e7\u00f5es neurol\u00f3gicas, tais como meningoencefalite, chagoma, abcesso cerebral ou AVC.  A miocardite da reativa\u00e7\u00e3o pode ser equivocadamente diagnosticada como rejei\u00e7\u00e3o do enxerto e tratada com intensifica\u00e7\u00e3o do tratamento imunossupressor, o que vai agravar a reativa\u00e7\u00e3o.  O diagn\u00f3stico diferencial entre a miocardite da rejei\u00e7\u00e3o e da reativa\u00e7\u00e3o ainda constitui um grande desafio.  Na presen\u00e7a de infiltrado inflamat\u00f3rio, ninhos de amastigotas e/ou PCR positiva paraT. cruzino mioc\u00e1rdio, podemos afirmar que existe reativa\u00e7\u00e3o, mas n\u00e3o \u00e9 poss\u00edvel excluir, com seguran\u00e7a, rejei\u00e7\u00e3o do enxerto associada. Apesar dessa complexidade, a taxa de sobrevida de receptores com CCDC submetidos ao TC n\u00e3o difere das de outras etiologias.  A monitora\u00e7\u00e3o tem como objetivo identificar os primeiros sinais de reativa\u00e7\u00e3o e estabelecer tratamento anti-10.2.3.2. Diagn\u00f3stico Parasitol\u00f3gico da Reativa\u00e7\u00e3o As provas sorol\u00f3gicas t\u00eam utilidade somente em potenciais doadores, diagn\u00f3stico de CCDC em potenciais receptores e em receptores soronegativos que recebem \u00f3rg\u00e3os de doadores soropositivos.  N\u00e3o t\u00eam papel no diagn\u00f3stico da RDC.  O objetivo da monitora\u00e7\u00e3o laboratorial \u00e9 identificar qualquer sinal subcl\u00ednico de RDC antes dos sintomas card\u00edacos e extracard\u00edacos, bem como de disfun\u00e7\u00e3o do enxerto. T. cruzie hemoculturas) e exames histol\u00f3gicos seriados de bi\u00f3psia endomioc\u00e1rdica, na procura de amastigotas deT. cruzi,testes esses com baixa sensibilidade.  Nos \u00faltimos anos, v\u00e1rios estudos demonstraram o valor do teste da PCR no sangue perif\u00e9rico e no mioc\u00e1rdio para detectar RDC precoce antes do surgimento de sintomas e/ou disfun\u00e7\u00e3o do enxerto.  Tradicionalmente, a monitora\u00e7\u00e3o laboratorial utilizava m\u00e9todos parasitol\u00f3gicos , com dor e/ou parestesia em membros inferiores, anorexia. Leucopenia significativa e agranulocitose s\u00e3o raras e, quando presentes, determinam interrup\u00e7\u00e3o do tratamento.  O nifurtimox n\u00e3o est\u00e1 dispon\u00edvel rotineiramente no Brasil. Essas medica\u00e7\u00f5es tripanossomicidas est\u00e3o contraindicadas em gestantes e pacientes com insufici\u00eancia renal ou hep\u00e1tica importante.  N\u00e3o existe evid\u00eancia suficiente que suporte a estrat\u00e9gia de tratamento antiT. cruziprofil\u00e1tico da RDC. \u00c9 importante considerar que esses f\u00e1rmacos t\u00eam efeitos colaterais importantes, nem todo receptor \u00e9 acometido de RDC e que um paciente pode ter mais de um epis\u00f3dio de RDC ap\u00f3s tratamento. Recomenda-se manter a monitora\u00e7\u00e3o da reativa\u00e7\u00e3o mesmo ap\u00f3s tratamento antiT. cruzi.  ; rejei\u00e7\u00e3o 2R ou 3R (10%-14%); sangramento no p\u00f3s-operat\u00f3rio (10%); infec\u00e7\u00e3o n\u00e3o relacionada aoT. cruzi(20%-30%); e insufici\u00eancia renal aguda (at\u00e9 70%). Por sua vez, em receptores com CCDC, a doen\u00e7a vascular coron\u00e1ria do enxerto parece ser menos frequente, enquanto a incid\u00eancia de neoplasias parece ser maior, embora nenhuma dessas diferen\u00e7as relatadas tenha sido confirmada em todas as s\u00e9ries.  Os desfechos cl\u00ednicos, morbidade e mortalidade em receptores de TC com e sem DC s\u00e3o semelhantes.  Uma explica\u00e7\u00e3o para esse melhor desempenho seria que, em decorr\u00eancia de caracter\u00edsticas de base, os pacientes com CCDC, em geral, s\u00e3o mais jovens, com menos comorbidades e menos cirurgias card\u00edacas pr\u00e9vias.  Em aparente contraste com esses dados, publica\u00e7\u00e3o recente relatou a evolu\u00e7\u00e3o de 376 transplantados entre 1997 e 2019 em \u00fanica institui\u00e7\u00e3o do Nordeste brasileiro, comparando as seguintes etiologias de IC: CCDC, CMI e cardiomiopatia n\u00e3o isqu\u00eamica em geral. Evidenciou-se, ap\u00f3s seguimento m\u00e9dio de 5 anos, estabilidade na sobrevida dos indiv\u00edduos com CCDC, enquanto ocorreu melhora subsequente desse par\u00e2metro nos outros dois grupos.  Apesar de toda a complexidade da DC no contexto de TC, os resultados finais s\u00e3o bons. No Brasil, a taxa de sobrevida de pacientes com CCDC submetidos ao TC \u00e9 de 76%, 71% e 46% em 6 meses, 5 e 10 anos, respectivamente, superior \u00e0quela da coorte de pacientes submetidos ao TC por outras etiologias.  Os dispositivos de assist\u00eancia circulat\u00f3ria mec\u00e2nica (DACM) s\u00e3o utilizados para restaurar a perfus\u00e3o tecidual em pacientes com IC avan\u00e7ada ou choque cardiog\u00eanico, refrat\u00e1rios \u00e0 terapia cl\u00ednica otimizada, incluindo o uso de medica\u00e7\u00f5es inotr\u00f3picas. Podem oferecer suporte ao VE, ao VD, ou a ambos.  Os DACM podem ser indicados como ponte para o TC ou como ponte para recupera\u00e7\u00e3o, quando h\u00e1 perspectiva de melhora da fun\u00e7\u00e3o ventricular ap\u00f3s insulto agudo, ou ainda como ponte para decis\u00e3o em pacientes cr\u00edticos, na incerteza quanto \u00e0 probabilidade de melhora do quadro cl\u00ednico. Em situa\u00e7\u00f5es espec\u00edficas, sobretudo na presen\u00e7a de contraindica\u00e7\u00e3o ao TC, os DACM podem ser utilizados como terapia de destino.  Os crit\u00e9rios de indica\u00e7\u00e3o e contraindica\u00e7\u00e3o \u00e0 utiliza\u00e7\u00e3o dos DACM em pacientes com DC podem ser os mesmos utilizados para outras etiologias.  Embora a disfun\u00e7\u00e3o sist\u00f3lica ventricular direita seja relativamente comum em pacientes com CCDC, em especial nos indiv\u00edduos que tamb\u00e9m apresentam disfun\u00e7\u00e3o sist\u00f3lica do VE, n\u00e3o h\u00e1 consenso quanto \u00e0 escolha do tipo de dispositivo mais apropriado nessa condi\u00e7\u00e3o.  As evid\u00eancias sobre o uso de DACM em pacientes com DC limitam-se a poucos relatos ou s\u00e9ries de casos na literatura, predominantemente como estrat\u00e9gia de ponte para transplante.  Posteriormente, em ensaio cl\u00ednico n\u00e3o controlado de fase I, incluindo seis pacientes com IC biventricular avan\u00e7ada, Moreiraet al. reportaram sucesso com a utiliza\u00e7\u00e3o de DACM esquerda como ponte para transplante em apenas dois casos.  O primeiro relato da utiliza\u00e7\u00e3o bem-sucedida de um DACM como ponte para transplante em paciente com CCDC ocorreu em 1994. et al. em dois indiv\u00edduos de uma coorte de pacientes submetidos a TC nos EUA.  Ruzzaet al. descreveram um caso bem-sucedido de cora\u00e7\u00e3o artificial total como ponte para transplante em paciente com CCDC.  Na Holanda, foi implantado DACM como ponte para TC em paciente com IC refrat\u00e1ria de etiologia da DC.  Mais recentemente, Atiket al. relataram outro caso de sucesso utilizando DACM esquerda de fluxo axial em paciente com DC e disfun\u00e7\u00e3o sist\u00f3lica biventricular.  Em pa\u00edses desenvolvidos, o DACM tem sido implantado em imigrantes com IC por DC. A utiliza\u00e7\u00e3o de DACM biventricular em pacientes com DC foi relatada por Kransdorf Em geral, considera-se que o suporte card\u00edaco mec\u00e2nico tem elevado potencial de \u00eaxito como estrat\u00e9gia de ponte para transplante, recupera\u00e7\u00e3o, tomada de decis\u00e3o ou terapia de destino em pacientes com CCDC. Contudo, atualmente, as maiores limita\u00e7\u00f5es \u00e0 sua aplicabilidade s\u00e3o o alto custo, a disfun\u00e7\u00e3o de VD e a necessidade de equipe especializada para o implante e manejo dos dispositivos. A Diretriz de Assist\u00eancia Circulat\u00f3ria Mec\u00e2nica da SBC recomenda avalia\u00e7\u00e3o criteriosa da fun\u00e7\u00e3o de VD como mandat\u00f3ria antes do implante, sendo que, na presen\u00e7a de disfun\u00e7\u00e3o moderada a importante, deve-se estar preparado para o implante de suporte biventricular.  Os par\u00e2metros hemodin\u00e2micos considerados \u00f3timos em rela\u00e7\u00e3o \u00e0 fun\u00e7\u00e3o ventricular direita e que reduziriam o risco de disfun\u00e7\u00e3o de VD ap\u00f3s implante s\u00e3o: PVC \u2264 8mmHg, press\u00e3o capilar pulmonar (PCP) \u2264 18mmHg, PVC/PCP \u2264 0,66, resist\u00eancia vascular pulmonar < 2 UW e trabalho indexado de VD \u2265 400mL/m  .  Os principais \u00edndices para avaliar dimens\u00f5es e fun\u00e7\u00e3o de VD s\u00e3o: avalia\u00e7\u00e3o semiquantitativa da contratilidade longitudinal e radial do VD, c\u00e1lculo da varia\u00e7\u00e3o fracional da \u00e1rea, deslocamento sist\u00f3lico do plano do anel tric\u00faspide (TAPSE) pelo modo M, velocidade sist\u00f3lica m\u00e1xima do anel tric\u00faspide lateral estimado pelo Doppler tecidual (s\u2019) e \u00edndice de performance do VD. O implante de DACM univentricular esquerdo \u00e9 motivo de restri\u00e7\u00f5es em pacientes com CCDC e dilata\u00e7\u00e3o importante do VD, insufici\u00eancia tric\u00faspide moderada a grave, anel da v\u00e1lvula tric\u00faspide > 45mm e press\u00e3o venosa central (PVC) > 15mmHg.  No entanto, a CCDC compartilha v\u00e1rias similaridades com diversas cardiopatias extensamente estudadas, em particular aquelas que cursam com fibrose mioc\u00e1rdica e disfun\u00e7\u00e3o sist\u00f3lica , tais como a CMI e a CMD,  permitindo que o racioc\u00ednio terap\u00eautico siga bases fisiopatol\u00f3gicas semelhantes. Dessa forma, o tratamento e a preven\u00e7\u00e3o das arritmias ventriculares e supraventriculares na CCDC tendem a seguir, em linhas gerais, orienta\u00e7\u00f5es semelhantes \u00e0s das demais cardiopatias.  A literatura m\u00e9dica relacionada ao tratamento das arritmias e preven\u00e7\u00e3o de morte s\u00fabita na CCDC \u00e9 relativamente escassa e insuficiente para a formula\u00e7\u00e3o de recomenda\u00e7\u00f5es fortes que se apoiem em evid\u00eancias diretamente obtidas em estudos aleatorizados, indiscutivelmente comprovando efic\u00e1cia terap\u00eautica (n\u00edvel A de evid\u00eancia).  Embora exista a cl\u00e1ssica rela\u00e7\u00e3o direta entre o grau de disfun\u00e7\u00e3o ventricular e a maior frequ\u00eancia de arritmia ventricular, a preval\u00eancia de arritmias ventriculares na CCDC \u00e9 maior quando comparada \u00e0s de outras cardiopatias.  Por outro lado, vale destacar que algumas particularidades espec\u00edficas, que podem influenciar o tratamento antiarr\u00edtmico, costumam ser mais marcantes na CCDC. Disfun\u00e7\u00e3o do n\u00f3 sinusal, dist\u00farbios da condu\u00e7\u00e3o atrioventricular e intraventricular e arritmias ventriculares s\u00e3o frequentemente encontrados tanto em pacientes assintom\u00e1ticos como nas formas mais avan\u00e7adas da doen\u00e7a.  a presen\u00e7a de trombos intracard\u00edacos  e a disautonomia card\u00edaca por les\u00e3o neuronal parassimp\u00e1tica  s\u00e3o mais frequentes na CCDC. Todos esses fatores tamb\u00e9m poderiam justificar a menor sobrevida de pacientes com CCDC em rela\u00e7\u00e3o a pacientes com cardiomiopatias de outras etiologias para um grau semelhante de dano mioc\u00e1rdico.  Al\u00e9m disso, o acometimento do VD,  A disfun\u00e7\u00e3o do n\u00f3 sinusal e os dist\u00farbios da condu\u00e7\u00e3o atrioventricular e intraventricular requerem maior cautela no emprego, por exemplo, de betabloqueadores, digital e amiodarona, devido ao risco de bradicardias excessivas e aparecimento ou agravamento de bloqueios preexistentes.  tende a provocar mais congest\u00e3o sist\u00eamica, requerendo doses maiores de diur\u00e9ticos e podendo induzir hipopotassemia acentuada, que implica risco inerente de morte global, s\u00fabita e cardiovascular.  Nesse contexto, al\u00e9m do uso rotineiro de inibidores de aldosterona (espironolactona/eplerenona),  suplementa\u00e7\u00e3o com pot\u00e1ssio por via oral, visando a manter seus n\u00edveis s\u00e9ricos entre 4,0 e 5,0mEq/L, pode ser necess\u00e1ria.  Al\u00e9m disso, as taquiarritmias ventriculares demandam tratamento com f\u00e1rmacos frequentemente associados a efeitos colaterais graves. O acometimento do VD, presente em 42% dos pacientes com disfun\u00e7\u00e3o do VE,  O escore de RASSI, desenvolvido nesse subgrupo populacional da CCDC, estratifica adequadamente o risco de mortalidade total, a\u00ed inclu\u00edda a predominante ocorr\u00eancia de morte s\u00fabita.  A morte s\u00fabita, muitas vezes inesperada e acometendo indiv\u00edduos com boa capacidade de esfor\u00e7o e durante a realiza\u00e7\u00e3o de exerc\u00edcios, predomina, nitidamente, em subpopula\u00e7\u00f5es de indiv\u00edduos ambulatoriais com CCDC.  Todavia, \u00e9 constata\u00e7\u00e3o frequente que muitos desses pacientes apresentam graus vari\u00e1veis de disfun\u00e7\u00e3o ventricular e IC clinicamente manifesta. Como corol\u00e1rio disso, \u00e9 plaus\u00edvel admitir-se que o tratamento otimizado da IC em pacientes com CCDC possa redundar em potencial benef\u00edcio coadjuvante para evitar a arritmia ventricular maligna e sua mais tem\u00edvel consequ\u00eancia, a morte s\u00fabita. Isso n\u00e3o tem ainda comprova\u00e7\u00e3o espec\u00edfica, sendo que somente alguns poucos estudos de IC inclu\u00edram amostras diminutas de pacientes com a etiologia da DC.  Portanto, a aplica\u00e7\u00e3o de alguns tratamentos farmacol\u00f3gicos para a CCDC complicada por IC, visando \u00e0 redu\u00e7\u00e3o de morte s\u00fabita, \u00e9 extrapolada de resultados obtidos em pacientes com outras etiologias de IC, assumindo-se que existam similaridades cl\u00ednicas e fisiopatol\u00f3gicas entre elas.  Por exemplo, o estudo MERIT-HF, que comparou o succinato de metoprololversusplacebo em pacientes com IC e fra\u00e7\u00e3o de eje\u00e7\u00e3o \u2264 40%, foi interrompido prematuramente (ap\u00f3s seguimento m\u00e9dio de 12 meses) devido \u00e0 redu\u00e7\u00e3o de 40% a 60% na mortalidade global e por agravamento da IC e tamb\u00e9m por morte s\u00fabita.  Resultados similares foram observados com carvedilol e bisoprolol em pacientes com ICFEr.  Doses otimizadas de IECA ou BRA, bem como de betabloqueadores  e de espironolactona, devem ser visadas na IC de etiologia da DC com aquela perspectiva antiarr\u00edtmica coadjuvante.  Em estudo de pequenas dimens\u00f5es, mas espec\u00edfico para CCDC, o carvedilol foi bem tolerado e associado \u00e0 tend\u00eancia de aumento da FEVE.  Mais recentemente, no estudo PARADIGM-HF, em pacientes com ICFEr, o sacubitril-valsartana reduziu significativamente a incid\u00eancia de morte s\u00fabita em compara\u00e7\u00e3o ao enalapril em dose n\u00e3o otimizada, tanto no grupo que recebeu CDI (redu\u00e7\u00e3o de 51%) como naqueles n\u00e3o submetidos ao implante de CDI (redu\u00e7\u00e3o de 19%).  \u00c9 ent\u00e3o plaus\u00edvel que outras recomenda\u00e7\u00f5es de diretrizes internacionais sejam potencialmente aplic\u00e1veis para redu\u00e7\u00e3o de morte total e s\u00fabita na CCDC cursando com IC.  Importante ressaltar que no estudo observacional REMADHE, houve menor utiliza\u00e7\u00e3o dos betabloqueadores nos pacientes com CCDC do que naqueles com outras etiologias.  As arritmias ventriculares podem ocorrer em qualquer cardiopatia e s\u00e3o proteiformes na ess\u00eancia, podendo se manifestar como: EV monom\u00f3rficas ou polim\u00f3rficas, isoladas, bigeminadas, trigeminadas e pareadas; TVNS ou TVS, que tamb\u00e9m podem ser monom\u00f3rficas ou polim\u00f3rficas. As arritmias ventriculares podem ser assintom\u00e1ticas e, em suas formas mais graves (TVS e FV), causar s\u00edncope, baixo d\u00e9bito e morte s\u00fabita.  O estudo EMIAT, que analisou pacientes p\u00f3s-infarto do mioc\u00e1rdio com FEVE < 40%, reportou preval\u00eancia de arritmia ventricular (definida como 10 ou mais EV/h ou TVNS no Holter) em 39% a 41% dos indiv\u00edduos.  J\u00e1 o estudo GESICA, em pacientes com IC grave de diversas etiologias, reportou alta ocorr\u00eancia de EV > 10/h (71%), EV pareadas (56%) e TVNS (33%) ao Holter.  A preval\u00eancia de epis\u00f3dios de TVNS ao Holter de 24 horas variou de 21% a 25% no estudo SCD-HeFT, que avaliou a mortalidade em pacientes com IC de etiologias isqu\u00eamica e n\u00e3o isqu\u00eamica.  A amiodarona possui os quatro efeitos antiarr\u00edtmicos da classifica\u00e7\u00e3o de Vaughan-Williams: bloqueio de canais de s\u00f3dio (classe I); inibi\u00e7\u00e3o n\u00e3o competitiva alfa- e beta-adren\u00e9rgica (classe II); interfer\u00eancia com os canais de pot\u00e1ssio, levando a prolongamento do potencial de a\u00e7\u00e3o, da repolariza\u00e7\u00e3o e da refratariedade (classe III); e bloqueio dos canais de c\u00e1lcio (classe IV). versusplacebo, outro f\u00e1rmaco antiarr\u00edtmico ou grupo controle) na preven\u00e7\u00e3o prim\u00e1ria de mortalidade total e s\u00fabita foi avaliado por meio de v\u00e1rias meta-an\u00e1lises. Em 1997, o estudo ATMA,  utilizando dados individuais de pacientes de oito ECR ap\u00f3s infarto agudo do mioc\u00e1rdio  e de cinco estudos incluindo pacientes com IC congestiva , mostrou redu\u00e7\u00e3o de 13% no risco de \u00f3bito total  e de 29% no risco de morte s\u00fabita de causa arritmog\u00eanica  com a amiodarona. N\u00e3o houve excesso de mortes n\u00e3o arr\u00edtmicas com a amiodarona e ambos os grupos de pacientes (ap\u00f3s infarto agudo do mioc\u00e1rdio e IC congestiva) se beneficiaram do tratamento antiarr\u00edtmico.  O uso de amiodarona ( utilizando metodologia hier\u00e1rquica bayesiana e dados publicados dos mesmos 13 estudos inclu\u00eddos no ATMA e de 2 estudos adicionais (CASCADE e ASSG) envolvendo pacientes recuperados de parada card\u00edaca ou com TVS, concluiu, de forma semelhante, que a amiodarona reduz a mortalidade por todas as causas em cerca de 19% , com redu\u00e7\u00f5es um pouco maiores na mortalidade card\u00edaca  e na morte s\u00fabita . Houve uma tend\u00eancia de redu\u00e7\u00e3o de risco de \u00f3bito tamb\u00e9m maior nos estudos que exigiram evid\u00eancia de ectopia ventricular frequente ou complexa como crit\u00e9rio de inclus\u00e3o (25%) em compara\u00e7\u00e3o aos demais estudos (10%).  No mesmo ano, outra meta-an\u00e1lise,  Ap\u00f3s seguimento mediano de 45,5 meses, a mortalidade total foi de 29% no grupo placebo, 28% no grupo amiodarona e 22% no grupo CDI, ou seja, enquanto a amiodarona apresentou efeito nulo na mortalidade total, em compara\u00e7\u00e3o ao placebo, a terapia com CDI causou uma redu\u00e7\u00e3o relativa de risco de 23% .  Com os resultados animadores com a amiodarona e o advento do CDI, o passo seguinte mais prov\u00e1vel seria a compara\u00e7\u00e3o focalizada na aloca\u00e7\u00e3o aleat\u00f3ria a amostras de pacientes tratados com amiodarona ou CDI ou placebo na preven\u00e7\u00e3o prim\u00e1ria de morte total. Esse foi o objetivo principal do estudo SCD-HeFT, publicado em 2005, que incluiu 2.521 pacientes com fra\u00e7\u00e3o de eje\u00e7\u00e3o \u2264 35%, em classe funcional II ou III da NYHA, sendo a IC de origem isqu\u00eamica em 52% dos pacientes e n\u00e3o isqu\u00eamica nos demais.  Vale ressaltar que, com base em an\u00e1lise pr\u00e9-especificada de subgrupos, os resultados n\u00e3o variaram de acordo com a etiologia da IC, mas variaram de acordo com a classe funcional da NYHA. Assim, em pacientes na classe III, observou-se aumento de mortalidade com a amiodarona (comparada ao placebo) e nenhuma diferen\u00e7a entre os tratamentos CDI e placebo. Apesar de a intera\u00e7\u00e3o entre CDI e classe funcional ter sido extremamente significativa , os autores ignoraram esses resultados e conclu\u00edram que em ambas as classes (II e III), a terapia com CDI unicameral ventricular foi capaz de reduzir a mortalidade total.  Seguindo esse mesmo paradigma, todas as diretrizes passaram a recomendar o implante de CDI, profilaticamente, a pacientes com fra\u00e7\u00e3o de eje\u00e7\u00e3o \u2264 35%, em classe funcional II e tamb\u00e9m III da NYHA. Apesar dos resultados incontestes proporcionados pelo estudo SCD-HeFT, duas ressalvas devem ser feitas. Primeiro, o crit\u00e9rio de inclus\u00e3o foi disfun\u00e7\u00e3o ventricular e n\u00e3o a documenta\u00e7\u00e3o de arritmia ventricular complexa e frequente ao Holter. Segundo, dentre as v\u00e1rias an\u00e1lises de subgrupos realizadas, a principal delas, a nosso ver, comparando amiodarona com placebo em pacientes que apresentavam TVNS documentada (22% da popula\u00e7\u00e3o do estudo), por motivos desconhecidos, n\u00e3o foi contemplada.  randomizando 674 pacientes com IC (fra\u00e7\u00e3o de eje\u00e7\u00e3o \u2264 40%) de etiologia isqu\u00eamica e n\u00e3o isqu\u00eamica e pelo menos 10 EV/hora ao Holter de 24 horas para receber amiodarona ou placebo, ap\u00f3s seguimento mediano de 45 meses, a amiodarona reduziu significativamente a frequ\u00eancia da arritmia ventricular e melhorou a fun\u00e7\u00e3o ventricular, mas n\u00e3o foi capaz de aumentar a sobrevida.  \u00c9 importante destacar que, no estudo CHF-STAT,  e AMIOVIRT (103 pacientes),  ambos abertos. O primeiro comparou amiodarona com grupo controle em cardiopatas isqu\u00eamicos e n\u00e3o isqu\u00eamicos com fra\u00e7\u00e3o de eje\u00e7\u00e3o < 35% e arritmia ventricular graus 2 ou 4 de Lown ao Holter, e o segundo comparou amiodarona com CDI em IC exclusivamente n\u00e3o isqu\u00eamica, com fra\u00e7\u00e3o de eje\u00e7\u00e3o \u2264 35% e TVNS ao Holter. No estudo piloto argentino EPAMSA, que incluiu 24 pacientes com CCDC, ap\u00f3s 1 ano de seguimento, as redu\u00e7\u00f5es de morte total e s\u00fabita com amiodarona foram de 71%  e 71% , respectivamente.  Entretanto, em an\u00e1lise de subgrupo pr\u00e9-especificada e com base em randomiza\u00e7\u00e3o estratificada pela etiologia da IC, houve tend\u00eancia de menor mortalidade com a amiodarona nos pacientes n\u00e3o isqu\u00eamicos . \u00c0 \u00e9poca da publica\u00e7\u00e3o do estudo SCD-HeFT, tamb\u00e9m j\u00e1 eram conhecidos os resultados de dois pequenos ECR, EPAMSA (127 pacientes) versus96%) e 3 anos (88%versus87%) n\u00e3o foram estatisticamente diferentes entre os grupos amiodarona e CDI .  J\u00e1 no estudo AMIOVIRT, interrompido precocemente pelo crit\u00e9rio de futilidade, as sobrevidas ap\u00f3s 1 ano (90% que incluiu 516 pacientes com IC grave de etiologia isqu\u00eamica e n\u00e3o isqu\u00eamica (48 pacientes com CCDC), em classe funcional predominantemente III ou IV da NYHA, apresentando pelo menos dois de tr\u00eas \u00edndices de disfun\u00e7\u00e3o ventricular sist\u00f3lica: ICT > 0,55, fra\u00e7\u00e3o de eje\u00e7\u00e3o \u2264 35% e DDVE \u2265 32cm/m 2 . Os pacientes foram randomizados para grupo amiodarona ou controle e, ap\u00f3s um tempo m\u00e9dio de acompanhamento de 13 meses, a mortalidade total foi de 41,4% no grupo controle e de 33,5% no grupo amiodarona, uma redu\u00e7\u00e3o relativa de risco de 28% . Os pacientes foram randomizados de acordo com a presen\u00e7a de TVNS ao Holter de admiss\u00e3o, que foi observada em 33,5% da popula\u00e7\u00e3o global do estudo. A redu\u00e7\u00e3o do risco de \u00f3bito com a amiodarona ocorreu independentemente da presen\u00e7a de arritmia ventricular, mas foi numericamente maior nos pacientes com TVNS documentada .  Resultados positivos com a amiodarona tamb\u00e9m foram observados em outro estudo argentino (GESICA),  Ap\u00f3s acompanhamento de 11 anos, o benef\u00edcio do CDI em compara\u00e7\u00e3o ao placebo permaneceu estatisticamente significativo, mas houve atenua\u00e7\u00e3o de efeito, com redu\u00e7\u00e3o relativa do risco de \u00f3bito diminuindo de 23%  para 13%  e intera\u00e7\u00e3o significativa entre tempo de seguimento (antes e ap\u00f3s 6 anos) e benef\u00edcio do CDI . Curiosamente, a an\u00e1lise de subgrupo, de acordo com a etiologia da IC, tamb\u00e9m mostrou resultados heterog\u00eaneos a longo prazo. Enquanto o efeito ben\u00e9fico do CDI se manteve nos pacientes com IC de etiologia isqu\u00eamica , naqueles com IC de etiologia n\u00e3o isqu\u00eamica, a redu\u00e7\u00e3o de mortalidade com o CDI n\u00e3o mais foi observada . Como, ap\u00f3s a publica\u00e7\u00e3o do ensaio original, mais da metade dos pacientes alocados para placebo ou amiodarona receberam implante de CDI ou dispositivo ressincronizador e a an\u00e1lise estat\u00edstica preconizada foi a \u201cinten\u00e7\u00e3o de tratar\u201d, essecrossoverpode ter interferido nos resultados. Todavia, esses resultados n\u00e3o sofreram altera\u00e7\u00f5es quando se utilizou a metodologia de an\u00e1lise \u201cas treated\u201d, que compara os grupos de acordo com o tratamento recebido e n\u00e3o conforme a aloca\u00e7\u00e3o inicial.  Mais recentemente, foram publicados os resultados de longo prazo do estudo SCD-HeFT.  identificou 15 estudos , totalizando 8.522 pacientes, que foram randomizados para amiodarona ou placebo/controle. A amiodarona reduziu o risco de morte s\u00fabita em 29%  e de morte cardiovascular em 18% . A redu\u00e7\u00e3o de risco de mortalidade por todas as causas (13%) n\u00e3o atingiu signific\u00e2ncia estat\u00edstica . An\u00e1lise de subgrupo pr\u00e9-especificada mostrou redu\u00e7\u00e3o do risco de morte total de 19% , com doses de amiodarona > 200mg/dia. J\u00e1 doses \u2264 200mg/dia n\u00e3o foram eficazes . Por outro lado, o uso de amiodarona esteve associado a um aumento de duas e cinco vezes, respectivamente, no risco de toxicidade pulmonar e tireoidiana. Os autores conclu\u00edram que a amiodarona representa uma alternativa vi\u00e1vel para prevenir a morte s\u00fabita card\u00edaca em pacientes n\u00e3o eleg\u00edveis ou que n\u00e3o t\u00eam acesso \u00e0 terapia com CDI.  Ap\u00f3s a publica\u00e7\u00e3o do estudo SCD-HeFT, mais algumas meta-an\u00e1lises foram realizadas, adicionando os resultados desse e de alguns outros trabalhos. A primeira delas  e incluiu 24 ECR totalizando 9.997 pacientes, com o objetivo de comparar amiodaronaversusplacebo/controle ou outros f\u00e1rmacos antiarr\u00edtmicos na preven\u00e7\u00e3o prim\u00e1ria  e secund\u00e1ria .  Outra revis\u00e3o sistem\u00e1tica com meta-an\u00e1lise, seguindo as recomenda\u00e7\u00f5es da colabora\u00e7\u00e3o do sistema Cochrane, foi publicada em 2015  Nos estudos de preven\u00e7\u00e3o prim\u00e1ria , a amiodarona reduziu significativamente a mortalidade s\u00fabita, cardiovascular e global, mas a qualidade da evid\u00eancia foi considerada baixa (compara\u00e7\u00e3o com placebo) ou moderada (compara\u00e7\u00e3o com outros f\u00e1rmacos antiarr\u00edtmicos). Na preven\u00e7\u00e3o secund\u00e1ria , n\u00e3o se observou redu\u00e7\u00e3o da mortalidade s\u00fabita e global, sendo a evid\u00eancia considerada de muito baixa ou baixa qualidade.  incluindo 11 estudos de pacientes com IC (isqu\u00eamica e n\u00e3o isqu\u00eamica) ou CMD n\u00e3o isqu\u00eamica associada a disfun\u00e7\u00e3o ventricular esquerda mostrou que a presen\u00e7a de TVNS ao Holter \u00e9 um preditor independente de morte s\u00fabita card\u00edaca ; 3) o \u00fanico ECR que comparou diretamente amiodarona com CDI em preven\u00e7\u00e3o prim\u00e1ria (AMIOVIRT)  n\u00e3o mostrou superioridade do CDI, mas \u00e9 limitado pelo seu pequeno tamanho amostral.  Com base nesses resultados: 1) \u00e9 razo\u00e1vel concluir que, comparada com placebo, grupo controle ou outro f\u00e1rmaco antiarr\u00edtmico, no que concerne \u00e0 preven\u00e7\u00e3o prim\u00e1ria, a amiodarona reduz modestamente a morte por todas as causas, com efeito mais expressivo na redu\u00e7\u00e3o de morte s\u00fabita, tanto na IC de etiologia isqu\u00eamica quanto  na IC de etiologia n\u00e3o isqu\u00eamica; 2) \u00e9 plaus\u00edvel especular que o efeito ben\u00e9fico da amiodarona seja maior quando se consegue documentar a presen\u00e7a de TVNS e de elevada densidade da arritmia ventricular ao Holter, fato que parece ser de maior relev\u00e2ncia em presen\u00e7a de disfun\u00e7\u00e3o ventricular. Corroborando essa suposi\u00e7\u00e3o, meta-an\u00e1lise  apesar de n\u00e3o comparar amiodarona com CDI, mas cada um dos dois contra placebo, n\u00e3o exigiu a presen\u00e7a de arritmia ventricular como crit\u00e9rio de inclus\u00e3o, n\u00e3o procedeu a an\u00e1lise de subgrupos baseada na presen\u00e7a de TVNS, mostrou benef\u00edcio do CDI apenas em pacientes em classe funcional II da NYHA e teve esse benef\u00edcio mantido a longo prazo apenas nos pacientes com IC de etiologia isqu\u00eamica, aspectos que devem ser considerados ao se tentar extrapolar seus resultados para a CCDC.  O estudo SCD-HeFT,  A preven\u00e7\u00e3o secund\u00e1ria da morte s\u00fabita diz respeito a pacientes que foram recuperados de uma parada card\u00edaca por FV ou TV sem pulso, ou que j\u00e1 apresentaram pelo menos um epis\u00f3dio documentado de TVS. Fazem parte desse grupo os pacientes com s\u00edncope de etiologia provavelmente card\u00edaca, que, uma vez levados ao EEF, apresentam indu\u00e7\u00e3o de FV ou de TVS hemodinamicamente inst\u00e1vel .  As taquiarritmias ventriculares sustentadas t\u00eam sido tipicamente agrupadas em uma \u00fanica categoria e coletivamente denominadas \u201camea\u00e7adoras \u00e0 vida\u201d ou \u201cmalignas\u201d. Embora a FV previsivelmente precipite a parada card\u00edaca, a n\u00e3o ser que seja de curta dura\u00e7\u00e3o e reverta espontaneamente , a TVS, por sua vez, cursa com ampla gama de manifesta\u00e7\u00f5es hemodin\u00e2micas e cl\u00ednicas.  Assim, deve-se evitar o agrupamento indiscriminado dessas v\u00e1rias entidades arr\u00edtmicas, pois diferen\u00e7as relacionadas aos seus progn\u00f3sticos e tratamentos devem existir. Certamente o grau de disfun\u00e7\u00e3o ventricular (expresso pela FEVE) e ainda os sintomas associados \u00e0 arritmia e o tipo de cardiopatia estrutural s\u00e3o elementos que devem ser considerados durante avalia\u00e7\u00e3o desses pacientes.  O ponto de corte dicotomizante para a FEVE tem sido geralmente de 35% ou 40% e uma das grada\u00e7\u00f5es de sintomas prop\u00f5e quatro classes: I - sem sintomas ou apenas palpita\u00e7\u00f5es; II - lipotimia, dor no peito ou dispneia; III - s\u00edncope, estado mental alterado ou outra evid\u00eancia de comprometimento hemodin\u00e2mico importante ; e IV - parada card\u00edaca (pulso e respira\u00e7\u00e3o ausentes).  \u00c9 bastante prov\u00e1vel que o progn\u00f3stico e o tratamento de um paciente com cardiopatia isqu\u00eamica, recuperado de parada card\u00edaca por FV e com FEVE de 30%, sejam diferentes daqueles de um paciente com CMD (p. ex. a pr\u00f3pria CCDC), TVS hemodinamicamente est\u00e1vel, FEVE relativamente preservada e sintoma de palpita\u00e7\u00f5es.  compararam amiodarona (ou outro f\u00e1rmaco antiarr\u00edtmico) com CDI na preven\u00e7\u00e3o secund\u00e1ria de morte total.  Tr\u00eas ECR   randomizou 1.016 pacientes (81% com cardiopatia isqu\u00eamica), recuperados de parada card\u00edaca por FV (45% dos pacientes), com TVS sincopal (21%) ou ainda com TVS, FEVE \u2264 40% e sintomas sugestivos de comprometimento hemodin\u00e2mico grave associados (34%), para terapia com CDI ou f\u00e1rmacos antiarr\u00edtmicos . A m\u00e9dia de idade foi de 65 anos, a FEVE m\u00e9dia foi de 32% no grupo CDI e de 31% no grupo antiarr\u00edtmico e 79% dos pacientes eram do sexo masculino. Ap\u00f3s seguimento m\u00e9dio de 18,2 meses, o estudo foi encerrado precocemente devido \u00e0 superioridade do CDI em reduzir morte total , com redu\u00e7\u00f5es relativas de risco de 39%, 27% e 31%, ap\u00f3s 1, 2 e 3 anos de acompanhamento, respectivamente .  O primeiro e maior deles (AVID)  randomizou 659 pacientes (83% com cardiopatia isqu\u00eamica) para CDI ou amiodarona, sendo 48% deles recuperados de parada card\u00edaca por FV, 13% com TVS sincopal, 25% com TVS (FC \u2265 150 bpm), FEVE \u2264 35%, causando pr\u00e9-s\u00edncope ou angina, e 14% deles com s\u00edncope e TVS induzida pela estimula\u00e7\u00e3o el\u00e9trica programada. A m\u00e9dia de idade foi de 64 anos, a FEVE m\u00e9dia foi de 34% no grupo CDI e de 33% no grupo amiodarona, e 85% dos pacientes eram do sexo masculino. Ap\u00f3s tempo m\u00e9dio de acompanhamento de 3 anos, houve redu\u00e7\u00e3o n\u00e3o significativa do risco anual de morte total  e de morte arr\u00edtmica  com o CDI.  O estudo canadense CIDS  foi realizado na cidade de Hamburgo, na Alemanha, e comparou o CDI com diferentes antiarr\u00edtmicos . Ao contr\u00e1rio dos ensaios anteriores, incluiu apenas pacientes recuperados de parada card\u00edaca (por FV em 84% e por TV em 16%). O bra\u00e7o da propafenona (58 pacientes) foi descontinuado ap\u00f3s seguimento m\u00e9dio de 11,3 meses por apresentar taxa de mortalidade 61% maior que a observada no grupo do CDI. Os demais pacientes, num total de 288 distribu\u00eddos igualmente entre os grupos CDI, amiodarona e metoprolol, permaneceram no estudo. A m\u00e9dia de idade foi de 58 anos, a FEVE m\u00e9dia foi de 46%, 80% dos pacientes eram do sexo masculino e 73% tinham cardiopatia isqu\u00eamica. Ao longo de seguimento m\u00e9dio de 57 meses, a mortalidade total foi menor no bra\u00e7o CDI em compara\u00e7\u00e3o com o bra\u00e7o amiodarona/metoprolol , embora a diferen\u00e7a n\u00e3o tenha atingido signific\u00e2ncia estat\u00edstica .  O menor dos tr\u00eas estudo, CASH,  Essa meta-an\u00e1lise, explorando dados individuais dos pacientes dos tr\u00eas estudos, foi colocada em um banco de dados com protocolo pr\u00e9-especificado e teve seus resultados publicados em 2000. Foram inclu\u00eddos 1.866 pacientes , com m\u00e9dia de idade de 63,5 anos, FEVE m\u00e9dia de 33,5%, a grande maioria do sexo masculino  e com diagn\u00f3stico de cardiopatia isqu\u00eamica (82%). As estimativas de benef\u00edcio do CDI observadas nos tr\u00eas estudos foram consistentes entre si  e, em conjunto, resultaram em redu\u00e7\u00e3o relativa de risco de \u00f3bito total de 28%  e de morte arr\u00edtmica de 50%  com o CDI, traduzindo-se em ganho m\u00e9dio de sobrevida de 4,4 meses, ap\u00f3s seguimento m\u00e9dio de 6 anos.  O t\u00e9rmino prematuro do estudo AVID, podendo superestimar o benef\u00edcio do CDI, assim como o n\u00famero menor de pacientes arrolados no CIDS e no CASH, podendo diminuir o poder dos testes estat\u00edsticos em detectar um real benef\u00edcio do tratamento com CDI, motivaram a realiza\u00e7\u00e3o de uma meta-an\u00e1lise, comparando o CDI exclusivamente com a amiodarona. versus19%) e o benef\u00edcio da terapia com CDI tamb\u00e9m fosse maior naqueles em uso de betabloqueador , essa diferen\u00e7a n\u00e3o foi estatisticamente significativa .  Entretanto, na an\u00e1lise de subgrupos, o benef\u00edcio relacionado ao aumento de sobrevida com CDI foi observado apenas em pacientes com FEVE \u2264 35%  e n\u00e3o naqueles com FEVE > 35% . Embora o uso de betabloqueadores tenha sido maior no grupo CDI  ou com expectativa de vida menor que 1 ano.  Com base nos resultados desses ECR,  Vale ressaltar que nenhum dos tr\u00eas ECR incluiu pacientes com TVS hemodinamicamente est\u00e1vel ou bem tolerada e que a an\u00e1lise de subgrupos da meta-an\u00e1lise referida anteriormente n\u00e3o mostrou benef\u00edcio do CDI em rela\u00e7\u00e3o \u00e0 amiodarona em pacientes com FEVE > 35%. Ainda, de acordo com essas diretrizes , apenas nos casos de indisponibilidade ou de contraindica\u00e7\u00e3o para a terapia com CDI ou quando essa for recusada pelo paciente, a amiodarona poderia ser utilizada com o objetivo de se tentar reduzir morte s\u00fabita (classe IIb).  Conforme j\u00e1 assinalado acima, embora mais comumente encontradas em fases mais avan\u00e7adas da CCDC, as arritmias ventriculares podem ocorrer j\u00e1 em est\u00e1gios iniciais da doen\u00e7a e mesmo na aus\u00eancia de comprometimento significativo da fun\u00e7\u00e3o ventricular sist\u00f3lica global. 11.1.6.1. Extrass\u00edstoles Ventriculares A densidade de EV tamb\u00e9m \u00e9 elevada, de tal forma que 45% e 89% dos pacientes sem e com IC, respectivamente, apresentam mais do que 1000 EV/h ao Holter.  Est\u00e3o presentes em 86% a 88% dos pacientes com CCDC sem IC (classes funcionais I e II) e em praticamente todos os pacientes com IC (classes funcionais III e IV) ao Holter de 24 horas.  isso \u00e9, disfun\u00e7\u00e3o ventricular sist\u00f3lica causada ou agravada pela arritmia e que pode ser atenuada ou revertida com a supress\u00e3o das EV e, assim, cursar com aumento de sobrevida.  Quando ocorrem em pacientes assintom\u00e1ticos e com fun\u00e7\u00e3o ventricular preservada, as EV n\u00e3o requerem tratamento. No entanto, em pacientes assintom\u00e1ticos e com alta densidade arr\u00edtmica (> 16-20% de EV ao Holter de 24h), h\u00e1 possibilidade de desenvolvimento de taquicardiomiopatia,  Ent\u00e3o, a amiodarona pode ser indicada, em doses de 200 a 600 mg/dia, pela sua elevada efic\u00e1cia em diminuir significativamente a densidade de EV.  Quando as EV s\u00e3o muito sintom\u00e1ticas, mesmo na aus\u00eancia de disfun\u00e7\u00e3o ventricular ou de realce tardio (fibrose) \u00e0 RMC, o uso de medicamentos antiarr\u00edtmicos se imp\u00f5e, mas esse deve ser individualizado, evitando-se, a princ\u00edpio, a amiodarona, em virtude de seus efeitos adversos. Nessa situa\u00e7\u00e3o, sugere-se o uso de um betabloqueador  ou propafenona. Por outro lado, se houver disfun\u00e7\u00e3o ventricular ou substrato arritmog\u00eanico de fibrose detect\u00e1vel \u00e0 RMC, antiarr\u00edtmicos da classe I n\u00e3o devem ser utilizados, devido aos seus efeitos pr\u00f3-arr\u00edtmicos e eventual efeito inotr\u00f3pico negativo, podendo ainda aumentar a mortalidade, conforme descrito em outras cardiopatias. 11.1.6.2. Taquicardia Ventricular N\u00e3o Sustentada uma preval\u00eancia muito maior se comparada \u00e0 de outras cardiopatias. Pode ser observada mesmo em pacientes com fun\u00e7\u00e3o ventricular normal e sua detec\u00e7\u00e3o no Holter ou durante teste ergom\u00e9trico constitui marcador independente de mau progn\u00f3stico.  Quando associada \u00e0 disfun\u00e7\u00e3o ventricular esquerda , achado relativamente comum na CCDC, aumenta o risco de \u00f3bito em 15 vezes se comparada a pacientes sem TVNS e com fun\u00e7\u00e3o ventricular normal.  Na aus\u00eancia de dados dispon\u00edveis para avalia\u00e7\u00e3o de desfechos relevantes, como mortalidade e interna\u00e7\u00e3o hospitalar, uma meta-an\u00e1lise de estudos antigos com a amiodarona na CCDC mostrou importante redu\u00e7\u00e3o da densidade de arritmia ventricular em registros seriados de Holter .  A TVNS acomete 42% dos pacientes com CCDC sem IC e 89% daqueles com IC,  e EPAMSA  inclu\u00edram pacientes com CCDC e mostraram redu\u00e7\u00e3o de mortalidade com a amiodarona. Entretanto, o pequeno n\u00famero de indiv\u00edduos com CCDC elencados nos dois estudos  impede uma conclus\u00e3o definitiva. Como ent\u00e3o conduzir os pacientes com TVNS? Na aus\u00eancia de disfun\u00e7\u00e3o ventricular, o tratamento farmacol\u00f3gico deve seguir, em linhas gerais, as mesmas orienta\u00e7\u00f5es preconizadas para o tratamento das EV. Em presen\u00e7a de disfun\u00e7\u00e3o ventricular, tr\u00eas op\u00e7\u00f5es est\u00e3o dispon\u00edveis: betabloqueador, amiodarona e CDI, esse \u00faltimo a ser discutido mais adiante.  Conforme mencionado anteriormente, os ECR argentinos GESICA  O objetivo do tratamento deve ser o al\u00edvio de sintomas (caso estejam presentes), a melhora da fun\u00e7\u00e3o ventricular e a preven\u00e7\u00e3o da morte s\u00fabita. Como n\u00e3o existem dados convincentes, por meio de ECR, para apoiar qualquer uma das tr\u00eas op\u00e7\u00f5es, as recomenda\u00e7\u00f5es para o tratamento desses pacientes baseiam-se na extrapola\u00e7\u00e3o de resultados de estudos realizados em outras doen\u00e7as card\u00edacas e em dados observacionais (que s\u00e3o limitados) relacionados \u00e0 CCDC.  Ap\u00f3s an\u00e1lise detalhada da literatura, optou-se pela indica\u00e7\u00e3o preferencial de um betabloqueador seletivo  associado ou n\u00e3o \u00e0 amiodarona, decis\u00e3o que dever\u00e1 ser individualizada e compartilhada com o paciente. 11.1.6.3. Taquicardia Ventricular Sustentada e Fibrila\u00e7\u00e3o Ventriculartorsades de pointes) e FV, que devem ser prontamente revertidas nas salas de emerg\u00eancia. A amiodarona constitui a melhor op\u00e7\u00e3o medicamentosa nos casos de TVS est\u00e1vel ou de FV refrat\u00e1ria ou recorrente.  Apesar de a preval\u00eancia das arritmias ventriculares sustentadas n\u00e3o ser amplamente conhecida, pacientes com CCDC, independentemente da fun\u00e7\u00e3o ventricular, podem apresentar TVS monom\u00f3rfica, TVS polim\u00f3rfica . Em caso de recidivas imediatas (\u201ctempestades el\u00e9tricas\u201d), deve-se considerar a administra\u00e7\u00e3o de antiarr\u00edtmicos , com suporte de oxig\u00eanio adequado, monitoriza\u00e7\u00e3o card\u00edaca e corre\u00e7\u00e3o de poss\u00edveis dist\u00farbios eletrol\u00edticos.  Segundo o protocolo do ACLS, dois f\u00e1rmacos s\u00e3o indicados para o tratamento de arritmias ventriculares sustentadas na sala de emerg\u00eancia: a amiodarona e a procainamida, ambas administradas por via endovenosa. As doses preconizadas est\u00e3o apresentadas no \u00c9 importante lembrar que a administra\u00e7\u00e3o endovenosa de amiodarona pode causar flebite e hipotens\u00e3o arterial, reduzir a frequ\u00eancia sinusal, aumentar a dura\u00e7\u00e3o do complexo QRS e do intervalo QT, aumentar a refratariedade do n\u00f3 atrioventricular, reduzir a FC  da TVS e melhorar o limiar de desfibrila\u00e7\u00e3o do CDI.  A procainamida pode aumentar o intervalo PR, a dura\u00e7\u00e3o do complexo QRS e o limiar de desfibrila\u00e7\u00e3o do CDI. Tamb\u00e9m pode causar hipotens\u00e3o arterial e redu\u00e7\u00e3o da FEVE, provocar diarreia e n\u00e1useas e desencadear sintomas e sinais da s\u00edndrome l\u00fapica eritematosa.  Outros f\u00e1rmacos antiarr\u00edtmicos de administra\u00e7\u00e3o endovenosa como lidoca\u00edna, verapamil, betabloqueadores  e sotalol apresentam baixa efic\u00e1cia para reverter taquiarritmias ventriculares sustentadas e devem ser evitados na CCDC ou usados apenas como op\u00e7\u00f5es secund\u00e1rias em escassos contextos.  Uma vez controlada a taquiarritmia ventricular sustentada ou revertido o quadro de parada card\u00edaca, o tratamento subsequente tem como objetivos principais prevenir as recorr\u00eancias e, principalmente, evitar a morte s\u00fabita. Apesar da elevada preval\u00eancia da CCDC na Am\u00e9rica Latina e da alta taxa de letalidade decorrente dessas arritmias, \u00e9 lastim\u00e1vel que inexistam ECR devidamente controlados, com contingente amostral adequado para finalmente esclarecer qual deve ser a melhor conduta a ser adotada caso a caso. Dentre as principais op\u00e7\u00f5es est\u00e3o o uso de amiodarona, o implante de CDI, a abla\u00e7\u00e3o por cateter ou uma associa\u00e7\u00e3o dessas terapias, com a escolha tendo ent\u00e3o que se basear nos resultados de estudos observacionais ou de registros realizados na CCDC, que s\u00e3o bastante heterog\u00eaneos e conflitantes, ou ainda na extrapola\u00e7\u00e3o de dados oriundos de ECR ou de diretrizes aplic\u00e1veis em outras cardiopatias e que apresentam algumas inconsist\u00eancias e podem n\u00e3o se aplicar \u00e0 CCDC devido a v\u00e1rias de suas peculiaridades. \u201cOne-size fits all: what\u2019s good for the gander is good for the goose\u201d, ou seja, CDI para todos os pacientes como terap\u00eautica ideal para prevenir morte s\u00fabita, parece n\u00e3o ser a mais apropriada na CCDC. Obviamente que, quando se fala em preven\u00e7\u00e3o de morte s\u00fabita, na verdade estamos nos referindo \u00e0 morte por todas as causas, pois, muitas vezes, n\u00e3o se consegue distinguir o mecanismo exato do \u00f3bito (pode haver erro na adjudica\u00e7\u00e3o) e, al\u00e9m disso, de nada adianta um tratamento prevenir a morte s\u00fabita sem reduzir a mortalidade total, pois estaria apenas modificando o modo de \u00f3bito.  Assim, a estrat\u00e9gia Vale destacar que, em compara\u00e7\u00e3o \u00e0 cardiopatia isqu\u00eamica e n\u00e3o isqu\u00eamica de outras etiologias, pacientes com CCDC tratados com CDI para preven\u00e7\u00e3o secund\u00e1ria tendem a apresentar FEVE mais alta, maior densidade e complexidade de arritmia ventricular espont\u00e2nea, maior n\u00famero de terapias apropriadas (choque e terapia antitaquicardia) e tamb\u00e9m das inapropriadas pelo CDI, tempo mais curto para o primeiro choque apropriado ap\u00f3s o implante, tempestades el\u00e9tricas mais frequentes e menor sobrevida livre de terapias do CDI, fatores que podem influenciar na escolha do tratamento. A FEVE, independentemente do tipo de cardiopatia, \u00e9 fator primordial na determina\u00e7\u00e3o do progn\u00f3stico e sele\u00e7\u00e3o da terapia mais adequada.  Devido \u00e0 sua elevada efic\u00e1cia antiarr\u00edtmica, baixa incid\u00eancia de pr\u00f3-arritmia e de efeitos colaterais intoler\u00e1veis, principalmente quando utilizada em doses mais baixas, e bom perfil de seguran\u00e7a, mesmo quando administrada a pacientes com disfun\u00e7\u00e3o ventricular, a amiodarona (introduzida em nosso meio h\u00e1 mais de 4 d\u00e9cadas) \u00e9 considerada o f\u00e1rmaco de primeira escolha no tratamento de pacientes com CCDC e arritmias ventriculares de alto risco. et al.  foram os primeiros a estudar o impacto do tratamento medicamentoso antiarr\u00edtmico na evolu\u00e7\u00e3o de pacientes com CCDC. Ao analisarem a curva atuarial de sobrevida de 34 pacientes com TVS monom\u00f3rfica tratados empiricamente com amiodarona, de maneira isolada ou em associa\u00e7\u00e3o com outros antiarr\u00edtmicos, e compararem-na com a curva de outra coorte de 42 pacientes n\u00e3o tratados ou que fizeram uso de procainamida ou quinidina, \u00fanicos medicamentos dispon\u00edveis \u00e0 \u00e9poca, constataram sobrevida significativamente maior no grupo tratado com amiodarona. Ap\u00f3s 1, 4 e 8 anos de acompanhamento, a sobrevida foi de 87%, 65% e 59%, respectivamente, para o grupo tratado com amiodarona e de 57%, 22% e 7%, respectivamente, para o grupo n\u00e3o tratado ou tratado com aqueles antiarr\u00edtmicos da classe I .  Rassi Jret al.  tamb\u00e9m relataram resultados a longo prazo sobre o uso emp\u00edrico de amiodarona no Brasil em coorte de 35 pacientes com CCDC e taquiarritmia ventricular sustentada . A m\u00e9dia de idade foi de 50 anos, a FEVE m\u00e9dia foi de 41%, 68,5% dos pacientes eram do sexo masculino e 86% estavam em classe funcional I/II. Ap\u00f3s 27 meses de acompanhamento, a probabilidade de recorr\u00eancia de TVS foi de 38%, 44% e 56% no seguimento de 1, 2 e 3 anos, respectivamente. A taxa de mortalidade card\u00edaca foi de 4%, 11% e 18% e a de morte s\u00fabita foi de 0%, 4% e 11% no seguimento de 1, 2 e 3 anos, respectivamente. De relev\u00e2ncia, todos os pacientes em classe funcional III ou IV e com FEVE < 30% tiveram recorr\u00eancia de TVS, sendo a mortalidade card\u00edaca nesse grupo de 80%. Por outro lado, apenas 30% dos pacientes em classe funcional I/II da NYHA e com FEVE > 30% apresentaram TVS recorrente  e nenhum foi a \u00f3bito. A dose m\u00e9dia de amiodarona, ao t\u00e9rmino do estudo, foi de 356 mg/dia e 15 (43%) pacientes relataram efeitos colaterais.  Scanavaccaet al.  avaliaram o papel da estimula\u00e7\u00e3o ventricular programada em predizer a efic\u00e1cia a longo prazo de f\u00e1rmacos antiarr\u00edtmicos da classe III. Foram estudados 115 pacientes com CCDC e taquiarritmia ventricular sustentada . A m\u00e9dia de idade foi de 52 anos, a FEVE m\u00e9dia foi de 49%, 60% dos pacientes eram do sexo masculino e 83% estavam em classe funcional I/II. Com base nos resultados do EEF, ap\u00f3s impregna\u00e7\u00e3o com amiodarona (78 pacientes) ou sotalol (37 pacientes), os pacientes foram divididos em tr\u00eas grupos: grupo 1 \u2013 sem indu\u00e7\u00e3o de TVS (20%); grupo 2 \u2013 indu\u00e7\u00e3o de TVS hemodinamicamente est\u00e1vel (39%); e grupo 3 \u2013 indu\u00e7\u00e3o de TVS hemodinamicamente inst\u00e1vel (41%).  Leite Ap\u00f3s seguimento m\u00e9dio de 52 meses, a mortalidade global foi de 39,1% (9%/ano), sendo significativamente maior no grupo 3 do que nos grupos 2 e 1 . J\u00e1 a recorr\u00eancia de TVS foi significativamente menor no grupo 1 do que nos grupos 2 e 3 . Portanto, em pacientes com TVS e FEVE relativamente preservada tratados com antiarr\u00edtmicos de classe III, o EEF parece identificar aqueles com menor risco de \u00f3bito que poderiam permanecer em tratamento medicamentoso. J\u00e1 nos de pior progn\u00f3stico, o CDI poderia ser a op\u00e7\u00e3o mais adequada \u00e0 luz dessas observa\u00e7\u00f5es. et al.  estudaram os preditores de mortalidade em 56 pacientes com CCDC e TV (TVS em 28 e TVNS em 28) e identificaram apenas a FEVE como marcador independente de mau progn\u00f3stico, de tal forma que FEVE < 40% aumenta o risco de \u00f3bito em 12 vezes . Os pontos de corte de maior acur\u00e1cia para morte s\u00fabita e morte total foram FEVE de 40% e 38%, respectivamente. Quanto \u00e0 evolu\u00e7\u00e3o cl\u00ednica da coorte de 28 pacientes com TVS, todos tratados empiricamente com amiodarona (quando o contexto era de indisponibilidade de implante de um CDI), esse grupo tinha m\u00e9dia de idade de 54 anos, FEVE m\u00e9dia de 42%, 64% dos pacientes eram do sexo masculino, 100% estavam em classe funcional I/II e 43% tinham hist\u00f3ria de s\u00edncope, tendo sido relatada taxa de sobrevida de 85% e 67% ap\u00f3s 1 e 3 anos de acompanhamento, respectivamente.  Sarabanda Efeitos adversos com a amiodarona incluem microdep\u00f3sitos corneanos, bradicardia sinusal, BAV, aumento do intervalo QT, efeitos dermatol\u00f3gicos (fotossensibilidade e colora\u00e7\u00e3o cinzento-azulada da pele), disfun\u00e7\u00e3o tireoidiana , toxicidade pulmonar e, menos comumente, hepatotoxicidade. Efeitos colaterais neurol\u00f3gicos tardios como tremores, parestesias e ataxia tamb\u00e9m podem ocorrer.  A toxicidade pulmonar \u00e9 a complica\u00e7\u00e3o mais s\u00e9ria e potencialmente fatal do uso de amiodarona. O comprometimento pulmonar secund\u00e1rio \u00e0 amiodarona se manifesta como pneumonia intersticial (mais frequente) ou pneumonia eosinof\u00edlica, pneumonite organizada, insufici\u00eancia respirat\u00f3ria aguda ou hemorragia alveolar difusa. Os sintomas iniciais s\u00e3o dispneia e tosse n\u00e3o produtiva, com ou sem febre. A radiografia de t\u00f3rax mostra opacidades difusas ou localizadas, reticulares ou consolidadas. A tomografia de t\u00f3rax revela comprometimento intersticial e opacidades difusas bilaterais.  Os primeiros relatos de toxicidade pulmonar referiam preval\u00eancia de 5% a 15% quando doses de manuten\u00e7\u00e3o \u2265 400mg/dia eram usualmente administradas. Atualmente, com as doses reduzidas para 200mg/dia, a incid\u00eancia varia de 1% a 5%. Os fatores de risco mais importantes para a toxicidade pulmonar s\u00e3o, al\u00e9m de altas doses di\u00e1rias de amiodarona (\u2265 400mg), maiores doses cumulativas (longos per\u00edodos de administra\u00e7\u00e3o), doen\u00e7a pulmonar pr\u00e9-existente, cirurgia tor\u00e1cica e angiografia pulmonar.  Em meta-an\u00e1lise que reuniu quatro estudos com total de 1.465 pacientes, n\u00e3o houve diferen\u00e7a significativa na ocorr\u00eancia de toxicidade pulmonar em pacientes que receberam amiodarona em dose baixa (definida como 150 a 330 mg/dia) em compara\u00e7\u00e3o com placebo.  Em outra meta-an\u00e1lise, que reuniu 43 estudos e 11.395 pacientes, o risco relativo para eventos adversos pulmonares secund\u00e1rios ao uso de amiodarona foi de 1,77, com doses \u2265 300mg/dia e com seguimento cl\u00ednico > 12 meses. Doses inferiores a 300 mg/dia n\u00e3o se associaram a incid\u00eancia aumentada de complica\u00e7\u00f5es pulmonares em compara\u00e7\u00e3o com placebo.  Em outro estudo, no entanto, mesmo doses inferiores a 200mg/dia foram associadas a aumento de altera\u00e7\u00f5es pulmonares. Assim, pacientes em uso de amiodarona devem receber a menor dose que seja eficaz, al\u00e9m de se submeter a monitoriza\u00e7\u00e3o cl\u00ednica e laboratorial de forma peri\u00f3dica e sistem\u00e1tica.  As doses iniciais da amiodarona, por via oral, em pacientes ambulatoriais, devem ser de 400 a 600 mg/dia, at\u00e9 se completar a dose de ataque cumulativa de 6 a 10 gramas. Em pacientes internados, as doses de ataque podem ser de 400 at\u00e9 1200 mg/dia. Em seguida, a manuten\u00e7\u00e3o deve ser individualizada e a menor dose eficaz determinada.  A Nesse curto per\u00edodo de acompanhamento, 42% dos pacientes receberam choques apropriados e 15,7% foram acometidos por tempestades el\u00e9tricas, n\u00fameros muito mais elevados quando comparados aos de portadores de CDI com outras cardiopatias . Vale ainda lembrar que a FEVE m\u00e9dia dos pacientes com CCDC tratados por CDI foi de 40 \u00b1 11%, indicando que significativa parcela dessa subpopula\u00e7\u00e3o n\u00e3o tinha disfun\u00e7\u00e3o ventricular sist\u00f3lica grave.  Em portadores de CDI, m\u00faltiplos choques, apropriados ou n\u00e3o, e tempestades el\u00e9tricas s\u00e3o comuns na CCDC e afetam o progn\u00f3stico e a qualidade de vida dos pacientes. Estudo observacional descreveu a evolu\u00e7\u00e3o de 89 pacientes com CCDC e CDI, a maioria devido \u00e0 preven\u00e7\u00e3o secund\u00e1ria, por per\u00edodo m\u00e9dio de 12 meses.  O estudo OPTIC, que n\u00e3o incluiu pacientes com CCDC, mostrou superioridade da associa\u00e7\u00e3o entre amiodarona e betabloqueadores na preven\u00e7\u00e3o de choques, comparativamente ao sotalol ou a outros betabloqueadores utilizados isoladamente.  Empiricamente, essa associa\u00e7\u00e3o farmacol\u00f3gica pode ser indicada para preven\u00e7\u00e3o de recorr\u00eancia de choques em pacientes com CDI e CCDC.  A associa\u00e7\u00e3o de amiodarona com betabloqueadores  \u00e9 considerada a de maior potencial para reduzir a morte arr\u00edtmica e o n\u00famero de terapias el\u00e9tricas apropriadas ou n\u00e3o, desencadeadas pelo CDI.  As recomenda\u00e7\u00f5es para o manuseio farmacol\u00f3gico das arritmias card\u00edacas e preven\u00e7\u00e3o de morte s\u00fabita na CCDC est\u00e3o representadas na Na ICFEr, a preval\u00eancia de FA aumenta com o agravamento da classe funcional (NYHA), variando entre 4,2% na classe I e 49,8% na classe IV.  O surgimento de FA associa-se ao aumento da mortalidade por todas as causas em pacientes com IC de qualquer etiologia, incluindo a CCDC.  A FA e a IC frequentemente coexistem. De acordo com o Framingham Heart Study, aproximadamente 40% dos pacientes com FA desenvolver\u00e3o IC e vice-versa.  Mas essa preval\u00eancia na CCDC n\u00e3o parece ser superior \u00e0quela em pacientes com outras cardiomiopatias estruturais.  A preval\u00eancia de FA na CCDC est\u00e1 aumentada em compara\u00e7\u00e3o com a de FA na popula\u00e7\u00e3o geral. Meta-an\u00e1lise de 49 estudos, incluindo 34.023 pacientes, revelou que a preval\u00eancia de FA na CCDC era duas vezes maior do que na popula\u00e7\u00e3o geral.  O tratamento farmacol\u00f3gico da FA no paciente com CCDC \u00e9 dificultado pelo comprometimento da fun\u00e7\u00e3o sist\u00f3lica biventricular e por dist\u00farbios do automatismo e dromotropismo el\u00e9trico. Por isso, a otimiza\u00e7\u00e3o da terap\u00eautica para IC \u00e9 mandat\u00f3ria e o uso de IECA ou BRA na ICFEr pode reduzir a incid\u00eancia de FA.  A conduta inicial em pacientes admitidos na sala de emerg\u00eancia com FA de alta resposta ventricular \u00e9 o controle da FC e a anticoagula\u00e7\u00e3o com medica\u00e7\u00f5es apropriadas. Em seguida, avalia-se a indica\u00e7\u00e3o da revers\u00e3o da arritmia.  A frequ\u00eancia ventricular da FA em pacientes com CCDC muitas vezes \u00e9 baixa, mas, se houver instabilidade hemodin\u00e2mica com taquicardia, a conduta mais apropriada pode ser a anticoagula\u00e7\u00e3o imediata, seguida da cardiovers\u00e3o el\u00e9trica. Pacientes sintom\u00e1ticos, por\u00e9m est\u00e1veis, e com FA de dura\u00e7\u00e3o < 48 horas, sem trombose mural detect\u00e1vel por ecocardiografia transesof\u00e1gica, podem ser cardiovertidos com propafenona ou amiodarona. Pacientes com dura\u00e7\u00e3o de FA \u2265 48 horas ou desconhecida, ou ainda com hist\u00f3rico de FA refrat\u00e1ria, devem, inicialmente, ser anticoagulados e medicados para controle da FC. Pacientes assintom\u00e1ticos e/ou com FC baixa e aqueles com intensa dilata\u00e7\u00e3o atrial devem, em geral, ser somente anticoagulados. 11.1.11.1. Revers\u00e3o para Ritmo Sinusal A amiodarona pode ser especialmente indicada quando, al\u00e9m da FA, os pacientes com CCDC apresentarem arritmias ventriculares, o que \u00e9 comumente observado no contexto.  A estrat\u00e9gia de revers\u00e3o da FA \u00e9 usualmente mais apropriada quando a FA \u00e9 de in\u00edcio recente, ocorre em pacientes mais jovens, muito sintom\u00e1ticos, com \u00e1trios pouco dilatados e com resposta ventricular elevada. Quando a IC se desenvolve ou agrava, pode tamb\u00e9m indicar a necessidade de revers\u00e3o do ritmo com amiodarona ou mesmo abla\u00e7\u00e3o por cateter. 11.1.11.2. Controle da Frequ\u00eancia Card\u00edaca A estrat\u00e9gia de controle cronotr\u00f3pico, sem revers\u00e3o a ritmo sinusal, \u00e9 geralmente mais indicada quando h\u00e1 FA de longa dura\u00e7\u00e3o ou com muita dilata\u00e7\u00e3o de c\u00e2maras e em pacientes muito idosos, com m\u00faltiplas comorbidades e recorr\u00eancias da arritmia. Quando os betabloqueadores s\u00e3o insuficientes para o controle da resposta ventricular, pode-se considerar a adi\u00e7\u00e3o de digoxina. Deve-se ressaltar que os bloqueadores de canais de c\u00e1lcio s\u00e3o contraindicados em pacientes com ICFEr. A amiodarona pode ser ocasionalmente usada para controle cronotr\u00f3pico se houver contraindica\u00e7\u00e3o para betabloqueadores e bloqueadores de canais de c\u00e1lcio, sem possibilidade de abla\u00e7\u00e3o por cateter.  As recomenda\u00e7\u00f5es para o tratamento farmacol\u00f3gico da FA na CCDC est\u00e3o representadas na Os processos de inflama\u00e7\u00e3o, necrose e rea\u00e7\u00e3o fibr\u00f3tica que acompanham a desorganiza\u00e7\u00e3o grave da arquitetura e estrutura do mioc\u00e1rdio na CCDC acometem n\u00e3o apenas as fibras contr\u00e1teis, mas tamb\u00e9m o sistema nervoso auton\u00f4mico e o tecido gerador e condutor do impulso el\u00e9trico no cora\u00e7\u00e3o.  O BAV tamb\u00e9m \u00e9 comum, apresentando-se sob todos os graus e podendo ser assintom\u00e1tico ou causar lipotimia, s\u00edncope e mesmo IC ou morte s\u00fabita.  De acordo com o Registro Brasileiro de Marca-passos, a CCDC \u00e9 a primeira causa de BAV na Am\u00e9rica Latina, sendo respons\u00e1vel por cerca de 25% das indica\u00e7\u00f5es de MP.  O acometimento do n\u00f3 sinusal ocorre precocemente no curso da CCDC e sua substitui\u00e7\u00e3o pela rea\u00e7\u00e3o fibr\u00f3tica provoca diferentes express\u00f5es de doen\u00e7a do n\u00f3 sinusal. A manifesta\u00e7\u00e3o mais frequente \u00e9 a bradicardia sinusal. A CCDC tamb\u00e9m provoca bloqueios intraventriculares, dentre os quais predomina o BRD isolado ou associado ao BDASE.  Em s\u00edntese, doen\u00e7a do n\u00f3 sinusal e BAVT s\u00e3o as bradiarritmias mais comumente tratadas com implante de MP em pacientes com CCDC.  A indica\u00e7\u00e3o de implante de MP em pacientes com BAVT de etiologia da DC, desde seu in\u00edcio na d\u00e9cada de 1970, pode ser considerada como obedecendo ao princ\u00edpio de plausibilidade extrema. De fato, a evid\u00eancia de n\u00edtido benef\u00edcio pelo implante do MP consistiu t\u00e3o somente no estudo observacional das curvas de sobrevida historicamente comparadas de 147 pacientes seguidos antes  com as de 74 pacientes seguidos ap\u00f3s o advento do dispositivo .  A preval\u00eancia do uso de MP em pacientes com CCDC foi relatada em poucas coortes, que mostraram taxas variando entre 3,5% e 14,1%.  Poucos estudos reportaram caracter\u00edsticas antropom\u00e9tricas e epidemiol\u00f3gicas ou os preditores de mortalidade de pacientes com MP e CCDC. Um estudo de coorte prospectiva, publicado em 2018, incluiu 396 portadores de MP que foram acompanhados por, pelo menos, 24 meses. A m\u00e9dia de idade foi de 62,5\u00b112,0 anos, sendo a maioria do sexo feminino (64%). Cerca de 95% dos pacientes estavam em classe funcional I ou II (NYHA). Aproximadamente 75% apresentavam BAV avan\u00e7ado como indica\u00e7\u00e3o para implante de MP, sendo que a estimula\u00e7\u00e3o de VD ocorreu em 82,2% dos casos. A taxa de mortalidade anual foi de 8,4%.  \u00c9 importante destacar o potencial papel protetor de se evitar estimula\u00e7\u00e3o ventricular desnecess\u00e1ria e considerar-se a indica\u00e7\u00e3o da estimula\u00e7\u00e3o direta do sistema de condu\u00e7\u00e3o, uma modalidade mais fisiol\u00f3gica, mas ainda n\u00e3o testada adequadamente na CCDC.  As De modo geral, as indica\u00e7\u00f5es de MP na CCDC n\u00e3o diferem das cl\u00e1ssicas aplicadas a cardiopatias de outras etiologias. 11.2.2.1. Preven\u00e7\u00e3o Prim\u00e1ria de Morte S\u00fabita Card\u00edaca conforme discutido em outro cap\u00edtulo desta diretriz.  O sucesso da preven\u00e7\u00e3o prim\u00e1ria de morte s\u00fabita card\u00edaca est\u00e1 atrelado ao reconhecimento dos indiv\u00edduos de risco mais elevado para esse evento. Nesse sentido, a estratifica\u00e7\u00e3o de risco de mortalidade geral, que \u00e9 predominantemente s\u00fabita no paciente com CCDC, conta com um instrumento de uso simples e r\u00e1pido, o escore de RASSI,  O impacto desse novo fator tamb\u00e9m se encontra esmiu\u00e7ado naquele cap\u00edtulo desta diretriz, em contexto geral da estratifica\u00e7\u00e3o do risco e sua rela\u00e7\u00e3o com o escore de RASSI.  Recentemente, adicionaram-se evid\u00eancias relevantes a respeito do papel da fibrose mioc\u00e1rdica na identifica\u00e7\u00e3o de indiv\u00edduos de alto risco na CCDC. A quantifica\u00e7\u00e3o de fibrose mioc\u00e1rdica > 12,3g foi reportada como fator de risco independente para o desfecho combinado de mortalidade por todas as causas, TC, estimula\u00e7\u00e3o antitaquicardia ou choque apropriado do CDI e morte s\u00fabita card\u00edaca abortada.  Nesse sentido, as anormalidades estruturais da CCDC, caracterizadas por inflama\u00e7\u00e3o, morte celular e fibrose reativa ou reparativa, constituem-se no substrato anat\u00f4mico mais prop\u00edcio para desencadear a morte s\u00fabita card\u00edaca. Isso porque se criam \u00e1reas de condu\u00e7\u00e3o lenta e se promovem bloqueios unidirecionais prop\u00edcios \u00e0 ocorr\u00eancia de reentrada el\u00e9trica. As EV, frequentes na CCDC, atuam como disparadores desses circuitos, desencadeando a TV/FV.  O estudo da correla\u00e7\u00e3o entre est\u00e1gios da CCDC e causas de mortalidade revela que a morte s\u00fabita card\u00edaca acomete em geral pacientes a partir do est\u00e1gio B da doen\u00e7a, sendo mais relevante no est\u00e1gio C e um pouco menos no est\u00e1gio D, no qual a IC refrat\u00e1ria \u00e9 causa da maioria dos \u00f3bitos. Em termos gerais, o principal mecanismo de morte s\u00fabita na CCDC \u00e9 arritmog\u00eanico, sendo que a TVS (FV subsequente) \u00e9 respons\u00e1vel pela imensa maioria dos eventos letais.  As evid\u00eancias cient\u00edficas a respeito da preven\u00e7\u00e3o prim\u00e1ria de morte s\u00fabita card\u00edaca na CCDC com uso de f\u00e1rmacos antiarr\u00edtmicos (basicamente amiodarona) s\u00e3o escassas e j\u00e1 foram discutidas anteriormente. Com rela\u00e7\u00e3o ao CDI, existe apenas o relato dos achados de uma s\u00e9rie de 13 casos, que n\u00e3o permite conclus\u00f5es sobre efic\u00e1cia terap\u00eautica. et al.  demonstraram, em estudo com 78 pacientes com TVNS e s\u00edncope ou pr\u00e9-s\u00edncope , durante seguimento m\u00e9dio de 56 meses, que a indu\u00e7\u00e3o de TVS monom\u00f3rfica em 25 pacientes (32%), todos posteriormente tratados com amiodarona, foi preditora da ocorr\u00eancia de TV espont\u00e2nea e de mortalidade card\u00edaca e total.  Embora o papel da estimula\u00e7\u00e3o ventricular programada na estratifica\u00e7\u00e3o de risco de pacientes com CCDC ainda n\u00e3o esteja bem estabelecido, Silvaet al.  demonstraram que, em pacientes com TVNS e indu\u00e7\u00e3o de TVS (n = 37) ou naqueles com TVS espont\u00e2nea (n = 78), o EEF poderia predizer a efic\u00e1cia de antiarr\u00edtmicos da classe III  a longo prazo. Imediatamente ap\u00f3s impregna\u00e7\u00e3o oral com os f\u00e1rmacos antiarr\u00edtmicos, a indu\u00e7\u00e3o de TVS hemodinamicamente inst\u00e1vel esteve relacionada \u00e0 maior mortalidade total, card\u00edaca e s\u00fabita, quando se comparou esses pacientes com aqueles nos quais n\u00e3o se conseguiu induzir a arritmia ou a arritmia induzida foi a TVS bem tolerada.  Conforme tamb\u00e9m j\u00e1 relatado nesta diretriz, Leite Esses dois estudos, apesar de observacionais, sugerem que o EEF poderia identificar pacientes com taquiarritmias ventriculares, que, uma vez tratados com f\u00e1rmacos antiarr\u00edtmicos, evoluiriam com pior progn\u00f3stico e maior risco de \u00f3bito e, nesses casos, o CDI poderia ser alternativa vi\u00e1vel.  Trata-se de ECR, multic\u00eantrico e aberto, desenhado para comparar os efeitos do CDI com a amiodarona na preven\u00e7\u00e3o prim\u00e1ria de mortalidade na CCDC, em pacientes com TVNS ao Holter de 24 horas e escore de RASSI \u2265 10 pontos. As indica\u00e7\u00f5es para implante de CDI em preven\u00e7\u00e3o prim\u00e1ria de morte s\u00fabita card\u00edaca est\u00e3o listadas na Sumariamente, pode-se afirmar que, at\u00e9 o momento, n\u00e3o h\u00e1 evid\u00eancias cient\u00edficas que lastreiam o uso do CDI, com recomenda\u00e7\u00e3o forte na preven\u00e7\u00e3o prim\u00e1ria de morte s\u00fabita card\u00edaca na CCDC. Nesse sentido, o estudo CHAGASICS, em andamento, dever\u00e1 fornecer brevemente, informa\u00e7\u00f5es relevantes. 11.2.2.2. Preven\u00e7\u00e3o Secund\u00e1ria de Morte S\u00fabita Card\u00edaca Considera-se, em geral, que o CDI seja recurso aplic\u00e1vel a alguns contextos de preven\u00e7\u00e3o secund\u00e1ria de morte s\u00fabita card\u00edaca para pacientes com CCDC. Sua efic\u00e1cia consiste na interrup\u00e7\u00e3o do evento arr\u00edtmico amea\u00e7ador da vida por meio de eletrochoque ou estimula\u00e7\u00e3o ventricular r\u00e1pida (antitaquicardia), evitando a ocorr\u00eancia de parada card\u00edaca e \u00f3bito subsequente, embora algumas arritmias abortadas pelo CDI pudessem reverter espontaneamente, n\u00e3o necessariamente culminando em \u00f3bito. A escolha dessa op\u00e7\u00e3o terap\u00eautica envolve a an\u00e1lise rigorosa de cinco fatores essenciais: 1. adjudica\u00e7\u00e3o da parada card\u00edaca ou evento arr\u00edtmico (TVS ou FV) devidamente documentado e sua correla\u00e7\u00e3o com irreversibilidade da causa; 2. convic\u00e7\u00e3o de que a terap\u00eautica cl\u00ednica e/ou procedimentos menos invasivos, de similar efic\u00e1cia, est\u00e3o esgotados; 3. certifica\u00e7\u00e3o de que o tratamento pleno da cardiopatia de base est\u00e1 sendo implementado; 4. valoriza\u00e7\u00e3o da estratifica\u00e7\u00e3o de risco da cardiomiopatia de base; e 5. condi\u00e7\u00e3o cl\u00ednica do paciente, expressa principalmente pelo grau de disfun\u00e7\u00e3o ventricular (FEVE) e tipo de sintoma relacionado \u00e0 arritmia.  de estudos cl\u00ednicos observacionais de centros \u00fanicos que avaliaram amostras populacionais pouco extensas  e de meta-an\u00e1lises desses estudos.  Esses fatores foram pouco contemplados nos estudos de preven\u00e7\u00e3o secund\u00e1ria de morte s\u00fabita card\u00edaca na CCDC. N\u00e3o existem ECR nessa popula\u00e7\u00e3o e as evid\u00eancias cient\u00edficas se restringem a dados de registros de empresas de dispositivos implant\u00e1veis,  A maior coorte de pacientes com CCDC tratados por implante de CDI para preven\u00e7\u00e3o secund\u00e1ria, em centro \u00fanico, arrolou 116 pacientes consecutivos, com m\u00e9dia de idade de 54 anos, sendo 62% do sexo masculino. A FEVE m\u00e9dia foi de 42%, 83% dos pacientes estavam em classe funcional I/II da NYHA e o motivo do implante de CDI foi a revers\u00e3o de parada card\u00edaca em 18% e TVS sintom\u00e1tica em 82% dos casos. Em seguimento m\u00e9dio de 45 meses, foram reportados: taxa de mortalidade total anual de 7,1%; terapias apropriadas em 50% e de inapropriadas em 11% da popula\u00e7\u00e3o. Os fatores independentes de pior progn\u00f3stico foram classe funcional III da NYHA e baixa FEVE. Pacientes com taxa de estimula\u00e7\u00e3o do VD superior a 40% tamb\u00e9m tiveram menor sobrevida.  Por outro lado, em coorte retrospectiva de 90 pacientes consecutivos com CCDC  tratados por implante de CDI, cerca de 30% dos quais tinham fun\u00e7\u00e3o card\u00edaca preservada, foi surpreendente observar que, em seguimento m\u00e9dio de 756 dias, a taxa de mortalidade anual foi elevada , ainda que, dos pacientes que faleceram, 88% estivessem em classe funcional I no momento do implante de CDI. Apesar de 65% dos pacientes receberem choque apropriado e terapia antitaquicardia, a taxa mensal de choques foi o \u00fanico preditor independente de mortalidade.  Reportou-se 72% de redu\u00e7\u00e3o de mortalidade total e 95% de redu\u00e7\u00e3o de morte s\u00fabita card\u00edaca na coorte tratada com CDI. Entretanto, quando se realizou a an\u00e1lise de subgrupo, houve importante intera\u00e7\u00e3o entre a FEVE e o benef\u00edcio do CDI. Enquanto pacientes com FEVE reduzida (< 40%) obtiveram benef\u00edcio significativo e expressivo com o CDI, aqueles com FEVE relativamente preservada (\u2265 40%) obtiveram pouco ou nenhum benef\u00edcio.  A taxa de mortalidade de outra coorte retrospectiva de 76 pacientes com CCDC, portadores de CDI, foi comparada com a de uma s\u00e9rie hist\u00f3rica de 28 pacientes com TVS tratados apenas com amiodarona.  Esses dados s\u00e3o consistentes com os resultados da meta-an\u00e1lise de ECR de preven\u00e7\u00e3o secund\u00e1ria em outras cardiopatias , que mostrou redu\u00e7\u00e3o de mortalidade total e s\u00fabita com o CDI (em compara\u00e7\u00e3o \u00e0 amiodarona) apenas em pacientes com FEVE < 35%.  Vale ressaltar que meta-an\u00e1lise incluindo esse estudo e outros cinco observacionais na CCDC n\u00e3o demonstrou diferen\u00e7a de mortalidade total entre uso de amiodarona  e CDI .  Recentemente, foi publicada revis\u00e3o sistem\u00e1tica e meta-an\u00e1lise de 13 estudos observacionais de pacientes com CCDC para reavaliar a efic\u00e1cia global do CDI na preven\u00e7\u00e3o de morte total e s\u00fabita. Foram inclu\u00eddos 1.041 pacientes, 92% de preven\u00e7\u00e3o secund\u00e1ria e apenas 8% de preven\u00e7\u00e3o prim\u00e1ria, com idade m\u00e9dia de 57 anos, 64% do sexo masculino, FEVE m\u00e9dia de 38%, 79% em classe funcional I/II, 79% em uso de amiodarona e 44% em uso de betabloqueador. Em seguimento de 2,8 anos, a taxa de mortalidade total foi de 9,0% ao ano e a taxa de morte s\u00fabita card\u00edaca foi de 2,0% ao ano, em 2,6 anos de seguimento. Terapias do CDI apropriadas (choques ou interven\u00e7\u00f5es antitaquicardia) ocorreram em 24,8% dos pacientes, anualmente. Taxas elevadas de choques inapropriados  e de tempestades arr\u00edtmicas  tamb\u00e9m foram observadas. et al.  compararam o comportamento cl\u00ednico evolutivo de dois grupos de pacientes: grupo 1, constitu\u00eddo de 318 pacientes, dos quais 36% com CCDC, cujo motivo do implante foi a TVS sintom\u00e1tica (s\u00edncope e/ou instabilidade hemodin\u00e2mica) ou a indu\u00e7\u00e3o de TVS ao EEF em pacientes com s\u00edncope recorrente de etiologia n\u00e3o esclarecida; e grupo 2, constitu\u00eddo de 97 pacientes, dos quais 15% com CCDC, cujo motivo do implante foi a recupera\u00e7\u00e3o de parada card\u00edaca por FV ou TVS sem pulso. Enquanto sexo masculino (75%versus73%) e classe funcional I/II da NYHA (77%versus76%) n\u00e3o diferiram entre os pacientes dos grupos 1 e 2, a m\u00e9dia de idade foi maior  e a FEVE m\u00e9dia menor  nos pacientes do grupo 1. Ap\u00f3s seguimento m\u00e9dio de 24 meses para o grupo 1 e de 26 meses para o grupo 2, houve maior mortalidade no grupo 2 , com ocorr\u00eancia similar de choques apropriados pelo CDI , denotando, possivelmente, maior gravidade da arritmia no subgrupo de pacientes recuperados de parada card\u00edaca.  Em rela\u00e7\u00e3o ao progn\u00f3stico dos tipos de arritmias que usualmente indicam implante de CDI, Limaet al.,  por sua vez, avaliaram o impacto da presen\u00e7a de s\u00edncope na mortalidade total e card\u00edaca de 78 pacientes com TVS monom\u00f3rfica . S\u00edncope durante TVS foi observada em 45 pacientes (58%) e esteve ausente em 33 (42%). Ap\u00f3s seguimento m\u00e9dio de 49 meses, n\u00e3o houve diferen\u00e7a na mortalidade total (33%versus39%) e card\u00edaca (27%versus30%), nem na recorr\u00eancia de TVS n\u00e3o fatal (58%versus54%) entre os pacientes com e sem s\u00edncope, respectivamente. Entretanto, a presen\u00e7a de s\u00edncope durante as recorr\u00eancias foi significativamente maior entre os pacientes que apresentaram o sintoma inicialmente . Assim, na CCDC, s\u00edncope durante apresenta\u00e7\u00e3o cl\u00ednica da TVS monom\u00f3rfica parece n\u00e3o estar associada a um aumento de mortalidade total e card\u00edaca.  Leite Com base no conjunto dos resultados sumarizados acima, pode-se concluir que o uso de CDI para preven\u00e7\u00e3o secund\u00e1ria de morte s\u00fabita card\u00edaca em pacientes com CCDC ainda carece de embasamento mais s\u00f3lido em evid\u00eancias cient\u00edficas. Esse cen\u00e1rio negativo, idealmente, deveria ser resolvido pela execu\u00e7\u00e3o de um ECR. Todavia, v\u00e1rios investigadores alegam impedimentos de ordem \u00e9tica para ado\u00e7\u00e3o desse caminho cient\u00edfico e n\u00e3o h\u00e1, nos dias atuais, perspectiva para tal.  Por outro lado, tamb\u00e9m se alega que existe ampla experi\u00eancia positiva acumulada ao longo dos anos com o uso de protocolos referendados por diretrizes internacionais e de \u00e2mbito nacional para pacientes com CMI ou CMD tratados com implante de CDI. Isso criou um cen\u00e1rio favor\u00e1vel \u00e0 extrapola\u00e7\u00e3o dessas regras na pr\u00e1tica cl\u00ednica, no sentido de pacientes com CCDC serem mais liberalmente tratados com CDI. Em contraposi\u00e7\u00e3o, deve-se reafirmar que a preven\u00e7\u00e3o secund\u00e1ria com implante de CDI na CCDC deve ser sempre respaldada em criteriosa decis\u00e3o individualizada paciente a paciente, de an\u00e1lise de risco/benef\u00edcio.  Esse princ\u00edpio geral, por sua vez, deriva de duas no\u00e7\u00f5es essenciais: a primeira \u00e9 que, mesmo para os cen\u00e1rios mais consolidados em diretrizes internacionais de pacientes com outras cardiopatias, o benef\u00edcio do CDI torna-se relativamente restrito \u00e0 vig\u00eancia de grave disfun\u00e7\u00e3o ventricular sist\u00f3lica, sendo muito menos significativo na aus\u00eancia desse fator. A outra no\u00e7\u00e3o j\u00e1 ressaltada acima \u00e9 que a complexa e peculiar fisiopatologia da CCDC implica em que, dificilmente, princ\u00edpios terap\u00eauticos apenas em parte validados em contextos de outras cardiopatias possam ser adequadamente extrapolados para a pr\u00f3pria CCDC. Assim, tanto a FEVE, tomando como ponto de corte ideal o valor de 40%, quanto o tipo de arritmia e sintoma associado foram valorizados para balizar melhor as indica\u00e7\u00f5es de CDI na preven\u00e7\u00e3o secund\u00e1ria de morte s\u00fabita card\u00edaca. European Society of Cardiology para tratamento de arritmias ventriculares dedicou expl\u00edcita men\u00e7\u00e3o \u00e0 CCDC e restringiu sobremaneira as indica\u00e7\u00f5es de CDI no contexto, de forma praticamente an\u00e1loga \u00e0s nossas recomenda\u00e7\u00f5es. As recomenda\u00e7\u00f5es desta diretriz est\u00e3o listadas na \u00c9 oportuno mencionar que, quando esta diretriz estava sendo finalizada, a recente publica\u00e7\u00e3o da Tamb\u00e9m n\u00e3o existem dados robustos a partir de ECR para embasar a utiliza\u00e7\u00e3o da terapia de ressincroniza\u00e7\u00e3o card\u00edaca (TRC) na CCDC. A TRC tem sido recomendada a pacientes com CMD e CMI, apresentando IC avan\u00e7ada, disfun\u00e7\u00e3o sist\u00f3lica grave e dissincronia ventricular, traduzida particularmente por complexo QRS alargado. Nesse contexto, essa modalidade tem sido descrita como agindo positivamente sobre o remodelamento ventricular esquerdo e promovendo redu\u00e7\u00e3o significativa da classe funcional de IC e melhora da qualidade de vida, com base em diversos outros par\u00e2metros funcionais.  especialmente na vig\u00eancia de BRE, FEVE \u2264 35%, dura\u00e7\u00e3o de QRS \u2265 130ms e insufici\u00eancia mitral.  Entretanto, como na CCDC a preval\u00eancia de BRE \u00e9 baixa, tal fato limita a indica\u00e7\u00e3o formal para TRC nesse cen\u00e1rio. A presen\u00e7a e a extens\u00e3o da fibrose mioc\u00e1rdica, que se associa a pior progn\u00f3stico independentemente da FEVE,  as arritmias ventriculares frequentes, a regurgita\u00e7\u00e3o tric\u00faspide e a disfun\u00e7\u00e3o de VD s\u00e3o exemplos de outros fatores desfavor\u00e1veis \u00e0 TRC na CCDC, que podem colocar os pacientes em maior risco de n\u00e3o resposta.  Alguns estudos evidenciaram benef\u00edcio do procedimento quanto \u00e0 redu\u00e7\u00e3o de mortalidade por IC,  Ademais, \u00e9 importante ressaltar que o implante de MP convencional , muito utilizado na CCDC, provoca inerente dissincronia do VE (\u201cBRE induzido\u201d), sobretudo quando o cabo-eletrodo est\u00e1 localizado na regi\u00e3o apical do VD. Isso se associa a preju\u00edzos hemodin\u00e2micos e agrava o progn\u00f3stico do paciente com IC tratado com MP.  todos de centros \u00fanicos, avaliaram a evolu\u00e7\u00e3o cl\u00ednica de pacientes com CCDC submetidos \u00e0 TRC e tr\u00eas deles  compararam o efeito dessa terapia entre pacientes com CCDC e com outras cardiopatias  ocasionam dano mioc\u00e1rdico e variados dist\u00farbios em todos os n\u00edveis de gera\u00e7\u00e3o e condu\u00e7\u00e3o da eletricidade card\u00edaca.  Tais \u00e1reas de fibrose (cicatrizes) podem ter localiza\u00e7\u00e3o subendoc\u00e1rdica, intramioc\u00e1rdica ou subepic\u00e1rdica do VE.  Adicionalmente, um istmo de mioc\u00e1rdio vi\u00e1vel entre o anel mitral e uma cicatriz na regi\u00e3o inferolateral do VE pode formar um circuito macrorreentrante de TVS.  Por fim, um circuito de macrorreentrada envolvendo os ramos direito e esquerdo (reentrada ramo a ramo) pode ser a causa menos comum de TVS.  O mecanismo eletrofisiol\u00f3gico fundamental da TVS na CCDC geralmente \u00e9 a reentrada do est\u00edmulo el\u00e9trico em regi\u00e3o de cicatriz ventricular, constitu\u00edda por extensa fibrose intersticial entremeada por fibras mioc\u00e1rdicas vi\u00e1veis. Isso ocorre mais frequentemente em regi\u00e3o inferolateral do VE (70% dos pacientes), podendo localizar-se tamb\u00e9m na regi\u00e3o apical do VE e no VD.  De forma gen\u00e9rica, os diferentes mecanismos reentrantes da TVS t\u00eam sido amplamente investigados pelo EEF invasivo, no qual a estimula\u00e7\u00e3o ventricular programada \u00e9 capaz de reproduzir essa arritmia em mais de 80% dos pacientes com hist\u00f3ria cl\u00ednica de TVS ou s\u00edncope e CCDC. Al\u00e9m disso, o mapeamento endoc\u00e1rdico e/ou epic\u00e1rdico tem demonstrado a presen\u00e7a de eletrogramas diast\u00f3licos anormais, pr\u00e9-sist\u00f3licos e mesodiast\u00f3licos, predominando nas regi\u00f5es de acinesia ou discinesia do VE.  Al\u00e9m da fibrose em regi\u00f5es circunscritas da parede ventricular, as les\u00f5es do sistema nervoso aut\u00f4nomo intracard\u00edaco, caracterizadas pela deple\u00e7\u00e3o neuronal ganglionar e disautonomia card\u00edaca, e a inflama\u00e7\u00e3o mioc\u00e1rdica cr\u00f4nica s\u00e3o altera\u00e7\u00f5es fisiopatol\u00f3gicas que podem contribuir para a instabilidade el\u00e9trica mioc\u00e1rdica e g\u00eanese das taquiarritmias ventriculares.  Durante o EEF utilizando t\u00e9cnicas de estimula\u00e7\u00e3o ventricular (encarrilhamento oculto), \u00e9 poss\u00edvel diferenciar o istmo cr\u00edtico do circuito de reentrada de outras regi\u00f5es n\u00e3o envolvidas no mecanismo da TV, o que pode ser confirmado pela interrup\u00e7\u00e3o da TV durante a abla\u00e7\u00e3o por radiofrequ\u00eancia.  e IC (que deve ter seu tratamento espec\u00edfico otimizado), demandando, para que se programe a abla\u00e7\u00e3o, a avalia\u00e7\u00e3o da fun\u00e7\u00e3o renal, ocorr\u00eancia de infec\u00e7\u00e3o e necessidade de medicamentos vasoativos em casos de tempestade el\u00e9trica. Em geral, a presen\u00e7a de comorbidades n\u00e3o deve contraindicar a abla\u00e7\u00e3o, principalmente nos casos de tempestade el\u00e9trica e choques recorrentes, pois, sem a interven\u00e7\u00e3o, a mortalidade \u00e9 muito elevada.  Os pacientes com CCDC e TVS geralmente apresentam doen\u00e7a card\u00edaca avan\u00e7ada PAINESD foi desenvolvido para identificar pacientes que podem apresentar descompensa\u00e7\u00e3o hemodin\u00e2mica durante a abla\u00e7\u00e3o de TV  e maior mortalidade precoce ap\u00f3s o procedimento. Como esse escore foi desenvolvido para pacientes com cardiopatias isqu\u00eamica e n\u00e3o isqu\u00eamica, mas n\u00e3o se incluiu a CCDC, n\u00e3o \u00e9 aplic\u00e1vel como preditor de mortalidade em 30 dias ap\u00f3s a abla\u00e7\u00e3o de TV.  O escore Como a abordagem na abla\u00e7\u00e3o deve ser preferencialmente epic\u00e1rdica,  na presen\u00e7a de megac\u00f3lon, o acesso ao espa\u00e7o peric\u00e1rdico pode ser obtido atrav\u00e9s de janela cir\u00fargica ou atrav\u00e9s da pun\u00e7\u00e3o guiada por laparoscopia.  Pacientes com CCDC podem tamb\u00e9m apresentar megaes\u00f4fago e/ou megac\u00f3lon.  e avaliar se o substrato-alvo est\u00e1 localizado na superf\u00edcie epic\u00e1rdica e endoc\u00e1rdica.  A angiotomografia de coron\u00e1rias pode mostrar \u00e1reas de afilamento  e hipoperfus\u00e3o, que est\u00e3o associadas ao substrato da arritmia. Tanto a RMC quanto a angiotomografia de coron\u00e1rias avaliam a espessura da gordura epic\u00e1rdica local e a localiza\u00e7\u00e3o das art\u00e9rias coron\u00e1rias, permitindo integra\u00e7\u00e3o com os sistemas de mapeamento eletroanat\u00f4mico.  A RMC pelo m\u00e9todo de contraste com gadol\u00ednio para realce tardio \u00e9 \u00fatil para identificar as \u00e1reas de fibrose softwarede processamento de imagem 3D da RMC, que permitem a defini\u00e7\u00e3o dos potenciais circuitos das arritmias.  Essas imagens possibilitam integra\u00e7\u00e3o com os sistemas de mapeamento eletroanat\u00f4mico e contribuem para o sucesso da abla\u00e7\u00e3o,  que se torna mais r\u00e1pida e eficaz, dispensando assim a reconstru\u00e7\u00e3o do mapeamento eletroanat\u00f4mico.  Recentemente, foram desenvolvidos Esse conceito \u00e9 v\u00e1lido apesar de o ECG apresentar limita\u00e7\u00f5es na defini\u00e7\u00e3o de TV epic\u00e1rdica.  Outro ponto importante no planejamento da abla\u00e7\u00e3o \u00e9 a avalia\u00e7\u00e3o do ECG de 12 deriva\u00e7\u00f5es durante a TV cl\u00ednica, o qual, sempre que poss\u00edvel, deve ser registrado. Isso permite a compara\u00e7\u00e3o com as TV induzidas no procedimento, sendo importante na busca da elimina\u00e7\u00e3o, pelo menos, da TV cl\u00ednica, visto que geralmente os pacientes com CCDC apresentam m\u00faltiplas morfologias de TV.  Frequentemente, pacientes com CCDC apresentam recorr\u00eancias ap\u00f3s abla\u00e7\u00e3o de TV, sendo comum a realiza\u00e7\u00e3o de m\u00faltiplos procedimentos. A informa\u00e7\u00e3o dos procedimentos anteriores \u00e9 fundamental no planejamento de nova abla\u00e7\u00e3o. Devem-se avaliar os mapas realizados anteriormente para comparar com o mapeamento atual, avaliar se alguma \u00e1rea cicatricial endo- ou epic\u00e1rdica n\u00e3o foi abordada no procedimento anterior e obter-se a informa\u00e7\u00e3o de o acesso epic\u00e1rdico ter sido realizado com sangramentos, pois, nesses casos, pode ocorrer a complica\u00e7\u00e3o de ader\u00eancias epic\u00e1rdicas.  Assim, a abla\u00e7\u00e3o por radiofrequ\u00eancia torna-se indicada em muitos casos refrat\u00e1rios ao tratamento cl\u00ednico.  Epis\u00f3dios de TV em indiv\u00edduos com CCDC apresentam altas taxas de recorr\u00eancia, mesmo ap\u00f3s terapia medicamentosa otimizada. Por exemplo, meta-an\u00e1lise recente relatou taxas de terapias apropriadas e tempestade el\u00e9trica de 9% e 25% ao ano, respectivamente, em portadores de CDI por profilaxia secund\u00e1ria.  A cicatriz mioc\u00e1rdica que propicia reentrada e TVS usualmente se localiza nas por\u00e7\u00f5es basais das paredes inferior e lateral do VE e o acometimento mesoc\u00e1rdico e epic\u00e1rdico \u00e9 frequente. Logo, os resultados iniciais da abla\u00e7\u00e3o de TV com abordagem endoc\u00e1rdica apresentaram-se frustrantes, com taxas de sucesso em torno de 17%.  e contribuiu para a otimiza\u00e7\u00e3o dos resultados das abla\u00e7\u00f5es de TV em pacientes com CCDC. Em ECR, observou-se que a abordagem endoc\u00e1rdica/epic\u00e1rdica combinada, comparada \u00e0 abordagem endoc\u00e1rdica exclusiva, correlacionava-se com menor taxa de recorr\u00eancia, 40% e 80% respectivamente, em 2 anos de seguimento.  O acesso epic\u00e1rdico por pun\u00e7\u00e3o percut\u00e2nea subxifoide, com agulha de Tuohy guiada por fluoroscopia, foi descrito em 1996  A complica\u00e7\u00e3o mais tem\u00edvel relacionada ao acesso epic\u00e1rdico percut\u00e2neo \u00e9 o sangramento, que pode ocorrer em cerca de 10% dos casos. A maioria \u00e9 de pequena monta e est\u00e1 relacionada \u00e0 pun\u00e7\u00e3o acidental do VD. Sangramento vultuoso com necessidade de abordagem cir\u00fargica ocorre em 2% dos casos. Les\u00f5es hep\u00e1ticas e intestinais podem ocorrer durante a pun\u00e7\u00e3o epic\u00e1rdica na presen\u00e7a de hepatomegalia significativa e megac\u00f3lon. Nesses casos, pode-se optar pelo acesso peric\u00e1rdico cir\u00fargico ou atrav\u00e9s de pun\u00e7\u00e3o subxifoide guiada por videolaparoscopia.  insufla\u00e7\u00e3o de di\u00f3xido de carbono (CO 2 ) no ap\u00eandice atrial direito  ou seio coron\u00e1rio,  agulha com sensor de press\u00e3o,  tomografia computadorizada,  RMC  e pun\u00e7\u00e3o guiada por mapeamento eletroanat\u00f4mico.  Dentre essas, vale destacar que, em estudo observacional multic\u00eantrico, a micropun\u00e7\u00e3o demonstrou menores taxas de derrame peric\u00e1rdico volumoso e de necessidade de corre\u00e7\u00e3o cir\u00fargica de sangramento, quando comparada \u00e0 t\u00e9cnica de pun\u00e7\u00e3o com agulha de maior calibre.  Nos \u00faltimos anos, surgiram varia\u00e7\u00f5es da t\u00e9cnica original de pun\u00e7\u00e3o epic\u00e1rdica que incluem: micropun\u00e7\u00e3o,  Algumas situa\u00e7\u00f5es podem limitar a efic\u00e1cia da abla\u00e7\u00e3o na superf\u00edcie epic\u00e1rdica, como nos casos em que a regi\u00e3o-alvo para abla\u00e7\u00e3o se localiza sob a gordura epic\u00e1rdica ou possui proximidade com o trajeto do nervo fr\u00eanico ou com as art\u00e9rias coron\u00e1rias.  Devido \u00e0 gravidade da doen\u00e7a e \u00e0 complexidade do procedimento, cuidados perioperat\u00f3rios s\u00e3o importantes para a redu\u00e7\u00e3o do risco de complica\u00e7\u00f5es. A pesquisa pr\u00e9via de trombos intracavit\u00e1rios \u00e9 mandat\u00f3ria e a monitoriza\u00e7\u00e3o invasiva da press\u00e3o arterial, a infus\u00e3o de f\u00e1rmacos vasoativos previamente \u00e0 indu\u00e7\u00e3o anest\u00e9sica e o suporte circulat\u00f3rio mec\u00e2nico em casos selecionados s\u00e3o \u00fateis \u00e0 otimiza\u00e7\u00e3o hemodin\u00e2mica perioperat\u00f3ria.  A abla\u00e7\u00e3o por cateter pode ser realizada com o paciente em TV ou em ritmo sinusal. Cada estrat\u00e9gia possui vantagens e desvantagens e n\u00e3o existem estudos comparando seus resultados na popula\u00e7\u00e3o com CCDC. Apesar de o procedimento realizado com o paciente em TV favorecer a identifica\u00e7\u00e3o dos istmos das taquicardias com maior acur\u00e1cia, a maioria das TV induzidas \u00e9 mal tolerada hemodinamicamente e necessita de cardiovers\u00e3o el\u00e9trica imediata.  Por\u00e9m, mesmo em TV hemodinamicamente est\u00e1veis, o tempo de mapeamento deve ser abreviado ao m\u00e1ximo pelo risco de baixo d\u00e9bito p\u00f3s-interven\u00e7\u00e3o. A abla\u00e7\u00e3o por cateter com o paciente em ritmo sinusal tem como objetivo a modifica\u00e7\u00e3o do substrato que consiste na identifica\u00e7\u00e3o e elimina\u00e7\u00e3o dos poss\u00edveis istmos respons\u00e1veis pelas taquicardias. Essas \u00e1reas est\u00e3o relacionadas \u00e0 cicatriz mioc\u00e1rdica, que \u00e9 identificada como regi\u00e3o de baixa voltagem no sistema de mapeamento eletroanat\u00f4mico e representada pelos potenciais tardios, fragmentados e de baixa amplitude. Embora menos espec\u00edfica, essa t\u00e9cnica tem a vantagem de manter o paciente hemodinamicamente est\u00e1vel por mais tempo durante o procedimento, quando h\u00e1 grave disfun\u00e7\u00e3o ventricular.  Vale ressaltar que a evolu\u00e7\u00e3o tecnol\u00f3gica do sistema de mapeamento eletroanat\u00f4mico, principalmente com os cateteres de mapeamento de alta defini\u00e7\u00e3o, aumentou significativamente a acur\u00e1cia da defini\u00e7\u00e3o anat\u00f4mica das regi\u00f5es de cicatriz, al\u00e9m de sua correla\u00e7\u00e3o funcional com a propaga\u00e7\u00e3o el\u00e9trica. Entretanto, estudos relacionados \u00e0 abla\u00e7\u00e3o de TV em pacientes com CCDC s\u00e3o escassos e praticamente n\u00e3o contemplam a tecnologia atualmente dispon\u00edvel.  Entretanto, variadas defini\u00e7\u00f5es de n\u00e3o indutibilidade (protocolos de estimula\u00e7\u00e3o heterog\u00eaneos e relev\u00e2ncia de indu\u00e7\u00e3o de TV r\u00e1pida ou \u201cn\u00e3o cl\u00ednica\u201d) associadas a uma varia\u00e7\u00e3o di\u00e1ria espont\u00e2nea nos resultados da estimula\u00e7\u00e3o ventricular programada representam relevantes limita\u00e7\u00f5es e defici\u00eancias na acur\u00e1cia dessa ferramenta em predizer o sucesso da abla\u00e7\u00e3o no curto e longo prazo.  Historicamente, a estimula\u00e7\u00e3o ventricular programada tem sido utilizada como a principal ferramenta para a avalia\u00e7\u00e3o da efetividade imediata do procedimento de abla\u00e7\u00e3o da TV.  Os pacientes que permanecem com TV lenta (ciclo > 300ms) induz\u00edvel ao final do procedimento exibem mais recorr\u00eancia do que aqueles sem TV indut\u00edvel.  Outras estrat\u00e9gias para avaliar o resultado durante o procedimento incluem verificar a elimina\u00e7\u00e3o da excitabilidade,  dos potenciais tardios,  dos eletrogramas locais anormais (LAVA),  ou dos canais da cicatriz,  bem como constatar a homogeneiza\u00e7\u00e3o do substrato,  o isolamento central da cicatriz  e a les\u00e3o guiada por imagem.  Apesar dessas limita\u00e7\u00f5es, a estimula\u00e7\u00e3o ventricular programada ao final do procedimento ainda permanece como a principal ferramenta para avalia\u00e7\u00e3o do sucesso agudo.  As complica\u00e7\u00f5es agudas incluem as de natureza vascular, o derrame peric\u00e1rdico, tamponamento card\u00edaco, dissocia\u00e7\u00e3o eletromec\u00e2nica, BAVT, paralisia do nervo fr\u00eanico, AVC e morte.  Essa taxa de recorr\u00eancia mostrou, portanto, resultado similar \u00e0 abla\u00e7\u00e3o de TV em pacientes com cardiopatias n\u00e3o isqu\u00eamicas em geral.  Recentemente, reportou-se ECR prospectivo de abla\u00e7\u00e3o de TV em pequeno grupo de pacientes com CCDC, sendo a abordagem sistem\u00e1tica epic\u00e1rdica e endoc\u00e1rdica superior \u00e0 endoc\u00e1rdica exclusiva, havendo no primeiro grupo recorr\u00eancia de TV durante seguimento m\u00e9dio de 19 meses da ordem de 40%.  Todos os meios dispon\u00edveis para detec\u00e7\u00e3o de epis\u00f3dios de TVS devem ser empregados, incluindo uma zona de monitoriza\u00e7\u00e3o pelo CDI, capaz de detectar as TVS lentas induzidas durante a abla\u00e7\u00e3o. Al\u00e9m da recorr\u00eancia em si de qualquer TVS, o seguimento deve registrar a densidade de arritmias, a ocorr\u00eancia de tempestade el\u00e9trica, interna\u00e7\u00f5es hospitalares e morte card\u00edaca e n\u00e3o card\u00edaca.  A recorr\u00eancia de TV no per\u00edodo p\u00f3s-abla\u00e7\u00e3o depende de v\u00e1rios fatores, os mais comuns sendo relacionados \u00e0 utiliza\u00e7\u00e3o de antiarr\u00edtmicos, \u00e0 programa\u00e7\u00e3o dos dispositivos card\u00edacos implant\u00e1veis e \u00e0 gravidade da cardiomiopatia.  As Na maioria dos casos, a mortalidade pelos fen\u00f4menos tromboemb\u00f3licos est\u00e1 relacionada a embolias encef\u00e1licas e pulmonares. Considerando que os eventos neurol\u00f3gicos s\u00e3o as manifesta\u00e7\u00f5es cl\u00ednicas usualmente mais expressivas, as complica\u00e7\u00f5es tromboemb\u00f3licas encef\u00e1licas s\u00e3o detectadas de forma mais frequente na pr\u00e1tica m\u00e9dica.  As complica\u00e7\u00f5es tromboemb\u00f3licas representam grupo heterog\u00eaneo de manifesta\u00e7\u00f5es cl\u00ednicas associadas \u00e0 CCDC, correspondendo a um dos tr\u00eas mecanismos essenciais de morte dessa cardiopatia ao lado de IC e morte s\u00fabita.  O AVC, do tipo cardioemb\u00f3lico, pode ser a primeira manifesta\u00e7\u00e3o cl\u00ednica da CCDC e ocorrer mesmo em est\u00e1gios precoces da hist\u00f3ria natural da doen\u00e7a, acometendo indiv\u00edduos de diversas faixas et\u00e1rias e apresentando-se com recorr\u00eancia frequente quando a profilaxia secund\u00e1ria n\u00e3o \u00e9 estabelecida. As manifesta\u00e7\u00f5es cl\u00ednicas s\u00e3o usualmente decorrentes da emboliza\u00e7\u00e3o de trombos card\u00edacos intracavit\u00e1rios que, por sua maior dimens\u00e3o, apresentam elevado potencial de obstru\u00e7\u00e3o da circula\u00e7\u00e3o proximal no sistema nervoso central, sendo geralmente associados a graves e incapacitantes sequelas neurol\u00f3gicas, quando n\u00e3o levam diretamente a morte.  Nesses estudos, os fen\u00f4menos tromboemb\u00f3licos foram mais comuns na circula\u00e7\u00e3o sist\u00eamica, embora tenham causado relativamente mais mortes por embolia pulmonar.  A incid\u00eancia de trombos card\u00edacos foi maior na s\u00edndrome cl\u00ednica de IC (36%) do que em casos de morte s\u00fabita (15%), sem rela\u00e7\u00e3o com idade ou sexo.  Estudos necrosc\u00f3picos revelam frequ\u00eancia vari\u00e1vel de trombose card\u00edaca na DC, com preval\u00eancia entre 27% e 79%, com leve predom\u00ednio de acometimento de c\u00e2maras direitas .  O aneurisma apical tamb\u00e9m \u00e9 um fator relevante, estando presente em 53,2% dos casos em s\u00e9rie de 148 aut\u00f3psias, dos quais 36,8% seriam complicados por trombose localizada, enquanto apenas 11,1% dos cora\u00e7\u00f5es sem aneurisma apical apresentavam trombos intracavit\u00e1rios.  Outro estudo, envolvendo 1.153 aut\u00f3psias, constatou presen\u00e7a de aneurisma apical em 52% dos casos,  com predom\u00ednio no sexo masculino.  Les\u00f5es inflamat\u00f3rias do endoc\u00e1rdio e estase sangu\u00ednea intracavit\u00e1ria s\u00e3o considerados fatores importantes na patog\u00eanese da trombose parietal card\u00edaca, relacionados \u00e0 ocorr\u00eancia de m\u00faltiplos fen\u00f4menos tromboemb\u00f3licos e elevado risco de morte por embolia. et al.  descreveram a presen\u00e7a de trombos intraventriculares em apenas 14,5% dos casos estudados. A baixa frequ\u00eancia de trombos descrita nesse estudo pode ser atribu\u00edda \u00e0 menor sensibilidade do m\u00e9todo de avalia\u00e7\u00e3o em rela\u00e7\u00e3o aos estudos de necr\u00f3psia, que, al\u00e9m disso, provavelmente foram realizados em fase mais avan\u00e7ada da doen\u00e7a.  Em estudo observacional prospectivo de 55 pacientes com CCDC e aneurisma apical avaliados por ventriculografia de contraste radiol\u00f3gico, Albanesi Filho Discinesias ventriculares regionais, em especial apicais, s\u00e3o condi\u00e7\u00f5es caracter\u00edsticas da CCDC, com maior preval\u00eancia em rela\u00e7\u00e3o a outras etiologias, predispondo, assim, \u00e0 forma\u00e7\u00e3o de trombos murais e eventos emb\u00f3licos, especialmente os sist\u00eamicos.  Como ocorre em outras cardiopatias, dilata\u00e7\u00e3o card\u00edaca e IC constituem fatores de risco reconhecidos para ocorr\u00eancia de eventos tromboemb\u00f3licos. A FA, manifesta\u00e7\u00e3o considerada relativamente tardia e em geral associada \u00e0 disfun\u00e7\u00e3o ventricular, constitui fator trombog\u00eanico adicional nessa cardiopatia.  A presen\u00e7a de disfun\u00e7\u00e3o mioc\u00e1rdica grave, les\u00e3o apical do VE, trombos intracavit\u00e1rios e fen\u00f4menos tromboemb\u00f3licos pr\u00e9vios, assim como dilata\u00e7\u00e3o das c\u00e2maras card\u00edacas e vig\u00eancia de IC, tem sido associada a maior risco de acidentes tromboemb\u00f3licos em estudos anatomopatol\u00f3gicos e cl\u00ednicos.  Em rela\u00e7\u00e3o \u00e0 embolia pulmonar, a maior parte dos eventos origina-se nas pr\u00f3prias cavidades card\u00edacas direitas, diferindo das demais cardiopatias, nas quais os trombos comumente prov\u00eam dos membros inferiores.  Admite-se que fen\u00f4menos emb\u00f3licos pulmonares sejam clinicamente subestimados na CCDC, a se considerar sua elevada preval\u00eancia em material de necropsias,  o mesmo ocorrendo com as emboliza\u00e7\u00f5es sist\u00eamicas n\u00e3o encef\u00e1licas. Tromboembolismo pulmonar pode acometer at\u00e9 37% dos pacientes com IC, mas poucas vezes \u00e9 relatado em pacientes sem essa s\u00edndrome. Em 85% dos casos, associa-se \u00e0 trombose mural das c\u00e2maras card\u00edacas direitas.  A mortalidade associada aos eventos tromboemb\u00f3licos na CCDC est\u00e1 em geral relacionada a embolias encef\u00e1licas e pulmonares, com mais de um territ\u00f3rio arterial comumente afetado. et al. em 1953.  Posteriormente, em 1955, Rocha & Andrade descreveram fen\u00f4menos tromboemb\u00f3licos sist\u00eamicos em pacientes com CCDC.  O tromboembolismo sist\u00eamico afeta principalmente o c\u00e9rebro, podendo constituir manifesta\u00e7\u00e3o cl\u00ednica inicial da DC, associando-se \u00e0 presen\u00e7a de trombos murais e aneurisma da ponta do VE. Devido \u00e0 sua maior express\u00e3o cl\u00ednica, o AVC tem sido alvo de muitas investiga\u00e7\u00f5es. Os primeiros registros de AVC emb\u00f3lico na CCDC foram feitos por Nussenzveig A presen\u00e7a de CCDC \u00e9 considerada fator independente de risco para ocorr\u00eancia de AVC isqu\u00eamico. Estudos de casos-controles mostraram que IC, arritmias ao ECG, g\u00eanero feminino e aneurisma da ponta de VE constituem fatores de risco independentes para tromboembolismo cerebral em pacientes com DC.  Em estudo utilizando ECO transtor\u00e1cico e transesof\u00e1gico, avaliando 75 pacientes, foram encontrados trombos murais de VE em 23% dos casos, em flagrante associa\u00e7\u00e3o com hist\u00f3ria pregressa de AVC. Aneurisma apical foi identificado em 47% dos pacientes, significativamente relacionado \u00e0 trombose mural e ocorr\u00eancia de AVC. Trombose do ap\u00eandice atrial esquerdo foi constatada em 4 pacientes e trombose do ap\u00eandice atrial direito em 1 paciente. Houve 13 mortes em 24 meses de seguimento, sendo 7 subitamente, 5 por progress\u00e3o de IC e 1 por AVC. Diferentemente de outras cardiopatias, na CCDC, o AVC ocorreu de forma mais frequente em pacientes com disfun\u00e7\u00e3o sist\u00f3lica ventricular esquerda leve e classe I pela NYHA.  Em contraste, essa incid\u00eancia revelou-se expressivamente maior, de 60% ao ano, nos pacientes com IC manifesta, nos quais, aneurisma da ponta do VE e trombose mural do VE foram observados em 23% e 37% dos casos, respectivamente. No conjunto de todas as s\u00e9ries descritas, a preval\u00eancia de trombose de c\u00e2maras direitas (53%) superou a de c\u00e2maras esquerdas (43%).  Entretanto, em s\u00e9ries hospitalares, a incid\u00eancia anual de fen\u00f4menos tromboemb\u00f3licos em pacientes com CCDC e disfun\u00e7\u00e3o ventricular leve a moderada mostrou-se baixa (1% a 2%).  Como a CCDC tamb\u00e9m cursa com um estado pr\u00f3-inflamat\u00f3rio e pr\u00f3-tromb\u00f3tico, a associa\u00e7\u00e3o dessas duas doen\u00e7as poderia atuar, de forma sin\u00e9rgica, para potencializar o aparecimento de eventos tromboemb\u00f3licos.  Ao longo da pandemia de COVID-19, doen\u00e7a causada pelo SARS-CoV-2, constatou-se maior predisposi\u00e7\u00e3o dos pacientes infectados \u00e0s complica\u00e7\u00f5es tromb\u00f3ticas arteriais e venosas, devido a altera\u00e7\u00f5es inflamat\u00f3rias, da microcircula\u00e7\u00e3o endotelial e estase sangu\u00ednea, dentre outros fatores.  Em decorr\u00eancia, h\u00e1 estudos em andamento testando terap\u00eauticas antitromb\u00f3ticas mais agressivas em tais contextos. A conduta frente \u00e0 coexist\u00eancia das duas infec\u00e7\u00f5es \u00e9 abordada em subt\u00f3pico espec\u00edfico desta diretriz.  Entretanto, at\u00e9 o momento, n\u00e3o existe evid\u00eancia clara dessa associa\u00e7\u00e3o em rela\u00e7\u00e3o a eventos cl\u00ednicos mais relevantes. Todavia, ambientes intervencionistas relatam que s\u00edndromes coronarianas agudas em pacientes com COVID-19 tendem a se apresentar mais tardiamente ap\u00f3s in\u00edcio dos sintomas e com maior gravidade cl\u00ednica.  Mesmo pacientes com CCDC sem disfun\u00e7\u00e3o ventricular global podem apresentar aumento significativo dos marcadores de risco de trombose, sugerindo estado pr\u00f3-tromb\u00f3tico em fases mais precoces da doen\u00e7a.  Como exposto, pacientes com formas mais avan\u00e7adas da CCDC t\u00eam maior risco de desenvolver epis\u00f3dios tromboemb\u00f3licos por apresentarem condi\u00e7\u00f5es favor\u00e1veis \u00e0 forma\u00e7\u00e3o de trombos, como estase venosa e baixo fluxo sangu\u00edneo, dilata\u00e7\u00e3o das c\u00e2maras card\u00edacas, disfun\u00e7\u00e3o sist\u00f3lica do VE e fen\u00f4menos inflamat\u00f3rios vasculares. Outros fatores, como altera\u00e7\u00f5es parietais por hipocontratilidade segmentar e arritmias, especialmente FA, contribuem para aumentar o risco de tromboembolismo. T. cruzi, quando comparados aos n\u00e3o infectados, apresentavam excesso de risco de AVC, da ordem de 70% .  Revis\u00e3o sistem\u00e1tica de oito estudos observacionais, abrangendo um total de 4.158 pacientes, permitiu evidenciar associa\u00e7\u00e3o clara entre CCDC e risco de AVC. Esse estudo indicou que pacientes cronicamente infectados por Um escore de risco (IPEC-FIOCRUZ) para ocorr\u00eancia de AVC baseado em pontos e a indica\u00e7\u00e3o de profilaxia de eventos emb\u00f3licos foram propostos pelos autores, considerando-se a presen\u00e7a de disfun\u00e7\u00e3o sist\u00f3lica do VE , aneurismas apicais (1 ponto), altera\u00e7\u00f5es prim\u00e1rias da repolariza\u00e7\u00e3o ventricular ao ECG (1 ponto) e idade > 48 anos (1 ponto). Pacientes com 4-5 pontos foram considerados de alto risco para AVC cardioemb\u00f3lico. Para essa an\u00e1lise foram exclu\u00eddos os fatores de risco cl\u00e1ssicos associados a complica\u00e7\u00f5es cardioemb\u00f3licas em outras cardiopatias, para os quais j\u00e1 estaria assegurada a indica\u00e7\u00e3o de profilaxia, como FA, trombos intracavit\u00e1rios e eventos cardioemb\u00f3licos pr\u00e9vios. Ainda assim, a frequ\u00eancia de eventos foi comparativamente maior que em outras cardiopatias em an\u00e1lises pareadas para o mesmo grau de disfun\u00e7\u00e3o sist\u00f3lica, demonstrando que a CCDC seja de fato uma entidade mais trombog\u00eanica.  Em coorte prospectiva de 1.043 pacientes com DC (com e sem cardiopatia), seguidos por tempo m\u00e9dio de 5,5 anos, encontrou-se incid\u00eancia de 3% de AVC cardioemb\u00f3lico, ou seja 0,56% ao ano. fluttere a FA possam ser mais frequentes na CCDC do que inicialmente se descrevia, com aumento da preval\u00eancia dessas arritmias em est\u00e1gios mais avan\u00e7ados da doen\u00e7a, acompanhando o agravamento da disfun\u00e7\u00e3o ventricular, e constituindo-se em fator trombog\u00eanico adicional.  Estudos recentes sugerem que o podem ser implicados na g\u00eanese do AVC isqu\u00eamico em pacientes com DC. O recente aumento da expectativa de vida dessa popula\u00e7\u00e3o e mudan\u00e7as em seu estilo de vida, com eventual incorpora\u00e7\u00e3o dos fatores de risco cardiovasculares cl\u00e1ssicos para aterosclerose , fazem com que o AVC isqu\u00eamico seja considerado uma das principais causas de morte em coortes hist\u00f3ricas de pacientes com DC,  embora nem sempre o mecanismo cardioemb\u00f3lico seja implicado.  Entretanto, embora as complica\u00e7\u00f5es cardioemb\u00f3licas sejam muito frequentes na CCDC, devendo ser sempre avaliadas como potencial fator causal para o AVC isqu\u00eamico, outros mecanismos, como eventos aterotromb\u00f3ticos ou lacunares, e, mais raramente, etiologias diversas de vasculites e coagulopatias  Eventualmente, mesmo a condi\u00e7\u00e3o de risco cardioemb\u00f3lico pode n\u00e3o significar de fato manifesta\u00e7\u00e3o da CCDC, mas estar associada \u00e0 pr\u00f3pria evolu\u00e7\u00e3o da cardiopatia do idoso, tamb\u00e9m respons\u00e1vel por aumento da incid\u00eancia de FA. Nem sempre \u00e9 poss\u00edvel estabelecer o nexo causal preciso do AVC em idosos e pacientes com m\u00faltiplas comorbidades cl\u00ednicas. Entretanto, o cuidado integral ao paciente deve ser considerado o tema mais relevante, estabelecendo-se tratamento e/ou profilaxia apropriados em cada situa\u00e7\u00e3o.  O AVC \u00e9 definido como um d\u00e9ficit neurol\u00f3gico, em geral focal, de in\u00edcio s\u00fabito, com dura\u00e7\u00e3o de pelo menos 24 horas, de causa presumivelmente vascular, eventualmente seguido de morte. A presen\u00e7a de sinais e sintomas neurol\u00f3gicos focais, que desaparecem em menos de 24 horas, caracteriza o ataque isqu\u00eamico transit\u00f3rio (AIT). O diagn\u00f3stico de AVC \u00e9 baseado nas manifesta\u00e7\u00f5es cl\u00ednicas apresentadas pelo paciente, com a presen\u00e7a de pelo menos uma das seguintes altera\u00e7\u00f5es neurol\u00f3gicas: d\u00e9ficit motor ou sensitivo, afasia ou disfasia, hemianopsia, desvio conjugado do olhar, ou in\u00edcio s\u00fabito de apraxia, ataxia ou d\u00e9ficit de percep\u00e7\u00e3o.  Essas caracterizam-se por sinais de disfun\u00e7\u00e3o cortical superior , hemianopsia hom\u00f4nima  e d\u00e9ficit motor e/ou altera\u00e7\u00e3o sensitiva de pelo menos duas \u00e1reas do corpo . Les\u00f5es corticais extensas geralmente ocasionam todos esses dist\u00farbios neurol\u00f3gicos, caracterizando assim a s\u00edndrome da circula\u00e7\u00e3o anterior total. Les\u00f5es corticais menos extensas podem levar \u00e0 s\u00edndrome da circula\u00e7\u00e3o anterior parcial, com presen\u00e7a de dois desses tr\u00eas conjuntos de manifesta\u00e7\u00f5es neurol\u00f3gicas.  Em pacientes com DC, devido ao predom\u00ednio de AVC isqu\u00eamico de etiologia cardioemb\u00f3lica, sintomas de manifesta\u00e7\u00e3o cortical s\u00e3o frequentemente observados e as s\u00edndromes da circula\u00e7\u00e3o anterior s\u00e3o as mais comuns, relacionadas ao territ\u00f3rio de irriga\u00e7\u00e3o das art\u00e9rias cerebrais m\u00e9dias e anteriores.  J\u00e1 as s\u00edndromes de circula\u00e7\u00e3o posterior s\u00e3o menos frequentes, afetando \u00e1reas de irriga\u00e7\u00e3o da art\u00e9ria cerebral posterior, como cerebelo e tronco cerebral. Essas manifestam-se com pelo menos uma das seguintes altera\u00e7\u00f5es: paralisia de nervos cranianos associada a d\u00e9ficit sensitivo-motor contralateral, d\u00e9ficit sensitivo-motor bilateral, altera\u00e7\u00f5es dos movimentos conjugados dos olhos, disfun\u00e7\u00e3o cerebelar sem d\u00e9ficit de trato longo ipsilateral, hemianopsia isolada ou cegueira cortical.  Os sinais e sintomas de AVC isqu\u00eamico secund\u00e1rio \u00e0 aterosclerose de grandes art\u00e9rias podem ser semelhantes e, portanto, indistingu\u00edveis daqueles presentes nos eventos cardioemb\u00f3licos quanto ao comprometimento motor ou sensitivo, por\u00e9m sem altera\u00e7\u00f5es das fun\u00e7\u00f5es corticais, como linguagem ou fun\u00e7\u00f5es cognitivas. mellitus.Os infartos cerebrais lacunares caracterizam-se pela presen\u00e7a de d\u00e9ficits motores e sensitivos puros, que podem ocorrer de forma isolada ou combinada, ou pela hemiparesia at\u00e1xica.  Alguns pacientes podem demonstrar s\u00edndromes lacunares, geralmente relacionadas \u00e0 presen\u00e7a de outros fatores de risco cardiovascular em concomit\u00e2ncia com a DC, como HAS e diabetes O AVC isqu\u00eamico silencioso pode ocorrer em propor\u00e7\u00e3o significativa de pacientes com CCDC, tendo sido relatado em 18% dos indiv\u00edduos inclu\u00eddos em estudo do tipo caso-controle posteriormente identificados com DC.  Na avalia\u00e7\u00e3o do AVC agudo, a tomografia computadorizada \u00e9 considerada a estrat\u00e9gia mais custo-efetiva, por se tratar de m\u00e9todo de r\u00e1pida execu\u00e7\u00e3o e ampla disponibilidade na maioria dos servi\u00e7os de emerg\u00eancia m\u00e9dica. A RM \u00e9 particularmente \u00fatil para a avalia\u00e7\u00e3o de les\u00f5es da circula\u00e7\u00e3o posterior, de pequenos infartos corticais, infartos lacunares e, sobretudo, para a an\u00e1lise de imagens n\u00e3o usuais quando h\u00e1 d\u00favidas sobre o diagn\u00f3stico de AVC.  A realiza\u00e7\u00e3o de tomografia computadorizada ou resson\u00e2ncia magn\u00e9tica (RM) de enc\u00e9falo \u00e9 recomendada para a confirma\u00e7\u00e3o diagn\u00f3stica de les\u00e3o estrutural decorrente de eventos vasculares, classifica\u00e7\u00e3o do tipo de evento e exclus\u00e3o de diagn\u00f3sticos diferenciais.  Em pacientes com DC e diagn\u00f3stico de AVC, os exames de imagem mostram predom\u00ednio de les\u00f5es cerebrais em topografia de irriga\u00e7\u00e3o das art\u00e9rias cerebrais m\u00e9dias, que s\u00e3o as \u00e1reas geralmente mais acometidas nos indiv\u00edduos com AVC isqu\u00eamico. Pacientes com DC e AVC isqu\u00eamico de etiologia indeterminada apresentam propor\u00e7\u00e3o elevada de acometimento estrutural em territ\u00f3rio de irriga\u00e7\u00e3o dos ramos inferiores da art\u00e9ria cerebral, que podem estar associados a \u00eambolos card\u00edacos, possivelmente devidos a fatores anat\u00f4micos e hemodin\u00e2micos.  Dessa forma, a pesquisa para infec\u00e7\u00e3o peloT. cruzimediante testes sorol\u00f3gicos deve ser considerada nos casos de AVC isqu\u00eamico em pacientes provenientes de \u00e1reas end\u00eamicas para a DC ou filhos de m\u00e3es com a mesma condi\u00e7\u00e3o de risco end\u00eamico, especialmente em casos de eventos cerebrovasculares secund\u00e1rios a tromboembolismo ou de etiologia indeterminada.  Os sinais e sintomas neurol\u00f3gicos decorrentes do AVC podem ser as primeiras manifesta\u00e7\u00f5es cl\u00ednicas de pacientes com DC.  Arritmias card\u00edacas, sobretudofluttere FA, disfun\u00e7\u00e3o sist\u00f3lica do VE, dilata\u00e7\u00e3o atrial esquerda, aneurisma apical e trombose intracavit\u00e1ria s\u00e3o fatores associados \u00e0 ocorr\u00eancia de AVC em pacientes com a CCDC.  Dessa forma, ECG e ECO transtor\u00e1cico de repouso s\u00e3o os exames complementares recomendados para a investiga\u00e7\u00e3o desses fatores de risco. Em pacientes com janela ecocardiogr\u00e1fica impr\u00f3pria para a adequada avalia\u00e7\u00e3o do \u00e1pice ventricular esquerdo, a ecocardiografia com contraste de microbolhas e a RMC podem ser \u00fateis para a identifica\u00e7\u00e3o de aneurismas e trombos murais nessa regi\u00e3o.  Reconhecidamente, a maioria dos pacientes com DC que desenvolvem AVC apresenta primariamente sinais de cardiomiopatia.  Nos casos de AVC isqu\u00eamico emb\u00f3lico de fonte trombog\u00eanica indeterminada ap\u00f3s avalia\u00e7\u00e3o inicial, pode-se considerar a complementa\u00e7\u00e3o diagn\u00f3stica com o monitoramento eletrocardiogr\u00e1fico cont\u00ednuo (Holter) de 24 horas e com a ecocardiografia transesof\u00e1gica. Se o paciente \u00e9 portador de MP ou CDI, pode-se interrogar o registro de eventos do dispositivo, com o mesmo intuito de se identificar arritmias com potencial embolig\u00eanico. mellitus, dislipidemia e tabagismo, em pacientes com DC pode ser elevada, principalmente naqueles que apresentam AVC isqu\u00eamico.  Nesses casos, a investiga\u00e7\u00e3o n\u00e3o invasiva de doen\u00e7a ateromatosa carot\u00eddea e das art\u00e9rias vertebrais por meio de exame ultrassom-Doppler, angiotomografia ou angiorresson\u00e2ncia \u00e9 recomendada, especialmente para os pacientes que demonstram infarto cerebral relacionado \u00e0 circula\u00e7\u00e3o cerebral anterior. Doppler transcraniano tamb\u00e9m pode ser \u00fatil nesses casos.  A concomitante preval\u00eancia de outros fatores de risco para doen\u00e7as cardiovasculares, como HAS, diabetes Diagn\u00f3stico diferencial com outras condi\u00e7\u00f5es cl\u00ednicas raras como vasculites ou trombofilias deve ser buscado nos casos de suspeita cl\u00ednica ou quando o diagn\u00f3stico permanece indeterminado por meio da realiza\u00e7\u00e3o de coagulograma, com avalia\u00e7\u00e3o do tempo de protrombina  e contagem de plaquetas ou pesquisa espec\u00edfica de outras etiologias mais incomuns.  Na As condutas terap\u00eauticas dependem do tempo de in\u00edcio dos sintomas, da vig\u00eancia de comorbidades e da gravidade e extens\u00e3o da \u00e1rea acometida pela isquemia cerebral. Essa \u00faltima pode se apresentar como AIT, infartos cerebrais silenciosos ou AVC isqu\u00eamicos, com sequelas motoras leves ou graves e transforma\u00e7\u00e3o hemorr\u00e1gica, causando morte, comprometimento cr\u00f4nico da cogni\u00e7\u00e3o ou dr\u00e1stica limita\u00e7\u00e3o f\u00edsica.  1) Controle de fun\u00e7\u00f5es vitais e temperatura; 2) Manejo de HAS, mas evitando causar hipotens\u00e3o e consequente agravamento da isquemia cerebral; 3) Controle de hiper ou hipoglicemia; 4) Hidrata\u00e7\u00e3o cuidadosa e controle do n\u00edvel de s\u00f3dio s\u00e9rico; 5) Prote\u00e7\u00e3o de vias a\u00e9reas e de degluti\u00e7\u00e3o, evitando infec\u00e7\u00e3o por broncoaspira\u00e7\u00e3o; 6) Identifica\u00e7\u00e3o precoce de hipoventila\u00e7\u00e3o, evitando reten\u00e7\u00e3o de CO 2 e hipoxemia, por meio da suplementa\u00e7\u00e3o de oxig\u00eanio; 7) Preven\u00e7\u00e3o de trombose venosa profunda, utilizando heparinas ou seus suced\u00e2neos orais ou m\u00e9todos mec\u00e2nicos de compress\u00e3o pneum\u00e1tica quando indicados; e 8) Determina\u00e7\u00e3o da extens\u00e3o da les\u00e3o cerebral por tomografia computadorizada ou RM do cr\u00e2nio para tratamento do edema cerebral e identifica\u00e7\u00e3o do risco ou presen\u00e7a de transforma\u00e7\u00e3o hemorr\u00e1gica, avaliando sintomas sugestivos como cefaleia intensa e persistente, sonol\u00eancia, rebaixamento do n\u00edvel de consci\u00eancia, al\u00e9m de piora dos d\u00e9ficits motores/sensoriais.  A abordagem terap\u00eautica inicial na CCDC \u00e9 semelhante \u00e0 de outras etiologias e objetiva estabilizar, reduzir danos e prevenir complica\u00e7\u00f5es por meio de internamento em terapia intensiva espec\u00edfica para pacientes com AVC, onde as seguintes medidas gerais devem ser observadas:  Nos casos agudos e mais graves, estando em janela terap\u00eautica e n\u00e3o havendo contraindica\u00e7\u00f5es, a tromb\u00f3lise deve ser institu\u00edda , sendo habitualmente utilizado o rt-PA intravenoso. Se a tomografia computadorizada de cr\u00e2nio inicial sugerir hipodensidade precoce, igual ou maior do que um ter\u00e7o do territ\u00f3rio da art\u00e9ria cerebral m\u00e9dia, a tromb\u00f3lise \u00e9 contraindicada, devido ao elevado risco de transforma\u00e7\u00e3o hemorr\u00e1gica. Em casos espec\u00edficos, a trombectomia endovascular permite o tratamento com janela terap\u00eautica maior, mas ainda inferior a 24 horas.  Ajustes frequentes da anticoagula\u00e7\u00e3o s\u00e3o necess\u00e1rios para manuten\u00e7\u00e3o da faixa terap\u00eautica ideal (RNI entre 2 e 3) e o tratamento deve continuar por toda a vida.  Passada a fase aguda do evento isqu\u00eamico, a anticoagula\u00e7\u00e3o oral com varfarina \u00e9 a terap\u00eautica estabelecida para a profilaxia secund\u00e1ria de complica\u00e7\u00f5es tromboemb\u00f3licas originadas do cora\u00e7\u00e3o, seja na vig\u00eancia de arritmias ou evid\u00eancia de trombose intracavit\u00e1ria. flutterou FA, com resultados potencialmente ben\u00e9ficos, eventualmente at\u00e9 superiores em rela\u00e7\u00e3o \u00e0 varfarina.  Mais recentemente, meta-an\u00e1lises comparando os novos anticoagulantes \u00e0 varfarina em indiv\u00edduos com trombose de VE associada \u00e0 CMI ou CMD sugerem que esses f\u00e1rmacos teriam efic\u00e1cia semelhante \u00e0 do antagonista da vitamina K quanto \u00e0 frequ\u00eancia de resolu\u00e7\u00e3o do trombo, preven\u00e7\u00e3o de AVC ou outros eventos tromboemb\u00f3licos e complica\u00e7\u00f5es hemorr\u00e1gicas.  Essa plausibilidade talvez se aplique a pacientes com a CCDC, mas ainda permanece por se demonstrar, e o custo do tratamento de longo prazo pode limitar seu uso em popula\u00e7\u00e3o com reconhecida vulnerabilidade e marginaliza\u00e7\u00e3o social.  Como op\u00e7\u00e3o mais simples, por n\u00e3o serem necess\u00e1rias consultas recorrentes para ajustes da anticoagula\u00e7\u00e3o, os novos anticoagulantes orais de a\u00e7\u00e3o direta ou indireta  podem ser empiricamente usados em pacientes com arritmias atriais cr\u00f4nicas do tipo O tempo para in\u00edcio da anticoagula\u00e7\u00e3o oral cr\u00f4nica ap\u00f3s o AVC isqu\u00eamico \u00e9 controverso, n\u00e3o tendo sido estudado de maneira sistem\u00e1tica. Aceita-se que, para pacientes com AIT, seja razo\u00e1vel o in\u00edcio de anticoagulantes 24 horas ap\u00f3s o in\u00edcio dos sintomas; para pacientes com d\u00e9ficits leves, ap\u00f3s 3 dias; para pacientes com d\u00e9ficits moderados, ap\u00f3s 6 a 8 dias; e para pacientes com d\u00e9ficits graves, ap\u00f3s 12 a 14 dias, desde que, em todas essas situa\u00e7\u00f5es, se exclua transforma\u00e7\u00e3o hemorr\u00e1gica ap\u00f3s avalia\u00e7\u00e3o por exame de neuroimageamento.  independentemente da etiologia da cardiopatia. A princ\u00edpio, todos os pacientes com 2 pontos ou mais  se beneficiariam da profilaxia com anticoagulantes; entretanto, o risco de complica\u00e7\u00f5es hemorr\u00e1gicas deve ser sempre avaliado durante o uso cr\u00f4nico desses medicamentos.  Escores de risco, como CHADS2 ou CHA2DS2-VASc, s\u00e3o empregados para orienta\u00e7\u00e3o de profilaxia prim\u00e1ria e secund\u00e1ria de AVC cardioemb\u00f3lico na vig\u00eancia de FA e de outros fatores de risco cardiovasculares,  Nesse contexto, a avalia\u00e7\u00e3o de riscoversusbenef\u00edcio deve ser definida de modo individual e compartilhada com o paciente e seus familiares.  O escore HAS-BLED  foi validado em diferentes coortes (n\u00e3o de indiv\u00edduos com DC) para definir o risco de complica\u00e7\u00f5es hemorr\u00e1gicas, com alto risco de sangramento identificado por um escore \u2265 3.  Durante o seguimento cl\u00ednico, faz-se necess\u00e1rio rastrear, de forma peri\u00f3dica, as potenciais condi\u00e7\u00f5es de risco para eventos cardioemb\u00f3licos, tais como: disfun\u00e7\u00e3o sist\u00f3lica ventricular e IC, presen\u00e7a de aneurismas ventriculares ou trombos murais e arritmias .  A preven\u00e7\u00e3o de eventos cardioemb\u00f3licos no paciente com CCDC \u00e9 de extrema import\u00e2ncia pelo elevado impacto negativo potencial dessas complica\u00e7\u00f5es na morbimortalidade e qualidade de vida.  O ECG, idealmente deve ser realizado com um tra\u00e7ado longo de pelo menos 30s, permitindo a identifica\u00e7\u00e3o de arritmias atriais.  O ECO permite a visibiliza\u00e7\u00e3o das cavidades card\u00edacas, identificando graus variados de disfun\u00e7\u00e3o sist\u00f3lica ventricular esquerda, \u00e1reas regionais de discinesia, aneurismas , contraste espont\u00e2neo e trombos murais, caracterizando-os como m\u00f3veis ou s\u00e9sseis, com elevado potencial de emboliza\u00e7\u00e3o, ou organizados.  Recomenda-se que todos os pacientes com DC sejam submetidos a ECG e ECO com periodicidade recorrente em seu seguimento ambulatorial e na avalia\u00e7\u00e3o cl\u00ednica de um evento cardioemb\u00f3lico agudo ou pr\u00e9vio. flutterou FA, tamb\u00e9m deve ser feita de forma seriada no seguimento cl\u00ednico de pacientes com DC por meio da realiza\u00e7\u00e3o de ECG anual, estrat\u00e9gia que tamb\u00e9m permite a identifica\u00e7\u00e3o da progress\u00e3o da forma cr\u00f4nica indeterminada para a de cardiopatia.  A busca ativa de arritmias com alto potencial embolig\u00eanico, como Al\u00e9m disso, a anamnese e o exame f\u00edsico s\u00e3o primordiais, avaliando sintomas como palpita\u00e7\u00e3o, taquicardia, dor precordial, tontura, lipotimia, mal-estar, fraqueza, dispneia, piora da classe funcional, dentre outros, que levam \u00e0 suspeita cl\u00ednica de uma arritmia. No exame f\u00edsico, o mais not\u00f3rio \u00e9 a identifica\u00e7\u00e3o de pulso ou ritmo card\u00edaco irregular \u00e0 ausculta. Como os eventos arr\u00edtmicos podem ocorrer de forma parox\u00edstica, a arritmia pode n\u00e3o ser identificada no momento da avalia\u00e7\u00e3o cl\u00ednica. Nos casos de suspei\u00e7\u00e3o cl\u00ednica persistente, faz-se necess\u00e1rio realizar o monitoramento eletrocardiogr\u00e1fico cont\u00ednuo utilizando o Holter de 24 horas.  Recomenda-se interrogar os dispositivos intracard\u00edacos, de forma sistem\u00e1tica, em cada avalia\u00e7\u00e3o prevista, buscando o registro de epis\u00f3dios silenciosos de FA. Uma adequada interface de atua\u00e7\u00e3o entre as equipes de seguimento cl\u00ednico (cardiologia cl\u00ednica e arritmologia) faz-se necess\u00e1ria para que interven\u00e7\u00f5es apropriadas sejam recomendadas, como o in\u00edcio de anticoagula\u00e7\u00e3o para preven\u00e7\u00e3o prim\u00e1ria.  Em pacientes com dispositivos implantados como MP, CDI ou ressincronizador, eventualmente a irregularidade do ritmo deixa de ser percebida ao exame f\u00edsico, sendo necess\u00e1ria a avalia\u00e7\u00e3o do ECG ou, mais apropriadamente, recorrer-se ao pr\u00f3prio registro de eventos, presente nesses aparelhos.  \u00c9 plaus\u00edvel admitir que as mesmas recomenda\u00e7\u00f5es seriam aplic\u00e1veis empiricamente, por extrapola\u00e7\u00e3o, a pacientes com CCDC.  De acordo com diretrizes recentes de IC e arritmologia, considerando cardiopatias de diversas etiologias, a constata\u00e7\u00e3o de trombose mural, fen\u00f4menos tromboemb\u00f3licos pr\u00e9vios e FA com CHA2DS2-VASc \u2265 2 j\u00e1 indicaria a anticoagula\u00e7\u00e3o como estrat\u00e9gia de profilaxia para eventos cardioemb\u00f3licos.  Por meio da an\u00e1lise de risco-benef\u00edcio, os investigadores proponentes desse escoreIPEC-FIOCRUZtamb\u00e9m sugeriram que, para indiv\u00edduos com a m\u00e1xima pontua\u00e7\u00e3o (4-5 pontos), a incid\u00eancia de AVC de 4,4% ao ano superaria a taxa estimada de 2,0% ao ano de sangramento grave associada ao uso de varfarina.  Como assinalado acima, reconhecendo o maior potencial embolig\u00eanico da CCDC, desenvolveu-se escore de risco espec\u00edfico de AVC cardioemb\u00f3lico para essa etiologia, ampliando as recomenda\u00e7\u00f5es classicamente estabelecidas para outras cardiopatias.  torna-se hoje imperativo que ele seja revisitado, para ser aplicado especificamente a pacientes com CCDC , com eventual corre\u00e7\u00e3o dos pontos atribu\u00edveis \u00e0s vari\u00e1veis , defini\u00e7\u00e3o mais adequada de faixas et\u00e1rias e, sobretudo, para ser respaldado por valida\u00e7\u00e3o externa.  Embora diretrizes anteriores tenham referendado o uso desse escore,  Com implementa\u00e7\u00e3o desses princ\u00edpios metodol\u00f3gicos, o escore poder\u00e1 ser revigorado e, coerente com seu ineg\u00e1vel e hist\u00f3rico papel cient\u00edfico no contexto, recuperar mais abrang\u00eancia e aplicabilidade do que atualmente se verifica.  Ademais, as emp\u00edricas condutas terap\u00eauticas sugeridas quando de sua formula\u00e7\u00e3o  idealmente dever\u00e3o ser lastreadas em estudos aleatorizados de comprova\u00e7\u00e3o de efic\u00e1cia.  Essa quest\u00e3o da validade externa de escores de risco assume especial relev\u00e2ncia para serem recomendados em aplica\u00e7\u00f5es pr\u00e1ticas, no contexto geral da CCDC, \u00e0 luz dos conceitos atuais. mellitus, dislipidemia, cessa\u00e7\u00e3o do tabagismo, perda de peso e atividade f\u00edsica regular  tamb\u00e9m s\u00e3o importantes para redu\u00e7\u00e3o de eventos cardioemb\u00f3licos nessa popula\u00e7\u00e3o. As recomenda\u00e7\u00f5es de tratamento e preven\u00e7\u00e3o de AVC cardioemb\u00f3lico na CCDC est\u00e3o resumidas na Considerando que recentemente se observa n\u00edtida tend\u00eancia \u00e0 maior sobrevida de pacientes com DC e, consequentemente, fatores de risco cardiovascular ocorram de forma mais frequente nessa popula\u00e7\u00e3o, amplia-se a preval\u00eancia de FA , com consequente risco adicional de AVC cardioemb\u00f3lico. Dessa forma, recomenda\u00e7\u00f5es de mudan\u00e7as no estilo de vida com controle da HAS, diabetesT. cruzi-HIV  \u00e9 uma realidade em \u00e1reas end\u00eamicas e n\u00e3o end\u00eamicas que albergam imigrantes infectados pelo parasito.  Com estimativa de 37 milh\u00f5es de pessoas vivendo com HIV/AIDS no mundo todo, o risco da coinfec\u00e7\u00e3oT. cruzi-HIV foi registrada inicialmente em 1990  como RDC, tendo sido citada em 1988 no Brasil pela identifica\u00e7\u00e3o do parasito no l\u00edquor de paciente com AIDS.  Descrita principalmente no Brasil e na Argentina, mas tamb\u00e9m em outros pa\u00edses , a RDC caracteriza-se por elevadas morbimortalidade e transmissibilidade materno-fetal,  interferindo na evolu\u00e7\u00e3o tanto da DC como da infec\u00e7\u00e3o por HIV. Em geral, acomete pacientes infectados por HIV com grave defici\u00eancia imunol\u00f3gica (c\u00e9lulas CD4 + < 200/mm 3 ) e carga viral detect\u00e1vel por falta de resposta \u00e0 terap\u00eautica antirretroviral efetiva. Na infec\u00e7\u00e3o ativa por HIV, a acentuada redu\u00e7\u00e3o de c\u00e9lulas CD4 + expressa a defici\u00eancia de resposta TH1,  respons\u00e1vel pela ativa\u00e7\u00e3o de CD4 + e de macr\u00f3fagos capazes de secretar IFN-\u03b3 e destruir os parasitos, assim ocorrendo aumento de parasitemia e parasitismo tecidual.  A coinfec\u00e7\u00e3o Na forma cong\u00eanita de coinfec\u00e7\u00e3oT. cruzi-HIV,  ocorrem abortos, baixo peso ao nascer, sepse e meningoencefalite. Mais raramente, formas oligossintom\u00e1ticas manifestam-se como quadros febris, eritema nodoso, mielite e pu\u00e9rpera assintom\u00e1tica, mas com natimorto por DC cong\u00eanita.  A RDC apresenta-se como meningoencefalite em cerca de 2/3 dos casos, seguindo-se miocardite, meningoencefalite mais miocardite, pericardite, duodenite, gastrite, eritema nodoso e colpite. T. cruzideve ser diferenciada de toxoplasmose e de doen\u00e7as infecciosas, tumorais e degenerativas. A miocardite aguda na RDC deve ser diferenciada da CCDC descompensada. N\u00edveis de CD4+ \u2264 200/mm 3 s\u00e3o observados em cerca de 2/3 dos casos, sendo menores na RDC do que em pacientes sem reativa\u00e7\u00e3o. A mortalidade na RDC foi de 63 pacientes em 120 casos .  RDC \u00e9 descrita em 10%-15% dos casos de coinfec\u00e7\u00e3o em estudos retrospectivos e em 10% em estudos prospectivos de pacientes em acompanhamento pr\u00e9vio.  A meningoencefalite causada por e 4,2% na Argentina,  sendo mais elevada em usu\u00e1rios de drogas il\u00edcitas.  Estimam-se cerca de 4.570-15.360 casos de coinfec\u00e7\u00e3o com base no n\u00famero de pacientes com infec\u00e7\u00e3o porT. cruzie HIV no Brasil e Argentina, sugerindo-se um n\u00famero muito subestimado na literatura em geral.  A preval\u00eancia da coinfec\u00e7\u00e3o tem sido estimada em 1,5%-5,0% no Brasil  AIDS foi a causa b\u00e1sica de morte em 2/3 dos casos e DC em 17,5%. A FIDC predomina em cerca de metade dos casos de coinfec\u00e7\u00e3o, a forma card\u00edaca ocorre em 37%, seguindo-se as formas digestiva e cardiodigestiva em 5% e 6%, respectivamente.  T\u00eam-se associado n\u00edveis reduzidos de CD4 + (no diagn\u00f3stico da coinfec\u00e7\u00e3o) ao progn\u00f3stico da reativa\u00e7\u00e3o e mortalidade por reativa\u00e7\u00e3o. A presen\u00e7a de parasitemia tamb\u00e9m tem sido associada \u00e0 resposta TH2, sugerindo desequil\u00edbrio a favor do parasito.  Entre as causas de mortalidade na coinfec\u00e7\u00e3o,  Dessa forma, recomenda-se que casos de infec\u00e7\u00e3o por HIV ou de DC sejam investigados ativamente do ponto de vista cl\u00ednico e epidemiol\u00f3gico com indica\u00e7\u00e3o de triagem sorol\u00f3gica, visando ao diagn\u00f3stico precoce e controle de ambas as infec\u00e7\u00f5es.  Na DC, em caso de provas discordantes , uma prova confirmat\u00f3ria (imunoblot/imunocromatogr\u00e1fica) ou imunoenzim\u00e1tica com ant\u00edgeno recombinante ou imunofluoresc\u00eancia \u00e9 indicada. Para a infec\u00e7\u00e3o por HIV, ELISA ou CLIA positiva para ant\u00edgenos HIV1 e HIV2 deve ser confirmada por prova imunoblot/imunocromatogr\u00e1fica para ant\u00edgenos HIV1 e HIV2.  Provas parasitol\u00f3gicas deT. cruziindiretas e PCR s\u00e3o espec\u00edficas, mas com sensibilidades baixas para diagn\u00f3stico (cerca de 50% na forma cr\u00f4nica), embora mais elevadas na coinfec\u00e7\u00e3o.  O diagn\u00f3stico da coinfec\u00e7\u00e3o \u00e9 realizado mediante positividade em duas provas sorol\u00f3gicas para ambas as infec\u00e7\u00f5es e/ou provas parasitol\u00f3gicas para o diagn\u00f3stico da DC.  M\u00e9todos de concentra\u00e7\u00e3o  s\u00e3o mais sens\u00edveis do que o simples exame no esfrega\u00e7o do sangue perif\u00e9rico ou a pesquisa do parasito a fresco em sangue perif\u00e9rico. A bi\u00f3psia pode ser indicada quando outros m\u00e9todos n\u00e3o invasivos falharem.  Em pacientes com RDC, as provas sorol\u00f3gicas para diagn\u00f3stico de DC podem ser negativas,  n\u00e3o invalidando o prosseguimento da investiga\u00e7\u00e3o por m\u00e9todos de microscopia direta. A PCR qualitativa e provas parasitol\u00f3gicas indiretas de enriquecimento, como hemocultura e xenodiagn\u00f3stico, t\u00eam baixo valor preditivo positivo para o diagn\u00f3stico da RDC, uma vez que podem ser positivas em pacientes cr\u00f4nicos sem reativa\u00e7\u00e3o.  Por outro lado, provas semiquantitativas, como contagem de ninfas no xenodiagn\u00f3stico  e de qPCR, costumam ser \u00fateis no monitoramento da RDC.  O diagn\u00f3stico da RDC deve ser efetivado por m\u00e9todos padr\u00e3o-ouro de pesquisa direta do parasito por microscopia no sangue e fluidos biol\u00f3gicos  e/ou em tecidos corados.  na dose de 5mg/kg/dia por 60 dias. O derivado nitroimidaz\u00f3lico (nifurtimox) \u00e9 indicado como segunda escolha quando o primeiro n\u00e3o estiver dispon\u00edvel ou houver evento adverso que impe\u00e7a a sua continuidade.  Nas primeiras semanas p\u00f3s-tratamento, a pesquisa direta do parasito por creme leucocit\u00e1rio ajuda a monitorar a falha terap\u00eautica em casos de resultado positivo; resultados negativos n\u00e3o indicam sucesso terap\u00eautico em curto tempo. O per\u00edodo de acompanhamento para o controle de cura deve ser realizado com PCR qualitativa ou exames parasitol\u00f3gicos indiretos (hemocultura) a partir de 3, 6, 9, 12, 24 meses e provas sorol\u00f3gicas aos 6, 12, 24 meses do in\u00edcio da terap\u00eautica.  O tratamento antiparasit\u00e1rio com benznidazol \u00e9 obrigat\u00f3rio em pacientes com RDC,  Em pacientes coinfectados sem RDC, tem-se mostrado melhor resposta antiparasit\u00e1ria quando ocorre parasitemia patente ou em n\u00edveis mais elevados inicialmente.  Recomenda-se o seguimento em unidades de refer\u00eancia para controle tanto da carga viral, com controle da terap\u00eautica antirretroviral efetiva para restaurar a resposta TH1, como da DC, com monitoramento da parasitemia, para evitar a RDC ou permitir seu diagn\u00f3stico e tratamento precoces . + < 200 c\u00e9lulas/mm 3 , em similaridade \u00e0 preven\u00e7\u00e3o de outras infec\u00e7\u00f5es oportun\u00edsticas, \u00e9 controversa, n\u00e3o havendo estudos prospectivos ou s\u00e9ries retrospectivas confi\u00e1veis a respeito na DC.  A indica\u00e7\u00e3o de profilaxia secund\u00e1ria com benznidazol (5mg/kg/dia 3x/semana) em pacientes com CD4  Ap\u00f3s o surgimento da AIDS na d\u00e9cada de 1980, diversas medidas e legisla\u00e7\u00f5es foram desenvolvidas e adotadas para aumentar o controle dos bancos e doadores de sangue, particularmente com a cria\u00e7\u00e3o de hemocentros e a centraliza\u00e7\u00e3o das atividades de controle e vigil\u00e2ncia sob a responsabilidade das Secretarias Estaduais de Sa\u00fade.  No Brasil, o rastreamento sorol\u00f3gico para DC \u00e9 obrigat\u00f3rio para todos os doadores de sangue desde 1969.  Na triagem sorol\u00f3gica s\u00e3o utilizados testes sorol\u00f3gicos automatizados de alta sensibilidade e especificidade para detec\u00e7\u00e3o de anticorpos da classe IgG anti-T. cruzi, sendo os mais utilizados os testes de ELISA e, mais recentemente, a CLIA.  Na triagem sorol\u00f3gica dos bancos de sangue, apenas um teste sorol\u00f3gico se faz necess\u00e1rio, podendo ser repetido se a amostra apresentar resultado positivo.  Caso positivo, o sangue doado n\u00e3o poder\u00e1 ser utilizado e o doador dever\u00e1 ser contactado e encaminhado para esclarecimento diagn\u00f3stico em centros de refer\u00eancia em DC.  A portaria do Minist\u00e9rio da Sa\u00fade n\u00ba 158 de 2016 estabelece como inapto para doa\u00e7\u00e3o de sangue indiv\u00edduo com hist\u00f3rico de contato domiciliar com triatom\u00edneos em \u00e1reas end\u00eamicas e quem apresenta diagn\u00f3stico cl\u00ednico ou laboratorial para DC.  No entanto, essas taxas podem sofrer varia\u00e7\u00f5es de acordo com as \u00e1reas onde s\u00e3o realizadas as doa\u00e7\u00f5es e a idade dos doadores, sendo habitualmente maiores em regi\u00f5es historicamente end\u00eamicas e em faixas et\u00e1rias mais altas.  Com o controle da transmiss\u00e3o vetorial e transfusional, a preval\u00eancia m\u00e9dia da DC entre doadores de sangue vem se reduzindo rapidamente. Proje\u00e7\u00f5es mais recentes estimam a preval\u00eancia para DC no Brasil em 0,18% dos potenciais doadores de sangue.  Estudo desenvolvido em Uberaba com grande n\u00famero de doadores por per\u00edodo de 15 anos demonstrou queda da taxa de preval\u00eancia de 0,03% ao ano, observando-se, no \u00faltimo ano estudado, apenas 0,08% dos doadores ineleg\u00edveis por soropositividade.  Pesquisas recentes desenvolvidas em doadores de sangue na regi\u00e3o Nordeste apuraram preval\u00eancias de 0,17% a 0,57% no estado do Cear\u00e1 e de 0,18% a 2,4% no estado do Piau\u00ed.  Todos os casos positivos devem ser encaminhados para centros de refer\u00eancia em DC para repeti\u00e7\u00e3o e realiza\u00e7\u00e3o de novos testes para confirma\u00e7\u00e3o ou descarte do diagn\u00f3stico da doen\u00e7a.  Com a queda da preval\u00eancia entre os doadores mais jovens, tem-se observado o aumento de casos inconclusivos ou indeterminados, sendo a maior parte resultante de testes falsos-positivos.  Recentemente, a OMS publicou recomenda\u00e7\u00f5es sobre a pr\u00e1tica de atividade f\u00edsica em indiv\u00edduos saud\u00e1veis e com condi\u00e7\u00f5es espec\u00edficas de sa\u00fade e doen\u00e7a. Em geral, recomenda-se a realiza\u00e7\u00e3o de 150 minutos de atividades f\u00edsicas de moderada intensidade e/ou 75 minutos de atividades f\u00edsicas vigorosas por semana para obten\u00e7\u00e3o de benef\u00edcios em termos de sa\u00fade cardiovascular.  A pr\u00e1tica de atividade f\u00edsica \u00e9 uma importante estrat\u00e9gia de interven\u00e7\u00e3o para a preven\u00e7\u00e3o e tratamento de in\u00fameras doen\u00e7as cr\u00f4nicas, principalmente aquelas relacionadas ao sistema cardiovascular.  Al\u00e9m disso, devem ser realizados exerc\u00edcios de fortalecimento para os principais grupamentos musculares pelo menos duas vezes por semana, com intensidade moderada, avaliada por meio de escala de esfor\u00e7o percebido. Exerc\u00edcios de flexibilidade e de equil\u00edbrio devem tamb\u00e9m ser realizados, principalmente em indiv\u00edduos idosos, com intuito de manuten\u00e7\u00e3o da amplitude de movimento e autonomia para a realiza\u00e7\u00e3o das atividades da vida di\u00e1ria.  Realizar pequenos volumes de atividade f\u00edsica traz mais benef\u00edcios \u00e0 sa\u00fade em compara\u00e7\u00e3o com ser inativo, sendo que maiores volumes de atividade f\u00edsica podem trazer melhores benef\u00edcios por importante rela\u00e7\u00e3o dose-resposta.  Benef\u00edcios de sa\u00fade podem ser obtidos mesmo para n\u00edveis de atividade f\u00edsica inferiores a essa recomenda\u00e7\u00e3o, devendo a pr\u00e1tica de atividade f\u00edsica ser iniciada de forma gradual em indiv\u00edduos previamente inativos.  Tais estudos, por\u00e9m, inclu\u00edram apenas pacientes com a forma card\u00edaca da doen\u00e7a, n\u00e3o havendo trabalhos adequados na literatura que avaliem a influ\u00eancia dessa estrat\u00e9gia na FIDC.  Entretanto, os benef\u00edcios da atividade f\u00edsica na sa\u00fade f\u00edsica e mental em indiv\u00edduos com DC ainda n\u00e3o foram plenamente explorados. Alguns trabalhos apresentam resultados promissores para a melhora da capacidade funcional e da qualidade de vida.  Assim, em linhas gerais, as recomenda\u00e7\u00f5es de exerc\u00edcios para pessoas com FIDC devem ser id\u00eanticas \u00e0s da popula\u00e7\u00e3o em geral, objetivando melhora dos par\u00e2metros de aptid\u00e3o f\u00edsica, controle de comorbidades e melhora da qualidade de vida. Interven\u00e7\u00f5es no estilo de vida que aumentem gradualmente os n\u00edveis de atividade f\u00edsica devem ser estimulados, levando sempre em considera\u00e7\u00e3o a capacidade f\u00edsica e funcional de cada indiv\u00edduo para a realiza\u00e7\u00e3o das atividades propostas. Alguns trabalhos t\u00eam demonstrado que a pr\u00e1tica de atividade f\u00edsica est\u00e1 associada \u00e0 melhoria do tr\u00e2nsito intestinal, entretanto seus efeitos em indiv\u00edduos com a forma digestiva da DC ainda n\u00e3o foram investigados.  Em trabalho pioneiro sobre o assunto, ECR investigou os efeitos de programa de reabilita\u00e7\u00e3o cardiovascular em pacientes com CCDC acompanhados por 3 meses, tendo o treinamento f\u00edsico promovido melhora da capacidade funcional e da qualidade de vida.  Os efeitos da atividade f\u00edsica na CCDC foram objeto de trabalhos recentes, principalmente por meio de programas de reabilita\u00e7\u00e3o cardiovascular.  Posteriormente, estudo de interven\u00e7\u00e3o relatou que um programa de reabilita\u00e7\u00e3o cardiovascular em pacientes com IC por DC foi associado \u00e0 melhora da fun\u00e7\u00e3o card\u00edaca avaliada pela FEVE, da for\u00e7a da musculatura respirat\u00f3ria e da qualidade de vida ap\u00f3s 8 meses de acompanhamento.  Dessa forma, o exerc\u00edcio f\u00edsico tem se mostrado como estrat\u00e9gia de interven\u00e7\u00e3o bastante eficaz na melhora de diversos par\u00e2metros cl\u00ednicos e da qualidade de vida na CCDC , enquanto a taxa de transmiss\u00e3o vertical em pa\u00edses end\u00eamicos varia de 0% a 18,2%.  A taxa de transmiss\u00e3o vertical porT. cruziapresenta diferen\u00e7as regionais, variando em torno de 1,0% no Brasil e de 4% a 12% em outros pa\u00edses do Cone Sul, e parece depender de fatores ligados ao parasito e ao hospedeiro.  A preval\u00eancia de infec\u00e7\u00e3o por No Brasil, a frequ\u00eancia da transmiss\u00e3o cong\u00eanita varia de 0% a 5,2%; entretanto, h\u00e1 grande heterogeneidade dependendo da regi\u00e3o avaliada. A taxa mais alta de transmiss\u00e3o cong\u00eanita regional foi observada na regi\u00e3o Sul-Sudeste , seguida pelas regi\u00f5es Nordeste  e Centro-Oeste .  A transmiss\u00e3o cong\u00eanita da DC pode ocorrer durante qualquer fase da doen\u00e7a materna; entretanto, a maior taxa de transmiss\u00e3o ocorre em gestantes com a fase aguda da doen\u00e7a, aproximadamente 30%, enquanto a taxa geral \u00e9 de 4,7%.  As evid\u00eancias de risco geral aumentado de aborto ou prematuridade em gestantes soropositivas s\u00e3o inconclusivas. No entanto, estudos sugerem que a infec\u00e7\u00e3o cr\u00f4nica materna n\u00e3o influencia o curso cl\u00ednico da gravidez ou a sa\u00fade dos rec\u00e9m-nascidos, desde que n\u00e3o haja transmiss\u00e3o vertical. Por\u00e9m, a infec\u00e7\u00e3o do feto aumenta a possibilidade de parto prematuro, baixo peso ao nascimento e natimortalidade. T. cruzi\u00e9 processo complexo, resultante da intera\u00e7\u00e3o de m\u00faltiplos fatores relacionados ao parasita, \u00e0 placenta e \u00e0 resposta imune do feto e da m\u00e3e.  A carga parasit\u00e1ria de mulheres infectadas durante a gravidez \u00e9 fator fundamental para a transmiss\u00e3o cong\u00eanita.  A parasitemia pode reaparecer com a RDC geralmente associada \u00e0 imunossupress\u00e3o fisiol\u00f3gica transiente que ocorre durante a gravidez.  Adicionalmente, o papel da idade da m\u00e3e e do n\u00famero de gesta\u00e7\u00f5es no aumento do risco de transmiss\u00e3o ainda precisa ser melhor investigado. Por outro lado, evid\u00eancias sugerem que a ativa\u00e7\u00e3o da resposta imunol\u00f3gica inata em gestantes pode contribuir para a redu\u00e7\u00e3o da ocorr\u00eancia e gravidade da infec\u00e7\u00e3o cong\u00eanita, mediante a regula\u00e7\u00e3o de mediadores pr\u00f3 e anti-inflamat\u00f3rios.  A transmiss\u00e3o cong\u00eanita doT. cruzicomo grupo de alto risco obst\u00e9trico.  O impacto da DC no transcurso da gravidez \u00e9 controverso. Alguns trabalhos apontam no sentido da benignidade dessa associa\u00e7\u00e3o, enquanto outros relatam elevada incid\u00eancia de complica\u00e7\u00f5es na gesta\u00e7\u00e3o e de mortalidade perinatal, bem como hipotrofia neonatal, considerando as gestantes infectadas pelo A cardiopatia, desde que assistida e sem maior gravidade, n\u00e3o contraindica a gravidez. Pacientes com IC e/ou arritmias graves devem ser desaconselhadas a engravidar, mas, caso engravidem, requerem acompanhamento e cuidados especiais.  Gestantes com CCDC t\u00eam progn\u00f3stico estreitamente relacionado \u00e0 gravidade da disfun\u00e7\u00e3o ventricular e classe funcional no in\u00edcio da gravidez. Pacientes que iniciam a gesta\u00e7\u00e3o em classe funcional I e II geralmente chegam ao parto sem intercorr\u00eancias; j\u00e1 aquelas em classe funcional III ou IV t\u00eam probabilidade de 25% a 50% de morte.  O tratamento etiol\u00f3gico n\u00e3o deve ser institu\u00eddo em gestantes nem em mulheres em idade f\u00e9rtil que n\u00e3o estejam em uso de contraceptivos. No entanto, j\u00e1 h\u00e1 evid\u00eancias de que o tratamento etiol\u00f3gico reduz o risco de transmiss\u00e3o cong\u00eanita numa gravidez subsequente.  Al\u00e9m disso, no caso exclusivo de DC aguda, o tratamento etiol\u00f3gico pode ser institu\u00eddo na gestante, levando-se em considera\u00e7\u00e3o a morbimortalidade materna, risco mais elevado de transmiss\u00e3o cong\u00eanita e de impacto na sa\u00fade do rec\u00e9m-nato. As gestantes com DC aguda grave  devem ser tratadas independentemente da idade gestacional pela alta morbimortalidade materna, al\u00e9m do alto risco de transmiss\u00e3o cong\u00eanita da DC (22% a 71%) e do potencial impacto na sa\u00fade dos neonatos. Gestantes com DC aguda n\u00e3o grave devem ser tratadas idealmente a partir do segundo trimestre de gesta\u00e7\u00e3o, devido ao risco potencial de malforma\u00e7\u00e3o cong\u00eanita relacionado ao benznidazol.  O uso de medicamentos com a\u00e7\u00e3o sobre o sistema cardiovascular pela gestante com DC deve seguir indica\u00e7\u00e3o m\u00e9dica seletiva e individualizada, devido ao risco potencial de efeitos colaterais sobre o feto. As m\u00e3es infectadas dever\u00e3o ser tratadas ap\u00f3s o parto e o per\u00edodo de lacta\u00e7\u00e3o para evitar a interrup\u00e7\u00e3o da lacta\u00e7\u00e3o como resultado de poss\u00edveis rea\u00e7\u00f5es adversas. A DC deve ser investigada sistematicamente em parentes e outras crian\u00e7as nascidas de m\u00e3es infectadas (diagn\u00f3stico sorol\u00f3gico) e os casos positivos devem ser avaliados clinicamente e tratados de acordo com os princ\u00edpios j\u00e1 expostos. T. cruzi, superando aquelas por transfus\u00e3o de sangue e transplante de \u00f3rg\u00e3os. Apesar da subnotifica\u00e7\u00e3o e subestima\u00e7\u00e3o evidentes globalmente, mais de dois milh\u00f5es de mulheres em idade f\u00e9rtil j\u00e1 est\u00e3o infectadas comT. cruzie 1%-10% dos beb\u00eas de m\u00e3es infectadas nascem com DC. Com base nas recentes demonstra\u00e7\u00f5es de que a transmiss\u00e3o cong\u00eanita pode ser evitada, a OMS mudou seu objetivo em 2018, do controle para a elimina\u00e7\u00e3o da DC cong\u00eanita.  Em \u00e1reas livres de vetores dentro e fora da Am\u00e9rica Latina, a transmiss\u00e3o vertical cong\u00eanita ou perinatal \u00e9 atualmente a principal forma de infec\u00e7\u00e3o pelo Em trabalhos realizados no Brasil, Argentina, Chile e Paraguai foi demonstrado que 60% a 90% dos rec\u00e9m-natos com infec\u00e7\u00e3o cong\u00eanita s\u00e3o assintom\u00e1ticos. Nos sintom\u00e1ticos, as altera\u00e7\u00f5es cl\u00ednicas mais frequentes foram prematuridade, baixo peso, febre e hepatoesplenomegalia.  A gravidade da DC cong\u00eanita varia amplamente, desde casos assintom\u00e1ticos at\u00e9 infec\u00e7\u00e3o fatal, que est\u00e1 relacionada ao n\u00edvel de parasitemia no nascimento.  O diagn\u00f3stico de infec\u00e7\u00e3o cong\u00eanita deve ser pesquisado em todas as crian\u00e7as nascidas de m\u00e3es soropositivas, n\u00e3o apenas no primeiro m\u00eas de vida, mas tamb\u00e9m aos 6 e 12 meses de idade. O acompanhamento por 1 ano \u00e9 essencial, pois propor\u00e7\u00e3o significativa de casos \u00e9 inicialmente negativa e a doen\u00e7a s\u00f3 \u00e9 detectada em um est\u00e1gio posterior. T. cruzi,mediante a utiliza\u00e7\u00e3o de m\u00e9todos de concentra\u00e7\u00e3o por centrifuga\u00e7\u00e3o, como a t\u00e9cnica do microhemat\u00f3crito.  Quando positivos, esses testes oferecem um diagn\u00f3stico indiscut\u00edvel e definitivo da infec\u00e7\u00e3o; contudo, nas situa\u00e7\u00f5es em que a carga parasit\u00e1ria \u00e9 baixa, principalmente quando a transmiss\u00e3o ocorre no \u00faltimo trimestre da gesta\u00e7\u00e3o ou durante o parto, os exames podem gerar resultados negativos falsos. Dessa forma, testes mais sens\u00edveis e automatizados s\u00e3o necess\u00e1rios para a detec\u00e7\u00e3o precoce da infec\u00e7\u00e3o cong\u00eanita. O resultado positivo determina o in\u00edcio imediato do tratamento etiol\u00f3gico.  A DC cong\u00eanita \u00e9 considerada aguda e, portanto, de notifica\u00e7\u00e3o obrigat\u00f3ria.  Os m\u00e9todos de diagn\u00f3stico mais recomendados no primeiro m\u00eas ap\u00f3s o nascimento baseiam-se na pesquisa direta do A sorologia negativa ap\u00f3s o per\u00edodo acima referido permite a exclus\u00e3o do diagn\u00f3stico de infec\u00e7\u00e3o peloT. cruzi.  Em caso de exame parasitol\u00f3gico negativo, deve-se completar a investiga\u00e7\u00e3o diagn\u00f3stica com testes sorol\u00f3gicos (com duas t\u00e9cnicas distintas), ap\u00f3s o 7\u00ba m\u00eas de vida. Estudo sorol\u00f3gico antes do 6\u00ba m\u00eas n\u00e3o \u00e9 \u00fatil, devido \u00e0 passagem passiva de anticorpos maternos para a crian\u00e7a. Ap\u00f3s o 10\u00ba m\u00eas, tais anticorpos desaparecem e o diagn\u00f3stico de DC cong\u00eanita \u00e9 mais preciso; entretanto, o atraso no diagn\u00f3stico diminui a efic\u00e1cia do tratamento e aumenta o risco de perda de acompanhamento do beb\u00ea.  Os m\u00e9todos moleculares representam alternativa promissora e t\u00eam sido amplamente utilizados para a detec\u00e7\u00e3o precoce das infec\u00e7\u00f5es cong\u00eanitas, especialmente na Europa. Contudo, s\u00e3o m\u00e9todos dispendiosos, exigem consider\u00e1vel treinamento t\u00e9cnico e necessitam de cuidadosa padroniza\u00e7\u00e3o, o que dificulta a sua implementa\u00e7\u00e3o na rotina laboratorial. Como consequ\u00eancia, os m\u00e9todos moleculares requerem valida\u00e7\u00f5es cl\u00ednicas mais amplas, antes de serem considerados padr\u00e3o-ouro para diagnosticar infec\u00e7\u00f5es cong\u00eanitas. T. cruzino rec\u00e9m-nato \u00e9 altamente eficaz e pode ser realizado com benznidazol (primeira op\u00e7\u00e3o no Brasil) ou nifurtimox, por 30 a 60 dias, com menos eventos adversos do que aqueles descritos em adultos, sendo a taxa de cura superior a 90%. As doses preconizadas para crian\u00e7as s\u00e3o benznidazol 10mg/kg/dia em 3 ou 2 tomadas e nifurtimox 15 mg/kg/dia em 3 tomadas, sendo que o benznidazol tem apresenta\u00e7\u00e3o de comprimidos de 12,5mg, que podem ser dilu\u00eddos em \u00e1gua. O benznidazol \u00e9 disponibilizado pelas secretarias estaduais de sa\u00fade e o nifurtimox deve ser solicitado \u00e0 OPAS, via grupo t\u00e9cnico de DC da Secretaria de Vigil\u00e2ncia Sanit\u00e1ria do Minist\u00e9rio da Sa\u00fade.  O tratamento da infec\u00e7\u00e3o pelo Ensaio cl\u00ednico recentemente publicado utilizou nifurtimox para tratar crian\u00e7as (0 a 17 anos de idade) na Argentina, Col\u00f4mbia e Bol\u00edvia e comparou o tratamento de 30 dias contra 60 dias de dura\u00e7\u00e3o. Ao final de 12 meses de seguimento, ambos os regimes demonstraram significativa soroconvers\u00e3o ou sororredu\u00e7\u00e3o comparativamente a controles hist\u00f3ricos, sendo o regime de 60 dias de dura\u00e7\u00e3o superior ao de 30 dias de dura\u00e7\u00e3o no grupo de 2-17 anos de idade. O nifurtimox foi bem tolerado, com efeitos adversos na maioria leves ou moderados e sem sequelas, sendo que apenas 4% desses eventos obrigaram \u00e0 interrup\u00e7\u00e3o do tratamento.  O tempo necess\u00e1rio para ocorrer a negativa\u00e7\u00e3o depende da idade e do in\u00edcio do tratamento. As crian\u00e7as diagnosticadas nos primeiros meses de vida negativar\u00e3o a sorologia entre o 2\u00ba e o 12\u00ba m\u00eas ap\u00f3s o in\u00edcio do tratamento. Os sistemas de sa\u00fade devem avaliar e implementar estrat\u00e9gias que facilitem o diagn\u00f3stico mais precocemente poss\u00edvel da infec\u00e7\u00e3o cong\u00eanita, considerando a frequente m\u00e1 ades\u00e3o das m\u00e3es aos atendimentos de acompanhamento nos centros de sa\u00fade.  O acompanhamento do resultado da terap\u00eautica etiol\u00f3gica deve ser realizado por testes parasitol\u00f3gicos e/ou moleculares nas semanas seguintes ao in\u00edcio do tratamento para neonatos com parasitemia. Ap\u00f3s o t\u00e9rmino do tratamento, os pacientes devem ser acompanhados a cada 6 meses com testes sorol\u00f3gicos quantitativos. O paciente \u00e9 considerado curado quando a sorologia se torna negativa em dois testes consecutivos.  Considerando o risco de transmiss\u00e3o ao rec\u00e9m-nato ou lactente pelo contato com secre\u00e7\u00f5es maternas, recomenda-se suspender temporariamente a amamenta\u00e7\u00e3o apenas nos casos de m\u00e3es com RDC ou em fase aguda e, mais enfaticamente, aquelas que portem fissuras ou sangramentos mamilares. \u00c9 importante a avalia\u00e7\u00e3o caso a caso considerando o grande benef\u00edcio da amamenta\u00e7\u00e3o nos primeiros meses de vida da crian\u00e7a. Conclusivamente, m\u00e3es que j\u00e1 estejam utilizando o tratamento antiparasit\u00e1rio h\u00e1 pelo menos 30 dias, mesmo nos casos acima apontados, podem amamentar livremente.  Pacientes com CCDC t\u00eam riscos cir\u00fargico e anest\u00e9sico aumentados por diversas raz\u00f5es, que devem ser consideradas nos per\u00edodos pr\u00e9, intra e p\u00f3s-operat\u00f3rio.  O cuidado pr\u00e9-operat\u00f3rio mais importante \u00e9 o controle da IC, com a otimiza\u00e7\u00e3o medicamentosa, e a corre\u00e7\u00e3o de eventuais dist\u00farbios hidroeletrol\u00edticos.  A avalia\u00e7\u00e3o da fun\u00e7\u00e3o ventricular por meio do ECO deve ser feita sempre que poss\u00edvel. O ECG deve ser realizado em todos os candidatos a cirurgia e, em pacientes com arritmias ou sintomas compat\u00edveis, a monitoriza\u00e7\u00e3o eletrocardiogr\u00e1fica din\u00e2mica pelo sistema Holter pode ser necess\u00e1ria. F\u00e1rmacos antiarr\u00edtmicos n\u00e3o devem ser suspensos, mas os anticoagulantes orais devem ser interrompidos. Os novos anticoagulantes orais inibidores diretos da trombina, como dabigatrana, ou os inibidores do fator Xa, como rivaroxabana, apixabana e edoxabana, podem simplesmente ser suspensos de 24 a 48 horas antes da cirurgia. No caso da varfarina, deve ser suspensa idealmente 5 dias antes da cirurgia, que poder\u00e1 ser realizada quando o INR for inferior a 1,5. Durante o per\u00edodo de suspens\u00e3o da varfarina, os pacientes com alto risco para eventos tromboemb\u00f3licos devem receber anticoagula\u00e7\u00e3o com heparinas, por exemplo enoxaparina subcut\u00e2nea em dose plena. Finalmente, a avalia\u00e7\u00e3o pr\u00e9-operat\u00f3ria do paciente com DC deve considerar a eventual presen\u00e7a de megaes\u00f4fago, que acarreta risco aumentado de aspira\u00e7\u00e3o pelas vias a\u00e9reas durante os per\u00edodos intra- e p\u00f3s-operat\u00f3rios.  A monitoriza\u00e7\u00e3o eletrocardiogr\u00e1fica cont\u00ednua \u00e9 essencial para controle de arritmias ventriculares malignas e bradiarritmias. A monitoriza\u00e7\u00e3o hemodin\u00e2mica invasiva arterial e venosa central \u00e9 interessante e dever\u00e1 ser implementada nos casos mais graves e em cirurgias de maior porte. O implante de MP card\u00edaco transvenoso tempor\u00e1rio deve ser considerado nos pacientes com grau avan\u00e7ado de BAV, principalmente quando associado a dist\u00farbios de condu\u00e7\u00e3o intraventricular. O ECO transesof\u00e1gico intraoperat\u00f3rio fornece valiosas informa\u00e7\u00f5es sobre a resposta inotr\u00f3pica \u00e0 medica\u00e7\u00e3o anest\u00e9sica e o estado vol\u00eamico do paciente, podendo ser muito \u00fatil em casos selecionados.  Durante a cirurgia, o paciente com CCDC requer um manejo anest\u00e9sico individualizado. O anestesista deve levar em considera\u00e7\u00e3o aspectos hemodin\u00e2micos, como a disfun\u00e7\u00e3o mioc\u00e1rdica, muitas vezes biventricular, os quais limitam a infus\u00e3o de volumes de l\u00edquidos e aumentam o risco de arritmias card\u00edacas.  A infus\u00e3o intraoperat\u00f3ria de volumes deve ser muito criteriosa. Pacientes em uso de vasodilatadores e diur\u00e9ticos para o tratamento de IC comumente apresentam n\u00edveis press\u00f3ricos baixos, bem como precisam de um tempo maior para a\u00e7\u00e3o de anest\u00e9sicos venosos, devido \u00e0 circula\u00e7\u00e3o mais lenta.  Al\u00e9m disso, a insufici\u00eancia hep\u00e1tica, consequente \u00e0 IC direita, e a insufici\u00eancia renal alteram a farmacocin\u00e9tica da maioria das medica\u00e7\u00f5es.  Os cuidados anestesiol\u00f3gicos s\u00e3o muito importantes. Nos pacientes com disfun\u00e7\u00e3o ventricular, a indu\u00e7\u00e3o anest\u00e9sica pode resultar em r\u00e1pida deteriora\u00e7\u00e3o hemodin\u00e2mica, que ocorre principalmente por vasoconstri\u00e7\u00e3o perif\u00e9rica e a\u00e7\u00e3o inotr\u00f3pica negativa induzida pelos agentes anest\u00e9sicos.  O melhor esquema anest\u00e9sico deve promover o menor grau de depress\u00e3o mioc\u00e1rdica e de vasodilata\u00e7\u00e3o poss\u00edvel. Todo anest\u00e9sico inalat\u00f3rio e a maioria dos anest\u00e9sicos venosos s\u00e3o depressores do mioc\u00e1rdio,  necessitando de titula\u00e7\u00e3o e monitoriza\u00e7\u00e3o criteriosa por parte do anestesista. Sempre que poss\u00edvel, conforme o tipo de cirurgia, t\u00e9cnicas de anestesia regional isoladamente ou em associa\u00e7\u00e3o com a anestesia geral devem ser utilizadas por apresentarem menor risco de instabilidade hemodin\u00e2mica.  A disfun\u00e7\u00e3o auton\u00f4mica do paciente com CCDC reduz a reserva contr\u00e1til e pode atenuar a a\u00e7\u00e3o de catecolaminas ex\u00f3genas, requerendo doses acima das usuais para estabiliza\u00e7\u00e3o hemodin\u00e2mica.  Independentemente do tipo de dispositivo, o termocaut\u00e9rio deve ser programado no modo bipolar e com a menor pot\u00eancia efetiva, utilizado de forma intermitente e com a placa neutra localizada o mais distante poss\u00edvel da unidade geradora.  Pacientes com CCDC frequentemente s\u00e3o portadores de dispositivos eletr\u00f4nicos implant\u00e1veis para o tratamento de arritmias e/ou IC. Em caso de utiliza\u00e7\u00e3o do termocaut\u00e9rio durante a cirurgia, tais dispositivos requerem aten\u00e7\u00e3o espec\u00edfica. A produ\u00e7\u00e3o de ru\u00eddos el\u00e9tricos pelo termocaut\u00e9rio leva a interpreta\u00e7\u00e3o equivocada dos eventos el\u00e9tricos do cora\u00e7\u00e3o por parte do dispositivo, com consequente inibi\u00e7\u00e3o de est\u00edmulos el\u00e9tricos necess\u00e1rios ou libera\u00e7\u00e3o de terapias de choque el\u00e9trico inapropriadas. Os portadores de MP devem ter o dispositivo programado no modo DOO ou VOO. Os portadores de CDI devem ter as terapias desligadas durante a cirurgia ou utilizarem um im\u00e3 sobre o dispositivo para inibi\u00e7\u00e3o de eventuais choques inapropriados. O acesso venoso central deve ser feito com cuidado nesses pacientes pelo risco de o fio guia gerar ru\u00eddos pelo contato com o eletrodo de choque, levando a descargas inadequadas.  O p\u00f3s-operat\u00f3rio de pacientes com CCDC dever\u00e1 ser feito em unidade de terapia intensiva nos casos com disfun\u00e7\u00e3o ventricular ou arritmias card\u00edacas e nas cirurgias de grande porte. A medica\u00e7\u00e3o anticoagulante oral em uso anterior \u00e0 cirurgia e que necessitou suspens\u00e3o tempor\u00e1ria no transoperat\u00f3rio, bem como as demais medica\u00e7\u00f5es para IC e arritmias, devem ser reintroduzidas assim que poss\u00edvel.  A dissemina\u00e7\u00e3o mundial da doen\u00e7a causada pelo novo coronav\u00edrus (SARS-Cov-2), a COVID-19, fez com que a OMS a declarasse pandemia em mar\u00e7o de 2020. Seguindo o mesmo perfil epidemiol\u00f3gico global, os estudos demonstraram inter-rela\u00e7\u00e3o entre potencial de gravidade e comorbidades com \u00eanfase em doen\u00e7a cardiovascular e taxas de letalidade maiores em pacientes com essas doen\u00e7as, comparativamente ao que ocorre na popula\u00e7\u00e3o geral.  por\u00e9m as taxas de mortalidade podem ir de 2,3% at\u00e9 27%  em popula\u00e7\u00f5es vulner\u00e1veis, incluindo idosos e pacientes com comorbidades,  devido a complica\u00e7\u00f5es graves, como pneumonia, tromboembolismo, sepse, insufici\u00eancia renal e card\u00edaca.  A infec\u00e7\u00e3o por SARS-CoV-2 pode afetar o sistema cardiovascular por diversos mecanismos, incluindo les\u00e3o mioc\u00e1rdica inflamat\u00f3ria (miocardite), tromboses intravasculares, s\u00edndrome de Takotsubo, causando IC, arritmias e choque circulat\u00f3rio.  Pacientes com IC t\u00eam maior mortalidade por COVID-19 do que pacientes sem IC,  podendo chegar a 40%.  Assim a preexist\u00eancia de IC \u00e9 fator de risco indubit\u00e1vel para mortalidade por COVID-19.  Dos pacientes com COVID-19, mais de 80% apresentam sintomas leves como febre, dor de garganta e tosse,  Por muitos deles serem cardiopatas, s\u00e3o vulner\u00e1veis a infec\u00e7\u00f5es graves e podem ter complica\u00e7\u00f5es graves causadas pela COVID-19,  inclusive maior mortalidade quando apresentam IC.  Al\u00e9m disso, h\u00e1 alta preval\u00eancia de comorbidades na popula\u00e7\u00e3o com DC que est\u00e1 envelhecendo gra\u00e7as a medidas de controle da transmiss\u00e3o de DC e melhora global do sistema de sa\u00fade.  Assim, \u00e9 poss\u00edvel, at\u00e9 prov\u00e1vel, que haja maior morbidade/mortalidade relacionada \u00e0 COVID-19 em pacientes com DC. No entanto, registro amplo recente no Brasil indicou que a mortalidade intra-hospitalar por COVID-19 foi similar entre pacientes com e sem DC, pareados por sexo, idade, hipertens\u00e3o e diabetesmellitus, mesmo sendo a IC e a FA mais prevalentes no grupo com a infec\u00e7\u00e3o cr\u00f4nica porT. cruzi.  A consequ\u00eancia da pandemia da COVID-19 sobre o estado de sa\u00fade de pacientes com DC ainda \u00e9, em grande parte, desconhecida.  Os pacientes com DC t\u00eam indicativo priorit\u00e1rio de vacina\u00e7\u00e3o anti-COVID-19 e configuram grupos de risco importantes nas estrat\u00e9gias vacinais, tanto para COVID-19 como para outras doen\u00e7as imunopreven\u00edveis por vacinas, com risco de desenvolvimento de pneumonias graves e/ou acometimento card\u00edaco.  A preven\u00e7\u00e3o da COVID-19 para os pacientes com DC, cursando em qualquer fase da mol\u00e9stia, segue as mesmas recomenda\u00e7\u00f5es para a popula\u00e7\u00e3o em geral, contidas nas diretrizes do Minist\u00e9rio da Sa\u00fade do Brasil, por\u00e9m com recomenda\u00e7\u00f5es redobradas e aten\u00e7\u00e3o especial \u00e0s indica\u00e7\u00f5es de vacinas, de acordo com a faixa et\u00e1ria, para profilaxia das infec\u00e7\u00f5es por pneumococos, v\u00edrus influenza e COVID-19.  Para indiv\u00edduos com DC que adquirem a infec\u00e7\u00e3o por SARS-CoV-2, recomenda-se que os cuidados m\u00e9dicos devam ser institu\u00eddos desde o n\u00edvel de APS, com \u00eanfase nas condi\u00e7\u00f5es de risco associados \u00e0 miocardite e aos fen\u00f4menos intravasculares tromboemb\u00f3licos . T. cruzi, n\u00e3o \u00e9 alcan\u00e7ado nas doses recomendadas e por per\u00edodos curtos de tempo. Contudo, o manejo e as indica\u00e7\u00f5es devem ser conduzidos por associa\u00e7\u00e3o de infectologista e cardiologista.  Em casos moderados ou graves de COVID-19, pode-se usar corticoterapia, quase sempre indicada a partir do 6\u00ba dia de doen\u00e7a e utilizada por per\u00edodo curto de tempo. N\u00e3o h\u00e1 qualquer contraindica\u00e7\u00e3o ao uso de corticoides nos pacientes com DC coinfectados com SARS-CoV-2, uma vez que seu efeito imunodepressor, que poderia ser danoso para a resposta do paciente ao Nos pacientes com CCDC e COVID-19 leve, devem-se manter as medica\u00e7\u00f5es cardiovasculares e a anticoagula\u00e7\u00e3o anteriormente indicadas, j\u00e1 que n\u00e3o h\u00e1 indicativos de que sejam prejudiciais. Nos casos moderados ou graves, a anticoagula\u00e7\u00e3o oral ser\u00e1 trocada por heparina de baixo peso molecular e a medica\u00e7\u00e3o cardiovascular dever\u00e1 ser reavaliada, conforme a hemodin\u00e2mica do paciente.  Depois disso, v\u00e1rios relatos de transmiss\u00e3o de DC ap\u00f3s doa\u00e7\u00e3o de rim, f\u00edgado, cora\u00e7\u00e3o ou medula \u00f3ssea surgiram na literatura mundial, sendo que a taxa de transmiss\u00e3o variou conforme o \u00f3rg\u00e3o, por exemplo de 13%  a 16%  no caso de transplante de rim, 20%  a 22%  no de f\u00edgado e at\u00e9 75% no de cora\u00e7\u00e3o.  Al\u00e9m disso, foi detectada RDC em receptores de \u00f3rg\u00e3os s\u00f3lidos de pacientes com DC cr\u00f4nica.  A transmiss\u00e3o da DC por transplante de \u00f3rg\u00e3os foi descrita pela primeira vez no Brasil em 1981 ap\u00f3s transplante de rim.  No caso do transplante de f\u00edgado, a experi\u00eancia ainda \u00e9 limitada, observando-se, por\u00e9m, que a incid\u00eancia de RDC varia conforme o centro de forma similar \u00e0 do transplante de rim.  Outra situa\u00e7\u00e3o \u00e9 o transplante de medula \u00f3ssea em pacientes com DC cr\u00f4nica assintom\u00e1ticos, no qual o risco de RDC variou de 17% a 40%.  A maior experi\u00eancia \u00e9 com transplante de rim, onde a RDC ocorre principalmente no primeiro ano, mas varia amplamente entre os centros, de 8% a 22%. o 2.600 de 2009 determina a testagem para DC: (1) em todas as doa\u00e7\u00f5es, seguindo-se os mesmos algoritmos utilizados para triagem de doadores de sangue; (2) para fins de inscri\u00e7\u00e3o dos potenciais receptores de \u00f3rg\u00e3os no Cadastro T\u00e9cnico \u00danico; e (3) em todos os cad\u00e1veres potenciais doadores de \u00f3rg\u00e3os, tecidos, c\u00e9lulas ou partes do corpo antes da aloca\u00e7\u00e3o dos enxertos. A portaria tamb\u00e9m estabelece que o cora\u00e7\u00e3o de doadores com DC n\u00e3o deva ser utilizado em transplante, enquanto rim, p\u00e2ncreas, f\u00edgado e pulm\u00e3o de doadores com DC podem ser transplantados, desde que autorizado pelo receptor e equipe de transplante, apesar do risco de transmiss\u00e3o e implicando em necessidade de monitoriza\u00e7\u00e3o ap\u00f3s o procedimento.  No Brasil, a Portaria n  com base na queda da parasitemia nessa fase do tratamento.  O risco nesse caso \u00e9 de transmiss\u00e3o da DC. No caso de doador vivo, idealmente ele dever\u00e1 ser tratado com benznidazol por 60 dias antes do procedimento. Caso seja imperativo que o transplante ocorra antes de se completar o tratamento, o transplante poder\u00e1 ser realizado ap\u00f3s 14 dias de tratamento,  J\u00e1 o uso profil\u00e1tico de benznidazol, que seria aplic\u00e1vel de rotina, \u00e9 controverso, alegando-se a toxicidade do f\u00e1rmaco associada \u00e0 baixa taxa de transmiss\u00e3o.  No caso de doador n\u00e3o tratado, a conduta mais recomendada \u00e9 a monitoriza\u00e7\u00e3o da ocorr\u00eancia de transmiss\u00e3o da DC e o tratamento dos casos diagnosticados, quando se observam bons resultados, com alta taxa de cura. T. cruzino sangue perif\u00e9rico semanalmente, at\u00e9 60 dias, e exames parasitol\u00f3gicos indiretos e sorol\u00f3gicos aos 30 e 60 dias ap\u00f3s o transplante. A seguir, exames cl\u00ednicos, sorol\u00f3gicos e parasitol\u00f3gicos (diretos/indiretos/PCR) devem ser realizados a cada 2 meses at\u00e9 1 ano de seguimento; posteriormente, a cada 6 meses, enquanto persistir a imunossupress\u00e3o . Al\u00e9m dos controles habituais, qualquer sinal cl\u00ednico suspeito de DC aguda dever\u00e1 ser investigado por meio de exames parasitol\u00f3gicos.  A monitoriza\u00e7\u00e3o \u00e9 feita com pesquisa direta de Em qualquer momento, caso seja detectada infec\u00e7\u00e3o aguda, o tratamento antiparasit\u00e1rio convencional dever\u00e1 ser institu\u00eddo.  Tamb\u00e9m \u00e9 importante ressaltar que exames sorol\u00f3gicos podem n\u00e3o se positivar devido \u00e0 imunossupress\u00e3o vigente nesses pacientes. A monitoriza\u00e7\u00e3o \u00e9 mais frequente no in\u00edcio, j\u00e1 que a maioria dos casos de transmiss\u00e3o com infec\u00e7\u00e3o aguda se d\u00e1 entre 3 e 29 semanas (m\u00e9dia de 8).  O PCR pode ser utilizado em lugar de exames parasitol\u00f3gicos indiretos.  Os testes parasitol\u00f3gicos devem ser feitos semanalmente durante o tratamento ou at\u00e9 que dois testes consecutivos negativos sejam obtidos.  Ao comparar 13 pacientes que n\u00e3o foram monitorados corretamente com 19 que fizeram monitoriza\u00e7\u00e3o semanal, viu-se que, no primeiro grupo, 5 pacientes tiveram diagn\u00f3stico de DC sintom\u00e1tica, dos quais 4 morreram, enquanto que, no outro grupo, 4 transmiss\u00f5es foram confirmadas e receberam tratamento antiparasit\u00e1rio e n\u00e3o desenvolveram doen\u00e7a sintom\u00e1tica.  A preval\u00eancia de DC entre candidatos a transplante de \u00f3rg\u00e3os s\u00f3lidos \u00e9 maior no de cora\u00e7\u00e3o, devido \u00e0 pr\u00f3pria caracter\u00edstica espec\u00edfica de ela cursar com IC refrat\u00e1ria em muitos casos.  e les\u00f5es tumor-s\u00edmile intracerebral (\u201cchagomas\u201d),  s\u00e3o incomuns. Em recipientes de transplante renal, RDC ocorre principalmente no primeiro ano ap\u00f3s o transplante ou quando se intensifica a imunossupress\u00e3o ap\u00f3s epis\u00f3dios de rejei\u00e7\u00e3o. A RDC pode ser totalmente assintom\u00e1tica e, quando manifesta\u00e7\u00f5es cl\u00ednicas aparecem, elas s\u00e3o usualmente na forma de envolvimento subcut\u00e2neo  em membros. Se o tratamento n\u00e3o \u00e9 institu\u00eddo, as les\u00f5es podem evoluir para \u00falceras dolorosas. Miocardite e encefalite tamb\u00e9m s\u00e3o descritas, mas menos frequentemente. A resposta ao tratamento \u00e9 boa, com sobrevida adequada do paciente e do enxerto a longo prazo.  Embora RDC possa ocorrer durante per\u00edodos de imunossupress\u00e3o ap\u00f3s qualquer transplante de \u00f3rg\u00e3o s\u00f3lido, formas graves dessa complica\u00e7\u00e3o, como meningoencefalite  Analogamente ao exposto acima, para outro contexto similar, h\u00e1 duas condutas debatidas para o receptor de transplante que j\u00e1 tem DC diagnosticada: fazer-se tratamento antes do transplante no receptor j\u00e1 assim infectado ou instituir-se conduta expectante para diagn\u00f3stico e tratamento da eventual RDC. O tratamento rotineiro de recipientes assintom\u00e1ticos, mas com DC, antes de receberem o transplante poderia, teoricamente, reduzir a chance de RDC ap\u00f3s a imunossupress\u00e3o; n\u00e3o h\u00e1 evid\u00eancia conclusiva, por\u00e9m, a favor dessa assertiva e da correspondente conduta profil\u00e1tica. Ao contr\u00e1rio, falha dessa conduta j\u00e1 foi relatada.  Ademais, em geral, o resultado do tratamento da RDC \u00e9 favor\u00e1vel, com altas taxas de cura e baixa mortalidade.  Portanto, a conduta preferida \u00e9 a monitoriza\u00e7\u00e3o de rotina da parasitemia e de outras evid\u00eancias de RDC, de forma a se poder instituir tratamento espec\u00edfico precocemente e aumentar o sucesso do tratamento com menor n\u00famero de casos graves ou fatais. T. cruzidevem ser acompanhados para investigar RDC semanalmente nos primeiros 2 meses, a cada 2 semanas do terceiro ao sexto m\u00eas e mensalmente depois disso at\u00e9 1 ano, e semanalmente por 2 meses ap\u00f3s intensifica\u00e7\u00e3o de imunossupress\u00e3o, ou a qualquer tempo se houver suspeita cl\u00ednica de DC aguda.  Todos os receptores infectados com Ninhos de formas amastigotas deT. cruzidevem ser procurados em todas as bi\u00f3psias. O diagn\u00f3stico de RDC \u00e9 feito pela identifica\u00e7\u00e3o de parasitas no sangue perif\u00e9rico por meio de m\u00e9todos diretos ou por qPCR, conforme descrito anteriormente, ou identifica\u00e7\u00e3o deT. cruziem bi\u00f3psias. RDC deve ser considerada em pacientes com febre inexplicada, dermopatia, miocardite ou encefalite.  Os testes de laborat\u00f3rio de prefer\u00eancia s\u00e3o os parasitol\u00f3gicos diretos. O PCR a ser usado deve ser o quantitativo, j\u00e1 que o qualitativo pode ser positivo em pacientes assintom\u00e1ticos. A vantagem do qPCR \u00e9 ser mais sens\u00edvel e positivar-se mais precocemente que os m\u00e9todos parasitol\u00f3gicos diretos.  Todos os recipientes infectados devem ser investigados uma vez por ano para as formas card\u00edaca e digestiva da DC. Todos com RDC devem ser tratados por 60 dias com benznidazol (5mg/kg/dia), sendo o nifurtimox (8mg/kg/dia) a segunda escolha. Durante o tratamento, testes parasitol\u00f3gicos devem ser feitos semanalmente at\u00e9 dois testes negativos serem obtidos.  \u00c9 importante frisar que os testes sorol\u00f3gicos n\u00e3o s\u00e3o \u00fateis para diagn\u00f3stico de RDC e que a soroconvers\u00e3o negativa j\u00e1 foi descrita em pacientes com DC cr\u00f4nica ap\u00f3s receberem transplantes, devido \u00e0 imunossupress\u00e3o. mechanistic target of rapamycin) poderiam favorecer o controle da replica\u00e7\u00e3o doT.cruzi,  assim constituindo um regime mais apropriado para pacientes em risco de DC. Por\u00e9m, ainda n\u00e3o h\u00e1 um regime \u00f3timo estabelecido.  Outro ponto ainda incerto \u00e9 o uso de protocolos espec\u00edficos quimioter\u00e1picos podendo influenciar a RDC. Assim, evitar globulina antitim\u00f3citos e minimizar o uso de micofenolato parece recomend\u00e1vel. Alguns estudos sugerem que inibidores de mTOR   e no Rio de Janeiro  em pacientes idosos com DC atendidos ambulatorialmente registraram a HAS como a mais frequente comorbidade.  Estudos transversais conduzidos no Cear\u00e1, mellitus, IC, insufici\u00eancia coronariana, hipotireoidismo, dispepsia, depress\u00e3o, AVC e insufici\u00eancia renal. Portanto, esses pacientes merecem especial aten\u00e7\u00e3o. Al\u00e9m disso, a presen\u00e7a de comorbidades cr\u00f4nicas pode resultar em frequentes consultas m\u00e9dicas e risco de intera\u00e7\u00f5es medicamentosas, efeitos adversos, bem como uso di\u00e1rio de cinco ou mais medica\u00e7\u00f5es de dif\u00edcil dom\u00ednio de administra\u00e7\u00e3o correta por parte do idoso.  Al\u00e9m da HAS, outras comorbidades tamb\u00e9m foram relatadas, como dislipidemia, osteoporose, osteoartrite, diabetes Em estudo realizado em Bambu\u00ed, em coorte de pacientes idosos com ou sem DC, as altera\u00e7\u00f5es eletrocardiogr\u00e1ficas eram nitidamente mais frequentes em pacientes com DC.  Anormalidades do ECG significantemente associadas com DC foram bradicardia sinusal, extrass\u00edstoles ventriculares ou supraventriculares frequentes, FA, BRD, BDASE, BAV de 1\u00ba grau e intervalo QT prolongado.  Nos estudos transversais citados, a forma cl\u00ednica predominante da DC foi a de cardiomiopatia; por\u00e9m, a informa\u00e7\u00e3o sobre o valor progn\u00f3stico das altera\u00e7\u00f5es entre idosos ainda \u00e9 escassa.  O BRD, em especial associado ao BDASE, foi fortemente associado \u00e0 presen\u00e7a de DC, sendo observado em 40% da popula\u00e7\u00e3o com DC e em apenas 8% dos idosos sem DC. Vari\u00e1veis do ECG independentemente associadas com maior risco de morte em pacientes com DC foram extrass\u00edstoles ventriculares ou supraventriculares frequentes, FA, BRD, zona el\u00e9trica inativa, altera\u00e7\u00f5es prim\u00e1rias da repolariza\u00e7\u00e3o ventricular e hipertrofia ventricular esquerda. Aqueles com ECG normal ou altera\u00e7\u00f5es menores n\u00e3o tinham maior risco de morte, quando comparados com a popula\u00e7\u00e3o n\u00e3o infectada.  Muitos idosos nunca tiveram uma avalia\u00e7\u00e3o cl\u00ednica inicial para a classifica\u00e7\u00e3o da DC e receberem o acompanhamento e tratamento adequados. Pode-se constatar isso em estudo transversal conduzido em \u00e1rea end\u00eamica de S\u00e3o Jo\u00e3o do Piau\u00ed, na regi\u00e3o semi\u00e1rida brasileira. Esse estudo evidenciou alta preval\u00eancia de DC nos idosos, chegando a 34% no grupo de 61 a 75 anos e 39% no grupo acima de 75 anos. Nessa regi\u00e3o, apesar do controle de transmiss\u00e3o da doen\u00e7a, o diagn\u00f3stico e tratamento foram interrompidos e muitos idosos nunca tiveram avalia\u00e7\u00e3o cl\u00ednica inicial. Essa regi\u00e3o, assim como outras com caracter\u00edsticas socioambientais semelhantes da regi\u00e3o semi\u00e1rida brasileira, continua sofrendo pela escassez de grupos de APS treinados para diagnosticar e tratar a popula\u00e7\u00e3o.  Em contraste com essas no\u00e7\u00f5es bastante fundamentadas, um estudo descreve que apenas 13% dos idosos t\u00eam ECG normal e sugerem que a gravidade da DC em idosos possa ser similar \u00e0 observada em adultos jovens.  Tais informa\u00e7\u00f5es, obviamente, carecem de mais substancialidade e comprova\u00e7\u00e3o.  Estudos cl\u00e1ssicos em \u00e1reas end\u00eamicas mostram que a FIDC \u00e9 a mais prevalente e que 30% a 40% desses indiv\u00edduos podem persistir indefinidamente com essa variante cl\u00ednica.  Considerando o impacto de fatores sociais, econ\u00f4micos e culturais na g\u00eanese e na evolu\u00e7\u00e3o da CCDC, o manejo cl\u00ednico em servi\u00e7os de sa\u00fade requer a conforma\u00e7\u00e3o de uma rede de aten\u00e7\u00e3o em um modelo que transcenda dimens\u00f5es biom\u00e9dicas. Para tanto, deve garantir acesso \u00e0 assist\u00eancia integral, hierarquizada e descentralizada, contemplando o processo de determina\u00e7\u00e3o social que permeia essa doen\u00e7a negligenciada, causa e consequ\u00eancia de pobreza estrutural.  N\u00e3o raro, as pessoas com CCDC s\u00e3o as que se encontram em condi\u00e7\u00f5es cr\u00edticas para alcance da aten\u00e7\u00e3o, o que inclui, por exemplo, itiner\u00e1rio terap\u00eautico longo, baixa resolutividade e diagn\u00f3stico tardio, muitas vezes em est\u00e1gios avan\u00e7ados da doen\u00e7a.  Como j\u00e1 descrito, pessoas com CCDC apresentam elevada carga de morbimortalidade quando comparadas a pessoas com outras cardiomiopatias. Em sua grande maioria, pertencem a classes sociais menos favorecidas com elevados graus de vulnerabilidade, o que dificulta, sobremaneira, o acesso a diagn\u00f3stico e tratamento.  Al\u00e9m disso, pacientes com CCDC enfrentam preconceito e estigma em diferentes contextos na sociedade, o que acaba por agravar mais ainda o seu sofrimento n\u00e3o apenas f\u00edsico, mas tamb\u00e9m psicol\u00f3gico e social. A DC est\u00e1 inclu\u00edda no rol das enfermidades mais negligenciadas em todo o mundo, especialmente na Am\u00e9rica Latina, segundo a OMS. Trata-se de uma condi\u00e7\u00e3o cr\u00f4nica bastante desafiadora para qualquer sistema de sa\u00fade p\u00fablica, uma vez que os acometidos podem demandar a\u00e7\u00f5es desde a baixa e m\u00e9dia complexidade tecnol\u00f3gica no setor sa\u00fade, em aproximadamente 70% a 80% dos casos (em grande parte na APS), at\u00e9 situa\u00e7\u00f5es que requerem acesso \u00e0 aten\u00e7\u00e3o terci\u00e1ria e quatern\u00e1ria, ampliando os custos relacionados \u00e0 sa\u00fade p\u00fablica. Reitera-se tamb\u00e9m, sobremaneira, o cr\u00edtico impacto negativo na qualidade de vida das pessoas acometidas, al\u00e9m de suas fam\u00edlias e comunidades.  No Brasil, entre 2000 e 2010, a carga da CCDC correspondeu a um total de 7.402.559 anos potenciais de vida comprometidos, sendo 9% desse total devido a anos de vida perdidos e 91% a anos de vida com incapacidade.  O SUS, em sua concep\u00e7\u00e3o hierarquizada e descentralizada, foi pensado com a finalidade de alcan\u00e7ar a integralidade como referencial, particularmente a partir de territ\u00f3rios da APS, com apoio matricial inclusive por servi\u00e7os de refer\u00eancia em casos mais complexos. Entretanto, requer investimentos aliados a uma gest\u00e3o p\u00fablica qualificada e amplamente engajada, que permita estrutura\u00e7\u00e3o de uma rede de aten\u00e7\u00e3o fundamentada em linhas de cuidado em forte integra\u00e7\u00e3o com a\u00e7\u00f5es de vigil\u00e2ncia em sa\u00fade.  Apontam-se, no entanto, alguns fatores para que o d\u00e9bito sanit\u00e1rio com essas pessoas acometidas pela DC permane\u00e7a presente, mesmo 113 anos ap\u00f3s a sua descoberta. Como exemplo desse ciclo de neglig\u00eancia, trata-se de uma doen\u00e7a que alcan\u00e7a uma popula\u00e7\u00e3o silenciosa e silenciada, com persistentes falhas da ci\u00eancia, do mercado e da sa\u00fade p\u00fablica.  Persistem quest\u00f5es b\u00e1sicas a serem respondidas nos contextos end\u00eamicos: quem s\u00e3o essas pessoas? onde est\u00e3o? como est\u00e3o?  Em contextos de maior complexidade no manejo cl\u00ednico, ao se recomendar a constitui\u00e7\u00e3o de servi\u00e7os estruturados de acompanhamento a pessoas com CCDC, alguns aspectos precisam ser observados, como espa\u00e7o ambulatorial apropriado, vinculado ou com retaguarda de um hospital terci\u00e1rio ou quatern\u00e1rio em cardiologia, com possibilidade de realizar exames complementares de m\u00e9dia e alta complexidade para estadiamento adequado do comprometimento card\u00edaco.  Deve ser considerada tamb\u00e9m a necessidade do acompanhamento de casos residentes em regi\u00f5es de dif\u00edcil acesso a servi\u00e7os com melhor estrutura\u00e7\u00e3o, como, por exemplo, regi\u00e3o Amaz\u00f4nica, \u00e1reas do pa\u00eds com caracter\u00edsticas rurais, urbanas e de periferias de cidades. Para esses casos, pode ser necess\u00e1ria a utiliza\u00e7\u00e3o de meios tecnol\u00f3gicos diferenciados, como a consulta por meio de telemedicina, elabora\u00e7\u00e3o de laudos de ECG e radiografia de t\u00f3rax \u00e0 dist\u00e2ncia, dentre outros.  Servi\u00e7os de sa\u00fade estruturados em CCDC podem tornar-se refer\u00eancia regional e estadual para casos com manejo cl\u00ednico mais complexo, tendo como objetivo o esclarecimento diagn\u00f3stico e o estadiamento do comprometimento visceral. Al\u00e9m disso, podem apoiar matricialmente os programas estaduais e municipais no processo de educa\u00e7\u00e3o permanente de profissionais das unidades de sa\u00fade da APS (considerando toda a equipe de sa\u00fade), o que inclui agentes comunit\u00e1rios de sa\u00fade e agentes de combate a endemias, no manejo cl\u00ednico da DC, uma vez que, embora end\u00eamica, ainda \u00e9 subdiagnosticada.  Para que um servi\u00e7o de sa\u00fade estruturado tenha seu pleno funcionamento, faz-se necess\u00e1ria a composi\u00e7\u00e3o de equipe multiprofissional em car\u00e1ter interdisciplinar, reconhecida como a melhor forma de aten\u00e7\u00e3o longitudinal e integral a condi\u00e7\u00f5es cr\u00f4nicas. Para al\u00e9m do diagn\u00f3stico e tratamento oportunos, requer a\u00e7\u00f5es de reabilita\u00e7\u00e3o e preven\u00e7\u00e3o quatern\u00e1ria.  Ao criar-se um servi\u00e7o destinado e vocacionado a pessoas com CCDC, torna-se importante contemplar suas peculiaridades, procurando compreend\u00ea-las dentro de um contexto biopsicossocial, exercendo a medicina onde a aten\u00e7\u00e3o \u00e9 centrada na pessoa acometida e n\u00e3o apenas na doen\u00e7a ou no \u00f3rg\u00e3o por ela afetado.  Nessa proposta de trabalho, a equipe deve reconhecer os elementos comuns que demandam forte intera\u00e7\u00e3o entre cada profissional, mas tamb\u00e9m as especificidades do processo de trabalho delimitado por suas possibilidades e responsabilidades de atua\u00e7\u00e3o. \u00c9 necess\u00e1rio que essa equipe tenha conhecimento acerca da CCDC, assim como da rotina de seu manejo, para que todos falem uma mesma linguagem. Dessa forma, busca-se evitar informa\u00e7\u00f5es distorcidas ou mesmo inver\u00eddicas.  O servi\u00e7o estruturado para condu\u00e7\u00e3o de casos de CCDC deve dispor idealmente dos seguintes profissionais: m\u00e9dico/a , enfermeiro/a, psic\u00f3logo/a, nutricionista, farmac\u00eautico/a, fisioterapeuta, educador/a f\u00edsico/a e assistente social, podendo ser ampliado de acordo com a ado\u00e7\u00e3o de novas interven\u00e7\u00f5es. A dimens\u00e3o da equipe dever\u00e1 ser ajustada \u00e0 realidade local, \u00e0s possibilidades de cada servi\u00e7o de sa\u00fade e, acima de tudo, \u00e0 demanda trazida pelas pessoas acometidas.  Acolher todos os casos vindos de: unidades da APS, unidades de aten\u00e7\u00e3o secund\u00e1ria [Unidades de Pronto-Atendimento Especializado (UPAE)], emerg\u00eancias cardiol\u00f3gicas e n\u00e3o cardiol\u00f3gicas, maternidades, hemocentros p\u00fablicos ou privados, servi\u00e7os de transplantes e servi\u00e7os especializados em HIV/AIDS para esclarecimento diagn\u00f3stico e realiza\u00e7\u00e3o de estadiamento;  Para confirmar o diagn\u00f3stico da DC \u00e9 necess\u00e1ria anamnese qualificada, dirigida ao contexto cl\u00ednico epidemiol\u00f3gico, com confirma\u00e7\u00e3o sorol\u00f3gica preferencialmente pelo LACEN; o 1.061, de 18 de maio de 2020 do Minist\u00e9rio da Sa\u00fade, que facilitar\u00e1 a melhor organiza\u00e7\u00e3o da rede de INSS da preval\u00eancia da DC cr\u00f4nica no Brasil (Minist\u00e9rio da Sa\u00fade do Brasil);  Realizar notifica\u00e7\u00e3o compuls\u00f3ria dos casos cr\u00f4nicos diagnosticados de acordo com a publica\u00e7\u00e3o da Portaria n  Estadiar, por meio da utiliza\u00e7\u00e3o de exames complementares, o grau de comprometimento card\u00edaco, mantendo di\u00e1logo permanente com as Unidades B\u00e1sicas de Sa\u00fade (UBS) e UPAE, de forma descentralizada, para que o fluxo de refer\u00eancia e contrarrefer\u00eancia seja efetivado. Casos na FIDC ou com dano card\u00edaco n\u00e3o significativo poder\u00e3o ser acompanhados nas UBS, pr\u00f3ximo ao domic\u00edlio, diminuindo, assim, a necessidade de tratamento fora do domic\u00edlio;  Pessoas acometidas com indica\u00e7\u00e3o de tratamento etiol\u00f3gico dever\u00e3o seguir as recomenda\u00e7\u00f5es indicadas em cap\u00edtulo espec\u00edfico destas diretrizes da SBC e poder\u00e3o ser acompanhados nas UBS, desde que a equipe de sa\u00fade esteja habilitada ao manejo cl\u00ednico desses casos;  Mulheres em idade f\u00e9rtil devem ser orientadas sobre a possibilidade de transmiss\u00e3o cong\u00eanita da DC quando gr\u00e1vidas e orientadas quanto a m\u00e9todos de contracep\u00e7\u00e3o. Caso desejem ou j\u00e1 estejam gr\u00e1vidas, devem ser acompanhadas pela equipe de APS em articula\u00e7\u00e3o com servi\u00e7o de obstetr\u00edcia de refer\u00eancia e receber tratamento de acordo com as diretrizes vigentes;  Casos de DC com IC, arritmias complexas, necessidade de implantes de MP, CDI e TC dever\u00e3o permanecer em acompanhamento em servi\u00e7o de maior complexidade. Em alguns casos, o uso de DACM pode ser necess\u00e1rio como interven\u00e7\u00e3o intermedi\u00e1ria para TC ou como alternativa ao TC com bons resultados;  Identificar comprometimento digestivo associado e, quando presente, orientar ou encaminhar para servi\u00e7o de refer\u00eancia em DC;  Tratar as comorbidades ou avaliar a necessidade de encaminhar os casos para interconsulta em servi\u00e7os especializados;  A reabilita\u00e7\u00e3o card\u00edaca deve estar integrada a servi\u00e7os estruturados de aten\u00e7\u00e3o a pessoas com CCDC pelo benef\u00edcio cl\u00ednico comprovado do exerc\u00edcio f\u00edsico sob supervis\u00e3o para a sa\u00fade e qualidade de vida;  Pessoas com dificuldade no entendimento de prescri\u00e7\u00f5es da equipe de sa\u00fade podem ser auxiliadas por profissional farmac\u00eautico compondo a equipe multiprofissional de assist\u00eancia, com a finalidade de esclarecer a posologia, intervalo entre doses, eventos adversos, intera\u00e7\u00f5es medicamentosas e estrat\u00e9gias para alcance de solu\u00e7\u00f5es; smartphonese internet, o atendimento remoto tem sido de grande import\u00e2ncia na condu\u00e7\u00e3o de pacientes mais graves que n\u00e3o podem aguardar por uma consulta ou comparecer presencialmente para pequenos ajustes, fato comprovado especialmente durante a pandemia da COVID-19;  Propiciar a\u00e7\u00f5es educativas (presenciais ou virtuais) permanentes com a pessoa acometida, familiares e cuidadores/as sobre a doen\u00e7a e o autocuidado, objetivando a identifica\u00e7\u00e3o oportuna de sinais e sintomas de descompensa\u00e7\u00e3o card\u00edaca, disponibilizando canal de comunica\u00e7\u00e3o  e diversas m\u00eddias sociais. Com a difus\u00e3o de meios de comunica\u00e7\u00e3o, celulares tipo Esclarecer sobre os dispositivos intracard\u00edacos, fun\u00e7\u00e3o e necessidade de implante de MP ou CDI, bem como de TC, procurando desfazer mitos e cren\u00e7as que podem impactar negativamente a qualidade de vida e a ades\u00e3o aos tratamentos propostos, assim como sobre a impossibilidade em doar sangue, \u00f3rg\u00e3os e tecidos;  Valorizar o conhecimento experiencial das pessoas acometidas sobre sua pr\u00f3pria doen\u00e7a, convidando-as a participar de reuni\u00f5es educativas, possibilitando a troca de viv\u00eancias, potencializando a autonomia e o empoderamento, estimulando a mudan\u00e7a de postura de sujeito passivo a ativo no seu processo terap\u00eautico e suas demandas;  Reuni\u00f5es de grupo com abordagem de temas espec\u00edficos como: aspectos nutricionais, atividade f\u00edsica, depress\u00e3o, direitos das pessoas com doen\u00e7as cr\u00f4nicas, aspectos m\u00e9dico-trabalhistas, aux\u00edlio-transporte, previdenci\u00e1rios, sexualidade, gesta\u00e7\u00e3o, amamenta\u00e7\u00e3o, mitos e verdades sobre DC;  Oferecer suporte psicol\u00f3gico objetivando diminuir o estigma, o autopreconceito, os tabus e as cren\u00e7as inadequadas em rela\u00e7\u00e3o \u00e0 doen\u00e7a. Esclarecer sobre a preven\u00e7\u00e3o de fatores agravantes como \u00e1lcool, tabagismo, drogas l\u00edcitas e il\u00edcitas em sua doen\u00e7a;  Desenvolver a\u00e7\u00f5es de educa\u00e7\u00e3o permanente junto a profissionais da sa\u00fade, com enfoque espec\u00edfico sobre as peculiaridades da CCDC, estimulando o ensino, a pesquisa e a extens\u00e3o multiprofissional; T. cruzi(inclusive diante da possibilidade de transmiss\u00e3o cong\u00eanita) e, nos casos confirmados, incorpor\u00e1-los ao servi\u00e7o para determinar o fluxo terap\u00eautico a ser seguido;  Identificar pela busca ativa e o aprofundamento da rela\u00e7\u00e3o m\u00e9dico-paciente, outros membros da fam\u00edlia no mesmo contexto de risco e vulnerabilidade da exposi\u00e7\u00e3o ao Estimular e apoiar a cria\u00e7\u00e3o de novas associa\u00e7\u00f5es de pessoas acometidas pela DC, visando a melhor integra\u00e7\u00e3o entre elas, estabelecendo um canal de comunica\u00e7\u00e3o ativo e propositivo junto \u00e0 sociedade, particularmente a comunidade cient\u00edfica, pol\u00edtica e sanit\u00e1ria, a respeito de suas reivindica\u00e7\u00f5es baseadas no direito \u00e0 sa\u00fade. Abre-se, portanto, um forte canal em busca da cidadania ativa, em prol de si pr\u00f3prio e da coletividade, transformando a sua dor e o seu sofrimento em um ato pol\u00edtico;  Apoiar sempre a luta contra preconceitos, a exemplo da necess\u00e1ria supera\u00e7\u00e3o da adjetiva\u00e7\u00e3o pelo termo \u201cchag\u00e1sico\u201d, que reduz a pessoa acometida pela doen\u00e7a em si. Na pr\u00e1tica cl\u00ednica, significa substituir o termo \u201cchag\u00e1sico\u201d por \u201cpessoa acometida ou afetada pela DC\u201d;  Divulgar a exist\u00eancia da FINDECHAGAS, criada em 2010, assim como do dia 14 de abril, como Dia Mundial da DC, reconhecido pela OMS em 2019;  Criar servi\u00e7os de telemedicina para a realiza\u00e7\u00e3o de consultas e elabora\u00e7\u00e3o de laudos de exames complementares, como ECG e radiografia de t\u00f3rax. De acordo com essa avalia\u00e7\u00e3o \u00e0 dist\u00e2ncia para apoio matricial, encaminhar os casos selecionados para atendimento em servi\u00e7os estruturados.  Espera-se que, uma vez estruturado, o servi\u00e7o seja capaz de proporcionar:  Servi\u00e7os de refer\u00eancia estruturados para acompanhamento de pessoas com CCDC poder\u00e3o comprovar o que tem sido descrito para outras doen\u00e7as cr\u00f4nicas.  Fortalecimento da rela\u00e7\u00e3o entre o profissional de sa\u00fade e a pessoa acometida pela DC;  Desenvolvimento de escuta ativa e qualificada e de aconselhamento para a DC;  Melhor conhecimento sobre a doen\u00e7a entre profissionais de sa\u00fade e pessoas acometidas;  Favorecimento de maior ades\u00e3o ao tratamento farmacol\u00f3gico e n\u00e3o farmacol\u00f3gico;  Menor morbimortalidade com diminui\u00e7\u00e3o de atendimentos de emerg\u00eancia e reinterna\u00e7\u00f5es hospitalares;  Impacto positivo na qualidade de vida; diversos estudos recentes focalizam esse relevante conceito com dados fundamentados e coerentes; Redu\u00e7\u00e3o do estigma e do preconceito; Maior empoderamento, autonomia e motiva\u00e7\u00e3o das pessoas acometidas para desenvolverem a\u00e7\u00f5es de autocuidado e buscarem seus direitos ; Redu\u00e7\u00e3o dos custos para sa\u00fade p\u00fablica. Embora se saiba que aparentemente a implanta\u00e7\u00e3o de um servi\u00e7o estruturado implica em investimento , acredita-se que a sua estrutura\u00e7\u00e3o nas redes de aten\u00e7\u00e3o poder\u00e1 ter uma rela\u00e7\u00e3o favor\u00e1vel de custo e efetividade em m\u00e9dio e longo prazos.  Em suma, os servi\u00e7os estruturados t\u00eam como miss\u00e3o prec\u00edpua promover assist\u00eancia que favore\u00e7a a estabilidade cl\u00ednica, psicol\u00f3gica e social de todas as pessoas acometidas pela DC.  muitas das quais com implica\u00e7\u00f5es sociais e trabalhistas.  A CCDC, ainda prevalente no Brasil, pode cursar com IC, arritmias ventriculares e dist\u00farbios de condu\u00e7\u00e3o do est\u00edmulo el\u00e9trico, AVC e outras complica\u00e7\u00f5es tromboemb\u00f3licas, pulmonares e sist\u00eamicas, configurando, portanto, situa\u00e7\u00f5es graves,  De acordo com aquele documento, o m\u00e9dico perito tinha que se valer de dados subjetivos para concluir a sua avalia\u00e7\u00e3o diagn\u00f3stica. Todavia, com os avan\u00e7os da medicina pericial, baseados em melhor conhecimento da evolu\u00e7\u00e3o cl\u00ednica e progn\u00f3stico de pacientes com CCDC, al\u00e9m dos avan\u00e7os relacionados aos m\u00e9todos complementares que diagnosticam a disfun\u00e7\u00e3o cardiovascular, a caracteriza\u00e7\u00e3o de cardiopatia como entidade m\u00f3rbida evoluiu, tornando-se necess\u00e1rio que o diagn\u00f3stico seja respaldado por avalia\u00e7\u00e3o cl\u00ednica rigorosa e comprova\u00e7\u00e3o laboratorial, conforme reza a II Diretriz Brasileira de Cardiopatia Grave da SBC, publicada em 2006.  O termo \u201ccardiopatia grave\u201d, cunhado por uma equipe multidisciplinar, foi referido pela primeira vez na legisla\u00e7\u00e3o brasileira no ano de 1952 mediante o Estatuto dos Funcion\u00e1rios Civis da Uni\u00e3o, pela lei 1.711 , e definido como \u201cdoen\u00e7a que leva, em car\u00e1ter tempor\u00e1rio ou permanente, a redu\u00e7\u00e3o da capacidade funcional do cora\u00e7\u00e3o, a ponto de acarretar risco \u00e0 vida ou impedir o servidor de exercer suas atividades laborais\u201d.  Por cardiopatia grave entende-se um amplo grupo de enfermidades e condi\u00e7\u00f5es cl\u00ednicas, de origem cardiol\u00f3gica, em que ocorre redu\u00e7\u00e3o significativa na perspectiva de sobrevida ou limita\u00e7\u00e3o significativa na capacidade funcional, ou ambas as situa\u00e7\u00f5es. A tipifica\u00e7\u00e3o de cardiopatia grave se destina precipuamente a atender quest\u00f5es na esfera trabalhista  ou proporcionar benef\u00edcios financeiros (libera\u00e7\u00e3o do FGTS e de PIS/PASEP) e fiscais  ou de aumento de proventos .  Primeiramente, \u00e9 preciso destacar que o termo \u201ccardiopatia grave\u201d pode ser encontrado em diversos processos judiciais, conforme explicitado na Lei Federal n\u00ba 7.713/1988, artigo 6\u00ba, inciso XIV. statusde cardiopatia grave \u00e9 definido somente ap\u00f3s a utiliza\u00e7\u00e3o apropriada de tratamento cl\u00ednico ou cir\u00fargico, quando recomendados, e identificada a aus\u00eancia de resposta satisfat\u00f3ria, ou ainda em situa\u00e7\u00f5es em que n\u00e3o h\u00e1 recursos terap\u00eauticos satisfat\u00f3rios ou, se houver, eles n\u00e3o s\u00e3o suficientes para modificar a situa\u00e7\u00e3o cl\u00ednica e progn\u00f3stica do indiv\u00edduo.  Em segundo lugar, \u00e9 importante esclarecer que o Altera\u00e7\u00f5es ocasionais em exames complementares n\u00e3o implicam em diagn\u00f3stico autom\u00e1tico de cardiopatia grave. De fato, a verifica\u00e7\u00e3o das limita\u00e7\u00f5es funcionais e a avalia\u00e7\u00e3o do progn\u00f3stico decorrem de ampla investiga\u00e7\u00e3o e contextualiza\u00e7\u00e3o do cen\u00e1rio cl\u00ednico do paciente com cardiopatia. Dito de outra maneira, entre os principais crit\u00e9rios de inclus\u00e3o no rol de cardiopatias graves, deve-se assegurar a realiza\u00e7\u00e3o de uma avalia\u00e7\u00e3o cl\u00ednica completa, algo que permita obter informa\u00e7\u00f5es sobre a capacidade funcional do paciente, e, paralelamente, obter informa\u00e7\u00f5es acerca da taxa estimada de sobrevida para a referida situa\u00e7\u00e3o.  A segunda parte decorre do grau de evid\u00eancia de risco de morte e esse dado deve ser obtido, no caso espec\u00edfico da CCDC, mediante a utiliza\u00e7\u00e3o de escores validados e publicados em emblem\u00e1ticos peri\u00f3dicos especializados.  A primeira parte \u00e9 realizada mediante consulta m\u00e9dica com anamnese e exame f\u00edsico detalhados, complementados pela realiza\u00e7\u00e3o de exames, tais como ECG, radiografia de t\u00f3rax, ecodopplercardiograma, Holter de 24 horas, teste ergom\u00e9trico ou ergoespirom\u00e9trico, dentre outros. Em situa\u00e7\u00f5es espec\u00edficas, podemos recorrer a exames mais sofisticados ou invasivos, como cintilografia mioc\u00e1rdica, RMC, angiotomografia ou cineangiocoronagrafia.  Infelizmente, a CCDC tem um curso vari\u00e1vel e imprevis\u00edvel, sendo uma das suas apresenta\u00e7\u00f5es a morte, que pode ser s\u00fabita, por evolu\u00e7\u00e3o progressiva de quadro de IC, ou decorrente de fen\u00f4meno tromboemb\u00f3lico. Estimar, portanto, o risco de morte de um paciente com CCDC \u00e9 um desafio cl\u00ednico relevante e foi deveras facilitado pela introdu\u00e7\u00e3o de um escore desenvolvido com essa finalidade. et al., publicado em 2006, acompanhando uma coorte de 424 pacientes com CCDC.  Durante o per\u00edodo do estudo, aproximadamente 8 anos, 130 pacientes evolu\u00edram para \u00f3bito. Os autores identificaram seis vari\u00e1veis associadas com morte: classe funcional III ou IV da NYHA = 5 pontos; evid\u00eancia de cardiomegalia na radiografia de t\u00f3rax = 5 pontos; disfun\u00e7\u00e3o ventricular esquerda global ou segmentar na ecocardiografia = 3 pontos; TVNS ao Holter de 24 horas = 3 pontos; QRS do ECG com baixa voltagem em todas as deriva\u00e7\u00f5es do plano frontal = 2 pontos; e sexo masculino = 2 pontos. Embasados nessa pontua\u00e7\u00e3o, os autores definiram tr\u00eas categorias de risco: baixo risco (0 a 6 pontos); risco intermedi\u00e1rio (7 a 11 pontos); e alto risco (12 a 20 pontos). Em 10 anos, a mortalidade dos tr\u00eas grupos foi, respectivamente, 10%, 44% e 84%.  Trata-se do escore idealizado por Rassi Jr. vigente e que ainda embasa o diagn\u00f3stico pericial de cardiopatia grave, lastreia-se muito mais na capacidade funcional/qualidade de vida do paciente ap\u00f3s ter esgotado os recursos terap\u00eauticos habituais, que em ci\u00eancia de predi\u00e7\u00e3o de risco. Em que pese a import\u00e2ncia do quadro cl\u00ednico e da classe funcional, a busca por novas ferramentas progn\u00f3sticas que permitam refinar os dados cl\u00ednicos ser\u00e1 fundamental para subsidiar melhor as per\u00edcias m\u00e9dicas e suas conclus\u00f5es.  De posse desse escore, o trabalho do perito pode ser mais facilmente parametrizado, traduzindo em n\u00fameros a realidade cl\u00ednica do paciente. Portanto, aquele que porventura contabilize \u2265 12 pontos no escore de RASSI seguramente ser\u00e1 considerado paciente com cardiopata grave. Entretanto, deve-se destacar que a II Diretriz Brasileira de Cardiopatia Grave da SBC, publicada em 2006,  \u00c9 not\u00f3ria a necessidade urgente da revis\u00e3o da referida diretriz para que tais avan\u00e7os cient\u00edficos possam ser debatidos com rigor sobre a sua utilidade durante a emiss\u00e3o de laudos periciais de pacientes com a DC.  Entre os aspectos cl\u00ednicos caracter\u00edsticos da CCDC, s\u00e3o citados IC congestiva, arritmias ventriculares complexas necessitando de implante de CDI, fen\u00f4menos tromboemb\u00f3licos e comprometimentos graves das fun\u00e7\u00f5es hep\u00e1tica e renal, secund\u00e1rios \u00e0 doen\u00e7a card\u00edaca de base. Vale ressaltar que \u00e9 de import\u00e2ncia capital avaliar a condi\u00e7\u00e3o funcional desses pacientes associada \u00e0 redu\u00e7\u00e3o da expectativa de vida, a despeito do arsenal terap\u00eautico otimizado para enquadr\u00e1-los na condi\u00e7\u00e3o de cardiopatia grave causada pela DC. statusde cardiopatia grave a indiv\u00edduos que busquem a Previd\u00eancia Social, com intuito de receber benef\u00edcios decorrentes dessa tipifica\u00e7\u00e3o. Para exercer essa fun\u00e7\u00e3o, o perito conta, al\u00e9m de sua forma\u00e7\u00e3o acad\u00eamica na \u00e1rea de sa\u00fade, com a realiza\u00e7\u00e3o de cursos de especializa\u00e7\u00e3o. Existem tamb\u00e9m diversos manuais que orientam o exerc\u00edcio correto dessa fun\u00e7\u00e3o. Al\u00e9m desses aspectos, h\u00e1 que se considerar aquilo que recebe o nome de \u201camplexo das leis\u201d. No caso da cardiopatia grave causada pela DC, ela se situa dentro do espectro da cardiopatia grave em geral. Essa se encontra amparada em tr\u00eas leis, que, por sua vez, se referem a respectivos regimes legais: regime jur\u00eddico \u00fanico (lei n\u00ba 8.112/90); regime previdenci\u00e1rio (lei n\u00ba 8.213/91); e regime fiscal (lei n\u00ba 11.052/04).  O perito m\u00e9dico-legal \u00e9 o profissional capacitado para avaliar e conceder (ou n\u00e3o) obiopump); e 4) cardiopatia terminal, quando a expectativa de vida se encontra bastante reduzida, n\u00e3o responsiva a qualquer tipo de terapia.  Do ponto de vista did\u00e1tico, pode-se classificar cardiopatia grave nas seguintes subdivis\u00f5es: 1) cardiopatias agudas, de evolu\u00e7\u00e3o r\u00e1pida, podendo transformar-se, progressivamente, em cardiopatias cr\u00f4nicas, caracterizadas por perda da capacidade f\u00edsica do indiv\u00edduo e funcional do cora\u00e7\u00e3o; 2) cardiopatias cr\u00f4nicas, caracterizadas por limitar progressivamente a capacidade f\u00edsica e funcional do cora\u00e7\u00e3o, ultrapassando os limites de efici\u00eancia dos mecanismos de compensa\u00e7\u00e3o card\u00edacos, n\u00e3o obstante o tratamento cl\u00ednico e/ou cir\u00fargico adequado adotado; 3) cardiopatias cr\u00f4nicas ou agudas que apresentam depend\u00eancia total de suporte inotr\u00f3pico farmacol\u00f3gico  ou mec\u00e2nico  e discernimento . Cabe ao perito, de posse do relat\u00f3rio m\u00e9dico e dos exames complementares, reavaliar o indiv\u00edduo para o qual se pleiteia ostatusde cardiopatia grave, a fim de validar ou n\u00e3o essa condi\u00e7\u00e3o. Uma FEVE inferior a 40%, com medica\u00e7\u00e3o otimizada, costuma ser um dos principais par\u00e2metros funcionais adotados. De modo geral, \u00e9 necess\u00e1ria uma avalia\u00e7\u00e3o mais ampla, a fim de encampar todos os aspectos do quadro cl\u00ednico e dos exames complementares, uma vez que h\u00e1 situa\u00e7\u00f5es lim\u00edtrofes, em que se observa quadro cl\u00ednico dissonante dos m\u00e9todos diagn\u00f3sticos, resultados divergentes entre exames ou direcionamento para outros dados de igual relev\u00e2ncia para a classifica\u00e7\u00e3o.  Diferentemente da Junta M\u00e9dica, a atua\u00e7\u00e3o pericial em sa\u00fade decorre rotineiramente da atua\u00e7\u00e3o de um \u00fanico perito, designado para avaliar se o Em casos de discord\u00e2ncia ou diverg\u00eancia nos crit\u00e9rios selecionados para a classifica\u00e7\u00e3o, tendo o perito negado a presen\u00e7a dessa condi\u00e7\u00e3o, a via judicial tem sido o recurso a seguir, naturalmente, havendo subs\u00eddio documental suficiente para deflagrar a via processual.  De maneira sucinta, al\u00e9m da pontua\u00e7\u00e3o do escore de RASSI \u2265 12 pontos, outras informa\u00e7\u00f5es importantes a indicar poss\u00edvel diagn\u00f3stico de cardiopatia grave em pacientes com CCDC s\u00e3o: classe funcional NYHA III ou IV isoladamente; epis\u00f3dios de s\u00edncope de repeti\u00e7\u00e3o, sem possibilidade de controle definitivo; presen\u00e7a de TV, principalmente se sintom\u00e1tica ou demandar atendimento emergencial; cardiomegalia acentuada; e presen\u00e7a de trombo no cora\u00e7\u00e3o ou antecedentes tromboemb\u00f3licos.  Vale ressaltar que a presen\u00e7a de disfun\u00e7\u00e3o do n\u00f3 sinusal sintom\u00e1tica ou de BAV avan\u00e7ado  n\u00e3o implica necessariamente em limita\u00e7\u00e3o funcional permanente, uma vez que o implante de MP pode reverter o quadro cl\u00ednico e melhorar significativamente o progn\u00f3stico, particularmente quando o paciente apresenta essas altera\u00e7\u00f5es de forma isolada. No entanto, na CCDC, principalmente nos est\u00e1gios avan\u00e7ados, \u00e9 comum a presen\u00e7a de bradiarritmias e bloqueios avan\u00e7ados associados \u00e0 depress\u00e3o da fun\u00e7\u00e3o mioc\u00e1rdica ou a arritmias ventriculares complexas, apontando para um maior comprometimento da fun\u00e7\u00e3o card\u00edaca sob outros aspectos, concomitantemente. Nesses casos, uma avalia\u00e7\u00e3o cardiol\u00f3gica ampla, conforme sugerida acima, permite ao perito m\u00e9dico identificar a real situa\u00e7\u00e3o do paciente em termos de limita\u00e7\u00e3o definitiva, tanto no que diz respeito \u00e0 situa\u00e7\u00e3o funcional quanto ao progn\u00f3stico.  De modo an\u00e1logo, a mera presen\u00e7a de sorologia positiva para DC ou a sua associa\u00e7\u00e3o com uma altera\u00e7\u00e3o eletrocardiogr\u00e1fica, por exemplo, BRD, n\u00e3o \u00e9 elemento suficiente para a caracteriza\u00e7\u00e3o de cardiopatia grave. Embora se saiba que uma fra\u00e7\u00e3o desses indiv\u00edduos evolua para formas incapacitantes no futuro, a maioria pode permanecer d\u00e9cadas nesse est\u00e1gio, sem sintomas, ou at\u00e9 completar seu ciclo de vida sem o agravamento cl\u00ednico dessa enfermidade.  A fim de que a fun\u00e7\u00e3o pericial seja exercida em sua plenitude, cabe ao m\u00e9dico-assistente fornecer relat\u00f3rios detalhados que descrevam com precis\u00e3o e clareza a situa\u00e7\u00e3o cl\u00ednica do paciente e anexar exames que a comprovem.  A defini\u00e7\u00e3o de cardiopatia grave nos tempos atuais encontra-se facilitada pelo avan\u00e7o do conhecimento da evolu\u00e7\u00e3o cl\u00ednica parametrizada, terap\u00eautica cl\u00ednica e por exames complementares existentes, a grande maioria deles com respaldo cient\u00edfico em termos do progn\u00f3stico desses pacientes. A reuni\u00e3o dessas informa\u00e7\u00f5es, qualificadas e organizadas em forma de escores desenvolvidos em indiv\u00edduos brasileiros, \u00e9 de grande valia para subsidiar o perito em sua avalia\u00e7\u00e3o e defini\u00e7\u00e3o dos mesmos. Entretanto, a capacidade de julgamento cl\u00ednico do m\u00e9dico deve ser exercitada em toda sua plenitude, agregando sinais e sintomas caracter\u00edsticos do paciente em quest\u00e3o, associados a dados dos exames complementares solicitados.  123I-MIBG \u2013 iodine-123-metaiodobenzylguanidine18F-FDG \u2013 18F-fluorodeoxyglucose+ACEI \u2013 angiotensin-converting-enzyme inhibitorACLS \u2013 Advanced Cardiovascular Life SupportAF \u2013 atrial fibrillationAIDS \u2013 acquired immunodeficiency syndromeANVISA \u2013 Brazilian Health Surveillance AgencyARB \u2013 angiotensin II receptor blockerATP \u2013 adenosine triphosphateAVB \u2013 atrioventricular blockBNP \u2013 brain natriuretic peptideCCCD \u2013 chronic cardiomyopathy of Chagas diseaseCCD \u2013 cardiomyopathy of Chagas diseaseCD \u2013 Chagas diseaseCI \u2013 confidence intervalCLIA \u2013 chemiluminescence immunoassayCMIA \u2013 chemiluminescent microparticle immunoassayCMRI \u2013 cardiac magnetic resonance imagingCONITEC \u2013 National Commission of Technology Incorporation in the SUSCOVID-19 \u2013 disease caused by the new coronavirusCRT \u2013 cardiac resynchronization therapyCTI \u2013 cardiothoracic indexCTX \u2013 cardiac transplantationCVP \u2013 central venous pressureDCM \u2013 dilated cardiomyopathyDTU \u2013 discrete typing unitsEBM \u2013 Evidence-Based MedicineECG \u2013 electrocardiogramECHO \u2013 echocardiographyECLIA \u2013 electrochemiluminescence immunoassayELISA \u2013 enzyme-linked immunosorbent assayEPS \u2013 electrophysiological studyFDA \u2013 Food and Drug AdministrationFINDECHAGAS \u2013 International Federation of Associations of Individuals With Chagas DiseaseFunda\u00e7\u00e3o Oswaldo CruzFIOCRUZ \u2013G-CFS \u2013 granulocyte-colony stimulating factorGLS \u2013 global longitudinal strainGRADE \u2013 Grading of Recommendations, Assessment, Development, and EvaluationsGWAS \u2013 Genome Wide Association StudyHF \u2013 heart failureHFmrEF \u2013 heart failure with mildly reduced ejection fractionHFrEF \u2013 heart failure with reduced ejection fractionHIV \u2013 human immunodeficiency virusHR \u2013 heart rateHRV \u2013 heart rate variabilityICD \u2013 implantable cardioverter-defibrillatorICM \u2013 ischemic cardiomyopathyIDI \u2013 integrated discrimination indexIFCD \u2013 indeterminate form of Chagas diseaseIFN-\u03b3 \u2013 interferon-gammaIHA \u2013 indirect hemagglutinationIIF \u2013 indirect immunofluorescenceIL \u2013 interleukinINR \u2013 international normalized ratioInstituto Nacional do Seguro Social)INSS \u2013 National Institute of Social Security SBC \u2013 Brazilian Society of Cardiology SINAN \u2013 Notifiable Diseases Information System SUS \u2013 Brazilian Unified Health System 486.2.8. Intracardiac Electrophysiological Study486.2.9. Exercise and Cardiopulmonary Tests486.2.10. Cardiac Catheterization497. Risk Stratification and Prognosis 498. Therapeutic Management in the Indeterminate Form of Chagas Disease 549. Etiological Treatment of Chagas Disease 569.1. Introduction 569.2. Drugs and Administration 579.3. Etiological Treatment of Individuals with Chagas Disease 609.4. Acute Infection 609.5. Congenital Infection 619.6. Children and Adolescents with Chronic Infection 619.7. Women of Reproductive Age with Chronic Infection 619.8. Adults with Chronic Infection 629.9. Reactivation of Chagas Disease 639.10. Accidental Infection 649.11. Assessment of Chagas Disease Cure after Etiological Treatment 649.11.1. Where to Treat an Individual with Chagas Disease6510. Therapeutic Management of Ventricular Dysfunction and Heart Failure 6610.1. Pharmacological Resources 6610.1.1. Heart Failure Classification6610.1.2. Maximum Dosage of Medications6610.1.3. The Contemporary Patient6610.1.4. Literature Review6610.1.5. Pharmacological Therapy6610.1.5.1. Diuretics6610.1.5.2. Renin-Angiotensin-Aldosterone System Inhibitors6710.1.5.3. Beta-blockers6710.1.5.4. Spironolactone6810.1.5.5. Ivabradine6810.1.5.6. Digoxin6810.1.5.7. Sacubitril-valsartan6810.1.5.8. Sodium-Glucose Cotransporter-2 Inhibitors6910.2. Non-Pharmacological Resources 7110.2.1. Cardiac Transplantation 7110.2.1.1. Immunosuppression Strategies7310.2.1.2. Induction Therapy7310.2.1.3. Maintenance Therapy7310.2.2. Diagnosis and Treatment of Rejection7310.2.3. Diagnosis and Treatment of T. cruzi-Infection Reactivation7410.2.3.1. Clinical Presentation7410.2.3.2. Parasitological Diagnosis of Reactivation 7410.2.3.3. Etiological Treatment of Reactivation7410.2.3.4. Post-Heart Transplant Complications and Survival7510.2.4. Mechanical Circulatory Support7511. Therapeutic Management of Cardiac Arrhythmias 7611.1. Pharmacological Resources 7611.1.1. Introduction7611.1.2. Sudden Death Prevention with Non-Antiarrhythmic Drugs 7611.1.3. Ventricular Arrhythmias in Cardiopathies of Other Etiologies7711.1.4. Amiodarone for Patients with Cardiopathies of Other Etiologies: Primary Prevention7711.1.5. Amiodarone for Patients with Cardiopathies of Other Etiologies: Secondary Prevention7911.1.6. Ventricular Arrhythmias in Patients with Chronic Cardiomyopathy of Chagas Disease: Characteristics and Treatment8011.1.6.1. Ventricular Extrasystoles8011.1.6.2. Nonsustained Ventricular Tachycardia8011.1.6.3. Sustained Ventricular Tachycardia and Ventricular Fibrillation8011.1.7. Care During the Use of Amiodarone8211.1.8. Prevention of Electrical Shock Recurrence in Patients Treated with Implantable Cardioverter-Defibrillator8211.1.9. Pharmacological Treatment of Atrial Fibrillation in Chronic Cardiomyopathy of Chagas Disease8311.1.10. Treatment in the Emergency Room8311.1.11. Outpatient Treatment8311.1.11.1. Reversion to Sinus Rhythm8311.1.11.2. Heart Rate Control8311.2. Pacemaker, Cardioverter-Defibrillator, and Cardiac Resynchronization Therapy 8511.2.1. Artificial Cardiac Pacemaker8511.2.2. Implantable Cardioverter-Defibrillator in CCCD8511.2.2.1. Primary Prevention of Sudden Cardiac Death8511.2.2.2. Secondary Prevention of Sudden Cardiac Death8711.2.3. Cardiac Resynchronization Therapy8911.3. Ablation Methods 9011.3.1. Sustained Ventricular Tachycardia: Clinical Presentation, Electrophysiological Mechanisms, and Sites of Origin9011.3.2. Clinical and Laboratory Pre-Ablation Assessment9011.3.3. Mapping Techniques for Ventricular Tachycardias9211.3.4. Outcomes and Complications During Ventricular Tachycardia Ablation9311.3.5. Ablation Results and Patients\u2019 Follow-up9312. Managements to Prevent and Treat Thromboembolic Complications 9312.1. Introduction 9312.2. Epidemiology of Thromboembolic Events 9412.3. Risk Factors and Mortality 9412.4. Risk Assessment of Stroke 9512.5. Clinical Findings and Diagnostic Investigation of Ischemic Stroke in Chagas Disease 9612.6. Treatment of Ischemic Stroke in Chagas Disease 9712.7. Prevention of Cardioembolic Events in Chagas Disease 9813. Management in Special Subgroups and Handling of Issues Related to T. cruzi-HIV Coinfection, Pregnancy, Physical Activity, Surgical Risk, General Anesthesia, and COVID-19 10013.1. T. cruzi-HIV Coinfection 10013.2. Seropositivity in Potential Donors at Blood Banks 10113.3. Physical Activity 10113.4. Pregnant Women 10213.5. Newborns 10313.6. Surgical and Anesthetic Risk 10413.7. Chagas Disease and Coronavirus Infection 10413.8. Noncardiac Transplantation and Immunosuppressive Therapy 10513.8.1. Donor with Chagas Disease and Recipient without Chagas Disease10513.8.2. Recipient with Chagas Disease10613.8.3. Autoimmune Diseases10713.9. Chagas Disease and Aging 10714. Recommendations for Implantation of Structured Health Services for the Follow-Up of Individuals with Chronic Cardiomyopathy of Chagas Disease 10714.1. Assignments of Structured Health Services for the Follow-up of Individuals with Chronic Cardiomyopathy of Chagas Disease 10814.2. Expected Benefits of Structured Health Services for the Follow-up of Individuals with Chronic Cardiomyopathy of Chagas Disease 10915. Definition of Severe Cardiopathy and Medico-Legal Assessment 11015.1. Introduction 11015.2. Concept and Scope 11015.3. Score to Predict the Risk of Death in Patients with Chronic Cardiomyopathy of Chagas Disease 11015.4. Clinical Aspects 11115.5. Medico-Legal Expert Assessment 11115.6. Conclusion 111Acknowledgements 111References 112Arquivos Brasileiros de Cardiologia,the current one would no longer be \u201cLatin American\u201d but would count essentially on an expressive number of Brazilian collaborators. The summoned group of notorious active researchers in the field would represent a comprehensive team of professionals from different parts of Brazil, involved in and directly contributing to the advance of the fight against CD. These researchers are responsible for this guideline authorship, as explained below.In 2021, the then president of the Brazilian Society of Cardiology (SBC), Dr. Marcelo Queiroga Cartaxo Lopes, commissioned us to coordinate the elaboration of the new guideline on Chagas disease (CD). The undertaking was justified because since 2011 the SBC had not directly been responsible for a guideline on that subject. Differently from the guideline published more than one decade ago in thethe scope of the current one was limited only to aspects related to the diagnosis and treatment of the most frequent and severe manifestation of CD, the cardiomyopathy of Chagas disease (CCD).In addition, considering that in 2015 we collaborated extensively with the Brazilian Society of Tropical Medicine guideline on the general context of CD,discrepancies exist mainly regarding the strength of the recommendations and levels of evidence related to the different types of treatment, as well as the appearance of new scientific evidence, corroborating the understanding that guidelines need to be periodically reviewed and updated.Despite the large number of documents on the theme in its varied aspects ,1-22This guideline, particularly its usual framework naturally directed to the formulation of rules of conduct and scientific evidence that support the countless aspects of CCD diagnosis and treatment, has some characteristics conferred by the temporal context of its elaboration. In fact, we lived the distressful circumstance of adding to CCD, a markedly inflammatory illness, the problems from the disease caused by the new coronavirus (COVID-19) pandemic, with its own inflammation component. Thus, the scientific community, both worldwide and specially in Brazil, had to face at least three big obstacles to control the pandemic: first, it is a special virus, with peculiar behavior regarding the injury to the host\u2019s organs; second, there were inherent and unpredictable difficulties regarding the epidemiological behavior of that virus; third, our national indigence, when we verify that, to overcome the pandemic, the appropriate measures bump into basic facts, such as the very precarious sanitary conditions of 30-40% of our population, lacking sewage, piped water, and minimally appropriate housing.To that set of challenges and obstacles, the Brazilian scientific community responded with notable readiness and efficiency, as exemplified by the large-scale development and application of vaccines against COVID-19. It is worth noting that the difficulties faced to widen the protection against contamination and to implement population vaccination were remains from the wars fought during the 20th century against the deleterious influence of the tobacco industry, which for a long time tried to hide the tobacco\u2019s harms.It is worth noting that some aspects of the concomitance of the infections byTrypanosoma cruzi(T. cruzi)and by coronavirus in the same individual are properly addressed in specific topics of this guideline.Denialist attitudes and dissemination of fake concepts, including by part of the medical community, represent an incremental obstacle to the performance of Science and Medicine in the fight against the pandemic.thcentury. In addition, a parallel can be drawn between the current scientific and medical community situation in the fight against the COVID-19 pandemic and the difficult context experienced by Carlos Chagas and his mentor Oswaldo Cruz during the first decades of the 20thcentury.Thus, the sanitary conquests in fighting the pandemic in the 21st century achieved by the scientific community, well represented by FIOCRUZ, a historical heir of its first and unsurpassed epigone, Oswaldo Cruz, are reminders of his success with the vaccination campaigns against yellow fever in the beginning of the 20Similarly to today\u2019s denialism, that great Brazilian, despite his scientifically epic discovery, had to confront the nihilism and misunderstanding of a considerable part of the medical community regarding his deeds in the history of Medicine, according to professor Jo\u00e3o Carlos Pinto Dias, and son of his direct collaborator, Emmanuel Dias, and also participating in this guideline. In addition, the early sudden death of Carlos Chagas might have been triggered emotionally, consequent to the obscurantist attack.As it has been reported, \u201cIt is plausible that his great humanistic perspicacity had provided him with the vision of the tragically real social meaning of the disease he had just discovered, affecting literally millions of vulnerable individuals in large areas of Brazil. In contrast to the denial by part of the academic community to accept the existence of the new disease, Carlos Chagas might have envisioned the national tragedy of his discovery, which still unfolds in multiple socially deplorable acts and chapters\u201d.It will never be too much to glorify Carlos Chagas\u2019 memory. According to Alejandro Hasslocher-Moreno, another collaborator of this guideline, \u201cCarlos Chagas was the right physician and scientist, at the right time, in the right place. The circumstances involving the disease\u2019s discovery had as protagonist an individual prepared to face a known challenge and, at the same time, to discover the unknown. In the biomedical context, the Brazilian science was boosted after the discovery of CD, gaining international recognition, one of the major legacies of Carlos Chagas to the Brazilian Science and Medicine\u201d.When revisiting and elaborating guidelines, it is justifiable to pay tribute to the emeritus physicians and scientists who either had left us right before the publication of the 2011 guideline or now, when we are finishing the 2022 guideline. We want to honor all of them for their legacy in CD research, and especially professors Joaquim Romeu Can\u00e7ado 1913-2011 (Belo Horizonte), Alu\u00edzio Rosa Prata 1920-2011 (Uberaba), Zilton Ara\u00fajo Andrade 1924-2020 , Jos\u00e9 Rodrigues Coura 1927-2021 (Rio de Janeiro), and Anis Rassi 1929-2021 (Goi\u00e2nia). To them we devote our gratitude and recognition. Their influence on this guideline kept us in the luminous scientific pathway trod by Carlos Chagas.The authors, collaborators and coordinators of this document are aware that, in this phase of intensified perception of CD as a neglected disease, it is mandatory to rescue the affected individuals from their miserable conditions and their deplorable medical-social implications. Thus, we should strive to minimize the stigma of CD, beginning by banning the term \u201cChagasic\u201d from this guideline. This is based on the recent understanding that instead of being an eponym to honor the historical trajectory of Carlos Chagas, that term, for some patients, would sound as if they had a true and painful incurable wound in their hearts.Involved in the elaboration of this guideline, we are clearly aware that our responsibility has greatly increased recently. In addition to being mainly directed to physicians and paramedics, the principles herein contained should be useful to guide managers and agencies in charge of providing proper public health conditions nationally. And last but not least, the individuals currently affected by the disease are much more in need for safe guidance by health professionals than in the past. The number of individuals with CD increased in parallel with the democratization of the information provided in the web. Health professionals must provide better instructions on how to manage and decrease the problems deriving from CD.We will use the introduction of this new guideline to describe the process that culminated in this document. Right from the beginning we realized that the timeline initially planned to be concluded in a few months did not correspond to our ambition to build a reflexive, scientifically deep document, with consistent clinical and population implications.The starting point was the meeting where the coordinators discussed the scientific principles to guide the elaboration of the topics, introducing the idea that the knowledge of experts would be essential to interpret and judge the applicability of the evidence, but not to foster opinions based on individual preferences. Disagreements would be solved by deep analysis of evidence, not by majority vote. At that time, we planted the seed of a guideline to challenge our own intuitions and recognized that often the truth antagonizes our expectations, requiring the cultivation of doubt, which usually contrasts with the eloquence of a group of opinion makers in their respective areas. This was the seed of a guideline built based on intense debates, creative attrition, and learning for all, totaling seven virtual meetings and 28 hours of debates.We hope we were able to \u2018rescue\u2019 at least most of the recommendations and the analyses of evidence that support them from the bias and other management deviations identified in previous contexts. We are sure that, unfortunately, the paradigm of EBM itself is currently abused and distorted, paradoxically amid the exponential multiplication of research and knowledge generated and disclosed without proportional control by entities that should supervise the entire process of advances in such a noble area of human activity. One example of such distortions, fortunately not observed in the context of CD, but very clear in some areas of Medicine, is the profusion of inappropriate, inconsistent, routine, or redundant meta-analyses, resulting in \u201cfake news\u201d, as already suggested.From conception to the last subject presented in this guideline, we tried to follow the most legit principles of the classic paradigm of Evidence-Based Medicine (EBM). Even though a comprehensive systematic review of the literature could not be performed, in some more polemic points we analyzed the evidence that should answer the so-called PICO question, which comprises the characteristics of the population (\u201dP\u201d), intervention (\u201cI\u201d), comparing control (\u201cC\u201d), and outcome (\u201cO\u201d).which briefly is \u201cCardiologists should improve their patients\u2019 clinical management, wisely administering medications and interventions that respect as much as possible the peculiar pathophysiology of the disease, neither appealing to measures without proof of benefit nor wasting plausible therapeutic opportunities\u201d.Thus, we retrieve and emphasize the essential principle of the last section of the SBC 2011 guideline,The construction of a guideline for medical management is an underppreciated opportunity of reflection on the rationale that enables the translation from the scientific paradigm to clinical decision. This type of reflection can develop strategies to reduce the gap between evidence and recommendation.Scientific evidence has two major functions: the epistemological function , relative to the construction of knowledge of causality, and the pragmatic function, which influences the decision-making process . In the first function, evidence of an exploratory character, whose quality is satisfactory, is valued by suggesting the scientific pathway. In the second function, the use of evidence with a high risk for bias or statistical imprecision servs more to justify the desire to act rather than to increase the likelihood that the action represents the best choice for the patient or population. It is the intuitive desire searching for scientific justification.The strength of the recommendation is usually related to the level of evidence. For this guideline, we adopted a simple classification based on the GRADE  approach,but with some modifications, grouping the studies into only 3 levels of quality of evidence , from which 2 grades of recommendation derive . The starting point in assessing the quality of the evidence should be the delineation of the research. Evidence originating from analytical experimental studies, such as randomized clinical trials (RCTs), and systematic reviews with meta-analyses of those studies are less prone to biases, being, consequently, considered of better quality or high level (A). In contrast, evidence originating from analytical observational studies  are considered of moderate level (B), and those originating from descriptive observational studies (without a comparing group), such as case series, are considered of low quality or low level (C).Guidelines usually make clinical recommendations based on the quality of the evidence found after careful search. Several systems have been proposed to classify evidence and to categorize the \u201cstrength\u201d of the clinical recommendation, such as GRADE, CEBM, SIGN, NZGG, SORT, USPSTF, ACCF/AHA/ESC, ACCP, IDSA, and NICE.One solution for this question is the recognition of the value of indirect evidence, originating from results of RCTs performed on other cardiopathies, and the understanding of the difference between representative sample and generalizable sample.In the specific case of CCD, because we do not usually have high quality evidence deriving from RCTs and, in some situations, not even from observational studies with convincing results to generate endorsed recommendations, there is a natural tendency to resort to free \u201cexpert opinion\u201d or \u201cconsensus\u201d, abstract words of uncertain significance and consequences, which should not be formally characterized as evidence.In observational descriptive studies, the sample representativeness is essential. For example, regarding the prognosis of a patient with heart failure (HF), what is observed in ischemic cardiomyopathy (ICM) might not apply to CCD. However, in analytical, observational, or experimental  studies, a nonrepresentative sample can become generalizable. For generalization to be justified, lack of interaction (effect modification) between the populations\u2019 differences and the effect of a risk factor or a medical management is required.Because biological interaction is a rare phenomenon, nonrepresentative samples generate generalizable concepts for different types of patients. This justifies a large part of the recommendations for elderly and children, subgroups usually not properly represented in RCTs. The prescription, for example, of an angiotensin-converting-enzyme inhibitor (ACEI) for a patient with CCD and reduced left ventricular ejection fraction (LVEF) is not based on preference or use of evidence of low quality in that type of population. It is based on evidence of high quality in patients with HF of other etiologies, in accordance with the perception that \u201ceffect modification\u201d by the cardiomyopathy etiology (interaction) is unlikely. This is how scientific knowledge is built. For example, the theory supporting the knowledge that the speed of light is constant did not derive from its measure in all environments and circumstances. Only a few measures, in accordance with the notion of low probability of interaction between the environment and speed of light, enable us to generalize that the speed of light is, in fact, constant.When making generalization, we should question if there is a characteristic in the population of interest that would change the study\u2019s result. For example, is there any characteristic of the patient with CCD that can modify the beneficial effect (interaction) of the vasodilating therapy, which was confirmed in ICM or dilated cardiomyopathy (CDM)? Probably not.In the absence of direct experimental evidence, which is obtained from the results of RCTs performed on CCD (level A), and of indirect evidence, which is obtained from extrapolation of the results of RCTs performed on other cardiopathies (level B), we chose to value the results obtained from observational analytical studies (level B) or from observational descriptive studies (level C), both performed on CCD, in addition to adopting the principle of extreme plausibility and the principle of asymmetry as level C of evidence.equipoise, decisions are not made based on experimental data, but on natural data. There are situations that do not require \u201cjudgement\u201d  and it would be unethical to perform an experiment with a control group. One example is the use of diuretic in HF with marked congestion, whose benefit has never been specifically measured in a placebo-controlled clinical trial, because of its almost deterministic character. If it were, we would have a number needed to treat (NNT) of 1 for symptom improvement and a possibly very relevant NNT for reduction of mortality.It is worth noting that decision-making that dispense empirical evidence is common in Medicine. In the essential absence ofThis is another circumstance in which the level C of evidence should be applied: absence of experimental evidence, but strong natural evidence. This should be emphatically differentiated from the paradigm of preference, contained in \u201cconsensus\u201d, because the evidence regarding the use of parachute requires no consensus. It is indisputable.By failing to understand that statement, the medical community places diuretics at a lower level of benefit because of the lack of experimental proof of mortality reduction. Therefore, in the presence of HF with systemic and/or pulmonary congestion, the careful prescription of a diuretic should be considered based on essential evidence, leading to its strong recommendation. For situations like that, the parachute analogy can be used as a strategy to reduce mortality of individuals in free fall.Another principle that will be used as level C of evidence is that of asymmetry of effect, which can be applied to situations in which, despite the lack of proof of the efficacy of a certain intervention, there is great asymmetry between the magnitude of a potential benefit and the magnitude of an occasional harm, such as the use of masks to control COVID-19 and the etiological treatment in middle-aged adults with the indeterminate form of CD (IFCD).Once the situations of extreme plausibility and asymmetry (level C) are resolved, we should solve the indications based on level B of evidence. This level should not be represented by evidence of dubious quality. The quality of the evidence should be of low risk for bias and high precision, here represented as indirect evidence of high level and direct evidence of satisfactory quality.versusrisk (harm/loss), of the doubt regarding feasibility (effectiveness), or even of cost-effectiveness questions .While the classification of the level of evidence is part of the scientific dimension, the strength of the recommendation involves and translates the dimension of clinical thinking: of the individual probability of benefit (magnitude of the effect)Thus, in analogy to the classification system adopted by ACC/AHA, we will name the grade of recommendation I and most of the time the grade of recommendation IIa as \u201cstrong\u201d, which should be applied to those situations with little or no doubt regarding the \u2018prescription\u2019 process, which becomes almost a rule, except if specific contraindications apply. For example, the prescription of etiological treatment in cases of reactivation of CD (RCD). In contrast, the term \u201cconditional\u201d recommendation will apply to grade IIb , whose decision-making depends on a clinical analysis individualized in its magnitude of benefit and risk, patient\u2019s values and preferences (shared decision-making), and aspects regarding the health system .In parallel with the organization of the scientific thinking applied to recommendation on therapeutic management, a predominant theme in any guideline, we should widen the discussion for recommendation of diagnostic tests, because we also have chapters on such dimensions of medical decision.In the context of diagnosis and differently from that of treatment, the grounding scientific concept of the level of evidence is not efficacy. Diagnosis involves the concept of accuracy, the ability to discriminate between sickness (sensitivity) and healthiness (specificity). Thus, the question is neither the conceptual proof of causality, nor the need for randomized experimental studies to minimize confounding factors. The need is to demonstrate enough accuracy so that the new information added by the test increases significantly the pretest diagnostic probability, within a structure of Bayesian thinking.In that case, the best level of evidence for diagnostic accuracy derives from cross-sectional studies with proper methodology for patients\u2019 selection, execution and reading of the predefined tests, performed to reduce systematic errors. It is worth noting that the studies of diagnostic accuracy are very sensitive to biases caused by retrospective observations from data banks .Thus, the quality of the evidence is essential, and recommendation based on preliminary information should be avoided. Similarly to what is used for treatment, the current guideline classifies as level of diagnostic evidence A and B those with satisfactory precision and low risk for bias, with level B refering to indirect evidence with high potential of generalization or to direct evidence of satisfactory quality. Level of evidence C is reserved for situations that do not require empirical evidence, incontrovertible situations. For example, the accuracy of the electrocardiogram (ECG) to define baseline cardiac rhythm.Regarding the strength of the recommendation, the accuracy observed is a necessary, but not sufficient, condition. An accurate test has not necessarily strong indication. For that, three essential conditions apply: first, the diagnosis should be clinically useful, that is, should benefit the patient; second, the test\u2019s additional information should be necessary and sufficient to increase the pretest diagnostic probability, which was previously undefined; and third, less complex, less invasive, of lower risk, or less expensive options should be absent. For example, although cardiac magnetic resonance imaging (CMRI) has better accuracy to assess systolic function, it is not strongly recommended because echocardiography (ECHO) is usually sufficiently accurate and widely available, unlike CMRI.equipoisebetween the intentional consequences of early diagnosis and the probability of harm. In such dubious circumstances, performing diagnostic tests by use of RCTs is suggested to substantiate the diagnostic effort.This analysis of the need for a certain diagnostic test and of its impact determines its strength of recommendation, which is usually defined based on clinical rationale. For example, in the case of a symptomatic patient, finding a defined problem is obviously useful, if a specific solution applies. However, the diagnostic usefulness becomes dubious in the case of screening tests, when there is strongFinally, it is worth emphasizing that the rationale described for diagnosis also applies to the definition of the level of evidence and strength of recommendation for risk factors and prognostic models.T. cruziand belongs to the group of neglected tropical diseases (NTD) from the World Health Organization (WHO).Discovered by Carlos Ribeiro Justiniano Chagas in 1909,in the 21stcentury it continues to affect mainly socially vulnerable individuals and can generate severe physical , psychological (fear and stigma), and socioeconomic impacts, which reflect directly and indirectly on the quality of life.Chagas disease, also known as American trypanosomiasis, is a transmissible, potentially life-threatening illness caused by the protozoan parasiteT. cruzitransmission to the human species.Political-institutional, economic, environmental  and social  factors are equally important central determinants of the global impact ofT. cruzistrains, vector species, and reservoirs of the etiological agent, from the One Health perspective.For a deeper analysis of CD, it is essential to identify the different epidemiological scenarios and their transmission dynamics, involving not only individuals at risk for infection or already infected but also differentT. cruziis a hemoflagellate parasite, transmitted mainly through the contact of feces of different species of bugs of theHemipteraorder,Reduviidaefamily,Triatominaesubfamily, whose habitat extends from Argentina and Chile to the southern half of the United States of America (USA), contaminated when sucking blood from infected individuals or animals.T. cruzi-infected individuals; 4. solid organ transplant from an infected person; and 5. accidents with biological materials, particularly in laboratories, in addition to sharing contaminated needles/syringes by individuals on illegal drugs.From that perspective, the CD prevention and control actions are directly related to theT. cruzitransmission modes.In addition, transmission can occur through: 1. ingestion of contaminated foods and beverages with triatomine bugs or their feces; 2. congenitally, from an infected mother to her fetus or newborn during pregnancy or delivery; 3. transfusion of blood or blood products fromWhen not properly treated, theT. cruziinfection can last a whole life.It is estimated that 30-40% of untreated infected individuals develop relevant clinical syndromes in the chronic phase, which can be life-threatening. In that phase, target-organs can be impaired, leading to cardiac, digestive, neurological, or mixed manifestations, which might require etiological treatment.This aspect emphasizes the importance of the timely diagnosis, in initial phases of disease, particularly in individuals originating from poor or socially vulnerable communities.Chagas disease is multisystemic and its natural history is characterized by an acute phase, which can last some weeks or months, usually asymptomatic or mildly symptomatic, and a chronic phase.A substantial proportion of the economic burden is consequent to loss of productivity due to early morbidity and mortality induced, particularly, by chronic cardiomyopathy.Globally, the annual burden is US$ 627.46 million in health costs, with a current global net value of US$ 24.73 billion . The global costs reached US$ 7.19 billion per year and US$ 188 billion throughout life. It is worth noting that approximately 10% of those costs are associated with areas where CD is not endemic, such as USA and Canada.Thus, overcoming barriers to diagnosis and treatment access with the proper implementation of whole attention to individuals with CD would reduce the occurrence of chronic complication and the costs associated with the national health systems , with a beneficial impact on the entire society.The economic burden generated by CD in the national health systems and society is significant, matching or even exceeding that of other diseases, such as rotavirus infection or cervical cancer, even in nonendemic areas.Broader policies that recognize the different dimensions of social determination are fundamental to reduce that burden, requiring the involvement of other areas beyond the health sector.Chagas disease is included in the 2030 Sustainable Development Goals (SDG) agenda, in its third objective, \u201censure healthy lives and promote well-being for all at all ages\u201d, aimed at \u201cending the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases, and fighting hepatitis, waterborne diseases and other communicable disease\u201d by 2030.From that perspective, a comprehensive economic assessment regarding measures to expand access to CD diagnosis and treatment revealed the importance of the serological screening of candidates for blood donation and pregnant women, as the best cost-effective public health strategies.There is strong evidence that the diagnosis and proper etiological treatment of CD have several benefits, such as prevention of the congenital transmission in treated mothers, serological cure in babies and children, and a reduction in the progression to advanced clinical forms of CD in acutely and chronically infected individuals.However, once the disease has progressed to a more advanced clinical phase, with severe heart impairment, the etiological treatment seems not to have any clinical benefit.This strengthens the need to develop enhanced diagnostic methods in the local health services to guarantee access to early, safe, and effective treatment.Despite the high morbidity and mortality burden of CD and the elevated costs for the national health systems and mainly for society, 70-90% of the individuals with CD are reported to ignore their diagnosis, and only 1% effectively receives proper etiological treatment in the 21st century.Those barriers include: lack and inconsistency of data on the disease; limitation of integrated actions of surveillance, control, and care in the Primary Health Care (PHC) network; distance to health services; complicated diagnostic flowcharts and slow and costly processes ; limited integration of policies and actions for reproductive, maternal, neonatal, and child health; disproportional impact of CD on more vulnerable populations; limited knowledge of both the population and healthcare professionals about the disease; limited interest of the media and pharmaceutical industry; reduced health education initiatives; limited availability of tools and materials in healthcare centers; fear; stigma and discrimination against affected individuals; low capacity for social mobilization and limited political leadership of individuals at higher risk.In addition to the complex political, geographical, socioeconomic, cultural, technological, and legal challenges of the territories with higher endemicity for CD, barriers are known to persist regarding access to diagnosis, treatment, and longitudinal care.In addition, there is clear need to overcome the access barriers related to the etiological treatment, currently limited to only two effective drugs - benznidazole and nifurtimox \u2013 which require relatively long periods of administration and may be associated with adverse reactions that can complicate treatment, requiring clinical and laboratory monitoring.Furthermore, the antiparasitic drugs have limitations regarding their use by pregnant women and those with advanced disease with cardiac or cardiodigestive involvement.However, for pregnant women with acute and severe clinical findings of CD ,a decision about that ethical dilemma has to be made.It is worth noting that the limited knowledge of healthcare professionals about CD is one of the critical factors to ensure wide access to proper diagnosis and treatment in the national health systems.In addition, the WHO\u2019s road map for NTD identified three strategic actions to eliminate the disease: action 1 \u2013 engage with public institutions/agencies involved in prevention and control in different countries  to recognize CD as a public health problem and establish policies and effective actions of prevention, control, care, and surveillance in all endemic territories; action 2 \u2013 qualify medical care, from permanent education during service to integrated action across the entire care network; and action 3 \u2013 ensure that countries where within-household/extra-household vector transmission still occurs, comply with the protocols of prevention, control, and surveillance.In one of the eleven WHO public health global campaigns, the 72nd World Health Assembly approved, on May 24, 2019, the designation of a World Chagas Disease Day aimed at raising public awareness on this NTD.Those movements get together in a wider Social Forum to tackle NTD in Brazil.In addition, those movements related to CD make up an international federation  representing endemic and nonendemic countries.It is noteworthy that society is increasingly participating in this endeavor. Social movements are engaging and taking a leading role in CD globally, as well as coordinating with other movements directed at NTD, in an effort to preserve fundamental rights such as access to health.stcentury, CD maintains an epidemiological pattern of endemicity in 21 Latin-American countries, with approximately 70 million individuals at risk for exposure toT. cruziinfection. There is relative difficulty in establishing more precise estimates in the context of a NTD, raising uncertainty. However, the currently available estimates have been fundamental to subsidize agendas for CD control. The WHO estimates 6-7 million infected individuals around the world, most in Latin America, indicating a reduction of approximately 65% as compared to 1980 (17 million).In the 21Approximately 63% of those cases are in countries of the Southern Cone Initiative, mainly Argentina (1.5 million), Brazil (1.2 million), Mexico (880 thousand) and Bolivia (610 thousand).In addition, under-reporting of cases and not reporting deaths due to CD represent critical obstacles, because they prevent the adoption of control measures more adjusted to local realities based on epidemiological surveillance.However, those global data differ from the individual estimates in several countries, hindering the exact establishment of CD prevalence in the Americas.T. cruzitransmission, was able to expressively reduce the global prevalence of CD.The agreed goals to eliminate transmission by the major vector species (Triatoma infestans) and by blood transfusion was achieved by several countries based on initiatives since the 1990 decade, with a significant reduction in the number of new cases; however, some critical areas of transmission still persist.Despite these difficulties, the development of regional initiatives, coordinated to interruptFurthermore, in most areas where vectorial interruption or transmission reduction was achieved, the population affected is getting older, increasing the burden of morbidity and mortality due to the coexistence of chronic-degenerative diseases, mostly cardiovascular diseases.In the elderly population, CCD remains a strong predictor of higher risk for death.The current challenges are even more important. Only 10%-30% of the individuals affected by CD are aware of their diagnosis, which contributes to the fact that only 1% of those requiring etiological treatment have actual access to it, maintaining morbidity, mortality, and social cost at high levels, with impairment of quality of life.although a significant reduction has been observed, considering the recording of over 45 thousand deaths annually in the 1980 decade. However, mortality still remains high,contributing to maintain CD a public health problem.Despite the significant reduction in prevalence, approximately 10-15 thousand deaths related to CD are reported every year,Beyond the classically endemic areas in Latin America, CD has been progressively reported in nonendemic countries , because of the migration movements associated with political-institutional, sanitary, environmental, and economic crises in some countries.Those global estimates are supported by recent data originating from countries, such as Spain, where, although the disease is not endemic, there is active research and focus on public health measures for control. In Spain, they estimated for 2018 over 55 thousand of the almost 2.6 million migrants from endemic countries (54% from Bolivia) living with CD, an estimated prevalence of 2.1%. Approximately 70% of migrants did not have an established diagnosis and most were not treated, 83% were older than 15 years and 60% were children.It is worth noting thatT. cruzican act as an opportunistic microorganism in individuals with other immunosuppression-associated pathologies, resulting in life-threatening clinical syndromes due to RCD.In addition, those populations live in precarious conditions, are socially vulnerable because of social and economic restrictions that hinder access to healthcare, which is aggravated by the poor professional experience in the specific health sector.T. cruzitransmission through blood transfusion has been more and more recognized. Although CD is rarely defined as a public health problem in nonendemic countries, in the past 10 years several blood centers implemented measures to mitigate the risk related to blood safety based on the recognition of epidemiological risk factors associated with Latin-American immigrants and the adoption of serological tests for screening.In those nonendemic contexts, the likelihood ofIn endemic regions, 1.12 million women at reproductive age are estimated to be infected,and the mean congenital transmission rate is estimated as 5%, mainly in high-risk endemic areas.Because the access to diagnosis ofT. cruziinfection in mothers or newborn babies is limited in most endemic areas, the prevalence in pregnant women and newborns can be underestimated.Even with such limitations, the incidence is estimated at 8000 to 15 000 cases of congenital transmission per year in Latin America.Of note, that mode of transmission has played a central role in maintainingT. cruziinfection in nonendemic areas.Thus, the occurrence of congenital infection can sustainT. cruzitransmission indefinitely, even in countries without the classic vectorial mode.In endemic contexts, the control of two transmission modes  puts into perspective the congenital mode, responsible for almost one third of the new infections in 2010.In addition, the diagnosis ofT. cruziinfection in pregnant women during the prenatal period, favoring the early screening of the newborn infection, as well as the diagnosis of infection in newborns from infected mothers, enabling the implementation of etiological treatment, would be highly effective and safe measures.To prevent congenital transmission in endemic areas, it is essential to guarantee access to diagnosis and etiological treatment to girls and women at reproductive age before pregnancy.playing an important role in the appearance of acute cases in the Brazilian Amazonian region and Venezuela.In those scenarios, mortality is higher during the acute phase as compared to that of acute cases caused by the classic vectorial transmission.Acute CD orally transmitted has considerable lethality in the first year after infection,as discussed in another chapter of this guideline.Oral transmission, on the other hand, has been reported particularly in the Amazonian region and subtropical Andes,stcentury, it is unequivocally important to sustain CD surveillance and control in all its evolutionary clinical phases, considering as criteria, the magnitude, spread potential, transcendence, vulnerability, and Brazil\u2019s international commitments.As a country of continental dimensions, throughout this century Brazil has undergone demographic, social, economic, and environmental changes, failing to overcome the critical socioeconomic and regional inequalities.In the 21However, Brazil has a public, universal, and democratic unified health system (SUS), whose quality should continue to enhance constantly, aimed at ensuring the access to health for all individuals, a right established in the 1988 Federal Constitution 1988.Considering Brazil\u2019s extension and diversity, with implications in the ecological, demographic, social, and economic dynamics of the regions, there are multiple clinical, epidemiological, and operational scenarios for disease control.In that context, CD remains the NTD with the highest morbidity and mortality burden, particularly among elderly men and those who had lived in important endemic areas of vectorial transmission.but the current weakening of the entomological surveillance operations in endemic municipalities is worrisome. The certification of interruption of Chagas disease transmission by the major domestic vector,T. infestans,was issued in 2006 by the Pan American Health Organization (PAHO), within the Southern Cone Initiative.Despite advances, the risk of CD transmission by vectors persists and has been assessed under different perspectives because of several factors, such as the existence of autochthonous triatomine species with a high potential of colonization, the presence of wild and domestic reservoirs ofT. cruzi, the increasing proximity between human populations and those environments, in addition to the persistence of residualT. infestansfoci, even in specific areas of the Bahia state, and the limitation of entomological surveillance actions.Vectorial control in endemic areas had a significant impact on both blood transfusion and congenital transmissions,T. cruzi, and, in 2000, 1 900 000 (1.0%).The WHO\u2019s most recent estimates indicate in 2010 1 156 821 infected individuals withT. cruzi(0.6%).However, the limitation of population-based studies hinders more realistic assessments about the magnitude of CD in Brazil.Thus, some studies based on systematic reviews and meta-analyses of data available in Brazil have estimated the number of infected individuals ranging from 1.9 to 4.6 million, figures that might be closer to the current variation from 1.0% to 2.4% of the population.Based on those proportions, the number of Brazilians infected withT. cruziestimated for 2020 is 1 365 585 to 3 213 142, of whom, 136 559 to 321 314 individuals with the chronic digestive form and 409 676 to 963 943 with the chronic cardiac form. Regarding the IFCD, the population estimated withT. cruziinfection ranged from 819 350 to 1 927 885 individuals.T. cruziinfected individuals and cases in the chronic phase of CD with cardiac and digestive forms in Brazil from 2020 to 2055.In Brazil, in 1980-1985, 6 180 000 (4.2%) individuals were estimated to be infected withT. cruziinfection in pregnant women in Brazil in 2010 was estimated as 1.1% (34 629 women), with a mean of 589 newborns with congenital infection (transmission rate of 1.7%),similar to the WHO\u2019s estimate (571 cases).The congenital transmission rate is lower (1.5-2.0%) as compared to the mean of 5% observed in other Southern Cone countries, such as Argentina, Paraguay and Bolivia. Such findings suggest that the presence of TcII associates with lower transmission as compared to that of TcV, which predominates in the Southern region of Brazil and those countries.The prevalence ofIn 2020, 146 cases were confirmed, mainly in the North region, with case fatality rate of 2% . The most frequently reported mode of transmission in Brazil in the past 15 years in cases of acute CD was the oral one,revealing the operational limitations of the surveillance process in Brazil, which have induced changes in the epidemiological profile of the disease in the past decade.Based on data from the Notifiable Diseases Information System (SINAN), the occurrence of cases of acute CD has been the aim of epidemiological surveillance, according to the Brazilian Ministry of Health definition of \u201ccase\u201d. From 2007 to 2019, 3060 cases of acute CD (mean of 222 cases/year) were confirmed in 219 municipalities.The differences observed between regions, especially with higher burden in the West-Central and Southeast regions, indicate socioeconomic inequities and different patterns of access to healthcare services in the SUS.The South region shows a reduction in the trend of mortality, the North region, an increase, while the Northeast region has no defined trend.The CD mortality burden in Brazil persists significantly high, despite the control actions implemented. Mortality is known to be more expressive at ages 50 to 64 years and older cohorts, probably due to the effects of the period of intensification of vectorial control actions, in addition to demographic changes.In addition to the probable underreporting of cases not associated with domiciliary vectorial transmission, that region had little impact from the systematic actions for triatomine control. This is justified because the local cycle ofT. cruzitransmission does not involve vectors with the ability of domiciliation, but is sustained in an enzootic cycle, with wild vectors implicated in cases associated with oral or extra-household vector transmission.Thus, it is reasonable to estimate that the accumulation of hundreds or even thousands of cases ofT. cruziinfection over time in the Amazonian region might be contributing to this specific epidemiological pattern.It is worth noting that the North region concentrates the majority of the new cases reported in the country.particularly as the affected population ages.The global analysis for the 2030-2034 period indicates a progressive decline in mortality (over 75% as compared to that in 2010-2014), mainly among the youngsters, ranging from 86%, in the age group from 20 to 24 years, to 50% in those aged 80 years and more.It is worth noting the significant reduction in the quality of life of individuals with CD and their families.Chagas disease continues to have a strong impact on Social Security and the services of the National Institute for Social Security (INSS) in the Brazilian states with higher prevalence,The PAHO document \u201cChronic Care for Neglected Infectious Diseases: Leprosy/Hansen\u2019s Disease, Lymphatic Filariasis, Trachoma, and Chagas Disease \u2013 A guide for morbidity management and disability prevention for primary health care services\u201d is a landmark, because it highlights several fundamental aspects in the care of individuals with CD, aiming at providing PHC teams with tools, and reinforces the importance of integrated surveillance actions.Integrated actions of care, surveillance and control of CD in PHC have been fundamental and strategic to reduce the morbidity and mortality burden, mainly in endemic territories, expanding access to diagnosis and etiological treatment.Epidemiological surveillance for CD comprises necessarily integrated actions that involve approaching human cases, vectors, and reservoirs, maintaining an interface with the healthcare network and special emphasis on the PHC role.T. cruziinfection in the human population by use of PHC screening programs, periodical serological inquiries in strategic populations, and analysis of the screening process of candidates for blood donation in blood centers; 4) to monitor the morbidity and mortality profile of CD, outlining actions to strengthen the healthcare network for infected individuals; 5) to maintain transmission byT. infestanseliminated and that by other important species under monitoring/control; and 6) to integrate actions of sanitary, environmental, vectorial, and reservoir surveillance with epidemiological surveillance actions.The major objectives of the epidemiological surveillance actions for CD in Brazil are as follows: 1) to early detect cases of acute CD for proper etiological treatment and application of measures to prevent the occurrence of new cases; 2) to conduct an epidemiological investigation of all acute cases, aiming to identify the mode of transmission and adopt proper control measures; 3) to monitorUp to May 2020, when the chronic phase of CD was included as an event of interest for epidemiological surveillance, by use of mandatory reporting of cases , only the traditional surveillance of cases in the acute phase was performed and included in the National List of Notifiable Diseases of Mandatory and Immediate Reporting.This enlargement in the surveillance scope is very important for our country to reach national recognition of patterns of disease occurrence and can be followed by other endemic countries. This new process of epidemiological surveillance is expected to be implanted in the entire Brazilian territory by 2022.The data available on the epidemiological surveillance of human cases do not enable estimating the nosological magnitude of American trypanosomiasis. Only 10-20% of the acute CD cases are estimated to be reported.T. cruziinfected individuals.To elaborate a prioritization model of municipalities for chronic CD surveillance, a team of the Ministry of Health conducted a preliminary multicriteria decision analysis based on three indices built from the following indicators: (a) epidemiological, directly related to chronic CD; (b) resulting from the progression of chronic CD; and (c) related to access to health services. The model defined as the most suitable was composed by 1345 municipalities of intermediate priority, 1003 of high, and 601 of very high priority for chronic CD, mainly in the Southeast and Northeast regions of the country.More recently, to recognize the magnitude of chronic CD in the country, the importance of rearticulating and integrating health surveillance actions have been discussed, aimed at the development of a large hierarchical network of health services in several territories to guarantee access for millions ofThus, three subindices were developed from the three indicators integrated in the previous analysis.The value of the index can range from 0 to 1, and the closer to the value \u20181\u2019, the higher the vulnerability for chronic CD  or with acquired immunodeficiency syndrome (AIDS), based on the existence of epidemiological antecedent. This recommendation has been debated more recently in other countries, such as the USA.It is worth noting that, for the purpose of epidemiological surveillance, since 2004 Brazil has inserted RCD in the list of diseases indicative of AIDS in the presence of HIV infection, from the definitive diagnosis of meningoencephalitis and myocarditis associated with CD.An additional perspective of CD surveillance in Brazil leads to the recommendation that an anti-Its pandemic character has been compounded by its high infectivity, even in its asymptomatic phases, leading to its rapid spread.The emergence of COVID-19, caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), has brought serious and unprecedented global challenges for the national health systems and humankind.which already bear a significant morbidity and mortality burden for NTD. Thus, the analysis of the current context of NTD provides relevant possibilities to approach gaps in COVID-19 control, because it is an important referential for the progress in responding to the needs of more vulnerable populations. Success in responding to COVID-19 control without reducing the NTD burden concomitantly points to flaws in the sustainability of the national health systems to maintain that control.As the COVID-19 global pandemic advances, it disproportionately impacts more and more socially vulnerable populations,The highest prevalence of comorbidities seems to be related to a worse prognosis in coinfection.Since the appearance of the pandemic caused by SARS-CoV-2, the cardiovascular involvement has been identified as a frequent complication of COVID-19.However, there is little evidence on the effects of COVID-19 on individuals with CD.Some studies have reported that COVID-19 may add new challenges in guaranteeing access to total healthcare  to those individuals and in the necessary development of new research analyzing the implications of SARS-CoV-2 coinfection.The concomitance of CD is particularly worrisome because it can cause cardiac, gastrointestinal, neurological and other complications, increasing susceptibility to COVID-19.However, it is worth noting the importance of considering the disease\u2019s different clinical forms and specific pathophysiological mechanisms associated.Thus, despite some similarity regarding pathophysiology, which involves high risk of thromboembolism in COVID-19 and in the chronic cardiomyopathy of Chagas disease (CCCD), cautiousness is required regarding the recommendation of immediate treatment for CD with anticoagulant drugs, whose potential benefit should be restricted to clinical scenarios in which there is a favorable adequate risk relation of hemorrhageversusthrombosis with the use of those drugs. Such principles are discussed in another chapter of this guideline.In addition, both diseases are similar regarding the susceptibility to risk factors, molecular patterns associated with the pathogen, recognition of glycosaminoglycans, inflammatory process, vascular hypercoagulability, microthrombosis and endotheliopathy, and, thus, may require treatments with similar principles.Although more than 80% of the cases of COVID-19 are mild or asymptomatic, severe cases have been more frequent among elderly and individuals with comorbidities, while, for CD, elderly with chronic cardiomyopathy are at a higher risk of death, which is partially justified by its association with age or other chronic conditions and by social poverty.Some studies have pointed to high levels of comorbidity in cases of CD associated with severe forms of COVID-19. It is important to emphasize that those comorbidities reflect the more advanced ages of the populations that are specially impacted by CD and COVID-19.Although coinfection might be associated with a higher risk for complications, with a worse clinical prognosis, a multicenter prospective study with 37 hospitals in 17 municipalities of 5 Brazilian states  reported that there was no significant differences in the clinical presentation nor in the outcomes of cases with CD as compared to controls, despite the evidence in the beginning of the study of higher frequency of chronic HF and atrial fibrillation (AF). In addition, that study reported lower level of reactive C protein among participants with CD.The significant increase of extreme poverty around the world in the past decade compounds the challenge of access to healthcare for individuals with CD.The higher social vulnerability of individuals with CD in the context of poverty can be increased by COVID-19, because of its political-economic impacts.In addition, individuals with CD might be afraid to search care because of fear of exposure to COVID-19, postponing the solution for complications related to disease and increasing the emotional burden of the disease due to the associated worries. And all that is compounded by the weakening, disorganization, and overload of the national health systems.92,Moreover, the inequity of COVID-19 expression in Brazil has been evidenced by the excessive mortality of black/mixed heritage individuals of all age groups.These racial disparities can be justified by historically determined socioeconomic conditions, which usually define who can maintain social distancing and avoid exposure to SARS-CoV-2.Brazil is one of the countries with the highest COVID-19 morbidity and mortality burdens and has called negative attention in the international scenario because of its lack of coordination and leadership regarding the COVID-19 surveillance and control actions.In addition, the risk of death from COVID-19 showed a wide range in the pandemic initial stages, with increased vulnerability of the peripheral areas, where the most vulnerable communities are found, jeopardizing the health system\u2019s ability to respond and increasing the inequities in health care.Despite those orientations, the specific Epidemiological Bulletin from the Ministry of Health raised the possibility of impact of the COVID-19 pandemic on the morbidity and mortality profile and surveillance actions for CD in Brazil.Through the informative note n\u00ba 9 from 2020 (CGZV/DEIDT/SVS/MS), recommendations from the Ministry of Health were established in Brazil to adapt surveillance and healthcare actions for individuals with CD considering the COVID-19 epidemiological situation.That bulletin points to evidence of cardiovascular diseases as critical risk factors for higher severity of the clinical syndrome associated with COVID-19. Based on that, individuals with CD should be considered a population at higher risk for worse clinical progression of COVID-19, requiring more careful attention by the SUS during the pandemic.During that period, 125 691 deaths from COVID-19 were reported, in 207 of which (0.2%) CD was mentioned as the condition contributing to death (part II of the certificate of death), with a higher proportion in the Southeast and Northeast regions. Most of those deaths occurred in female individuals (52.7%), of mixed heritage (42.0%), with a mean age of 74 years (SD\u00b111.36), and in the age group over 75 years (53.0%).In addition, that epidemiological bulletin from March to August 2020 reported 1746 deaths in Brazil with CD as the underlying cause of death , 29 of which cited COVID-19 or severe acute respiratory syndrome as an aggravating condition or a condition contributing directly or indirectly to the causal chain of death (parts I and II of the certificate of death), with a higher proportion in the Southeast and Northeast regions.T. cruziand SARS-CoV-2 coinfection as an important uninvestigated causal binomial of death in CD endemic regions.Some hypotheses point toThe regionalized temporal trend analysis in the country, from 2009 to 2019, reveals propensity for a statistically significant reduction in the specific coefficient of mortality from the disease. However, a tendency to increase was observed in the coefficient of incidence of acute phase cases, which was statistically significant in the North region; however, in 2020, the number of cases reported was lower than that foreseen.In addition, a reduction in treatment was observed, evidenced by the reduction in benznidazole distribution and the entomological surveillance assessment in the state coordinations,indicating a possible reduction in the sensitivity of the healthcare and surveillance network, probably related to directing municipal and state efforts to fight the COVID-19 pandemic.Regarding diagnosis, a 24% reduction was observed in the number of requests for laboratory tests for CD diagnosis processed in 2020 as compared to the mean from 2017 to 2019.the reports of state representatives indicate that, in many territories, the foreseen control activities for 2020 could not be performed, not even partially.Even with guidance on the need to readapt the entomological surveillance activities in the context of COVID-19,this could be even more ominous for those individuals already with CCCD when they get infected with SARS-CoV-2.Finally, because of the recent evidence that cardiovascular sequelae persist in the long term in individuals with COVID-19,and endemic countries,indicate the pressing need to adopt comprehensive policies regarding public health to effectively control the inter-human transmission of theT. cruziinfection and to reach an optimal level of care for already infected individuals, focused on providing both diagnostic and therapeutic opportunities.Recent publications by researchers and managers from both nonendemicthcentury. It was only from the year 2000 on that the notion of the persistence of the parasite in the myocardial has consolidated as the primordial mechanism for the CCCD installation. This rescued the concept of CD as a truly infectious entity and that of CCCD as caused by a low-intensity, but virtually incessant, focal inflammatory process. The tissue aggression, causing necrosis and reactive and repairing fibrosis, is directly stimulated byT. cruziand the adverse immune reaction to parasite persistence.The CCCD pathogenesis is still object of intense debate. In the acute phase of CD, the intense tissue parasitism has always been recognized as an essential mechanism; however, in the chronic phase, this has not occurred and other pathogenetic hypotheses predominated during the second half of the 20The prognosis of CCCD is usually more ominous than that of non-inflammatory cardiomyopathies. The identification of prognostic factors and therapeutic targets is critically dependent on that knowledge. The direct lysis of infected cells is significant mainly during the acute phase of the infection, when intracellular parasites are abundant and myocarditis is usually diffuse and intense. On the other hand, chronically infected individuals have a clearly different disease progression. Decades after the infection, approximately 60% of infected individuals remain free from clinical manifestations of the disease for their entire life (stage A - IFCD), 10% develop gastrointestinal disease, and 30% develop CCCD, which can be classified into stages B1/B2 (less advanced cardiomyopathy) or C/D (severe cardiomyopathy), as detailed in another chapter of this guideline.The major pathogenic hypotheses to explain the beginning and progression of CCCD include: 1) direct parasite-induced damage to the tissues; 2) indirect inflammatory/immune damage to the tissues; 3) neurogenic disorders; 4) microvascular disorders. The neurogenic hypothesis was based on intracardiac neuronal depletion and consequent dysautonomia, but there are unavoidable obstacles to the postulated cardiopathy resulting from parasympathetic deprivation (\u2018parasympathetic-deprived\u2019 cardiopathy). Evidence from experimental models and human disease indicates that inflammatory infiltrates are the major cause of damage to the cardiac tissue. However, more recent evidence has shown that genetic susceptibility and mitochondrial damage are important parts in the CCCD pathogenesis. Cardiac microcirculatory lesions have been reported in CCCD, but microvascular ischemia can result from the action of inflammatory mediators and constitute a mechanism of positive feedback, potentializing the inflammatory and mitochondrial damages, as discussed in the following section.T. cruziantibodies that partially control the parasitism, establishing persistent, although low-grade, infection.In the acute phase of the infection, which has been investigated in more details in murine models, parasitemia and intense parasitism of the tissues trigger a strong immune response. Initially there is innate immune response, followed by that depending on cytotoxic T lymphocytes and T lymphocytes that produce inflammatory cytokines, such as interferon-gamma (IFN-\u03b3) and tumor necrosis factor alpha (TNF-\u03b1), and specific anti-T. cruzishow different severities of CCCD, characterized by electrocardiographic and echocardiographic changes, associated with varied serum levels of TNF-\u03b1 and nitric oxide, suggesting that variations in the host\u2019s genetics can determine chronic disease severity.Different lineages of mice infected with the same lineage ofA relation between the intensity of the acute phase ofT. cruziinfection and the severity of its chronic phase has been proposed. Patients with CCCD have diffuse myocarditis  with fibrosis and hypertrophy. Myocarditis is due to bothT. cruzi-specific lymphocytes and autoimmune T lymphocytes, which produce large amounts of IFN-\u03b3 and TNF-\u03b1. In CCCD, IFN-\u03b3 plays a central pathogenic role by inducing cell damage via several mechanisms, while other inflammatory mediators also act.Persistent parasitic stimulation induces the systemic production of IFN-\u03b3 and TNF-\u03b1 in individuals with chronic CD, which is particularly intense in those with CCCD as compared to those with the IFCD.Significant systemic immune effects were observed in the peripheral blood of patients with chronic CD, which are associated with the distinct clinical forms. It is important to note that qualitative differences are clearly observed in the systemic cellular responses of patients with the IFCD and cardiac clinical form. Those differences are influenced by an immune-regulated cytokine network, which orchestrates the immune response. While individuals with IFCD have a balanced immune-regulatory profile modulated by the production of interleukin (IL)-10,patients with CCCD have an increased frequency of CD4+ and CD4-CD8- T cells producing IFN-\u03b3, as well as increased levels of circulating TNF-\u03b1 in the peripheral blood.Recent review on systemic and heart-specific immune alterations has shown that patients with CCCD have a characteristic inflammatory cytokine profile.Also, patients with CCCD have reduced numbers of circulating Th17 T cellsand of monocytes producing IL-10,CD4+CD25+ regulatory T cells (Tregs),as well as reduced levels of Ebi/IL-27p28as compared to individuals with the IFCD , was low or undetectable.and those same cells were identified in the cardiac tissue of patients with CCCD, along with their chemokine receptors . CCL5 and CXCL9 were the most often expressed chemokines and the severity of myocardial inflammation correlated positively with the mRNA expression of CXCL9.The number of CCR5+ CXCR3+ Th1 T cells producing IFN-\u03b3 is higher in patients with CCCD than in those with the IFCD,T. cruziinfection, CCL3, CCL4 and CCL5, acting via CCR1 or CCR5, control the migration of T cells and macrophages to the cardiac tissue, leading to cardiomyocyte damage, conduction abnormalities, and ventricular dysfunction.This suggests that Th1 chemoattractive chemokines locally produced play a significant role in the selective accumulation of Th1 T cells in the heart in the CCCD. In addition, it indicates that there is essentially no regulation via either T cells or regulatory cytokines in the myocardium infiltrated with Th1 of patients with CCCD.In animal models of CCCD, in the acute and chronic phases ofThe low regulation could explain the inflammatory infiltrate destructiveness, most probably due to the excessive collateral damage caused by the T cells producing IFN-\u03b3. The non-antagonism to IFN-\u03b3 in patients with CCCD might be related to the decreased number of the T cells producing IL10 and Ebi/IL27R and regulatory ones, all able to suppress the production of IFN-\u03b3 and/or differentiation of Th1 T cells.et al. were the first to implicate myocardial mitochondrial dysfunction and oxidative stress in the pathogenesis of CCCD in murine models.The remarkable similarity between cardiac, digestive, and autonomic disorders in the mitochondriopathies ,as well as the broad clinical spectrum of symptomatic CD,suggest mitochondrial dysfunction as a fundamental component of the CCCD pathogenesis.Wanand mitochondrial DNA,in addition to other observations (not published) andin vivoproduction of adenosine triphosphate (ATP),has been described in the myocardium of patients with CCCD.In CCCD, the myocardium shows signs of reduced mitochondrial activity and energy production. The reduction in mitochondrial ribosomal RNAwhich could contribute to the worse prognosis associated with CCCD. The discovery of the association of CCCD with rare variants of mitochondrial genes, described in more details in this chapter, supports the role played by mitochondrial dysfunction in the myocardial injury of patients with CCCD and can be a mechanism to perpetuate the inflammation and damage in cardiomyocytes.The myocardial levels and activity of the enzymes of the mitochondrial energy metabolism, ATP synthase and creatine kinase, are even lower than those in other cardiomyopathies,and in the murine acute infection byT. cruzi.Recent studies have shown the modulation of the expression of some microRNAs (miRNAs), molecules that specifically control the translation of mRNA in the cardiac tissue of patients with CCCDT. cruzi-infected mice genetically deficient in microRNA-155 have supported the relationship of miRNA with infection control and production of inflammatory cytokines.In addition, the discoveries inhave suggested the participation of genetic factors in the different progressions of the disease. Patients with CCCD have more intense inflammatory response than those with the IFCD, who seem to have a better regulated immune response.Finding that approximately 30% of the patients with CD develop chronic cardiomyopathy and the presence of family cases of CCCDGiven the importance of the inflammatory mechanisms in the pathogenesis of CCCD, several studies have focused the common or frequent polymorphisms in the genes related to inflammatory and immune responses, thus causing important variations in the expression of inflammatory cytokines and chemokines involved in the disease\u2019s pathogenesis. Each common or frequent polymorphism is typically responsible for small phenotypic effects (approximately 10% of the population/phenotype).Of those, SNP in 8 genes were associated with the severity of CCCD: SNPs in genes IL17a, IL18, IL27b/Ebi3, CCR2, CXCL9, CXCL10, and MICA were more frequent in patients with CCCD and significant left ventricular (LV) dysfunction (LVEF < 40%) as compared to other patients with CCCD.A recent review of 145 association studies on candidate polymorphisms in 76 genes has revealed 62 single nucleotide polymorphisms (SNPs) of 44 genes to be associated with the CCCD phenotype.involving 600 patients with CD, and the other in 2021, involving 3413 individuals.Only the latter revealed a significant single variant in the entire genome (p < 10-) close to the SAC3D1 gene.Two genome association studies were performed using the GWAS (Genome Wide Association Study) technique, comparing CCCD and IFCD, one in 2013,In the six families studied, 22 rare high-impact non-synonymous heterozygous pathogenic variants were found associated with CCCD, located in 20 genes. Only seropositive individuals with the pathogenic genetic variants developed CCCD, but neither seropositive individuals without the genetic variants nor seronegative siblings with the pathogenic genetic variants did. There was a significant accumulation of specific variants of CCCD (86%) in mitochondrial or inflammation-related genes. In addition, all families studied showed at least one gene variant linked to CCCD. The results of that study indicated that the gene contribution to cause CCCD is polygenic and mediated by several rare genetic variants that differ in the families, being related to mitochondrial changes and inflammation.A recent study has assessed the role of rare gene variants in the progression to CCCD in nuclear families with multiple cases of CD by using whole exome sequencing.The results indicate that mitochondrial dysfunction and inflammation, key-processes in the CCCD pathophysiology, are at least partially genetically determined. This can depend on a double-aggression mechanism. Thus, IFN-\u03b3 and proinflammatory cytokines induced by chronic infection would trigger mitochondrial dysfunction and clinical disease in patients with gene variants that cause subclinical impairment of mitochondrial function in organs of high metabolic demand, such as heart and myenteric ganglion neuronal cells. Mitochondrial lesion can be the mechanism that perpetuates the tissue inflammatory changes because of the release of inner components of damaged mitochondria by innate immune response.There is increasing evidence, both clinical and experimental, of coronary microvascular abnormalities in the pathogenesis of CCCD. Several studies have indicated that the myocardial damage might result from microvascular changes mainly associated with inflammation, which lead to myocardial ischemia and necrosis with occasional reparative fibrosis.In addition, the myocardial fibers in the proximity of the vascular lesions showed myocytolysis, a cellular lesion closely related to myocardial ischemia.The first evidence that coronary microcirculation disorders may play a role in the myocardial damage of CD in humans has been obtained from postmortem studies describing severe vascular changes, with intimal hyperproliferation, wall thickening, and obstruction of the small intramural coronary arterioles in hearts of patients with CCCD.et al. have described coronary microcirculatory changes with vascular dilation and rarefaction in hearts of patients with CCCD, which differed from those usually observed in patients with idiopathic DCM.In a more recent study, HiguchiThus, observations from postmortem studies strongly suggest the participation of microvascular ischemia in the genesis of the inflammatory foci and myocytolysis, which lead to reparative fibrosis, the fundamental histopathological features of CCCD.In addition, several studies have shown that the myocardial perfusion defects were topographically related to LV wall motion impairment occurring in patients in the early phases of CCCD with no other evidence of cardiac impairment,suggesting that microvascular ischemia is an early disorder in the disease progression, preceding regional ventricular dysfunction and possibly related to hibernating or stunned myocardium induction. Similar results were obtained in studies with doppler ECHO, showing reduction in the coronary vasodilation reserve, a microvascular dysfunction index, in patients with the IFCD as compared to normal controls.In the clinical scenario, studies using myocardial perfusion scintigraphy have shown high prevalence (30% to 50%) of perfusion defects in patients with CCCD and angiographically normal coronary arteries, strongly suggesting the presence of coronary microvascular dysfunction.A retrospective longitudinal study using myocardial perfusion scintigraphy in patients with CCCD has shown that microvascular ischemia is topographically related to areas that develop myocardial fibrosis during the disease progression. These results support the hypothesis that microvascular ischemia can be directly involved in the mechanism that leads to regional fibrosis and LV systolic dysfunction progression in CCCD.T. cruzihave shown, using high-resolution myocardial perfusion scintigraphyin vivo, a close topographic relation between myocardial perfusion defects at rest with histological evidence of inflammation and regional/global LV systolic dysfunction.In addition, another study with that experimental model has confirmed, by use of positron emission tomography computed tomography (PET/CT) withF-fluorodeoxyglucose (F-FDG), that the regions with myocardial hypoperfusion at rest corresponded to areas with viable myocardium and inflammation.More recent studies in an experimental model of Syrian hamsters chronically infected byT. cruzihas shown that the prolonged use of dipyridamole, a vasodilating agent of the coronary microcirculation, was associated with a significant reduction in myocardial perfusion defects at rest, indirectly supporting the presence of viable, but hypoperfused myocardium caused by coronary microcirculation dysfunction in experimental CCCD.Another recent study with the same model of hamsters chronically infected by2. Endothelial lesions caused directly by parasitic aggression;3. Functional and structural changes induced by substances secreted by the inflammatory infiltrate in the myocardial tissue close to the coronary microvessels, mainly endothelin and cytokines. This late mechanism is supported by studies evidencing that myocardial inflammation changes are associated with the occurrence of platelet plugs, obstructive proliferation of the vascular intimal layer, and microarteriolar spasm.The mechanisms potentially involved in the genesis of coronary microvascular dysfunction in CCCD are: 1. Functional changes in the coronary tree, with increased vasoreactivity and spasm of small intramural arterial branches;This discovery has been confirmed in studies with experimentallyT. cruzi-infected animals, showing cardiac neuronal parasitism associated with periganglionitis and degenerative abnormalities in Schwann cells and nervous fibers.It is worth noting that the neural depopulation also affects the intramural ganglia of several digestive system organs, mainly the esophagus and colon, which is clearly implicated in the pathophysiology of megaesophagus and megacolon of CD.Autonomic cardiac denervation is an important characteristic of CCCD and was first described in human postmortem studies showing intense intramural neuronal depopulation, greater than that observed in any other cardiovascular disease.There is evidence that the damage can continue in the chronic phase because of the localized inflammation.Neuronal depopulation in CCCD has been postulated to occur during the acute phase of the infection, secondary to the direct parasitism of neurons, the degeneration caused by periganglionic inflammation, and the antineuronal autoimmune reaction.Patients with CCCD have deprivation of the tonic inhibitory action of the parasympathetic system in the sinus node and also lack of the vagal-mediated mechanism to respond with rapid bradycardia or tachycardia to transient blood pressure or venous return changes.Dysautonomia in patients with CCCD can be detected before the development of ventricular dysfunction, as well as in the early stage of the chronic phase and even in the indeterminate and digestive forms of CD.Several functional abnormalities of the autonomic reflex control of heart rate (HR) in patients with CCCD have been described as a consequence of the anatomically detected autonomic cardiac denervation.I-MIBG myocardial scintigraphy has been used in patients with CD to provide accurate information on the integrity of the sympathetic nervous fibers within the LV myocardium.In that study, 37 patients were investigated by use ofI-MIBG imaging and the results were correlated with myocardial perfusion and regional LV wall motion impairment. Defects inI-MIBG uptake were observed in most patients: 33% of those with a normal ECG and normal ECHO and 77% of those with regional LV wall motion impairment. In addition, patients with more severe ventricular dysfunction had a higher prevalence of defects in theI-MIBG uptake (92%). There was a clear topographic correlation of the myocardial sympathetic denervated areas, perfusion myocardial defects, and regional LV wall motion abnormalities.More recently,I-MIBG scintigraphy has shown strong topographic concordance between myocardial sympathetic denervated areas and myocardial hypoperfusion areas during stress.Those results indicated that sympathetic denervation is an early disorder in the CCCD pathophysiology, preceding the development of LV regional contractile abnormalities or global contractile dysfunction. This hypothesis has been corroborated by the results of an independent study evidencing abnormalI-MIBG absorption in most patients with CD without any sign of cardiac involvement.Another study usingI-MIBG imaging, and the risk for malignant ventricular arrhythmias. This is a clinically relevant aspect because it associates the presence and extension of sympathetic denervation with severe arrhythmia in patients with CCCD and it is potentially implicated as the mechanism of sudden death.In addition, clinical studies have reported a quantitative relation between the extension of myocardial denervation, usingDespite the extensive documentation of conspicuous autonomic denervation in the early stages of CD and the recent demonstration of its potential participation in the mechanism that triggers severe ventricular arrhythmias, the \u201cneurogenic theory\u201d still lacks demonstration of the pathophysiological links between those phenomena and the essential myocardial lesions in CCCD.Autonomic denervation has also been proposed to be associated with coronary microvascular spasm and trigger myocardial ischemia, leading to myocardial necrosis. However, that mechanism still awaits more clear evidence.The pathogenesis of CCCD is still an enigma consisting of multiple complex aspects related to the variety of pathogens, as well as to the host\u2019s genetics and immune system, as shown inT. cruzi-infected individuals can progress with diffuse myocarditis of low intensity, which does not associate with severe cardiovascular disorders, being not even diagnosed. In rare patients, acute inflammation can lead to a significant loss of myocardial contractility, with chamber dilatation and HF with biventricular ejection fraction reduction, sometimes with concomitant electrical disorders  and pericardial effusion. Such changes are usually self-limited to a few weeks, not causing clinically manifest sequelae.The pathophysiology of CCD can be briefly described as follows. In the acute phase, mostT. cruziin the specialized conduction tissue, in the contractile myocardium, and in the intramural autonomic system.Cardiac damage in the chronic phase, however, results from fundamental changes  caused directly or indirectly byThe frequent impairment of sinus and atrioventricular nodes, as well as of the His bundle, due to inflammatory, degenerative, and fibrotic changes leads to sinus dysfunction and varied atrioventricular and intraventricular blocks. By being more individualized structures, the right branch and the left anterosuperior fascicle are more vulnerable and more frequently damaged. Inflammatory foci and fibrotic areas in the ventricular myocardium, especially in apical, posterolateral and inferobasal regions, can produce electrophysiological changes and favor the appearance of reentry, the major electrophysiological mechanism of malignant ventricular tachyarrhythmias, which cause sudden death even in patients without previous HF and without severe LV systolic dysfunction.Another very common consequence of myocardial lesions is biventricular dysfunction, characteristic of CCCD. Initially, there is regional impairment, similar to that occurring in the cardiopathy due to coronary obstruction, but dilation and generalized hypokinesia, usually of both ventricles, gradually occur, conferring the hemodynamic pattern of DCM to CCCD. In more advanced phases of the natural history, there are global cardiac dilation and marked cardiac mass increase, due to the combination of myocardial hypertrophy and fibrosis at degrees varying from patient to patient.From the earliest phases, dyssynergies or ventricular aneurysms predispose to thromboembolic complications. In advanced stages, global dilation, venous stasis, and AF are additional factors that propitiate thrombus formation and consequent pulmonary and systemic embolism, such as in the central nervous system, where they cause stroke. In addition to malignant arrhythmias and refractory HF, CCCD can cause embolism to the pulmonary circuit and several systemic organs, resulting in renal, splenic, and mesenteric infarctions, or embolism to the arteries of the limbs.Such characteristics of the CCCD pathophysiology can be understood as resulting from important pathogenic mechanisms, such as those approached in the chapter of pathogenesis, with the additional emphasis on aspects described in the next section.T. cruzi, CD, has its natural history divided into acute and chronic phases.The acute phase is usually oligosymptomatic with unspecific symptoms, but 5-10% of the cases can have more expressive symptoms in the presence of intense parasitemia,with fever and lesion in the pathogen inoculation site. It can complicate with meningoencephalitis, myocarditis, and other manifestations.The infectious-parasitic disease caused byThe other chronically infected patients develop the determined forms, with cardiac and/or digestive impairment.Four to eight weeks after the infection, when the parasitemia drops to undetectable levels and the acute phase symptoms disappear, begins the chronic phase, which usually lasts for several decades. In the chronic phase, 60-70% of the individuals have no symptom, and the routine additional tests related to the heart and digestive system show no abnormality. That is the IFCD.T. cruziitself) mechanisms play a fundamental role.Since the acute phase, CD has a multifactorial pathophysiology, in which the immune and primary inflammatory , which will trigger intense inflammatory response aimed at controlling parasitemia. Innate immunity activation generates intense secretion of pro-inflammatory cytokines, such as TNF-\u03b1, IFN-\u03b3, and several interleukins, especially IL-10.That intense inflammatory response resulting from the activation of innate immunity cells and production of pro-inflammatory mediators, although crucial to control the infection, contributes to cause direct lesion to the cardiomyocytes \u2013 also attacked by the usually conspicuous tissue parasitism. This pathophysiologic set represents the typical diffuse myocarditis of the acute phase of CD, which, in most cases, has a benign and self-limited course.In the acute phase, there is exposure of theT. cruzitrigger the humoral and cellular immune responses, with activation of B and T lymphocytes. The chronic phase, thus, begins in most patients who did not eliminate the parasite in the acute phase window of opportunity.After the intense inflammatory phase, causing a reduction in parasitemia and tissue parasitism, the macrophages and dendritic cells that phagocytedas well as the cross-recognition by CD4+ T cells ofT. cruziantigens and amino acid sequences of cardiac myosin are important aspects of the pathophysiology of myocardial dysfunction during the chronic phase.The presence of the parasite\u2019s DNA in the myocardium,T.cruziantigens from cross-reaction with the heart to CD4+ T lymphocytes, which migrate to the heart, producing inflammatory cytokines that increase the recruiting and activation of immune system cells, triggering late hypersensitivity reaction. Of the inflammatory cytokines, TNF-\u03b1 and IFN-\u03b3 are significantly increased in patients with CCCD.Regarding the cellular immune response, infected macrophages presentA recent study has directly compared the T lymphocytic subpopulation in individuals with CCCD and idiopathic DCM, evidencing a clear difference in the immunoregulatory profile and higher immune activation in CCCD, although those two conditions have similar hemodynamic characteristics.Several factors are implicated in the etiopathogenesis of CD in the heart, but, regardless of the major mechanisms of tissue damage, the common final pathway is intense inflammatory infiltrate and reactive and reparative myocardial fibrosis. The structural, geometrical, and functional cardiac disorganization essentially results from myocardial necrosis and consequent replacement by fibrous tissue, damaging the perivascular and interstitial content, important histopathological markers of CD.Such alterations are sufficient to cause dilation and consequent biventricular contractile dysfunction, and the myocardial fibrosis is far more intense as compared to that of other cardiomyopathies. Complex mechanisms activate the cascade of cellular and molecular response, intensifying the inflammatory response, oxidative stress, and progressive loss of cardiomyocytes through necrosis and/or apoptosis, in addition to promoting overload and further dysfunction of the residual myocardium.Such changes have been reported to be more conspicuous in patients with CD as compared to that occurring, at a lower level, in other cardiomyopathies.However, despite being one of the most remarkable aspects in the CD pathophysiology, the actual etiopathogenetic role of those changes, including those described in the inter-trunk cardiac plexus, remains uncertain.Anatomical pathological and functional changes of the autonomic nervous system, at various severity levels, have been described in humans and experimental animals since the initial studies by Carlos Chagas and collaborators.T. cruziinfection, those changes, such as ganglionitis, periganglionitis, neuritis, and perineuritis, cause a significant ganglionic density reduction and neural depopulation in experimental animal modelsand patients with CD.Based on studies with experimental models, those anatomical pathological changes in the inter-trunk cardiac plexus have been postulated to occur predominantly during the acute phase of the infectionand to continue in the chronic phase at lower intensity.Such changes result from four factors acting in isolation or combination: direct parasitism of neurons,intense periganglionic inflammatory process,autoimmune antineural reaction,and periganglionic microvascular dysfunction.Directly dependent on theIn addition, sympathetic reinnervation has been reported in humans during the chronic phase of CD after procedures, such as cardiac transplantation (CTX)and stem-cell therapy.Damage to the autonomic structures can be partially compensated, because the autonomic neurons, within limits, maintain a certain ability to functionally recover.Several physiological and pharmacological tests have evidenced abnormal functional responses, supporting that pathophysiological hypothesis.However, restoration of the functional neuroeffector junctions, due to axonal regeneration during the chronic phase, is disorganized, random, and incomplete. The parasympathetic innervation has a similar behavior: there is marked destruction of nervous fibers, with a reduction in the cardiac acetylcholine levels during the acute phase, followed by disorganized, random, and incomplete functional restoration during the chronic phase.Thus, a theory was initially formulated that a \u2018parasympathetic-deprived\u2019 cardiopathy would install in the heart, in other words, there would be an actual \u201ccardioneuropathy induced by a relative non-antagonized excess of catecholamines\u201d.According to that pathophysiological theory, the heart, unprotected due to the absence of the moderator parasympathetic effect, would be subjected to the stress of the intense toxic stimulation of the adrenergic system.Neuronal depopulation occurs predominantly in the parasympathetic intramural ganglia of the heart and myenteric plexuses.However, several pieces of evidence hinder the confirmation that a \u201ccatecholamine-induced cardioneuropathy\u201d decisively contributes to the pathogenesis of the cardiac form of CD. In contrast, it is virtually impossible to eliminate the possibility of the involvement of that mechanism in the process. Even more important, there would be signs that the vagal-cholinergic pathway plays a fundamental direct role in preventing the cardiac impairment that occurs in CD.Furthermore, at the myocardial level, sympathetic denervation is described in I-MIBG scintigraphy of the heart.Disorders in that radiotracer uptake, which reflects the adrenergic integrity at ventricular level, tend to intensify as the disease progresses.Those studies evidence strong association between the sympathetic denervation areas, wall motion abnormalities, and myocardial hypoperfusion in many patients, contributing to the installation of potentially fatal arrhythmias. Studies onT. cruziinfection in humans and experimental models with Syrian hamsters have suggested that the sympathetic autonomic denervation and microvascular dysfunction are closely related and active in the initial stages of CCCD.Among the obstacles to the \u2018parasympathetic-deprived\u2019 theory and despite the predominant vagal dysfunction, there is the finding of the concomitant attenuation of the adrenergic regulation of the sinus node-mediated cardiac chronotropism.Thus, attenuation of the cytotoxicity of T lymphocytes by cholinergic-muscarinic stimulation was observed, and afferent and efferent signs that would compose an arch, the \u201cneuroimune\u201d or \u201cinflammatory\u201d reflex, were postulated.Additional aspects related to the complex dysautonomic pathophysiology observed in CD involve the so-called anti-inflammatory cholinergic pathway. The conceptual base resides in the evidence that the inflammatory process in CD influences and is influenced by the immune-mediated autonomic balance.In the CD context, it was hypothesized that the cardiac parasympathetic tonus depression could contribute to exacerbate inflammation during the chronic phase, a pathophysiological conception that goes back to the beginning of the investigations about CD.According to that concept, the nervous and immune systems communicate in a two-way manner and use that interaction to mediate the cytokines and neurotransmitters they have in common. The efferent pathway of the central nervous system would act on the immune system through its parasympathetic component, making the anti-inflammatory cholinergic pathway. The parasympathetic system innervates the organs of the immune system and its mediator, acetylcholine, acts on that system cells, especially macrophages, by activating the acetylcholine receptor.Such antibodies are postulated to result from antigenic mimicry ,and the disorders mediated by circulating autoantibodies can confer particular characteristics to the CD dysautonomia as compared to other neuronal affections.The mechanisms that induce autonomic dysfunction in CD include the production of circulating autoantibodies, particularly against cholinergic receptors (Ac-M), as well as against adrenergic receptors (Ac-\u03b2).The development of an infectious disease is usually a complex phenomenon related to several factors of the environment, the infectant pathogen, and the host. Thus, the assessment of the genetic characteristics of the host and pathogen can contribute to solve the enigma: why approximately 30% of the infected individuals develop CCCD, while the rest remains asymptomatic and without clinical manifestations for the entire life.T. cruzirecognizes seven discrete typing units (DTU), TcI-TcVI and Tcbat.This genetic diversity is a potential target for innovation in new trypanocidal drugs.The genetic diversity ofin vitrostudies has evidenced that, despite the preliminary signs of relevant differences in the parasite\u2019s sensitivity to the etiological treatment, there is significant heterogeneity in the results, even considering only studies on the sensitivity of severalT. cruziDTU to a single trypanocidal drug, benznidazole, which hinders the accurate identification of more and less sensitive parasite\u2019s strains to treatment.Recent research has indicated that the parasite strains detected in patients, regardless of their clinical presentation, reflect the major circulating DTU in the domestic transmission cycles of a certain region. Recent systematic review and meta-analysis ofT. cruzistrains and the different geographical distribution of DTU in humans, there are regional variations in the sensitivity of the serological tests, causing potential implications in the response to parasiticide treatment options.In several studies of micro-outbreaks of orally transmitted parasites, wild strains are implicated. Because of the genotypic and phenotypic differences ofSuch genotypic characteristics have been recently summarized to clarify their potential associations with clinical manifestations of CD, emphasizing the persistence of significant uncertainties regarding knowledge as well as of relevant challenges in those research lines.Similarly, studies of genetic polymorphism have focused the host\u2019s characteristics that influence the development and severity of the clinical presentations. In that context, the SNPs are defined when at least two alternative nucleotides occur in the genome at significant frequency . The SNPs show Mendelian inheritance and are used as genetic markers.T. cruziinfection.The TNF polymorphism is one of the most studied in CD. In Brazil, a reduction in the survival of patients with the TNF-308A allele or TNFa2 microsatellite allele has been reported,but no association was found between the TNF-308 polymorphism and the CD clinical presentations.Similarly, another study in Peruvian patients, comparing those with CDversuscontrol individuals withoutT. cruziinfection, has shown no major association of the TNF-308, -244, and -238 polymorphisms with CD.Several studies have assessed the human genetic polymorphism and included correlations with elements of the immune response, adaptive and regulatory, duringIn contrast to that described for mediators related to the immune profile, the genetic assessment related to the angiotensin-converting-enzyme system evidenced some disagreement, but the DD genotype has been associated with a higher risk for HF and mortality in the myocardial disease of ischemic etiology.In two different populations with CD, including a Brazilian one, no valid association regarding those polymorphisms has been observed.However, in another population from the Brazilian northeastern region, a higher prevalence of the I/D polymorphism has been reported in patients with HF as compared to asymptomatic patients with CD.Such discrepancies can be due to the fact that final phenotypes are considered dependent on environmental factors,requiring large samples to demonstrate effects of the genes involved in complex traces, such as those in the complicated clinical syndromes, such as HF of CD etiology.In another cohort study, in HF due to idiopathic cardiomyopathy, the DD genotype has been shown to remain a predictor of mortality.But a recent meta-analysis has revealed the association with CCCD development in rs2458298, nearby the SAC3D1 gene, indicating the host\u2019s genetic variability as a susceptibility factor to CCCD development afterT. cruziinfection.More recent studies on genetic aspects and using GWAS technology have involved bigger samples and generated more consistent and relevant information. For example, previously the SNPs have not been strongly associated with CCCD.T. cruziinfection, with potential pathophysiological and therapeutical implications.In the acute phase of the infection, the parasite\u2019s adhesion to and penetration into the host\u2019s cells occur via lecithins that bind to carbohydrate residues attached to the host cell membrane, mainly the sialic acid. Recent review about the family of human galactoside-binding proteins, called galectins, has reported on their significant participation in the innate and adaptive immunomodulation toInside the host\u2019s cells, trypomastigote forms transform into amastigote forms, but, for as long as the parasitized cells remain intact, no local inflammatory reaction is observed. When the parasitized cell ruptures, epi-, trypo-, and amastigote forms of the parasite, intact or degenerated, are released, along with cell components that act as immunogens , to the extracellular medium, stimulating the presence of inflammatory mediators, which cause vasodilation and increase vascular permeability, factors typically implicated in the inflammatory process exacerbation.in vitro, T. cruzi-sensitized lymphocytes have a cytotoxic action against cardiomyocytes; (2) the mononuclear inflammatory infiltrate and occasional formation of granulomas suggest the possibility of late hypersensitivity reaction.In the early acute phase, the inflammation is focal, topographically associated with intense parasitism, and can coalesce and become diffuse. In contrast, the chronic phase is more obscure and complex, because, although there is active inflammatory reaction, the parasitism is scarce and cannot completely explain the inflammatory foci. Thus, the hypothesis of late hypersensitivity and autoimmunity has been raised to explain the maintenance of inflammation and lesions in the chronic phase of the disease by: (1) molecules of the parasite and of the cardiomyocytes are structurally similar, which could explain common antigenic properties and immune cross-reaction:These more controversial pathophysiological aspects of the inflammatory lesions of the CCCD have been partially clarified in recent studies using more sensitive tests to detect the parasite. Such tests suggest that, even scarce, the parasite persistence in the tissues is a continuous source of antigens, which can mediate the low-grade, but incessant, inflammatory response.T. cruziDNA in inflammatory foci in almost all cases studied. In addition, the accumulation of CD8+ T lymphocytes, which predominate in chronic myocarditis, correlates with the focal presence of parasite antigens. In addition to the degenerated trypanosomes, the cell rupture can cause the release of microorganisms that were in theT. cruzicytoplasm. This hypothesis is based on the observation of endomyocardial biopsies of patients with CCCD showing electron-lucent microparticles and nanovesicles containing DNA from archaea \u2013 the oldest microorganisms in nature that can parasitize trypanosomes \u2013 in the region of inflammatory foci.Techniques of molecular biology, such as polymerase chain reaction (PCR), applied to myocardial fragments of patients with CCCD have shownArchaea, numerous in the serum of patients with HF due to CD, are associated with inflammation, because they uptake interstitial proteins and generate immune response with CD8+ T lymphocytes, with no response of CD4+ T cells. Lipidic archaea are increased in the IFCD, as well as protecting exosomes that capture AMZ1  from the external medium, preventing the activation of enzymes and protecting against collagen degradation and inflammation. Thus, according to that hypothesis, archaea could play a fundamental role in the myocardial inflammation and microcirculation dilation.T. cruzihas tropism for the adipose tissue, which can be another pathophysiological link of the extensive inflammatory changes present in the chronic phase and explored as a therapeutic target.Still, from the histopathological viewpoint, former studies have evidenced thatSeveral clinical manifestations in patients with CCCD mimic those of coronary obstructive disease: 30-40% of those patients have chest pain, which is usually atypical with no clear relation to physical exertion and variable duration, for long symptomatic periods. Those patients\u2019 ECG usually show ST-T alterations and areas of electrical inactivity, simulating changes due to ischemia and/or myocardial infarction. More characteristically, patients with CCCD usually show ventricular wall motion abnormalities similar to those due to necrosis and infarction associated with coronary obstructions. Finally, several myocardial perfusion disorders have been described in the different phases of the CCCD.These pathophysiological changes are attributed to coronary structural and regulatory abnormalities at microvascular level. Histologically, extreme vasodilation, not seen in other DCMs, has been described, with a reduction in distal perfusion pressure, myocytolysis, and ischemia in borderline regions of double coronary irrigation , postulated as more susceptible to ischemia.Such ischemic lesions are believed to contribute to the installation of akinetic areas and ventricular aneurysms, such as apex thinning and typical inferolateral fibrosis frequently detected as the origin of sustained ventricular tachycardia (SVT).Of note, all those structural and functional changes are found in the presence of angiographically normal subepicardial coronary arteries with no early detectable atherosclerosis on computed tomography angiography.A common consequence of those microcirculatory disorders is fibrosis, which develops slowly and progressively, with interstitial deposition of fibronectin, laminin, and collagen, leading to expansion and distension of the extracellular matrix, contributing to the progressive loss of myocardial contractile activity and appearance of cardiac arrhythmias. There is no other human myocarditis in which fibrosis develops so intensely and with so peculiar characteristics as that of the CCCD.T. cruzi-infection natural history or even CCCD. The parasite life cycle itself, through new knowledge of its interaction with the human host, and the vector as an intermediate host, with the better understanding of its genetic characteristics, can be revisited to assess the therapeutic possibilities of the trypanocidal effect.Several recent investigations have focused on some pathophysiological changes that can be therapeutic targets to favorably influence theThus, after a preclinical study evidencing a reduction in fibrosis with the transforming growth factor-beta inhibitor,that cytokine antagonism has become an important therapeutic target in the context.However, the most recently identified perspectives reside in the possibility of inflammatory response modulation. In the IFCD and CCCD, several mechanisms of inflammatory activation of IL-1Beta have been shown.An extensive analysis of several aspects hypothetically related to multiple strategies to control the parasite and its inflammatory consequences has been recently reported to improve the prognosis of infected individuals.In addition, there is evidence that the clinical forms of CD (IFCD and CCCD) involve different subpopulations of CD4- and CD8- immune memory cells, raising the possibility of a new anti-inflammatory strategy to control CD in the heart.A pioneer randomized study with a small sample of 37 patients with CCCD has assessed the therapy with granulocyte-colony stimulating factor (G-CSF), which is clinically used to support chemotherapy and bone marrow transplantation and has shown promising results inT. cruzi-infected mice. That study has reported good tolerability to treatment for 1 year, suggesting that further studies with G-CSF should be conducted in humans with CCCD.In another line of research about natural drugs with strong anti-inflammatory and antioxidant activity, such as curcumin and resveratrol, the results with experimental animals have been reviewed, encouraging future initiatives in humans.T. cruzi-infected individuals. The aim was to identify biomarkers to predict the risk of developing CCCD and to monitor the evolution and therapeutic interventions in that context.Finally, the genetic polymorphism, which pathophysiologically regulates the levels of pro- and anti-inflammatory factors (as exemplified by IL-10), has been recently revisited in a meta-analysis of several studies with some subpopulations ofT. cruziinfection.The incidence of the acute myocarditis of CD depends on the parasite load and strain, host, and infection transmission mode . Depending on the diagnostic tool, the detection of myocarditis can vary from 40% to 100% in the acute phase ofThere are inflammatory lesions in the myocardium, endocardium, pericardium, and intramural autonomic nervous system of the heart and several other organs, similarly to those observed in viral myocarditis. The hematoxylin-eosin and Giemsa stains can easily evidence amastigote forms of the parasite.As already discussed in the chapter on the pathogenesis of CD, the anatomical pathology of the acute phase is directly related to the parasitism of the cardiac cells, the inflammatory reaction immediately evoked by the infectious process, and the consequent microcirculatory impairment.A characteristic finding is the presence of small nodules lined up as beads in a rosary, which is called moniliform epicarditis. Despite the true pancarditis, the cardiac valves, typically avascular structures, are often spared. The severity of the cardiac lesions is influenced by the infection transmission mode . In most cases, the infection has a benign course, being virtually oligosymptomatic, or, less often, very severe, leading to death.T. cruzitransmission (ingestion of foods not sanitarily prepared and contaminated by macerated triatomine bugs or by their excrementa). Subclinical aspects have been frequent. Acute inflammation can begin right before the fever subsides, which usually occurs within 15 to 20 days from the disease beginning.Recently, the most studied clinical aspects have been those related to the myocarditis caused by oralTachycardia is usually present, and, in most severe cases, symptoms and signs of acute HF can be observed, particularly the C hemodynamic profile (poor tissue perfusion and pulmonary and/or systemic congestion).The ECG shows unspecific ventricular repolarization changes, low-voltage QRS complexes, supra- or ventricular extrasystoles, and even sustained ST-segment elevation. Atrioventricular or even intraventricular conduction disorders, common in the chronic phase, are less frequent in the acute myocarditis.Some patients, similarly to that occurring in viral myocarditis, can manifest chest pain, dyspnea, and palpitations, sometimes imitating coronary artery disease symptoms.The ECHO frequently detects pericardial effusion of variable proportions, with diffuse hypocontractility of both ventricles, which is an attribute of the most severe cases of myocarditis.T. cruzi.In a study involving 126 individuals aged < 18 years, most of whom (68.3%) diagnosed with the acute form after oral transmission and followed up for 10.9 years, the evolution was considered benign, although 2.4% persisted with cardiac changes.The most accepted hypothesis for the fatal outcome of a significant number of orally infected patients is due to large inoculation, with ingestion of a high parasite load, in addition to the easy intense penetration of parasites through the gastrointestinal mucosa, very permeable toT. cruziinfection can be fatal .The natural history of the acute phase of CD caused by the classic vector transmission (excrementa of the hematophagous bug) includes a high number of individuals whose infection is not even diagnosed because they are asymptomatic or oligosymptomatic and progress to practically spontaneous remission. In a reduced number of cases, the acuteis less clear than that registered for the micro outbreaks recently observed after oral transmission. However, it is evident that more symptomatic cases have unfavorable outcomes because of their association with a more intense acute myocarditis.But, most importantly, the large majority of individuals acutely infected byT. cruziusually progress to the chronic phase, being characterized as having the IFCD.The natural history of the acute phase myocarditis caused by classic vectorial transmissionThe natural history of the acute myocarditis of CD and IFCD is yet to be clarified. Some studies have properly assessed that evolution. However, several influences can bias the results, such as the affected population\u2019s age range, transmission mode, parasite load and strain, follow-up duration, and previous etiological treatment, which can completely and favorably change the natural history.A cross-sectional study conducted in the municipality of Bambu\u00ed, Minas Gerais state, in the 1940-1950 decades, on the acute phase of CD diagnosed after classic vectorial transmission, has reported 8.3% of case-fatality in the acute phase of children < 10 years of age. Of 130 individuals followed up from 1 to 3 years after the acute phase, 71.5% showed no ECG changes and 30% had normal cardiac dimensions. After 3 to 5 years, those numbers were 65.7% and 87.5%, respectively. It is worth noting that the population sample was basically formed by children in the post-world war-II period, who received no etiological treatment.ln scale] = 0.4946). For the individuals followed up from the IFCD on, that risk was 1.9% .A more recent study on the natural history of CD has assessed two groups of patients: one followed up since the diagnosis in the acute phase and the other followed up from the IFCD onward. The study has assessed the risk of developing CCCD by use of systematic review and meta-analysis of 32 studies. The following were considered for the diagnosis of CCCD: appearance of arrhythmias or ECG changes; evidence of ventricular contractile abnormalities on ECHO; and death associated with CD. After the acute phase, the estimated annual risk of progression to chronic cardiopathy was elevated, 4.6% , and deaths among them are very rare and probably not more frequent than those occurring in sex- and age-matched individuals not infected byT. cruzi.After the acute phase, untreatedAlthough several individuals can remain indefinitely in the IFCD, in others, some decades after the acute infection, CD becomes clinically evident with disorders in specific organs, mainly heart, esophagus, and colon, characterizing the determined chronic clinical forms: cardiac, digestive, or mixed (cardiodigestive).In Brazil, 20% to 30% of the patients are estimated to develop the cardiac form, 5% to 8%, esophageal disorders, and 4% to 6%, colonic disorders. With population aging, a greater part of infected individuals tends to develop the cardiac form, although recognition of the real prevalence is hindered by the coexistence of other cardiovascular diseases associated with aging.The clinical manifestations of CD differ significantly in different Latin-American regions, and digestive syndromes are less often reported outside Brazil. From the epidemiological and clinical viewpoints, chronic cardiomyopathy is the most important form of CD because of its high morbidity and mortality and consequent medical and social impacts.Epidemiological studies in endemic areas, observation in blood donors, and meta-analysis results, after systematic review, have shown that approximately 2% of the patients progress annually from IFCD to a clinical form of CD.T. cruziinfection in the \u201cabsence of any clinical syndrome\u201d of CD.Its possibility for progression to cardiac and/or digestive disease was originally described by Eurico Villela and Carlos Chagas in 1923and highlighted in the 1950 decade by Laranjaet al.Those authors defined IFCD as the 10-to-30-year asymptomatic period extending from the end of the acute phase to the late initiation of cardiopathy from chronic infection.The term \u201cindeterminate form\u201d was used, for the first time, by Carlos Chagas in 1916 to designateSince then, several authors have used different terms to refer to that stage of CD, such as latent, asymptomatic, subclinical, laboratory, or \u201cpotentially cardiac\u201d form, with no strict standardization of the diagnostic criteria, leading to different and even conflicting interpretations of the real meaning of the IFCD.The consensus emphasized that the presence of alterations identified on the most sophisticated investigative tests does not invalidate the previously presented concept, reinforcing the good medium-term prognosis of the cases, as confirmed by clinical follow-up as well as by ECG and ECHO.In 1984, a group of experts met in the city of Arax\u00e1, Minas Gerais state, to elaborate a consensus document reassuring the IFCD concept validity, as well as defining the objective diagnostic criteria previously cited.Elimination of the term has been even suggested, with its replacement by \u2018chronic CD with no evident pathology\u2019, when not only conventional ECG and chest radiography, but routinely performed doppler ECHO, Holter, and exercise testing resulted normal.However, the classical concept of IFCD has been reassured in national and international guidelines.As there is still criticism about the IFCD concept, some suggestions for its modification have been made, such as replacement of \u2018normal findings on chest X-ray\u2019 by \u2018normal findings on ECHO\u2019 to define IFCD presence.It is worth noting that, in clinical practice and epidemiological studies, patients with CD, normal findings on ECG and chest X-ray, and no digestive manifestations, do not routinely undergo gastrointestinal tract radiological assessment. This has led to the operational concept of \u201cchronic CD with no apparent cardiopathy\u201d, because the classical definition of IFCD requires the radiological assessment of the esophagus and colon.In addition, invasive methods, such as endomyocardial biopsy, have shown histological changes in a substantial number of patients with IFCD, but at low intensity. Of 33 patients with IFCD undergoing endomyocardial biopsy, 60% have shown degenerative changes, fiber volume alterations, interstitial edema, inflammatory infiltrate, and fibrosis in small amount.As the investigative methods became more sophisticated, several alterations, usually discrete and with no prognostic implication, could be detected in those individuals, as reported in studies with Doppler ECHO, radionuclide ventriculography, exercise test, cardiopulmonary exercise test, autonomic tests, and ambulatorial ECG.In addition, more sensitive echocardiographic methods, such as tissue Dopplerand myocardial global longitudinal strain (GLS)with speckle tracking echocardiography (STE), have shown alterations in patients with IFCD. However, such studies have not had sufficient follow-up to define if patients with those mild alterations would progress in a different way, and, eventually, to ventricular dysfunction.Currently, CMRI provides the same data, with the advantage of being noninvasive.The following cardiac primary outcomes were considered in that systematic review: (1) development of symptoms, in general, or of HF, specifically; (2) development of structural cardiomyopathy or cardiac arrhythmias, as observed in abnormal ECG or echocardiographic findings; and (3) presence of complications due to severe cardiomyopathy, such as sudden death, death associated with advanced HF, pulmonary embolism, or stroke. Twenty-three studies have reported observational longitudinal findings for patients with IFCD. Most of them were prospective cohorts conducted in Brazil or Argentina between 1960 and 2005. In studies with information on age group, the means ranged from 10 years to 44 years, the general mean being 31 years. The mean follow-up duration was 8.5 years, varying from 3 years to 18 years. That study concluded that the estimated annual combined rate of progression to CCCD was 1.9% . The cumulative probabilities of cardiomyopathy evidence were approximately 17% and 31% in 10 years and 20 years, respectively.For the past 60 years, the risk of chronic cardiomyopathy development has been assessed in cohort studies, which have been gathered in a recent systematic review and meta-analysis.the authors found no difference regarding the rate of progression based on the investigation year (before or after 1985), study size (> or < 200 participants), participants\u2019 mean age (< or > 32 years), or sex predominance. However, in studies originated from Brazil, the annual rate of progression to cardiomyopathy was significantly higher  as compared to those from studies from other South-American countries , reinforcing the importance of regional differences in disease course.Although the rate of progression to cardiomyopathy is well defined, several doubts persist about the mechanisms involved in disease progression. In that same systematic review,In addition, the authors have reported that the subgroup receiving antiparasite treatment had an estimated annual combined rate of progression to cardiomyopathy significantly lower  as compared to the subgroup not receiving etiological treatment .with a murine model ofT. cruziinfection has shown that parasite persistence correlates with the presence of cardiac disease, while parasite elimination from the tissues is associated with inflammation improvement.Those results corroborate with the general pathophysiological notion that there is substantial evidence that parasite persistence (load) is a fundamental factor for IFCD progression to CCCD. A reference studyThe presence of parasitemia correlates significantly with known markers of disease progression, such as prolonged QRS, reduced LVEF, and higher levels of troponin and N-terminal pro-brain natriuretic peptide (NT-proBNP).Subsequent studies have shown that inflammation and fibrosis extension, as well as disease severity, are associated with persistence of the parasite DNA in cardiac lesions observed in patients with CD.Additional results of the NIH-REDS2 cohort, with a mean 8.7-year follow-up of the original cohort,have shown that the incidence of cardiomyopathy inT. cruziseropositive blood donors was 13.8  events/1000 per year  as compared to 4.6  events/1000 per year  in seronegative controls, with a difference in the absolute incidence ofT. cruziinfection of 9.2  events/1000 per year. Anti-T. cruziantibody levels at the beginning of the study, an indirect measure of parasite load, were associated with the development of cardiomyopathy, with adjusted odds ratio of 1.4  per unit of increase in antibody levels.In a cohort with 1813 patients with CCCD, those previously treated with benznidazole showed a significantly reduced parasitemia, lower prevalence of severe cardiomyopathy markers, and lower mortality after a 2-year follow-up.et al.showing that treatment with benznidazole, as compared to absence of etiological treatment, was associated with a reduction in the progression of CD and an increase in negative seroconversion. Other observational studies have reported similar results.The importance of parasite persistence for the development of CCCD is corroborated by an extensive nonrandomized clinical trial by ViottiThose results have been object of divergent and complementary discussions and interpretations,and the importance of parasite persistence in patients with established cardiopathy remains controversial, as detailed in the chapter of etiological treatment in this guideline.There is yet evidence that, once the cardiopathy is established, tissue parasitism loses importance for the disease\u2019s clinical course, and immune damages to the tissues predominate. According to this hypothesis, once the cardiopathy is established and the tissue parasite factor is eliminated, there would no longer be a chance of reversion to a less ominous natural history, because irreversible lesions would already be installed. Thus, the prospective, multicenter, randomized BENEFIT study, involving 2854 patients with CCCD receiving benznidazole or placebo for as long as 80 days and with a mean follow-up of 5.4 years, has shown that the use of the trypanocidal drug reduced parasitemia, but did not significantly influence clinical cardiac deterioration as compared to a control group.The most important symptoms are: dyspnea on exertion, fatigue, palpitations, dizziness, syncope, chest pain , and lower limb edema.The natural history of CCCD is characteristically slow and progressive, although occasionally more abrupt. Its clinical manifestations vary from asymptomatic (\u2018silent\u2019 cardiopathy) to severe findings, with refractory HF, rhythm disorders, and thromboembolic phenomena, the three major clinical syndromes.The physical examination reveals one or more abnormalities: systolic murmur of mitral and/or tricuspid regurgitation; splitting of the second heart sound, usually associated with right bundle branch block (RBBB); diffuse and displaced apical thrust; and arrhythmias, extrasystoles being the most common ones.5.2.4.1 Abnormalities on Complementary TestsThe absence of electrocardiographic changes, however, is no absolutely reliable indicator of the cardiac impairment absence.The RBBB, isolated or in association with other changes, is the most common electrocardiographic abnormality.It is more typically associated with left anterior fascicular block (LAFB) and ventricular extrasystoles (VE). The QRS duration is directly related to the LV size and inversely related to LVEF.A QRS duration > 120ms and QT interval > 440ms have moderate accuracy to predict reduced LVEF in patients with CD.The ECG in CD has fundamental diagnostic and prognostic values.The combination of intraventricular conduction disorders with extrasystoles or sinus bradycardia associates with both LVEF reduction and LV volume increase.It is worth noting that the electrocardiographic changes caused by CD tend, in older individuals, to add to those caused by the biological aging process itself.A more detailed presentation of the ECG changes of CCCD and of those not sufficient to make that diagnosis is found in other chapters of this guideline.The ECG abnormalities most frequently associated with LVEF reduction in CD are frequent supraventricular and ventricular extrasystoles, AF, intraventricular blocks, pathologic Q waves, and ST-T alterations.There is low correlation between the cardiac silhouette enlargement on chest radiography and the systolic ventricular dysfunction degree.However, cardiomegaly detected based on cardiothoracic index (CTI) > 0.5 on radiography correlates better with LV diastolic diameter (LVDD) increase, suggesting the presence of LV systolic dysfunction.Chest radiography is an important test to diagnose patients with CCCD, enabling the assessment not only of the enlargement of cardiac chambers, but, especially, of the pulmonary congestion grade, an imperceptible change on usual ECHO.In CCCD, the radiological findings are similar to those detected in other DCMs. However, an interesting particularity refers to a fact described by clinicians decades ago: several patients with evident systemic congestion, including ascites, hepatomegaly, and anasarca, show a clear disproportion between the advanced cardiomegaly and pulmonary congestion that is usually mild or even absent.It is the most often used noninvasive test to assess cardiac function because of its wide availability and high reliability regarding performance and interpretation, as well as its relatively low cost. It enables determining the evolutionary status of the disease, as well as the most subtle cardiac impairment alterations, especially in the less advanced phases of cardiomyopathy. In CCCD, up to 13% of the patients in stage B (see HF classification) have a characteristic regional deficit, despite preserved global biventricular systolic function.It is worth noting that such isolated regional LV motion alterations evidence poor prognosis, as observed in serial studies with ECHO.For decades, transthoracic ECHO has been an important tool for the diagnosis and follow-up of patients with the different forms of CD.Of several parameters analyzed, the most important ones are: LVEF, left atrial diameter, left atrial volume, systolic and diastolic LV diameters, diastolic function, right ventricular (RV) systolic function, global and regional LV contractility, global RV contractility, and presence of apical aneurysm.Despite this pathophysiological notion, evidence derived from studies using other methods, such as radionuclide ventriculography, CMRI, and more specialized ECHO, indicates that some patients with CCCD have early important isolated RV morphofunctional changes.In such conditions, in the absence of concomitant LV pathological involvement and while the impedance of the pulmonary circuit remains reduced, the RV dysfunction might remain unnoticed because the LVvis-a-tergois sufficient to maintain the flow and pulmonary vascular resistance normal, as reported in a publication on the subject.The RV echocardiographic analysis is hindered by technical difficulties regarding the RV chamber itself and the essence of the ultrasonographic method. Thus, RV dysfunction is more often evidenced when there is concomitant and significant LV involvement.Finally, when present in the natural history of the disease, the clinically manifest RV systolic dysfunction significantly worsens the prognosis of patients with CCCD.5.2.4.2. Cardiac ArrhythmiasT. cruzi. When patients with ECG changes at rest and manifest HF undergo dynamic electrocardiography assessment, almost all of them (99%) have VEs, which, in 87% of the patients, are multiform or present as repetitive (paired) forms or even as nonsustained ventricular tachycardia (NSVT), that is, three or more successive ventricular ectopic beats, lasting less than 30 seconds.Cardiac arrhythmia is an extremely common manifestation of CCCD, and ventricular ectopic activity predominates since the early phases of its natural history. Ventricular extrasystoles have been shown in 15% to 55% of individuals with positive serology forIn addition, involvement of the sinus node and the atrioventricular conduction system is very frequent in patients with CCCD. Sinus node dysfunction can manifest as bradycardia or even sinus arrest, second-degree sinoatrial block, junctional rhythm, and accelerated idioventricular rhythm. First-degree atrioventricular block (AVB) is one of the most frequent atrioventricular conduction disorders, and can be transient or permanent. Second-degree AVB is less frequent and classified into the following types: Mobitz I (Wenckebach), Mobitz II or advanced-degree. Third-degree or total AVB (TAVB) can occur in 10% of the patients, being more frequent than in any other acquired cardiopathy. Atrial fibrillation tends to manifest later, usually associated with more advanced degrees of systolic dysfunction and ventricular dilation.Sudden death is usually precipitated by physical exercises and can be associated with SVT or ventricular fibrillation (VF) and, less frequently, asystole or TAVB. Approximately 40% to 50% of the cases of sudden death are asymptomatic prior to the fatal episode, but most patients have concomitant severe impairment of the ventricular systolic function and of the conduction system. The severity of ventricular arrhythmias tends to correlate with the ventricular dysfunction degree. However, differently from other diseases, patients with CCCD and malignant ventricular arrhythmias may present relatively preserved LV global function, but with regional dyskinesias indicating localized fibrosis.Episodes of malignant ventricular arrhythmias are much more frequent in patients with CCCD than in those with other forms of cardiopathy, such as the one resulting from coronary artery disease or DCM of other etiologies.The arrhythmias can be asymptomatic or cause palpitation, dizziness, dyspnea, weakness, presyncope, syncope, or cardiac arrest. Sudden death accounts for 50% to 65% of the deaths due to CD.5.2.4.3. Heart Failure SyndromeHeart failure manifests in many patients throughout the natural history of CCCD, usually with biventricular dysfunction, including early symptoms, such as dyspnea, fatigue, lower limb edema, and atypical chest pain. Diastolic dysfunction can be observed in the early stages of CCCD, in the absence of regional or global LV systolic dysfunction, and can be explained by a certain degree of LV diffuse fibrosis.As already mentioned, in some patients, right HF can be more prominent than left HF, but RV dysfunction, when clinically manifest, is usually associated with LV dysfunction in an advanced stage of CCCD.The HF classification according to LVEF is shown inThe classification of HF of CD etiology, considering the presence or absence of functional and/or structural defects in general and LV systolic function especially, is useful when applied to CCCD, after mild modifications from the 2011 SBC guidelines, enabling the identification of different subgroups or evolutionary stages from the prognostic and therapeutic viewpoint.5.2.4.4. Systemic and Pulmonary Thromboembolic SyndromeFrom the clinical viewpoint, thromboembolic phenomena to the brain predominate, followed by embolism to other systemic organs and limbs, and lastly by pulmonary embolism diagnosed during life. Stroke can be the first devastating manifestation of the disease.This syndrome is very common in CCCD, venous and arterial thromboembolic phenomena being the third cause of death.The high frequency of the thromboembolic syndrome in CCCD can be due to several factors that can predominate depending on the disease\u2019s phase. Thus, the apical aneurysm can be an early alteration in CCCD, but, more commonly, thrombosis in systemic veins that can cause pulmonary embolism are complications of HF, when cardiac output and venous return are hindered. In the presence of HF, dilation of the chambers favors atrial and ventricular mural thrombosis, causing systemic and/or pulmonary embolism. Atrial fibrillation is more frequent in advanced cases of CCCD, increasing the risk for thromboembolic complications.The incidence of stroke in patients with known CD ranges from 0.56 to 2.67 per 100 individuals-year.Thus, CCCD should be regularly included in the differential diagnosis of stroke in Latin America.Ventricular systolic dysfunction, enlarged left atrial volume, apical aneurysm, cavitary mural thrombosis, and arrhythmias, such as AF, seem to be important risk factors for stroke of CD etiology, characteristically of cardioembolic nature.In 50-70% of the patients, stroke manifests as a partial anterior circulation syndrome, which includes two of the three signs: motor or sensory deficit involving face, arm and leg; homonymous hemianopsia; and upper cerebral dysfunction, expressed as aphasia or visuospatial deficit. Less often, patients will have lacunar or posterior circulation syndrome.Chagas disease is a major cause of stroke in Latin America, accounting for up to 20% of this complication in endemic areas.IPEC-FIOCRUZ)has been developed in a prospective observational study with 1043 patients.As discussed in a specific chapter of this guideline on thromboembolic complications of CD, that score needs to be reviewed to contemplate updated scientific considerations.A risk score for stroke , indirect hemagglutination (IHA), enzyme-linked immunosorbent assay (ELISA), and, in recent years, non-conventional tests, such as chemiluminescent microparticle immunoassay (CMIA) and electrochemiluminescence immunoassay (ECLIA) in automated platform, in addition to rapid tests. Non-purified and purified products  can be used as antigens in all those tests.Two positive tests indicate that the patient is seropositive, with detection of anti-T. cruziantibodies by use of two different methodologies, meaning that the patient is infected withT. cruzi. When the result is non-reagent (two non-reagent tests of different principles), the serology is negative; in such cases, usually there is no epidemiology, and clinical manifestations, if present, can be explained by causes other thanT. cruziinfection. In a third unusual possibility (< 5% of the cases), the results are non-concordant, with a reagent test and another non-reagent (The combination of the results of the two tests enables the classification of the patient\u2019s serum as positive (two reagent tests) or negative (two non-reagent tests), considering concordant results of the two tests performed.reagent .Finally, in another possibility, one of the test\u2019s results is undetermined, that is, in the narrow range between negative and positive, the \u2018grey\u2019 region. An example is the passive transfer of antibodies from an infected mother to her child. The progressive decrease in the level of maternal antibodies in the non-infected offspring, around the third month of age, can correspond to that grey region, an undetermined result.In those rare situations of discordance, the clinician, after analyzing the epidemiological and clinical data, should assess if the patient underwent previous specific treatment and if there is any history of cutaneous leishmaniasis or other diseases, especially autoimmune ones. In such cases, a new blood sample should be collected. Usually, the discordant result becomes concordant in the new sample. If the result remains undetermined, the patient should be referred to a specialized service/laboratory, where other techniques will be performed for a conclusion to be reached. Exceptionally the referral laboratory will not reach a conclusion regarding the individual\u2019s infectious status, and parasitological methods can be used. In such cases, a clinical assessment with ECG should be performed. However, even in the presence of a normal EGC, the patient with an inconclusive serology should be instructed not to donate blood.6.1.4.1. Inconclusive Serological ResultsAs already mentioned, inconclusive serological results are not usually found (< 5%), being often associated with the presence of other diseases, especially visceral or cutaneous leishmaniasis, systemic lupus erythematosus, and chronic liver diseases, usually with increased gamma globulin levels. These are the so-called cross reactions. Thus, other causes should be investigated, and the patient asked about any previous treatment with benznidazole. If affirmative, the individual\u2019s antibody levels might have decreased as a consequence of the treatment, turning the serology result undetermined.6.1.4.2. Test Result Not Corresponding to Clinical ExpectationAs already mentioned, two serological tests of different principles should be requested, preferably including the titles obtained, indicating the levels of antibodies. Usually both results are either positive or negative. Rarely the results of the two tests are discordant as follows: one negative and the other positive, or one positive and the other undetermined. In these situations, a new blood sample should be collected, using the same techniques and, if possible, a third one . Usually, this procedure enables a conclusive result.T. cruziinfection, while the serological tests are negative, requiring a new blood sample collection in a referral or specialized laboratory for new tests. According to such laboratories, when the results of three tests of different principles are negative, usually it is notT. cruziinfection. Thus, there are cases of RBBB due to other causes, and families with some members not infected byT. cruziare often found, leading to the hypothesis of natural resistance to CD, already known in other infections, such as hanseniasis and tuberculosis. In addition, spontaneous cure, although rare, can occur. Exceptional cases ofT. cruziinfection without the detection of serum antibodies have been reported.In such cases and if suspected, parasitological tests should be performed to solve the doubt.Several interferences can lead to a false reagent result, not confirmed by two other negative tests. In other cases, one test can be non-reagent while the same serum is reagent by the other two tests. Clinical and epidemiological data usually lead to a diagnosis. In other circumstances, the clinical and epidemiological data may point to6.1.4.3. ParasitemiaAlthough most chronic patients have low parasite load in peripheral blood, approximately 20% of them can have high parasitemia detected by serial multiplication tests . In cases of RCD due to immunosuppression (HIV and others), most patients have high parasitemia. It is worth noting that \u201creactivation\u201d means that the individual, from the laboratory viewpoint, is in the acute phase, defined by the detection of parasites in the peripheral blood on direct examination, which is only observed in a short period of the early acute phase and during reactivation itself in the chronic phase. Of note, the laboratory definition of the acute phase consists in the presence of viable parasites in peripheral blood.6.1.4.4. Negative Serology in Patients in the Chronic PhaseAlthough possible, it is exceptional and has been reported in Bolivia.6.1.4.5. Spontaneous Cureet al.after collecting blood from infected patients in Central America years after their acute phase, which had been duly registered with positive direct parasitological tests when no specific treatment was available. The rarity of spontaneous cure has been confirmed by a later study with 110 individuals in the chronic phase of CD, followed up for over 10 years, reporting that none of them showed further levels lower than the initial ones.Nevertheless, the occurrence of spontaneous cure has been shown to be < 1%. Usually, in the second sample collection, some antibodies are always detected, meaning that their levels do not become totally negative. If they do, other hypotheses should be assessed, of which the most likely is difference between tests of distinct origins.Spontaneous cure of CD has been reported by Zeled\u00f3n6.1.4.6. Acute Phase DiagnosisExceptional in Brazil nowadays, it is practically limited to cases of oral transmission through the ingestion of food contaminated with infected triatomines or their feces, particularly in the Amazonian region (approximately 350 cases per year). Oral transmission currently represents the major cause of acute disease in several South American countries.In general, acute CD can be caused by triatomines , contaminated blood transfusion or solid organ transplantation, vertical or congenital transmission, and laboratory accident. In a naturally or iatrogenically immunosuppressed individual, RCD is considered as acute phase. In such cases, the laboratory diagnosis is made through the direct search of the parasite by use of parasitological methods including PCR.6.1.4.7. Blood ServicesThe objective of blood services is to provide good-quality blood and, thus, they should use high-sensitivity tests, capable of detecting > 99% of infected samples. However, that reasoning does not apply to the CD diagnosis. As a result of the necessary care to obtain blood with no infectious agent, the specificity can be lower (98%), leading to blood exclusion, but not necessarily meaning that a particular donor is infected. Frequently, when donating blood, an individual can be notified that he/she might be infected. In such circumstance, two serological tests of different principles should be requested, as already mentioned. Although, in the case series of referral services, 70% to 80% of the donors excluded are effectively infected, a significant proportion (20% to 30%) of those individuals will not be confirmed to have CD, reinforcing the need for a new blood collection and two serological tests.6.1.4.8. Congenital TransmissionT. cruzitransmission pathway in vector-free regions and in several endemic areas.The prevalence rate of that type of transmission in Brazil is 1.7%, one of the lowest indices as compared to those of other South American countries.It is important to consider that babies with clinical signs suggestive of acute CD and born from women with chronicT. cruziinfection should undergo the diagnostic tests for infection as soon as possible. The early diagnosis of congenital CD is extremely important, because the trypanocidal treatment of infected babies in their first year of life leads to cure in 100% of the cases.Vertical  transmission represents the majorT. cruziand no fetal infection occurs, the possibility of passing antibodies (IgG) from mother to fetus through the placenta during pregnancy should be considered. Thus, to detect congenital transmission, the parasitological diagnosis is recommended in the umbilical cord blood or in the newborn in the first 72 hours. Alternatively, in the absence of signs and symptoms of infection, the diagnosis can be made during the first months of life by use of direct parasitological methods , with assessment of two or three samples to increase sensitivity.Babies with negative initial parasitological tests should undergo serologic tests between 9 and 12 months of age, when maternal antibodies have disappeared. The persistence of unchanged anti-T. cruziantibody titles in children from the age of 9 months on indicates congenital infection, while absence of those antibodies at that time rules out the possibility of infection in the child.However, when the mother is infected with6.1.4.9. Serology of Infected Individuals Treated with Chemotherapy DrugsIn addition and to a smaller proportion (25%), patients treated in the late chronic phase showed a negative serology only decades after undergoing treatment. This relates to the duration of the parasite-patient coexistence .The analysis of the cure should be based on negative serological tests or even on the reduction (as long as significant) of antibody levels, preferably with diagnostic tests using non-purified antigens.The follow-up of patients by use of laboratory tests after specific treatment of the infection is approached with more details in the chapter regarding chemotherapy for the disease in general. Here, for those looking for support to exclude or confirm the diagnosis, it is worth noting that it is a very sensitive and complex subject to be reduced to a few principles. According to J. R. Can\u00e7ado, \u201cit is obvious that, if an infected individual has antibodies and parasites, both need to disappear so that the individual can be considered cured (after chemotherapy)\u201d. This precept applies to treated individuals in the acute phase (70% of cure) in a period of months, as well as to children receiving the trypanocidal treatment in the chronic but recent phase, confirming a negative serology (ELISA with recombinant antigens) in 58% to 62% of the cases after 3 to 4 years of follow-up.6.1.4.10. Rapid Serological TestsRapid diagnostic tests are typically easy to handle and do not require a reference laboratory for specialized diagnosis as compared to the classical serological techniques. Several types of rapid tests are available for the diagnosis of CD. Many can be performed on serum or peripheral blood and stored at room temperature for long periods of time. Their use is indicated in endemic areas, mainly in field research , because they contribute to increase access to diagnosis. However, despite being used for that purpose, the rapid tests for CD are not usually recommended as an independent diagnostic method by the WHO, because of their low sensitivity.6.1.4.11. Parasitological TestsParasitological tests should be requested in special situations, not routinely. There are several types of parasitological tests for the chronic phase of CD, which, because of low parasitemia, are aimed at promoting the multiplication of the few parasites present by use of blood culture, xenodiagnosis, inoculation in experimental animals, or identification of nucleic acids (DNA or RNA) specific to the protozoan parasite, using the PCR technique.bioterium), as well as highly-qualified individuals. Usually, those techniques are performed only at specialized research centers. Blood culture and xenodiagnosis used in the chronic phase have low and variable sensitivities (approximately 20%); when repeated, the probability of detection can be increased, reaching up to 60% of sensitivity.For some patients with very low parasitemia, even successive tests will yield persistently negative results.The multiplication of the parasites can take several weeks; thus, the result can take time. It involves \u201cin house\u201d techniques, which require special conditions , but special reagents and technical conditions are also needed. Because of its importance, the PCR technique is detailed below.6.1.4.11.1. Indications for Parasitological Tests, particularly Polymerase Chain ReactionPCR has been valued for patients\u2019 assessment and monitoring when a positive PCR result for the parasite genetic material by the end of the trypanocidal treatment indicates therapeutic failure.However, after treatment, a negative PCR result does not indicate cure of the infection. It is worth noting that the negative serological conversion in treated chronic patients who respond favorably to treatment may take years.The PCR can indicate in advance therapeutic failure, evidencing resistance to the trypanocidal treatment and therapeutic ineffectiveness.One of the major indications for parasitological tests is the follow-up of patients treated with benznidazole or other chemotherapy drugs. Accurate diagnostic methods and reliable markers of the response to the parasiticide treatment are priorities in the research and resource development in general for application in CD.In cases of immunosuppression resulting from CTX, the exclusion of rejection and the detection of RCD can be done early by use of PCR performed in peripheral blood samples and endomyocardial biopsy.In addition, in cases of RCD, PCR is useful, enabling the early detection of reactivation. Monitoring RCD in immunosuppressed individuals is an area of increasing interest. The RCD in infected patients in the chronic phase who acquire HIV or during immunosuppressive therapies, after organ transplantation, autoimmune diseases or cancer, usually increases parasitemia, characterizing acute CD.6.1.4.11.2. Interpretation of the Results of Parasitological TestsT. cruzinor that the infection has been cured.By definition, parasitological tests can only be valued if positive, showing the presence of parasites or their amplified structures (PCR). A negative test, per se, has no value, because the result is only valid for the sample collected. Another sample collected on another day can be positive. Thus, a negative parasitological test does not mean that the individual is not infected by6.1.4.12. Polymerase Chain ReactionSince the 1990s, PCR has been used as a supportive molecular method for the diagnosis of patients in the chronic phase of CD, because of its higher sensitivity as compared to that of parasite multiplication tests (blood culture and xenodiagnosis) and its high potential for use in trypanocidal chemotherapy monitoring.Several studies have shown positive PCR results in 40% to 70% of chronic patients previously diagnosed by use of conventional serology. This variability in positivity depends on several factors, such as parasite load, volume of the blood collected, blood sample for DNA isolation, DNA purification method, target region to be amplified, characteristics of the populations studied, as well as the high genetic diversity observed in the parasite DTU.For those patients, molecular-based detection methods have a limited diagnostic value, because their sensitivity is significantly lower than that of serological tests.Different combinations of molecular targets, sets of reaction initiators, extraction methods, and DNA amplification platforms have been used to assess the accuracy of the method in peripheral blood samples of patients with chronic CD. Usually, the diagnostic sensitivity is lower as compared to that of serological tests.Nevertheless, in case of positive samples, the PCR enables the characterization of theT. cruziinfectant DTU directly in the patient\u2019s blood, not requiring the parasite\u2019s previous isolation.It is worth noting that a positive PCR result confirms the parasite\u2019s presence in a certain sample; however, because of parasites\u2019 scarcity and intermittent circulation, which characterize the chronic phase, a negative PCR result does not exclude infection.T. cruzigenetic material, the following is recommended: the use of conserved DNA sequences , which are exclusive ofT. cruzi(specificity); and these sequences should be represented in multiple copies in the genome (higher sensitivity). The most often used targets in conventional PCR  have been the DNA from the kinetoplasts or kDNA  and the repeating units (satellite DNA) present in the nuclear genome.For selecting the molecular target to detect theT. cruzias compared to the kDNA minicircles.The real time or quantitative PCR (qPCR) can determine the parasite load by quantifying specific DNA sequences. For the quantification assays, satellite DNA sequences are preferably used, because of their smaller variability in the number of copies between the different genetic lineages of6.1.4.13. Operational Procedures for PCR Use1. Blood collection: 10mL of peripheral blood (minimum of 5mL) are usually collected in tubes with EDTA (any other anticoagulant inhibits the enzyme of the reaction). The blood is immediately transferred to a tube containing the same volume (1:1) of a lysis buffer for sample preservation, the 6M guanidine hydrochloride - 0.2M EDTA solution (pH 8.0).2. Sample processing: the blood in the guanidine solution is boiled in water bath  to promote a homogeneous distribution of the parasite\u2019s target DNA sequences, enabling DNA extraction from a lower sample volume (300 \u00b5L). The boiled material remains at room temperature for 48 to 72 hours and can undergo DNA extraction. The remaining material is stored in the refrigerator or cold chamber, without freezing.3. Two 300-\u00b5L copies undergo DNA extraction using commercial kits based on purification through silica minicolumns, according to the manufacturer\u2019s recommendations.4. The PCR protocols follow those standardized in-house by the laboratories, usually based on the international consensus description.5. For qualitative PCR, the test result is the visualization of the amplified product (of the kDNA or satellite DNA) from the agarose gel electrophoresis stained with fluorescent agents that intersperse with DNA.and require the inclusion, in each assay, of standard samples with preestablished concentrations of parasites , which serve as calibrating samples for the absoluteT. cruziquantification. The results generated in qPCR are visualized in real time as graphs issued by the equipment, without requiring running an electrophoresis.6. For qPCR, the protocols also follow the international consensusT. cruzicells) and negative (DNA extracted from blood known to be non-infected and a tube containing ultrapure water without DNA) controls is highly recommended.7. The use of positive  for the new PCR test directed to some human gene . This is a decisive step to exclude false-negative results due to the presence of inhibitors in blood samples or the loss or poor quality of the DNA extracted.9. Recently, a diagnosis kit for PCR produced by the FIOCRUZ (Bio-Manguinhos) has been made available and approved by the sanitary authorities, which will facilitate its use in the Public Health Central Laboratories (LACEN).Thus, well-defined electrocardiographic changes in the infected individual indicate the presence of cardiomyopathy.The most frequent and defined alterations are atrioventricular conduction blocks, right bundle branch and left anterosuperior fascicle blocks, ventricular repolarization alterations, and ventricular ectopic beats. Almost all electrocardiographic abnormalities can be found in CD, in which cardiac electric activity formation and conduction alterations predominate.The ECG is the most important initial cardiovascular test to assess patients with CD, enabling the classification of its clinical forms.RBBB is frequently associated with LAFB, the most commonly found combination in CCCD. Left bundle branch block (LBBB) is rare and of worse prognosis.Complete or incomplete RBBB is the most common conduction disorder in CD, found in 10% to 50% of infected patients, depending on the characteristics of the sample studied.Atrioventricular blocks are common, of varied degrees, and can be the first manifestation of the disease. Advanced AVBs result from extensive lesions of the atrioventricular node and His-Purkinje system, can progress with syncope and need for definitive PM implantation, predisposing to sudden death from asystole.Sinus node dysfunction frequently expresses as bradycardia and can cause episodes of sinoatrial block and sinus arrest. Sinus node dysfunction accompanied by symptoms of reduced cerebral blood flow characterizes sinus node disease, which, in some patients, typically alternates bradycardia and tachycardia episodes.Usually, AF is associated with a more pronounced and extensive myocardial damage, diffuse involvement of the conduction system, ventricular arrhythmias, and stroke.Atrial fibrillation in CCCD is a late alteration, found in up to 5% of the ECG tracings.Ventricular arrhythmias, such as polymorphic VE and ventricular tachycardia (VT), are predictors of syncope and sudden cardiac death due to VF. Pathological Q waves and loss of R wave progression from V1 to V3-V4 indicate inactive electrical areas and result from myocardial fibrosis. Diffuse conduction disorders and low QRS voltage are usually associated with marked ventricular dysfunction.Association of two or more abnormalities in the same electrocardiographic tracing is one characteristic of severe cardiopathy. Conduction disorders associated with ventricular arrhythmias are the most frequent. Coexistence of pathological Q waves indicates more significant impairment of ventricular function. Thus, the higher the number of electrocardiographic changes, the worse the prognosis.With the current more comprehensive control of vectorial transmission and theT. cruzi-infected population aging, chronic diseases, such as hypertensive and ischemic heart diseases, can coexist with CCCD and the typical abnormalities of these conditions can overlap the typical ones of CD.In addition, although there are typical abnormalities of CCCD, they are neither specific of that condition nor appear in all cases.Traditional epidemiological studies, assessing electrocardiographic changes in CD, have been conducted predominantly with individuals infected through classical vectorial transmission and included younger individuals.Regarding the relationship between electrocardiographic changes and prognosis, recent investigations by independent groups of researchers have highlighted the potential contribution of the analysis of those changes, using artificial intelligence and machine learning resources, to predict ventricular dysfunction and myocardial fibrosis, two fundamental prognostic factors in CD.For patients with symptoms suggestive of cardiac arrhythmias, such as palpitations, syncope, and recovery from sudden death, an ECG at rest is mandatory before performing new tests, such as Holter, stress ECG, or intracardiac electrophysiological study (EPS).When CD diagnosis is suspected or confirmed, ECG should be performed and repeated regularly to assess the appearance or progression of abnormalities. In individuals with normal ECG, new changes indicate progression to the cardiac form, requiring additional tests.A recent study has shown that the presence of cardiomegaly based on the CTI can be properly identified by an increased LVDD, measured on ECHO.Considering its large availability, chest X-ray is one of the most used tests to diagnose cardiovascular impairment, and mainly to assess pulmonary congestion. Even in symptomatic patients, an enlarged cardiac area with little congested pulmonary fields is often found. In addition, RV enlargement signs on posteroanterior and lateral projections are common and significant, and signs of right pleural effusion secondary to systemic congestion can be found. An increased CTI is an independent predictor of death in individuals with CCCD.The echocardiographic signs can vary from localized alterations in segmental contraction in the initial stages of cardiopathy to important dilation of cardiac chambers with biventricular dysfunction in more advanced stages. The presence and severity of the alterations on ECHO, in association with clinical data, are criteria used for the classification of CD in stages A to D, with an intrinsic prognostic value, as mentioned in another chapter of this guideline.Echocardiography is the most used imaging test for the initial assessment and follow-up of patients with CD.6.2.3.1. Left Ventricular Systolic FunctionBecause of the presence of geometrical and segmental alterations, M mode is not recommended for assessing LV dimensions and systolic function. Those should be analyzed preferably by using two-dimensional mode and estimation of volumes, with the biplanar method (Simpson). As in other cardiomyopathies, three-dimensional ECHO is superior to two-dimensional ECHO for assessing volumes and ejection fraction, mainly in suspected LV foreshortening in apical view or in the presence of segmental contraction abnormalities with distortion of the suspected geometry, such as in aneurysms frequently identified with the method.The DCM of CD is characterized by LV enlargement and segmental and/or diffuse hypokinesia, and LV systolic dysfunction is the most important predictor of death.The prognostic value of those early regional alterations in patients with the IFCD has not been defined. A recent study, including 144 patients with CD, but without evidence of cardiac impairment, has shown that the radial strain assessed on STE was a predictor of the development of cardiomyopathy.In patients with reduced LVEF and CCCD or idiopathic DCM, reduced GLS was a predictor of combined outcomes regardless of the LVEF.Speckle tracking ECHO enables the early diagnosis of systolic dysfunction by assessing myocardial deformation in patients with CD. Several studies have assessed systolic deformation, in the longitudinal, radial, and circumferential axes, of patients with the IFCD or cardiopathy. The most consistent results have assessed GLS, as in other nonischemic cardiomyopathies. Even in patients in the earliest stages of cardiopathy, as those with preserved ejection fraction (stage B1) or those with the IFCD (stage A), regional alterations in myocardial deformation are observed. In patients with the IFCD, the regional alterations identified on STE occur mainly in the LV inferior and inferolateral segments.6.2.3.2. Segmental Changes in Ventricular ContractilityIn patients with CCCD, an altered segmental motion score at rest (> 1) could identify those at higher risk for clinically relevant outcomes, such as global mortality, despite the initially preserved global ventricular function.Segmental alterations are most frequently found in the inferior and inferolateral walls, in addition to the apical segments. The regional pattern of impairment, not related to the coronary territory, is characteristic of this cardiomyopathy.Segmental changes can be present in 10% of patients in the CD\u2019s early stage and in up to 50% in the presence of dilatation and systolic dysfunction. These regional wall motion abnormalities, when incipient, identify individuals at risk for progressing to global ventricular dysfunction and arrhythmias.The mean prevalence of apical aneurysm in different echocardiographic series was 8.5% (ranging from 1.6% to 8.6%) in asymptomatic patients or those with mild cardiopathy and up to 55% (ranging from 47% to 64%) in patients with moderate to severe LV systolic dysfunction.The aneurysms are not restricted to the apex or inferolateral wall, and can be found in the septum, anterolateral wall, and right ventricle.Intraventricular thrombi can be associated with those aneurysms, being considered important risk factors for embolic events.Ventricular aneurysms vary in size and shape, from small finger-like (\u201cglove finger\u201d) to large apical (\u201csaccular\u201d) aneurysms, which can be hard to differentiate from those found in ischemic cardiopathy.Although transthoracic ECHO at rest is fundamental in the CCCD assessment because it enables the identification of segmental alterations, mainly apical aneurysms, its execution can be technically challenging. The use of deep breath and non-conventional echocardiographic views, such as the intermediate between the apical 4- and 2-chamber views, with posterior angulation of the transducer, can be necessary, as well as the complementary use of ultrasound contrast imaging.6.2.3.3. Left Ventricular Diastolic FunctionThe diastolic function analysis can be challenging because of confounding factors, resulting from the occasional presence of AF and PM in the right chambers. The gradual increase in the E/e\u2019 ratio occurs from the IFCD and a value greater than 15 is a predictor of worse outcome in patients with mild to moderate systolic dysfunction.There is evidence that the E/e\u2019 ratio correlates independently with serum levels of brain natriuretic peptide (BNP).The alteration in myocardial relaxation is the first to appear, and can be present even in patients with the IFCD. As the cardiomyopathy progresses, the diastolic dysfunction can worsen and show a typical restrictive pattern.The left atrial volume correlates independently with mortality.Left atrial function in CCCD is more impaired than in other etiologies, such as idiopathic DCM, probably because of the associated intrinsic atrial myopathic impairment.When assessed by use of strain, the left atrial function also was an independent predictor of clinical events in patients with CD.Similarly, left atrial dysfunction indices assessed on three-dimensional ECHO and by strain were independent predictors of recent-onset AF in those patients\u2019 follow-up.Diastolic dysfunction contributes decisively to atrial remodeling, whose volume can be increased in any stage of the CCCD.6.2.3.4. Right Ventricular AssessmentRV impairment more rarely can occur primarily and prematurely as compared to LV impairment.The RV systolic dysfunction, assessed by use of conventional echocardiographic parameters, such as Tei index, was an independent predictor of poor prognosis in CCCD.The RV systolic function analysis by use of STE, especially in the chamber\u2019s free wall, showed satisfactory accuracy, correlating with other methods, such as CMRI.In addition, three-dimensional ECHO is a promising tool to assess RV systolic function.Right ventricular assessment on conventional ECHO, using dedicated projections, allows the quantification of RV dimensions, volumes , and contractile function, and should be performed in all patients with CCCD. Although frequently associated with LV dysfunction,6.2.3.5. Stress EchocardiographyAlthough the pharmacological test usually uses dobutamine, which has an arrhythmogenic potential, the method proved safe in CCCD, and an altered segmental contraction index at rest is an independent predictor of arrhythmias during the test.Pharmacological stress (and possibly exercise stress) ECHO can show the two-phase contractile reserve in those patients, who typically have no subepicardial coronary artery obstruction.Although CMRI is not a test for the initial assessment of CD, the method has proven useful for CCCD diagnosis and risk stratification. Patients undergoing investigation of cardiomyopathy with no specific suspicion of CD and not residing in an endemic area frequently do not undergo serological tests for CD. In such cases, a typical global or regional systolic dysfunction pattern associated with a specific myocardial fibrosis pattern and location on CMRI can raise the suspicion and indicate the need for the specific serological test.In addition, CMRI can be useful to detect early myocardial involvement in CD, mainly in the IFCD, when all other tests are usually normal.In addition, CMRI can estimate the prognosis. The amount of myocardial fibrosis strongly correlates with markers of disease severity, ventricular arrhythmias, severe cardiovascular events, and even death.On CMRI, new noninvasive tools can identify myocardial inflammatory activity  at an early stage before the development of irreversible lesions, such as necrosis and fibrosis, and aid risk stratification and even therapeutic decision-making.The CMRI can be useful to detect intracardiac thrombi in certain patients, especially those with limited echocardiographic images and no indication for invasive angiocardiography.The prognostic potential of CMRI in CCCD will much likely depend on confirmation by on-going studies and should corroborate the expansion of the already used risk stratification methods.Recent investigations have shown that CMRI has a good potential to assess the prognosis of patients with CCCD, independently of that provided by the RASSI score, allowing the re-stratification of those at low to intermediate risk of death.The CMRI should include biventricular systolic function assessment through SSFP (steady-state free precession) techniques, T2-weighted images and/or T2 mapping for the assessment of myocardial edema, in addition to the mandatory use of late gadolinium enhancement to detect gross regional myocardial fibrosis. In addition, the pre- (native) and post-contrast myocardial T1 mapping technique should be included to calculate the myocardial extracellular volume, which is a measure of interstitial and diffuse fibrosis that can be present in this cardiomyopathy, even in myocardial regions with no evident late enhancement. The global pre- and post-contrast T1-weighted enhancement  or the early gadolinium enhancement can be useful to detect hyperemia/inflammation. In addition, long inversion time late gadolinium enhancement (~ 600ms) should be used, specifically in suspected intracavitary thrombus, to increase the sensitivity of its detection.To assess mitral or tricuspid regurgitation, usually present in advanced CCCD, cine magnetic resonance imaging (MRI) and phase contrast cine MRI (mapping sequence) are used.It is worth noting the classical example of CCCD on CMRI, which involves the basal and medial inferolateral segments and the LV apex, with typical contractile changes on cine MRI and characteristic myocardial fibrosis pattern and distribution on late enhancement. A typical finger-like LV apical aneurysm can be clearly seen on cine and late enhancement MRI.Recent scientific position statement on CD of the American Heart Association has recommended CMRI in certain patients with cardiopathy to assess the fibrosis extension and even serial CMRI for individuals with complex ventricular arrhythmias, especially NSVT.Another consensus document on imaging in CD of the European Association of Cardiovascular Imaging and the SBC Cardiovascular Imaging Department has recommended that CRMI should be indicated for certain patients with severe ventricular arrhythmias to quantify the extension of myocardial fibrosis and assess the risk of sudden death with potential impact on the indication for an implantable cardioverter-defibrillator (ICD). In addition, CMRI should be indicated for the assessment of LVEF when 2-D ECHO is considered unsatisfactory and contrast or three-dimensional ECHO is not available.Nuclear medicine is a noninvasive imaging modality but requires the use of radiation. In CD, it can be used to assess biventricular function as an alternative to CMRI and to analyze myocardial perfusion when stenotic epicardial or microvascular coronary artery disease is suspected, in addition to assessing cardiac sympathetic innervation.6.2.5.1. Radionuclide VentriculographyNuclear medicine is an option for the analysis of the systolic function of both ventricles, especially in patients with contraindication to CMRI and in the rare cases in which ECHO cannot be technically performed. Radionuclide ventriculography could be considered the gold-standard method for measuring the ejection fraction of both ventricles because it allows integrated sampling of several cardiac cycles. Therefore, it minimizes the occasional variability that limits, in some circumstances, the reliability of the methods that analyze only a few cycles. In addition, radionuclide ventriculography is used to determine the diastolic and systolic volumes without resorting to geometrical assumptions, as well as to provide information on regional contractility and the presence of ventricular aneurysms, characteristic of CD.Radionuclide ventriculography can be used, with limitations, to assess diastolic function, whose alteration can be one of the earliest manifestations of CD. In addition, RV dysfunction, which can also be an early sign of CCD, can be accurately assessed with nuclear medicine techniques, whose use in patients with CCCD, however, is still logistically limited.6.2.5.2. Myocardial PerfusionThe prevalence of obstructive coronary artery disease is not usually high among patients with CCCD, even in the presence of precordial pain. However, several researchers have independently reported coronary microcirculation dysfunction in those patients, and the presence of perfusion defects have prognostic value, because they can precede the development of myocardial contractile dysfunction.The presence of scintigraphic changes in patients with CCCD can translate the inflammatory mechanism through which, at least partially, the cardiac muscle is destroyed in CCCD and replaced by fibrous tissue. Myocardial perfusion imaging by single-photon emission computed tomography (SPECT) is effective in detecting cardiac muscle perfusion disorders, even when lesions in epicardial coronary arteries are absent.With lower logistic availability, PET/CT is an alternative test to study inflammatory and perfusion alterations, as well as myocardial viability loss or preservation, in ventricular areas that show contractile deficit, being a suitable test for microcirculation study.6.2.5.3. Sympathetic Innervation Assessmentenables the detection of ventricular sympathetic innervation defects, especially in the inferior, posterolateral, and apical walls, long before any contractile defect in those segments appears.These myocardial innervation alterations might be associated with a higher risk for SVT and worse prognosis.Depression of the myocardial sympathetic innervation occurs at the ventricular level early in CD and maybe at higher intensity than in other heart diseases. This can be associated with the loss of reflex autonomic control and even precede any other cardiac impairment. Nuclear medicine, by use of I-MIBG scintigraphy,Computed tomography of coronary arteries, similarly to invasive angiocardiography based on cardiac catheterization, uses ionizing radiation and iodine contrast medium, being primarily used for the noninvasive study of coronary anatomy in several clinical contexts.Computed tomography of coronary arteries in general is more indicated when the probability of obstructive subepicardial coronary artery disease is low but should be ruled out in patients with CCCD and atypical precordial pain.In CD, the experience with this approach in clinical practice is limited and applies to patients with contraindication to other imaging methods, such as CMRI and myocardial scintigraphy, in whom the echocardiographic study shows technical limitations.Preliminary experience with the method has shown that Brazilian patients with CD have a reduced prevalence of obstructive subepicardial coronary artery disease, thus corroborating older evidence supported by invasive angiographic studies.The pathogenesis of CCCD is complex and multifactorial, includes tissue damage by the parasite and exacerbated immune response, leading to inflammatory reaction, autonomic nervous system involvement, and microcirculation impairment. The result of these pathogenetic mechanisms is cell necrosis and their replacement by localized areas of myocardial fibrosis.being usually a primordial manifestation of cardiac involvement. The combination of areas of fibrosis, autonomic dysfunction, and conduction system impairment favors the occurrence of both bradyarrhythmias and tachyarrhythmias, sometimes before cardiac structural alterations are detected on imaging tests, such as ECHO. This early manifestation of arrhythmias in CCCD characterizes the disease as an arrhythmogenic cardiomyopathy,whose first clinical manifestation can be sudden death.In fact, sudden cardiac death is the major cause of death in CCCD, accounting for approximately 60% of the deaths.The zones of fibrosis have predilection for the conduction system ,The detection of cardiac arrhythmias on Holter or during exercise testing is an essential part of the routine assessment of patients with CCCD, enabling the diagnosis of sinus node dysfunction, atrioventricular conduction disorders, supraventricular tachyarrhythmias and ectopic beats, ventricular ectopic beats, and NSVT or SVT.A study assessing the occurrence of ventricular ectopic beats on Holter in patients with CCCD has shown that the apparently random behavior of that arrhythmia in 24-hour recordings disappears when longer periods, of 7 days, are analyzed, suggesting that longer Holter recordings would be more suitable in this context.In the RASSI score, the identification of NSVT on Holter adds 3 points of a total of 18 or 20 possible points . In addition to risk stratification, Holter enables the assessment of symptoms, such as palpitations and syncope, frequent in those patients and usually resulting from the arrhythmias found.The presence of NSVT on Holter is an independent predictor of all-cause mortality in patients with CCCD.Although parasympathetic dysfunction predominates, sympathetic involvement (lower intensity) is also present.A retrospective study has reported preliminary evidence that such alterations, reflected in several HRV parameters, can signal the risk for sudden death.The HRV assessed during short Holter recordings and with machine learning technique has shown the ability to predict echocardiographic alterationsand could be correlated with the RASSI score, the most endorsed prognosticator of mortality risk, in patients with cardiomyopathy with or without associated digestive involvement.Holter also enables the autonomic nervous system assessment by use of heart rate variability (HRV) analysis. Several studies have shown autonomic alterations in different stages and forms of CD.In addition, the EPS allows the sinus node and atrioventricular conduction assessment, as well as defining accurately whether the dromotropic disorder is in the atrioventricular node or His bundle, or is infra-Hisian. The frequent paroxysmal occurrence of TAVB due to the His-Purkinje system impairment, consequent to its well-known conduction behavior in the \u201ceverything or nothing\u201d form , determines that, in certain cases, only the invasive investigation with EPS allows the accurate diagnosis and proper treatment.In CCCD, there are reentry arrhythmogenic substrates related to areas of fibrosis, and the EPS enables the induction of SVT or even VF, which, in some contexts, gain a prognostic conotation.However, the general clinical applicability of the exercise test has not been well established, although the cardiopulmonary test, with direct measurement of oxygen consumption (VO2max), can be considered gold-standard for assessing physical functioning and efficacy of rehabilitation programs.The conventional maximum exercise test and the cardiopulmonary assessment test can detect important alterations, such as ventricular arrhythmias induced by exercise and chronotropic incompetence.Because these arrhythmias also occur in patients with no apparent cardiopathy, conventional maximum exercise test is clinically relevant for risk stratification in the population with CD, especially regarding work legal advice.Exertion-induced ventricular arrhythmias are a marker of cardiovascular death risk in patients with CD.2peak is an important criterion for CTX in patients with advanced forms of cardiopathy. However, its prognostic value should be better understood in the context of preventive strategies, risk stratification, and early diagnosis. In addition, cutoff points should be established to be specifically used in CCCD.Few studies have assessed the efficacy of exercise test variables in predicting the survival of patients with CCCD. The VOAs already mentioned, patients with CCCD frequently have atypical chest pain and electrocardiographic abnormalities, such as ST-segment changes and pathological Q waves, in addition to regional contractile and myocardial perfusion disorders that mimic coronary atherosclerotic disease. In most cases, assessment of epicardial coronary arteries shows no obstructive subepicardial atherosclerotic disease, those changes being attributed to coronary microvascular dysfunction.In addition, researchers have reported improvement in symptoms and myocardial perfusion when patients with CCCD were treated with platelet inhibitors and microvascular vasodilators, the first demonstration of benefit achieved in this context.Recent studies have evidenced that the ventricular dysfunction associated with CD microvascular disease is more prominent than that observed in the microcirculatory disorder from other etiologies.In addition, cardiac catheterization can be performed in candidates to CTX due to advanced HF to assess pulmonary vascular resistance. Moreover, cardiac catheterization enables performing post-transplant endomyocardial biopsy when the differentiation between rejection andT. cruzi-infection reactivation is mandatory in some patients.Cardiac catheterization, thus, can be used when patients with intermediate or high probability of obstructive coronary artery disease have typical anginal pain and/or multiple risk factors for atherosclerotic disease or a large ischemic area evidenced on noninvasive tests. During the hemodynamic study, contrast left ventriculography, because of its high temporal and spatial resolution, can show small apical aneurysms and/or other segmental ventricular contractile changes, which might not be detected on other imaging methods.The other systematic review with 52 studies including only patients with manifest cardiopathy has shown an annual mean rate of mortality of 7.9% , but with highly heterogeneous results, and individual rates ranging from 0.5% to 38.3%/year, depending on the baseline characteristics of each study population or in those with the IFCD .ulation.In recent decades, several risk factors for morbidity and mortality have been identified to quantify the severity of CCCD, assess its prognosis, and suggest more suitable therapeutic strategies. However, when considered in isolation, variables associated with worse prognosis usually have low positive predictive value, which limits their use. Thus, prognostic models built from several combinations of demographic, clinical, and laboratory parameters began to be investigated.To be applied in clinical practice, the risk stratification model should be simple and use a non-excessive number of variables that are well defined, easily accessed, and have satisfactory discriminatory power (C statistics). Even more important, the model should be validated by researchers from other centers  and in posterior periods , and, if possible, be capable of predicting other outcomes different from that to which it was developed and in different scenarios .It is worth emphasizing that prognostic models without external validation, even if properly developed, are of little use and have low evidence-based sustainability, being not recommended for daily practice use. Usually, the prognostic model performs better in the data set from which it originated than in the new data set in validation analyses.et al.developed and validated a risk score to predict all-cause death in CCCD. In an original cohort involving 424 outpatients with a mean 7.9-year follow-up, total mortality was 31% (130/424), deaths due to cardiovascular causes represented 87% of the total (113/130), and sudden cardiac death represented 62% of the total (81/130). In the external validation cohort (153 patients), the total mortality rate was 23% (35/153) in a mean 7.7-year follow-up, and most deaths (57%) occurred suddenly.In 2006, Rassi JrMultivariate analysis identified six independent predictors of mortality, which were attributed points corresponding to their strength of association with the outcome in question  based on the Cox model beta regression coefficient . The inenables replacing the CTI measurement on chest X-ray by LVDD measurement on ECHO, because a good correlation between CTI > 0.50 and LVDD > 60mm has been observed;requires the use of neither formulas nor calculators because it is a feasible score of simple memorization; can predict the three major causes of death: total, cardiovascular, and sudden;and was externally validated in four different cohorts, at different times, and by independent researchers.Of note in two of those cohorts,the outcome assessed was different from that of the original publication , and, even so, the RASSI score showed highly reproducible results , which are part of the initial mandatory investigation of patients with CCCD; assesses LV function subjectively, dismissing ejection fraction measurement by the Simpson method and valuing both global and segmental myocardial contractility changes, which have recently been confirmed as important independent predictors of risk for cardiovascular events by use of careful analysis of the BENEFIT study database;results .myocardial fibrosis presence and extension on CMRI detected with late enhancement techniqueor T1 mapping,the latter assessing the interstitial component of myocardial fibrosis; and the induction of sustained ventricular tachyarrhythmias on EPS.The RASSI score strength, particularly regarding its accuracy for stratification in subgroups of risk, is supported by results of recent investigations in different contexts, showing, for example, a strong positive correlation of the risk levels with the following: cardiac dysautonomia grade;In another study, assessing patients who had undergone cardiopulmonary exercise testing, the RASSI score addition to the anaerobic threshold increased the area under the ROC curve from 0.706 to 0.800, and all-cause death was the primary outcome on logistic regression analysis.When assessing the prevalence and prognostic value of ventricular dyssynchrony on ECHO and of the RASSI score in patients with CCCD, considering as outcome the combination of total death and hospitalization, only the RASSI score could predict the combined events on multivariate analysis .2slope  and the RASSI score  associated with higher mortality on multivariate analysis after a mean 32-month follow-up.In patients with HF and LVEF< 45%, when assessing the prognostic value of the variables obtained on cardiopulmonary exercise testing and of other variables, only the increased VE/VCOusing multivariate analysis to better assess prognosis in CCCD and comprising approximately 4300 patients, has shown that the most consistent and relevant predictors of total mortality, sudden cardiac death, and cardiovascular death were New York Heart Association (NYHA) functional class III or IV, cardiomegaly on chest X-ray, LV systolic dysfunction assessed on ECHO or cineventriculography, in addition to NSVT on 24-hour Holter. Using these four variables in an integrated way, an algorithm can be elaborated to stratify the risk of death in patients with CD in a simplified and logic way by use of clinical parameters and complementary methods available in most cardiologic services in our country (A systematic review of 12 studies (1985 to 2006),country .per se, identifies high-risk cases, because almost all these patients have systolic ventricular dysfunction on ECHO and NSVT on Holter. Of note, the combination of ventricular dysfunction with NSVT, independently of the functional class, identifies a group with a 15-fold higher risk as compared to patients without both abnormalities.The presence of NYHA functional class III or IV,expects to solve that deficiency.Although the RASSI score has a well-established theoretical base as an independent predictor of fatal events and has been externally validated in multiple studies, it is infrequently used on the daily practice. One of the reasons for that might be the low availability in the Brazilian SUS, outside university-affiliated hospitals, of the simple diagnostic methods used for calculating the score, such as ECHO and 24-hour Holter. This guideline, by strongly recommending the application of the RASSI score as the principal method for risk stratification of all patients as soon as the diagnosis of cardiomyopathy is confirmed, as already established in other consensus of international societies,CHronic use of Amiodarone aGAinSt Implantable Cardioverter-defibrillator) is in its conclusion phase. It compares amiodaroneversusdefibrillator for total mortality reduction as a primary prevention strategy and has the following inclusion criteria: presence of at least one NSVT episode on 24-hour Holter and a RASSI score \u2265 10 points.In addition, despite projecting the risk of death in the long run and under highly heterogeneous prognostic conditions, the RASSI score usefulness to guide clinical management and subsequent therapy is yet to be determined. It is worth noting that the valuable information on risk provided by the score to patients and their physicians can guide follow-up and, possibly, treatment strategies. In this way, the Brazilian multicenter RCT CHAGASICS  can undergo annual clinical reviews, while intermediate- or high-risk patients should do it more often (every 3 or 6 months).RV systolic dysfunction (Tei index);LV diastolic dysfunction (E/e\u2019 ratio);left atrial volume increase;changes in myocardial deformation indices;parasympathetic and sympathetic dysfunction;specific changes on ECG;T-wave amplitude variability;T-wave axis deviation;QT interval dispersion;changes on high-resolution ECG ;HRV reduction;prolonged QRS complex duration;VO2peak reduction;exercise time reduction;increased serum levels of type B natriuretic peptides (BNP and NT-proBNP);and others.Such factors and variables, when analyzed by use of multivariate models or transformed into risk scores, associate with worse prognosis. In addition, they provide information on the mechanisms related to disease progression and the less explored aspects of their complex prognostication.Other studies on the CCCD prognosis have focused on different risk markers, such as: LVEF reduction;The following limitations affect their applicability: use of non-standardized variables that are difficult to measure and to reproduce, usually extracted from complementary tests of restrict access or not available in common practice; inclusion of a reduced number of patients or outcomes; non-inclusion of all variables known to be associated with worse prognosis in most of those models (the four previously cited); and, particularly, absence of external validation.However, as the above mentioned studies are very heterogeneous, acknowledging their limitations is necessary.It seems there is a growing number of publications trying to develop new risk models rather than validating or improving the existing ones.Thus, the scores proposed are not ready to be used in routine medical care, because almost all studies lack external and independent validation.has developed a simplified score to be used in endemic regions without access to cardiological investigation other than ECG. The score included clinical and electrocardiographic data, in addition to NT-proBNP measurement, to predict the risk of death in 2 years of patients with CCCD.Five independent predictors of death were identified and points were attributed as follows: age (10 points per decade); NYHA functional class greater than I (15 points); HR \u226580 beats/min (20 points); QRS duration \u2265 150ms (15 points); and abnormal age-adjusted NT-proBNP (55 points). Patients were then classified into three risk categories . External validation was performed applying the score to another independent population with CD. After a 2-year follow-up, in the development cohort, 110 patients died, and the global mortality rate was 3.5 deaths per 100 individuals-year. The mortality rates observed in the groups of low, intermediate, and high risk were 0%, 3.6%, and 32.7%, respectively, in the derivation cohort, and 3.2%, 8.7%, and 19.1%, respectively, in the validation cohort. The score discrimination was good in the development cohort (C statistics: 0.82) and the validation cohort (C statistics: 0.71).The major limitations of the score are the use of NT-proBNP measurement, which is not usually available in PHC, and lack of independent and extensive external validation, as occurs with the RASSI score.A recent study, using data from the NIH SaMi-Trop cohort,or quantificationof myocardial fibrosis with the late enhancement technique in CMRI, as a continuous variable  or as dichotomous variable (using the cutoff point of 12.3 g), proved to be an important risk predictor for severe cardiovascular events, such as total death, cardiovascular death, and occurrence of sustained ventricular tachyarrhythmias, independently of the ventricular function and RASSI score. It is worth noting that one of the studiesenabled the direct comparison between the prognostic value of the myocardial fibrosis amount and the RASSI score.In two other studies, the mere identificationversusHR: 1.33; 95% CI, 0.68-2.61; p = 0.406). Expressed as continuous variables , both were risk predictors, but with higher relevance for the RASSI score , that is, for each additional point in the RASSI score, the risk of death increases by 23%, while for each 1 additional gram of myocardial fibrosis, that increase is of only 2%. The mass of fibrosis, as dichotomous variable, had a C statistic of 0.709  to predict death from any cause, while, for the RASSI score, that value was not informed.Using total mortality as the final outcome (considered secondary outcome), after a median 5.4-year follow-up, the power of association of the RASSI score was more significant than that of myocardial fibrosis. Expressed as categorical variables , only the RASSI score was associated with worse prognosis . Also, the method should still be tested to assess if it can improve the performance of the already existing risk stratification models by use of new statistical techniques, such as reclassification table, net reclassification index (NRI) and integrated discrimination index (IDI).by the end of 10 years we would have 61 deaths in the low-risk group, 84 deaths in the intermediate-risk group, and 168 deaths in the high-risk group. Thus, of a total of 313 deaths in the 10-year follow-up, although most deaths (168 or 54%) occur in the high-risk group (which is desirable in terms of risk stratification), we would still have 145 deaths in the low- and intermediate-risk groups. For a new risk predictor to prove its clinical usefulness, once added to the RASSI score, it should ideally be able to correctly identify the low- and intermediate-risk patients who will die or, less likely, those at high risk who will survive. Myocardial fibrosis might be that marker, a hypothesis yet to be tested.According to the prevalence of the risk groups in the RASSI score, it is known that if it is applied to 1000 patients with cardiomyopathy, 610 will be classified as at low risk for total death, 190 as at intermediate risk, and 200 as at high risk. With death rates in 10 years of 10%, 44%, and 84%, respectively, for the three subgroups,In addition, there is no report in the literature that a change in the RASSI score (particularly a reduction in the number of points) can assess and monitor the efficacy of a certain treatment and improve patients\u2019 prognosis. However, because the score includes six variables, attributing 0 to 20 points to the set, and two variables are more likely to undergo changes , this is another interesting investigation to be considered.a prioriat high risk for death, as well as patients with ischemic, hypertensive or associated valvular disease, to prevent confusion with deaths not related to CCCD, were excluded from the calculation and standardization of the RASSI score.Finally, it is worth emphasizing that patients aged > 70 years, or with artificial cardiac PM, or documented SVT or VF, by beingIn the mean 36-month follow-up, only 1 of the 72 patients presented spontaneous SVT.The prognostic value of the EPS in patients with CCCD is yet to be established. Regarding primary prevention of sudden death, data available suggest that the EPS has no prognostic usefulness in patients with isolated VE or NSVT, provided the LV systolic function is normal. In a study including 72 patients with preserved LV function (mean ejection fraction of 0.60) and 400 to 1200 VE/hour on Holter (35% with NSVT), the programmed ventricular stimulation did not induce SVT in any patient.has assessed the prognostic value of SVT induction in response to programmed ventricular stimulation in 78 patients with NSVT on Holter (mean LVEF of 0.47 \u00b1 0.18) and no clinical history of sustained arrhythmias. Monomorphic SVT was induced in 25 patients (32%), all of them treated with class III antiarrhythmic drugs, most of them with amiodarone and only one with sotalol. After mean 56-month follow-up, the probabilities of cardiac death and combined events  were 2.2 and 2.6 times greater (p < 0.05), respectively, in inducible patients as compared to non-inducible. In contrast, the induction of polymorphic VT or VF had no prognostic significance, being, probably, an unspecific ventricular response to the test.Another studyRegarding secondary prevention (patients with documented sustained ventricular arrhythmias or resuscitated sudden death), some authors have assessed the importance of EPS for risk stratification and antiarrhythmic therapy choice, but data available are limited.has included 115 patients with symptomatic VT (mean LVEF of 0.49 \u00b1 0.14), of whom, 78 with spontaneous SVT and 37 with spontaneous NSVT and EPS-induced SVT. After impregnation with Vaughan-Williams class III antiarrhythmic drugs , the patients were divided into three groups, based on their responses to a subsequent electrophysiological test. Patients in group 1 had no inducible SVT, those in group 2 had well-tolerated inducible SVT, and those in group 3 had hemodynamically unstable inducible SVT. After a mean 52-month follow-up, the total mortality rate was significantly higher in group 3 as compared to groups 1 and 2 .The largest observational studyBased on those results, although the EPS can identify patients at higher risk for death or who do not respond well to treatment with antiarrhythmic drugs, its role in guiding other types of therapies, such as ICD implantation, remains undefined, resulting in little usefulness of the method for that purpose.and was classically confirmed in 1985,when it was defined as the situation of an asymptomatic chronicallyT. cruzi-infected individual, with normal physical examination and no changes on chest X-ray, conventional ECG, and esophageal and colonic contrast radiography.The IFCD is a latent period that usually begins right after the end of the acute phase and can last indefinitely, for an individual\u2019s entire life. This stage of CD has been recognized since the first studies by Carlos ChagasIn this situation, the term \u201cwithout apparent cardiopathy\u201d should be used instead. Similarly, that classical denomination does not apply to patients without digestive symptoms, who had undergone neither esophageal nor colonic assessment by use of contrast imaging tests.The classical definition of the IFCD does not include individuals with \u201cunspecific\u201d electrocardiographic changes, which do not define CCCD.For example, low QRS complex voltage in the frontal plane, which indicates poor prognosis according to the RASSI score, can also be detected in individuals with emphysema or morbid obesity ; host\u2019s genetic aspects; severity of the initial acute infection related to the transmission mode; exposure to reinfection with the parasite in sustained vectorial transmission areas; host\u2019s nutritional status and presence of comorbidities; social context; quality of life of individuals with CD; and absence of trypanocidal treatment.Despite decades of research, the factors that lead to the development of CCCD in 30% of the individuals with the IFCD have not been totally clarified.with mortality overlapping that of the non-infected general population, as long as the ECG findings are normal.An individual with IFCD can remain for several decades in that condition,and annual or even biannual serial ECG can detect progression to CCCD.Although knowledge on the natural history of CD is scarce, it is worth emphasizing the usually good prognosis of IFCD,The annual rates of progression from IFCD to CCCD vary from 0.3% to 10.3% (mean of 1.9%).In IFCD, the presence of changes on ECHO due to regional dyssynergies, even when the global systolic ventricular function is preserved, can imply a risk for clinical events, such as TAVB, stroke, ventricular tachyarrhythmias and/or HF, indicating worse prognosis as compared to that of individuals in the IFCD with normal ECHO findings.Electrocardiographic changes can appear during follow-up in varying percentages, but with no direct relation to LVEF, which usually remains unaltered.T. cruziin the same age group have similar mortality rates.The annual incidence of sudden death among individuals with CD and normal ECG is low and similar to that of the population without CD.Sudden death is a rare complication that occurs in the general population equally; thus, its cause should not straightaway be atributted to CD.The good prognosis of patients with the IFCD has been reported in several longitudinal studies that concluded that individuals with the IFCD and controls not infected byand young adults treated with those drugs less often progress to CCCD as compared to non-treated ones.Regarding treatment with trypanocidal drugs in the chronic phase of CD, the IFCD is one of the major indications,A patient with normal ECG and segmental ventricular contractile abnormalities on ECHO should undergo the same investigative assessment given to a patient with an electrocardiographic abnormality that defines CCCD.The follow-up of individuals with the IFCD should be maintained at the PHC level, with annual or biannual electrocardiographic assessment, because some electrocardiographic changes have an evolutive character and define the CCCD.In patients with IFCD, the relation between aging and comorbidities seems not to depend on the presence of CD itself.However, old patients with IFCD constitute a particularly vulnerable population group regarding the harmful effects of chronic degenerative diseases.Among cardiovascular comorbidities, systemic arterial hypertension (SAH) predominates, followed by coronary artery disease.The monitoring and treatment of these comorbidities, in addition to dyslipidemia and diabetesmellitus, should be individualized. Controlling these conditions is fundamental to the secondary prevention of CCCD.Patients with the IFCD can have comorbidities whose frequency increases as the population ages.T. cruzi should be conservative aiming to characterize IFCD and establish the following recommendations: 1) In the absence of cardiovascular and digestive symptoms  with normal findings on physical examination and ECG (preferably with 30-sec recording acquired on a single lead), no additional test is necessary, not even chest, esophageal, and colonic radiography; 2) Directed anamnesis, physical examination, and ECG should be repeated annually or biannually; 3) Physical exercises should not be restricted, not even competitive ones; 4) No professional restriction applies, not even for the conduction of collective vehicles; and 5) Psychological support is essential, explaining the favorable prognostic notions, which guide the most conservative medical managements.The general medical management of an individual chronically infected byIn patients with IFCD, performing ECG annually or biannually is strongly recommended, with level of evidence B. It is worth emphasizing that trypanocidal treatment with benznidazole should be offered to individuals with the IFCD up to the age of 50 years, as a strong recommendation, level of evidence B.T. cruziinfection remains a critical challenge when analyzing the advances over the past 50 years.The importance of that type of treatment for CD is unequivocal for individuals affected and for their families and communities. This is a central issue for the national health systems, and barriers should be overcome to ensure access to diagnosis and proper treatment to all patients.This ethical dilemma requires a more proactive behavior of healthcare managers and professionals , social movements, and all stakeholders.Ensuring effective, efficient, and safe access to etiological treatment  forAdvances in the field have been insufficient for a consistent public health response aimed at controlling the disease in the local health care network of several countries.In many locoregional scenarios, diagnostic methods and therapeutic drugs are not available, and the local populations are not properly informed about them.Chagas disease belongs in the large group of NTD, and critical flaws of science, market environment, and public health make its management even more challenging.There is strong evidence that both drugs are effective in reducing disease\u2019s duration and clinical severity by enabling the elimination of parasites with early treatment,with potential gains in quality of life through prevention of physical functioning limitations.For the past five decades, there has been a huge limitation of etiological treatment options, with availability of only two drugs that proved effective, benznidazole (1971) and nifurtimox (1965).However, studies available so far have not allowed the recommendation of therapeutic schedules different from those classically established. It is worth noting that, in the Brazilian SUS, benznidazole is the most available and used drug, despite its limited operationalization relative to the expected demand.Benznidazole is still the most effective trypanocidal drug, which has been systematically confirmed in clinical trials comparing it with new drugs. However, there are critical gaps for the development of new less toxic therapeutic options aimed at improving the safety profile and access to treatment. The conduction of new studies is strategic to assess the use of not only combined therapies, but also shorter therapeutic schedules, with fixed and smaller doses. In addition, better and more reliable clinical parameters and laboratory biomarkers to assess treatment efficacy should be sought.and has the potential benefit of reducing parasitemia, with a positive impact on the patient\u2019s clinical evolution, such as halting progression to the cardiac form, reducing clinical complications in the two phases of disease, increasing life expectancy, and improving physical functioning and quality of life.Proper etiological treatment is known to be cost-effectiveand to offer the drug continuously, which is still hindered by the limited number of its providers and its low demand in local health systems.Thus, it is fundamental to avoid missed opportunities to establish the diagnosis and treatment. Considering that CD relates to poverty and social vulnerability, the comprehensive healthcare of individuals with CD will be able to reduce health inequities, particularly in endemic territories.One of the major challenges is the need to make etiological treatment available and implemented in local health systemsThe following referential documents were based on the methodological procedures of the GRADE system,specifically adapted for these guidelines (see chapter related).This specific chapter on etiological treatment is based on the analysis of consensus, clinical protocols, and therapeutic guidelines, which have been written and recently updated in different contexts. They represent relevant strategies aimed at contributing to increase access to diagnosis and treatment to support clinical decisions.Gu\u00eda para el diagnosis y el tratamiento de la enfermedad de Chagas).In addition, the 2011 I Latin-American Guideline for the Diagnosis and Treatment of Cardiopathy of Chagas Disease, coordinated by the SBC, was contemplated in the review.One of the regional clinical guidelines analyzed is the 2019 PAHO/WHO Guidelines for the Diagnosis and Treatment of Chagas Disease  in CD, conducted by the National Commission of Technology Incorporation in the SUS (CONITEC), Secretariat of Science, Technology, and Strategic Supplies of the Brazilian Ministry of Health.was analyzed in the sequence of the 2005 Brazilian Consensus on CD.Additionally, the 2015 Second Brazilian Consensus on CD, an important landmark, coordinated by the Health Surveillance Secretariat of the Brazilian Ministry of Health in partnership with the Brazilian Society of Tropical Medicine,Some clinical studies have included other drugs without proven efficacy, such as alopurinol and azole antifungal drugs (by molecule repositioning),which, however, are not included in the scope of this guideline.Two antiparasite nitroheterocyclic compounds with efficacy established for the etiological treatment of CD are available: benznidazole, a nitroimidazole agent, and nifurtimox, a nitrofuran compound.T. cruzi-infected individuals without evidence of damaged target organs, and their results were limited to only parasitological aspects with long-term qPCR assessment (12 months).Despite the disappointing results with the new drugs, the comparative studies reinforced the relevant role of benznidazole in the CD treatment.Studies in the past 7 years have assessed the efficacy and safety of monotherapy or therapies combining benznidazole and other agents, such as posaconazole or fosravuconazole. Those studies were conducted inA recent review has identified 109 epidemiological studies published after 1997 on the etiological treatment of CD , including 23 116 individuals. The studies were highly heterogeneous regarding not only clinical management for etiological treatment, but also study design and conduction, which limits the evidence available.In great part, evidence on CD should be presented because it is grounded onT. cruziinfection treatment. Once proved the trypanocidal action, in the absence of experimental randomized studies with relevant clinical outcomes, evidence from less robust, observational and good quality studies should be considered.The \u2018conditional\u2019 grade of recommendation established by PAHO for benznidazole and nifurtimox use, mainly in patients with chronic CD, is justified by the limited certainty level of the body of evidence on the results of efficacy, originating from the scarcity of RCT in this area.Moreover, considering the principle of asymmetry, the magnitude of an occasional damage from treatment, if it occurs, is significantly smaller than the benefit associated, particularly with qualified follow-up. Thus, the etiological treatment for CD is justified in a considerable number of cases.From the perspective of the managers, treatment with benznidazole, thus, can be adopted as a health policy in specific contexts, considering the balance between benefits, risks, and health priorities. Healthcare professionals might have different choices for decision-making, which should always be shared with the individuals affected by the disease. Finally, most individuals affected, when well informed, most likely would want to receive the intervention.The use of nifurtimox in Brazil is recommended when benznidazole is not tolerated, as in the occurrence of severe adverse events and in some other particular and specific circumstances.Benznidazole is the first option in the Brazilian context, because of not only the larger experience with its use, but also its profile of adverse events and availability, particularly the pediatric presentations.Similarly, their indication in cases with other severe conditions (liver and kidney failure) should be carefully and individually assessed, according to clinical severity.The etiological treatment with any of these drugs should not be routinely and indiscriminately instituted for women of childbearing potential who are not on an effective contraceptive method.In the Brazilian SUS network, only tablets of 100 mg and 12.5 mg are available.In 2017, benznidazole was approved by the USA Food and Drug Administration (FDA) forT. cruziinfection treatment, which, however, did not ensure full access to the drug in that country.Benznidazole is available as tablets of 100mg and 50mg, for adults, and of 12.5 mg and 50 mg, for children. Its absorption occurs in the gastrointestinal tract, while its excretion is predominantly renal, with a mean life of 12 hours.However, the distribution of 12.5mg tablets of benznidazole is centralized in the Ministry of Health, because of the limited registry of pediatric cases in Brazil.The Brazilian Ministry of Health acquires the 100mg tablets of benznidazole and delivers them to the State Health Secretariats in response to requirements in the Strategic Supply Information System. The distribution flow to the regional health agencies and/or municipalities is established by each secretariat, integrating actions of pharmaceutical care, epidemiological surveillance, and primary healthcare.For adults with chronic CD, benznidazole is administered orally at the dosage of 5mg/kg/day divided into two or three doses, for 60 days, with a recommended maximum dosage of 300mg/day. For individuals with acute CD, the dose can be of as much as 10mg/kg/day. For individuals weighing over 60 kg, the therapeutic schedule can be extended to achieve the ideal target dose, maintaining 300 mg as the daily limit to prevent adverse events.The 300mg benznidazole regimen can be used for the number of days equivalent to the individual\u2019s weight, limited to a total of 80 days even for individuals weighing over 80 kg.This dosage, which seems better tolerated, has been originally proposed by Professor Anis Rassi (in memoriam) and adopted later in the second half of the research with approximately 1500 individuals enrolled in the BENEFIT study, published in 2015.The process to define the proper dose of benznidazole that ensures efficacy and tolerability has been established through a trial-and-error approach.The pediatric formulation of 12.5mg soluble tablets can be used, enabling the treatment of newborns and children up to 2 years of age.The major advantage of 50-mg tablets (not available in Brazil) is the possibility of treating the rest of the pediatric population, including adolescents and young adults.For children, the benznidazole dosage can vary from 5 to 10mg/kg/day, divided into two daily doses for 60 days, with a maximum dosage of 300mg/day. If the daily dosage exceeds 300 mg, extension of the treatment duration is recommended so the total calculated dosage for 60 days can be reached.STOP-CHAGASand E1224,showing no long-term antiparasite effect of posaconazole or fosravuconazole alone, have reported evidence greater than 85% for early parasite clearance (negative PCR) after 2 to 4 weeks of treatment with benznidazole alone or in association with posaconazole or fosravuconazole, an effect sustained during the 12-month follow-up.More recently, the randomized clinical trials CHAGASAZOL,That clinical trial has evidenced that benznidazole induced effective antiparasite response (ranging from 83% to 89%), regardless of treatment duration (2 or 4 weeks), daily dosage (150mg or 300mg), or combination with fosravuconazole, being well tolerated (3% of severe adverse events) by adults with chronic disease.Although not \u201cdefinitive\u201d, the study suggests the use of benznidazole as standard treatment and emphasizes the need for new studies with shorter drug regimens or with reduced benznidazole dosages.Later, the BENDITA clinical trial, a phase 2, multicenter, randomized, double-blind, double-dummy clinical trial, conducted in Bolivia, including individuals aged from 18 years to 50 years with the IFCD, has been published.However, stronger evidence for the adoption of short-course therapy lacks. In this context, other ongoing clinical trials are as follows: the BETTY trial \u2013 a double-blind, noninferiority, randomized, controlled trial of short-course benznidazole treatment to reduceT. cruziparasite load in women of reproductive age;the MULTIBENZ study \u2013 a phase II, randomized, noninferiority, double-blind, multicenter clinical trial assessing the efficacy and safety of different dosages of benznidazole for the treatment of adults with chronic CD;and the TESEO study - an open-label, randomized, prospective, phase-2 clinical trial assessing the safety and efficacy of new therapeutic schedules with benznidazole and nifurtimox for adults with chronic CD, in addition to assessing biomarkers.These findings increase the evidence that new benznidazole regimens could expand access to etiological treatment and ensure greater tolerability.The mean incidence of adverse events associated with benznidazole use is approximately 50%, and cutaneous manifestations, gastrointestinal symptoms, and nervous system disorders have been the most common causes of treatment interruption.Despite the benznidazole\u2019s efficacy demonstrated in several studies, limitations regarding tolerability apply because of its relatively high toxicity, which can lead to the treatment interruption in approximately 10-25% of the cases.Dermatitis begins by the end of the first week of treatment, and shows good response to treatment with antihistamines or small doses of oral corticosteroids.In addition, gastrointestinal intolerance (13%), with nauseas, vomiting and diarrhea, paresthesia (10%), and arthralgias (8%) can be found.Based on Amazonian case series in areas of higher occurrence of CD, the frequency of adverse events due to benznidazole was 20.2% in children and adolescents with CD in the acute phase. In these reports, the cutaneous alterations  were the most commonly found (72%), followed by alopecia (3%), gastrointestinal disorders (2%), and insomnia (2%).Cutaneous adverse events are the most frequent, particularly urticarial dermatitis (45%) and rash (30%), and usually do not require treatment interruption because of their low intensity.Peripheral polyneuropathy with paresthesia and pain in the lower limbs is most common in adults and usually begins by the end of the 60 day treatment, particularly after 50 days. It can have a significant impact on functioning and quality of life because it can last several months, even after treatment interruption, and does not respond well to treatment with anti-inflammatory drugs and polyvitamins. The occurrence of fever, adenomegaly, and oropharyngeal pain suggests early bone marrow depression and agranulocytosis, one of the most severe, although rare, effects of benznidazole. In such cases, significant leukopenia develops at the expense of segmented neutrophils (febrile neutropenia), indicating the need for immediate drug interruption and proscription. That is the reason why routine hemogram is indicated 3 weeks after beginning treatment.The success achieved was associated with close monitoring of the cases, which strengthened surveillance, as well as counseling with qualified information and timely identification of adverse events with their management, leading to a lower dropout rate,reinforcing the importance of longitudinal care.Briefly, despite all that, etiological treatment with benznidazole can be safely conducted in the context of PHC. A protocol by the Doctors Without Borders has shown consistent results, because up to 89.8% of the individuals treated could conclude the treatment, although 56.0% developed an adverse event.Considering the chronic nature of CD, the pharmacotherapeutic follow-up enables, in addition to etiological treatment, the recognition of events associated with other drugs used, improving adhesion to treatment and quality of life.In the context of pharmaceutical care, the protocol of benznidazole dispensation at intervals of approximately 7 days is recommended, which can increase use safety by enabling a closer and qualified follow-up, with timely detection and registry of adverse events.In 2020, the FDA/USA approved its use for the treatment of CD in children under the age of 18 years,extending access to treatment based on evidence available.In the case of intolerance to benznidazole, nifurtimox can be recommended. It is available as tablets of 120mg (adults) and 30mg (children).Nifurtimox is not available in the pharmaceutical market in Brazil, its provision being regulated by a standard protocol of the Health Surveillance Secretariat of the Ministry of Health via PAHO, according to specific demand, usually related to suspicion or confirmation of resistance or intolerance to benznidazole.Nifurtimox has gastrointestinal absorption, hepatic metabolization via cytochrome P450, and preferential renal elimination.The CHICO study, a clinical prospective, controlled trial to assess the efficacy and safety of a new pediatric formulation of nifurtimox for children with CD aged between 0 and 17 years after 1 year of treatment, has confirmed that the 60-day treatment regimen was more effective than the same dosage for 30 days.In adults, nifurtimox is used at the dosage of 10mg/kg/day orally, in three daily doses for 60 days. In children, the recommended dosage is 15 mg/kg/day orally, also in three daily doses for 60 days.In the USA, of 243 individuals being treated, 222 (91.4%) reported at least one adverse event . The categories of adverse events reported were gastrointestinal (68.7%), neurological (60.5%), and constitutional (46.5%), and the most reported were nausea (50.6%), anorexia (46.1%), weight loss (35.0%), headache (33.3%), and abdominal pain (23.1%). At least 90% of the patients of all age ranges studied  reported adverse events.Of 1042 adverse events with available data regarding severity, 680 (65.3%) were mild, 254 (24.4%) were moderate, and 108 (10.4%) were severe. The most frequent severe adverse events were depression (22.6%), peripheral neuropathy (18.5%), paresthesia (17.9%), and dizziness/vertigo (17.2%). The proportion of individuals with at least one severe adverse event was higher among individuals over the age of 50 years (31.8%) as compared to those aged 18-50 years (18.1%).With nifurtimox, the mean frequency of adverse events is approximately 85%, the most frequent being gastrointestinal intolerance, such as anorexia and weight loss (60%), rheumatological events, such as arthralgias (35%), and cutaneous manifestations (15%).The adverse events and toxicity of nifurtimox stand out as reduced digestive tolerance, reflected by anorexia, nauseas, and vomiting, with weight loss and psychiatric disorders most frequent in adults.Based on a comparative analysis of adverse effects, the 2019 PAHO guidelines for the diagnosis and treatment of CD reported no substantial difference between benznidazole and nifurtimox considering the evidence analyzed and expertise of PAHO\u2019s technical panel. However, specific profiles of predominant adverse events were recognized, nifurtimox being associated mainly with weight loss and psychiatric adverse effects, while benznidazole was associated with cutaneous and neurological reactions.For both antiparasite drugs, ensuring clinical monitoring of their use is fundamental for the assessment and timely management of adverse events, with emphasis on tolerability.In oral transmission contexts , in 75% to 100% of the cases, mild clinical syndrome occurs, as in children, or evident illness with prolonged febrile syndrome is observed.As already mentioned in another chapter of this guideline, considering the natural history of CD, most individuals with established infection remain asymptomatic throughout life. In the acute phase, 90% of the classical vectorial transmission cases remain asymptomatic or oligosymptomatic, and, of the 10% with evidence of clinical syndrome, less than half progress to more severe forms or death.T. cruziinfection in the acute phase depend exclusively on the presence of the parasite, while, in the chronic phase, these lesions are partially explained by the parasite persistence in the tissues and the immune response to the parasite.It is worth noting that the lesions derived from theIn the chronic phase, approximately 60-70% of the cases remain asymptomatic, while 30-40% progress to the disease\u2019s clinical forms usually after several years,with some potentially severe complications, particularly the cardiovascular ones, associated with high morbidity and mortality.Treatment, when indicated in the chronic phase, is aimed at reducing the parasitemia levels, preventing the appearance or progression of lesions in target organs, in addition to preventing transmission.The chronic phase of CD includes the indeterminate form (asymptomatic) and the cardiac, digestive, and cardiodigestive forms.T. cruzilineages (TcI to TcVI) to antiparasite drugs.These aspects reinforce the importance of following all cases up, independently of the place of treatment in the health care network.The response to etiological treatment, confirmed in parasitological terms, varies and depends on the following factors: age at the time of diagnosis; disease\u2019s phase and duration; complementary tests used to assess therapeutic efficacy; post-treatment follow-up duration; associated conditions; and susceptibility of the differentThus, the etiological treatment of an individual with CD should be conducted according to the individual\u2019s characteristics and the disease\u2019s clinical form, as shown inThe treatment should be performed as early as possible after the infection is diagnosed, independently of theT. cruzitransmission mode, considering the potential benefits.In the acute phase of CD, the grade of recommendation of the etiological treatment for all cases  is \u2018strong\u2019, even with level of evidence B of moderate quality regarding the benefit of the trypanocidal effect.Considering the association of nontreated acute CD with mortality in up to 5% of diagnosed casesand the potential progression to the chronic phase in all cases, potential benefits are much superior regarding adverse events, which are mostly mild.In the acute phase, despite the moderate level of scientific evidence and limited certainty regarding clinical outcomes, the treatment has high efficacy, increases the likelihood of serological and/or parasite tests becoming negative, in addition to improving the potentially severe clinical syndrome of the acute phase, thus, preventing progression to the manifest chronic form by reducing damages to specific organs.Thus, even in asymptomatic cases or when diagnostic confirmation is impossible, but suspicion persists , empirical treatment can be considered.Therefore, the intervention should be adopted by health managers as a health policy in most situations, given that most healthcare professionals agree with the recommendation of that treatment and that most individuals affected, when informed, want to undergo the intervention.In addition, even with level of evidence C, this indication is justified by the associated high risk (20-70%) of congenital transmission, with potential impact on the health of the neonates, and considering that the rare reports of etiological treatment during pregnancy would be associated with small evidence of malformations.For pregnant women, at any gestational age, with severe acute clinical syndrome related to myocarditis or meningoencephalitis, antiparasite treatment should be indicated independently of the gestational age, because of high maternal morbidity and mortality.However, pregnant women in the acute phase of CD without clinical severity should ideally wait for the second gestational trimester to undergo etiological treatment. Despite the potential benefit of reducing neonatal CD, the occasional occurrence of perinatal mortality or fetal malformation is uncertain. Thus, counseling about the risks and benefits of the etiological treatment should be performed, with shared decision, knowing that, in some cases, non-treatment is justifiable.Similarly to individuals with acute infection, those diagnosed with CD through congenital transmission should receive etiological treatment. In such cases, the grade of recommendation is \u2018strong\u2019, independently of the diagnosis being established by use of parasitological methods still in the first weeks, or conventional serological tests, 9 months after birth.This strong recommendation, despite the moderate quality of the evidence available (level B) favoring trypanocidal treatment, is based on both the predictable benefits in a potentially severe clinical situation and the higher likelihood of actual cure of the infection.T. cruziinfection, and the disease\u2019s clinical stage.These aspects will be detailed in the following sections. It is worth noting that, given the current evidence about CD and the relevance of epidemiological surveillance of chronic cases in Brazil, expanding access to health care is strategic, as is the development of comprehensive healthcare beyond etiological treatment, always keeping in mind the possibility of mother-to-child transmission.The etiological treatment of an individual in the chronic phase of suspected congenital transmission should be performed considering the current age, the time ofFor this management, it is worth emphasizing the potential benefits in a more severe epidemiological context, in addition to the likelihood of influencing, with treatment, outcomes such as turning serology and parasitemia negative.For this population, the etiological treatment has grade of recommendation \u2018strong\u2019 and level of evidence B.This decision is based on significant benefits regarding the reduction of damages to specific organs, without increasing the risk for adverse effects given the better tolerance to antiparasite drugs in those age groups.Antiparasite treatment is indicated to all children (aged 12 years or less) and adolescents (aged 13 to 18 years) diagnosed with the IFCD, considering the higher likelihood of turning serology negative, which indicates proper response to therapy.Cohorts with long-term follow-up using conventional serological methods, such as cure control with a mean follow-up of over 10 years for each case, and conducted in the Amazon context have shown the success of the etiological treatment in this population. In these cohorts, the treatment caused minimal complications with potential for chronicity, despite the persistence of reactive serology.In addition, the longer life expectancy of that population justifies that the treatment might be more effective in children as compared to adults.In addition, the use of nifurtimox can be considered a valid alternative, particularly in cases involving children, adolescents, and young adults with recent infection in the presence of intolerance to benznidazole.However, evidence relative to prevention of the disease\u2019s clinical manifestations with the use of benznidazole is limited by the short follow-up period of the studies, and that is even more limited for nifurtimox, which should remain as a therapeutic alternative.T. cruziinfection, the grade of recommendation for the etiological treatment with benznidazole is \u2018strong\u2019, considering the additional strategic benefit of controlling congenital transmission of CD.For women of reproductive age (15 to 49 years) with chronicThus, even with level of evidence B, with moderate certainty regarding the risk/benefit analysis, the grade of recommendation for the treatment was established as \u2018strong\u2019.In addition, the effective use of contraceptive methods systematically and correctly should be recommended to these women during the entire trypanocidal treatment period, and pregnancy should be ruled out before beginning treatment.In endemic areas, these women should be systematically advised and assessed regarding the presence of triatomines, which should be eliminated from the households and their vicinities to prevent reinfection.Antiparasite treatment reduces significantly the likelihood of congenital transmission, and neither fetal nor neonatal adverse events have been observed.However, pregnant women with acute and severe CD, expressed as myocarditis or meningoencephalitis, or even in the acute phase of non-severe disease diagnosed in the first trimester should be carefully assessed and the decision regarding etiological treatment should be shared, individualized, as previously discussed.For pregnant women with chronic CD, treatment is not recommended given that the risk of congenital transmission is low, around 1.5% to 2% in Brazil.In the Brazilian Amazonian region, where acute infections predominate, vertical transmission has been reported due to lack of knowledge about the pregnant status in contexts of outbreak or familial microepidemics, with some very good documentation on congenital infection even after beginning maternal treatment with benznidazole.T. cruzi, to be assessed over four years. One of the relevant objectives of this international consortium is to assess, in a randomized controlled study, whether a shorter trypanocidal therapeutic regimen with benznidazole (two weeks) is at least as effective as the usual one (60 days) and whether it has fewer adverse effects.Finally, it is worth noting the important international initiative, the \u2018CUIDA Chagas\u2019, to which the Brazilian Ministry of Health adhered, involving Bolivia, Colombia, and Paraguay, in addition to five Brazilian states . The project began in 2022 and includes diagnostic and therapeutic measures and models for the elimination of the vertical transmission of CD among women of reproductive age chronically infected withThis recommendation has, thus, a conditional level depending on the case analyzed, given the limited evidence available for some populations.However, in such cases, aspects relative to the principle of asymmetry  should be considered. Thus, this decision should be shared between the physician, health team, individual affected and family, depending on the phase of infection, and patient\u2019s age and clinical conditions.The potential benefit of etiological treatment for all adults with chronic CD is not supported by a strong recommendation with high level of evidence for that indication, nor generically for any clinical-epidemiological situation.It is worth noting that, as reported for adolescents, for adults of any age with recently acquired infection, regardless of the transmission mode, the grade of recommendation for treatment is \u2018strong\u2019, with level of evidence B.It is worth noting that the PAHO clinical practice guidelines published in 2018 did not adopt that age stratification, considering the questions: \u2018Which is the safest and most effective therapy for adults with chronic T. cruzi infection with/without lesions in specific organs?\u2019 For cases in the IFCD, etiological treatment was established as \u2018conditional\u2019 with level of evidence \u2018weak\u2019, while, for cases with lesions in organs, the treatment was not recommended, with moderate level of evidence. The methodological procedures of the PAHO guidelines were developed from systematic reviews and primary studies published up to August 2017  and manual research with analysis using the GRADE system.Considering the stratification defined in the research plan of a significant number of consistent studies to assess etiological treatment, this document established the age cutoff point of 50 years, as in other national and international reference documents.T. cruziinfection.Since 2017, new studies have been published increasing the body of evidence and demarcating the establishment of the recommendations present in this document, expanding the opportunity of access to treatment ofThe recommendation is strong with level of evidence B, considering more recent studies recognizing that the etiological treatment can reduce the risk of long-term cardiac disease,even without clear evidence about the impact on mortality.The probability of negative parasitemia in the short run is higher, while non-reagent serology is observed only in the long run.However, the treatment can be associated with considerable risk for adverse events, which are mostly mild and minimized by use of qualified monitoring,but in some cases are sufficiently severe to cause therapy interruption.In adults up to 50 years of age with the IFCD, treatment is recommended, considering that its advantages seem to exceed the disadvantages, and that there is more evident benefit regarding cardiac disease prevention.In individuals aged 50 years and older in the chronic phase of CD, the benefit of etiological treatment in the IFCD has an even higher grade of uncertainty, leading to a conditional recommendation for etiological treatment with level of evidence C.Usually, these perspectives indicate the possibility of conditional recommendation for etiological treatment in this population.As previously shown, the factor \u2018age\u2019 should be relativized in terms of etiological treatment and particularly considered for individuals with recent infection  or who were infected during adulthood with no comorbidities and in a clear process of demographic transition in the Brazilian society, with longer life expectancy.The initial phases of the CCCD consist in only ECG changes , with global systolic ventricular function preserved or slightly reduced (LVEF > 40%), and stages B1 and B2 of HF without severe arrhythmias.For adults with determined chronic forms in initial non-advanced phases (cardiac and digestive), the indication for etiological treatment should be a shared decision, with information about potential benefits and risks, thus offering the possibility of treatment, being \u2018treating with benznidazole\u2019 or \u2018not\u2019 valid alternatives, if no contraindication applies. In such cases, the recommendation of etiological treatment is conditional, with level of evidence C.because the treatment is aimed at preventing cardiac damage. For patients with digestive disorders installed and even in those without the digestive form, there is no evidence that the antiparasite treatment prevents or delays the appearance or progression of megaesophagus and megacolon.Some patients with megaesophagus can have the efficacy of treatment with benznidazole hindered by interference with its ingestion or absorption.Although the diagnosis of chronic digestive form represents no contraindication to etiological treatment, clinical rehabilitation, dilation or surgical correction of megaesophagus is recommended before initiating the etiological treatment to ensure drug transit and absorption in the digestive tract.Etiological treatment can be considered independently of the diagnosis of isolated or associated chronic digestive form, that is, cardiodigestive disease,Thus, antiparasite treatment should not be recommended for individuals with advanced organ lesions (stages C and D of cardiac forms) or very old.In such cases, the etiological treatment does not change the disease\u2019s natural history, can be associated with increased risk for severe adverse events, in addition to inducing direct and indirect costs for the individuals affected and their families, thus expanding their social vulnerability.When chronic cardiomyopathy is already installed, usually there is no evidence that the etiological treatment might significantly impact evolution to death or progression of cardiac disease, although it increases the probability of eliminating parasitemia, assessed by PCR.So, all efforts should be made for timely diagnosis and etiological treatment in cases of CD to prevent disease progression. It should be noted that the annual risk of mortality in CCCD is considerable  and mainly attributed to cardiovascular disorders, especially in the presence of low LVEF and classified as stages C and C/D.In such situation, the indication for etiological treatment would have \u2018conditional\u2019 recommendation and level of evidence C.Individuals with severe megaesophagus, which hinders the proper absorption of the trypanocidal agent, are in a special situation. In the absence of manifest cardiopathy or in its initial stage, in which the etiological treatment is aimed at preventing cardiovascular disease progression, etiological treatment can be indicated after surgery for megaesophagus.In addition, when compared to placebo, there was no benefit regarding regional ventricular dysfunction, an early alteration often detected in those individuals and with a poor prognosis.Notably the careful analysis of the results from the BENEFIT trial, the most comprehensive RCT on trypanocidal therapy in patients with CCCD (mostly nonadvanced), enabled the identification of some relevant aspects. In fact, when considering the entire population, involving patients from five Latin American countries , the etiological treatment with benznidazole had no favorable impact on mortality and other severe outcomes from cardiomyopathy.For example, as compared to the group treated with placebo, the group treated with benznidazole showed a statistically significant reduction in the rate of hospitalization due to cardiovascular causes, which, although highly valued in several studies involving patients with HF, was not even discussed in the primary analysis of the BENEFIT trial.However, the global analysis of that study\u2019s results has been criticized, which might have prevented the duly appreciation of some methodological flaws with relevant implications in the applicability of the study\u2019s results.In contrast,post-hocanalysis of that study\u2019s results evidenced that the etiological treatment effect on Brazilians patients (40% of that study\u2019s sample) might have been positive, particularly when comparing the results in the Brazilian subgroup with those observed in the other four countries participating in BENEFIT.There are other aspects that deserve critical appreciation. The initial analysis of the BENEFIT trial subgroups was arbitrary, non-prespecified, and did not follow defensible criteria, being, therefore, biased.T. cruzistrains and nifurtimox. There are scientific reasons why the treatment of patients based on trypanocidal drugs  should consider both the parasite genetic diversityand the complex interaction of several parasite lineages with the human host, resulting in several clinical expression forms.In the meantime, this possibility should be considered the generator of a hypothesis to be tested in a subsequent study specifically designed to prove or refute it. The corollary hypothesis of the interpretation that the etiological treatment is more effective when applied to Brazilians already with CCCD is biologically plausible and can be supported by the predominance of TcII parasite genotype observed in Brazil, which can be more sensitive to benznidazole as compared to otherBased on these considerations, the \u2018conditional\u2019 grade of recommendation for offering etiological treatment to individuals already with non-advanced CCCD in Brazil can be considered with emphasis on the higher potential benefit than that in other countries. Finally, it should be pointed out the significant severity of CD and the need for timely diagnosis and comprehensive care to individuals with cardiopathy, based on qualified clinical management.In addition, considering current evidence about etiological treatment as well as relevance of epidemiological surveillance, mandatory reporting of cases of chronic CD should be implemented, enabling the extension of access to diagnosis and treatment to more individuals affected.T. cruzichronic infection, characterized by an increase in parasitemia (similar to that of the disease\u2019s acute phase) and immune system\u2019s inability to control the infection, usually associated with drug-induced immunosuppression \u2013 transplantations, immunosuppressive treatments \u2013 or coinfection with HIV.The RCD consists in the aggravation ofThe prevalence of RCD based on parasitemia in immunosuppressed individuals with CD, without trypanocidal prophylaxis, was approximately 28%, and distributed as follows: 1.8% in liver transplanted individuals; 23.3% in bone marrow transplanted; 27.3% in kidney transplanted; 30.9% in heart transplanted; and 39.6% in individuals with HIV infection/AIDS.The RCD is associated with high morbidity and mortality because of the central nervous system infection and myocarditis and has a critical impact on quality of life.Despite the moderate level of evidence (B), the recommendation is classified as strong, because the antiparasite drugs can have benefits in preventing the consequences of reactivation, as well as in its control and even recurrence.If RCD occurs, the etiological treatment indicated for the acute phase of CD should be initiated.statusassessed because of the increased risk for immune reconstitution inflammatory syndrome.In HIV infection, in the presence of chronic CD without reactivation and no previous etiological treatment, patients should preferably be treated with benznidazole and have their immuneThere is no consistent evidence to recommend secondary prophylaxis for transplanted individuals, but that can be indicated in selected cases, particularly the most immunosuppressed ones.For transplanted patients with RCD, the same treatment schedule used for non-transplanted ones is indicated, benznidazole being the preferred alternative due to its better profile regarding adverse events and the largest experience with its use in the country.Usually, the etiological treatment can contribute to prevent clinical complications, such as cardiopathy, and should be considered with the same recommendations and levels of evidence used in other situations related to non- immunosuppressed individuals with chronic CD.It is worth noting that the RCD episodes can occur repeatedly and should be treated when documented, justifying regular parasitological monitoring while the immunosuppression condition is maintained.For both HIV-infected and transplanted individuals, qPCR can aid in clinical monitoring; however, its routine recommendation is yet to be defined.T. cruziand at high risk for disease transmission, such as sharp instruments, contact with non-intact mucosa or skin, or manipulation of biological material with live parasites , primary prophylaxis is indicated, beginning with benznidazole at the dosage of 7 to 10 mg/kg immediately after the accident and for 10 days.The grade of recommendation for this management is \u2018strong\u2019, despite the limited level of evidence (C), but considering the principle of asymmetry.In laboratory accidents with biological material contaminated withIf the serological tests are reagent, the conventional antiparasite treatment should be performed as previously described for the acute phase. In situations of minimum risk, such as the mere superficial contact with blood of individuals in the chronic phase of CD, drug prophylaxis is not indicated and serological tests are recommended immediately after and on the 20th, 40th, and 60th days after the accident.If seroconversion occurs, the conventional treatment for the acute phase of CD should be initiated with post-therapeutic monitoring as recommended for the acute phase. If the serology remains positive after treatment, a possible therapeutic failure should be documented for a new treatment with benznidazole or nifurtimox.Serological tests should be performed before initiating treatment and on the 20th, 40th, and 60th days after treatment for monitoring an occasional seroconversion.Ensuring access to treatment is fundamental, which has a clear social function given the negligence regarding individuals affected by the disease. Usually, arguments associated with adverse events and not being able to document cure are used to justify non-treatment in the SUS. As a chronic condition, CD requires comprehensive and longitudinal care to all individuals affected.In a disease with only two therapeutic options with consistent indications for use, there is no evidence available about complementary methods to assess, in the routine context of health services, the etiological treatment effect on parasite elimination, particularly in the chronic phase.There is no complementary method to confirm advancement for cure (which would be considered gold-standard), making serological and molecular tests, even with all technical limitations, potentially available and useful methods to assess response to antiparasite treatment in the chronic phase.The quality of the evidence supporting the use of negative serology to replace clinically relevant outcomes is \u2018low\u2019 or \u2018very low\u2019, actually representing an indirect outcome.Thus, there is no evidence regarding the need for follow-up with serological control after a complete treatment or retreatment course.which usually occurs in only 1/3 of the cases, depending on different factors, such as age at the time of treatment, time elapsed between treatment and follow-up, and the area in which the infection occurred.For children and adolescents, a serological test can become negative within 5 years in 3/4 of the cases.Analyses of children and adolescents with acute CD in the Amazon region indicate persistent reactive serological tests in almost 55% of the cases, in a mean follow-up of approximately 11 years after treatment, and 17% of the cases showed sustained negative serological responses.In addition, in adults, it may take more than two decades for a serological test to become negative after treatment,and it is not available as a validated and agreed technique in the SUS, restricting its applicability to research activities.However, a positive PCR in the first 24 months after treatment indicates the possibility of therapeutic failure.Although some studies have suggested the use of PCR to monitor and control therapeutic response, the sensitivity of PCR is variableThe percentages of cure reported by several studies after antiparasite treatment of CD differ, but the importance of the etiological treatment is acknowledged in both the acute phase and some clinical forms of chronic disease.making the usefulness of etiological treatment unquestionable in a considerable part of the clinical situations, independently of the demonstration of cure, except for acute CD. Thus, for the chronic phase of CD, defining the criterion for cure has no practical use, contributing greatly as a strong barrier to access.In addition, even with all the already mentioned limitations of the current antiparasite therapy, elimination of parasitemia can be achieved in some scenarios,In addition to the technical-scientific leadership in CD management, Brazil has a great differential as compared to most CD endemic countries: the SUS, the Brazilian public health system that provides comprehensive and democratic health care, a right ensured to Brazilian citizens by the 1988 Federal Constitution. Thus, the SUS provides access to diagnosis and treatment for CD in the country.with clinical benefits in the short and long run, diagnosis, treatment, and surveillance of chronic CD could not be consistently implemented in the Brazilian territory.Questions such as centralization of actions, surveillance and control of CD have contributed to this situation. Thus, a global unified overview of the current development stage of initiatives to control CD in Brazil, despite the achievements over almost 120 years, indicates the need for implementation and integration of the measures in the PCDT with sustained surveillance of CD and adhesion to national and international guidelines.However, despite the favorable context and referential available from ordinances, guidelines, consensus, and PCDT itself,T. cruziinfection is feasible, safe, and operationally practicable in the PHC.The PHC can assume the management of individuals with non-severe acute CD, the IFCD, or even the chronic forms  of stable non-severe disease, as well as of pregnant women with chronic CD without comorbidities.There is evidence that family doctors and their teams, knowing the particularities of the medications and disease, can clinically manage those cases.Particularities of the SUS healthcare network should be considered, recognizing, however, that etiological treatment of theDepending on the severity of the clinical conditions, mainly in the acute phase or RCD, as well as decompensated chronic forms, support might be needed for the plan of care or referral to more specialized healthcare units, or even hospitalization in sporadic conditions.T. cruziinfection in different contexts of CD, according to the strength of recommendation and level of evidence, based on the GRADE system.T. cruziinfection.The essential conclusions of that publication are in accordance with the recommendations presented in this guideline. Finally, in addition to the search for more solid scientific evidence, all efforts should be made to ensure access to diagnosis and etiological treatment of CD in the national health systems.When this chapter was being concluded, the update of an old systematic review and respective meta-analysis was published regarding studies on the etiological treatment with benznidazole for individuals withOur recommendations prioritize patients with reduced LVEF, because most pharmacological therapies have been validated in that scenario. The difference between the scientific study inclusion criteria and the clinical indication should be understood. Studies usually select patients with lower LVEF (< 35% or < 40%) to optimize the incidence of the outcome of interest, increasing the statistical power. Because the magnitude of the absolute effect (NNT) is more relevant in high-risk patients  and no plausible reason is identified for the occurrence of qualitative interaction (disappearance of effect) when a certain LVEF cutoff point is exceeded, we chose to generalize our recommendations for the use of the essential drugs to treat HF in patients with LVEF < 55%, preventing excessive categorization.continuumof inverse relation between LVEF and therapeutic benefit, that is, the lower the LVEF value, the higher the absolute benefit of the therapy proposed. To simplify, strong recommendations for LVEF \u2264 40% will be \u2018conditional\u2019 for LVEF between 41% and 54%. In addition, we consider that in patients with segmental contractility abnormalites, but without global ventricular dysfunction, who are classified as stage B of HF, the body of evidence is still insufficient to promote any recommendation.However, it is worth considering the existence of arationalefor that is based on some justifications. The dosage proposed or even reached for patients in clinical trials is part of a scientific strategy, aimed to generate contrast between groups and test conceptual hypotheses. Once the concept has been demonstrated, it should be applied in an individualized way, weighting benefits and risks. Thus, choosing a drug dosage relates more to clinical reasoning than to evidence. There are no convincing scientific data about the magnitude of the incremental benefit related to maximum dosage (versusweighted dosage) and whether it overcomes unintentional consequences. In addition, tolerability and adverse effects are underestimated in RCTs of efficacy, in which ideal candidates for the treatment in question are usually selected and care is better controlled. Thus, we do not transform efficacy into effectiveness by standardizing the maximum. The increase in effectiveness results from careful individualization.This guideline does not support the obstinacy in reaching the maximum dosage of medications to the detriment of polypharmacy, preferring to emphasize the individualization of each drug best dosage for each patient. TheAs the life of patients with CCCD and HF is prolonged, they tend to suffer from other diseases that appear with aging., and SAH in 1/3 of the patients,differing, thus, from studies showing younger individuals frequently without comorbidities. Also, there is a possibility of a different clinical course of HF from CD as compared to HF from ischemic and idiopathic dilated etiologies.That might be due to the more severe autonomic dysfunction, higher density of ventricular arrhythmia and intracardiac blocks, greater load of myocardial fibrosis, most frequent RV impairment, and higher degree of cardiac sphericity/remodeling and myocardial inflammation \u2013 factors that could interfere with response to standard pharmacological treatment.Recently, a RCT of patients with CCCD from a single center (FIOCRUZ) has reported mean age of 65 years, mean body mass index of 27.4 kg/mThe worst clinical course, merely from the statistical viewpoint, suggests greater absolute benefit from treatment with level B of evidence when compared to the target populations of the studies, and should not implicate in the violation of the principle of indirect evidence, that is, extrapolation.is part of a comprehensive initiative of translational research aimed at experimentally and clinically exploring hypotheses about the potential benefit of supplementation with nutrients, such as selenium, and antagonism to inflammatory factors to change the CCCD course.The primordial value of these incipient investigations might reside in their strongly pathophysiology-based hypothesis on the inflammatory nature of CCCD. Only guided research will be able to provide the responses to those interventions.The previously cited study from FIOCRUZMedical Subject Headings(MESH) were used: \u201cbeta-blockers, spironolactone, sacubitril-valsartan, ivabradine, sodium-glucose transporter 2 inhibitors\u201d, \u201cheart failure\u201d or \u201cChagas disease\u201d, with limit of the type of publication . The MedLine/PubMed, Lilacs, Web of Science and EMBASE databases were used as search sources.For each drug or class of drug used in the treatment of HF, a systematic review of the literature up to August 22, 2021, has been conducted, aiming to answer the following PICO question of EBM: \u201cAre these drugs effective to relieve symptoms and/or reduce mortality of symptomatic patients with systolic HF secondary to CCCD, with a safety profile similar to that for HF of other etiologies?\u201d. The following10.1.5.1. Diureticsversusplacebo can cause the mistaken impression that, differently from beta-blockers or ACEIs, loop diuretics do not reduce mortality. This lack of studies could be due to the absence ofequipoisefor the type of patient whose prognostic benefit was validated for other therapies. That is, in HF, the administration of a diuretic is a therapy of extreme plausibility, corresponding to the parachute paradigm,justifying, in this guideline, level of evidence C regarding pharmacological indication. Thus, we strongly recommend diuretic therapy for HF with moderate to severe ejection fraction reduction and for cases with mild ejection fraction reduction, in the presence of pulmonary or systemic congestion.The diuretic therapy in HF is misunderstood in its magnitude of effect. The lack of RCTs comparing diuretic10.1.5.2. Renin-Angiotensin-Aldosterone System InhibitorsIn addition, these drugs can be replaced by angiotensin II receptor blockers (ARBs) in case of poor tolerability.However, in HF of CCCD, there is no direct evidence of benefit from RCT performed specifically in that population. Thus, the evidence regarding the use of ACEI in CCCD is indirect, originated from studies of excellent quality that tested the efficacy of that treatment in the most common types of cardiomyopathy (ischemic and idiopathic dilated) (level B). Considering that ejection fraction is a prognosticcontinuum, rather than a binary, dichotomic variable, the higher the degree of ventricular dysfunction, the higher the absolute benefit. Thus, the recommendation is strong for patients with HF and LVEF \u2264 40%, while \u2018conditional\u2019 for patients with HF with mildly reduced ejection fraction (HFmrEF).Several clinical trials of quality have shown that, in patients with HF and reduced LVEF, several ACEI reduce relevant outcomes of morbidity and mortality.These patients frequently have reduced systolic blood pressure, and can become more hypotensive and symptomatic with the introduction of ACEI or ARB, which should be gradually up-titrated, aiming to reduce the dosages of diuretics when the patient no longer has edema.Studies with a very reduced number of patients, assessing captopril and enalapril in HF of CCCD, have evidenced a reduction in the sympathetic neuro-humoral activation and in serum angiotensin levels, in addition to improvement of diastolic dysfunction and ventricular remodeling.In recent decades, international guidelines have emphasized the search for the therapeutic target dosage of ACEI or ARB for patients with HF with reduced ejection fraction (HFrEF), which can be misleading and a limitation in clinical practice, considering that patients with CCCD are prone to symptomatic arterial hypotension. Thus, we should search for the best tolerated dosage and proceed to slow titration in that group of patients subject to dosage limitations.10.1.5.3. Beta-blockersOn that occasion, one patient received alprenolol, 50 mg twice a day, and the others, practolol at dosages ranging from 50 mg to 400 mg, twice a day. The authors reported clinical improvement, cardiomegaly reduction, and ventricular function improvement assessed on phonocardiogram, ECHO, apexcardiogram, and carotid pulse curve. Despite the promising results reported by the Swedish group, the use of beta-blockers in HF was only properly assessed in the 1990s.The first experiences using beta-blockers for the treatment of patients with HF date back to the 1970s, when some researchers assessed the effect of the drug on seven patients with cardiomyopathy, advanced HF, and tachycardia.U.S. Carvedilol Heart Failure Study,which randomized 1094 patients for carvedilol or placebo and showed a reduction in mortality.The seminal study suggesting benefit from beta-blockers in HFrEF was theinvolving 10 clinical trials and 18 254 patients with HFrEF, beta-blockers reduced global mortality by 27%.In the past 25 years of clinical investigation, beta-blockers were consolidated for the treatment of HF. In a meta-analysisThus, surveillance is mandatory regarding worsening, appearance of bradycardia, cardiac block, and hypotension, especially in the first weeks of treatment adjustment.Importantly, patients with HFrEF can get worse in the initial phase of the beta-blocker treatment.In the context of HF, that is especially important, because patients with CCCD are more susceptible to the occurrence of those adverse manifestations when on beta-blockers. Although CCCD has not been included in large multicenter studies investigating beta-blockers and mortality, in addition to the peculiarities of that syndrome, known to be associated with dysregulation of the autonomic nervous system, as reviewed in another chapter of this guideline, there is no biological plausibility in questioning the benefit of beta-adrenergic block in the treatment of HFrEF from CCCD.has compared those on beta-blockers with those not using those drugs. Despite the limitation of the small sample size for direct comparison, the authors have suggested beneficial effects of beta-blockers related to increased survival . It is worth noting that, in that study, the use of beta-blocker was not randomized, with a high risk of confounding bias due to indication.Analysis of a small group of patients (n = 68) with HF due to CD from the REMADHE trialcontinuum, rather than a dichotomic variable, more severe systolic dysfunction tends to be associated with a higher absolute benefit. Thus, the recommendation is strong for patients with HF and LVEF \u2264 40% and conditional for patients with HFmrEF.We consider that the evidence regarding the use of beta-blockers for patients with HFrEF due to CD is indirect, originating from studies of excellent quality that tested the efficacy of that treatment in the most common types of cardiomyopathy (level B). Considering that ejection fraction is a prognosticversusthe HF severity (favors a beta-blocker). This is a rare situation in which this guideline recognizes the limitation of static recommendations, being open to the dynamism of medical thinking grounded in rationality and evidence .Severe ventricular arrhythmia requiring amiodarone is a special case. The association of a beta-blocker with amiodarone can be inappropriate because of bradycardia and/or QT interval prolongation. We consider that, in such context, there is no proof that a beta-blocker should be the priority. This is a case to base decision-making on clinical judgement, and the physician should decide which drug to prescribe initially based on the arrhythmia severity (favors amiodarone)10.1.5.4. SpironolactoneSpironolactone is the preferable antagonist of mineralocorticoid receptor, the major binding site of aldosterone and responsible for its physiological actions, with direct involvement in the pathophysiology of HF., or serum potassium level > 5.0mEq/L.In general, spironolactone is indicated for all patients with symptomatic HF and LVEF \u2264 35%, regardless of the concomitant use of ACEI, ARB, or beta-blockers, except for patients with serum creatinine > 2.5mg/dL or creatinine clearance < 30mL/min/1.73mThe study was early terminated after 24 months, with a satisfactory number of outcomes to indicate precision and interim analysis showing 35% reduction in the risk of death.The RALES study, a randomized, double-blind, placebo-controlled study supporting that indication, was published in 1999. That study assessed if the use of spironolactone, at dosages ranging from 25 mg to 50 mg, would be better than placebo for HFrEF (\u2264 35%) and functional class III-IV, with the concomitant use of ACEI and furosemide.Thus, observation of the contraindication criteria for spironolactone use and judicious surveillance are essential in the clinical management of patients on that drug.Patients with creatinine > 2.5 mg/dL were excluded, and the incidence of hyperkalemia was minimum in both groups. This should be highlighted because the Canadian study of epidemiological surveillance reported that the spironolactone prescription rate increased substantially after the publication of the RALES study, followed by an increase in the morbidity and mortality rates associated with hyperkalemia.Despite the minimum representation of CCD in the RALES study (and this was not specified in its baseline table), there is no biological plausibility to question the potential benefit of aldosterone block regarding HFrEF progression in CCD. Thus, we consider it a good application of level of evidence B . Considering indications and contraindications, the recommendation should be strong for patients with symptomatic CCCD, LVEF \u2264 40%, creatinine \u2264 2.5mg/dL, and serum potassium \u2264 5.0mEq/dL, while conditional for patients with HFmrEF.10.1.5.5. IvabradineIvabradine is a selective funny channels current blocker and, thus, an inhibitor of the PM activity in the sinus node, resulting in selective reduction of HR without changing hemodynamic parameters, such as blood pressure or myocardial contractility, and without interfering in intracardiac electrical conduction.In that study, ivabradine was tested at the maximum dosage of 7.5 mg, twice a day, in patients with HF (LVEF \u2264 35%), sinus rhythm, and HR > 70bpm, regardless of the use of beta-blockers when tolerated. The study reported a 26% relative reduction in the risk of hospitalization, in addition to mortality from HF of 26%.The SHIFT trial, a randomized, double-blind, placebo-controlled clinical study, published in 2010, supports the use of ivabradine for HF.by use ofpost-hocanalysis, has assessed 38 patients with HF due to CD, assigned to two groups as follows: ivabradine group, 20 patients; placebo group, 18 patients. Although patients with CCCD usually have a worse prognosis, with higher prevalence of RBBB, lower blood pressure levels, higher rate of use of diuretics, spironolactone, digoxin, and lower rate of use of ACEI/ARB and beta-blockers, when compared to the general population of the SHIFT study, ivabradine did not associate with higher prevalence of severe bradycardia, AVB, hypotension, or syncope. In addition, ivabradine was effective in reducing the HR of those patients and improving the HF functional class.A substudy of the SHIFT trial,A therapeutic recommendation should not be based on exploratory study. In the SHIFT trial, the CCCD was not well represented. However, generalization does not depend only on representativeness, and we recognize no probable mechanism of interaction that raises the suspicion that the CD etiology changes the effect of therapy with ivabradine to the point of losing efficacy as shown in the general set of patients included in the SHIFT trial. Thus, we defined the level of evidence B, which represents indirect evidence of good quality for the use of ivabradine in patients with CCCD and HF. The strength of the recommendation should be \u2018conditional\u2019 because it depends on the perception that HR is high when the beta-blocker dosage cannot be increased. Given this specificity, we chose not to extend that indication to patients with LVEF > 40%.10.1.5.6. DigoxinIn clinical practice, the drug can be indicated for patients in NYHA functional class III and IV, despite optimized treatment with other drugs, especially in the presence of AF with high ventricular response.When reviewing the literature, we identified no study assessing the safety and efficacy of digoxin in CD. Thus, we will use indirect scientific evidence that digoxin improves symptoms and reduces hospitalizations.Regarding digitalis, the therapeutic dosage is very close to the toxic one, which increases the potential for adverse effects, because of the conduction system involvement, causing bradyarrhythmias, AVB, and other general clinical manifestations.10.1.5.7. Sacubitril-valsartanas compared to enalapril. Although it can be considered a precise study with a low risk of bias, showing a 20% relative risk reduction with that drug association in the primary combined outcome of hospitalization from HF and cardiovascular death, there was margin for scientific questioning of its conceptual design.With a heterodox comparator, the study was not able to differentiate whether the benefit found was due to the innovative molecule in the treatment (sacubitril) or whether it was due to the inadequate difference regarding the dosages of the traditional angiotensin system inhibitors . Another limitation was the presence of arun-inphase in a phase III study, which overestimates the applicability of the treatment, because it selected in advance the patients who tolerate a more intense vasodilating therapy.Sacubitril-valsartan is a drug combination of a neprilysin inhibitor , sacubitril, and a traditional angiotensin II receptor blocker, valsartan. The PARADIGM-HF trial was the major study for scientific validation of this drug combinationFrom the PARADIGM-HF trial publication, many cardiologists began to perceive the sacubitril-valsartan combination as more effective than the traditional vasodilation with ACEI, which has influenced recommendations of guidelines on HF. In Brazil, the sacubitril-valsartan use was approved in May 2017 by the Brazilian Health Surveillance Agency (ANVISA), and, in August 2019, it was incorporated into the SUS.of patients with HF and LVEF \u2265 45%, and the PARADISE-MI study, of HF complicating acute myocardial infarction.In both scenarios, the results could not reject the null hypothesis in their primary analyses. It is worth noting that the PARADISE-MI study was the only to compare sacubitril-valsartan with the proper dosage of ACEI (10 mg/day of ramipril).In addition, unlike the homogeneous benefit verified with several angiotensin-II system inhibitors studied, the sacubitril-valsartan combination did not prove superiority in other contexts. Two examples of that are the PARAGON-HF study,Thus, we consider inappropriate an indication based on the expectation that this drug combination is superior to the traditional therapy. On the other hand, there is no evidence that this therapy is harmful, making it a valid therapeutic alternative, if the doctor wants to modify a standard treatment due to clinical or logistic reason. It is worth noting that the report supporting the incorporation of sacubitril-valsartan into SUS has estimated an incremental cost-effectiveness ratio of R$22.769 per year of life gained with quality.Regarding the indication of that combination for patients with HF caused by CCCD, in addition to the literature review technique already mentioned, Google Scholar was used to search the gray literature for any reference that could clarify this issue, and annals of medical congresses were assessed for this information.Thus, a case series conducted with patients with CCCD treated with sacubitril-valsartan in a reference hospital for that disease in Brazil has reported, after 6 months, symptomatic improvement of the individuals.the authors reported that up to 44% of the patients had the major criteria of exclusion of the PARADIGM-HF trial. In addition, they reported that the lower blood pressure levels, common in CCCD, could lead to underuse of some drugs in this context.In a prospective observational study of 136 consecutive patients with HF in a single university-affiliated hospital center, including the HF etiologies of ICM, CCCD, and idiopathic cardiomyopathy,Another study, assessing the proportion of patients with CCCD randomized to two recent clinical trials (PARADIGM-HF and ATMOSPHERE), has found that only 7.6% of the randomized patients in Latin America had that etiology.post-hocanalysis of a subgroup of the PARADIGM-HF trial has suggested that sacubitril-valsartan, as compared to enalapril, could lead to a similar or even higher (37%) reduction in death and hospitalization of patients with CCCD, as compared to those with HF of other etiologies, despite lack of statistical significance and imprecision of estimates of effect.The ongoing PARACHUTE trial  is an exclusive study of patients with HF from CCCD. Similarly to the PARADIGM trial,the comparators are not the orthodox ones and the effect of sacubitril associated with the maximized dosage of valsartan will be compared to that of enalapril at a non-maximum dosage, of 20 mg daily.AIn summary, patients with CCCD have not been well represented in the sacubitril-valsartan studies. Thus, although we presented some evidence on the use of that therapy for patients with HF caused by CCCD, it is not enough to support a recommendation, due to its exploratory character. However, the evidence serves to exemplify the principle of indirect evidence: generalization does not depend only on representativeness, and we do not recognize any probable mechanism of interaction that makes us suspect that the etiology of the heart disease modifies the effect of this therapy. Therefore, we defined that the sacubitril-valsartan treatment for patients with HFrEF and CCCD is an alternative with level of evidence B, although not a superior innovation as compared to the traditional treatment. Regarding recommendation, this should not be the preferred treatment, but considered an alternative when clinical judgement suggests the need for therapeutic change . This indication is not to be extended to patients with LVEF > 40%.10.1.5.8. Sodium-Glucose Cotransporter-2 InhibitorsIn recent years, this class of drugs brought enthusiasm to the scientific community because of the demonstration of incremental benefit to the traditional treatment, in terms of prognostic improvement of HF and renal dysfunction. In this chapter, we revise whether the level of evidence is proportional to the enthusiasm and translate it into decision-making in the context of HF from CCCD.mellitus. The SGLT2 acts in the proximal convoluted tubule and responds for 90% of the reabsorption of the filtered glucose in the glomerulus. The SGLT2 inhibitors promote renal excretion of glucose, which is the mechanism of its glycemia reduction effect.There were two initial observations regarding the intermediate effects: first, the efficacy of those inhibitors as glycemia reductors in individuals with diabetes is modest, with mean reductions in glycated hemoglobin ranging from 0.4% to 1.1%, as compared to placebo;second, they promote consistent body weight reduction as compared to other antidiabetic drugs.Sodium-glucose cotransporter-2 (SGLT2) inhibitors are drugs originally tested for the treatment of hyperglycemia in patients with type 2 diabetesThe initial strategy of the manufacturers of this class of drugs was to assess its safety for individuals with diabetes, focusing on macrovascular outcomes  and using counterintuitive approach of non-inferiority testing compared to placebo. Although counterintuitive, the deviation of the null hypothesis to a value different from zero is a suitable method to test safety, because a tolerance interval of adverse effect can be justified based on a demonstrated benefit.which is scientifically valid. However, the clinical question persisted: in the absence of proven incremental benefit, would the demonstration of safety be a justification to recommend the addition of that treatment to patients with diabetes?Non-inferiority compared to placebo (safety) has been confirmed in several studies of that class of drugs,which comprised a primary efficacy outcome if the non-inferiority hypothesis for severe event was demonstrated. SGLT2 inhibitors promote natriuresis, osmotic diuresis (due to glucosuria), and weight loss, mechanisms thata prioriincrease the probability of the benefit demonstrated. Based on those results, the hypothesis that the SGLT2 inhibitors improved the prognosis of patients with HFrEF was tested.Then an apparent reduction in the HF-related outcomes in the groups treated was perceived. These were the secondary outcomes of studies, except for the DECLARE\u2013TIMI 58 clinical trial,mellitus. The DAPA-HFand EMPEROR-Reducedstudies have assessed the effect of dapagliflozin and empagliflozin, respectively, on the incidence of the combined outcome of cardiovascular death and hospitalization from HF, as compared to placebo, in patients with HFrEF. The first to be published, the DAPA-HF study, included 4744 patients with HF and LVEF \u2264 40%, in NYHA functional class II to IV, already using optimized pharmacological therapy, and elevation of NT-proBNP levels. Diabetesmellituswas present in 42% of the sample and 99% of the individuals were in functional class II or III at the time of randomization. The HF etiology was nonischemic in 44% of the cases, with no mention to CD, although it was a multicontinental clinical trial, with approximately 17% of the participants recruited in Latin-American centers.Thus, clinical trials with SGLT2 inhibitors began to be conducted in patients with symptomatic HF, regardless of the presence of type 2 diabetesversus502 events, respectively; HR 0.74; 95% CI, 0.65-0.85). The benefit was observed in both components of the primary outcome and proved to be consistent in the pre-specified analyses in different subgroups, such as the presence or absence of type 2 diabetesmellitus.In addition, there was a reduction in the risk of all-cause death in the group treated with dapagliflozinversusthe placebo group .The patients were randomized for the use of dapagliflozin, 10 mg/day, or placebo, at a 1:1 ratio. After a median 18-month follow-up, dapagliflozin was associated with a reduction in the risk for the primary outcome, which included cardiovascular death and hospitalization from HF , regarding the benefit of dapagliflozin on the primary outcome and found no change of effect.were exclusion criteria.The safety profile of dapagliflozin was satisfactory, with low incidence of severe adverse events. Importantly, when assessing the eligibility criteria of the DAPA-HF study, systolic blood pressure < 95 mm Hg and glomerular filtration rate < 30mL/min/1.73minvestigated the effect of empagliflozin, as compared to placebo, in patients with HFrEF (\u2264 40%) on optimized medical therapy and defined inclusion criteria and primary outcome similar to those of the DAPA-HF study. However, the 3730 participants of the study (50% with type 2 diabetesmellitus) showed higher mean levels of atrial natriuretic peptides and lower mean LVEF values as compared to those of the dapagliflozin study sample. Once more, CD was not represented as an etiology of HF, although 34% of the study participants had been recruited in Latin-American countries. After a median 16-month follow-up, empagliflozin reduced by 25% the combined risk of hospitalization from HF and cardiovascular death as compared to placebo . However, differently from the DAPA-HF study, that benefit seemed to be basically due to reduction in hospitalizations from HF. In the pre-specified subgroup analyses, the effect of empagliflozin on the primary outcome remained consistent.The EMPEROR-Reduced study, published in 2020,Similarly to the DAPA-HF study, in the EMPEROR-Reduced study, patients on SGLT2 inhibitor showed lower values of systolic blood pressure, body weight, and NT-proBNP after a 1-year follow-up as compared to baseline values.has extended the investigation of empagliflozin to patients with HFmrEF (> 40%). The relative reduction in the risk of events was similar to that observed in patients with LVEF \u2264 40%, which is expected, because an arbitrary limit of ejection fraction does not define two different diseases. Of note patients with HFmrEF have better prognosis, which reduces the absolute magnitude of the benefit: NNT of 19 in the first two studies with LVEF < 40% and NNT of 30 in the EMPEROR-Preserved trial.More recently, the EMPEROR-Preserved trialThose studies have satisfactory statistical precision and low risk of bias. Thus, it seems adequate to state that there is effect of benefit, whose magnitude, represented by a 25% relative risk reduction, is at the level  of most therapies approved for HF. Therefore, from the pragmatic viewpoint, these drugs are safe and moderately beneficial.Regarding cost-effectiveness, the recent incorporation of dapagliflozin into SUS was based on a report from the CONITEC presenting an economic model with incremental cost-effectiveness ratio of R$9296 per year of life saved with quality, being within an acceptable definition of efficiency.versushow much of that is due specifically to the molecule innovation? There are reports of favorable effects of those drugs on intermediate outcomes, both metabolic and neuro-humoral, such as an increase in the circulating levels of vasodilators and a reduction in the levels of vasoconstrictors. However, clinical trials have not focused on the pertinent proof of concept that these are the effects that mediate the clinical benefit. None of them has generated a counterfactual (second control group) based on the diuretic therapy to answer the question: if a patient not receiving the innovative drug had the same level of diuresis improvement, would his outcome be different? This question could also be explored by use of mediation analysis , with data from the clinical trials and a post-randomization mediator variable that represented the effect on diuresis. We have not detected this type of approach in the literature.However, there is one conceptual question: how much of the benefit of those drugs derives from diuretic therapy improvementFinally, how to translate our interpretation of the evidence into a recommendation of therapy with gliflozins in individuals with HF of CD? Once more, that subpopulation has not been represented in clinical trials. In accordance with data presented for other contexts, generalization does not depend only on representativeness, and we do not know any probable mechanism of interaction that raises the suspicion that the etiology of CCCD modifies the effect of that therapy to the point of loss of efficacy. Therefore, we defined that there is level of evidence B for HF from CCCD, that is, indirect and of good quality. Regarding the strength of recommendation, in the absence of the counterfactual that there is benefit beyond the diuretic effect, we chose a conditional recommendation for patients with HFrEF, and prescription should be based on clinical findings suggesting the need for therapeutic increment.The recommendations for the pharmacological treatment of HF in CCCD are shown inDespite all the advance observed in drug treatment, in intensive care, and surgical strategies, including the use of implantable cardiac devices, for the treatment of HF, this clinical syndrome persists with high morbidity and mortality and considerable economic impact on the health system, mainly in its more advanced phases.Thus, CTX in advanced CCCD is considered a strong recommendation, with level of evidence B, similarly to that occurring in other cardiac diseases with classical indications, as long as there is no contraindication to the procedure and some peculiarities are considered, such as, unfavorable socioeconomic conditions and presence of megacolon and/or megaesophagus, which can increase the risks of postoperative complications and jeopardize the CTX result.The CTX is still considered the best treatment for refractory HF, with evident influence on the patient survival increase and quality of life improvement, especially in CCCD, whose prognosis is poor as compared to HF of other etiologies.10.2.1.1. Immunosuppression StrategiesThe immunosuppressive regimens for CTX can be classified as of induction and of maintenance and they do not depend on the etiology of the HF leading to CTX indication. Induction regimens cause intense postoperative early immunosuppression, while maintenance regimens are used throughout life to prevent rejection.10.2.1.2. Induction TherapyPatients at high risk for fatal rejection, who could benefit from induction therapy are those with high titers of anti-HLA antibodies in the immune panel (PRA = panel reactive antibody > 10%), who are considered more vulnerable: young women with a previous pregnancy, patients with previous multiple transfusions, and users of mechanical circulatory support. The major inductors are polyclonal antithymocyte immunoglobulin  and IL-2 receptor inhibitors, which have low immunogenicity, such as daclizumab and basiliximab.The induction therapy for transplanted patients consists in intense immunosuppressive treatment, during transplant or in the immediate postoperative period, used in those at high risk for rejection to reduce this risk or delay the use of higher doses of calcineurin inhibitors, minimizing renal damage, particularly in patients with impaired renal function.T. cruziinfection. Induction therapy is still controversial, and despite being used in 50% of the cardiac recipients, so far large RCTs have not been conducted to demonstrate the benefit of induction therapyversusno induction therapy.There are no data available on its effects on a recipient with CCCD.Although those agents can reduce the risk of early rejection and/or minimize renal damage, they are associated with an increased risk of infection, and, thus, can reactivate10.2.1.3. Maintenance TherapyThe basic maintenance immunosuppressive therapy in heart transplanted patients usually includes a calcineurin inhibitor, such as cyclosporine A or tacrolimus. These agents should be associated with mycophenolate mofetil (MMF) or mycophenolate sodium or azathioprine or rapamycin or everolimus. Prednisone is also added to this standard regimen, and, in most patients, it can and should be suspended approximately 6 months after transplantation if no rejection occurs.T. cruziinfection.There is no study comparing immunosuppressive regimens in patients with CCCD; however, a higher number of reactivations has been diagnosed with the use of MMFversusazathioprine.Thus, strategies to change the immunosuppressive regimen, such as replacement of MMF with azathioprine or MMF dose reduction, have been proposed, but these strategies have not been tested in RCTs.In the context of CCCD, the induction and/or maintenance immunosuppressive therapy can reactivateThe early reduction in immunosuppressive agents, mainly corticosteroids, is recommended to prevent RCD, but this can facilitate rejection episodes. So, patients with CCCD should receive the least intense immunosuppressive therapy possible, provided that there is no rejection.Rejection is classified into hyperacute, mediated by antibodies, and acute cellular, which represents the most prevalent form of rejection. Histologically, rejection is defined by an inflammatory infiltrate, in which lymphocytes typically predominate, and myocyte damage. The International Society for Heart & Lung Transplantation (ISHLT) revised the categories of acute cellular rejection (R) as follows: 0R (no rejection), 1R (mild), 2R (moderate), or 3R (severe).The incidence of rejection requiring treatment has progressively reduced over the years, currently affecting only 12.6% of the recipients in the first year after CTX.The frequency of hyperacute rejection after CTX due to CD has not been reported.Hyperacute rejection is an uncommon event, mediated by antibodies previously formed in the recipients, and manifests as severe graft failure within minutes or a few hours after the CTX procedure.Acute cellular rejection occurs in 10% to 14% of the recipients with CCCD and there is no difference in the incidence of acute cellular rejection episodes (2R or 3R) between CTX recipients with or without CD.T. cruziinfection can occur in the transplanted heart, making the differential diagnosis between rejection and RCD a great challenge.Endomyocardial biopsy remains the standard method for the diagnosis of rejection, and the frequency of the biopsies varies according to the transplant center protocol. Secondary myocarditis to reactivation of theThe presence of nests ofT. cruziamastigotes with mononuclear inflammatory infiltrate in endomyocardial biopsy fragments does not exclude concomitant graft rejection, because the two conditions can occur simultaneously.The definition for one of those two conditions is difficult if parasites are not found in the biopsy fragments. Depending on the routine histopathological staining techniques, if parasites are not seen, the histopathological inflammatory characteristics found in rejection (2R or 3R) and in RCD are verry similar. Thus, the mononuclear inflammatory infiltrate detection on the endomyocardial biopsy slides is not sufficient to rule out the diagnosis of RCD and represents a dilemma, because the aggressive immunosuppressive treatment to abort rejection can facilitate and intensify RCD.Rejection is a risk factor for RCD, and more than 85% of the patients have at least one episode of rejection before RCD occurs.Therapy for rejection in transplanted patients with or without CD is similar. Usually, mild rejection (1R), in the absence of clinical or hemodynamic impairment, requires no additional intervention. However, more severe rejection (\u2265 2R) requires aggressive supplementary immunosuppressive therapy.10.2.3.1. Clinical PresentationConsidering its potential morbidity and mortality, the diagnosis and proper management of RCD in the context of organ transplant is extremely important.Immunosuppressive therapy increases the risk of RCD, whose incidence after CTX ranges from 19.6% to 90%.The diagnosis of RCD is based on clinical signs and symptoms and on the presence of parasites in the blood, cerebrospinal and other fluids, bone marrow, or tissues.The CTX should be performed following a clinical and laboratory structured protocol to monitor the infection reactivation and its subsequent treatment.T. cruzitreatment. The clinical reactivation has cardiac and extracardiac manifestations that include: myocarditis; ventricular dysfunction; arrhythmias; new atrioventricular/intraventricular blocks on ECG; skin lesions ; fever; bone marrow impairment; and neurological manifestations, such as meningoencephalitis, chagomas, cerebral abscess, and stroke.The myocarditis of reactivation can be mistakenly diagnosed as graft rejection and treated with intensification of the immunosuppressive treatment, which will worsen reactivation.The differential diagnosis between myocarditis of rejection and of reactivation is still a great challenge.In the presence of inflammatory infiltrate, nests of amastigotes and/or positive PCR forT. cruziin the myocardium, we can claim that reactivation is present, but associated graft rejection cannot be safely excluded. Despite this complexity, the survival rate of recipients with CCCD undergoing CTX does not differ from those of cardiomyopathies of other etiologies.Monitoring is aimed at identifying the firsts signs of reactivation and timely establishing anti-10.2.3.2. Parasitological Diagnosis of ReactivationSerological tests are useful only for potential donors, diagnosis of CCCD in potential recipients, and seronegative recipients who receive organs from seropositive donors.They play no role in the diagnosis of RCD.The objective of laboratory monitoring is to identify any subclinical sign of RCD before cardiac and extracardiac symptoms appear, as well as graft dysfunction.T. cruziand blood cultures) and serial histological testing of endomyocardial biopsy, in the search forT. cruziamastigotes, but those are low-sensitivity tests.In recent years, several studies have evidenced the value of PCR in peripheral blood and myocardium to detect early RCD before the appearance of symptoms and/or graft dysfunction.Traditionally, laboratory monitoring uses parasitological methods , with pain and/or paresthesia in lower limbs, and anorexia. Significant leukopenia and agranulocytosis are rare but, when present, determine treatment interruption.Nifurtimox is not routinely available in Brazil. These trypanocidal medications are contraindicated to pregnant women and patients with important renal or hepatic failure.There is no sufficient evidence to support the prophylactic anti-T. cruzitreatment for RCD. It is worth considering that those drugs have important side effects, not every recipient has RCD, and one patient can have more than one episode of RCD after treatment. Monitoring of reactivation should be maintained even after anti-T. cruzitreatment; rejection 2R or 3R (10%-14%); postoperative bleeding (10%); infection not related toT. cruzi(20%-30%); and acute renal failure (up to 70%). However, in recipients with CCDC, graft coronary artery disease appears to be less frequent, while the incidence of neoplasms seems to be higher, although none of these reported differences has been confirmed in all case series.The clinical outcomes, morbidity and mortality, in CTX recipients with or without CD are similar.One reason for that better performance would derive from the baseline characteristics, since patients with CCCD are usually younger, have fewer comorbidities, and less often have undergone previous cardiac surgery.However, a recent study has reported the evolution of 376 transplanted patients between 1997 and 2019 in a single center in Northeastern Brazil, comparing the following etiologies of HF: CCCD, CMI, and nonischemic cardiomyopathy. A mean 5-year follow-up evidenced stability in survival for individuals with CCCD, while that parameter improved subsequently in the other two groups.Despite all the complexity of CD in the context of CTX, the results are good. In Brazil, the survival rates of patients with CCCD undergoing CTX in 6 months, 5 years, and 10 years are 76%, 71%, and 46%, respectively, superior to those of the cohort of patients undergoing CTX due to other etiologies.Mechanical circulatory support devices (MCSDs) are used to restore tissue perfusion in patients with advanced HF or cardiogenic shock refractory to optimized clinical therapy, including the use of inotropic drugs. They can provide support to the left or right ventricle, or both.Mechanical circulatory support can be indicated as bridge to CTX or to recovery, in the perspective of ventricular function improvement after acute injury, or even as a bridge to decision-making in critical patients, when improvement of clinical findings is uncertain. In specific situations, mainly in the presence of contraindication to CTX, MCSDs can be used as permanent therapy.The indication and contraindication criteria for the use of MCSDs in patients with CD can be the same applied to other etiologies.Although RV systolic dysfunction is relatively common in patients with CCCD, especially in those who also have LV systolic dysfunction, there is no consensus regarding the choice of the most appropriate type of device in this condition.Evidence on the use of MCSDs for patients with CD is limited to a few reports or case series, mainly as bridge to CTX.After that, in a noncontrolled phase I clinical trial, including six patients with advanced biventricular HF, Moreiraet al. reported the successful use of left MCSD as bridge to CTX in only two cases.The first report of the successful use of MCSDs as bridge to CTX in a patient with CCCD occurred in 1994.et al. have reported the use of biventricular MCSD in two patients with CD from a cohort of patients undergoing CTX in the USA.Ruzzaet al. have reported a successful case of total artificial heart as bridge to CTX in a patient with CCCD.In the Netherlands, a MCSD has been implanted as bridge to CTX in a patient with refractory HF due to CD.More recently, Atiket al. have reported another successful case of axial flow left MCSD used in a patient with CD and biventricular systolic dysfunction.In developed countries, MCSDs have been implanted in immigrants with HF due to CD. KransdorfMechanical cardiac support is usually considered to have a high potential for success as bridge to CTX, recovery, decision-making, or permanent therapy in patients with CCCD. However, currently, the major limitations to its applicability are high cost, RV dysfunction, and need for a specialized team for device implantation and management. The SBC guideline on mechanical circulatory support recommends careful assessment of the RV function as mandatory before implantation, and, in the presence of moderate to severe dysfunction, one should be prepared for biventricular support implantation.The hemodynamic parameters considered optimal regarding RV function and that would reduce the risk of RV dysfunction after implantation are: central venous pressure \u2264 8mmHg, pulmonary capillary pressure (PCP) \u2264 18mmHg, CVP/PCP \u2264 0.66, pulmonary vascular resistance < 2 UW, and RV work index \u2265 400mL/m.The major indices to assess RV dimensions and function are: RV longitudinal and radial contractility semiquantitative assessment; fractional area change; tricuspid annular plane systolic excursion (TAPSE) on M mode; lateral tricuspid annulus peak systolic velocity estimated by tissue Doppler (s\u2019); and RV myocardial performance index. Left ventricular MCSD implantation should be considered with restrictions to patients with CCCD and significant RV dilation, moderate to severe tricuspid insufficiency, tricuspid annulus > 45 mm, and central venous pressure (CVP) > 15mmHg.However, CCCD shares similarities with several extensively studied cardiopathies, particularly those with myocardial fibrosis and systolic dysfunction , such as ICM and DCM,allowing the therapeutic rationale to follow similar pathophysiological bases. Thus, the treatment and prevention of ventricular and supraventricular arrhythmias in CCCD tend to follow directions similar to those of the other cardiopathies.Medical literature related to arrhythmia treatment and sudden death prevention in CCCD is scarce and insufficient for the formulation of strong recommendations supported by evidence directly obtained from randomized studies and that indisputably proves therapeutic efficacy (level of evidence A).Despite the classical direct relationship between the degree of ventricular dysfunction and the higher frequency of ventricular arrhythmia, the prevalence of ventricular arrhythmias in CCCD is higher as compared to that in other cardiopathies.However, some specific characteristics that can influence antiarrhythmic treatment are usually more striking in CCCD. Sinus node dysfunction, atrioventricular and intraventricular conduction disorders, and ventricular arrhythmias are frequently found in both asymptomatic and more advanced disease forms.presence of intracardiac thrombi,and cardiac dysautonomia due to parasympathetic neuronal lesionare more frequent in CCCD. All those factors could explain the shorter survival of patients with CCCD as compared to that of patients with cardiomyopathies of other etiologies and similar myocardial damage.In addition, RV impairment,Sinus node dysfunction and atrioventricular and intraventricular conduction disorders require more caution with the use of beta-blockers, digitalis, and amiodarone, because of the risk of excessive bradycardias and appearance or worsening of preexisting blockades.tends to cause more systemic congestion, requiring higher doses of diuretics that can induce severe hypopotassemia, increasing the risk for global, sudden, and cardiovascular death.In this context, in addition to the routine use of aldosterone inhibitors (spironolactone/eplerenone),oral supplementation with potassium, aimed to maintain its serum levels between 4.0 and 5.0mEq/L, might be necessary.In addition, ventricular tachyarrhythmias demand treatment with drugs frequently associated with severe side effects. Right ventricular impairment, present in 42% of the patients with LV dysfunction,The RASSI score, developed in that subgroup of CCCD, stratifies the risk of total mortality, which includes the predominant occurrence of sudden death.Sudden death, sometimes unexpected and affecting individuals with good functional capacity during exercise training, clearly predominates in outpatient subpopulations with CCCD.However, many of those patients often have varied ventricular dysfunction degrees and clinically manifest HF. The optimized HF treatment in patients with CCCD is likely to result in a potential auxiliary benefit to prevent malignant ventricular arrhythmia and its most feared consequence, sudden death. This has not been specifically proven, and only a few studies on HF have included small samples of patients with HF due to CD.Thus, the use of some pharmacological treatments for CCCD complicated with HF, aimed at reducing sudden death, has been extrapolated from results obtained in patients with HF of other etiologies, assuming the existence of clinical and pathophysiological similarities between them.For example, the MERIT-HF trial, comparing metoprolol succinateversusplacebo for patients with HF and ejection fraction \u2264 40%, was early discontinued (after a mean 12-month follow-up) due to a 40%-60% reduction in overall mortality, in mortality from HF worsening, and in sudden death.Similar results have been observed with carvedilol and bisoprolol in patients with HFrEF.Optimized dosages of ACEI or ARB, as well as of beta-blockers  and spironolactone, should be aimed at for HF due to CD with that auxiliary antiarrhythmic perspective.In a small, but CCCD-specific study, carvedilol has been well tolerated and associated with a trend to increase LVEF.More recently, in the PARADIGM-HF trial, in patients with HFrEF, sacubitril-valsartan significantly reduced the incidence of sudden death as compared to enalapril at a non-optimal dose in the group receiving ICD (51% reduction) and in that not undergoing ICD implantation (19% reduction).Thus, other recommendations from international guidelines might be applied to reduce total and sudden death in CCCD with HF.It is worth noting that in the REMADHE observational study, beta-blockers were less often used for patients with CCCD than for those with other etiologies.Ventricular arrhythmias can occur in any cardiopathy and manifest as: monomorphic or polymorphic, isolated, bigeminy, trigeminy, and paired VE; NSVT or SVT, which can also be monomorphic or polymorphic. Ventricular arrhythmias can be asymptomatic and, in their most severe forms (SVT and VF), cause syncope, low output, and sudden death.The EMIAT study, assessing patients after myocardial infarction with LVEF < 40%, has reported prevalence of ventricular arrhythmia (defined as 10 or more VE/hour or NSVT on Holter) in 39% to 41% of the individuals.The GESICA study, in patients with severe HF of several etiologies, has reported high occurrence of VE > 10/hour (71%), paired VE (56%), and NSVT (33%) on Holter.The prevalence of NSVT episodes on 24-hour Holter has ranged from 21% to 25% in the SCD-HeFT study, which assessed mortality of patients with HF of ischemic and nonischemic etiologies.Amiodarone has the four antiarrhythmic effects of the Vaughan-Williams classification: sodium channel block (class I); noncompetitive alpha- and beta-adrenergic inhibition (class II); interference with potassium channels, leading to prolongation of the action potential, repolarization, and refractoriness (class III); and calcium channel block (class IV).versusplacebo, other antiarrhythmic drugs, or control group for the primary prevention of total mortality and sudden death has been assessed in several meta-analyses. In 1997, the ATMA study,using individual data of patients from eight RCTs after acute myocardial infarction  and five studies including patients with congestive HF , showed a reduction of 13% in the risk of total death (p = 0.03) and of 29% in the risk of arrhythmogenic sudden death (p = 0.0003) with amiodarone. There was no excess of nonarrhythmic deaths with amiodarone, and both groups of patients  benefited from the antiarrhythmic treatment.The use of amiodaroneusing Bayesian hierarchical modeling and data from the same 13 studies included in the ATMA trial in addition to two other studies (CASCADE and ASSG) involving survivors of cardiac arrest or SVT, concluded that amiodarone reduces all-cause mortality by approximately 19% (p < 0.01) and determines slightly higher reductions in cardiac mortality  and sudden death . There was a trend towards a higher reduction in the risk of death in the studies requiring evidence of frequent or complex ventricular ectopia as an inclusion criterion (25%) as compared to other studies (10%).In that same year, another meta-analysis,After a median 45.5-month follow-up, total mortality was 29% in the placebo group, 28% in the amiodarone group, and 22% in the ICD group, that is, while amiodarone had no effect on total mortality as compared to placebo, the ICD therapy caused a 23% relative risk reduction (p = 0.007).With the encouraging amiodarone results and the ICD emergence, the next most likely step would be comparison focused on random assignment of patients treated with amiodarone or ICD or placebo in primary prevention of death from any cause. This was the major objective of the SCD-HeFT study, published in 2005, including 2521 patients with ejection fraction \u2264 35%, NYHA functional class II or III, HF of ischemic origin in 52% of the patients and nonischemic in the remaining.Based on pre-specified subgroup analysis, the results did not vary according to HF etiology, but varied according to NYHA functional class. Thus, in class III patients, an increase in mortality was observed with amiodarone (as compared to placebo), while no difference was observed between the ICD and placebo treatments. Despite the extremely significant (p < 0.001) interaction between ICD and functional class, the authors ignored these results and concluded that, in both classes (II and III), therapy with single-chamber ventricular ICD could reduce total mortality.According to that same paradigm, all guidelines began to recommend ICD, prophylactically, in patients with ejection fraction \u2264 35% and NYHA functional class II and III. Despite the indisputable results of the SCD-HeFT study, two limitations apply. First, the inclusion criterion was ventricular dysfunction and not the recording of complex and frequent ventricular arrhythmia on Holter. Second, of all subgroup analyses, the most important one, from our viewpoint, comparing amiodarone to placebo in patients with recorded NSVT (22% of the study population), for unknown reasons, was not contemplated.randomizing 674 patients with HF (ejection fraction \u2264 40%) of ischemic and nonischemic etiology and at least 10 VE/hour on 24-hour Holter to receive amiodarone or placebo, after a median 45-month follow-up, amiodarone significantly reduced the ventricular arrhythmia frequency and improved ventricular function but could not increase survival.In the CHF-STAT study,and AMIOVIRT (103 patients)were known. The first compared amiodarone with a control group in patients with ischemic and nonischemic heart disease, ejection fraction < 35%, and Lown\u2019s grade 2 or 4 ventricular arrhythmia on Holter. The second compared amiodarone with ICD for exclusively nonischemic HF, ejection fraction \u2264 35%, and NSVT on Holter. In the Argentine pilot study EPAMSA, which included 24 patients with CCCD, after a 1-year follow-up, the reductions in total death and sudden death with amiodarone were 71% (p = 0.02) and 71% (p = 0.04), respectively.In pre-specified subgroup analysis and based on randomization stratified according to HF etiology, there was a trend towards lower mortality with amiodarone in nonischemic patients (p = 0.07). At the time the SCD-HeFT study was published, the results of two small RCTs, EPAMSA (127 patients)versus96%) and 3 years (88%versus87%) did not statistically differ between the amiodarone and the ICD groups (p = 0.8), respectively.In the AMIOVIRT study, early terminated because of the futility criterion, survivals after 1 year (90%which included 516 patients with severe HF of ischemic and nonischemic etiology (48 patients with CCCD), mainly NYHA functional class III or IV, presenting at least two of the following three criteria: ventricular systolic dysfunction indices: CTI > 0.55; ejection fraction \u2264 35%; and LVDD \u2265 32 cm/m. Patients were randomized to an amiodarone or a control group. After a mean 13-month follow-up, total mortality was 41.4% in the control group and 33.5% in the amiodarone group, a relative risk reduction of 28% (p = 0.024). Patients were randomized according to the presence of NSVT on Holter on admission, which was observed in 33.5% of the entire population studied. The reduction in the risk of death with amiodarone occurred regardless of the presence of ventricular arrhythmia but was numerically higher in patients with recorded NSVT (34%versus24.5%).Positive results with amiodarone have also been observed in another Argentine study (GESICA),After a 11-year follow-up, the benefit of ICD as compared to placebo remained statistically significant, but attenuation of effect was observed, with relative reduction in the risk of death decreasing from 23% (after 45.5 months) to 13% . In addition, there was a significant interaction between follow-up duration (less or more than 6 years) and benefit from ICD (p < 0.0015) and the subgroup analysis according to HF etiology showed heterogeneous long-term results. While the beneficial effect of ICD persisted in patients with ischemic HF , in those with nonischemic HF, a reduction in mortality with the use of ICD was no longer observed . Considering that, after the publication of the original trial, more than half of the patients assigned to the placebo or amiodarone group received an ICD or resynchronization therapy and that the recommended statistical analysis was \u201cintention to treat\u201d, this crossover might have interfered with the results. However, these results did not change when the \u201cas treated\u201d analysis was used, comparing the groups according to the treatment received and not according to the initial assignment.More recently, the long-term results of the SCD-HeFT study have been published.identified 15 studies , with a total of 8522 patients randomized to amiodarone or placebo/control. Amiodarone reduced the risk of sudden death by 29% (p < 0.001) and of cardiovascular death by 18% (p = 0.004). The reduction in the risk of all-cause mortality (13%) did not reach statistical significance (p = 0.093). Pre-specified subgroup analysis showed a 19% reduction in the risk of total death  with amiodarone doses > 200mg/day. However, doses \u2264 200mg/day were not effective . In addition, the use of amiodarone was associated with a two- and five-fold increase in the risk of pulmonary and thyroid toxicity, respectively. The authors concluded that amiodarone is a feasible alternative to prevent sudden cardiac death in ineligible patients or in those with no access to ICD therapy.After the SCD-HeFT study publication, more meta-analyses were performed. The first meta-analysisand included 24 RCTs with a total of 9997 patients. The objective was to compare amiodaroneversusplacebo/control or other antiarrhythmic drugs in primary (high-risk patients for sudden death) and secondary  preventions.Another systematic review with meta-analysis, following the Cochrane systematic review guidelines, was published in 2015In the studies of primary prevention , amiodarone significantly reduced sudden, cardiovascular, and all-cause mortality, but the quality of the evidence was considered low (compared to placebo) or moderate (compared to other antiarrhythmic drugs). In the studies of secondary prevention , no reduction in sudden and all-cause mortality was observed, and the quality of the evidence was considered low or very low.including 11 studies with patients with HF (ischemic and nonischemic) or nonischemic DCM associated with LV dysfunction has shown that the presence of NSVT on Holter is an independent predictor of sudden cardiac death ; 3) the only RCT that compared directly amiodarone to ICD in primary prevention (AMIOVIRT)has shown no superiority of ICD; however, that study was limited by its small sample size.Based on those results: 1) it is reasonable to conclude that, as compared to placebo or control group or other antiarrhythmic drug, regarding primary prevention, amiodarone modestly reduces all-cause death, having a more expressive reducing effect on sudden death in patients with HF of both ischemic and mainly nonischemic etiology; 2) it is plausible to speculate that the beneficial effect of amiodarone is higher when NSVT and high ventricular arrhythmia density can be recorded on Holter, which seems to be highly relevant in the presence of ventricular dysfunction. Corroborating this assumption, a meta-analysisalthough not comparing amiodarone to ICD, but each of them to placebo instead, did not require the presence of ventricular arrhythmia as an inclusion criterion, did not perform subgroup analysis based on the presence of NSVT, and showed ICD benefit only for patients in NYHA functional class II (but not class III), a benefit that was maintained in the long run only for those with ischemic HF. All these aspects should be considered when attempting to extrapolate the SCD-HeFT study results to CCCD.The SCD-HeFT study,Secondary prevention of sudden death relates to patients who recovered from cardiac arrest due to VF or pulseless VT, or who already had at least one documented SVT episode. The other example of this group are patients with syncope of cardiac etiology, whose EPS showed induction of VF or hemodynamically unstable (or even stable according to some authors) SVT.Sustained ventricular tachyarrhythmias have been typically grouped into a single category and collectively named \u201clife-threatening\u201d or \u201cmalignant\u201d. Although VF predictably precipitates cardiac arrest, unless if its duration is short and reverts spontaneously (a very rare and poorly documented event), SVT has a wide range of hemodynamic and clinical manifestations.Thus, indiscriminate grouping of these arrhythmic entities should be avoided because they differ regarding their prognoses and treatments. The ventricular dysfunction degree (expressed by LVEF) and the symptoms associated with the arrhythmia and the type of structural cardiopathy should be considered during the patients\u2019 assessment.The dichotomizing cutoff point for LVEF has usually been 35% or 40%, and a symptom grading has proposed four classes: I - no symptom or only palpitations; II - lipothymia, chest pain or dyspnea; III - syncope, altered mental state or other evidence of important hemodynamic impairment ; and IV - cardiac arrest (neither pulse nor breathing).It is very likely that the prognosis and treatment of a patient with ischemic heart disease, who recovered from cardiac arrest due to VF and with LVEF of 30%, differ from those of a patient with DCM, such as CCCD, hemodynamically stable SVT, relatively preserved LVEF, and palpitations.have compared amiodarone (or other antiarrhythmic drug) with ICD for secondary prevention of all cause death.Three RCTs the first and largest of them, has assessed 1016 patients (81% with ischemic heart disease) who had been resuscitated from cardiac arrest due to VF (45% of the patients) or who had syncopal SVT (21%) or SVT, with LVEF \u2264 40% and symptoms suggestive of severe hemodynamic impairment (34%). The patients were randomized for therapy with ICD or antiarrhythmic drugs (amiodarone in 96% of the cases), had a mean age of 65 years, mean LVEF of 32% in the ICD group and 31% in the antiarrhythmic group, and 79% were of the male sex. After a mean 18.2-month follow-up, the study was early terminated because of the ICD superiority in reducing total death (15.8%versus24%), with relative risk reductions of 39%, 27%, and 31%, after 1, 2, and 3 years of follow-up, respectively .The AVID study,has randomized 659 patients (83% with ischemic heart disease) for ICD or amiodarone, 48% of whom had survived cardiac arrest due to VF, 13% had syncopal SVT, 25% had SVT (HR \u2265 150 bpm), LVEF \u2264 35%, causing presyncope or angina, and 14% had syncope and SVT induced by programmed electrical stimulation. Their mean age was 64 years, mean LVEF was 34% in the ICD group and 33% in the amiodarone group, and 85% were of the male sex. After a mean 3-year follow-up, there was a nonsignificant reduction in the annual risk of total death  and of arrhythmic death  with ICD.The Canadian Implantable Defibrillator Study (CIDS)was performed in the city of Hamburg, Germany, and compared ICD to different antiarrhythmic drugs . Differently from the previous trials, it included only patients resuscitated from cardiac arrest . The propafenone arm (58 patients) was discontinued after a mean 11.3-month follow-up because of a mortality rate 61% higher than that observed in the ICD group. The other patients, total of 288 equally assigned to the ICD, amiodarone, and metoprolol groups, remained in the study. The mean age was 58 years, mean LVEF of 46%, 80% were of the male sex, and 73% had ischemic heart disease. In a mean 57-month follow-up, all-cause mortality was lower in the ICD arm as compared to the amiodarone/metoprolol arm (36.4%versus44.4%), although the difference did not reach statistical significance (1-sided p = 0.08).The smallest of the three studies, the CASH,Individual patient data from the three studies were merged into a master database according to a pre-specified protocol and the results were published in 2000. The meta-analysis included 1866 patients  with mean age of 63.5 years, mean LVEF of 33.5%, most of them of the male sex (81.5%) and diagnosed with ischemic heart disease (82%). The estimates of ICD benefit from the three studies were consistent with each other (p heterogeneity = 0.306). There was a 28% relative risk reduction in death from any cause  and a 50% reduction in arrhythmic death  with the ICD, reflecting a mean survival gain of 4.4 months after a mean 6-year follow-up.The early termination of the AVID study, which could have overestimated the benefit of ICD, in addition to the smaller number of patients enrolled in the CIDS and CASH studies, which could have reduced the power of the statistical tests to detect a real benefit of the ICD treatment, have motivated the conduction of a meta-analysis comparing ICD exclusively with amiodarone.versus19%) and the benefit of ICD therapy also higher in those on beta-blockers (HR = 0.58versusHR = 0.88), this difference was not statistically significant .However, in the subgroup analysis, the benefit related to survival increase with ICD was observed only in patients with LVEF \u2264 35% (HR = 0.66) and not in those with LVEF > 35% . Although the use of beta-blockers was higher in the ICD group , only when ICD therapy is unavailable or contraindicated or refused by the patient, amiodarone could be used in an attempt to reduce sudden death (class IIb).As already mentioned, although more commonly found in more advanced phases of CCCD, ventricular arrhythmias can occur at the early disease stages and even in the absence of significant global systolic ventricular function impairment.11.1.6.1. Ventricular ExtrasystolesThe density of VE is also elevated, so that 45% and 89% of the patients without and with HF, respectively, have more than 1000 VE/h on Holter.Ventricular extrasystoles are present in 86% to 88% of the patients with CCCD without HF  and in almost all patients with HF  on 24-hour Holter.that is, ventricular systolic dysfunction caused or worsened by the arrhythmia, which can be attenuated or reversed with suppression of the VEs, and, thus, survival may be increased.When VEs occur in asymptomatic patients with preserved ventricular function, they require no treatment. However, in asymptomatic patients with high arrhythmia density (> 16-20% of VE on 24-hour Holter), tachycardiomyopathy may develop,Thus, amiodarone can be indicated, at the dosage of 200 to 600 mg/day, because of its high efficacy in significantly reducing the VE density.When the VEs are very symptomatic, even in the absence of ventricular dysfunction or late enhancement (fibrosis) on CMRI, the use of antiarrhythmic drugs is mandatory, but should be individualized, and amiodarone should be avoided at first, because of its adverse effects. In this situation, the use of a beta-blocker  or propafenone is suggested. However, in the presence of ventricular dysfunction or arrhythmogenic substrate of fibrosis on CMRI, class I antiarrhythmic drugs should not be used, because of their proarrhythmic effects and occasional negative inotropic effect, which could increase mortality, as described for other cardiopathies.11.1.6.2. Nonsustained Ventricular Tachycardiaa prevalence much higher than that in other cardiopathies. It can be observed even in patients with normal ventricular function and its detection on Holter or during exercise testing is an independent marker of poor prognosis.When associated with LV dysfunction , a relatively common finding in CCCD, it increases the risk of death by 15 times as compared to that of patients without NSVT and with normal ventricular function.In the absence of data to assess relevant outcomes, such as mortality and hospitalization, a meta-analysis of old studies with amiodarone in CCCD has shown an important reduction in the ventricular arrhythmia density on serial Holter records .Nonsustained ventricular tachycardia affects 42% of the patients with CCCD without HF and 89% of those with HF,and EPAMSA,including patients with CCCD, have shown a reduction in mortality with amiodarone. However, the small number of individuals with CCCD in those two studies (only 72) hinders a definitive conclusion. Thus, how to manage patients with NSVT? In the absence of ventricular dysfunction, the pharmacological treatment should follow, in general, the same recommendation for the treatment of VEs. When ventricular dysfunction is present, three options are available: beta-blocker, amiodarone, and ICD, which is discussed ahead.As already mentioned, the Argentine RCTs GESICAThe treatment should be aimed at relieving symptoms (when present), improving ventricular function, and preventing sudden death. Because there are no convincing data derived from RCT to support any of those three options, the recommendations for the treatment of those patients are based on extrapolation of the results from the studies performed in other heart diseases and on CCCD-related observational data, which are limited.After a thorough analysis of the literature, we chose to preferably indicate a selective beta-blocker , either associated or not with amiodarone, a decision that should be tailored to the patients\u2019 needs and shared with them.11.1.6.3. Sustained Ventricular Tachycardia and Ventricular Fibrillationtorsades de pointes), and VF, which should be timely reversed in the emergency room. Amiodarone is the best drug option in cases of stable SVT and refractory or recurrent VF.Although the prevalence of sustained ventricular arrhythmias is not widely known, patients with CCCD, regardless of the ventricular function, can have monomorphic SVT, polymorphic SVT . In case of immediate relapse , administration of antiarrhythmic drugs (preferably amiodarone) should be considered, with proper oxygen support, cardiac monitoring, and correction of possible electrolyte disorders.According to the ACLS protocol, two drugs are indicated for the treatment of sustained ventricular arrhythmias in the emergency room, amiodarone and procainamide, both by the intravenous route. The dosages recommended are shown inIt is worth noting that the intravenous administration of amiodarone can cause phlebitis and arterial hypotension, reduce sinus rate, increase the duration of the QRS complex and of the QT interval, increase atrioventricular node refractoriness, reduce the HR (slow down) of the SVT, and improve the ICD defibrillation threshold.Procainamide can increase the PR interval, the QRS complex duration, and the ICD defibrillation threshold. In addition, it can cause arterial hypotension and LVEF reduction, diarrhea and nausea, and trigger symptoms and signs of the lupus erythematosus syndrome.Other antiarrhythmic drugs of intravenous administration, such as lidocaine, verapamil, beta-blockers , and sotalol have low efficacy in reversing sustained ventricular tachyarrhythmias and should be avoided in CCCD or used only as secondary options in a few contexts.Once sustained ventricular tachyarrhythmia is controlled or the cardiac arrest is reversed, the subsequent treatment is aimed at preventing relapse and, mainly, sudden death. Despite the high prevalence of CCCD in Latin America and the high fatality rate from those arrhythmias, there is no properly controlled RCT with proper sampling to finally clarify which is the best management to be adopted in each case. Regarding such management, some of the major options are the use of amiodarone, ICD implantation, catheter ablation, or an association of these therapies. The choice for the best option is based either on the results of observational studies or reports on CCCD records, which are very heterogeneous and conflicting, or still on data extrapolated from RCTs or guidelines on other cardiopathies, which have some inconsistencies and might not be applied to CCCD because of its peculiarities.\u201cOne-size fits all: what\u2019s good for the gander is good for the goose\u201d, that is, ICD for all patients as the ideal therapy to prevent sudden death, seems not to be the most appropriate in CCCD. Obviously, when we talk about sudden death prevention, we are actually referring to all-cause death, because sometimes one cannot distinguish the exact mechanism of death (adjudication error might exist), and there is no use in a treatment that prevents sudden death without reducing total mortality, because it would be only modifying the mode of death.Thus, the strategyIt is worth noting that, as compared to ischemic and nonischemic heart diseases of other etiologies, patients with CCCD treated with ICD for secondary prevention tend to have higher LVEF, higher spontaneous ventricular arrhythmia density and complexity, higher number of both appropriate (shock and antitachycardia therapy) and inappropriate ICD therapies, shorter time for the first appropriate shock after implantation, most frequent electrical storms, and shorter survival free from ICD therapy, factors that can influence the choice of treatment. Regardless of the type of heart disease, LVEF is the major factor to determine the prognosis and selection of the most suitable therapy.Because of its high antiarrhythmic efficacy, low incidence of proarrhythmia and of intolerable side effects, mainly when used at lower dosages, in addition to its good safety profile, even when administered to patients with ventricular dysfunction, amiodarone (introduced in Brazil more than four decades ago) is considered the first choice for the treatment of patients with CCCD and high-risk ventricular arrhythmias.et al.were the first to study the impact of antiarrhythmic drug treatment on the evolution of patients with CCCD. They have analyzed the survival curve of 34 patients with monomorphic SVT empirically treated with amiodarone, isolated or in association with other antiarrhythmic drugs, and compared it with the curve of another cohort of 42 patients not treated or treated with procainamide or quinidine, the only drugs available then. Those authors have reported a significantly higher survival in the group treated with amiodarone. After 1, 4, and 8 years of follow-up, survivals were 87%, 65%, and 59%, respectively, for the group treated with amiodarone, and 57%, 22%, and 7%, respectively, for the group not treated or treated with those class I antiarrhythmics (p < 0.01).Rassi Jret al.have also reported long-term results with the empirical use of amiodarone in Brazil in a cohort of 35 patients with CCCD and sustained ventricular tachyarrhythmia . The mean age was 50 years, mean LVEF was 41%, 68.5% of the patients were of the male sex, and 86% were in functional class I/II. After 27 months, the probabilities of SVT recurrence were 38%, 44%, and 56% in the 1-year, 2-year, and 3-year follow-up, respectively. The cardiac mortality rates were 4%, 11%, and 18%, and the sudden death rates were 0%, 4%, and 11% in the 1-year, 2-year, and 3-year follow-up, respectively. It is worth noting that all patients in functional class III or IV and with LVEF < 30% had SVT recurrence, and the cardiac mortality in that group was 80%. However, only 30% of the patients in NYHA functional class I/II and with LVEF > 30% had recurrence of SVT (p < 0.05) and none died. The mean dose of amiodarone, by the end of the study, was 356 mg/day and 15 (43%) patients reported side effects.Scanavaccaet al.have assessed the role of programmed ventricular stimulation to predict the long-term efficacy of class III antiarrhythmics. Those authors have studied 115 patients with CCCD and sustained ventricular tachyarrhythmia . Mean age was 52 years, mean LVEF was 49%, 60% of the patients were of the male sex, and 83% were in functional class I/II. Based on the EPS results, after loading with amiodarone (78 patients) or sotalol (37 patients), the patients were divided into three groups: group 1 \u2013 no SVT induction (20%); group 2 \u2013 hemodynamically stable SVT induction (39%); and group 3 \u2013 hemodynamically unstable SVT induction (41%).LeiteAfter a mean 52-month follow-up, total mortality was 39.1% (9%/year), significantly higher in group 3 than in groups 2 and 1 . The SVT recurrence was significantly smaller in group 1 than in groups 2 and 3 . Thus, in patients with SVT and relatively preserved LVEF treated with class III antiarrhythmics, EPS apparently identifies those at lower risk of death who could remain on drug treatment. However, for those with worse prognosis, ICD could be an a more appropriate option based on those observations.et al.,studying the predictors of mortality in 56 patients with CCCD and VT (SVT in 28 and NSVT in 28), have identified only LVEF as an independent marker of poor prognosis: LVEF < 40% increases the risk of death by 12 times (p = 0.0001). The most accurate cutoff points for sudden death and total death were LVEF of 40% and 38%, respectively. In the 28 patients with SVT, all empirically treated with amiodarone (when ICD implantation was not available), mean age was 54 years, mean LVEF was 42%, 64% were of the male sex, 100% were in functional class I/II, 43% had history of syncope, and the survival rates after 1 and 3 years of follow-up were 85% and 67%, respectively.SarabandaAdverse effects with amiodarone include corneal microdeposits, sinus bradycardia, AVB, QT interval prolongation, dermatologic effects (photosensitivity and blue skin discoloration), thyroid dysfunction , pulmonary toxicity, and, less commonly, hepatotoxicity. Late neurological side effects, such as tremors, paresthesia, and ataxia can occur.Pulmonary toxicity is the most severe and potentially fatal complication of amiodarone. Pulmonary impairment secondary to amiodarone manifests as interstitial pneumonia (most frequent) or eosinophilic pneumonia, organized pneumonitis, acute respiratory failure, or diffuse alveolar hemorrhage. The initial symptoms are dyspnea and dry cough, with or without fever. The chest X-ray shows diffuse or localized, reticular or consolidated opacities. Chest tomography shows interstitial impairment and bilateral diffuse opacities.The first reports on pulmonary toxicity indicated a prevalence ranging from 5% to 15% when maintenance doses \u2265 400mg/day were regularly administered. Currently, with the reduction of the dose to 200mg/day, the incidence ranges from 1% to 5%. The most important risk factors for pulmonary toxicity are, in addition to the high daily doses of amiodarone (\u2265 400mg), higher cumulative doses (long periods of administration), previous pulmonary disease, thoracic surgery, and pulmonary angiography.In a meta-analysis with four studies involving a total of 1465 patients, there was no significant difference in the occurrence of pulmonary toxicity in patients receiving amiodarone at a low dose (defined as 150-330 mg/day) as compared to placebo.In another meta-analysis with 43 studies and 11 395 patients, the relative risk for adverse pulmonary events secondary to the use of amiodarone was 1.77, at doses \u2265 300 mg/day and clinical follow-up > 12 months. Doses lower than 300 mg/day were not associated with the increased incidence of pulmonary complications as compared to placebo.In another study, however, even doses lower than 200 mg/day were associated with an increase in pulmonary alterations. Thus, patients on amiodarone should receive the lowest effective dose and undergo clinical and laboratory monitoring periodically and systematically.The initial oral doses of amiodarone for individuals on outpatient care should range from 400 to 600mg/day, until the cumulative attack dose of 6-10 grams is achieved. For in-hospital patients, the attack doses can range from 400 to 1200 mg/day. Maintenance should be individualized, and the lowest effective dose determined.In that short follow-up, 42% of the patients received appropriate shocks and 15.7% experienced electrical storms, numbers much higher than those of individuals with ICD and other heart diseases . The mean LVEF of patients with CCCD treated with an ICD was 40 \u00b1 11%, indicating that a significant part of that subpopulation did not have severe ventricular systolic dysfunction.In individuals with ICD, multiple shocks, either appropriate or not, and electrical storms are common in CCCD and affect the patient\u2019s prognosis and quality of life. An observational study has reported the evolution of 89 patients with CCCD and ICD, most of whom due to secondary prevention, for a mean 12-month period.The OPTIC study, which has not included patients with CCCD, has shown the superiority of the association of amiodarone and beta-blockers to prevent shocks as compared to sotalol or any other beta-blocker used in isolation.Empirically, that pharmacological association can be indicated to prevent the recurrence of shocks in patients with ICD and CCCD.The association of amiodarone with beta-blockers  is considered to have the highest potential to reduce arrhythmic death and the number of both appropriate and inappropriate electrical shocks delivered by the ICD.The recommendations for the pharmacological management of cardiac arrhythmias and sudden death prevention in CCCD are shown inIn HFrEF, the prevalence of AF increases with the functional class (NYHA) aggravation, ranging from 4.2% in class I to 49.8% in class IV.The appearance of AF associates with increased all-cause mortality in patients with HF of any etiology, including CCCD.Atrial fibrillation and HF frequently coexist. According to the Framingham Heart Study, approximately 40% of the patients with AF develop HF and vice-versa.However, the prevalence of AF in CCCD does not seem to be higher than that in other structural cardiomyopathies.The prevalence of AF in CCCD is increased as compared to that in the general population. A meta-analysis of 49 studies, including 34 023 patients, has revealed that the prevalence of AF in CCCD was twice that in the general population.The pharmacological treatment of AF in CCCD is hindered by systolic biventricular dysfunction, as well as by electrical automatism and dromotropism disturbances. Thus, optimization of the HF therapy is mandatory, and the use of ACEI or ARB in HFrEF can reduce the incidence of AF.The initial management of patients admitted to the emergency room with AF of high ventricular response is to control HR and anticoagulation with proper medications. Then, indication for arrhythmia reversion should be assessed.The ventricular rate of AF in patients with CCCD is often low, but, if hemodynamic instability with tachycardia occurs, the most appropriate management can be immediate anticoagulation, followed by electrical cardioversion. Symptomatic, but stable, patients with AF for less than 48 hours, without mural thrombi detectable on transesophageal ECHO, can undergo cardioversion with propafenone or amiodarone. Patients with AF duration \u2265 48 hours or unknown, or refractory AF history, should initially undergo anticoagulation and be medicated for HR control. Asymptomatic patients and/or with low HR and those with intense atrial dilatation usually should be only anticoagulated.11.1.11.1. Reversion to Sinus RhythmAmiodarone can be especially indicated when, in addition to AF, patients with CCCD have ventricular arrhythmias, which is usually observed.The strategy of AF reversion is usually more appropriate when AF is of recent onset, occurs in younger patients, is very symptomatic, with little atrial dilatation and high ventricular response. When HF develops or worsens, rhythm reversion with amiodarone or even catheter ablation might be necessary.11.1.11.2. Heart Rate ControlThe chronotropic control strategy, without reversion to sinus rhythm, is usually more indicated in the presence of long-duration AF or large dilatation of the chambers and in very old patients with multiple comorbidities and recurrence of arrhythmia. When beta-blockers are not sufficient to control ventricular response, the addition of digoxin can be considered. It is worth noting that calcium channel blockers are contraindicated in patients with HFrEF. Amiodarone can be occasionally used for chronotropic control when beta-blockers and calcium channel blockers are contraindicated, and catheter ablation is not possible.The recommendations for the pharmacological treatment of AF in CCCD are shown inThe inflammatory processes, necrosis and fibrotic reaction, that follow the severe disorganization of myocardial architecture and structure in CCCD affect not only the contractile fibers, but also the autonomic nervous system and the tissue that generates and conducts the electrical impulse in the heart.All degrees of AVB are commonly found and can be asymptomatic or cause lipothymia, syncope, and even HF or sudden death.According to the Brazilian Pacemaker Registry, CCCD is the first cause of AVB in Latin America, accounting for approximately 25% of PM indications.Sinus node dysfunction occurs early in CCCD. The sinus node replacement with fibrotic reaction determines different expressions of the sinus node disease, its most frequent manifestation being sinus bradycardia. In addition, CCCD causes intraventricular blocks, of which isolated or LAFB-associated RBBB predominates.Sinus node disease and TAVB are the bradyarrhythmias most commonly treated with PM implantation in patients with CCCD.The indication of PM implantation for patients with TAVB due to CD, since its beginning in the 1970s, can be considered as obeying the extreme plausibility principle. In fact, the evidence of the clear benefit of PM implantation consists solely in the observational study historically comparing the survival curves of 147 patients followed up before the PM appearance  with those of 74 patients followed up after the PM appearance .The prevalence of the PM use in patients with CCCD has been reported in a few cohorts, with rates ranging from 3.5% to 14.1%.Few studies have reported on the anthropometric and epidemiological characteristics or mortality predictors of patients with CCDC and a PM. A prospective cohort study published in 2018 included 396 patients with a PM followed up for, at least, 24 months. Their mean age was 62.5 \u00b1 12.0 years, and most were of the female sex (64%). Approximately 95% of the patients were in NYHA functional class I or II. Approximately 75% had advanced AVB as the indication for PM implantation, and RV stimulation occurred in 82.2% of the cases. The annual mortality rate was 8.4%.It is worth noting the potential protective role of avoiding unnecessary ventricular stimulation and of considering the indication for direct stimulation of the conduction system, which is a more physiological modality, but that has not been properly tested in CCCD.In general, the indications for PM implantation in CCCD do not differ from the classical ones applied to heart diseases of other etiologies.11.2.2.1. Primary Prevention of Sudden Cardiac Deathalready discussed in another chapter of this guideline.The success of primary prevention of sudden cardiac death relates to the identification of individuals at high risk for the event. The risk stratification of total mortality, which is mainly sudden in patients with CCCD, relies on a tool of simple and rapid use, the RASSI score,The impact of this new factor is detailed in that same chapter of this guideline, in the general context of risk stratification and its relationship with the RASSI score.Recently, relevant additional evidence of the role of myocardial fibrosis in the identification of high-risk individuals with CCCD has been presented. The quantification of myocardial fibrosis > 12.3g has been reported as an independent risk factor for the combined outcome of all-cause mortality, CTX, antitachycardia stimulation or appropriate ICD shock, and aborted sudden cardiac death.The structural abnormalities of CCCD, characterized by inflammation, cellular death, and reactive or reparative fibrosis, are the anatomic substrate more likely to trigger sudden cardiac death, because they create slow conduction areas and unidirectional blocks prone to the occurrence of electrical reentry. The VEs, frequent in CCCD, act as triggers of those circuits, resulting in VT/VF.The study of the correlation between the CCCD stages and the mortality causes has revealed that sudden cardiac death usually affects patients from the stage B on, being onward more relevant in stage C and a little less in stage D, in which refractory HF is the cause of most deaths. In general terms, the major mechanism of sudden death in CCCD is arrhythmogenic, and SVT (subsequent VF) accounts for most lethal events.The scientific evidence regarding primary prevention of sudden cardiac death in CCCD by using antiarrhythmic drugs  is scarce and has already been discussed. Regarding ICD, there is only the report of the findings of a series of 13 patients, not allowing conclusions on therapeutic efficacy.et al.have conducted a study with 78 patients with NSVT and syncope or presyncope  with a mean follow-up of 56 months. Those authors have shown that the induction of monomorphic SVT in 25 patients (32%), all subsequently treated with amiodarone, was a predictor of spontaneous VT and of cardiac and total mortality.Although the role of programmed ventricular stimulation in risk stratification of patients with CCCD has not been well established, Silvaet al.have shown that, in patients with NSVT and induced SVT (n = 37) or with spontaneous SVT (n = 78), the EPS could predict the long-term efficacy of class III antiarrhythmic drugs (mainly amiodarone). Immediately after oral loading with antiarrhythmic drugs, the induction of hemodynamically unstable SVT was related to higher total, cardiac, and sudden mortality when compared to patients in whom arrhythmia could not be induced or the arrhythmia induced was well-tolerated SVT.In addition, as already reported in this guideline, LeiteThese two studies, although observational, suggest that the EPS could identify patients with ventricular tachyarrhythmias, who, once treated with antiarrhythmic drugs, would evolve to worse prognosis and higher risk of death, and, in such cases, ICD could be a feasible alternative.It is a multicenter, open RCT designed to compare the effects of ICD with amiodarone for primary prevention of mortality in CCCD, in patients with NSVT on 24-hour Holter and RASSI score \u2265 10 points. The indications for ICD implantation in primary prevention of sudden cardiac death are shown inBriefly, so far, there is no scientific evidence supporting the use of ICD, with strong recommendation, for primary prevention of sudden cardiac death in CCCD. The ongoing CHAGASICS trial should soon provide relevant information.11.2.2.2. Secondary Prevention of Sudden Cardiac DeathThe ICD is usually considered a resource to be used in some contexts of secondary prevention of sudden cardiac death for patients with CCCD. Its efficacy consists in the interruption of the life-threatening arrhythmic event by use of electric shock or rapid ventricular stimulation (antitachycardia), preventing the occurrence of cardiac arrest and subsequent death, although some arrhythmias aborted by the ICD could revert spontaneously, not necessarily culminating in death. The choice of this therapeutic option involves the thorough analysis of five essential factors: 1. duly documentation of the arrhythmic event causing the cardiac arrest (SVT or VF) and its correlation with irreversibility of the cause; 2. conviction that less invasive clinical therapy and/or procedures, of similar efficacy, have failed; 3. certainty that the underlying heart disease is being fully treated; 4. appreciation of the underlying cardiomyopathy risk stratification; and 5. patient\u2019s clinical condition, expressed mainly by the ventricular dysfunction (LVEF) grade and the arrhythmia-related symptom type.single-center observational clinical studies assessing small population samples,and meta-analyses of those studies.These factors have received little attention in studies of secondary prevention of sudden cardiac death in CCCD. There is no RCT in that population and the scientific evidence is limited to data from records from manufacturers of implantable devices,The largest cohort of patients with CCCD treated with ICD implantation for secondary prevention in a single center has enrolled 116 consecutive patients, 62% of the male sex, and mean age of 54 years. The mean LVEF was 42%, 83% of the patients were in NYHA functional class I/II, and the reason for ICD implantation was resuscitation from cardiac arrest in 18% and symptomatic SVT in 82% of the cases. In a mean 45-month follow-up, the following was reported: annual total mortality rate of 7.1%; appropriate therapies in 50% and inappropriate in 11% of the population. The independent factors of worse prognosis were NYHA functional class III and low LVEF. Patients with RV stimulation rate over 40% also had shorter survival.On the other hand, in a retrospective cohort of 90 consecutive patients with CCCD  treated with ICD implantation, 30% of whom had preserved cardiac function, in a mean 756-day follow-up, the annual mortality rate was high (16.1%). Of the patients who died, 88% were in functional class I at the time of ICD implantation. Although 65% of the patients experienced appropriate shock and antitachycardia therapy, the monthly rate of shocks was the only independent predictor of mortality.A 72% reduction in total mortality and a 95% reduction in sudden cardiac death were reported in the cohort treated with ICD. However, when subgroup analysis was performed, there was a significant interaction between LVEF and benefit from ICD. While patients with reduced LVEF (< 40%) had a significant and expressive benefit with ICD, those with relatively preserved LVEF (\u2265 40%) had little or no benefit.The mortality rate of another retrospective cohort of 76 patients with CCCD and ICD has been compared to that of a historical series of 28 patients with SVT treated only with amiodarone.These data are consistent with the results of a meta-analysis of RCTs of secondary prevention in other heart diseases , which showed a reduction in total and sudden mortality with ICD (as compared to amiodarone) only in patients with LVEF < 35%.It is worth emphasizing that a meta-analysis including that study and other five observational studies in CCCD has shown no difference in total mortality between the use of amiodarone (9.6%/year) and ICD (9.7%/year).Recently, a systematic review and meta-analysis has been published including 13 observational studies on CCCD to reassess the global efficacy of ICD to prevent total and sudden death. It included 1041 patients, 92% of them in secondary prevention and only 8% in primary prevention, with mean age of 57 years, 64% of the male sex, mean LVEF of 38%, 79% in functional class I/II, 79% on amiodarone, and 44% on beta-blockers. In a 2.8-year follow-up, total mortality rate was 9.0% per year, and, in a 2.6-year follow-up, sudden cardiac death rate was 2.0% per year. Appropriate ICD therapies (shocks or antitachycardia interventions) occurred in 24.8% of the patients, annually. High rates of inappropriate shocks (4.7%/year) and arrhythmic storms (9.1%/year) have also been observed.et al.have compared the clinical evolution of two groups of patients: group 1, with 318 patients, 36% of whom had CCCD, whose cause of ICD implantation was symptomatic SVT (syncope and/or hemodynamic instability) or SVT induction on EPS in patients with recurrent syncope of unknown etiology; and group 2, with 97 patients, 15% of whom had CCCD, whose cause of ICD implantation was resuscitation from cardiac arrest due to VF or pulseless SVT. While sex  and NYHA functional class I/II (77%versus76%) did not differ between groups 1 and 2, the mean age was higher  and the mean LVEF was lower  in group 1. After a mean follow-up of 24 months for group 1 and of 26 months for group 2, mortality was higher in group 2 , and both groups experienced appropriate ICD shocks similarly , which might indicate higher arrhythmia severity in the subgroup of patients resuscitated from cardiac arrest.Regarding the prognosis of the arrhythmia types that usually indicate the need for ICD implantation, Limaet al.have assessed the impact of syncope on total and cardiac mortality of 78 patients with monomorphic SVT . Syncope during SVT was observed in 45 patients (58%), but not in 33 patients (42%). After a mean 49-month follow-up, neither total (33%versus39%) and cardiac mortality (27%versus30%), nor nonfatal SVT recurrence (58%versus54%) differed between patients with and without syncope, respectively. However, the presence of syncope during recurrences was significantly higher among patients who had that symptom initially . Thus, in CCCD, syncope during monomorphic SVT seems not to be associated with an increase in total and cardiac mortality.In another study, LeiteGiven the set of results summarized in the previous paragraphs, one can conclude that more scientifically based evidence is still necessary to support the use of ICD for secondary prevention of sudden cardiac death in patients with CCCD. This should ideally be solved with the conduction of an RCT. However, several researchers claim to have ethical concerns about adopting that scientific path, and currently there is no perspective on that.Others have claimed that there is large positive experience built up over the years with the use of protocols supported by international and national guidelines for patients with ICM or DCM treated with ICD implantation. This created a scenario favorable to the extrapolation of those rules to clinical practice, so that patients with CCCD would be more liberally treated with ICD. However, secondary prevention with ICD implantation in CCCD should be always supported by a thoughtful individualized decision-making with risk/benefit analysis.That general principle derives from two essential notions. The first is that even in scenarios supported by international guidelines for patients with other cardiopathies, the benefit of ICD is relatively restricted to the existence of severe ventricular systolic dysfunction, being less significant in the absence of that factor. The other one, already mentioned, is that the complex and peculiar pathophysiology of CCCD implies that therapeutic principles only partially validated for other cardiopathies can hardly be properly extrapolated to CCCD. Therefore, both LVEF, considering the ideal cutoff point of 40%, and the type of arrhythmia and symptom associated have been used to better support the indications of ICD for secondary prevention of sudden cardiac death.for the treatment of ventricular arrhythmias explicitly mentioned CCCD and restricted the indications for ICD in that context, very similarly to our recommendations.Of note, by the time this guideline was being finished, a recent publication of the European Society of CardiologyThere are no solid data from RCTs to support the use of cardiac resynchronization therapy (CRT) in CCCD. The CRT has been recommended to patients with DCM and ICM, presenting with advanced HF, severe systolic dysfunction, and ventricular dyssynchrony, mainly represented by a widened QRS complex. The CRT has been described as acting positively on LV remodeling, promoting a significant reduction in the functional class of HF, and improving quality of life, based on several other functional parameters.especially in the presence of LBBB, LVEF \u2264 35%, QRS duration \u2265 130ms, and mitral regurgitation.However, in CCCD the prevalence of LBBB is low, which limits the formal indication of CRT in that scenario. The presence and extension of myocardial fibrosis, which is associated with a worse prognosis regardless of LVEF,as well as frequent ventricular arrhythmias, tricuspid regurgitation, and RV dysfunction are examples of other factors that do not favor CRT in CCCD and that can increase the patients\u2019 risk of nonresponse.Some studies have evidenced a benefit of CRT regarding HF mortality reduction,Importantly, the implantation of the conventional (single-chamber) PM, often used in CCCD, causes LV dyssynchrony (\u201cinduced LBBB\u201d) mainly when the lead is placed in the RV apical region. This is associated with hemodynamic impairment and worsens the prognosis of patient with HF treated with PM.have assessed the clinical course of patients with CCCD undergoing CRT, and three of themhave compared the effect of that therapy in CCCD with that in other cardiopathies  cause myocardial damage and varied disorders at all levels of cardiac electrical impulse generation and conduction.These areas of fibrosis (scars) can be located in the LV subendocardial, intramyocardial, or subepicardial regions.In addition, an isthmus of viable myocardium between the mitral annulus and a scar in the LV inferolateral region can form a macroreentrant circuit of SVT.Finally, a macroreentrant circuit involving the right and left branches (bundle branch reentry) can be the least common cause of SVT.The fundamental electrophysiological mechanism of SVT in CCCD is usually the electrical stimulus reentry in the ventricular scar, constituted by extensive interstitial fibrosis intermingled with viable myocardial fibers. This is more frequent in the LV inferolateral region (70% of the patients), but can also occur in the LV apical region or in the right ventricle.In general, the different reentrant mechanisms of SVT have been thoroughly investigated by use of invasive EPS, in which the programmed ventricular stimulation can reproduce that arrhythmia in more than 80% of the patients with clinical history of SVT or syncope and CCCD. In addition, endocardial and/or epicardial mapping has shown abnormal diastolic, presystolic, and mid-diastolic electrograms, predominating in the regions of LV akinesia and dyskinesia.In addition to fibrosis in circumscribed ventricular wall regions, the intracardiac autonomic nervous system injury, characterized by ganglionic neuronal depletion and cardiac dysautonomia, and the chronic myocardial inflammation are pathophysiological changes that can contribute to myocardial electrical instability and genesis of ventricular tachyarrhythmias.During EPS using ventricular stimulation techniques , the critical isthmus of the reentry circuit can be differentiated from the other regions not involved in the VT mechanism, which can be confirmed by the interruption of VT during radiofrequency ablation.and HF (which should have its specific treatment optimized), requiring, in order to program ablation, the assessment of kidney function, the presence of infection, and the need for vasoactive drugs in cases of electrical storm. Usually, the presence of comorbidities should not contraindicate ablation, mainly in cases of electrical storm and recurrent shocks, because, without the intervention, mortality is very high.Patients with CCCD and SVT usually have advanced heart diseasePAINESD risk score has been developed to identify patients that might have hemodynamic decompensation during VT ablationand higher post-procedure early mortality. Because the original cohort included patients with ischemic and nonischemic cardiopathies, except CCCD, it cannot be used to predict 30-day mortality after VT ablation.TheThe approach for ablation should be preferably epicardial;however, in the presence of megacolon, the access to the pericardial space must be obtained through a surgical window or laparoscopy-guided puncture.In addition, patients with CCCD can have megaesophagus and/or megacolon.and to assess whether the target substrate is located on the epicardial or endocardial surface.Coronary computed tomography angiography can identify the areas of thinningand hypoperfusion, which are associated with the arrhythmia substrate. Both CMRI and coronary computed tomography angiography assess the local epicardial fat thickness and location of the coronary arteries, allowing integration with the electroanatomic mapping systems.Late gadolinium enhancement on CMRI is useful to identify areas of myocardial fibrosisThese images enable integration with electroanatomic mapping systems and contribute to a successful ablation,which becomes faster and more effective, thus eliminating the need for electroanatomic mapping reconstruction.Recently, some software for processing 3D images from CMRI have been developed, allowing the definition of potential circuits of arrhythmia.This is a valid concept although ECG has limitations to define epicardial VT.Another important point in the ablation planning is the 12-lead ECG assessment during clinical VT, which, whenever possible, should be recorded. This allows comparison with procedure-induced VTs, being important in the search for elimination of clinical VT, given that patients with CCCD usually have multiple morphologies of VT.Frequently, patients with CCCD have recurrences after VT ablation, requiring multiple procedures to be performed. Information on the previous procedures is fundamental to plan the new ablation. It is worth noting the following: the maps of previous procedures should be assessed and compared to the current one; the presence of an endo- or epicardial scarring area not approached in the previous procedure should be assessed; and information on bleeding during the previous epicardial access should be obtained, because, if affirmative, epicardial adherence can occur.Thus, radiofrequency ablation is indicated in many cases refractory to clinical treatment.The recurrence rates of VT episodes in individuals with CCCD are high, even after optimized drug therapy. A recent meta-analysis has reported rates of appropriate therapies and electrical storm of 9% and 25% per year, respectively, in patients with ICD for secondary prophylaxis.A myocardial scar that propitiates reentry and SVT is usually located in the basal portions of the inferior and lateral LV walls, and mid-myocardial and epicardial impairment is frequent. Thus, the initial results of VT ablation with endocardial approach are frustrating with success rates around 17%.and has contributed to optimize the results of VT ablations in patients with CCCD. In an RCT, the combined endocardial/epicardial approach, as compared to the exclusively endocardial one, showed a lower rate of recurrence, 40% and 80%, respectively, in a 2-year follow-up.Epicardial access by use of percutaneous subxiphoid puncture with fluoroscope-guided Tuohy needle was described in 1996The most feared complication related to percutaneous epicardial access is bleeding, which can occur in approximately 10% of the cases. Most bleedings are small and related to accidental RV puncture. Massive bleeding requiring surgical approach occurs in 2% of the cases. Hepatic and intestinal lesions can occur during epicardial puncture in the presence of significant hepatomegaly and megacolon. In these cases, pericardial access through either surgery or videolaparoscopy-guided subxiphoid puncture can be chosen.insufflation of carbon dioxide (CO2) in the right atrial appendageor coronary sinus;needle embedded with a real-time pressure monitor;computed tomography;CMRI;and puncture guided by electroanatomic mapping.Of these, it is worth noting that, in a multicenter observational study, micropuncture has shown lower rates of massive pericardial effusion and of need for surgical correction of bleeding, as compared to the puncture technique with a high caliber needle.In recent years, the following variations of the original epicardial puncture technique have appeared: micropuncture;Some situations can limit the efficacy of ablation on the epicardial surface, such as an ablation target region located under the epicardial fat or close to the trajectory of the phrenic nerve or coronary arteries.Because of disease severity and procedural complexity, perioperative care is important to reduce the risk of complications. The search for previous intracavitary thrombi is mandatory, while invasive blood pressure monitoring, infusion of vasoactive drugs prior to anesthesia induction, and mechanical circulatory support in selected cases are useful to perioperative hemodynamic optimization.Catheter ablation can be performed with the patient in VT or sinus rhythm. Each strategy has advantages and disadvantages and there is no study comparing the results in a population with CCCD. Although the procedure performed in a patient in VT favors the identification of tachycardia isthmuses more accurately, most induced VTs are poorly hemodynamically tolerated and warrant immediate electrical cardioversion.However, even in hemodynamically stable VTs, the mapping time should be maximally shortened due to the risk of low cardiac output post intervention. Catheter ablation in a patient in sinus rhythm is aimed at modifying the substrate, which consists in the identification and elimination of possible tachycardia isthmuses. These areas are related to myocardial scarring, which is identified as a low-voltage region in the electroanatomic mapping system and represented by late, fragmented, and low-amplitude potentials. Although less specific, this technique has the advantage of maintaining the patient hemodynamically stable for a longer period during the procedure, when there is severe ventricular dysfunction.Of note the technological evolution of the electroanatomic mapping system, mainly the high-definition mapping catheters, significantly increased the accuracy of the anatomical definition of scar regions, in addition to its functional correlation with electrical propagation. However, studies related to VT ablation in patients with CCCD are scarce and practically do not contemplate the currently available technology.However, varied definitions of non-inducibility  associated with the spontaneous daily variation in the results of programmed ventricular stimulation represent relevant limitations and deficiencies in the accuracy of this tool to predict the short- and long-term success of ablation.Historically, programmed ventricular stimulation has been used as the major tool to assess the immediate effectivity of the VT ablation procedure.Patients who remain with slow VT (cycle > 300ms) induced at the end of the procedure more often have recurrence than those without induced VT.Other strategies to assess the procedure\u2019s result during ablation include verifying the elimination of excitability,late potentials,local abnormal ventricular activities (LAVA),and scar channels,in addition to checking substrate homogenization,central isolation of the scar,and lesion by use of imaging guidance.Despite those limitations, programmed ventricular stimulation at the end of the procedure remains the major tool to assess the immediate ablation success.The acute complications include the vascular ones, pericardial effusion, cardiac tamponade, electromechanical dissociation, TAVB, phrenic nerve paralysis, stroke, and death.This recurrence rate was similar to that of VT ablation in patients with nonischemic cardiopathies in general.Recently, a prospective RCT on VT ablation in a small group of patients with CCCD has reported the superiority of the systematic epicardial/endocardial approach over the exclusively endocardial one, with 40% VT recurrence in a mean 19-month follow-up in the first group.All available means for the detection of SVT episodes should be used, including an ICD monitoring zone, capable of detecting slow SVT induced during ablation. In addition to recurrence of any SVT, the follow-up should record the density of arrhythmias, occurrence of electrical storm, hospitalizations, and cardiac and noncardiac death.Post-ablation VT recurrence depends on several factors, the most common being related to the use of antiarrhythmic drugs, programming of implantable cardiac devices, and cardiomyopathy severity.In most cases, mortality due to thromboembolic phenomena is related to cerebral and pulmonary embolisms. Considering that neurologic events are usually the most expressive clinical manifestations, the cerebral thromboembolic complications are most frequently detected in medical practice.Thromboembolic complications represent a heterogeneous group of clinical manifestations associated with CCCD, corresponding to one of its three essential mechanisms of death alongside HF and sudden death.Cardioembolic stroke can be the first clinical manifestation of CCCD, occur even in early stages of the disease, affect individuals of several age groups, and new episodes can frequently occur when secondary prophylaxis is not established. The clinical manifestations are usually due to embolism of intracardiac thrombi that, because of their dimensions, have a high potential of obstructing the proximal circulation in the central nervous system, being usually associated with severe and disabling neurological sequelae if not leading directly to death.In those studies, thromboembolic phenomena were more common in the systemic circulation and caused relatively more deaths due to pulmonary embolism.The incidence of cardiac thrombi was higher in the HF clinical syndrome (36%) than in cases of sudden death (15%), with relationship to neither age nor sex.Postmortem studies have shown a variable frequency of cardiac thrombosis in CD, with prevalence ranging from 27% to 79% and a slight predominance of impairment of the right chambers over the left ones .In addition, apical aneurysm is a relevant factor, being present in 53.2% of 148 autopsies, of which 36.8% would be complicated by localized thrombosis, while only 11.1% of the hearts without apical aneurysm had intracavitary thrombi.Another study, involving 1153 autopsies, identified the presence of apical aneurysm in 52% of the cases,predominating in the male sex.Endocardial inflammatory lesions and intracavitary blood stasis are considered important factors in the pathogenesis of parietal thrombosis in the heart, related to the occurrence of multiple thromboembolic phenomena and high risk of death due to embolism.et al.have reported the presence of intraventricular thrombi in only 14.5% of the cases. The low frequency of thrombi described in that study could be attributed to the lower sensitivity of the assessment method as compared to postmortem studies, which, in addition, were probably performed in more advanced phases of the disease.In a prospective observational study of 55 patients with CCCD and apical aneurysm assessed by use of cine ventriculography, Albanesi FilhoRegional ventricular dyskinesias, mainly apical, are a major characteristic of CCCD, in which their prevalence is higher as compared to that in other etiologies, thus predisposing to the formation of mural thrombi and embolic events, especially systemic ones.Similarly to other cardiopathies, cardiac dilatation and HF are well-known risk factors for the occurrence of thromboembolic events. Atrial fibrillation, a relatively late manifestation and usually associated with ventricular dysfunction, is an additional thrombogenic factor in that cardiopathy.The presence of severe myocardial dysfunction, LV apical lesion, intracavitary thrombi, previous thromboembolic phenomena, dilatation of the cardiac chambers, and HF has been associated with a higher risk of thromboembolic accidents in anatomopathological and clinical studies.Regarding pulmonary embolism, most events originate in the right cardiac cavities, differently from other cardiopathies, in which the thrombi commonly originate from the lower limbs.Pulmonary embolic phenomena are clinically underestimated in CCCD, considering their high prevalence in postmortem examinations,the same occurring with noncerebral systemic embolisms. Pulmonary thromboembolism can affect up to 37% of patients with HF, but it is rarely reported in patients without HF. In 85% of the cases, it associates with mural thrombosis of the right cardiac chambers.The mortality associated with thromboembolic events in CCCD is usually related to cerebral and pulmonary embolisms, with more than one arterial territory commonly affected.et al. in 1953.In 1955, Rocha & Andrade described systemic thromboembolic phenomena in patients with CCCD.Systemic thromboembolism affects mainly the brain and can be the initial clinical manifestation of CD, associating with the presence of mural thrombi and LV apical aneurysm. Because of its higher clinical expression, stroke has been in the center of several investigations. Embolic stroke in CCCD was first reported by NussenzveigThe presence of CCCD is considered an independent risk factor for the occurrence of ischemic stroke. Case-control studies have shown that HF, arrhythmias on ECG, female sex, and LV apical aneurysm are independent risk factors for cerebral thromboembolism in patients with CD.In a study using transthoracic and transesophageal ECHO and assessing 75 patients, LV mural thrombi were found in 23% of the cases, in a clear association with the history of stroke. Apical aneurysm was identified in 47% of the patients and significantly related to mural thrombosis and stroke. Thrombosis of the left atrial appendage was identified in 4 patients, while thrombosis of the right atrial appendage, in 1 patient. There were 13 deaths in a 24-month follow-up, 7 of which were sudden, 5 due to HF progression, and 1 due to stroke. Differently from other cardiopathies, in CCCD, stroke was more frequent in patients with mild LV systolic dysfunction and NYHA class I.However, that incidence was significantly higher (60% per year) in patients with manifest HF, in whom LV apical aneurysm and LV mural thrombosis were observed in 23% and 37% of the cases, respectively. Overall, lumping all the case series, the prevalence of thrombosis of the right chambers (53%) exceeded that of the left chambers (43%).Two hospital case series have reported a low annual incidence (1% to 2%) of thromboembolic phenomena in patients with CCCD and mild to moderate ventricular dysfunction.Considering that CCCD also propitiates a proinflammatory and prothrombotic state, the association of those two diseases could act synergistically to potentialize the appearance of thromboembolic events.The COVID-19 pandemic, the disease caused by SARS-CoV-2, has evidenced higher predisposition of infected patients to arterial and venous thrombotic complications, because of inflammatory changes, those of the endothelial microcirculation and blood stasis.Therefore, ongoing studies are testing more aggressive antithrombotic therapies in those settings. Patient management when both infections coexist is addressed in a specific topic of this guideline.However, so far, there has been no clear evidence of more relevant clinical events in the association of both diseases. Nevertheless, interventional settings have reported that acute coronary syndromes in patients with COVID-19 tend to present later after symptom onset and with higher clinical severity.Even patients with CCCD without global ventricular dysfunction can have a significant increase in the risk markers of thrombosis, suggesting a prothrombotic state in the earliest stages of disease.As already discussed, patients with more advanced forms of CCCD are at higher risk for developing thromboembolic episodes because they are more susceptible to thrombus formation, due to the presence of venous stasis and low blood flow, dilatation of cardiac chambers, LV systolic dysfunction, and inflammatory vascular phenomena. Other factors, such as segmental hypocontractility and arrhythmias, especially AF, contribute to increase the risk for thromboembolism.T. cruzi-infected patients, as compared to noninfected ones, there was an excessive risk for stroke of approximately 70% .A systematic review of eight observational studies, involving 4158 patients, has evidenced the clear association between CCCD and the risk for stroke. That study has shown that, in chronicallyThe authors have proposed a risk score (IPEC-FIOCRUZ)for the stroke occurrence based on points and the indication for prophylaxis of embolic events, considering the presence of LV systolic dysfunction (any grade and location - 2 points), apical aneurysms (1 point), primary alterations of ventricular repolarization on ECG (1 point), and age > 48 years (1 point). Patients with 4-5 points were considered at high risk for cardioembolic stroke. That analysis excluded the classical risk factors associated with cardioembolic complications in other cardiopathies, for which the indication of prophylaxis is already ensured, such as AF, intracavitary thrombi, and previous cardioembolic events. However, the frequency of events was higher than that in other cardiopathies in paired analyses for the same grade of systolic dysfunction, showing that CCCD is in fact a more thrombogenic entity.A prospective cohort of 1043 patients with CD (with and without cardiopathy), in a mean 5.5-year follow-up, has reported a 3% incidence of cardioembolic stroke, that is, 0.56% per year.Recent studies have suggested that atrial flutter and AF might be more frequent in CCCD than initially reported, and their prevalence increases in more advanced disease stages, accompanying the ventricular dysfunction worsening and being an additional thrombogenic factor.can be implicated in the ischemic stroke genesis of patients with CD. The recent increase in life expectancy of that population and changes in lifestyle, with contribution of the classical cardiovascular risk factors for atherosclerosis , make ischemic stroke one of the major causes of death in historical cohorts of patients with CD,although not always the cardioembolic mechanism is implicated.However, although cardioembolic complications are very frequent in CCCD and should always be assessed as a potential causal factor for ischemic stroke, other mechanisms, such as atherothrombotic or lacunar strokes, and, more rarely, several etiologies of vasculitis and coagulopathiesOccasionally, even the cardioembolic risk condition might not mean a manifestation of CCCD but be associated with the progression of cardiopathy in the elderly, also responsible for the increased incidence of AF. The precise causal nexus of stroke in the elderly and patients with multiple clinical comorbidities might not always be established. However, comprehensive care to patients should be considered the most relevant theme, and appropriate treatment and/or prophylaxis should be established in each situation.Stroke is defined as a usually focal neurological deficit, of sudden onset, lasting at least for 24 hours, of presumably vascular cause, occasionally followed by death. The presence of focal neurological signs and symptoms that disappear in less than 24 hours characterizes the transient ischemic attack (TIA). The diagnosis of stroke is based on clinical manifestations, with the presence of at least one of the following neurological changes: motor or sensory deficit, aphasia or dysphasia, hemianopsia, conjugate eye deviation, or sudden onset of apraxia, ataxia, or sensory perceptual deficit.They are characterized by signs of superior cortical dysfunction , homonymous hemianopsia , and motor deficit and/or sensory alteration of at least two body areas . Extensive cortical lesions usually cause all those neurological disorders, thus characterizing the total anterior circulation syndrome. Less extensive cortical lesions can lead to partial anterior circulation syndrome, with two of those three sets of neurological manifestations.In patients with CD, because of the predominance of cardioembolic stroke, symptoms of cortical manifestation are frequently observed and the anterior circulation syndromes, related to impairment of the territory of the middle and anterior cerebral arteries, are the most common.The posterior circulation syndromes, related to impairment of the posterior cerebral artery territory, such as the cerebellum and brain stem, are less frequent. These syndromes manifest with at least one of the following alterations: paralysis of the cranial nerves associated with contralateral sensory/motor deficit; bilateral sensory/motor deficit; conjugate eye deviation; cerebellar dysfunction without ipsilateral long-tract deficit; isolated hemianopsia or cortical blindness.The signs and symptoms of ischemic stroke secondary to atherosclerosis of the great vessels can be similar, and, thus, indistinguishable from those present in cardioembolic events regarding sensory/motor deficit, however without alteration of the cortical functions, such as speech or cognitive functions.mellitus.Lacunar strokes are characterized by the presence of sensory/motor deficits, which can occur in isolation or in combination, or by ataxic hemiparesis.Some patients can experience lacunar syndromes, usually related to the presence of other cardiovascular risk factors concomitant with CD, such as SAH and diabetesSilent ischemic stroke can occur in a significant proportion of patients with CCCD, having been reported in 18% of the individuals with CD included in a case-control study.When assessing acute stroke, computed tomography is the most cost-effective strategy, because it is a fast method largely available in most emergency services. The MRI is particularly useful to assess posterior circulation lesions, small cortical infarctions, lacunar infarctions, and mainly to analyze unusual images when there is doubt about the diagnosis of stroke.Brain computed tomography or MRI is recommended to confirm the diagnosis of structural lesions due to vascular events, to classify the type of event, and to exclude differential diagnoses.In patients with CD and diagnosis of stroke, the imaging tests show a predominance of cerebral lesions in the territory of the middle cerebral arteries, which is usually the most affected area in individuals with ischemic stroke. A large proportion of patients with CD and ischemic stroke of undetermined etiology have structural impairment of the territory of the cerebral artery lower branches, which can be associated with embolism from the heart, possibly due to anatomic and hemodynamic factors.Thus, investigation ofT. cruziinfection by use of serological tests should be considered in cases of ischemic stroke in patients from CD endemic areas or children of mothers at the same endemic risk, mainly in cases of cerebrovascular events secondary to thromboembolism or of undetermined etiology.The neurological signs and symptoms of stroke can be the first clinical manifestations of patients with CD.Cardiac arrhythmias, mainly atrial flutter and AF, LV systolic dysfunction, left atrial dilatation, apical aneurysm, and intracavitary thrombosis are associated with stroke in patients with CCCD.Thus, ECG and transthoracic ECHO at rest are recommended to investigate those risk factors. For patients with poor echocardiographic window for proper assessment of the LV apex, microbubble contrast ECHO and CMRI can be useful to identify aneurysms and mural thrombi in the region.Most patients with CD who develop stroke are known to have cardiomyopathy signs.In cases of embolic ischemic stroke whose thrombogenic source remains undetermined after initial assessment, additional diagnostic investigation can be made with 24-hour Holter monitoring and transesophageal ECHO. If the patient has a PM or ICD, the device\u2019s event recording can be assessed aiming to identify arrhythmias with the potential to produce embolization.mellitus, dyslipidemia, and smoking, in patients with CD can be high, mainly in those with ischemic stroke.In such cases, noninvasive investigation of atheromatous disease of the carotid and vertebral arteries by use of Doppler ultrasound, computed tomography angiography, or magnetic resonance angiography is recommended, mainly for patients with cerebral infarction related to the anterior cerebral circulation. In addition, transcranial Doppler can be useful in such cases.The concomitant prevalence of other risk factors for cardiovascular diseases, such as SAH, diabetesDifferential diagnosis with other rare clinical conditions, such as vasculitis and thrombophilias, in cases of clinical suspicion or when the diagnosis remains undetermined should be investigated by use of blood coagulation tests, with assessment of prothrombin time  and platelet count or specific search for other rare etiologies.The therapeutic management of ischemic stroke in CD depends on the time from symptom onset, comorbidities, and severity and extension of the ischemic area. The cerebral ischemia can present as TIA, silent cerebral infarctions, or ischemic stroke with mild or severe motor sequelae and hemorrhagic transformation, causing death, chronic cognition impairment or drastic physical limitation.1) Control of vital functions and temperature; 2) Management of SAH, avoiding hypotension and consequent cerebral ischemia worsening; 3) Control of hyper- or hypoglycemia; 4) Careful hydration and serum sodium level control; 5) Protection of the airways and swallowing, preventing infection from bronchoaspiration; 6) Early identification of hypoventilation, preventing CO2retention and hypoxemia by use of oxygen supplementation; 7) Prevention of deep venous thrombosis by use of heparin or its oral substitutes or mechanical methods of pneumatic compression when indicated; and 8) Determination of the cerebral damage extension by use of brain computed tomography or MRI to treat cerebral edema and identify the risk for or presence of hemorrhagic transformation, assessing suggestive symptoms, such as intense and persistent headache, sleepiness, decreased level of consciousness, in addition to worsening of the motor/sensory deficits.The initial therapeutic approach to stroke in CCCD is similar to that in other etiologies, aiming to stabilize and reduce damages, and prevent complications through admission to the specific intensive care unit for patients with stroke, where the following general measures should be observed:For acute and more severe cases presenting in the therapeutic window (time from symptom onset <4.5 hours) and with no contraindication, thrombolysis should be instituted, usually with intravenous rt-PA. If initial brain computed tomography suggests early hypodensity equal to or greater than one third of the middle cerebral artery territory, thrombolysis is contraindicated because of the high risk for hemorrhagic transformation. In specific cases, endovascular thrombectomy enables treatment with a larger therapeutic window, but still shorter than 24 hours.Frequent anticoagulation adjustments are necessary to maintain the target therapeutic range (INR between 2 and 3) and treatment should continue throughout life.After the acute phase of the ischemic event, oral anticoagulation with warfarin is the treatment established for the secondary prophylaxis of thromboembolic complications originated from the heart, in the presence of either arrhythmias or intracavitary thrombosis.More recently, meta-analyses comparing the new anticoagulants to warfarin in individuals with LV thrombosis associated with ICM or DCM have suggested that those drugs would have efficacy similar to that of vitamin K antagonists regarding frequency of thrombus resolution, and prevention of stroke or other thromboembolic events and hemorrhagic complications.This plausibility might apply to patients with CCCD, but remains to be demonstrated, and the cost of long-term treatment might limit its use in populations of known vulnerability and social marginalization.As a simpler option, for not requiring recurrent medical visits to adjust anticoagulation, the new oral anticoagulants of direct or indirect action  can be empirically used for patients with chronic atrial arrhythmias, such as atrial flutter or AF, with potentially beneficial results, even superior to warfarin.The right time to begin chronic oral anticoagulation after ischemic stroke is controversial and has not been studied systematically. For patients with TIA, it is reasonable to begin anticoagulants 24 hours after symptom onset; for patients with mild deficits, after 3 days; for patients with moderate deficits, after 6 to 8 days; and for patients with severe deficits, after 12 to 14 days, as long as, in all these situations, hemorrhagic transformation is ruled out after neuroimaging assessment.regardless of the cardiopathy etiology. At first, all patients with 2 or more points  benefit from prophylaxis with anticoagulants; however, the risk for hemorrhagic complications should be always assessed during the chronic use of those drugs.Risk scores, such as CHADS2 and CHA2DS2-VASc, are used to guide the primary and secondary prophylaxis of cardioembolic stroke in the presence of AF and other cardiovascular risk factors,In that context, the riskversusbenefit assessment should be defined individually and shared with the patients and their families.The HAS-BLED score  has been validated in different cohorts  to define the risk for hemorrhagic complications, with high risk of bleeding identified by a score \u2265 3.During clinical follow-up, it is necessary to periodically screen the potential risks for cardioembolic events, such as: systolic ventricular dysfunction and HF, and presence of ventricular aneurysms, mural thrombi, and arrhythmias .Prevention of cardioembolic events in patients with CCCD is extremely important because of the high potentially negative impact of those complications on morbidity, mortality, and quality of life.A long ECG tracing of at least 30s should be ideally performed to enable the identification of atrial arrhythmias.The ECHO allows the visualization of the cardiac cavities, identifying different grades of LV systolic dysfunction, regional areas of dyskinesia, aneurysms , spontaneous contrast, and mural thrombi, characterizing them as mobile or sessile, with high potential for embolism, or organized.All patients with CCCM should undergo ECG and ECHO periodically during outpatient follow-up and at the clinical assessment of an acute or previous cardioembolic event.Arrhythmias with high potential for embolism, such as atrial flutter or AF, should be actively sought during the clinical follow-up of patients with CD by use of annual ECG, a strategy to identify disease progression from the indeterminate chronic form to cardiopathy.In addition, the clinical history and physical examination are essential for the assessment of symptoms, such as palpitation, tachycardia, chest pain, dizziness, lipothymia, malaise, weakness, dyspnea, and functional class worsening, which lead to the clinical suspicion of arrhythmia. Regarding physical examination, the most important is the detection on auscultation of irregular pulse or cardiac rhythm. Because arrhythmic events can occur in paroxysms, arrhythmia might not be identified at the time of clinical assessment. If the clinical suspicion persists, continuous electrocardiographic monitoring by use of 24-hour Holter is required.These intracardiac devices should be systematically assessed on each visit, aiming at identifying the recording of silent episodes of AF. A proper interface between the clinical follow-up teams  is necessary for the recommendation of appropriate interventions, such as the beginning of anticoagulation for primary prevention.In patients with implanted devices, such as PM, ICD or cardiac resynchronization, the irregular rhythm might not be detected on physical examination, and an ECG assessment might be necessary or, even more appropriately, to resort to the event recording of those devices.It is plausible to admit that the same recommendations would empirically apply, by extrapolation, to patients with CCCD.According to recent guidelines on HF and arrhythmology, considering heart diseases of several etiologies, the identification of mural thrombosis, previous thromboembolic phenomena, and AF with CHA2DS2-VASc \u2265 2 would already indicate anticoagulation for prophylaxis against cardioembolic events.By use of risk-benefit analysis, the researchers proposing thatIPEC-FIOCRUZscore have also suggested that, for individuals with maximum score (4-5 points), the 4.4% annual incidence of stroke would exceed the estimated 2.0% annual rate of severe bleeding associated with the use of warfarin.As already mentioned, recognizing the CCCD higher potential to produce embolism, a risk score specific for cardioembolic stroke was developed for this etiology, widening the recommendations classically established for other cardiopathies.its review is currently mandatory for its specific use in patients with CCCD , with occasional correction of the points attributed to the variables , more adequate definition of age groups, and mainly external validation.Although previous guidelines have confirmed the use of that score,With the implementation of the methodological principles, the score can be invigorated and, in consistency with its undeniable and historical scientific role, recover its coverage and applicability.In addition, the empirical therapeutic managements suggested by the time it was formulatedshould be ideally supported by randomized studies of efficacy.The external validation of risk scores is especially relevant for their recommendation in clinical practice, in the context of CCCD, considering the current concepts.mellitus, and dyslipidemia, as well as smoking cessation, weight loss, and regular physical activityare also important to reduce cardioembolic events in that population.Considering the clear trend towards longer survival of patients with CD recently observed with a consequent increase in the frequency of cardiovascular risk factors in that population, there is an increase in the prevalence of AF , resulting in additional risk for cardioembolic stroke. Thus, recommendations for lifestyle changes with control of SAH, diabetesT. cruzi-HIV coinfectionis a reality in endemic and nonendemic areas with immigrants infected with the parasite.With estimates of 37 million individuals living with HIV/AIDS worldwide, the risk ofT. cruzi-HIV coinfection was initially reported in 1990as RCD, and cited in 1988 in Brazil with the identification of the parasite in the cerebrospinal fluid of a patient with AIDS.Described mainly in Brazil and Argentina, but also in other countries , the RCD is characterized by high morbidity and mortality and maternal-fetal transmission,interfering in the evolution of both CD and HIV infection. TheT. cruzi-HIV coinfection usually affects HIV-infected patients with severe immunodeficiency (CD4+cells < 200/mm) and detectable viral load due to failure to respond to effective antiretroviral therapy. In active HIV infection, the marked reduction in CD4+cells expresses the deficiency in TH1 response,responsible for the activation of CD4+and macrophages capable of secreting IFN-\u03b3 and destroying the parasites, thus increasing parasitemia and tissue parasitism.TheIn the congenital form of theT. cruzi-HIV coinfection,abortions, low birth weight, sepsis, and meningoencephalitis occur. More rarely, oligosymptomatic forms manifest as fever, erythema nodosum, myelitis, and as an asymptomatic postpartum woman with a stillborn baby due to congenital CD.The RCD presents as meningoencephalitis in approximately 2/3 of the cases, followed by myocarditis, meningoencephalitis plus myocarditis, pericarditis, duodenitis, gastritis, erythema nodosum, and colpitis.T. cruzishould be differentiated from toxoplasmosis, tumors, and infectious and degenerative diseases. Acute myocarditis in RCD should be differentiated from decompensated CCCD. Levels of CD4+ \u2264 200/mmare observed in approximately 2/3 of the cases and are even lower in RCD than in patients without RCD. A study has reported a 52.5% mortality in RCD (63 patients out of 120).Retrospective studies have reported RCD in 10%-15% of the coinfection cases, while prospective studies have reported RCD in 10% of patients in previous follow-up.The meningoencephalitis caused byand 4.2% in Argentina,being higher among illicit drug users.Approximately 4570-15 360 cases of coinfection have been estimated based on the number of patients infected withT. cruziand HIV in Brazil and Argentina, suggesting a usually underestimated number in the literature.The prevalence of coinfection has been estimated at 1.5%-5.0% in BrazilAIDS was the underlying cause of death in 2/3 of the cases and CD in 17.5%. The IFCD predominated in approximately half of the coinfection cases, the cardiac form occurred in 37%, followed by the digestive and cardiodigestive forms in 5% and 6%, respectively.Reduced levels of CD4+(in the diagnosis of coinfection) have been associated with the prognosis of RCD and mortality from RCD. In addition, the presence of parasitemia has been associated with the TH2 response, suggesting imbalance favoring the parasite.Of the mortality causes in coinfection,Thus, cases of HIV infection or CD should be actively investigated from the clinical and epidemiological viewpoints with indication for serological screening, aimed at the early diagnosis and control of both infections.In CD, in case of discordant tests , a confirmation test (immunoblotting/immunochromatography) or immunoenzymatic test with recombinant antigen or immunofluorescence is indicated. For the HIV infection, a positive ELISA or CLIA for the HIV1 and HIV2 antigens should be confirmed by use of immunoblotting/immunochromatography for the HIV1 and HIV2 antigens.Indirect parasitological tests and PCR forT. cruziare specific but have low sensitivity for the diagnosis (approximately 50% in the chronic form), although higher in the coinfection.Coinfection is diagnosed by two positive serological tests for both infections and/or parasitological tests for the diagnosis of CD.Concentration techniques  are more sensitive than the parasite search in simple peripheral blood smear or fresh peripheral blood. Biopsy can be indicated when other noninvasive methods fail.Patients with RCD can have negative CD serological tests,but the investigation should continue by use of direct microscopic methods. Qualitative PCR and indirect parasitological tests with enrichment, such as blood culture and xenodiagnosis, have low positive predictive value for the diagnosis of RCD, because they can be positive in chronic patients without reactivation.However, semiquantitative tests, such as nymph count on the xenodiagnosisand qPCR, are usually useful for RCD monitoring.The diagnosis of RCD should be made by use of the gold-standard methods of direct microscopic detection of the parasite in blood and biological fluids  and/or in stained tissues.at the dose of 5 mg/kg/day for 60 days. Nifurtimox is indicated as second choice when benznidazole is not available or in the presence of an adverse event contraindicating its use.In the first weeks after treatment, the direct search for the parasite in the leukocyte cream helps monitor therapeutic failure in positive cases; negative results do not indicate therapeutic success in the short run. Cure control should be followed up with qualitative PCR or indirect parasitological tests (blood culture) within 3, 6, 9, 12, and 24 months of therapy onset and with serological tests within 6, 12, and 24 months of therapy onset.The antiparasite treatment with benznidazole is mandatory for patients with RCD,Coinfected patients without RCD have shown better antiparasite response in the presence of higher parasitemia levels or higher levels initially.Follow-up is recommended at reference healthcare services to control both the viral load, with effective antiretroviral therapy control to restore the TH1 response, and CD, with parasitemia monitoring to avoid RCD or to enable its early diagnosis and treatment .+< 200cells/mm, similarly to the prevention of other opportunistic infections, is controversial, and there are neither reliable prospective studies nor retrospective series on CD.The indication for secondary prophylaxis with benznidazole (5mg/kg/day 3x/week) in patients with CD4After the appearance of AIDS in the 1980s, several measures and legislations have been developed and adopted to increase the control of blood banks and donors, particularly with the creation of blood centers and the centralization of the control and surveillance activities under the responsibility of the State Health Secretariats.In Brazil, serological screening for CD has been mandatory for all blood donors since 1969.The serological screening for CD comprises automated serological tests of high sensitivity and specificity to detect anti-T. cruziIgG antibodies, of which the most often used are ELISA and, more recently, CLIA.For the serological screening at blood banks, only one serological test is necessary and it can be repeated if the result is positive.In such case, the donated blood cannot be used and the donor should be contacted and referred to a CD reference health center for diagnosis elucidation.The Ministry of Health Ordinance n\u00ba 158 from 2016 established as unfit for blood donation individuals with history of household contact with triatomines in endemic areas in addition to those with a clinical or laboratory diagnosis of CD.However, these rates can vary according to the areas where the donations occur and the age of donors, being usually higher in historically endemic regions and at the older groups.With the control of vectorial and blood transfusion transmission, the mean prevalence of CD among blood donors has been decreasing rapidly. More recent projections have estimated a CD prevalence of 0.18% of the potential blood donors in Brazil.A study performed in the city of Uberaba, state of Minas Gerais, with a large number of donors for 15 years has shown a 0.03% annual drop in the prevalence rate, and, in the last year studied, only 0.08% of the donors were ineligible due to seropositivity.Recent studies conducted with blood donors in the Northeast region have reported prevalence of 0.17% to 0.57% in the state of Cear\u00e1 and of 0.18% to 2.4% in the state of Piau\u00ed.All positive cases should be referred to CD reference health centers to undergo new tests to confirm or rule out the diagnosis of CD.With the drop in prevalence among younger donors, an increase in inconclusive or undetermined cases has been observed, most of which resulting from false-positive tests.Recently, the WHO has published recommendations on the practice of physical activity by healthy individuals and those with specific health conditions and diseases. Usually, 150 minutes of moderate physical activity and/or 75 minutes of vigorous physical activity per week are recommended for cardiovascular health benefits.The practice of physical activity is an important intervention strategy to prevent and treat several chronic diseases, mainly those related to the cardiovascular system.In addition, moderate strengthening exercises for the major muscle groups should be performed at least twice a week and assessed by use of the perceived exertion scale. Flexibility and balance exercises should also be practiced, mainly by the elderly, to maintain amplitude of movement and autonomy for daily life activities.Small amounts of physical activity can be more beneficial to health as compared to being inactive, and, due to the dose-response relationship, higher amounts can be even more beneficial.Health benefits can be obtained even at lower physical activity levels, and previous inactive individuals should begin training gradually.Such studies, however, have included only patients with the cardiac form of CD, and so far there has been no proper assessment of the influence of that strategy on the IFCD.However, the benefits of physical activity to physical and mental health of individuals with CD have not been completely explored. Some studies have shown promising results regarding improvement of physical functioning and quality of life.Thus, the recommendation of physical exercises for individuals with the IFCD should be identical to those of the general population, aiming to control comorbidities, as well as to improve physical fitness and quality of life. Lifestyle interventions that gradually increase physical activity levels should be encouraged, considering each individual\u2019s physical capacity and functioning. Some studies have shown that the practice of physical exercises is associated with improvement in bowel transit, but its effects on individuals with the digestive form of CD have not been investigated.In a pioneer study on the topic, a RCT has assessed the effects of a cardiovascular rehabilitation program on patients with CCCD followed up for 3 months, and the physical training promoted improvement of physical fitness and quality of life.The effects of physical activity on CCCD have been recently assessed, mainly by use of cardiovascular rehabilitation programs.Later, an intervention study has reported that a cardiovascular rehabilitation program for patients with HF due to CD was associated with improvement of the cardiac function assessed by use of LVEF, of respiratory muscle strength, and of quality of life after 8 months of follow-up.Thus, physical exercise has been proven to be an effective intervention strategy to improve several clinical and quality of life parameters in CCCD , while the vertical transmission rate in endemic countries ranges from 0% to 18.2%.TheT. cruzivertical transmission rate differs between regions, varying from around 1.0% in Brazil to 4%-12% in other Southern Cone countries, and seems to depend on parasite- and host-related factors.The prevalence ofIn Brazil, the congenital transmission rate of CD ranges from 0% to 5.2%; however, there is great heterogeneity depending on the geographical region assessed. The highest regional congenital transmission rate was observed in the Southern-Southeastern region (2.1%), followed by the Northeastern (1.6%) and West-Central (0.9%) regions.The congenital transmission of CD can occur at any phase of the maternal disease; however, the highest transmission rate occurs among pregnant women in the acute phase of disease, approximately 30%, while the overall rate is 4.7%.The evidence of increased risk for abortion or prematurity among seropositive pregnant women is inconclusive. However, studies have suggested that the maternal chronic infection influences neither the clinical course of pregnancy nor the newborn health, as long as there is no vertical transmission. However, the fetal infection increases the likelihood of premature delivery, low birth weight, and natimortality.T. cruziis a complex process, resulting from the interaction of multiple factors related to the parasite, placenta, and fetal and maternal immune response.The parasite load of women infected during pregnancy is fundamental to congenital transmission.Parasitemia can reappear with the RCD usually associated with the transient physiological immunosuppression of pregnancy.In addition, the role of maternal age and number of gestations in increasing the risk for transmission awaits further investigation. However, there is evidence that the innate immune response activation, by use of pro- and anti-inflammatory mediators, in pregnant women can contribute to reduce the occurrence and severity of the congenital infection.The congenital transmission ofT. cruzi-infected pregnant women a group at high obstetrical risk.The impact of CD on the course of pregnancy is controversial. Some studies have pointed to the benignity of the association, while others have reported a high incidence of pregnancy complications and perinatal mortality, as well as of neonatal hypotrophy, consideringHeart disease, as long as assisted and not severe, does not contraindicate pregnancy. Patients with HF and/or severe arrhythmias should be oriented not to get pregnant, but if they do, they require special follow-up and care.The prognosis of pregnant women with CCCD is closely related to the severity of ventricular dysfunction and functional class at the beginning of pregnancy. Patients in functional class I/II at the beginning of pregnancy usually reach delivery uneventfully; however, those in functional class III/IV have a 25% to 50% probability of death.The etiological treatment should not be administered to pregnant women nor women at reproductive age not using contraception. Importantly, there is evidence that etiological treatment reduces the risk for congenital transmission in a subsequent pregnancy.In addition, in the exclusive case of acute CD, the etiological treatment can be instituted for pregnant women, considering maternal morbidity and mortality, higher risk of congenital transmission, and impact on the newborn health. Pregnant women with severe acute CD  should be treated regardless of the gestational age because of the high maternal morbidity and mortality, in addition to the high risk of congenital transmission of CD (22% to 71%), and the potential impact on the newborn health. Pregnant women with non-severe acute CD should be ideally treated after the second trimester of pregnancy, because of the potential risk of congenital malformation related to benznidazole.The use of cardiovascular drugs by pregnant women with CD should follow selective and individualized medical indication, because of the potential risk of side effects on the fetus. Infected mothers should be treated after the delivery and lactation period to prevent interrupting breastfeeding because of possible adverse reactions. CD should be investigated systematically in the relatives and other children born from infected mothers , and the positive cases should be assessed clinically and treated according to the already discussed principles.T. cruziinfection is mainly disseminated through congenital or perinatal vertical transmission, which exceeds blood transfusion and organ transplantation. Despite underreporting and underestimation worldwide, over two million women at reproductive age are infected withT. cruziand 1%-10% of the children from infected mothers are born with CD. Based on recent demonstrations that congenital transmission can be avoided, the OMS changed its objective in 2018, from control to elimination of congenital CD.Currently, in vector-free areas inside and outside Latin America,Studies conducted in Brazil, Argentina, Chile, and Paraguay have shown that 60% to 90% of the newborns with congenital infection are asymptomatic. Among the symptomatic ones, the most frequent clinical manifestations were prematurity, low birth weight, fever, and hepatosplenomegaly.The severity of congenital CD varies widely, from asymptomatic cases to fatal infection, which is related to the parasitemia level at birth.The congenital infection should be investigated in all children born from seropositive mothers, not only in the first month of life, but also at 6 and 12 months of age. Follow-up for 1 year is essential, because a significant proportion of cases is initially negative, the disease being only detected at a later stage.When positive, those tests provide the undeniable and definitive diagnosis of the infection; however, when the parasite load is low, mainly when transmission occurs in the last trimester of pregnancy or during delivery, the tests can generate false negative results. Thus, more sensitive and automated tests are necessary to the early detection of congenital infection. The positive result determines immediate etiological treatment.Congenital CD is considered acute, thus requiring mandatory reporting.The most recommended diagnostic methods in the first month after birth are the direct parasitological tests, by using methods of centrifuge concentration, such as microhematocrit.thmonth, such antibodies disappear and the diagnosis of congenital CD is more precise; however, delay in the diagnosis reduces the efficacy of the treatment and increases the risk of losing to follow-up.A negative serology after that period allows excluding the diagnosis ofT. cruziinfection.In the case of a negative parasitological test, the diagnostic investigation should include serological tests (with two different techniques), after the 7th month of life. A serological study before the 6th month is not useful, because of the passive transfer of maternal antibodies to the baby. After the 10The molecular methods represent a promising alternative and have been widely used for the early detection of congenital infections, mainly in Europe. However, they are expensive, and require considerable technical training and careful standardization, which hinder their implementation in laboratory routine. Thus, the molecular methods require wider clinical validations before being considered gold-standard for the diagnosis of congenital infections.T. cruzi-infected newborn is highly effective and can be performed with benznidazole (first option in Brazil) or nifurtimox, for 30 to 60 days, with fewer adverse events as compared to that of adults, and the rate of cure exceeds 90%. The doses recommended for children are 10mg/kg/day of benznidazole in 3 or 2 doses, and 15mg/kg/day of nifurtimox in 3 doses. Benznidazole is available as tablets of 12.5mg, which can be diluted into water and is provided by the State Health Secretariats, while nifurtimox should be requested to the PAHO, through the CD technical group of the Health Surveillance Secretariat of the Brazilian Ministry of Health.The treatment of theversus60 days. By the end of a 12-month follow-up, both regimens showed significant seroconversion or a reduction in the serum levels as compared to historical controls, and the 60 day regimen was superior to the 30 day regimen in the age group of 2-17 years. Nifurtimox was well tolerated, with mainly mild or moderate adverse effects without sequelae, and only 4% of those events determined interruption of treatment.A recently published clinical trial using nifurtimox to treat children (0 to 17 years of age) in Argentina, Colombia, and Bolivia has compared treatments for 30 daysThe time necessary for a test to become negative depends on the patient\u2019s age and treatment onset. The serology of children diagnosed in the first months of life will become negative between the 2ndand 12thmonth after treatment onset. The healthcare systems should assess and implement strategies to facilitate the earliest possible diagnosis of the congenital infection, considering the frequent poor adhesion of mothers to follow-up visits in healthcare centers.The etiological treatment should be followed up by use of parasitological and/or molecular tests in the weeks following treatment onset for neonates with parasitemia. After the end of treatment, the patients should be followed up with quantitative serological tests every 6 months. The patient is considered cured when the serology turns negative in two consecutive tests.Considering the risk of transmission to the newborn through the contact with maternal secretions, breastfeeding should be temporarily suspended only for mothers with RCD or in the acute phase, and more emphatically for those with nipple fissures or bleedings. The individualized assessment of each case is important, considering the great benefit of breastfeeding in the first months of life. In conclusion, mothers on antiparasite treatment for at least 30 days, even in the cases mentioned, can breastfeed freely.Patients with CCCD have increased surgical and anesthetic risks due to several reasons, which should be considered in the pre-, intra-, and postoperative periods.The most important preoperative care is HF control with drug optimization and the correction of occasional electrolyte disorders.Ventricular function should be assessed by ECHO whenever possible. All candidates to surgery should undergo ECG, and, for those with arrhythmias or compatible symptoms, ambulatory ECG monitoring (Holter) may be necessary. Antiarrhythmic drugs should not be suspended, but oral anticoagulants should be interrupted. The new oral anticoagulants, direct thrombin inhibitors, or direct factor Xa inhibitors, such as rivaroxaban, apixaban, and edoxaban, can simply be suspended 24 to 48 hours prior to surgery. Warfarin, however, should be ideally suspended 5 days prior to surgery, which can be performed when the INR is lower than 1.5. During warfarin suspension, the patients at high risk for thromboembolic events should undergo anticoagulation with heparins, such as subcutaneous full-dose enoxaparin. Finally, preoperative assessment of patients with CD should consider the occasional presence of megaesophagus, which increases the risk of bronchoaspiration in the intra- and postoperative periods.Continuous electrocardiographic monitoring is essential to control malignant ventricular arrhythmias and bradyarrhythmias. Invasive arterial and central venous hemodynamic monitoring is useful and should be implemented in more severe cases and major surgeries. Implantation of a temporary transvenous cardiac PM should be considered in patients with advanced AVB, mainly when associated with intraventricular conduction disorders. Intraoperative transesophageal ECHO provides valuable information on the inotropic response to anesthetic medication and the patient\u2019s blood volume status, being useful in selected cases.During surgery, patients with CCCD require individualized anesthetic management. The anesthesiologist should consider hemodynamic aspects, such as myocardial dysfunction, sometimes biventricular, which limit the volume infusion and increase the risk for cardiac arrhythmias.Intraoperative volume infusion should be judicious. In patients on HF treatment with vasodilators and diuretics, blood pressure levels are commonly low and the time needed for the onset of venous anesthetic action is longer because of the slower blood circulation.In addition, hepatic failure, consequent to right HF, and renal failure alter the pharmacokinetics of most medications.Anesthetic care is very important. In patients with ventricular dysfunction, the induction of anesthesia can result in rapid hemodynamic deterioration, which occurs mainly by peripheral vasoconstriction and negative inotropic action induced by anesthetic agents.The best anesthetic regimen should cause the lowest possible grade of myocardial depression and vasodilation. All inhalation anesthetics and most venous anesthetics are myocardial depressant drugs,requiring titration and judicious monitoring by the anesthesiologist. Whenever possible, according to the surgery type, regional anesthesia techniques should be used isolated or associated with general anesthesia due to the lower risk of hemodynamic instability.The autonomic dysfunction of patients with CCCD reduces the contractile reserve and can attenuate the action of exogenous catecholamines, requiring higher doses than the usual ones for hemodynamic stabilization.Regardless of the device type, the thermal cautery should be placed in the bipolar mode at the lowest effective power and be used intermittently with the neutral plate placed as far as possible from the generating unit.Patients with CCCD frequently have implantable electronic devices for the treatment of arrhythmias and/or HF. If a thermal cautery is used during surgery, specific attention is needed. The production of electrical noise by the thermal cautery might lead the device to misinterpret cardiac electrical events, resulting in inhibition of necessary electrical stimuli or triggering inappropriate electrical shock. Patients with a PM should have their devices placed in the DOO or VOO mode. ICD patients should have their devices turned off during surgery or a magnet should be placed on the device to prevent occasional inappropriate shocks. Central venous access should be carefully obtained in those patients because the guidewire can generate noise by contacting the shocking electrode, leading to inappropriate electrical discharges.In the postoperative period, patients with CCCD and ventricular dysfunction or cardiac arrhythmias, as well as those undergoing major surgeries, should be at an intensive care unit. The oral anticoagulant used prior to surgery that was temporarily suspended perioperatively, as well as the other medications for HF and arrhythmias, should be reintroduced as soon as possible.The worldwide spread of COVID-19 made the WHO declare it a pandemic in March 2020. Following the same global epidemiological profile, studies have shown an interrelationship between potential of severity and comorbidities with emphasis on cardiovascular disease and higher fatality rates in patients with those diseases as compared to the general population.but mortality rates can vary from 2.3% to 27%in vulnerable populations, such as the elderly and patients with comorbidities,due to severe complications, including pneumonia, thromboembolism, sepsis, renal failure, and HF.The SARS-CoV-2 infection can affect the cardiovascular system in several ways, such as inflammatory myocardial injury (myocarditis), intravascular thrombosis, and takotsubo syndrome, causing HF, arrhythmias, and circulatory shock.Patients with HF have higher mortality from COVID-19 than those without HF,and that rate can reach 40%.Thus, previous HF is an undeniable risk factor for mortality from COVID-19.Of the patients with COVID-19, more than 80% have mild symptoms, such as fever, sore throat, and cough,Because many of those patients have heart disease, they are vulnerable to severe infections and can have severe complications from COVID-19,such as higher mortality in the presence of HF.In addition, there is high prevalence of comorbidities in the population with CD, which is aging due to CD transmission control and global improvement of the health system.Thus, it is possible, and even likely, that the COVID-19-related morbidity/mortality is higher in patients with CD. However, a recent comprehensive registry in Brazil has shown that the in-hospital mortality from COVID-19 was similar between patients with and without CD, paired for sex, age, hypertension, and diabetesmellitus, even with HF and AF being more prevalent in the group with chronicT. cruzi infection.The consequences of the COVID-19 pandemic on the health of patients with CD have not been totally understood.Patients with CD have priority indication for anti-COVID-19 vaccination and are important risk groups in vaccination strategies, not only for COVID-19 but also for other immune preventable diseases with risk for the development of severe pneumonias and/or cardiac impairment.The COVID-19 prevention for patients at any stage of CD follows the same recommendations for the general population presented in the Brazilian Ministry of Health guidelines, although with emphasized recommendations and special attention to vaccine indications according to the age groups, for prophylaxis of pneumococcal infections, influenza virus, and COVID-19.For individuals with CD who get infected with SARS-CoV-2, medical care should be instituted since the PHC level, with emphasis on the risks associated with myocarditis and thromboembolic intravascular phenomena .T. cruziinfection, is not reached at the recommended doses and for short periods of time. However, the management and indications should be shared by an infectiologist and a cardiologist.In moderate or severe COVID-19 cases, corticotherapy can be used, almost always from the 6th day of disease on and for a short period of time. There is no contraindication to the use of corticosteroids for patients with CD coinfected with SARS-CoV-2 because their immunosuppressant effect, which could reactivateFor patients with CCCD and mild COVID-19, the previously estabilished cardiovascular medication and anticoagulation should be maintained, because there is no indication that they are harmful. For moderate or severe cases, oral anticoagulation should be replaced by low-molecular-weight heparin and the cardiovascular medication reassessed according to the patient\u2019s hemodynamic state.After that, CD transmission after kidney, liver, heart, or bone marrow donation has been reported worldwide, and the transmission rate has varied according to the transplanted organ: 13%to 16%for kidney, 20%to 22%for liver, and 75% for heart.In addition, RCD has been detected in patients with chronic CD recipients of solid organs.The transmission of CD through organ transplantation was described for the first time in Brazil in 1981 after renal transplantation.Regarding liver transplantation, the experience is limited, and the incidence of RCD varies according to the center similarly to that in renal transplantation.For bone marrow transplantation in patients with asymptomatic chronic CD, the RCD has ranged from 17% to 40%.The largest experience is in renal transplantation, in which RCD occurs mainly in the first year and varies among centers from 8% to 22%.o2600 from 2009 determines testing for CD: (1) in all donations, with the same algorithms used for blood donor screening; (2) for registration of potential organ recipients in the Unified Technical Register; and (3) in all dead donors of organs, tissues, cells, or body parts prior to graft allocation. That ordinance establishes that the heart from a donor with CD should not be used for transplantation, while the kidneys, pancreas, liver, and lungs of donors with CD can be transplanted as long as authorized by the recipient and transplant team, despite the risk of transmission and implicating in need for post-procedure monitoring.In Brazil, the Ordinance nbased on the parasitemia drop in that phase of treatment.In this situation, there is risk for CD transmission. Living donors with CD should be ideally treated with benznidazole for 60 days before the procedure. If there is no time for treatment completion, the transplantation can occur after 14 days of treatment,However, the prophylactic use of benznidazole, which would be routinely applied, is controversial, considering its toxicity and the low transmission rate.For untreated donors, monitoring the occurrence of CD transmission is recommended, as well as treatment of the diagnosed cases, when good results are observed with a high rate of cure.T. cruziin peripheral blood weekly for up to 60 days, in addition to indirect parasitological and serological tests at 30 and 60 days after transplantation. Then, clinical, serological, and parasitological (direct/indirect/PCR) tests should be performed every 2 months up to 1 year of follow-up; after that, every 6 months, while immunosuppression, whose duration depends on the transplant modality and type, persists. In addition to the usual monitoring efforts, any suspicious clinical sign of acute CD should be investigated by use of parasitological tests.Monitoring is performed with the direct search forAt any time, if acute infection is detected, conventional antiparasite treatment should be instituted.In addition, it is worth noting that the serological tests might not turn positive because of the patients\u2019 immunosuppression. Monitoring should be more frequent right after transplantation, because, in most cases, transmission and acute infection occur between the 3rd and 29th weeks (mean of 8 weeks).PCR can be used in the place of indirect parasitological tests.The parasitological tests should be performed weekly during treatment or up to two consecutive negative tests are obtained.A study comparing 13 patients not correctly monitored with 19 who underwent weekly monitoring has shown that 5 patients in the first group were diagnosed with symptomatic CD, 4 of whom died, while, in the other group, 4 transmissions were confirmed, the patients received antiparasite treatment and did not develop symptomatic disease.The prevalence of CD among candidates for solid organ transplantation is higher in the heart group because of the CD specific characteristic of progressing to refractory HF in many cases.and intracerebral tumor-like lesions (\u201cchagomas\u201d),are not common. In renal transplantation recipients, RCD occurs mainly in the first year after the procedure or when the immunosuppression intensifies after rejection episodes. The RCD can be totally asymptomatic but, when clinical manifestations appear, they usually consist of the subcutaneous lesions  in the limbs. If the treatment is not initiated, the lesions can progress to painful ulcers. Myocarditis and encephalitis are also described but less frequently. The response to treatment is good, with suitable long-term survival of the patient and graft.Although the RCD can occur during the immunosuppression period following any solid organ transplantation, severe forms of that complication, such as meningoencephalitisThere are two managements for transplant recipients already diagnosed with CD: treat before transplantation the already infected recipient or remain vigilant to diagnose and treat an eventual RCD. The routine treatment of asymptomatic recipients with CD before undergoing transplantation could theoretically reduce the chance of an RCD after immunosuppression; there is no conclusive evidence, however, favoring that statement and the correspondent prophylactic management. On the contrary, failure of that management has been reported.In addition, the result of the treatment of RCD is usually favorable, with high rates of cure and low mortality.Thus, the preferred management is the routine monitoring of parasitemia and other RCD evidence, so that early specific treatment can be initiated, increasing the treatment success with a smaller number of severe and fatal cases.T. cruzi-infected recipients should be followed up for the investigation of RCD once a week in the first 2 months, every 2 weeks from the third to the sixth month, and, after that, monthly up to 1 year. After intensification of immunosuppression, the follow-up should be weekly for 2 months, or at any time if acute CD is clinically suspected.AllNests ofT. cruziamastigotes should be searched in all biopsies. The RCD is diagnosed by the identification of parasites in the peripheral blood by use of direct methods or qPCR, as already described, orT. cruziidentification in biopsies. The RCD should be considered in patients with unexplained fever, dermopathy, myocarditis, or encephalitis.Direct parasitological tests are the preferred laboratory tests. The qPCR is the one to be used, because the qualitative one can be positive in asymptomatic patients. The qPCR is more sensitive and turns positive earlier than the direct parasitological methods.All infected recipients should be investigated once a year for the cardiac and digestive forms of CD. All individuals with RCD should be treated for 60 days with benznidazole (5mg/kg/day), nifurtimox (8mg/kg/day) being the second choice. During treatment, parasitological tests should be performed weekly until two negative tests are obtained.It is worth emphasizing that serological tests are not useful for the diagnosis of RCD and that negative seroconversion has been reported in patients with chronic CD after being transplanted because of immunosuppression.T.cruzi replication,thus being a more appropriate regimen for patients at risk for CD. However, an optimal regimen has not been established.It is still uncertain whether the use of specific protocols of chemotherapy drugs can influence the RCD. Thus, avoiding the use of antithymocyte globulin and minimizing the use of mycophenolate seem recommendable. Some studies have suggested that mechanistic target of rapamycin (mTOR) inhibitors could favor the control ofThus, surveillance for RCD and proper treatment are recommended. In addition, there is no evidence favoring the prophylactic use of benznidazole prior to corticosteroid at immunosuppressive dose. Monitoring possible RCD is the best management.The experience with CD associated with autoimmune diseases is scarce and limited mainly to case reports, most of them related to systemic lupus erythematosus.T. cruzichronically infected individuals.However,T. cruziinfection remains an independent predictor of all-cause mortality and stroke in the elderly.These are new challenges for the care of patients with CD, when the degenerative diseases of the elderly, SAH, diabetesmellitus, dyslipidemia, and coronary artery disease, compound the injury to the heart caused by CD, thus influencing the prognosis and quality of life of that population.The combination of successful public policies to control CD transmission, the increase in life expectancy of Brazilians, and the improvement in housing conditions in endemic regions has changed the patients\u2019 profile, propitiating an increase in the mean age ofCross-sectional studies conducted in the states of Cear\u00e1,S\u00e3o Paulo (city of Campinas),and Rio de Janeiroin elderly individuals with CD on outpatient care have reported SAH as the most frequent comorbidity.At the same time, information on how CD presents in the elderly is scarce, because most longitudinal studies have been performed a long time ago in predominantly young populations.mellitus, HF, coronary artery disease, hypothyroidism, dyspepsia, depression, stroke, and renal failure. Thus, those patients require special attention. Moreover, chronic comorbidities can result in frequent visits to the medical office and risk for drug interactions, adverse effects, and the daily use of five or more medications difficult to be correctly managed by the elderly.In addition to SAH, other comorbidities have been reported, such as dyslipidemia, osteoporosis, osteoarthritis, diabetesIn a study conducted in Bambu\u00ed, a cohort of elderly with and without CD, electrocardiographic changes were clearly more frequent in patients with CD.The ECG abnormalities significantly associated with CD were sinus bradycardia, frequent ventricular or supraventricular extrasystoles, AF, RBBB, LAFB, 1st-degree AVB, and prolonged QT interval.In the cross-sectional studies mentioned, cardiomyopathy was the predominant clinical form of CD; however, information on the prognostic value of the changes in the elderly is still scarce.The RBBB, especially when associated with LAFB, was strongly associated with the presence of CD, being observed in 40% of the population with CD and in only 8% of the elderly without CD. The ECG variables independently associated with increased risk of death in patients with CD were frequent ventricular or supraventricular extrasystoles, AF, RBBB, inactive electrical zone, primary alterations of ventricular repolarization, and LV hypertrophy. Those with normal ECG findings or mild changes did not have increased risk of death as compared to the noninfected population.Many elderlies do not have either an initial clinical assessment to classify CD or appropriate follow-up care and treatment. This can be seen in the cross-sectional study conducted in the endemic area of S\u00e3o Jo\u00e3o do Piau\u00ed, in the Brazilian semiarid region. That study has evidenced high prevalence of CD in the elderly, which reached up to 34% in the age group of 61-75 years and 39% in the age group over 75 years. In that region, despite the disease transmission control, the diagnosis and treatment were suspended, and many elderlies never had an initial clinical assessment. That region, as well as others with socioenvironmental characteristics similar to those of the Brazilian semiarid region, continues to suffer with the scarcity of PHC groups trained to diagnose and treat the population.In contrast, a study has reported that only 13% of the elderlies have normal ECG findings, suggesting that the severity of CD in the elderly can be similar to that in young adults.This information requires further investigation for substantiation and confirmation.Classical studies in endemic areas have shown that the IFCD is the most prevalent form of CD and that 30% to 40% of the individuals can indefinitely persist in that clinical form.Considering the impact of social, economic, and cultural factors on the genesis and evolution of CCCD, its clinical management in healthcare services requires the formation of a care network in a model that transcends biomedical dimensions. Thus, it should ensure access to comprehensive, hierarchical, and decentralized care, encompassing the social determination process that permeates this neglected disease, cause and consequence of structural poverty.Regarding healthcare provision, the conditions of individuals with CCCD are usually critical, which include long treatment with a low rate of success, and late diagnosis, usually in advanced stages of disease.As already described, individuals with CCCD have high morbidity and mortality as compared to those with other cardiomyopathies. Most of them belong to underprivileged social classes and are highly vulnerable, which hinder their access to diagnosis and treatment.In addition, patients with CCCD face bias and stigma in different social contexts, which compounds even more their not only physical, but psychological and social suffering. Chagas disease is among the most neglected diseases worldwide, especially in Latin America, according to the WHO. It is a challenging chronic condition for any public health system because the affected individuals can demand health actions from low/medium technological complexity, in approximately 70% to 80% of the cases (mainly in PHC), up to access to tertiary and quaternary care, increasing public health-related costs. It is worth emphasizing the critical negative impact on the quality of life of affected individuals, their families, and communities.In Brazil, from 2000 to 2010, the CCCD burden corresponded to a total of 7 402 559 potential years of life impaired, 9% of which due to years of life lost and 91% due to years lived with disability.The SUS, in its hierarchical and decentralized conception, has been designed to reach comprehensiveness as a referential, particularly for PHC territories, with support from the matrix, such as referral services for more complex cases. However, it requires investments in addition to qualified and engaged public management that enables the formation of a care network grounded in lines of care strongly integrated with health surveillance actions.There are some factors that can explain the persistence of the sanitary gap experienced by individuals with CD, even 113 years after CD discovery. As an example of the cycle of negligence, CD affects a silent and silenced population that faces persistent science, market, and public health challenges.Basic questions remain unanswered in the endemic context: Who are these individuals? Where are they? How are they?In more complex clinical management contexts, when recommending the formation of structured services for the follow-up of individuals with CCCD, some aspects require attention, such as an appropriate outpatient space affiliated to a tertiary or quaternary hospital with cardiological assistance that can provide additional intermediary to high complexity tests for proper cardiac staging.In addition, regarding access to better structured services, it is worth noting the need for follow-up of individuals living in challenging areas, such as the Amazonian region, rural areas, and urban peripheries. In such cases, the use of differentiated technological media, such as teleconsultation and remote ECG and chest X-ray reporting, might be necessary.Structured health services in CCCD might become a regional and state reference for cases requiring more complex clinical management, aimed at diagnosis clarification and staging of organ impairment. In addition, those services might support state and municipal permanent education programs for PHC professionals , which include communitarian health and endemic combat agents, for the clinical management of CD, which, although endemic, is still underdiagnosed.For a structured health service to be fully functional, it requires an interdisciplinary multiprofessional team, known as the best way to provide longitudinal and comprehensive care to chronic diseases. In addition to timely diagnosis and treatment, those diseases require rehabilitation and quaternary prevention.When creating a health service dedicated to the management of individuals with CCCD, it is important to contemplate their peculiarities, understand their biopsychosocial context, and practice patient-centered, instead of disease- or organ-centered, medicine.In that work model, the team should recognize the common elements that demand strong interaction between the professionals, as well as the work process specificities delimited by their acting possibilities and responsibilities. In addition, the team should have knowledge of CCCD, as well as its management, so that all can communicate well. This is meant to avoid distorted or untrue information.A structured service for management of CCCD cases should ideally count on the following professionals: physicians , nurses, psychologists, nutritionists, pharmacists, physical therapists, physical educators, and social workers. The team can be enlarged with the adoption of new people responsible for other interventions, and its dimension should be adjusted to the local reality, the possibilities of each health service, and, most of all, the demands from affected individuals.Receive all cases proceeding from PHC units, secondary health care units [specialized emergency care units (UPAE)], cardiological and non-cardiological emergencies, maternity hospitals, public or private blood centers, transplant services, as well as HIV/AIDS specialized services, for CD diagnosis and staging;The CD diagnosis confirmation requires qualified anamnesis, directed at the clinical epidemiological context, with serological confirmation, preferably by the LACEN;According to the Ministry of Health Ordinance n\u00ba 1.061, from May 18, 2020, diagnosed chronic cases of CD must be reported (compulsory notification) to improve the INSS network organization for the chronic CD prevalence in Brazil ;Stage cardiac impairment, by use of additional tests, maintaining communication with the Basic Healthcare Units (UBS) and UPAE, in a decentralized way, to accomplish referral and counter-referral flow. Individuals with the IFCD or nonsignificant cardiac impairment can be followed up in the UBS close to their dwellings, thus reducing the demand for treatment in other centers;Individuals with CD and indication for etiological treatment should be managed according to the recommendations in this guideline\u2019s specific chapter and followed up in a UBS as long as the health team is trained in the clinical management of these cases;Women at reproductive age should be educated about the possibility of congenital transmission of CD and contraceptive methods. If they want to get or are already pregnant, they should be followed up by the PHC team in association with a referral obstetrics service and be treated according to the current guidelines;Patients with CD and HF, complex arrhythmias, need for PM or ICD implantation or CTX should be followed up at a higher complexity service. In some cases, the use of MCSD might be necessary as a bridge to CTX or an alternative to CTX if with good results;Identify associated digestive organic and functional impairment, and, when present, treat or refer the patient to a CD specialized service;Treat comorbidities or assess the need to refer patients for medical assessment at specialized services;Cardiac rehabilitation should be integrated into structured health services of care to individuals with CCCD because of the proven clinical benefit of supervised physical exercise for their health and quality of life;Individuals with difficulty to understand the prescriptions of the health team should be helped by a pharmacist from the multiprofessional team to clarify dosage, interval between doses, adverse events, drug interactions, and strategies;DISC Chagas,DISC IC) and social media information available. With the dissemination of cell phones and the internet, remote care has proven to be greatly important in the management of more severe patients who cannot wait for a consultation or for small adjustments, which has been confirmed during the COVID-19 pandemic;Provide permanent education  to affected individuals, their families, and caregivers on the disease and selfcare to the timely identification of cardiac decompensation signs and symptoms, making a communication channel  and incorporate the confirmed cases to the health service to determine the treatment to be adopted;Identify, through active search and doctor-patient relationship deepening, other family members in the same context of risk forEncourage and support the creation of new associations of individuals with CD aimed at their better integration, establishing an active and purposeful communication channel with society, particularly the scientific, political, and health community, regarding their right to health claims. This would represent a strong channel in the search for active citizenship to transform their pain and suffering into a political act;Always support the fight against prejudice, such as the necessary exclusion of the adjective \u2018Chagasic\u2019, which belittles the individuals affected by the disease. In clinical practice, it means to replace the term \u2018Chagasic\u2019 by \u2018individual affected with CD\u2019;Publicize the existence of the FINDECHAGAS federation, created in 2010, as well as of the \u201814th of April\u2019 as the CD World Day, recognized by the WHO in 2019;Create telemedicine services for medical consultations and reporting of additional tests, such as ECG and chest X-ray. Based on this remote assessment, refer selected cases for management at structured health services.Once structured, the service is expected to be able to provide:Structured referral services for the follow-up of individuals with CCCD will be able to confirm what has been described for other chronic diseases.Strengthening of the relationship between health professionals and individuals with CD;Development of active listening of individuals with CD and counseling about CD;Updated knowledge on the disease for healthcare professionals and affected individuals;Means to favor adhesion to pharmacological and nonpharmacological treatment;Means to lower morbidity and mortality, thus reducing emergency visits and rehospitalizations;Positive impact on quality of life; several recent studies have emphasized this relevant concept supported by coherent data;Stigma and prejudice reduction;Empowerment, autonomy, and motivation of affected individuals to develop selfcare and search their rights ;Reduction in public health costs.Although the implantation of a structured service requires financial as well as technical and operational investments, its structuration in a healthcare network is believed to favorably impact medium- and long-term cost and effectiveness.Briefly, the major mission of structured services is to promote care that favors the clinical, psychological, and social stability of all individuals with CD.sometimes with social and work implications.Chronic cardiomyopathy of Chagas disease, still prevalent in Brazil, can progress to HF, ventricular arrhythmias, electrical conduction disorders, stroke, and other thromboembolic, pulmonary, and systemic complications, which represent severe situations,According to that document, the medico-legal expert had to rely on subjective data to conclude their diagnostic investigation. However, with the advances of medico-legal medicine, based on better knowledge of the clinical course and prognosis of patients with CCCD, in addition to advances related to complementary methods to diagnose cardiovascular dysfunction, the characterization of cardiopathy as a morbid entity has evolved, requiring diagnosis supported by strict clinical assessment and laboratory confirmation, according to the SBC II Brazilian Guideline on Severe Cardiopathy, published in 2006.The term \u201csevere cardiopathy\u201d, created by a multidisciplinary team, appeared for the first time in the Brazilian legislation in 1952 in the statute of the union civil servants, as the law 1711 . Severe cardiopathy was defined as \u201ca disease that leads to a temporary or permanent reduction in the heart\u2019s functional capacity, which can be life-threatening or prevent servants from doing their work activities\u201d.Severe cardiopathy comprises a large group of illnesses and clinical conditions of cardiac origin, characterized by a significant reduction in the survival perspective or significant limitation in physical capacity or both. The typification of severe cardiopathy is mainly aimed at complying with work issues  or providing financial benefits (release of FGTS and PIS/PASEP) and tax benefits , or income increasing .The term \u201csevere cardiopathy\u201d can be found in several legal processes, according to the Federal Law n\u00ba 7713/1988, article 6th, item XIV.statusis only defined after no satisfactory response to the appropriate clinical or surgical treatment, when recommended, or when there is no satisfactory therapy, or, even if there is, it is not sufficient to change the individual\u2019s clinical condition and prognosis.In addition, it is important to clarify that the severe cardiopathyOccasional changes in additional tests do not automatically imply diagnosis of severe cardiopathy. The verification of functional limitations and prognostic assessment result from a comprehensive investigation and contextualization of the clinical scenario of a patient with cardiopathy. Among the major inclusion criteria in the roll of severe cardiopathies, complete clinical assessment should be ensured, to provide information on the patient\u2019s physical capacity and, in parallel, information on the estimated survival rate for the condition in question should be obtained.The information on survival derives from the level of evidence of the risk of death, which can be obtained, in the specific case of CCCD, by using scores validated and published in specialized journals.Complete clinical assessment is obtained through medical consultation with detailed anamnesis and physical examination, complemented with tests, such as ECG, chest X-ray, Doppler ECHO, 24-hour Holter, exercise testing, or cardiopulmonary exercise testing. In specific situations, more sophisticated or invasive tests might be necessary, such as myocardial scintigraphy, CMRI, coronary CT angiography, or coronary angiography.The CCCD course is variable and unpredictable, and one of its presentations is death, which can either be sudden, due to HF progression or result from thromboembolic phenomena. Therefore, estimating the risk of death of patients with CCCD is a clinical challenge and has been facilitated with the introduction of a score developed with that purpose.et al., published in 2006, when following up a cohort of 424 patients with CCCD.During the study period, approximately 8 years, 130 patients died. Those authors identified six variables associated with death: NYHA functional class III or IV = 5 points; evidence of cardiomegaly on chest X-ray = 5 points; global or segmental LV dysfunction on ECHO = 3 points; NSVT on 24-hour Holter = 3 points; low-voltage QRS on ECG in all frontal leads = 2 points; and male sex = 2 points. Based on this score, those authors defined three risk categories: low risk (0-6 points); intermediate risk (7-11 points); and high risk (12-20 points). The 10-year mortality in the three groups was 10%, 44%, and 84%, respectively.That is the score created by Rassi Jr.which currently supports the medico-legal expert diagnosis of severe cardiopathy, is based rather on the patient\u2019s physical capacity/quality of life after usual therapeutic resources have failed, than on the risk prediction science. Despite the importance of the clinical findings and functional class, the search for new prognostic tools to refine clinical data is fundamental to subsidize better medico-legal investigations and their conclusions.By using the RASSI score, the work of the medical expert can be easily parameterized, translating into numbers the patient\u2019s clinical reality. Thus, a RASSI score \u2265 12 points certainly indicates severe cardiopathy. However, it is worth noting that the SBC II Brazilian Guideline on Severe Cardiopathy, published in 2006,The need for urgent review of that guideline is noticeable so that the usefulness of those scientific advances on the release of medico-legal investigative reports about patients with CD can be fully debated.The most characteristic clinical aspects of CCCD are congestive HF, complex ventricular arrhythmias requiring ICD implantation, thromboembolic phenomena, and severe impairment of liver and kidney functions secondary to the underlying heart disease. It is worth noting that it is crucial to assess the physical functioning of those patients regarding their life expectancy reduction despite the optimized therapeutic arsenal to classify them as having severe cardiopathy caused by CD.statusof severe cardiopathy to individuals who seek the social security to receive benefits because of their typification. To become an efficient medico-legal expert, in addition to an academic education in the health area, the professional must take training and specialization courses. There are several manuals for that correct practice. In addition, it involves embracing the law. Severe cardiopathy caused by CD is usually within the severe cardiopathy spectrum and supported by three laws, which refer to the following legal regimens: unified legal regimen (law n\u00ba 8.112/90); social security regimen (law n\u00ba 8.213/91); and taxation regimen (law n\u00ba 11.052/04).The medico-legal expert is a professional trained to assess and provide (or not) theFrom the didactical viewpoint, severe cardiopathy can be classified as follows: 1) acute cardiopathies, of rapid progression, that can gradually turn into chronic cardiopathies, characterized by the loss of patient\u2019s physical ability and of heart functional capacity; 2) chronic cardiopathies, characterized by progressive limitation of the physical aptitude and heart functional capacity, exceeding the limits of efficiency of the cardiac compensation mechanisms, regardless of the appropriate clinical and/or surgical treatment adopted; 3) chronic or acute cardiopathies requiring permanent inotropic pharmacological  or mechanical  support; and 4) terminal cardiopathy, when life expectancy is extremely reduced, nonresponsive to any type of therapy.statusapplies to a certain individual. This function requires emotional balance (not to be influenced by aspects other than the specific criteria) and discernment . The expert, based on the medical report and additional tests, reassesses the individual to validate or not the severe cardiopathy condition litigated. A LVEF lower than 40% on optimized medication, is usually one of the major functional parameters adopted. Usually, a more detailed assessment is necessary to investigate all aspects of the clinical findings and of the additional tests because borderline situations occur, with discordance between clinical findings and diagnostic methods, divergent test results, or need for aditional equally relevant data for a proper decision.Differently from the medical board, the medico-legal expert acting results from the routine work of one single expert, designated to assess whether the severe cardiopathyIn cases of discordance or divergence in the criteria selected for classification, and having the expert denied the presence of the disease, the judicial pathway is the natural choice in the presence of sufficient documentation.In addition to a RASSI score \u2265 12 points, other important information to indicate the possible diagnosis of severe cardiopathy in patients with CCCD is as follows: isolated NYHA functional class III or IV; repeated episodes of syncope with no possibility of definitive control; presence of VT, mainly if symptomatic or requiring emergency care; marked cardiomegaly; and presence of cardiac thrombus or previous thromboembolic episodes.It is worth noting that the presence of symptomatic sinus node dysfunction or advanced AVB  not necessarily implies permanent functional limitation, because PM implantation might reverse the clinical findings and significantly improve the prognosis, particularly when those alterations occur in isolation. However, in CCCD, mainly in advanced stages, bradyarrhythmias and advanced blocks associated with myocardial dysfunction or complex ventricular arrhythmias are common, indicating more severe impairment. In such cases, a comprehensive cardiac assessment, as previously suggested, allows the medico-legal expert to identify the patient\u2019s actual situation in terms of definitive limitation, regarding both function and prognosis.Similarly, the mere presence of positive serology for CD or its association with an electrocardiographic change, such as RBBB, is not sufficient to characterize severe cardiopathy. Although some of those individuals are known to progress to disabling forms, most can remain for decades in that stage, without symptoms, or even complete their life without clinical worsening.For the medico-legal investigation to be fully evaluated, the assistant physician should issue detailed reports describing precisely and clearly the patient\u2019s clinical findings and add the tests that confirm the diagnosis.The definition of severe cardiopathy is currently facilitated by advances of the knowledge on parameterized clinical evolution, clinical therapy, and additional tests, most of them with scientific support in terms of prognosis. This information, qualified and organized as scores developed in Brazilians, is highly valuable to support the medico-legal expert in their assessment. However, the physician\u2019s clinical rationale should be fully used to aggregate characteristic signs and symptoms, as well as data from the additional tests performed."}
+{"text": "To synthesize scientific evidence to characterize health care for transvestites and transsexuals in Brazil. This is a systematic review, conducted from July 2020 to January 2021 and updated in September 2021, whose protocol is registered in the International Prospective Register of Systematic Reviews (PROSPERO) platform, under code CRD42020188719. The survey of evidence was carried out in four databases and eligible articles were evaluated for methodological quality, and those with a low risk of bias were included. Fifteen articles were selected and the findings were grouped into six categories according to their thematic approaches: Possibilities to transform health care; Transvestiphobia and transphobia: violations inside and outside the Brazilian Unified Health System (SUS); Professional unpreparedness to care for transvestites and transsexuals; Search for health care alternatives; Right to health for transvestites and transsexuals: utopia or reality?; The Transsexualization Process: advances and challenges. There is evidence that health care for transvestites and transsexuals in Brazil is still exclusive, fragmented, centered on specialized care and guided by curative actions, resembling the care models that preceded the SUS and which have been heavily criticized since the Brazilian Sanitary Reform. In addition, the term transvestite precedes the term transsexual and is more frequent in Brazil and in other Latin American countries, designating people who experience female roles, but who do not recognize themselves as men or women.Transgender identities are diverse and not limited to a specific definition. However, in this study, transgender people are understood as those who have a gender identity opposite to the sex assigned at birth. Compared to other population groups, transvestites and transsexuals have high rates of mental suffering, including suicidal ideation and attempts, due to the discrimination and rejection they face throughout their lives and in all institutional spaces. In addition, other health problems are caused, mainly, by bodily transformations resulting from attempts to align the phenotype with gender identity. Thus, these factors end up generating a lower life expectancy and greater difficulties for these people to access health services.In the global context, transvestites and transsexuals represent a small portion of the general population. However, the discrimination and social exclusion imposed on these people put them in the worst health and life conditions. Given this reality, health care should not be configured only in assistance to this population\u2019s health problems, but also in broad and concrete actions to welcome transvestites and transgender people, which help them face gender identity-based discrimination.In Brazil, similar to the reality of other countries, transvestites and transgender women are socially more vulnerable: among lesbians, gays, bisexuals, queers, intersexuals, asexuals and other categories of gender and sexuality (LGBTTQIA+), they are the main victims of violence, especially bodily injuries and homicides by firearms. In addition, SUS is constituted by doctrinal principles , to which the health care model, expressed in policies, programs, services organization and care provision, must turn to, in order to recognize the social determinants of the health-disease process and health inequalities.The Brazilian health system, regulated in 1990 and called the Unified Health System (SUS), is mostly composed of public and free health services, complemented by some services from the private network financed by the State.Based especially on the principle of equity, health care practices should be carried out in a more fruitful way to serve the most vulnerable people, including transvestites and transgender people. Initiatives aimed at this population have been implemented in the SUS over the years, such as the National LGBT Comprehensive Health Policy, created in 2011, and the Transsexual Process Program in the SUS, created in 2008 and expanded in 2013, as well as theses and dissertations on transvestism, transsexuality and health, especially after the expansion of the Transsexualizing Process in the SUS. Furthermore, it is possible to identify some integrative reviews on the health of the transvestite and transsexual population in Brazil, specifically on the difficulties these people face in accessing health services. However, there are no systematic reviews that present summarized evidence on the other aspects related to health care for the Brazilian transvestite and transsexual population.In the scientific literature, there has been an increase in the publication of articles on the health of the Brazilian LGBTTQIA+ population after the creation of the National LGBT Integral Health PolicyConsidering that Brazil is a country of continental dimensions, with diverse and profound inequalities, especially in the realization of the universal right to health, the question is: how has health care for transvestites and transsexuals been provided within the scope of the SUS? As a result, the objective of this study is to synthesize scientific evidence to characterize health care for transvestites and transsexuals in the country.followed the recommendations of the checklist Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (Prisma-P), and is registered on the International Prospective Register of Systematic Reviews (Prospero) platform, under code CRD42020188719.This is a systematic review of the scientific literature, conducted from July 2020 to January 2021 and updated in September 2021. The research protocol. Likewise, they can point out necessary changes to professional practices or recommendations for carrying out other investigations, aiming to fill gaps in knowledge.From the formulation of a well-defined problem-question and an explicit and reproducible methodology, systematic review studies are able to identify, select, evaluate and summarize already available scientific evidenceThe survey of evidence, in Portuguese and English, that integrates this systematic review was carried out from consultations to the following databases: Scientific Electronic Library Online (SciELO), US National Library of Medicine (Pubmed), Literatura Latino-Americana e do Caribe em Ci\u00eancias da Sa\u00fade (Lilacs) and Biblioteca Virtual em Sa\u00fade (BVS). The BVS, a digital platform coordinated by the Centro Latino-Americano e do Caribe de Informa\u00e7\u00e3o em Ci\u00eancias da Sa\u00fade (BIREME), gathers data from different electronic databases in the health area, such as: Base Regional de Informes de Avalia\u00e7\u00e3o de Tecnologias em Sa\u00fade das Am\u00e9ricas (Brisa), Litt\u00e9rature Scientifique in Sant\u00e9 (Lissa), Medical Literature Analysis and Retrieval System Online (MedLine), Sistema de Informaci\u00f3n de la Biblioteca de la Organizaci\u00f3n Mundial de la Salud (Wholis), \u00cdndice Bibliogr\u00e1fico Espa\u00f1ol en Ciencias de la Salud (IBECS), Base de Dados em Enfermagem (BDENF), Bibliografia Brasileira de Odontologia (BBO), among others.To conduct the electronic search of the studies, previously defined strategies were used after different attempts, consisting of a block of health care-related descriptors in the Brazilian context and a block of keywords related to transvestites and transgender people, respecting the specificities of each database .In the SciELO, Lilacs and BVS databases, the search strategies were composed of descriptors extracted from the vocabulary of the Descritores em Ci\u00eancias da Sa\u00fade (DECS) and, for the search in PubMed, equivalent terms from the Medical Subject Headings (MESH) were used. Strategies were applied covering all indexes ., with the necessary adaptations , using a specific checklist for studies with a qualitative approach, as well as the classification proposed by Almeida et al., the risk of bias in the articles was rated as high (with up to 49% of affirmative responses), moderate (affirmative responses between 50% and 69%) and low (70% or more of affirmative responses). In this review study, the final synthesis was composed only of articles with low risk of bias.Based on the checklist presented by Lockwood et al.The entire process of screening, eligibility and assessment of the methodological quality of the articles was carried out by two independent researchers. In case of doubt or disagreement, the researchers met virtually to discuss and establish a consensus.The synthesis of the findings was carried out through the formal narrative and by preparing tables containing some data of the articles: title, authorship, year of publication, objective, sample/target audience, place of study , type of study, methodological approach, results and conclusions..The results of the studies included in the systematic review were grouped categorically, according to their thematic approaches, and interpreted with the support of the scientific literature that deals with the issue investigated here. Finally, the final writing of this manuscript followed the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-analyses checklist (Prisma)By searching the databases of interest for this systematic review, it was possible to retrieve 1,164 titles. After removing duplicates, screening after reading titles and abstracts, including other publications by checking the references of the screened articles, and updating the search, 45 articles were submitted to full reading. Of these, 24 were submitted to methodological quality assessment and 15 were included in the results synthesis, with 14 articles published in Portuguese and one article published in English ., that is, they do not present explicit information about the researchers\u2019 cultural or theoretical location and its possible influence on the study  caused by the simple fact that it is a group that breaks with the hegemonic pattern, which tries to define the gender only by the anatomy of genital organs.. In addition, more than structural, transvestitephobia and transphobia are also institutional violence, that is, they are present in institutions such as the SUS.This aversion soon emerges within the family, when transvestites and transsexuals in search of recognition of their gender identities are not accepted by the family itself. This non-acceptance also occurs on the part of people from social circles, negatively influence health care practices for this specific public.Therefore, recognizing the violence suffered by transvestites and transsexuals must be part of the work process in the health area, in order to try to welcome and support the victims. However, discriminatory acts, such as disrespect for the social name and lack of understanding about transvestism and transsexuality on the part of health professionals and managers, even avoiding them. In the case of transsexual men, as reported by Sousa and Iriartbased on a study carried out in Salvador, Bahia, institutional transphobia prevents their access to health services that meet their specific needs and demands, including hormonal monitoring for body modifications.As a result, transvestites and transsexuals feel insecure when using health services. In addition, the prejudice and stigma of health professionals related to them ends up keeping them away from access to combined HIV prevention strategies, such as the use of PrEP.Data from a study with Brazilian transsexual women reveal that health professionals\u2019 previous conception that they would live with the Human Immunodeficiency Virus (HIV), among other Sexually Transmitted Infections (STIs), causes these users to stop seeking SUS services, considered discriminatory by these women. In their view, the unpreparedness for health care for this specific public is due to the fragile approach to questions about gender diversity and sexuality during the professional training process.The findings reveal that health professionals, especially nursing professionals, are not properly qualified to welcome and care for transvestites and transgender people in health services. In addition, the absence of permanent educational actions, which disseminate the guidelines of the National Policy for Integral LGBT Health and which qualify the care for transvestites and transsexuals in the SUS, makes nursing professionals perpetuate stigmas and continue to limit care for these people, disrespecting them and basing their care practices only on curative actions.As a result, some nurses are unaware of the subjectivities of a transvestite or transsexual person and their health needs and demands. Faced with these violations, a minority of transvestites and transsexuals opt for private assistance, but most cannot afford a health plan, becoming dependent on alternative self-care practices, on the support of people in the social network or religious spaces of African origin, or body transformations without proper professional follow-up.Due to professional unpreparedness, and the discriminatory acts experienced within SUS establishments already pointed out in the results of this article, transvestites and transsexuals avoid seeking care in these institutional spaces.In this context, body transformations, such as inappropriate hormone therapy, industrial silicone grafting and breast self-mutilation, can cause other health problems, such as cardiovascular and aesthetic complications. This clearly characterizes another risk factor for the lives of transvestites and transgender people. However, for Brazilian social minorities, such as transvestites and transsexuals, this fundamental right has not been real.According to the Federal Constitution of Brazil, access to health is a basic right for all people, guaranteed through public policies aimed at reducing the risk of diseases and injuries, as well as allowing universal and equal access to health actions and services.The right to health for transvestites and transsexuals, or the lack of it, can be understood by three aspects: the right to exist, considering that these people still struggle to have their social names respected, including in the SUS; right to equity, as health services are not yet prepared to assist transvestites and transsexuals; and social participation, because transvestites and transsexuals need to exercise social control to access and remain in health services, and to demand the creation of specific services to offer transsexualizing procedures. Such procedures, as well as the creation of qualified services to offer them, represent a step forward in promoting the health of transvestites and transsexuals.In Brazil, the transgender procedures, on an experimental basis, have been authorized by the Federal Council of Medicine (CFM) since 1997, being incorporated into the SUS in 2008, when the Ministry of Health founded the Transsexualizing Process program and formally recognized that body transformations are also health needs of the transvestite and transsexual population. However, there is a fragile bond between health professionals and users, especially with trans women.Therefore, it is expected that the services enabled to offer the procedures provided for in the Transsexualization Process are welcoming, discrimination-free environments, as they are made up of multidisciplinary teams duly qualified to care for transvestites and transsexuals in a humane way, this situation can be explained by the existence of medical superiority and a care protocol, lasting two years, which treats gender identity transition as a disorder, making this diagnosis a condition for access to specific health services for this part of the population. As a result, in these services, transvestites and transsexuals are constantly asked about the veracity of their gender identities and intentions, not allowing them autonomy in the production of care.According to Oliveira and Romanini. Therefore, analyzing the health care model, whether for the general population or for specific groups, such as the group of transvestites and transgender people, implies understanding what public health policies exist to mitigate or nullify inequities and how these policies reflected in programs, actions, services and research for this purpose.The health care model consists of a set of knowledge and combinations of resources  to meet individual and collective health needs.In view of the results of this systematic review, it is clear that health care for transvestites and transsexuals in Brazil is still exclusionary, fragmented, centered on specialized care and guided by curative actions, resembling the care models that preceded the SUS and which have been strongly criticized since the 1970s, from the Brazilian Sanitary Reform movement. At the time, the critics highlighted the importance of profound changes not only in the health system, so that care was humanized, equitable and comprehensive, guaranteeing universal access to all men and women, despite transsexuality being a phenomenon recognized since the late 19th century, issues related to transgender identities in the Brazilian public health began to be visible only after 1979, with the possibility of medical interventions, when the CFM was consulted for the first time on mammoplasty in transgender people.According to Ar\u00e1n et al.. It should be noted that the existence of these procedures in the SUS is a fundamental initiative not only to meet a need for transvestites and transsexuals, but also to assist in the construction of subjectivities and identities neglected by society and the State.Going forward in time, and acknowledging the existence of numerous debates that took place on the subject, including in the legal field, in 1997 \u2013 as already discussed in this article \u2013 the reassignment procedures were authorized by the CFM and incorporated into the SUS 11 years later, so that transvestites and transsexuals can benefit from these specialized health services, especially psychiatric follow-up for at least two years in order to confirm the diagnosis of transsexuality. While this diagnosis represents the winning of the right to health for transvestites and transsexuals, it also contributes to the permanence of the stigma on these people, as it does not consider the personal and historical issues of each subject, assigning the recognition of gender identity to a psychiatric and normalizing procedure.However, criticisms are made of the care protocols established by the Ministry of Health, through regulations.Furthermore, access to reassignment procedures is not the only health need for transvestites and transsexuals in Brazil. In addition to access to these procedures, it is necessary to promote the fight against discrimination based on gender identity so that transvestites and transsexuals can access any space with dignity, such as health promotion spaces, without being victims of violence.If access to gender reassignment procedures were the only health need of Brazilian transvestites and transsexuals, it would be very unequal and far from being met, since in the country there are only ten services authorized by the Ministry of Health to offer the procedures provided for in the Transsexualizing Process program, most of them located in the Southeast and none in the North, constant dialogue between SUS management and the social segments that represent transvestites and transsexual people , the implementation of the National LGBT Comprehensive Health Policy, strategies to disseminate the meaning of being a transvestite or transsexual to the community in general, review of work practices in healthand changes in professional training in health.The findings of this systematic review also reveal possible ways to transform the current health care model for transvestites and transsexuals in the SUS: it would be interesting to develop intersectoral strategies to combat discrimination against transvestites and transsexuals.Considering these possibilities, the relevance of the participation of social movements representing this segment in the formulation and conduction of public health policies, through the exercise of citizenship and social control, is highlighted here. In the process of building the SUS and its health policies, joining the social struggle for the country\u2019s re-democratization, the LGBTTQIA+ movement played an important role, placing sexual and gender diversity on the agenda as social markers and structural determinants of the health-disease processAs a result of the work of LGBTTQIA+ social movements in health, we highlight the creation of the Brazil without Homophobia Program and the Technical Committee on Health of the LGBT Population at the Ministry of Health in 2004, the holding of the 1st National Seminar on Health of the LGBT Population in 2007, the institution of the Transsexualizing Process in the SUS in 2008, the regulation of the use of the social name of transvestites and transsexuals in the SUS in 2009, the formulation of the National Policy for Integral LGBT Health, etc.In conclusion, health care for transvestites and transsexuals in Brazil does not correspond to the health care model advocated in the legal-legal framework of SUS. Therefore, it is necessary to develop strategies to deal with specific issues of transvestites and transsexuals, with emphasis on the vulnerabilities that permeate these people\u2019s lives.In addition to guaranteeing health care, it is necessary to provide opportunities for access to education, employment, housing, food, etc. These actions should not only come from transvestites and transsexuals, but from those who believe in the potential of the SUS and in an egalitarian and democratic society.With regard to the actions of health professionals in relation to transvestites and transsexuals, this analysis focused on nursing professionals, as the studies retrieved and included in this review addressed only this professional category. In order not to induce that the professional lack of preparation for the health care of transvestites and transgender people in the Brazilian health system is a specificity of nursing professionals, and considering that the work in the SUS must be interprofessional and collaborative, further studies are recommended that investigate the way in which other health professionals deal with transvestites and transgender people.At the same time that criticisms are made, it is important to highlight that this analysis about the work of nurses, in favor of care for transvestites and transsexuals, may result from advances in research on gender diversity in the field of nursing. However, as shown in the results presented here, it is still necessary to change work practices, allowing a significant transformation in the daily life of health care spaces for transvestites and transsexuals.As limitations of the study, we point out the possibility that some articles do not use the descriptors adopted in the search strategies of this review and the existence of other articles indexed in databases not consulted. However, to bypass this possible situation, manual searches were performed.In addition, other limitations refer to the non-inclusion of studies developed in the North region of Brazil, considering that the SUS is present throughout the national territory, and to the authors\u2019 choice to exclude from the systematic review articles that analyzed health care for transvestites and transsexuals together with aspects related to health care for other people in the LGBTTQIA+ group..The non-inclusion of articles that deal with health care for transvestites and transsexuals in states in the North region is justified by the fact that existing studies did not meet the inclusion criteria adopted in the systematic review, or did not have a low risk of bias, according to the checklist used to assess the methodological quality of the articlesThe choice to exclude articles that addressed health care for transvestites and transsexuals together with health care for other people in the LGBTTQIA+ group is justified by virtue of the National Policy for LGBT Integral Health, which partially recognizes the specific needs and identities of transvestites and transsexuals, because, despite the existence of intersections between gender and sexuality issues, they demand different analyses and investments.. However, these decisions may have limited the results of the systematic review, as it is expected that aspects about transvestites and transsexuals will be addressed together with those related to lesbian, gay, bisexual, non-binary people, etc., due to the existence of a single health policy for the entire LGBTTQIA+ population in Brazil.In this sense, it would be important to put in place new policies and specific programs for the health of transvestites and transsexuals, prioritizing coping with the vulnerabilities faced by these people . Al\u00e9m disso, a denomina\u00e7\u00e3o travesti antecede o termo transexual e \u00e9 mais frequente no Brasil e em outros pa\u00edses da Am\u00e9rica Latina, designando pessoas que vivenciam pap\u00e9is femininos, mas que n\u00e3o se reconhecem enquanto homens ou mulheres.As identidades transg\u00eaneras s\u00e3o diversas e n\u00e3o se limitam a uma defini\u00e7\u00e3o espec\u00edfica. Por\u00e9m, neste estudo, as pessoas transexuais s\u00e3o compreendidas como aquelas que possuem uma identidade de g\u00eanero oposta ao sexo atribu\u00eddo ao nascimento. Entretanto, a discrimina\u00e7\u00e3o e a exclus\u00e3o social impostas a essas pessoas as colocam nas piores condi\u00e7\u00f5es de sa\u00fade e de vida. Comparando com os demais grupos populacionais, as travestis e transexuais apresentam altos \u00edndices de sofrimento mental, incluindo a idea\u00e7\u00e3o e tentativa suicida, em virtude da discrimina\u00e7\u00e3o e rejei\u00e7\u00e3o que enfrentam ao longo de suas vidas e em todos os espa\u00e7os institucionais. Al\u00e9m disso, outros problemas de sa\u00fade s\u00e3o ocasionados, principalmente, pelas transforma\u00e7\u00f5es corporais oriundas das tentativas de alinhamento do fen\u00f3tipo \u00e0 identidade de g\u00eanero. Assim, esses fatores acabam por gerar uma menor expectativa de vida e maiores dificuldades de acesso aos servi\u00e7os de sa\u00fade por essas pessoas.No contexto mundial, travestis e transexuais representam uma parcela pequena da popula\u00e7\u00e3o geralqueers, intersexuais, assexuais e demais categorias de g\u00eanero e sexualidade (LGBTTQIA+), elas s\u00e3o as principais v\u00edtimas de viol\u00eancia, sobretudo de les\u00f5es corporais e de homic\u00eddios por armas de fogo. Diante dessa realidade, a aten\u00e7\u00e3o \u00e0 sa\u00fade n\u00e3o deve configurar-se somente em assist\u00eancia aos problemas de sa\u00fade dessa popula\u00e7\u00e3o, mas tamb\u00e9m em a\u00e7\u00f5es amplas e concretas para acolher as travestis e as pessoas transexuais, que as auxiliem no enfrentamento \u00e0 discrimina\u00e7\u00e3o por identidade de g\u00eanero.No Brasil, semelhante \u00e0 realidade de outros pa\u00edses, as travestis e mulheres transexuais s\u00e3o socialmente mais vulner\u00e1veis: entre l\u00e9sbicas, gays, bissexuais,. Al\u00e9m disso, o SUS \u00e9 constitu\u00eddo por princ\u00edpios doutrin\u00e1rios , aos quais o modelo de aten\u00e7\u00e3o \u00e0 sa\u00fade, expresso em pol\u00edticas, programas, organiza\u00e7\u00e3o dos servi\u00e7os e oferta de cuidados, deve voltar-se, para reconhecer os determinantes sociais do processo sa\u00fade-doen\u00e7a e das iniquidades em sa\u00fade.O sistema de sa\u00fade brasileiro, regulamentado em 1990 e denominado Sistema \u00danico de Sa\u00fade (SUS), \u00e9 majoritariamente composto por servi\u00e7os p\u00fablicos e gratuitos de sa\u00fade, com a complementa\u00e7\u00e3o de alguns servi\u00e7os da rede privada financiados pelo Estado.Baseando-se especialmente no princ\u00edpio da equidade, as pr\u00e1ticas de aten\u00e7\u00e3o \u00e0 sa\u00fade devem ser realizadas de maneira mais prof\u00edcua para atender as pessoas mais vulner\u00e1veis, entre essas, as travestis e as pessoas transexuais. Iniciativas direcionadas a essa popula\u00e7\u00e3o v\u00eam sendo implementadas no SUS ao longo dos anos, como a Pol\u00edtica Nacional de Sa\u00fade Integral LGBT, criada em 2011, e o programa Processo Transexualizador no SUS, criado em 2008 e ampliado em 2013, assim como de teses e disserta\u00e7\u00f5es sobre travestilidade, transexualidade e sa\u00fade, principalmente ap\u00f3s a amplia\u00e7\u00e3o do Processo Transexualizador no SUS. Ademais, \u00e9 poss\u00edvel identificar algumas revis\u00f5es integrativas sobre a sa\u00fade da popula\u00e7\u00e3o travesti e transexual no Brasil, especificamente sobre as dificuldades que essas pessoas enfrentam para ter acesso aos servi\u00e7os de sa\u00fade. Entretanto, n\u00e3o existem revis\u00f5es sistem\u00e1ticas que apresentem evid\u00eancias sumarizadas sobre os demais aspectos relacionados \u00e0 aten\u00e7\u00e3o \u00e0 sa\u00fade da popula\u00e7\u00e3o travesti e transexual brasileira.Na literatura cient\u00edfica, observa-se um aumento na publica\u00e7\u00e3o de artigos sobre a sa\u00fade da popula\u00e7\u00e3o LGBTTQIA+ brasileira ap\u00f3s a cria\u00e7\u00e3o da Pol\u00edtica Nacional de Sa\u00fade Integral LGBTConsiderando que o Brasil \u00e9 um pa\u00eds de dimens\u00e3o continental, com diversas e profundas desigualdades, sobretudo na efetiva\u00e7\u00e3o do direito universal \u00e0 sa\u00fade, questiona-se: como tem ocorrido a aten\u00e7\u00e3o \u00e0 sa\u00fade para travestis e transexuais no \u00e2mbito do SUS? Em fun\u00e7\u00e3o disso, o objetivo deste estudo \u00e9 sintetizar evid\u00eancias cient\u00edficas para caracterizar a aten\u00e7\u00e3o \u00e0 sa\u00fade para travestis e transexuais no pa\u00eds.seguiu as recomenda\u00e7\u00f5es dochecklist Preferred Reporting Items for Systematic Review and Meta-analysis Protocols(Prisma-P), e est\u00e1 registrado na plataformaInternational Prospective Register of Systematic Reviews(Prospero), sob o c\u00f3digo CRD42020188719.Trata-se de uma revis\u00e3o sistem\u00e1tica da literatura cient\u00edfica, conduzida de julho de 2020 a janeiro de 2021 e atualizada em setembro de 2021. O protocolo de pesquisa. Da mesma forma, podem apontar mudan\u00e7as necess\u00e1rias \u00e0s pr\u00e1ticas profissionais ou recomenda\u00e7\u00f5es para a realiza\u00e7\u00e3o de outras investiga\u00e7\u00f5es, visando preencher lacunas do conhecimento.A partir da formula\u00e7\u00e3o de uma pergunta-problema bem definida e de uma metodologia expl\u00edcita e reprodut\u00edvel, os estudos de revis\u00e3o sistem\u00e1tica s\u00e3o capazes de identificar, selecionar, avaliar e sumarizar evid\u00eancias cient\u00edficas j\u00e1 dispon\u00edveisScientific Eletronic Library Online(SciELO),US National Library of Medicine(Pubmed), Literatura Latino-Americana e do Caribe em Ci\u00eancias da Sa\u00fade (Lilacs) e Biblioteca Virtual em Sa\u00fade (BVS). A BVS, plataforma digital coordenada pelo Centro Latino-Americano e do Caribe de Informa\u00e7\u00e3o em Ci\u00eancias da Sa\u00fade (Bireme), re\u00fane dados de diferentes bases eletr\u00f4nicas da \u00e1rea da sa\u00fade, tais como: Base Regional de Informes de Avalia\u00e7\u00e3o de Tecnologias em Sa\u00fade das Am\u00e9ricas (Brisa),Litt\u00e9rature Scientifique em Sant\u00e9(Lissa), Medical Literature Analysis and Retrievel System Online(MedLine),Sistema de Informaci\u00f3n de la Biblioteca de la Organizaci\u00f3n Mundial de la Salud(Wholis),\u00cdndice Bibliogr\u00e1fico Espa\u00f1ol en Ciencias de la Salud(IBECS), Base de Dados em Enfermagem (BDENF), Bibliografia Brasileira de Odontologia (BBO), entre outras.O levantamento das evid\u00eancias, em portugu\u00eas e ingl\u00eas, que integra esta revis\u00e3o sistem\u00e1tica foi realizado a partir de consultas \u00e0s seguintes bases de dados:Para conduzir a busca eletr\u00f4nica dos estudos, foram utilizadas estrat\u00e9gias previamente definidas ap\u00f3s diferentes tentativas, compostas por um bloco de descritores relacionados \u00e0 aten\u00e7\u00e3o \u00e0 sa\u00fade no contexto brasileiro e por um bloco de descritores relacionados \u00e0s travestis e pessoas transexuais, respeitando as especificidades de cada base de dados .Medical Subject Headings(MESH). As estrat\u00e9gias foram aplicadas contemplando todos os \u00edndices .Nas bases SciELO, Lilacs e BVS, as estrat\u00e9gias de busca foram compostas por descritores extra\u00eddos do vocabul\u00e1rio do portal Descritores em Ci\u00eancias da Sa\u00fade (DECS) e, para a busca na PubMed, foram utilizados termos equivalentes do, com as devidas adapta\u00e7\u00f5es , sendo utilizado umchecklistespec\u00edfico para estudos com abordagem qualitativa, uma vez que todos os artigos eleg\u00edveis possu\u00edam essa abordagem metodol\u00f3gica.Os artigos selecionados foram lidos novamente na \u00edntegra para que a qualidade metodol\u00f3gica deles fosse avaliada por dois pesquisadores previamente calibrados, visando garantir uniformidade na avalia\u00e7\u00e3o cr\u00edtica. Isso aconteceu por meio das ferramentas de avalia\u00e7\u00e3o cr\u00edtica dochecklistapresentado por Lockwoodet al., assim como na classifica\u00e7\u00e3o proposta por Almeidaet al., o risco de vi\u00e9s dos artigos foi classificado entre alto (com at\u00e9 49% de respostas afirmativas), moderado (respostas afirmativas entre 50% e 69%) e baixo (70% ou mais de respostas afirmativas). Neste estudo de revis\u00e3o, a s\u00edntese final foi composta somente por artigos com baixo risco de vi\u00e9s.Com base noTodo o processo de triagem, elegibilidade e avalia\u00e7\u00e3o da qualidade metodol\u00f3gica dos artigos foi realizado por dois pesquisadores independentes. Em caso de d\u00favida ou discord\u00e2ncia, os pesquisadores se reuniram virtualmente para discutir e estabelecer um consenso.A s\u00edntese dos achados foi realizada por meio da narrativa formal e com o aux\u00edlio da constru\u00e7\u00e3o de tabelas contendo alguns dados dos artigos: t\u00edtulo, autoria, ano de publica\u00e7\u00e3o, objetivo, amostra/p\u00fablico-alvo, local de realiza\u00e7\u00e3o do estudo (Unidade Federativa do Brasil), tipo de estudo, abordagem metodol\u00f3gica, resultados e conclus\u00f5es.checklist Prefered Reporting Items for Systematic Reviews and Meta-analyses(Prisma).Os resultados dos estudos inclu\u00eddos na revis\u00e3o sistem\u00e1tica foram agrupados categoricamente, de acordo com as suas aproxima\u00e7\u00f5es tem\u00e1ticas, e interpretados com o suporte da literatura cient\u00edfica que trata sobre a quest\u00e3o aqui investigada. Por fim, a reda\u00e7\u00e3o final do presente manuscrito obedeceu \u00e0s recomenda\u00e7\u00f5es doPor meio da busca nas bases de dados de interesse desta revis\u00e3o sistem\u00e1tica, foi poss\u00edvel recuperar 1.164 t\u00edtulos. Ap\u00f3s a remo\u00e7\u00e3o das duplicatas, da triagem a partir da leitura dos t\u00edtulos e resumos, da inclus\u00e3o de outras publica\u00e7\u00f5es mediante a verifica\u00e7\u00e3o das refer\u00eancias dos artigos triados, e da atualiza\u00e7\u00e3o de busca, 45 artigos foram submetidos \u00e0 leitura integral. Desses, 24 foram submetidos \u00e0 avalia\u00e7\u00e3o da qualidade metodol\u00f3gica e 15 foram inclu\u00eddos na s\u00edntese dos resultados, sendo 14 artigos publicados em portugu\u00eas e um artigo publicado em ingl\u00eas .checklistutilizado para nortear a avalia\u00e7\u00e3o da qualidade metodol\u00f3gica, ou seja, n\u00e3o apresentam informa\u00e7\u00f5es expl\u00edcitas acerca da localiza\u00e7\u00e3o cultural ou te\u00f3rica dos(as) pesquisadores(as) e sua poss\u00edvel influ\u00eancia no estudo  pesquisadores(as), assim como suas orienta\u00e7\u00f5es te\u00f3ricas, podem influenciar a condu\u00e7\u00e3o da pesquisa, desde a coleta dos dados at\u00e9 a divulga\u00e7\u00e3o dos resultados. Portanto, \u00e9 importante que os artigos que prezem pelo rigor metodol\u00f3gico explicitem as poss\u00edveis influ\u00eancias dos(as) pesquisadores(as) no estudo, ou as estrat\u00e9gias adotadas para diminuir essas potenciais influ\u00eanciasA s\u00edntese dos estudos inclu\u00eddos  revela Em sua totalidade, os artigos possuem a abordagem qualitativa como \u00fanica caracter\u00edstica metodol\u00f3gica. Al\u00e9m disso, seis dos artigos tiveram travestis e mulheres transexuais como sujeitos das pesquisas e tr\u00eas foram desenvolvidos com profissionais de sa\u00fade, especificamente com enfermeiras(os), focando na percep\u00e7\u00e3o destes sobre a aten\u00e7\u00e3o \u00e0 sa\u00fade para travestis e transexuais.Ainda de acordo com a s\u00edntese contida no; di\u00e1logo constante entre a gest\u00e3o do SUS e os segmentos sociais que representam travestis e pessoas transexuais, na perspectiva de compreender e respeitar as especificidades de sa\u00fade dessa parcela da popula\u00e7\u00e3o; efetiva\u00e7\u00e3o da Pol\u00edtica Nacional de Sa\u00fade Integral LGBT, garantindo o acesso de travestis e transexuais aos diferentes estabelecimentos do SUS; estrat\u00e9gias de divulga\u00e7\u00e3o do significado de ser travesti ou transexual para a comunidade em geral, visando afirmar as subjetividades e respeitar as necessidades dessas pessoas; revis\u00e3o das pr\u00e1ticas de trabalho em sa\u00fade, envolvendo o resgate da promo\u00e7\u00e3o do cuidado, altru\u00edsmo pelos profissionais de sa\u00fade, desenvolvimento da autonomia de travestis e transexuais e inclus\u00e3o de trabalhadores(as) transexuais nas equipes de sa\u00fade; e mudan\u00e7as na forma\u00e7\u00e3o profissional em sa\u00fade, incentivando a integra\u00e7\u00e3o ensino-servi\u00e7o-comunidade, a inclus\u00e3o de conte\u00fados sobre g\u00eanero e sexualidade nos curr\u00edculos dos cursos da \u00e1rea da sa\u00fade e o desenvolvimento de a\u00e7\u00f5es de educa\u00e7\u00e3o permanente acerca do cuidado humanizado \u00e0s travestis e transexuais para os trabalhadores do SUS.No que tange \u00e0 aten\u00e7\u00e3o \u00e0 sa\u00fade para travestis e transexuais no Brasil, os artigos revelam, de forma quase un\u00e2nime, as dificuldades existentes para a efetiva\u00e7\u00e3o dos princ\u00edpios basilares do SUS. Diante do diagn\u00f3stico acerca dessas dificuldades, que ser\u00e3o abordadas nas categorias seguintes, s\u00e3o apontadas possibilidades para transformar esse modelo de aten\u00e7\u00e3o \u00e0 sa\u00fade, tais como: desenvolvimento de estrat\u00e9gias intersetoriais para o combate \u00e0 discrimina\u00e7\u00e3o contra travestis e transexuais, inclusive nos servi\u00e7os de sa\u00fadeNo decorrer de suas vidas, travestis bem como mulheres e homens transexuais s\u00e3o v\u00edtimas de atitudes preconceituosas, reflexo de uma viol\u00eancia estrutural (travestifobia e transfobia) causada pelo simples fato de se tratar de um grupo que rompe com o padr\u00e3o hegem\u00f4nico, que tenta definir o g\u00eanero somente pela anatomia dos \u00f3rg\u00e3os genitais.. Al\u00e9m disso, mais do que estrutural, a travestifobia e a transfobia s\u00e3o viol\u00eancias tamb\u00e9m institucionais, ou seja, est\u00e3o presentes em institui\u00e7\u00f5es como o SUS.Essa avers\u00e3o surge logo no seio familiar, quando travestis e transexuais em busca do reconhecimento de suas identidades de g\u00eanero passam a n\u00e3o serem aceitos pela pr\u00f3pria fam\u00edlia. Essa n\u00e3o aceita\u00e7\u00e3o ocorre igualmente por parte de pessoas do conv\u00edvio social, influenciam negativamente as pr\u00e1ticas de aten\u00e7\u00e3o \u00e0 sa\u00fade para esse p\u00fablico espec\u00edfico.Portanto, o reconhecimento das viol\u00eancias sofridas por travestis e transexuais deve fazer parte do processo de trabalho na \u00e1rea da sa\u00fade, a fim de tentar acolher e dar suporte \u00e0s v\u00edtimas. Por\u00e9m, atos discriminat\u00f3rios, como o desrespeito ao nome social e a incompreens\u00e3o sobre travestilidade e transexualidade por parte dos profissionais e gestores da sa\u00fade, chegando a evit\u00e1-los. No caso de homens transexuais, como relata Sousa e Iriarta partir de um estudo realizado em Salvador, na Bahia, a transfobia institucional impede o acesso deles aos servi\u00e7os de sa\u00fade que atendam \u00e0s suas necessidades e demandas espec\u00edficas, incluindo o acompanhamento hormonal para as modifica\u00e7\u00f5es corporais.Com isso, travestis e transexuais sentem inseguran\u00e7a ao recorrerem aos servi\u00e7os de sa\u00fade. Al\u00e9m disso, o preconceito e estigma dos profissionais de sa\u00fade relacionados a elas acaba por afast\u00e1-las do acesso \u00e0s estrat\u00e9gias de preven\u00e7\u00e3o combinada do HIV, como o uso da PrEP.Dados de um estudo com mulheres transexuais brasileiras revelam que a concep\u00e7\u00e3o pr\u00e9via dos profissionais de sa\u00fade de que elas conviveriam com o V\u00edrus da Imunodefici\u00eancia Humana (HIV), entre outras Infec\u00e7\u00f5es Sexualmente Transmiss\u00edveis (IST), faz com que essas usu\u00e1rias deixem de buscar pelos servi\u00e7os do SUS, considerados discriminat\u00f3rios por essas mulheres. Na vis\u00e3o deles, o despreparo para a aten\u00e7\u00e3o \u00e0 sa\u00fade desse p\u00fablico espec\u00edfico \u00e9 decorrente da fr\u00e1gil abordagem das quest\u00f5es sobre diversidade de g\u00eanero e sexualidade durante o processo de forma\u00e7\u00e3o profissional.Os achados revelam que profissionais de sa\u00fade, em especial profissionais de enfermagem, n\u00e3o est\u00e3o devidamente qualificados para acolher e cuidar de travestis e pessoas transexuais nos servi\u00e7os de sa\u00fade. Ademais, a aus\u00eancia de a\u00e7\u00f5es educativas permanentes, que divulguem as diretrizes da Pol\u00edtica Nacional de Sa\u00fade Integral LGBT e que qualifiquem os cuidados \u00e0s travestis e transexuais no SUS, faz com que profissionais de enfermagem perpetuem estigmas e continuem a limitar o cuidado a essas pessoas, desrespeitando-as e pautando as suas pr\u00e1ticas de aten\u00e7\u00e3o somente em a\u00e7\u00f5es curativas.Em decorr\u00eancia disso, alguns enfermeiros(as) desconhecem as subjetividades de uma pessoa travesti ou transexual e suas necessidades e demandas de sa\u00fade. Diante dessas viola\u00e7\u00f5es, uma minoria de travestis e transexuais optam pela assist\u00eancia privada, por\u00e9m, a maioria n\u00e3o possui condi\u00e7\u00f5es financeiras para arcar com as despesas de um plano de sa\u00fade, tornando-se dependentes de pr\u00e1ticas alternativas de autocuidado, do apoio de pessoas da rede social ou espa\u00e7os religiosos de matriz africana, ou de transforma\u00e7\u00f5es corporais sem o devido acompanhamento profissional.Devido ao despreparo profissional, e aos atos discriminat\u00f3rios vivenciados no interior dos estabelecimentos do SUS j\u00e1 apontados nos resultados deste artigo, travestis e transexuais evitam buscar por cuidados nesses espa\u00e7os institucionais.Nesse contexto, as transforma\u00e7\u00f5es corporais, como a hormonioterapia inapropriada, o enxerto de silicone industrial e a automutila\u00e7\u00e3o mam\u00e1ria, podem ocasionar outros problemas de sa\u00fade, como complica\u00e7\u00f5es cardiovasculares e est\u00e9ticas. Isso caracteriza claramente mais um fator de risco \u00e0 vida de travestis e pessoas transexuais. Entretanto, para minorias sociais brasileiras, como travestis e transexuais, esse direito fundamental n\u00e3o tem sido real.Segundo a Constitui\u00e7\u00e3o Federal do Brasil, o acesso \u00e0 sa\u00fade \u00e9 um direito b\u00e1sico de todas as pessoas, garantido mediante pol\u00edticas p\u00fablicas que visam diminuir o risco de doen\u00e7as e agravos, assim como permitir o acesso universal e igualit\u00e1rio \u00e0s a\u00e7\u00f5es e servi\u00e7os de sa\u00fade.O direito \u00e0 sa\u00fade para travestis e transexuais, ou a n\u00e3o concretude dele, pode ser compreendido por tr\u00eas aspectos: o direito de existir, considerando que essas pessoas ainda lutam para terem seus nomes sociais respeitados, inclusive no SUS; direito \u00e0 equidade, pois os servi\u00e7os de sa\u00fade ainda n\u00e3o est\u00e3o preparados para atenderem travestis e transexuais; e a participa\u00e7\u00e3o social, porque travestis e transexuais precisam exercer o controle social para acessar e permanecer nos servi\u00e7os de sa\u00fade, e para reivindicar a cria\u00e7\u00e3o de servi\u00e7os espec\u00edficos para a oferta de procedimentos transexualizadores. Tais procedimentos, assim como a cria\u00e7\u00e3o dos servi\u00e7os habilitados para ofert\u00e1-los, representam um avan\u00e7o na promo\u00e7\u00e3o da sa\u00fade de travestis e transexuais.No Brasil, os procedimentos transgenitalizadores, a t\u00edtulo experimental, est\u00e3o autorizados pelo Conselho Federal de Medicina (CFM) desde 1997, sendo incorporados ao SUS em 2008, quando o Minist\u00e9rio da Sa\u00fade fundou o programa Processo Transexualizador e reconheceu formalmente que as transforma\u00e7\u00f5es corporais tamb\u00e9m s\u00e3o necessidades de sa\u00fade da popula\u00e7\u00e3o travesti e transexual. Todavia, nota-se um v\u00ednculo fr\u00e1gil entre profissionais de sa\u00fade e usu\u00e1rios(as), em especial com mulheres trans.Por isso, espera-se que os servi\u00e7os habilitados para a oferta dos procedimentos previstos no Processo Transexualizador sejam espa\u00e7os acolhedores e ausentes de discrimina\u00e7\u00e3o, pois s\u00e3o constitu\u00eddos por equipes multiprofissionais e devidamente qualificadas para cuidar de travestis e transexuais de forma humanizada, tal situa\u00e7\u00e3o pode ser justificada pela exist\u00eancia de uma superioridade m\u00e9dica e de um protocolo assistencial, com dura\u00e7\u00e3o de dois anos, que trata a transi\u00e7\u00e3o da identidade de g\u00eanero como transtorno, fazendo desse diagn\u00f3stico uma condi\u00e7\u00e3o para se ter acesso aos servi\u00e7os de sa\u00fade espec\u00edficos dessa parcela da popula\u00e7\u00e3o. Com isso, nesses servi\u00e7os, as travestis e transexuais s\u00e3o constantemente indagadas(os) quanto \u00e0 veracidade das suas identidades de g\u00eanero e de suas inten\u00e7\u00f5es, n\u00e3o permitindo a elas/eles uma autonomia na produ\u00e7\u00e3o de cuidados.Segundo Oliveira e Romanini. Portanto, analisar o modelo de aten\u00e7\u00e3o \u00e0 sa\u00fade, seja para a popula\u00e7\u00e3o geral ou para grupos espec\u00edficos, como o grupo de travestis e pessoas transexuais, implica em compreender quais s\u00e3o as pol\u00edticas p\u00fablicas de sa\u00fade existentes para mitigar ou anular as iniquidades e como essas pol\u00edticas refletem em programas, a\u00e7\u00f5es, servi\u00e7os e pesquisas para tal.O modelo de aten\u00e7\u00e3o \u00e0 sa\u00fade consiste em um conjunto de saberes e combina\u00e7\u00f5es de recursos  para atender a necessidades de sa\u00fade individuais e coletivas.Diante dos resultados da presente revis\u00e3o sistem\u00e1tica, percebe-se que a aten\u00e7\u00e3o \u00e0 sa\u00fade para travestis e transexuais no territ\u00f3rio brasileiro ainda \u00e9 excludente, fragmentada, centralizada no cuidado especializado e pautada por a\u00e7\u00f5es curativas, assemelhando-se aos modelos de aten\u00e7\u00e3o que antecederam o SUS e que s\u00e3o fortemente criticados desde a d\u00e9cada de 1970, a partir do movimento da Reforma Sanit\u00e1ria Brasileira. Na ocasi\u00e3o, as cr\u00edticas evidenciavam a import\u00e2ncia de profundas transforma\u00e7\u00f5es n\u00e3o somente no sistema de sa\u00fade, para que a aten\u00e7\u00e3o fosse humanizada, equ\u00e2nime e integral, garantindo o acesso universal a todos e todaset al., apesar da transexualidade ser um fen\u00f4meno reconhecido desde o final do s\u00e9culo XIX, as quest\u00f5es relacionadas \u00e0s identidades transg\u00eaneras na sa\u00fade p\u00fablica brasileira passaram a ter visibilidade somente a partir de 1979, com a possibilidade de interven\u00e7\u00f5es m\u00e9dicas, quando se consultou, pela primeira vez, o CFM sobre a mamoplastia de aumento em pessoas transexuais.Segundo Ar\u00e1n. Cabe ressaltar que a exist\u00eancia desses procedimentos no SUS \u00e9 uma iniciativa fundamental n\u00e3o s\u00f3 para atender uma necessidade de travestis e transexuais, mas, tamb\u00e9m, para auxiliar na constru\u00e7\u00e3o de subjetividades e identidades negligenciadas pela sociedade e pelo Estado.Avan\u00e7ando no tempo, e reconhecendo a exist\u00eancia de in\u00fameros debates que ocorreram acerca do assunto, inclusive no campo jur\u00eddico, em 1997 \u2013 como j\u00e1 foi abordado neste artigo \u2013, os procedimentos transgenitalizadores foram autorizados pelo CFM e incorporados ao SUS 11 anos depois, para que travestis e transexuais possam usufruir desses servi\u00e7os de sa\u00fade especializados, principalmente o acompanhamento psiqui\u00e1trico por no m\u00ednimo dois anos a fim de se confirmar o diagn\u00f3stico de transexualidade. Ao mesmo tempo em que esse diagn\u00f3stico representa a conquista do direito \u00e0 sa\u00fade de travestis e transexuais, ele contribui para a perman\u00eancia do estigma sobre essas pessoas, pois n\u00e3o considera as quest\u00f5es pessoais e hist\u00f3ricas de cada sujeito, atribuindo o reconhecimento da identidade de g\u00eanero a um procedimento psiqui\u00e1trico e normalizador.Entretanto, cr\u00edticas s\u00e3o feitas aos protocolos assistenciais estabelecidos pelo Minist\u00e9rio da Sa\u00fade, por meio de normativas.Ademais, o acesso aos procedimentos transgenitalizadores n\u00e3o \u00e9 a \u00fanica necessidade de sa\u00fade de travestis e transexuais no Brasil. Para al\u00e9m do acesso a esses procedimentos, \u00e9 necess\u00e1rio promover o combate \u00e0 discrimina\u00e7\u00e3o por identidade de g\u00eanero para que travestis e transexuais possam acessar dignamente qualquer espa\u00e7o, como os espa\u00e7os de promo\u00e7\u00e3o da sa\u00fade, sem serem v\u00edtimas de viol\u00eancias.Se o acesso aos procedimentos transgenitalizadores fosse a \u00fanica necessidade de sa\u00fade de travestis e transexuais brasileiras, ele seria muito desigual e longe de ser atendido, pois no pa\u00eds s\u00f3 existem dez servi\u00e7os habilitados pelo Minist\u00e9rio da Sa\u00fade para a oferta dos procedimentos previstos no programa Processo Transexualizador, sendo a maioria localizada no Sudeste e nenhum na regi\u00e3o Norte, o di\u00e1logo constante entre a gest\u00e3o do SUS e os segmentos sociais que representam travestis e pessoas transexuais, a efetiva\u00e7\u00e3o da Pol\u00edtica Nacional de Sa\u00fade Integral LGBT, estrat\u00e9gias de divulga\u00e7\u00e3o do significado de ser travesti ou transexual para a comunidade em geral, a revis\u00e3o das pr\u00e1ticas de trabalho em sa\u00fadee as mudan\u00e7as na forma\u00e7\u00e3o profissional em sa\u00fade.Os achados desta revis\u00e3o sistem\u00e1tica tamb\u00e9m revelam poss\u00edveis caminhos para transformar o atual modelo de aten\u00e7\u00e3o \u00e0 sa\u00fade para travestis e transexuais no SUS: seriam interessantes o desenvolvimento de estrat\u00e9gias intersetoriais para o combate \u00e0 discrimina\u00e7\u00e3o contra travestis e transexuais.Considerando essas possibilidades, destaca-se aqui a relev\u00e2ncia da participa\u00e7\u00e3o dos movimentos sociais representativos desse segmento na formula\u00e7\u00e3o e condu\u00e7\u00e3o das pol\u00edticas p\u00fablicas de sa\u00fade, por meio do exerc\u00edcio da cidadania e do controle social. No processo de constru\u00e7\u00e3o do SUS e das suas pol\u00edticas de sa\u00fade, aglutinando-se com a luta social pela redemocratiza\u00e7\u00e3o do pa\u00eds, o movimento LGBTTQIA+ teve uma importante atua\u00e7\u00e3o, colocando em pauta a diversidade sexual e de g\u00eanero como marcadores sociais e determinantes estruturais do processo sa\u00fade-doen\u00e7aComo fruto da atua\u00e7\u00e3o dos movimentos sociais LGBTTQIA+ na sa\u00fade, destacam-se a cria\u00e7\u00e3o do Programa Brasil sem Homofobia e do Comit\u00ea T\u00e9cnico de Sa\u00fade da Popula\u00e7\u00e3o LGBT no Minist\u00e9rio da Sa\u00fade em 2004, a realiza\u00e7\u00e3o do I Semin\u00e1rio Nacional de Sa\u00fade da Popula\u00e7\u00e3o LGBT em 2007, a institui\u00e7\u00e3o do Processo Transexualizador no SUS em 2008, a normatiza\u00e7\u00e3o do uso do nome social de travestis e transexuais no SUS em 2009, a formula\u00e7\u00e3o da Pol\u00edtica Nacional de Sa\u00fade Integral LGBT etc.Concluindo, a aten\u00e7\u00e3o \u00e0 sa\u00fade para travestis e transexuais no Brasil n\u00e3o corresponde ao modelo de aten\u00e7\u00e3o \u00e0 sa\u00fade preconizado no arcabou\u00e7o jur\u00eddico-legal do SUS. Portanto, \u00e9 necess\u00e1rio desenvolver estrat\u00e9gias para lidar com quest\u00f5es espec\u00edficas de travestis e transexuais, com destaque para as vulnerabilidades que permeiam as vidas dessas pessoas.Para al\u00e9m da garantia da assist\u00eancia \u00e0 sa\u00fade, \u00e9 preciso proporcionar oportunidades de acesso \u00e0 educa\u00e7\u00e3o, emprego, moradia, alimenta\u00e7\u00e3o etc. Essas a\u00e7\u00f5es n\u00e3o devem partir somente de travestis e transexuais, mas daqueles(as) que acreditam na potencialidade do SUS e em uma sociedade igualit\u00e1ria e democr\u00e1tica.No que tange \u00e0 atua\u00e7\u00e3o de profissionais de sa\u00fade frente \u00e0s travestis e transexuais, essa an\u00e1lise deteve-se aos profissionais de enfermagem, pois os estudos recuperados e inclu\u00eddos nesta revis\u00e3o abordavam somente essa categoria profissional. Para n\u00e3o induzir que o despreparo profissional para a aten\u00e7\u00e3o \u00e0 sa\u00fade de pessoas travestis e transexuais no sistema de sa\u00fade brasileiro \u00e9 uma especificidade dos(as) profissionais de enfermagem, e considerando que o trabalho no SUS deve ser interprofissional e colaborativo, recomenda-se mais estudos que investiguem a forma na qual outros profissionais da sa\u00fade lidam com travestis e pessoas transexuais.Ao mesmo tempo em que s\u00e3o tecidas cr\u00edticas, \u00e9 importante destacar que essa an\u00e1lise acerca do trabalho de enfermeiras(os), em prol da aten\u00e7\u00e3o \u00e0s travestis e transexuais, pode ser resultante de avan\u00e7os nas pesquisas sobre diversidade de g\u00eanero na \u00e1rea da enfermagem. Todavia, conforme demonstrado nos resultados aqui apresentados, ainda \u00e9 necess\u00e1rio mudar pr\u00e1ticas de trabalho, permitindo uma transforma\u00e7\u00e3o significativa no cotidiano dos espa\u00e7os de aten\u00e7\u00e3o \u00e0 sa\u00fade para travestis e transexuais.Como limita\u00e7\u00f5es do estudo, aponta-se a possibilidade de alguns artigos n\u00e3o utilizarem os descritores adotados nas estrat\u00e9gias de busca da presente revis\u00e3o e da exist\u00eancia de outros artigos indexados em bases de dados n\u00e3o consultadas. Todavia, para contornar essa poss\u00edvel situa\u00e7\u00e3o, buscas manuais foram realizadas.Al\u00e9m disso, outras limita\u00e7\u00f5es referem-se \u00e0 n\u00e3o inclus\u00e3o de estudos desenvolvidos na regi\u00e3o Norte do Brasil, considerando que o SUS est\u00e1 presente em todo o territ\u00f3rio nacional, e \u00e0 escolha dos autores em excluir da revis\u00e3o sistem\u00e1tica artigos que analisavam a aten\u00e7\u00e3o \u00e0 sa\u00fade para travestis e transexuais conjuntamente com os aspectos relacionados \u00e0 aten\u00e7\u00e3o \u00e0 sa\u00fade para as demais pessoas do grupo LGBTTQIA+.checklistutilizado para a avalia\u00e7\u00e3o da qualidade metodol\u00f3gica dos artigos.A n\u00e3o inclus\u00e3o de artigos que versem sobre a aten\u00e7\u00e3o \u00e0 sa\u00fade para travestis e transexuais em estados da regi\u00e3o Norte justifica-se pelo fato de que os estudos existentes n\u00e3o atenderam os crit\u00e9rios de inclus\u00e3o adotados na revis\u00e3o sistem\u00e1tica, ou n\u00e3o possu\u00edam baixo risco de vi\u00e9s, conforme oJ\u00e1 a escolha pela exclus\u00e3o dos artigos que abordavam a aten\u00e7\u00e3o \u00e0 sa\u00fade para travestis e transexuais em conjunto com a aten\u00e7\u00e3o \u00e0 sa\u00fade para as demais pessoas do grupo LGBTTQIA+, justifica-se em virtude da Pol\u00edtica Nacional de Sa\u00fade Integral LGBT reconhecer parcialmente as necessidades espec\u00edficas e identit\u00e1rias de travestis e transexuais, pois, apesar da exist\u00eancia de intercruzamentos entre as quest\u00f5es de g\u00eanero e de sexualidade, elas demandam an\u00e1lises e investimentos diferentes.. No entanto, essas decis\u00f5es podem ter limitado os resultados da revis\u00e3o sistem\u00e1tica, pois \u00e9 esperado que os aspectos sobre travestis e transexuais sejam abordados conjuntamente com os relacionados \u00e0s pessoas l\u00e9sbicas, gays, bissexuais, n\u00e3o-bin\u00e1rias etc., por causa da exist\u00eancia de uma pol\u00edtica de sa\u00fade \u00fanica para toda a popula\u00e7\u00e3o LGBTTQIA+ do Brasil.Nesse sentido, seria importante efetivar novas pol\u00edticas e programas espec\u00edficos para a sa\u00fade de travestis e transexuais, priorizando o enfrentamento \u00e0s vulnerabilidades enfrentadas por essas pessoas"}
+{"text": "Trata-se de estudo transversal, de basepopulacional, com dados de 19.962 mulheres de 15 a 49 anos. Os desfechos foramuso e tipo de contraceptivo, classificados em: contraceptivos revers\u00edveis decurta dura\u00e7\u00e3o (SARC), longa dura\u00e7\u00e3o (LARC) e permanentes. As vari\u00e1veisexplicativas foram: caracter\u00edsticas da hist\u00f3ria reprodutiva, sociodemogr\u00e1ficas ede acesso aos servi\u00e7os de sa\u00fade. Utilizou-se a regress\u00e3o log\u00edstica multinomialpara estimativas da odds ratio (OR), tendo os SARC comocategoria de refer\u00eancia. As an\u00e1lises foram realizadas no m\u00f3dulosurvey do software Stata, que considerou o efeito do planoamostral complexo da Pesquisa Nacional de Sa\u00fade de 2019. Apreval\u00eancia do uso de contraceptivos foi de 83,7%. Do total de usu\u00e1rias, 72%usavam SARC, 23,2% m\u00e9todos permanentes e 4,8%, LARC. Mulheres com maiorescolaridade, plano de sa\u00fade, que tiveram partos e participaram de grupos deplanejamento reprodutivo tiveram maior chance de usar LARC na compara\u00e7\u00e3o com ouso de SARC, enquanto o cadastro na unidade b\u00e1sica de sa\u00fade se associou a menorchance de uso. Ainda, quanto maior a idade e paridade, al\u00e9m de viver com ocompanheiro, maior a chance de usar m\u00e9todos permanentes em rela\u00e7\u00e3o ao uso deSARC. Apesar da elevada cobertura de contracep\u00e7\u00e3o, o mixcontraceptivo permanece obsoleto, com predom\u00ednio do uso de SARC. Al\u00e9m disso,observou-se importante desigualdade de acesso, sendo os LARC acess\u00edveis apenaspor mulheres com melhores condi\u00e7\u00f5es socioecon\u00f4micas, enquanto os m\u00e9todospermanentes foram associados a um perfil de maior vulnerabilidade social.O objetivo deste estudo \u00e9 descrever o  Al\u00e9m disso, mulheres mais jovens e com maior vulnerabilidade social t\u00eam menoracesso ao uso de contraceptivos revers\u00edveis de longa dura\u00e7\u00e3o (LARC) Destaca-se ainda a manuten\u00e7\u00e3o de um ,,mix se mostrou obsoleto ,Pesquisa Nacional deDemografia e Sa\u00fade (PNDS), de 2006 ,,Por outro lado, muitas vezes os estudos sobre contracep\u00e7\u00e3o no Brasil - principalmenteaqueles em n\u00edvel nacional mixcontraceptivo brasileiro com os dados mais recentes da PNS de 2019, al\u00e9m de estimarque fatores est\u00e3o associados ao tipo de contraceptivo usado pelas brasileiras,considerando-se a classifica\u00e7\u00e3o dos m\u00e9todos quanto ao tempo de a\u00e7\u00e3o. Umainvestiga\u00e7\u00e3o dos principais grupos de m\u00e9todos , bem como dos m\u00e9todos permanentes, \u00e9 mais escassa e poderiacontribuir para o melhor entendimento do mix contraceptivo no pa\u00edse suas repercuss\u00f5es. Ademais, poderia elucidar diferen\u00e7as em rela\u00e7\u00e3o aos fatores quese associam ao uso de LARC e aos m\u00e9todos permanentes. A continuidade desses estudostamb\u00e9m se faz necess\u00e1ria em meio aos cortes or\u00e7ament\u00e1rios na \u00e1rea da sa\u00fade ,Diante do exposto, o objetivo deste estudo \u00e9 descrever o Trata-se de estudo epidemiol\u00f3gico transversal que utilizou dados da segunda edi\u00e7\u00e3o daPNS, de 2019. A PNS \u00e9 um inqu\u00e9rito de base populacional, representativo da popula\u00e7\u00e3obrasileira, que tem como objetivo fornecer informa\u00e7\u00f5es sobre os determinantes,condicionantes e necessidades de sa\u00fade da popula\u00e7\u00e3o brasileira A popula\u00e7\u00e3o deste estudo foi composta por mulheres de 15 a 49 anos que responderam aom\u00f3dulo referente \u00e0 sa\u00fade da mulher .Do totaEste estudo tem tr\u00eas desfechos de interesse: o uso de m\u00e9todos contraceptivos, o tipode m\u00e9todo contraceptivo usado e os grupos de m\u00e9todos contraceptivos modernos segundotempo de a\u00e7\u00e3o no organismo. A vari\u00e1vel uso de contraceptivos foi criada a partir dasquest\u00f5es R34 , R35 e R36 . O uso de m\u00e9todos contraceptivos foi categorizadoem n\u00e3o (0) e sim (1). Mulheres que responderam que n\u00e3o usavam m\u00e9todos contraceptivospor terem realizado laqueadura ou vasectomia pelo parceiro foram inclu\u00eddas nacategoria sim.Para a cria\u00e7\u00e3o da vari\u00e1vel tipo de m\u00e9todo contraceptivo usado pelas brasileiras,considerou-se o contraceptivo mais eficaz usado pela mulher Ap\u00f3s a defini\u00e7\u00e3o de um m\u00e9todo para cada mulher, os m\u00e9todos contraceptivos foramclassificados quanto ao tempo de a\u00e7\u00e3o no organismo em: (1) contraceptivosrevers\u00edveis de curta dura\u00e7\u00e3o (SARC) ; (2) LARC (DIU e implantes); e (3)permanentes (laqueadura e vasectomia). Para a an\u00e1lise do desfecho tipo de m\u00e9todocontraceptivo, as mulheres que usavam apenas \u201ctabelinha\u201d (n = 167), outros m\u00e9todoscontraceptivos tradicionais (n = 39) ou relataram apenas o uso da p\u00edlula do diaseguinte como m\u00e9todo contraceptivo (n = 20) e as mulheres que n\u00e3o usavam m\u00e9todocontraceptivo (n = 3.322) foram exclu\u00eddas, totalizando 16.414 usu\u00e1rias decontracep\u00e7\u00e3o moderna .per capita, emsal\u00e1rios m\u00ednimos - at\u00e9 1, de 1 a 3 e mais que 3; trabalho remunerado - sim e n\u00e3o).Para defini\u00e7\u00e3o do valor do sal\u00e1rio m\u00ednimo, que corresponde \u00e0 remunera\u00e7\u00e3o m\u00ednima dotrabalhador fixada por lei, considerou-se o valor em vigor no m\u00eas de refer\u00eancia dapesquisa As vari\u00e1veis explicativas inclu\u00edram: caracter\u00edsticas da hist\u00f3ria reprodutiva ; acesso aos servi\u00e7os de sa\u00fade; ecaracter\u00edsticas sociodemogr\u00e1ficas . Em seguida, a preval\u00eancia do tipo de m\u00e9todo classificado quanto ao tempo dea\u00e7\u00e3o, incluindo a categoria de n\u00e3o usu\u00e1rias, foi estimada segundo as caracter\u00edsticasda hist\u00f3ria reprodutiva, do acesso aos servi\u00e7os de sa\u00fade e sociodemogr\u00e1ficas.odds ratio (OR) n\u00e3o ajustada com os IC95% de cada vari\u00e1velexplicativa com o tipo de m\u00e9todo classificado quanto ao tempo de a\u00e7\u00e3o, desfechoprincipal do estudo. A categoria de refer\u00eancia foi: mulheres que usavam SARC. Aseguir, as vari\u00e1veis com valor de p < 0,20 foram inseridas no modelomultivariado. Utilizou-se o crit\u00e9rio forward, sendo as vari\u00e1veis den\u00edvel mais proximal (hist\u00f3ria reprodutiva) inseridas primeiro, seguidas pelasvari\u00e1veis do n\u00edvel intermedi\u00e1rio (acesso aos servi\u00e7os de sa\u00fade) e, por \u00faltimo, asvari\u00e1veis do n\u00edvel distal (caracter\u00edsticas sociodemogr\u00e1ficas). As vari\u00e1veis comvalor de p > 0,05 foram retiradas do modelo, utilizando-se o crit\u00e9riobackward. Destaca-se que o modelo multinomial gerou aestimativa de dois valores de OR: o primeiro comparando os m\u00e9todos de longa dura\u00e7\u00e3ocom os de curta dura\u00e7\u00e3o, e o segundo comparando os m\u00e9todos permanentes com os decurta dura\u00e7\u00e3o. Utilizou-se o teste Wald em cada entrada de vari\u00e1vel no modelo, etamb\u00e9m ap\u00f3s o modelo final, para avaliar a contribui\u00e7\u00e3o de cada vari\u00e1vel namodelagem Depois, foi utilizado o modelo de regress\u00e3o log\u00edstica multinomial para estimar aproxy de renda e com alta taxa de resposta, e o plano de sa\u00fadecomo um determinante importante do acesso aos LARC, conforme reportado por algunsestudos ,Tamb\u00e9m foi avaliada a rela\u00e7\u00e3o entre as vari\u00e1veis explicativas para inser\u00e7\u00e3o no modelomultivariado. Utilizou-se an\u00e1lise de distribui\u00e7\u00e3o entre os pares de vari\u00e1veisexplicativas e o teste qui-quadrado de Pearson nessa etapa. Observou-se que asmulheres com maior renda eram as que tinham maior escolaridade  e acesso aplano de sa\u00fade , com signific\u00e2ncia estat\u00edstica das diferen\u00e7as entre aspropor\u00e7\u00f5es . Assim, no modelo final, optou-se pela manuten\u00e7\u00e3o dasvari\u00e1veis escolaridade e plano de sa\u00fade, considerando-se a escolaridade comohttps://www.stata.com), vers\u00e3o 15.0, considerando-se o n\u00edvel de 5%de signific\u00e2ncia. As estimativas foram realizadas no m\u00f3dulo survey,que considerou na an\u00e1lise o efeito do plano amostral da PNS , com o objetivo de produzir estimativas populacionais para asubpopula\u00e7\u00e3o de mulheres em idade reprodutiva ,Os dados foram analisados com aux\u00edlio do software Stata , nasregi\u00f5es Sudeste  e Nordeste , tinha mais de 35 anos , de 10 a12 anos de estudo , era parda , com renda de at\u00e9 um sal\u00e1rio m\u00ednimo(58%) e trabalho remunerado , vivia com companheiro , j\u00e1 teve partos, n\u00e3o participou de grupos de planejamento reprodutivo , n\u00e3o tinhaplano de sa\u00fade  e era cadastrada na UBS  .A preval\u00eancia do uso de contraceptivos foi de 83,7%  (dado n\u00e3omostrado). Do total de usu\u00e1rias, os m\u00e9todos mais utilizados pelas brasileiras eram:p\u00edlula , preservativo masculino , laqueadura  e injet\u00e1veis . Ao clasQuanto ao tipo de m\u00e9todo usado, observou-se maior propor\u00e7\u00e3o de uso de SARC pelasmulheres que viviam nas regi\u00f5es Sul  e Sudeste , que tinham entre 15 e24 anos  e que n\u00e3o viviam com companheiro (73%) . Em relaQuanto aos fatores associados ao tipo de m\u00e9todo usado pelas brasileiras, observamosnas an\u00e1lises n\u00e3o ajustadas que a chance de usar LARC em rela\u00e7\u00e3o aos SARC foi maiorpara mulheres que viviam em \u00e1reas urbanas, nas regi\u00f5es Sudeste e Centro-oeste, quetinham trabalho remunerado, viviam com companheiro, tinham plano de sa\u00fade ehist\u00f3rico de um a dois partos anteriores. Destaca-se que, quanto maior a faixaet\u00e1ria, a escolaridade e a renda, maior a chance de usar LARC quando comparados aosSARC . Por outNas an\u00e1lises n\u00e3o ajustadas para o uso de m\u00e9todos permanentes observou-se que quantomaior a faixa et\u00e1ria e maior o n\u00famero de partos, maior a chance de uso em rela\u00e7\u00e3oaos SARC. Al\u00e9m disso, mulheres pardas, que tinham cadastro na UBS e viviam comcompanheiro tamb\u00e9m tinham maior chance de uso de m\u00e9todos permanentes se comparadas\u00e0s usu\u00e1rias de SARC. Observou-se ainda que possuir maior escolaridade e renda, viverem \u00e1reas urbanas e nas regi\u00f5es Sul e Sudeste, ter trabalho remunerado e plano desa\u00fade e haver participado de grupos de planejamento reprodutivo foram associados amenor chance de uso de m\u00e9todos permanentes quando comparados aos SARC. No modelomultivariado, as vari\u00e1veis que permaneceram associadas foram faixa et\u00e1ria, paridade,regi\u00e3o de moradia, escolaridade, participa\u00e7\u00e3o em grupo de planejamento reprodutivo eviver com companheiro  .,mix contraceptivoobsoleto, com mais de 60% das mulheres usando p\u00edlula ou preservativo, 17% dasmulheres esterilizadas e apenas 5% usando LARC, corroborando achados de outrosestudos (que inclu\u00edram somente mulheres de 18 a 49 anos), com poucas mudan\u00e7as emrela\u00e7\u00e3o a 2013 ,Os resultados do presente estudo evidenciam a manuten\u00e7\u00e3o de uma elevada preval\u00eanciade uso de contraceptivos pelas mulheres brasileiras, superior a 80%, conformeobservado em estudos pr\u00e9vios mix contraceptivo diversificado,como tamb\u00e9m foi observado em pa\u00edses como a China e Vietn\u00e3, que t\u00eam altaspreval\u00eancias de contracep\u00e7\u00e3o, apesar do uso concentrado em um ou dois m\u00e9todos Nesse sentido, destaca-se que altas preval\u00eancias de uso de contraceptivos n\u00e3o setraduzem necessariamente em um 14,\u200d15.Sabe-se que, no Brasil e em v\u00e1rios pa\u00edses de baixa e m\u00e9dia renda, a maioria dasgesta\u00e7\u00f5es ocorre antes de qualquer uso de contraceptivo, o que repercute em umapropor\u00e7\u00e3o grande de mulheres com menos de 30 anos atingindo o n\u00famero de filhosdesejado e com um per\u00edodo longo para evitar um filho extra Nosso estudo tamb\u00e9m mostrou que mulheres mais jovens, nul\u00edparas e sem cadastro nasUBS apresentaram menor preval\u00eancia de uso de contraceptivos, o que pode contribuirpara a elevada ocorr\u00eancia de gesta\u00e7\u00f5es na adolesc\u00eancia no pa\u00eds Nossos resultados tamb\u00e9m apontam para um poss\u00edvel problema de disponibilidade dem\u00e9todos contraceptivos, visto que os m\u00e9todos mais usados, como a p\u00edlula e opreservativo, tamb\u00e9m s\u00e3o os mais dispon\u00edveis nas UBS, enquanto o DIU \u00e9 o m\u00e9todomenos dispon\u00edvel Por outro lado, uma avalia\u00e7\u00e3o com provedores de contracep\u00e7\u00e3o moderna em pa\u00edses daAm\u00e9rica Latina, \u00c1sia e \u00c1frica mostrou que entre 40% e 49% das usu\u00e1rias de m\u00e9todoscontraceptivos modernos obtiveram seus m\u00e9todos por meio do setor privado, sendo queo aumento do uso de contraceptivos observado entre 1992 e 2012 foi impulsionado peloaumento do uso de SARC O aumento do uso de LARC, mais especificamente do DIU, provavelmente est\u00e1 relacionado\u00e0 regulamenta\u00e7\u00e3o da inser\u00e7\u00e3o do DIU ap\u00f3s o parto e abortamento nas maternidades,,O presente estudo tamb\u00e9m evidenciou iniquidades em rela\u00e7\u00e3o ao acesso aos LARC, umavez que as mulheres com maior vulnerabilidade social apresentaram menor preval\u00eancia de uso desses m\u00e9todos. Esses achados foramconfirmados no modelo final, com maior chance de uso desses m\u00e9todos contraceptivospor aquelas com melhores condi\u00e7\u00f5es socioecon\u00f4micas, tais como maior escolaridade eacesso ao plano de sa\u00fade, corroborando achados de outros estudos ,Acrescenta-se a esse cen\u00e1rio a menor disponibilidade do DIU no setor p\u00fablico nessespa\u00edses, onde as mulheres com maior vulnerabilidade social usualmente acessam oscontraceptivos Outro fator associado a maior chance de usar LARC foi a participa\u00e7\u00e3o em grupos deplanejamento reprodutivo, o que reflete a import\u00e2ncia de conhecer as op\u00e7\u00f5es dem\u00e9todos contraceptivos dispon\u00edveis para uma decis\u00e3o livre e informada a respeito damelhor op\u00e7\u00e3o contraceptiva para cada mulher. A baixa preval\u00eancia de acesso a essesgrupos refor\u00e7a a baixa disponibilidade de aconselhamento - importante pr\u00e1tica paragarantia desses direitos, para al\u00e9m do acesso ao m\u00e9todo contraceptivo.Por conseguinte, destaca-se que a educa\u00e7\u00e3o em sa\u00fade sexual e reprodutiva constitui-secomo um dos pilares para a promo\u00e7\u00e3o do uso de contraceptivos, especialmente dos LARCe para o grupo de mulheres mais jovens, incluindo adolescentes ,Por fim, houve uma redu\u00e7\u00e3o da preval\u00eancia de realiza\u00e7\u00e3o da laqueadura e um discretoaumento da vasectomia em rela\u00e7\u00e3o a 2013, considerando-se mulheres de 18 a 49 anos.Ademais, observamos um perfil de maior vulnerabilidade social para mulheres queusaram esses m\u00e9todos contraceptivos, o que pode estar relacionado \u00e0 fecundidade altaem idades mais jovens, bem como a dificuldades de acessar outros contraceptivos maiseficazes Uma preocupa\u00e7\u00e3o em rela\u00e7\u00e3o \u00e0s altas preval\u00eancias de m\u00e9todos permanentes em mulherescom maior vulnerabilidade social refere-se ao qu\u00e3o bem informadas essas mulheresest\u00e3o sobre a natureza permanente do m\u00e9todo e sobre a disponibilidade de outroscontraceptivos modernos, como os LARC, que t\u00eam efic\u00e1cia semelhante a esses m\u00e9todos,,Finalmente, destaca-se, como um dos nossos principais resultados sobre a associa\u00e7\u00e3ode fatores sociodemogr\u00e1ficos ao uso de LARC e m\u00e9todos permanentes, que mulheres commelhores condi\u00e7\u00f5es socioecon\u00f4micas t\u00eam maior chance de usar LARC e menor chance deusar m\u00e9todos permanentes, o que evidencia a manuten\u00e7\u00e3o de importante desigualdadesocial no acesso a contracep\u00e7\u00e3o no pa\u00eds, conforme observado em estudos pr\u00e9vios, decar\u00e1ter descritivo Apesar dos avan\u00e7os das pol\u00edticas nesse \u00e2mbito a partir da d\u00e9cada de 1980, nos \u00faltimosanos temos observado cortes no or\u00e7amento da sa\u00fade Algumas quest\u00f5es relacionadas ao question\u00e1rio da PNS precisam ser corrigidas parapermitir melhor monitoramento desses indicadores no pa\u00eds. O uso atual decontraceptivos n\u00e3o est\u00e1 bem definido na pergunta correspondente, que vem depoisde outra sobre atividade sexual nos \u00faltimos 12 meses; pode-se inferir que esteseja o per\u00edodo de refer\u00eancia. A laqueadura e a vasectomia n\u00e3o foram inclu\u00eddascomo m\u00e9todos contraceptivos, e sim como motivos para n\u00e3o se evitar uma gesta\u00e7\u00e3o,o que pode levar a uma subestima\u00e7\u00e3o do uso desses m\u00e9todos. Al\u00e9m disso, oinqu\u00e9rito excluiu quest\u00f5es sobre aborto e idade da primeira gesta\u00e7\u00e3o e n\u00e3oincluiu quest\u00f5es sobre o desejo de engravidar, um dos determinantes do uso decontraceptivos. Por outro lado, o inqu\u00e9rito de 2019 avan\u00e7a em rela\u00e7\u00e3o ao de 2013ao incluir mulheres a partir de 15 anos e ao considerar o m\u00e9todo mais eficazusado pela mulher - apesar de agrupar o implante em uma categoria de m\u00e9todos decurta dura\u00e7\u00e3o, o que foi corrigido neste estudo.mix contraceptivo no pa\u00eds se mant\u00e9mobsoleto, com alta preval\u00eancia de SARC, principalmente entre mulheres mais jovens enul\u00edparas. Tamb\u00e9m evidenciou os fatores associados ao tipo de contraceptivo usadopelas mulheres brasileiras, demonstrando que estes se associam de forma diferente emrela\u00e7\u00e3o ao uso de LARC e m\u00e9todos permanentes.Nossos achados mostraram que o Ressalta-se a import\u00e2ncia do monitoramento dos indicadores de contracep\u00e7\u00e3o no pa\u00eds,visto que constituem ferramenta de avalia\u00e7\u00e3o e implementa\u00e7\u00e3o de pol\u00edticas p\u00fablicasde planejamento reprodutivo. Mesmo com uma alta cobertura de uso de contracep\u00e7\u00e3o, adesigualdade persiste evidenciando a necessidade de amplia\u00e7\u00e3o do acesso a m\u00e9todosmais eficazes, principalmente nos servi\u00e7os p\u00fablicos de sa\u00fade e para mulheres maisjovens e com maior vulnerabilidade social, de maneira a tornar poss\u00edvel a meta daAgenda 2030 de \u201cn\u00e3o deixar ningu\u00e9m para tr\u00e1s\u201d.Por fim, nossos achados apontam para a necessidade de um aconselhamento contraceptivoqualificado para que as mulheres possam fazer uma escolha livre e informada docontraceptivo mais adequado a sua necessidade, respeitando-se, assim, os direitossexuais e reprodutivos."}
+{"text": "Entre o Segredo e a Solid\u00e3o: Aborto na Adolesc\u00eanciaO livro Pesquisa Nacional de Aborto de 2021 trouxe dados reveladores sobre avida reprodutiva das jovens, mostrando que 52% das entrevistadas tinham 19 anos ou menosquando fizeram o primeiro aborto A O livro est\u00e1 estruturado em uma apresenta\u00e7\u00e3o, quatro cap\u00edtulos sobre os resultados econsidera\u00e7\u00f5es finais. Na Apresenta\u00e7\u00e3o, temos um panorama dos dados nacionais einternacionais sobre aborto e s\u00e3o discutidas as dificuldades de obten\u00e7\u00e3o de informa\u00e7\u00f5esconfi\u00e1veis sobre o aborto provocado em contextos de ilegalidade. Apesar disso, estudosnacionais mostram a expressiva magnitude do processo, a correla\u00e7\u00e3o com a morbidade e amortalidade materna e a maior ocorr\u00eancia de desfechos negativos entre mulheres negras,menos escolarizadas e mais jovens A relev\u00e2ncia do estudo de Ferrari \u00e9 demonstrada pela pr\u00f3pria observa\u00e7\u00e3o de que o abortoprovocado \u00e9 pouco tratado na ampla literatura sobre gravidez adolescente, assim comoquest\u00f5es espec\u00edficas dos adolescentes s\u00e3o pouco esclarecidas nos estudos sobre o abortono Brasil. N\u00e3o \u00e9 de somenos, experenciar uma gravidez, decidir interromp\u00ea-la e realizarum aborto em situa\u00e7\u00e3o de clandestinidade e vulnerabilidade em um momento da vida deaprendizado da sexualidade.No Cap\u00edtulo 1, Ferrari faz uma an\u00e1lise do tema do aborto no Brasil, dos anos de 1970 at\u00e9a d\u00e9cada mais recente, colocando em an\u00e1lise os diferentes espa\u00e7os e atores participantesdo debate. Autoridades governamentais, organiza\u00e7\u00f5es partid\u00e1rias, legisladores,operadores do direito, setores m\u00e9dicos, pesquisadores, autoridades religiosas, m\u00eddia emovimentos sociais, especialmente feministas e movimentos de sa\u00fade s\u00e3o alguns dos atoresenvolvidos nas contendas quanto ao tema. Observa o autor que no plano da produ\u00e7\u00e3o deconhecimentos e desenvolvimento de pol\u00edticas de assist\u00eancia \u00e0s situa\u00e7\u00f5es de abortoveem-se alguns avan\u00e7os, contudo obst\u00e1culos importantes persistem e podem serexemplificados pelas pol\u00eamicas sobre o direito de interromper a gesta\u00e7\u00e3o no contexto daepidemia de Zika v\u00edrus. Al\u00e9m disso, o horizonte de retrocessos est\u00e1 sempre \u00e0espreita.Ferrari observa que os debates sobre reprodu\u00e7\u00e3o e adolesc\u00eancia tendem a se centrar nagravidez como fato dado, n\u00e3o considerando a quest\u00e3o da gesta\u00e7\u00e3o indesejada, os processosde decis\u00e3o sobre mant\u00ea-la ou n\u00e3o, as estrat\u00e9gias para viabilizar a decis\u00e3o deinterromper, as dificuldades em virtude da menoridade civil, as rela\u00e7\u00f5es desiguais deg\u00eanero, a falta de autonomia financeira, a falta de informa\u00e7\u00f5es e conhecimentos sobre oprocedimento abortivo, entre outras coisas.No Cap\u00edtulo 2, o caminho metodol\u00f3gico \u00e9 detalhado. \u00c9 muito interessante o relato sobre aconstru\u00e7\u00e3o do campo, as estrat\u00e9gias de aproxima\u00e7\u00e3o com as adolescentes e oestabelecimento do v\u00ednculo de confian\u00e7a, condi\u00e7\u00e3o sine qua non para que lhe contassemexperi\u00eancias de inicia\u00e7\u00e3o sexual, gravidez e aborto. Psic\u00f3logo de forma\u00e7\u00e3o, trabalhandono ambulat\u00f3rio de uma ONG atuante na favela, Ferrari inicialmente se prop\u00f4s a separar opsic\u00f3logo do pesquisador, mas teve a sensibilidade de se render \u00e0 din\u00e2mica relacionalque as pr\u00f3prias adolescentes impuseram, em que a separa\u00e7\u00e3o r\u00edgida - e artificial - entreos dois pap\u00e9is n\u00e3o parecia ser relevante. O m\u00e9todo e t\u00e9cnicas escolhidos teve comopreocupa\u00e7\u00e3o central permitir que as hist\u00f3rias de aborto flu\u00edssem a partir da perspectivadas jovens entrevistadas, e o modo de conduzi-los foi magistral. Tamb\u00e9m nesse aspecto, aobra de Ferrari \u00e9 altamente recomendada a pesquisadora(e)s do aborto e, de modo geral,dos temas que envolvem sexualidade, reprodu\u00e7\u00e3o e g\u00eanero.As hist\u00f3rias contadas pelas adolescentes s\u00e3o apresentadas e discutidas nos Cap\u00edtulos 3 e4. A op\u00e7\u00e3o do autor de apresentar partes abrangentes de seu acervo de entrevistas noCap\u00edtulo 3 foi muito oportuna. Os leitores s\u00e3o expostos n\u00e3o apenas \u00e0s an\u00e1lises, mas \u00e0sfalas das adolescentes, surtindo um efeito de maior proximidade com elas, conformepretendido por Ferrari. Ao l\u00ea-las, temos um contato mais v\u00edvido com suas experi\u00eancias esomos convidadas a participar ativamente da discuss\u00e3o do material. Os relatos s\u00e3o muitotocantes, ningu\u00e9m sai inc\u00f3lume. Passam por v\u00e1rios temas como o processo de inicia\u00e7\u00e3osexual, masturba\u00e7\u00e3o, din\u00e2micas das rela\u00e7\u00f5es com parceiros afetivo-sexuais, usos decontraceptivos, experi\u00eancia de engravidamento, decis\u00e3o pelo aborto, itiner\u00e1rios pararealiz\u00e1-lo. Sentimentos m\u00faltiplos, amb\u00edguos e conflitantes est\u00e3o envolvidos nessesitiner\u00e1rios, tais quais culpa e al\u00edvio, solid\u00e3o e solidariedade, estigmatiza\u00e7\u00e3o eafirma\u00e7\u00e3o da pr\u00f3pria autonomia.No Cap\u00edtulo 4, Ferrari discute como, a partir da gravidez indesejada, as adolescentesbuscam estrat\u00e9gias para acessar o procedimento do aborto, com os poucos recursos quedisp\u00f5em, mesmo correndo diversos riscos. O abandono pelos parceiros, antes ou depois doaborto, \u00e9 um componente traum\u00e1tico da experi\u00eancia. Muitas vezes s\u00e3o parceiros com idadesignificativamente maior, pertencentes a outra classe social ou casados. Com eles, asjovens mant\u00eam v\u00ednculos afetivo-sexuais assim\u00e9tricos, com autonomia limitada para decidirquando e como ter - ou n\u00e3o - rela\u00e7\u00f5es, negociar o uso da camisinha e, em face de umagesta\u00e7\u00e3o, lev\u00e1-la adiante ou interromp\u00ea-la.Outro componente da experi\u00eancia das adolescentes \u00e9 o sentimento de culpa que se acentuaem contextos sociais e familiares em que o tema do aborto \u00e9 silenciado ou associado aopecado pela vis\u00e3o religiosa. O estigma social refor\u00e7a o segredo e a solid\u00e3o do aborto naadolesc\u00eancia, apontando a extrema fragilidade e sofrimento das jovens em suasexperi\u00eancias individuais e trajet\u00f3rias abortivas. S\u00e3o relatos de dor, desamparo esolid\u00e3o, antes e depois do aborto. O aborto ilegal \u00e9 realizado mesmo com todos os riscosenvolvidos, seja da cl\u00ednica da favela, cl\u00ednicas de outros bairros ou com o uso demedicamento sem origem conhecida comprado na pr\u00f3pria favela. Nesse \u00faltimo caso, o autorsublinha novamente o contexto de opress\u00e3o de g\u00eanero ao discutir relatos dasadolescentes, uma vez que elas n\u00e3o podem comprar diretamente o medicamento para abortarna favela, pois nesse caso a compra \u00e9 restrita aos homens, ou seja, uma forma decontrole da sexualidade feminina.As meninas sozinhas ou apoiadas por amigas devem arcar com os cuidados de sa\u00fadenecess\u00e1rios no resguardo, por exemplo repouso, medicamentos para dor e sangramento. Asredes de amizade e a Internet s\u00e3o os meios priorit\u00e1rios pelos quais elas acessam ainforma\u00e7\u00e3o para cuidar da pr\u00f3pria sa\u00fade sexual e reprodutiva. O medo de serem julgadas,maltratadas, denunciadas ou presas afasta as mulheres dos servi\u00e7os de sa\u00fade paracuidados pr\u00e9 e p\u00f3s abortamento, sobretudo se forem mulheres negras e perif\u00e9ricas Nesse emaranhado de viv\u00eancias, \u00e9 poss\u00edvel perceber tamb\u00e9m resili\u00eancia e resist\u00eancia; oaborto pode ser de certa forma libert\u00e1rio para as adolescentes. Em geral, o sentimento \u00e9de al\u00edvio com a interrup\u00e7\u00e3o da gesta\u00e7\u00e3o, seja para perseguirem seus projetos de vida,seja para se livrar de um v\u00ednculo marcado por opress\u00f5es e viol\u00eancias. Nenhumaadolescente relatou arrependimento. Conforme Ferrari sugere, nas Considera\u00e7\u00f5es Finais, odireito ao aborto \u00e9 central para o processo de autonomia das mulheres.Para jovens negras e perif\u00e9ricas, o aprendizado da sexualidade se d\u00e1 em contextos deiniquidades e viol\u00eancias de g\u00eanero, ra\u00e7a e classe. O cen\u00e1rio desnudado pela pesquisa deFerrari \u00e9 de injusti\u00e7a estrutural, com suas express\u00f5es nas viv\u00eancias afetivas, sexuais ereprodutivas das adolescentes. O livro \u00e9 leitura necess\u00e1ria e indispens\u00e1vel parapesquisadores, ativistas, profissionais de sa\u00fade e todas as pessoas que t\u00eam interesse emdesvendar o contexto social caracterizado pela falta de acesso \u00e0 sa\u00fade, desigualdade deg\u00eanero, racismo estrutural, clandestinidade e ilegalidade do aborto que atinge com maiorimpacto as adolescentes negras moradoras das periferias urbanas."}
+{"text": "To analyze the association between hearing loss and health vulnerability in children aged 25 to 36 months.Analytical observational cross-sectional study conducted through child hearing screening in nine day-care centers. The screening consisted of anamnesis, otoscopy, tympanometry, transient otoacoustic emissions, and pure tone audiometry. For each exam performed, the 'pass' and 'fail' criteria were established. The children's residential addresses were georeferenced and a choropleth map of the spatial distribution was built, considering the Health Vulnerability Index (HVI). The analysis of the association between the HVI and the variables sex, auditory assessment, and region area of the household was performed using Pearson's Chi-square and Fisher's Exact tests.Ninety-five children of both sexes were evaluated, of which 44.7% presented alterations in at least one of the exams performed, being referred for otorhinolaryngological evaluation and subsequent auditory assessment. Of the observed changes, 36.9% occurred in the tympanometry and 7.8% in the transient otoacoustic emissions. Among children referred for reassessment, 9.7% were diagnosed with conductive hearing loss, 13.6% results within normal limits and 21.4% did not attend for assessment. Of the children who presented the final diagnosis of conductive hearing loss (9.7%), 1.9% were classified as low-risk HVI and 6.8% as medium-risk HVI. There was statistical significance between HVI and the child's place of residence.The association between hearing loss and HIV was not statistically significant; however, it was possible to observe that 77.7% of the children with hearing loss resided in sectors with medium- risk HIV The concepts of hearing and vulnerability may seem subtly articulated. However, it is essential to discuss auditory diagnoses considering vulnerability and health conditions, especially in early childhood.-3, as well as the importance of the access to and transit in the health system to ensure timely comprehensive assistance.This discussion does not exclude the understanding that children\u2019s first years of life is when the central auditory system undergoes its greatest maturation, and the auditory pathway presents greater neural plasticity-6. According to previous research data despite being mandatory, the coverage of neonatal hearing screening (NHS) in the Southeast Region reaches only 70.3% of newborns. The study shows that Brazilian rates are still low, despite their positive evolution - between January 2008 and June 2015, the final coverage was 31.8%, ranging between Brazilian regions from 19% to 100%. This indicates unequal spatial distribution, with better coverages concentrated in the South and Southeast Regions.The identification and diagnosis process in children is complex and may be hindered by socioeconomic, assistance, and cultural barriers. Studies show that hearing loss is identified at the mean age of 2 and a half to 3 years, which is already late, given the scientific recommendations that electronic devices should be preferably fit before 6 months old. This study considered vulnerability from the perspective of social health determinants, approaching the Health Vulnerability Index (HVI) developed by the Municipal Department of Health of Belo Horizonte, articulating it with the hearing screening process in the age range from 25 to 36 months.In this context, it is unquestionably necessary to discuss vulnerability and the use of its indicators in hearing prevalence and diagnosis studies. The literature points out that using these instruments may help understand the needs and data to develop policies, make decisions, and publicize information,10.The initial diagnosis knowingly does not reach all Brazilian children, and many of them get to preschool without adequate approach. Thus, hearing screening in preschoolers may prevent difficulties in oral and written language development, as both are directly related to hearing. About 50% of hearing losses could be avoided or have their sequelae minimized if identification, diagnosis, and rehabilitation measures were taken earlier, especially in schoolchildrenGiven the relevance of diagnosing hearing loss at an adequate age in childhood, its impact on children\u2019s global development and quality of life, and its relationship with social determinants, this study aimed to analyze the association between hearing changes and health vulnerability in children aged 25 to 36 months attending public day care centers.This cross-sectional, analytical, observational study was approved by the Ethics Committee of the Federal University of Minas Gerais under number 931.831 and is part of a larger study entitled Development of a Pediatric Hearing Screening Instrument.The sample of the present study comprised children aged 25 to 36 months attending day care centers partnered with the municipal government of Belo Horizonte. The sample calculation was made for the larger project, which assessed children in three age ranges: 12 to 18 months, 25 to 36 months, and 37 to 48 months. This research assessed only those aged 25 to 36 months. The main study\u2019s sample calculation addressed the three age groups. It considered a 5% error, a 5% level of significance, a 10% population loss, and that the actual hearing change rates in the population of Belo Horizonte would hardly exceed 30%. Thus, the final calculation suggested a sample of 108 in each age group. However, in the present study, only 95 parents/guardians of children aged 25 to 36 months signed an informed consent form (ICF), which defined the sample size.This study encompassed nine day care centers in the metropolitan area of Belo Horizonte, located in each of the nine administrative regions of the city: Barreiro, Central-South, East, Northeast, Northwest, North, West, Pampulha, and Venda Nova. One day care center from each region was selected to ensure the whole municipality of Belo Horizonte was represented. Their principals were asked whether they agreed to participate, and the parents/guardians of all children in the study\u2019s age range were invited to the research.The inclusion criteria to participate in the study were children aged 25 to 36 months, attending day care centers partnered with the municipal government of Belo Horizonte, and whose parents/guardians agreed with their participation and signed an ICF. Children who did not attend the day care center on the day of screening or diagnostic assessment or whose parents informed they had given up on their participation at any stage of the study were excluded.The study had three stages - the first one was named screening, the second one, diagnosis, and the last one, georeferencing. The screening was carried out at the day care centers, and the diagnosis (for those who \u201cfailed\u201d in the first stage) was conducted at the HC/UFMG S\u00e3o Geraldo Hospital. Each stage had specific procedures.The first-stage assessments took place between February and December 2017, in two weekdays, one of them in the morning and the other in the afternoon. The whole assessment took a mean of 10 to 20 minutes per child. The terms \u201cpass\u201d and \u201cfail\u201d were used to classify the audiological examination results. The following screening procedures were used:Otoscopy: the external auditory meatus was inspected with a Pocket Junior otoscope with fiber-optic light 2.5V 22840 - Welch Allyn. .Tympanometry: conducted with Madsen Otoflex 100 acoustic-immittance meter, calibrated according to ANSI S3.6, to assess whether the tympanic-ossicular chain was intact with the tympanometry curve and research the ipsilateral and contralateral acoustic reflexes in all children assessed with otoscopy. Tympanometry results were analyzed based on the normal standard suggested by Jerger and Jerger\u00ae equipment, manufactured by ECHODIA. The record protocol in screening mode used nonlinear click stimuli at 80 dBSPL, with a 12-millisecond test window, totaling 512 stimuli. TEOAE were considered present when the reproducibility was equal to or greater than 70% and the signal-to-noise ratio (SNR) was equal to or greater than 3 dB, using the \u201cpass/fail\u201d criteria. Children whose unilateral or bilateral result was \u201cfail\u201d were referred for otorhinolaryngological and speech-language-hearing assessments.Transient otoacoustic emissions (TEOAE): performed in a portable sound booth, mini model, measuring 90 x 90 x 155 cm. TEOAE was recorded with Elios\u00ae equipment, manufactured by ECHODIA, and TDH supra-aural earphones. The air-conduction thresholds were researched (sweep technique at 20 dB), at frequencies: 500, 1000, 2000 and 4000 Hz. always using playful resources to entertain the child. Those whose auditory thresholds were above 20 dBHL in at least one of the test frequencies  were referred for otorhinolaryngological and speech-language-hearing assessments.\u25cf Pure-tone threshold audiometry: conducted in a portable sound booth, mini model, measuring 90 x 90 x 155 cm, using EliosThe parents received a feedback document with the examinations and results. In the case of children who \u201cfailed\u201d any examination, the document informed the scheduled appointment for otorhinolaryngological and speech-language-hearing assessment at the audiology service to reach a diagnosis.The second stage - i.e., the diagnostic assessment of children who \u201cfailed\u201d at least one of the examinations conducted at the day care center - took place at the HC/UFMG S\u00e3o Geraldo outpatient center. The diagnostic assessment had the following procedures: otorhinolaryngological assessment, tympanometry, TEOAE, conditioned pure-tone audiometry, and auditory brainstem response (ABR). The assessment team had an otorhinolaryngologist, two speech-language-hearing therapists, and two undergraduate speech-language-hearing interns. They conducted the following procedures:Otorhinolaryngological assessment: thoroughly conducted, removing cerumen with warm water and curette, when necessary. The cases with acute upper airway infection underwent treatment and were later referred to community health centers for follow-up with an outpatient otorhinolaryngologist. Chronic cases received instructions and were also referred to community health centers..Acoustic immittance: The equipment used for diagnosis was an acoustic-immittance meter, model AT 235, manufactured by Interacoustics, calibrated on August 23, 2017, with certificate no. 4251/2017. Ipsilateral and contralateral acoustic reflexes were researched at 1, 2, and 4 kHz. Tympanometry results were analyzed based on the normal standards suggested by Jerger and Jerger.Pure-tone threshold audiometry and speech audiometry: conducted with an audiometer AD229b, manufactured by Interacoustics, calibrated on August 23, 2017, with certificate no. 4246/2017. It used the descending technique at 250, 500, 1000, 2000, 3000, 4000, and 8000 Hz (air-conduction) and 500, 1000, 2000, 3000, and 4000 Hz (bone-conduction). Speech audiometry was conducted in a simple order, using auditory masking when necessary. The results were analyzed based on the normal standard proposed by the International Bureau for Audiophonology (BIAP)\u00ae equipment, manufactured by ECHODIA, researching the electrophysiological thresholds and the integrity of the auditory pathways. The protocol used rarefied click stimuli, 3000-Hz low-pass filter, 50-Hz high-pass filter, with 17 clicks per second and at least 1000 acquisitions. The electrodes were positioned at Cz, Fz, A1, and A2, and the stimuli were presented via insert earphones. Impedance was maintained at the maximum limit of 5 kilohms. The integrity of the auditory pathways was assessed in two sweeps at 80 dBnHL, researching the latencies of waves I, III, and V, the interpeak intervals, and the reproducibility. The electrophysiological threshold was determined as the last intensity at which the wave V appeared.ABR: recorded with Elios\u00ae equipment, manufactured by ECHODIA, using nonlinear click stimuli at 80 dBSPL and 12-millisecond test window, totaling 512 stimuli. TEOAEs were considered present when the reproducibility was equal to or greater than 70% and SNR was equal to or greater than 3 dB.\u25cf TEOAE: performed with EliosAs for the flow of attention in the second stage, after the otorhinolaryngological assessment and procedure, the children were referred for acoustic immittance and then audiometry and TEOAE. Those whose examinations were all within normal standards obtained the result of normal hearing. Children who could not be conditioned to undergo audiometry were referred for objective examination (ABR). At the end of the assessment, parents/guardians received the examination results. When necessary, the children were referred to the family\u2019s reference community health center to enroll the child in the Hearing Health Service. and socioeconomic and health variables to analyze the characteristics of population groups who live in the various census sectors. The index comprises variables on permanent private homes with inadequate or absent water supply, sewage, and waste collection; the number of people per household; the percentage of illiterate people; the percentage of private homes with per capita income of up to half a minimum wage; the householder\u2019s mean nominal monthly income; and the percentage of multiracial, black, or indigenous people. At the end of the process, HVI is classified into the following four categories: low, medium, high, and very high health vulnerability. This study identified the risk corresponding to the census sectors in which each participating child lived. In the analysis, the high and very high categories were grouped into one.Lastly, data were treated and analyzed. The participating children\u2019s home address was searched to identify their census sector and HVI, developed and used by the Municipal Department of Health of Belo Horizonte to organize the health services in the municipality. HVI is a compound indicator that uses 2010 census dataThe following variables were selected for data analysis: sex; age (in months); region of residence; otoscopy, tympanometry, otoacoustic emissions (OAE), and audiometry screening results (classified as either \u201cpassed\u201d or \u201cfailed\u201d); referrals (yes or no); diagnostic assessment results ; and HVI of the census sectors where the children lived .Georeferencing of the places where children lived was based on their home addresses, then identifying the respective census sectors and classifications, using ArcGis program, version 10.5, ArcMap tool, and Google Earth Pro, version 7.3.1. The children\u2019s addresses were located with Google Earth Pro, from which .kml extension files were extracted for georeferencing on ArcGis, thus producing maps over the 2012-HVI basis of the municipal government of Belo Horizonte. Out of the total 95 addresses, 94.8% were processed and georeferenced, identifying their census sectors in Google Earth. Five addresses could not be manually located, which corresponds to 5.2% of all addresses available.The descriptive analysis used the distribution of absolute and relative frequencies of the categorical variables and measures of central tendency, position, and dispersion of the children\u2019s ages.The association analysis considered two response variables - (1) OAE results and (2) HVI. It was assessed whether the former associated with audiometry and tympanometry results in the screening and diagnostic assessments and whether the latter associated with sex, examination results, referrals, and diagnoses. The association analyses used Peason\u2019s chi-square and Fisher\u2019s exact tests, considering statistically significant associations with p-value \u2264 0.05. Data were entered, processed, and analyzed in SPSS software, version 21.0.The study assessed 95 children who attended nine day care centers located in the nine regions of Belo Horizonte. Of the 46 subjects referred for diagnosis, 26 attended the assessment. Of these, 14 had normal results at the end of the assessments; two did not let the professionals assess them and were submitted to ABR, obtaining normal results; and 10 had abnormal results. Hence, the result/diagnosis of 10.5% of the 26 subjects assessed was conductive hearing loss; they were referred to the community health center to be enrolled in the Hearing Health Service for follow-up. Participants who did not attend stage 2 (diagnosis) on the scheduled date were recontacted. However, 22 children (47.8%) did not attend it, even after various rescheduling attempts , Table 1Most (56.3%) of the 95 children included in the research were females , with a In screening, 46 children  failed and were, therefore, referred to the second stage. However, 22 of them did not attend the diagnostic assessment - i.e., only 52.2% were assessed. Hence, those who attended diagnostic assessment and had normal results in all examinations  were 14.7% of the total sample, whereas those with abnormal results were 10.5% .The 95 children whose parents signed an ICF were distributed into regions as follows: 12 lived in Barreiro; 10, in the Central-South; 16, in the East; 14, in the Northeast; 10, in the Northwest; 14, in the West; 10, in Pampulha; and 4, in Venda Nova. As for HVI, 59.2% of participating children lived in medium-risk census regions, while 9.7% lived in high/very high-risk census regions. It was not possible to identify the regions of 4.9% of the participants because they did not live in Belo Horizonte .Of the children who failed the tympanometry in the first stage (screening), 10.0% lived in low-risk census regions; 24.4%, in medium-risk; and 4.4% in regions that posed a high/very high risk of acquiring a disease and dying. Of those who failed OAE, also performed at the day care centers, 3.6% lived in low-risk census regions; 9.1%, in medium-risk; and 1.8%, in high/very high-risk census regions.The association analysis between TEOAE results in the second stage and tympanometry and audiometry results  revealedThe responses \u201cfail\u201d and \u201cdoes not live in Belo Horizonte\u201d were excluded from the georeferencing for the association analysis between HVI and screening examinations. It revealed no statistically significant association between any of the results . HoweverThe association analysis between HVI and sex and second-stage audiological examinations found no statistically significant result in any of the analyses .The association analysis between HVI and screening results (\u201cpass\u201d and \u201cfail\u201d) found no statistically significant values. However, it was verified that 8.9% of the children who \u201cpassed\u201d it  lived in low-risk census regions; 37.8%, in medium-risk regions; and 5.6% in high/very high-risk regions. Of those who \u201cpassed\u201d the screening, 12.2% lived in low-risk census regions; 30.0%, in medium-risk regions; and 5.6%, in high/very high-risk regions. The association analysis between HVI and diagnosis likewise did not find statistically significant values. Of the children with a diagnosis of change, 77.7% were from medium-risk census regions. The association analysis between HVI and the results of stages one and two did not find statistically significant values. Of the total 22 children who did not attend the diagnostic stage, 17 (77%) lived in low and medium-risk census regions, although the association was not statistically significant (p = 0.306) .The analyses in this study showed that almost half of the children screened at the day care centers \u201cfailed\u201d it and had to be referred to the diagnostic stage. However, little more than half of them attended the assessment. The prevalence of conductive hearing loss in the assessed sample was 13.7%.,15, the present study has an unprecedented approach, aiming to broaden the discussion on factors associated with hearing loss intervention results and strategies for this age range.Even though the literature discusses hearing screening in students in terms of protocolization and purpose and the assessment of students. According to the recommendations of the Commission for the Early Detection of Childhood Deafness (CODEPEH) regarding early diagnosis, the period from 0 to 6 years old requires greater attention to prevent and promote health, and it is when hearing must be periodically assessed.Thus, the age addressed in this study was intentionally defined at 25 to 36 months, given their language and hearing development process and enrolment in preschool. Also, this is the age that connects studies on NHS.In this context, a longitudinal study in 35,668 children that had been submitted to NHS and retested after first grade verified that 3.65 per 1,000 children had permanent hearing loss. The prevalence of moderate to profound bilateral hearing loss was 1.51 per 1,000. However, the NHS had identified only 0.9 children with this degree of hearing loss per 1,000,18-20. Thus, hearing screening is extremely important in the school context, as the population in this age range is more vulnerable to diseases (including otitis media) because of their still developing immune system.The prevalence of conductive hearing loss verified in this study is not surprising, as the literature points out that otitis media is the most common cause of hearing loss in children aged 1 to 5 years,18-20 is that almost half of the sample failed examinations, and about 40.0% failed tympanometry (screening) with types B and C tympanograms at the time of the assessment. This \u2018\u2019moment\u201d of hearing deprivation can cause central auditory processing disorders, phonetic and phonological deviations, and learning, reading, and writing difficulties,18.Another information that corroborates the literature concerning the occurrence of conductive loss and indicated that 24.12% of the assessed sample had middle-ear changes, and the most common abnormal tympanograms were types B and C. Also, a study conducted in inland Malawi, in West Africa, in 281 children aged 4 to 6 years indicated conductive loss in 46.9% of the sample. The varying results may be ascribed to factors such as sample definition, given that the age range may be related to conductive loss susceptibility or assessment seasonality, as conductive losses are more common in certain climate conditions.It can be verified that the literature on the topic has various results on the prevalence of conductive hearing loss in studies involving hearing screening. A study conducted in Rio de Janeiro assessed 431 children aged 1 to 12 years. A study conducted at a reference NHS service of a University Hospital assessed 261 newborns with risk factors for hearing loss and verified that 13.40% of them \u201cfailed\u201d TEOAE due to temporary conductive loss, identified with tympanometry and otorhinolaryngological assessments. Thus, the results reinforce the importance of using this procedure and corroborates the literature that indicates that performing TEOAE timely can help reach a hearing loss diagnosis earlier and define further assessments and the beginning of interventions, such as hearing aid fitting and hearing rehabilitation.The occurrence of almost 15% of OAE \u201cfail\u201d results in this study\u2019s children who had \u201cpassed\u201d the tympanometry suggests that these cases have hearing thresholds above 30 dBHL. Nonetheless, other studies highlight that audiometry is more sensitive than TEOAE, although both can be used to screen preschoolers and schoolers.When relating different examinations, it must also be pointed out that more than 15% of the children who \u201cpassed\u201d OAE did not let professionals perform audiometry on them. This corroborates research in 200 children aged 2 to 5 years, whose comparison analysis between these examinations indicated that about 12% of them did not undergo audiometry for the lack of effective conditioning or impossibility of placing the earphones , whereas only 2% of participants did not accept the TEOAE probe. Therefore, the researchers concluded that audiometry is not indicated for preschoolers\u2019 assessmentThe present study reinforces the question and broadens the discussion on preschoolers\u2019 hearing screening protocol. The statistical significance between second-stage TEOAE and tympanometry and audiometry results also demonstrates the importance and appropriateness of OAE as a school screening procedure.8. However, the present study had the adherence of only one-fourth of the sample referred for diagnosis at a specialized service in the health system - which may have compromised the final result. This finding corroborates a study in preschools in the same municipality, which likewise had low adherence to the diagnostic stage.Constructing the method in two stages (screening and diagnosis) is adequate and mentioned in the literature.In a recent literature review, the studies report adherences to diagnosis ranging from 10% to 65%. The potential reasons they cite for low adherence include the impossibility to contact parents and report the results, the parents\u2019 lack of knowledge of the medical meaning of hearing loss, the cost of subsequent care, the parents\u2019 unavailability to be absent at work, and geographical barriers. In general, there was an almost unanimous recommendation that this aspect is crucial to increase the overall effectiveness of school hearing screening programs worldwide. Other similar studies,26-28 also showed that conductive loss was the most recurrent among preschoolers.The final result of more than one-third of the children who attended diagnosis was conductive hearing loss. This information converges with a similar study conducted in 87 Chilean children aged 3 to 5 years, in which 15% of the sample had conductive hearing loss by the municipal government, which indicated that less than 40% of the population lived in medium-risk census regions, and a little more than one-fourth lived in high/very high-risk regions. Two issues may explain this. The first one is the selection of one day care center per administrative region, so that the sample distribution did not correspond to the population scenario in the municipality. The second explanation is the institutions\u2019 profiles, which are day care centers partnered with the municipal government.Concerning the third stage of the study , most participating children  lived in medium-risk census regions, and less than 10% lived in high/very high-risk regions. These data do not corroborate the HVI distribution published in 2018.The HVI vulnerability analysis shows that the apparent similarity in the profile of children who \u201cfailed\u201d the first and second stages may result from the greater concentration of participants in medium-risk census regions. Hence, the greater concentration of changes in this stratum must be cautiously analyzed, verifying it based on the distribution of participants in each stratum. Nevertheless, it must be considered that the 7.8% loss at georeferencing may refer to addresses in urban agglomerations, which would correspond to very-high HVI areas. Research in children who lived in the same municipality of this study and were assessed at a reference NHS service in 2010 and 2011 showed that 46.6% of the children lived in high or very high-risk census regions, and there was a greater proportion of \u201cfail\u201d results in children who lived in areas of greater health vulnerabilityEven though the present study did not find statistical significance in the association between HVI and sex and auditory examination, there is some similarity with the abovementioned study. The proportion of children who \u201cfailed\u201d the first stage and lived in low-risk census regions was smaller than those who \u201cfailed\u201d it and lived in medium-risk regions.. The methodology used in this study makes progress in addressing social health determinants regarding hearing diagnoses and, therefore, proposing strategies. Thus, it is clearly important to approach the hearing function in integration with life and discuss to what extent vulnerability can hinder prevention, monitoring, and diagnostic actions.Lastly, it is important to highlight the hearing screening approach used in this study. Research on this topic usually studies it from a clinical-assistance or prevention perspectiveThis study found no statistically significant association between hearing loss and HVI. However, it was found that 77.7% of the children diagnosed with hearing loss lived in HVI middle-risk census regions. A articula\u00e7\u00e3o dos conceitos de audi\u00e7\u00e3o e vulnerabilidade pode parecer t\u00eanue. Contudo, \u00e9 fundamental a discuss\u00e3o do diagn\u00f3stico auditivo sob a luz das condi\u00e7\u00f5es de vulnerabilidade e sa\u00fade, sobretudo em crian\u00e7as em seus anos iniciais.-3 e, tampouco, da import\u00e2ncia do acesso e trajet\u00f3ria no sistema de sa\u00fade na garantia da assist\u00eancia integral e em tempo oportuno.\u00c9 preciso destacar que tal discuss\u00e3o n\u00e3o exclui a compreens\u00e3o de que os primeiros anos de vida da crian\u00e7a s\u00e3o o per\u00edodo em que ocorre o maior processo de matura\u00e7\u00e3o do sistema auditivo central assim como a plasticidade neural da via auditiva-6. Segundo dados de pesquisa pr\u00e9via mesmo a Triagem Auditiva Neonatal sendo obrigat\u00f3ria, a cobertura na regi\u00e3o sudeste atinge apenas 70,3% dos rec\u00e9m-nascidos. O estudo mostra que embora no Brasil ocorra uma evolu\u00e7\u00e3o positiva, os \u00edndices ainda s\u00e3o baixos, pois no per\u00edodo de janeiro de 2008 a junho de 2015 a cobertura final foi de 31,8% com varia\u00e7\u00e3o entre as regi\u00f5es brasileiras de 19% a 100%, indicando distribui\u00e7\u00e3o espacial desigual e as melhores coberturas concentradas nas Regi\u00f5es Sul e Sudeste.O processo de identifica\u00e7\u00e3o e diagn\u00f3stico em crian\u00e7as \u00e9 complexo e pode ser atravessado por barreiras socioecon\u00f4micas, assistenciais e culturais. Estudos mostram que a m\u00e9dia de idade em que ocorre a identifica\u00e7\u00e3o da perda auditiva est\u00e1 em torno de dois anos e meio a tr\u00eas anos de idade, o que j\u00e1 \u00e9 tardio considerando as recomenda\u00e7\u00f5es cient\u00edficas que priorizam a adapta\u00e7\u00e3o de dispositivos eletr\u00f4nicos antes dos seis meses de idade. No presente estudo a vulnerabilidade foi considerada sob a perspectiva dos determinantes sociais da sa\u00fade sendo estudada com o uso \u00cdndice de Vulnerabilidade \u00e0 Sa\u00fade (IVS), desenvolvido pela Secretaria Municipal de Sa\u00fade de Belo Horizonte em busca da articula\u00e7\u00e3o com o processo de triagem auditiva na faixa et\u00e1ria de 25 a 36 meses.Neste contexto, indubitavelmente, \u00e9 preciso inserir a discuss\u00e3o sobre a vulnerabilidade e uso dos seus indicadores em estudos de preval\u00eancia e diagn\u00f3stico em audi\u00e7\u00e3o. A literatura aponta que o uso desses instrumentos pode facilitar a compreens\u00e3o de demandas e de informa\u00e7\u00e3o para formula\u00e7\u00e3o de pol\u00edticas, para a tomada de decis\u00f5es, ou ainda na divulga\u00e7\u00e3o de informa\u00e7\u00f5es,10.Sabe-se que o diagn\u00f3stico inicial n\u00e3o alcan\u00e7a a totalidade das crian\u00e7as brasileiras e, portanto, muitas chegam \u00e0 educa\u00e7\u00e3o infantil sem uma abordagem adequada. Em conseguinte, a triagem auditiva em escolares inseridos na educa\u00e7\u00e3o infantil poder\u00e1 prevenir dificuldades no desenvolvimento da linguagem oral e escrita, j\u00e1 que ambas est\u00e3o diretamente ligadas \u00e0 audi\u00e7\u00e3o. Cerca de 50% das perdas auditivas poderiam ser evitadas ou suas sequelas diminu\u00eddas se ocorressem precocemente medidas de identifica\u00e7\u00e3o, diagn\u00f3stico e reabilita\u00e7\u00e3o, principalmente em crian\u00e7as em idade escolarDiante da relev\u00e2ncia do diagn\u00f3stico da defici\u00eancia auditiva em tempo oportuno na inf\u00e2ncia, seu impacto no desenvolvimento global e na qualidade de vida da crian\u00e7a e a triangula\u00e7\u00e3o com os determinantes sociais, este estudo tem como objetivo analisar a associa\u00e7\u00e3o entre altera\u00e7\u00f5es auditivas e a vulnerabilidade \u00e0 sa\u00fade em crian\u00e7as na faixa et\u00e1ria de 25 a 36 meses matriculados em creches p\u00fablicas.Trata-se de estudo observacional anal\u00edtico do tipo transversal, aprovado pelo Comit\u00ea de \u00c9tica da Universidade Federal de Minas Gerais sob o n\u00famero 931.831 e faz parte de um estudo maior intitulado Desenvolvimento de instrumento para triagem auditiva infantil.No presente estudo a amostra foi composta por crian\u00e7as na faixa et\u00e1ria de 25 a 36 meses matriculadas em creches conveniadas \u00e0 prefeitura municipal de Belo Horizonte. O c\u00e1lculo amostral foi realizado para o projeto maior, no qual foram avaliadas crian\u00e7as em tr\u00eas diferentes faixas et\u00e1rias: 12 a 18 meses, 25 a 36 meses e 37 a 48 meses. Entretanto, esta pesquisa avaliou apenas as crian\u00e7as da faixa et\u00e1ria de 25 a 36 meses de idade. O C\u00e1lculo amostral foi realizado para o estudo principal, considerando: os tr\u00eas grupos et\u00e1rios, que a verdadeira taxa de altera\u00e7\u00e3o auditiva na popula\u00e7\u00e3o de Belo Horizonte dificilmente exceda 30%; erro de 5%; e n\u00edvel de signific\u00e2ncia de 5%. Considerando perda de 10% da popula\u00e7\u00e3o, o c\u00e1lculo final sugeriu amostra de 108 de cada grupo et\u00e1rio. Por\u00e9m, no presente estudo, apenas 95 respons\u00e1veis de crian\u00e7as na faixa et\u00e1ria de 25 a 36 meses de idade assinaram o termo de consentimento livre esclarecido (TCLE), o que definiu o tamanho amostral.Este estudo foi realizado em nove creches da regi\u00e3o metropolitana de Belo Horizonte, localizadas em cada uma das nove regionais administrativas da cidade: Barreiro, Centro-Sul, Leste, Nordeste, Noroeste, Norte, Oeste, Pampulha e Venda Nova. Para que fosse obtida representatividade de todo o munic\u00edpio de Belo Horizonte, uma creche em cada regional foi selecionada e a dire\u00e7\u00e3o consultada sobre a ades\u00e3o. Em cada creche participante, todos os respons\u00e1veis pelas crian\u00e7as na faixa et\u00e1ria do estudo foram convidados a participar.Os Crit\u00e9rios de inclus\u00e3o para a participa\u00e7\u00e3o no estudo foram crian\u00e7as na faixa et\u00e1ria entre 25 e 36 meses, matriculadas em creches conveniadas \u00e0 Prefeitura de Municipal de Belo Horizonte cujos pais ou respons\u00e1veis legais aceitarem e assinarem o TCLE. Foram exclu\u00eddas crian\u00e7as que n\u00e3o compareceram \u00e0 creche no dia da triagem ou avalia\u00e7\u00e3o diagn\u00f3stica ou que respons\u00e1veis informaram a desist\u00eancia de participa\u00e7\u00e3o em alguma etapa do estudo.O estudo constou de tr\u00eas etapas, sendo a primeira denominada triagem, a segunda diagn\u00f3stico e a \u00faltima georreferenciamento. A triagem foi realizada nas creches e o diagn\u00f3stico no Hospital S\u00e3o Geraldo HC/UFMG, para aquelas crian\u00e7as que \u2018\u2019falharam\u201d na primeira etapa. Cada etapa contou com procedimentos espec\u00edficos.As avalia\u00e7\u00f5es na primeira etapa foram realizadas entre os meses de fevereiro a dezembro de 2017, em dois dias da semana, sendo um no per\u00edodo da manh\u00e3 e outro no outro no per\u00edodo da tarde. O tempo m\u00e9dio para a realiza\u00e7\u00e3o de toda a avalia\u00e7\u00e3o foi entre 10 a 20 minutos por crian\u00e7a. Para classificar os resultados dos exames audiol\u00f3gicos foram utilizados os termos: \u201cpassa\u201d e \u201cfalha\u201d. Os procedimentos da triagem foram os seguintes:Meatoscopia: a inspe\u00e7\u00e3o do meato ac\u00fastico externo foi realizada com o Otosc\u00f3pio Pocket Junior com ilumina\u00e7\u00e3o por fibra \u00f3tica 2,5V 22840 \u2013 Welch Allyn.Timpanometria: realizada com o imitanci\u00f4metro Madsen Otoflex 100, calibrado segundo o padr\u00e3o ANSI S3.6 com o objetivo de avaliar a integridade do sistema t\u00edmpano-ossicular, por meio da curva timpanom\u00e9trica e pesquisa dos reflexos ac\u00fasticos ipsi e contralaterais, de todas as crian\u00e7as avaliadas na meatoscopia. Os resultados da timpanometria foram analisados segundo o padr\u00e3o de normalidade sugerido por Jerger e JergerEmiss\u00f5es Otoac\u00fasticas Transientes (EOAT): realizada em cabina ac\u00fastica port\u00e1til modelo mini com dimens\u00f5es de 90x90x155cm. O aparelho utilizado para o registro das EOAT foi o Elios\u00ae da marca ECHODIA. O protocolo de registro adotado, modo screening, utilizou est\u00edmulos cliques n\u00e3o lineares a uma intensidade de 80 dB NPS e a janela de testagem foi de 12 milissegundos, com 512 est\u00edmulos. As EOAT foram consideradas presentes quando a reprodutibilidade for igual ou maior a 70% e a rela\u00e7\u00e3o S/R , igual ou maior a 3dB foi utilizado o crit\u00e9rio \u2018\u2019passa\u201d e \u2018\u2019falha\u201d. As crian\u00e7as que apresentaram resultado \u2018\u2019falha\u201d, uni ou bilateralmente, foram encaminhadas para avalia\u00e7\u00e3o otorrinolaringol\u00f3gica e fonoaudiol\u00f3gica.) Sempre foram utilizados recursos l\u00fadicos para o condicionamento da crian\u00e7a. As crian\u00e7as que apresentaram limiares auditivos acima de 20dB NA em pelo menos uma das frequ\u00eancias testadas, \u2018\u2019falha\u201d, foram encaminhadas para avalia\u00e7\u00e3o otorrinolaringol\u00f3gica e fonoaudiol\u00f3gica.\u25cf Audiometria tonal liminar: realizada em cabina ac\u00fastica port\u00e1til modelo mini com dimens\u00f5es de 90x90x155cm com o aparelho utilizado Elios\u00ae da marca ECHODIA, com uso de fones supra-aurais TDH. Foi realizada pesquisa de limiares de Via A\u00e9rea (t\u00e9cnica de varredura em 20 dB), nas frequ\u00eancias: 500, 1000, 2000 e 4000 Hz.Vale destacar que os pais receberam um documento de devolutiva contendo os exames realizados e os resultados. No caso das crian\u00e7as que apresentaram \u2018\u2019falha\u201d em algum exame, no mesmo documento constou o agendamento para avalia\u00e7\u00e3o otorrinolaringol\u00f3gica e fonoaudiol\u00f3gica para conclus\u00e3o diagn\u00f3stica, no servi\u00e7o de AudiologiaA segunda etapa, ou seja, a avalia\u00e7\u00e3o diagn\u00f3stica das crian\u00e7as que \u201cfalharam\u201d em algum dos exames realizados na creche foi realizada no Ambulat\u00f3rio S\u00e3o Geraldo HC/UFMG. A avalia\u00e7\u00e3o diagn\u00f3stica constou dos seguintes procedimentos: avalia\u00e7\u00e3o otorrinolaringol\u00f3gica, timpanometria, EOAT, audiometria tonal condicionada e Potencial Evocado Auditivo de Tronco Encef\u00e1lico (PEATE). Constaram da equipe de avalia\u00e7\u00e3o uma m\u00e9dica otorrinolaringologista, duas fonoaudi\u00f3logas e duas estagi\u00e1rias alunas da gradua\u00e7\u00e3o em Fonoaudiologia que realizaram os seguintes procedimentos:Avalia\u00e7\u00e3o Otorrinolaringol\u00f3gica: Foi realizada avalia\u00e7\u00e3o otorrinolaringol\u00f3gica completa com remo\u00e7\u00e3o de cer\u00famen com \u00e1gua morna ou cureta quando necess\u00e1rio. Nos casos de infec\u00e7\u00e3o aguda de vias a\u00e9reas superiores foi realizado tratamento com posterior encaminhamento para as Unidades B\u00e1sicas de Sa\u00fade - UBS para continuar o acompanhamento com otorrinolaringologista ambulatorial. Casos cr\u00f4nicos foram orientados e tamb\u00e9m encaminhados \u00e0 UBS..Imitanciometria: O aparelho utilizado para o diagn\u00f3stico foi o Impedanci\u00f4metro modelo AT 235 da marca Interacoustics, calibrado em 23 de agosto de 2017 certificado 4251/2017. Foram pesquisados os reflexos ac\u00fasticos ipsi e contralaterais nas frequ\u00eancias de 1,2 e 4 kHz. Os resultados da timpanometria foram analisados segundo o padr\u00e3o de normalidade sugerido por Jerger e JergerAudiometria tonal liminar e Logoaudiometria: O aparelho utilizado foi o Audi\u00f4metro AD229b da marca Interacoustics, calibrado em 23 de agosto de 2017 certificado 4246/2017. T\u00e9cnica descendente nas frequ\u00eancias de 250, 500, 1000, 2000, 3000, 4000 e 8000Hz, por via a\u00e9rea e por via \u00f3ssea nas frequ\u00eancias de 500, 1000, 2000, 3000 e 4000Hz, logoaudiometria por meio ordem simples e mascaramento auditivo quando necess\u00e1rio. Os resultados foram analisados segundo o padr\u00e3o de normalidade proposto por BIAPPEATE: O aparelho utilizado para o registro do PEATE foi o Elios\u00ae da marca ECHODIA. Foram pesquisados a integridade de vias auditivas e de limiar eletrofisiol\u00f3gico. O protocolo utilizado foi: est\u00edmulo clique rarefeito, filtro passa-baixo 3000 Hz e passa-alto 50 Hz com 17 cliques por segundo e n\u00famero m\u00ednimo de 1000 aquisi\u00e7\u00f5es. Os eletrodos foram posicionados em Cz, Fz, A1 e A2 e o est\u00edmulo foi apresentado por meio do fone de inser\u00e7\u00e3o. As imped\u00e2ncias foram mantidas com limite m\u00e1ximo at\u00e9 5Kohms. A integridade das vias auditivas foi avaliada em duas varreduras na intensidade de 80dBnNA, por meio da pesquisa das lat\u00eancias das ondas I, III e V, os intervalos interpicos assim como a reprodutibilidade. O limiar eletrofisiol\u00f3gico foi determinado na \u00faltima intensidade onde ocorreu a \u00faltima apari\u00e7\u00e3o da onda V.\u25cf EOAT: realizada com o equipamento Elios\u00ae da marca ECHODIA com est\u00edmulos cliques n\u00e3o lineares a uma intensidade de 80 dB NPS e a janela de testagem foi de 12 milissegundos, com 512 est\u00edmulos. As EOAT foram consideradas presentes quando a reprodutibilidade for igual ou maior a 70% e a rela\u00e7\u00e3o S/R , igual ou maior a 3dB.Quanto ao fluxo de atendimento na segunda etapa, vale esclarecer que ap\u00f3s a avalia\u00e7\u00e3o e conduta otorrinolaringol\u00f3gica, as crian\u00e7as foram encaminhadas para a realiza\u00e7\u00e3o da Imitanciometria e na sequ\u00eancia a audiometria e EOAT. As crian\u00e7as que apresentaram todos os exames dentro dos padr\u00f5es de normalidade tiveram resultado: Audi\u00e7\u00e3o normal. As crian\u00e7as que n\u00e3o puderam ser condicionadas para a realiza\u00e7\u00e3o da audiometria foram encaminhadas para a realiza\u00e7\u00e3o do exame objetivo - PEATE. Ao final da avalia\u00e7\u00e3o foram entregues aos pais ou aos respons\u00e1veis os resultados dos exames realizados, e quando necess\u00e1rio foram realizados encaminhamentos para a unidade b\u00e1sica de sa\u00fade de refer\u00eancia da fam\u00edlia para realiza\u00e7\u00e3o do cadastro da crian\u00e7a no Servi\u00e7o de Sa\u00fade Auditiva., e, por meio de vari\u00e1veis socioecon\u00f4micas e de saneamento, analisa as caracter\u00edsticas de grupos populacionais que vivem em setores censit\u00e1rios. O \u00edndice \u00e9 composto por vari\u00e1veis referentes aos domic\u00edlios particulares permanentes com abastecimento de \u00e1gua, esgotamento sanit\u00e1rio e destino do lixo inadequados ou ausentes; a raz\u00e3o de moradores por domic\u00edlio; o percentual de pessoas analfabetas; o percentual de domic\u00edlios particulares com rendimento per capita at\u00e9 1/2 sal\u00e1rio m\u00ednimo; o rendimento nominal mensal m\u00e9dio das pessoas respons\u00e1veis; e o percentual de pessoas de ra\u00e7a/cor parda, preta ou ind\u00edgena. Ao final do processo, o IVS \u00e9 classificado em quatro categorias, baixa, m\u00e9dia, elevada e muito elevada vulnerabilidade \u00e0 sa\u00fade. No presente estudo foi realizada a identifica\u00e7\u00e3o do risco correspondente aos setores censit\u00e1rios em que residia cada crian\u00e7a avaliada, sendo que para fins de an\u00e1lise, as categorias elevado e muito elevado, agrupadas em uma.Por fim, foi realizado o tratamento e an\u00e1lise dos dados. A busca dos endere\u00e7os correspondentes \u00e0 resid\u00eancia das crian\u00e7as avaliadas foi realizada e teve como objetivo a identifica\u00e7\u00e3o do setor censit\u00e1rio e do IVS, desenvolvido e utilizado pela Secretaria Municipal da Sa\u00fade de Belo Horizonte para organiza\u00e7\u00e3o dos servi\u00e7os de sa\u00fade no munic\u00edpio. O IVS \u00e9 um indicador composto, que utilizou dados do Censo de 2010Para an\u00e1lise de dados as vari\u00e1veis selecionadas para estudo foram: sexo; idade (em meses); regional de resid\u00eancia; resultados dos exames de meatoscopia, timpanometria, emiss\u00f5es otoac\u00fasticas e audiometria, na triagem, classificados como \u201cpassou\u201d e \u201cfalhou\u201d; encaminhamentos realizados (sim e n\u00e3o); resultados avalia\u00e7\u00e3o diagn\u00f3stica (exames normais e perdas auditivas); e o IVS dos setores censit\u00e1rios de resid\u00eancia das crian\u00e7as, categorizado em baixo, m\u00e9dio e elevado/muito elevado risco.O georreferenciamento dos locais de moradia das crian\u00e7as foi feito com base no endere\u00e7o de resid\u00eancia de cada crian\u00e7a e em seguida foram identificados os respectivos setores censit\u00e1rios e suas classifica\u00e7\u00f5es. Para tal, foram utilizados os programas ArcGis vers\u00e3o 10.5 ferramenta ArcMap e o Google Earth Pro vers\u00e3o 7.3.1. Para a localiza\u00e7\u00e3o dos endere\u00e7os das crian\u00e7as foi utilizado o Google Earth Pro, do qual foram extra\u00eddos os arquivos de extens\u00e3o .kml para ser georreferenciado sobre o ArcGis e produzir os mapas sobre a base do IVC-2012 \u2013 Prefeitura Municipal de Belo Horizonte. Do total de 95 endere\u00e7os, 94,8% foram processados e georreferenciados, sendo os setores censit\u00e1rios identificados por meio do programa Google Earth. N\u00e3o foi poss\u00edvel a localiza\u00e7\u00e3o manual de 5 endere\u00e7os, correspondendo a 5,2% do total de endere\u00e7os dispon\u00edveis.Para a an\u00e1lise descritiva foram utilizadas distribui\u00e7\u00e3o de frequ\u00eancias absolutas e relativas das vari\u00e1veis categ\u00f3ricas e medidas de tend\u00eancia central, posi\u00e7\u00e3o e dispers\u00e3o da vari\u00e1vel idade.Para as an\u00e1lises de associa\u00e7\u00e3o, considerou-se duas vari\u00e1veis resposta: (1) resultado das EOA e (2) IVS. Para a primeira, avaliou-se a associa\u00e7\u00e3o com os resultados da audiometria e da timpanometria na triagem e na avalia\u00e7\u00e3o diagn\u00f3stica. Em rela\u00e7\u00e3o ao IVS, analisou-se a associa\u00e7\u00e3o com o sexo, resultados dos exames, encaminhamentos e diagn\u00f3stico. Para as an\u00e1lises de associa\u00e7\u00e3o foram utilizados os testes Qui-quadrado de Pearson e Exato de Fisher, sendo consideradas como associa\u00e7\u00f5es estatisticamente significantes as que apresentaram valor de p \u2264 0,05. Para entrada, processamento e an\u00e1lise dos dados foi utilizado o software SPSS, vers\u00e3o 21.0.Foram avaliadas 95 crian\u00e7as pertencentes a nove creches de cada uma das nove regionais de Belo Horizonte. Dos 46 sujeitos encaminhados para o diagn\u00f3stico, 26 compareceram. Dos que compareceram, 14 sujeitos apresentaram os resultados dentro da normalidade no final da avalia\u00e7\u00e3o, 2 n\u00e3o permitiram ser avaliados, foram submetidos ao PEATE e apresentaram resultado dentro da normalidade e 10 tiveram os resultados alterados. Dos 26 sujeitos avaliados, 10,5% tiveram o resultado/diagn\u00f3stico de Perda Auditiva do tipo Condutiva e foram encaminhados para a Unidade B\u00e1sica de Sa\u00fade para realizar o cadastro no Servi\u00e7o de Aten\u00e7\u00e3o \u00e0 Sa\u00fade Auditiva para dar continuidade ao acompanhamento. Os participantes que n\u00e3o compareceram para a Etapa 2 \u2013 Diagn\u00f3stico, na data em que foi agendado, foram contatados novamente. Ap\u00f3s v\u00e1rias tentativas de agendamento, 22 crian\u00e7as  n\u00e3o compareceram .Das 95 crian\u00e7as inclu\u00eddas na pesquisa, a maioria  era do sexo feminino  com m\u00e9diAp\u00f3s a triagem 46 crian\u00e7as, ou seja, 48,4% da amostra apresentaram resultado \u201cfalha\u201d e, portanto, foram encaminhadas para a segunda etapa e destas 22 n\u00e3o compareceram para a realiza\u00e7\u00e3o do diagn\u00f3stico, ou seja apenas 52,2% compareceram. Das crian\u00e7as que compareceram a etapa de avalia\u00e7\u00e3o diagn\u00f3stica em rela\u00e7\u00e3o a amostra total, 14,7% tiveram resultados normais em todos os exames realizados  e 10,5% tiveram o resultado \u2018alterado\u2019 .Do total de 95 crian\u00e7as cujos pais assinaram o TCLE 12 crian\u00e7as residiam na regional Barreiro, 10 na Centro Sul, 16 na Leste, 14 na Nordeste, 10 na Noroeste, 14 na Oeste, 10 na Pampulha e 4 na regional Venda Nova. Em rela\u00e7\u00e3o ao IVS foi observado que 59,2% das crian\u00e7as participantes residiam em setores censit\u00e1rios de m\u00e9dio risco e 9,7% em elevado/muito elevado risco. N\u00e3o foi poss\u00edvel a identifica\u00e7\u00e3o em 4,9% dos participantes por n\u00e3o residirem em Belo Horizonte .Das crian\u00e7as que falharam na timpanometria, realizada na primeira etapa (triagem) 10,0% residem em setores censit\u00e1rios de baixo risco; 24,4% de m\u00e9dio risco e 4,4% em setores de elevado/muito elevado risco de adoecer e morrer. Das que falharam nas EOA, tamb\u00e9m realizada nas creches, 3,6% residem em setores censit\u00e1rios de baixo risco, 9,1% de m\u00e9dio risco e 1,8% em setores de elevado/muito elevado risco.A an\u00e1lise de associa\u00e7\u00e3o entre o resultado das emiss\u00f5es otoac\u00fasticas transientes da segunda etapa com os exames de timpanometria e audiometria  revelaraPara an\u00e1lise da associa\u00e7\u00e3o entre o IVS e os exames realizados na etapa de triagem foram exclu\u00eddas as respostas \u201cperda\u201d e \u201cn\u00e3o reside em BH\u201d do georreferenciamento. A an\u00e1lise permitiu observar que n\u00e3o houve associa\u00e7\u00e3o com signific\u00e2ncia estat\u00edstica em quaisquer dos resultados . Vale deNa an\u00e1lise de associa\u00e7\u00e3o entre o IVS e sexo e exames audiol\u00f3gicos na segunda etapa n\u00e3o houve resultado com signific\u00e2ncia estat\u00edstica em quaisquer das an\u00e1lises realizadas .Na an\u00e1lise de associa\u00e7\u00e3o entre o IVS e os resultados da triagem \u2013\u201cpassa\u201d e \u201cfalha\u201d- n\u00e3o foram observados valores com signific\u00e2ncia estat\u00edstica. Entretanto, verificou-se que entre as crian\u00e7as que tiveram os resultados \u2018\u2019passa\u201d , 8,9% delas residem em setores censit\u00e1rios de baixo risco, 37,8% em setores de m\u00e9dio risco e 5,6% em setores de risco Elevado/Muito elevado. Das crian\u00e7as que apresentaram resultado \u2018\u2019falha\u201d, 12,2% residiam em setores censit\u00e1rios de baixo risco, 30,0% em setores de risco M\u00e9dio e 5,6% em setores de risco Elevado/Muito elevado. Na an\u00e1lise de associa\u00e7\u00e3o entre o IVS e o diagn\u00f3stico tamb\u00e9m n\u00e3o foram observados valores com signific\u00e2ncia estat\u00edstica. Das crian\u00e7as que apresentaram diagn\u00f3stico alterado 77,7% s\u00e3o provenientes de setores censit\u00e1rios de m\u00e9dio risco. As an\u00e1lises de associa\u00e7\u00e3o entre o IVS e resultados da etapa um e dois n\u00e3o revelaram resultados com signific\u00e2ncia estat\u00edstica. Do total de 22 crian\u00e7as que n\u00e3o compareceram \u00e0 etapa diagn\u00f3stica, 17 (77%) residem em setor censit\u00e1rio de risco baixo e m\u00e9dio, contudo a associa\u00e7\u00e3o n\u00e3o foi estatisticamente significativa  .As an\u00e1lises do presente estudo revelaram que quase metade das crian\u00e7as triadas nas creches apresentaram resultado \u201cfalha\u201d e necessitaram de encaminhamento para a etapa de diagn\u00f3stico, contudo, pouco mais da metade compareceu. A preval\u00eancia da altera\u00e7\u00e3o auditiva condutiva, na amostra avaliada, correspondeu a 13,7%.,15, a abordagem apresentada no presente estudo \u00e9 in\u00e9dita e tem como objetivo ampliar a discuss\u00e3o de fatores associados a resultados e estrat\u00e9gias de interven\u00e7\u00e3o de perdas auditivas nessa faixa et\u00e1ria.Embora a literatura discuta a triagem auditiva em escolares na perspectiva da protocoliza\u00e7\u00e3o e da finalidade e avalia\u00e7\u00e3o de escolares. Segundo as recomenda\u00e7\u00f5es da Comiss\u00e3o para a detec\u00e7\u00e3o precoce da surdez na inf\u00e2ncia (CODEPEH), em rela\u00e7\u00e3o ao diagn\u00f3stico precoce, o per\u00edodo dos zero aos seis anos demanda maior aten\u00e7\u00e3o para a preven\u00e7\u00e3o e promo\u00e7\u00e3o da sa\u00fade, quando as avalia\u00e7\u00f5es audiol\u00f3gicas devem ser realizadas periodicamente.Deste modo, a defini\u00e7\u00e3o da faixa et\u00e1ria, entre 25 e 36 meses, para o estudo foi intencional, devido ao processo de desenvolvimento de linguagem e audi\u00e7\u00e3o e da etapa de ingresso na educa\u00e7\u00e3o infantil. Al\u00e9m disso, \u00e9 a idade de liga\u00e7\u00e3o entre estudos que envolvem a triagem auditiva neonatal.Neste contexto, um estudo longitudinal com 35.668 crian\u00e7as que foram submetidas a triagem auditiva neonatal e testadas novamente ap\u00f3s o primeiro ano da escola prim\u00e1ria constatou que 3,65 a cada 1.000 crian\u00e7as tinham perda auditiva permanente. A preval\u00eancia de perda auditiva bilateral de grau moderado a profundo foi de 1,51 em 1.000. Entretanto, apenas 0,9 a cada 1.000 com este grau de perda auditiva tinha sido identificada pela triagem auditiva neonatal,18-20 . Assim, a triagem auditiva \u00e9 de extrema import\u00e2ncia no contexto escolar porque a popula\u00e7\u00e3o nessa faixa et\u00e1ria \u00e9 mais vulner\u00e1vel a doen\u00e7as devido ao seu sistema imunol\u00f3gico ainda estar em desenvolvimento, inclusive a otite m\u00e9dia.A preval\u00eancia de perda auditiva condutiva verificada no presente estudo n\u00e3o surpreende, visto que a literatura aponta a otite m\u00e9dia como a causa mais comum de perda auditiva em crian\u00e7as na faixa et\u00e1ria de 1 a 5 anos,18-20 \u00e9 o fato de quase metade da amostra, falhar em algum dos exames realizados, sendo que cerca de 40,0% com falha na timpanometria (triagem) com configura\u00e7\u00e3o de curvas do tipo B e C no momento da avalia\u00e7\u00e3o. Esse \u2018\u2019momento\u201d de priva\u00e7\u00e3o auditiva pode provocar desordens do processamento auditivo central, desvio fon\u00e9tico e fonol\u00f3gico, dificuldade de aprendizagem, leitura e escrita,18.Outro dado que corrobora a literatura quanto \u00e0 ocorr\u00eancia de altera\u00e7\u00f5es condutivas indicou que, 24,12% da amostra avaliada tinha altera\u00e7\u00e3o de orelha m\u00e9dia e os timpanogramas alterados mais comuns foram os do tipo \u201cB\u201d e \u201cC\u201d. J\u00e1 estudo realizado no interior da cidade de Malawi na \u00c1frica Ocidental, com 281 crian\u00e7as faixa et\u00e1ria de 4 a 6 anos, indicou altera\u00e7\u00e3o condutiva em 46,9% da amostra. A varia\u00e7\u00e3o entre resultados pode ser atribu\u00edda a fatores tais como defini\u00e7\u00e3o de amostragem, pois a faixa et\u00e1ria pode estar relacionada a suscetibilidade de altera\u00e7\u00f5es condutivas ou a sazonalidade da avalia\u00e7\u00e3o, visto que perdas condutivas s\u00e3o mais comuns em determinadas condi\u00e7\u00f5es clim\u00e1ticas.\u00c9 poss\u00edvel verificar na literatura sobre a tem\u00e1tica resultados diversos quanto a preval\u00eancia de altera\u00e7\u00f5es auditivas condutivas em estudos envolvendo triagem auditiva. Estudo realizado no Rio de Janeiro avaliou 431 crian\u00e7as na faixa et\u00e1ria de um a 12 anos. Em um estudo realizado no Servi\u00e7o de Refer\u00eancia em Triagem Auditiva Neonatal de um Hospital Universit\u00e1rio que avaliou 261 neonatos com Indicador de Risco para Perda Auditiva (IRDA), foi verificado que 13,40% de resultado falha nas EOAT em decorr\u00eancia de altera\u00e7\u00e3o condutiva tempor\u00e1ria identificada por meio da timpanometria e avalia\u00e7\u00e3o otorrinolaringol\u00f3gica. Deste modo, os resultados refor\u00e7am a import\u00e2ncia do uso do procedimento e corrobora a literatura que indica que a realiza\u00e7\u00e3o da EOAT em tempo oportuno pode antecipar o diagn\u00f3stico da perda auditiva, favorecer o delineamento de outras avalia\u00e7\u00f5es e in\u00edcio de interven\u00e7\u00f5es como a adapta\u00e7\u00e3o de AASI e reabilita\u00e7\u00e3o auditiva.No presente estudo a ocorr\u00eancia de quase 15% do resultado falha nas emiss\u00f5es otoac\u00fasticas das crian\u00e7as que apresentaram resultado passa na timpanometria sugere nestes casos limiares superiores a 30dBNA. Outros estudos, por\u00e9m, salientam que embora ambas ferramentas possam ser utilizadas na triagem de pr\u00e9-escolares e escolares, a audiometria apresenta maior sensibilidade quando comparada a EOAT.Outro dado que vale ser mencionado ao abordar a triangula\u00e7\u00e3o de exames \u00e9 o fato de mais de 15% das crian\u00e7as com resultado passa nas emiss\u00f5es otoac\u00fasticas n\u00e3o permitirem a realiza\u00e7\u00e3o da audiometria. Esse dado corrobora pesquisa realizada com 200 crian\u00e7as na faixa et\u00e1ria entre 2 e 5 anos que em uma an\u00e1lise de compara\u00e7\u00e3o entre estes exames indicou em torno de 12% n\u00e3o realiza\u00e7\u00e3o da audiometria por falta de condicionamento efetivo, ou impossibilidade de coloca\u00e7\u00e3o dos fones (recusa da crian\u00e7a) e em, contrapartida, somente 2% dos participantes n\u00e3o permitiram a coloca\u00e7\u00e3o da sonda para a realiza\u00e7\u00e3o das EOAT. Assim, os pesquisadores conclu\u00edram que a audiometria n\u00e3o \u00e9 um exame indicado para avalia\u00e7\u00e3o em pr\u00e9-escolaresO presente estudo refor\u00e7a tal questionamento e amplia a discuss\u00e3o do protocolo de triagem auditiva em pr\u00e9-escolares. Outro ponto que evidencia a import\u00e2ncia e pertin\u00eancia das emiss\u00f5es otoac\u00fasticas como procedimento de triagem escolar foi a signific\u00e2ncia estat\u00edstica entre o resultado das emiss\u00f5es otoac\u00fasticas transientes da segunda etapa com os exames de timpanometria e audiometria.8, no presente estudo a ades\u00e3o de apenas \u00bc da amostra encaminhada para diagn\u00f3stico no componente especializado do sistema de sa\u00fade pode ter comprometido o resultado final. Este achado corrobora estudo realizado na educa\u00e7\u00e3o infantil do mesmo munic\u00edpio e apresentou baixa ades\u00e3o \u00e0 etapa de diagn\u00f3stico.Embora a metodologia da constru\u00e7\u00e3o de duas etapas, triagem e diagn\u00f3stico, seja adequada e mencionada pela literatura.Em uma revis\u00e3o de literatura recente, os estudos relatam uma varia\u00e7\u00e3o da ades\u00e3o ao diagn\u00f3stico entre 10% e 65%. As raz\u00f5es potenciais citadas para a baixa ades\u00e3o inclu\u00edram a impossibilidade de contatar e notificar os pais sobre os resultados, a falta de conhecimento dos pais sobre o significado m\u00e9dico da perda auditiva, o custo dos cuidados subsequentes, a inabilidade dos pais para faltar ao trabalho e barreiras geogr\u00e1ficas. De modo geral, houve uma recomenda\u00e7\u00e3o quase un\u00e2nime de que este \u00e9 um aspecto crucial para aumentar a efic\u00e1cia geral dos programas de triagem auditiva escolar em todo o mundo. Outros estudos similares,26-28 tamb\u00e9m mostraram que a perda condutiva apresentou maior ocorr\u00eancia entre pr\u00e9-escolares.Contudo, das crian\u00e7as que compareceram, mais de um ter\u00e7o tiveram, como resultado final, perda auditiva do tipo condutiva. Este dado est\u00e1 em converg\u00eancia com estudo similar realizado no Chile com 87 crian\u00e7as na faixa et\u00e1ria entre 3 a 5 anos, no qual 15% da amostra apresentaram perda auditiva do tipo condutiva pela prefeitura do munic\u00edpio que indicava menos de 40% da popula\u00e7\u00e3o residente em setores censit\u00e1rios de risco m\u00e9dio e pouco mais de \u00bc em setores de elevado/muito elevado. Tal fato pode ser explicado por duas quest\u00f5es. A primeira em decorr\u00eancia da sele\u00e7\u00e3o de uma creche por regional administrativa e, portanto, a distribui\u00e7\u00e3o da amostra n\u00e3o correspondente ao cen\u00e1rio populacional do munic\u00edpio. E a segunda explica\u00e7\u00e3o reside no perfil das institui\u00e7\u00f5es, creches conveniadas a prefeitura.Quanto \u00e0 terceira etapa do estudo, a an\u00e1lise da vulnerabilidade \u00e0 sa\u00fade, vale destacar que a maioria das crian\u00e7as participantes, quase 2/3 da amostra, residiam em setores censit\u00e1rios de risco m\u00e9dio e menos de 10% em setores de elevado/muito elevado risco. Tais dados n\u00e3o corroboram a distribui\u00e7\u00e3o do IVS publicada em 2018.Ao analisar a vulnerabilidade expressa pelo IVS \u00e9 poss\u00edvel verificar que a aparente similaridade no perfil de crian\u00e7as com resultado falha na primeira e na segunda etapas pode ser resultado da maior concentra\u00e7\u00e3o de participantes nos setores censit\u00e1rios de risco m\u00e9dio. Deste modo, a an\u00e1lise de que h\u00e1 maior concentra\u00e7\u00e3o de altera\u00e7\u00f5es neste estrato deve ser realizada com cautela e usando como balizador a distribui\u00e7\u00e3o dos participantes em cada estrato. De qualquer modo, vale considerar que os 7,8% de perda no momento do georreferenciamento podem configurar os endere\u00e7os correspondentes a \u00e1reas de aglomerados urbanos e, portanto, correspondentes \u00e0s \u00e1reas de IVS muito elevado. Uma pesquisa realizada com crian\u00e7as residentes no mesmo mun\u00edcipio do presente estudo e avaliadas por um Servi\u00e7o de Refer\u00eancia de Triagem Auditiva Neonatal (SRTAN), nos anos de 2010 e 2011, mostrou que 46,6% das crian\u00e7as residiam em setores censit\u00e1rios de risco elevado ou muito elevado e maior propor\u00e7\u00e3o de \u201cresultado falha\u201d em crian\u00e7as residentes em \u00e1reas de maior vulnerabilidade \u00e0 sa\u00fadeAinda que o presente estudo n\u00e3o tenha indicado signific\u00e2ncia estat\u00edstica na associa\u00e7\u00e3o do IVS com sexo e os exames auditivos, h\u00e1 alguma similaridade com o estudo supracitado, pois \u00e9 poss\u00edvel observar que a propor\u00e7\u00e3o de crian\u00e7as que apresentaram resultado falha na primeira etapa - e residiam em setores censit\u00e1rios de baixo risco foi menor do os que apresentaram resultado falha e residiam em setores de m\u00e9dio risco.. A metodologia delineada para o presente estudo permite avan\u00e7ar na perspectiva da determina\u00e7\u00e3o social da sa\u00fade no contexto do diagn\u00f3stico auditivo e na, consequente, proposi\u00e7\u00e3o de estrat\u00e9gias. Assim, fica clara a import\u00e2ncia de pensar a fun\u00e7\u00e3o auditiva na integra\u00e7\u00e3o com a vida e estabelecer a discuss\u00e3o do quanto a vulnerabilidade pode atravessar as a\u00e7\u00f5es de preven\u00e7\u00e3o, monitoramento e diagn\u00f3stico.H\u00e1 que se destacar, por fim, a abordagem dada ao processo de triagem auditiva no presente estudo. Dentre as pesquisas na tem\u00e1tica, a via de regra \u00e9 o estudo na perspectiva cl\u00ednica-assistencial ou de preven\u00e7\u00e3oNo presente estudo n\u00e3o houve associa\u00e7\u00e3o com signific\u00e2ncia estat\u00edstica entre altera\u00e7\u00e3o auditiva e IVS, entretanto foi poss\u00edvel observar que 77,7% das crian\u00e7as com diagn\u00f3stico de perda auditiva residiam em setores censit\u00e1rios de risco m\u00e9dio para o \u00cdndice de Vulnerabilidade em Sa\u00fade."}
+{"text": "Classe de Recomenda\u00e7\u00e3o e N\u00edvel de Evid\u00eancia 52. Resumo das Principais Orienta\u00e7\u00f5es eRecomenda\u00e7\u00f5es 53. Introdu\u00e7\u00e3o e Equipamento 63.1. Introdu\u00e7\u00e3o 63.2. Higieniza\u00e7\u00e3o e Preven\u00e7\u00e3o de Infec\u00e7\u00f5es 84. Espessura Mediointimal e Detec\u00e7\u00e3o dePlacas das Art\u00e9rias Car\u00f3tidas para Avalia\u00e7\u00e3o doRisco Cardiovascular 84.1. Defini\u00e7\u00e3o Ultrassonogr\u00e1fica da Espessura Mediointimal e daPlaca Carot\u00eddea 95. Avalia\u00e7\u00e3o das Estenoses Carot\u00eddeas 95.1. Crit\u00e9rios Anat\u00f4micos 95.2. Papel da Angiotomografia e Angiorresson\u00e2ncia 105.3. Crit\u00e9rios de Velocidade 115.4. Considera\u00e7\u00f5es T\u00e9cnicas para a Avalia\u00e7\u00e3o ao Doppler 115.5. Estenose da Art\u00e9ria Car\u00f3tida Interna 115.5.1. Estenoses Menores que 50% 125.5.2. Estenoses Maiores que 50% 125.5.3. Suboclus\u00f5es e Oclus\u00f5es 145.6. Estenose da Art\u00e9ria Car\u00f3tida Comum e Art\u00e9ria Car\u00f3tida Externa 145.7. Condi\u00e7\u00f5es que Afetam as Medidas de Velocidade 156. Avalia\u00e7\u00e3o Ultrassonogr\u00e1fica ap\u00f3s Endarterectomia eStent 15Implante de 6.1. Introdu\u00e7\u00e3o 156.2. Protocolo do Exame 166.3. Avalia\u00e7\u00e3o ecogr\u00e1fica ap\u00f3s endarterectomia carot\u00eddea 166.4. Achados do Exame de USV P\u00f3s-endarterectomia 167. Avalia\u00e7\u00e3o Morfol\u00f3gica das Placas Carot\u00eddeas 167.1. Estudo da morfologia da placa 167.1.1. Morfologia da Placa 167.1.2. Caracter\u00edsticas das Placas Ateroscler\u00f3ticas e Risco de DCV 167.1.3. Medida do Volume da Placa 167.2. Caracteriza\u00e7\u00e3o da Placa Ateroscler\u00f3tica pela Angiotomografia eAngiorresson\u00e2ncia Magn\u00e9tica 197.2.1. Dissec\u00e7\u00e3o de Vasos Cervicais 198. Agente de Realce de Ultrassom na Caracteriza\u00e7\u00e3o daPlaca Ateroscler\u00f3tica 198.1. Caracter\u00edsticas e Propriedades dos Agentes deRealce de Ultrassom 198.2. Aspectos T\u00e9cnicos que Influenciam a Obten\u00e7\u00e3o de Imagemcom Contraste 198.3. \u00cdndice Mec\u00e2nico 208.4. Ganho de Imagem 208.5. Quantidade de Contraste 208.6. Diagn\u00f3stico de Oclus\u00e3o e Sub Oclus\u00e3o 208.7. Avalia\u00e7\u00e3o da Neovasculariza\u00e7\u00e3o e Vulnerabilidade das Placas 208.8. Dissec\u00e7\u00e3o 218.9. Inflama\u00e7\u00e3o 218.10 Avalia\u00e7\u00e3o de Stent 218.11 Prepara\u00e7\u00e3o do Contraste 218.12. Protocolo B\u00e1sico de Exame de Ultrassonografia Vascularcom Contraste de Microbolhas 229. Avalia\u00e7\u00e3o da Doen\u00e7a Ateromatosa em Art\u00e9riasVertebrais 229.1. Introdu\u00e7\u00e3o 229.2. Avalia\u00e7\u00e3o Ultrassonogr\u00e1fica de Vertebrais 229.3. Metodologia do Exame de Rotina 229.4. Par\u00e2metros Normais 229.5. Quantifica\u00e7\u00e3o da Estenose 229.5.1. Estenose Proximal (V0-V1) 229.5.2. Estenose Vertebral nos Demais Segmentos (V2-V4) 239.5.3. Oclus\u00e3o de Vertebral 239.6. S\u00edndrome do Roubo pela Art\u00e9ria Subcl\u00e1via 2310. Doppler Transcraniano na Doen\u00e7a Ateroscler\u00f3ticaCarot\u00eddea e Vertebral Extracraniana 2310.1. T\u00e9cnicas do Exame 2310.2. Protocolo Padr\u00e3o do DTC \u201cCego\u201d Convencional 2510.3. Protocolo padr\u00e3o de Doppler Transcraniano emMonitoriza\u00e7\u00e3o Cont\u00ednua 2710.4. Utilidade cl\u00ednica do Doppler transcraniano na doen\u00e7aateroscler\u00f3tica cervical 2710.4.1. Identifica\u00e7\u00e3o de Pacientes com HITS 2710.4.2. Repercuss\u00f5es Hemodin\u00e2micas Induzidas 2710.4.3. Avalia\u00e7\u00e3o de Estenose Vertebral Intracraniana (V4) 2810.5. Recomenda\u00e7\u00f5es 29Refer\u00eancias 29As declara\u00e7\u00f5es de consenso foram classificadas conforme o mostrado nos O resumo das principais orienta\u00e7\u00f5es desse painel de especialistas est\u00e1 descrito no 1 e as novas recomenda\u00e7\u00f5es em rela\u00e7\u00e3o aos t\u00f3picos higieniza\u00e7\u00e3o do equipamento, defini\u00e7\u00e3o de placa carot\u00eddea, espessura mediointimal, gradua\u00e7\u00e3o da estenose e morfologia de placa.O 1O uso do ultrassom (US) na medicina foi iniciado nos anos 1940 e, desde ent\u00e3o, vem tendo papel importante no diagn\u00f3stico das doen\u00e7as cardiovasculares (DCV). Devido \u00e0 sua ampla aplicabilidade, relativo baixo custo e reprodutibilidade, o US tem seu papel estabelecido no aux\u00edlio diagn\u00f3stico de diversas patologias. Esta diretriz foi elaborada por cardiologistas membros do Departamento de Imagem Cardiovascular (DIC) da Sociedade Brasileira de Cardiologia (SBC), angiologistas e cirurgi\u00f5es vasculares membros da Sociedade Brasileira de Angiologia e Cirurgia Vascular (SBACV) e radiologistas membros do Col\u00e9gio Brasileiro de Radiologistas (CBR), especialistas em ultrassonografia vascular (USV), com o objetivo de orientar a melhor utiliza\u00e7\u00e3o dessa t\u00e9cnica, dentro dos conhecimentos recomendados na literatura m\u00e9dica atual, atualizando, com o mesmo enfoque, a diretriz previamente publicada em 2015.16 Outros t\u00f3picos foram adicionados nessa atualiza\u00e7\u00e3o, como USV transcraniana, utiliza\u00e7\u00e3o de agente de realce ultrassonogr\u00e1fico e alguns pontos do diagn\u00f3stico de estenoses carot\u00eddea pela angio-TC (angiotomografia) e angio-RM (angiografia por resson\u00e2ncia magn\u00e9tica). Entretanto, o leitor interessado dever\u00e1 recorrer a publica\u00e7\u00f5es mais amplas e espec\u00edficas sobre essas outras modalidades de imagem.A fundamenta\u00e7\u00e3o do diagn\u00f3stico pela USV de importantes patologias foi embasada nas recomenda\u00e7\u00f5es do painel de especialistas do DIC de 2015, 2016 e 2019.Nosso objetivo \u00e9 difundir as melhores pr\u00e1ticas da USV entre os profissionais da \u00e1rea, homogeneizar a interpreta\u00e7\u00e3o dos exames e contribuir para um aproveitamento adequado dessa ferramenta n\u00e3o invasiva, amplamente dispon\u00edvel e de baixo custo.1A descri\u00e7\u00e3o sobre equipamentos, aplicativos, transdutores e aspectos relacionada \u00e0 imagem est\u00e3o descritas na \u00edntegra da Recomenda\u00e7\u00e3o de 2015.Al\u00e9m dos requisitos tecnol\u00f3gicos e t\u00e9cnicos dos aparelhos e do examinador, \u00e9 fundamental mencionar a import\u00e2ncia da higieniza\u00e7\u00e3o dos aparelhos e medidas de preven\u00e7\u00e3o de infec\u00e7\u00e3o entre os profissionais. Qualquer equipamento m\u00e9dico de diagn\u00f3stico que entre em contato com o paciente gera risco de infec\u00e7\u00e3o. O risco de infec\u00e7\u00e3o \u00e9 baixo, mas existem relatos de contamina\u00e7\u00e3o do transdutor de ultrassom, principalmente endocavit\u00e1rios e associados \u00e0 inser\u00e7\u00e3o de acesso central, al\u00e9m da contamina\u00e7\u00e3o do gel por m\u00faltiplas bact\u00e9rias.17 que determina a necessidade de esteriliza\u00e7\u00e3o/desinfec\u00e7\u00e3o dos equipamentos, os procedimentos com USV s\u00e3o classificados como: 1) cr\u00edticos, quando o transdutor encosta em tecido est\u00e9reis; 2) semicr\u00edticos, quando acessa membranas mucosas, tecidos n\u00e3o \u00edntegros (com ou sem contamina\u00e7\u00e3o por sangue); e 3) n\u00e3o cr\u00edticos, quando n\u00e3o h\u00e1 contato com tecidos est\u00e9reis, mucosas ou tecidos n\u00e3o \u00edntegros. Para os procedimentos cr\u00edticos, \u00e9 necess\u00e1ria a limpeza e esteriliza\u00e7\u00e3o ou higieniza\u00e7\u00e3o completa (HC ou HLD \u2013 high level desinfection). Nos classificados como semicr\u00edticos, a limpeza associada \u00e0 HC \u00e9 suficiente. J\u00e1 para os n\u00e3o cr\u00edticos, apenas a limpeza superficial (LS ou LLD \u2013 low level desinfection) \u00e9 necess\u00e1ria.Na classifica\u00e7\u00e3o de Spaulding,A maior parte dos exames diagn\u00f3sticos de car\u00f3tida e transcranianos se enquadram como n\u00e3o cr\u00edticos. A utiliza\u00e7\u00e3o de coberturas  n\u00e3o \u00e9 recomendada, por\u00e9m a higieniza\u00e7\u00e3o tamb\u00e9m deve ser mantida. Ap\u00f3s o exame, o transdutor deve ser higienizado com pano para a retirada do gel, seguido de uso de \u00e1gua e sabonete, aguardando a secagem antes da desinfec\u00e7\u00e3o, que deve abordar o transdutor, cabo e teclado, com produtos como compostos com am\u00f4nio quatern\u00e1rio, \u00e1lcool ou fen\u00f3is. Caso haja necessidade de HC, recomenda-se manter o transdutor submerso em solu\u00e7\u00e3o de gluteralde\u00eddo, per\u00f3xido de hidrog\u00eanio ou \u00e1cido periac\u00e9tico por 8 a 15 minutos. \u00c9 necess\u00e1rio manter o cuidado com a preven\u00e7\u00e3o da infec\u00e7\u00e3o relacionada ao exame, que, apesar de m\u00ednima, pode ocorrer, principalmente em laborat\u00f3rios, cl\u00ednicas e hospitais em que s\u00e3o realizados exames diversos. \u00c9 sempre importante confirmar com o fabricante do aparelho quais solu\u00e7\u00f5es higienizadoras podem ser utilizadas, j\u00e1 que elas podem danificar pl\u00e1stico do transdutor e do cabo.20 dos documentos de consenso de Mannheim 2004-2006-201121 e do consenso da Sociedade Americana de Ecocardiografia,22 os especialistas brasileiros na \u00e1rea da USV se mobilizaram para difundir a pr\u00e1tica correta da medida da espessura mediointimal (EMI) e da detec\u00e7\u00e3o da placa ateroscler\u00f3tica das art\u00e9rias car\u00f3tidas.Com a publica\u00e7\u00e3o das diretrizes brasileiras de 2007, 2013 e 2019,25 O aumento da EMI parece envolver principalmente a camada m\u00e9dia, enquanto a forma\u00e7\u00e3o da placa carot\u00eddea se relaciona ao espessamento da camada \u00edntima e o seu crescimento em dire\u00e7\u00e3o ao l\u00famen do vaso.26Sabe-se que os fatores de risco cardiovasculares tradicionais est\u00e3o associados ao aumento da EMI.27 mostraram, em recente publica\u00e7\u00e3o, uma score de percentil combinado com medi\u00e7\u00f5es da EMI na art\u00e9ria car\u00f3tida comum (ACC) distal e art\u00e9ria car\u00f3tida interna (ACI) proximal, que melhoraram a predi\u00e7\u00e3o de risco de eventos cardiovasculares al\u00e9m do alcan\u00e7ado por fatores de risco tradicionais, mesmo quando adicionada a medida do escore de c\u00e1lcio no modelo do estudo.Estudos cl\u00ednicos adotaram uma ampla variedade de limites da EMI e, notadamente, o ponto de corte da estratifica\u00e7\u00e3o de risco baseada em valores num\u00e9ricos depende das caracter\u00edsticas de base dos indiv\u00edduos. Polak et al.28 Chamamos aten\u00e7\u00e3o que, no contexto do envelhecimento populacional, deve-se ter aten\u00e7\u00e3o a uma poss\u00edvel superestima\u00e7\u00e3o do risco cardiovascular em idosos com poucos fatores de risco, levando ao uso excessivo de medica\u00e7\u00f5es. Uma acurada identifica\u00e7\u00e3o dos que seriam verdadeiramente de baixo risco poderia resultar em melhor evolu\u00e7\u00e3o cl\u00ednica, com prov\u00e1veis implica\u00e7\u00f5es econ\u00f4micas. Uma recente suban\u00e1lise do estudo MESA comparou a habilidade de marcadores de risco \u201cnegativos\u201d em modificar para baixo a estimativa do risco cardiovascular em 10 anos, entre eles, a medida da EMI < percentil 25.29Embora a medida da EMI n\u00e3o seja recomendada \u201cde rotina\u201d na popula\u00e7\u00e3o geral, se pensarmos na predi\u00e7\u00e3o de risco cardiovascular como uma estimativa a longo prazo, o valor dessa medida talvez seja de relevante import\u00e2ncia.20 caracteriza a placa ateroscler\u00f3tica como uma medida da EMI > 1,5 mm, sendo, assim, importante para o ecografista vascular saber realizar essas medidas. Outro aspecto importante para a correta realiza\u00e7\u00e3o dessa medida \u00e9 o fato de ser utilizada em diversos protocolos de pesquisa. A t\u00e9cnica e a interpreta\u00e7\u00e3o da medida da EMI est\u00e3o descritas no texto base dessa atualiza\u00e7\u00e3o.1A diretriz brasileira de dislipidemia de 201730 V\u00e1rias publica\u00e7\u00f5es estudaram a PC como indicador progn\u00f3stico de eventos cardiovasculares, demonstrando seu poder preditivo para a incid\u00eancia de DCV da presen\u00e7a de placa carot\u00eddea com eventos cardiovasculares.39A placa carot\u00eddea (PC) \u00e9 uma manifesta\u00e7\u00e3o da aterosclerose e parece ser um preditor de risco cardiovascular mais forte do que a medida da EMI isoladamente. Uma recente metan\u00e1lise que incluiu 11 estudos populacionais, com mais de 54.000 pacientes, demostrou que a PC, quando comparada \u00e0 EMI, teve uma maior acur\u00e1cia diagn\u00f3stica como preditor de infarto agudo do mioc\u00e1rdio (IAM).40 e a V Diretriz Brasileira de Dislipidemias e Preven\u00e7\u00e3o da Aterosclerose19 recomendam a presen\u00e7a de aterosclerose carot\u00eddea subcl\u00ednica, detectada por metodologia de imagem, como crit\u00e9rio de identifica\u00e7\u00e3o de pacientes em alto risco de eventos coronarianos. Al\u00e9m disso, tanto as diretrizes brasileiras quanto o consenso da Sociedade Americana de Ecocardiografia (SAE)22 recomendam a utiliza\u00e7\u00e3o da placa carot\u00eddea como fator agravante do risco em pacientes de risco intermedi\u00e1rio.A I Diretriz Brasileira de Preven\u00e7\u00e3o Cardiovascular21 A A EMI \u00e9 caracterizada ao modo bidimensional por uma dupla linha com defini\u00e7\u00e3o das interfaces luz-\u00edntima e m\u00e9dia-advent\u00edcia. A dist\u00e2ncia entre as duas interfaces ac\u00fasticas \u00e9 considerada a medida da EMI. A PC pode ser definida como uma estrutura focal estendendo-se no m\u00ednimo 0,5 mm para a luz do vaso e/ou medindo mais do que 50% do valor da medida da EMI adjacente e/ou, ainda, uma medida de EMI maior que 1,5 mm.26 consideraram que a EMI maior ou igual a 1,5 mm pode ser considerada como equivalente de placa ateromatosa, principalmente se a imagem for difusa (Tipo II). Os mesmos autores tamb\u00e9m classificaram como placa tipo I a presen\u00e7a de protuber\u00e2ncia em dire\u00e7\u00e3o \u00e0 luz do vaso com medida inferior a 1,5 mm. Esae painel de especialistas entende que a placa classificada como tipo I por Johri et al.26 \u00e9 equivalente \u00e0s duas primeiras defini\u00e7\u00f5es de placa do estudo de Mannheim.7 Nesse contexto, \u00e9 importante que o ultrassonografista esteja atento principalmente \u00e0 classifica\u00e7\u00e3o da placa tipo I, tendo como par\u00e2metro exames anteriores.Em recente publica\u00e7\u00e3o, Johri et al.A USV \u00e9 capaz de avaliar estenoses carot\u00eddeas tanto pelo crit\u00e9rio de velocidades quanto pela quantifica\u00e7\u00e3o da estenose feita pelas medidas dos di\u00e2metros residuais, preferencialmente pelo corte transverso.41 a) crit\u00e9rios de velocidades n\u00e3o permitem discriminar faixas mais estreitas de estenoses devido \u00e0 sobreposi\u00e7\u00e3o (\u201coverlap\u201d) que ocorre entre as diversas faixas;42 b) h\u00e1 grande varia\u00e7\u00e3o das medidas de velocidades entre os equipamentos, provocando discrep\u00e2ncias no resultado; c) a corre\u00e7\u00e3o do \u00e2ngulo provoca grande varia\u00e7\u00e3o interobservador; d) houve significativa melhora na qualidade de imagem ultrassonogr\u00e1fica ao modo B nos \u00faltimos anos.Os que advogam que a quantifica\u00e7\u00e3o seja feita por crit\u00e9rios anat\u00f4micos se baseiam nas seguintes premissas:43Entre os participantes desse painel, houve consenso de que o crit\u00e9rio fundamental para a quantifica\u00e7\u00e3o das estenoses carot\u00eddeas \u00e9 o hemodin\u00e2mico. O crit\u00e9rio anat\u00f4mico deve ser usado para caracterizar as estenoses inferiores a 50% (sem repercuss\u00e3o hemodin\u00e2mica). Ap\u00f3s serem categorizadas pelo crit\u00e9rio de velocidade, sugere-se, informar os resultados da faixa de estenose em intervalos de 10%.1Todas as considera\u00e7\u00f5es sobre a medida realizada pelo crit\u00e9rio anat\u00f4mico est\u00e3o detalhadas na diretriz anterior a essa atualiza\u00e7\u00e3o, n\u00e3o tendo sido realizada nenhuma altera\u00e7\u00e3o em rela\u00e7\u00e3o ao documento anterior.Em pacientes com sintomas neurol\u00f3gicos isqu\u00eamicos focais correspondentes ao territ\u00f3rio carot\u00eddeo, a angio-TC ou a angio-RM s\u00e3o indicadas para detectar estenose carot\u00eddea quando a ultrassonografia n\u00e3o pode ser obtida ou gera resultado n\u00e3o diagn\u00f3stico .North American Symptomatic Carotid Trial) ou ECST .45 A mensura\u00e7\u00e3o  do grau de estenose carot\u00eddea pode ser feita de formas diferentes a partir desses crit\u00e9rios.46Tanto a angio-TC quanto a angio-RM, com t\u00e9cnicas de p\u00f3s-processamento, podem produzir imagens angiogr\u00e1ficas semelhantes \u00e0s da angiografia de subtra\u00e7\u00e3o digital e permitir medi\u00e7\u00f5es de estenose de acordo com os crit\u00e9rios NASCET  na avalia\u00e7\u00e3o de grau de estenose carot\u00eddea, em compara\u00e7\u00e3o ao padr\u00e3o-ouro , tem o benef\u00edcio adicional de serem t\u00e9cnicas n\u00e3o invasivas e que possibilitam a avalia\u00e7\u00e3o do l\u00famen vascular no plano axial verdadeiro  e alguma an\u00e1lise da parede arterial .49 Bartlett et al.48 demonstraram uma correla\u00e7\u00e3o linear entre a medida em mil\u00edmetros do l\u00famen residual, ao n\u00edvel da estenose da car\u00f3tida, com o grau de estenose estimado pela angiografia com o m\u00e9todo do estudo NASCET.41 Os limites de 1,4 a 2,2 mm podem ser usados para avaliar uma estenose moderada (50 a 69%) com uma sensibilidade de 75% e uma especificidade de 93,8%. Um di\u00e2metro da luz residual \u2264 1,3 mm correlaciona-se com uma estenose superior a 70% e pode ser usado como valor de corte, com sensibilidade de 88,2%, especificidade de 92,4% e valor preditivo negativo de 98%, sendo uma ferramenta excelente para diagnosticar ou afastar uma estenose importante.Atualmente tomografias computadorizadas de alta velocidade e com multidetectores permitem a avalia\u00e7\u00e3o direta do di\u00e2metro do l\u00famen carot\u00eddeo e dos tecidos adjacentes com alt\u00edssima resolu\u00e7\u00e3o espacial.Cabe destacar a necessidade de identificar os casos de suboclus\u00e3o carot\u00eddea  quando n\u00e3o deve ser medida numericamente a estenose, sendo qualificada apenas como suboclus\u00e3o e subclassificada como \u201ccom colapso total\u201d quando for observada acentuada redu\u00e7\u00e3o distal do calibre/sinal do cord\u00e3o ou \u201ccom colapso parcial\u201d quando for observada redu\u00e7\u00e3o mais discreta do calibre distal do vaso.49A situa\u00e7\u00e3o de suboclus\u00e3o \u201ccom colapso parcial\u201d nem sempre \u00e9 clara e evidente, e existem alguns crit\u00e9rios por imagem que podem ajudar sua identifica\u00e7\u00e3o, evitando erros: calibre do l\u00famen no plano da estenose < 1,3 mm, medida do calibre da art\u00e9ria car\u00f3tida interna distal < 3,5 mm, rela\u00e7\u00e3o car\u00f3tida interna doente/car\u00f3tida interna contralateral < 0,87, rela\u00e7\u00e3o car\u00f3tida interna doente/car\u00f3tida externa do mesmo lado < 1,27 e contrasta\u00e7\u00e3o menor em rela\u00e7\u00e3o ao vaso contralateral.A medida direta da luz residual minimizaria potenciais erros de medida, quando se faz a rela\u00e7\u00e3o com a luz da car\u00f3tida interna distal, principalmente nos casos de colapso das paredes nas estenoses acentuadas .50correlacionaram as medidas de velocidade obtidas pelo Doppler com a medida da luz residual realizada em esp\u00e9cimes cir\u00fargicas retiradas \u201cem bloco\u201d, sugerindo que uma estenose importante, definida como di\u00e2metro do l\u00famen residual \u2264 1,5 mm, associada a altera\u00e7\u00f5es hemodin\u00e2micas significativas estipuladas pelos crit\u00e9rios de velocidade, tem 100% de especificidade e at\u00e9 96% de sensibilidade. Mais recentemente, Yurdakul et al.51 demonstraram, utilizando a t\u00e9cnica B-flow, com melhor resolu\u00e7\u00e3o temporal e espacial e menor ocorr\u00eancia do fen\u00f4meno de \u201cextravasamento\u201d que o Doppler colorido e o Power Doppler, que uma luz residual menor que 1,5 mm apresentava performance semelhante \u00e0 angiografia com subtra\u00e7\u00e3o digital pelo m\u00e9todo NASCET para estimar estenose do ramo interno entre 70 e 99%, com sensibilidade de 93%, especificidade de 94% e acur\u00e1cia de 94%.Suwanwela et al.B-flow, B-flow angio e Doppler colorido. A compara\u00e7\u00e3o das percentagens de diminui\u00e7\u00e3o do di\u00e2metro distal (arteriografia) pelos crit\u00e9rios anat\u00f4micos locais (US) e as correspondentes medidas da luz residual pela ultrassonografia e tomografia computadorizada est\u00e3o demostradas na A 58V\u00e1rias institui\u00e7\u00f5es publicaram seus crit\u00e9rios de avalia\u00e7\u00e3o das estenoses por an\u00e1lises das velocidades do fluxo, com algumas diferen\u00e7as em sua interpreta\u00e7\u00e3o.55 avaliaram 10 institui\u00e7\u00f5es americanas e mostraram que, entre elas, havia a utiliza\u00e7\u00e3o de diferentes crit\u00e9rios Doppler ultrassonogr\u00e1ficos para a gradua\u00e7\u00e3o das estenoses carot\u00eddeas, gerando diferen\u00e7as significativas no n\u00famero de interven\u00e7\u00f5es, subsequentemente impactando em custos no sistema de sa\u00fade. Recentemente, Columbo et al.59 levantaram dados de 338 centros diagn\u00f3sticos americanos, em duas popula\u00e7\u00f5es, 4.791 pacientes \u2265 65 anos do Cardiovascular Health Study e 28.483 pacientes assintom\u00e1ticos, submetidos a revasculariza\u00e7\u00e3o carot\u00eddea, pertencentes ao Vascular Quality Initiative Registry (www.vqi.org) e que demonstraram uma grande varia\u00e7\u00e3o de pontos de corte da velocidade de pico sist\u00f3lica (VPS) entre as institui\u00e7\u00f5es, tanto para estenoses maiores que 50%, como para estenoses maiores que 70%, implicando em disparidades no diagn\u00f3stico das estenoses e nas decis\u00f5es de interven\u00e7\u00e3o.Arous et al.57 refor\u00e7aram a necessidade de se normatizar os par\u00e2metros para o diagn\u00f3stico das estenoses carot\u00eddeas.Em editorial referente ao mesmo estudo, Kim e Zierler1 Dessa forma, como outros autores tamb\u00e9m sugeriram, houve a aprova\u00e7\u00e3o de uma abordagem multiparam\u00e9trica para a quantifica\u00e7\u00e3o das estenoses da ACI.58Em 2015, o Departamento de Imagem Cardiovascular da Sociedade Brasileira de Cardiologia (DIC-SBC) publicou recomenda\u00e7\u00f5es para a quantifica\u00e7\u00e3o das estenoses das art\u00e9rias car\u00f3tidas, englobando crit\u00e9rios de avalia\u00e7\u00e3o de fluxo ao Doppler, associados \u00e0 avalia\u00e7\u00e3o anat\u00f4mica da placa. Tamb\u00e9m teve como objetivo subdividir os graus de estenose em decis, de forma que o resultado ultrassonogr\u00e1fico fornecesse informa\u00e7\u00f5es mais objetivas, auxiliando na decis\u00e3o terap\u00eautica.15 A visualiza\u00e7\u00e3o da placa, seja hipo ou hiperecog\u00eanica, assim como calcificada, com ou sem sombra ac\u00fastica, \u00e9 imprescind\u00edvel para o diagn\u00f3stico da estenose, uma vez que condi\u00e7\u00f5es hemodin\u00e2micas diversas podem cursar com velocidades elevadas ou reduzidas independentemente da presen\u00e7a de estenoses.A avalia\u00e7\u00e3o da velocidade do sangue pelo m\u00e9todo Doppler deve ser realizada em conjunto com a avalia\u00e7\u00e3o da placa ao bidimensional. Deve-se aferir, ao Doppler pulsado, o tra\u00e7ado espectral nas car\u00f3tidas comuns, internas e externas bilateralmente e em qualquer ponto em que haja suspeita de estenose sugerida pelas imagens em Modo B e/ou Doppler colorido.1Para considera\u00e7\u00f5es t\u00e9cnicas para a avalia\u00e7\u00e3o pelo Doppler, como \u00e2ngulo de insona\u00e7\u00e3o correto e local da medida das velocidades, indicamos a consulta da diretriz anterior a essa atualiza\u00e7\u00e3o.O presente documento revisa os crit\u00e9rios publicados pelo DIC-SBC em 2015, com atualiza\u00e7\u00e3o dos seus dados. A 59Este documento sugere que as subdivis\u00f5es para a categoria das estenoses menores que 50% continuem sendo realizadas pela an\u00e1lise ao Modo B, utilizando preferencialmente o corte ultrassonogr\u00e1fico transverso que forne\u00e7a a melhor imagem para o c\u00e1lculo de redu\u00e7\u00e3o do l\u00famen.Entre os crit\u00e9rios para a avalia\u00e7\u00e3o das estenoses, destaca-se a VPS, que, na presen\u00e7a da placa, \u00e9 considerada um par\u00e2metro importante e objetivo. No entanto, a an\u00e1lise conjunta com outros par\u00e2metros, como a VDF e as raz\u00f5es de velocidades, confere confiabilidade e facilita o diagn\u00f3stico  e 5. Al\u00e91Este documento corrobora a subdivis\u00e3o da classifica\u00e7\u00e3o das estenoses da ACI em decis, conforme a 62A correla\u00e7\u00e3o entre par\u00e2metros de velocidade pela USV com a angiografia j\u00e1 foi demonstrada por diversos autores, conforme apresentado na 63 Recentemente, Barlinn et al.,64 utilizando os crit\u00e9rios da German Society of Ultrasound in Medicine (DEGUM) tamb\u00e9m mostraram uma sensibilidade menor para a avalia\u00e7\u00e3o das estenoses entre 50 e 69% do que nas entre 70 e 99% .A USV tem boa acur\u00e1cia na identifica\u00e7\u00e3o das estenoses maiores que 70%, por\u00e9m o mesmo n\u00e3o acontece para estenoses menores que 50% e, em especial, as entre 50 e 69%.62 AbuRahma et al.65encontraram boa acur\u00e1cia na valida\u00e7\u00e3o do consenso de 2003, mas sugerem que, para estenoses ACI \u2265 70%, a VPS > 230 cm/s deveria ser usada em pacientes sintom\u00e1ticos, enquanto, para os assintom\u00e1ticos, a abordagem multiparam\u00e9trica  deveria ser considerada, ou ent\u00e3o uma VPS > 280 cm/s.O consenso de 2003 e o Joint do Reino Unido preconizam o VPS > 230 cm/s para a identifica\u00e7\u00e3o das estenoses > 70%, tendo sido validado por outros autores em suas institui\u00e7\u00f5es.65mostraram uma melhor especificidade com a VPS \u2265 137 cm/s do que com 125 cm/s (91% x 85%), optando pela VPS de 140 cm/s j\u00e1 utilizada em sua institui\u00e7\u00e3o.67 Valor semelhante foi encontrado em nosso meio por Petisco et al.,59 em que a VPS \u2265 141 cm/s apresentou uma melhor especificidade do que a VPS \u2265 125 cm/s (90% x 83%), com acur\u00e1cia semelhante. Outros valores de VPS est\u00e3o presentes na literatura, como descritos pelo DEGUM e pelo EQUALIS , em que, respectivamente, VPS > 200 cm/s e 230 cm/s identificariam estenoses \u2265 50 % e VPS maiores que 300 cm/s e 320 cm/s corresponderiam a \u2265 70%.68 Recentemente, Gornick et al.4 avaliaram retrospectivamente exames ultrassonogr\u00e1ficos de 167 pacientes (299 car\u00f3tidas), comparando os crit\u00e9rios do consenso de 2003 com a angiografia, e observaram que a VPS \u2265 180 cm/s obteve uma melhor sensibilidade, especificidade e acur\u00e1cia  para identificar as estenoses \u2265 50%, assim como a associa\u00e7\u00e3o de crit\u00e9rios: a VPS \u2265 125 cm/s, com a raz\u00e3o VPS ACI/VPS ACC \u2265 2 . Refor\u00e7ando a necessidade de uma padroniza\u00e7\u00e3o internacional dos crit\u00e9rios ultrassonogr\u00e1ficos, propostas recentes contam com uma abordagem multiparam\u00e9trica para uma classifica\u00e7\u00e3o mais precisa das estenoses.69No diagn\u00f3stico das estenoses entre 50 e 69%, o consenso de 2003 e o Joint do Reino Unido preconizam a VPS entre 125 e 230 cm/s, no entanto, alguns autores encontraram melhor desempenho com VPS maiores para as estenoses > 50%. AbuRahma et al.71 Para o diagn\u00f3stico das estenoses maiores que 80%, a VDF > 140 cm/s \u00e9 utilizada h\u00e1 anos pela Universidade de Washington e mostrou-se com especificidade maior que 90% tamb\u00e9m em outros estudos.72 Arous et al.73 demonstraram que a VPS \u2265 450 cm/s ou a VDF \u2265 120 cm/s identificaram as estenoses \u2265 80% com uma area under curve (AUC) de 0,66, n\u00e3o havendo diferen\u00e7a significativa na AUC entre as VDF \u2265 120 cm/s e \u2265 140 cm/s .Al\u00e9m da VPS, a VDF pode ser \u00fatil no diagn\u00f3stico das estenoses > 70% e 80%. O consenso de 2003 sugere a VDF > 100 cm/s como par\u00e2metro adicional para a identifica\u00e7\u00e3o das obstru\u00e7\u00f5es > 70%, assim como outros autores obtiveram boa especificidade utilizando esse par\u00e2metro.77 A raz\u00e3o VPS ACI/VDF ACC (\u00edndice de St Mary\u2019s), subdivide as estenoses > 50% em decis,78 por\u00e9m n\u00e3o foi muito estudada, podendo haver sobreposi\u00e7\u00e3o dos valores para graus diferentes de estenose. A raz\u00e3o VDF ACI/VDF ACC pode identificar estenoses > 80% da ACI quando maior que 5,5, segundo alguns autores,80 mas com correla\u00e7\u00e3o inferior com a angiografia.62Al\u00e9m das velocidades absolutas, as raz\u00f5es de velocidades s\u00e3o particularmente \u00fateis, seja como adjuvantes na quantifica\u00e7\u00e3o das estenoses, seja em casos especiais, em que as velocidades podem estar alteradas por outras condi\u00e7\u00f5es que podem subestimar ou superestimar o grau de estenose. S\u00e3o elas: VPS ACI/VPS ACC, VPS ACI/VDF ACC e VDF ACI/VDF ACC. A mais utilizada \u00e9 a raz\u00e3o VPS ACI/VPS ACC, avaliada e endossada por diversos estudos.67 Ressalta-se tamb\u00e9m a import\u00e2ncia de comparar o fluxo p\u00f3s-esten\u00f3tico com o fluxo no vaso contralateral.81O fluxo p\u00f3s-esten\u00f3tico pode auxiliar na identifica\u00e7\u00e3o das estenoses muito severas e em placas calcificadas, com sombra ac\u00fastica, quando h\u00e1 turbul\u00eancia do fluxo ap\u00f3s a placa, redu\u00e7\u00e3o significativa da velocidade (VPS < 30 cm/s) e alargamento do tempo de acelera\u00e7\u00e3o.color e/ou power Doppler, com fluxo filiforme (string sign ou trickle flow), por\u00e9m, pode estar associado a velocidades altas, baixas ou indetect\u00e1veis, o que eventualmente dificulta o diagn\u00f3stico. Nas suboclus\u00f5es com presen\u00e7a de velocidade sist\u00f3lica elevada no ponto da estenose, nota-se redu\u00e7\u00e3o significativa da velocidade distal \u00e0 mesma.5O diagn\u00f3stico ultrassonogr\u00e1fico da suboclus\u00e3o baseia-se na demonstra\u00e7\u00e3o do estreitamento da luz do vaso ao 61Segundo o consenso de 2003 para a diferencia\u00e7\u00e3o entre suboclus\u00e3o e oclus\u00e3o, recomenda-se n\u00e3o utilizar par\u00e2metros de velocidade ao Doppler, mas, sim, a opini\u00e3o do observador acerca das imagens. Como a suboclus\u00e3o pode ser confundida com a oclus\u00e3o, o Joint do Reino Unido e a AHA (American Heart Association) recomendam a complementa\u00e7\u00e3o com outro m\u00e9todo para definir: angio-TC, angio-RM ou angiografia convencional., power Doppler, Doppler espectral e \u00e0 avalia\u00e7\u00e3o com inje\u00e7\u00e3o de contraste com microbolhas, assim como a presen\u00e7a de fluxo de alta resist\u00eancia na ACC, e do fluxo em staccato \u2013 fluxo com velocidade muito reduzida e de alt\u00edssima resist\u00eancia no ponto da oclus\u00e3o ou pr\u00e9-oclus\u00e3o81  da ACI podem cursar com fluxo retr\u00f3grado da art\u00e9ria oft\u00e1lmica.43Outra via colateral pode ser feita com fluxo anter\u00f3grado por ramos distais da ACE ipsilateral que se conectam com o ramo oft\u00e1lmico da ACI, podendo, ent\u00e3o, ser detectado fluxo retr\u00f3grado na art\u00e9ria oft\u00e1lmica.Nos casos em que h\u00e1 oclus\u00e3o da art\u00e9ria car\u00f3tida comum, a car\u00f3tida interna pode encontrar-se p\u00e9rvia, com fluxo anter\u00f3grado proveniente da art\u00e9ria car\u00f3tida externa e seus ramos.62A incid\u00eancia isolada de estenose da ACC \u00e9 baixa, e pouco se sabe sobre a evolu\u00e7\u00e3o dessa les\u00e3o. Suspeita-se que pacientes com estenose isolada da ACC apresentem mais sintomas hemisf\u00e9ricos, afasia e amaurose fugaz.N\u00e3o h\u00e1 evid\u00eancias de que as recomenda\u00e7\u00f5es para a gradua\u00e7\u00e3o da estenose da ACI devam ser aplicadas para classificar as les\u00f5es na ACC ou na ACE.power Doppler do fluxo e pelo modo B , estenoses de origem ateroscler\u00f3tica ou arterites com envolvimento do arco a\u00f3rtico, ramos e car\u00f3tida comum.85Devemos ter em mente que as altera\u00e7\u00f5es card\u00edacas geram efeitos sist\u00eamicos, ou seja, as modifica\u00e7\u00f5es encontradas nas ondas de fluxo das art\u00e9rias car\u00f3tidas estar\u00e3o presentes bilateralmente, assim como acometem os demais leitos arteriais.1As condi\u00e7\u00f5es que afetam as medidas de velocidades est\u00e3o pormenorizadas na diretriz do DIC 2015 precedente a esta atualiza\u00e7\u00e3o.86 Sabe-se que o exame de USV apresenta baixo custo e boa acur\u00e1cia em compara\u00e7\u00e3o com a angiografia, por\u00e9m n\u00e3o h\u00e1 consenso quanto \u00e0 periodicidade do acompanhamento.87Interven\u00e7\u00f5es no territ\u00f3rio carot\u00eddeo por via cir\u00fargica convencional ou por via endovascular s\u00e3o frequentemente realizadas, especialmente para o tratamento de les\u00f5es ateroscler\u00f3ticas. O acompanhamento ap\u00f3s esses procedimentos \u00e9 essencial para identificar precocemente qualquer altera\u00e7\u00e3o que possa interferir na perviedade ap\u00f3s o tratamento e garantir melhores resultados p\u00f3s-operat\u00f3rios.O exame p\u00f3s-interven\u00e7\u00e3o \u00e9 semelhante ao de diagn\u00f3stico. \u00c9 essencial a avalia\u00e7\u00e3o e descri\u00e7\u00e3o de todos os achados inerentes aos procedimentos.patch.O tratamento cir\u00fargico da estenose car\u00f3tida \u00e9 feito por meio de incis\u00e3o na parede anterior, remo\u00e7\u00e3o da placa de aterosclerose e s\u00edntese da art\u00e9ria com ou sem coloca\u00e7\u00e3o de 88 que, felizmente, s\u00e3o infrequentes.90Uma das principais preocupa\u00e7\u00f5es ap\u00f3s a endarterectomia (EAC) de car\u00f3tida \u00e9 a taxa de reestenose e o risco de acidente vascular cerebral (AVC) subsequente91As reestenoses diagnosticadas entre 6 e 12 meses ap\u00f3s a EAC s\u00e3o, geralmente, decorrentes de hiperplasia neointimal. J\u00e1 as les\u00f5es que se desenvolvem ap\u00f3s 24 e 36 meses tendem a representar recorr\u00eancia do processo ateroscler\u00f3tico.92 n\u00e3o encontraram valor significativo para a repeti\u00e7\u00e3o de USV de rotina ap\u00f3s EAC com patch. J\u00e1 para Bandyk et al.,93 e Zierler et al.,86 o benef\u00edcio da vigil\u00e2ncia supera seu risco, e recomendam a vigil\u00e2ncia com USV com grau de recomenda\u00e7\u00e3o 1B.AbuRahma et al.patch tiver sido usado, ele poder\u00e1 criar uma dilata\u00e7\u00e3o no local da EAC de v\u00e1rias dimens\u00f5es  normalmente aparecer\u00e1 como uma linha dupla brilhante que representa a espessura do material e os efeitos da penetra\u00e7\u00e3o do ultrassom.86As suturas de fechamento de arteriotomia podem ser vistas como ecos brilhantes e uniformemente espa\u00e7ados ao longo da parede da ACC e ACI na imagem em modo B . Se um pimens\u00f5es . EnquantDevem-se aferir as medidas dos di\u00e2metros no vaso nativo, nos locais das anastomoses e na regi\u00e3o do alargamento, caso haja, para que se possa acompanhar e comparar posteriormente.As principais caracter\u00edsticas ultrassonogr\u00e1ficas e complica\u00e7\u00f5es ap\u00f3s interven\u00e7\u00f5es carot\u00eddeas foram descritas e ilustradas nas recomenda\u00e7\u00f5es do DIC de 2015. Nesta atualiza\u00e7\u00e3o, houve apenas uma mudan\u00e7a nos crit\u00e9rios de reestenose, e o patch e a possibilidade de despropor\u00e7\u00e3o de calibre no final da endarterectomia na car\u00f3tida interna.Apesar de a maioria dos estudos considerar a estenose > 70% ap\u00f3s EAC como crit\u00e9rio de gravidade na reestenose, o seu ponto de corte varia na literatura. Assim, novos estudos s\u00e3o necess\u00e1rios para a padroniza\u00e7\u00e3o dos crit\u00e9rios de velocidades ultrassonogr\u00e1ficos nas reestenoses ap\u00f3s EAC. Entretanto, devem ser levadas em considera\u00e7\u00e3o as diferen\u00e7as de velocidade encontradas nas endarterectomias com ou sem 93 para a gradua\u00e7\u00e3o das estenoses > 70% ap\u00f3s EAC, sendo VPS > 300 cm/s, VDF > 125 cm/s, raz\u00e3o das VPS ACI/ACC > 5. Para a vigil\u00e2ncia pela USV, seguindo os mesmos autores, recomendamos o intervalo de 1, 3 e 12 meses ap\u00f3s o procedimento.Recomendamos a ado\u00e7\u00e3o dos crit\u00e9rios recentes de Bandyk et al.stent carot\u00eddeo. Entretanto, h\u00e1 mais de 2 d\u00e9cadas estudam-se aspectos morfol\u00f3gicos e histopatol\u00f3gicos ligados \u00e0 instabilidade da placa ateroscler\u00f3tica, isto \u00e9, placas com o mesmo grau de estenose n\u00e3o necessariamente apresentam o mesmo potencial isqu\u00eamico para eventos tromboemb\u00f3licos. A habilidade de identificar qual placa seria mais inst\u00e1vel ou vulner\u00e1vel pode ter um papel fundamental na decis\u00e3o terap\u00eautica.O estudo da morfologia da placa ateroscler\u00f3tica vem ganhando espa\u00e7o dentro da avalia\u00e7\u00e3o da aterosclerose carot\u00eddea. Convencionalmente, a gradua\u00e7\u00e3o da estenose carot\u00eddea sempre teve o papel de maior destaque nos exames de imagem de car\u00f3tidas e vertebrais, j\u00e1 que \u00e9 a vari\u00e1vel mais utilizada na tomada de decis\u00e3o cir\u00fargica da endarterectomia ou do implante de 94 A defini\u00e7\u00e3o de placa ateroscler\u00f3tica se encontra na parte 2 desse documento  em pacientes com acidentes vasculares encef\u00e1licos (AVEs) repetidos e estenoses n\u00e3o significativas pode direcionar para a interven\u00e7\u00e3o carot\u00eddea ou intensifica\u00e7\u00e3o do tratamento farmacol\u00f3gico de acordo com as melhores pr\u00e1ticas m\u00e9dicas.ocumento  e se man96A caracteriza\u00e7\u00e3o da morfologia da placa tem um papel importante na ocorr\u00eancia de eventos cerebrovasculares e pode tamb\u00e9m ser um importante preditor de eventos. A pesquisa das caracter\u00edsticas relacionadas ao maior risco de eventos demonstra um esfor\u00e7o para identificar os par\u00e2metros relacionados \u00e0 placa que, juntamente com o grau de estenose, podem predizer com maior precis\u00e3o a presen\u00e7a de placa vulner\u00e1vel e o risco associado de eventos isqu\u00eamicos. O US, entretanto, tem limita\u00e7\u00f5es inerentes ao m\u00e9todo nessa caracteriza\u00e7\u00e3o. Outros m\u00e9todos ainda n\u00e3o foram incorporados na rotina para essa avalia\u00e7\u00e3o, j\u00e1 que ainda n\u00e3o h\u00e1 nada totalmente estabelecido provando uma melhora adicional na estratifica\u00e7\u00e3o de risco.1 A caracteriza\u00e7\u00e3o da placa ateroscler\u00f3tica pode ser preditiva de progress\u00e3o do grau de estenose e eventos cl\u00ednicos. Placas hipoecog\u00eanicas, heterog\u00eaneas e irregulares s\u00e3o marcadoras de risco de eventos como AVC e ataque isqu\u00eamico transit\u00f3rio (AIT).A descri\u00e7\u00e3o da morfologia da placa deve ser realizada nos laudos do exame de USV carot\u00eddea como j\u00e1 descrito na recomenda\u00e7\u00e3o do DIC de 2015, de acordo com o Neste documento, atualizamos em rela\u00e7\u00e3o ao valor de algumas caracter\u00edsticas das placas ateroscler\u00f3ticas e risco de DCV, avalia\u00e7\u00e3o do volume de placa e dados da angio-TC e angio-RM.97Herr et al. utilizaram um m\u00e9todo semelhante ao GSM em pacientes avaliados para doen\u00e7a cardiovascular. Os autores conclu\u00edram que o aumento da ecogenicidade da placa carot\u00eddea (tecido fibroso e/ou semelhante ao c\u00e1lcio) se correlacionou com o aumento de doen\u00e7a arterial coron\u00e1ria, e uma combina\u00e7\u00e3o de altura da placa, percentual de c\u00e1lcio e/ou percentual de gordura aumenta o risco de eventos cardiovasculares. Esse estudo aponta para o potencial de incorpora\u00e7\u00e3o da an\u00e1lise da composi\u00e7\u00e3o da placa pelo ultrassom carot\u00eddeo na estratifica\u00e7\u00e3o de risco .97softwares para reconstru\u00e7\u00e3o em 3D possibilitaram estudos e recomenda\u00e7\u00f5es sistem\u00e1ticas para a padroniza\u00e7\u00e3o e quantifica\u00e7\u00e3o da placa arterial carot\u00eddea na estratifica\u00e7\u00e3o de risco para a doen\u00e7a ateroscler\u00f3tica cardiovascular.26 Por meio dessa t\u00e9cnica pr\u00e1tica e reprodut\u00edvel, \u00e9 poss\u00edvel quantificar o volume, caracterizar a anatomia e fun\u00e7\u00e3o da parede arterial, incluindo a caracteriza\u00e7\u00e3o da placa, com resolu\u00e7\u00e3o espacial aprimorada.98 A principal vantagem da quantifica\u00e7\u00e3o 3D \u00e9 a capacidade de medir uma les\u00e3o espec\u00edfica em todos os planos, t\u00e9cnica que possibilita o acompanhamento da progress\u00e3o da les\u00e3o e do tratamento da mesma.Nos \u00faltimos anos, os avan\u00e7os em torno da ultrassonografia ocorreram em grande escala. A cria\u00e7\u00e3o de sondas vasculares com tecnologia tridimensional e de 98O volume da placa carot\u00eddea equivale ao conte\u00fado ateroscler\u00f3tico medido em um segmento arterial definido. A import\u00e2ncia dessa aferi\u00e7\u00e3o se d\u00e1 devido \u00e0 possibilidade diagn\u00f3stica de placas em art\u00e9rias angiograficamente normais e em les\u00f5es carot\u00eddeas com menos de 50% de estenose.A aquisi\u00e7\u00e3o do volume de placa da car\u00f3tida pode ser mensurada por meio de dois m\u00e9todos distintos, de acordo com o equipamento dispon\u00edvel:Protocolo de regi\u00e3o \u00fanica, em que h\u00e1 reconstru\u00e7\u00e3o de um segmento espec\u00edfico ou placa \u00fanica.Protocolo de vaso completo, em que h\u00e1 reconstru\u00e7\u00e3o de um conjunto de dados adquiridos ao longo do trajeto examinado.99 A avalia\u00e7\u00e3o ultrassonogr\u00e1fica da EMI e o volume de placa t\u00eam sido usados para estratifica\u00e7\u00e3o de risco e avalia\u00e7\u00e3o de terapias antiateroscler\u00f3ticas. Segundo Wannarong et al.,99 a medida do volume de placa e sua progress\u00e3o s\u00e3o superiores \u00e0s medidas de EMI em ambas as situa\u00e7\u00f5es.O volume total da placa, medido de 1,5 cm da art\u00e9ria car\u00f3tida comum distal at\u00e9 1 cm distal \u00e0 bifurca\u00e7\u00e3o, \u00e9 fator preditor de eventos futuros de DCV.98 o volume de PC em pacientes com sintomas de isquemia cerebral \u00e9 maior em pacientes nas primeiras semanas da manifesta\u00e7\u00e3o, quando o risco de AVE tamb\u00e9m \u00e9 maior. No entanto, n\u00e3o houve rela\u00e7\u00e3o significativa entre o volume da placa e a estenose carot\u00eddea. Noflatscher et al. demonstraram forte correla\u00e7\u00e3o entre o volume total de placa carot\u00eddea com fatores de risco cardiovascular  e o n\u00famero de leitos vasculares acometidos.100 No entanto, atualmente, os dados para classifica\u00e7\u00e3o de volume da placa s\u00e3o limitados, e mais estudos s\u00e3o necess\u00e1rios para estabelecer valores de corte preditores de DCV.26De acordo com o estudo de Ball et al.,102 Torna-se importante a racionalidade na tomada de decis\u00e3o de quando indicar uma ou outra t\u00e9cnica, individualizando-se caso a caso, de acordo com as particularidades cl\u00ednicas. Esses exames, entretanto, n\u00e3o s\u00e3o utilizados para a avalia\u00e7\u00e3o de risco cardiovascular e, sim, para pacientes j\u00e1 sintom\u00e1ticos ou j\u00e1 inicialmente rastreados por outro m\u00e9todo, como a ultrassonografia vascular, e para avalia\u00e7\u00e3o da gravidade da estenose e extens\u00e3o da doen\u00e7a. Todavia, esses m\u00e9todos de imagem s\u00e3o muito \u00fateis para o diagn\u00f3stico da dissec\u00e7\u00e3o de vasos cervicais e hematoma intramural, onde o US n\u00e3o \u00e9 t\u00e3o acurado.Entre as v\u00e1rias indica\u00e7\u00f5es da angio-RM e da angio-TC est\u00e1 a caracteriza\u00e7\u00e3o das placas e da parede arterial por possu\u00edrem resolu\u00e7\u00e3o espacial submilim\u00e9trica, com acur\u00e1cia similar na detec\u00e7\u00e3o desses processos quando considerados os equipamentos e t\u00e9cnicas mais modernos dispon\u00edveis.A angio-CT e a angio-RM s\u00e3o \u00fateis no diagn\u00f3stico de dissec\u00e7\u00e3o arterial cervical (recomenda\u00e7\u00e3o Classe I \u2013 N\u00edvel de evid\u00eancia: C) e s\u00e3o t\u00e9cnicas n\u00e3o invasivas de grande acur\u00e1cia, que se tornaram m\u00e9todos de escolha na suspeita de dissec\u00e7\u00e3o arterial em lugar da angiografia digital (padr\u00e3o-ouro).vessel wall imaging\u201d) contribui para essa detec\u00e7\u00e3o superior.As t\u00e9cnicas de angio-TC e angio-RM nos equipamentos mais modernos dispon\u00edveis demonstram acur\u00e1cia similar na detec\u00e7\u00e3o de dissec\u00e7\u00f5es arteriais. Destaca-se, contudo, a maior sensibilidade da RM na demonstra\u00e7\u00e3o de hematomas murais e sua capacidade superior em diferenciar dissec\u00e7\u00f5es agudas e subagudas . Um recurso t\u00e9cnico adicional e mais recente , ecorreal\u00e7ador, ao termo agente de contraste, para diferenciar dos contrastes que usam iodo ou gadol\u00ednio.107O maior avan\u00e7o da ultrassonografia ap\u00f3s a introdu\u00e7\u00e3o do modo B e do Doppler foi a introdu\u00e7\u00e3o de agentes de contraste, ampliando muito o valor desse m\u00e9todo e a sua utiliza\u00e7\u00e3o na pr\u00e1tica cl\u00ednica.108 A utiliza\u00e7\u00e3o do ARUS abriu novos horizontes no campo da pesquisa em muitas patologias arteriais, uma vez que ele \u00e9 capaz de fornecer novos conjuntos de dados que podem ser fundamentais no manejo do paciente. Os aspectos a seguir devem ser do pleno conhecimento para sua utiliza\u00e7\u00e3o.A grande inova\u00e7\u00e3o t\u00e9cnica foi a introdu\u00e7\u00e3o de m\u00f3dulos de imagem espec\u00edficos para o ARUS nos equipamentos de US com a utiliza\u00e7\u00e3o da harm\u00f4nica de pulso invertido, possibilitando a visualiza\u00e7\u00e3o direta de sinais emitidos por esses agentes, independentemente de suas velocidades. Devido \u00e0s caracter\u00edsticas pr\u00f3prias dos sinais das microbolhas , s\u00e3o criadas imagens \u201cespec\u00edficas das microbolhas\u201d, que podem exibir volume e perfus\u00e3o de par\u00eanquimas teciduais com sensibilidade e resolu\u00e7\u00e3o espacial extremamente elevadas.O ARUS, ao contr\u00e1rio daqueles agentes empregados para a resson\u00e2ncia magn\u00e9tica (RM) e a tomografia computadorizada (TC) que utilizam as caracter\u00edsticas f\u00edsicas e qu\u00edmicas das c\u00e9lulas para o seu efeito, utiliza as caracter\u00edsticas f\u00edsicas do pr\u00f3prio m\u00e9todo ultrassonogr\u00e1fico, ou seja, quanto maior a diferen\u00e7a de densidade entre os meios, maior a reflex\u00e3o da energia emitida e maior a amplitude do sinal de US. Indiscutivelmente, o meio gasoso \u00e9 o que promove a maior diferen\u00e7a, correspondendo a um aumento do sinal da ordem de 30 decib\u00e9is.109Assim, n\u00e3o h\u00e1 contraindica\u00e7\u00e3o ao uso em pacientes com insufici\u00eancia renal, uma vantagem com ampla aplica\u00e7\u00e3o em diab\u00e9ticos, hipertensos, cardiopatas e outras doen\u00e7as que cursam com insufici\u00eancia renal cr\u00f4nica.Os ARUS s\u00e3o microbolhas de g\u00e1s contidas em c\u00e1psulas com membrana fosfolip\u00eddica que possuem flexibilidade e estabilidade. O agente SonoVue\u00ae (Bracco Imaging S.p.A.) \u00e9 o \u00fanico produto liberado atualmente no Brasil pela Ag\u00eancia Nacional de Vigil\u00e2ncia Sanit\u00e1ria (Anvisa) e pelo rol da Ag\u00eancia Nacional de Sa\u00fade Suplementar (ANS). O SonoVue\u00ae consiste em microesferas de g\u00e1s hexafluoreto de enxofre encapsuladas. As microbolhas possuem di\u00e2metro m\u00e9dio de 2,3 \u00b5m . Por ser um g\u00e1s lipof\u00edlico, tem baixa solubilidade no sangue e n\u00e3o se difunde para fora da c\u00e1psula. Essa capa proteica composta de uma camada \u00fanica de fosfolip\u00eddios atua como surfactante, conferindo-lhe estabilidade e flexibilidade ao longo de seu trajeto na macro e microcircula\u00e7\u00e3o sangu\u00ednea. O SonoVue\u00ae \u00e9, portanto, considerado um agente integrante exclusivo do pool de sangue e um marcador da circula\u00e7\u00e3o sangu\u00ednea . Ap\u00f3s a ruptura da microbolha, o g\u00e1s \u00e9 exalado na respira\u00e7\u00e3o atrav\u00e9s dos pulm\u00f5es em sua quase totalidade, n\u00e3o sofrendo qualquer metaboliza\u00e7\u00e3o hep\u00e1tica ou excre\u00e7\u00e3o renal.software espec\u00edfico para estudo com ARUS, o que pode estar inclu\u00eddo na configura\u00e7\u00e3o original da m\u00e1quina ou ser adquirido \u00e0 parte. Entretanto, mesmo naqueles sem o m\u00f3dulo de imagem espec\u00edfico para contraste, alguns par\u00e2metros podem ser configurados pelo pr\u00f3prio operador. Para a obten\u00e7\u00e3o de melhor resultado durante o estudo contrastado, alguns conceitos e regulagens do equipamento devem obrigatoriamente ser conhecidos.Atualmente, a maioria dos fabricantes de equipamentos de US possui O comportamento das microbolhas, quando expostas ao US, varia de acordo com a pot\u00eancia de US emitida, ou seja, a amplitude da onda ac\u00fastica, a qual \u00e9 denominada de \u00edndice mec\u00e2nico (IM) nos equipamentos. Em estudos sem ARUS, o IM encontra-se na faixa de 1,6 a 1,9; entretanto, sob essa pot\u00eancia ac\u00fastica, a microbolha invariavelmente entra em oscila\u00e7\u00e3o vigorosa e se rompe, gerando dois efeitos indesejados: aumento abrupto da intensidade do sinal com borramento excessivo na imagem e marcada redu\u00e7\u00e3o da concentra\u00e7\u00e3o de agente, com consequente encurtamento do tempo de exame. Esse modo de imagem, chamado de \u201cimagem por estimula\u00e7\u00e3o ac\u00fastica\u201d, n\u00e3o necessita de equipamentos com tecnologia espec\u00edfica para contraste, mas, por outro lado, n\u00e3o utiliza todo o potencial do agente, limitando-se \u00e0 fun\u00e7\u00e3o de ecorreal\u00e7ador.wash in) ao local de estudo, o per\u00edodo de realce e a concentra\u00e7\u00e3o das microbolhas na estrutura-alvo, muito importante para situa\u00e7\u00f5es como o estudo dos vasos nutridores da parede vascular (vasa vasorum), das placas carot\u00eddeas, da distribui\u00e7\u00e3o capilar (perfus\u00e3o) renal e de massas em geral.108Ao reduzirmos o IM para \u2264 0,2, conseguimos n\u00e3o somente manter a integridade das microbolhas, como tamb\u00e9m fazer com que elas oscilem de forma n\u00e3o linear  e entrem em resson\u00e2ncia, emitindo frequ\u00eancias (as chamadas \u201cfrequ\u00eancias harm\u00f4nicas\u201d) diferentes da frequ\u00eancia fundamental emitida pelo transdutor. Os equipamentos dotados dessa tecnologia conseguem filtrar esses sinais emitidos especificamente pelas microbolhas, obtendo um estudo mais duradouro e que destaca o sinal das microbolhas em detrimento dos tecidos, estes praticamente anulados na imagem que aparece como fundo escuro. Essa forma de estudo, chamada tamb\u00e9m de \u201cestudo com contraste com baixo IM\u201d, permite avaliar de forma cont\u00ednua o tempo de chegada do  e, em \u00faltimo caso, aumentar o IM, tendo como consequ\u00eancia a maior destrui\u00e7\u00e3o de bolhas no campo proximal.110 Em geral, os equipamentos permitem o estudo simult\u00e2neo com Modo B e contraste em telas paralelas (lado a lado).Um controle do equipamento que merece aten\u00e7\u00e3o no estudo contrastado \u00e9 o ganho da imagem, que amplifica o sinal recebido durante o p\u00f3s-processamento no equipamento. O ganho elevado produz uma imagem brilhante e um aumento generalizado no ru\u00eddo de fundo, obscurecendo o sinal do contraste . Durante o estudo com contraste, deve-se, portanto, reduzir o ganho do equipamento at\u00e9 que a imagem fique virtualmente de cor preta, exceto para estruturas altamente ecog\u00eanicas. Alguns fabricantes possuem controles de ajuste de ganho para estudos contrastados, que podem facilmente ser ativados e desativados durante o estudo. Quando se realiza um ajuste manual, deve-se ter a menor quantidade de sinais ac\u00fasticos antes da inje\u00e7\u00e3o do agente e entender se esse sinal \u00e9 provocado por aumento do IM  ou do ganho .110 Uma forma de destacar os diferentes n\u00edveis de realce provocados pelo contraste em uma estrutura \u00e9 ajustando a dose do agente para n\u00edveis que permitam a opacifica\u00e7\u00e3o adequada, sem borramento ou atenua\u00e7\u00e3o, e aumentando o n\u00edvel da faixa din\u00e2mica (dynamic range) do equipamento. Doses baixas, por sua vez, n\u00e3o alcan\u00e7ar\u00e3o o n\u00edvel de opacifica\u00e7\u00e3o desejado.A dose do ecorreal\u00e7ador a ser injetado deve ser previamente estudada pelo examinador. Doses altas provocam inicialmente borramento (satura\u00e7\u00e3o) do sinal e atenua\u00e7\u00e3o (sombra ac\u00fastica) das estruturas no campo distal, at\u00e9 que haja queda para concentra\u00e7\u00f5es adequadas do n\u00edvel de contraste. Al\u00e9m disso, n\u00e3o ser\u00e1 poss\u00edvel distinguir pequenas diferen\u00e7as de realce entre estruturas, uma vez que o limite superior da faixa din\u00e2mica  do equipamento foi ultrapassado.111As indica\u00e7\u00f5es para uso de contraste em ultrassonografia vascular e especificamente nas car\u00f3tidas s\u00e3o resumidas no 113 O US contrastado determina melhor visualiza\u00e7\u00e3o endovascular, caracterizando a geometria detalhada dos segmentos pr\u00e9-esten\u00f3ticos, intraesten\u00f3ticos e p\u00f3s-esten\u00f3ticos desprovidos de artefatos ou depend\u00eancia de angulo113 ; e um sistema de transfer\u00eancia. O produto \u00e9 de f\u00e1cil preparo \u00e0 beira do leito, seguindo-se as instru\u00e7\u00f5es do fabricante. Ap\u00f3s transferir o conte\u00fado da seringa para o frasco com p\u00f3, o mesmo dever\u00e1 ser agitado durante 20 segundos para a forma\u00e7\u00e3o das microbolhas e para a solu\u00e7\u00e3o salina transformar-se em uma suspens\u00e3o com aspecto leitoso (indicando distribui\u00e7\u00e3o homog\u00eanea das microbolhas). Nesse estado, a suspens\u00e3o pode ser armazenada por at\u00e9 6 horas. Se as microbolhas se acumularem na superf\u00edcie durante o repouso, a solu\u00e7\u00e3o poder\u00e1 ser novamente agitada para que as microbolhas readquiram distribui\u00e7\u00e3o homog\u00eanea antes do uso. A via usual de administra\u00e7\u00e3o \u00e9 uma inje\u00e7\u00e3o intravenosa em bolus em veia de calibre adequado para pun\u00e7\u00e3o com agulha de 20 G de di\u00e2metro . Um pequeno volume inicial deve ser administrado, seguido de um flush com 10 mL de solu\u00e7\u00e3o salina a 0,9% para empurrar o agente de contraste at\u00e9 a veia central (o que ocorre em segundos).O SonoVue\u00ae \u00e9 composto por um wash in e wash out) e devem ser registrados continuamente para posterior an\u00e1lise. Em alguns casos espec\u00edficos, como na pesquisa de endoleaks tardios p\u00f3s-coloca\u00e7\u00e3o de pr\u00f3teses endovasculares a\u00f3rticas, o tempo de avalia\u00e7\u00e3o pode chegar a 5 minutos; nesses casos, clipes menores podem ser registrados. Deve-se ter em mente que, quanto maior o IM, maior a destrui\u00e7\u00e3o de bolhas e menor o tempo de dura\u00e7\u00e3o do contraste. Ap\u00f3s a ruptura das bolhas, o hexafluoreto de enxofre \u00e9 rapidamente eliminado pelos pulm\u00f5es, em cerca de 2 minutos.A dose recomendada na maioria das publica\u00e7\u00f5es para inje\u00e7\u00e3o \u00fanica nos estudos de USV \u00e9 de 2,4 mL, podendo variar de 1 a 4,8 mL, a sonda empregada e a sensibilidade do equipamento dispon\u00edvel . Os primeiros 10 a 40 segundos ap\u00f3s o bolus correspondem \u00e0 curva de realce do contraste .\u2013 Prepara\u00e7\u00e3o da solu\u00e7\u00e3o de contraste com microbolhas (SonoVue\u00ae) de acordo com as orienta\u00e7\u00f5es do fabricante do produto.software espec\u00edfico, ajuste de IM , ganho de imagem (escurecer o fundo) e escolha de janelas adequadas que reduzam a profundidade do \u00f3rg\u00e3o alvo do estudo.\u2013 Acionamento do modo de imagem espec\u00edfico para contraste no equipamento de US; caso n\u00e3o haja \u2013 Administra\u00e7\u00e3o da solu\u00e7\u00e3o com contraste, ajustes para reduzir excesso de realce e registro de imagens (clipes) digitais durante os 10 a 60 segundos ap\u00f3s bolus inicial; nos casos de exames espec\u00edficos com maior dura\u00e7\u00e3o, registrar clipes necess\u00e1rios no decorrer do tempo  para an\u00e1lise posterior.O exame com contraste de microbolhas \u00e9 fundamentalmente din\u00e2mico, e a dura\u00e7\u00e3o do estudo \u00e9 curta em raz\u00e3o da r\u00e1pida destrui\u00e7\u00e3o das microbolhas pelas ondas de US, mesmo quando se utiliza um IM muito baixo. Portanto, o registro em m\u00eddia digital din\u00e2mica \u00e9 essencial para posterior processamento e reavalia\u00e7\u00e3o cuidadosa das imagens, garantindo diagn\u00f3stico seguro e armazenamento perene dos resultados.softwares espec\u00edficos, o acesso ao produto em unidades da rede p\u00fablica de sa\u00fade e a aus\u00eancia completa de \u201cjanela\u201d ultrassonogr\u00e1fica. As contraindica\u00e7\u00f5es cl\u00ednicas s\u00e3o IAM, doen\u00e7a pulmonar obstrutiva cr\u00f4nica (DPOC) severa, arritmias card\u00edacas graves e hipersensibilidade ao ARUS (rara).111As principais limita\u00e7\u00f5es do uso ARUS em USV s\u00e3o inexperi\u00eancia do examinador, a aus\u00eancia de 118 As placas ateroscler\u00f3ticas se localizam predominantemente na origem das art\u00e9rias vertebrais, sendo que na maioria dos casos s\u00e3o extens\u00f5es de placas das art\u00e9rias subcl\u00e1vias.119 A presen\u00e7a de estenose vertebrobasilar na vig\u00eancia de um AVE ou AIT envolvendo a circula\u00e7\u00e3o posterior aumenta em aproximadamente 33% o risco de recorr\u00eancia no primeiro m\u00eas ap\u00f3s o evento inicial.121A investiga\u00e7\u00e3o de envolvimento ateroscler\u00f3tico nas art\u00e9rias vertebrais extracranianas atrav\u00e9s da USV \u00e9 indissoci\u00e1vel do estudo das car\u00f3tidas. Isso \u00e9 essencial para o diagn\u00f3stico e tratamento das les\u00f5es carot\u00eddeas severas, bem como para avalia\u00e7\u00e3o criteriosa dos riscos da abordagem cir\u00fargica. Aproximadamente 25% dos acidentes vasculares isqu\u00eamicos encef\u00e1licos envolvem a circula\u00e7\u00e3o posterior, e a doen\u00e7a ateroscler\u00f3tica corresponde a 20% dos casos.1A descri\u00e7\u00e3o detalhada da anatomia das art\u00e9rias do sistema vertebrobasilar pode ser encontrada na diretriz do DIC 2015 que antecede esta atualiza\u00e7\u00e3o.Com os recursos t\u00e9cnicos atualmente dispon\u00edveis, consegue-se estudar a art\u00e9ria vertebral em toda a sua extens\u00e3o, incluindo o segmento intracraniano e a art\u00e9ria basilar proximal. Recomendamos incluir, na rotina de avalia\u00e7\u00e3o, o estudo da origem do vaso (sede mais frequente das estenoses) e os demais segmentos extracranianos.A posi\u00e7\u00e3o do paciente \u00e9 a mesma adotada para o estudo das car\u00f3tidas. A profundidade do campo de imagem pode variar com a anatomia do pesco\u00e7o. A escala de cores deve ser reduzida, aumentando-se a sensibilidade de detec\u00e7\u00e3o do fluxo em cores.1A metodologia do exame est\u00e1 descrita na recomenda\u00e7\u00e3o publicada em 2015 pelo DIC.1 e demonstrados na Os par\u00e2metros anat\u00f4micos e hemodin\u00e2micos de hipoplasia da art\u00e9ria vertebral est\u00e3o descritos na publica\u00e7\u00e3o de 2015color Doppler e no aumento de velocidades de fluxo no local da les\u00e3o . Em vertebrais com curso tortuoso, pode haver um aumento fisiol\u00f3gico das velocidades. Uma curva espectral amortecida \u00e0 vazante corrobora a presen\u00e7a de estenose significativa proximal. Em casos com imagem bidimensional de boa qualidade, pode-se identificar a redu\u00e7\u00e3o luminal do vaso e medir, com o aux\u00edlio do powerangio, o l\u00famen residual pelo crit\u00e9rio anat\u00f4mico distal.O diagn\u00f3stico baseia-se na identifica\u00e7\u00e3o de turbilhonamento ao 122 com valores de corte para a defini\u00e7\u00e3o dos graus de estenose proximal da art\u00e9ria vertebral. A VPS na origem do vaso \u00e9 o par\u00e2metro de maior especificidade para quantifica\u00e7\u00e3o de estenose vertebral proximal quando comparada aos demais crit\u00e9rios espectrais como \u00edndice de velocidade m\u00e1xima (IVV) e velocidade diast\u00f3lica final (VDF).Recomendamos a utiliza\u00e7\u00e3o da color Doppler, aumento localizado das velocidades de fluxo, aumento dos \u00edndices de velocidade e amortecimento do fluxo distal, uma vez que n\u00e3o existem tabelas de quantifica\u00e7\u00e3o das estenoses para esses segmentos.123Quando o local da estenose \u00e9 identificado ao ultrassom, sua avalia\u00e7\u00e3o deve se basear em an\u00e1lise multiparam\u00e9trica, como turbul\u00eancia ao Nos casos de segmentos n\u00e3o visualiz\u00e1veis ao exame convencional (segmento V4 intracraniano), os achados s\u00e3o indiretos e correlacionam-se com o n\u00edvel da estenose e emerg\u00eancia do ramo cerebelar posterior inferior (ACPI). Nas estenoses pr\u00e9-emerg\u00eancia do ramo cerebelar posterior inferior (pr\u00e9-ACPI), as curvas espectrais apresentam velocidades reduzidas e padr\u00e3o de resist\u00eancia elevada registradas nos segmentos V1-V2. Estenose ap\u00f3s emerg\u00eancia do ramo cerebelar posterior inferior (p\u00f3s-ACPI) n\u00e3o causa altera\u00e7\u00e3o de fluxo, pois h\u00e1 desvio para o cerebelo. Nesses casos, o estudo com Doppler transcraniano (DTC) torna-se indispens\u00e1vel para o diagn\u00f3stico.Os achados variam de acordo com o n\u00edvel da oclus\u00e3o. O 126 Nesse caso, a morfologia da curva espectral e a dire\u00e7\u00e3o da onda de fluxo na art\u00e9ria vertebral do mesmo lado da subcl\u00e1via comprometida, em repouso ou ap\u00f3s manobra de provoca\u00e7\u00e3o de hiperemia reativa , permitem avaliar o efeito de \u201croubo\u201d. Ao contr\u00e1rio das estenoses vertebrais distais, em que o primeiro componente afetado \u00e9 o componente diast\u00f3lico, no \u201croubo\u201d, a primeira altera\u00e7\u00e3o ocorre durante a fase sist\u00f3lica, com breve desacelera\u00e7\u00e3o do fluxo sist\u00f3lico (quase impercept\u00edvel para examinadores menos experientes).Estenose hemodinamicamente significativa ou oclus\u00e3o do tronco braquiocef\u00e1lico ou de segmento proximal da art\u00e9ria subcl\u00e1via (direita ou esquerda) provocam efeito de \u201croubo\u201d de fluxo da vertebral contralateral  para suprir a subcl\u00e1via acometida.O O objetivo fundamental do DTC em portadores (assintom\u00e1ticos ou n\u00e3o) de doen\u00e7a ateroscler\u00f3tica carot\u00eddea ou vertebral extracraniana \u00e9 investigar o valor preditivo de ocorr\u00eancia de acidente vascular encef\u00e1lico isqu\u00eamico (AVEi).129As ferramentas de real valor oferecidas pelo DTC s\u00e3o: a) detec\u00e7\u00e3o de microembolia encef\u00e1lica espont\u00e2nea; b) registro de informa\u00e7\u00f5es hemodin\u00e2micas durante a monitoriza\u00e7\u00e3o transoperat\u00f3ria (endarterectomia) e em procedimentos endovasculares.129A t\u00e9cnica do DTC varia na depend\u00eancia da indica\u00e7\u00e3o cl\u00ednica. Na avalia\u00e7\u00e3o ambulatorial e transoperat\u00f3ria, a necessidade de monitoriza\u00e7\u00e3o cont\u00ednua e de longa dura\u00e7\u00e3o requer uma aparelhagem espec\u00edfica, com capacete ajust\u00e1vel ao cr\u00e2nio e com fixador(es) de transdutor(es). Isso garantir\u00e1 a captura de evento transit\u00f3rio com informa\u00e7\u00e3o necess\u00e1ria para a defini\u00e7\u00e3o da conduta terap\u00eautica mais adequada.Os aparelhos exclusivamente dedicados ao DTC s\u00e3o \u201ccegos\u201d em raz\u00e3o da aus\u00eancia de imagem bidimensional e do mapeamento de fluxo em cores (MFC), com \u00f3bvia perda de informa\u00e7\u00f5es anat\u00f4micas \u00fateis. No entanto, esses aparelhos permitem a monitoriza\u00e7\u00e3o cont\u00ednua de fluxo pela possibilidade de contar com o capacete craniano para a fixa\u00e7\u00e3o do transdutor.131 Al\u00e9m disso, pode-se fazer o rastreamento de s\u00edtio de estenose intravascular segmentar intracraniana in situ, presente em 10% dos casos de AVEi.135Devemos realizar inicialmente o exame padr\u00e3o de DTC convencional, com a finalidade de an\u00e1lise da anatomia vascular e busca de poss\u00edveis vias colaterais de fluxo.137O exame padr\u00e3o de DTC \u201ccego\u201d inclui a insona\u00e7\u00e3o do fluxo em segmentos de todas as art\u00e9rias tronculares: circula\u00e7\u00e3o anterior, constitu\u00edda por ramos das car\u00f3tidas internas direita e esquerda; e circula\u00e7\u00e3o posterior, constitu\u00edda por ramos da art\u00e9ria basilar, que por sua vez, resulta da conflu\u00eancia das art\u00e9rias vertebrais direita e esquerda.Ambas as circula\u00e7\u00f5es se conectam atrav\u00e9s de art\u00e9rias \u201ccomunicantes\u201d (anterior e posteriores direita e esquerda), integrando um circuito conhecido como \u201cpol\u00edgono de Willis\u201d . Essa arO transdutor com frequ\u00eancia de 2 MHz (ou menos) \u00e9 um elemento obrigat\u00f3rio para o DTC, pois a localiza\u00e7\u00e3o profunda dos vasos intracranianos exige ondas de US de baixa frequ\u00eancia. A identifica\u00e7\u00e3o do vaso insonado pelo Doppler \u201ccego\u201d depende de: a) janela ultrassonogr\u00e1fica utilizada; b) posi\u00e7\u00e3o do transdutor em rela\u00e7\u00e3o ao cr\u00e2nio (\u00e2ngulo de incid\u00eancia do US); c) profundidade do \u201cvolume amostral\u201d; d) caracter\u00edsticas das curvas espectrais das ondas de fluxo . Esses par\u00e2metros definem a art\u00e9ria examinada , exceto Dec\u00fabito dorsal e transdutor de 2 MHz suavemente posicionado sobre cada uma das cinco janelas ultrassonogr\u00e1ficas cl\u00e1ssicas, em sequ\u00eancia livre, para garantir o estudo de fluxo em todas as art\u00e9rias tronculares intracranianas: a) transorbitais (direita e esquerda); b) transtemporais (direita e esquerda); c) transforaminal.a)Janelas transorbitais: examinar oft\u00e1lmicas e sif\u00f5es carot\u00eddeos (por\u00e7\u00f5es intracavernosas de car\u00f3tidas internas). Transdutor apoiado sobre o globo ocular, com p\u00e1lpebra fechada, sem qualquer press\u00e3o local  Janelas transtemporais:situadas acima do arco zigom\u00e1tico (cerca de 1 cm de dist\u00e2ncia do meato auditivo externo), variam individualmente em extens\u00e3o e qualidade. Transdutor inicialmente em posi\u00e7\u00e3o perpendicular ao cr\u00e2nio; em seguida, sutilmente inclinado anterior e posteriormente para a obten\u00e7\u00e3o de imagens referentes \u00e0s curvas espectrais de fluxo de car\u00f3tida interna distal, cerebral anterior (A1), cerebral m\u00e9dia (M1), topo de basilar e cerebral posterior (P1 e P2) ipsilaterais (laterais . As comuc) Janela transforaminal: \u00fanica via de acesso aos fluxos em luzes de segmentos intracranianos das vertebrais (V4) e \u00e0 origem da basilar , poder\u00e1 ainda ser colocado sentado no leito ou em uma cadeira, facilitando o posicionamento do examinador. O Doppler puls\u00e1til evidenciar\u00e1 o fluxo afastando-se do transdutor em luzes de vertebrais e basilar; e nas cerebelares posteroinferiores, a dire\u00e7\u00e3o ser\u00e1 inversa.As curvas espectrais de fluxo registradas nas art\u00e9rias tronculares intracranianas apresentam morfologia semelhante entre si, diferindo somente nas velocidades pr\u00f3prias de cada vaso e na dire\u00e7\u00e3o em rela\u00e7\u00e3o ao transdutor. O padr\u00e3o \u00e9 de baixa resist\u00eancia para todos os segmentos, exceto em oft\u00e1lmica .high intensity transient signals)  . A conta140 Nos pacientes com estenose carot\u00eddea sintom\u00e1tica recente (menos de 7 dias) o risco de AVCi recorrente \u00e9 de 26% em 30 dias.140 Portanto, o rastreamento da microembolia permitir\u00e1 a intensifica\u00e7\u00e3o da terapia antitromb\u00f3tica, baseada nos resultados de estudos multic\u00eantricos CARESS (Clopidogrel and Aspirin for Reduction of Emboli in Symptomatic Carotid Stenosis)141 e CLAIR (CLopidogrel plus Aspirin for Infarction Reduction),142 ou a antecipa\u00e7\u00e3o da endarterectomia ou do tratamento endovascular.A presen\u00e7a de microembolia distalmente a estenose carot\u00eddea indica um risco 7,5 vezes maior de AVEi recorrente ou epis\u00f3dio de ataque isqu\u00eamico transit\u00f3rio.Asymptomatic Carotid Emboli Study) identificou um risco anual de AVCi ou AIT ipsilateral \u00e0 estenose de 7,1% nos pacientes com HITS e de 3,0% naqueles sem microembolia.143A estratifica\u00e7\u00e3o de risco de pacientes com estenose carot\u00eddea assintom\u00e1tica \u00e9 outra grande utilidade da identifica\u00e7\u00e3o de HITS. O estudo ACES  \u00e9 o mecanismo atrav\u00e9s do qual o fluxo sangu\u00edneo encef\u00e1lico se mant\u00e9m relativamente constante, mesmo diante de varia\u00e7\u00f5es da press\u00e3o de perfus\u00e3o encef\u00e1lica (PPE).148Os fatores que influenciam a perfus\u00e3o encef\u00e1lica s\u00e3o a PPE e a resist\u00eancia cerebrovascular (microcircula\u00e7\u00e3o). O fluxo sangu\u00edneo encef\u00e1lico pode manter-se constante durante a varia\u00e7\u00e3o da press\u00e3o arterial m\u00e9dia (PAM) se ocorrerem altera\u00e7\u00f5es compensat\u00f3rias na microcircula\u00e7\u00e3o (arter\u00edolas). Existem dois m\u00e9todos para a avalia\u00e7\u00e3o do estado de autorregula\u00e7\u00e3o encef\u00e1lica: o est\u00e1tico e o din\u00e2mico. O DTC \u00e9 um dos m\u00e9todos mais utilizados para a estimativa de mudan\u00e7as na perfus\u00e3o encef\u00e1lica. A autorregula\u00e7\u00e3o din\u00e2mica traduz as altera\u00e7\u00f5es transit\u00f3rias do fluxo sangu\u00edneo encef\u00e1lico ap\u00f3s r\u00e1pidas mudan\u00e7as na press\u00e3o arterial e pode ser provocada pelo teste do manguito femoral: manguitos de press\u00e3o arterial posicionados nas coxas de paciente s\u00e3o mantidos insuflados e, em seguida, s\u00e3o desinsuflados abruptamente com objetivo de provocar hiperemia nos membros inferiores e queda da press\u00e3o arterial sist\u00eamica. A autorregula\u00e7\u00e3o encef\u00e1lica far\u00e1 com que a hipotens\u00e3o n\u00e3o cause mudan\u00e7a no fluxo sangu\u00edneo cerebral.149 Entre os testes de avalia\u00e7\u00e3o da reserva microcirculat\u00f3ria, a inala\u00e7\u00e3o de CO2 consiste em inspirar, de maneira controlada, uma mistura gasosa enriquecida com CO2.150 A hipercapnia gera dilata\u00e7\u00e3o de arter\u00edolas e aumento do fluxo sangu\u00edneo  pode ser estimada atrav\u00e9s do teste de reatividade cerebrovascular, cujo objetivo \u00e9 quantificar a capacidade de dilata\u00e7\u00e3o de um determinado territ\u00f3rio arterial, identificando pacientes com estenoses hemodinamicamente cr\u00edticas e alto risco de fal\u00eancia circulat\u00f3ria encef\u00e1lica.angu\u00edneo ; a hipoc151No per\u00edodo intraoperat\u00f3rio, a monitoriza\u00e7\u00e3o de fluxo em cerebrais m\u00e9dias com DTC permite a an\u00e1lise das varia\u00e7\u00f5es de velocidades de fluxo sangu\u00edneo em resposta ao uso de anest\u00e9sicos vol\u00e1teis  e agentes hipn\u00f3ticos (desencadeiam diminui\u00e7\u00e3o do fluxo sangu\u00edneo encef\u00e1lico).155 Tal mecanismo tem sido descrito tamb\u00e9m imediatamente ou at\u00e9 24 a 48 horas ap\u00f3s ressec\u00e7\u00e3o de malforma\u00e7\u00f5es arteriovenosas. O DTC pode detectar curvas espectrais com velocidades aumentadas e baixa pulsatilidade e resist\u00eancia em vasos cerebrais. A medida de velocidades de fluxo em cerebrais m\u00e9dias servir\u00e1 de guia durante o tratamento at\u00e9 a normaliza\u00e7\u00e3o.S\u00edndrome de hiperperfus\u00e3o: no p\u00f3s-operat\u00f3rio imediato de endarterectomia carot\u00eddea, em paciente com estenose severa, o leito cerebral de pequenos vasos (art\u00e9rias piais e arter\u00edolas) pode apresentar vasodilata\u00e7\u00e3o cr\u00f4nica e com perda da capacidade de vasoconstric\u00e7\u00e3o ap\u00f3s restaura\u00e7\u00e3o s\u00fabita da perfus\u00e3o com a endarterectomia. Isso resultar\u00e1 em hiperemia cerebral inadequada assim que a press\u00e3o normal for introduzida no leito tecidual vasodilatador, e poder\u00e1 ocorrer morbidade significativa associada com edema, hipertens\u00e3o intracraniana e hemorragia.O estudo de rotina das art\u00e9rias vertebrais n\u00e3o deveria restringir-se aos segmentos extracranianos, pois placas estenosantes graves ou at\u00e9 mesmo oclus\u00f5es em segmentos intracranianos (V4) do sistema vertebrobasilar podem n\u00e3o provocar qualquer anormalidade em curvas espectrais de fluxo em topografia cervical (V0-V3). Se a placa ateroscler\u00f3tica estiver localizada antes da emerg\u00eancia do ACPI da vertebral intracraniana, as curvas espectrais ser\u00e3o de baixa amplitude e elevada resist\u00eancia em V1-V3 ipsilateral. Caso a les\u00e3o estenosante ou a oclus\u00e3o da luz situe-se acima do ACPI, poder\u00e1 haver desvio de fluxo para o cerebelo, e as curvas espectrais ser\u00e3o normais  .A inclus\u00e3o do estudo dos segmentos intracranianos do sistema vertebrobasilar requer transdutor setorial com 2,0 MHz (ou menos) com mapeamento de fluxo em cores. Atrav\u00e9s do forame magno, o US alcan\u00e7ar\u00e1 as art\u00e9rias e permitir\u00e1 a visualiza\u00e7\u00e3o de fluxo intraluminal, definindo a anatomia regional. O fluxo em vertebrais afasta-se do transdutor e, em ACPI, tem dire\u00e7\u00e3o contr\u00e1ria, facilitando a identifica\u00e7\u00e3o dos vasos.As recomenda\u00e7\u00f5es deste grupo de especialistas para o DTC na doen\u00e7a carot\u00eddea ateroscler\u00f3tica est\u00e3o resumidas no Em pacientes com placas ateroscler\u00f3ticas carot\u00eddeas ou vertebrais extracranianas, a investiga\u00e7\u00e3o de \u201cmicroembolia silenciosa\u201d deve ser realizada com aparelho de DTC \u201ccego\u201d com capacete para fixa\u00e7\u00e3o dos transdutores no cr\u00e2nio. A monitoriza\u00e7\u00e3o cont\u00ednua de fluxo em cerebrais m\u00e9dias ou basilar deve ocorrer durante no m\u00ednimo 4 horas consecutivas.A avalia\u00e7\u00e3o pr\u00e9-endarterectomia da \u201creserva vasomotora cerebral\u201d \u00e9 uma informa\u00e7\u00e3o valiosa para a redu\u00e7\u00e3o de risco de isquemia encef\u00e1lica grave durante cirurgia.A monitoriza\u00e7\u00e3o peroperat\u00f3ria e no m\u00ednimo nos 90 minutos imediatos p\u00f3s-endarterectomia \u00e9 fundamental para o diagn\u00f3stico simult\u00e2neo e tratamento precoce de consequ\u00eancias de emboliza\u00e7\u00e3o gasosa ou s\u00f3lida (part\u00edculas de placas ateroscler\u00f3ticas ou trombos).Recomendamos a inclus\u00e3o da avalia\u00e7\u00e3o dos segmentos intracranianos de vertebrais e de basilar  nos exames de rotina de car\u00f3tidas e vertebrais cervicais de pacientes sintom\u00e1ticos e sem les\u00f5es anat\u00f4micas extracranianas que justifiquem a cl\u00ednica. 1. Class of Recommendation and Level of Evidence 52. Summary of the Main Recommendations 53. Introduction and Equipment 63.1. Introduction 63.2. Cleaning and Prevention of Infections 64. Intima-media Thickness andDetection of Carotid Artery Plaques forCardiovascular Risk Assessment 84.1. Ultrasound Features of Intima-media Thickness andCarotid Plaque 95. Assessment of Carotid Stenosis 95.1. Anatomical Criteria 95.2. The Role of Computed Tomography Angiography AndMagnetic Resonance Angiography 95.3. Velocity Criteria 115.4. Technical Considerations for Doppler Assessment 115.5. Internal Carotid Artery Stenosis 115.5.1. < 50% stenoses 115.5.2. > 50% stenoses 115.5.3. Occlusions and Near Occlusions 135.6. Stenosis of the Common Carotid Artery andExternal Carotid Artery 145.7. Conditions that Affect Velocity Measurements 146. Ultrasound Evaluation after Endarterectomy andStent Implantation 146.1. Introduction 146.2. Test Protocol 146.3. Ultrasound Evaluation after Carotid Endarterectomy 156.4. Vascular Ultrasound Findings after Endarterectomy 157. Morphological Assessment of Carotid Plaques 167.1. Investigation of Plaque Morphology 177.1.1. Plaque Morphology 177.1.2. Characteristics of Atherosclerotic Plaques and Risk ofCardiovascular Disease 177.1.3. Plaque Volume 177.2. Atherosclerotic Plaque Characterization by Computed TomographyAngiography and Magnetic Resonance Angiography 177.2.1. Cervical Artery Dissection 188. Ultrasound Enhancing Agents in theCharacterization of Atherosclerotic Plaques 188.1. Characteristics and Properties of Ultrasound Enhancing Agents 198.2. Technical Aspects that Affect the Acquisition ofContrast-enhanced Images 198.3. Mechanical Index 198.4. Imaging Gain 198.5. Contrast Agent Dose 208.6. Diagnosis of Occlusion and Near-occlusion 208.7. Evaluation of Plaque Vulnerability and Neovascularization 208.8. Dissection 208.9. Inflammation 218.10 Follow-up after Stenting 218.11 Contrast Preparation 218.12. Basic Protocol for Vascular Ultrasound withMicrobubble Contrast Agents 219. Evaluation of Atheromatous Disease inVertebral Arteries 219.1. Introduction 219.2. Ultrasound evaluation of vertebral arteries 229.3. Methodology of Routine Examination 229.4. Normal Parameters 229.5. Stenosis Quantification 229.5.1. Proximal Stenosis (V0-V1) 229.5.2. Vertebral Stenosis in the Remaining Segments (V2-V4) 229.5.3. Vertebral Artery Occlusion 229.6. Subclavian Steal Syndrome 2210. Transcranial Doppler in Extracranial Carotid andVertebral Atherosclerotic Disease 2310.1. Imaging Techniques 2310.2. Standard Protocol for a Conventional \u201cBlinded\u201d TranscranialDoppler Examination 2410.3. Standard Protocol for Continuous Transcranial Doppler 2510.4. Clinical Usefulness of Transcranial Doppler inCervical Atherosclerotic Disease 2610.4.1. Identification of Patients with HITS 2610.4.2. Induced Hemodynamic Repercussions 2710.4.3. Evaluation of Intracranial Vertebral Stenosis (V4) 2810.5. Recommendations 28References 29Consensus statements were classified according to A summary of the main recommendations developed by this expert panel is described in 1 as well as new recommendations on equipment cleaning, carotid plaque definition, media-intimal thickness, grading of stenoses, and plaque morphology.The 2015 Guideline recommendations are summarized in 1The ultrasound (US) was introduced in the field of Medicine in the 1940s and has played an important role in the diagnosis of cardiovascular diseases (CVD) since then. The wide applicability, relatively low cost, and reproducibility of the US also made it an established tool in the diagnosis of several other diseases. This Guideline was developed by cardiologists from the Department of Cardiovascular Imaging (DIC) at the Brazilian Society of Cardiology (SBC), angiologists and vascular surgeons from the Brazilian Society of Angiology and Vascular Surgery (SBACV), and radiologists from the Brazilian College of Radiologists (CBR) \u2013 who are experts in vascular ultrasound (VUS) \u2013 with the aim of supporting the best use of VUS based on the current medical literature, as well as of updating the 2015 Guideline.16 Other topics included in this update are: transcranial Doppler, US enhancing agents (USEAs), and diagnostic aspects of carotid stenosis by computed tomography angiography (CTA) and magnetic resonance angiography (MRA). However, interested readers should seek more comprehensive and specific publications for further information on these other imaging modalities.The rationale for the use of VUS in the diagnosis of important diseases was based on the recommendations of the 2015, 2016, and 2019 DIC expert panel.Our aim is to disseminate the best VUS practices among professionals, standardize the interpretation of imaging scans, and promote the best possible use of this noninvasive, widely available, and inexpensive tool.1Equipment, software, probe, and other imaging-related aspects are thoroughly described in the 2015 Guideline.In addition to the technical and technological requirements of both equipment and the examiner, cleaning the equipment and adhering to infection prevention measures are of utmost importance among professionals. Any diagnostic equipment that gets in contact with a patient poses a risk of infection \u2013 although the risk is low, there are reports of transducer contamination, especially using endocavitary probes and in association with central venous access, in addition to bacterial contamination of the US gel.17 which determines the level of sterilization/decontamination required for a medical device, VUS procedures are classified as a) critical when the transducer comes into contact with sterile tissue, b) semi-critical when it comes into contact with mucous membranes and nonintact skin (with or without blood contamination), and c) noncritical when there is no contact with sterile tissues, mucous membranes, or nonintact skin. Cleaning and sterilization or high-level disinfection (HLD) are required for critical procedures; cleaning combined with HLD for semi-critical procedures; and low-level disinfection for noncritical procedures.According to the Spaulding classification,Most carotid and transcranial diagnostic tests are classified as noncritical. The use of a probe cover  is not recommended, but disinfection is required. After the examination, the transducer should be cleaned with a cloth to remove the gel and washed with soap and water. The transducer, the cable, and the keyboard should then be dried before disinfection using quaternary ammonium compounds, alcohols, or phenols. If HLD is required, it is recommended immersing the transducer in a solution of glutaraldehyde, hydrogen peroxide, or peracetic acid for 8-15 minutes. Although the risk of infection is very low, care should be taken to prevent test-related infections, especially in laboratories, clinics, and hospitals where various examinations are performed. Always check with the equipment\u2019s manufacturer which disinfectants can be used, as they may damage the transducer and cable.20 the 2004-2006-2011 Mannheim consensus statement,21 and the American Society of Echocardiography (ASE) Consensus Statement,22 Brazilian experts in VUS joined forces to describe the correct way to measure the intima-media thickness (IMT) and detect atherosclerotic plaques in carotid arteries.After publication of the 2007, 2013, and 2019 Brazilian Guidelines,25 The increase in IMT appears to involve mostly the middle layer, whereas carotid plaque (CP) is related to the thickening of the inner layer and its protrusion into the vessel lumen.26Traditional cardiovascular risk factors are known to be associated with increased IMT.27 described a combined percentile score with IMT measurements at the distal common carotid artery (CCA) and proximal internal carotid artery (ICA) that improved cardiovascular risk prediction compared with traditional risk factors, even when the calcium score was added to the study model.Clinical trials have adopted a wide range of IMT values and, of note, the cutoff point for risk stratification based on numerical values depends on the baseline characteristics of the patient. A recent study by Polak et al.28 Importantly, in the setting of population aging, cardiovascular risk may be overestimated in older adults with few risk factors, leading to excessive use of medications. The accurate identification of those at actual low risk could result in better clinical outcomes, with economic implications. A recent sub-analysis of the MESA study compared the capacity of \u2018negative\u2019 risk markers to downgrade the 10-year cardiovascular risk estimate, such as an IMT value below the 25th percentile.29Although IMT measurement is not routinely recommended in the general population, if we consider long-term cardiovascular risk prediction, this may be a valuable measure.20 atherosclerotic plaque can be defined as IMT > 1.5 mm, so it is important for the vascular sonographer to know how to perform these measurements. Moreover, IMT measurements have a long track record of having been used in research protocols. The technique and interpretation of IMT measurement are described in the document that was the basis for this update.1According to the 2017 Brazilian guideline for dyslipidemia,30 Several publications have studied CP as a prognostic indicator of cardiovascular events, demonstrating its predictive power for the incidence of CVD and coronary events.39CP is a manifestation of atherosclerosis and appears to be a stronger predictor of cardiovascular risk than IMT measurement alone. A recent meta-analysis of 11 population-based studies including more than 54,000 patients showed that CP had a higher diagnostic accuracy for the prediction of myocardial infarction (MI) than IMT.40 and the V Brazilian Guideline for Dyslipidemia and Atherosclerosis Prevention19 recommend the presence of subclinical carotid atherosclerosis, detected by imaging tests, as a criterion for identifying patients at high risk of coronary events. Furthermore, the Brazilian guidelines as well as the ASE Consensus Statement22 recommended that CP should be considered an aggravating factor in patients at intermediate risk.The I Brazilian Guideline for Cardiovascular Prevention21On B-mode US, the IMT is characterized by a double-line pattern representing the lumen-intima and the media-adventitia interfaces. The IMT is the distance between the two acoustic interfaces. CP is defined as a focal structure extending at least 0.5 mm into the vessel lumen, and/or measuring more than 50% of the adjacent IMT, and/or an IMT > 1.5 mm.26 an IMT \u2265 1.5 mm was considered equivalent to atherosclerotic plaque (type II), especially if the image was diffuse. Type I plaque was defined by an extension < 1.5 mm into the vessel lumen. We understand that type I plaque, as defined by Johri et al.,26 corresponds to the first 2 plaque definitions presented in Mannheim\u2019s study.7 Therefore, the sonographer should pay particular attention to the classification of type I plaque, using previous scans as a parameter.In a recent study by Johri et al.,VUS is able to characterize carotid stenosis through both the velocity criteria and quantification of stenosis using residual diameter measurements, preferably through the transverse plane.41: a) the velocity criteria cannot differentiate narrower degrees of stenosis due to overlap of velocity ranges42; b) velocity measurements vary greatly between different devices, leading to discrepant results; c) angle correction causes large inter-observer variation; d) the image quality of B-mode US has significantly improved in recent years.Those who advocate that carotid stenosis should be quantified using the anatomical criteria base their opinion on the following43Members of this expert panel agree that the fundamental criterion for the quantification of carotid stenoses is hemodynamic. The anatomical criteria should be used to quantify stenoses < 50% with no hemodynamic repercussions. After classification using the velocity criteria, it is recommended to inform the degree of stenosis in 10% intervals.1All considerations on the measurement of stenosis using the anatomical criteria are detailed in the 2015 Guideline, and no changes have been made in relation to the previous document.45 The degree of carotid stenosis is measured differently  according to each criterion.46In patients with focal ischemic neurological symptoms corresponding to the territory supplied by the carotid artery, CTA or MRA is indicated to detect carotid stenosis when the US cannot be performed or yields nondiagnostic results . Both CTA and MRA with postprocessing techniques can provide angiographic images with similar quality to digital subtraction angiography (DSA), allowing stenosis to be measured according to the North American Symptomatic Carotid Trial (NASCET) or European Carotid Surgery Trial (ECST) criteria.47Compared with the gold standard technique (DSA), US, CTA, and MRA have the additional benefit of being noninvasive and allowing evaluation of the vascular lumen in the true axial plane  and some imaging of the arterial wall (not feasible in angiography as it is an exclusively luminographic technique).49 Bartlett et al.48 demonstrated a linear correlation between millimeter measurements of carotid stenosis and the degree of stenosis estimated by angiography using the NASCET method.41 Threshold values of 1.4 to 2.2 mm can be used to evaluate for moderate stenosis (50%-69%) with a sensitivity of 75% and a specificity of 93.8%. A \u2264 1.3-mm residual lumen diameter corresponds to > 70% stenosis and may be used as a cut-off value to diagnose or exclude significant stenosis with a sensitivity of 88.2%, a specificity of 92.4%, and a negative predictive value of 98%.Current high-speed, multidetector CTA techniques allow direct evaluation of the carotid lumen diameter and surrounding tissue with high spatial resolution.Of note, in carotid near-occlusion , the degree of stenosis should not be measured numerically but rather classified as near-occlusion with total collapse, when there is marked reduction of the distal ICA caliber/string sign, or near-occlusion with partial collapse, when there is less marked reduction in the distal IAC caliber.49Cases of near-occlusion with partial collapse are not always clear and evident, therefore there are some imaging criteria that may aid in their correct identification: 1) stenosis caliber < 1.3 mm, 2) distal ICA diameter < 3.5 mm, 3) diseased ICA/contralateral ICA ratio < 0.87, 4) diseases ICA/ipsilateral external carotid artery (ECA) ratio < 1.27, and lower contrast enhancement compared with the contralateral vessel.Direct measurement of the residual lumen would minimize potential measurement errors compared with the distal ICA lumen, especially in cases of collapse of the walls in severe stenoses .50correlated Doppler velocities with residual lumen measurements from surgical pathological specimens removed en bloc and suggested that the Doppler criteria has 100% specificity and 96% sensitivity for detecting significant stenosis, defined as residual lumen diameter \u22641.5 mm, in association with significant hemodynamic changes defined by the velocity criteria. In a recent study, Yurdakul et al.51 used B-flow imaging, which has better spatial and temporal resolution and less contrast extravasation than color and power Doppler, to demonstrate that a residual lumen diameter < 1.5 mm performs similarly to DSA using the NASCET method to estimate 70%-99% ICA stenosis, with a sensitivity of 93%, specificity of 94%, and accuracy of 94%.Suwanwela et al.58Several institutions have published criteria for evaluating stenoses by analysis of flow velocities, with some differences between them.55 investigated 10 New England institutions and found that they used different duplex ultrasonography Doppler criteria for grading carotid stenoses, which led to significant differences in the number and subsequent costs of interventions. Columbo et al.59 examined data from 338 diagnostic centers in the United States relating to two groups: 4,791 patients aged \u226565 years from the Cardiovascular Health Study and 28,483 asymptomatic patients who underwent carotid artery revascularization in the Vascular Quality Initiative registry (www.vqi.org). The authors found great variation in peak systolic velocity (PSV) cut-off points between institutions, both for stenoses greater than 50% and greater than 70%, which led to discrepancies in the diagnosis of stenosis and treatment choices. This study was addressed in an editorial written by Kim and Zierler,57 who highlighted the need for standardization of diagnostic parameters for carotid stenosis.Arous et al.1 Thus, as other authors have also suggested, a consensus was reached on the use of a combined approach for the quantification of ICA stenosis.58In 2015, the Department of Cardiovascular Imaging of the Brazilian Society of Cardiology (DIC-SBC) published recommendations for the quantification of carotid artery stenosis, including criteria for flow assessment using Doppler associated with anatomical assessment of the plaque. It also divided the degree of stenosis into deciles so that US findings could provide more objective information, assisting in the therapeutic decision.15 Visualization of the plaque, whether hypo or hyperechogenic, calcified, and with or without acoustic shadowing, is essential for the diagnosis of stenosis, as different hemodynamic conditions can progress with high or low velocities regardless of the presence of stenosis.Doppler assessment of blood flow velocity should be performed in combination with two-dimensional (2D) evaluation of the plaque. The spectral tracing in the CCA, ICA, and ECA should be measured bilaterally using pulsed Doppler, as well as in any site where B-mode and/or color Doppler suggest the presence of stenosis.1Technical considerations for Doppler assessment, such as the correct insonation angle and the location for velocity measurement, are described in the 2015 Guideline.This document reviews and updates the criteria published by the 2015 DIC-SBC Guideline. The sequence for carotid stenosis assessment recommended by DIC-SBC is shown in 59This document suggests that < 50% stenoses continue to be graded using B-mode imaging, preferably using the transverse plane that provides the best image for measuring lumen reduction.PSV stands out among the criteria for the evaluation of stenoses, and, in the presence of plaque, is considered an important and objective parameter. However, combined analysis with other parameters, such as the EDV and velocity ratios, confers reliability and facilitates the diagnosis  and 5. F1This document supports dividing the degree of ICA stenosis into deciles, according to 62The correlation between velocity parameters by VUS and angiography has already been demonstrated by several authors .60-6263 Recently, Barlinn et al.64 showed that the German Society of Ultrasound in Medicine (DEGUM) criteria also had a lower sensitivity for the evaluation of stenoses between 50% and 69% than between 70% and 99% .VUS has good accuracy in identifying > 70% stenoses but the same does not apply for < 50% stenoses, particularly between 50% and 69%.62 AbuRahma et al.65 found good accuracy in the 2003 consensus validation but suggest that, for \u2265 70% ICA stenoses, a PSV cutoff of > 230 cm/s should be used in symptomatic patients, whereas a combined approach should be used in asymptomatic patients , or a PSV > 280 cm/s.The 2003 Society of Radiologists in Ultrasound (SRU) consensus and the UK Joint Recommendations recommend a PSV cutoff of > 230 cm/s for the identification of > 70% stenoses, and this value was validated by other authors in their institutions.65showed better specificity with a PSV \u2265 137 cm/s than with 125 cm/s (91% x 85%) and opted for a PSV of 140 cm/s, which was already used in their institution.67 A similar value was found in the study by Petisco et al.,59 in which a PSV \u2265 141 cm/s had better specificity than a PSV \u2265 125 cm/s (90% x 83%), with similar accuracy. Other PSV values have been described in the literature. The DEGUM and the External Quality Assurance in Laboratory Medicine in Sweden (EQUALIS) reported, respectively, that PSV values > 200 cm/s and 230 cm/s could diagnose \u2265 50% stenoses and PSV values > 300 cm/s and 320 cm/s could diagnose \u2265 70% stenoses.68 Gornick et al.4 retrospectively assessed US scans of 167 patients (299 carotid arteries) comparing the 2003 criteria proposed by the SRU consensus with angiography. They observed that PSVs \u2265 180 cm/s had better sensitivity, specificity, and accuracy  to diagnose \u2265 50% stenoses, as well as the association of a PSV \u2265 125 cm/sec with an ICA/CCA PSV ratio of \u2265 2  Reinforcing the need for internationally standardized US criteria, recent proposals rely on a combined approach for a more accurate stenosis classification.69To diagnose 50%-69% stenoses, the 2003 consensus and the UK Joint Recommendations recommend a PSV between 125 and 230 cm/s; however, some authors found that higher PSV values were better at diagnosing > 50% stenoses. AbuRahma et al.71 For the diagnosis of > 80% stenoses, an EDV > 140 cm/s has been used for years by the University of Washington, and was shown to have specificity greater than 90% in other studies as well.72 Arous et al.73 demonstrated that a PSV \u2265 450 cm/s or an EDV \u2265 120 cm/s can diagnose \u2265 80% stenoses with an area under curve (AUC) of 0.66, with no significant difference in AUC between EDVs \u2265 120 cm/s and \u2265 140 cm/s .In addition to PSV, EDV can also be useful in the diagnosis of > 70% and 80% stenoses. The 2003 SRU consensus suggests an EDV > 100 cm/s as an additional parameter for identifying obstructions > 70%, and other authors have obtained good specificity using this parameter as well.77 The ICA PSV/CCA EDV ratio (St Mary\u2019s index) divides > 50% stenoses into deciles,78 but has not been much investigated, and there may be overlapping values for different degrees of stenosis. According to some authors,80 the ICA EDV/CCA EDV ratio can identify > 80% ICA stenoses when greater than 5.5, but has a lower correlation with angiography.62In addition to absolute velocities, velocity ratios \u2013 ICA PSV/CCA PSV, ICA PSV/CCA EDV, and ICA EDV/CCA EDV \u2013 are also particularly useful, either as an aid in quantifying stenosis or in particular cases where velocities may be altered due to other conditions that may underestimate or overestimate the degree of stenosis. The ICA PSV/CCA PSV ratio is the most used and has been evaluated and recommended by several studies.67 It is also important to compare the post stenotic flow with the contralateral flow.81Post stenotic flow can assist in the identification of very severe stenoses and stenoses in calcified plaques, with acoustic shadow, when there is turbulent flow after the plaque, significant reduction in velocity (PSV < 30 cm/s), and an increased acceleration time.5The diagnosis of carotid near-occlusions is based on the narrowing of the vessel lumen on color/power Doppler, with thread-like flow (string sign or trickle flow); however, it may be associated with high, low, or undetectable velocities, which occasionally hinders the diagnosis. In near occlusions with high PSV in the stenosis, the velocity distal to the stenosis is significantly reduced.61The 2003 SRU consensus recommends differentiating between near occlusion and occlusion based on the examiner\u2019s opinion rather than Doppler velocity parameters. The UK Joint Recommendations and the American Heart Association (AHA) recommend using an additional diagnostic method to differentiate near occlusions from occlusions, such as CTA, MRA, or conventional angiography.81Total carotid occlusions are characterized by the absence of patent lumen in gray-scale US and undetectable flow on color, power, and spectral Doppler and with the use of microbubble contrast agents, in addition to the presence of high-resistance flow in the CCA and staccato flow (very reduced and highly resistant flow in the occlusion or before the occlusion) .3,81In the presence of ICA occlusion, compensatory mechanisms, such as the development of collateral circulation, arise with the aim of preventing cerebral ischemia, but the most important way of collateralization route is through the circle of Willis.8 However, this condition is not present in all cases of ICA occlusion because there are different patterns of retrobulbar circulation,9 and it is known that hemodynamically significant stenoses (greater than 70% and near occlusions) of the ICA can progress with retrograde flow in the ophthalmic artery.43Another source of collateral flow is created from anterograde flow in the distal branches of the ipsilateral ECA that connect to the ophthalmic branch of the ICA, allowing the detection of retrograde blood flow in the ophthalmic artery.In cases of CCA occlusion, the ICA may be patent, with anterograde flow from the ECA and its branches.62The incidence of isolated CCA stenosis is low, and little is known about the clinical course of these lesions. Patients with isolated CCA stenosis are suspected to experience more hemispheric symptoms, aphasia, and amaurosis fugax.There is no evidence to support that recommendations for grading ICA stenosis should be applied to the classification of lesions in the CCA or ECA.This working group recommends that CCA stenoses should be quantified not only using velocity measurements, but also pre and post stenotic velocity ratios > 2 for those greater than 50%, as well as the measurement of lumen narrowing on color/power Doppler and B-mode imaging . It shouThe main criteria described in the literature for quantifying ECA stenoses are summarized in 84 In addition to valve diseases, other conditions, such as significant left ventricular systolic dysfunction, cardiac arrhythmias, tachycardia, and bradycardia, can alter the waveform in the arterial system, including the carotid arteries, without the presence of stenosis in these vessels.Some conditions, whether due to arterial stenosis or local non-vascular reasons, affect spectral analysis measurements. They may be located distally or proximally to the carotid bifurcation or in the contralateral carotid artery \u2013 among the first, we underline aortic valve diseases (stenosis or insufficiency), atherosclerotic stenosis, and arteritis involving the aortic arch, branches, and CCA.85It should be noted that cardiac alterations generate systemic effects, that is, changes in waveforms in the carotid artery present bilaterally, just as they affect the other arterial beds.1Conditions affecting velocity measurements are detailed in the 2015 DIC Guideline preceding this update.86 Compared with angiography, VUS is known to be inexpensive and to have good accuracy, but there is no consensus on the periodicity of follow-up.87Endovascular and conventional carotid interventions are frequently performed, especially for the treatment of atherosclerotic lesions. Follow-up is essential to identify any changes that may interfere with patency after treatment as early as possible and ensure better postoperative results.Follow-up VUS is similar to the diagnostic examination. It is essential to evaluate and describe all findings.Surgical treatment of carotid stenosis is performed by means of an incision in the anterior wall, removal of the atherosclerotic plaque, and artery repair with or without placement of a patch.88, which are fortunately infrequent.90Two of the main concerns after carotid endarterectomy (CEA) is the rate of restenosis and the risk of subsequent stroke91Restenosis developed between 6 and 12 months after CEA are usually due to neointimal hyperplasia. Lesions developing after 24 to 36 months tend to represent recurrence of the atherosclerotic process.92 found no significant value for repeating routine VUS after CEA with a patch closure. Bandyk et al.93 and Zierler et al.,86 on the other hand, believe the benefits of surveillance outweigh the risks and recommend VUS surveillance with a grade of recommendation of 1B.AbuRahma et al.86The arteriotomy closure sutures may be seen as bright, evenly spaced echoes along the wall of the CCA and ICA in B-mode imaging . If a paThe diameters of the native vessel, the anastomosis sites, and the enlarged region, if any, should be measured so that they can be followed and compared later.The main US features and complications after carotid interventions were described and illustrated in the 2015 DIC Guideline. In this update, only 1 change was made in the restenosis criteria. Although most studies consider > 70% stenosis after CEA as a criterion for restenosis severity, this cutoff point varies in the literature. Thus, further studies are needed to standardize the criteria for US velocities in restenosis after CEA. However, velocity differences found in CEA with or without the use of a patch and the possibility of disparate calibers after CEA should be considered.93 for grading > 70% stenoses after CEA . For VUS surveillance, according to the same authors, we recommend intervals of 1, 3, and 12 months after the procedure.We recommend the recent criteria by Bandyk et al.The morphology of the atherosclerotic plaque has been increasingly studied in the evaluation of carotid atherosclerosis. Conventionally, the degree of carotid stenosis has always had the most prominent role in carotid and vertebral imaging studies, as it is the most used parameter in the decision-making process for CEA and carotid stenting. However, for over 2 decades, morphological and histopathological aspects linked to atherosclerotic plaque instability have been studied, that is, plaques with the same degree of stenosis do not necessarily have the same ischemic potential for thromboembolic events. Identifying which plaque would be more unstable or vulnerable may play a key role in therapeutic decision.94 The definition of atherosclerotic plaque is described in the second part of this document .Plaque morphology should be described in the VUS report, as recommended in the 2015 DIC Guideline, using the parameters on In this document, we updated the value of some characteristics of atherosclerotic plaques and the risk of cardiovascular disease (CVD), assessment of plaque volume, and data from CTA and MRA.97Herr et al. used a method similar to grayscale median analysis to assess the severity of CVD and risk of cardiovascular events in patients who had recently undergone coronary angiography. Increased echogenicity of CP  was correlated with increased coronary artery disease, and a combination of plaque height, percent calcium, and/or percent fat increased the risk of cardiovascular events. The study highlights the possibility of using CP composition on US for risk stratification .9726 This practical and reproducible technique allows quantifying the volume and characterizing the anatomy and function of the arterial wall, including the plaque, with improved spatial resolution.98 The main advantage of 3D quantification is the ability to measure a specific lesion in all planes, a technique that allows monitoring the progression of the lesion and its treatment.In recent years, advances in US technology have occurred at large scale. The creation of three-dimensional (3D) vascular probes and software for 3D reconstruction allowed the conduction of studies and elaboration of systematic recommendations for standardization of the quantification of carotid arterial plaque for the purposes of CVD risk stratification.98CP volume (CPV) is the equivalent of atherosclerotic burden measured within a defined length of artery. This measurement is important because it can assist in the diagnosis of plaques in angiographically normal arteries and in carotid arteries with < 50% stenosis.CPV may be measured using 2 different approaches, depending on the equipment available:Single-region protocol, in which a specific segment or only one plaque is reconstructed;Full-vessel protocol, in which a dataset acquired along the length of the vessel is reconstructed.99 US evaluation of IMT and plaque volume has been used in risk stratification and for the evaluation of antiatherosclerotic therapies. According to Wannarong et al.,99 the measurement and progression of CPV are superior to IMT in both situations.Total CPV, measured from 1.5 cm distal to the CCA to 1 cm distal to the bifurcation, is a predictor of future CVD events.98 CPV was higher in patients with symptoms of cerebral ischemia during the first weeks of symptoms, when the risk of stroke is also higher. However, there was no significant relationship between CPV and carotid stenosis. Noflatscher et al. demonstrated a strong correlation between total CPV and cardiovascular risk factors , as well as the number of affected vascular beds.100 However, current data for plaque volume classification are limited, and further studies are needed to establish predictive cutoff values for CVD.26In the study by Ball et al.,102 The decision on whether to indicate one method or the other should be individualized, according to the clinical particularities of each patient. However, these tests are not used to assess cardiovascular risk, but rather for patients who are asymptomatic or who were initially screened by another method, such as USV, and to assess the severity of the stenosis and the extent of the disease. These imaging methods are very useful for the diagnosis of cervical artery dissection and intramural hematoma, for which the US is not as accurate.Among the various indications for CTA and MRA is the characterization of plaques and the arterial wall, as they have submillimeter spatial resolution, with accuracy in detecting these processes similar to the most modern equipment and techniques available.CTA and MRA are noninvasive and highly accurate methods that can assist in the diagnosis of cervical artery dissection  and have supplanted digital angiography (gold standard) as the method of choice for suspected arterial dissection.In the most modern equipment available, CTA and MRA techniques showed similar accuracy in detecting arterial dissections. However, MRI has greater sensitivity for demonstrating mural hematomas and greater capacity for differentiating between acute and subacute dissections . Vessel wall imaging, an additional and more recent technical resource, contributes to the superior detection capacity.106 The term USEA/echo enhancer is preferred over the term contrast agent to differentiate it from gadolinium and iodinated contrasts.107One of the greatest advances in US technology after the introduction of B-mode imaging and Doppler US are the USEAs, which significantly increased the value and use of US in clinical practice.108 The use of USEAs has opened new horizons in the study of several arterial diseases by providing new sets of data that can be fundamental in patient management. Essential information for the use of USEAs is described below.The great technical innovation was the introduction of contrast-specific imaging modes on US scanners with the use of pulse inversion harmonics, allowing direct visualization of signals emitted by contrast agent microbubbles independently of their velocity. Specific characteristics of microbubble signals, which are fundamentally different from those of static tissue, allow the creation of microbubble-specific images that can display blood volume and parenchymal perfusion with extremely high sensitivity and spatial resolution.Unlike MRI and CT contrast agents, which use physical and chemical properties of cells to generate their effect, USEAs use the physical properties of the US itself, that is, the greater the difference in density between the two media, the greater the reflection of emitted energy and the larger the amplitude of US signal. Unquestionably, the gaseous medium provides the greatest difference, corresponding to a signal increase of approximately 30 decibels.109Thus, there is no contraindication to its use in patients with renal failure, which is extremely advantageous for patients with diabetes, hypertension, heart disease, and other diseases that progress with chronic renal failure.USEAs consist of gas-filled microbubbles encapsulated within a phospholipid shell that is flexible and stable. SonoVue\u00ae (Bracco Imaging S.p.A.) is the only USEA currently approved for use in Brazil by the National Health Surveillance Agency (Anvisa) and the National Regulatory Agency for Private Health Insurance and Plans (ANS). SonoVue\u00ae consists of encapsulated microspheres of sulfur hexafluoride gas. The microbubbles have a mean diameter of 2.3 \u00b5m, which prevents them from crossing blood vessel walls and reaching the interstitial space. As a lipophilic gas, it has low blood solubility and does not spread outside the capsule. This protein shell composed of a single layer of phospholipids acts as a surfactant, providing stability and flexibility while it travels along the macro and microcirculation. Therefore, SonoVue\u00ae is considered a real blood-pool contrast agent and a marker of blood circulation\u2014this property distinguishes it from MRI and CT contrast agents, which can cross into the extracellular space. After the microbubble ruptures, the gas is almost entirely exhaled via the lungs, without undergoing liver metabolism or renal excretion.Currently, most US device manufacturers have a dedicated software for imaging studies with contrast, which may be included in the original device configuration or purchased separately. However, even machines without a dedicated USEA mode have some parameters that can be configured by the operator. Some concepts and adjustments of the US machine that the operator should know in order to obtain the best imaging results are described below.The signals obtained from microbubbles are dependent on the transmitted US power, that is, the amplitude of the acoustic wave . In non-USEA examinations, the MI ranges from 1.6 to 1.9; however, with this acoustic power, the microbubbles oscillate violently and rupture, leading to two undesired effects: a sudden increase in signal intensity with an excessive blurring of the image, and a significant reduction in contrast concentration, consequently reducing the examination time. This imaging mode, called \u201cimaging by acoustic stimulation\u201d, does not require machines with a dedicated contrast agent mode but, on the other hand, does not take full advantage of the contrast agent\u2019s potential and is limited to the function of echo enhancer.108By reducing the MI to \u2264 0.2, the microbubbles remain intact and begin to oscillate in an asymmetric manner  until they become resonant and emit different frequencies (known as harmonic frequencies) from the fundamental frequency of the transducer. Equipment suitable for this technology can filter signals transmitted specifically by microbubbles, allowing for a longer examination with a more enhanced microbubble signal compared with surrounding tissue, which is practically null (dark background). This imaging mode, also known as low-MI imaging, allows continuous assessment of time of contrast arrival in the region of interest (wash in), enhancement duration, and microbubble concentration in the target lesion, which is very important in cases such as imaging of the vasa vasorum, CPs, distribution of renal capillaries (perfusion), and masses in general.110One major limitation of low-MI imaging is reduced depth of penetration, as the US wave becomes more attenuated while traveling through the tissue. Some solutions include selecting different acoustic windows that bring the target lesion closer to the nearfield, using wide-band transducers with lower frequencies (often necessary in carotid artery imaging), and, if penetration is still insufficient, increasing the MI, which has the disadvantage of increasing microbubble destruction in the nearfield.110 In general, US machines allow simultaneous assessment with B-mode and contrast agents, on parallel screens (side by side).A noteworthy machine setting in imaging studies with contrast is imaging gain, which amplifies the signal received during postprocessing. High gain settings produce a bright image with enhanced background noise, which may obscure contrast signal . During the examination, gain settings should therefore be reduced until the image becomes virtually black, except for highly echogenic structures. Some manufacturers provide automatic gain adjustment settings that can easily be turned on and off during the examination. When manually adjusting the gain settings, there should be the least amount of acoustic signal before injection of the contrast agent, and it is important to understand whether the signal is caused by an increase in MI (tissue structures become visible on the image) or gain (widespread noise increase over the whole image).110 One way of distinguishing different enhancing levels in a structure is to adjust the USEA dose to allow adequate opacification, with no blurring or attenuation, and increase the dynamic range of the machine. On the other hand, low doses will not reach the desired opacification level.The USEA dose to be injected should always be previously assessed by the examiner. High doses initially blur the signal (saturation) and attenuate (acoustic shadowing) structures in the distal field until contrast concentrations drop to an adequate level. In addition, small differences in enhancement will no longer be distinguishable, as the upper limit of the machine\u2019s dynamic range  has been exceeded.111Indications for the use of contrast agents in VUS, and specifically for carotid arteries, are summarized in 113 Contrast-enhanced US improves endovascular visualization, characterizing the geometry of prestenotic, intra-stenotic and poststenotic segments without artifacts or angle dependence113  solution, and 1 transfer system. The USEA is easy to prepare at the bedside, following the manufacturer\u2019s instructions. After emptying the contents of the syringe into the vial, shake the vial for 20 seconds to form microbubbles and obtain a white milky homogeneous liquid, which indicates that the microbubbles are homogeneously distributed. In this state, the suspension can be stored for up to 6 hours. If microbubbles accumulate on the surface during rest, shake the vial again until microbubble distribution becomes heterogenous again. The usual route of administration is by a bolus intravenous injection using a needle catheter of at least 20G, preferably in the antecubital fossa. A small volume should be administered initially, followed by a flush of 10mL of 0.9% saline to push the contrast agent into the central vein (which happens in seconds).In VUS studies, the most recommended dose for a single injection is 2.4 mL, ranging from 1 to 4.8 mL according to the target organ, the probe used, and the sensitivity of the machine available. It should be noted that probes with higher frequencies need higher doses, in this case, 4.8 mL. The first 10 to 40 seconds after bolus injection correspond to the time-intensity curve contrast enhancement (wash in and wash out) and should be continuously recorded for later review. In some cases, such as in the investigation of late endoleaks after aortic stenting, the examination may reach up to 5 minutes, and shorter video clips may be recorded. The examiner should bear in mind that the higher the MI, the greater the degree of bubble disruption and the shorter the duration of contrast. After the bubbles disrupt, sulfur hexafluoride is quickly excreted by the lungs (approximately 2 minutes).111SonoVue\u00ae is a safe contrast agent with a low rate of complications. Anaphylactic reactions have been reported in approximately < 0.0014% of cases.After determining the indication for the use of a microbuble contrast agent in VUS, the mandatory protocol described below must be followed.\u2013 Repeat and record standard VUS examination of the target organ.\u2013 Secure venous access for injection of contrast solution with microbubbles .\u2013 Prepare the solution with the microbubble contrast agent (SonoVue\u00ae) following the manufacturer\u2019s instructions.\u2013 Activate the dedicated USEA mode in the machine; if there is no specific software, adjust the MI (< 0.6 and as close as possible to 0.1), image gain (darken the background), and choose the appropriate windows to reduce the depth of the target organ under study.\u2013 Administer the contrast solution, make adjustments to reduce excessive enhancement, and record digital images (video clips) for 10 to 40 seconds after the initial bolus injection; in longer examinations (5 to 8 minutes), record only the necessary parts for later analysis.Examination with microbubble contrast agents is fundamentally dynamic, and the duration of the examination is short because the microbubbles are rapidly ruptured by US waves, even when using a very low MI setting. Thus, recording video clips of the examination is essential for later processing and careful review of images, ensuring the correct diagnosis and permanent storage of test results.111The main limitations of USEAs in VUS are the examiner\u2019s inexperience, the lack of specific software, difficult access to USEAs in the public health system, and the complete absence of an ultrasound \u201cwindow\u201d. Clinical contraindications include MI, severe chronic obstructive pulmonary disease, severe cardiac arrhythmias, and hypersensitivity to USEAs (rare).118 Atherosclerotic plaques are predominantly located at the origin of the vertebral arteries, and in most cases they are extensions from the subclavian arteries.119 The presence of vertebrobasilar stenosis in the setting of stroke or TIA involving the posterior circulation increases the risk of recurrence by approximately 33% in the first month after the initial event.121The investigation of atherosclerotic involvement of the extracranial vertebral artery using VUS is interwoven with the imaging of the carotid arteries. This is essential for the diagnosis and treatment of severe carotid lesions, as well as for a careful assessment of the risks of the surgical approach. Approximately 25% of ischemic strokes involve the posterior circulation, and atherosclerotic disease corresponds to 20% of cases.1A detailed description of the anatomy of the vertebrobasilar system arteries can be found in the 2015 DIC Guideline that precedes this update.With the technical resources currently available, it is possible to image the entire vertebral artery, including the intracranial segment and the proximal basilar artery. We recommend including the origin of the vessel (most common site of stenosis) and the other extracranial segments in routine evaluation.Patient positioning is the same as for imaging of the carotid arteries. Depth of field may vary according to neck anatomy. The color scale should be reduced, and the sensitivity of color flow detection should be increase.1The complete methodology is described in the 2015 DIC Guideline.1 and shown in The anatomical and hemodynamic parameters of vertebral artery hypoplasia are described in the 2015 GidelineThe diagnosis of proximal stenoses is based on the identification of turbulence on color Doppler and an increase in flow velocities at the lesion site . In tortuous vertebral arteries, there may be a physiological increase in velocities. A dampened waveform pattern corroborates the presence of significant proximal stenosis. If the 2D image is high quality, it is possible to detect a narrowing of the vessel lumen and measure, using power angiography, the residual lumen according to the distal anatomical criterion.122 to define the degrees of proximal stenosis on the vertebral artery. PSV at the origin of the vertebral artery is the most specific parameter for quantification of proximal vertebral stenosis when compared with other spectral criteria, such as the peak velocity index and EDV.We recommend using the cutoff values in 123The diagnosis of stenosis in the remaining segments is based on a combined analysis of turbulence on color Doppler, local increase in flow velocities, increase in velocity indices, and damping in distal flow, as there are no quantification tables for stenoses in the V2-V4 segments.For segments that cannot be visualized on conventional examination, such as the intracranial segment (V4), findings are indirect and correlate with the degree of stenosis and the origin of the posterior inferior cerebellar artery (PICA). Spectral curves of stenoses before the origin of the PICA show reduced velocities and an elevated resistance pattern on segments V1-V2, whereas stenoses after the origin of the PICA do not cause flow alterations, as there is deviation to the cerebellum. In these cases, transcranial Doppler (TCD) imaging is essential to confirm the diagnosis.Findings vary according to the level of occlusion. 126 In this case, the subclavian steal may be detected through the evaluation of spectral waveform morphology and flow direction in the vertebral artery on the same side as the abnormal subclavian artery, at rest or after induction of reactive hyperemia . Unlike distal vertebral stenoses, in which the first component to be affected is the diastolic one, the earliest manifestation of the subclavian steal syndrome is a mild deceleration of blood flow during the systolic phase .A subclavian steal effect can arise from hemodynamically significant stenosis or occlusion of the brachiocephalic trunk or proximal segment of the subclavian artery (right or left): if the caliber of the ipsilateral vertebral artery is normal and there is no associated significant atheromatous disease, blood supply of the affected subclavian artery is maintained through a steal effect from the contralateral side.The classification of different spectral curve morphologies observed in vertebral arteries is described in The fundamental aim of TCD in patients with symptomatic or asymptomatic extracranial carotid and vertebral atherosclerotic disease is to investigate the predictive value of ischemic stroke occurrence.129TCD offers some valuable tools, including the a) detection of spontaneous cerebral microemboli and b) recording of hemodynamic information during intraoperative monitoring (endarterectomy) and during endovascular procedures.129The imaging technique depends on the clinical indication. In outpatient and intraoperative evaluations, the need for continuous and long-term monitoring requires specific equipment, including an adjustable headset for fixing the probe. This will ensure that all necessary information is recorded during the transient event to define the most appropriate therapeutic approach.TCD devices are \u201cblind\u201d due to the absence of 2D imaging and color flow mapping (CFM), which means that useful anatomical information is lost during the examination. However, by providing a headset for probe fixation, these devices allow for continuous flow monitoring.131 In addition, in situ investigation of the site of intracranial segmental intravascular stenosis can be performed, which is present in 10% of cases of ischemic stroke.135A standard conventional TCD examination should be initially performed, with the aim of evaluating the vascular anatomy and detecting any possible collateral flow.137The standard \u201cblinded\u201d TCD examination consists of insonating the segments of all arteries: anterior circulation, including the right and left internal carotid arteries and their branches; and posterior circulation, including the basilar artery  and its branches.Both anterior and posterior circulations are connected by communicating arteries (left and right anterior and posterior), integrating a system of arteries known as the circle of Willis . This vaA transducer with a frequency \u2264 2 MHz must be used in TCD examinations, as the deep location of the intracranial arteries requires the use of low-frequency waves for visualization. Identification of the insonated vessel by \u201cblinded\u201d Doppler depends on the a) acoustic window used; b) position of the transducer in relation to the skull (angle of incidence); c) depth of \u201csample volume\u201d; d) characteristics of waveform spectral curves . The parameters on Position the patient in supine and gently place the 2-MHz transducer over each of the five classic acoustic windows, in no specific order, to ensure imaging of all intracranial arteries: a) transorbital (right and left); b) transtemporal (right and left); c) transforaminal.a) Transorbital windows: image the ophthalmic arteries and carotid siphons . The transducer should be placed over the eye, with the patient with the eye closed, without applying local pressure (pressure .b) Transtemporal windows: located above the zygomatic arch , they vary individually in length and quality. The transducer should be initially placed perpendicular to the skull and then subtly tilted anteriorly and posteriorly to obtain images from the ipsilateral distal internal carotid, anterior cerebral (A1), middle cerebral (M1), top of the basilar, and posterior cerebral (P1 and P2) arteries (arteries . The comc) Transforaminal window: only access to the lumens of the intracranial segments of the vertebral arteries (V4) and to the origin of the basilar artery . The patient should be positioned in lateral decubitus, with the chin touching the thorax to expose the occipital region (topography of the foramen magnum), or sitting in the bed or a chair to facilitate positioning of the examiner. Pulsed Doppler will show the flow moving away from the transducer in the vertebral and basilar lumens; in the PICAs, flow direction is reversed.Spectral waveforms recorded in the intracranial arteries have similar morphology, differing only in the specific velocities of each vessel and in the direction in relation to the transducer. Low frequency should be used in all segments except the ophthalmic, which is the only artery with a high resistance index\u2014although it branches off the ICA, it supplies extracranial structures.139The patient should wear an adjustable headset with 2 or more \u201cblind\u201d transducers fixed to it and placed over the temporal windows, directed towards the middle cerebral arteries . Continu140 In patients with recent symptomatic carotid stenosis (less than 7 days), the risk of recurrent ischemic stroke is 26% at 30 days.140 Therefore, microembolism screening can support the intensification of antithrombotic therapy, as shown in the Clopidogrel and Aspirin for Reduction of Emboli in Symptomatic Carotid Stenosis141 and Clopidogrel plus Aspirin for Infarction Reduction142 studies, or anticipate endarterectomy and endovascular treatment.Microembolism distal to carotid stenosis indicates a 7.5 times greater risk of recurrent ischemic stroke or TIA.143The identification of HITSs is also useful in the risk stratification of patients with asymptomatic carotid stenosis. The Asymptomatic Carotid Emboli Study identified an annual risk of ischemic stroke or TIA ipsilateral to the stenosis of 7.1% in patients with HITSs and 3.0% in those without microembolism.147 Likewise, in patients with TIA, the presence of HITS is associated with the occurrence of ischemic stroke or new TIA.147Microembolism was detected in 49% of patients in the first 24 hours after the onset of ischemic stroke, and this rate progressively and significantly decrease after 48 hours.During endarterectomy, real-time detection of emboli released in the carotid occlusion phase of atherosclerotic plaque resection can be easily and quickly performed with continuous TCD monitoring, ensuring greater safety during the procedure and reducing postoperative ischemic complications.Special attention should be given to the evaluation of intracranial hemodynamic repercussions induced during flow monitoring of the middle cerebral arteries, which should be performed with a TCD device with a headset. In symptomatic patients, monitoring should last for at least 1 hour; in asymptomatic patients, monitoring should be extended to 4 hours in order to obtain better accuracy. The analysis of cerebral autoregulation and cerebral vasomotor reserve (CVR) provides some of the most useful information.Cerebral autoregulation (or autoregulatory pressure) is a mechanism that maintains cerebral blood flow relatively constant despite changes in cerebral perfusion pressure (CPP).148Factors affecting cerebral perfusion include CPP and cerebrovascular resistance (microcirculation). Cerebral blood flow can remain constant despite variations in mean arterial pressure (MAP) if compensatory changes occur in the microcirculation (arterioles). There are two methods for assessing the state of cerebral autoregulation: a static and a dynamic one. TCD is one of the most used methods for estimating changes in cerebral perfusion. Dynamic autoregulation translates transient changes in cerebral blood flow after rapid changes in blood pressure and can be provoked by the femoral cuff test: a blood pressure cuff placed on the patient\u2019s thighs is inflated and then abruptly deflated with the aim of inducing hyperemia in the legs and a drop in systemic blood pressure. Cerebral autoregulation will ensure that hypotension does not alter the cerebral blood flow.149 Among the tests for the evaluation of microcirculatory reserve, CO2 inhalation consists of inhaling in a controlled manner a gas mixture enriched with CO2.150 Hypercapnia causes dilation of arterioles and increased blood flow  may present with chronic vasodilation and loss of vasoconstriction capacity after sudden restoration of perfusion by CEA. This will lead to inadequate cerebral hyperemia once normal pressure is introduced into the vasodilator tissue bed, and significant morbidity associated with edema, intracranial hypertension, and hemorrhage may occur.Routine imaging of vertebral arteries should not be restricted to the extracranial segments, as plaques with severe stenosis, or even occlusions in intracranial segments (V4) of the vertebrobasilar system, may not cause any abnormality in spectral flow curves in cervical topography (V0-V3). If the atherosclerotic plaque is located before the origin of the PICA in the intracranial spine, the spectral curves will show low amplitude and high resistance in ipsilateral V1-V3. If the stenotic lesion or lumen occlusion is located above the PICA, there may be flow deviation to the cerebellum, and the spectral curves will be normal, which makes the TCD a valuable diagnostic tool .Imaging of the intracranial segments of the vertebrobasilar system requires a \u2264 2.0-MHz sectoral transducer with CFM. Through the foramen magnum, the US will reach the arteries and provide visualization of the intraluminal flow, defining the regional anatomy. Vertebral artery flow moves away from the transducer and, in the PICA, has the opposite direction, facilitating vessel identification.Our recommendations on the use of TCD in carotid atherosclerotic disease are summarized in In patients with extracranial carotid and vertebral atherosclerotic disease, silent microembolism should be investigated with a \u201cblinded\u201d TCD device with a headset for transducer fixation. Continuous flow monitoring in the middle and basilar cerebral arteries should be performed for at least 4 consecutive hours.Pre-CEA assessment of CVR provides valuable information for reducing the risk of severe cerebral ischemia during surgery.Perioperative monitoring and for at least 90 minutes immediately after CEA is essential for simultaneous diagnosis and early treatment of complications resulting from gas or solid embolization (pieces of atherosclerotic plaques or thrombi).We recommend including imaging of the intracranial segments of the vertebral and basilar arteries  in routine examinations of carotid and cervical vertebral arteries of symptomatic patients without extracranial anatomical lesions that warrant clinical attention."}
+{"text": "Estudo Longitudinal da Sa\u00fade dos IdososBrasileiros (ELSI-Brasil) e inclu\u00eddos os participantes cominforma\u00e7\u00f5es completas nas vari\u00e1veis de interesse (n = 7.957). Solid\u00e3o foi avari\u00e1vel de desfecho, cuja medida baseou-se na pergunta \u201cCom que frequ\u00eancia o(a)senhor(a) se sentiu sozinho(a) ou solit\u00e1rio(a): sempre, algumas vezes oununca?\u201d. As vari\u00e1veis independentes compreenderam indicadores sociodemogr\u00e1ficose comportamentos e condi\u00e7\u00f5es de sa\u00fade. As an\u00e1lises inclu\u00edram o testequi-quadrado de Pearson, para c\u00e1lculo das frequ\u00eancias relativas, e a regress\u00e3ode Poisson, para estimativa das raz\u00f5es de preval\u00eancia (RP) e respectivosintervalos de 95% de confian\u00e7a (IC95%). A preval\u00eancia de sempre sentir solid\u00e3ofoi de 16,8%; de algumas vezes, 31,7%; e de nunca, 51,5%. Foram observadasassocia\u00e7\u00f5es significativas entre sempre sentir solid\u00e3o e depress\u00e3o , morar s\u00f3 , baixa escolaridade, sexo feminino ,autoavalia\u00e7\u00e3o de sa\u00fade ruim/muito ruim  e qualidadedo sono ruim/muito ruim . Dado seu potencial depreju\u00edzo \u00e0 qualidade de vida, \u00e9 necess\u00e1rio conhecer longitudinalmente astrajet\u00f3rias da solid\u00e3o e as vari\u00e1veis associadas e usar esse conhecimento para odelineamento de pol\u00edticas p\u00fablicas e interven\u00e7\u00f5es em sa\u00fade que poder\u00e3obeneficiar o bem-estar biopsicossocial de adultos e idosos brasileiros. O objetivo foi investigar a preval\u00eancia de solid\u00e3o e suas associa\u00e7\u00f5es comindicadores sociodemogr\u00e1ficos e de sa\u00fade em amostra nacionalmente representativade adultos e idosos brasileiros. Foram analisados dados da linha de base(2015-2016) do  O ELSI-Brasil \u00e9 um estudo de basedomiciliar, conduzido em amostra nacional representativa da popula\u00e7\u00e3o brasileira n\u00e3oinstitucionalizada com 50 anos e mais, residente em 70 munic\u00edpios das cinco regi\u00f5esmacrogeogr\u00e1ficas do pa\u00eds. O processo amostral utilizou um delineamento quecontemplou a sele\u00e7\u00e3o por est\u00e1gios que combinaram a estratifica\u00e7\u00e3o de unidadesprim\u00e1rias de amostragem (munic\u00edpios) e, em cada um deles, de setores censit\u00e1rios edomic\u00edlios. Todos os moradores dos domic\u00edlios selecionados que tivessem 50 anos oumais foram considerados eleg\u00edveis para a entrevista. Mais detalhes podem ser vistosno site da pesquisa (https://elsi.cpqrr.fiocruz.br/) e em outra publica\u00e7\u00e3o Trata-se de pesquisa transversal cujos dados foram extra\u00eddos do banco eletr\u00f4nico dalinha de base (2015-2016) do http://elsi.cpqrr.fiocruz.br/data-access/ (acessado em01/Ago/2021).O banco de dados est\u00e1 localizado em um reposit\u00f3rio mantido pela Funda\u00e7\u00e3o Oswaldo Cruz(Fiocruz) e disponibilizado para os pesquisadores interessados, mediante senha, nosite A amostra foi formada por adultos e idosos brasileiros n\u00e3o institucionalizados,com 50 anos ou mais, que tinham registros completos de resposta \u00e0s vari\u00e1veis deinteresse desta pesquisa e que responderam ao item escalar sobre solid\u00e3o semajuda de um mediador. A Neste estudo, solid\u00e3o foi a vari\u00e1vel dependente. Foram considerados comovari\u00e1veis independentes os indicadores sociodemogr\u00e1ficos sexo, idade,escolaridade e arranjos de moradia, os comportamentos de sa\u00fade qualidade dadieta e atividade f\u00edsica e as condi\u00e7\u00f5es de sa\u00fade qualidade do sono, sintomasdepressivos e autoavalia\u00e7\u00e3o de sa\u00fade.,A solid\u00e3o foi definida como um sentimento negativo e doloroso, ou uma experi\u00eanciaemocional aversiva, individual e privada de que as rela\u00e7\u00f5es sociais dispon\u00edveiss\u00e3o insuficientes para satisfazer as necessidades do indiv\u00edduo ou paraproporcionar-lhe a intimidade emocional desejada Os indicadores sociodemogr\u00e1ficos foram investigados por itens de autorrelato pormeio dos quais os entrevistados informaram sobre sexo (com as op\u00e7\u00f5es masculino efeminino); idade cronol\u00f3gica, posteriormente confirmada pela data do nascimentoconstante dos registros de cada participante e categorizada em faixas de 50-59,60-69, 70-79 e 80 anos ou mais; escolaridade  participante foi aprovado(a) na escola serviu paracalcular o tempo de escolaridade); e arranjo de moradia, em que se perguntou \u201cNototal, quantas pessoas moram nesta casa?\u201d , as respostas foram posteriormente codificadas como tr\u00eas ou mais,dois e sozinho(a).,Um dos comportamentos de sa\u00fade avaliados foi a qualidade da dieta, referente \u00e0frequ\u00eancia do consumo semanal de alimentos que comp\u00f5em uma dieta saud\u00e1vel ou n\u00e3osaud\u00e1vel, a primeira composta por itens que favorecem a sa\u00fade  e a segunda composta por itens queexp\u00f5em o organismo a riscos \u00e0 sa\u00fade .O instrumento que gerou o indicador de qualidade da dieta foi composto por cincoitens com cinco frequ\u00eancias cada um: todos os dias da semana (= 4), em cinco ouseis dias da semana (= 3), em tr\u00eas ou quatro dias da semana (= 2), em um ou doisdias da semana (= 1) e quase nunca ou nunca (= 0). Para os alimentos que seconfiguram como risco \u00e0 sa\u00fade, a pontua\u00e7\u00e3o foi invertida. Os pontos eram somadose o total podia variar de 0 a 16. Quanto maior a pontua\u00e7\u00e3o, melhor a qualidadeda alimenta\u00e7\u00e3o. A nova vari\u00e1vel foi categorizada considerando-se os tercis dadistribui\u00e7\u00e3o: dieta de boa qualidade ou alimenta\u00e7\u00e3o saud\u00e1vel (= melhor tercil),dieta de qualidade intermedi\u00e1ria (= tercil intermedi\u00e1rio) e dieta de m\u00e1qualidade ou alimenta\u00e7\u00e3o n\u00e3o saud\u00e1vel (= pior tercil) Question\u00e1rio Internacional deAtividade F\u00edsica , traduzido e validado para o Brasil Outro comportamento de sa\u00fade avaliado foi o n\u00edvel de pr\u00e1tica de atividade f\u00edsica,realizado por meio da vers\u00e3o breve do Center for Epidemiological Studies DepressionScale) A qualidade do sono foi avaliada pela pergunta: \u201cComo o senhor avalia a qualidadedo seu sono: muito boa, boa, mais ou menos, ruim ou muito ruim?\u201d. Asintensidades extremas foram somadas . Os sintomas depressivos foram avaliados pela escala CES-D8 foram baseadasem raz\u00f5es de preval\u00eancia (RP) e IC95%, estimados por meio de an\u00e1lises deregress\u00e3o de Poisson univariada e multivariada. Foram inclu\u00eddas no modelo deregress\u00e3o m\u00faltipla as vari\u00e1veis independentes que, na an\u00e1lise univariada,apresentaram associa\u00e7\u00f5es com a vari\u00e1vel dependente com signific\u00e2nciaestat\u00edstica, indicadas por p < 0,20. No modelo final, permaneceram aquelasque exibiram valores de signific\u00e2ncia, indicadas por p < 0,05. A an\u00e1lise dosdados foi realizada com os comandos svy do software Stata,vers\u00e3o 15.0 (https://www.stata.com), utilizando-se as pondera\u00e7\u00f5es decorrentesdo desenho amostral.Foi realizada an\u00e1lise descritiva das caracter\u00edsticas dos participantes e segundoos n\u00edveis de solid\u00e3o . As medidas de frequ\u00eancia,seus respectivos intervalos de 95% de confian\u00e7a (IC95%) e a compara\u00e7\u00e3o entre osn\u00edveis de solid\u00e3o foram obtidos pelo teste qui-quadrado de Pearson. As an\u00e1lisesdas associa\u00e7\u00f5es entre as vari\u00e1veis independentes e o desfecho . Osparticipantes assinaram termos de consentimento livre e esclarecido para cada umdos procedimentos da pesquisa e autorizaram acesso a bancos de dados secund\u00e1rioscorrespondentes. O ELSI-Brasil foi financiado pelo Minist\u00e9rio da Sa\u00fade:Departamento de Ci\u00eancia e Tecnologia/Secretaria de Ci\u00eancia, Tecnologia e InsumosEstrat\u00e9gicos ; Coordena\u00e7\u00e3ode Sa\u00fade da Pessoa Idosa na Aten\u00e7\u00e3o Prim\u00e1ria/Departamento de Gest\u00e3o do CuidadoIntegral/Secretaria de Aten\u00e7\u00e3o Prim\u00e1ria \u00e0 Sa\u00fade .A preval\u00eancia de sempre sentir solid\u00e3o foi de 16,8%; a de algumas vezes sentirsolid\u00e3o, 31,7%; e a de nunca sentir solid\u00e3o, 51,5% . A maiorNa an\u00e1lise m\u00faltipla , a solidEste estudo avaliou a preval\u00eancia de solid\u00e3o de acordo com seus n\u00edveis de intensidadeem adultos brasileiros n\u00e3o institucionalizados com 50 anos ou mais, antes dapandemia de COVID-19, e suas associa\u00e7\u00f5es com vari\u00e1veis sociodemogr\u00e1ficas ecomportamentos e condi\u00e7\u00f5es de sa\u00fade. Embora a maior parte dos participantes tenhadeclarado nunca se sentir solit\u00e1ria, foi observada maior probabilidade de sempresentir solid\u00e3o entre mulheres, pessoas que moravam sozinhas, que nunca foram \u00e0escola, que pontuaram para depress\u00e3o e as que avaliaram a pr\u00f3pria sa\u00fade e aqualidade do sono como ruins/muito ruins.,,,,Os achados deste estudo mostram que o sentimento de solid\u00e3o intensa \u00e9 mais frequenteentre idosos de 80 anos ou mais, quando comparados aos idosos mais jovens. Essesresultados s\u00e3o consistentes com os de estudos pr\u00e9vios, ainda que o sentimento desolid\u00e3o nem sempre seja mais prevalente em idosos com 80 anos ou mais em compara\u00e7\u00e3oa adultos mais jovens ,O dado que revela a maior intensidade de solid\u00e3o entre mulheres do que entre homens \u00e9concordante com os achados pr\u00e9vios de que os n\u00edveis de solid\u00e3o em mulheres idosass\u00e3o mais altos que os dos homens quando se usa instrumento direto de medida desolid\u00e3o A observa\u00e7\u00e3o de que houve mais idosos de baixa escolaridade entre os que relataramsempre sentir solid\u00e3o condiz com o resultado de outro estudo em que essa rela\u00e7\u00e3o foianalisada lifespan), os fatores derisco para solid\u00e3o s\u00e3o diferentes para cada est\u00e1gio da vida, devido \u00e0 influ\u00eancia degrandes eventos marcadores da experi\u00eancia de cada faixa et\u00e1ria. Assim, na velhice,torna-se mais prov\u00e1vel que viver sozinho reflita o estado de viuvez Na pesquisa ora relatada, observou-se que os indiv\u00edduos que moravam sozinhosapresentaram n\u00edveis mais altos de solid\u00e3o do que os que moravam com uma ou maispessoas. Esses achados s\u00e3o congruentes com os do estudo de Hutten et al. ,Apesar da corresid\u00eancia com filhos, parentes e amigos n\u00e3o ser um fator de prote\u00e7\u00e3opara solid\u00e3o t\u00e3o forte quanto viver com um c\u00f4njuge ,,Neste estudo, contrariando nossas hip\u00f3teses, sempre sentir solid\u00e3o n\u00e3o se relacionousignificativamente com comportamentos de sa\u00fade (dieta saud\u00e1vel e pr\u00e1tica deexerc\u00edcios f\u00edsicos). Uma das raz\u00f5es pelas quais se acredita que indiv\u00edduossolit\u00e1rios sejam levados ao desengajamento de atividades promotoras de sa\u00fade \u00e9 arela\u00e7\u00e3o entre solid\u00e3o e redu\u00e7\u00e3o do funcionamento cognitivo, de modo especial asfun\u00e7\u00f5es executivas, que englobam a capacidade de planejar e tomar decis\u00f5es, tornandomais dif\u00edcil a ado\u00e7\u00e3o de um estilo de vida saud\u00e1vel ,,Os resultados que indicaram associa\u00e7\u00e3o entre solid\u00e3o mais frequente e piorautoavalia\u00e7\u00e3o de sa\u00fade replicam dados obtidos em estudos pr\u00e9vios H\u00e1 evid\u00eancias de que a rela\u00e7\u00e3o entre autoavalia\u00e7\u00e3o negativa de sa\u00fade e solid\u00e3o emidosos possa ser parcialmente mediada por sono de m\u00e1 qualidade ,,Os resultados refor\u00e7am a bem documentada correla\u00e7\u00e3o entre solid\u00e3o e depress\u00e3o emidosos e adultos na meia-idade. Embora haja evid\u00eancias de que solid\u00e3o e depress\u00e3os\u00e3o construtos distintos, sabe-se que compartilham sentimentos, tais como percep\u00e7\u00e3onegativa das intera\u00e7\u00f5es sociais, senso antecipado de rejei\u00e7\u00e3o, redu\u00e7\u00e3o das respostasa est\u00edmulos positivos e aumento do estresse Este estudo tem limita\u00e7\u00f5es. Devido ao seu delineamento transversal, n\u00e3o se podeestabelecer rela\u00e7\u00e3o temporal nem causal entre as vari\u00e1veis. A amostra limitou-se aadultos brasileiros n\u00e3o institucionalizados com mais de 50 anos, motivo pelo qual osresultados n\u00e3o podem ser generalizados para a popula\u00e7\u00e3o geral. Foi utilizadoinstrumento de medida direta e de item \u00fanico, o que pode ter contribu\u00eddo para umasubestimativa da preval\u00eancia de solid\u00e3o, especialmente em homens. Os comportamentose as condi\u00e7\u00f5es de sa\u00fade foram baseados em autorrelatos dos entrevistados, que podemter sido influenciados pela cogni\u00e7\u00e3o e pela desejabilidade social. Outras vari\u00e1veispotencialmente importantes n\u00e3o foram inclu\u00eddas, entre elas, por exemplo, renda,tra\u00e7os de personalidade, multimorbidade e fragilidade. Todavia, at\u00e9 onde sabemos,este \u00e9 o primeiro estudo que investiga a preval\u00eancia de n\u00edveis de solid\u00e3o em amostrapopulacional representativa de adultos brasileiros com 50 anos ou mais e suasassocia\u00e7\u00f5es com comportamentos e condi\u00e7\u00f5es de sa\u00fade.Em conclus\u00e3o, apesar de neste estudo a maioria de adultos com 50 anos ou mais terdeclarado nunca sentir solid\u00e3o, esse sentimento foi mais intenso entre aqueles comdepress\u00e3o, do sexo feminino, que n\u00e3o frequentaram a escola, que moravam s\u00f3s, quetinham pior qualidade do sono e que apresentavam percep\u00e7\u00e3o negativa da pr\u00f3priasa\u00fade. Os dados apontam a solid\u00e3o como uma condi\u00e7\u00e3o a ser levada em conta porservi\u00e7os e profissionais respons\u00e1veis pelo cuidado de adultos e idosos, dado seupotencial para prejudicar a qualidade de vida nesses grupos.S\u00e3o necess\u00e1rios estudos que promovam o conhecimento longitudinal das trajet\u00f3rias dasolid\u00e3o e suas vari\u00e1veis associadas. Esse conhecimento poder\u00e1 servir de base para odelineamento de pol\u00edticas p\u00fablicas e a\u00e7\u00f5es que poder\u00e3o ajudar indiv\u00edduos mais velhose solit\u00e1rios a se manterem saud\u00e1veis, especialmente diante de doen\u00e7as que acarretemrestri\u00e7\u00f5es sociais. No longo prazo, a\u00e7\u00f5es governamentais promotoras da igualdade deoportunidades ao longo de toda a vida, al\u00e9m do uso e da avalia\u00e7\u00e3o constante deestrat\u00e9gias de interven\u00e7\u00e3o em sa\u00fade psicossocial, poder\u00e3o beneficiar o bem-estar deadultos e idosos brasileiros."}
+{"text": "As redes sociais e comunit\u00e1rias constituem um importante determinante social desa\u00fade, especialmente nos segmentos populares da sociedade civil e em suas lutaspara garantir o direito \u00e0 sa\u00fade. Esta pesquisa buscou compreender quais s\u00e3o asredes sociais e comunit\u00e1rias constitu\u00eddas por mulheres residentes em umacomunidade de baixa renda e sua rela\u00e7\u00e3o com a produ\u00e7\u00e3o da sa\u00fade nesse gruposocial. Foram realizadas entrevistas semiestruturadas com 11 mulheresparticipantes de uma organiza\u00e7\u00e3o n\u00e3o governamental (ONG) da comunidade, e osdados foram submetidos \u00e0 an\u00e1lise de conte\u00fado. A an\u00e1lise destacou quatrocategorias: a comunidade como uma grande rede - formada por m\u00faltiplas redesdin\u00e2micas interligadas; a rede das \u201ctias\u201d - mulheres com papel importante nocuidado da comunidade, tratadas como parte da fam\u00edlia; as rodas de conversa -como o rito de encontro peri\u00f3dico nas cal\u00e7adas, apontado como importante espa\u00e7ogarantidor de estabilidade emocional e qualidade de vida; e as benzedeiras e ouso de plantas medicinais - refer\u00eancias de cuidado na comunidade, queproporcionam preven\u00e7\u00e3o/tratamento \u00e0 sa\u00fade e encaminhamento para a unidade desa\u00fade quando necess\u00e1rio. Conclui-se que as redes sociais e comunit\u00e1rias formadaspelas participantes s\u00e3o determinantes sociais importantes. Assim, \u00e9 necess\u00e1ria avaloriza\u00e7\u00e3o de tais redes pelos equipamentos de sa\u00fade inscritos noterrit\u00f3rio. A compreens\u00e3o contempor\u00e2nea de sa\u00fade, fruto de uma constru\u00e7\u00e3o hist\u00f3rica, acaracteriza como uma produ\u00e7\u00e3o social. Nessa perspectiva, depreende-se que a situa\u00e7\u00e3ode sa\u00fade das popula\u00e7\u00f5es est\u00e1 intimamente relacionada ao contexto em que elas vivem,bem como \u00e0 posi\u00e7\u00e3o que ocupam na pir\u00e2mide social A partir dessa compreens\u00e3o, emergem os determinantes sociais da sa\u00fade (DSS), que s\u00e3ofatores sociais, econ\u00f4micos, culturais, \u00e9tnico-raciais, psicol\u00f3gicos ecomportamentais que impactam o processo sa\u00fade-doen\u00e7a As redes sociais e comunit\u00e1rias emergem como um conjunto, ou trama, de rela\u00e7\u00f5es einterc\u00e2mbios entre indiv\u00edduos, grupos ou organiza\u00e7\u00f5es que partilham interessescomuns H\u00e1 uma rela\u00e7\u00e3o estreita entre os DSS e as desigualdades sociais. Nesse sentido, emcontextos comunit\u00e1rios de vulnerabilidade, a popula\u00e7\u00e3o feminina merece uma especialaten\u00e7\u00e3o. Mulheres negras s\u00e3o marcadas pela viol\u00eancia e pela exclus\u00e3o. Elas ganham oequivalente a 40% do valor recebido pelos homens brancos ,Apesar de os DSS serem alvo de estudos nacionais e internacionais Essa investiga\u00e7\u00e3o parte do pressuposto de que a mulher moradora de periferia, apartir de seu contexto, assume um protagonismo no cuidado e na prote\u00e7\u00e3o de suafam\u00edlia, al\u00e9m de ter um alto potencial para construir redes, buscando enfrentar osdesafios n\u00e3o somente pessoais, mas de toda a comunidade. Diante do exposto, asseguintes quest\u00f5es nortearam a pesquisa: quais redes sociais e comunit\u00e1rias s\u00e3otecidas por mulheres residentes em uma comunidade de alta vulnerabilidade social?Como as redes sociais e comunit\u00e1rias influenciam na produ\u00e7\u00e3o da sa\u00fade de mulheresresidentes em uma comunidade de baixa renda? Esta investiga\u00e7\u00e3o teve como objetivoidentificar as redes sociais e comunit\u00e1rias constitu\u00eddas por mulheres residentes emuma comunidade de baixa renda e sua rela\u00e7\u00e3o com a produ\u00e7\u00e3o da sa\u00fade nesse gruposocial.RedesSociais e Comunit\u00e1rias Tecidas por Mulheres de Baixa Renda Inscritas em umaOrganiza\u00e7\u00e3o N\u00e3o Governamental: A Produ\u00e7\u00e3o Social da Sa\u00fadeEste artigo constitui parte dos resultados da disserta\u00e7\u00e3o intitulada A pesquisa, de natureza qualitativa, foi realizada em um munic\u00edpio localizado na Zonada Mata de Minas Gerais, que tem aproximadamente 570 mil habitantes, com alto \u00cdndicede Desenvolvimento Humano Municipal (IDH-M) . O cen\u00e1rio do estudo foi umbairro de 4.735 habitantes, com claro predom\u00ednio da popula\u00e7\u00e3o negra, a qual abrange69,04% de seus residentes. O bairro teve sua origem na d\u00e9cada de 1920, oriundo doprocesso de decad\u00eancia do caf\u00e9 na regi\u00e3o A escolha do cen\u00e1rio da pesquisa deu-se por conveni\u00eancia, considerando a inser\u00e7\u00e3opr\u00e9via do pesquisador na comunidade, como diretor de uma ONG que desenvolve projetosde enfrentamento da pobreza, a qual atua em v\u00e1rias frentes, entre elas, a sa\u00fade. Oestudo teve como participantes mulheres adultas, inscritas em um dos projetosdesenvolvidos pela ONG desde 2001, voltado para a sa\u00fade da mulher, denominado VidaPlena, o qual conta com a participa\u00e7\u00e3o de 13 mulheres. Foram exclu\u00eddas duasparticipantes que, apesar de pertencerem ao projeto, n\u00e3o moravam mais na comunidade,chegando-se assim a um grupo de 11 mulheres.A coleta dos dados deu-se em duas etapas. A primeira ocorreu por meio de umquestion\u00e1rio estruturado para caracteriza\u00e7\u00e3o do p\u00fablico, aplicado pelo pesquisadorem visitas domiciliares, no m\u00eas de novembro de 2018. Na segunda, foi feitaentrevista semiestruturada, em mar\u00e7o de 2019. O pesquisador optou por um ambientereservado para que as participantes concedessem seus depoimentos. O local foi eleitopelas pr\u00f3prias mulheres, que optaram por realizar as entrevistas em seus pr\u00f3priosdomic\u00edlios.O agendamento das entrevistas aconteceu presencialmente, ap\u00f3s as reuni\u00f5es semanais doprojeto Vida Plena, do qual todas s\u00e3o participantes. Antes de conceder asentrevistas, as participantes foram informadas quanto aos objetivos do estudo esobre a import\u00e2ncia de sua participa\u00e7\u00e3o na pesquisa. O Termo de Consentimento Livree Esclarecido (TCLE) foi lido pelo pesquisador e assinado pelas participantes. Paragarantir o anonimato, as participantes foram identificadas com a letra M (demulher), seguida do algarismo ar\u00e1bico correspondente \u00e0 ordem de realiza\u00e7\u00e3o daentrevista, a saber: M1, M2, M3\u2026 M11. Diante do exposto, as seguintes quest\u00f5esorientaram a entrevista: como \u00e9 para voc\u00ea ser membro desta comunidade? Como voc\u00eaparticipa da vida da comunidade? Quais grupos/espa\u00e7os comunit\u00e1rios voc\u00eafrequenta/faz parte? Como voc\u00ea se sente nesses espa\u00e7os?A an\u00e1lise dos dados pautou-se na t\u00e9cnica de an\u00e1lise de conte\u00fado de Laurence BardinEste estudo obteve parecer favor\u00e1vel do Comit\u00ea de \u00c9tica e Pesquisa com Seres Humanosda universidade p\u00fablica do munic\u00edpio do estudo .per capita abaixo da linha da indig\u00eancia  e outras duas tinham renda abaixo da linha dapobreza . Somente uma, portanto, estava acima da linha dapobreza.As participantes tinham m\u00e9dia de idade de 47 anos - a mais nova tinha 23 anos e amais idosa, 74. Do grupo, cinco nunca tiveram a carteira assinada e somente umatinha essa realidade no momento da entrevista, apesar de tr\u00eas estarem trabalhando.No que tange \u00e0 escolaridade, duas nunca estudaram, seis tinham Ensino Fundamentalincompleto e uma, completo. A renda m\u00e9dia das participantes era de R$ 803,54 - amenor renda era de R$ 170,00 e a maior era de R$ 1.600,00. Das 11 mulheres, oitotinham renda Sete participantes estavam desempregadas e seis sobreviviam de pens\u00e3o. Tr\u00eas recebiamBolsa Fam\u00edlia; destas, duas tinham esse benef\u00edcio como \u00fanica renda. Dez moravam emcasa pr\u00f3pria e uma pagava aluguel. Nenhuma das mulheres tinha registro do im\u00f3vel emque morava. Somente uma comprou a casa. As demais ganharam o terreno e constru\u00edram oim\u00f3vel ou j\u00e1 o ganharam constru\u00eddo pela Sociedade de S\u00e3o Vicente de Paulo do bairro- uma organiza\u00e7\u00e3o cat\u00f3lica de \u00e2mbito internacional, composta por leigos, denominadosvicentinos. Eles desenvolvem um trabalho que visa auxiliar o pobre a se emancipar dasitua\u00e7\u00e3o de pobreza em que vive, provendo necessidades b\u00e1sicas como alimenta\u00e7\u00e3o,moradia e vestu\u00e1rio, com vistas a resgatar a dignidade humana.O relato das participantes da pesquisa apresenta o bairro como uma forte teia derela\u00e7\u00f5es solid\u00e1rias, de forma que os moradores est\u00e3o sempre preocupados comtodos: seja em situa\u00e7\u00f5es de obras, nas dificuldades financeiras, na sa\u00fade ou nosconflitos. As mulheres verbalizaram poder contar com essa rede local, que figuracomo uma rede ativa, sem necessidade de ser acionada pelo demandante. Quem est\u00e1ao redor \u00e9 proativo em contribuir, ou seja, n\u00e3o \u00e9 preciso amizade ou grandeafinidade para agir. Ser morador da comunidade e precisar de ajuda s\u00e3o ascondi\u00e7\u00f5es para a rede atuar:No tempo da obra, cada um ficou numa casa. Nessa hora, espalhei todomundo. Ficaram dois filhos na D. [amiga] e dois com a gentel\u00e1 em cima [na casa de outra amiga]\u201d (M2).\u201cn\u00e3o tenho que chegar e falar para a pessoa: aqui, se voc\u00ea precisar,voc\u00ea me fala. N\u00e3o! Se eu estou vendo que voc\u00ea precisa, eu tenho que mostrarmeus pr\u00e9stimos\u201d (M3).\u201c...Eu usei telefone da D. por 15 anos. (...) ligando paraS\u00e3o Paulo, Belo Horizonte, Sete Lagoas. Eu pagava, na verdade, mas ela n\u00e3oera obrigada a me emprestar. Eu reconhe\u00e7o isso tudo. Um dia eu cheguei e viela com o p\u00e9 enfaixado. Eu falei: \u2018O que que foi, D.?\u2019. Ela falou: \u2018Eu torcio p\u00e9\u2019 (...). Ningu\u00e9m tinha m\u00e1quina e estava o cesto delacheio de roupa. A\u00ed falei: \u2018Ah, D., eu vou l\u00e1 em casa e daqui a pouco euvolto aqui para conversar com a senhora\u2019. Vim aqui, troquei de roupa,voltei (...). Na m\u00e3o eu lavei aquela quantidade de roupa.Precisava de banhar o p\u00e9 dela. O que me custava? Hoje era ela, amanh\u00e3 podiaser eu. A\u00ed eu fiquei um m\u00eas cuidando dela. Ela fala isso at\u00e9 hoje\u201d(M3).\u201cPertencer \u00e0 comunidade, para as mulheres deste estudo, significa fazer parte deuma grande fam\u00edlia. Tal sentimento emerge por causa dos fortes la\u00e7os deconfian\u00e7a e reciprocidade constru\u00eddos entre as pessoas da comunidade:Existe o parente de sangue, mas existe o parente madrinha. Ele vira umparente. Tem hora que ele \u00e9 mais perto que o de sangue. Porque na minhafam\u00edlia mesmo de pai e m\u00e3e n\u00e3o tinha esse neg\u00f3cio. Se arrumasse filho, sevira. Sai para rua. N\u00e3o tinha \u2018meu p\u00e9 me d\u00f3i\u2019, n\u00e3o. Eu vim vivendo eaprendendo isso. Irm\u00e3o (...) era engra\u00e7ado (...)punha pra rua mesmo (...). N\u00e3o tinha \u2018meu p\u00e9 med\u00f3i\u2019\u201d (M2).\u201cQualquer um eu considero parente. Tipo a J. N\u00f3s conversamos pra caramba,n\u00f3s brincamos. A dona L., a N., a F.\u201d (M4).\u201cEu n\u00e3o tenho parentes aqui, mas eu tenho pessoas que eu possocontar\u201d (M3).\u201cO sentimento de fam\u00edlia, relatado pelas participantes, \u00e9 expresso pelo afeto epelos la\u00e7os constru\u00eddos longitudinalmente com algumas pessoas da comunidade, queelas tratam e consideram como \u201ctias\u201d, isto \u00e9, como parte de suas fam\u00edlias:Tia L., tia R. Desde pequeninha a gente toma ben\u00e7a \u00e0 tia R. A gentesempre tomou ben\u00e7a. Tia L., tia R., tia C., irm\u00e3 da tia L., tia V., irm\u00e3 datia L. tamb\u00e9m. Ali para mim todo mundo \u00e9 tia. E a gente consideramesmo\u201d (M7).\u201cGosto muito da tia L. (...) eu chamo ela de tiamesmo (...) como se fosse. Mas nem \u00e9. Eu considero a tia L.como se fosse realmente minha tia\u201d (M1).\u201cEssas tias desempenham importante papel no apoio \u00e0 maternidade. Acompanham desdea gravidez, passando pelo parto, at\u00e9 o puerp\u00e9rio. Ensinam, cuidam, receitamch\u00e1s, ouvem e aconselham quem vive ang\u00fastias. Devido a isso, t\u00eam um importanterespeito na comunidade:Dona M. d\u00e1 banho, cura o umbigo do nen\u00e9m, leva o almo\u00e7o todo dia e umch\u00e1 de folha de algod\u00e3o. Porque o algod\u00e3o voc\u00ea sabe que \u00e9 anti-inflamat\u00f3rio.Ent\u00e3o, leva durante o resguardo: um m\u00eas. Ela ainda ficou com uma meninainternada. Eu ia cuidar da outra que ficou aqui. Tinha que dar mamadeira aela, tinha que dar banho. Tinha que curar o umbigo\u201d (M3).\u201cNascia uma crian\u00e7a. \u00c0s vezes ela mesmo fez o parto. A\u00ed ela tinha quevir (...) pegava a banheira, o sabonete, a toalha. Eufalava assim: \u2018M\u00e3e, leva a \u00e1gua quente de uma vez. S\u00f3 t\u00e1 faltando isso.Ferve a \u00e1gua e leva, porque voc\u00ea t\u00e1 levando tudo!\u2019\u201d (M7).\u201cRecebi ajuda tamb\u00e9m na minha \u00faltima gravidez e na s\u00edfilis, quando perdio nen\u00e9m. A J., A. e a M. Todas me deram um grande apoio\u201d (M11)\u201cAs participantes da pesquisa revelam em suas narrativas a compreens\u00e3o de queexiste uma capilarizada rede dial\u00f3gica entre elas e a comunidade. Relatam ocostume de, ao fim do dia e em especial nos fins de semana, os moradoressentarem em frente \u00e0s suas casas, na cal\u00e7ada, e passarem horas dialogando. Falamsobre tudo: crises, conflitos e medos, trocando ideias e recebendo conselhos unsdos outros:Isso me faz bem. \u00c9 muito bom. Uma fala de um problema e outra tamb\u00e9m.Minha tia, quando fala, ela fica mais leve. O problema some. Quando a gentesenta ali \u00e9 o momento de refletir, desabafar. Como foi a semana inteira. \u00c9bom. Voc\u00ea pode perceber que o bairro inteiro \u00e9 assim. Faz isso\u201d(M3).\u201cSe voc\u00ea olhar pelo emocional, faz muito bem. A gente distrai, esquece osmomentos de estresse. Das brigas das crian\u00e7as (...). \u00c9 overdadeiro psic\u00f3logo de pobre. Porque voc\u00ea relaxa, bate papo, conversa comtodo mundo, voc\u00ea fala at\u00e9 o que n\u00e3o quer\u201d (M1).\u201cAproveito para ficar com a fam\u00edlia. Sentamos em frente de casa e ficamosconversando de nossas vidas, nossa luta. S\u00e3o momentos bons. Gosto muitodisso. Nem sempre tem bebida, o importante \u00e9 estar junto\u201d (M8).\u201cNesse contexto, projetos como os desenvolvidos pela ONG da qual elas fazem parteservem para fortalecer movimentos j\u00e1 existentes no \u00e2mbito comunit\u00e1rio, tornandoa troca entre as mulheres uma atividade sistematizada que favorece o interc\u00e2mbiode saberes e a cria\u00e7\u00e3o de v\u00ednculos, redes e pr\u00e1ticas solid\u00e1rias maispotentes:Na ONG, as pessoas sabem conversar. At\u00e9 para falar de fofoca(...). Voc\u00eas sabem interpretar outras coisas para quem n\u00e3o tem a menteaberta. Ali \u00e9 um lugar para abrir a mente (...). Eu gostode ir l\u00e1\u201d (M6).\u201cAli, voc\u00ea conversa (...). E as meninas dizem: \u2018eu fizisso (...), eu fui em tal lugar\u2019 (...)assim, assim. Foi assim (...). Elas te ajudam aresolver coisas que (...) voc\u00ea fica ali, igual a uma boba,sem saber o que fazer. Sei l\u00e1 (...). \u00c9, \u00e9, \u00e9 bom. \u00c9 bom.Elas falam muito, mas \u00e9 bom. At\u00e9 no seu dia de estresse, voc\u00ea perde oestresse l\u00e1. E quando eu entrei para o Vida Plena que eu comecei aajudar (...) e me fez olhar tamb\u00e9m um pouquinho mais paramim\u201d (M1).\u201cEle [o projeto] \u00e9 uma reuni\u00e3o que fala sobre qualquerassunto, fala sobre doen\u00e7a, hipertens\u00e3o, fala sobre qualquer tipo deassunto. Eu gosto. Eu aprendo bastante tamb\u00e9m (...).Adquire mais experi\u00eancia\u201d (M4).\u201cO Vida Plena \u00e9 a gente conversar. Juntar as mulheres da comunidade,conversar, ter palestra, ter entendimento, rir um pouquinho. A gente sair umpouco do nosso mundo, sabe?\u201d (M5).\u201cO uso da medicina natural remete a uma quest\u00e3o cultural aprendida pelas mulheres,expressa por elas como uma pr\u00e1tica que atravessa gera\u00e7\u00f5es e que se materializaem suas experi\u00eancias cotidianas na/com a comunidade:Porque eu nasci e me criei na ro\u00e7a. Eu sa\u00ed de l\u00e1 tinha 21 anos. Foi l\u00e1que eu aprendi\u201d (M3).\u201cFa\u00e7o igual \u00e0 minha av\u00f3. Eu aprendi com ela a usar planta e acho que elaaprendeu com gente do mato\u201d (M7).\u201cAprendi com meus pais na ro\u00e7a, a gente bebia muito essas coisas. A\u00edpeguei o costume e fa\u00e7o at\u00e9 hoje\u201d (M10).\u201cO uso da medicina natural est\u00e1 atrelado a alguns nomes de refer\u00eancia nacomunidade, como as benzedeiras e estimuladoras da fitoterapia, que s\u00e3o as tiasanteriormente descritas:Uso bastante. Ch\u00e1. Mais do que comprado. Pra gripe, infec\u00e7\u00e3o, a gentegosta mais de ch\u00e1 (...). Dona M., m\u00e3e da N. Porque ela \u00e9benzedeira, n\u00e9? Daqui do bairro. Ela tem muito ch\u00e1 medicinal, muita folha,muita erva. Ela me fala o que que eu tenho que fazer, onde que eu vou pegar.O que ela tem, j\u00e1 junta. Ela \u00e9 \u00f3tima para essas coisas\u201d (M1).\u201cGosto (...). Eu gosto. N\u00e3o entendo das plantas do mato.A C. sabe. Ela conhece muito mato (...). Ch\u00e1 delaranja (...). Ch\u00e1 mesmo, assim. Eu tomo porque os outrosme d\u00e3o\u201d (M2).\u201cA dona C., l\u00e1 em cima, ela est\u00e1 sempre catando ch\u00e1. Ela receita para osoutros. Ela que tem esse neg\u00f3cio do ch\u00e1. Ela recolhe o ch\u00e1 para as pessoasque pedem pra ela. Ela pega e conhece muito rem\u00e9dio de mato que \u00e9bom\u201d (M10).\u201cExiste uma clara preocupa\u00e7\u00e3o das benzedeiras com a sa\u00fade das pessoas. Apesar deestimularem a pr\u00e1tica de plantas medicinais, compreendem que esta n\u00e3o responde atodas as situa\u00e7\u00f5es de sa\u00fade apresentadas pela comunidade:Normalmente, eu uso o ch\u00e1, se n\u00e3o resolver \u00e9 que eu levo nom\u00e9dico (...)\u201d (M1).\u201cTem umas que vem e diz: \u2018Ah, eu queria cana de macaco para rins\u2019. Eufalo: \u2018Eu, se fosse voc\u00ea, eu ia procurar um m\u00e9dico\u2019. Porque eu sei que oneg\u00f3cio j\u00e1 est\u00e1 feio e ch\u00e1 nenhum vai fazer efeito. \u2018Ah, mas eu tomei outrodia que sua m\u00e3e me deu (...) foi t\u00e3o bom\u2019. Mas se voltout\u00e3o r\u00e1pido \u00e9 bom voc\u00ea procurar um m\u00e9dico. Porque \u00e0s vezes tamb\u00e9m voc\u00ea vaificar dando ch\u00e1, a pessoa vai engambelando com ch\u00e1 e n\u00e3o vai aonde tem queir\u201d (M7).\u201cConsiderando a rela\u00e7\u00e3o de grande confian\u00e7a nessas tias, evidenciou-se que elass\u00e3o consideradas refer\u00eancias em sa\u00fade pelas participantes do estudo, sendoprocuradas antes da unidade b\u00e1sica de sa\u00fade (UBS) local para a resolu\u00e7\u00e3o dasquest\u00f5es de sa\u00fade:Tenho mais confian\u00e7a nas senhoras daqui do bairro [do que nom\u00e9dico]. Ainda mais com o Dr. M. [m\u00e9dico da UBS]. Deusque me perdoe. O m\u00e9dico nem olha na nossa cara. Nem olha. Eu, tipo assim,quando estou muito gripada vou na E., que ela tem uma erva, voc\u00ea lava, fazum xarope e bebe. Eu evito ir no m\u00e9dico. Voc\u00ea acorda duas horas da manh\u00e3,com esse frio, com chuva e ainda ser maltratado? Eu prefiro ir nessasmulheres e perguntar, que elas falam. \u00c9 s\u00f3 perguntar a elas que elas sabemde tudo\u201d (M3).\u201cMe sinto mais \u00e0 vontade com elas [as benzedeiras].Tenho mais intimidade com elas. Porque alguns m\u00e9dicos s\u00e3o educados,mas tem uns que nem na sua cara n\u00e3o olha. Ent\u00e3o acaba que a gente n\u00e3ofala\u201d (M1).\u201cAcho que com a D. C. eu falo melhor do que com o m\u00e9dico. Me sinto mais \u00e0vontade. Porque o m\u00e9dico enche a gente tanto de pergunta\u201d(M11).\u201cUma das marcas do bairro pesquisado \u00e9 a for\u00e7a das redes sociais locais. Opertencimento e prazer em ser da comunidade s\u00e3o comprovados pela rotina dasmulheres, marcada por poucas sa\u00eddas para outras regi\u00f5es. Assim, grande parte darotina, incluindo compras e divers\u00e3o, ocorre dentro da comunidade. Essecomportamento foi tamb\u00e9m identificado na pesquisa de Sarti Extrapolando a rela\u00e7\u00e3o das participantes com o territ\u00f3rio da comunidade em que vivem,\u00e9 preciso fazer um contraponto: em que medida essa estreita e intensa rela\u00e7\u00e3o com obairro vela a exclus\u00e3o social que vivem ao morar em uma regi\u00e3o perif\u00e9rica de altavulnerabilidade social? A literatura reporta que, considerando os problemasecon\u00f4micos, demogr\u00e1ficos e sociais, habitar na cidade implica tamb\u00e9m condi\u00e7\u00f5esinadequadas de moradia, experi\u00eancias de exclus\u00e3o social, reprodu\u00e7\u00e3o de iniquidades eagravos \u00e0 popula\u00e7\u00e3o Nesse sentido, pode-se analisar que o uso exponencial do territ\u00f3rio onde vivem se d\u00e1em virtude do n\u00e3o direito \u00e0 cidade, experimentado por popula\u00e7\u00f5es que habitam emregi\u00f5es perif\u00e9ricas/de alta vulnerabilidade social Neste estudo, evidenciou-se tamb\u00e9m a for\u00e7a da fam\u00edlia como agente de prote\u00e7\u00e3o ecuidado comunit\u00e1rio, que contrasta com as imagens sociais negativas formuladas sobrefam\u00edlias pobres. A literatura aponta a tend\u00eancia de interpreta\u00e7\u00e3o dessas imagenscomo desestruturadas e disfuncionais Uma das bases da qualidade de vida local \u00e9 a amizade, entendida como conhecer, serconhecido e respeitado por todos. Amaral Ao serem analisados conjuntamente o forte v\u00ednculo com a comunidade, a rela\u00e7\u00e3o deamizade entre os moradores, a l\u00f3gica de uma fam\u00edlia extensa ligada por m\u00faltiplosla\u00e7os de parentesco, compadrio e vizinhan\u00e7a, com a marcante viv\u00eancia dasolidariedade na rotina das entrevistadas, nota-se o contexto para a forma\u00e7\u00e3o dem\u00faltiplas redes sociais na comunidade. A literatura coaduna com o que foievidenciado nesta pesquisa ao afirmar que comunidade \u00e9 constitu\u00edda por m\u00faltiplasredes, como a dos vizinhos, da fam\u00edlia extensa, das madrinhas e tias. Al\u00e9m disso, ascondi\u00e7\u00f5es de inser\u00e7\u00e3o n\u00e3o s\u00e3o iguais - nem sempre basta residir na comunidade Segundo Menezes et al. Ficou evidente na pesquisa que o n\u00edvel de participa\u00e7\u00e3o nas m\u00faltiplas redes foisingular para cada mulher, a depender de fatores como: tempo de moradia, idade,personalidade, n\u00famero de familiares residentes no bairro, atitudes de reciprocidadeda pessoa, entre outros. Por isso, nem todas as participantes estavam plenamenteinseridas nas m\u00faltiplas redes e isso influenciou na qualidade de vida relatada porelas ao viver na comunidade.Um fator importante que a pesquisa evidencia \u00e9 o uso de plantas medicinais. Esse n\u00e3o\u00e9 um costume recente, mas derivado da origem rural dos antepassados dessas mulheres.Por isso, n\u00e3o nasce de um simples processo adaptativo local diante dos desafios noacesso a tratamentos e f\u00e1rmacos no Sistema \u00danico de Sa\u00fade (SUS). Na comunidade,algumas mulheres s\u00e3o refer\u00eancia no uso de plantas medicinais, devido ao uso pr\u00f3priode plantas para esse fim e \u00e0 exist\u00eancia de canteiros em suas casas com algumasvariedades. No entanto, o uso da fitoterapia n\u00e3o ocorre somente pela ricadiversidade de plantas nas comunidades \u00c9 reportado na literatura que em comunidades de baixa renda a coexist\u00eancia de fatorescomo a pobreza, a baixa escolaridade, a presen\u00e7a de curandeiros e parteiras, bemcomo a disponibilidade de plantas medicinais e de derivados vegetais preparados demaneira artesanal - a exemplo das garrafadas -, justifica a pr\u00e1tica expressiva dafitoterapia como recurso priorit\u00e1rio de preven\u00e7\u00e3o e tratamento de doen\u00e7as H\u00e1, ainda, as benzedeiras, que adotam uma pr\u00e1tica antiga, com somente duasrefer\u00eancias na regi\u00e3o pesquisada. Elas s\u00e3o grandes promotoras da fitoterapia, pois oritual de benze\u00e7\u00e3o est\u00e1 sempre interligado ao uso de plantas. Leite & LimaJunior Na comunidade, as mulheres que s\u00e3o refer\u00eancia em plantas e as benzedeiras desempenhamdois importantes pap\u00e9is na produ\u00e7\u00e3o de sa\u00fade das participantes da pesquisa.Primeiro, o de preven\u00e7\u00e3o e investimento em sa\u00fade, pois elas multiplicam orienta\u00e7\u00f5ese pr\u00e1ticas de preven\u00e7\u00e3o a diversas enfermidades e agravos de sa\u00fade; e segundo, o deatuarem no primeiro passo de cuidado das enfermidades b\u00e1sicas da popula\u00e7\u00e3o. Apostura de uma benzedeira demonstrou n\u00e3o haver separa\u00e7\u00e3o entre o uso dosfitoter\u00e1picos e o acesso \u00e0 UBS. Ela apontou que quando identifica que o uso dasplantas n\u00e3o atendeu \u00e0 queixa da pessoa, deixa de fornecer a mat\u00e9ria-prima e aorienta a buscar atendimento na UBS.As entrevistadas, por sua vez, apontaram buscar primeiro as benzedeiras e utilizarprioritariamente as plantas medicinais para o tratamento de diversas enfermidades,devido ao v\u00ednculo e \u00e0 confian\u00e7a que t\u00eam nas mulheres de refer\u00eancia. Apenas quando aspr\u00e1ticas tradicionais n\u00e3o atendem \u00e0 demanda \u00e9 que as participantes buscam o sistemaformal de sa\u00fade. As mulheres da pesquisa foram categ\u00f3ricas em afirmar que se sentemmais acolhidas ao relatar os sinais e sintomas \u00e0s benzedeiras, sentindo-se melhorcompreendidas e orientadas por essas refer\u00eancias de cuidado na comunidade.As entrevistas apontam que um espa\u00e7o significativo na rotina das mulheres foiconstitu\u00eddo pelo bate-papo e pela conviv\u00eancia na cal\u00e7ada, que deixou de ser umsimples local p\u00fablico de tr\u00e2nsito na comunidade. Sentadas ao ch\u00e3o, elas se abrem,ouvem conselhos, refletem sobre seus desafios, atualizam as informa\u00e7\u00f5es dacomunidade e confraternizam com comida e bebidas - muitas relatam al\u00edvio de estresseap\u00f3s esses momentos. H\u00e1, inclusive, datas semanais fixas para ocorrer esses eventos,referidos pelas entrevistadas como \u201cpsic\u00f3logo de pobre\u201d ou \u201cpostinho\u201d, em alus\u00e3o \u00e0UBS. Segundo Mello Ao estudarem o espa\u00e7o p\u00fablico e privado nas favelas, Peregrino et al. Esta pesquisa tem como limita\u00e7\u00e3o o crit\u00e9rio de escolha das participantes, pois asmulheres integrantes do projeto social de uma ONG foram selecionadas porconveni\u00eancia do entrevistador, o que caracteriza uma rede social informal dacomunidade. Assim, n\u00e3o houve participa\u00e7\u00e3o de nenhuma mulher fora da rede, o quepermitiria uma melhor an\u00e1lise dos resultados. Al\u00e9m disso, o pesquisador tem la\u00e7osantigos com as participantes, com algumas h\u00e1 mais de dez anos. Adicionalmente, \u00e9homem, branco e diretor da institui\u00e7\u00e3o de que as mulheres participam. Isso, semd\u00favidas, interferiu nas respostas das participantes.Esta pesquisa buscou compreender como as redes sociais e comunit\u00e1rias influenciam naprodu\u00e7\u00e3o da sa\u00fade de mulheres de baixa renda atendidas por uma ONG. Foramidentificadas m\u00faltiplas redes sociais, como a de vizinhos, amigos, madrinhas/tias ebenzedeiras, que constituem redes din\u00e2micas, as quais se interligam e formamcomplexos mosaicos.Evidenciou-se que essas redes est\u00e3o em constante movimento de constru\u00e7\u00e3o ereconstru\u00e7\u00e3o. N\u00e3o basta morar no bairro para estar inserido nelas, pois existemn\u00edveis de perten\u00e7a diferenciados. \u00c9 preciso desejo e investimento da pessoa. Asm\u00faltiplas redes solid\u00e1rias num contexto de fortes la\u00e7os acabam gerando uma grande eextensa fam\u00edlia, sendo sua marca mais simb\u00f3lica as \u201ctias\u201d, interpretadas nesteestudo como \u201cm\u00e3es coletivas\u201d que ajudam, protegem e cuidam de todos.As redes sociais e comunit\u00e1rias locais s\u00e3o potencializadas pelas institui\u00e7\u00f5espresentes no bairro, incluindo a ONG da qual as mulheres participam. Os projetos daONG estimulam o fortalecimento das redes j\u00e1 presentes na comunidade, por meio de umaconviv\u00eancia qualificada e da minimiza\u00e7\u00e3o de seus fatores de risco. Ademais,propiciam melhores condi\u00e7\u00f5es de habita\u00e7\u00e3o e empregabilidade para as mulheres.Destacam-se, ainda, as redes tecidas no cotidiano, como no rito de encontro peri\u00f3diconas cal\u00e7adas, que foi apontado como espa\u00e7o significativo para estabilidade emocionale qualidade de vida das mulheres e comparado, pelas participantes, \u00e0 a\u00e7\u00e3o de umprofissional de sa\u00fade e de equipamentos como a UBS. Por fim, existe o costume do usode fitoter\u00e1picos estimulado pelas benzedeiras e mulheres de refer\u00eancia em plantas.Essas l\u00edderes s\u00e3o refer\u00eancia na produ\u00e7\u00e3o social de sa\u00fade para as mulheres,especialmente diante dos desafios de acolhimento e ambi\u00eancia da UBS.Os achados desta investiga\u00e7\u00e3o identificaram que as redes sociais e comunit\u00e1riastecidas pelas mulheres participantes da pesquisa s\u00e3o importantes DSS que atuam demodo a promover sa\u00fade no grupo pesquisado. Elas conferem \u00e0s mulheres suportematerial e emocional para a qualidade de vida, atuando direta e/ou indiretamente napreven\u00e7\u00e3o de morbidades, promo\u00e7\u00e3o de cuidados e sa\u00fade emocional.Esta pesquisa aponta para a import\u00e2ncia de os equipamentos de sa\u00fade visibilizarem,valorizarem e potencializarem as redes sociais e comunit\u00e1rias em regi\u00f5es de especialinteresse social, pois elas podem ser importantes aliadas na produ\u00e7\u00e3o social desa\u00fade de uma comunidade. Al\u00e9m disso, s\u00e3o necess\u00e1rios estudos que busquem compreendercomo essas redes s\u00e3o constitu\u00eddas em diferentes contextos da sociedade -considerando o n\u00e3o direito \u00e0 cidade vivenciado por popula\u00e7\u00f5es de baixa renda -, oque pode revelar resultados distintos dos encontrados nesta investiga\u00e7\u00e3o."}
+{"text": "Some of these students even blame themselves for not effectively following the reading and writing proposals in higher education, implying that this is due to an intrinsic disorder.The data allow us to state that, despite the increase in the number of students in higher education, many still feel excluded from academic life, especially for not using academic discourse genres in a proficient way. It is the University responsibility, along with all actors involved in higher education, to promote actions that consider the right to education for all students. According to those data, in 2018, 7.14% of the population had access to Higher Education, which accounts for over 3.4 million students, with 75.4% of them enrolled in private institutions, and 24.6% in public Higher Education institutions (HEI). Thus, on one hand, the increase in the number of enrolments in HEIs could be considered an advancement. On the other hand, it is necessary to cogitate that the students\u2019 accessibility has not occurred in a similar way, mainly to those socially and economically disadvantaged students, to whom school has been inefficient in terms of their right to literacy.Statistical data from the Brazilian Higher Education Census, pointing out the gaps left by the basic education system, as teaching-learning processes have been ineffectively managed, mainly towards the illiteracy rates. Moreover, students\u2019 socioeconomic conditions hinder their basic and higher-education trajectory, even interfering in their choice of a major or the HEI that they intend to enroll.In that sense, recent research conducted in Brazil unveils several factors which make academic settings less accessible, is the fact that 34% of the undergraduates present limitations to reading, analyzing, interpreting texts, making inferences, and performing activities which demand critical-reflexive thinking. These data imply that a significant number of students who enter Higher Education have poor literacy conditions to access academic discourse genres.Another factor that hinders their accessibility to Higher Education, according to research held by the National Indicator of Functional Illiteracy ,6 have found that groups of students who graduate from High School do not know how to use academic discourse genres. However, HEI faculty expect their undergraduates to master the linguistic resources from those genres.Therefore, Brazilian students\u2019 relation to such genres has been a matter of concern in several areas of knowledge, including Education and Health. Studies unveils that Higher-Education students present different ways of thinking, interacting and producing academic activities, and a significant group of undergraduates is uneasy about the texts using the discourse genres from academic settings. This study states that such genres are not automatically acquired when those students are attending the university. Practices and experiences make them acquire this knowledge. Other studies,9 corroborate this discussion on students feeling unprepared to attend a university course, reporting that they often blame themselves by their supposed lags in reading, interpreting and writing academic texts.Another study, which focused on the use of scientific texts by undergraduates, verified that students usually have difficulties in using these genres due to gaps in the literacy practices pervading basic school through Higher Education. To the authors, the work using the written modality of the language in basic education usually consists of decontextualized and mechanical activities, which do not consider its use in meaningful contexts of daily life.A study, that considers language as an open system, a social product, fundamental for establishing discursive activities. Language enables the dialogical relations among people within the same society/community. This approach takes into account the history of each subject and the social relations that he/she establishes with other subjects and their respective values.The current article is grounded in the dialogical perspective of language, developed by the Bakhtin\u00b4s Circle,12 explains how discursive genres are constituted and work, considering their relation to the social interactive situation and the social sphere of each activity. It conveys that discourse genres are relatively stable utterances, which reflect and refract the uncountable human activities occurring in innumerable social interactive situations. In addition, during the process of language appropriation each person gets aware of him/herself and others, and of his/her role in the dialogues by means of the varied discursive genres. It should be pointed that each field of human activity produces its own discursive genres. Thus, some genres are more often used in daily life, such as letters, messages, drug package inserts, and other genres, such as academic ones, are used in more formal communication, such as abstracts, articles, and other scientific productions within these settings.That perspective.By understanding that genres are modes of using the discourse, in order for them to become socially accessible, one understands that a certain stability in its organization is necessary, which depends on the production conditions for each genre, as well as its goal. Thus, academic writing means to actively respond statements of others, in such a way that written practices, which occur in different interactive situations within the academic scope, may enable students to participate in these settings and understand the genres that pervade them, and then re-mean their practices with the written languageGrounded in that perspective, this study focuses on people\u2019s education, who may play a significant role working with the oral and written languages after graduation, such as speech therapists and educators. Therefore, this study aims to analyze the perception of students from Speech Therapy and Education courses on their reading and writing experiences and practices with academic texts.It is a quanti-qualitative, crosscut, analytical study, participants were selected by convenience. Data collection was held by means of a semi-structured questionnaire.Sample inclusion criteria were as follows: to be a student enrolled in Speech Therapy or Education courses, any academic terms, at a private university from Southern Brazil.Regarding the procedures for data collection, the head researcher, a speech therapist, requested the coordinators\u2019 permission of the Speech Therapy and Education courses so that students answered a questionnaire during classes. After the coordinators\u2019 agreement, some professors from the afore mentioned courses also set, previously by e-mail, liberated some time during their classes for two researchers, Speech Therapy undergraduates, trained by the head researcher, to apply the research instrument. On the previously set days, the researchers went to the classrooms, introduced themselves, explained the students the research objectives, and invited them to participate in it. Those who agreed to participate, firstly, signed the Free Informed Consent Form and subsequently, individually and in writing, answered a self-applied questionnaire, elaborated by the researchers. The questionnaire consisted of open and closed questions addressing the following aspects: the academic texts that the undergraduates read and write during graduation, if they have the skills and knowledge to read and write such texts, if they have any difficulties in using such discursive genres in the academic settings, and how they cope with those difficulties.A pilot testing was performed with five Speech-Therapy undergraduates. After some adequacies, the final questionnaire was applied. Data collection was conducted in all academic terms of the respective courses between June and September, 2018. On average, it took 20 minutes to fill out the questionnaire.From 149 Speech-Therapy undergraduates, and 210 Education undergraduates, 234 of them agreed to participate in the study, that is, 94 from the Speech-Therapy course and 140 from the Education course. After the data collection, the participants were identified as Speech-Therapy subjects (STS), from 1 to 94, and subjects from the Education course (ES), from 1 to 140., that is, a set of communicative analysis techniques, which aim to obtain the description of message contents, enabling inferences from the transmitted information, in this case, the responses to the self-applied questionnaires. The analysis of the material was conducted in three steps: 1) Pre-analysis, in which the collected material was reviewed, and thematic axes were defined and named based on the questions of the instrument, as follows: Axis 1 \u2013 Sociodemographic profile of the sample; Axis 2: Academic discourse genres read and written in Speech-Therapy and Education courses; Axis 3: Necessary conditions and knowledge to read and write academic discourse genres, difficulties and ways to cope with them. In step 2) Material exploration, cutoffs and classifications of the defined themes were performed. Thus, all the responses with common features were grouped in a single category, and in step 3) treatment, inference and interpretation of the results were performed.Data qualitative analysis was underpinned by the Content AnalysisRegarding the quantitative analysis, Sphinx iQ2 and Statistica 13.5 softwares were used. In the data analysis, descriptive statistics were used (absolute and relative frequency tables). All tests were performed at the significance level of 0.05 (5%). Comparisons were made only between the total results of the questions, as for the partial testing, in most cases, the number of responses were insufficient for the application of the used tests. It should be pointed out that questions enabled multiple answers on the part of the participants that is why the occurrence percentage, in general, extrapolates 100%.This research was approved by the Ethics Board under number 69021617.9.000.8040.Concerning the academic discourse genres read and written by the participants, there is a prevalence of scientific articles, abstracts, reviews and books in both courses, according to what was demonstrated in By means of the odds-ratio test, significance level of 0.05 (5%), it was verified significant difference in the response proportion of the categories: Scientific Article (p=0.0024), Book Report and others (p=0.0039). In the Scientific Article category, the proportion of responses was significantly higher for the Speech-Therapy course, while the Book Report and others category was higher for the Education course.The responses on the necessary conditions and knowledge are shown in By means of the odds-ratio test, significance level of 0.05 (5%), it was verified significant difference in the proportion of answers in the categories: Comprehension/Interpretation (p=0.0491) and Knowledge of the academic discourse genre (p=0.0015). In the category Comprehension/Interpretation, the proportion of answers was significantly higher for the Education course, while in the category Knowledge of the discursive gender, it was higher for the Speech-Therapy course.The results on the difficulties in reading and writing texts belonging to academic discursive genres, which students report to have, are shown in By means of the chi-square test, significance level of 0.05 (5%), it was verified that Speech-Therapy undergraduates perceive more difficulties in the use of academic discursive genres than Education undergraduates.Regarding the difficulties mentioned in the use of academic discursive genres, data are displayed in By means of the odds-ratio test, significance level of 0.05 (5%), it was verified significant difference in answer proportion of the categories: Normative Aspects (p=0.0002) and Subjects\u2019 intrinsic difficulties (p=0.0099). In these two categories, the proportion of answers was significantly higher for the Speech-Therapy course.Concerning Axis 1 \u2013 Sociodemographic profile of the participants, significant female prevalence was perceived, that is, 84% in the Speech-Therapy course and 90% in the Education course. In relation to the age ranges, Speech-Therapy undergraduates\u2019 ages ranged from 17 to 48 years, and 17 to 46 years among Education undergraduates, mean age of 25 years for the former course and 22 years for the latter. In both courses, most undergraduates attended basic and high school in public institutions, and they are attending their first major. which showed that 82% of students enrolled in the first term of their course were female, and among them, 76% attended high-school in public schools. A study pointed that students from licensing courses in Brazil are usually female, formerly attended public schools and belong to disadvantaged social classes. In another study that analyzed the profile of 11,662 Speech-Therapy undergraduates, by means of the National Exam of Students\u2019 Performance , between 2004 and 2010, the sociodemographic data unveiled high prevalence of the female population. Apart from that, other authors verified that Brazilian Speech-Therapy features a similarity to Europe in the prevalence of female professionals, where 95% of speech therapists are women.Those data corroborate with one research on the number of females in Higher Education unveiled that women\u2019s educational process and their insertion in Higher Education are fundamental. In addition, part of those women understand that the access to HEIs represents their possibility of social inclusion and competition for better job positions. Concerning this subject, another study evidenced that their access to education is one of the main ways of social mobility, being essential to get a diploma, as well as for their qualification and better standards of life.Study.The prevalence of women in Higher Education can also be related to the changes in society due to the consolidation of the capitalist system. Since the 1970s, many women while fighting for their rights, respect and recognition, have gained space in several areas, including education and job marketConcerning Axis 2\u2013 Read and written academic discursive genres, in ,12 and structures. Thus, when students referred to abstracts, it cannot be assumed a genre crystallization, that is, every abstract is read and written in the same way. For example, a discourse genre such as a report, in the Speech-Therapy graduation course, it may mean a report of an initial interview and assessment. However, in the Education course, this genre may mean a description of classroom activities. Therefore, it should be pointed out that each course makes use of texts belonging to distinctive discourse genres. It also deems necessary to understand that there are differences concerning reading and writing of such genres, depending on where and who is producing them. Still concerning that, a study specified that genres vary according to each interaction sphere, being changeable and giving way to the new. Each sphere of human activities produces its respective discourse genres, that is why, the better a subject masters a discourse genre, the easier its use will be for him/her.Through the participants\u2019 responses, it is possible to infer that they make use of several texts from academic discourse genres, which hold diversity and heterogeneity, with their own features found that the prevalence in the production of book reports, book reviews and abstracts may indicate that the use of such genres as check instruments by the professor on students\u2019 level of text reading and comprehension.Among the responses given by the participants of the Speech-Therapy and Education courses, book report, abstract and book review were mentioned by respondents from both courses. A study which allow the release of scientific results, demanding undergraduates\u2019 better performance and better level of knowledge. Such discourse genres, pervasive in the university, have their own communication rules, which are very often new to undergraduates.As for monographs, scientific works, dissertations and theses, mentioned by students from both courses, they are academic discourse genres,22 point that one who produces a text should know the constituents of the discourse genre, whether they are linguistic, ideological or communicative, which articulate within different contexts of use in the socially-shared human experiences. Therefore, the undergraduate must have contact with the diverse academic discourse genres for its occurrence. In addition, the HEIs must provide students with reflections on their uses and goals. Only the individual interpretation of the text content is not usually enough for students to access them.Considering Axis 3 \u2013 Necessary conditions and knowledge to read and write academic discourse genres, the participants\u2019 responses from both courses demonstrates the prevalent understanding on the need to interpret or understand those genres in order to read and write them. The words interpretation and comprehension seem to have the same meaning to the undergraduates. In this sense, some studiesBelow, excerpts from Speech-Therapy and Education undergraduates\u2019 responses on the necessary conditions and knowledge to read and write academic texts are described:For me to read and write it\u2019s necessary to interpret the subject, and I also need to have knowledge about such genres (STS59).First, I must have the widest possible knowledge on the subject and the text genre to be written. And, above all, to write correctly, with syntactic agreement and coherence (STS77).I must have good interpretation and comprehension (ES50)..In the answers above, one can observe that, to some students, knowledge on the genres of the academic discourse is fundamental for them to have access to the activities pervading those settings. STS77, for example, highlighted the importance of knowing not only the discourse genres, but also understanding the text features encompassing the written language, such as coherence and cohesion. Coherence is related to the meaning that the text has to its readers, being considered one of the principles of text interpretation, which occurs during communicative situations. As for cohesion, it is understood as a tool, which helps coherence and it refers to the connections between the parts of the discourse, being the element that provides texts with stability and continuity delimited that the discourse genres have constitutive-functional properties, which are divided into: plasticity, that is, each genre can be modified according to the socio-historical conditions; penetrability, that is, a genre can be intertwined with others, and unicity, that is to say, genres are relatively stable verbal communications.The written language features different values, functions and uses. In addition, it is constituted by three dimensions: normative (spelling and grammar), textual , and discursive (conditions for production). All of those dimensions must be considered in the use of language in any interactive situations. The knowledge of the academic discourse genres is fundamental in order for students to make meaningful use of the discursive practices within the academic settings, and use them for their communicative purposes. A study. This document rules over Brazilian basic education, and embodies the constitutional concept of non-exclusive education, highlighting teaching by means of discursive practices, focusing on the use of discourse genres.Some students point text and knowledge aspects of the discourse genres as relevant, and this is in accordance with the Brazilian Common Core Curriculum When asked whether they have difficulties in using academic discourse genres, most undergraduates from both courses answered it affirmatively. However, there was a significant difference between the courses, with prevalence of difficulties demonstrated by the Speech-Therapy undergraduates. In general, they associated their assumed difficulties with not having the mastery of the normative aspects of the language, difficulties in text interpretation, and individual constraints. Regarding the Education undergraduates, they pointed prevalent difficulties related to text interpretation.Some difficulties, concerning normative and vocabulary issues, can be observed in the excerpts below:Finding the appropriate words to write (ES42).Comprehension of the formal vocabulary (ES71).I have difficulty in the graphic stresses (STS61).It is necessary to know the spelling patterns; after all, I\u2019m going to work with that (ES79).Spelling rules, it is necessary to know grammar and the standard norm, and as I don\u2019t, I have difficulty in writing (STS21). found that students tend to believe that they only need to master the spelling rules to produce and interpret a text. Thus, many undergraduates focus on the mastery of the grammar structures, punctuation, and vocabulary acquisition in order to produce or read academic texts. They do not think about the discursive aspects involved in the process of using writing.In the statements above, it is observed that many undergraduates correlate their assumed difficulties in writing only to normative issues and the language vocabulary. Such answers can be related to the excessive valuing of the formal aspects of the language along their educational process, once writing appropriation has been approached as a ready and finished code. A studyIn addition to the difficulties in using academic discourse genres, some students pointed that they occur due to coherence and cohesion-related issues, as can be verified in the excerpts below:Coherence and cohesion, I\u2019ve even gone to the neurologist, but nothing has worked. There are also some similar cases in my family (STS12).Cohesion and coherence, it\u2019s always been like this since high school, it\u2019s very hard for me to write. In Portuguese, I always got low marks, and my dad called me stupid (ES61).Cohesion and coherence, my text are never understandable (STS32).From these responses, it can be inferred that the difficulties reported by some students, apart from the textual aspects, lead to their own perception as poor writers. That perception can be connected with other people\u2019s speech, such as ES61, who reported that her father called her \u201cstupid\u201d, which may have hindered her performance, as she is a poor reader and writer.. When those conditions are limited to individual factors that brings about guilt in the students, strengthening their feeling of inability and suffering.Undergraduates should not be held individually responsible for their supposed limitations in reading and writing, as they evolve from political, economic, educational and cultural determinantsThe excerpts below show that the difficulties reported by some students are related to the interpretation/comprehension of academic texts.Understanding of the genres required by the college (STS17).I have a lot of difficulty in interpreting the articles, theses; I only got to know that in college (ES03)Difficulty in understanding a monograph and thesis; only in college I saw that kind of text (STS 26).During the reading, difficulty in interpreting the words in manuscripts (ES8).Difficulty in understanding manuscripts and some books (SP60). which found that many students feel that they are the only responsible for knowledge and the relation they establish with the academic genres, as if reading of these genres only depended on them, not taken into account the experience evolved from their social practice.The responses above convey that some students assume that they have difficulties in reading, understanding and producing academic discourse genres. Some students state that they should already have mastered academic discourse genres by the time they started their major. Thus, facing the need of reading and interpreting texts, which they are little or no familiar with, they get to the conclusion that they have difficulties. These data corroborate with a study,27 indicate that higher education implies a considerable amount of intellectual activities, which demand reading and comprehension of new contents, concepts and technical-scientific vocabulary. Starting a university course means a transition, in which students face diverse educational demands from the ones formerly experienced, which can be viewed as barriers for their effective participation in this level of their education. Thus, the students are required to respond in a competent, autonomous and individual way to the demands imposed by this new experience.Brazilian studies,25,28 point out that they are associated with the educational lag in the former educational levels. Moreover, similarly to this research, those studies have evidenced that undergraduates relate their difficulties in using academic discourse genres to their former experience with the written language, before attending college. Briefly, they link their problems with the written language to their language learning, marked by the use of mechanical, decontextualized activities during their schooling process, usually based only on evaluation criteria.Regarding the difficulties in reading and writing texts from the academic discourse genre, several Brazilian studies unveiled that the experience and insertion in those discourse genres impact the students, which may generate suffering, thus, hindering their appropriation of reading and writing in these academic discourse genres.From the undergraduates\u2019 responses, one can perceive that many believe that their first contact with the academic discourse genre only occurred when they started their major. Thus, within the academic settings, many students blame themselves for not being able to keep up with this level of their education, as they are not familiar with those discourse genres. A study,25,27,28 conducted with undergraduates showed their assumed difficulties and pointed to the need of HEIs to get prepared for quality access in them, in a way that students can get appropriated from the discourse genres used in academic settings, so that they can properly discuss their related subjects. From their answers, one can perceive that some respondents connect their difficulties in the use of those genres to their own inherent aspects, such as, intellectual deficit, lack of attention and concentration, relentlessness, lack of understanding and lack of interest. Examples from such positions can be observed subsequently:Brazilian studiesI have to read millions of times to understand; sometimes I think I have a problem (ES9).I read and can\u2019t understand, I think I only understand something in the tenth time. I\u2019ve already thought about seeing a doctor, after a medication (ES90).I think I suffer from some attention deficit, as I\u2019ve had difficulty in understanding since I was a child (ES95).I try to practice more, because I know I have difficulty in learning and understanding what teachers explain. As a child, I had follow-up by a neurologist and a psychologist due to my problem (STS60). conveyed that such strategies enable greater reading fluency, an essential factor for text comprehension. Therefore, what some students report as a difficulty, that is, reading a text several times in order to understand it, actually, it is a demand of academic discourse genres, once these genres require re-reading and re-writing.The need of reading a text more than once and their concentration deficit were pointed to some students as difficulties. Probably, such observations are connected with the way their learning of reading and writing occurred in their earlier school years, that is, by means of mechanical and repetitive activities. Reading and reading comprehension depend on a number of factors, such as the type of text, the discourse genre, the world knowledge on the subject, the linguistic knowledge, the purpose. Thus, reading goes beyond the word decoding. Reading means to master the connection between grapheme and phoneme. Reading entails even more complex skills, such as selection, anticipation, inference and verification strategies. A study found that blaming students for their failure may cause subjective effects, consequently, discouraging them and leading them away from that language modality.One can assume from those undergraduates\u2019 responses that some blamed themselves for not being able to access some academic discourse genres. Many stated that they have difficulties due to their own disorders, holding responsible for their failure in the proposed academic reading and writing activities. StudyHowever, many difficulties in the use of academic discourse genres, reported by the undergraduates, are part of the appropriation process of such genres. In this process, practices and experiences with texts from academic discourse genres are fundamental, being necessary that the university teachers understand that students entering Higher Education do not have enough experience and knowledge for the effective use of academic discourse genres.The research data in this study were collected in a single Brazilian university. However, literature and larger Brazilian studies presented similar data. In the past years, there has been an expansion in the attendance of Higher Education by students from varied social classes and groups with distinctive practices and lived experiences towards reading and writing. Facing the heterogeneity of those undergraduates, HEIs are challenged to offer the access to superior education to all. By addressing academic literacy, it is necessary to know the appropriation process and the reality of the academic discourse genres, that is to say, to understand the literacy conditions of each individual, his/her life history and, subsequently, think over the diverse forms of access required by the universities..An example of intervention that can be developed at this educational level, in order to expand students\u2019 literacy conditions, ensuring accessible and quality education to all, is the literacy workshops. In these workshops, it is possible to conduct rounds of discussions with the students, within a scenario of collective construction and interlocution, which aims to promote relations and meaningful practices of reading and writing of academic discourse genres. Moreover, it aims to re-mean life histories of suffering in this settingThis study evidenced the view of Speech Therapy and Education undergraduates on their experiences and practices with reading and writing of academic discourse genres. Results showed that a significant number of students from both courses assume that they have some difficulties in academic reading and writing, which may point to gaps in the practice with this language mode during their earlier school years. Some students even held themselves responsible for their failure in reading and writing, implying that it could be a syndrome or disorder of their own. According to the undergraduates, the difficulties in reading and writing of academic discursive genres were related to the normative and textual aspects of the language, to their lack of knowledge on the vocabulary, and weaknesses towards text interpretation.University and faculty should promote actions considering the right to education for all students. Specifically, in relation to the students from Speech-Therapy and Education courses, involved with the knowledge production in the language field, the HEIs must consider the offer of literacy workshops, rounds of discussion, and other practices and interactions that privilege the use of the written language mode. Such activities should enable students to advance in their processes of appropriation and expansion of their possibilities to cope with the diverse academic discourse genres.  demonstram um crescimento significativo do acesso ao Ensino Superior (ES), desde a d\u00e9cada de 1990. Segundo esses dados, em 2018, 7,14% da popula\u00e7\u00e3o teve acesso ao ES, o que equivale h\u00e1 mais de 3,4 milh\u00f5es de alunos, sendo que desse total, 75,4% matricularam-se em Institui\u00e7\u00f5es de Ensino Superior (IES) privadas e 24,6% em IES p\u00fablicas. Entretanto, se por um lado, a expans\u00e3o do n\u00famero de matr\u00edculas nas IES pode ser considerada um avan\u00e7o, por outro, \u00e9 preciso ponderar que a acessibilidade dos alunos n\u00e3o ocorre de forma equivalente, especialmente, por alunos menos favorecidos social e economicamente, para quem a escola tem se mostrado ineficaz, no que diz respeito ao direito ao letramento.Dados estat\u00edsticos do Censo de Educa\u00e7\u00e3o Superior, ressaltando as lacunas deixadas pelo sistema de educa\u00e7\u00e3o b\u00e1sica, uma vez que os processos de ensino-aprendizagem nem sempre s\u00e3o conduzidos de forma efetiva, especialmente, com rela\u00e7\u00e3o ao n\u00edvel de alfabetismo. Al\u00e9m disso, condi\u00e7\u00f5es socioecon\u00f4micas dos alunos impactam em sua trajet\u00f3ria educacional b\u00e1sica e superior, inclusive, interferindo na escolha do curso e da IES que pretendem se matricular.Nessa dire\u00e7\u00e3o, recente pesquisa realizada no Brasil denuncia v\u00e1rios fatores que tornam o ambiente universit\u00e1rio menos acess\u00edvel, \u00e9 que 34% dos ingressantes apresentam restri\u00e7\u00f5es para ler, analisar, interpretar textos, fazer infer\u00eancias e realizar atividades que exijam um pensamento cr\u00edtico-reflexivo. Esse dado indica que as condi\u00e7\u00f5es de letramento de um n\u00famero significativo de estudantes que ingressam no ES s\u00e3o insuficientes para lhes dar acesso aos g\u00eaneros do discurso pr\u00f3prios da esfera acad\u00eamica.Outro fator que interfere na acessibilidade ao ES, segundo pesquisa realizada pelo Indicador Nacional de Alfabetismo Funcional,6 indicam que grupos de estudantes, ao concluir o n\u00edvel m\u00e9dio e ingressar no ES desconhecem os g\u00eaneros do discurso que circulam na esfera acad\u00eamica. Por\u00e9m, os professores das IES, em geral, esperam que o aluno ingresse no ES dominando os recursos lingu\u00edsticos pertencentes a esses g\u00eaneros.Dessa forma, a rela\u00e7\u00e3o estabelecida por estudantes brasileiros com tais g\u00eaneros tem sido alvo de preocupa\u00e7\u00f5es em v\u00e1rias \u00e1reas do conhecimento, incluindo a Educa\u00e7\u00e3o e a Sa\u00fade. Pesquisas explicita que alunos do ES apresentam diferentes formas de pensar, interagir e produzir atividades acad\u00eamicas na Universidade, e que um grupo significativo de alunos demonstra estranhamento perante os textos pertencentes aos g\u00eaneros do discurso no \u00e2mbito universit\u00e1rio. Esse estudo argumenta que tais g\u00eaneros n\u00e3o s\u00e3o adquiridos automaticamente apenas pelo fato do aluno estar na universidade. Mas, sim, a partir de pr\u00e1ticas e viv\u00eancias que possibilitem que se apropriem deste conhecimento. Outras pesquisas,9 coadunam com essa discuss\u00e3o acerca do sentimento de despreparo de muitos estudantes ao frequentar esse n\u00edvel de ensino, denunciando que, frequentemente, eles culpam a si mesmos pelas supostas defasagens que apresentam para ler, interpretar e escrever textos acad\u00eamicos.Outro estudo, que enfocou o uso de textos cient\u00edficos por discentes que frequentam o ES, verificou que, geralmente, estudantes apresentam dificuldades para usar esse g\u00eanero devido a defasagens com rela\u00e7\u00e3o \u00e0s pr\u00e1ticas de letramento oriundas da educa\u00e7\u00e3o b\u00e1sica, as quais permanecem no ES. Para os autores, o trabalho com a modalidade escrita da l\u00edngua, na educa\u00e7\u00e3o b\u00e1sica, comumente, ocorre a partir de atividades descontextualizadas e mec\u00e2nicas que n\u00e3o levam em considera\u00e7\u00e3o o seu uso em contextos significativos da vida di\u00e1ria.Um estudo, que considera a l\u00edngua como um sistema aberto fundamental para o estabelecimento das atividades discursivas, sendo um produto social da linguagem. \u00c9 a l\u00edngua que torna poss\u00edvel as rela\u00e7\u00f5es dial\u00f3gicas entre pessoas inseridas em uma mesma sociedade/comunidade. Essa abordagem concebe a hist\u00f3ria de cada sujeito e as rela\u00e7\u00f5es sociais que ele estabelece com outros sujeitos e seus respectivos valores.O presente trabalho sustenta-se na perspectiva dial\u00f3gica de linguagem, desenvolvida pelo C\u00edrculo de Bakhtin,12 explica como se constituem e funcionam os g\u00eaneros discursivos, considerando sua rela\u00e7\u00e3o com a situa\u00e7\u00e3o social de intera\u00e7\u00e3o e a esfera social de cada atividade. Indica que os g\u00eaneros do discurso s\u00e3o enunciados relativamente est\u00e1veis, que refletem e refratam as incont\u00e1veis atividades humanas que ocorrem em in\u00fameras situa\u00e7\u00f5es sociais de intera\u00e7\u00e3o. E, no processo de apropria\u00e7\u00e3o da linguagem, cada pessoa toma consci\u00eancia de si e dos outros, e de seu papel nos di\u00e1logos, por meio dos diferentes g\u00eaneros discursivos. Ressalte-se que cada esfera da atividade humana produz seus respectivos g\u00eaneros discursivos. Assim, alguns g\u00eaneros s\u00e3o mais utilizados no cotidiano, como as cartas, bilhetes, bulas de rem\u00e9dio, e outros g\u00eaneros, tais como os acad\u00eamicos, s\u00e3o utilizados em comunica\u00e7\u00e3o mais formal, como nos resumos, artigos e demais produ\u00e7\u00f5es cient\u00edficas dessa esfera.Tal perspectiva.Ao entender que os g\u00eaneros s\u00e3o formas de uso do discurso, a fim de que se torne socialmente acess\u00edvel, compreende-se que \u00e9 preciso certa estabilidade na sua organiza\u00e7\u00e3o, a qual depende das condi\u00e7\u00f5es de produ\u00e7\u00e3o de cada g\u00eanero e de sua finalidade. A partir disso, cabe esclarecer que escrever, na universidade, \u00e9 responder ativamente a dizeres dos outros, de modo que as pr\u00e1ticas de escrita que ocorrem nas diferentes situa\u00e7\u00f5es de intera\u00e7\u00e3o no interior da esfera acad\u00eamica, possam permitir que o aluno participe dessa esfera e compreenda os g\u00eaneros que nela circulam, ressignificando suas pr\u00e1ticas com a linguagem escritaCom base em tal perspectiva, esta pesquisa volta-se para a forma\u00e7\u00e3o de pessoas que, ap\u00f3s o t\u00e9rmino da gradua\u00e7\u00e3o, podem exercer um papel relevante no trabalho com a linguagem oral e escrita, como \u00e9 o caso de fonoaudi\u00f3logos e de pedagogos. Com esse entendimento, pretende-se, neste estudo, analisar a percep\u00e7\u00e3o de alunos dos cursos de Fonoaudiologia e de Pedagogia a respeito de suas experi\u00eancias e pr\u00e1ticas de leitura e escrita de textos pertencentes ao g\u00eanero do discurso na esfera acad\u00eamica.Trata-se de um estudo de car\u00e1ter quanti-qualitativo, de corte transversal e do tipo anal\u00edtico, sendo os participantes selecionados por conveni\u00eancia. A coleta de dados foi efetivada por meio da aplica\u00e7\u00e3o de um question\u00e1rio semiestruturado.Os crit\u00e9rios de inclus\u00e3o da amostra foram: ser discente matriculado, nos cursos de Fonoaudiologia ou Pedagogia, de qualquer per\u00edodo, em uma Universidade privada localizada no sul do Brasil.Como procedimentos para a coleta de dados, inicialmente, a fonoaudi\u00f3loga, pesquisadora respons\u00e1vel solicitou-permiss\u00e3o junto aos coordenadores dos cursos de gradua\u00e7\u00e3o em Fonoaudiologia e Pedagogia, para que durante as aulas os alunos respondessem a um question\u00e1rio. Ap\u00f3s a concord\u00e2ncia dos coordenadores, foi acordado, antecipadamente por e-mail, com alguns professores dos referidos cursos, um hor\u00e1rio para que durante suas aulas, duas pesquisadoras, estudantes de Fonoaudiologia, treinadas pela pesquisadora principal, aplicassem o instrumento da pesquisa. Nos dias estabelecidos, as pesquisadoras compareceram nas salas de aula, se apresentaram, explicaram para os estudantes os objetivos da pesquisa e, posteriormente, os convidaram a participar da mesma. Aqueles que concordaram, primeiramente, assinaram o Termo de Consentimento Livre e Esclarecido (TCLE) e a seguir responderam, individualmente e por escrito, a um question\u00e1rio autoaplic\u00e1vel, elaborado pelos pesquisadores. Esse continha perguntas abertas e fechadas, que abordavam os seguintes aspectos: quais textos pertencentes ao g\u00eanero do discurso na esfera acad\u00eamica o aluno escreve e l\u00ea durante a gradua\u00e7\u00e3o, se possui habilidades e conhecimentos para ler e escrever tais textos, se possui dificuldades no uso desses g\u00eaneros discursivos na esfera acad\u00eamica e como lida com tais dificuldades.Cabe esclarecer que foi feito um teste-piloto com esse question\u00e1rio, com cinco estudantes de Fonoaudiologia. Ap\u00f3s as adequa\u00e7\u00f5es, o question\u00e1rio final foi aplicado. A coleta de dados ocorreu entre junho e setembro de 2018, em todos os per\u00edodos dos respectivos cursos. O preenchimento dos question\u00e1rios durou, em m\u00e9dia, 20 minutos.De um total de 149 discentes matriculados no curso de Fonoaudiologia, e dos 210 alunos matriculados no curso de Pedagogia, 234 responderam positivamente ao convite, sendo 94 do Curso de Fonoaudiologia e 140 da gradua\u00e7\u00e3o em Pedagogia. Ap\u00f3s a coleta de dados, os participantes foram identificados como sujeitos do curso de Fonoaudiologia (SF), de 1 a 94 e (SP) de 1 a 140 para o curso de Pedagogia., ou seja, em um conjunto de t\u00e9cnicas de an\u00e1lise das comunica\u00e7\u00f5es que objetiva obter, a partir de um procedimento sistem\u00e1tico, a descri\u00e7\u00e3o do conte\u00fado das mensagens, permitindo infer\u00eancias \u00e0s informa\u00e7\u00f5es transmitidas que, neste caso, foram as respostas dos question\u00e1rios autoaplic\u00e1veis. A an\u00e1lise do material realizou-se a partir de tr\u00eas fases: 1) Pr\u00e9-an\u00e1lise, na qual foi explorado o material coletado, e feito o levantamento e a nomea\u00e7\u00e3o dos eixos tem\u00e1ticos norteados pelas perguntas explicitadas no question\u00e1rio, conforme demonstrado a seguir: Eixo 1 \u2013 Perfil sociodemogr\u00e1fico da amostra; Eixo 2: G\u00eaneros do discurso lidos e escritos na esfera acad\u00eamica durante a forma\u00e7\u00e3o em Fonoaudiologia e Pedagogia; Eixo 3: Condi\u00e7\u00f5es e conhecimentos necess\u00e1rios para ler e escrever os g\u00eaneros do discurso na esfera acad\u00eamica, as dificuldades encontradas e modos de enfrentamento das mesmas. Na fase 2) Explora\u00e7\u00e3o do material, foram feitos recortes e classifica\u00e7\u00f5es dos temas levantados. Desse modo, todas as respostas que tiveram caracter\u00edsticas comuns foram agrupadas em uma mesma categoria e na fase 3) realizou-se o tratamento dos resultados, a infer\u00eancia e a interpreta\u00e7\u00e3o.A an\u00e1lise qualitativa dos dados pautou-se na An\u00e1lise de Conte\u00fadoPara a an\u00e1lise quantitativa, utilizou-se das ferramentas Sphinx iQ2 e Statistica 13.5. Na an\u00e1lise dos dados, foram usadas estat\u00edsticas descritivas (tabelas de frequ\u00eancias absolutas e relativas). Todos testes se embasaram no n\u00edvel de signific\u00e2ncia de 0,05 (5%). As compara\u00e7\u00f5es foram realizadas somente entre os resultados totais das quest\u00f5es, j\u00e1 que para os resultados parciais, na maioria dos casos, o n\u00famero de respostas foi insuficiente para a aplica\u00e7\u00e3o dos testes utilizados. Destaca-se que as perguntas permitiram m\u00faltiplas respostas por parte dos participantes, raz\u00e3o pela qual o percentual de ocorr\u00eancia, em geral, extrapola 100%.Esta pesquisa foi provada pelo Comit\u00ea de \u00c9tica com o parecer n\u00famero 69021617.9.000.8040.A Quanto aos textos pertencentes aos g\u00eaneros discursivos na esfera acad\u00eamica lidos e escritos pelos participantes, h\u00e1 uma preval\u00eancia de artigos cient\u00edficos, resumos, resenha e livros, tanto no curso de Fonoaudiologia como no de Pedagogia, conforme pode ser visualizado na Atrav\u00e9s do teste de diferen\u00e7a de propor\u00e7\u00f5es, ao n\u00edvel de signific\u00e2ncia de 0,05 (5%), verificou-se que existe diferen\u00e7a significativa na propor\u00e7\u00e3o de respostas das categorias: Artigo Cient\u00edfico , Fichamento e outros . Na categoria Artigo Cient\u00edfico, a propor\u00e7\u00e3o de respostas foi significativamente maior para o curso de Fonoaudiologia, enquanto que a categoria Fichamento e outros foi maior para o curso de Pedagogia.As respostas acerca das condi\u00e7\u00f5es e conhecimentos necess\u00e1rios est\u00e3o dispostas na Por meio do teste de diferen\u00e7a de propor\u00e7\u00f5es, ao n\u00edvel de signific\u00e2ncia de 0,05 (5%), verificou-se que existe diferen\u00e7a significativa na propor\u00e7\u00e3o de respostas das categorias: Compreens\u00e3o/Interpreta\u00e7\u00e3o  e Conhecer o g\u00eanero discursivo na esfera acad\u00eamica . Na categoria Compreens\u00e3o/Interpreta\u00e7\u00e3o a propor\u00e7\u00e3o de respostas foi significativamente maior para o curso de Pedagogia, enquanto que a categoria Conhecer o g\u00eanero discursivo foi maior para o curso de Fonoaudiologia.Os resultados acerca das dificuldades na leitura e na escrita de textos pertencentes aos g\u00eaneros discursivos na esfera acad\u00eamica que os alunos afirmam apresentar est\u00e3o dispostos na Por meio do teste qui-quadrado, ao n\u00edvel de signific\u00e2ncia de 0,05 (5%), verificou-se que os estudantes do curso de Fonoaudiologia percebem que apresentam mais dificuldades no uso dos g\u00eaneros discursivos na esfera acad\u00eamica do que os estudantes de Pedagogia.Quanto a quais dificuldades apresentam no uso dos g\u00eaneros discursivos na esfera acad\u00eamica, os dados s\u00e3o apresentados na Por meio do teste de diferen\u00e7a de propor\u00e7\u00f5es, ao n\u00edvel de signific\u00e2ncia de 0,05 (5%), verificou-se que existe diferen\u00e7a significativa na propor\u00e7\u00e3o de respostas das categorias: Aspectos Normativos  e Dificuldades inerentes aos sujeitos . Nessas duas categorias a propor\u00e7\u00e3o de respostas foi significativamente maior para o curso de Fonoaudiologia.Com rela\u00e7\u00e3o ao Eixo 1 - Caracteriza\u00e7\u00e3o do perfil sociodemogr\u00e1fico dos participantes, percebeu-se uma predomin\u00e2ncia significativa de mulheres, ou seja, 84% no curso de Fonoaudiologia e 90% em Pedagogia. Quanto \u00e0 faixa et\u00e1ria, estudantes de Fonoaudiologia apresentaram idades que variaram de 17 a 48 anos; e 17 a 46 anos no curso de Pedagogia, sendo a m\u00e9dia de 25 anos para o primeiro curso e 22 para o segundo. Observou-se que, em ambos os cursos, a maioria dos discentes cursou tanto o ensino fundamental, como o m\u00e9dio em escolas p\u00fablicas e est\u00e1 cursando sua primeira gradua\u00e7\u00e3o. que demonstrou que 82% dos estudantes matriculados no primeiro per\u00edodo de licenciatura, eram mulheres e, dentre essas 76% cursaram o Ensino M\u00e9dio em escolas da rede p\u00fablica de ensino. Estudo apontou que, no Brasil, os alunos de cursos de licenciatura, em geral, s\u00e3o do sexo feminino, egressos de escolas p\u00fablicas e pertencem a fam\u00edlias de classes sociais menos favorecidas. Em outro estudo que analisou o perfil de 11.662 alunos do curso de Fonoaudiologia, a partir do Exame Nacional de Desempenho de Estudante (ENADE), entre 2004 e 2010, os dados sociodemogr\u00e1ficos revelaram que, neste curso, h\u00e1 uma preval\u00eancia elevada da popula\u00e7\u00e3o feminina. Al\u00e9m desse, outros autores verificaram que a Fonoaudiologia brasileira apresenta uma similaridade no predom\u00ednio de profissionais do sexo feminino, tal como na Europa, onde 95% dos fonoaudi\u00f3logos s\u00e3o mulheres.Esses dados coincidem com uma pesquisa acerca do n\u00famero de mulheres no ES revelou que o processo de escolariza\u00e7\u00e3o feminina e sua inser\u00e7\u00e3o em cursos superiores \u00e9 fundamental, e que parte dessas mulheres entendem que o acesso \u00e0s IES representa a possibilidade de inclus\u00e3o social e concorr\u00eancia por melhores postos de trabalho. A esse respeito, outra pesquisa demonstrou que o acesso \u00e0 educa\u00e7\u00e3o formal \u00e9 um dos principais meios de mobilidade social, sendo essencial para obten\u00e7\u00e3o de diplomas de ensino superior e para a qualifica\u00e7\u00e3o e melhoria de vida.Estudo.O predom\u00ednio de mulheres neste n\u00edvel de ensino pode tamb\u00e9m relacionar-se com as mudan\u00e7as ocorridas na sociedade em fun\u00e7\u00e3o da consolida\u00e7\u00e3o do sistema capitalista. Pois, a partir da d\u00e9cada de 1970, muitas mulheres ao lutarem por seus direitos, respeito e reconhecimento, passaram a conquistar espa\u00e7os em diversas \u00e1reas, inclusive na \u00e1rea da educa\u00e7\u00e3o e no mercado de trabalhoCom rela\u00e7\u00e3o ao Eixo 2\u2013 G\u00eaneros discursivos lidos e escritos na esfera acad\u00eamica, percebe-se na ,12 e estruturas pr\u00f3prias. Assim, quando os alunos responderam resumo, isso n\u00e3o sup\u00f5e uma cristaliza\u00e7\u00e3o do g\u00eanero, ou seja, que todo resumo na esfera acad\u00eamica \u00e9 lido e escrito da mesma forma. Para exemplificar, o g\u00eanero discursivo relat\u00f3rio, no curso de Fonoaudiologia, pode significar um relat\u00f3rio de entrevista inicial e avalia\u00e7\u00e3o fonoaudiol\u00f3gica, por\u00e9m, quando usado pelos alunos do curso de Pedagogia, esse g\u00eanero pode representar uma descri\u00e7\u00e3o das a\u00e7\u00f5es realizadas em sala de aula. Assim, \u00e9 preciso destacar que, al\u00e9m de cada curso fazer uso de textos pertencentes a g\u00eaneros discursivos distintos, \u00e9 preciso, tamb\u00e9m compreender que existem diferen\u00e7as com rela\u00e7\u00e3o a leitura e escrita de tais g\u00eaneros a depender de onde e por quem s\u00e3o produzidos. A esse respeito, um estudo especificou que os g\u00eaneros variam de acordo com cada esfera de intera\u00e7\u00e3o, sendo mut\u00e1veis e dando espa\u00e7o para o novo. Cada esfera da atividade humana produz seus respectivos g\u00eaneros discursivos, de modo que, quanto melhor um sujeito domina um g\u00eanero discursivo, mais f\u00e1cil ser\u00e1 seu uso.\u00c9 poss\u00edvel refletir a partir das respostas dos participantes de ambos os cursos, que esses fazem uso de v\u00e1rios textos pertencentes a g\u00eaneros discursivos na esfera acad\u00eamica, ambiente no qual h\u00e1 uma diversidade e heterogeneidade de g\u00eaneros discursivos que apresentam caracter\u00edsticas revelou que a preval\u00eancia na produ\u00e7\u00e3o de fichamentos, resenhas e resumos pode ser um indicativo da utiliza\u00e7\u00e3o desses g\u00eaneros como instrumentos de checagem, por parte do professor, do n\u00edvel de leitura e compreens\u00e3o dos textos pelos alunos.Cabe destacar, dentre as respostas fornecidas pelos participantes do curso de Fonoaudiologia e de Pedagogia, que fichamento, resumo e resenha foram citados em ambos os cursos. Um estudo que permitem a divulga\u00e7\u00e3o de resultados de investiga\u00e7\u00e3o cient\u00edfica, exigindo mais desempenho e um melhor n\u00edvel de conhecimento do aluno. Esses g\u00eaneros discursivos que circulam na universidade configuram-se como formas de comunica\u00e7\u00e3o com regras pr\u00f3prias, as quais, muitas vezes, se apresentam como uma novidade para os estudantes.J\u00e1 as monografias, trabalhos cient\u00edficos, disserta\u00e7\u00f5es e teses, citados por alunos de ambos os cursos, s\u00e3o g\u00eaneros discursivos na esfera acad\u00eamica,22 apontam que quem produz um texto deve conhecer as caracter\u00edsticas que constituem o g\u00eanero discursivo, sejam essas lingu\u00edsticas, ideol\u00f3gicas ou comunicativas, as quais se articulam nos diferentes contextos de uso das experi\u00eancias humanas, que s\u00e3o socialmente compartilhadas. Para que isso ocorra, \u00e9 necess\u00e1rio que o aluno tenha contato com os diferentes g\u00eaneros discursivos na esfera acad\u00eamica e que a IES lhe oportunize reflex\u00f5es sobre seus usos e finalidades. Entende-se que somente a interpreta\u00e7\u00e3o individual do conte\u00fado dos textos, muitas vezes, n\u00e3o \u00e9 suficiente para que o aluno os acesse.Quanto ao Eixo 3 - Condi\u00e7\u00f5es e conhecimentos necess\u00e1rios para ler e escrever os g\u00eaneros discursivos na esfera acad\u00eamica, verificou-se, nas respostas dos participantes de ambos os cursos, que predomina o entendimento de que para l\u00ea-los e escrev\u00ea-los \u00e9 preciso interpret\u00e1-los ou compreend\u00ea-los. As palavras interpreta\u00e7\u00e3o e compreens\u00e3o parecem ter o mesmo significado para os estudantes. A esse respeito, alguns estudosAbaixo est\u00e3o descritos excertos de respostas de alunos dos cursos de Fonoaudiologia e Pedagogia sobre as condi\u00e7\u00f5es e conhecimentos necess\u00e1rios para ler e escrever textos acad\u00eamicos:Para que eu consiga ler e escrever \u00e9 necess\u00e1rio interpretar o assunto, e tamb\u00e9m preciso ter conhecimento de tais g\u00eaneros (SF59).Primeiro ter conhecimento, o mais amplo poss\u00edvel pelo assunto e sobre o g\u00eanero textual a ser escrito. E o principal, escrever corretamente com concord\u00e2ncia e coer\u00eancia (SF77).Devo ter uma boa interpreta\u00e7\u00e3o e compreens\u00e3o (SP50)..Nas respostas acima, \u00e9 poss\u00edvel visualizar que, para alguns alunos, o conhecimento dos g\u00eaneros discursivos na esfera acad\u00eamica \u00e9 fundamental para que consigam ter acesso \u00e0s atividades que circulam neste ambiente. SF77, por exemplo, destacou a import\u00e2ncia de, al\u00e9m de conhecer os g\u00eaneros discursivos, compreender os aspectos textuais que envolvem a linguagem escrita, tais como a coer\u00eancia e a coes\u00e3o. A coer\u00eancia relaciona-se ao sentido que o texto tem para os leitores, sendo considerada um dos princ\u00edpios da interpretabilidade textual, que ocorre durante as situa\u00e7\u00f5es de comunica\u00e7\u00e3o. J\u00e1 a coes\u00e3o \u00e9 entendida como uma ferramenta que ajuda a coer\u00eancia e refere-se \u00e0s conex\u00f5es entre as partes do discurso, sendo o elemento da textualidade que d\u00e1 estabilidade e continuidade aos textos delimitou que os g\u00eaneros discursivos possuem propriedades constitutivo-funcionais, as quais dividem-se em: plasticidade, ou seja, cada g\u00eanero pode modificar-se de acordo com as condi\u00e7\u00f5es s\u00f3cio-hist\u00f3ricas; penetrabilidade, isso \u00e9, um g\u00eanero pode se intercalar entre outros g\u00eaneros; e unicidade, ou seja, os g\u00eaneros s\u00e3o comunica\u00e7\u00f5es verbais relativamente est\u00e1veis.Entende-se que a linguagem escrita apresenta diferentes valores, fun\u00e7\u00f5es e usos, e que al\u00e9m disso, se constitui a partir de tr\u00eas dimens\u00f5es: normativa (ortografia e gram\u00e1tica), textual  e discursiva (condi\u00e7\u00f5es de produ\u00e7\u00e3o). Todas essas dimens\u00f5es devem ser consideradas, no uso desta modalidade de linguagem, em qualquer situa\u00e7\u00e3o interativa. O conhecimento dos g\u00eaneros discursivos que circulam na esfera acad\u00eamica \u00e9 fundamental para que o estudante fa\u00e7a uso significativo das pr\u00e1ticas discursivas que ocorrem no ambiente universit\u00e1rio e use-as a partir de suas inten\u00e7\u00f5es comunicativas. Um estudo. Esse documento rege a educa\u00e7\u00e3o b\u00e1sica brasileira e materializa o conceito constitucional de educa\u00e7\u00e3o n\u00e3o excludente, enfatizando o ensino por meio de pr\u00e1ticas discursivas, com \u00eanfase no uso de g\u00eaneros discursivos.Cabe ressaltar o fato de alguns alunos apontarem aspectos textuais e de conhecimentos dos g\u00eaneros discursivos como importantes, pois isso vai de encontro ao que est\u00e1 posto na pr\u00f3pria Base Nacional Comum CurricularQuando questionados se apresentam dificuldades com rela\u00e7\u00e3o ao uso dos g\u00eaneros discursivos na esfera acad\u00eamica, a maioria dos alunos, de ambos os cursos, referiu que sim. Contudo, houve uma diferen\u00e7a significativa entre os dois cursos, com predomin\u00e2ncia de dificuldades explicitadas por estudantes do curso de Fonoaudiologia. Estes, em geral, associaram suas supostas dificuldades ao n\u00e3o dom\u00ednio dos aspectos normativos da l\u00edngua, a dificuldades na interpreta\u00e7\u00e3o textual e tamb\u00e9m a limita\u00e7\u00f5es individuais. J\u00e1 os alunos de Pedagogia apontaram, predominantemente, dificuldades relacionadas \u00e0 interpreta\u00e7\u00e3o textual.Algumas das dificuldades, relacionadas \u00e0s quest\u00f5es normativas e ao vocabul\u00e1rio, podem ser observadas nos excertos abaixo:Encontrar as palavras corretas para escrever (SP42).Compreens\u00e3o de vocabul\u00e1rio formal (SP71).Tenho dificuldade com os acentos (SF61).\u00c9 necess\u00e1rio conhecer os padr\u00f5es ortogr\u00e1ficos, afinal trabalharei com isso (SP79).Normas ortogr\u00e1ficas, \u00e9 necess\u00e1rio conhecer a gram\u00e1tica e a norma padr\u00e3o e como eu n\u00e3o sei tenho dificuldade para escrever (SF21). apontou que os alunos tendem a acreditar que necessitam somente dominar as normas ortogr\u00e1ficas para produzir e interpretar um texto. Assim, muitos universit\u00e1rios, ao produzir ou ler textos vinculados a este ambiente, focam-se unicamente no dom\u00ednio da estrutura\u00e7\u00e3o gramatical, pontua\u00e7\u00e3o, aquisi\u00e7\u00e3o de vocabul\u00e1rio, sem refletir acerca dos aspectos discursivos envolvidos no processo de uso da escrita.Observa-se, nas afirma\u00e7\u00f5es acima, que muitos alunos atrelam suas supostas dificuldades com a escrita apenas a quest\u00f5es normativas e ao vocabul\u00e1rio da l\u00edngua. Tais respostas podem estar relacionadas ao excesso de valoriza\u00e7\u00e3o de aspectos formais da l\u00edngua, ao longo do processo escolar, uma vez que a apropria\u00e7\u00e3o da escrita vem sendo, usualmente, abordada como um c\u00f3digo pronto e acabado. EstudoAinda com rela\u00e7\u00e3o \u00e0s dificuldades no uso dos g\u00eaneros discursivos na esfera acad\u00eamica, alguns alunos apontaram que essas ocorrem devido a quest\u00f5es relacionadas \u00e0 coer\u00eancia e \u00e0 coes\u00e3o, como pode ser verificado nos fragmentos abaixo:Coer\u00eancia e principalmente coes\u00e3o, j\u00e1 fui at\u00e9 no neurologista, mas nada adiantou na minha fam\u00edlia j\u00e1 tem alguns casos assim (SF12).Coes\u00e3o e coer\u00eancia, sempre foi assim desde o ensino m\u00e9dio, \u00e9 muito dif\u00edcil para mim escrever. Em portugu\u00eas, sempre tirava notas vermelhas e meu pai me chamava de burra (SP61).Coes\u00e3o e coer\u00eancia, os meus textos nunca ficam compreensivos (SF32).Pode-se inferir a partir dessas respostas que as dificuldades de escrita, referidas por alguns estudantes, para al\u00e9m dos aspectos textuais, remetem \u00e0 percep\u00e7\u00e3o que eles t\u00eam de si como maus escritores. Tal percep\u00e7\u00e3o pode tamb\u00e9m vincular-se a fala de outras pessoas, como por exemplo SP61, que revelou que seu pai a chamava de \u201cburra\u201d, o que pode ter interferido em sua posi\u00e7\u00e3o, enquanto m\u00e1 leitora e escritora.. Quando se restringe tais condi\u00e7\u00f5es a fatores individuais, isso gera culpabiliza\u00e7\u00e3o dos alunos, potencializando o sentimento de incapacidade e de sofrimento.Compreende-se que os alunos que frequentam o ES n\u00e3o devem ser responsabilizados individualmente pelas restritas condi\u00e7\u00f5es de leitura e escrita que acreditam ter, pois as mesmas s\u00e3o constru\u00eddas a partir de determinantes pol\u00edticos, econ\u00f4micos, educacionais e culturaisNos excertos abaixo \u00e9 poss\u00edvel visualizar que as dificuldades referidas por alguns alunos relacionam-se \u00e0 interpreta\u00e7\u00e3o/compreens\u00e3o dos textos acad\u00eamicos.Compreens\u00e3o dos g\u00eaneros exigidos pela faculdade (SF17).Tenho muita dificuldade para interpretar os artigos, teses, fui conhecer apenas quando entrei na faculdade (SP03).Dificuldade em compreender monografia e tese, s\u00f3 na faculdade que vi esse tipo de texto (SF 26).Durante a leitura dificuldade de interpretar as palavras que tem nos artigos cient\u00edficos (SP8).Dificuldade para compreender os artigos cient\u00edficos e alguns livros (SP60). que verificou que muitos alunos se sentem os \u00fanicos respons\u00e1veis pelo conhecimento e pela rela\u00e7\u00e3o que estabelecem com os g\u00eaneros acad\u00eamicos, como se a leitura desse g\u00eanero dependesse s\u00f3 de si e n\u00e3o da experi\u00eancia a partir do seu uso social.Percebe-se, pelas respostas acima, que alguns alunos sup\u00f5em que possuem dificuldades para ler, compreender e produzir diversos g\u00eaneros discursivos na esfera acad\u00eamica. Alguns estudantes afirmam que ao chegarem no ES, j\u00e1 deveriam ter o dom\u00ednio dos g\u00eaneros que ali circulam. Assim, ao se depararem com a necessidade de ler e interpretar textos, com os quais, muitas vezes, apresentam pouca ou nenhuma familiaridade, concluem que possuem dificuldades. Esses dados est\u00e3o de acordo com uma pesquisa,27 indicam que a escolariza\u00e7\u00e3o em n\u00edvel universit\u00e1rio pressup\u00f5e uma consider\u00e1vel quantidade de trabalho intelectual, que exige leitura, compreens\u00e3o de novos conte\u00fados, conceitos e vocabul\u00e1rios t\u00e9cnico-cient\u00edficos. O ingresso neste n\u00edvel de ensino \u00e9 marcado por uma transi\u00e7\u00e3o, na qual o estudante se depara com exig\u00eancias educacionais diferentes das experienciadas anteriormente, as quais podem ser vistas como barreiras para que participem efetivamente desse n\u00edvel de forma\u00e7\u00e3o. Assim, \u00e9 exigido que o aluno responda de forma competente, aut\u00f4noma e individual \u00e0s demandas impostas por essa nova experi\u00eancia.Pesquisas nacionais,25,28 apontam que essas est\u00e3o associadas ao despreparo educacional dos n\u00edveis de educa\u00e7\u00e3o anteriores ao ingresso na Universidade. Al\u00e9m disso, assim como na pesquisa aqui apresentada, esses estudos demonstraram que estudantes universit\u00e1rios associam as dificuldades com o uso dos g\u00eaneros acad\u00eamicos \u00e0 sua hist\u00f3ria pregressa com a l\u00edngua escrita, antes de ingressarem na Universidade. Em outras palavras, eles vinculam problemas com a modalidade escrita da l\u00edngua a uma hist\u00f3ria marcada pelo uso de atividades mec\u00e2nicas e descontextualizadas, durante a escolariza\u00e7\u00e3o, em geral, baseada apenas em crit\u00e9rios avaliativos.Com rela\u00e7\u00e3o \u00e0s dificuldades de leitura e escrita de textos pertencentes ao g\u00eanero do discurso na esfera acad\u00eamica, v\u00e1rios estudos nacionais revelou que a experi\u00eancia e a inser\u00e7\u00e3o nesses g\u00eaneros incide em um estranhamento por parte dos alunos, o que pode gerar sofrimento nos estudantes, comprometendo a apropria\u00e7\u00e3o da leitura e escrita destes g\u00eaneros no ambiente universit\u00e1rio.A partir das respostas dos discentes percebe-se que muitos acreditam que seu primeiro contato com o g\u00eanero discursivo na esfera acad\u00eamica aconteceu apenas quando ingressaram na Universidade. Assim, nesse ambiente, muitos discentes por n\u00e3o terem familiaridade com tais g\u00eaneros se culpam por n\u00e3o conseguir dar conta desse n\u00edvel de ensino. Uma pesquisa,25,27,28 realizadas com alunos que frequentam o ensino superior, demonstraram as supostas dificuldades apresentadas pelos estudantes, e apontaram para a necessidade das IES se prepararem para que o acesso a comunidade acad\u00eamica seja de qualidade, de modo que os alunos consigam se apropriar dos g\u00eaneros discursivos que circulam na universidade a ponto de poder discutir, com propriedade, os assuntos nela tratados. Percebe-se, nas respostas, de alguns participantes que eles atrelaram suas dificuldades no uso desses g\u00eaneros a aspectos inerentes a si mesmos, como por exemplo, dificuldade intelectual, falta de aten\u00e7\u00e3o e concentra\u00e7\u00e3o, inquieta\u00e7\u00e3o, falta de compreens\u00e3o e falta de interesse. Exemplos dessas posi\u00e7\u00f5es podem ser visualizados na sequ\u00eancia:Pesquisas nacionaisTenho que ler milh\u00f5es de vezes para poder entender, as vezes acho que tenho algum problema (SP9).Leio e n\u00e3o entendo, acho que s\u00f3 na d\u00e9cima vez que entendo algo, j\u00e1 pensei em ir no m\u00e9dico para receitar algum rem\u00e9dio (SP90).Penso que sofro de algum problema de aten\u00e7\u00e3o de algum dist\u00farbio, pois desde crian\u00e7a tenho dificuldade de entender (SP95).Tento praticar cada vez mais, porque sei que tenho dificuldade para aprender e entender o que os professores explicam, fiz acompanhamento com neuro e psic\u00f3loga na inf\u00e2ncia devido ao meu problema (SF60). descreveu que tais estrat\u00e9gias propiciam uma maior flu\u00eancia na leitura, fator fundamental para compreens\u00e3o do texto. Percebe-se que, o que alguns estudantes referem como dificuldade, por exemplo, ler um texto v\u00e1rias vezes para compreend\u00ea-lo, \u00e9, na realidade uma demanda da leitura de textos pertencentes a g\u00eaneros discursivos na esfera acad\u00eamica, ou seja, esses g\u00eaneros, em geral, exigem a releitura e a reescrita.A necessidade de realizar a leitura de um texto mais de uma vez e a falta de concentra\u00e7\u00e3o foram apontadas por alguns estudantes como dificuldades. Esses apontamentos, provavelmente, est\u00e3o atrelados \u00e0 maneira como ocorreu a aprendizagem da leitura e escrita durante os primeiros anos escolares, ou seja, a partir de atividades mec\u00e2nicas e repetitivas. A leitura e sua compreens\u00e3o dependem de in\u00fameros fatores, como do tipo do texto lido, do g\u00eanero discursivo, do conhecimento de mundo acerca do assunto, dos conhecimentos lingu\u00edsticos, da sua finalidade. Assim, para ler \u00e9 preciso mais do que decodificar as palavras, isto \u00e9, conhecer e dominar a rela\u00e7\u00e3o entre o grafema e o fonema. Ler envolve outras capacidades ainda mais complexas, tais como estrat\u00e9gias de sele\u00e7\u00e3o, antecipa\u00e7\u00e3o, infer\u00eancia e verifica\u00e7\u00e3o. Um estudo demonstrou que a culpabiliza\u00e7\u00e3o dos estudantes, pelo seu insucesso, causa efeitos subjetivos nos mesmos, levando-os a consequentemente sentirem-se desencorajados a escrever e afastando-se dessa modalidade de linguagem.A partir das respostas destes estudantes pode-se conjecturar que alguns sentiam-se culpados por n\u00e3o conseguirem ter acesso aos g\u00eaneros do discurso que circulam na Universidade. Muitos afirmaram que possuem dificuldades devido a um dist\u00farbio inerente a eles mesmos, se responsabilizando pelo pr\u00f3prio fracasso diante das atividades com a leitura e a escrita propostas na Universidade. EstudoEntretanto, \u00e9 preciso esclarecer que muitas dificuldades no uso dos g\u00eaneros discursivos na esfera acad\u00eamica, referidas pelos estudantes, fazem parte do processo de apropria\u00e7\u00e3o de tais g\u00eaneros. Nesse processo, as pr\u00e1ticas e viv\u00eancias com textos pertencentes aos g\u00eaneros do discurso na esfera acad\u00eamica s\u00e3o indispens\u00e1veis, sendo necess\u00e1rio que os atores envolvidos no ES compreendam que o aluno, ao ingressar na Universidade, n\u00e3o possui experi\u00eancias e conhecimentos suficientes para o uso efetivo dos g\u00eaneros discursivos que ali circulam.\u00c9 preciso elucidar que apesar dos dados da pesquisa aqui apresentada terem sido coletados em apenas uma Universidade brasileira, a literatura e as pesquisas nacionais de grande porte apresentaram dados semelhantes. Nos \u00faltimos anos houve uma amplia\u00e7\u00e3o do ingresso no ES, de diversos alunos de diferentes classes e grupos sociais e com distintas pr\u00e1ticas e viv\u00eancias com a leitura e a escrita. Diante da heterogeneidade deste alunado, cabe as IES enfrentar o desafio de oferecer uma educa\u00e7\u00e3o de acesso a todos. Assim, ao abordar a quest\u00e3o do letramento acad\u00eamico, \u00e9 preciso conhecer o processo de apropria\u00e7\u00e3o e a realidade da leitura e escrita dos g\u00eaneros discursivos na esfera acad\u00eamica, ou seja, compreender as condi\u00e7\u00f5es de letramento de cada um, suas hist\u00f3rias de vida e, assim, repensar a respeito das diversas formas de acesso exigidas nas Universidades..Um exemplo de a\u00e7\u00e3o que pode ser desenvolvida nesse n\u00edvel de ensino, a fim de ampliar as condi\u00e7\u00f5es de letramento dos alunos garantindo uma educa\u00e7\u00e3o acess\u00edvel e de qualidade para todos, s\u00e3o as oficinas de letramento. Nessas, \u00e9 poss\u00edvel realizar rodas de conversa como os alunos, a partir de um espa\u00e7o de constru\u00e7\u00e3o coletiva e interlocu\u00e7\u00e3o que objetiva promover rela\u00e7\u00f5es e pr\u00e1ticas significativas de leitura e escrita dos g\u00eaneros discursivos na esfera acad\u00eamica, al\u00e9m de ressignificar hist\u00f3rias de sofrimento nesse contextoEste estudo evidenciou a vis\u00e3o de alunos dos cursos de Fonoaudiologia e Pedagogia acerca de suas experi\u00eancias e pr\u00e1ticas com a leitura e a escrita de textos pertencentes aos g\u00eaneros discursivos na esfera acad\u00eamica. Os resultados demonstraram que parcela significativa de estudantes de ambos os cursos sup\u00f5e que apresenta alguma dificuldade com a leitura e a escrita nessa esfera, o que pode ser um indicativo das lacunas no trabalho com essa modalidade de linguagem durante os n\u00edveis de ensino que antecederam a vida acad\u00eamica. Alguns discentes, inclusive, se responsabilizaram por seu fracasso na leitura e na escrita, subentendendo que isso se deve a um dist\u00farbio ou transtorno inerente a eles mesmos. As dificuldades com a leitura e escrita dos g\u00eaneros discursivos na esfera acad\u00eamica, segundo os alunos, vincularam-se tamb\u00e9m aos aspectos normativos e textuais da l\u00edngua, ao desconhecimento do vocabul\u00e1rio e a fragilidades relativas a interpreta\u00e7\u00e3o textual.Cabe a Universidade e a todos os atores nela envolvidos promover a\u00e7\u00f5es que considerem o direito a educa\u00e7\u00e3o de todos os alunos. Com rela\u00e7\u00e3o, especificamente, aos alunos dos cursos de Fonoaudiologia e Pedagogia, envolvidos com a produ\u00e7\u00e3o do conhecimento na \u00e1rea da linguagem, as IES devem considerar a oferta de oficinas de letramento, rodas de conversa, e outras pr\u00e1ticas e viv\u00eancias que favore\u00e7am o uso da modalidade escrita da l\u00edngua. Essas atividades devem permitir que os estudantes avancem em seus processos de apropria\u00e7\u00e3o e amplia\u00e7\u00e3o de suas possibilidades de enfrentamento dos diferentes g\u00eaneros discursivos na esfera acad\u00eamica."}
+{"text": "To characterize the knowledge, skills, opinions, and main barriers perceived by speech-language pathologists, in child language in Brazil, regarding evidence-based practice (EBP).The study was conducted between August 2021 and July 2022 using an online questionnaire. In addition to sociodemographic and field data, 22 items related to EBP were considered and subdivided into \u201cknowledge\u201d, \u201cskills\u201d, \u201copinion\u201d and \u201cbarriers\u201d. Each item had five response options . A total of 122 speech-language pathologists who work with child language answered the questionnaire. Their responses were described by the percentage of frequency distribution. The time since graduation and the level of proficiency in English were considered to compare the distribution pattern of the answers.Although most speech-language pathologists report having learned the basics of EBP in their academic training, there are weaknesses in their knowledge and lack of mastery of search strategies and critical evaluation of scientific articles. Although most agree that EBP\u2019s use is necessary for speech-language practice and consider the need to increase the use of scientific evidence in their daily practice, the lack of articles, difficulties related to the practical application of scientific results and lack of collective support among colleagues are identified as barriers.This study alerts the academic community to the urgency of considering EBP in the context of Brazilian Speech-Language Pathology. The main objective of EBP is to reduce the uncertainty of the professional at the time of a clinical decision. It associates three pillars: clinical experience of the professional; preferences of the family and/or the client; and external (information available in the literature) and internal evidence . However, there are still many barriers that prevent its effective implementation, especially in Speech-Language Pathology-6. In summary, despite having some theoretical basis, speech-language pathologists (SLP) who work with language disorders in the international scenario recognize the insufficient time, the extensive workload, the scarcity of research in the area, the quality of available evidence and the lack of resources in the work environment as the main obstacles to the implementation of EBP,5,7,8.The importance of EBP has been frequently discussed in the medical and scientific community,10. However, it is essential to point out that in language disorders studies with the best levels of evidence are still scarce and there is a deficit in the knowledge of professionals regarding the processes of diagnosis and speech-language intervention,11.Scientific evidence does not seem to be decisive for the selection of intervention approaches, especially in the performance with child language. The most considered factor for decision-making is the clinical experience of the SLP. As much as the professional's experience is relevant, the effectiveness of EBP depends on its association with internal evidence and client preferences,5,7,8. Formal training on EBP at graduation or during continuing education appears as a strong predictor for the execution of such practice during its clinical performance,6,12.In an international context, SLPs who work with language, in general, have positive attitudes and are favorable to the implementation of EBP, although there are still barriersHowever, in the Brazilian context, there is a lack of studies that investigate such a scenario. Therefore, the aim of the study was to characterize the knowledge, skills, opinions, and main barriers perceived by SLPs in child language in Brazil, regarding evidence-based practice.This study is linked to a broader project that investigates how Brazilian SLPs act in the diagnosis and intervention in child language. The project was approved by the Research Ethics Committee . The informed consent form was presented before the questionnaire and participation was voluntary and anonymous. The participants were informed about the project\u2019s objectives, the estimated time for response and how to contact the researchers in case of questions. The guidelines of the National Research Ethics Commission (CONEP) for procedures in research in a virtual environment, published in February 2021, were followed in order to preserve the protection, safety and rights of participants.,13. The questionnaire was composed of 22 items subdivided into the categories \u201cknowledge\u201d, \u201cskills\u201d, \u201copinion\u201d and \u201cbarriers\u201d. In each item it was necessary to specify the level of agreement by a Likert scale with five response options . The questionnaire was preceded by questions related to sociodemographic aspects and work field.The first stage of the study consisted of the elaboration of a questionnaire on evidence-based practice from instruments used by Physical TherapyGoogle Forms. Before data collection began, we asked five undergraduate students to complete the questionnaire in search of errors or inconsistencies, aiming to improve the applicability of the instrument.The questionnaire was available in an open form on the platform Contact with potential participants occurred by social media. Instagram mentions of digital influencers and a sponsored ad on Instagram targeted SLPs with an interest in child language, the study was sent by email in the research newsletter to the associates of the Brazilian Society of Speech-Language Pathology (SBFa). Due to the recent implementation of the general data protection law, the Federal Council and the Regional Council of Speech-Language Pathology reported that it was unfeasible to disseminate the study by e-mail to active professionals.Access to the questionnaire was provided by a shortened link. All questions were mandatory, and the order of presentation was standardized. The questionnaire was spread over eight pages, each with about five multiple-choice questions. When submitting the questionnaire, it was no longer possible to make changes and a copy of the answers was sent to the participant. The answers were automatically stored in a Google spreadsheet.Google Forms survey view rates could not be calculated. However, all questionnaires submitted indicated agreement with the study and were complete. A priori, no measures were adopted to prevent duplication of responses, however e-mail was used to eliminate these occurrences before the analysis. In this sample we had three duplicate forms and chose to keep the first submission.Due to the characteristics of the platform As inclusion criteria, participants should have a degree in Speech-Language Pathology and work with language disorders in childhood. According to the Federal Council of Speech-Language Pathology, in June 2021 there were 48,391 SLPs in Brazil. Of these, 1155 hold the title of language specialist. However, not every professional who works with child language has the title of specialist and not every specialist works with child language. Thus, it was not possible to have an accurate estimate of the population of interest.The sample calculation was performed using GPower software. For an effect size of 0.3 and a statistical power of 0.8, the estimated sample would be 167 participants. In order to reach this sample, data collection took place between August 2021 and July 2022.Finally, 122 SLPs participated in this study who declared to act clinically in the area of child language in Brazil. The group was composed of 96.7% by women, with the predominant age group between 41 and 50 years (32.8%), university education in a private institution (53.3%) and for less than 5 years (31.1%), with specialization in the area (36.1%), according to GPower was used to calculate effect size and statistical power.The statistical treatment of the data was performed in the SPSS software version 24. Frequency distribution was used for descriptive analysis. The inferential analysis was performed using the chi-square test considering for the time since graduation two categories (up to 9 years since graduation and from 10 years since graduation) and for English proficiency three categories . The significance level adopted was 5%. In addition to the sample calculation, the software Participants expressed concern about continuing education, as 82% claim to have participated in scientific congresses, courses or updates in the area . In addition, 63.1% claim to have the habit of reading scientific articles, 20.5% very often and 42.6% often. The databases most used for searching articles were Scielo (33.6%), PubMed (24.8%) and Google Scholar (23.2%). None of the participants indicated using the SpeechBite Database .PBE does not take into account the limitations of my clinical practice\u201d  and \u201cEBP does not take into account patient preferences\u201d , according to Regarding knowledge, most participants indicated that they had learned the basics of EBP during their academic training (36.1% agree and 20.5% strongly agree) and consider that it improves the quality of care (35.2% agree and 54.1% strongly agree) and helps in making decisions about treatment (47.5% agree and 39.3% strongly agree). However, inconsistencies were identified in the items. \u201cIn my academic training I learned the basics for EBP\u201d. With regard to English proficiency, the difference suggests that SLPs with poor proficiency have less knowledge about EBP than those with moderate or good and excellent mastery. Regarding training time, the difference suggests that SLPs up to 9 years after graduation were less decided about having had access to this content than their peers trained more than 10 years ago.The inferential analysis indicated differences according to English proficiency (p<0.001) and time since graduation (p=0.021) only in the item \u201cWith regard to skills, most participants indicated using EBP (44.3% agree and 41.0% strongly agree) and having an interest in learning or improving their skills (37.3% agree and 59.8% strongly agree). However, when it comes to formal training in critical evaluation of scientific articles, most disagree or are neutral .24.6% of SLPs indicated that they had training in strategies for searching for scientific articles, while 22.1% of them disagreed with this statement. In addition, 31.1% consider themselves capable of understanding the statistical analysis of the articles, but another 31.1% were not decided about this item, as shown in Inferential analysis indicated differences according to English proficiency for all items, except interest in improving or learning about EBP. The difference suggests that SLPs with poor English proficiency have fewer skills than their peers with moderate, good or excellent English proficiency. There were no differences related to time since graduation.In the opinion of most participants, the application of EBP is necessary for speech-language practice (32.8% agree and 59.8% strongly agree) and considers it necessary to increase the use of scientific evidence in their daily practice (42.6% agree and 36.1% strongly agree). However, most disagree or have doubts that such a practice will positively influence their financial return or that there is no strong scientific evidence for the interventions used .The inferential analysis indicated differences according to English proficiency for the item \u201cthe incorporation of EBP places too much responsibility on the speech-language pathologist\u201d (p=0.009). This difference suggests that SLPs with poor English proficiency believe that EBP burdens the professional more frequently than SLPs with greater English proficiency. The time since graduation had a difference for the item \u201cstrong scientific evidence is lacking for most of the interventions I use in patients\u201d (p=0.046). In this case, the difference suggests that SLPs who have been trained for at least 10 years agree more often about the lack of evidence than their peers who have been trained for less time.The time available is insufficient for the execution of the EBP\u201d (23.0% agree and 4.9% strongly agree). However, most agree with the items \u201cThere is a lack of articles that make it possible to generalize the findings of the scientific literature to my patient population\u201d (41.0% agree and 14.8% strongly agree), \u201cThere is difficulty in applying the results of scientific research to patients with unique characteristics\u201d (43.4% agree and 13.1% strongly agree) and \u201cThere is a lack of collective support among my co-workers for the implementation of EBP\u201d (37.7% agree and 10.7% strongly agree), as shown in Regarding barriers, the minority of participants indicated agreement with the item \u201cThe time available is insufficient for the execution of the EBP\u201d (p=0.036). This difference suggests that the management of time to perform EBP is considered a major barrier for SLPs that have graduated for less than nine years. There were no differences related to English proficiency.The inferential analysis indicated differences according to the time since graduation only in the item \u201cThis study sought to characterize the knowledge, skills, opinions, and main barriers related to EBP of Brazilians SLPs in child language..The first aspect considered relates to continuing education. SLPs have shown to recognize the importance of reading articles and participating in events for scientific updating. By itself, the habit of reading scientific articles indicates a positive attitude towards the pillar of the search for external evidence. However, while more than half of the participants claim to read scientific articles frequently, only a third of SLPs have training in search strategies. This discrepancy may influence the choice of databases used, indicating that there is an ease in performing searches in more commonly disseminated databases and with a greater presence of material in Portuguese, such as Scielo and even Google Scholar. Added to this, the trend of using studies available in full text and virtually, enables the search in more popular journals, a scenario known as FUTON bias (Full Text On the Net),5.Knowledge about the basis of EBP does not seem to be part of the academic training of all SLPs. The more recently graduated professionals were less sure about having learned this topic and those with lower English proficiency had less knowledge about EBP. This finding warns the need to reconsider its approach both in undergraduate and graduate studies, since insufficient exposure to EBP decreases the frequency of use of studies for clinical decision-making,2,15.The aspects with the lowest agreement rate are related to how EBP deals with the professional's limitations and the client's preferences. These aspects make up the EBP triad and should be considered at the time of clinical decision-makingWith regard to skills, most participants indicated using EBP, having an interest in learning or improving their skills, and recognizing the benefits of EBP for decision-making and intervention quality. However, regarding formal training in critical evaluation of scientific articles and interpretation of statistical analysis, most SLPs disagreed or were neutral to the statement.,2,15. If we also consider that difficulties in mastering English accentuate the impairment of these skills, we may wonder if even when looking for evidence, these SLPs would not be restricting themselves to national articles. If one of the principles of EBP suggests basing it on the best available scientific evidence, it is to be expected that articles published in journals with greater impact should be studied. Without any demerit to national journals, it is necessary to consider that intervention studies are costly and that few are conducted in Brazil, due to the difficulties of investment in the area.This difficulty may impair the applicability of the results found in scientific articles to clinical practice, since the critical analysis of the professional is necessary.Here it is interesting to point out that in the opinion of the majority there is a lack of strong evidence for the interventions used. However, we note that access to databases such as Cochrane, the ASHA evidence map and SpeechBite is underreported. This factor can be explained both by their lack of knowledge and by the difficulty in accessing and interpreting results in English. It is worth noting, however, that in the context of language, studies that consider the particularities of language are also essential. Therefore, such a finding strengthens that a potentially important barrier to the adoption of evidence is its availability in multiple languages,13, suggesting that the profile identified in our study is similar to other health professions in Brazil. On the other hand, it is necessary to consider that child language still lacks studies with scientific evidence for intervention. This alerts us that for the advancement of EBP in the area, researchers' efforts are also necessary, in order to develop and publish studies aimed at clinical practice in childhood.Regarding the barriers, the scarcity of literature and the difficulty of applying its results in clinical practice are pointed out. Such a pattern is similar to Physical Therapy,11. Considering that there is little quality evidence available to support decision-making, it would be beneficial to have spaces for dialogue and exchange among SLPs. This practice could even be implemented from graduation.In addition, the lack of collective support in the workplace is similarly pointed out as a barrier. This finding indicates that the scenario in which the professional is working may be the source of the perceived barriers and limitations to the successful implementation of EBP,11-13. This finding may be associated with the fragility of knowledge about EBP of the professionals surveyed. As pointed out, it is possible that most are still experiencing difficulties in finding scientific evidence, analyzing it critically and considering how to incorporate it into their practice.This study differs from the literature by not pointing out time as the main barrier to the implementation of EBP,5,7.In summary, in the opinion of most of the SLPs surveyed, EBP is necessary for speech-language pathology practice and the use of scientific evidence in their daily practice should be greater. Although there are weaknesses in its knowledge and barriers to its implementation, the incorporation of the theme in academic training could strengthen the use of EBP pillars for clinical decision-makingAmong its limitations, the study was developed exclusively in a virtual environment, which may have contributed to the restriction in the number of responses. However, since there is no official record of SLPs working in the area, it was not possible to locate this audience in any other way. Another aspect that could be improved is the data collection instrument itself, since it would be interesting to include open questions that would allow a better understanding of the application of EBP by these professionals.However, it is worth noting that this study is a pioneer in Brazil in seeking to understand the relationship of SLPs working in child language with EBP. Its results make an important alert to university professors working in undergraduate and graduate studies, as well as indicate to SLPs an essential aspect for their professional improvement.Thus, this study alerts the academic community to the urgency of considering EBP in the context of Brazilian Speech-Language Pathology. Reducing the distance between training and clinical practice, favoring the use of quality evidence, should be a collective effort of clinicians, professors, and researchers in the area.Although most of the SLPs surveyed claim to have learned the basics of EBP in their academic training, use and have an interest in improving their skills, there are weaknesses in their knowledge and lack of mastery of search strategies and critical evaluation of scientific articles. Although most agree that EBP\u2019s use is necessary for speech-language pathology practice and consider the need to increase the use of scientific evidence in their daily practice, the lack of articles, difficulties related to the practical application of scientific results and lack of collective support among colleagues are identified as barriers. ,2.A pr\u00e1tica baseada em evid\u00eancias (PBE) equivale a um conjunto de crit\u00e9rios para avalia\u00e7\u00e3o da evid\u00eancia cient\u00edfica. O principal objetivo da PBE \u00e9 reduzir a incerteza do profissional no momento de uma decis\u00e3o cl\u00ednica. Ela associa tr\u00eas pilares: a experi\u00eancia cl\u00ednica do profissional; as prefer\u00eancias da fam\u00edlia e /ou do cliente; e as evid\u00eancias externas (informa\u00e7\u00f5es dispon\u00edveis na literatura) e internas . No entanto, ainda existem muitas barreiras que impedem sua implementa\u00e7\u00e3o efetiva, sobretudo na Fonoaudiologia-6. Em s\u00edntese, apesar de possu\u00edrem algum embasamento te\u00f3rico, os fonoaudi\u00f3logos que atuam com transtornos da linguagem em cen\u00e1rio internacional reconhecem o tempo insuficiente, a carga de trabalho extensa, a escassez de pesquisas na \u00e1rea, a qualidade das evid\u00eancias dispon\u00edveis e a falta de recursos no ambiente de trabalho como os principais obst\u00e1culos para execu\u00e7\u00e3o da PBE,5,7,8.A import\u00e2ncia da PBE vem sendo frequentemente discutida na comunidade m\u00e9dica e cient\u00edfica,10. Entretanto, \u00e9 fundamental pontuar que na atua\u00e7\u00e3o fonoaudiol\u00f3gica com os transtornos da linguagem estudos com os melhores n\u00edveis de evid\u00eancia ainda s\u00e3o escassos e h\u00e1 d\u00e9ficit no conhecimento dos profissionais referente aos processos de diagn\u00f3stico e interven\u00e7\u00e3o fonoaudiol\u00f3gica,11.As evid\u00eancias cient\u00edficas parecem n\u00e3o ser determinantes para a sele\u00e7\u00e3o de abordagens de interven\u00e7\u00e3o, principalmente na atua\u00e7\u00e3o com linguagem infantil. O fator mais considerado para a tomada de decis\u00e3o \u00e9 a experi\u00eancia cl\u00ednica do fonoaudi\u00f3logo. Por mais que a experi\u00eancia do profissional seja relevante, a efic\u00e1cia da PBE depende de sua associa\u00e7\u00e3o \u00e0s evid\u00eancias internas e \u00e0s prefer\u00eancias dos clientes,5,7,8. O treinamento formal acerca das bases da PBE na gradua\u00e7\u00e3o ou durante a forma\u00e7\u00e3o continuada aparece como um forte preditor para execu\u00e7\u00e3o de tal pr\u00e1tica durante sua atua\u00e7\u00e3o cl\u00ednica,6,12.Em contexto internacional, os fonoaudi\u00f3logos que atuam com linguagem, de maneira geral, possuem atitudes positivas e favor\u00e1veis \u00e0 execu\u00e7\u00e3o da PBE, embora ainda existam barreirasNo entanto, em contexto nacional h\u00e1 aus\u00eancia de estudos que investiguem tal cen\u00e1rio. Portanto, o objetivo do estudo foi caracterizar o conhecimento, habilidades, opini\u00f5es e principais barreiras percebidas por fonoaudi\u00f3logos, da \u00e1rea de linguagem infantil no Brasil, a respeito da pr\u00e1tica baseada em evid\u00eancias.Este estudo est\u00e1 vinculado a um projeto mais amplo que busca investigar como fonoaudi\u00f3logos brasileiros atuam no diagn\u00f3stico e interven\u00e7\u00e3o em linguagem infantil. O projeto foi aprovado pelo Comit\u00ea de \u00c9tica em Pesquisa (parecer n\u00ba 4.878.557). O termo de consentimento livre esclarecido foi apresentado antes do question\u00e1rio e a participa\u00e7\u00e3o ocorreu de forma volunt\u00e1ria e an\u00f4nima. Os participantes foram informados sobre os objetivos do projeto, o tempo estimado para resposta e a forma de contato com as pesquisadoras em caso de d\u00favidas. As orienta\u00e7\u00f5es da Comiss\u00e3o Nacional de \u00c9tica em Pesquisa (CONEP) para procedimentos em pesquisas em ambiente virtual, publicadas em fevereiro de 2021, foram seguidas visando preservar a prote\u00e7\u00e3o, seguran\u00e7a e os direitos dos participantes.,13. O question\u00e1rio foi composto por 22 itens subdivididos nas categorias \u201cconhecimento\u201d, \u201chabilidades\u201d, \u201copini\u00e3o\u201d e \u201cbarreiras\u201d. Em cada item era preciso especificar o n\u00edvel de concord\u00e2ncia por meio de uma escala Likert com cinco op\u00e7\u00f5es de resposta . O question\u00e1rio foi precedido por quest\u00f5es relacionadas a aspectos sociodemogr\u00e1ficos e do campo de trabalho.A primeira etapa do estudo consistiu na elabora\u00e7\u00e3o de um question\u00e1rio sobre pr\u00e1tica baseada em evid\u00eancias a partir de instrumentos utilizados pela FisioterapiaGoogle Forms. Antes do in\u00edcio da coleta de dados, solicitamos a cinco estudantes de gradua\u00e7\u00e3o que preenchessem o question\u00e1rio em busca de erros ou inconsist\u00eancias, visando o aprimoramento da aplicabilidade do instrumento.O question\u00e1rio foi disponibilizado em um formul\u00e1rio aberto na plataforma O contato com os participantes em potencial ocorreu por m\u00eddias sociais. O estudo foi divulgado por e-mail no boletim informativo de pesquisas aos associados da Sociedade Brasileira de Fonoaudiologia (SBFa), por men\u00e7\u00e3o no Instagram de influenciadores digitais e por um an\u00fancio patrocinado no Instagram cujo p\u00fablico-alvo eram os fonoaudi\u00f3logos com interesse em linguagem infantil. Devido \u00e0 recente implementa\u00e7\u00e3o da lei geral de prote\u00e7\u00e3o de dados, o Conselho Federal e os Regionais de Fonoaudiologia informaram ser invi\u00e1vel divulgar o estudo por e-mail aos profissionais ativos.O acesso ao question\u00e1rio foi disponibilizado por um link encurtado. Todas as quest\u00f5es eram obrigat\u00f3rias e a ordem de apresenta\u00e7\u00e3o foi padronizada. O question\u00e1rio foi distribu\u00eddo em oito p\u00e1ginas, cada uma com cerca de cinco quest\u00f5es de m\u00faltipla escolha. Ao submeter o question\u00e1rio n\u00e3o era mais poss\u00edvel realizar altera\u00e7\u00f5es e uma c\u00f3pia das respostas foi enviada ao participante. As respostas foram armazenadas automaticamente em planilha do Google.Google Forms n\u00e3o foi poss\u00edvel calcular as taxas de visualiza\u00e7\u00e3o do question\u00e1rio. Por\u00e9m, todos os question\u00e1rios submetidos indicaram concordar com o estudo e estavam completos. A priori, nenhuma medida foi adotada para prevenir duplicidade de respostas, entretanto o e-mail foi utilizado para eliminar essas ocorr\u00eancias antes da an\u00e1lise. Nessa amostra tivemos tr\u00eas formul\u00e1rios duplicados e optamos por manter a primeira submiss\u00e3o.Devido \u00e0s caracter\u00edsticas da plataforma Como crit\u00e9rio de inclus\u00e3o, os participantes deveriam ter gradua\u00e7\u00e3o em Fonoaudiologia e atuar com quadros de transtornos de linguagem na inf\u00e2ncia. De acordo com o Conselho Federal de Fonoaudiologia, em junho de 2021 havia 48.391 fonoaudi\u00f3logos no Brasil. Desses, 1155 possuem t\u00edtulo de especialista em Linguagem. Entretanto, nem todo profissional que atua com linguagem infantil possui t\u00edtulo de especialista e nem todo especialista atua com linguagem infantil. Assim, n\u00e3o foi poss\u00edvel ter uma estimativa precisa da popula\u00e7\u00e3o de interesse.O c\u00e1lculo amostral foi realizado no software GPower. Para um tamanho de efeito de 0,3 e um poder estat\u00edstico de 0,8, a amostra estimada seria de 167 participantes. Com intuito de alcan\u00e7ar essa amostra, a coleta de dados ocorreu entre agosto de 2021 e julho de 2022.Por fim, participaram deste estudo 122 fonoaudi\u00f3logos que declararam atuar clinicamente na \u00e1rea da linguagem infantil no Brasil. O grupo foi composto 96,7% por mulheres, com faixa et\u00e1ria predominante entre 41 e 50 anos , forma\u00e7\u00e3o universit\u00e1ria em institui\u00e7\u00e3o privada  e h\u00e1 menos de 5 anos , com especializa\u00e7\u00e3o na \u00e1rea , conforme GPower foi utilizado para calcular o tamanho do efeito e o poder estat\u00edstico.O tratamento estat\u00edstico dos dados foi realizado no software SPSS vers\u00e3o 24. Para a an\u00e1lise descritiva foi utilizada a distribui\u00e7\u00e3o de frequ\u00eancia. A an\u00e1lise inferencial foi realizada usando o teste qui-quadrado considerando para o tempo de forma\u00e7\u00e3o duas categorias (formado at\u00e9 9 anos e formado a partir de 10 anos) e para o dom\u00ednio do ingl\u00eas tr\u00eas categorias . O n\u00edvel de signific\u00e2ncia adotado foi de 5%. Al\u00e9m do c\u00e1lculo amostral, o software Os participantes demonstraram preocupa\u00e7\u00e3o com a forma\u00e7\u00e3o continuada, pois 82% afirmam ter participado de congressos cient\u00edficos, cursos ou atualiza\u00e7\u00f5es na \u00e1rea . Al\u00e9m disso, 63,1% afirmam ter o h\u00e1bito de ler artigos cient\u00edficos, sendo 20,5% muito frequentemente e 42,6% frequentemente. As bases de dados mais utilizadas para a busca dos artigos foram Scielo , PubMed  e Google acad\u00eamico . Nenhum participante indicou utilizar a base SpeechBite .A PBE n\u00e3o leva em conta as limita\u00e7\u00f5es da minha pr\u00e1tica cl\u00ednica\u201d  e \u201cA PBE n\u00e3o leva em conta as prefer\u00eancias do paciente\u201d , conforme Com rela\u00e7\u00e3o ao conhecimento, a maioria dos participantes indicou ter aprendido as bases da PBE durante a forma\u00e7\u00e3o acad\u00eamica  e considerar que ela melhora a qualidade do atendimento  e auxilia na tomada de decis\u00f5es sobre o tratamento . Por\u00e9m inconsist\u00eancias foram identificadas nos itens \u201cNa minha forma\u00e7\u00e3o acad\u00eamica aprendi as bases para a PBE\u201d. Com rela\u00e7\u00e3o ao dom\u00ednio do ingl\u00eas, a diferen\u00e7a sugere que fonoaudi\u00f3logos com dom\u00ednio pobre possuem menos conhecimento sobre PBE do que aqueles com dom\u00ednio moderado ou bom e excelente. Com rela\u00e7\u00e3o ao tempo de forma\u00e7\u00e3o, a diferen\u00e7a sugere que os fonoaudi\u00f3logos formados at\u00e9 9 anos estavam menos decididos sobre terem tido acesso a esse conte\u00fado do que seus pares formados h\u00e1 mais de 10 anos.A an\u00e1lise inferencial indicou diferen\u00e7as de acordo com o dom\u00ednio do ingl\u00eas  e tempo de forma\u00e7\u00e3o  apenas no item \u201cNo que se refere \u00e0s habilidades, a maioria dos participantes indicou utilizar a PBE  e ter interesse em aprender ou aprimorar suas habilidades . Por\u00e9m, quando se trata de treinamento formal em avalia\u00e7\u00e3o cr\u00edtica de artigos cient\u00edficos, a maioria discorda ou se mostra neutra .24,6% dos fonoaudi\u00f3logos indicam possuir treinamento em estrat\u00e9gias de busca de artigos cient\u00edficos, ao passo que 22,1% deles discordou de tal afirma\u00e7\u00e3o. Ademais, 31,1% se consideram capazes de compreender a an\u00e1lise estat\u00edstica dos artigos, mas outros 31,1% se mostraram indecisos sobre esse item, conforme A an\u00e1lise inferencial indicou diferen\u00e7as de acordo com o dom\u00ednio do ingl\u00eas para todos os itens, exceto o interesse em aprimorar ou aprender sobre PBE. A diferen\u00e7a sugere que os fonoaudi\u00f3logos com dom\u00ednio pobre do ingl\u00eas possuem menos habilidades do que seus pares com dom\u00ednio moderado, bom ou excelente. N\u00e3o houve diferen\u00e7as relacionadas ao tempo de forma\u00e7\u00e3o.Na opini\u00e3o da maioria dos participantes a aplica\u00e7\u00e3o da PBE \u00e9 necess\u00e1ria para a pr\u00e1tica fonoaudiol\u00f3gica  e considera preciso aumentar o uso de evid\u00eancias cient\u00edficas em sua pr\u00e1tica di\u00e1ria . No entanto, a maioria discorda ou tem d\u00favidas de que tal pr\u00e1tica ir\u00e1 influenciar positivamente em seu retorno financeiro ou que n\u00e3o haja evid\u00eancias cient\u00edficas fortes para as interven\u00e7\u00f5es que utiliza .A an\u00e1lise inferencial indicou diferen\u00e7as de acordo com o dom\u00ednio do ingl\u00eas para o item \u201cA incorpora\u00e7\u00e3o da PBE coloca uma responsabilidade demasiada sobre o fonoaudi\u00f3logo\u201d . Essa diferen\u00e7a sugere que fonoaudi\u00f3logos com pobre dom\u00ednio do ingl\u00eas acreditam que a PBE sobrecarrega o profissional com maior frequ\u00eancia do que fonoaudi\u00f3logos com maior dom\u00ednio do ingl\u00eas. O tempo de forma\u00e7\u00e3o teve diferen\u00e7a para o item \u201cEst\u00e3o faltando fortes evid\u00eancias cient\u00edficas para a maioria das interven\u00e7\u00f5es que eu uso nos pacientes\u201d . Nesse caso, a diferen\u00e7a sugere que os fonoaudi\u00f3logos formados h\u00e1 pelo menos 10 anos concordam com mais frequ\u00eancia sobre a falta de evid\u00eancias do que seus pares formados h\u00e1 menos tempo.O tempo dispon\u00edvel \u00e9 insuficiente para a execu\u00e7\u00e3o da PBE\u201d . Por\u00e9m, a maioria concorda com os itens \u201cH\u00e1 falta de artigos que possibilitem a generaliza\u00e7\u00e3o dos achados da literatura cient\u00edfica para a minha popula\u00e7\u00e3o de pacientes\u201d , \u201cH\u00e1 dificuldade na aplica\u00e7\u00e3o dos resultados da investiga\u00e7\u00e3o cient\u00edfica para pacientes com caracter\u00edsticas \u00fanicas\u201d  e \u201cH\u00e1 falta de apoio coletivo entre meus colegas de trabalho para a execu\u00e7\u00e3o da PBE\u201d , conforme Com rela\u00e7\u00e3o \u00e0s barreiras, a minoria dos participantes indicou concordar com o item \u201cO tempo dispon\u00edvel \u00e9 insuficiente para a execu\u00e7\u00e3o da PBE\u201d . Essa diferen\u00e7a sugere que o gerenciamento do tempo para execu\u00e7\u00e3o da PBE \u00e9 considerado uma barreira maior para os fonoaudi\u00f3logos formados h\u00e1 menos de nove anos. N\u00e3o houve diferen\u00e7as relacionadas ao dom\u00ednio do ingl\u00eas.A an\u00e1lise inferencial indicou diferen\u00e7as de acordo com o tempo de forma\u00e7\u00e3o apenas no item \u201cEste estudo buscou caracterizar o conhecimento, habilidades, opini\u00f5es e principais barreiras relacionadas \u00e0 PBE de fonoaudi\u00f3logos na \u00e1rea de linguagem infantil no Brasil..O primeiro aspecto considerado se relaciona \u00e0 forma\u00e7\u00e3o continuada. Os fonoaudi\u00f3logos demonstraram reconhecer a import\u00e2ncia de ler artigos e participar de eventos para atualiza\u00e7\u00e3o cient\u00edfica. Por si s\u00f3, o h\u00e1bito de leitura de artigos cient\u00edficos indica atitude positiva em rela\u00e7\u00e3o ao pilar da busca por evid\u00eancias externas. Por\u00e9m, enquanto mais da metade dos participantes afirma ler artigos cient\u00edficos com frequ\u00eancia, apenas um ter\u00e7o dos fonoaudi\u00f3logos possui treinamento em estrat\u00e9gias de busca. Tal discrep\u00e2ncia pode influenciar na escolha das bases de dados utilizadas, indicando que h\u00e1 uma facilidade em realizar buscas em bases mais comumente disseminadas e com maior presen\u00e7a de material em portugu\u00eas, como Scielo e at\u00e9 mesmo o Google Acad\u00eamico. Somado a isso, a tend\u00eancia da utiliza\u00e7\u00e3o de estudos disponibilizados na \u00edntegra e virtualmente, viabiliza a busca em peri\u00f3dicos mais populares, cen\u00e1rio conhecido como vi\u00e9s de FUTON (Full Text On the Net),5.O conhecimento sobre as bases da PBE parece n\u00e3o fazer parte da forma\u00e7\u00e3o acad\u00eamica de todos os fonoaudi\u00f3logos. Os profissionais formados mais recentemente tinham menos certeza sobre terem aprendido esse tema e aqueles com menor dom\u00ednio do ingl\u00eas possuem menos conhecimento sobre PBE. Tal achado alerta para a necessidade de se reconsiderar sua abordagem tanto na gradua\u00e7\u00e3o, quanto na p\u00f3s-gradua\u00e7\u00e3o, j\u00e1 que a exposi\u00e7\u00e3o insuficiente \u00e0 PBE diminui a frequ\u00eancia de uso de estudos para tomada de decis\u00e3o cl\u00ednica,2,15.Os aspectos com menor \u00edndice de concord\u00e2ncia se relacionam a como a PBE lida com as limita\u00e7\u00f5es do profissional e as prefer\u00eancias do cliente. Esses aspectos comp\u00f5em a tr\u00edade da PBE e devem ser considerados no momento de tomada de decis\u00e3o cl\u00ednicaNo que se refere \u00e0s habilidades, a maioria dos participantes indicou utilizar a PBE, ter interesse em aprender ou aprimorar suas habilidades, al\u00e9m de reconhecer os benef\u00edcios da PBE para a tomada de decis\u00f5es e qualidade da interven\u00e7\u00e3o. Por\u00e9m, com rela\u00e7\u00e3o ao treinamento formal em avalia\u00e7\u00e3o cr\u00edtica de artigos cient\u00edficos e interpreta\u00e7\u00e3o da an\u00e1lise estat\u00edstica, a maioria dos fonoaudi\u00f3logos discordou possuir ou se mostrou neutra \u00e0 afirma\u00e7\u00e3o.,2,15. Se considerarmos ainda que dificuldades no dom\u00ednio do ingl\u00eas acentuam o comprometimento dessas habilidades, podemos nos questionar se mesmo ao buscarem evid\u00eancias, esses fonoaudi\u00f3logos n\u00e3o estariam se restringindo a artigos nacionais. Se um dos princ\u00edpios da PBE sugere o embasamento nas melhores evid\u00eancias cient\u00edficas dispon\u00edveis, h\u00e1 de se esperar que artigos publicados em revistas com maior impacto devam ser estudados. Sem nenhum dem\u00e9rito aos peri\u00f3dicos nacionais, \u00e9 preciso considerar que estudos de interven\u00e7\u00e3o s\u00e3o onerosos e que poucos s\u00e3o conduzidos no Brasil, devido \u00e0s dificuldades de investimento na \u00e1rea.Essa dificuldade pode prejudicar a aplicabilidade dos resultados encontrados em artigos cient\u00edficos \u00e0 pr\u00e1tica cl\u00ednica, j\u00e1 que a an\u00e1lise cr\u00edtica do profissional \u00e9 necess\u00e1ria.Aqui \u00e9 interessante pontuar que na opini\u00e3o da maioria h\u00e1 falta de fortes evid\u00eancias para as interven\u00e7\u00f5es utilizadas. Todavia, notamos que o acesso a bases de dados como a Cochrane, o mapa de evid\u00eancias da ASHA e a SpeechBite \u00e9 pouco reportado. Esse fator pode tanto ser explicado por seu desconhecimento, quanto pela dificuldade em acessar e interpretar resultados em l\u00edngua inglesa. Vale destacar, por\u00e9m que no contexto da linguagem, estudos que considerem as particularidades da l\u00edngua tamb\u00e9m s\u00e3o essenciais. Portanto, tal achado fortalece que uma barreira potencialmente importante para a ado\u00e7\u00e3o de evid\u00eancias \u00e9 sua disponibilidade em v\u00e1rios idiomas,13, sugerindo que o perfil identificado em nosso estudo seja similar ao de outras profiss\u00f5es da sa\u00fade no Brasil. Por outro lado, \u00e9 necess\u00e1rio considerar que a \u00e1rea de linguagem infantil ainda carece de estudos com evid\u00eancias cient\u00edficas para interven\u00e7\u00e3o. O que nos alerta que para o avan\u00e7o da PBE na \u00e1rea s\u00e3o necess\u00e1rios esfor\u00e7os tamb\u00e9m dos pesquisadores, no sentido de desenvolver e publicar estudos voltados para a pr\u00e1tica cl\u00ednica na inf\u00e2ncia.Com rela\u00e7\u00e3o \u00e0s barreiras, a escassez de literatura e a dificuldade de aplicar seus resultados na pr\u00e1tica cl\u00ednica s\u00e3o apontadas. Tal padr\u00e3o \u00e9 semelhante ao de fisioterapeutas,11. Ao considerar que h\u00e1 poucas evid\u00eancias de qualidade dispon\u00edveis para embasar a tomada de decis\u00e3o, seria ben\u00e9fico haver espa\u00e7os de di\u00e1logo e troca entre os fonoaudi\u00f3logos. Essa pr\u00e1tica inclusive poderia ser implementada desde a gradua\u00e7\u00e3o.Al\u00e9m disso, a falta de apoio coletivo no ambiente de trabalho \u00e9 similarmente apontada como uma barreira. Esse achado indica que o cen\u00e1rio em que o profissional est\u00e1 atuando pode ser fonte das barreiras e limita\u00e7\u00f5es percebidas para o sucesso da implementa\u00e7\u00e3o da PBE,11-13. Esse achado pode estar associado \u00e0 fragilidade dos conhecimentos sobre PBE dos profissionais inquiridos. Como apontado, \u00e9 poss\u00edvel que a maioria ainda esteja enfrentando dificuldades para encontrar evid\u00eancias cient\u00edficas, analis\u00e1-las de forma cr\u00edtica e considerar como incorpor\u00e1-las em sua pr\u00e1tica.Este estudo destoa da literatura ao n\u00e3o apontar o tempo como a principal barreira para implementa\u00e7\u00e3o da PBE,5,7.Em s\u00edntese, na opini\u00e3o da maioria dos fonoaudi\u00f3logos inquiridos, a PBE \u00e9 necess\u00e1ria para a pr\u00e1tica fonoaudiol\u00f3gica e o uso de evid\u00eancias cient\u00edficas em sua pr\u00e1tica di\u00e1ria deveria ser maior. Por mais que haja fragilidades em seu conhecimento e barreiras para sua implementa\u00e7\u00e3o, a incorpora\u00e7\u00e3o do tema na forma\u00e7\u00e3o acad\u00eamica poderia fortalecer o uso dos pilares da PBE para tomada de decis\u00e3o cl\u00ednicaDentre suas limita\u00e7\u00f5es, o estudo foi desenvolvido exclusivamente em meio virtual, o que pode ter contribu\u00eddo para a restri\u00e7\u00e3o no n\u00famero de respostas. Por\u00e9m, uma vez que n\u00e3o h\u00e1 um registro oficial dos fonoaudi\u00f3logos que atuam na \u00e1rea n\u00e3o foi poss\u00edvel localizar esse p\u00fablico de outra maneira. Outro aspecto que poderia ser aprimorado \u00e9 o pr\u00f3prio instrumento de coleta de dados, visto que seria interessante incluir quest\u00f5es abertas que permitissem ter uma melhor compreens\u00e3o da aplica\u00e7\u00e3o da PBE por esses profissionais.Entretanto, vale destacar que este estudo \u00e9 pioneiro no Brasil ao buscar compreender a rela\u00e7\u00e3o de fonoaudi\u00f3logos que atuam na \u00e1rea de linguagem infantil com a PBE. Seus resultados fazem um importante alerta aos docentes atuantes na gradua\u00e7\u00e3o e na p\u00f3s-gradua\u00e7\u00e3o, bem como indicam aos fonoaudi\u00f3logos um aspecto essencial para seu aprimoramento profissional.Assim, este estudo alerta a comunidade acad\u00eamica para a urg\u00eancia de se considerar a PBE no contexto da Fonoaudiologia brasileira. Reduzir a dist\u00e2ncia entre a forma\u00e7\u00e3o e a pr\u00e1tica cl\u00ednica, favorecendo o uso de evid\u00eancias de qualidade, deve ser um esfor\u00e7o coletivo de cl\u00ednicos, docentes e pesquisadores da \u00e1rea.Embora a maioria dos fonoaudi\u00f3logos inquiridos afirme ter aprendido as bases da PBE em sua forma\u00e7\u00e3o acad\u00eamica, utilizar e ter interesse em aprimorar suas habilidades, h\u00e1 fragilidades em seu conhecimento e falta de dom\u00ednio das estrat\u00e9gias de busca e avalia\u00e7\u00e3o cr\u00edtica dos artigos cient\u00edficos. Ainda que a maioria concorde que a aplica\u00e7\u00e3o da PBE \u00e9 necess\u00e1ria para a pr\u00e1tica fonoaudiol\u00f3gica e considere precisar aumentar o uso de evid\u00eancias cient\u00edficas em sua pr\u00e1tica di\u00e1ria, s\u00e3o apontadas como barreiras a falta de artigos, dificuldades relacionadas \u00e0 aplica\u00e7\u00e3o pr\u00e1tica de resultados cient\u00edficos e falta de apoio coletivo entre os colegas."}
+{"text": "To estimate the proportions of awareness, treatment, and control of diabetes mellitus (DM) in the Brazilian adult population.This is a cross-sectional study, with data from a representative sample of the Brazilian population, taken from the National Health Survey(PNS 2014/2015). Outcomes were defined based on glycated hemoglobin (HbA1c) measurements, self-reported DM diagnosis, and use of hypoglycemic agents or insulin. The proportion of DM awareness, treatment, and control was estimated according to sociodemographic characteristics, health conditions, and access to health services, and their respective 95% confidence intervals.Bolsa Fam\u00edliaprogram.DM prevalence in the Brazilian population was of 8.6% (95%CI: 7.8\u20139.3): 68.2% (95%CI: 63.9\u201372.3) were aware of their diagnosis, 92.2% (95%CI: 88.6\u201394.7) of those who were aware were undergoing drug treatments, and, of these, 35.8% (95%CI: 30.5\u201341.6) had controlled HbA1c levels. The proportions of DM awareness, control, and treatment were lower in men aged 18 to 39 years, individuals with low education, without health insurance, and beneficiaries of theApproximately one in ten Brazilians has DM. A little more than half of this population is aware of their diagnosis, a condition measured by HbA1c dosage and clinical diagnosis. Among those who know, the vast majority are undergoing drug treatments. However, less than half of these have their HbA1c levels controlled. Worse scenarios were found in subgroups with high social vulnerability. Approximately 50% of DM cases do not receive timely diagnosis  , and about 90% of cases are type 2  . A study conducted with glycated hemoglobin (HbA1c) data obtained from the National Health Survey (PNS) showed a 6.6% prevalence of DM (HbA1c \u2265 6.5%) in the Brazilian population  . Additionally, self-reported DM increased from 6.2% in 2013 to 7.7% in 2019  . In 2021, theRelat\u00f3rio de Vigil\u00e2ncia de Fatores de Risco e Prote\u00e7\u00e3o para Doen\u00e7as Cr\u00f4nicas por Inqu\u00e9rito Telef\u00f4nico(Surveillance System for Risk and Protective Factors for Chronic Diseases by Telephone Survey \u2013 Vigitel) presented a 9.1% prevalence of self-reported DM in the Brazilian adult population  . Therefore, estimates of the magnitude of DM in the Brazilian population in general  , and in specific groups, such as men, black and mixed people, people with average or complete educational levels, and obese people, are well defined  .Diabetes mellitus (DM) is one of the major public health problems of the twenty-first century. The number of people with DM in the world is estimated at 537 million in 2021, with a projection of 643 million for 2030 and 783 million for 2045  . The same study also showed that the treatment of this disease in patients ranged from 52.6% to 99%. The prevalence of DM control (HbA1c levels < 7%) ranged from 3.5% to 7.5%  . However, some studies performed this verification by means of fasting glycemia or casual glycemia and showed a 31.4% to 61.4% variation  . Specifically in Brazil, a study conducted in the 1990s  , and, more recently, theEstudo Longitudinal de Sa\u00fade do Adulto(ELSA)  identified about 50% of ignorance of the diagnosis.Population studies in Latin America showed that the lack of knowledge on the DM diagnosis ranged from 10.3% to 50%, being higher in Guatemala (48.8%), Uruguay (48.7%), and Nicaragua (43.3%), and lower in Colombia (23.5%), South American meridian countries (20.2%), and Costa Rica (10.3\u201328.4%)  . Thus, it is possible to highlight the need to estimate disease control parameters in population subgroups, such as the ability to detect/know the diagnosis, treatment, and control, in addition to its prevalence, as has been discussed internationally  .DM control on a populational level requires an articulation of actions directed to the prevention, detection, and control of the pathology, including a partnership between civil society and government agencies  . A study developed in Latin America\u2019s private health services, including the Brazilian health service, showed that blood glucose levels are less controlled in patients with type 2 DM (DM2)  .Inadequate DM control can lead to several complications, such as blindness, chronic kidney disease, and high risk of cardiovascular diseases, and all these outcomes contribute to the increase of health service costs. DM is a manageable disease in primary health care (PHC) services, since public health systems have effective strategies for its early detection, treatment, and control. In Brazil, a study with a regional sample showed worse levels of glycemic control in patients treated by the public health service The reliable assessment of the magnitude and treatment of population DM is only possible with representative studies of the Brazilian population and diagnostic techniques of high sensitivity and specificity. Despite the specific data on DM treatment and control in Brazil, the evaluation of these parameters in the population needs to advance. Thus, the aim of this study is to estimate the proportions of awareness, treatment, and control in a representative sample of the Brazilian adult population.Pesquisa Nacional de Sa\u00fade\u2013 PNS) was conducted in 2013 and extended until 2015 for the collection of biological material. Details about the sampling methodology of the PNS are presented in previous publications  . This is a survey with cluster sampling in three stages: the census tracts correspond to a fixed number of private households, and for each household a participant aged 18 years or older is randomly selected. The total number of households visited was 81,167. Of these, 69,994 contained residents. At the end, 64,384 home interviews and 60,202 individual interviews were conducted.The National Health Survey  of a sample stored in a tube containing ethylenediaminetetraacetic acid (EDTA). It is worth mentioning that the full described step was performed by laboratories certified by the National Glycohemoglobin Standardization Program  .Blood material (7 ml) was collected at any time of the day, without fasting 2  and self-perceived health .The sociodemographic variables used were: sex ; age group ; race/skin color ; schooling ; region of residence ; private health plan ; receipt ofThe prevalence of DM was calculated according to the diagnostic criteria defined in this study. Next, estimates of the proportion of other outcomes of interest  and their respective 95% confidence intervals were calculated. These proportions were also estimated according to sociodemographic characteristics, and Pearson\u2019s chi-square test was used to analyze the differences in the proportions of outcomes between the groups. All estimates were calculated in the Stata 14.0 software survey module.This study used a secondary, publicly available, and free of charge database, respecting the participants\u2019 confidentiality, not requiring prior approval by the Ethics and Research Committee. The PNS was approved by the National Research Ethics Commission, under CAAE No. 10853812.7.0000.0008, and complies with all ethical precepts, in accordance with the recommendations for research with human beings of Resolution No. 466/12.Bolsa Fam\u00edliaprogram (90.6%), with excellent self-perceived health (64.9%), and mainly from the Southeast region (44.3%) (The adult population was composed mostly of women (52.1%), of the white race/skin color (47.8%), with low schooling (49.3%), without health insurance (70.3%), non-beneficiaries of the(44.3%) . DM preWe estimated that 68.2% (95%CI: 63.9\u201372.3) of people with diabetes were aware of their diagnosis and, of these, 92.2% (95%CI: 88.6\u201394.7) were on medication treatments. We estimated that 35.9% (95%CI: 30.5\u201341.6) of people had HbA1c levels considered normal (< 6.5%) and 48.1% (95%CI: 42.2\u201353.9) had HbA1c levels below 7%, that is, with normalized or controlled glucose homeostasis, among those who received some type of pharmacological treatment .Bolsa Fam\u00edlia, 51.8% (95%CI: 44.0\u201356.0) among those with good/excellent self-perceived health, and 51.5% (95%CI: 42.9\u201360.0) in residents of the North region of the country (The proportion of DM awareness was of 41.7% (95%CI: 25.6\u201360.0) in 18 to 39 years age group, 65.7% (95%CI: 60.6\u201370.5) among participants without health insurance, 47.5% (95%CI: 31.6\u201364.0) in the group which receivedcountry . The saIn this study, we estimate that approximately one in ten Brazilians has a diabetes diagnosis and, of these, 68.2% are aware of their diagnosis. In addition, most diabetics are undergoing drug treatment, and less than half of these have their HbA1c levels below 6.5%, that is, controlled. When considering more flexible glycemic control goals,we observed that 48.1% of the adult population has HbA1c < 7%, and 65.7% of older adults have HbA1c < 7.5%.Bolsa Fam\u00edliaprogram.The highest DM prevalence was in the group over 60 years of age, who declared themselves to be of the yellow/indigenous race/skin color, with low schooling, with poor self-perceived health, and in Brazil\u2019s Midwest and Southeast populations. The proportions of DM awareness, control, and treatment were lower in men aged 18 to 39 years, individuals with low education, without health insurance, and beneficiaries of theolsa Fam\u00edliaprogram, and residents of the northern region of the country, as another study already observed  .The high proportions of participants who are unaware of their diagnosis are, in this study, concentrated in groups of low socioeconomic levels, participants of the B .An additional aspect, which was shown in a recent study, is that populations with few socioeconomic resources also have high rates of smoking, overweight and obesity prevalence, low consumption of fruits and vegetables, and high consumption of sugar-sweetened beverages, and, in women, low access to cervical and breast cancer screening programs  , should be reissued. However, strategies for the use of light care, low cost and wide accessibility technology for the Brazilian population may be necessary.Strategies, such as the National Campaign for DM Detection, which reached more than 20 million Unified Health System (SUS) users aged over 40 years  . A low-cost, non-invasive, and easy-to-apply alternative would be the use of the Finnish Diabetes Risk Score (FINDRISC), which measures the risk of DM2 development in adults. This strategy has had its validity demonstrated at a national level  .The Brazilian population is certainly not far from global prevalence estimates. A recent study shows that approximately 50% of adult diabetics are not aware of their diagnosis, and that, of these, 84.3% are living in developing countries Bolsa Fam\u00edliaprogram groups. These findings reinforce the link between social vulnerability and low access to effective disease control, corroborating findings of other studies  .Low prevalence of controlled diabetes, measured by glycated hemoglobin levels (< 6.5%), was present in the low schooling and beneficiaries of the , which can be justified by the lower severity of the pathology, and it is also possible to favor management through non-pharmacological measures, such as encouraging physical activity and healthy eating. In addition, type 1 DM (DM1), not identified in this study, may present lower glycemic control, due to the severity of the disease, as well as its resistance to medication use  .Estimates using data from the PNS 2019 showed that younger people had lower medication consumption  . Lower hospitalization due to DM or complications were identified among women, which may mean better disease control among them, which coincides with our findings  .We were also able to identify a higher frequency of hospitalization in young people aged 18 to 29 years, which is understandable given the higher prevalence of DM1 in young adults, the acute symptoms of the disease and the non-adaptation to new care and lower adherence to caregiver practices Farm\u00e1cia Popular) and Health Has No Price (Sa\u00fade N\u00e3o Tem Pre\u00e7o) programs, which allow free access to these drugs in Basic Health Units and pharmacies accredited to the programs. The surveillance systems also showed that 70.3% of people diagnosed with DM obtained free oral medicines through the SUS pharmacy or the Popular Pharmacy (Farm\u00e1cia Popular) program, and that 90% had free access to insulin  . Notably, the National Survey on Access, Use and Promotion of the Rational Use of Medicines , a population-based household survey, showed that 21.4% of participants paid for diabetes medication, and 78.6% got it for free  . Still confirming these conclusions, 57.4% of the PNS 2013 participants reported obtaining drugs for diabetes via theFarm\u00e1cia Popularprogram  . In this study, we do not have information to clarify whether the prevalence of participants without treatment is related to the choice of medications or to access difficulties  .The high proportion of people with diabetes in treatment estimated in this study refers to the public policies implemented to improve access to medication, through the Popular Pharmacy   , and Myanmar (40.8%)  . Previous studies estimated a prevalence of 26% and 78% of glycemic level control in a population attended by public health services and in a population attended by private services, respectively, but these are local studies without national representation, which makes it difficult to compare them to our study  .The maintenance of glucose levels within the normal range is essential for coping with DM. In this study, the prevalence of control was low, not far from findings in other populations, such as those of Iranian Kurdistan (18.30%)  . It is noteworthy that the complexity inherent to drug therapies contributes to increase medication error risks and requires the user to have the skills to comply with the care provided by health professionals  . The challenge of drug therapy was accompanied by the quantity of drugs in use, resulting from patients with high complexity, who used polypharmacy  . The patient\u2019s empowerment in the self-care process, health education, especially in relation to medication schedule information, and the correct use of drugs in accordance with the medical prescription, are necessary strategies to achieve disease control  .Failures in glycemic control may contribute to increase risks of cardiovascular diseases, nephropathies, neuropathies, retinopathies, and hospitalizations  . Studies show that there is no link between patients with DM and the actions of health professionals, corroborating for the discontinuity of treatment adherence and directly impacting its control  .Glycemic control is essential to decrease the risk of DM complications and cardiovascular diseases. Other important factors are the lipid profile monitoring and the appropriate treatment to achieve glycemic control. DM management in primary care follows a strategy of healthy lifestyle habit encouragement. However, in practice, the program is mostly focused on medicine supply. This work process hinders the achievement of objectives such as the recognition and dimensioning of health problems, both individually and collectively, which help more effectively in health actions/interventions, as shown in a study developed in the city of S\u00e3o Paulo  . In this perspective, the strategies that contribute to the patient\u2019s empowerment can help in the process of developing the adoption of new attitudes and skills, which will promote changes in habits/lifestyle and, consequently, in self-care. Clinical trials using education strategies through telephone interventions, training programs and home visits, have shown that these interventions contribute positively to an improvement of HbA1c levels results, to empowerment and self-care  . Home visits by community health agents (CHA) contribute to controlling and supervising treatment and improving adherence to self-care practices related to DM2  .The low DM control results identified in this study can be explained by the complexity of the management of the disease, which includes the monitoring of glycemic values, adherence to treatment and the inclusion of regular physical activity and diet changes  , called Prevent Brazil (Previne Brasil), because it only strengthens biomedical strategies, which could lead to delays in DM detection and worsen and decrease control prevalence. In addition, it is worth pointing out that the effects generated by the covid-19 pandemic may, in the short term, affect the performance of care provided to chronic diseases, worsening control and detection levels of the disease  .Notably, the magnitude of harm shown may worsen as a result of the new PHC financing model in SUS A limitation of this study is the lack of data regarding the medication used, its time of use, and the adherence to treatment, which was limited to recording only the use of antidiabetic drugs and/or insulin injections. Non-pharmacological measures are also necessary for glycemic control, and they were not evaluated in this study. These data would allow a better understanding of the low performance of glycemic level control found in the Brazilian population, despite the wide access to medication and treatment. However, the use of population-based data and national representativeness constitutes adequate external validity.We highlight that the measurement of HbA1c levels collected from venous and non-capillary blood was used, which is considered the gold standard for detecting the disease. The lack of consensus to define the cutoff point of HbA1c in disease control hinders the process of evaluation and monitoring of DM. Therefore, this study chose to work with two cutoff points.Another limitation is the non-distinction between the DM types (DM1 or DM2). This is an unprecedented population study that uses laboratory data with representativeness of the Brazilian population to estimate DM awareness, treatment, and control, which are fundamental aspects to help public health programs cope with the disease.Bolsa Fam\u00edliaprogram, presented worse performance regarding awareness of the disease. The data from this study may contribute to strengthen public policies that aim to promote healthy lifestyles. The implementation of innovative strategies to assist in DM control is fundamental to face the disease burden attributed to DM in Brazil.The proportion of DM awareness in the Brazilian population was estimated at 68%, and of these, 92% were undergoing drug treatment. Adequate control was estimated at 36%, considering the strictest criterion (HbA1c < 6.5%). Some population subgroups, such as those who do not have health insurance, those who reported having poor self-perceived health, and beneficiaries of the . Aproximadamente 50% dos casos de DM n\u00e3o recebem diagn\u00f3stico oportuno, e cerca de 90% dos casos desta doen\u00e7a s\u00e3o do tipo 2. Estudo realizado com dados da hemoglobina glicada (HbA1c), obtidos da Pesquisa Nacional de Sa\u00fade (PNS), mostrou uma preval\u00eancia de 6,6% de DM  na popula\u00e7\u00e3o brasileira. Adicionalmente, o DM autorreferido teve um aumento de 6,2%, em 2013, para 7,7% em 2019. O Relat\u00f3rio de Vigil\u00e2ncia de Fatores de Risco e Prote\u00e7\u00e3o para Doen\u00e7as Cr\u00f4nicas por Inqu\u00e9rito Telef\u00f4nico (Vigitel) apresentou, em 2021, uma preval\u00eancia de DM autorreferido de 9,1% na popula\u00e7\u00e3o adulta brasileira. Portanto, estimativas da magnitude do DM na popula\u00e7\u00e3o brasileira em geral, e em grupos espec\u00edficos, tais como homens, pretos e pardos, com n\u00edvel de escolaridade m\u00e9dio ou completo e obesos, est\u00e3o bem delimitadas.O diabetes mellitus (DM) constitui-se um dos maiores problemas de sa\u00fade p\u00fablica do s\u00e9culo XXI. Estima-se que o n\u00famero de pessoas com DM no mundo era de 537 milh\u00f5es em 2021, com proje\u00e7\u00e3o para 643 milh\u00f5es em 2030 e 783 milh\u00f5es em 2045. Nesse mesmo estudo tamb\u00e9m foi mostrado que o tratamento dessa doen\u00e7a nos pacientes variou de 52,6% a 99%. A preval\u00eancia do controle de DM (n\u00edveis de HbA1c < 7%) variou de 3,5% a 7,5%. Por\u00e9m, alguns estudos realizaram essa verifica\u00e7\u00e3o por meio da glicemia de jejum ou pela glicemia casual, e mostraram varia\u00e7\u00e3o de 31,4% a 61,4%. Especificamente no Brasil, um estudo realizado na d\u00e9cada de 1990, e, mais recentemente, o estudo Estudo Longitudinal de Sa\u00fade do Adulto (ELSA), identificaram cerca de 50% de desconhecimento do diagn\u00f3stico.Estudos populacionais na Am\u00e9rica Latina mostraram que a aus\u00eancia de conhecimento do diagn\u00f3stico de DM variou de 10,3% a 50%, sendo maior na Guatemala , Uruguai  e Nicar\u00e1gua , e menor na Col\u00f4mbia , pa\u00edses do meridiano da Am\u00e9rica do Sul  e na Costa Rica . Assim, destaca-se a necessidade de, al\u00e9m da sua preval\u00eancia, estimar par\u00e2metros do controle da doen\u00e7a em subgrupos populacionais, tais como a capacidade de detec\u00e7\u00e3o/conhecimento do diagn\u00f3stico, tratamento e controle, como vem sendo discutido em \u00e2mbito internacional.O controle do DM em n\u00edvel populacional exige uma articula\u00e7\u00e3o de a\u00e7\u00f5es direcionadas para preven\u00e7\u00e3o, detec\u00e7\u00e3o e controle da patologia, incluindo parceria da sociedade civil com \u00f3rg\u00e3os governamentais. Estudo desenvolvido em servi\u00e7o privado de sa\u00fade da Am\u00e9rica Latina, incluindo o Brasil, evidenciou que os n\u00edveis de glicemia est\u00e3o subcontrolados em pacientes com DM tipo 2 (DM2).O controle inadequado do DM pode levar a diversas complica\u00e7\u00f5es, como cegueira, doen\u00e7a renal cr\u00f4nica e alto risco de doen\u00e7as cardiovasculares, e todos esses desfechos contribuem com o alto custo para os servi\u00e7os de sa\u00fade. O DM \u00e9 uma doen\u00e7a pass\u00edvel de manejo nos servi\u00e7os de aten\u00e7\u00e3o prim\u00e1ria \u00e0 sa\u00fade (APS), uma vez que os sistemas p\u00fablicos de sa\u00fade t\u00eam estrat\u00e9gias eficazes para sua detec\u00e7\u00e3o precoce, tratamento e controle. No Brasil, um estudo com amostra regional mostrou n\u00edveis piores de controle glic\u00eamico de pacientes tratados no servi\u00e7o p\u00fablico de sa\u00fadeA avalia\u00e7\u00e3o confi\u00e1vel da magnitude e do tratamento do DM populacional s\u00f3 \u00e9 poss\u00edvel com estudos representativos da popula\u00e7\u00e3o brasileira e t\u00e9cnicas de diagn\u00f3stico de alta sensibilidade e especificidade. Embora existam alguns dados espec\u00edficos sobre o tratamento e controle da DM no Brasil, \u00e9 preciso avan\u00e7ar na avalia\u00e7\u00e3o desses par\u00e2metros na popula\u00e7\u00e3o. Assim, o objetivo deste estudo \u00e9 estimar as propor\u00e7\u00f5es de conhecimento do diagn\u00f3stico, tratamento e controle do DM em uma amostra representativa da popula\u00e7\u00e3o adulta brasileira.. Resumidamente, trata-se de inqu\u00e9rito com amostragem por conglomerados em tr\u00eas est\u00e1gios: os setores censit\u00e1rios correspondem a um n\u00famero fixo de domic\u00edlio particular, e para cada domic\u00edlio foi sorteado um participante com idade igual ou superior a 18 anos. O n\u00famero total de domic\u00edlios visitados foi de 81.167. Destes, 69.994 continham residentes. Ao final, foram realizadas 64.384 entrevistas domiciliares e 60.202 individuais.A PNS foi conduzida em 2013 e estendida at\u00e9 2015 para coleta de material biol\u00f3gico. Detalhes sobre a metodologia de amostragem da PNS est\u00e3o apresentados em publica\u00e7\u00f5es anteriores.A coleta de material biol\u00f3gico foi realizada em subamostra com 25% dos setores censit\u00e1rios pesquisados, totalizando 8.952 indiv\u00edduos, que responderam ao question\u00e1rio base e foram os sujeitos do presente estudo. Com o prop\u00f3sito de obter estimativas populacionais, a \u00faltima fase contou com o peso de p\u00f3s-estratifica\u00e7\u00e3o de acordo com sexo, idade, escolaridade e regi\u00e3o, a fim de alcan\u00e7ar representatividade da popula\u00e7\u00e3o adulta do pa\u00edsForam realizadas entrevistas por meio da aplica\u00e7\u00e3o de um question\u00e1rio no domic\u00edlio do participante por entrevistadores treinados. Dados sociodemogr\u00e1ficos, hist\u00f3rico m\u00e9dica pessoal e vari\u00e1veis de estilo de vida foram registrados. Tamb\u00e9m incluiu aspectos relacionados a diagn\u00f3sticos e tratamento de diabetes, aferi\u00e7\u00f5es de peso, altura, circunfer\u00eancia da cintura e press\u00e3o arterial no morador com 18 anos ou mais em cada domic\u00edlio selecionado aleatoriamente.. A HbA1c foi determinada a partir da cromatografia l\u00edquida de alta performance (HPLC) de amostra armazenada em tubo contendo \u00e1cido etilenodiamino tetra-ac\u00e9tico (EDTA). Vale mencionar que toda a etapa descrita foi executada por laborat\u00f3rios certificados peloNational Glycohemoglobin Standardization Program.A coleta de material sangu\u00edneo (7 ml), foi feita em qualquer hor\u00e1rio do dia, sem realiza\u00e7\u00e3o de jejum, \u201cfaixa et\u00e1ria\u201d , \u201cra\u00e7a/cor\u201d , \u201cescolaridade\u201d , \u201cregi\u00e3o de resid\u00eancia\u201d , al\u00e9m das vari\u00e1veis \u201cplano de sa\u00fade privado\u201d (tem plano de sa\u00fade e n\u00e3o tem plano de sa\u00fade), \u201crecebimento de Bolsa Fam\u00edlia\u201d (recebe Bolsa Fam\u00edlia e n\u00e3o recebe Bolsa Fam\u00edlia) e \u201cautopercep\u00e7\u00e3o de sa\u00fade\u201d .survey, do software Stata 14.0.Foi calculada a preval\u00eancia de DM conforme o crit\u00e9rio de diagn\u00f3stico definido neste estudo. Em seguida foram calculadas as estimativas de propor\u00e7\u00e3o dos demais desfechos de interesse  e seus respectivos intervalos de 95% de confian\u00e7a. Essas propor\u00e7\u00f5es tamb\u00e9m foram estimadas segundo as caracter\u00edsticas sociodemogr\u00e1ficas, e utilizou-se o teste qui-quadrado de Pearson para a an\u00e1lise das diferen\u00e7as das propor\u00e7\u00f5es dos desfechos entre os grupos. Todas as estimativas foram calculadas no m\u00f3duloPara este estudo foi utilizada base de dados secund\u00e1ria, de acesso p\u00fablico e gratuito, respeitando a confidencialidade dos participantes, dispensando aprova\u00e7\u00e3o pr\u00e9via em Comit\u00ea de \u00c9tica e Pesquisa. Ressalta-se que a PNS foi aprovada pela Comiss\u00e3o Nacional de \u00c9tica em Pesquisa com respectivo parecer: CAAE n\u00ba 10853812.7.0000.0008, e cumpre todos os preceitos \u00e9ticos, em conformidade com as recomenda\u00e7\u00f5es para pesquisa com seres humanos da Resolu\u00e7\u00e3o n\u00ba 466/12.A popula\u00e7\u00e3o adulta foi composta em sua maioria por mulheres , de ra\u00e7a/cor branca , com baixa escolaridade , sem plano de sa\u00fade , n\u00e3o benefici\u00e1rios do Programa Bolsa Fam\u00edlia , com \u00f3tima percep\u00e7\u00e3o de sa\u00fade , e principalmente provenientes da regi\u00e3o Sudeste  . A prevFoi estimado que 68,2%  das pessoas com diabetes tinham conhecimento do seu diagn\u00f3stico, sendo que, destes, 92,2%  estavam em tratamento medicamentoso. Foi estimado que 35,9%  tinham n\u00edveis de HbA1c considerados normais , e 48,1%  estavam com n\u00edveis de HbA1c abaixo de 7%, ou seja, com homeostase da glicose normalizada ou controlada entre os que receberam algum tipo de tratamento farmacol\u00f3gico .A propor\u00e7\u00e3o de conhecimento do diagn\u00f3stico de DM foi de 41,7%  na faixa et\u00e1ria de 18 a 39 anos, 65,7%  entre participantes sem plano de sa\u00fade, 47,5%  no grupo que recebe o benef\u00edcio Bolsa Fam\u00edlia, 51,8%  entre aqueles com boa/\u00f3tima autopercep\u00e7\u00e3o de sa\u00fade, e 51,5%  em residentes da regi\u00e3o Norte do pa\u00eds . Nesta Ainda naNeste estudo foi estimado que aproximadamente um a cada dez brasileiros tem diagn\u00f3stico de diabetes, e destes, 68,2% t\u00eam conhecimento do diagn\u00f3stico. Al\u00e9m disso, a maioria dos diab\u00e9ticos encontra-se sob tratamento medicamentoso, e menos da metade desses tem seus n\u00edveis de HbA1c inferiores a 6,5%, ou seja, controlados. Ao considerar metas de controle glic\u00eamico mais flex\u00edveis, observou-se que 48,1% da popula\u00e7\u00e3o adulta t\u00eam HbA1c < 7%, e 65,7% dos idosos t\u00eam HbA1c < 7,5%.As mais altas preval\u00eancias de DM foram no grupo acima de 60 anos, que se declararam da ra\u00e7a/cor amarela/ind\u00edgena, de baixa escolaridade, com autopercep\u00e7\u00e3o de sa\u00fade ruim, e nas popula\u00e7\u00f5es do Centro\u2013Oeste e Sudeste brasileiros. Baixas propor\u00e7\u00f5es de conhecimento, controle e tratamento foram mais frequentes em homens, com idade de 18 a 39 anos, indiv\u00edduos que possuem baixa escolaridade, sem plano de sa\u00fade e benefici\u00e1rios do Programa Bolsa Fam\u00edlia..As altas propor\u00e7\u00f5es de participantes que desconhecem seu diagn\u00f3stico neste estudo se concentram nos grupos de baixos n\u00edveis socioecon\u00f4micos, participantes do programa Bolsa Fam\u00edlia, e residentes da regi\u00e3o Norte do pa\u00eds, como j\u00e1 observados em outro estudo.Um aspecto adicional, que foi mostrado em estudo recente, observou que popula\u00e7\u00f5es com poucos recursos socioecon\u00f4micos tamb\u00e9m apresentam altas preval\u00eancias de tabagismo, excesso de peso e obesidade, baixo consumo de frutas e hortali\u00e7as e alto consumo de bebidas ado\u00e7adas, e, nas mulheres, baixo acesso a programas de rastreamento de c\u00e2ncer de colo e mama, devem ser reeditadas. Por\u00e9m, estrat\u00e9gias de uso de tecnologia leve do cuidado, de baixo custo e ampla acessibilidade da popula\u00e7\u00e3o brasileira podem ser necess\u00e1rias.Estrat\u00e9gias como a Campanha Nacional da Detec\u00e7\u00e3o de DM, a qual atingiu mais de 20 milh\u00f5es de usu\u00e1rios do Sistema \u00danico de Sa\u00fade (SUS) com idade superior a 40 anos. Uma alternativa de baixo custo, n\u00e3o invasiva e de f\u00e1cil aplica\u00e7\u00e3o, seria o uso do Escore Finland\u00eas de Risco de Diabetes (FINDRISC), o qual mede o risco de desenvolver DM2 em adultos. Essa estrat\u00e9gia tem sua validade demonstrada em n\u00edvel nacional.A popula\u00e7\u00e3o brasileira certamente n\u00e3o est\u00e1 longe das estimativas de preval\u00eancias globais. Recente estudo apresenta que aproximadamente 50% dos diab\u00e9ticos adultos n\u00e3o sabem do seu diagn\u00f3stico, e que, destes, 84,3% est\u00e3o residindo em pa\u00edses em desenvolvimento.Baixas preval\u00eancias de controle do diabetes aferido pelos n\u00edveis de hemoglobina glicada  foram mostrados nos grupos de baixa escolaridade e benefici\u00e1rios do Programa Bolsa Fam\u00edlia. Esses achados refor\u00e7am a vulnerabilidade social e o acesso a um controle eficaz das doen\u00e7as, corroborando achados de outros estudos, o que pode ser justificado pela menor gravidade da patologia, sendo poss\u00edvel favorecer o manejo por meio de medidas n\u00e3o farmacol\u00f3gicas, como o incentivo \u00e0 atividade f\u00edsica e a alimenta\u00e7\u00e3o saud\u00e1vel. Al\u00e9m disso, o DM do tipo 1 (DM1), n\u00e3o identificado neste estudo, pode apresentar menor controle glic\u00eamico, em decorr\u00eancia da gravidade da doen\u00e7a, bem como a resist\u00eancia ao uso de medicamentos.Estimativas usando dados da PNS 2019 demonstraram que os mais jovens faziam menor consumo de medica\u00e7\u00e3o. Tamb\u00e9m identificaram menor interna\u00e7\u00e3o por causa da DM ou de alguma complica\u00e7\u00e3o entre as mulheres, o que pode significar melhor controle entre elas, dado que coincide com os achados do presente estudo.Tamb\u00e9m foi poss\u00edvel identificar uma maior frequ\u00eancia de interna\u00e7\u00e3o nos jovens de 18 a 29 anos, o que pode ser compreendido pela maior preval\u00eancia de DM1 em adultos jovens, em fun\u00e7\u00e3o dos sintomas agudos da doen\u00e7a e, ainda, da n\u00e3o adapta\u00e7\u00e3o aos novos cuidados e da menor ades\u00e3o \u00e0s pr\u00e1ticas de cuidadores. Destacam-se tamb\u00e9m os resultados obtidos pela Pesquisa Nacional sobre Acesso, Utiliza\u00e7\u00e3o e Promo\u00e7\u00e3o do Uso Racional de Medicamentos (PNAUM), um inqu\u00e9rito domiciliar de base populacional, que mostrou que 21,4% obtiveram os medicamentos para diabetes de forma paga, e 78,6% de forma gratuita. Ainda confirmando estas conclus\u00f5es, 57,4% relataram na PNS 2013 terem obtido f\u00e1rmacos para diabetes no Programa Farm\u00e1cia Popular. Neste estudo, n\u00e3o temos informa\u00e7\u00f5es para esclarecer se a preval\u00eancia de participantes sem tratamento est\u00e1 relacionada com a escolha de medicamentos ou se seria em decorr\u00eancia da dificuldade de acesso.A alta propor\u00e7\u00e3o de pessoas com diabetes em tratamento estimada neste estudo responde \u00e0s pol\u00edticas p\u00fablicas implantadas para a melhoria do acesso \u00e0 medica\u00e7\u00e3o, por meio dos programas Farm\u00e1cia Popular e Sa\u00fade N\u00e3o Tem Pre\u00e7o, o que possibilita acesso gratuito desses rem\u00e9dios nas Unidades B\u00e1sicas de Sa\u00fade e nas farm\u00e1cias credenciadas ao programa. Os sistemas de vigil\u00e2ncia tamb\u00e9m evidenciaram que 70,3% das pessoas diagnosticadas com DM obtiveram rem\u00e9dios orais gratuitos atrav\u00e9s da farm\u00e1cia do SUS ou do Programa Farm\u00e1cia Popular, e que 90% tiveram acesso gr\u00e1tis \u00e0 insulina. Destaca-se tamb\u00e9m a necessidade de realizar exame de glicemia de jejum e HbA1c duas vezes ao ano, em indiv\u00edduos que est\u00e3o sobre controle glic\u00eamico, e a cada tr\u00eas meses para aqueles que n\u00e3o est\u00e3o.O acompanhamento dos pacientes com diabetes ap\u00f3s o diagn\u00f3stico, na APS, inclui a realiza\u00e7\u00e3o da consulta m\u00e9dica, de enfermagem e participa\u00e7\u00e3o em grupos de diab\u00e9ticos, e o quantitativo de consultas com cada profissional sofre altera\u00e7\u00e3o em decorr\u00eancia da condi\u00e7\u00e3o cl\u00ednica do paciente, Coreia e Mianmar . Estudos anteriores estimaram em 26% e 78% a preval\u00eancia de controle de n\u00edveis glic\u00eamicos em popula\u00e7\u00e3o atendida em servi\u00e7os p\u00fablicos de sa\u00fade e servi\u00e7os privados, respectivamente, por\u00e9m trata-se de estudos locais e sem representatividade nacional, o que dificulta a sua compara\u00e7\u00e3o com o presente trabalho.A manuten\u00e7\u00e3o dos n\u00edveis de glicose dentro da normalidade \u00e9 fundamental para o enfrentamento do DM. Neste estudo, a preval\u00eancia de controle foi baixa, n\u00e3o muito longe de achados em outras popula\u00e7\u00f5es, como as de Curdist\u00e3o iraniano . Destaca-se que a complexidade inerente \u00e0s terapias medicamentosas contribui para elevar o risco quanto ao erro de medica\u00e7\u00e3o, e necessita que o usu\u00e1rio detenha habilidades para cumprir os cuidados dispensados pelos profissionais da sa\u00fade. O desafio da terapia medicamentosa foi acompanhado pelo quantitativo de medicamentos em uso, decorrente dos pacientes que apresentam alta complexidade e faziam uso de polifarm\u00e1cia.O empoderamento do paciente no processo de autocuidado, a educa\u00e7\u00e3o em sa\u00fade, especialmente quanto \u00e0s informa\u00e7\u00f5es referentes ao hor\u00e1rio de medica\u00e7\u00e3o, e o uso correto dos f\u00e1rmacos em conformidade com a prescri\u00e7\u00e3o m\u00e9dica, s\u00e3o estrat\u00e9gias necess\u00e1rias para atingir o controle da doen\u00e7a.Falhas no controle glic\u00eamico podem contribuir para elevar o risco de doen\u00e7as cardiovasculares, nefropatias, neuropatias, retinopatias, bem como aumento de hospitaliza\u00e7\u00f5es. Estudos mostram que n\u00e3o existe v\u00ednculo entre os pacientes portadores de DM e a\u00e7\u00f5es dos profissionais de sa\u00fade, corroborando para descontinuidade da ades\u00e3o ao tratamento e impactando diretamente no seu controle.O controle glic\u00eamico \u00e9 fundamental para diminuir o risco das complica\u00e7\u00f5es do DM e de doen\u00e7a cardiovascular. Deve-se atentar tamb\u00e9m para o monitoramento do perfil lip\u00eddico, e deve-se dar tratamento adequado para atingir o controle glic\u00eamico. O manejo do DM na aten\u00e7\u00e3o prim\u00e1ria segue estrat\u00e9gia do incentivo de h\u00e1bitos de vida saud\u00e1veis. Por\u00e9m, na pr\u00e1tica, o programa tem foco basicamente na oferta de medicamentos. Esse processo de trabalho dificulta o alcance dos objetivos, como reconhecimento e dimensionamento dos problemas de sa\u00fade, tanto no \u00e2mbito individual quanto coletivo, os quais auxiliam de forma mais eficaz nas a\u00e7\u00f5es/interven\u00e7\u00f5es de sa\u00fade, como mostrado em um estudo desenvolvido no mun\u00edcipio de S\u00e3o Paulo. Nesta perspectiva, as estrat\u00e9gias que contribuem para o empoderamento do paciente podem auxiliar no processo de desenvolvimento de ado\u00e7\u00e3o de novas atitudes e habilidades, que ir\u00e3o promover altera\u00e7\u00f5es nos h\u00e1bitos/estilo de vida e, consequentemente, no autocuidado. Ensaios cl\u00ednicos utilizando estrat\u00e9gias de educa\u00e7\u00e3o por meio de interven\u00e7\u00e3o telef\u00f4nica, programa de capacita\u00e7\u00e3o, e visita domiciliar, mostraram que essas interven\u00e7\u00f5es t\u00eam contribu\u00eddo positivamente para melhoria dos resultados dos n\u00edveis de HbA1c, bem como para o empoderamento e autocuidado. As visitas domiciliares realizadas pelos agentes comunit\u00e1rios de sa\u00fade (ACS) contribuem para o controle e supervis\u00e3o do tratamento, melhorando a ades\u00e3o \u00e0s pr\u00e1ticas de autocuidado referentes \u00e0 DM2.Os resultados do baixo controle do DM identificados neste estudo podem ser explicados pela complexidade do manejo da doen\u00e7a, que perpassa pelo monitoramento dos valores glic\u00eamicos, ades\u00e3o ao tratamento, bem como pela inclus\u00e3o de pr\u00e1tica de atividade f\u00edsica regular e altera\u00e7\u00e3o na dieta, denominado \u201cPrevine Brasil\u201d, pois fortalece apenas as estrat\u00e9gias biom\u00e9dicas, o que poderia acarretar atrasos na detec\u00e7\u00e3o do DM e piora e diminui\u00e7\u00e3o da preval\u00eancia de controle. Al\u00e9m disso, vale destacar que os efeitos gerados pela pandemia do covid\u201319 poder\u00e3o, em curto prazo, afetar o desempenho do cuidado dispensado \u00e0s doen\u00e7as cr\u00f4nicas, piorando os n\u00edveis de controle e detec\u00e7\u00e3o da doen\u00e7a.Ressalta\u2013se que a magnitude de agravos mostrados pode piorar em decorr\u00eancia do novo modelo de financiamento da APS no SUSUma limita\u00e7\u00e3o deste estudo refere\u2013se \u00e0 falta de dados referentes \u00e0 medica\u00e7\u00e3o utilizada, seu tempo de uso e ades\u00e3o ao tratamento, que se limitou a registrar apenas o uso de antidiab\u00e9ticos e/ou inje\u00e7\u00f5es de insulina. Medidas n\u00e3o farmacol\u00f3gicas s\u00e3o tamb\u00e9m necess\u00e1rias ao controle glic\u00eamico, e n\u00e3o foram avaliadas neste estudo, por exemplo. Esses dados possibilitariam um melhor conhecimento do baixo desempenho no controle dos n\u00edveis glic\u00eamicos encontrados na popula\u00e7\u00e3o brasileira, apesar do amplo acesso aos medicamentos e ao tratamento. Contudo, a utiliza\u00e7\u00e3o de dados com base populacional e representatividade nacional configura uma adequada validade externa.Destaca-se tamb\u00e9m a medida dos n\u00edveis de HbA1c colhida de sangue venoso e n\u00e3o capilar, considerada padr\u00e3o ouro para detec\u00e7\u00e3o da doen\u00e7a. A aus\u00eancia de consenso para defini\u00e7\u00e3o do ponto de corte da HbA1c no controle da doen\u00e7a contribui para dificultar o processo de avalia\u00e7\u00e3o e monitoramento do DM. Sendo assim, este estudo optou por trabalhar com os dois pontos de corte.Registra-se ainda, como limita\u00e7\u00e3o, a n\u00e3o distin\u00e7\u00e3o entre o tipo de DM (DM1 ou DM2). Ressalta-se que este \u00e9 um estudo populacional in\u00e9dito que utiliza dados laboratoriais com representatividade da popula\u00e7\u00e3o brasileira para estimar o conhecimento, tratamento e controle do DM, aspectos fundamentais para contribuir com os programas de sa\u00fade p\u00fablica no enfrentamento da doen\u00e7a.A propor\u00e7\u00e3o de conhecimento do DM na popula\u00e7\u00e3o brasileira foi estimada em 68%, e, destes, 92%, estavam em tratamento medicamentoso. O controle adequado foi estimado em 36%, considerando o crit\u00e9rio mais rigoroso . Alguns subgrupos populacionais, tais como os que n\u00e3o possuem plano de sa\u00fade, os que relataram ter autopercep\u00e7\u00e3o de sa\u00fade ruim e os benefici\u00e1rios do Programa Bolsa Fam\u00edlia, apresentaram pior desempenho do conhecimento sobre a doen\u00e7a. Os dados deste estudo podem contribuir para o fortalecimento de pol\u00edticas p\u00fablicas que objetivam promover o estilo de vida saud\u00e1vel. A implementa\u00e7\u00e3o de estrat\u00e9gias inovadoras para auxiliar no controle do DM \u00e9 fundamental para enfrentar a carga de doen\u00e7a atribu\u00edda ao DM no Brasil."}
+{"text": "Objetivou-se caracterizar as principais causas de \u00f3bito de mulheres comnotifica\u00e7\u00e3o de viol\u00eancia interpessoal durante a gravidez e identificar osfatores associados a essas mortes. Trata-se de um estudo caso-controle realizadoa partir da an\u00e1lise de dados sobre viol\u00eancia e \u00f3bitos ocorridos no Brasil entre2011 e 2017. Os dados provenientes do Sistema de Informa\u00e7\u00e3o de Agravos deNotifica\u00e7\u00e3o e do Sistema de Informa\u00e7\u00e3o sobre Mortalidade foram analisados pormeio da regress\u00e3o log\u00edstica m\u00faltipla. Os resultados mostraram que 56,4% dos\u00f3bitos foram em decorr\u00eancia de causas externas, sendo 80,1% desses devido aofeminic\u00eddio. Identificou-se como fatores de risco associados ao \u00f3bito: faixaet\u00e1ria de 30 a 39 anos ; agress\u00e3o por arma de fogo e por objeto perfurocortante . Como fatores de prote\u00e7\u00e3o, observou-se: ser casada/uni\u00e3o est\u00e1vel ; ter escolaridade acima de quatro anos  e residir em munic\u00edpios com popula\u00e7\u00e3o acima de 100 milhabitantes . Esta pesquisa foi importante parademonstrar a magnitude do feminic\u00eddio entre mulheres com notifica\u00e7\u00e3o deviol\u00eancia durante a gravidez, assim como as fragilidades na produ\u00e7\u00e3o deinforma\u00e7\u00f5es sobre as causas externas de \u00f3bito no per\u00edodo grav\u00eddico-puerperal.Al\u00e9m disso, evidenciou-se os motivos que vulnerabilizam as mulheres para o\u00f3bito, refor\u00e7ando a necessidade urgente do rastreamento pelos profissionais desa\u00fade da viol\u00eancia na gesta\u00e7\u00e3o. \u00c9 importante salientar que a maioria dos estudospesquisou a viol\u00eancia por parceiro \u00edntimo, visto que esse \u00e9 reportado como oprincipal agressor Em rela\u00e7\u00e3o ao feminic\u00eddio, um importante estudo caso-controle realizado nos EstadosUnidos ,,Ainda, estudos t\u00eam apontado o homic\u00eddio como a principal causa de \u00f3bito materno noper\u00edodo grav\u00eddico-puerperal nos Estados Unidos ,\u00c9 importante pontuar, entretanto, que os efeitos da viol\u00eancia na sa\u00fade materno-fetalpodem ser evit\u00e1veis. A gesta\u00e7\u00e3o oferece muitas oportunidades de rastreamento einterven\u00e7\u00e3o precoce no sistema de sa\u00fade Considerando a preval\u00eancia da viol\u00eancia na gravidez no Brasil, sua potencialidadepara causar mortes e a evitabilidade destas por meio de interven\u00e7\u00f5es do sistema desa\u00fade, o objetivo deste texto foi caracterizar as principais causas de \u00f3bito demulheres com notifica\u00e7\u00e3o de viol\u00eancia interpessoal durante a gravidez e identificaros fatores associados a essas mortes. Trata-se do primeiro estudo brasileiro ainvestigar tal associa\u00e7\u00e3o, contribuindo para melhor compreens\u00e3o sobre os fen\u00f4menosviol\u00eancia e \u00f3bito entre mulheres.,,,Para fins desta pesquisa, considerou-se homic\u00eddio como sin\u00f4nimo de feminic\u00eddio, dadoo alto \u00edndice de viol\u00eancia fatal por quest\u00f5es de g\u00eanero descritas na literaturanacional e internacional linkage) realizado pelo Minist\u00e9rio da Sa\u00fade. Olinkage considerou dados do Sistema de Informa\u00e7\u00e3o deAgravos de Notifica\u00e7\u00e3o (SINAN), m\u00f3dulo \u201cviol\u00eancias interpessoais eautoprovocadas\u201d referentes ao per\u00edodo de 2011 a 2016 e dados de \u00f3bito do Sistemade Informa\u00e7\u00e3o sobre Mortalidade (SIM), ocorridos entre janeiro de 2011 esetembro de 2017.Trata-se de um estudo observacional anal\u00edtico, do tipo caso-controle, realizado apartir dos registros de viol\u00eancia interpessoal durante a gravidez e dosregistros de \u00f3bito dessas mulheres. Foram utilizados dados secund\u00e1riosnacionais, n\u00e3o nominais, provenientes do relacionamento de bancos de dados contra mulheres de todas as idades no SINAN, enquanto no SIMforam identificados 3.196.446 \u00f3bitos de mulheres por todas as causas e idades.Ap\u00f3s o Partindo do banco de dados disponibilizado pelo Minist\u00e9rio da Sa\u00fade, comocrit\u00e9rio de inclus\u00e3o no estudo considerou-se: (i) mulheres com registro deviol\u00eancia interpessoal; (ii) idade entre 10 e 49 anos; (iii) estar gr\u00e1vida nomomento da notifica\u00e7\u00e3o da viol\u00eancia .Foram crit\u00e9rios de exclus\u00e3o no estudo: (i) mulheres com mais de uma notifica\u00e7\u00e3ode viol\u00eancia; (ii) registro de viol\u00eancia autoprovocada; (iii) n\u00e3o residir emmunic\u00edpios em que ocorreram \u00f3bitos .A exclus\u00e3o de mulheres que tinham mais de uma notifica\u00e7\u00e3o no SINAN foi necess\u00e1riaporque as informa\u00e7\u00f5es para os anos 2015 e 2016 eram preliminares, ou seja, n\u00e3ohaviam sido submetidas \u00e0 rotina de limpeza pelo Minist\u00e9rio da Sa\u00fade. Portanto,as duplicidades poderiam superestimar as viol\u00eancias, j\u00e1 que a notifica\u00e7\u00e3oduplicada seria considerada como um novo epis\u00f3dio.Como n\u00e3o houve acesso aos dados nominais, para proceder a exclus\u00e3o acimareferida, considerou-se um identificador existente no banco de dados queinformava o n\u00famero de notifica\u00e7\u00f5es referentes a cada mulher. Ao final desseprocesso, optou-se por considerar as mulheres com apenas uma notifica\u00e7\u00e3o deviol\u00eancia no per\u00edodo completo (2011-2016), portanto, todas as mulheresidentificadas com mais de uma notifica\u00e7\u00e3o foram exclu\u00eddas. Ainda assim, foiposs\u00edvel analisar a viol\u00eancia de repeti\u00e7\u00e3o a partir dos registros no campo 53(\u201cocorreu outras vezes?\u201d), que est\u00e1 presente na ficha de notifica\u00e7\u00e3o. Talinforma\u00e7\u00e3o foi utilizada como uma vari\u00e1vel explicativa do estudo.Tamb\u00e9m foram exclu\u00eddos os registros de viol\u00eancia autoprovocada, considerando queo objetivo deste estudo foi analisar a viol\u00eancia interpessoal. Para aidentifica\u00e7\u00e3o e exclus\u00e3o desses registros, realizou-se a an\u00e1lise dos dadosrelativos ao campo 54 da ficha de notifica\u00e7\u00e3o do SINAN (\u201ca les\u00e3o foiautoprovocada?\u201d), al\u00e9m da categoria aberta \u201coutros\u201d do campo 56 (\u201ctipo deviol\u00eancia\u201d). Nesse \u00faltimo campo, buscou-se registros referentes a agress\u00f5esautoinfligidas, tentativa de suic\u00eddio, autoexterm\u00ednio ou situa\u00e7\u00f5es correlatasque n\u00e3o haviam sido assinaladas no campo 54.Al\u00e9m disso, com o intuito de tornar a amostra mais homog\u00eanea, foram exclu\u00eddasmulheres que n\u00e3o residiam nos munic\u00edpios em que ocorreram \u00f3bitos. O munic\u00edpio deresid\u00eancia das mulheres foi identificado atrav\u00e9s da vari\u00e1vel \u201cc\u00f3digo domunic\u00edpio\u201d na notifica\u00e7\u00e3o do SINAN.Ap\u00f3s a aplica\u00e7\u00e3o dos crit\u00e9rios de inclus\u00e3o e exclus\u00e3o referidos, foram definidosos grupos caso e controle. Para o grupo caso foram selecionadas todas asmulheres com notifica\u00e7\u00e3o de viol\u00eancia interpessoal no SINAN no per\u00edodo de2011-2016 que tiveram registro de \u00f3bito no SIM .Para o grupo controle, em princ\u00edpio seriam selecionadas todas as mulheres comnotifica\u00e7\u00e3o de viol\u00eancia interpessoal no SINAN no per\u00edodo de 2011-2016 que n\u00e3otiveram \u00f3bito registrado. Contudo, observou-se um n\u00famero elevado de mulheres nogrupo controle (n = 14.145) em rela\u00e7\u00e3o ao grupo caso (n = 259) e, uma vez que umn\u00famero t\u00e3o elevado n\u00e3o aumentaria o poder estat\u00edstico do estudo ,Com o intuito de selecionar um subconjunto de dados com caracter\u00edsticassemelhantes \u00e0 amostra inicial, ou seja, aquela que melhor representasse apopula\u00e7\u00e3o do estudo, foi empregada a valida\u00e7\u00e3o cruzada. Tal m\u00e9todo estat\u00edstico \u00e9utilizado para avaliar a variabilidade de um conjunto de dados e aconfiabilidade dos modelos treinados, dividindo os dados em dois segmentos: umusado para treinar um modelo e o outro usado para validar e estimar o desempenhodesse modelo Na aplica\u00e7\u00e3o da valida\u00e7\u00e3o cruzada, foram geradas aleatoriamente dez amostras detamanhos iguais baseadas em diferentes sele\u00e7\u00f5es dos dados iniciais. Para cadauma dessas amostras geradas foram aplicados os procedimentos de modelagemdescritos na an\u00e1lise dos dados.area under thecurve) ROC (receiver operating characteristic). Acompara\u00e7\u00e3o possibilitou a interpreta\u00e7\u00e3o da qualidade dos dados, demonstrando arepresentatividade da amostra e a sensibilidade do modelo \u00e0 varia\u00e7\u00f5es Para valida\u00e7\u00e3o e compara\u00e7\u00e3o do desempenho dos modelos das amostras obtidas pormeio da reamostragem, foi utilizada a m\u00e9trica AUC , sendo esse consideradoindependentemente do tipo de causa b\u00e1sica. Essa vari\u00e1vel teve como fonte deinforma\u00e7\u00e3o o SIM, sendo que as causas b\u00e1sicas foram organizadas em cap\u00edtulos eagrupamentos, de acordo com a estrutura e princ\u00edpios da Classifica\u00e7\u00e3oInternacional de Doen\u00e7as, 10\u00aa revis\u00e3o (CID-10) Faixa et\u00e1ria em anos ; trimestre gestacional ; ra\u00e7a/cor ; escolaridade em anos deestudo ; situa\u00e7\u00e3o conjugal/estado civil; defici\u00eancia/transtorno; porte do munic\u00edpio de resid\u00eancia em n\u00famero de habitantes ; zona de resid\u00eancia ;local de ocorr\u00eancia ;viol\u00eancia de repeti\u00e7\u00e3o ; v\u00ednculo com o(a) agressor(a)(desconhecido(a), parceiro \u00edntimo, familiar, conhecido(a), outros); tipo deviol\u00eancia ; meio de agress\u00e3o .missing data) foram agrupadas com os registrosinformados como \u201cignorado\u201d.Todas as vari\u00e1veis explicativas foram extra\u00eddas do SINAN e categorizadas parapermitir melhor visualiza\u00e7\u00e3o dos resultados. As vari\u00e1veis com campos sempreenchimento , optou-se por agreg\u00e1-las \u00e0 categoria solteira.Para a vari\u00e1vel \u201cra\u00e7a/cor\u201d, tamb\u00e9m em raz\u00e3o do baixo n\u00famero de mulheresdeclaradas como ind\u00edgenas e amarelas, para fins de an\u00e1lise estat\u00edstica, essasforam agrupadas juntamente \u00e0s pretas e pardas, compondo a categoria\u201cpreta/parda/ind\u00edgena/amarela\u201d. Na an\u00e1lise descritiva dos dados cada ra\u00e7a/corfoi apresentada separadamente.O \u201cporte do munic\u00edpio de resid\u00eancia\u201d foi estabelecido por meio de estimativa dapopula\u00e7\u00e3o residente no meio do per\u00edodo, dispon\u00edvel no Departamento deInform\u00e1tica do SUS (DATASUS) Em rela\u00e7\u00e3o \u00e0 vari\u00e1vel \u201cv\u00ednculo com o(a) agressor(a)\u201d, os campos assinalados como\u201cc\u00f4njuge\u201d, \u201cex-c\u00f4njuge\u201d, \u201cnamorado(a)\u201d e \u201cex-namorado(a)\u201d, al\u00e9m de v\u00ednculoscorrelatos descritos no campo aberto \u201coutros\u201d, foram considerados como \u201cparceiro\u00edntimo\u201d. As categorias \u201cpai\u201d, \u201cm\u00e3e\u201d, \u201cpadrasto\u201d, \u201cmadrasta\u201d, \u201cfilho(a)\u201d,irm\u00e3o(a)\u201d foram agrupados como familiares. \u00c0 categoria conhecido(a) foraminclu\u00eddas: \u201ccuidador(a)\u201d, \u201cpatr\u00e3o/chefe\u201d e \u201cpessoa com rela\u00e7\u00e3o institucional\u201d.J\u00e1 \u00e0 categoria \u201coutros\u201d foi acrescentada \u201cpolicial/agente da lei\u201d.Viva: Instrutivo Notifica\u00e7\u00e3o de Viol\u00eanciaInterpessoal e AutoprovocadaAs respostas \u00e0s vari\u00e1veis \u201ctipo de viol\u00eancia\u201d e \u201cmeio de agress\u00e3o\u201d foramreorganizadas, visto que, no preenchimento dos campos na ficha do SINAN, \u00e9poss\u00edvel assinalar mais de uma op\u00e7\u00e3o. Para essa reorganiza\u00e7\u00e3o considerou-se comorefer\u00eancia o manual Inicialmente, foi realizada a descri\u00e7\u00e3o das causas de morte e das caracter\u00edsticasgerais dos grupos caso e controle, segundo as vari\u00e1veis sociodemogr\u00e1ficas dasmulheres e caracter\u00edsticas da viol\u00eancia.forward, permanecendo no modelo vari\u00e1veis que apresentaramvalor de p < 0,05.Ap\u00f3s isso, utilizou-se a regress\u00e3o log\u00edstica para analisar cada uma das vari\u00e1veisexplicativas em rela\u00e7\u00e3o ao desfecho de interesse (an\u00e1lise univariada). Emseguida, para a an\u00e1lise m\u00faltipla, foram consideradas aquelas vari\u00e1veis queapresentaram o valor de p < 0,25 na an\u00e1lise anterior. Para a constru\u00e7\u00e3o domodelo de regress\u00e3o log\u00edstica m\u00faltipla foi utilizado procedimento de sele\u00e7\u00e3oodds ratio (OR) com intervalo de 95%de confian\u00e7a (IC95%). Para avalia\u00e7\u00e3o da multicolinearidade das vari\u00e1veis nomodelo ajustado, foi utilizado o teste de fator de infla\u00e7\u00e3o da vari\u00e2ncia (VIF).Por fim, o teste de Hosmer e Lemeshow foi utilizado para verifica\u00e7\u00e3o daadequa\u00e7\u00e3o de ajuste do modelo Para verificar a intensidade da associa\u00e7\u00e3o entre as vari\u00e1veis explicativas e odesfecho, foi estimada a http://www.r-project.org), e as interpreta\u00e7\u00f5es foram feitasconsiderando o n\u00edvel de signific\u00e2ncia de \u03b1 = 0,05.Todas as an\u00e1lises foram realizadas no software R, vers\u00e3o 4.0.3 .Este estudo integra dois projetos de pesquisa: Considerando a amostra inicial, das 14.404 mulheres com registro de viol\u00eanciainterpessoal na gravidez, 259  morreram no per\u00edodo estudado.Em rela\u00e7\u00e3o \u00e0s causa b\u00e1sicas de \u00f3bito, segundo o cap\u00edtulo da CID-10, observou-se que56,4% das causas foram classificados no cap\u00edtulo XX - Causas externas, 10,8% foramclassificadas no cap\u00edtulo XV - Gravidez, parto e puerp\u00e9rio e 6,9% no cap\u00edtulo I -Algumas doen\u00e7as infecciosas e parasit\u00e1rias .Analisando as causas de acordo com o agrupamento de categorias da CID-10 para cada umdos cap\u00edtulos descritos anteriormente, observou-se que no cap\u00edtulo I, o HIV foirespons\u00e1vel pela maior parte dos \u00f3bitos . No cap\u00edtulo XV, \u201coutrasafec\u00e7\u00f5es obst\u00e9tricas\u201d representaram 28,6% (8/28) dos casos e os agrupamentos\u201cgravidez que termina em aborto\u201d e \u201cedema, protein\u00faria e transtornos hipertensivos\u201drepresentaram 17,9% (5/28) dos casos, cada .No cap\u00edtulo XX, os feminic\u00eddios (nomeados na CID-10 como \u201cagress\u00f5es\u201d) representaram80,1% (117/146) dos casos, seguidos dos \u201cacidentes\u201d  e \u201cles\u00f5esautoprovocadas\u201d . Destaca-se que do total de \u00f3bitos (n = 259), osfeminic\u00eddios representaram 45,2% .Sobre a ra\u00e7a/cor, o agrupamento das categorias preta/parda/amarela/ind\u00edgena teve umpercentual semelhante para os dois grupos, representando 54% no grupo caso e 52% nocontrole. Como caracter\u00edsticas particulares dos grupos caso e controle, observou-seque, dentre as mulheres com registro de \u00f3bito (caso), um alto percentual tinha idadeentre 20-29 anos  e residiam em munic\u00edpios com popula\u00e7\u00e3o \u2264 100 mil habitantes. Por outro lado, as mulheres sem registro de \u00f3bito (controle) tinham, em suamaioria, 10-19 anos  e residiam em munic\u00edpios com mais de 500 mil habitantes. Destaca-se que no grupo caso, 12,4% das mulheres tinham menos de quatroanos de estudo, enquanto no grupo controle essa propor\u00e7\u00e3o foi de 6%. Al\u00e9m disso,diferentemente do esperado, enquanto no grupo caso 30,1% das mulheres tinhamregistro de viol\u00eancia de repeti\u00e7\u00e3o, no grupo controle esse percentual foi de 40,4%.Houve um importante percentual de respostas assinaladas como \u201cignorado\u201d, evidenciandoa extens\u00e3o da incompletude  dosdados do SINAN. Em rela\u00e7\u00e3o ao preenchimento das caracter\u00edsticas sociodemogr\u00e1ficasdas mulheres, as vari\u00e1veis ra\u00e7a/cor, situa\u00e7\u00e3o conjugal/estado civil,defici\u00eancia/transtorno tiveram um grau de incompletude regular (10% a 20%), enquantoescolaridade apresentou um grau de incompletude ruim (20% a 50%), conforme o escoreproposto por Romero & Cunha Com ajuda da an\u00e1lise m\u00faltipla, as seguintes vari\u00e1veis foram associadas ao \u00f3bito:\u201cfaixa et\u00e1ria\u201d, \u201cescolaridade\u201d, \u201csitua\u00e7\u00e3o conjugal/estado civil\u201d, \u201cporte domunic\u00edpio de resid\u00eancia\u201d e \u201cmeio de agress\u00e3o\u201d .Observou-se como fatores de risco: idade entre 30-39 anos, uma vez que mulheres nessafaixa et\u00e1ria tiveram 2,53  vezes a chance de \u00f3bito quandocomparadas \u00e0s mulheres na faixa et\u00e1ria entre 10-19 anos; agress\u00e3o por arma de fogoou por objetos perfurocortantes, j\u00e1 que as chances de \u00f3bito por esses meios foram,respectivamente, 14,21  e 4,45  vezes a chancede \u00f3bito em compara\u00e7\u00e3o \u00e0 agress\u00e3o por amea\u00e7a .Como fatores de prote\u00e7\u00e3o foram identificados: ser casada/uni\u00e3o consensual , quando comparada a categoria solteira/vi\u00fava, ter escolaridadesuperior a quatro anos  e residir em munic\u00edpios com popula\u00e7\u00e3o superior a 100 mil habitantes  .Os resultados deste estudo apontaram para um n\u00famero expressivo de mortes por causasexternas, sobretudo por feminic\u00eddios, que representaram 45,2% do total de \u00f3bitos. Osfatores de risco para o \u00f3bito de mulheres com notifica\u00e7\u00e3o de viol\u00eancia durante agravidez foram: idade entre 30-39 anos e/ou ter sofrido agress\u00e3o por meio do uso dearma de fogo ou por objeto perfurocortante. Ainda, os resultados mostraram que sersolteira/vi\u00fava, com baixa escolaridade e/ou residir em munic\u00edpios at\u00e9 100 milhabitantes tamb\u00e9m se constitu\u00edram fatores de risco para os \u00f3bitos, considerando queser casada/uni\u00e3o est\u00e1vel, com escolaridade acima de quatro anos e/ou residir emmunic\u00edpios com popula\u00e7\u00e3o > 100 mil habitantes apresentaram-se como fatores deprote\u00e7\u00e3o.No Brasil, observou-se uma tend\u00eancia de crescimento da mortalidade de mulheres emidade f\u00e9rtil por causas externas em todas as regi\u00f5es ,,,Dados do Observat\u00f3rio Obst\u00e9trico Brasileiro ,,Em rela\u00e7\u00e3o \u00e0s causas de \u00f3bito classificadas no cap\u00edtulo XV , esta pesquisa mostrou que a maior parte dessas foi relacionada a \u201coutrasafec\u00e7\u00f5es obst\u00e9tricas\u201d. Evidencia-se que essas mortes, assim como as demais listadasno mesmo cap\u00edtulo, podem estar relacionadas \u00e0s causas violentas, entretanto n\u00e3o foiposs\u00edvel analis\u00e1-las. Apesar do Minist\u00e9rio da Sa\u00fade Assim, observamos que a produ\u00e7\u00e3o de dados fidedignos quanto ao feminic\u00eddio no per\u00edodograv\u00eddico-puerperal ainda \u00e9 um desafio, tal situa\u00e7\u00e3o contribui para a invisibilidadedas viol\u00eancias nos protocolos voltados para a sa\u00fade materno-infantil, pol\u00edticas deenfrentamento \u00e0s desigualdades de g\u00eanero e propostas de vigil\u00e2ncia do \u00f3bito materno,Os resultados tamb\u00e9m mostraram que a \u201cgravidez que termina em aborto\u201d foi a segundacausa de \u00f3bito materno entre mulheres que sofreram viol\u00eancia. Considerando que aviol\u00eancia \u00e9 um fator de risco para o abortamento ,,Considerando as doen\u00e7as infecciosas, o HIV tamb\u00e9m foi descrito como associado \u00e0viol\u00eancia ,Sobre a faixa et\u00e1ria, algumas hip\u00f3teses poderiam contribuir para explicar o fato demulheres com idade entre 30-39 anos terem maior chance de \u00f3bito. Uma delas \u00e9 que amortalidade geral de mulheres em idade f\u00e9rtil \u00e9 diretamente proporcional ao aumentoda idade, embora seja mais frequente entre 40-49 anos Importante observar, contudo, que nesta pesquisa a viol\u00eancia de repeti\u00e7\u00e3o n\u00e3o foiestatisticamente associada ao \u00f3bito. Por\u00e9m, essa an\u00e1lise pode ter sido prejudicadaem fun\u00e7\u00e3o da decis\u00e3o metodol\u00f3gica de exclus\u00e3o das mulheres que tiveram mais de umanotifica\u00e7\u00e3o de viol\u00eancia na amostra selecionada e pela elevada incompletude dasrespostas para essa vari\u00e1vel.,,,,O estado civil solteira/vi\u00fava se apresentou neste estudo como um fator de risco parao \u00f3bito, corroborando a literatura que aponta que h\u00e1 uma maior propor\u00e7\u00e3o de \u00f3bitosentre solteiras, sejam elas mulheres em idade f\u00e9rtil (\u00f3bito por todas as causas)A escolaridade inferior a quatro anos foi fator de risco para a ocorr\u00eancia do \u00f3bito,isso ocorre porque mulheres com n\u00edveis educacionais mais altos geralmente apresentammaior autoconfian\u00e7a, habilidades no uso de informa\u00e7\u00f5es e recursos, rede de apoio eautonomia financeira, conferindo a elas maiores recursos para reconhecer e romper ociclo de viol\u00eancia em relacionamentos abusivos. Esse resultado refor\u00e7a a import\u00e2nciada escolariza\u00e7\u00e3o de meninas e mulheres na preven\u00e7\u00e3o da viol\u00eancia ,O maior porte do munic\u00edpio como um fator de prote\u00e7\u00e3o se d\u00e1 possivelmente devido amaior disponibilidade e organiza\u00e7\u00e3o da rede de servi\u00e7os relacionados aoenfrentamento da viol\u00eancia contra as mulheres ofertados nessas localidades ,,Al\u00e9m da menor disponibilidade de servi\u00e7os especializados, \u00e9 importante refletir sobrecomo o sistema social baseado na cultura patriarcal se faz presente na vida dasmulheres, contribuindo para naturalizar e legitimar as diversas formas de viol\u00eancia.Esse sistema que oprime e controla as mulheres atravessa a vida de todas, por\u00e9m,para aquelas residentes em munic\u00edpios de menor porte, a fragilidade das redes deapoio, bem como a hegemonia do discurso patriarcal podem dificultar a resist\u00eancia ea subvers\u00e3o, mantendo-as em rela\u00e7\u00f5es abusivas para preservar uma suposta ideia deinstitui\u00e7\u00e3o familiar ,,,,,Sobre os meios de agress\u00e3o, a arma de fogo e objeto perfurocortante constitu\u00edram-secomo importantes fatores associados ao \u00f3bito, resultado esperado devido \u00e0 maiorletalidade desses meios. Tal achado refor\u00e7a a necessidade de pol\u00edticas que visem aredu\u00e7\u00e3o da viol\u00eancia armada, como leis restritivas de porte Este estudo apresentou algumas limita\u00e7\u00f5es, entre elas destaca-se aquelas relativas aouso de dados secund\u00e1rios como: subnotifica\u00e7\u00e3o de casos ; falta de padroniza\u00e7\u00e3o na coleta de dados e aus\u00eancia de informa\u00e7\u00f5es,resultante do elevado volume de campos com preenchimento ignorado. Os problemas naqualidade dos registros dos dados podem ter enviesados resultados de determinadascategorias de vari\u00e1veis, podendo ser, inclusive, o motivo da n\u00e3o associa\u00e7\u00e3o dealgumas vari\u00e1veis que s\u00e3o sabidamente relacionadas \u00e0 viol\u00eancia, como a ra\u00e7a/cor, aviol\u00eancia por parceiro \u00edntimo e a viol\u00eancia de repeti\u00e7\u00e3o. Essas limita\u00e7\u00f5es indicam anecessidade de sensibiliza\u00e7\u00e3o e capacita\u00e7\u00e3o de profissionais sobre a import\u00e2ncia danotifica\u00e7\u00e3o e da qualidade no preenchimento das fichas.Outra limita\u00e7\u00e3o se relaciona ao menor n\u00famero de ocorr\u00eancia em algumas categorias dasvari\u00e1veis analisadas, fato inerente ao agravo, o que pode ter contribu\u00eddo para amaior amplitude de alguns dos intervalos de confian\u00e7a. Ainda, \u00e9 importanteconsiderar que, por se tratarem de informa\u00e7\u00f5es nacionais, h\u00e1 heterogeneidade dosdados, assim, sugerimos a realiza\u00e7\u00e3o de outros estudos cujas an\u00e1lises partam dedados regionais.Por outro lado, por utilizar dados secund\u00e1rios, algumas limita\u00e7\u00f5es comuns ao desenhocaso-controle foram minimizadas, configurando-se como for\u00e7as. Dentre elas,destaca-se o vi\u00e9s da mem\u00f3ria, j\u00e1 que os dados sobre a exposi\u00e7\u00e3o j\u00e1 estavamcoletados. Tamb\u00e9m, no caso do vi\u00e9s de sele\u00e7\u00e3o, casos e controles foram provenientesda mesma amostra, ou seja, mulheres na mesma faixa et\u00e1ria, com viol\u00eanciainterpessoal notificada na gravidez, que residiam nos mesmos munic\u00edpios. Al\u00e9m disso,h\u00e1 a possibilidade de assegurar a sequ\u00eancia dos eventos (viol\u00eancia e \u00f3bito) e,considerando a baixa incid\u00eancia do desfecho de interesse, a odds ratio fornece umaboa estimativa do risco relativo.Por fim, ressalta-se que os resultados apresentados permitem a identifica\u00e7\u00e3o defatores que vulnerabilizam as mulheres para o \u00f3bito que devem ser considerados naproposi\u00e7\u00e3o e avalia\u00e7\u00e3o das a\u00e7\u00f5es de enfrentamento \u00e0s viol\u00eancias. Indicam tamb\u00e9m anecessidade de um olhar mais atento aos munic\u00edpios de menor porte, por interm\u00e9dio dodesenvolvimento de pesquisas que busquem compreender a realidade das viol\u00eanciasnessas localidades e, tamb\u00e9m, da implementa\u00e7\u00e3o das redes de prote\u00e7\u00e3o \u00e0 mulher.Esta investiga\u00e7\u00e3o foi importante, ainda, para evidenciar a magnitude do feminic\u00eddioentre mulheres com notifica\u00e7\u00e3o de viol\u00eancia durante a gesta\u00e7\u00e3o, assim como asfragilidades na produ\u00e7\u00e3o da informa\u00e7\u00f5es sobre as causas externas de \u00f3bito no per\u00edodograv\u00eddico-puerperal e, sobretudo, para refor\u00e7ar a necessidade urgente da inclus\u00e3o dorastreamento da viol\u00eancia nos protocolos de assist\u00eancia ao pr\u00e9-natal, parto epuerp\u00e9rio, a fim de detectar precocemente os casos, com vistas a contribuir pararedu\u00e7\u00e3o dos desfechos letais."}
+{"text": "V\u00e1rios conceitos e termos, por vezes dif\u00edceis de serem compreendidospor aqueles n\u00e3o familiarizados com o assunto, s\u00e3o apresentados de forma leve, agrad\u00e1vele compreensiva, por\u00e9m sempre com o rigor t\u00e9cnico-cient\u00edfico necess\u00e1rio Nesse sentido, a fil\u00f3sofa Sabina Leonelli, autora do livro O livro conta com um feliz pref\u00e1cio de Beth\u00e2nia Almeida e Mauricio Barreto, que conseguetraduzir como a busca para a solu\u00e7\u00e3o dos desafios enfrentados pelo Centro de Integra\u00e7\u00e3ode Dados e Conhecimentos para Sa\u00fade, Funda\u00e7\u00e3o Oswaldo Cruz (Cidacs/Fiocruz Bras\u00edlia), naintegra\u00e7\u00e3o de grandes volumes de dados, se mostrou uma janela de oportunidades para umamaior aproxima\u00e7\u00e3o com Sabina Leonelli e toda sua equipe de t\u00e9cnicos e cientistas,surgindo, desse encontro, a inspira\u00e7\u00e3o para a elabora\u00e7\u00e3o da obra.O Que \u00c9 Big Data, apresenta a conceitua\u00e7\u00e3o de umbig data a partir da vis\u00e3o da autora e avan\u00e7a em uma discuss\u00e3o dascaracter\u00edsticas esperadas para essa ferramenta, que v\u00e3o muito al\u00e9m de \u201cmuitos dados\u201d.Nesse cap\u00edtulo tamb\u00e9m se discute a rela\u00e7\u00e3o intr\u00ednseca, por vezes revolucion\u00e1ria, entrebig data, dados abertos e a abordagem focada em dados para gera\u00e7\u00e3ode conhecimento. Os argumentos apresentados levam o leitor a refletir sobre a forma defazer ci\u00eancia centrada nos dados ou na teoria e sobre como a concep\u00e7\u00e3o inicial de umbig data pode impactar positivamente e negativamente nos resultadosde uma investiga\u00e7\u00e3o.O cap\u00edtulo 1, Sinais de Alerta: Cinco Maneiras como o Big Data Prejudica aPesquisa, a autora apresenta para o leitor os atributos que limitam o usode um big data. S\u00e3o listados itens como: conservadorismo ; inseguran\u00e7a ; mistifica\u00e7\u00e3o (como um fen\u00f4meno decorrente dedados parciais ou pouco representativos); corrup\u00e7\u00e3o ; e danos sociais (tamb\u00e9mcomo fen\u00f4menos das fontes pouco confi\u00e1veis e que podem gerar resultados que impactamnegativamente a sociedade). Esse cap\u00edtulo \u00e9 encerrado com uma discuss\u00e3o sobre a \u00e9ticacomo parte integrante da ci\u00eancia, em que \u00e9 feito um balan\u00e7o de como os bigdata podem ser potencializadores da ci\u00eancia e do avan\u00e7o do conhecimento,assim como podem comprometer, ou mesmo sabotar, a qualidade e a confiabilidade dosachados cient\u00edficos com impactos importantes na percep\u00e7\u00e3o social do valor daci\u00eancia.No cap\u00edtulo 2, Como Evitar o Pior: A Abordagem Relacional da Epistemologia do BigData, o livro se aprofunda na discuss\u00e3o da necessidade de desenvolvimentode ferramentas que permitam entender a capacidade dos dados de inspirar, corrigir,confirmar ou negar a intui\u00e7\u00e3o humana. Com essa motiva\u00e7\u00e3o, s\u00e3o apresentadas as basesfilos\u00f3ficas para proposi\u00e7\u00f5es de formas de interven\u00e7\u00e3o na produ\u00e7\u00e3o, gest\u00e3o e an\u00e1lise deum big data, visando minimizar os riscos decorrentes deconservadorismo, inseguran\u00e7a, mistifica\u00e7\u00e3o, corrup\u00e7\u00e3o e danos sociais descritos nocap\u00edtulo 2. A autora ainda destaca o papel dos dados nos processos de pesquisa e aconstru\u00e7\u00e3o de conhecimento baseado em dados, defendendo esse tipo de abordagem, por\u00e9msem perder a vis\u00e3o cr\u00edtica consciente.No cap\u00edtulo 3, Como Incentivar o Melhor? Em Dire\u00e7\u00e3o a umaCi\u00eancia Participativa e Respons\u00e1vel, que retorna a discuss\u00e3o do bigdata como uma ferramenta para combater o fen\u00f4meno da p\u00f3s-verdade e defor\u00e7as que tentam manipular os fatos. A autora afirma que n\u00e3o h\u00e1 solu\u00e7\u00e3o m\u00e1gica ouperfeita para a crise epist\u00eamica dos tempos atuais, decorrente de uma era de tens\u00f5es eincertezas inerente \u00e0 multiplicidade de vozes. Segundo Sabina Leonelli, as solu\u00e7\u00f5es paramelhorar o julgamento dos dados apresentados passam necessariamente por: melhorintegra\u00e7\u00e3o da \u00e9tica com a pesquisa cient\u00edfica; maior participa\u00e7\u00e3o social; edesacelera\u00e7\u00e3o dos tempos da pesquisa. Nesse cap\u00edtulo tamb\u00e9m s\u00e3o exibidos os princ\u00edpiosorientadores para facilitar a transforma\u00e7\u00e3o do big data em conhecimentoconfi\u00e1vel, tais como: (1) entender o dado como uma categoria relacional; (2) manter umamanuten\u00e7\u00e3o regular e de longo prazo da infraestrutura; (3) aperfei\u00e7oar a infraestruturae habilidade de gerenciamento dos dados; (4) preservar o espa\u00e7o para a pesquisaexplorat\u00f3ria; (5) minimizar os riscos de discrimina\u00e7\u00e3o e desigualdade com o uso do maiorn\u00famero poss\u00edvel de fontes; (6) ter \u00e9tica, seguran\u00e7a e responsabilidade social comopartes integrantes da pesquisa centrada em dados; (7) vincular o uso do bigdata para fins de pesquisa ao di\u00e1logo social; e (8) fomentar o interesse ea disponibilidade de ferramentas para que todos os setores envolvidos em determinadobig data possam se relacionar e interagir.O livro avan\u00e7a para o cap\u00edtulo 4, big data depende das tecnologias envolvidas na produ\u00e7\u00e3o,no armazenamento e na an\u00e1lise dos dados e que esses atributos s\u00e3o, na verdade,consequ\u00eancia das decis\u00f5es e escolhas das pessoas respons\u00e1veis pela concep\u00e7\u00e3o e pelogerenciamento desses big data. Destacam-se como mensagens desse livroque o big data, como fonte de gera\u00e7\u00e3o de conhecimento humano, dependeda gest\u00e3o e confiabilidade dos dados e de como a sociedade interage com esses dados.Al\u00e9m disso, a autora defende veementemente que a pluralidade e a variabilidade dossaberes e m\u00e9todos do mundo da pesquisa s\u00e3o atributos valiosos que devem ser reconhecidose explorados como pot\u00eancias que beneficiam o aperfei\u00e7oamento de um bigdata, e n\u00e3o como fonte de complica\u00e7\u00f5es por apontarem limita\u00e7\u00f5es eproblemas.Em seu cap\u00edtulo de conclus\u00e3o, a autora refor\u00e7a a tese de que o conhecimento gerado apartir de um Em suma, trata-se de uma refer\u00eancia obrigat\u00f3ria para os todos os profissionais,independentemente de suas forma\u00e7\u00f5es, que desejam ingressar no mundo da ci\u00eancia de dados,o qual se consolida cada vez mais como uma \u00e1rea do conhecimento humano e j\u00e1 causagrandes impactos e transforma\u00e7\u00f5es na sociedade."}
+{"text": "To analyze the impact of the covid-19 pandemic on the functioning of Specialized Rehabilitation Centers (CER) in the SUS. An analysis of the variation in outpatient production of the CER was carried out based on data from the Outpatient Information System of the Unified Health System (SIA-SUS) from March 2019 to December 2021. Such results were compared with CER managers\u2019 perceptions about the impacts of the pandemic on the units, measured by a web survey applied between November 2020 and February 2021. Monthly averages of 247 procedures were calculated, organized into 18 groups, for three periods \u2013 year before the pandemic (YBP) and first (YP1) and second (YP2) years of the pandemic. Through the online form, information was collected on: operation and organization of services; post-covid-19 rehabilitation; actions to support the needs of users and professionals; strategies and challenges experienced. There was a 33.3% reduction in the total number of procedures in YP1 compared to YBP. There were no reductions in procedures performed by nurses and for ostomates. There was greater impairment for group activities, visual therapies and home visits. In YP2, there was a recovery of averages in relation to YBP in 11 groups of procedures, with an increase of 104.1% in Cardiorespiratory Physiotherapy. In the answers to the online form, 91.7% of the managers indicate structural and/or organizational changes in the CER, such as: creation of prioritization criteria for assistance; introduction of telerehabilitation; changes in the work process and; provision of professional training. Half of the CER already treated people with covid-19 sequelae, but not all of them had been trained to do so. Limitations in participation and social support for PWD were identified. There was a severe impact of the covid-19 pandemic on the CER. Added to the damming up of previous demands are those of post-covid-19 users, configuring a challenging picture. It is necessary to strengthen the Care Network for Persons with Disabilities, with expansion and greater integration of services and a more inclusive organization to overcome these challenges. Reflecting the profound social inequalities and implemented policies, the pandemic generated greater impacts on vulnerable populations, and can be characterized as a syndemic2.As one of the countries most affected by the covid-19 pandemic, Brazil accounts for the second highest number of deaths in the world3.Among the most vulnerable groups, people with disabilities (PWD) stand out, who tend to experience more precarious living conditions and face greater barriers to access public goods and services, including health. Such conditions make them more susceptible to the effects of the pandemic4. However, despite differences between countries, it is common for PWD health policies to face: lack of strategic planning, lack of resources and infrastructure; flaws in services management and in information production; barriers to access; difficulties in social participation of PWD and their families4.Part of the PWD need continuous assistance at different care levels, with emphasis on rehabilitation, defined as \u201ca set of measures that help people with disabilities or about to acquire disabilities to have and maintain an ideal functionality in the interaction with their environment\u201d6, which increased waiting lists for care. On the other hand, there were more people in need of rehabilitation after prolonged hospitalizations and patients with post-covid-19 syndrome, or long-term covid, characterized by persistent symptoms from mild to severe presentation, after the acute phase of infection, resulting from the systemic involvement of the organism7. The close relationship of covid-19 with the production of disabilities leads to the need for a greater number of rehabilitation actions9.This scenario has been aggravated by the pandemic in at least two ways. Initially, adapting protocols for the contingency of the disease, restricting the movement of people and redirecting resources to emergency areas affected the provision of elective services, such as rehabilitation and other care for PWD10.Growing health care needs put even more pressure on overburdened health systems. In the Brazilian case, it is important to highlight that the first integrated and comprehensive care policy for people with disabilities, the Care Network for People with Disabilities (RCPD), dates from 2012 and still faces difficulties in its implementation. One of the central elements of this policy are the Specialized Rehabilitation Centers (CER), specialized care units that act as a regional reference in the health care network and were created as an innovation in the RCPD. CER are qualified to treat two or more types of disability , in the multidisciplinary outpatient rehabilitation modelConsidering the importance of the CER in the RCPD, the objectives of this article are to analyze the impact of the pandemic on the functioning of these services and provide subsidies to inform public policies aimed at guaranteeing PWD\u2019s right to health.This study analyzed the variation in the outpatient production of CER, recorded in the SIA/SUS between March 2019 and December 2021, and compared these results with CER managers\u2019 perceptions about the impacts of the pandemic on their units.11 (2020) were selected for analysis. Data extraction was performed in March 2022 using the method developed by Saldanha et al.12. The procedures were organized into 18 groups: i) care for the person with a stoma; ii) group activity; iii) multidisciplinary assessment in visual rehabilitation; iv) medical consultation; v) consultation with a higher-level professional (except physicians); vi) Dispensation of Orthoses, Prostheses and Special Materials (OPM) for physical disabilities; vii) dispensation of OPM for visual disabilities; viii) dispensation of hearing aids; ix) provision of wheelchairs; x) diagnostic services; xi) cardiorespiratory physiotherapy; xii) supply of materials for ostomies; xiii) speech therapy; xiv) hearing therapy; xv) physical therapy; xvi) intellectual therapy; xvii) visual therapy; xviii) home visit. These procedures were also evaluated according to the performer\u2019s professional category.A total of 247 procedures registered in the System of Management of the Table of Procedures, Medications and Ortheses/Prostheses and Special Materials (SIGTAP) of SUS, listed by the Rehabilitation Instruction of the Ministry of HealthData from all CER accredited by SUS in November 2019 were analyzed, according to information from the Department of Specialized and Thematic Care of the Ministry of Health Secretariat of Specialized Health Care, which presented production data in the selected period.To assess the effect of the pandemic, monthly averages of the number of procedures were calculated in three periods: year before the pandemic in the country (YBP) from March 2019 to February 2020; first year of the pandemic (YP1) from March 2020 to February 2021; and second year of the pandemic (YP2) from March to December 2021.An evolution in the number of procedures performed was observed by comparing the averages of YP1 and YBP, and between YP2 and YBP, using the following expression: 13.This is a non-probabilistic, convenience sample. Recruitment took place by telephone contact and email invitations to the CER accredited by SUS at the time. Individuals who identified themselves as CER \u201cmanagers\u201d were included. To prevent duplicate responses, the respondent\u2019s e-mail address was used as the only marker.The results were contextualized and triangulated with the CER managers\u2019 perception, measured by a web survey, applied between November 2020 and February 2021, on the Google Forms platform. To guarantee data quality, the research followed the criteria proposed by the Checklist for Reporting Results of Internet E-SurveysThe questionnaire prepared by the researchers contained 44 questions, of which 42 were closed, divided into the following themes: general characteristics of the respondent and the CER; functioning of the service during the pandemic; professional training; structure for telerehabilitation; care flow for post-covid-19 patients; social support. Open questions addressed the main challenges experienced and the strategies used for coping.Only complete questionnaires were registered on the database, without weighting the questions. After consistency analysis, descriptive analysis of categorical variables was performed, presented in percentage results. For the open questions, there was identification of relevant thematic content and with greater repetition.For questions about the impact of the pandemic on activities, the Likert scale was used. In this case, responses were converted into numerical data . There was the answer option \u201cdid not perform\u201d the activity previously, to filter the respondents who would be accounted for each type of activity. Results are presented as the average obtained from the set of valid responses. The analyses were conducted using the Rv3.5 software and followed these steps: i) content analysis applied to the answers to the questions, then submitted to pre-analysis, ii) exploration of the material and iii) treatment of the results, according to the main themes identified.This study was carried out within the scope of the national research \u201cChallenges of implementing the Care Network for Persons with Disabilities in different regional contexts: multidimensional and multiscale approach\u201d, approved by the Ethics Committee of the Faculty of Public Health of the University of S\u00e3o Paulo, under the number 4,726,914.Comparison between periods shows a decrease of 33.3% in the total number of procedures in the first year of the pandemic, that is, a loss of 178,700.33 monthly procedures . After tThe greatest losses in YP1 occurred for collective and individual therapeutic care of all specialties, accompanied by diagnostic approaches and distribution of orthoses, prostheses and special materials . Only caIn the comparison between YP2 and YBP, recovery was observed in 11 of the 18 groups, with emphasis on the 104.1% increase in Cardiorespiratory Physiotherapy procedures. Group activities, multidisciplinary assessments, visual therapies, hearing therapies, speech therapy and provision of wheelchairs and OPM for visual disability had not yet recovered the average number of procedures in YP2.The analysis of procedures by performing professional category reveals that only nursing procedures did not suffer a reduction in YP1. In YP2, dentists, pedagogues/psychopedagogues and physicians had not yet reached the average number of YBP procedures .A total of 93 responses to the online form were received. Excluding repeated entries, a final number of 85 respondents was obtained, active in 34.3% of the total number of qualified CER; among them, physiotherapists (35.3%), speech-language-hearing therapists (12.9%), social workers (10.6%), psychologists (9.4%) administrators (7.1%) and other professionals (24.7%). Among the participants, 70.6% worked in CER with up to 50 professionals.The perception of the responding managers is that all actions were affected, with greater damage to user group activities, visual therapies and home visits . When asRegarding the organization of services during the pandemic, 91.7% of managers indicate structural and/or organizational changes in the units to adapt to the new reality . In confCER professionals were relocated to other units in 41.2% of cases. In 60.0% of the CER, workers started to perform other functions in the same unit. And there were removals of workers due to a condition or suspicion of covid-19 in 97.6% of the CER that answered the survey.Criteria for prioritizing patients who should be seen in person were introduced. The most reported were: individuals at risk of injuries or delay in functionality; greater neuromotor impairment; people with dysphagia and; children in development stimulation. Acute conditions and care for people without comorbidities were also identified as priorities. For PWD with comorbidities, remote care was prioritized, with a view to reducing their exposure and the risk of contamination in the health service.Most managers stated that there was professional training on: prevention and transmission of covid-19 (77.65%), use of PPE (84.71%) and care flow for covid-19 (63.53%).At the moment when the web survey was conducted, half of the services were already providing care to people with covid-19 sequelae. In 81.4% of these services, such users were prioritized for scheduling, and in 55.8% a specific protocol was used. Care guidelines for post-covid-19 rehabilitation cases were received by 54.1% of managers. Structural adaptations in the unit to receive these cases were made in 34.1%. However, 63.5% stated that professional training on rehabilitation after covid-19 had not been offered.Although 83.5% of the managers reported tele-assistance, technological resources for telerehabilitation were unavailable or insufficient in more than half of the units, which led professionals to use their cell phones for audio and video calls (68.7%). In 27.1% of cases, users did not have the structural conditions to be served virtually.A survey of the served population\u2019s health needs was carried out in 32.6% of the CER. Managers were not able to describe specific tools used in this diagnosis. Telephone contacts and remote consultations limited to the adaptation of rehabilitation procedures and occasional referrals to other services were reported. Only 9.4% mentioned articulation actions with the health network, territory and/or other sectors.As part of the fight against the pandemic, 62.3% of the services carried out social assessment actions and directed users to social assistance resources . Deliberative council meetings for social participation were suspended or reduced in 42.9% of the units. Informational materials on the specificities of PWD and the covid-19 pandemic were produced and/or disseminated by 63.5% of the services.In the open questions, there were reports of total shutdown of some services in the initial moments of the pandemic, in addition to struggles and ease regarding understanding and adhering to the new formats of care by users and their families. Insufficient adequate transport, fear of contamination and insecurity were some of the factors described by managers that would have led to the discontinuation of therapies, at the initiative of users. The teams\u2019 performance in reinventing the ways of working and in the initiative to develop protocols for the new demands was highlighted.Well-structured action plans and strategies, with systematized organization by the institution itself and integrated action with the health network actions to face the pandemic, were rarely described. Difficulties were reported to obtain instructions from higher authorities, lack of support for the introduction of telehealth services and registration and billing of this procedure, as well as pressure for the productivity of services that made it difficult to maintain biosafety protocols.14. The findings presented here demonstrate a profound decrease in the number of procedures performed, especially in the initial months of the pandemic, as well as a decrease in the offer of therapeutic groups and individual consultations, a high rate of professional leave and an insufficient structure for telerehabilitation. These can be configured as additional challenges for the consolidation of this network.Even before the covid-19 pandemic, difficulties in implementing the RCPD were already being discussed to guarantee equity in access and comprehensiveness of care16. This impact can be even greater, since the \u201cnumber of procedures\u201d should not be confused with the \u201cnumber of services\u201d performed, because a single service can comprise more than one procedure.The results presented are in line with other studies in relation to impairments in accessing health services by PWDThere is a convergence between the managers\u2019 perception and the losses verified for the outpatient production of CER in YP1. However, activities such as team meetings, networking and matrix support could not be compared due to the absence of codes for recording procedures at the time of data collection, even though they configure key actions in the formulation of strategies in a crisis situation. A similar situation occurs for multidisciplinary assessments in hearing, physical and intellectual rehabilitation. Such procedures are given to initial assessments of new users accessing rehabilitation services.The procedure that underwent the greatest decrease during the analyzed period was that of \u201cgroup activities\u201d. The need for social distancing is a decisive factor for this finding. However, collective activities are essential for maintaining motor gains and preventing chronic diseases, in addition to providing socialization, exchange of experiences and knowledge. Prolonging non-performance of group activities may severely impact users\u2019 physical, social and cognitive conditions.Procedures aimed specifically at visual disability, as well as hearing and speech rehabilitation, have not returned to pre-pandemic performance levels, which denotes the risk of aggravating disparities in care for different types and levels of disability.The increase in \u201cConsultation of higher-level professionals (except doctors)\u201d in YP2 can be explained by the wide use of this code, encompassing both face-to-face therapies and virtual ones implemented . In addition, the code may have been used for individual calls originating from suspended groups.Although in 2021 there was a greater wave of cases and deaths, there was an increase in some procedures to pre-YBP levels. This fact may be related to local guidelines for the resumption of elective outpatient care from the first half of 2021, concomitant with the start of vaccination and dissemination of prevention measures, especially the use of masks.17. The relocation of functions among workers, and from them to other health units, may also have made it difficult to maintain activities. In some municipalities, especially physiotherapists were displaced to cover the created hospital beds.The high occurrence of professional leave due to covid-19 in the responding CER is similar to that observed in other countries18. Patients hospitalized in intensive care units for long periods need to be included in rehabilitation programs to deal with the consequences of immobility and the use of mechanical ventilation19.The sequelae of covid-19, due to their complexity and diversity, have presented themselves as an additional challenge for health care networks20.In Brazil, these cases of post-covid-19 functional disabilities started to be directed to rehabilitation services. This fact may explain the significant increase in physiotherapeutic procedures for respiratory and cardiovascular conditions, and procedures related to ostomy care, especially tracheostomies resulting from the need for prolonged intubation, corroborating Dinuzzi et al.11. Even so, there was an effort to guarantee priority access to these patients, even if difficulties were identified for the reconfiguration of services to occur in a timely manner to adequately serve them.When responding to post-covid-19 demands, the CER undergo a change in the service profile. Cardiorespiratory rehabilitation was not an action commonly performed in the CER, since the service is oriented to attend to hearing, physical, intellectual and visual disabilitiesThis situation was not necessarily accompanied by the increase and training of teams or by the expansion of the capacity of services. Without network expansion, it is likely that other users will experience greater difficulties in ensuring the necessary care. The quality of care for new and old demands in rehabilitation will depend on the instrumentalization of multidisciplinary teams, through permanent education, evaluation and monitoring of changes in work processes, and the matrix of cases and experiences.21, the results show that part of the services did not have adequate and institutionally guaranteed conditions for the use of this tool.Although telerehabilitation is identified as a promising strategy for maintaining assistance to PWD during the pandemic22. Teleconsultations were authorized by class councils and the Ministry of Health based on the tensions generated by the pandemic. Also, new work tools had to be quickly assimilated by health professionals and services.The use of telehealth in Brazil is challenging due to regulatory and structural factors10. With precarious internet access in many Brazilian locations, telerehabilitation programs could hardly be applied extensively, and would run the risk of discriminating against the digitally excluded population if there are no significant changes in public policies23.Although most respondents state that users are able to access telerehabilitation, it is necessary to highlight that the CER are concentrated in state capitals and municipalities with better infrastructure24. The specificities within this heterogeneous group were not covered by the coping plans, including regarding even greater vulnerabilities, such as institutionalized PWD, living on the streets, immigrants and women25. Such negligence reflects a process of systematic invisibility26. Despite the recommendations for the adoption of inclusive measures, based on the logic of the law27, no data were observed to suggest this implementation.Protocols and guidelines for the general population were replicated without customization for PWD and their reference services28.Most respondents stated that they carried out some type of action aimed at providing social support to their users during isolation, which can be considered positive as compared to the fragility of social support actions in coping with covid-19 identified in other areas of assistance29.The analysis of public policies adopted during the pandemic period, as well as future reformulations, depends on the production of reliable and specific epidemiological information on the population living with disabilities. Failure to meet this assumption can configure, in itself, a mechanism of social exclusion, since disaggregated data on the involvement of covid-19 by status, type and severity of disability are rare, although extremely necessary30.One of the limits of this study is inherent to the use of SIA-SUS data. Even though there may be a delay in recording procedures, it is an information system with considerable agility that should be used for planning, supply analysis, coverage and selection of prioritiesAnother known limitation is that the web survey did not use a probabilistic sample. Even so, CER responses were obtained with characteristics similar to those of the services available in the country . It is bBy overlapping two sources of information, secondary data and managers\u2019 perceptions, the results obtained by analyzing the former come to life, bringing them closer to reality with the use of a methodological approach pertinent to the proposed objective. Understanding the reality of PWD care in the country, including territories without CER, and variations within the different stages of the pandemic, requires targeted studies.In the early months of the covid-19 pandemic, there was a severe impact on the ability to provide services in the CER in Brazil. Such effects may have also occurred on other rehabilitation services. In addition to the reduction in rehabilitation procedures and consultations, substantial changes were observed in the functioning of the teams, which led to the damming of existing demands.The results show a scenario that needs to be changed and point out ways in which policy makers and service managers can follow to improve care for PWD.Rehabilitation services will have to deal not only with the inclusion of new treatment protocols for the post-covid-19 patient, but also with attending to: users who have suffered consequences from the decrease in volume, or forced interruption, of their therapies; those who present losses resulting from health conditions aggravated by isolation; in addition to all those referred by new diagnoses of congenital and acquired deficiencies. In short, the scenario is one of extreme overload for these services.The covid-19 pandemic highlights the need to strengthen the SUS and the RCPD, through expansion and integration of health services, with co-responsibility between primary health care and specialized, hospital and rehabilitation care. Favoring the full exercise of autonomy and functional capacity can only be achieved through broad social protection and inclusive social organization, during and after the pandemic. 1. Reflexo das profundas desigualdades sociais e das pol\u00edticas implementadas, a pandemia gerou impactos maiores sobre popula\u00e7\u00f5es vulner\u00e1veis, e pode ser caracterizada como uma sindemia2.O Brasil \u00e9 um dos pa\u00edses mais afetados pela pandemia de covid-19, e responde pelo segundo maior n\u00famero de mortes no mundo3.Dentre os grupos mais vulner\u00e1veis, o das pessoas com defici\u00eancia (PCD) se sobressai, visto que tende a experimentar condi\u00e7\u00f5es de vida mais prec\u00e1rias e enfrentar maiores barreiras de acesso a bens e servi\u00e7os p\u00fablicos, inclusive de sa\u00fade. Tais condicionantes as tornam mais suscet\u00edveis aos efeitos da pandemia4. Contudo, apesar de diferen\u00e7as entre pa\u00edses, \u00e9 comum que as pol\u00edticas de sa\u00fade para PCD enfrentem: aus\u00eancia de planejamento estrat\u00e9gico, falta de recursos e infraestrutura; falhas na gest\u00e3o de servi\u00e7os e na produ\u00e7\u00e3o de informa\u00e7\u00f5es; barreiras ao acesso; baixo envolvimento das PCD e seus familiares4.Parcela das PCD necessita de cuidados continuados em diferentes n\u00edveis assistenciais, com destaque para reabilita\u00e7\u00e3o, definida como \u201cum conjunto de medidas que ajudam pessoas com defici\u00eancia ou prestes a adquirir defici\u00eancias a terem e manterem uma funcionalidade ideal na intera\u00e7\u00e3o com seu ambiente\u201d6, o que aumentou filas de espera por atendimento. Por outro lado, houve maior n\u00famero de pessoas que necessitam de reabilita\u00e7\u00e3o ap\u00f3s interna\u00e7\u00f5es prolongadas e de pacientes com s\u00edndrome p\u00f3s-covid-19, ou covid longa, caracterizada por sintomas persistentes de apresenta\u00e7\u00e3o leve a severa, ap\u00f3s a fase aguda de infec\u00e7\u00e3o, decorrentes do acometimento sist\u00eamico do organismo7. A estreita rela\u00e7\u00e3o da covid-19 com a produ\u00e7\u00e3o de defici\u00eancias leva \u00e0 necessidade de um maior n\u00famero de a\u00e7\u00f5es de reabilita\u00e7\u00e3o9.Este cen\u00e1rio foi agravado pela pandemia em pelo menos duas dire\u00e7\u00f5es. Inicialmente, a adequa\u00e7\u00e3o aos protocolos para conting\u00eancia da doen\u00e7a, restri\u00e7\u00e3o da circula\u00e7\u00e3o de pessoas e redirecionamento de recursos para \u00e1reas emergenciais afetaram a oferta de servi\u00e7os eletivos, como a reabilita\u00e7\u00e3o e outros cuidados para PCD10.O aumento das necessidades de sa\u00fade pressiona ainda mais os sobrecarregados sistemas de sa\u00fade. No caso brasileiro, \u00e9 relevante destacar que a primeira pol\u00edtica integrada e abrangente de cuidados \u00e0s PCD, a Rede de Cuidados \u00e0 Pessoa com Defici\u00eancia (RCPD), data de 2012 e ainda enfrenta dificuldades em sua implementa\u00e7\u00e3o. Um dos elementos centrais desta pol\u00edtica s\u00e3o os Centros Especializados em Reabilita\u00e7\u00e3o (CER), unidades de aten\u00e7\u00e3o especializada que atuam como refer\u00eancia regional da rede de aten\u00e7\u00e3o \u00e0 sa\u00fade e foram criadas como inova\u00e7\u00e3o na RCPD. Os CER s\u00e3o habilitados a atender dois ou mais tipos de defici\u00eancia , no modelo de reabilita\u00e7\u00e3o ambulatorial multiprofissionalConsiderando a import\u00e2ncia dos CER na RCPD, os objetivos do presente artigo s\u00e3o analisar o impacto da pandemia no funcionamento desses servi\u00e7os e fornecer subs\u00eddios para informar pol\u00edticas p\u00fablicas voltadas \u00e0 garantia do direito \u00e0 sa\u00fade das PCD.Este estudo analisou a varia\u00e7\u00e3o da produ\u00e7\u00e3o ambulatorial dos CER, registrada no SIA/SUS entre mar\u00e7o de 2019 e dezembro de 2021, e cotejou tais resultados com as percep\u00e7\u00f5es de gestores de CER acerca dos impactos da pandemia em suas unidades.11 (2020). A extra\u00e7\u00e3o dos dados foi realizada em mar\u00e7o de 2022 pelo m\u00e9todo elaborado por Saldanha et al.12. Os procedimentos foram organizados em 18 grupos: i) atendimento \u00e0 pessoa ostomizada; ii) atividade em grupo; iii) avalia\u00e7\u00e3o multiprofissional em reabilita\u00e7\u00e3o visual; iv) consulta m\u00e9dica; v) consulta de profissional de n\u00edvel superior (exceto m\u00e9dico); vi) dispensa\u00e7\u00e3o de \u00d3rteses, Pr\u00f3teses e Materiais Especiais(OPM) para defici\u00eancia f\u00edsica; vii) dispensa\u00e7\u00e3o de OPM para defici\u00eancia visual; viii) dispensa\u00e7\u00e3o de aparelhos auditivos; ix) dispensa\u00e7\u00e3o de cadeiras de rodas; x) exame diagn\u00f3stico; xi) fisioterapia cardiorrespirat\u00f3ria; xii) fornecimento de materiais para ostomias; xiii) terapia fonoaudiol\u00f3gica; xiv) terapia-reabilita\u00e7\u00e3o auditiva; xv) terapia-reabilita\u00e7\u00e3o f\u00edsica; xvi) terapia-reabilita\u00e7\u00e3o intelectual; xvii) terapia-reabilita\u00e7\u00e3o visual; xviii) visita domiciliar. Esses procedimentos foram ainda avaliados segundo a categoria profissional do executante.Foram selecionados para an\u00e1lise 247 procedimentos registrados no Sistema de Gerenciamento da Tabela de Procedimentos, Medicamentos e \u00d3rteses/Pr\u00f3teses e Materiais Especiais (SIGTAP) do SUS, elencados pelo Instrutivo de Reabilita\u00e7\u00e3o do Minist\u00e9rio da Sa\u00fadeForam analisados dados de todos os CER habilitados em novembro de 2019, segundo informa\u00e7\u00f5es do Departamento de Aten\u00e7\u00e3o Especializada e Tem\u00e1tica da Secretaria de Aten\u00e7\u00e3o Especializada em Sa\u00fade do Minist\u00e9rio da Sa\u00fade, que apresentaram dados de produ\u00e7\u00e3o no per\u00edodo selecionado.Para avaliar o efeito da pandemia, foram calculadas m\u00e9dias mensais do n\u00famero de procedimentos em tr\u00eas per\u00edodos: ano anterior \u00e0 pandemia no pa\u00eds (AAP) de mar\u00e7o de 2019 a fevereiro de 2020; primeiro ano de pandemia (AP1) de mar\u00e7o de 2020 a fevereiro de 2021; e segundo ano de pandemia (AP2) de mar\u00e7o a dezembro de 2021.Observou-se a evolu\u00e7\u00e3o do n\u00famero de procedimentos realizados pela compara\u00e7\u00e3o entre m\u00e9dias de AP1 e APP, e entre AP2 e APP, utilizando-se a seguinte express\u00e3o: Checklist for Reporting Results of Internet E-Surveys13.Os resultados foram contextualizados e triangulados com a percep\u00e7\u00e3o de gestores dos CER, aferida por formul\u00e1rio on-line, aplicado entre novembro de 2020 e fevereiro de 2021, na plataforma Google Forms. Para garantia da qualidade dos dados, a pesquisa seguiu os crit\u00e9rios propostos pelo Trata-se de uma amostra n\u00e3o probabil\u00edstica, de conveni\u00eancia. O recrutamento se deu por contato telef\u00f4nico e convites por e-mail para os CER habilitados \u00e0 \u00e9poca. Foram inclu\u00eddos indiv\u00edduos que se identificaram como \u201cgestores\u201d de CER. Para prevenir respostas duplicadas, utilizou-se o endere\u00e7o de e-mail do respondente como marcador \u00fanico.O question\u00e1rio elaborado pelos pesquisadores continha 44 perguntas, das quais 42 eram fechadas, divididas entre os seguintes eixos tem\u00e1ticos: caracter\u00edsticas gerais do respondente e do CER; funcionamento do servi\u00e7o durante a pandemia; capacita\u00e7\u00e3o profissional; estrutura para telerreabilita\u00e7\u00e3o; fluxo assistencial para paciente p\u00f3s-covid-19; apoio social. Quest\u00f5es abertas abordavam os principais desafios vivenciados e as estrat\u00e9gias utilizadas para o enfrentamento.Somente question\u00e1rios completos foram registrados no banco de dados, sem pondera\u00e7\u00e3o de valor \u00e0s quest\u00f5es. Ap\u00f3s an\u00e1lise de consist\u00eancia, realizou-se an\u00e1lise descritiva das vari\u00e1veis categ\u00f3ricas, apresentada em resultados percentuais. Para as perguntas abertas, houve identifica\u00e7\u00e3o dos conte\u00fados tem\u00e1ticos relevantes e com maior repeti\u00e7\u00e3o.software Rv3.5 e seguiram estas etapas: i) an\u00e1lise de conte\u00fado aplicada \u00e0s respostas das quest\u00f5es, depois submetidas a pr\u00e9-an\u00e1lise, ii) explora\u00e7\u00e3o do material e iii) tratamento dos resultados, segundo as principais tem\u00e1ticas identificadas.Nas quest\u00f5es sobre o impacto da pandemia nas atividades foi empregada a escala de Likert. Neste caso, as respostas foram convertidas em dados num\u00e9ricos . Havia a op\u00e7\u00e3o de resposta \u201cn\u00e3o realizava\u201d a atividade previamente, para filtrar os respondentes que seriam contabilizados em cada tipo de atividade. Os resultados s\u00e3o apresentados pela m\u00e9dia obtida do conjunto de respostas v\u00e1lidas. As an\u00e1lises foram conduzidas usando o Este estudo foi executado no \u00e2mbito da pesquisa nacional \u201cDesafios da implementa\u00e7\u00e3o da Rede de Cuidados \u00e0 Pessoa com Defici\u00eancia em diferentes contextos regionais: abordagem multidimensional e multiescalar\u201d, aprovada pelo Comit\u00ea de \u00c9tica da Faculdade de Sa\u00fade P\u00fablica da Universidade de S\u00e3o Paulo, sob o n\u00famero 4.726.914.websurvey.Na A compara\u00e7\u00e3o entre per\u00edodos evidencia diminui\u00e7\u00e3o de 33,3% no n\u00famero total de procedimentos no primeiro ano de pandemia, ou seja, perda de 178.700,33 procedimentos mensais . Ap\u00f3s esAs maiores perdas em AP1 ocorreram para atendimentos terap\u00eauticos coletivos e individuais de todas as especialidades, acompanhados por abordagens diagn\u00f3sticas e dispensa\u00e7\u00e3o de \u00f3rteses, pr\u00f3teses e materiais especiais . Apenas Na compara\u00e7\u00e3o entre AP2 e AAP, observa-se recupera\u00e7\u00e3o de 11 dos 18 grupos, com destaque para o aumento de 104,1% dos procedimentos de Fisioterapia Cardiorrespirat\u00f3ria. As atividades em grupo, avalia\u00e7\u00f5es multiprofissionais, terapias visuais, terapias auditivas, terapia fonoaudiol\u00f3gica e dispensa\u00e7\u00e3o de cadeiras de rodas e de OPM para defici\u00eancia visual ainda n\u00e3o haviam recuperado o n\u00famero m\u00e9dio de procedimentos em AP2.A an\u00e1lise dos procedimentos por categoria profissional executante revela que apenas os procedimentos de enfermagem n\u00e3o sofreram redu\u00e7\u00e3o em AP1. Em AP2, cirurgi\u00f5es dentistas, pedagogos/psicopedagogos e m\u00e9dicos ainda n\u00e3o haviam alcan\u00e7ado a m\u00e9dia de procedimentos de APP .Foram recebidas 93 respostas ao formul\u00e1rio on-line. Exclu\u00eddas as entradas repetidas, obteve-se o n\u00famero final de 85 respondentes, atuantes em 34,3% do total de CER habilitados; dentre eles, fisioterapeutas , fonoaudi\u00f3logos , assistentes sociais , psic\u00f3logos  administradores  e outros profissionais . Entre os participantes, 70,6% atuavam em CER com at\u00e9 50 profissionais.A percep\u00e7\u00e3o dos gestores respondentes \u00e9 de que todas as a\u00e7\u00f5es foram afetadas, com maior preju\u00edzo para as atividades em grupo de usu\u00e1rios, terapias visuais e visitas domiciliares. Quando questionados sobre as dificuldades vivenciadas, houve relatos de servi\u00e7os totalmente paralisados nos momentos iniciais da pandemia.Em rela\u00e7\u00e3o \u00e0 organiza\u00e7\u00e3o dos servi\u00e7os durante a pandemia, 91,7% dos gestores indicam mudan\u00e7as estruturais e/ou organizacionais nas unidades para adapta\u00e7\u00e3o \u00e0 nova realidade . Em confHouve realoca\u00e7\u00e3o de profissionais dos CER para outras unidades em 41,2% dos casos. Em 60,0% dos CER, trabalhadores passaram a desempenhar outras fun\u00e7\u00f5es na mesma unidade. E houve afastamento de trabalhadores devido a quadro ou suspeita de covid-19 em 97,6% dos CER que responderam \u00e0 pesquisa.Crit\u00e9rios para prioriza\u00e7\u00e3o dos pacientes que deveriam ser atendidos presencialmente foram introduzidos. Os mais relatados foram: indiv\u00edduos com risco de agravos ou de atraso na funcionalidade; maior comprometimento neuromotor; disf\u00e1gicos e; crian\u00e7as em estimula\u00e7\u00e3o do desenvolvimento. Quadros agudos e o atendimento de pessoas sem comorbidades tamb\u00e9m foram apontados como prioridades. Para as PCD com comorbidades foram priorizados atendimentos \u00e0 dist\u00e2ncia, com vistas a diminuir sua exposi\u00e7\u00e3o e o risco de contamina\u00e7\u00e3o no servi\u00e7o de sa\u00fade.A maior parte dos gestores afirmou que houve capacita\u00e7\u00e3o profissional sobre: preven\u00e7\u00e3o e transmiss\u00e3o da covid-19 , uso de EPI  e fluxo assistencial para covid-19 .websurvey, metade dos servi\u00e7os j\u00e1 realizava atendimentos de pessoas com sequelas de covid-19. Em 81,4% destes servi\u00e7os tais usu\u00e1rios eram priorizados para agendamento, e em 55,8% protocolo espec\u00edfico era empregado. As diretrizes assistenciais para casos de reabilita\u00e7\u00e3o p\u00f3s-covid-19 foram recebidas por 54,1% dos gestores. Adapta\u00e7\u00f5es estruturais na unidade para receber estes casos foram feitas em 34,1%. No entanto, 63,5% afirmaram que n\u00e3o havia sido ofertada capacita\u00e7\u00e3o profissional sobre reabilita\u00e7\u00e3o ap\u00f3s covid-19.No momento de aplica\u00e7\u00e3o do Embora 83,5% dos gestores relatem a realiza\u00e7\u00e3o de teleatendimentos, recursos tecnol\u00f3gicos para telerreabilita\u00e7\u00e3o eram indispon\u00edveis ou insuficientes em mais da metade das unidades, o que levou profissionais a utilizar os pr\u00f3prios celulares para chamadas de \u00e1udio e v\u00eddeo . Em 27,1% dos casos, os usu\u00e1rios n\u00e3o tinham condi\u00e7\u00f5es estruturais para serem atendidos virtualmente.O levantamento das necessidades em sa\u00fade da popula\u00e7\u00e3o atendida foi feito em 32,6% dos CER. Gestores n\u00e3o foram capazes de descrever ferramentas espec\u00edficas utilizadas nesse diagn\u00f3stico. Relataram-se contatos telef\u00f4nicos e atendimentos remotos limitados \u00e0 adequa\u00e7\u00e3o de condutas de reabilita\u00e7\u00e3o e eventuais encaminhamentos para outros servi\u00e7os. Apenas 9,4% mencionaram a\u00e7\u00f5es de articula\u00e7\u00e3o com a rede de sa\u00fade, territ\u00f3rio e/ou outros setores.Como parte do enfrentamento da pandemia, 62,3% dos servi\u00e7os realizaram a\u00e7\u00f5es de avalia\u00e7\u00e3o social e direcionamento dos usu\u00e1rios para recursos da assist\u00eancia social . Reuni\u00f5es de conselhos deliberativos para participa\u00e7\u00e3o social foram suspensas ou reduzidas em 42,9% das unidades. Foram produzidos e/ou divulgados materiais informativos sobre especificidades das PCD e a pandemia de covid-19 por 63,5% dos servi\u00e7os.Nas quest\u00f5es abertas, houve relatos de paralisa\u00e7\u00e3o total de alguns servi\u00e7os nos momentos iniciais da pandemia, al\u00e9m de dificuldades e facilidades quanto \u00e0 compreens\u00e3o e ader\u00eancia aos novos formatos de atendimentos pelos usu\u00e1rios e suas fam\u00edlias. A insufici\u00eancia de transporte adequado, o medo de contamina\u00e7\u00e3o e inseguran\u00e7a foram alguns fatores descritos pelos gestores que teriam levado \u00e0 descontinuidade das terapias, por iniciativa dos usu\u00e1rios. Foi destacada a atua\u00e7\u00e3o das equipes na reinven\u00e7\u00e3o dos modos de atuar e na iniciativa de desenvolver protocolos para as novas demandas.Raramente foram descritos planos de a\u00e7\u00e3o e estrat\u00e9gias bem estruturadas, com organiza\u00e7\u00e3o sistematizada da pr\u00f3pria institui\u00e7\u00e3o e atua\u00e7\u00e3o integrada \u00e0s a\u00e7\u00f5es da rede de sa\u00fade para o enfrentamento \u00e0 pandemia. Foram reportadas dificuldades para obter instru\u00e7\u00f5es por inst\u00e2ncias superiores, falta de suporte para introdu\u00e7\u00e3o do teleatendimento e para registro e faturamento desse procedimento, bem como press\u00e3o pela produtividade dos servi\u00e7os que dificultou a manuten\u00e7\u00e3o dos protocolos de biosseguran\u00e7a.14. Os achados aqui apresentados demonstram uma profunda diminui\u00e7\u00e3o dos procedimentos realizados, sobretudo nos meses iniciais da pandemia, bem como a diminui\u00e7\u00e3o da oferta de grupos terap\u00eauticos e atendimentos individuais, alto \u00edndice de afastamento de profissionais e estrutura insuficiente para telerreabilita\u00e7\u00e3o. Estes podem se configurar como desafios adicionais para a consolida\u00e7\u00e3o dessa rede.Antes mesmo da pandemia de covid-19 j\u00e1 se discutiam dificuldades de implanta\u00e7\u00e3o da RCPD para garantir equidade no acesso e integralidade do cuidado16. Esse impacto pode ser ainda maior, uma vez que o \u201cn\u00famero de procedimentos\u201d n\u00e3o deve ser confundido com o \u201cn\u00famero de atendimentos\u201d executados, j\u00e1 que um \u00fanico atendimento pode compreender mais de um procedimento.Os resultados apresentados v\u00e3o ao encontro de outros estudos em rela\u00e7\u00e3o aos preju\u00edzos no acesso a servi\u00e7os de sa\u00fade pelas PCDNota-se converg\u00eancia entre a percep\u00e7\u00e3o dos gestores e as perdas verificadas para a produ\u00e7\u00e3o ambulatorial dos CER em AP1. Contudo, atividades como reuni\u00f5es de equipe, articula\u00e7\u00e3o em rede e matriciamento n\u00e3o puderam ser comparadas pela aus\u00eancia de c\u00f3digos para registros dos procedimentos na \u00e9poca do levantamento dos dados, mesmo que configurem a\u00e7\u00f5es-chave na formula\u00e7\u00e3o de estrat\u00e9gias em situa\u00e7\u00e3o de crise. Situa\u00e7\u00e3o semelhante ocorre para avalia\u00e7\u00f5es multiprofissionais em reabilita\u00e7\u00e3o auditiva, f\u00edsica e intelectual. Tais procedimentos s\u00e3o dados a avalia\u00e7\u00f5es iniciais de novos usu\u00e1rios acessando os servi\u00e7os de reabilita\u00e7\u00e3o.O procedimento que sofreu maior diminui\u00e7\u00e3o, durante o per\u00edodo analisado, foi o de \u201catividades em grupo\u201d. A necessidade de distanciamento social \u00e9 fator decisivo para tal achado. No entanto, as atividades coletivas s\u00e3o essenciais para manuten\u00e7\u00e3o dos ganhos motores e para preven\u00e7\u00e3o dos agravos cr\u00f4nicos, al\u00e9m de propiciar socializa\u00e7\u00e3o, trocas de experi\u00eancias e de saberes. O prolongamento da n\u00e3o realiza\u00e7\u00e3o das atividades em grupo poder\u00e1 impactar severamente as condi\u00e7\u00f5es f\u00edsicas, sociais e cognitivas dos usu\u00e1rios.Procedimentos voltados especificamente para defici\u00eancia visual, assim como reabilita\u00e7\u00e3o auditiva e terapia fonoaudiol\u00f3gica, n\u00e3o retomaram patamares de execu\u00e7\u00e3o anteriores \u00e0 pandemia, o que denota o risco de agravar disparidades na assist\u00eancia para diferentes tipos e n\u00edveis de defici\u00eancia.O incremento de \u201cConsulta de profissionais de n\u00edvel superior (exceto m\u00e9dico)\u201d em AP2 pode ser explicado pela ampla utiliza\u00e7\u00e3o deste c\u00f3digo, englobando tanto as terapias presenciais mantidas quanto as virtuais implantadas . Al\u00e9m disso, o c\u00f3digo pode ter sido utilizado para atendimentos individuais originados a partir de grupos suspensos.Ainda que no ano de 2021 tenha ocorrido uma maior onda de casos e mortes, houve aumento de alguns procedimentos a n\u00edveis anteriores a APP. Este fato pode estar relacionado \u00e0s orienta\u00e7\u00f5es locais de retomada de atendimentos ambulatoriais eletivos a partir do primeiro semestre de 2021, concomitantes ao in\u00edcio da vacina\u00e7\u00e3o e divulga\u00e7\u00e3o de medidas de preven\u00e7\u00e3o, sobretudo o uso de m\u00e1scaras.17. O remanejamento de fun\u00e7\u00f5es entre os trabalhadores, e destes para outras unidades de sa\u00fade tamb\u00e9m pode ter dificultado a manuten\u00e7\u00e3o das atividades. Em alguns munic\u00edpios, especialmente os fisioterapeutas foram deslocados para cobrir os leitos hospitalares criados.A elevada ocorr\u00eancia de afastamento profissional por covid-19 nos CER respondentes \u00e9 similar \u00e0 verificada em outros pa\u00edses18. Pacientes hospitalizados em unidades de terapia intensiva por longos per\u00edodos necessitam ser inclu\u00eddos em programas de reabilita\u00e7\u00e3o para lidar com as consequ\u00eancias do imobilismo e do uso de ventila\u00e7\u00e3o mec\u00e2nica19.As sequelas de covid-19, por sua complexidade e diversidade, t\u00eam se apresentado como um desafio adicional para as redes de aten\u00e7\u00e3o \u00e0 sa\u00fadeet al20.No Brasil, estes casos de incapacidades funcionais p\u00f3s-covid-19 passaram a ser direcionados para servi\u00e7os de reabilita\u00e7\u00e3o. Este fato pode explicar o expressivo aumento dos procedimentos fisioterap\u00eauticos para quadros respirat\u00f3rios e cardiovasculares, e dos procedimentos relacionados aos cuidados de ostomias, sobretudo as traqueostomias resultantes da necessidade de intuba\u00e7\u00e3o prolongada, corroborando Dinuzzi 11. Ainda assim, houve esfor\u00e7o de garantir o acesso priorit\u00e1rio a estes pacientes, mesmo que se identifiquem dificuldades para que a reconfigura\u00e7\u00e3o dos servi\u00e7os ocorresse em tempo h\u00e1bil para atend\u00ea-los adequadamente.Ao responder pelas demandas p\u00f3s-covid-19, os CER passam por mudan\u00e7a no perfil de atendimento. A reabilita\u00e7\u00e3o cardiorrespirat\u00f3ria n\u00e3o era uma a\u00e7\u00e3o comumente realizada nos CER j\u00e1 que o servi\u00e7o \u00e9 orientado para o atendimento das defici\u00eancias auditiva, f\u00edsica, intelectual e visualTal situa\u00e7\u00e3o n\u00e3o necessariamente foi acompanhada pelo aumento e capacita\u00e7\u00e3o das equipes ou pela expans\u00e3o da capacidade de atendimento dos servi\u00e7os. Sem expans\u00e3o da rede, \u00e9 prov\u00e1vel que outros usu\u00e1rios vivenciem maiores dificuldades para garantir o cuidado necess\u00e1rio. A qualidade do atendimento para novas e antigas demandas em reabilita\u00e7\u00e3o depender\u00e1 da instrumentaliza\u00e7\u00e3o das equipes multiprofissionais, por meio de educa\u00e7\u00e3o permanente, avalia\u00e7\u00e3o e acompanhamento das modifica\u00e7\u00f5es nos processos de trabalho, e do matriciamento de casos e experi\u00eancias.21, os resultados demonstram que parte dos servi\u00e7os n\u00e3o apresentava condi\u00e7\u00f5es adequadas, e institucionalmente garantidas, para a utiliza\u00e7\u00e3o dessa ferramenta.Embora a telerreabilita\u00e7\u00e3o seja identificada como estrat\u00e9gia promissora de manuten\u00e7\u00e3o da assist\u00eancia \u00e0s PCD durante a pandemia22. As teleconsultas foram autorizadas por conselhos de classe e pelo Minist\u00e9rio da Sa\u00fade a partir dos tensionamentos gerados pela pandemia. Ainda, novos instrumentos de trabalho tiveram de ser rapidamente assimilados por profissionais e servi\u00e7os de sa\u00fade.O uso da telessa\u00fade no Brasil \u00e9 desafiador devido a fatores regulat\u00f3rios e estruturais10. Com acesso prec\u00e1rio \u00e0 internet em muitas localidades brasileiras, programas de telerreabilita\u00e7\u00e3o dificilmente poderiam ser aplicados de forma extensiva, e incorreriam no risco de discriminar a popula\u00e7\u00e3o exclu\u00edda digitalmente caso n\u00e3o haja mudan\u00e7as significativas nas pol\u00edticas p\u00fablicas23.Apesar de a maioria dos respondentes afirmar que os usu\u00e1rios t\u00eam condi\u00e7\u00f5es de acesso \u00e0 telerreabilita\u00e7\u00e3o, \u00e9 necess\u00e1rio destacar que os CER se concentram em capitais estaduais e munic\u00edpios com maior infraestrutura24. As especificidades dentro deste grupo heterog\u00eaneo n\u00e3o foram contempladas pelos planos de enfrentamento, inclusive quanto a vulnerabilidades ainda maiores, como PCD institucionalizadas, vivendo em situa\u00e7\u00e3o de rua, imigrantes e mulheres25. Tal neglig\u00eancia reflete um processo de invisibilidade sistem\u00e1tica26. Apesar das recomenda\u00e7\u00f5es para a ado\u00e7\u00e3o de medidas inclusivas, pautadas na l\u00f3gica do direito27, n\u00e3o se observaram dados que sugerissem essa implementa\u00e7\u00e3o.Protocolos e diretrizes para a popula\u00e7\u00e3o geral foram replicados sem personaliza\u00e7\u00e3o para PCD e seus servi\u00e7os de refer\u00eancia28.A maioria dos respondentes afirmou realizar algum tipo de a\u00e7\u00e3o voltada para o apoio social a seus usu\u00e1rios durante o isolamento, o que pode ser considerado positivo se comparado com a fragilidade nas a\u00e7\u00f5es de suporte social no enfrentamento da covid-19 identificada em outros \u00e2mbitos de assist\u00eancia29.A an\u00e1lise das pol\u00edticas p\u00fablicas adotadas durante o per\u00edodo de pandemia, assim como reformula\u00e7\u00f5es futuras, depende da produ\u00e7\u00e3o de informa\u00e7\u00f5es epidemiol\u00f3gicas fidedignas e espec\u00edficas sobre a popula\u00e7\u00e3o que vive com defici\u00eancias. O n\u00e3o atendimento desse pressuposto pode configurar, por si s\u00f3, um mecanismo de exclus\u00e3o social, uma vez que dados desagregados sobre o acometimento pela covid-19 por status, tipo e severidade da defici\u00eancia s\u00e3o raros, ainda que extremamente necess\u00e1rios30.Um dos limites deste estudo \u00e9 inerente ao uso de dados do SIA-SUS. Ainda que possa haver atraso no registro dos procedimentos, trata-se de um sistema de informa\u00e7\u00f5es com consider\u00e1vel agilidade e que deve ser utilizado para planejamento, an\u00e1lise de oferta, cobertura e sele\u00e7\u00e3o de prioridadeswebsurvey n\u00e3o utilizou uma amostra probabil\u00edstica. Ainda assim, foram obtidas respostas de CER com caracter\u00edsticas parecidas \u00e0s dos servi\u00e7os habilitados no pa\u00eds (Outro limite conhecido \u00e9 que o  no pa\u00eds . AcreditAo sobrepor duas fontes de informa\u00e7\u00e3o, dados secund\u00e1rios e as percep\u00e7\u00f5es dos gestores, os resultados obtidos pela an\u00e1lise dos primeiros ganham vida, aproximando-os da realidade com o uso de abordagem metodol\u00f3gica pertinente ao objetivo proposto. A compreens\u00e3o da realidade dos cuidados para PCD no pa\u00eds, incluindo territ\u00f3rios sem CER, e varia\u00e7\u00f5es dentro das diferentes fases da pandemia, exigem estudos direcionados.Nos meses iniciais da pandemia de covid-19, houve um severo impacto sobre a capacidade de presta\u00e7\u00e3o de servi\u00e7os nos CER no Brasil. \u00c9 poss\u00edvel que tais efeitos tamb\u00e9m tenham ocorrido sobre outros servi\u00e7os de reabilita\u00e7\u00e3o. Al\u00e9m da redu\u00e7\u00e3o de procedimentos e consultas de reabilita\u00e7\u00e3o realizados, foram constatadas substanciais mudan\u00e7as no funcionamento das equipes, que levaram ao represamento de demandas j\u00e1 existentes.Os resultados evidenciam um cen\u00e1rio que precisa ser alterado e apontam caminhos pelos quais os formuladores de pol\u00edticas e gestores de servi\u00e7os podem seguir para a melhora dos cuidados \u00e0s PCD.Os servi\u00e7os de reabilita\u00e7\u00e3o ter\u00e3o de lidar n\u00e3o apenas com a inclus\u00e3o de novos protocolos de tratamento para o paciente p\u00f3s-covid-19, como atender: usu\u00e1rios que sofreram consequ\u00eancias da diminui\u00e7\u00e3o do volume, ou da interrup\u00e7\u00e3o for\u00e7ada, de suas terapias; os que apresentam preju\u00edzos decorrentes de condi\u00e7\u00f5es de sa\u00fade agravadas pelo isolamento; al\u00e9m de todos aqueles encaminhados por novos diagn\u00f3sticos de defici\u00eancias cong\u00eanitas e adquiridas. Em suma, o cen\u00e1rio \u00e9 de extrema sobrecarga para esses servi\u00e7os.A pandemia de covid-19 ressalta a necessidade de fortalecer o SUS e a RCPD, por meio de amplia\u00e7\u00e3o e integra\u00e7\u00e3o dos servi\u00e7os de sa\u00fade, com a corresponsabiliza\u00e7\u00e3o entre aten\u00e7\u00e3o prim\u00e1ria \u00e0 sa\u00fade, aten\u00e7\u00e3o especializada, hospitalar e de reabilita\u00e7\u00e3o. O favorecimento do exerc\u00edcio pleno da autonomia e da capacidade funcional s\u00f3 poder\u00e1 ser atingido a partir de prote\u00e7\u00e3o social ampla e organiza\u00e7\u00e3o social inclusiva, durante e ap\u00f3s a pandemia."}
+{"text": "The Research Group consisted of 16 children diagnosed with Developmental Language Disorder, 13 males and 3 females, mean age of 7.3. The Control Group counted on 64 subjects paired in gender, age, education and socioeconomic level with the Control Group in a 4:1 ratio. The ability to decode words and pseudowords of both groups was evaluated, measuring the time spent to correctly read words and the percentage of correct answers, also considering the length of the word/pseudoword. The writing evaluation was carried out in the control group, which had its spelling errors analyzed and categorized. All data underwent descriptive and inferential statistical analysis.The data indicated a longer decoding time and a lower percentage of correct answers for the children from the Research Group. Regarding spelling errors, there was a predominance of arbitrary spelling errors.The data showed that children with Developmental Language Disorder tend to have a longer decoding time, greater percentage of errors than their peers and tend to present spelling errors more concentrated in natural orthography. Also, impairment in phonological aspects is an important feature, and these children often have unintelligible speech. Some studies. However, these are impaired abilities in DLD children due to alterations in several language subsystems.In this context, we know that phonological processing skills are associated with success in the learning process because together, they are responsible for the ability to analyze the sound structure of speech, retention of information, and quick access to representations of the phonological information of the language. These children have difficulties related to reading and writing, probably resulting from the impairment of oral language and phonological processing characteristic of DLD. There is a growing number of studies related to the written language skills of children with DLD, as well as the importance of their characterization for making differential diagnoses in Specific Learning Disorders and even the co-occurrence of these conditions.Therefore, these disorders lead to a longer time for linguistic solidification in children with DLD than in people in typical development and lead to important repercussions in the process of acquisition of written language, which will lead to different impacts throughout the individual's life and, consequently, in their school career.However, there are few Brazilian studies dedicated to better understanding these children's written language disorders, as well as their acquisition process. This is because, until the paradigm and nomenclature changed from Specific Language Disorder (SLD) to DLD(1), manifestations of written language were little investigated in this population, mainly in Brazil. However, the importance of a holistic approach to the alterations of DLD children is evident, especially considering that this disorder longitudinally affects all language subsystemsThus, studies that investigate manifestations in the written language of children with DLD are of paramount importance to better understand the impairments of this population and outline not only therapeutic plans involving written language but also to develop actions that promote the development of educational public policies for these children who are not currently supported by any legislation. As hypotheses, it is expected that children with DLD present impairments in the decoding and acquisition of writing.Therefore, this study aimed to verify the performance of children diagnosed with DLD in decoding and writing tests under dictation.Retrospective cross-sectional study, approved by the Ethics and Research Committee of the School Medicine of the University of S\u00e3o Paulo under n\u00ba 2,262,300. The study was conducted in the Laboratory for Speech-Language Investigation in Pediatrics of the Speech-Language Pathology graduation degree of the University of S\u00e3o Paulo. Because the study was retrospective, carried out in a database, the Informed Consent Form (ICF) was waived.,2, who were treated at a speech-language therapy school clinic. The people in the service are primarily of medium-low socioeconomic level. It is important to point out that this variable was considered when evaluating and diagnosing DLD, according to the most recent guidelines, which include an evaluation battery of all language subsystems and their underlying abilities,2. The inclusion criteria for this group were: having a diagnosis of DLD; being of formal school age (6 to 10 years old); and being regularly enrolled in Elementary School. The Control Group (CG) had 64 subjects paired in gender, age, education, and socioeconomic level with the RG in a 4:1 ratio, that is, each child in the RG was paired with 4 children in the CG.The participants in this study were 80 children aged 6 to 10 years old, divided into two groups. The Research Group (RG) was composed of 16 children, 13 males, and 3 females, with a mean age of 7.3, with a diagnosis of DLD based on recent international criteria. The mean age of the CG was 7.2. The inclusion criteria for the CG were: not having complaints or alterations in oral and written language; being regularly enrolled in elementary school; not having learning complaints; having adequate performance in speech-language screening performed in the previous study. RG participants were assessed for their decoding and writing skills and CG children only for decoding. This is because the decoding test used has specific parameters and variables that were recently published and the writing analysis is performed by an instrument published in the form of a standardized test, eliminating the need for a CG for such variable.The CG was built specifically for the decoding test and has children with typical oral language development, reading, and writing, confirmed by speech-language therapy procedures performed in a previous studyProtocolo de Acompanhamento do Desenvolvimento da Decodifica\u00e7\u00e3o) was used and it consists of linguistically balanced words according to the Brazilian Portuguese (BP) decoding rules, also respecting the variation in word length from mono to polysyllables for children in this school age group. The test also has non-words that were derived from real words and that also follow the BP decoding rules, as well as the variation from mono to polysyllables. Both tasks were carried out face-to-face and consisted of asking the child to decode the words in the way they believed to be the correct way. The words are presented starting with monosyllables, followed by disyllables, and so on. When the child makes ten consecutive errors the test is finished. The procedure is the same for words and non-words. The correct word decoding time and the percentage of correct answers were counted both for each type of stimulus (from mono to polysyllable) and for total values for the category (words or non-words). The choice of such an instrument was because it specifically analyzes decoding, which is known to be a fundamental skill for the later stages of literacy, and because it contains stimuli that are based on the structure of Brazilian Portuguese, with adequate linguistic balance, as described above. Data were tabulated in a specific spreadsheet and underwent statistical analysis.For decoding evaluation and analysis, the Decoding Development Monitoring Protocol  structure; in addition, the words have phonographemic correspondence considered transparent. An analysis of the writing performance was carried out and, for children with alphabetic writing, the categorization of the spelling errors profile was performed based on the guidelines of the Pro-Orthography Test. In this perspective, the errors were classified, in percentage, in natural and arbitrary spelling errors. Data were tabulated in a specific spreadsheet and underwent statistical analysis.Regarding writing, a list of words used in a previous study was used, which proved to be adequate for children with DLDp \u2264 0.05). The SPSS Statistics software, version 28.0, was used. Generalized Estimation Equations (GEE) were also carried out to verify the effects for each variable separately, within the group, and also the effects of the interaction between all the studied variables  between the groups. Regarding writing, the percentage of children with an alphabetic level of writing was verified, and, of these, the percentage of types of errors, natural or arbitrary spelling.Statistical analysis was performed to characterize the groups in reading time and percentage of correct answers according to the type and length of words, in addition to the total values; the effect of the group, the type of word, and the length of the word on the time and percentage of correct answers were also investigated. The statistical significance value adopted was equal to 5% , although it is common for orthographic writing to occur later due to the multiple representations that BP presents in the sense of the phoneme for the grapheme. The need for further studies in the area is highlighted to advance the understanding of the process of acquisition of writing by DLD children literate in BP.It is important to point out that in recent studies, children with DLD tend to present a greater number of spelling errors in words that depend on phonographemic conversion and greater ease in correctly spelling arbitrary spelling words, which are more linked to the lexical route and are less dependent on phonological skills points out that children with language disorders tend to have difficulties related to understanding oral language and decoding ability, which is reinforced in the data of the present study, as children from the RG had a slower decoding time and a higher percentage of errors than their typical peers.About decoding, the literature-5, and which were not the object of this study, may interfere with their literacy process. In this way, it is suggested, in future research, further investigation on these aspects.This study also points out the length of the word as an important variable, since there was an increase in the decoding time as a function of the length of the words for both groups, being always higher in the RG. Regarding pseudowords, which are more related to the phonological route, there was an increase in time for both groups, which was more expressive, once again, in RG. Therefore, the alterations verified in the decoding abilities of children with DLD in this study reinforce the hypothesis that the phonological processing difficulties present in this population, described in different studies. As mentioned, children with DLD have difficulties in phonological processing, which can also influence their ability to recognize words when they are learning to read. In addition, the difficulty in the phonological aspect of these children reduces the efficiency of metaphonological skills, such as phonological awareness and phonological short-term memory, important for decoding, and tend to be more related to their linguistic age than chronological,4.When the individual uses the phonological route to read, the decoding time tends to be longer and the decoding is less fluent,7,12,13, there are still few studies of this nature in Brazil. Therefore, this study shows fundamental evidence regarding the performance of children with DLD in decoding and writing skills and reinforces the importance of further studies in the area.Even though this theme is addressed in greater depth in the worldData show that children with DLD tend to have longer decoding times than their typical peers and below-expected results in writing, similar to what we observe in world literature. Furthermore, a longer decoding time and a lower percentage of correct answers were observed regardless of the length of the word, with greater difficulty in pseudowords. This study enables reflections on the written language performance of DLD children and reinforces the need for studies in the area. ,2.O transtorno do desenvolvimento da linguagem (TDL) caracteriza-se pela presen\u00e7a de altera\u00e7\u00f5es significativas no processo de aquisi\u00e7\u00e3o e desenvolvimento da linguagem, excluindo-se crian\u00e7as com altera\u00e7\u00f5es justificadas por fatores s\u00f3cio-ambientais, bi ou multilinguismo al\u00e9m de condi\u00e7\u00f5es biom\u00e9dicas onde s\u00e3o esperadas altera\u00e7\u00f5es de linguagem,4 apontam d\u00e9ficits importantes nos componentes do processamento fonol\u00f3gico em crian\u00e7as com TDL, como a mem\u00f3ria de curto prazo fonol\u00f3gica e a consci\u00eancia fonol\u00f3gica, que s\u00e3o consideradas habilidades fundamentais para o processo de aquisi\u00e7\u00e3o da linguagem em sua modalidade escrita.Comumente observa-se nessas crian\u00e7as preju\u00edzos na aquisi\u00e7\u00e3o lexical, que varia conforme o grau do transtorno e a crian\u00e7a pode apresentar dificuldades no vocabul\u00e1rio expressivo e receptivo. Ademais, os preju\u00edzos nos aspectos fonol\u00f3gicos \u00e9 uma caracter\u00edstica importante, sendo comum essas crian\u00e7as apresentarem fala inintelig\u00edvel. Alguns estudos. Todavia, conforme citado, essas s\u00e3o habilidades prejudicadas em crian\u00e7as com TDL devido \u00e0s altera\u00e7\u00f5es em diversos subsistemas da linguagem.Neste contexto, sabe-se que as habilidades do processamento fonol\u00f3gico associam-se com o sucesso no processo de aprendizagem porque somadas s\u00e3o respons\u00e1veis respectivamente, pela capacidade de an\u00e1lise da estrutura sonora da fala, reten\u00e7\u00e3o de informa\u00e7\u00f5es e o acesso r\u00e1pido a representa\u00e7\u00f5es das informa\u00e7\u00f5es fonol\u00f3gicas da l\u00edngua. Sabe-se que essas crian\u00e7as apresentam dificuldades referentes \u00e0 leitura e \u00e0 escrita, provavelmente decorrentes dos preju\u00edzos da linguagem oral e do processamento fonol\u00f3gico caracter\u00edsticos do TDL. H\u00e1 um crescente no n\u00famero de estudos relacionados \u00e0s habilidades de linguagem escrita de crian\u00e7as com TDL, bem como a import\u00e2ncia da sua caracteriza\u00e7\u00e3o para a efetua\u00e7\u00e3o de diagn\u00f3sticos diferenciais em rela\u00e7\u00e3o aos Transtornos Espec\u00edficos de Aprendizagem e, at\u00e9 mesmo, a co-ocorr\u00eancia destes quadros.Essas altera\u00e7\u00f5es, portanto, acarretam em um tempo maior para a solidifica\u00e7\u00e3o lingu\u00edstica em crian\u00e7as com TDL quando comparadas \u00e0 popula\u00e7\u00e3o em desenvolvimento t\u00edpico e levam \u00e0 repercuss\u00f5es importantes no processo de aquisi\u00e7\u00e3o da linguagem escrita, as manifesta\u00e7\u00f5es da linguagem escrita eram pouco investigadas nesta popula\u00e7\u00e3o, principalmente no Brasil. No entanto, evidencia-se a import\u00e2ncia de uma abordagem hol\u00edstica das altera\u00e7\u00f5es de crian\u00e7as TDL, principalmente considerando-se que tal transtorno acomete, longitudinalmente, todos os subsistemas da linguagem, que levar\u00e3o a diferentes impactos ao longo da vida do indiv\u00edduo e, consequentemente, na sua trajet\u00f3ria escolar.Apesar disso, s\u00e3o escassos os estudos brasileiros que se dedicam a melhor entender as altera\u00e7\u00f5es de linguagem escrita dessas crian\u00e7as, bem como seu processo de aquisi\u00e7\u00e3o. Isso decorre do fato de que at\u00e9 a mudan\u00e7a de paradigma e de nomenclatura de Dist\u00farbio Espec\u00edfico de Linguagem (DEL) para Transtorno do Desenvolvimento de LinguagemDessa forma, torna-se primordial estudos que investiguem as manifesta\u00e7\u00f5es na linguagem escrita de crian\u00e7as com TDL, para melhor entender os preju\u00edzos desta popula\u00e7\u00e3o e delinear n\u00e3o apenas planejamentos terap\u00eauticos que envolvam a linguagem escrita, mas desenvolver a\u00e7\u00f5es que promovam o desenvolvimento de pol\u00edticas p\u00fablicas educacionais para essas crian\u00e7as que, atualmente, n\u00e3o s\u00e3o amparadas por nenhuma legisla\u00e7\u00e3o a respeito. Como hip\u00f3teses, espera-se que as crian\u00e7as com TDL apresentem preju\u00edzos na decodifica\u00e7\u00e3o e na aquisi\u00e7\u00e3o da escrita.Sendo assim, o objetivo do presente estudo \u00e9 verificar o desempenho de crian\u00e7as com diagn\u00f3stico de TDL em provas de decodifica\u00e7\u00e3o e escrita sob ditado.Estudo retrospectivo transversal, aprovado pelo Comit\u00ea de \u00c9tica e Pesquisa da Faculdade de Medicina da Universidade de S\u00e3o Paulo sob n\u00ba 2.262.300. O estudo foi realizado no Laborat\u00f3rio de Investiga\u00e7\u00e3o Fonoaudiol\u00f3gica em Pediatria do curso de Fonoaudiologia da Universidade de S\u00e3o Paulo. Em decorr\u00eancia de a pesquisa ser retrospectiva, realizada em banco de dados, o Termo de Consentimento Livre e Esclarecido foi dispensado.,2, e que foram atendidas no ambulat\u00f3rio do referido Laborat\u00f3rio. O p\u00fablico do servi\u00e7o \u00e9 prioritariamente de n\u00edvel socioecon\u00f4mico m\u00e9dio-baixo. Importante ressaltar que tal vari\u00e1vel foi considerada quando da avalia\u00e7\u00e3o e diagn\u00f3stico de TDL, conforme diretrizes mais recentes, que incluem uma bateria de avalia\u00e7\u00e3o de todos os subsistemas da linguagem e suas habilidades subjacentes,2. Os crit\u00e9rios de inclus\u00e3o para este grupo foram: possuir diagn\u00f3stico de TDL, estar em idade de escolariza\u00e7\u00e3o formal (6 a 10 anos de idade) e estar regularmente matriculado no Ensino Fundamental I. O Grupo Controle (GC) contou com 64 sujeitos pareados em g\u00eanero, idade, escolaridade e n\u00edvel socioecon\u00f4mico com o GP na propor\u00e7\u00e3o 4:1, ou seja, cada crian\u00e7a do GP, foi pareada com 4 crian\u00e7as do GC.Participaram deste estudo 80 crian\u00e7as na faixa et\u00e1ria de 6 a 10 anos de idade, separadas em dois grupos. O Grupo-Pesquisa (GP) foi composto por 16 crian\u00e7as, sendo 13 do sexo masculino e 3 do sexo feminino, m\u00e9dia de idade de 7,3, com diagn\u00f3stico de Transtorno do Desenvolvimento da Linguagem (TDL) baseados em crit\u00e9rios internacionais recentes. A m\u00e9dia de idade do GC foi de 7,2. Os crit\u00e9rios de inclus\u00e3o do GC foram: n\u00e3o possuir queixas ou altera\u00e7\u00f5es de linguagem oral e escrita; estar regularmente matriculado em escola do ensino fundamental I; n\u00e3o possuir queixas de aprendizagem; possuir desempenho adequado em triagem fonoaudiol\u00f3gica realizada no estudo anterior. Os indiv\u00edduos do GP foram avaliados quanto \u00e0s suas habilidades de decodifica\u00e7\u00e3o e escrita e as crian\u00e7as do GC apenas quanto \u00e0 decodifica\u00e7\u00e3o. Isso decorre do fato de a prova de decodifica\u00e7\u00e3o utilizada ter par\u00e2metros e vari\u00e1veis espec\u00edficas que foram publicadas recentemente e a an\u00e1lise da escrita ser realizada por instrumento publicado em forma de teste padronizado, dispensando a necessidade de Grupo Controle para tal vari\u00e1vel.O GC foi constru\u00eddo especificamente para a prova de decodifica\u00e7\u00e3o e conta com crian\u00e7as com desenvolvimento de linguagem oral, leitura e escrita t\u00edpicos, confirmado por procedimentos fonoaudiol\u00f3gicos realizados em estudo anterior que consiste de palavras balanceadas linguisticamente conforme as regras de decodifica\u00e7\u00e3o do Portugu\u00eas Brasileiro (PB) respeitando-se tamb\u00e9m a varia\u00e7\u00e3o de extens\u00e3o de palavras de mono a poliss\u00edlabos para crian\u00e7as desta faixa escolar. A prova tamb\u00e9m conta com n\u00e3o-palavras que foram derivadas das palavras reais e que tamb\u00e9m seguem as regras de decodifica\u00e7\u00e3o do PB, bem como a varia\u00e7\u00e3o de mono a poliss\u00edlabos. Ambas as tarefas foram realizadas de forma presencial e consistiram em solicitar \u00e0 crian\u00e7a a decodificar as palavras da maneira que elas acreditavam ser a forma correta. As palavras s\u00e3o apresentadas iniciando-se pelos monoss\u00edlabos, seguindo para diss\u00edlabos e assim sucessivamente. Quando a crian\u00e7a comete dez erros consecutivos a prova \u00e9 finalizada. O procedimento \u00e9 o mesmo para palavras e n\u00e3o-palavras. Foram contabilizados o tempo de decodifica\u00e7\u00e3o de palavras corretas e a porcentagem de acertos tanto para cada tipo de est\u00edmulo (de mono a poliss\u00edlabo) quanto valores totais para a categoria . A escolha de tal instrumento se deu em decorr\u00eancia de este analisar especificamente a decodifica\u00e7\u00e3o, que sabe-se ser habilidade fundamental para as fases posteriores da alfabetiza\u00e7\u00e3o e por conter est\u00edmulos que s\u00e3o baseados na estrutura do Portugu\u00eas Brasileiro, com adequado balanceamento lingu\u00edstico, conforme descrito anteriormente. Os dados foram tabulados em planilha espec\u00edfica e passaram por an\u00e1lise estat\u00edstica.Para avalia\u00e7\u00e3o e an\u00e1lise da decodifica\u00e7\u00e3o foi utilizado o Protocolo de Acompanhamento do Desenvolvimento da Decodifica\u00e7\u00e3o (PRADE). A prova consiste em um ditado de oito palavras e oito pseudopalavras; ambas as listas de palavras foram compostas de palavras diss\u00edlabas com estrutura CV ; al\u00e9m disso, as palavras possuem correspond\u00eancia fono-graf\u00eamica consideradas transparentes. Realizou-se an\u00e1lise do desempenho em escrita e, para crian\u00e7as com escrita alfab\u00e9tica, foi realizada categoriza\u00e7\u00e3o do perfil de erros ortogr\u00e1ficos com base nas diretrizes do Teste Pr\u00f3-Ortografia. Nesta perspectiva, os erros foram classificados, em porcentagem, em erros de ortografia natural e arbitr\u00e1ria. Os dados foram tabulados em planilha espec\u00edfica e passaram por an\u00e1lise estat\u00edstica.Em rela\u00e7\u00e3o \u00e0 escrita, foi utilizada uma lista de palavras utilizada em estudo anterior, que mostraram-se adequadas para crian\u00e7as com TDLFoi realizada an\u00e1lise estat\u00edstica com o objetivo de caracterizar os grupos em rela\u00e7\u00e3o ao tempo de leitura e porcentagem de acertos de acordo com o tipo e a extens\u00e3o das palavras, al\u00e9m dos valores totais; investigou-se tamb\u00e9m o efeito do grupo, do tipo de palavra e da extens\u00e3o da palavra sobre o tempo e a porcentagem de acertos. O valor de signific\u00e2ncia estat\u00edstica adotado foi igual a 5% . Utilizou-se o software SPSS Statistics, vers\u00e3o 28.0. Foram realizadas tamb\u00e9m equa\u00e7\u00f5es de estima\u00e7\u00f5es generalizadas (GEE) para verificar os efeitos para cada vari\u00e1vel isoladamente, intragrupo e tamb\u00e9m os efeitos da intera\u00e7\u00e3o entre todas as vari\u00e1veis estudadas  intergrupo. Em rela\u00e7\u00e3o \u00e0 escrita, foi verificada a porcentagem de crian\u00e7as com n\u00edvel alfab\u00e9tico de escrita e, destas, a porcentagem da tipologia de erros, de ortografia natural ou arbitr\u00e1ria.No que diz respeito \u00e0 an\u00e1lise da escrita, das crian\u00e7as classificadas em n\u00edvel alfab\u00e9tico, os dados indicaram que, em m\u00e9dia, 76,58% dos erros foram de ortografia natural e 35,13% de ortografia arbitr\u00e1ria. Observou-se tamb\u00e9m grande variabilidade no desvio padr\u00e3o com valores de 22,95 e 18,68, respectivamente.Em rela\u00e7\u00e3o a decodifica\u00e7\u00e3o, observou-se maior tempo de decodifica\u00e7\u00e3o no GP em compara\u00e7\u00e3o com o GC . Al\u00e9m diA , o que em crian\u00e7as com transtorno do desenvolvimento da linguagem ocorre de modo mais lento.Este estudo teve como objetivo verificar o desempenho de crian\u00e7as com diagn\u00f3stico de TDL em provas de decodifica\u00e7\u00e3o e escrita para assim entender melhor suas manifesta\u00e7\u00f5es e o processo de aquisi\u00e7\u00e3o das habilidades da linguagem escrita nesta popula\u00e7\u00e3o. A base da aquisi\u00e7\u00e3o da linguagem escrita adv\u00e9m de habilidades adquiridas e aprimoradas a partir da linguagem oral.Neste contexto, considerando as crian\u00e7as em n\u00edvel alfab\u00e9tico de escrita notou-se uma porcentagem maior de erros de escrita natural do que arbitr\u00e1rios, o que corrobora a hip\u00f3tese de que as altera\u00e7\u00f5es em processamento fonol\u00f3gico dessas crian\u00e7as dificultam a convers\u00e3o fonema-grafema e consequentemente o desenvolvimento da escrita,12. Ressalta-se, tamb\u00e9m que a maioria destes estudos foram realizados em l\u00ednguas estrangeiras com diferentes caracter\u00edsticas de opacidade e transpar\u00eancia,12. Entretanto, os dados do presente estudo refor\u00e7am tal hip\u00f3tese uma vez que observamos o mesmo perfil de erros em uma l\u00edngua transparente, como \u00e9 o Portugu\u00eas Brasileiro (PB), apesar de ser comum a escrita ortogr\u00e1fica ocorrer mais tardiamente devido \u00e0s m\u00faltiplas representa\u00e7\u00f5es que o PB apresenta no sentido do fonema para o grafema. Salienta-se a necessidade de mais estudos na \u00e1rea para que se avance no entendimento do processo de aquisi\u00e7\u00e3o da escrita por crian\u00e7as TDL alfabetizadas em PB.\u00c9 importante salientar que em estudos recentes, crian\u00e7as com TDL tendem a apresentar maior n\u00famero de erros ortogr\u00e1ficos em palavras que dependem da convers\u00e3o fono-graf\u00eamica e maior facilidade em grafar corretamente palavras de ortografia arbitr\u00e1ria, que est\u00e3o mais ligadas \u00e0 rota lexical e s\u00e3o menos dependentes de habilidades fonol\u00f3gicas, aponta que crian\u00e7as com dist\u00farbios da linguagem tendem a apresentar dificuldades relacionadas desde a compreens\u00e3o da linguagem oral at\u00e9 a capacidade de decodifica\u00e7\u00e3o, o que \u00e9 refor\u00e7ado nos dados do presente estudo, pois as crian\u00e7as do GP apresentaram tempo de decodifica\u00e7\u00e3o mais lento e maior porcentagem de erros em rela\u00e7\u00e3o a seus pares t\u00edpicos.No que se refere \u00e0 decodifica\u00e7\u00e3o, a literatura-5, e que n\u00e3o foram objeto do presente estudo, podem interferir em seu processo de alfabetiza\u00e7\u00e3o. Dessa maneira, sugere-se, em pesquisas futuras, investiga\u00e7\u00e3o mais aprofundada sobre tais aspectos.O presente estudo tamb\u00e9m aponta a extens\u00e3o da palavra como uma vari\u00e1vel importante, uma vez que houve aumento no tempo de decodifica\u00e7\u00e3o em fun\u00e7\u00e3o da extens\u00e3o das palavras para ambos os grupos, sendo sempre superior no GP. Em rela\u00e7\u00e3o \u00e0s pseudopalavras, que est\u00e3o mais relacionadas \u00e0 rota fonol\u00f3gica, verificou-se aumento no tempo de ambos os grupos sendo este mais expressivo, uma vez mais, no GP. Sendo assim, as altera\u00e7\u00f5es verificadas nas habilidades de decodifica\u00e7\u00e3o das crian\u00e7as com TDL deste estudo refor\u00e7am a hip\u00f3tese de que as dificuldades de processamento fonol\u00f3gico presente nesta popula\u00e7\u00e3o descritas em diferentes pesquisas. Conforme mencionado, as crian\u00e7as com TDL apresentam dificuldades no processamento fonol\u00f3gico, o que pode influenciar tamb\u00e9m em sua capacidade de reconhecimento das palavras quando est\u00e3o aprendendo a ler. Al\u00e9m disso, a dificuldade no aspecto fonol\u00f3gico dessas crian\u00e7as reduz a efici\u00eancia das habilidades metafonol\u00f3gicas, como a consci\u00eancia fonol\u00f3gica e mem\u00f3ria de curto prazo fonol\u00f3gica, importantes para a decodifica\u00e7\u00e3o, e que tendem a estar mais relacionadas \u00e0 sua idade lingu\u00edstica do que cronol\u00f3gica,4.Sabe-se que, quando o indiv\u00edduo se utiliza da rota fonol\u00f3gica para ler, o tempo de decodifica\u00e7\u00e3o tende a ser maior e a decodifica\u00e7\u00e3o apresenta-se menos fluente,7,12,13 ainda h\u00e1 poucos estudos desta natureza no Brasil. Sendo assim, o presente estudo apresenta evid\u00eancias fundamentais a respeito do desempenho de crian\u00e7as com TDL em habilidades de decodifica\u00e7\u00e3o e escrita e refor\u00e7a a import\u00e2ncia de novos estudos na \u00e1rea.Cabe salientar que, apesar de tal tem\u00e1tica ser abordada mais aprofundadamente no mundoOs dados evidenciam que crian\u00e7as com TDL tendem a apresentar maior tempo de decodifica\u00e7\u00e3o do que seus pares t\u00edpicos e resultados abaixo do esperado no que se refere \u00e0 escrita, consonante com o que se observa na literatura mundial. Ademais, observou-se maior tempo de decodifica\u00e7\u00e3o e menor porcentagem de acertos independentemente da extens\u00e3o da palavra, com maior dificuldade nas pseudopalavras. O presente estudo possibilita reflex\u00f5es sobre o desempenho em linguagem escrita de crian\u00e7as TDL e refor\u00e7a a necessidade de estudos na \u00e1rea"}
+{"text": "Momento mais prop\u00edcio para discutir o Sistema \u00danico de Sa\u00fade (SUS) n\u00e3o h\u00e1. O sistema desa\u00fade brasileiro passou por um duro teste com a pandemia de COVID-19 e quatro anos de umgoverno com diversas pr\u00e1ticas e discursos que constitu\u00edam obst\u00e1culos para seufuncionamento.Mas por que mais um livro sobre SUS? Paulo Capel Narvai, que j\u00e1 produziu em torno de 200publica\u00e7\u00f5es no campo da Sa\u00fade P\u00fablica, prova como essa tem\u00e1tica \u00e9 inesgot\u00e1vel, n\u00e3o s\u00f3para atualiza\u00e7\u00e3o do que aconteceu no per\u00edodo mais recente, mas devido \u00e0 necessidade devoltar d\u00e9cadas atr\u00e1s, e at\u00e9 mesmo s\u00e9culos, para compreender como chegamos aondeestamos.O livro, de forma satisfat\u00f3ria, escapa do compromisso do formato tecnicista e seassemelha a uma conversa com quem o l\u00ea. \u00c9 como se o leitor tivesse passado um caf\u00e9,puxado um banquinho e parado para escutar a experi\u00eancia acumulada de Narvai nesses maisde 50 anos como intelectual, profissional e militante do SUS.Um dos fatores que contribuem para essa sensa\u00e7\u00e3o \u00e9 o fato de o livro n\u00e3o ter propriamenteuma organiza\u00e7\u00e3o convencional de cap\u00edtulos, como obras cl\u00e1ssicas para estudantes eprofissionais. H\u00e1 uma escolha muito autoral e, como em uma conversa, existem v\u00e1riasformas de se come\u00e7ar - e diversos desdobramentos em paralelo.Ainda que a leitura seja bastante prazerosa e aparentemente despretensiosa, bem comoexplicitamente se trate de uma vis\u00e3o do autor sobre o SUS, a obra n\u00e3o deixa de terrigor. O autor transita por importantes refer\u00eancias te\u00f3ricas, registros factuaishist\u00f3ricos e elementos autobiogr\u00e1ficos de quem vivenciou os per\u00edodos - e participoudeles ativamente - antes, durante e depois da reforma sanit\u00e1ria e se posiciona de formatransparente.1 defende uma ideia bastante conhecida: o SUScomo um direito de todas as pessoas e um dever do Estado. Para isso, recorre \u00e0 hist\u00f3ria- do Brasil e da sa\u00fade p\u00fablica - e a debates sobre esse tema. Ao fazer esse percurso,mostra que, embora essa ideia esteja registrada, dessa forma, na Constitui\u00e7\u00e3oFederal de 1988, desde sua origem tal premissa \u00e9 amea\u00e7ada de diversasformas e disputada por diferentes for\u00e7as pol\u00edticas e econ\u00f4micas, nacionais einternacionais.Ao longo dos cap\u00edtulos, Narvai a hist\u00f3ria que a Hist\u00f3ria n\u00e3o conta\u201d , ao romper com o automatismo decontar a hist\u00f3ria da sa\u00fade p\u00fablica em uma perspectiva euroc\u00eantrica. O autor se dedica aapresentar a interpreta\u00e7\u00e3o e as formas de cuidado dos povos origin\u00e1rios e escravizados.Al\u00e9m disso, n\u00e3o se furta em abordar como o Brasil \u00e9 constitu\u00eddo e constru\u00eddo sob asmarcas de viol\u00eancia, opress\u00e3o e explora\u00e7\u00e3o. O exterm\u00ednio dos povos origin\u00e1rios ocorreutamb\u00e9m a partir das doen\u00e7as trazidas pelos europeus - n\u00e3o apenas no Brasil, mas naAm\u00e9rica Latina. Depois, houve um longo per\u00edodo de escraviza\u00e7\u00e3o, em que o Brasil foi umdos \u00faltimos pa\u00edses a abolir esse sistema e o local que mais recebeu povos escravizadosoriundos do continente africano. Muitos foram dizimados desde o caminho, por epidemia,desnutri\u00e7\u00e3o e suic\u00eddio Do ponto de vista hist\u00f3rico, h\u00e1 um compromisso com a hist\u00f3ria \u201cvista de baixo\u201d, ou denarrar \u201cA sa\u00fade p\u00fablica no Brasil surge como medida para conter uma situa\u00e7\u00e3o j\u00e1 bastante grave deepidemias e condi\u00e7\u00f5es insalubres e indignas a qual boa parte da classe trabalhadora erasubmetida, p\u00f3s-per\u00edodo colonial. A forma de resolver esses problemas estava muito longede ser embasada por uma consci\u00eancia sanit\u00e1ria. Houve a instaura\u00e7\u00e3o da pol\u00edcia m\u00e9dica eum modelo \u201ccampanhista\u201d muito limitado. Todo esse breve panorama mostra o aspecto\u201crevolucion\u00e1rio\u201d de uma reforma, tal qual a aprova\u00e7\u00e3o do SUS, mesmo em uma Rep\u00fablica com\u201cconstru\u00e7\u00e3o inacabada\u201d como a do Brasil SUSistas e SUScitas. OsSUSistas, s\u00e3o, como explica o autor, aqueles que compreendem asa\u00fade como um direito social fundamental, impass\u00edvel de ser negado a qualquer serhumano. Os SUScistas, por sua vez, defendem ou tomam decis\u00f5es eposicionamentos tratando a sa\u00fade como um bem privado, que se adquire individualmenteconforme suas condi\u00e7\u00f5es. Eles concebem a sa\u00fade, ainda, como oposta \u00e0 doen\u00e7a. Paraabordar a pol\u00eamica, o autor recorre a polariza\u00e7\u00f5es - como Fidel Castro e Barack Obama -e a express\u00f5es que, \u00e0s vezes, s\u00e3o tratadas como sin\u00f4nimas ou continuidades, mas que t\u00eamdistin\u00e7\u00f5es, tal como aten\u00e7\u00e3o prim\u00e1ria e aten\u00e7\u00e3o b\u00e1sica, necessidades em sa\u00fade enecessidades de sa\u00fade, Alma-Ata e Astana, entre outras.Com rela\u00e7\u00e3o aos debates, \u00e9 poss\u00edvel sintetiz\u00e1-los na polariza\u00e7\u00e3o entre o que o autorchama de Constitui\u00e7\u00e3o Federal, volta comfor\u00e7a nesse contexto recente em que foi t\u00e3o amea\u00e7ado pelo Governo de Jair MessiasBolsonaro e pela pandemia. Vinculada a essa tem\u00e1tica, a participa\u00e7\u00e3o social \u00e9 abordadatamb\u00e9m como um elemento central para enfrentar os interesses privatistas e permitir queo projeto da reforma sanit\u00e1ria siga e persista, mesmo nos marcos de um sistemacapitalista.Dois temas que s\u00e3o abordados e merecem destaque para refletir sobre o futuro s\u00e3o sa\u00fade edesenvolvimento e sa\u00fade e democracia. Nesse contexto de emerg\u00eancia clim\u00e1tica, \u00e9 salutarrecuperar o processo de industrializa\u00e7\u00e3o e as estrat\u00e9gias de diferentes governos epensar como \u00e9 poss\u00edvel que o progresso industrial e econ\u00f4mico do pa\u00eds n\u00e3o apenas n\u00e3ocomprometa o meio ambiente, como tamb\u00e9m acompanhe o desenvolvimento das condi\u00e7\u00f5es devida e de sa\u00fade de toda a sociedade. O t\u00f3pico sa\u00fade e democracia, t\u00e3o presente na 8\u00aaConfer\u00eancia Nacional de Sa\u00fade e na Por fim, o livro indica v\u00e1rios caminhos para refletir e pensar sobre a ideia de que o SUS\u201cn\u00e3o funciona\u201d. A obra mostra, por um lado, que o sistema de sa\u00fade sobreviveu a despeitode tantos ataques e que, sim, funciona. Sem o SUS, sem d\u00favida, estar\u00edamos muito piores.Por outro, deixa em aberto se as dificuldades e os obst\u00e1culos persistem apenas por n\u00e3osermos fortes o suficiente diante da ofensiva neoliberal. Seria poss\u00edvel implementar,dentro do Estado capitalista neoliberal, uma \u201creforma revolucion\u00e1ria\u201d? Responder a essapergunta exigiria um aprofundamento maior sobre a concep\u00e7\u00e3o de Estado, que n\u00e3o opera nal\u00f3gica do sensato e racional, mas sim para manuten\u00e7\u00e3o do sistema capitalista. Ainda quen\u00e3o adentre esse debate, a conclus\u00e3o de apostar na participa\u00e7\u00e3o social e a ideia de umadisputa em aberto entre os interesses mercantis  e os interesses societ\u00e1rios (a consolida\u00e7\u00e3o dessa \u201creformarevolucion\u00e1ria\u201d) convocam o leitor a se posicionar em um momento crucial dahist\u00f3ria."}
+{"text": "Perspectivas de CSP Com rela\u00e7\u00e3o ao artigo publicado na se\u00e7\u00e3o off-label), embora seja um ponto de vista v\u00e1lido, retirou adiscuss\u00e3o do contexto. A decis\u00e3o foi tomada em um cen\u00e1rio de maior interesse do sistemap\u00fablico de sa\u00fade e contra interesses da ind\u00fastria farmac\u00eautica.A cr\u00edtica \u00e0 possibilidade de incorpora\u00e7\u00e3o de medicamentos sem registro em bula em entrevista ao portal OutraSa\u00fade off-label na Conitecfoi a degenera\u00e7\u00e3o macular relacionada \u00e0 idade (DMRI), em que o bevacizumabe apresentavamaior efici\u00eancia que o ranibizumabe. A DMRI \u00e9 a causa mais comum de cegueira em idososem pa\u00edses desenvolvidos. A preval\u00eancia da DMRI no Brasil \u00e9 estimada em cerca de 10% emindiv\u00edduos com mais de 80 anos off-label. A \u00fanica diferen\u00e7a foi o custo - o tratamento anual combevacizumabe pode representar uma redu\u00e7\u00e3o de cerca de R$ 20.000,00 por olho tratado(c\u00e1lculo com base no Sistema Integrado de Administra\u00e7\u00e3o de Servi\u00e7os Gerais - SIASG).Manter a proibi\u00e7\u00e3o de uso off-label em casos excepcionais como odescrito \u00e9 do interesse apenas da ind\u00fastria farmac\u00eautica e pode impedir o acesso de umtratamento eficaz para muitos pacientes.O contexto inicial da discuss\u00e3o sobre medicamentos n\u00e3o \u00e9 da suacompet\u00eancia\u201d A Ag\u00eancia Nacional de Vigil\u00e2ncia Sanit\u00e1ria (Anvisa), embora provocada pela Conitec, n\u00e3otem se posicionado a favor de incluir em bula indica\u00e7\u00f5es comprovadamente eficazes,apenas por contrariar interesses econ\u00f4micos, alegando que \u201coff-label representa o melhorinteresse p\u00fablico s\u00e3o: imunossupressores para transplante card\u00edaco, hep\u00e1tico e pulmonar,inclusive everolimo e tacrolimo, alvos de pol\u00edtica das parcerias de desenvolvimentoprodutivo (PDP) com o Instituto de Tecnologia em F\u00e1rmacos, Funda\u00e7\u00e3o Oswaldo Cruz(Farmanguinhos/Fiocruz) off-label, desde que embasada em evid\u00eancias adequadas, burlapr\u00e1ticas predat\u00f3rias do mercado.Outros cen\u00e1rios de destaque em que o uso off-label que mais gerou mobiliza\u00e7\u00e3o social foi o domicofenolato de mofetila nos protocolos cl\u00ednicos e diretrizes terap\u00eauticas (PCDT) del\u00fapus eritematoso sist\u00eamico, que apresenta evid\u00eancias da atua\u00e7\u00e3o da Conitec com aavalia\u00e7\u00e3o de tecnologias em sa\u00fade (ATS) pautada em necessidades sociais. O medicamentotinha comprova\u00e7\u00f5es cient\u00edficas robustas e elementos suficientes para que a Anvisapudesse atualizar sua indica\u00e7\u00e3o em bula. A Conitec declarou que, apesar das fortesevid\u00eancias, por quest\u00f5es regulat\u00f3rias, o micofenolato de mofetila n\u00e3o foi incorporado noPCDT de l\u00fapus em 2017 e foi inclu\u00eddo somente em 2022, cinco anos depois. Nesse per\u00edodode cinco anos, potencialmente, muitos pacientes com l\u00fapus perderam seus rins por faltade acesso.Um dos casos de Outro ponto de discord\u00e2ncia com as opini\u00f5es dos autores \u00e9 a respeito da cria\u00e7\u00e3o de tr\u00eascomit\u00eas em substitui\u00e7\u00e3o ao plen\u00e1rio, com a inclus\u00e3o de representantes dos N\u00facleos deAvalia\u00e7\u00e3o de Tecnologias em Sa\u00fade (NATS). A mudan\u00e7a \u00e9 adequada e resulta de demandas dopr\u00f3prio plen\u00e1rio, que muitas vezes necessita apoio de um metodologista no suporte \u00e0tomada de decis\u00e3o. A exist\u00eancia de comit\u00eas diversos, em especial para equipamentos,permitir\u00e1 melhorias no processo de incorpora\u00e7\u00e3o e especializa\u00e7\u00e3o dos membros de formasemelhante a outros pa\u00edses, como a Inglaterra. O volume de pedidos e a complexidade dasdecis\u00f5es, que frequentemente consomem mais de tr\u00eas horas de reuni\u00e3o, como no caso daincorpora\u00e7\u00e3o de vacinas para COVID-19 em crian\u00e7as Quanto \u00e0 condu\u00e7\u00e3o pol\u00edtica das decis\u00f5es, em todas as inst\u00e2ncias decis\u00f3rias h\u00e1 umcomponente pol\u00edtico, uma vez que os decisores representam a sociedade, isso por si s\u00f3n\u00e3o \u00e9 errado. O problema \u00e9 o sequestro pol\u00edtico da sa\u00fade p\u00fablica, ao qual nosposicionamos de forma contr\u00e1ria antecipa\u00e7\u00e3o \u00e0 implementa\u00e7\u00e3o detecnologias emergentes\u201d, ao contr\u00e1rio do argumentado no texto. Nos anos de2021 e 2022, foram elaborados pareceres completos, com modelos econ\u00f4micos de diversastecnologias para COVID-19, incluindo todas as vacinas, anticorpos monoclonais,nirmatrelvir/ritonavir e molnupiravir, em di\u00e1logo precoce com a Anvisa, permitindo adecis\u00e3o com suporte de evid\u00eancias para a emerg\u00eancia de sa\u00fade p\u00fablica, mesmo antes dademanda da ind\u00fastria. Certamente, o processo de prioriza\u00e7\u00e3o ainda pode ser melhorado,tema que compete \u00e0s \u00e1reas t\u00e9cnicas do Minist\u00e9rio da Sa\u00fade, e n\u00e3o \u00e0 Conitec.Ainda com rela\u00e7\u00e3o \u00e0 COVID-19, houve, sim, \u201cQuanto \u00e0 heterogeneidade dos pareceres, \u00e9 um ponto real, mas sem solu\u00e7\u00e3o imediata. Foramelaboradas diversas diretrizes metodol\u00f3gicas https://www.instagram.com/participasus/), tem por objetivo traduzir acomplexidade da ATS para pacientes e familiares.Por fim, quanto \u00e0 inclus\u00e3o de outros segmentos sociais, acreditamos que os pacientes,maiores interessados no t\u00f3pico e foco de todo o nosso trabalho, est\u00e3o inadequadamenterepresentados na Conitec pelo Conselho Nacional de Sa\u00fade (CNS), que incluirepresentantes de pacientes e da ind\u00fastria farmac\u00eautica. \u00c9 um desafio conseguir umarepresenta\u00e7\u00e3o de pacientes qualificada, que realmente contribua com esse fundamentalponto de vista para a decis\u00e3o. A participa\u00e7\u00e3o de pacientes foi ampliada pela cria\u00e7\u00e3o daexperi\u00eancia do paciente e da consulta p\u00fablica, mas ainda carece de qualifica\u00e7\u00e3o eadequada representa\u00e7\u00e3o. Esfor\u00e7os como o do projeto em constru\u00e7\u00e3o, ParticipaSUS(Resolu\u00e7\u00e3o WHA67.23Como todo o projeto de Estado, a avalia\u00e7\u00e3o da incorpora\u00e7\u00e3o de tecnologias em sa\u00fade \u00e9 umassunto complexo, como registrado na O debate \u00e9 ben\u00e9fico para a sociedade, por\u00e9m \u00e9 necess\u00e1rio o conhecimento do contextohist\u00f3rico e a adequada avalia\u00e7\u00e3o dos atores no processo pol\u00edtico e das for\u00e7as inclu\u00eddasno mesmo. Cabe reconhecer o esfor\u00e7o e a dedica\u00e7\u00e3o de toda a equipe da secretariaexecutiva e dos membros do plen\u00e1rio da Conitec, sem os quais a tomada de decis\u00e3o estariarestrita a um pequeno grupo de acad\u00eamicos."}
+{"text": "The objective of this research was to obtain the speech and language therapists\u2019 point of view about the use of therapeutic lying as a communication strategy in dementia care.The present research was a quantitative, qualitative, and descriptive cross-sectional study. Data was collected through an online survey with multiple choices and open answer questions.The quantitative results indicated that the majority of the speech and language therapists have already used therapeutic lying as a communicative strategy and wish to learn more about it, considering the technique as relatively valid, ethical and adequate. The qualitative results indicated the reasons for the usage of the technique: to reassure the patient in case of agitation; to encourage engagement in therapy; to avoid stress-related to memory loss; to manage difficulty or refusal to eat; to manage difficulty or refusal for drug treatment; to prevent patients from leaving the building; to manage delirium, confusion and/or paranoia; to ensure safety; and for use when other strategies do not work.The majority of speech and language therapists use therapeutic lying in their clinical practice, taking into consideration the best interest of the person with dementia, although professionals recognize their lack of knowledge on the subject. They have considered the communication strategy as relatively ethical, valid and adequate. The article calls attention to the necessity of education and guidelines for speech and language therapists in the use of therapeutic lying among people with dementia. It is defined as an acquired syndrome, usually of a chronic or progressive nature, that significantly impairs the independence of the affected person.Dementia is a neurological disorder characterised by cognitive and functional decline, in which there is loss in two or more cognitive domains  and it is not related to natural aging indicates that the number of people with dementia may triple from 50 million to 152 million by 2050, due to world population aging. In Brazil, many studies,5 show dementia prevalence by regions with variable results. The most common types of dementia are Alzheimer's disease (AD), vascular dementia, Lewy body dementia, Parkinson's disease, and frontotemporal dementia,5.Data from the Pan American Health Organisation, which impairs the lives of this population physically, psychologically, socially and economically. Studies estimate that more than 90% of people with dementia develop at least one challenging behaviour, which maybe a predictor for the admission of this population into long-term care facilities. Furthermore, people with dementia also present language impairment, which can cause difficulty to keep a conversation, besides the impairments in memory and other cognitive abilities. In this context, Speech and Language Therapists (SLTs) have an important role in the rehabilitation of this population since they facilitate adaptation and training of cognitive abilities, optimization of communicative and behavioural functions, and make use of compensatory communication strategies tailored to each individual.People with dementia often have behavioural changes that are difficult to deal with. These changes are called challenging behaviours. One of the most frequently used communication strategies to deal with challenging behaviour-15 is Therapeutic Lying (TL). This term refers to lying that aims to serve the patient's interest, especially when there is a disagreement between the reality of the caregiver/health professional and the person with dementia,17. Studies show that most health professionals have already used TL in clinical practice,13,18. TL can take on a quick-fix role in dealing with critical moments and can be seen as a non-pharmacological intervention in the management of challenging behaviour. In addition, it can be used by SLTs as a communication tool in cases when the person with dementia is unable to understand the information received or the action requested, and of them making decisions that are in their best interest.Communication skills are essential for health professionals who work with patients under palliative care, regardless of their training or area of expertise, lying is characterised as the act of \u201ctrying to convince another person to accept something that is false for one's benefit or that of another, to maximise a gain or avoid a loss\u201d, which creates a negative social value as it is usually used to manipulate, deceive, or distract another person. These characteristics bring up the question of TL being in agreement with moral and ethics values, mainly in the professional field. There is the possibility that TL may be considered a form of abuse of the autonomy of the person with dementia if it is not regulated or is used inappropriately or ineffectively. For this reason, it is necessary to know when the person with dementia is able to decide by her/himself and also how to use this strategy in an efficient way.What makes this communication strategy controversial is the fact that according to Matias et al.,20-22, there are still few studies on the use of TL as a communication strategy in the care of people with dementia, even though it is frequently used in clinical practice. It is essential to inform SLTs about the technique of TL and qualify them to step in appropriately in situations in which patients present challenging behaviour. In this way, the purpose of the present study is to obtain the opinion of Brazilian SLTs regarding the use of TL as a communication strategy in the management of people with dementia.When considering TL as a communication strategy, the SLTs, who are health professionals and work in all aspects related to human communication, should play a fundamental role in guidance for the use of TL by caregivers or other health professionals. However, there are no reports in the literature about SLTs' practices nor research on this topic. To make it possible for SLTs to contribute to the guidance for the use of TL it is firstly necessary to know if they know about this communication strategy and what is their point of view about the use of it. Despite getting more attention recentlyThis is a quantitative and qualitative, cross-sectional and descriptive research, which has been approved by the local ethics committee under protocol number 2.733.408. The sample of this study is characterised as a convenience sample.Data collection was carried out through an online questionnaire (Annex A) created by the researchers. The questionnaire had 25 questions, 14 of which were multiple choice questions and 11 were open answer questions. The questionnaire was made available on Google Forms platform and was aimed at Brazilian SLTs. Access to the questions was only allowed after SLTs read and agreed with the consent form. To consent to participate in the study, the participant needed to click \u201cI agree\u201d.The study was disseminated through social media and email lists. This was exclusively for SLTs born and working in Brazil with experience in the area of dementia. SLT students, retired or non-active SLTs in the specific area were excluded. The participants who did not complete the questionnaire were also excluded from the study., summarised by the authors and described in a narrative form.Data was exported from Google Forms to Google SpreadSheet and transformed into Microsoft Excel to be analysed later using the Statistical Package for the Social Sciences Program (SPSS), version 21. Regarding the quantitative data, continuous variables were described on mean and standard deviation, and categorical variables in absolute and relative frequency. Qualitative data was analysed using the content analysis method82 individuals answered the questionnaire. One was excluded for not being a SLT and nine for not having experience with people with dementia. Therefore, the final sample consisted of 72 participants.Regarding the descriptive data, female participants made up 100% of the sample. The most frequent educational level was postgraduation (48.6%), followed by PhD (18.1%), master's degree (13.9%), undergraduation (12.5%) and post-doc (6.9%). The Southern region of Brazil was the most frequent demographic region (45.8%), followed by the Southeast (33.3%), Midwest (12.5%), Northeast (6.9%) and North (1.4%). The study time for SLTs averaged 1.51 years (\u00b19.89) and the time of experience with dementia was 7.56 years (\u00b15.97).Concerning the opinion of SLTs about the use of TL, 77.8% considered the practice relatively ethical, 12.5% considered it very ethical and 9.7% did not consider it ethical at all. When they were asked how valid is it to lie to benefit the patient and reduce caregivers' stress, 65.3% considered it relatively valid, while 27.8% considered it very valid and 6.9% not valid at all. Finally, regarding the opinion of the sample on the use of TL by the professional class, 68.1% expressed that the practice is relatively appropriate, 23.6% agreed it is very appropriate and 8.3% considered that it is not appropriate at all. was used. Some examples of participants' reports are shown in For qualitative data, open answer questions were created for participants to comment on their choices regarding the reasons and situations that led some of them to use TL as a strategy in their clinical practice. To perform the analysis of this data, the content analysis methodConcerning how valid and ethical the use of TL would be, the answers could be responded to according to a Likert scale .When the participants were asked how valid they believed it to be to lie to the patient to benefit them, those who considered the practice \u201cvery valid\u201d thought that TL rapidly ensures the patients cooperation, tranquillity and their safety. The SLTs who defended this option, reinforced the importance of family authorization. The individuals who chose to answer \u201crelatively valid\u201d, affirmed that it is necessary to investigate the appropriate moment for the use of TL and the content used. These professionals considered using TL as a last resource, first applying other strategies, such as the use of distracting themes to change focus. The SLTs who marked the option \u201cnot valid at all\u201d believed that lying constitutes a mistake and hurts interpersonal relationships. They thought that the benefits for the use of TL would be more aligned to family members and caregivers. In this way, they believe that other techniques could play a better role than the use of lying.Regarding how ethical the individuals consider TL, those who marked the option \u201cvery ethical\u201d claimed that the intention of the TL is not to deceive or hide something from the patient, but to manage the behaviour he/she presents for his/her own good. The participants who considered the use of TL as \u201crelatively ethical\u201d, explained their choice through the importance of keeping patient's autonomy and the quality of the information used in the strategy. They also considered family's participation fundamental. When selecting the option \u201cnot at all ethical\u201d, the motivation presented by the participants was mainly based on the definition of ethics, since for them, lying characterises a disruption of this principle.With regards to comments on other situations in which TL could be used, only answers that had not been previously mentioned in other items of the questionnaire were considered. The only issue highlighted in this section was the need for knowledge about TL as a communication strategy.The present study has investigated the view of Brazilian SLTs on the use of TL as a communication strategy in the management of individuals with dementia, since the profession strategically studies human communication. The SLT's role in this issue of TL could be through the use of TL as a communication strategy in the care of people with dementia. It is used in order to decrease behavioural changes in patients and ensure better participation of them in therapies. In addition, SLTs can train caregivers and others health professionals on how to use TL properly with people suffering with dementia.,15 in relation to the fact that these professionals had already used TL in their clinical practice, irrespective if they had not been properly informed about this communication strategy and its ethical issues.The findings of this study confirm the results of research previously carried out by other health professionals, such as psychologists, psychiatrists and nurses,18 for specific regulations so that professionals can apply the technique with greater mastery and safety.SLTs needed to consider how ethical it would be to use TL as a communication strategy with people with dementia, also how valid it would be to lie to the patient to benefit them and to reduce caregivers' stress and how appropriate they considered the use of TL as a communication strategy. The majority of participants judged it as relatively ethical (77.8%), valid (65.3%) and appropriate (68.1%). However, the ethical question had the highest number of negative responses  when compared to validity , appropriateness , which shows the need addressed by previous studies,18, recommendations of organizations that are a reference in the subject of dementia were verified. The Alzheimer's Society of the USA  disapproves the use of TL to avoid inappropriate behaviour, while the Brazilian Alzheimer's Association (ABRAZ), which has a tab on its website with guidelines for dealing with symptoms of disease, does not mention the use of this strategy. Likewise, the code of ethics of SLT updated by the Brazilian Federal Council of Speech Therapy in 2021, states in Chapter IV, Art. 7, item III: \u201cmaking false statements about any situations or circumstances of SLT practice\u201d is an ethical violation\u201d. The above statement reflects on whether the use of TL by SLT is appropriate. Considering that the purpose of the technique is for the benefit of the patient, the use of TL is, at the same time, in line with Chapter IV, Art. 6, which deals with the professional's responsibilities and mentions that it is a duty of care for the SLT \u201cto perform the practice fully, using all knowledge and resources needed to promote the well-being of the client\u201d.Considering the lack of adequate instruction and documentation regarding the use of TL in the care of people with dementia that some studies have pointed out addressed the creation and application of British guidelines, a 12 item set of recommendations on the use of TL. These guidelines are based on the principle that TL could only be considered as a form of therapy after verifying the cognitive abilities of each patient and verifying their inability to understand information given by professionals/caregivers and to make decisions for his/her best interest.Ian James et al. carried out in the USA with this population participating in a discussion group, in which a questionnaire was applied about how acceptable they would consider being lied to. The results showed that patients believe that lying is valid only in certain circumstances, especially to ensure their safety or to minimise \u201ctruth-related stresses\u201d, which indicates that individuals with dementia believe that the benefit from TL as a communication strategy is valid and effective.Thereby, the opinion of people with dementia must still be considered, as in the study by Day et al.Regarding the reports of situations in which SLT have used or could use TL as a communication strategy, it is possible to realise that most of the positive answers from the participants were focused on the patient's well-being, safety and collaboration. The negative answers showed a concern with ethical and practical aspects, with deontological opinions affirming that in their opinion lying is immoral, without considering the positive effects that the use of this strategy could have on the patient. and/or validation of new protocols that guarantee the best way to use this strategy.Furthermore, the results of the present study highlighted the lack of knowledge about TL, due to the shortage of bibliography and national research, in addition to the topic not being addressed during professional training. This is evident by the fact that 65.3% of the sample, stated that they have already used the strategy. However, only 23.8% had heard about it and only 5.6% had already found information on the topic in the literature. Possibly, these numbers are due to the fact that the technique is in regular use, but its users are not aware that it is a strategy, that with greater knowledge can have very positive effects in clinical practice. Noticing the number of SLTs who responded that were interested in knowing more about the subject, we suggest that further research be carried out, taking into account the opinion of Brazilian people with dementia and their relatives/caregivers. Simultaneously, this should be aligned with the development of recommendations for the use of TL, as in the protocol suggested by James et al.The present study presents a limitation regarding the sample. Since there is no real data on how many SLTs work in the field of dementia in Brazil, there is no reference to the distribution of the number of participants by regions, which makes it impossible to carry out a sample or statistical calculation on their representation. Possibly, the predominance of participants from the Southern region of the country was due to the fact that the researchers are from this region and have disseminated the research in their networks, which cover more professionals from this place. In this way, it can be considered a sampling bias.In general, Brazilian SLTs use TL in their clinical practice, taking into account the benefit of the person with dementia, although they recognize the lack of knowledge on this subject. Most participants considered this strategy relatively ethical, valid and appropriate, reinforcing the need for a regulation of its use to ensure the safety of those involved. Furthermore, the participants showed a real interest in learning more about TL, especially due to the lack of literature and contact with the technique during their professional training. . \u00c9 definida como uma s\u00edndrome adquirida de natureza cr\u00f4nica ou progressiva que interfere significativamente na independ\u00eancia da pessoa acometida.A dem\u00eancia \u00e9 uma s\u00edndrome neurol\u00f3gica caracterizada por decl\u00ednio cognitivo e funcional, com preju\u00edzo em dois ou mais dom\u00ednios cognitivos  que n\u00e3o \u00e9 relacionado ao envelhecimento natural indicam que o n\u00famero de pessoas com dem\u00eancia poder\u00e1 triplicar de 50 milh\u00f5es para 152 milh\u00f5es at\u00e9 2050, conforme o envelhecimento da popula\u00e7\u00e3o mundial. No Brasil, diversos estudos,5 demonstram a preval\u00eancia da doen\u00e7a por regi\u00f5es com resultados vari\u00e1veis. Os tipos mais frequentes de dem\u00eancia s\u00e3o a doen\u00e7a de Alzheimer (DA), dem\u00eancia vascular, dem\u00eancia de Corpos de Lewy, doen\u00e7a de Parkinson e dem\u00eancia frontotemporal,5.Dados da Organiza\u00e7\u00e3o Pan-Americana de Sa\u00fade de 2017, que prejudicam a qualidade de vida desta popula\u00e7\u00e3o tanto fisicamente quanto psicologicamente, socialmente e economicamente. Estudos estimam que mais de 90% dos acometidos desenvolvem ao menos um comportamento desafiador no curso da doen\u00e7a, sendo estes comportamentos os preditores da admiss\u00e3o destas pessoas em institui\u00e7\u00f5es de longa perman\u00eancia. Al\u00e9m disso, pessoas com dem\u00eancia tamb\u00e9m apresentam deteriora\u00e7\u00e3o da linguagem, que pode causar uma redu\u00e7\u00e3o na habilidade de manter conversa\u00e7\u00f5es al\u00e9m dos d\u00e9ficits de mem\u00f3ria ou de outros dom\u00ednios cognitivos. Neste contexto, o fonoaudi\u00f3logo tem um papel fundamental na interven\u00e7\u00e3o e tratamento desta popula\u00e7\u00e3o, pois promove a adapta\u00e7\u00e3o e treino de habilidades cognitivas, otimiza\u00e7\u00e3o das fun\u00e7\u00f5es comunicativas e comportamentais, al\u00e9m de lan\u00e7ar m\u00e3o do uso de estrat\u00e9gias de comunica\u00e7\u00e3o compensat\u00f3rias a cada caso.Pessoas com dem\u00eancia frequentemente apresentam altera\u00e7\u00f5es comportamentais que s\u00e3o dif\u00edceis de manejar, chamadas de comportamentos desafiadores. Uma das estrat\u00e9gias de comunica\u00e7\u00e3o mais frequentemente empregadas para lidar com comportamentos desafiadores-15 \u00e9 a Mentira Terap\u00eautica (MT) - uma mentira aplicada com o objetivo de atender o melhor interesse do paciente, sobretudo quando h\u00e1 diverg\u00eancia entre a realidade do cuidador/profissional de sa\u00fade e da pessoa acometida pela doen\u00e7a,17. Estudos apontam que a maioria dos profissionais de sa\u00fade j\u00e1 fez uso da MT na pr\u00e1tica cl\u00ednica,13,18. A MT pode assumir um papel de interven\u00e7\u00e3o e solu\u00e7\u00e3o \u00e1gil para lidar com momentos cr\u00edticos, pois representa um potencial de interven\u00e7\u00e3o n\u00e3o-farmacol\u00f3gica no gerenciamento dos comportamentos desafiadores. Ademais, poderia ser utilizada por fonoaudi\u00f3logos como estrat\u00e9gia de comunica\u00e7\u00e3o na terapia em casos em que a pessoa com dem\u00eancia \u00e9 incapaz de compreender a informa\u00e7\u00e3o recebida ou a\u00e7\u00e3o solicitada e tomar decis\u00f5es para seu melhor interesse.Habilidades de comunica\u00e7\u00e3o s\u00e3o essenciais aos profissionais da s\u00e1ude que atuam com pacientes sob cuidados paliativos, independente de sua forma\u00e7\u00e3o ou \u00e1rea de especialidade, como o ato de \u201ctentar convencer outra pessoa a aceitar aquilo que o pr\u00f3prio indiv\u00edduo sabe que \u00e9 falso, em benef\u00edcio pr\u00f3prio ou de outros, para maximizar um ganho ou evitar uma perda\u201d constituindo uma intera\u00e7\u00e3o de valor social negativo, pois geralmente \u00e9 utilizada para manipular, enganar, iludir ou distrair o outro. Essas caracter\u00edsticas p\u00f5em em quest\u00e3o se a MT seria condizente com valores morais e \u00e9ticos, principalmente no \u00e2mbito profissional. H\u00e1 ainda a possibilidade de a MT ser considerada como uma forma de abuso \u00e0 autonomia da pessoa com dem\u00eancia caso n\u00e3o seja regulamentada ou seja empregada de forma inadequada e ineficiente, pois \u00e9 necess\u00e1rio saber definir quando a pessoa com dem\u00eancia \u00e9 capaz de decidir por si mesma e como aplicar a estrat\u00e9gia de forma eficaz.O que torna o uso dessa estrat\u00e9gia controverso \u00e9 o fato de, geralmente, a mentira ser caracterizada, de acordo com Matias et al.,20-22, ainda h\u00e1 poucos estudos sobre o uso da MT como estrat\u00e9gia de comunica\u00e7\u00e3o no cuidado de pessoas com dem\u00eancia, possuindo pouca evid\u00eancia cient\u00edfica mesmo sendo amplamente utilizada na pr\u00e1tica cl\u00ednica. Torna-se imprescind\u00edvel informar sobre a estrat\u00e9gia e habilitar fonoaudi\u00f3logos  a intervir apropriadamente nas situa\u00e7\u00f5es em que pacientes apresentam comportamentos desafiadores, visando sempre o melhor interesse do paciente. Dessa forma, o objetivo do presente estudo \u00e9 obter a vis\u00e3o do fonoaudi\u00f3logo brasileiro a respeito da utiliza\u00e7\u00e3o da MT como estrat\u00e9gia de comunica\u00e7\u00e3o no manejo de pacientes com dem\u00eancia.Ao considerarmos a MT como uma estrat\u00e9gia de comunica\u00e7\u00e3o, o fonoaudi\u00f3logo, que \u00e9 o profissional da sa\u00fade que atua em todos aspectos referentes \u00e0 comunica\u00e7\u00e3o humana, poderia ter um papel fundamental na orienta\u00e7\u00e3o quanto ao uso da MT por cuidadores e outros profissionais da sa\u00fade. No entanto, n\u00e3o h\u00e1 relatos na literatura de atua\u00e7\u00f5es e pesquisas da fonoaudiologia sobre o tema. Para que o fonoaudi\u00f3logo possa contribuir para a orienta\u00e7\u00e3o do uso da MT \u00e9 necess\u00e1rio primeiro saber se esta classe profissional conhece essa estrat\u00e9gia de comunica\u00e7\u00e3o e qual a sua opini\u00e3o sobre o uso dela do ponto de vista \u00e9tico. Apesar de estar ganhando mais aten\u00e7\u00e3o recentementeTrata-se de uma pesquisa quantitativa e qualitativa, transversal, de car\u00e1ter descritivo, que foi aprovada pelo comit\u00ea de \u00e9tica local sob parecer de n\u00famero 2.733.408. A amostra deste estudo se caracteriza como uma amostra de conveni\u00eancia.Google Forms para que os participantes pudessem responder individualmente. O acesso \u00e0s quest\u00f5es foi permitido somente ap\u00f3s a confirma\u00e7\u00e3o de leitura e concord\u00e2ncia dos participantes referente ao Termo de Consentimento Livre e Esclarecido (TCLE), disponibilizado de forma online previamente \u00e0 apresenta\u00e7\u00e3o do question\u00e1rio. Para consentir em participar do estudo, o participante precisava clicar em \u201ceu concordo\u201d.A coleta de dados foi realizada de modo online atrav\u00e9s de um question\u00e1rio (Anexo A) elaborado pelas pesquisadoras, contendo 25 quest\u00f5es, sendo 14 de m\u00faltipla escolha e 11 de resposta aberta, direcionado a fonoaudi\u00f3logos do Brasil. O question\u00e1rio foi elaborado pelas autoras e disponibilizado na plataforma O estudo foi divulgado atrav\u00e9s de redes sociais e de listas de e-mails. Foram inclu\u00eddos fonoaudi\u00f3logos nascidos e atuantes no Brasil com experi\u00eancia na \u00e1rea de dem\u00eancias. Estudantes de fonoaudiologia, fonoaudi\u00f3logos aposentados ou n\u00e3o atuantes em dem\u00eancias foram considerados como crit\u00e9rios de exclus\u00e3o. Os participantes que n\u00e3o conclu\u00edram o question\u00e1rio foram exclu\u00eddos do estudo.Microsoft Excel para serem analisados posteriormente atrav\u00e9s do programa Statistical Package for the Social Sciences (SPSS), vers\u00e3o 21. Quanto aos dados quantitativos, as vari\u00e1veis cont\u00ednuas foram descritas em m\u00e9dia e desvio padr\u00e3o, e as categ\u00f3ricas em frequ\u00eancia absoluta e relativa. Os dados qualitativos foram analisados atrav\u00e9s do m\u00e9todo de an\u00e1lise de conte\u00fado, sumarizados pelas autoras e descritos em forma de narrativa.Os dados foram exportados da plataforma Google Forms para Google SpreadSheets e transformados em Responderam ao question\u00e1rio 82 sujeitos. Destes, um foi exclu\u00eddo por n\u00e3o ser fonoaudi\u00f3logo e nove por n\u00e3o possu\u00edrem experi\u00eancia com pessoas com dem\u00eancia. Sendo assim, a amostra final foi composta por 72 participantes.Em rela\u00e7\u00e3o aos dados descritivos, evidenciou-se o predom\u00ednio do sexo feminino (100%). A especializa\u00e7\u00e3o  foi maioria quanto ao grau de escolaridade, seguida por doutorado , mestrado , gradua\u00e7\u00e3o  e p\u00f3s-doutorado . A regi\u00e3o sul foi observada como regi\u00e3o demogr\u00e1fica mais frequente  seguida pela regi\u00e3o sudeste , centro-oeste , nordeste  e norte . O tempo de forma\u00e7\u00e3o desses profissionais teve como m\u00e9dia 12,51 anos , enquanto o tempo de experi\u00eancia com dem\u00eancia 7,56 anos .Quanto \u00e0 opini\u00e3o dos fonoaudi\u00f3logos sobre o uso da MT, 77,8% da amostra considera a pr\u00e1tica relativamente \u00e9tica, 12,5% considera muito \u00e9tica e 9,7% n\u00e3o considera nem um pouco \u00e9tica. Quando perguntados sobre o qu\u00e3o v\u00e1lido \u00e9 mentir para beneficiar o paciente e reduzir o estresse dos cuidadores, 65,3% consideraram relativamente v\u00e1lido, enquanto 27,8% consideraram muito v\u00e1lido e 6,9% nem um pouco v\u00e1lido. Por fim, em rela\u00e7\u00e3o \u00e0 opini\u00e3o da amostra sobre o uso da MT pela classe profissional, 68,1% dos participantes manifestaram que a pr\u00e1tica \u00e9 relativamente adequada, 23,6% manifestaram que ser muito adequada e 8,3% consideraram que n\u00e3o \u00e9 nem um pouco adequada.A . Alguns exemplos de relatos dos participantes foram agrupados nas categorias expostas no Quanto aos dados qualitativos, foram elaboradas perguntas de resposta aberta para que os participantes pudessem comentar suas escolhas com rela\u00e7\u00e3o aos motivos e situa\u00e7\u00f5es que os levaram a utilizar a MT como estrat\u00e9gia na sua pr\u00e1tica cl\u00ednica. Para realizar a an\u00e1lise desses dados, utilizou-se o m\u00e9todo de an\u00e1lise de conte\u00fadoA respeito do qu\u00e3o v\u00e1lido e \u00e9tico seria o uso da MT, dividiu-se os coment\u00e1rios correspondentes a cada item da escala Likert de tr\u00eas pontos  em cada pergunta.Quando questionados sobre o qu\u00e3o v\u00e1lido acreditavam que seja mentir para o paciente para benefici\u00e1-lo, aqueles que consideraram a pr\u00e1tica como \u201cmuito v\u00e1lida\u201d, defenderam a MT para garantir a coopera\u00e7\u00e3o, tranquilidade e seguran\u00e7a do paciente de forma r\u00e1pida. Os fonoaudi\u00f3logos que defenderam esta op\u00e7\u00e3o refor\u00e7aram a import\u00e2ncia da autoriza\u00e7\u00e3o da fam\u00edlia. Os sujeitos que optaram por responder \u201crelativamente v\u00e1lido\u201d afirmaram que \u00e9 necess\u00e1rio averiguar o momento adequado e o conte\u00fado utilizado. Estes profissionais consideram o uso da MT como \u00faltimo recurso, aplicando primeiramente outras estrat\u00e9gias, como a utiliza\u00e7\u00e3o de temas distratores para mudan\u00e7a de foco. Os fonoaudi\u00f3logos que assinalaram a op\u00e7\u00e3o \u201cnem um pouco v\u00e1lido\u201d expressaram que a mentira constitui um engano e fere as rela\u00e7\u00f5es interpessoais, e os benef\u00edcios seriam mais voltados aos familiares e cuidadores. Nesse sentido, eles acreditam que outras t\u00e9cnicas desempenham melhor o papel que a mentira teria no cuidado das pessoas com dem\u00eancias.Em rela\u00e7\u00e3o ao qu\u00e3o \u00e9tico os sujeitos consideraram a MT, os que marcaram a op\u00e7\u00e3o \u201cmuito \u00e9tico\u201d alegaram que a inten\u00e7\u00e3o da MT n\u00e3o \u00e9 enganar ou esconder algo do paciente, mas sim de manejar o comportamento que ele apresenta para o seu pr\u00f3prio bem. Os sujeitos que consideraram o uso da MT como \u201crelativamente \u00e9tico\u201d justificaram sua escolha atrav\u00e9s da autonomia do paciente como foco e da qualidade da informa\u00e7\u00e3o utilizada no emprego da estrat\u00e9gia, julgando a participa\u00e7\u00e3o da fam\u00edlia como fundamental. Ao selecionar a op\u00e7\u00e3o \u201cnem um pouco \u00e9tico\u201d, a motiva\u00e7\u00e3o apresentada pelos participantes baseou-se principalmente na defini\u00e7\u00e3o de \u00e9tica, visto que, para eles, a mentira caracteriza uma quebra deste princ\u00edpio.No que concerne aos coment\u00e1rios sobre outras situa\u00e7\u00f5es em que a MT poderia ser utilizada, considerou-se apenas as respostas que n\u00e3o haviam sido previamente mencionadas em outros itens do question\u00e1rio. A \u00fanica quest\u00e3o destacada nesta se\u00e7\u00e3o foi a necessidade de um conhecimento maior acerca da MT como estrat\u00e9gia de comunica\u00e7\u00e3o.O presente estudo investigou a vis\u00e3o do fonoaudi\u00f3logo brasileiro sobre o uso da MT como uma estrat\u00e9gia de comunica\u00e7\u00e3o no manejo de pacientes com dem\u00eancia, visto que a fonoaudiologia \u00e9 a profiss\u00e3o que tem como objeto de estudo a comunica\u00e7\u00e3o humana. A atua\u00e7\u00e3o do fonoaudi\u00f3logo neste tema poderia se dar atrav\u00e9s do uso da MT como uma estrat\u00e9gia de comunica\u00e7\u00e3o durante seu atendimento, a fim de minimizar altera\u00e7\u00f5es comportamentais dos pacientes e garantir uma melhor ades\u00e3o dos mesmos, assim como, atrav\u00e9s do treinamento e orienta\u00e7\u00e3o de cuidadores e outros profissionais da sa\u00fade sobre como usar a MT adequadamente nesta popula\u00e7\u00e3o.,15, em rela\u00e7\u00e3o ao fato destes profissionais j\u00e1 terem utilizado a MT na sua pr\u00e1tica cl\u00ednica, mesmo que n\u00e3o estivessem apropriadamente informados sobre a estrat\u00e9gia de comunica\u00e7\u00e3o e suas quest\u00f5es \u00e9ticas.Os achados do presente estudo corroboram com os resultados das pesquisas previamente feitas com outros profissionais de sa\u00fade, como psic\u00f3logos, psiquiatras e enfermeirosO ,18 de uma regulamenta\u00e7\u00e3o espec\u00edfica de refer\u00eancia para que os profissionais possam aplicar essa t\u00e9cnica com maior propriedade e seguran\u00e7a.Quando os fonoaudi\u00f3logos precisaram considerar o qu\u00e3o \u00e9tico seria utilizar a MT como estrat\u00e9gia de comunica\u00e7\u00e3o com pessoas com dem\u00eancia, o qu\u00e3o v\u00e1lido seria mentir para o paciente para benefici\u00e1-lo e para reduzir o estresse dos cuidadores, al\u00e9m do qu\u00e3o adequado consideram a utiliza\u00e7\u00e3o da MT como estrat\u00e9gia de comunica\u00e7\u00e3o a ser trabalhada com familiares/cuidadores de pessoas com dem\u00eancia pelo profissional da fonoaudiologia, a grande maioria julgou como relativamente \u00e9tico , v\u00e1lido  e adequado . No entanto, a quest\u00e3o \u00e9tica apresentou o maior n\u00famero de respostas negativas  quando comparada \u00e0 validez  e adequa\u00e7\u00e3o , evidenciando a necessidade abordada por estudos pr\u00e9vios,18 apontam, verificou-se as recomenda\u00e7\u00f5es de organiza\u00e7\u00f5es que s\u00e3o refer\u00eancia no tema das dem\u00eancias a para a profiss\u00e3o da fonoaudiologia. A sociedade de Alzheimer dos EUA  condena o uso da MT para evitar estresse, enquanto a Associa\u00e7\u00e3o Brasileira de Alzheimer (ABRAZ), que possui em seu website uma aba com diversas orienta\u00e7\u00f5es para lidar com os sintomas da doen\u00e7a, n\u00e3o faz men\u00e7\u00e3o ao uso dessa estrat\u00e9gia em particular. Do mesmo modo, verificou-se o c\u00f3digo de \u00e9tica da fonoaudiologia atualizado pelo Conselho Federal de Fonoaudiologia em 2021, cujo Cap. IV, Art. 7\u00ba, item III descreve que: \u201cfazer declara\u00e7\u00f5es falsas sobre quaisquer situa\u00e7\u00f5es ou circunst\u00e2ncias da pr\u00e1tica fonoaudiol\u00f3gica\u201d consiste em infra\u00e7\u00e3o \u00e9tica. Este item do c\u00f3digo de \u00e9tica traz a reflex\u00e3o sobre o uso da MT pelo profissional fonoaudi\u00f3logo ser apropriado. Considerando que o objetivo da t\u00e9cnica \u00e9 o benef\u00edcio do paciente, o uso da MT vai, ao mesmo tempo, ao encontro do Cap. IV, Art. 6\u00ba, que trata das responsabilidades do profissional e menciona que \u00e9 um dever do fonoaudi\u00f3logo \u201cexercer a atividade de forma plena, utilizando-se dos conhecimentos e recursos necess\u00e1rios, para promover o bem-estar do cliente\u201d.Considerando a car\u00eancia de instru\u00e7\u00e3o e documenta\u00e7\u00e3o adequada quanto a utiliza\u00e7\u00e3o de MT na assist\u00eancia a pessoas com dem\u00eancia que algumas pesquisas aborda a cria\u00e7\u00e3o e aplica\u00e7\u00e3o de um protocolo de orienta\u00e7\u00f5es, composto por um conjunto de 12 diretrizes sobre o uso da MT. Estas diretrizes t\u00eam como princ\u00edpio que a MT s\u00f3 poderia ser considerada como forma de terapia ap\u00f3s a verifica\u00e7\u00e3o das habilidades cognitivas de cada paciente e constata\u00e7\u00e3o da incapacidade deste de compreender informa\u00e7\u00f5es dadas pelos profissionais/cuidadores e de tomar decis\u00f5es para seu melhor interesse.O estudo de James et al. realizado nos EUA com pessoas com dem\u00eancia participantes de um grupo de discuss\u00e3o, em que um question\u00e1rio foi aplicado sobre o qu\u00e3o aceit\u00e1vel eles considerariam que fosse mentido para eles. Obteve-se resultados que demonstraram que pacientes acreditam que a mentira \u00e9 v\u00e1lida somente em determinadas circunst\u00e2ncias, especialmente para garantir a seguran\u00e7a ou para minimizar \u201cestresses relacionados \u00e0 verdade\u201d, o que indica que esta popula\u00e7\u00e3o acredita beneficiar-se da MT como estrat\u00e9gia de comunica\u00e7\u00e3o v\u00e1lida e eficaz.Tendo isso em vista, h\u00e1 ainda de se considerar a opini\u00e3o das pessoas acometidas pela doen\u00e7a, como no estudo de Day et al.Sobre os relatos de situa\u00e7\u00f5es em que os fonoaudi\u00f3logos utilizaram ou poderiam utilizar a MT como estrat\u00e9gia de comunica\u00e7\u00e3o, \u00e9 poss\u00edvel perceber que a maior parte das respostas positivas focou no bem-estar do paciente como motivo principal, al\u00e9m da seguran\u00e7a e colabora\u00e7\u00e3o do mesmo. J\u00e1 as respostas negativas demonstraram uma maior preocupa\u00e7\u00e3o com os aspectos \u00e9ticos e pr\u00e1ticos, contando com opini\u00f5es deontol\u00f3gicas afirmando que a mentira \u00e9 imoral, sem considerar os efeitos positivos que o uso dessa estrat\u00e9gia acarretaria para o paciente., e/ou valida\u00e7\u00e3o de novos protocolos que garantam a melhor forma de fazer uso dessa estrat\u00e9gia.Ademais, os resultados do presente estudo salientaram a falta de conhecimento sobre a MT, devido \u00e0 escassez de bibliografia e pesquisas nacionais, al\u00e9m do tema n\u00e3o ser abordado durante a forma\u00e7\u00e3o profissional. Isso se mostra evidente pelo fato de que 65,3% da presente amostra ter afirmado que j\u00e1 utilizou a estrat\u00e9gia, no entanto, apenas 23,8% j\u00e1 ouviram falar sobre ela e apenas 5,6% j\u00e1 encontraram informa\u00e7\u00f5es sobre o tema na literatura. Possivelmente, esses n\u00fameros se devem ao fato de que a t\u00e9cnica \u00e9 de uso regular, por\u00e9m seus usu\u00e1rios n\u00e3o t\u00eam conhecimento que se trata de uma estrat\u00e9gia que, com maiores conhecimentos, pode ter grandes efeitos positivos na pr\u00e1tica cl\u00ednica. Atentando para a quantidade de fonoaudi\u00f3logos que responderam ter interesse em saber mais sobre o assunto, sugere-se que mais pesquisas sejam feitas levando em considera\u00e7\u00e3o a opini\u00e3o de pessoas brasileiras com dem\u00eancia e seus familiares/cuidadores, conjuntamente com o desenvolvimento de recomenda\u00e7\u00f5es para o uso da MT, a exemplo do protocolo sugerido por James et al.O estudo realizado apresentou uma limita\u00e7\u00e3o em rela\u00e7\u00e3o \u00e0 amostra, que deve ser levada em conta ao interpretar os resultados. Visto que n\u00e3o h\u00e1 dados reais sobre quantos fonoaudi\u00f3logos atuam na \u00e1rea de dem\u00eancias no Brasil, n\u00e3o h\u00e1 refer\u00eancia da distribui\u00e7\u00e3o de n\u00famero de participantes pelas regi\u00f5es, o que impossibilitou um c\u00e1lculo amostral ou estat\u00edstico sobre a representatividade delas na amostra. Possivelmente, houve predom\u00ednio de participantes do sul do pa\u00eds devido ao fato de as pesquisadoras serem desta regi\u00e3o e terem divulgado a pesquisa em suas redes, que abrangem mais profissionais deste local, o que pode ser considerado, desta forma, um vi\u00e9s amostral.De modo geral, os fonoaudi\u00f3logos brasileiros utilizam a MT em sua pr\u00e1tica cl\u00ednica e o fazem levando em considera\u00e7\u00e3o o benef\u00edcio da pessoa com dem\u00eancia, embora reconhe\u00e7am a falta de conhecimento acerca do assunto. A grande maioria dos participantes considera essa estrat\u00e9gia de comunica\u00e7\u00e3o relativamente \u00e9tica, v\u00e1lida e adequada, refor\u00e7ando a necessidade de regulamenta\u00e7\u00e3o que supervisione seu uso para garantir a seguran\u00e7a dos envolvidos e demonstrando um grande interesse em aprender mais sobre, dada a escassez de literatura e contato com a t\u00e9cnica durante a forma\u00e7\u00e3o profissional."}
+{"text": "Interventions for parental training for families of hard of hearing children, including cochlear implant users, are identified as optimizing their developmental outcomes. In this single-case intervention study, we aim to describe the use of videofeedback in a remote environment, as well as to identify its effectiveness, based on the analysis of mother-child interaction, both for the mother's communicative behaviors and for the behaviors of the mother, receptive and expressive language of the child. Pre- and post-intervention measurements were performed, based on video analysis of the mother's interaction with the child, by blind judges, as well as through the application of assessment instruments for the child and the mother. There were 13 sessions, 3 of which were for evaluation before and after the intervention and 10 of teleconsultation sessions in which the videofeedback tool was used with the mother. Data were analyzed descriptively and inferentially, using the JT method, which determined the Reliable Change Index (BMI) and Clinical Significance. There was reliable positive change in the child's receptive and expressive language, as well as reliable positive change and clinically significant change in mother-child interaction after the 10 sessions of remote videofeedback intervention. Based on the reliable changes observed in this study, we present this model (televideofeedback) as a potential to optimize resources and efforts for therapeutic success in children's auditory rehabilitation, which should be studied in research with a rigorous method, for the broad recommendation of its use. The use of parenting interventions after the diagnosis of hearing loss makes caregivers, including family members and anyone regularly involved in the child's care, more active and responsive in communicating with children. However, parental support provides an understanding of the roles of caregivers, both in establishing the consistent use of hearing aids and in optimizing the child's hearing and language development, essential aspects for effective results in this population-7.The complex and multifaceted interactional processes that take place between the children and their caregivers are considered vital for healthy development, it is worth considering the different models proposed for family-centered interventions, to increase the level of support and enrichment of family interactions, with a potential impact on the psychosocial and neurocognitive development of children with hearing loss.Thus, based on the premise that the family environment plays an important role in promoting the development of oral language skills in children with hearing loss-7.Therefore, research dedicated to studying different models of intervention with families can help the speech therapist understand which program pattern best suits the context and needs of the assisted family, varying its intensity, duration, framework , as well as where it can be implemented -7.Among the models of parental training or intervention with families, there are those focused on the interactions between caregivers and hard of hearing children , which have been consistently related to enhancing the quality of the linguistic stimuli offered, also giving families more confidence to deal with the daily situations they experience. Thus, facilitating the listening and language environment for their children, shaping an ideal communicative scenario that encourages the child's language initiative and autonomy, especially in the first years of life, to take advantage of the window of opportunity for development, later introduced in the United Kingdom, spreading rapidly in clinical practice, with the aim of working on the development of attuned interactions. Recently, video analysis of family-child interaction has been used more systematically in studies of children's auditory rehabilitation,5,6.To work with interaction, the techniques of recording videos and therefore analyzing the interaction of the family-child dyad have been used over the years, initially by Psychology, as in the primary studies of Harry Biemans (1990) based on Trevarthen's theory of intersubjectivity offers a possibility of intervention that makes it possible to improve the quality of the family-child relationship by reinforcing the positive interactions that exist in the video analyzed. VF is an intervention model that involves changes in individuals to improve relationships and/or communication in a variety of contexts, including clinical and at-risk populations such as families and children with hearing loss, promoting a positive change that is favorable to child development and family-child interaction,5,6.The use of the video feedback (VF) procedure,6.In this way, by viewing positive clips of the interaction between the adult and the child, reflections are made with the family about their potential as a stimulating agent. There is also guidance on the aspects that can be improved in the child's hearing and language environment, generating a positive cycle of empowerment and training for parents to interact with their hard of hearing children in Brazil, this research was undertaken to investigate its feasibility based on the application of a clinical case in a pilot study.As its basis is the recording and analysis of the video by the professional, followed by the VF session with the family, during the Sars-Cov-2 pandemic, its use in remote format began to be considered. Thus, given the possibility of synchronous and asynchronous teleconsultations under the regulations of the Federal Council of Speech and Hearing Therapy (CFFa), CFFa resolution no. 580/2020.It should be noted that remote intervention models with hard of hearing children have already been studied and have been highlighted as effective for children's hearing rehabilitation. This is especially because it optimizes the participation of the family as the protagonists of changes in their children's development, as well as financial and logistical benefits in terms of access to trained professionalsBased on these considerations, the question of this study was: \u201cIs televideofeedback, a low-cost technological tool, applicable and does it promote change in communication behaviors in the mother-child dyad studied?\u201d. The hypothesis is that this model can be used by the speech therapist in teleconsultations and can be a catalyst for a more attuned interaction between the family and the child, with benefits for their communication. in the world and in Brazil and the impossibility of having enough specialist professionals in all regions of the country, as well as the need to provide families with individualized support and specific information to improve the development of children with hearing loss, based on their daily interactions, this study aimed to describe, through a single-case intervention study, the use of the VF tool, applied in a remote environment, as well as to identify the reliable changes in the interaction between mother and child and in the receptive and expressive language of the child, a cochlear implant user, before and after the intervention.Considering the statistics of hearing lossChecklist of information to include when writing a case report).This is a single-case intervention study, approved by the institutional Research Ethics Committee . The participation of the mother, the child's main caregiver, was conditional on accepting the invitation, as well as signing the Informed Consent Form (ICF) and the Image Form (Voice/Video), in digital format. The writing of this case study was based on the CARE checklist  and ten intervention sessions, intensively. Each session lasted 50 minutes, occurred on five weekdays, and was distributed over two weeks.As inclusion criteria for inviting the participating family, the child should have a diagnosis of hearing loss of any type or degree, with no other disabilities associated with the hearing impairment, make effective use of an Individual Sound Amplification Device (ISAD), and/or Cochlear Implant (CI), be up to six years old, and be undergoing rehabilitation in the Hearing and Language program at the SUVAG/RN Center, with attendance equal to or greater than 75%. In addition to being willing to take part in the intensive intervention, which took place over 10 consecutive days, excluding weekends, the family had to have an electronic device  with internet access that allowed them to connect. Inclusion criteria were established, focusing on the population of hearing families. Thus, if the main guardian was deaf, they would not be included in the study, although the same intervention protocol could be applied to deaf families, provided the researcher was fluent in Brazilian Sign Language (LIBRAS).The exclusion criteria were a child who had not yet adapted to ISAD or CI, used LIBRAS, had an attendance rate of less than 75%, and had other disabilities associated with hearing loss, so we decided to study a case without other disabilities associated with hearing loss. However, it should be noted that the proposed intervention is applicable to specific groups.Regarding the family, their unwillingness to take part in the intensive intervention and their inability to access the internet were exclusion criteria in this study. The characterization of the child and their mother is shown in  whose scores were obtained from the observation of the speech therapist in charge of the service's rehabilitation team and the Brazilian Functional Hearing Performance Indicators - Reduced Version (FAPI-r) family form was applied. The reduced version of the FAPI-r consists of a 25-item form for the speech therapist to use with the child and a 15-item form for the family. Both are organized into 15 sections in which the family member reports the frequency with which auditory behaviors are observed at home, covering the skills of sound awareness, auditory feedback, auditory discrimination and recognition, auditory comprehension, auditory short-term memory, and auditory linguistic processing.For the child's assessment, which was carried out remotely, it was used the Hearing and Language CategoriesIn the application of the FAPI-r (family version), it was observed that at the pre-intervention moment, according to the mother's observations, the child had already acquired the skills of sound awareness (100%), auditory feedback (100%) and was in the process of acquiring the skills of auditory discrimination and recognition (75%), auditory comprehension (75%), auditory short-term memory  and auditory linguistic processing (75%). At the post-intervention stage, there was a change in the scores for auditory discrimination and recognition skills (100%) and auditory comprehension (100%). The others remained with the same scores. Although it cannot be said that this change was the result of the intervention process, it was observed that the questions in which the mother reported an improvement in her hearing skills referred to: discrimination of the communicative intent of statements, identification of critical elements in sentences (two and three elements)and in a children's story, indicating that the dialogic process enriched by the proposed intervention may have influenced the mother's perception and her greater attention to these skills during interactions with her daughter.The following protocols were used to assess the mother:.Parental Stress Scale (PSS) - This is a self-report instrument with 18 items representing four factors  answered on a Likert scale (zero to five) designed to measure the level of stress experienced by fathers and mothers of children under the age of 18. The total score can vary between 0 and 72 points, so the higher the score, the greater the parental stress.Rosenberg Self-Esteem Scale (RSE) - an instrument with ten closed sentences which aims to provide an overall assessment of the individual's positive or negative attitude towards themselves, answered on a Likert scale (one to four), ranging from \u201ctotally agree\u201d to \u201ctotally disagree\u201d. The score can oscillate between 10 and 40 and the higher the score obtained on the scale, the higher the individual's level of self-esteem.Family Environment Resource Inventory (FER): script applied in the form of a semi-structured interview to characterize material resources and family routines. The sum of the scores for items 1 to 7 results in a gross score, while topics 8, 9, and 10 have specific scores indicated on the formIt is worth noting that although these protocols were applied to characterize and monitor the mother, in this pilot study we did not aim to verify the effect of the intervention on the measures of family environment resources, parental stress, and the mother's self-esteem, considering the specific characteristics of the intervention, its short term and the complexity of the variables analyzed.It was observed that in the assessment of parental stress, comparing the pre- and post-intervention scores, there was a slight decrease in the score, but in the pre-intervention assessment there were already low levels of parental stress.The RSE, measured by the total of the items, is classified into self-esteem categories: low, medium, and high. Since the pre-intervention assessment, the mother had high self-esteem, scoring above 30 in both scenarios.It should be noted that this was a case in which the mother's characteristics  were positive for the therapeutic work. Therefore, it is important that these measures are considered when assessing families to better understand the needs of each one of them so that more assertive approaches can be adopted.Regarding the family environment, the FER showed a view of the resources, characteristics, and behaviors at home, with a slight increase in the examples given by the mother. She described the closeness of the family in carrying out shared activities inside and outside the home environment on a regular basis.playing, watching movies, watching children's programs on TV, reading books, magazines\u201d and after the intervention she changed the items to \u201cplaying, watching movies, listening to the child's stories; talking about the subjects she brings up\u201d.A change was noticed in the examples of item 4, where pre-intervention the mother listed \u201cIn item 8, the mother referred to herself in all the situations, as not only the main caregiver, but also an agent who conducts stimulating activities.The availability of physical resources such as toys, games, magazines and books remained the same before and after the intervention.According to the mother's account, her attention was refocused post-intervention, to listen more to what the child brings to the daily routine, as well as the perception of her empowerment as an agent who cooperates with her daughter's learning, based on daily activities.) by three independent judges, two of whom were blind.In addition to these evaluations, all 11 interaction videos recorded between January 9 and 21, 2022 (excluding weekends) were analyzed using the Family-Child Interaction Analysis Tool , 1 (shows a little competence), 2 (shows good competence) or 3 (shows excellent competence).Agreement between the judges was almost perfect, with Kappa of 0.79 and 91% agreement (p \u2264 0.007), as shown in Alongside the VF tele intervention sessions of this study, the children and their mothers continued to attend the group and individual sessions offered by the Hearing and Language program. In this context, with remote participation due to the pandemic, they have participated in two ways. Firstly, they attended individual speech therapy sessions with the family and the child once a week according to the Aurioral Method. Secondly, they had group sessions three times a week, two focusing on auditory stimulation and one on family needs. Each session lasted 30 minutes.,6 and was carried out in 10 synchronous 50-minute sessions, with an individual framework.The VF teleintervention was based on a model already tested with families of hard of hearing childrenTo carry out the procedures with the family, the researcher used a computer with a webcam and headphones and a wired fiber optic broadband internet connection with a connection speed of 400 megabytes. The teleconsultation environment followed all the rules of the resolution of the Brazilian Federal Council of Speech and Hearing Therapy (CFFa) No. 580/2020(9), carried out on a secure platform, in a confidential manner.For the teleintervention to be operational, the mother had to be trained beforehand to familiarize her with the GSuite video call platform, as well as preparing for the recording and uploading of the videos via GSuite Drive, which comprised the first of the 13 sessions.The interaction videos were recorded by the mother herself, on her own cell phone, with an average duration of ten minutes per video, and then shared with the researcher via cloud storage. The VF session was scheduled after the sending signal.It's important to note that the environment in which the videos were recorded was natural, familiar to the child, and with the resources available in the child's own home. The mother was instructed to interact with the child in natural situations at home, such as her routine.The main researcher analyzed each video of the interaction and proceeded to plan the sessions, always highlighting 3 positive points observed in the interaction and preparing guidelines to improve the mother's communicative interaction with her daughter.The interaction video with the selection of positive micro-moments was shown to the mother via Google Meet's screen sharing function. During the sessions, which took place in a dialogical manner, the mother was led to reflect on the clip presented and the positive points of each clip were discussed, and guidance given to improve communication..All the data analyzed was entered into an Excel\u00ae spreadsheet for descriptive and qualitative analysis, based on the observations made at the end of the adapted protocol, which makes it possible to analyze reliable change and clinical significance by verifying the reliability of the changes obtained between the pre- and post-intervention scores, with the aim of identifying whether the changes, even in studies with only one or a few participants, are of a reliable nature and whether they are clinically relevant, investigating the Reliable Change Index - RCI and the Clinical Significance of the changes.The inferential analysis of the data presented in this manuscript was carried out using the JT statistical methodThe results presented below comprise the analysis of the videos carried out by the blind judges, highlighting the variables of the mother's general communicative competence and the child's receptive and expressive language behaviors.Regarding the intervention process, it was noted that the mother's general communication skills improved over the course of the sessions. She went from scores of 1 to 2 (from low competence to good competence) and until the eighth video she remained between scores 2 and 3 . From the ninth video onwards, the mother, who had scores of good communicative competence (2), was evaluated by the two judges and the researcher as having excellent overall communication competence during the interaction. This indicates that 8 sessions were necessary for the mother to reach the maximum level of performance in the interaction according to the analysis tool used, as shown in As for the child's performance, as shown in . Therefore, interventions that optimize the dialogical interaction between families and caregivers with these children are important and can be implemented in children's hearing rehabilitation services, preferably at an early stage-7.The communicative competence of the main caregiver of a child with hearing loss has been shown to be an important factor in their hearing and language development, it was possible to simultaneously demonstrate the reliability of the changes and the clinical significance in this case observed in the mother  there was a significant qualitative leap in this variable. Through the JT Methode mother . when both criteria are reached. This data corroborates the literature on the potential of the VF tool to improve communicative behavior and interaction between hearing caregivers and their hard of hearing children,5,6.Thus, the mother showed different scores pre- and post-intervention, achieving a performance compatible with that of a non-clinical population, falling within the \u201crecovery\u201d classification suggested by the authors.It was observed during the teleconsultations that allowing the mother to be the child's stimulating agent directly, even under the remote guidance of the speech therapist, promoted an important and necessary change in her role about her daughter, which is confirmed by studies that have used teleaudiology in the care of families of hard of hearing children-8.Thus, considering the number of hours the deaf or hard of hearing child is regularly at home or in school, using methods that direct the child's families and caregivers' attention to optimize their daily interactions is justified. It becomes an agent for optimizing these children's daily learning possibilities-4. However, more robust evidence is needed to state whether the effect of interventions on families is maintained over time, as well as their impact on the child's performance longitudinally.Regarding the effect of parental interventions on the language development of hard of hearing children, some studies point to significant improvements, calculated using the values of the evaluation instrument applied, was considered a reliable and positive index when the values reached numbers higher than 1.96, so we can infer that the intervention produced a reliable positive change  for the variables studied in the child's behavior: \u201cReceptive Vocabulary\u201d abulary\u201d  and \u201cExpabulary\u201d . and 10 sessions of indirect therapy (focused on training the mother) would not be expected to be sufficient to meet all the specific speech therapy intervention needs for the child's language development. Even so, there was reliable improvement (reliable positive change), and the participant was categorized as \u201cimproved\u201d .However, there was no clinical significance for either measure, i.e. there was an improvement in the child's receptive and expressive language behaviors, but not enough to place them in the non-clinical population. This was to be expected, as the language development needs of hard of hearing children are extensiveAs it was not a controlled clinical environment, some variables were noticed during the sessions, such as the lack of interference from other family members, external noises, and difficulty in positioning the camera. On the other hand, we observed spontaneity in the interaction between mother and child, the availability of material resources from the routine and the child's comfortable environment in a non-clinical situation., can improve interventions such as video feedback-guided teleintervention.By analyzing the child's and adult's attempts to communicate and the exchange of conversational turns, you can understand the child's real linguistic environment. This analysis, also made possible by technological resources such as LENA Based on this case study, there is a need to use this methodology in randomized experimental studies with an adequate sample size to estimate the effects of this parental training model, to optimize efforts for therapeutic success in the population of hard of hearing children.Given the scarcity of research on VF programs and their applicability in hearing rehabilitation, this study is relevant because it contributes to the production of evidence on the effectiveness of VF teleintervention and expands the possibility of implementing programs using this tool.Although this was a single case, the analysis using the Jacobson and Truax (JT) method allowed us to verify the effectiveness of the intervention, measured by the reliable change in the mother's interaction behaviors with her daughter and the child's receptive and expressive language, with a significant clinical change in the mother's communicative behaviors.As this is a single case study, it is not yet possible to generalize these results. Further research with greater methodological robustness and investigation into the guarantees of maintaining results with the intervention is needed, which is the main limitation of this study.The continuity of research into parental training for families of children with hearing loss is relevant in Brazil, given the diversity of our culture and the situations of vulnerability that may have repercussions on the need to develop specific training models for our population. , propiciando ou limitando as oportunidades de estimula\u00e7\u00e3o da audi\u00e7\u00e3o, linguagem e dos aspectos sociais da crian\u00e7a, os quais s\u00e3o adquiridos por uma intera\u00e7\u00e3o efetiva e sintonizada.Os processos interacionais complexos e multifacetados que ocorrem entre as crian\u00e7as e seus cuidadores s\u00e3o considerados vitais para um desenvolvimento saud\u00e1vel-7.A utiliza\u00e7\u00e3o de interven\u00e7\u00f5es parentais ap\u00f3s a confirma\u00e7\u00e3o do diagn\u00f3stico da defici\u00eancia auditiva torna os cuidadores, incluindo familiares e qualquer pessoa regularmente envolvida no cuidado da crian\u00e7a, mais ativos e responsivos na comunica\u00e7\u00e3o com as crian\u00e7as. O suporte parental, portanto, proporciona o entendimento dos pap\u00e9is dos cuidadores, sejam eles no estabelecimento do uso consistente do dispositivo auxiliar \u00e0 audi\u00e7\u00e3o, como tamb\u00e9m na otimiza\u00e7\u00e3o do desenvolvimento da audi\u00e7\u00e3o e da linguagem da crian\u00e7a, aspectos essenciais para resultados efetivos nesta popula\u00e7\u00e3o, cabe considerar os diferentes modelos propostos para as interven\u00e7\u00f5es centradas na fam\u00edlia, a fim de elevar o n\u00edvel de apoio e enriquecimento \u00e0s intera\u00e7\u00f5es familiares, com potencial impacto ao desenvolvimento psicossocial e neurocognitivo das crian\u00e7as com defici\u00eancia auditiva.Assim, a partir da premissa de que o ambiente familiar desempenha importante papel na promo\u00e7\u00e3o do desenvolvimento de habilidades de linguagem oral em crian\u00e7as com defici\u00eancia auditiva-7.Desta feita, pesquisas dedicadas a estudar diferentes modelos de interven\u00e7\u00e3o junto \u00e0s fam\u00edlias podem auxiliar o fonoaudi\u00f3logo a entender qual o padr\u00e3o de programa que mais se adeque ao contexto e \u00e0s necessidades da fam\u00edlia assistida, variando sua intensidade, dura\u00e7\u00e3o, enquadre , al\u00e9m do local onde pode ser implementado -7.Dentre os modelos de capacita\u00e7\u00e3o parental ou interven\u00e7\u00e3o com fam\u00edlias, h\u00e1 aqueles focalizados nas intera\u00e7\u00f5es dos cuidadores e crian\u00e7as com defici\u00eancia auditiva , os quais t\u00eam sido consistentemente relacionados \u00e0 potencializa\u00e7\u00e3o da qualidade dos est\u00edmulos lingu\u00edsticos oferecidos, proporcionando tamb\u00e9m \u00e0s fam\u00edlias mais confian\u00e7a para lidar com as situa\u00e7\u00f5es di\u00e1rias vivenciadas e, assim, facilitar o ambiente de audi\u00e7\u00e3o e linguagem para seus filhos, moldando, desta forma, um cen\u00e1rio comunicativo ideal que encoraje a iniciativa de linguagem e autonomia da crian\u00e7a, principalmente nos primeiros anos de vida, de modo a aproveitar a janela de oportunidades para o desenvolvimento, posteriormente introduzida no Reino Unido, difundindo-se rapidamente na pr\u00e1tica cl\u00ednica, com intuito de se trabalhar no desenvolvimento de intera\u00e7\u00f5es sintonizadas. Mais recentemente, as an\u00e1lises de v\u00eddeo da intera\u00e7\u00e3o fam\u00edlia-crian\u00e7a t\u00eam sido utilizadas em estudos na reabilita\u00e7\u00e3o auditiva infantil de maneira mais sistem\u00e1tica,5,6.Para trabalhar com a intera\u00e7\u00e3o, as t\u00e9cnicas de registro de v\u00eddeos e conseguinte an\u00e1lise da intera\u00e7\u00e3o da d\u00edade fam\u00edlia-crian\u00e7a, t\u00eam sido utilizadas ao longo dos anos, inicialmente pela Psicologia, como nos estudos prim\u00e1rios de Harry Biemans (1990) com base na teoria da intersubjetividade de Trevarthenvideofeedback (VF) traz uma possibilidade de interven\u00e7\u00e3o que viabiliza a melhora na qualidade da rela\u00e7\u00e3o fam\u00edlia-crian\u00e7a, com o refor\u00e7o das intera\u00e7\u00f5es positivas existentes no v\u00eddeo analisado. O VF \u00e9 um modelo de interven\u00e7\u00e3o que envolve mudan\u00e7as dos indiv\u00edduos com prop\u00f3sito de aprimorar situa\u00e7\u00f5es de relacionamento e/ou comunica\u00e7\u00e3o em contextos variados, dentre eles, popula\u00e7\u00f5es cl\u00ednicas e de risco como as fam\u00edlias e crian\u00e7as com defici\u00eancia auditiva, promovendo uma modifica\u00e7\u00e3o positiva favor\u00e1vel ao desenvolvimento infantil e \u00e0 intera\u00e7\u00e3o fam\u00edlia-crian\u00e7a,5,6.A utiliza\u00e7\u00e3o do procedimento de ,6.Desta forma, a partir da visualiza\u00e7\u00e3o de clipes positivos da intera\u00e7\u00e3o entre o adulto e a crian\u00e7a s\u00e3o realizadas reflex\u00f5es com a fam\u00edlia sobre seu potencial como agente estimulador, bem como orienta\u00e7\u00f5es sobre os aspectos que podem ser aperfei\u00e7oados no ambiente de audi\u00e7\u00e3o e linguagem da crian\u00e7a, gerando um ciclo positivo de empoderamento e capacita\u00e7\u00e3o dos pais para intera\u00e7\u00e3o com seus filhos(as) com defici\u00eancia auditiva, a referida pesquisa foi, ent\u00e3o, iniciada de modo a se investigar, a partir da aplica\u00e7\u00e3o em um estudo piloto de um caso cl\u00ednico, a sua viabilidade.Como sua base \u00e9 o registro e an\u00e1lise do v\u00eddeo pelo profissional, seguida da sess\u00e3o de VF com a fam\u00edlia, por ocasi\u00e3o da pandemia do Sars-Cov-2, sua utiliza\u00e7\u00e3o em formato remoto passou a ser considerada e, no Brasil, dada a possibilidade da realiza\u00e7\u00e3o de teleconsultas s\u00edncronas e ass\u00edncronas sob regulamenta\u00e7\u00e3o do Conselho Federal de Fonoaudiologia (CFFa), resolu\u00e7\u00e3o CFFa n\u00ba 580/2020.Ressalta-se que modelos de interven\u00e7\u00e3o remoto com a popula\u00e7\u00e3o de crian\u00e7as com defici\u00eancia auditiva j\u00e1 foram estudados e t\u00eam sido destacados como efetivos para a reabilita\u00e7\u00e3o auditiva infantil, especialmente porque otimizam a participa\u00e7\u00e3o da fam\u00edlia como protagonista das mudan\u00e7as no desenvolvimento de seus filhos(as), al\u00e9m de benef\u00edcios financeiros e log\u00edsticos quanto ao acesso a profissionais capacitadostelevideofeedback, ferramenta tecnol\u00f3gica de baixo custo, \u00e9 aplic\u00e1vel e promove mudan\u00e7a nos comportamentos de comunica\u00e7\u00e3o na d\u00edade m\u00e3e-crian\u00e7a estudada?\u201d A hip\u00f3tese \u00e9 de que este modelo \u00e9 pass\u00edvel de uso pelo fonoaudi\u00f3logo em teleconsultas e pode ser um catalisador para a intera\u00e7\u00e3o mais sintonizada entre a fam\u00edlia e a crian\u00e7a, com benef\u00edcios para sua comunica\u00e7\u00e3o.A partir destas considera\u00e7\u00f5es, a pergunta deste estudo foi: \u201co  no mundo e no Brasil e a inviabilidade de profissionais especialistas em n\u00famero suficiente em todas as regi\u00f5es do pa\u00eds, bem como a necessidade de se fornecer \u00e0s fam\u00edlias um suporte individualizado e com informa\u00e7\u00f5es espec\u00edficas para melhorar o desenvolvimento da crian\u00e7a com defici\u00eancia auditiva, a partir de suas intera\u00e7\u00f5es di\u00e1rias, este estudo teve por objetivos descrever, por meio de um estudo de interven\u00e7\u00e3o de caso \u00fanico, o uso da ferramenta de VF, aplicada em ambiente remoto, bem como identificar as mudan\u00e7as confi\u00e1veis na intera\u00e7\u00e3o da m\u00e3e e crian\u00e7a e na linguagem receptiva e expressiva da crian\u00e7a, usu\u00e1ria de implante coclear, antes e ap\u00f3s a interven\u00e7\u00e3o.Considerando, pois, as estat\u00edsticas da defici\u00eancia auditivao do parecer 3.440.683). A participa\u00e7\u00e3o da m\u00e3e, cuidadora principal da crian\u00e7a, foi condicionada \u00e0 aceita\u00e7\u00e3o do convite, bem como \u00e0 assinatura do Termo de Consentimento Livre e Esclarecido (TCLE) e Termo de Imagem (Voz/V\u00eddeo), em formato digital. A reda\u00e7\u00e3o deste estudo de caso baseou-se no checklist CARE (Checklist of information to include when writing a case report).Trata-se de um estudo de interven\u00e7\u00e3o, de caso \u00fanico, aprovado pelo Comit\u00ea de \u00c9tica em Pesquisa Institucional  e 10 sess\u00f5es de interven\u00e7\u00e3o, de forma intensiva, com 50 minutos por sess\u00e3o, nos cinco dias da semana, distribu\u00eddas, portanto, em duas semanas.tablet ou smartphone) com acesso \u00e0 internet que permitisse a conex\u00e3o. Foram estabelecidos crit\u00e9rios de inclus\u00e3o tendo como foco a popula\u00e7\u00e3o de fam\u00edlias ouvintes. Desta forma, caso o respons\u00e1vel principal fosse surdo(a), n\u00e3o estaria inclu\u00eddo(a) no estudo, ainda que o mesmo protocolo de interven\u00e7\u00e3o pudesse ser aplicado em fam\u00edlias surdas, desde que o pesquisador fosse fluente em L\u00edngua Brasileira de Sinais (LIBRAS).Como crit\u00e9rios de inclus\u00e3o para o convite \u00e0 fam\u00edlia participante, a crian\u00e7a deveria possuir diagn\u00f3stico de perda auditiva de qualquer tipo ou grau, sem outras defici\u00eancias associadas \u00e0 defici\u00eancia auditiva, fazer uso efetivo de Aparelho de Amplifica\u00e7\u00e3o Sonora Individual (AASI) e/ou Implante Coclear (IC), ter at\u00e9 seis anos de idade e estar em reabilita\u00e7\u00e3o no programa Audi\u00e7\u00e3o e Linguagem do Centro SUVAG/RN, com frequ\u00eancia igual ou superior a 75%. A fam\u00edlia, al\u00e9m da disponibilidade de participar da interven\u00e7\u00e3o intensiva, realizada em 10 dias consecutivos, excetuando o final de semana, deveria ter um dispositivo eletr\u00f4nico . A vers\u00e3o reduzida do FAPI-r \u00e9 composta por um formul\u00e1rio para o fonoaudi\u00f3logo para aplica\u00e7\u00e3o com a crian\u00e7a, constando de 25 itens, e outro para a fam\u00edlia com 15 itens, ambos organizados em 15 se\u00e7\u00f5es nas quais o familiar informa a frequ\u00eancia com que os comportamentos auditivos s\u00e3o observados em casa, abrangendo as habilidades de consci\u00eancia sonora, feedback auditivo, discrimina\u00e7\u00e3o auditiva e reconhecimento, compreens\u00e3o auditiva, mem\u00f3ria auditiva de curto prazo e processamento auditivo lingu\u00edstico.Para a avalia\u00e7\u00e3o da crian\u00e7a, realizada de forma remota, foram utilizadas as Categorias de Audi\u00e7\u00e3o e de Linguagemfeedback auditivo (100%) e estava em processo de aquisi\u00e7\u00e3o das habilidades de discrimina\u00e7\u00e3o auditiva e reconhecimento (75%), compreens\u00e3o auditiva (75%), mem\u00f3ria auditiva de curto prazo  e processamento auditivo lingu\u00edstico (75%). No momento p\u00f3s-interven\u00e7\u00e3o, houve modifica\u00e7\u00e3o nas pontua\u00e7\u00f5es das habilidades de discrimina\u00e7\u00e3o auditiva e reconhecimento (100%) e compreens\u00e3o auditiva (100%). As demais permaneceram com as mesmas pontua\u00e7\u00f5es. Embora n\u00e3o se possa afirmar que tal mudan\u00e7a decorreu do processo de interven\u00e7\u00e3o realizado, observou-se que as quest\u00f5es em que a m\u00e3e relatou melhora nas habilidades auditivas referiram-se a: discrimina\u00e7\u00e3o da inten\u00e7\u00e3o comunicativa das declara\u00e7\u00f5es, identifica\u00e7\u00e3o de elementos cr\u00edticos em frases (dois e tr\u00eas elementos) e em hist\u00f3ria infantil, indicando que o processo dial\u00f3gico enriquecido pela interven\u00e7\u00e3o proposta pode ter influenciado a percep\u00e7\u00e3o da m\u00e3e e sua maior aten\u00e7\u00e3o a estas habilidades durante as intera\u00e7\u00f5es com a filha.Na aplica\u00e7\u00e3o do FAPI-r (vers\u00e3o fam\u00edlia) observou-se que no momento pr\u00e9-interven\u00e7\u00e3o, de acordo com as observa\u00e7\u00f5es da m\u00e3e, a crian\u00e7a j\u00e1 tinha adquirido as habilidades de consci\u00eancia sonora (100%), Para a avalia\u00e7\u00e3o da m\u00e3e, foram aplicados os seguintes protocolos:Likert (zero a cinco) desenvolvido com o objetivo de mensurar o n\u00edvel de estresse vivenciado por pais e m\u00e3es de filhos menores de 18 anos. A pontua\u00e7\u00e3o total pode variar entre 0 e 72 pontos, de forma que quanto mais elevado o escore, maior o estresse parental.Escala de Estresse Parental (EEP) - Instrumento de autorrelato, distribu\u00eddo em 18 itens representando quatro fatores  respondidos em escala Likert (um a quatro), variando entre \u201cconcordo totalmente\u201d e \u201cdiscordo totalmente\u201d. A pontua\u00e7\u00e3o pode oscilar entre 10 a 40 sendo que quanto maior o escore obtido na escala, maior o n\u00edvel de autoestima do indiv\u00edduo.Escala de Autoestima de Rosenberg (EAR) - instrumento com dez senten\u00e7as fechadas que prop\u00f5e avaliar de forma global a atitude positiva ou negativa do indiv\u00edduo em rela\u00e7\u00e3o a si mesmo, respondidos em escala .Invent\u00e1rio de Recursos do Ambiente Familiar (RAF): roteiro aplicado sob forma de entrevista semi-estruturada para a caracteriza\u00e7\u00e3o dos recursos materiais e das rotinas familiares. A soma da pontua\u00e7\u00e3o dos itens assinalados nos quesitos 1 a 7 resultam em sua pontua\u00e7\u00e3o bruta, j\u00e1 os t\u00f3picos 8, 9 e 10, possuem pontua\u00e7\u00e3o espec\u00edfica indicada no formul\u00e1rioVale ressaltar que embora tenham sido aplicados tais protocolos para a caracteriza\u00e7\u00e3o e acompanhamento da m\u00e3e, neste estudo piloto n\u00e3o tivemos como objetivo a verifica\u00e7\u00e3o do efeito da interven\u00e7\u00e3o nas medidas de recursos do ambiente familiar, estresse parental e de auto-estima da m\u00e3e, considerando a caracter\u00edstica espec\u00edfica da interven\u00e7\u00e3o, seu curto prazo e a complexidade das vari\u00e1veis analisadas.Observou-se que na avalia\u00e7\u00e3o de estresse parental, comparando os escores pr\u00e9 e p\u00f3s-interven\u00e7\u00e3o, houve discreta diminui\u00e7\u00e3o da pontua\u00e7\u00e3o, mas na avalia\u00e7\u00e3o pr\u00e9, j\u00e1 apresentava baixos n\u00edveis de estresse parental.A EAR, medida pela somat\u00f3ria dos itens, \u00e9 classificada nas categorias de autoestima: baixa, m\u00e9dia e alta. A m\u00e3e, desde a avalia\u00e7\u00e3o pr\u00e9-interven\u00e7\u00e3o possu\u00eda uma autoestima elevada, pontuando com valores acima de 30 em ambos os cen\u00e1rios.Destaca-se, pois, que trata-se de um caso em que as caracter\u00edsticas da m\u00e3e  foram positivas para o trabalho terap\u00eautico. \u00c9 importante, portanto, que tais medidas sejam consideradas na avalia\u00e7\u00e3o das fam\u00edlias para a melhor compreens\u00e3o das necessidades de cada fam\u00edlia para que condutas mais assertivas sejam adotadas.\u201cBrincar, Assistir a filmes, Assistir a programas infantis na TV, Ler livros, revistas\u201c e ap\u00f3s a interven\u00e7\u00e3o adicionou/substituiu pelos itens \u201cBrincar, Assistir a filmes, Ouvir as est\u00f3rias da crian\u00e7a; conversar sobre os assuntos que ela traz. No item 8, a m\u00e3e referenciou a si mesma em todas as situa\u00e7\u00f5es expostas, para al\u00e9m da cuidadora principal, uma agente que conduz as atividades estimuladoras. A disponibilidade de recursos f\u00edsicos como oferta de brinquedos, brincadeiras, revistas e livros se mantiveram no pr\u00e9 e p\u00f3s-interven\u00e7\u00e3o.Sobre o ambiente familiar, observou-se, pelo RAF, uma vis\u00e3o dos recursos, caracter\u00edsticas e comportamentos dispostos em casa, com discreto aumento dos exemplos dados pela respons\u00e1vel. A m\u00e3e descreveu a proximidade da fam\u00edlia na realiza\u00e7\u00e3o das atividades compartilhadas dentro e fora do ambiente do lar e com regularidade. Foi percebido mudan\u00e7a nas exemplifica\u00e7\u00f5es do item 4, na qual no momento pr\u00e9 interven\u00e7\u00e3o a m\u00e3e listou o H\u00e1, portanto, a partir do relato da m\u00e3e, uma reorienta\u00e7\u00e3o da aten\u00e7\u00e3o dela, no p\u00f3s-interven\u00e7\u00e3o, para ouvir mais o que a crian\u00e7a traz na rotina di\u00e1ria, bem como a percep\u00e7\u00e3o de seu empoderamento como um agente que coopera com a aprendizagem de sua filha, a partir das atividades do dia a dia.) por 3 ju\u00edzes independentes, sendo dois deles cegos. Os ju\u00edzes possuem forma\u00e7\u00e3o em fonoaudiologia, com experi\u00eancia na reabilita\u00e7\u00e3o auditiva superior a 4 anos e familiaridade com a utiliza\u00e7\u00e3o da ferramenta na pr\u00e1tica cl\u00ednica. O Instrumento de An\u00e1lise de Intera\u00e7\u00e3o Fam\u00edlia-Crian\u00e7a \u00e9 constitu\u00eddo de uma escala observacional dos comportamentos comunicativos na intera\u00e7\u00e3o dos pais ouvintes com seus filhos com defici\u00eancia auditiva, na qual a frequ\u00eancia dos comportamentos \u00e9 pontuada em uma Escala do tipo Likert, de 1 a 7, sendo o comportamento de menor frequ\u00eancia \u201cN\u00e3o vi\u201d e o de maior frequ\u00eancia \u201cVi sempre\u201d, e ainda campos de \u201cn\u00e3o tenho certeza\u201d ou \u201cn\u00e3o se aplica\u201d, nas dimens\u00f5es emocionais e comportamentais da crian\u00e7a e do cuidador principal. O instrumento tamb\u00e9m cont\u00e9m a an\u00e1lise geral da compet\u00eancia comunicativa do cuidador, pontuada em escala de: 0 (n\u00e3o mostra compet\u00eancia), 1 (mostra um pouco de compet\u00eancia), 2 (mostra uma boa compet\u00eancia) ou 3 (mostra uma compet\u00eancia excelente). A concord\u00e2ncia entre os ju\u00edzes apresentou-se quase-perfeita, com Kappa de 0,79 e 91% de concord\u00e2ncia , conforme a Al\u00e9m destas avalia\u00e7\u00f5es, todos os 11 v\u00eddeos de intera\u00e7\u00e3o registrados no per\u00edodo de 9 a 21 de janeiro de 2022 (excetuando os finais de semana) foram analisados a partir do Instrumento de An\u00e1lise de Intera\u00e7\u00e3o Fam\u00edlia-Crian\u00e7a , at\u00e9 o oitavo v\u00eddeo manteve-se entre os escores 2 e 3  e a partir do nono v\u00eddeo, a m\u00e3e que tinha escores de boa compet\u00eancia comunicativa (2), foi avaliada pelos 2 ju\u00edzes e pela pesquisadora como tendo excelente compet\u00eancia geral na comunica\u00e7\u00e3o durante a intera\u00e7\u00e3o, o que indica que 8 sess\u00f5es foram necess\u00e1rias para que a m\u00e3e atingisse o n\u00edvel m\u00e1ximo de desempenho na intera\u00e7\u00e3o de acordo com o instrumento de an\u00e1lise empregado, conforme apresentado nas Sobre o desempenho da crian\u00e7a, conforme apresentado nas  e, portanto, interven\u00e7\u00f5es que otimizem a intera\u00e7\u00e3o dial\u00f3gica entre as fam\u00edlias e cuidadores com estas crian\u00e7as s\u00e3o importantes e pass\u00edveis de serem implementadas em servi\u00e7os de reabilita\u00e7\u00e3o auditiva infantil, preferencialmente de forma precoce-7.A compet\u00eancia comunicativa do cuidador principal da crian\u00e7a com defici\u00eancia auditiva tem se demonstrado um fator importante para o seu desenvolvimento de audi\u00e7\u00e3o e linguagem, foi poss\u00edvel demonstrar, pois, simultaneamente a confiabilidade das mudan\u00e7as e a signific\u00e2ncia cl\u00ednica, neste caso, observada na m\u00e3e (Em nosso estudo de caso observamos que houve melhora progressiva da compet\u00eancia de comunica\u00e7\u00e3o da m\u00e3e ao longo das sess\u00f5es e que a partir da oitava sess\u00e3o (nono v\u00eddeo) observou-se um salto qualitativo importante nesta vari\u00e1vel. Por meio do M\u00e9todo JTa na m\u00e3e . quando ambos crit\u00e9rios s\u00e3o atingidos, dado que corrobora com a literatura sobre o potencial da ferramenta de VF no aperfei\u00e7oamento do comportamento comunicativo e da intera\u00e7\u00e3o entre cuidadores ouvintes e seus filhos(as) com defici\u00eancia auditiva,5,6.Assim, a m\u00e3e apresentou escores distintos pr\u00e9 e p\u00f3s interven\u00e7\u00e3o, atingindo um desempenho compat\u00edvel com a de uma popula\u00e7\u00e3o n\u00e3o cl\u00ednica, com enquadre na classifica\u00e7\u00e3o de \u201crecupera\u00e7\u00e3o\u201d sugerida pelos autores.Observou-se durante as teleconsultas que a oportunidade de ser diretamente o agente estimulador da crian\u00e7a, ainda que sob orienta\u00e7\u00e3o remota do fonoaudi\u00f3logo, promoveu uma mudan\u00e7a importante e necess\u00e1ria no papel desta m\u00e3e em rela\u00e7\u00e3o \u00e0 sua filha, o que \u00e9 confirmado por estudos que empregaram a telefonoaudiologia no atendimento \u00e0 popula\u00e7\u00e3o de fam\u00edlias de crian\u00e7as com defici\u00eancia auditiva-8.Deste modo, ao considerarmos o n\u00famero de horas em que a crian\u00e7a com defici\u00eancia auditiva regularmente est\u00e1 em casa, e - dependendo da faixa et\u00e1ria - no ambiente escolar, justifica-se o emprego de m\u00e9todos que direcionam a aten\u00e7\u00e3o da fam\u00edlia e/ou cuidadores da crian\u00e7a a otimizar suas intera\u00e7\u00f5es di\u00e1rias, tornar-se um agente otimizador das possibilidades de aprendizado cotidiano destas crian\u00e7as-4, no entanto, evid\u00eancias mais robustas s\u00e3o necess\u00e1rias para afirmar se o efeito das interven\u00e7\u00f5es \u00e0s fam\u00edlias mant\u00e9m-se ao longo do tempo, assim como o seu impacto no desempenho da crian\u00e7a longitudinalmente.Sobre o efeito das interven\u00e7\u00f5es parentais no desenvolvimento da linguagem da crian\u00e7a com defici\u00eancia auditiva, alguns estudos apontam melhoras significativas calculado por meio dos valores do instrumento de avalia\u00e7\u00e3o aplicado, foi considerado \u00edndice confi\u00e1vel e positivo quando os valores atingiram n\u00fameros superiores \u00e0 1,96 e, desta forma, podemos inferir que a interven\u00e7\u00e3o produziu mudan\u00e7a positiva confi\u00e1vel  para as vari\u00e1veis estudadas do comportamento da crian\u00e7a: \u201cVocabul\u00e1rio Receptivo\u201d ceptivo\u201d  e \u201cVocabceptivo\u201d . e 10 sess\u00f5es de terapia indireta  n\u00e3o seriam esperadas como suficientes para atingir todas as necessidades de interven\u00e7\u00e3o fonoaudiol\u00f3gica espec\u00edficas para o desenvolvimento lingu\u00edstico da crian\u00e7a. Ainda assim, houve melhora confi\u00e1vel (mudan\u00e7a positiva confi\u00e1vel), sendo a participante categorizada em \u201cmelhorado\u201d (atingiu o IMC mas n\u00e3o a signific\u00e2ncia cl\u00ednica).No entanto, n\u00e3o houve signific\u00e2ncia cl\u00ednica para ambas as medidas, ou seja, houve melhora nos comportamentos observados na crian\u00e7a em sua linguagem receptiva e expressiva, por\u00e9m n\u00e3o o suficiente para posicion\u00e1-la na popula\u00e7\u00e3o n\u00e3o-cl\u00ednica. Este dado era esperado, j\u00e1 que as necessidades de desenvolvimento da linguagem na crian\u00e7a com defici\u00eancia auditiva s\u00e3o amplasLanguage ENviromental Analysis System), pode vir a aperfei\u00e7oar interven\u00e7\u00f5es como a teleinterven\u00e7\u00e3o guiada por VF.Por n\u00e3o se tratar de um ambiente cl\u00ednico e controlado, algumas vari\u00e1veis como a n\u00e3o interfer\u00eancia de outros familiares, ru\u00eddos externos e dificuldade de posicionamento da c\u00e2mera foram percebidas durante as sess\u00f5es. Em contrapartida, foi observada a espontaneidade na intera\u00e7\u00e3o entre a m\u00e3e e a crian\u00e7a, a disponibilidade de recursos materiais a partir da rotina e tamb\u00e9m a ambienta\u00e7\u00e3o confort\u00e1vel da crian\u00e7a em situa\u00e7\u00e3o n\u00e3o cl\u00ednica. Ao analisar as tentativas de comunica\u00e7\u00e3o da crian\u00e7a, do adulto e a troca de turnos de conversa\u00e7\u00e3o, pode-se compreender o real ambiente lingu\u00edstico desta crian\u00e7a. Tal an\u00e1lise, tamb\u00e9m possibilitada por recursos tecnol\u00f3gicos como o LENA (Diante o exposto, a partir deste estudo de caso, destaca-se que h\u00e1 a necessidade de se empregar esta metodologia em estudos experimentais randomizados e com n amostral adequado para se estimar os efeitos deste modelo de capacita\u00e7\u00e3o parental, de modo a otimizar os esfor\u00e7os para o sucesso terap\u00eautico na popula\u00e7\u00e3o de crian\u00e7as com defici\u00eancia auditiva.Dada a escassez de pesquisas sobre programas com VF e sua aplicabilidade na reabilita\u00e7\u00e3o auditiva, este estudo mostra-se relevante por contribuir com a produ\u00e7\u00e3o de evid\u00eancias sobre a efetividade da teleinterven\u00e7\u00e3o por VF e ampliar a possibilidade de implementa\u00e7\u00e3o de programas utilizando esta ferramenta.Ainda que se trate de caso \u00fanico, a an\u00e1lise com o m\u00e9todo JT permitiu a verifica\u00e7\u00e3o da efetividade da interven\u00e7\u00e3o, medida pela mudan\u00e7a confi\u00e1vel dos comportamentos de intera\u00e7\u00e3o da m\u00e3e com a filha e da crian\u00e7a em rela\u00e7\u00e3o \u00e0 linguagem receptiva e expressiva, com mudan\u00e7a cl\u00ednica significativa nos comportamentos comunicativos da m\u00e3e.Por tratar-se de um estudo de caso \u00fanico ainda n\u00e3o \u00e9 poss\u00edvel generalizar tais resultados, sendo necess\u00e1rio o desenvolvimento de outras pesquisas com maior robustez metodol\u00f3gica e investiga\u00e7\u00e3o das garantias de manuten\u00e7\u00e3o de resultados com a interven\u00e7\u00e3o, sendo esta a principal limita\u00e7\u00e3o deste estudo.A continuidade das pesquisas na tem\u00e1tica da capacita\u00e7\u00e3o parental para fam\u00edlias de crian\u00e7as com defici\u00eancia auditiva \u00e9 relevante no Brasil, dada a diversidade de nossa cultura e das situa\u00e7\u00f5es de vulnerabilidade que podem repercutir na necessidade de desenvolvimento de modelos espec\u00edficos de capacita\u00e7\u00e3o para a nossa popula\u00e7\u00e3o."}
+{"text": "Para cada banco agregado gerado, foi ajustado um modelode Poisson multin\u00edvel. A melhoria na escolaridade da popula\u00e7\u00e3o brasileira n\u00e3orefletiu na diminui\u00e7\u00e3o da mortalidade por dengue. Houve um aumento na taxa demortalidade por dengue no Brasil e um crescimento da diferen\u00e7a de taxas demortalidade entre menos e mais escolarizados. Independentemente do processo deimputa\u00e7\u00e3o, os resultados mostraram maiores taxas de mortalidade por dengue entreos menos escolarizados. A baixa escolaridade afetou de forma mais pronunciada osmais jovens.A dengue pode estar associada a vari\u00e1veis de n\u00edvel individual, como escolaridade,aumentando o risco de adoecimento. O objetivo deste trabalho \u00e9 analisar asdisparidades da mortalidade por dengue entre os menos e mais escolarizados noBrasil entre os anos de 2010 e 2018. Este \u00e9 um estudo do tipo ecol\u00f3gicoretrospectivo das diferen\u00e7as na taxa de mortalidade por dengue entre menos emais escolarizados no Brasil, atrav\u00e9s das taxas de mortalidade por dengue geral,por idade, sexo e Unidade Federativa (UF). Um procedimento de Isso sedeve, provavelmente, aos desafios metodol\u00f3gicos relativos \u00e0 falta de preenchimentoda vari\u00e1vel escolaridade no banco de dados sobre mortalidade. Dessa forma, oobjetivo deste trabalho \u00e9 analisar os diferenciais de mortalidade por dengue segundoo n\u00edvel de escolaridade no Brasil entre 2010 e 2018.Este \u00e9 um estudo ecol\u00f3gico retrospectivo que busca compreender as diferen\u00e7as namortalidade por dengue entre menos e mais escolarizados no Brasil, de 2010 a2018 , mediante as taxas de mortalidade geral por dengue, por idade, sexo eUnidades Federativas (UF). A pesquisa abrange o Brasil, maior pa\u00eds da Am\u00e9rica doSul e sexto mais populoso do mundo. Sua popula\u00e7\u00e3o \u00e9 predominantemente urbana,com maior concentra\u00e7\u00e3o nas regi\u00f5es Nordeste e Sudeste. O pa\u00eds \u00e9 dividido emcinco macrorregi\u00f5es e 27 UF.Para calcular a taxa de mortalidade, os dados sobre \u00f3bitos foram coletados noSistema de Informa\u00e7\u00e3o sobre Mortalidade (SIM) do Minist\u00e9rio da Sa\u00fade. Asinforma\u00e7\u00f5es das mortes por dengue foram selecionadas considerando a causa b\u00e1sicada Declara\u00e7\u00e3o de \u00d3bito (DO), segundo as terminologias da Classifica\u00e7\u00e3oInternacional de Doen\u00e7as, 10\u00aa revis\u00e3o (CID-10), A90 (dengue cl\u00e1ssico) e A91(febre hemorr\u00e1gica devida ao v\u00edrus do dengue), entre 2010 e 2018, para todas asUF do Brasil.Censo Demogr\u00e1fico de 2010PesquisaNacional por Amostra de Domic\u00edlios (PNAD) para 2012-2018 doInstituto Brasileiro de Geografia e Estat\u00edstica (IBGE) Os dados das popula\u00e7\u00f5es estratificadas por sexo, idade, escolaridade e UF paracada ano do per\u00edodo de 2010 a 2018 foram inicialmente calculados utilizando-seas informa\u00e7\u00f5es dos microdados do bootstrap do grupo de dados original, considerando a estrutura multin\u00edvel.Bootstrap \u00e9 um m\u00e9todo de reamostragem de dados comreposi\u00e7\u00e3o que permite estimar a variabilidade e, por conseguinte, intervalos de95% de confian\u00e7a (IC95%) de estat\u00edsticas complexas, com base na distribui\u00e7\u00e3oemp\u00edrica das reamostras bootstrapforam preenchidos por meio de imputa\u00e7\u00e3o m\u00faltipla multivariate imputation by chained equations), t\u00e9cnica queatua sob a suposi\u00e7\u00e3o de que, dadas as vari\u00e1veis usadas no procedimento deimputa\u00e7\u00e3o, os dados faltantes est\u00e3o ausentes aleatoriamente , o que significa que a probabilidade deum valor estar faltando depende apenas dos valores observados, e n\u00e3o dos n\u00e3oobservados.O n\u00e3o preenchimento geral da vari\u00e1vel escolaridade no per\u00edodo de estudo nas DO noBrasil foi de 22,1%. Um procedimento de imputa\u00e7\u00e3o para essa e demais vari\u00e1veisfoi implementado de modo a considerar a estrutura multin\u00edvel dos dados, ou seja,\u00f3bitos por dengue observados em cada UF ao longo dos anos. Inicialmente, toma-seum conjunto de amostras predictive mean matching), que tem comoprinc\u00edpio identificar um valor adequado entre os dados completos, mediantecrit\u00e9rios de similaridade com a informa\u00e7\u00e3o faltante default adotado pelos softwares que disponibilizam esseprocedimento e, portanto, o valor assumido nessa an\u00e1lise. Importante ressaltarque essa etapa deve ser realizada no processo de gera\u00e7\u00e3o de cada base de dadoscompleta pela imputa\u00e7\u00e3o m\u00faltipla.Diferentes m\u00e9todos podem ser utilizados no processo de imputa\u00e7\u00e3o m\u00faltipla. Nesteestudo, os valores foram imputados pelo m\u00e9todo de correspond\u00eancia preditiva Por meio da t\u00e9cnica bootstrap, foram gerados cinco bancos dedados completos por meio da imputa\u00e7\u00e3o m\u00faltipla, utilizando as vari\u00e1veis ano,idade, sexo, ra\u00e7a e UF. O n\u00famero de imputa\u00e7\u00f5es igual a cinco \u00e9 o maisfrequentemente utilizado, pois se mostra suficiente para conclus\u00f5es v\u00e1lidas semo inconveniente de aumentar em demasia a vari\u00e2ncia (2) Para cada amostra (3) Cada banco foi agregado por sexo, idade , ano, UF e escolaridade (< 8anos de estudo e \u2265 8 anos de estudo) e compatibilizado com os dados dasrespectivas popula\u00e7\u00f5es sob risco estimadas. O ponto de corte da escolaridade (8anos) foi escolhido por ser a \u00fanica forma de compatibilizar os bancos demortalidade e o banco de popula\u00e7\u00f5es;(4) Para cada banco agregado, ajustado por um modelo Poisson multin\u00edvel, osestados federados foram considerados como unidades de segundo n\u00edvel; e asmedidas tomadas dentro dos estados ao longo dos anos como unidades de primeiron\u00edvel. Desse modo, considerou-se que as taxas de mortalidade observadas em umamesma UF s\u00e3o possivelmente correlacionadas. A partir desses modelos, foramestimados taxas, raz\u00f5es de taxas e respectivos IC95% obtidos a partir dospercentis 2,5% e 97,5% da distribui\u00e7\u00e3o emp\u00edrica dessas quantidades.Integrated Nested Laplace Approximations) Para tornar computacionalmente vi\u00e1vel a estimativa de todos os par\u00e2metros domodelo em tempo h\u00e1bil, foi utilizado um modelo Bayesiano, com par\u00e2metros obtidospor aproxima\u00e7\u00e3o aninhada integrada de Laplace ,com os pacotes microdatasus, MICE,INLA e ggplot2.Todas as an\u00e1lises utilizaram o software R 4.0.4 , em 2010, para 34,9%, em 2018 .O n\u00famero de \u00f3bitos por dengue no Brasil entre 2010 e 2018 foi de 4.166 casos, compredomin\u00e2ncia de indiv\u00edduos do sexo masculino  e com mais de 80 anos (17%).As taxas de mortalidade foram mais elevadas no Estado de Goi\u00e1s  e Mato Grosso do Sul  e menos elevadasem Santa Catarina (sem \u00f3bitos) e no Rio Grande do Sul. Na s\u00e9rie de anos, o ano de2015 foi o que apresentou o maior n\u00famero de \u00f3bitos por dengue , enquanto 2018exibiu o menor registro de mortes por dengue .As raz\u00f5es de taxas (RT) entre indiv\u00edduos com menor e maior n\u00edvel de escolaridade noBrasil foram de 2,9 e 3,0 por 1 milh\u00e3o de habitantes no banco, sem e com imputa\u00e7\u00e3o,respectivamente. Esses resultados sugerem, em geral, que foi atribu\u00eddo tempo deescolaridade menor que 8 anos a pessoas com escolaridade n\u00e3o preenchida. Ap\u00f3s aimputa\u00e7\u00e3o dos dados, as RT entre menos e mais escolarizados nas UF deixaram de serestatisticamente significativas, considerando-se o n\u00edvel de 5% de signific\u00e2ncia, comexce\u00e7\u00e3o de S\u00e3o Paulo, Rio de Janeiro e Distrito Federal . RessaltAs UF com maiores taxas de mortalidade entre os menos escolarizados foram Goi\u00e1s , Mato Grosso  e MatoGrosso do Sul , ambos localizados na Regi\u00e3oCentro-oeste do Brasil.Para os estados com maior n\u00famero de \u00f3bitos, as RT preditas entre os menos e os maisescolarizados foram semelhantes, comparando-se os dados sem imputa\u00e7\u00e3o com os dadosimputados. Considerando o modelo sem imputa\u00e7\u00e3o, em alguns estados houve maiordiscrep\u00e2ncia entre a taxa geral de mortalidade e a raz\u00e3o de mortalidade entre osmenos e os mais escolarizados, como no Paran\u00e1, onde a taxa geral foi baixa  e a raz\u00e3o foi maior, e no Mato Grosso do Sul, onde a taxageral foi alta  e a RT foi de 2,1. A maior RT entremenos e mais escolarizados aconteceu no Distrito Federal; e a menor, no Amazonas,levando em considera\u00e7\u00e3o o modelo imputado e resultados com signific\u00e2ncia estat\u00edstica.Analisando os ajustes pelos modelos de Poisson multin\u00edvel, as estimativas pontuaisdas RT foram pr\u00f3ximas, considerando os dados n\u00e3o imputados e os imputados . Os inteConsiderando o modelo de intera\u00e7\u00e3o do ano com a escolaridade, controlado pelas demaisvari\u00e1veis, as RT entre os menos e os mais escolarizados aumentaram de 2012 a 2016.No modelo de intera\u00e7\u00e3o da escolaridade com a idade, controlado pelas outrasvari\u00e1veis, o efeito da escolaridade foi maior entre os mais jovens e decaiu com oavan\u00e7ar da idade. No modelo de intera\u00e7\u00e3o entre sexo e escolaridade, controlado pelasdemais vari\u00e1veis, a RT entre os menos e os mais escolarizados foi maior entre oshomens .Embora a escolaridade geral da popula\u00e7\u00e3o brasileira nos \u00faltimos anos tenha aumentadoO m\u00e9todo de imputa\u00e7\u00e3o escolhido pouco afetou os coeficientes estimados, mas aumentoua vari\u00e2ncia das RT. Por essa raz\u00e3o, a maior parte das RT entre os menos e os maisescolarizados deixaram de ser estatisticamente significativas ap\u00f3s a imputa\u00e7\u00e3o dosdados. Apesar disso, o m\u00e9todo usado se mostrou vantajoso, pois levou em conta aestrutura hier\u00e1rquica/multin\u00edvel dos dados e a incerteza a respeito do n\u00e3opreenchimento da escolaridade. Independentemente do processo de imputa\u00e7\u00e3o, osresultados mostraram maiores taxas de mortalidade por dengue entre os menosescolarizados, na maioria das UF.,,Nas \u00faltimas d\u00e9cadas, o n\u00edvel de escolaridade aumentou principalmente nas regi\u00f5es maispobres do pa\u00eds, como Norte e Nordeste ,,,O acesso e a utiliza\u00e7\u00e3o dos servi\u00e7os de sa\u00fade tamb\u00e9m s\u00e3o pontos norteadores doentendimento da mortalidade por dengue e da escolaridade. H\u00e1 fortes evid\u00eancias deque o acesso e a utiliza\u00e7\u00e3o desses servi\u00e7os s\u00e3o bastante desiguais entre osdiferentes grupos sociais ,As taxas de mortalidade por dengue foram menores em dois estados da Regi\u00e3o Sul, amais fria do pa\u00eds, fator que dificulta o crescimento e a propaga\u00e7\u00e3o do vetor dadengue A maioria dos estudos aponta o sexo feminino como predominante em n\u00famero de casos emortes por dengue ,O aumento do efeito da escolaridade na intera\u00e7\u00e3o com o ano entre os anos de 2012 e2016 pode resultar do aumento no n\u00famero de casos nesse per\u00edodo, principalmente em2015 e 2016, quando houve a introdu\u00e7\u00e3o de outras arboviroses transmitidas pelo mesmovetor no cen\u00e1rio nacional, que em aspectos cl\u00ednicos, se assemelham com a dengue eacometem de forma semelhante os mesmos grupos sociais, Zika e chikungunya ,A taxa de mortalidade por dengue apresentou uma rela\u00e7\u00e3o direta com a idade, emconson\u00e2ncia com achados de outros estudos As principais limita\u00e7\u00f5es deste estudo devem-se ao fato de estarmos trabalhando comdados obtidos de forma secund\u00e1ria. Poss\u00edveis \u00f3bitos por dengue podem n\u00e3o ter sidonotificados no sistema devido \u00e0 falta de vigil\u00e2ncia oportuna em sa\u00fade ou \u00e0 falta deacesso, variando de local para local do pa\u00eds. Al\u00e9m disso, a incompatibilidade dasinforma\u00e7\u00f5es dos bancos de dados do sistema de mortalidade e dos bancos populacionaislimitou o uso de maior n\u00famero de categorias para descrever a escolaridade.Possivelmente, o impacto da educa\u00e7\u00e3o seria maior se pud\u00e9ssemos considerar os que t\u00eamcurso superior, pois no Brasil h\u00e1 forte rela\u00e7\u00e3o entre curso superior e melhorescondi\u00e7\u00f5es de vida Os pontos fortes do estudo foram a utiliza\u00e7\u00e3o de base populacional, apesar daslimita\u00e7\u00f5es descritas anteriormente, a especifica\u00e7\u00e3o correta do modelo estat\u00edsticousado, levando-se em conta a correla\u00e7\u00e3o intr\u00ednseca dos dados, e a poss\u00edvelaplicabilidade da mesma metodologia para outras doen\u00e7as, desde que n\u00e3o sejamrestritas a popula\u00e7\u00f5es espec\u00edficas."}
+{"text": "The first group, composed of three expert judges, evaluated the 123 lexical items after creating the instrument, judging the applicability of the figures in the context of child assessment, and suggesting adjustments to compose the content. From the observations, the instrument was adapted and directed to the group of non-specialist judges who, through the application of the instrument, had their responses evaluated according to the ease or difficulty of eliciting the instrument's items.The predictions obtained positive results for content validity and response processes.the study allowed to improve the test items more judiciously, benefiting clinical and scientific use. Working at the service of interpersonal communication, language is composed of linguistic domains that contemplate use, form, and content. Phonology is responsible for the functional study of phonemes, which are the minimum sound units capable of establishing the distinction between words of the same language.Language is configured as an inherently human ability capable of objectively representing abstract thought through a complex system of shared codes,3, considering the complexity of the distinctive features of phonemes.Gradually, language is acquired and developed through a hierarchy that includes all language domains. In the case of acquiring mastery of phonology, the child must organize the different sounds that make up the phonological system of their mother tongue so that it stabilizes. Studies show that the typical acquisition of language occurs up to 5 years of age. This is characterized in children over 4 years of age, who mostly present consonant exchanges in speech. In addition, having auditory thresholds within normal standards, not demonstrating alterations in the lexicon and syntax concerning expressive language, absence of evident neurological alterations, as well as normal cognitive abilities and intact comprehension ability. Therefore, it is necessary to carry out hearing tests, language assessments, and verification of the child's intelligence, to guarantee the correct diagnosis of PD.However, when there is no adequate development of phonology, speech production errors are observed, as is the case of Phonological Disorder (PD). It is important, therefore, to have an efficient method that assesses the child's phonological inventory, seeking a parameter of how their development and speech are progressing. The systematization of the evaluation will allow the accurate comparison of the child's phonological system with that of the target language, allowing the detailed investigation of the aspects that compose speech. This entire diagnostic process must consist of tests with valid, reliable, and accurate interpretations so that the diagnosis is as appropriate as possible. To be valid, the assessment instrument must gather evidence that it measures what it purports to measure. To be reliable, the test needs to indicate whether it is reproducible over time and whether there is control over measurement errors,9.To better understand this picture, in addition to carrying out all the assessments that confirm the diagnosis, it is necessary to carry out an effective phonological assessment, since only this can describe in detail the changes in the individual's speech,10.Therefore, the instrument must go through validity stages to collect evidence, consisting of validity of content, response processes, and construct. The validity of content and response processes are those that arise during the constitution of the test. The content assessment takes place right after the theoretical elaboration of an instrument and is carried out with the help of one or more groups of specialists willing to judge, independently, each item that makes up the test prototype. Next, the process-response evaluates part of the target audience; it is important to understand what are the greatest difficulties and facilities found by the subjects during the evaluation so that the test can be improved. The construct, on the other hand, consists of analyzing the instrument in terms of a representative sample of a domain. The lack of validation of phonological assessment protocols in Brazilian Portuguese (BP) may impair the safety of clinical evidence to draw an accurate diagnosis, adequate conduct, and correct intervention planning. Although there are already tests available to aid in the evaluation and diagnosis, the most used instruments, such as the Child's Phonological Assessment (AFC) and the ABFW - Child Language Test - Phonology have limitations and have not yet been have scientifically proven psychometric indicators of validity and reliability. There are others, such as the Phonological Assessment Instrument (INFONO) and the Speech Assessment Instrument for Acoustic Analysis (IAFAC), but less publicized and not yet available for clinical use. Therefore, it is extremely important to carry out a validation study to bring advances in the area, seeking a scientifically proven gold standard for the evaluation of the phonological domain in BP. This may help in the diagnostic process, in addition to providing parameters for several studies. The present study aims to analyze the evidence of the content stages and response processes in the validity of the Phonological Assessment Instrument (IAF) , which is already used by some speech therapists.In Brazil, few speech-language instruments standardize their methodological pathways for the elaboration of valid and reliable testsThis study was approved by the Research Ethics Committee (CEP) of a federal university under number 5.045.533. The research study corresponds to an observational, controlled cross-sectional, descriptive, and quantitative study, whose data were used for the content validity and response processes of the IAF.The IAF is a software designed to evaluate the child's speech sound system efficiently, thoroughly, and optimally. The instrument was elaborated with 123 words, belonging to children's vocabulary, extracted from popular children's stories, easily represented in an image or photo, and of the noun type, with an image corresponding to each lexical item. The items were carefully selected so that the words included all consonant phonemes in all syllabic positions in BP, with five occurrences of each phoneme and syllable position, totaling 235 phonemic possibilities. The collection of the child's speech should occur from the naming of each of the images, by observing the illustrations or photographs, which takes approximately 10 minutes for the application. The evaluator must record the audio of the speech collection, and later listen to and observe the children's elicitations and register the information to the software. This process takes between 10 and 30 minutes, depending on the evaluator's practice and skill. After entering the data into the instrument, the results are automatically generated and expressed in descriptive and quantitative reports by: degree of speech severity, contrastive analysis, phonological processes, and change in distinctive features. for each item numbered from 1 to 4, as explained in After the theoretical construction of the instrument, three expert judges were invited to judge the 123 items in the prototype. The judges who signed the Free and Informed Consent Form (ICF) and who were minimally masters in linguistics with expertise in typical and atypical phonological acquisition participated in the research. They should indicate the level of adequacy of each lexical item for the proposal and choose, between two options, the image that best represents it. At this stage, they should answer the question \u201cIs the target word adequate to belong in a child speech assessment instrument?\u201d quantitatively, through an electronic form, organized on a Likert scaleFor the qualitative approach, experts should justify their choices with their own criteria, recorded in descriptive comments on the same electronic form. For answers 1 or 2, the judges were instructed to suggest at least one new word for replacement, considering the same aspects listed during the elaboration of the instrument . To understand the level of intra and inter-judge correspondence, the Content Validity Index (CVI) was calculated.. For the significance of 5% and power of 80%, the result was a minimum sample of 165 children.After feedback from the expert judges, the necessary sample size was calculated to determine a Kappa coefficient of 0.80, significantly higher than 0.60, indicating good agreement and with an estimated 25% prevalence of PD The IAF was applied to a group of students, aged between 5 years and 8 years and 11 months, from a public school in the municipal network of the city of Porto Alegre. The sample of this study is composed of data from 176 children, with typical phonological acquisition or with PD, considering that none has auditory, neurological, and/or cognitive alterations, school difficulties, history of neuropsychomotor delay, and/or intercurrences in pregnancy or childbirth. This was checked through prior assessment and information collected in interviews with those responsible. All parents or guardians signed the ICF and Authorization for Audio Use; and, in the case of children over 7 years old, they also signed a Term of Assent.Based on the sample's speech collections, a fourth judge, independent and blinded, classified the subjects' answers according to the level of difficulty observed in each of the lexical items. The answers were labeled according to the need for intervention by the applicator, described in The analysis of the three expert judges regarding the prototype of the IAF instrument indicated a CVI of 0.98, which represents a very good index for the content validity of the test. To compose the instrument, those images in which at least two of the three judges agreed were chosen.As can be seen in The criteria described by the judges were similar, despite having been defined individually and independently in an essay text box on the form used, which explains the percentage obtained in the calculation of the CVI and the homogeneity of the answers, in which 116 items reached the maximum convergence. However, seven of the items presented divergences, they were: \u201cbucket/balde\u201d, \u201cbicycle/bicicleta\u201d, \u201cgum/chiclete\u201d, \u201ciron/ferro\u201d, \u201csnow/neve\u201d, \u201cdrone/zang\u00e3o\u201d and \u201czombie/zumbi\u201d.In these cases, only one of the three judges considered that the target words were not adequate, which was represented by the proper CVI of 0.75. For most items, there was no suggestion of a new word. For \u201cbicycle/bicicleta\u201d one of the judges suggested the use of a pseudoword so that the target could be reached. As for \u201ciron/ferro\u201d, one of the specialists proposed changing it to \u201cvacation/f\u00e9rias\u201d or \u201cclay/barro\u201d or \u201chorseshoe/ferradura\u201d or to the sentence \u201cclose the door/fecha a porta\u201d.The adaptation of \u201cchewing gum/chiclete\u201d to the target \u201cchicl\u00e9\u201d, which is more common in children's vocabulary and did not cause changes in phonemes or target positions. Therefore, both the elicitation of \u201cchewing gum/chiclete\u201d or \u201cchewing gum/chicl\u00e9\u201d are considered correct for completing the instrument. In contrast, the words \u201cdrone/zang\u00e3o\u201d and \u201czombie/zumbi\u201d could not be changed, as there is no diversity of words with /z/ at the beginning of the word. The suggestion to use pseudowords was not accepted, as the purpose of the instrument is to search for quick naming without the frequent need for intervention by the applicator. Likewise, \u201ciron/ferro\u201d was not altered by the difficulty of visual representation of the suggestions \u201cvacation/f\u00e9rias\u201d, \u201cclay/barro\u201d, \u201chorseshoe/ferradura\u201d or \u201cclose the door/fecha a porta\u201d. The lexical items \u201cbucket/balde\u201d and \u201csnow/neve\u201d were not changed due to the lack of justification and a new suggestion by the judge.The instrument, already adapted, was completely applied to 176 children at school to obtain evidence of the validity of the response process. The most difficult items were: item 62 with 25% recognition in spontaneous naming, item 118 with 25% recognition, item 107 with 53% recognition, item 43 with 60% recognition, item 101 with 61% recognition and items 46, 87, and 47 with 69% recognition. As shown in The form of intervention by the applicator, such as providing clues or using the delayed imitation feature, which stood out the most in each item, can be seen in , which means that the interrelationship of the items supports the theoretically proposed structure.The instrument's internal consistency was calculated using Cronbach's Alpha and the 123 items had a consistency of 0.844. This result helps to infer that all the constituent elements are in agreement with each otherConsidering the objectives of this study and the results shown, it was found that the IAF scores presented adequate indicators of content validity and response processes. Thus, the evaluated instrument can proceed to the next stages of validity and reliability..It was possible to observe that those items highlighted by the expert judges, during the construction of content, were not necessarily the same items of difficulty of the target audience, during the analysis of the response processes. The exception was the word \u201ciron/ferro\u201d, one of the items identified as \u201cinadequate\u201d by the judges, which presented identification below 70% by the sample. In this sense, the validity based on the response processes gives indications of how the clinical application of the instrument will be. This happens in the same way that it allows the organization of manuals and additional guidelines for the applicators, in addition to the theoretical evaluationDespite depending on the correct spontaneous naming of figures, the evaluation procedure demands the elicitation of target phonemes. This increases the possibility of the child's desired response. Accepting \u201ctecla\u201d for the item \u201ckeyboard/teclado\u201d, for example, since the target phonemes remain identical. Likewise, \u201ctelha\u201d for \u201croof/telhado\u201d, \u201cchicl\u00e9\u201d for \u201cchewing gum/chiclete\u201d and \u201clixo\u201d for \u201ctrash can/lixeira\u201d are accepted.. Seeking to meet the assessment demands, the applicator may have a sequence of strategies that encourage a speech closer to natural and estimate the subject's speech intelligibility. These strategies include the use of hints, the use of the close method, and the use of delayed imitation in the case of the IAF.The figures provide the necessary support to encourage natural speech since the collection must be as close as possible to the child's spontaneous oral languageThe use of hints is usually the most intuitive for the applicator. So that the child's engagement is not lost, dialogue with the child is maintained, favoring their commitment during the evaluation. The tips include small interventions to direct the subject's thinking, such as saying \u201cIt's the one you put in coffee\u201d for item 2, \u201csugar/a\u00e7\u00facar\u201d; or \u201cIt is what it is, not its name\u201d for item 87, \u201cplanet/planeta\u201d, represented by the figure of the planet Saturn.. Using item 43, \u201cexplosion/explos\u00e3o\u201d, as an example: at a given moment, the applicator uses the tip \u201cwe call the fire department when that happens\u201d and the child answers \u201cfire/inc\u00eandio\u201d to the target, needing more tips or even more delayed imitation to elicit correctly. At another time, the applicator uses the close method with the phrase \u201cwhen it goes \u2018BOOM\u2019, we call it...\u201d and promptly gets the answer \u201cexplosion/explos\u00e3o\u201d. This occurs because this method uses the skills of recurrent auditory and cognitive associations in the search for the answer, as recommended in speech therapy.However, in various situations, there are more effective ways to obtain the desired response, such as using the close method resource. This resource, widely present in clinical practice, consists of using a phrase that leaves gaps for the target word .When the child demonstrates greater difficulties in reaching the target, imitation resources can be used as a last alternative to guarantee to obtain a phoneme sample. Among these resources, however, priority is given to delayed imitation to the detriment of direct imitation. Direct imitation consists of the immediate repetition of the model provided by the instrument's applicator, while delayed imitation only allows repetition after a period of latency and distraction. Thus, in delayed imitation, the applicator provides the model and warns that he will return to the image in the sequence. Now it has become a mental image- the signifier, or the interiorized image that represents a content or object,21. In the context of phonological assessment, therefore, imitation should be used as a last resort for target elicitation.It is reinforced that the instrument applicator must keep in mind the prioritization of spontaneity at the time of evaluation. The repetition provided by the imitation resource tends to make the speech truncated, in addition to masking the difficulty of sounds of the child with PD  resulted in the prevalence of studies with the presence of content validation, however, few carried out the reliability test using Cronbach's alpha. The present study demonstrated a high internal consistency estimate for the IAF (0.844), meaning that the responses obtained with the instrument are safe for evaluation. Another national instrument obtained a median of 0.816, also indicating a satisfactory consistency of the items that make up the instrument to assess BP phonemes.A descriptive study that sought to analyze the validation procedures used in oral language assessment instruments showed that no study found demonstrated results of all types concomitantly , which indicates the lack of improvement of studies in the field of speech therapy. From this, the search for evidence of content and response processes in the IAF is not enough to make it a gold standard for validity, according to Psychometrics.A systematic review of the evidence of validity in the development of instruments in speech therapyAs it collects data from students from schools in the city of Porto Alegre/RS, the present study had limitations such as the use of reduced sample size and variability. Also in this sense, there was a failure in the application of the complete instrument in 3 children able to participate in the study, which may have influenced the results. It is important to emphasize that the IAF still has a long way to go for its validation, as it is necessary to establish construct and reliability standards with security. It also needs to carry out studies with representative population samples from the Brazilian territory.The present study contributes to clinical practice based on scientific evidence in the field of language. By seeking evidence of content validity with expert judges, this study attests to the existence of an instrument close to the ideal quality proposed by the scientific community. On the other hand, when looking for evidence of the validity of the response process with non-specialist judges and children, this study confers attributes close to clinical practice and indicates which difficulties may arise during the evaluation.This study was able to demonstrate evidence of content validity and response process in the Phonological Assessment Instrument, IAF. Together, with this study, it was possible to adjust and improve the test items in a more judicious manner, benefiting clinical and scientific use. . Funcionando a servi\u00e7o da comunica\u00e7\u00e3o interpessoal, a linguagem \u00e9 composta por dom\u00ednios lingu\u00edsticos que contemplam o uso, a forma e o conte\u00fado. A fonologia compete ao estudo funcional dos fonemas, que s\u00e3o as unidades sonoras m\u00ednimas capazes de estabelecer a distin\u00e7\u00e3o entre voc\u00e1bulos de uma mesma l\u00edngua.A linguagem se configura como uma habilidade inerentemente humana capaz de representar objetivamente o pensamento abstrato atrav\u00e9s de um sistema complexo de c\u00f3digos compartilhados, que \u00e9 a l\u00edngua. Funcio,3, considerando a complexidade dos tra\u00e7os distintivos dos fonemas.Gradativamente, a linguagem \u00e9 adquirida e desenvolvida atrav\u00e9s de uma hierarquia que inclui todos os dom\u00ednios lingu\u00edsticos. No caso da aquisi\u00e7\u00e3o do dom\u00ednio da fonologia, \u00e9 preciso que a crian\u00e7a organize os diversos sons que comp\u00f5em o sistema fonol\u00f3gico de sua l\u00edngua materna para que este se estabilize. Estudos mostram que a aquisi\u00e7\u00e3o t\u00edpica da linguagem ocorre at\u00e9 os 5 anos de idade. Este \u00e9 caracterizado em crian\u00e7as acima de 4 anos de idade, que apresentam majoritariamente trocas consonantais na fala, tendo limiares auditivos dentro dos padr\u00f5es de normalidade, n\u00e3o demonstrando altera\u00e7\u00f5es no l\u00e9xico e na sintaxe com rela\u00e7\u00e3o \u00e0 linguagem expressiva, aus\u00eancia de altera\u00e7\u00f5es neurol\u00f3gicas evidentes, assim como habilidades cognitivas normais e capacidade de compreens\u00e3o intacta. Sendo assim, \u00e9 necess\u00e1ria a realiza\u00e7\u00e3o de testes de audi\u00e7\u00e3o, avalia\u00e7\u00e3o da linguagem e verifica\u00e7\u00e3o da intelig\u00eancia da crian\u00e7a, para garantir o correto diagn\u00f3stico do TF.Entretanto, quando n\u00e3o h\u00e1 o desenvolvimento adequado da fonologia, se observam erros de produ\u00e7\u00e3o de fala, como \u00e9 o caso do Transtorno Fonol\u00f3gico (TF). \u00c9 importante, portanto, que se tenha um m\u00e9todo eficiente que avalie o invent\u00e1rio fonol\u00f3gico da crian\u00e7a, buscando um par\u00e2metro de como est\u00e1 o seu desenvolvimento e a sua fala. A sistematiza\u00e7\u00e3o da avalia\u00e7\u00e3o permitir\u00e1 a compara\u00e7\u00e3o acurada do sistema fonol\u00f3gico da crian\u00e7a com o da l\u00edngua alvo, possibilitando a investiga\u00e7\u00e3o minuciosa dos aspectos que comp\u00f5em a fala.Para entender melhor tal quadro, al\u00e9m da realiza\u00e7\u00e3o de todas as avalia\u00e7\u00f5es que confirmam o diagn\u00f3stico, \u00e9 necess\u00e1rio realizar uma efetiva avalia\u00e7\u00e3o fonol\u00f3gica, j\u00e1 que somente esta poder\u00e1 descrever detalhadamente as trocas na fala do indiv\u00edduo. \u00c9 impo para que o diagn\u00f3stico seja o mais adequado poss\u00edvel. Para ser v\u00e1lido, o instrumento de avalia\u00e7\u00e3o deve reunir evid\u00eancias de que mede realmente o que se prop\u00f5e a mensurar. Para ser confi\u00e1vel, por outro lado, o teste precisa indicar se \u00e9 reprodut\u00edvel ao longo do tempo e se h\u00e1 controle dos erros de mensura\u00e7\u00e3o,9.Todo esse processo diagn\u00f3stico deve ser composto por testes com interpreta\u00e7\u00f5es v\u00e1lidas, confi\u00e1veis e precisas para qu,10.Logo, para mensurar ao que se prop\u00f5e, o instrumento deve passar por etapas de validade para recolher evid\u00eancias, constitu\u00eddas por validade de: conte\u00fado, processos de resposta e construto. A validade de conte\u00fado e a de processos de respostas s\u00e3o as que surgem durante a constitui\u00e7\u00e3o do teste. A de conte\u00fado ocorre logo ap\u00f3s a elabora\u00e7\u00e3o te\u00f3rica de um instrumento e \u00e9 realizada com o aux\u00edlio de um ou mais grupos de especialistas dispostos a julgar, independentemente, cada item que comp\u00f5e o prot\u00f3tipo do teste. Na sequ\u00eancia, a de processo-resposta avalia parte do p\u00fablico-alvo; \u00e9 importante perceber quais s\u00e3o as maiores dificuldades e facilidades encontradas pelos sujeitos durante a realiza\u00e7\u00e3o da avalia\u00e7\u00e3o para que o teste seja aprimorado. J\u00e1 a de construto consiste na an\u00e1lise do instrumento no que tange \u00e0 amostra representativa de um dom\u00ednio. A falta de valida\u00e7\u00e3o dos protocolos de avalia\u00e7\u00e3o fonol\u00f3gica em Portugu\u00eas Brasileiro (PB) pode prejudicar a seguran\u00e7a das evid\u00eancias cl\u00ednicas para tra\u00e7ar um diagn\u00f3stico preciso, uma conduta adequada e um planejamento de interven\u00e7\u00e3o correto. Embora j\u00e1 existam testes dispon\u00edveis para auxiliar na avalia\u00e7\u00e3o e diagn\u00f3stico, os instrumentos mais utilizados, como a Avalia\u00e7\u00e3o Fonol\u00f3gica da Crian\u00e7a (AFC) e o ABFW - Teste de Linguagem Infantil - Fonologia apresentam limita\u00e7\u00f5es e ainda n\u00e3o possuem indicadores psicom\u00e9tricos de validade e fidedignidade comprovados cientificamente. Existem outros, como Instrumento de Avalia\u00e7\u00e3o Fonol\u00f3gica (INFONO) e o Instrumento de Avalia\u00e7\u00e3o de Fala para An\u00e1lise Ac\u00fastica (IAFAC), por\u00e9m menos divulgados e ainda n\u00e3o dispon\u00edveis para o uso cl\u00ednico. Portanto, \u00e9 de extrema import\u00e2ncia a realiza\u00e7\u00e3o de um estudo de valida\u00e7\u00e3o para trazer avan\u00e7os na \u00e1rea, buscando um padr\u00e3o-ouro cientificamente comprovado para a avalia\u00e7\u00e3o do dom\u00ednio fonol\u00f3gico em PB, auxiliando no processo diagn\u00f3stico, al\u00e9m de fornecer par\u00e2metros para diversos estudos. Dito isso, o presente estudo objetiva analisar as evid\u00eancias das etapas de conte\u00fado e de processos de resposta na validade do Instrumento de Avalia\u00e7\u00e3o Fonol\u00f3gica (IAF) , que j\u00e1 \u00e9 utilizado por alguns fonoaudi\u00f3logos.No Brasil, poucos s\u00e3o os instrumentos fonoaudiol\u00f3gicos que padronizam seus percursos metodol\u00f3gicos para elabora\u00e7\u00e3o de testes v\u00e1lidos e fidedignosEste trabalho \u00e9 aprovado pelo Comit\u00ea de \u00c9tica em Pesquisa (CEP) de uma universidade federal sob parecer n\u00famero 5.045.533. A pesquisa corresponde a um estudo observacional, transversal controlado, descritivo e quantitativo, cujos dados foram utilizados para a validade de conte\u00fado e de processos de resposta do IAF.software delineado para avaliar o sistema de sons da fala infantil de forma eficiente, minuciosa e otimizada. O instrumento foi elaborado com 123 palavras, pertencem ao vocabul\u00e1rio infantil, extra\u00eddas de hist\u00f3rias infantis populares, facilmente representadas em imagem ou foto e s\u00e3o do tipo substantivo, com uma imagem correspondente a cada item lexical. Os itens foram criteriosamente selecionados de forma que as palavras contemplassem todos os fonemas consonantais em todas as posi\u00e7\u00f5es sil\u00e1bicas do PB, com cinco ocorr\u00eancias de cada fonema e posi\u00e7\u00e3o sil\u00e1bica, totalizando 235 possibilidades fon\u00eamicas. A coleta da fala da crian\u00e7a deve ocorrer a partir da nomea\u00e7\u00e3o de cada uma das imagens, pela observa\u00e7\u00e3o das ilustra\u00e7\u00f5es ou fotografias, que leva aproximadamente 10 minutos para a aplica\u00e7\u00e3o. O avaliador deve gravar o \u00e1udio da coleta de fala, e posteriormente, ouvir e observar as elicita\u00e7\u00f5es das crian\u00e7as e registrar as informa\u00e7\u00f5es no software. Tal processo leva em torno de 10 a 30 minutos, dependendo da pr\u00e1tica e habilidade do avaliador. Ap\u00f3s a inser\u00e7\u00e3o dos dados no instrumento, os resultados s\u00e3o gerados automaticamente e expressos em relat\u00f3rios descritivos e quantitativos por: grau de severidade de fala, an\u00e1lise contrastiva, processos fonol\u00f3gicos e mudan\u00e7a de tra\u00e7os distintivos.O IAF \u00e9 um Likert para cada item numerado de 1 a 4, conforme explicitado no Ap\u00f3s a constru\u00e7\u00e3o te\u00f3rica do instrumento, foram convidados tr\u00eas ju\u00edzes especialistas para realizar o julgamento dos 123 itens no prot\u00f3tipo. Participaram da pesquisa os ju\u00edzes que assinaram Termo de Consentimento Livre e Esclarecido (TCLE) e que eram minimamente mestres em lingu\u00edstica com expertise em aquisi\u00e7\u00e3o fonol\u00f3gica t\u00edpica e at\u00edpica. Eles deveriam indicar o n\u00edvel de adequa\u00e7\u00e3o de cada item lexical para a proposta e escolher, entre duas op\u00e7\u00f5es, a imagem que melhor o representasse. Nessa etapa, deveriam responder \u00e0 pergunta \u201cA palavra-alvo \u00e9 adequada para pertencer a um instrumento de avalia\u00e7\u00e3o de fala infantil?\u201d de forma quantitativa, por meio de um formul\u00e1rio eletr\u00f4nico, organizado em escala Para a abordagem qualitativa, os especialistas deveriam justificar suas escolhas com seus pr\u00f3prios crit\u00e9rios, registrados em coment\u00e1rios descritivos no mesmo formul\u00e1rio eletr\u00f4nico. Para respostas 1 ou 2, os ju\u00edzes foram orientados a sugerir ao menos uma nova palavra para substitui\u00e7\u00e3o, considerando os mesmos aspectos elencados durante a elabora\u00e7\u00e3o do instrumento . Para compreender o n\u00edvel de correspond\u00eancia intra e inter-ju\u00edzes, foi realizado o c\u00e1lculo de \u00cdndice de Validade de Conte\u00fado (IVC).. Para signific\u00e2ncia de 5% e poder de 80%, o resultado foi uma amostra m\u00ednima de 165 crian\u00e7as.Ap\u00f3s a devolutiva dos ju\u00edzes especialistas, foi calculado o tamanho amostral necess\u00e1rio para determinar um coeficiente Kappa de 0.80, significativamente superior \u00e0 0.60, indicando boa concord\u00e2ncia e com estimativa de 25% de preval\u00eancia de TFO IAF foi aplicado em um grupo de estudantes, entre 5 anos e 8 anos e 11 meses, de uma escola p\u00fablica da rede municipal da cidade de Porto Alegre. A amostra deste estudo \u00e9 composta de dados de 176 crian\u00e7as, com aquisi\u00e7\u00e3o fonol\u00f3gica t\u00edpica ou com TF, considerando que nenhuma possui altera\u00e7\u00f5es auditivas, neurol\u00f3gicas e/ou cognitivas, dificuldades escolares, hist\u00f3rico de atraso neuropsicomotor e/ou de intercorr\u00eancias em gravidez ou parto, conferidas por meio de avalia\u00e7\u00e3o pr\u00e9via e informa\u00e7\u00f5es recolhidas em entrevista com os respons\u00e1veis. Todos os pais ou os respons\u00e1veis assinaram TCLE e Autoriza\u00e7\u00e3o para Uso de \u00c1udio; e, no caso de crian\u00e7as acima de 7 anos, essas tamb\u00e9m assinaram Termo de Assentimento.Com base nas coletas de fala da amostra, um quarto juiz, independente e cegado, classificou as respostas dos sujeitos quanto ao n\u00edvel de dificuldade observado em cada um dos itens lexicais. As respostas foram rotuladas conforme a necessidade de interven\u00e7\u00e3o do aplicador, descrito no A an\u00e1lise dos tr\u00eas ju\u00edzes especialistas a respeito do prot\u00f3tipo do instrumento IAF indicou IVC de 0,98, o que representa um \u00edndice muito bom para a validade de conte\u00fado do teste. Para compor o instrumento foram escolhidas aquelas imagens em que pelo menos dois dos tr\u00eas ju\u00edzes estavam de acordo.Likert, para pertencer a um instrumento de avalia\u00e7\u00e3o de fala infantil. Os ju\u00edzes classificaram as palavras de acordo com seus pr\u00f3prios crit\u00e9rios, sendo eles: a palavra ser ou n\u00e3o frequente no universo infantil; a palavra ser ou n\u00e3o boa para verifica\u00e7\u00e3o do alvo; e a palavra proporcionar nomea\u00e7\u00e3o espont\u00e2nea adequada.Como pode ser observado na Os crit\u00e9rios descritos pelos ju\u00edzes foram semelhantes, apesar de terem sido definidos de forma individual e independente em caixa de texto dissertativa no formul\u00e1rio utilizado, o que explica a porcentagem obtida no c\u00e1lculo de IVC e a homogeneidade das respostas, em que 116 itens atingiram converg\u00eancia m\u00e1xima. No entanto, sete dos itens apresentaram diverg\u00eancias, foram eles: \u201cbalde\u201d, \u201cbicicleta\u201d, \u201cchiclete\u201d, \u201cferro\u201d, \u201cneve\u201d, \u201czang\u00e3o\u201d e \u201czumbi\u201d. Nesses casos, apenas um dos tr\u00eas ju\u00edzes considerou que as palavras-alvo n\u00e3o eram adequadas, o que ficou representado pelo IVC pr\u00f3prio de 0,75. Para a maioria dos itens n\u00e3o houve sugest\u00e3o de nova palavra. Para \u201cbicicleta\u201d um dos ju\u00edzes sugeriu uso de pseudopalavra para que o alvo fosse atingido. J\u00e1 para \u201cferro\u201d, um dos especialistas prop\u00f4s a troca para \u201cf\u00e9rias\u201d ou \u201cbarro\u201d ou \u201cferradura\u201d ou para a ora\u00e7\u00e3o \u201cfecha a porta\u201d.Foi realizada a adapta\u00e7\u00e3o de \u201cchiclete\u201d para o alvo \u201cchicl\u00e9\u201d, que \u00e9 mais comum no vocabul\u00e1rio infantil e n\u00e3o provocou altera\u00e7\u00e3o nos fonemas ou nas posi\u00e7\u00f5es-alvo. Sendo assim, tanto a elicia\u00e7\u00e3o de \u201cchiclete\u201d ou de \u201cchicl\u00e9\u201d s\u00e3o consideradas corretas para o preenchimento do instrumento. Em contrapartida, as palavras \u201czang\u00e3o\u201d e \u201czumbi\u201d n\u00e3o puderam ser alteradas, pois n\u00e3o h\u00e1 diversidade de voc\u00e1bulos com /z/ no in\u00edcio da palavra. A sugest\u00e3o para uso de pseudopalavras n\u00e3o foi acatada, pois o objetivo do instrumento \u00e9 a busca pela nomea\u00e7\u00e3o r\u00e1pida sem a necessidade frequente de interven\u00e7\u00e3o do aplicador. Da mesma forma, \u201cferro\u201d n\u00e3o foi alterado pela dificuldade de representa\u00e7\u00e3o visual das sugest\u00f5es \u201cf\u00e9rias\u201d, \u201cbarro\u201d, \u201cferradura\u201d ou \u201cfecha a porta\u201d. Os itens lexicais \u201cbalde\u201d e \u201cneve\u201d n\u00e3o foram alterados pela falta de justificativa e nova sugest\u00e3o por parte do juiz.O instrumento, j\u00e1 adaptado, foi completamente aplicado em 176 crian\u00e7as na escola para obten\u00e7\u00e3o de evid\u00eancias de validade de processo de resposta. Os itens de maior dificuldade foram: item 62 com 25% de reconhecimento em nomea\u00e7\u00e3o espont\u00e2nea, item 118 com 25% de reconhecimento, item 107 com 53% de reconhecimento, item 43 com 60% de reconhecimento, item 101 com 61% de reconhecimento e os itens 46, 87 e 47 com 69% de reconhecimento. Conforme apresentado na A forma de interven\u00e7\u00e3o do aplicador, como o fornecimento de pistas ou o uso do recurso de imita\u00e7\u00e3o retardada, que mais se destacou em cada item, pode ser conferida na , o que significa que a inter-rela\u00e7\u00e3o dos itens permite suportar a estrutura teoricamente proposta.A consist\u00eancia interna do instrumento foi calculada atrav\u00e9s do Alpha de Cronbach e os 123 itens apresentaram a consist\u00eancia de 0,844. Esse resultado ajuda a inferir que todos os elementos constituintes est\u00e3o de acordo entre siConsiderando os objetivos deste estudo e os resultados exibidos, verificou-se que os escores do IAF apresentaram adequados indicadores de validade de conte\u00fado e de processos de resposta. Assim, o instrumento avaliado est\u00e1 apto a prosseguir para as pr\u00f3ximas etapas de validade e de fidedignidade..Foi poss\u00edvel observar que aqueles itens destacados pelos ju\u00edzes especialistas, durante a constru\u00e7\u00e3o de conte\u00fado, n\u00e3o necessariamente foram os mesmos itens de dificuldade do p\u00fablico-alvo, durante a an\u00e1lise dos processos de resposta. A exce\u00e7\u00e3o foi a palavra \u201cferro\u201d, um dos itens apontados como \u201cn\u00e3o adequado\u201d pelos ju\u00edzes, que apresentou identifica\u00e7\u00e3o abaixo de 70% pela amostra. Nesse sentido, a validade com base nos processos de resposta d\u00e1 ind\u00edcios de como ser\u00e1 a aplica\u00e7\u00e3o cl\u00ednica do instrumento, da mesma forma que permite a organiza\u00e7\u00e3o de manuais e orienta\u00e7\u00f5es adicionais aos aplicadores, para al\u00e9m da avalia\u00e7\u00e3o te\u00f3ricaApesar de depender da correta nomea\u00e7\u00e3o espont\u00e2nea das figuras, o procedimento de avalia\u00e7\u00e3o demanda a elicita\u00e7\u00e3o dos fonemas-alvo. Isso amplia a possibilidade de resposta almejada da crian\u00e7a, aceitando-se \u201ctecla\u201d para o item \u201cteclado\u201d, por exemplo, j\u00e1 que os fonemas-alvos se mant\u00eam id\u00eanticos. Da mesma forma, aceita-se \u201ctelha\u201d para \u201ctelhado\u201d, \u201cchicl\u00e9\u201d para \u201cchiclete\u201d e \u201clixo\u201d para \u201clixeira\u201d.5. Procurando alcan\u00e7ar as demandas de avalia\u00e7\u00e3o, o aplicador pode dispor de uma sequ\u00eancia de estrat\u00e9gias que incentivem uma fala mais pr\u00f3xima do natural e estimem a inteligibilidade de fala do avaliado. Essas estrat\u00e9gias incluem o uso de dicas, o uso do m\u00e9todo close e a utiliza\u00e7\u00e3o do recurso de imita\u00e7\u00e3o retardada no caso do IAF.As figuras fornecem o apoio necess\u00e1rio para incentivar a fala natural, j\u00e1 que \u00e9 importante que a coleta se aproxime ao m\u00e1ximo da linguagem oral espont\u00e2nea da crian\u00e7a O uso de dicas costuma ser o mais intuitivo para o aplicador. Para que o engajamento da crian\u00e7a n\u00e3o se perca, mant\u00e9m-se o di\u00e1logo com a crian\u00e7a, favorecendo o empenho dela durante a avalia\u00e7\u00e3o. As dicas incluem pequenas interven\u00e7\u00f5es para direcionar o pensamento do sujeito, tal como dizer \u201c\u00e9 aquele que se coloca no caf\u00e9\u201d para o item 2, \u201ca\u00e7\u00facar\u201d; ou \u201c\u00e9 o que ele \u00e9, n\u00e3o o nome dele\u201d para o item 87, \u201cplaneta\u201d, representado pela figura do planeta Saturno.m\u00e9todo close. Esse recurso, amplamente presente na pr\u00e1tica cl\u00ednica, consiste no emprego de uma frase que deixe lacunas para a palavra alvo. Utilizando o item 43, \u201cexplos\u00e3o\u201d, como exemplo: em um determinado momento, o aplicador usa a dica \u201ca gente chama os bombeiros quando isso acontece\u201d e a crian\u00e7a responde \u201cinc\u00eandio\u201d para o alvo, necessitando de mais dicas ou ainda de imita\u00e7\u00e3o retardada para elicidar corretamente; em outro momento, o aplicador utiliza o m\u00e9todo close com a frase \u201cquando faz \u2018BOOM\u2019, a gente chama de...\u201d e obt\u00e9m prontamente a resposta \u201cexplos\u00e3o\u201d. Isso ocorre porque esse m\u00e9todo utiliza as habilidades de associa\u00e7\u00f5es auditivas e cognitivas recorrentes na busca pela resposta, assim como preconizado na terapia fonoaudiol\u00f3gica.No entanto, em variadas situa\u00e7\u00f5es h\u00e1 maneiras mais eficazes de se obter a resposta almejada, como a utiliza\u00e7\u00e3o do recurso de .Quando a crian\u00e7a demonstra maiores dificuldades para atingir o alvo, os recursos de imita\u00e7\u00e3o podem ser utilizados como \u00faltima alternativa para garantia de obten\u00e7\u00e3o de amostra de fonema. Dentre esses recursos, no entanto, prioriza-se a imita\u00e7\u00e3o retardada em detrimento da direta. A imita\u00e7\u00e3o direta consiste na repeti\u00e7\u00e3o imediata do modelo fornecido pelo aplicador do instrumento, enquanto a imita\u00e7\u00e3o retardada s\u00f3 permite repeti\u00e7\u00e3o ap\u00f3s um per\u00edodo de lat\u00eancia e distra\u00e7\u00e3o. Dessa forma, na imita\u00e7\u00e3o retardada, o aplicador fornece o modelo e avisa que retornar\u00e1 \u00e0 imagem na sequ\u00eancia, tornando-se agora uma imagem mental, o significante ou a imagem interiorizada que representa um conte\u00fado ou objeto,21. No contexto da avalia\u00e7\u00e3o fonol\u00f3gica, portanto, deve-se utilizar a imita\u00e7\u00e3o como \u00faltimo recurso para elicita\u00e7\u00e3o dos alvos.Refor\u00e7a-se que o aplicador do instrumento deve ter em mente a prioriza\u00e7\u00e3o da espontaneidade no momento de avalia\u00e7\u00e3o. A repeti\u00e7\u00e3o proporcionada pelo recurso de imita\u00e7\u00e3o tende a tornar a fala truncada, al\u00e9m de mascarar os sons de dificuldade da crian\u00e7a com TF teve como resultado a preval\u00eancia de estudos com presen\u00e7a de valida\u00e7\u00e3o de conte\u00fado, no entanto, poucos realizaram o teste de confiabilidade pelo alfa de Cronbach. O presente estudo demonstrou estimativa de consist\u00eancia interna alta para o IAF , significando que as respostas obtidas com o instrumento s\u00e3o seguras para a avalia\u00e7\u00e3o. Outro instrumento nacional obteve mediana de 0,816 indicando, tamb\u00e9m, uma consist\u00eancia satisfat\u00f3ria dos itens que comp\u00f5em o instrumento para avaliar os fonemas do PB.Um estudo descritivo que buscou analisar os procedimentos de valida\u00e7\u00e3o utilizados em instrumentos de avalia\u00e7\u00e3o de linguagem oral apresentou que nenhum estudo encontrado demonstrou resultados de todos os tipos concomitantemente , o que indica a falta de aprimoramento dos trabalhos na \u00e1rea da Fonoaudiologia. A partir disso, tem-se que a busca por evid\u00eancias de conte\u00fado e de processos de resposta no IAF n\u00e3o \u00e9 suficiente para o tornar padr\u00e3o-ouro para validade, conforme a Psicometria.Uma revis\u00e3o sistem\u00e1tica sobre evid\u00eancias de validade no desenvolvimento de instrumentos na FonoaudiologiaPor coletar dados de alunos de escolas do munic\u00edpio de Porto Alegre/RS, o estudo apresentado teve como limita\u00e7\u00f5es o uso de amostra reduzida em tamanho e variabilidade. Tamb\u00e9m nesse sentido, ocorreu falha na aplica\u00e7\u00e3o do instrumento completo em 3 crian\u00e7as aptas a participar do estudo, o que pode ter influenciado os resultados. \u00c9 importante ressaltar que o IAF ainda possui um longo caminho para sua valida\u00e7\u00e3o, pois \u00e9 preciso estabelecer os padr\u00f5es de construto e fidedignidade com seguran\u00e7a, bem como realizar estudos com amostras populacionais e representativas do territ\u00f3rio brasileiro.O presente trabalho contribui com a pr\u00e1tica cl\u00ednica baseada em evid\u00eancias cient\u00edficas no \u00e2mbito da linguagem. Ao buscar evid\u00eancias de validade de conte\u00fado com ju\u00edzes especialistas, este estudo atesta a exist\u00eancia de um instrumento pr\u00f3ximo \u00e0 qualidade ideal proposta pela comunidade cient\u00edfica. Por outro lado, ao buscar evid\u00eancias de validade de processo de resposta com ju\u00edzes n\u00e3o especialistas, as crian\u00e7as, este estudo confere os atributos pr\u00f3ximos \u00e0 pr\u00e1tica cl\u00ednica e indica quais dificuldades podem surgir durante a avalia\u00e7\u00e3o.Este trabalho p\u00f4de demonstrar evid\u00eancias de validade de conte\u00fado e de processo de resposta no Instrumento de Avalia\u00e7\u00e3o Fonol\u00f3gica, IAF. Conjuntamente, com este estudo, foi poss\u00edvel adequar e aprimorar os itens de teste de forma mais criteriosa, beneficiando o uso cl\u00ednico e cient\u00edfico."}
+{"text": "Perform content validation of a decannulation protocol for tracheostomized adult patients.To validate the content of the protocol developed by speech therapists, the Delphi technique was used. The 11 items of the protocol were judged by experts through rounds via e-mail and were classified as adequate, partially adequate or inadequate, in addition to providing comments and suggestions on each item. 30 speech therapists, 30 respiratory physiotherapists and 30 physicians responsible for the tracheostomy and decannulation procedure were invited. The percentage of agreement adopted was \u2265 80% and the process was interrupted when this percentage was obtained in all items.At the end of the process, 24 professionals participated in the third round, being 46% speech therapists, 29% physiotherapists and 25% physicians. After the experts' suggestions and comments, two items were kept as they were in the initial protocol, seven were reformulated, six were included and two were excluded. The final version of the protocol included: identification, absence of abundant secretions, characteristics of the secretion, effective cough, ability to remove secretions, tolerate the deflated cuff, aptitude in the decannulation process, level of consciousness, change of cannula to a smaller caliber, absence of current/active infection, spontaneous and effective swallowing of saliva, use of a speech valve, aptitude for occlusion of the cannula, assessment of aptitude for decannulation and objective examinations.Through the Delphi Technique, the content of the instrument was validated, with substantial changes occurring. The next stage of instrument validation is obtaining evidence of validity in relation to the internal structure. Besides these, TT is performed in various surgical specialties other than intensive care,3.There has been an increase in hospital TT in the last decade. This is an essential stage in the clinical progress and rehabilitation of patients who have been tracheotomized but do not depend on mechanical ventilation anymore. However, there is limited scientific evidence on decannulation and no standardized recommendations or validated protocols for the procedure,3.There are various indications for TT, and when the artificial air passage is no longer needed, the removal process (named decannulation) takes place-7 - in which decannulation is more often individualized rather than a protocolized process,7.Data found in the literature regarding the aptitude/readiness for decannulation are limited to experts\u2019 opinions, research studies, single-center experiences, non-validated scores to predict successful decannulation, and some randomized clinical trials focused on organizational issues such as TT teams conducted by intensivists or the effects of specific decisions on outcomes like dysphagia or sleep quality,6,7.To our knowledge, there is no validated protocol to guide decannulation, as the literature only has some articles on physiological changes that occur after decannulation, with diverging opinions among specialists on the topic-8. Content validity is the determination of whether the content items are representative based on the judgment of experts in a specific field-8.Validating a protocol is a methodological procedure to assess its quality, which can be defined as the protocol\u2019s capacity to precisely measure that for which it is intended - i.e., the phenomenon in question,2,9-13.Content validation makes it possible to associate abstract concepts with observable and measurable indicators addressed by an assessment instrument, determining its representativity, and demonstrating whether it effectively explores the requirements to measure the phenomenon being investigated, through a methodological strategy selected to that end-12. A study in the literature used this method and obtained experts\u2019 consensus on a list of TT decannulation prerequisites for adults, as follows: cured or reverted clinical condition that led to TT indication, tolerated TT cannula occlusion without stridor, adequate airway patency (assessed with laryngoscopy), adequate awareness level, intact airway protection laryngopharyngeal functions , presence of effective coughing, and absence of new indications for surgery or anesthesia. The authors of the said study strongly recommend adding other parameters, such as the type and amount of secretions and frequency of necessary aspiration. Thus, the present study deemed it necessary to approach the indications anew with the Delphi method to analyze the variables from an updated perspective, adequate to the reality being researched and including prerequisites absent in the abovementioned study.The Delphi method is widely used in content validation studies and makes up the methodology in various areas and approaches,9,12.The multiple perspectives in a group of experts provide a more valid result than the judgment of a single specialist - even if they are the best specialist in their field,14-16. Submitting their content to experts\u2019 appraisal refines the instrument for subsequent validation and reliability procedures.It must be highlighted that assessment instruments and clinical protocols are integral parts of clinical practice, health assessment, and research, providing scientifically robust results when appropriately developed and validatedGiven the above, this article aimed to validate the content of a multidisciplinary decannulation protocol for tracheotomized adults, using the Delphi method.The study met the human research ethics criteria, according to Resolution 466/2012 of the National Health Council, and was approved by the institution\u2019s Research Ethics Committee, under approval number 4.458.519. Participating signed an informed consent form, thus agreeing to the procedure and disclosure of the research and its results.. This research conducted the methodological quantitative and qualitative validation study of a temporary TT decannulation protocol.The first decannulation protocol version was initially developed based on a national and international literature review concerning decannulation criteria and data on the medical records of 189 hospitalized tracheotomized adults, which were collected and statistically treated-7,17. Hence, the first protocol version included the following items: the capacity to remove secretions by swallowing or spitting them; absence of abundant secretions, requiring tracheal tube aspiration three times every 8 hours at the most; tolerance to TT cannula occlusion for at least 48 hours; awareness level scoring 12 to 15 on the Glasgow Coma Scale (GCS); absence of active infections; the presence of spontaneous saliva swallowing; negative blue-dye test result; tolerance to permanently deflated cuff for at least 24 hours; plastic cannula switched for a metal one; absence of dysphagia; oral diet allowed in meals; and use of the speaking valve.The initial protocol items approached statistically significant variables in the cited study, adding items considered relevant in the literature in the areaThe Delphi method was used to validate the content of the first version of the adult decannulation protocol, collecting experts\u2019 opinions on the topic, tabulating data, and assessing procedure criteria.. It is a research and instrument validation methodological strategy, seeking opinion consensus from a group of specialists, using structured questionnaires organized in phases, cycles, or rounds-20. It aims to obtain the maximum consensus from a group of specialists on a given topic when a unanimous opinion is inexistent due to contradictory information or the lack of scientific evidence,21-23.The Delphi method is named after the Oracle of Delphi, where ancient Greeks sought counsel and answer about the future,6,21,23.Researchers selected the specialists based on their knowledge and experience on the research topic. They were invited to give their opinion on this specific subject by filling out an assessment questionnaire anonymously.The researchers analyzed the results between each round of questionnaires. They observed the tendencies and diverging opinions along with their justifications, systematizing and compiling them to resend to the group afterward. Thus, after learning the other members\u2019 opinions and the group\u2019s responses, participants had the opportunity to refine, change, or defend their answers and resend them to the researchers to redevelop the questionnaire according to the new information. This process was repeated until they reached a consensusIt was defined that the study sample should comprise at least 30 specialists, experts on the topic, with a specialization, at least 5 years of practical/clinical experience in decannulating tracheotomized patients, and distinct academic training .. Hence, 90 participants were invited .Throughout the Delphi method, a 30 to 50% abstention rate is expected in the first round, and 20 to 30% in the second oneSpecialists were invited via e-mail, which formally presented the study objectives, purpose, development, stages, estimated time, deadlines to return questionnaires, and other details inherent to the study. A protocol explanation handbook and a link to the online protocol assessment questionnaire were annexed to the e-mail.They scored all items in the initial protocol - as well as in the reformulated protocol based on the specialists\u2019 suggestions, which was resent for appreciation - using a Likert scale, as adequate (3), partially adequate (2), or inadequate (1).The specialists\u2019 observations, comments, and suggestions were recorded in an Excel spreadsheet regarding each item they assessed for later analysis and changes.,12,25, calculated by dividing the number of assessors who agreed with the item by the total number of assessors. Specialists\u2019 observations and suggestions were recorded in a separate file and used in each round to reformulate and adjust the protocol items.In each round, the agreement between specialists\u2019 appraisals was assessed with the content validity index (CVI),19. Items were kept when their CVI was \u2265 80% and revised when their reformulation had been suggested. Those whose CVI was \u2264 80% were excluded. After adjustments had been made according to the specialists\u2019 suggestions, the protocol was resent to them for a new appraisal. The process was concluded when all protocol items reached the percentage of agreement.The percentage of agreement used in each round to select variables considered appropriate to the protocol - chosen according to indications in the literature - was 80% or aboveParticipants were characterized regarding their profession/occupation and sociodemographic characteristics, such as age, sex, occupation, time since graduation, postgraduate degree, and time of experience with tracheotomized patients. Hence, descriptive analysis was performed with absolute and relative frequencies.Protocol content validation needed three rounds until all its items reached an 80% agreement between specialists .In the first round, 39 of the 90 invited specialists answered the questionnaire - 19 SLH therapists, 11 physicians, and nine physical therapists. Hence, there was a 57% absence rate from the invitation to the first round. The subsequent absence rates were 26% in the second round  and 17% in the third and last round .The professionals who participated in the three assessment rounds conducted in this study were 28 to 52 years old, with a mean age of 40 years (SD = 6). The largest number of specialists was that of SLH therapists in the first (49%), second (48%), and third rounds (46%), followed by physicians (28%) and physical therapists (23%) in the first round. In the second and third rounds, the answers were sent by SLH therapists (45.8%), followed by physical therapists (29.2%) and physicians (25%) .Concerning occupational data, most participants had graduated more than 11 years before (75%), and all of them (100%) had a specialization in their field. In the first round, there was a similar proportion of participants with a master\u2019s (67%) and a doctoral degree (62%), though different from those with a postdoctoral degree (28%). In the third and last round, there was an important difference between the number of professionals with a master\u2019s (29%) and a doctoral degree (75%). The specialists\u2019 predominating time of experience with tracheotomized patients was from 11 to 20 years .After this round, all items reached an \u2265 80% agreement index, thus ending the Delphi method. Hence, the protocol content was validated. The protocol items assessed by specialists are described below .The items were maintained unaltered after they reached the \u2265 80% CVI and specialists had no more suggestions for changes - otherwise, they would have been reformulated and resent for a new round of appraisal. Based on the experts\u2019 suggestions and comments, two items were kept as they were from the initial protocol, seven were reformulated, six were included, and two were excluded. The final protocol, after the third round, is available in According to the experts\u2019 suggestions and comments, the items\u2019 capacity to remove secretions by swallowing or spitting them and the presence of spontaneous saliva swallowing were maintained as they were in the initial protocol.The seven reformulated items are presented below, along with the experts\u2019 main comments/suggestions: identification data , absence of abundant secretions , coughing , awareness level , absence of active infections ; cannula occlusion; and evaluation of the aptitude for decannulation.The six other items that were included addressed complementary data, characteristics of the secretion, toleration to deflated cuff, exchange for a thinner cannula, use of the speaking valve, and objective examinations performed.They suggested excluding the items on the blue dye test and oral diet. The reason why they would have the blue-dye test item removed is that it can be a false negative in up to 50% of the cases and, therefore, is not a reliable parameter to be considered; moreover, SLH clinical assessments have the final word over the test. As for the oral diet, the specialists\u2019 main observations were that the possibility of decannulating a patient is not always related to whether they are apt for an oral diet - analyzed alone, it is not a parameter that indicates criteria and risk for TT decannulation. Thus, there is no relationship between allowing an oral diet and decannulating, which, consequently, is not directly dependent on the former. Furthermore, patients with dysphagia, who cannot and are not allowed to have an oral diet, may have unobstructed airways and the capacity to protect the lower airways, enabling decannulation.The final protocol, after the third round, is available in Lastly, the comparative observation between contents in the initial and final protocols shows the following main changes, based on the specialists\u2019 assessments and observations: between the first and second rounds, the following items were included: interdisciplinary protocol; previous respiratory diseases and dysphagia; reason for TT and complications; TT cannula diameter and absence or presence of a cuff; viscosity characteristics and aspect of the secretion; use of the speaking valve; and tolerance to deflated cuff. Also, the items\u2019 absence of abundant secretions and coughing were modified/reformulated.Changes between the second and third rounds referred to the amount and aspect of aspirated secretions and the evaluation of coughing.After the three rounds with the specialists\u2019 suggestions, the following items remained in the final protocol version: identification, absence of abundant secretions, characteristics of the secretion, effective coughing, capacity to remove secretions, tolerance to deflated cuff, criteria: being apt for decannulation, awareness level (GCS), exchange for a thinner cannula, absence of current/active infections, spontaneous effective saliva swallowing, use of the speaking valve, criteria: being apt for cannula occlusion, evaluation of the aptitude for decannulation, objective examinations ..The three participating professional categories are closely related to decannulation, and their decisions determine the conduction and outcomes of the whole process. This enabled a more reliable construction, without individual dominance over the assessment instrument proposed in this study.The lack of validated decannulation protocols in hospitals may lead to clinical and respiratory complications, such as premature decannulation, respiratory failure, secretion accumulated in pharyngeal recess with increased risk of bronchoaspiration, impaired lower airway protection mechanism, lower-airway stridor, sepses, enlarged stoma, and changes in the mucosa-26.Validating health protocols is an important task to ensure safety, evidence, and quality in actions related to the assistance to patients, especially in hospitals, to promote safe, effective, and efficient actions-9. Guidelines are developed based on responses to the Delphi method to provide an important base to produce and assess studies and publications,9.The Delphi method is used to generate a sample of specialists\u2019 opinions, preventing overassertive individuals from dominating the process. Hence, it has been considered an adequate means of extracting useful data from personal experiences that can be transformed into empirical data for future studies. Most specialists agree that the higher the study design is located in the hierarchy, the more rigorous its methodology will be.Evidence obtained from committees of experts\u2019 reports or opinions and/or respected authorities\u2019 clinical experiences belongs to Level IV in the pyramid of evidence.The specialists who participated in this study had a satisfactory profile of clinical experience in the area, with many years of experience with tracheotomized patients. This corroborates the literature, which states that participating experts must have an affinity with the proposition that is meant to be validated - hence, they must have academic or scientific productions and/or professional experience in the area in which the study is grounded, thus being characterized as experts,23. Expertise refers to a continuum that includes subjective and objective expertise, both related to academic training and experience on the research topic. Hence, specialists must be recruited according to their experience and credibility on the topic,26. They should be at least 10 (fewer than this does not generate enough ideas) and at the most 50  participating specialists, experts on the topic, with different academic training to broaden the clinical reasoning around the issue at hand-28.All specialists had a specialization postgraduate degree, and a significant number of them had master\u2019s and doctoral degrees. The literature states that good-quality assessments require a panel of experts qualified on the topic, with academic training and expertise appropriate to the issue being analyzed, based on the quality of their contribution,24,27,29.The initial proposal in this study was to count on at least 30 participating specialists. However, the final number of participants was 24 in the third round, with a good CVI. Moreover, even though the final number of specialists was smaller than expected, it is still within the suggested in the literature as adequate to maintain the quality of the Delphi method in the consensus of opinionsAbstentions did not change the quality of the content validation process for the decannulation protocol. The lack of homogeneity between professional categories in all rounds may have been a fragility of this study, as the protocol is meant to be multiprofessional.On the other hand, the analysis of the professionals\u2019 profiles showed that participants have adequate training and time of experience in the decannulation of tracheotomized patients, which enables adequate and appropriate analyses, observations, and suggestions.Thus, the main changes in the first protocol version according to the specialists\u2019 observations and suggestions refer to the following items: complementary data , quantification of secretions and identification of their characteristics, tolerance to deflated cuff, use of the speaking valve, standardization of the cannula occlusion resource, and removal of the items on the blue-dye test and oral diet. These changes led to the second version, whose main suggested changes referred to the following items: detailed aspects of the secretions, use of the speaking valve, objective examinations performed, and criteria for the aptitude for decannulation. Changes made in the second round led to the third protocol version, which is available in Concerning the item on patients being allowed to have an oral diet, an important percentage of participating physicians, physical therapists, and SLH therapists questioned the direct relationship between the patient\u2019s readiness to receive an oral diet and their aptitude for decannulation. No studies were found addressing the relationship between being decannulated and receiving an oral diet.Among the specialists\u2019 considerations, they suggested excluding or disregarding this item as an important part of the protocol. Most of them were SLH therapists, who \u201care the professionals legally certified to assess, diagnose, and provide SLH treatment of oropharyngeal dysphagia and manage it in newborns, children, adolescents, adults, and older adults\u201d . Therefore, it was decided to exclude this item from the protocol. was developed by surveying important data in the literature regarding decannulation. It considered clinical and statistical criteria, and its content was substantially modified and adjusted based on the specialists\u2019 assessments. Thus, the authors considered the protocol validated regarding its content. As described in the literature, content validity determines if content items are representative, based on the judgment of specialists in a specific area, defining whether the protocol\u2019s content effectively explores the requirements to measure a certain phenomenon to be investigated,2 - which was the process that took place in this validation study.The decannulation protocol proposed and assessed in the studyDespite the possible abovementioned limitations, this study is to our knowledge the first one to propose the validation of a decannulation protocol from a multiprofessional perspective. The final protocol encompassed the most important items for decannulation, helping identify clinical and respiratory characteristics and, consequently, correct decision-making to prevent complications in this process.Future protocol validation and reliability stages must take place in different services, applying it to hospitalized patients.This study described the validation, with the Delphi method, of a multidisciplinary decannulation protocol for tracheotomized adults. Given the results, the validity evidence was considered satisfactory.The specialists\u2019 contributions helped improved the instrument and validated its content. The next validation stage is to obtain validity evidence regarding its internal structure, and then submit the instrument to other reliability and validation parameters, by applying the protocol to the target population. .No ambiente hospitalar a traqueostomia \u00e9 um procedimento cir\u00fargico de rotina, que consiste na inser\u00e7\u00e3o de uma c\u00e2nula atrav\u00e9s de um orif\u00edcio na traqueia, comunicando-a com o meio externo e tornando a via a\u00e9rea p\u00e9rvia,2, estimando-se que entre 10 a 15% dos pacientes em unidade de terapia intensiva submetidos \u00e0 ventila\u00e7\u00e3o mec\u00e2nica necessitar\u00e3o de traqueostomia como parte de seus cuidados, al\u00e9m das traqueostomias feitas por v\u00e1rias especialidades cir\u00fargicas fora dos cuidados intensivos,3.Na \u00faltima d\u00e9cada, evidencia-se aumento no n\u00famero de traqueostomias realizadas em n\u00edvel hospitalar, que \u00e9 uma etapa essencial para a evolu\u00e7\u00e3o cl\u00ednica e reabilita\u00e7\u00e3o do paciente traqueostomizado n\u00e3o mais dependente da ventila\u00e7\u00e3o mec\u00e2nica, por\u00e9m, as evid\u00eancias cient\u00edficas sobre decanula\u00e7\u00e3o s\u00e3o limitadas e ainda n\u00e3o h\u00e1 recomenda\u00e7\u00f5es padronizadas ou protocolos validados para o procedimento,3.V\u00e1rias s\u00e3o as indica\u00e7\u00f5es para a realiza\u00e7\u00e3o do procedimento de traqueostomia e, quando n\u00e3o h\u00e1 mais a necessidade de se manter uma via a\u00e9rea artificial, ocorre o processo de retirada, denominado decanula\u00e7\u00e3o-7, onde o processo de decanula\u00e7\u00e3o \u00e9 mais frequentemente individualizado do que protocolizado,7.Os dados encontrados na literatura sobre a aptid\u00e3o/prontid\u00e3o para decanula\u00e7\u00e3o foram limitados \u00e0 opini\u00e3o de especialistas, estudos de pesquisa, experi\u00eancia em um \u00fanico centro, pontua\u00e7\u00f5es n\u00e3o validadas para prever o sucesso da decanula\u00e7\u00e3o e alguns ensaios cl\u00ednicos randomizados que se concentraram em quest\u00f5es organizacionais, como equipes de traqueostomia conduzidas por intensivistas ou os efeitos de decis\u00f5es espec\u00edficas em desfechos como disfagia ou qualidade do sono,6,7.N\u00e3o h\u00e1, no nosso conhecimento, protocolo validado para guiar o processo de decanula\u00e7\u00e3o, sendo encontrados na literatura alguns artigos sobre as modifica\u00e7\u00f5es fisiol\u00f3gicas ocorridas ap\u00f3s a decanula\u00e7\u00e3o, com opini\u00f5es divergentes entre os especialistas sobre o tema-8. A validade de conte\u00fado \u00e9 a determina\u00e7\u00e3o da representatividade de itens que expressam um conte\u00fado, baseada no julgamento de especialistas em uma \u00e1rea espec\u00edfica-8.A valida\u00e7\u00e3o de um protocolo pode ser entendida como um procedimento metodol\u00f3gico pelo qual \u00e9 avaliada sua qualidade, que pode ser definida como a capacidade de um protocolo medir com precis\u00e3o o que pretende medir, ou seja, o fen\u00f4meno estudado,2,9-13.A valida\u00e7\u00e3o de conte\u00fado possibilita associar conceitos abstratos com indicadores observ\u00e1veis e mensur\u00e1veis contidos em um instrumento de avalia\u00e7\u00e3o, determinando sua representatividade e evidenciando se este explora, de maneira efetiva, os quesitos para a mensura\u00e7\u00e3o de um determinado fen\u00f4meno a ser investigado, por meio de alguma estrat\u00e9gia metodol\u00f3gica escolhida para tal-12, sendo descrito na literatura um estudo que utilizou a referida t\u00e9cnica e que obteve consenso de especialistas em uma lista de pr\u00e9-requisitos a serem considerados para a decanula\u00e7\u00e3o de traqueostomia em adultos: cura ou revers\u00e3o do quadro cl\u00ednico que indicou a realiza\u00e7\u00e3o da traqueostomia, tolera oclus\u00e3o da c\u00e2nula de traqueostomia sem estridor, pat\u00eancia das vias a\u00e9reas adequada , adequado n\u00edvel de consci\u00eancia, fun\u00e7\u00f5es laringofaringeas de prote\u00e7\u00e3o de vias a\u00e9reas preservadas , presen\u00e7a de tosse eficaz e aus\u00eancia de novas propostas cir\u00fargicas e anest\u00e9sicas. No referido estudo, os autores recomendam fortemente a considera\u00e7\u00e3o adicional de alguns par\u00e2metros, tais como o tipo e quantidade de secre\u00e7\u00f5es e frequ\u00eancia de aspira\u00e7\u00e3o necess\u00e1ria. Sendo assim, no presente estudo, julgou-se necess\u00e1rio realizar nova abordagem das indica\u00e7\u00f5es \u00e0 luz da t\u00e9cnica Delphi, para analisar as vari\u00e1veis em uma perspectiva mais atualizada e adequada \u00e0 realidade pesquisada, inclusive, incluindo pr\u00e9-requisitos que n\u00e3o se encontravam presentes no estudo descrito pelos autores no estudo citado.A t\u00e9cnica Delphi \u00e9 amplamente utilizada em estudos de valida\u00e7\u00e3o de conte\u00fado, compondo a metodologia de diversas \u00e1reas e abordagens,9,12.A multiplicidade de perspectivas associada ao grupo de especialistas produz um resultado mais v\u00e1lido do que um julgamento dado por um especialista individual, mesmo que esse especialista seja o melhor em sua \u00e1rea,14-16 sendo que a submiss\u00e3o de seu conte\u00fado \u00e0 avalia\u00e7\u00e3o de especialistas permite refinar o instrumento para realiza\u00e7\u00e3o posterior dos procedimentos de valida\u00e7\u00e3o e confiabilidade.\u00c9 importante ressaltar que os instrumentos de avalia\u00e7\u00e3o e protocolos cl\u00ednicos s\u00e3o partes integrantes da pr\u00e1tica cl\u00ednica, da avalia\u00e7\u00e3o em sa\u00fade e de pesquisas, capazes de apresentar resultados cientificamente robustos quando s\u00e3o desenvolvidos e validados de maneira apropriadaDiante do exposto, o presente artigo tem como objetivo realizar a valida\u00e7\u00e3o de conte\u00fado de um protocolo multidisciplinar da decanula\u00e7\u00e3o de pacientes adultos traqueostomizados por meio da T\u00e9cnica Delphi.O estudo obedeceu aos Crit\u00e9rios da \u00c9tica em Pesquisa com Seres Humanos, Resolu\u00e7\u00e3o 466/2012 do Conselho Nacional de Sa\u00fade, sendo aprovado pelo Comit\u00ea de \u00c9tica em Pesquisa (CEP) da institui\u00e7\u00e3o, com n\u00famero de aprova\u00e7\u00e3o 4.458.519 e os participantes assinaram Termo de Consentimento Livre e Esclarecido, consentindo, desta forma, com a realiza\u00e7\u00e3o e divulga\u00e7\u00e3o da pesquisa e dos seus resultados.. Nesse estudo, foi realizado estudo metodol\u00f3gico, quanti-qualitativo de valida\u00e7\u00e3o de protocolo de decanula\u00e7\u00e3o de traqueostomia de uso tempor\u00e1rio.A primeira vers\u00e3o do protocolo de decanula\u00e7\u00e3o foi elaborada inicialmente a partir de revis\u00e3o de literatura nacional e internacional acerca dos crit\u00e9rios de decanula\u00e7\u00e3o e de dados dos prontu\u00e1rios de 189 pacientes adultos traqueostomizados hospitalizados, coletados e submetidos a tratamento estat\u00edstico-7,17. Assim, a primeira vers\u00e3o do protocolo incluiu as seguintes itens: capacidade de remover secre\u00e7\u00f5es deglutindo ou cuspindo; aus\u00eancia de secre\u00e7\u00f5es abundantes, com necessidade de aspira\u00e7\u00e3o traqueal com sonda no m\u00e1ximo tr\u00eas vezes em cada 08 horas e toler\u00e2ncia \u00e0 oclus\u00e3o da c\u00e2nula de traqueostomia num per\u00edodo m\u00ednimo de 48 horas; n\u00edvel de consci\u00eancia com pontua\u00e7\u00e3o entre 12 a 15, de acordo com a Escala de coma de Glasgow (ECG); aus\u00eancia de infec\u00e7\u00f5es ativas; presen\u00e7a de degluti\u00e7\u00e3o espont\u00e2nea de saliva; resultado negativo do Teste Blue Dye; toler\u00e2ncia ao balonete desinsuflado permanentemente por no m\u00ednimo 24 horas; realiza\u00e7\u00e3o de troca de c\u00e2nula pl\u00e1stica por met\u00e1lica; aus\u00eancia de disfagia; dieta por via oral liberada para as refei\u00e7\u00f5es e uso de v\u00e1lvula de fona\u00e7\u00e3o.Os itens do protocolo inicial contemplam as vari\u00e1veis com signific\u00e2ncia estat\u00edstica no referido estudo, acrescidas de itens considerados relevantes na literatura da \u00e1reaPara a valida\u00e7\u00e3o de conte\u00fado da primeira vers\u00e3o do protocolo de decanula\u00e7\u00e3o em adultos, foi utilizada a t\u00e9cnica Delphi, a fim de coletar opini\u00f5es de peritos no assunto, tabular os dados e avaliar os crit\u00e9rios para o procedimento.. \u00c9 uma estrat\u00e9gia metodol\u00f3gica de pesquisa e de valida\u00e7\u00e3o de instrumentos atrav\u00e9s do consenso de opini\u00f5es de um grupo de especialistas por meio de question\u00e1rios estruturados articulados em fases, ciclos, rodadas ou rounds-20, visando obter um m\u00e1ximo de consenso de um grupo de especialistas sobre um determinado tema, quando a unanimidade de opini\u00e3o n\u00e3o existe em virtude da falta de evid\u00eancias cient\u00edficas ou quando h\u00e1 informa\u00e7\u00f5es contradit\u00f3rias,21-23.A t\u00e9cnica Delphi tem seu nome derivado do Or\u00e1culo de Delfos, lugar procurado pelos gregos antigos para obten\u00e7\u00e3o de conselhos e respostas sobre o futuro,6,21,23.Os especialistas foram selecionados pelos pesquisadores com base no conhecimento e experi\u00eancia sobre o tema pesquisado e foram convidados a fornecer opini\u00f5es sobre este assunto espec\u00edfico, por meio do preenchimento de um question\u00e1rio avaliativo. Os question\u00e1rios foram preenchidos de forma an\u00f4nima entre o grupo.Os resultados foram analisados pelos pesquisadores entre cada rodada de question\u00e1rios. Foram observadas as tend\u00eancias e as opini\u00f5es dissonantes, bem como suas justificativas, sistematizando-as e compilando-as para, posteriormente, as reenviar ao grupo. Assim, depois de conhecer as opini\u00f5es dos outros membros e a resposta do grupo, os participantes tiveram a oportunidade de refinar, alterar ou defender as suas respostas e enviar novamente aos pesquisadores, para que eles reelaborassem o novo question\u00e1rio a partir dessas novas informa\u00e7\u00f5es. Esse processo foi repetido at\u00e9 se atingir um consensoPara compor a amostra do estudo foi definida a participa\u00e7\u00e3o de pelo menos 30 especialistas peritos no assunto, com especializa\u00e7\u00e3o e experi\u00eancia pr\u00e1tica/cl\u00ednica m\u00ednima de cinco anos em decanula\u00e7\u00e3o de pacientes traqueostomizados e com forma\u00e7\u00f5es distintas ., foram convidados 90 participantes .Como no transcorrer do m\u00e9todo Delphi, espera-se \u00edndice de absten\u00e7\u00e3o de 30 a 50% na primeira rodada e de 20 a 30% na segunda rodadaO convite aos especialistas foi feito por via eletr\u00f4nica, e-mail, mediante carta formal contendo os objetivos, finalidade e desenvolvimento do estudo, etapas, tempo estimado, prazos para devolu\u00e7\u00e3o das respostas aos question\u00e1rios e demais detalhes inerentes ao estudo. Anexo ao e-mail foram enviados o manual explicativo do protocolo e o link para acesso ao question\u00e1rio online avaliativo do protocolo.Todos os itens do protocolo inicial, bem como dos protocolos reformulados de acordo com a sugest\u00e3o dos especialistas e reenviados para aprecia\u00e7\u00e3o, foram avaliados e pontuados por eles de acordo com a escala Likert, em adequado(3), parcialmente adequado(2) ou inadequado(1).As observa\u00e7\u00f5es, coment\u00e1rios e sugest\u00f5es dos especialistas foram registradas em planilha do Excel, relacionadas a cada item avaliado, para posterior an\u00e1lise e modifica\u00e7\u00f5es sugeridas.,12,25, calculado pelo n\u00famero de avaliadores concordantes com o item dividido pelo n\u00famero total de avaliadores. As observa\u00e7\u00f5es e sugest\u00f5es dos especialistas foram registradas em arquivo separado e utilizadas, a cada rodada, para reformula\u00e7\u00e3o e ajuste dos itens do protocolo.A cada rodada foi avaliada a concord\u00e2ncia entre as avalia\u00e7\u00f5es dos especialistas pelo \u00cdndice de Valida\u00e7\u00e3o de Conte\u00fado (IVC),19. Os itens foram mantidos quando o IVC  foi \u2265 80% e revisados quando havia sugest\u00f5es para reformula\u00e7\u00e3o. Foram exclu\u00eddos quando IVC foi \u2264 80%. Ap\u00f3s os ajustes sugeridos pelos especialistas, o protocolo era reenviado para nova aprecia\u00e7\u00e3o dos especialistas. O processo foi interrompido quando o percentual de concord\u00e2ncia foi obtido com rela\u00e7\u00e3o a todos os itens do protocolo.O percentual de concord\u00e2ncia adotado a cada rodada para sele\u00e7\u00e3o das vari\u00e1veis consideradas pertinentes ao protocolo, escolhido de acordo com as indica\u00e7\u00f5es da literatura, foi valor maior ou igual a 80%Os participantes foram caracterizados em rela\u00e7\u00e3o \u00e0 profiss\u00e3o/ocupa\u00e7\u00e3o e \u00e0s caracter\u00edsticas sociodemogr\u00e1ficas, como idade, sexo, profiss\u00e3o, tempo de conclus\u00e3o do curso de gradua\u00e7\u00e3o, p\u00f3s-gradua\u00e7\u00e3o e tempo de experi\u00eancia com pacientes traqueostomizados. Para tal, realizou-se an\u00e1lise descritiva por meio de frequ\u00eancia absoluta e relativa das vari\u00e1veis.Para a valida\u00e7\u00e3o de conte\u00fado do protocolo, foram necess\u00e1rias tr\u00eas rodadas at\u00e9 que a concord\u00e2ncia dos especialistas participantes sobre todos os itens do protocolo atingisse o percentual estabelecido de 80% .Na primeira rodada, o question\u00e1rio foi respondido por 39 dos 90 especialistas convidados, sendo 19 fonoaudi\u00f3logos, 11 m\u00e9dicos e 09 fisioterapeutas, portanto, com \u00edndice de absten\u00e7\u00e3o de 57% entre o convite e a participa\u00e7\u00e3o na primeira rodada da t\u00e9cnica. Nas rodadas seguintes, o \u00edndice de absten\u00e7\u00e3o observado foi de 26% na segunda rodada  e 17% na terceira e \u00faltima rodada .Nas tr\u00eas rodadas de avalia\u00e7\u00e3o realizadas nesse estudo, participaram profissionais de 28 a 52 anos, com m\u00e9dia de idade de 40 anos (dp=6). A maior parte do grupo de especialistas participantes foi de fonoaudi\u00f3logos tanto na primeira rodada (49%) quanto na segunda (48%) e na terceira (46%), seguida dos m\u00e9dicos (28%) e dos fisioterapeutas (23%) na primeira rodada. Na segunda e terceira rodadas, as respostas foram enviadas por fonoaudi\u00f3logos , seguidos pelos fisioterapeutas  e m\u00e9dicos (25%) .Com rela\u00e7\u00e3o aos dados profissionais, a maioria dos participantes tem mais de 11 anos de formado (75%) e todos (100%) possuem Especializa\u00e7\u00e3o na \u00e1rea de atua\u00e7\u00e3o. Na primeira rodada, a propor\u00e7\u00e3o entre os que possuem mestrado (67%) e doutorado (62%) s\u00e3o semelhantes, se diferenciando dos resultados dos que possuem p\u00f3s-doutorado (28%). Na terceira e \u00faltima rodada, com rela\u00e7\u00e3o ao n\u00famero de profissionais que possuem mestrado (29%) e doutorado (75%), foi observada uma diferen\u00e7a importante. O tempo de experi\u00eancia com pacientes traqueostomizados predominante entre os especialistas participantes foi entre 11 a 20 anos .Ap\u00f3s esta rodada, todos os itens tiveram \u00edndice de concord\u00e2ncia \u2265 80% finalizando, ent\u00e3o, a t\u00e9cnica Delphi, sendo o protocolo considerado validado, no que se refere ao seu conte\u00fado. Os itens do protocolo avaliados pelos especialistas encontram-se descritos abaixo .Os itens foram mantidos tal como estavam quando o IVC  foi \u2265 80% e n\u00e3o havia sugest\u00f5es de modifica\u00e7\u00e3o por nenhum dos especialistas, caso contr\u00e1rio, foram reformulados e reenviados para avalia\u00e7\u00e3o na pr\u00f3xima rodada. De acordo com as sugest\u00f5es e coment\u00e1rios dos peritos, dois itens foram mantidos como estavam no protocolo inicial, sete foram reformulados, seis inclu\u00eddos e dois exclu\u00eddos. O protocolo final, ap\u00f3s a terceira rodada, pode ser consultado no De acordo com as sugest\u00f5es e coment\u00e1rios dos peritos, os itens capacidade para remover secre\u00e7\u00f5es deglutindo ou cuspindo e presen\u00e7a de degluti\u00e7\u00e3o espont\u00e2nea de saliva foram mantidos como estavam no protocolo inicial.Os sete itens reformulados s\u00e3o apresentados a seguir, acompanhados dos principais coment\u00e1rios/sugest\u00f5es dos especialistas: dados de identifica\u00e7\u00e3o , aus\u00eancia de secre\u00e7\u00f5es abundantes , tosse (nem todos os servi\u00e7os disp\u00f5em do medidor de fluxo de tosse), n\u00edvel de consci\u00eancia , aus\u00eancia de infec\u00e7\u00e3o ativa ; oclus\u00e3o da c\u00e2nula e avalia\u00e7\u00e3o da aptid\u00e3o para decanula\u00e7\u00e3o.Os seis itens inclu\u00eddos foram dados complementares, caracter\u00edsticas da secre\u00e7\u00e3o, tolera o balonete desinsuflado, troca de c\u00e2nula por menor calibre, uso de v\u00e1lvula de fala e exames objetivos realizados.Foi sugerida a exclus\u00e3o dos itens teste Blue Dye e dieta por via oral liberada. No que se refere ao teste Blue Dye, foi sugerida a exclus\u00e3o, considerando-se que o teste pode ser falso negativo em at\u00e9 50% dos casos, n\u00e3o sendo um par\u00e2metro confi\u00e1vel para ser considerado, al\u00e9m de ser a avalia\u00e7\u00e3o cl\u00ednica fonoaudiol\u00f3gica considerada suprema em rela\u00e7\u00e3o ao teste. Com rela\u00e7\u00e3o ao item dieta por VO liberada, as principais observa\u00e7\u00f5es dos especialistas foram que nem sempre a possibilidade de decanula\u00e7\u00e3o do paciente ser\u00e1 relacionada \u00e0 condi\u00e7\u00e3o de receber dieta por via oral (VO), pois \u00e9 um par\u00e2metro que analisado sozinho n\u00e3o indica crit\u00e9rios e riscos para decanula\u00e7\u00e3o de traqueostomia, portanto, n\u00e3o h\u00e1 rela\u00e7\u00e3o e depend\u00eancia direta da possibilidade de libera\u00e7\u00e3o de dieta por VO com a decanula\u00e7\u00e3o. Al\u00e9m disto, pacientes disf\u00e1gicos, com impossibilidade de libera\u00e7\u00e3o de dieta por VO podem ter uma via a\u00e9rea p\u00e9rvia e capacidade de prote\u00e7\u00e3o de vias a\u00e9reas inferiores que permita a decanula\u00e7\u00e3o.O protocolo final, ap\u00f3s a terceira rodada, pode ser consultado no Por fim, de acordo com observa\u00e7\u00e3o comparativa entre os conte\u00fados dos protocolos inicial e final, observamos que as principais modifica\u00e7\u00f5es realizadas, de acordo com a avalia\u00e7\u00e3o e observa\u00e7\u00f5es dos especialistas foram: entre a primeira e a segunda rodadas, a inclus\u00e3o dos itens protocolo interdisciplinar; doen\u00e7as respirat\u00f3rias e disfagia pregressas; motivo da realiza\u00e7\u00e3o da TQT e intercorr\u00eancias; di\u00e2metro da c\u00e2nula de traqueostomia e aus\u00eancia ou presen\u00e7a de Cuff, caracter\u00edsticas de viscosidade e aspecto da secre\u00e7\u00e3o, uso de v\u00e1lvula de fona\u00e7\u00e3o e toler\u00e2ncia ao balonete desinsuflado e a modifica\u00e7\u00e3o/reformula\u00e7\u00e3o dos itens aus\u00eancia de secre\u00e7\u00f5es abundantes e tosse.As mudan\u00e7as observadas entre a segunda e a terceira rodadas foram relacionadas \u00e0 quantidade e aspecto da secre\u00e7\u00e3o aspirada e avalia\u00e7\u00e3o da tosse.Ap\u00f3s as tr\u00eas rodadas com as sugest\u00f5es dos especialistas, os itens que permaneceram na vers\u00e3o final do protocolo foram: identifica\u00e7\u00e3o, aus\u00eancia de secre\u00e7\u00f5es abundantes, caracter\u00edsticas da secre\u00e7\u00e3o, tosse eficaz, capacidade para remover secre\u00e7\u00f5es, tolera o balonete desinsuflado, crit\u00e9rios: aptid\u00e3o ao processo de decanula\u00e7\u00e3o, n\u00edvel de consci\u00eancia (ECG), troca de c\u00e2nula para menor calibre, aus\u00eancia de infec\u00e7\u00e3o vigente/ ativa, degluti\u00e7\u00e3o espont\u00e2nea e eficaz de saliva, uso de v\u00e1lvula de fala (VF), crit\u00e9rios: aptid\u00e3o \u00e0 oclus\u00e3o da c\u00e2nula, avalia\u00e7\u00e3o da aptid\u00e3o para decanula\u00e7\u00e3o, exames objetivos ..As tr\u00eas categorias profissionais participantes s\u00e3o especialidades intimamente envolvidas no processo de decanula\u00e7\u00e3o e cujas decis\u00f5es s\u00e3o determinantes da condu\u00e7\u00e3o e do desfecho de todo o processo, o que possibilitou a constru\u00e7\u00e3o mais confi\u00e1vel e sem a ocorr\u00eancia de domin\u00e2ncia individual do instrumento de avalia\u00e7\u00e3o proposto nesse estudo.A falta de protocolo validado de decanula\u00e7\u00e3o em servi\u00e7os hospitalares pode ocasionar complica\u00e7\u00f5es cl\u00ednicas e respirat\u00f3rias, como decanula\u00e7\u00e3o prematura, insufici\u00eancia respirat\u00f3ria, ac\u00famulo de secre\u00e7\u00f5es em recessos far\u00edngeos com aumento de risco de broncoaspira\u00e7\u00e3o, comprometimento do mecanismo de prote\u00e7\u00e3o das vias a\u00e9reas inferiores, estridor em vias a\u00e9reas inferiores, sepses, aumento do estoma e altera\u00e7\u00f5es de mucosa-26.A valida\u00e7\u00e3o de protocolos em sa\u00fade se constitui em tarefa importante quando se pretende possibilitar seguran\u00e7a, evid\u00eancias e qualidade \u00e0s a\u00e7\u00f5es relacionadas \u00e0 assist\u00eancia ao paciente, especialmente no contexto hospitalar, no sentido de promover a\u00e7\u00f5es seguras, eficazes e eficientes-9. Com base nas respostas das t\u00e9cnicas Delphi, s\u00e3o elaboradas diretrizes que atuam como uma base importante para a realiza\u00e7\u00e3o e avalia\u00e7\u00e3o de estudos ou publica\u00e7\u00f5es,9.A t\u00e9cnica Delphi \u00e9 utilizada com o objetivo de gerar uma amostragem da opini\u00e3o de especialistas, evitando a domin\u00e2ncia por indiv\u00edduos particularmente assertivos. Assim, tem sido considerada como uma forma adequada de extrair dados \u00fateis de experi\u00eancias pessoais que podem ser transformadas em dados emp\u00edricos para estudos futuros. A maioria dos especialistas concorda que quanto mais alto na hierarquia estiver posicionado o desenho do estudo, mais rigorosa ser\u00e1 a metodologia.As evid\u00eancias de relat\u00f3rios ou opini\u00f5es de comit\u00eas de especialistas e / ou experi\u00eancia cl\u00ednica de autoridades respeitadas se enquadram no N\u00edvel IV da pir\u00e2mide de evid\u00eancias.Os especialistas participantes do estudo apresentaram satisfat\u00f3rio perfil de experi\u00eancia cl\u00ednica na \u00e1rea, com muitos anos de experi\u00eancia com pacientes traqueostomizados, o que corrobora a literatura, que preconiza que os peritos participantes dever\u00e3o apresentar afinidade com a proposi\u00e7\u00e3o que se busca validar, portanto, devem possuir produ\u00e7\u00e3o acad\u00eamica, cient\u00edfica e/ou experi\u00eancia profissional na \u00e1rea em que se fundamenta o estudo de maneira que o configure como um peritoexpertise de acordo com a quest\u00e3o a ser analisada, devendo tomar por base a qualidade de sua contribui\u00e7\u00e3o,23. A expertise est\u00e1 relacionada a um continuum, que inclui expertise subjetiva e expertise objetiva, ambas relacionadas \u00e0 forma\u00e7\u00e3o acad\u00eamica e \u00e0 experi\u00eancia relacionada ao tema pesquisado. Desta forma, os especialistas devem ser escolhidos pela sua experi\u00eancia e credibilidade no assunto,26, sendo sugerido um tamanho de amostra de no m\u00ednimo 10 (um tamanho menor n\u00e3o gera ideias suficientes) e de no m\u00e1ximo 50 participantes  especialistas peritos no assunto, com diferentes forma\u00e7\u00f5es, para ampliar o racioc\u00ednio cl\u00ednico em torno do assunto investigado-28.Com rela\u00e7\u00e3o \u00e0 forma\u00e7\u00e3o dos especialistas, todos possu\u00edam p\u00f3s-gradua\u00e7\u00e3o em n\u00edvel de especializa\u00e7\u00e3o, uma amostra numericamente expressiva possu\u00eda mestrado e doutorado. A literatura refere que, para se obter uma avalia\u00e7\u00e3o com boa qualidade, \u00e9 recomendado selecionar um painel de especialistas qualificados no tema, com caracter\u00edsticas de forma\u00e7\u00e3o acad\u00eamica e ,24,27,29.No presente estudo, apesar da proposta inicial ter a perspectiva de contar com a participa\u00e7\u00e3o de um m\u00ednimo de 30 especialistas, observou-se um n\u00famero final de 24 participantes na terceira rodada com bom \u00edndice de valida\u00e7\u00e3o do conte\u00fado. Ademais, apesar do n\u00famero final de especialistas ter sido menor do que o esperado, constata-se que este n\u00famero se encontra dentro do sugerido na literatura como adequado para manter a qualidade da T\u00e9cnica Delphi no consenso de opini\u00f5esAs absten\u00e7\u00f5es n\u00e3o alteraram a qualidade do processo de valida\u00e7\u00e3o do conte\u00fado do protocolo de decanula\u00e7\u00e3o. Considera-se que a falta homogeneidade das categorias profissionais em todas as rodadas pode ter sido uma fragilidade relacionada ao estudo, j\u00e1 que se pretende um protocolo multiprofissional.Por outro lado, a an\u00e1lise do perfil dos profissionais demonstrou que os participantes t\u00eam forma\u00e7\u00e3o e tempo de experi\u00eancia adequados na \u00e1rea de decanula\u00e7\u00e3o de pacientes traqueostomizados, o que possibilita an\u00e1lises, observa\u00e7\u00f5es e sugest\u00f5es adequadas e pertinentes ao tema.Blue Dye e dieta por via oral liberada. Tais altera\u00e7\u00f5es culminaram na vers\u00e3o 2, que, por sua vez, teve como principais sugest\u00f5es de modifica\u00e7\u00e3o os itens aspectos detalhados das secre\u00e7\u00f5es, uso de v\u00e1lvula de fala, exames objetivos realizados e crit\u00e9rios de aptid\u00e3o \u00e0 decanula\u00e7\u00e3o. As modifica\u00e7\u00f5es decorrentes desta segunda rodada, culminaram na vers\u00e3o 3 do protocolo, que pode ser consultada no Assim, de acordo com as observa\u00e7\u00f5es e sugest\u00f5es dos especialistas, as principais altera\u00e7\u00f5es ocorridas na vers\u00e3o 1 do protocolo se referem aos itens dados complementares , quantifica\u00e7\u00e3o e identifica\u00e7\u00e3o das caracter\u00edsticas das secre\u00e7\u00f5es, toler\u00e2ncia \u00e0 defla\u00e7\u00e3o do balonete, uso de v\u00e1lvula de fala, padroniza\u00e7\u00e3o do recurso para oclus\u00e3o da c\u00e2nula e retirada dos itens teste Com rela\u00e7\u00e3o ao item dieta por VO liberada um percentual importante de especialistas m\u00e9dicos, fisioterapeutas e fonoaudi\u00f3logos, questionou a rela\u00e7\u00e3o direta entre a habilidade do paciente para a libera\u00e7\u00e3o e ingesta de dieta por via oral e a aptid\u00e3o para a decanula\u00e7\u00e3o. N\u00e3o foram encontrados estudos que abordaram a rela\u00e7\u00e3o entre decanula\u00e7\u00e3o e a libera\u00e7\u00e3o da dieta por VO.Dentre as considera\u00e7\u00f5es dos especialistas, observou-se sugest\u00e3o de exclus\u00e3o ou de desconsidera\u00e7\u00e3o deste item como importante parte do protocolo pelos especialistas, sendo a maior parte destes, fonoaudi\u00f3logos e, considerando-se que \u201co fonoaudi\u00f3logo \u00e9 o profissional legalmente habilitado para realizar a avalia\u00e7\u00e3o, diagn\u00f3stico e tratamento fonoaudiol\u00f3gicos das disfagias orofar\u00edngeas, bem como o gerenciamento destas no rec\u00e9m-nascido, na crian\u00e7a, no adolescente, no adulto e no idoso\u201d , optou-se por excluir este item do protocolo. foi elaborado por meio de levantamento na literatura de dados importantes no processo de decanula\u00e7\u00e3o considerando-se crit\u00e9rios cl\u00ednicos e estat\u00edsticos, sendo substancialmente modificado e adequado, em termos de conte\u00fado, conforme avalia\u00e7\u00e3o dos especialistas. Assim, os autores consideraram o protocolo validado no que se refere ao seu conte\u00fado. Conforme descrito na literatura, a validade de conte\u00fado \u00e9 a determina\u00e7\u00e3o da representatividade de itens que expressam um conte\u00fado, baseada no julgamento de especialistas em uma \u00e1rea espec\u00edfica, determinando se o conte\u00fado de um protocolo explora, de maneira efetiva, os quesitos para a mensura\u00e7\u00e3o de um determinado fen\u00f4meno a ser investigado,2, processo que ocorreu neste estudo de valida\u00e7\u00e3o.O protocolo de decanula\u00e7\u00e3o proposto e avaliado em um estudoApesar das poss\u00edveis limita\u00e7\u00f5es citadas anteriormente, esse estudo \u00e9, no nosso conhecimento, o primeiro a propor a valida\u00e7\u00e3o de protocolo de decanula\u00e7\u00e3o em uma perspectiva multiprofissional. O protocolo final contemplou os itens mais importantes para o processo de decanula\u00e7\u00e3o, favorecendo a identifica\u00e7\u00e3o de caracter\u00edsticas cl\u00ednicas e respirat\u00f3rias e, consequentemente, a tomada de decis\u00f5es acertadas para prevenir complica\u00e7\u00f5es durante esse processo.Etapas futuras de valida\u00e7\u00e3o e de confiabilidade do protocolo devem ocorrer em diferentes servi\u00e7os com aplica\u00e7\u00e3o em pacientes hospitalizados.O presente estudo descreve a valida\u00e7\u00e3o de conte\u00fado de um protocolo multidisciplinar de decanula\u00e7\u00e3o de pacientes adultos traqueostomizados por meio da T\u00e9cnica Delphi e, diante dos resultados encontrados, considera-se que as evid\u00eancias de validade obtidas s\u00e3o satisfat\u00f3rias.As contribui\u00e7\u00f5es dos especialistas permitiram aprimorar o instrumento, sendo validado o conte\u00fado. A pr\u00f3xima etapa de sua valida\u00e7\u00e3o \u00e9 a obten\u00e7\u00e3o de evid\u00eancias de validade em rela\u00e7\u00e3o a estrutura interna, para depois o instrumento ser submetido para obten\u00e7\u00e3o de outros par\u00e2metros de valida\u00e7\u00e3o e confiabilidade, por meio da aplica\u00e7\u00e3o do protocolo com a popula\u00e7\u00e3o alvo."}
+{"text": "In the wake of studies targeting atherosclerotic plaques and searching for quantifiable variables that contribute additional information to therapeutic decision-making, plaque assessment using Shear Wave Elastography (SWE) is emerging as a reproducible and promising alternative. We used a single Logiq S8 device  with an 8.5-11MHz multifrequency linear transducer at 10MHz in longitudinal section. We considered relevant criteria for image acquisition: adequate longitudinal insonation, differentiation of the intima-media complex, delineation of proximal and distal tunica adventitia and the vascular lumen, good visualization of the atherosclerotic plaque, cardiac cycle in ventricular diastole, and absence of incongruous changes. SWE is an emerging and extremely promising method for assessment of carotid plaques that may contribute to therapeutic decision-making based on characteristics related to the atherosclerotic plaque, with inter-device and inter-examiner reproducibility. The Oxford Plaque Study3 it was observed that objectives parameters correlated increased risk of development of stroke in relation to the area of the atherosclerotic plaque, presence of \u201cdiscrete white areas\u201d (DWAs), and grayscale median (GSM) values less than 30, with up to 70% stroke risk at 5 years when all three factors were present.10Using data from the North American Symptomatic Carotid Endarterectomy Trial (NASCET),11 Ultrasonography incorporating shear wave elastography (SWE) is a recent technique in which a powerful acoustic wave is emitted by an ultrasound probe, inducing a perpendicular wave after hitting the target tissue  and the Brazilian Society of Angiology and Vascular Surgery (Sociedade Brasileira de Angiologia e de Cirurgia Vascular \u2013 SBACV), using a single Logiq S8  ultrasound machine with an 8.5-11 MHz multifrequency linear transducer at 10 MHz in longitudinal section.Dual mode (displaying two images) was used for all assessments so that the examiner had the B-mode image available on the left, to maintain insonation steady over the area of interest, with the elastography processing image on the right. The area selected for elastography processing had to include the anterior and posterior tunica adventitia and the vascular lumen, with the objective of specifying adequate frames that show hardness tending to zero in the arterial lumen (blood) and satisfactorily delimiting the vascular wall .The number of foci, focal distance, time gain compensation (TGC), and gain were not standardized for B mode, color mode, or Doppler mode when performing elastography. It should be considered that the method is independent of B-mode gain, unlike GSM assessment, which requires standardized gain to analyze pixels. For elastography, the priority is to obtain images that maximize the morphological aspects of the atherosclerotic plaque.It is also important to point out that use of elastography is still limited to equipment with high processing power that has the dedicated software onboard. This differentiates it from GSM, which can be effectively performed using any ultrasound machine, but must be analyzed after post-processing.We chose to acquire images for a minimum of 10 seconds, because of the considerable drop in frame rate (expressed in FPS) when elastography is performed, since it puts a high demand on the machine\u2019s processing power, and also because of vascular mobility, which was a determinant factor in the technical difficulty of performing the examination in the carotid region. The number of frames acquired before a satisfactory image is achieved is still subjective and may be broadly determined by the processing power of the equipment being used. It is expected that the number of frames in a given interval of time will be proportional to the machine\u2019s processing power and there will possibly be minor implications secondary to the cardiac cycle.With relation to the cardiac and vascular cycles, we acquired images in consonance with ventricular diastole , which aArterial systole (or ventricular diastole) can be observed indirectly by the reduction of arterial diameter on B-mode , with no need for an electrocardiogram to be fitted during the examination. According to Young\u2019s modulus, during the passage of the pulse wave, deformation of the vascular wall is maximal and directly proportional to the force exerted on it by the blood column.We assess the region of interest within the atherosclerotic plaque, excluding the posterior tunica adventitia by measuring within a circular area, obtaining a result in kilopascals (kPa), the international unit of pressure, from a single frame, as long as it meets a series of adequacy criteria . The imaThis study does not present any data that could identify patients, comprising a technical description and a review of the literature. However, the methodology described was part of a pilot study, the protocol for which was approved by the Ethics Committee at our institution, with Ethics Appraisal Submission Certificate number 36750720.4.0000.5411, emitted by the Research Ethics Committee at the Universidade Estadual Paulista, Faculdade de Medicina de Botucatu (UNESP-FMB), consolidated opinion number 4.296.479.19 Logiq E9 20 e Aplio 500 .22 These machines\u2019 high processing power is needed to obtain a high FPS while performing the technique and to obtain images quickly, between two pulse waves, avoiding artifacts caused by movement of the vascular tissue. In addition to the technical difficulty of obtaining images free from artifacts caused by movement of tissues, use of suboptimal equipment for the examination can result in elevated subjectivity of image acquisition.Elastography is not yet an accessible method, especially not in developing countries, to a great extent because of the costs involved in performing the technique, usually employing high end equipment that is very often limited to research centers. The models employed most recently include the Supersonic Aiexplorer ,22 In 2020, Marlevi et al.13 performed a study comparing SWE and magnetic resonance imaging (MRI), findings that results differed between cross-sectional and longitudinal images. Considering the circular region of interest and the greater exposure of the atherosclerotic plaque, the longitudinal plane appears preferable for these measurements.To date, the majority of in vivo studies have performed measurements related to the characteristics of atherosclerotic plaques in longitudinal section.13 and was more sensitive but less specific than CT.15 With regard to the comparison between SWE and GSM, the former offers the possible advantage of being less dependent on B-mode standardization to obtain the value measured, improving inter-examiner and inter-apparatus reproducibility,23 although the GSM measure does allow for grayscale standardization with image post-processing. Ramnarine et al.22 conducted a study with 54 atherosclerotic plaques, observing that SWE achieved a better predictive value than GSM for identification of symptomatic plaques.22When compared with other imaging methods such as MRI and computed tomography (CT), SWE was able to identify vulnerable plaques, validated by MRI,20 It also offers a statistically significant correlation for identification of symptomatic and vulnerable plaques.22 Since this is a novel and emerging method, its adoption is still restricted to research centers and the methodology still needs to be standardized.To date, SWE has demonstrated good reproducibility for the carotid region.Shear wave elastography is an emerging method with promise in the context of assessment of carotid plaques and in the future, it may contribute to therapeutic decision making based on characteristics related to the atherosclerotic plaque, with inter-device and inter-examiner reproducibility. As more studies are conducted, it is possible that relevant prognostic factors can be extracted from plaque stiffness assessments, particularly considering that plaques with a lipid core and intra-plaque hemorrhages increase the likelihood of thrombotic events and these have much lower stiffness than calcium or fibrosis. However, standardized methodology for performing elastography of carotid plaques has not yet been defined, which has contributed to difficulties with adoption of the method.Cutting-edge vascular ultrasonography equipment is needed to conduct examinations free from major examiner subjectivity, because of the considerable reduction in FPS related to the examination\u2019s high processing demands and the artifacts related to the pulse wave.With constant technological and scientific development, it is possible that elastography during carotid plaque echography will become common, considering that it only takes a few seconds and that the machine itself can calculate the stiffness of the atherosclerotic plaque in a quantitative manner without the need for analysis after post-processing, which is an important limitation of other methods of plaque assessment, such as GSM. 1 e estudos randomizados em grandes popula\u00e7\u00f5es de pacientes sintom\u00e1ticos4 e assintom\u00e1ticos6 . Conclus\u00f5es acerca da melhor terap\u00eautica para esses pacientes foram propostas com n\u00edvel de evid\u00eancia satisfat\u00f3rio, com fluxogramas terap\u00eauticos bem definidos pelos consensos da European Society for Vascular Surgery (ESVS)7 e da Society for Vascular Surgery (SVS)8 ; entretanto, a an\u00e1lise objetiva da placa ateroscler\u00f3tica para tomada de decis\u00e3o ainda \u00e9, em grande parte, restrita ao grau de estenose apresentado.O acidente vascular cerebral (AVC) oriundo da estenose carot\u00eddea de origem extracraniana foi um assunto extensamente estudado durante as \u00faltimas d\u00e9cadas, com correla\u00e7\u00f5es causais bem definidas9 , ulcera\u00e7\u00f5es foram observadas em at\u00e9 58,1% das placas carot\u00eddeas sintom\u00e1ticas, e hemorragias e inflama\u00e7\u00f5es estiveram presentes em at\u00e9 64,6% e 66,8% dos casos, respectivamente.Postula-se que o risco do AVC tamb\u00e9m esteja intimamente relacionado a caracter\u00edsticas morfol\u00f3gicas da placa ateroscler\u00f3tica. No trabalho desenvolvido pelo Oxford Plaque Study3 , observaram-se par\u00e2metros objetivos correlacionados a risco aumentado de desenvolvimento do AVC em rela\u00e7\u00e3o \u00e0 \u00e1rea da placa ateroscler\u00f3tica, presen\u00e7a de \u201c\u00e1reas brancas discretas\u201d  e valores de mediana de escala de cinza  inferiores a 30, com riscos de AVC em 5 anos chegando a at\u00e9 70% na presen\u00e7a dos tr\u00eas fatores10 .Utilizando dados oriundos do grupo North American Symptomatic Carotid Endarterectomy Trial (NASCET)11 . A ultrassonografia associada a elastografia por cisalhamento  \u00e9 uma t\u00e9cnica recente, em que uma onda ac\u00fastica potente \u00e9 emitida pela sonda ecogr\u00e1fica, induzindo uma onda perpendicular ap\u00f3s chocar-se com o tecido objetivado  e pela Sociedade Brasileira de Angiologia e de Cirurgia Vascular (SBACV), utilizando um \u00fanico aparelho Logiq S8 com um transdutor linear multifrequencial 8,5-11 MHz em 10 MHz em corte longitudinal.O modo dual (apresenta\u00e7\u00e3o da imagem em duas janelas) foi utilizado para todas as avalia\u00e7\u00f5es, de modo que o examinador obtivesse acesso \u00e0 imagem em modo B para manuten\u00e7\u00e3o de insona\u00e7\u00e3o regular sobre a \u00e1rea de interesse \u00e0 esquerda e o processamento da elastografia \u00e0 direita. A \u00e1rea de processamento da elastografia deve englobar a t\u00fanica advent\u00edcia anteriormente e posteriormente, al\u00e9m do l\u00famen vascular, com o objetivo de caracterizar quadros adequados que demonstrem uma dureza que tende a zero no l\u00famen arterial (sangue) e delimite a parede vascular satisfatoriamente .time gain compensation (TGC) e o ganho dos modos B, colorido ou Doppler n\u00e3o foram padronizados para a realiza\u00e7\u00e3o da elastografia. Deve-se considerar a independ\u00eancia do m\u00e9todo em rela\u00e7\u00e3o ao ganho do modo B, diferentemente da avalia\u00e7\u00e3o de GSM, que necessita de uma padroniza\u00e7\u00e3o de ganho para a avalia\u00e7\u00e3o de pixels. Dessa forma, deve-se priorizar a obten\u00e7\u00e3o de imagens que maximizem os aspectos morfol\u00f3gicos da placa ateroscler\u00f3tica.O n\u00famero de focos, a dist\u00e2ncia focal, a software pr\u00f3prio, presente na m\u00e1quina. Essa \u00e9 uma especifica\u00e7\u00e3o que difere da avalia\u00e7\u00e3o da GSM, que pode ser realizada de forma eficaz em qualquer aparelho, mas que depende de uma avalia\u00e7\u00e3o a partir de p\u00f3s-processamento.\u00c9 importante salientar que a elastografia ainda \u00e9 um m\u00e9todo restrito para uso em aparelhos com alto poder de processamento e que contem com frame rate (quadros por segundo [FPS]) durante a realiza\u00e7\u00e3o da elastografia, que recruta um expressivo poder de processamento do aparelho, al\u00e9m da mobilidade vascular, que foi fator determinante para a dificuldade t\u00e9cnica do exame no territ\u00f3rio. A quantidade de quadros obtidos at\u00e9 aquisi\u00e7\u00e3o de uma imagem satisfat\u00f3ria ainda \u00e9 subjetiva e pode ser largamente determinada pelo poder de processamento do aparelho em quest\u00e3o. Espera-se uma quantidade de quadros em um intervalo de tempo proporcional ao processamento do aparelho, possivelmente com menores implica\u00e7\u00f5es secund\u00e1rias ao ciclo card\u00edaco.Optamos pela aquisi\u00e7\u00e3o de imagens por um per\u00edodo m\u00ednimo de 10 segundos, considerando a queda expressiva do stress) e \u03b5 representa a deforma\u00e7\u00e3o axial do s\u00f3lido (strain), que, simplificadamente, aponta para um aumento da dureza da parede arterial durante a passagem da onda de pulso , sem a necessidade de eletrocardiograma acoplado ao exame. De acordo com o m\u00f3dulo de Young, durante a passagem da onda de pulso, a deforma\u00e7\u00e3o da parede vascular \u00e9 m\u00e1xima e diretamente proporcional \u00e0 for\u00e7a imprimida sobre ela pela coluna de sangue.A observa\u00e7\u00e3o da s\u00edstole arterial (ou di\u00e1stole ventricular) pode ser feita de forma indireta pela redu\u00e7\u00e3o do di\u00e2metro arterial ao modo B , unidade internacional de tens\u00e3o, a partir de quadro \u00fanico, desde que preenchida uma s\u00e9rie de crit\u00e9rios para adequa\u00e7\u00e3o . A imageO presente estudo n\u00e3o apresenta dados que identifiquem pacientes, com representa\u00e7\u00e3o t\u00e9cnica e revis\u00e3o de literatura. Entretanto, a metodologia exposta faz parte de estudo-piloto, cujo protocolo foi aprovado pelo Comit\u00ea de \u00c9tica de nossa institui\u00e7\u00e3o, com Certificado de Apresenta\u00e7\u00e3o de Aprecia\u00e7\u00e3o \u00c9tica n\u00famero 36750720.4.0000.5411, Comit\u00ea de \u00c9tica em Pesquisa (CEP) da Universidade Estadual Paulista, Faculdade de Medicina de Botucatu (UNESP-FMB), sob o registro de parecer consubstanciado 4.296.479.19 , Logiq E9 20 e Aplio 500 22 . O elevado poder de processamento desses aparelhos \u00e9 relevante para a obten\u00e7\u00e3o de FPS elevados durante a realiza\u00e7\u00e3o da t\u00e9cnica e para a obten\u00e7\u00e3o de imagens de forma \u00e1gil entre duas ondas de pulso, evitando artefatos causados pela mobiliza\u00e7\u00e3o do tecido vascular. Al\u00e9m da dificuldade t\u00e9cnica para obter imagens livres de artefato causado por mobiliza\u00e7\u00e3o tecidual, o uso de aparelhos n\u00e3o otimizados para o exame pode levar a uma elevada subjetividade na obten\u00e7\u00e3o das imagens.A elastografia ainda \u00e9 um m\u00e9todo pouco acess\u00edvel, especialmente em pa\u00edses em desenvolvimento, em grande parte devido ao custo empregado na realiza\u00e7\u00e3o da t\u00e9cnica, usualmente em aparelhos top de linha muitas vezes restritos a centros de pesquisa. Entre os aparelhos mais recorrentemente utilizados, encontramos Supersonic Aiexplorer in vivo realizou a medida das caracter\u00edsticas relativas \u00e0 placa ateroscler\u00f3tica em cortes longitudinais22 . Em 2020, Marlevi et al.13 , em estudo comparativo entre SWE e resson\u00e2ncia magn\u00e9tica (RNM), identificaram achados que diferiram entre imagens em plano transverso e longitudinal. Considerando o delineamento circular da \u00e1rea de aferi\u00e7\u00e3o e a maior exposi\u00e7\u00e3o da placa ateroscler\u00f3tica, o plano longitudinal parece ser prefer\u00edvel para a medida.At\u00e9 o momento, a maior parte estudos 13 , sendo mais sens\u00edvel e menos espec\u00edfica do que a TC15 . Quanto \u00e0 compara\u00e7\u00e3o entre SWE e GSM, a primeira apresenta a poss\u00edvel vantagem de depender menos de padroniza\u00e7\u00e3o do modo B para se obter o valor medido, o que torna a avalia\u00e7\u00e3o entre examinadores e aparelhos mais reprodut\u00edvel23 , embora a medida de GSM permita a padroniza\u00e7\u00e3o da escala de cinza no p\u00f3s-processamento de imagem. Em estudo com 54 placas ateroscler\u00f3ticas, Ramnarine et al.22 observaram que a SWE apresentou um valor preditivo superior \u00e0 GSM na identifica\u00e7\u00e3o de placas sintom\u00e1ticas.Quando comparada com outros m\u00e9todos de imagem como RNM e a tomografia computadorizada (TC), a SWE foi capaz de identificar placas vulner\u00e1veis, validadas por RNM20 . Apresenta, ainda, correla\u00e7\u00e3o estatisticamente significativa na identifica\u00e7\u00e3o de placas sintom\u00e1ticas e vulner\u00e1veis22 . Como um m\u00e9todo novo e emergente, a sua difus\u00e3o ainda \u00e9 restrita a centros de pesquisa, e sua metodologia ainda precisa ser padronizada.At\u00e9 o momento, a SWE tem apresentado boa reprodutibilidade no territ\u00f3rio carot\u00eddeoA SWE \u00e9 um m\u00e9todo emergente e promissor no contexto da avalia\u00e7\u00e3o de placas carot\u00eddeas, podendo contribuir no futuro para a tomada de decis\u00e3o terap\u00eautica baseada em caracter\u00edsticas relativas \u00e0 placa ateroscler\u00f3tica de forma reprodut\u00edvel entre aparelhos e examinadores. Com o desenvolvimento de mais estudos, \u00e9 poss\u00edvel que fatores progn\u00f3sticos relevantes possam ser extra\u00eddos a partir da avalia\u00e7\u00e3o da rigidez da placa, em especial se considerando que placas de n\u00facleo lip\u00eddico e hemorragias intraplacas aumentam a chance de eventos tromb\u00f3ticos e que estes apresentam uma rigidez muito inferior ao c\u00e1lcio ou fibrose. Uma metodologia padronizada para a realiza\u00e7\u00e3o da elastografia em placas carot\u00eddeas, entretanto, ainda n\u00e3o foi definida, o que contribui para a dificuldade na dissemina\u00e7\u00e3o do m\u00e9todo.Aparelhos de ultrassonografia vascular de ponta ainda s\u00e3o necess\u00e1rios para a realiza\u00e7\u00e3o de um exame livre de maior subjetividade do examinador devido \u00e0 expressiva queda dos FPS relativa \u00e0 alta demanda de processamento do exame e artefatos relativos \u00e0 onda de pulso.Com a constante evolu\u00e7\u00e3o tecnol\u00f3gica e cient\u00edfica, \u00e9 poss\u00edvel que a elastografia se torne uma realidade na avalia\u00e7\u00e3o da ecografia da placa carot\u00eddea, considerando que sua realiza\u00e7\u00e3o leva apenas alguns segundos e que o pr\u00f3prio aparelho utilizado pode calcular a rigidez da placa ateroscler\u00f3tica de forma quantitativa sem a necessidade de avalia\u00e7\u00e3o a partir de p\u00f3s-processamento, o que \u00e9 um limitante importante de outros m\u00e9todos de avalia\u00e7\u00e3o da placa tal qual a GSM."}
+{"text": "O Sistema Nacional de Gerenciamento de Produtos Controlados (SNGPC) armazenadados de dispensa\u00e7\u00e3o de medicamentos industrializados, manipulados e insumosfarmac\u00eauticos sob controle especial e antimicrobianos, a partir dos registros defarm\u00e1cias e drogarias privadas. Este trabalho explorou a qualidade dos dadosinseridos no SNGPC, a partir dos registros de dispensa\u00e7\u00e3o de antibi\u00f3ticosindustrializados, com o objetivo de propor seu emprego em estudos de utiliza\u00e7\u00e3ode medicamentos (DUR). A pesquisa foi desenvolvida por meio de desenhodescritivo e retrospectivo, examinando o conjunto dados brutos do sistema, parao per\u00edodo de janeiro de 2014 a dezembro de 2020. Um total de 475.805.207registros de dispensa\u00e7\u00e3o de medicamentos foi coletado. Os antibi\u00f3ticoscorresponderam em m\u00e9dia a 54,5% do total de registros. A dimens\u00e3o de qualidade\u201cn\u00e3o informado\u201d foi identificada, sistematicamente, nas vari\u00e1veis \u201cprinc\u00edpioativo\u201d, \u201csexo\u201d, \u201cidade\u201d e \u201cCID-10\u201d. As quantidades de frascos e caixas variaramde 1 a 536 unidades, e as quantidades de formas farmac\u00eauticas dispensadas de 1 a7.500 unidades. Os resultados mostram que 25% dos registros extrapolam umaterapia individual e que o sistema n\u00e3o apresenta um mecanismo de cr\u00edtica paraevitar dispensa\u00e7\u00f5es n\u00e3o conformes ao padr\u00e3o terap\u00eautico para a classe. Apesardas vulnerabilidades decorrentes da qualidade dos dados, que podem sersuperadas, o SNGPC possibilita construir diferentes planos anal\u00edticos,envolvendo tempo e outras agrega\u00e7\u00f5es, na investiga\u00e7\u00e3o de uso comunit\u00e1rio deantimicrobianos e medicamentos sob controle especial, o que faz dele uma potentefonte de dados para DUR.  De modo sistem\u00e1tico,empregam um conjunto de m\u00e9todos descritivos e anal\u00edticos para a quantifica\u00e7\u00e3o,compreens\u00e3o e avalia\u00e7\u00e3o dos processos de prescri\u00e7\u00e3o, dispensa\u00e7\u00e3o e consumo demedicamentos Os estudos de utiliza\u00e7\u00e3o de medicamentos  dediferentes fontes De modo geral, esses dados podem ser coletados a partir de bancos interligados ou n\u00e3oa determinado sistema de informa\u00e7\u00e3o Especificamente na \u00e1rea de medicamentos, um estudo identificou 125 fontes de dados emnove pa\u00edses da Am\u00e9rica Latina. Destas, somente 30% estavam dispon\u00edveis publicamentee de modo apropriado e 71% apresentavam limita\u00e7\u00f5es de acesso. Entre os pa\u00edsesestudados, o Brasil apresentou o maior n\u00famero de fontes para DUR (38), das quaismetade t\u00eam acesso limitado ou dependente de alguma legisla\u00e7\u00e3o e apenas 16% est\u00e3odispon\u00edveis para pesquisadores ,Portaria SVS/MS n\u00ba 344/1998 e suasatualiza\u00e7\u00f5es Resolu\u00e7\u00e3o RDC n\u00ba20/2011 e suas substitui\u00e7\u00f5es ,,,O Sistema Nacional de Gerenciamento de Produtos Controlados (SNGPC), ligado \u00e0 Ag\u00eanciaNacional de Vigil\u00e2ncia Sanit\u00e1ria (Anvisa) e criado em 2007, armazena dados dedispensa\u00e7\u00e3o de medicamentos industrializados, manipulados e insumos farmac\u00eauticossob controle especial a partir dos registros de farm\u00e1cias e drogarias privadas emtodo o territ\u00f3rio nacional Um dos objetivos do SNGPC \u00e9 contribuir para a produ\u00e7\u00e3o de conhecimentos em DUR. Emagosto de 2020, a Anvisa, em cumprimento \u00e0 legisla\u00e7\u00e3o, disponibilizou dados dedispensa\u00e7\u00f5es realizadas a partir de janeiro de 2014 para pesquisa ,,,O Brasil tem sido apontado como o maior consumidor de antibi\u00f3ticos entre os pa\u00edses daAm\u00e9rica Latina e, quando comparado aos demais pa\u00edses do mundo, est\u00e1 entre os cincoprimeiros, sendo correspons\u00e1vel pelo aumento global em 35% na \u00faltima d\u00e9cada Este trabalho explorou a qualidade dos dados inseridos no SNGPC a partir dosregistros de dispensa\u00e7\u00e3o de antimicrobianos industrializados, com o objetivo depropor sua utiliza\u00e7\u00e3o em DUR. A partir dessa explora\u00e7\u00e3o, foi elaborado um banco paraDUR de antibi\u00f3ticos.website da Anvisa comma-separatedvalues) referem-se \u00e0s dispensa\u00e7\u00f5es mensais realizadas no per\u00edodo dejaneiro de 2014 a dezembro de 2020. De modo a exemplificar a utiliza\u00e7\u00e3o do SNGPCpara DUR, selecionaram-se os antibi\u00f3ticos para uso sist\u00eamico  Foi realizado um estudo descritivo, retrospectivo, do conjunto de dados brutosreferentes aos registros de dispensa\u00e7\u00e3o de medicamentos industrializadospresentes no SNGPC. Os dados foram coletados no per\u00edodo de 26 de mar\u00e7o a 1\u00ba deabril de 2021, diretamente do O trabalho foi desenvolvido em tr\u00eas fases, cumprindo um caminho sistem\u00e1tico dedepura\u00e7\u00e3o , sintetizadas na,,,A Fase 1 caracterizou-se pela coleta dos dados brutos, seguida de uma explora\u00e7\u00e3oquanto ao montante de registros e da categoriza\u00e7\u00e3o dos medicamentos dispensados.Foi feita a coleta dos registros, disponibilizados em arquivos mensais, noper\u00edodo de 26 de mar\u00e7o a 1\u00ba de abril de 2021. Nessa fase, n\u00e3o foram eliminadosregistros, de modo que todos os medicamentos registrados foram classificados deacordo com a regulamenta\u00e7\u00e3o sanit\u00e1ria pertencente A Fase 2 dedicou-se a uma primeira sele\u00e7\u00e3o de princ\u00edpios ativos de interesse doestudo: os antibi\u00f3ticos.,,Cada registro no SNGPC corresponde a apenas um produto dispensado, emapresenta\u00e7\u00e3o com um \u00fanico princ\u00edpio ativo ou em associa\u00e7\u00e3o com dois ou mais.Foram geradas frequ\u00eancias simples dos princ\u00edpios ativos dispensados em cada m\u00easde an\u00e1lise, de modo a identificar sua presen\u00e7a no banco. Os antibi\u00f3ticos foramidentificados com aux\u00edlio da legisla\u00e7\u00e3o sanit\u00e1ria vigente \u00e0 \u00e9poca do registro decada dispensa\u00e7\u00e3o O SNGPC permite o registro de um mesmo princ\u00edpio ativo de diferentesnomenclaturas: gen\u00e9rico, comercial, princ\u00edpio ativo ou, ainda, pelo sal/base doprinc\u00edpio ativo. Para garantir a sele\u00e7\u00e3o de todos os antibi\u00f3ticos registrados,foram elaborados dicion\u00e1rios capazes de vincular a informa\u00e7\u00e3o no campo\u201cprinc\u00edpio ativo\u201d, registrado no SNGPC, \u00e0s vari\u00e1veis necess\u00e1rias para a execu\u00e7\u00e3ode DUR.l,,,,Foram produzidos dicion\u00e1rios mensais estruturados, para cada antibi\u00f3tico,incluindo as seguintes vari\u00e1veis-chave em ordem hierarquizada: (1) Denomina\u00e7\u00e3oComum Brasileira (DCB) Uma vez selecionados os antibi\u00f3ticos por princ\u00edpio ativo, procedeu-se \u00e0 Fase 3.Um mesmo antibi\u00f3tico pode ser de uso sist\u00eamico, t\u00f3pico, oftalmol\u00f3gico,otol\u00f3gico. Portanto, sua classifica\u00e7\u00e3o ATC e a atribui\u00e7\u00e3o da dose di\u00e1riadefinida (DDD) de cada antibi\u00f3tico foram feitas considerando a via deadministra\u00e7\u00e3o. Foram extra\u00eddas frequ\u00eancias simples da vari\u00e1vel\u201cdescri\u00e7\u00e3o_apresenta\u00e7\u00e3o\u201d dos antibi\u00f3ticos selecionados (Fase 2) e foi elaboradoum segundo dicion\u00e1rio, que adicionou as informa\u00e7\u00f5es da via de administra\u00e7\u00e3oUma vez realizada essa opera\u00e7\u00e3o, foi implementado o terceiro dicion\u00e1rio (tamb\u00e9mFase 3) com a designa\u00e7\u00e3o da DDD Ao todo, foram elaborados tr\u00eas dicion\u00e1rios, atualizados mensalmente. O primeiroabordou as classifica\u00e7\u00f5es dos antibi\u00f3ticos, o segundo desvinculou as informa\u00e7\u00f5escontidas em um \u00fanico campo (descri\u00e7\u00e3o_apresenta\u00e7\u00e3o) em vari\u00e1veis novas e oterceiro inseriu a DDD do antibi\u00f3tico na via de administra\u00e7\u00e3o dispensada. Foramexclu\u00eddos todos os antibi\u00f3ticos que n\u00e3o pertenciam ao n\u00edvel J01 e todos aquelescom incompletude no campo \u201cdescri\u00e7\u00e3o_apresenta\u00e7\u00e3o\u201d.Todas as classifica\u00e7\u00f5es nas Fases 2 e 3 foram realizadas por dois pesquisadoresde forma independente e as d\u00favidas e discord\u00e2ncias resolvidas por consenso.http://www.r-project.org) ap\u00f3s o t\u00e9rmino da Fase 3 de cada m\u00eas,estruturados com 31 vari\u00e1veis .O banco de dados resultante est\u00e1 depositado no reposit\u00f3rio de dados de pesquisada Funda\u00e7\u00e3o Oswaldo Cruz (Fiocruz) .As estruturas adicionais que fundamentaram os dicion\u00e1rios foram elaboradas nosoftware Excel (https://products.office.com/).As fases de caracteriza\u00e7\u00e3o, limpeza, vincula\u00e7\u00e3o e as an\u00e1lises de verifica\u00e7\u00e3o paraprodu\u00e7\u00e3o de um banco adequado a DUR foram realizadas no software estat\u00edstico R,vers\u00e3o 4.0.2, cujo c\u00f3digo est\u00e1 dispon\u00edvel no Um total de 475.805.207 registros de dispensa\u00e7\u00e3o de medicamentos, por princ\u00edpioativo, foi coletado de janeiro de 2014 a dezembro de 2020. Esses dados foramextra\u00eddos do SNGPC em 84 arquivos mensais ao longo do per\u00edodo.Portaria n\u00ba 344/1998 e atualiza\u00e7\u00f5es) corresponderam em m\u00e9dia a28% do total dos medicamentos registrados no SNGPC a cada ano, enquanto osantimicrobianos (RDC n\u00ba 20/2011 e suas substitui\u00e7\u00f5es)corresponderam ao dobro dos registros de controle especial. Nota-se a presen\u00e7a de16% de registros de medicamentos n\u00e3o inclu\u00eddos nas legisla\u00e7\u00f5es citadas. Houve menosde 1% de dados NI no campo \u201cprinc\u00edpio_ativo\u201d. O menor percentual de registros paraantimicrobianos ocorreu no ano de 2020 , opondo-se ao maior percentual deregistros para medicamentos de controle especial no mesmo ano .A A A dimens\u00e3o de qualidade NI foi identificada, sistematicamente, nas vari\u00e1veis\u201cprinc\u00edpio_ativo\u201d, \u201csexo\u201d, \u201cidade\u201d e \u201cCID-10\u201d. Verificam-se percentuais de at\u00e9 99%dos registros em todos os anos para a vari\u00e1vel CID-10. As vari\u00e1veis \u201csexo\u201d e\u201cidade\u201d, que remetem \u00e0s caracter\u00edsticas demogr\u00e1ficas do usu\u00e1rio, est\u00e3o ausentes emcerca de 23% dos registros e, se considerados somente antibi\u00f3ticos, esse percentualcai para 2%, com maior percentual em 2020 .A vari\u00e1vel \u201cprinc\u00edpio_ativo\u201d foi analisada sob duas dimens\u00f5es de qualidade. Aconformidade com a DCB n\u00e3o ultrapassou 68,8% em todas as fases e em todos os anos,com m\u00e9dia percentual de 52% entre os ATB J01. O percentual de NI somente foiposs\u00edvel mensurar na Fase 1, devido ao processo de depura\u00e7\u00e3o das etapas seguintes,sendo inferior a 0,5% da totalidade de registros.A vari\u00e1vel \u201cdescri\u00e7\u00e3o_apresenta\u00e7\u00e3o\u201d apresentou completude somente ap\u00f3s a Fase 3, comobten\u00e7\u00e3o do grupo ATB J01.As informa\u00e7\u00f5es do prescritor, do tipo de receita e do tipo de unidade de medidaapresentaram completude em todos os registros.outliers cujosvalores podem ser discutidos.A outliers que representam as idades fora do intervalo esperadopara essa vari\u00e1vel (idade > 100 anos ou seu correspondente em meses).A distribui\u00e7\u00e3o de idades \u00e9 composta pelas vari\u00e1veis \u201cidade\u201d  e \u201cunidade_idade\u201d  e \u00e9 mostrada em 3C. Do conjunto de dados, 96,4% foram registrados com idadeem anos, 2% em meses e 1,6% com informa\u00e7\u00e3o ausente. O estreitamento nas caixasrepresenta todas as idades inferiores a 100 anos. Registraram-se idades em meses de0 a 999, com Me = 7 e terceiro quartil = 10. As idades medidas em anos distribuem-sede 0 a 999, com Me = 35 e terceiro quartil = 53. Para ambas as medidas, notam-seO trabalho avaliou a totalidade dos registros do SNGPC - cerca de 475 milh\u00f5es - nomomento de abertura p\u00fablica de seus dados pela Anvisa, quanto \u00e0 nota\u00e7\u00e3o domedicamento registrado, \u00e0 completude de informa\u00e7\u00e3o da apresenta\u00e7\u00e3o, \u00e0 consist\u00eanciado conjunto de registros e aos dados faltantes. O banco relativo \u00e0s notifica\u00e7\u00f5es deantimicrobianos, j\u00e1 verificado quanto \u00e0s caracter\u00edsticas citadas, foi acrescido devari\u00e1veis espec\u00edficas para DUR. N\u00e3o obstante, as falhas de informa\u00e7\u00e3o da DCB e deinforma\u00e7\u00f5es complementares evidenciaram potenciais problemas na vincula\u00e7\u00e3o dos dadosaos sistemas de classifica\u00e7\u00e3o e a outras vari\u00e1veis usadas em DUR.,,Na qualidade de potencial fonte de dados para DUR, o SNGPC oferece vantagens eoportuniza a constru\u00e7\u00e3o de diferentes planos de an\u00e1lises, envolvendo par\u00e2metros comotempo, espa\u00e7o e outras agrega\u00e7\u00f5es. Fontes semelhantes, que agregam registros devenda e dispensa\u00e7\u00e3o de medicamentos, t\u00eam sido frequentemente utilizadas emdiferentes pa\u00edses em sistemas de vigil\u00e2ncia, de acompanhamento de custos em sa\u00fade ede copagamentos ,Os dados registrados nesses bancos n\u00e3o t\u00eam finalidade de pesquisa e, portanto, origor no preenchimento escapa do controle do pesquisador. Por essa raz\u00e3o, uma fasede pr\u00e9-processamento - limpeza, sele\u00e7\u00e3o, vincula\u00e7\u00e3o, ajustes e transforma\u00e7\u00e3o dedados - se faz necess\u00e1ria antes da an\u00e1lise estat\u00edstica desses dados ,,Os campos \u201cprinc\u00edpio_ativo\u201d e \u201cdescri\u00e7\u00e3o_apresenta\u00e7\u00e3o\u201d constituem vari\u00e1veis-chavespara o encadeamento das demais informa\u00e7\u00f5es do sistema e, consequentemente, para osprincipais resultados. Essas vari\u00e1veis refletem exatamente as informa\u00e7\u00f5es domedicamento quando submetidas no ato de solicita\u00e7\u00e3o ou renova\u00e7\u00e3o do registrosanit\u00e1rio Logo, seria esperado encontrar a totalidade de princ\u00edpios ativos descritos segundo aDCB e a completude de informa\u00e7\u00f5es quanto \u00e0 sua descri\u00e7\u00e3o, uma vez que s\u00e3o requisitosobrigat\u00f3rios para efetiva\u00e7\u00e3o do registro sanit\u00e1rio ,A identifica\u00e7\u00e3o de registros de princ\u00edpios ativos n\u00e3o inclu\u00eddos nas legisla\u00e7\u00f5espertinentes ao sistema e a falta de informa\u00e7\u00f5es oportunizam vieses de confundimentosse analisado o montante de registros. Sabe-se que informa\u00e7\u00f5es ausentes podem constarnos registros de bancos secund\u00e1rios e que decorrem de diferentes situa\u00e7\u00f5es A informa\u00e7\u00e3o da vari\u00e1vel \u201cquantidade_vendida\u201d n\u00e3o reflete o quantitativo total deforma farmac\u00eautica b\u00e1sica dispensada - descrita na vari\u00e1vel \u201cdescri\u00e7\u00e3o_apresenta\u00e7\u00e3o\u201d-, indica o volume de embalagens prim\u00e1rias (frascos) ou secund\u00e1rias (caixas). Essamedida foi utilizada em DUR, principalmente nos anteriores ao advento da DDD ,,,Tais constata\u00e7\u00f5es levantam algumas hip\u00f3teses, como erros na entrada de dados ousitua\u00e7\u00f5es que descumprem a legisla\u00e7\u00e3o - repasse de grandes quantidades parahospitais e dispensa\u00e7\u00e3o sem apresenta\u00e7\u00e3o de receita outliersregistrados tanto para idade em meses quanto em anos, que apontam para erros deinforma\u00e7\u00e3o. Essas distor\u00e7\u00f5es podem comprometer estudos futuros com sele\u00e7\u00e3o depopula\u00e7\u00e3o por faixa et\u00e1ria, induzindo vieses de sele\u00e7\u00e3o No que se refere \u00e0s informa\u00e7\u00f5es obrigat\u00f3rias registradas no receitu\u00e1rio - sexo, idadee identifica\u00e7\u00e3o do respons\u00e1vel pela prescri\u00e7\u00e3o -, somente a identifica\u00e7\u00e3o doprofissional prescritor foi completamente atendida em todos os anos. Sexo e idades\u00e3o informa\u00e7\u00f5es de f\u00e1cil capta\u00e7\u00e3o e a aus\u00eancia de preenchimento no momento dadispensa\u00e7\u00e3o deveria apontar a necessidade de monitoramento e a\u00e7\u00f5es da Anvisa. Quanto\u00e0s medidas atribu\u00eddas \u00e0 idade, os percentis encontrados refletem a distribui\u00e7\u00e3opopulacional brasileira em cada ano Cabe lembrar que o sistema requer preenchimento de dois campos distintos, \u201cidade\u201d e\u201cunidade_idade\u201d. Portanto, para selecionar popula\u00e7\u00e3o de interesse, faz-se necess\u00e1riofiltrar registros que espelhem idades em anos ou em meses e combin\u00e1-los com avari\u00e1vel num\u00e9rica \u201cidade\u201d. Caso o pesquisador selecione apenas a vari\u00e1vel \u201cidade\u201d,poder\u00e1 incorrer em vi\u00e9s de sele\u00e7\u00e3o, uma vez que ter\u00e1 em sua amostra idadesrelacionadas \u00e0 categoria n\u00e3o desejada no estudo.,,antimicrobial stewardship)para otimizar desde a sele\u00e7\u00e3o at\u00e9 a administra\u00e7\u00e3o do antibi\u00f3tico, com \u00eanfase naredu\u00e7\u00e3o da resist\u00eancia microbiana ,,A regulamenta\u00e7\u00e3o sanit\u00e1ria n\u00e3o obriga a informa\u00e7\u00e3o da CID-10 para prescri\u00e7\u00e3o deantimicrobianos ,,,Destacam-se o decaimento de registros de dispensa\u00e7\u00e3o de antibi\u00f3ticos e o aumento dosmedicamentos de controle especial, como ansiol\u00edticos e hipn\u00f3ticos, no ano de 2020,in\u00edcio da pandemia de COVID-19. O aumento desse consumo tem sido relatado emdiferentes pa\u00edses, inclusive no Brasil, nesse per\u00edodo Al\u00e9m da incompletude e dos problemas j\u00e1 apontados, cabe destacar uma preocupa\u00e7\u00e3orelacionada \u00e0 forma como os dados alimentam o SNGPC. Em primeiro lugar, as farm\u00e1ciaspodem inserir novos registros de dispensa\u00e7\u00e3o pregressa a qualquer momento, semlimite de tempo. Al\u00e9m disso, \u00e9 poss\u00edvel reunir registros de diversos pontos dedispensa\u00e7\u00e3o em um \u00fanico ponto, mesmo que estejam em jurisdi\u00e7\u00f5es diferentes O estudo foi limitado pelo tempo. Os resultados apresentados refletem os registros dedispensa\u00e7\u00e3o at\u00e9 o per\u00edodo de coleta dos dados, uma vez que o sistema permiteatualiza\u00e7\u00e3o retroativa. Portanto, \u00e9 poss\u00edvel que, em an\u00e1lises futuras, os totaisaqui relatados possam apresentar alguma diferen\u00e7a. Outra limita\u00e7\u00e3o se refere aosistema de vincula\u00e7\u00e3o feito por dicion\u00e1rios. Foi uma etapa executada manualmente,registro a registro, estando sujeita a erros, ainda que tenha sido realizada pordois pesquisadores de forma independente, com a finalidade de minimizar poss\u00edveiserros de classifica\u00e7\u00e3o.Em dezembro de 2021, a Anvisa suspendeu a transmiss\u00e3o eletr\u00f4nica dos registros dedispensa\u00e7\u00e3o dos medicamentos do SNGPC, devido a recorrentes instabilidades nosistema, que produziriam erros de acesso, lentid\u00e3o na funcionalidade, noprocessamento e na valida\u00e7\u00e3o dos arquivos O trabalho possibilitou, a partir das informa\u00e7\u00f5es registradas no SNGPC - bancoadministrativo, sem finalidade prec\u00edpua de pesquisa - produzir um banco para DUR,mediante etapas sistem\u00e1ticas de verifica\u00e7\u00e3o de dados faltantes, de consist\u00eancia, decompletude e da adi\u00e7\u00e3o de novas vari\u00e1veis.Um dos objetivos do trabalho foi exatamente explorar essa potencialidade do SNGPCpara DUR. N\u00e3o obstante, mesmo sendo banco administrativo, o sistema deveria contercr\u00edticas que impedissem registros de quantidades dispensadas claramenteincompat\u00edveis com o consumo de um \u00fanico paciente. Esse tipo de falha de registroleva a grandes erros administrativos e inviabiliza o monitoramento e a tomada dedecis\u00e3o. Por isso, \u00e9 t\u00e3o importante usar o SNGPC em estudos que contemplemintervalos temporais longos e \u00e1reas geogr\u00e1ficas extensas, para que o impacto deinconsist\u00eancias, como a apontada, seja minimizado.Al\u00e9m disso, sugere-se que os princ\u00edpios ativos sejam exclusivamente descritos segundoa DCB, seguidos pelo respectivo c\u00f3digo da ATC. Adicionalmente, o SNGPC deveriaimpedir o registro de princ\u00edpios ativos que n\u00e3o s\u00e3o, pela regulamenta\u00e7\u00e3o sanit\u00e1ria,objeto de controle sanit\u00e1rio.Em dezembro de 2022, ap\u00f3s um ano de suspens\u00e3o de transmiss\u00e3o dos dados pelasfarm\u00e1cias, a Anvisa tornou novamente acess\u00edvel o conjunto de registros dedispensa\u00e7\u00e3o, mas mudou a regulamenta\u00e7\u00e3o, desobrigando a transmiss\u00e3o eletr\u00f4nica dosregistros pelos estabelecimentos e favorecendo o \u201capag\u00e3o\u201d parcial ou total dos dadosdo SNGPC, que caracterizou o per\u00edodo 2021-2022.Nesse sentido, a fonte de dados produzida por este estudo \u00e9 de grande utilidade paraa comunidade de pesquisadores em DUR. O volume de registros coletados revela aimport\u00e2ncia do sistema como ferramenta para vigil\u00e2ncia e planejamento de a\u00e7\u00f5es nouso apropriado de medicamentos."}
+{"text": "To understand the meanings that the therapeutic bond assumes for clinical speech therapists.The research was approved by the Ethics Committee, being of a transversal character, with a quantitative-qualitative approach in the Content Analysis. The research with the participation of 96 clinical speech therapists, registered in the Speech Therapy Council of the 3rd region (CRFa 3), which covers the States of Paran\u00e1 and Santa Catarina.Of the 96 speech therapists included, a significant part of the participants defined the therapeutic bond as a relationship/interaction. Regarding the role of the bond for the speech therapy clinical work, most professionals declared theirs as a fundamental basis and another part of the bond is necessary for the evolution/development of the patient.It is possible to understand that, according to the therapeutic patients, it is essential to sustain, maintain the clinical work for users, impacting the resignification of the complaint and the minimization of the users' suffering. The alliance established between clinical speech-language pathologists and patients directly influences the development of the therapeutic process, including the mitigation of suffering given the complaints and symptoms the patient presents.The therapeutic bond depends on the relationship between clinicians and subjects who seek them in suffering. Such a relationship involves feelings of trust, security, care, or their opposites, distrust, hostility, and opposition, depending on the previous histories of the people involved. Thus, to scrutinize the therapeutic bond, we must distinguish the theoretical bases and aspects defining it.However, studying this relationship is a challenging exercise. It involves a search to understand the complexity of human relationships, which undergo successive adaptations and transformations, influenced by the internal and external interactions of subjects with themselves and others.According to a psychoanalytic perspective, there are basically two types of bonds: positive and negative. The first relates to a feeling close to love, and the second is better known as hostility. Therefore, the bond should not be considered only as the transfer of feelings of affection or empathy. Rather, it also includes feelings of anger and hatred and sometimes expresses indifference.These feelings manifested in the clinic indicate the possibilities and difficulties faced by patients and clinicians when establishing the therapeutic bond. However, regardless of the affection patients direct to therapists and vice-versa, it is important to clarify that both feelings stem from unconscious fantasies associated with the first bonds established in the lives of each person. The care given to babies, more or less affectionate, leads children to delimit an internal representational model of themselves. This self-image, elaborated according to the exchanges between them and their caregivers, explains a bonding pattern the subject tends to resume in other significant interpersonal relationships, including with professionals they may choose for clinical work.According to the psychological theory of attachment, which maintains intersections with the psychoanalytic perspective, the relationship between the baby and the mother or other people caring for the child is decisive for the child's development and developing future relationships.According to Collective Health, the bond is considered a conditioner of health processes insofar as it assumes the role of enabling co-responsibility, continuity, and longitudinally of care. The alliances bonding health workers and their patients must be based on relationships of affection and trust, enabling a deepening of co-responsibility for health, assuming a therapeutic potential.Thus, considering the different perspectives aimed at explaining the bond and, regardless of the theoretical position adopted, there is a remarkable agreement that the patient-professional relationship plays a relevant role in health actions. It is understood that speech-language pathology clinical practices should value this relationship. When considering the bond, therapists can broaden and qualify their listening, welcoming the uniqueness of the story narrated by the patient. This indispensable attitude in the therapeutic process requires therapists to understand their roles and limits so that the therapeutic environment does not become a place of power over the other. However, in the opposite direction, such a space should provide the establishment of a horizontal relationship, from which patients can feel welcomed and strengthened to explain their singularities.From a clinical perspective, a crucial aspect that must be considered when establishing the therapeutic bond is the posture assumed by the speech-language pathologist when faced with the patient's complaint, including the development of a work capable of taking a clinical stance based on a supposed knowledge. Some studies state that the therapeutic bond is essential for building and sustaining the therapeutic process because it brings the professional closer to the subject's truths, improving their adherence and engagement in this process-11.The change in the professional's gaze away from pathology to focus on the suffering subject enables an approach that opens up space to resignify the patient's symptom. Nevertheless, it is worth noting that a superficial understanding of the bonding phenomenon tends to lead professionals to reproduce a practice based on re-educational techniques without considering the subjects and their singular histories. In this direction, the speech-language pathology clinic seeks the normalization and standardization of subjects. It uses procedures that make it impossible to establish a therapeutic relationship through which patients can accept and resignify their symptoms, mitigating their suffering. Thus, based on this understanding, this study aimed to understand the meanings the therapeutic bond assumes for clinical speech-language pathologists.However, even though speech-language pathologists consider that, in general, the bond is essential for the referral of clinical work, there is a limited number of studies in speech-language pathology seeking to deepen this themeThis is a cross-sectional study with a quantitative and qualitative approach. It is based on Content Analysis (CA), which aims to analyze linguistic materials. The Ethics Committee approved it with the document no. 34894720.6.0000.8040. All research participants signed the Informed Consent Form (ICF).In order to carry out this investigation, we prepared a semi-structured electronic questionnaire and implemented it on the Google Forms platform. The questionnaire  comprise. These 12 professionals responded, evaluated, and suggested improvements to the data collection instrument, enabling the authors to observe gaps in it. These gaps were revised and adapted, enabling the instrument's application to more participants.In order to verify the tangibility of the questionnaire before sending the instrument to all professionals registered with CRFa 3, we conducted a pilot study with 12 speech therapists living in Paran\u00e1 and Santa Catarina, captured by the snowball technique. This qualitative technique proposes that, after locating some people who match the study profile, they are invited to recommend other subjects capable of integrating the research and so on, progressivelyThe study included 146 clinical speech-language pathologists with active registration in the Speech-Language Pathology Council of the 3rd region (CRFa 3), which covers two southern Brazilian states (Paran\u00e1 and Santa Catarina). Data collection was organized based on the inclusion of answers from 96 speech-language pathologists who met the eligibility criteria. This study preserved, coded, and recognized the participants' identities using Arabic numbers ranging from 1 to 96.Inclusion criteria included professionals with a clinical practice of one year or more. On the other hand, exclusion criteria included professionals not working in the speech-language pathology clinic at the time of data collection.The electronic data collection instrument was sent through the Speech-Language Pathology Council of the 3rd Region (CRFa 3), by e-mail, to 4,297 professional speech-language pathologists registered with the organization. Along with the electronic questionnaire, we sent the Informed Consent Form (ICF) and a summary of the project, which explained its objective and justification. On March 13, 2021, we sent the questionnaire to professionals. However, due to the low number of answers, we sent the questionnaire again on April 26, 2021, through the CRFa 3. Therefore, the study included all professionals who were willing to answer the questionnaire and who met the inclusion criteria within two months after the instrument was first sent.. It is an analysis method that considers objective and subjective aspects of texts produced during the research to discuss the data collected through systematic procedures that can organize quantitative and qualitative indicators,16. Specifically, CA is defined as a set of methodological tools, which analyzes different verbal and non-verbal content sources in a refined and critical way, increasing its level of effectiveness.Data analysis was based on Content Analysis (CA). Content Analysis has a quantitative-qualitative character and allows using statistical parameters to study communication phenomenaThe quantitative analysis sought to characterize the socio-demographic profile of the participating speech-language pathologists through descriptive statistical analysis. We used the chi-square test to verify the existence of an association between the different categorical variables evaluated. All analyses were performed in the statistical software Jasp, version 0.14.1, with a 5% significance level.. In this regard, we conducted thematic and lexical analyses to organize this study's categories.Regarding the linguistic and discursive materials collected through the questionnaire, which sought to apprehend what speech-language pathologists understand about the therapeutic bond in Speech-Language Pathology, we organized them following the CA procedures.The organization followed the three phases of CA: 1) Pre-analysis, in which the material obtained in the data collection is prepared; 2) Exploration of the material, stage in which the categories are grouped based on the registration units, according to their common characteristics, around the words and themes mentioned by the participants; 3) Treatment of Results, phase in which the interpretation of the research data is performed, making it possible to produce inferencesA total of 100% of the 96 speech-language pathologists included were professionally active and working as clinical speech-language pathologists. Regarding the length of training, 37.5% were speech-language pathologists who had graduated for more than 20 years, followed by professionals with three to seven years of training, totaling 21.1%. Regarding the academic level, there was a predominance of 60.4% of participants with specialization/improvement, followed by 18.8% who had only undergraduate degrees, and only 4.2% had a doctorate degree.From the total number of professionals who participated in this study, 34.4% had been working clinically for more than 20 years, and 15.6% between one and four years. Regarding the area of activity, there is a greater number of participating speech-language pathologists who worked with language (85.4%), followed by those working with dysphagia/motricity (68.8%). Professionals working in the field of voice accounted for 28.1%, and those working in audiology, 17.7%.Regarding complementary training specifically focused on the therapeutic bond, only 30.2% sought further training on the subject. When this 30.2% was asked about the type of training they had, 72.9% stated that they had attended courses, 55.2% participated in study groups, 51.7% in lectures, 17.2% in seminars, 6.9% in scientific congresses, and 24.1% sought other means to deepen their knowledge on therapeutic bond.In axis 1, most professionals defined the therapeutic bond as a relationship/interaction (47.9%). Another 26% defined it as trust/acceptance. However, it is worth noting that 26% did not answer the question.In order to organize this axis, the professionals were asked about the role of the therapeutic bond in the speech-language pathology clinical practice. The answers were grouped into categories related to affinity/trust, base/fundamental, motivation/engagement, evolution/development, and others, as shown in Regarding the therapeutic bond's role in clinical speech-language pathology work, the professionals most significantly described it as the basis/fundamental (38.5%) and necessary for the patient's evolution/development (25%). Furthermore, 8.3% related the bond to motivation/engagement in therapeutic work, 12.5% described other characteristics, and 3.1% did not answer the question.There was an association between the participants' training time and their answers regarding the therapeutic bond's role (p = 0.036). For professionals who graduated more than 20 years ago, the bond is the foundation of the speech-language pathology clinic. Meanwhile, for professionals who graduated less than 14 years ago and more than eight years ago, the bond is responsible for the evolution and development of the therapeutic work .There was also an association between the time of clinical practice and the participants' answers regarding the therapeutic bond's role (p= 0.050). For speech-language pathologists who have been working clinically for more than 20 years, the therapeutic bond was the basis of their work. Meanwhile, for professionals who have been working for more than five and less than ten years, the bond is an element that develops the therapeutic work .The results presented in . The therapeutic bond allows access through language to the conscious and unconscious contents of individuals, bringing out their subjectivity, so necessary for the referral of speech-language pathology clinical work.Regarding the participants' area of activity, the predominance of professionals working in the language area is noteworthy. The predominance of speech-language pathologists who work clinically in language can be justified because language is one of the essential cornerstones for establishing and sustaining the bond. For it is through language that every human being constitutes itself as a subject, understands the world, and acts upon it. The therapeutic relationship should also be considered in rehabilitating subjects with chronic orofacial pain. According to the author, such a relationship broadens the therapist's listening, making it possible to assist subjects in relieving their pain, to the extent that their life story is considered in the understanding of their symptoms.Moreover, the therapeutic bond is associated with significant improvements in the communication skills of subjects undergoing speech-language pathology treatment. In this same study, the bond is also associated with the fact that patients feel valued and listened to by the professional and not just conceived as consumers and buyers of hearing aids.It is worth mentioning that even though the audiology literature recognizes the importance of the bond between the speech-language pathologist and the patient in the audiological clinical work, the number of audiologists who agreed to participate in this study was limited. According to a study focused on the audiological rehabilitation of older people, the therapeutic bond is considered fundamental, as it impacts the reduction of postponement of consultations and adherence to the proposed treatmentAnother point worth noting in the results shown in .Axis 1, which, according to . Furthermore, there is a need for patients to be considered and understood as biopsychosocial beings. Thus, it is possible to resignify the anguish and the symptom they experience. Such achievement is only possible through the relationship established between patients and therapists, which allows professionals to recognize the need of the subjects who seek them and thus intervene more effectively, helping them in mitigating their suffering,23.Therefore, the bonding relationship, constituted in the therapeutic sphere, is permeated by the coexistence of the parallel between the affective experiences lived by the subjects throughout their history and the relational experiences elaborated in the therapeutic space, as proposed by the attachment theory. According to Collective Health studies, qualified listening maximizes the therapeutic potential. It contributes to consolidating the therapeutic relationship, as it respects the patient's uniqueness, strengthening the trust and participation of those involved in the therapeutic process.In this perspective, following the first sub-axis, another part of the research participants related the therapeutic bond to listening, trust, and acceptance, among others. Qualified therapeutic listening promotes holistic care, which can strengthen bonds, enabling an approximation between the professional and the truths reliably related to the subject's real suffering.Regarding trust, it should be considered one of the primary points of therapeutic work, as it allows patients to feel comfortable and safe to share their life stories, promoting more authentic interactions toward the re-elaboration of the symptom. However, such trust only becomes possible based on welcoming the patient, making them feel safe to bring out their uniqueness.Regarding the therapeutic bond's role in speech-language pathology clinical practice, 38.5% of professionals understand it as a fundamental basis for their clinical practice. The therapeutic bond is pointed out as paramount for designing the therapeutic work because, in addition to building a secure base that helps patients address their demands, the relationship between patients and clinicians can contribute to subjects suffering and can resignify their previous affective bonds. According to the attachment theory, especially in circumstances in which the subjects grew up in interpersonal contexts based on distrust and fear, the therapist can assume a position that can promote a safe bond. This safe bond leads the patient to face another relationship model supported by a link that enables trust and security, reworking difficult relationships experienced in previous situations.Furthermore, from a psychoanalytic perspective, the therapeutic bond should be considered an underlying factor in all clinical practice. Therefore, it is a necessary condition for therapeutic work referral. In other words, it is an element that permeates all clinical activity, without which, tendentiously, there is no possibility of treatment, care, and/or resignification of the symptom. In this direction, the therapeutic bond can significantly improve the engagement, motivation, autonomy, and social participation of subjects inside and outside the therapeutic setting.Motivation and engagement were associated with the therapeutic bond's role by 8.3% of the speech-language pathologists participating in this study. According to a study based on Collective Health, the therapeutic relationship, insofar as it opens space for subjects to explain their particularities, allows them to understand their role in the work to be developed, leading them to assume an active position in the relationship with the clinician.A significant proportion of 25% of the speech-language pathologists related the bond to the therapy's evolution and development. Regarding this relationship, it is worth noting that the therapeutic bond should not be associated only with \u201ccure\u201d or symptom suppression but as an opportunity that allows patients to reframe their life stories, pains, and previous bonds. According to the National Health Promotion Policy, health care should not be limited only to disease recovery but to an activity in which the professional, through qualified and welcoming listening, promotes the maximization of autonomy, empowerment, and social participation of patients, assisting them in the process of becoming the author of their history actively and consciouslyRegarding the understanding of speech-language pathologists about the meanings that the therapeutic bond assumes in the clinical practice of speech-language pathology, it was postulated as an essential part of the design and outcome of the therapeutic process. It can strengthen motivation and engagement factors and help subjects resignify their symptoms. . A alian\u00e7a firmada entre o fonoaudi\u00f3logo cl\u00ednico e o paciente tem influ\u00eancia direta no desenvolvimento do processo terap\u00eautico, incluindo a minimiza\u00e7\u00e3o do sofrimento diante das queixas e sintomas que tal paciente apresenta.O v\u00ednculo terap\u00eautico depende da rela\u00e7\u00e3o constitu\u00edda entre um profissional cl\u00ednico e o sujeito que o busca em sofrimento, sendo que tal rela\u00e7\u00e3o envolve sentimentos de confian\u00e7a, seguran\u00e7a, cuidado, ou os seus opostos, desconfian\u00e7a, hostilidade, oposi\u00e7\u00e3o, a depender das hist\u00f3rias pregressas das pessoas envolvidas. Dessa forma, para perscrutar o v\u00ednculo terap\u00eautico \u00e9 preciso distinguir bases te\u00f3ricas e aspectos que o definem.Contudo, estudar essa rela\u00e7\u00e3o \u00e9 um exerc\u00edcio desafiador, pois envolve uma busca por compreender a complexidade das rela\u00e7\u00f5es humanas, que sofrem sucessivas adapta\u00e7\u00f5es e transforma\u00e7\u00f5es, influenciadas pelas intera\u00e7\u00f5es internas e externas do sujeito, consigo mesmo e com os outros.De acordo com uma perspectiva psicanal\u00edtica, basicamente, existem dois tipos de v\u00ednculo: o positivo e o negativo. O primeiro est\u00e1 ligado a um sentimento que \u00e9 pr\u00f3ximo ao amor, e o segundo \u00e9 mais conhecido como hostilidade. Por isso, o v\u00ednculo n\u00e3o deve ser considerado apenas como a transfer\u00eancia de sentimentos de carinho, afeto ou empatia. Ao contr\u00e1rio, ele, tamb\u00e9m, abarca sentimentos de raiva e de \u00f3dio, al\u00e9m de explicitar, por vezes, indiferen\u00e7a.Esses sentimentos, manifestados na cl\u00ednica, s\u00e3o indicativos de possibilidades e de dificuldades enfrentadas pelo paciente e pelo cl\u00ednico, na constitui\u00e7\u00e3o do v\u00ednculo terap\u00eautico. Mas, independentemente dos afetos que o paciente direciona ao terapeuta e vice-versa, cabe esclarecer que os sentimentos de ambos decorrem de fantasias inconscientes, associadas aos primeiros v\u00ednculos estabelecidos, na vida de cada um. Os cuidados destinados ao beb\u00ea, mais ou menos afetivos, levam a crian\u00e7a a delimitar um modelo representacional interno de si mesma. Essa autoimagem, elaborada em fun\u00e7\u00e3o das trocas que se d\u00e3o com os seus cuidadores, explicita um padr\u00e3o de v\u00ednculo que o sujeito tende a retomar em outras rela\u00e7\u00f5es interpessoais significativas, inclusive, com profissionais que ele venha a eleger para um trabalho cl\u00ednico.Conforme a teoria psicol\u00f3gica do apego, que mant\u00e9m pontos de intersec\u00e7\u00e3o com a \u00f3tica psicanal\u00edtica, a rela\u00e7\u00e3o que se organiza entre o beb\u00ea e a m\u00e3e ou outras pessoas que lhe dedicam cuidados, em seus primeiros anos de vida, \u00e9 determinante para o desenvolvimento da crian\u00e7a e para a constru\u00e7\u00e3o de suas rela\u00e7\u00f5es futuras.Na concep\u00e7\u00e3o da Sa\u00fade Coletiva, o v\u00ednculo \u00e9 visto como condicionante dos processos de sa\u00fade, na medida em que assume o papel de viabilizador da corresponsabilidade, continuidade e longitudinalidade do cuidado. As alian\u00e7as que vinculam trabalhadores de sa\u00fade e seus usu\u00e1rios devem se embasar em rela\u00e7\u00f5es de afeto e confian\u00e7a, capazes de permitir aprofundamento de corresponsabiliza\u00e7\u00e3o pela sa\u00fade, assumindo um potencial terap\u00eautico.Assim, tendo em vista a exist\u00eancia de diferentes perspectivas que se prop\u00f5em a explicar o v\u00ednculo e considerando que, independentemente do posicionamento te\u00f3rico adotado, h\u00e1 uma not\u00e1vel concord\u00e2ncia de que a rela\u00e7\u00e3o paciente-profissional desempenha relevante fun\u00e7\u00e3o nas a\u00e7\u00f5es voltadas \u00e0 sa\u00fade, entende-se que as pr\u00e1ticas cl\u00ednicas fonoaudiol\u00f3gicas devem valorizar essa rela\u00e7\u00e3o. Pois, ao considerar o v\u00ednculo, o terapeuta pode ampliar e qualificar a sua escuta, acolhendo a singularidade da hist\u00f3ria narrada pelo paciente. Essa postura, indispens\u00e1vel no processo terap\u00eautico, exige do terapeuta a compreens\u00e3o do seu papel e de seus limites, para que o ambiente terap\u00eautico n\u00e3o se torne um lugar de poder sobre o outro. Mas, em dire\u00e7\u00e3o oposta, que tal espa\u00e7o proporcione o estabelecimento de uma rela\u00e7\u00e3o horizontalizada, a partir da qual o paciente possa se sentir acolhido e fortalecido para explicitar a sua pr\u00f3pria singularidade.De um ponto de vista cl\u00ednico, um aspecto crucial a ser considerado, na constitui\u00e7\u00e3o do v\u00ednculo terap\u00eautico, \u00e9 a postura assumida pelo fonoaudi\u00f3logo, frente a queixa do paciente, incluindo o desenvolvimento de um trabalho capaz de assumir uma postura cl\u00ednica fundamentada em um suposto saber. Alguns estudos afirmam que o v\u00ednculo terap\u00eautico \u00e9 essencial para a constru\u00e7\u00e3o e para a sustenta\u00e7\u00e3o do processo terap\u00eautico, pois, aproxima o profissional das verdades do sujeito, potencializando a sua ades\u00e3o e o seu engajamento nesse processo-11.A mudan\u00e7a de olhar do profissional esvaindo-se da patologia, para focalizar o sujeito em sofrimento, viabiliza uma conduta que abre espa\u00e7o para ressignificar o sintoma do paciente. Ressalta-se, por\u00e9m, que um entendimento superficial sobre o fen\u00f4meno vincular, tendenciosamente, leva o profissional a reproduzir uma pr\u00e1tica baseada em t\u00e9cnicas reeducativas, sem levar em conta o sujeito e sua hist\u00f3ria singular. Nessa dire\u00e7\u00e3o, a cl\u00ednica fonoaudiol\u00f3gica acaba por buscar a normaliza\u00e7\u00e3o e a padroniza\u00e7\u00e3o dos sujeitos, utilizando-se de procedimentos que impossibilitam a constitui\u00e7\u00e3o de uma rela\u00e7\u00e3o terap\u00eautica, por meio da qual o paciente pode aceitar e ressignificar seus sintomas, mitigando o seu sofrimento. Assim, a partir desse entendimento, a presente pesquisa objetiva compreender os sentidos que o v\u00ednculo terap\u00eautico assume para fonoaudi\u00f3logos cl\u00ednicos.Entretanto, apesar de os fonoaudi\u00f3logos considerarem que, de forma geral, o v\u00ednculo \u00e9 essencial para o encaminhamento de um trabalho cl\u00ednico, h\u00e1 um n\u00famero restrito de pesquisas, no campo da Fonoaudiologia, que buscam aprofundamento sobre essa tem\u00e1ticaEsse estudo \u00e9 de car\u00e1ter transversal e de abordagem quanti-qualitativa, pautada na An\u00e1lise do Conte\u00fado (AC), a qual se prop\u00f5e a analisar materiais lingu\u00edsticos. Foi aprovado pelo por Comit\u00ea de \u00c9tica, com documento n\u00ba. 34894720.6.0000.8040. E todos os participantes da pesquisa assinaram o Termo de Consentimento Livre e Esclarecido (TCL).Googles forms, visando atender ao objetivo da pesquisa. O question\u00e1rio, que est\u00e1 apresentado no Para a realiza\u00e7\u00e3o da presente investiga\u00e7\u00e3o, foi elaborado um question\u00e1rio, eletr\u00f4nico semi-estruturado, sendo que o mesmo foi implementado na plataforma . Esses 12 profissionais responderam, avaliaram e sugeriram melhorias ao instrumento de coleta de dados, possibilitando \u00e0s autoras observarem lacunas no mesmo, as quais foram revistas e adequadas, viabilizando a aplica\u00e7\u00e3o do instrumento a um maior n\u00famero de participantes.Para verifica\u00e7\u00e3o da tangibilidade do question\u00e1rio, antes do envio do instrumento para todos os profissionais inscritos do CRFa 3, foi feito um estudo piloto que contou com a participa\u00e7\u00e3o de 12 fonoaudi\u00f3logos residentes no Paran\u00e1 e em Santa Catarina, captados pela t\u00e9cnica da bola de neve. Essa t\u00e9cnica qualitativa prop\u00f5e que, ap\u00f3s a localiza\u00e7\u00e3o de algumas pessoas que correspondam ao perfil do estudo, elas sejam convidadas a recomendar outros sujeitos capazes de integrar a pesquisa e, assim, progressivamenteResponderam ao estudo 146 fonoaudi\u00f3logos cl\u00ednicos, com registro ativo no Conselho de Fonoaudiologia da 3\u00aa regi\u00e3o (CRFa 3), abrangendo dois Estados do sul do Brasil: Paran\u00e1 e Santa Catarina. A coleta de dados foi organizada a partir da inclus\u00e3o das respostas de 96 profissionais fonoaudi\u00f3logos, que cumpriam os crit\u00e9rios de elegibilidade. Os participantes tiveram suas identidades preservadas, sendo codificados e reconhecidos, na pesquisa, por meio de n\u00fameros ar\u00e1bicos, que v\u00e3o de 1 at\u00e9 96.Em fun\u00e7\u00e3o de crit\u00e9rios de inclus\u00e3o, foram considerados profissionais com tempo de atua\u00e7\u00e3o cl\u00ednica, igual ou maior de um ano. Por outro lado, tendo em vista os crit\u00e9rios de exclus\u00e3o, foram retirados do estudo profissionais que n\u00e3o estavam atuando na cl\u00ednica fonoaudiol\u00f3gica, no momento da coleta de dados.e-mail, para 4.297 profissionais fonoaudi\u00f3logos, inscritos no \u00f3rg\u00e3o. Juntamente com o question\u00e1rio eletr\u00f4nico, foi enviado o Termo de Consentimento Livre e Esclarecido (TCLE), bem como um resumo do projeto, o qual explicava o seu objetivo e justificativa. No dia 13 de mar\u00e7o de 2021, o question\u00e1rio foi enviado aos profissionais e, devido ao baixo n\u00famero de respostas, no dia 26 de abril o question\u00e1rio foi reencaminhado, novamente, pelo CRFa 3. Assim, compuseram a pesquisa todos os profissionais que se mobilizaram para responder o question\u00e1rio e que se adequaram aos crit\u00e9rios de inclus\u00e3o, no per\u00edodo de dois meses, ap\u00f3s o primeiro envio do instrumento.O instrumento eletr\u00f4nico de coleta de dados foi encaminhado via Conselho Regional de Fonoaudiologia 3\u00aa regi\u00e3o (CRFa 3), pelo ambiente virtual . Trata-se de um m\u00e9todo de an\u00e1lise que considera aspectos objetivos e subjetivos de textos produzidos durante a pesquisa, a fim de discutir os dados coletados por meio de procedimentos sistem\u00e1ticos capazes de organizar indicadores quantitativos e qualitativos,16. De forma espec\u00edfica, a AC \u00e9 definida como um conjunto de instrumentos metodol\u00f3gicos, que analisa diferentes fontes de conte\u00fado verbais e n\u00e3o-verbais, de forma refinada e cr\u00edtica, aumentando o seu n\u00edvel de efetividade.A an\u00e1lise dos dados apoiou-se na An\u00e1lise de Conte\u00fado (AC), que apresenta car\u00e1ter quanti-qualitativo, permitindo utilizar par\u00e2metros estat\u00edsticos para estudar os fen\u00f4menos da comunica\u00e7\u00e3oA an\u00e1lise quantitativa buscou caracterizar o perfil sociodemogr\u00e1fico dos profissionais fonoaudi\u00f3logos participantes, atrav\u00e9s de an\u00e1lise estat\u00edstica descritiva. Para verificar a exist\u00eancia de associa\u00e7\u00e3o entre as diferentes vari\u00e1veis categ\u00f3ricas avaliadas, foi utilizado o teste Qui-quadrado. Todas as an\u00e1lises foram realizadas no software estat\u00edstico Jasp, vers\u00e3o 0.14.1, sendo adotado um n\u00edvel de signific\u00e2ncia de 5%.. Nessa dire\u00e7\u00e3o, para o tratamento dos dados, foram elaboradas an\u00e1lises tem\u00e1ticas e lexicais, as quais organizaram as categorias do presente estudo.No que se refere aos materiais lingu\u00edstico e discursivo coletados por meio da aplica\u00e7\u00e3o do question\u00e1rio, que buscou apreender o que os profissionais fonoaudi\u00f3logos compreendem sobre o v\u00ednculo terap\u00eautico no campo da Fonoaudiologia, o mesmo foi organizado seguindo os procedimentos da AC.A organiza\u00e7\u00e3o ocorreu seguindo as tr\u00eas fases da AC: 1) a Pr\u00e9-an\u00e1lise, em que se d\u00e1 a prepara\u00e7\u00e3o do material obtido na coleta de dados; 2) a Explora\u00e7\u00e3o do material, etapa em que as categorias s\u00e3o agrupadas a partir das unidades de registro, em fun\u00e7\u00e3o de suas caracter\u00edsticas comuns, em torno dos voc\u00e1bulos e dos temas referidos pelos participantes; 3) o Tratamento dos Resultados, fase em que se realiza a interpreta\u00e7\u00e3o dos dados da pesquisa, sendo poss\u00edvel produzir infer\u00eanciasA Dos 96 fonoaudi\u00f3logos inclu\u00eddos, 100% estavam ativos profissionalmente e atuando como fonoaudi\u00f3logos cl\u00ednicos. No que concerne ao tempo de forma\u00e7\u00e3o, 37,5% eram fonoaudi\u00f3logos formados a mais de 20 anos, seguido dos profissionais com tr\u00eas a sete anos de forma\u00e7\u00e3o, perfazendo 21,1%. Em rela\u00e7\u00e3o ao n\u00edvel acad\u00eamico, observou-se uma predomin\u00e2ncia de 60,4% de participantes com especializa\u00e7\u00e3o/aperfei\u00e7oamento, seguida de 18,8% que possu\u00edam somente gradua\u00e7\u00e3o, sendo que apenas 4,2% apresentavam doutorado.Do total de profissionais que participaram deste estudo, 34,4% atuavam clinicamente a mais de 20 anos e 15,6% entre um e quatro anos. Com rela\u00e7\u00e3o a \u00e1rea de atua\u00e7\u00e3o, h\u00e1 um n\u00famero maior de fonoaudi\u00f3logos participantes que atuavam na \u00e1rea da linguagem, com 85,4%, seguido dos atuantes na \u00e1rea de disfagia/motricidade, representando 68,8% dos participantes. Com menor n\u00famero representacional est\u00e3o os profissionais da \u00e1rea da voz, com 28,1% e da audiologia, com 17,7%.No que concerne a forma\u00e7\u00e3o complementar voltada especificamente ao v\u00ednculo terap\u00eautico, apenas 30,2% buscaram aprofundamento sobre a tem\u00e1tica. E quando esses 30,2% foram questionados sobre o tipo de forma\u00e7\u00e3o que realizaram, 72,9% afirmaram ter frequentado cursos, 55,2% participaram de grupos de estudos, 51,7% de palestras, 17,2% de semin\u00e1rios, 6,9% participaram de congressos cient\u00edficos e 24,1% buscaram outros meios para aprofundar os seus conhecimentos sobre v\u00ednculo terap\u00eautico.A rela\u00e7\u00e3o/intera\u00e7\u00e3o, representando 47,9% do total de participantes. Outros 26% o definiram como acolhimento/confian\u00e7a. Entretanto, chama aten\u00e7\u00e3o o fato de 26% n\u00e3o responderem \u00e0 quest\u00e3o.No eixo 1, a maior parte dos profissionais definiu v\u00ednculo terap\u00eautico como sendo Para organiza\u00e7\u00e3o desse eixo, os profissionais foram questionados sobre qual o papel do v\u00ednculo terap\u00eautico para a pr\u00e1tica cl\u00ednica fonoaudiol\u00f3gica. E as respostas foram agrupadas em categorias relacionadas a afinidade/confian\u00e7a, base/fundamental, motiva\u00e7\u00e3o/engajamento, evolu\u00e7\u00e3o/desenvolvimento e outros, conforme ilustrado pela base/fundamental, representando 38,5% das respostas, e necess\u00e1rio para a evolu\u00e7\u00e3o/desenvolvimento do paciente, de acordo com 25% das respostas, 8,3% relacionaram v\u00ednculo \u00e0 motiva\u00e7\u00e3o/engajamento no trabalho terap\u00eautico, 12,5% descreveram outras caracter\u00edsticas e 3,1% n\u00e3o responderam \u00e0 pergunta.Referente ao papel do v\u00ednculo terap\u00eautico para o trabalho cl\u00ednico fonoaudiol\u00f3gico, os profissionais o descreveram, de forma mais significativa, como sendo a Houve associa\u00e7\u00e3o entre o tempo de forma\u00e7\u00e3o dos participantes e as respostas desses participantes com rela\u00e7\u00e3o ao papel v\u00ednculo terap\u00eautico (p = 0.036). Para os profissionais que conclu\u00edram a gradua\u00e7\u00e3o h\u00e1 mais de 20 anos, o v\u00ednculo \u00e9 entendido como fundamento da cl\u00ednica fonoaudiol\u00f3gica. E para os profissionais que conclu\u00edram a gradua\u00e7\u00e3o h\u00e1 menos de 14 anos e h\u00e1 mais de oito anos, o v\u00ednculo \u00e9 tomado como respons\u00e1vel pela evolu\u00e7\u00e3o e pelo desenvolvimento do trabalho terap\u00eautico .Verificou-se, tamb\u00e9m, associa\u00e7\u00e3o entre o tempo de atua\u00e7\u00e3o cl\u00ednica e as respostas dos participantes quanto ao papel do v\u00ednculo terap\u00eautico (p= 0.050). Para os fonoaudi\u00f3logos que atuam, clinicamente, h\u00e1 mais de 20 anos, o v\u00ednculo terap\u00eautico foi postulado como a base de seu trabalho. E, para os profissionais que atuam h\u00e1 mais de cinco e h\u00e1 menos de 10 anos, o v\u00ednculo \u00e9 apontado como elemento que leva o trabalho terap\u00eautico a se desenvolver .Observou-se, nos resultados explicitados na . O v\u00ednculo terap\u00eautico permite, por via da linguagem, acessar os conte\u00fados conscientes e inconscientes do sujeito, trazendo \u00e0 tona a sua subjetividade, t\u00e3o necess\u00e1ria para o encaminhamento do trabalho cl\u00ednico fonoaudiol\u00f3gico.Em rela\u00e7\u00e3o a \u00e1rea de atua\u00e7\u00e3o dos participantes, chama aten\u00e7\u00e3o a predomin\u00e2ncia de profissionais que atuam na \u00e1rea da linguagem. A predomin\u00e2ncia de fonoaudi\u00f3logos que atuam clinicamente na \u00e1rea da linguagem pode ser justificada pelo fato de a linguagem ser um dos pilares essenciais para o estabelecimento e sustenta\u00e7\u00e3o do v\u00ednculo. Pois, \u00e9 por meio da linguagem que todo ser humano se constitui como sujeito, compreende o mundo e age sobre ele. A rela\u00e7\u00e3o terap\u00eautica deve, tamb\u00e9m, ser considerada na reabilita\u00e7\u00e3o de sujeitos que apresentam dor orofacial cr\u00f4nica. Segundo a autora, tal rela\u00e7\u00e3o amplia a escuta do terapeuta, sendo poss\u00edvel auxiliar o sujeito no al\u00edvio de sua dor, na medida em que a sua hist\u00f3ria de vida \u00e9 considerada para a compreens\u00e3o de seus sintomas.Al\u00e9m disso, o v\u00ednculo terap\u00eautico \u00e9 associado a significativas melhorias das habilidades comunicativas de sujeitos em tratamento fonoaudiol\u00f3gico. Nesse mesmo estudo, o v\u00ednculo, tamb\u00e9m, est\u00e1 associado ao fato dos pacientes se sentirem valorizados e escutados pelo profissional e n\u00e3o apenas concebidos como consumidores e compradores de pr\u00f3teses auditivas.Conv\u00e9m ressaltar que, apesar de a literatura da \u00e1rea da audiologia reconhecer a import\u00e2ncia do v\u00ednculo entre o fonoaudi\u00f3logo e o paciente no trabalho cl\u00ednico audiol\u00f3gico, foi restrito o n\u00famero de audiologistas que aceitaram participar da presente pesquisa. De acordo com estudo voltado \u00e0 reabilita\u00e7\u00e3o audiol\u00f3gica de pessoas idosas, o v\u00ednculo terap\u00eautico \u00e9 considerado fundamental, na medida em que impacta na diminui\u00e7\u00e3o do adiamento de consultas e na ades\u00e3o ao tratamento propostoOutro ponto que merece aten\u00e7\u00e3o, nos resultados evidenciados na .No eixo 1, no qual, de acordo com a . Tamb\u00e9m h\u00e1 a necessidade de o paciente ser considerado, compreendendo-o como um ser biopsicossocial, para que seja poss\u00edvel ressignificar a ang\u00fastia e o sintoma que se apresenta a ele. E tal feito s\u00f3 se torna poss\u00edvel por meio da rela\u00e7\u00e3o estabelecida entre paciente e terapeuta, a qual permite ao profissional reconhecer a necessidade do sujeito que o busca e, assim, intervir de forma mais efetiva, auxiliando-o na mitiga\u00e7\u00e3o de seu sofrimento,23.Nessa dire\u00e7\u00e3o, a rela\u00e7\u00e3o vincular, constitu\u00edda em \u00e2mbito terap\u00eautico, \u00e9 perpassada pela coexist\u00eancia do paralelo entre as experi\u00eancias afetivas vivenciadas pelos sujeitos ao longo de sua hist\u00f3ria e as experi\u00eancias relacionais elaboradas no espa\u00e7o terap\u00eautico, conforme proposto pela teoria do apego. De acordo com estudos da Sa\u00fade Coletiva, uma escuta qualificada maximiza o potencial terap\u00eautico e contribui para a consolida\u00e7\u00e3o da rela\u00e7\u00e3o terap\u00eautica, na medida em que respeita a singularidade do paciente, fortalecendo a confian\u00e7a e a participa\u00e7\u00e3o dos envolvidos no processo terap\u00eautico.Nessa perspectiva, seguindo com o primeiro subeixo, outra parte dos participantes da pesquisa relacionaram v\u00ednculo terap\u00eautico \u00e0 escuta, confian\u00e7a, acolhimento, entre outros. Uma escuta terap\u00eautica qualificada promove uma aten\u00e7\u00e3o hol\u00edstica, capaz de fortalecer la\u00e7os vinculares, viabilizando uma aproxima\u00e7\u00e3o entre o profissional e as verdades fidedignamente relacionadas ao real sofrimento do sujeito.No que concerne a confian\u00e7a, a mesma deve ser considerada como um dos pontos primordiais do trabalho terap\u00eautico, pois permite que o paciente se sinta \u00e0 vontade e seguro para compartilhar a sua hist\u00f3ria de vida, promovendo intera\u00e7\u00f5es mais aut\u00eanticas, rumo a reelabora\u00e7\u00e3o do sintoma. Mas, tal confian\u00e7a s\u00f3 se torna poss\u00edvel com base no acolhimento direcionado ao paciente, levando- o a se sentir seguro para trazer \u00e0 tona a sua singularidade.Acerca do papel do v\u00ednculo terap\u00eautico, na pr\u00e1tica cl\u00ednica fonoaudiol\u00f3gica, observou-se que 38,5% dos profissionais entende o v\u00ednculo terap\u00eautico como base fundamental para sua pr\u00e1tica cl\u00ednica. O v\u00ednculo terap\u00eautico \u00e9 apontado como primordial para o delineamento do trabalho terap\u00eautico, pois, para al\u00e9m da constru\u00e7\u00e3o de uma base segura que auxilia o paciente a abordar as suas demandas, a rela\u00e7\u00e3o entre o pr\u00f3prio paciente e o cl\u00ednico pode contribuir para que o sujeito, em sofrimento, possa ressignificar os seus v\u00ednculos afetivos anteriores. Conforme a teoria do apego, principalmente, em circunst\u00e2ncias nas quais os sujeitos cresceram em contextos interpessoais baseados na desconfian\u00e7a e no medo, o terapeuta pode assumir uma posi\u00e7\u00e3o capaz de promover um v\u00ednculo seguro que leve o paciente a se deparar com um outro modelo de rela\u00e7\u00e3o, apoiado em um elo que viabilize confian\u00e7a e seguran\u00e7a, reelaborando rela\u00e7\u00f5es dif\u00edceis vivenciadas em situa\u00e7\u00f5es pregressas.Tamb\u00e9m, segundo uma perspectiva psicanal\u00edtica, o v\u00ednculo terap\u00eautico deve ser considerado como fator subjacente a todo fazer cl\u00ednico. Pois, \u00e9 uma condi\u00e7\u00e3o necess\u00e1ria para o encaminhamento do trabalho terap\u00eautico, ou seja, um elemento que perpassa toda a atividade cl\u00ednica, sem o qual, tendenciosamente, n\u00e3o h\u00e1 possibilidades de tratamento, cuidado e/ou ressignifica\u00e7\u00e3o do sintoma. Nessa dire\u00e7\u00e3o, o v\u00ednculo terap\u00eautico \u00e9 capaz de potencializar, de forma significativa, o engajamento, a motiva\u00e7\u00e3o, a autonomia e participa\u00e7\u00e3o social dos sujeitos dentro e fora do setting terap\u00eautico.Motiva\u00e7\u00e3o e engajamento foram associados ao papel do v\u00ednculo terap\u00eautico, na vis\u00e3o de 8,3% dos fonoaudi\u00f3logos, participantes da presente pesquisa. Segundo estudo pautado na sa\u00fade coletiva, a rela\u00e7\u00e3o terap\u00eautica, na medida em que abre espa\u00e7o para que o sujeito explicite as suas particularidades, permite que ele compreenda o seu papel no trabalho a ser desenvolvido, levando-o a assumir uma posi\u00e7\u00e3o ativa na rela\u00e7\u00e3o com o cl\u00ednico.Parte consider\u00e1vel de 25% dos fonoaudi\u00f3logos relacionou o v\u00ednculo \u00e0 evolu\u00e7\u00e3o e ao desenvolvimento da terapia. Sobre essa rela\u00e7\u00e3o, cabe ressaltar que o v\u00ednculo terap\u00eautico n\u00e3o deve ser associado apenas a \u201ccura\u201d ou supress\u00e3o do sintoma, mas, como uma oportunidade que permite ao paciente ressignificar a sua hist\u00f3ria de vida, suas dores e v\u00ednculos anteriores. De acordo com a Pol\u00edtica Nacional de Promo\u00e7\u00e3o da Sa\u00fade, os cuidados voltados a sa\u00fade n\u00e3o deveriam se limitar somente a recupera\u00e7\u00e3o da doen\u00e7a, mas a uma atividade na qual o profissional, mediante a uma escuta qualificada e acolhedora, promova a maximiza\u00e7\u00e3o da autonomia, empoderamento e participa\u00e7\u00e3o social do paciente, auxiliando-o no processo de se tornar autor da sua pr\u00f3pria hist\u00f3ria de forma ativa e conscienteNo que se refere especificamente a compreens\u00e3o dos profissionais fonoaudi\u00f3logos acerca dos sentidos que o v\u00ednculo terap\u00eautico assume na pr\u00e1tica cl\u00ednica fonoaudiol\u00f3gica, o mesmo foi postulado como parte essencial para o delineamento e desfecho do processo terap\u00eautico, sendo capaz de potencializar os fatores de motiva\u00e7\u00e3o, engajamento e ajuda ao sujeito, na ressignifica\u00e7\u00e3o de seu sintoma."}
+{"text": "To describe the development and validation of a test, called BATUTA, that assesses the musical perception of people with hearing impairment that are hearing aid (HA) users. BATUTA is a computerized test with 35 subtests, divided into the rhythm, pitch, and timbre modules, and the participants must answer whether the sound samples and/or parts of the songs, presented in pairs, are the same or not.The BATUTA creation process consisted of four stages: test development, submission to the expert committee for content validation; pilot application with 51 normal hearing participants and retest to validate reliability. The process was based on several recommendations for the development and validation of musical assessment instruments. A deep investigation of the guidelines related to sound samples used, musical attributes evaluated, testing environment and the most appropriate response method was undertaken to ensure dependability.The Content Validity Index (CVI) and expert agreement rates, when analyzed with the committee's recommendations, resulted in corrections and new audio recordings to ensure compliance to the test. The pilot test scores indicated internal consistency and the retest confirmed the reliability of BATUTA.The results demonstrated the viability of BATUTA to assess the musical perception of people with hearing impairment that are HA users. However, the same progress has not been observed in musical perception, which tends to be difficult compared to the perception of individuals with normal hearing.Noteworthy efforts have been undertaken in recent decades to enhance the speech perception of individuals with hearing impairment who use auxiliary hearing devices, whether Hearing Aids (HA) or Cochlear Implants (CI). Furthermore, the spectral and temporal differences observed between speech and music contribute to increasing the contrast in musical perception by users of these devices.The explanation for the low quality of musical perception by users of auxiliary hearing devices is rooted in the acoustic characteristics of music, which are hard to transduce and result in distortion of the final output.The human ear is sensitive to variations in phase, duration, and frequency, which translate into the sensation of pitch, present in the melody and harmony of music; and in the characteristics of rhythm related to the rate of repetition of sounds, as well as timbre, designated as the most complex of the musical elements because it integrates all others,6. Conversely, the richness of musical elements and the complexity of music convert the musical experience into a universal manifestation and highlight it as an important part of people's lives, whether they are hearing or not.The combination of the spectral elements pitch, melody, and harmony, and the temporal elements, along with timbre, makes music the most challenging of auditory stimuli.Therefore, music is a form of human expression with the potential to evoke memories and emotions. It is a facilitator for people to enjoy common interests and engage in collective activities. Furthermore, through music, people can interpret and assign meanings to their experiences and understand them better, which is why the effects of perception and appreciation of music have been pointed out as relevant to well-being,8, and to evaluate this population's musical perception-14.Given this perspective, several studies have been developed to understand the musical perception of people with hearing impairment, with particular emphasis on research focused on CI users. This situation justifies the development of research aimed at satisfying the users of this type of hearing device, including regarding the musical perception of this population.Despite the gradual increase in access to CIs for the Brazilian population with hearing impairment, there is a significant predominance in the recommendation of HAs , designed to evaluate the musical perception of people with hearing impairment who are HA users.Thus, this study aims to describe the development and validation process of a musical perception test called BATUTA,17 and the guide for developing and validating tests in Speech Therapy.The development and validation of BATUTA followed recommendations for content validation during the instrument-building processThe process comprised four stages: (1) Test development; (2) Content validation by an expert committee; (3) Pilot test administration to participants with normal hearing to assess internal consistency; (4) Retest administration to validate reliability. when presented in pairs.BATUTA is a computerized test with 35 subtests categorized into rhythm, pitch, and timbre modules . Partici. Researchers from the Music and Audiology areas participated. These conditions are relevant procedures to ensure evidence of validity based on the test content.The BATUTA's development was preceded by a systematic review that uncovered the panorama of musical perception evaluation in people with hearing impairment.The systematic review enables the control of heterogeneity, a common issue in music research. It demonstrated that employing synthesizers to evaluate instrument recognition and melody can yield inaccurate outcomes. The reason for these inaccuracies is that synthesizers fall short of replicating the instruments\u2019 authentic tonal quality, or 'timbre'Therefore, the sound sample recordings of the pitch and timbre modules comprised real instruments played by professional musicians. They were converted into MP3 files.The MP3 audio file recordings were converted to the MP4 audio and video standard, which were the basis for creating the videos generated in the Microsoft Photos video editor application. Then, the videos were uploaded to the YouTube video-sharing platform. Finally, their upload was made to the Google Forms research management application, where the first version of BATUTA was constructed.The videos, whose duration ranges from 13 s to 28 s, present the first sound with the number 1, a brief pause with the black screen, and the second sound with the number 2 . After wThe sound samples of the rhythm module were generated in the Audacity\u00ae 2.3.1 software, with a xylophone timbre built using a sampler at the frequency of 1,000 Hz. Each sample has an average duration of 10 s, with small, allowed variations to preserve the sequences of stimuli and complete rhythmic cycles.The rhythm module, designed to evaluate the element responsible for the speed and marking of beats and pauses in musical pieces, comprises pulse, tempo, and meter. The standard pulse for the subtest was set at 60 bpm beats, taken as a base one pulse per second, with subdivisions of 90 bpm and 120 bpm. and a decrease of 55% for ritardando. In turn, the sample meter subtests record the beats and pauses in the 3/4, 4/4, and 5/4 formats.From the protocol established by the 60 s of constant pulse, the sound samples of the tempo subtest were calculated proportionally, with an increase of 160% for accelerando played on the following instruments: cello, guitar, violin, piano, bassoon, flute, and clarinet, in the keys of C major and A major. In turn, the harmony subtest comprised recordings of the chords major, minor, and diminished, taking the notes C and A as fundamentals and playing on the piano.Regarding the pitch module, the melody subtest was expressed by the first bars of the song Asa Branca.It is worth mentioning the close relationship between melody and harmony with pitch, with the melody defined as the sequence of several pitches that comprise the musical phrase. Meanwhile, harmony comprises the vertical relationship between pitches, which, when played simultaneously, form the musical chordsCiranda Cirandinha , played on the cello, guitar, violin, piano, bassoon, flute, and clarinet in the key of C3 (256 Hz).The timbre module refers to the quality of sound and the discrimination of instruments playing the same musical notes. It was developed with recordings of the first bars of .Fourteen professional musicians, masters, and doctors in Music, or professionals of exceptional knowledge in the area, were invited to the committee of experts responsible for assessing the BATUTA's ability to accurately measure the phenomenon of musical perceptionThe invitation to the experts was made through an electronic message presenting BATUTA. After the musicians' positive response, they were sent the access link to BATUTA on Google Forms. The message exchange was private, and the experts, who had an average of 15 days to return the evaluation, worked individually and independently.The committee's analysis comprised listening to the samples of each subtest and responding to the following questions through a Likert scale: (1) Stimulus presentation time: (1) adequate, (2) long, and (3) short; (2) Quality of the stimulus recording: (1) good, (2) regular, and (3) bad; (3) Fulfillment of the objective to which the test proposes: (1) fully fulfills, (2) partially fulfills, and (3) does not fulfill.The experts had to answer five questions related to the test format: (1) The instructions for participants are; (2) The interface of BATUTA is; (3) The response format of BATUTA  is; (4) The choice of songs is; (5) The total time required to answer BATUTA is. Response alternatives through a Likert scale: inadequate; somewhat adequate; reasonably adequate; and totally adequate.The experts' involvement ended with an open-ended question: \u201cWhat improvements are needed in BATUTA?\u201d. This question was included in the evaluation process to allow them to offer suggestions and provide constructive feedback to enhance the test..The Content Validation Index (CVI) was used to measure the percentage of judges who agreed on certain aspects of the instrument and its items. In cases where the CVI was less than the recommended value of 80%, the samples were excluded or reformulated.Furthermore, the CVI data were cross-referenced with the responses to the open-ended question using a methodological triangulation approach. It involved analyzing numerical indicators alongside the arguments put forth by the expert committee membersThe sample included students, teachers, employees of a school-clinic, patient companions, and family members. They agreed to participate in the research by signing the Free and Informed Consent Term.Volunteers underwent audiometric evaluation before the BATUTA application. This evaluation involved conventional threshold tonal audiometry, assessing airway thresholds for frequencies ranging from 250 Hz to 8,000 Hz, and bone conduction for frequencies ranging from 500 Hz to 4,000 Hz in cases where airway thresholds exceeded 25 dB HL.Inclusion criteria comprised: (1) having auditory thresholds up to 25 dB HL bilaterally in the researched frequencies, (2) being at least 18 years old, and (3) not having cognitive impairments that hindered discrimination of the \u201cequal/different\u201d concepts, as assessed during the test familiarization section. There were no gender or education level distinctions among the volunteers. The exclusion criteria were: (1) being an amateur or professional musician, (2) having previous music education, and (3) being a HA user.. Among the participants, 70.6% were female, and 29.4% were male. The sample\u2019s age ranged from 19 to 55 years, with an average of 32.31 \u00b1 10.82.The convenience sample comprised 51 volunteers who met the inclusion criteria, with stimulus presentation through a speaker positioned at 0\u00ba Azimuth and 1 m away from the participant,22,23, at an intensity of 70 dBA as measured by a decibel meter,22. The computer used for testing was a Lenovo Yoga 520-14IKB notebook, combined with a 30-watt RMS Bose SoundTouch 10 wireless speaker.The pilot test application of BATUTA was carried out in a quiet room before the testing, which the same administrator supervised throughout the process.Participants underwent a familiarization sessionThe responses were tabulated in Microsoft Excel (version 16.0). A value of 1 (one) was assigned to correct responses, and a value of 0 (zero) was assigned to incorrect responses. The total number of correct answers for the 35 sound samples and for the rhythm, pitch, and timbre modules was calculated using inferential statistics..Given that BATUTA is an instrument with dichotomous responses (same/different), despite the Cronbach's alpha coefficient being the most well-known measure in evaluating internal consistency, the Kuder-Richardson (KR-20) test was applied, which is used as a reference for evaluating the internal consistency of instruments that use this type of variablesThe BATUTA's consistency in producing consistent results over time and space was evaluated through a retest. Fourteen participants, randomly selected from the initial sample, were invited to complete the same version of BATUTA.. The agreement of participant responses at the two different times was assessed using the Kappa coefficient (k).The retest was conducted approximately 20 days after the initial test, which was deemed sufficient to prevent test recall and ensure no clinical changes had occurred in the participants,17. The CVI scores for the BATUTA modules were 80% for rhythm, 75% for pitch, and 86% for timbre. The experts\u2019 responses were analyzed for the Content Validity Index (CVI) and the percentage of agreement among the committee membersDespite the high CVI score for the rhythm module, the experts pointed out problems in meeting the objectives of the meter subtest (64%).The CVI data for the recording quality analysis and objectives of the harmony subtest recorded scores below 78%, resulting in poor performance for the pitch module (75%)..Once the quantitative phase of BATUTA's content validation was completed, the qualitative analysis of the descriptive responses provided by the expert committee on \u201cWhat could be improved in BATUTA\u201d began. Thus, the observations and recommendations of the experts were carefully read and analyzed, as described in Therefore, the recording of the sound stimuli of the harmony subtest, whose quality was classified as regular by four experts and poor by one of them, was corrected with new recordings. Regarding the compliance of this same subtest, it was possible to relate the results of the experts' evaluation to the quality of the audio files based on comments about the presence of echo in the samples. The re-recording corrected the problems pointed out for the harmony item.The experts' observations regarding the instructions and the guidelines at the beginning of the test or before the presentation of the sound samples resulted in more detailed instructions at the beginning of each module and/or subtest.After the adjustments, the pilot test was applied with the 51 participants, who listened to each of the 35 sound samples and answered \u201csame/different\u201d to the questions regarding the modules: (1) rhythm: Are the samples?; (2) pitch: Are the song snippets?/Are the chords?; (3) timbre: Are song snippets played by instruments? . The average response time was 20 minutes, and repetitions were allowed, although not encouraged.The participant and the examiner were in the room during the pilot testRegarding participants\u2019 performance in the test, the results revealed that the lowest index was 82%, corresponding to the correct response for 29 samples, and 54.89% of the participants obtained results above average. The Kuder-Richardson test (KR-20) was used in evaluating the internal consistency of the pilot test. The result for the 35 questions with dichotomous responses, expressed as \u201csame/different\u201d, as estimated by statistical analysis, was 0.62.The reliability of BATUTA was validated through a retest test conducted with 14 participants drawn from the initial group. The results of the two applications of the test were used to calculate the Kappa coefficient (K), which resulted in a value of 0.89.. Furthermore, there is a lack of guidelines for constructing and using tests in Speech Therapy.Despite the availability of many assessment tools for speech therapy, only a few undergo the validation process to gather evidence for their endorsement.Regarding musical perception, the national literature includes an instrument designed to assess the recognition of traditional Brazilian melodies and examine the performance of children with normal hearingBATUTA, in this same trend, presents the uniqueness of containing excerpts from the Brazilian folk songbook and is the first musical perception test that evaluates the attributes of rhythm, pitch, and timbre developed for the Brazilian population. Since music is not a culturally neutral phenomenon, it is reasonable to consider this a promising aspect of the test.. Moreover, it was possible to systematize guidelines regarding musical elements evaluated, test environment, mode of presentation of sound stimuli, and type of response suitable for the proposed testing to structure the concepts and the argument of the function measured for the elaboration of a robust construct.The performance of a systematic review on musical perception tests in people with hearing impairment before the construction of BATUTA produced evidence that allowed us to overcome difficulties encountered in previous studies related to the heterogeneity in music. Although the study focused on CI users, these findings can be applied to the type of sound stimuli used in the tests. The filters and algorithms employed in HA and CI programming restrict the dynamic range, making it more challenging to perceive synthesized sounds through HAs. Consequently, this finding motivated the decision to record sound samples for the pitch and timbre modules using real instruments instead of generating synthesized sounds.An example illustrating this is the result of a meta-analysis, which revealed that cochlear implant (CI) users face greater difficulty perceiving melody compared to timbre, particularly when timbre is assessed using digitized sounds and melody tests are conducted with synthesized samples.Since content validation plays a crucial role in the selection and application of an instrument, the experts chosen for this stage were selected based on their training, qualifications, and availability. These professionals were considered experts in the field and acted as judges, evaluating and confirming the clarity, relevance, and fidelity of BATUTA. Since there was no response for inadequate, it can be concluded that the experts' interaction with BATUTA was good.The percentage of agreement among the committee of experts regarding the format of the test was above 90% for all questions, which is desirableThe triangulation of the CVI results with the categories, or thematic axes, proposed from the responses of what could improve in BATUTA allowed the correlation of objective data with descriptive content. Furthermore, it ensured rigor and objectivity in the analysis of the arguments expressed by the experts. From these data, it was possible to implement improvements in sound samples to achieve the proposed objectives.. It suggests that the experts were meticulous in evaluating BATUTA, and adherence to their recommendations indicates test quality.Results show distinct hearing patterns among laypersons, students, and music teachers. Notably, teachers demonstrated a wider range of technical criteria for performance analysisThe analysis of the pilot test results showed that 54.89% of the participants scored above average for the 35 items surveyed and that even those with lower results obtained a fair number of correct answers. In other words, participants who answered 29 questions correctly had an accuracy rate of 82%.Based on this context, it can be concluded that the participants' responses were consistent. The BATUTA's basis on protocols designed to assess musical perception in individuals with hearing impairment, coupled with the consistent data obtained during the pilot test, indicates the feasibility of using BATUTA to evaluate the musical perception of individuals with HI who are HA users..The testing conditions recommended for individuals with hearing impairment who use HA are similar to those described in the methodology applied to normal hearing participants, except for stimulus intensity. Studies included in the systematic review propose that HI participants should adjust the volume of the stimuli presented through a speaker to a comfortable audibility level. An interpretation of the coefficient suggests that a value of 0.89 indicates excellent agreement and represents the reliability of BATUTA.The reliability of BATUTA was assessed by examining the consistency of measurements under test-retest conditions. The agreement of answers among participants was evaluated using the Kappa coefficient, which ranges from -1 to 1.The Kappa coefficient was chosen due to its recommendation for evaluating agreement measures in the healthcare field, particularly in instruments with nominal categories.Reliability is referred to by several terms, such as fidelity, equivalence, consistency, objectivity, reproducibility, stability, and homogeneity, depending on the literature and the aspect of the test being emphasizedFor assessing internal consistency, options include the Kuder-Richardson test and Cronbach's alpha coefficient. While the alpha coefficient is commonly used, the Kuder-Richardson (KR-20) technique is recommended for scales with dichotomous responses like BATUTA, which uses the options of \u201csame/different\u201d..Regarding interpretation, both Cronbach's alpha coefficient and Kuder-Richardson values above 0.70 are considered ideal, although this value is not universally accepted. Some studies suggest that values close to 0.60 are satisfactory, leading to the acceptance of BATUTA's internal consistency with a result of 0.62In summary, the interpretation of BATUTA results proposes that each correct answer is awarded 1.0 point, and the final scores are analyzed as follows: \u2265 33 correct (above 94%): excellent musical perception; 29 to 32 correct: good musical perception; 25 to 28 correct: reasonable musical perception; \u2264 24 correct (below 68%): difficulty in musical perception.The development of BATUTA was presented, including the theory and construct behind it, the reasons for its creation, and the intended target population.Adherence to established guidelines in tests and protocols for assessing musical perception in individuals with hearing impairment, along with the results of content validation, internal consistency, and reliability stages of the pilot test conducted with individuals with normal hearing, indicated the suitability of BATUTA for evaluating musical perception in individuals with HI who use HA.BATUTA is suitable for use in its intended population. Future studies can compare musical perception between individuals with normal hearing and those with hearing impairment, between hearing aid users with specific adjustments for music appreciation, and between hearing aid users and cochlear implant users. Furthermore, they can explore other possibilities related to researching musical perception in this population.BATUTA has the potential to offer an innovative perspective in speech therapy, both in the selection and recommendation of HA and in monitoring users of assistive hearing devices who seek to engage with the musical realm. -3. Contudo, o mesmo progresso n\u00e3o foi observado no dom\u00ednio da percep\u00e7\u00e3o musical, que tende a ser dif\u00edcil quando comparada \u00e0 percep\u00e7\u00e3o de indiv\u00edduos ouvintes.Not\u00e1veis esfor\u00e7os foram empreendidos nas \u00faltimas d\u00e9cadas para melhorar a percep\u00e7\u00e3o da fala de pessoas com defici\u00eancia auditiva, usu\u00e1rias de dispositivos auditivos auxiliares, sejam eles aparelhos de amplifica\u00e7\u00e3o sonora individual (AASI) ou implantes cocleares (IC). Adicionalmente, as diferen\u00e7as espectrais e temporais observadas entre a fala e a m\u00fasica contribuem para acentuar o contraste na percep\u00e7\u00e3o musical por usu\u00e1rios desses dispositivos.A explica\u00e7\u00e3o para a baixa qualidade na percep\u00e7\u00e3o musical por usu\u00e1rios de dispositivos auditivos auxiliares est\u00e1 fundamentada em caracter\u00edsticas ac\u00fasticas da m\u00fasica, que s\u00e3o de dif\u00edcil transdu\u00e7\u00e3o e resultam na distor\u00e7\u00e3o do resultado final(pitch), presente na melodia e na harmonia da m\u00fasica; e nas caracter\u00edsticas do ritmo, relacionado \u00e0 taxa de repeti\u00e7\u00e3o dos sons, tanto quanto do timbre, designado como o mais complexo dos elementos musicais por integrar todos demais.O ouvido humano \u00e9 sens\u00edvel a varia\u00e7\u00f5es sonoras de fase, dura\u00e7\u00e3o e frequ\u00eancia, que se traduzem em termos da sensa\u00e7\u00e3o de tonalidade pitch, melodia e harmonia e dos elementos temporais, somados ao timbre, faz da m\u00fasica o mais desafiador dos est\u00edmulos auditivos,6. Em contrapartida, a riqueza dos elementos musicais e a complexidade da m\u00fasica, convertem a experi\u00eancia musical em uma manifesta\u00e7\u00e3o universal e a evidenciam como uma parte importante da vida das pessoas, sejam elas ouvintes ou n\u00e3o.O conjunto dos elementos espectrais .Destaca-se, assim, o papel da m\u00fasica como uma relevante forma de express\u00e3o humana, com potencial para evocar lembran\u00e7as e emo\u00e7\u00f5es, al\u00e9m de funcionar como um facilitador para que as pessoas desfrutem de interesses em comum e realizem atividades coletivamente. Ademais, por meio da m\u00fasica as pessoas conseguem interpretar e atribuir significados para suas experi\u00eancias e compreend\u00ea-las melhor, raz\u00e3o pela qual os efeitos da percep\u00e7\u00e3o e a aprecia\u00e7\u00e3o musical t\u00eam sido apontadas como relevantes para o bem-estar,8, assim como para avaliar a percep\u00e7\u00e3o musical desse p\u00fablico-14.Diante dessa perspectiva, v\u00e1rios estudos foram desenvolvidos com a finalidade de compreender a percep\u00e7\u00e3o musical de pessoas com defici\u00eancia auditiva, sendo dado maior destaque para pesquisas focadas em usu\u00e1rios de IC, circunst\u00e2ncia que justifica o desenvolvimento de pesquisas voltadas \u00e0 satisfa\u00e7\u00e3o dos usu\u00e1rios de desse tipo de dispositivo auditivo, inclusive no que se refere \u00e0 percep\u00e7\u00e3o musical desta popula\u00e7\u00e3o.Apesar do crescimento gradual no acesso da popula\u00e7\u00e3o brasileira com defici\u00eancia auditiva ao IC, h\u00e1 uma significativa predomin\u00e2ncia na indica\u00e7\u00e3o de AASI , destinado a avaliar a percep\u00e7\u00e3o musical de pessoas com defici\u00eancia auditiva, usu\u00e1rias de AASI.Assim, o presente estudo tem como objetivo descrever o processo de desenvolvimento e de valida\u00e7\u00e3o de um teste de percep\u00e7\u00e3o musical, denominado BATUTA,17 e no guia de recomenda\u00e7\u00f5es para elabora\u00e7\u00e3o e processo de valida\u00e7\u00e3o de testes em Fonoaudiologia.O desenvolvimento e a valida\u00e7\u00e3o do BATUTA foram baseados nas recomenda\u00e7\u00f5es para valida\u00e7\u00e3o de conte\u00fado durante os processos de constru\u00e7\u00e3o de instrumentosO processo se deu em quatro etapas: (1) Desenvolvimento do teste (2); Submiss\u00e3o do teste ao comit\u00ea de especialistas para valida\u00e7\u00e3o de conte\u00fado; (3) Aplica\u00e7\u00e3o do teste piloto em participantes com audi\u00e7\u00e3o normal para valida\u00e7\u00e3o de coer\u00eancia interna; (4) Aplica\u00e7\u00e3o do reteste para valida\u00e7\u00e3o de confiabilidade.pitch e timbre  Tempo de apresenta\u00e7\u00e3o dos est\u00edmulos (1) adequado (2) longo (3) curto; (2) Qualidade da grava\u00e7\u00e3o dos est\u00edmulos (1) boa (2) regular (3) ruim (3); Cumprimento do objetivo a que o teste se prop\u00f5e (1) cumpre totalmente (2) cumpre parcialmente (3) n\u00e3o cumpre.A an\u00e1lise do comit\u00ea consistiu na audi\u00e7\u00e3o das amostras de cada subteste e nas respostas das seguintes quest\u00f5es por meio de uma escala As instru\u00e7\u00f5es para os participantes s\u00e3o; (2) A interface do BATUTA \u00e9; (3) O formato de resposta do BATUTA  \u00e9; (4) A escolha das can\u00e7\u00f5es \u00e9; (5) O tempo total necess\u00e1rio para responder o BATUTA \u00e9. Com alternativas de resposta, por meio de escala Likert: inadequado; pouco adequado; razoavelmente adequado; e totalmente adequado.Os especialistas tamb\u00e9m foram solicitados a responder cinco quest\u00f5es, relativas ao formato do teste: (1) O que precisa melhorar no BATUTA? A inser\u00e7\u00e3o desta pergunta na avalia\u00e7\u00e3o teve como objetivo lhes proporcionar um espa\u00e7o para fazer sugest\u00f5es e fornecer um feedback produtivo para o aperfei\u00e7oamento do teste.A participa\u00e7\u00e3o dos especialistas foi finalizada com uma quest\u00e3o aberta: .O \u00cdndice de Valida\u00e7\u00e3o de Conte\u00fado (IVC) foi utilizado para medir a porcentagem de ju\u00edzes que estava em concord\u00e2ncia sobre determinados aspectos do instrumento e de seus itens. Nos casos em que o IVC foi inferior ao valor recomendado de 80%, as amostras foram exclu\u00eddas ou reformuladas.Adicionalmente, os dados do IVC foram correlacionados com as respostas expressas na \u00faltima pergunta do teste piloto, por meio da triangula\u00e7\u00e3o metodol\u00f3gica dos indicadores num\u00e9ricos e da argumenta\u00e7\u00e3o oferecida pelos membros do comit\u00ea de especialistasA amostra foi composta por estudantes, docentes e funcion\u00e1rios de uma cl\u00ednica-escola, al\u00e9m de acompanhantes de pacientes e familiares, que expressaram sua concord\u00e2ncia em participar da pesquisa por meio da assinatura do Termo de Consentimento Livre e Esclarecido (TCLE), aprovado pelo comit\u00ea de \u00e9tica conforme parecer consubstanciado n. 3.468.404.Os volunt\u00e1rios foram submetidos \u00e0 avalia\u00e7\u00e3o audiom\u00e9trica previamente \u00e0 aplica\u00e7\u00e3o do BATUTA, por meio da realiza\u00e7\u00e3o de audiometria tonal liminar convencional, com pesquisa dos limiares de via a\u00e9rea para as frequ\u00eancias de 250 Hz a 8.000 Hz, e de via \u00f3ssea para as frequ\u00eancias de 500 Hz a 4.000 Hz, nos casos em que os limiares de via a\u00e9rea apresentaram valores superiores a 25 dB NA.Como crit\u00e9rios de inclus\u00e3o, foram estabelecidos (1) apresentar resultado dos limiares auditivos de at\u00e9 25 dB NA nas frequ\u00eancias pesquisadas, bilateralmente; (2) ter idade m\u00ednima de 18 anos e (3) n\u00e3o apresentar altera\u00e7\u00f5es cognitivas que impedissem a discrimina\u00e7\u00e3o dos conceitos igual/diferente, detect\u00e1veis na se\u00e7\u00e3o de familiariza\u00e7\u00e3o com o teste. Ainda, n\u00e3o foram feitas distin\u00e7\u00f5es de g\u00eanero e grau de escolaridade entre os volunt\u00e1rios. Os crit\u00e9rios de exclus\u00e3o adotados foram: (1) ser m\u00fasico amador ou profissional; (2) ser ou ter sido estudante de m\u00fasica e (3) ser usu\u00e1rio de dispositivos auditivos auxiliares.. Dentre os participantes, 70,6% eram do g\u00eanero feminino e 29,4% do g\u00eanero masculino. A idade da amostra variou entre 19 e 55 anos, com m\u00e9dia de 32,31 \u00b1 10,82.Cinquenta e um volunt\u00e1rios que cumpriram os crit\u00e9rios de inclus\u00e3o compuseram uma amostra de conveni\u00eancia, com apresenta\u00e7\u00e3o dos est\u00edmulos por meio de uma caixa ac\u00fastica posicionada \u00e0 0\u00ba Azimute e a 1m de dist\u00e2ncia do participante,22,23, na intensidade de 70 dBA aferida por decibel\u00edmetro,22. O computador utilizado para a testagem foi o notebook Lenovo Yoga 520-14IKB, combinado \u00e0 caixa ac\u00fastica Bose SoundTouch 10 wireless speaker de 30 wats RMS.A aplica\u00e7\u00e3o do teste piloto do BATUTA foi realizada em uma sala silenciosa, que foi acompanhada pela mesma aplicadora durante todo o processo.Houve uma sess\u00e3o de familiariza\u00e7\u00e3o dos participantes previamente \u00e0 testagemMicrosoft Excel (vers\u00e3o 16.0). Quando a resposta correta era igual foi atribu\u00eddo o valor 1 (um) quando a resposta foi igual e 0 (zero) quando a resposta foi diferente, em toda a coluna correspondente \u00e0 amostra sonora avaliada. No caso de a resposta correta ser diferente, foi atribu\u00eddo o valor o 1 (um) quando a resposta foi diferente e 0 (zero) quando a resposta foi igual. A soma dos acertos para as 35 amostras sonoras, tanto quanto para os valores dos m\u00f3dulos ritmo, pitch e timbre, foram calculadas por meio de estat\u00edstica inferencial.As respostas foram tabuladas no alfa de Cronbach ser a medida mais conhecida na avalia\u00e7\u00e3o da consist\u00eancia interna, foi aplicado o teste Kuder-Richardson (KR-20), utilizado como refer\u00eancia para avaliar a consist\u00eancia interna de instrumentos que contam com esse tipo de vari\u00e1veis.Sendo o BATUTA um instrumento com respostas dicot\u00f4micas , apesar do coeficiente de A capacidade do BATUTA em reproduzir um resultado de forma consistente, no tempo e no espa\u00e7o, foi mensurada por meio da aplica\u00e7\u00e3o do reteste. Foram convidados 14 participantes, escolhidos aleatoriamente dentre os que constitu\u00edram a amostra inicial, para responderem a mesma vers\u00e3o do BATUTA.. O coeficiente de Kappa (k) foi calculado para medir a concord\u00e2ncia das respostas dos participantes nos dois momentos distintos.A nova administra\u00e7\u00e3o do BATUTA se deu cerca de 20 dias ap\u00f3s a primeira testagem, sendo este um per\u00edodo que foi considerado longo o suficiente para evitar a lembran\u00e7a do teste e curto o suficiente para garantir que n\u00e3o tenha ocorrido nenhuma mudan\u00e7a cl\u00ednica nos participantes,17. Os escores do IVC para os m\u00f3dulos BATUTA foram ritmo 80%, pitch 75% e timbre 86% e os resultados da avalia\u00e7\u00e3o para cada subteste do BATUTA est\u00e3o relacionados na As respostas dos especialistas foram analisadas quanto ao IVC e \u00e0 porcentagem de concord\u00e2ncia entre os membros do comit\u00eaApesar do alto \u00edndice de IVC para o m\u00f3dulo de ritmo, os especialistas apontaram problemas no cumprimento dos objetivos do subteste compasso (64%).pitch (75%).Os dados do IVC, para a an\u00e1lise da qualidade de grava\u00e7\u00e3o e objetivos do subteste harmonia registraram escores abaixo de 78% e resultaram em baixo desempenho para o m\u00f3dulo de A .Uma vez conclu\u00edda a fase quantitativa de valida\u00e7\u00e3o de conte\u00fado do BATUTA deu-se in\u00edcio ao processo de an\u00e1lise qualitativa das respostas descritivas oferecidas pelo comit\u00ea de especialistas sobre \u201cO que poderia melhorar no BATUTA\u201d. Desse modo, as observa\u00e7\u00f5es e recomenda\u00e7\u00f5es dos especialistas foram criteriosamente lidas e analisadas, conforme descrito no regular por quatro especialistas e ruim por um deles, foi corrigida com novas grava\u00e7\u00f5es. No que se refere ao cumprimento desse mesmo subteste, foi poss\u00edvel relacionar os resultados da avalia\u00e7\u00e3o dos especialistas \u00e0 qualidade dos \u00e1udios, a partir dos coment\u00e1rios sobre a presen\u00e7a de eco nas amostras, e a regrava\u00e7\u00e3o corrigiu os problemas apontados para o item harmonia.Assim, a grava\u00e7\u00e3o dos est\u00edmulos sonoros do subteste harmonia, cuja qualidade foi classificada como As observa\u00e7\u00f5es dos especialistas referentes \u00e0s instru\u00e7\u00f5es e \u00e0s consignas no in\u00edcio do teste, ou antes da apresenta\u00e7\u00e3o das amostras sonoras, resultaram em orienta\u00e7\u00f5es mais detalhadas ao in\u00edcio de cada m\u00f3dulo e/ou subteste.igual/diferente para as perguntas referentes aos m\u00f3dulos: (1) ritmo: as amostras s\u00e3o?; (2) pitch: os trechos da can\u00e7\u00e3o s\u00e3o?/os acordes s\u00e3o?; (3) timbre: os trechos da can\u00e7\u00e3o s\u00e3o tocados por instrumentos?Ap\u00f3s as adequa\u00e7\u00f5es deu-se in\u00edcio \u00e0 aplica\u00e7\u00e3o do teste piloto com os 51 participantes, que ouviram cada uma das 35 amostras sonoras, e responderam  . O tempo m\u00e9dio de resposta foi de 20 minutos as repeti\u00e7\u00f5es foram permitidas, embora n\u00e3o fossem encorajadas.Estiveram presentes na sala durante a realiza\u00e7\u00e3o do teste piloto o participante e o examinadorOs resultados dos 51 participantes, considerando os valores de 1 (um) e 0 (zero), atribu\u00eddos para as respostas igual/diferente das 35 amostras sonoras, assim como dos m\u00f3dulos do Batuta, est\u00e3o descritos na No que se refere ao desempenho dos participantes no teste, os resultados revelaram que o menor \u00edndice foi 82%, correspondente \u00e0 resposta correta para 29 amostras, e 54,89% dos participantes obtiveram resultados acima da m\u00e9dia. O n\u00famero de acertos, o \u00edndice de acertos e a propor\u00e7\u00e3o de participantes com valores iguais ou superiores para cada faixa de acertos est\u00e3o descritos na O teste de Kuder-Richardson (KR-20) foi utilizado na avalia\u00e7\u00e3o da consist\u00eancia interna do teste piloto. O resultado para as 35 quest\u00f5es com respostas dicot\u00f4micas, expressas em igual/diferente, estimado pela an\u00e1lise estat\u00edstica foi de 0.62.Kappa (K) que resultou no valor de 0,89.A confiabilidade do BATUTA foi validada por meio do teste-reteste conduzido com 14 participantes extra\u00eddos do grupo inicial. Os resultados das duas aplica\u00e7\u00f5es do teste foram utilizados para o c\u00e1lculo do coeficiente de . Al\u00e9m disso, h\u00e1 falta de diretrizes na constru\u00e7\u00e3o e no uso de testes em Fonoaudiologia.Apesar do avan\u00e7o nos instrumentos de avalia\u00e7\u00e3o dispon\u00edveis para a pr\u00e1tica fonoaudiol\u00f3gica, um n\u00famero limitado \u00e9 submetido ao processo de valida\u00e7\u00e3o em busca de evid\u00eancias por sua homologa\u00e7\u00e3o.No campo da percep\u00e7\u00e3o musical, a literatura nacional \u00e9 representada por um instrumento desenvolvido para avaliar o reconhecimento de melodias tradicionais brasileiras e investigar o desempenho de crian\u00e7as com audi\u00e7\u00e3o normalpitch e timbre, desenvolvido para a popula\u00e7\u00e3o brasileira. Posto que que a m\u00fasica n\u00e3o \u00e9 um fen\u00f4meno culturalmente neutro, \u00e9 razo\u00e1vel considerar que este \u00e9 um aspecto promissor do teste.O BATUTA, nesta mesma tend\u00eancia, apresenta a singularidade de conter trechos do cancioneiro folcl\u00f3rico brasileiro e \u00e9 o primeiro teste de percep\u00e7\u00e3o musical que avalia os atributos ritmo, . Ademais, foi poss\u00edvel sistematizar as diretrizes a respeito de elementos musicais avaliados, ambiente do teste, modo de apresenta\u00e7\u00e3o dos est\u00edmulos sonoros e tipo de resposta adequados para a testagem proposta, de modo a estruturar os conceitos e a argumenta\u00e7\u00e3o da fun\u00e7\u00e3o medida para a elabora\u00e7\u00e3o de um construto robusto.A realiza\u00e7\u00e3o de uma revis\u00e3o sistem\u00e1tica sobre os testes de percep\u00e7\u00e3o musical em pessoas com defici\u00eancia auditiva, previamente \u00e0 constru\u00e7\u00e3o do BATUTA, produziu evid\u00eancias que possibilitaram contornar dificuldades encontradas em estudos anteriores relacionados \u00e0 heterogeneidade presente na m\u00fasica. Ainda que o p\u00fablico pesquisado tenha sido de usu\u00e1rios de IC \u00e9 poss\u00edvel relacionar estes achados ao tipo de est\u00edmulo sonoro aplicado nos testes, pois os filtros e algoritmos que governam a programa\u00e7\u00e3o de AASIs e ICs fornecem uma faixa din\u00e2mica reduzida e, desse modo, ouvir um som sintetizado por meio de AASI tende a ser mais desafiador. Este resultado motivou a grava\u00e7\u00e3o das amostras sonoras dos m\u00f3dulos pitch e timbre com instrumentos reais, ao inv\u00e9s da gera\u00e7\u00e3o de sons sintetizados.Um exemplo deste contexto \u00e9 o resultado da metan\u00e1lise que evidenciou a dificuldade maior dos usu\u00e1rios de IC na percep\u00e7\u00e3o da melodia do que na percep\u00e7\u00e3o do timbre, em compara\u00e7\u00e3o aos grupos de ouvintes, com o timbre avaliado a partir de sons digitalizados e os testes de melodia feitos com amostras sintetizadasexperts neste dom\u00ednio, j\u00e1 que atuaram como ju\u00edzes e atestaram a clareza, pertin\u00eancia e fidedignidade do BATUTA.Sendo a valida\u00e7\u00e3o de conte\u00fado um fator determinante na escolha e/ou na aplica\u00e7\u00e3o do instrumento, a sele\u00e7\u00e3o dos especialistas para o cumprimento desta etapa considerou a forma\u00e7\u00e3o, a qualifica\u00e7\u00e3o e a disponibilidade dos profissionais, que foram considerados . Visto que n\u00e3o houve nenhuma resposta para inadequado pode-se concluir que a intera\u00e7\u00e3o dos especialistas com o BATUTA foi boa.A porcentagem de concord\u00e2ncia entre os membros do comit\u00ea de especialistas quanto ao formato do teste foi acima de 90% para todas as quest\u00f5es, o que \u00e9 desej\u00e1velA triangula\u00e7\u00e3o dos resultados do IVC com as categorias, ou eixos tem\u00e1ticos, propostos a partir das respostas do que poderia melhorar no BATUTA, permitiu a correla\u00e7\u00e3o dos dados objetivos com o conte\u00fado descritivo e garantiu rigor e objetividade \u00e0 an\u00e1lise dos argumentos expressos pelos especialistas. A partir destes dados foi poss\u00edvel implementar melhorias nas amostras sonoras para alcan\u00e7ar os objetivos propostos.performances. Assim, \u00e9 poss\u00edvel inferir que os especialistas foram exigentes na avalia\u00e7\u00e3o do BATUTA e que o atendimento \u00e0s recomenda\u00e7\u00f5es \u00e9 um indicador de qualidade do teste.\u00c9 interessante mencionar os resultados que indicam a presen\u00e7a de padr\u00f5es de audi\u00e7\u00e3o diferentes entre leigos, estudantes e professores de m\u00fasica, sendo os professores aqueles que utilizaram um repert\u00f3rio maior de crit\u00e9rios t\u00e9cnicos para a an\u00e1lise de A an\u00e1lise dos resultados do teste piloto demonstrou que 54,89% dos participantes apresentaram resultados acima da m\u00e9dia para os 35 itens pesquisados e que mesmo aqueles com menor resultado obtiveram um n\u00famero satisfat\u00f3rio de acertos. Isto \u00e9, os participantes que acertaram 29 quest\u00f5es, tiveram um \u00edndice de 82% de acerto.Diante deste cen\u00e1rio, \u00e9 poss\u00edvel concluir que as respostas dos participantes foram consistentes. A fundamenta\u00e7\u00e3o do BATUTA em protocolos desenvolvidos para avaliar a percep\u00e7\u00e3o musical de pessoas com DA, e o conjunto de dados homog\u00eaneos na aplica\u00e7\u00e3o do teste piloto participantes ouvintes, permitem inferir que sua aplica\u00e7\u00e3o na testagem da percep\u00e7\u00e3o musical de pessoas com DA, usu\u00e1rias de AASI, \u00e9 vi\u00e1vel..Conv\u00e9m apontar que as condi\u00e7\u00f5es de testagem recomendadas para pessoas com DA, usu\u00e1rias de AASI, s\u00e3o as mesmas descritas na metodologia aplicada aos participantes ouvintes, \u00e0 exce\u00e7\u00e3o da intensidade de apresenta\u00e7\u00e3o dos est\u00edmulos. Tal como evidenciado nos estudos inclu\u00eddos na revis\u00e3o sistem\u00e1tica, prop\u00f5e-se que este p\u00fablico tenha liberdade para ajustar o volume dos est\u00edmulos, apresentados em uma sala silenciosa por meio de caixa ac\u00fastica, a um n\u00edvel de audibilidade confort\u00e1velKappa, que pode variar de -1 a 1. A interpreta\u00e7\u00e3o do coeficiente sugere o valor de 0,89 para como indicador de \u00f3tima concord\u00e2ncia e representa a confiabilidade do BATUTA.A confiabilidade do BATUTA, avaliada pela consist\u00eancia das medidas realizadas nas condi\u00e7\u00f5es de teste-reteste, verificou a concord\u00e2ncia das respostas entre participantes por meio do c\u00e1lculo do coeficiente Kappa foi escolhido por ser recomendado para avaliar medidas de concord\u00e2ncia na \u00e1rea da sa\u00fade e considerado um \u00edndice \u00fatil para a validar a concord\u00e2ncia em instrumentos com categorias nominais.O coeficiente de .Conv\u00e9m mencionar que a confiabilidade tamb\u00e9m \u00e9 tratada como fidedignidade, equival\u00eancia, consist\u00eancia, objetividade, reprodutibilidade, estabilidade e homogeneidade, a depender da literatura utilizada e do aspecto do teste destacado no estudoKuder-Richardson e o coeficiente alpha de Cronbach. Apesar do coeficiente de alfa de Croncach ser o tipo de teste mais utilizado, a an\u00e1lise de consist\u00eancia interna por meio da t\u00e9cnica de Kuder-Richardson (KR-20) \u00e9 recomendada para escalas com respostas dicot\u00f4micas, como no caso do BATUTA, cujas op\u00e7\u00f5es s\u00e3o igual/diferente.Dentre as op\u00e7\u00f5es para an\u00e1lises da consist\u00eancia interna de um instrumento de medida encontram-se o teste de alfa de Cronbach quanto dos valores de Kuder-Richardson recomenda-se de que resultados superiores a 0,70 sejam considerados ideais, embora este valor n\u00e3o seja um consenso. Alguns estudos apontam valores pr\u00f3ximos a 0,60 como satisfat\u00f3rios, o que conduz \u00e0 aprova\u00e7\u00e3o da consist\u00eancia interna do BATUTA com o resultado de 0,62.Tanto na interpreta\u00e7\u00e3o do coeficiente de Finalmente, a partir da fundamenta\u00e7\u00e3o apresentada, prop\u00f5e-se como interpreta\u00e7\u00e3o dos resultados do BATUTA que cada resposta correta pontue 1,0 (um ponto) e que, ao serem somados todos os acertos, os escores finais sejam desta forma analisados: \u2265 33 acertos (acima de 94%): \u00f3tima percep\u00e7\u00e3o musical; 29 a 32 acertos: boa percep\u00e7\u00e3o musical; 25 a 28 acertos: percep\u00e7\u00e3o musical razo\u00e1vel; \u2264 24 acertos (abaixo de 68%): dificuldade na percep\u00e7\u00e3o musical.Foram apresentados a teoria e o construto por meio dos quais o BATUTA foi desenvolvido, assim como as justificativas para sua concep\u00e7\u00e3o e a popula\u00e7\u00e3o alvo a que se destina.O cumprimento de diretrizes estabelecidas em testes e protocolos destinados \u00e0 testagem da percep\u00e7\u00e3o musical em pessoas com DA, e os resultados das etapas de valida\u00e7\u00e3o de conte\u00fado, de consist\u00eancia interna e de confiabilidade do teste piloto em pessoas com audi\u00e7\u00e3o normal, indicaram a viabilidade do BATUTA para a avalia\u00e7\u00e3o da percep\u00e7\u00e3o musical em pessoas com DA, usu\u00e1rias de AASI.O BATUTA \u00e9 pass\u00edvel para aplica\u00e7\u00e3o na popula\u00e7\u00e3o a que se destina e futuros estudos poder\u00e3o ser conduzidos com o objetivo de comparar a percep\u00e7\u00e3o musical entre ouvintes e pessoas com defici\u00eancia auditiva, entre usu\u00e1rios de AASI com prescri\u00e7\u00f5es de regulagens espec\u00edficas para a aprecia\u00e7\u00e3o da m\u00fasica, entre usu\u00e1rios de AASI e IC, e tantas outras possibilidades voltadas a pesquisar e a percep\u00e7\u00e3o musical desse p\u00fablico.O BATUTA tem o potencial de fornecer uma perspectiva inovadora no que diz respeito ao atendimento fonoaudiol\u00f3gico, tanto na fase de sele\u00e7\u00e3o e indica\u00e7\u00e3o do AASI, quanto no acompanhamento dos usu\u00e1rios de dispositivos auditivos auxiliares que desejem ter acesso ao universo musical."}
+{"text": "No per\u00edodo, havia registro de 46.574.995 nascidos vivos e 10.024 casos de gastrosquise entre eles. Identificamos 5.632 \u00f3bitos infantis por gastrosquise. O percentual de incompletude diminuiu de 6,52% para 1,87%, com varia\u00e7\u00e3o percentual anual (VPA) de -14,5%, e a completude atingiu a excel\u00eancia (\u2264 5% de incompletude), exceto no Centro-oeste do pa\u00eds. Raz\u00e3o \u00f3bito/caso acima de 1 foi encontrada nas regi\u00f5es Norte e Nordeste e em alguns estados do Centro-oeste, mas houve diminui\u00e7\u00e3o, aproximando-se da mortalidade encontrada em estudos no Sul e Sudeste. Sua redu\u00e7\u00e3o foi mais acentuada at\u00e9 2009-2010  e menor posteriormente . A qualidade do registro de gastrosquise reflete as diferen\u00e7as regionais da qualidade geral do SINASC, configurando-se uma condi\u00e7\u00e3o marcadora para malforma\u00e7\u00f5es que demandam aten\u00e7\u00e3o neonatal complexa.O objetivo deste estudo foi avaliar a evolu\u00e7\u00e3o da completude e da consist\u00eancia do registro de gastrosquise no Sistema de Informa\u00e7\u00f5es sobre Nascidos Vivos (SINASC) no Brasil. Trata-se de estudo de s\u00e9rie temporal sobre a completude da vari\u00e1vel \u201cocorr\u00eancia de anomalia cong\u00eanita\u201d e a consist\u00eancia do diagn\u00f3stico de gastrosquise no SINASC, nos bi\u00eanios entre 2005 e 2020, para Unidades da Federa\u00e7\u00e3o, regi\u00e3o e Brasil. A consist\u00eancia foi estimada pela raz\u00e3o entre \u00f3bitos por gastrosquise registrados no Sistema de Informa\u00e7\u00f5es sobre Mortalidade (SIM) e o total de casos registrados no SINASC. A tend\u00eancia temporal foi analisada por regress\u00e3o  A partir de 1999, foi inclu\u00edda a informa\u00e7\u00e3o sobre ocorr\u00eancia de anomalia cong\u00eanita ,,,,,,H\u00e1 um crescente interesse no uso de dados administrativos em pesquisa, avalia\u00e7\u00e3o e vigil\u00e2ncia em sa\u00fade, entretanto, seu uso deve ser precedido da avalia\u00e7\u00e3o de qualidade Trata-se de estudo ecol\u00f3gico de s\u00e9rie temporal para avaliar a qualidade do registro de gastrosquise no SINASC. Como fontes de dados, foram usadas bases n\u00e3o identificadas do SINASC e do Sistema de Informa\u00e7\u00f5es sobre Mortalidade (SIM), de abrang\u00eancia nacional, no per\u00edodo entre 2005 e 2020.https://datasus.saude.gov.br/transferencia-de-arquivos/.Os dados SINASC Foram inclu\u00eddos todos os registros do SINASC no per\u00edodo de 2005 a 2020. As unidades de an\u00e1lise foram as UFs, as regi\u00f5es e o Brasil como um todo, ao longo de bi\u00eanios. Devido \u00e0 pequena quantidade de casos registrados anualmente, os registros foram agrupados a cada dois anos, aumentando a estabilidade da s\u00e9rie temporal.Duas dimens\u00f5es de qualidade foram avaliadas: completude da vari\u00e1vel \u201cocorr\u00eancia de anomalia cong\u00eanita\u201d no SINASC e consist\u00eancia dessa vari\u00e1vel em compara\u00e7\u00e3o ao diagn\u00f3stico de gastrosquise no SIM.Os dados faltantes da vari\u00e1vel \u201cocorr\u00eancia de anomalia cong\u00eanita\u201d foram obtidos pela soma de registros \u201cignorados\u201d e \u201csem informa\u00e7\u00e3o\u201d no campo 34 da DNV at\u00e9 2010 e no campo 6 a partir de 2011. O percentual de incompletude foi obtido pela divis\u00e3o do n\u00famero de registros com dados faltantes pelo total de registros. A completude da informa\u00e7\u00e3o sobre anomalia cong\u00eanita no SINASC foi classificada de acordo com o percentual de incompletude segundo Romero & Cunha Os dados do SIM referentes aos \u00f3bitos infantis, no mesmo per\u00edodo, foram usados para composi\u00e7\u00e3o do indicador de consist\u00eancia do SINASC. Para essa an\u00e1lise, foi calculado o indicador \u201craz\u00e3o \u00f3bito/caso\u201d, que se refere \u00e0 divis\u00e3o dos registros de \u00f3bito por gastrosquise pelos registros de nascidos vivos com gastrosquise em determinado local e per\u00edodo. Espera-se que esse n\u00famero seja menor que 1 e pr\u00f3ximo \u00e0 sobrevida observada no pa\u00eds, segundo estudo de revis\u00e3o Os \u00f3bitos por gastrosquise foram identificados no SIM pela recupera\u00e7\u00e3o do c\u00f3digo \u201cQ793\u201d da 10\u00aa revis\u00e3o da Classifica\u00e7\u00e3o Internacional de Doen\u00e7as (CID-10) nas vari\u00e1veis correspondentes \u00e0s causas da morte, descritas na causa b\u00e1sica de \u00f3bito ou nas linhas A, B, C, D e II do campo 49 da DO at\u00e9 2010 e do campo 40 a partir de 2011. Os nascidos vivos com gastrosquise foram identificados no SINASC por meio da recupera\u00e7\u00e3o do mesmo c\u00f3digo na vari\u00e1vel \u201cocorr\u00eancia de anomalia cong\u00eanita\u201d, derivada do campo 34 da DNV at\u00e9 2010 e do campo 41 a partir de 2011. At\u00e9 2010, era poss\u00edvel descrever a anomalia e informar o c\u00f3digo da CID-10. A partir de 2011, a anomalia passou a ser somente descrita e esse c\u00f3digo determinado na Secretaria Municipal de Sa\u00fade joinpoint, que ajusta tend\u00eancias lineares e suas mudan\u00e7as (pontos de inflex\u00e3o) em escala logar\u00edtmica, por interm\u00e9dio do m\u00e9todo de permuta\u00e7\u00e3o de Monte Carlo. Por meio da t\u00e9cnica, s\u00e3o comparados modelos com nenhum ou mais pontos de inflex\u00e3o para escolha do melhor ajuste para a s\u00e9rie temporal. A unidade temporal de an\u00e1lise foi cada bi\u00eanio, gerando a varia\u00e7\u00e3o percentual anual (VPA), que representa a intensidade e a dire\u00e7\u00e3o da tend\u00eancia estimada para cada segmento identificado em cada s\u00e9rie, que foi considerada estatisticamente significante quando p \u2264 0,05 ,A tend\u00eancia temporal de ambos os indicadores, \u201ccompletude\u201d e \u201craz\u00e3o \u00f3bito/caso\u201d, foi analisada por regress\u00e3o tipo http://www.r-project.org) por meio da interface RStudio .Os dados foram processados no aplicativo R  e do Instituto Nacional de Sa\u00fade da Mulher, da Crian\u00e7a e do Adolescente Fernandes Figueira, Funda\u00e7\u00e3o Oswaldo Cruz (IFF/Fiocruz) .O n\u00famero total de registros de nascidos vivos analisados foi 46.574.995, dentre os quais havia 10.024 casos de gastrosquise. O total de \u00f3bitos por gastrosquise identificado foi de 5.632.Na A tend\u00eancia temporal evidenciou significante diminui\u00e7\u00e3o do percentual de incompletude ao longo de todo o per\u00edodo no Brasil, de 6,52% para 1,87% , com consequente melhora da qualidade da informa\u00e7\u00e3o. Quanto \u00e0s regi\u00f5es, a Norte obteve aumento significativo de 2005-2006 a 2011-2012 e posterior diminui\u00e7\u00e3o , enquanto a Sudeste teve diminui\u00e7\u00e3o expressiva ao longo de todo o per\u00edodo . As demais regi\u00f5es n\u00e3o apresentaram signific\u00e2ncia estat\u00edstica em suas mudan\u00e7as. No bi\u00eanio final, a incompletude sobre ocorr\u00eancia de anomalia cong\u00eanita foi menor na Regi\u00e3o Sul, seguida pelas regi\u00f5es Sudeste, Norte, Nordeste e Centro-oeste .Raz\u00e3o \u00f3bito/caso de gastrosquise acima de 1 foi encontrada nas regi\u00f5es Norte e Nordeste, sendo as maiores nos estados do Acre, Roraima, Amap\u00e1, Alagoas, Piau\u00ed e Maranh\u00e3o. As regi\u00f5es Sul e Sudeste revelaram as menores raz\u00f5es em todo o per\u00edodo. Somente o Estado do Esp\u00edrito Santo apresentou raz\u00e3o 1,40 no primeiro bi\u00eanio. A Regi\u00e3o Centro-oeste n\u00e3o obteve raz\u00e3o acima de 1, mas esse resultado ocorreu em seus estados Mato Grosso do Sul e Mato Grosso .A tend\u00eancia temporal evidenciou diminui\u00e7\u00e3o da raz\u00e3o \u00f3bito/caso de 0,74 no bi\u00eanio inicial para 0,46 no final, estatisticamente significante, mais acentuada at\u00e9 2009-2010 , seguida de redu\u00e7\u00e3o mais suave at\u00e9 2019-2020 . Quanto \u00e0s regi\u00f5es, a queda na raz\u00e3o \u00f3bito/caso foi significativa em todas, exceto na Regi\u00e3o Norte, sendo mais acentuada no Sul entre os bi\u00eanios 2005-2006 e 2013-2014 . No bi\u00eanio final, a raz\u00e3o \u00f3bito/caso foi menor na Regi\u00e3o Sul , seguida das regi\u00f5es Sudeste, Centro-oeste, Nordeste e Norte .Neste estudo, identificou-se que a completude do registro de anomalias cong\u00eanitas no Brasil foi excelente e melhorou ao longo do tempo. No entanto, houve diferen\u00e7as regionais, que seguem o padr\u00e3o descrito para a cobertura do SINASC no Brasil entre 2012 e 2014 A tend\u00eancia temporal de diminui\u00e7\u00e3o da incompletude da vari\u00e1vel ocorr\u00eancia de anomalias cong\u00eanitas deve ter grande impacto na avalia\u00e7\u00e3o dessas condi\u00e7\u00f5es, cuja preval\u00eancia \u00e9 baixa, muitas delas doen\u00e7as raras A raz\u00e3o \u00f3bito/caso analisou especificamente o diagn\u00f3stico de gastrosquise. Resultados acima de 1 no Norte e Nordeste indicam sub-registro significativo no SINASC e corroboram a menor cobertura observada para esse sistema nessas regi\u00f5es ,,,A tend\u00eancia temporal de diminui\u00e7\u00e3o da raz\u00e3o \u00f3bito/caso foi significante para o Brasil como um todo, atingindo os menores valores no \u00faltimo bi\u00eanio no Sul e Sudeste. Esses resultados foram compat\u00edveis com a mortalidade observada em estudos de s\u00e9ries hospitalares nessas regi\u00f5es Para o Brasil como um todo, houve diminui\u00e7\u00e3o tanto da incompletude da vari\u00e1vel de ocorr\u00eancia de anomalia cong\u00eanita quanto da raz\u00e3o \u00f3bito/caso de gastrosquise, ao longo do per\u00edodo de estudo. Por\u00e9m, entre as regi\u00f5es, essa rela\u00e7\u00e3o direta somente foi verificada no Sudeste, indicando que pode haver diferentes perfis de sub-registro para as anomalias cong\u00eanitas nas diferentes regi\u00f5es, de modo a afetar mais um ou outro indicador.Estudo da confiabilidade da DNV como fonte de informa\u00e7\u00e3o sobre os defeitos cong\u00eanitos no Munic\u00edpio de S\u00e3o Carlos identificou tanto erros na transcri\u00e7\u00e3o do prontu\u00e1rio para a DNV quanto na codifica\u00e7\u00e3o e na alimenta\u00e7\u00e3o do SINASC, cuja origem dos dados \u00e9 a DNV arquivada na vigil\u00e2ncia epidemiol\u00f3gica do munic\u00edpio Em 2020, o funcionamento dos servi\u00e7os de sa\u00fade no Brasil foi significativamente afetado pela pandemia de COVID-19. Por\u00e9m, considerando a gravidade da malforma\u00e7\u00e3o estudada, n\u00e3o foi aventada a possibilidade de piora do seu registro por causa da pandemia, o que \u00e9 confirmado por um estudo da tend\u00eancia temporal de preval\u00eancia de gastrosquise no Brasil entre 2007 e 2020. A pesquisa identificou aumento relativo de 21,2% da preval\u00eancia. Quanto \u00e0s regi\u00f5es, houve aumento estatisticamente significativo no Norte e Nordeste. No Sul, houve redu\u00e7\u00e3o, iniciada no per\u00edodo entre 2013 e 2014, portanto, n\u00e3o associada \u00e0 pandemia. Houve aumento dos casos de \u00f3bitos fetais ao longo do tempo. A inclus\u00e3o dos dados de 2020 neste estudo n\u00e3o levou \u00e0 diminui\u00e7\u00e3o de casos de gastrosquise, indicando que a pandemia n\u00e3o afetou o registro dessa condi\u00e7\u00e3o Limita\u00e7\u00f5es desta pesquisa est\u00e3o relacionadas com a avalia\u00e7\u00e3o de apenas duas dimens\u00f5es de qualidade.linkage de dados entre SINASC e outros sistemas, como o SIM e o Sistema de Informa\u00e7\u00f5es Hospitalares (SIH), devido ao potencial de recupera\u00e7\u00e3o de casos dessa t\u00e9cnica, tanto para anomalias cong\u00eanitas como para demais vari\u00e1veis dos sistemas de informa\u00e7\u00e3o ,Futuras pesquisas devem buscar melhoria na qualidade da informa\u00e7\u00e3o por meio de ,,,,A an\u00e1lise de patologia espec\u00edfica, como a gastrosquise, pode ser mais \u00fatil na identifica\u00e7\u00e3o de anomalias cong\u00eanitas graves e potencialmente cur\u00e1veis, sendo sugerida para al\u00e9m da an\u00e1lise tradicional sobre ocorr\u00eancia de anomalias cong\u00eanitas em geral ou de grupos de c\u00f3digo CID. O grupo de malforma\u00e7\u00f5es e deformidades cong\u00eanitas do sistema osteomuscular (c\u00f3digos CID Q65 at\u00e9 Q79) \u00e9 muito heterog\u00eaneo, incluindo desde polidactilia, que tem bom progn\u00f3stico e baixa morbidade, at\u00e9 patologias extremamente graves, como gastrosquise e h\u00e9rnia diafragm\u00e1tica. Esse \u00e9 o grupo de malforma\u00e7\u00f5es mais frequente no Brasil Conclui-se que a qualidade do registro de gastrosquise refletiu as diferen\u00e7as regionais de cobertura e qualidade geral do SINASC. A raz\u00e3o \u00f3bito/caso capturou sub-registro no sistema e demonstrou aproximar-se da mortalidade nos locais com alta cobertura e baixa incompletude. A avalia\u00e7\u00e3o do registro de gastrosquise no SINASC se insere na perspectiva de vigil\u00e2ncia de anomalias cong\u00eanitas"}
+{"text": "Acesso \u00e0s Urg\u00eancias e Aten\u00e7\u00e3o Hospitalar: Uma Quest\u00e3o de DireitosHumanosUma verdadeira aula sobre o Sistema \u00danico de Sa\u00fade (SUS)! Na verdade, mais do que isso, aleitura de \u00c9 sob essa perspectiva que as autoras chamam a aten\u00e7\u00e3o para um aspecto fundamental, e quemuitas vezes nos passa despercebido: o acesso \u00e0s urg\u00eancias \u00e9, simultaneamente, umanalisador do estado de sa\u00fade do sistema de sa\u00fade e um potente recurso para a promo\u00e7\u00e3oda sa\u00fade desse sistema - e, por conseguinte, dos cidad\u00e3os que dele dependem parapromover, proteger e recuperar a sua pr\u00f3pria. Elas nos mostram como a diferencia\u00e7\u00e3o earticula\u00e7\u00e3o entre urg\u00eancias e emerg\u00eancias e as respectivas condi\u00e7\u00f5es estruturais eoperacionais de seus processos de trabalho configuram um ponto cr\u00edtico para o bomfuncionamento do SUS. Da mesma forma, e em rela\u00e7\u00e3o com essa delicada e estrat\u00e9gicadiferencia\u00e7\u00e3o/articula\u00e7\u00e3o, mostram-nos o papel a ser desempenhado, de um lado, por umarede hospitalar bem dimensionada e preparada e, de outro lado, por uma rede de aten\u00e7\u00e3oprim\u00e1ria \u00e0 sa\u00fade (APS) igualmente bem planejada e capacitada.As autoras deixam claro como uma rede hospitalar funcional \u00e9 essencial para garantir umfluxo adequado entre urg\u00eancias, emerg\u00eancias, acesso a interven\u00e7\u00f5es que envolvemtecnologias materiais que dependem do complexo hospitalar e regresso ao planoambulatorial, preferencialmente para o seguimento longitudinal da APS. O cap\u00edtulo 3 nosmostra, de modo fundamentado em dados, como problemas de diversas ordens t\u00eam tornado oshospitais em barreiras para o bom funcionamento das urg\u00eancias e emerg\u00eancias, porquerepresam as emerg\u00eancias com pouca disponibiliza\u00e7\u00e3o do acesso ao cuidado hospitalar, comtodos os efeitos de retroa\u00e7\u00e3o sobre as inst\u00e2ncias que o antecedem na linha de cuidado:emerg\u00eancias lotadas, queda na qualidade do cuidado oferecido e sobrecarga dosprofissionais - e eu acrescentaria a import\u00e2ncia desse desarranjo sobre a pr\u00f3priaseguran\u00e7a dos pacientes ,Por sua vez, se \u00e9 verdade que uma APS com cobertura adequada tende a dar maiorvisibilidade e acesso a situa\u00e7\u00f5es que requerem atendimentos de urg\u00eancia e emerg\u00eancia e,nesse sentido, a aumentar potencialmente a demanda por esses atendimentos, \u00e9 verdade,tamb\u00e9m, que um cuidado longitudinal de qualidade, com a\u00e7\u00f5es consistentes de promo\u00e7\u00e3o dasa\u00fade, preven\u00e7\u00e3o, diagn\u00f3stico precoce e tratamento adequado, e mesmo de atendimento aalgumas modalidades de urg\u00eancia, tender\u00e1 a tornar mais seletiva e adequada a demanda \u00e0semerg\u00eancias e aos hospitais. Assim, embora a APS sozinha certamente n\u00e3o consigaresponder \u00e0 crescente complexidade das demandas atuais por sa\u00fade Este talvez seja o tra\u00e7o mais original e fecundo da obra: o ato de situar a quest\u00e3o doacesso \u00e0s urg\u00eancias na din\u00e2mica de suas rela\u00e7\u00f5es com as diferentes inst\u00e2ncias e n\u00edveisque comp\u00f5em um sistema de sa\u00fade, sem descuidar das especificidades t\u00e9cnicas dessecomponente (cap\u00edtulo 2). Estas \u00faltimas s\u00e3o descritas e discutidas com min\u00facia e rigor,mas sem perder em clareza e didatismo. Assim situada, a tecnicidade se v\u00ea livre de umaleitura tecnicista das urg\u00eancias, emerg\u00eancias e aten\u00e7\u00e3o hospitalar. Elas s\u00e3o parte deredes  livres ou n\u00e3o das injun\u00e7\u00f5es hist\u00f3ricas e pol\u00edticas, de que nos d\u00e3o conta asan\u00e1lises comparativas das urg\u00eancias em sistemas de sa\u00fade universais (cap\u00edtulo 4), assimcomo a discuss\u00e3o emblem\u00e1tica da recente experi\u00eancia brasileira com a pandemia deCOVID-19.Mas h\u00e1 ainda outro elemento de fundamental import\u00e2ncia que desejo destacar. N\u00e3o seriaposs\u00edvel o sucesso alcan\u00e7ado por esse texto na leitura din\u00e2mica e contextual de um temat\u00e3o atravessado por normatividades t\u00e9cnicas, n\u00e3o seria poss\u00edvel evitar tecnicismos naabordagem de um aspecto t\u00e3o instrumental da organiza\u00e7\u00e3o das pr\u00e1ticas de sa\u00fade se n\u00e3ohouvesse uma refer\u00eancia, uma \u201ctotalidade compreensiva\u201d a ancorar as an\u00e1lises em um forte\u201ccompromisso pr\u00e1tico\u201d, no sentido \u00e9tico e pol\u00edtico, com a equidade e com as popula\u00e7\u00f5esvulnerabilizadas lutar contra as insufici\u00eancias estruturais e contra a viola\u00e7\u00e3o dosdireitos humanos, traduzidas na n\u00e3o concretiza\u00e7\u00e3o da integralidade, dauniversalidade e da equidade nos servi\u00e7os p\u00fablicos de sa\u00fade\u201d (p. 149).Com efeito, \u00e9 essa refer\u00eancia que confere ao texto esse frescor do vivido, essaconcretude que permite resistir a leituras das urg\u00eancias e da assist\u00eancia hospitalarcomo um sistema abstrato de rela\u00e7\u00f5es mec\u00e2nicas, regidas por teleologias de car\u00e1terestritamente instrumental. \u00c9 essa refer\u00eancia que possibilita a cr\u00edtica imanente dat\u00e9cnica, por dentro da t\u00e9cnica, mas n\u00e3o reduzida \u00e0 tecnicalidade. \u00c9 ela que, como j\u00e1dito, permite \u00e0s autoras criticar o SUS para defend\u00ea-lo. Est\u00e1 aqui uma inconfund\u00edvelmarca da afilia\u00e7\u00e3o \u00e0 tradi\u00e7\u00e3o da Sa\u00fade Coletiva. S\u00f3 ela permite entender que o \u00faltimopar\u00e1grafo de um texto sobre acesso a urg\u00eancias e assist\u00eancia hospitalar convoque seusleitores a \u201cPor isso, vou me permitir, como resenhista, fazer uma ousada proposta aos leitores, aindaque correndo o risco de contrariar suas autoras: que comecem a leitura do livro do fimpara o come\u00e7o. Talvez essa pequena \u201csubvers\u00e3o\u201d ajude a fazer jus \u00e0 potente hermen\u00eauticasubjacente ao excelente e inspirador trabalho de Gisele e Mariana."}
+{"text": "To develop an assessment script to observe hearing and central auditory processing in preschool children.To The script was prepared based on a search in the Scielo databases and in the library of a university in the state of S\u00e3o Paulo using the following keywords: \u201ccentral auditory processing\u201d, \u201chearing and language\u201d, \u201cauditory processing disorders\u201d, \u201cauditory processing in preschool children\u201d, and \u201cvocabulary assessment\u201d, resulting in the selection of fourteen articles and two books. Then, questions related to auditory development and a script for assessing central auditory processing were prepared.The script consists of eight parts, namely: Identification and Anamnesis, Information about Mother and Pregnancy, Complaints, Auditory Development, Language Development, Motor Development, Simplified Auditory Processing Evaluation and Behavioral Audiological Assessment.The script is essential, given the lack of screening instruments in the literature for central auditory processing in preschool children that thoroughly investigate the entire process that permeates the auditory and language development of children aged 43 to 47 months. Hearing thresholds within the normal range and the proper functioning of central structures are essential for linguistic development.Hearing is widely understood as a prerequisite for the acquisition and development of oral language. In this sense, exposure to auditory experiences, especially in the first 3 years of life, which is considered a critical period of development, allows for the cortical organization that is necessary to ensure the normal development of hearing and language skills. In children with normal development, the cochlea is active from birth, unlike the central auditory system, which undergoes a maturation process through interference during childhood and adolescence.Another important factor is the peripheral auditory system, which is interconnected with the central auditory system. The peripheral auditory system comprises the outer, middle, inner ear and vestibulocochlear nerve, and is responsible for capturing, transmitting and transducing the sound wave and its processing in the cochlea and cochlear portion of the vestibulocochlear nerve through the following stages:Auditory skills evolve from birth to two years of age, following a hierarchyDetection: the ability to perceive the presence and absence of sounds, which occurs from the intrauterine stage;Discrimination: the ability to differentiate two sounds the same or different, which is found even in newborns who can discriminate verbal sounds;Localization: the ability to identify where the sound comes from, which is a stage that develops from four to 24 months;Auditory recognition: the ability to associate signifier and meaning, pointing out figures or following orders;Listening comprehension: the ability to understand speech, answer questions and retell stories.. In turn, sound localization occurs from four months of age and evolves as age increases. Sound localization begins with localization in the horizontal axis and progresses to the vertical position, from indirect to direct, then, later, there is localization in the longitudinal and transverse axis, involving the brainstem and cortex. Plasticity and maturation depend on stimulation, as specific neural pathways are activated and reinforced with the auditory experience, and neuroplasticity allows structural and functional changes to occur when there is stimulation.According to these same authors, the ability to detect sounds has been present since intrauterine life, with the integrity of the peripheral auditory system, cochlea and acoustic nerve. Therefore, the ability to discriminate sounds can be observed in a newborn, when children differentiate their mothers' voices from the voices of other women. Children aged eight to ten months inhibit activities by recognizing when they hear the word \u201cno\u201d. Between nine and thirteen months, they recognize simple verbal commands, such as \u201cto say goodbye\u201d and from twelve months, children should be able to recognize their own names, which usually occurs from fifteen to eighteen months. From eighteen months to two years of age, auditory recognition skills evolve and children acquire story comprehension skills and the ability to answer questions about a story.From the end of the first year of life, the auditory recognition ability emerges, evolving from simple to complex levels.In this context, the experiences and auditory situation in which the child is exposed are essential for the development and acquisition of language. During the process of maturation and plasticity it is essential to have a lot of stimulation to reinforce specific neural pathways. In this sense, some studies report that complications in language, speech and learning have been related to difficulty in processing acoustic stimuli.Thus, it is essential to know the functioning of the physiological mechanisms of the auditory system to have knowledge of auditory information processing, known as Central Auditory Processing (CAP). In addition, auditory disabilities must be identified early, as well as the relationship between these detected alterations and the learning of the language to which the child is exposed.The CAP refers to mechanisms and processes of the auditory system, which are responsible for sound localization, sound discrimination, and auditory recognition, temporal aspects of hearing involving resolution, masking, integration and temporal sequence, as well as auditory performance with concurrent acoustic signals and in unfavorable acoustic situations. These skills can be developed through verbal and non-verbal stimuli and, if altered, they may affect speech and language areas. This assessment investigates auditory skills through behavioral observation of performance in different tasks, such as sound localization, temporal ordering, temporal resolution, dichotic task, monotic listening task and concurrent stimuli in the same ear. Central Auditory Processing Disorder (CAPD) occurs when there is an impairment in auditory skills, even though the individual has normal auditory acuity and intelligence. Even if hearing is adequate, this disorder can be considered an inability to attend, discriminate, recognize, remember and understand informationThe script consisted of the following topics:Questions about participant identification and anamnesis, with essay and objective questions about information about the mother and the pregnancy..Behavioral auditory test for audiological assessment and Central Auditory ProcessingBehavioral audiological assessment using musical instruments.For verification, the instrument was sent with a questionnaire for evaluation by three speech-language pathologists, two being language specialists and one audiologist. All three judges were scholars and had extensive experience in their respective fields., used as a reference, as it was not expected for the age.The questionnaire submitted to the judges also included a brief introduction to the research, its objectives and methods. Then, five objective questions were elaborated, in which the judge should mark \u201cyes\u201d or \u201cno\u201d. In the last part, there was a free space for the judges to make observations regarding the script. All judges agreed with the removal of the memory of four syllables belonging to the ASPAThe evaluation script consisted of eight parts, as described below, and can be found in The first part describes the child's main data, including name, age, sex, date of birth, place of birth, name of the school and session, and with whom they spend most of their time. In addition, this part also collects basic data information about family members, such as name and age, education level and amount of time they spend together for possible analysis of parent/child interaction.The second part collects data regarding the mother and pregnancy, such as alcohol consumption; if the mother is a smoker and if she used medication. The questionnaire also includes questions about maternal diseases, such as HIV, syphilis, hypertension, diabetes mellitus, rubella, herpes, toxoplasmosis, cardiovascular disease and kidney disease. In addition, the questionnaire includes information on possible hospitalization and complications during pregnancy and at how many weeks the delivery took place.These topics are directly associated with the health of the fetus during pregnancy. Any of these diseases can affect a child's healthy birth, including hearing and language.Part three of the questionnaire includes questions related to agitation, inattention; difficulty hearing and understanding in noisy environments; difficulty relating to people; and difficulties in performing global and fine motor activities, such as: \u201cDoes the child have complaints related to agitation?\u201d, and \u201cDoes the child have difficulties in performing global motor activities?\u201d.In turn, part four, referring to auditory development, investigates cases of recurrent otitis in early childhood, whether there is otological history, otalgia, trauma, whether antibiotics were used and data on the family history of hearing loss, such as: \u201cDoes the child have a history of recurrent ear infections in early childhood?\u201d, and \u201cDoes the child have frequent earaches?\u201d.The focus on the topic of language development is to analyze whether it is appropriate for the child's age. This topic investigates whether the preschool child is able to match three or more words, to identify body parts, or to understand instructions. In addition, the topic includes the following questions: \u201cIs the child able to recognize adjectives such as \u2018\u2019big\u201d, \u2018\u2019small\u201d, and \u2018\u2019happy\u201d?\u201d; \u201cIs the child able to use articles, such as \u201cthe\u201d and \u201ca\u201d?\u201d; \u201cIs the child able to use plurals such as \u201ccandy\u201d and \u201ccandies\u201d?\u201d; \u201cIs the child able to use prepositions, such as \u201cwith\u201d, \u201cfrom\u201d, \u201cto\u201d?\u201d; and \u201cIs the child able to use auxiliary verbs, such as \u201cto have\u201d, and \u201cto be\u201d?\u201d.In addition, the topic investigates the child's understanding of abstract concepts of quantity. The questionnaire also investigates whether the child is able to make deductions, formulate questions, requests actions, objects (such as giving a toy or getting water), permission (using \u201cMay I...\u201d); uses negation, recounts past events, or anticipates the future. Other questions also assess whether the child is able to understand and is able to retell stories with narrative turns, keep a conversation topic waiting for their turn and whether they sing songs .Part six includes questions for parents about motor development.The initial part of the protocol collects data on the patient's name and age, the evaluator's name, and the evaluation date.The first part of the protocol refers to the \u201csound localization test\u201d, which investigates the child\u2019s performance in right, left, top, front and back localization. According to the authors, the criterion of normality is to have four correct answers in five directions. The sound localization test table must be filled in with the number of correct answers and whether it is normal or altered. It should also be noted whether the assessment of the auditory ability of sound localization is normal or altered.Part two begins the \u201cMemory Test for Verbal or Non-Verbal Sounds in Sequence\u201d, which is first subdivided into the Memory Test for Verbal Sounds (MTVS) in sequence with three sounds, in which the isolated phonoarticulatory production of the syllables PA TA CA must be carried out, and also fill in the table with \u201cyes\u201d or \u201cno\u201d, and the performance of the production of PA TA CA, TA PACA and CA TA PA. According to the authors, the criterion of normality in this case is to reach two or more correct answers in the MTVS in 3 attempts (\u22652/3), and the result must be divided by three .The final part includes the completion of the questionnaire and must be filled in with the responses of the Memory Test for Verbal Sounds, including three verbal sounds in sequence. The same rule applies for the Memory Test for Non-Verbal Sounds, including three non-verbal sounds in sequence. The four non-verbal sounds test was withdrawn from the study, as it was considered to be inappropriate for the age group of the study. In this part of the study, the respondent must include the number of correct answers and whether it is normal or altered.The respondent must also answer whether the assessment of the auditory temporal ordering ability is normal or altered. The following table should be filled in with the possible behaviors that were observed during the test, including: inadequate attention span, inadequate memory capacity, inadequate motor attitude, difficulty understanding requests and whether the child tires easily.At the end of the test, the questionnaire details that the normality criterion for the sound localization test is to obtain more than four correct answers. As instructed by the authors, the evaluator must indicate the number of correct answers in a specific protocol, in addition to reporting whether the result is normal or changed (according to the score achieved). On the other hand, to reach the normality criterion in the sequence test for verbal sounds, the child must obtain at least two correct answers in the three named sequences, while the normality criterion is also to obtain two correct answers in three attempts for non-verbal sounds. Based on the findings of the three tests, the evaluator must conclude if there is a change in Central Auditory Processing. The four non-verbal sounds test was withdrawn from the study, as it was considered to be inappropriate for the age group of the study.For the behavioral audiological assessment, the researchers developed a table based on the instruments that will be used, observing the child's auditory behavior according to the musical instrument. Thus, there is a table divided into instruments, intensity and responses. In this context, the instruments included are: drum, rattle, musical rattle, reco-reco and agogo with two bells. All these instruments should be tested at low, medium and strong intensity and the response must be recorded. The child at the age analyzed by the study is expected to respond to all musical instruments at the lowest intensity and directly in all directions.Regarding the suggestions proposed by the judges, one of them proposed the use of the Language Development Assessment-LDA 2 protocol in the evaluation of preschool children. In addition, it was also suggested to include the educational level of the parents in the anamnesis. In the complaints, it was also suggested to change \u201chandedness\u201d to another topic, which is \u201cidentification and anamnesis\u201d. For language development questions, include a question to see if the child can match four or more words.It should be noted that little material regarding the CAP in preschool children was found in the research for the development of the script. On the other hand, there are many more studies involving school-age children, which shows the importance of material covering this age so that it is possible to detect early.. Some authors report that the first years of life are critical for development and that the auditory experiences during this period are directly linked to the development of hearing skills, such as detection, discrimination, location, recognition and listening comprehension. In this way, the neuromuscular and sensory system maturation in an integral way is directly linked to speech and language skills. The auditory ability of speech perception arises when an articulatory pattern of language is acquired, as the sensory and motor aspects are being covered.As language shares underlying cognitive mechanisms with auditory skills, the integrity of the peripheral and central auditory system is critical to properly develop oral and written communication. There are factors, such as the integrity of the peripheral auditory system and the maturation of the central nervous system, especially with regard to the primary and secondary auditory areas that can directly influence auditory development. These factors must be extensively investigated to understand possible changes. Thus, the script aimed to thoroughly investigate the main risk factors for changes in the CAP.Central auditory processing, which develops until, on average, ten to twelve years of age, is the mechanism responsible for auditory skills.Peripheral alterations and history of secretory otitis media during early childhood can compromise the maturation of the auditory pathways. This impairment has an impact on central auditory skills and the learning process, hence the need to investigate the patient's auditory history.The questions about the child's auditory development, history, if there was any trauma, family history and if he/she used antibiotics that could be ototoxic are addressed in part four of the script, which is called \u201cauditory development\u201d. According to the literature, the etiology of CAP disorders includes otitis, high and continuous fevers, specific disorders of the development of auditory function, damage to the conduction pathways and sensory deprivation during early childhood. The complaints were addressed in part three of the script, as the difficulty in understanding speech in the presence of background noise, greater distractibility, reduced attention, communication difficulties and low academic performance are signs of risk CAP for disorders.All these factors mentioned above will effectively impact the auditory development, as well as the patient's oral and written language. Difficulties can be observed by family members and caregivers through behaviors, such as difficulties in performing complex or longer tasks, distraction, sensitivity to loud sounds, difficulty following verbal orders, repetition of verbal stimuli, difficulty understanding jokes and language figurative.Auditory processing disorders consist of an inability to attend to, discriminate, recognize, remember, or understand auditory informationIf any impairment is found in the areas described above, there is a need for an in-depth assessment. It is important to assess skills that are part of normal language development, as many oral language disorders can be detected and followed up early..Part five of the script, characterized as \u201clanguage development\u201d, addresses the main development milestones. Impairments in the interpretation of sensory information may be indicative of hearing impairment, which, in the future, may lead to an auditory processing disorder, and in the acquisition of speech and languageAccording to the researched literature, there is no instrument that investigates the relationship between language and hearing, especially CAP in preschool children, only in school-age children. The researchers searched for articles and materials on the subject in the Lilacs, SciELO, PubMed databases and in the collection of books and theses in the institution's library, but only protocols and scripts that included children over six years of age were found. Thus, it is essential to develop material that aims at the early screening of risks and possible hearing and language alterations.Therefore, this script is an instrument to be used in clinical practice for assessments, screening and monitoring of preschool children to indicate possible risks for auditory information processing disorder. This study aimed at early detection of possible disorders for monitoring and stimulation of auditory skills so that the damage can be remedied or reduced for the child.The script is part of an ongoing study that will evaluate children under the age of six. The research has not yet taken place due to the COVID-19 pandemic.The researchers prepared a research script to carry out an assessment and find possible risks for CAP disorder in preschool children. The script is essential, given the lack of screening instruments in the literature for CAP in preschool children that thoroughly investigate the entire process that permeates the auditory and language development of children aged 43 to 47 months.The period selected for the investigation is critical for development, and some factors mentioned, such as otitis and the use of ototoxic drugs, among others, can cause changes in auditory development that impact the development of oral and written language and school learning. . Os limiares auditivos dentro dos padr\u00f5es de normalidade e o funcionamento adequado das estruturas centrais s\u00e3o de fundamental import\u00e2ncia para o desenvolvimento lingu\u00edstico.A audi\u00e7\u00e3o \u00e9 considerada um pr\u00e9-requisito para a aquisi\u00e7\u00e3o e desenvolvimento da linguagem oral. A exposi\u00e7\u00e3o \u00e0s experi\u00eancias auditivas, principalmente nos tr\u00eas primeiros anos de vida, considerado per\u00edodo cr\u00edtico do desenvolvimento, permite a organiza\u00e7\u00e3o cortical necess\u00e1ria para garantir o desenvolvimento normal da audi\u00e7\u00e3o e da linguagem. Em crian\u00e7as com desenvolvimento dentro do padr\u00e3o de normalidade, a c\u00f3clea est\u00e1 em a\u00e7\u00e3o desde o nascimento, diferente do sistema auditivo central que passa por um processo de amadurecimento atrav\u00e9s das interfer\u00eancias no per\u00edodo da inf\u00e2ncia e adolesc\u00eancia.O sistema auditivo perif\u00e9rico est\u00e1 interligado com o sistema auditivo central. O sistema auditivo perif\u00e9rico abrange a orelha externa, m\u00e9dia, interna e nervo vestibulococlear, tendo como fun\u00e7\u00e3o captar, transmitir e realizar transdu\u00e7\u00e3o da onda sonora e seu processamento na c\u00f3clea e por\u00e7\u00e3o coclear do nervo vestibulococlear. As etapas podem ser consideradas como:As habilidades auditivas evoluem desde o nascimento at\u00e9 os dois anos de idade, seguindo uma hierarquiaDetec\u00e7\u00e3o: perceber presen\u00e7a e aus\u00eancia de sons, ocorre desde intra\u00fatero;Discrimina\u00e7\u00e3o: diferencia\u00e7\u00e3o de dois sons iguais ou diferentes, rec\u00e9m-nascidos discriminam sons verbais;Localiza\u00e7\u00e3o: identificar de onde vem o som, essa etapa se desenvolve dos quatro aos 24 meses;Reconhecimento auditivo: associa\u00e7\u00e3o do significante e significado, apontando figuras ou cumprindo ordens;Compreens\u00e3o auditiva: entender falas, responder perguntas e recontar hist\u00f3rias.. A localiza\u00e7\u00e3o sonora, por sua vez, ocorre a partir de quatro meses e evolui conforme a idade aumenta. Inicia-se por localiza\u00e7\u00e3o no eixo horizontal e progride para a posi\u00e7\u00e3o vertical, da maneira indireta para direta. Posteriormente, h\u00e1 a localiza\u00e7\u00e3o no eixo longitudinal e transversal, envolvendo tronco encef\u00e1lico e c\u00f3rtex. A plasticidade e matura\u00e7\u00e3o s\u00e3o dependentes de estimula\u00e7\u00e3o, visto que adicionado experi\u00eancia auditiva as vias neurais espec\u00edficas s\u00e3o ativadas e refor\u00e7adas, logo, a neuroplasticidade permite que ocorram mudan\u00e7as estruturais e funcionais diante \u00e0 estimula\u00e7\u00e3o.Segundo os mesmos autores, desde a vida intrauterina, com integridade do sistema auditivo perif\u00e9rico, c\u00f3clea e nervo ac\u00fastico, a habilidade de detectar sons j\u00e1 est\u00e1 presente. A habilidade de discrimina\u00e7\u00e3o de sons pode ser observada em um rec\u00e9m-nascido, em que a crian\u00e7a diferencia a voz da sua m\u00e3e de outras mulheres. Crian\u00e7as de oito a dez meses inibem atividades ao reconhecer quando a palavra \u2018\u2019n\u00e3o\u201d \u00e9 falada; entre nove e 13 meses, reconhecem comandos verbais simples como \u2018\u2019d\u00e1 tchau\u201d e, a partir de 12 meses, a crian\u00e7a deve reconhecer o pr\u00f3prio nome ocorrendo geralmente dos 15 aos 18 meses. Dos 18 meses a dois anos de idade, a habilidade de reconhecimento auditivo evolui para compreens\u00e3o de hist\u00f3rias e habilidades de responder perguntas sobre uma hist\u00f3ria.A habilidade de reconhecimento auditivo surge no final do primeiro ano de vida, evoluindo dos n\u00edveis simples para complexos.Uma condi\u00e7\u00e3o necess\u00e1ria para o desenvolvimento e aquisi\u00e7\u00e3o da linguagem s\u00e3o as experi\u00eancias e situa\u00e7\u00f5es auditivas em que a crian\u00e7a fica exposta. \u00c9 imprescind\u00edvel que haja muita estimula\u00e7\u00e3o durante o processo de matura\u00e7\u00e3o e plasticidade para refor\u00e7ar as vias neurais espec\u00edficas. Estudos demonstram que complica\u00e7\u00f5es na linguagem, fala e aprendizado tem sido relacionadas com dificuldade no processamento dos est\u00edmulos ac\u00fasticos.Desta forma, conhecer o funcionamento dos mecanismos fisiol\u00f3gicos do sistema auditivo \u00e9 fundamental para o conhecimento do processamento da informa\u00e7\u00e3o auditiva, conhecido como Processamento Auditivo Central (PAC). Al\u00e9m disso, \u00e9 de grande import\u00e2ncia reconhecer inabilidades auditivas precocemente, bem como a rela\u00e7\u00e3o entre essas altera\u00e7\u00f5es detectadas e a aprendizagem da l\u00edngua em que a crian\u00e7a est\u00e1 exposta.O PAC refere-se a mecanismos e processos do sistema auditivo, que s\u00e3o respons\u00e1veis pela localiza\u00e7\u00e3o sonora, discrimina\u00e7\u00e3o sonora, reconhecimento auditivo, aspectos temporais da audi\u00e7\u00e3o envolvendo resolu\u00e7\u00e3o, mascaramento, integra\u00e7\u00e3o e sequ\u00eancia temporal, tamb\u00e9m pelo desempenho auditivo com sinais ac\u00fasticos em competi\u00e7\u00e3o e em situa\u00e7\u00f5es ac\u00fasticas desfavor\u00e1veis. Essas habilidades podem ser por est\u00edmulos verbais e n\u00e3o-verbais e, se alteradas, afetam \u00e1reas de fala e linguagem. Trata-se de uma avalia\u00e7\u00e3o das habilidades auditivas por meio de observa\u00e7\u00e3o comportamental do desempenho frente a diferentes tarefas, tais como localiza\u00e7\u00e3o sonora, ordena\u00e7\u00e3o temporal, resolu\u00e7\u00e3o temporal, tarefa dic\u00f3tica, tarefa de escuta mon\u00f3tica e est\u00edmulos competitivos na mesma orelha. Quando h\u00e1 um impedimento nas habilidades auditivas, mesmo que o indiv\u00edduo possua acuidade auditiva e intelig\u00eancia normal, ocorre o Transtorno do Processamento Auditivo Central (TPAC). Esse transtorno pode ser considerado uma inabilidade de atender, discriminar, reconhecer, recordar e compreender informa\u00e7\u00f5es mesmo que a audi\u00e7\u00e3o esteja adequada. Altera\u00e7\u00f5es podem ocorrer por intercorr\u00eancias nos processos de desenvolvimento. Os transtornos trazem repercuss\u00f5es na percep\u00e7\u00e3o de fala, mem\u00f3ria, linguagem e aprendizado da linguagem,6-8.A avalia\u00e7\u00e3o do PAC permite a verifica\u00e7\u00e3o dos comportamentos auditivos e determina aqueles que est\u00e3o dentro do processo de evolu\u00e7\u00e3o de uma crian\u00e7a t\u00edpica e aqueles que est\u00e3o desviados ou com algum n\u00edvel de dist\u00farbio.O diagn\u00f3stico precoce \u00e9 de extrema import\u00e2ncia em pr\u00e9-escolares para que a interven\u00e7\u00e3o seja feita de maneira efetiva. Falhas no desenvolvimento de pr\u00e9-escolares acarretaram um desempenho escolar inadequado, logo detec\u00e7\u00e3o precoces por meio de triagens e a realiza\u00e7\u00e3o de interven\u00e7\u00f5es \u00e9 essencial nos primeiros cinco anosNota-se na literatura a necessidade de mais pesquisas em pr\u00e9-escolares sobre o diagn\u00f3stico do desenvolvimento auditivo e PAC para que ocorra avalia\u00e7\u00e3o precoce. Atrav\u00e9s dela poss\u00edveis altera\u00e7\u00f5es podem ser identificadas previamente causando menor impacto na vida acad\u00eamica da crian\u00e7a.O objetivo geral \u00e9 elaborar um roteiro de avalia\u00e7\u00e3o auditiva e PAC para crian\u00e7as pr\u00e9-escolares.Foi realizada a elabora\u00e7\u00e3o de um roteiro de avalia\u00e7\u00e3o auditiva e do PAC (Anexo A) que faz parte do projeto intitulado \u201cRela\u00e7\u00e3o entre o desenvolvimento auditivo e de vocabul\u00e1rio de crian\u00e7as de 43 a 47 meses de idade\u201d. Este projeto possui consentimento do Comit\u00ea de \u00c9tica da PUC-Campinas para realiz\u00e1-lo, CEP 3.426.010/2019. Todos os indiv\u00edduos envolvidos assinaram o Termo de Consentimento Livre e Esclarecido.Realizou-se uma pesquisa bibliogr\u00e1fica atrav\u00e9s da base de dados Scielo e biblioteca pertencente a uma institui\u00e7\u00e3o utilizando as palavras-chaves: \u2018\u2019processamento auditivo central\u201d, \u2018\u2019audi\u00e7\u00e3o e linguagem\u201d, \u2018\u2019dist\u00farbios do processamento auditivo\u201d, \u2018\u2019processamento auditivo em pr\u00e9-escolares\u201d, \u2018\u2019avalia\u00e7\u00e3o do vocabul\u00e1rio\u201d. N\u00e3o houve limita\u00e7\u00f5es quanto ao ano e idioma para a sele\u00e7\u00e3o. As pesquisas encontradas deveriam seguir crit\u00e9rios para serem inclu\u00eddas, como: abordar a rela\u00e7\u00e3o entre a audi\u00e7\u00e3o e a linguagem, abordar os principais m\u00e9todos de triagem do e os transtornos do PAC.Foram encontradas 22 refer\u00eancias, mas aplicando os crit\u00e9rios acima descritos, foram inclu\u00eddos 14 artigos cient\u00edficos e dois livros apresentados no O roteiro foi estruturado, primeiramente, por perguntas, do primeiro ao sexto t\u00f3pico, divididas em objetivas e dissertativas, totalizando 68 quest\u00f5es. Em seguida, na segunda parte do roteiro, do t\u00f3pico sete e oito, est\u00e3o configurados os protocolos a serem utilizados para avalia\u00e7\u00e3o do desenvolvimento auditivo. O roteiro \u00e9 destinado para pais e respons\u00e1veis responderem, tendo tempo m\u00e9dio de dura\u00e7\u00e3o de 20 minutos.. Retirado do livro \u2018\u2019Testes Auditivos Comportamentais para Avalia\u00e7\u00e3o\u201d, como meio de avalia\u00e7\u00e3o de localiza\u00e7\u00e3o sonora, mem\u00f3ria de sons verbais e n\u00e3o verbais. Esse instrumento mostrou-se completo visto que n\u00e3o h\u00e1 na literatura recursos suficientes para avalia\u00e7\u00e3o auditiva e do PAC de pr\u00e9-escolares.A avalia\u00e7\u00e3o do PAC, presente no roteiro, foi baseada na Avalia\u00e7\u00e3o Simplificada do Processamento Auditivo (ASPA)O roteiro foi constitu\u00eddo dos seguintes t\u00f3picos:Perguntas sobre identifica\u00e7\u00e3o do participante e anamnese, com quest\u00f5es dissertativas e objetivas sobre os dados maternos e de gesta\u00e7\u00e3o..Teste auditivo comportamental para avalia\u00e7\u00e3o audiol\u00f3gica e do PACAvalia\u00e7\u00e3o audiol\u00f3gica comportamental por meio de instrumentos musicais.Para verifica\u00e7\u00e3o do instrumento, o mesmo foi encaminhado com um question\u00e1rio para avalia\u00e7\u00e3o de coer\u00eancia de tr\u00eas ju\u00edzes, fonoaudi\u00f3logos, dois especialistas em linguagem e um audiologista. Todos s\u00e3o acad\u00eamicos e possuem vasta experi\u00eancia em suas respectivas \u00e1reas., usado como refer\u00eancia, pois n\u00e3o era esperado para a idade.O question\u00e1rio enviado aos ju\u00edzes possui uma breve introdu\u00e7\u00e3o da pesquisa, seus objetivos e m\u00e9todos. Em seguida, foram elaboradas cinco perguntas objetivas, em que o juiz assinalou \u2018\u2019sim\u201d ou \u2018\u2019n\u00e3o\u201d. Na \u00faltima parte, havia um espa\u00e7o para observa\u00e7\u00f5es pertinentes ao roteiro. Todos concordaram com a retirada da mem\u00f3ria de quatro s\u00edlabas pertencente ao ASPAO roteiro de avalia\u00e7\u00e3o est\u00e1 constitu\u00eddo por oito partes descritas a seguir e encontra-se no Anexo A.Na primeira parte h\u00e1 os principais dados da crian\u00e7a, incluindo nome, idade, sexo feminino ou masculino, data de nascimento, naturalidade, escola em que est\u00e1 matriculada e per\u00edodo e com quem passa a maior parte do seu tempo. H\u00e1 tamb\u00e9m dados b\u00e1sicos sobre os familiares, sendo nome e idade, grau de escolaridade e quantidade de tempo que passam juntos para poss\u00edvel an\u00e1lise de intera\u00e7\u00e3o pais/crian\u00e7a.Na segunda parte encontram-se os dados referentes a m\u00e3e e a gesta\u00e7\u00e3o, como ingest\u00e3o de bebida alco\u00f3lica; se a m\u00e3e \u00e9 tabagista e se fez uso de medicamentos. H\u00e1 tamb\u00e9m perguntas sobre doen\u00e7as maternas como HIV, s\u00edfilis, hipertens\u00e3o, diabetes, rub\u00e9ola, herpes, toxoplasmose, doen\u00e7as cardiovasculares e doen\u00e7as renais. Al\u00e9m disso, se ocorreu interna\u00e7\u00e3o e intercorr\u00eancias durante a gesta\u00e7\u00e3o e com quantas semanas o parto foi realizado.Estes t\u00f3picos possuem liga\u00e7\u00e3o direta com a sa\u00fade do feto durante a gesta\u00e7\u00e3o. Qualquer uma dessas doen\u00e7as pode afetar o nascimento saud\u00e1vel da crian\u00e7a, incluindo audi\u00e7\u00e3o e linguagem.Na parte tr\u00eas, h\u00e1 questionamentos relacionados \u00e0 agita\u00e7\u00e3o, desaten\u00e7\u00e3o; dificuldade para ouvir e entender em ambientes ruidosos; dificuldade para se relacionar com as pessoas; dificuldades para realizar atividades motoras globais e finas, como, por exemplo: \u2018\u2019apresenta queixas relacionadas a agita\u00e7\u00e3o?\u201d, \u2018\u2019apresenta dificuldade para realizar atividades motoras globais?\u201d.Na parte quatro, referente ao desenvolvimento auditivo, investiga-se casos de otites recorrentes na primeira inf\u00e2ncia, se h\u00e1 antecedentes otol\u00f3gicos, otalgia, trauma, se fez uso de antibi\u00f3ticos e qual o hist\u00f3rico familiar em rela\u00e7\u00e3o a perdas auditivas, como: \u2018\u2019hist\u00f3rico de otites recorrentes na primeira inf\u00e2ncia?\u201d, \u2018\u2019sente dores frequentemente?\u201d.No t\u00f3pico de desenvolvimento de linguagem, o foco \u00e9 analisar se o mesmo est\u00e1 adequado para a idade da crian\u00e7a. Questiona-se se o pr\u00e9-escolar faz combina\u00e7\u00e3o de tr\u00eas ou mais palavras, identifica as partes do corpo, compreende instru\u00e7\u00f5es que lhe s\u00e3o direcionadas. Reconhece pronomes que diferenciam os sexos; reconhece adjetivos, como \u2018\u2019grande\u201d, \u2018\u2019pequeno\u201d, \u2018\u2019feliz\u201d; faz uso de artigos, como \u2018\u2019o\u201d, \u2018\u2019a\u201d, \u2018\u2019um\u201d, \u2018\u2019uma\u201d; faz uso de plurais, como \u2018\u2019bala-balas\u2019; faz uso de preposi\u00e7\u00f5es, como \u2018\u2019com\u201d, \u2018\u2019de\u201d, \u2018\u2019para\u201d e faz uso de verbos auxiliares, como \u2018\u2019 ter\u201d, \u2018\u2019ser\u201d, \u2018\u2019estar\u201d.Al\u00e9m disso, observa-se a compreens\u00e3o de conceitos abstratos, de quantidade. Nota-se tamb\u00e9m se a crian\u00e7a faz dedu\u00e7\u00f5es, formula perguntas, solicita a\u00e7\u00f5es, objetos (como dar um brinquedo ou pegar \u00e1gua), permiss\u00e3o (com \u2018\u2019posso\u201d); usa a nega\u00e7\u00e3o, relata acontecimentos do passado ou antecipa do futuro. Compreende e consegue recontar hist\u00f3rias com turnos narrativos, t\u00f3pico de conversa\u00e7\u00e3o aguardando seu turno e se canta m\u00fasicas .Na parte seis, pergunta-se aos pais sobre desenvolvimento motor.O protocolo tem in\u00edcio com o nome do paciente e a idade, o nome do avaliador e a data de avalia\u00e7\u00e3o.A primeira parte do protocolo refere-se ao \u2018\u2019teste de localiza\u00e7\u00e3o sonora\u201d, o qual investiga o desempenho da crian\u00e7a na localiza\u00e7\u00e3o \u00e0 direita, \u00e0 esquerda, em cima, \u00e0 frente e atr\u00e1s. O crit\u00e9rio de normalidade, de acordo com os autores, \u00e9 acertar quatro de cinco dire\u00e7\u00f5es. A tabela do teste de localiza\u00e7\u00e3o sonora deve ser preenchida com a quantidade de acertos e se est\u00e1 normal ou alterado. Deve-se tamb\u00e9m assinalar se a avalia\u00e7\u00e3o da habilidade auditiva de localiza\u00e7\u00e3o sonora encontra-se normal ou alterada.Na parte dois se inicia o \u2018\u2019Teste de mem\u00f3ria para sons verbais ou n\u00e3o verbais em sequ\u00eancia\u201d, subdividido primeiro em Teste de Mem\u00f3ria para Sons Verbais (TMSV) em sequ\u00eancia com tr\u00eas sons, em que deve ser realizada a produ\u00e7\u00e3o fonoarticulat\u00f3ria isolada das s\u00edlabas PA TA CA, e tamb\u00e9m preencher na tabela com \u2018\u2019sim\u201d ou \u2018\u2019n\u00e3o\u201d, o desempenho da produ\u00e7\u00e3o do PA TA CA, TA PA CA e CA TA PA. O crit\u00e9rio de normalidade, segundos os autores, \u00e9 igual ou maior a dois acertos para TMSV em 3 tentativas (\u22652/3), o resultado deve ser dividido por tr\u00eas .Na parte final h\u00e1 a conclus\u00e3o, deve ser preenchido com as respostas do teste de mem\u00f3ria sequencial de sons verbais, incluindo tr\u00eas sons verbais. Aplica-se a mesma regra para o teste de mem\u00f3ria sequencial de sons n\u00e3o verbais, incluindo tr\u00eas sons n\u00e3o verbais. O teste de quatro sons n\u00e3o verbais foi retirado pois n\u00e3o estava adequado para a faixa et\u00e1ria do estudo. Neste momento \u00e9 colocado os acertos e se est\u00e1 normal ou alterado.Deve preencher se a avalia\u00e7\u00e3o da habilidade auditiva de ordena\u00e7\u00e3o temporal est\u00e1 normal ou alterada. A tabela seguinte \u00e9 preenchida com os poss\u00edveis comportamentos que foram observados durante a realiza\u00e7\u00e3o do teste, incluindo: capacidade de aten\u00e7\u00e3o inadequada, capacidade de mem\u00f3ria inadequada, atitude motora inadequada, dificuldade de compreender as solicita\u00e7\u00f5es e cansa-se facilmente.Finalizando o teste, \u00e9 explicado que, para o teste de localiza\u00e7\u00e3o sonora, \u00e9 colocado como crit\u00e9rio de normalidade, acima de quatro acertos. Como orientado pelas autoras, o avaliador dever\u00e1 marcar, em protocolo espec\u00edfico, o n\u00famero de acertos e se est\u00e1 normal ou alterado . Para o teste de sequ\u00eancia para sons verbais dever\u00e1 haver ao menos dois acertos nas tr\u00eas sequ\u00eancias nomeadas como crit\u00e9rio de normalidade, assim como para sons n\u00e3o verbais, em que dever\u00e1 haver tamb\u00e9m dois acertos em tr\u00eas tentativas. Com os achados dos tr\u00eas testes, o avaliador concluir\u00e1 se h\u00e1 altera\u00e7\u00e3o de PAC. O teste de quatro sons foi retirado pois n\u00e3o se apresentava adequado para a idade do presente estudo.Em avalia\u00e7\u00e3o audiol\u00f3gica comportamental, foi constru\u00edda uma tabela a partir dos instrumentos que ser\u00e3o utilizados, observando o comportamento auditivo da crian\u00e7a diante do instrumento musical. H\u00e1 uma tabela dividida em instrumentos, intensidade e respostas. Os instrumentos ser\u00e3o: tambor, chocalho, guizo, reco-reco e agog\u00f4 de duas camp\u00e2nulas, todos devem ser testados em fraco, m\u00e9dio e forte e a resposta deve ser anotada. \u00c9 esperado que a crian\u00e7a na idade analisada pelo estudo responda a todos os instrumentos musicais na intensidade mais fraca e diretamente para todas as dire\u00e7\u00f5es.Em rela\u00e7\u00e3o \u00e0s sugest\u00f5es propostas pelos ju\u00edzes, um deles prop\u00f4s que o protocolo Avalia\u00e7\u00e3o do Desenvolvimento da Linguagem- ADL 2 pudesse ser utilizado na avalia\u00e7\u00e3o dos pr\u00e9-escolares. Foi sugerido incluir, na anamnese, grau de instru\u00e7\u00e3o/escolaridade dos pais. Nas queixas, foi sugerido tamb\u00e9m retirar \u2018\u2019prefer\u00eancia manual\u201d para ser inserido em outro t\u00f3pico, sendo este \u2018\u2019identifica\u00e7\u00e3o e anamnese\u201d. Nas quest\u00f5es de desenvolvimento de linguagem, incluir uma pergunta para saber se a crian\u00e7a combina quatro palavras ou mais.Na pesquisa para constru\u00e7\u00e3o do roteiro foi encontrado pouco material referente ao PAC em pr\u00e9-escolares. J\u00e1 em escolares o foco de estudos \u00e9 maior, mostrando a import\u00e2ncia de um material que abrange essa idade para que seja poss\u00edvel detectar de maneira precoce.. Autores afirmam que os primeiros anos de vida s\u00e3o considerados cr\u00edticos para o desenvolvimento e, as experiencias auditivas vivenciadas neste per\u00edodo, est\u00e3o diretamente ligadas ao desenvolvimento das habilidades da audi\u00e7\u00e3o, tais como detec\u00e7\u00e3o, discrimina\u00e7\u00e3o, localiza\u00e7\u00e3o, reconhecimento e compreens\u00e3o auditiva. Dessa forma, a matura\u00e7\u00e3o neuromuscular e do sistema sensorial de forma \u00edntegra tem liga\u00e7\u00e3o direta com as habilidades de fala e linguagem. Quando se adquire um padr\u00e3o articulat\u00f3rio de l\u00edngua, h\u00e1 a habilidade auditiva de percep\u00e7\u00e3o de fala, pois os aspectos sensoriais e motores est\u00e3o sendo abrangidos.A integridade do sistema auditivo, perif\u00e9rico e central, \u00e9 fundamental para desenvolver adequadamente a comunica\u00e7\u00e3o oral e escrita, uma vez que a linguagem compartilha mecanismos cognitivos subjacentes com as habilidades auditivas. H\u00e1 fatores, como a integridade do sistema auditivo perif\u00e9rico e a matura\u00e7\u00e3o do sistema nervoso central, principalmente no que se refere \u00e0s \u00e1reas auditivas prim\u00e1rias e secund\u00e1rias que podem influenciar diretamente no desenvolvimento auditivo. Esses fatores devem ser amplamente investigados para entendimento de poss\u00edveis altera\u00e7\u00f5es. Dessa forma, o roteiro buscou observar, de forma minuciosa, os principais fatores de risco para a altera\u00e7\u00e3o no PAC.O mecanismo respons\u00e1vel pelas habilidades auditivas \u00e9 o PAC, o qual desenvolve-se at\u00e9, em m\u00e9dia, de dez a 12 anos de idade.Durante a primeira inf\u00e2ncia, altera\u00e7\u00f5es perif\u00e9ricas e hist\u00f3ricos de otite m\u00e9dia secretora, podem comprometer a matura\u00e7\u00e3o das vias auditivas. Este comprometimento apresenta repercuss\u00e3o nas habilidades auditivas centrais e no processo de aprendizagem, por isso a necessidade de investigar o hist\u00f3rico auditivo do paciente.As quest\u00f5es sobre o desenvolvimento auditivo da crian\u00e7a, o hist\u00f3rico, se houve algum trauma, qual o hist\u00f3rico familiar e se fez/faz uso de antibi\u00f3ticos que possam ser otot\u00f3xicos est\u00e3o abordados na parte quatro do roteiro nomeada por \u2018\u2019desenvolvimento auditivo\u201d. Segundo a literatura, a etiologia dos transtornos de PAC inclui otites, febres altas e cont\u00ednuas, dist\u00farbios espec\u00edficos do desenvolvimento da fun\u00e7\u00e3o auditiva, les\u00f5es nas vias de condu\u00e7\u00e3o e priva\u00e7\u00e3o sensorial durante a primeira inf\u00e2ncia. As queixas foram abordadas no roteiro, na parte tr\u00eas, pois a dificuldade em compreender a fala em presen\u00e7a de ru\u00eddo de fundo, maior distratibilidade, aten\u00e7\u00e3o reduzida, dificuldade de comunica\u00e7\u00e3o e baixo desempenho acad\u00eamico s\u00e3o sinais de risco para altera\u00e7\u00f5es do PAC.Todos esses fatores citados anteriormente ir\u00e3o influenciar, de forma efetiva, no desenvolvimento auditivo, na linguagem oral e escrita do paciente. As dificuldades encontradas podem ser observadas pelos familiares e cuidadores por meio de comportamentos, tais como dificuldades na realiza\u00e7\u00e3o de tarefas complexas ou mais longas, distra\u00e7\u00e3o, sensibilidade a sons altos, dificuldade em seguir ordens verbais, repeti\u00e7\u00e3o de est\u00edmulos verbais, dificuldade em compreender piada e linguagem figurada.Os transtornos do processamento auditivo consistem em uma inabilidade de atentar, discriminar, reconhecer, recordar ou compreender informa\u00e7\u00f5es auditivasCom a apresenta\u00e7\u00e3o de preju\u00edzos nas \u00e1reas acima descritas, h\u00e1 a necessidade de uma avalia\u00e7\u00e3o aprofundada. \u00c9 importante avaliar habilidades que fazem parte do desenvolvimento normal da linguagem, pois diversos dist\u00farbios de linguagem oral podem ser detectados e acompanhados de forma precoce..Na parte cinco, caracterizada como \u2018\u2019desenvolvimento de linguagem\u201d, foram citados os principais marcos do desenvolvimento. Preju\u00edzos na interpreta\u00e7\u00e3o de informa\u00e7\u00f5es sensoriais podem ser indicativos de altera\u00e7\u00e3o auditiva o que, futuramente, pode acarretar em um transtorno do processamento auditivo, e na aquisi\u00e7\u00e3o da fala e linguagemDe acordo com a literatura pesquisada, n\u00e3o h\u00e1 um instrumento que observe a rela\u00e7\u00e3o de linguagem e audi\u00e7\u00e3o, em especial do PAC em pr\u00e9-escolares, apenas em crian\u00e7as em idade escolar. Foram pesquisados artigos e materiais sobre o tema nas bases de dados Lilacs, Sielo, PUBmed e acervo de livros e teses em biblioteca de institui\u00e7\u00e3o, no entanto foram observados apenas protocolos e roteiros que contemplavam crian\u00e7as acima de seis anos de idade. Dessa forma, reafirma-se a import\u00e2ncia da constru\u00e7\u00e3o do material que visa o rastreio precoce de riscos e poss\u00edveis altera\u00e7\u00f5es de audi\u00e7\u00e3o e linguagem.O presente roteiro constituiu, portanto, um instrumento para ser utilizado na pr\u00e1tica cl\u00ednica para avalia\u00e7\u00f5es, triagens e acompanhamento de pr\u00e9-escolares para indicar poss\u00edveis riscos para o transtorno do processamento da informa\u00e7\u00e3o auditiva. O intuito do estudo \u00e9 a detec\u00e7\u00e3o precoce dos poss\u00edveis transtornos para acompanhamento e estimula\u00e7\u00e3o das habilidades auditivas para que, no futuro, os preju\u00edzos sejam sanados ou menores para a crian\u00e7a.O roteiro faz parte de um estudo em andamento, que avaliar\u00e1 crian\u00e7as menores de seis anos de idade. A pesquisa, at\u00e9 o presente momento, ainda n\u00e3o ocorreu por conta da pandemia do COVID-19.Foi elaborado um roteiro de pesquisa para realizar avalia\u00e7\u00e3o e indicar poss\u00edveis riscos para o transtorno do PAC em pr\u00e9-escolares. O roteiro, Anexo A, \u00e9 de extrema import\u00e2ncia visto que n\u00e3o h\u00e1 na literatura instrumentos de triagem de PAC em pr\u00e9-escolares que investiguem, de forma minuciosa, todo o processo que permeia o desenvolvimento auditivo e de linguagem de crian\u00e7as de 43 a 47 meses.Este per\u00edodo a ser investigado \u00e9 cr\u00edtico para o desenvolvimento, fatores citados, como otites, uso de medicamentos otot\u00f3xicos, entre outros, podem causar altera\u00e7\u00e3o no desenvolvimento auditivo, causam impacto no desenvolvimento da linguagem oral e escrita, e consequentemente na aprendizagem escolar."}
+{"text": "Agente Escuta\u2019 application, in addition to identifying problems and possibilities for improvement.To evaluate the usability and satisfaction of users with the interface of the \u2018Descriptive exploratory translational study, characterized by a usability test with a quantitative and qualitative approach, subdivided into three stages: (I) prior evaluation of usability by 10 judges, including students, primary care professionals, professors and researchers in Information Technology and Speech Therapy; (II) evaluation of the application by the target audience, that is, community health agents from six municipalities in Rio Grande do Norte; (III) evaluation of the satisfaction of the agents who used the application in their work routine. The System Usability Scale and the Net Promoter Score were used, in addition to a qualitative evaluation of the opinions.Usability was rated as excellent by judges, regardless of category. In the evaluation by community health agents, usability was considered good and there was no effect of the city of origin. It was found that the perception of the judges and the target audience were different, with a lower score for the participants in the second stage. However, most would give positive publicity to the product. The heuristic with the highest score was ease of memorization and participants in the third stage were interested in continuing to use the tool in practice, even after the end of the study.Agente Escuta prototype showed good usability and satisfaction and aspects that could be improved in future solutions were identified.The  In Brazil, the National Primary Care Policy (NPCP) provides for the articulation of institutions in partnership with the health departments to offer permanent and continuing education for PHC professionals.The expansion and improvement of Primary Health Care (PHC) are viewed as the primary initiatives to foster qualitative changes in healthcare for the coming decades worldwide. Thus, the importance of PHC in hearing health is undeniable, as well as the need to develop tools that reach different locations in the country.When specifically considering hearing health, the World Health Organization (WHO) report in 2021 highlights alarming projections regarding the prevalence of hearing loss, with an estimate that 900 million people may have some degree of hearing loss by 2050. The document reiterates the number of preventable causes, as well as the annual global cost of US$ 750 billion for untreated hearing loss. Thus, innovations in health education based on mHealth  are already a reality and have grown exponentially in the last five years in other countries,6.Considering this context, there has been considerable growth in innovative programs and technologies aimed at strengthening this level of care. Technological solutions in telehealth began to be developed for health professionals, such as Community Health Workers (CHW), to overcome barriers to accessing hearing health care, using smartphones, tablets, computers and other portable devicesInformatiza APS\u201d program, which is part of the Ministry of Health's digital health strategy, and the e-SUS AD and e-SUS territory apps aimed at facilitating the work process of local CHWs.In Brazil, the trend has not been different. Currently, there is the \u201c. These validated mHealth technologies enabled PHC to perform hearing screenings using automated tests with a smartphone interface. Considering this, the CHWs began to conduct hearing screening for children in different community contexts, including home visits and monitoring of early childhood development.In South Africa, since the 2000s, mHealth technologies have been used in the hearing health program.Evaluations of this model have proved that the CHW can be trained to screen children reliably and time-efficiently. However, there are challenges in this program, such as the levels of environmental noise during the exams, which must be adequate so that they do not affect the reference rates of the hearing screening. Another challenge lies in monitoring the quality of the hearing screening conducted by CHWs.Therefore, the usability evaluation of mobile applications is a strategy to ensure that interactive systems are adapted to users and their tasks, and that there are no negative quotients regarding their use. The objective of a usability evaluation is to verify the degree to which a system or product is effective, that is, how well the system fulfills the tasks for which it was designed; efficient, that is, how many resources, such as time or effort, are required to use the system to perform the tasks for which the system was designed; and, finally, whether it favors positive attitudes and responses from would-be usersAgente Escuta\u2019 application, developed in this study, was designed to assist PHC professionals in monitoring the development of hearing and language, based on developmental milestones. Another objective of the app is to promote continuing education in hearing health for CHWs in an interactive way.However, the \u2018Agente Escuta\u2019 application, in addition to identifying problems and possibilities for improvements.However, as it is an unprecedented app, there are no previous studies on its usability or characterization of its implementation in the Brazilian context. Therefore, the objective of the present study was to verify the usability and satisfaction of users with the interface of the \u2018Agente Escuta\u2019 app with a quantitative and qualitative approach to identify difficulties and possible improvements in the tool.This is an exploratory translational study with a prospective descriptive design. It was carried out through a usability test of the \u2018The study was structured in three stages, namely: (I) prior evaluation of usability by 10 judges, including students, primary care professionals, professors and researchers in Information Technology and Speech Therapy; (II) evaluation of the application by the target audience, CHWs from six municipalities in Rio Grande do Norte (RN), Brazil; (III) evaluation of the satisfaction of the CHW who used the application in their work routine.Following the Guidelines and Regulatory Standards for Research Involving Human Subjects (Resolution 466/12), the study was only initiated after approval by the Institution's Research Ethics Committee (number process 4.695.580) and upon signing of the Free Consent Form, providing all necessary explanations regarding study participation.In partnership with the Metr\u00f3pole Digital Institute of the Federal University of Rio Grande do Norte (MDI/FURN), recognized for its projects with an interface in health, the prototype of the application was developed over a period of one year, between 2020 and 2021. The first version of the tool was developed with an average of 15,000 lines of code and predominantly in Javascript language, with the back-end and front-end of the mobile version and the dashboard of the web version being programmed. The software registration at the National Institute of Industrial Property (NIIP) was issued in November/2021 with protocol number BR512021002590-3.Escuta Game, presented on the home screen, which contains daily situations related to hearing health.The app works on two main axes: continuing education in hearing health, and monitoring of the development of hearing and language in children from zero to 12 months of age. In the continuing education axis, tabs are available for content review, namely: the most frequent doubts about hearing health raised by the CHWs while using the app, a flowchart with the development milestones in the first two years of life, and -17. For the construction of its functionalities, a survey was carried out of already validated tools, such as guidance booklets based on development milestones, questionnaires and international and national guidelines. When answered, the specific questionnaire for each child will only be available again in the following month, with the subsequent age group, which reduces the chances of a duplicate response within the month. According to the \u201cfailure\u201d criterion proposed in the follow-up questionnaire, the app automatically refers the user to the \u201chealth centers\u201d tab, where all the hearing health centers in the region are listed so as to facilitate the referral for audiological evaluation.In terms of monitoring hearing and language, the application provides questions regarding the age of the registered childAll this information is sent to the MySQL database, which is a relational database connected to a private server with technology based on cryptography, and can be continuously accessed only by the administrator profile (ADM), who, in this case, are the researchers in charge.In the ADM version, information is available on the number of questionnaires applied, successes and errors in the game, results of each child monitored, location, risk indicators for hearing loss of the registered children, whether the NHS was performed, and results obtained.For the prior evaluation of the usability of the app, two judges from each category, not involved with the development of the app or in other stage of the research, were invited, namely: undergraduate and graduate students in Speech Therapy, CHW, professors and researchers in Technology of Information and in Speech Therapy. The 10 evaluators were selected based on their professional activities, history of developing mobile applications with a health interface and/or participation in university internships with actions directly linked to the promotion of children's hearing health in PHC.To obtain a paired analysis, it was decided to include two participants in each category. A third judge would be invited if the total scores of the usability scale between the two evaluators showed more than 20 points of difference in the individual evaluation. A total of three male and seven female judges, aged between 21 and 48, participated in this first stage.. Thus, the sample size of 15 CHWs was defined, with a minimum representativeness of five users in each mesoregion of RN.In the second stage of the research, the usability of the app was evaluated by CHWs interested in using the tool in their daily practice. The definition of the minimum sample size was based on the estimate that a single user is capable of finding, on average, 31% of the usability issues, five users are enough to identify 85% of the issues and that, when carrying out the test with 15 users, approximately 100% of the problems can be identifiedTo guarantee greater representativeness of the general context of the RN, it was decided to select the municipalities through a draw by conglomerates. For the draw, the four mesoregions of RN were considered, namely: Agreste Potiguar, Central Potiguar, East Potiguar and West Potiguar. Except for Natal, which was selected because it is the state capital, the municipalities of each mesoregion were randomly selected, namely: Caic\u00f3, Upanema, Santa Cruz, S\u00e3o Miguel do Gostoso and Jo\u00e3o C\u00e2mara.In agreement with the municipal health secretaries, for each municipality drawn, Primary Health Care Unit (PHCU), inserted in neighborhoods with a greater number of children aged between zero and 12 months, was selected.\u2018Agente Escuta\u2019; using the app freely, during a period of two months, not being necessary to effectively use the app in the work routine; and fully answering the questionnaires to assess usability. For the third stage, three months of consecutive use of the app were required.Inclusion criteria for the first two stages included: owning a smartphone with the Android operating system, in any version, with 11 megabytes of memory available on the cell phone for the free download of A total of 41 CHWs, out of the 91 CHWs working in the 12 selected PHCU, were invited to participate in this study to meet the determined sample number. A total of 35 CHWs participated in the study, as five CHWs did not download the app in the reference period of the study and one did not complete the user test. The distribution of CHWs in relation to location and sociodemographic characteristics is shown in All participants received the downloadable file in .apk format with the prototype of the application, sent individually. Along with the file, a tutorial video on how to download the prototype on smartphones was attached.During the study period, three CHWs, in addition to carrying out the usability test, completed three consecutive months of effective use of the app, which enabled the execution of the third stage of the study.Agente Escuta: ISO 25010 - mobile app analysis; ISO 25062 - user satisfaction and effectiveness of the tool tested; ISO 16982 - user\u2019s opinion about the application's interface, and ISO 14998 - software evaluation.The methodology of this study considered the guidelines of the International Organization for Standardization (ISO), a group of technical standards that establish a quality management model. To this end, the following standards were considered when choosing the evaluation tools for the , previously translated and validated into European Portuguese. The SUS method can be used to evaluate products, services, hardware, software, websites, applications or any other type of interface. Used in previous studies with the same purpose, it contains 10 items to be answered individually and applied anonymously.To assess the usability of the app, the System Usability Scale (SUS) was used, one of the most accepted instruments due to its reliabilityThe SUS was made available in digital online format through Google Forms, and the link was sent individually to each participant at all stages. The questionnaire was answered anonymously using the Likert Scale, in which 1 indicated complete disagreement and 5 complete agreement.. Thus, questions 3, 4, 7 and 10 were related to \u201cease of learning\u201d, questions 5, 6 and 8 to \u201cproduct efficiency\u201d, question 2 to \u201cease of memorization\u201d, question 6 to \u201cminimization of errors\u201d and questions 1, 4 and 9 to \u201csatisfaction of use\u201d.The questions were subdivided taking into account heuristics which indicate important aspects of usability ,20.For the analysis of SUS results, the sum of the individual contribution of each item was considered. For odd items, 1 was subtracted from the participant's response, whereas for even items, 5 was subtracted from the user's response. After obtaining the score for each item, the scores were added and the result was multiplied by 2.5. The result obtained was the participant's satisfaction index, which can vary from 0 to 100. The average and standard deviation (\u03c3) of the satisfaction indices of all participants were calculated to obtain the app's usability level classification. The average SUS score is 68 (50th percentile) and is considered a cutoff point, that is, an average above this value suggests a good level of usability and an open question for observations and recommendations were used. The NPS is a simple and concise way of examining the satisfaction of patients, users or clients with a service; it is referred to as \u201cthe final question\u201d, suggesting that it is a summary of user satisfaction of some service or product.To measure app usability and satisfaction, in addition to the SUS instrument, the Net Promoter Score (NPS).The assumption is that individuals scoring 9 or 10 will give the product positive publicity; they are called \u2018promoters\u2019. Individuals answering 7 or 8 are considered indifferent (\u201cpassive\u201d). Finally, individuals who answer 0 to 6 are likely to be dissatisfied customers and are called \u201cdetractors\u201d. The NPS is then calculated as the difference between the percentage of \u201cpromoters\u201d and \u201cdetractors\u201d and can range from -100% to +100%. The higher the percentage, the greater the chance that the product will be recommended to other users\u2018Agente Escuta\u2019 to another user?\u201d and the response option was made available on a Likert scale from zero to 10, where zero corresponded to \u201cnot likely\u201d and 10 to \u201cextremely likely\u201d.The NPS was made available to research participants through the same Google Forms link, but in a session after SUS, with the question \u201cHow likely are you to recommend . The questionnaire contained 10 items that represented practical situations of auditory monitoring mediated by the app, with the following response options: (1) strongly disagree, (2) disagree, (3) indifferent, (4) agree, (5) strongly agree. The CHWs answered this instrument using an online form, as in the previous stages.Regarding the third stage of the study, the participating CHWs answered an additional satisfaction questionnaire prepared based on a previous instrumentFor the descriptive analysis, the average SUS and NPS score was considered for each category of judges and for the CHWs of each municipality, in addition to the thematic categorization of the qualitative variables related to the suggestions and improvements indicated.The inferential analysis was first performed with the Shapiro-Wilk adherence test in each group, with normal data distribution being observed in stage 1 (p= 0.078) and absence of normality in stage 2 (p= 0.047). Thus, the one-way Analysis of Variance (ANOVA) was used to compare the SUS score between the categories of judges; the Kruskal-Wallis test to compare SUS and NPS among participants in each municipality; and the Mann-Whitney test to compare usability in the perception of judges and target audience, the CHWs. The analysis was performed using the Software Statistical Package for the Social Sciences (SPSS), version 24, and the significance level adopted was 5%.\u2018Agente Escuta\u2019 app with a score higher than the 50th percentile of the SUS, with an average of 93.50 in the total score (\u03c3 = 5.90), suggesting, according to the evaluators of the first stage, that the beta version this tool does not face major usability difficulties.In the usability assessment with the SUS method in the first stage of this study, the participation of a third judge from the same category was not necessary, considering that there was no difference greater than 20 points between the evaluators . All theIt was also possible to observe that the category with the lowest usability score in the SUS was that of IT professionals (average = 83.75), and the highest scores were attributed by graduate students in speech therapy and PHC professionals (average = 97.50). The one-way ANOVA showed that there was no effect of the judges\u2019 category on the usability score obtained , with similar evaluations.For the analysis of the judges' intra-category agreement percentage, the responses were grouped into positive, negative or neutral. For the odd-numbered SUS items, the responses \u201cagree\u201d and \u201ccompletely agree\u201d were considered positive, while \u201cdisagree\u201d and \u201ccompletely disagree\u201d were classified as negative. On the other hand, for the even items, the opposite was adopted. The percentage of agreement between judges in the same categories ranged from 80% , 90% (undergraduate students) and 100% for the other categories.2 (5) = 7.637; p= 0.177].In the second stage, also using the SUS tool, the average scores of the 35 participating CHWs were calculated according to the municipalities . The totWhen comparing the scores of the two stages using the Mann-Whitney test, it was clear that the perception of the judges and the target audience were different , with a lower score for the CHWs.When considering the intra-group assessment of stage 2, greater agreement was seen in relation to the second SUS statement \u201cI find the application unnecessarily complicated\u201d in which 22 participants (62.85%) strongly disagreed with the statement. The last statement of the questionnaire \u201cI needed to learn several new things before I could use the application\u201d had the greatest heterogeneity in the responses ., in the judges\u2019 assessment, a lower score was obtained for \u201csatisfaction of use\u201d, with an average score of 90.60. According to the evaluation of the CHWs participating in the second stage, the lowest score was for \u201cminimizing errors\u201d, with an average score of 73.57. Participants in both stages showed a higher score for the heuristic referring to \u201cease of memorization\u201d, with an average of 97.50 in the first stage and 80.71 in the second stage.Regarding heuristicsAfter using and evaluating the tool, participants recorded comments and suggestions to be implemented in future versions of the app. There was similarity in the responses obtained among the participants of the two stages, so they could be compiled into seven representative statements .Regarding the final satisfaction question, asked through the NPS tool, the Mann-Whitney Test showed a difference between the judges' assessment in stage 1 and the perception of potential users in stage 2 . Considering the total of 10 judges, eight (80%) answered \u201c10\u201d on the Likert scale, one answered \u201c9\u201d and another answered \u201c8\u201d. Following the NPS criteria, 90% of the judges would be \u2018promoters\u2019, that is, they would give positive publicity to the product, and 10% would be \u201cindifferent\u201d . As the 2 (5) = 3.945; p = 0.557].On the other hand, in the second stage, the NPS of the 35 CHWs resulted in +48.58%. A total of 21 (60.00%) participants answered \u201c10\u201d and \u201c9\u201d on the Likert scale, 10 (28.57%) answered \u201c8\u201d and \u201c7\u201d, and four (11.42%) answered \u201c6\u201d, with a predominance of 'promoters' . The KruEscuta Game in the revision of auditory health contents (Question 4), and desire to continue using the app in the work routine (Question 10).Regarding the additional satisfaction questionnaire, only three CHWs met the prerequisite of effective use of the app in their work routine for three consecutive months, and the others used it for different periods. The three participants were from different municipalities and followed up 22 children aged between one and 12 months (average of 5.55 months and standard deviation of 3.46 months). Despite the level of education of these CHWs covering incomplete secondary education, complete secondary education and incomplete higher education, the restricted number of participants does not allow any inference to be made about the impact of educational level on the results obtained. It was found that there was an agreement of answers in the items related to the importance and relevance of carrying out auditory monitoring , positive influence of the There was a difference of opinion on questions related to the ease of applying the hearing and language monitoring questionnaire through the app, and to the community's acceptance of using the app as a tool . It was found that in each topic the negative analysis was made by only one CHW, who differed in the questions..Among the various activities carried out by the PHC, the auditory monitoring of all children in the community during childcare consultations is recommended as one of the steps of the auditory identification and intervention program in the first years of life,6,23,24.An alternative to enhance auditory monitoring is the articulation with the CHWs, who are recognized for being the professionals most aware of the real needs of the community. To achieve this, studies around the world are investing in the development of tools that help the CHWs to monitor hearing, even in remote communitiesAgente Escuta\u2019, in the first stage of this study, showed that the two categories that scored the most in the first stage are directly inserted in the reality of hearing monitoring by the PHC and in the development of research aimed at this population, that is, PHC professionals and graduate students in Speech Therapy. However, even professional IT evaluators, who are not familiar with the auditory monitoring stage in practice, kept positive evaluations.The purpose of the app was to provide support in the structuring of a referral flow, becoming a facilitator in the implementation of hearing health actions in the CHW's work routine. The result of the usability evaluation of the \u2018Thus, the fact that there were no differences in the evaluations between the judges\u2019 categories indicated that usability was well evaluated both by professionals involved in the development of technological solutions and by evaluators who experience PHC.On the other hand, in the second stage, the general score of the CHWs was lower than in the first stage. Therefore, it is considered that the PHC professionals who participated in the first stage did not represent the CHWs in the Rio Grande do Norte municipalities, since greater difficulties were observed in the usability of the tool by the participants in the second stage..Although apps aimed at the health area have gained prominence in recent years due to the availability of access and ease of use of functionalities that were previously only available through the computer, aspects such as internet availability, access to mobile devices aimed exclusively at work, and technical training for the handling of technological tools by health professionals is crucial for the successful implementation of m-health in the work routineInformatiza APS\u201d, which aims to support the computerization of health units and the qualification of PHC data throughout the country. Some apps for smartphones have already been developed to help PHC professionals in their work routines, namely: e-SUS AD, e-SUS territory and e-SUS AB. However, the analysis of usability or user satisfaction regarding these technological solutions was not found in the researched literature.That said, there is a digital health initiative by the Ministry of Health, \u201c,25. It was thought that the CHW's difficulties with basic computing were linked to poor access to computers in the PHC.In Brazilian studies on remote hearing health training through CD-ROM, Cybertutor and online course available on the platform of the Ministry of Health, it was found that CHW professionals had difficulties with basic information technology. These data showed that adherence to permanent health education strategies may have been impacted by the technical difficulty in handling web and desktop interface programs. These data about the popularization of smartphones raised the hypothesis that mobile applications aimed at auditory monitoring could have an advantage over strategies with web and desktop implementation. However, it was observed in this study that, even with wide access to smartphones, CHW professionals have basic technical difficulties in mobile applications, such as finding the application on the home screen of the mobile device, registering a password and remembering the email.A survey carried out in 2020 pointed out that the number of smartphones in Brazil is equivalent to more than one device per inhabitant, with a total of 234 million.In this way, mobile applicability tools aimed at this user audience need a well-designed interface so that users can extract as much as possible from the app, without major technical difficulties. Dissatisfaction in use can cause a bad impression on the users and they may give up using the app, which is not desirable.Usability is linked to the quality of user interaction with the interface, be it a system, tool or mobile application. Usability evaluations seek to analyze the system interface quality, and whether that product is intuitive enough to the point of not having so many or almost no failures that affect the use, with a quality that is at least acceptable. Usability tests aim to find usability issues in interfaces according to how users use them. In this case, users test the system functionalities, reporting possible interaction issues during use. The results pointed to serious usability issues identified by the SUS method. Participating evaluators indicated that most health-oriented mobile applications developed in Bangladesh scored lower on the aesthetic and graphic design heuristic. The authors concluded that the unintuitive design could explain the lack of adherence to the use of apps in the country's health services.In Bangladesh, a study carried out a review and assessed the usability of the different m-Health apps in the countryIn the results of this study, the graphic design and aesthetics of the app were well evaluated in both the first and second stages. In addition, in the judges' perception, a higher score was obtained for questions related to \u201cease of learning\u201d, with an average score of 97.50, which may be linked to the well-structured and easy-to-use graphical interface of the app..In the second stage, the participating CHWs evaluated the interface in a similar way, but with an average score of 80.71. When considering the score of questions related to the interface and the low percentage of CHWs who used the application in their work routines (8.57%), it was possible to observe that although the app graphic design has a good score, this variable did not directly reflect on adherence to the effective use of the app. Therefore, the actual implementation of the application was not linked to graphic design satisfaction, as seen in the systematic review in Bangladesh. In the second stage, the lowest score was for \u201cease of learning\u201d, with 71.00. It is believed that this drop in scores related to satisfaction and ease of learning can be explained by the fact that some of the app features did not meet the evaluators\u2019 expectations such as, for example, the absence of the \u201cI forgot the password\u201d option and the \u201cdoubts\u201d tab, which does not offer the possibility for the user to register their doubts directly in the app, and the TAN response options during the registration of children monitored by the app, which end up leaving the possibility of filling in the wrong data.The lowest score among the SUS questions, in the judges\u2019 evaluation of the first stage of the study, was in \u201csatisfaction of use\u201d, with an average score of 89.00. Although it was the lowest score, it still represents an excellent usability valueFilling errors in children's registration can be minimized by the ADM version of the app, which has access to all information registered by users. Therefore, if there is any incompatible information in the data regarding the TAN, the ADM has the possibility of correcting them through its web version.In addition, the version of this app was designed with the \u201cdoubts\u201d tab in a forum format, as suggested by the evaluators. However, during the development of the interface, it was observed that the option of inserting questions directly into the app would make the software more robust and, consequently, would require more free memory on the device for the download. Considering the possibility of users not being able to download the app due to lack of available memory on their smartphones, it was decided to leave the \u201cdoubts\u201d tab with the questions fixed and editable only by the ADM, who was in direct contact with the participants' doubts.Other aspects highlighted in the evaluators' responses were typing errors and suggestions for inserting simple features, such as the \u201cI forgot the password\u201d option right on the login screen. These topics are easy to correct and improvements can be implemented in future versions of the app..Regarding the NPS evaluation result, a study conducted in South Africa with a hybrid application (web and face-to-face) to monitor the hearing of patients resulted in a score of +87% in the users' NPS. The authors pointed out that, given this NPS value, it is highly likely that users will recommend the hybrid clinic to friends and familyConsidering the results of the NPS assessment in this study, +100% of the evaluators in the first stage would probably recommend the use of the app to other users, remaining in the category of \u2018promoters\u2019 as regards NPS assessment. As for the participants of the second stage, who scored +48.58% in the NPS, they demonstrate that, although the tool does not present serious usability issues, it would still not be as recommended for other users when compared to the participants in the first stage.. The lack of clarity about the CHW's attributions can cause overload in the workday and because they do not have a clear career plan these professionals end up performing several non-standard tasks. This is a relevant finding for the implementation of new tools, as in addition to adequate usability, the motivation of professionals for effective use is of critical importance.A Brazilian study on hearing health training showed that professionals who dropped out of the study pointed out as main reasons the turnover of professionals and positions, lack of participation of managers, and high demand for CHW-related activitiesSatisfaction with app use in the work routine was impaired, since, during the period of this study, the functions of the CHWs were redirected to support actions by health professionals focused on the COVID-19 pandemic, such as intense testing and the national vaccination campaign. Thus, despite the promising results, the small number of CHWs who used the app effectively in their work routine in the third stage does not allow generalizing the data obtained, which is a limitation of the study.Agente Escuta\u2019, developed to help the auditory and language monitoring stage in the PHC, presented good usability according to participants in Rio Grande do Norte, with 90% of the judges and 60% of the CHWs giving positive publicity to the product. The CHWs who used the app in their routine agreed with the importance and relevance of carrying out auditory monitoring, indicated the positive influence of the Escuta Game in reviewing content on hearing health and showed interest in continuing to use the app in their work routine.The smartphone app prototype \u2018Improvements should be implemented in the next versions of the application or in proposing other technological solutions for the target audience, according to the suggestions of the evaluators of this study. . No Brasil, a Pol\u00edtica Nacional de Aten\u00e7\u00e3o B\u00e1sica (PNAB) prev\u00ea a articula\u00e7\u00e3o de institui\u00e7\u00f5es em parceria com as secretarias de sa\u00fade a fim de propiciar a educa\u00e7\u00e3o permanente e continuada para os profissionais da APS.A expans\u00e3o e a qualifica\u00e7\u00e3o da Aten\u00e7\u00e3o Prim\u00e1ria \u00e0 Sa\u00fade (APS) t\u00eam sido vistas como principais iniciativas para produzir mudan\u00e7as qualitativas na sa\u00fade para as pr\u00f3ximas d\u00e9cadas em todo o mundo. Assim, \u00e9 ineg\u00e1vel a import\u00e2ncia da APS na \u00e1rea de sa\u00fade auditiva, bem como a necessidade de desenvolvimento de ferramentas com alcance \u00e0s diferentes localidades do pa\u00eds.Ao considerar especificamente a sa\u00fade auditiva, o relat\u00f3rio da Organiza\u00e7\u00e3o Mundial da Sa\u00fade (OMS) em 2021 destaca proje\u00e7\u00f5es alarmantes em rela\u00e7\u00e3o \u00e0 preval\u00eancia da perda auditiva, com estimativa de que 900 milh\u00f5es de pessoas poder\u00e3o ter algum grau de perda auditiva at\u00e9 2050. Al\u00e9m disso, reitera o quantitativo de causas pass\u00edveis de preven\u00e7\u00e3o, bem como o custo global anual de US$ 750 bilh\u00f5es para a perda auditiva n\u00e3o tratadasmartphones, tablets, computadores e outros dispositivos port\u00e1teis. Assim, inova\u00e7\u00f5es na \u00e1rea da educa\u00e7\u00e3o em sa\u00fade baseadas em mHealth (sa\u00fade m\u00f3vel) j\u00e1 s\u00e3o realidade e cresceram exponencialmente nos \u00faltimos cinco anos em outros pa\u00edses,6.Diante deste cen\u00e1rio, nota-se um crescimento consider\u00e1vel de programas e tecnologias inovadoras que visam fortalecer este n\u00edvel de aten\u00e7\u00e3o. Solu\u00e7\u00f5es tecnol\u00f3gicas em telessa\u00fade come\u00e7aram a ser desenvolvidas para os profissionais da sa\u00fade, como os Agente Comunit\u00e1rios de Sa\u00fade (ACS), no intuito de superar as barreiras ao acesso em cuidados com a sa\u00fade auditiva, usando  e os apps e-SUS AD e e-SUS territ\u00f3rio, com o intuito de facilitar o processo de trabalho dos ACS locais.No Brasil, a tend\u00eancia n\u00e3o tem sido diferente, atualmente t\u00eam-se o programa \u201cInformatiza APS\u201d que faz parte da estrat\u00e9gia de sa\u00fade digital do Minist\u00e9rio da Sa\u00fade. Essas tecnologias de mHealth validadas, permitiram a realiza\u00e7\u00e3o de triagens auditivas pela APS, usando testes automatizados com a interface de smartphone. Diante disso, os ACS come\u00e7aram a realizar a triagem auditiva para crian\u00e7as em uma variedade de contextos comunit\u00e1rios, incluindo visitas domiciliares e o acompanhamento do desenvolvimento da primeira inf\u00e2ncia.Na \u00c1frica do Sul, desde os anos 2000, s\u00e3o utilizadas tecnologias de sa\u00fade m\u00f3vel no programa de sa\u00fade auditiva.Avalia\u00e7\u00f5es desse modelo demonstraram que os ACS podem ser treinados para rastrear crian\u00e7as de maneira confi\u00e1vel e com efici\u00eancia de tempo. Por\u00e9m, h\u00e1 desafios neste programa, como os n\u00edveis de ru\u00eddo ambiental durante os exames, que devem estar adequados para que n\u00e3o influenciem nas taxas de refer\u00eancia da triagem auditiva. Um outro desafio est\u00e1 em monitorar a qualidade da triagem auditiva feita pelos ACS.Nesse sentido, a avalia\u00e7\u00e3o da usabilidade de aplica\u00e7\u00f5es m\u00f3veis representa uma estrat\u00e9gia de assegurar que os sistemas interativos sejam adaptados aos usu\u00e1rios, \u00e0s suas tarefas e que n\u00e3o haja quocientes negativos de seu uso. O objetivo de uma avalia\u00e7\u00e3o de usabilidade \u00e9 averiguar o grau em que um sistema ou produto \u00e9 eficaz, ou seja, qu\u00e3o bem o desempenho do sistema atende \u00e0s tarefas para as quais foi projetado; eficiente, isto \u00e9, quantos recursos, como tempo ou esfor\u00e7o, s\u00e3o necess\u00e1rios para usar o sistema a fim de realizar tarefas para as quais o sistema foi projetado, e por fim, se o mesmo favorece atitudes e respostas positivas dos pretensos usu\u00e1riosPosto isso, o aplicativo \u201cAgente Escuta\u201d, desenvolvido neste estudo, foi idealizado com o prop\u00f3sito de auxiliar os profissionais da APS no acompanhamento do desenvolvimento da audi\u00e7\u00e3o e da linguagem, com base nos marcos do desenvolvimento. Um outro objetivo do app \u00e9 o de promover a educa\u00e7\u00e3o continuada em sa\u00fade auditiva dos ACS de forma interativa.Por\u00e9m, por se tratar de um app in\u00e9dito, n\u00e3o existem estudos pr\u00e9vios sobre sua usabilidade ou a caracteriza\u00e7\u00e3o da sua implementa\u00e7\u00e3o em contexto brasileiro. Diante disso, o objetivo do presente estudo foi verificar a usabilidade e satisfa\u00e7\u00e3o dos usu\u00e1rios com a interface do aplicativo \u201cAgente Escuta\u201d, al\u00e9m de identificar problemas e possibilidades de melhorias.Trata-se de um estudo translacional explorat\u00f3rio com delineamento prospectivo descritivo. Foi realizado por meio de um teste de usabilidade do app \u201cAgente Escuta\u201d com abordagem quantitativa e qualitativa, a fim de identificar dificuldades e poss\u00edveis melhorias na ferramenta.O estudo foi estruturado em tr\u00eas etapas, a saber: (I) avalia\u00e7\u00e3o pr\u00e9via da usabilidade por 10 ju\u00edzes, incluindo estudantes, profissionais da aten\u00e7\u00e3o prim\u00e1ria, docentes e pesquisadores em Tecnologia da Informa\u00e7\u00e3o e Fonoaudiologia; (II) avalia\u00e7\u00e3o do aplicativo pelo p\u00fablico-alvo, ACS de seis munic\u00edpios do Rio Grande do Norte (RN), Brasil; (III) Avalia\u00e7\u00e3o da satisfa\u00e7\u00e3o dos ACS que utilizaram o aplicativo na rotina de trabalho.Seguindo as orienta\u00e7\u00f5es das Diretrizes e Normas Regulamentadoras de Pesquisa Envolvendo Seres Humanos (Resolu\u00e7\u00e3o 466/12), o estudo s\u00f3 foi iniciado ap\u00f3s aprova\u00e7\u00e3o do Comit\u00ea de \u00c9tica em Pesquisa da Institui\u00e7\u00e3o (parecer n\u00famero 4.695.580) e mediante assinatura do Termo de Consentimento Livre e Esclarecido, sendo fornecido todo esclarecimento necess\u00e1rio a respeito da sua participa\u00e7\u00e3o no estudo.Javascript, sendo programada a back-end e front-end da vers\u00e3o m\u00f3vel e a dashboard da vers\u00e3o web. O registro do software no Instituto Nacional da Propriedade Industrial (INPI) foi expedido em novembro/2021 sob n\u00famero de protocolo BR512021002590-3.Em parceria com o Instituto Metr\u00f3pole Digital da Universidade Federal do Rio Grande do Norte (IMD/UFRN), reconhecido por seus projetos com interface na sa\u00fade, o prot\u00f3tipo do aplicativo foi desenvolvido no per\u00edodo de um ano, entre 2020 e 2021. A primeira vers\u00e3o da ferramenta foi desenvolvida com uma m\u00e9dia de 15.000 linhas de c\u00f3digo e em linguagem predominantemente O app funciona sob dois eixos principais, o da educa\u00e7\u00e3o continuada em sa\u00fade auditiva e o do acompanhamento do desenvolvimento da audi\u00e7\u00e3o e da linguagem das crian\u00e7as de zero a 12 meses de idade. No eixo da educa\u00e7\u00e3o continuada, s\u00e3o disponibilizadas abas para revis\u00e3o de conte\u00fados, a saber: as d\u00favidas mais frequentes sobre sa\u00fade auditiva levantadas pelos ACS durante o uso do app, um fluxograma com os marcos de desenvolvimento nos dois primeiros anos de vida e o Escuta Game, apresentado na tela inicial, que cont\u00e9m situa\u00e7\u00f5es di\u00e1rias sobre sa\u00fade auditiva.-17. A Para a constru\u00e7\u00e3o de suas funcionalidades, foi realizado um levantamento de ferramentas j\u00e1 validadas, como cartilhas de orienta\u00e7\u00e3o baseadas nos marcos do desenvolvimento, question\u00e1rios e diretrizes internacionais e nacionais. Ao respond\u00ea-las, o question\u00e1rio espec\u00edfico de cada crian\u00e7a s\u00f3 ficar\u00e1 novamente dispon\u00edvel no m\u00eas seguinte, com a faixa et\u00e1ria subsequente, o que diminui as chances de preenchimento duplo no m\u00eas. De acordo com o crit\u00e9rio \u201cfalha\u201d proposto no question\u00e1rio de acompanhamento, o app automaticamente referencia o usu\u00e1rio para a aba \u201ccentros de sa\u00fade\u201d onde est\u00e3o elencados todos os centros de sa\u00fade auditiva da regi\u00e3o a fim de facilitar o encaminhamento para avalia\u00e7\u00e3o audiol\u00f3gica.No eixo do acompanhamento da audi\u00e7\u00e3o e da linguagem, o aplicativo disponibiliza as quest\u00f5es referentes \u00e0 idade da crian\u00e7a cadastradaTodas estas informa\u00e7\u00f5es s\u00e3o enviadas para o banco de dados MySQL, que consiste em um banco de dados relacional, conectado a um servidor privado com tecnologia baseada em criptografia e que podem ser acessadas continuamente apenas pelo perfil de administrador (ADM), que no caso s\u00e3o os pesquisadores respons\u00e1veis.Na vers\u00e3o do ADM s\u00e3o disponibilizadas informa\u00e7\u00f5es sobre o quantitativo de question\u00e1rios aplicados, acertos e erros no jogo, os resultados de cada crian\u00e7a acompanhada, localidade, IRDA das crian\u00e7as cadastradas, se realizou a TAN e os resultados obtidos.Para a avalia\u00e7\u00e3o pr\u00e9via da usabilidade do app foram convidados dois ju\u00edzes de cada categoria, n\u00e3o envolvidos com o desenvolvimento do app ou em outras etapas da pesquisa, a saber: estudantes de gradua\u00e7\u00e3o e p\u00f3s-gradua\u00e7\u00e3o em Fonoaudiologia, ACS, docentes e pesquisadores em Tecnologia da Informa\u00e7\u00e3o e em Fonoaudiologia. Os 10 avaliadores foram selecionados por sua atua\u00e7\u00e3o profissional, hist\u00f3rico de desenvolvimento de aplica\u00e7\u00f5es m\u00f3veis com interface na sa\u00fade e/ou participa\u00e7\u00e3o em est\u00e1gio universit\u00e1rio com a\u00e7\u00f5es diretamente ligadas \u00e0 promo\u00e7\u00e3o da sa\u00fade auditiva infantil na APS.Optou-se pela inclus\u00e3o de dois participantes em cada categoria, a fim de se obter uma an\u00e1lise pareada. Um terceiro juiz seria convidado caso os escores totais da escala de usabilidade entre os dois avaliadores apresentassem mais do que 20 pontos de diferen\u00e7a na avalia\u00e7\u00e3o individual. Ao total, participaram desta primeira etapa, tr\u00eas ju\u00edzes do sexo masculino e sete do sexo feminino, com idades entre 21 e 48 anos.. Assim, definiu-se o tamanho da amostra de 15 ACS, com representatividade m\u00ednima de cinco usu\u00e1rios em cada mesorregi\u00e3o do RN.Na segunda etapa da pesquisa a usabilidade do app foi avaliada por ACS interessados em utilizar a ferramenta em sua pr\u00e1tica di\u00e1ria. A defini\u00e7\u00e3o do n amostral m\u00ednimo, teve como referencial a estimativa de que um \u00fanico usu\u00e1rio \u00e9 capaz de encontrar em m\u00e9dia 31% dos problemas de usabilidade, cinco usu\u00e1rios s\u00e3o suficientes para identificar 85% dos problemas e que ao realizar o teste com 15 usu\u00e1rios, aproximadamente, 100% dos problemas podem ser identificadosA fim de garantir maior representatividade do contexto geral do RN, optou-se por selecionar os munic\u00edpios mediante sorteio por conglomerados. Para o sorteio considerou-se as quatro mesorregi\u00f5es do RN, a saber: Agreste Potiguar, Central Potiguar, Leste Potiguar e Oeste Potiguar. Com exce\u00e7\u00e3o de Natal que foi selecionada por ser a capital do estado, os munic\u00edpios de cada mesorregi\u00e3o foram sorteados, sendo eles: Caic\u00f3, Upanema, Santa Cruz, S\u00e3o Miguel do Gostoso e Jo\u00e3o C\u00e2mara.Em comum acordo com os secret\u00e1rios municipais de sa\u00fade, para cada munic\u00edpio sorteado foram selecionadas UBS inseridas em bairros com maior quantitativo de crian\u00e7as com idades entre zero e 12 meses.smartphone com sistema operacional Android, em qualquer vers\u00e3o, com 11 megabytes de mem\u00f3ria dispon\u00edvel no celular para o download gratuito do \u201cAgente Escuta\u201d; utilizar o app de forma livre, durante o per\u00edodo de dois meses, sem a necessidade de utiliza\u00e7\u00e3o efetiva do app na rotina de trabalho, al\u00e9m de responder de forma completa os question\u00e1rios para avalia\u00e7\u00e3o da usabilidade. Para a terceira etapa exigiu-se tr\u00eas meses de uso consecutivo do app.Como crit\u00e9rios de inclus\u00e3o para as duas primeiras etapas adotou-se possuir Do total de 91 ACS atuantes nas 12 UBS selecionadas, 41 ACS foram convidados a participar do presente estudo com vistas a atender ao n amostral determinado. Participaram do estudo 35 ACS, pois cinco ACS n\u00e3o fizeram download do app no per\u00edodo de refer\u00eancia do estudo e um n\u00e3o realizou o teste de usu\u00e1rio de forma completa. A distribui\u00e7\u00e3o dos ACS em rela\u00e7\u00e3o \u00e0 localidade e as caracter\u00edsticas sociodemogr\u00e1ficas est\u00e1 apresentada na .apk com o prot\u00f3tipo do aplicativo, enviado de forma individual. Juntamente com o arquivo, foi anexado um tutorial em v\u00eddeo de como baixar o prot\u00f3tipo em seus smartphones.Todos os participantes receberam o arquivo para download em formato No per\u00edodo do estudo, tr\u00eas ACS al\u00e9m de realizarem o teste de usabilidade, completaram tr\u00eas meses consecutivos de uso efetivo do app, o que viabilizou a execu\u00e7\u00e3o da terceira etapa do estudo.A metodologia deste estudo considerou as diretrizes da Organiza\u00e7\u00e3o Internacional de Normaliza\u00e7\u00e3o (ISO), um grupo de normas t\u00e9cnicas que estabelece um modelo de gest\u00e3o da qualidade. Para tanto, foram consideradas na escolha das ferramentas de avalia\u00e7\u00e3o do Agente Escuta as normas: ISO 25010- referente a an\u00e1lise de app m\u00f3veis; ISO 25062- que diz respeito a satisfa\u00e7\u00e3o do usu\u00e1rio e efic\u00e1cia da ferramenta testada; ISO 16982- opini\u00e3o dos usu\u00e1rios sobre a interface do aplicativo e ISO 14998 - avalia\u00e7\u00e3o do produto software.System Usability Scale (SUS), um dos instrumentos mais aceitos devido \u00e0 sua confiabilidade e previamente traduzido e validado para o portugu\u00eas europeu. O m\u00e9todo SUS pode ser utilizado para avaliar produtos, servi\u00e7os, hardware, software, websites, aplica\u00e7\u00f5es ou qualquer outro tipo de interface. Utilizado em estudos pr\u00e9vios, com a mesma finalidade, cont\u00e9m 10 itens a serem respondidos individualmente e aplicados de forma an\u00f4nima.Para avaliar a usabilidade do app foi utilizada a Google Forms, cujo link foi enviado individualmente para cada participante em todas as etapas. O question\u00e1rio foi respondido de forma an\u00f4nima, por meio da Escala de Likert, em que 1 foi indicativo de forte desacordo e 5 de forte concord\u00e2ncia.O SUS foi disponibilizado em formato digital on-line pelo . Sendo assim, as perguntas 3, 4, 7 e 10 relacionadas a \u201cfacilidade de aprendizagem\u201d, as quest\u00f5es 5, 6 e 8 associadas \u00e0 \u201cefici\u00eancia do produto\u201d, a quest\u00e3o 2 relacionada a \u201cfacilidade de memoriza\u00e7\u00e3o\u201d, quest\u00e3o 6 \u00e0 \u201cminimiza\u00e7\u00e3o de erros\u201d e perguntas 1, 4 e 9 sobre a \u201csatisfa\u00e7\u00e3o do uso\u201d.As quest\u00f5es foram subdivididas levando em considera\u00e7\u00e3o heur\u00edsticas que indicam aspectos importantes sobre a usabilidade,20.Para a an\u00e1lise dos resultados do SUS considerou-se a soma da contribui\u00e7\u00e3o individual de cada item. Para os itens \u00edmpares foi subtra\u00eddo 1 \u00e0 resposta do participante, ao passo que para os itens pares foi subtra\u00eddo 5 a resposta do usu\u00e1rio. Depois de obter o escore de cada item, somou-se os escores e multiplicou-se o resultado por 2,5. O resultado obtido foi o \u00edndice de satisfa\u00e7\u00e3o do participante que pode variar de 0 a 100. Foi realizada a m\u00e9dia e desvio padr\u00e3o (\u03c3) dos \u00edndices de satisfa\u00e7\u00e3o de todos os participantes para obter-se a classifica\u00e7\u00e3o do n\u00edvel de usabilidade do app. A pontua\u00e7\u00e3o m\u00e9dia do SUS \u00e9 68 (percentil 50) e se configura como um ponto de corte, ou seja, uma m\u00e9dia acima desse valor sugere um bom n\u00edvel de usabilidadeNet Promoter Score (NPS) e uma quest\u00e3o aberta para observa\u00e7\u00f5es e recomenda\u00e7\u00f5es. O NPS representa uma forma simples e concisa de examinar a satisfa\u00e7\u00e3o dos pacientes, usu\u00e1rios ou clientes diante de um servi\u00e7o; \u00e9 referido como \u201ca quest\u00e3o final\u201d, sugerindo que \u00e9 um resumo da satisfa\u00e7\u00e3o do usu\u00e1rio de algum servi\u00e7o ou produto.Para a mensura\u00e7\u00e3o da usabilidade e satisfa\u00e7\u00e3o do app, al\u00e9m do instrumento SUS, foi utilizado o .A suposi\u00e7\u00e3o \u00e9 que os indiv\u00edduos com pontua\u00e7\u00e3o 9 ou 10 dar\u00e3o publicidade positiva ao produto; eles s\u00e3o chamados de 'promotores'. Indiv\u00edduos que respondem 7 ou 8 s\u00e3o considerados indiferentes (\u201cpassivos\u201d). Por fim, os indiv\u00edduos que respondem de 0 a 6 provavelmente s\u00e3o clientes insatisfeitos e s\u00e3o rotulados como \u201cdetratores\u201d. O NPS \u00e9 ent\u00e3o calculado como a diferen\u00e7a entre a porcentagem de \u201cpromotores\u201d e a de \u201cdetratores\u201d, e pode variar de -100% a +100%. Quanto maior a porcentagem mais o produto tender\u00e1 a ser indicado a outros usu\u00e1riosGoogle Forms, por\u00e9m em uma sess\u00e3o ap\u00f3s o SUS, com a pergunta \u201cQual a probabilidade de voc\u00ea recomendar o \u2018Agente Escuta\u2019 a um outro usu\u00e1rio?\u201d e foi disponibilizada a op\u00e7\u00e3o de resposta em uma escala Likert de zero a 10, onde o zero estava correspondente a \u201cnada prov\u00e1vel\u201d e o 10 a \u201cextremamente prov\u00e1vel\u201d.O NPS foi disponibilizado aos participantes da pesquisa no mesmo link do . O question\u00e1rio cont\u00e9m 10 itens que representam situa\u00e7\u00f5es pr\u00e1ticas do acompanhamento auditivo mediado pelo app, com as categorias de resposta: (1) discordo totalmente, (2) discordo, (3) neutro, (4) concordo, (5) concordo totalmente. De forma similar \u00e0s etapas anteriores, os ACS responderam este instrumento por meio de formul\u00e1rio online.Ao considerar a terceira etapa do estudo, os ACS participantes responderam um question\u00e1rio adicional de satisfa\u00e7\u00e3o, elaborado com base em um instrumento pr\u00e9vioPara a an\u00e1lise descritiva, foi considerado o escore m\u00e9dio do SUS e NPS para cada categoria de ju\u00edzes e para os ACS de cada munic\u00edpio, al\u00e9m da categoriza\u00e7\u00e3o tem\u00e1tica das vari\u00e1veis qualitativas relacionadas \u00e0s sugest\u00f5es e melhorias indicadas.Software Statistical Package for the Social Sciences (SPSS), vers\u00e3o 24 e o n\u00edvel de signific\u00e2ncia adotado foi 5%.A an\u00e1lise inferencial foi realizada primeiramente com o teste de ader\u00eancia Shapiro-Wilk em cada grupo, sendo constatada distribui\u00e7\u00e3o normal dos dados da etapa 1  e aus\u00eancia de normalidade na etapa 2 . Assim, empregou-se a An\u00e1lise de Vari\u00e2ncia (ANOVA) de uma via para comparar o escore do SUS entre as categorias de ju\u00edzes; o teste de Kruskal-Wallis para a compara\u00e7\u00e3o do SUS e do NPS entre os participantes de cada munic\u00edpio; e o teste de Mann-Whitney para comparar a usabilidade na percep\u00e7\u00e3o dos ju\u00edzes e do p\u00fablico-alvo, os ACS. A an\u00e1lise foi realizada por meio do Na avalia\u00e7\u00e3o da usabilidade pelo m\u00e9todo SUS na primeira etapa deste estudo, n\u00e3o foi necess\u00e1ria a participa\u00e7\u00e3o de um terceiro juiz da mesma categoria, tendo em vista que n\u00e3o houve diferen\u00e7a superior a 20 pontos entre os avaliadores . Nota-seAl\u00e9m disso, foi poss\u00edvel observar que a categoria com menor escore de usabilidade no SUS, foi a de profissionais de T.I  e as maiores pontua\u00e7\u00f5es foram atribu\u00eddas pelos alunos de p\u00f3s-gradua\u00e7\u00e3o em fonoaudiologia e profissionais da APS . A ANOVA a um fator evidenciou que n\u00e3o existiu efeito da categoria dos ju\u00edzes sobre o escore de usabilidade obtido , com avalia\u00e7\u00f5es similares.Para an\u00e1lise do percentual de concord\u00e2ncia intra-categoria dos ju\u00edzes, as respostas foram agrupadas entre positivas, negativas ou neutras. Para os itens \u00edmpares do SUS, as respostas \u201cconcordo\u201d e \u201cconcordo plenamente\u201d foram consideradas positivas, enquanto \u201cdiscordo\u201d e \u201cdiscordo plenamente\u201d foram classificadas como negativas. Por outro lado, para os itens pares, adotou-se o oposto. O percentual de concord\u00e2ncia entre os ju\u00edzes das mesmas categorias variou entre 80% (profissionais da T.I), 90%  e 100% para as demais categorias.2 (5) = 7,637; p= 0,177].Na segunda etapa, tamb\u00e9m por meio da ferramenta SUS, foi realizada a m\u00e9dia dos escores dos 35 ACS participantes, de acordo com os munic\u00edpios . O escorNa compara\u00e7\u00e3o dos escore das duas fases por meio do teste de Mann-Whitney, foi not\u00f3ria que a percep\u00e7\u00e3o dos ju\u00edzes e do p\u00fablico-alvo foram distintas , com menor escore para os ACS.Ao considerar a avalia\u00e7\u00e3o intra-grupo da etapa 2, foi visto maior concord\u00e2ncia em rela\u00e7\u00e3o \u00e0 segunda afirma\u00e7\u00e3o do SUS \u201ceu acho o aplicativo desnecessariamente complicado\u201d em que 22 participantes  discordaram fortemente da afirmativa. J\u00e1 a \u00faltima afirma\u00e7\u00e3o do question\u00e1rio \u201cEu precisei aprender v\u00e1rias coisas novas antes de conseguir usar o aplicativo\u201d foi a que obteve maior heterogeneidade nas respostas ., na avalia\u00e7\u00e3o pelos ju\u00edzes, obteve-se menor pontua\u00e7\u00e3o em \u201csatisfa\u00e7\u00e3o do uso\u201d, com escore m\u00e9dio de 90,60. J\u00e1 de acordo com a avalia\u00e7\u00e3o dos ACS participantes da segunda etapa o menor escore foi em rela\u00e7\u00e3o a \u201cminimiza\u00e7\u00e3o de erros\u201d, com pontua\u00e7\u00e3o m\u00e9dia de 73,57. Os participantes, de ambas as etapas, apontaram um maior escore para a heur\u00edstica referente a \u201cfacilidade de memoriza\u00e7\u00e3o\u201d, com m\u00e9dia de 97,50 na primeira fase e 80,71 na segunda.No que concerne as heur\u00edsticasAp\u00f3s o uso e a avalia\u00e7\u00e3o da ferramenta, os participantes registraram coment\u00e1rios e sugest\u00f5es para implementa\u00e7\u00e3o em futuras vers\u00f5es do app. Houve similaridade nas respostas obtidas entre os participantes das duas etapas, assim as mesmas puderam ser compiladas em sete falas representativas .J\u00e1 referente \u00e0 pergunta de satisfa\u00e7\u00e3o final, realizada por meio da ferramenta NPS, o Teste de Mann-Whitney mostrou diferen\u00e7a entre a avalia\u00e7\u00e3o dos ju\u00edzes na etapa 1 e a percep\u00e7\u00e3o dos usu\u00e1rios em potencial, participantes da etapa 2 . Do total de 10 ju\u00edzes, oito (80%) responderam \u201c10\u201d na escala Likert, um avaliador respondeu \u201c9\u201d e outro avaliador respondeu \u201c8\u201d. Seguindo os crit\u00e9rios do NPS, 90% dos ju\u00edzes seriam \u2018promotores\u2019, ou seja, dariam publicidade positiva ao produto e 10% seria \u201cindiferente\u201d . Como o 2 (5) = 3,945 ; p = 0,557].Por outro lado, na segunda etapa, o NPS referente aos 35 ACS resultou em +48,58%. Desse total, 21  responderam entre \u201c10\u201d e \u201c9\u201d na escala Likert, 10  responderam \u201c8\u201d e \u201c7\u201d e quatro  responderam \u201c6\u201d, com predom\u00ednio de \u2018promotores\u2019 . O testeEm rela\u00e7\u00e3o ao question\u00e1rio adicional de satisfa\u00e7\u00e3o, apenas tr\u00eas ACS atenderam ao pr\u00e9-requisito de uso efetivo do app em sua rotina de trabalho por tr\u00eas meses consecutivos, sendo que os demais utilizaram por um per\u00edodo variado. Os tr\u00eas participantes eram de munic\u00edpios distintos e acompanharam o total de 22 crian\u00e7as, na faixa et\u00e1ria de um a 12 meses . Apesar do n\u00edvel de escolaridade destes ACS abranger ensino m\u00e9dio incompleto, m\u00e9dio completo e superior incompleto, o n\u00famero restrito de participantes n\u00e3o permite fazer qualquer infer\u00eancia do impacto do n\u00edvel instrucional nos resultados obtidos. Constatou-se que houve concord\u00e2ncia de respostas nos quesitos relacionados \u00e0 import\u00e2ncia e relev\u00e2ncia de se realizar o acompanhamento auditivo , sobre a influ\u00eancia positiva do Escuta Game na revis\u00e3o dos conte\u00fados sobre sa\u00fade auditiva (Quest\u00e3o 4) e sobre o desejo de continuar utilizando o app na rotina de trabalho (Quest\u00e3o 10).A diverg\u00eancia de opini\u00e3o foi observada nos quesitos relacionados \u00e0 facilidade de aplica\u00e7\u00e3o do question\u00e1rio de acompanhamento da audi\u00e7\u00e3o e da linguagem por meio do app, assim como a aceita\u00e7\u00e3o da comunidade do uso do aplicativo como ferramenta . Constatou-se que em cada t\u00f3pico a an\u00e1lise negativa foi realizada por apenas um ACS, que diferiu entre as quest\u00f5es..Dentre as diversas atividades desempenhadas pela APS, o acompanhamento auditivo de todas as crian\u00e7as da comunidade durante as consultas de puericultura \u00e9 preconizado como uma das etapas do programa de identifica\u00e7\u00e3o e interven\u00e7\u00e3o auditiva nos primeiros anos de vida,6,23,24.Uma alternativa para potencializar o acompanhamento auditivo \u00e9 a articula\u00e7\u00e3o com os ACS, que s\u00e3o reconhecidos por serem os profissionais mais cientes das reais necessidades da comunidade. Para isso, estudos ao redor do mundo est\u00e3o investindo no desenvolvimento de ferramentas que auxiliem o ACS no acompanhamento da audi\u00e7\u00e3o, mesmo em comunidades remotasO intuito do app foi de fornecer apoio na estrutura\u00e7\u00e3o de um fluxo de encaminhamento, tornando-se um facilitador na implementa\u00e7\u00e3o de a\u00e7\u00f5es de sa\u00fade auditiva na rotina de trabalho dos ACS. O resultado da avalia\u00e7\u00e3o da usabilidade do Agente Escuta, na primeira etapa deste estudo, revelou que as duas categorias que mais pontuaram na primeira fase, est\u00e3o inseridas diretamente na realidade do acompanhamento auditivo pela APS e no desenvolvimento de pesquisas voltadas para essa popula\u00e7\u00e3o, ou seja, os profissionais da APS e os alunos de p\u00f3s-gradua\u00e7\u00e3o em Fonoaudiologia. Por\u00e9m, mesmo os avaliadores profissionais de T.I que n\u00e3o conhecem a etapa de acompanhamento auditivo na pr\u00e1tica, mantiveram as avalia\u00e7\u00f5es positivas.Dessa forma, a aus\u00eancia de diferen\u00e7as nas avalia\u00e7\u00f5es entre as categorias de ju\u00edzes, indicou que a usabilidade foi bem avaliada tanto na percep\u00e7\u00e3o de profissionais da \u00e1rea de desenvolvimento de solu\u00e7\u00f5es tecnol\u00f3gicas quanto para os avaliadores que vivenciam a realidade da APS.Por outro lado, na segunda etapa, o escore geral dos ACS foi inferior aos achados da primeira fase. Considera-se, portanto, que os profissionais da APS que participaram da primeira fase n\u00e3o representaram os ACS dos munic\u00edpios potiguares, visto que foram observadas maiores dificuldades na usabilidade da ferramenta por parte dos participantes da segunda fase.internet, acesso a dispositivos m\u00f3veis voltados exclusivamente para o trabalho e treinamentos t\u00e9cnicos para o manuseio de ferramentas tecnol\u00f3gicas por parte dos profissionais de sa\u00fade, s\u00e3o cruciais para o sucesso da implementa\u00e7\u00e3o da m-health na rotina laboral.Embora os apps voltados para a \u00e1rea da sa\u00fade tenham ganhado destaque nos \u00faltimos anos, pela disponibilidade de acesso e facilidade de uso de funcionalidades que antes s\u00f3 eram disponibilizadas pelo computador, aspectos como disponibilidade de . Alguns apps para smartphones j\u00e1 foram desenvolvidos visando auxiliar os profissionais da APS em suas rotinas de trabalho, s\u00e3o eles: e-SUS AD, e-SUS territ\u00f3rio e e-SUS AB. Por\u00e9m, n\u00e3o foi encontrada na literatura pesquisada a an\u00e1lise da usabilidade ou satisfa\u00e7\u00e3o dos usu\u00e1rios quanto a estas solu\u00e7\u00f5es tecnol\u00f3gicas.Posto isso, existe uma iniciativa da sa\u00fade digital do Minist\u00e9rio de Sa\u00fade, o \u201cInformatiza APS\u201d, que tem como objetivo subsidiar a informatiza\u00e7\u00e3o das unidades de sa\u00fade e a qualifica\u00e7\u00e3o dos dados da APS de todo o pa\u00edsCybertutor e em curso online disponibilizado na plataforma do Minist\u00e9rio da Sa\u00fade, verificou-se que os profissionais ACS possu\u00edam dificuldades com inform\u00e1tica b\u00e1sica. Esses dados revelaram que a ades\u00e3o \u00e0s estrat\u00e9gias de educa\u00e7\u00e3o permanente em sa\u00fade pode ter sido influenciada pela dificuldade t\u00e9cnica em manusear programas de interface web e no desktop,25. Imaginava-se que as dificuldades dos ACS com a inform\u00e1tica b\u00e1sica estivessem atreladas ao baixo acesso a computadores na APS.Em estudos brasileiros envolvendo capacita\u00e7\u00f5es em sa\u00fade auditiva \u00e0 dist\u00e2ncia, por meio de CD-ROM, smartphones no Brasil \u00e9 equivalente a mais de um aparelho por habitante, com um total de 234 milh\u00f5es. Esses dados acerca da populariza\u00e7\u00e3o dos smartphones levantaram a hip\u00f3tese de que as aplica\u00e7\u00f5es m\u00f3veis voltadas para o acompanhamento auditivo poderiam possuir vantagem em rela\u00e7\u00e3o \u00e0s estrat\u00e9gias com implementa\u00e7\u00e3o web e desktop. Por\u00e9m, o observado neste estudo foi que mesmo com o amplo acesso aos smartphones, os profissionais ACS tamb\u00e9m possuem dificuldades t\u00e9cnicas b\u00e1sicas em aplica\u00e7\u00f5es m\u00f3veis, tais como encontrar o aplicativo na tela de in\u00edcio do aparelho m\u00f3vel, cadastrar uma senha e lembrar o e-mail.Uma pesquisa realizada em 2020 apontou que o quantitativo de .Dessa forma, as ferramentas de aplicabilidade m\u00f3vel voltadas para esse p\u00fablico de usu\u00e1rios necessitam de uma interface bem elaborada, com o objetivo de que os usu\u00e1rios consigam extrair o m\u00e1ximo poss\u00edvel do app, sem grandes dificuldades t\u00e9cnicas. A insatisfa\u00e7\u00e3o no uso pode ocasionar uma m\u00e1 impress\u00e3o perante o usu\u00e1rio e at\u00e9 mesmo a desist\u00eancia no uso do app, o que n\u00e3o \u00e9 desej\u00e1vel.A usabilidade est\u00e1 ligada \u00e0 qualidade da intera\u00e7\u00e3o de um usu\u00e1rio ao utilizar uma interface, seja ela de um sistema, uma ferramenta ou uma aplica\u00e7\u00e3o m\u00f3vel. As avalia\u00e7\u00f5es de usabilidade buscam analisar a qualidade de interfaces de um sistema, verificando se aquele produto se mostra intuitivo o bastante, a ponto de n\u00e3o ter tantos ou quase nenhum tipo de falha que afete na utiliza\u00e7\u00e3o pelo usu\u00e1rio, com uma qualidade no m\u00ednimo aceit\u00e1vel. Os testes de usabilidade visam encontrar problemas de usabilidade em interfaces de acordo com a utiliza\u00e7\u00e3o que os usu\u00e1rios fazem delas. Neste caso, os usu\u00e1rios testam as funcionalidades do sistema, reportando poss\u00edveis problemas de intera\u00e7\u00e3o em sua utiliza\u00e7\u00e3om-Health do pa\u00eds. Os resultados apontaram s\u00e9rios problemas de usabilidade identificados pelo m\u00e9todo SUS. Os avaliadores participantes indicaram que a grande maioria das aplica\u00e7\u00f5es m\u00f3veis voltadas para a sa\u00fade, desenvolvidas em Bangladesh, pontuaram menos para a heur\u00edstica do design est\u00e9tico e gr\u00e1fico. Os autores conclu\u00edram que o design pouco intuitivo poderia justificar a falta de ades\u00e3o do uso de apps nos servi\u00e7os de sa\u00fade do pa\u00eds.Em Bangladesh, um estudo realizou uma revis\u00e3o e avaliou a usabilidade dos diversos apps de Nos resultados do presente estudo, o design gr\u00e1fico e a est\u00e9tica do app foram bem avaliados tanto na primeira quanto na segunda fase. Al\u00e9m disso, na percep\u00e7\u00e3o dos ju\u00edzes foi obtido um maior escore para as quest\u00f5es relacionadas a \u201cfacilidade de aprendizagem\u201d, com pontua\u00e7\u00e3o m\u00e9dia de 97,50, o que pode estar atrelado \u00e0 interface gr\u00e1fica do app bem estruturada e de f\u00e1cil manuseio..Na segunda fase, os ACS participantes avaliaram a interface de forma semelhante, por\u00e9m, com pontua\u00e7\u00e3o m\u00e9dia de 80,71. Ao considerar o escore das quest\u00f5es relacionadas \u00e0 interface e a baixa porcentagem de ACS que de fato utilizaram o aplicativo em suas rotinas de trabalho , foi poss\u00edvel observar que embora o design gr\u00e1fico do app tenha uma boa pontua\u00e7\u00e3o, esta vari\u00e1vel n\u00e3o refletiu diretamente na ades\u00e3o ao uso efetivo do app. Diante disso, a implementa\u00e7\u00e3o do aplicativo de fato, n\u00e3o se mostrou atrelada \u00e0 satisfa\u00e7\u00e3o do design gr\u00e1fico como visto na revis\u00e3o sistem\u00e1tica em Bangladesh. J\u00e1 na segunda fase, a menor pontua\u00e7\u00e3o foi no que diz respeito \u00e0 \u201cfacilidade de aprendizagem\u201d com 71,00. Acredita-se que essa queda nas pontua\u00e7\u00f5es referentes \u00e0 satisfa\u00e7\u00e3o e facilidade aprendizagem pode ser justificada por algumas funcionalidades do app n\u00e3o terem alcan\u00e7ado as expectativas dos avaliadores, como exemplo, a aus\u00eancia da op\u00e7\u00e3o \u201cesqueci a senha\u201d e a aba de \u201cd\u00favidas\u201d que n\u00e3o possui a possibilidade do usu\u00e1rio cadastrar suas d\u00favidas diretamente no app e as op\u00e7\u00f5es de respostas da TAN, durante o cadastro das crian\u00e7as acompanhadas pelo app, que acabam deixando possibilidade de preenchimento errado dos dados.A menor pontua\u00e7\u00e3o dentre as quest\u00f5es do SUS, na avalia\u00e7\u00e3o dos ju\u00edzes da primeira etapa do estudo, foi em \u201csatisfa\u00e7\u00e3o do uso\u201d com escore m\u00e9dio de 89,00. Embora tenha sido a pontua\u00e7\u00e3o mais baixa, esse escore ainda representa um valor de usabilidade excelenteweb.Os erros de preenchimento no cadastro das crian\u00e7as podem ser minimizados pela vers\u00e3o ADM do app, que tem acesso a todas as informa\u00e7\u00f5es cadastradas pelos usu\u00e1rios. Logo, se h\u00e1 alguma informa\u00e7\u00e3o incompat\u00edvel dos dados em rela\u00e7\u00e3o a TAN, o ADM tem a possibilidade de corrigi-los por meio da sua vers\u00e3o download. Pensando na possibilidade dos usu\u00e1rios n\u00e3o conseguirem baixar o app por falta de mem\u00f3ria dispon\u00edvel em seus smartphones, foi optado por deixar a aba de \u201cd\u00favidas\u201d com as perguntas fixadas e edit\u00e1veis apenas pelo ADM, que esteve em contato direto com as d\u00favidas dos participantes.Al\u00e9m disso, a vers\u00e3o deste app foi idealizada com a aba \u201cd\u00favidas\u201d em formato de f\u00f3rum, como sugerido pelos avaliadores. Por\u00e9m, durante o desenvolvimento da interface foi observado que a op\u00e7\u00e3o de inserir d\u00favidas diretamente no app tornaria o software mais robusto e, consequentemente, iria necessitar de mais mem\u00f3ria livre no dispositivo para o Outros aspectos pontuados nas respostas dissertativas dos avaliadores foram os erros de digita\u00e7\u00e3o e sugest\u00f5es da inser\u00e7\u00e3o de funcionalidades simples, como a op\u00e7\u00e3o \u201cesqueci a senha\u201d logo na tela de login do app. Esses t\u00f3picos apontados s\u00e3o de f\u00e1cil corre\u00e7\u00e3o e as melhorias poder\u00e3o ser implementadas em futuras vers\u00f5es do app.web e presencial) para o acompanhamento da audi\u00e7\u00e3o de pacientes, resultou em uma pontua\u00e7\u00e3o +87% no NPS dos usu\u00e1rios. Os autores apontaram que diante desse valor do NPS, \u00e9 altamente prov\u00e1vel que os usu\u00e1rios recomendem a cl\u00ednica h\u00edbrida a amigos e familiares.Em rela\u00e7\u00e3o ao resultado da avalia\u00e7\u00e3o pelo NPS, em um estudo desenvolvido na \u00c1frica do Sul, com uma aplica\u00e7\u00e3o h\u00edbrida (Levando em considera\u00e7\u00e3o os resultados da avalia\u00e7\u00e3o no NPS neste estudo, +100% dos avaliadores da primeira etapa provavelmente recomendariam o uso do app para outros usu\u00e1rios, mantendo-se na categoria de \u2018promotores\u2019 em rela\u00e7\u00e3o \u00e0 avalia\u00e7\u00e3o do NPS. J\u00e1 em rela\u00e7\u00e3o aos participantes da segunda fase que apontaram +48,58% no NPS, demonstram que a ferramenta embora n\u00e3o apresente s\u00e9rios problemas de usabilidade, ainda n\u00e3o seria t\u00e3o recomendada para outros usu\u00e1rios quando comparado aos participantes da primeira etapa.. A falta de clareza sobre as atribui\u00e7\u00f5es do ACS pode provocar sobrecarga na jornada de trabalho e, por n\u00e3o possu\u00edrem um plano de carreira definido, estes profissionais acabam realizando tarefas diversificadas e sem padroniza\u00e7\u00e3o. Este \u00e9 um ponto importante para a implementa\u00e7\u00e3o de novas ferramentas, pois al\u00e9m de adequada usabilidade, a motiva\u00e7\u00e3o dos profissionais para o uso efetivo \u00e9 essencial.Em um estudo brasileiro com foco na capacita\u00e7\u00e3o em sa\u00fade auditiva dessa categoria, os profissionais que desistiram do estudo apontaram como principais motivos, a rotatividade de profissionais e cargos, falta de participa\u00e7\u00e3o dos gestores e a elevada demanda de atividades voltadas aos ACSA satisfa\u00e7\u00e3o do uso do app na rotina de trabalho foi prejudicada, uma vez que no per\u00edodo deste estudo, as fun\u00e7\u00f5es dos ACS foram redirecionadas para apoiar a\u00e7\u00f5es dos profissionais de sa\u00fade voltadas \u00e0 pandemia da COVID-19, como a testagem intensa e a campanha nacional de vacina\u00e7\u00e3o. Assim, apesar dos resultados promissores, o n\u00famero reduzido de ACS que utilizou o app na rotina de trabalho de forma efetiva na terceira etapa n\u00e3o permite generalizar os dados obtidos, sendo esta uma limita\u00e7\u00e3o do estudo.smartphones \u201cAgente Escuta\u201d, desenvolvido para auxiliar a etapa de acompanhamento auditivo e de linguagem na APS, apresentou boa usabilidade segundo os participantes potiguares, sendo que 90% dos ju\u00edzes e 60% dos ACS dariam publicidade positiva ao produto. Os ACS que utilizaram o app na rotina, concordaram com a import\u00e2ncia e relev\u00e2ncia de se realizar o acompanhamento auditivo, indicaram influ\u00eancia positiva do Escuta Game na revis\u00e3o dos conte\u00fados sobre sa\u00fade auditiva e demonstraram interesse em continuar utilizando o app na rotina de trabalho.O prot\u00f3tipo do app para Melhorias dever\u00e3o ser implementadas para as pr\u00f3ximas vers\u00f5es do aplicativo ou na proposi\u00e7\u00e3o de outras solu\u00e7\u00f5es tecnol\u00f3gicas para o p\u00fablico-alvo, de acordo com as sugest\u00f5es dos avaliadores deste estudo."}
+{"text": "G\u00eanero e Sa\u00fade: Uma Articula\u00e7\u00e3o Necess\u00e1ria, de grande amplitude ef\u00f4lego te\u00f3rico/anal\u00edtico, visa dialogar com profissionais de sa\u00fade e educa\u00e7\u00e3o,pesquisadores, estudantes, gestores, ativistas e p\u00fablico em geral interessado no debatesobre g\u00eanero e sa\u00fade.O livro de Brand\u00e3o & Alzuguir A obra \u00e9 alicer\u00e7ada nas experi\u00eancias profissionais e acad\u00eamicas das autoras e pretendesubsidiar a\u00e7\u00f5es em sa\u00fade mais inclusivas, equitativas e justas. Uma quest\u00e3o parecetraduzir o objetivo principal do trabalho: como reflex\u00f5es de g\u00eanero em sua \u00edntimaconex\u00e3o com marcadores sociais da diferen\u00e7a podem contribuir para o cuidado integral \u00e0sa\u00fade, sobretudo no \u00e2mbito do Sistema \u00danico de Sa\u00fade (SUS)?O livro, escrito e publicado no contexto da pandemia de COVID-19, ressoa os desafiosdesse momento dram\u00e1tico de crise sanit\u00e1ria, agravado por um governo pouco afeito \u00e0squest\u00f5es humanit\u00e1rias, negacionista e absurdamente negligente quanto \u00e0s pol\u00edticasp\u00fablicas de cunho social, incluindo as de sa\u00fade. Assim, produzir um trabalho voltado aosdireitos humanos, \u00e0 cidadania e \u00e0 justi\u00e7a social em um per\u00edodo de amea\u00e7a \u00e0s fr\u00e1geisconquistas da democracia brasileira confere a ele um m\u00e9rito sem precedentes. Seria umaesp\u00e9cie de pren\u00fancio de tempos melhores.Nas primeiras p\u00e1ginas do livro, a dedicat\u00f3ria que homenageia os filhos das autoras, m\u00e3escientistas, aparece como uma sinaliza\u00e7\u00e3o afetiva e pol\u00edtica fundamental para as p\u00e1ginase para os debates que se sucedem. Trata-se de reconhecer que tal obra foi produzidaapesar e a partir de in\u00fameros desafios postos pela vida acad\u00eamica associada \u00e0maternidade, conferindo um reconhecimento amplo e valioso a todas as m\u00e3es pesquisadoras,cujos cotidianos se tornaram ainda mais dif\u00edceis com a pandemia e seus desdobramentos,tais como trabalho remoto, dom\u00e9stico e esgotamento f\u00edsico e mental.Implica\u00e7\u00f5es de G\u00eanero na Produ\u00e7\u00e3o do ConhecimentoCient\u00edfico. Nele, partindo do questionamento \u201cci\u00eancia tem g\u00eanero? Ecor/ra\u00e7a e classe?\u201d, as autoras abordam o impacto do g\u00eanero e de outros marcadoressociais da diferen\u00e7a na produ\u00e7\u00e3o cient\u00edfica, demonstrando o apagamento de mulheres quefizeram hist\u00f3rias que a Hist\u00f3ria n\u00e3o conta - ou como traz o memor\u00e1vel samba da Esta\u00e7\u00e3oPrimeira de Mangueira, de 2019: \u201cDesde 1500 tem mais invas\u00e3o do quedescobrimento/Tem sangue retinto pisado/Atr\u00e1s do her\u00f3i emoldurado/Mulheres, tamoios,mulatos/Eu quero um pa\u00eds que n\u00e3o est\u00e1 no retrato\u201d - considerando-se umfazer cient\u00edfico que se estrutura a partir de princ\u00edpios e valores masculinos, do homembranco. Al\u00e9m disso, fundamentando-se nas contribui\u00e7\u00f5es dos estudos feministas daci\u00eancia, Brand\u00e3o & Alzuguir Assim, a partir da inspira\u00e7\u00e3o proporcionada pelo agradecimento do livro, escolho comoabre-alas o cap\u00edtulo 3: Parent in ScienceApostando na possibilidade de se produzir uma ci\u00eancia feminista, que questiona osdualismos de g\u00eanero presentes nas interpreta\u00e7\u00f5es dos resultados cient\u00edficos e noimagin\u00e1rio social, as autoras, embaladas pelas discuss\u00f5es sobre a sobrecarga quemulheres, m\u00e3es, pesquisadoras sofreram durante a COVID-19, problematizam: a poucavisibilidade e valor social relativos ao trabalho dom\u00e9stico, sem o qual nenhumacomunidade de cientistas consegue desempenhar suas atividades; e as injusti\u00e7as sociaisadvindas da cobran\u00e7a por igual produtividade de m\u00e3es e pais cientistas, o que teminspirado movimentos como o Nesse sentido, o reconhecimento de que a ci\u00eancia n\u00e3o \u00e9 neutra; do car\u00e1ter situado,social, hist\u00f3rico e inevitavelmente parcial do conhecimento; e das marcas edesigualdades de g\u00eanero presentes no \u00e2mbito acad\u00eamico e na vida social opera como eixoestruturante do livro, perpassando os demais cap\u00edtulos, que se conectam e completam.Panorama Hist\u00f3rico e Conceitual sobre a Categoria deG\u00eanero, as autoras discorrem acerca do surgimento da categoria de g\u00eanero,em meados do s\u00e9culo XX, demonstrando sua import\u00e2ncia para a compreens\u00e3o cr\u00edtica epol\u00edtica da realidade social e para a valoriza\u00e7\u00e3o de outra episteme, forjada no di\u00e1logocom os movimentos feministas.No cap\u00edtulo 1, Para descrever a emerg\u00eancia do conceito de g\u00eanero, as autoras percorrem as formula\u00e7\u00f5es dete\u00f3ricas consagradas, em sua maioria feministas, ressaltando o estabelecimento dosistema sexo/g\u00eanero para o entendimento das opress\u00f5es pautadas nas ideias de diferen\u00e7asalicer\u00e7adas em explica\u00e7\u00f5es de ordem naturalizante. Coroando o debate, desestabilizam-sea ideia essencialista de que os sexos biol\u00f3gicos determinariam pap\u00e9is e atributosfemininos e masculinos e a perspectiva de sexo como uma base biol\u00f3gica fixa, invari\u00e1vele pr\u00e9-social, afirmando-se que ele seria, tal como o g\u00eanero, discursivo e cultural.Tal arcabou\u00e7o conduz a duas importantes reflex\u00f5es: (1) de que forma as normas de g\u00eaneroproduzem adoecimento, acirrando as vulnerabilidades sociais?; (2) como a (re)produ\u00e7\u00e3o depr\u00e1ticas discriminat\u00f3rias no interior de institui\u00e7\u00f5es de cuidado (sa\u00fade/educa\u00e7\u00e3o)reifica processos sociais de discrimina\u00e7\u00e3o e exclus\u00e3o?Diferen\u00e7aSexual e Medicaliza\u00e7\u00e3o dos Corpos, que aborda a produ\u00e7\u00e3o da diferen\u00e7asexual na modernidade e o processo de medicaliza\u00e7\u00e3o dos corpos femininos e masculinos.Nessa parte do livro, as autoras indicam que a no\u00e7\u00e3o de diferen\u00e7a sexual - como supostofundamento do g\u00eanero - na leitura de dois corpos distintos \u00e9 uma conven\u00e7\u00e3o social que seperpetua h\u00e1 s\u00e9culos no Ocidente. Muitos aspectos sociais, pol\u00edticos e econ\u00f4micos, naconstitui\u00e7\u00e3o da modernidade, concorreram para o estabelecimento do binarismo sexual.\u00c9 nessa dire\u00e7\u00e3o reflexiva que passamos do cap\u00edtulo 1 para o cap\u00edtulo 2, O incremento das biotecnologias e da medicaliza\u00e7\u00e3o dos corpos nos \u00faltimos tempos foitornando as supostas \u201cevid\u00eancias\u201d das diferen\u00e7as sexuais ancoradas nos corpos ainda maismarcantes. A tentativa de conhecer e \u201cdomar\u201d os corpos a partir do \u201cdiscurso hormonal\u201dest\u00e1 na ordem do dia, com destaque para a testosterona e a ocitocina, igualmentegenerificados.Os investimentos m\u00e9dicos e n\u00e3om\u00e9dicos com o objetivo de estabilizar e naturalizar uma diferencia\u00e7\u00e3o sexual entredois corpos distintos afetam, impedem ou ocultam a emerg\u00eancia de corpos,comportamentos, identidades e desejos que se desviam da correspond\u00eancia entre sexo,g\u00eanero e orienta\u00e7\u00e3o sexual\u201d. Tais dimens\u00f5es, sabemos, endossam estigmas eproduzem discrimina\u00e7\u00e3o, preconceito e, muitas vezes, viol\u00eancia.As consequ\u00eancias dessa \u201ccorrida\u201d do aprimoramento corporal s\u00e3o muitas, mas o que maispreocupa, tal como explicitam Brand\u00e3o & Alzuguir A Centralidade da Abordagem Interseccional na Compreens\u00e3o dosProcessos Sa\u00fade e Doen\u00e7a, discute-se o modo pelo qual g\u00eanero, classesocial, ra\u00e7a/etnia, gera\u00e7\u00e3o e orienta\u00e7\u00e3o sexual se articulam sinergicamente e produzemhierarquias sociais em sa\u00fade, com impactos significativos na possibilidade deautocuidado e acesso a uma assist\u00eancia digna e de qualidade. A perspectiva feministainterseccional \u00e9 acionada, com evid\u00eancia para as autoras brasileiras, para mostrar comoas m\u00faltiplas opress\u00f5es est\u00e3o relacionadas \u00e0s exclus\u00f5es sociais. S\u00e3o conferidos destaquesao p\u00fablico LGBTQIA+, \u00e0s mulheres e aos jovens negros pelas recorrentes viola\u00e7\u00f5es dedireitos a que est\u00e3o submetidos - entre eles, o de existir. H\u00e1, portanto, o pleito porum resgate \u00e9tico para que o valor das diferen\u00e7as que marcaram a Constitui\u00e7\u00e3o Cidad\u00e3 e oSUS sejam retomados e se desdobrem em equidade e integralidade no cuidado e para que serjovem, mulher, negro e/ou LGBTQIA+, perif\u00e9ricos, n\u00e3o seja sin\u00f4nimo de adoecimento ousenten\u00e7a de morte.No quarto cap\u00edtulo, Direitos Sexuais e Direitos Reprodutivos: DebatesContempor\u00e2neos, apresenta um breve hist\u00f3rico da formula\u00e7\u00e3o das no\u00e7\u00f5es dedireitos sexuais e reprodutivos, destacando a import\u00e2ncia desse resgate diante docrescente movimento antig\u00eanero nos contextos nacional e internacional. As autorasdefendem a perman\u00eancia das pautas e a\u00e7\u00f5es pr\u00f3-diversidade sexual e de g\u00eanero,consubstanciadas em pol\u00edticas p\u00fablicas. Al\u00e9m disso, pleiteiam que a perspectiva dajusti\u00e7a reprodutiva possa sedimentar a uni\u00e3o entre direitos reprodutivos e justi\u00e7asocial.O cap\u00edtulo 5, e \u00faltimo, No que tange aos direitos sexuais, as autoras mostram a dificuldade de sua defesadesatrelada dos direitos reprodutivos. Esses \u00faltimos, especialmente com a pandemia,sofreram retrocessos e viola\u00e7\u00f5es, marcas de uma hist\u00f3ria brasileira que j\u00e1 foi capaz deproduzir uma cultura de esteriliza\u00e7\u00e3o e que, at\u00e9 hoje, submete popula\u00e7\u00f5es maisvulner\u00e1veis a procedimentos compuls\u00f3rios que violam seus direitos No \u00faltimo cap\u00edtulo, as autoras destacam o p\u00e2nico moral que cerca os temas aborto etrabalho sexual, abordando, infelizmente, de forma insuficiente os direitos relacionadosao exerc\u00edcio da sexualidade por pessoas vivendo com HIV/aids. Em um momento p\u00f3s-desmonteda pol\u00edtica de aids, que j\u00e1 foi refer\u00eancia mundial, a disponibiliza\u00e7\u00e3o de profilaxiapr\u00e9-exposi\u00e7\u00e3o (PrEP) e profilaxia p\u00f3s-exposi\u00e7\u00e3o (PEP) n\u00e3o deve ser vista apenas como\u201cmedicaliza\u00e7\u00e3o do problema\u201d, mas sim como tecnologia chave na \u201cpreven\u00e7\u00e3o combinada\u201d parapessoas sob risco acrescido.Por fim, as autoras escrevem com tamanho envolvimento e generosidade que a cada cap\u00edtulonos sentimos conduzidos/as em um fant\u00e1stico desbravar te\u00f3rico e reflexivo, que em nenhummomento se descola da realidade social e das vidas concretas das pessoas em suaimport\u00e2ncia e materialidade."}
+{"text": "O ressarcimento ao Sistema \u00danico de Sa\u00fade (SUS) \u00e9 a interface mais vis\u00edvel darela\u00e7\u00e3o entre sa\u00fade p\u00fablica e privada, e sua an\u00e1lise pode ampliar o conhecimentosobre o uso do SUS pelo setor suplementar. O presente estudo objetivoucaracterizar os benefici\u00e1rios de planos privados de sa\u00fade que realizaramhemodi\u00e1lise no SUS entre 2012 e 2019 em rela\u00e7\u00e3o a: sexo, faixa et\u00e1ria, regi\u00e3o deresid\u00eancia, caracter\u00edsticas dos planos privados de sa\u00fade e das operadoras e aassist\u00eancia prestada a eles. Visou tamb\u00e9m comparar caracter\u00edsticas dos planosprivados de sa\u00fade e modalidade das operadoras daqueles benefici\u00e1rios com dadosdos demais benefici\u00e1rios do Brasil. Construiu-se uma base centrada no indiv\u00edduoa partir de dados da Ag\u00eancia Nacional de Sa\u00fade Suplementar (ANS); informa\u00e7\u00f5essobre benefici\u00e1rios do Brasil foram consultadas no Departamento de Inform\u00e1ticado SUS (DATASUS). Utilizou-se distribui\u00e7\u00f5es de frequ\u00eancias para resumir osdados, padroniza\u00e7\u00e3o por idade e sexo para caracter\u00edsticas dos planos privados desa\u00fade e modalidade das operadoras, e raz\u00e3o para comparar frequ\u00eancias. Um totalde 31.941 benefici\u00e1rios realizou hemodi\u00e1lise no SUS, 11.147  destes forade seu munic\u00edpio de resid\u00eancia, e 6.423  utilizaram o SUS por 25 mesesou mais. Comparados aos demais benefici\u00e1rios do Brasil, aqueles que realizaramhemodi\u00e1lise no SUS estavam vinculados mais frequentemente a planos privados desa\u00fade antigos , coletivos por ades\u00e3o ,individuais/familiares , ambulatoriais , municipais  e/ou a filantropias . Planos privados de sa\u00fade comcaracter\u00edsticas restritivas podem ter dificultado o acesso dos benefici\u00e1rios querealizaram hemodi\u00e1lise no SUS \u00e0s redes de suas operadoras, e representado maisum fator que pode ter influenciado o uso do SUS por aqueles benefici\u00e1rios, mesmocom a cobertura prevista em seus contratos. Por\u00e9m, o setor privado oferta os mesmos servi\u00e7os realizados pelo setorp\u00fablico Lei n\u00ba9.656/1998,,H\u00e1, desde a d\u00e9cada de 1970, previs\u00e3o para ressarcimento ao er\u00e1rio da assist\u00eanciaprestada a benefici\u00e1rios de planos privados de sa\u00fade, apesar de n\u00e3o ter apresentadoregistros de restitui\u00e7\u00e3o dos valores devidos at\u00e9 a O ressarcimento ao SUS \u00e9 a interface mais vis\u00edvel entre os setores p\u00fablico esuplementar de sa\u00fade per capita dosatendimentos realizados no SUS a benefici\u00e1rios de planos privados de sa\u00fade, uma vezque representa um caminho para uma regula\u00e7\u00e3o mais efetiva do mercado suplementar,,,A integra\u00e7\u00e3o de bases da sa\u00fade \u00e9 uma alternativa para organizar a informa\u00e7\u00e3o porpaciente A escassez de pesquisas sobre o benefici\u00e1rio de plano privado de sa\u00fade que utiliza oSUS \u00e9 ainda maior em rela\u00e7\u00e3o a procedimentos ambulatoriais de alta complexidade,pois a cobran\u00e7a dessa assist\u00eancia \u00e9 recente, desde 2015, retroativa aos atendimentosocorridos desde 2012 ,,,,,Al\u00e9m disso, a doen\u00e7a renal cr\u00f4nica \u00e9 um problema de sa\u00fade p\u00fablica mundial. Aincid\u00eancia e a preval\u00eancia de pacientes em fal\u00eancia funcional renal que precisam dedi\u00e1lise s\u00e3o crescentes ,,,Desde 1999, a Sociedade Brasileira de Nefrologia realiza inqu\u00e9ritos anuais sobrepacientes em di\u00e1lise, sob financiamento p\u00fablico e privado. Por\u00e9m a ades\u00e3o dasunidades de di\u00e1lise ao censo \u00e9 volunt\u00e1ria, e a subnotifica\u00e7\u00e3o foi crescente na\u00faltima d\u00e9cada Neste contexto, nosso estudo objetivou caracterizar os benefici\u00e1rios de planosprivados de sa\u00fade que realizaram hemodi\u00e1lise no SUS entre 2012 e 2019, dividindo-osem rela\u00e7\u00e3o ao sexo, \u00e0 faixa et\u00e1ria, \u00e0 regi\u00e3o de resid\u00eancia, \u00e0s caracter\u00edsticas dosplanos privados de sa\u00fade e das operadoras, e \u00e0 assist\u00eancia prestada a eles.Adicionalmente, comparou-se as caracter\u00edsticas dos planos privados de sa\u00fade e asmodalidades das operadoras daqueles benefici\u00e1rios com as informa\u00e7\u00f5es dos demaisbenefici\u00e1rios do Brasil.Estudo transversal, descritivo, quantitativo, utilizando dados n\u00e3o p\u00fablicosdisponibilizados pela ANS. Foram eleg\u00edveis todos os benefici\u00e1rios de planos privadosde sa\u00fade com doen\u00e7a renal cr\u00f4nica  que realizaram no SUS pelo menos uma hemodi\u00e1lise , e que tiveram essa assist\u00eancia identificada pararessarcimento, entre 1\u00ba de abril de 2012 e 31 de dezembro de 2019. N\u00e3o utilizamosoutros tipos de di\u00e1lise  porque representavam menos de 4% dos atendimentos identificados pararessarcimento ao SUS no per\u00edodo estudado.O banco disponibilizado estava organizado com foco nos atendimentos e foi adaptado emtr\u00eas etapas, conforme esquematizado na Na etapa I, exclu\u00edmos os benefici\u00e1rios com idade menor do que 13 anos, uma vez quepodem ter sido registrados erroneamente, pois a hemodi\u00e1lise 0305010107 est\u00e1vinculada a pacientes a partir dessa idade As vari\u00e1veis foram classificadas em caracter\u00edsticas do plano privado de sa\u00fade, daoperadora e da assist\u00eancia prestada, al\u00e9m das sociodemogr\u00e1ficas: sexo , idade , regi\u00e3ode resid\u00eancia  Lei n\u00ba 9.656/1998), tipo de plano, abrang\u00eanciageogr\u00e1fica da cobertura assistencial , segmenta\u00e7\u00e3o assistencial ,franquia (sim ou n\u00e3o) e coparticipa\u00e7\u00e3o (sim ou n\u00e3o). As vari\u00e1veis da operadoraforam: modalidade  e porte .As vari\u00e1veis dos planos privados de sa\u00fade foram \u00e9poca da contrata\u00e7\u00e3o  de benefici\u00e1rios que realizaram hemodi\u00e1lise no SUS foiapresentada segundo regi\u00e3o geogr\u00e1fica, UF e regi\u00e3o da UF de resid\u00eancia. Paradiminuir o vi\u00e9s de compara\u00e7\u00e3o http://www.r-project.org). Este estudo n\u00e3o precisou ser apreciadopor comit\u00ea de \u00e9tica, porque utilizou dados secund\u00e1rios anonimizados, e os resultadosforam apresentados de forma agregada, sem possibilidade de identifica\u00e7\u00e3o individual,conforme previsto na Resolu\u00e7\u00e3o n\u00ba 510, de 7 de abril de 2016 Utilizamos distribui\u00e7\u00f5es de frequ\u00eancias para resumir os dados das vari\u00e1veiscateg\u00f3ricas e medidas de tend\u00eancia central e de variabilidade para vari\u00e1veisquantitativas. Para comparar as frequ\u00eancias, foi utilizada a raz\u00e3o entre elas. Aan\u00e1lise foi realizada no software estat\u00edstico R, vers\u00e3o 4.1.0 , 11,4% (2013), 15,13% (2014),6,68% (2015), 13,06% (2016), 8,98% (2017), 8,99% (2018) e 9,17% (2019). A maioriaera do sexo masculino  e estava na faixa de 45-64 anos , seguida debenefici\u00e1rios com 65 anos ou mais . O grupo feminino era, em mediana, tr\u00easanos mais jovem e com variabilidade maior nas idades .A maior parte dos benefici\u00e1rios que realizaram hemodi\u00e1lise no SUS residia na Regi\u00e3oSudeste, na UF de S\u00e3o Paulo. Em geral, se concentraram nas regi\u00f5es metropolitanasdas capitais , principalmente noAmazonas , Amap\u00e1 , Roraima  eAcre . Por outro lado, nas seguintes UF a maior parte dosbenefici\u00e1rios residia no interior: Santa Catarina , Minas Gerais, Paran\u00e1 , Mato Grosso do Sul  e Para\u00edba . A propor\u00e7\u00e3o de benefici\u00e1rios que realizaramhemodi\u00e1lise no SUS foi pr\u00f3xima entre as regi\u00f5es, sendo maior no Nordeste e menor noSul. Entre as UF e respectivas regi\u00f5es metropolitanas essa propor\u00e7\u00e3o foidiscrepante, sendo a menor constatada na Regi\u00e3o Metropolitana de Florian\u00f3polis e a maior na Regi\u00e3o Metropolitana do Amap\u00e1 .Do total de benefici\u00e1rios, 34,9% foram assistidos fora de seu munic\u00edpio deresid\u00eancia, e 95,54% realizaram hemodi\u00e1lise em prestadores privados. A maior parteutilizou o SUS por at\u00e9 tr\u00eas meses, 39,1% por mais de um ano e 20,11% por 25 meses oumais. Os benefici\u00e1rios se concentravam em operadoras de grande porte e em contratossem previs\u00e3o de franquia e/ou coparticipa\u00e7\u00e3o .A mediana do n\u00famero de sess\u00f5es de hemodi\u00e1lise por benefici\u00e1rio foi 98 . A mediana do valoridentificado foi R$ 27,97 mil . Os benefici\u00e1rios contabilizaram 5,81 milh\u00f5es de sess\u00f5es de hemodi\u00e1lise,a um custo total de R$ 1,67 bilh\u00f5es nos 93 meses estudados.A maior parte dos benefici\u00e1rios que realizaram hemodi\u00e1lise no SUS estava vinculada acontratos novos, do tipo \u201ccoletivo empresariais\u201d, com abrang\u00eancia geogr\u00e1fica porgrupo de munic\u00edpios e de segmenta\u00e7\u00e3o assistencial ambulatorial+hospitalar, bem comoa operadoras da modalidade \u201cmedicina de grupo\u201d. Em rela\u00e7\u00e3o aos demais benefici\u00e1riosdo Brasil, aqueles que realizaram hemodi\u00e1lise no SUS estavam vinculados maisfrequentemente a contratos antigos , coletivos por ades\u00e3o , individuais/familiares , ambulatoriais  e municipais , e a filantropias . Assim como os demais benefici\u00e1rios do Brasil, amaioria dos que realizaram hemodi\u00e1lise no SUS se concentrava em planos coletivos,mas a frequ\u00eancia de coletivos por ades\u00e3o era maior  .Entre 2012 e 2019, mais de 30 mil benefici\u00e1rios de planos privados de sa\u00fade foramsubmetidos a 5,8 milh\u00f5es de sess\u00f5es de hemodi\u00e1lise no SUS, e mais de 20% delesutilizaram o SUS por 25 meses ou mais. Se comparados aos demais benefici\u00e1rios doBrasil, aqueles estavam vinculados mais frequentemente a contratos antigos,coletivos por ades\u00e3o, individuais/familiares, ambulatoriais, municipais e afilantropias. Planos privados de sa\u00fade com caracter\u00edsticas restritivas podem terdificultado o acesso dos benefici\u00e1rios que realizaram hemodi\u00e1lise no SUS \u00e0s redes desuas operadoras, e terem representado mais um dentre os diversos fatores que podemter influenciado a utiliza\u00e7\u00e3o da rede p\u00fablica por aqueles benefici\u00e1rios emdetrimento da cobertura prevista em seus contratos.A menor quantidade de benefici\u00e1rios que realizaram hemodi\u00e1lise no SUS foi registradaem 2015 , coincidindo com o in\u00edcio da cobran\u00e7a para ressarcimento ao SUS dosprocedimentos ambulatoriais de alta complexidade ,Pesquisa Nacional de Sa\u00fade de 2013 (PNS 2013) ,,O sexo e a idade dos benefici\u00e1rios que realizaram hemodi\u00e1lise no SUS foramsemelhantes aos de pacientes em di\u00e1lise reportados por outros estudos no Brasil,,A maior parte de benefici\u00e1rios que realizaram hemodi\u00e1lise no SUS residia no Sudeste,na UF de S\u00e3o Paulo, em regi\u00f5es com maior concentra\u00e7\u00e3o de emprego e crescimentoecon\u00f4mico N\u00e3o existem dados p\u00fablicos individualizados sobre benefici\u00e1rios em terapia renalsubstitutiva no Brasil que permitissem saber quantos desses benefici\u00e1rios realizaramhemodi\u00e1lise no SUS. Isso impossibilitou identificar se as desigualdades regionaisencontradas nesse estudo refletiam a utiliza\u00e7\u00e3o do SUS pelo setor suplementar, ou seeram reflexo da distribui\u00e7\u00e3o daqueles benefici\u00e1rios nessas regi\u00f5es. Por\u00e9m, asmaiores propor\u00e7\u00f5es de benefici\u00e1rios que realizaram hemodi\u00e1lise no SUS estavam nas UFdo Nordeste e do Norte, coincidindo com as limita\u00e7\u00f5es assistenciais observadas pelasPNS 2013 e 2019, que se mostravam maiores entre pessoas com plano de sa\u00faderesidentes nessas regi\u00f5es menos desenvolvidas do pa\u00eds. Nessas PNS, Nordeste e Nortetamb\u00e9m apresentaram as menores propor\u00e7\u00f5es de pessoas que consideraram o plano desa\u00fade bom ou muito bom, sendo o outro extremo ocupado pela Regi\u00e3o Sul ,Cerca de 28% dos benefici\u00e1rios utilizaram o SUS por menos de tr\u00eas meses, podendo serelacionar \u00e0s altas taxas de mortalidade nesse per\u00edodo, \u00e0s poss\u00edveis ocorr\u00eancias depacientes renais agudos Para os 20,11% de benefici\u00e1rios que realizaram hemodi\u00e1lise no SUS por 25 meses oumais, os per\u00edodos de utiliza\u00e7\u00e3o n\u00e3o poderiam ser explicados por limita\u00e7\u00f5es decar\u00eancia para realizar hemodi\u00e1lise quando da contrata\u00e7\u00e3o de um plano privado desa\u00fade Neste estudo, para mais da metade dos benefici\u00e1rios que realizaram hemodi\u00e1lise no SUSos planos privados de sa\u00fade n\u00e3o previam franquia ou coparticipa\u00e7\u00e3o, coincidindo coma pr\u00e1tica de algumas operadoras que, para regularem o acesso aos servi\u00e7os,utilizaram mais autoriza\u00e7\u00e3o pr\u00e9via, per\u00edcia m\u00e9dica e, em menor propor\u00e7\u00e3o,coparticipa\u00e7\u00f5es ,O fato de mais de um ter\u00e7o dos benefici\u00e1rios que realizaram hemodi\u00e1lise no SUS tersido assistido fora de seu munic\u00edpio de resid\u00eancia pode estar relacionado \u00e0 pol\u00edticade organiza\u00e7\u00e3o dos servi\u00e7os de hemodi\u00e1lise em redes regionalizadas A predomin\u00e2ncia de prestadores privados em detrimento da rede pr\u00f3pria do SUS foireflexo da pol\u00edtica p\u00fablica de financiamento de hemodi\u00e1lises no Brasil. Desde ad\u00e9cada de 1970, a facilidade para o credenciamento junto \u00e0 Previd\u00eancia Socialimpulsionou a expans\u00e3o e a consolida\u00e7\u00e3o da assist\u00eancia de alto custo/complexidadepredominantemente prestada por servi\u00e7os privados e alinhada a um mercadomonopolizado de equipamentos e insumos para di\u00e1lises ,,As 5,81 milh\u00f5es de sess\u00f5es de hemodi\u00e1lise que encontramos correspondem a 5,7% do quefoi realizado no SUS no mesmo per\u00edodo Lei n\u00ba 9.656/1998 Em nosso estudo, 62,75% dos benefici\u00e1rios eram de operadoras de grande porte, o quepode ser reflexo do mercado suplementar brasileiro, no qual, entre 2012 e 2019, emm\u00e9dia 68,65% dos v\u00ednculos m\u00e9dico-assistenciais pertenciam a elas Assim como os demais benefici\u00e1rios do Brasil, aqueles que realizaram hemodi\u00e1lise noSUS tinham, majoritariamente, planos privados de sa\u00fade coletivos, o que pode serresultado da menor disponibilidade de planos individuais/familiares em rela\u00e7\u00e3o aoscoletivos, principalmente os empresariais Fator agravante \u00e9 que, para corresponder aos potenciais clientes de planos privadosde sa\u00fade individuais/familiares, sujeitos \u00e0 regula\u00e7\u00e3o mais incisiva pela ANS A maior frequ\u00eancia de v\u00ednculos coletivos e individuais/familiares dos benefici\u00e1riosque realizaram hemodi\u00e1lise no SUS, em rela\u00e7\u00e3o aos demais benefici\u00e1rios do Brasil,pode estar relacionada \u00e0 dificuldade em contratar um plano privado de sa\u00fade viaempregador. A doen\u00e7a renal cr\u00f4nica e a terapia renal substitutiva afetamnegativamente a qualidade de vida dos pacientes ,Em rela\u00e7\u00e3o aos demais benefici\u00e1rios do Brasil, as frequ\u00eancias de planos privados desa\u00fade ambulatoriais e de abrang\u00eancia municipal entre os que realizaram hemodi\u00e1liseno SUS foram maiores. Planos ambulatoriais e municipais configuram a m\u00ednimasegmenta\u00e7\u00e3o e cobertura geogr\u00e1fica regulamentadas e s\u00e3o mais baratos Por outro lado, o paciente em fal\u00eancia funcional renal, que depende de consultasregulares a especialistas e exames espec\u00edficos, pode estar contratando um planoprivado de sa\u00fade para ter acesso mais r\u00e1pido a esses procedimentos Nessa perspectiva, \u00e9 poss\u00edvel que pacientes em terapia renal substitutiva se esforcempara manter um plano privado de sa\u00fade a fim de melhorar o acesso aos servi\u00e7osassistenciais. Um contrato refer\u00eancia  inclui as segmenta\u00e7\u00f5esambulatorial+hospitalar+obstetr\u00edcia e atendimento integral ilimitado \u00e0surg\u00eancias/emerg\u00eancias ap\u00f3s 24 horas da contrata\u00e7\u00e3o ,Benefici\u00e1rios que realizaram hemodi\u00e1lise no SUS foram sete vezes mais frequentes emoperadoras filantr\u00f3picas quando comparados aos demais benefici\u00e1rios do Brasil. Aoferta de planos privados de sa\u00fade por filantropias se organizou em redesassistenciais fragmentadas, uma vez que um mesmo hospital se tornou operadora, al\u00e9mde continuar a prestar assist\u00eancia ao SUS e a outras empresas do setor suplementar.Como resultado, o acesso dos benefici\u00e1rios dessas operadoras pode estar restrito aum m\u00ednimo de servi\u00e7os ou a um \u00fanico estabelecimento hospitalar, muitas vezeslocalizado em periferias das grandes cidades, ou em munic\u00edpios menores Lei n\u00ba9.656/1998Ainda sobre as filantropias, ressaltamos que, dentro do per\u00edodo estudado, 21,81% dosequipamentos de hemodi\u00e1lise no Brasil estavam em entidades sem fins lucrativos ,,Com base na revis\u00e3o de literatura realizada, este foi o primeiro estudo a descreveros benefici\u00e1rios de planos privados de sa\u00fade que realizaram hemodi\u00e1lise no SUS,utilizando uma base centrada no indiv\u00edduo, composta pela completude de dadosdispon\u00edveis quando da solicita\u00e7\u00e3o de acesso junto \u00e0 ANS. Assim, era escassa aliteratura sobre benefici\u00e1rios que utilizaram o SUS, em especial para procedimentosambulatoriais, cuja cobran\u00e7a para ressarcimento \u00e9 recente Este estudo tem algumas limita\u00e7\u00f5es. A hemodi\u00e1lise exige assist\u00eancia continuada, o queleva \u00e0 ocorr\u00eancia de grande n\u00famero de atendimentos para um mesmo benefici\u00e1rio querealizou hemodi\u00e1lise no SUS. Isso pode ter aumentado a probabilidade de perda dedados para compor a base da assist\u00eancia identificada para ressarcimento, pois ospares prov\u00e1veis s\u00e3o encontrados por meio de blocos l\u00f3gicos, e n\u00e3o por umaidentifica\u00e7\u00e3o un\u00edvoca, como o Cadastro de Pessoas F\u00edsicas (CPF) ,Al\u00e9m disso, os benefici\u00e1rios foram individualizados por meio de identificador \u00fanicodo v\u00ednculo contratual do SIB/ANS A predominante dupla-porta dos servi\u00e7os de di\u00e1lise no Brasil pode dificultar osmecanismos de auditoria financeira e favorecer que um mesmo atendimento seja cobradodo SUS e da operadora. Por outro lado, benefici\u00e1rios podem optar por utilizar o SUS,mesmo tendo contratado cobertura para hemodi\u00e1lise, porque existem servi\u00e7os deexcel\u00eancia e transporte sanit\u00e1rio p\u00fablicos, ou mesmo porque o SUS oferece maiorgarantia de continuidade assistencial diante da incerteza de manter um plano privadode sa\u00fade em um pa\u00eds com constantes crises econ\u00f4micas e tamanhas desigualdades s\u00f3cioregionais. Nesse contexto, nossos resultados sugerem que planos privados de sa\u00fadecom caracter\u00edsticas restritivas podem representar mais um dentre os fatores quepodem influenciar seus benefici\u00e1rios a utilizarem a rede p\u00fablica de hemodi\u00e1lise emdetrimento da cobertura prevista em seus planos privados de sa\u00fade.Por fim, o estudo do ressarcimento ao SUS a partir de uma base centrada nobenefici\u00e1rio de plano privado de sa\u00fade ampliou o conhecimento sobre o uso do sistemapelo setor suplementar, para al\u00e9m do enfoque fragmentado sobre atendimentos, valorese processos. Esse tipo de an\u00e1lise tem potencial para lan\u00e7ar luz ao uso do SUS porbenefici\u00e1rios que necessitam de outra assist\u00eancia ambulatorial cont\u00ednua, ou utilizama rede p\u00fablica para algum tipo de interna\u00e7\u00e3o recorrente. Por\u00e9m, a dificuldade deintegra\u00e7\u00e3o de bases p\u00fablicas da sa\u00fade no Brasil \u00e9 um problema para esses estudos,sendo importante que os \u00f3rg\u00e3os respons\u00e1veis aprimorem a divulga\u00e7\u00e3o de informa\u00e7\u00f5es.Refor\u00e7a-se, assim, a necessidade de apoiar pol\u00edticas p\u00fablicas de sa\u00fade e orientarpol\u00edticas de regula\u00e7\u00e3o setorial diante da complexa rela\u00e7\u00e3o entre os setores p\u00fablicoe privado de sa\u00fade brasileiros."}
+{"text": "To analyze the impact of the different phases of the covid-19 pandemic on hospitalizations for oral (CaB) and oropharyngeal (CaOR) cancer in Brazil, carried out within the scope of the Brazilian Unified Health System (SUS). We obtained data regarding hospital admissions due to CaB and CaOR between January 2018 and August 2021 from the SUS Hospital Information System, analyzing hospital admissions as rates per 100,000 inhabitants. We divided the pandemic (January 2020 to August 2021) and pre-pandemic (January 2018 to December 2019) periods into four-month periods, comparing the pandemic period rates with analogous rates for the pre-pandemic period \u2013 for Brazil, by macro-region and by a group of procedures performed during hospitalization. We also analyzed the impact of the pandemic on the average cost of hospitalizations, expressing the results in percentage change. Rates of hospitalization in the SUS due to CaB and CaOR decreased during the pandemic in Brazil. The most significant reduction occurred in the second four-month period of 2020 (18.42%), followed by decreases in the third four-month period of 2020 (17.76%) and the first and second four-month periods of 2021 , compared with 2019. The South and Southeast showed the most expressive and constant reductions between the different phases of the pandemic. Hospitalizations for clinical procedures suffered a more significant decrease than for surgical procedures. In Brazil, the average expenditure per hospitalization in the four-month pandemic periods was higher than in the reference periods. After more than a year of the pandemic\u2019s beginning in Brazil, the SUS hospital care network for CaB and CaOR had yet to be re-established. The repressed demand for hospitalizations for these diseases, which have fast evolution, will possibly result in delays in treatment, negatively impacting the survival of these patients. Future studies are needed to monitor this situation. In Brazil, this subtype occupies the fifth position among the most frequent neoplasms in men2. Its incidence in Brazil, for both sexes, was estimated at 5.6 cases per 100,000 inhabitants by the Global Cancer Observatory 2020 (Globocan); it is the second highest rate in Latin America, lower only than the rate in Cuba3.Cancer currently occupies the second position among the diseases that cause the most deaths and years of life lost due to disability worldwide. According to the 2019 Global Burden of Disease Study, oral (CaB) and oropharyngeal (CaOR) cancers accounted for approximately 2.3% of new cases and 3.1% of deaths from all cancers in the world in 2019, which represents about 540,000 new cases and 313,000 deaths4. Surgeries, which tend to be highly complex, require hospitalization, and radio and chemotherapy treatments, as well as clinical treatments for complications or intercurrences, may also require hospital care. Invasive or advanced-stage lesions often involve mutilating surgical approaches, such as glossectomy and maxillectomy, of which possible consequences are orofacial deformities and functional deficits. Due to treatment sequelae, these patients may depend on hospital care, including recurrent and long-period hospitalizations. More than half of patients with head and neck cancer \u2013 a group that includes oral and oropharyngeal cancers \u2013 start treatment with lesions in advanced stages6 and, consequently, are more dependent on highly complex care and the hospital environment. Oral and oropharyngeal cancers are considered health problems with high economic and social impact, and, in general, the more complex the treatment required, the more expensive it becomes7. From 2008 to 2016, the Brazilian Unified Health System (SUS) spent around 500 million reais on hospitalizations to treat this subtype of cancer8.The treatment of CaB and CaOR involves surgery and/or radiotherapy associated, or not, with chemotherapy and depends on the hospital structure10. The fear of contamination by the new disease may also have kept symptomatic patients away from health services. Regarding CaB and CaOR, empirical evidence from the initial period of the pandemic indicated a reduction in the number of diagnostic procedures and hospitalizations in Brazil12, even in the face of the non-interruption of the operation of reference cancer services in the country. Timely diagnosis and treatment are critical factors for the survival of patients with CaB and CaOR14, and due to their potential to cause delays in the identification and treatment of these diseases, possible disruptions in the care network due to the pandemic need to be understood.The covid-19 pandemic has affected health systems worldwide, and care provision to cancer patients has also reflected this health crisis. Reduction in the routine activities of cancer care services and the number of surgeries, postponement of elective treatments and diagnostic procedures, and suspension of screening services were some of the impacts reported in the literature15. Since February 2020, when the first case of the disease was reported in the country, the pandemic has been characterized by different phases, with periods of resurgence and others of attenuation. Although national lockdown policies were not implemented, there was greater rigidity in local measures  of social distancing in periods of worsening pandemic16. During these periods, the Brazilian health system faced intense overload, which may have impacted the care for other diseases prevalent in the country. However, the impact of the breakdown of health services on care for other conditions, considering the different stages of the pandemic in Brazil, is not yet known. Surveillance of cancer care services is essential to maintain their effectiveness and to comprehend and mitigate the possible effects of the current health crisis in the care of this disease. Thus, this study aims to analyze the impact of covid-19 on hospitalizations for CaB and CaOR in the SUS, considering the different phases of the pandemic.At the beginning of March 2022 \u2013 this study\u2019s conduction period \u2013, Brazil had more than 29 million confirmed cases and about 653,000 deaths by covid-19This study analyzed hospitalizations for CaB and CaOR (ICD-10 C00-C10), recorded in the SUS Hospital Information System (SIH-SUS) between January 2018 and August 2021. This information system consolidates and makes available \u2013 publicly and anonymously \u2013 data on all hospital admissions in Brazil within the scope of the SUS. To ensure that the most recent periods of the study did not reflect possible delays in the consolidation of data by the SIH \u2013 as hospitalizations can be processed in the SIH with some delay concerning the period in which they occurred \u2013, information from the period of interest was retrieved from the databases from the months following that period (until November 2021). The SIH databases, made available by month and by Federation Unit (UF), were unified using the TabWin, a tabulation tool the Brazilian Ministry of Health offers.We compared the months of the pandemic period (2020 and 2021) with their analogs in the reference period (2018 and 2019) to analyze the effect of the pandemic on hospital admissions for CaB and CaOR \u2013 the comparison of the pandemic years with the average of the years 2018 and 2019 was performed as a validation analysis of the comparison with the year 2019. We analyzed the study period by month and four-month period, assessing monthly and four-monthly hospitalizations using rates \u2013 dividing the number of hospitalizations in the month or the four months in each UF and macro-region by the number of inhabitants and multiplying by 100,000. We collected the number of hospitalizations by the state of residence and month of hospitalization and obtained the number of inhabitants in each UF/macro-region using population projections from the Brazilian Institute of Geography and Statistics (IBGE). We presented the comparison between the rates as a percentage of variation, obtained by the equation: [ -1] *100.Each hospital admission recorded in the SIH is linked to the primary procedure performed in that hospitalization. We extracted the number of procedures per group from the SIH using the Procedure Group selection to understand the impact of the pandemic on the types of procedures performed on patients hospitalized for CaB and CaOR. The SUS classifies the procedures performed in their health services into eight groups. Groups 3  and 4  are the main ones for hospitalizations in which the primary diagnosis is CaB and CaOR. We analyzed the four-monthly number of procedures for these two groups using rates \u2013 dividing the number of clinical and surgical procedures (separately) in the four months in each macro-region by the number of inhabitants and multiplying by 100,000. We compared the 2021 and 2020 rates with 2019 as a percentage of change. Finally, we calculated the average expenditure per hospitalization to analyze the impact of the pandemic on the amounts spent on hospitalizations. We divided the total amount spent on hospitalizations due to CaB and CaOR  per four-month period by the number of hospitalizations in the same period, in each macro-region \u2013 both metrics obtained from the SIH. Then, we compared the mean value per hospitalization between the four months of the pandemic with its analogs in the reference period.We presented this study\u2019s results by UF and macro-region of Brazil: North, Northeast, Southeast, South, and Midwest. For the presentation by UF, we created maps with cartographic bases obtained through the IBGE website. All analyses employed the Stata 14.0 software.Hospitalization rates for CaB and CaOR in Brazil carried out by the SUS reduced in pandemic years compared with the reference years (2018 and 2019). For Brazil, the most significant reductions occurred in the second and third four-month periods of 2020 and the first and second ones of 2021, respectively, 18.42%, 17.76%, 14.64%, and 17.07% of reduction, considering the comparison with the rates of the analogous 2019 four-month periods. In these periods, a decrease occurred in the rates of the country\u2019s five regions. The South presented the most expressive decreases (above 20%), while the Northeast region had the smallest reductions in the third four-month period of 2020 and the first and second four-month periods of 2021 \u2013 of less than 5%. The analysis of the groups of procedures performed on patients hospitalized for CaB and CaOR indicated that clinical procedures suffered a more significant reduction than surgical ones, comparing the 2021 and 2020 four-month periods with those of 2019. From the second four-month period of 2020 onward, the rates of both groups of procedures decreased in all periods. However, the decrease percentage was consistently more significant in rates for clinical procedures. Compared to the 2019 four-month periods, the most significant variation in the rates of clinical procedures occurred in the second four-month period of 2020 (-24.62%). In that same period, the variation in surgical procedures was -11.97% . The cliIn general, the analyses considering 2019 as a reference showed similar results to the validation analysis, which considered 2018 and 2019 average values as a reference.This study showed that hospitalizations for CaB and CaOR carried out by the SUS decreased in all phases of the pandemic in Brazil. The first and most crucial reduction occurred in the second four-month period of 2020 when the pandemic began to intensify in the country, prompting local governments to institute social distancing measures to contain the so-called first wave. From then on \u2013 until the end of the study period \u2013 even though there were periods with a less expressive reduction than that experienced in the second four-month period of 2020, hospital admissions for CaB and CaOR carried out by the SUS no longer returned to their pre-pandemic level. Identifying a sustained reduction in these rates is one of the main results of this analysis. By investigating the impact of the pandemic on hospital admissions for CaB and CaOR within the public health system in Brazil, this investigation provided evidence of the magnitude and distribution of the problem and can contribute to mitigating it.17. Possible reasons for this effect are diverse and may be related to the overload of the hospital structure due to the influx of cases of covid-19 requiring hospitalization, the concern to guarantee hospital beds for these cases, the lack of professionals, supplies, and/or equipment \u2013 depleted or reallocated for covid-19 assistance \u2013, to the social consequences of the social distancing measures, and the economic crisis arising from the health crisis and the fear of the patients themselves of being infected by the new virus, thus choosing not to seek the healthcare services19, among others. Other countries, such as India, Spain, and the United Kingdom, also reported reductions in the capacity of the hospital system to treat cases of head and neck cancer due to the pandemic scenario20. In Spain, a study carried out in 44 hospital services indicated that 45.5% of them had to suspend oncological surgeries considered high priority in patients with head and neck cancer at some point during the pandemic21. However, these results are not directly comparable to those of this study \u2013 despite the similarity of the theme, the outcomes under analysis are different.Since they are considered essential, the SUS\u2019s hospital and cancer care services remained in operation during the pandemic in Brazil. However, maintaining these services did not prevent the health crisis triggered by covid-19 from affecting hospital capacity for this disease, as indicated by the results of this article and research carried out in the initial period of the pandemic24. However, specifically for CaB and CaOR, this is not the recommended situation. A statistical modeling study estimated that, in the pandemic context, cases of CaB and CaOR would be among the types most favored by immediate treatment, compared with postponement25. In updated recommendations for the period of the covid-19 pandemic, the European Society for Medical Oncology indicates that mouth and oropharynx tumors at the T1 stage should already be a high/medium priority for primary surgery, and all other ones should be a high priority26. Therefore, we believe that the reduction in hospitalizations found in this analysis is not essentially reflecting programmed delays in the treatment of neoplasms. The results may represent more serious situations, such as (1) barriers to accessing hospital treatment during the pandemic; and (2) impacts of the pandemic on the diagnosis of these diseases, with under-identifying cases that should be admitted to the hospital network for treatment. Decreased numbers of diagnostic procedures for oral cancer occurred in Brazil28. The reduction in hospitalizations due to underdiagnosis is a likely and worrying scenario, as cases not diagnosed during this period may arrive at hospital services with tumors at a more advanced stage, with a lower survival chance29.The reduction in cancer hospitalizations may still indicate, in part, postponement of treatment due to medical decisions to balance risks, as cancer patients have worse outcomes when affected by covid-19 than the general population15, assumed that the first four-month period of 2020 represented the initial period of the pandemic in Brazil; the second represented the first wave; the third, the first period of attenuation of social distancing measures; and finally, the two four-month periods of 2021 represented the second wave of the pandemic. The first and most crucial drop in hospital admissions for CaB and CaOR within the scope of the SUS occurred in the first wave phase, when the health system faced its first collapse, with the depletion of material and human resources and structural overload due to the intense spread of covid-19 across the country. This was also the phase in which local governments implemented the most restrictive social distancing measures16. The reductions identified in the first wave phase are, therefore, compatible with the disorderly character of that period. However, although there were slight recoveries compared with the first wave phase, none of the subsequent ones showed a return of rates to pre-pandemic levels. The maintenance of these reductions more than a year after the start of the pandemic suggests that the impact of this health crisis on hospital care for CaB and CaOR was not a momentary situation, resulting only from an initial adaptation of care to a new and atypical context. The impact of this sustained reduction in mortality/survival from these neoplasms in the short and medium term is still uncertain and needs to be monitored, mainly because these are subtypes of cancer that, in regular times, are already too lethal \u2013 the average five-year survival is 50%5.This study analyzed the phases of the pandemic by four months and, considering the variation in the weekly number of deaths in the country since the notification of the first case (in February 2020)30, including higher rates of procedures for diagnosing oral cancer12. Due to the more significant provision of health services in these regions, more malignant lesions are likely diagnosed and, proportionally, more in the initial stages. As cancer diagnosis was an area greatly affected by the pandemic in the country, regions that performed more of these procedures possibly showed more significant reductions in hospitalizations. Furthermore, cases in initial staging are less likely to have been prioritized for treatment by the health system in the context of a health crisis since, given the limited supply of hospital structure for treatment, more advanced and urgent cases are expectedly prioritized.This study also identified that the reduction in hospital admissions carried out by the SUS varied in magnitude in the different macro-regions of the country. The North and, above all, the Northeast were the regions that showed the smallest reductions in hospitalization rates. On the other hand, the South and Southeast regions showed more significant and constant reductions during the different phases of the pandemic. Brazil\u2019s South and Southeast regions have the best indicators of access to health servicesThe South and Southeast regions showed a notable increase in the mean value per hospitalization for CaB and CaOR, starting from the first wave phase \u2013 for the other regions, this trend was not so clear. We hypothesize that the South and Southeast have a higher possibility of organizing the flow of care in periods of limited resources through selective screening, including telemedicine, monitoring cases, and prioritizing more serious situations \u2013 which require more costly interventions. However, the pattern of expenditures in these regions may also reflect a decrease in the diagnosis of lesions at an earlier stage, which requires less invasive and costly treatments. Finally, clinical procedures linked to hospitalizations decreased more than surgical procedures in all pandemic phases, starting from the first wave phase. Guidelines for managing CaB and CaOR during the pandemic did not advocate replacing surgery with other treatment modalities. We believe the present results indicate that clinical demands are more likely to correspond to an elective and postponable or manageable need in an outpatient setting than surgical demands.31, thus depending on the SUS for care/hospitalization needs. In addition, oral cancer is an outcome associated with socioeconomic conditions: individuals in more vulnerable situations \u2013 and who, consequently, depend more on public health services \u2013 are at increased risk of developing this disease32. Therefore, despite analyzing only data linked to the SUS, this article includes a significant portion of the population affected by this disease. Considering the universal nature of the SUS and the impossibility of accurately equating the proportion of patients with CaB and CaOR using health insurance plans in the hospital environment, it is noteworthy that the rates presented were calculated using the total population as a denominator.This study has several limitations that must be considered when interpreting its results. The SIH covers hospitalizations carried out by the SUS and does not consider those occurring within the scope of the supplementary network . Therefore, this study does not present an overview of all hospitalizations due to CaB and CaOR that occurred in the country. Data from the 2019 National Health Survey indicate that approximately 71.5% of the Brazilian population does not have a health insurance planThe hospitalization rates presented here may account for more than one hospital admission of the same patient for the same cause, as the SIH provides consolidated data; therefore, these duplications cannot be identified and excluded. However, this is not a critical limitation for this analysis, which aimed to measure reductions in the provision of hospital services possibly associated with the pandemic without considering aspects related to individual risks. Furthermore, we highlight that analyzing the data by macro-region and using the four months to represent the pandemic phases \u2013 with standardization of this division for all regions \u2013 disregards the heterogeneity in the space-time patterns of dissemination present in the course of the pandemic in Brazil. Future studies that consider local characteristics of the dynamics of the pandemic in the country may be necessary.This study revealed that, after more than a year of the beginning of the pandemic in Brazil, the hospital care network for CaB and CaOR of the SUS had not yet been re-established. It also showed evidence that, during the pandemic, the hospital network prioritized more serious cases of CaB and CaOR. The hospitalizations reductions may reflect barriers to access to hospital treatment due to the pandemic\u2019s overload and disruption of this sector. The repressed demand for hospitalizations for cases of CaB and CaOR, which are rapidly evolving diseases, will be  related to delays in starting treatment, with a negative impact on the survival of these patients \u2013 a situation that will worsen proportionally to the time this breakdown lasts. This study highlights the need for health management attention to the CaB and CaOR care network, as this, in addition to the immediate need to resume its care capacity, will probably need to expand it in the short term to mitigate the probable damage caused by the pandemic in the care of these diseases and prevent this disruption from increasing the mortality. 1. No Brasil, esse subtipo ocupa a quinta posi\u00e7\u00e3o entre as neoplasias mais incidentes nos homens2. Sua incid\u00eancia no Brasil, para ambos os sexos, foi estimada em 5,6 casos a cada 100 mil pessoas pelo Global Cancer Observatory 2020 (Globocan) e \u00e9 a segunda taxa mais alta da Am\u00e9rica Latina, menor apenas do que a taxa de Cuba3.O c\u00e2ncer ocupa, atualmente, a segunda posi\u00e7\u00e3o entre as doen\u00e7as que mais causam mortes e anos de vida perdidos por incapacidade no mundo. De acordo com Global Burden of Disease Study de 2019, os c\u00e2nceres bucal (CaB) e de orofaringe (CaOR) foram respons\u00e1veis por cerca de 2,3% dos casos novos e 3,1% dos \u00f3bitos ocorridos por todos os c\u00e2nceres no mundo no ano em quest\u00e3o, o que representa cerca 540 mil novos casos e 313 mil \u00f3bitos4. As cirurgias, que costumam ser de alta complexidade, requerem interna\u00e7\u00f5es hospitalares e os tratamentos r\u00e1dio e quimioter\u00e1pico, bem como tratamentos cl\u00ednicos de complica\u00e7\u00f5es ou intercorr\u00eancias tamb\u00e9m podem exigir hospitaliza\u00e7\u00f5es. Les\u00f5es invasivas ou com estadiamento avan\u00e7ado muitas vezes envolvem abordagens cir\u00fargicas mutiladoras, por exemplo, glossectomia e maxilectomia, das quais deformidades orofaciais e d\u00e9ficits funcionais s\u00e3o poss\u00edveis consequ\u00eancias; esses pacientes podem depender da assist\u00eancia hospitalar, incluindo a interna\u00e7\u00e3o nesses ambientes de maneira recorrente e por longos per\u00edodos, devido \u00e0s sequelas do tratamento. Mais da metade dos pacientes com c\u00e2ncer de cabe\u00e7a e pesco\u00e7o \u2013 grupo no qual est\u00e3o inclu\u00eddos os c\u00e2nceres bucal e de orofaringe \u2013 iniciam o tratamento com les\u00f5es em est\u00e1gios avan\u00e7ados6 e, consequentemente, s\u00e3o mais dependentes de cuidados de alta complexidade e do ambiente hospitalar. Os c\u00e2nceres bucal e de orofaringe s\u00e3o considerados agravos \u00e0 sa\u00fade de alto impacto econ\u00f4mico e social e, de modo geral, quanto mais complexo o tratamento exigido, mais caro ele se torna7. De 2008 a 2016, o Sistema \u00danico de Sa\u00fade do Brasil (SUS) gastou cerca de 500 milh\u00f5es de reais em interna\u00e7\u00f5es hospitalares para tratamento desse subtipo de c\u00e2ncer8.O tratamento dos CaB e CaOR envolve cirurgia e/ou radioterapia associadas, ou n\u00e3o, \u00e0 quimioterapia e depende de estrutura hospitalar10. O receio de contamina\u00e7\u00e3o pela nova doen\u00e7a tamb\u00e9m pode ter afastado pacientes sintom\u00e1ticos dos servi\u00e7os de sa\u00fade. Em rela\u00e7\u00e3o ao CaB e CaOR, evid\u00eancias emp\u00edricas do per\u00edodo inicial da pandemia indicaram redu\u00e7\u00e3o no n\u00famero de procedimentos de diagn\u00f3stico e nas hospitaliza\u00e7\u00f5es no Brasil12, mesmo diante da n\u00e3o interrup\u00e7\u00e3o do funcionamento dos servi\u00e7os de refer\u00eancia em c\u00e2ncer no pa\u00eds. Diagn\u00f3stico e tratamento em tempo oportuno s\u00e3o fatores-chave para a sobrevida dos pacientes com CaB e CaOR14 e, por seu potencial de causar atrasos na identifica\u00e7\u00e3o e no tratamento dessas doen\u00e7as, poss\u00edveis desestrutura\u00e7\u00f5es na rede de cuidados devido \u00e0 pandemia precisam ser compreendidas.A pandemia por covid-19 afetou os sistemas de sa\u00fade no mundo todo e a presta\u00e7\u00e3o de cuidados em pacientes com c\u00e2ncer tamb\u00e9m vem refletindo essa crise sanit\u00e1ria. Redu\u00e7\u00e3o nas atividades de rotina dos servi\u00e7os de aten\u00e7\u00e3o ao c\u00e2ncer e no n\u00famero de cirurgias, adiamento de tratamentos eletivos e de procedimentos diagn\u00f3sticos e suspens\u00e3o de servi\u00e7os de rastreamento foram alguns dos impactos reportados na literatura15. Desde fevereiro de 2020, quando foi notificado o primeiro caso da doen\u00e7a no pa\u00eds, a pandemia foi caracterizada por diferentes fases, com per\u00edodos de recrudescimento e outros de atenua\u00e7\u00e3o. Apesar de n\u00e3o terem sido implementadas pol\u00edticas nacionais de lockdown, houve maior rigidez nas medidas locais (municipais e estaduais) de distanciamento social nos per\u00edodos de agravamento da pandemia16. Nesses per\u00edodos, o sistema de sa\u00fade brasileiro enfrentou intensa sobrecarga, que pode ter refletido no cuidado \u00e0s outras doen\u00e7as prevalentes no pa\u00eds. Contudo, o impacto da desestrutura\u00e7\u00e3o dos servi\u00e7os de sa\u00fade na aten\u00e7\u00e3o a outros agravos, considerando as diferentes fases da pandemia no Brasil, ainda n\u00e3o \u00e9 conhecido. A vigil\u00e2ncia dos servi\u00e7os de aten\u00e7\u00e3o ao c\u00e2ncer \u00e9 fundamental para a manuten\u00e7\u00e3o da sua efetividade e para equacionar e mitigar os poss\u00edveis efeitos da atual crise sanit\u00e1ria no cuidado a essa doen\u00e7a. Desse modo, o objetivo deste trabalho \u00e9 analisar o impacto da covid-19 nas hospitaliza\u00e7\u00f5es por CaB e CaOR no SUS, considerando as diferentes fases da pandemia.No in\u00edcio de mar\u00e7o 2022 \u2013 per\u00edodo de realiza\u00e7\u00e3o deste estudo \u2013 o Brasil contabilizava mais de 29 milh\u00f5es de casos confirmados e cerca de 653 mil \u00f3bitos por covid-19Este estudo analisou as hospitaliza\u00e7\u00f5es por CaB e CaOR (CID-10 C00-C10), registradas no Sistema de Informa\u00e7\u00f5es Hospitalares do SUS (SIH-SUS), que ocorreram entre janeiro de 2018 a agosto de 2021. Esse sistema de informa\u00e7\u00e3o consolida e disponibiliza, de maneira p\u00fablica e an\u00f4nima, dados de todas as interna\u00e7\u00f5es hospitalares realizadas no Brasil no \u00e2mbito do SUS. Para garantir que os per\u00edodos mais recentes do estudo n\u00e3o refletissem poss\u00edveis atrasos na consolida\u00e7\u00e3o dos dados pelo SIH \u2013 pois as interna\u00e7\u00f5es podem ser processadas no SIH com algum atraso em rela\u00e7\u00e3o ao per\u00edodo em que ocorreram \u2013, foram resgatadas informa\u00e7\u00f5es do per\u00edodo de interesse nos bancos de dados dos meses subsequentes a esse per\u00edodo (at\u00e9 novembro de 2021). Os bancos de dados do SIH, que s\u00e3o disponibilizados por m\u00eas e por Unidade da Federa\u00e7\u00e3o (UF), foram unificados por meio da ferramenta de tabula\u00e7\u00e3o TabWin, disponibilizada pelo Minist\u00e9rio da Sa\u00fade do Brasil.Para analisar o efeito da pandemia sobre as interna\u00e7\u00f5es hospitalares por CaB e CaOR, os meses do per\u00edodo pand\u00eamico (2020 e 2021) foram comparados com seus an\u00e1logos no per\u00edodo de refer\u00eancia (2018 e 2019) \u2013 a compara\u00e7\u00e3o dos anos pand\u00eamicos com a m\u00e9dia dos anos 2018 e 2019 foi feita como an\u00e1lise de valida\u00e7\u00e3o da compara\u00e7\u00e3o com o ano de 2019. O per\u00edodo do estudo foi analisado por m\u00eas e por quadrimestre. As interna\u00e7\u00f5es mensais e quadrimestrais foram analisadas sob a forma de taxas \u2013 o n\u00famero de interna\u00e7\u00f5es no m\u00eas ou no quadrimestre em cada UF e macrorregi\u00e3o foi dividido pelo n\u00famero de habitantes e multiplicado por 100 mil. As interna\u00e7\u00f5es foram coletadas por UF de resid\u00eancia e pelo m\u00eas de interna\u00e7\u00e3o. O n\u00famero de habitantes em cada UF/macrorregi\u00e3o foi obtido por meio das proje\u00e7\u00f5es populacionais do Instituto Brasileiro de Geografia e Estat\u00edstica (IBGE). A compara\u00e7\u00e3o entre as taxas foi apresentada como percentual de varia\u00e7\u00e3o, obtido por meio da equa\u00e7\u00e3o: [(taxa do per\u00edodo pand\u00eamico sob an\u00e1lise/taxa do per\u00edodo an\u00e1logo em ano de refer\u00eancia) -1] *100.Cada admiss\u00e3o hospitalar registrada no SIH est\u00e1 vinculada ao procedimento principal realizado naquela hospitaliza\u00e7\u00e3o. Para compreens\u00e3o do impacto da pandemia nos tipos de procedimentos realizados nos pacientes internados por CaB e CaOR, a quantidade de procedimentos, por grupo, foi extra\u00edda do SIH, por meio da sele\u00e7\u00e3o Grupo de Procedimento. O SUS classifica os procedimentos realizados em seus servi\u00e7os de sa\u00fade em oito grupos. Os grupos 3 (Procedimentos Cl\u00ednicos) e 4 (Procedimentos Cir\u00fargicos) s\u00e3o os principais em interna\u00e7\u00f5es nas quais o diagn\u00f3stico principal \u00e9 CaB e CaOR. A quantidade quadrimestral dos procedimentos desses dois grupos foi analisada sob a forma de taxas: o n\u00famero de procedimentos cl\u00ednicos e cir\u00fargicos (separadamente) no quadrimestre, em cada macrorregi\u00e3o, foi dividido pelo n\u00famero de habitantes e multiplicado por 100 mil. A compara\u00e7\u00e3o entre as taxas de 2021 e 2020 com 2019 foi apresentada como percentual de varia\u00e7\u00e3o. Por fim, para an\u00e1lise do impacto da pandemia sobre os valores gastos nas hospitaliza\u00e7\u00f5es, foi calculado o gasto m\u00e9dio por hospitaliza\u00e7\u00e3o: o valor total das interna\u00e7\u00f5es por CaB e CaOR , por quadrimestre, foi dividido pelo n\u00famero de interna\u00e7\u00f5es no mesmo per\u00edodo \u2013 as duas m\u00e9tricas foram obtidas no SIH. O valor m\u00e9dio por interna\u00e7\u00e3o foi ent\u00e3o comparado entre os quadrimestres da pandemia e os seus an\u00e1logos do per\u00edodo de refer\u00eancia.Os resultados deste estudo foram apresentados por UF e por macrorregi\u00e3o do Brasil \u2013 Norte, Nordeste, Sudeste, Sul e Centro-Oeste. Para apresenta\u00e7\u00e3o por UF, foram criados mapas cujas bases cartogr\u00e1ficas foram obtidas por meio do website do IBGE. Todas as an\u00e1lises foram realizadas no software Stata 14.0.As taxas de interna\u00e7\u00e3o hospitalar por CaB e CaOR no Brasil, realizadas no \u00e2mbito do SUS, reduziram nos anos pand\u00eamicos em compara\u00e7\u00e3o com os anos de refer\u00eancia (2018 e 2019). Para o Brasil, as maiores redu\u00e7\u00f5es foram identificadas no segundo e terceiro quadrimestres de 2020 e no primeiro e segundo quadrimestres de 2021: respectivamente, 18,42%, 17,76%, 14,64% e 17,07% de redu\u00e7\u00e3o, considerando a compara\u00e7\u00e3o com as taxas dos quadrimestres an\u00e1logos do ano de 2019. Nesses per\u00edodos, houve redu\u00e7\u00e3o nas taxas das cinco regi\u00f5es do pa\u00eds e o Sul foi a que apresentou as diminui\u00e7\u00f5es mais expressivas (acima de 20%). J\u00e1 a regi\u00e3o Nordeste foi a que apresentou as menores diminui\u00e7\u00f5es no terceiro quadrimestre de 2020 e no primeiro e segundo quadrimestres de 2021 \u2013 de menos de 5%. Esses resultados e as taxas de cada per\u00edodo est\u00e3o expostos na A A As an\u00e1lises dos grupos de procedimentos realizados nos pacientes internados por CaB e CaOR indicaram que os procedimentos cl\u00ednicos sofreram maior redu\u00e7\u00e3o do que os procedimentos cir\u00fargicos, considerando a compara\u00e7\u00e3o dos quadrimestres de 2021 e 2020 com os de 2019. A partir do segundo quadrimestre de 2020, houve queda nas taxas de ambos os grupos de procedimentos, em todos os quadrimestres; contudo, a porcentagem de diminui\u00e7\u00e3o foi sempre maior nas taxas dos procedimentos cl\u00ednicos. Em compara\u00e7\u00e3o com os quadrimestres de 2019, a maior varia\u00e7\u00e3o nas taxas dos procedimentos cl\u00ednicos ocorreu no segundo quadrimestre de 2020 . Nesse mesmo per\u00edodo, a varia\u00e7\u00e3o nos procedimentos cir\u00fargicos foi de -11,97% . Os procA varia\u00e7\u00e3o do gasto m\u00e9dio por hospitaliza\u00e7\u00e3o, considerando os per\u00edodos pr\u00e9-pand\u00eamico e pand\u00eamico, \u00e9 apresentada na De modo geral, as an\u00e1lises que consideraram como refer\u00eancia o ano de 2019 apresentaram resultados semelhantes \u00e0 an\u00e1lise de valida\u00e7\u00e3o, que considerou como refer\u00eancia a m\u00e9dia dos valores dos anos 2018 e 2019.Este estudo mostrou que as hospitaliza\u00e7\u00f5es por CaB e CaOR no \u00e2mbito do SUS sofreram redu\u00e7\u00e3o em todas as fases da pandemia no Brasil. A primeira e mais importante diminui\u00e7\u00e3o ocorreu no segundo quadrimestre de 2020, per\u00edodo no qual a pandemia come\u00e7ou a se acentuar no pa\u00eds, impelindo governos locais a institu\u00edrem medidas de afastamento social na tentativa de conter a chamada primeira onda. A partir de ent\u00e3o \u2013 e at\u00e9 o final do per\u00edodo de estudo \u2013, mesmo tendo havido per\u00edodos com redu\u00e7\u00e3o menos expressiva do que a experimentada no segundo quadrimestre de 2020, as interna\u00e7\u00f5es hospitalares por CaB e CaOR realizadas pelo SUS n\u00e3o mais retomaram o seu patamar pr\u00e9-pandemia. A identifica\u00e7\u00e3o de uma redu\u00e7\u00e3o sustentada nessas taxas \u00e9 um dos principais resultados desta an\u00e1lise. Ao investigar o impacto da pandemia sobre as interna\u00e7\u00f5es hospitalares por CaB e CaOR no \u00e2mbito do sistema p\u00fablico de sa\u00fade do Brasil, esta investiga\u00e7\u00e3o forneceu ind\u00edcios da magnitude e da distribui\u00e7\u00e3o do problema e pode contribuir para o seu enfrentamento.17. Poss\u00edveis raz\u00f5es para esse efeito s\u00e3o diversas e podem estar relacionadas \u00e0 sobrecarga da estrutura hospitalar em decorr\u00eancia do afluxo de casos de covid-19 que demandaram hospitaliza\u00e7\u00e3o, \u00e0 preocupa\u00e7\u00e3o em garantir leitos hospitalares para esses casos, \u00e0 falta de profissionais, suprimentos e/ou equipamentos \u2013 esgotados ou realocados para a assist\u00eancia \u00e0 covid-19 \u2013, aos reflexos sociais das medidas de distanciamento social e da crise econ\u00f4mica emergente da crise sanit\u00e1ria e ao receio dos pr\u00f3prios pacientes de se contaminarem pelo novo v\u00edrus, optando assim por n\u00e3o procurarem os servi\u00e7os de sa\u00fade19, entre outras. Redu\u00e7\u00f5es na capacidade do sistema hospitalar para tratamento de casos de c\u00e2ncer de cabe\u00e7a e pesco\u00e7o em decorr\u00eancia do cen\u00e1rio pand\u00eamico foram relatadas tamb\u00e9m em outros pa\u00edses, como \u00cdndia, Espanha e Reino Unido20. Na Espanha, um estudo realizado em 44 servi\u00e7os hospitalares indicou que 45,5% deles precisaram suspender cirurgias oncol\u00f3gicas consideradas de alta prioridade em pacientes com c\u00e2ncer de cabe\u00e7a e pesco\u00e7o em algum momento da pandemia21. Esses resultados, contudo, n\u00e3o s\u00e3o diretamente compar\u00e1veis aos deste estudo \u2013 apesar da semelhan\u00e7a do tema, os desfechos sob an\u00e1lise s\u00e3o distintos.Por serem considerados de car\u00e1ter essencial, os servi\u00e7os hospitalares e de aten\u00e7\u00e3o ao c\u00e2ncer do SUS mantiveram-se em funcionamento durante a pandemia no Brasil. Contudo, a manuten\u00e7\u00e3o desses servi\u00e7os n\u00e3o impediu que a crise sanit\u00e1ria desencadeada pela covid-19 afetasse a capacidade hospitalar referente a essa doen\u00e7a, conforme indicaram os resultados deste artigo e de pesquisas realizadas no per\u00edodo inicial da pandemia24. Contudo, especificamente para CaB e CaOR, essa n\u00e3o \u00e9 a situa\u00e7\u00e3o preconizada. Estudo de modelagem estat\u00edstica estimou que, no contexto pand\u00eamico, os casos de CaB e CaOR estariam entre os tipos mais favorecidos pelo tratamento imediato, em compara\u00e7\u00e3o com o adiamento25. Em recomenda\u00e7\u00f5es atualizadas para o per\u00edodo da pandemia de covid-19, a European Society for Medical Oncology indica que tumores de boca e orofaringe em estadiamento T1 j\u00e1 devem ser considerados como alta/m\u00e9dia prioridade para cirurgia prim\u00e1ria e que todos os demais estadiamentos devem ser considerados como alta prioridade26. Entende-se, ent\u00e3o, que a redu\u00e7\u00e3o nas hospitaliza\u00e7\u00f5es encontradas nesta an\u00e1lise n\u00e3o esteja refletindo essencialmente adiamentos programados de tratamento das neoplasias; os resultados podem estar retratando situa\u00e7\u00f5es mais graves, como: (1) barreiras ao acesso a tratamento hospitalar durante a pandemia; e (2) impactos da pandemia no diagn\u00f3stico dessas doen\u00e7as, com sub-identifica\u00e7\u00e3o de casos que deveriam estar sendo admitidos na rede hospitalar para tratamento. Redu\u00e7\u00f5es na realiza\u00e7\u00e3o de procedimentos de diagn\u00f3stico de c\u00e2ncer bucal foram identificadas no Brasil28. A redu\u00e7\u00e3o das hospitaliza\u00e7\u00f5es em decorr\u00eancia de subdiagn\u00f3stico \u00e9 um cen\u00e1rio prov\u00e1vel e inquietante, pois casos que deixaram de ser diagnosticados nesse per\u00edodo poder\u00e3o chegar aos servi\u00e7os hospitalares com les\u00f5es em estadiamento mais avan\u00e7ado, para as quais a chance de sobrevida \u00e9 menor29.A redu\u00e7\u00e3o das hospitaliza\u00e7\u00f5es por c\u00e2ncer pode ainda estar refletindo, em parte, adiamentos de tratamento por decis\u00f5es m\u00e9dicas, com o objetivo de equilibrar riscos, pois pacientes com c\u00e2ncer t\u00eam piores desfechos quando acometidos pela covid-19 do que a popula\u00e7\u00e3o em geral15, assumiu que o primeiro quadrimestre de 2020 representou o per\u00edodo inicial da pandemia no Brasil; o segundo, representou a primeira onda; o terceiro, o primeiro per\u00edodo de atenua\u00e7\u00e3o e afrouxamento das medidas de distanciamento social; e, por fim, os dois quadrimestres de 2021 representaram a segunda onda da pandemia. A primeira e mais importante queda nas admiss\u00f5es hospitalares por CaB e CaOR no \u00e2mbito do SUS ocorreu na fase da primeira onda, per\u00edodo no qual o sistema de sa\u00fade enfrentou o primeiro colapso, com esgotamento de recursos materiais e humanos e sobrecarga estrutural em decorr\u00eancia da intensa dissemina\u00e7\u00e3o da covid-19 pelo pa\u00eds. Essa tamb\u00e9m foi a fase de implementa\u00e7\u00e3o, pelos governos locais, das medidas mais restritivas de afastamento social16. As redu\u00e7\u00f5es identificadas na fase da primeira onda s\u00e3o, ent\u00e3o, compat\u00edveis com o car\u00e1ter desordenado desse per\u00edodo. Contudo, apesar de haver discretas recupera\u00e7\u00f5es em rela\u00e7\u00e3o \u00e0 fase de primeira onda, nenhuma das fases seguintes exibiu retorno das taxas ao patamar pr\u00e9-pandemia. A sustenta\u00e7\u00e3o dessas redu\u00e7\u00f5es ap\u00f3s mais de um ano do in\u00edcio da pandemia sugere que o impacto dessa crise sanit\u00e1ria na aten\u00e7\u00e3o hospitalar ao CaB e CaOR n\u00e3o foi uma situa\u00e7\u00e3o moment\u00e2nea, decorrente apenas de uma adapta\u00e7\u00e3o inicial da assist\u00eancia a um contexto novo e at\u00edpico. O impacto dessa redu\u00e7\u00e3o sustentada na mortalidade/sobrevida por essas neoplasias a curto e m\u00e9dio prazo ainda \u00e9 incerto e precisa ser monitorado, em especial, porque se tratam de subtipos de c\u00e2ncer que, em tempos normais, j\u00e1 s\u00e3o demasiadamente letais \u2013 a sobrevida m\u00e9dia em cinco anos \u00e9 de 50%5.Este estudo analisou as fases da pandemia por quadrimestres e, considerando a varia\u00e7\u00e3o do n\u00famero semanal de \u00f3bitos no pa\u00eds desde a notifica\u00e7\u00e3o do primeiro caso (em fevereiro de 2020)30, incluindo maiores taxas de realiza\u00e7\u00e3o de procedimentos para diagn\u00f3stico de c\u00e2ncer bucal12. Pela maior provis\u00e3o de servi\u00e7os de sa\u00fade, \u00e9 prov\u00e1vel que, nessas regi\u00f5es, sejam diagnosticadas mais les\u00f5es malignas e, proporcionalmente, mais les\u00f5es em estadiamento inicial. Como o diagn\u00f3stico do c\u00e2ncer foi uma \u00e1rea bastante afetada pela pandemia no pa\u00eds, \u00e9 poss\u00edvel que regi\u00f5es que realizavam mais desses procedimentos manifestem maiores redu\u00e7\u00f5es nas hospitaliza\u00e7\u00f5es. Ainda, entende-se que casos em estadiamento inicial t\u00eam menor chance de terem sido priorizados para tratamento pelo sistema de sa\u00fade em contexto de crise sanit\u00e1ria, visto que, diante de oferta limitada de estrutura hospitalar para tratamento, \u00e9 esperado que casos mais avan\u00e7ados e urgentes sejam prioridade.Este estudo tamb\u00e9m identificou que a redu\u00e7\u00e3o nas admiss\u00f5es hospitalares realizadas pelo SUS variou em magnitude nas diferentes macrorregi\u00f5es do pa\u00eds. Norte e, sobretudo, Nordeste foram as regi\u00f5es que apresentaram as menores redu\u00e7\u00f5es nas taxas de hospitaliza\u00e7\u00e3o. J\u00e1 as regi\u00f5es Sul e Sudeste apresentaram redu\u00e7\u00f5es maiores e constantes durante as diferentes fases da pandemia. Sul e Sudeste s\u00e3o as regi\u00f5es do Brasil que apresentam melhores indicadores de acesso a servi\u00e7os de sa\u00fadeSul e Sudeste exibiram um not\u00e1vel aumento do valor m\u00e9dio por interna\u00e7\u00e3o por CaB e CaOR, a partir da fase da primeira onda \u2013 para as demais regi\u00f5es, essa tend\u00eancia n\u00e3o foi t\u00e3o clara. Entende-se que Sul e Sudeste tenham mais possibilidade de organiza\u00e7\u00e3o do fluxo do cuidado em per\u00edodos de exiguidade de recursos, por meio de triagem seletiva, inclusive com uso de telemedicina, e de acompanhamento dos casos e de prioriza\u00e7\u00e3o de situa\u00e7\u00f5es mais graves \u2013 e que necessitam de interven\u00e7\u00f5es mais onerosas. Contudo, o padr\u00e3o dos gastos nessas regi\u00f5es tamb\u00e9m pode estar refletindo uma diminui\u00e7\u00e3o do diagn\u00f3stico de les\u00f5es em estadiamento mais inicial, que demandam tratamentos menos invasivos e custosos. Por fim, os procedimentos cl\u00ednicos vinculados \u00e0s interna\u00e7\u00f5es diminu\u00edram mais do que os procedimentos cir\u00fargicos em todas as fases da pandemia, a partir da fase de primeira onda. As orienta\u00e7\u00f5es para manejo CaB e CaOR durante a pandemia n\u00e3o preconizaram substitui\u00e7\u00f5es de cirurgia por outras modalidades de tratamento. Entende-se que os presentes resultados estejam refletindo o fato de que as demandas cl\u00ednicas t\u00eam maior chance de corresponderem a uma necessidade eletiva e adi\u00e1vel ou manej\u00e1vel em ambiente ambulatorial do que as demandas cir\u00fargicas.31, dependendo assim do SUS frente a necessidades de atendimento/hospitaliza\u00e7\u00e3o. Al\u00e9m disso, o c\u00e2ncer bucal \u00e9 um desfecho associado a condi\u00e7\u00f5es socioecon\u00f4micas: indiv\u00edduos em condi\u00e7\u00f5es mais vulner\u00e1veis \u2013 e que, consequentemente, dependem mais dos servi\u00e7os p\u00fablicos de sa\u00fade \u2013 t\u00eam risco aumentado de desenvolver essa doen\u00e7a32. Assim, apesar de analisar apenas os dados vinculados ao SUS, entende-se que este artigo inclui parcela expressiva da popula\u00e7\u00e3o acometida por essa doen\u00e7a. Considerando o car\u00e1ter universal do SUS e a impossibilidade de equacionar com precis\u00e3o a propor\u00e7\u00e3o de pacientes com CaB e CaOR usu\u00e1ria de planos de sa\u00fade em \u00e2mbito hospitalar, destaca-se que as taxas apresentadas foram calculadas usando como denominador a popula\u00e7\u00e3o total.Este estudo apresenta uma s\u00e9rie de limita\u00e7\u00f5es que devem ser consideradas na interpreta\u00e7\u00e3o dos seus resultados. O SIH abrange as interna\u00e7\u00f5es realizadas pelo SUS e n\u00e3o contabiliza as que ocorrem no \u00e2mbito da rede suplementar (hospitais privados e conveniados a seguros de sa\u00fade); com isso, este estudo n\u00e3o apresenta o panorama de todas as interna\u00e7\u00f5es por CaB e CaOR ocorridas no pa\u00eds. Dados da Pesquisa Nacional de Sa\u00fade de 2019 indicam que cerca de 71,5% da popula\u00e7\u00e3o brasileira n\u00e3o tem posse de plano de sa\u00fadeAs taxas de interna\u00e7\u00e3o aqui apresentadas podem estar contabilizando mais de uma admiss\u00e3o hospitalar de um mesmo paciente pela mesma causa, pois o SIH disponibiliza os dados de modo consolidado e, sendo assim, essas duplicidades n\u00e3o podem ser identificadas e exclu\u00eddas. Todavia, entende-se que essa n\u00e3o \u00e9 uma limita\u00e7\u00e3o cr\u00edtica para esta an\u00e1lise, que objetivou dimensionar redu\u00e7\u00f5es na presta\u00e7\u00e3o de servi\u00e7os hospitalares possivelmente associadas \u00e0 pandemia, sem considerar aspectos relativos a riscos individuais. Ainda, pontua-se que a op\u00e7\u00e3o de an\u00e1lise dos dados por macrorregi\u00e3o e usando os quadrimestres para representar as fases da pandemia \u2013 com padroniza\u00e7\u00e3o dessa divis\u00e3o para todas as regi\u00f5es \u2013 desconsidera a heterogeneidade nos padr\u00f5es espa\u00e7o-temporais de dissemina\u00e7\u00e3o que esteve presente no transcorrer da pandemia no Brasil. Futuros estudos que considerem caracter\u00edsticas de ordem local da din\u00e2mica da pandemia no pa\u00eds podem ser oportunos.Este artigo revelou que, ap\u00f3s mais de um ano do in\u00edcio da pandemia no Brasil, a rede hospitalar de cuidado ao CaB e CaOR do SUS ainda n\u00e3o tinha se restabelecido. Tamb\u00e9m apresentou ind\u00edcios de que, durante a pandemia, a rede hospitalar priorizou casos mais graves de CaB e CaOR. As interna\u00e7\u00f5es que deixaram de ser realizadas podem estar refletindo barreiras ao acesso a tratamento hospitalar, pela sobrecarga e desestrutura\u00e7\u00e3o desse setor em decorr\u00eancia da pandemia. A demanda reprimida por hospitaliza\u00e7\u00f5es para casos de CaB e CaOR, que s\u00e3o doen\u00e7as de r\u00e1pida evolu\u00e7\u00e3o, estar\u00e1 (e j\u00e1 est\u00e1) relacionada aos atrasos para in\u00edcio do tratamento, com impacto negativo para a sobrevida desses pacientes \u2013 situa\u00e7\u00e3o que se agravar\u00e1 proporcionalmente ao tempo que durar essa desestrutura\u00e7\u00e3o. Este estudo destaca a necessidade de aten\u00e7\u00e3o da gest\u00e3o em sa\u00fade para a rede de cuidado ao CaB e CaOR, pois esta, al\u00e9m da necessidade imediata de retomada da sua capacidade de aten\u00e7\u00e3o, provavelmente precisar\u00e1 ampli\u00e1-la, j\u00e1 em curto prazo, para mitigar os prov\u00e1veis danos da pandemia no cuidado a essas doen\u00e7as e evitar um reflexo dessa disrup\u00e7\u00e3o no aumento da mortalidade."}
+{"text": "To compare the efficiency of different vocal self-assessment instruments for dysphonia screening.Instrumento de Rastreio da Disfonia (IRDBR). To analyze assertiveness in relation to the presence of dysphonia, the cutoff points of each instrument and the decision rule recommended by the IRDBR were used. An exploratory analysis was performed to compare mean scores of instruments and verify associations between variables.262 dysphonic and non-dysphonic individuals participated in the research. The mean age was 41.3 (\u00b114.5) years. The diagnosis of dysphonia was based on the auditory-perceptual analysis of the sustained vowel \u201c\u00e9\u201d and on laryngological diagnosis. The responses of the instruments were collected: Voice-Related Quality of Life (V-RQOL), Voice Handicap Index (VHI), VHI-10, Voice Symptoms Scale (VoiSS), and the Brazilian Dysphonia Screening Tool, (Br-DST) called in Brazilian Portuguese BR (84.0%), VQL (80.9%), VHI (78.2%), and VHI-10 (75.2%).The instruments evaluated were sensitive to capture the impact of dysphonia in a similar way regardless of professional voice use and type of dysphonia. There was a difference only in VoiSS scores for the variable gender, with a higher score for females. Regarding global assertiveness, the instruments showed high rates of success in classification, with emphasis on the VoiSS, which had the highest rate (86.3%), followed by the IRDBR. The IRDBR is a short, simple, and easy-to-apply tool for screening procedures.The VoiSS has the highest assertiveness index in the identification of dysphonia, followed by the IRD Therefore, the importance of a complete and efficient vocal evaluation is paramount for the diagnosis of a possible voice disorder, which includes auditory, acoustic, and aerodynamic perceptual analysis of voice, in addition to laryngeal examination and evaluation from the patient's perspective.Voice disorders affect 3 to 9% of the population and produce a series of negative impacts on the quality of life of individuals. Therefore, a screening tool does not need to be a complete diagnostic tool. The use of short screening tools for the pre-selection of at-risk individuals to be referred for later diagnostic confirmation may allow expanding the scope and resolution of preventive epidemiological actions in the field of voice,6.However, performing a full-scale voice assessment procedure is not always feasible, as the diagnosis of a voice disorder is a process that demands time, material resources, and specialized professionals. In population surveys or preventive campaigns, specific mechanisms are recommended for screening, as they aim to select individuals with high chances of presenting dysphonia early in order to be referred for a complete confirmatory diagnostic evaluation at a later time. It is important that a protocol for screening purposes be formally elaborated and psychometrically tested so that, for the selection of items, the results of an extensive and rich literature review, empirical experiences of researchers with an idea built for such an instrument are considered, in addition to syntactic and semantic aspects that contribute to clarity, relevance, coherence, and scope of questions to be applied to the population.The indispensable requirements for a screening instrument are easy application, broad usability, speed, low cost, and ability to provide answers with efficient and satisfactory interpretation,8. A recent study has proposed a screening instrument called Brazilian Dysphonia Screening Tool (Br-DST), prepared from items from the \u201cVoice Handicap Index - VHI\u201d and \u201cVoice Symptoms Scale - VoiSS,\u201d which showed high indexes of sensitivity and diagnostic accuracy using logistic regression models and other statistical measurements such as Odds Ratio (OR) and probability estimates for data analysis. For use in Brazil, the translation of the title of this instrument into Instrumento de Rastreio da Disfonia (IRDBR) is important; this nomenclature that will be used throughout this work.From this perspective, when tracking voice disorders it is important to measure aspects that contribute to the identification of dysphonia, such as personal factors, occupational risk factors, or vocal manifestations themselvesBR is an instrument composed of only two items with a dichotomous response scale (yes/no), which leads to different decisions based on the responses obtained. These items were selected based on the analysis of statistical relevance of each item of the original instruments. Therefore, the set of questions that presented the greatest association with the presence of the vocal disorder was chosen. That work proved that there are more significant items than others when the aim is to identify the presence of dysphonia and that issues identified as the most relevant may form a quick and simple instrument for its screening.The IRD. This is the instrument called Dysphonia Risk Screening Protocol (Protocolo de Rastreio do Risco de Disfonia - PRRD), which consists of 18 questions and uses a 10-cm visual analogue scale, with score calculation for individuals of different age groups with and without vocal complaints. The PRRD is a general protocol designed for gender-independent and professional voice use; it is applicable only to adults and the elderly.Another screening instrument to identify the risk of dysphonia was previously proposed in the literature with high efficiency in the discrimination of individuals with and without dysphonia in different sample groupsHowever, the aforementioned instrument consists of a structure of 18 questions and a score obtained through the value extracted from a 10-cm visual analogue scale plus an overall score, along with other partial scores. The structure of the instrument is not so simple and, therefore, less viable for use in population-based screening procedures; it is, therefore, a more effective tool for use in traditional individualized procedures in voice clinics., and the instrument for Screening for Voice Disorders in the Older Adults (Rastreamento de Altera\u00e7\u00f5es Vocais em Idosos - RAVI) was developed specifically for the elderly population. Both, although they have a proven efficiency in their validation processes, have a limited use to a specific audience and are not indicated for the general population.Also, there are other screening protocols for dysphonia genuinely developed and validated in Brazil. The Screening Index for Voice Disorder - SIVD was developed to identify voice disorders in teachersInstrumento de Rastreio da Disfonia (IRDBR), and the traditional self-assessment instruments: Voice-Related Quality of Life (V-RQOL), Voice Handicap Index (VHI), and Voice Symptoms Scale (VoiSS) for dysphonia screening.Thus, the objective of this study is to compare the efficiency of the This is a quantitative, cross-sectional and retrospective study, evaluated and approved by the Research Ethics Committee of the Institution of origin, with opinion no. 3,470,951/19. As this is a documentary research, the use of the Informed Consent (IC) was waived, and the consent of the laboratory that stores and has responsibility for the data used was required.Data were extracted from a pre-existing digital database belonging to the voice research laboratory of a higher education institution. This database stores clinical data from patients of both sexes and all age groups who voluntarily sought speech therapy at the speech therapy school clinic linked to this laboratory and presented a voice-related complaint. Individuals aged between 18 and 78 years were included who presented all the information related to vocal anamnesis, auditory-perceptual voice assessment, and laryngological assessment and those who answered all the items of the self-assessment questionnaires selected for this study.Data from 262 individuals were included; they had a mean age of 41.3 years (SD = 14.5), a minimum of 18 and a maximum of 78 years (maximum age recorded in the database used) and were allocated into two groups: dysphonic (D) and non-dysphonic (ND). Most participants were female, non-voice professionals, and dysphonic. All participants who reported in the anamnesis using their voice as the main work tool were called voice professionals. Regarding the type of dysphonia, there was a higher percentage of behavioral dysphonia. Regarding the intensity of the deviation, mild dysphonia was the majority in relation to moderate and intense dysphonia .The classification of participants regarding the presence of dysphonia was performed according to the combination of medical and speech-language pathology diagnosis based on laryngeal examination and auditory-perceptual assessment. All dysphonic individuals presented vocal complaints, presence of \u201cstructural or functional alteration in the larynx,\u201d and voice quality deviation. The subjects of the ND group did not present vocal complaints. They had a result of \u201cabsence of structural or functional alteration of the larynx\u201d recorded in the database and absence of vocal quality deviation.. Voices with a score below 35.5 mm were considered to have normal vocal quality variability (NVQV).The variable \u201cvocal deviation intensity\u201d extracted from the research database was obtained through auditory-perceptual analysis of the sustained vowel \u201c\u00e9\u201d in maximum phonation time. The analysis was performed using the Vocal Deviation Scale (VDS), a 100-mm visual analogue scale that uses the general degree of deviation (G) to represent the intensity of vocal deviation from the following cut-off points: 35.6 to 50.5 mm mild to moderate deviation; 50.6 to 90.5 mm, moderate deviation; and 90.6 to 100 mm, severe deviationkappa coefficient. The results were recorded in the database and accessed to select the voices used in the present study. In this study, only the results of the speech therapist with the highest kappa coefficient (0.80) were used, indicating the judge's good internal reliability.The auditory-perceptual analysis of all voices was performed by three speech-language pathologists specialized in voice, with more than ten years of experience in vocal assessment, which contributes to the reliability of the analysis performed. In the assessment session, 20% of the samples were randomly reassessed, and the reliability of the listeners' ratings was analyzed using Cohen's ; the Voice Handicap Index - VHI, and its reduced version the Voice Handicap Index-10, which measures the disadvantage that a vocal disorder may bring to the patient's life; and the Voice Symptoms Scale - VoiSS, which assesses the self-perception of vocal symptoms and the impact produced by the voice disorder.All responses to the items of the following vocal self-assessment questionnaires, in their translated, adapted and validated versions for Brazilian Portuguese, were also extracted from the database: Voice-Related Quality of Life - V-RQOL, which measures voice-related quality of life. The cut-off point established to indicate the presence of dysphonia through the V-RQOL is 91.25 points for the total score, with sensitivity indexes of 0.97 and efficiency of 0.91.The V-RQOL has ten items divided into two domains: socio-emotional and physical. It is the only instrument that uses a specific calculation to obtain its total and domain scores. For its interpretation, it is understood that the higher the score, the better the voice-related quality of life. Its reduced version, the VHI-10, has ten items. It produces a single total score calculated by the simple sum of the answers to items, which may vary from 0 to 40 points. For both instruments, the higher the score produced, the worse the disadvantage perceived by the individual. The cutoff points established to indicate the presence of dysphonia are 19 points for the original version's total score, with maximum indexes of sensitivity and efficiency (=1.00), and 7.5 points for the short version, with sensitivity index of 0.98 and efficiency index of 0.99.The VHI has 30 items divided into three domains: emotional, physical and organic. It has a total score expressed by the simple sum of the responses obtained in all items, which may range from 0 to 120 points. The VoiSS allows obtaining data on functionality, emotional impact, and physical symptoms that a voice problem may trigger in an individual's life. The total score is obtained through the simple sum of answers, which can range from 0 to 120. The higher the score, the greater the perception of the general level of vocal alteration in relation to limitations in voice use, emotional reactions, and physical symptoms by the patient. The cut-off point established to indicate the presence of dysphonia through the VoiSS is 16 points, with maximum sensitivity and efficiency indexes (=1.00).The VoiSS also has 30 items divided into three domains: limitation, emotional and physical. It is currently considered the most rigorous and psychometrically more robust instrument for vocal self-assessmentInstrumento de Rastreio da Dysphonia (IRDBR)\u201d has only two questions and was created from the analysis of items of the three instruments mentioned above: V-RQOL, VHI, and VoiSS. The use of logistic regression models and other statistical decision-making techniques to analyze these traditional instruments results in a new two-item structure with high levels of sensitivity and diagnostic accuracy for the identification of dysphonia. The objective is to track individuals easily and quickly with a high probability of having any vocal disorder in order to properly select and refer those who need a diagnostic evaluation and other specialized procedures.The dysphonia screening tool called \u201cBR is composed of two questions with dichotomous answers (yes/no): 1) \u201cDo I feel like I have to force my voice for it to come out?\u201d and 2) \u201cIs my voice hoarse?\u201d There are three decision rules guided by the instrument, which are based on the answers of the individual (Annex A). An answer \u201cyes\u201d to both items indicates a high probability of dysphonia and guides immediate referral for detailed diagnostic evaluation (Decision A); an answer \u201cyes\u201d only the for item 2 indicates a moderate probability of dysphonia and recommends a personalized vocal guidance and the need for monitoring voice (Decision B); finally, any other type of answer (\u201cno\u201d to both items or \u201cyes\u201d only to item 1) indicates a low probability of dysphonia and recommends personalized vocal guidance without the immediate need for referral to complementary assessments (Decision C). The instrument has a sensitivity index of 0.86 and an efficiency index of 0.83 for the decision recommended.The IRD and the decision rules A and B recommended by the IRDBR were considered. They point to a high and moderate probability of dysphonia (answer \u201cyes\u201d to both items or only item 2). The aim is to compare the efficiency of IRDBR and traditional instruments of vocal self-assessment that originated it.To analyze the assertiveness of the instruments in relation to the vocal diagnosis of individuals, the cutoff points established for V-RQOL, VHI, and VoiSSDescriptive analysis of variables was performed using mean, standard deviation, and frequency distribution with the aim of characterizing the sample. The Kolmogorov Smirnov normality test was used to confirm the hypothesis of non-normality of data and guide the use of non-parametric hypothesis tests (\u03b1= 0.05). Exploratory data analysis was performed using the Mann-Whitney test and the Pearson Chi-square test to compare mean scores of instruments with each other and verify associations between the distribution of data and the variables studied. Statistical analysis was performed using the software R, version 3.5.1, and SPSS, version 23.0. The significance level was 0.05 for all results.The comparison of means of total scores in self-assessment instruments for dysphonic (D) and non-dysphonic (ND) groups showed that all instruments have different means for both groups, which indicates that their scores adequately discriminate vocal disorders. However, the non-dysphonic group has a mean value above the cut-off point for normal individuals in all instruments .The means of total scores of the instruments V-RQOL, VHI, VHI-10, and VoiSS were compared between groups in terms of gender, professional voice use, and type of dysphonia . There wBR were used to identify the vocal disorder. The VoiSS presented the highest percentage of correct answers in the identification of the presence of dysphonia, followed by the IRDBR and V-RQOL, both with the same percentage of correct answers (86.1%) and, in sequence, VHI and VHI-10. The IRDBR, with only two items, has a high rate of success in identifying dysphonia, which is very close to the first instrument (VoiSS), which has a much higher number of items , elaborado a partir de itens dos question\u00e1rios \u201c\u00cdndice de Desvantagem Vocal - IDV\u201d e \u201cEscala de Sintomas Vocais - ESV\u201d, que demonstrou elevados \u00edndices de sensibilidade e acur\u00e1cia diagn\u00f3stica utilizando modelos de regress\u00e3o log\u00edstica e outras medidas estat\u00edsticas como Odds Ratio (OR) e estimativas de probabilidade para an\u00e1lise de dados. Para utiliza\u00e7\u00e3o no Brasil, sugere-se a tradu\u00e7\u00e3o do t\u00edtulo desse instrumento para Instrumento de Rastreio da Disfonia (IRDBR), nomenclatura que ser\u00e1 utilizada no decorrer desse trabalho.Nessa perspectiva, no rastreamento de dist\u00farbios vocais, \u00e9 importante que sejam mensurados aspectos que contribuam para a identifica\u00e7\u00e3o de uma disfonia, como fatores pessoais, fatores de riscos ocupacionais ou manifesta\u00e7\u00f5es vocais propriamente ditasBR \u00e9 um instrumento composto por apenas dois itens com escala de resposta dicot\u00f4mica (sim/n\u00e3o), que direcionam para decis\u00f5es diferentes a partir das respostas obtidas. Esses itens foram selecionados a partir da an\u00e1lise da relev\u00e2ncia estat\u00edstica de cada um dos itens dos instrumentos originais, sendo escolhidos, portanto, o conjunto de quest\u00f5es que apresentou maior associa\u00e7\u00e3o com a presen\u00e7a do dist\u00farbio vocal. O trabalho comprovou que existem itens mais significativos em rela\u00e7\u00e3o a outros quando se almeja identificar a presen\u00e7a da disfonia e que esses identificados como mais relevantes podem compor um instrumento r\u00e1pido e simples para o seu rastreio.O IRD. Trata-se do instrumento intitulado como Dysphonia Risk Screening Protocol ou Protocolo de Rastreio do Risco de Disfonia - PRRD, que \u00e9 composto por 18 quest\u00f5es e utiliza uma escala visual anal\u00f3gica de 10 cm, com c\u00e1lculo de pontua\u00e7\u00e3o para indiv\u00edduos de diferentes faixas et\u00e1rias com e sem queixas vocais. O PRRD \u00e9 um protocolo geral projetado para uso independente de sexo e uso profissional da voz, aplic\u00e1vel apenas para adultos e idosos.Um outro instrumento de triagem para identificar o risco de disfonia foi anteriormente proposto na literatura com elevada efici\u00eancia na discrimina\u00e7\u00e3o de indiv\u00edduos com e sem disfonia em diferentes grupos amostraisNo entanto, o referido instrumento consiste em uma estrutura de 18 quest\u00f5es e um escore obtido por meio do valor extra\u00eddo de uma escala visual anal\u00f3gica de 10 cm adicionado a uma pontua\u00e7\u00e3o geral, juntamente com outras pontua\u00e7\u00f5es parciais. Considera-se que a estrutura do instrumento n\u00e3o \u00e9 t\u00e3o simples e, por isso, menos vi\u00e1vel para utiliza\u00e7\u00e3o em procedimentos populacionais de triagem sendo, portanto, uma ferramenta mais eficaz para uso em procedimentos tradicionais individualizados nas cl\u00ednicas de voz., e o instrumento de Rastreio de Altera\u00e7\u00f5es Vocais no Idoso - RAVI foi desenvolvido especificamente para a popula\u00e7\u00e3o idosa. Ambos, embora apresentem efici\u00eancia comprovada em seu processo de valida\u00e7\u00e3o, t\u00eam uso limitado a um p\u00fablico espec\u00edfico e n\u00e3o s\u00e3o indicados para a popula\u00e7\u00e3o em geral.Al\u00e9m deste, existem outros protocolos de rastreio para disfonia genuinamente desenvolvidos e validados no Brasil. O \u00cdndice de Triagem para Dist\u00farbio de Voz - ITDV foi desenvolvido para identifica\u00e7\u00e3o de dist\u00farbios vocais em professoresBR), e dos instrumentos de autoavalia\u00e7\u00e3o tradicionais: Question\u00e1rio de Qualidade de Vida em Voz (QVV), \u00cdndice de Desvantagem Vocal (IDV) e Escala de Sintomas Vocais (ESV), para o rastreio da disfonia.Assim, o objetivo desse estudo foi comparar a efici\u00eancia do Instrumento de Rastreio da Disfonia  foi dispensado e a anu\u00eancia do laborat\u00f3rio que armazena e tem a responsabilidade sobre os dados utilizados foi requerida.Os dados foram extra\u00eddos de um banco de dados digital pr\u00e9-existente pertencente ao laborat\u00f3rio de pesquisa em Voz de uma institui\u00e7\u00e3o de ensino superior. Tal banco de dados armazena dados cl\u00ednicos de pacientes de ambos os sexos e todas as faixas et\u00e1rias, que procuraram voluntariamente o atendimento fonoaudiol\u00f3gico na cl\u00ednica-escola de Fonoaudiologia vinculada a esse laborat\u00f3rio, apresentando alguma queixa relativa \u00e0 voz. Foram inclu\u00eddos indiv\u00edduos com idade entre 18 e 78 anos, que apresentaram todas as informa\u00e7\u00f5es relativas \u00e0 anamnese vocal, avalia\u00e7\u00e3o perceptivo-auditiva da voz e avalia\u00e7\u00e3o laringol\u00f3gica, e que responderam a todos os itens dos question\u00e1rios de autoavalia\u00e7\u00e3o selecionados para este estudo.Foram inclu\u00eddos dados de 262 indiv\u00edduos, com m\u00e9dia de idade de 41,3 anos , m\u00ednima de 18 e m\u00e1xima de 78 anos (idade m\u00e1xima registrada no banco de dados utilizado), que foram alocados em dois grupos: disf\u00f4nicos (D) e n\u00e3o disf\u00f4nicos (ND). A maioria dos participantes foram do sexo feminino, n\u00e3o profissionais da voz e disf\u00f4nicos. Foram denominados como profissionais da voz todos os participantes que referiram, na anamnese, utilizar a voz como principal ferramenta de trabalho. Em rela\u00e7\u00e3o ao tipo de disfonia, observou-se um percentual maior de disfonias comportamentais e quanto \u00e0 intensidade do desvio, disfonias de grau leve foram a maioria em rela\u00e7\u00e3o a disfonias de grau moderado e intenso .A classifica\u00e7\u00e3o dos participantes quanto \u00e0 presen\u00e7a de disfonia foi realizada de acordo com a combina\u00e7\u00e3o do diagn\u00f3stico m\u00e9dico e fonoaudiol\u00f3gico, a partir do exame lar\u00edngeo e da avalia\u00e7\u00e3o perceptivo-auditiva. Todos os indiv\u00edduos disf\u00f4nicos apresentaram queixa vocal, presen\u00e7a de \u201caltera\u00e7\u00e3o estrutural ou funcional na laringe\u201d e desvio da qualidade vocal. Os sujeitos do grupo ND n\u00e3o apresentavam queixa vocal, apresentaram resultado de \u201caus\u00eancia de altera\u00e7\u00e3o estrutural ou funcional da laringe\u201d registrado na base de dados e aus\u00eancia de desvio da qualidade vocal.. As vozes com pontua\u00e7\u00e3o inferior at\u00e9 35,5 mm foram consideradas com variabilidade normal da qualidade vocal (VNQV).A vari\u00e1vel \u201cintensidade do desvio vocal\u201d extra\u00edda do banco de dados da pesquisa, foi obtida por meio de an\u00e1lise perceptivo-auditiva da vogal sustentada \u201c\u00e9\u201d em tempo m\u00e1ximo de fona\u00e7\u00e3o. A an\u00e1lise foi realizada por meio da Escala de Desvio Vocal (EDV), uma escala visual anal\u00f3gica de 100 mm que utiliza o grau geral de desvio (G) para representar a intensidade do desvio vocal, a partir dos seguintes pontos de corte: 35,6 a 50,5 mm desvio leve a moderado, 50,6 a 90,5 mm desvio moderado e 90,6 a 100 mm desvio intensokappa de Cohen. Os resultados foram registrados no banco de dados e acessados para a sele\u00e7\u00e3o das vozes utilizadas no presente estudo. Nesse estudo, foram utilizados apenas os resultados do fonoaudi\u00f3logo com maior coeficiente kappa , indicando boa confiabilidade interna do juiz.A an\u00e1lise perceptivo-auditiva de todas as vozes foi feita por tr\u00eas fonoaudi\u00f3logos especialistas em voz com mais de 10 anos de experi\u00eancia em avalia\u00e7\u00e3o vocal, o que contribui a favor da confiabilidade da an\u00e1lise realizada. Na sess\u00e3o de avalia\u00e7\u00e3o, 20% das amostras foram reavaliadas aleatoriamente e a confiabilidade das avalia\u00e7\u00f5es dos ouvintes foi analisada usando o coeficiente ; o \u00cdndice de Desvantagem Vocal - IDV, e sua vers\u00e3o reduzida o \u00cdndice de Desvantagem Vocal-10, que mensuram a desvantagem que um dist\u00farbio vocal pode trazer para a vida do paciente; e a Escala de Sintomas Vocais - ESV, que avalia a autopercep\u00e7\u00e3o dos sintomas vocais e o impacto produzido pelo dist\u00farbio de voz.Tamb\u00e9m foram extra\u00eddas do banco de dados todas as respostas dos itens dos seguintes question\u00e1rios de autoavalia\u00e7\u00e3o vocal, em suas vers\u00f5es traduzidas, adaptadas e validadas para o portugu\u00eas brasileiro: Question\u00e1rio de Qualidade de Vida em Voz - QVV, que mensura a qualidade de vida relacionada \u00e0 voz. O ponto de corte estabelecido para indicar a presen\u00e7a da disfonia por meio do QVV \u00e9 de 91,25 pontos para o escore total, com \u00edndices de sensibilidade de 0,97 e efici\u00eancia de 0,91.O QVV possui 10 itens divididos em 2 dom\u00ednios, socioemocional e f\u00edsico. \u00c9 o \u00fanico instrumento que utiliza um c\u00e1lculo espec\u00edfico para obten\u00e7\u00e3o dos seus escores total e por dom\u00ednios, e para sua interpreta\u00e7\u00e3o, entende-se que quanto maior o escore obtido, melhor \u00e9 a qualidade de vida relacionada \u00e0 voz. J\u00e1 sua vers\u00e3o reduzida o IDV-10, possui 10 itens, e produz um escore total \u00fanico, calculado pelo somat\u00f3rio simples das respostas de seus itens, que pode variar de 0 a 40 pontos. Para ambos instrumentos, quanto maior o escore produzido, pior \u00e9 a desvantagem percebida pelo indiv\u00edduo. Os pontos de corte estabelecidos para indicar a presen\u00e7a da disfonia s\u00e3o de 19 pontos para o escore total da vers\u00e3o original, com \u00edndices m\u00e1ximos de sensibilidade e efici\u00eancia , e de 7,5 pontos para a vers\u00e3o reduzida, com \u00edndices de sensibilidade de 0,98 e efici\u00eancia de 0,99.O IDV possui 30 itens divididos em 3 dom\u00ednios, emocional, f\u00edsico e org\u00e2nico, e possui escore total expresso pelo somat\u00f3rio simples das respostas obtidas em todos os itens, que pode variar de 0 a 120 pontos. Por meio da ESV \u00e9 poss\u00edvel obter dados sobre funcionalidade, impacto emocional e sintomas f\u00edsicos que um problema de voz pode desencadear na vida de um indiv\u00edduo. O escore total \u00e9 obtido por meio de somat\u00f3rio simples das respostas, que pode variar de 0 a 120, e quanto maior o escore maior \u00e9 a percep\u00e7\u00e3o do n\u00edvel geral de altera\u00e7\u00e3o vocal em rela\u00e7\u00e3o \u00e0 limita\u00e7\u00e3o no uso da voz, rea\u00e7\u00f5es emocionais e sintomas f\u00edsicos por parte do paciente. O ponto de corte estabelecido para indicar a presen\u00e7a da disfonia a partir do escore total \u00e9 de 16 pontos, com \u00edndices m\u00e1ximos de sensibilidade e efici\u00eancia .A ESV tamb\u00e9m possui 30 itens divididos em 3 dom\u00ednios, limita\u00e7\u00e3o, emocional e f\u00edsico, e atualmente \u00e9 considerada o instrumento mais rigoroso e psicometricamente mais robusto para a autoavalia\u00e7\u00e3o vocalBR)\u201d possui apenas duas quest\u00f5es a serem investigadas e foi elaborada a partir da an\u00e1lise dos itens dos tr\u00eas instrumentos referidos anteriormente: QVV, IDV e ESV. A utiliza\u00e7\u00e3o de modelos de regress\u00e3o log\u00edstica e outras t\u00e9cnicas estat\u00edsticas de tomada de decis\u00e3o na an\u00e1lise desses instrumentos tradicionais resultaram em uma nova estrutura de dois 2 itens com elevados \u00edndices de sensibilidade e acur\u00e1cia diagn\u00f3stica para identifica\u00e7\u00e3o da disfonia. Seu objetivo \u00e9 rastrear, de forma simples e r\u00e1pida, indiv\u00edduos com alta probabilidade de apresentarem qualquer dist\u00farbio vocal, a fim de selecionar e encaminhar adequadamente aqueles que precisem de uma avalia\u00e7\u00e3o diagn\u00f3stica e demais condutas especializadas.J\u00e1 a ferramenta para rastreio da disfonia denominada \u201cInstrumento de Rastreio da Disfonia (IRDBR \u00e9 composto por duas perguntas com respostas dicot\u00f4micas (sim/n\u00e3o): 1) \u201cSinto que tenho que fazer for\u00e7a para minha voz sair?\u201d e 2) \u201cMinha voz \u00e9 rouca?\u201d. S\u00e3o tr\u00eas regras de decis\u00e3o direcionadas pelo instrumento, que se baseiam nas respostas apresentadas pelo indiv\u00edduo (Anexo A). A resposta \u201csim\u201d aos dois itens indica elevada probabilidade de disfonia e orienta o encaminhamento imediato para avalia\u00e7\u00e3o diagn\u00f3stica detalhada (Decis\u00e3o A); a resposta \u201csim\u201d apenas para o item 2 indica uma probabilidade moderada de disfonia e orienta o oferecimento de orienta\u00e7\u00f5es vocais personalizadas e a necessidade de monitoramento do caso (Decis\u00e3o B); por fim, qualquer outro tipo de resposta (\u201cn\u00e3o\u201d para os dois itens ou \u201csim\u201d apenas para o item 1) indica baixa probabilidade de disfonia, e direciona o oferecimento de orienta\u00e7\u00f5es vocais personalizadas, sem necessidade imediata de encaminhamento para avalia\u00e7\u00f5es complementares (Decis\u00e3o C). O instrumento apresenta com \u00edndices de sensibilidade de 0,86 e efici\u00eancia de 0,83 para a decis\u00e3o preconizada.O IRD e as regras de decis\u00e3o A e B preconizadas pelo IRDBR, que apontam alta e moderada probabilidade de disfonia (resposta \u201csim\u201d aos dois itens ou apenas ao item 2). O intuito foi comparar a efici\u00eancia do IRDBR e dos instrumentos tradicionais de autoavalia\u00e7\u00e3o vocal que o originaram, para a detec\u00e7\u00e3o da disfonia.Para analisar a assertividade dos instrumentos em rela\u00e7\u00e3o ao diagn\u00f3stico vocal dos indiv\u00edduos, foram utilizados os pontos de corte estabelecidos para o QVV, IDV e ESVKomolgorov Smirnov foi utilizado para confirmar a hip\u00f3tese de n\u00e3o normalidade dos dados e orientar a utiliza\u00e7\u00e3o de testes de hip\u00f3tese n\u00e3o param\u00e9tricos . A an\u00e1lise explorat\u00f3ria dos dados foi realizada por meio do teste de Mann-Whitney e do teste Qui-quadrado de Pearson, para comparar as m\u00e9dias dos escores dos instrumentos entre si e verificar associa\u00e7\u00f5es entre a distribui\u00e7\u00e3o dos dados e as vari\u00e1veis estudadas. A an\u00e1lise estat\u00edstica foi realizada por meio dos softwares R vers\u00e3o 3.5.1 e SPSS vers\u00e3o 23.0. Considerou-se o n\u00edvel de signific\u00e2ncia de 0,05 para todos os resultados.A an\u00e1lise descritiva das vari\u00e1veis foi realizada por meio de m\u00e9dia, desvio-padr\u00e3o e distribui\u00e7\u00e3o de frequ\u00eancia, com o objetivo de caracterizar a amostra. O teste de normalidade A compara\u00e7\u00e3o das m\u00e9dias dos escores totais dos instrumentos de autoavalia\u00e7\u00e3o, dos grupos de disf\u00f4nicos (D) e n\u00e3o disf\u00f4nicos (ND), mostrou que todos os instrumentos apresentam m\u00e9dias diferentes para os dois grupos, o que indica que seus escores discriminam adequadamente o dist\u00farbio vocal. No entanto, destaca-se que o grupo n\u00e3o disf\u00f4nico apresenta m\u00e9dia superior ao ponto de corte para indiv\u00edduos normais em todos os instrumentos .A compara\u00e7\u00e3o das m\u00e9dias dos escores totais dos instrumentos QVV, IDV, IDV-10 e ESV entre grupos com rela\u00e7\u00e3o ao sexo, uso profissional da voz e tipo de disfonia tamb\u00e9m foi investigada . Foi obsBR para identifica\u00e7\u00e3o do dist\u00farbio vocal. A ESV foi o instrumento que apresentou o maior percentual de acerto na identifica\u00e7\u00e3o da presen\u00e7a da disfonia, seguida do IRDBR e do QVV, ambos com o mesmo percentual de acerto  e, na sequ\u00eancia, IDV e IDV-10. Destaca-se que o IRDBR, com apenas 2 itens, apresenta uma elevada taxa de acerto na identifica\u00e7\u00e3o da disfonia, muito pr\u00f3xima ao primeiro instrumento (ESV) que possui uma quantidade bem superior de itens (Por fim, foi realizada a an\u00e1lise de associa\u00e7\u00e3o entre a propor\u00e7\u00e3o de disf\u00f4nicos identificada pelos instrumentos e pelo diagn\u00f3stico pr\u00e9vio da disfonia. Nessa etapa, foram utilizados os pontos de corte do QVV, IDV, IDV-10, ESV e as regras de decis\u00e3o orientadas pelo IRDde itens .BR, que dessa vez, apresentou desempenho superior ao QVV (Com o intuito de observar a assertividade geral dos instrumentos, tanto para classificar a presen\u00e7a quanto a aus\u00eancia da disfonia, foram somados os acertos e os erros cometidos por esses na classifica\u00e7\u00e3o da disfonia dos participantes da pesquisa. Os resultados apontaram que a ESV permanece em primeiro lugar quanto ao \u00edndice de assertividade, seguida do IRDr ao QVV .,20.A autoavalia\u00e7\u00e3o vocal apresenta grande relev\u00e2ncia no processo investigativo da manifesta\u00e7\u00e3o da disfonia, por ser a avalia\u00e7\u00e3o capaz de oferecer informa\u00e7\u00f5es que v\u00e3o al\u00e9m da perspectiva cl\u00ednica, informando o impacto da disfonia na percep\u00e7\u00e3o do pr\u00f3prio paciente. Os instrumentos de autoavalia\u00e7\u00e3o caracterizam o acometimento da disfonia nas dimens\u00f5es f\u00edsica, social e emocional do paciente disf\u00f4nico, e assim, trazem importantes contribui\u00e7\u00f5es para o diagn\u00f3stico e monitoramento dos casos de disfonia-17. De fato, nesta pesquisa, seus escores foram determinantes para discriminar o grupo disf\u00f4nicos e o grupo n\u00e3o disf\u00f4nico. No entanto, apesar da diferen\u00e7a significativa encontrada entre as m\u00e9dias dos grupos em todos os instrumentos, foi poss\u00edvel observar que a m\u00e9dia dos seus escores estavam superiores aos seus respectivos pontos de corte no grupo n\u00e3o disf\u00f4nicos.Todos os instrumentos de autoavalia\u00e7\u00e3o utilizados na pesquisa s\u00e3o recomendados para utiliza\u00e7\u00e3o em diferentes amostras e mostram-se seguros para diferenciar grupos.Compreende-se que esses valores podem ter sido influenciados pelo ambiente de aloca\u00e7\u00e3o dos participantes que comp\u00f5em o banco de dados da pesquisa, o ambulat\u00f3rio de Voz de uma Cl\u00ednica-Escola de Fonoaudiologia de uma Institui\u00e7\u00e3o de Ensino Superior. Considera-se que, por mais que os indiv\u00edduos n\u00e3o apresentassem diagn\u00f3stico de disfonia, a pr\u00f3pria procura pelo servi\u00e7o caracteriza a percep\u00e7\u00e3o de algum aspecto que motive o desejo ou a necessidade do atendimento, o que eleva \u00e0 modifica\u00e7\u00e3o da pontua\u00e7\u00e3o dos instrumentos de autoavalia\u00e7\u00e3o. \u00c9 poss\u00edvel ainda refletir que esses instrumentos possuem itens que englobam diversos aspectos da manifesta\u00e7\u00e3o da disfonia, que muitas vezes n\u00e3o apresentam rela\u00e7\u00e3o direta com a percep\u00e7\u00e3o do cl\u00ednico,22-24. Apenas para a ESV observou-se diferen\u00e7a em rela\u00e7\u00e3o ao sexo, com escores maiores para o sexo feminino em rela\u00e7\u00e3o ao masculino, fato que pode estar relacionado \u00e0 maior preval\u00eancia da disfonia e de sintomas vocais em mulheres, em virtude da predisposi\u00e7\u00e3o anatomofisiol\u00f3gica que lhe \u00e9 pr\u00f3pria para desenvolver problemas de voz-23,25.N\u00e3o houve diferen\u00e7a quanto \u00e0 pontua\u00e7\u00e3o dos escores dos instrumentos em rela\u00e7\u00e3o \u00e0s vari\u00e1veis sociodemogr\u00e1ficas analisadas, indicando que os instrumentos estudados s\u00e3o sens\u00edveis para captar o impacto da disfonia de forma semelhante para homens, mulheres, profissionais da voz ou n\u00e3o, e independentemente do tipo de disfonia apresentado o que \u00e9 confirmado pela literatura. Nessa pesquisa, observou-se que todos os instrumentos apresentaram elevados \u00edndices de efic\u00e1cia nessa classifica\u00e7\u00e3o, corroborando o descrito em estudos anteriores-18.Conforme conhecido na literatura, os instrumentos de autoavalia\u00e7\u00e3o vocal tradicionais utilizados nesta pesquisa apresentam pontos de corte com elevado poder discriminat\u00f3rio para diferenciar indiv\u00edduos disf\u00f4nicos e vocalmente saud\u00e1veis, estabelecidos a partir de crit\u00e9rios de sensibilidade e especificidade estat\u00edsticos,17-18,26, apresentou-se como mais assertivo em rela\u00e7\u00e3o \u00e0 identifica\u00e7\u00e3o da disfonia. Trata-se de um instrumento com alto grau de validade, confiabilidade e capacidade de resposta quanto a mudan\u00e7as vocais, considerado como classificador perfeito na discrimina\u00e7\u00e3o de pacientes com e sem dist\u00farbios vocais,26-27. J\u00e1 o IRDBR e o QVV estiveram empatados em segundo lugar em rela\u00e7\u00e3o \u00e0 taxa de assertividade.Ao ranquear os instrumentos em rela\u00e7\u00e3o ao maior \u00edndice de efici\u00eancia, a ESV, j\u00e1 considerado na literatura como o instrumento de autoavalia\u00e7\u00e3o vocal mais robusto psicometricamente e amplamente validado que se tem dispon\u00edvel atualmenteBR \u00e9 destac\u00e1vel. Esse instrumento recentemente desenvolvido permite a classifica\u00e7\u00e3o da disfonia de forma mais curta e eficiente, com menor tempo de aplica\u00e7\u00e3o e elevada capacidade discriminativa. Prop\u00f5e a investiga\u00e7\u00e3o r\u00e1pida, simples e eficaz da disfonia, e parece caracterizar-se como a alternativa mais vi\u00e1vel em procedimentos de rastreio. Seus dois itens relacionam-se aos aspectos \u201crouquid\u00e3o\u201d e \u201cesfor\u00e7o vocal\u201d, sintomas importantes na investiga\u00e7\u00e3o do impacto de uma poss\u00edvel disfonia na vida do indiv\u00edduo. Por apresentar correla\u00e7\u00e3o direta com altera\u00e7\u00f5es do mecanismo fisiol\u00f3gico de produ\u00e7\u00e3o vocal presente na maior parte dos transtornos vocais, indiv\u00edduos que possuem a voz rouca e seca t\u00eam aproximadamente 3 vezes mais chance de serem disf\u00f4nicos,21,26,28.O desempenho apresentado pelo IRDBR encontram-se em conson\u00e2ncia com a literatura pois, de acordo com o autorrelato do paciente, a sensa\u00e7\u00e3o de esfor\u00e7o vocal e o sintoma rouquid\u00e3o s\u00e3o fortemente associados \u00e0 presen\u00e7a de disfonia, sendo esses itens de maior peso em um instrumento de rastreio.Dessa forma, os resultados apresentados pelo instrumento IRD-30. O elevado \u00edndice de assertividade a partir do ponto de corte desse instrumento confirma sua efic\u00e1cia para identificar indiv\u00edduos disf\u00f4nicos, j\u00e1 citada em estudo anterior.A rela\u00e7\u00e3o dos \u00edndices do QVV com a presen\u00e7a da disfonia n\u00e3o \u00e9 consensual na literatura, por\u00e9m, grande parte dos estudos que abordam essa quest\u00e3o apontam diferen\u00e7as significativas quanto aos escores do QVV entre indiv\u00edduos com e sem dist\u00farbios de voz,31-32. Adicionalmente, o IDV-10 tamb\u00e9m \u00e9 considerado sens\u00edvel a diversas popula\u00e7\u00f5es e \u00e0 detec\u00e7\u00e3o de pequenas altera\u00e7\u00f5es vocais a partir da avalia\u00e7\u00e3o do impacto de um problema de voz utilizando-se uma quantidade reduzida de itens. Por\u00e9m, o processo de redu\u00e7\u00e3o do instrumento n\u00e3o foi realizado por meio de an\u00e1lise fatorial e seus crit\u00e9rios psicom\u00e9tricos n\u00e3o foram totalmente esclarecidos, o que fragiliza sua estrutura. Nesse estudo, contudo, seus \u00edndices de acerto foram menores em rela\u00e7\u00e3o aos demais instrumentos, o que conduz \u00e0 decis\u00e3o de n\u00e3o recomend\u00e1-lo de forma preferencial em a\u00e7\u00f5es de rastreio para detec\u00e7\u00e3o da disfonia.O IDV e o IDV-10, foram os instrumentos que obtiveram menor percentual de acerto para identifica\u00e7\u00e3o da disfonia e na an\u00e1lise da assertividade geral, quando comparados aos outros instrumentos estudados. No entanto, na literatura, a forte rela\u00e7\u00e3o entre os escores do IDV e o diagn\u00f3stico vocal do paciente \u00e9 observada de forma frequente e esse instrumento \u00e9 considerado como um perfeito classificador para identificar a presen\u00e7a da disfoniaBR se mostra como ferramenta diferencial para a detec\u00e7\u00e3o da disfonia em procedimentos de rastreio, ao considerar sua estrutura curta, simples, de f\u00e1cil e r\u00e1pida de aplica\u00e7\u00e3o, associada aos seus elevados \u00edndices de efici\u00eancia em compara\u00e7\u00e3o aos instrumentos utilizados como refer\u00eancia na autoavalia\u00e7\u00e3o vocal. As vantagens desse instrumento e, sobretudo, sua viabilidade de aplica\u00e7\u00e3o em a\u00e7\u00f5es coletivas envolvendo grupos populacionais caracteriza-o como melhor op\u00e7\u00e3o a ser utilizada no rastreio dos dist\u00farbios de voz. No entanto, cabe ressaltar que essa \u00e9 uma ferramenta que deve ser utilizada exclusivamente para fins de rastreio e que, em hip\u00f3tese alguma, substitui a avalia\u00e7\u00e3o fonoaudiol\u00f3gica e otorrinolaringol\u00f3gica completa.Dessa forma, \u00e9 poss\u00edvel afirmar que o IRDRessalta-se, como limita\u00e7\u00e3o desse estudo o n\u00famero reduzido de pacientes com disfonias org\u00e2nicas na composi\u00e7\u00e3o da amostra. O equil\u00edbrio no quantitativo da amostra em rela\u00e7\u00e3o aos variados tipos de disfonias deve ser explorado, a fim de garantir que a efic\u00e1cia do instrumento seja mais fortemente comprovada. Considera-se como outra limita\u00e7\u00e3o a utiliza\u00e7\u00e3o da an\u00e1lise perceptivo-auditiva de apenas um dos tr\u00eas ju\u00edzes dispon\u00edveis e a aus\u00eancia da an\u00e1lise da confiabilidade inter-avaliadores. Apesar da ampla experi\u00eancia pr\u00e9via e do elevado \u00edndice de confiabilidade interna do juiz selecionado, a an\u00e1lise inter-avaliadores poderia trazer mais seguran\u00e7a \u00e0 escolha de uma \u00fanica an\u00e1lise para classifica\u00e7\u00e3o dos participantes do estudo.BR, instrumentos que podem ser considerados os mais indicados para esse procedimento. O IRDBR \u00e9 uma ferramenta recente, curta, simples e de f\u00e1cil aplica\u00e7\u00e3o por qualquer profissional da sa\u00fade, que apresenta elevada efici\u00eancia para rastreamento da disfonia.Os instrumentos de autoavalia\u00e7\u00e3o vocal s\u00e3o ferramentas com elevada efici\u00eancia para o rastreio de dist\u00farbios da voz em grupos populacionais. Entre eles, a ESV apresenta maior \u00edndice de assertividade na identifica\u00e7\u00e3o da disfonia, seguida do IRD"}
+{"text": "To understand health professionals\u2019 perceptions about vaccination against human papillomavirus (HPV) in the Santa M\u00f4nica rural settlement in Terenos, Mato Grosso do Sul. Quantitative and qualitative methodologies, consultations on vaccination cards, records of community health agents and the focus group technique were used. The main factors of hesitation and vaccine refusal were analyzed, as well as the health team\u2019s strategies for the process of immunization against HPV, from June to August 2018. Of 121 children and adolescents, 81 (66.94%) received the complete vaccination schedule. Complete vaccination coverage for women was 73.17% (60/82) and for men, 53.8% (21/39). It was observed that, although strategies are adopted for vaccine promotion, such as mobile actions, the public is resistant due to superficial knowledge about the vaccine and its use in an early age group, showing itself to be susceptible to the negative influence of the media and to society\u2019s taboos. In addition, difficulties regarding the use of the Unified Health System card and the shortage of professionals were also observed. The results explain the immunization coverage below the target and reinforce the need to strengthen the family health strategy, as well as the permanent and continuing education of professionals, in order to increase parental confidence and adherence to vaccination. In Brazil, the Unified Health System included the HPV vaccine in the vaccination schedule through the National Immunization Program (PNI), in 2014. The program includes girls and boys aged 9 to 14 years, patients living with the human immunodeficiency virus (HIV/Aids), transplanted and undergoing chemotherapy and radiotherapy, aged between 9 and 26 years. Recently, it was extended to women up to 45 years old and with immunosuppression.A total of 124 countries and territories had already implemented national immunization programs for HPV vaccination by 2019.Since the implementation of the quadrivalent vaccine against HPV in the primary care network, the program has sought to reach the minimum target of 80% vaccine coverage. In this way, it contributes to reducing the incidence and mortality of different types of cancer induced by viral types HPV 16, 18, 6 and 11, including cervical, vulvar, vaginal, penile and anal, and oropharynx cancer, in addition to genital warts. Brazil has 972,289 families distributed in 9,374 settlements, which corresponds to an area of 87,978,041.18 hectares, destined for agrarian reform settlements. In the State of Mato Grosso do Sul, 27,764 families are distributed in 204 settlements in different municipalities.Children and adolescents residing in settlements must be vaccinated against HPV established by the National Policy for Comprehensive Health of the Rural and Forest Populations, which aims to meet the health care needs of this target population. Preliminary surveys carried out in the Santa M\u00f4nica \u2013 Rural II settlement complex, belonging to the municipality of Terenos, in the state of Mato Grosso do Sul , indicated that adherence to vaccination against HPV for the year 2014 did not reach the national target recommended by the Ministry of Health .In 2014, most Brazilian municipalities reached the target established in the first dose (87%); however, only 32% of them reached the goal in the second doseGiven this evidence, this study aims to understand health professionals\u2019 perception about vaccination against HPV in the Santa M\u00f4nica settlement complex and contribute to health action measures that can improve this vaccine coverage, analyzing the main hesitation factors or vaccine refusal, as well as the strategies of the local health team for immunization against the human papillomavirus.This is a descriptive-exploratory study of a quantitative and qualitative nature that took place in the Santa M\u00f4nica - Rural II settlement complex, in the municipality of Terenos (MS), from June to August 2018.The research involved the three existing social forces: Settlement Carlos Ferrari, organized through the single central workers (CUT), with a total of 86 families; Emerson Rodrigues Settlement, constituted by the Landless Rural Workers Movement (MST), with 186 families; Settlement of the Federation of Agricultural Workers (FETAGRI), with a total of 443 families.In the 715 lots made available for land reform, 599 families are registered and assisted by the family health strategy (ESF), including 1,253 people. Of these, 82 are girls and 39 are boys within the age range for receiving the HPV vaccine. It is worth mentioning that the distance between the river basic health unit (UBSF) and the lots can reach 18 kilometers.Quantitative data collection for surveying vaccination coverage took place at the health unit itself, through manual records carried out by nine community health agents, after consulting vaccination cards. In this way, it was possible to cover the entire assigned area of the ESF in the Santa M\u00f4nica \u2013 Rural II complex, divided into nine micro-areas, named numerically from 1 to 9.The organization of vaccination coverage data  was carried out using electronic spreadsheets in Microsoft Excel.All records of girls between March 2014 and March 2018 were considered. For boys, the interval between July 2017 and March 2018 was considered. The target audience was classified, according to their vaccination status, as CV (complete vaccination schedule \u2013 two doses); IV (incomplete vaccination schedule \u2013 only the first dose) and NV (not vaccinated). Data were also distributed according to sex and age.Qualitative data on the health professionals\u2019 perception about vaccination against HPV were obtained through a conversation circle at the health unit and records of observations and experiences carried out during the research process.Of the 18 health unit workers, 12 (two men and ten women) made up the conversation circle, seven community health agents, one nurse, one doctor, one dentist, one dental assistant and one pharmacy attendant. Eight professionals lived in the settlement and four lived elsewhere. For the purposes of recording and demonstrating results, professionals were identified by the letter P followed by a numerical representation (P1 to P12).The generating questions for the conversation circle were: 1) how is the team organized to achieve vaccination coverage? 2) what difficulties does the team face in achieving the goals? 3) what could facilitate the achievement of goals? 4) How do you perceive the community\u2019s relationship with vaccination? What about the HPV vaccine? and 5) what age group has more and less regularity in HPV vaccination? Why do you believe this happens? Such questions were aimed at exchanging experiences and lessons learned and raising awareness of the problems faced on a daily basis.The conversation circle, lasting approximately one hour, was recorded. In addition, the participants were asked to authorize and sign the free and informed consent form. After the \u201cformal\u201d closing of the conversation circle, it was noticed that the participants continued to discuss the subject during the collective lunch, when the observations and facts experienced related to the research theme were recorded.The research was approved by the Research Ethics Committee of the Federal University of Mato Grosso do Sul with approval opinion No. 2,685,410, on May 30, 2018.. They are also higher than those found in Brazil, which did not exceed 45.1% among girls aged 9 to 15 years.Taking into account that the results expressed in percentages were obtained through the quotient between the number of children of each sex and the total number of children living in the analyzed micro-area(s), it was observed that, of the 121 children and adolescents participating in the research, 81 (66.94%) received the complete vaccination schedule (first and second dose). Complete vaccination coverage for females was 73.17% (60/82), higher than for males, with 53.8% (21/39). These results are higher than those of Mato Grosso do Sul, which reached 51.1% among girls and 46.7% among boysTheBy observing the distribution of complete vaccination coverage (1st and 2nd doses) of the target population of the study by age according to sex, it is observed that there was no vaccination adherence in the first year for both sexes, gradually increasing with age. However, vaccine adherence decreased in both genders in the last year of vaccine administration ., while other studies have found that vaccination against HPV is not associated with age at first sexual intercourse or the number of sexual partners.Several reasons for hesitation or refusal of the vaccine were pointed out by parents and guardians . Vaccin. In this study, some parents reported to professionals their difficulties in talking about HPV vaccination with such young girls. However, they reported that the inclusion of boys as a target audience facilitated the approach of children and adolescents about the vaccine. This finding reinforces the need to change paradigms and break family taboos.The fact that the vaccine is exclusively for the primary prevention of a sexually transmitted infection also influences its acceptance.In a qualitative analysis, it was observed that less than 10% of knowledge providers knew that HPV vaccination offered some cancer prevention and benefits for men. Thus, the vaccine was rarely offered to boys, which may explain the lower vaccination coverage found in this studyMothers\u2019 reports to health professionals in the Santa M\u00f4nica Settlement reinforced the importance of reoffering the meningococcal C vaccine in the same age group as the HPV vaccine for boys, as well as expanding the age group for both sexes, in order to expand the number of individuals vaccinated against HPV.. Women\u2019s lack of knowledge, in rural areas, about how HPV is transmitted and care for prevention can also justify adherence below the target.In general, the vaccine adherence of the population in this study was below the recommended target (80%), thus requiring measures to promote adherence to the HPV vaccine. The different realities found across the micro-regions may reflect differences in the involvement of both the population and professionals with vaccine adherence and administration. The low adherence in two micro-areas (1 and 9) can be partly explained by the fact that they are located more than 15 kilometers away from the health unit. The spatial heterogeneity between micro-regions may be one of the reasons for differences in vaccination coverage, which indicates that managers should plan specific strategies for each territory.The reasons for refusal or hesitation found in this study are consistent with previously reported key issues, such as concerns about the efficacy, safety and possible adverse effects of vaccines, misinformation about related diseases by the target population, parents and health professionals, negative influence of the community, and lack of trust in authorities and pharmaceutical companies.Since 2012, the World Health Organization has been working to minimize delay in accepting or refusing vaccination despite the availability of vaccine services, through the SAGE Working Group on Vaccine Hesitancy. It is noteworthy that hesitation to vaccinate does not always imply vaccine refusal, since hesitant individuals may accept certain vaccines, but still have doubts about them. In this study, it was possible to observe that the negative influence of the media, by circulating erroneous information about the HPV vaccine and its adverse/side effects, led many parents to prohibit their children from being vaccinated.Fear about possible vaccine side effects is also relevantAnother issue that made it difficult was [posts on] Facebook, because they post [people] fainting, feeling sick, catching diseases, then there is the unfortunate coincidence of taking the vaccine and having another type of problem that has nothing to do with it, then they say it is from the vaccine. (P2).This fact also explains the lower percentage of individuals vaccinated with the complete schedule in micro-areas 1 and 9, as well as the differences in vaccination coverage between the first and second doses.Beliefs that governments withhold information about side effects have already been reported in some qualitative studies, which negatively influences the campaigns that the Ministry of Health runs to promote the vaccine against HPV.It is observed that vaccine promotion strategies have undergone changes over the years, after negative consequences generated by the government\u2019s refractory communication in the face of a series of doubts related to the safety or convenience of the vaccine during the first phase of implementation. The inclusion of religious communities, health professionals, families and adolescents as relevant interlocutors, before and during the execution of the first vaccination campaign, could have contributed to better vaccine adherence results.Currently, access to social media is present in all levels of education and socioeconomic level, including the population of settlements, which may favor the dissemination of information about the importance of the HPV vaccine. On the other hand, the dissemination of false information impairs adherence to vaccination.Belief in a low risk of contracting HPV or developing cervical cancer correlated with the availability of supposed alternative methods was also pointed out as a reason for the lack of need for the vaccine against HPV, which may partly justify adherence to the vaccine below than recommended.Fear of the pain that the vaccine can cause in adolescents was reported by parents and guardians in qualitative studies, as well as fear of the size of the needles and pain during the injection, which is supposed to increase with each dose of the vaccine. Also, the mistaken belief that the vaccine is administered in the cervix, concerns about cleaning the needle and the fear that the injection could lead to loss of virginity were also reported issues.Although the logistical challenges in health units also create barriers to accessing vaccines in different places, in the present study this difficulty was not observed. Health units had enough doses to serve the entire local target audience and logistical issues do not justify the delay in vaccination or low adherence Another argument reported by parents and professionals for non-adherence to the vaccine was the requirement by the Municipal Health Department that the SUS card from Terenos, municipality of residence, be presented when vaccinating. The main reasons given for the difficulty in acquiring or carrying the SUS card were transportation costs, time and distance to the unit to request the card, and forgetting it on vaccination day. The loss of cards also made it difficult to know the vaccination status of children and adolescents..Many children and adolescents had the SUS card from the municipality of Campo Grande (MS), which made it impossible to vaccinate in the Santa M\u00f4nica settlement, since, for the settled individual to have access to the vaccine, he would have to carry the Terenos card. Although the SUS has universality as a principle when it comes to emergency care, outpatient procedures must be regulated by the municipal reference system; therefore, vaccines must be administered, for the most part, in the municipality of residenceCommunity members from the Santa M\u00f4nica settlement mentioned many times that they do not transfer the SUS card to the municipality of Terenos, where they legally reside, because practically all specialized services are carried out in Campo Grande, capital of Mato Grosso do Sul, and the most viable route from the settlement to the city of Terenos goes through the capital.In this study, professionals justified the benefit of mobile actions, pointing out limitations for greater effectiveness of this strategy, which include the need for more vehicles and available professionals.The mobile action, campaigns in micro-areas, in schools, which get closer to the population. Unfortunately, the Brazilians, they keep postponing it again and again. When you say: \u201con such day we will be vaccinating, and we\u2019ll be there just for that, you\u2019ll arrive and vaccinate and go away in no time\u201d, then people are more concerned. (P-8)The exclusive availability of professionals and the agility of the mobile systems encourage adherence to vaccination, unlike care in health units with few professionals, where each of them performs several tasks, resulting in a longer waiting time for care and, consequently, in greater resistance of the family to seek the vaccine..On the other hand, active search for the target public does not always increase vaccination adherence, as observed in a study carried out in South Africa, where the expected adherence was not achieved even with the introduction of a vaccination program against HPV in schools, in 2014. A possible justification for this result is the parents\u2019 hesitation, a fact capable of causing delays or refusal of the vaccine by the children and adolescents themselvesProfessionals argued that information on changes in the vaccination schedule including priority groups was not passed on even in a newsletter, as is customary and the responsibility of the Municipality of Terenos Health Department.We only hear a lot about children in this age group, so far nothing has come to us from the Health Department about priority groups. (P4)There are several cancers with chemotherapy treatment here, and we didn\u2019t pay attention that these people have to take it, I don\u2019t know if this is still valid. (P5)Because as far as I know, the HPV vaccine is more exclusive for this public of children. (P1)The competent bodies\u2019 precariousness of communication with this area of difficult access was verified. Professionals\u2019 performance in the settlements\u2019 health unit requires appropriate training that makes use of the understanding of the reality experienced by the rural population, covering the local specificity. It is recommended to prioritize the performance of professionals existing in the community, as they bring with them the experiences and paths taken and, therefore, are able to understand the working dynamics of women and men in/of the field, as well as the distance from this territorialization to the access to that service.In the present study, health workers carried out relevant reflections and created perspectives for new attitudes in the health context, such as vaccination, carefulness with users, the problems they experienced as well because they were themselves, for the most part, settlement residents. The conversation circle also allowed elements to be listed in health promotion, such as new rules for the vaccine against HPV, which were added to the knowledge already acquired. Thus, it can be stated that the conversation circle cannot be considered only a form of data collection, but, above all, an educational process with equalization of knowledge and decision making by the participants..The results found reveal the need for a careful analysis of the factors that may have influenced vaccine adherence below the recommended level, with a view to restructuring the strategy of the national vaccination policy for the target population. It has already been shown that intervention practices to increase health professionals\u2019 knowledge about the epidemiology of HPV and its relationship with cancer are essential to increase the rate of recommendation and adherence to the vaccine, and may improve behavior with other immunizations. The training of professionals should encourage their commitment to the objective of guiding public policies aimed at health care for the agrarian reform population. The reality observed in this study can serve as a basis for a better understanding of the reality of other existing settlements in Brazil.Joint action between the education, health and population sectors is necessary for the population to become aware of the importance of immunization against HPVThese policies need to clarify doubts that can lead to distrust and anticipation factors that cause hesitation or vaccine refusal. Equally important, local research is conducted to better understand HPV vaccination hesitancy and other determinants of adoption to inform and shape national policy..Studies that specifically explore educational interventions for health professionals are still limited, but it is known that nurses and family physicians are commonly referred to in qualitative studies as those who most influence decisions about vaccination against HPV. In addition, the influence of family, parents of other children and friends who have not been vaccinated or who recommended the vaccine is also observedThe results found in this population reinforce the need for actions that promote knowledge about HPV and vaccination. The strengthening of the ESF and the permanent and continuous education of professionals, as well as the preparation and distribution of explanatory material to the community, will certainly contribute to increase parents\u2019 confidence in relation to their children\u2019s vaccination. .O c\u00e2ncer cervical \u00e9 correlacionado com a infec\u00e7\u00e3o pelo papilomav\u00edrus humano (HPV), sendo considerado um fator etiol\u00f3gico para o desenvolvimento de neoplasias, com envolvimento, principalmente, dos tipos de alto risco oncog\u00eanico HPV16 e HPV18. No Brasil, o Sistema \u00danico de Sa\u00fade incluiu a vacina contra o HPV no calend\u00e1rio vacinal por interm\u00e9dio do Programa Nacional de Imuniza\u00e7\u00e3o (PNI), no ano de 2014. O programa contempla meninas e meninos de 9 a 14 anos, pacientes vivendo com o v\u00edrus da imunodefici\u00eancia humana (HIV/Aids), transplantados e em quimioterapia e radioterapia com faixa et\u00e1ria de 9 a 26 anos. Recentemente, houve a amplia\u00e7\u00e3o para mulheres de at\u00e9 45 anos e com imunossupress\u00e3o.Um total de 124 pa\u00edses e territ\u00f3rios j\u00e1 havia implementado programas nacionais de imuniza\u00e7\u00e3o para a vacina\u00e7\u00e3o contra o HPV at\u00e9 2019.Desde a implanta\u00e7\u00e3o da vacina quadrivalente contra o HPV na rede de aten\u00e7\u00e3o prim\u00e1ria, o programa tem buscado alcan\u00e7ar a meta m\u00ednima de 80% de cobertura vacinal. Dessa forma, contribui para a redu\u00e7\u00e3o da incid\u00eancia e mortalidade por diferentes tipos de c\u00e2nceres induzidos pelos tipos virais HPV 16, 18, 6 e 11, dentre eles o de colo do \u00fatero, o vulvar, o vaginal, no p\u00eanis e regi\u00e3o anal, de orofaringe, al\u00e9m das verrugas genitais. O Brasil possui 972.289 fam\u00edlias distribu\u00eddas em 9.374 assentamentos, o que corresponde a uma \u00e1rea de 87.978.041,18 hectares, destinadas para assentamentos de reforma agr\u00e1ria. No Estado do Mato Grosso do Sul, 27.764 fam\u00edlias est\u00e3o distribu\u00eddas em 204 assentamentos em diversos munic\u00edpios.Crian\u00e7as e adolescentes residentes em assentamentos devem ter assegurada a vacina\u00e7\u00e3o contra o HPV estabelecida pela Pol\u00edtica Nacional de Sa\u00fade Integral das Popula\u00e7\u00f5es do Campo e da Floresta, que visa atender as necessidades de aten\u00e7\u00e3o \u00e0 sa\u00fade desse p\u00fablico-alvo. Levantamentos preliminares realizados no complexo de assentamentos Santa M\u00f4nica \u2013 Rural II, pertencente ao munic\u00edpio de Terenos, no estado de Mato Grosso do Sul , indicaram que a ades\u00e3o \u00e0 vacina\u00e7\u00e3o contra o HPV para o ano de 2014 n\u00e3o alcan\u00e7ou a meta nacional preconizada pelo Minist\u00e9rio da Sa\u00fade .Em 2014, grande parte dos munic\u00edpios brasileiros atingiu a meta preconizada na primeira dose (87%); entretanto, apenas 32% deles atingiram a meta na segunda doseDiante dessas evid\u00eancias, este trabalho tem o objetivo de compreender a percep\u00e7\u00e3o dos profissionais de sa\u00fade acerca da vacina\u00e7\u00e3o contra o HPV no complexo de assentamentos Santa M\u00f4nica e contribuir com medidas de a\u00e7\u00e3o em sa\u00fade que possam melhorar essa cobertura vacinal, analisando os principais fatores de hesita\u00e7\u00e3o ou recusa vacinal, bem como as estrat\u00e9gias da equipe de sa\u00fade local para imuniza\u00e7\u00e3o contra o papilomav\u00edrus humano.Trata-se de um estudo descritivo-explorat\u00f3rio de natureza quantitativa e qualitativa ocorrido no complexo de assentamentos Santa M\u00f4nica \u2013 Rural II, no munic\u00edpio de Terenos (MS), no per\u00edodo de junho a agosto de 2018.A pesquisa envolveu as tr\u00eas for\u00e7as sociais existentes: Assentamento Carlos Ferrari, organizado por meio da central \u00fanica dos trabalhadores (CUT), com um total de 86 fam\u00edlias; Assentamento Emerson Rodrigues, constitu\u00eddo pelo movimento dos trabalhadores rurais sem terra (MST), com 186 fam\u00edlias; Assentamento da Federa\u00e7\u00e3o dos Trabalhadores da Agricultura (FETAGRI), com um total de 443 fam\u00edlias.Nos 715 lotes disponibilizados para reforma agr\u00e1ria, 599 fam\u00edlias est\u00e3o cadastradas e assistidas pela estrat\u00e9gia de sa\u00fade da fam\u00edlia (ESF), incluindo 1.253 pessoas. Destas, 82 s\u00e3o meninas e 39 s\u00e3o meninos dentro da faixa et\u00e1ria de contempla\u00e7\u00e3o da vacina contra o HPV. Vale ressaltar que a dist\u00e2ncia entre a unidade b\u00e1sica de sa\u00fade fluvial (UBSF) e os lotes pode chegar a 18 quil\u00f4metros.A coleta de dados quantitativos para levantamento da cobertura vacinal ocorreu na pr\u00f3pria unidade de sa\u00fade, por meio dos registros manuais realizados por nove agentes comunit\u00e1rios de sa\u00fade, ap\u00f3s consulta em cart\u00f5es vacinais. Dessa forma, foi poss\u00edvel cobrir toda a \u00e1rea adstrita da ESF no complexo Santa M\u00f4nica \u2013 Rural II, dividida em nove micro\u00e1reas, nomeadas numericamente de 1 a 9.A organiza\u00e7\u00e3o dos dados de cobertura vacinal  se deu por meio da confec\u00e7\u00e3o de planilhas eletr\u00f4nicas em Microsoft Excel.statusvacinal, como VC ; VI  e NV (n\u00e3o vacinados). Os dados tamb\u00e9m foram distribu\u00eddos segundo o sexo e a idade.Foram considerados todos os registros de meninas entre mar\u00e7o de 2014 e mar\u00e7o de 2018. Para os meninos foi considerado o intervalo entre julho de 2017 a mar\u00e7o de 2018. O p\u00fablico-alvo foi classificado, conforme seuOs dados qualitativos sobre a percep\u00e7\u00e3o dos profissionais de sa\u00fade acerca da vacina\u00e7\u00e3o contra o HPV foram obtidos por meio de uma roda de conversa na unidade de sa\u00fade e de registros de observa\u00e7\u00f5es e viv\u00eancias realizadas durante o processo de pesquisa.Dos 18 trabalhadores da unidade de sa\u00fade, 12 (dois homens e dez mulheres) compuseram a roda de conversa, sendo sete agentes comunit\u00e1rios de sa\u00fade, um enfermeiro, uma m\u00e9dica, um odont\u00f3logo, um auxiliar de odontologia e um atendente de farm\u00e1cia. Oito profissionais eram moradores no assentamento e quatro moravam em outros locais. Para fins de registro e demonstra\u00e7\u00e3o dos resultados, os profissionais foram identificados pela letra P seguida de uma representa\u00e7\u00e3o num\u00e9rica (P1 a P12).As quest\u00f5es geradoras para a roda de conversa foram: 1) como a equipe se organiza para atingir a cobertura vacinal? 2) que dificuldades a equipe enfrenta para atingir as metas? 3) o que poderia facilitar o atingimento das metas? 4) como percebem a rela\u00e7\u00e3o da comunidade com a vacina\u00e7\u00e3o? E com a vacina do HPV? e 5) que faixa et\u00e1ria tem maior e menor regularidade na vacina\u00e7\u00e3o do HPV? Por que acreditam que isso ocorra? Tais quest\u00f5es tiveram como objetivo a troca de experi\u00eancias e aprendizados e a conscientiza\u00e7\u00e3o dos problemas enfrentados cotidianamente.A roda de conversa, com dura\u00e7\u00e3o de aproximadamente uma hora, foi gravada. Al\u00e9m disso, pediu-se a autoriza\u00e7\u00e3o e a assinatura do termo de consentimento livre e esclarecido aos participantes. Ap\u00f3s o encerramento \u201cformal\u201d da roda de conversa, percebeu-se que os participantes continuaram debatendo o assunto durante a merenda coletiva, momento em que foram realizados os registros das observa\u00e7\u00f5es e fatos vivenciados relacionados ao tema da pesquisa.A pesquisa teve aprova\u00e7\u00e3o do Comit\u00ea de \u00c9tica em Pesquisa da Universidade Federal de Mato Grosso do Sul com parecer de aprova\u00e7\u00e3o n\u00ba 2.685.410, em 30 de maio de 2018.. Tamb\u00e9m s\u00e3o superiores aos encontrados no Brasil, que n\u00e3o ultrapassaram 45,1% entre meninas de 9 a 15 anos.Levando em conta que os resultados expressados em porcentagens foram obtidos por meio do quociente entre o n\u00famero de crian\u00e7as de cada sexo e o n\u00famero total de crian\u00e7as moradoras da(s) micro\u00e1rea(s) analisada(s), foi observado que, das 121 crian\u00e7as e adolescentes participantes da pesquisa, 81  receberam o esquema vacinal completo (primeira e segunda dose). A cobertura vacinal completa feminina foi de 73,17% (60/82), superior \u00e0 masculina, com 53,8% (21/39). Esses resultados s\u00e3o superiores aos de Mato Grosso do Sul, que atingiram 51,1% entre meninas e 46,7% entre meninosAAo observar a distribui\u00e7\u00e3o da cobertura vacinal completa (1\u00aa e 2\u00aa doses) da popula\u00e7\u00e3o-alvo do estudo por idade segundo o sexo, observa-se que n\u00e3o houve ades\u00e3o vacinal no primeiro ano para ambos os sexos, aumentando gradativamente conforme a idade. No entanto, a ades\u00e3o vacinal decresceu em ambos os sexos no \u00faltimo ano de contempla\u00e7\u00e3o da vacina ., enquanto outros estudos descobriram que a vacina\u00e7\u00e3o contra o HPV n\u00e3o est\u00e1 associada \u00e0 idade da primeira rela\u00e7\u00e3o sexual ou ao n\u00famero de parceiros sexuais.Diversos motivos para hesita\u00e7\u00e3o ou recusa \u00e0 vacina foram apontados por pais e respons\u00e1veis . A hesi. Neste estudo, alguns pais relataram aos profissionais suas dificuldades em falar sobre a vacina\u00e7\u00e3o contra o HPV com meninas t\u00e3o jovens. Entretanto, relataram que a inclus\u00e3o dos meninos como p\u00fablico-alvo facilitou a abordagem das crian\u00e7as e adolescentes acerca da vacina. Tal constata\u00e7\u00e3o refor\u00e7a a necessidade de mudan\u00e7a de paradigmas e rompimento de tabus familiares.O fato de a vacina ser exclusiva para preven\u00e7\u00e3o prim\u00e1ria de uma infec\u00e7\u00e3o sexualmente transmiss\u00edvel tamb\u00e9m influencia na sua aceita\u00e7\u00e3o.Em uma an\u00e1lise qualitativa, foi observado que menos de 10% dos provedores de conhecimento sabiam que a vacina\u00e7\u00e3o contra o HPV oferecia alguma preven\u00e7\u00e3o ao c\u00e2ncer e benef\u00edcios para os homens. Dessa forma, a vacina foi pouco ofertada aos meninos, o que pode justificar as menores coberturas vacinais encontradas neste estudoRelatos de m\u00e3es aos profissionais de sa\u00fade do Assentamento Santa M\u00f4nica refor\u00e7aram a import\u00e2ncia da reoferta da vacina meningoc\u00f3cica C na mesma faixa et\u00e1ria da vacina contra o HPV para meninos, assim como a amplia\u00e7\u00e3o da faixa et\u00e1ria para ambos os sexos, a fim de expandir o n\u00famero de indiv\u00edduos vacinados contra o HPV.. O d\u00e9ficit de conhecimento das mulheres, em zonas rurais, sobre a forma de transmiss\u00e3o do HPV e cuidados para a preven\u00e7\u00e3o tamb\u00e9m podem justificar a ades\u00e3o abaixo da meta.Em geral, a ades\u00e3o vacinal da popula\u00e7\u00e3o deste estudo demonstrou-se abaixo da meta preconizada (80%), necessitando, portanto, de medidas que promovam a ades\u00e3o \u00e0 vacina contra o HPV. As diferentes realidades encontradas entre as microrregi\u00f5es podem refletir diferen\u00e7as no envolvimento tanto da popula\u00e7\u00e3o quanto dos profissionais com a ades\u00e3o e administra\u00e7\u00e3o da vacina. A baixa ades\u00e3o em duas micro\u00e1reas (1 e 9) pode ser justificada, em parte, por se localizarem a mais de 15 quil\u00f4metros de dist\u00e2ncia da unidade de sa\u00fade. A heterogeneidade espacial entre microrregi\u00f5es pode ser uma das raz\u00f5es para as diferen\u00e7as na cobertura vacinal, o que indica que gestores devem planejar estrat\u00e9gias espec\u00edficas para cada territ\u00f3rio.Os motivos de recusa ou hesita\u00e7\u00e3o encontrados neste estudo s\u00e3o concordantes com quest\u00f5es-chave relatadas anteriormente, como preocupa\u00e7\u00f5es quanto \u00e0 efic\u00e1cia, seguran\u00e7a e poss\u00edveis efeitos adversos das vacinas, desinforma\u00e7\u00e3o sobre as doen\u00e7as relacionadas por parte da popula\u00e7\u00e3o alvo, pais e profissionais de sa\u00fade, influ\u00eancia negativa da comunidade e falta de confian\u00e7a nas autoridades e empresas farmac\u00eauticasSAGE Working Group on Vaccine Hesitancy. Ressalta-se que a hesita\u00e7\u00e3o em vacinar nem sempre implica na recusa da vacina, uma vez que indiv\u00edduos hesitantes podem aceitar certas vacinas, mas ainda t\u00eam d\u00favidas sobre elas.Desde 2012, a Organiza\u00e7\u00e3o Mundial de Sa\u00fade tem trabalhado para minimizar o atraso na aceita\u00e7\u00e3o ou recusa da vacina\u00e7\u00e3o a despeito da disponibilidade de servi\u00e7os de vacinas, por meio do grupo. Neste estudo foi poss\u00edvel observar que a influ\u00eancia negativa da m\u00eddia, ao circular informa\u00e7\u00f5es equivocadas sobre a vacina contra o HPV e seus efeitos adversos/colaterais, fez com que muitos pais proibissem seus filhos de serem vacinados.O medo sobre poss\u00edveis efeitos colaterais da vacina tamb\u00e9m se mostra relevantefacebook, porque eles postam desmaiando, passando mal, pegam doen\u00e7as, da\u00ed d\u00e1 a infeliz coincid\u00eancia de tomar a vacina e d\u00e1 um outro tipo de problema que n\u00e3o tem nada a ver, da\u00ed eles falam que \u00e9 da vacina. (P2)Outra quest\u00e3o que dificultou foi o tal do.Esse fato tamb\u00e9m justifica o menor percentual de indiv\u00edduos vacinados com esquema completo nas micro\u00e1reas 1 e 9, bem como as diferen\u00e7as de cobertura vacinal entre a primeira e a segunda dose.As cren\u00e7as de que os governos ret\u00eam informa\u00e7\u00f5es sobre efeitos colaterais j\u00e1 foram relatadas em alguns estudos qualitativos, o que influencia negativamente nas campanhas que o Minist\u00e9rio da Sa\u00fade faz para promover a vacina contra o HPV.Observa-se que as estrat\u00e9gias de promo\u00e7\u00e3o \u00e0 vacina t\u00eam sofrido modifica\u00e7\u00f5es ao longo dos anos, ap\u00f3s consequ\u00eancias negativas geradas pela comunica\u00e7\u00e3o refrat\u00e1ria do governo frente a uma s\u00e9rie de d\u00favidas relacionadas \u00e0 seguran\u00e7a ou conveni\u00eancia da vacina durante a primeira fase de implanta\u00e7\u00e3o. A inclus\u00e3o das comunidades religiosas, profissionais de sa\u00fade, fam\u00edlias e adolescentes como interlocutores relevantes, antes e durante a execu\u00e7\u00e3o da primeira campanha de vacina\u00e7\u00e3o, poderia ter contribu\u00eddo para melhores resultados de ades\u00e3o vacinal.Atualmente, o acesso \u00e0s m\u00eddias sociais se faz presente em todas as faixas de escolaridade e n\u00edvel socioecon\u00f4mico, inclusive na popula\u00e7\u00e3o dos assentamentos, o que pode favorecer a dissemina\u00e7\u00e3o de informa\u00e7\u00f5es sobre a import\u00e2ncia da vacina contra o HPV. Em contrapartida, a veicula\u00e7\u00e3o de informa\u00e7\u00f5es falsas prejudica a ades\u00e3o \u00e0 vacina\u00e7\u00e3o.A cren\u00e7a em um baixo risco de contrair HPV ou desenvolver o c\u00e2ncer cervical correlacionado com a disponibilidade de supostos m\u00e9todos alternativos tamb\u00e9m foi apontada como motivo para falta de necessidade da vacina contra o HPV, o que pode justificar, em parte, a ades\u00e3o \u00e0 vacina abaixo do preconizado.O medo da dor que a vacina pode causar nos adolescentes foi relatado por pais e respons\u00e1veis em estudos qualitativos, assim como o medo do tamanho das agulhas e a dor durante a inje\u00e7\u00e3o, que supostamente aumenta a cada dose da vacina. Ainda, a cren\u00e7a equivocada que a vacina seja administrada no colo do \u00fatero, preocupa\u00e7\u00f5es com a limpeza da agulha e o medo de que a inje\u00e7\u00e3o possa levar \u00e0 perda da virgindade tamb\u00e9m foram quest\u00f5es relatadas.Embora os desafios log\u00edsticos em unidades de sa\u00fade tamb\u00e9m criem barreiras no acesso \u00e0s vacinas em diversos locais, no presente estudo essa dificuldade n\u00e3o foi observada. As unidades de sa\u00fade dispunham de doses suficientes para atender a todo o p\u00fablico-alvo local e as quest\u00f5es log\u00edsticas n\u00e3o justificam o atraso na vacina\u00e7\u00e3o ou baixa ades\u00e3ostatusvacinal das crian\u00e7as e adolescentes.Outro argumento relatado pelos pais e profissionais para a n\u00e3o ades\u00e3o \u00e0 vacina foi a exig\u00eancia da Secretaria Municipal de Sa\u00fade de que se apresentasse o cart\u00e3o do SUS de Terenos, munic\u00edpio de resid\u00eancia, no ato de vacinar. Os principais motivos apontados para a dificuldade em adquirir ou portar o cart\u00e3o do SUS foram os custos de transporte, o tempo e a dist\u00e2ncia at\u00e9 a unidade para solicitar o cart\u00e3o e, ainda, o seu esquecimento no dia da vacina\u00e7\u00e3o. O extravio dos cart\u00f5es tamb\u00e9m dificultou o conhecimento do.Muitas crian\u00e7as e adolescentes possu\u00edam o cart\u00e3o SUS do munic\u00edpio de Campo Grande (MS) o que impossibilitava a vacina\u00e7\u00e3o no assentamento Santa M\u00f4nica, j\u00e1 que, para o indiv\u00edduo assentado ter acesso \u00e0 vacina, deveria portar o cart\u00e3o de Terenos. Embora o SUS tenha como princ\u00edpio a universalidade quando se trata do atendimento de urg\u00eancia, os procedimentos ambulatoriais devem ser regulados pelo sistema municipal de refer\u00eancia; por isso, as vacinas devem ser administradas, em sua grande maioria, no munic\u00edpio de resid\u00eanciaIntegrantes da comunidade do assentamento Santa M\u00f4nica mencionaram muitas vezes que n\u00e3o transferem o cart\u00e3o SUS para o munic\u00edpio de Terenos, onde juridicamente residem, pelo fato de que praticamente todos os servi\u00e7os especializados s\u00e3o realizados em Campo Grande, capital de Mato Grosso do Sul, e que o trajeto mais vi\u00e1vel do assentamento at\u00e9 a cidade de Terenos passa pela capital.Neste estudo, os profissionais justificaram o benef\u00edcio das a\u00e7\u00f5es volantes, apontando limita\u00e7\u00f5es para a maior efic\u00e1cia dessa estrat\u00e9gia que incluem a necessidade de mais ve\u00edculos e profissionais dispon\u00edveis.O volante, as campanhas nas micro\u00e1reas, nas escolas, que chegam mais perto da popula\u00e7\u00e3o. Infelizmente o brasileiro, vai deixando, vai deixando. Quando voc\u00ea fala: \u201ctal dia vai estar vacinando, e a gente vai estar s\u00f3 pra isso, voc\u00ea vai chegar e vacinar \u2018rapid\u00e3o\u2019 e j\u00e1 vai embora\u201d, da\u00ed as pessoas se preocupam mais. (P-8)A disponibilidade exclusiva dos profissionais e a agilidade dos sistemas volantes estimulam a ades\u00e3o \u00e0 vacina\u00e7\u00e3o, ao contr\u00e1rio do atendimento nas unidades de sa\u00fade com poucos profissionais, em que cada um deles exerce v\u00e1rias atribui\u00e7\u00f5es, resultando em maior tempo de espera no atendimento e, consequentemente, em maior resist\u00eancia da fam\u00edlia a procurar a vacina..Por outro lado, a busca ativa do p\u00fablico-alvo nem sempre aumenta a ades\u00e3o \u00e0 vacina\u00e7\u00e3o, como observado em estudo realizado na \u00c1frica do Sul, onde n\u00e3o foi atingida a ades\u00e3o esperada, mesmo com a introdu\u00e7\u00e3o de um programa de vacina\u00e7\u00e3o contra o HPV nas escolas, em 2014. Uma poss\u00edvel justificativa para esse resultado \u00e9 a hesita\u00e7\u00e3o dos pais, fato capaz de gerar atrasos ou recusa \u00e0 vacina por parte das pr\u00f3prias crian\u00e7as e adolescentesOs profissionais argumentaram que as informa\u00e7\u00f5es das mudan\u00e7as no calend\u00e1rio vacinal com inclus\u00e3o de grupos priorit\u00e1rios n\u00e3o foram repassadas nem mesmo em boletim, como \u00e9 de costume e de responsabilidade da Secretaria de Sa\u00fade do Munic\u00edpio de Terenos.A gente s\u00f3 ouve falar muito das crian\u00e7as na faixa et\u00e1ria, at\u00e9 ent\u00e3o n\u00e3o chegou nada da Secretaria de Sa\u00fade pra n\u00f3s sobre grupos priorit\u00e1rios. (P4)Aqui tem v\u00e1rios c\u00e2nceres com tratamento quimioter\u00e1pico, e a gente n\u00e3o se atentou que estas pessoas t\u00eam que tomar, n\u00e3o sei se isso ainda est\u00e1 valendo. (P5)Porque at\u00e9 onde eu sei a vacina do HPV \u00e9 mais exclusiva pra este p\u00fablico de crian\u00e7as. (P1)Foi constatada a precariedade da comunica\u00e7\u00e3o dos \u00f3rg\u00e3os competentes a essa \u00e1rea de dif\u00edcil acesso. A atua\u00e7\u00e3o dos profissionais na unidade de sa\u00fade dos assentamentos requer uma forma\u00e7\u00e3o apropriada que instrumentalize a compreens\u00e3o da realidade vivenciada pela popula\u00e7\u00e3o do campo contemplando a especificidade local. Recomenda-se priorizar a atua\u00e7\u00e3o dos profissionais existentes na comunidade, pois estes trazem consigo as experi\u00eancias e trajet\u00f3rias vivenciadas e, portanto, s\u00e3o capazes de compreender a din\u00e2mica do trabalho da mulher e homem no/do campo, bem como a dist\u00e2ncia dessa territorializa\u00e7\u00e3o para o acesso a esse servi\u00e7o.No presente estudo, os trabalhadores em sa\u00fade realizaram reflex\u00f5es pertinentes e criaram perspectivas para novas atitudes inseridas no contexto da sa\u00fade, como a vacina\u00e7\u00e3o, o cuidado com os usu\u00e1rios, os pr\u00f3prios problemas tamb\u00e9m vivenciados por serem, em sua maioria, moradores de assentamento. A roda de conversa permitiu tamb\u00e9m que fossem elencados elementos na promo\u00e7\u00e3o da sa\u00fade, como novas regras da vacina contra o HPV, que se somaram ao conhecimento j\u00e1 adquirido. Dessa forma, pode-se afirmar que a roda de conversa n\u00e3o pode ser considerada somente uma forma de coleta de dados, mas, sobretudo, um processo educativo com equaliza\u00e7\u00e3o de conhecimentos e tomadas de decis\u00e3o pelos participantes..Os resultados encontrados revelam a necessidade de uma an\u00e1lise criteriosa dos fatores que podem ter influenciado para a ades\u00e3o vacinal abaixo do recomendado com vistas a uma reestrutura\u00e7\u00e3o da estrat\u00e9gia da pol\u00edtica nacional de vacina\u00e7\u00e3o para a popula\u00e7\u00e3o alvo. J\u00e1 foi demonstrado que pr\u00e1ticas de interven\u00e7\u00e3o para aumentar o conhecimento dos profissionais de sa\u00fade sobre a epidemiologia do HPV e sua rela\u00e7\u00e3o com o c\u00e2ncer s\u00e3o essenciais para aumentar a taxa de recomenda\u00e7\u00e3o e ades\u00e3o \u00e0 vacina, podendo melhorar o comportamento com outras imuniza\u00e7\u00f5es. A forma\u00e7\u00e3o dos profissionais deve instigar seu comprometimento com o objetivo de pautar pol\u00edticas p\u00fablicas voltadas para a assist\u00eancia \u00e0 sa\u00fade da popula\u00e7\u00e3o da reforma agr\u00e1ria. A realidade observada neste estudo pode servir de base para o melhor entendimento da realidade de outros assentamentos existentes no Brasil.A a\u00e7\u00e3o conjunta entre os setores de educa\u00e7\u00e3o, sa\u00fade e popula\u00e7\u00e3o \u00e9 necess\u00e1ria para que a popula\u00e7\u00e3o se conscientize sobre a import\u00e2ncia da imuniza\u00e7\u00e3o contra o HPVEssas pol\u00edticas precisam esclarecer as d\u00favidas que podem levar \u00e0 desconfian\u00e7a e a fatores de antecipa\u00e7\u00e3o que causam hesita\u00e7\u00e3o ou recusa vacinal. Igualmente importante \u00e9 que a pesquisa local seja conduzida para entender melhor a hesita\u00e7\u00e3o na vacina\u00e7\u00e3o contra o HPV e outros determinantes da ado\u00e7\u00e3o para informar e moldar pol\u00edticas nacionais..Estudos que exploram especificamente as interven\u00e7\u00f5es educacionais para profissionais de sa\u00fade ainda s\u00e3o limitados, mas sabe-se que enfermeiros e m\u00e9dicos de fam\u00edlia s\u00e3o comumente referidos em estudos qualitativos como os que mais influenciam nas decis\u00f5es de vacina\u00e7\u00e3o contra o HPV. Al\u00e9m disso, observa-se tamb\u00e9m a influ\u00eancia da fam\u00edlia, pais de outras crian\u00e7as e amigos que n\u00e3o vacinaram ou que recomendaram a vacinaOs resultados encontrados nessa popula\u00e7\u00e3o refor\u00e7am a necessidade de a\u00e7\u00f5es que promovam o conhecimento sobre o HPV e a vacina\u00e7\u00e3o. O fortalecimento da ESF e a educa\u00e7\u00e3o permanente e continuada dos profissionais, bem como a confec\u00e7\u00e3o e distribui\u00e7\u00e3o de material explicativo \u00e0 comunidade, certamente contribuir\u00e3o para aumentar a confian\u00e7a dos pais em rela\u00e7\u00e3o \u00e0 vacina\u00e7\u00e3o de seus filhos."}
+{"text": "Este trabalho objetivou caracterizar interna\u00e7\u00f5es de residentes no Paran\u00e1, Brasil,ocorridas no per\u00edodo neonatal em munic\u00edpio diferente do de resid\u00eancia, entre2008 e 2019, e descrever redes de deslocamento para o primeiro e o \u00faltimo bi\u00eanioda s\u00e9rie, correspondentes aos per\u00edodos anterior e posterior a iniciativas deregionaliza\u00e7\u00e3o dos servi\u00e7os de sa\u00fade no estado. Dados sobre interna\u00e7\u00f5es decrian\u00e7as com idade entre 0 e 27 dias foram obtidos por meio do Sistema deInforma\u00e7\u00f5es Hospitalares do Sistema \u00danico de Sa\u00fade (SIH-SUS). Para cada bi\u00eanio eregional de sa\u00fade, foram calculados a propor\u00e7\u00e3o de interna\u00e7\u00f5es ocorridas fora domunic\u00edpio de resid\u00eancia, a dist\u00e2ncia m\u00e9dia ponderada pelo fluxo dosdeslocamentos, bem como indicadores de sa\u00fade e de oferta de servi\u00e7os. Modelosmistos foram ajustados para avaliar a tend\u00eancia bianual dos indicadores e paraverificar fatores associados \u00e0 taxa de mortalidade neonatal (TMN). No total,76.438 interna\u00e7\u00f5es foram selecionadas, variando de 9.030, em 2008-2009, a17.076, em 2018-2019. A compara\u00e7\u00e3o entre as redes obtidas para 2008-2009 e asexistentes em 2018-2019 evidenciou aumento no n\u00famero de destinos frequentes e napropor\u00e7\u00e3o de deslocamentos dentro da mesma regional de sa\u00fade. Observou-setend\u00eancia decrescente para a dist\u00e2ncia, para a propor\u00e7\u00e3o de nascidos vivos comApgar no quinto minuto \u2264 7 e para a TMN. Na an\u00e1lise ajustada para a TMN, al\u00e9m doefeito de bi\u00eanio , apenas a propor\u00e7\u00e3o de nascidosvivos com idade gestacional inferior a 28 semanas apresentou signific\u00e2nciaestat\u00edstica . A demanda por assist\u00eancia hospitalar noper\u00edodo neonatal aumentou ao longo do per\u00edodo estudado. As redes de deslocamentosugerem impacto positivo da regionaliza\u00e7\u00e3o, embora o investimento em regi\u00f5es compotencial para se tornarem polos assistenciais seja necess\u00e1rio. Nas \u00faltimas tr\u00eas d\u00e9cadas, o Brasil vivenciou um processo de redu\u00e7\u00e3o das desigualdadessocioecon\u00f4micas, universaliza\u00e7\u00e3o do acesso aos servi\u00e7os de sa\u00fade e promo\u00e7\u00e3o depol\u00edticas p\u00fablicas estrat\u00e9gicas na \u00e1rea de sa\u00fade materno-infantil. Esse cen\u00e1rioimplicou mudan\u00e7as no perfil social e reprodutivo das mulheres e nos fatores de riscopara a mortalidade infantil, resultando em decl\u00ednio de \u00f3bitos no per\u00edodop\u00f3s-neonatal (entre 28 e 365 dias de vida) Por outro lado, novos desafios ganharam evid\u00eancia, em especial os relacionados \u00e0demanda por assist\u00eancia a mulheres com gesta\u00e7\u00e3o de alto risco e a rec\u00e9m-nascidos comcondi\u00e7\u00f5es marcadoras de morbidade neonatal grave, como a prematuridade e a asfixiaao nascer ,,,Atualmente, a mortalidade neonatal, correspondente ao \u00f3bito de nascidos vivos entre 0e 27 dias de vida, \u00e9 o principal componente do indicador de mortalidade infantil,apresentando, para o Brasil, taxa m\u00e9dia de 9,46 \u00f3bitos a cada 1.000 nascidos vivosno per\u00edodo de 2007 a 2017 Esta pesquisa objetivou caracterizar interna\u00e7\u00f5es de residentes no Paran\u00e1, Brasil,ocorridas no per\u00edodo neonatal em munic\u00edpio diferente do de resid\u00eancia, entre 2008 e2019, bem como indicadores de sa\u00fade materno-infantil e de oferta de servi\u00e7osrelacionados \u00e0 assist\u00eancia aos rec\u00e9m-nascidos no per\u00edodo neonatal segundo regionaisde sa\u00fade. Buscou-se, ainda, descrever redes de deslocamento para o primeiro e o\u00faltimo bi\u00eanio da s\u00e9rie, correspondentes aos per\u00edodos anterior e posterior ainiciativas de regionaliza\u00e7\u00e3o dos servi\u00e7os de sa\u00fade no estado.Este estudo ecol\u00f3gico, com perspectiva espa\u00e7otemporal, analisou dados de interna\u00e7\u00f5esde rec\u00e9m-nascidos residentes no Estado do Paran\u00e1, ocorridas durante o per\u00edodoneonatal (at\u00e9 o 27\u00ba dia de vida) em munic\u00edpio diferente do de resid\u00eancia da m\u00e3e.Para o per\u00edodo de 2008 a 2019, as informa\u00e7\u00f5es foram obtidas por meio do Sistema deInforma\u00e7\u00f5es Hospitalares do Sistema \u00danico de Sa\u00fade (SIH-SUS), do Sistema deInforma\u00e7\u00f5es sobre Mortalidade (SIM) e do Sistema de Informa\u00e7\u00f5es sobre Nascidos Vivos(SINASC), dispon\u00edveis na Plataforma de Ci\u00eancia de Dados Aplicada \u00e0 Sa\u00fade da Funda\u00e7\u00e3oOswaldo Cruz (PCDaS/Fiocruz) e no Departamento de Inform\u00e1tica do Sistema \u00danico deSa\u00fade (DATASUS). Dados sobre leitos de unidade de terapia intensiva (UTI) neonatal foram coletados no Cadastro Nacional de Estabelecimentosde Sa\u00fade (CNES).Portaria n\u00ba 1.459/2011) Os dados foram agrupados em bi\u00eanios, considerando tr\u00eas momentos distintos:pr\u00e9-implanta\u00e7\u00e3o da Rede de Aten\u00e7\u00e3o \u00e0 Sa\u00fade Materno-Infantil no Paran\u00e1 (2008-2009 e2010-2011); implanta\u00e7\u00e3o do Programa Rede M\u00e3e Paranaense (2012-2013 e 2014-2015),assumido como compromisso do Plano de Governo para a Sa\u00fade no quadri\u00eanio 2012-2014,ap\u00f3s institui\u00e7\u00e3o da Rede Cegonha no \u00e2mbito do Sistema \u00danico de Sa\u00fade(mj ) observada para os munic\u00edpios-origem (Oi ) localizados em uma mesma regional de sa\u00fade, ponderada por seu fluxo desa\u00edda (Fi ), conforme express\u00e3o apresentada a seguir:A partir de informa\u00e7\u00f5es obtidas no SIH-SUS, cada par distinto entre local deresid\u00eancia (origem) e de ocorr\u00eancia da interna\u00e7\u00e3o do rec\u00e9m-nascido no per\u00edodoneonatal (destino) representou um deslocamento. Os deslocamentos foram agrupadossegundo regional de sa\u00fade e bi\u00eanio e caracterizados pelas seguintes m\u00e9tricas: (a)propor\u00e7\u00e3o de interna\u00e7\u00f5es ocorridas em munic\u00edpio diferente do de resid\u00eancia; (b)propor\u00e7\u00e3o de interna\u00e7\u00f5es ocorridas fora do munic\u00edpio de resid\u00eancia, por\u00e9m na mesmaregional de sa\u00fade; (c) m\u00e9dia da aresta de sa\u00edda m\u00e9dia , i= 1, 2, \u2026, nj ; e di : aresta de sa\u00edda m\u00e9dia, correspondente \u00e0 dist\u00e2ncia m\u00e9dia identificada entreOi e seus k munic\u00edpios-destino (Dk ), ponderada pela frequ\u00eancia de interna\u00e7\u00f5es (fk ) ocorridas em Dk , k= 1, 2, \u2026, K:Tal que, Al\u00e9m dessas m\u00e9tricas, foram tamb\u00e9m calculados por regional de sa\u00fade e bi\u00eanio: (d)n\u00famero de leitos de UTI neonatal a cada 1.000 nascidos vivos; e (e) indicadores desa\u00fade materno-infantil - propor\u00e7\u00e3o de nascidos vivos com peso < 1.500g, com idadegestacional inferior a 28 semanas ou com Apgar no quinto minuto de vida \u2264 7,propor\u00e7\u00e3o de m\u00e3es com 35 anos ou mais e TMN.Para o primeiro (2008-2009) e o \u00faltimo bi\u00eanio (2018-2019) do per\u00edodo estudado, redesde deslocamento foram inferidas utilizando grafos definidos por n\u00f3s e arestas. Cadan\u00f3 representa a localiza\u00e7\u00e3o espacial da sede do munic\u00edpio e cada aresta indica umdeslocamento. Os n\u00f3s apresentam tamanho proporcional ao grau de entrada, que temcomo refer\u00eancia o munic\u00edpio de ocorr\u00eancia da interna\u00e7\u00e3o (destino) e quantifica on\u00famero de munic\u00edpios atendidos em determinado destino. Al\u00e9m dessa m\u00e9trica,calculou-se tamb\u00e9m para compara\u00e7\u00e3o dos principais destinos o fluxo de entrada,correspondente ao n\u00famero de interna\u00e7\u00f5es ocorridas em munic\u00edpios diferentes dos deorigem dos indiv\u00edduos. As arestas, por sua vez, s\u00e3o proporcionais ao fluxo de sa\u00edda,que tem como refer\u00eancia o munic\u00edpio de resid\u00eancia da m\u00e3e (origem) e quantifica on\u00famero de interna\u00e7\u00f5es de dada origem ocorridas em determinado destino A) 2008-2009 e (B) 2018-2019,medidas de varia\u00e7\u00e3o percentual, [(B -A)/A]*100, foram calculadas tantopara comparar caracter\u00edsticas dos principais destinos (grau e fluxo de entrada) comopara comparar a dist\u00e2ncia m\u00e9dia ponderada, a propor\u00e7\u00e3o de interna\u00e7\u00f5es ocorridas emmunic\u00edpio diferente do de resid\u00eancia e a de interna\u00e7\u00f5es ocorridas em munic\u00edpios damesma regional de sa\u00fade.Para os bi\u00eanios (http://www.r-project.org), e o mapeamento das redes foi feito com oprograma Gephi . O c\u00f3digo em R e os bancos dedados est\u00e3o dispon\u00edveis em: https://github.com/Hellengeremias/RedeNeoPR.Por fim, considerando todos os bi\u00eanios entre 2008 e 2019, realizou-se an\u00e1lise deregress\u00e3o linear simples com intercepto aleat\u00f3rio (modelo misto) Entre 2008 e 2019, foram selecionadas 76.438 interna\u00e7\u00f5es ocorridas no per\u00edodoneonatal em munic\u00edpio diferente do de resid\u00eancia da m\u00e3e. A frequ\u00eancia de interna\u00e7\u00f5esde residentes no Paran\u00e1 em outros estados brasileiros representou aproximadamente 1%desse total. Para as interna\u00e7\u00f5es que ocorreram no Paran\u00e1, a an\u00e1lise por bi\u00eaniosrevelou um aumento progressivo no n\u00famero de interna\u00e7\u00f5es (fluxo de sa\u00edda), que passoude 9.030, em 2008-2009, para 17.076, em 2018-2019, representando 34,67% e 42,52% dototal de interna\u00e7\u00f5es de crian\u00e7as com at\u00e9 27 dias de vida ocorridas no estado.Dos deslocamentos que aconteceram no Paran\u00e1, observaram-se 2.539 pares origem-destinodistintos e dist\u00e2ncia m\u00e9dia, ponderada pelo fluxo de cada deslocamento, de 50,56km.A Na A an\u00e1lise dos munic\u00edpios-origem agrupados por bi\u00eanio e regional de sa\u00fade indicadiscreta redu\u00e7\u00e3o na medida de dist\u00e2ncia entre 2008-2009 e 2018-2019. Das 22regionais de sa\u00fade do estado, 15 apresentaram VP negativa para a dist\u00e2ncia m\u00e9diaponderada pelo fluxo de sa\u00edda, com destaque para a 19\u00aa regional de sa\u00fade, que mostrou redu\u00e7\u00e3o de 123,18km para 59,86km . Por outro lado, a 21\u00aa regional de sa\u00fade  exibiu aumento de 101,62km para 137,49km  entre o primeiro e o\u00faltimo bi\u00eanio da s\u00e9rie estudada. No bi\u00eanio recente, a 20\u00aa regional de sa\u00fade  tamb\u00e9m apresentou medida de dist\u00e2ncia superior a 100km entreorigem-destino .Com rela\u00e7\u00e3o \u00e0 propor\u00e7\u00e3o de interna\u00e7\u00f5es ocorridas fora do munic\u00edpio de resid\u00eancia,observa-se, em geral, um aumento na compara\u00e7\u00e3o entre o primeiro e o \u00faltimo bi\u00eanioestudado, com destaque para a 21\u00aa regional de sa\u00fade , que, al\u00e9m de dist\u00e2ncia superior a 100km, apresentou, no bi\u00eanio recente,77,97% das interna\u00e7\u00f5es no per\u00edodo neonatal em munic\u00edpio diferente do de resid\u00eanciada m\u00e3e. Vale destacar que, embora a frequ\u00eancia de interna\u00e7\u00f5es ocorridas fora domunic\u00edpio de resid\u00eancia tenha aumentado, identificou-se maior concentra\u00e7\u00e3o dedeslocamentos dentro da mesma regional de sa\u00fade no bi\u00eanio recente: em 18 das 22regionais de sa\u00fade houve deslocamentos predominantemente intrarregionais.Em 2008-2009, 14 regional de sa\u00fade apresentaram esse perfil .No per\u00edodo recente, ainda h\u00e1 deslocamentos frequentes para outras regionais de sa\u00fade.Na macrorregi\u00e3o leste, as regionais de sa\u00fade 1\u00aa (Paranagu\u00e1), 3\u00aa (Ponta Grossa) e 21\u00aa(Tel\u00eamaco Borba) t\u00eam como principal destino a 2\u00aa regional de sa\u00fade (Metropolitana),com frequ\u00eancias de, respectivamente, 44,7%, 69,8% e 72,8%. Na macrorregi\u00e3o noroeste,destaca-se a 13\u00aa regional de sa\u00fade (Cianorte), com frequ\u00eancia de deslocamento paraoutras regionais de sa\u00fade de 38%, predominando como destinos as regionais de sa\u00fade12\u00aa (Umuarama) e 15\u00aa (Maring\u00e1), com frequ\u00eancias de 14,2% e 11,8%,respectivamente.A TMN para o Estado do Paran\u00e1 variou de 8,98 \u00f3bitos/1.000 nascidos vivos, em2008-2009, a 7,44 \u00f3bitos/1.000 nascidos vivos, em 2018-2019. A A an\u00e1lise de regress\u00e3o linear m\u00faltipla com intercepto aleat\u00f3rio que considerou a TMNcomo resposta de interesse evidenciObservou-se aumento na frequ\u00eancia de interna\u00e7\u00f5es de crian\u00e7as com at\u00e9 27 dias de vidaocorridas fora do munic\u00edpio de resid\u00eancia entre 2008 e 2019, por\u00e9m com maiorconcentra\u00e7\u00e3o de deslocamentos dentro da mesma regional de sa\u00fade em anos recentes. Asredes de deslocamento obtidas para os bi\u00eanios 2008-2009 e 2018-2019 revelaram que osprincipais destinos para interna\u00e7\u00e3o no per\u00edodo neonatal foram representados pormunic\u00edpios-sede das regionais de sa\u00fade, embora no bi\u00eanio mais recente outrosmunic\u00edpios tenham ganhado protagonismo como destinos frequentes. A 21\u00aa regional desa\u00fade (Tel\u00eamaco Borba) destacou-se tanto pela frequ\u00eancia elevada de interna\u00e7\u00f5esocorridas fora do munic\u00edpio de resid\u00eancia como pela maior dist\u00e2ncia entreorigem-destino. Embora, individualmente, a TMN e a dist\u00e2ncia m\u00e9dia ponderada tenhamapresentado tend\u00eancia decrescente no per\u00edodo estudado, a an\u00e1lise de regress\u00e3o linearcom intercepto aleat\u00f3rio n\u00e3o indicou associa\u00e7\u00e3o entre essas vari\u00e1veis. Apenas apropor\u00e7\u00e3o de nascidos vivos com idade gestacional inferior a 28 semanas permaneceuassociada \u00e0 TMN ap\u00f3s ajuste para as demais covari\u00e1veis.A partir da d\u00e9cada de 1990, o Brasil passou por sucessivas melhorias no campo dasa\u00fade p\u00fablica, impulsionadas pela cria\u00e7\u00e3o do SUS no fim dos anos 1980, pelaimplanta\u00e7\u00e3o do Programa Sa\u00fade da Fam\u00edlia (PSF), no in\u00edcio dos anos 1990 ,Tais medidas, em conjunto com pol\u00edticas de outros setores voltadas \u00e0 redu\u00e7\u00e3o dedesigualdades socioecon\u00f4micas, promoveram mudan\u00e7as positivas no perfil social ereprodutivo das mulheres, como o aumento da escolaridade, da inser\u00e7\u00e3o no mercado detrabalho e do acesso a m\u00e9todos contraceptivos. Al\u00e9m disso, contribu\u00edram para aredu\u00e7\u00e3o de fatores de risco para \u00f3bitos infantis, sobretudo os ocorridos no per\u00edodop\u00f3s-neonatal, com a amplia\u00e7\u00e3o do n\u00famero de consultas durante o pr\u00e9-natal e oprimeiro ano de vida, aumento da cobertura vacinal e melhoria das condi\u00e7\u00f5es demoradia e de saneamento b\u00e1sico 4. Para evitar tal ocorr\u00eancia, s\u00e3o necess\u00e1rios investimentosem infraestrutura e no treinamento de recursos humanos para utiliza\u00e7\u00e3o adequada detecnologias e pr\u00e1ticas assistenciais no parto e imediatamente ap\u00f3s o nascimento,visto que marcadores de gravidade no nascimento - como asfixia, prematuridade ebaixo peso - e complica\u00e7\u00f5es maternas na gesta\u00e7\u00e3o e durante o parto ,,Por outro lado, \u00f3bitos ocorridos no per\u00edodo neonatal passaram a representar oprincipal componente da mortalidade infantil, em especial os ocorridos at\u00e9 o sextodia de vida ,Tal cen\u00e1rio, por sua estreita rela\u00e7\u00e3o com a oferta de servi\u00e7os especializados, requera configura\u00e7\u00e3o de redes de aten\u00e7\u00e3o \u00e0 sa\u00fade para organiza\u00e7\u00e3o da assist\u00eanciahospitalar no per\u00edodo neonatal de modo a reduzir desigualdades de acesso epossibilitar o atendimento em tempo oportuno As redes de aten\u00e7\u00e3o \u00e0 sa\u00fade podem ser estudadas mediante a identifica\u00e7\u00e3o de origens edestinos, correspondentes ao local de resid\u00eancia e de ocorr\u00eancia do atendimento,retrato que auxilia na avalia\u00e7\u00e3o da demanda e na organiza\u00e7\u00e3o da oferta de servi\u00e7osde sa\u00fade de alta complexidade, revelando concentra\u00e7\u00f5es e vazios espaciais. Al\u00e9mdisso, o conhecimento de caracter\u00edsticas relacionadas ao acesso ao servi\u00e7o, comodisponibilidade de meios de transporte ou dist\u00e2ncia, tempo e custo envolvidos nodeslocamento, tamb\u00e9m \u00e9 importante para compreender essas redes Este estudo, ao avaliar a rede de deslocamentos para interna\u00e7\u00f5es no per\u00edodo neonatal,observou aumento na frequ\u00eancia de interna\u00e7\u00f5es ocorridas fora do munic\u00edpio deresid\u00eancia, provavelmente como consequ\u00eancia da organiza\u00e7\u00e3o do fluxo de sa\u00edda, emdecorr\u00eancia da rede de aten\u00e7\u00e3o institu\u00edda e do aumento da demanda por servi\u00e7os dealta complexidade. Algumas caracter\u00edsticas s\u00e3o descritas como marcadores danecessidade de assist\u00eancia hospitalar ao rec\u00e9m-nascido, como idade materna \u2265 35anos, interna\u00e7\u00e3o da m\u00e3e por complica\u00e7\u00e3o obst\u00e9trica, prematuridade, baixo peso, Apgarno quinto minuto < 7 e malforma\u00e7\u00e3o cong\u00eanita Tais marcadores apresentam estreita rela\u00e7\u00e3o com mudan\u00e7as no perfil social ereprodutivo das mulheres e no de gravidade das condi\u00e7\u00f5es de sa\u00fade de crian\u00e7as aonascer No entanto, apesar do aumento de interna\u00e7\u00f5es fora do munic\u00edpio de resid\u00eancia,observaram-se concentra\u00e7\u00e3o de deslocamentos dentro da mesma regional de sa\u00fade eaumento no n\u00famero de munic\u00edpios que se destacaram como destinos frequentes,assinalando o impacto positivo da conforma\u00e7\u00e3o de regi\u00f5es negociadas econtratualizadas para expans\u00e3o e regionaliza\u00e7\u00e3o do acesso a servi\u00e7os de sa\u00fade nas\u00e1reas obst\u00e9trica e neonatal.Sousa et al. ,Neste estudo tamb\u00e9m foram identificadas regi\u00f5es que, al\u00e9m do aumento da frequ\u00eancia deinterna\u00e7\u00f5es ocorridas fora do munic\u00edpio de resid\u00eancia, apresentam dist\u00e2ncia m\u00e9diapercorrida entre munic\u00edpio de resid\u00eancia e de ocorr\u00eancia da interna\u00e7\u00e3o superior a100km, como a 21\u00aa regional de sa\u00fade (Tel\u00eamaco Borba). Esse dado sugere que a regi\u00e3oainda \u00e9 carente de servi\u00e7os especializados Nesse sentido, em 2020, um hospital regional estadual foi inaugurado na cidade deTel\u00eamaco Borba, munic\u00edpio-sede da 21\u00aa regional de sa\u00fade, inicialmente voltado \u00e0assist\u00eancia durante a pandemia de COVID-19. Recentemente, o local passou por umaestrutura\u00e7\u00e3o de modelo assistencial, visando ofertar servi\u00e7os especializados na \u00e1reade sa\u00fade materno-infantil, com previs\u00e3o de leitos de enfermaria, alojamento conjuntopara maternidade, ber\u00e7\u00e1rios e leitos de UTI neonatal Esta pesquisa apresenta limita\u00e7\u00f5es. Os dados s\u00e3o secund\u00e1rios, obtidos de sistemas deinforma\u00e7\u00e3o em sa\u00fade, portanto, pode haver erros de registro, subnotifica\u00e7\u00f5es ouatrasos em seu processamento. Al\u00e9m disso, o banco de dados do SIH-SUS contabilizasomente interna\u00e7\u00f5es hospitalares financiadas pelo SUS. Por fim, as redes dedeslocamento permitem apenas investigar rela\u00e7\u00f5es intermunicipais do tipoorigem-destino determinadas pela presen\u00e7a do servi\u00e7o e dificuldades relacionadas \u00e0sposs\u00edveis trajet\u00f3rias, como tempo e custo, n\u00e3o foram analisadas.,O estudo de redes de deslocamento para assist\u00eancia hospitalar no per\u00edodo neonatalpode auxiliar a gest\u00e3o regional na organiza\u00e7\u00e3o das refer\u00eancias intermunicipais, demodo a otimizar recursos e servi\u00e7os e reduzir desigualdades de acesso"}
+{"text": "To investigate verb fluency performance in individuals with Alzheimer\u2019s disease compared with healthy older adults by analyzing total correct responses, number of clusters, average cluster size, and number of switches.This is a case-control study of 39 healthy older adults and 29 older adults with a diagnosis of Alzheimer\u2019s disease. Verb fluency performance was analyzed in terms of total number of correct verbs retrieved, number of clusters, average cluster size, and number of switches. To obtain the study outcomes, we previously conducted a procedure for categorization of the verbs that would compose the clusters. The classification of verbs was adapted for this study, including assessment by raters and analysis of inter-rater reliability.Individuals with Alzheimer\u2019s disease showed significantly poorer performance than healthy controls in the number of switches and total number of correct verbs retrieved. The two groups did not differ significantly in the other measures.In this study, individuals with Alzheimer\u2019s disease showed impaired verb fluency, characterized by a reduced number of verbs retrieved and fewer transitions between verb categories. The findings suggest that, in Alzheimer\u2019s disease, verb fluency is more sensitive to cognitive deficits resulting from executive dysfunction than from semantic disruption. Overall, verbal fluency tasks require cognitive skills in language, semantic memory, executive function, and working memory. However, each task type involves different cognitive demands and may recruit certain areas of the brain according to the criteria used for word production,6. High levels of education and general cognitive functioning are associated with better performance in verbal fluency tasks,6.Verbal fluency is a neuropsychological assessment in which participants should produce, usually within one minute, as many words as possible from a given cue. According to word production criteria, verbal fluency can be divided into semantic or category fluency , phonemic or letter fluency , action or verb fluency (generation of verbs or words that represent \u201cthings that people do\u201d), and free fluency. Additionally, when retrieved, nouns and verbs activate different areas of the brain. Retrieval of common and proper nouns is primarily mediated by posterior and anterior temporal regions, respectively, whereas verb retrieval is primarily mediated by frontal regions, highlighting the potential utility of verb fluency as an indicator of executive function abilities,9. Verb fluency has therefore been suggested as a marker of frontostriatal dysfunction given its sensitivity to the integrity of these brain networks and as a novel measure of executive function and linguistic skills,9.Verb fluency is more complex than traditional noun fluency tasks, as verbs have more inflections and more syntactic relationships with other words in a sentence than nouns-12. These characteristics are related to the predominant involvement of left temporal lobe regions linked to semantic memory processing,13,14. Conversely, studies investigating verb fluency in AD reported that people with AD showed poorer performance than their healthy peers,15 and those with mild cognitive impairment. This task was also indicative of the conversion from cognitive health to mild cognitive impairment. However, it remains unclear whether the cognitive verb fluency deficits observed in people with AD are either executive or semantic in nature, or both. To this end, methods that analyze not only the total number of verbs retrieved but also their characteristics and forms of retrieval (clustering and switching) may be particularly useful.Verbal fluency tasks are widely used as part of cognitive assessment in individuals with neurodegenerative diseases. Verbal fluency impairment has been described in Alzheimer\u2019s disease (AD), especially impairment in semantic fluency, which is more commonly affected than phonemic fluency,18. While clustering relies on the semantic knowledge available in verbal working memory, switching relies on the processes that involve attention and executive functions,18. There is evidence that people with impaired switching abilities have frontal lobe damage, whereas those with impaired clustering abilities have temporal lobe damage,18.Traditionally, performance in verbal fluency tasks, including verb fluency, is assessed by the total score of correct responses. However, clustering and switching analysis can be used as an alternative method. Clustering involves the production of words within the same semantic subcategory, whereas switching involves shifting from one subcategory (cluster) to anotherIn people with AD, clustering and switching analysis in verb fluency can be of particular relevance to understanding the cognitive nature of the verb retrieval deficits observed in this population. This knowledge, in turn, can provide essential information for a better understanding of the neurobiology of human language and, from a clinical perspective, for the development of an appropriate treatment plan in neuropsychological rehabilitation of people with AD. These alternative methods of verb fluency analysis, if used in combination with other assessment resources, may also be investigated for their utility as a tool for detection and diagnosis of AD in future studies. Therefore, the current study aimed to investigate verb fluency performance in individuals with AD compared with healthy older adults by analyzing total correct responses, number of clusters, average cluster size, and number of switches.This is a case-control study.Participants in this study were selected from the database of a larger project that included individuals with AD (AD group - ADG) and healthy older adults (control group - CG). Participants in the ADG were recruited from the neurodementia outpatient clinic of Hospital de Cl\u00ednicas de Porto Alegre (HCPA), southern Brazil. The CG consisted of community-dwelling individuals participating in local social groups, matched with ADG participants for age, sex, and education. All participants, in both groups, were older than 65 years and native speakers of Brazilian Portuguese. who were at the mild-to-moderate stage of AD. Neurological diagnosis included physical examination, laboratory testing, neuroimaging studies, and neuropsychological assessment. Dementia severity was determined using global Clinical Dementia Rating (CDR) scores .The ADG consisted of older adults with a neurological diagnosis of probable AD according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and National Institute of Neurological and Communicative Disorders and Stroke - Alzheimer\u2019s Disease and Related Disorders Association (NINCDS-ADRDA) criteria. Only individuals with scores above the MMSE cutoff, without a history of neurological or psychiatric disorders, without a history of alcohol, substance, or benzodiazepine abuse, and without uncorrected visual or hearing impairment were included in the CG.Controls underwent a brief interview for assessing their health conditions and functional independence. The Mini-Mental State Examination (MMSE) was also administeredFrom the initial sample of 102 participants classified as having AD  or healthy controls , those with missing data or who were unable to perform the verb fluency task due to difficulty understanding the task instructions were excluded from the current study. Therefore, the final sample analyzed in this study consisted of 68 participants, 29 in the ADG and 39 in the CG.The study was approved by HCPA Research Ethics Committee (registration number 11-0178). Written informed consent was obtained from each study participant. to Brazilian Portuguese by Beber and Chaves:32: \u201cI\u2019ll set one minute, and during this time, I\u2019d like you to tell me as many words as possible that mean things that people do - for example, eat and walk. Do you understand what I mean?\u201d. If the answer was yes: \u201cCan you please give me an example?\u201d. If the response was acceptable, the examiner stated: \u201cNow, let\u2019s get started. Please tell me other words that mean things that people do, besides eat and walk.\u201d. If the response was unacceptable, the examiner repeated the instructions and provided another example. For individuals with a higher level of education, the words \u2018verb\u2019 or \u2018action\u2019 can be used to explain the task. During the task, the examiner made use of a recording protocol, timer, and recorder.The verb fluency task was administered and recorded in a single session, after verifying all inclusion and exclusion criteria. Instructions for the verb fluency task were adapted from Piatt et al.To obtain the total score for verbs correctly generated and for clustering and switching, the following procedures were performed: 1) development of a database of words retrieved by the participants; 2) operationalization of verb categories; 3) standardization of the selection of measures between raters; 4) categorization of words and selection of the variables by independent raters; 5) analysis of inter-rater reliability; 6) new categorization of discordant items; and 7) final version of the categorization of words retrieved.Step 1: Development of a database of retrieved wordsFor the present study, verbs produced in one minute by older adults were used in the verb fluency task. The verbs produced by each participant were entered into a Microsoft Excel spreadsheet.Step 2: Operationalization of verb categories, which considered only two superordinate categories: action verbs, which included verbs expressing concrete, observable actions; and mental state verbs, which included verbs whose meaning relates to understanding, discovering, planning, or deciding and verbs of perception, cognition, and emotion (unobservable verbs). This categorization was also used by Paek and Murray in a sample of individuals with AD and healthy older adults.To define which verb categories would compose the clusters, three different raters independently categorized the verbs produced by 20 participants (10 in the ADG and 10 in the CG). Responses were divided into two major categories: observable and unobservable actions. This was based on the procedure for categorization of verbs used in a previous study of adults with schizophrenia vs healthy adultsIn the present study, additionally, the verbs within each major category were divided into subcategories according to the semantic clustering strategies used by the participants and observed by the raters:Observable actions: 1) actions related to body parts ; 2) routine actions ; and 3) actions with objects .Unobservable actions: 1) psychological actions ; and 2) verbs of existence and auxiliaries.The raters then met to discuss these categories and to determine which categories would be used and which words would be accepted in each category.Step 3: Standardization of the selection of measures between ratersTwo different raters independently selected word clusters from the verbs retrieved by 10 participants (5 in the ADG and 5 in the CG) according to the categories established in the previous step. For each participant, the raters scored the total number of clusters, average cluster size, and number of switches. Subsequently, the raters discussed these measures in order to standardize the selection of categories and participants\u2019 scores. A table containing examples of verbs belonging to each category was developed .Step 4: Categorization of words retrieved and selection of clusters and switches by independent ratersAfter determining the measures, the two raters trained in the previous step independently analyzed the verbs produced by each participant, blinded to which group individual participants had been allocated. The raters determined the number of clusters, average cluster size, number of switches, and total number of verbs retrieved by each participant. The selection process for each variable is described below.Total number of correct words retrieved: total number of words retrieved, excluding repetitions and errors. Repetitions were defined as verbs mentioned more than once. Errors were defined as words not morphologically classified as verbs . In addition, the verbs \u2018eat\u2019 and \u2018walk\u2019 were also considered errors when participants retrieved them as one of the first two successively generated words, because both were used as example verbs in the task instructions. For example, if a participant retrieved \u201ceat, walk, travel, jog, leave, sleep, travel, leave,\u201d a total of four words retrieved would be correct .Number of clusters: total number of clusters for each participant. The items generated by each participant were considered to form a cluster when at least two successively generated words belonged to the same category. Single words were not considered clusters. For example, the sequence \u201cwalk, jog, comb, climb, drop, escape, sweep, wash, dry, dress, comb\u201d shows a total of four clusters  and one single word (comb). Different from the total number of words retrieved, errors and repetitions were included in the calculation of number of clusters, as these data provide important information about the strategies and cognitive processes used by the participants.Average cluster size: cluster size was counted beginning with the second word produced in each cluster . Average cluster size was calculated by summing the sizes of each cluster produced by each participant and dividing this value by the total number of clusters for each participant. Therefore, in the example above, the average cluster size for the participant would be 1.5 (obtained by dividing six by four). Errors and repetitions were also included in the calculation of average cluster size.Number of switches: switches were calculated as the number of transitions between clusters, including single words. Using again the example above, the sequence \u201cwalk, jog, comb, climb, drop, escape, sweep, wash, dry, dress, comb\u201d shows a total of four switches . Errors and repetitions were also included in this measure, that is, the total production of each participant was considered.Step 5: Analysis of inter-rater reliability, using the R irr package,25. ICC values \u2265 0.75 were considered excellent correlations. The following ICC values were obtained: 0.982 for number of clusters, 0.958 for average cluster size, and 0.992 for number of switches.Inter-rater reliability for each variable scored by the two independent raters  was determined by the intraclass correlation coefficient (ICC)Step 6: New categorization of discordant itemsAfter inter-rater reliability analysis, discordant items between the two raters were reanalyzed one by one by two newly trained raters, who independently categorized these items. The scores of the two new raters were used to reach a decision on the final score for these items.Step 7: Final version of the categorization of variablesConsidering all the steps, all the final scores for each participant were defined and tabulated for analysis in the four study variables .. The level of significance was set at 5% for all analyses.Categorical variables were expressed as absolute and relative frequencies, and continuous variables were expressed as mean (SD). The descriptive characteristics of the groups were compared using Student\u2019s t test and the chi-square test. Study outcomes  were compared between groups by analysis of covariance (ANCOVA) using age and education as covariates. Data were analyzed using SPSS, version 25. The ICC was used to determine inter-rater reliability, using the R irr packageParticipants in the CG and ADG were then compared for the study outcomes , controlling for differences in age and education, which were included as covariates in the statistical analysis. Additionally, the study outcomes were compared only within the ADG by comparing participants with mild vs moderate AD. There was no statistically significant difference in any of the variables analyzed . which was also used in a previous study of individuals with AD and healthy older adults. However, our procedure differed slightly in that the verbs were divided into subcategories within the two major categories proposed by these authors. We made this decision after observing that the verbs generated by our participants and the semantic strategies employed by them required a more refined classification of verb categories in order not to miss the wealth of information provided by our sample.This study aimed to investigate verb fluency performance in individuals with AD compared with cognitively healthy older adults. To this end, we used a thorough methodological approach in categorizing verbs according to semantic criteria in order to obtain the study variables: total number of correct words retrieved, number of clusters, average cluster size, and number of switches. The procedure for categorization of verbs was based on the classification proposed by Smirnova et al.,13,14. Verbs are considered the grammatical class that most requires a complex semantic organization for retrieval and, therefore, would be the most sensitive to deficits.As for the comparison of the outcomes of interest between the CG and ADG, our data suggest that there is a quantitative difference in the production of verbs between the groups, with a lower word production in individuals with AD than in controls, as described in previous studies,26,27. A reduced number of switches suggests that individuals with AD have limited organizational strategies for verb retrieval and, possibly, retrieve a reduced number of verbs as a consequence. Therefore, this specific impairment in the verb fluency task would occur as a result of executive function deficits and not necessarily due to difficulties in lexical-semantic access to this class of words .In the present study, the ADG and CG differed in the number of switches, but not in the number and size of clusters. This is consistent with the findings from previous studies comparing semantic fluency performance between healthy older adults and individuals with AD in terms of clustering and switching strategies. The decrease in switching ability was associated with the decline in working memory. In another study of adults over 50 years of age with neurodegenerative disease, switching strategies in verbal fluency also proved to be sensitive to pathological changes in executive abilities.The poorer performance of older adults with AD (vs without AD) in verb switching may result from working memory deficits. A previous study investigated the relationship between verbal fluency performance and working memory performance in older people with and without cognitive decline by means of clustering and switching analysis. However, when compared in terms of AD severity, those with more advanced disease performed more poorly in the verb naming task, but scores did not differ in the verb fluency task, as also observed in the present study. The authors suggested that, in individuals with AD, deficits in verb processing have a predominantly semantic nature, which does not exclude the influence of impairments in other cognitive domains. As the performance in verb processing also depends on the task used for verb retrieval, the results of the present study indicate that, in the verb fluency task, the ADG\u2019s poorer performance was mostly driven by executive dysfunction, demonstrating that this task is more sensitive to executive impairment than to disruption in semantic verb processing.Another hypothesis is that verb fluency deficits would be related to language deficits. A study compared the performance of healthy older adults, older adults with mild AD, and older adults with moderate AD in verb fluency and verb naming tasks and concluded that patients with AD were equally impaired in verb fluency and verb namingFurthermore, although they were not the focus of our study, some qualitative differences were observed in verb production between the study participants. Overall, participants with AD used complementary words to describe the verbs, which appears to be directly related to the quality of the verb, retrieving verbs that can be used more generally and in less specific contexts . This may suggest difficulty retrieving less frequent verbs in Portuguese. Also, participants may have had difficulty understanding the task itself. This may have occurred at the time they were given the instructions or in the process of holding the instructions in mind, which suggests a decline in working memory capacity. However, the qualitative data obtained in this study are insufficient to further interrogate this topic, thus being reported as secondary results of the research. Future research along these lines is warranted to further explore this phenomenon.The assessment of clustering included repetitions, which differs from the traditional assessment of data obtained in fluency tasks that considers only the total number of non-repeated words. This decision was based on the assumption that clustering analysis may help identify word retrieval strategies used by the participants. The present data suggest that individuals with AD use fewer semantic strategies than healthy controls, retrieving verbs that are apparently unconnected. Despite the clear correlation between the number of words retrieved and number of clusters, the first measure loses its explanatory power at this level of analysis.Finally, our study provides evidence that verb fluency performance, in terms of total number of verbs retrieved and switching ability, is impaired in individuals with AD. Specifically in this task, verb fluency deficits may be predominantly executive in nature, highlighting the participants\u2019 difficulty using cognitive strategies to retrieve verbs. These findings can be useful in different ways. First, both the verb fluency task itself and the switching ability in this task may be markers of conversion to AD, but not necessarily of disease progression . Second, this cognitive feature may be relevant to treatment planning in neuropsychological rehabilitation. For example, in interventions aimed at reducing anomies, training in the use of different strategies to retrieve verbs/actions can help patients access these words more easily. Third, our findings suggest that temporal lobe structures (affected in the early stages of AD) and their connections are also important in the search for cognitive strategies to retrieve verbs.Additional investigation is needed to further explore this topic, including studies with larger sample sizes that also investigate the different presentations of AD , as this was not possible in the present study. The methods used here might be applied to populations with other neurological diseases or even to healthy individuals of different ages and levels of education in order to understand more clearly the neural processing of verbs and the utility of the verb fluency task.The current study showed that older adults with AD have impairments in both total number of correct verbs retrieved during the verb fluency task and switching ability compared with healthy older adults. The results indicate that verb fluency is more sensitive to cognitive deficits resulting from the executive dysfunction than from the semantic disruption observed in people with AD.In clinical settings, the verb fluency task may be used as part of cognitive assessment in individuals with AD, also assisting in the diagnosis, monitoring and decision-making for neuropsychological rehabilitation through the switching and clustering measures. In research settings, the methods used in the current study may be further explored in other neurological diseases in order to understand their cognitive profiles. -3. De modo geral, as tarefas de flu\u00eancia verbal exigem a utiliza\u00e7\u00e3o de habilidades cognitivas de linguagem, mem\u00f3ria sem\u00e2ntica, fun\u00e7\u00f5es executivas e mem\u00f3ria de trabalho. No entanto, acredita-se que cada tipo de tarefa pode demandar mais de determinado processo cognitivo e recrutar determinadas \u00e1reas cerebrais de acordo com o crit\u00e9rio utilizado para a gera\u00e7\u00e3o das palavras,6. Pode-se afirmar tamb\u00e9m que altos n\u00edveis de desempenho cognitivo geral e educacional est\u00e3o associados com um melhor desempenho nas tarefas de flu\u00eancia verbal,6.A flu\u00eancia verbal \u00e9 uma tarefa de avalia\u00e7\u00e3o neuropsicol\u00f3gica na qual o indiv\u00edduo deve evocar, geralmente durante um minuto, o maior n\u00famero de palavras de acordo com uma dada caracter\u00edstica ou crit\u00e9rio. Os tipos de flu\u00eancia verbal, de acordo com o crit\u00e9rio de evoca\u00e7\u00e3o das palavras s\u00e3o: flu\u00eancia verbal sem\u00e2ntica , flu\u00eancia verbal fon\u00eamica ou ortogr\u00e1fica , flu\u00eancia de verbos ou de a\u00e7\u00f5es , e a flu\u00eancia verbal livre. Al\u00e9m disso, quando evocados, os substantivos e verbos ativam \u00e1reas distintas no c\u00e9rebro. A evoca\u00e7\u00e3o de substantivos comuns e nomes pr\u00f3prios s\u00e3o mediadas predominantemente e respectivamente pelas regi\u00f5es temporal posterior e anterior do c\u00e9rebro,9. J\u00e1 a evoca\u00e7\u00e3o de verbos ocorre mediada, principalmente, pelas regi\u00f5es frontais do c\u00e9rebro, o que a torna um potencial indicador na avalia\u00e7\u00e3o das habilidades ligadas \u00e0s fun\u00e7\u00f5es executivas,9. A flu\u00eancia de verbos tem sido sugerida pela literatura como um marcador de comprometimento frontoestriatal pela sua sensibilidade \u00e0 integridade destas redes do c\u00e9rebro e como uma nova medida de funcionamento executivo e lingu\u00edstico,9.A flu\u00eancia verbal de verbos \u00e9 mais complexa do que as tarefas de flu\u00eancia verbal que envolvem a gera\u00e7\u00e3o de substantivos, pois os verbos possuem maior inflex\u00e3o e maior rela\u00e7\u00e3o sint\u00e1tica com outras palavras-12. Essas caracter\u00edsticas est\u00e3o relacionadas a um predom\u00ednio do comprometimento de regi\u00f5es do lobo temporal esquerdo, especificamente ligadas ao processamento da mem\u00f3ria sem\u00e2ntica,13,14. J\u00e1 os estudos que investigaram a flu\u00eancia de verbos na DA encontraram uma pior performance em rela\u00e7\u00e3o aos seus pares saud\u00e1veis,15, em rela\u00e7\u00e3o a sujeitos com comprometimento cognitivo leve e esta tarefa tamb\u00e9m foi um indicativo da convers\u00e3o de indiv\u00edduos cognitivamente saud\u00e1veis em comprometimento cognitivo leve. Ainda, \u00e9 preciso elucidar melhor qual a natureza cognitiva dos d\u00e9ficits na flu\u00eancia de verbos na DA, se ocorre no n\u00edvel sem\u00e2ntico ou executivo, ou em ambos. Para isso, m\u00e9todos que analisam com mais profundidade as caracter\u00edsticas dos verbos evocados e a forma de evoca\u00e7\u00e3o , para al\u00e9m do n\u00famero total de verbos gerados apenas, podem ser de grande utilidade.As tarefas de flu\u00eancia verbal, em geral, s\u00e3o muito utilizadas na avalia\u00e7\u00e3o cognitiva de sujeitos com doen\u00e7as neurodegenerativas. Na doen\u00e7a de Alzheimer (DA), j\u00e1 foram descritos d\u00e9ficits na realiza\u00e7\u00e3o de tarefas de flu\u00eancia verbal, especialmente na sem\u00e2ntica, que costuma estar mais afetada que a ortogr\u00e1ficaclustering (agrupamento) e switching . Os clusters s\u00e3o agrupamentos de palavras com a mesma subcategoria sem\u00e2ntica. J\u00e1 a altern\u00e2ncia ou switching ocorre quando um cluster termina e se inicia outro cluster ou uma palavra isolada,18. O processo de clustering depende do conhecimento sem\u00e2ntico dispon\u00edvel na mem\u00f3ria de trabalho, j\u00e1 o switching depende dos processos que envolvem a aten\u00e7\u00e3o e fun\u00e7\u00f5es executivas,18. Existem evid\u00eancias de que pessoas com problemas em realizar o switching tenham maior comprometimento de \u00e1reas frontais do c\u00e9rebro, enquanto que as com problemas para realizar o clustering tenham maior comprometimento de \u00e1reas temporais,18.A forma mais tradicional para se analisar a performance nas tarefas de flu\u00eancia verbal, incluindo a flu\u00eancia de verbos, \u00e9 o escore total de palavras emitidas de forma correta. Por\u00e9m, outra metodologia poss\u00edvel \u00e9 a an\u00e1lise de clustering e switching na flu\u00eancia de verbos de pessoas com DA pode ser de grande relev\u00e2ncia para compreender a natureza cognitiva do d\u00e9ficit na evoca\u00e7\u00e3o de verbos que ocorre nessa popula\u00e7\u00e3o. Por consequ\u00eancia, compreender a natureza cognitiva desta dificuldade fornece subs\u00eddios para uma melhor compreens\u00e3o da neurobiologia da linguagem humana e, do ponto de vista cl\u00ednico, para um adequado planejamento terap\u00eautico da reabilita\u00e7\u00e3o neuropsicol\u00f3gica das pessoas com DA. Ainda, outros m\u00e9todos de an\u00e1lise da flu\u00eancia de verbos podem ser investigados pensando em seu uso como ferramenta de detec\u00e7\u00e3o e diagn\u00f3stico da DA, obviamente em combina\u00e7\u00e3o com outros recursos avaliativos. Sendo assim, este estudo teve como objetivo investigar o desempenho na tarefa de flu\u00eancia de verbos de pessoas com DA em compara\u00e7\u00e3o \u00e0 idosos saud\u00e1veis, a partir da an\u00e1lise do n\u00famero total de palavras corretas evocadas, do n\u00famero de clusters, do tamanho m\u00e9dio dos clusters e do n\u00famero de switches.A an\u00e1lise de Este estudo se caracteriza como um estudo de caso-controle.Os participantes foram selecionados a partir da an\u00e1lise de um banco de dados de um projeto maior que possu\u00eda participantes classificados em grupo com DA (GDA) e grupo de idosos saud\u00e1veis (grupo controle - GC).Os participantes do GDA foram recrutados do ambulat\u00f3rio de neurodem\u00eancias do Hospital de Cl\u00ednicas de Porto Alegre (HCPA), RS. J\u00e1 o GC foi composto por indiv\u00edduos recrutados de grupos sociais da comunidade local, procurando manter um perfil semelhante ao GDA quanto a idade, sexo e escolaridade. Para ambos os grupos, s\u00f3 foram inclu\u00eddos participantes falantes do portugu\u00eas brasileiro com idade maior que 65 anos.Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) e National Institute of Neurological and Communicative Disorders and Stroke - Alzheimer's Disease and Related Disorders Association (NINCDS-ADRDA) e que estavam em est\u00e1gio leve e/ou moderado da DA. Para o diagn\u00f3stico neurol\u00f3gico, foram realizados al\u00e9m do exame f\u00edsico, exames laboratoriais e de neuroimagem, e uma avalia\u00e7\u00e3o neuropsicol\u00f3gica. A gravidade da dem\u00eancia foi avaliada por meio de pontua\u00e7\u00f5es globais do Clinical Dementia Rating (CDR) .No GDA foram inclu\u00eddos apenas adultos idosos que receberam o diagn\u00f3stico neurol\u00f3gico de DA prov\u00e1vel a partir dos crit\u00e9rios diagn\u00f3sticos do . Foram inclu\u00eddos no GC apenas indiv\u00edduos com pontua\u00e7\u00e3o acima do ponto de corte no MEEM, sem hist\u00f3rico de problemas neurol\u00f3gicos ou transtornos psiqui\u00e1tricos ou abuso de \u00e1lcool, drogas ou benzodiazep\u00ednicos; e sem defici\u00eancia visual ou auditiva n\u00e3o corrigida.Para o GC, foi realizada uma breve entrevista que objetivava a verifica\u00e7\u00e3o das condi\u00e7\u00f5es de sa\u00fade e independ\u00eancia funcional dos participantes. Al\u00e9m disso, foi aplicado o Mini-Exame do Estado Mental (MEEM)Da amostra inicial de 102 participantes j\u00e1 classificados em GDA (n= 40) e GC (n= 62), foram exclu\u00eddos, especificamente para este estudo, os participantes que possu\u00edam dados faltantes e que n\u00e3o conseguiram executar a tarefa da flu\u00eancia de verbos por dificuldade na compreens\u00e3o da ordem. Deste modo, a amostra final deste artigo foi composta por 68 indiv\u00edduos .Este estudo foi aprovado pelo Comit\u00ea de \u00c9tica em Pesquisa do HCPA (n\u00famero de registro 11-0178) e todos os participantes assentiram em participar do estudo atrav\u00e9s da assinatura de um Termo de Consentimento Livre e Esclarecido. por Beber e Chaves:32: \u201cIrei marcar um minuto, e durante este tempo voc\u00ea ter\u00e1 que dizer o m\u00e1ximo de palavras que significam coisas que podemos fazer, como por exemplo, comer e andar. Voc\u00ea entendeu?\u201d. Se a resposta for sim: \u201cD\u00ea-me um exemplo, ent\u00e3o.\u201d. Se o exemplo estiver correto: \u201cAgora, iremos come\u00e7ar. Diga-me outras palavras que representam coisas que podemos fazer, al\u00e9m de comer e andar.\u201d. Se o exemplo dado estiver incorreto, d\u00ea a explica\u00e7\u00e3o novamente com mais um exemplo. Para pessoas com maior escolaridade podem ser utilizados os termos \u201cverbo\u201d ou \u201ca\u00e7\u00e3o\u201d para explicar a tarefa. Durante a tarefa, o examinador fez uso de um protocolo de registro, cron\u00f4metro e gravador.A tarefa de flu\u00eancia de verbos foi coletada e gravada em uma \u00fanica sess\u00e3o, ap\u00f3s a verifica\u00e7\u00e3o de todos os crit\u00e9rios de inclus\u00e3o e exclus\u00e3o. Nessa tarefa, os participantes ouviram a seguinte instru\u00e7\u00e3o, adaptada para o portugu\u00eas brasileiro de Piatt et al.clustering e switching foram realizadas os seguintes procedimentos: 1) elabora\u00e7\u00e3o do banco de dados com as palavras evocadas pelos participantes; 2) operacionaliza\u00e7\u00e3o das categorias de verbos; 3) uniformiza\u00e7\u00e3o da extra\u00e7\u00e3o de medidas entre avaliadores; 4) categoriza\u00e7\u00e3o das palavras e extra\u00e7\u00e3o das vari\u00e1veis pelos ju\u00edzes de forma independente; 5) an\u00e1lise de fidedignidade da an\u00e1lise pela concord\u00e2ncia entre ju\u00edzes; 6) nova categoriza\u00e7\u00e3o dos itens discordantes e 7) vers\u00e3o final da categoriza\u00e7\u00e3o das palavras evocadas.Para a extra\u00e7\u00e3o do escore total de verbos gerados corretamente e das vari\u00e1veis de Etapa 1: Elabora\u00e7\u00e3o do banco de palavras evocadasPara esse estudo, foram utilizados verbos evocados durante um minuto pelos adultos idosos na tarefa de flu\u00eancia verbal de verbos. Os verbos evocados por cada um dos participantes foram transcritos para uma planilha do Microsoft Excel.Etapa 2: Operacionaliza\u00e7\u00e3o das categorias de verbosclusters, tr\u00eas diferentes ju\u00edzes categorizaram de forma independente os verbos gerados por 20 participantes (10 GDA e 10 GC). Organizou-se as palavras em duas grandes categorias: a\u00e7\u00f5es observ\u00e1veis e n\u00e3o observ\u00e1veis. Esse agrupamento baseou-se na categoriza\u00e7\u00e3o usada em um estudo pr\u00e9vio que organizou verbos evocados por uma amostra de adultos com esquizofrenia e adultos saud\u00e1veis. Os autores consideraram apenas duas grandes categorias: a primeira que inclu\u00eda verbos que exprimem a\u00e7\u00f5es concretas, observ\u00e1veis e a segunda que contemplava verbos cujo significado est\u00e3o relacionados \u00e0 compreens\u00e3o, descobertas, planejamentos, decis\u00f5es, percep\u00e7\u00e3o, cogni\u00e7\u00e3o e emo\u00e7\u00e3o (verbos n\u00e3o observ\u00e1veis). Essa forma de categorizar j\u00e1 foi utilizada tamb\u00e9m por Paeka e Murray com uma amostra de idosos com DA e saud\u00e1veis.Para a defini\u00e7\u00e3o de quais categorias de verbos iriam compor os Adicionalmente, os verbos de cada grande categoria foram distribu\u00eddos em subcategorias, de acordo com as estrat\u00e9gias de agrupamento sem\u00e2ntico utilizadas pelos participantes e observadas pelos ju\u00edzes:A\u00e7\u00f5es observ\u00e1veis: 1) a\u00e7\u00f5es de corpo , 2) a\u00e7\u00f5es de rotina , 3) a\u00e7\u00f5es com objetos .A\u00e7\u00f5es n\u00e3o observ\u00e1veis: 1) a\u00e7\u00f5es psicol\u00f3gicas  e 2) verbos de exist\u00eancia e auxiliares.A seguir, as categorias criadas foram discutidas pelos ju\u00edzes, que definiram quais categorias seriam utilizadas e quais palavras seriam aceitas em cada uma delas.Etapa 3: uniformiza\u00e7\u00e3o da extra\u00e7\u00e3o de medidas entre avaliadoresclusters, o tamanho m\u00e9dio dos clusters e a quantidade de switches. As medidas ent\u00e3o foram discutidas entre os avaliadores, a fim de uniformizar a extra\u00e7\u00e3o de categorias e pontua\u00e7\u00e3o dos participantes. Nessa fase, foi organizada uma tabela com exemplos de verbos pertencentes a cada categoria , grupos de palavras que formaram clusters, conforme as categorias estabelecidas na etapa anterior. Ap\u00f3s, pontuaram, para cada um dos participantes a quantidade total de ategoria .clusters e switches pelos ju\u00edzes de forma independenteEtapa 4: Categoriza\u00e7\u00e3o das palavras evocadas e extra\u00e7\u00e3o das vari\u00e1veis clusters, tamanho m\u00e9dio dos clusters, n\u00famero de switches, e o n\u00famero total de verbos evocados por cada participante. Segue abaixo como foram extra\u00eddas cada uma das vari\u00e1veis utilizadas.Ap\u00f3s a aferi\u00e7\u00e3o das medidas, os dois ju\u00edzes avaliadores treinados na etapa anterior analisaram os verbos produzidos por cada um dos participantes de forma independente e cega quanto ao grupo em que o participante estava alocado. Os ju\u00edzes contabilizaram o n\u00famero de N\u00famero total de palavras corretas evocadas: quantidade total de palavras evocadas, excluindo-se repeti\u00e7\u00f5es e erros. As repeti\u00e7\u00f5es s\u00e3o verbos mencionados mais de uma vez. J\u00e1 os erros s\u00e3o as palavras n\u00e3o classificadas morfologicamente como verbos . Al\u00e9m disso, tamb\u00e9m s\u00e3o erros os verbos \u201ccomer\u201d ou \u201candar\u201d nas situa\u00e7\u00f5es em que os participantes os evocaram entre os dois primeiros itens da sequ\u00eancia, em raz\u00e3o de ambos os verbos fazerem parte do rapport da tarefa. Assim, por exemplo, na evoca\u00e7\u00e3o \u201ccomer, andar, viajar, caminhar, sair, dormir, viajar, sair\u201d tem-se um total de quatro palavras corretas evocadas .N\u00famero de clusters: quantidade total de clusters de cada participante. Considerou-se que os itens gerados por cada participante formam um cluster quando pelo menos duas palavras evocadas em sequ\u00eancia pertenciam \u00e0 mesma categoria. Palavras isoladas n\u00e3o foram consideradas clusters. Considerando o seguinte exemplo, \u201candar, caminhar, pentear, subir, descer, fugir, varrer, lavar, secar, vestir, pentear\u201d; conclui-se que h\u00e1 um total de 4 clusters  e 1 palavra isolada (pentear). Diferente da quantidade total de palavras evocadas, para o n\u00famero de clusters foram inclu\u00eddos erros e repeti\u00e7\u00f5es, em raz\u00e3o de esses dados fornecerem ind\u00edcios importantes sobre as estrat\u00e9gias e processos cognitivos utilizados pelos participantes.M\u00e9dia do tamanho dos clusters: para calcular o tamanho de cada cluster, conta-se a quantidade total de palavras a partir da segunda palavra produzida . Para a m\u00e9dia do tamanho de clusters, somou-se os tamanhos de cada um dos clusters produzidos por cada participante e dividiu-se esse valor pelo n\u00famero total de clusters de cada participante. Assim, no exemplo acima, a m\u00e9dia do tamanho de clusters desse participante seria de 1,5 (obtido por interm\u00e9dio da divis\u00e3o entre seis e quatro). Da mesma forma que no total de clusters, os erros e as repeti\u00e7\u00f5es foram considerados para formar a m\u00e9dia do tamanho dos clusters.N\u00famero de switches: para essa medida, analisa-se o n\u00famero total de trocas entre clusters e/ou palavras isoladas. Tomando como exemplo novamente a sequ\u00eancia \u201candar, caminhar, pentear, subir, descer, fugir, varrer, lavar, secar, vestir, pentear\u201d. Nesse caso, tem-se quatro switches . Nessa medida, tamb\u00e9m foram considerados os erros e as repeti\u00e7\u00f5es, ou seja, a produ\u00e7\u00e3o total de cada participante.Etapa 5: An\u00e1lise de fidedignidade das an\u00e1lises pela concord\u00e2ncia entre ju\u00edzesclusters, m\u00e9dia do tamanho dos clusters e n\u00famero de switches), analisou-se o coeficiente de correla\u00e7\u00e3o intraclasse (ICC), utilizando o pacote \u201cirr\u201d para linguagem R,25. Ressalta-se que considerou-se ICCs maiores ou iguais a 0,75 como correla\u00e7\u00f5es excelentes. Foram obtidos os seguintes valores de ICC: 0,982 para o n\u00famero de clusters, 0,958 para tamanho m\u00e9dio dos clusters, e 0,992 para o n\u00famero de switches.A fim de verificar a fidedignidade das an\u00e1lises feitas para cada vari\u00e1vel pontuada pelos dois ju\u00edzes independentes .Considerando todas estas etapas, ao final foram definidas e tabuladas para an\u00e1lise todas as pontua\u00e7\u00f5es finais de cada participante nas quatro vari\u00e1veis de an\u00e1lise  foram comparados entre os grupos atrav\u00e9s do teste ANCOVA, utilizando idade e escolaridade como covariantes. Para estas essas an\u00e1lises, foi utilizado o Statistical Package for Social Sciences (SPSS) vers\u00e3o 25. Tamb\u00e9m foi realizada uma an\u00e1lise do coeficiente de correla\u00e7\u00e3o intraclasse (ICC) para inferir a concord\u00e2ncia entre os ju\u00edzes, utilizando o pacote \u201cirr\u201d para linguagem R. O n\u00edvel de signific\u00e2ncia utilizado neste estudo foi de 5%.Vari\u00e1veis categ\u00f3ricas foram descritas em frequ\u00eancia absoluta e relativa enquanto vari\u00e1veis cont\u00ednuas foram descritas em m\u00e9dia e desvio padr\u00e3o. As caracter\u00edsticas descritivas dos grupos foram comparadas utilizando o teste t de Student e Qui-Quadrado. Os desfechos do estudo , controlando as diferen\u00e7as de idade e escolaridade, que foram inclu\u00eddas como covariantes na an\u00e1lise estat\u00edstica. A switches e do total de verbos gerados foi estatisticamente inferior no GDA.Os participantes do GC e do GDA foram ent\u00e3o comparados quanto aos desfechos de interesse no estudo .Neste estudo, os grupos diferiram com ao n\u00famero de switching de verbos de sujeitos com DA em compara\u00e7\u00e3o a idosos sem DA, talvez decorra de dificuldades relacionadas \u00e0 mem\u00f3ria de trabalho. Um estudo pr\u00e9vio investigou a rela\u00e7\u00e3o da performance da flu\u00eancia verbal com o desempenho da mem\u00f3ria de trabalho em idosos com e sem decl\u00ednio cognitivo utilizando a metodologia de clustering e switching. O decr\u00e9scimo nas habilidades de switching foi relacionado com o decl\u00ednio da mem\u00f3ria de trabalho. A an\u00e1lise do switching utilizada na flu\u00eancia verbal se mostrou sens\u00edvel \u00e0s poss\u00edveis altera\u00e7\u00f5es nas habilidades relacionadas \u00e0s fun\u00e7\u00f5es executivas tamb\u00e9m em um estudo com adultos maiores de 50 anos com doen\u00e7a neurodegenerativa.O pior desempenho no . Nela, conclu\u00edram que os pacientes com DA apresentaram tanto preju\u00edzo na quantidade de palavras evocadas na flu\u00eancia de verbos, quanto na nomea\u00e7\u00e3o dos verbos. Entretanto, quando comparados os grupos quanto a gravidade da DA, encontraram que os com a doen\u00e7a mais avan\u00e7ada obtiveram pior desempenho na tarefa de nomea\u00e7\u00e3o, mas n\u00e3o diferiram quanto \u00e0 flu\u00eancia de verbos, da mesma forma que ocorreu neste estudo. Tal estudo sugere que a dificuldade dos sujeitos com DA em processar verbos tem um predom\u00ednio sem\u00e2ntico, o que n\u00e3o exclui a influ\u00eancia de preju\u00edzos em outros dom\u00ednios cognitivos. Como o desempenho no processamento de verbos tamb\u00e9m depende da tarefa utilizada para a emiss\u00e3o de verbos, podemos concluir com base nos resultados da presente pesquisa que, na tarefa de flu\u00eancia de verbos, o d\u00e9ficit executivo \u00e9 o que mais dirige o desempenho dos sujeitos, demonstrando a maior sensibilidade desta tarefa ao funcionamento executivo do que ao processamento sem\u00e2ntico dos verbos.Outra hip\u00f3tese seria de que os d\u00e9ficits na flu\u00eancia de verbos tenham rela\u00e7\u00e3o com d\u00e9ficits de linguagem. Um estudo comparou o desempenho de idosos saud\u00e1veis, idosos com DA leve e idosos com DA moderada em tarefas de flu\u00eancia de verbos e de nomea\u00e7\u00e3o de verbosAdicionalmente, mesmo n\u00e3o tendo sido o foco do estudo, foram observadas algumas diferen\u00e7as qualitativas na produ\u00e7\u00e3o de verbos dos participantes deste estudo. De uma forma geral, os participantes do grupo com DA utilizaram palavras complementares ao descrever verbos, isto parece estar diretamente ligado a qualidade do verbo, sendo evocados verbos que podem ser considerados mais generalistas e que podem ser utilizados em contextos menos espec\u00edficos . Isso pode sugerir uma dificuldade de evoca\u00e7\u00e3o de verbos menos frequentes na l\u00edngua portuguesa. Tamb\u00e9m pode haver uma dificuldade na compreens\u00e3o da tarefa em si, que pode ter ocorrido no momento de compreender a instru\u00e7\u00e3o ou no processo de manter a instru\u00e7\u00e3o em mente, o que sugere um decl\u00ednio na mem\u00f3ria operacional. No entanto, os dados qualitativos obtidos neste estudo s\u00e3o insuficientes para o aprofundamento destas quest\u00f5es, se mostrando como achados secund\u00e1rios da pesquisa. Tal fen\u00f4meno poder\u00e1 ser explorado com mais \u00eanfase em estudos futuros.clusters levou em conta as palavras repetidas, isto difere da avalia\u00e7\u00e3o mais usual dos dados obtidos nas tarefas de flu\u00eancias, que considera apenas o n\u00famero total das palavras n\u00e3o repetidas. Esta decis\u00e3o \u00e9 baseada no pressuposto de que a an\u00e1lise dos agrupamentos ajuda a verificar as estrat\u00e9gias de evoca\u00e7\u00e3o utilizadas pelos participantes. Os dados obtidos por este estudo sugerem que os pacientes com DA utilizam menos estrat\u00e9gias sem\u00e2nticas, evocando verbos sem conex\u00e3o aparente entre si, quando comparados ao grupo controle. Ainda que haja uma correla\u00e7\u00e3o evidente entre o n\u00famero de palavras evocadas e o n\u00famero de agrupamentos, a primeira medida perde a capacidade explicativa deste n\u00edvel de an\u00e1lise.A avalia\u00e7\u00e3o dos switching, est\u00e1 prejudicada em pessoas com DA. Especificamente nesta tarefa de flu\u00eancia de verbos, a dificuldade pode ter uma natureza predominantemente executiva, demonstrando a dificuldade dos sujeitos em utilizar estrat\u00e9gias cognitivas para evocar verbos. Estes achados podem ser \u00fateis em diferentes aspectos. Primeiro, \u00e9 poss\u00edvel que a tarefa de flu\u00eancia de verbos e a habilidade de switching nesta tarefa sejam marcadores de convers\u00e3o da DA, mas n\u00e3o necessariamente de progress\u00e3o da doen\u00e7a (pois n\u00e3o houve diferen\u00e7a significativa dos desfechos estudados entre pessoas com DA leve e moderada). Segundo, esta caracter\u00edstica cognitiva \u00e9 relevante de ser considerada no planejamento terap\u00eautico da reabilita\u00e7\u00e3o neuropsicol\u00f3gica. Por exemplo, em interven\u00e7\u00f5es que visam a redu\u00e7\u00e3o de anomias, o treinamento do uso de diferentes estrat\u00e9gias para evocar verbos/a\u00e7\u00f5es pode auxiliar os pacientes a acessarem essas palavras com mais facilidade. Terceiro, os achados sugerem que os lobos temporais (atingidos j\u00e1 nas fases iniciais da DA) e suas conex\u00f5es tamb\u00e9m s\u00e3o importantes na busca por estrat\u00e9gias cognitivas para evocar verbos.Finalmente, este estudo apresenta dados que demonstram que o desempenho na flu\u00eancia de verbos, quanto ao n\u00famero total de verbos evocados e a capacidade de Sugerimos que este tema de pesquisa seja mais profundamente explorado em estudos futuros com amostras maiores e que investiguem tamb\u00e9m as diversas apresenta\u00e7\u00f5es da DA , j\u00e1 que isso n\u00e3o foi poss\u00edvel na presente pesquisa. A metodologia empregada aqui tamb\u00e9m pode ser utilizada em popula\u00e7\u00f5es com outras doen\u00e7as neurol\u00f3gicas ou mesmo em sujeitos saud\u00e1veis de diferentes faixas et\u00e1rias e n\u00edveis de escolaridade, a fim de compreender de forma mais profunda o processamento neural dos verbos e a utilidade da tarefa de flu\u00eancia de verbos.switching quando comparados a idoso saud\u00e1veis. Os resultados demonstram que a flu\u00eancia de verbos \u00e9 mais sens\u00edvel aos d\u00e9ficits cognitivos decorrentes de disfun\u00e7\u00e3o executiva que ocorrem na popula\u00e7\u00e3o estudada, do que aos d\u00e9ficits sem\u00e2nticos.Este estudo demonstrou que sujeitos com DA tem um preju\u00edzo no n\u00famero de verbos gerados corretamente na tarefa de flu\u00eancia de verbos e na habilidade de switching e clustering. Ainda, no \u00e2mbito cient\u00edfico, a metodologia empregada no presente estudo pode ser mais explorada em outras doen\u00e7as neurol\u00f3gicas para compreens\u00e3o de seus perfis cognitivos.\u00c9 poss\u00edvel que a tarefa de flu\u00eancia de verbos seja empregada na rotina cl\u00ednica para a avalia\u00e7\u00e3o cognitiva desta popula\u00e7\u00e3o auxiliando no diagn\u00f3stico, acompanhamento e na tomada de decis\u00e3o para a reabilita\u00e7\u00e3o neuropsicol\u00f3gica, atrav\u00e9s tamb\u00e9m das medidas de"}
+{"text": "Objetivo\u2003Apresentar e validar um registro eletr\u00f4nico de sa\u00fade (RES) multifuncional para atendimento ambulatorial a portadoras de endocrinopatias na gesta\u00e7\u00e3o e comparar a taxa de preenchimento de informa\u00e7\u00f5es de sa\u00fade com o prontu\u00e1rio convencional.M\u00e9todos\u2003Desenvolvemos um RES denominado Ambulat\u00f3rio de Endocrinopatias na Gesta\u00e7\u00e3o eletr\u00f4nico (AMBEG) para registro sistematizado das informa\u00e7\u00f5es de sa\u00fade. O AMBEG foi utilizado para atendimento obst\u00e9trico e endocrinol\u00f3gico de gestantes acompanhadas no ambulat\u00f3rio de endocrinopatias na gesta\u00e7\u00e3o na maternidade refer\u00eancia em gesta\u00e7\u00e3o de alto risco na Bahia, no per\u00edodo de janeiro de 2010 a dezembro de 2013. Aleatoriamente foram selecionadas 100 pacientes atendidas com o AMBEG e 100 pacientes atendidas com prontu\u00e1rio convencional com registro em papel e comparou-se a taxa de preenchimento de informa\u00e7\u00f5es cl\u00ednicas.Resultados\u2003Foram realizados 1461 atendimentos com o AMBEG: 253, 963 e 245 respectivamente, admiss\u00f5es, consultas de seguimento e puerp\u00e9rio. Eram portadoras de diabetes 77,2% e sendo 60,1% portadoras de diabetes pr\u00e9-gestacional. O AMBEG substituiu, satisfatoriamente, o prontu\u00e1rio convencional. O percentual de informa\u00e7\u00f5es cl\u00ednicas registradas em ambos os prontu\u00e1rios foi significativamente maior no AMBEG: queixas cl\u00ednicas , altura uterina , ganho de peso total  e dados espec\u00edficos sobre o diabetes  revelando diferen\u00e7a significativa . A possibilidade de exportar dados cl\u00ednicos para planilhas facilitou e agilizou a an\u00e1lise estat\u00edstica de dados.Conclus\u00f5es\u2003O AMBEG \u00e9 uma ferramenta \u00fatil no atendimento cl\u00ednico a mulheres portadoras de endocrinopatias na gesta\u00e7\u00e3o. A taxa de preenchimento de informa\u00e7\u00f5es cl\u00ednicas foi superior \u00e0 do prontu\u00e1rio convencional. A presen\u00e7a de diabetes mellitus na gesta\u00e7\u00e3o est\u00e1 associada a elevado risco de complica\u00e7\u00f5es.Tecnologias de informa\u00e7\u00e3o e comunica\u00e7\u00e3o em sa\u00fade (TICS) tem o potencial de otimizar a efici\u00eancia e efetividade dos profissionais de sa\u00fade.O uso do RES em portadores de diabetes est\u00e1 associado a melhores taxas de intensifica\u00e7\u00e3o de tratamento, monitora\u00e7\u00e3o, seguimento e otimiza o controle glic\u00eamico e lip\u00eddico.O objetivo do presente estudo \u00e9 apresentar um registro eletr\u00f4nico de sa\u00fade desenvolvido para atendimento de portadoras de endocrinopatias na gesta\u00e7\u00e3o, com \u00eanfase em diabetes, e os resultados do acompanhamento de gestantes no per\u00edodo de tr\u00eas anos, comparando a taxa de preenchimento das informa\u00e7\u00f5es do prontu\u00e1rio eletr\u00f4nico ao convencional.O presente trabalho reporta o desenvolvimento e a valida\u00e7\u00e3o de um aplicativo de banco de dados para atendimento de gestantes portadoras de diabetes no pr\u00e9-natal e um estudo do tipo caso-controle para comparar o atendimento m\u00e9dico por meio do prontu\u00e1rio eletr\u00f4nico ao convencional.Foi desenvolvido um aplicativo do banco de dados do Microsoft Access\u00ae, denominado Ambulat\u00f3rio de Endocrinopatias na Gesta\u00e7\u00e3o eletr\u00f4nico (AMBEG), para o registro eletr\u00f4nico sistematizado de informa\u00e7\u00f5es de sa\u00fade para o atendimento m\u00e9dico obst\u00e9trico e endocrinol\u00f3gico. Ap\u00f3s o desenvolvimento e teste, o AMBEG foi utilizado para o atendimento cl\u00ednico de uma amostra populacional consecutiva de pacientes acompanhadas ao ambulat\u00f3rio de endocrinopatias na gesta\u00e7\u00e3o da Maternidade Professor Jos\u00e9 Maria de Magalh\u00e3es Netto (MPJMMN) durante o per\u00edodo de janeiro de 2010 a dezembro de 2013. A pesquisa foi aprovada pelo comit\u00ea de \u00e9tica em pesquisa local.access/Jet, Microsoft SQL Server, Oraclee quaisquer dados compat\u00edveis comOpen Database Connectivity. Os campos de dados, formato de distribui\u00e7\u00e3o, constru\u00e7\u00e3o dos formul\u00e1rios foram criados a partir da organiza\u00e7\u00e3o habitual dos prontu\u00e1rios no atendimento convencional, sequenciando a ordem de entradas dos campos de acordo com a entrevista m\u00e9dica. Com o foco no acompanhamento do diabetes, foram acrescidos campos que garantissem a entrada de dados sobre todos os aspectos relevantes do acompanhamento cl\u00ednico como: dieta, tratamento, automonitora\u00e7\u00e3o, uso de insulinas e hipoglicemias. Foram criadas telas para atendimento \u00e0 primeira consulta, acompanhamento evolutivo da paciente (\u201cretorno\u201d), registro de dados laboratoriais, ultrassonografia obst\u00e9trica e dados de puerp\u00e9rio da portadora de patologias endocrinol\u00f3gicas na gesta\u00e7\u00e3o. O AMBEG seguiu as orienta\u00e7\u00f5es e inclui todos os itens obrigat\u00f3rios do prontu\u00e1rio eletr\u00f4nico definidos pela resolu\u00e7\u00e3o do CFM n. 1.638/2002.Para o desenvolvimento do AMBEG utilizou-se o aplicativo Microsoft Access\u00ae, que \u00e9 um sistema de gerenciamento de banco de dados da Microsoft que permite o desenvolvimento r\u00e1pido de aplica\u00e7\u00f5es que envolvem modelagem, estrutura de dados e interface a ser utilizada pelos usu\u00e1rios. \u00c9 capaz de utilizar dados armazenados emOs usu\u00e1rios do AMBEG foram o m\u00e9dico endocrinologista e os m\u00e9dicos residentes de obstetr\u00edcia e endocrinologia que cumpriam est\u00e1gio regular no ambulat\u00f3rio de endocrinopatias na gesta\u00e7\u00e3o. Os m\u00e9dicos usu\u00e1rios eram ensinados a utilizar o AMBEG atrav\u00e9s de demonstra\u00e7\u00e3o breve de cerca de dez minutos e treinados durante um atendimento. O aplicativo \u00e9 autoexplicativo e tem campos com mensagens, caixas de listas e m\u00e1scaras que controlam a entrada de dados. Ao final da consulta, o atendimento era impresso, assinado e arquivado.A avalia\u00e7\u00e3o do desempenho do aplicativo foi feita por meio da compara\u00e7\u00e3o da taxa de preenchimento de dados do atendimento no prontu\u00e1rio preenchido a m\u00e3o, denominado \u201catendimento convencional\u201c com a do preenchimento no prontu\u00e1rio eletr\u00f4nico, denominado \u201catendimento eletr\u00f4nico\u201d. Consideramos a diferen\u00e7a da taxa de preenchimento do dado \u201cqueixas cl\u00ednicas\u201d como o desfecho principal para o c\u00e1lculo do tamanho amostral. Estimando-se uma diferen\u00e7a m\u00e9dia na taxa de preenchimento de 15%, com o poder de 80% e o n\u00edvel de signific\u00e2ncia de 5%, o tamanho da amostra calculado para cada grupo foi de 99 indiv\u00edduos. Por meio de n\u00fameros aleat\u00f3rios gerados em Microsoft Excel\u00ae foram selecionados 100 prontu\u00e1rios preenchidos por atendimento convencional e 100, por atendimento eletr\u00f4nico.As informa\u00e7\u00f5es registradas no atendimento do primeiro retorno foram utilizadas para comparar a taxa de preenchimento de informa\u00e7\u00f5es entre os dois tipos de atendimento. Foram escolhidas vari\u00e1veis consideradas pelos autores como essenciais e representativas do atendimento \u00e0 portadora de diabetes na gesta\u00e7\u00e3o e categorizados em nove dom\u00ednios de dados: 1. Dados sobre queixas: descri\u00e7\u00e3o de presen\u00e7a ou nega\u00e7\u00e3o de queixas cl\u00ednicas ou obst\u00e9tricas; 2. Data\u00e7\u00e3o da gesta\u00e7\u00e3o: descri\u00e7\u00e3o da idade gestacional; 3. Exame f\u00edsico: descri\u00e7\u00e3o da press\u00e3o arterial, altura do fundo uterino, peso materno e ganho total de peso; 4. Aspectos nutricionais: descri\u00e7\u00e3o do uso de ado\u00e7ante artificial e descri\u00e7\u00e3o de ader\u00eancia ou n\u00e3o \u00e0 dieta; 5. Uso de medica\u00e7\u00f5es: descri\u00e7\u00e3o de hipoglicemiantes orais e de suplementos maternos; 6. Dados sobre insulinoterapia: informa\u00e7\u00e3o sobre o uso de insulina e esquema de insuliniza\u00e7\u00e3o; 7. Dados de automonitora\u00e7\u00e3o: registro de percentuais de glicemia acima, dentro e fora da meta; 8. Dados sobre hipoglicemias: descri\u00e7\u00e3o sobre hist\u00f3ria de hipoglicemia no per\u00edodo interconsulta e sobre reconhecimento e tratamento de hipoglicemias; descri\u00e7\u00e3o sobre o uso ou n\u00e3o do cart\u00e3o do diab\u00e9tico; 9. Dados sobre conduta: informa\u00e7\u00f5es sobre altera\u00e7\u00e3o ou n\u00e3o da conduta. Era considerada informa\u00e7\u00e3o \u201cpresente\u201d quando o campo estava preenchido e \u201causente\u201d quando n\u00e3o houvesse informa\u00e7\u00f5es.Todos os dados inseridos nos campos da entrevista m\u00e9dica eram, por comando simples, exportados para planilhas de Excel, que possibilitavam a an\u00e1lise estat\u00edstica.TM. Os dados dos registros eletr\u00f4nicos foram expressos como m\u00e9dia e desvio-padr\u00e3o ou mediana e varia\u00e7\u00e3o e as vari\u00e1veis categ\u00f3ricas, como valor absoluto e percentual. Vari\u00e1veis com dados dicot\u00f4micos foram comparadas utilizando-se o teste do qui-quadrado ou pelo exato de Fisher.A an\u00e1lise estat\u00edstica foi feita com programa SPSS v. 20.0 para WindowsO AMBEG foi desenvolvido com uma tela prim\u00e1ria, para direcionamento da navega\u00e7\u00e3o por meio de bot\u00f5es de cadastro de egressas, acesso \u00e0 primeira consulta e retornos e o fechamento da ferramenta 5678A anamnese completa e exame f\u00edsico foram registrados nos campos da tela \u201cprimeira consulta\u201d e as abas na borda superior davam acesso \u00e0s telas de \u201cretorno\u201d, \u201cpuerp\u00e9rio\u201d, \u201clab e imagem\u201d e \u201cUSG\u201d, onde eram inseridos, a cada consulta, respectivamente, dados sobre a evolu\u00e7\u00e3o durante a gravidez, do puerp\u00e9rio, exames laboratoriais, de imagem e ultrassonografia obst\u00e9trica. Em todas as telas de atendimento existiram campos alfa num\u00e9ricos, que permitem escrita livre; campos num\u00e9ricos, para vari\u00e1veis cont\u00ednuas como peso, altura, press\u00e3o arterial, altura do fundo uterino, batimentos fetais, idade gestacional, etc.; campos apoiados por listas permitem entradas categ\u00f3ricas predeterminadas e campos num\u00e9ricos com c\u00e1lculos autom\u00e1ticos, para otimizar e agilizar o atendimento como o c\u00e1lculo da idade gestacional (IG) e data prevista do parto pela data da \u00faltima menstrua\u00e7\u00e3o (DUM) e a primeira ultrassonografia; ganho de peso total e semanal, \u00edndice de massa corp\u00f3rea (IMC), dose total di\u00e1ria (DTD) de insulina e dose por quilo de peso, intervalo de tempo entre consultas, etc.Os usu\u00e1rios do AMBEG foram os m\u00e9dicos endocrinologistas e residentes de endocrinologia e obstetr\u00edcia, sendo que, estes \u00faltimos, faziam est\u00e1gio regular no ambulat\u00f3rio de endocrinopatias na gesta\u00e7\u00e3o por per\u00edodo de dois meses. A maioria dos m\u00e9dicos que utilizaram o AMBEG relataram estar muito satisfeitos com o uso e a impress\u00e3o foi que o AMBEG era de f\u00e1cil manejo, capaz de organizar a sequ\u00eancia de atendimento e minimizar falhas. Os c\u00e1lculos autom\u00e1ticos no AMBEG auxiliaram e agilizaram o atendimento, segundo os usu\u00e1rios (dados n\u00e3o mostrados).Durante o per\u00edodo de utiliza\u00e7\u00e3o, a necessidade de suporte t\u00e9cnico foi m\u00ednima e n\u00e3o ocasionou nenhum preju\u00edzo ao atendimento.Por meio do aplicativo eletr\u00f4nico 319 pacientes foram atendidas. Considerando-se primeiras consultas e consultas de retorno e puerp\u00e9rio, um total de 1460 atendimentos foram realizados no per\u00edodo avaliado, sendo 252 primeiras consultas, 963 \u201cretornos\u201d e 245 avalia\u00e7\u00f5es em puerp\u00e9rio. Sessenta e sete pacientes foram registradas pela primeira vez na tela \u201cRetorno\u201d, mas eram primeira consulta. Haviam sido admitidas e feita a primeira consulta na interna\u00e7\u00e3o, em prontu\u00e1rio preenchido a m\u00e3o.n\u2009=\u2009246). A m\u00e9dia de idade materna foi de 32\u2009\u00b1\u200910 anos e idade gestacional de 25\u2009\u00b1\u20097,8 semanas. O principal motivo de encaminhamento ao endocrinologista foi o diabetes , seguido de patologias tireoidianas. O diabetes pr\u00e9-gestacional foi o principal tipo de diabetes encaminhado correspondendo a 60,1% dos casos , altura do fundo uterino , ganho total de peso  e quest\u00f5es especificas para as portadoras de diabetes: dieta , esquema de insulina , controle glic\u00eamico , hist\u00f3ria de hipoglicemias , reconhecimento  e tratamento de hipoglicemias  e se porta consigo o cart\u00e3o de diabetes .A compara\u00e7\u00e3o da frequ\u00eancia de registro de informa\u00e7\u00f5es nos nove dom\u00ednios de dados entre os dois tipos de atendimento est\u00e1 demonstrada naO uso da informa\u00e7\u00e3o cl\u00ednica eletr\u00f4nica tem o potencial de melhorar a qualidade e a efici\u00eancia do cuidado m\u00e9dico.Nos \u00faltimos anos tem havido especial interesse e investimento em tecnologias de informa\u00e7\u00e3o e comunica\u00e7\u00e3o em sa\u00fade em v\u00e1rias partes do mundo.Os m\u00e9dicos que utilizaram o AMBEG aprenderam rapidamente como operar o RES. Relataram estar satisfeitos com as funcionalidades, referiram ser de f\u00e1cil manejo e capaz de organizar a sequ\u00eancia de atendimento, minimizando falhas. Reportaram tamb\u00e9m que os c\u00e1lculos autom\u00e1ticos foram \u00fateis e agilizaram o atendimento. Ainda que ginecologistas e obstetras revelem elevada satisfa\u00e7\u00e3o com os sistemas eletr\u00f4nicos para atendimento ao pacienteEletronic Health Records for Clinical ResearchO presente trabalho tamb\u00e9m demonstrou a facilidade no acesso \u00e0s informa\u00e7\u00f5es coletadas, armazenamento e an\u00e1lise dos dados cl\u00ednicos registrados eletronicamente. O registro cl\u00ednico em prontu\u00e1rios preenchido a m\u00e3o imp\u00f5e dificuldades no acesso e levantamento de dados, limitando avalia\u00e7\u00f5es de qualidade de atendimento, consultas e pesquisas m\u00e9dicas. O registro eletr\u00f4nico no AMBEG possibilitou a exporta\u00e7\u00e3o r\u00e1pida de informa\u00e7\u00f5es com a cria\u00e7\u00e3o de bancos de dados. Os campos estruturados permitiram consulta r\u00e1pida e an\u00e1lise, fornecendo informa\u00e7\u00f5es para pesquisas e levantamentos epidemiol\u00f3gicos. A utiliza\u00e7\u00e3o de dados de prontu\u00e1rios eletr\u00f4nicos para dar suporte a pesquisas cl\u00ednicas \u00e9 uma tend\u00eancia mundial e iniciativas, como o projetoA frequ\u00eancia do registro de dados cl\u00ednicos considerados relevantes na consulta foi significativamente maior no atendimento feito com o AMBEG em rela\u00e7\u00e3o ao atendimento convencional, em papel. A estrutura\u00e7\u00e3o dos campos de dados de consulta, a legibilidade, praticidade e os c\u00e1lculos autom\u00e1ticos provavelmente auxiliaram na organiza\u00e7\u00e3o do atendimento e na lembran\u00e7a do questionamento dos dados da consulta. Estas funcionalidades e os resultados do presente estudo segue a dire\u00e7\u00e3o atual dos conhecimentos que demonstram a utilidade do registro eletr\u00f4nico em melhorar a qualidade do registro cl\u00ednico.linkscom informa\u00e7\u00f5es m\u00e9dicas para educa\u00e7\u00e3o continuada e sistemas de alertas e avisos que funcionam como apoio a decis\u00e3o diagn\u00f3stica e terap\u00eautica. Adicionalmente, o registro de informa\u00e7\u00f5es foi significativamente mais frequente na consulta realizado com o AMBEG, entretanto n\u00e3o avaliamos o impacto do uso na qualidade da assist\u00eancia pr\u00e9-natal e perinatal da gestante portadora de diabetes. Acreditamos que a sistematiza\u00e7\u00e3o do atendimento e o preenchimento mais completo dos dados relevantes da consulta possam se associar a redu\u00e7\u00e3o de eventos maternos e fetais, o que poder\u00e1 ser investigado em outros estudos. A informa\u00e7\u00e3o sobre o tempo de atendimento n\u00e3o foi registrada para permitir a compara\u00e7\u00e3o, portanto n\u00e3o podemos assegurar se o prontu\u00e1rio eletr\u00f4nico reduz o tempo de consulta, mas esta funcionalidade tamb\u00e9m pode ser agregada ao aplicativo possibilitando avalia\u00e7\u00f5es futuras.Apresentaram-se como limita\u00e7\u00f5es do trabalho, o tipo do PEP e a aus\u00eancia de avalia\u00e7\u00e3o dos desfechos materno-fetais. O AMBEG \u00e9 um PEP b\u00e1sico, que funciona como um registro eletr\u00f4nico de sa\u00fade. Os PEP completosComo pontos fortes do trabalho destacamos a originalidade do RES e aus\u00eancia de publica\u00e7\u00f5es sobre o assunto na literatura brasileira. Diante das dificuldades de assist\u00eancia em sa\u00fade no Brasil, da crescente preval\u00eancia do diabetes na gesta\u00e7\u00e3o com suas complica\u00e7\u00f5es e da necessidade de padroniza\u00e7\u00e3o de atendimento e da conduta para otimizar as metas em sa\u00fade, demonstramos a utiliza\u00e7\u00e3o de uma ferramenta de baixo custo com suporte t\u00e9cnico m\u00ednimo capaz de aumentar a frequ\u00eancia do registro de dados cl\u00ednicos no pr\u00e9-natal de portadoras de diabetes na gesta\u00e7\u00e3o. A maior frequ\u00eancia de registro de dados cl\u00ednicos sobre hipoglicemias merece destaque pois estas informa\u00e7\u00f5es representam aten\u00e7\u00e3o dedicada \u00e0 seguran\u00e7a para a bin\u00f4mio materno-fetal o que poderia reduzir morbidades. O AMBEG tem o potencial de melhorar a assist\u00eancia pr\u00e9-natal de alto risco, incorporar tecnologias para otimizar os desfechos cl\u00ednicos atrav\u00e9s da facilita\u00e7\u00e3o de ader\u00eancia aos protocolos cl\u00ednicos e assistenciais, oferecer mais seguran\u00e7a \u00e0 paciente, al\u00e9m de proporcionar fonte de dados para levantamentos epidemiol\u00f3gicos e tratamento estat\u00edstico \u00fateis para programas de aten\u00e7\u00e3o especializada ao diabetes na gesta\u00e7\u00e3o e pesquisa cl\u00ednica.O registro eletr\u00f4nico AMBEG \u00e9 uma ferramenta de baixo custo, com necessidade de m\u00ednimo suporte t\u00e9cnico e f\u00e1cil utiliza\u00e7\u00e3o que aumentou a frequ\u00eancia de registro de informa\u00e7\u00f5es da consulta e padronizou o atendimento cl\u00ednico a mulheres portadoras de endocrinopatias na gesta\u00e7\u00e3o, com \u00eanfase no diabetes. O potencial de expans\u00e3o da ferramenta \u00e9 amplo com perspectiva de melhora no atendimento por meio de tecnologia incorporada como alertas e interoperacionalidade com outros sistemas ambulatoriais e hospitalares. Recomenda-se mais estudos para avaliar o impacto a utiliza\u00e7\u00e3o da ferramenta nos desfechos cl\u00ednicos."}
+{"text": "Objetivo\u2003Verificar diferen\u00e7as em alguns aspectos nutricionais de gestantes acompanhadas em servi\u00e7o de aten\u00e7\u00e3o pr\u00e9-natal em uma cidade do interior e na regi\u00e3o metropolitana.M\u00e9todos\u2003Foram avaliadas gestantes em atendimento pr\u00e9-natal na cidade de Belo Horizonte (BH), regi\u00e3o metropolitana, e Paula C\u00e2ndido (PC), interior de MG. Aplicou-se um Question\u00e1rio de Frequ\u00eancia Alimentar (QFA) contendo informa\u00e7\u00f5es socioecon\u00f4micas e sobre o h\u00e1bito alimentar, al\u00e9m disso, foram aferidos peso e altura no momento do atendimento e questionado o peso pr\u00e9-gestacional, para posterior c\u00e1lculo do IMC (\u00edndice de massa corp\u00f3rea). A an\u00e1lise dos dados foi dividida por regi\u00e3o e trimestre gestacional, utilizando o software SPSS vers\u00e3o 15.0, teste t para compara\u00e7\u00e3o de m\u00e9dias e qui-quadrado de independ\u00eancia, com 5% de signific\u00e2ncia.Resultados\u2003Foram inclu\u00eddas 240 gestantes, sendo 90 do interior e 150 da regi\u00e3o metropolitana. Destas, a maioria s\u00e3o casadas , n\u00e3o trabalham fora de casa , predominantemente se alimentam 3 a 4 vezes ao dia no 1\u00b0 e 2\u00b0 trimestre  e fazem 5 a 6 refei\u00e7\u00f5es ao dia no 3\u00b0 trimestre em BH (44%). Houve ganho de peso significativo somente no 1\u00b0 trimestre . Ganho de peso versus h\u00e1bito alimentar foi significativo para as vari\u00e1veis \u201calmo\u00e7a ou janta fora de casa,\u201d no 1\u00b0 trimestre BH ; \u201cquantas vezes consome leite,\u201d no 1\u00b0 trimestre PC; \u201cquantas vezes consomefastfood,\u201d no 3\u00b0 trimestre BH .Conclus\u00f5es\u2003As gestantes em ambas regi\u00f5es se alimentam de forma adequada, apesar da preval\u00eancia de sobrepeso pr\u00e9-gestacional em BH e baixo n\u00edvel de escolaridade e renda, principalmente no interior, indicador que pode ser pouco favor\u00e1vel \u00e0 nutri\u00e7\u00e3o das gestantes neste per\u00edodo. Estudos de associa\u00e7\u00e3o entre h\u00e1bito alimentar e sa\u00fade do rec\u00e9m-nascido ir\u00e3o contribuir para maiores informa\u00e7\u00f5es sobre a nutri\u00e7\u00e3o no per\u00edodo gestacional. A gesta\u00e7\u00e3o \u00e9 um per\u00edodo que imp\u00f5e necessidades nutricionais aumentadas, e a adequada nutri\u00e7\u00e3o \u00e9 primordial para a sa\u00fade da m\u00e3e e do feto. Gestantes devem consumir alimentos em variedade e quantidade espec\u00edficas, considerando as recomenda\u00e7\u00f5es dos guias alimentares e as pr\u00e1ticas alimentares culturais, para atingir as necessidades energ\u00e9ticas e nutricionais, e as recomenda\u00e7\u00f5es de ganho de peso.As gestantes s\u00e3o suscet\u00edveis \u00e0 inadequa\u00e7\u00e3o nutricional, pelo aumento da demanda de energia, macro e micronutrientes, que ocorrem durante a gravidez. A qualidade da alimenta\u00e7\u00e3o e o estado nutricional da mulher, antes e durante a gravidez, afetam o crescimento e o desenvolvimento fetal, bem como a evolu\u00e7\u00e3o da gesta\u00e7\u00e3o.A inadequa\u00e7\u00e3o do ganho de peso durante a gesta\u00e7\u00e3o tem sido apontada como fator de risco tanto para a m\u00e3e quanto para o concepto.Neste sentido, \u00e9 fundamental dispor de instrumentos capazes de avaliar a ingest\u00e3o alimentar materna de forma a identificar, com efic\u00e1cia e precis\u00e3o, associa\u00e7\u00f5es diretas entre a alimenta\u00e7\u00e3o e a sa\u00fade da m\u00e3e e do feto. Na literatura atual sobre as rela\u00e7\u00f5es entre a alimenta\u00e7\u00e3o, sa\u00fade e preven\u00e7\u00e3o de doen\u00e7as n\u00e3o transmiss\u00edveis destaca-se, precisamente, o interesse exponencial em examinar a alimenta\u00e7\u00e3o humana numa perspectiva multidimensional, por oposi\u00e7\u00e3o \u00e0 vis\u00e3o direcionada para apenas um nutriente, alimento, ou mesmo, grupo de alimentos.O presente estudo teve como objetivo verificar se existem diferen\u00e7as importantes em alguns aspectos nutricionais entre dois grupos de gestantes acompanhadas em servi\u00e7os de aten\u00e7\u00e3o pr\u00e9-natal, na regi\u00e3o metropolitana e em uma pequena cidade do interior do Estado de Minas Gerais, Brasil.O presente trabalho teve a participa\u00e7\u00e3o de 240 gestantes, em idade entre 18 a 40 anos, em atendimento pr\u00e9-natal no Ambulat\u00f3rio Jenny Faria, em Belo Horizonte (BH) e Posto de Sa\u00fade Padre Ant\u00f4nio Mendes, situado na cidade de Paula C\u00e2ndido (PC), MG. As gestantes foram divididas em grupos, de acordo com cada trimestre, sendo 30 gestantes por trimestre na cidade do interior e 50 por trimestre na regi\u00e3o metropolitana, totalizando 90 gestantes acompanhadas em Paula C\u00e2ndido e 150 em Belo Horizonte. O quantitativo amostral foi baseado a partir da metodologia de diversos estudos publicados. O trabalho apresentou modelo do tipo transversal, havendo um contato com cada gestante.Foi aplicado um question\u00e1rio de frequ\u00eancia alimentar(QFA) contendo informa\u00e7\u00f5es como idade, cor, escolaridade, estado civil, trabalho fora de casa e renda mensal. Al\u00e9m disto, foram aferidos o peso e estatura atual, assim como questionado o peso habitual anterior \u00e0 gesta\u00e7\u00e3o . Caso a gestante n\u00e3o se lembrasse, foi utilizado o primeiro peso no cart\u00e3o da gestante, posteriormente foi calculado o IMC (\u00edndice de massa corp\u00f3rea) pr\u00e9-gestacional e atual.Em rela\u00e7\u00e3o \u00e0 alimenta\u00e7\u00e3o foram analisadas quest\u00f5es como: quantas refei\u00e7\u00f5es fazem ao dia, se tem costume de tomar caf\u00e9 (com a\u00e7\u00facar) toda hora, \u00f3leo utilizado nas refei\u00e7\u00f5es e consumo de refrigerante.fastfood; alimentos ricos em a\u00e7\u00facares e/ou gorduras; refrigerante e doces.O QFA foi dividido em grupos alimentares e considerando os h\u00e1bitos regionais. Utilizou-se como refer\u00eancia o question\u00e1rio espec\u00edfico para gestantes, validado por Giacomello et al.Os crit\u00e9rios de exclus\u00e3o para o estudo foi a presen\u00e7a de diabetes ou outras doen\u00e7as end\u00f3crinas, ecl\u00e2mpsia ou pr\u00e9-ecl\u00e2mpsia, anemia ou outra defici\u00eancia nutricional previamente detectada em exame, al\u00e9m de vegetarianismo e intoler\u00e2ncia a gl\u00faten e/ou lactose, pois poderia influenciar no h\u00e1bito alimentar.A ingest\u00e3o alimentar habitual foi avaliada levando em considera\u00e7\u00e3o as por\u00e7\u00f5es recomendadas para cada grupo de alimentos na Pir\u00e2mide Alimentar Adaptada para gestantesEm rela\u00e7\u00e3o \u00e0 an\u00e1lise estat\u00edstica, foi realizado uma an\u00e1lise descritiva para as vari\u00e1veis quantitativas e qualitativas, com o uso de medidas de tend\u00eancia central .Em um segundo momento, foi realizado uma compara\u00e7\u00e3o entre regi\u00e3o metropolitana e interior, relacionando o ganho de peso com as vari\u00e1veis de alimenta\u00e7\u00e3o. A compara\u00e7\u00e3o foi feita de forma inferencial, utilizando o teste qui-quadrado de Independ\u00eancia para avaliar rela\u00e7\u00e3o do ganho de peso com a alimenta\u00e7\u00e3o, diferenciando para cada regi\u00e3o. O n\u00edvel de signific\u00e2ncia para todos os testes foi de 5%, e utilizado o programa SPSS vers\u00e3o 15.0.Em rela\u00e7\u00e3o \u00e0s vari\u00e1veis socioecon\u00f4micas, em ambos os grupos, houve predom\u00ednio das gestantes que s\u00e3o casadas  e n\u00e3o trabalham fora de casa , a vari\u00e1vel escolaridade apresentou maior porcentagem de ensino m\u00e9dio completo na regi\u00e3o metropolitana (46%) e ensino fundamental incompleto na regi\u00e3o interior  .p\u2009=\u20090,002), peso pr\u00e9-gestacional , peso atual  IMC pr\u00e9-gestacional  e IMC atual . No 3\u00b0 trimestre houve signific\u00e2ncia apenas para vari\u00e1vel peso atual   .n\u2009=\u200922). O ganho de peso foi dividido por trimestre e calculado o ganho ponderal significativo ou n\u00e3o, baseado nas recomenda\u00e7\u00f5es propostas pelo IOM.A frequ\u00eancia das refei\u00e7\u00f5es di\u00e1rias obtiveram predom\u00ednio de 3 a 4 refei\u00e7\u00f5es por dia no 1\u00b0 e 2\u00b0 trimestres , exceto entre as gestantes do 3\u00b0 trimestre de BH, que consumiam 5 a 6 refei\u00e7\u00f5es ao dia ; \u201cquantas vezes consome leite,\u201d no 1\u00b0 trimestre do grupo do interior ; \u201cquantas vezes consomefastfood,\u201d no 3\u00b0 trimestre das gestantes de BH   .*Um resultado importante encontrado no estudo foi a preval\u00eancia de sobrepeso no per\u00edodo pr\u00e9-gestacional na regi\u00e3o metropolitana, j\u00e1 que todas as m\u00e9dias de IMC se enquadraram na faixa de sobrepeso. Al\u00e9m disto, foi observado ganho de peso significativo somente no primeiro trimestre em ambas as regi\u00f5es, no segundo e terceiro trimestres a maioria das gestantes obtiveram ganho de peso dentro do recomendado.A gesta\u00e7\u00e3o pode atuar como desencadeante da obesidade ou como agravante, quando esta for preexistente. Na avalia\u00e7\u00e3o do estado nutricional durante per\u00edodo da gesta\u00e7\u00e3o, houve um aumento no sobrepeso quando comparados com o per\u00edodo pr\u00e9-gestacional, semelhantes a outros estudos.O estado nutricional pr\u00e9-gestacional \u00e9 um dos principais fatores associados ao ganho de peso durante a gravidez.Em rela\u00e7\u00e3o \u00e0s vari\u00e1veis socioecon\u00f4micas, notamos que o n\u00edvel de escolaridade \u00e9 menor no interior e, al\u00e9m disto, menos gestantes se encontram inseridas no mercado de trabalho. A literatura refere que condi\u00e7\u00f5es socioecon\u00f4micas desfavor\u00e1veis produzem resultados insatisfat\u00f3rios na sa\u00fade da popula\u00e7\u00e3o em geral, e quanto maior a renda, maior o poder de compra e acesso a alimenta\u00e7\u00e3o variada,Como dito anteriormente, foi observado nas gestantes de BH uma tend\u00eancia a sobrepeso e maior n\u00edvel de escolaridade, tal como em estudo realizado em S\u00e3o Paulo, em que gestantes com quatro anos ou mais de estudo apresentaram ganho de quase dois quilos a mais quando comparadas \u00e0s demais, sendo a escolaridade considerada um marcador de acesso aos alimentos.fastfood, alimentos ricos em a\u00e7\u00facares e/ou gorduras e refrigerante. Isto pode ser consequ\u00eancia do fato de uma nutricionista aplicar os question\u00e1rios, levando as gestantes a informar uma alimenta\u00e7\u00e3o saud\u00e1vel, j\u00e1 que as mesmas possuem informa\u00e7\u00f5es sobre alimenta\u00e7\u00e3o saud\u00e1vel, por\u00e9m, nem sempre as colocam em pr\u00e1tica.O n\u00famero de refei\u00e7\u00f5es di\u00e1rias \u00e9 menor que o preconizado por Accioly et al,Uma limita\u00e7\u00e3o do estudo foi a utiliza\u00e7\u00e3o do QFA como m\u00e9todo de avalia\u00e7\u00e3o do consumo alimentar, uma vez que ele cont\u00e9m grupos de alimentos, limitando uma compara\u00e7\u00e3o com hist\u00f3ria diet\u00e9tica.Estudos recentes demonstram que alimentos processados e industrializados tem sido identificado entre as gestantes em diversas regi\u00f5es do mundo e reflete as mudan\u00e7as ocorridas no mundo moderno, como a busca por maior comodidade, praticidade e rapidez, que afetam diretamente a alimenta\u00e7\u00e3o da popula\u00e7\u00e3o.Nota-se preval\u00eancia de consumo de frutas, leite e salada de vegetais crus ou cozidos . Estes h\u00e1bitos contribuem com a adequa\u00e7\u00e3o de prote\u00ednas e carboidratos simples e complexos e dos micronutrientes (vitaminas e minerais). Assim, podem estar associados a melhores condi\u00e7\u00f5es de sa\u00fade da gestante e ao crescimento e desenvolvimento fetal. Deve-se salientar que esses padr\u00f5es apresentam em suas composi\u00e7\u00f5es nutrientes essenciais para a sa\u00fade humana e s\u00e3o considerados os mais pr\u00f3ximos das recomenda\u00e7\u00f5es diet\u00e9ticas emanadas atualmente para gesta\u00e7\u00e3o e como tal, pode ser o mais intuitivamente associado \u00e0s melhores condi\u00e7\u00f5es de sa\u00fade na gesta\u00e7\u00e3o, ao crescimento e desenvolvimento adequado do feto.Muito ainda h\u00e1 que ser feito para que mais gestantes atentem para educa\u00e7\u00e3o nutricional satisfat\u00f3ria. S\u00f3 assim, elas poder\u00e3o compreender melhor o per\u00edodo e as mudan\u00e7as que est\u00e3o vivenciando e poder\u00e3o praticar h\u00e1bitos alimentares saud\u00e1veis.O presente estudo permitiu concluir que as gestantes da regi\u00e3o metropolitana e interior, de modo geral, se alimentam de maneira adequada, com h\u00e1bitos alimentares diversificados e favor\u00e1veis \u00e0 manuten\u00e7\u00e3o da sa\u00fade, rico em frutas e verduras. Por\u00e9m, tamb\u00e9m se verificou um perfil sociodemogr\u00e1fico pouco favor\u00e1vel ao per\u00edodo gestacional, com baixa escolaridade e renda das entrevistadas, principalmente no interior. Sugere-se que estudos mais detalhados sejam realizados, verificando a associa\u00e7\u00e3o entre o perfil alimentar da gestante e a sa\u00fade do rec\u00e9m-nascido, para que seja poss\u00edvel identificar os fatores de risco gestacionais para a sa\u00fade da m\u00e3e e do concepto."}
+{"text": "Ele busca reduzir a mortalidade hospitalar, melhorar os processos hospitalares, \u2013 com foco na seguran\u00e7a e qualidade assistencial ao paciente cardiol\u00f3gico \u2013 e tamb\u00e9m reconhecer como centros de excel\u00eancia em cardiologia os hospitais que atinjam as metas propostas. A m\u00e9trica de avalia\u00e7\u00e3o deste programa baseia-se em identificar a taxa de ades\u00e3o dos profissionais de sa\u00fade \u00e0s recomenda\u00e7\u00f5es das diretrizes da SBC e da AHA no tratamento destas tr\u00eas doen\u00e7as card\u00edacas. Al\u00e9m disso, analisar o efeito sobre os desfechos tempo de interna\u00e7\u00e3o, mortalidade por doen\u00e7a card\u00edaca, mortalidade por todas as causas, reinterna\u00e7\u00e3o, qualidade de vida e percep\u00e7\u00e3o de sa\u00fade dos pacientes antes e ap\u00f3s a implementa\u00e7\u00e3o do programa.2Visando o aumento da qualidade no cuidado cardiovascular em hospitais p\u00fablicos brasileiros surge o Programa Boas Pr\u00e1ticas em Cardiologia (BPC),5 se debru\u00e7a sobre dados de 1036 pacientes adultos internados com diagn\u00f3stico prim\u00e1rio de SCA e IC no per\u00edodo de 2016 a 2019 em um hospital p\u00fablico terci\u00e1rio de Minas Gerais, onde o Programa BPC foi aplicado.Contribuindo com esta iniciativa, o estudo de Passaglia et al.,benchmark estabelecido pelo Programa BPC. O indicador de aconselhamento para parar de fumar ficou em 81,5%. Em rela\u00e7\u00e3o ao tratamento da IC, dos 5 indicadores de desempenho previstos, somente 3  tiveram taxa de ades\u00e3o acima de 85,0%. Os outros 2  ficaram em 82,7% e 70,9%, respectivamente. Ou seja, abaixo do patamar preconizado. A taxa de \u00f3bito na interna\u00e7\u00e3o ficou em 2,9% dos 763 pacientes com SCA e em 17,9% dos 273 pacientes com IC. Os dados evidenciados por este estudo demonstram nitidamente um espa\u00e7o para aperfei\u00e7oamento nos processos de cuidado e ades\u00e3o \u00e0s melhores pr\u00e1ticas baseadas em evid\u00eancias no tratamento da IC neste hospital terci\u00e1rio p\u00fablico.Embora neste estudo as taxas de ades\u00e3o global dos profissionais assistenciais aos indicadores de desempenho estabelecidos nas diretrizes da SBC e AHA terem sido altas e semelhantes, tanto no tratamento da SCA , quanto no tratamento da IC , se faz necess\u00e1rio escrutinar cada indicador. Na SCA, dos 8 indicadores de desempenho propostos, 7 foram avaliados (a terapia de reperfus\u00e3o adequada n\u00e3o pode ser aferida). Destes, 6  apresentaram taxa de ades\u00e3o acima de 85,0%, 6 A relev\u00e2ncia do estudo de Passaglia et al.5 vem corroborar a import\u00e2ncia da utiliza\u00e7\u00e3o de m\u00e9tricas de avalia\u00e7\u00e3o e acompanhamento, como esta implementada pelo Programa BPC, que objetivamente explicitem defici\u00eancias e virtudes e contribuem com o aperfei\u00e7oamento dos processos hospitalares e da qualidade na assist\u00eancia em cardiologia.Programas se prop\u00f5em a melhorar a qualidade da assist\u00eancia em hospitais p\u00fablicos do SUS contribuem, de um lado, para a qualidade no atendimento e melhora dos desfechos e, de outro, n\u00e3o menos importante, para a redu\u00e7\u00e3o da inefici\u00eancia e consequente mitiga\u00e7\u00e3o de desperd\u00edcios financeiros de recursos escassos. A defini\u00e7\u00e3o de indicadores, metas de desempenho e monitoramento fazem parte do arcabou\u00e7o de conhecimento para a implanta\u00e7\u00e3o de a\u00e7\u00f5es que visem \u00e0 efici\u00eancia e qualidade da presta\u00e7\u00e3o de servi\u00e7o em sa\u00fade. 1 considers the quality of care as \u201c\u2026the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with evidence-based professional knowledge.\u201d In addition, it considers quality health services to be those that are effective, efficient, safe, equitable, and people-centered.1The World Health Organization2 was created, an initiative of the Sociedade Brasileira de Cardiologia (SBC) in partnership with the Ministry of Health of Brazil and support from the American Heart Association (AHA) and the Hospital HCor, through the adaptation of the AHA program entitled Get With The Guidelines\u00ae (GWTG).4 The Brazilian program focuses on the most expensive heart diseases, such as acute coronary syndrome (ACS), atrial fibrillation (AF), and heart failure (HF). It seeks to reduce hospital mortality, improve hospital processes \u2013 with a focus on safety and quality of care for cardiac patients \u2013 and also recognize hospitals that achieve the proposed goals as centers of excellence in cardiology. The evaluation metric of this program is based on identifying the adherence rate of health professionals to the recommendations of the SBC and AHA guidelines in treating these three heart diseases. In addition, to analyze the effect on the outcomes, length of stay, mortality from heart disease, all-cause mortality, rehospitalization, quality of life, and patients perception of health before and after the program implementation.2Aiming to increase the quality of cardiovascular care in Brazilian public hospitals, the Good Practices in Cardiology Program (BPC)5 focuses on data from 1036 adult patients hospitalized with a primary diagnosis of ACS and HF from 2016 to 2019 in a tertiary public hospital in Minas Gerais, where the BPC Program implementation was applied.Contributing to this initiative, the study by Passaglia et al.Although in this study the overall adherence rates of healthcare professionals attending performance indicators established in the SBC and AHA guidelines have been high and similar, both in the treatment of ACS (92.9%), as in the treatment of HF (91.2%), it is necessary scrutinize each indicator. In ACS, of the eight proposed performance indicators, seven were evaluated (appropriate reperfusion therapy cannot be measured). Of these, six  showed adherence rate above 85.0%, benchmark established by the BPC Program. The indicator counseling to stop smoking was 81.5%. Regarding the treatment of HF, of the five predicted performance indicators, only three  had an adherence rate above 85.0%. The other two  were 82.7% and 70.9%, respectively. Both are below the recommended level. The death rate during hospitalization was 2.9% of the 763 patients with ACS and 17.9% of the 273 patients with HF. The data evidenced by this study clearly demonstrate a space for improvement in care processes and adherence to evidence-based to the best evidence-based practices in the treatment of HF in this public tertiary hospital.6 The relevance of the study by Passaglia et al.5 corroborates the importance of using evaluation and follow-up metrics, such as the one implemented by the BPC Program, which objectively reveals deficiencies and virtues and contributes to the improvement of hospital processes and the quality of care in cardiology.Programs that aim to improve the quality of care in hospitals in the Brazilian public health system (SUS) contribute, on the one hand, to the quality of care and improvement of outcomes and, on the other hand, not least, to the reduction of inefficiency and consequent mitigation of financial waste of scarce resources. The definition of indicators, performance targets, and monitoring are parts of the knowledge framework for implementing actions aimed at the efficiency and quality of health service delivery."}
+{"text": "Primavera silenciosa , o rev\u00e9s do desenvolvimento tecnol\u00f3gico damodernidade industrial na agricultura: a polui\u00e7\u00e3o qu\u00edmica. A abordagem b\u00e9lica de combate\u00e0s pragas que se aproveitavam dos agroecossistemas desequilibrados das monoculturasresultou no uso indiscriminado do DDT, de organoclorados e outros agrot\u00f3xicos. A obra ea atua\u00e7\u00e3o de Rachel Carson incentivaram intenso ativismo ambiental nas d\u00e9cadas seguintese levaram \u00e0 proibi\u00e7\u00e3o de algumas dessas subst\u00e2ncias no Norte global, bem como revelarama irresponsabilidade cient\u00edfica do governo estadunidense junto \u00e0 ind\u00fastria qu\u00edmica  torna-se o fiocondutor do livro para abordar a invisibiliza\u00e7\u00e3o da toxicidade. De acordo com osautores, o termo contempla o estudo da ignor\u00e2ncia em tr\u00eas tipos taxon\u00f4micos. O primeiroseria a ignor\u00e2ncia tradicional, o desconhecimento sobre determinado assunto. O segundotipo \u00e9 resultante de decis\u00f5es seletivas da comunidade cient\u00edfica, em que algunsintegrantes prop\u00f5em resolu\u00e7\u00f5es que passivamente aceitam procedimentos e par\u00e2metros detoxicidade com risco para a sa\u00fade humana e ambiental. Por fim, h\u00e1 a ignor\u00e2nciaconstru\u00edda de maneira ativa e premeditada. Essa modalidade \u00e9 feita diretamente pelacomunidade cient\u00edfica em seus relatos para a m\u00eddia ou em relat\u00f3rios t\u00e9cnicos, assim comopor membros do governo ou das empresas com interesse em delinear estrat\u00e9gias para gerarinforma\u00e7\u00f5es duvidosas, criar incertezas ou manipular dados. A an\u00e1lise historiogr\u00e1ficadesses dois \u00faltimos tipos de ignor\u00e2ncia navega por uma t\u00eanue linha de interpreta\u00e7\u00e3o deintencionalidades, entre a neglig\u00eancia involunt\u00e1ria e a deliberada.Nove dos dez cap\u00edtulos se referem \u00e0 Espanha (e um ao Chile) e apresentam um pa\u00eds onde assubst\u00e2ncias qu\u00edmicas causaram e ainda causam sofrimento, com uma viol\u00eancia lenta sobreas pessoas, cujo processos de resist\u00eancia s\u00e3o invisibilizados e assim\u00e9tricos em rela\u00e7\u00e3oa grupos hegem\u00f4nicos, como grandes corpora\u00e7\u00f5es ou Estados autorit\u00e1rios (assim como osgovernos de Franco ou Pinochet). Em todos os textos houve um claro posicionamentocr\u00edtico para analisar e revelar os mecanismos sutis de oculta\u00e7\u00e3o dessas toxicidades pelapr\u00e1tica e pelo discurso t\u00e9cnico-cient\u00edfico das empresas e institui\u00e7\u00f5es estatais.A maioria dos cap\u00edtulos \u00e9 de integrantes do grupo de pesquisa Toxic Spain e derivou dosdebates ocorridos principalmente na Escola de Primavera de Hist\u00f3ria da Ci\u00eancia, emMenorca, 2015. Tais preparo e organiza\u00e7\u00e3o trouxeram grande coes\u00e3o e unicidade ao livro,articulando estilo de escrita, uso de conceitos e an\u00e1lise de fontes historiogr\u00e1ficas. Osautores apostaram em caminhos interdisciplinares para contemplar tanto dadosquantitativos e estat\u00edsticos resultantes de estudos de determinadas subst\u00e2ncias ouespa\u00e7os enfermos quanto o estudo de testemunhos pessoais, jornais e document\u00e1rios. Outroaspecto de coes\u00e3o, al\u00e9m da narrativa da constru\u00e7\u00e3o da ignor\u00e2ncia e desses caminhosinterdisciplinares e suas fontes, foi o uso da m\u00eddia visual no in\u00edcio de cada cap\u00edtulo,com fotografias de jornais, charges, document\u00e1rios e outros, apontando como o tema datoxicidade perpassava a sociedade espanhola, explicitando-o ou invisibilizando-o.Dos dez cap\u00edtulos, quatro concentram a an\u00e1lise em subst\u00e2ncias perigosas com altopotencial de toxicidade. O primeiro cap\u00edtulo, \u201cEl vinu espa\u00f1ol y el espiritu alem\u00e1n\u201d,retrata como se deu a chegada do \u00e1lcool industrial alem\u00e3o em disputa com o vinhoespanhol num complexo conflito discursivo entre elites quanto \u00e0 sua toxicidade, emjornais, revistas e relat\u00f3rios. Em \u201cLa (in)visibilizaci\u00f3n del riesgo de fumigacionescianh\u00eddricas\u201d, o autor explana como os t\u00e9cnicos exaltavam a efic\u00e1cia do \u00e1cido cian\u00eddricocontra os insetos herb\u00edvoros nas oliveiras enquanto ocultavam o risco \u00e0 vida dostrabalhadores rurais. Ainda no \u00e2mbito rural de combate \u00e0s pragas, em \u201cEl escarabajo delmarqu\u00e9s\u201d o autor aponta como o uso do ars\u00eanico contra o besouro da batata antecedeu emd\u00e9cadas o amplo uso do DDT na \u00e9poca da ditadura de Francisco Franco (1939-1975). Ainvisibiliza\u00e7\u00e3o da toxicidade tornou-se projeto de governo e buscou legitima\u00e7\u00e3o juntoaos t\u00e9cnicos e cientistas vinculados \u00e0s institui\u00e7\u00f5es p\u00fablicas, especialmente na propostade limites de toxicidade para a vida humana. O cap\u00edtulo \u201cEl ministro en bicicleta\u201d exp\u00f5ea participa\u00e7\u00e3o do ministro franquista Laureano Lopez Rod\u00f3 na flexibiliza\u00e7\u00e3o dos limitese padr\u00f5es do risco nocivo dessas e outras subst\u00e2ncias no Congresso das Na\u00e7\u00f5es Unidaspara o Meio Ambiente, em Estocolmo, em 1972.Os demais seis cap\u00edtulos contam hist\u00f3rias das zonas de sacrif\u00edcio, espa\u00e7os insalubres comalta toxicidade oculta em que uma lenta e invis\u00edvel viol\u00eancia atinge v\u00edtimas igualmenteinvis\u00edveis, cujo sofrimento n\u00e3o cabe nas estat\u00edsticas. Alguns desses dados tornaram-sesecretos como assunto de Estado, por exemplo os dados m\u00e9dicos das v\u00edtimas deradioatividade em \u201cBa\u00f1adores, detectores e ignorancia nuclear\u201d. A ignor\u00e2ncia seletivapor parte do poder p\u00fablico dava destaque a documentos que amenizavam os riscos enquantoomitia estudos cient\u00edficos sobre a toxicidade, como a hist\u00f3ria da transforma\u00e7\u00e3o doantigo lix\u00e3o de Barcelona em um parque natural, em \u201cLa restauraci\u00f3n del paisaje\u201d. Essemesmo paradoxo de cria\u00e7\u00e3o de \u00e1rea protegida num espa\u00e7o contaminado por res\u00edduos t\u00f3xicostamb\u00e9m \u00e9 examinado no cap\u00edtulo \u201cToxicidad e invisibilidade en la Albufera\u201d, que analisao modo como produtores de arroz se valeram de uma \u201cfachada\u201d verde para seus produtos,ocultando a intoxica\u00e7\u00e3o do ambiente e de seus consumidores. A est\u00e9tica e o uso das artesvisuais marca a colet\u00e2nea como um todo, mas em \u201cCapitalismo qu\u00edmico y representacionesart\u00edsticas\u201d a cria\u00e7\u00e3o de obras de arte \u00e9 colocada em evid\u00eancia. Nesse texto, s\u00e3omencionadas algumas das obras que valorizavam a est\u00e9tica da paisagem da hist\u00f3rica mina ac\u00e9u aberto de Corta Atalaya, ressaltando a beleza, invisibilizando a toxicidade elegitimando a atividade mineradora, ao mesmo tempo que outras obras denunciavam demaneira mais proativa a contamina\u00e7\u00e3o qu\u00edmica. As ret\u00f3ricas de oferta de emprego edesenvolvimento econ\u00f4mico eclipsaram os riscos da contamina\u00e7\u00e3o por cloro dostrabalhadores da f\u00e1brica Ercros, em \u201cDesempleo o miseria\u201d, e por cobre no Chile, em\u201cCoreografias del abandono\u201d.Numa complexa e coesa hist\u00f3ria social da ci\u00eancia, a obra contempla tanto a produ\u00e7\u00e3o doconhecimento cient\u00edfico no \u00e2mbito das institui\u00e7\u00f5es e laborat\u00f3rios como a divulga\u00e7\u00e3odesse conhecimento. E revela nessas hist\u00f3rias uma sociedade do risco   , em que"}
+{"text": "To evaluate the quality of anthropometric data of children recorded in the Food and Nutrition Surveillance System (SISVAN) from 2008 to 2017. Descriptive study on the quality of anthropometric data of children under five years of age admitted in primary care services of the Unified Health System, from the individual databases of SISVAN. Data quality was annually assessed using the indicators: coverage, completeness, sex ratio, age distribution, weight and height digit preference, implausible z-score values, standard deviation, and normality of z-scores. In total, 73,745,023 records and 29,852,480 children were identified. Coverage increased from 17.7% in 2008 to 45.4% in 2017. Completeness of birth date, weight, and height corresponded to almost 100% in all years. The sex ratio was balanced and approximately similar to the expected ratio, ranging from 0.8 to 1. The age distribution revealed higher percentages of registrations from the ages of two to four years until mid-2015. A preference for terminal digits \u201czero\u201d and \u201cfive\u201d was identified among weight and height records. The percentages of implausible z-scores exceeded 1% for all anthropometric indices, with values decreasing from 2014 onwards. A high dispersion of z-scores, including standard deviations between 1.2 and 1.6, was identified mainly in the indices including height and in the records of children under two years of age and residents in the North, Northeast, and Midwest regions. The distribution of z-scores was symmetric for all indices and platykurtic for height/age and weight/age. The quality of SISVAN anthropometric data for children under five years of age has improved substantially between 2008 and 2017. Some indicators require attention, particularly for height measurements, whose quality was lower especially among groups more vulnerable to nutritional problems. Anthropometric data are periodically collected to provide a clear understanding of the magnitude and distribution of nutritional problems in a country, as well as to design and monitor interventions to improve the nutritional status of the population5. The availability of accurate prevalence estimates of stunting, wasting, overweight and obesity in children is essential to monitor local, national and global progress towards the goals of eradicating hunger and all forms of malnutrition6.Anthropometry is universally used for nutritional surveillance of population groups7. The collection, recording and analysis of anthropometric data are routinely performed through population surveys by health professionals in primary care services, aimed at planning and organizing nutritional care and attention in SUS7. For anthropometric data to generate reliable information about the nutritional and health status of the local population, it is necessary to follow quality standards in the collection, recording and analysis of such data.In Brazil, the monitoring of nutritional status is part of Food and Nutrition Surveillance (FNS), provided by the law that created the Brazilian Unified Health System (SUS), and consists of the continuous description of food and nutrition conditions of the Brazilian population10. Thus, several indicators have been proposed and used to assess the quality of such data, including population coverage12, completeness of birth date and anthropometric measurements14, preference for digits of age, height, and weight16, percentage of biologically implausible values17, as well as dispersion and distribution of standardized measures of weight and height18.The quality of anthropometric data can be affected by multiple factors including sampling strategy, team training, measurement techniques and tools, non-response rate, data entry and processing methods10. However, the application of these indicators has still been incipient to assess the quality of data routinely collected in health services. In Brazil, coverage indicators have been solely used to assess the quality of anthropometric data of the population assisted in SUS health services12.These indicators have been widely used to verify and control the quality of anthropometric data in population surveys and research, such as demographic and health surveys, in which they are used to account for the variability in data quality among different sites over time19. This study is expected to guide those involved in FNS actions on how to improve the quality of anthropometric data in order to provide greater reliability to the metrics for local, state and national monitoring of the nutritional status of the Brazilian children population.Aiming to expand this approach, the objective of this study was to evaluate the quality of anthropometric data of children under five years of age recorded in the Food and Nutrition Surveillance System (SISVAN), a tool of the Ministry of Health to monitor the nutritional status of Brazilians served in Primary Health Care (PHC). This study covers the evaluation of multiple quality indicators, recommended by the Technical Expert Advisory group on nutrition Monitoring (TEAM) of the World Health Organization (WHO) and the United Nations Children\u2019s Fund (UNICEF)This is a descriptive study on the evaluation of the quality of anthropometric data of children aged 0 to 59 months, attended in PHC services in Brazil, in the period between 2008 and 2017. The information was obtained from the individual and anonymized SISVAN databases.The raw data from SISVAN, made available for use in this project by the Center for Data and Knowledge Integration for Health (CIDACS), Oswaldo Cruz Foundation (Fiocruz), were used in accordance with institutional protocols for data security and privacy and as established by Resolution 466/2012 of the National Research Ethics Committee of the National Health Council. The project was submitted and approved by the ethics committee of the Institute of Collective Health of the Federal University of Bahia (CAAE: 41695415.0.0000.5030).Bolsa Familia Program (BFP) Management System, in e-SUS APS, and in SISVAN20. Data on the nutritional status monitoring of BFP beneficiaries, which occurs at least twice a year, are incorporated into SISVAN at the end of each BFP term (first term from January to June and second term from July to December). The records from the e-SUS APS are gradually incorporated into the Health Information System for Primary Care, respecting the schedule of data submission by health teams, and then exported to SISVAN after processing and validation of data20.The SISVAN databases are composed of nutritional and food monitoring records from the PHC Health Information Systems. Regarding nutritional status, these databases include anthropometric data recorded in the 19: 1) completeness ; 2) sex ratio; 3) age distribution ; 4) digit preference of height and weight ; 5) implausible z-score values (percentage of implausible z-scores); 6) standard deviation of z-scores; and 7) normality of z-scores . To analyze the indicators, data on sex, date of birth, age (months and years), height (cm) and weight (kg) measurements were used, as well as the z-scores of the anthropometric indices commonly used to assess the nutritional status of children: Height/Age (H/A), Weight/Age (W/A), Weight/Height (W/H), and Body Mass Index/Age (BMI/A). Z-scores were calculated using the \u201cSTATA igrowup package\u201d tool and the WHO child growth reference curves21. The estimated quality indicators are described in detail in The quality of anthropometric data was assessed by means of multiple indicators, recommended by WHO-UnicefData were analyzed using Stata software version 15.1 . Since the same record can be entered in the different information systems that comprise SISVAN, duplicate records were identified and removed considering the following variables: identification code of the individual, date of birth, date of follow-up, weight, and height. Duplicate records were accepted when all values of considered variables were equal. Quality indicators were annually described and according to the following variables when applicable: sex, age, region, and federative unit.In total, 73,745,023 records and 29,852,480 children under five years of age were identified in the SISVAN nutritional status databases between 2008 and 2017, after excluding 27,167,791 duplicate records. The coverage of the target SUS-using population increased from 17.7% in 2008 to 45.4% in 2017 . The covThe percentage of records with complete birth date in SISVAN was high for the entire period studied, ranging from 99.9% in 2008 to 100% in 2017 . The perThe sex ratio ranged between 0.8 and 1 over the years. Variability in this indicator was identified among 2012 and 2014, when ratios showed higher numbers of girls compared to boys .Histograms of age in completed years revealed a pattern of higher percentages of registrations among ages two to four years until mid-2015, when the age distribution became more uniform . Such a Histograms in Figure 2a show almost 100% of preferences for the terminal digit zero for height, and terminal digits zero and five for weight. Almost 90% of height records (largest possible number) would need to be redistributed to obtain an uniform distribution of terminal digits across all years; while for terminal digits of weight, the percentage of records that would need to be redistributed reduced from 50.2% in 2008 to 40.4% in 2017 . The disThe percentages of implausible z-scores according to WHO cutoff points varied until mid-2014, when a decrease was observed in the following years for all anthropometric indices : H/A 3..Standard deviation values greater than 1 for plausible z-score measures were found for all anthropometric indices throughout the period . The lowThe distribution curves of z-scores in 2008 and 2017 showed flattening and leftward deviation for H/A, and more modest flattening and rightward deviations were observed in the distributions of z-scores of W/H, W/A, and BMI/I, compared to the normal distribution pattern of WHO child growth curves . AccordiThis study examined the quality of anthropometric data of children seen in PHC between 2008 and 2017. It is the first one assessing the quality of individual SISVAN data in Brazil, covering multiple indicators and different dimensions. Overall, the results show that the quality of anthropometric data collected and recorded in PHC information systems has improved substantially over the years. These findings represent a milestone for the consolidation of SISVAN, allowing better clarity and reliability in the use and analysis of data to identify nutritional problems in the population and for decision making in food and nutrition policies.7); expansion of the coverage of community health agents and family health teams11; expansion and qualification of PHC, through the Family Health Support Teams and the Primary Health Care Access and Quality Improvement Program (PMAQ-AB)7; and investment in FNS actions through the Financing for Food and Nutrition Actions (FNA) and financial support for municipalities to purchase appropriate anthropometric equipment for primary care22.Completeness is one of the dimensions of data quality that is directly related to selection biases and, consequently, to the representativeness of the results. High completeness was observed throughout the period in date of birth and anthropometric measurements, which are mandatory information for registration. The results also showed a growing expansion of SISVAN coverage over the years, especially among the SUS user population. This expansion can be attributed to important advances: the successful articulation of FNS actions with other education and social assistance policies The preference for height and weight digits may signal from the rounding of measurements to the use of inadequate equipment and care during data collection and recording. A preference for the terminal digits zero and five was observed in measurements of height and weight, indicating systematic error by the rounding of measurements. Among whole numbers, several noticeable peaks for height measurements were observed , revealing possible problems with equipment or rounding of measurements. On the other hand, the distribution of whole numbers for weight was very adequate.8. In most anthropometric rulers, centimeter marks are larger and easier to read than millimeter marks, inducing less diligent or less knowledgeable staff to record rounded values. As observed in the SISVAN data, rounding of weight measurements was less common, possibly due to the use of digital scales whose displays provide numerical values with easy-to-read decimals.Although critical to obtaining accurate prevalence of nutritional status, these results are relatively common and expected, especially for height measurements26.It is also worth mentioning the adequacy of structures and equipment for collecting these data in basic health units. According to a recent study, based on data from the external evaluation of PMAQ-AB in 2014, only 35% of primary health units in Brazil had an adequate structure for the development of FNS, including adult and child scales, anthropometric ruler, measuring tape, and child health booklet19. A similar result was found for the z-score dispersion indicator. Although values of standard deviation remained stable over the years, a large dispersion of z-scores was noted for most indices. Previous studies have reported wide variation in the standard deviation of anthropometric z-scores in children under five years of age in demographic and health surveys in several low- and middle-income countries18.The implausibility, dispersion, and normality indicators of z-scores are usually associated with measurement errors, inaccurate date of birth, or errors in data recording. Despite the reduction of implausible values among SISVAN records from 2014, the percentages still exceeded 1% for all indices, suggesting low data quality according to the WHO implausibility systemConsistent patterns of higher percentages of implausibility and dispersion of z-scores were observed among anthropometric indices including height measurement, and records of children under two years of age and residents of the North, Northeast, and Midwest regions. Such results point to well-known errors and limitations on the collection and recording of anthropometric measurements. It is generally expected that the standard deviation of H/A and BMI/A is higher than that of the other indices, due to the greater difficulty and chance of errors in collecting height and age measurements.,27. Furthermore, it is noteworthy that regions where the standard deviation and percentage of implausible values were higher are the most vulnerable from the point of view of adequate structure for nutritional surveillance in primary health units, according to a study with data from PMAQ-AB26.This pattern is especially expected in the group of children younger than two years of age, whose height is measured with them lying down and the accuracy of age in months is more critical due to the faster growth rate in this age groupDifferent parameters and normality measures were used to assess the distribution of z-scores for each anthropometric index. From the Kernel density plots, we observed distribution deviations to the left for H/A, and to the right for W/H, W/A and BMI/A, as compared to the normal distribution pattern of the WHO growth curves. Although the z-score distributions were symmetric for the four indices, kurtic distributions were identified for H/A and W/A (Fisher-Pearson coefficient > 4).28. Thus, it is possible that unusual distributions may occur in more heterogeneous populations, such as in countries with large social inequalities. The SISVAN population represents the users of PHC in Brazil, composed mostly of BFP beneficiaries; i.e., a more socioeconomically vulnerable population. The distributions found in this study are consistent with estimates of malnutrition in this population, which reveal persistent prevalence of short stature and increasing burden of overweight and obesity in children30.Despite these findings, there is still no consistent evidence to suggest that the dispersion and deviation from a Gaussian distribution is due to data quality alone. The WHO reference population used to derive the z-scores was restricted to a healthy population living in favorable environmental conditions for healthy growth19.This study has some limitations. Interpretation of certain indicators alone may not be sufficient to draw conclusions on the quality of the data, especially for indicators that take into account the dispersion and distribution of z-scores. More research is needed to quantify in definitive terms how much of the distribution of z-scores is attributable to population heterogeneity or measurement error. In the absence of cut-off points or more appropriate approaches that consider such limitations, a joint assessment of quality indicators is recommendedBased on the results of this study, we highlight the importance of actions to improve critical points identified in the quality of anthropometric data from SISVAN: 1) maintenance and expansion of intersectoral policies and health programs that promote FNS actions, as occur in the BFP, School Health Program and Growing Healthy Program; 2) development of qualification and continuing education actions ; 3) maintenance and expansion of financial support to municipalities for structuring FNS in PHC, through the acquisition and periodic calibration of anthropometric equipment; 4) computerization in PHC services, allowing professionals in primary health units to promptly record data on care, including weight and height data, in the patient\u2019s electronic medical record in e-SUS APS; and 5) implantation and implementation of routine for continuous verification and production of reports on the quality of data in SISVAN.Overall, the results suggest that the quality of anthropometric data in SISVAN has substantially improved over the years. However, some indicators still require attention. The coverage of the target population remains incipient for a surveillance system whose objective is the universal monitoring of the public that uses SUS primary care. The accuracy and quality of anthropometric measurements, especially of height, were lower in records of children under two years of age and residents in North, Northeast, and Midwest regions. Such groups are the portion of the child population most vulnerable to nutritional problems, requiring accurate estimates that can support the monitoring of the population nutritional profile and the development of public policies. 2. Dados antropom\u00e9tricos s\u00e3o periodicamente coletados para fornecer um entendimento claro da magnitude e distribui\u00e7\u00e3o dos problemas nutricionais em um pa\u00eds e para projetar e monitorar interven\u00e7\u00f5es com o prop\u00f3sito de melhorar o estado nutricional da popula\u00e7\u00e3o3. A disponibilidade de estimativas precisas da preval\u00eancia de d\u00e9ficit de crescimento, baixo peso, sobrepeso e obesidade na popula\u00e7\u00e3o infantil \u00e9 fundamental para monitorar o progresso local, nacional e global em dire\u00e7\u00e3o \u00e0s metas de erradica\u00e7\u00e3o da fome e de todas as formas de m\u00e1 nutri\u00e7\u00e3o6.A antropometria \u00e9 universalmente utilizada para a vigil\u00e2ncia nutricional de grupos populacionais7. A coleta, registro e an\u00e1lise de dados antropom\u00e9tricos s\u00e3o realizados por meio de inqu\u00e9ritos populacionais e rotineiramente pelos profissionais de sa\u00fade nos servi\u00e7os de aten\u00e7\u00e3o prim\u00e1ria, visando o planejamento e organiza\u00e7\u00e3o do cuidado e da aten\u00e7\u00e3o nutricional no SUS7. Para que os dados antropom\u00e9tricos gerem informa\u00e7\u00f5es fidedignas sobre o estado nutricional e sobre a situa\u00e7\u00e3o de sa\u00fade da popula\u00e7\u00e3o local, \u00e9 necess\u00e1rio seguir padr\u00f5es de qualidade para coleta, registro e an\u00e1lise de tais dados.No Brasil, o monitoramento do estado nutricional \u00e9 parte da Vigil\u00e2ncia Alimentar e Nutricional (VAN), prevista na lei que cria o Sistema \u00danico de Sa\u00fade (SUS), e consiste na descri\u00e7\u00e3o cont\u00ednua das condi\u00e7\u00f5es de alimenta\u00e7\u00e3o e nutri\u00e7\u00e3o da popula\u00e7\u00e3o brasileira8. Nesse sentido, v\u00e1rios indicadores t\u00eam sido propostos e utilizados para avalia\u00e7\u00e3o da qualidade desses dados, incluindo cobertura populacional12, completude da data de nascimento e das medidas antropom\u00e9tricas14, prefer\u00eancia por d\u00edgitos de idade, altura e peso16, percentual de valores biologicamente implaus\u00edveis17, bem como dispers\u00e3o e distribui\u00e7\u00e3o das medidas padronizadas de peso e altura18.A qualidade dos dados antropom\u00e9tricos pode ser afetada por m\u00faltiplos fatores que incluem a estrat\u00e9gia de amostragem, treinamento da equipe, t\u00e9cnicas e ferramentas de medi\u00e7\u00e3o, taxa de n\u00e3o resposta, m\u00e9todos de entrada e processamento dos dados10. Entretanto, a aplica\u00e7\u00e3o desses indicadores ainda tem sido muito incipiente para avaliar a qualidade de dados coletados rotineiramente em servi\u00e7os de sa\u00fade. No Brasil, indicadores de cobertura t\u00eam sido unicamente utilizados para avaliar a qualidades dos dados antropom\u00e9tricos da popula\u00e7\u00e3o atendida em servi\u00e7os de sa\u00fade do SUS12.Esses indicadores t\u00eam sido amplamente utilizados para verifica\u00e7\u00e3o e controle de qualidade dos dados antropom\u00e9tricos de inqu\u00e9ritos e pesquisas populacionais, a exemplo das pesquisas de demografia e sa\u00fade, nas quais s\u00e3o usados para contabilizar a variabilidade na qualidade dos dados entre diferentes locais e ao longo do tempo19. Espera-se com este trabalho orientar os envolvidos em a\u00e7\u00f5es de VAN sobre como melhorar a qualidade dos dados antropom\u00e9tricos, visando oferecer maior confiabilidade \u00e0s m\u00e9tricas para o monitoramento local, estadual e nacional do estado nutricional da popula\u00e7\u00e3o infantil brasileira.Com vistas \u00e0 amplia\u00e7\u00e3o dessa abordagem, o objetivo deste estudo foi avaliar a qualidade dos dados antropom\u00e9tricos de crian\u00e7as menores de 5 anos registradas no Sistema de Vigil\u00e2ncia Alimentar e Nutricional (Sisvan), ferramenta do Minist\u00e9rio da Sa\u00fade para monitorar o estado nutricional dos brasileiros atendidos na Aten\u00e7\u00e3o Prim\u00e1ria \u00e0 Sa\u00fade (APS). Este estudo abrange a avalia\u00e7\u00e3o de m\u00faltiplos indicadores de qualidade, recomendados por Grupo T\u00e9cnico Consultivo de Especialistas em Vigil\u00e2ncia Nutricional (TEAM) da Organiza\u00e7\u00e3o Mundial de Sa\u00fade (OMS) e do Fundo das Na\u00e7\u00f5es Unidas para Inf\u00e2ncia (Unicef)Trata-se de um estudo descritivo sobre a avalia\u00e7\u00e3o da qualidade dos dados antropom\u00e9tricos de crian\u00e7as de 0 a 59 meses de idade, atendidas nos servi\u00e7os de APS do Brasil, no per\u00edodo entre 2008 e 2017. As informa\u00e7\u00f5es foram obtidas a partir das bases de dados individuais e anonimizados do Sisvan.Os dados brutos do Sisvan, disponibilizados para uso neste projeto pelo Centro de Integra\u00e7\u00e3o de Dados e Conhecimentos para Sa\u00fade (Cidacs), Funda\u00e7\u00e3o Oswaldo Cruz (Fiocruz), foram utilizados em conformidade com os protocolos institucionais de seguran\u00e7a e privacidade de dados e conforme estabelece a Resolu\u00e7\u00e3o 466/2012 da Comiss\u00e3o Nacional de \u00c9tica em Pesquisa do Conselho Nacional de Sa\u00fade. O projeto foi submetido e aprovado pelo comit\u00ea de \u00e9tica do Instituto de Sa\u00fade Coletiva da Universidade Federal da Bahia (CAAE: 41695415.0.0000.5030).20. Os dados referentes ao acompanhamento do estado nutricional dos benefici\u00e1rios do Programa Bolsa Fam\u00edlia (PBF), que ocorre no m\u00ednimo duas vezes por ano, s\u00e3o incorporadas ao Sisvan no final de cada vig\u00eancia do PBF (primeira vig\u00eancia de janeiro a junho e segunda vig\u00eancia de julho a dezembro). Os registros provenientes do e-SUS APS s\u00e3o incorporados gradativamente ao Sistema de Informa\u00e7\u00e3o em Sa\u00fade para a Aten\u00e7\u00e3o B\u00e1sica, respeitando o cronograma de envio de dados pelas equipes de sa\u00fade, e posteriormente exportados para o Sisvan ap\u00f3s processamento e valida\u00e7\u00e3o dos dados20.As bases de dados do Sisvan s\u00e3o compostas pelos registros do acompanhamento nutricional e alimentar provenientes dos Sistemas de Informa\u00e7\u00e3o em Sa\u00fade da APS. Em rela\u00e7\u00e3o ao estado nutricional, as bases de dados do Sisvan incluem dados antropom\u00e9tricos registrados no Sistema de Gest\u00e3o do Programa Bolsa Fam\u00edlia, no e-SUS APS e no Sisvan19: 1) completude ; 2) raz\u00e3o entre sexos; 3) distribui\u00e7\u00e3o da idade ; 4) prefer\u00eancia por d\u00edgitos de estatura e peso ; 5) valores de escore-z implaus\u00edveis ; 6) desvio-padr\u00e3o dos escores-z; e 7) normalidade dos escores-z . Para an\u00e1lise dos indicadores foram utilizados os dados de sexo, data de nascimento, idade (meses e anos), as medidas de estatura (cm) e peso (kg), bem como os escores-z dos \u00edndices antropom\u00e9tricos comumente utilizados na avalia\u00e7\u00e3o do estado nutricional de crian\u00e7as: estatura/idade (E/I), peso/idade (P/I), peso/estatura (P/E) e \u00edndice de massa corporal/idade (IMC/I). Os escores-z foram calculados utilizando a ferramenta \u201cSTATA igrowup package\u201d e as curvas de refer\u00eancia de crescimento infantil da OMS21. Os indicadores de qualidade estimados encontram-se descritos em detalhes no A qualidade dos dados antropom\u00e9tricos foi avaliada por meio de m\u00faltiplos indicadores, recomendados pela OMS-UnicefOs dados foram analisados utilizando o software Stata vers\u00e3o 15.1 . Uma vez que o mesmo registro pode ser digitado nos diferentes sistemas de informa\u00e7\u00e3o que comp\u00f5em o Sisvan, os registros duplicados foram identificados e removidos considerando as seguintes vari\u00e1veis: c\u00f3digo de identifica\u00e7\u00e3o do indiv\u00edduo, data de nascimento, data do acompanhamento, peso e estatura. A duplicidade do registro foi aceita quando todos os valores das vari\u00e1veis consideradas eram iguais. Os indicadores de qualidade foram descritos anualmente e segundo as seguintes vari\u00e1veis, quando aplic\u00e1vel: sexo, idade, regi\u00e3o e unidade federativa.No total, 73.745.023 registros e 29.852.480 crian\u00e7as menores de 5 anos foram identificados nas bases de dados sobre estado nutricional do Sisvan entre 2008 e 2017, ap\u00f3s a exclus\u00e3o de 27.167.791 registros duplicados. A cobertura da popula\u00e7\u00e3o-alvo usu\u00e1ria do SUS aumentou de 17,7% em 2008 para 45,4% em 2017 . Em relaO percentual de registros com data de nascimento completa no Sisvan foi alta para todo o per\u00edodo estudado, variando de 99,9% em 2008 a 100% em 2017 . O perceA raz\u00e3o entre sexos variou entre 0,8 e 1 ao longo dos anos. A variabilidade nesse indicador foi identificada entre 2012 e 2014, quando as raz\u00f5es mostravam maior n\u00famero de meninas em rela\u00e7\u00e3o a meninos .Os histogramas da idade em anos completos revelam um padr\u00e3o de maiores percentuais de registros entre as idades de 2 a 4 anos at\u00e9 meados de 2015, quando a distribui\u00e7\u00e3o da idade se tornou mais uniforme . Esse paOs histogramas da Figura 2a mostram prefer\u00eancia de quase 100% pelo d\u00edgito terminal zero para estatura e uma prefer\u00eancia dos d\u00edgitos terminais zero e cinco para peso. Quase 90% dos registros de estatura (maior n\u00famero poss\u00edvel) precisariam ser redistribu\u00eddos para obter uma distribui\u00e7\u00e3o uniforme dos d\u00edgitos terminais em todos os anos; enquanto para os d\u00edgitos terminais de peso, o percentual de registros que precisariam ser redistribu\u00eddos reduziu de 50,2% em 2008 para 40,4% em 2017 . A distrvs. 1,9% em 2017), P/E , P/I  e IMC/I . Os maiores percentuais de implausibilidade foram identificados entre os registros de crian\u00e7as menores de 2 anos e das regi\u00f5es Norte, Nordeste e Centro-Oeste ; a amplia\u00e7\u00e3o da cobertura de agentes comunit\u00e1rios de sa\u00fade e equipes de sa\u00fade da fam\u00edlia11; a amplia\u00e7\u00e3o e qualifica\u00e7\u00e3o da APS, por meio dos N\u00facleos de Apoio a Sa\u00fade da Fam\u00edlia e do Programa de Melhoria do Acesso e da Qualidade da Aten\u00e7\u00e3o B\u00e1sica (PMAQ-AB)7; e os investimento nas a\u00e7\u00f5es de VAN, por meio do Financiamento das A\u00e7\u00f5es de Alimenta\u00e7\u00e3o e Nutri\u00e7\u00e3o (FAN) e do apoio financeiro destinado aos munic\u00edpios para aquisi\u00e7\u00e3o de equipamentos antropom\u00e9tricos adequados na aten\u00e7\u00e3o prim\u00e1ria22.A completude \u00e9 uma das dimens\u00f5es da qualidade de dados, que est\u00e1 diretamente relacionada a vieses de sele\u00e7\u00e3o e consequentemente \u00e0 representatividade dos resultados. Observou-se em todo per\u00edodo alta completude da data de nascimento e das medidas antropom\u00e9tricas, que s\u00e3o informa\u00e7\u00f5es obrigat\u00f3rias para realiza\u00e7\u00e3o do registro. Os resultados tamb\u00e9m mostram uma crescente expans\u00e3o das coberturas do Sisvan ao longo dos anos, sobretudo entre a popula\u00e7\u00e3o usu\u00e1ria do SUS. Essa expans\u00e3o pode ser atribu\u00edda a importantes avan\u00e7os: a articula\u00e7\u00e3o bem-sucedida das a\u00e7\u00f5es de VAN com outras pol\u00edticas de educa\u00e7\u00e3o e assist\u00eancia social A prefer\u00eancia por d\u00edgitos de estatura e peso pode sinalizar desde o arredondamento de medidas at\u00e9 o uso de equipamentos e cuidados inadequados durante a coleta e registro dos dados. Observou-se prefer\u00eancia dos d\u00edgitos terminais zero e cinco nas medidas de estatura e peso, indicando erro sistem\u00e1tico pelo arredondamento das medidas. Entre os n\u00fameros inteiros, v\u00e1rios picos percept\u00edveis para medida de estatura foram observados , revelando poss\u00edveis problemas com equipamento ou arredondamento das medidas. Por outro lado, a distribui\u00e7\u00e3o dos n\u00fameros inteiros para peso foi muito adequada.8. Na maioria das r\u00e9guas antropom\u00e9tricas, as marcas de cent\u00edmetros s\u00e3o maiores e mais f\u00e1ceis de ler do que as de mil\u00edmetros, induzindo as equipes menos diligentes ou menos instru\u00eddas a registrar os valores arredondados. Como observado nos dados do Sisvan, o arredondamento das medidas de peso foi menos comum, devido possivelmente ao uso de balan\u00e7as digitais cujo displays fornecem valores num\u00e9ricos com decimais de f\u00e1cil leitura.Embora cr\u00edticos para obten\u00e7\u00e3o de preval\u00eancias precisas do estado nutricional, esses resultados s\u00e3o relativamente comuns e esperados, especialmente para as medidas de estatura26.Vale ainda ressaltar a adequa\u00e7\u00e3o das estruturas e equipamentos para coleta desses dados nas unidades b\u00e1sicas de sa\u00fade. De acordo com um estudo recente, realizado a partir dos dados da avalia\u00e7\u00e3o externa do PMAQ-AB em 2014, somente 35% das unidades b\u00e1sicas de sa\u00fade no Brasil possu\u00edam estrutura adequada para desenvolvimento das a\u00e7\u00f5es de alimenta\u00e7\u00e3o e nutri\u00e7\u00e3o, incluindo balan\u00e7a para adultos, balan\u00e7a infantil, r\u00e9gua antropom\u00e9trica, fita m\u00e9trica e caderneta de sa\u00fade da crian\u00e7a19. Resultado similar foi encontrado para o indicador de dispers\u00e3o dos escores-z. Embora os valores de desvio-padr\u00e3o tenham se mantido est\u00e1veis ao longo dos anos, notou-se uma grande dispers\u00e3o dos escores-z para a maioria dos \u00edndices. Estudos pr\u00e9vios relatam ampla varia\u00e7\u00e3o no desvio-padr\u00e3o de escores-z antropom\u00e9tricos em crian\u00e7as menores de 5 anos em pesquisas de demografia e sa\u00fade em v\u00e1rios pa\u00edses de baixa e m\u00e9dia renda18.Os indicadores de implausibilidade, dispers\u00e3o e normalidade dos escores-z est\u00e3o normalmente associados a erros de mensura\u00e7\u00e3o, data de nascimento imprecisa ou erros no registro dos dados. Apesar da redu\u00e7\u00e3o de valores implaus\u00edveis entre os registros do Sisvan a partir de 2014, os percentuais ainda excediam 1% para todos os \u00edndices, sugerindo baixa qualidade dos dados de acordo com o sistema de implausibilidade da OMSPadr\u00f5es consistentes de maiores percentuais de implausibilidade e dispers\u00e3o dos escores-z foram observados entre os \u00edndices antropom\u00e9tricos incluindo a medida de estatura e entre os registros de crian\u00e7as menores de 2 anos de idade e residentes das regi\u00f5es Norte, Nordeste e Centro-Oeste. Esses resultados apontam para erros e limita\u00e7\u00f5es bem conhecidos acerca da coleta e registro de medidas antropom\u00e9tricas. Geralmente, espera-se que o desvio-padr\u00e3o dos escores-z de E/I e IMC/I seja maior que o dos demais \u00edndices, devido a maior dificuldade e chance de erros na coleta das medidas de estatura e idade.,27. Al\u00e9m disso, vale destacar que as regi\u00f5es onde o desvio-padr\u00e3o e percentual de valores implaus\u00edveis foram maiores s\u00e3o as mais vulner\u00e1veis do ponto de vista de estrutura adequada para vigil\u00e2ncia nutricional nas unidades b\u00e1sicas de sa\u00fade, segundo estudo com dados do PMAQ-AB26.Esse padr\u00e3o \u00e9 especialmente esperado no grupo de crian\u00e7as menores de 2 anos, cujo comprimento/estatura \u00e9 medido com a crian\u00e7a deitada e a precis\u00e3o da idade em meses \u00e9 mais cr\u00edtica devido \u00e0 velocidade de crescimento mais acelerada nessa faixa et\u00e1riaDiferentes par\u00e2metros e medidas de normalidade foram utilizados para avaliar a distribui\u00e7\u00e3o dos escores-z de cada \u00edndice antropom\u00e9trico. A partir dos gr\u00e1ficos de densidade de Kernel, observamos desvios da distribui\u00e7\u00e3o \u00e0 esquerda para E/I e \u00e0 direita para P/E, P/I e IMC/I, quando comparado ao padr\u00e3o de distribui\u00e7\u00e3o normal das curvas de crescimento da OMS. Embora as distribui\u00e7\u00f5es dos escores-z tenham se mostrado sim\u00e9tricas para os quatro \u00edndices, distribui\u00e7\u00f5es c\u00farticas foram identificadas para E/I e P/I (coeficiente Fisher-Pearson > 4).28. Assim, \u00e9 poss\u00edvel que distribui\u00e7\u00f5es incomuns ocorram em popula\u00e7\u00f5es mais heterog\u00eaneas, como em pa\u00edses com grandes desigualdades sociais. A popula\u00e7\u00e3o do Sisvan representa os usu\u00e1rios da APS no Brasil, composta em sua maioria por benefici\u00e1rios do PBF; ou seja, uma popula\u00e7\u00e3o socioeconomicamente mais vulner\u00e1vel. As distribui\u00e7\u00f5es encontradas em nosso estudo s\u00e3o coerentes com as estimativas de m\u00e1 nutri\u00e7\u00e3o dessa popula\u00e7\u00e3o, que revelam persistente preval\u00eancia de baixa estatura e crescente carga de sobrepeso e obesidade infantil30.Apesar desses achados, ainda n\u00e3o existem evid\u00eancias consistentes para sugerir que a dispers\u00e3o e o desvio de uma distribui\u00e7\u00e3o gaussiana s\u00e3o devidos apenas \u00e0 qualidade dos dados. A popula\u00e7\u00e3o de refer\u00eancia da OMS, usada para derivar os escores-z, foi restrita a uma popula\u00e7\u00e3o saud\u00e1vel vivendo em condi\u00e7\u00f5es ambientais favor\u00e1veis ao crescimento saud\u00e1vel19.Este estudo apresenta algumas limita\u00e7\u00f5es. A interpreta\u00e7\u00e3o de certos indicadores isoladamente pode n\u00e3o ser suficiente para obter conclus\u00f5es sobre a qualidade dos dados, especialmente para indicadores que levam em considera\u00e7\u00e3o a dispers\u00e3o e distribui\u00e7\u00e3o dos escores-z. Mais pesquisas s\u00e3o necess\u00e1rias para quantificar em termos definitivos quanto da distribui\u00e7\u00e3o dos escores-z \u00e9 atribu\u00eddo \u00e0 heterogeneidade da popula\u00e7\u00e3o e a erros de medi\u00e7\u00e3o. Na aus\u00eancia de pontos de corte ou abordagens mais apropriadas que levem em conta essas limita\u00e7\u00f5es, uma avalia\u00e7\u00e3o conjunta dos indicadores de qualidade \u00e9 recomendadaCom base nos resultados deste estudo, destaca-se a import\u00e2ncia de a\u00e7\u00f5es para melhoria dos pontos cr\u00edticos identificados na qualidade dos dados antropom\u00e9tricos do Sisvan: 1) manuten\u00e7\u00e3o e expans\u00e3o de pol\u00edticas intersetoriais e programas de sa\u00fade que promovam a\u00e7\u00f5es de VAN, como ocorrem no PBF, Programa Sa\u00fade na Escola e Crescer Saud\u00e1vel; 2) desenvolvimento de a\u00e7\u00f5es de qualifica\u00e7\u00e3o e educa\u00e7\u00e3o permanente ; 3) manuten\u00e7\u00e3o e amplia\u00e7\u00e3o do apoio financeiro aos munic\u00edpios para estrutura\u00e7\u00e3o da VAN na APS, por meio da aquisi\u00e7\u00e3o e calibra\u00e7\u00e3o peri\u00f3dica de equipamentos antropom\u00e9tricos; 4) informatiza\u00e7\u00e3o nos servi\u00e7os da APS, permitindo que profissionais nas unidades b\u00e1sicas de sa\u00fade prontamente registrem os dados dos atendimentos, incluindo os dados de peso e estatura, no prontu\u00e1rio eletr\u00f4nico do paciente no e-SUS APS; e 5) implanta\u00e7\u00e3o e implementa\u00e7\u00e3o de rotina para verifica\u00e7\u00e3o e produ\u00e7\u00e3o cont\u00ednua de relat\u00f3rios sobre a qualidade dos dados do Sisvan.Em geral, nossos resultados sugerem que a qualidade dos dados antropom\u00e9tricos do Sisvan tem substancialmente melhorado ao longo dos anos. Entretanto, alguns indicadores ainda requerem aten\u00e7\u00e3o. A cobertura da popula\u00e7\u00e3o-alvo permanece incipiente para um sistema de vigil\u00e2ncia cujo objetivo \u00e9 o monitoramento universal do p\u00fablico usu\u00e1rio da aten\u00e7\u00e3o prim\u00e1ria do SUS. A precis\u00e3o e a qualidade das medidas antropom\u00e9tricas, sobretudo para estatura, foram inferiores nos registros de crian\u00e7as menores de 2 anos e residentes das regi\u00f5es Norte, Nordeste e Centro-Oeste. Esses grupos representam a parcela da popula\u00e7\u00e3o infantil mais vulner\u00e1vel a agravos nutricionais, necessitando de estimativas precisas que possam subsidiar o monitoramento do perfil nutricional da popula\u00e7\u00e3o e a elabora\u00e7\u00e3o de pol\u00edticas p\u00fablicas."}
+{"text": "O trabalho analisa a maneira como o futebol se inseriu na vida dos banc\u00e1rios da cidade de S\u00e3o Paulo entre 1929 e 1932. Para isso, trata de quem eram esses trabalhadores e como eles davam sentido \u00e0s pr\u00e1ticas esportivas na Liga Banc\u00e1ria de Esportes Atl\u00e9ticos. Foram utilizadas como fontes relat\u00f3rios, documentos e publica\u00e7\u00f5es da Associa\u00e7\u00e3o dos Funcion\u00e1rios de Bancos do Estado de S\u00e3o Paulo. As reflex\u00f5es sobre \u201cclasse\u201d e \u201ccultura de classe\u201d, o conceito de \u201cexperi\u00eancia\u201d e a concep\u00e7\u00e3o de \u201cclasse m\u00e9dia\u201d foram utilizados na an\u00e1lise das fontes, na qual se observou varia\u00e7\u00e3o entre as representa\u00e7\u00f5es sobre o esporte e as pr\u00e1ticas de futebol dos banc\u00e1rios. Hoje, j\u00e1 n\u00e3o se pode julgar um povo no seu grau de civiliza\u00e7\u00e3o sem se observar a sua vida esportiva .O objetivo deste estudo foi analisar como o futebol se inseriu na vida de banc\u00e1rios da cidade de S\u00e3o Paulo entre 1929 e 1932, o que exigiu uma compreens\u00e3o sobre quem eram esses trabalhadores e como eles davam sentido \u00e0s pr\u00e1ticas esportivas na Liga Banc\u00e1ria de Esportes Atl\u00e9ticos (LBEA).As escolhas para a delimita\u00e7\u00e3o deste estudo s\u00e3o respaldadas por uma an\u00e1lise social do Brasil daquele per\u00edodo, na qual \u00e9 poss\u00edvel perceber como as atividades esportivas eram difundidas em meio \u00e0 circula\u00e7\u00e3o de discursos associados \u00e0 sa\u00fade. As primeiras d\u00e9cadas do s\u00e9culo XX apresentam um aumento substancial no n\u00famero de colunas esportivas nos jornais, que, aos poucos, v\u00e3o ganhando p\u00e1ginas inteiras dedicadas ao tema. Outrossim, as pautas jornal\u00edsticas que abordavam a sa\u00fade nas quest\u00f5es da urbaniza\u00e7\u00e3o, da higiene e de pr\u00e1ticas consideradas saud\u00e1veis ganhavam visibilidade em S\u00e3o Paulo e nos peri\u00f3dicos urbanos.Certamente essa dissemina\u00e7\u00e3o dos esportes, em particular do futebol, n\u00e3o era uma caracter\u00edstica exclusiva da cidade de S\u00e3o Paulo. Ao contr\u00e1rio, tratava-se de um processo transnacional que, segundo historiadores do esporte, serviu para o estabelecimento n\u00e3o apenas de uma agenda cultural no \u00e2mbito mais amplo do imperialismo brit\u00e2nico, mas tamb\u00e9m como um concurso social que promovia as elites de cidades como Roma, Paris, Nova York e Londres. Nesses contextos citadinos, as classes burguesas disputavam o protagonismo dessas pr\u00e1ticas esportivas, que fascinavam os praticantes e os seus p\u00fablicos. Assim, o imp\u00e9rio brit\u00e2nico foi um duradouro exportador de futebol, remo, ciclismo e turfe para v\u00e1rias cidades em uma perspectiva global , e S\u00e3o PNo Brasil, essas disputas entre as elites pelo controle do esporte tamb\u00e9m eram patentes, como revelam os estudos de Belle \u00c9poque e da Primeira Guerra Mundial.Nos anos 1920 e 1930 no Brasil, essas pr\u00e1ticas ganhavam novos sentidos em um contexto cultural, social e pol\u00edtico que passava por transforma\u00e7\u00f5es. Conforme explicam Diferentemente do per\u00edodo anterior, entre o fim do s\u00e9culo XIX e as primeiras d\u00e9cadas do s\u00e9culo XX, no qual havia uma persist\u00eancia pretensamente impositiva de padr\u00f5es europeus de civilidade, a produ\u00e7\u00e3o cultural brasileira nos anos 1920 e 1930 buscava uma \u201cmodernidade nativa\u201d . Nessa perspectiva, Por outro lado, como relata Maur\u00edcio No momento no qual a educa\u00e7\u00e3o e a sa\u00fade s\u00e3o articuladas como relevantes pol\u00edticas para o projeto moderno de pa\u00eds , os espoNo que se refere \u00e0 d\u00e9cada de 1930, s\u00e3o muitos os estudos que abordam a necessidade de projetos nacionais de educa\u00e7\u00e3o e sa\u00fade para a conforma\u00e7\u00e3o da sociedade brasileira, em um tempo no qual m\u00e9dicos higienistas e educadores escolanovistas . O futebol, entretanto, era o esporte mais difundido nos jornais e, por isso, por meio de sua visibilidade, era relevante para os higienistas colocarem em curso a sua conforma\u00e7\u00e3o e fiscaliza\u00e7\u00e3o.Nesse sentido, a d\u00e9cada de 1930, para Essa educa\u00e7\u00e3o f\u00edsica marcada por uma moral c\u00edvica pautada por comportamentos aceitos e recomendados por m\u00e9dicos e educadores em uma perspectiva de sa\u00fade n\u00e3o era exclusiva de S\u00e3o Paulo ou do Rio de Janeiro. A literatura especializada internacional tamb\u00e9m refor\u00e7a essas expectativas sobre os esportes na educa\u00e7\u00e3o de jovens e trabalhadores . Como seNa impossibilidade de constru\u00e7\u00e3o de uma interpreta\u00e7\u00e3o gen\u00e9rica sobre a perspectiva dos trabalhadores na pr\u00e1tica esportiva, optamos pelo estudo de uma categoria profissional em particular: os banc\u00e1rios. Desse modo, pela originalidade das fontes sobre uma perspectiva sindical em rela\u00e7\u00e3o aos esportes no per\u00edodo, este estudo pretende contribuir sobre outras formas de apreens\u00e3o da pr\u00e1tica esportiva e, em especial, do futebol.Nos jornais, sobretudo na cidade de S\u00e3o Paulo, os cronistas esportivos noticiavam os acontecimentos e resultados dos jogos, principalmente daqueles realizados pela Liga Amadora de Futebol (LAF), Liga Paulista de Futebol (LPF) e Associa\u00e7\u00e3o Paulista de Esportes Atl\u00e9ticos (Apea). Os jogos n\u00e3o vinculados a associa\u00e7\u00f5es e ligas esportivas tinham maior ou menor destaque na m\u00eddia, a depender do jornal e de quem eram os sujeitos que os praticavam. Analisando esses peri\u00f3dicos, nos deparamos com a LBEA, vinculada \u00e0 Associa\u00e7\u00e3o dos Funcion\u00e1rios de Bancos do Estado de S\u00e3o Paulo.Ela foi fundada em 16 de abril de 1923, por Francisco Silva Pinto, funcion\u00e1rio do City Bank. O intuito da liga era o de ser uma associa\u00e7\u00e3o assistencialista. Oferecia m\u00e9dico, enfermaria, dentista, servi\u00e7o de farm\u00e1cia, curso de contabilidade, departamento de coloca\u00e7\u00f5es e servi\u00e7os jur\u00eddicos. Tentava-se promover a identifica\u00e7\u00e3o entre os banc\u00e1rios . Vejamos\u2013 que vai de 1923 a 1932 \u2013 baseando sua organiza\u00e7\u00e3o na assist\u00eancia prestada aos associados  e setembro de 1939. Em 1931, a associa\u00e7\u00e3o muda seu nome para Associa\u00e7\u00e3o dos Banc\u00e1rios de S\u00e3o Paulo \u2013 \u00d3rg\u00e3o Sindical.Nessa interroga\u00e7\u00e3o \u00e0s fontes, formaram o corpo documental, principalmente, os relat\u00f3rios da associa\u00e7\u00e3o e o jornal mensal Entre 1929 e 1932, o jornal manteve certa regularidade com edi\u00e7\u00f5es mensais, totalizando 43 n\u00fameros publicados nesse per\u00edodo. Cada fasc\u00edculo tinha de quatro a oito p\u00e1ginas, e o jornal alcan\u00e7ou a tiragem de cinco mil exemplares em 1932. Era um ve\u00edculo privilegiado de comunica\u00e7\u00e3o entre os dirigentes da associa\u00e7\u00e3o e os trabalhadores banc\u00e1rios, refletindo um esfor\u00e7o de arregimenta\u00e7\u00e3o e uma preocupa\u00e7\u00e3o de doutrinar no \u201cideal sindicalista\u201d .Vida Banc\u00e1ria publicados no per\u00edodo pesquisado. A partir dela, dois movimentos foram poss\u00edveis: (1) ter uma vis\u00e3o geral de quais eram as discuss\u00f5es existentes dentro da associa\u00e7\u00e3o, quais as reivindica\u00e7\u00f5es desses trabalhadores, e qual a vis\u00e3o de sua situa\u00e7\u00e3o de classe; e (2) selecionar os artigos que discutiam, especificamente, a pr\u00e1tica esportiva e as quest\u00f5es de sa\u00fade entre os banc\u00e1rios. Uma tabela com ano, n\u00famero, p\u00e1gina, t\u00edtulo, autor, grande tema e resumo foi produzida, contendo cada um dos artigos do jornal. Ap\u00f3s a primeira leitura, de 451 artigos, foram encontrados 116 que tratavam do tema. Eles foram analisados a partir da perspectiva da hist\u00f3ria social inglesa, notadamente das reflex\u00f5es de E.P. A an\u00e1lise documental se deu a partir da leitura integral dos n\u00fameros do Vida Banc\u00e1ria era o respons\u00e1vel por promover a lideran\u00e7a dos dirigentes da associa\u00e7\u00e3o, divulgar suas a\u00e7\u00f5es, projetos e, sobretudo, as concep\u00e7\u00f5es sobre o trabalho dos banc\u00e1rios. Em suas p\u00e1ginas, \u00e9 poss\u00edvel observar a organiza\u00e7\u00e3o de uma associa\u00e7\u00e3o que se destaca pelo assistencialismo. Em particular, no per\u00edodo estudado, tanto a associa\u00e7\u00e3o quanto a linha editorial do Vida Banc\u00e1ria esmeravam-se nas tentativas de sistematiza\u00e7\u00e3o de a\u00e7\u00f5es assistencialistas, com o provimento dos servi\u00e7os j\u00e1 citados. Houve, em 1929, uma proposta de entregar o jornal a pessoas estranhas \u00e0 diretoria da associa\u00e7\u00e3o, mas o projeto n\u00e3o foi adiante. Em 1932, Vida Banc\u00e1ria passa a circular com caracter\u00edsticas de revista e circula\u00e7\u00e3o restrita , o esporte n\u00e3o era uma das pr\u00e1ticas mais concorridas entre os banc\u00e1rios, mas aquele quadro deveria mudar, pois a educa\u00e7\u00e3o f\u00edsica seria uma quest\u00e3o de import\u00e2ncia central, uma vez que contribuiria para a manuten\u00e7\u00e3o da sa\u00fade. Ele ressalta o utilitarismo do esporte como ferramenta compensat\u00f3ria para o desgaste propiciado pelo trabalho. Seria, ent\u00e3o, preciso promov\u00ea-lo como iniciativa de higiene e sa\u00fade, preparando o trabalhador para uma \u00e1rdua jornada. Sem d\u00favida, essa poderia ser uma apropria\u00e7\u00e3o do esporte por parte da parcela dos banc\u00e1rios que dirigia a associa\u00e7\u00e3o, que atuava mais como uma entidade de assist\u00eancia do que uma organiza\u00e7\u00e3o sindical. Havia, no entanto, outras apropria\u00e7\u00f5es do esporte no \u00e2mbito da estrutura\u00e7\u00e3o dessa categoria profissional. Enfim, quem seriam esses banc\u00e1rios? Seria poss\u00edvel uma defini\u00e7\u00e3o mais ampla desses trabalhadores? E como eles se inseriam no universo pol\u00edtico-social e esportivo da cidade?Tamb\u00e9m na quest\u00e3o esportiva, havia a inten\u00e7\u00e3o de promover e disponibilizar um servi\u00e7o aos banc\u00e1rios. Segundo as linhas do Em 1929, ap\u00f3s a posse da nova diretoria, o presidente da associa\u00e7\u00e3o foi procurado por representantes do London Bank Club com a proposta de cria\u00e7\u00e3o de uma liga esportiva, que se dedicaria apenas ao futebol, \u201co \u00fanico esporte que tem tido um certo incremento entre os banc\u00e1rios\u201d . Uma reuni\u00e3o com representantes dos clubes banc\u00e1rios foi marcada para se discutir o tema na associa\u00e7\u00e3o. No dia marcado, representantes dos clubes dos bancos Franc\u00eas e Italiano, Banco de Minas, British Bank, London Bank, Banco Comercial, Casa Banc\u00e1ria Conde e Almeida, Royal Bank e Banco Com\u00e9rcio e Ind\u00fastria compareceram \u00e0 sede da associa\u00e7\u00e3o. A cria\u00e7\u00e3o da LBEA foi aprovada por sete desses clubes, sendo contr\u00e1rio apenas o representante do Banco Com\u00e9rcio e Ind\u00fastria. O princ\u00edpio dos estatutos seria o seguinte: todo jogador inscrito na liga deveria ser s\u00f3cio da associa\u00e7\u00e3o.Nova reuni\u00e3o ficou marcada para se decidir sobre a organiza\u00e7\u00e3o definitiva da LBEA, de seus estatutos e da elei\u00e7\u00e3o da diretoria. A not\u00edcia da necessidade de filia\u00e7\u00e3o \u00e0 associa\u00e7\u00e3o para tomar parte na liga, no entanto, repercutiu negativamente nos bancos. A associa\u00e7\u00e3o, por sua vez, argumentava que essa cl\u00e1usula havia sido aprovada pelos presentes, n\u00e3o se podendo atribuir a imposi\u00e7\u00e3o de tal regra a ela. Decide-se, ent\u00e3o, por patrocinar a LBEA sem a necessidade de filia\u00e7\u00e3o dos jogadores \u00e0 associa\u00e7\u00e3o.A funda\u00e7\u00e3o de uma liga de futebol sob o patroc\u00ednio da associa\u00e7\u00e3o de classe dos banc\u00e1rios estava em conson\u00e2ncia com o pensamento de lideran\u00e7as comunistas do per\u00edodo, que apoiavam a chamada \u201cproletariza\u00e7\u00e3o dos esportes\u201d. O que se pretendia com isso era a tomada para si, por parte dos sindicatos e das associa\u00e7\u00f5es, da organiza\u00e7\u00e3o do esporte dos trabalhadores. Isso porque essas lideran\u00e7as acreditavam que o futebol, \u201cesporte burgu\u00eas\u201d, estava desviando as aten\u00e7\u00f5es dos trabalhadores, tirando deles o foco na luta por melhores condi\u00e7\u00f5es de trabalho e de vida. Ap\u00f3s anos de nega\u00e7\u00e3o do futebol como parte da cultura dos trabalhadores, passou-se a defender a pr\u00e1tica desse esporte nos sindicatos. Entendia-se que, caso eles n\u00e3o tivessem contato com o futebol dentro dos sindicatos, o teriam fora deles, ent\u00e3o seria melhor para a luta oper\u00e1ria que esses trabalhadores pudessem praticar os seus esportes sob o patroc\u00ednio de seus sindicatos. Fato \u00e9 que, nesse momento em que lideran\u00e7as comunistas come\u00e7aram a olhar para o futebol como um \u201cmal necess\u00e1rio\u201d a ser cultivado dentro dos sindicatos, a associa\u00e7\u00e3o criou sua pr\u00f3pria liga, que congregava clubes de diversos estabelecimentos banc\u00e1rios. Por\u00e9m, o fato de que os jogadores n\u00e3o precisavam ser filiados \u00e0 associa\u00e7\u00e3o para tomar parte nos campeonatos pode indicar que, ao contr\u00e1rio do que acontecia em outros contextos \u2013 como o da juventude comunista do Rio de Janeiro dos anos 1930 , da Alemanha com a Socialist Workers\u2019 Gymnastics Federation  ou da InAinda no per\u00edodo analisado houve a filia\u00e7\u00e3o da LBEA \u00e0 Apea. Ela era uma das duas associa\u00e7\u00f5es respons\u00e1veis pelo esporte na cidade de S\u00e3o Paulo naquele momento. Esse acontecimento pode nos dar ind\u00edcios de pelo menos tr\u00eas coisas: (1) a LBEA tinha alguma relev\u00e2ncia nos meios esportivos paulistanos, uma vez que fora reconhecida pela m\u00e1xima institui\u00e7\u00e3o esportiva do estado; (2) havia, por parte dos esportistas banc\u00e1rios, uma busca pela institucionaliza\u00e7\u00e3o de sua pr\u00e1tica esportiva, e o respaldo da Apea era o primeiro passo a ser dado nesse sentido; e (3) a Apea tinha a inten\u00e7\u00e3o de controlar o m\u00e1ximo poss\u00edvel o esporte paulistano, j\u00e1 que congregava em torno de si outras associa\u00e7\u00f5es esportivas menores. Era interessante para essas associa\u00e7\u00f5es, uma vez que conseguiam o respaldo da principal organizadora do esporte paulistano, e era interessante para a Apea, que adquiria o monop\u00f3lio da organiza\u00e7\u00e3o esportiva, tornando-se grande o suficiente para superar sua rival, a LPF.No que se refere ao mundo futebol\u00edstico paulistano, 1929 ficou marcado pela unifica\u00e7\u00e3o das duas ligas que comandavam o futebol na cidade \u2013 a LAF e a Apea. O Clube Atl\u00e9tico Paulistano \u2013 fundador de ambas as ligas \u2013 decide abandonar a LAF e fechar o seu departamento de futebol quando a discuss\u00e3o sobre a profissionaliza\u00e7\u00e3o desse esporte come\u00e7a a ficar mais s\u00e9ria. A partir da\u00ed, at\u00e9 meados da d\u00e9cada seguinte, a discuss\u00e3o sobre o profissionalismo seria ponto de destaque entre cronistas esportivos.Havia grande resist\u00eancia dos clubes em regulamentar a profissionaliza\u00e7\u00e3o do jogo, que, no entanto, passa a ser apoiada por boa parte dos cronistas esportivos da \u00e9poca, por diversos motivos. Um deles seria a necessidade de se impedir a evas\u00e3o dos bons jogadores paulistas, que estavam sendo levados por times europeus que j\u00e1 adotavam o futebol profissional . Outro mO esporte deve ser cultivado para a sa\u00fade do corpo e do esp\u00edrito; aplicar na vida pr\u00e1tica os benef\u00edcios que ele proporciona.N\u00e3o \u00e9 s\u00f3 cultiv\u00e1-lo fanaticamente, vivendo quase que exclusivamente para ele. Que vivam para ele, e dele, os profissionais, est\u00e1 muito certo. Mas um amador?, n\u00e3o.O esporte, cultivado assim cegamente, traz como consequ\u00eancia o empedernecimento do c\u00e9rebro. Conseguem enrijecer os m\u00fasculos, mas tornam o c\u00e9rebro embrutecido ou r\u00fastico; conseguem efici\u00eancia e admira\u00e7\u00e3o, mas, \u00e0s vezes, consequ\u00eancias desagrad\u00e1veis.Um indiv\u00edduo que s\u00f3 cuida de esporte \u00e9 um indiv\u00edduo nulo para a coletividade: j\u00e1 pelo esp\u00edrito quase obtuso, j\u00e1 pela indiferen\u00e7a com que encaram os outros magnos problemas da coletividade, muitas vezes com desconhecimento completo.Pratique-se o esporte na sua verdadeira finalidade, traduzindo na moral, no car\u00e1ter, no trabalho, na vida coletiva o revigoramento que ele d\u00e1 ao corpo. O esporte \u00e9 indispens\u00e1vel, mas, moderado, bem compreendido e melhor aplicado.No plano nacional, as transforma\u00e7\u00f5es pol\u00edticas ocorridas durante as d\u00e9cadas de 1920 e 1930 ajudam a compreender o momento pelo qual o pa\u00eds passava. Era uma fase de transi\u00e7\u00e3o pol\u00edtica em que se concretizariam, a partir do movimento de 1930, a centraliza\u00e7\u00e3o da pol\u00edtica e a interven\u00e7\u00e3o do Estado nas quest\u00f5es sociais e trabalhistas. Aconteceram tamb\u00e9m amplia\u00e7\u00f5es dos setores urbanos e das camadas m\u00e9dias que impulsionariam altera\u00e7\u00f5es no campo pol\u00edtico, como \u201co questionamento das bases do sistema olig\u00e1rquico da Primeira Rep\u00fablica\u201d , fomentando disputas regionais e afetando as elei\u00e7\u00f5es presidenciais. Um cen\u00e1rio pol\u00edtico que teve como desfecho a deposi\u00e7\u00e3o de Washington Lu\u00eds e a vit\u00f3ria de Get\u00falio, dando in\u00edcio \u00e0 Era Vargas.Esse \u00e9 um per\u00edodo repleto de acontecimentos pol\u00edticos e sociais importantes. J\u00e1 em 1931 tem-se a Lei de Sindicaliza\u00e7\u00e3o, com o objetivo de combater organiza\u00e7\u00f5es que permanecessem independentes . O decreFica claro, a partir do exposto, que 1929 foi marcante para a associa\u00e7\u00e3o, com a funda\u00e7\u00e3o da LBEA, com o in\u00edcio das movimenta\u00e7\u00f5es que levariam ao golpe de 1930 e com os conflitos no cen\u00e1rio futebol\u00edstico da cidade de S\u00e3o Paulo. Foi o momento em que houve o fechamento do time de futebol do C.A. Paulistano, quando as discuss\u00f5es sobre o profissionalismo no futebol se avolumaram. A partir de 1933, no entanto, tem-se uma mudan\u00e7a na autocompreens\u00e3o dos banc\u00e1rios, que tornaram o sindicato mais combativo politicamente, o que vai impactar a visibilidade das pr\u00e1ticas esportivas em suas publica\u00e7\u00f5es peri\u00f3dicas . Por issOs banc\u00e1rios formavam uma categoria profissional bastante numerosa nos anos 1930. Em 1931, um levantamento realizado pela associa\u00e7\u00e3o mostrou que havia na cidade 2.629 banc\u00e1rios , sendo que 1.459 dela faziam parte . Eles eram divididos entre escritur\u00e1rios e cont\u00ednuos. Os primeiros trabalhavam na administra\u00e7\u00e3o do banco. Eram gerentes, subgerentes, contadores, procuradores, escritur\u00e1rios, caixas, correntistas etc. Suas fun\u00e7\u00f5es estavam ligadas \u00e0s atividades-fim dos bancos. J\u00e1 os cont\u00ednuos eram funcion\u00e1rios do quadro de portaria. Eram porteiros, vigias, ascensoristas, telefonistas etc. e tinham fun\u00e7\u00f5es ligadas \u00e0s atividades-meio das ag\u00eancias.O modo como se viam, como mais ou menos pr\u00f3ximos de outras categorias de trabalhadores variava, mas, durante todo o per\u00edodo analisado, eles se enxergavam como trabalhadores. Eram, em suas palavras, \u201coper\u00e1rios da casaca\u201d , que tinham condi\u00e7\u00f5es de trabalho ruins e recebiam pouco pelo trabalho realizado e para a manuten\u00e7\u00e3o do padr\u00e3o de vida que deveriam aparentar ter. Pela sociedade, por\u00e9m, eram vistos como uma classe privilegiada, j\u00e1 que recebiam mais do que a m\u00e9dia salarial da cidade e pareciam sustentar um bom padr\u00e3o de vida.Segundo status social, a partir de seu trabalho; e que utilizam roupas de passeio no local de trabalho. As tr\u00eas caracter\u00edsticas apresentadas se complementam para a forma\u00e7\u00e3o do que ele entende por um funcion\u00e1rio de \u201ccolarinho branco\u201d. O status social que consegue por meio do trabalho estaria ligado ao fato de receber por m\u00eas e, portanto, de conseguir se diferenciar de outro tipo de trabalhador, o que recebe por dia ou hora. Ainda o fato de utilizar roupas de passeio traz a esse trabalhador mais status, j\u00e1 que, novamente, n\u00e3o ser\u00e1 confundido com o oper\u00e1rio. No entanto, a possibilidade de utiliza\u00e7\u00e3o de vestimenta de passeio s\u00f3 \u00e9 poss\u00edvel pelo exerc\u00edcio de uma profiss\u00e3o que garante status social. \u00c9 uma via de m\u00e3o dupla. Esses trabalhadores de \u201ccolarinho branco\u201d passaram a ser vistos pela sociedade de maneira diversa de outros tipos de trabalhadores, mas tamb\u00e9m se enxergavam como diferentes deles, com uma identidade profissional pr\u00f3pria. Eles tinham outros anseios, outras perspectivas e outro status.1 e nos diversos artigos que tratam das condi\u00e7\u00f5es de vida dos banc\u00e1rios. Em um n\u00famero do Vida Banc\u00e1ria de 1942, tratando da composi\u00e7\u00e3o salarial m\u00e9dia dos banc\u00e1rios em 1935 e 1941, temos as seguintes cifras:2Os sal\u00e1rios variavam muito de banco para banco e dentro do pr\u00f3prio banco, como \u00e9 poss\u00edvel constatar nas tabelas feitas pela associa\u00e7\u00e3o, em meados dos anos 1930Nesse mesmo artigo \u00e9 apresentada uma estat\u00edstica feita pelo Minist\u00e9rio da Fazenda sobre o custo de vida no Rio de Janeiro entre 1912 e 1941. Toma-se por m\u00e9dia uma fam\u00edlia de quatro pessoas, e entende-se que uma fam\u00edlia do Rio e uma de S\u00e3o Paulo precisariam do mesmo valor de 1:040$000 para sua subsist\u00eancia em 1935. Em 1943 o sal\u00e1rio-m\u00ednimo era de 360 cruzeiros , e em 1944 o ordenado m\u00e9dio dos banc\u00e1rios era de 700 cruzeiros . Esses n\u00fameros demonstram a dificuldade em definir a m\u00e9dia salarial dos banc\u00e1rios e qual o seu padr\u00e3o de vida; por\u00e9m, \u00e9 poss\u00edvel perceber, a partir dos dados apresentados, que se tratava de uma categoria de trabalhadores que ganhava mais do que o sal\u00e1rio-m\u00ednimo do estado de S\u00e3o Paulo, que, aprovado em junho de 1939, era de 200$000 para a zona da capital .Levando-se em considera\u00e7\u00e3o os dados apresentados, podemos concluir que os sal\u00e1rios recebidos pelos banc\u00e1rios n\u00e3o eram suficientes para sustentar o padr\u00e3o de vida m\u00e9dio de uma fam\u00edlia de quatro pessoas. E eles diziam isso correntemente. Viam-se como trabalhadores mal remunerados, como \u00e9 poss\u00edvel perceber na passagem a seguir, escrita por Americano Meridional em junho de 1934 (p.2):Da\u00ed a vida necessitada que passa e que \u00e9 obrigado a passar, por v\u00e1rias circunst\u00e2ncias, vejamos: \u2013 custo de vida exorbitante, alta dos g\u00eaneros, artigos de uso, casa, locomo\u00e7\u00e3o, divers\u00f5es etc. em face dos sal\u00e1rios baix\u00edssimos, humilhante[s] e microsc\u00f3picos que nos s\u00e3o pagos em doses homeop\u00e1ticas. ... que obrigam os banc\u00e1rios a se tornarem escravos das casas de penhores, dos agiotas, dos t\u00edtulos, dos protestos, das d\u00edvidas insol\u00faveis, das presta\u00e7\u00f5es, dos judeus.Havia uma exig\u00eancia constante sobre os funcion\u00e1rios de bancos a respeito de sua forma de vestir, sua apar\u00eancia e seu comportamento.Obrigados, pela natureza do trabalho e pela sua situa\u00e7\u00e3o social, a aparentar, apresentando-se decentemente, esses novos m\u00e1rtires da sociedade moderna vivem num c\u00edrculo cruel de mis\u00e9rias, de necessidades e de humilha\u00e7\u00f5es.Barba feita, roupa limpa e sem remendos, sorrisos para os clientes, boas e custosas amizades, tudo isso tem os companheiros banc\u00e1rios que apresentar numa hipocrisia obrigat\u00f3ria, quando, por tr\u00e1s da m\u00e1scara dessa felicidade mentirosa, vivem numa luta torturante, atroz, acabrunhadora, com os agiotas, com o desconforto, com o sacrif\u00edcio inevit\u00e1vel da fam\u00edlia, com credores impacientes e mesmo com a fome. Da\u00ed, certas doen\u00e7as, e a desmoraliza\u00e7\u00e3o pelas d\u00edvidas, culminando no desemprego, porque aos bancos n\u00e3o fica bem ter funcion\u00e1rios doentes ou sem moral .status diferenciado.Essas exig\u00eancias contribu\u00edam para que fossem vistos como parte dos setores privilegiados da sociedade. Tendo sempre que estar muito bem vestidos, gastavam parte consider\u00e1vel de seus sal\u00e1rios com roupas. Esta era a maior das queixas: a necessidade de uma apar\u00eancia sempre impec\u00e1vel, que n\u00e3o condizia com a realidade econ\u00f4mica, mas que ajudava na manuten\u00e7\u00e3o de um As an\u00e1lises de Assim, como os funcion\u00e1rios do com\u00e9rcio analisados por No in\u00edcio de 1929 a LBEA era apenas uma ideia que consistia na defesa da import\u00e2ncia de uma organiza\u00e7\u00e3o esportiva para os banc\u00e1rios. L.C.  escreve:A mais simples an\u00e1lise ressalta que, entre os banc\u00e1rios, a propens\u00e3o para os esportes n\u00e3o \u00e9 das mais acentuadas. Como que a querer destruir esta asser\u00e7\u00e3o, poderiam nos apontar as muitas esquadras de futebolistas que existem pelos bancos, algumas j\u00e1 de antiga funda\u00e7\u00e3o. ...Para os banc\u00e1rios, a educa\u00e7\u00e3o f\u00edsica \u00e9 uma quest\u00e3o de capital import\u00e2ncia e, como tal, deve ser encarada. Passando longas horas arcados sobre uma escrivaninha, na \u00e1rdua tarefa de enfileirar algarismos, dispendendo com isso grandes reservas de energia, todo o organismo reclama, depois, a pr\u00e1tica salutar dos esportes, para refazer-se dessas perdas de vitalidade. ...Urge, em nosso meio, mover-se uma intensa propaganda esportiva, concitando os nossos colegas a aderirem aos clubes internos que, com esse fim, j\u00e1 existem em muitos de nossos bancos para que possamos, dentro em pouco, contar com um grande contingente de esportistas. ...Julgamos imprescind\u00edvel a cria\u00e7\u00e3o de uma liga, essencialmente bancaria, \u00e0 qual os clubes internos ficassem subordinados.Para ele, os banc\u00e1rios deveriam se juntar aos clubes j\u00e1 existentes para praticar algum exerc\u00edcio f\u00edsico, que provavelmente seria o futebol \u2013 o esporte que fazia sucesso entre eles no per\u00edodo. Eles deveriam faz\u00ea-lo para recupera\u00e7\u00e3o das energias dispendidas no trabalho. Foi esse o impulsionador da cria\u00e7\u00e3o da LBEA, em conson\u00e2ncia com o ideal higienista que tinha por finalidade tomar a\u00e7\u00f5es normativas no campo do trabalho  e, partiNo caso dos banc\u00e1rios, apesar da pouca competitividade entre os concorrentes do campeonato, as discuss\u00f5es e os incidentes eram recorrentes e n\u00e3o ficavam atr\u00e1s dos torneios oficiais. Os \u201ccasos\u201d, como se referiam os cronistas aos desentendimentos no interior dos campos, avolumavam-se rodada ap\u00f3s rodada. Sobre o assunto, Peregrino Memolo Netto  escreve: \u201cA educa\u00e7\u00e3o esportiva em nossa terra ainda est\u00e1 longe de atingir o grau em que ela merecia estar, atendendo-se ao nosso progresso t\u00e9cnico\u201d. Para ele \u2013 que era funcion\u00e1rio do London Bank e foi presidente em 1929, suplente da diretoria em 1933, secret\u00e1rio-geral da LBEA em 1935 e membro da diretoria da associa\u00e7\u00e3o em 1937 e 1938 \u2013 os desentendimentos que ocorriam entre os futebolistas banc\u00e1rios tinham ainda menos raz\u00e3o de ser do que os que se davam nos campos do futebol oficial. Isso porque:Em primeiro lugar, os jogos da liga n\u00e3o t\u00eam renda de bilheteria e, por conseguinte, n\u00e3o possuem uma assist\u00eancia numerosa e partid\u00e1ria, capaz de influir no \u00e2nimo do jogador. Em segundo lugar, os elementos que atuam nos campos da liga s\u00e3o elementos de uma mesma classe, absolutamente homog\u00eaneos, e que, n\u00f3s o supomos, n\u00e3o s\u00e3o desconhecedores da educa\u00e7\u00e3o esportiva .Vida Banc\u00e1ria. Yapo  escrevia que \u201cdeitar cedo, levantar cedo o mais poss\u00edvel e n\u00e3o usar nunca o fumo e o m\u00ednimo poss\u00edvel as bebidas alco\u00f3licas s\u00e3o as s\u00f3lidas bases de quem deseja ser um bom atleta\u201d; ou ainda que \u201ctodo esportista, \u00e0 propor\u00e7\u00e3o que melhora o seu f\u00edsico, deve envidar todos os esfor\u00e7os para que as suas qualidades morais tamb\u00e9m se elevem e se nobilitem\u201d. Yapo, ali\u00e1s, era um dos maiores propagadores das pr\u00e1ticas que se deveria adotar para tornar-se um bom atleta. Ele, em outra edi\u00e7\u00e3o do jornal, afirmava ser necess\u00e1rio que \u201cabandonemos e combatamos o \u00e1lcool, o fumo, o jogo e os excessos viciosos que s\u00e3o o cancro horrendo que suga as energias morais e f\u00edsicas dos nossos jovens patr\u00edcios e, portanto, consomem as for\u00e7as da Na\u00e7\u00e3o. Cultivemos o esporte sem excessos e pelo amor ao esporte!\u201d .Por \u201ceduca\u00e7\u00e3o esportiva\u201d o autor provavelmente entendia os preceitos defendidos pelo amadorismo, que consistiam no cavalheirismo, no respeito ao advers\u00e1rio, no deleite da pr\u00e1tica do jogo e no respeito \u00e0s regras previamente acordadas. Se era poss\u00edvel supor que essa \u201ceduca\u00e7\u00e3o esportiva\u201d era dominada pelos banc\u00e1rios, n\u00e3o se pode dizer o mesmo da \u201ceduca\u00e7\u00e3o f\u00edsica\u201d. Nesse momento havia a necessidade de se ensinar aos trabalhadores banc\u00e1rios sobre os benef\u00edcios que a pr\u00e1tica de exerc\u00edcios f\u00edsicos poderia lhes trazer. Assim, diversas advert\u00eancias sobre o assunto foram feitas por meio das p\u00e1ginas do Vida Banc\u00e1ria em conson\u00e2ncia com os dirigentes da associa\u00e7\u00e3o, e caminhavam na dire\u00e7\u00e3o de um alinhamento com os c\u00f3digos morais propalados por m\u00e9dicos e educadores em uma perspectiva de \u201ceduca\u00e7\u00e3o esportiva\u201d, concomitantemente, na dire\u00e7\u00e3o contr\u00e1ria, as pr\u00e1ticas esportivas daqueles trabalhadores banc\u00e1rios ganhavam outros sentidos na busca de uma divers\u00e3o desinteressada, do j\u00fabilo, do prazer, a despeito da moralidade expressa naqueles impressos. Do mesmo modo, Ao passo que as representa\u00e7\u00f5es sobre as pr\u00e1ticas esportivas eram constru\u00eddas pelos redatores do Nesse sentido, esse discurso adotado pelo \u00f3rg\u00e3o oficial da associa\u00e7\u00e3o n\u00e3o parece ter muita conex\u00e3o com a realidade das disputas futebol\u00edsticas. Um exemplo \u00e9 o encontro amistoso entre C.E. Induscomio e o E.C. Sudameris, em outubro de 1929, como parte de um convescote banc\u00e1rio. O evento reuniu quase setecentas pessoas, contando banc\u00e1rios e seus familiares, no parque da Vila Galv\u00e3o, e teve como ponto alto o encontro entre os dois times. Antes do in\u00edcio de um jogo bastante movimentado os quadros se alinharam no gramado para uma troca de gentilezas. O Sudameris ofereceu uma corb\u00e9lia ao Induscomio, que retribuiu o gesto oferecendo \u201caos capit\u00e3es, ju\u00edzes, representante da liga banc\u00e1ria e diretores de ambos os clubes um delicioso copo de vinho espumante\u201d . O consumo de \u00e1lcool, demonizado por Yapo, esteve presente antes do in\u00edcio do jogo sem nenhuma cerim\u00f4nia. Outro caso emblem\u00e1tico para demonstrar o descolamento entre o discurso de ideal esportivo e a pr\u00e1tica da LBEA \u00e9 a cerim\u00f4nia de premia\u00e7\u00e3o do campeonato de 1931.chopp Antarctica o que, naturalmente, veio aumentar o seu entusiasmo\u201d .Realizada em 21 de janeiro de 1932, essa cerim\u00f4nia contou com a presen\u00e7a de muitos banc\u00e1rios no sal\u00e3o nobre da associa\u00e7\u00e3o. Na ocasi\u00e3o, o doutor Francisco de Paula Reim\u00e3o Hellmeister, presidente da liga (e que faria parte da diretoria da associa\u00e7\u00e3o em 1936), fez um discurso de sauda\u00e7\u00e3o \u00e0s equipes vencedoras do campeonato, Induscomio e British Bank. Ap\u00f3s os capit\u00e3es das equipes terem recebido os respectivos trof\u00e9us, era hora de come\u00e7ar a festa. \u201cAos presentes foi oferecido grande quantidade de \u2018cristalino\u2019 Vida Banc\u00e1ria, o que a liga faz \u00e9 oferecer bebida alco\u00f3lica aos presentes, dessa vez em grande quantidade. Essa pr\u00e1tica nos d\u00e1 ind\u00edcios de que o ideal higienista de forma\u00e7\u00e3o de atletas, em que seria preciso cuidar do corpo e da alimenta\u00e7\u00e3o para se tornar um ser humano moral e fisicamente mais habilitado, n\u00e3o encontrava eco nas pr\u00e1ticas dos esportistas banc\u00e1rios do per\u00edodo. Ou seja, a experi\u00eancia desses sujeitos parecia distante das representa\u00e7\u00f5es sobre a pr\u00e1tica esportiva vigentes naquele momento. Acreditamos que, para eles, mais do que se tornar atletas com bons rendimentos, de corpos sadios e moral elevada, era a utiliza\u00e7\u00e3o do tempo livre na participa\u00e7\u00e3o em um ambiente de descontra\u00e7\u00e3o e de congra\u00e7amento entre os pares que fazia com que se vinculassem aos clubes e disputassem campeonatos. Eles buscavam a vit\u00f3ria, mas ela n\u00e3o estava necessariamente atrelada a possuir valores atl\u00e9ticos refinados, como se pregava nas p\u00e1ginas do \u00f3rg\u00e3o da associa\u00e7\u00e3o.Novamente, contrariando a representa\u00e7\u00e3o de bons atletas veiculada pelo A pr\u00e1tica futebol\u00edstica fazia parte da experi\u00eancia e da cultura dos banc\u00e1rios. \u00c9 poss\u00edvel, no entanto, perceber, a partir do exposto, que eles resistiam e ressignificavam as ideias propostas pelos seus representantes no \u00f3rg\u00e3o oficial de sua associa\u00e7\u00e3o de classe, de maneira semelhante ao que demostrou Assim, os banc\u00e1rios paulistanos aproveitavam a exist\u00eancia de uma liga de futebol organizada por sua associa\u00e7\u00e3o para praticar o futebol, parte de sua cultura, e importante vetor de sua experi\u00eancia , sem queMesmo n\u00e3o parecendo surtir efeito, a propaganda do ideal higienista de esporte continua forte nas p\u00e1ginas do peri\u00f3dico banc\u00e1rio. Tem in\u00edcio uma campanha para expans\u00e3o dos horizontes esportivos. Era preciso n\u00e3o parar no futebol. Olhando-se para outras na\u00e7\u00f5es era poss\u00edvel ver o atraso do esporte banc\u00e1rio brasileiro. Nos EUA e na Inglaterra eram praticadas todas as modalidades esportivas, \u201cencaixadas regularmente nas diversas esta\u00e7\u00f5es do ano. L\u00e1, raro \u00e9 o estabelecimento banc\u00e1rio que n\u00e3o tenha a sua pra\u00e7a de esportes confortavelmente montada\u201d. At\u00e9 mesmo na Argentina era poss\u00edvel encontrar estabelecimentos de cr\u00e9dito \u201ccom seus est\u00e1dios magnificamente montados, com campos de futebol, de atletismo, quadras de t\u00eanis, piscinas etc.\u201d . A LBEA,com dois anos apenas de vida, arregimenta ela, sob sua bandeira, nada menos que 13 agremia\u00e7\u00f5es, representando 15 bancos. Se no futebol \u00e9 ela forte, por que n\u00e3o poder\u00e1 ser no cestobol, no atletismo, na nata\u00e7\u00e3o, no remo etc.? ... Uma vez que temos muitos elementos para tal, atr\u00e1s dos quais naturalmente acorrer\u00e3o muitos outros, n\u00e3o se justifica o fato de permanecermos unicamente nos campeonatos de futebol .Vida Banc\u00e1ria:O atletismo j\u00e1 fazia sucesso entre os banc\u00e1rios em 1929. Apesar de ainda n\u00e3o ser parte dos esportes patrocinados pela liga, alguns banc\u00e1rios o praticavam no C.A. Paulistano, clube de elite de S\u00e3o Paulo. Esse esporte era assim propagandeado no O atletismo praticado racionalmente, isto \u00e9, sem excessos prejudiciais, de acordo com o f\u00edsico das pessoas e acompanhado pela gin\u00e1stica e exerc\u00edcios respirat\u00f3rios, \u00e9 indubitavelmente um espl\u00eandido esporte para a melhoria do f\u00edsico e do moral de uma ra\u00e7a. Nele, a lealdade e a polidez nunca cedem os primeiros lugares a outras qualidades, quaisquer que elas sejam .Em 1931 o projeto do campeonato de atletismo finalmente se concretizou. Muitos eram os benef\u00edcios que o \u201cesporte base\u201d poderia trazer. De maneira geral,a corrida a p\u00e9, que realiza uma gin\u00e1stica pulmonar, atraente e eficaz, \u00e9 um dos exerc\u00edcios melhores e mais completos, porque \u00e9 essencialmente est\u00eanico, isto \u00e9, um exerc\u00edcio que provoca aumento de vigor e atividade e deixa depois do repouso uma respira\u00e7\u00e3o f\u00e1cil, profunda e mais lenta, al\u00e9m de produzir uma sensa\u00e7\u00e3o sedativa do sistema nervoso e determinar o desenvolvimento tor\u00e1cico, muscular e \u00f3sseo .Para os banc\u00e1rios, no entanto, os benef\u00edcios do atletismo n\u00e3o paravam por a\u00ed. O aprimoramento f\u00edsico aparecia como t\u00e3o importante quanto o da ra\u00e7a. Yapo  dizia que \u201c\u00e0 classe de funcion\u00e1rios de bancos, composta na sua quase totalidade de rapazes de bom preparo e instru\u00e7\u00e3o, n\u00e3o escapava o valor do esporte b\u00e1sico, quer na forma\u00e7\u00e3o das qualidades f\u00edsicas, quer no enrijecimento das qualidades morais do indiv\u00edduo\u201d. Por meio desses excertos \u00e9 poss\u00edvel, novamente, perceber como os discursos sobre a pr\u00e1tica esportiva, nesse caso, sobre o atletismo, estavam em conson\u00e2ncia com as ideias de uma perspectiva higienista em um sentido amplo, a despeito da heterogeneidade do higienismo, pois por parte dos organizadores das competi\u00e7\u00f5es entre os banc\u00e1rios seria uma forma de fomentar h\u00e1bitos e comportamentos que promoveriam uma melhoria das condi\u00e7\u00f5es de vida daqueles trabalhadores e, por conseguinte, de sua imagem na sociedade.Se os benef\u00edcios f\u00edsicos do esporte eram importantes para os banc\u00e1rios que passavam horas do dia fechados nas ag\u00eancias, com m\u00e1 ilumina\u00e7\u00e3o e pouca ventila\u00e7\u00e3o, sem conforto, com pouco espa\u00e7o e suscet\u00edveis \u00e0 tuberculose, os benef\u00edcios morais n\u00e3o poderiam ser considerados menos importantes do ponto de vista dos organizadores das competi\u00e7\u00f5es. Era preciso ter moral elevada para ser banc\u00e1rio. Afinal, a posi\u00e7\u00e3o social ocupada por esses sujeitos exigia deles uma identidade profissional bastante diferente da exigida de outras categorias de trabalhadores. Retid\u00e3o de car\u00e1ter, n\u00e3o envolvimento com ilicitudes ou agiotagem e ter sempre boa apar\u00eancia eram apenas algumas dessas exig\u00eancias. Desse modo, o discurso de que o esporte ajudava na consagra\u00e7\u00e3o de um indiv\u00edduo f\u00edsica e moralmente melhor cabia muito bem \u00e0 identidade do banc\u00e1rio. Isso porque a pr\u00e1tica esportiva ainda ajudava na intera\u00e7\u00e3o entre os funcion\u00e1rios \u2013 por\u00e9m, apenas se praticado com cautela; do contr\u00e1rio, poderia gerar conflitos nos locais de trabalho, como demonstrou Fatima At\u00e9 aqui foi poss\u00edvel analisar como a LBEA enxergava a pr\u00e1tica esportiva nos meios banc\u00e1rios. Para ela, como explicitado, os esportes eram uma forma de melhorar f\u00edsica e moralmente os trabalhadores banc\u00e1rios, que frequentavam locais de trabalho pouco higi\u00eanicos, com pouca ilumina\u00e7\u00e3o e ventila\u00e7\u00e3o, e que tinham grande quantidade de trabalho.Vida Banc\u00e1ria. No entanto, mesmo que esse respaldo existisse no discurso, a pr\u00e1tica esportiva fugia do modelo esperado pela diretoria da liga, como foi poss\u00edvel perceber com os casos de consumo de bebida alco\u00f3lica pelos atletas. Formava-se, assim, uma cultura esportiva que ia al\u00e9m da pr\u00e1tica esportiva pura e simples. Ela se ligava, tamb\u00e9m, aos momentos de sociabilidade dos banc\u00e1rios, promovendo congra\u00e7amento e divers\u00e3o, contribuindo para a forma\u00e7\u00e3o de uma cultura de classe.Se n\u00e3o \u00e9 poss\u00edvel afirmar que essa vis\u00e3o higienista de esporte era consensual entre os esportistas da LBEA, podemos dizer que ela recebia respaldo, pelo menos em parte, dos seus dirigentes, uma vez que eles eram os respons\u00e1veis pela se\u00e7\u00e3o esportiva do jornal Esses momentos de sociabilidade eram bastante valorizados entre eles, o que demonstra uma diferencia\u00e7\u00e3o entre essa e outras categorias de trabalhadores. Fazendo parte do que se entendia como classe m\u00e9dia, seu emprego, assim como suas roupas, seus locais de moradia, sua alimenta\u00e7\u00e3o e sua ocupa\u00e7\u00e3o do tempo livre eram diferentes daqueles dos oper\u00e1rios, forjando uma identidade profissional.H\u00e1 dificuldade em situar esses trabalhadores na esfera social, uma vez que s\u00e3o entendidos pela sociedade na qual se inserem de uma maneira, e se entendem de outra. No entanto, levando em considera\u00e7\u00e3o sua identidade profissional, sua faixa salarial e sua vida cultural, com a busca por divertimentos e instru\u00e7\u00e3o, pode-se dizer que eles faziam parte da classe m\u00e9dia urbana que ganhava for\u00e7a no pa\u00eds no in\u00edcio do s\u00e9culo XX. E, em sua busca por divertimentos, elegeram como um dos seus preferidos o futebol, praticado no interior da sua associa\u00e7\u00e3o de classe. Al\u00e9m disso, apesar do poss\u00edvel interesse dos empregadores para que seus funcion\u00e1rios praticassem esportes \u2013 numa tentativa de controle do corpo e do tempo de n\u00e3o trabalho \u2013, o que se percebe na experi\u00eancia desses sujeitos foi uma ressignifica\u00e7\u00e3o das pr\u00e1ticas, subvertendo a imposi\u00e7\u00e3o, seja de patr\u00f5es, seja dos organizadores do esporte banc\u00e1rio, transformando as competi\u00e7\u00f5es esportivas em momentos de divertimento e congra\u00e7amento."}
+{"text": "To validate a set of indicators for monitoring the quality of surgical procedures in the Brazilian Unified Health System (SUS). Validation study developed in 5 stages: 1) literature review; 2) prioritization of indicators; 3) content validation of indicators by RAND/UCLA consensus method; 4) pilot study for reliability analysis; and 5) development of instruction for tabulation of outcome indicators for monitoring via official information systems. From the literature review, 217 indicators of surgical quality were identified. The excluded indicators were: those based on scientific evidence lower than 1A, similar, specific, which corresponded to sentinel events; and those that did not apply to the SUS context. Twenty-six indicators with a high level of scientific evidence were submitted to expert consensus. Twenty-two indicators were validated, of which 14 process indicators and 8 outcome indicators with content validation index \u226580%. Of the validated process indicators, 6 were considered substantially reliable  and 2 had almost perfect reliability , when the inter-rater agreement was analyzed. One could measure and establish tabulation mechanism for TabWin for 7 outcome indicators. The study contributes to the development of a set of potentially effective surgical indicators for monitoring the quality of care and patient safety in SUS hospital services. Such therapeutic resource has been increasingly regarded as an essential component of public health, its role growing in importance with the increase in life expectancy2. However, little is known about the quality and safety of surgeries performed in SUS.The Brazilian Unified Health System (SUS) performs about five million surgeries annually, mostly elective surgical procedures2, an increase of about 36.8% since the launch of the Second Global Challenge for Patient Safety, Safe Surgeries Saves Lives3.This is a crucial gap since, despite their benefits, surgeries also present risks to the patient and costs to the health system. Data shows 312.9 million surgeries were performed in 2012 worldwide4, technical standards and regulations for inspection and monitoring purposes. However, there is still a lack of a standardized set of indicators for monitoring surgeries in SUS. Such monitoring is important since it enables quality improvement and provides learning to teams, in addition to enabling the development of regulatory capacity, being essential for a good clinical performance6.The Ministry of Health, health sector regulatory agencies and non-governmental bodies have supported initiatives to improve the quality and safety of surgeries through actions related to the elaboration of public policies8and to stimulate positive changes towards achieving quality at a reasonable cost9. These indicators are used as direct measures of the quality and safety of the care provided; however, they are still insufficient. Therefore, we are dealing with a scenario in which the existing indicators are not standardized and consolidated, nor periodically measured by the care network, leading to a void of important information and lack of comparability between existing information, negatively affecting the planning and quality management of care in the SUS.In the last decade, indicators have been developed to guide initiatives for improvement of quality in perioperative careThus, this study aims to identify and validate a minimum set of process and outcome indicators that can be used to monitor the quality of surgical procedures in SUS.This study is part of the QualiCir Project, an intervention project aimed at improving the quality and safety of surgical procedures in the state of Rio Grande do Norte (RN), and is developed in partnership with the QualiSa\u00fade Research Group of the Federal University of Rio Grande do Norte and the RN Public Health Secretariat.This is a methodological study on the validation of perioperative quality indicators applicable to elective surgical procedures performed in SUS. The study was developed in 5 stages: 1) literature review; 2) selection of indicators for consensus; 3) content validation of indicators; 4) pilot study for reliability analysis; and 5) development of instructions for tabulation of outcome indicators.Stage 1 - Literature review: A search was performed in PubMed and Google Scholar databases, looking for articles of current systematic reviews (< 5 years of publication). As search strategy, the keywords \u201cquality indicators\u201d and \u201csurgical procedures\u201d were included. Searches were also carried out on official State websites and documents, pursuing indicators developed by national organizations regarded as reference in the promotion of patient care and safety, so to obtain a list of potential indicators to be used to measure surgical quality in the Brazilian context. Indicators were selected from regulatory agencies in the health sector11, Patient Safety Indicators (ISEP-Brazil Project)12, Health System Performance Assessment Project (PROADESS)13, and the Collaborating Center for Quality and Patient Safety (PROQUALIS)14.Stage 2 - Selection of indicators for consensus: Based on the indicators found in the previous step, those that had the following criteria were selected: a) aspects related to the entire surgical process; b) high scientific evidence (1A); c) able to evaluate the quality of surgical care in any hospital of the national health system; d) can be used to implement improvement measures based on their results. Indicators that were similar amongst themselves, sentinels, not applied to the SUS context, that evaluate a specific surgical procedure or patient group, with contradictory evidence, and indicators that present measurement difficulties  were excluded.Stage 3 - Content validation of the indicators: Validation was performed using the RAND/UCLA method15, which associates aspects of the Delphi and Nominal Group methods14 and combines the observation of the available scientific evidence with the collective judgment of experts. The validation of indicators is done through a consensus opinion derived from a group, with aggregated individual opinions, which is an established approach for the development of health indicators5. The group of specialists consisted of eight surgeons and two nurses. Nine members of this group of specialists worked in public institutions in four different Brazilian states, and one was a Spanish surgeon who coordinated a similar study in his country.Two rounds of consensus were established: the first occurred by completing the electronic questionnaire sent by email and the second was developed by web conferencing.Google Forms platform, based on similar studies16, containing five closed questions for each indicator, using a Likert-type scale for responses. The following criteria were used for the evaluation and selection of indicators: 1) Is the indicator clearly relevant?; 2) Does the indicator measure the quality of care or safety in surgical care?; 3) Can the indicator be modified with improvement interventions implemented by the hospital?; 4) Are the data for the indicator measurement possible to collect?; and 5) Is the wording of the indicator clear, with correct terminology and leaving no doubts?A questionnaire was developed using the 17 in the five proposed items would be considered valid for the measurement of surgical quality. Indicators that did not reach this value in the first round were taken to the second round.Indicators that obtained a content validation index (CVI) greater than 80%As a subsidy for the two rounds, an indicator form was developed containing the following information: title, measure, justification, indicator type, data source, numerator and denominator description, clarifications/definition of terms, limitations/exceptions, and bibliographic references.Stage 4 - Pilot study for reliability analysis: For reliability analysis of process indicators, a pilot study was carried out in a hospital of the RN state health network. Three samples were established from the set of surgeries described in the Management System of the Table of Procedures (SIGTAP) of SUS. Sample 1 (A1): All procedures of the surgical procedures group, except the subgroups of minor surgeries and surgeries of the skin, subcutaneous tissue and mucosa, upper airway surgery, vision apparatus surgery, obstetric surgery and other surgeries; sample 2 (A2): Surgical procedures of the subgroup digestive tract surgeries (colon and rectum surgeries); sample 3 (A3): Surgical procedures of the osteomuscular apparatus subgroup surgeries (arthroscopy and knee prosthesis).19. The adequacy of indicators by sample type was established by consulting experts. Most of the process indicators were evaluated in sample A1, with the exception of the indicators \u201cTimely removal of surgical nasogastric tubes\u201d and \u201cEarly removal of bladder catheter\u201d, which were evaluated in sample 2.Collection was carried out by two independent evaluators, with previous experience in collecting data from medical records, in a cross-sectional manner, in samples of 30 medical records each, referring to elective surgeries occurred in 2020, selected systematically20: poor agreement (Kappa < 0.00), mild agreement (0.00 \u2264 Kappa \u2264 0.20), fair agreement (0.21 \u2264 Kappa \u2264 0.40), moderate agreement (0.41 \u2264 Kappa \u2264 0.60), substantial agreement (0.61 \u2264 Kappa \u2264 0.80) and perfect agreement (0.81 \u2264 1.00).For the analysis of interobserver reliability, the Kappa index was calculated to identify the level of agreement according to the parameters established by Landis and KochStage 5 - Identification of tabulation mechanism for result indicators so that they can be monitored via official information systems - The validated result indicators were analyzed for their possibility of monitoring through the use of data from official information systems, from the identification of tabulation mechanism for TabWin/DataSus with the Hospital Information System of SUS  database.The research was carried out under the approval of the Research Ethics Committee of the Federal University of Rio Grande do Norte , following the ethical precepts in research with human beings, according to resolution CNS/MS 466/12.217 quality or safety indicators related to surgical procedures, totaling 183 process indicators and 34 outcome indicators were found. The choice to use the content of systematic reviews as the main reference for the literature search was made to avoid the repetition of a recent study with similar objectives.Of the 183 process indicators, 138 were excluded by the criterion of low scientific evidence (< 1A) . AlthougAs for the outcome indicators, 10 indicators were excluded because they were considered similar, eight were very specific, two did not allow the development of improvement cycles and four were related to sentinel events. At the end of this trial, 16 process indicators and 10 outcome indicators were submitted to content validation with the group of experts. The selection flow of indicators can be seen in In the first round, which was attended by 100% of the invited experts, validation questionnaires were sent by email and 26 indicators were presented to the group. In this round, the 13 indicators that received CVI greater than 80% were considered valid for measuring surgical quality within the SUS. The other 13 indicators, due to achieving CVI equal to or less than 80% in any of the evaluated criteria, were submitted to the second round of consensus. This step occurred through web conferencing and was attended by 80% of the invited experts. Discussions on indicators with CVI \u2264 80% took place at the time and, subsequently, a new evaluation was carried out, as can be seen in At the end of the second round, four indicators received CVI \u2264 80% and were not considered valid: the indicator \u201cPreoperative use of oral carbohydrates\u201d, which presented CVI of 75% in the criterion related to the writing of the indicator; the indicator \u201cImproved recovery\u201d had CVI of 75% in the criteria related to the availability of data for measurement and clarity in the writing; the indicators \u201cPost-surgical stroke\u201d and \u201cUnscheduled admission to an intensive care unit\u201d obtained CVI of 75% in the criteria related to the availability of data and the possibility of modifying the indicator through improvement interventions. Thus, 22 indicators were considered valid for the measurement of quality in surgeries, of which 14 were process and 8 were outcome indicators. The data source, numerator and denominator of these indicators are described in The qualification sheets of the validated indicators were reformulated according to suggestions of the experts, with the addition and reformulation of terms and concepts.To analyze the reliability of the indicators, whose data source are the medical records, a retrospective pilot study was carried out at the Regional Hospital Mariano Coelho (HRMC), in Currais Novos/RN, between September and October 2021. The HRMC has 32 qualified surgical beds, and is a reference in the performance of elective surgical procedures for the health region in which the hospital is inserted.Due to the HRMC qualification profile, it was not possible to collect the indicators \u201cPostoperative discharge with postoperative evaluation, prophylaxis of venous thromboembolism and postoperative rehabilitation\u201d, and \u201cRecord of pressure and time during controlled ischemia in surgery\u201d. The search for another institution of the state hospital network that was qualified to perform orthopedic surgeries to evaluate these indicators was considered; however, this was not possible given the low number of orthopedic elective surgeries performed in 2020 due to the covid-19 pandemic, in addition to the lack of pneumatic tourniquet in the hospital institutions that make up the state network.20, as can be seen in As for the reliability analysis, six indicators showed substantial reliability and two almost perfect reliabilityFor outcome indicators, whose data source is SIH-SUS, it was observed that seven of the eight validated indicators can be monitored from the TabWin/DATASUS tabulator. Data are publicly accessible and available at https://datasus.saude.gov.br/transferencia-de-arquivos/.It was not possible to perform tabulation for the indicator \u201cPost-surgical readmission\u201d. As this is a system that analyzes hospital production, it does not link hospitalizations to an individual user record, i.e., through the system one cannot identify how many times a single user was admitted to the hospital, nor is it possible to ascertain whether one admission would be related to the previous one.An instruction was prepared to tabulate the result indicators for the TabWin/DATASUS application for teams that will collect data and monitor it. All results obtained with the other indicators can be seen in This study contributed to the development of a set of 22 indicators with a high level of evidence, which underwent a rigorous content validation process to enable the monitoring of the quality of surgical care within the SUS. These indicators can guide the management of institutions and of the hospital network as a whole, identifying weaknesses that must be addressed, aiming at providing safe care to the population. This is, therefore, an initial set of highly relevant indicators for monitoring and improving the quality of surgical care within the scope of SUS RN, with the possibility of being used by any other health service.8. Thus, continuously monitoring these indicators enables one to identify weaknesses in the provision of care. According to Donabedian, process indicators are the only direct measure of quality, as the structure may not be used and outcomes may be due to factors other than good care21.From the process indicators, one may evaluate all the steps and activities performed in the implementation of a treatment or care episodebenchmarking. That is, it enables the comparison of health services from the state hospital network and also at the national level, which strengthens information systems22.Monitoring of the outcome indicators \u201cPost-surgical mortality\u201d, \u201cPost-surgical readmission\u201d and \u201cAverage length of stay with and without death\u201d through the information system enables the measurement of the quality of an isolated health service, as well as 23 to assess surgical care. A similar study16 developed for the Spanish health system also pointed out the indicators: \u201cPost-surgical readmission\u201d, \u201cProphylaxis of venous thromboembolism\u201d, \u201cAdequate antibiotic prophylaxis\u201d and \u201cSurgical site infection\u201d as valid indicators to assess surgical quality; however, these indicators are directed only to surgeries of the digestive tract.The post-surgical mortality indicator is among the indicators proposed by the Lancet CommissionBenchmarking has been used to seek opportunities for improvement and make comparisons of similar organizations24. It has been listed as a strategy by the World Health Organization (WHO) in the Global Action Plan for Patient Safety 2021-203022, and the development of \u201cgood\u201d indicators is a success factor for benchmarking actions25.In addition, 11 indicators could be measured with the available data sources , of which 8 process indicators were evaluated in medical records and 3 outcome indicators were measured with SIH-SUS data, exploring the feasibility of using this system to evaluate the quality of surgical care. For the indicators \u201cScreening for postoperative delirium\u201d, \u201cUse of safe surgery checklist\u201d and \u201cProphylaxis of adequate perioperative venous thromboembolism\u201d, one should institutionalize protocols related to these indicators, which signals an opportunity for improvement for the hospital where the pilot was developed.20.The inter-rater reliability, tested by Kappa statistics for eight process indicators, found values that characterize a substantial and almost perfect degree of reliability, which reinforces the solidity of these indicators. The Kappa test is considered adequate to evaluate the reliability of inter-rater categorical and nominal variables, and is frequently used to evaluate the reliability in this type of study26. There was a four-fold increase in SSI when post-discharge surveillance was performed27, which leads one to the finding that patient\u2019s medical record does not prove to be the best source of data for monitoring this indicator for the vast majority of procedures performed by the SUS.For the Surgical Site Infection (SSI) indicator, whose data sources may be medical records or system data, it was not possible to analyze the reliability, since the event was not observed in the medical records selected to compose the sample. Most SSIs occur, on average, four to six days after the procedure, and the average length of stay for the procedures included in the study was 1.5 days. Studies indicate that, in procedures in which the postoperative length of stay is short, SSI data, obtained only from hospitalized patients, do not reflect the actual occurrence of infection28. The underreporting of secondary diagnosis in surgical admissions impacts the accuracy of measures calculated for these indicators, which is an opportunity for improvement for the health information system.For the outcome indicators \u201cComplications related to anesthesia\u201d, \u201cPostoperative sepsis\u201d, \u201cPulmonary edema or deep vein thrombosis\u201d, measurement via the information system was not possible. The results were null, possibly due to underreporting of secondary events in the Hospital Admission Authorization (AIH) forms. A study on the reliability of AIH data in the country identified a high degree of underreporting of secondary diagnosis29, its implementation has not yet been completed. The CMD implementation would enable the use of administrative, clinical-administrative, and clinical data through a single document, in addition to enabling more specific analyzes, since it would relate the information to the identification of users through integration with the base of the National Health Card system. Despite the efforts and studies carried out in the field of patient safety, the ability to reduce risk, avoid harm, and improve health care safety is still hampered by the absence of high-quality information systems22.The Minimum Health Care Data Set (CMD), conceived in 2015, is a strategy assumed by managers of the three SUS management spheres to reduce fragmentation of information systems, and would replace the main health care information systems in the country. However, despite having been officially instituted by resolution of the Tripartite Intermanagerial Commission30. The use of the RAND/UCLA method to establish consensus, through the use of remote communication resources (internet), allowed to bring together qualified specialists from various regions of the country. The interest of experts in the studied area, associated with the observed consensus indexes, gave credibility to the results, as can be seen in other studies31.The review of existing literature and consensus methods are increasingly used and recommended by the scientific community for this type of studyAs limitations of this study, we can highlight the performance of the pilot study in a single hospital, whose care profile did not include surgical procedures of the musculoskeletal system, as well as the conduct of the pilot study in a pandemic period, which decreased the sample universe, due to the cancellation of elective surgeries throughout the hospital network. Other limitations, which may be the subject of further studies, are the non-assessment of structural indicators and the non-performance of the feasibility analysis for the collection of indicators.benchmarking between health units, promotes the identification of priorities through the strengthening and optimization of monitoring strategies and improvements aimed at patient safety in SUS hospitals.This study contributed to the development of a set of quality indicators in the surgical sphere, which translates as an effective mechanism for measuring the performance and quality of care offered by the hospital service network of RN and Brazil. There are 22 indicators that were considered valid, with 8 process indicators considered reliable and seven result indicators, in which parameters were identified for tabulation using the official information systems. This set of indicators enables the documentation of quality of care, enables comparisons and Therefore, this is an innovative proposal, compatible with the Brazilian reality, to guide public managers and researchers in the process of monitoring surgical quality. 1. Cada vez mais esse recurso terap\u00eautico vem sendo considerado componente essencial da sa\u00fade p\u00fablica e seu papel ganha import\u00e2ncia com o aumento da expectativa de vida2. Entretanto, pouco se sabe sobre a qualidade e seguran\u00e7a das cirurgias realizadas no SUS.O Sistema \u00danico de Sa\u00fade (SUS) realiza anualmente cerca de cinco milh\u00f5es de cirurgias, em sua maioria procedimentos cir\u00fargicos eletivos2, um aumento de cerca de 36,8% desde o lan\u00e7amento do Segundo Desafio Global para a Seguran\u00e7a do Paciente, Cirurgias Seguras Salvam Vidas3.Essa \u00e9 uma lacuna importante, pois, apesar dos benef\u00edcios, as cirurgias tamb\u00e9m apresentam riscos ao paciente e custos ao sistema de sa\u00fade. Dados mostram que, em 2012, foram realizadas 312,9 milh\u00f5es de cirurgias no mundo4, normas t\u00e9cnicas e regulamenta\u00e7\u00f5es, para fins de fiscaliza\u00e7\u00e3o e de monitoramento. Por\u00e9m, ainda h\u00e1 uma car\u00eancia de um conjunto padronizado de indicadores para o monitoramento das cirurgias no SUS. Esse monitoramento \u00e9 importante, uma vez que possibilita melhoria da qualidade e proporciona aprendizado \u00e0s equipes, al\u00e9m de possibilitar a melhoria da capacidade regulat\u00f3ria, sendo essencial ao bom desempenho cl\u00ednico6.O Minist\u00e9rio da Sa\u00fade, as ag\u00eancias reguladoras do setor de sa\u00fade e os \u00f3rg\u00e3os n\u00e3o governamentais t\u00eam apoiado iniciativas para melhorar a qualidade e seguran\u00e7a das cirurgias, atrav\u00e9s de a\u00e7\u00f5es relacionadas \u00e0 elabora\u00e7\u00e3o de pol\u00edticas p\u00fablicas8 e estimular mudan\u00e7as positivas em rela\u00e7\u00e3o ao alcance da qualidade a um custo razo\u00e1vel9. Esses indicadores s\u00e3o usados como medidas diretas da qualidade e seguran\u00e7a do atendimento prestado; por\u00e9m, ainda s\u00e3o insuficientes. Entretanto, lidamos com um cen\u00e1rio em que os indicadores existentes n\u00e3o s\u00e3o padronizados e consolidados, ou medidos periodicamente pela rede assistencial, o que nos leva a um vazio de informa\u00e7\u00f5es importantes e falta de comparabilidade entre as informa\u00e7\u00f5es existentes, afetando negativamente o planejamento e gest\u00e3o da qualidade do cuidado no SUS.Na \u00faltima d\u00e9cada foram desenvolvidos indicadores para orientar as iniciativas de melhoria da qualidade para os cuidados perioperat\u00f3riosLogo, o objetivo deste estudo \u00e9 identificar e validar um conjunto m\u00ednimo de indicadores de processo e resultado que possam ser utilizados para o monitoramento da qualidade dos procedimentos cir\u00fargicos no SUS.O estudo faz parte do Projeto QualiCir, projeto de interven\u00e7\u00e3o que visa melhorar a qualidade e seguran\u00e7a nos procedimentos cir\u00fargicos no estado do Rio Grande do Norte (RN), desenvolvido em parceria com o Grupo de Pesquisa QualiSa\u00fade da Universidade Federal do Rio Grande do Norte e Secretaria de Sa\u00fade P\u00fablica do RN.Este \u00e9 um estudo metodol\u00f3gico de valida\u00e7\u00e3o de indicadores de qualidade perioperat\u00f3ria aplic\u00e1veis aos procedimentos cir\u00fargicos eletivos realizados no SUS. Foi desenvolvido em 5 etapas: 1) revis\u00e3o de literatura; 2) sele\u00e7\u00e3o dos indicadores para consenso; 3) valida\u00e7\u00e3o de conte\u00fado dos indicadores; 4) estudo piloto para an\u00e1lise da confiabilidade; e 5) desenvolvimento de instrutivo para tabula\u00e7\u00e3o de indicadores de resultado.Etapa 1 - Revis\u00e3o de literatura: Foi realizada busca em bases de dados, PubMed e Google Acad\u00eamico, por artigos de revis\u00f5es sistem\u00e1ticas atuais (< 5 anos de publica\u00e7\u00e3o). A estrat\u00e9gia de busca incluiu, como palavras-chave, \u201cindicadores de qualidade\u201d e \u201cprocedimentos cir\u00fargicos\u201d. Tamb\u00e9m foram realizadas buscas em sites e documentos oficiais nacionais por indicadores desenvolvidos por organiza\u00e7\u00f5es nacionais consideradas refer\u00eancia na promo\u00e7\u00e3o do cuidado e da seguran\u00e7a do paciente, na perspectiva de se obter uma lista de potenciais indicadores que possam ser utilizados para mensura\u00e7\u00e3o da qualidade cir\u00fargica no contexto brasileiro. Foram selecionados indicadores de ag\u00eancias reguladoras do setor de sa\u00fade11; Indicadores de Seguran\u00e7a do Paciente (Projeto ISEP-Brasil)12; Projeto de Avalia\u00e7\u00e3o do Desempenho do Sistema de Sa\u00fade (PROADESS)13 e do Centro Colaborador para Qualidade e Seguran\u00e7a do Paciente (PROQUALIS)14.Etapa 2 - Sele\u00e7\u00e3o dos indicadores para consenso: A partir dos indicadores encontrados na etapa anterior, foram selecionados aqueles que possu\u00edam os seguintes crit\u00e9rios: a) aspectos relacionados a todo o processo cir\u00fargico; b) evid\u00eancia cient\u00edfica alta (1A); c) servem para avaliar a qualidade da assist\u00eancia cir\u00fargica em qualquer hospital do sistema nacional de sa\u00fade; d) podem ser usados para implementar medidas de melhoria com base em seus resultados. Exclu\u00edram-se indicadores similares, sentinelas, n\u00e3o aplicados ao contexto do SUS, que avaliam procedimento cir\u00fargico ou grupo de pacientes espec\u00edfico, com evid\u00eancias contradit\u00f3rias e indicadores que apresentam dificuldades de medi\u00e7\u00e3o .Etapa 3 - Valida\u00e7\u00e3o de conte\u00fado dos indicadores: Foi realizada mediante uso do m\u00e9todo RAND/UCLA15, metodologia que associa aspectos dos m\u00e9todos Delphi e de Grupo Nominal14, e combina a observa\u00e7\u00e3o das evid\u00eancias cient\u00edficas dispon\u00edveis com o julgamento coletivo de especialistas. A valida\u00e7\u00e3o dos indicadores \u00e9 feita por meio de uma opini\u00e3o de consenso derivada de um grupo, com opini\u00f5es individuais agregadas, sendo esta uma abordagem estabelecida para o desenvolvimento de indicadores de sa\u00fade5. O grupo de especialistas foi composto por oito cirurgi\u00f5es e duas enfermeiras. Nove integrantes desse grupo de especialistas trabalhavam em institui\u00e7\u00f5es p\u00fablicas em quatro estados brasileiros distintos, e um era um cirurgi\u00e3o espanhol que coordenou estudo semelhante em seu pa\u00eds.Foram estabelecidas duas rodadas de consenso: a primeira ocorreu por meio do preenchimento do question\u00e1rio eletr\u00f4nico enviado por e-mail e segunda ocorreu por webconfer\u00eancia.Google Forms, baseado em estudos semelhantes16, contendo cinco perguntas fechadas para cada indicador, utilizando a escala Likert para resposta. Foram utilizados, para a avalia\u00e7\u00e3o e sele\u00e7\u00e3o dos indicadores, os seguintes crit\u00e9rios: 1) o indicador \u00e9 claramente relevante?; 2) o indicador mede a qualidade do cuidado ou seguran\u00e7a na assist\u00eancia cir\u00fargica?; 3) o indicador pode ser modificado com interven\u00e7\u00f5es de melhoria implementadas pelo hospital?; 4) os dados para a mensura\u00e7\u00e3o do indicador s\u00e3o poss\u00edveis de coletar?; e 5) a reda\u00e7\u00e3o do indicador \u00e9 clara, com terminologia correta e n\u00e3o deixa d\u00favidas?Foi desenvolvido um question\u00e1rio utilizando a plataforma 17 nos cinco itens propostos seriam considerados v\u00e1lidos para a mensura\u00e7\u00e3o da qualidade cir\u00fargica. Os indicadores que n\u00e3o atingissem esse valor na primeira rodada seriam levados para a segunda rodada.Os indicadores que obtivessem um \u00edndice de valida\u00e7\u00e3o de conte\u00fado (IVC) maior que 80%Como subs\u00eddio para as duas rodadas, foi desenvolvida a ficha dos indicadores, contendo as informa\u00e7\u00f5es: t\u00edtulo, medida, justificativa, tipo do indicador, fonte de dados, descri\u00e7\u00e3o do numerador e denominador, esclarecimentos/defini\u00e7\u00e3o dos termos, limita\u00e7\u00f5es/exce\u00e7\u00f5es e refer\u00eancias bibliogr\u00e1ficas.Etapa 4 - Estudo piloto para an\u00e1lise da confiabilidade: Para an\u00e1lise de confiabilidade dos indicadores de processo, foi realizado estudo piloto em um hospital da rede estadual de sa\u00fade do RN. Tr\u00eas amostras foram estabelecidas a partir do conjunto de cirurgias descrito no Sistema de Gerenciamento da Tabela de Procedimentos (SIGTAP) do SUS. Amostra 1 (A1): Todos os procedimentos do grupo procedimentos cir\u00fargicos, exceto os subgrupos pequenas cirurgias e cirurgias de pele, tecido subcut\u00e2neo e mucosa, cirurgia das vias a\u00e9reas superiores, cirurgia do aparelho da vis\u00e3o, cirurgia obst\u00e9trica e outras cirurgias; amostra 2 (A2): Procedimentos cir\u00fargicos do subgrupo cirurgias do aparelho digestivo (cirurgias de c\u00f3lon e reto); amostra 3 (A3): Procedimentos cir\u00fargicos do subgrupo cirurgias do aparelho osteomuscular (artroscopia e pr\u00f3tese de joelho).19. A adequa\u00e7\u00e3o dos indicadores por tipo de amostra foi estabelecida mediante consulta a especialistas. A maioria dos indicadores de processo foi avaliada na amostra A1, com exce\u00e7\u00e3o dos indicadores \u201cRetirada oportuna das sondas nasog\u00e1stricas operat\u00f3rias\u201d e \u201cRemo\u00e7\u00e3o precoce do cateter vesical\u201d, que foram avaliados na amostra 2.A coleta foi realizada por dois avaliadores independentes, com experi\u00eancia anterior em coleta de dados em prontu\u00e1rios, de forma transversal, em amostras de 30 prontu\u00e1rios cada, referentes a cirurgias eletivas ocorridas em 2020, selecionadas aleatoriamente de forma sistem\u00e1tica20: concord\u00e2ncia pobre (Kappa < 0.00), concord\u00e2ncia leve , concord\u00e2ncia justa , concord\u00e2ncia moderada , concord\u00e2ncia substancial  e concord\u00e2ncia perfeita .Para a an\u00e1lise da confiabilidade interobservador, foi calculado o \u00edndice de Kappa, para identificar o n\u00edvel de concord\u00e2ncia segundo os par\u00e2metros estabelecidos por Landis e KochEtapa 5 - Identifica\u00e7\u00e3o de mecanismo de tabula\u00e7\u00e3o para os indicadores de resultado para que possam ser monitorados via sistemas de informa\u00e7\u00f5es oficiais - Os indicadores de resultados validados foram analisados quanto \u00e0 sua possibilidade de monitoramento por meio da utiliza\u00e7\u00e3o dos dados dos sistemas de informa\u00e7\u00f5es oficiais, a partir da identifica\u00e7\u00e3o de mecanismo de tabula\u00e7\u00e3o para o TabWin/DataSus com o banco de dados do Sistema de Informa\u00e7\u00f5es Hospitalares do SUS (SIH-SUS).A pesquisa foi executada sob aprova\u00e7\u00e3o do Comit\u00ea de \u00c9tica em Pesquisa da Universidade Federal do Rio Grande do Norte , seguindo os preceitos \u00e9ticos em pesquisa com seres humanos, de acordo com a resolu\u00e7\u00e3o CNS/MS 466/12.Foram encontrados 217 indicadores de qualidade ou seguran\u00e7a relacionados a procedimentos cir\u00fargicos, totalizando 183 indicadores de processo e 34 indicadores de resultado. A op\u00e7\u00e3o por utilizar o conte\u00fado das revis\u00f5es sistem\u00e1ticas como refer\u00eancia principal para a busca bibliogr\u00e1fica se deu na perspectiva de evitar a repeti\u00e7\u00e3o de um estudo recente com objetivos parecidos.Dos 183 indicadores de processo, 138 foram exclu\u00eddos pelo crit\u00e9rio da baixa evid\u00eancia cient\u00edfica (< 1A) . Embora Quanto aos indicadores de resultado, 10 indicadores foram exclu\u00eddos por serem considerados similares, oito eram muito espec\u00edficos, dois n\u00e3o possibilitaram o desenvolvimento de ciclos de melhoria e quatro estavam relacionados a evento sentinela. Ao final desse processo, 16 indicadores de processo e 10 indicadores de resultado foram submetidos \u00e0 valida\u00e7\u00e3o de conte\u00fado junto ao grupo de especialistas. O fluxo de sele\u00e7\u00e3o dos indicadores pode ser observado na Na primeira rodada, que teve participa\u00e7\u00e3o de 100% dos especialistas convidados, foram enviados, por e-mail, os question\u00e1rios de valida\u00e7\u00e3o, e 26 indicadores foram apresentados ao grupo. Nessa rodada, os 13 indicadores que receberam IVC maior que 80% foram considerados v\u00e1lidos para mensura\u00e7\u00e3o da qualidade cir\u00fargica no \u00e2mbito do SUS. Os outros 13 indicadores, por alcan\u00e7arem IVC igual ou inferior a 80% em qualquer um dos crit\u00e9rios avaliados, foram submetidos a segunda rodada de consenso. Essa etapa ocorreu mediante webconfer\u00eancia e teve ades\u00e3o de 80% dos especialistas convidados. Na ocasi\u00e3o, ocorreram discuss\u00f5es sobre os indicadores com IVC \u2264 80% e, posteriormente, realizada nova avalia\u00e7\u00e3o, conforme pode ser observado no Ao t\u00e9rmino da segunda rodada, quatro indicadores receberam IVC \u2264 80% e n\u00e3o foram considerados v\u00e1lidos: o indicador \u201cUso de carboidratos orais no pr\u00e9-operat\u00f3rio\u201d, que apresentou IVC de 75% no crit\u00e9rio relacionado \u00e0 reda\u00e7\u00e3o do indicador; o indicador \u201cRecupera\u00e7\u00e3o aprimorada\u201d teve IVC de 75% nos crit\u00e9rios relacionados \u00e0 disponibiliza\u00e7\u00e3o dos dados para mensura\u00e7\u00e3o e clareza na reda\u00e7\u00e3o; os indicadores \u201cAcidente vascular cerebral no p\u00f3s-cir\u00fargico\u201d e \u201cAdmiss\u00e3o n\u00e3o programada em unidade de terapia intensiva\u201d obtiveram IVC de 75% nos crit\u00e9rios relacionados \u00e0 disponibiliza\u00e7\u00e3o de dados e \u00e0 possibilidade de modifica\u00e7\u00e3o do indicador mediante interven\u00e7\u00f5es de melhoria. Desse modo, 22 indicadores foram considerados v\u00e1lidos para a mensura\u00e7\u00e3o da qualidade em cirurgias, sendo 14 de processo e 8 de resultado. A fonte dos dados, o numerador e o denominador desses indicadores est\u00e3o descritos no As fichas de qualifica\u00e7\u00e3o dos indicadores validados foram reformuladas de acordo com as sugest\u00f5es dos especialistas, com a adi\u00e7\u00e3o e reformula\u00e7\u00e3o de termos e conceitos.Para an\u00e1lise da confiabilidade dos indicadores, cuja fonte de dados s\u00e3o os prontu\u00e1rios, realizou-se um estudo piloto retrospectivo no Hospital Regional Mariano Coelho (HRMC), em Currais Novos/RN, nos meses de setembro e outubro de 2021. O HRMC \u00e9 um hospital que possui 32 leitos cir\u00fargicos habilitados, refer\u00eancia na realiza\u00e7\u00e3o procedimentos cir\u00fargicos eletivos para a regi\u00e3o de sa\u00fade em que est\u00e1 inserido.Devido ao perfil de habilita\u00e7\u00e3o do HRMC, n\u00e3o foi poss\u00edvel realizar a coleta dos indicadores \u201cAlta p\u00f3s-operat\u00f3ria com avalia\u00e7\u00e3o p\u00f3s-operat\u00f3ria, profilaxia de tromboembolismo venoso e reabilita\u00e7\u00e3o p\u00f3s-cir\u00fargica\u201d, e \u201cRegistro de press\u00e3o e tempo durante isquemia controlada em cirurgia\u201d. Foi cogitada a busca de outra institui\u00e7\u00e3o da rede estadual hospitalar que fosse habilitada para realiza\u00e7\u00e3o de cirurgias ortop\u00e9dicas para avalia\u00e7\u00e3o desses indicadores; entretanto, n\u00e3o foi poss\u00edvel, diante do baixo n\u00famero de cirurgia eletivas ortop\u00e9dicas realizadas no ano de 2020, em virtude da pandemia de covid-19, al\u00e9m da inexist\u00eancia de torniquete pneum\u00e1tico nas institui\u00e7\u00f5es hospitalares que comp\u00f5em a rede estadual.20, como pode ser observado na Quanto \u00e0 an\u00e1lise de confiabilidade, seis indicadores apresentaram confiabilidade substancial e dois confiabilidade quase perfeitaPara os indicadores de resultado, cuja fonte de dados \u00e9 o SIH-SUS, foi observado que sete dos oito indicadores validados podem ser monitorados a partir do tabulador TabWin/DATASUS). Os dados s\u00e3o de acesso p\u00fablico e est\u00e3o dispon\u00edveis no endere\u00e7o eletr\u00f4nico https://datasus.saude.gov.br/transferencia-de-arquivos/.N\u00e3o foi poss\u00edvel realizar tabula\u00e7\u00e3o para o indicador \u201cReadmiss\u00e3o p\u00f3s-cir\u00fargica\u201d. Por se tratar de um sistema que analisa a produ\u00e7\u00e3o hospitalar, ele n\u00e3o vincula as interna\u00e7\u00f5es a um registro individual do usu\u00e1rio, ou seja, por meio do sistema n\u00e3o \u00e9 poss\u00edvel identificar quantas vezes um \u00fanico usu\u00e1rio foi admitido no hospital, tampouco \u00e9 poss\u00edvel averiguar se uma admiss\u00e3o estaria relacionada \u00e0 outra anterior.Foi elaborado instrutivo de tabula\u00e7\u00e3o dos indicadores de resultado para o aplicativo TabWin/DATASUS para as equipes que far\u00e3o a coleta de dados e monitoramento. Todos os resultados obtidos com os outros indicadores podem ser observados na O estudo contribuiu para o desenvolvimento de um conjunto de 22 indicadores com alto n\u00edvel de evid\u00eancia, que passaram por processo rigoroso de valida\u00e7\u00e3o de conte\u00fado para possibilitar o monitoramento da qualidade da assist\u00eancia cir\u00fargica no \u00e2mbito do SUS. Esses indicadores poder\u00e3o orientar a gest\u00e3o da institui\u00e7\u00e3o e a gest\u00e3o da rede hospitalar como um todo, identificando as fragilidades que devem ser trabalhadas, visando a oferta de uma assist\u00eancia segura \u00e0 popula\u00e7\u00e3o. Trata-se, ent\u00e3o, de conjunto inicial de indicadores altamente relevantes para o monitoramento e a melhoria da qualidade da assist\u00eancia cir\u00fargica no \u00e2mbito do SUS do RN com possibilidade de ser utilizado por qualquer outro servi\u00e7o de sa\u00fade.8. Logo, monitorar continuamente esses indicadores possibilita identificar fragilidades na presta\u00e7\u00e3o do cuidado. Segundo Donabedian, os indicadores de processo s\u00e3o a \u00fanica medida direta da qualidade, pois a estrutura pode n\u00e3o ser utilizada e os resultados podem se dever a outros fatores para al\u00e9m da boa assist\u00eancia21.A partir dos indicadores de processo, \u00e9 poss\u00edvel avaliar todas as etapas e atividades realizadas na implementa\u00e7\u00e3o de um tratamento ou epis\u00f3dio de cuidadobenchmarking. Ou seja, possibilita a compara\u00e7\u00e3o de servi\u00e7os de sa\u00fade da rede hospitalar estadual e tamb\u00e9m em n\u00edvel nacional, o que fortalece os sistemas de informa\u00e7\u00e3o22.O monitoramento dos indicadores de resultado \u201cMortalidade p\u00f3s- cir\u00fargica\u201d, \u201cReadmiss\u00e3o p\u00f3s-cir\u00fargica\u201d e \u201cTempo m\u00e9dio de interna\u00e7\u00e3o com e sem \u00f3bito\u201d, por meio do sistema de informa\u00e7\u00e3o, possibilita a mensura\u00e7\u00e3o da qualidade de um servi\u00e7o de sa\u00fade isolado, como tamb\u00e9m viabiliza o 23 para avaliar os cuidados cir\u00fargicos. Estudo similar16 desenvolvido para o sistema de sa\u00fade espanhol apontou tamb\u00e9m os indicadores: \u201cReadmiss\u00e3o p\u00f3s-cir\u00fargica\u201d, \u201cProfilaxia de tromboembolismo venoso\u201d, \u201cAntibioticoprofilaxia adequada\u201d e \u201cInfec\u00e7\u00e3o do s\u00edtio cir\u00fargico\u201d como indicadores v\u00e1lidos para avaliar a qualidade cir\u00fargica; entretanto, estes indicadores s\u00e3o direcionados apenas para cirurgias do aparelho digestivo.O indicador de mortalidade p\u00f3s-cir\u00fagica est\u00e1 entre os indicadores propostos pela Comiss\u00e3o Lancetbenchmarking vem sendo utilizado para buscar oportunidades de melhoria e fazer compara\u00e7\u00f5es de organiza\u00e7\u00f5es semelhantes24. Foi listado como estrat\u00e9gia pela Organiza\u00e7\u00e3o Mundial da Sa\u00fade (OMS) no Plano de a\u00e7\u00e3o global para a seguran\u00e7a do paciente 2021-203022, e o desenvolvimento de \u201cbons\u201d indicadores \u00e9 um fator de sucesso para a\u00e7\u00f5es de benchmarking25.O Outrossim, 11 indicadores puderam ser medidos com as fontes de dados dispon\u00edveis , sendo os 8 indicadores de processo avaliados em prontu\u00e1rios e 3 indicadores de resultado medidos com dados do SIH-SUS, explorando a viabilidade do emprego desse sistema para avaliar a qualidade da assist\u00eancia cir\u00fargica. Para os indicadores \u201cTriagem de delirium p\u00f3s-operat\u00f3rio\u201d, \u201cUtiliza\u00e7\u00e3o de lista de verifica\u00e7\u00e3o de cirurgia segura\u201d e \u201cProfilaxia de tromboembolismo venoso perioperat\u00f3ria adequada\u201d, faz-se necess\u00e1ria a institucionaliza\u00e7\u00e3o de protocolos relacionados a esses indicadores, o que sinaliza uma oportunidade de melhoria para o hospital onde foi desenvolvido o piloto.20.A confiabilidade interavaliadores, testada pela estat\u00edstica Kappa para oito indicadores de processo, encontrou valores que caracterizam um grau de confiabilidade substancial e quase perfeita, o que refor\u00e7a a solidez desses indicadores. O teste de Kappa \u00e9 considerado adequado para avaliar a confiabilidade de interavaliadores de vari\u00e1veis categ\u00f3ricas e nominais, e \u00e9 utilizado com frequ\u00eancia para avaliar a confiabilidade neste tipo de estudo26. Observou-se um aumento da ISC de quatro vezes quando a vigil\u00e2ncia p\u00f3s-alta foi realizada27, o que nos leva \u00e0 constata\u00e7\u00e3o de que o prontu\u00e1rio do paciente n\u00e3o se revela como a melhor fonte de dados para o monitoramento desse indicador para a grande maioria dos procedimentos realizados pelo SUS.Para o indicador Infec\u00e7\u00e3o do S\u00edtio Cirurgico (ISC), cujas fontes de dados podem ser prontu\u00e1rios ou dados do sistema, n\u00e3o foi poss\u00edvel analisar a confiabilidade, uma vez que n\u00e3o foi observado o evento nos prontu\u00e1rios selecionados para compor a amostra. A maioria das ISC, ocorre, em m\u00e9dia, de quatro a seis dias ap\u00f3s o procedimento, e a m\u00e9dia do tempo de interna\u00e7\u00e3o para os procedimentos inclu\u00eddos no estudo foi de 1,5 dias de perman\u00eancia. Estudos apontam que, nos procedimentos em que o tempo de perman\u00eancia p\u00f3s-operat\u00f3rio \u00e9 curto, os dados de ISC, obtidos somente de pacientes internados, n\u00e3o refletem a real ocorr\u00eancia de infec\u00e7\u00e3o28. O sub-registro de diagn\u00f3stico secund\u00e1rio nas interna\u00e7\u00f5es cir\u00fargicas impacta na precis\u00e3o das medidas calculadas para esses indicadores, o que se configura como uma oportunidade de melhoria para o sistema de informa\u00e7\u00f5es em sa\u00fade.Para os indicadores de resultado \u201cComplica\u00e7\u00f5es relacionadas \u00e0 anestesia\u201d, \u201cSepse p\u00f3s-operat\u00f3ria\u201d, \u201cEdema pulmonar ou trombose venosa profunda\u201d, n\u00e3o foi poss\u00edvel a mensura\u00e7\u00e3o via sistema de informa\u00e7\u00e3o. Os resultados foram nulos, possivelmente em virtude de sub-registro de eventos secund\u00e1rios nas fichas de Autoriza\u00e7\u00e3o de Interna\u00e7\u00e3o Hospitalar (AIH). Um estudo sobre a confiabilidade dos dados da AIH no pa\u00eds identificou elevado grau de sub-registro de diagn\u00f3stico secund\u00e1rio na AIH29, ainda n\u00e3o teve sua implanta\u00e7\u00e3o conclu\u00edda. A implanta\u00e7\u00e3o do CMD possibilitaria a utiliza\u00e7\u00e3o de dados administrativos, cl\u00ednico-administrativos e cl\u00ednicos por meio de um \u00fanico documento, al\u00e9m de possibilitar an\u00e1lises mais espec\u00edficas, uma vez que relacionaria as informa\u00e7\u00f5es \u00e0 identifica\u00e7\u00e3o dos usu\u00e1rios por meio da integra\u00e7\u00e3o com a base do sistema Cart\u00e3o Nacional de Sa\u00fade. Apesar dos esfor\u00e7os e trabalhos desenvolvidos na \u00e1rea da seguran\u00e7a do paciente, a capacidade para reduzir o risco, evitar danos e melhorar a seguran\u00e7a dos cuidados de sa\u00fade ainda \u00e9 prejudicada pela aus\u00eancia de sistemas de informa\u00e7\u00e3o de alta qualidade22.O Conjunto M\u00ednimo de Dados da Aten\u00e7\u00e3o \u00e0 Sa\u00fade (CMD), idealizado em 2015, \u00e9 uma estrat\u00e9gia assumida pelos gestores das tr\u00eas esferas de gest\u00e3o do SUS para redu\u00e7\u00e3o da fragmenta\u00e7\u00e3o dos sistemas de informa\u00e7\u00e3o, e substituiria os principais sistemas de informa\u00e7\u00e3o da aten\u00e7\u00e3o \u00e0 sa\u00fade do pa\u00eds. Entretanto, apesar de ter sido oficialmente institu\u00eddo por resolu\u00e7\u00e3o da Comiss\u00e3o Intergestores Tripartite30. A utiliza\u00e7\u00e3o de m\u00e9todo RAND/UCLA para o estabelecimento de consenso, mediante o uso de recursos de comunica\u00e7\u00e3o \u00e0 dist\u00e2ncia (internet), permitiu reunir especialistas qualificados de v\u00e1rias regi\u00f5es do pa\u00eds. O interesse dos especialistas na \u00e1rea estudada, associado aos \u00edndices de consenso observados, conferiu credibilidade aos resultados, como pode ser observado em outros estudos31.A revis\u00e3o da literatura existente e os m\u00e9todos de consenso s\u00e3o cada vez mais utilizados e recomendados pela comunidade cient\u00edfica para este tipo de estudoComo limita\u00e7\u00f5es deste estudo, podemos destacar a realiza\u00e7\u00e3o do estudo piloto em um \u00fanico hospital, cujo perfil de assist\u00eancia n\u00e3o incluiu procedimentos cir\u00fargicos do aparelho osteomuscular e a realiza\u00e7\u00e3o do estudo piloto em um per\u00edodo pand\u00eamico, o que diminuiu o universo amostral, em virtude do cancelamento de cirurgias eletivas em toda a rede hospitalar. Outras limita\u00e7\u00f5es, que podem ser alvos de novos estudos, s\u00e3o a n\u00e3o avalia\u00e7\u00e3o de indicadores de estrutura e a n\u00e3o realiza\u00e7\u00e3o da an\u00e1lise da factibilidade para coleta dos indicadores.benchmarking entre unidades de sa\u00fade, promove a identifica\u00e7\u00e3o de prioridades, por meio do fortalececimento e otimiza\u00e7\u00e3o das estrat\u00e9gias de monitoramento e de melhorias dirigidas \u00e0 seguran\u00e7a do paciente em hospitais do SUS.O estudo contribuiu com o desenvolvimento de um conjunto de indicadores de qualidade no \u00e2mbito cir\u00fargico, que se traduz como mecanismo eficaz de mensura\u00e7\u00e3o do desempenho e da qualidade dos servi\u00e7os ofertados pela rede de servi\u00e7os hospitalares do RN e do Brasil. S\u00e3o 22 indicadores que foram considerados v\u00e1lidos, sendo 8 indicadores de processo considerados confi\u00e1veis e sete indicadores de resultados, em que foram identificados par\u00e2metros para tabula\u00e7\u00e3o utilizando os sistemas de informa\u00e7\u00f5es oficiais. Esse conjunto de indicadores possibilita a documenta\u00e7\u00e3o da qualidade do cuidado, viabiliza compara\u00e7\u00f5es e o Logo, trata-se de uma proposta inovadora, compat\u00edvel com a realidade brasileira, para orientar gestores p\u00fablicos e pesquisadores no processo de monitoramento da qualidade cir\u00fargica."}
+{"text": "Estimate the reproducibility of hearing screening results using the uHear\u2122 smartphone-based app in two response modes: self-test response and test-operator.Reliability study conducted with 65 individuals aged \u226518 years assisted at the Speech-language and Hearing Therapy clinic of a public higher-education institution. Hearing screening was conducted by a single researcher using the uHear app and earbud headphones in a soundproof booth. Participants responded to sound stimuli in both self-test response mode and test-operator mode. The order in which these two uHear test modes were applied was altered according to the entrance of each participant in the study. The correspondence between the hearing thresholds obtained from each response mode was analyzed and their Intraclass Correlation Coefficient (ICC) was estimated.A correspondence of \u00b15 dBHL >75% was observed between these hearing thresholds. The ICC values showed excellent agreement between the two response modes at all frequencies >40 dBHL tested.The two hearing screening response modes using the uHear app presented high reproducibility, suggesting that the test-operator mode is a viable alternative when the self-test response mode is not recommended. In addition, these applications are of low cost and can be self-response rapidly and easily-5.Over the past decade, smartphone-based applications have emerged as a tool to perform hearing screening with good accuracy to identify hearing loss compared with conventional pure-tone audiometry (PTA),3,6,7,8. Moreover, this tool can favor hearing loss assessment in large populations, contributing to both the development and implementation health prevention and promotion actions.Studies have reinforced conventional PTA as the gold-standard examination for hearing diagnosis, but they have also pointed out that hearing screening using smartphone-based applications can be an alternative in the context of Primary Health Care (PHC) for groups at risk of hearing loss with limited access to specialized servicesSeveral different hearing screening applications are currently available on digital platforms, with highlight for uHear\u2122, which operates on the IOS platform and is available free of charge. This app enables assessment of 0.5-6 kHz air thresholds with maximum testing output of 90 dBHL and measure the ambient noise before the test.,4-6,9,10. The test-operator mode is an alternative to record hearing screening responses that is provided by other applications, but which is not yet available on uHear.Previous studies have described uHear as a promising screening tool, with sensitivity of 76-100% and specificity of 33-100%, to identify hearing loss in the self-test response mode, which is the only one provided by this applicationThis test mode, in which the patient\u2019s responses to stimuli are recorded by a professional, can favor the hearing screening of individuals with motor difficulties or who are not familiar with technology. Thus, this study aimed to estimate the reproducibility of hearing screening results using the uHear app in two different response modes: self-test response mode and test-operator mode.This study was approved by the Human Research Ethics Committee of the aforementioned Institution under protocol no. 2.588.097. This reliability study was conducted at the Speech-language and Hearing Therapy clinic of a public higher-education institution in northeastern Brazil between May and August 2018. Users of this clinic undergoing basic hearing assessment were invited to participate in the study. All participants signed an Informed Consent Form (ICF) prior to study commencement.This study is part of a major project aimed at investigating the validity of hearing screening using smartphone-based applications compared with that of conventional PTA. Sample size was determined based on the results of a pilot study conducted in the major project for two different response modes using the uHear app. Initially, the means and standard deviations of the hearing thresholds generated at the tested frequencies were estimated and the lowest measures for each response mode were identified. Considering these values, those that presented a minimum difference of \u00b15 dBHL between the two response modes were selected. From these measures, and assuming a confidence interval of 95%, power of 80%, and ratio of 1, the study sample size was estimated in 65 individuals.Users of the clinic aged \u226518 years were included in the study. Exclusion criteria were as follows: users with otorrhea and/or obstruction in the external acoustic meatus, or who could not understand the test procedure. All participants underwent otoscopy and answered a brief questionnaire on sociodemographic data . Subsequently, the participants were instructed about the procedure for the hearing threshold screening with the assistance of prototypes of the app screen and demonstration of the different response recording modes..Hearing screening was conducted by a single researcher in a soundproof booth using the uHear app  on a tablet  operating on the IOS platform and earbud headphones . The test tones at the frequencies of 1, 2, 4, 6 and 0.5 kHz were presented at 40 dBHL, initially to the right ear and then to the left ear, according to the configurations established by the manufacturer. For each frequency, the test stimulus is reduced by 10 dBHL for every positive response registered and increased by 5 dBHL when the sound is not perceived by the participant, with a hearing threshold being considered when two positive responses were recorded for every three stimuli presentedAll participants underwent hearing screening in two different response modes: a) self-response, with the participant recording the response by touching the tablet screen upon hearing the tone presented; b) test-operator, with the researcher, positioned behind the participant, recording the response by touching the tablet screen whenever the participant raised their hand, indicating the sound detection.The order in which the two response modes were applied on the uHear app was alternated as the participants entered the study. The hearing screening results on the uHear app are presented in a graph that identifies the degree of hearing loss. Thus, to estimate the hearing threshold numeric value, an instrument made of transparent material, prepared by the researchers, was placed on the tablet screen, allowing identification of the corresponding value. Test duration was also timed for each of the response modes used.The data obtained were organized and analyzed on the Epidata, Epidata Analysis and Rcommander software. The differences between the hearing thresholds generated in the two response modes were calculated by subtracting the values registered in the self-response mode from those recorded in the test-operator mode. For the individuals who presented no responses, a numeric value of 95 dBHL was established as the hearing threshold, that is, 5 dBHL above the device maximum threshold. From the differences found, the frequency of correspondence between the thresholds generated in the two response modes was estimated considering variations of \u22645 dBHL and above 10 dBHL.. The agreement coefficient was also calculated according to the different testing frequencies and outputs. The Student\u2019s t-test was used to compare the test mean duration for the two modes.To identify the reproducibility of the hearing thresholds between the different response modes, the intra-rater reliability was estimated using the Intraclass Correlation Coefficient (ICC), whose values vary between 0 and 1, where ICC <0.4 indicate poor reproducibility, ICC of 0.4-0.74 represent satisfactory-to-good reproducibility, and ICC \u22650.75 correspond to excellent reproducibilityAll analyses were performed considering the responses obtained only in the right ear of each participant by drawing lots, since this study does not aim to identify the influence of the tested ear on the reproducibility of the response modes.Hearing screening using the smartphone-based uHear app was conducted with 67 participants. Two of them were excluded because of a lack of understanding of the study procedure. The 65 participants that composed study final sample were mostly women (73.8%), aged >40 years , and had completed high school (69.2%). Additionally, most participants reported having a family income greater than one minimum wage and not being currently employed: retired (29.2%) or housewives (15.4%).A high correspondence (>75%) between the hearing thresholds obtained in the self-response and test-operator response modes was observed for all frequencies tested when considering differences \u22645 dBHL . The corAgreement between the hearing thresholds obtained in the self-response and test-operator response modes varied between 0.826 and 0.927, indicating excellent reproducibility at all frequencies analyzed.p=0.65).The mean hearing assessment runtime on the uHear app in the self-test response mode was 5.63 min , whereas this time was 5.55 min  in the test-operator response mode. No statistically significant difference was observed between the response modes regarding hearing screening runtime In this context, it is believed that hearing assessments on uHear in the test-operator response mode can be performed by a person trained in the use of smartphones, thus enlarging its potential use in large populations, as well as in those living distant from large urban centers. Therefore, this is a tool that can be easily used in the context of PHC to identify disabling hearing loss.Surprisingly, the findings reveal that both response modes presented low reproducibility for testing outputs \u226440 dBHL. Initially, this could be associated with the influence of ambient noise, which would hamper the detection of weak intensity tones. However, all hearing assessments were performed in a soundproof booth, thus minimizing this influence.Another plausible explanation for this result is the effect of learning, since hearing screening in the two different response modes was carried out in sequence. Although the first response mode was alternated among the participants, which could have reduced the effect of learning on a specific response mode, it should not be discarded the possibility that this effect may have favored better thresholds in the second testing, regardless of the response mode used.Moreover, among individuals with hearing close to the normality patterns (<40 dBHL), it is believed that their participation in this study may have been their first contact with the detection of pure tones, as well as with a hearing assessment procedure. Thus, the hearing thresholds generated from the first response mode tested may have been worse compared with those of participants with previous experience in hearing assessments.It is also important to highlight, as a potential limitation to this study, that the participants were selected in a hearing assessment service, where there are a large number of individuals with hearing loss, which compromised the reproducibility analysis for weak intensity tones.It should also be considered the potential influence of lack of familiarization of some individuals with the touchscreen technology when obtaining hearing thresholds in the self-test response mode. To minimize this potential bias, all participants were introduced to prototypes of the initial and final screens of the application, and a detailed explanation on how and where they should register their responses on the smartphone screen was provided.In contrast, the influence of the participation of a researcher in the process of recording the responses in the test-operator mode also should not be discarded, since the uHear app automatically manages the interval between the stimulus presentations as well as the time provided to record the responses. Thus, the worse results may have been obtained because of the increase in the time elapsed between signaling the test tone detection by the patient and recording this response on the smartphone screen by the researcher.Preliminary evidence of this study showed high reproducibility for the two response modes to the hearing screening using the uHear app. Thus, in addition to the self-test response mode, suggested by the application developer, the test-operator response mode can also be used in hearing screening to identify disabling hearing losses, thus enabling the assessment of individuals with motor difficulties or those who are not familiar with the touchscreen technology. . Adicionalmente, s\u00e3o de f\u00e1cil e r\u00e1pida aplica\u00e7\u00e3o, baixo custo e podem ser utilizados de maneira autoaplicada-5.Na \u00faltima d\u00e9cada, aplicativos para dispositivos m\u00f3veis surgem como uma ferramenta para realiza\u00e7\u00e3o de triagens auditivas com boa acur\u00e1cia para identifica\u00e7\u00e3o da perda auditiva, em compara\u00e7\u00e3o com a audiometria convencional,3,6,7,8. Al\u00e9m disso, esta ferramenta pode favorecer a estimativa da perda auditiva em grandes popula\u00e7\u00f5es, colaborando para a elabora\u00e7\u00e3o e implementa\u00e7\u00e3o de a\u00e7\u00f5es de preven\u00e7\u00e3o e promo\u00e7\u00e3o de sa\u00fade.Embora as investiga\u00e7\u00f5es j\u00e1 conduzidas reforcem que audiometria convencional \u00e9 o exame padr\u00e3o-ouro para o diagn\u00f3stico auditivo, tamb\u00e9m apontam que a triagem auditiva com aplicativos para dispositivos m\u00f3veis pode ser uma alternativa, a ser utilizada em Unidades B\u00e1sicas de Sa\u00fade, para a promo\u00e7\u00e3o do cuidado em grupos populacionais de risco para a perda auditiva, com acesso limitado a servi\u00e7os especializados de sa\u00fade auditiva.Diferentes aplicativos para triagem auditiva s\u00e3o atualmente disponibilizados nas plataformas digitais. Dentre eles, destaca-se o uHear, o qual opera na plataforma IOS e \u00e9 disponibilizado gratuitamente. Adicionalmente, este aplicativo permite avaliar os limiares a\u00e9reos de 0,5 a 6 kHz ofertando tons com intensidade m\u00e1xima de 90 dBNA e possibilita a medi\u00e7\u00e3o do n\u00edvel de ru\u00eddo ambiente,4-6,9,10. O modo de resposta com intermedia\u00e7\u00e3o do examinador \u00e9 uma alternativa para o registro de respostas \u00e0 triagem auditiva, ofertada por outros aplicativos, mas ainda n\u00e3o dispon\u00edvel no uHear.Estudos pr\u00e9vios indicam o uHear como uma ferramenta promissora de triagem, com sensibilidade de 76% a 100% e especificidade de 33% a 100%, para a identifica\u00e7\u00e3o da perda auditiva, utilizando o modo de resposta autoaplicado, o qual \u00e9 disponibilizado pelo aplicativoEste modo de resposta, no qual o registro da resposta no dispositivo \u00e9 realizado por um examinador sempre que o indiv\u00edduo informa a detec\u00e7\u00e3o do tom teste, pode favorecer a triagem auditiva de indiv\u00edduos que n\u00e3o t\u00eam aproxima\u00e7\u00e3o com a tecnologia ou pessoas com dificuldades motoras. Assim, o objetivo deste estudo foi estimar a reprodutibilidade dos resultados da triagem auditiva com o aplicativo uHear, utilizando dois diferentes modos de resposta, o modo autoaplicado e o modo com intermedia\u00e7\u00e3o.Este estudo foi aprovado pelo Comit\u00ea de \u00c9tica em Pesquisa com Seres Humanos da institui\u00e7\u00e3o proponente sob protocolo n\u00famero 2.588.097. Trata-se de um estudo de confiabilidade realizado, no per\u00edodo de maio a agosto de 2018, em uma cl\u00ednica escola de Fonoaudiologia de uma institui\u00e7\u00e3o p\u00fablica de ensino superior da regi\u00e3o nordeste do pa\u00eds. Foram convidados a participar do estudo os usu\u00e1rios que compareceram \u00e0 referida cl\u00ednica para realiza\u00e7\u00e3o de avalia\u00e7\u00e3o audiol\u00f3gica b\u00e1sica e todos que concordaram assinaram o Termo de Consentimento Livre e Esclarecido.Este estudo est\u00e1 vinculado a um Projeto m\u00e3e, o qual tem por objetivo investigar a validade da triagem auditiva com aplicativos para smartphone em compara\u00e7\u00e3o com a audiometria tonal liminar. O tamanho da amostra do presente estudo foi determinado a partir dos resultados do estudo piloto do Projeto m\u00e3e, utilizando-se os dois diferentes modos de resposta na triagem auditiva com o aplicativo uHear. Inicialmente, foram estimadas as m\u00e9dias e desvios padr\u00f5es dos limiares auditivos obtidos nas frequ\u00eancias testadas e identificadas as menores medidas para cada um dos modos de resposta. Considerando estes valores, foram selecionados aqueles que apresentavam uma diferen\u00e7a m\u00ednima de 5 dB entre os dois modos de resposta. A partir destas medidas, assumindo um intervalo de confian\u00e7a de 95%, poder de 80% e raz\u00e3o 1, foi estimada a participa\u00e7\u00e3o de 65 indiv\u00edduos no estudo.Foram inclu\u00eddos os usu\u00e1rios com idade superior a 18 anos, e exclu\u00eddos aqueles que apresentavam otorr\u00e9ia, obstru\u00e7\u00e3o em meato ac\u00fastico externo ou que n\u00e3o compreenderam o procedimento do teste. Todos os participantes foram submetidos \u00e0 meatoscopia e responderam a um breve question\u00e1rio que abordou dados sociodemogr\u00e1ficos . Em seguida foi realizada orienta\u00e7\u00e3o sobre o procedimento de pesquisa dos limiares auditivos, com o aux\u00edlio de prot\u00f3tipos da tela do aplicativo, e demonstra\u00e7\u00e3o dos diferentes modos de registro das respostas.\u2122, Victoria, BC, Canad\u00e1) atrav\u00e9s de tablet com sistema operacional IOS  e fones de ouvido intra-aurais . Os tons teste nas frequ\u00eancias de 1, 2, 4, 6 e 0,5 kHz foram apresentados em 40 dBNA, inicialmente na orelha direita e posteriormente na orelha esquerda, conforme as configura\u00e7\u00f5es estabelecidas pelo fabricante do aplicativo. Para cada frequ\u00eancia, o est\u00edmulo teste \u00e9 reduzido em 10 dBNA a cada resposta positiva registrada e aumentado em 5 dBNA quando o som n\u00e3o foi percebido pelo participante, sendo considerado limiar auditivo quando registradas duas respostas positivas para tr\u00eas est\u00edmulos apresentados.A triagem auditiva foi realizada sempre pelo mesmo pesquisador, em cabina ac\u00fastica, utilizando o aplicativo para smartphone uHear  autoaplicado, no qual o pr\u00f3prio participante registrou a resposta com o toque na tela do tablet sempre que ouvia o som apresentado; b) com intermedia\u00e7\u00e3o, no qual o pesquisador, posicionado atr\u00e1s do participante, registrava a resposta tocando na tela do tablet sempre que o participante levantava a m\u00e3o, indicando a detec\u00e7\u00e3o do som.A ordem de realiza\u00e7\u00e3o dos dois modos de resposta ao aplicativo uHear foi alternada de acordo com a entrada do participante no estudo. Os resultados da triagem auditiva com o uHear s\u00e3o apresentados em forma de gr\u00e1fico, identificando o grau da perda auditiva. Assim, para a estimativa do valor num\u00e9rico do limiar auditivo foi utilizado um instrumento em material transparente, elaborado pelos pesquisadores, que ao ser sobreposto a tela do tablet permitiu a identifica\u00e7\u00e3o do valor correspondente. Tamb\u00e9m foi registrado o tempo de execu\u00e7\u00e3o do teste em cada um dos modos de resposta.Os dados obtidos foram organizados e analisados nos programas Epidata, Epidata Analysis e Rcommander. Foram calculadas as diferen\u00e7as entre os limiares auditivos obtidos nos dois modos de resposta mediante a subtra\u00e7\u00e3o dos valores dos limiares identificados atrav\u00e9s do modo autoaplicado e dos valores dos limiares registrados no modo com intermedia\u00e7\u00e3o do pesquisador. Para os indiv\u00edduos que apresentaram aus\u00eancia de respostas foi estabelecido o valor num\u00e9rico de 95 dBNA como limiar auditivo, isto \u00e9, 5 dBNA acima do limite m\u00e1ximo do equipamento. A partir das diferen\u00e7as encontradas foi estimada a frequ\u00eancia de correspond\u00eancia entre os limiares obtidos nos dois modos de resposta, considerando varia\u00e7\u00f5es de at\u00e9 5 dBNA, iguais a 10 dBNA e superiores a 10 dBNA.. O coeficiente de concord\u00e2ncia tamb\u00e9m foi calculado de acordo com as diferentes frequ\u00eancias e intensidades. O teste t de Student foi utilizado para comparar as m\u00e9dias do tempo de execu\u00e7\u00e3o do teste nos dois modos.Para a identifica\u00e7\u00e3o da reprodutibilidade dos limiares auditivos entre os diferentes modos de resposta, foi analisada a concord\u00e2ncia do teste intraobservador por meio do Coeficiente de Correla\u00e7\u00e3o Intraclasse (CCI), o qual varia entre 0 e 1. Valores de CCI inferiores a 0,4 indicam reprodutibilidade pobre. J\u00e1 a reprodutibilidade satisfat\u00f3ria a boa \u00e9 identificada quando o CCI varia de 0,4 a 0,74 e valores iguais e superiores a 0,75 revelam que a reprodutibilidade \u00e9 excelenteTodas as an\u00e1lises do presente estudo foram realizadas considerando as respostas obtidas apenas na orelha direita de cada participante, estabelecida mediante sorteio. Esta decis\u00e3o metodol\u00f3gica foi baseada no fato de que o estudo n\u00e3o tem o prop\u00f3sito de identificar a influ\u00eancia da orelha testada na reprodutibilidade dos modos de resposta.A triagem auditiva com o aplicativo para smartphone uHear foi realizada com 67 participantes, sendo dois exclu\u00eddos por n\u00e3o compreens\u00e3o do procedimento do estudo. Entre os 65 participantes inclu\u00eddos na pesquisa, a maioria era do g\u00eanero feminino , apresentava faixa et\u00e1ria superior a 40 anos, com m\u00e9dia de idade de 51,4 anos  e escolaridade igual ou superior ao ensino m\u00e9dio . Adicionalmente, a maioria dos participantes relatou renda familiar superior a um sal\u00e1rio-m\u00ednimo e n\u00e3o inser\u00e7\u00e3o no mercado de trabalho, declarando-se como aposentado  e dona de casa .Observou-se uma elevada correspond\u00eancia (> 75%) entre os limiares obtidos no modo de resposta autoaplicado e com intermedia\u00e7\u00e3o do pesquisador, para todas as frequ\u00eancias testadas, quando consideradas diferen\u00e7as de at\u00e9 5 dBNA . Os percA concord\u00e2ncia entre os limiares auditivos obtidos nos modos autoaplicado e com intermedia\u00e7\u00e3o do pesquisador variou de 0,826 a 0,927 indicando uma reprodutibilidade excelente em todas as frequ\u00eancias pesquisadas.Na O tempo m\u00e9dio de execu\u00e7\u00e3o do aplicativo uHear no modo de resposta autoaplicado foi 5,63 minutos . J\u00e1 no modo com intermedia\u00e7\u00e3o do pesquisador o tempo m\u00e9dio foi 5,55 minutos . N\u00e3o foi observada diferen\u00e7a estatisticamente significante entre os modos de resposta, quanto ao tempo de execu\u00e7\u00e3o .Os limiares auditivos obtidos com o aplicativo uHear atrav\u00e9s do modo de resposta com intermedia\u00e7\u00e3o do pesquisador e do modo autoaplicado apresentam elevada reprodutibilidade, em todas as frequ\u00eancias pesquisadas, para intensidades superiores a 40 dBNA. Este achado \u00e9 evidenciado tanto pela elevada ocorr\u00eancia de limiares correspondentes entre os dois modos de resposta, quanto por coeficientes de correla\u00e7\u00e3o intraclasse de satisfat\u00f3rio a bom e excelentes. Al\u00e9m disso, o tempo de execu\u00e7\u00e3o do teste nos dois modos de resposta foi semelhante.-10 e, em sua maioria, revelam elevadas medidas de sensibilidade e especificidade do teste com este modo de resposta. Contudo, dificuldades motoras ou n\u00e3o proximidade com a tecnologia touch screen,7 foram apresentadas como poss\u00edveis limita\u00e7\u00f5es para o uso deste modo de resposta, sendo sugerido o aux\u00edlio de familiares ou cuidadores para o uso de testes com aplicativos em idosos com dificuldades no manuseio de dispositivos m\u00f3veis.O presente estudo foi a primeira investiga\u00e7\u00e3o conduzida utilizando o modo de resposta com intermedia\u00e7\u00e3o do pesquisador para a triagem auditiva com o aplicativo uHear, o que n\u00e3o permite compara\u00e7\u00f5es com resultados pr\u00e9vios. At\u00e9 o momento, as pesquisas conduzidas tiveram por objetivo identificar a acur\u00e1cia diagn\u00f3stica do aplicativo para identifica\u00e7\u00e3o da perda auditiva, em compara\u00e7\u00e3o com a audiometria tonal liminar ou triagem audiom\u00e9trica. Nestas pesquisas o modo autoaplicado foi utilizado para o registro das respostastouch screen, os achados do presente estudo apontam uma alternativa vi\u00e1vel de modo de resposta que pode favorecer a utiliza\u00e7\u00e3o do aplicativo em investiga\u00e7\u00f5es auditivas nas popula\u00e7\u00f5es com tal particularidade. Da mesma forma, o tempo de execu\u00e7\u00e3o similar para ambos os modos de resposta corrobora essa viabilidade.Considerando que o modo autoaplicado pode representar uma barreira para os indiv\u00edduos que apresentam dificuldade ou incapacidade com o uso da tecnologia Adicionalmente, o modo de registro intermediado por um pesquisador/examinador favorece a identifica\u00e7\u00e3o de situa\u00e7\u00f5es n\u00e3o desej\u00e1veis para o momento da avalia\u00e7\u00e3o, como elevados ru\u00eddos ambientais inesperados ou demonstra\u00e7\u00f5es de fadiga por parte do examinado, as quais exigiriam a interrup\u00e7\u00e3o do teste, mas poderiam n\u00e3o ser notificadas pelo examinado no modo de resposta autoaplicado.. Assim, a elevada reprodutibilidade dos limiares auditivos no presente estudo, identificada em intensidades superiores a 40 dBNA, permite inferir que a acur\u00e1cia dos testes realizados com o modo intermediado por um pesquisador/examinador pode ser semelhante \u00e0quela observada no modo autoaplicado.Cabe ressaltar ainda que a triagem auditiva com o aplicativo uHear, utilizando o modo de resposta autoaplicado, apresenta boa acur\u00e1cia para a identifica\u00e7\u00e3o de perdas auditivas incapacitantes em adultos (> 40 dBNA na melhor orelha)A partir deste cen\u00e1rio, acredita-se que a avalia\u00e7\u00e3o auditiva com uHear, utilizando o modo de resposta com intermedia\u00e7\u00e3o do pesquisador, pode ser mediada por pessoa treinada para manusear o smartphone, ampliando o seu potencial de utiliza\u00e7\u00e3o para triagens auditivas de grandes popula\u00e7\u00f5es, bem como de popula\u00e7\u00f5es distantes de grandes centros urbanos, se configurando como uma ferramenta de f\u00e1cil aplicabilidade em a\u00e7\u00f5es na rede b\u00e1sica de aten\u00e7\u00e3o \u00e0 sa\u00fade para identifica\u00e7\u00e3o da perda auditiva incapacitante.Surpreendentemente, nossos achados revelam que para intensidades at\u00e9 40 dBNA a reprodutibilidade dos modos de resposta foi baixa. Inicialmente \u00e9 poss\u00edvel relacionar este achado com a influ\u00eancia do ru\u00eddo ambiental, o qual dificultaria a detec\u00e7\u00e3o de tons teste apresentados em fraca intensidade. Contudo, todas as avalia\u00e7\u00f5es auditivas do presente estudo foram realizadas em cabina ac\u00fastica, minimizando, assim, esta influ\u00eancia.Outra explica\u00e7\u00e3o plaus\u00edvel para este resultado seria o efeito da aprendizagem, j\u00e1 que a triagem auditiva atrav\u00e9s dos dois diferentes modos de resposta ao teste foi realizada em sequ\u00eancia. Apesar de alternarmos o primeiro modo de resposta ao teste entre os participantes, o que potencialmente minimizaria o efeito de aprendizagem para um modo de resposta espec\u00edfico, n\u00e3o \u00e9 poss\u00edvel descartar que este efeito tenha favorecido melhores limiares na segunda testagem, independentemente do modo de resposta utilizado.Adicionalmente, entre indiv\u00edduos com audi\u00e7\u00e3o pr\u00f3xima aos padr\u00f5es de normalidade (< 40 dBNA), acredita-se que a participa\u00e7\u00e3o no presente estudo pode ter sido o primeiro contato com a detec\u00e7\u00e3o de tons puros, bem como com o procedimento de avalia\u00e7\u00e3o auditiva. Assim, \u00e9 poss\u00edvel que os limiares auditivos obtidos no primeiro modo de resposta testado tenham sido piores em compara\u00e7\u00e3o com aqueles participantes com experi\u00eancia pr\u00e9via de avalia\u00e7\u00e3o auditiva.\u00c9 importante destacar ainda, como potencial limita\u00e7\u00e3o do presente estudo, a sele\u00e7\u00e3o dos participantes a partir de um servi\u00e7o de avalia\u00e7\u00e3o audiol\u00f3gica, incluindo maior n\u00famero de indiv\u00edduos com perda auditiva, o que comprometeu a an\u00e1lise da reprodutibilidade para tons de fraca intensidade.touch screen. Para minimizar este poss\u00edvel vi\u00e9s foi apresentado a todos os participantes prot\u00f3tipos da tela inicial e final do aplicativo e explica\u00e7\u00e3o detalhada de como e onde os participantes deveriam registrar suas respostas na tela do dispositivo m\u00f3vel.Deve-se considerar tamb\u00e9m a poss\u00edvel influ\u00eancia na obten\u00e7\u00e3o dos limiares auditivos no modo de resposta autoaplicado em indiv\u00edduos que n\u00e3o tenham proximidade com a tecnologia Em contraponto, n\u00e3o podemos descartar a influ\u00eancia da inclus\u00e3o do pesquisador no processo de registro das respostas no modo com intermedia\u00e7\u00e3o, pois o aplicativo uHear gerencia automaticamente o intervalo entre as apresenta\u00e7\u00f5es dos est\u00edmulos, bem como o tempo destinado para o registro da resposta. Assim, \u00e9 poss\u00edvel que piores resultados tenham sido obtidos em fun\u00e7\u00e3o do aumento do tempo decorrido entre a sinaliza\u00e7\u00e3o da detec\u00e7\u00e3o do tom teste, pelo examinado, e o registro desta resposta na tela do dispositivo m\u00f3vel, pelo pesquisador.touch screen.As evid\u00eancias preliminares deste estudo demonstraram que os dois modos de resposta \u00e0 triagem auditiva com o aplicativo uHear apresentam elevada reprodutibilidade. Assim, al\u00e9m do modo de resposta autoaplicado, sugerido pelo desenvolvedor do aplicativo, o modo com intermedia\u00e7\u00e3o do pesquisador tamb\u00e9m pode ser utilizado na triagem auditiva para identifica\u00e7\u00e3o de perdas auditivas incapacitantes, viabilizando a avalia\u00e7\u00e3o de indiv\u00edduos com dificuldades motoras ou que n\u00e3o tenham aproxima\u00e7\u00e3o com a tecnologia"}
+{"text": "To identify the risk of dysphagia and its association with signs suggestive of sarcopenia, nutritional status and frequency of oral hygiene in the hospitalized elderly.This is an analytical cross-sectional study with the participation of 52 elderly patients admitted to a medical clinic at a public hospital in the Federal District, Brazil. The Eating Assessment Tool, Strength, Assistance with walking, Rise from a chair, Climb stairs and Falls + Calf Circumference and the Mini Nutritional Assessment shortform were applied, in addition to the collection of sociodemographic data and health conditions.Among the elderly participants, 30.8% were at risk of self-reported dysphagia. The factors associated with the risk of dysphagia were: signs suggestive of sarcopenia (p=0.04), nutritional status (p<0.001) and oral hygiene frequency (p=0.03).In the geriatric population of the present study, with the majority of the participants having tested positive for Covid-19, the risk of dysphagia was associated with signs suggestive of sarcopenia, nutritional status and frequency of oral hygiene. These impairments also affect the stomatognathic system, its structures - tongue, cheeks, jaw, lips, occlusal area, and palate, as well as its functions, such as suction, breathing, mastication, speech, and deglutition.This disability in the older population is generally manifested by difficulty in mastication or in starting the deglutition process, with the presence of cough, choking, heartburn, chest pain, nasal regurgitation during meals and a feeling of food stuck in the throat after eating. These effects make the dynamics of swallowing more vulnerable to disorders caused by minor health alterations, such as infections of the upper airways.These changes in the functionality of deglutition can be classified as dysphagia, an alteration defined as a \u201cdisrupted dietary habits\u201d, with a condition that involves a perceived or actual difficulty to form or safely move a bolus from the oral cavity to the stomach.Over the past decade, such swallowing-related alterations have led to increasing awareness of the need to acknowledge oropharyngeal dysphagia as a geriatric syndrome that causes the following sequence of disorders: (1) Dehydration; (2) Anorexia \u2192 unwillingness to eat; (3) Weight loss \u2192 protein-energy undernutrition; (4) Sarcopenia \u2192 decline in function; (5) Aspiration: chemical or bacterial; (6) Decreased pleasure in eating/drinking; (7) Embarrassment in social situations; (8) Isolation \u2192 depression; (9) Caregiver stress; (10) Dysphoria; and (11) Death.The associated risk factors are unclear about the potential confusion factors or the mediators of dysphagia. Most studies are based on reverse causality and the preceding factors are not confirmed, nor is the deglutition alteration or the worsening health, such as sarcopenia, fragility and psychological state. Its tendency and increasing development in the older population, along with its consequences for oral function and deglutition, might result in oral fragility and indicate a poor health state.Among these factors, sarcopenia is defined as a skeletal muscle disease with the main determinant being a low muscle strength that outweighs the function of low muscle mass.Such a decline in oral function and dysphagia can lead to undernutrition, aspiration pneumonia, asphyxiation and occasionally death. Malnutrition presents a high prevalence among the frail elderly, and dysphagia is independently associated with undernutrition. The decline in oral function can be an important predictor for the progression of malnutrition in older populations.Aspiration pneumonia, on the other hand, is one of the most critical complications of dysphagia, characterizing an infectious process caused by the bronchoaspiration of oropharyngeal secretions containing food residues and saliva with possible oral pathogens. Due to poor oral hygiene, saliva contaminated with a high amount of various species of bacteria can harbor microbes that, if colonized and aspirated, can result in bacterial pneumonia. As a result, the combined impacts of poor oral hygiene and dysphagia can increase the risk of aspiration pneumonia4,5. The present study aimed to detect the risk of dysphagia and its correlation with signs suggestive of sarcopenia, nutritional status, and oral hygiene in the hospitalized elderly.Therefore, the older population presents a great risk of dysphagia due to the aging process. Such an alteration is frequent and belatedly detected, often associated with the senescence process, thus delaying investigations This is a cross-sectional study involving 52 older patients hospitalized in the patient care unit of a public hospital in the Federal District (DF), Brazil, between September and December 2021. The sample group was selected by convenience and composed of older individuals aged 60 years or older. We excluded from the population those individuals who presented severe cognitive impairments affecting perceptual ability, judgment and language, and/or those who had an amputated lower limb, were wearing orthopedic prostheses on their lower limbs, had edema or were on a suspended oral diet.This study is part of the research project \u201cAssessment of the risk of dysphagia in the hospitalized elderly and its relation to nutrition, sarcopenia, hydration and quality of life: a cross-sectional analytical and observational study\u201d, approved by the Research Ethics Committee from the Ceil\u00e2ndia College of the University of Bras\u00edlia (CEP/FCE - Faculdade de Ceil\u00e2ndia da Universidade de Bras\u00edlia), decision number 3,749,828, and by the Research Ethics Committee from the Foundation for Teaching and Research in Health Sciences of the Federal District\u2019s Health Department , decision number 3,820,960. All participants were instructed on the research objectives and data confidentiality and signed the Informed Consent Form.Initially, the sociodemographic data and health information of the participants were researched, such as age, sex, education, race, color, pathologies, type of diet and dysgeusia. All data were collected with a structured survey by accessing the participant's medical record through the TrakCare\u00ae health information system of the Federal District\u2019s Health Department and through questions answered by the participants at the time of anamnesis.The frequency of oral hygiene was assessed by asking the participant how many times a day they performed it, with the following answer options: not at all; once; twice; three times; four or more times. (EAT-10) was subsequently applied, which is a practical tool for routine use in the care of older patients, being composed of a subjective and specific questionnaire to assess the degree of dysphagia symptoms. Each question has a score from 0 (no problems) to 4 (severe problem) and a maximum score of 40 points, with no risk of dysphagia for cohort scores < 3 points, and risk of dysphagia for scores higher than or equal to 3. The instrument starts with the question: \u201cHow much of a problem are these situations for you? Mark the best number for your case\u201d, continuing with the following statements: my swallowing problem makes me lose weight; my swallowing problem keeps me from eating out; I have to force myself to drink liquids; I have to force myself to swallow food (solid); I have to force myself to swallow medicine; it hurts to swallow; my swallowing problem takes away my pleasure in eating; I get food stuck in my throat; I cough when I eat and swallowing makes me stressed. After the participant had responded, the scores of the corresponding answers in each item were added up and a result greater than or equal to three was an indicator of alteration.The Eating Assessment Tool.The EAT-10 questionnaire application was followed by the SARC-F  + Calf Circumference (CC) to detect the risk of sarcopenia. The ensuing questions were asked: How much difficulty do you have to lift or carry 5.0kg? How much difficulty do you have to walk across a room? How much difficulty do you have to get up from a chair or bed? How much difficulty do you have to climb 10 steps of a staircase? How many times have you fallen in the past year? The following answers were possible and quantifiable: none = 0, some = 1, a lot or cannot do it = 2, and for the question: how many times have you fallen in the past year? The measurable values of the answers were none = 0; 1-3 falls = 1; 4 or more falls = 27 recommendation (2018): 0 points for women with >33 cm, 10 points for \u226433 cm; 0 points for men with >34 cm, and 10 points for \u226434 cm.Next, the anthropometric measurement of the Calf Circumference was collected. The assessment was performed with an inelastic tape measure on the most protruding part of the right leg, with the participant's leg bent to a 90-degree angle with the knee. To avoid the error bias inherent to CC measurements, this procedure was performed by a single anthropometrist (the main researcher). The assessment was conducted in bed for bedridden participants and sitting in a chair for ambulatory patients. The CC score was based on the EWGSOP2 The SARC-F + CC questionnaire application was followed by the sum of the answer scores (0 - 20 points) and the participant was thusly classified: absence of signs suggestive of sarcopenia (0 - 10 points) and presence of signs suggestive of sarcopenia (11 - 20 points).. One of the advantages of this version is the exclusion of redundant items that required special training, addressing the patient\u2019s subjectivity and memory or generating too many blanks or \u201cI don\u2019t know\u201d answers.The risk of undernutrition was assessed by the Mini Nutritional Assessment Short-Form (revised MNA\u00ae-SF). The Brazilian Consensus on Nutrition and Dysphagia recommends that nurses apply the short version of this instrument to ensure the identification of at-risk older patients, as well as a possible referral for a nutritional assessment in cases of scores lower than or equal to 12,13.The revised MNA\u00ae-SF is a screening composed of five questions with answer options corresponding to points (varying between 0 and 3) in the final sum. It assesses lower food intake, weight loss, mobility, psychological stress or acute illness, neuropsychological problems and Body Mass Index (BMI). In the end, the scores of the answers were added up to reach the final screening score: 12-14 points: regular nutritional status; 8-11 points: at risk of undernutrition, and 0-7 points: malnourishedThe results were analyzed and interpreted on Microsoft Excel 2018 and the Statistical Package of Social Sciences (SPSS), version 19.0. The Chi-squared test was applied to detect whether there was an association between the EAT-10 variable classification and the qualitative variables. All analyses adopted a 95% confidence interval.The sample included 52 participants aged on average 73 (\u00b18.3) years old. The average length of hospital stay at the day of the data collection was 5.5 (\u00b13.86) days . The sexRespiratory problems were the main reason for hospitalization, with 39 (75.00%) of the older patients infected by the coronavirus (Covid-19).Diabetes Mellitus (DM) and Systemic Arterial Hypertension (SAH) were found in most of the participants. Beside DM and SAH, 65.38% of the sample group presented other comorbidities. Most of the participants were on a mostly orally administered bland diet. Even though cough was an associated symptom, most of the patients denied such complaints. The data related to oral health showed that a large number of the participants used total denture and performed oral hygiene twice a day. As to smoking and alcoholism, most of the patients reported never having smoked or consumed alcohol, followed by those who had smoked and consumed alcohol but lost the habit.Of the 52 participants, 30.8% were at self-reported risk of dysphagia according to the EAT-10, and 69.2% did not present such risk.The data on According to p-value for the test of these variables reached <0.05. Hence, was accepted the statistical hypothesis that the variables are dependent.As statistically demonstrated, there is a correlation between the risk of dysphagia (EAT-10) and the variables of the SARCF+CC, the revised MNA\u00ae-SF and the oral hygiene frequency. Consequently, the odds ratio of individuals presenting risk of dysphagia (EAT-10) when exposed to alterations in these instruments . carried out in 2016, whose participants were mostly female (67.1%) with a mean age of 71 years (minimum of 60 and maximum of 102 years).Despite being balanced, the sample group composition revealed that most of the hospitalized elderly in the patient care unit between September and December 2021 were female, aged on average 73 years (minimum of 61 and maximum of 94 years), white, married and with incomplete elementary education. These findings corroborate a study. It is worth highlighting that the present study was not targeted to associating the risk of dysphagia with the covid-19 infection; however, that was the epidemiological scenario found.The clinical data collected indicated respiratory reasons for hospitalization (76.92%) associated with covid-19 (75.00%). The literature reports that this number is within the cases related to the second pandemic wave, with a small reduction of cases in younger patients (until 49 years) and an increase in the older patients (\u226560 years) among white individuals has also detected a greater occurrence of SAH among participants, describing it as present in 60.5% of the dysphagia patients. This proportion of individuals with SAH and DM found in the study indicates the demand for a greater vigilance and monitoring in order to prevent disabilities and their consequences in the quality of life of these individuals, as well as in the health system.As to the comorbidities, SAH and DM appeared, respectively, in 65.38% and 42.31% of the sample group, while other associated pathologies also occurred in 65.38%. Another studyp<0.05) with signs suggestive of sarcopenia. Among the 52 (100.0%) individuals in the sample, 12 (23.07%) presented the risk of dysphagia with symptoms of sarcopenia according to the SARC+F+CC. The risk of sarcopenia among elderly patients with a risk of dysphagia (16-100.0%) is even higher, encompassing 12 individuals (75.0%).The hospitalized older patients at risk of dysphagia presented an association  is a neurotropic virus that can cause peripheral nerve disease. Glossopharyngeal and vagal neuropathy, which are among the neurological manifestations of Covid-19, can lead to dysphagia.As above mentioned, 75.0% of the older individuals were hospitalized during the research period due to a Covid-19 infection. A study from 2020.In addition to this potential neurological manifestation, researchers have identified that the inflammatory process of the Covid-19, combined with undernutrition and low mobility during hospitalization, might predetermine a secondary sarcopenia and sarcopenic dysphagia. Nonetheless, only a few published studies have investigated the dysphagia in non-intubated individuals with Covid-19,21, the SARS-CoV-2 infection is a risk factor for impaired swallowing.Such epidemiological conditions of the Covid-19 found in 75.0% of the participants might have represented a bias since, as reported in other studies, with lower muscle mass reducing the bolus propulsion strength, thus generating post-swallowing oropharyngeal residue retention. After the detection of the sarcopenia risk, it is important that the medical team follow up, namely, the speech-language pathologist must assess the tongue pressure strength, the nutrition team must evaluate the nutrient intake, and the nursing staff must monitor the food acceptability as well as the dietary supply, as prevention and rehabilitation measures.Such an exposition to sarcopenia symptoms may result in sarcopenic dysphagia.The medical team should bear in mind that nutritional status is a relevant component for preserving the well-being and health of older individuals, especially upon hospitalization. An inadequate nutrition favors the onset of several diseases in this population, being a predisposing factor to fragility syndrome, sarcopenia and longer hospitalization periodsIn this context, the present study found an association (p< 0.05) between the risk of dysphagia and the nutritional status of the hospitalized elderly. Among the 16 (100.0%) individuals at risk of dysphagia, 11 (68.75%) were at risk of undernutrition, 4 (25.00%) were malnourished and only 1 (6.25%) presented a regular nutritional status. As to the nutritional alterations of older patients with a risk of dysphagia, 93.75% presented an unfavorable nutritional status, probably requiring or having required a care plan and bedside monitoring. with 49 older patients in a university hospital in Bras\u00edlia and found similar results. Elderly individuals at risk of dysphagia and undernutrition represented 51.0% of the sample group, while malnourished patients at risk of dysphagia corresponded to 20.0%.Researchers have conducted a study investigated the correlation between the deglutition function and the nutritional status in older patients in Japan, finding that malnutrition occurred in 60.5% of the 38 (100.0%) patients at risk of dysphagia according to the EAT-10. The authors explained such a high occurrence by comparing the nutritional status and dysphagia characteristics while including the elderly at risk of malnutrition and malnourished in the same undernutrition classification.Meanwhile, another study, the present study also found a larger number of older individuals at risk of dysphagia and malnutrition (93.75%). Therefore, considering this classification related to a high number of hospitalized patients at risk of dysphagia associated with the nutritional status alteration, the findings herein indicate the need of tracking and monitoring the altered swallowing function and nutritional risk by the multi-professional team.After using a classification similar to that of these authors, and the risks could have been present before hospitalization. It is worth mentioning that this study was not aimed at pointing out the total hospitalization time, but the hospitalization time at the unit in the moment of the instruments\u2019 application.The present study carried out such a comparison including older individuals of the community due to the fact that the number of hospitalization days of the participants in the moment of research was considerably lower (5.5 \u00b13.86) than other studies.Results have indicated that such an association might be explained by the fact that dysphagia directly damages the ability to eat and drink, thus reducing the food intake of energy, water and other nutrients, resulting in malnutrition and dehydration. In older individuals, food and liquid ingestion are generally already reduced due to age-related alterations, in addition to social, emotional and health problems. Since undernutrition is associated with a loss of mass and muscle function, also affecting the mastication and deglutition muscles, dysphagia is a strong alteration of functionality and might onset the process of health risk in the elderlyHowever, by analyzing only the hospitalized older patients at risk of malnutrition and dehydration, it was found 63.46% and 9.62%, respectively, amounting to 73.08% of the altered sample, according to the revised MNA\u00ae-SF, which is a considerably high amount that requires tracking and monitoring by the medical team.As depicted in  (IBRANUTRE) assessed the nutritional status and prevalence of undernutrition in four thousand hospitalized individuals, in addition to evaluating the knowledge regarding the nutritional status and use of nutritional therapy by the medical teams. Malnutrition was present in 48.1% of the hospitalized individuals and severe malnutrition occurred in 12.5%, nevertheless, there is little medical knowledge on undernutrition and nutritional therapy is underprescribed. Malnutrition presented a correlation with the primary diagnosis on admission, age (60 years), presence of cancer or infection, and a longer hospital stay (p < 0.05).The Brazilian National Survey on Hospital Malnutrition,29 have demonstrated that these alterations and correlations might be initially involved with anorexia of aging. As age advances, food ingestion decreases, muscle mass is reduced and body fat mass increases. The causes of anorexia of aging include: decreased sense of smell and taste with lesser association; alterations in the gastric fundus compliance due to nitric oxide deficiency; decreased antral stretch with greater association with postprandial anorexia; as well as gastroparesis in response to large meals.Some studiesAs already mentioned, most of these hospitalized elderly had no attendants throughout hospitalization due to the Covid-19, which might have interfered with food ingestion and resulted in the undernutrition risk.The frequency of oral hygiene by the older individuals studied showed to be correlated with the risk of dysphagia. Most of them (53.0%) reported performing less than three oral hygiene procedures a day, which might be associated both to the lack of habit, since most of them used dental prostheses, and/or a lack of encouragement, assistance as well as instruction by the medical team throughout hospitalization.The hospitalized elderly exposed to the risk of performing oral hygiene up to three times a day presented 13.42 times more chances of dysphagia risk according to the EAT-10, when compared to those who performed oral hygiene more than three times a day . Thus, t,31.It is paramount to preserve good oral health in hospitalized geriatric patients, since it is strongly associated with nutritional ingestion, lower risk of respiratory and cardiovascular diseases and better quality of life. Oral diseases caused by plaque were identified as a major risk for the patient\u2019s ability to eat, communicate, and socialize addressed the issue of how many frail and medically compromised older individuals are still able to perform oral and prosthesis hygiene by themselves, and how many of them need help to perform this activity. Oral hygiene and cleaning of dentures require a certain level of manual dexterity, visual acuity, procedural and cognitive skills, along with a sufficient mobility of the shoulder as well as elbow joints.Such a low frequency of oral hygiene among the hospitalized elderly can be explained by the reports indicating that most of the time there is a lack of attendants or caretakers, which could have encouraged or helped the patients with their hygiene. A research studyFurther studies addressing the adaptation process of older patients experiencing such harmful alterations to functional and satisfactory swallowing should be conducted to establish a better technical and supportive understanding of the risk detection, for a better quality of life and recovery of these individuals. Further research should also investigate the matter of financial costs, suggesting instruments that are easy and low cost to apply, promoting a more controlled monitoring of the risk of dysphagia, saving resources without harming the quality of the services.It is worth highlighting that the EAT-10, the SARC-F+CC and the revised MNA\u00ae-SF instruments were applied to detect the risk of dysphagia, signs suggestive of sarcopenia and risk of undernutrition, respectively. In the case of a positive result, the health care professionals conducting the evaluation must issue a referral of the patient to a speech-language pathologist and/or nutritionist, and/or physician for diagnostic assessment and therapy intervention.The non-statistical findings herein show that all individuals with a risk of dysphagia according to the EAT-10 (16/30.8%) were hospitalized due to respiratory problems resulting from a Covid-19 infection. Thus, the present study indicates the need for research addressing the risk of dysphagia in older patients hospitalized due to Covid-19, in order to find whether this health condition is associated with sarcopenia, nutritional status and oral hygiene frequency.The challenge for the future is to disseminate and broaden the recognition of dysphagia as an important geriatric syndrome, in addition to showing its impact on the older population to healthcare professionals, especially during hospitalization. Further instruments with high sensitivity and specificity should be developed for a faster and easier application.The elderly population studied herein, mostly tested positive for Covid-19, presented a risk of dysphagia associated with signs suggestive of sarcopenia, nutritional status and oral hygiene frequency. .O processo natural de envelhecimento junto com as s\u00edndromes geri\u00e1tricas, traz diversas altera\u00e7\u00f5es morfol\u00f3gicas que comprometem a comunica\u00e7\u00e3o humana, entre elas: altera\u00e7\u00f5es de linguagem, audi\u00e7\u00e3o, voz e motricidade facial. Esse comprometimento afeta o sistema estomatogn\u00e1tico: suas estruturas - l\u00edngua, bochechas, mand\u00edbula, l\u00e1bios, \u00e1rea oclusal e palato, e suas fun\u00e7\u00f5es - suc\u00e7\u00e3o, respira\u00e7\u00e3o, mastiga\u00e7\u00e3o, fala e degluti\u00e7\u00e3o.Geralmente, esse comprometimento na popula\u00e7\u00e3o idosa se manifesta pela dificuldade em mastigar ou iniciar o processo de degluti\u00e7\u00e3o, com a presen\u00e7a de tosse, engasgos, pirose, dor tor\u00e1cica e regurgita\u00e7\u00e3o nasal durante as refei\u00e7\u00f5es e sensa\u00e7\u00e3o de alimento parado na garganta ap\u00f3s as refei\u00e7\u00f5es. Estes efeitos tornam a din\u00e2mica da degluti\u00e7\u00e3o mais vulner\u00e1vel a dist\u00farbios causados por pequenas altera\u00e7\u00f5es de sa\u00fade, como infec\u00e7\u00f5es de vias a\u00e9reas superiores.Essas modifica\u00e7\u00f5es na funcionalidade da degluti\u00e7\u00e3o poder\u00e3o ser classificadas como disfagia, uma altera\u00e7\u00e3o definida como uma \u201calimenta\u00e7\u00e3o perturbada\u201d com condi\u00e7\u00e3o que envolve dificuldade percebida ou real em formar ou mover um bolo alimentar com seguran\u00e7a da cavidade oral at\u00e9 o estomago.Com essas altera\u00e7\u00f5es relacionadas \u00e0 degluti\u00e7\u00e3o, na \u00faltima d\u00e9cada, tem havido uma crescente conscientiza\u00e7\u00e3o de que a disfagia orofar\u00edngea deve ser reconhecida como uma s\u00edndrome geri\u00e1trica. Isso porque ela ocasiona uma sequ\u00eancia de dist\u00farbios como descrita a seguir: (1) Desidrata\u00e7\u00e3o (2) Anorexia \u2192 relut\u00e2ncia em se alimentar (3) Perda de peso \u2192 desnutri\u00e7\u00e3o energ\u00e9tica proteica (4) Sarcopenia \u2192 diminui\u00e7\u00e3o da fun\u00e7\u00e3o (5) Aspira\u00e7\u00e3o: qu\u00edmica ou bacteriana (6) Diminui\u00e7\u00e3o do prazer de comer / beber (7) Constrangimento em situa\u00e7\u00f5es sociais (8) Isolamento \u2192 depress\u00e3o (9) Estresse do cuidador (10) Disforia (11) Morte.Os fatores de risco associados n\u00e3o esclarecem quanto aos potenciais fatores de confus\u00e3o e aos mediadores da disfagia. Os estudos, em sua maioria, est\u00e3o sujeitos a causalidade-reversa e n\u00e3o se confirma o que vem antes, a altera\u00e7\u00e3o na degluti\u00e7\u00e3o ou o agravo \u00e0 sa\u00fade, como por exemplo a sarcopenia, fragilidade e o estado psicol\u00f3gico. Devido a sua tend\u00eancia e desenvolvimento crescente na popula\u00e7\u00e3o idosa, suas consequ\u00eancias na fun\u00e7\u00e3o oral e na degluti\u00e7\u00e3o, podem resultar em fragilidade oral e indicar um mau estado de sa\u00fade.Dentre esses fatores a sarcopenia \u00e9 definida como uma doen\u00e7a do m\u00fasculo esquel\u00e9tico, com a baixa for\u00e7a muscular superando o papel da baixa massa muscular como principal determinante.Essa diminui\u00e7\u00e3o da fun\u00e7\u00e3o oral e a disfagia podem levar \u00e0 desnutri\u00e7\u00e3o, pneumonia por aspira\u00e7\u00e3o, asfixia e, \u00e0s vezes, morte. A desnutri\u00e7\u00e3o apresenta alta preval\u00eancia entre os idosos fr\u00e1geis, e o risco de disfagia est\u00e1 independentemente associado \u00e0 desnutri\u00e7\u00e3o. A diminui\u00e7\u00e3o da fun\u00e7\u00e3o oral pode ser um importante preditor da progress\u00e3o da desnutri\u00e7\u00e3o em popula\u00e7\u00f5es idosas.J\u00e1 a pneumonia aspirativa, uma das complica\u00e7\u00f5es mais cr\u00edticas da disfagia, \u00e9 um processo infeccioso provocado pela broncoaspira\u00e7\u00e3o de secre\u00e7\u00f5es orofar\u00edngeas contendo res\u00edduos alimentares e saliva com poss\u00edveis pat\u00f3genos orais. Devido \u00e0 m\u00e1 higiene oral, a saliva contaminada com uma quantidade elevada de v\u00e1rias esp\u00e9cies de bact\u00e9rias pode abrigar micr\u00f3bios que, se colonizados e aspirados, podem resultar em pneumonia bacteriana. Como resultado, os impactos combinados de m\u00e1 higiene oral e disfagia podem aumentar o risco de pneumonia por aspira\u00e7\u00e3o4,5. Este estudo tem o objetivo de identificar o risco de disfagia e sua associa\u00e7\u00e3o com os sinais sugestivos de sarcopenia, estado nutricional e frequ\u00eancia da higiene oral em idosos hospitalizados.Dessa forma, a popula\u00e7\u00e3o idosa apresenta grandes riscos para disfagia, devido aos efeitos do processo de envelhecimento. Essa altera\u00e7\u00e3o \u00e9 frequente e tardiamente identificada, sendo associada, muitas vezes, a este processo de senesc\u00eancia e, assim, postergando as investiga\u00e7\u00f5esTrata-se de um estudo transversal realizado com 52 idosos internados em unidade de enfermaria, cl\u00ednica m\u00e9dica, de um hospital p\u00fablico no Distrito Federal (DF) durante o per\u00edodo entre setembro e dezembro de 2021. A popula\u00e7\u00e3o amostral, selecionada por conveni\u00eancia, foi constitu\u00edda por idosos, com idade igual ou superior a 60 anos. Foram exclu\u00eddos idosos que apresentaram altera\u00e7\u00f5es cognitivas graves que afetavam a capacidade perceptiva, de discernimento e de linguagem e/ou que possu\u00edam algum membro inferior amputado, estivesse em uso de pr\u00f3teses ortop\u00e9dicas em membros inferiores, com edema ou que estavam com dieta via oral suspensa.O presente estudo \u00e9 derivado do projeto de pesquisa \u201cAvalia\u00e7\u00e3o do risco de disfagia em idosos hospitalizados e sua rela\u00e7\u00e3o com a nutri\u00e7\u00e3o, sarcopenia, hidrata\u00e7\u00e3o e qualidade de vida: um estudo transversal anal\u00edtico e observacional\u201d, aprovado pelo Comit\u00ea de \u00c9tica e Pesquisa da Faculdade de Ceil\u00e2ndia da Universidade de Bras\u00edlia (CEP/FCE), conforme parecer n\u00famero 3.749.828 e pelo Comit\u00ea de \u00c9tica e Pesquisa da Funda\u00e7\u00e3o de Ensino e Pesquisa em Ci\u00eancias da Sa\u00fade da Secretaria de Sa\u00fade do Distrito Federal (CEP/FEPECS), conforme parecer n\u00famero 3.820.960. Todos os participantes foram informados sobre os objetivos da pesquisa e a confidencialidade dos dados e assinaram o Termo de Consentimento Livre e Esclarecido.TrakCare\u00ae de informa\u00e7\u00e3o em sa\u00fade da Secret\u00e1ria de Sa\u00fade do Distrito Federal e atrav\u00e9s de perguntas respondidas pelo participante no momento da anamnese.Inicialmente, foi realizada a busca de dados sociodemogr\u00e1ficos e de sa\u00fade dos participantes como exemplo a idade, sexo, escolaridade, ra\u00e7a, cor, patologias, tipo de dieta ofertada e altera\u00e7\u00f5es no paladar, que foram coletadas por meio de um levantamento estruturado acessando o prontu\u00e1rio do participante atrav\u00e9s do sistema A frequ\u00eancia da higiene oral foi levantada perguntando ao participante quantas vezes ele realizava a higiene oral ao dia, tendo as seguintes op\u00e7\u00f5es de resposta: n\u00e3o realizo; uma vez; duas vezes; tr\u00eas vezes; quatro ou mais vezes.Eating Assessment Tool (EAT-10) que \u00e9 um instrumento pr\u00e1tico, para uso rotineiro no cuidado aos idosos; \u00e9 um question\u00e1rio subjetivo e espec\u00edfico para avaliar o grau dos sintomas da disfagia. Cada quest\u00e3o tem uma pontua\u00e7\u00e3o de 0 (sem problemas) a 4 (problema grave) sendo a pontua\u00e7\u00e3o m\u00e1xima de 40 pontos e a notas de coorte < 3 pontos sem risco para disfagia e maior ou igual a 3 com risco para disfagia. O instrumento aborda o participante questionando \u201co quanto essas situa\u00e7\u00f5es s\u00e3o um problema para voc\u00ea? Marque o melhor n\u00famero para o seu caso\u201d, e segue com os questionamentos: meu problema de engolir me faz perder peso; meu problema para engolir n\u00e3o me deixa comer fora de casa; preciso fazer for\u00e7a para beber l\u00edquidos; preciso fazer for\u00e7a para engolir comida (s\u00f3lido); preciso fazer for\u00e7a para engolir rem\u00e9dios; d\u00f3i para engolir; meu problema para engolir me tira o prazer de comer; fico com comida presa/ entalada na garganta; eu tusso quando como e engolir me deixa estressado. Ap\u00f3s o participante ter respondido, somaram-se os valores das respostas correspondentes em cada item onde um resultado maior ou igual a tr\u00eas foi indicador de altera\u00e7\u00e3o.Em seguida foi aplicado o Strength, Assistance with walking, Rise from a chair, Climb stairs and Falls) + Circunfer\u00eancia da Panturrilha (CP) para an\u00e1lise do risco de sarcopenia. Foram aplicadas as seguintes perguntas: Quanta dificuldade o senhor (a) tem para levantar ou carregar 5,0kg? Quanta dificuldade o senhor (a) tem para andar por um quarto? Quanta dificuldade o senhor (a) tem para levantar de uma cadeira ou cama? Quanta dificuldade o senhor (a) tem para subir 10 degraus de escada? Quantas vezes o senhor (a) caiu no \u00faltimo ano? As respostas poss\u00edveis e quantific\u00e1veis foram: nenhuma = 0, alguma = 1, muita ou n\u00e3o consegue = 2, e para a pergunta: quantas vezes o senhor (a) caiu no \u00faltimo ano? Os valores mensur\u00e1veis das respostas foram: nenhuma = 0; 1-3 quedas = 1; 4 ou mais quedas = 2.Ap\u00f3s aplica\u00e7\u00e3o do EAT-10 foi iniciado o question\u00e1rio SARC-F (7 (2018): mulheres >33cm 0 pontos; \u226433 cm 10 pontos; homens >34cm 0 pontos e \u226434cm 10 pontos.Em seguida foi realizada a medida antropom\u00e9trica da circunfer\u00eancia da panturrilha. A medida foi realizada na perna direita, com uma fita m\u00e9trica inel\u00e1stica, na sua parte mais protuberante, com o participante com a perna dobrada formando um \u00e2ngulo de 90 graus com o joelho e para evitar o vi\u00e9s de erro inerente \u00e0 CP, esse procedimento foi realizado por um \u00fanico antropometrista . Em participantes acamados a aferi\u00e7\u00e3o foi realizada no leito e em deambulantes sentados em uma cadeira. A pontua\u00e7\u00e3o para CP seguiu o recomendado pelo EWGSOP2Ap\u00f3s aplica\u00e7\u00e3o do question\u00e1rio SARC-F + CP fez se o somat\u00f3rio dos valores das respostas (0 - 20 pontos) e o participante foi classificado em: aus\u00eancia de sinais sugestivos de sarcopenia (0 - 10 pontos) e sugestivo de sarcopenia (11 - 20 pontos)Mini Nutritional Assessment Short-Form (MNA-SF revised\u00ae). O consenso brasileiro de nutri\u00e7\u00e3o e disfagia recomenda a aplica\u00e7\u00e3o, pelo enfermeiro, dessa vers\u00e3o reduzida, garantindo a identifica\u00e7\u00e3o dos idosos em risco e a possibilidade de indica\u00e7\u00e3o quando o escore for menor ou igual a 12 para avalia\u00e7\u00e3o espec\u00edfica com nutricionista. Podemos citar como benef\u00edcios dessa vers\u00e3o a exclus\u00e3o de itens redundantes, que necessitavam de treinamento especial, que envolviam subjetividade e mem\u00f3ria do paciente ou que produzissem muitas respostas em branco ou \u201cn\u00e3o sei\u201d.O risco de desnutri\u00e7\u00e3o foi avaliado pela aplica\u00e7\u00e3o da revised\u00ae \u00e9 um question\u00e1rio de triagem composto por 5 perguntas com op\u00e7\u00f5es de respostas correspondentes a pontos (podem variar de 0 a 3), para somat\u00f3ria no final da avalia\u00e7\u00e3o. Aborda diminui\u00e7\u00e3o da ingesta alimentar, perda de peso, mobilidade, estresse psicol\u00f3gico ou doen\u00e7a aguda, problemas neuropsicol\u00f3gicos e \u00cdndice de Massa Corp\u00f3rea (IMC). Ao final foi realizada a somat\u00f3ria dos n\u00fameros correspondentes \u00e0s respostas para obter o escore final da triagem: 12-14 pontos: estado nutricional normal; 8-11 pontos: sob risco de desnutri\u00e7\u00e3o e 0-7 pontos: desnutrido,13.O MNA-SF Statistical Package of Social Sciences\u201d (SPSS) vers\u00e3o 19.0. A fim de averiguar se existe uma associa\u00e7\u00e3o entre a vari\u00e1vel classifica\u00e7\u00e3o EAT- 10 e as vari\u00e1veis qualitativas foi utilizado o teste de Qui-Quadrado. O n\u00edvel de confian\u00e7a adotado neste estudo foi equivalente a 95%.Para a an\u00e1lise e interpreta\u00e7\u00e3o dos resultados foram utilizados os programas Microsoft Excel 2018 e o \u201cA amostra foi composta por 52 participantes com idade m\u00e9dia de 73  anos. O tempo de interna\u00e7\u00e3o, tendo a rela\u00e7\u00e3o com o dia da coleta de dados, apresentou uma m\u00e9dia de 5,5  dias . O sexo A quest\u00e3o respirat\u00f3ria foi o motivo de interna\u00e7\u00e3o principal, estando infectados pelo Coronav\u00edrus (Covid-19) 39  dos idosos.O Diabetes Mellitus (DM) e a Hipertens\u00e3o Arterial Sist\u00eamica (HAS) foram encontrados em grande parte dos participantes. Al\u00e9m do DM e HAS, 65,38% apresentaram outras comorbidades. No que tange a dieta, a maioria dos participantes estavam com dieta do tipo branda, com predomin\u00e2ncia da via de administra\u00e7\u00e3o oral. A queixa relacionada a disfagia mais afirmada foi a tosse, mas a maioria dos participantes negaram queixas relacionadas. Os dados relacionados \u00e0 sa\u00fade bucal mostraram que uma grande parte estavam em uso de pr\u00f3tese dent\u00e1ria total e realizavam a higiene oral duas vezes ao dia. Em rela\u00e7\u00e3o ao tabagismo e etilismo ocorreu a predomin\u00e2ncia de afirma\u00e7\u00f5es de nunca terem fumado ou consumido bebida alco\u00f3lica, seguido por aqueles que j\u00e1 fizeram uso de cigarros e \u00e1lcool, mas n\u00e3o possuem mais o h\u00e1bito.Dos 52 participantes 30,8% apresentaram risco de disfagia autorrelatada pelo EAT-10 e 69,2% n\u00e3o apresentaram esse risco.Os dados da A Conforme a revised\u00ae e frequ\u00eancia da higiene oral pois o p-valor apresentado para o teste dessas vari\u00e1veis foram <0,05, logo aceitamos a hip\u00f3tese estat\u00edstica de que as vari\u00e1veis s\u00e3o dependentes.Nas revised\u00ae e frequ\u00eancia da higiene oral. Desta forma, realizou-se a raz\u00e3o de chances (odds ratio) dos indiv\u00edduos apresentarem risco de disfagia (EAT-10) estando expostos as altera\u00e7\u00f5es nesses instrumentos (Como demonstrado estatisticamente h\u00e1 uma associa\u00e7\u00e3o do risco de disfagia (EAT-10) com as vari\u00e1veis do SARCF+CP, MNA-SF rumentos . realizado em 2016 onde a maioria eram do sexo feminino (67.1%) com m\u00e9dia de idade de 71 anos (m\u00ednimo de 60 anos e m\u00e1ximo de 102 anos).A composi\u00e7\u00e3o da amostra revelou que mesmo estando balanceada, a maioria dos idosos hospitalizados na cl\u00ednica m\u00e9dica entre setembro e dezembro de 2021 pertenciam ao sexo feminino, m\u00e9dia de idade de 73 anos (m\u00ednimo de 61 anos e o m\u00e1ximo de 94 anos), afirmaram ser da ra\u00e7a/cor branca, casados e possu\u00edam ensino fundamental incompleto. Esses achados v\u00e3o ao encontro com outro estudo. Lembramos que n\u00e3o foi objetivo do estudo associar o risco de disfagia com a infec\u00e7\u00e3o pelo Covid-19, sendo esta a realidade epidemiol\u00f3gica encontrada.Os dados cl\u00ednicos levantados apontaram que o motivo das interna\u00e7\u00f5es foi respirat\u00f3rio  tendo liga\u00e7\u00e3o com o Covid-19 . A literatura traz que esse n\u00famero est\u00e1 dentro dos casos relacionados \u00e0 segunda onda da pandemia, onde houve pequena redu\u00e7\u00e3o proporcional de casos nas faixas et\u00e1rias mais jovens (at\u00e9 49 anos de idade) e aumento nas faixas mais idosas (\u226560 anos) entre indiv\u00edduos de ra\u00e7a/cor branca, que apontou essa caracter\u00edstica em 60,5% dos pacientes portadores de disfagia. Essa propor\u00e7\u00e3o de participantes com HAS e DM apresentada no estudo, demonstra a necessidade de uma maior vigil\u00e2ncia e monitoramento para preven\u00e7\u00e3o de incapacidades e de suas consequ\u00eancias na qualidade de vida desses indiv\u00edduos e no sistema de sa\u00fade.Em rela\u00e7\u00e3o as comorbidades, a HAS e o DM apresentaram respectivamente em 65,38% e 42,31% da amostra, estando tamb\u00e9m outras patologias associadas em 65,38%. Essa maior presen\u00e7a de HAS entre os participantes, tamb\u00e9m foi identificada em outro estudop<0,05) com sinais sugestivos de sarcopenia. Entre os 52  indiv\u00edduos da amostra, 12  apresentaram risco de disfagia com sinais sugestivos de sarcopenia pelo SARC+F+CP. Quando se observa esse risco de sarcopenia dentro dos idosos com risco de disfagia  esse n\u00famero apresenta-se mais alto 12 .Os idosos hospitalizados com risco de disfagia apresentaram associa\u00e7\u00e3o  \u00e9 um v\u00edrus neurotr\u00f3pico que pode provocar doen\u00e7as nos nervos perif\u00e9ricos. A neuropatia glossofar\u00edngea e vagal, que est\u00e3o entre as manifesta\u00e7\u00f5es neurol\u00f3gicas da Covid-19, pode levar a disfagia.Como mencionado anteriormente 75,0% dos idosos estavam hospitalizados por motivo de infec\u00e7\u00e3o pelo Covid-19 durante a pesquisa. Em um estudo de 2020.Al\u00e9m dessa poss\u00edvel manifesta\u00e7\u00e3o neurol\u00f3gica, pesquisadores identificaram que o processo inflamat\u00f3rio da Covid-19 combinado com a desnutri\u00e7\u00e3o e baixa mobilidade durante a hospitaliza\u00e7\u00e3o, pode predeterminar o indiv\u00edduo \u00e0 sarcopenia secund\u00e1ria e disfagia sarcop\u00eanica, no entanto, h\u00e1 poucos estudos publicados sobre disfagia em indiv\u00edduos n\u00e3o intubados com Covid-19,21, a infec\u00e7\u00e3o pelo SARS-CoV-2 \u00e9 um fator de risco para altera\u00e7\u00f5es na degluti\u00e7\u00e3o.Esse quadro epidemiol\u00f3gico da Covid-19 encontrado em 75,0% dos participantes pode ter sido um poss\u00edvel motivo de vi\u00e9s, j\u00e1 que como demonstrado em outros estudosNa , onde redu\u00e7\u00e3o de massa muscular diminuiu as for\u00e7as de propuls\u00e3o do bolus alimentar resultando em res\u00edduo orofar\u00edngeo p\u00f3s-degluti\u00e7\u00e3o. \u00c9 importante que ap\u00f3s essa identifica\u00e7\u00e3o de risco para sarcopenia a equipe de sa\u00fade, em especial o fonoaudi\u00f3logo, avalie a for\u00e7a de press\u00e3o da l\u00edngua, a equipe de nutri\u00e7\u00e3o acompanhe o aporte nutricional e a enfermagem o processo de aceita\u00e7\u00e3o e oferta da dieta como preven\u00e7\u00e3o e reabilita\u00e7\u00e3o do indiv\u00edduo.Essa exposi\u00e7\u00e3o aos sinais sugestivos de sarcopenia, pode acarretar na disfagia sarcop\u00eanica.A equipe de sa\u00fade assistencial, dever\u00e1 ter em mente que o estado nutricional \u00e9 um relevante componente para manter o bem-estar e a sa\u00fade de idosos, ainda mais se estes estiverem hospitalizados. Uma nutri\u00e7\u00e3o inapropriada para este p\u00fablico contribui para o aparecimento de v\u00e1rias doen\u00e7as e \u00e9 fator predisposto para a s\u00edndrome da fragilidade, sarcopenia e aumento do tempo de interna\u00e7\u00e3oDessa forma, o estudo apresentou uma associa\u00e7\u00e3o  entre o risco de disfagia e o estado nutricional dos idosos hospitalizados. Dentre os 16  indiv\u00edduos com risco de disfagia, 11  estavam sob risco de desnutri\u00e7\u00e3o, 4  estavam desnutridos e somente 1  apresentou estado nutricional normal. Considerando as altera\u00e7\u00f5es nutricionais nesses idosos com risco de disfagia, temos que 93,75% apresentavam um estado nutricional desfavor\u00e1vel e que provavelmente necessitariam ou necessitaram de um plano de cuidados e monitoramento beira leito. com 49 idosos em um hospital universit\u00e1rio de Bras\u00edlia e chegaram a resultados semelhantes. Idosos com risco de disfagia e risco de desnutri\u00e7\u00e3o representaram 51,0%, j\u00e1 os desnutridos e com risco de disfagia 20,0%.Pesquisadores realizaram um estudo que investigou a associa\u00e7\u00e3o entre a fun\u00e7\u00e3o da degluti\u00e7\u00e3o e o estado nutricional em idosos da comunidade no Jap\u00e3o, mostraram que entre os 38  indiv\u00edduos com risco de disfagia pelo EAT-10 a desnutri\u00e7\u00e3o esteve presente em 60,5%. Esse n\u00famero mais alto \u00e9 explicado porque os autores quando realizaram a compara\u00e7\u00e3o das caracter\u00edsticas para o estado nutricional e disfagia incluiriam os idosos com risco de desnutri\u00e7\u00e3o e desnutridos na mesma classifica\u00e7\u00e3o de desnutri\u00e7\u00e3o.J\u00e1 outro estudo temos um n\u00famero maior de idosos com risco de disfagia e desnutri\u00e7\u00e3o . Portanto, considerando essa classifica\u00e7\u00e3o com alto n\u00famero de indiv\u00edduos hospitalizados em risco de disfagia e altera\u00e7\u00e3o no estado nutricional, o presente estudo traz a necessidade de rastreamento e acompanhamento pela equipe multiprofissional nas altera\u00e7\u00f5es da degluti\u00e7\u00e3o e risco nutricional.Quando realizamos uma classifica\u00e7\u00e3o semelhante \u00e0 realizada pelos autores e os riscos apresentados poderiam j\u00e1 estar presentes tamb\u00e9m na comunidade antes da hospitaliza\u00e7\u00e3o. Vale lembrar que n\u00e3o foi objetivo do estudo demonstrar o tempo total de interna\u00e7\u00e3o e sim o tempo de interna\u00e7\u00e3o na unidade no momento da aplica\u00e7\u00e3o dos instrumentos.Foi feita essa compara\u00e7\u00e3o com idosos da comunidade por motivo de que os dias de interna\u00e7\u00e3o dos participantes no momento da pesquisa era consideravelmente pequeno  em compara\u00e7\u00e3o a outros estudos.Resultados indicam que essa associa\u00e7\u00e3o pode ser explicada pelo fato de que a disfagia prejudica diretamente a capacidade de comer e beber, reduz a ingest\u00e3o alimentar de energia, \u00e1gua e outros nutrientes, resultando em desnutri\u00e7\u00e3o e desidrata\u00e7\u00e3o. Em idosos, a ingest\u00e3o de alimentos e l\u00edquidos geralmente j\u00e1 est\u00e1 reduzida devido a altera\u00e7\u00f5es relacionadas \u00e0 idade e devido a problemas sociais, emocionais ou de sa\u00fade. Como a desnutri\u00e7\u00e3o \u00e9 acompanhada de perda de massa e fun\u00e7\u00e3o muscular, afetando tamb\u00e9m os m\u00fasculos mastigat\u00f3rios e de degluti\u00e7\u00e3o, a disfagia \u00e9 uma forte altera\u00e7\u00e3o de funcionalidade e pode desencadear processos de riscos \u00e0 sa\u00fade de idososrevised\u00ae. \u00c9 consideravelmente um n\u00famero alto que requer rastreio e monitoramento por parte da equipe assistencial.Mas quando se analisa somente os idosos hospitalizados com risco de desnutri\u00e7\u00e3o e desnutri\u00e7\u00e3o esse estudo apresentou respectivamente 63,46% e 9,62% totalizando 73,08% da amostra alterada segundo a MNA-SF Conforme a  (IBRANUTRE) avaliou o estado nutricional e a preval\u00eancia de desnutri\u00e7\u00e3o em 4000 mil indiv\u00edduos hospitalizados, al\u00e9m do conhecimento do estado nutricional pelas equipes de sa\u00fade e o uso de terapia nutricional. Foi demonstrado que a desnutri\u00e7\u00e3o esteve presente em 48,1% dos hospitalizados e a desnutri\u00e7\u00e3o grave em 12,5%, j\u00e1 o conhecimento m\u00e9dico sobre desnutri\u00e7\u00e3o \u00e9 baixo e a terapia nutricional \u00e9 subprescrita. A desnutri\u00e7\u00e3o apresentou rela\u00e7\u00e3o com o diagn\u00f3stico prim\u00e1rio na admiss\u00e3o, idade (60 anos), presen\u00e7a de c\u00e2ncer ou infec\u00e7\u00e3o e maior tempo de interna\u00e7\u00e3o .Um Inqu\u00e9rito Nacional Brasileiro de Nutri\u00e7\u00e3o Hospitalar,29 demonstrando que essas altera\u00e7\u00f5es e rela\u00e7\u00f5es podem estar envolvidas inicialmente com a anorexia do envelhecimento. Com o envelhecimento, h\u00e1 uma diminui\u00e7\u00e3o da ingest\u00e3o alimentar, juntamente com um decl\u00ednio da massa muscular e um aumento da massa gorda. Dentre as causas da anorexia do envelhecimento podemos citar: a diminui\u00e7\u00e3o do olfato e do paladar com menor rela\u00e7\u00e3o; altera\u00e7\u00f5es na complac\u00eancia do fundo do est\u00f4mago devido \u00e0 defici\u00eancia de \u00f3xido n\u00edtrico e diminui\u00e7\u00e3o do estiramento antral com maior rela\u00e7\u00e3o na anorexia p\u00f3s-prandial, assim como o retardo do esvaziamento g\u00e1strico em resposta a grandes refei\u00e7\u00f5es.H\u00e1 estudosComo j\u00e1 mencionamos anteriormente, esses idosos hospitalizados estavam em sua maioria sem acompanhantes durante a hospitaliza\u00e7\u00e3o por motivo do Covid-19 e isso poder\u00e1 ter interferido na ingesta alimentar e ter proporcionado um quadro de risco para desnutri\u00e7\u00e3o.J\u00e1 a quantidade de vezes que os idosos realizam a higiene oral apresentou associa\u00e7\u00e3o com o risco de disfagia. A maioria dos idosos  relataram menos de tr\u00eas procedimentos de higieniza\u00e7\u00e3o oral por dia. Isso pode estar ligado tanto a cultura de n\u00e3o ter a pr\u00e1tica do h\u00e1bito, visto que a maioria fazia uso de pr\u00f3tese dent\u00e1ria e/ou a falta de incentivo, ajuda e orienta\u00e7\u00e3o por parte da equipe de sa\u00fade durante a hospitaliza\u00e7\u00e3o.Idosos hospitalizados expostos ao risco de realizarem at\u00e9 tr\u00eas higienes orais ao dia apresentam 13,42 vezes mais chances de apresentarem risco de disfagia pelo EAT-10 em compara\u00e7\u00e3o aos que realizam mais de tr\u00eas higienes orais ao dia . Sendo a,31.Durante a hospitaliza\u00e7\u00e3o a preserva\u00e7\u00e3o de uma boa sa\u00fade bucal \u00e9 importante para pacientes geri\u00e1tricos, pois est\u00e1 fortemente relacionada \u00e0 ingest\u00e3o nutricional, diminui\u00e7\u00e3o do risco de doen\u00e7as respirat\u00f3rias e cardiovasculares e melhor qualidade de vida. As doen\u00e7as bucais causadas pela placa bacteriana foram identificadas como um grande risco para a capacidade do paciente de comer, comunicar e socializar relatou que em idosos fr\u00e1geis e medicamente comprometidos, coloca-se a quest\u00e3o de quais destes ainda s\u00e3o capazes de realizar uma higiene bucal e da pr\u00f3tese suficiente sozinhos ou que precisam de assist\u00eancia para essa atividade, pois a higieniza\u00e7\u00e3o oral e a limpeza das pr\u00f3teses necessitam de um certo n\u00edvel de destreza manual, acuidade visual, habilidades processuais, cognitivas e mobilidade suficiente das articula\u00e7\u00f5es do ombro e cotovelo.Essa baixa frequ\u00eancia de higiene oral em idosos hospitalizados, apresentada no estudo, pode ser explicada pelos relatos que na maior parte do tempo eles n\u00e3o tinham acompanhantes ou cuidadores que poderiam incentivar ou ajudar na higieniza\u00e7\u00e3o. Uma pesquisaNovos estudos, que abordam o processo de adapta\u00e7\u00e3o do idoso \u00e0s altera\u00e7\u00f5es prejudiciais para uma degluti\u00e7\u00e3o funcional e satisfat\u00f3ria, dever\u00e3o ser realizados para uma melhor compreens\u00e3o t\u00e9cnica e assistencial na identifica\u00e7\u00e3o de riscos, melhora da qualidade de vida e reabilita\u00e7\u00e3o destes. \u00c9 preciso tamb\u00e9m estudos de custos financeiros, que demonstrem que instrumentos de f\u00e1cil aplica\u00e7\u00e3o e baixo custo, poder\u00e3o favorecer o rastreio de risco de disfagia com controle e racionaliza\u00e7\u00e3o de recursos empregados, sem que se perca a qualidade dos servi\u00e7os prestados.revised\u00ae, s\u00e3o utilizados respectivamente para a identifica\u00e7\u00e3o de pessoas com risco de disfagia, sinais sugestivos de sarcopenia e risco de desnutri\u00e7\u00e3o. Se a identifica\u00e7\u00e3o for positiva, o profissional identificador dever\u00e1 realizar o encaminhamento para o fonoaudi\u00f3logo e/ou nutricionista e/ou m\u00e9dico para a avalia\u00e7\u00e3o diagn\u00f3stica e condutas terap\u00eauticas.Lembramos que os instrumentos EAT-10, SARC-F+CP e a MNA-SF Em nosso estudo, foi poss\u00edvel observar, n\u00e3o estatisticamente, que todos os indiv\u00edduos com risco de disfagia pelo EAT-10 , tinham como motivo de interna\u00e7\u00e3o a quest\u00e3o respirat\u00f3ria decorrente da infec\u00e7\u00e3o pelo Covid-19. Dessa forma, esse estudo apontou a necessidade de pesquisas envolvendo o risco de disfagia em idosos hospitalizados por Covid-19, demonstrando se h\u00e1 associa\u00e7\u00e3o desse quadro de sa\u00fade com a sarcopenia, estado nutricional e frequ\u00eancia da higiene oral.O desafio futuro \u00e9 divulgar e aumentar o reconhecimento da disfagia como uma importante s\u00edndrome geri\u00e1trica e demonstrar aos profissionais de sa\u00fade seu impacto na sa\u00fade da popula\u00e7\u00e3o, em especial nos idosos durante uma hospitaliza\u00e7\u00e3o. \u00c9 importante o desenvolvimento de mais instrumentos com alta sensibilidade e especificidade com r\u00e1pida e f\u00e1cil aplica\u00e7\u00e3o.Na popula\u00e7\u00e3o geri\u00e1trica deste estudo, em sua maioria com Covid-19, o risco de disfagia esteve associado aos sinais sugestivos de sarcopenia, estado nutricional e frequ\u00eancia da higiene oral."}
+{"text": "Twenty-two professors answered an online questionnaire containing 31 items related to APT, involving items about the professional profile, conditions for APT in undergraduate and postgraduate courses in Speech Therapy, APT structure, and evaluation of the APT effect.it was observed that there is a variation in APT procedures performed in Brazil. The main requirements indicated by the respondents for the APT involve the use of synthesized voices in the initial moments, followed by human voices later; the use of speech tasks with sustained vowels and connected speech; the insertion of complementary information such as gender, age, the profession of the speaker and the spectrography of the vocal signal; training with a minimum time of six hours; the evaluation of the training effect by comparing intra- and inter-judge agreement before and after training; the addition of the parameters of general degree of vocal deviation, roughness, breathiness, and strain; the use of validated continuous and numerical scales; and offering it from the second year of the undergraduate program.although there is variability in the response of experts, a minimum set of requirements indicated for performing APT with new judges was identified. APE identifies the presence/absence of vocal deviations, characterizes the intensity and type of vocal deviation, and provides important information on the social acceptability of that voice. Since it is based on impressions, APE is subjective and influenced by various factors, including the judge\u2019s training. The subjectivity and arbitrariness inherent to this method may justify the tendency to name it \u201cauditory-perceptual judgment\u201d (APJ), rather than APE,4.Auditory-perceptual evaluation (APE) of voice is considered the gold-standard method used by speech-language-hearing (SLH) therapists in clinical voice assessment. In it, the evaluator judges, based on their auditory impression (perception), the speaker\u2019s voice characteristics, such as voice quality, pitch, loudness, resonance, articulation, and so on.Training APJ skills changes the perception system and auditory information processing, improving the listener\u2019s capacity to respond to stimuli to which they have been trained. Such changes create an auditory memory that is accessed in future assessments, enabling them to recognize patterns deemed normal or deviated-9. These strategies have negative aspects, such as expenses with material , the unfeasibility of immediately analyzing the effects of training and the availability of judges to in-person meetings. Moreover, APT is conducted in various ways, hindering the comparison of training requirements and effects.Strategies such as auditory anchors, immediate feedback, and standardized scales are used in auditory-perceptual training (APT) to minimize its subjectivity. Virtual environments allow for making mistakes and correcting them from the initial phases of training without any consequences to either patients or students. The user\u2019s performance can also be immediately assessed with objective measures obtained from their interaction with the virtual environment.New technologies are being used to complement traditional teaching strategies with interactive approaches. Applications such as training simulators (TS) and serious games provide controlled experiences, including various situations professionals will find in real scenarios, helping them learn and transfer such skills to practical work. The lack of well-established such definitions in the literature and/or consensus between researchers in the area poses a challenge to proposing a TS. In this case, combining specialists\u2019 practical experience and the knowledge reported in the literature is the main strategy to define requirements and model a robust TS adequate to real needs.The first stage to develop an application for this type of training is defining the training structure, requirements, and parameters that will be used in the application and then assessing the users\u2019 performance,14 are not consistent in terms of training time, number of stimuli and vocal parameters, type of scale, and nature of the voices they use. Above all, they do not indicate a hierarchy to present stimuli and tasks in APT . This justifies consulting professors specialized in voice and experienced in APT to establish requirements to bridge these gaps and support TS modeling definitions for APT.There may be occasional divergences between the knowledge available in the literature and the training that takes place in specialists\u2019 everyday practice. Moreover, some requirements pointed out in the literature are subjective and need to be more clearly and objectively translated for implementation in TS. Studies approaching APTEstablishing APT requirements may help develop a TS for this assessment. An APT simulator modality may help structure and standardize training, analyze performance, understand the judge\u2019s learning curve, and flexibilize the training time. It can also be carried out in settings other than institutions, as no in-person meetings are needed to train with the simulator. Thus, this research aimed to identify a set of requirements to develop a TS for APT based on the experience of professors who provide APT.This quantitative, descriptive, cross-sectional study was approved by the originating institution\u2019s Research Ethics Committee under evaluation report no. 4.746.039 and conducted between April and July 2021.,14. They found inconsistencies in the training processes concerning training time, number of stimuli and vocal parameters, types of scale, and nature of the voices they approached. Hence, consulting specialists in voice that provide APT aims to minimize these inconsistencies and ground the definitions to model a TS for APT.Firstly, researchers consulted recently published reviews on APJ and APT,14. The following variables were included in this stage: associated information during APT; number of hours; types of voices; number of voices; types of speech tasks; scales; and parameters.The questionnaire used in this research was developed in three stages to ensure the instrument would support the definition of requirements to develop a TS for APT, namely: consulting the literature and surveying the specialists\u2019 opinions on APT and the development of simulation tools. In the first questionnaire development stage, the literature available was surveyed to identify the main variables to be addressed in APTIn the second stage, the variables selected in the literature survey were presented to an SLH therapist who specialized in voice and a computer scientist, both experienced in developing simulation tools to train health professionals\u2019 skills. The questions in this stage were structured according to the questionnaire model developed by Macedo and Machado (2015), who researched, along with professors, the requirements to train health professionals to inject medications. This model was adapted due to the lack of instruments in the field of voice aimed at understanding the requirements for APT. Thus, the authors of the said publication formalized a script to develop instruments to obtain information from specialists to define requirements for simulators.. The participation of a computer scientist in this project was likewise essential to TS programming, artificial intelligence, and graphic design. She also participated in the questionnaire conceptualization, structuring the questions to include relevant variables to be selected, as well as other important ones to TS modeling, such as year/period of APT; prerequisites to begin APT; auditory description of the parameters that are trained; hierarchy of APT stages; other applications (games or simulators) used in APT; and form of APT effect assessment.The process of developing and implementing a TS requires interdisciplinary professional work to produce effective and efficient tools. Computer scientists work in TS arts, entertainment, artificial intelligence, and programming. Hence, they are part of interdisciplinary teams that develop applications, working along with expert professionals in the area to which the product is intended (APT), in which the three specialists obtained the maximum score.Three SLH therapists specialized in voice with expertise in APT participated in the third stage, through snowball sampling . The first SLH therapist works in the originating institution and belongs to the same research group as the authors, though not participating in the previous stages. The second one works in the same institution as the researchers, but not in that research group. The third one is not from the originating institution. In this stage, the specialists\u2019 expertise was assessed with the Fehring Model, with scores adapted to the area of voiceThe questionnaire developed in the second stage (31-item version) was individually and remotely  presented to the three SLH therapists to identify and change items that were not coherent with their intended collection and the respondent\u2019s interpretation. The specialists were asked what they had understood after reading each item. If their interpretation was not aligned with the intended collection, the item had to be reformulated based on the participating specialists\u2019 suggestions. No misalignments were identified in this stage between the questionnaire and the specialists\u2019 interpretations. However, they made some suggestions to improve its quality, leading to the following changes: text adjustments ; changes in the type of response collection ; and reducing the number of open-ended questions to decrease the time taken to answer the questionnaire and facilitate professors\u2019 participation, with a more practical instrument, as in the item \u201cWhat speech task do you use in APT with CAPE-V?\u201d.The final version of the questionnaire had 31 items (five open-ended and 26 closed-ended questions), organized into four blocks: 1) Professional profile; 2) Conditions for APT in undergraduate and postgraduate SLH programs; 3) APT structure; and 4) APT effect assessment. It was divided into blocks to understand the specific topic addressed by each item and make it easier to analyze and discuss results. The division was made by the authors and approved by the specialist SLH therapists.To recruit participants, e-mails were sent to the coordinators of 81 undergraduate SLH programs and five postgraduate specialization programs in voice, requesting the contact of the professors responsible for the APT of undergraduate SLH students or postgraduate SLH therapists. This research was also presented directly to some such professors. The e-mail has a brief description of the research, its objectives, participation criteria, and a link to the informed consent form.The following eligibility criteria were established for this research, considering its objective: being an undergraduate or postgraduate SLH professor; having experience in teaching any course that includes APT; having conducted APT at least once. Participants that met these criteria and agreed with the informed consent form were invited to continue, answering the questionnaire in Google Forms.Hence, the final sample had 22 professors, of which 15 (68.2%) taught in undergraduate and master\u2019s programs, two (9.1%) taught only in specialization programs in voice, and five (22.7%) trained undergraduate and specialization students in voice. Considering that one professor per institution provides APT, the sample comprised about 26% of the population. Despite the efforts to have more professors participate in the research, many e-mails were not answered, even after sending them three times.The sample had representatives from three regions of Brazil , including the following federative units: S\u00e3o Paulo , Pernambuco , Para\u00edba , Minas Gerais , Rio de Janeiro , Federal District , and Rio Grande do Norte . According to their professional profile, most interviewees  had a doctoral degree and had been teaching for more than 10 years in undergraduate programs at public institutions, where they provide APT in required courses.The data spreadsheet was extracted from Google Forms to calculate the relative frequency measures of closed-ended items. The open-ended items were qualitatively analyzed and grouped into categories according to the content of the answers.Concerning the conditions for APT, most interviewees  reported that it is offered to undergraduate students in or after the second year of the SLH program. Also, 15 interviewees (68.18%) stated that there is a better moment during the undergraduate program to provide APT, and all of them agree that it is after its second year .Respondents generally associate additional information of the speakers in APT, such as their sex , age , complaint , spectrogram , and laryngeal examination result .The total number of APT hours in the classroom range from less than 2 hours to more than 8 hours. Most responses ranged from 6 to 8 hours of training .Most participants use human voices  in APT, while five (22.7%) use both human and synthesized voices. The number of voices used in APT is quite evenly distributed among participants into \u201cUp to 20 voices\u201d , \u201c21 to 40 voices\u201d , and \u201cMore than 50 voices\u201d .The most used speech tasks in APT are number count , spontaneous speech , CAPE-V sentences , /a/ vowels , and /\u025b/ vowels . GRBAS  and CAPE-V  are the most used scales.Respondents generally begin APT by identifying the presence/absence of vocal deviation. However, they diverge in the sequence of the subsequent stages. Concerning a possible APT stage hierarchy, most of them gave the following order: identifying the presence of vocal deviation as the first training level , assessing voice quality predominantly as the second level , and assessing the degree of vocal deviation as the last level .All interviewees include the general degree of vocal deviation (G), roughness (R), breathiness (B), and strain (S) as APT parameters. They were asked to describe the auditory characteristics related to the training parameters, but they seemed to have difficulties defining those related to R and S. From the auditory standpoint, B seems to be more easily explained, reported by interviewees as \u201cany audible air escape during voice production\u201d. The interviewees\u2019 responses did not specifically define auditory characteristics and/or defined physiological/anatomical correlates of R and S. The responses regarding R referred to \u201cirregular vibration\u201d, \u201cnoise\u201d, \u201cdirty voice\u201d, and \u201csandy voice\u201d. As for S, the responses mentioned \u201ctight sensation\u201d, \u201cvocal effort\u201d, and \u201cvocal hyperfunction\u201d.More than half of the interviewees  consider that APT must last more than 8 hours to improve the judges\u2019 performance and reliability. Most participants  do not use any type of simulator or game in APT.About 60% of interviewees (n = 13) do not assess the judges\u2019 reliability after APT. As for those who assess their reliability after APT, the methods cited are interrater and intrarater agreement tests, observing and discussing assessments, and formal assessment tests. Of these, 22.7% (n = 5) reported difficulties assessing APT effects because of the lack of comparison parameters and calibrating instruments for the training and the unfeasibility of performing statistical test procedures during APT.More than half of the interviewees , who use CAPE-V and the Vocal Deviation Scale (VDS) agree with the assessment that coincides with the reference judge value or is 10 mm above or below this value. As for those who use GRBAS, 50% (n = 10) agree with the assessment that coincides with the degree ascribed to the reference judge, while the other half  admits one degree higher or lower. APT is considered very important to SLH students\u2019 initial training by 86.4% (n = 19) of the interviewees.. APT models in the literature are inconsistent regarding variables involved in training,14. To define the best way of providing APT, we must first know the various training methods that have been used and recorded in the literature. They must also be described to enable an adequate assessment of their results, comparing training methods, and defining to which populations the results may be applicable.APJ is influenced by various factors, including the judges\u2019 training.It is not an easy task to establish the requirements to provide training through a TS, especially in the case of such subjective training as APT. Hence, the knowledge available in the literature must be combined with specialists\u2019 practical experience to address these difficulties and objectively define the requirements for a robust TS. Experienced judges have better-defined inner standards and experience to train beginners. Inner standards result from APT and APJ experiences throughout their academic training and career. Hence, both professional training  and temporal characteristics (years working with APJ) have been pointed out to determine a judge\u2019s experience. This study considered both forms, as all interviewees had a doctoral degree with more than 10 years of teaching and experience in APJ and APT.Thus, it is essential to consult judges experts in APT to plan the training of new SLH therapists and develop training models based on specialists\u2019 opinionsThis research found that specialists agree that APT must be provided from the second year of undergraduate programs. Initial years\u2019 students take basic courses on health sciences, which are necessary to understand physiological/anatomical behavior regarding the quality of the voices under assessment.. These aspects justify adding such information along with the voices used in training inexperienced judges.The classification of vocal deviation depends on additional information other than the voice, such as the speaker\u2019s sex, age, and occupation. Moreover, the visual support of the spectrogram tracing can significantly increase voice quality APJ reliability among inexperienced judges, as it increases interrater and intrarater agreement in most analysis parameters,20. Vocal parameters can be controlled to produce unidimensional synthesized voices (with only one deviated parameter), thus simplifying the inexperienced judges\u2019 assessment.Even though most interviewees use human voices in APT, synthesized ones seem to be more adequate for this purpose, especially in the initial moments of the inexperienced judges\u2019 training, 57, and 220 voices. Considering APT that encompasses the most universal parameters , the various degrees , and matching per sex , a range from 30 to 60 voices seems minimally enough to provide APT.Studies in the area seemingly do not consider the number of voices used in APT as an important variable. It varies considerably, as some studies reported using 30. Associations between speech tasks, muscle adjustments, and auditory correlates are important to train beginning judges, which justifies the variety of vocal tasks in APT.Speech tasks such as sustained vowels and linked speech make it possible to assess both glottal source information and muscle adjustments in the vocal tract. A study used anchor stimuli in APT and found increased intrarater and interrater reliability after 2 hours of training. Given the interviewees\u2019 opinions and studies in the area, the judges\u2019 reliability is expected to increase after 6 to 8 hours of training. A more precise definition of the necessary APT time will only be possible with studies that assess the judges\u2019 performance after different APT training times.The number of hours and stimuli used in APT varied considerably between the interviewees\u2019 responses. These variations are also found in the review of APT methods by Walden and Khayumov (2020), in which the training time ranged from 30 minutes to 20 hours. It is not known which one is best to train inexperienced SLH therapists. Hence, the instrument should be chosen based on the training goals, speech samples available, and estimated training time.GRBAS and CAPE-V are the most used and accepted instruments worldwide to record APJ in clinical and scientific contexts. These instruments help standardize APE and have particularities in how they are recorded, the parameters they assess, and the type of speech task they use. G, R, and B have a greater agreement, whereas S has a lower interrater and intrarater agreement and is, therefore, considered less reliable in APJ than the other ones,23,24. All interviewees include G, R, B, and S in APT. Thus, including at least these parameters in APE training is justified.G, R, B, and S are among the universal parameters most used in APJ.Describing auditory characteristics of R and S poses a challenge to interviewees. Although R is recurrent in clinical voice assessment, interviewees used physiological/anatomical correlates that occur in phonation when trying to describe its auditory characteristics. The same occurred with S, as they mistook effort (speaker\u2019s perception) for strain (muscle contractile activity)Concerning the sequence of APT levels, identifying the presence/absence of vocal deviations is considered easier for inexperienced judges because it is a categorical, binary classification. On the other hand, characterizing the predominating type of vocal quality deviation requires a more complex categorical classification, including at least three possibilities . The most complex APT level is believed to be the assessment of vocal deviation intensity, concerning either global deviation or its components . On this level, assessment is based on a continuum from the absence of a given vocal characteristic to its presence in an intense degree.. Greater proximity is expected between inexperienced judges\u2019 and reference judges\u2019 assessments after APT (interrater agreement). Likewise, inexperienced judges are expected to have more consistent assessments (intrarater agreement). Hence, it is important to assess APT effects to monitor results and implement new necessary strategies.One way of assessing APT effects is with intrarater and interrater agreement measures. Statistical agreement tests quantify the proximity of assessments before and after APT.When using instruments with continuous 100-mm scales in APJ , a variability of up to 10 mm between raters is admissible - as long as such variation does not exceed the limits (cutoff scores) that change the degree of deviatioThe interviewees\u2019 responses varied regarding APT procedures. Given the survey of professors experienced in APJ and the knowledge available in the literature, developing a TS for APT must consider the following requirements: beginning APT with the task of classifying the presence/absence of vocal deviation, advancing to classify the predominating vocal quality, and then classify the degrees of vocal deviation; using synthesized voices in initial moments, progressing later to human voices; using 30 to 60 voices; using speech tasks with sustained vowels and linked speech; adding complementary information, such as the speaker\u2019s sex, age, and occupation and their voice spectrogram; providing at least 6 hours of training; assessing the effects of training by comparing intrarater and interrater agreement before and after training; adding the parameters of general degree of vocal deviation, roughness, breathiness, and strain (at least); using continuous numerical scales; and providing training from the second year of the undergraduate program.These established requirements are flexible and can be changed as studies advance in the area. However, they are a starting point to propose and develop a TS. pitch, a loudness, a resson\u00e2ncia, a articula\u00e7\u00e3o, entre outros. A APA permite identificar a presen\u00e7a/aus\u00eancia de um desvio vocal, caracterizar a intensidade e o tipo de desvio presente na voz, al\u00e9m de fornecer informa\u00e7\u00f5es importantes quanto \u00e0 aceitabilidade social dessa voz. Por sua natureza impression\u00edstica, a APA \u00e9 considerada subjetiva e sofre influ\u00eancia de diversos fatores, entre eles, o treinamento do juiz. A subjetividade e a natureza arbitr\u00e1ria inerentes a esse m\u00e9todo de avalia\u00e7\u00e3o podem justificar a tend\u00eancia ao uso da nomenclatura \u201cjulgamento perceptivo-auditivo\u201d (JPA) em substitui\u00e7\u00e3o \u00e0 express\u00e3o \u201can\u00e1lise perceptivo-auditiva\u201d,4.A an\u00e1lise perceptivo-auditiva (APA) da voz \u00e9 considerada o padr\u00e3o-ouro entre os m\u00e9todos utilizados pelo fonoaudi\u00f3logo para a avalia\u00e7\u00e3o cl\u00ednica da voz. Ela consiste em um julgamento, a partir das impress\u00f5es auditivas (percep\u00e7\u00e3o) do avaliador, acerca das caracter\u00edsticas vocais do falante, tais como a qualidade vocal, o .O treinamento das habilidades relacionadas ao JPA desenvolve mudan\u00e7as no sistema de percep\u00e7\u00e3o e no processamento da informa\u00e7\u00e3o auditiva, o que melhora a capacidade do ouvinte em responder aos est\u00edmulos treinados. Essas mudan\u00e7as criam uma mem\u00f3ria auditiva que \u00e9 acessada durante futuras avalia\u00e7\u00f5es, permitindo o reconhecimento de padr\u00f5es julgados normais ou desviadosfeedback imediato e o uso de escalas padronizadas s\u00e3o utilizados no treinamento perceptivo-auditivo (TPA) com o objetivo de reduzir a sua subjetividade-9. Tais estrat\u00e9gias possuem pontos negativos, tais como as despesas com materiais , a inviabilidade para a an\u00e1lise imediata do efeito do treinamento e a disponibilidade dos ju\u00edzes para encontros presenciais. Al\u00e9m disso, o TPA \u00e9 realizado de diversas formas, e isto dificulta a compara\u00e7\u00e3o dos requisitos e dos efeitos dos treinamentos.As estrat\u00e9gias como o uso de \u00e2ncoras auditivas, o serious games (SG) possibilitam experi\u00eancias controladas, incluindo diversas situa\u00e7\u00f5es que o profissional ir\u00e1 encontrar nos cen\u00e1rios reais, o que pode facilitar a aprendizagem e a transfer\u00eancia dessas habilidades para a realidade pr\u00e1tica. A utiliza\u00e7\u00e3o de ambientes virtuais permite que os erros sejam cometidos e corrigidos desde as fases iniciais do treinamento, sem acarretar preju\u00edzos para pacientes e alunos. Al\u00e9m disso, \u00e9 poss\u00edvel realizar a avalia\u00e7\u00e3o imediata do desempenho do usu\u00e1rio por meio de medidas objetivas resultantes da intera\u00e7\u00e3o entre o usu\u00e1rio e o ambiente virtual.Com o surgimento de novas tecnologias, as estrat\u00e9gias tradicionais de ensino v\u00eam sendo complementadas com abordagens de ensino interativas. O uso de aplica\u00e7\u00f5es como simuladores de treinamento (ST) e . Quando essas defini\u00e7\u00f5es n\u00e3o s\u00e3o bem estabelecidas na literatura e/ou n\u00e3o existe consenso entre os pesquisadores da \u00e1rea, isso se torna um desafio para a proposi\u00e7\u00e3o de um ST. Nesses casos, a combina\u00e7\u00e3o da experi\u00eancia pr\u00e1tica de especialistas e o conhecimento relatado na literatura \u00e9 a principal estrat\u00e9gia para as defini\u00e7\u00f5es dos requisitos e para a modelagem de um ST robusto e adequado \u00e0s necessidades reais.Nesse sentido, a primeira etapa para o desenvolvimento de uma aplica\u00e7\u00e3o para esse tipo de treinamento \u00e9 a defini\u00e7\u00e3o da estrutura do treinamento, dos requisitos e dos balizadores que ser\u00e3o utilizados para compor a aplica\u00e7\u00e3o e realizar a avalia\u00e7\u00e3o de desempenho do usu\u00e1rio,14 n\u00e3o s\u00e3o consistentes quanto \u00e0 defini\u00e7\u00e3o do tempo de treinamento realizado; \u00e0 quantidade de est\u00edmulos utilizados; ao n\u00famero de par\u00e2metros vocais treinados; ao tipo de escala utilizada; \u00e0 natureza das vozes utilizadas; e, sobretudo, n\u00e3o indicam se existe uma hierarquia para apresenta\u00e7\u00e3o dos est\u00edmulos e tarefas durante o TPA . Com isso, justifica-se a consulta a docentes especialistas em Voz que possuam experi\u00eancia com TPA, com o objetivo de estabelecer requisitos que preencham estas lacunas e respaldem as defini\u00e7\u00f5es adotadas para a modelagem de um ST para o TPA.Eventualmente, podem ocorrer diverg\u00eancias entre o conhecimento disposto na literatura e o treinamento realizado na pr\u00e1tica cotidiana dos especialistas. Al\u00e9m disso, alguns requisitos dispostos na literatura possuem car\u00e1ter subjetivo, e precisam ser traduzidos de maneira clara e objetiva para a implementa\u00e7\u00e3o em um ST. Os estudos que abordam o TPAO estabelecimento de requisitos para o TPA pode contribuir para o desenvolvimento de um ST para esta avalia\u00e7\u00e3o. Uma modalidade de simulador de TPA pode contribuir para a estrutura\u00e7\u00e3o e padroniza\u00e7\u00e3o do treinamento, permitir a an\u00e1lise do desempenho e a compreens\u00e3o da curva de aprendizagem dos ju\u00edzes, flexibilizar o tempo de treinamento. Al\u00e9m disso, pode ser realizado em outros ambientes al\u00e9m das institui\u00e7\u00f5es, tendo em vista que n\u00e3o h\u00e1 necessidade de encontros presenciais para a aplica\u00e7\u00e3o do treinamento com o simulador. Dessa forma, o objetivo desta pesquisa \u00e9 identificar um conjunto de requisitos para o desenvolvimento de um simulador de treinamento perceptivo-auditivo (TPA) a partir da experi\u00eancia de docentes que realizam o TPA.Trata-se de um estudo transversal, descritivo, com abordagem quantitativa. Foi aprovado pelo CEP da Institui\u00e7\u00e3o de origem sob parecer n\u00ba 4.746.039 e realizado no per\u00edodo de abril a julho de 2021.,14. Dessa forma, foram observadas inconsist\u00eancias nos processos de treinamento que envolvem as vari\u00e1veis tempo de treinamento realizado; quantidade de est\u00edmulos utilizados; n\u00famero de par\u00e2metros vocais treinados; tipo de escala utilizada; e natureza das vozes utilizadas. Posto isso, a consulta a especialistas em Voz que realizam o TPA tem o objetivo de reduzir essas inconsist\u00eancias e basear as defini\u00e7\u00f5es adotadas para a modelagem de um ST para o TPA.Inicialmente, foram consultadas revis\u00f5es publicadas recentemente sobre o JPA e a realiza\u00e7\u00e3o do TPA,14. As vari\u00e1veis adicionadas nesta etapa foram: informa\u00e7\u00f5es associadas durante o TPA; n\u00ba de horas; tipos de vozes; quantidade de vozes; tipo de tarefa de fala; escalas utilizadas; e par\u00e2metros treinados.O question\u00e1rio utilizado nesta pesquisa foi elaborado em tr\u00eas etapas, a fim de garantir um instrumento que possibilitasse o suporte \u00e0 defini\u00e7\u00e3o dos requisitos para o desenvolvimento de um ST para o TPA, a saber: consulta \u00e0 literatura; opini\u00e3o de especialistas no desenvolvimento de ferramentas de simula\u00e7\u00e3o; e opini\u00e3o de especialistas em TPA. Na primeira etapa para elabora\u00e7\u00e3o do question\u00e1rio, foi realizado um levantamento na literatura dispon\u00edvel para identificar as principais vari\u00e1veis a serem consideradas no TPANa segunda etapa, as vari\u00e1veis selecionadas a partir da consulta \u00e0 literatura foram apresentadas a um fonoaudi\u00f3logo especialista em Voz e uma cientista da computa\u00e7\u00e3o, ambos com experi\u00eancia no desenvolvimento de ferramentas de simula\u00e7\u00e3o para treinamento de habilidades em profissionais da sa\u00fade. Nesta etapa, as perguntas foram estruturadas seguindo o modelo do question\u00e1rio desenvolvido por Macedo e Machado (2015), que pesquisaram, junto a docentes, sobre os requisitos para o treinamento de profissionais da sa\u00fade quanto \u00e0 aplica\u00e7\u00e3o de medicamentos injet\u00e1veis. O modelo do question\u00e1rio utilizado foi adaptado devido \u00e0 falta de instrumentos na \u00e1rea de Voz que tenham por objetivo entender os requisitos para o TPA. Assim, na referida publica\u00e7\u00e3o os autores formalizaram uma proposta de roteiro para o desenvolvimento de instrumentos utilizados para obten\u00e7\u00e3o de informa\u00e7\u00f5es com especialistas para a defini\u00e7\u00e3o de requisitos a serem utilizados em simuladores.expertise na \u00e1rea objeto do determinado produto. Assim, a participa\u00e7\u00e3o de uma cientista da computa\u00e7\u00e3o neste projeto foi essencial para a programa\u00e7\u00e3o do ST, implementa\u00e7\u00e3o da intelig\u00eancia artificial, e design gr\u00e1fico do ST. Na concep\u00e7\u00e3o do question\u00e1rio, a participa\u00e7\u00e3o da cientista da computa\u00e7\u00e3o esteve relacionada a estruturar as perguntas de modo que as vari\u00e1veis relevantes para serem selecionadas fossem contempladas no question\u00e1rio e a adicionar outras vari\u00e1veis consideradas importantes para a modelagem de um ST, como: ano/per\u00edodo de aplica\u00e7\u00e3o do TPA; pr\u00e9-requisitos para iniciar o TPA; descri\u00e7\u00e3o auditiva dos par\u00e2metros treinados; hierarquia das etapas do TPA; uso de outras aplica\u00e7\u00f5es (jogos ou simuladores) para o TPA; e forma de avalia\u00e7\u00e3o do efeito do TPA.O processo de desenvolvimento e implementa\u00e7\u00e3o de um ST requer a atua\u00e7\u00e3o profissional interdisciplinar, a fim de produzir ferramentas efetivas e eficientes. Os profissionais das Ci\u00eancias da Computa\u00e7\u00e3o atuam na arte, entretenimento, intelig\u00eancia artificial e programa\u00e7\u00e3o do ST. Dessa forma, os cientistas da computa\u00e7\u00e3o integram a equipe interdisciplinar no desenvolvimento de diferentes aplica\u00e7\u00f5es, e trabalham associado aos profissionais com expertise em TPA, seguindo uma amostra bola de neve . O primeiro fonoaudi\u00f3logo recrutado atua na mesma institui\u00e7\u00e3o de origem, pertence ao mesmo grupo de pesquisa dos autores, por\u00e9m n\u00e3o participou das etapas anteriores. O segundo fonoaudi\u00f3logo recrutado atua na mesma institui\u00e7\u00e3o de origem dos pesquisadores e \u00e9 externo ao grupo de pesquisa. O terceiro fonoaudi\u00f3logo recrutado \u00e9 externo \u00e0 institui\u00e7\u00e3o de origem dos autores. Nesta etapa, a expertise dos especialistas foi avaliada segundo a adapta\u00e7\u00e3o do sistema de pontua\u00e7\u00e3o \u201cThe Fehring Model\u201d para a \u00e1rea de Voz (TPA), na qual os tr\u00eas especialistas obtiveram pontua\u00e7\u00e3o m\u00e1xima.Na terceira etapa, participaram tr\u00eas fonoaudi\u00f3logos especialistas em Voz com De forma individual e remota (por videochamada), a vers\u00e3o do question\u00e1rio resultado da segunda etapa, composta por 31 itens, foi apresentada aos tr\u00eas fonoaudi\u00f3logos com o objetivo de identificar e modificar os itens que n\u00e3o estivessem alinhados quanto a inten\u00e7\u00e3o de coleta do item e a interpreta\u00e7\u00e3o do respondente. Ap\u00f3s a leitura de cada item se perguntava o que o especialista compreendeu. Caso a interpreta\u00e7\u00e3o do especialista estivesse desalinhada com a inten\u00e7\u00e3o de coleta do item, o item deveria ser reformulado a partir das sugest\u00f5es que o especialista fornecesse combinado com as dos demais participantes. Nesta etapa n\u00e3o houve desalinhamento entre as interpreta\u00e7\u00f5es dos especialistas e o question\u00e1rio, por\u00e9m algumas sugest\u00f5es foram dadas para melhorar a qualidade do instrumento. As modifica\u00e7\u00f5es realizadas nesta etapa foram: ajustes de texto como no item \u201cVoc\u00ea usa outros recursos durante o treinamento perceptivo-auditivo?\u201d para \u201cDurante o treinamento perceptivo-auditivo voc\u00ea associa alguma outra informa\u00e7\u00e3o sobre a voz apresentada?\u201d; mudan\u00e7as no tipo de coleta de respostas como ao inv\u00e9s de usar caixa de sele\u00e7\u00e3o \u201chumanas\u201d e \u201csintetizadas\u201d para o item \u201cAs vozes utilizadas no treinamento s\u00e3o:\u201d para m\u00faltipla escolha adicionando a op\u00e7\u00e3o \u201cambas\u201d, para facilitar a an\u00e1lise posterior; e redu\u00e7\u00e3o do n\u00famero de itens com respostas abertas, para diminuir o tempo de aplica\u00e7\u00e3o do question\u00e1rio e facilitar a participa\u00e7\u00e3o dos docentes com um instrumento mais pr\u00e1tico de responder como no item \u201cQue tarefa de fala voc\u00ea utiliza para o treinamento perceptivo-auditivo com o CAPE-V?\u201d.A vers\u00e3o final do question\u00e1rio incluiu 31 itens (5 subjetivos e 26 objetivos) organizados em quatro blocos: 1) Perfil Profissional; 2) Condi\u00e7\u00f5es para o TPA nos cursos de gradua\u00e7\u00e3o e p\u00f3s-gradua\u00e7\u00e3o em Fonoaudiologia; 3) Estrutura do TPA; e 4) Avalia\u00e7\u00e3o do efeito do TPA. A divis\u00e3o em blocos teve o intuito de tornar compreens\u00edvel a tem\u00e1tica espec\u00edfica da qual os itens se remetem e facilitar a an\u00e1lise e discuss\u00e3o dos resultados. Esta divis\u00e3o foi feita pelos autores e aprovada pelos fonoaudi\u00f3logos especialistas.e-mail para a coordena\u00e7\u00e3o de 81 cursos de gradua\u00e7\u00e3o em Fonoaudiologia e cinco cursos de p\u00f3s-gradua\u00e7\u00e3o lato sensu em Voz, solicitando-se o contato do professor respons\u00e1vel pelo TPA dos alunos de gradua\u00e7\u00e3o em Fonoaudiologia ou fonoaudi\u00f3logos p\u00f3s-graduandos, e/ou a divulga\u00e7\u00e3o desta pesquisa para esses professores. O e-mail continha uma breve descri\u00e7\u00e3o da pesquisa, seus objetivos, os crit\u00e9rios para participa\u00e7\u00e3o e o link para acesso ao Termo de Consentimento Livre e Esclarecido (TCLE).Para recrutamento dos participantes, foi enviado Google Forms.Considerando-se o objetivo do estudo, foram estabelecidos os seguintes crit\u00e9rios de elegibilidade para participa\u00e7\u00e3o nesta pesquisa: ser docente em n\u00edvel de gradua\u00e7\u00e3o e/ou p\u00f3s-gradua\u00e7\u00e3o em Fonoaudiologia; ter experi\u00eancia no ensino de alguma disciplina em que se realize o TPA; e j\u00e1 ter realizado o TPA ao menos uma vez. Os participantes que se enquadrassem nos crit\u00e9rios elencados e estivessem de acordo com o TCLE eram convidados a dar continuidade, respondendo a o question\u00e1rio na ferramenta stricto sensu, dois  atuavam somente no n\u00edvel da p\u00f3s-gradua\u00e7\u00e3o lato sensu em Voz e cinco  atuavam no treinamento de alunos de gradua\u00e7\u00e3o e p\u00f3s-gradua\u00e7\u00e3o lato sensu em Voz. Considerando que a popula\u00e7\u00e3o de docentes que realizem o TPA seja de um docente por institui\u00e7\u00e3o, a amostra comp\u00f5e cerca de 26% da popula\u00e7\u00e3o. Ressalta-se que apesar dos esfor\u00e7os para buscar a participa\u00e7\u00e3o de mais docentes, muitos e-mails n\u00e3o foram respondidos, mesmo ap\u00f3s tr\u00eas envios.Dessa forma, a amostra final foi composta por 22 docentes. Desses, 15  atuavam no n\u00edvel de gradua\u00e7\u00e3o e p\u00f3s-gradua\u00e7\u00e3o A amostra incluiu representantes de tr\u00eas regi\u00f5es do Brasil  das seguintes unidades da federa\u00e7\u00e3o: S\u00e3o Paulo , Pernambuco , Para\u00edba , Minas Gerais , Rio de Janeiro , Distrito Federal  e Rio Grande do Norte . De acordo com o perfil profissional, os entrevistados foram, em sua maioria , doutores com mais de 10 anos de doc\u00eancia em cursos de gradua\u00e7\u00e3o em institui\u00e7\u00f5es p\u00fablicas, onde realizam o TPA em componentes curriculares obrigat\u00f3rios.Google Forms e foram calculadas medidas de frequ\u00eancia relativa para os itens com respostas objetivas. Os itens com respostas subjetivas foram analisados de forma qualitativa e agrupados em categorias, de acordo com o que as respostas mencionavam.A planilha de dados foi extra\u00edda do Sobre as condi\u00e7\u00f5es para o treinamento nos cursos de gradua\u00e7\u00e3o em Fonoaudiologia, a maior parte dos entrevistados  afirma que o TPA \u00e9 feito a partir do segundo ano do curso de gradua\u00e7\u00e3o. Quando perguntados se h\u00e1 um melhor momento ao longo da gradua\u00e7\u00e3o para que este treinamento seja realizado, 15 dos entrevistados  afirmaram que existe e todos concordam que deve ser realizado a partir do segundo ano do curso de gradua\u00e7\u00e3o .De maneira geral, os respondentes associam outras informa\u00e7\u00f5es dos falantes durante o TPA, tais como o g\u00eanero , a idade , a queixa , o espectrograma  e o resultado do exame lar\u00edngeo  dos falantes.O n\u00famero total de horas de TPA em sala de aula variou de menos de 2hs a mais de 8hs. A maior parte das respostas est\u00e3o em um intervalo entre 6 e 8 horas de treinamento .A maioria dos participantes utilizam vozes humanas  na realiza\u00e7\u00e3o do TPA, enquanto cinco  utilizam vozes humanas e sintetizadas. A quantidade de vozes utilizadas no TPA foi semelhante entre os intervalos \u201cAt\u00e9 20 vozes\u201d , \u201cEntre 21 e 40 vozes\u201d  e \u201cMais de 50 vozes\u201d .As tarefas de fala mais utilizadas no TPA s\u00e3o contagem de n\u00fameros , fala espont\u00e2nea , frases do CAPE-V , vogais /a/  e vogal /\u025b/ . As escalas mais usadas s\u00e3o a GRBAS  e a CAPE-V .De modo geral, os respondentes iniciam o TPA pela identifica\u00e7\u00e3o da presen\u00e7a/aus\u00eancia de desvio vocal. Por\u00e9m, divergem quanto \u00e0 sequ\u00eancia das etapas posteriores. Quando perguntados sobre uma poss\u00edvel hierarquiza\u00e7\u00e3o das etapas do TPA, a maioria indicou a seguinte ordem de aplica\u00e7\u00e3o: identifica\u00e7\u00e3o da presen\u00e7a de desvio vocal como 1\u00ba n\u00edvel de treinamento , avalia\u00e7\u00e3o da qualidade vocal predominante como 2\u00ba n\u00edvel  e avalia\u00e7\u00e3o do grau de desvio vocal como \u00faltimo n\u00edvel .Todos os entrevistados incluem os par\u00e2metros grau geral de desvio vocal (G), rugosidade (R), soprosidade (B) e tens\u00e3o (S) no TPA. Quando solicitada a descri\u00e7\u00e3o de caracter\u00edsticas auditivas relacionadas aos par\u00e2metros inclu\u00eddos no treinamento, os entrevistados parecem demonstrar dificuldades para definir caracter\u00edsticas auditivas para os par\u00e2metros R e S. O par\u00e2metro B, do ponto de vista auditivo, parece ser mais f\u00e1cil de ser explicado. As respostas dos entrevistados se referiam \u00e0: \u201cQualquer escape de ar aud\u00edvel durante a produ\u00e7\u00e3o vocal\u201d. As respostas dos entrevistados n\u00e3o foram espec\u00edficas ao definir caracter\u00edsticas auditivas e/ou definiam os correlatos anatomofisiol\u00f3gicos para R e S. Para R, as respostas se referiam \u00e0: \u201cirregularidade vibrat\u00f3ria\u201d, \u201cru\u00eddo\u201d, \u201cvoz suja\u201d, \u201cpresen\u00e7a de areia\u201d. Para S, as respostas faziam refer\u00eancia \u00e0: \u201cSensa\u00e7\u00e3o de aperto\u201d, \u201cesfor\u00e7o vocal\u201d, \u201chiperfun\u00e7\u00e3o vocal\u201d.Mais da metade dos entrevistados  considera que o TPA deve ter dura\u00e7\u00e3o acima de 8 horas para alcan\u00e7ar melhoria no desempenho e na confiabilidade dos ju\u00edzes. A maioria dos participantes  n\u00e3o utiliza nenhum tipo de simulador ou jogo para o TPA.Cerca de 60% dos entrevistados (n=13) n\u00e3o fazem avalia\u00e7\u00e3o da confiabilidade dos ju\u00edzes ap\u00f3s o TPA. Dentre os que avaliam a confiabilidade ap\u00f3s o TPA, os m\u00e9todos citados foram: teste de concord\u00e2ncia inter e intra-avaliador; observa\u00e7\u00e3o e discuss\u00e3o das avalia\u00e7\u00f5es; Prova . Desses, 22,7% (n=5) referem ter dificuldade para a avalia\u00e7\u00e3o do efeito do TPA pela falta de par\u00e2metros para compara\u00e7\u00e3o, falta de instrumentos calibradores para treino e porque o procedimento com teste estat\u00edstico \u00e9 invi\u00e1vel de ser realizado durante o TPA.Mais da metade dos entrevistados  que utilizam os instrumentos CAPE-V e a Escala de Desvio Vocal (EDV) considera como correta a avalia\u00e7\u00e3o que coincide com os valores do juiz de refer\u00eancia ou est\u00e1 10 mm para mais ou para menos desse valor. Entre os entrevistados que utilizam a escala GRBAS, 50% (n=10) considera como correta a avalia\u00e7\u00e3o que coincide com o grau atribu\u00eddo pelo juiz de refer\u00eancia e a outra parte  admite um grau para mais ou para menos. O TPA \u00e9 considerado muito importante na forma\u00e7\u00e3o inicial do aluno de Fonoaudiologia para 86,4% (n=19) dos entrevistados.. Os modelos de TPA registrados na literatura apresentam inconsist\u00eancias a respeito das vari\u00e1veis envolvidas no treinamento,14. Para definir a melhor forma de realizar o TPA \u00e9 necess\u00e1rio, inicialmente, conhecer os diversos m\u00e9todos de treinamento j\u00e1 utilizados e registrados na literatura. Al\u00e9m disso, estes modelos devem ser descritos de modo que permitam a avalia\u00e7\u00e3o adequada dos seus resultados, a compara\u00e7\u00e3o entre treinamentos, e a determina\u00e7\u00e3o para quais popula\u00e7\u00f5es os resultados podem ser aplic\u00e1veis.O JPA \u00e9 influenciado por diversos fatores, entre eles, o treinamento dos ju\u00edzes.Estabelecer requisitos para que um treinamento seja realizado por meio de um ST n\u00e3o \u00e9 uma tarefa f\u00e1cil, sobretudo, quando se trata de um treinamento subjetivo como o TPA. Para suprir estas dificuldades e tornar as defini\u00e7\u00f5es dos requisitos do ST mais objetivas, a combina\u00e7\u00e3o entre o conhecimento dispon\u00edvel na literatura e a experi\u00eancia pr\u00e1tica de especialistas torna-se essencial para a proposi\u00e7\u00e3o de um ST mais robusto. Ju\u00edzes experientes possuem padr\u00f5es internos mais definidos e experi\u00eancia para conduzir o treinamento de iniciantes. Os padr\u00f5es internos s\u00e3o gerados pelo TPA e pelas experi\u00eancias com o JPA ao longo da sua forma\u00e7\u00e3o acad\u00eamica e do exerc\u00edcio profissional. Dessa forma, tanto a forma\u00e7\u00e3o profissional  quanto a caracter\u00edstica temporal (anos de atua\u00e7\u00e3o com JPA) t\u00eam sido referidas para determinar a experi\u00eancia de um juiz. Neste estudo, ambas as formas foram consideradas, tendo em vista que todos os entrevistados foram fonoaudi\u00f3logos doutores, com mais de 10 anos de doc\u00eancia e com experi\u00eancia em JPA e TPA.Dessa forma, a consulta a ju\u00edzes com expertise em TPA no planejamento do treinamento de novos fonoaudi\u00f3logos \u00e9 fundamental para o desenvolvimento de modelos de treinamento baseado na opini\u00e3o de especialistasNesta pesquisa, observou-se que os especialistas concordam que o TPA deve ser realizado a partir do segundo ano do curso de gradua\u00e7\u00e3o. Nos anos iniciais da gradua\u00e7\u00e3o, os alunos estudam disciplinas b\u00e1sicas das ci\u00eancias da sa\u00fade que s\u00e3o necess\u00e1rias para entender o comportamento anatomofisiol\u00f3gico correspondente \u00e0 qualidade vocal das vozes avaliadas.. Sendo assim, justifica-se a adi\u00e7\u00e3o destas informa\u00e7\u00f5es junto \u00e0 apresenta\u00e7\u00e3o das vozes durante o treinamento de ju\u00edzes inexperientes.A classifica\u00e7\u00e3o do desvio vocal depende de algumas informa\u00e7\u00f5es complementares \u00e0 voz como o g\u00eanero, a idade e a profiss\u00e3o do falante. Al\u00e9m disso, o apoio visual do tra\u00e7ado espectrogr\u00e1fico pode aumentar significativamente a confiabilidade do JPA da qualidade vocal de ju\u00edzes inexperientes, porque promove aumento da concord\u00e2ncia inter e intra ju\u00edzes da maior parte dos par\u00e2metros analisados,20. Em vozes sintetizadas, os par\u00e2metros vocais podem ser controlados para a produ\u00e7\u00e3o de vozes unidimensionais (apenas um par\u00e2metro desviado) e, assim, simplificar a avalia\u00e7\u00e3o de ju\u00edzes inexperientes.Apesar de a maioria dos entrevistados utilizarem vozes humanas para o TPA, o uso de vozes sintetizadas parece ser mais adequado para esta finalidade, principalmente durante os momentos iniciais do treinamento de ju\u00edzes inexperientes, 57, e 220 vozes. Considerando um TPA que envolva os par\u00e2metros mais universais , os diversos graus  e o pareamento por g\u00eanero (masculino e feminino), entende-se que o intervalo de 30 a 60 vozes \u00e9 minimamente suficiente para a realiza\u00e7\u00e3o do TPA.A quantidade de vozes utilizadas parece n\u00e3o ser explorada nos estudos da \u00e1rea como uma vari\u00e1vel importante para o TPA. Essa quantidade possui muita varia\u00e7\u00e3o e alguns estudos mencionam a utiliza\u00e7\u00e3o de 30. Associa\u00e7\u00f5es entre tarefa de fala, ajustes musculares e correlatos auditivos s\u00e3o importantes para o treinamento de ju\u00edzes iniciantes e por isso justifica-se a variedade de tarefas vocais durante o TPA.A utiliza\u00e7\u00e3o de tarefas de fala como vogais sustentadas e fala encadeada permitem a avalia\u00e7\u00e3o tanto de informa\u00e7\u00f5es correspondentes a fonte gl\u00f3tica quanto aos ajustes musculares realizados no trato vocal. Um estudo que utilizou est\u00edmulos \u00e2ncoras durante o TPA, observou aumento da confiabilidade intra e interavaliadores ap\u00f3s duas horas de treinamento. Tendo em vista a opini\u00e3o dos entrevistados e os estudos na \u00e1rea, espera-se que haja aumento na confiabilidade dos ju\u00edzes a partir de seis a oito horas de treino. A defini\u00e7\u00e3o mais precisa sobre o tempo necess\u00e1rio para TPA s\u00f3 ser\u00e1 poss\u00edvel com estudos que avaliem o desempenho dos ju\u00edzes em diferentes intervalos de tempo durante o TPA.A quantidade de horas e o n\u00famero de est\u00edmulos utilizado no TPA apresentaram uma ampla varia\u00e7\u00e3o entre as respostas dos entrevistados. Estas varia\u00e7\u00f5es tamb\u00e9m s\u00e3o encontradas na revis\u00e3o sobre m\u00e9todos de TPA de Walden e Khayumov (2020), em que o tempo de treinamento variou de 30 minutos a 20 horas. N\u00e3o se sabe qual o melhor instrumento a ser utilizado no treinamento de fonoaudi\u00f3logos em forma\u00e7\u00e3o, por isso, recomenda-se que a escolha do instrumento seja baseada no objetivo do treinamento, nas amostras de falas dispon\u00edveis e no tempo de treinamento estimado.Quanto aos instrumentos utilizados para a marca\u00e7\u00e3o do JPA, a escala GRBAS e o protocolo CAPE-V s\u00e3o os mais utilizados e aceitos mundialmente no contexto cl\u00ednico e cient\u00edfico. Estes instrumentos ajudam na padroniza\u00e7\u00e3o da APA e possuem particularidades quanto ao modo de marca\u00e7\u00e3o, aos par\u00e2metros que avaliam e ao tipo de tarefa de fala a ser utilizada. Destes, os que apresentam maiores concord\u00e2ncias s\u00e3o o G, o R e o B. O par\u00e2metro S apresenta menor concord\u00e2ncia inter e intra ju\u00edzes, sendo considerado menos confi\u00e1vel no JPA em compara\u00e7\u00e3o aos outros par\u00e2metros,23,24. Todos os entrevistados incluem os par\u00e2metros de G, R, B e S na aplica\u00e7\u00e3o do TPA. Portanto, justifica-se a inclus\u00e3o, minimamente, destes par\u00e2metros no treinamento da APA.Os descritores G, R, B e S est\u00e3o entre os par\u00e2metros universais mais utilizados no JPA.A descri\u00e7\u00e3o de caracter\u00edsticas propriamente auditivas para os par\u00e2metros de R e S s\u00e3o um desafio para os entrevistados. Apesar do par\u00e2metro R ser recorrente na avalia\u00e7\u00e3o cl\u00ednica da voz, ao tentar descrever caracter\u00edsticas auditivas, os entrevistados utilizam a descri\u00e7\u00e3o de correlatos anatomofisiol\u00f3gicos que ocorrem no momento da fona\u00e7\u00e3o. O mesmo ocorre para o par\u00e2metro S, no qual confundem-se os conceitos de esfor\u00e7o  e tens\u00e3o (atividade de contratilidade muscular)continuum que vai desde a aus\u00eancia de uma determinada caracter\u00edstica vocal at\u00e9 a presen\u00e7a em grau intenso desta caracter\u00edstica.Para a sequencializa\u00e7\u00e3o dos n\u00edveis do TPA, entende-se que a identifica\u00e7\u00e3o da presen\u00e7a/aus\u00eancia do desvio vocal seja mais f\u00e1cil para ju\u00edzes iniciantes por se tratar de uma classifica\u00e7\u00e3o categ\u00f3rica e bin\u00e1ria. A caracteriza\u00e7\u00e3o do tipo de desvio da qualidade vocal predominante exige uma classifica\u00e7\u00e3o categ\u00f3rica mais complexa, incluindo, no m\u00ednimo, tr\u00eas possibilidades . Entende-se que o n\u00edvel mais complexo do TPA seja a avalia\u00e7\u00e3o da intensidade do desvio vocal, seja para o desvio global ou para a avalia\u00e7\u00e3o dos componentes de rugosidade, soprosidade e tens\u00e3o. Neste n\u00edvel, a avalia\u00e7\u00e3o \u00e9 baseada em um . Espera-se que haja maior proximidade entre as avalia\u00e7\u00f5es dos ju\u00edzes inexperientes e o juiz de refer\u00eancia ap\u00f3s o TPA . Tamb\u00e9m \u00e9 esperado que os ju\u00edzes inexperientes se tornem mais consistentes em suas avalia\u00e7\u00f5es . Por isso, \u00e9 importante a realiza\u00e7\u00e3o da avalia\u00e7\u00e3o do efeito do TPA para monitoramento dos resultados obtidos e implementa\u00e7\u00e3o de novas estrat\u00e9gias que sejam necess\u00e1rias.Uma forma de avaliar o efeito do TPA \u00e9 a utiliza\u00e7\u00e3o de medidas de concord\u00e2ncia intra e interavaliador. Os testes estat\u00edsticos de concord\u00e2ncia quantificam a proximidade das avalia\u00e7\u00f5es antes e depois do TPA.Quando utilizado instrumentos com escalas cont\u00ednuas de 100 mm para o JPA, tais como cont\u00ednuos CAPE-V e EDV, admite-se uma variabilidade de at\u00e9 10 mm entre avaliadores, desde que tal varia\u00e7\u00e3o n\u00e3o ultrapasse os limites  para modificar o grau do desvio avaliadoExiste varia\u00e7\u00e3o nas respostas dos entrevistados quanto aos procedimentos de TPA. A partir da pesquisa com docentes experientes em JPA e o conhecimento disposto na literatura, o desenvolvimento de um ST para o TPA deve considerar os seguintes requisitos: iniciar o TPA pela tarefa de classifica\u00e7\u00e3o de presen\u00e7a/aus\u00eancia de desvio vocal, avan\u00e7ando para a classifica\u00e7\u00e3o da predomin\u00e2ncia da qualidade vocal e, por \u00faltimo, a classifica\u00e7\u00e3o dos graus de desvios vocais; usar de vozes sintetizadas nos momentos iniciais seguindo para vozes humanas posteriormente; utilizar entre 30 a 60 vozes; utilizar tarefas de fala com vogais sustentadas e fala encadeada; inserir informa\u00e7\u00f5es complementares como o g\u00eanero, idade, profiss\u00e3o do falante e espectrografia da voz; conter no m\u00ednimo 6 horas de treinamento; avaliar o efeito do treinamento pela compara\u00e7\u00e3o da concord\u00e2ncia intra e inter-juiz pr\u00e9 e p\u00f3s treinamento; adicionar os par\u00e2metros de grau geral de desvio vocal, rugosidade, soprosidade e tens\u00e3o (no m\u00ednimo); utilizar escalas cont\u00ednuas e num\u00e9ricas; e ser realizado a partir do segundo ano de gradua\u00e7\u00e3o.Destaca-se que os requisitos estabelecidos s\u00e3o flex\u00edveis e podem ser alterados com o avan\u00e7ar dos estudos na \u00e1rea, por\u00e9m servem como ponto de partida para a proposi\u00e7\u00e3o e o desenvolvimento de um ST."}
+{"text": "To analyze the access of women to the public health system network to childbirth care, highlighting the barriers related to the \u201cavailability and accommodation\u201d dimension in a health macroregion of Pernambuco. Ecological study, conducted based on hospital birth records from the Hospital Information System of the Brazilian Unified Health System (SUS), and information from the state\u2019s Hospital Beds Regulation Center, about women residing in health macroregion II, in 2018. Displacements were reviewed considering the geographic distance between the municipality of residence and that of the childbirth; estimated time of displacement of pregnant women; ratio of shifts blocked for admission of pregnant women for delivery; and the reason for unavailability. In 2018, health macroregion II performed 84% of usual risk childbirths, and 46.9% of high-risk childbirths. The remaining high-risk childbirths (51.1%) occurred in macroregion I, especially in Recife. The reference maternity for high-risk childbirths in that macroregion had 30.4% of the days of day shifts and 38.9% of the night shifts blocked for admission of childbirths; the main reason was the difficulty in maintaining the full team in service.Cegonha Network. Women residing in the health macroregion II of Pernambuco face great barriers of access in search of hospital care for childbirth, traveling great distances even when pregnant women of usual risk, leading to pilgrimage in search of this care. There is difficulty regarding availability and accommodation in high-risk services and obstetric emergencies, with shortage of physical and human resources. The obstetric care network in macroregion II of Pernambuco is not structured to ensure equitable access to care for pregnant women at the time of childbirth. This highlights the need for restructuring this healthcare services pursuant to what is recommended by the  However, high levels of preventable maternal, fetal, and neonatal morbidity and mortality still persistRede Cegonha (RC). The RC was launched in 2011 as a strategy for organizing maternal and child care, aiming to change the model of delivery and birth care and reduce maternal and neonatal morbidity and mortality2.This persistent situation justified the implementation of several programs, policies, and health strategies, including the 3, entering commitments to change childbirth and delivery care practices5. This networked organization is important to ensure women\u2019s access to healthcare services, especially those for childbirth care, avoiding the occurrence of disorderly flows of pregnant women, which can lead to pilgrimage of women seeking care for childbirth6. An important aspect to overcome access difficulties is the organization of this network to overpower the persistence of great differences in the distribution and quality of services offered between regions and health macroregions7.This shift in the obstetric and neonatal care model was discussed by managers in various health regions of the country, including the adhesion of the health macroregion II of Pernambuco8 when they say that access to healthcare services is difficult, especially to those of greater complexity, specialized services, and hospitals with more technological resources. This demands users to travel long distances to get the necessary care.However, it is known that despite the many efforts toward advancing actions and services in health regions, we agree with Shimizu et al.10, varying among authors and changing over time11. For the purpose of this article, we adopted the concept of access systematized by Levesque et al.12, which defines it as the opportunity to reach and obtain adequate healthcare services in situations of perceived need for care. It is results from the interface between the characteristics of individuals, families, social and physical environments and the characteristics of health systems, organizations, and providers.In this sense, it is understood that access to healthcare services is an important component in all health systems. However, there is no consensus in the literature about its concept12.In their theoretical model, the authors formulated five dimensions involving the concept of access  and five users\u2019 individual abilities . In this paper we chose to work with the \u201cavailability and accommodation\u201d dimension, which encompasses the physical existence and production potential of the service, involving structural aspects, facilities, distribution, human resources, contexts, and urban geography. It is configured in the fact of reaching a healthcare service in a timely mannerIn this sense, an important point is to review the access of women served in the public network to childbirth care services in the health macroregion II of Pernambuco, highlighting the barriers related to the dimension \u201cavailability and accommodation\u201d.Sistema de Informa\u00e7\u00e3o Hospitalar) of the Brazilian Unifed Health System (SIH-SUS), and information from the state\u2019s Hospital Beds Regulation Center  about women residing in health macroregion II, from January 1 to December 31, 2018.A population-based ecological study, conducted based on hospital birth records from the the Hospital Information System , with the redefinition of the territorial organization of the state in 12 health regions grouped into four health macroregions, aiming to subsidize the organization of the health network in a regionalized, hierarchical, and resolutive manner3. Health macroregion II is located in the Agreste region of the State of Pernambuco. It is composed of health regions IV and V. The IV health region has its administrative headquarters in Caruaru and comprises 32 municipalities, with a population of 1,324,382 inhabitants3 . It houses a maternity that is reference to the macroregion II regarding high-risk pregnant women, but it lacks Intensive Care Unit (ICU) for these women. The health region V, with administrative headquarters in the municipality of Garanhuns, comprises 21 municipalities and 534,793 inhabitants3  and has a regional maternity hospital for high-risk pregnant women.In Pernambuco, the network organization is ruled in the Regionalization Master Plan , including all municipalities in macroregion II, taking into account pregnant women at the time for habitual and high-risk deliveries, according to the definitions of the Brazilian Ministry of Health incorporated by the SIH. The SIH database and information on the operation of the shifts were provided by the Pernambuco State Health Department.To review the displacement of pregnant women, flow maps were built using the ArcGIS 10.4 program, differentiated for pregnant women with usual risk deliveries and for pregnant women with high-risk deliveries, having as unit of analysis the health regions and health macroregion.14.The flow maps represent the displacement of women in space, demonstrating the movement by means of vectors drawn to represent the itinerary traveled by the pregnant women, characterized by thicknesses proportional to the number of childbirths. Flows were categorized for pregnant women with usual risk deliveries: IV health region  and for V health region . As for deliveries of high-risk pregnant women, flows were defined in the same way for both health regions: 1-10 deliveries; 11-50 deliveries; 51-100 deliveries; and \u2265 101 deliveries. In this sense, the dominant flow was defined as the largest flow (starting from 10 deliveries) in each municipality, which allowed identifying the framework of the connections network14, helping to identify the organization of services in a regionalized network. Similarly, the organization of the service for high-risk obstetric delivery is also an important component of \u201cavailability and accommodation\u201d to find to what extent the service is structured in the health macroregion to reduce barriers to access.The study of flows is a key component for observing issues related to access, identifying the distances traveledThe research was approved by the Research Ethics Committee of the Research Center Aggeu Magalh\u00e3es/Fiocruz, according to Resolution 510/16, under CAAE n. 63796717.4.0000.5190.In 2018, 77.7% of childbirths occurred in health macroregion II were classified as usual risk and 22.3% as high-risk. When considering the health regions, it was found that 26.4% of childbirths from high-risk pregnant women were from residents in the IV health region, while in the V region this figure was 13.5% .Regarding the place of delivery, it was observed that 84% of childbirths from high-risk pregnant women were in the health macroregion II. However, when analyzing the childbirths from women with usual and high obstetric risk occurring outside their region of residence, it is found that 66.4% of deliveries from pregnant women with usual risk occurred in municipalities up to 30 km away, and 17.1% occurred in municipalities more than 120 km away. Regarding childbirths from high-risk pregnant women, 49.1% of the women needed to travel more than 120 km, taking more than two hours of travel to have their childbirth or obstetric emergency attended. These results show that many women had to travel to very distant municipalities to get assistance, even though they were high-risk pregnant women .The IV health region managed to perform 75.2% of childbirths from pregnant women at usual risk within its territory, while the V region performed 87.8% of these childbirths. When considering the two largest municipalities in macroregion II, it was found that Caruaru and Garanhuns performed 97% and 97.3% of these childbirths in their territory, respectively. However, for smaller municipalities, almost half of the women had their children outside their municipality of residence.When analyzed only the childbirths from high-risk pregnant women, the reference maternity hospital of macroregion II performed only 46.9% of deliveries of women residing in this macroregion. Therefore, the other high-risk childbirths were performed in macroregion I, especially in the cities of Recife (89.1%) and Vit\u00f3ria de Santo Ant\u00e3o (10.7%). Of the childbirths from high-risk pregnant women living in the IV region , 51.7% wOnly 26.9% of deliveries from high-risk pregnant women residing in the V region were performed in macroregion II and the remainder was referred to macroregion I, mainly to the cities of Recife and Vit\u00f3ria de Santo Ant\u00e3o . It is nRegarding obstetric care to high-risk pregnant women, in 2018 the reference maternity hospital of health macroregion II had 30.4% of day shifts and 38.9% of night shifts closed for admission of pregnant women , and the15 in a national survey, showing that a quarter of pregnant women in the Northeast region were considered high-risk, especially those belonging to the age extremes (under 15 years and women of 35 years or older), with three or more previous pregnancies and those with negative outcomes in previous pregnancies.Determining the risk of a pregnancy is important to develop actions that may reduce maternal and infant morbidity and mortality. In this study, 22.3% of the pregnancies reviewed were considered of high-risk. These findings are close to those found by Viellas et al.The V health region showed lower proportions of high-risk pregnant women. This is possibly due to the inadequate classification of childbirths as to risk, since in this region there is no maternity hospital to serve the high obstetric risk. The reference maternity hospital for this region is located in the IV health region. This fact leads to a false impression that among women residing in the 5th region there is a lower proportion of pregnant women with high obstetric risk when, in fact, what happens is that in the absence of an appropriate high-risk obstetric service, many women have this type of delivery in reference maternity hospitals for usual risk.8.The organization of health regions and macroregions are important instances to guarantee access to healthcare services; however, their conformation does not guarantee that access to these services is facilitated. Although the efforts made to organize services on a macro scale are acknowledged, the difficulty in accessing more complex services still remains. Moreover, there are difficulties in organizing local systemsRede Cegonha advocates the guarantee by the municipalities of access to care for pregnant women and, if necessary, referral to services of different technological densities2. High percentages of pregnant women traveling in search of a place to give birth demonstrate barriers to access. However, researchers have observed in a nationwide study that only 58.7% of pregnant women interviewed received guidance on the link to the maternity unit of reference for childbirth16.From the perspective of obstetric care, the Rede Cegonha in health macroregions to avoid unnecessary displacement and, consequently, improve access is the implementation of Normal Delivery Centers . The CPN aim to contribute to the redefinition of the childbirth care model, rescuing the right to privacy and dignity of women by giving birth in a place close to their family environment, with appropriate technological resources in case of need17.One of the alternatives for structuring the 13, when they observed differences in the supply of childbirth care services among regions and states in Brazil.Regarding high-risk pregnant women, many had to travel a long way, more than two hours, to deliver in macroregion I, showing barriers of access to more complex services. This fact has already been pointed out by Almeida et al.12, reflecting the disorder of the obstetric care network.In Pernambuco there is a concentration of high risk obstetric care services in macroregion I, mainly in the state capital. In macroregions II and IV there are two high-risk maternity hospitals. However, in macroregion II there is no obstetric Intensive Care Unit (ICU), although there is a neonatal Intermediate Care Unit (IMCU). This scenario reveals the non-incorporation of the concept of access, notably the dimension \u201cavailability and accommodation\u201d18. In Pernambuco, there are only two obstetric ICUs, one located in the capital and the other in the sert\u00e3o region of the state. The late access to services contributes to the worsening of many situations when obstetric complications occur.This inadequacy has also been documented in research conducted in all regions of Brazil6. On the other hand, Silva et al.19 found that most users assisted in the healthcare network of Recife lived outside the capital. This finding shows the breakdown of the obstetric care network in Pernambuco, leading to the pilgrimage of women in search of a suitable place for delivery, a fact also observed in another study20.The excessive occupation of obstetric beds in macroregion I, due to its concentration of high-risk care services, has as a consequence the displacement of women residing in other municipalities15, as well as in research conducted in S\u00e3o Luiz and Ribeir\u00e3o Preto21.Pilgrimage for childbirth has also been documented in other nationwide studies, where the Northeast presented the worst results (25.1%)Although the existence of a regionalized network presumes displacement between care sites, these referrals should happen in a coordinated manner, through organized flows and well-defined protocols, avoiding pilgrimage and, consequently, expanding the access of women to healthcare services. However, the findings of the current survey revealed the persistence of difficulties in the provision of care to high obstetric risk, especially when one observes a high proportion of closed shifts, mainly due to insufficient professionals. This fact may discredit the service, causing women to seek care in other health units.22 in 2012. The author verified that, although there were enough obstetric beds, there was a deficit of approximately 40% of obstetricians and more than 50% of anesthesiologists. Several authors have pointed out that the \u201cabsence of a doctor on duty\u201d was the main difficulty for women to access care for childbirth in the first health unit searched23.In macroregion II, the shortage of professionals, especially physicians, is a recurring problem. This problem has already been observed by Ara\u00fajoRegi\u00e3o e Redes (Region and Networks), conducted in the five Brazilian regions, pointed out the insufficient physical capacity and unavailability of human resources, besides the large gaps in healthcare still found throughout the Brazilian territory, as important points that contribute to hinder the regionalization policy in the country, resulting in disengagement of services23.The study 24. The difficulty of access to healthcare services beyond the reach of women in an adequate and timely way is considered a violation of human rights.In this survey, we observed barriers to the access of pregnant women, especially for those with obstetric high-risk deliveries. It is a worrisome fact in the perspective of worsening problems for the access to the obstetric care network, due to the Covid-19 pandemicThe study design presented some limitations. Using the centroid rather than the woman\u2019s address to calculate the distance is a considerable limitation, because the distance to the service in the same municipality may be greater than to reach the service in a neighboring municipality, even from another health macroregion.Another limitation is that the analysis of access failed in including aspects such as cost and means of transportation used for displacement, and it was not possible to identify the reasons for long trips in search of hospital care for childbirth. This shows that the option to work with one of the five dimensions of access (availability and accommodation) brought limitations to the analysis, since these dimensions are interrelated.Thus, it is suggested that future studies should bring to the analysis the experience of women who are seeking healthcare services, the aspects of individuals, services and the context in which they are inserted. However, it is indisputable how the availability and accommodation dimension disclosed that many women from the interior of Pernambuco travel long distances in search of obstetric care.25. Although Brazil is considered to have improved the access of users to good practices and appropriate technologies for childbirth, especially in the Northeast region, with influence of the Stork Network in this process, as shown by Leal et al.26, the findings of this research reveal that problems related to the dimension of access regarding availability and accommodation still persist, as evidenced in the macroregion II of Pernambuco. Thus, it is considered that the obstetric healthcare network in the state is not structured to ensure equitable access to birth care, which highlights the need for its restructuring and approximation with the recommendations of the Rede Cegonha.This is not only a local reality, being widely evidenced in other regions of Brazil 1.Nas tr\u00eas \u00faltimas d\u00e9cadas, o Brasil vem apresentando avan\u00e7os na aten\u00e7\u00e3o \u00e0 sa\u00fade das mulheres, em decorr\u00eancia de esfor\u00e7os e iniciativas do governo e da sociedade, em especial do movimento organizado de mulheres. No entanto, ainda persistem elevados n\u00edveis de morbimortalidade materna, fetal e neonatal evit\u00e1veis2.Essa persistente situa\u00e7\u00e3o justificou a implanta\u00e7\u00e3o de v\u00e1rios programas, pol\u00edticas e estrat\u00e9gias de sa\u00fade, entre elas a Rede Cegonha (RC), lan\u00e7ada em 2011, como estrat\u00e9gia para organiza\u00e7\u00e3o da assist\u00eancia materna e infantil, com o objetivo de mudan\u00e7a do modelo de aten\u00e7\u00e3o ao parto e nascimento e de redu\u00e7\u00e3o da morbimortalidade materna e neonatal3, firmando-se compromissos de altera\u00e7\u00e3o das pr\u00e1ticas de aten\u00e7\u00e3o ao parto e nascimento5. Essa organiza\u00e7\u00e3o da rede \u00e9 importante para assegurar o acesso das mulheres aos servi\u00e7os de sa\u00fade, em especial aos de aten\u00e7\u00e3o ao parto, evitando a ocorr\u00eancia de fluxos desordenados de gestantes, que podem levar \u00e0 peregrina\u00e7\u00e3o das mulheres em busca de atendimento para o parto6. Um aspecto importante para superar as dificuldades de acesso \u00e9 a organiza\u00e7\u00e3o dessa rede para que ven\u00e7a a persist\u00eancia de grandes diversidades na distribui\u00e7\u00e3o e na qualidade dos servi\u00e7os ofertados, entre regi\u00f5es e macrorregi\u00f5es de sa\u00fade7.Essa mudan\u00e7a de modelo da aten\u00e7\u00e3o obst\u00e9trica e neonatal foi discutida por gestores nas diversas regi\u00f5es de sa\u00fade do pa\u00eds, inclusive com a ades\u00e3o da macrorregi\u00e3o de sa\u00fade II de Pernambuco8 quando dizem que o acesso aos servi\u00e7os de sa\u00fade, sobretudo os de maior complexidade, aos servi\u00e7os especializados e a hospitais com mais recursos tecnol\u00f3gicos, \u00e9 dif\u00edcil, exigindo que os usu\u00e1rios percorram grandes dist\u00e2ncias para conseguirem o atendimento necess\u00e1rio.No entanto, sabe-se que apesar dos diversos esfor\u00e7os para prover a\u00e7\u00f5es e servi\u00e7os nas regi\u00f5es de sa\u00fade, concorda-se com Shimizu et al.10, variando entre autores e mudando ao longo do tempo11. Para efeito do presente artigo, adotou-se o conceito de acesso sistematizado por Levesque et al.12, em que \u00e9 definido como a oportunidade de alcan\u00e7ar e obter servi\u00e7os de sa\u00fade adequados em situa\u00e7\u00f5es de necessidade percebida de cuidados, sendo resultado da interface entre as caracter\u00edsticas de pessoas, fam\u00edlias, ambientes sociais e f\u00edsicos e as caracter\u00edsticas dos sistemas, organiza\u00e7\u00f5es e prestadores de sa\u00fade.Nesse sentido, entende-se que o acesso aos servi\u00e7os de sa\u00fade \u00e9 um componente importante em todos os sistemas de sa\u00fade. Entretanto, n\u00e3o h\u00e1 consenso na literatura sobre o seu conceito12.Em seu modelo te\u00f3rico os autores formularam cinco dimens\u00f5es que envolvem o conceito de acesso  e cinco respectivas capacidades individuais dos usu\u00e1rios . Neste artigo optou-se por trabalhar com a dimens\u00e3o \u201cdisponibilidade e acomoda\u00e7\u00e3o\u201d, que abarca a exist\u00eancia f\u00edsica e o potencial de produ\u00e7\u00e3o do servi\u00e7o e envolve os aspectos estruturais, as instala\u00e7\u00f5es, a distribui\u00e7\u00e3o, os recursos humanos, os contextos e a geografia urbana. Configura-se no fato de alcan\u00e7ar um servi\u00e7o de sa\u00fade e em tempo oportunoNessa dire\u00e7\u00e3o, considerou-se importante analisar o acesso de mulheres atendidas na rede p\u00fablica aos servi\u00e7os de aten\u00e7\u00e3o ao parto na macrorregi\u00e3o de sa\u00fade II de Pernambuco, destacando-se as barreiras relacionadas \u00e0 dimens\u00e3o \u201cdisponibilidade e acomoda\u00e7\u00e3o\u201d.Foi realizado um estudo ecol\u00f3gico de base populacional a partir dos registros de partos hospitalares do Sistema de Informa\u00e7\u00e3o Hospitalar (SIH) e de informa\u00e7\u00f5es da Central de Regula\u00e7\u00e3o de Leitos do Estado de Pernambuco sobre mulheres residentes na macrorregi\u00e3o de sa\u00fade II do estado, no per\u00edodo entre primeiro de janeiro e 31 de dezembro de 2018.3. A macrorregi\u00e3o de sa\u00fade II est\u00e1 localizada no Agreste do Estado de Pernambuco e \u00e9 composta pelas regi\u00f5es de sa\u00fade IV e V. A IV regi\u00e3o de sa\u00fade possui sede administrativa em Caruaru e compreende 32 munic\u00edpios, com uma popula\u00e7\u00e3o de 1.324.382 habitantes3 (415.471 mulheres em idade f\u00e9rtil) e disp\u00f5e de uma maternidade que \u00e9 a refer\u00eancia da macrorregi\u00e3o II para gestantes de alto risco, mas sem UTI para essas gestantes. A V regi\u00e3o de sa\u00fade, com sede administrativa no munic\u00edpio de Garanhuns, \u00e9 composta por 21 munic\u00edpios e 534.793 habitantes3 (163.667 mulheres em idade f\u00e9rtil) e possui uma maternidade regional para atendimento de gestantes de risco habitual.Em Pernambuco, a organiza\u00e7\u00e3o da rede est\u00e1 normatizada no Plano Diretor de Regionaliza\u00e7\u00e3o (PDR), com a redefini\u00e7\u00e3o da organiza\u00e7\u00e3o territorial do estado em 12 regi\u00f5es de sa\u00fade agrupadas em quatro macrorregi\u00f5es de sa\u00fade, com o objetivo de subsidiar a organiza\u00e7\u00e3o da rede de sa\u00fade de forma regionalizada, hier\u00e1rquica e resolutiva12, foram utilizados os deslocamentos das mulheres por meio das vari\u00e1veis: dist\u00e2ncia percorrida pelas mulheres em busca de assist\u00eancia ao parto de risco habitual e de alto risco obst\u00e9trico e o tempo de deslocamento entre o munic\u00edpio de resid\u00eancia e o de ocorr\u00eancia. Tamb\u00e9m foram analisadas vari\u00e1veis relacionadas ao servi\u00e7o de atendimento a partos de alto risco obst\u00e9trico, refer\u00eancia para as mulheres da macrorregi\u00e3o II, para isso foram utilizadas as seguintes vari\u00e1veis: propor\u00e7\u00e3o de dias de plant\u00f5es diurnos e noturnos fechados para admiss\u00e3o de gestantes no momento do parto e o motivo do fechamento dos plant\u00f5es, a partir de informa\u00e7\u00f5es da Central de Regula\u00e7\u00e3o de Leitos de Pernambuco, que funciona com o apoio de um call center, que recebe liga\u00e7\u00f5es de todas as unidades de sa\u00fade do Estado que lidam com casos de urg\u00eancia/emerg\u00eancia, UTI e obstetr\u00edcia. A central consolida as informa\u00e7\u00f5es sobre as demandas e os atendimentos realizados.Para analisar o acesso por meio da dimens\u00e3o \u201cdisponibilidade e acomoda\u00e7\u00e3o\u201d, proposta por Levesque et al.13.As dist\u00e2ncias intermunicipais foram geoprocessadas a partir de c\u00e1lculos das dist\u00e2ncias entre os centroides dos munic\u00edpios de resid\u00eancia e ocorr\u00eancia. No c\u00e1lculo do deslocamento geogr\u00e1fico, n\u00e3o foram considerados os deslocamentos intramunicipais; portanto, se o parto ocorreu no pr\u00f3prio munic\u00edpio de resid\u00eancia, a dist\u00e2ncia foi igual a zero, segundo metodologia proposta por Almeida et alAs dist\u00e2ncias geogr\u00e1ficas e o tempo de deslocamento foram calculados estimados e agrupados em cinco categorias , incluindo todos os munic\u00edpios da macrorregi\u00e3o II, levando em considera\u00e7\u00e3o as gestantes na ocasi\u00e3o por partos de risco habitual e de alto risco, de acordo as defini\u00e7\u00f5es do Minist\u00e9rio da Sa\u00fade, incorporadas pelo SIH. O banco do SIH e as informa\u00e7\u00f5es sobre o funcionamento dos plant\u00f5es foram cedidos pela Secretaria Estadual de Sa\u00fade de Pernambuco.Para a an\u00e1lise dos deslocamentos das gestantes foram constru\u00eddos mapas de fluxo por meio do programa ArcGIS 10.4, diferenciados para gestantes com partos de risco habitual e para gestantes com partos de alto risco, tendo como unidade de an\u00e1lise as regi\u00f5es de sa\u00fade e a macrorregi\u00e3o de sa\u00fade.14.Os mapas de fluxo representam o deslocamento das mulheres no espa\u00e7o, demonstrando o movimento por meio de vetores tra\u00e7ados para representar o itiner\u00e1rio percorrido pelas gestantes, caracterizados por meio de espessuras proporcionais ao n\u00famero de partos. Os fluxos foram categorizados para as gestantes de partos de risco habitual: IV regi\u00e3o de sa\u00fade  e para a V regi\u00e3o de sa\u00fade . J\u00e1 para os partos de gestantes de alto risco, os fluxos foram definidos da mesma forma para as duas regi\u00f5es de sa\u00fade: 1\u201310 partos; 11\u201350 partos; 51\u2013100 partos; e \u2265 101 partos. Nesse sentido, o fluxo dominante foi definido como o maior fluxo (a partir de 10 partos) de cada munic\u00edpio, o que permitiu identificar o arcabou\u00e7o da rede de liga\u00e7\u00f5es14, ajudando a identificar a organiza\u00e7\u00e3o dos servi\u00e7os em rede regionalizada. Do mesmo modo, a organiza\u00e7\u00e3o do servi\u00e7o de aten\u00e7\u00e3o ao parto de alto risco obst\u00e9trico tamb\u00e9m se configura um importante componente de \u201cdisponibilidade e acomoda\u00e7\u00e3o\u201d para observar em que medida o servi\u00e7o est\u00e1 estruturado na macrorregi\u00e3o de sa\u00fade para diminuir barreiras de acesso.O estudo dos fluxos \u00e9 componente fundamental para observa\u00e7\u00e3o de quest\u00f5es ligadas ao acesso, identificando as dist\u00e2ncias percorridasA pesquisa foi aprovada pelo Comit\u00ea de \u00c9tica em Pesquisa do Centro de Pesquisas Aggeu Magalh\u00e3es/Fiocruz, conforme Resolu\u00e7\u00e3o 510/16, sob CAAE n. 63796717.4.0000.5190.Em 2018, 77,7% dos partos ocorridos na macrorregi\u00e3o de sa\u00fade II foram classificados como de risco habitual e 22,3% de alto risco. Ao considerar as regi\u00f5es de sa\u00fade, verificou-se que 26,4% dos partos de gestantes de alto risco foram de residentes na IV regi\u00e3o de sa\u00fade, enquanto na V regi\u00e3o esse valor foi de 13,5% .No que se refere ao local de realiza\u00e7\u00e3o dos partos, observou-se que 84% dos partos de gestantes de risco habitual foram realizados na pr\u00f3pria macrorregi\u00e3o de sa\u00fade II. Todavia, ao serem analisados os partos de risco habitual e de alto risco obst\u00e9trico ocorridos fora da regi\u00e3o de resid\u00eancia, observou-se que 66,4% dos partos de gestantes de risco habitual ocorrem em munic\u00edpios com dist\u00e2ncia de at\u00e9 30 km e, 17,1% ocorrem em munic\u00edpios com mais 120 km. Com rela\u00e7\u00e3o aos partos de gestantes de alto risco, 49,1% das mulheres necessitaram se deslocar mais de 120 km, demorando mais de duas horas de viagem para ter o parto ou emerg\u00eancia obst\u00e9trica atendida. Esses resultados demonstram que muitas mulheres tiveram que se deslocar para munic\u00edpios muito distantes para conseguir assist\u00eancia, mesmo sendo gestantes de risco habitual .Na A IV regi\u00e3o de sa\u00fade conseguiu realizar 75,2% dos partos de gestantes de risco habitual dentro do seu territ\u00f3rio, enquanto a V regi\u00e3o realizou 87,8% desses partos. Ao considerar os dois maiores munic\u00edpios da macrorregi\u00e3o II, verificou-se que Caruaru e Garanhuns realizaram 97% e 97,3% desses partos em seu territ\u00f3rio, respectivamente. Entretanto, para os munic\u00edpios menores, quase a metade das mulheres tiveram seus filhos fora do seu munic\u00edpio de resid\u00eancia.Quando analisados apenas os partos de gestantes de alto risco, a maternidade de refer\u00eancia da macrorregi\u00e3o II realizou apenas 46,9% dos partos de mun\u00edcipes residentes nessa macrorregi\u00e3o. Como consequ\u00eancia, os demais partos de gestantes de alto risco foram realizados na macrorregi\u00e3o I, sobretudo nos munic\u00edpios de Recife  e Vit\u00f3ria de Santo Ant\u00e3o . Dos partos de gestantes de alto risco de mulheres residentes na IV regi\u00e3o , 51,7% fDos partos de gestantes de alto risco de residentes na V regi\u00e3o apenas 26,9% foram realizados na macrorregi\u00e3o II e o restante fora encaminhado para macrorregi\u00e3o I, principalmente para os munic\u00edpios de Recife e Vit\u00f3ria de Santo Ant\u00e3o . RessaltCom rela\u00e7\u00e3o a assist\u00eancia obst\u00e9trica de gestantes de alto risco, em 2018, a maternidade de refer\u00eancia da macrorregi\u00e3o de sa\u00fade II, teve 30,4% dos plant\u00f5es diurnos e 38,9% dos noturnos fechados para admiss\u00e3o de gestantes  e o prin15, em inqu\u00e9rito de base nacional, evidenciando que um quarto das gestantes da regi\u00e3o Nordeste eram considerados alto de risco, principalmente aquelas pertencentes aos extremos et\u00e1rios (menores de 15 anos e mulheres com 35 anos ou mais de idade), com tr\u00eas ou mais gesta\u00e7\u00f5es anteriores e aquelas com desfechos negativos em gesta\u00e7\u00f5es anteriores.A determina\u00e7\u00e3o do risco de uma gesta\u00e7\u00e3o \u00e9 importante para se desenvolver a\u00e7\u00f5es que possam reduzir a morbimortalidade materna e infantil. Neste estudo, foram consideradas de alto risco 22,3% das gesta\u00e7\u00f5es analisadas. Esses achados s\u00e3o pr\u00f3ximos daqueles encontrados por Viellas et al.A V regi\u00e3o de sa\u00fade apresentou menores propor\u00e7\u00f5es de gestantes de alto risco, o que possivelmente se deve \u00e0 classifica\u00e7\u00e3o inadequada dos partos quanto ao risco, j\u00e1 que nessa regi\u00e3o n\u00e3o existe maternidade para atender ao alto risco obst\u00e9trico. A maternidade de refer\u00eancia para essa regi\u00e3o est\u00e1 localizada na IV regi\u00e3o de sa\u00fade. Esse fato leva a uma falsa impress\u00e3o de que entre as mulheres residentes na V regi\u00e3o h\u00e1 menor propor\u00e7\u00e3o de gestantes de alto risco obst\u00e9trico, quando, na verdade, o que ocorre \u00e9 que, na aus\u00eancia de um servi\u00e7o obst\u00e9trico de alto risco adequado, muitas mulheres realizam esse tipo de parto em maternidades de refer\u00eancia para risco habitual.8.A organiza\u00e7\u00e3o das regi\u00f5es de sa\u00fade e macrorregi\u00f5es s\u00e3o inst\u00e2ncias importantes para garantia de acesso aos servi\u00e7os de sa\u00fade, entretanto sua conforma\u00e7\u00e3o n\u00e3o garante que o acesso a esses servi\u00e7os seja facilitado. Embora se reconhe\u00e7a os esfor\u00e7os realizados para organiza\u00e7\u00e3o dos servi\u00e7os em escala macro, ainda permanece a dificuldade de acesso aos servi\u00e7os de maior complexidade. Ademais, h\u00e1 dificuldades na organiza\u00e7\u00e3o dos sistemas locais2. Altos percentuais de deslocamentos das gestantes em busca de um local para o parto demonstram barreiras de acesso. Um importante componente da rede para supera\u00e7\u00e3o das barreiras de acesso \u00e9 a vincula\u00e7\u00e3o da gestante ao local do parto, entretanto, pesquisadores j\u00e1 observaram, em estudo de abrang\u00eancia nacional, que somente 58,7% das gestantes entrevistadas receberam orienta\u00e7\u00e3o sobre \u00e0 vincula\u00e7\u00e3o \u00e0 maternidade de refer\u00eancia para o parto16.Na perspectiva da aten\u00e7\u00e3o obst\u00e9trica, a Rede Cegonha preconiza a garantia, por parte dos munic\u00edpios, de acesso ao atendimento das gestantes e, se necess\u00e1rio, o encaminhamento a servi\u00e7os de diferentes densidades tecnol\u00f3gicas17.Uma das alternativas para estrutura\u00e7\u00e3o da Rede Cegonha nas macrorregi\u00f5es de sa\u00fade para evitar deslocamentos desnecess\u00e1rios e, consequentemente, melhorar o acesso \u00e9 a implanta\u00e7\u00e3o dos Centros de Parto Normal (CPN), que t\u00eam como objetivo contribuir para a redefini\u00e7\u00e3o do modelo assistencial ao parto, resgatando o direito \u00e0 privacidade e \u00e0 dignidade da mulher ao dar \u00e0 luz num local pr\u00f3ximo ao seu ambiente familiar, com recursos tecnol\u00f3gicos apropriados em casos de eventual necessidade13, quando observou diferen\u00e7as na oferta dos servi\u00e7os de aten\u00e7\u00e3o ao parto entre as regi\u00f5es e estados do Brasil.Com rela\u00e7\u00e3o \u00e0s gestantes de alto risco, muitas mulheres tiveram que realizar grandes deslocamentos, com mais de duas horas de viagem para realiza\u00e7\u00e3o do parto na macrorregi\u00e3o I, evidenciando barreiras de acesso para servi\u00e7os de maior complexidade. Esse fato j\u00e1 foi apontado por Almeida et al.12, refletindo na desorganiza\u00e7\u00e3o da rede de assist\u00eancia obst\u00e9trica.Em Pernambuco h\u00e1 uma concentra\u00e7\u00e3o de servi\u00e7os de aten\u00e7\u00e3o ao alto risco obst\u00e9trico na macrorregi\u00e3o I, principalmente na capital do estado. Nas Macrorregi\u00f5es II e IV existem duas maternidades de alto risco. Por\u00e9m, na macrorregi\u00e3o II n\u00e3o existe Unidade de Terapia Intensiva (UTI) obst\u00e9trica, embora tenha Unidade de Cuidados Intermedi\u00e1rios (UCI) neonatal. Esse cen\u00e1rio revela a n\u00e3o incorpora\u00e7\u00e3o do conceito de acesso, em especial da dimens\u00e3o \u201cdisponibilidade e acomoda\u00e7\u00e3o\u201d18. Em Pernambuco s\u00f3 existem duas UTIs obst\u00e9tricas, uma situada na capital e outra no sert\u00e3o do estado. A demora no acesso ao servi\u00e7o contribui para o agravamento de muitas situa\u00e7\u00f5es quando da ocorr\u00eancia de complica\u00e7\u00f5es obst\u00e9tricas.Essa inadequa\u00e7\u00e3o tamb\u00e9m tem sido documentada em pesquisa realizada em todas as regi\u00f5es do Brasil6. Por outro lado, Silva et al.19 identificaram que a maioria das usu\u00e1rias atendidas na rede de sa\u00fade do Recife residiam fora da capital, evidenciando a desestrutura\u00e7\u00e3o da rede de aten\u00e7\u00e3o obst\u00e9trica em Pernambuco, levando \u00e0 peregrina\u00e7\u00e3o das mulheres em busca de um local adequado para o parto, fato tamb\u00e9m j\u00e1 observado em outro estudo20.A excessiva ocupa\u00e7\u00e3o de leitos obst\u00e9tricos na macrorregi\u00e3o I, em raz\u00e3o de sua concentra\u00e7\u00e3o de servi\u00e7os de aten\u00e7\u00e3o ao alto risco, tem como consequ\u00eancia o deslocamento das mulheres residentes para outros munic\u00edpios15, bem como em pesquisa realizada em S\u00e3o Luiz e Ribeir\u00e3o Preto21.A peregrina\u00e7\u00e3o por ocasi\u00e3o do parto tamb\u00e9m foi documentada em outros estudos de abrang\u00eancia nacional, onde o Nordeste apresentou os piores resultados Embora a exist\u00eancia de rede regionalizada pressuponha deslocamentos entre os pontos de aten\u00e7\u00e3o, essas transfer\u00eancias devem acontecer de forma coordenada, mediante fluxos organizados e por meio de protocolos bem definidos, evitando a peregrina\u00e7\u00e3o e, consequentemente, ampliando o acesso das mulheres aos servi\u00e7os de sa\u00fade. Todavia, os achados da presente pesquisa revelaram a persist\u00eancia de dificuldades na oferta de aten\u00e7\u00e3o ao alto risco obst\u00e9trico, sobretudo quando se observa uma elevada propor\u00e7\u00e3o de plant\u00f5es fechados, principalmente em raz\u00e3o da insufici\u00eancia de profissionais. Esse fato pode desacreditar o servi\u00e7o, fazendo com que as mulheres busquem atendimento em outras unidades de sa\u00fade.22, em 2012, que verificou, embora existissem leitos obst\u00e9tricos em n\u00famero suficiente, que havia um d\u00e9ficit de aproximadamente 40% de obstetras e de mais de 50% de anestesistas. Diversos autores t\u00eam apontado que a \u201caus\u00eancia de m\u00e9dico plantonista\u201d foi a principal dificuldade de acesso das mulheres em conseguir atendimento para realiza\u00e7\u00e3o do parto na primeira unidade de sa\u00fade procurada23.Na macrorregi\u00e3o II a falta de profissionais, sobretudo m\u00e9dicos, \u00e9 um problema recorrente, j\u00e1 constatado por Ara\u00fajo23.A pesquisa Regi\u00e3o e Redes, realizada nas cinco regi\u00f5es brasileiras, apontou a insuficiente capacidade f\u00edsica e indisponibilidade de recursos humanos, al\u00e9m dos grandes vazios assistenciais ainda presentes em todo territ\u00f3rio brasileiro, como pontos importantes que contribuem para dificultar a pol\u00edtica de regionaliza\u00e7\u00e3o no pa\u00eds, tendo como consequ\u00eancia a desarticula\u00e7\u00e3o dos servi\u00e7os24. A dificuldade de acesso aos servi\u00e7os de sa\u00fade fora do alcance das mulheres em tempo adequado e oportuno \u00e9 considerada uma viola\u00e7\u00e3o dos direitos humanos.Nesta pesquisa, observou-se barreiras de acesso das gestantes, principalmente para aquelas com partos de alto risco obst\u00e9trico, fato preocupante na perspectiva do agravamento dos problemas para o acesso \u00e0 rede de aten\u00e7\u00e3o obst\u00e9trica, em raz\u00e3o da pandemia da covid-19O desenho do estudo apresentou algumas limita\u00e7\u00f5es. Usar o centroide e n\u00e3o o endere\u00e7o da mulher para calcular a dist\u00e2ncia \u00e9 uma limita\u00e7\u00e3o consider\u00e1vel, pois a dist\u00e2ncia para o servi\u00e7o do mesmo munic\u00edpio pode ser maior do que para chegar ao servi\u00e7o de um munic\u00edpio vizinho, inclusive de outra macrorregi\u00e3o de sa\u00fade.Outra limita\u00e7\u00e3o \u00e9 que a an\u00e1lise do acesso n\u00e3o contemplou aspectos como custo e meios de transporte utilizados para os deslocamentos, n\u00e3o sendo poss\u00edvel identificar os motivos da realiza\u00e7\u00e3o de longos percursos em busca de atendimento hospitalar para o parto. Isso revela que a op\u00e7\u00e3o por trabalhar com uma das cinco dimens\u00f5es do acesso (disponibilidade e acomoda\u00e7\u00e3o) trouxe limita\u00e7\u00f5es \u00e0 an\u00e1lise, j\u00e1 que essas dimens\u00f5es s\u00e3o interrelacionadas.Sendo assim, sugere-se que estudos futuros possam trazer para a an\u00e1lise a experi\u00eancia das mulheres que est\u00e3o na busca por servi\u00e7os sa\u00fade, os aspectos dos indiv\u00edduos, dos servi\u00e7os e do contexto em que est\u00e3o inseridos. No entanto, \u00e9 indiscut\u00edvel como, a partir da dimens\u00e3o disponibilidade e acomoda\u00e7\u00e3o, foi poss\u00edvel observar que muitas mulheres do interior de Pernambuco percorrem longas dist\u00e2ncias em busca de assist\u00eancia obst\u00e9trica.25. Ademais, embora considere-se que no Brasil tenha tido uma melhoria no acesso de usu\u00e1rias \u00e0s boas pr\u00e1ticas e \u00e0s tecnologias apropriadas ao parto, sobretudo na regi\u00e3o Nordeste, com influ\u00eancia da Rede Cegonha nesse processo, conforme demonstram Leal et al.26, os achados da presente pesquisa revelam que ainda persistem problemas relacionados \u00e0 dimens\u00e3o de acesso no que se refere a disponibilidade e acomoda\u00e7\u00e3o como evidenciado na Macrorregional II de Pernambuco. Assim, considera-se que a rede de aten\u00e7\u00e3o obst\u00e9trica no estado n\u00e3o est\u00e1 estruturada para garantir um acesso equ\u00e2nime \u00e0 assist\u00eancia ao parto, o que evidencia a necessidade de sua reestrutura\u00e7\u00e3o e aproxima\u00e7\u00e3o com o preconizado pela Rede Cegonha.Essa n\u00e3o \u00e9 apenas uma realidade local, sendo amplamente evidenciada em outras regi\u00f5es do Brasil"}
+{"text": "Use of endolaser for chronic venous disease involves choosing the laser wavelength and optical fiber to use and the quantity of energy to be administered. Efficacy is assessed by the venous occlusion rate and safety is evaluated in terms of side effects.To determine the incidence of total post-endolaser saphenous vein occlusion at 1-year follow-up. To describe side effects and their incidence and rates of reintervention or supplementary treatment during the postoperative period.A retrospective, observational cohort study with a quantitative approach, enrolling patients with saphenous vein incompetence treated with intravenous 1,470 nm laser ablation. Data were input to an MS Excel 2019 spreadsheet, calculating means and standard deviations with the software\u2019s Power Query supplement.38 patients and 104 venous segments were eligible for the study. 100% were occluded at 30 days and 99.04% were still occluded at 1 year after the procedure. Mean Linear Endovenous Energy Density administered to the internal saphenous vein was 2,040.52 W/cm/s with standard deviation of \u00b1 1,510.06 W/cm/s and 1,168.4 W/cm/s with standard deviation of \u00b1 665.011 W/cm/s was administered to the external saphenous vein. Pain along the saphenous path was the most common side effect, with eight cases (21.05%), followed by one case of paresthesia (2.63%).The total occlusion rate at 1-year follow-up suggests the technique is promising and is currently applicable in this sample. The incidence of pain and paresthesia may be caused by the high mean energy delivered in some cases. It is recommended that multicenter studies be conducted with larger and more uniform samples in terms of their Clinical-Etiological-Anatomical-Pathological classifications. It is known that the clinical expression of chronic venous disease (CVD) has a wide spectrum of manifestations, varying from asymptomatic cases, with esthetic problems including telangiectasies or reticular veins, to severe symptomology, such as dermatofibrosis and ulcerations.There are few good quality longitudinal studies to confirm the incidence and prevalence of CVD in the general population and there are discrepancies between those that do exist in terms of their methodology and consequent results.The largest epidemiological study in the Brazilian population is still a 1986 publication by Maffei et al. that assessed 1,755 patients at routine appointments at a University health center in Botucatu (SP), which reported a 47.6% prevalence of all types of varicose veins, with the highest rate among women who were not pregnant, at 50.9%. Cases considered moderate or severe were detected in 21.2%, even though only 5.5% of the patients had visited the health center for consultations related to varicose veins or CVD.In general, treatment for CVD will be recommended if the patient has relevant symptoms, clinical signs of chronic venous disease, and reflux in venous segments, primarily in the great and/or small saphenous veins.Use of lasers for endoluminal treatment emerged after a publication by Bon\u00e9 (apud Hamdan).One metric for analysis of therapeutic success of EVLA is the occlusion rate, which is one of the principal markers, primarily when analyzed with follow-up over time, while others include the number of side effects and the need for reoperation.Taking into account the still scant number of publications specifically about EVLA using different operating techniques and considering that it is a relatively new and evolving method, especially in the Brazilian context, this research output article will present the clinical results achieved with the methodology, contributing to the attempt to perfect the treatment, achieving the greatest efficacy and least invasivity.The primary objective of this study was to demonstrate the incidence of total venous occlusion using 1,470 nm endolaser to treat venous segments, as confirmed with Doppler ultrasonography, at 30 days and 1 year postoperative. An additional objective was to describe the side effects and their incidence during the postoperative period and report rates of reintervention or supplementary treatment.This is a retrospective, observational cohort study with a quantitative approach, enrolling patients with lower limb CVD treated with EVLA at a vascular surgery service. All data were collected and analyzed retrospectively from preoperative patient records and post-laser ablation charts. The project was approved by the Ethics Committee at the Unicesumar institution, under CAAE number 15333619.9.00005539 and consolidated opinion number 4.736.805.The present study applied the following patient eligibility criteria: having undergone EVLA of the great and small saphenous veins to treat CVD; conducted between March 2018 to October 2019; having a Clinical-Etiological-Anatomical-Pathological (CEAP) class of C2 to C5; having had Doppler ultrasonography 1 year after the procedure; and having signed a free and informed consent form (FICF).At the clinic in question, all patients are prescribed laser thermoablation as treatment of choice and vein stripping is only indicated if the patient refuses EVLA or has a venous aneurysm. In cases in which venous dilatation was up to 12 mm from the saphenofemoral junction, treatment included ligature of the SFJ.In a hospital surgery setting, all patients were given spinal anesthesia before undergoing EVLA with a diode endolaser at a wavelength of 1,470 nm with a 600 micra radial fiber. The procedure was started with insertion of the optical fiber from the distal point of venous insufficiency up to 0.5 cm distal of the SFJ or SPJ, under Doppler ultrasound guidance. Perivascular tumescence of the venous segment to be treated was obtained with chilled saline and, with the patient in the Trendelemburg position, irradiation with the intravenous laser was started at a cranial-caudal traction velocity of 1 mm per second. At the end of the procedure, the Linear Endovenous Energy Density (LEED) was calculated in watts per centimeter per second.At the end of the procedure, analgesia with nonsteroidal anti-inflammatories was prescribed for 5 days and 20 to 35 mmHg elastic compression stockings for 48 hours. Patients were also encouraged to start walking immediately after hospital discharge, which was on the same day as the procedure, about 3 to 4 hours after it had been completed.The clinical features extracted for analysis from preoperative medical records were age, sex, venous segment involved, extent of venous insufficiency, and diameter of the saphenous vein. The variables extracted from the surgical chart were power, in watts, and LEED (W/cm/s). Postoperative data obtained from the 30-day and 1-year follow-ups were: occlusion rate according to Doppler ultrasound, need for reintervention or supplementary treatment, and side effects such as skin hyperpigmentation, burning sensations, pain along the course of the vein, and paresthesia, which were analyzed as presence or absence, with no scales or grading instruments, plus deep venous thrombosis and pulmonary embolism, assessed according to echography findings combined with patients\u2019 clinical characteristics during the postoperative period.For the purposes of this study, the occlusion rate is defined as the percentage of lumen obliterated by EVLA after the procedure, considering 100% as being when there is no recanalization whatsoever at any point along the path of the vein. As such, recanalization is defined as any percentage of obliteration that has been reversed.After arranging the data in an MS Excel 2019 spreadsheet, all calculations of means and standard deviations were performed using the program\u2019s Power Query supplement.The sample size calculation with 95% confidence interval employed the 98.1% occlusion rate described by Silva et al.For the study in question, the sample size would be approximately 80 patients who underwent the procedure on venous segments with an estimated confidence interval from 95.1% to 100% for the 1-year occlusion rate.Missing data were removed from the analysis so they would not be presented in the text or tables. No information with any relation to author bias was used.From March 2018 to October 2019, the Clinivasc vascular surgery service diagnosed 658 patients with CVD caused by saphenous vein involvement, 112 of whom had indications for surgical treatment. Forty patients were eligible for the analysis according to the predefined inclusion criteria and 72 were excluded because they did not have treatment, were treated with a different method from EVLA, had conservative treatment, or did not meet the inclusion criteria.A total of 38 patients were enrolled, with two excluded because they refused the FICF. One of the eligible patients was not followed-up at 1 year. Of the 38 patients enrolled, 76 lower limbs and 104 venous segments were treated, the majority of which were GSVs, with 94 segments, 50 in left limbs and 44 in right limbs, while there were 10 SSV segments, three in left and seven in right limbs. The unit of analysis for occlusion rate and LEED was the venous segment (104). For side effects, the unit was the patient (38).As shown in The highest incidence among the side effects analyzed at 30 days and 1 year was pain along the path of the saphenous vein after occlusion . RegardiThis study suggests that treatment of varicose veins with EVLA has great efficacy, considering the horizon of up to 1 year after treatment, shown by the high rates of occlusion maintained over this period and the low incidence of side effects, their benign character, and their relative facility of resolution.The efficacy of this method consists of emitting thermal energy generated by the laser, causing irreversible damage to the wall of the vessel, primarily by denaturing collagen, which occurs from 70 to 100\u00ba C, compounded by provocation of inflammatory and fibrogenic reactions that lead to permanent occlusion of the incompetent vein.Our data reveal extremely elevated occlusion rates, both at 30-day follow-up (100%) and at 1 year (99.04%), with just a single venous segment exhibiting partial recanalization (0.96%). These are superior figures to the standards reported by several authors of similar studies.Galanopoulos et al.Although no analysis was conducted of the patients beyond 12 months, other authors believe that in the immense majority of cases, recanalization of venous segments occurs within the first 3 postoperative months, and in cases with occlusion beyond 12 months, the likelihood of future recanalization is lower when a comparison is made.In the present study, specifically with relation to LEED and occlusion rate, the results were not stratified by CEAP, which is a point that could be taken into consideration with the heterogeneous nature of the sample and as a suggestion for future studies. Nevertheless, it is relevant to mention that there is not necessarily any proportionality between the CEAP classification\u2019s clinical item (C) and venous diameter, which is a determinant factor in the LEED calculation and thermal ablation.The laser devices used for thermal ablation are monochromatic, i.e., they each emit a single light wavelength close to infrared, although many different wavelengths can be used . Each wavelength has a dominant tissue chromophore, i.e., the substance or tissue with the highest absorption rate, with hemoglobin predominating at bands up to 1,064 nm and then water primarily from 1,100 nm onwards.The choice of the 1,470 nm wavelength is based on the fact that this value provokes up to 40 times more absorption by the water molecules when compared with hemoglobin at the same wavelength. This factor is of interest in treatment, since using hemoglobin as the target causes a huge thrombotic phenomenon, but also a proportional effect on thrombolytic system activation, which is an important factor predisposing to recanalization and, consequently, therapeutic failure, whereas, with water, molecular excitation is predominantly in the vein wall, which is the treatment\u2019s target site.It should be pointed out that, although the wavelength employed is focused on the water molecules in the vascular endothelium, blood cells are on average 60% water molecules and, as such, also absorb a great quantity of energy, producing coagulation, although at lower proportions than wavelengths that focus directly on hemoglobin.Therefore, in addition to the fact that its dominant chromophore is water, the 1,470 nm diode laser is also preferred because of the smaller quantity of energy needed, since devices with longer wavelengths require lower energy densities and lower power settings to achieve the therapeutic effect.Aktas et al.Radial fibers were launched onto the market in 2008 and are now the most widely used type of fiber, especially for 1,470 nm diode lasers.The standard for describing the energy used in ablative procedures is LEED, measured in joules per centimeter by the great majority of authors. However, based on the physical definitions applied to the laser, LEED originates from the ratio of the power of the laser, measured in watts, multiplied by the velocity of fiber traction, measured in centimeters per second, so the measurement unit of LEED would be expressed as W/cm/s.In this study, laser power was calculated individually for each patient, primarily based on the measurement of the diameter of the insufficient vein, taking into consideration other determinant factors, such as the radial fiber, the velocity of reflux, and the number of tributary veins. The mean fiber traction velocity was 1 mm/s, which is the standard recommendation for segments of up to 10 mm.The Trendelemburg position is used while retracting the fiber because it yields saphenous veins containing a considerably reduced quantity of intravascular blood, since large quantities would allow a high proportion of the energy to be absorbed by blood cells, reducing the energy available for the vein wall, in addition to strongly inducing the coagulation cascade, provoking recanalization.4 preoperative classification and factors that could possibly be considered involved in this outcome include presence of thrombophlebitis prior to treatment, which would provoke histological changes to the thickness of the venous wall because of fibrotic tissues, which could reduce the ablative effects; and the fact that the patient was 75 years old and had already been living with venous vascular disease for a long period of time and, because of this, probably had intimal and medial layers that were significantly thicker and responded less to ablation.The only case of recanalization involved a patient with a CNowadays, many authors consider that the complications and postoperative side effects of EVLA are minimal, particularly when compared with vein stripping.In general, this study observed similar proportions of adverse effects to other publications, with no severe or permanent side effects.With relation to possible reasons for pain and paresthesia, no injuries were observed due to endothelial perforation by the fiber with extravascular administration of energy to adjacent tissues or nerve branches. Two pathophysiologic situations were therefore identified as possibly responsible for the symptoms. The first would be use of elevated LEED combined with a reduced fiber traction velocity which could cause tissue damage to nerve branches close to the saphenous vein because of elevated temperature. A second possibility would be failure of the perivascular tumescence to achieve sufficient distance between the nerve branches and the fiber, allowing transfer of heat and causing injury.It is believed that the cases in which LEED was higher than average were selected cases in which the surgeon\u2019s preoperative and intraoperative clinical analysis revealed a need to administer additional energy to achieve total obliteration of the venous segment, confirmed by the high standard deviation of energy level compared to the mean for the sample.It is believed that, in general, it is possible that use of lower LEEDs combined with the chilled tumescence administered at the time of ablation to form a liquid halo offering thermal protection and increasing the distance to nerve branches would have attenuated patient symptomology.The only case of paresthesia occurred after a procedure involving the left internal saphenous vein and normal sensitivity returned within 6 months. There is an up to 7% risk of nerve damage after laser ablation because of the possibility of thermal insult from the veins.Finally, there was a predominance of female patients in this study, which is a tendency confirmed in other publications.The following should be considered as limitations of this study: it lacks follow-up beyond 1 year; does not report preoperative clinical features or diameter of the saphenous veins because of a lack of data; the sample is heterogeneous in terms of CEAP; it has no control group; the sample is relatively small; the chart template for postoperative consultations used at the service prevented insertion of additional information such as transitory pigmentation or greater detail on other side effects; the postoperative assessments were conducted by the authors; and the research was restricted to a single treatment center.With regard to the small sample size, even though the study has revealed important findings, it should be pointed out that the ideal sample size (80 patients) would have ensured more robust results, providing better evidence on the efficacy and safety of the procedure. Moreover, the postoperative charts do not detail the specific site of adverse effects, only stating that they had occurred after the procedure.In view of the sample described and the statistical analysis conducted, the nine patients with side effects were not considered relevant in terms of questioning the therapeutic viability of the technique, particularly since the prognosis and outcomes of the great majority of the symptoms were benign. It can also be observed that the occlusion rates at 30 days and 1 year, of 100% and 99.04% respectively, were satisfactory and similar to references from the literature mentioned above, permitting the conclusion that, in this context, the technique was promising in the sample analyzed. However, it is not possible to make recommendations based on strong evidence.In the context of endolaser treatment for CVD, this study has made contributions in several areas: the current applicability of EVLA at 1 year post-treatment, as demonstrated and compared with similar authors; the technique employed that made it possible to achieve these results, which includes the choice of a diode laser with a wavelength tuned to water as dominant chromophore, a large diameter radial fiber, the Trendelemburg position during the procedure, and the perivascular tumescence with chilled saline; the epidemiological profile of the patients who sought treatment for CVD; possible factors that determine side effects and their respective outcomes; and description of how EVLA functions, in terms of the physical and histological mechanisms involved.However, promising the results of this study, notwithstanding the limitations described above, it can only be considered as a starting point for further research into treatment of insufficient saphenous veins, primarily multicenter analyses and especially with respect to sample size and homogeneity, correlation with venous diameter, and patients\u2019 CEAP, and making comparisons with other methods of treating the disease.Since this is a retrospective cohort with the limitations that have already been covered in this material, this study can be classified as evidence level 2b.  . \u00c9 necess\u00e1rio mencionar que manifesta\u00e7\u00f5es id\u00eanticas podem ter origens fisiopatol\u00f3gicas distintas, variando entre os diversos mecanismos, como incompet\u00eancia valvar, obstru\u00e7\u00e3o venosa e/ou disfun\u00e7\u00e3o da bomba muscular .Sabe-se que a express\u00e3o cl\u00ednica da doen\u00e7a venosa cr\u00f4nica (DVC) possui largo espectro de manifesta\u00e7\u00f5es, variando de quadros assintom\u00e1ticos, com problemas est\u00e9ticos que apresentam telangiectasias ou veias reticulares, at\u00e9 sintomatologia grave, como dermatofibrose e ulcera\u00e7\u00f5es . No entanto, a DVC \u00e9 considerada uma das doen\u00e7as mais comuns de membros inferiores na popula\u00e7\u00e3o adulta, havendo cada vez mais procura por tratamentos.Atualmente, s\u00e3o poucos os estudos longitudinais de boa qualidade para confirmar n\u00fameros de incid\u00eancia e preval\u00eancia da DVC na popula\u00e7\u00e3o geral, e existem discrep\u00e2ncias quanto \u00e0 metodologia e aos consequentes resultados dos trabalhos .Para a popula\u00e7\u00e3o brasileira, o maior estudo epidemiol\u00f3gico ainda \u00e9 de Maffei et al., realizado em 1986, que avaliou 1.755 pacientes em exame de rotina no centro de sa\u00fade universit\u00e1rio em Botucatu (SP), demonstrando que a preval\u00eancia de veias varicosas de todos os tipos foi de 47,6%, ocorrendo principalmente em mulheres n\u00e3o gr\u00e1vidas na taxa de 50,9%. Os casos considerados moderados ou graves foram constatados em 21,2%, sendo que, da amostra analisada, somente 5,5% dos pacientes foram ao servi\u00e7o de sa\u00fade para consulta relacionada \u00e0s veias varicosas ou por DVC . A conduta pode ser feita, dependendo da recomenda\u00e7\u00e3o, de forma conservadora ou de maneira cir\u00fargico-intervencionista, sendo, essa \u00faltima, o padr\u00e3o-ouro para o tratamento das veias varicosas . O hist\u00f3rico de procedimentos \u00e9 de longa data, percorrendo diversos m\u00e9todos e com amplas modifica\u00e7\u00f5es, sendo a safenectomia com ligadura na jun\u00e7\u00e3o safeno femoral (JSF) e safeno popl\u00edtea (JSP), respectivamente para as veias safenas magna (VSM) e parva (VSP), o m\u00e9todo de escolha por longo per\u00edodo de tempo .De forma geral, o tratamento da DVC ser\u00e1 recomendado se o paciente possuir sintomas relevantes, sinais cl\u00ednicos de doen\u00e7a venosa cr\u00f4nica e refluxo de segmentos venosos, principalmente nas veias safenas magna e/ou parvalaser para terapia endoluminal surgiu ap\u00f3s a publica\u00e7\u00e3o de Bon\u00e9 (apud Hamdan) . A partir de ent\u00e3o, a abla\u00e7\u00e3o t\u00e9rmica endovenosa a laser  passou a ser utilizada no contexto das veias varicosas, e os m\u00e9todos cir\u00fargicos cl\u00e1ssicos come\u00e7aram a ser questionados n\u00e3o s\u00f3 pela invasibilidade, mas tamb\u00e9m pelo tempo de recupera\u00e7\u00e3o, pela necessidade de internamento, pelos efeitos colaterais e pelas complica\u00e7\u00f5es p\u00f3s-procedimento . Atualmente, de acordo com o American Venous Forum, a EVLA possui forte recomenda\u00e7\u00e3o para o tratamento da incompet\u00eancia de veia safena por sua seguran\u00e7a e efetividade, al\u00e9m de precisar de menos tempo para convalesc\u00eancia, dor e morbidade quando comparada \u00e0 cirurgia aberta .O uso do Como forma de an\u00e1lise do sucesso terap\u00eautico no contexto da EVLA, tem-se a taxa de oclus\u00e3o como um dos principais marcadores, principalmente quando ela \u00e9 analisada em seguimento de tempo, bem como a quantidade de efeitos colaterais produzidos e a necessidade de reopera\u00e7\u00e3o.Tendo em vista o n\u00famero ainda reduzido de publica\u00e7\u00f5es espec\u00edficas sobre a EVLA utilizando diferentes t\u00e9cnicas operat\u00f3rias, por se tratar de um m\u00e9todo relativamente novo e em evolu\u00e7\u00e3o, especialmente no contexto brasileiro, a presente produ\u00e7\u00e3o cient\u00edfica visa expor resultados cl\u00ednicos obtidos mediante a utiliza\u00e7\u00e3o da metodologia, bem como contribuir em busca do aprimoramento da terap\u00eautica com maior efici\u00eancia e menor invasibilidade.endolaser de 1.470 nm para o tratamento de trajetos venosos, constatando, por meio da ultrassonografia com Doppler, os per\u00edodos de 30 dias e 1 ano de p\u00f3s-operat\u00f3rio. Adicionalmente, tamb\u00e9m foi um objetivo demonstrar quais foram os efeitos colaterais e qual sua incid\u00eancia no p\u00f3s-operat\u00f3rio, bem como a necessidade de reinterven\u00e7\u00e3o ou complemento da opera\u00e7\u00e3o para a terap\u00eautica.O objetivo prim\u00e1rio deste trabalho foi demonstrar a incid\u00eancia de oclus\u00f5es venosas totais utilizando o laser abla\u00e7\u00e3o. O projeto foi aprovado pelo comit\u00ea de \u00e9tica da institui\u00e7\u00e3o Unicesumar, com o n\u00famero CAAE 15333619.9.00005539 e parecer consubstanciado 4.736.805.Trata-se de um estudo observacional retrospectivo de uma coorte com abordagem quantitativa de pacientes com DVC em membros inferiores tratados por EVLA por um servi\u00e7o de cirurgia vascular. Todos os dados foram coletados e analisados de maneira retrospectiva atrav\u00e9s dos prontu\u00e1rios pr\u00e9-operat\u00f3rios e das fichas p\u00f3s-O presente estudo considerou como crit\u00e9rios de elegibilidade dos pacientes estudados: ter sido submetido a t\u00e9cnica EVLA nas veias safenas parva e magna para o tratamento de DVC; possuir Cl\u00ednica-Etiol\u00f3gica-Anat\u00f4mica-Patol\u00f3gica (CEAP) C2 a C5; realiza\u00e7\u00e3o do procedimento entre mar\u00e7o de 2018 e outubro de 2019; ultrassonografia com Doppler 1 ano ap\u00f3s a realiza\u00e7\u00e3o do procedimento; aceite do Termo de Consentimento Livre e Esclarecido (TCLE).laser como o tratamento de escolha, sendo a fleboextra\u00e7\u00e3o somente indicada em situa\u00e7\u00f5es de recusa do paciente e aneurismas venosos. Nos casos de dilata\u00e7\u00f5es venosas distando at\u00e9 12 mm da jun\u00e7\u00e3o safeno femoral, o tratamento foi direcionado para ligadura de JSF.No servi\u00e7o em quest\u00e3o, todos os pacientes t\u00eam primariamente a indica\u00e7\u00e3o de termoabla\u00e7\u00e3o por endolaser diodo de 1.470 nm de comprimento de onda com fibra radial de 600 micras. O procedimento foi iniciado com a inser\u00e7\u00e3o da fibra \u00f3ptica no ponto distal \u00e0 insufici\u00eancia venosa at\u00e9 0,5 cm distal a JSF ou JSP, guiada pelo ultrassom com Doppler. Foi realizada a tumesc\u00eancia perivascular no segmento venoso a ser tratado com soro gelado e, com o paciente em posi\u00e7\u00e3o de Trendelemburg, iniciou-se a irradia\u00e7\u00e3o do laser endovenoso com velocidade de tra\u00e7\u00e3o cr\u00e2nio-caudal de 1 mm por segundo, sendo calculado, ao final, o Linear Endovenous Energy Density (LEED) em watts por cent\u00edmetro por segundo.Em ambiente cir\u00fargico hospitalar, todos os pacientes sob anestesia raquimedular foram submetidos \u00e0 t\u00e9cnica EVLA com Ao final do procedimento, foram prescritas analgesia com anti-inflamat\u00f3rio n\u00e3o hormonal por 5 dias e meia el\u00e1stica de 20 a 35 mmHg por 48 horas. Ainda, foi encorajado o deambular precoce imediatamente ap\u00f3s a alta hospitalar, ocorrida no mesmo dia do procedimento ap\u00f3s 3 a 4 horas de sua realiza\u00e7\u00e3o.Os aspectos cl\u00ednicos analisados nos prontu\u00e1rios do pr\u00e9-operat\u00f3rio foram idade, sexo, segmento venoso acometido, extens\u00e3o da insufici\u00eancia e di\u00e2metro da veia safena. Na ficha operat\u00f3ria, as vari\u00e1veis foram a pot\u00eancia, calculada em watts, e o LEED (W/cm/s). Os dados no p\u00f3s-operat\u00f3rio de 30 dias e 1 ano foram: taxa de oclus\u00e3o via ultrassom com Doppler, necessidade de reinterven\u00e7\u00e3o ou complemento da terap\u00eautica, al\u00e9m dos efeitos colaterais como: hiperpigmenta\u00e7\u00e3o de pele, ard\u00eancia, dor no trajeto e parestesia, sendo avaliados somente quanto \u00e0 presen\u00e7a ou n\u00e3o, n\u00e3o havendo escalas ou instrumentos de gradua\u00e7\u00e3o dos mesmos, al\u00e9m de trombose venosa profunda e embolia pulmonar, avaliadas com base em ecografia mencionada somada a caracter\u00edsticas cl\u00ednicas nos pacientes no p\u00f3s-operat\u00f3rio.Para o estudo, entende-se por taxa de oclus\u00e3o a porcentagem do l\u00famen obliterado pela EVLA ap\u00f3s o procedimento, considerando-se de 100% quando n\u00e3o h\u00e1 recanaliza\u00e7\u00e3o em nenhum ponto do trajeto venoso. Dessa forma, fica tamb\u00e9m definida a recanaliza\u00e7\u00e3o como qualquer percentual em que a oblitera\u00e7\u00e3o tenha se desfeito.Ap\u00f3s a estrutura\u00e7\u00e3o dos dados cadastrados em planilha MS Excel 2019, todos os c\u00e1lculos relativos \u00e0s m\u00e9dias e aos desvios padr\u00e3o foram realizados a partir do suplemento Power Query, no mesmo programa. , e \u00b13% de erro padr\u00e3o. A popula\u00e7\u00e3o caracterizou-se como infinita (finita n\u00e3o enumer\u00e1vel).Para o c\u00e1lculo do tamanho da amostra com intervalo de confian\u00e7a de 95%, considerou-se como refer\u00eancia a taxa de oclus\u00e3o de 98,1% descrita por Silva et al. .Para o estudo em quest\u00e3o, o tamanho da amostra seria de aproximadamente 80 pacientes submetidos ao procedimento nos segmentos venosos com intervalo de confian\u00e7a estimado entre 95,1% e 100% para a taxa de oclus\u00e3o em 1 anoDados faltantes foram retirados de an\u00e1lise e descontinuados de poss\u00edvel apresenta\u00e7\u00e3o textual ou em tabelas. N\u00e3o houve utiliza\u00e7\u00e3o de informa\u00e7\u00e3o com rela\u00e7\u00e3o de vi\u00e9s aos autores.Do m\u00eas de mar\u00e7o de 2018 at\u00e9 outubro de 2019, o servi\u00e7o de cirurgia vascular Clinivasc diagnosticou 658 pacientes com DVC devido a acometimento de veias safenas, dos quais 112 possu\u00edam indica\u00e7\u00e3o de tratamento cir\u00fargico. Quarenta pacientes foram eleg\u00edveis para an\u00e1lise segundo os crit\u00e9rios de inclus\u00e3o pr\u00e9-determinados, e 72 foram desconsiderados devido a n\u00e3o realiza\u00e7\u00e3o/desist\u00eancia do tratamento, realiza\u00e7\u00e3o cir\u00fargica via m\u00e9todo n\u00e3o EVLA, tratamentos conservadores e por n\u00e3o se enquadrarem nos crit\u00e9rios de inclus\u00e3o.Foram inclu\u00eddos 38 pacientes, havendo duas exclus\u00f5es por recusa do TCLE. N\u00e3o houve seguimento para al\u00e9m de 1 ano dos pacientes eleg\u00edveis. A Entre os 38 pacientes considerados, foram tratados 76 membros inferiores e 104 segmentos venosos, dos quais a VSM foi maioria com 94 trajetos, sendo 50 em membro esquerdo e 44 em membro direito, enquanto para a VSP, foram 10 segmentos, tr\u00eas em membro esquerdo e sete em direito. Quanto \u00e0 densidade de energia utilizada, o c\u00e1lculo foi feito em W/cm/s demonstrado em LEED m\u00e9dio na A unidade de an\u00e1lise para a taxa de oclus\u00e3o e LEED foram os segmentos venosos (104). Para os efeitos colaterais, foram os pacientes (38).Conforme a Entre os efeitos colaterais analisados no per\u00edodo de 30 dias a 1 ano, o de maior incid\u00eancia foi a dor no trajeto da veia safena p\u00f3s-oclus\u00e3o . Em relaO presente estudo sugere grande efic\u00e1cia do tratamento de veias varicosas pela EVLA, considerando-se o prazo de at\u00e9 1 ano p\u00f3s-terap\u00eautica, fato corroborado pelas altas taxas de oclus\u00e3o mantidas nesse per\u00edodo, pela baixa incid\u00eancia de efeitos colaterais, por seu car\u00e1ter benigno, al\u00e9m de relativa facilidade de resolu\u00e7\u00e3o.laser, causar dano irrevers\u00edvel \u00e0 parede do vaso, seja primariamente pela desnatura\u00e7\u00e3o de col\u00e1geno, que ocorre entre 70 e 100\u00ba C, somada \u00e0 evoca\u00e7\u00e3o de rea\u00e7\u00f5es inflamat\u00f3rias e fibrog\u00eanicas, que culminam na oclus\u00e3o permanente da veia incompetente . No artigo, consideramos como fatores determinantes para o sucesso terap\u00eautico: a fibra radial, o laser diodo, o comprimento de onda de 1.470 nm e a t\u00e9cnica operat\u00f3ria utilizada.A efici\u00eancia do m\u00e9todo em quest\u00e3o consiste em, por meio da emiss\u00e3o de energia t\u00e9rmica gerada pelo  . Em publica\u00e7\u00e3o semelhante de Silva et al. , que utilizou EVLA com comprimento de onda e fibra id\u00eanticos, foram constatadas, em 180 segmentos venosos tratados, taxas de oclus\u00e3o semelhantes de 97,22% em 30 dias e de 98,10% em 1 ano dos vasos avaliados.Nossos dados revelaram taxas de oclus\u00e3o extremamente elevadas, tanto para o seguimento de 30 dias (100%) quanto ao 1\u00ba ano p\u00f3s-operat\u00f3rio , com somente um trajeto venoso apresentando recanaliza\u00e7\u00e3o parcial , n\u00fameros inclusive acima dos padr\u00f5es de diversos autores com estudos similares afirmaram que a maior parte dos estudos j\u00e1 indicava taxa de oclus\u00e3o de aproximadamente 100% em uma semana, com esse n\u00famero caindo ao longo do tempo, por\u00e9m se mantendo acima de 90% em diversas s\u00e9ries. Al\u00e9m disso, os autores pontuaram a correla\u00e7\u00e3o da proporcionalidade direta da quantidade de energia e taxa de oclus\u00e3o, fato tamb\u00e9m sugerido pelo presente estudo.Galanopoulos et al. .Embora n\u00e3o tenha sido feita a an\u00e1lise dos pacientes ap\u00f3s 12 meses, outros autores acreditam que a recanaliza\u00e7\u00e3o de segmentos venosos ocorre, na imensa maioria dos casos, dentro dos primeiros 3 meses de p\u00f3s-operat\u00f3rio, e que, em casos de oclus\u00e3o acima de 12 meses, a chance de recanaliza\u00e7\u00e3o futura \u00e9 mais improv\u00e1vel quando feita a compara\u00e7\u00e3oNo presente estudo, especificamente quanto ao LEED e \u00e0 taxa de oclus\u00e3o, n\u00e3o houve estratifica\u00e7\u00e3o dos resultados por CEAP, ponto a ser levado em considera\u00e7\u00e3o pela heterogeneidade da amostra e como sugest\u00e3o para futuros estudos. Ainda assim, \u00e9 cab\u00edvel mencionar que n\u00e3o h\u00e1 proporcionalidade obrigat\u00f3ria entre a classifica\u00e7\u00e3o em seu item cl\u00ednico (C) e o di\u00e2metro venoso, fator esse que \u00e9 determinante para o c\u00e1lculo do LEED e da abla\u00e7\u00e3o t\u00e9rmica.laser utilizados na termoabla\u00e7\u00e3o possuem car\u00e1ter monocrom\u00e1tico, ou seja, emitem luz \u00fanica e pr\u00f3xima ao infravermelho, al\u00e9m de possu\u00edrem diversos comprimentos de onda utiliz\u00e1veis . Cada comprimento de onda det\u00e9m um crom\u00f3foro tecidual dominante, ou seja, subst\u00e2ncia ou tecido com maior taxa de absor\u00e7\u00e3o, havendo preval\u00eancia para hemoglobina, nas faixas at\u00e9 1.064 nm, e para \u00e1gua, principalmente a partir de 1.100 nm .Os dispositivos a  .A escolha do comprimento de onda de 1.470 nm se baseia no fato de esse valor promover at\u00e9 40 vezes mais absor\u00e7\u00e3o pelas mol\u00e9culas de \u00e1gua quando comparado com a hemoglobina na mesma faixa. Esse fator se mostra interessante para a terap\u00eautica, j\u00e1 que a utiliza\u00e7\u00e3o da hemoglobina como alvo causa enorme fen\u00f4meno tromb\u00f3tico, mas proporcional efeito ativador do sistema trombol\u00edtico, sendo um fator predisponente importante para recanaliza\u00e7\u00e3o e, consequentemente, falha terap\u00eautica, enquanto, para a \u00e1gua, a excita\u00e7\u00e3o molecular tem predom\u00ednio na parede venosa, local-alvo da terapia .\u00c9 necess\u00e1rio esclarecer que, embora o comprimento de onda utilizado tenha foco nas mol\u00e9culas de \u00e1gua do endot\u00e9lio vascular, as c\u00e9lulas sangu\u00edneas s\u00e3o compostas, em m\u00e9dia, por 60% das mesmas mol\u00e9culas e, portanto, tamb\u00e9m absorvem grande quantidade de energia, produzindo coagula\u00e7\u00e3o, apesar de em menores propor\u00e7\u00f5es quando comparadas com comprimentos de onda que focam diretamente a hemoglobinalaser diodo de 1.470 nm tem sua prefer\u00eancia devido \u00e0 menor quantidade de energia necess\u00e1ria a ser dispendida, isso porque os dispositivos com maior comprimento de onda necessitam de menores densidades de energia juntamente com menores pot\u00eancias a serem operadas para a obten\u00e7\u00e3o da terap\u00eautica . O uso de menor energia e pot\u00eancia, nesse caso, proporciona menores chances de absor\u00e7\u00e3o excessiva de calor, impedindo carboniza\u00e7\u00e3o, perfura\u00e7\u00e3o de parede, dor e equimose p\u00f3s-operat\u00f3ria .Desse modo, em adi\u00e7\u00e3o ao aspecto do crom\u00f3foro dominante \u00e1gua, a utiliza\u00e7\u00e3o do  obtiveram, em 1 ano p\u00f3s-EVLA 7 , recanaliza\u00e7\u00f5es com 980 nm e dois  com 1.470 nm de um total de 78 e 74 trajetos venosos respectivamente.Em pesquisa comparativa entre os comprimentos de onda, Aktas et al.laser diodo de 1.470 nm . Seu uso tem sido atrelado \u00e0 sua ponteira de quartzo, que permite refletir seu feixe eletromagn\u00e9tico em dire\u00e7\u00e3o radial e de forma homog\u00eanea com menor penetra\u00e7\u00e3o e perfura\u00e7\u00f5es, reduzindo efeitos colaterais como dor e hematomas . Em outro estudo que faz a compara\u00e7\u00e3o com a fibra linear, foi constatado que a fibra radial demanda menos energia para a obten\u00e7\u00e3o da oclus\u00e3o . O uso da fibra de 600 micras, devido a seu maior di\u00e2metro e sua maior densidade energ\u00e9tica dissipada, possibilita atingir temperaturas finais mais elevadas, permitindo melhor distribui\u00e7\u00e3o e condu\u00e7\u00e3o de calor at\u00e9 as t\u00fanicas vasculares .A fibra radial foi introduzida no mercado em 2008 e, atualmente, \u00e9 a fibra mais utilizada, especialmente para o laser, o LEED se origina da raz\u00e3o da pot\u00eancia do laser, medida em watts, multiplicada pela velocidade de tra\u00e7\u00e3o da fibra, dimensionada em cent\u00edmetros por segundo, logo, a unidade de medida em LEED seria expressa em W/cm/s .A descri\u00e7\u00e3o da energia para os procedimentos ablativos utiliza o LEED como padr\u00e3o, mensurada pela grande maioria dos autores na unidade de joules por cent\u00edmetro. No entanto, pelas defini\u00e7\u00f5es f\u00edsicas aplicadas ao laser foi individualizado para cada paciente, principalmente com base na medida do di\u00e2metro da veia insuficiente, levando em considera\u00e7\u00e3o outros fatores delineadores, como a fibra radial, a velocidade de refluxo e a quantidade veias tribut\u00e1rias. A velocidade de tra\u00e7\u00e3o da fibra obteve uma m\u00e9dia de 1 mm/s, padr\u00e3o recomendado para segmentos de at\u00e9 10 mm . Como LEED para veia safena interna, obtivemos a m\u00e9dia de 2.040,52\u00b11.510,06 W/cm/s e, para veia safena externa, 1.168,4\u00b1665,011 W/cm/s.Neste estudo, o c\u00e1lculo da pot\u00eancia do  . A realiza\u00e7\u00e3o de tumesc\u00eancia vascular \u00e9 valorizada pela capacidade de proteger os tecidos perivasculares, agindo como dissipador de calor, e ainda causar aumento da \u00e1rea de contato luminal pela diminui\u00e7\u00e3o do di\u00e2metro venoso .A op\u00e7\u00e3o pela posi\u00e7\u00e3o de Trendelemburg durante a retra\u00e7\u00e3o da fibra se d\u00e1 por essa propiciar veias safenas com redu\u00e7\u00e3o importante na quantidade de sangue intravascular, j\u00e1 que a presen\u00e7a desse permite a alta absor\u00e7\u00e3o de energia pelas c\u00e9lulas sangu\u00edneas, diminuindo a disponibilidade para parede venosa, al\u00e9m de induzir fortemente a cascata de coagula\u00e7\u00e3o, promovendo a recanaliza\u00e7\u00e3o4 no pr\u00e9-operat\u00f3rio, sendo considerados como poss\u00edveis fatores para esse desfecho: presen\u00e7a de tromboflebite anterior ao tratamento, a qual provoca altera\u00e7\u00e3o histol\u00f3gica com espessamento da parede venosa por um tecido fibr\u00f3tico, podendo reduzir os efeitos ablativos; e o paciente possu\u00eda 75 anos de idade e j\u00e1 havia convivido com doen\u00e7a vascular venosa por longo per\u00edodo de tempo e, por isso, provavelmente possu\u00eda camadas \u00edntima e m\u00e9dia significativamente mais espessas com menor resposta \u00e0 abla\u00e7\u00e3o . O paciente em quest\u00e3o apresentou edema persistente. Para o caso, foi realizado complemento da terap\u00eautica por meio de sess\u00e3o \u00fanica de escleroterapia no local, com o paciente evoluindo clinicamente de forma desejada e concluindo o tratamento.O \u00fanico caso de recanaliza\u00e7\u00e3o envolveu um paciente com classifica\u00e7\u00e3o C . Nessa amostra, pacientes foram liberados para deambular no mesmo dia do procedimento, al\u00e9m de retornarem mais rapidamente \u00e0s atividades di\u00e1rias e \u00e0 ocupa\u00e7\u00e3o laboral .Atualmente, as complica\u00e7\u00f5es e os efeitos colaterais p\u00f3s-operat\u00f3rias da EVLA j\u00e1 s\u00e3o considerados m\u00ednimos por diversos autores, principalmente quando comparados com a fleboextra\u00e7\u00e3o . Especialmente em nossos dados, o fen\u00f4meno da dor p\u00f3s-operat\u00f3ria teve certa relev\u00e2ncia, estando, em alguns casos, associada a eritema local; no entanto, ela se resolveu dentro do per\u00edodo de 30 dias com o uso da analgesia n\u00e3o esteroidal.De forma geral, a pesquisa obteve propor\u00e7\u00f5es semelhantes a outras quanto aos efeitos adversos, inclusive n\u00e3o havendo efeitos colaterais graves e permanentesEm rela\u00e7\u00e3o \u00e0s poss\u00edveis justificativas para a dor e parestesia, foi verificada a inexist\u00eancia de les\u00e3o por perfura\u00e7\u00e3o endotelial pela fibra com disparo extravascular em tecidos adjacentes e ramos nervosos. Foram, no entanto, elencadas duas situa\u00e7\u00f5es fisiopatol\u00f3gicas, possivelmente determinando os sintomas. A primeira foi por conta do uso de LEEDs elevados associados \u00e0 diminui\u00e7\u00e3o da velocidade de tra\u00e7\u00e3o da fibra que, ao aumentar a temperatura e sua difus\u00e3o, possivelmente causou les\u00e3o tecidual e de ramos neurais pr\u00f3ximos \u00e0 veia safena. Em segundo lugar, possivelmente houve falha no afastamento com tumesc\u00eancia perivascular de ramos nervosos, determinando passagem t\u00e9rmica e les\u00e3o.Quanto \u00e0s ocasi\u00f5es em que o LEED ficou acima da m\u00e9dia, entende-se que esses foram casos seletos, em que, atrav\u00e9s da an\u00e1lise cl\u00ednica pr\u00e9 e intraoperat\u00f3ria do cirurgi\u00e3o, foi necess\u00e1ria maior dispers\u00e3o energ\u00e9tica para a obten\u00e7\u00e3o de oblitera\u00e7\u00e3o completa do segmento venoso, comprovada pelo alto desvio padr\u00e3o de energia em rela\u00e7\u00e3o \u00e0 m\u00e9dia dos casos.Acredita-se, de maneira geral, que a utiliza\u00e7\u00e3o de menores LEEDs associados \u00e0 tumesc\u00eancia gelada realizada no momento da abla\u00e7\u00e3o para a forma\u00e7\u00e3o de halo h\u00eddrico de prote\u00e7\u00e3o t\u00e9rmica e afastamento de ramos nervosos possivelmente reduza a sintomatologia apresentada pelos pacientes.laser abla\u00e7\u00e3o, devido ao poss\u00edvel insulto t\u00e9rmico nas veias . O quadro \u00e9 agravado caso n\u00e3o seja realizada a tumesc\u00eancia com soro gelado. Foi observada, no mesmo caso, presen\u00e7a de cefaleia ap\u00f3s anestesia raquimedular. Outro paciente, tamb\u00e9m por conta da anestesia, referiu dor no derm\u00e1tomo de nervo lombar \u00e0 esquerda, com remiss\u00e3o ap\u00f3s medica\u00e7\u00e3o anticonvulsivante e antiepil\u00e9tica por 15 dias.O \u00fanico caso de parestesia ocorreu ap\u00f3s procedimento na veia safena interna esquerda, retornando \u00e0 sensibilidade normal antes de 6 meses. A les\u00e3o nervosa possui risco de at\u00e9 7% ap\u00f3s  . A explica\u00e7\u00e3o envolve desde quest\u00f5es de hist\u00f3rico familiar, rela\u00e7\u00e3o com gravidez e at\u00e9 pelo aspecto est\u00e9tico dos membros inferiores, confirmada, inclusive, pela m\u00e9dia feminina de idade 11,353 anos inferior quando comparada ao sexo masculino e pelo maior desvio padr\u00e3o, de 13,351 anos. A Por fim, neste estudo, foi constatada a predomin\u00e2ncia de pacientes do sexo feminino, uma tend\u00eancia que se confirma em outras publica\u00e7\u00f5esDevem-se considerar como limita\u00e7\u00f5es para este estudo: falta de seguimento al\u00e9m de 1 ano; n\u00e3o relacionar os aspectos cl\u00ednicos e o di\u00e2metro das veias safenas no pr\u00e9-operat\u00f3rio por falta de dados; amostra heterog\u00eanea quanto ao CEAP; n\u00e3o possuir grupo-controle; amostra relativamente pequena; modelo de fichas para o p\u00f3s-operat\u00f3rio utilizadas pelo servi\u00e7o, impedindo a adi\u00e7\u00e3o de outras informa\u00e7\u00f5es, como pigmenta\u00e7\u00e3o transit\u00f3ria e maior discrimina\u00e7\u00e3o de outros efeitos colaterais; avalia\u00e7\u00e3o p\u00f3s-operat\u00f3ria feita pelos autores; e a pesquisa ter sido realizada somente em um centro de tratamento.Considerando-se o reduzido tamanho amostral, ainda que revelador de importantes achados neste trabalho, deve-se frisar que uma amostra ideal (com 80 pacientes) asseguraria resultados mais robustos, permitindo, com melhores evid\u00eancias, ponderar acerca da efic\u00e1cia e seguran\u00e7a do procedimento. Ademais, as fichas para o p\u00f3s-operat\u00f3rio n\u00e3o possu\u00edam descrimina\u00e7\u00e3o quanto ao local espec\u00edfico dos efeitos adversos, somente apontavam que eles ocorreram ap\u00f3s o procedimento.Em vista \u00e0 casu\u00edstica apresentada e \u00e0 an\u00e1lise estat\u00edstica realizada, n\u00e3o foi constatada relev\u00e2ncia nos nove pacientes com efeitos colaterais a ponto de questionar a viabilidade terap\u00eautica da t\u00e9cnica, al\u00e9m de ser verificado o bom progn\u00f3stico e a evolu\u00e7\u00e3o benigna da grande maioria dos sintomas. Tamb\u00e9m foi poss\u00edvel observar que as taxas de oclus\u00e3o no seguimento de 30 dias e 1 ano de p\u00f3s-operat\u00f3rio, respectivamente de 100% e 99,04%, foram satisfat\u00f3rias e similares a literaturas supracitadas, permitindo apontar que, nesse contexto, a t\u00e9cnica foi promissora na amostra. Contudo, n\u00e3o houve a viabilidade de realizar recomenda\u00e7\u00f5es com grande evid\u00eancia.endolaser para a DVC, este estudo acrescenta em diversas vertentes: a atual aplicabilidade da EVLA no 1\u00b0 ano p\u00f3s-tratamento como demonstrado e comparado com autores semelhantes; a t\u00e9cnica utilizada que possivelmente proporcionou tais resultados, que inclui laser diodo com comprimento de onda para crom\u00f3foro dominante \u00e1gua, fibra radial de grande di\u00e2metro, posi\u00e7\u00e3o de Trendelemburg durante procedimento e tumesc\u00eancia perivascular com soro gelado; o perfil epidemiol\u00f3gico dos pacientes que procuraram por tratamento para DVC; poss\u00edveis fatores que determinaram os efeitos colaterais e seus respectivos desfechos; e descri\u00e7\u00e3o do funcionamento da EVLA quanto a seus mecanismos f\u00edsico-histol\u00f3gicos.No contexto da terapia com Por mais promissores que os resultados deste estudo tenham sido, ainda que com as limita\u00e7\u00f5es j\u00e1 descritas, ele pode e deve ser apenas considerado como ponto de partida para a realiza\u00e7\u00e3o de novas pesquisas no contexto da terap\u00eautica de veias safenas insuficientes, principalmente em an\u00e1lise multic\u00eantrica e especialmente em tamanho e homogeneidade de amostra, correla\u00e7\u00e3o com di\u00e2metro venoso e CEAP dos pacientes, realizando compara\u00e7\u00f5es com outas modalidades terap\u00eauticas para a doen\u00e7a.Por se tratar de coorte retrospectiva com as limita\u00e7\u00f5es j\u00e1 apresentadas neste material, o estudo pode ser enquadrado no n\u00edvel de evid\u00eancia 2b."}
+{"text": "To assess the effectiveness of myotherapy exercises in increasing tongue pressure and strength. A secondary aim was to analyze the exercise types, training parameters, and functional results.This systematic literature review was based on the Prisma protocol guidelines.The review included clinical trials that assessed the effects of tongue muscle training, with no restriction on the language or year of publication.The steps included eliminating duplicates; reading abstracts and excluding studies that did not meet the inclusion criteria; reading selected articles in full text, extracting important data, and gathering them in a table; and meta-analysis, using the inverse variance method. The methodological quality of the studies was assessed with the Joanna Briggs Institute\u2019s tool. The quality of evidence was assessed with the Grading System of Recommendations Assessment, Development and Evaluation.The meta-analysis indicated a significant increase in maximum anterior and posterior pressure as an effect of training. The most performed exercise was tongue pressure against the palate. However, training parameters varied between studies, and whether exercises alone led to functional improvement cannot be stated. The quality of the evidence was considered low.Myotherapy exercises increased anterior and posterior tongue pressure in adults, but the quality of this evidence is low. The studies used various exercise types and training parameters. It cannot be stated whether exercises alone led to functional improvement. Its structure is characteristic of unique organisms called muscular hydrostats, which also include the trunks of elephants and tentacles of octopuses,3. These organs are made exclusively of muscles that can make and sustain various movements thanks to their fibers, which are oriented in various directions: longitudinal, vertical, transversal, and, in some cases, circular,3.The tongue, which is involved in all functions of the stomatognathic system, is essential to the nutrition and communication process and occlusion stability. Types I and IIa muscle fibers predominate in the anterior portion of tongue morphology. Type I fibers are resistant to fatigue, while type IIa fibers contract quickly. This combination favors speech movements, which are quick and repetitive and do not need much strength. The base of the tongue predominantly has type IIb fibers, which can generate greater strength, important for swallowing.The tongue has intrinsic and extrinsic muscles, whose different groups interact to carry out its functions - most movements require intense and simultaneous contraction of various groups. Moreover, besides myotherapy and preferably associated with it, speech-language-hearing therapists can use orofacial myofunctional therapy to improve stomatognathic system structures and functions with assisted functional training.Given all these specificities, it may not be a good option to treat changes in tongue strength and/or resistance by applying exercise physiology based on the same principles used for the other body muscles. Exercise-based therapy, called myotherapy, is used to rehabilitate and/or prevent orofacial muscle changes. It belongs to the area of oral-motor control as part of speech-language-hearing practices, aiming to improve strength, resistance, mobility, and coordination. However, while the diversity of exercises broadens individualized treatment possibilities and positively impacts their effectiveness, it can also hinder the knowledge and development of such techniques if their effects are not addressed in studies. This article presents the results of an investigation on the effects of tongue training to reflect on its effectiveness in the perspective of speech-language-hearing care.Researchers have been trying for some years to find methods to improve tongue muscle training; hence, many instruments and exercises have been developed to this endThis research aimed to assess the effectiveness of myotherapy exercises to increase tongue pressure and strength. Secondarily, it aimed to analyze which exercise types and training parameters  are used and their functional results.. The review had the following stages: developing the research question, defining keywords and article eligibility criteria, selecting articles, and critically assessing them.This systematic review of the literature was registered in the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42021224324) and developed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)The research question for this study was as follows: \u201cDo tongue myotherapy exercises increase its strength/pressure?\u201d. Secondarily, the study sought to find the types, parameters, and functional effects of the exercises that are used.Biblioteca Brasileira de Odontologia  via Virtual Health Library (VHL), CINAHL, Cochrane, EMBASE, LILACS (via VHL), MEDLINE (via PubMed), Scopus, and Web of Science. The descriptors were obtained from the Medical Subject Headings (MeSH), Health Sciences Descriptors (DeCS), and EMBASE Subject Headings (Emtree), as follows: tongue, muscle strength, physical endurance, resistance training, exercise therapy, rehabilitation, exercise, as well as the free terms: lingual and tongue strength, and their equivalents in Portuguese and Spanish. The search strategies are shown in Articles were selected by surveying the national and international literature, with no restriction on the language or year of publication, in the following databases: Eligibility criteria were defined based on the PICOT elements: participants ; intervention (tongue strength/pressure or resistance training exercises); comparator ; outcomes ; type of study . After analyzing the titles and abstracts, the texts that were or could be compatible with the eligibility criteria were read in full text.The inclusion criteria for article eligibility were as follows: original research articles designed as clinical trials; whose sample comprised individuals above 18 years old that were submitted to tongue muscle exercises; that had a comparator group comprising individuals who were not submitted to the approached exercises or underwent other therapeutic strategies; and that assessed as outcomes the strength or pressure values and/or orofacial function performance. The exclusion criteria were studies that did not address at least one of the following data: exercise type, training parameters, and results regarding at least one of the outcomes.After reading the full text of the articles that met the eligibility criteria, their data were collected in a table developed to contain the following information: author, year of publication, the country where the study was conducted, characteristics of the sample, exercise type, training parameters, instruments used in data collection, and study results, emphasizing tongue pressure or strength values.. This instrument presents criteria to assess the methodological quality of studies, with three possible answers: yes, this criterion is verified; no, this criterion is not verified; and it is unclear. Each positive answer scores 1 point and, the other ones score 0 points. The higher the score, the greater the internal quality and the smaller the risk of bias regarding the study\u2019s methodological quality. It was determined that studies with less than 50% of positive answers would be considered as having low methodological quality; between 50 and 75% of positive answers, intermediate methodological quality; and with 75% or more positive answers, high methodological quality.The methodological quality of these studies was assessed with JBI\u2019s Critical Appraisal Checklist for Randomized Controlled Trial Studies.Publication bias was analyzed with funnel plots and the Egger test, using the STATA statistical program, version 13.0. The quality of evidence was assessed with the Grading of Recommendations Assessment, Development and Evaluation (GRADE)\u00ae spreadsheet. Articles assessed positively by two researchers were included in the study. Data were likewise extracted into a Microsoft Excel\u00ae spreadsheet by at least one of the researchers and verified by at least one of the other ones. The quality of the studies was analyzed by one researcher and verified by another one.All research stages were carried out by three researchers, who also conducted manually and independently the data analysis that determined whether studies met the eligibility criteria, using a binary scale (yes/no) and a Microsoft ExcelThe intervention effect measure considered for meta-analysis was the difference in anterior and posterior tongue pressure before and after the intervention, using the inverse variance method in STATA, version 13.0. The studies were analyzed both together and subdivided into clinical conditions and age.The search in the databases initially found 526 references on tongue muscle training exercises . After removing the duplicates, 274 articles remained, and after excluding articles by abstract reading, 26 remained, which were read in full text. After excluding another 12 articles for not meeting the eligibility criteria, 14 articles reached the final inclusion phase for analysis, as shown in . The very instruments used to measure tongue strength/pressure, despite their considerable number, are likewise recent, and some are still being improved. Nevertheless, many countries are concerned with stomatognathic function rehabilitation. Two out of the 14 articles  are Brazilian,14, whereas South Korea published the most, with eight articles-22; as for the other ones, two are from the United States,24, one from China, and one from Belgium. The predominating age range in the samples comprised young adults and older adults, ranging from 24 to 85 years old, in an approximately even number of men and women.The analysis of the studies included in this research readily showed that the interest in the topic is fairly recent, as they were published between 2003 and 2020. This may be explained by the also recent appearance of oral-motor control as a regulated speech-language-hearing practice. In Brazil, for example, speech-language-hearing therapy was regulated as a profession only in 1981, and titles of specialists, including oral-motor control, were regulated as late as 1996-17,19 and one due to oral cavity and/or oropharyngeal cancer, in a recent postoperative period from tumor resection surgery. Changes in tongue strength/pressure can affect both the oral and pharyngeal phases of swallowing, and adequate strength must be used to ensure effective and safe swallowing - which explains the significant number of studies in this population included in this research. The review also included one study in people with post-stroke dysarthria. The individuals in these studies had similar mean ages, ranging from 56.2 to 67.3 years. The main findings of the studies in individuals with dysphagia or dysarthria after stroke or mouth and/or oropharyngeal cancer are shown in Most studies approached people with dysphagia, four of them due to stroke, which makes them more vulnerable to dysphagia. This justifies that half of the studies in individuals without a history of orofacial changes addressed older adults,22,26, while the other half comprised adults,23,24. Paying attention to tongue strength and its relationship with swallowing is more relevant among older adults, whose tone decreases due to the loss of muscle mass (which is inherent to aging) and reserve strength,14 (. Both studies comprised adults in groups whose mean ages ranged from 45 to 48 years.This research included two studies on primary snoring and/or obstructive sleep apnea (OSA),14 . Both co,14, with many parameter and frequency variations and lasting from 1 to 3 months. Tongue pressure and strength exercises were predominantly used in older adults and healthy adults. Older adults also underwent swallowing training and their training period was longer - 8 weeks on average,22,26, while healthy adults completed training in 4 to 6 weeks,23,24. Individuals with cancer, usually submitted to radiotherapy or chemotherapy, mainly performed mobility exercises for the speech articulation organs . Individuals with post-stroke dysphagia-17,19 performed tongue protrusion, retraction, lifting, and lowering for about 4 weeks. Exercises with tongue pressure against the palate were the most used in the studies, varying between isometric and isotonic exercises,20-24,26, which is probably explained by their ease of performance.Oropharyngeal exercises predominated in the studies on primary snoring and/or OSA-24,26, measured with the Iowa Oral Performance Instrument (IOPI). Four studies used videofluoroscopy, the gold standard method for the functional assessment of swallowing,17,19,25. Two studies used ultrasound to assess tongue and suprahyoid muscle thickness,21, and another two used polysomnography,14. Other outcomes analyzed in the studies included tongue resistance,24 using IOPI, diadochokinesia, the percentage of correctly articulated consonants, salivary flow rate, impact on oral health, sleep quality, and snoring characteristics,14.The maximum anterior and/or posterior pressure were the main outcomes analyzed in the studies. Studies in individuals with OSA,14 and dysphagia,16,19 found functional improvements. Function performance benefits from improved structural strength and resistance, although it must be pointed out that the participants in these studies also underwent functional training. Therefore, it cannot be stated whether the exercises had any effect on the function.In general, the experimental groups (EG) had their tongue pressure increased after the treatment. Also, control groups (CG) that performed some exercises (even if different from those of EG) improved in comparison with the other CG that did not perform exercises in the studies in which they participated. Based on the concepts of exercise physiology, results were expected from the exercises because strength training recruits more motor units, increases recruitment speed and coordination, and transforms undifferentiated fibers into strength or resistance fibers2 value of 0% and p-value = 0.650, indicating that the studies are generally homogeneous regarding the values they measured. In general, the analysis of the studies shows, in the column with the difference of means, that EG had higher values, at 6.05 kPa, with p-value < 0.001 - i.e., with a statistical significance. Some studies had more than one EG,23,26; hence, each EG was compared with CG in an independent row. The subgroup analysis showed statistically significant differences for all subgroups, with increased pressure at 5.74 kPa among adults without orofacial changes (p < 0.001); at 7.78 kPa among older adults without orofacial changes (p < 0.001), which was the group with the best pressure gain results from the exercises; and at 3.57 kPa among individuals with orofacial changes (p = 0.049), which was the group with the least result.The first meta-analysis included 11 studies that addressed maximum anterior tongue pressure before and after the intervention in EG and CG . It can 2 value of 48.5% indicates a moderate heterogeneity for these values. The column with the difference of means shows that EG generally had higher values, at 5.45 kPa, with p < 0.001, indicating statistical evidence of differences in posterior pressure between the groups submitted to exercises and CG. Two studies had more than one EG,26; hence, each EG was compared with CG in an independent row. The subgroup analysis showed statistically significant differences for all subgroups, with increased pressure at 9.32 kPa among older adults without orofacial changes (p < 0.001), which was the group with the best pressure gain results from the exercises; and at 3.57 kPa among individuals with orofacial changes (p = 0.049), which was the group with the least result. No study was found that assessed this outcome in adults without orofacial changes.The second meta-analysis included five studies that addressed maximum posterior tongue pressure before and after the intervention in EG and CG . The dia, combined with the absence of morphological and/or neurological changes that might hinder exercises and strength/pressure gains.The group of healthy older adults probably had the best results because they initially had lower tongue pressure values (which is inherent to the aging process and is explained by the decreased muscle mass)The methodological quality analysis of the studies  had resuThe funnel plots  and 5 shThe assessment of the quality of evidence for anterior and posterior tongue pressure began with the maximum score because the review used randomized clinical trials. Afterward, the score decreased by 2 points for the two outcomes, thus resulting in a weak certainty regarding both. In the case of anterior pressure, the score decreased because the methodological quality of more than 50% of the studies was classified as low or intermediate. As for posterior pressure, it decreased because of issues with direct evidence (absence of studies in adults that assessed this outcome) and imprecision (few participants) .This research identified that few studies have addressed this topic, especially regarding posterior tongue pressure. All included articles reported some type of benefit of tongue muscle training, with either increased anterior and/or posterior tongue pressure measures or functional improvement. The meta-analysis indicated that myofunctional exercises increased the outcomes analyzed and that older adults had the greatest benefit from this therapy. On the other hand, most of the studies had biases related to methodological quality (particularly concerning absent or inadequate randomization of participants into groups and the blinding of outcome assessors), and their quality of evidence was low. Thus, the results must be cautiously interpreted., which must be considered when interpreting the findings in this study.The limitations of this research include the search in few databases and not searching the grey literature, thus possibly failing to identify some relevant study. Another important limitation was the heterogeneity it verified regarding the sample\u2019s characteristics and the exercise types used in the various studies. Different exercises may lead to different tongue pressure gain resultsMyotherapy exercises increase anterior and posterior tongue pressure in adults. However, the quality of this evidence is low. The studies used various exercise types and training parameters. It cannot be stated whether exercises led to functional improvements. . Sua estrutura \u00e9 caracter\u00edstica de organismos muito particulares chamados de hidr\u00f3statos musculares, como a tromba de um elefante ou os tent\u00e1culos de um polvo,3. Trata-se de \u00f3rg\u00e3os formados exclusivamente por m\u00fasculos, capazes de criar e sustentar movimentos diversos, por apresentarem fibras em v\u00e1rias dire\u00e7\u00f5es: longitudinal, vertical, transversal e, em alguns casos, circular,3.Envolvida em todas as fun\u00e7\u00f5es do sistema estomatogn\u00e1tico, a l\u00edngua \u00e9 um \u00f3rg\u00e3o fundamental tanto no processo de nutri\u00e7\u00e3o e comunica\u00e7\u00e3o, quanto na estabilidade da oclus\u00e3o. Apresenta, em sua constitui\u00e7\u00e3o morfol\u00f3gica, predom\u00ednio de fibras musculares dos tipos I e IIa na sua por\u00e7\u00e3o anterior. As fibras do tipo I s\u00e3o resistentes \u00e0 fadiga e as do tipo IIa apresentam r\u00e1pida contra\u00e7\u00e3o. Essa combina\u00e7\u00e3o favorece os movimentos da fala, que s\u00e3o r\u00e1pidos, repetitivos e n\u00e3o requerem muita for\u00e7a. Na base da l\u00edngua predominam fibras do tipo IIb, que possuem maior capacidade de gera\u00e7\u00e3o de for\u00e7a, o que \u00e9 importante para a degluti\u00e7\u00e3o.A l\u00edngua \u00e9 composta por m\u00fasculos intr\u00ednsecos e extr\u00ednsecos e o desempenho de suas fun\u00e7\u00f5es ocorre mediante a intera\u00e7\u00e3o de diferentes grupos musculares, sendo que a maior parte dos movimentos requer intensa contra\u00e7\u00e3o de v\u00e1rios grupos ao mesmo tempo. Entretanto, al\u00e9m da mioterapia, e preferencialmente associada a essa, o fonoaudi\u00f3logo pode lan\u00e7ar m\u00e3o da terapia miofuncional orofacial, que busca melhorar as estruturas e fun\u00e7\u00f5es do sistema estomatogn\u00e1tico por meio de treino funcional assistido.Devido a todas essas especificidades, a aplica\u00e7\u00e3o da fisiologia do exerc\u00edcio para o tratamento das altera\u00e7\u00f5es relacionadas \u00e0 for\u00e7a e/ou \u00e0 resist\u00eancia da l\u00edngua, baseada nos mesmos princ\u00edpios utilizados para os demais m\u00fasculos do corpo, pode n\u00e3o ser uma boa op\u00e7\u00e3o. Esta modalidade terap\u00eautica baseada em exerc\u00edcios, chamada de mioterapia, \u00e9 utilizada para a reabilita\u00e7\u00e3o das altera\u00e7\u00f5es orofaciais de origem muscular e/ou na preven\u00e7\u00e3o dessas altera\u00e7\u00f5es; faz parte da pr\u00e1tica fonoaudiol\u00f3gica em Motricidade Orofacial (MO) e tem por objetivo melhorar a for\u00e7a, resist\u00eancia, mobilidade e coordena\u00e7\u00e3o. Contudo, ao mesmo tempo em que a diversidade de exerc\u00edcios promove uma amplia\u00e7\u00e3o das possibilidades no tratamento individualizado, afetando positivamente a sua efic\u00e1cia, pode dificultar o conhecimento e o desenvolvimento dessas mesmas t\u00e9cnicas se n\u00e3o houver estudos acerca de seus efeitos. O presente artigo traz os resultados de uma investiga\u00e7\u00e3o acerca dos efeitos do treinamento da l\u00edngua a fim de refletir sobre a sua efetividade na perspectiva do cuidado fonoaudiol\u00f3gico.H\u00e1 alguns anos pesquisadores t\u00eam procurado m\u00e9todos para aprimorar o treinamento da musculatura da l\u00edngua e muitos instrumentos e exerc\u00edcios t\u00eam sido elaborados com essa finalidadeO objetivo desta pesquisa foi avaliar a efic\u00e1cia de exerc\u00edcios mioter\u00e1picos no aumento da press\u00e3o e da for\u00e7a lingual. Buscou-se, de forma secund\u00e1ria, analisar quais os tipos de exerc\u00edcios utilizados, os par\u00e2metros de treinamento  e os resultados funcionais obtidos.International Prospective Register of Systematic Reviews (PROSPERO) (CRD42021224324) e desenvolvida de acordo com as diretrizes do protocolo Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), que envolveu as seguintes etapas: elabora\u00e7\u00e3o da pergunta norteadora, estabelecimento de palavras-chave e de crit\u00e9rios de elegibilidade de artigos, sele\u00e7\u00e3o dos artigos e avalia\u00e7\u00e3o cr\u00edtica desses.Foi realizada uma revis\u00e3o sistem\u00e1tica da literatura, registrada na plataforma A pergunta que norteou o presente estudo foi: os exerc\u00edcios mioter\u00e1picos para a l\u00edngua proporcionam aumento de for\u00e7a/press\u00e3o dessa musculatura? De forma secund\u00e1ria, buscou-se conhecer quais os tipos, par\u00e2metros e efeitos funcionais dos exerc\u00edcios utilizados.Medical Subject Heading (MeSH), Descritores em Ci\u00eancias da Sa\u00fade (DeCS) e Embase Subject Headings (Emtree), utilizados na busca foram tongue, muscle strength, physical endurance, resistance training, exercise therapy, rehabilitation, exercise e, os termos livres, lingual e tongue strength, assim como seus equivalentes em portugu\u00eas e espanhol, conforme estrat\u00e9gias de busca apresentadas no Para sele\u00e7\u00e3o dos artigos, houve levantamento na literatura nacional e internacional, sem restri\u00e7\u00e3o de idioma ou do ano de publica\u00e7\u00e3o, utilizando-se as bases de dados Biblioteca Brasileira de Odontologia (BBO), via Biblioteca Virtual em Sa\u00fade (BVS), CINAHL, Cochrane, EMBASE, Lilacs (via BVS), Medline (via Pubmed), Scopus e Web of Science. Os descritores, obtidos nas plataformas Para defini\u00e7\u00e3o dos crit\u00e9rios de elegibilidade, foram utilizados os elementos do PICOT: participantes ; interven\u00e7\u00e3o (exerc\u00edcios para treino de for\u00e7a/press\u00e3o ou resist\u00eancia de l\u00edngua); comparador ; desfechos ; tipo de estudo (ensaios cl\u00ednicos randomizados ou n\u00e3o). Ap\u00f3s o estudo dos t\u00edtulos e resumos, os textos compat\u00edveis com ou que deixaram d\u00favidas quanto aos crit\u00e9rios de elegibilidade foram lidos na \u00edntegra.Sendo assim, com rela\u00e7\u00e3o aos crit\u00e9rios de elegibilidade, foram considerados os seguintes crit\u00e9rios de inclus\u00e3o: artigos originais de pesquisa com delineamento do tipo ensaios cl\u00ednicos; com amostra composta por indiv\u00edduos acima de 18 anos que realizaram exerc\u00edcios para musculatura da l\u00edngua; grupo comparador composto por indiv\u00edduos que n\u00e3o realizaram os exerc\u00edcios propostos ou realizaram outras estrat\u00e9gias terap\u00eauticas; e que avaliaram como desfecho os valores de for\u00e7a ou press\u00e3o e/ou o desempenho em fun\u00e7\u00f5es orofaciais. Constitu\u00edram os crit\u00e9rios de exclus\u00e3o n\u00e3o abordar pelo menos um dos seguintes dados: tipo do exerc\u00edcio, par\u00e2metros de realiza\u00e7\u00e3o e resultados obtidos para pelo menos um desfecho.Ap\u00f3s a leitura na \u00edntegra dos artigos que contemplavam os crit\u00e9rios de elegibilidade, os dados foram reunidos em uma tabela que permitia o preenchimento de informa\u00e7\u00f5es sobre: autor, ano de publica\u00e7\u00e3o, pa\u00eds onde o estudo foi realizado, caracter\u00edsticas da amostra, tipo do exerc\u00edcio, par\u00e2metros do treinamento, instrumentos utilizados na coleta de dados e os resultados do estudo, com \u00eanfase para os valores de press\u00e3o ou for\u00e7a da l\u00edngua.Critical Appraisal Checklist for Randomized Controlled Trials Studies. O instrumento apresenta crit\u00e9rios para avalia\u00e7\u00e3o da qualidade metodol\u00f3gica dos estudos com tr\u00eas possibilidades de resposta: sim, este crit\u00e9rio se verifica; n\u00e3o, este crit\u00e9rio n\u00e3o se verifica e n\u00e3o est\u00e1 claro. Atribuiu-se um ponto para cada resposta sim e zero ponto para as demais respostas. Quanto maior a pontua\u00e7\u00e3o atingida, maior a qualidade interna e menor o risco de vi\u00e9s relacionado \u00e0 qualidade metodol\u00f3gica do estudo. Determinou-se que estudos com menos de 50% das respostas positivas seriam considerados de baixa qualidade metodol\u00f3gica, estudos entre 50 e 75% das respostas positivas considerados de m\u00e9dia qualidade metodol\u00f3gica e estudos com 75% ou mais respostas positivas seriam considerados de alta qualidade metodol\u00f3gica.A avalia\u00e7\u00e3o da qualidade metodol\u00f3gica dos estudos inclu\u00eddos foi realizada por meio da ferramenta JBI funnel plot e teste de Egger, utilizando-se o programa estat\u00edstico STATA, vers\u00e3o 13.0. A avalia\u00e7\u00e3o da qualidade da evid\u00eancia foi realizada pelo Sistema Grading of Recommendations Assessment, Development and Evaluation (GRADE).O vi\u00e9s de publica\u00e7\u00e3o foi analisado por meio de \u00ae. Os artigos que obtiveram respostas sim por parte de duas avaliadoras foram inclu\u00eddos no estudo. A extra\u00e7\u00e3o dos dados foi feita, tamb\u00e9m em planilha Microsoft Excel\u00ae, por pelo menos uma pesquisadora e conferida por pelo menos outra pesquisadora. A an\u00e1lise de qualidade dos estudos foi realizada por uma pesquisadora e conferida por outra pesquisadora.Todas as etapas da pesquisa foram realizadas por tr\u00eas pesquisadoras. A an\u00e1lise dos dados que determinou o cumprimento dos crit\u00e9rios de elegibilidade mediante a uma escala bin\u00e1ria (sim/n\u00e3o) foi realizada de forma manual e independente pelas tr\u00eas participantes, utilizando-se uma planilha do Microsoft ExcelPara a metan\u00e1lise, a medida de efeito da interven\u00e7\u00e3o considerada foi a diferen\u00e7a de press\u00e3o anterior e a diferen\u00e7a de press\u00e3o posterior da l\u00edngua entre os momentos antes e ap\u00f3s a interven\u00e7\u00e3o, a qual foi realizada por meio do m\u00e9todo do inverso da vari\u00e2ncia no software estat\u00edstico STATA, vers\u00e3o 13.0. Os estudos foram analisados em conjunto, bem como de forma subdividida por condi\u00e7\u00e3o cl\u00ednica e idade.Foram localizadas, inicialmente, 526 refer\u00eancias nas bases consultadas sobre exerc\u00edcios destinados ao treinamento da musculatura da l\u00edngua . Ap\u00f3s a elimina\u00e7\u00e3o das duplicatas ficaram 274 artigos e, com a exclus\u00e3o de artigos pela leitura do resumo permaneceram 26, que foram lidos na \u00edntegra. Ap\u00f3s a exclus\u00e3o de outros 12 artigos, que n\u00e3o cumpriram os crit\u00e9rios de elegibilidade, chegaram \u00e0 fase final de inclus\u00e3o para a an\u00e1lise 14 artigos, conforme apresentado na . Os pr\u00f3prios instrumentos para medir for\u00e7a/press\u00e3o de l\u00edngua, apesar de diversos, s\u00e3o recentes e alguns continuam em aperfei\u00e7oamento. Apesar disso, observa-se que a preocupa\u00e7\u00e3o com a reabilita\u00e7\u00e3o das fun\u00e7\u00f5es estomatogn\u00e1ticas se manifesta em diversos pa\u00edses. Dos 14 artigos, todos publicados em l\u00edngua inglesa, dois s\u00e3o brasileiros,14, sendo que os oriundos da Coreia do Sul somam o maior n\u00famero, com oito textos-22; dos Estados Unidos s\u00e3o dois,24; e China e B\u00e9lgica contam com um artigo de cada na\u00e7\u00e3o inclu\u00eddos nesta pesquisa. A faixa et\u00e1ria predominante das amostras compreendeu adultos jovens e idosos entre 24 e 85 anos, num quantitativo aproximado de homens e mulheres.Ao se iniciar a an\u00e1lise dos estudos inclu\u00eddos nesta pesquisa, nota-se que o interesse pelo tema \u00e9 recente, os artigos foram publicados de 2003 a 2020. Este fato pode ser explicado pelo tamb\u00e9m recente surgimento da Motricidade Orofacial como pr\u00e1tica fonoaudiol\u00f3gica regulamentada. No Brasil, por exemplo, a regulamenta\u00e7\u00e3o da profiss\u00e3o de fonoaudi\u00f3logo s\u00f3 ocorreu em 1981, sendo que a concess\u00e3o de T\u00edtulos de Especialistas, incluindo a \u00e1rea de Motricidade Orofacial, foi regulamentada apenas em 1996-17,19 e um com pessoas com c\u00e2ncer em cavidade oral e/ou orofaringe submetidas \u00e0 cirurgia de ressec\u00e7\u00e3o do tumor em p\u00f3s-operat\u00f3rio recente. Altera\u00e7\u00f5es na for\u00e7a/press\u00e3o da l\u00edngua podem afetar tanto a fase oral quanto a fase far\u00edngea da degluti\u00e7\u00e3o, sendo o emprego da for\u00e7a adequada crucial para uma degluti\u00e7\u00e3o eficiente e segura, o que explica o n\u00famero expressivo de estudos inclu\u00eddos nesta pesquisa realizados com essa popula\u00e7\u00e3o. Inclui-se tamb\u00e9m nesta pesquisa um estudo realizado com pessoas com disartria p\u00f3s-AVC. As m\u00e9dias de idade dos indiv\u00edduos destes estudos foram semelhantes, e variaram de 56,2 a 67,3 anos. O A maioria dos estudos foi realizada com pessoas com disfagia, quatro deles devido a acidente vascular cerebral (AVC), estando mais propensos \u00e0 disfagia. Isso justifica o fato de que a metade dos estudos realizados com indiv\u00edduos sem hist\u00f3rico de altera\u00e7\u00f5es orofaciais tenha sido realizada com idosos,22,26, enquanto a outra metade foi realizada com adultos,23,24. Os Essa aten\u00e7\u00e3o \u00e0 for\u00e7a da l\u00edngua e sua rela\u00e7\u00e3o com a degluti\u00e7\u00e3o \u00e9 mais relevante em se tratando de idosos, que apresentam t\u00f4nus reduzido devido \u00e0 perda de massa muscular, natural do envelhecimento, e menor for\u00e7a de reserva,14 ,14  foram in,14 predominaram os exerc\u00edcios orofar\u00edngeos, com diversas varia\u00e7\u00f5es de par\u00e2metros e frequ\u00eancia e dura\u00e7\u00e3o de um a tr\u00eas meses. Exerc\u00edcios de press\u00e3o e fortalecimento de l\u00edngua foram realizados predominantemente por idosos e adultos h\u00edgidos, sendo que os idosos realizaram tamb\u00e9m treino de degluti\u00e7\u00e3o, al\u00e9m de permanecerem em treinamento por mais tempo, em m\u00e9dia oito semanas,22,26, enquanto os h\u00edgidos completavam o treinamento entre quatro e seis semanas,23,24. Os indiv\u00edduos com c\u00e2ncer - geralmente submetidos \u00e0 radioterapia ou quimioterapia - realizaram principalmente exerc\u00edcios para mobilidade dos \u00f3rg\u00e3os fonoarticulat\u00f3rios . Indiv\u00edduos com disfagia p\u00f3s-AVC-17,19 realizaram protrus\u00e3o, retra\u00e7\u00e3o, eleva\u00e7\u00e3o e abaixamento de l\u00edngua por um per\u00edodo aproximado de quatro semanas. Observou-se que o exerc\u00edcio mais realizado dentre os estudos analisados foi o de press\u00e3o de l\u00edngua contra o palato, variando entre isom\u00e9trico e isot\u00f4nico,20-24,26, o que provavelmente se explica pela facilidade de execu\u00e7\u00e3o do exerc\u00edcio.Nos estudos relacionados ao ronco prim\u00e1rio e/ou AOS-24,26, mensuradas utilizando o Iowa Oral Performance Instrument (IOPI). A videofluoroscopia, m\u00e9todo padr\u00e3o ouro para a avalia\u00e7\u00e3o funcional da degluti\u00e7\u00e3o, foi utilizada em quatro estudos,17,19,25. A ultrassonografia para avalia\u00e7\u00e3o da espessura da l\u00edngua e musculatura suprahioidea,21, bem como a polissonografia,14 foram realizadas em dois estudos cada. Outros desfechos analisados foram a resist\u00eancia da l\u00edngua,24 utilizando-se o IOPI, diadococinesia, porcentagem de consoantes articuladas corretamente, taxa de fluxo salivar, impacto na sa\u00fade oral, qualidade do sono e caracter\u00edsticas do ronco,14.Os principais desfechos analisados pelos estudos foram a press\u00e3o m\u00e1xima anterior e/ou posterior. Melhora nos aspectos funcionais foi verificada nos estudos com indiv\u00edduos com AOS,14 e disfagia,16,19. A realiza\u00e7\u00e3o das fun\u00e7\u00f5es se beneficia da melhora de for\u00e7a e resist\u00eancia das estruturas, mas \u00e9 preciso ressaltar que o treino funcional tamb\u00e9m foi realizado pelos participantes dos estudos mencionados. Portanto, n\u00e3o \u00e9 poss\u00edvel avaliar se os exerc\u00edcios em si promoveram qualquer efeito na fun\u00e7\u00e3o.De modo geral, os grupos de estudo apresentaram aumento da press\u00e3o da l\u00edngua ap\u00f3s o tratamento e o grupo controle que realizou algum exerc\u00edcio (mesmo que fosse diferente do grupo de estudo) mostrou melhoras em rela\u00e7\u00e3o aos outros grupos controle que n\u00e3o fizeram exerc\u00edcios nos estudos dos quais participaram. Baseado nos conceitos de fisiologia do exerc\u00edcio, era de se esperar que a realiza\u00e7\u00e3o de exerc\u00edcios apresentasse resultados, considerando que o treino de for\u00e7a promove recrutamento de mais unidades motoras, aumenta a velocidade e coordena\u00e7\u00e3o do recrutamento e transforma fibras indiferenciadas em fibras de for\u00e7a ou resist\u00eancia2 de 0% e o de p=0,650, no teste Q de Cochran, indicam que os estudos, no geral, s\u00e3o homog\u00eaneos quanto aos valores mensurados. Analisando os estudos, de forma geral, na coluna de diferen\u00e7a de m\u00e9dias, verifica-se que o grupo experimental apresentou valores maiores em 6,05 kPa, com valor de p<0,001, portanto apresentando signific\u00e2ncia estat\u00edstica. Alguns estudos apresentaram mais de um grupo experimental,23,26, por isso, cada grupo de estudo em compara\u00e7\u00e3o ao controle foi tratado em uma linha independente. Na an\u00e1lise por subgrupos, houve diferen\u00e7a estatisticamente significante para todos os subgrupos, com aumento de press\u00e3o em 5,74 kPa para adultos sem altera\u00e7\u00f5es orofaciais ; em 7,78 kPa para idosos sem altera\u00e7\u00f5es orofaciais , sendo este o grupo com melhor resultado de ganho de press\u00e3o devido ao exerc\u00edcio; e em 3,57 kPa para indiv\u00edduos com altera\u00e7\u00f5es orofaciais , sendo este o grupo com menor resultado.Onze estudos, por apresentarem a vari\u00e1vel press\u00e3o m\u00e1xima anterior da l\u00edngua antes e ap\u00f3s interven\u00e7\u00e3o no grupo de estudo e no grupo controle, foram utilizados na primeira metan\u00e1lise . Observa2 de 48,5% indicou heterogeneidade moderada para estes valores. Na coluna de diferen\u00e7a de m\u00e9dias, observa-se que o grupo experimental, no geral, apresentou valores maiores em 5,45 kPa, com p<0,001, mostrando evid\u00eancia estat\u00edstica de diferen\u00e7a de press\u00e3o posterior entre os grupos submetidos aos exerc\u00edcios e o grupo controle. Dois estudos apresentaram mais de um grupo experimental,26, por isso cada grupo de estudo em compara\u00e7\u00e3o ao controle foi tratado em uma linha independente. Na an\u00e1lise por subgrupos, houve diferen\u00e7a estatisticamente significante para todos, com aumento de press\u00e3o em 9,32 kPa para idosos sem altera\u00e7\u00f5es orofaciais , sendo este o grupo com melhor resultado de ganho de press\u00e3o devido ao exerc\u00edcio; e em 3,57 kPa para indiv\u00edduos com altera\u00e7\u00f5es orofaciais , sendo este o grupo com menor resultado. N\u00e3o foram encontrados estudos que avaliaram este desfecho em adultos sem altera\u00e7\u00f5es orofaciais.Cinco estudos apresentaram a vari\u00e1vel press\u00e3o m\u00e1xima posterior da l\u00edngua antes e ap\u00f3s interven\u00e7\u00e3o no grupo de estudo e no grupo controle e foram utilizados na segunda metan\u00e1lise . Observa) aliado \u00e0 aus\u00eancia de altera\u00e7\u00f5es morfol\u00f3gicas e/ou neurol\u00f3gicas que poderiam dificultar a realiza\u00e7\u00e3o do exerc\u00edcio e o ganho de for\u00e7a/press\u00e3o.Os melhores resultados observados no grupo de idosos h\u00edgidos provavelmente ocorreram por apresentarem, inicialmente, menores valores de press\u00e3o lingual  e imprecis\u00e3o (n\u00famero de participantes reduzido) .Esta pesquisa identificou que poucos s\u00e3o os estudos realizados sobre o tema, especialmente no que diz respeito \u00e0 press\u00e3o posterior da l\u00edngua. Todos os artigos inclu\u00eddos mostraram algum tipo de benef\u00edcio do treinamento da musculatura da l\u00edngua, quer seja o aumento da medida de press\u00e3o anterior e/ou posterior da l\u00edngua quer seja a melhora funcional. A metan\u00e1lise indicou que o exerc\u00edcio miofuncional resultou no aumento dos desfechos analisados, sendo que os indiv\u00edduos idosos foram os que mais se beneficiaram da terap\u00eautica. Contudo, a maioria dos estudos inclu\u00eddos apresentou vieses relacionados \u00e0 qualidade metodol\u00f3gica, principalmente quanto \u00e0 falta ou inadequa\u00e7\u00e3o da randomiza\u00e7\u00e3o dos participantes nos grupos e cegamento dos avaliadores dos desfechos, e a qualidade da evid\u00eancia foi considerada baixa. Portanto, \u00e9 necess\u00e1ria cautela na interpreta\u00e7\u00e3o dos resultados. e isso deve ser considerado na interpreta\u00e7\u00e3o dos achados deste estudo.Como limita\u00e7\u00f5es da presente pesquisa, tem-se a quantidade reduzida de bases utilizadas na busca e a n\u00e3o investiga\u00e7\u00e3o da literatura cinzenta, o que pode ter ocasionado a n\u00e3o identifica\u00e7\u00e3o de algum estudo relevante. Outra importante limita\u00e7\u00e3o \u00e9 a heterogeneidade verificada, tanto relacionada \u00e0s caracter\u00edsticas da amostra quanto aos tipos de exerc\u00edcios empregados nas diferentes pesquisas. Exerc\u00edcios diferentes podem gerar resultados distintos no ganho de press\u00e3o da l\u00ednguaOs exerc\u00edcios mioter\u00e1picos promovem o aumento da press\u00e3o anterior e posterior da l\u00edngua de indiv\u00edduos adultos; por\u00e9m, a qualidade dessa evid\u00eancia \u00e9 baixa. H\u00e1 variabilidade quanto aos tipos de exerc\u00edcios utilizados e par\u00e2metros de treinamento. N\u00e3o \u00e9 poss\u00edvel afirmar que os exerc\u00edcios promovem melhora funcional."}
+{"text": "This study has as objective the translation and cross-cultural adaptation of the Model Disability Survey (MDS), a World Health Organization instrument that provides comprehensive information on disability/functioning, for Brazil. This is a cross-sectional methodological study, carried out through five stages \u2013 initial translation, synthesis of translations, reverse translation, review by a specialist committee, and pre-test \u2013, considering properties such as semantic, idiomatic, experimental, and conceptual equivalence. Translators, researchers, a mediating team, health professionals, a methodologist and a language specialist were needed to pass through the stages. Statistical analysis was produced from absolute and relative frequencies, measures of central tendency and dispersion, normality tests and content validity index (CVI) > 0.80. The MDS has 474 items, which generated 1,896 analyzes of equivalence. Of these, 160 items had a CVI < 0.80 in at least one of the four types of equivalence and required adjustments. After adaptations and approval by the judges, the pre-final version went on to the pre-test with 30 participants from four regions of the Brazilian Northeast. Regarding this sample, 83.3% are women, single, with an average age of 33.7 years (SD 18.8), self-declared as black or brown, active workers, with technical education and living with three residents. Interviews lasted 123 minutes on average, where 127 health conditions were mentioned, and the most frequent cited were anxiety and back pain. Answers were analyzed and 63 items were cited as needing some adjustment, two of which were submitted for analysis by the committee because they presented a CVI < 0.80. The instrument, guide and presentation cards were adjusted after a new pre-test. The MDS was translated and cross-culturally adapted to Brazilian Portuguese and showed adequate content validity. In Brazil, according to data from the 2019 National Health Survey (PNS), 17.2 million people aged 2 years or over (8.4% of the population) have some type of disability, and of these 8.5 million (24.8%) are older people2 .In 2011, the World Health Organization (WHO) estimated that more than one billion people, equivalent to 15% of the world\u2019s population, have a disability3 . In addition, it is understood that the limited number of questions included in censuses, such as that in Brazil, is not sufficient to measure the number of Persons With Disabilities (PWD), and that, in this scenario, the use of cross-culturally adapted and validated standardized instruments is essential to fill this gap4 .The existing worldwide data on disability need to be standardized, given that, to date, no gold standard instrument has been used for collecting data that provides comprehensive and systematic documentation on the subject5 . The World Report on Disability emphasizes the importance of countries in general being aware of the number of existing PWD, as well as their life contexts, with a view to adapting the provision of services and making them more efficient1 .In this sense, it can be assumed that it is necessary to develop standardized methodologies for collecting PWD data, in line with cultural aspects and consistently applied, which allow international comparisons and monitoring of progress with regard to public policies6 checklist, the Core Sets, the World Health Organization Disability Assessment Schedule (WHODAS 2.0)7 , and the Brazilian Functioning Index (IFBr).In Brazil and in the world, there are measurement instruments aligned with the biopsychosocial model, translated and cross-culturally adapted, which aim to measure functionality, including the International Classification of Functioning, Disability and Health (ICF)6 . The Core Sets are summarized lists of ICF codes with application to specific health conditions, in a quick and easy manner; however, they focus the assessment on the disease/health condition. The WHODAS 2.0 is a generic instrument that assesses the perceived disability associated with the health condition, and it is quick to apply. Nevertheless, it was not created for population surveys and does not have cut-off points for levels of disability7 .The ICF checklist is a generic instrument for health conditions that measures functionality, but the limitation of codes that can be used by each interviewee is a negative point for its application8 . Faced with the need for some changes in the IFBr, the Adapted Brazilian Functioning Index (IFBrA) was created, which is used to assess the need for retirement, and its use is restricted to adults with disabilities active in the labor market11 .The IFBr is an instrument proposed by the Brazilian government in 2011 with the objective of identifying external factors that can influence the individual\u2019s life and how much they can impact on their functionality. It generates a score that classifies the individual\u2019s level of dependence or functional independence as mild, moderate, and severe6 . Especially for countries with equity-based health systems, knowing how many people have disabilities is not enough to determine their health needs; for this, data on disability are needed12 .Another point to be highlighted is the importance of using a standardized tool for collecting population data on the impact of disability on people\u2019s lives, thus avoiding data collection with discordant or mistaken understandings regarding functionality13 . This instrument has two versions, comprehensive and summarized, both standardized for data collection in surveys at the population level, which provide information about how people spend their lives and the barriers they encounter, taking into account environmental and personal factors, capacity and performance, allowing comparisons between groups with different levels of functionality15 .Given the above, the Model Disability Survey (MDS) emerged from a World Bank-WHO partnership13 . In a study with populations from Chile and Sri Lanka, the instrument (short version) revealed valid metrics to measure disability16 .The MDS has already been implemented through national surveys in Chile (2015), Sri Lanka (2015), Philippines (2017), Qatar (2017), Costa Rica (2018) and Afghanistan (2019), regionally in Cameroon (2016), Pakistan (2017) and United Arab Emirates (2018), and also through pilot studies in Cambodia (2014), Malawi (2014) and Oman (2016), thus it has been translated into Arabic, Spanish, Sinhalese, Filipino, French, Khmer, and Dari. However, one has found no studies detailing the MDS translation and cross-cultural adaptation procedures in these countries17 , whose construction facilitates health surveys that compare data on disability at the international level18 . The results from national surveys allow and guide the planning and development of public policies aimed at the full social integration of PWD19 . In this context, the objective of this research was to make the translation and cross-cultural adaptation of the comprehensive version of the MDS for Brazil, as well as analyzing the content validity of this Brazilian version.The MDS is based on the theoretical basis of the ICFRede Fus\u00e3o ).This is a study on MDS cross-cultural translation and adaptation to Brazilian Portuguese, developed by the Research and Innovation Network in Sustainable Development Functionality, Health and Goals , individual questionnaire , and representative questionnaire (with the same items listed in the previous module)21 and complied with the Consensus-based Standards for the Selection of Health Measurement Instruments (Cosmin)22 recommendations. Besides, it followed the guidelines of Beaton and collaborators23 , which provide broad support for the semantic, idiomatic, experimental, and conceptual requirements, establishing five stages, namely: I. Initial translation; II. Synthesis of translations; III. Reverse translation; IV. Review by specialist committee, and V. Pre-test.The process of MDS translation and cross-cultural adaptation followed the guidelines by Fortes and Ara\u00fajoThe first MDS translation (T1 \u2013 stage I) was made by a company specialized in translations, and then the document was revised by the Pan American Health Organization (PAHO) team, representing the translation made with clinical expertise. The second translation (T2) was made by two lay foreign translators with a broad command of Brazilian Portuguese, both not informed of the concepts quantified by the research and without training in the health area.The synthesis of T1 and T2 (T12 version - stage II) was made by a team of 10 researchers from the health area of the Universidade Federal do Rio Grande do Norte (UFRN), four research professors, one master\u2019s student, and five scientific initiation students. T12 was made via virtual meetings, analyzes and comparative discussions about the questionnaires. In order to ensure the quality of the process, all items were peer-reviewed.In the reverse translation stage (stage III), T12 was translated into English again (BT1). This translation was made by a bilingual Canadian translator, who has command of Brazilian Portuguese, without knowledge of the original instrument and concepts explored in the research.24 to select specialists and considered the minimum composition to be: methodologists, health professionals, language professionals, and translators involved in the process. In this sense, the selection criteria were: being a professional with knowledge of functionality, disability or of the process of translation and validation of health measurement instruments. The specialists were selected from different Brazilian states by consulting their Lattes Curricula of the National Council for Scientific and Technological Development (CNPq), forming a committee with four judges  and a specialist in languages. The judges received seven documents with T1, T2, T12, BT1, the MDS in English, the MDS guide in English and Portuguese, schedule of meetings, and other guidelines related to equivalence. These professionals read and analyzed the documents in full with the help of the mediating committee , and the residual divergences were sent to the language specialist. This mediation team had the main role of guiding the judge committee during the stage, planning and executing strategic virtual meetings, as well as making all necessary adjustments and adaptations to the documents in accordance with the committee\u2019s guidelines.Stage IV was based on the criteria of JasperEach questionnaire item was evaluated using a tool created in Google Sheets, which enabled analyzes being conducted, shared individually with each judge. This tool included all items from the original instrument and from the T12 version, subdivided according to the MDS modules, with qualitative and quantitative fields, one for considerations about translations, adequacy of items and possible suggestions, respectively; and another to classify the semantic, idiomatic, experimental, and conceptual equivalence as adequate translation (AT), partially adequate translation (PAT), and inadequate translation (IT).25 was considered, which refers to the degree to which the content of an instrument reflects adequately the construct measured. The CVI is based on the specialists\u2019 evaluation for each item according to the relevance of the content of an instrument, usually judged by means of Likert scales26 . As four members (25% per member)25 composed the committee, when one of the judges disagreed with an item, it was reviewed.In the process of individual evaluation of the items, a Content Validity Index (CVI) greater than 80%The judges\u2019 suggestions were grouped together with their respective justifications and adjusted according to the judges\u2019 consensus. Finally, an integrative seminar was held with the members of this stage through a virtual meeting so that to analyze the instrument in its pre-final version and make adjustments before the pre-test.For the pre-test stage (stage V), the inclusion criteria for participants were: people over 18 years of age and with the cognitive ability to answer the questionnaire. The exclusion criteria adopted were: refusing to answer all the questions in the questionnaire and withdrawing from the interview before it was completed.The sample consisted of 30 participants, selected for convenience according to the eligibility criteria and interviewers\u2019 location. Participants were invited by telephone and the interview was conducted in person, in a reserved room. The collection was carried out by eight members of the research project team, composed of professors and students from the UFRN master\u2019s degree courses, who received prior training to carry out the interviews and had knowledge of the study subject.Answers to the questionnaire were sent by the interviewers to an online database, using Google Forms previously prepared for this stage, in addition to a specific form to assess the interviewee\u2019s understanding. This form was used to record the items that, due to the participant\u2019s report or perception of difficulty observed during the interview, required adjustments to improve understanding. All interviewers were instructed to apply the questions of the comprehension form at the end of each MDS module.After completing the collection of stage V, all items mentioned in the understanding form were analyzed. For this analysis, the CVI was also considered: % agreement=number of participants who agreed/total number of participants*100. That is, 80%=X/30*100.In this sense, when there were seven or more citations of disagreement regarding an item in the understanding form (IVC < 80), it was re-analyzed by the specialist committee. The adjusted items were evaluated by the 30 participants through a new pre-test stage, performed only with these pending items, according to a Likert scale of level of understanding, with the following answer alternatives: 1. Very good; 2. Good; 3. Regular quality; 4. Poor; 5. Very poor. At this stage, if there were seven or more citations per item listed as \u201cPoor\u201d or \u201cVery poor,\u201d it was re-analyzed. As the pre-test was done only with the missing items, the interviewers could take this stage via telephone, in order to facilitate the collection process.The synthesis of all stages of MDS translation and cross-cultural adaptation is presented in the 20 guide and the presentation cards file were translated as well, which was done by Brazilian professionals with extensive experience in translations and Portuguese teachers, and subsequently submitted to the specialist committee. Therefore, they went through a process similar to that of the comprehensive instrument.The MDS\u00ae, version 2016, and analyzed using the Statistical Package for Social Sciences (SPSS for Windows)\u00ae, version 25.0. The sample distribution was presented by means of absolute and relative frequency, and the descriptive analysis was performed using measures of central tendency and dispersion, that is, median and quartiles, respectively. Shapiro-Wilk normality test was applied to verify the distribution normality of the quantitative variables. CVI was used during stages IV and V to measure the proportion or percentage of agreement on the instrument items and establish that the stages were carried out until all items, or a set of items, reached agreement > 0.8026.All data collected were entered into a database, created using Microsoft ExcelAll participants in stage V were informed about the research and authorized their participation by signing the Informed Consent Form (ICF). The study complied with the ethical precepts that govern research with human beings in accordance with Resolution No. 466/12 of the National Health Council (CNS), and specified in the Declaration of Helsinki, with the approval of the Institutional Research Ethics Committee of the Faculdade de Ci\u00eancias da Sa\u00fade do Trairi (Facisa) under No. 4.102.958 and Ethical Assessment Presentation Certificate (Caae) No. 31112020.4.0000.5568.During the specialist committee stage, the MDS was considered with a total of 474 items, in which statements and module titles count was also included. However, as each item was analyzed according to four types of equivalence , there were a total of 1,896 analyzes per judge. A total of 327 equivalents (17.25%) were considered partially adequate and inadequate by the specialists. Taking into account only the divergent items, that is, those in which at least one of the four types of equivalence was classified as PAT or IT by at least one judge, a total of 160 items were sent for discussion with the other judge committee members to deliberation and consensus about the pre-final version.Due to the large number of items present in the MDS, the In the pre-test application stage, the interviews were carried out in different states of the Brazilian Northeast, 22 in Rio Grande do Norte (73.3%), four in Cear\u00e1 (13.3) and four in Para\u00edba (13.3 %), and had an average duration of 123 minutes. Participants mentioned 127 health conditions and most reported having more than one condition, among which the most prevalent were anxiety (14), back pain or herniated disc (13), arthritis or arthrosis (11), hypertension (8), asthma or allergic respiratory disease (8), migraine (8), trouble sleeping (7), gastritis or ulcer (6), tinnitus (6), vision loss (5), depression (5), diabetes (4), and other health conditions (32).After analyzing the answers from the form related to the participants\u2019 understanding, 63 items needed some adjustment for understanding and, of these, two  were sent for analysis by the specialist committee for presenting CVI < 0.80. Such items were submitted to the judge committee and the modifications were made. The items were re-applied to the 30 participants via telephone. The new structure of the items was evaluated by the participants according to a Likert scale of level of understanding, with a CVI > 80 .21 without the need for review by the committee. All adjustments and layouts made in the questionnaire were replicated in the guide and instrument presentation cards, which are available for access on Google drive via linkaIn addition to these, the other items, with errors in grammar, spelling, typing and formatting, were judged by the mediators, observed and adjusted in the questionnaire and in the guide, as recommended by the checklist by Fortes and Ara\u00fajo16 .The use of MDS-Brasil will contribute to surveying the Brazilians\u2019 health needs, knowledge of health conditions, identification of environmental factors, activity limitations, and restrictions on population participation. The comprehensive version of the MDS-Brasil requires application time of around 12 to 15 minutes and should be explored in population surveys, as it is highly capable of generating broad and rich data that aim to improve the lives of persons with different degree disabilities. The summary version (Brief MDS) uses questions selected from the original MDS and can be used as a complementary starting point module for countries interested in developing their own disability modules for household surveys, with an estimated application time of 15 minutes13 , and that the short version is already available for use in surveys16 .During the process of applying the MDS to the target population, it was observed that the greatest difficulty reported by the participants, and perceived by the research team, was related to the time needed to complete the interview, since the shortest period of time spent was 1 hour and 10 minutes, and the longest 2 hours and 50 minutes. The comments referred to by the sample were based, above all, on the fact that the questionnaire was extensive, tiring and with redundant questions, however it is worth noting that the MDS has a modular format, then the country can choose the modules to be applied, respecting the mandatory modulesMoreover, this application time also includes filling out the ICF and the comprehension questionnaire . On the other hand, since a tablet application is used during the interview in the population survey and also considering that the interviewer is trained and has experience for its application, it is possible to infer that there will be greater agility to conduct the interview and record the information.The fact that the sample evaluated in the pre-test was not composed of persons with different disabilities is considered a study limitation, and, therefore, not all questionnaire items were applied.13 . In this sense, the convergent validity, internal consistencies and other psychometric properties of the Brazilian version of the MDS will be measured in the coming months by the research network.The psychometric evaluation of the instrument is still necessary, mainly involving populations with disabilities or with specific health conditions15 . Moreover, making the MDS available for use in population data surveys offers an opportunity to generate health indicators on functionality, overcoming the limited approach of mortality and morbidity indicators, contributing to more equitable health care, and allowing the design of collective health interventions that address the real needs of the population27 .After analyzing the psychometric properties of the MDS-Brasil, regional and national surveys are expected to be carried out to delineate the profile of functionality and health needs in Brazil from the perspective of the biopsychosocial model, fulfilling one of the applications of the ICF as a social policy tool in the planning of social security systems, compensation systems and the design and implementation of public policiesThe MDS was translated into Brazilian Portuguese and adapted cross-culturally for the Brazilian population with adequate content validity, resulting in the MDS-Brazil version, a WHO tool. The study complied with current international and national operational standards for studies of translation and cross-cultural adaptation of health instruments.The target audience accepted and understood the Brazilian version of the MDS, which is indicated for population, regional and national surveys, for PWD and people without disabilities. 1 . No Brasil, de acordo com dados da Pesquisa Nacional de Sa\u00fade (PNS) de 2019, 17,2 milh\u00f5es de pessoas com 2 anos ou mais de idade  possuem algum tipo de defici\u00eancia, e destes 8,5 milh\u00f5es  s\u00e3o idosos2 .A Organiza\u00e7\u00e3o Mundial da Sa\u00fade (OMS), em 2011, estimou que mais de um bilh\u00e3o de pessoas, o equivalente a 15% da popula\u00e7\u00e3o mundial, t\u00eam alguma defici\u00eancia3 . Al\u00e9m disso, compreende-se que o n\u00famero limitado de perguntas inclu\u00eddas em censos, como o do Brasil, n\u00e3o \u00e9 suficiente para fornecer uma medida precisa da quantidade de pessoas com defici\u00eancia (PCD), e que, nesse cen\u00e1rio, a utiliza\u00e7\u00e3o de instrumentos padronizados, adaptados transculturalmente e validados \u00e9 imprescind\u00edvel para o preenchimento dessa lacuna4 .Mundialmente, os dados existentes sobre defici\u00eancia carecem de padroniza\u00e7\u00e3o, pois at\u00e9 o momento n\u00e3o se utiliza um instrumento padr\u00e3o-ouro para coleta de dados que propicie uma documenta\u00e7\u00e3o abrangente e sistem\u00e1tica sobre o tema5 . O Relat\u00f3rio Mundial sobre a Defici\u00eancia ressalta a import\u00e2ncia dos pa\u00edses em geral terem conhecimento do n\u00famero de PCD existentes, bem como seus contextos de vida, visando adequar a presta\u00e7\u00e3o de servi\u00e7os e torn\u00e1-los mais resolutivos1 .Nesse sentido, compreende-se que \u00e9 necess\u00e1rio o desenvolvimento de metodologias padronizadas para a coleta de dados de PCD, em conson\u00e2ncia com aspectos culturais e aplicadas de forma consistente, que possibilitem compara\u00e7\u00f5es internacionais e permitam o monitoramento de progressos no que se refere \u00e0s pol\u00edticas p\u00fablicas6 , os Core Sets , o World Health Organization Disability Assessment Schedule (WHODAS 2.0)7 e o \u00cdndice de Funcionalidade Brasileiro (IFBr).No Brasil e no mundo h\u00e1 instrumentos de medida alinhados ao modelo biopsicossocial, traduzidos e adaptados transculturalmente, que visam mensurar funcionalidade, entre eles o checklist da Classifica\u00e7\u00e3o Internacional de Funcionalidade, Incapacidade e Sa\u00fade (CIF)6 . Os Core Sets s\u00e3o listas resumidas dos c\u00f3digos da CIF com aplica\u00e7\u00e3o para condi\u00e7\u00f5es de sa\u00fade espec\u00edficas, de modo r\u00e1pido e f\u00e1cil, contudo, centralizam a avalia\u00e7\u00e3o na doen\u00e7a/condi\u00e7\u00e3o de sa\u00fade. O WHODAS 2.0 trata-se de instrumento gen\u00e9rico que avalia a incapacidade percebida associada \u00e0 condi\u00e7\u00e3o de sa\u00fade, sendo de r\u00e1pida aplica\u00e7\u00e3o. Todavia, n\u00e3o foi criado para inqu\u00e9ritos populacionais e n\u00e3o possui pontos de corte para n\u00edveis de defici\u00eancia7 .O checklist da CIF \u00e9 um instrumento gen\u00e9rico para as condi\u00e7\u00f5es de sa\u00fade que mensura funcionalidade, todavia, a limita\u00e7\u00e3o de c\u00f3digos que podem ser utilizados por cada entrevistado constitui um ponto negativo para sua aplica\u00e7\u00e3o8 . Diante da necessidade de algumas modifica\u00e7\u00f5es no IFBr, foi elaborado o \u00cdndice de Funcionalidade Brasileiro Adaptado (IFBrA), o qual \u00e9 utilizado para avaliar a necessidade da aposentadoria, estando seu uso restrito a pessoas adultas com defici\u00eancias ativas no mercado de trabalho11 .O IFBr \u00e9 um instrumento proposto pelo governo brasileiro em 2011 com o objetivo de identificar fatores externos que podem influenciar a vida do indiv\u00edduo e o quanto podem impactar em sua funcionalidade. O IFBr gera pontua\u00e7\u00e3o que quantifica o n\u00edvel de depend\u00eancia ou independ\u00eancia funcional do indiv\u00edduo em leve, moderada e grave6 . Ressalta-se que, principalmente para pa\u00edses com sistemas de sa\u00fade baseados na equidade, saber quantas pessoas apresentam defici\u00eancias n\u00e3o \u00e9 suficiente para determinar suas necessidades de sa\u00fade; para isso, s\u00e3o necess\u00e1rios dados sobre a incapacidade12 .Outro ponto a ser destacado \u00e9 a import\u00e2ncia da utiliza\u00e7\u00e3o de uma ferramenta padronizada para levantamento de dados populacionais sobre o impacto da incapacidade na vida das pessoas, evitando assim que ocorra coleta de dados com compreens\u00f5es destoantes ou equivocadas a respeito da funcionalidadeModel Disability Survey (MDS), a partir de uma parceria entre o Banco Mundial e a OMS13 . Tal instrumento apresenta duas vers\u00f5es, abrangente e resumida, ambas de car\u00e1ter padronizado para coleta de dados em inqu\u00e9ritos em n\u00edvel populacional, que fornecem informa\u00e7\u00f5es sobre como as pessoas conduzem suas vidas e as barreiras que encontram, levando em considera\u00e7\u00e3o fatores ambientais e pessoais, capacidade e desempenho, permitindo compara\u00e7\u00f5es entre grupos com diferentes n\u00edveis de funcionalidade15 .Diante do exposto, surgiu o 13 . Em estudo com popula\u00e7\u00f5es do Chile e do Sri Lanka, o instrumento (vers\u00e3o resumida) revelou m\u00e9tricas v\u00e1lidas para mensurar a defici\u00eancia16 .O instrumento MDS j\u00e1 foi implementado por meio de inqu\u00e9ritos nacionais no Chile (2015), Sri Lanka (2015), Filipinas (2017), Catar (2017), Costa Rica (2018) e Afeganist\u00e3o (2019), regionalmente em Camar\u00f5es (2016), Paquist\u00e3o (2017) e Emirados \u00c1rabes Unidos (2018), tamb\u00e9m por meio de estudos piloto em Camboja (2014), Mal\u00e1iu (2014) e Om\u00e3 (2016), sendo, portanto, traduzido para os idiomas \u00e1rabe, espanhol, cingal\u00eas, filipino, franc\u00eas, quemer e dari. No entanto, n\u00e3o foram encontrados estudos que detalhassem os procedimentos de tradu\u00e7\u00e3o e adapta\u00e7\u00e3o transcultural do MDS nesses pa\u00edses17 , cuja constru\u00e7\u00e3o facilita inqu\u00e9ritos de sa\u00fade que comparam internacionalmente dados sobre incapacidade ou defici\u00eancia18 . Os resultados provenientes de inqu\u00e9ritos nacionais permitem e norteiam o planejamento e desenvolvimento de pol\u00edticas p\u00fablicas voltadas \u00e0 plena integra\u00e7\u00e3o social das PCD19 . Nesse contexto, o objetivo desta pesquisa foi realizar a tradu\u00e7\u00e3o e adapta\u00e7\u00e3o transcultural da vers\u00e3o abrangente do MDS para o Brasil, assim como analisar a validade de conte\u00fado dessa vers\u00e3o brasileira.O MDS fundamenta-se na base te\u00f3rica da CIFTrata-se de um estudo de tradu\u00e7\u00e3o e adapta\u00e7\u00e3o transcultural do instrumento MDS para o portugu\u00eas do Brasil, desenvolvido pela Rede de Pesquisa e Inova\u00e7\u00e3o em Funcionalidade, Sa\u00fade e Objetivos de Desenvolvimento Sustent\u00e1vel (Rede Fus\u00e3o).20 . O MDS \u00e9 predominantemente utilizado em popula\u00e7\u00f5es com 18 anos ou mais, embora tamb\u00e9m possua um m\u00f3dulo infantil.O prop\u00f3sito do MDS \u00e9 coletar dados sobre todas as dimens\u00f5es da defici\u00eancia de forma a conseguir informa\u00e7\u00f5es abrangentes e relevantes que ajudem pa\u00edses a constru\u00edrem um retrato da defici\u00eancia, com relev\u00e2ncia particular para a pol\u00edtica em defici\u00eancia; compara\u00e7\u00f5es internacionais diretas e confi\u00e1veis de dados sobre o assunto; e monitoramento nacional e global da implementa\u00e7\u00e3o da Conven\u00e7\u00e3o Internacional sobre os Direitos das Pessoas com Defici\u00eancia. O MDS \u00e9 subdivido em: question\u00e1rio sobre o domic\u00edlio , question\u00e1rio individual  e question\u00e1rio do representante (com os mesmos itens enumerados no m\u00f3dulo anterior)21 e obedeceu \u00e0s recomenda\u00e7\u00f5es do Consensus-based Standards for the Selection of Health Measurement Instruments (Cosmin)22 . Al\u00e9m disso, seguiu as orienta\u00e7\u00f5es de Beaton e colaboradores23 , que fornecem amplo respaldo \u00e0s exig\u00eancias sem\u00e2ntica, idiom\u00e1tica, experimental e conceitual, estabelecendo cinco etapas, sendo elas: I. Tradu\u00e7\u00e3o inicial, II. S\u00edntese das tradu\u00e7\u00f5es, III. Tradu\u00e7\u00e3o reversa, IV. Revis\u00e3o por comit\u00ea de especialistas e V. Pr\u00e9-teste.O processo de tradu\u00e7\u00e3o e adapta\u00e7\u00e3o transcultural do question\u00e1rio MDS seguiu as orienta\u00e7\u00f5es de Fortes e Ara\u00fajoA primeira tradu\u00e7\u00e3o (T1 \u2013 etapa I) do instrumento MDS foi realizada por empresa especializada em tradu\u00e7\u00f5es e, em seguida, o documento foi revisado pela equipe da Organiza\u00e7\u00e3o Pan-Americana da Sa\u00fade (Opas), representando a tradu\u00e7\u00e3o realizada com expertise cl\u00ednica. A segunda tradu\u00e7\u00e3o (T2) foi feita por dois tradutores leigos, de origem estrangeira e com amplo dom\u00ednio do portugu\u00eas, ambos n\u00e3o informados dos conceitos quantificados pela pesquisa e sem forma\u00e7\u00e3o na \u00e1rea da sa\u00fade.A s\u00edntese das tradu\u00e7\u00f5es T1 e T2 (vers\u00e3o T12 \u2013 etapa II) foi realizada por uma equipe de 10 pesquisadores da \u00e1rea da sa\u00fade da Universidade Federal do Rio Grande do Norte (UFRN), sendo eles quatro professoras pesquisadoras, uma discente de mestrado e cinco discentes de inicia\u00e7\u00e3o cient\u00edfica. A elabora\u00e7\u00e3o da T12 foi realizada via reuni\u00f5es virtuais, an\u00e1lises e discuss\u00f5es comparativas dos question\u00e1rios. A fim de garantir a qualidade do processo, todos os itens passaram por revis\u00e3o por pares.Na etapa de tradu\u00e7\u00e3o reversa (etapa III), a vers\u00e3o T12 foi submetida a nova tradu\u00e7\u00e3o para o idioma ingl\u00eas (BT1). Esta foi realizada por um tradutor bil\u00edngue, nativo do Canad\u00e1, que possui dom\u00ednio do portugu\u00eas, sem conhecimento do instrumento original e dos conceitos explorados na pesquisa.24 para sele\u00e7\u00e3o dos especialistas e considerou como composi\u00e7\u00e3o m\u00ednima: metodologistas, profissionais da sa\u00fade, profissionais de idiomas e tradutores envolvidos no processo. Nesse sentido, os crit\u00e9rios para sele\u00e7\u00e3o foram: ser profissional com conhecimento sobre funcionalidade, defici\u00eancia ou sobre o processo de tradu\u00e7\u00e3o e valida\u00e7\u00e3o de instrumentos de medida em sa\u00fade. Os especialistas foram selecionados de diferentes estados brasileiros por meio de consulta ao Curr\u00edculo Lattes do Conselho Nacional de Desenvolvimento Cient\u00edfico e Tecnol\u00f3gico (CNPq), formando o comit\u00ea com quatro ju\u00edzes (sendo um deles metodologista e todos profissionais da \u00e1rea da sa\u00fade) e uma especialista em idiomas. Os ju\u00edzes receberam sete documentos com as vers\u00f5es T1, T2, T12, BT1, instrumento MDS em ingl\u00eas, manual do MDS em ingl\u00eas e portugu\u00eas, cronograma das reuni\u00f5es e demais orienta\u00e7\u00f5es relacionadas \u00e0s equival\u00eancias. Esses profissionais realizaram a leitura e an\u00e1lise completa dos documentos com aux\u00edlio da comiss\u00e3o mediadora  e as diverg\u00eancias residuais foram enviadas para a especialista em idiomas. Essa equipe de media\u00e7\u00e3o tinha como papel principal nortear o comit\u00ea de ju\u00edzes ao decorrer da etapa, planejar e executar reuni\u00f5es virtuais estrat\u00e9gicas, assim como realizar todos os ajustes e adequa\u00e7\u00f5es necess\u00e1rios nos documentos de acordo com as orienta\u00e7\u00f5es do comit\u00ea.A etapa IV baseou-se nos crit\u00e9rios de JasperCada item do question\u00e1rio foi avaliado por meio de uma ferramenta elaborada nas Planilhas Google, que viabilizou as an\u00e1lises, compartilhadas individualmente com cada juiz. Essa ferramenta incluiu todos os itens do instrumento original e da vers\u00e3o T12, subdivido de acordo com os m\u00f3dulos do MDS, com campos de car\u00e1ter qualitativo e quantitativo, sendo, respectivamente, um para considera\u00e7\u00f5es sobre as tradu\u00e7\u00f5es, adequa\u00e7\u00e3o dos itens e poss\u00edveis sugest\u00f5es; e outro para classificar as equival\u00eancias sem\u00e2ntica, idiom\u00e1tica, experimental e conceitual como tradu\u00e7\u00e3o adequada (TA), tradu\u00e7\u00e3o parcialmente adequada (TPA) e tradu\u00e7\u00e3o inadequada (TI).25 , que se refere ao grau em que o conte\u00fado de um instrumento reflete adequadamente o construto que est\u00e1 sendo medido. O IVC \u00e9 baseado na avalia\u00e7\u00e3o de especialistas para cada item de acordo com a relev\u00e2ncia do conte\u00fado de um instrumento, julgado geralmente por meio de escalas Likert26 . Como o comit\u00ea contou com a participa\u00e7\u00e3o de quatro membros (25% por membro)25 , quando um dos ju\u00edzes discordou a respeito de um item, este foi considerado alvo de alguma revis\u00e3o.No processo de avalia\u00e7\u00e3o individual dos itens, foi considerado o \u00edndice de validade de conte\u00fado (IVC) maior que 80%As sugest\u00f5es realizadas pelos ju\u00edzes foram agrupadas, junto das respectivas justificativas, e ajustadas de acordo com o consenso dos ju\u00edzes. Por fim, foi realizado um semin\u00e1rio integrativo, com os membros dessa etapa, por meio de reuni\u00e3o virtual para an\u00e1lise do instrumento em sua vers\u00e3o pr\u00e9-final e ajustes antes do pr\u00e9-teste.Para a etapa de pr\u00e9-teste (etapa V), os crit\u00e9rios de inclus\u00e3o de participantes foram: pessoas maiores de 18 anos e com capacidade cognitiva de responder ao question\u00e1rio. Os crit\u00e9rios de exclus\u00e3o adotados foram: negar-se a responder a todas as perguntas do question\u00e1rio e desistir da entrevista antes de ser finalizada.A amostra foi composta por 30 participantes, selecionada por conveni\u00eancia de acordo com os crit\u00e9rios de elegibilidade e a localidade dos entrevistadores. Os participantes foram convidados por contato telef\u00f4nico e a entrevista foi realizada de forma presencial, em sala reservada. A coleta foi feita por oito membros da equipe do projeto de pesquisa, composto por docentes e discentes dos mestrados da UFRN, que receberam treinamento pr\u00e9vio para realiza\u00e7\u00e3o das entrevistas e possu\u00edam conhecimento sobre a tem\u00e1tica do estudo.As respostas ao question\u00e1rio foram enviadas pelos entrevistadores para um banco de dados on-line, por meio de Formul\u00e1rios Google previamente elaborados para esta etapa, al\u00e9m de um espec\u00edfico para avaliar a compreens\u00e3o do entrevistado. Esse formul\u00e1rio foi utilizado para registro dos itens que, por autorrelato do participante ou por percep\u00e7\u00e3o de dificuldade observada durante a entrevista, necessitavam de ajustes para melhorar o entendimento. Todos os entrevistadores foram orientados a aplicar as perguntas do formul\u00e1rio de compreens\u00e3o ao final de cada m\u00f3dulo do MDS.Ap\u00f3s a finaliza\u00e7\u00e3o da coleta da etapa V, todos os itens citados no formul\u00e1rio de compreens\u00e3o foram analisados. Para essa an\u00e1lise tamb\u00e9m foi considerado o IVC: % concord\u00e2ncia=n\u00famero de participantes que concordaram/n\u00famero total de participantes*100. Ou seja, 80%=X/30*100.Nesse sentido, quando houve sete ou mais cita\u00e7\u00f5es de discord\u00e2ncia a respeito de um item no formul\u00e1rio de compreens\u00e3o (IVC < 80), este passou por nova an\u00e1lise do comit\u00ea de especialistas. Os itens ajustados foram avaliados pelos 30 participantes por meio de nova etapa de pr\u00e9-teste, realizada apenas com esses itens pendentes, de acordo com uma escala Likert de n\u00edvel de compreens\u00e3o, com as seguintes alternativas de respostas: 1. Muito boa, 2. Boa, 3. Regular, 4. Ruim, 5. Muito ruim. Nessa etapa, caso houvesse sete ou mais cita\u00e7\u00f5es por item elencados como \u201cRuim\u201d ou \u201cMuito ruim\u201d, este era reanalisado. Como a nova realiza\u00e7\u00e3o do pr\u00e9-teste se deu apenas com os itens faltantes, foi permitido aos entrevistadores a realiza\u00e7\u00e3o dessa etapa via contato telef\u00f4nico, visando facilitar o processo de coleta.O resumo de todas as etapas de tradu\u00e7\u00e3o e adapta\u00e7\u00e3o transcultural do MDS est\u00e1 contido na 20 e o arquivo dos cart\u00f5es de apresenta\u00e7\u00e3o tamb\u00e9m passaram por processo de tradu\u00e7\u00e3o, feito por profissionais naturais do Brasil com ampla experi\u00eancia em tradu\u00e7\u00f5es e professores de l\u00edngua portuguesa, e posteriormente foram encaminhados para o comit\u00ea de especialistas. Portanto, passaram por um processo semelhante ao do instrumento abrangente.O manual do MDS\u00ae, vers\u00e3o 2016, e analisados com o programa Statistical Package for the Social Science (SPSS for Windows )\u00ae, vers\u00e3o 25.0. A distribui\u00e7\u00e3o da amostra foi apresentada por meio de frequ\u00eancia absoluta e relativa, e a an\u00e1lise descritiva foi realizada utilizando as medidas de tend\u00eancia central e dispers\u00e3o, sendo mediana e quartis respectivamente. Para verificar a normalidade de distribui\u00e7\u00e3o das vari\u00e1veis quantitativas, foi aplicado o teste de normalidade de Shapiro-Wilk. O IVC foi utilizado durante as etapas IV e V para medir a propor\u00e7\u00e3o ou porcentagem de concord\u00e2ncia sobre os itens do instrumento e estabelecer que as etapas fossem realizadas at\u00e9 todos os itens, ou conjunto de itens, atingirem concord\u00e2ncia > 0,8026 .Todos os dados coletados foram inseridos em um banco de dados, elaborado por meio do Microsoft ExcelTodos os participantes da etapa V foram informados sobre a pesquisa e autorizaram a participa\u00e7\u00e3o atrav\u00e9s da assinatura do Termo de Consentimento Livre e Esclarecido (TCLE). O estudo cumpriu os preceitos \u00e9ticos que regem a pesquisa com seres humanos conforme Resolu\u00e7\u00e3o n\u00ba 466/12 do Conselho Nacional de Sa\u00fade (CNS), e especificado na Declara\u00e7\u00e3o de Helsinque, com a aprova\u00e7\u00e3o do Comit\u00ea de \u00c9tica em Pesquisa Institucional da Faculdade de Ci\u00eancias da Sa\u00fade do Trairi (Facisa) sob o n. 4.102.958 e Certificado de Apresenta\u00e7\u00e3o de Aprecia\u00e7\u00e3o \u00c9tica (Caae) n. 31112020.4.0000.5568.Durante a etapa do comit\u00ea de especialistas, o instrumento MDS foi considerado com totalidade de 474 itens, na qual tamb\u00e9m foi inclu\u00edda a contagem dos enunciados e t\u00edtulos dos m\u00f3dulos. No entanto, como cada item foi analisado de acordo com quatro equival\u00eancias , houve um total de 1.896 an\u00e1lises por juiz. A Um total de 327 equival\u00eancias  foram julgadas como parcialmente adequadas e inadequadas pelos especialistas. Considerando apenas os itens divergentes, ou seja, aqueles nos quais pelo menos uma das quatro equival\u00eancias foi classificada como TPA ou TI por pelo menos um juiz, obteve-se um total de 160 itens encaminhados para discuss\u00e3o com os demais membros do comit\u00ea de ju\u00edzes para delibera\u00e7\u00e3o e consenso da vers\u00e3o pr\u00e9-final.Em raz\u00e3o do grande n\u00famero de itens presentes no question\u00e1rio MDS, o Na etapa de aplica\u00e7\u00e3o do pr\u00e9-teste, as entrevistas foram realizadas em diferentes estados do Nordeste brasileiro, sendo 22 no Rio Grande do Norte , quatro no Cear\u00e1  e quatro na Para\u00edba , e tiveram um tempo m\u00e9dio de 123 minutos de dura\u00e7\u00e3o. Na Foram citadas 127 condi\u00e7\u00f5es de sa\u00fade pelos participantes e a maioria informou possuir mais de uma condi\u00e7\u00e3o, dentre elas as mais prevalentes foram ansiedade (14), dores nas costas ou h\u00e9rnia de disco (13), artrite ou artrose (11), hipertens\u00e3o (8), asma ou doen\u00e7a respirat\u00f3ria al\u00e9rgica (8), enxaqueca (8), problemas para dormir (7), gastrite ou \u00falcera (6), zumbido (6), perda da vis\u00e3o (5), depress\u00e3o (5), diabetes (4) e outras condi\u00e7\u00f5es de sa\u00fade (32).Ap\u00f3s a an\u00e1lise das respostas do formul\u00e1rio de compreens\u00e3o dos participantes, 63 itens necessitaram de algum ajuste para o entendimento e, destes, dois  foram encaminhados para an\u00e1lise do comit\u00ea de especialistas por possu\u00edrem IVC < 0,80. Tais itens foram encaminhados ao comit\u00ea de ju\u00edzes e as modifica\u00e7\u00f5es foram executadas. Os itens foram reaplicados nos 30 participantes via contato telef\u00f4nico. A nova estrutura dos itens foi avaliada pelos participantes de acordo com uma escala Likert de n\u00edvel de compreens\u00e3o, sendo obtido IVC > 80 .21 sem necessidade de revis\u00e3o pelo comit\u00ea. Todos os ajustes e diagrama\u00e7\u00f5es realizados no question\u00e1rio foram replicados no manual e cart\u00f5es de apresenta\u00e7\u00e3o do instrumento, que est\u00e3o dispon\u00edveis para acesso atrav\u00e9s do link do drivea .Al\u00e9m destes, os demais itens, com erros de gram\u00e1tica, ortografia, digita\u00e7\u00e3o e formata\u00e7\u00e3o, foram julgados pelos mediadores, observados e ajustados no question\u00e1rio e no manual, conforme preconizado pelo checklist de Fortes e Ara\u00fajoBrief MDS) utiliza perguntas selecionadas do MDS original e pode ser utilizado como um m\u00f3dulo complementar de ponto de partida para pa\u00edses interessados em desenvolver seus pr\u00f3prios m\u00f3dulos de defici\u00eancia para pesquisas domiciliares, com um tempo estimado de aplica\u00e7\u00e3o de 15 minutos16 .O uso do MDS-Brasil contribuir\u00e1 para o levantamento das necessidades em sa\u00fade dos brasileiros, o conhecimento de condi\u00e7\u00f5es de sa\u00fade, a identifica\u00e7\u00e3o de fatores ambientais, a limita\u00e7\u00e3o de atividades e as restri\u00e7\u00f5es de participa\u00e7\u00e3o populacional. A vers\u00e3o abrangente do MDS-Brasil demanda tempo de aplica\u00e7\u00e3o em torno de 120 a 15 minutos e deve ser explorada em inqu\u00e9ritos populacionais, pois \u00e9 altamente capaz de gerar dados amplos e ricos que visam melhorar a vida de pessoas com defici\u00eancias em diferentes graus. J\u00e1 a vers\u00e3o resumida . Por outro lado, uma vez que durante a entrevista no inqu\u00e9rito populacional seja utilizado um aplicativo de tablet e considerando tamb\u00e9m que o entrevistador tenha treinamento e experi\u00eancia para sua aplica\u00e7\u00e3o, acredita-se que haver\u00e1 maior agilidade para conduzir a entrevista e registrar as informa\u00e7\u00f5es.Uma limita\u00e7\u00e3o deste estudo se pauta no fato de que a amostra avaliada no pr\u00e9-teste n\u00e3o foi composta por pessoas com variadas defici\u00eancias, portanto, nem todos os itens do question\u00e1rio foram aplicados.13 . Nesse sentido, a validade convergente, as consist\u00eancias internas e as demais propriedades psicom\u00e9tricas da vers\u00e3o brasileira do MDS ser\u00e3o mensuradas nos pr\u00f3ximos meses pela rede de pesquisa.Ainda \u00e9 necess\u00e1ria a avalia\u00e7\u00e3o psicom\u00e9trica do instrumento, principalmente envolvendo popula\u00e7\u00f5es com defici\u00eancias ou com condi\u00e7\u00f5es de sa\u00fade espec\u00edficas15 . Al\u00e9m disso, a disponibiliza\u00e7\u00e3o do MDS para uso no levantamento de dados populacionais oferece oportunidade de gera\u00e7\u00e3o de indicadores de sa\u00fade sobre a funcionalidade, superando a abordagem limitada de indicadores de mortalidade e morbidade, contribuindo para um cuidado em sa\u00fade mais equitativo e permitindo o desenho de interven\u00e7\u00f5es coletivas em sa\u00fade que contemplem as reais necessidade da popula\u00e7\u00e3o27 .Ap\u00f3s a an\u00e1lise das propriedades psicom\u00e9tricas do MDS-Brasil, aguarda-se a execu\u00e7\u00e3o de inqu\u00e9ritos regionais e nacionais para delineamento do perfil de funcionalidade e necessidades em sa\u00fade no Brasil sob a perspectiva do modelo biopsicossocial, cumprindo uma das aplica\u00e7\u00f5es da CIF como ferramenta de pol\u00edtica social no planejamento dos sistemas de previd\u00eancia social, sistemas de compensa\u00e7\u00e3o e projeto e implementa\u00e7\u00e3o de pol\u00edticas p\u00fablicasFoi realizada a tradu\u00e7\u00e3o do MDS para o portugu\u00eas do Brasil, adaptando o instrumento transculturamente para a popula\u00e7\u00e3o brasileira com adequada validade de conte\u00fado, resultando na vers\u00e3o MDS-Brasil, ferramenta da OMS. O estudo cumpriu as normas operacionais internacionais e nacionais vigentes para estudos de tradu\u00e7\u00e3o e adapta\u00e7\u00e3o transcultural de instrumentos em sa\u00fade.Verificou-se aceita\u00e7\u00e3o e compreens\u00e3o do p\u00fablico-alvo da vers\u00e3o brasileira do MDS, que \u00e9 indicado para inqu\u00e9ritos populacionais, regionais e nacionais, para PCD e pessoas sem defici\u00eancias."}
+{"text": "O artigo analisa a epidemia de gripe de 1918 em Diamantina, no interior de Minas Gerais. A partir de fontes bibliogr\u00e1ficas e documentais, discute como o ramal ferrovi\u00e1rio da Estrada de Ferro Vit\u00f3ria a Minas, inaugurado em 1914, contribuiu para a chegada da doen\u00e7a \u00e0 cidade que, at\u00e9 ent\u00e3o, era representada no discurso de suas elites como isolada e salubre. Aborda as imbricadas rela\u00e7\u00f5es entre a expans\u00e3o dos sistemas de transportes pelo interior do Brasil, o meio ambiente, o conhecimento cient\u00edfico e os processos sa\u00fade/doen\u00e7a. A epidemia de gripe de 1918 \u00e9 recorrentemente destacada na literatura como uma das mais letais na hist\u00f3ria. Era outubro de 1918 quando os jornais de Diamantina, no norte de Minas Gerais, publicaram as primeiras not\u00edcias sobre a epidemia que avan\u00e7ava pelo mundo e j\u00e1 se manifestava em algumas cidades brasileiras. O clima ameno e o isolamento regional foram destacados no discurso oficial como os elementos que garantiriam o abrandamento da doen\u00e7a. No entanto, a epidemia avan\u00e7ou, desorganizou o cotidiano da cidade e fez v\u00edtimas. Nem mesmo os locais percebidos como \u201cisolados\u201d permaneceram ilesos \u00e0 sua manifesta\u00e7\u00e3o. O artigo analisa esse contexto a partir do munic\u00edpio de Diamantina, onde a ferrovia da Estrada de Ferro Vit\u00f3ria a Minas (EFVM), inaugurada em 1914, contribuiu para a chegada da doen\u00e7a na cidade que era representada nos discursos de suas elites como \u201cisolada e salubre\u201d. O progresso e o fim do isolamento trariam tamb\u00e9m a doen\u00e7a.influenza teve seu avan\u00e7o facilitado pelas rotas de com\u00e9rcio e de maior circula\u00e7\u00e3o de pessoas. Em Minas Gerais, um dos estados brasileiros que mais se havia beneficiado com a pol\u00edtica ferrovi\u00e1ria republicana, a malha ferrovi\u00e1ria teve forte influ\u00eancia na prolifera\u00e7\u00e3o da doen\u00e7a.Segundo Quando a epidemia irrompeu, o pa\u00eds, orientado pelos ideais da Rep\u00fablica (1889), estava em efervescente busca pela imagem de moderno, e as ferrovias foram entendidas como essenciais para esse processo. Foi a partir do novo regime que ocorreu uma defini\u00e7\u00e3o mais precisa das compet\u00eancias federais e estaduais em rela\u00e7\u00e3o \u00e0s concess\u00f5es para a constru\u00e7\u00e3o ferrovi\u00e1ria   . As linNo Brasil do in\u00edcio do s\u00e9culo XX, as regi\u00f5es atravessadas por ferrovias foram objeto de a\u00e7\u00f5es sanit\u00e1rias relativamente bem-sucedidas. Segundo A Madeira-Mamor\u00e9, ou Ferrovia do Diabo, como ficou conhecida, pretendia ligar a Amaz\u00f4nia brasileira \u00e0 boliviana, principalmente com base dos interesses relacionadas \u00e0 explora\u00e7\u00e3o do l\u00e1tex na regi\u00e3o. Considerando suas duas fases de implementa\u00e7\u00e3o (1878-1879 e 1907-1912), mais de seis mil pessoas foram vitimadas pelas \u201cmol\u00e9stias reinantes\u201d na \u00e1rea atravessada, principalmente pela mal\u00e1ria   . A BrazDestacamos tamb\u00e9m o estudo de Certamente, as condi\u00e7\u00f5es materiais ocasionadas pela constru\u00e7\u00e3o do ramal de Diamantina, como os sulcos que se acumularam no solo, o desmatamento produzido ou os abrigos prec\u00e1rios dos trabalhadores envolvidos em sua constru\u00e7\u00e3o e manuten\u00e7\u00e3o \u2013 que em 1910 contava com 1.200 trabalhadores  \u2013, produziram efeitos na sa\u00fade e no ambiente local e ainda precisam de mais investiga\u00e7\u00f5es. Nossa preocupa\u00e7\u00e3o, por\u00e9m, n\u00e3o se reduz ao per\u00edodo de sua constru\u00e7\u00e3o (1909-1914), discutimos tamb\u00e9m como, pouco depois de os trabalhos de engenharia terem sido conclu\u00eddos, o pleno funcionamento da ferrovia tornou aquela parte de Minas Gerais mais sens\u00edvel \u00e0 epidemia de gripe de 1918 ao aproxim\u00e1-la da Estrada de Ferro Central do Brasil (EFCB), uma das malhas ferrovi\u00e1rias mais coesas do pa\u00eds no per\u00edodo   .H\u00e1 estudos que indicam como as ferrovias facilitaram a dissemina\u00e7\u00e3o da epidemia de 1918 no Brasil. Minas e Rio Grande do Sul: o estado da doen\u00e7a e o estado da sa\u00fade , de 1918, o m\u00e9dico afirmou que as ferrovias eram fruto da \u201cpoliticagem mineira\u201d e que, apesar de em toda parte serem percebidas como \u201celemento de progresso e crescimento econ\u00f4mico\u201d, em Minas, seriam meios para favorecer oligarquias, produzir malef\u00edcios como d\u00e9ficits constantes e impactos na sa\u00fade dos mineiros. O m\u00e9dico reclamava da falta de uma estrutura sanit\u00e1ria centralizada no estado. Afirmou que os governos municipais tinham maior autonomia diante de quest\u00f5es relacionadas \u00e0 sa\u00fade p\u00fablica, salvo em casos mais graves como epidemias. No entanto, nem todas as c\u00e2maras municipais tinham recursos para desenvolver pol\u00edticas p\u00fablicas eficientes, por isso, as considerava \u201cc\u00e9lulas doentes\u201d que, por conseguinte, tamb\u00e9m adoeciam todo \u201co organismo\u201d. Penna afirmou que n\u00e3o havia recursos para assistir a enorme massa de gente que acompanhava a penetra\u00e7\u00e3o das estradas e \u201celevava o n\u00famero dos deposit\u00e1rios de germens perigosos\u201d. A mol\u00e9stia de Chagas e o impaludismo foram as doen\u00e7as citadas por ele .Mesmo no per\u00edodo em que irrompeu a epidemia, a rela\u00e7\u00e3o entre a expans\u00e3o das comunica\u00e7\u00f5es ferrovi\u00e1rias e as doen\u00e7as j\u00e1 era debatida. O m\u00e9dico mineiro Belis\u00e1rio Penna (1868-1939), por exemplo, fez duras cr\u00edticas aos empreendimentos ferrovi\u00e1rios realizados, principalmente, em sua terra natal. Na obra influenza do trato respirat\u00f3rio de su\u00ednos; e, somente em 1933, os investigadores brit\u00e2nicos Wilson Smith, Christopher Andrews e Patrick Laidlaw identificaram esse v\u00edrus, denominado Myxovirus influenzae , como o agente causador da gripe no ser humano .1As ferrovias, portanto, al\u00e9m de cargas e passageiros, transportavam seres invis\u00edveis que, ao se instalar nas superf\u00edcies que compunham o material rodante dos trens, percorriam grandes dist\u00e2ncias para dar continuidade ao seu pr\u00f3prio ciclo biol\u00f3gico e coloniza\u00e7\u00e3o de novas \u00e1reas. influenza ao tocar, com as m\u00e3os, uma superf\u00edcie ou um objeto contaminado com o v\u00edrus e, em seguida, tocar os olhos, boca ou nariz ( A transmiss\u00e3o do v\u00edrus pode ocorrer por contato direto (pessoa-pessoa) pela via respirat\u00f3ria, por meio de got\u00edculas ou aeross\u00f3is expelidos por indiv\u00edduo infectado durante o ato de espirrar, tossir ou falar. H\u00e1 tamb\u00e9m possibilidade de cont\u00e1gio por transmiss\u00e3o indireta \u2013 uma pessoa pode adquirir u nariz   . Consid2 teve entre suas manifesta\u00e7\u00f5es cl\u00ednicas letais a extrema cianose, que corresponde a pele e mucosas de colora\u00e7\u00e3o azul escura por m\u00e1 oxigena\u00e7\u00e3o, traduzindo fal\u00eancia dos pulm\u00f5es infectados em transferir oxig\u00eanio para a corrente sangu\u00ednea, acompanhada de tosse e pneumonia . O exato n\u00famero de \u00f3bitos causados pela epidemia de gripe de 1918 segue desconhecido, porque muitos locais afetados n\u00e3o possu\u00edam registros de estat\u00edsticas de mortalidade , contudo, apenas no in\u00edcio do s\u00e9culo XX um projeto com esse objetivo se consolidou. A demanda pela constru\u00e7\u00e3o de uma ferrovia foi uma das estrat\u00e9gias \u00e0s quais recorreram as elites diamantinenses com o objetivo de consolidar investimentos que exigiam escoadouros para a produ\u00e7\u00e3o vin\u00edcola e t\u00eaxtil , as elites diamantinenses operacionalizaram o hist\u00f3rico discurso de isolamento regional com o objetivo de angariar aliados para a perspectiva de que a ferrovia seria o meio mais r\u00e1pido e eficaz de promover a integra\u00e7\u00e3o do norte de Minas ao restante do pa\u00eds. Esse discurso foi permeado por representa\u00e7\u00f5es associadas \u00e0s caracter\u00edsticas biof\u00edsicas da serra do Espinha\u00e7o, a que o munic\u00edpio est\u00e1 circunscrito. A \u00e1rea possui altitudes consider\u00e1veis, estendendo-se por mais de 1.200 quil\u00f4metros de Minas Gerais \u00e0 Bahia   .O Jequitinhonha , afirmava que a ferrovia seria o elemento civilizador que, ao \u201cquebrar as montanhas\u201d, permitiria \u00e0 cidade recuperar \u201ca energia [do per\u00edodo minerador] que lhe era pr\u00f3pria\u201d .A serra do Espinha\u00e7o est\u00e1 na interse\u00e7\u00e3o de tr\u00eas grandes biomas brasileiros, a saber: Mata Atl\u00e2ntica, Cerrado e Caatinga. Al\u00e9m disso, de importantes bacias hidrogr\u00e1ficas do pa\u00eds: rio S\u00e3o Francisco, rio Jequitinhonha e rio Doce. O s\u00edtio da cidade de Diamantina possui altitudes que variam entre 1.100 e 1.350 metros   , p.45. Chorografia do munic\u00edpio de Diamantina , publicada originalmente em 1899, o intelectual diamantinense Jos\u00e9 Augusto Neves (1875-1955) louva as benesses do clima local. O autor afirma que a sede municipal de Diamantina tinha aspecto \u201calegre, com clima ameno e sadio\u201d. Especificamente sobre o clima, As condi\u00e7\u00f5es serranas informavam n\u00e3o s\u00f3 que a cidade era de dif\u00edcil acesso, mas tamb\u00e9m que se tratava de um ambiente com clima ameno. Na obra \u00c9 importante salientar tamb\u00e9m, em termos do discurso de isolamento, que aspectos hist\u00f3ricos do processo de coloniza\u00e7\u00e3o regional contribu\u00edram igualmente para a representa\u00e7\u00e3o da regi\u00e3o como um espa\u00e7o isolado. O modelo de administra\u00e7\u00e3o implantado no distrito diamantino a partir de 1771, que visava garantir o controle e a seguran\u00e7a da minera\u00e7\u00e3o de diamantes, ficou na mem\u00f3ria local como momento de grande repress\u00e3o e viol\u00eancia realizadas pelas autoridades sobre toda a popula\u00e7\u00e3o, indiscriminadamente   , p.75.Nem sempre, contudo, a percep\u00e7\u00e3o do isolamento apresentou-se de modo negativo. No in\u00edcio da atividade mineradora, por exemplo, o governo portugu\u00eas tinha um entendimento predominante de que o dif\u00edcil acesso a algumas regi\u00f5es de Minas Gerais dificultaria o contrabando de min\u00e9rios extra\u00eddos. Outro aspecto refere-se ao imagin\u00e1rio social acerca da identidade mineira (mineiridade), que se formou no per\u00edodo da minera\u00e7\u00e3o. Em geral, a perspectiva era a de que o territ\u00f3rio tornava os mineiros mais propensos \u00e0 tranquilidade e \u00e0 modera\u00e7\u00e3o, portanto, conciliadores natos. Essas caracter\u00edsticas, especialmente no contexto republicano, eram apontadas como positivas. Al\u00e9m disso, devido \u00e0 fama aur\u00edfera e \u00e0 ideia de um r\u00e1pido enriquecimento, predominava tamb\u00e9m uma vis\u00e3o de Minas Gerais como uma terra de pensamento liberal e que, justamente por ser isolada, entre as montanhas, seria reduto de uma identidade genuinamente brasileira. Portanto, o tom de valora\u00e7\u00e3o acerca do isolamento oscila, dependendo do per\u00edodo abordado. Em Diamantina, sua percep\u00e7\u00e3o em tom negativo se real\u00e7ou quando, na regi\u00e3o, a demanda por ferrovias fez-se crescente. Essa conjuntura tornou o conflito \u2013 real ou potencial \u2013 com o meio biof\u00edsico daquele espa\u00e7o cada vez mais percebido como dram\u00e1tico, e a inaugura\u00e7\u00e3o de um ramal ferrovi\u00e1rio foi apontada como \u201co meio de remediar tamanho inconveniente que representava o isolamento da regi\u00e3o\u201d .Era fevereiro de 1902 quando, por meio do decreto n.4.377, se consolidou um projeto em vias de alcan\u00e7ar a cidade. Fruto da fus\u00e3o e modifica\u00e7\u00e3o de concess\u00f5es liberadas para a constru\u00e7\u00e3o de duas estradas de ferro no territ\u00f3rio mineiro em 1890, o projeto deu forma \u00e0 estrada de ferro que tamb\u00e9m prometia ligar aquela por\u00e7\u00e3o de Minas ao litoral brasileiro .O decreto estabelecia a constru\u00e7\u00e3o de uma ferrovia a partir de Vit\u00f3ria, no litoral do Esp\u00edrito Santo, em dire\u00e7\u00e3o ao norte mineiro, tendo como ponta de trilho o munic\u00edpio de Diamantina. Criada a Companhia Vit\u00f3ria a Minas em 5 de agosto de 1902, foram iniciados os estudos visando alcan\u00e7ar o territ\u00f3rio diamantinense. Os estudos estiveram a cargo do engenheiro Em\u00edlio Schnoor (1855-1923). Na presid\u00eancia da nova companhia estava o engenheiro Jo\u00e3o Teixeira Soares (1848-1927) e, entre os diretores, Pedro Nolasco. Os trabalhos de constru\u00e7\u00e3o foram iniciados em 1903 em Vit\u00f3ria . O mapa a seguir mostra detalhes da rota planejada.O projeto ferrovi\u00e1rio previa a cria\u00e7\u00e3o de uma rede regional de comunica\u00e7\u00f5es. Minas, a partir da EFVM, teria acesso ao litoral do Esp\u00edrito Santo e, posteriormente, ligaria o munic\u00edpio de Pe\u00e7anha ao de Filad\u00e9lfia, atual Te\u00f3filo Otoni. Deste \u00faltimo, teria liga\u00e7\u00e3o com a Estrada de Ferro de Caravelas, no litoral baiano. Tamb\u00e9m foi planejada a liga\u00e7\u00e3o com a EFCB, que j\u00e1 estava em territ\u00f3rio mineiro, com vistas a chegar \u00e0s margens do rio S\u00e3o Francisco .A EFCB avan\u00e7ava por Minas desde 1869, sendo a primeira ferrovia em territ\u00f3rio mineiro, quando ainda tinha por nome Estrada de Ferro Dom Pedro II   , p.2. DO ambicioso projeto, no entanto, n\u00e3o deu certo. Em 1908, quando a ferrovia j\u00e1 estava no territ\u00f3rio mineiro, com a ponta dos trilhos no quil\u00f4metro 313, na esta\u00e7\u00e3o da cidade mineira de Cachoeirinha, \u00e0 direita do rio Doce, os concession\u00e1rios da empresa consideraram alterar o tra\u00e7ado da via-f\u00e9rrea   , p.7. E2  \u2013, \u00e1rea em que seria poss\u00edvel explorar quantidades exorbitantes de min\u00e9rio de ferro. Dessa feita, diante da maior rentabilidade econ\u00f4mica, os concession\u00e1rios da EFVM consideraram alterar a rota que tinha Diamantina como destino. Assim, ocorreu. Em 1909, foram aprovadas as modifica\u00e7\u00f5es no tra\u00e7ado da EFVM.Os primeiros estudos do Servi\u00e7o Geol\u00f3gico e Mineral\u00f3gico do Brasil indicavam o munic\u00edpio de Itabira, na Zona da Mata mineira, como uma das \u00e1reas do quadril\u00e1tero ferr\u00edfero \u2013 estrutura geol\u00f3gica cuja forma assemelha-se a um quadrado com extens\u00e3o de 7.000kmA alternativa r\u00e1pida e vi\u00e1vel para que Diamantina fosse contemplada com trilhos seria a constru\u00e7\u00e3o de um ramal que ligasse a cidade \u00e0 EFCB, que j\u00e1 avan\u00e7ava na altura do munic\u00edpio vizinho de Curvelo. Assim, em julho do mesmo ano, com media\u00e7\u00e3o de pol\u00edticos locais e de uma Comiss\u00e3o Popular Permanente fundada em Diamantina, foi autorizada a constru\u00e7\u00e3o de um ramal ferrovi\u00e1rio que sairia do distrito curvelano de Curralinho, atual munic\u00edpio de Corinto, em dire\u00e7\u00e3o a Diamantina.A Comiss\u00e3o Popular Permanente, criada em 31 de janeiro de 1909, foi organizada em Diamantina num contexto em que os planos da EFVM de chegar \u00e0 cidade pareciam declinar em favor de Itabira. Essa comiss\u00e3o lan\u00e7ou m\u00e3o de v\u00e1rios recursos para chamar a aten\u00e7\u00e3o das autoridades para a quest\u00e3o ferrovi\u00e1ria na cidade. O seu principal objetivo era envidar esfor\u00e7os para que pelo menos os trilhos da Central do Brasil, em Curralinho, chegassem a Diamantina. Para tanto, a comiss\u00e3o organizou encontros e manifesta\u00e7\u00f5es nas ruas de Diamantina e de Belo Horizonte, trocas de of\u00edcios com personalidades do norte mineiro, abaixo-assinados e a elabora\u00e7\u00e3o de relat\u00f3rios com avalia\u00e7\u00f5es positivas sobre as caracter\u00edsticas ambientais da regi\u00e3o . O di\u00e1logo com personalidades pol\u00edticas locais, como Francisco S\u00e1 (1892-1936), tamb\u00e9m marcou a atua\u00e7\u00e3o da referida comiss\u00e3o.Nascido na regi\u00e3o, em Gr\u00e3o-Mogol, S\u00e1 foi nomeado, em julho de 1909, ministro de Via\u00e7\u00e3o e Obras P\u00fablicas pelo ent\u00e3o presidente Nilo Pe\u00e7anha (1867-1924). Uma vez ministro, S\u00e1 aproveitou a ocasi\u00e3o e se apressou em atender \u00e0s demandas de seus conterr\u00e2neos. No mesmo m\u00eas em que tomou posse, foi apresentado ao presidente o decreto n.7.455, que alterava a concess\u00e3o n.4.337, de fevereiro de 1902. O novo decreto tratava das resolu\u00e7\u00f5es sobre a linha Curralinho-Diamantina, definindo que \u201cfica substitu\u00eddo o trecho de Sant\u2019Anna dos Ferros a Serro, da Estrada de Ferro Vit\u00f3ria a Diamantina, pela de Curralinho, da Estrada Central do Brasil, \u00e0 cidade de Diamantina\u201d. O prolongamento de Curralinho a Diamantina seria realizado pela EFVM.O Norte comemorou a assinatura do decreto. Na edi\u00e7\u00e3o de 17 de julho, al\u00e9m de elogios a Francisco S\u00e1, foram reproduzidos pelo menos 14 telegramas que teriam sido enviados \u00e0 Comiss\u00e3o Popular Permanente e que elogiavam a postura desta em prol do prolongamento Estrada de Ferro Curralinho a Diamantina. Entre os remetentes estavam Pedro Mata, Carlos Otoni, Wenceslau Braz e Juscelino Barbosa. Garantida a constru\u00e7\u00e3o do ramal da Central do Brasil at\u00e9 a cidade, a comiss\u00e3o passou a empreender novas batalhas, fosse observando, passo a passo, a constru\u00e7\u00e3o que foi iniciada em 16 de outubro de 1909, fosse tendo choques diretos com o que poderia descarrilar a locomotiva antes mesmo de os trilhos serem colocados.O jornal O tra\u00e7ado do futuro ramal de Diamantina foi apontado como sinuoso, entre espig\u00f5es e grotas, contando com constante movimento de terras devido \u00e0 inclina\u00e7\u00e3o lateral do terreno. O andamento das obras enfrentou dificuldades por causa das caracter\u00edsticas do terreno atravessado, do clima e de alguns rios: das Velhas, Jabuticabas, Capim Branco, Pardo e Tabatinga . Al\u00e9m disso, foram constantes as reclama\u00e7\u00f5es relativas \u00e0s condi\u00e7\u00f5es prec\u00e1rias dos trabalhadores empregados na constru\u00e7\u00e3o do ramal. A EFVM precisou enviar um fiscal para investigar den\u00fancias das irregularidades. Os empreiteiros do ramal elevavam o pre\u00e7o dos g\u00eaneros aliment\u00edcios, e os sal\u00e1rios dos oper\u00e1rios eram baixos . Por conta desses aspectos, as obras s\u00f3 foram conclu\u00eddas em 1914, com a inaugura\u00e7\u00e3o da esta\u00e7\u00e3o de Diamantina em 3 de maio.2 de extens\u00e3o. As esta\u00e7\u00f5es que compunham a linha, at\u00e9 a irrup\u00e7\u00e3o do epis\u00f3dio epid\u00eamico de 1918, eram: Curralinho, Ro\u00e7a do Brejo, Santo Hip\u00f3lito, Rodeador, Riacho das Varas, Bara\u00fanas, Guinda, Diamantina .O ramal ferrovi\u00e1rio inaugurado em Diamantina em 1914 era bem diferente e mais modesto do que apontavam os primeiros estudos para sua constru\u00e7\u00e3o. A nova ferrovia iniciou sua opera\u00e7\u00e3o plena contando com oito esta\u00e7\u00f5es e o total de 147kmLogo no in\u00edcio de suas atividades, foram recorrentes as reclama\u00e7\u00f5es sobre a presta\u00e7\u00e3o de servi\u00e7os na linha, percebida como extremamente cara e lenta. Mesmo em 1909, no in\u00edcio de sua constru\u00e7\u00e3o, j\u00e1 era manifestado o desejo de que a linha fosse encampada pela Uni\u00e3o e integrada \u00e0 Central do Brasil. A demanda pela encampa\u00e7\u00e3o foi refor\u00e7ada pela crise econ\u00f4mica gerada pela Primeira Guerra Mundial (1914-1918) e partiu tanto de interesses diamantinenses quanto da pr\u00f3pria Vit\u00f3ria-Minas.P\u00e3o de Santo Antonio  como \u201ca maior iniquidade administrativa do Brasil\u201d. Toda essa situa\u00e7\u00e3o contribuiu para a retomada do discurso de isolamento regional. Eram duas estradas diferentes, portanto, duas formas de administra\u00e7\u00e3o tamb\u00e9m distintas. Esse aspecto acentuava a morosidade na presta\u00e7\u00e3o de servi\u00e7os da linha. Mas as dificuldades n\u00e3o se limitavam aos aspectos burocr\u00e1ticos. O ramal, como a orienta\u00e7\u00e3o de grande parte do tra\u00e7ado da EFVM, tinha a bitola m\u00e9trica (1m).3 Esse aspecto t\u00e9cnico era considerado mais econ\u00f4mico e vi\u00e1vel para uma zona que, desde seu in\u00edcio, foi percebida como sendo de baixa produtividade. J\u00e1 a EFCB possu\u00eda um sistema de bitola mista . A nosso ver, por\u00e9m, a constata\u00e7\u00e3o da epidemia de gripe na cidade em 1918, antes mesmo de o ramal se tornar parte da EFCB, representou o cumprimento do prop\u00f3sito da ferrovia de integrar aquele sert\u00e3o, visto que mesmo os inc\u00f4modos vividos em grandes centros, como o referido epis\u00f3dio epid\u00eamico, puderam atingir aquele espa\u00e7o antes percebido como um dos mais abandonados de Minas Gerais.Quando a epidemia for\u00e7ou a ferrovia Central do Brasil a reduzir as suas atividades, o ramal de Diamantina permaneceu em funcionamento. O per\u00edodo da Primeira Guerra Mundial trouxe muitas dificuldades ao processo de amortiza\u00e7\u00e3o dos contratos internacionais da EFVM. Continuar as atividades seria, portanto, uma maneira de evitar maiores preju\u00edzos \u00e0s linhas Vit\u00f3ria-Itabira e Curralinho-Diamantina .Era 1919 quando Ceciliano Abel de Almeida, chefe do tr\u00e1fego da EFVM, agradeceu aos funcion\u00e1rios da companhia pela subordina\u00e7\u00e3o \u201cnos dias dif\u00edceis, do surto da gripe\u201d. Em suas palavras, no ano anterior, \u201cs\u00f3 n\u00e3o foi alterado o servi\u00e7o dos trens e das esta\u00e7\u00f5es porque muitos, dedicadamente vinham cuidar das suas obriga\u00e7\u00f5es, quando j\u00e1 sentiam os primeiros sintomas da mol\u00e9stia ou quando apenas entravam em convalescen\u00e7a\u201d . Essa postura contribuiu para que mais indiv\u00edduos fossem expostos ao risco de cont\u00e1gio pelo v\u00edrus da doen\u00e7a.Verdadeiramente assombrosa foi a epidemia de gripe que irrompeu no Estado em fins de 1918. O Governo tudo envidou para socorrer a popula\u00e7\u00e3o do Estado, v\u00edtima dessa grande calamidade. ... Para a obten\u00e7\u00e3o de m\u00e9dicos [bem] como de medicamentos o governo lutou a princ\u00edpio com grandes dificuldades, devido \u00e0 irrup\u00e7\u00e3o simult\u00e2nea da epidemia em toda a parte   , p.67.Minas Gerais possu\u00eda a maior malha ferrovi\u00e1ria do pa\u00eds , e esse aspecto certamente influenciou a percep\u00e7\u00e3o declarada por Arthur da Silva Bernardes (1875-1955), presidente do estado, sobre a epidemia como fen\u00f4meno \u201csimult\u00e2neo\u201d em toda parte. A extens\u00e3o ferrovi\u00e1ria mineira em tr\u00e1fego em 1918 era de 6.557,298km   , p.105.A linha Curralinho-Diamantina n\u00e3o estava isenta do contato com lugares onde a epidemia j\u00e1 estava ocorrendo. Embora fosse curta , possu\u00eda liga\u00e7\u00e3o direta com a Central do Brasil, na \u00e9poca a segunda maior ferrovia do pa\u00eds    , p.105.A Central do Brasil partia da capital federal, Rio de Janeiro, e tinha como objetivo alcan\u00e7ar o rio S\u00e3o Francisco, na altura de Pirapora (MG). No mapa a seguir, de 1919, destacamos detalhes de sua linha-tronco por Minas Gerais. O itiner\u00e1rio era composto pelas cidades de Belo Horizonte (vermelho), Sete Lagoas (amarelo), Curvelo (azul) e seu distrito Curralinho (rosa) \u2013 deste \u00faltimo, partia o prolongamento at\u00e9 Diamantina (verde).Na cidade do Rio de Janeiro, com 910.710 habitantes, cerca de 15 mil indiv\u00edduos morreram v\u00edtimas da epidemia e, pelo menos, 600 mil foram a leito, o equivalente a cerca de \u201c66% da popula\u00e7\u00e3o local\u201d   , p.105.Desse modo, partindo do Rio de Janeiro, passando por Belo Horizonte, em dire\u00e7\u00e3o ao norte de Minas, o contato entre a gripe espanhola e a cidade de Diamantina seria inevit\u00e1vel. O material rodante do ramal diamantinense em 1918 era composto por quatro locomotivas, sete carros de passageiros, sete carros de bagagens, sete carros de correios e, ainda, 49 vag\u00f5es . Os munic\u00edpios de Curvelo e Diamantina estavam separados por oito esta\u00e7\u00f5es. Com fluxo cont\u00ednuo, os trens sa\u00edam do distrito curvelano de Curralinho \u00e0s segundas, quartas e sextas-feiras, e sa\u00edam de Diamantina \u00e0s ter\u00e7as e quintas-feiras e aos s\u00e1bados.A linha Curralinho-Diamantina, em sua maioria, era composta por esta\u00e7\u00f5es de quarta classe. Essas esta\u00e7\u00f5es tinham dois quartos, armaz\u00e9m, ag\u00eancia, cozinha e p\u00e1tio. Apenas na ponta de trilho, a sede municipal, foi constru\u00edda uma esta\u00e7\u00e3o de primeira classe. Essa possu\u00eda um armaz\u00e9m, uma biblioteca e telegrafia, dois quartos, sala de visitas, sala de jantar, cozinha, banheiro, plataforma e um sal\u00e3o de embarque   .P\u00e3o de Santo Antonio , a saber: \u201cNa esta\u00e7\u00e3o do nosso ramal, pode se dar, a qualquer hora, um desastre evit\u00e1vel. A meninada ali pinta o sete, por um milagre, n\u00e3o houve ainda uma desgra\u00e7a a lamentar-se\u201d.A esta\u00e7\u00e3o ferrovi\u00e1ria da sede municipal de Diamantina, situada no largo Dom Jo\u00e3o, sua maior pra\u00e7a p\u00fablica no per\u00edodo, foi um importante espa\u00e7o de sociabilidades. Muitos eventos aconteciam ao seu redor, e em sua proximidade estava localizada outra importante institui\u00e7\u00e3o, o Semin\u00e1rio Episcopal. Alguns exemplos dos eventos que ocorriam na esta\u00e7\u00e3o eram a chegada de figuras ilustres, missas, despedidas e prociss\u00f5es. A movimenta\u00e7\u00e3o constante de pessoas chegou a mobilizar alertas recorrentes no jornal Em torno das esta\u00e7\u00f5es houve incentivo ao com\u00e9rcio e \u00e0 cria\u00e7\u00e3o de uma estrutura para atender \u00e0s demandas de passageiros . Em Diamantina, em 1918, funcionavam pelo menos tr\u00eas hot\u00e9is: Hotel do Com\u00e9rcio, Hotel Itamb\u00e9 e Hotel Diamantina e Gomes  e uma Escola Normal   .Eram essas as condi\u00e7\u00f5es de Diamantina quando a epidemia irrompeu. A estimativa \u00e9 de que em 1918 a linha tenha transportado cerca de 16.130 pessoas . A ferrovia pode ter contribu\u00eddo para a dissemina\u00e7\u00e3o da doen\u00e7a na regi\u00e3o por meio de passageiros infectados que viajaram na linha, sem necessariamente perceber a amea\u00e7a que representavam. Ou, ainda, o material rodante  e permanente  daquele ramal poderiam abrigar em suas superf\u00edcies pat\u00f3genos, como v\u00edrus, ampliando a sua dissemina\u00e7\u00e3o. A estrada de ferro, ao expor a cidade a maior contato com o v\u00edrus da doen\u00e7a, deixou de representar apenas benef\u00edcios e progresso para aquele local.A peste , de Albert Camus, o historiador estadunidense Inspirado no livro Posto isso, analisamos a manifesta\u00e7\u00e3o do epis\u00f3dio epid\u00eamico em Diamantina, onde os discursos sobre isolamento e salubridade local, dada sua localiza\u00e7\u00e3o estar circunscrita \u00e0 serra do Espinha\u00e7o, acabaram sendo elaborados a partir das representa\u00e7\u00f5es da referida serra. Entre o repert\u00f3rio desses discursos esteve a ideia de que, por conta das caracter\u00edsticas do ambiente serrano, Diamantina sofreria menos com a epidemia de gripe, e isso n\u00e3o aconteceu. A \u201csenhorita espanhola\u201d visitou a cidade e, quando partiu, n\u00e3o deixou saudades.A Estrela Polar , aos 27 de outubro, noticiou que a situa\u00e7\u00e3o epid\u00eamica seria consequ\u00eancia grave dos pecados humanos \u2013 portanto, um castigo divino. Em outra edi\u00e7\u00e3o do mesmo ano, de 8 de novembro, o artigo \u201cA li\u00e7\u00e3o dos acontecimentos\u201d denominava a doen\u00e7a \u201cmaligna influenza \u201d e \u201ctuf\u00e3o da morte\u201d.A partir de fins de outubro de 1918, jornais diamantinenses come\u00e7aram a publicar as primeiras not\u00edcias sobre a doen\u00e7a. O jornal cat\u00f3lico Em outros surtos epid\u00eamicos ocorridos na hist\u00f3ria brasileira, a rela\u00e7\u00e3o entre as enfermidades e os pecados humanos tamb\u00e9m esteve presente. A Estrela Polar , aos 15 de dezembro, em Riacho das Varas, atual distrito diamantinense de Conselheiro Mata, foi realizada uma festa de penit\u00eancia para o \u201cglorioso m\u00e1rtir\u201d. \u201cCom grande acompanhamento de fi\u00e9is\u201d, o evento contou com uma missa matinal e prociss\u00e3o que se dirigiu \u00e0 esta\u00e7\u00e3o da EFVM. Esses acontecimentos p\u00fablicos, durante a epidemia que j\u00e1 circulava pela cidade, certamente sujeitaram mais pessoas ao risco de contamina\u00e7\u00e3o pela doen\u00e7a.Em Diamantina, pedidos de provis\u00e3o para a realiza\u00e7\u00e3o de prociss\u00f5es para S\u00e3o Sebasti\u00e3o foram recorrentes como uma resposta \u00e0 epidemia de 1918. O santo m\u00e1rtir \u00e9 reconhecido como protetor dos enfermos. Costumeiramente, as festas em sua homenagem acontecem no m\u00eas de janeiro, mas verificamos a realiza\u00e7\u00e3o de prociss\u00f5es no munic\u00edpio dedicadas ao referido santo em novembro de 1918. O padre Leopoldo A chave explicativa que esteve relacionada \u00e0s percep\u00e7\u00f5es religiosas representa uma das respostas da sociedade de Diamantina, essencialmente cat\u00f3lica, \u00e0s experi\u00eancias que a epidemia desencadeou. Aspecto que confirma a afirmativa de A Estrela Polar, o artigo intitulado \u201cO transmissor da espanhola\u201d, que inicialmente teria sido publicado na revista portuguesa Brot\u00e9ria , discutia a semelhan\u00e7a entre a gripe espanhola e uma enfermidade identificada como \u201cdoen\u00e7a dos tr\u00eas dias\u201d. A perspectiva era a de que o fleb\u00f3tomo, inseto da fam\u00edlia dos Psychodidae , seria o vetor das duas doen\u00e7as. Tamb\u00e9m foi recorrente nos jornais, al\u00e9m da vulgariza\u00e7\u00e3o das controv\u00e9rsias cient\u00edficas acerca da epidemia que irrompia, recomenda\u00e7\u00f5es sobre as melhores formas de tratar os sintomas da doen\u00e7a.Al\u00e9m da abordagem religiosa, nos jornais locais h\u00e1 registros de outras respostas \u00e0 epidemia. No jornal Hemophilus influenza ), que, desde o fim do s\u00e9culo XIX, muitos acreditavam ser o agente causador da doen\u00e7a. Apenas na d\u00e9cada de 1930, como j\u00e1 foi mencionado, o v\u00edrus influenza foi indicado como o agente viral causador da gripe no ser humano . Entretanto, desde a virada para o s\u00e9culo XX muitos estudos indicaram a possibilidade de um v\u00edrus filtr\u00e1vel ser a causa da gripe humana, entre eles o do instituto de pesquisa brit\u00e2nico Medical Research Council  recomendava que a boca, a garganta e as fossas nasais fossem \u201cconstantemente e perfeitamente\u201d lavadas, pois seriam \u201cas principais, sen\u00e3o \u00fanicas entradas do micr\u00f3bio ou micr\u00f3bios, ainda n\u00e3o conhecidos, portadores da influenza \u201d. Para a lavagem da boca e garganta, seria necess\u00e1rio bochechar e gargarejar com folhas de eucalipto, canela, sal e \u00e1gua fervida. Para a limpeza das narinas, por sua vez, recomendava-se o uso moderado de \u201cuma pitadinha\u201d de rap\u00e9. Aspectos dessa natureza tamb\u00e9m s\u00e3o evidenciados na an\u00e1lise de outras ocorr\u00eancias da epidemia no Brasil. O jornal Ainda nos jornais, m\u00e9dicos que prestavam servi\u00e7os itinerantes divulgaram as vantagens de seus servi\u00e7os. Segue uma narrativa que elucida bem esse cen\u00e1rio em Diamantina:influenza , o seguinte rem\u00e9dio, que acho muito bom: folhas de eucalipto, de camar\u00e1 ou cambar\u00e1, manga, pitanga, laranja-da-terra lim\u00e3o, alfavaca, louro, mel\u00e3o-de-s\u00e3o-caetano, flores de mamoeiro, flores de bananeira. Deite-se um punhado de cada uma dessas folhas e flores em um grande bule, e ponha-se de infus\u00e3o por uma hora em 3 garrafas de \u00e1gua bem fervendo, tomando-se depois uma x\u00edcara de 2 em 2 horas. Os casos leves e benignos curam-se com essa infus\u00e3o de ervas agasalhando na cama. Est\u00e1 muito aconselhado o tratamento pela ess\u00eancia de canela. Vou fazer uma den\u00fancia inocente, anunciando que h\u00e1 um p\u00e9 de canela no quintal do Dr. Telles de Menezes, um outro no de D. Josefina Fel\u00edcio e com certeza tamb\u00e9m na ch\u00e1cara do falecido Juca Neves, de saudos\u00edssima mem\u00f3ria .O dr. Jos\u00e9 R. Monteiro da Silva, ilustrado m\u00e9dico que h\u00e1 muitos anos se dedica ao tratamento das mol\u00e9stias por meio de ervas medicinais, aconselha, contra a O ch\u00e1 de ervas foi indicado como uma alternativa mais \u201cf\u00e1cil, barata e eficaz\u201d \u00e0s drogas da farm\u00e1cia que, segundo o relato, estariam \u201ccar\u00edssimas\u201d. A assertiva seria recorrer \u00e0s folhas que poderiam ser encontradas, inclusive, na casa de alguns m\u00e9dicos da cidade. Em Diamantina, no per\u00edodo, tr\u00eas farm\u00e1cias, as institui\u00e7\u00f5es Motta & Prado, Pharmacia Horta e Gruta de Lourdes, puderam oferecer seus produtos que, vinculados a no\u00e7\u00f5es de cientificidade, chamavam para si a efic\u00e1cia no combate \u00e0 doen\u00e7a a fim de \u00e0s mais clientes.A primeira manifesta\u00e7\u00e3o oficial sobre a epidemia em Diamantina ocorreu pela imprensa em 10 de novembro de 1918. Cosme Alves do Couto, agente executivo em exerc\u00edcio, cargo hoje equivalente ao de prefeito, frisou que seu discurso pretendia \u201cdesfazer o pavor causado pela pandemia de gripe\u201d. Segue o texto:influenza . Parece, Sr., Redator, que o clima de Diamantina \u00e9 privilegiado contra o terr\u00edvel mal, que assola em todos os cantos do Brasil, que deveria ser aconselhado pelos m\u00e9dicos para ref\u00fagio das pessoas timoratas e at\u00e9 dos convalescentes atacados em outros pontos do pa\u00eds .A exist\u00eancia desta epidemia foi verificada aqui no dia 23 pelo m\u00e9dico do 3\u00ba batalh\u00e3o onde se alastrou com rapidez, por\u00e9m, de forma t\u00e3o benigna que at\u00e9 hoje n\u00e3o se verificou um s\u00f3 \u00f3bito em nosso meio causado exclusivamente pela pavorosa A lentid\u00e3o e a nega\u00e7\u00e3o do estado de doen\u00e7a n\u00e3o \u00e9 um fen\u00f4meno neutro ( Outubro29) Anna Pereira Gomes, 76 anos de idade, \u2018sem assist\u00eancia m\u00e9dica\u2019.30) Maria Theodora, 50 anos de idade, \u2018sem assist\u00eancia m\u00e9dica\u2019.31) Hermano de Siqueira, 24 anos de idade, pneumonia.Novembro03) Jo\u00e3o Inoc\u00eancio de Faria, nefrite04) Maria Luiza, rec\u00e9m-nascida04) Joaquim Salvador, preso na cidade, \u2018gripe complicada\u2019 com tuberculose04) Benedito Ribeiro de Souza, \u2018gripe complicada\u2019.06) Maria, rec\u00e9m-nascida .A qualidade do ar do territ\u00f3rio de Minas Gerais foi recorrente nas representa\u00e7\u00f5es sobre o estado. No final do s\u00e9culo XIX muitas pessoas foram atra\u00eddas ao territ\u00f3rio mineiro em busca de tratamento para doen\u00e7as como, por exemplo, a tuberculose . O entendimento de que locais montanhosos seriam mais saud\u00e1veis devido aos ventos frequentes derivava de teorias miasm\u00e1ticas que, sinteticamente, compreendiam enfermidade e salubridade a partir da fixa\u00e7\u00e3o ou deslocamento dos ares. Apesar da preval\u00eancia do paradigma da bacteriologia no in\u00edcio do s\u00e9culo XX, concep\u00e7\u00f5es miasm\u00e1ticas continuaram presentes nas a\u00e7\u00f5es de sa\u00fade e saneamento e na cultura popular, como revelado no discurso de Alves do Couto.Apesar da \u00eanfase do discurso oficial de que a salubridade local iria abrandar a enfermidade, h\u00e1 registros de ocorr\u00eancias de doen\u00e7as que desorganizavam o cotidiano daquela regi\u00e3o antes mesmo do epis\u00f3dio epid\u00eamico de 1918. Um exemplo pode ser observado em 1908, quando a Delegacia de Higiene de Diamantina adotou algumas medidas para conter o avan\u00e7o da var\u00edola, que teria sido detectada nos distritos de Rio Manso e Rio Preto, que atualmente correspondem \u00e0s cidades de Couto de Magalh\u00e3es de Minas e S\u00e3o Gon\u00e7alo do Rio Preto, respectivamente. As medidas de controle adotadas foram a requisi\u00e7\u00e3o de pra\u00e7as para instala\u00e7\u00e3o de um cord\u00e3o sanit\u00e1rio e o uso de \u201cmedicamentos e desinfetantes\u201d . Esse exemplo, como a epidemia de 1918, indica que a ret\u00f3rica ostentada sobre a salubridade regional n\u00e3o podia ser sustentada \u2013 considerando, especialmente, o crescimento demogr\u00e1fico e os novos motes que se estabeleciam: abastecimento de \u00e1gua, rede de esgotos, insalubridade urbana e maior circula\u00e7\u00e3o facilitada pela linha ferrovi\u00e1ria da EFVM.A demora em reconhecer o avan\u00e7o e o estado epid\u00eamico em Diamantina, portanto, demonstra que, at\u00e9 aquele momento, nenhuma estrat\u00e9gia visando combater a epidemia havia sido preparada. Embora tenha sido destacada inicialmente com car\u00e1ter benigno, a gripe avan\u00e7ou. Em 9 de novembro de 1918, isto \u00e9, um dia antes da manifesta\u00e7\u00e3o do Poder Executivo municipal, uma carta foi enviada pela irm\u00e3 Eug\u00eania a dom Joaquim Silv\u00e9rio, arcebispo de Diamantina. Na correspond\u00eancia foi apresentada a situa\u00e7\u00e3o dos alunos do quarto ano, entre os quais \u201cmuitos\u201d teriam sido \u201catacados pela epidemia\u201d. Assim, segundo a religiosa, \u201cseria mais conveniente que a distribui\u00e7\u00e3o dos diplomas\u201d se realizasse em mar\u00e7o de 1919. Posto isso, a irm\u00e3 encerrou sua correspond\u00eancia pedindo uma b\u00ean\u00e7\u00e3o e uma prece \u201cpara que nosso senhor nos proteja\u201d . A doen\u00e7a come\u00e7ava a desorganizar o cotidiano da cidade.A subnotifica\u00e7\u00e3o da doen\u00e7a pode ter sido um dos efeitos diretos da postura do Poder Executivo municipal. Al\u00e9m de a gripe ser uma doen\u00e7a comum, o discurso oficial pode ter contribu\u00eddo para o fato de que, a princ\u00edpio, pouca import\u00e2ncia tenha sido dada aos primeiros casos ocorridos em Diamantina. Como consequ\u00eancia, as manifesta\u00e7\u00f5es anteriores da doen\u00e7a podem nem mesmo ter sido registradas. Como destacou causa mortis era gripe e mol\u00e9stia desconhecida. Em novembro, per\u00edodo mais intenso de convalescen\u00e7a da doen\u00e7a na cidade, do total de 73 mortes, 47 podem ser associadas \u00e0 epidemia, uma vez que as causas apontadas foram: gripe intestinal, br\u00f4nquio-pneumonia-gripal, influenza , gripe card\u00edaca, mol\u00e9stia desconhecida e gripe com complica\u00e7\u00f5es. A partir de dezembro, os \u00f3bitos diminu\u00edram (20 mortes), entre as quais pelo menos oito podem ser associadas ao epis\u00f3dio epid\u00eamico.Reflexos dessa desorganiza\u00e7\u00e3o podem ser evidenciados nos dados constantes no livro de \u00f3bito dispon\u00edvel no Arquivo Eclesi\u00e1stico da Arquidiocese e nos registros da Santa Casa da cidade, que n\u00e3o convergem. No livro de \u00f3bito de 1918, em outubro foram registradas 17 mortes em Diamantina. Dessas, pelo menos duas podem ser associadas \u00e0 gripe de 1918, pois o diagn\u00f3stico apresentado como Os registros da Santa Casa, por sua vez, apresentam dados divergentes dos j\u00e1 mencionados. O livro de entradas e sa\u00eddas da Santa Casa de Diamantina, entre novembro de 1918 e fevereiro de 1919, registrou o total de 77 pacientes, dos quais apenas 47 foram diagnosticados com gripe. No livro, os indiv\u00edduos registrados eram todos do sexo masculino, e dos gripados ocorreram apenas tr\u00eas mortes.No que diz respeito \u00e0 gripe, no entanto, os n\u00fameros nunca s\u00e3o exatos. O car\u00e1ter familiar da doen\u00e7a contribuiu para uma disson\u00e2ncia nos n\u00fameros apontados pelas fontes, por exemplo, para uma mesma cidade ou um mesmo hospital. Em Diamantina, uma justificativa primeira deve-se ao fato de que o livro de \u00f3bito registra apenas indiv\u00edduos que pertenciam \u00e0 sede do munic\u00edpio, ao passo que os registros da Santa Casa registram indiv\u00edduos oriundos de distritos municipais mais distantes e at\u00e9 mesmo outros munic\u00edpios, como Curvelo e Montes Claros.P\u00e3o de Santo Antonio , nos d\u00e3o pistas sobre a a\u00e7\u00e3o daquela institui\u00e7\u00e3o diante do surto epid\u00eamico na cidade e nos ajudam a compreender melhor os motivos na diverg\u00eancia dos n\u00fameros e como ocorreu o combate \u00e0 doen\u00e7a no munic\u00edpio. Segundo o m\u00e9dico, a Santa Casa teria estabelecido acordo com a C\u00e2mara Municipal para que a cidade n\u00e3o passasse pelas desgra\u00e7as que outros centros vivenciavam. O diretor do hospital declarou que a institui\u00e7\u00e3o estava preparada para servir a trezentos gripados e devidamente aparelhada para enfrentar, com vantagem, a situa\u00e7\u00e3o.Al\u00e9m disso, declara\u00e7\u00f5es do m\u00e9dico Ant\u00f4nio Mota, diretor da Santa Casa, em edi\u00e7\u00e3o de 8 de dezembro do jornal A pauta principal da entrevista com o diretor da Santa Casa tratou das reclama\u00e7\u00f5es de parte de popula\u00e7\u00e3o quanto \u00e0 falta de atendimento e das recorrentes rela\u00e7\u00f5es de \u00f3bitos verificados como \u201csem assist\u00eancia m\u00e9dica\u201d. Para Mota, a diminuta porcentagem de \u00f3bitos verificados no estabelecimento, totalizando seis mulheres e quatro homens, evidenciava ser infundadas as reclama\u00e7\u00f5es. Afirmou tamb\u00e9m que o pequeno coeficiente de mortalidade seria ainda menor caso se considerasse que as pessoas s\u00f3 procuravam o abrigo hospitalar quando j\u00e1 estavam bastante debilitadas.Na ocasi\u00e3o, o diretor da Santa Casa informou ainda que, at\u00e9 o dia 2 de dezembro de 1918, a institui\u00e7\u00e3o havia recebido 232 gripados, entre os quais 120 eram militares. Segundo o diretor, a institui\u00e7\u00e3o gastou uma quantia superior a um conto de r\u00e9is, e, diante de \u201cdespesas extraordin\u00e1rias\u201d, foi importante o aux\u00edlio do arcebispo dom Joaquim Silveiro de Souza, que prestou colabora\u00e7\u00e3o com \u201cgenerosa doa\u00e7\u00e3o de 200$00\u201d. Afirmou ainda que o acordo estabelecido em novembro de 1918 com a C\u00e2mara Municipal possibilitou que as enfermarias da Santa Casa pudessem atender os enfermos, incluindo \u201calguns levados contra sua pr\u00f3pria vontade, para serem tratados como pensionistas da c\u00e2mara\u201d. Como a situa\u00e7\u00e3o pedia mais agilidade a fim de \u201cevitar delongas nas entradas, foram suspensas todas as formalidades regimentais: a administra\u00e7\u00e3o interna do estabelecimento, exercida por irm\u00e3s de S\u00e3o Vicente de Paulo, estava sempre pronta para receber os doentes\u201d . Esse aspecto pode ter contribu\u00eddo para a discrep\u00e2ncia entre os dados j\u00e1 mencionados.No registro de entradas e sa\u00eddas da Santa Casa foram apontadas as respectivas profiss\u00f5es dos doentes acometidos pela gripe: lavradores, mineiros, carroceiros, jardineiros, pedreiros, padeiros, negociantes, carpinteiros e um foguista, sendo lavradores os mais recorrentes. O perfil indica, sobretudo, que se tratava de indiv\u00edduos pobres. O foguista, por exemplo, trabalhador respons\u00e1vel por operar as caldeiras das locomotivas a vapor, sofria constantes atrasos em seus sal\u00e1rios. H\u00e1 registro em Diamantina de que os trabalhadores da EFVM viviam em prec\u00e1rias condi\u00e7\u00f5es, recebendo os seus sal\u00e1rios com atraso de at\u00e9 quatro meses . Nesse sentido, corroboramos os estudos que indicam que a epidemia de gripe de 1918 afetou em maior medida pessoas mais expostas \u00e0 pobreza  destacou que:O jornal Quando foi do in\u00edcio da epidemia, cujas cortes aguerridas ocupam ainda hoje nosso territ\u00f3rio, ceifando, dia a dia, vidas por todos os t\u00edtulos preciosas, o ilustre superintendente do Ramal de Diamantina, solicitou, telegraficamente, do governo do Estado, aux\u00edlio e socorro contra a peste que invadia a vasta regi\u00e3o da Estrada. Que resposta lhe deram os grandes senhores do poder?\u2013 N\u00e3o ser poss\u00edvel atend\u00ea-lo.A \u201cen\u00e9rgica e inteligente\u201d atua\u00e7\u00e3o do superintendente ferrovi\u00e1rio foi assertiva, na perspectiva do redator do jornal, pois \u201cse dependessem da resposta do governo mineiro\u201d, o pessoal da estrada n\u00e3o teria assist\u00eancia m\u00e9dica, que foi fornecida pela diretoria da EFVM. O discurso indica que a resposta dos \u00f3rg\u00e3os estaduais \u00e0s necessidades municipais em tempos epid\u00eamicos foi insatisfat\u00f3ria. No artigo foi destacado ainda que mesmo a C\u00e2mara Municipal, quando demandou aten\u00e7\u00e3o do governo mineiro, \u201csentindo-se sem defesa e meios de combate\u201d, teve como resposta: \u201c1/2 quilo de quinino e dois pequenos frascos com ess\u00eancia de Canela! Isto, para cerca de 20 mil pessoas\u201d .Al\u00e9m da ferrovia, caminhos e trilhas contribu\u00edram para o avan\u00e7o da doen\u00e7a, uma vez que eram rotas-padr\u00e3o de circula\u00e7\u00e3o de pessoas. As caravanas que avan\u00e7avam pela regi\u00e3o sobre o lombo de burros e mulas, intituladas tropas de muares, por exemplo, tamb\u00e9m podem ter contribu\u00eddo para a dissemina\u00e7\u00e3o da doen\u00e7a. Segundo P\u00e3o de Santo Antonio (15 dez. 1918), a doen\u00e7a se manifestou com car\u00e1ter benigno, e, para sorte dos habitantes da localidade de poucos recursos, \u201capenas 4 ou 5 pessoas faleceram devido complica\u00e7\u00f5es\u201d. Em Riacho das Varas, com esta\u00e7\u00e3o da linha Curralinho-Diamantina, a gripe tamb\u00e9m foi destacada como benigna, tendo causado apenas um caso fatal, \u201cmesmo assim por complica\u00e7\u00e3o com outras mol\u00e9stias\u201d. No distrito de Curralinho, o m\u00e9dico Zozimo Ramos Couto registrou 59 gripados.4 Sebasti\u00e3o Pereira da Luz foi \u201cacometido de assalto pela sorrateira \u2018gripe\u2019 no distrito diamantinense de S\u00e3o Gon\u00e7alo do Rio Preto\u201d .Em Merc\u00eas de Ara\u00e7ua\u00ed, que n\u00e3o contava com esta\u00e7\u00e3o da EFVM, a gripe grassava desde outubro e teria \u201catacado todos os lares\u201d. Segundo o jornal De Curvelo, sede do entroncamento da Central do Brasil, o padre Thiago em correspond\u00eancia enviada a dom Joaquim Silv\u00e9rio, em 23 de novembro de 1918, desejava ao arcebispo sa\u00fade diante da doen\u00e7a que \u201cgrassa[va] por toda a parte\u201d. E continuou: \u201cAqui em Curvelo n\u00e3o somos dos mais infelizes, os casos s\u00e3o muitos, mas em geral de car\u00e1ter benigno\u201d. Em outro munic\u00edpio, no Serro, que fazia liga\u00e7\u00e3o com Diamantina pela estrada do Gavi\u00e3o, outra correspond\u00eancia para o arcebispo, datada de 6 de dezembro daquele ano, informava que os serranos estariam \u201ca bra\u00e7os com a gripe\u201d. Havia cerca de cinquenta vitimados e um morto. E a medida de urg\u00eancia da Caridade no Serro foi a organiza\u00e7\u00e3o de um hospital, na casa dos Ottoni, cedida pela C\u00e2mara Municipal. A prioridade era o \u201ctratamento dos que nem casa tinham\u201d.P\u00e3o de Santo Antonio foi publicado que a \u201csenhorita espanhola muito chorosa partia sem deixar saudades\u201d. O desejo era o de que uma \u201cimpetuosa rajada de vento a destru\u00edsse, ou a levasse aos infinitos\u201d. Contudo, ocorr\u00eancias da gripe tamb\u00e9m foram registradas em 1919, sobretudo no m\u00eas de janeiro.Era in\u00edcio de dezembro de 1918 quando a epidemia come\u00e7ou a entrar em franco decl\u00ednio na cidade. Aos poucos o cotidiano era retomado. O Tiro de Guerra, por exemplo, que havia suspendido suas atividades a partir do dia 10 de dezembro, retomou seu funcionamento regular. Em 15 de dezembro no P\u00e3o de Santo Antonio publicou uma pequena nota afirmando que os campos come\u00e7avam \u201ca ser frequentados pelas apreciadoras das gabirobas\u201d, e seria esse um sinal evidente de que j\u00e1 dizia adeus a \u201cmaligna pandemia\u201d. A esperan\u00e7a nas condi\u00e7\u00f5es serranas era mais uma vez refor\u00e7ada, e a epidemia de 1918 estava sendo relegada ao esquecimento.Em 1\u00ba de dezembro de 1918 o jornal No artigo, relacionamos a propaga\u00e7\u00e3o da gripe de 1918 \u00e0s condi\u00e7\u00f5es espec\u00edficas do ramal ferrovi\u00e1rio de Diamantina, que, transportando mercadorias e pessoas, buscou cumprir o prop\u00f3sito de integrar aquela cidade a outras regi\u00f5es do pa\u00eds. As caracter\u00edsticas biof\u00edsicas da serra do Espinha\u00e7o impulsionaram a elabora\u00e7\u00e3o da imagem de um sert\u00e3o isolado para aquela por\u00e7\u00e3o do norte de Minas Gerais. Observamos, contudo, que durante o epis\u00f3dio epid\u00eamico, as condi\u00e7\u00f5es serranas foram valoradas positivamente sendo indicadas como os elementos que tornariam brando o epis\u00f3dio epid\u00eamico e garantiriam, tamb\u00e9m, o \u201cenvio de doentes de outras localidades para a regi\u00e3o\u201d. Entretanto, apesar do discurso oficial de cidade salubre, a epidemia atacou o cotidiano diamantinense, que, diante da incapacidade das autoridades estaduais de oferecer suporte em rela\u00e7\u00e3o ao avan\u00e7o da doen\u00e7a, teve a presta\u00e7\u00e3o de socorro deixada a cargo de atores locais.O avan\u00e7o da epidemia de gripe contribuiu para afirmar que a ferrovia teria cumprido o seu prop\u00f3sito de integrar aquele sert\u00e3o. Esse epis\u00f3dio, quatro anos ap\u00f3s a inaugura\u00e7\u00e3o do ramal, exp\u00f4s a natureza perigosa da t\u00e3o reclamada integra\u00e7\u00e3o regional. A moderniza\u00e7\u00e3o chegava \u00e0quele sert\u00e3o pelos trilhos percebidos como solu\u00e7\u00e3o para o diagn\u00f3stico de atraso e isolamento. Contudo, os trens trouxeram mudan\u00e7as ambientais e problemas de sa\u00fade p\u00fablica como a chegada, em fins de 1918, da epidemia de gripe. Ao informar sobre os riscos que a ferrovia rec\u00e9m-inaugurada em Diamantina representou para a epidemia de gripe de 1918, nosso estudo mostra como s\u00e3o imbricadas as rela\u00e7\u00f5es entre moderniza\u00e7\u00e3o, mudan\u00e7as ambientais e prolifera\u00e7\u00e3o de doen\u00e7as. Dessa forma, contribui com a reflex\u00e3o sobre como futuras epidemias podem se espalhar.Outra contribui\u00e7\u00e3o refere-se ao esfor\u00e7o de contar a hist\u00f3ria do norte de Minas em termos diferentes, por meio da hist\u00f3ria da sa\u00fade e das doen\u00e7as, uma vez que a mem\u00f3ria do auge da minera\u00e7\u00e3o ainda \u00e9 o forte motor da hist\u00f3ria regional. Nosso estudo, al\u00e9m de contribuir com a historiografia regional, procura conect\u00e1-la \u00e0 historiografia nacional ao considerar que a constru\u00e7\u00e3o das ferrovias brasileiras no in\u00edcio do s\u00e9culo XX esteve acompanhada da busca por uma identidade nacional cuja caracter\u00edstica principal seria a modernidade. No entanto, como a experi\u00eancia de Diamantina evidencia, esse processo n\u00e3o teve apenas os efeitos desejados. Nos trilhos do almejado progresso tamb\u00e9m embarcaram a devasta\u00e7\u00e3o da natureza e as doen\u00e7as epid\u00eamicas."}
+{"text": "The validation process involved the validity of content, criteria and construct. The research stages were developed between August / 2018 to December / 2019 in the western and central-western regions of Paran\u00e1.the instrument demonstrated an acceptable agreement on the content validity through the evaluation of judges; the criterion validity through the established criterion showed no association; in the analysis of construct validity using the technique of known groups, it demonstrated homogeneity in the variables age, nationality and family income.the developed analysis indicated that the psychometric properties of the validation of the Brazilian version of the scale are consistent and adequate, which allows the recommendation of the application of the instrument in a national context. Due to this reason, the economic sector has invested in the manufacture and sale of fertilizers and pesticides to control pests and weeds. This reality intensifies the discussions about the impacts of the indiscriminate use of pesticides and their consequences on public health. In this ranking, Paran\u00e1 is the third largest consumer from Brazil, which makes it a valid reference for research related to this theme.Data from the Brazilian Health Regulatory Agency (ANVISA) place Brazil as the largest consumer of pesticides in the world in recent harvests, with the prospect of increasing every year the intensive use of pesticides in cropsAlthough the discussion about the deleterious effects of pesticides on the body of directly or indirectly exposed populations is not recent, very little has been done in relation to attention and concrete intervention regarding its use. Actions aimed at minimizing the impacts of poisoning are still segregated and ineffective, making the control of the consumption and misuse of these chemical products difficult..In recent years, studies have focused on investigating the possible harm of pesticides to farmers' health, with a focus on pregnant women, who are characterized as a higher-risk population. Research in this area points to complications and intercurrences in pregnancy, often unknown by the woman herself. This issue reveals an emerging health care concern but mainly highlights the great risk that a fragile population, such as pregnant women, is exposed to,5. Among these factors, which put the pregnant woman's health at risk, is excessive exposure to pesticides, whose harm has already been evidenced by experimental research, which is still in progress in human beings, allowing to anticipate the presence of alterations in newborns, children of mothers who were exposed to pesticides before and during pregnancy,5.The existence of any intercurrences during pregnancy can generate undesirable outcomes with different impairments to the fetus, such as low birth weight, prematurity, and congenital malformations, which are considered risk factors for infant mortalityAlthough there is already evidence of the pathological consequences caused by pesticides, there are few protocols in the public health system in Brazil that efficiently and effectively investigate working women exposed to pesticides during the prenatal period. It can be inferred that this absence is based on the false idea that women, by staying at home, away from agricultural work, would not be exposed to the harmful effects of pesticides. Undoubtedly, pregnant women who live in agricultural areas or close to them are at greater risk when compared to other pregnant women, which requires greater attention and monitoring by public health policies. Not only are effective care actions necessary, but it is also urgent to establish a protocol that can place this pregnant woman in the high-risk category, and not just in the usual risk category, allowing her to have access to more specific exams that can even evaluate the levels of toxicity present in the body..There is already a concern in other countries regarding the exposure of pregnant women to pesticides used in agriculture and in Thailand research is already being carried out using the Knowledge, Attitudes and Practices (KAP) Questionnaire, as it is an effective instrument for understanding the factors associated with exposure to pesticides in the prenatal period of the KAP questionnaire, which is an instrument that collaborates to identify the knowledge, attitudes, and practices of pregnant women with regard to exposure to pesticides, into Brazilian Portuguese, was carried out. In this preliminary study, carried out in Brazil, it was possible to verify significant associations between women's knowledge and the stage of pregnancy, in addition to indicating behaviors characterized as risky, as well as safe practices when dealing with toxic products. From the results obtained, it was also possible to infer that the longer the pregnancy, the greater the knowledge about the risks of exposure to pesticides, as well as the adoption of safe attitudes and practices during the gestational period, both at home and at work.In this sense, a translationDespite the favorable results for the use of the KAP questionnaire to survey the knowledge, attitudes, and practices of pregnant farmers in Brazil, to obtain better reliability, it is necessary to validate this instrument to verify whether it is valid for assessing these issues in a larger sample of participants.The aim of this study was to validate the KAP questionnaire in populations of pregnant women exposed to pesticides in the State of Paran\u00e1/Brazil.th and 10th Health Regions, in addition to pregnant women contacted through an active search, from August 2018 to December 2019, were recruited for this research. All individuals involved (or their guardians) signed the Free and Informed Consent Form.This research was approved by the Ethics Committee for Research Involving Human Beings of the Centro Universit\u00e1rio Assis Gurgacz with co-participation of the Ethics Committee for Research Involving Human Beings of the Paran\u00e1 State Department of Health (CEPSH/SESA/HT) under opinion number 3.422 .972. The sample was non-probabilistic for convenience, due to the accessibility and availability of the population. Pregnant women who attended prenatal consultations and meetings at the Basic Health Units of their respective municipalities, belonging to the 4The study sample included 382 pregnant women of all gestational periods, divided into two groups: Not Exposed to Pesticides - 62 pregnant women not exposed to pesticides - and Exposed to Pesticides - 320 pregnant women exposed to pesticides. The exposed pregnant women were women directly or indirectly involved in agriculture, exposed to pesticides, literate, and with apparent emotional and cognitive conditions to answer the questionnaire without help. The Not Exposed to Pesticides Group was composed of pregnant women with no direct or indirect link to agriculture. As this is the validation of an instrument, requiring a large number of subjects, the application of the instrument was carried out by Primary Health Care professionals, through training on the objectives of the instrument and its theoretical basis. The number of subjects in each test was variable.The KAP questionnaire addresses the Knowledge, Attitudes, and Practices of pregnant farmers and includes comprehensive questions on:Knowledge about pesticides - information on training to use the products, routes of exposure and risks involved, acute and chronic effects on health, symptoms of toxicity, and effective methods to prevent exposure.Attitudes about the use of pesticides - information about beliefs for responsible and safe use, susceptibility to health effects, effectiveness of pesticides, and reason for using them.Practices for the safe use of pesticides - information on occupational and domestic use, use of personal protective equipment, and use of other safe precautions during and after the use of pesticides., which refers to the fact that an instrument measures exactly what it is intended to measure, there are three aspects that must be considered: content validity ; criterion validity (how accurately a test measures the outcome it was designed to measure); and construct validity,10 (whether the variables that are being tested for behave in a way to support the theory).For validity. After the analysis, the items that scored 1 and 2 were excluded from the instrument, and the items that scored 3 and 4 were added and divided by the total number of responses, generating the agreement index among the specialists.Regarding content validity, a committee of experts consisting of three judges, researchers in the field of toxicology that study the effects of pesticides on the human body, was formed to evaluate the instrument's items. The committee evaluated question by question using a Likert scale, assigning scores from 1 to 4 to each item presented. Shorter analysis options were used: 1 = not clear, 2 = not very clear, 3 = quite clear, 4 = very clear participated.For criterion validity, as there is no gold standard instrument for correlation analysis, concurrent validity, using an established criterion, which is three brief questions that assess the same construct: \u201c1- Do you believe you have adequate knowledge about the effects of pesticides?; 2 - Do you believe you have adequate attitudes towards pesticides?; 3 - Do you believe you have safe practices regarding pesticides?\u201d, was chosen. The answer alternatives were yes or no. In this step, 244 pregnant women exposed to pesticides-11. Subsequently, the responses of both groups were analyzed and compared in order to verify different responses between them.For construct validity, given the characteristics of the questionnaire, it was not possible to analyze the convergent validity, since the original study does not present validation tests, nor the factor analysis, since the questions that make up the questionnaire do not follow a pattern. To list the necessary evidence to guarantee construct validity, the known group\u00b4 technique was used. In this technique, the instrument was applied in two groups: Exposed to Pesticides Group, composed of 320 pregnant women, and Not Exposed to Pesticides Group, composed of 62 pregnant womenData were analyzed using descriptive and inferential analysis. The SPSS 25.0 software was used. A descriptive analysis of nominal qualitative variables by relative frequency and percentage was performed. Descriptive analysis of discrete and continuous quantitative and ordinal qualitative variables was performed by calculating measures of central tendency (mean and median), variability (standard deviation), and position (first quartile and third quartile).The inferential analysis of the association between the variables was performed using Fisher's Exact Test and Pearson's Chi-Square Test. The distribution analysis of the quantitative variables was performed using the Shapiro-Wilk test, and all variables had non-normal distribution. The inferential analysis of the quantitative variables as a function of nominal qualitative variables of two categories (independent groups) was performed using the Mann-Whitney test. The agreement analysis between the quantitative variables was performed using the Intraclass Correlation Coefficient test and between the qualitative variables using the Kappa test.th Health Region, which covers the west region of the State of Paran\u00e1, had greater participation  than the 4th Health Region, corresponding to the southeast region of the state .This research was carried out between August 2018 and December 2019. The sample of the present study consisted of 382 pregnant women, divided into two groups: Not Exposed to Pesticides - 62 pregnant women not exposed to pesticides - and Exposed to Pesticides - 320 pregnant women exposed to pesticides. The groups and the number of participants in each stage of the validation study varied. The 10rd trimester . The majority of the participants were Brazilian  and the most frequent level of education was complete high school . Only 17.8% of all the participants were studying at the time of the research. The family income of 31.6% of the participants was less than a salary (R$975.00), and between one and two salaries for 44.7%. Regarding previous pregnancies, an average of two pregnancies was observed. Most of the interviewees reported that they lived in an agricultural area .Considering only the Exposed to Pesticides Group, the average age of the participants was 26 years and six months, and the trimesters of pregnancy showed greater participation of pregnant women in the 3Regarding the occupation of the women in the Exposed to Pesticides Group, 54.38% (n=174) reported working since they became pregnant, while 45.63% (n=146) deny having worked. Of those who indicated having worked, when asked if their work involves agriculture, 25.63% (n=82) answered yes and 28.75% (n=92) no; another 146 (45.63%) pregnant women did not answer this question, as a questionnaire criterion, since they indicated they were not working during pregnancy. When asked if they currently work, 60.94% (n=195) answered yes and 39.06% (n=125) no; 72.19% (n=231) reported that they were working a year ago, against 27.81% (n=89), who answered not being working in this period. Regarding when they stopped working, 6.25% (n=20) reported that they stopped working before knowing about the pregnancy, 32.19% (n=103) after knowing about the pregnancy, and another 197 (61.56%) answered that they did not have interrupted their work.As for occupational planning, 102 (31.88%) reported that they would stop working only when the doctor determined or when they were no longer able to work, while 97 (30.31%) intended to work until they gave birth. 120 (37.50%) pregnant women still did not know when they would stop working. After giving birth, 251 (78.44%) intended to work, 16.56% (n=53) did not intend to work, and 5% (n=16) did not yet know. Regarding the return to work, 35.63% (n=114) believed returning between 3 months after giving birth, 9.38% (n=30) between 3 and 6 months after giving birth, 7.5% (n=24) 6 months after giving birth, and 47.5% (n=152) still did not know.Concerning the medical resources used to perform prenatal care, more than 70% of the participants reported using the Unified Health System, followed by supplementary health (23%). In this question, the participants could choose more than one alternative if they used more than one service. As for the number of prenatal consultations, the average was 2.51 times. Regarding the month of the first visit to the doctor, it occurred at the 2.16 months of gestation.The characterization of the scores for Knowledge, Attitudes and Practices was made from a determined score, based on the percentage of questions answered correctly, indicating that the higher the average, the greater the degree of knowledge, or attitudes and practices carried out. The analysis of Knowledge allowed verifying a significant level of knowledge of pregnant women about all related items, and most of the interviewees agreed that the damage caused by pesticides affects different populations, regardless of whether they are farmers or not, as well as recognized the main routes of poisoning and its symptoms.Most of the pregnant women interviewed did not receive training on pesticides  and only 20 pregnant women (6.25%), who received training, reported that it was offered by the companies that supply the products, companies/cooperatives linked to their job, and syndicates, about 2 years ago. Only these women answered questions about the topics discussed in the training.The analysis of Attitudes showed a low mean score for the items \u201cUse of appropriate clothing at work\u201d, \u201cUse of pesticides and care\u201d, \u201cReasons for using pesticides at home\u201d and \u201cReasons for using pesticides at work\u201d. And regarding \u201cAttitudes taken at home\u201d, such as care with washing fruits and vegetables before eating, \u201cHarmful attitudes for the fetus\u201d, \u201cResponsibility for the safe use of pesticides, reading the packaging label\u201d, as well as \u201cResponsibility for safe use of pesticides, reuse of packaging\u201d, this was characterized as a safe attitude that demonstrates responsibility regarding the use of pesticides by most pregnant women.The analysis of Practices for the safe use of pesticides refers to the use of protective equipment, which includes precautionary practices at home and at work, as effective ways to prevent exposure to pesticides, revealed safe practices in the three trimesters of pregnancy.The results for validity, which refer to the fact that the instrument measures exactly what it proposes to measure, were obtained from the analysis of the three main types of validity: content validity, criterion validity, and construct validity. was used. Three judges analyzed each question assigning a score from 1 to 4, where: 1 = unclear item; 2 = slightly unclear item; 3 = quite clear item; and 4 = very clear item. The count of the number of questions with grades three and four was done and the total count was divided by the total number of questions evaluated. The calculation was performed for each judge individually and for the total number of judges. The results showed that the Content Validity Index was between 0.94 and 0.97 for the individual judges and 0.96 for the total of judges, which demonstrated acceptable agreement among the members of the committee of experts.To analyze content validity, the Content Validity IndexFor the criterion validity analysis, the domain scores of each construct were compared between two independent groups, constituted from the answers to questions that analyze the same construct. For this, participants were instructed to answer yes or no to the questions: a) \u201cDo you believe you have adequate knowledge about the effects of pesticides?\u201d; b) \u201cDo you believe you have adequate attitudes towards pesticides?\u201d, and c) \u201cDo you believe you have safe practices regarding pesticides?\u201d. Due to the non-normal distribution of the scores, the non-parametric Mann-Whitney test was used to compare the two independent groups. In addition, for the nominal qualitative variables of domains or questions of the construct Knowledge, an association between the categories of answers to the questions and the categories of answers to the domains or questions of the construct , 2, 3 waFor the construct validity analysis, the pregnant women in the Exposed to Pesticides Group were compared to the pregnant women in the Not Exposed to Pesticides Group, in order to verify differences in the scores of the domains of the constructs of Knowledge, Attitudes and Practices of the KAP questionnaire. The analysis allowed inferring that the groups were homogeneous for the variables age, nationality, education, and family income .In the analysis of the scores of the questions of the constructs Knowledge, Practices and Attitudes of the KAP questionnaire, according to the groups of female farmers, it was observed that there was a statistical difference between the groups, and only for the domain \u201cAttitudes in home\u201d (p<0.001) the Exposed to Pesticides Group had a lower score than the Not Exposed to Pesticides Group .Fisher's Exact Test and Pearson's Chi-Square Test were used to associate the domains or nominal qualitative questions and the groups. It was observed that there was an association between the \u201cKnowledge about other effects of pesticides\u201d domain and the answer no in the Exposed to Pesticides Group (p=0.012).,13.The KAP questionnaire is used worldwide to assess Knowledge, Attitudes and Practices on various subjects and in different populations. The questionnaire differs according to the area and type of study, having already been applied to pregnant women to investigate prenatal care and routine exams,7.Although there are few studies, mainly in Brazil, using protocols similar to KAP, some inferences can be made from the results obtained from the validation process carried out in the present study. When we compare the data from this research to the values obtained in other protocols, with other populations, we observe some controversies regarding both knowledge, attitudes and practices, as well as the validation process, which will be discussed throughout this discussionIn the demographic analysis of the group of pregnant women exposed to pesticides, it was noted that the average age was 26 years and six months, with greater participation of pregnant women in the 3rd trimester ; the most frequent level of education was complete high school , and only 17.8% of the total number of participants was studying at the time of the research.th highest HDI and the 6th highest average real salary per inhabitant of the federative units, with an average per capita income of R$ 2,552.00. This data is in accordance with the analysis of the country's economic growth, which, taking GDP, per capita income and the sectoral production of the federative entities as a reference, the South and Southeast regions account for more than 70% of production and income, having 56% of the Brazilian population.The family income of approximately 32% of the participants was less than one minimum wage (R$975.00), the current value at the time of the research, and between one and two minimum wages for 44.7%. According to the last census carried out in 2014, the State of Paran\u00e1 has about 17% of its population in rural areas, and gains economic prominence with the 5. Evidence indicates that, although almost all Brazilian pregnant women (98%) begin prenatal care, the better the women's income, the greater their participation in prenatal procedures and exams.In the pregnant women who participated in this study, a low average family income was noted, which negatively interferes with their access to health services, since family income and maternal education are considered the main determinants for adequate prenatal care,7. The use of the KAP questionnaire also proved to be efficient in the assessment of educational measures in pregnant women regarding other subjects, such as gestational care and smoking,18. Most of the interviewees agreed that the damage caused by pesticides affects different populations, regardless of whether they are farmers or not, as well as recognized the main routes and signs and symptoms of intoxication.The findings for the Knowledge items were similar to the results found in the previously developed study about the translation of the questionnaire, in which pregnant women, in general, demonstrated satisfactory knowledge about pesticides, and the longer the gestational trimester, the greater the knowledgeIn the items related to knowledge about the damage caused by pesticides to human health and the risks of pesticides, the average was lower, however, it remained above 50%. The pregnant women in this study also did not demonstrate knowledge (63.75%) or did not report knowledge (23.75%) about other effects that pesticides can cause, in addition to those suggested by the questionnaire..Pesticides affect human health directly and indirectly, as well as the environment in general, causing an imbalance in biomes. However, the totality of its impacts is not clearly defined and known yet, due to the multiplicity of factors involved. In this sense, knowledge about contamination risks is closely related to the way in which these populations relate to existing dangers, processes that are strongly biased by determinants of social, cultural, and economic orders.According to the literature, signs and symptoms of intoxication differ between acute and chronic, classified as mild, moderate, and severe. Among the symptoms of acute intoxication are headache, irritation, irritant or hypersensitivity contact dermatitis, nausea, vomiting, abdominal cramps, dizziness, generalized weakness, increased salivation and sweating, hypotension, cardiac arrhythmias, respiratory failure, acute pulmonary edema, seizures, changes in consciousness, shock, and coma, which may progress to death. Chronic symptoms manifest themselves through numerous pathologies that affect various organs and systems, with emphasis on immunological, hematological, hepatic, and neurological problems, congenital malformations, and tumorsFor the recognition of risks and, therefore, the development of appropriate care, it is fundamental to carry out activities and/or educational programs that guide, clarify and teach strategies and safe forms of care. In the sample of this study, most pregnant women interviewed did not receive training on pesticides (93.75%), and only 20 pregnant women (6.25%), who received it, reported that it was offered through the companies that supply the products, companies/cooperatives linked to their job, and syndicates, about 2 years ago. Only the interviewees who reported having received training answered the questions about these topics.These data conflict with the findings on the knowledge of pregnant women about pesticides, since they had high levels of knowledge, however, they did not receive training on the products. This may indicate that possibly this knowledge does not come from instruction or training, but something acquired through other means, such as information on television, newspapers, and the internet, or acquired through popular and intergenerational knowledge, since many of them come from farming families.. Specifically, in the state of Paran\u00e1, several government initiatives have been carried out to better assist this population, such as the program called \u201cM\u00e3e Paranaense\u201d, which proposes the organization of maternal and child care in prenatal and puerperal actions and follow-up of the child growth and development, especially in the first year of life.In recent years, with the proposal of the Family Health Strategy Program, which brings the general population closer to health care units, prenatal care coverage has been intensified, reducing risk pregnancies and childbirth complications, in addition to campaigns in the pre-and neonatal periodsIn this sense, it is assumed that pregnant women who undergo prenatal care and participate in guidance, lectures, and conversations with health professionals, have more knowledge about gestational care and are alert to possible risks and take precautions for the comprehensive care for their fetus, even though pesticide is not the target topic..Advances in the health area and evidence-based practice give rise to the constant need for valid and reliable measures, using calibrated instruments, to measure reality according to standards. In Brazil, the number of cross-cultural adaptations of instruments designed and validated in other cultures and the number of constructions of new questionnaires has increased significantly, supported by international educational institutions and funding from government agencies, since a large part of this research is aimed at improving the health condition of the general population.Assessment instruments are part of clinical practice and research in different areas of knowledge, and the assessment of their quality is essential for selecting instruments that provide valid and reliable measurements for their target population, respecting their particularities. In this study, the selected judges, who were invited to participate spontaneously in this study, were invited, as they develop research related to the theme of this study.Content validity refers to the judgment on the instrument, carried out by different expert examiners, who analyze the representativeness of the items in relation to the content areas and the relevance of the objectives to be measured was used. Three judges analyzed each question assigning a score from 1 to 4, where: 1 = unclear item; 2 = slightly unclear item; 3 = quite clear item; and 4 = very clear item. The count of the number of questions with grades three and four was done and the total count was divided by the total number of questions evaluated. The calculation was performed for each judge individually and for the total number of judges. The results showed that the Content Validity Index was between 0.94 and 0.97 for the individual judges and 0.96 for the total of judges, which demonstrated acceptable agreement among the members of the committee of experts, indicating that the evaluated items of the questionnaire have valid and accurate measures.To analyze content validity, the Content Validity Index.Criterion validity is the existing correlation between the measure evaluated in relation to another measure or instrument that serves as an evaluation criterion, which has the same or similar attributes, and consists of the relationship between scores of a given instrument and some external criterion. For this, participants were instructed to answer yes or no to the questions: a) \u201cDo you believe you have adequate knowledge about the effects of pesticides?\u201d; b) \u201cDo you believe you have adequate attitudes towards pesticides?\u201d, and c) \u201cDo you believe you have safe practices regarding pesticides?\u201d.In the case of this study, for the analysis of criterion validity, the domain scores of each construct were compared between two independent groups constituted from the answers to questions that analyze the same construct. After applying the questionnaire, three questions were tested in order to confirm the criterion validityThe results showed that there was no difference or association between the criterion questions and the domains or questions in the questionnaire. In the case of the KAP questionnaire, no gold standard questionnaire was found for comparison. The original questionnaire in English is not validated and, for this reason, it does not present the analyzes for such a comparison.It is possible that the established criterion, by presenting direct questions with objective answers, did not favor, being a weak criterion of comparison, since it limits the answers of the pregnant women. An alternative to be considered is to create a scale that allows more flexibility in responses. Furthermore, it is also believed that this was a reflection, after having answered all the questions in the questionnaire and having rethought about their knowledge, attitudes and practices.. The variation in the strength of the correlation from medium to strong, found for the aspects considered in this research, was explained by the differences between the items and the way of evaluating the two protocols  of the test, with a view to having elements that can clarify the meaning of the instrument. That is, we sought to verify the knowledge, attitudes and practices of pregnant women exposed to pesticides regarding these products. Construct validity is subdivided into three types: hypothesis testing, structural or factorial validity, and cross-cultural validity-11.In the case of this study, construct validity is fundamental, since it helps the researcher to determine and better understand the cognitive and psychological issues that are being measured by the test. In this study, for this analysis, the pregnant women in the Exposed to Pesticides Group were compared to the pregnant women in the Not Exposed to Pesticides Group to verify differences in the scores of the domains of the constructs of knowledge, attitudes and practices of the KAP Questionnaire. The analysis allowed inferring that the groups were homogeneous for the variables age, nationality, study, and family income. The analysis of the scores of the questions of the constructs Knowledge, Practices and Attitudes of the KAP Questionnaire showed that there was a statistical difference between the groups of pregnant women and only in the domain \u201cAttitudes at home\u201d the Exposed to Pesticides Group presented a lower score than the Not Exposed to Pesticides Group. This identifies that the pregnant women in the Not Exposed to Pesticides Group are more careful with cleaning fruits and vegetables before eating, with their work clothes, and with their own homes. Regarding this, when analyzing the questions regarding family income and education level, which could be factors that interfere in this question, it is observed that, in this study, these variables are homogeneous.In the hypothesis test, one of the strategies of this testing is the technique of known groups, in which different groups of individuals fill out the research instrument and, then, the results of the groups are comparedHowever, the Exposed to Pesticides Group presented higher scores than the Not Exposed to Pesticides Group in the domains \u201cknowledge about the population at risk\u201d, \u201cknowledge of intoxication symptoms\u201d, \u201charmful attitudes towards the fetus\u201d, \u201cresponsibility for the safe use of pesticides, read the packaging label\u201d, \u201cresponsibility for the safe use of pesticides, reuse of packaging\u201d, \u201cuse of pesticides and care\u201d, \u201cprecautionary practices\u201d, \u201cpractices regarding domestic animals\u201d. It is possible that, due to the fact that pesticides are not a reality close to unexposed pregnant women, they have no concern or knowledge about the subject and, perhaps, these subjects have never been discussed in the environment in which they live. With regard to exposed pregnant women, it is the opposite. Although the vast majority of them have not been instructed on the safe use and care of products, this topic is part of their experience and, indirectly, is being discussed by product sellers, agronomists, syndicate representatives and by their own families, since there is a common and general sense that \u201cpoison is harmful\u201d.Following the steps of construct validation, structural or factorial validity provides tools to assess the correlations in a large number of variables, defining the factors, that is, the variables strongly related to each other11. In this study, the characteristics of the instrument did not allow performing the factor analysis, as the KAP Questionnaire presents a variation in its question models: it has questions with \u201cyes\u201d and \u201cno\u201d alternatives, with Likert and essay scales. Another peculiarity of the questionnaire is that the answer to a question, whether yes or no, directly interferes with whether you will answer the next question or section of the questionnaire. These singularities make the factor analysis difficult since it is not possible to categorize the data., which aimed to translate, adapt and develop the preliminary normative study of the KAP Questionnaire into Brazilian Portuguese. In that study, the KAP Questionnaire was translated into Brazilian Portuguese, being analyzed by judges from areas related to the object of the study, allowing the revision and adequacy of the terms. Afterwards, the questionnaire was applied in a pilot group, in order to carry out the semantic analysis and cross-cultural adaptation of the terms. After adaptation, the instrument was back-translated into English. From the results, it was possible to verify that this instrument was coherent and satisfactory for surveying the knowledge, attitudes and practices of Brazilian pregnant women in relation to pesticides. In the present study, there were significant differences between knowledge and the stage of pregnancy, and the longer the pregnancy, the greater the knowledge about the risks of exposure to pesticides, as well as the adoption of safe attitudes and practices during the gestational period, at home and at work.This step was carried out in a previous studyConcluding this discussion, it should be noted that, in this study, the KAP Questionnaire was validated in pregnant women exposed to pesticides, through content, criterion, and construct validity. The research, developed in two health regions in the State of Paran\u00e1, did not effectively count on all exposed pregnant women, which would express the cultural reality of the regions. Another limitation concerns the characteristics of the questionnaire, which, as it does not follow a pattern, did not allow for important analyses, such as exploratory factor analysis.On the other hand, the significant number of pregnant women who participated in the study, and the fulfillment of all reliability and validity stages, allowed obtaining reliable data and the inference that the instrument is valid for application in Brazilian populations. Another bias to be highlighted is that despite the favorable validity results, indicating the possibility of using this questionnaire to survey the Knowledge, Attitudes and Practices of pregnant women farmers in Brazil, its application in the form of an interview, with the presence of the community health agents or another health professional, may have caused some embarrassment, which may have influenced the responses, especially regarding attitudes and practices taken at home.Although the evidence that unsafe practices related to pesticides are associated with increased exposure of the Brazilian population to these products is not confirmed, it is possible that this is the main reason for the occurrence of the increase in changes generated by these risk behaviors, however, actual exposure measurements would be needed to confirm this hypothesis. This was not the focus of this study, but the responses obtained from the application of this instrument may be useful for future interventions.Future research should aim to develop more homogeneous and reduced instruments, which facilitate the application in an even larger number of subjects, and present the complete analysis of its validation. Another focus of interest related to the theme would be the investigation of the men, partners of these pregnant women, and residents of the countryside, regarding their knowledge, attitudes and practices about the products, with regard to the concern with the pregnancy, since this issue does not should be a woman's sole concern.The negative effects of pesticides on pregnant women and their newborns deserve attention from public health policies, since, as seen, research carried out in several countries proves that there are complications in pregnancy and to the health of the fetus. Scientific research has precisely the function of presenting specific situations so that, with effective public strategies, pesticides can stop causing problems to the population.This study can be an initial path in understanding the reality of pregnant women and can be considered a guiding guide for future practices and actions aimed at the care of women exposed to pesticides. The validation of knowledge, attitude and practice assessment tools will help to develop useful and efficient programs.This study validated the KAP questionnaire considering its content, criterion, and construct. The developed analysis indicated that the psychometric properties of the cross-cultural adaptation of the Brazilian version of the scale are consistent and adequate for application in Brazil, which allows the recommendation to apply the instrument in a national context. It is important that the validated version of the questionnaire be applied in regions of Brazil to understand the cultural characteristics of each region, in order to propose effective measures for health promotion and damage prevention. .A produ\u00e7\u00e3o agr\u00edcola brasileira tem se tornado cada vez mais eficiente ao longo dos anos. Decorrente desse motivo, o setor econ\u00f4mico tem investido na fabrica\u00e7\u00e3o e na comercializa\u00e7\u00e3o de fertilizantes e agrot\u00f3xicos para o controle de pragas e ervas daninhas. Tal realidade faz com que se intensifiquem as discuss\u00f5es sobre os impactos da utiliza\u00e7\u00e3o indiscriminada de agrot\u00f3xicos e suas consequ\u00eancias na sa\u00fade p\u00fablica. Nesse ranking, o Paran\u00e1 \u00e9 o terceiro maior consumidor do Brasil, o que o torna um referencial v\u00e1lido para pesquisas relacionadas ao tema.Dados da Ag\u00eancia Nacional de Vigil\u00e2ncia Sanit\u00e1ria (ANVISA) colocam o Brasil como maior consumidor de agrot\u00f3xico mundial nas \u00faltimas safras, com perspectiva de aumentar a cada ano o uso intensivo de agrot\u00f3xicos nas lavourasEmbora a discuss\u00e3o sobre os efeitos delet\u00e9rios dos agrot\u00f3xicos no organismo das popula\u00e7\u00f5es expostas direta ou indiretamente n\u00e3o seja recente, muito pouco se tem feito em rela\u00e7\u00e3o \u00e0 aten\u00e7\u00e3o e interven\u00e7\u00e3o concreta sobre o seu uso. As a\u00e7\u00f5es que visam minimizar os impactos das intoxica\u00e7\u00f5es ainda s\u00e3o segregadas e pouco efetivas, dificultando o controle sobre o consumo e mau uso desses produtos qu\u00edmicos..Nos \u00faltimos anos, os estudos se at\u00eam a investigar os poss\u00edveis danos \u00e0 sa\u00fade dos agricultores, com aten\u00e7\u00e3o principal \u00e0s mulheres gestantes, caracterizadas como popula\u00e7\u00e3o de maior risco. As pesquisas nessa \u00e1rea apontam para complica\u00e7\u00f5es e intercorr\u00eancias na gravidez, muitas vezes desconhecidas pela pr\u00f3pria mulher. Essa quest\u00e3o transparece uma preocupa\u00e7\u00e3o emergente de cuidado \u00e0 sa\u00fade, mas principalmente evidencia o grande risco que uma popula\u00e7\u00e3o fr\u00e1gil, como a das gestantes, est\u00e1 exposta,5. Dentre esses fatores, que colocam em risco a sa\u00fade da gestante, incluem-se a exposi\u00e7\u00e3o demasiada aos agrot\u00f3xicos, cujos malef\u00edcios j\u00e1 foram evidenciados por pesquisas experimentais, e seguem em andamento em seres humanos, permitindo antecipar a presen\u00e7a de altera\u00e7\u00f5es nos rec\u00e9m-nascidos, filhos de m\u00e3es que estiveram expostas aos agrot\u00f3xicos antes e durante a gesta\u00e7\u00e3o,5.Fato \u00e9 que a exist\u00eancia de quaisquer intercorr\u00eancias na gesta\u00e7\u00e3o pode gerar desfechos indesej\u00e1veis com diferentes comprometimentos ao feto, como baixo peso ao nascimento, prematuridade e malforma\u00e7\u00f5es cong\u00eanitas, que s\u00e3o considerados fatores de risco para a mortalidade infantilEmbora j\u00e1 existam comprova\u00e7\u00f5es sobre as consequ\u00eancias patol\u00f3gicas causadas pelos agrot\u00f3xicos, no sistema de sa\u00fade p\u00fablica no Brasil s\u00e3o escassos protocolos que atendam, com efici\u00eancia e efic\u00e1cia, as mulheres trabalhadoras expostas aos agrot\u00f3xicos durante o per\u00edodo pr\u00e9-natal. Pode-se inferir que essa aus\u00eancia se baseia na falsa ideia de que a mulher, por permanecer em casa, longe do trabalho agr\u00edcola, n\u00e3o estaria exposta aos efeitos danosos dos agrot\u00f3xicos. Indubitavelmente, a gestante que reside em \u00e1reas agr\u00edcolas ou pr\u00f3xima a elas, apresenta maior risco, quando comparada a outras gestantes, o que requer maior aten\u00e7\u00e3o e acompanhamento das pol\u00edticas de sa\u00fade p\u00fablica. N\u00e3o somente s\u00e3o necess\u00e1rias a\u00e7\u00f5es eficazes de cuidado, como tamb\u00e9m \u00e9 urgente o estabelecimento de um protocolo que possa enquadrar esta gestante na categoria de alto risco, e n\u00e3o apenas no risco habitual, permitindo a ela o acesso a exames mais espec\u00edficos que possam, inclusive, avaliar os n\u00edveis de toxicidade presentes no organismo..A esse respeito, j\u00e1 existem em outros pa\u00edses, a preocupa\u00e7\u00e3o quanto \u00e0 exposi\u00e7\u00e3o das gestantes aos agrot\u00f3xicos utilizados na agricultura, sendo que na Tail\u00e2ndia j\u00e1 est\u00e3o sendo realizadas experi\u00eancias com o Question\u00e1rio Conhecimento, Atitudes e Pr\u00e1ticas (CAP), por ser esse um instrumento eficaz para compreender os fatores associados com a exposi\u00e7\u00e3o aos agrot\u00f3xicos no per\u00edodo pr\u00e9-natal do Question\u00e1rio CAP, o qual se constitui como um instrumento que colabora para a identifica\u00e7\u00e3o dos conhecimentos, atitudes e pr\u00e1ticas das mulheres gestantes no que se refere \u00e0 exposi\u00e7\u00e3o aos agrot\u00f3xicos. Nesse estudo preliminar, realizado no Brasil, foi poss\u00edvel verificar associa\u00e7\u00f5es significativas entre o conhecimento das mulheres e a fase da gesta\u00e7\u00e3o, al\u00e9m de indicar comportamentos caracterizados como de riscos, bem como as pr\u00e1ticas seguras diante dos produtos t\u00f3xicos. A partir dos resultados encontrados, tamb\u00e9m foi poss\u00edvel depreender que quanto mais tempo de gesta\u00e7\u00e3o, maior \u00e9 o conhecimento sobre os riscos da exposi\u00e7\u00e3o aos agrot\u00f3xicos, como tamb\u00e9m a tomada de atitudes e pr\u00e1ticas seguras durante o per\u00edodo gestacional, tanto em casa como no trabalho.Nesse sentido, foi realizada a tradu\u00e7\u00e3oApesar dos resultados favor\u00e1veis \u00e0 utiliza\u00e7\u00e3o do Question\u00e1rio CAP para levantamento do conhecimento, das atitudes e das pr\u00e1ticas de gestantes agricultoras no Brasil, para obter melhor confiabilidade \u00e9 necess\u00e1ria a valida\u00e7\u00e3o deste instrumento, a fim de verificar se o mesmo \u00e9 v\u00e1lido para avaliar o que se prop\u00f5e, utilizando uma amostra maior de participantes.O objetivo deste estudo foi realizar a valida\u00e7\u00e3o do Question\u00e1rio CAP em popula\u00e7\u00f5es de gestantes expostas a agrot\u00f3xicos no Estado do Paran\u00e1.A presente pesquisa foi aprovada pelo Comit\u00ea de \u00c9tica em Pesquisa Envolvendo Seres Humanos do Centro Universit\u00e1rio Assis Gurgacz com coparticipa\u00e7\u00e3o do Comit\u00ea de \u00c9tica em Pesquisa Envolvendo Seres Humanos da Secretaria de Estado da Sa\u00fade do Paran\u00e1 (CEPSH/SESA/HT), sob parecer n\u00famero 3.422.972. A amostra foi n\u00e3o probabil\u00edstica por conveni\u00eancia, em fun\u00e7\u00e3o da acessibilidade e disponibilidade da popula\u00e7\u00e3o. Foram recrutadas gestantes que frequentaram consultas e encontros pr\u00e9-natais nas Unidades B\u00e1sicas de Sa\u00fade de seus respectivos munic\u00edpios, pertencentes a 4\u00aa e a 10\u00aa Regionais de Sa\u00fade, al\u00e9m de gestantes contatadas por meio de busca ativa, no per\u00edodo de Agosto de 2018 e Dezembro de 2019. Todos os indiv\u00edduos envolvidos (ou seus respons\u00e1veis) assinaram o Termo de Consentimento Livre e Esclarecido.A amostra do estudo incluiu 382 gestantes de todos os per\u00edodos gestacionais, divididas em dois grupos: Grupo N\u00e3o-Expostas a Agrot\u00f3xicos - 62 mulheres gr\u00e1vidas n\u00e3o-expostas a agrot\u00f3xicos; Grupo Expostas a Agrot\u00f3xicos - 320 mulheres gr\u00e1vidas expostas a agrot\u00f3xicos. As gestantes expostas s\u00e3o mulheres envolvidas direta ou indiretamente com a agricultura, sendo elas expostas aos agrot\u00f3xicos, alfabetizadas e com aparente condi\u00e7\u00f5es emocionais e cognitivas de responder ao question\u00e1rio sem aux\u00edlio. O Grupo N\u00e3o-Exposta a Agrot\u00f3xicos foi composto por gestantes, sem v\u00ednculo direto ou indireto com a agricultura. Por se tratar da valida\u00e7\u00e3o de um instrumento, necessitando de um grande n\u00famero de sujeitos, a aplica\u00e7\u00e3o do instrumento foi realizada por profissionais da Aten\u00e7\u00e3o B\u00e1sica em Sa\u00fade, mediante treinamento sobre os objetivos do instrumento e sua base te\u00f3rica. O n\u00famero de sujeitos em cada teste foi vari\u00e1vel.O question\u00e1rio CAP aborda o Conhecimento, Atitudes e Pr\u00e1ticas de gestantes agricultoras e inclui quest\u00f5es abrangentes sobre:O conhecimento sobre agrot\u00f3xicos - informa\u00e7\u00e3o sobre o treinamento para uso dos produtos, rotas de exposi\u00e7\u00e3o e riscos envolvidos, efeitos agudos e cr\u00f4nicos sobre a sa\u00fade, sintomas da toxicidade e m\u00e9todos efetivos para prevenir a exposi\u00e7\u00e3o.As atitudes sobre o uso dos agrot\u00f3xicos - informa\u00e7\u00e3o sobre cren\u00e7as para a responsabilidade de um uso seguro, susceptibilidade para efeitos sobre a sa\u00fade, efetividade dos agrot\u00f3xicos e raz\u00e3o para uso deles.As pr\u00e1ticas para o uso seguro dos agrot\u00f3xicos - informa\u00e7\u00e3o sobre o uso ocupacional e dom\u00e9stico, uso de equipamento de prote\u00e7\u00e3o individual e uso de outras precau\u00e7\u00f5es seguras durante e depois da utiliza\u00e7\u00e3o dos agrot\u00f3xicos., que se refere ao fato de um instrumento medir exatamente o que se prop\u00f5e a medir, h\u00e1 tr\u00eas aspectos que devem ser considerados: validade de conte\u00fado ; validade de crit\u00e9rio ; e validade de construto,10 (se as vari\u00e1veis que est\u00e3o sendo testadas se comportam de forma a sustentar a teoria).Para a validade. Ap\u00f3s a an\u00e1lise, os itens que pontuaram 1 e 2 foram exclu\u00eddos do instrumento, e os itens que pontuaram 3 e 4 foram somados e divididos pelo n\u00famero total de resposta, gerando o \u00edndice de concord\u00e2ncia entre os especialistas.Para a validade de conte\u00fado, foi selecionado um comit\u00ea de especialistas, composto por tr\u00eas ju\u00edzes, pesquisadores da \u00e1rea de toxicologia, que estudam os efeitos dos agrot\u00f3xicos no organismo humano. Os mesmos avaliaram quest\u00e3o a quest\u00e3o utilizando a escala a Likert, atribuindo pontua\u00e7\u00e3o de 1 a 4, a cada item apresentado. Foram utilizadas op\u00e7\u00f5es mais curtas de an\u00e1lise, sendo elas: 1 = n\u00e3o claro, 2 = pouco claro, 3 = bastante claro, 4 = muito claro.Referente a validade de crit\u00e9rio, por n\u00e3o haver um instrumento padr\u00e3o-ouro para an\u00e1lise de correla\u00e7\u00e3o, optou-se pela validade concorrente, com o uso de um crit\u00e9rio estabelecido, sendo ele tr\u00eas perguntas breves, que avaliam o mesmo construto: \u201c1- Voc\u00ea acredita que possui conhecimento adequado sobre os agrot\u00f3xicos?; 2 - Voc\u00ea acredita que possui atitudes adequadas frente aos agrot\u00f3xicos?; 3 - Voc\u00ea acredita que possui pr\u00e1ticas seguras em rela\u00e7\u00e3o aos agrot\u00f3xicos?\u201d. As alternativas de respostas eram \u201csim\u201d e \u201cn\u00e3o\u201d. Nessa etapa participaram 244 gestantes expostas a agrot\u00f3xicos-11. Posteriormente, as respostas de ambos os grupos foram analisadas e comparadas a fim de verificar respostas diferentes entre eles.No que diz respeito a validade de construto, dada as caracter\u00edsticas do question\u00e1rio, n\u00e3o foi poss\u00edvel realizar a an\u00e1lise da validade convergente, pois o estudo base n\u00e3o apresenta testes de valida\u00e7\u00e3o, nem a an\u00e1lise fatorial, pois as quest\u00f5es que comp\u00f5em o question\u00e1rio n\u00e3o seguem um padr\u00e3o. Para elencar evid\u00eancias necess\u00e1rias, a fim de garantir a valida\u00e7\u00e3o do construto, foi realizada a t\u00e9cnica de Grupos Conhecidos. Nessa t\u00e9cnica, o instrumento foi aplicado nos dois grupos: Grupo Expostas a Agrot\u00f3xicos, composto por 320 gestantes e Grupo N\u00e3o Expostas a Agrot\u00f3xicos, composto por 62 gestantesOs dados foram analisados de forma descritiva e inferencial. Utilizou-se o software SPSS 25.0. A an\u00e1lise descritiva das vari\u00e1veis qualitativas nominais foi realizada por frequ\u00eancia relativa e percentual. A an\u00e1lise descritiva das vari\u00e1veis quantitativas discretas e cont\u00ednuas, e qualitativas ordinais foi realizada por do c\u00e1lculo de medidas de tend\u00eancia central (m\u00e9dia e mediana), variabilidade (desvio padr\u00e3o) e posi\u00e7\u00e3o (primeiro quartil e terceiro quartil).A an\u00e1lise inferencial de associa\u00e7\u00e3o entre as vari\u00e1veis foi realizada com os Teste Exato de Fisher e Qui-Quadrado de Pearson. A an\u00e1lise de distribui\u00e7\u00e3o das vari\u00e1veis quantitativas foi realizada com o teste Shapiro-Wilk, e todas obtiveram distribui\u00e7\u00e3o n\u00e3o-normal. A an\u00e1lise inferencial das vari\u00e1veis quantitativas em fun\u00e7\u00e3o de vari\u00e1veis qualitativas nominais de duas categorias (grupos independentes) foi realizada com o teste de Teste de Mann-Whitney. A an\u00e1lise da concord\u00e2ncia entre as vari\u00e1veis quantitativas foi realizada com o teste de Coeficiente de Correla\u00e7\u00e3o Intraclasse, e entre as vari\u00e1veis qualitativas foi realizada com o teste de Kappa.A pesquisa foi realizada entre Agosto de 2018 e Dezembro de 2019. A amostra do presente estudo foi composta por 382 gestantes, divididas em dois grupos: Grupo N\u00e3o Expostas a Agrot\u00f3xicos - 62 mulheres gr\u00e1vidas n\u00e3o expostas a agrot\u00f3xicos; Grupo Expostas a Agrot\u00f3xicos - 320 mulheres gr\u00e1vidas expostas a agrot\u00f3xicos. Os grupos e n\u00famero de participantes em cada etapa do estudo de valida\u00e7\u00e3o foi vari\u00e1vel. A 10\u00aa Regional de Sa\u00fade, que abrange a regi\u00e3o Oeste do Estado do Paran\u00e1 teve participa\u00e7\u00e3o maior  que a 4\u00aa Regional de Sa\u00fade, correspondente a regi\u00e3o Sudeste do estado .Considerando apenas o Grupo Expostas a Agrot\u00f3xicos, a idade m\u00e9dia das participantes foi de 26 anos e seis meses, e os trimestres de gesta\u00e7\u00e3o mostram uma maior participa\u00e7\u00e3o de gestantes no 3\u00b0 trimestre . A maioria das participantes era de nacionalidade brasileira  e o grau de escolaridade mais frequente foi o de ensino m\u00e9dio completo , sendo que apenas 17,8% do total das participantes encontravam-se estudando no momento da pesquisa. A renda familiar de 31,6% das participantes era de menos de um sal\u00e1rio m\u00ednimo , valor vigente \u00e0 \u00e9poca da pesquisa, e entre um e dois sal\u00e1rios para 44,7%. Sobre as gesta\u00e7\u00f5es anteriores, observou-se uma m\u00e9dia de duas gesta\u00e7\u00f5es. A maior parte das entrevistadas relatam que viviam em uma \u00e1rea agr\u00edcola .Referente a ocupa\u00e7\u00e3o das gestantes do Grupo Expostas a Agrot\u00f3xicos, 54,38% (n=174) relataram trabalhar desde que ficaram gr\u00e1vidas, enquanto que 45,63% (n=146) negam ter trabalhado. Das que assinalaram ter trabalhado, quando questionadas se o trabalho envolve a agricultura, 25,63% (n=82) responderam sim e 28,75% (n=92) n\u00e3o; outras 146  gestantes n\u00e3o responderam a essa quest\u00e3o, como um crit\u00e9rio do question\u00e1rio, uma vez que assinalaram n\u00e3o estar trabalhando na gravidez. Quando questionadas se atualmente trabalham, 60,94% (n=195) afirmaram, e 39,06% (n=125) negaram; 72,19% (n=231) relatam que h\u00e1 um ano atr\u00e1s estavam trabalhando, contra 27,81% (n=89) que n\u00e3o. Relativo \u00e0 quando parou de trabalhar, 6,25% (n=20) relatam que pararam antes de saber da gesta\u00e7\u00e3o, 32,19% (n=103) ap\u00f3s saber da gravidez, e outras 197  afirmam n\u00e3o ter interrompido o trabalho.Sobre o planejamento ocupacional, 102  relataram que iriam parar de trabalhar apenas quando o m\u00e9dico determinasse ou quando n\u00e3o conseguissem mais trabalhar, enquanto que 97  pretendiam trabalhar at\u00e9 dar \u00e0 luz, e outras 120  gestantes ainda n\u00e3o sabiam quando parariam. Ap\u00f3s dar \u00e0 luz, 251  das gestantes pretendiam trabalhar, 16,56% (n=53) n\u00e3o, e 5% (n=16) n\u00e3o sabiam ainda. Sobre o per\u00edodo de retorno ao trabalho, 35,63% (n=114) acreditavam retornar entre 3 meses ap\u00f3s dar \u00e0 luz, 9,38% (n=30) 3 e 6 meses ap\u00f3s dar \u00e0 luz, 7,5% (n=24) 6 meses ap\u00f3s dar \u00e0 luz, e 47,5% (n=152) ainda n\u00e3o tinham esse conhecimento.Acerca dos recursos m\u00e9dicos utilizados para realiza\u00e7\u00e3o do pr\u00e9-natal, o destaque foi o Sistema \u00danico de Sa\u00fade, representado por mais de 70% das usu\u00e1rias, seguido da sa\u00fade suplementar com 23%. Nessa quest\u00e3o, a gestante poderia assinalar mais de uma alternativa, caso utilizasse mais de um servi\u00e7o. Referente a quantas consultas participou no pr\u00e9-natal, a m\u00e9dia foi de 2,51 vezes. Sobre o m\u00eas da primeira visita ao programa, este foi de 2,16 meses de gesta\u00e7\u00e3o.A caracteriza\u00e7\u00e3o dos escores para Conhecimento, Atitudes e Pr\u00e1ticas foi feita a partir de um score determinado com base na porcentagem de quest\u00f5es respondidas corretamente, indicando que quanto maior a m\u00e9dia, maior o grau de conhecimento, ou atitudes e pr\u00e1ticas tomadas. A an\u00e1lise de Conhecimento permitiu verificar um n\u00edvel de conhecimento significativo das gestantes sobre todos os itens relacionados, sendo que a maioria das entrevistadas concordaram sobre os danos dos agrot\u00f3xicos afetarem diferentes popula\u00e7\u00f5es, independentemente de serem agricultores ou n\u00e3o, bem como, reconheceram as principais vias de intoxica\u00e7\u00e3o e seus sintomas.A maioria das gestantes entrevistadas n\u00e3o receberam treinamento sobre os agrot\u00f3xicos , e apenas 20 gestantes  que o receberam, relatam que o mesmo foi realizado por interm\u00e9dio das empresas fornecedoras dos produtos, empresas/cooperativas vinculadas ao seu emprego, e sindicatos, h\u00e1 cerca de 2 anos. Apenas essas mulheres responderam as quest\u00f5es sobre os t\u00f3picos discutidos no treinamento.A an\u00e1lise sobre as Atitudes demonstrou m\u00e9dia de acertos baixa nos itens \u201cUso de vestimenta adequada no trabalho\u201d, \u201cUso de agrot\u00f3xicos e cuidados\u201d, \u201cMotivos para o uso de agrot\u00f3xicos em casa\u201d e \u201cMotivos para uso de agrot\u00f3xicos no trabalho\u201d. E referente a \u201cAtitudes tomadas em casa\u201d, como cuidados com a lavagem de frutas e verduras antes de comer, \u201cAtitudes prejudiciais para o feto\u201d, \u201cResponsabilidade para uso seguro dos agrot\u00f3xicos, ler r\u00f3tulo das embalagens\u201d bem como \u201cResponsabilidade para uso seguro dos agrot\u00f3xicos, reutiliza\u00e7\u00e3o das embalagens\u201d foi caracterizada como atitudes seguras e que demonstra responsabilidade quanto ao uso de agrot\u00f3xicos por grande parte das gestantes.A an\u00e1lise sobre \u201cPr\u00e1ticas\u201d para o uso seguro dos agrot\u00f3xicos, que incluem pr\u00e1ticas de precau\u00e7\u00e3o, em casa e no trabalho, como formas efetivas de prevenir a exposi\u00e7\u00e3o a agrot\u00f3xicos, refere-se ao uso de equipamento de prote\u00e7\u00e3o e os resultados revelam pr\u00e1ticas seguras nos tr\u00eas trimestres de gesta\u00e7\u00e3o.Os resultados para a Validade, que se referem ao fato do instrumento medir exatamente o que se prop\u00f5e a medir, foi obtido a partir da an\u00e1lise dos tr\u00eas tipos principais de validade: validade de conte\u00fado, validade de crit\u00e9rio e validade de constructo.. Tr\u00eas ju\u00edzes analisaram cada quest\u00e3o atribuindo uma pontua\u00e7\u00e3o de 1 a 4, em que: 1 = item n\u00e3o claro; 2 = item pouco claro; 3 = item bastante claro; e 4 = item muito claro. Foi contabilizada a contagem do n\u00famero de quest\u00f5es com notas tr\u00eas e quatro, e o total da contagem foi dividido pelo n\u00famero total de quest\u00f5es avaliadas. O c\u00e1lculo foi realizado para cada juiz individualmente, e para o total de ju\u00edzes. Os resultados mostram que o IVC foi entre 0,94 e 0,97 para os ju\u00edzes individuais, e de 0,96 para o total de ju\u00edzes, o que demonstrou concord\u00e2ncia aceit\u00e1vel entre os membros do comit\u00ea de especialistas.Para analisar a validade de conte\u00fado, utilizou-se o \u00cdndice de Validade de Conte\u00fadoPara a an\u00e1lise da validade de crit\u00e9rio, os escores dos dom\u00ednios de cada construto foram comparados entre dois grupos independentes constitu\u00eddos a partir das respostas para quest\u00f5es que analisam o mesmo construto. Para isso, os participantes foram orientados a responder \u201csim\u201d ou \u201cn\u00e3o\u201d para as perguntas: a) \u201cVoc\u00ea acredita que tem conhecimento adequado sobre os efeitos dos produtos agrot\u00f3xicos?\u201d; b) \u201cVoc\u00ea acredita que tem atitudes adequadas frente aos agrot\u00f3xicos?\u201d, e c) \u201cVoc\u00ea acredita que possui pr\u00e1ticas seguras sobre os agrot\u00f3xicos?\u201d. Devido a distribui\u00e7\u00e3o n\u00e3o-normal dos escores foi utilizado o teste n\u00e3o-param\u00e9trico para compara\u00e7\u00e3o de dois grupos independentes Teste de Mann-Whitney. Al\u00e9m disso, para as vari\u00e1veis qualitativas nominais de dom\u00ednios ou perguntas do construto conhecimento, foi realizada associa\u00e7\u00e3o entre as categorias de respostas \u00e0s quest\u00f5es, e as categorias de resposta aos dom\u00ednios ou perguntas do construto , 2, 3. OPara a an\u00e1lise da validade de construto, as gestantes do Grupo Expostas a Agrot\u00f3xicos foram comparadas \u00e0s gestantes do Grupo N\u00e3o Expostas a Agrot\u00f3xicos, a fim de verificar diferen\u00e7as nos escores dos dom\u00ednios dos construtos de conhecimento, atitudes e pr\u00e1ticas do Question\u00e1rio CAP. A an\u00e1lise permite inferir que os grupos foram homog\u00eaneos para as vari\u00e1veis idade, nacionalidade, estuda atualmente e renda familiar .Na an\u00e1lise dos escores das perguntas dos construtos conhecimento, pr\u00e1ticas e atitudes do Question\u00e1rio CAP em fun\u00e7\u00e3o dos grupos em agricultoras, observou-se que houve diferen\u00e7a estat\u00edstica entre os grupos, sendo que apenas para o dom\u00ednio \u201cAtitudes em casa\u201d  o Grupo Expostas a Agrot\u00f3xicos apresentou menor escore que o Grupo N\u00e3o Expostas a Agrot\u00f3xicos .Foi utilizado o Teste Exato de Fisher e o Teste Qui-Quadrado de Pearson para associar os dom\u00ednios ou quest\u00f5es qualitativas nominais e os grupos. Observou-se que houve associa\u00e7\u00e3o entre o dom\u00ednio \u201cconhecimento sobre outros efeitos dos agrot\u00f3xicos\u201d e a resposta n\u00e3o no Grupo Expostas .,13.O question\u00e1rio CAP \u00e9 usado mundialmente para avaliar o Conhecimento, as Atitudes e as Pr\u00e1ticas de diversos assuntos e em diferentes popula\u00e7\u00f5es. O instrumento se difere de acordo com a \u00e1rea e o tipo de estudo, j\u00e1 tendo sido aplicado em gestantes, a fim de investigar os cuidados no per\u00edodo pr\u00e9-natal e exames de rotina,7.Embora existam poucas pesquisas, principalmente no Brasil, utilizando protocolos semelhantes a esse, algumas infer\u00eancias podem ser feitas a partir dos resultados obtidos do processo de valida\u00e7\u00e3o no presente estudo. Quando comparamos os dados dessa pesquisa aos valores obtidos em outros protocolos, com outras popula\u00e7\u00f5es, observamos algumas controv\u00e9rsias no que se referem tanto ao conhecimento, as atitudes e as pr\u00e1ticas, quanto ao processo de valida\u00e7\u00e3o, que ser\u00e3o comentadas no decorrer desta discuss\u00e3oNa an\u00e1lise demogr\u00e1fica do grupo de gestantes expostas, notou-se que a m\u00e9dia de idade foi de 26 anos e seis meses, com maior participa\u00e7\u00e3o de gestantes no 3\u00b0 trimestre ; o grau de escolaridade mais frequente foi o de ensino m\u00e9dio completo , sendo que apenas 17,8% do total das participantes encontravam-se estudando no momento da pesquisa.per capita de R$ 2.552,00. Esse dado vai de acordo com a an\u00e1lise de crescimento econ\u00f4mico do pa\u00eds, que, tomando como refer\u00eancia PIB, renda per capita e produ\u00e7\u00e3o setorial dos entes federativos, as regi\u00f5es Sul e Sudeste respondem por mais de 70% da produ\u00e7\u00e3o e da renda, acomodando 56% da popula\u00e7\u00e3o brasileira.A renda familiar de aproximadamente 32% das participantes era de menos de um sal\u00e1rio m\u00ednimo , valor vigente na \u00e9poca da pesquisa, entre um e dois sal\u00e1rios para 44,7%. De acordo com o \u00faltimo censo realizado, em 2014, o Estado do Paran\u00e1 possui cerca de 17% de sua popula\u00e7\u00e3o em \u00e1rea rural, e ganha destaque econ\u00f4mico com o 5\u00ba maior IDH e 6\u00aa maior m\u00e9dia salarial real habitual das unidades federativas, com uma renda m\u00e9dia . Evid\u00eancias apontam que apesar de quase a totalidade das gestantes brasileiras (98%) come\u00e7ar o pr\u00e9-natal, quanto melhor a renda das mulheres, maior a participa\u00e7\u00e3o nos procedimentos e exames relativos ao pr\u00e9-natal.Nas gestantes que participaram desse estudo, notou-se renda m\u00e9dia familiar baixa, e isso interfere negativamente no acesso dessas mulheres aos servi\u00e7os de sa\u00fade, uma vez que renda familiar e escolaridade materna s\u00e3o considerados como os principais determinantes para a realiza\u00e7\u00e3o de pr\u00e9-natal adequado,7. O uso do question\u00e1rio CAP tamb\u00e9m demonstrou ser eficiente na avalia\u00e7\u00e3o de medidas educativas em gestantes, quanto a outros assuntos, como cuidados gestacionais e tabagismo,18. A maioria das entrevistadas concordou que os danos dos agrot\u00f3xicos afetaram diferentes popula\u00e7\u00f5es, independentemente de serem agricultores ou n\u00e3o, bem como, reconheceram as principais vias e sinais e sintomas de intoxica\u00e7\u00e3o.Os achados para os itens Conhecimento foram semelhantes ao estudo de tradu\u00e7\u00e3o do instrumento, desenvolvidos anteriormente, onde as gestantes de maneira geral demonstraram conhecimento satisfat\u00f3rio sobre os agrot\u00f3xicos, sendo que quanto maior o trimestre de gesta\u00e7\u00e3o, maior foi o conhecimentoNos itens referentes ao conhecimento sobre o preju\u00edzo dos agrot\u00f3xicos para a sa\u00fade humana e sobre riscos dos agrot\u00f3xicos a m\u00e9dia apresentou-se mais baixa, entretanto, manteve-se acima dos 50%. As gestantes desse estudo tamb\u00e9m n\u00e3o demonstraram conhecer  ou n\u00e3o relatam conhecimento  sobre outros efeitos que os agrot\u00f3xicos podem causar, al\u00e9m dos sugeridos pelo question\u00e1rio..Os agrot\u00f3xicos afetam a sa\u00fade humana direta e indiretamente, bem como o meio ambiente em geral, ocasionando desequil\u00edbrio nos biomas. Entretanto, nem todos os impactos s\u00e3o claramente definidos e conhecidos, devido a multiplicidade de fatores envolvidos. Nesse sentido, o conhecimento sobre os riscos de contamina\u00e7\u00e3o est\u00e1 intimamente relacionado \u00e0 forma, atrav\u00e9s da qual estas popula\u00e7\u00f5es se relacionam com os perigos existentes, processos estes fortemente enviesados por determinantes de ordens social, cultural e econ\u00f4mica.De acordo com a literatura, os sinais e sintomas de intoxica\u00e7\u00e3o diferem entre agudos e cr\u00f4nicos, classificados em leves, moderados e graves. Entre os sintomas de intoxica\u00e7\u00e3o agudos s\u00e3o caracterizados por cefaleia, irrita\u00e7\u00e3o, dermatite de contato irritativa ou por hipersensibilidade, n\u00e1usea, v\u00f4mitos, c\u00f3licas abdominais, tonturas, fraqueza generalizada, saliva\u00e7\u00e3o e sudorese aumentadas, hipotens\u00e3o, arritmias card\u00edacas, insufici\u00eancia respirat\u00f3ria, edema agudo de pulm\u00e3o, convuls\u00f5es, altera\u00e7\u00f5es da consci\u00eancia, choque, coma, podendo evoluir para \u00f3bito. Os sintomas cr\u00f4nicos manifestam-se por meio de in\u00fameras patologias que atingem v\u00e1rios \u00f3rg\u00e3os e sistemas, com destaque para os problemas imunol\u00f3gicos, hematol\u00f3gicos, hep\u00e1ticos, neurol\u00f3gicos, malforma\u00e7\u00f5es cong\u00eanitas e tumoresPara o reconhecimento dos riscos e, com isso, o desenvolvimento de cuidados apropriados, \u00e9 fundamental a ocorr\u00eancia de atividades e/ou programas educativos, que orientem, esclare\u00e7am e ensinem estrat\u00e9gias e formas seguras de cuidados. Na amostra deste estudo, a maioria das gestantes entrevistadas n\u00e3o recebeu treinamento sobre os agrot\u00f3xicos , e apenas 20 gestantes  que o receberam, relatam que o mesmo foi realizado por interm\u00e9dio das empresas fornecedoras dos produtos, empresas/cooperativas vinculadas ao seu emprego, e sindicatos, h\u00e1 cerca de 2 anos. Apenas as entrevistadas que referiram ter tido treinamento \u00e9 que responderam as quest\u00f5es sobre os t\u00f3picos discutidos nessa ocasi\u00e3o.Esses dados conflitam com os achados sobre o conhecimento das gestantes sobre agrot\u00f3xicos, uma vez que elas apresentaram altos n\u00edveis de conhecimento, no entanto, n\u00e3o receberam treinamento sobre os produtos. Isso pode indicar, que possivelmente esse conhecimento n\u00e3o \u00e9 advindo de uma instru\u00e7\u00e3o ou treinamento, mas algo adquirido por outros meios, como informativos em televis\u00e3o, jornais e internet, ou adquiridos por meio do saber popular e intergeracional, j\u00e1 que muitas delas s\u00e3o oriundas de fam\u00edlias agricultoras.. Especificamente, no estado do Paran\u00e1, diversas iniciativas governamentais t\u00eam sido executadas a fim de melhor assistir essa popula\u00e7\u00e3o, a citar o programa denominado \u201cM\u00e3e Paranaense\u201d, que prop\u00f5e a organiza\u00e7\u00e3o da aten\u00e7\u00e3o materno-infantil nas a\u00e7\u00f5es de pr\u00e9-natal e puerp\u00e9rio, e acompanhamento do crescimento e desenvolvimento das crian\u00e7as, em especial no primeiro ano de vida.Nos \u00faltimos anos, com a proposta do Programa Estrat\u00e9gia de Sa\u00fade da Fam\u00edlia, que aproxima a popula\u00e7\u00e3o, em geral, das unidades de cuidados \u00e0 sa\u00fade, intensificou-se a cobertura de acompanhamento pr\u00e9-natal, diminuindo as gesta\u00e7\u00f5es de risco e complica\u00e7\u00f5es de parto, al\u00e9m das campanhas nos per\u00edodos pr\u00e9 e neonatalNesse sentido, sup\u00f5e-se que gestantes que realizam o acompanhamento pr\u00e9-natal e participam de orienta\u00e7\u00f5es, palestras e conversas com os profissionais da sa\u00fade, apresentam mais conhecimento sobre os cuidados gestacionais e est\u00e3o alertas com rela\u00e7\u00e3o aos poss\u00edveis riscos e tomada de precau\u00e7\u00f5es para o cuidado integral com seu feto, mesmo o tema agrot\u00f3xicos n\u00e3o sendo o tema alvo..O avan\u00e7o na \u00e1rea da sa\u00fade e a pr\u00e1tica baseada em evid\u00eancias faz emergir a necessidade constante de medidas v\u00e1lidas e confi\u00e1veis, usando instrumentos calibrados, para medir constru\u00e7\u00f5es aplicadas de acordo com os padr\u00f5es. No Brasil, o n\u00famero de adapta\u00e7\u00f5es de instrumentos elaborados e validados em outras culturas e o n\u00famero de constru\u00e7\u00f5es de novos question\u00e1rios t\u00eam aumentado significativamente, apoiados por institui\u00e7\u00f5es educacionais internacionais e o financiamento de ag\u00eancias governamentais, uma vez que, grande parte dessas pesquisas, s\u00e3o destinadas a melhoria da condi\u00e7\u00e3o de sa\u00fade da popula\u00e7\u00e3o geral.Os instrumentos de medida integram a pr\u00e1tica cl\u00ednica e a pesquisa em diferentes \u00e1reas do conhecimento, e a avalia\u00e7\u00e3o de sua qualidade \u00e9 fundamental para a sele\u00e7\u00e3o de instrumentos que forne\u00e7am medidas v\u00e1lidas e confi\u00e1veis \u00e0quela popula\u00e7\u00e3o, respeitando suas particularidades. Nesse estudo, os ju\u00edzes foram selecionados por desenvolverem pesquisas relacionadas \u00e0 tem\u00e1tica deste estudo, e convidados a participar espontaneamente.A validade de conte\u00fado refere-se ao julgamento sobre o instrumento, resulta do julgamento de diferentes examinadores especialistas, que analisam a representatividade dos itens em rela\u00e7\u00e3o \u00e0s \u00e1reas de conte\u00fado e a relev\u00e2ncia dos objetivos a medir. Tr\u00eas ju\u00edzes analisaram cada quest\u00e3o atribuindo uma pontua\u00e7\u00e3o de 1 a 4, em que: 1 = item n\u00e3o claro; 2 = item pouco claro; 3 = item bastante claro; e 4 = item muito claro. Foi contabilizada a contagem do n\u00famero de quest\u00f5es com notas tr\u00eas e quatro, e total da contagem foi dividido pelo n\u00famero total de quest\u00f5es avaliadas. O c\u00e1lculo foi realizado para cada juiz individualmente, e para o total de ju\u00edzes. O \u00cdndice de Validade de Conte\u00fado foi entre 0,94 e 0,97 para os ju\u00edzes individuais, e de 0,96 para o total de ju\u00edzes, o que demonstrou concord\u00e2ncia aceit\u00e1vel entre os membros do comit\u00ea de especialistas, representando que os itens avaliados do question\u00e1rio s\u00e3o medidas v\u00e1lidas e precisas.Para analisar a validade de conte\u00fado, que se refere ao grau em que o conte\u00fado de um instrumento reflete adequadamente o construto que est\u00e1 sendo medido, utilizou-se o \u00cdndice de Validade de Conte\u00fado.A validade de crit\u00e9rio \u00e9 a correla\u00e7\u00e3o existente entre a medida avaliada em rela\u00e7\u00e3o \u00e0 outra medida ou instrumento que serve como crit\u00e9rio de avalia\u00e7\u00e3o, que possui atributos iguais ou semelhantes, e consiste na rela\u00e7\u00e3o entre pontua\u00e7\u00f5es de um determinado instrumento e algum crit\u00e9rio externo. Para isso, os participantes foram orientados a responder \u201csim\u201d ou \u201cn\u00e3o\u201d para as perguntas: a) \u201cVoc\u00ea acredita que tem conhecimento adequado sobre os efeitos dos produtos agrot\u00f3xicos? \u201c; b) \u201cVoc\u00ea acredita que tem atitudes adequadas frente aos agrot\u00f3xicos?\u201d, e c) \u201cVoc\u00ea acredita que possui praticas seguras sobre os agrot\u00f3xicos?\u201d.No caso desse estudo, para a an\u00e1lise da validade de crit\u00e9rio, os escores dos dom\u00ednios de cada construto foram comparados entre dois grupos independentes constitu\u00eddos a partir das respostas para quest\u00f5es que analisam o mesmo construto. Ap\u00f3s a aplica\u00e7\u00e3o do question\u00e1rio, foi realizada a testagem de tr\u00eas quest\u00f5es a fim de confirmar a validade de crit\u00e9rioOs resultados apontaram que n\u00e3o houve diferen\u00e7a ou associa\u00e7\u00e3o entre as quest\u00f5es crit\u00e9rio e os dom\u00ednios ou perguntas do question\u00e1rio. No caso do question\u00e1rio CAP, n\u00e3o foi encontrado um question\u00e1rio padr\u00e3o-ouro para compara\u00e7\u00e3o. O question\u00e1rio original em ingl\u00eas n\u00e3o \u00e9 validado, e por esse motivo n\u00e3o apresenta as an\u00e1lises para tal compara\u00e7\u00e3o.\u00c9 poss\u00edvel que o crit\u00e9rio estabelecido, por apresentar perguntas diretas com respostas objetivas, n\u00e3o tenha favorecido, sendo um crit\u00e9rio fraco de compara\u00e7\u00e3o, uma vez que limita as respostas das gestantes. Uma alternativa a ser pensada \u00e9 criar uma escala que permita mais flexibilidade nas respostas. Ademais, tamb\u00e9m se acredita que isso tenha sido uma reflex\u00e3o ap\u00f3s ter respondido todas as quest\u00f5es do question\u00e1rio e ter repensado acerca de seu conhecimento, atitudes e pr\u00e1ticas.. A varia\u00e7\u00e3o da for\u00e7a da correla\u00e7\u00e3o de m\u00e9dia a forte encontrada para os aspectos considerados na presente pesquisa foi justificada pelas diferen\u00e7as entre os itens e o modo de avalia\u00e7\u00e3o dos dois protocolos  do teste, com vistas a ter elementos que possam esclarecer o significado do instrumento. Ou seja, buscou-se verificar qual o conhecimento, atitudes e pr\u00e1ticas de gestantes expostas a agrot\u00f3xicos sobre esses produtos. A validade de construto \u00e9 subdividida em tr\u00eas tipos: teste de hip\u00f3teses, validade estrutural ou fatorial e validade transcultural-11.No caso deste estudo, a validade de construto \u00e9 fundamental, uma vez que ele auxilia o pesquisador a determinar e entender melhor as quest\u00f5es cognitivas e psicol\u00f3gicas que est\u00e3o sendo medidas pelo teste. Nesse estudo, para essa an\u00e1lise, as gestantes do Grupo Expostas a Agrot\u00f3xicos foram comparadas as gestantes do Grupo N\u00e3o Expostas a Agrot\u00f3xicos a fim de verificar diferen\u00e7as nos escores dos dom\u00ednios dos construtos de conhecimento, atitudes e pr\u00e1ticas do Question\u00e1rio CAP. A an\u00e1lise permitiu inferir que os grupos foram homog\u00eaneos para as vari\u00e1veis idade, nacionalidade, estuda atualmente e renda familiar. A an\u00e1lise dos escores das perguntas dos construtos conhecimento, pr\u00e1ticas e atitudes do Question\u00e1rio CAP demonstrou que houve diferen\u00e7a estat\u00edstica entre os grupos de gestantes, e apenas no dom\u00ednio \u201cAtitudes em casa\u201d o Grupo Expostas a Agrot\u00f3xicos apresentou menor escore que o Grupo N\u00e3o Expostas a Agrot\u00f3xicos. Isso identifica que as gestantes do Grupo N\u00e3o Expostas a Agrot\u00f3xicos t\u00eam mais cuidados com a higieniza\u00e7\u00e3o de frutas e verduras antes de comer, com suas roupas de trabalho, e a pr\u00f3pria casa em si. Sobre isso, ao se analisar quest\u00f5es referente a renda familiar e n\u00edvel de escolaridade, que poderiam ser fatores que interferissem nessa quest\u00e3o, se observa que nesse estudo, essas vari\u00e1veis s\u00e3o homog\u00eaneas.No teste de hip\u00f3teses, uma das estrat\u00e9gias dessa testagem \u00e9 a t\u00e9cnica de grupos conhecidos, na qual grupos diferentes de indiv\u00edduos preenchem o instrumento de pesquisa e em seguida, os resultados dos grupos s\u00e3o comparadosEntretanto, o Grupo Expostas a Agrot\u00f3xicos apresentou maiores escores que o grupo N\u00e3o Expostas nos dom\u00ednios \u201cconhecimento sobre popula\u00e7\u00e3o de risco\u201d, \u201cconhecimento dos sintomas de intoxica\u00e7\u00e3o\u201d, \u201catitudes prejudiciais para o feto\u201d, \u201cresponsabilidade para uso seguro dos agrot\u00f3xicos, ler r\u00f3tulo das embalagens\u201d \u201cresponsabilidade para uso seguro dos agrot\u00f3xicos, reutiliza\u00e7\u00e3o das embalagens\u201d, \u201cuso de agrot\u00f3xicos e cuidados\u201d, \u201cpr\u00e1ticas de precau\u00e7\u00e3o\u201d, \u201cpr\u00e1ticas referentes a animais dom\u00e9sticos\u201d. \u00c9 poss\u00edvel que, devido ao fato dos agrot\u00f3xicos n\u00e3o serem uma realidade pr\u00f3xima das gestantes n\u00e3o expostas, elas n\u00e3o tenham preocupa\u00e7\u00e3o, ou conhecimento sobre o assunto, e talvez esses assuntos nunca tenham sido discutidos no ambiente em que vivem. Com as gestantes expostas, \u00e9 o contr\u00e1rio; embora grande maioria delas n\u00e3o tenha tido instru\u00e7\u00e3o sobre o uso seguro e cuidado com os produtos, esse tema faz parte da viv\u00eancia delas, e indiretamente est\u00e1 sendo comentado pelos vendedores de produtos, agr\u00f4nomos, representante sindicais, e pelos pr\u00f3prios familiares, uma vez que h\u00e1 um senso comum e generalista de que o \u201cveneno faz mal\u201d.. Nesse estudo, as caracter\u00edsticas do instrumento n\u00e3o permitiram a an\u00e1lise fatorial, pois o Question\u00e1rio CAP apresenta varia\u00e7\u00e3o nos modelos de quest\u00f5es: possui quest\u00f5es com alternativas \u201csim\u201d e \u201cn\u00e3o\u201d, com escala likert e dissertativa. Outra particularidade do question\u00e1rio \u00e9 que a resposta de uma quest\u00e3o, se sim ou n\u00e3o, interfere diretamente se ir\u00e1 responder a pr\u00f3xima quest\u00e3o ou se\u00e7\u00e3o do question\u00e1rio. Essas singularidades dificultam a an\u00e1lise fatorial, uma vez que n\u00e3o consegue categorizar os dados.Seguindo as etapas da valida\u00e7\u00e3o do construto, a validade estrutural ou fatorial fornece ferramentas para avaliar as correla\u00e7\u00f5es em um grande n\u00famero de vari\u00e1veis, definindo os fatores, ou seja, as vari\u00e1veis fortemente relacionadas entre si, que teve por objetivo traduzir, adaptar e desenvolver o estudo normativo preliminar do Question\u00e1rio para a l\u00edngua portuguesa. No referido estudo o question\u00e1rio CAP foi traduzido para o portugu\u00eas brasileiro, analisado por ju\u00edzes de \u00e1reas relacionadas ao objeto do estudo, permitindo a revis\u00e3o e adequa\u00e7\u00e3o dos termos; na sequ\u00eancia foi aplicado em um grupo piloto, a fim de realizar a an\u00e1lise sem\u00e2ntica e adapta\u00e7\u00e3o transcultural de termos. Ap\u00f3s a adequa\u00e7\u00e3o, o instrumento foi retrotraduzido para o ingl\u00eas. A partir dos resultados foi poss\u00edvel verificar que esse instrumento foi coerente e satisfat\u00f3rio para o levantamento do conhecimento, atitudes e pr\u00e1ticas de gestantes brasileiras em rela\u00e7\u00e3o aos agrot\u00f3xicos. No presente estudo, verificou-se associa\u00e7\u00f5es significativas entre o conhecimento e a fase de gesta\u00e7\u00e3o, sendo que quanto mais tempo de gesta\u00e7\u00e3o, maior foi o conhecimento sobre os riscos \u00e0 exposi\u00e7\u00e3o dos agrot\u00f3xicos, bem como a tomada de atitudes e pr\u00e1ticas seguras durante o per\u00edodo gestacional, em casa e no trabalho.Essa etapa foi realizada em estudo anteriorFinalizando essa discuss\u00e3o, ressalta-se que neste estudo, foi realizada a valida\u00e7\u00e3o do Question\u00e1rio CAP em gestantes expostas aos agrot\u00f3xicos, por meio da validade de conte\u00fado, crit\u00e9rio e construto. A pesquisa, desenvolvida em duas regionais de sa\u00fade do Estado do Paran\u00e1, n\u00e3o contou efetivamente com a totalidade de gestantes expostas, que expressariam a realidade cultural das regi\u00f5es. Outra limita\u00e7\u00e3o \u00e9 sobre as caracter\u00edsticas do question\u00e1rio, que por n\u00e3o seguir um padr\u00e3o, n\u00e3o permitiu an\u00e1lises importantes, como a an\u00e1lise fatorial explorat\u00f3ria.Por outro lado, o n\u00famero significativo de gestantes que participaram do estudo, e o cumprimento de todas as etapas de confiabilidade e validade, permitiu a obten\u00e7\u00e3o de dados confi\u00e1veis e a infer\u00eancia de que o instrumento \u00e9 v\u00e1lido para aplica\u00e7\u00e3o em popula\u00e7\u00f5es brasileiras. Outro vi\u00e9s a ser destacado, \u00e9 que apesar dos resultados favor\u00e1veis de validade, indicando a possibilidade de utiliza\u00e7\u00e3o deste Question\u00e1rio CAP para levantamento do Conhecimento, das Atitudes e das Pr\u00e1ticas de gestantes agricultoras no Brasil, a sua aplica\u00e7\u00e3o em forma de entrevista, com a presen\u00e7a das agentes comunit\u00e1rias de sa\u00fade ou outro profissional da sa\u00fade pode ter gerado algum constrangimento, podendo resultar em alguma influ\u00eancia nas respostas, principalmente acerca de atitudes e pr\u00e1ticas tomadas em casa.Apesar de n\u00e3o ser confirmadas as evid\u00eancias de que as pr\u00e1ticas inseguras relacionadas aos agrot\u00f3xicos estejam associadas ao aumento da exposi\u00e7\u00e3o da popula\u00e7\u00e3o brasileira a esses produtos, \u00e9 poss\u00edvel que seja esse o principal motivo da ocorr\u00eancia do aumento das altera\u00e7\u00f5es geradas por esses comportamentos de risco, no entanto, seriam necess\u00e1rias medidas reais de exposi\u00e7\u00e3o para confirmar essa hip\u00f3tese. Esse n\u00e3o foi o foco deste estudo, mas as respostas obtidas a partir da aplica\u00e7\u00e3o deste instrumento podem ser \u00fateis para futuras interven\u00e7\u00f5es.Pesquisas futuras devem ter como objetivo desenvolver instrumentos mais homog\u00eaneos e reduzidos, que facilitem a aplica\u00e7\u00e3o em um n\u00famero ainda maior de sujeitos, e a an\u00e1lise completa da valida\u00e7\u00e3o. Outro foco de interesse relacionado ao tema, seria a investiga\u00e7\u00e3o dos homens, companheiros dessas gestantes, residentes do campo, quanto aos seus conhecimentos, atitudes e pr\u00e1ticas frente aos produtos, no que diz respeito a preocupa\u00e7\u00e3o com a gesta\u00e7\u00e3o, uma vez que essa n\u00e3o deve ser uma preocupa\u00e7\u00e3o \u00fanica da mulher.Os efeitos negativos dos agrot\u00f3xicos em gestantes e seus rec\u00e9m-nascidos merecem aten\u00e7\u00e3o das pol\u00edticas p\u00fablicas na \u00e1rea de sa\u00fade, pois conforme visto, pesquisas realizadas em v\u00e1rios pa\u00edses comprovam intercorr\u00eancias na gravidez e na sa\u00fade do feto. As pesquisas cient\u00edficas t\u00eam justamente a fun\u00e7\u00e3o de apresentar situa\u00e7\u00f5es espec\u00edficas para que, com medidas p\u00fablicas eficazes, possam deixar de causar problemas \u00e0 popula\u00e7\u00e3o.Esse estudo pode ser um caminho inicial no entendimento da realidade das gestantes, e pode ser considerado um guia norteador de futuras pr\u00e1ticas e a\u00e7\u00f5es voltadas ao cuidado da mulher exposta aos agrot\u00f3xicos. A valida\u00e7\u00e3o das ferramentas de avalia\u00e7\u00e3o de conhecimentos, atitudes e pr\u00e1ticas ajudar\u00e1 a desenvolver programas \u00fateis e eficientes.Este estudo validou o question\u00e1rio CAP considerando seu conte\u00fado, crit\u00e9rio e construto. A an\u00e1lise desenvolvida indicou que as propriedades psicom\u00e9tricas da adapta\u00e7\u00e3o transcultural da vers\u00e3o brasileira da escala s\u00e3o consistentes e adequadas para aplica\u00e7\u00e3o no Brasil, o que permite a recomenda\u00e7\u00e3o de aplica\u00e7\u00e3o do instrumento em contexto nacional. \u00c9 importante que a vers\u00e3o validada do question\u00e1rio seja aplicada em regi\u00f5es do Brasil para entender as caracter\u00edsticas culturais de cada regi\u00e3o, a fim de propor medidas efetivas de promo\u00e7\u00e3o da sa\u00fade e preven\u00e7\u00e3o de danos."}
+{"text": "To build and validate a logical model of the line of care for people with chronic kidney disease. This is a descriptive study with a qualitative approach, with documentary research and analysis of primary data collected in interviews with key informants, carried out from May to September 2019, in the Guarani Aquifer Health Region, belonging to the Regional Health Department 13. Based on the theoretical framework proposed by McLaughlin and Jordan, five stages were followed: collection of relevant information; description of the problem and context; defining the elements of the logical model; construction and validation. The logical model was organized into three care dimensions \u2013 primary health care, specialized care and high complexity care \u2013 composed of structure, process and result components. The constructed logical model has the potential to contribute to the assessment of the line of care for people with chronic kidney disease, in order to achieve better results in the management of this disease, something that favors both the patient and the health system. The worldwide increase in this disease is mainly driven by the increase in the prevalence of diabetes mellitus, arterial hypertension, obesity and aging1. In Brazil, the estimated prevalence of CKD \u2013 in stages 3 to 5 \u2013 in adults is 6.7%, and 21.4% in people over 60 years of age2.Chronic kidney disease (CKD) is recognized as one of the main public health problems in the world, with an estimated global prevalence of 13.4%3. In 2015, expenses with renal replacement therapy (RRT) represented more than 2 billion reais, corresponding to 5% of SUS expenses with medium and high complexity services, consumed by the partial management of a single disease. Furthermore, its incidence is increasing, which ratifies prevention as an action of interest and importance for public health, highlighting the role of primary health care (PHC)4.Between 2000 and 2012, approximately 280 thousand patients were identified in dialysis programs in the Unified Health System (SUS) network, which corresponded to 85% of dialysis performed in the country5.In 2017, there were 1.2 million deaths due to CKD, placing it in the 12th position in causes of death in the world, while, in Brazil, this disease was responsible for 35,000 deaths, occupying the 10th positionKidney Disease Outcomes Quality Initiative (K/DOQI)6. In Brazil, the National Policy for Attention to Patients with Kidney Disease (PNAPDR) was only published in 20047.Although the prevalence of CKD is high, the first guideline for its diagnosis and treatment was only issued in 2002, by the National Kidney Foundation, in the document 9. In order to organize the care network and the financing of actions related to the approach to CKD, the line of care presents the following attributions of the HCN care points, according to the components: PHC and specialized outpatient care, the latter subdivided into Specialized Unit in CKD, High Complexity Care Unit in Nephrology and Specialized Unit in CKD with RRT/Dialysis9. These guidelines marked a step forward in the country\u2019s public policy, since they systematized this line of care based on comprehensiveness \u2013 mainly with PHC \u2013 and defining early diagnosis and timely treatment of CKD as one of the attributions of its team.In 2014, the clinical guidelines for the care of patients with CKD in the SUS and the criteria for organizing the line of care for people with CKD were published \u2013 contained in the health care network (HCN) for people with chronic diseases10. In this sense, a strategy that can contribute to this evaluation is the development of a logical model, as it allows visually and systematically presenting the relationships between the necessary resources, interventions and effects \u2013 products, results and impact \u2013 that a program/intervention intends to achieve12.Thus, there are legal subsidies that favor changes in the work processes of the PHC teams and, also, that establish quality indicators for the monitoring and evaluation of care for people with CKD12. Modeling an intervention makes it possible to explain the links between the intervention and its effects, through a schematic representation that reveals its structure, processes and results. Modeling must, therefore, explain the logical path of the intervention and reveal its objectives and, for this reason, it must be done in interaction with the actors who operate it, making it possible to improve the intelligibility of a complex system13. Among the advantages of using the logical model are: building a common understanding of the program and resource expectations, the number of customers reached and their results; its usefulness for program design or improvement; presenting the program\u2019s place within the organization, and presenting a balanced set of key performance measurement and evaluation questions that improve data collection and the program\u2019s usefulness12.Health evaluation has the potential to present logical arguments of how and why a program is or is not meeting the specific needs for which it was created. In turn, the logical model presents itself as an evaluative tool by detailing characteristics of a program, establishing the logical relationship between its components and the expected results in the short, medium and long termThus, the objectives of this study were to develop and validate the logical model of the line of care for CKD patients.14. The line of care for people with CKD for this Health Region was drawn up by a multidisciplinary working group representing all parts of the HCN, but its monitoring had not yet started. There was, then, a manifestation of the DRS 13 to the researchers about the interest in carrying out an investigation that would help the evaluation process, considering the worrying rates of this Region regarding the prevalence of CKD. Finally, this condition justified the choice of this field of study.In order to build and validate the logical model, a descriptive study with a qualitative approach was carried out, from May to September 2019, in the Guarani Aquifer Health Region \u2013 which comprises 10 municipalities, with a total of 945,738 inhabitants \u2013, belonging to the Regional Health Department (DRS) 13 \u2013 Ribeir\u00e3o Preto-SP12: 1) Collecting relevant information; 2) Describing the problem and context; 3) Defining the elements of the logical model; 4) Building the logical model; and 5) Validating the logical model.The logical model was built according to the five stages proposed by McLaughlin and Jordan15.In the development of steps 1, 2, 3 and 4, documentary research was carried out. The criteria used to select the documents were: 1) authenticity, that is, the document is of unquestionable origin; 2) credibility, it is an original and undistorted document; 3) representativeness, within its typology \u2013 in this case, legal documents \u2013, which present the content to be analyzed; and 4) meaning, that is, whether the document was clear and comprehensible16, and the identification of the prevalence rate of patients on dialysis in the Guarani Aquifer Health Region. At this stage, the primary information obtained from the interviewees was also considered , also coordinator of the non-communicable chronic diseases (NCDs) steering group. Finally, a semi-structured interview was carried out with key informants, following the questions pointed out by MClauglin and Jordan12 , and the21. In Brazil, according to the National Health Survey , the prevalence of self-reported CKD is 1.42%, that is, approximately two million individuals, which reveals the dimension of the disease in the country21. Early diagnosis, immediate referral, and implementation of measures to reduce/stop the progression of CKD are among the key strategies to improve its outcomes21.CKD is recognized as a complex disease that requires multiple approaches in its treatment. It is even associated with high morbidity and mortality rates, prevalence and incidence rates still unknown in many countries, and a great socioeconomic impact, becoming a challenge for global public health7.The PNAPDR proposed the organization of the comprehensive care line \u2013 promotion, prevention, treatment and recovery \u2013, permeating all points of care, such as expanding the coverage of care for patients with arterial hypertension and diabetes mellitus, the qualification of assistance and the promotion of continuing education for health professionals17. This regulation highlighted that, although the advances were representative, the fragmentation of health actions and the need to qualify care management was still evident. Thus, the development of HCN was presented as an innovative organizational process, with the potential to positively impact health indicators.In 2010, the ordinance that established the guidelines for the organization of HCN in SUS was published; it aimed to promote the systemic integration of health actions and services, with the provision of continuous, comprehensive, quality, responsible and humanized care, in addition to increasing SUS\u2019s performance in terms of access, equity, clinical and health efficacy and economic efficiency8.In this logic, in the years 2013 and 2014, the HCN of People with NCDs was established, which established guidelines for the organization of its Care Lines, for its principles and objectives and for the competences of each federal entity. The Care Lines must express the assistance flows that must be guaranteed to the user, in order to meet the health needs related to a chronic condition and define the actions and services that will be offered by each component of the HCN of People with NCDs, based on clinical guidelines and the reality of each Health Region18.In turn, the criteria for organizing the line of care for people with CKD, and the clinical guidelines for care, were published in 2014, defining the attributions of PHC, specialized outpatient care, and high complexity care18.From the publication of the ordinance of the line of care for people with CKD, the health regions began the process of regional discussion about it. According to key informants, a steering group was formed with representatives from the three health regions of the DRS 13 territory, from the hemodialysis service providers and from the DRS 13 planning group. The group met to develop the line of care based on the organization of services, which was approved by the Regional Interagency Commissions (CIR) of the three regions of DRS 13 and by the Bipartite Interagency Commission (Deliberation CIB/SP \u2013 47/2015). However, according to the interviewees, until the date of the interview, in May 2019, there had been no monitoring of the line of care within the PHC scope, while the quality indicators of medium and high complexity services were monitored, since they were related to qualification and remuneration of specialized services\u201cA regional steering group was formed with participants from the municipalities, representatives of management and services, approved in CIR, and we followed the steps set out in the ordinance \u2026 The Care Line was approved in the CIR, we await publication by the Ministry of Health which, due to the release of financial resources, took more than two years\u201d. (Interviewee No. 1)The estimated number of cases in the different stages of CKD in the Guarani Aquifer Health Region  indicate\u201cToday what you have in the official systems, for example, the exams carried out, you can pull, in what the Care Line proposes, the exams of each phase that we have to follow. So, as a production, it can be surveyed. What is more complicated, I think, is precisely in relation to Primary Care, how many patients I am following, how many hypertensive patients there are, what stage they are in\u2026\u201d. (Interviewee No. 6)\u201cThese hypertensive patients are difficult, we don\u2019t have a tool to assess this. Hiperdia is over. It was good when it was there, you know, and the municipalities used it and it was linked to the distribution of medicine\u2026\u201d. (Interviewee No. 2)When asked about the factors they considered to influence the effective implementation of the line of care, the interviewees pointed out conditions related to the work process, care models, professional qualification and the quality of PHC.\u201cThe factors that make it difficult are the work processes, they  do not understand what a network is, each one does a little bit. Truly understanding why there are so many patients is also lacking. When we went to do the Care Line, we did not find much data, the municipalities do not have this data, it was necessary to use references from studies\u201d. (Interviewee No. 1)\u201cI\u2019m critical of the performance. I think we have the right structures, we are in a privileged region in terms of support and technology, but we have a lot to do with the way it is organized, the model of assistance, training and qualification of professionals, I think this hinders\u201d. (Interviewee No. 2)\u201cThe specialized [care] and discharge work well, they play their role, I think we have to intervene in Primary Care\u201d. (Interviewee No. 1)9, which subdivide the guidelines and responsibilities according to the level of technological density of the HCN services. Likewise, the actions that must be performed were based on the activities already foreseen by the SUS norms, and, based on them, the inputs for carrying out the planning as a whole were established. The logical model was improved based on its prior appreciation, by which information was complemented and verified before validation. During validation, the model was presented to six key informants, who participated in the development of the care line for people with CKD or worked at some point in the HCN. The semi-structured questionnaire  \u00e9 reconhecida como um dos principais problemas de sa\u00fade p\u00fablica no mundo, com preval\u00eancia global estimada em 13,4%3. Em 2015, os gastos com terapia renal substitutiva (TRS) representaram mais de 2 bilh\u00f5es de reais, correspondendo a 5% dos gastos do SUS com servi\u00e7os de m\u00e9dia e alta complexidade, consumidos pelo manejo parcial de uma s\u00f3 doen\u00e7a. Ademais, a sua incid\u00eancia est\u00e1 aumentando, o que ratifica a preven\u00e7\u00e3o como a\u00e7\u00e3o de interesse e import\u00e2ncia para a sa\u00fade p\u00fablica, destacando-se o papel da aten\u00e7\u00e3o prim\u00e1ria \u00e0 sa\u00fade (APS)4.Entre os anos de 2000 e 2012, foram identificados aproximadamente 280 mil pacientes em programas de di\u00e1lise na rede do Sistema \u00danico de Sa\u00fade (SUS), o que correspondeu a 85% das di\u00e1lises realizadas no pa\u00eds5.Em 2017, ocorreram 1,2 milh\u00f5es de \u00f3bitos em decorr\u00eancia da DRC, colocando-a na 12\u00aa posi\u00e7\u00e3o em causas de morte no mundo, enquanto que, no Brasil, essa doen\u00e7a foi respons\u00e1vel por 35 mil mortes, ocupando a 10\u00aa posi\u00e7\u00e3oNational Kidney Foundation, no documento Kidney Disease Outcomes Quality Initiative (K/DOQI)6. No Brasil, a Pol\u00edtica Nacional de Aten\u00e7\u00e3o ao Portador de Doen\u00e7a Renal (PNAPDR) s\u00f3 foi publicada em 20047.Embora a preval\u00eancia da DRC seja alta, a primeira diretriz para o seu diagn\u00f3stico e tratamento foi realizada apenas em 2002, pela 9. Com o objetivo de organizar a rede assistencial e o financiamento das a\u00e7\u00f5es relacionadas \u00e0 abordagem da DRC, a linha de cuidado apresenta as seguintes atribui\u00e7\u00f5es dos pontos de aten\u00e7\u00e3o da RAS, segundo os componentes: APS e aten\u00e7\u00e3o especializada ambulatorial, esta \u00faltima subdividida em Unidade Especializada em DRC, Unidade de Assist\u00eancia de Alta Complexidade em Nefrologia e Unidade Especializada em DRC com TRS/Di\u00e1lise9. Essas diretrizes marcaram um avan\u00e7o na pol\u00edtica p\u00fablica do pa\u00eds, uma vez que sistematizaram essa linha de cuidado pautando-se na integralidade \u2013 principalmente com a APS \u2013 e definindo como uma das atribui\u00e7\u00f5es de sua equipe o diagn\u00f3stico precoce e o tratamento oportuno da DRC.Em 2014, foram publicadas as diretrizes cl\u00ednicas para o cuidado ao paciente com DRC no SUS e os crit\u00e9rios para a organiza\u00e7\u00e3o da linha de cuidado da pessoa com DRC \u2013 contida na rede de aten\u00e7\u00e3o \u00e0 sa\u00fade (RAS) das pessoas portadoras de doen\u00e7as cr\u00f4nicas10. Nesse sentido, uma estrat\u00e9gia que pode contribuir com essa avalia\u00e7\u00e3o \u00e9 a elabora\u00e7\u00e3o do modelo l\u00f3gico, pois permite apresentar de maneira visual e sistem\u00e1tica as rela\u00e7\u00f5es entre os recursos necess\u00e1rios, interven\u00e7\u00f5es e efeitos \u2013 produtos, resultados e impacto \u2013 que se pretende alcan\u00e7ar com um programa/interven\u00e7\u00e3o12.Assim, nota-se a exist\u00eancia de subs\u00eddios legais que favorecem mudan\u00e7as nos processos de trabalho das equipes de APS e, ainda, que estabelecem indicadores de qualidade para o monitoramento e avalia\u00e7\u00e3o da aten\u00e7\u00e3o \u00e0s pessoas com DRC12. Modelizar uma interven\u00e7\u00e3o possibilita explicitar os v\u00ednculos entre a interven\u00e7\u00e3o e seus efeitos, por meio de uma representa\u00e7\u00e3o esquem\u00e1tica que revele sua estrutura, processos e resultados. A modeliza\u00e7\u00e3o deve, portanto, explicitar o caminho l\u00f3gico da interven\u00e7\u00e3o e revelar seus objetivos e, por esse motivo, deve ser feita em intera\u00e7\u00e3o com os atores que a operam, tornando poss\u00edvel o aprimoramento da inteligibilidade de um sistema complexo13. Entre as vantagens na utiliza\u00e7\u00e3o do modelo l\u00f3gico, est\u00e3o: a constru\u00e7\u00e3o de um entendimento comum do programa e das expectativas de recursos, a quantidade de clientes alcan\u00e7ados e seus resultados; a sua utilidade para o desenho ou melhoria do programa; a apresenta\u00e7\u00e3o do espa\u00e7o ocupado pelo programa na organiza\u00e7\u00e3o, e a apresenta\u00e7\u00e3o de um conjunto equilibrado de pontos-chave de medi\u00e7\u00e3o de desempenho e quest\u00f5es de avalia\u00e7\u00e3o, que melhoram a coleta de dados e a utilidade do programa12.A avalia\u00e7\u00e3o em sa\u00fade tem potencial para apresentar argumenta\u00e7\u00f5es l\u00f3gicas de como e porque um programa est\u00e1 ou n\u00e3o atendendo as necessidades espec\u00edficas para as quais foi criado. Por sua vez, o modelo l\u00f3gico se apresenta como uma ferramenta avaliativa por detalhar caracter\u00edsticas de um programa, estabelecendo a rela\u00e7\u00e3o l\u00f3gica entre seus componentes e os resultados esperados em curto, m\u00e9dio e longo prazoDesse modo, os objetivos deste estudo foram elaborar e validar o modelo l\u00f3gico da linha de cuidado do portador de DRC.14. A linha de cuidado da pessoa com DRC para essa Regi\u00e3o de Sa\u00fade foi elaborada por um grupo de trabalho multiprofissional e representativo de todos os pontos da RAS, mas seu monitoramento ainda n\u00e3o havia sido iniciado. Houve, ent\u00e3o, uma manifesta\u00e7\u00e3o do DRS 13 aos pesquisadores sobre o interesse em realizar uma investiga\u00e7\u00e3o que auxiliasse o processo avaliativo, considerando os \u00edndices preocupantes dessa Regi\u00e3o acerca da preval\u00eancia da DRC. Por fim, essa condi\u00e7\u00e3o justificou a escolha desse campo de estudo.Para a constru\u00e7\u00e3o e valida\u00e7\u00e3o do modelo l\u00f3gico, realizou-se um estudo de car\u00e1ter descritivo e de abordagem qualitativa, de maio a setembro de 2019, na Regi\u00e3o de Sa\u00fade do Aqu\u00edfero Guarani \u2013 que comporta 10 munic\u00edpios, com um total de 945.738 habitantes \u2013, pertencente ao Departamento Regional de Sa\u00fade (DRS) 13 \u2013 Ribeir\u00e3o Preto-SP12: 1) Coleta de informa\u00e7\u00f5es relevantes; 2) Descri\u00e7\u00e3o do problema e o contexto; 3) Defini\u00e7\u00e3o dos elementos do modelo l\u00f3gico; 4) Constru\u00e7\u00e3o do modelo l\u00f3gico; e 5) Valida\u00e7\u00e3o do modelo l\u00f3gico.O modelo l\u00f3gico foi constru\u00eddo segundo as cinco etapas propostas por McLaughlin e Jordan15.No desenvolvimento das etapas 1, 2, 3 e 4, foi realizada a pesquisa documental. Os crit\u00e9rios empregados para sele\u00e7\u00e3o dos documentos foram: 1) autenticidade, ou seja, o documento ser de origem inquestion\u00e1vel; 2) credibilidade, trata-se de documento original e sem distor\u00e7\u00f5es; 3) representatividade, dentro de sua tipologia \u2013 no caso, documentos legais \u2013, que apresentam o conte\u00fado a ser analisado; e 4) significa\u00e7\u00e3o, ou seja, se o documento era claro e compreens\u00edvel16, e a identifica\u00e7\u00e3o da taxa de preval\u00eancia de pacientes em di\u00e1lise na Regi\u00e3o de Sa\u00fade do Aqu\u00edfero Guarani. Nessa etapa, tamb\u00e9m foram consideradas as informa\u00e7\u00f5es prim\u00e1rias obtidas junto aos entrevistados , e o estudo foi aprovado por Comit\u00ea de \u00c9tica em Pesquisa (CAAE: 58545116.3.000.5414).O modelo l\u00f3gico foi validado por seis informantes-chave, selecionados de forma intencional: um membro da equipe de planejamento de um munic\u00edpio do DRS 13, um articulador da APS da Regi\u00e3o de Sa\u00fade do Aqu\u00edfero Guarani, um enfermeiro de um servi\u00e7o de di\u00e1lise, dois profissionais da equipe de gest\u00e3o/planejamento do DRS 13 \u2013 sendo estes profissionais que participaram da elabora\u00e7\u00e3o da linha de cuidado da pessoa com DRC do DRS13 \u2013, e um profissional da equipe de gest\u00e3o/planejamento da Secretaria de Estado da Sa\u00fade de S\u00e3o Paulo (SES-SP), tamb\u00e9m coordenador do grupo condutor de doen\u00e7as cr\u00f4nicas n\u00e3o transmiss\u00edveis (DCNT). Enfim, realizou-se uma entrevista semiestruturada com os informantes-chave, seguindo os questionamentos apontados por MClauglin e Jordan21. No Brasil, segundo a Pesquisa Nacional de Sa\u00fade , a preval\u00eancia de DRC autorreferida \u00e9 de 1,42%, ou seja, aproximadamente dois milh\u00f5es de indiv\u00edduos, o que revela a dimens\u00e3o da doen\u00e7a no pa\u00eds21. O diagn\u00f3stico precoce, o encaminhamento imediato e a institui\u00e7\u00e3o de medidas para diminuir/interromper a progress\u00e3o da DRC est\u00e3o entre as estrat\u00e9gias-chave para melhorar os seus desfechos21.A DRC \u00e9 reconhecidamente uma doen\u00e7a complexa que exige m\u00faltiplas abordagens em seu tratamento. Est\u00e1 associada, inclusive, a altos coeficientes de morbidade e mortalidade, a taxas de preval\u00eancia e incid\u00eancia ainda desconhecidas em muitos pa\u00edses, e a um grande impacto socioecon\u00f4mico, tornando-se um desafio para a sa\u00fade p\u00fablica mundial7.A PNAPDR prop\u00f4s a organiza\u00e7\u00e3o da linha de cuidado integral \u2013 promo\u00e7\u00e3o, preven\u00e7\u00e3o, tratamento e recupera\u00e7\u00e3o \u2013, perpassando todos os pontos de aten\u00e7\u00e3o, como a amplia\u00e7\u00e3o da cobertura de atendimento aos portadores de hipertens\u00e3o arterial e de diabetes mellitus, a qualifica\u00e7\u00e3o da assist\u00eancia e a promo\u00e7\u00e3o da educa\u00e7\u00e3o permanente dos profissionais da sa\u00fade17. Essa normativa ressaltou que, embora fossem representativos os avan\u00e7os, ainda era evidente a fragmenta\u00e7\u00e3o das a\u00e7\u00f5es de sa\u00fade e a necessidade de qualificar a gest\u00e3o do cuidado. Assim, o desenvolvimento das RAS se apresentou como um processo organizativo inovador, com potencial para impactar positivamente os indicadores de sa\u00fade.Em 2010, foi publicada a portaria que estabeleceu as diretrizes para a organiza\u00e7\u00e3o da RAS no SUS; nela, objetivou-se promover a integra\u00e7\u00e3o sist\u00eamica de a\u00e7\u00f5es e servi\u00e7os de sa\u00fade, com provis\u00e3o de aten\u00e7\u00e3o cont\u00ednua, integral, de qualidade, respons\u00e1vel e humanizada, al\u00e9m de incrementar o desempenho do SUS, em termos de acesso, equidade, efic\u00e1cia cl\u00ednica e sanit\u00e1ria e efici\u00eancia econ\u00f4mica8.Nessa l\u00f3gica, nos anos de 2013 e 2014, foi institu\u00edda a RAS das Pessoas com DCNT, que estabeleceu diretrizes para a organiza\u00e7\u00e3o de suas Linhas de Cuidado, para os seus princ\u00edpios e objetivos e para as compet\u00eancias de cada ente federado. As Linhas de Cuidado devem expressar os fluxos assistenciais que devem ser garantidos ao usu\u00e1rio, a fim de atender \u00e0s necessidades de sa\u00fade relacionadas a uma condi\u00e7\u00e3o cr\u00f4nica e definir as a\u00e7\u00f5es e os servi\u00e7os que ser\u00e3o ofertados por cada componente da RAS das Pessoas com DCNT, baseadas em orienta\u00e7\u00f5es cl\u00ednicas e na realidade de cada Regi\u00e3o de Sa\u00fade18.Por sua vez, os crit\u00e9rios para organiza\u00e7\u00e3o da linha de cuidado da pessoa com DRC, e as diretrizes cl\u00ednicas para o cuidado, foram publicados em 2014, com a defini\u00e7\u00e3o das atribui\u00e7\u00f5es da APS, da aten\u00e7\u00e3o especializada ambulatorial e da assist\u00eancia de alta complexidade18.A partir da publica\u00e7\u00e3o da portaria da linha de cuidado da pessoa com DRC, as regi\u00f5es de sa\u00fade iniciaram o processo de discuss\u00e3o regional sobre ela. De acordo com os informantes-chave, formou-se um grupo condutor com representantes das tr\u00eas regi\u00f5es de sa\u00fade do territ\u00f3rio do DRS 13, dos prestadores dos servi\u00e7os de hemodi\u00e1lise e do grupo de planejamento do DRS 13. O grupo se reuniu para elaborar a linha de cuidado a partir da organiza\u00e7\u00e3o dos servi\u00e7os, a qual foi aprovada pelas Comiss\u00f5es Intergestores Regionais (CIR) das tr\u00eas regi\u00f5es do DRS 13 e pela Comiss\u00e3o Intergestores Bipartite (Delibera\u00e7\u00e3o CIB/SP \u2013 47/2015). No entanto, segundo os entrevistados, at\u00e9 a data da entrevista, em maio de 2019, n\u00e3o havia sido realizado nenhum monitoramento da linha de cuidado no \u00e2mbito da APS, enquanto que os indicadores de qualidade dos servi\u00e7os de m\u00e9dia e alta complexidade eram acompanhados, uma vez que estavam relacionados com a habilita\u00e7\u00e3o e remunera\u00e7\u00e3o dos servi\u00e7os especializados\u201cFoi formado um grupo condutor regional com participantes dos munic\u00edpios, representantes da gest\u00e3o e dos servi\u00e7os, aprovados em CIR, e seguimos as etapas previstas na portaria \u2026 A Linha de Cuidado foi aprovada na CIR, aguardamos a publica\u00e7\u00e3o pelo Minist\u00e9rio da Sa\u00fade que, devido a libera\u00e7\u00e3o de recursos financeiros, demorou mais de dois anos\u201d. (Entrevistado n.\u00ba 1)O n\u00famero de casos estimados nos diferentes est\u00e1gios de DRC na Regi\u00e3o de Sa\u00fade do Aqu\u00edfero Guarani  indica q\u201cHoje o que voc\u00ea tem nos sistemas oficiais, por exemplo, os exames realizados, voc\u00ea consegue puxar, no que a Linha de Cuidado prop\u00f5e, os exames de cada fase que temos que acompanhar. Ent\u00e3o, como produ\u00e7\u00e3o, isso d\u00e1 pra levantar. O que \u00e9 mais complicado, eu acho, \u00e9 exatamente em rela\u00e7\u00e3o \u00e0 Aten\u00e7\u00e3o B\u00e1sica, quantos pacientes eu estou acompanhando, quantos hipertensos tem, qual o est\u00e1gio deles\u2026\u201d. (Entrevistado n.\u00ba 6)\u201cEsses hipertensos \u00e9 uma dificuldade, a gente n\u00e3o tem ferramenta para avaliar isso. O Hiperdia n\u00e3o tem mais. Ele era bom quando existia, n\u00e9, e os munic\u00edpios usavam ele e estava vinculado \u00e0 distribui\u00e7\u00e3o de medicamento\u2026\u201d. (Entrevistado n.\u00ba 2)Quando perguntados sobre os fatores que consideravam influenciar a efetiva implanta\u00e7\u00e3o da linha de cuidado, os entrevistados apontaram condi\u00e7\u00f5es relacionadas ao processo de trabalho, aos modelos de aten\u00e7\u00e3o, \u00e0 qualifica\u00e7\u00e3o profissional e \u00e0 qualidade da APS.\u201cOs fatores que dificultam s\u00e3o os processos de trabalho, n\u00e3o entendem (os profissionais) o que \u00e9 rede, cada um faz um pedacinho. Tamb\u00e9m falta entender de fato o porqu\u00ea tem tanto paciente. Quando fomos fazer a Linha de Cuidado, n\u00e3o localizamos muitos dados, os munic\u00edpios n\u00e3o t\u00eam esses dados, foi preciso usar refer\u00eancias de estudos\u201d. (Entrevistado n.\u00ba 1)\u201cSou cr\u00edtico em rela\u00e7\u00e3o \u00e0 atua\u00e7\u00e3o. Acho que temos as estruturas adequadas, estamos em regi\u00e3o privilegiada em rela\u00e7\u00e3o a suporte e tecnologia, mas pecamos muito na forma como se organiza, modelo de assist\u00eancia, treinamento e capacita\u00e7\u00e3o dos profissionais, acho que isso atrapalha\u201d. (Entrevistado n.\u00ba 2)\u201cA especializada e a alta funcionam bem, eles fazem o papel deles, eu acho que tem que intervir \u00e9 na Aten\u00e7\u00e3o B\u00e1sica\u201d. (Entrevistado n.\u00ba 1)9, que subdividem as diretrizes e responsabilidades de acordo com o n\u00edvel de densidade tecnol\u00f3gica dos servi\u00e7os da RAS. Da mesma forma, as a\u00e7\u00f5es que devem ser desempenhadas fundamentaram-se nas atividades j\u00e1 previstas pelas normas do SUS, sendo, a partir delas, estabelecidos os insumos para a realiza\u00e7\u00e3o do planejamento como um todo.O modelo l\u00f3gico foi aprimorado a partir de sua aprecia\u00e7\u00e3o pr\u00e9via, pela qual informa\u00e7\u00f5es foram complementadas e verificadas antes da valida\u00e7\u00e3o. Durante a valida\u00e7\u00e3o, o modelo foi apresentado a seis informantes-chave, que participaram da elabora\u00e7\u00e3o da linha de cuidado da pessoa com DRC ou atuaram em algum ponto da RAS. O question\u00e1rio semiestruturado (Quadro), proposto por McLaughlin e Jordan12, foi aplicado aos participantes na etapa 5, que responderam afirmativamente \u00e0s quest\u00f5es. Os informantes-chave explicitaram o contexto da elabora\u00e7\u00e3o da linha de cuidado e validaram o modelo12, n\u00e3o sugerindo a inclus\u00e3o de nenhuma nova informa\u00e7\u00e3o.O modelo l\u00f3gico, constru\u00eddo por meio de um diagrama , apresen23, assim como o aumento na taxa de incid\u00eancia estimada, que, em 2018, foi 20% superior \u00e0 observada em 2013. No Brasil, a hipertens\u00e3o arterial se mant\u00e9m como a principal causa-base da DRC, seguida pela doen\u00e7a renal do diabetes24.A DRC tem recebido aten\u00e7\u00e3o da comunidade cient\u00edfica internacional e nacional, e sua elevada preval\u00eancia est\u00e1 demonstrada em estudos recentes24, indicando a necessidade de fortalecimento de pol\u00edticas de preven\u00e7\u00e3o a esse agravo.O SUS conta com a PNAPDR desde 2004, mas s\u00f3 quase dez anos depois, em 2013, que se publicaram a linha de cuidado e as diretrizes cl\u00ednicas da DRC. No entanto, os dados do Censo Brasileiro de Di\u00e1lise, at\u00e9 2018, apontaram aumento crescente nas taxas de incid\u00eancia e preval\u00eancia de pacientes em di\u00e1lise19, desconsiderando \u00e0 APS.A linha de cuidado da pessoa com DRC estabelece as atribui\u00e7\u00f5es dos pontos de aten\u00e7\u00e3o da RAS, norteando a organiza\u00e7\u00e3o do trabalho dos profissionais e dos servi\u00e7os. No entanto, o seu monitoramento e avalia\u00e7\u00e3o abrangem basicamente indicadores voltados \u00e0 alta complexidadeNesse estudo, a elabora\u00e7\u00e3o do modelo l\u00f3gico, a partir da an\u00e1lise de documentos oficiais possibilitou a constru\u00e7\u00e3o de um primeiro diagrama de rela\u00e7\u00e3o entre estrutura, processo e resultado. A entrevista com profissionais que atuavam em diversos pontos da linha de cuidado detalhou os componentes desse modelo, tornando-o mais completo e possibilitando a identifica\u00e7\u00e3o de fatores do contexto interno que poderiam interferir na sua implanta\u00e7\u00e3o.Com rela\u00e7\u00e3o \u00e0s dimens\u00f5es assistenciais do modelo l\u00f3gico, destaca-se a aten\u00e7\u00e3o dada pelos informantes-chave \u00e0 APS. Todos comentaram sobre o seu papel fundamental na organiza\u00e7\u00e3o da linha de cuidado, mas tamb\u00e9m sobre as suas fragilidades relacionadas ao processo de trabalho, capacita\u00e7\u00e3o, qualifica\u00e7\u00e3o das equipes e \u00e0 falta de informa\u00e7\u00f5es para o monitoramento e avalia\u00e7\u00e3o.25. Nesse sentido, a territorializa\u00e7\u00e3o \u00e9 a primeira etapa do planejamento. Por meio dela, realiza-se o reconhecimento da \u00e1rea de atua\u00e7\u00e3o do servi\u00e7o de sa\u00fade e suas condi\u00e7\u00f5es socioambientais, caracteriza-se a popula\u00e7\u00e3o e seus problemas de sa\u00fade, a din\u00e2mica de sua intera\u00e7\u00e3o com equipamentos sociais adjacentes e com outros setores, para identificar necessidades e propor a\u00e7\u00f5es promotoras e de prote\u00e7\u00e3o \u00e0 sa\u00fade, al\u00e9m de preven\u00e7\u00e3o dos agravos25.O primeiro bloco de atividades da dimens\u00e3o da APS abarca grande parte das a\u00e7\u00f5es previstas pela Pol\u00edtica Nacional de Aten\u00e7\u00e3o B\u00e1sicaPortanto, \u00e9 essencial garantir no territ\u00f3rio equipes multiprofissionais e infraestrutura que permitam o conhecimento dos problemas/necessidades e potencialidades da comunidade, condi\u00e7\u00f5es fundamentais para subsidiar o planejamento, monitoramento e avalia\u00e7\u00e3o das a\u00e7\u00f5es de sa\u00fade.No segundo bloco, cujo insumo \u00e9 a realiza\u00e7\u00e3o de atividades educativas, a aus\u00eancia da educa\u00e7\u00e3o popular em sa\u00fade como a\u00e7\u00e3o relaciona-se ao fato de ela n\u00e3o constar no item \u201ceduca\u00e7\u00e3o em sa\u00fade\u201d, das normativas consultadas e da viv\u00eancia dos informantes-chave sobre o tema. Todavia, entendemos que seja importante para o empoderamento do usu\u00e1rio e consequente participa\u00e7\u00e3o na tomada de decis\u00e3o.Os blocos seguintes se relacionam com a garantia de atendimentos na aten\u00e7\u00e3o especializada, transporte e sistema de refer\u00eancia e contrarrefer\u00eancia. Sobre o uso do prontu\u00e1rio eletr\u00f4nico, embora pudesse ser considerado como um insumo, diante da disponibilidade do PEC e-SUS pelo Minist\u00e9rio da Sa\u00fade, foi considerado como uma a\u00e7\u00e3o, seja o pr\u00f3prio PEC e-SUS ou qualquer outro sistema do tipo. O prontu\u00e1rio eletr\u00f4nico permite a otimiza\u00e7\u00e3o dos atendimentos cl\u00ednicos, a acessibilidade aos dados da assist\u00eancia e dos procedimentos realizados, a integra\u00e7\u00e3o de informa\u00e7\u00f5es, o cadastramento dos domic\u00edlios, al\u00e9m de apoiar o ensino e a pesquisa. Ademais, esse prontu\u00e1rio favorece a comunica\u00e7\u00e3o na RAS, por exemplo, por meio de um sistema de refer\u00eancia e contrarrefer\u00eancia, contribuindo para a coordena\u00e7\u00e3o e continuidade do cuidado e vincula\u00e7\u00e3o do usu\u00e1rio \u00e0s equipes.Em rela\u00e7\u00e3o aos produtos da APS, embora sejam dif\u00edceis de serem mensurados, referem-se ao que se espera das atividades propostas. Acredita-se que o modelo l\u00f3gico desperte reflex\u00f5es sobre eles e, consequentemente, a elei\u00e7\u00e3o de indicadores de estrutura, de processo e de resultados por dimens\u00e3o da linha de cuidado.A dimens\u00e3o da aten\u00e7\u00e3o especializada foi referida como a parte da linha de cuidado que \u201cmais funciona\u201d, com indicadores de monitoramento bem definidos, assim como a alta complexidade. Destaca-se que, entre os entrevistados, n\u00e3o estavam profissionais especialistas da alta complexidade, o que pode ser uma limita\u00e7\u00e3o do estudo, considerando que estes poderiam propor modifica\u00e7\u00f5es e ou complementa\u00e7\u00f5es ao modelo.26.O modelo l\u00f3gico, embora tenha sido elaborado em uma RS, o que pode representar uma limita\u00e7\u00e3o, comporta as tr\u00eas dimens\u00f5es da aten\u00e7\u00e3o \u00e0 sa\u00fade: prim\u00e1ria, secund\u00e1ria e terci\u00e1ria. A sua utiliza\u00e7\u00e3o por profissionais e gestores, cotejada com as distintas realidades, pode colaborar com o monitoramento/avalia\u00e7\u00e3o da linha de cuidado, e com a identifica\u00e7\u00e3o de potencialidades e desafios, auxiliando no planejamento e na tomada de decis\u00f5esH\u00e1 o reconhecimento de que, no pa\u00eds, a abordagem ao portador de DRC no SUS necessita de incremento. A linha de cuidado da pessoa com DRC, ao detalhar as atribui\u00e7\u00f5es pelas dimens\u00f5es de aten\u00e7\u00e3o da RAS, caracteriza-se como um norteador da organiza\u00e7\u00e3o do processo de trabalho dos profissionais e dos servi\u00e7os, com \u00eanfase na APS, componente ainda pouco explorado e valorizado.No contexto da avalia\u00e7\u00e3o em sa\u00fade, o modelo l\u00f3gico apresentado auxilia na proposi\u00e7\u00e3o de indicadores de desempenho aplic\u00e1veis \u00e0s tr\u00eas dimens\u00f5es assistenciais, mas principalmente \u00e0 APS, pois, embora seja reconhecida como ordenadora da rede e coordenadora do cuidado, apresenta v\u00e1rias debilidades organizacionais, e, por isso, tem sido desprivilegiada nas discuss\u00f5es e nos investimentos. Ainda, os indicadores a serem elaborados a partir dessa linha de cuidado da pessoa portadora de DCNT podem ser empregados em outras Linhas do tipo, contribuindo com o aperfei\u00e7oamento da a\u00e7\u00e3o gestora e viabilizando a efetiva implementa\u00e7\u00e3o dessa estrat\u00e9gia de organiza\u00e7\u00e3o do cuidado.Admite-se que o modelo l\u00f3gico sugerido tenha potencial de contribuir com processos de avalia\u00e7\u00e3o da linha de cuidado da pessoa com DRC, com vistas ao alcance de melhores resultados no manejo dessa doen\u00e7a, tanto para o seu portador quanto para o sistema de sa\u00fade."}
+{"text": "O desequil\u00edbrio do sistema nervoso aut\u00f4nomo (SNA) na insufici\u00eancia card\u00edaca (IC) cria um ciclo vicioso, o excesso de atividade simp\u00e1tica e a diminui\u00e7\u00e3o da atividade vagal contribuindo para a piora da IC. A estimula\u00e7\u00e3o el\u00e9trica transcut\u00e2nea de baixa intensidade do ramo auricular do nervo vago (taVNS) \u00e9 bem tolerada e abre novas possibilidades terap\u00eauticas. Gerar hip\u00f3tese da aplicabilidade e benef\u00edcio da taVNS na IC atrav\u00e9s da compara\u00e7\u00e3o intergrupos de par\u00e2metros ecocardiogr\u00e1ficos, teste de caminhada de 6 min, variabilidade da frequ\u00eancia card\u00edaca pelo Holter (SDNN e rMSSD), question\u00e1rio de qualidade de vida de Minnesota e classe funcional pela New York Heart Association. Estudo cl\u00ednico prospectivo, duplo cego, randomizado com metodologia sham, unic\u00eantrico. Avaliados 43 pacientes e alocados em 2 grupos: o Grupo 1 recebeu taVNS (frequ\u00eancias 2/15 Hz) e Grupo 2 recebeu sham. Nas compara\u00e7\u00f5es, valores de p<0,05 foram considerados significativos. Na fase p\u00f3s-interven\u00e7\u00e3o, observou-se que o Grupo 1 se manteve com melhor rMSSD  e atingiu melhor SDNN . Ao compararmos os par\u00e2metros intragrupos, antes e ap\u00f3s interven\u00e7\u00e3o, observou-se que todos melhoraram significativamente no grupo 1 e n\u00e3o houve diferen\u00e7as no grupo 2. A taVNS \u00e9 uma interven\u00e7\u00e3o segura, de f\u00e1cil execu\u00e7\u00e3o e que sugere prov\u00e1vel benef\u00edcio na IC pela melhora na variabilidade da frequ\u00eancia card\u00edaca, o que indica melhor equil\u00edbrio auton\u00f4mico. Novos estudos com maior n\u00famero de pacientes s\u00e3o necess\u00e1rios para responder \u00e0s quest\u00f5es levantadas por esse estudo. Sua mortalidade permanece elevada com sobrevida m\u00e9dia de cinco anos ap\u00f3s o diagn\u00f3stico de apenas 35% se n\u00e3o tratada. No Brasil, dados do registro BREATHE (Brazilian Registry of Acute Heart Failure) mostraram a IC como principal causa de rehospitaliza\u00e7\u00f5es, al\u00e9m de elevada taxa de mortalidade hospitalar.A IC (insufici\u00eancia card\u00edaca) \u00e9 considerada uma s\u00edndrome grave afetando, no mundo, mais de 23 milh\u00f5es de pessoas. e est\u00e3o associados ao aumento do t\u00f4nus simp\u00e1tico e diminui\u00e7\u00e3o do t\u00f4nus parassimp\u00e1tico, como na IC, doen\u00e7as inflamat\u00f3rias intestinais e s\u00edndrome da dor cr\u00f4nica. A atividade simp\u00e1tica aumentada pode ser regulada por f\u00e1rmacos e a atividade parassimp\u00e1tica reduzida pode ser estimulada pelo treinamento f\u00edsico, por exemplo.Desequil\u00edbrios do SNA (sistema nervoso aut\u00f4nomo) t\u00eam sido observados em diversas doen\u00e7as mostrando que a estimula\u00e7\u00e3o invasiva do nervo vago melhorou a classe funcional pela NYHA (New York Heart Association), o teste de caminhada de 6 minutos (TC6min), a qualidade de vida pelo question\u00e1rio de Minnesota (MLHFQ) e os n\u00edveis de NT-proBNP  em pacientes com ICFER (IC com fra\u00e7\u00e3o de eje\u00e7\u00e3o reduzida).Recentemente, foi publicada metan\u00e1lise atrav\u00e9s de eletrodos (taVNS) ou pequenas agulhas (paVNS) colocadas na concha e/ou na parte inferior do tragus.A estimula\u00e7\u00e3o auricular do nervo vago (aVNS) \u00e9 produzida por estimula\u00e7\u00e3o el\u00e9trica n\u00e3o invasiva do nervo vago na orelha, o que, combinada com seus efeitos anti-inflamat\u00f3rios, leva a uma melhora da oxigena\u00e7\u00e3o dos tecidos.A regulariza\u00e7\u00e3o do equil\u00edbrio auton\u00f4mico mediada pela VNS diminui a atividade simp\u00e1tica e provoca a libera\u00e7\u00e3o de \u00f3xido n\u00edtrico e classe funcional (NYHA) aplicados antes de iniciar e ao finalizar as interven\u00e7\u00f5es (taVNS eSham). Analisamos tamb\u00e9m a aplicabilidade e benef\u00edcio da taVNS na ICFER atrav\u00e9s da compara\u00e7\u00e3o intragrupos dos dados supracitados.N\u00e3o h\u00e1 estudos atuais sobre taVNS na IC. No presente estudo buscamos analisar e gerar a hip\u00f3tese da aplicabilidade e benef\u00edcio da taVNS na ICFER atrav\u00e9s da compara\u00e7\u00e3o intergrupos do ecocardiograma, TC6min, variabilidade da frequ\u00eancia card\u00edaca pelo Holter (SDNN e rMSSD), MLHFQsham, sendo avaliados pacientes com IC e fra\u00e7\u00e3o de eje\u00e7\u00e3o < 50% em regime ambulatorial. Foram atendidos pacientes provenientes do ambulat\u00f3rio de IC da Secretaria de Sa\u00fade de Cabo Frio  e pacientes encaminhados por outros m\u00e9dicos para o ambulat\u00f3rio do Hospital Santa Izabel em Cabo Frio.Estudo cl\u00ednico prospectivo, duplo cego, randomizado, com metodologiaAo estimularmos o nervo vago aferente em n\u00edvel auricular modula-se o sistema nervoso auton\u00f4mico card\u00edaco intr\u00ednseco para atingir o efeito cardioprotetor. Os pacientes foram estimulados a n\u00edvel auricular at\u00e9 que percebessem um formigamento no local do est\u00edmulo, bem abaixo do limiar de dor, o que tornou exequ\u00edvel e confort\u00e1vel o procedimento.shamfoi escalada a enfermeira Rafaela dos Santos Cardoso Carneiro que, ap\u00f3s treinamento e prepara\u00e7\u00e3o adequados, realizou as interven\u00e7\u00f5es e aplicou os testes. Coletaram-se dados atrav\u00e9s do acompanhamento dos pacientes e exames cardiol\u00f3gicos n\u00e3o invasivos como ecocardiograma e HOLTER ECG 24 h. A avalia\u00e7\u00e3o funcional foi abordada pelo TC6MIN, e a classe funcional-NYHA e o question\u00e1rio de qualidade de vida Minnesota-MLHFQ foram tamb\u00e9m utilizados.Para evitar que o pesquisador tivesse conhecimento de quem recebeu taVNS ou enquanto frequ\u00eancias na faixa de 10-25Hz produzem boa modula\u00e7\u00e3o parassimp\u00e1tica. Escolhemos o modo misto, utilizando tanto baixas (2 Hz) quanto m\u00e9dias frequ\u00eancias (15 Hz) de modo a obtermos ambos os benef\u00edcios auton\u00f4micos.Utilizamos, em nosso estudo, o equipamento de eletroestimula\u00e7\u00e3o cut\u00e2nea EL-30 , com os seguintes par\u00e2metros de estimula\u00e7\u00e3o: largura de pulso de 500 \u00b5s, intensidade abaixo do limiar doloroso, 5 segundos 2 Hz / 5 segundos 15 Hz. Estudos recentes mostraram que baixas frequ\u00eancias t\u00eam efeito maior na diminui\u00e7\u00e3o da atividade simp\u00e1tica,Foi usado ecocardiograma com alta qualidade de imagem e processamento, por meio da sonda Setorial Matricial XDclear, o Vivid S70N-GE.O gravador digital de Holter Cardiolight-Cardios, com tecnologia digital de aquisi\u00e7\u00e3o do sinal de 800 pontos por segundo com processamento em tempo real (DSP) foi utilizado em nosso estudo.A interven\u00e7\u00e3o (taVNS) ocorreu durante 30 minutos de segunda-feira a sexta-feira, totalizando 20 sess\u00f5es. As avalia\u00e7\u00f5es e coleta de dados foram feitas antes de iniciar o estudo e ap\u00f3s a \u00faltima sess\u00e3o de cada participante.sham.No per\u00edodo entre 03-02-2021 e 05-01-2022 foram inicialmente recrutados 52 pacientes, mas devido \u00e0 pandemia de COVID-19 perdemos o seguimento de 9 pacientes. Logo, 43 pacientes conclu\u00edram o estudo, 22 pacientes no grupo taVNS e 21 no gruposham-simulado, ao vir \u201c1\u201d (um) recebia taVNS-interven\u00e7\u00e3o.A randomiza\u00e7\u00e3o foi realizada atrav\u00e9s de sorteio eletr\u00f4nico e confec\u00e7\u00e3o de envelopes lacrados distribu\u00eddos de forma bin\u00e1ria. \u00c0 medida que os participantes eram recrutados um envelope era aberto: ao vir \u20180\u201d (zero) recebiaDessa forma, os pacientes foram alocados em 2 grupos:\u2013Grupo 1 (22 pacientes) recebeu a interven\u00e7\u00e3o taVNS, com um eletrodo transcut\u00e2neo na concha superior (cimba) e o outro no l\u00f3bulo direito, nas frequ\u00eancias 2/15 Hz no per\u00edodo de 30 minutos. Estimulamos dessa forma o nervo vago na concha superior e o grande nervo auricular no l\u00f3bulo. Tais locais foram escolhidos baseados na inerva\u00e7\u00e3o da orelha, facilidade t\u00e9cnica para coloca\u00e7\u00e3o dos eletrodos e para uniformizar o tratamento.\u2013Grupo 2 (21 pacientes) recebeu a interven\u00e7\u00e3osham, com ambos os eletrodos transcut\u00e2neos no l\u00f3bulo direito nas frequ\u00eancias 2/15 Hz por per\u00edodo de 1 minuto, e depois desligado e mantido por 29 minutos.  versus gruposham. Um tamanho amostral de 40 pacientes (20 em cada grupo) forneceria pelo menos 80% de poder do teste para detectar essa diferen\u00e7a, em um n\u00edvel alfa de signific\u00e2ncia de 0,05.Com base em estudos anteriores,As vari\u00e1veis cont\u00ednuas foram apresentadas atrav\u00e9s de m\u00e9dia \u00b1 desvio-padr\u00e3o (DP) ou mediana  conforme normalidade dos dados, e as vari\u00e1veis categ\u00f3ricas foram apresentadas atrav\u00e9s de frequ\u00eancias absoluta e relativa.Todas as vari\u00e1veis cont\u00ednuas foram testadas para normalidade pelo teste de Shapiro-Wilks.tde Student n\u00e3o pareado (ou Mann-Whitney), etde Student pareado para compara\u00e7\u00f5es intragrupos. O teste do qui-quadrado (ou exato de Fisher) foi usado para compara\u00e7\u00e3o entre as vari\u00e1veis categ\u00f3ricas.As compara\u00e7\u00f5es nas caracter\u00edsticas das vari\u00e1veis cont\u00ednuas entre os grupos foram realizadas por meio do testeValores de p < 0,05 foram considerados estatisticamente significativos e todos os testes foram bicaudais.R Statistic3.5.1 .Todas as an\u00e1lises estat\u00edsticas foram realizadas utilizando-se o softwareHumanos: A coleta de dados cl\u00ednicos e a realiza\u00e7\u00e3o de exames cardiol\u00f3gicos foram feitos pelo investigador.Financeiros: N\u00e3o houve recursos de terceiros, al\u00e9m de recursos pr\u00f3prios.O pesquisador n\u00e3o teve conhecimento sobre a conduta cl\u00ednica promovida pelos pacientes integrantes do estudo e provenientes do ambulat\u00f3rio de cardiologia, garantindo assim o tratamento \u00f3timo para IC nos 2 grupos. Este estudo foi aprovado pelo CEP sob o parecer 4.486.173 em 29/12/2020 de conformidade com a resolu\u00e7\u00e3o 466/2012 e cadastrado no ReBEC/World Health Organization, UTN: U111112552081, e na Plataforma Brasil: 38606820.6.0000.5243.As caracter\u00edsticas cl\u00ednicas basais foram similares na maioria dos par\u00e2metros nos 2 grupos . No entsham)na fase pr\u00e9-interven\u00e7\u00e3o apresentou melhor qualidade de vida  e tend\u00eancia a melhor desempenho no TC6M  como se pode observar naO Grupo 2  e atingiu melhor SDNN  . Nos deNota-se que o SDNN nos dois grupos antes da taVNS apresentava n\u00edveis semelhantes, mas analisando aAo comparar os par\u00e2metros antes e ap\u00f3s a interven\u00e7\u00e3o na an\u00e1lise intragrupos, constatamos que muitos melhoraram significativamente no Grupo 1 e n\u00e3o houve diferen\u00e7a no Grupo 2.Houve benef\u00edcio no Grupo 1 ap\u00f3s taVNS quanto \u00e0 qualidade de vida, enquanto n\u00e3o houve o mesmo benef\u00edcio no grupo controle ap\u00f3s 30 dias de estimula\u00e7\u00e3o . Da mesN\u00e3o observamos nenhuma intercorr\u00eancia ou abandono do tratamento por eventos adversos em nosso estudo.O resumo do design e dos achados do estudo pode ser observado na .sham, houve melhora do \u00edndice de variabilidade de frequ\u00eancia card\u00edaca no grupo interven\u00e7\u00e3o, n\u00e3o havendo benef\u00edcios nos demais par\u00e2metros. Por outro lado, quando se comparou as vari\u00e1veis intragrupos, observou-se melhora no TC6M e MLHFQ ap\u00f3s a taVNS, enquanto n\u00e3o se modificaram no grupo controle.Este estudo mostrou que, em pacientes com ICFEr, quando comparamos o est\u00edmulo com taVNS vs. que a redu\u00e7\u00e3o da variabilidade card\u00edaca \u00e9 um preditor independente no aumento na morte s\u00fabita na IC e mesmo na popula\u00e7\u00e3o geral. Podemos sugerir que a taVNS, trazendo um aumento na variabilidade da FC, possa estar associada \u00e0 redu\u00e7\u00e3o de morte s\u00fabita por interferir indiretamente na redu\u00e7\u00e3o da cascata inflamat\u00f3ria da IC, com menor carga arr\u00edtmica, atrav\u00e9s de um melhor equil\u00edbrio neurohumoral.Sabemos desde 1998 com o estudo de Nolan et al. e BEAT HF o uso de terapia de ativa\u00e7\u00e3o do barorreflexo foi segura e conferiu benef\u00edcio na IC. O presente estudo demonstrou a mesma seguran\u00e7a, facilidade de execu\u00e7\u00e3o e menores efeitos colaterais, al\u00e9m de mostrar benef\u00edcio na variabilidade da FC e sugerir melhoras no TC6M e na qualidade de vida. Com a melhora da capacidade funcional, foi percept\u00edvel em todos os pacientes o desejo de persistir no tratamento mesmo durante um per\u00edodo de pandemia e riscos.De acordo com os estudos HOPE4 HF mostraram o benef\u00edcio e a facilidade da execu\u00e7\u00e3o da taVNS em humanos de forma n\u00e3o invasiva e foi poss\u00edvel confirmar neste estudo a mesma facilidade de execu\u00e7\u00e3o.Frangos et al. em 2015 usando VNS, falharam no objetivo prim\u00e1rio quanto \u00e0 melhoria das medidas ecocardiogr\u00e1ficas ap\u00f3s VNS, mas demonstraram melhoria na qualidade de vida, achado este que foi poss\u00edvel demonstrar em nosso estudo sem a necessidade de interven\u00e7\u00e3o invasiva.Zannad et al., no estudo NECTAR HF,A melhora na qualidade de vida acarretou uma melhor ades\u00e3o ao tratamento, no estilo de vida, uma percept\u00edvel satisfa\u00e7\u00e3o do paciente e um engajamento maior ao perceber resultados palp\u00e1veis e um novo foco sobre seu posicionamento quanto \u00e0 IC e suas expectativas. envolvendo 85 centros, n\u00e3o demonstraram redu\u00e7\u00e3o da mortalidade ao utilizar VNS, mas sim um benef\u00edcio no teste de caminhada de 6 minutos, o que se alinha com nossos achados, com a vantagem que utilizamos a via auricular do nervo vago.Gold et al., no estudo INOVATE HF, Esses efeitos positivos demonstraram que a maioria dos pacientes se tornaram menos sintom\u00e1ticos e mais capazes para as atividades do dia-a-dia ap\u00f3s o tratamento com VNS. O teste de caminhada de seis minutos foi realizado em cinco estudos relativamente recentes, com aumento significativo da dist\u00e2ncia percorrida em pacientes tratados por VNS. Esses achados se alinham com a melhora no TC6M e na qualidade de vida observados neste estudo no grupo taVNS, apontando que esses pacientes se tornaram fisicamente mais aptos ap\u00f3s a estimula\u00e7\u00e3o vagal. Por outro lado, o presente estudo n\u00e3o foi capaz de demonstrar melhora na classe funcional NYHA, provavelmente porque a maior parte dos pacientes j\u00e1 estavam em classes I ou II desde o in\u00edcio.A classe funcional da NYHA e a qualidade de vida melhoraram ap\u00f3s VNS em v\u00e1rios estudos. demonstraram que a VNS no lado esquerdo ou direito n\u00e3o apresentou diferen\u00e7a nos resultados e foi seguro. Neste estudo, optou-se por manter o est\u00edmulo no ouvido externo direito por simples conven\u00e7\u00e3o.No estudo ANTHEM HF, Premchand et al. demonstraram que taVNS suprimiu e reduziu a carga de fibrila\u00e7\u00e3o atrial em pacientes sem IC, al\u00e9m de reduzir os n\u00edveis de citocinas pr\u00f3-inflamat\u00f3rias. Recentemente, o mesmo grupo demonstrou, num estudo piloto, que a taVNS reduziu os n\u00edveis de fator de necrose tumoral alfa e melhorou a qualidade de vida em pacientes com IC com fra\u00e7\u00e3o de eje\u00e7\u00e3o preservada. Nosso estudo vem gerar a hip\u00f3tese que a taVNS possa vir tamb\u00e9m a ser ben\u00e9fica em pacientes com IC com fra\u00e7\u00e3o de eje\u00e7\u00e3o reduzida, pois observou-se melhora na variabilidade de frequ\u00eancia card\u00edaca no grupo taVNS.Em 2015 e novamente em 2020, no estudo TREAT AF, Stavrakis et al. demonstraram de forma sistem\u00e1tica os efeitos ben\u00e9ficos e anti-inflamat\u00f3rios da taVNS, n\u00e3o apenas pelos mecanismos cl\u00e1ssicos expostos em seus estudos, mas tamb\u00e9m por outros ainda n\u00e3o bem compreendidos. Este estudo vem gerar uma hip\u00f3tese ao demonstrar que, ao modularmos o excesso de atividade simp\u00e1tica e estimularmos a atividade parassimp\u00e1tica, obtivemos resultados promissores na insufici\u00eancia card\u00edaca.Kaniusas et al. realizaram metan\u00e1lise sobre estudos cl\u00ednicos randomizados comparando VNS invasiva + tratamento medicamentoso vs. tratamento medicamentoso na IC, e observaram que em pacientes com ICFEr o uso de VNS foi associado \u00e0 melhora na classe funcional NYHA, qualidade de vida, TC6M e redu\u00e7\u00e3o dos n\u00edveis de NT-proBNP. Neste estudo foi poss\u00edvel observar melhora na variabilidade da frequ\u00eancia card\u00edaca, qualidade de vida e TC6M, com menos efeitos adversos que os estudos invasivos e que usaram dispositivos implant\u00e1veis.Em recente publica\u00e7\u00e3o, Sant\u2019Anna et al.Este estudo apresentou algumas limita\u00e7\u00f5es:O Grupo 1 teve na fase pr\u00e9-interven\u00e7\u00e3o, idade superior, pior qualidade de vida e maior rMSSD que o Grupo 2, o que pode prejudicar as an\u00e1lises ap\u00f3s a interven\u00e7\u00e3o. Atribu\u00edmos tal achado ao pequeno tamanho de amostra, mas os resultados mostraram que tais discrep\u00e2ncias n\u00e3o influ\u00edram nos achados finais;A pandemia de COVID-19 foi um obst\u00e1culo para realiza\u00e7\u00e3o desse estudo. Ressalta-se a preocupa\u00e7\u00e3o dos pacientes por serem cardiopatas e do risco de cont\u00e1gio. Tais obst\u00e1culos foram contornados mudando o ambiente e informando que seriam fornecidas medidas protetivas, embora tal fato n\u00e3o tenha afetado a an\u00e1lise dos dados;Outra limita\u00e7\u00e3o trazida pela pandemia foi a crise econ\u00f4mica dificultando a mobiliza\u00e7\u00e3o para realizar o tratamento e exames seriados. Fornecemos passagem, ajuda de custo alimentar e o fundamental esclarecimento sobre a import\u00e2ncia do tratamento;N\u00e3o dosamos biomarcadores neste estudo, no entanto, at\u00e9 \u00e0 \u00e9poca do recrutamento n\u00e3o disp\u00fanhamos de laborat\u00f3rio dispon\u00edvel em nossa regi\u00e3o. No entanto, a ideia original era gerar hip\u00f3tese para tratamento ambulatorial, o que foi feito;Uma importante limita\u00e7\u00e3o decorre do curto prazo do estudo. A maioria dos estudos de estimula\u00e7\u00e3o vagal demonstraram um resultado mais percept\u00edvel ap\u00f3s um per\u00edodo maior de estimula\u00e7\u00e3o, enquanto o per\u00edodo de tratamento deste estudo foi de apenas 1 m\u00eas. Como ainda assim os resultados foram promissores, espera-se que novos estudos venham em breve esclarecer o tempo m\u00ednimo e o ideal para se obter um efeito razo\u00e1vel da modula\u00e7\u00e3o vagal na IC;Outro fator limitante foi a classe funcional NYHA dos pacientes, a maioria foi classe I  ou II , e com isso o objetivo de avaliar a melhora de classe funcional nesses pacientes perdeu um pouco o sentido. Novos estudos envolvendo uso de taVNS no tratamento da IC devem excluir a classe I da NYHA, uma vez que nesses pacientes j\u00e1 se atingiu o benef\u00edcio cl\u00ednico almejado.A taVNS \u00e9 uma interven\u00e7\u00e3o segura, de f\u00e1cil execu\u00e7\u00e3o e pode conferir benef\u00edcio na IC pela melhora nos par\u00e2metros de variabilidade de frequ\u00eancia card\u00edaca (SDNN), o que indica melhor equil\u00edbrio auton\u00f4mico. Mostrou-se tamb\u00e9m, na compara\u00e7\u00e3o intragrupos antes e ap\u00f3s o tratamento, melhora na qualidade de vida e no teste de caminhada de 6 minutos no grupo taVNS.A partir desses resultados, pode-se aventar a hip\u00f3tese de amplia\u00e7\u00e3o da indica\u00e7\u00e3o da neuromodula\u00e7\u00e3o vagal auricular em pacientes com IC, embora novos estudos com maior n\u00famero de pacientes sejam necess\u00e1rios para responder \u00e0s quest\u00f5es levantadas pelo presente estudo. Its mortality remains high, with average five-year survival after diagnosis of only 35% if untreated.In Brazil, data from the BREATHE registry (Brazilian Registry of Acute Heart Failure)showed HF as the main cause of rehospitalizations and a high hospital mortality rate.Heart failure (HF) is considered a serious syndrome affecting more than 23 million people worldwide.and are associated with increased sympathetic tonus and decreased parasympathetic tonus,such as in HF,inflammatory bowel diseases, and chronic pain syndrome. Drugs can regulate the increased sympathetic activity, and the reduced parasympathetic activity can be stimulated by physical training, for example.ANS (autonomic nervous system) imbalances have been observed in several diseaseswas published showing that invasive stimulation of the vagus nerve improved the functional class by the New York Heart Association(NYHA), the 6-minute walk test (6MWT), the quality of life by the Minnesota questionnaire (MLHFQ) and the NT-proBNP levels  in patients with HFrER (heart failure with reduced ejection fraction).Recently, a meta-analysisthrough electrodes (taVNS) or small needles (paVNS) placed in the concha and/or lower part of the tragus.Auricular vagus nerve stimulation (aVNS) is produced by non-invasive electrical stimulation of the vagus nerve in the earwhich, combined with its anti-inflammatory effects, leads to improved tissue oxygenation.The regulation of autonomic balance mediated by VNS decreases sympathetic activity and causes the release of nitric oxide,and functional class (NYHA) applied before starting and at the end of the interventions (taVNS andsham). We also analyzed the applicability and benefit of taVNS in HFrER by intragroup comparison of the abovementioned data.There are no current studies on taVNS in HF. In the present study, we sought to analyze and hypothesize the applicability and benefit of taVNS in HFrER by comparing intergroup echocardiographic parameters, 6MWT, Holter heart rate variability (SDNN and rMSSD), MLHFQA prospective, double-blind, randomized clinical study, with sham methodology, evaluating patients with HF and ejection fraction < 50% on an outpatient basis. Patients from the HF outpatient clinic of the Cabo Frio Health Secretariat  and patients referred by other physicians to the outpatient clinic of Hospital Santa Izabel in Cabo Frio were treated.When we stimulate the afferent vagus nerve at the auricular level, the intrinsic cardiac autonomic nervous system is modulated to achieve the cardioprotective effect. Patients were stimulated at the auricular level until they felt tingling at the stimulus site, well below the pain threshold, which made the procedure feasible and comfortable.To prevent the researcher from knowing who received taVNS or sham, nurse Rafaela dos Santos Cardoso Carneiro was chosen, who, after adequate training and preparation, carried out the interventions and applied the tests. Data were collected through patient follow-up and non-invasive cardiological tests such as echocardiography and 24-hour HOLTER ECG. The 6MWT addressed functional assessment, and the NYHA functional class and the Minnesota quality of life questionnaire (MLHFQ) were also used.while frequencies in the 10-25Hz range produce good parasympathetic modulation.We chose the mixed mode, using both low (2 Hz) and medium frequencies (15 Hz) to obtain both autonomic benefits.Our study used the EL-30 electrical stimulation equipment  with the following stimulation parameters: pulse width of 500 \u00b5s, intensity below the painful threshold, 5 seconds 2 Hz / 5 seconds 15 Hz. Recent studies have shown that low frequencies have a greater effect on decreasing sympathetic activity,A high image and processing quality echocardiogram was used, the Vivid S70N-GE, with the XDclear Matrix Sector probe.The Holter Cardiolight-Cardios digital recorder, with digital signal acquisition technology at 800 points per second with real-time processing (DSP), was employed in our study.The intervention (taVNS) took 30 minutes from Monday to Friday, totaling 20 sessions. Assessments and data collection were performed before starting the study and after the last session of each participant.shamgroup.From 2021-02-03 to 2022-01-05, 52 patients were initially recruited, but due to the COVID-19 pandemic, we lost the follow-up of 9 patients. Therefore, 43 patients completed the study, 22 in the taVNS group and 21 in theshamintervention; when \u20181\u2019 (one) came up, they received taVNS.Randomization was carried out through an electronic raffle and the creation of sealed envelopes distributed in a binary way. As participants were recruited, an envelope was opened: when \u20180\u2019 (zero) came up, they received theThus, patients were allocated into 2 groups:Group 1 (22 patients) received the taVNS intervention, with a transcutaneous electrode on the superior concha (cimba) and the other on the right lobe, at frequencies 2/15 Hz over 30 minutes. This way, we stimulate the superior concha\u2019s vagus nerve and the lobe\u2019s great auricular nerve. Such sites were chosen based on the innervation of the ear, the technical facility for placing the electrodes and standardizing the treatment.shamintervention, with both transcutaneous electrodes on the right lobe at frequencies 2/15 Hz for 1 minute, then turned off and maintained for 29 minutes. (Group 2 (21 patients) received theinutes. e2Inclusion criteria:Outpatients with compensated or recovered HF NYHA classes I-IV, receiving optimal pharmacological therapy in the last 3 months.Age over 18 years old.LVEF (left ventricle ejection fraction) less than 50% documented by echocardiography.Exclusion criteria:Patients hospitalized for HF or using intravenous therapy for HF in the last 30 days.Patients with severe mitral regurgitation or severe aortic stenosis.Heart surgery or angioplasty, or stroke within the last 3 months.Pacemaker users.Patients with an LVEF \u2265 50%.the present study was designed to detect a 30% improvement in quality of life scores, 6-min walk test, and HR variability in the taVNS group versus theshamgroup. A sample size of 40 patients (20 in each group) would provide at least 80% test power to detect this difference at an alpha significance level of 0.05.Based on previous studies,Continuous variables were presented as mean \u00b1 standard deviation (SD) or median (interquartile range) according to data normality, and categorical variables were presented as absolute and relative frequencies. All continuous variables were tested for normality using the Shapiro-Wilks test.Comparisons in the characteristics of continuous variables between groups were performed using the unpaired Student\u2019s t-test (or Mann-Whitney) and paired Student\u2019s t-test for intragroup comparisons. The chi-square (or Fisher\u2019s exact) test was used to compare categorical variables.R Statistic3.5.1 .P values < 0.05 were considered statistically significant, and all tests were two-tailed. All statistical analyzes were performed using the softwareHumans: the main investigator performed the collection of clinical data and the performance of cardiological examinations.Financial: there were no resources from third parties besides our own resources.The researcher was unaware of the clinical conduct promoted by the patients participating in the study and coming from the cardiology outpatient clinic, thus guaranteeing the optimal treatment for HF in the 2 groups. This study was approved by the Ethical Committee under opinion 4,486,173 on 12/29/2020 following resolution 466/2012 and registered at ReBEC , UTN: U111112552081, and at Plataforma Brasil: 38606820.6.0000.5243.Baseline clinical characteristics were similar in most parameters in the 2 groups . Howevesham) in the pre-intervention phase had a better quality of life (p= 0.013) and a tendency to better performance in the 6MWT , as displayed inGroup 2  and achieved a better SDNN  . There It was noted that SDNN in both groups before taVNS had similar levels, but analyzingshamgroup after 30 days of stimulation  or II (39.5%), and therefore the objective of evaluating the improvement in functional class in these patients lost its meaning. New studies involving the use of taVNS in the treatment of HF should exclude NYHA class I since the desired clinical benefit has already been achieved in these patients.taVNS is a safe, easy-to-perform intervention and can benefit HF by improving heart rate variability parameters (SDNN), which indicates better autonomic balance. In intragroup comparisons before and after treatment, improved quality of life and the 6-minute walk test in the taVNS group were also shown.Based on these results, one can suggest expanding the indication of auricular vagal neuromodulation in patients with HF, although new studies with a larger number of patients are needed to answer the questions raised by the present study."}
+{"text": "To investigate the effect of a voice and communication training program for oral presentations on higher education students.The proposed training program was based on the areas of social skills, voice projection techniques, and neurolinguistic programming. Thirty-eight students participated in the training with active learning methodologies at the university. Before and after the intervention, the participants recorded a short oral presentation on a topic of their choice. The recording was presented to the other participants and to a panel formed by three examiners (two articulation therapists and a psychologist), who evaluated the oral presentation performances. Moreover, each individual self-assessed their communication. The evaluation criteria covered the linguistic aspects, formal and non-formal, verbal and non-verbal communication, planning, and elaboration of the presentation.All participants improved their performance in oral presentations regarding verbal and para-verbal aspects, ability to keep the audience, emotional control, planning, objective, content, approach, organization, visual resource, form of presentation, language, and general elements .The proposed training program is effective in improving the performance of university students in oral presentations. In this context, communication is a fundamental skill to be developed and improved throughout academic and professional trajectory. Up to 89.3% of students would prefer that their undergraduate courses offered lessons on how to improve public speaking. Most people face difficulties in oral presentations, especially in the academic environment,6. The lack of mastering such a skill when presenting seminars leads students to not know how to speak, stand, gesture, or look at the audience. In other words, they do not know how to cope with a situation of exposure-8.Public speaking abilities might be a determinant for professional success since it is demanded by the market, becoming a professional skill.A survey involving 2,001 American universities reported an incompatibility between the perception of the newly graduated of their communication skills and the evaluation of their employers. While 80% of the newly graduated considered themselves prepared in terms of communication skills for the work market, only 44% of the employers considered that those skills were adequate for the work market. In addition, such skills predicted a 79.1% chance of a new graduate being hired. Vocal resources are linked to vocal quality and dynamics, including parameters such as pitch, loudness, intonation, accentuation, modulation, pauses, and rhythm, among others. Verbal resources are speech, the use of words, and the elaboration of speech. Non-verbal resources are body language, complemented by vocal resources and supporting visual signs,11.Communication takes place in a multimodal way, using verbal, vocal, and non-verbal resources.Communication situations such as public speaking, talking about matters outside our scope, or personal emotional topics might lead anxiety to manifest. Anxiety may emerge in situations of change, new experiences, and other common situations of human development. However, when anxiety is too intense, it can damage professional, academic, and social experiences. Public exposure situations may cause performance anxiety, described as a state of anxiety that emerges in particular conditions and can be considered a reaction to a stimulus. It is a transitory condition that occurs upon the confrontation with a given stimulus. Public speaking, acting, singing, playing a musical instrument in public, or competing in events are known examples of stimuli,3,8,12. Thus, training that allows these experiences and skills might improve performance in presentations, hence reducing complaints.In this sense, enhancing the experience and skill of coping with public speaking situations might soften negative impacts. NLP proposes the possibility of programming actions by using the language concerned primarily with reaching results. NLP works by identifying individual patterns, changing their responses to stimuli, and self-regulation. In addition, NLP covers techniques that enable oral presentations by making them common activities that can be performed by students.Neuro-linguistic programming (NLP) is based on neurosciences to emphasize that human behavior originates from neurological processes. It is an important set of skills based on the psychological features of human beings through which individuals achieve the competence of using their skills as much as possibleBased on this, this study aimed to investigate the effect of a voice and communication program on oral presentations in higher education students.The research project of this intervention study was subjected to and approved by the Human Research Ethics Committee (CEP \u2013 abbreviation in Portuguese) of the School of Dentistry of \u2013 University of S\u00e3o Paulo \u2013 FOB/USP, protocol number 2,820,877. All participants signed the informed consent form (TCLE), according to the CEP rules.The convenience sample included 38 higher education students from a public university in the state of S\u00e3o Paulo, 27 females and 11 males aged on average 21.8 years old. All students were in the first year of the Speech-Language Therapy (n=20), Medicine (n=15), and Dentistry (n=3) undergraduate courses.To recruit participants, the survey was shared at the university itself , as well as on social media profiles to which students had access. An e-mail address and telephone number were made available to those interested in taking part in the research. Those who got in touch received a registration form consisting of the following fields: personal details, interest, and willingness to take part in the research along with the necessary information about the research and a report on their main difficulties in oral presentations (such as seminars), as shown in Annex 1.. Before data collection, the participants received a free and informed consent form containing the research calendar  and instructions on the importance of attending all meetings, since otherwise would compromise the results.The participants were selected based on the following inclusion criteria: to be actively enrolled in the first year of undergraduate courses at the institution of origin in the year of the research project; to report difficulties in using linguistic and non-linguistic resources in oral presentations ; to be available and accept participating in all the proposed activities. The exclusion criterion was having taken any courses in oral expression or Neuro-linguistic Programming \u2013 NLPThe assessment was carried out through an assessment form named \u201cOral Presentation Assessment Form \u2013 OPF\u201d (Annex 2) based on an oral presentation using PowerPoint on a topic of choice of each participant, which was the same for both the pre- and post-presentation moments. The participant choosing the topic is for us to disregard the technical knowledge and mastery variable and analyze the quality of the oral presentation. Each participant had three minutes for the presentation.The examiners were calibrated together the week before at a three-hour training meeting, during which the researcher presented the research proposal, all the items on the assessment form were discussed and any doubts were clarified.The assessment was conducted in two steps: one week before training and one week after the training, considered as pre- and post-intervention, respectively, using the OPF (Annex 2), developed by the researchers and introduced in the item Instruments.For a blind assessment, three independent examiners were invited. The assessment panel consisted of two articulation therapists, a language specialist (with extensive experience in linguistics), a voice specialist, and a psychologist with experience in social skills.The oral presentations in the pre- and post-intervention steps were recorded for the self-assessment. The footage was provided to the study participants for them to watch and assess their performance. Along with the footage, we provided the self-assessment form, composed of two parts that should be filled in distinct moments. The footage of the pre-intervention moment was provided one week after the first meeting, and the participants had two weeks to fill out the self-assessment form. The footage of the post-intervention was only provided one week after the last meeting, and the participants had two weeks to fill out the self-assessment form.The same assessment criterion by the examiners was considered for ruling \u201cimprovement, worsening, or neutrality\u201d. The footage was performed in full HD using the Handycam Sony Hdr-CX405 HD equipment and provided to the participants via share drive. Each participant had access only to their respective footage.. Upon literature review, the form needed to be elaborated since no other validated protocols were found that assessed each participant\u2019s performance according to the demands of our study. The presentation must be analyzed by focusing on the items addressed in the support material, which was provided to and worked with the research participants.The \u201cOral Presentation Assessment Form \u2013 OPF\u201d (Annex 2) was elaborated by the researchers in this study before the start of the intervention, based on protocols of similar assessmentsThe same form was used both in the pre- and post-intervention assessments, and the examiners could not access the pre-intervention form any longer at the post-intervention step to prevent one assessment from influencing the other. The form consists of two parts, both containing qualitative and quantitative criteria since both were assigned numerical values in the final  analysis, as follows:Part I \u2013 The following elements were assessed: linguistic criteria  and communication  complementary elements., loudness, eye contact, smiling when suitable, adequate posture, keeping the audience, and emotional control. All these components were subjected to a Likert scale ranging \u201calways\u201d (assigned with a score of 5), \u201coften\u201d (score 4), \u201csometimes\u201d (score 3), \u201crarely\u201d (score 2), and \u201cnever\u201d (score 1).The following components of the linguistic criteria were considered: vocabulary, grammar, pronunciation, intonation, pauses, and mean presentation time. The following communication complementary  were considered: articulationPart II \u2013 Covering the general aspects of oral presentation, to which scores from 0 (zero) to 10 (ten) were assigned, as follows: planning, content, approach, organization, visual resource, Form of presentation, emotional control, language, and general assessment. The analysis criterion was assigned a score between 0 (unprepared) to 10 (excellent).For an \u2018improvement\u2019 to be ruled, the individual must increase at least one level in the Likert scale of the OPF and at least one point in the score by comparing the pre- and post-intervention steps with the General Assessment. In turn, for a \u2018worsening\u2019 to be ruled, the individual must decrease a level in the Likert scale and one point in the score. Finally, for \u2018neutrality\u2019 to be ruled, the individual must keep the same score based on the examiner\u2019s mean., which aims to self-assess cognitive aspects in situations where public speaking is a stressor. The SSPS is a self-administered instrument consisting of two sub-scales, positive self-assessment, and negative self-assessment, each with five items scored on a scale from zero to five, according to the original description of the scale. Participants were asked to fill in the scale as soon as they had finished presenting, as they needed to describe their real feelings about the situation of being exposed in public.The first part consisted of the Scale for Self-Evaluation during Public Speaking (Annex 3), an adaptation of the \u201cSelf-statements during Public Speaking Scale \u2013 SSPS\u201dThe SSPS scale has two subdivisions: positive (SSPS-P) and negative (SSPS-N) self-affirmations. The participants must choose the score with which they most related, from 0 (strongly disagree with the statement) to 5 (strongly agree with the statement). The items of the SSPS linked to aspects regarded as positive in the self-assessment are those numbered 1, 3, 5, 6, and 9, whereas those regarded as negative are items 2, 4, 7, 8, and 10. Thus, there are ten items on the self-assessment scale (five positive and five negative).The second part of the self-assessment instrument for this survey was designed by the researchers, based on the second part of the \u201cOPF\u201d, so that the participants and judges could assess the same variables. Participants had to answer this part by assessing their performance after watching their footage. The footage was made available to each participant, and each only had contact with their footage, which was not made available to the others.,17,18, neurolinguistic programming tools,19, and vocal projection and expressiveness techniques,15,17,20 as theoretical references. The taxonomic model of communication training used was based , so that they could access it whenever necessary throughout the training period.This research was conducted over eight weeks at the hours that were convenient to all participants.-3The intervention program consisted of ten meetings with theoretical and practical content, weekly, with each meeting lasting an average of two hours. However, the first meeting was held a month before the intervention started to explain the research and sign the consent forms. The last meeting was held to give the participants feedback on their performance. The total number of meetings was to ensure that the participants completed the training within the agreed timeframe of one semester in higher education, as well as based on the results of the abovementioned pilot study and other communication surveysThe research location was one of the classrooms of the studied university, which is a large space that holds up to 50 students, with mobile chairs for various uses depending on the training dynamics. We performed a descriptive and inferential statistical analysis using the Statistic 10.0 program. Since most of the time the normality test did not show a normal distribution, the Wilcoxon non-parametric test was applied. The significance level of p\u22640.05% was adopted.Next, we describe the results of 38 participants included for data analysis. We only considered the data from participants who completed the training, with no absences (100% attendance). Although 42 individuals were registered at the start, four (9.5%) of them took the training but had their outcomes disregarded due to two absences throughout the intervention.The results below describe the assessment by the examiners by comparing the pre- and post-intervention analyses. In The most frequent complaints by the participants regarding public speaking were nervousness (76%), insecurity (74%), anxiety (68%), not being able to convey/express what they want to say (63%), fear of forgetting or making mistakes (60%), followed by shyness (53%), knowing the best posture (53%), being embarrassed to speak in public (50%), speaking clearly (50%), projecting the voice correctly (42%), among others (8%).The results in The proposed training program was effective in improving the communication skills of university students. All variables measured linked to verbal and non-verbal resources improved after the training both by the examiners' and students\u2019 perceptions. It is worth noting that among the qualitative elements analyzed by the examiners, the most highlighted improvement occurred for eye contact, smiling when suitable, and adequate posture during presentation. As to the quantitative aspects, the most highlighted improvement occurred in approach, presentation organization, the language used, and the form of presentation.,10.Despite the greater improvement perceived by the students in their self-assessments coincided, in qualitative terms, with the examiners\u2019 assessment for the items of presentation organization and language, most of these students perceived a greater improvement in emotional control and their general assessment . Prior research has also reported that the same aspects mentioned by both the examiner and the participants in this study are complementary, which means that usual emotions influence facial expression, voice, and body posture,19,23-25 integrated into a prior didactic material that provided the basis for both the training development and the support material to instruct on the use of linguistic resources in oral presentations for higher education students. Specifically, the items of body posture and facial expression showed a significant improvement, both according to the examiners and the participants. Such a result is based on the mean values reached through greater eye contact, smiling when suitable during the presentation, and body posture by comparing the pre- and post-intervention assessments described herein, which corroborates findings of similar studies in fields related to training and communication,13,14,19.Our study covered techniques and tools from different fields,19,23 demonstrates that throughout communication, emotion can be expressed both consciously and unconsciously through elements such as linguistic utterance, paralinguistic features, or vocal features. Our study corroborates such information more specifically through the participants\u2019 self-assessment, who reported better emotional control by comparing the means before and after the training.When working with human communication, emotion is an important factor in conveying the intention convincingly, hence being a relevant part of natural, spontaneous human communication. The literature, these complaints might result from a lack of speaking practice, insufficient knowledge on the topic, and negative self-image, with the lack of experience as the most important factor,23, which led the training herein proposed to reach positive outcomes.Such a positive self-assessment of the participants\u2019 emotional aspect is significant since their most frequent complaints before starting the intervention, which supported their decision to participate in the training, were nervousness, insecurity, anxiety, and not being able to convey/express what they want to say. According to a prior study \u2013 indicated that the positive self-affirmations increased significantly. In turn, the negative affirmations about their presentations also decreased significantly, thus reinforcing the results of other studies,8,22. Such studies have pointed out that a negative self-image influences oral presentations, whereas when the individual feels prepared, this self-image tends to improve.Still regarding self-image, the self-assessment by the participants \u2013 shown in one of the instruments,14,19 as a tool for developing the teaching material and training, in addition to proposing the exercise of mental state change,19,26 by directing the effort toward social skills to promote greater confidence and encouraging during the presentation.Based on such a consideration regarding the self-image of a good communicator, we chose to follow the assumptions of Neuro-linguistic Programming \u2013 NLP,26, the proposed training gave the participants a theoretical introduction to how a presentation should be designed for different types of audiences and the importance of reaching everyone. This concept was later named in the assessment, as in similar studies,12,27, as \u201cmaking eye contact with everyone present\u201d and \u201cability to maintain the audience\u2019s interest\u201d, considered within the \u201cgeneral\u201d criterion. These aspects were rated similarly in terms of post-intervention improvement by both the judges and the participants themselves, being items with the most significant changes, as shown by the results obtained in studies with similar populations,12,27.To make the change in mental state possible,20,23. These activities simulated oral exposition situations of voice projection, pauses, posture, gestures, and other linguistic and communication skills, as suggested in the literature,24,27-29.The training worked the communication skills through practical activities in which the participants performed voice and body exercises based on the relationship between voice and communication skills pointed out in studies of the field,20, enhancing the articulation pattern, favoring voice projection, softening emission, and,28,29 improving the pneumo-phonoarticulatory coordination and promoting greater balance of voice production.We believe that the improvement in elements such as articulation, loudness, intonation, pauses, and average presentation time reached with the proposed training is linked to the use of specific vocal techniques aimed at, according to studies in the field, and working together with all these variables enables communication that is appropriate to the context and discourse. It also allows them to improve their self-image and the speaker\u2019s communication, which is corroborated in studies not only with similar populations such as university students,12,27 but also with other populations, including those involving other professionals,2,7,20.These skills  are part of expressivenessThe study participants\u2019 improvement in vocabulary, grammar, and the use of pronouns may have been brought about by the language content covered in the first and last chapters of the theoretical-practical material prepared for the training. The material guided the way of speaking, word choice, and regency so that the students would be aware of these aspects when giving an oral presentation.,17,18,20 as observable and measurable behaviors. The focus is moved from merely emotional matters initially reported by the participants, such as fear and anxiety about public speaking,16,23,30.For the speaker to have a larger view on their performance, the relationship among all aspects involved in communication must be addressed, such as language, voice, communicative skill, linguistic and non-linguistic genders used when communicating, as well as focusing on their social skills,3,7,22, such as facilitating self-regulation, providing a sense of self-continuity, speeding up the processing of relevant information, helping to set goals, influencing social perception, and contributing to the projection of a consistent and desirable self-image to others.The self-assessment included in the study brought important results, with several positive implications for the individual, as pointed out in similar studiesThe participants in this study pointed to an improvement in \u201cplanning\u201d, \u201cobjectives\u201d, \u201ccontent\u201d, \u201capproach\u201d, \u201corganization\u201d, and \u201cvisual resources\u201d in their self-assessment, either because of training addressing how to structure research and presentation \u2013 using basic concepts of research methodology and presentation \u2013 or because of the focus on the theoretical and practical preparation for presentation. Such a result corroborates other studies reporting that preparing for the topic, like mastering the theme, coherence, scientific background, and Form of presentation, might decrease the fear of public speaking by 75%.,30.Knowledge of the content directly affects the style the presenter conducts it, demonstrating a greater or lesser degree of confidence and critical handling of the content to engage the audience, as shown in previous worksAnother aspect to be discussed is the Self-Assessment Scale for Public Speaking (SSPS). Since a limitation of this study was the absence of validated questionnaires that included the items required to assess the participants\u2019 performance according to the demands of the study, the SSPS scale was translated and adapted to the needs of the research.As for the results of the scale, the scores show that by increasing the SSPS-P (positive self-affirmations) subscale score and decreasing the SSPS-N (negative self-affirmations) subscale score, the participants became more self-confident and able to face the public speaking situation and showed to be less anxious and better prepared after taking the communication training.,19 that used the same scale have highlighted that negative self-affirmations might be more closely associated with anxiety about public speaking than positive self-affirmations. Such a scenario might indicate that by pointing out negative self-affirmations less often, the participants become less prone to reaffirming or increasing their anxiety about public speaking and even evolving into a social phobia or related anxiety disorder. Studies in the field,22,23,26 have reported that training for public exposure and communication, such as cognitive-behavioral techniques and social skills, are effective in treating social phobias related to the fear of public speaking.Studies aimed at analyzing a speech therapy intervention for university students in seminar presentations showed positive effects on oral aspects and better confidence perception by the participants when better reaching their audiences. The examiner speech therapists in the above-mentioned study observed advances regarding oral, body, and interaction aspects. Thus, our general results corroborate such findings and open a reflection on why this fear is still one of the most prevalent among university students. Is it not the role of universities to prepare students for this activity?The results of a study-3, it is worth reflecting on how it has handled this training.Every year, thousands of students are admitted to universities in search of a profession, and, during their training, they encounter tasks that demand intellectual growth and the improvement of skills, such as public speaking. If a higher education institution believes that it needs to prepare its students to communicate effectively in their future professional environments.Should intervention programs on oratory and improving oral communication performance not be part of the professional training curriculum? Training professionals for the job market should focus on teaching skills and abilities beyond the technical content of a given profession. Universities need to provide the conditions for students to learn not only about the content of the profession but also about the behavioral requirements of the job they have chosenA limitation of this study might be including students from only one educational institution (despite three undergraduate courses). However, as the participants improved their performance in all aspects analyzed after the intervention, the proposed training proved applicable as an auxiliary tool for the planning and improvement of communication training for such a population. Therefore, our research contributes to speech therapists proposing training programs and speech therapy consultancy in the area at universities, representing a promising professional field.We suggest that similar studies using the training proposed here be developed in other higher education institutions. The goal is that this study can contribute to the teaching of skills and abilities beyond technical content within universities. We also expect this material to be able to integrate subject content at various universities and provide support for university students in the area of communication.The proposed training program was effective in improving the communication skills of university students in oral presentations. There has been an improvement \u2013 from the perspective of both the examiners and the participants \u2013 in skills linked to the verbal and non-verbal resources used, as well as in the qualitative aspects, such as eye contact, smiling when suitable, and adequate posture during the presentation. In addition, the quantitative aspects also improved, such as presentation organization, language used, and visual resources.In the self-assessment, the students participating in the study also reported improved emotional control during the oral presentations and in their overall evaluations after the training, including the clarity of the message, whether the goals were met, and whether it was interesting, enjoyable/informative, or thought-provoking. -4. Nesse contexto, a comunica\u00e7\u00e3o \u00e9 uma habilidade essencial a ser desenvolvida e aprimorada durante a vida acad\u00eamica e profissional. Demonstra-se que at\u00e9 89,3% dos estudantes gostariam que seu programa de gradua\u00e7\u00e3o inclu\u00edsse aulas para melhorar a modalidade de comunica\u00e7\u00e3o em p\u00fablico. A maioria das pessoas apresenta dificuldades em se expor em apresenta\u00e7\u00f5es orais, principalmente no meio acad\u00eamico,6. Por n\u00e3o o dominarem \u00e9 comum que os alunos em situa\u00e7\u00e3o de semin\u00e1rio n\u00e3o saibam como falar, como se posicionar, gesticular, como olhar para as pessoas, ou seja, n\u00e3o sabem como agir diante da situa\u00e7\u00e3o de exposi\u00e7\u00e3o-8.A compet\u00eancia de falar em p\u00fablico pode ser um dos determinantes do sucesso profissional. Faz parte da exig\u00eancia do mercado de trabalho e passa a ser uma qualifica\u00e7\u00e3o profissional.Uma pesquisa com 2.001 universidades americanas demonstrou que havia uma incompatibilidade entre a percep\u00e7\u00e3o dos rec\u00e9m-formados quanto \u00e0s suas habilidades de comunica\u00e7\u00e3o e a avalia\u00e7\u00e3o dos empregadores. Enquanto 80% dos rec\u00e9m-formados consideravam que estavam preparados em termos de habilidades de comunica\u00e7\u00e3o para o mercado de trabalho, apenas 44% dos empregadores consideram que essas habilidades estavam adequadas para o mercado de trabalho. Al\u00e9m disso, observou-se que essas habilidades prediziam em 79,1% a chance de um rec\u00e9m-formado ser contratado. Os recursos vocais s\u00e3o relacionados \u00e0 qualidade e din\u00e2mica vocal, incluindo par\u00e2metros como pitch, loudness, entona\u00e7\u00e3o, acentua\u00e7\u00e3o, modula\u00e7\u00e3o, pausas, ritmo, entre outros. Os recursos verbais s\u00e3o a fala propriamente dita, uso de palavras e elabora\u00e7\u00e3o do discurso. Os recursos n\u00e3o verbais s\u00e3o a linguagem corporal, sendo complementados pelos recursos vocais e signos visuais de apoio,11.A comunica\u00e7\u00e3o acontece de maneira multimodal, por meio de recursos verbais, vocais e n\u00e3o verbais.Situa\u00e7\u00f5es de comunica\u00e7\u00e3o como o falar em p\u00fablico, falar de assuntos que n\u00e3o domina ou de conte\u00fados emocionais relacionados ao lado pessoal s\u00e3o potencialmente propensos \u00e0 manifesta\u00e7\u00e3o de ansiedade nas pessoas. A ansiedade pode ocorrer frente a situa\u00e7\u00f5es de mudan\u00e7as, de experi\u00eancias novas, e outras situa\u00e7\u00f5es habituais do desenvolvimento humano. Por\u00e9m, quando a ansiedade \u00e9 muito intensa, ela pode gerar preju\u00edzos na vida profissional, acad\u00eamica e social das pessoas. As situa\u00e7\u00f5es de exposi\u00e7\u00e3o em p\u00fablico podem causar a ansiedade de desempenho, descrita como um estado de ansiedade que ocorre em condi\u00e7\u00f5es particulares e pode ser considerada como uma rea\u00e7\u00e3o a um est\u00edmulo. \u00c9 uma condi\u00e7\u00e3o transit\u00f3ria e ocorre durante o confronto com um est\u00edmulo espec\u00edfico. Falar em p\u00fablico, atuar, cantar ou tocar um instrumento musical em p\u00fablico ou competir em eventos s\u00e3o exemplos de est\u00edmulos conhecidos,3,8,12. Portanto, treinamentos que possibilitem essas experi\u00eancias e o desenvolvimento de tais habilidades podem melhorar o desempenho nas apresenta\u00e7\u00f5es e, consequentemente, minimizar as queixas.Nesse contexto, o aumento da experi\u00eancia e da capacidade de lidar com situa\u00e7\u00f5es de falar em p\u00fablico pode suavizar os impactos negativos. A PNL prop\u00f5e a possibilidade de programar a a\u00e7\u00e3o das pessoas por meio do uso da linguagem, importando-se primariamente com a obten\u00e7\u00e3o de resultados. Atua identificando os padr\u00f5es das pessoas, alterando suas respostas aos est\u00edmulos e sua autorregula\u00e7\u00e3o. Al\u00e9m disso, apresenta t\u00e9cnicas que facilitam as apresenta\u00e7\u00f5es orais, pois torna as atividades habituais e podem ser empregadas pelos estudantes.A programa\u00e7\u00e3o neurolingu\u00edstica (PNL) embasada nas Neuroci\u00eancias enfatiza que o comportamento humano se origina de processos neurol\u00f3gicos. A sua import\u00e2ncia est\u00e1 no fato de que \u00e9 um conjunto de habilidades baseadas nas caracter\u00edsticas psicol\u00f3gicas dos seres humanos, por meio das quais os indiv\u00edduos obt\u00eam a compet\u00eancia de usar suas capacidades pessoais tanto quanto poss\u00edvelCom base no exposto, o objetivo do presente estudo foi investigar o efeito de um programa de treinamento em voz e comunica\u00e7\u00e3o para apresenta\u00e7\u00f5es orais em estudantes de Ensino Superior.Trata-se de um estudo de interven\u00e7\u00e3o, sendo que o projeto da pesquisa foi submetido e aprovado sob n\u00famero de protocolo 2.820.877 pelo Comit\u00ea de \u00c9tica em Pesquisa em Seres Humanos (CEP) da Faculdade de Odontologia de Bauru - Universidade de S\u00e3o Paulo - FOB/USP e todos os participantes assinaram o termo de consentimento livre e esclarecido (TCLE), conforme normas do CEP.Foi constitu\u00edda uma amostra por conveni\u00eancia de 38 estudantes de Ensino Superior de uma Universidade P\u00fablica do Estado de S\u00e3o Paulo, sendo 27 do sexo feminino e 11 do sexo masculino com a faixa et\u00e1ria m\u00e9dia de 21,8 anos. Todos alunos do 1\u00ba ano de Gradua\u00e7\u00e3o dos cursos: Fonoaudiologia (n=20), Medicina (n=15) e Odontologia (n=3).Para recrutar os participantes, a pesquisa foi divulgada na pr\u00f3pria universidade , assim como foram utilizadas divulga\u00e7\u00f5es nas redes sociais em perfis aos quais os alunos tivessem acesso. Foi disponibilizado um e-mail e telefone para contato aos interessados em participar da pesquisa. Aos que entraram em contato, foi disponibilizada uma ficha de cadastro composta pelos campos: dados pessoais, interesse e disponibilidade em participar da pesquisa com as informa\u00e7\u00f5es necess\u00e1rias sobre sua realiza\u00e7\u00e3o e, por \u00faltimo, o participante tinha que relatar quais suas principais dificuldades nas apresenta\u00e7\u00f5es orais , conforme ficha de cadastro dispon\u00edvel no Anexo 1.. Foi entregue um termo de compromisso para os participantes com o calend\u00e1rio da pesquisa  antes da coleta de dados iniciar, explicando a import\u00e2ncia de n\u00e3o haver falta em nenhum dos encontros, dado o comprometimento que isso acarretaria nos resultados do estudo.Para selecionar os participantes, foram estabelecidos os seguintes crit\u00e9rios de inclus\u00e3o: cursar, com matr\u00edcula ativa, o primeiro ano dos Cursos de Gradua\u00e7\u00e3o na institui\u00e7\u00e3o de origem no ano de desenvolvimento da pesquisa; relatar dificuldades em usar recursos lingu\u00edsticos e n\u00e3o lingu\u00edsticos para se apresentar oralmente ; ter disponibilidade e aceitar participar de todas as atividades propostas. O crit\u00e9rio de exclus\u00e3o foi ter realizado algum curso de express\u00e3o oral ou Programa\u00e7\u00e3o Neurolingu\u00edstica - PNLA avalia\u00e7\u00e3o foi realizada por meio de uma ficha de avalia\u00e7\u00e3o denominada \u201cFormul\u00e1rio de avalia\u00e7\u00e3o da apresenta\u00e7\u00e3o oral - FAO\u201d (Anexo 2), com base em uma apresenta\u00e7\u00e3o oral sobre t\u00f3pico da pr\u00f3pria escolha em PowerPoint, previamente selecionada por cada participante, sendo o mesmo para os momentos de avalia\u00e7\u00e3o pr\u00e9 e p\u00f3s-interven\u00e7\u00e3o. Justifica-se a escolha do tema ser realizada pelo participante para se excluir a vari\u00e1vel conhecimento e dom\u00ednio t\u00e9cnico e observar a qualidade da apresenta\u00e7\u00e3o oral. Cada participante teve tr\u00eas minutos para apresenta\u00e7\u00e3o.A calibra\u00e7\u00e3o dos ju\u00edzes foi realizada na semana pr\u00e9via em conjunto, em reuni\u00e3o de treinamento com dura\u00e7\u00e3o de tr\u00eas horas, na qual a pesquisadora apresentou a proposta da pesquisa e foram discutidos todos os itens do formul\u00e1rio de avalia\u00e7\u00e3o e esclarecidas as d\u00favidas.A avalia\u00e7\u00e3o foi realizada em dois momentos: uma semana antes do in\u00edcio do treinamento e uma semana ap\u00f3s o final do treinamento, considerados como pr\u00e9 e p\u00f3s-interven\u00e7\u00e3o, com uso do FAO (Anexo 2), constru\u00eddo pelas pesquisadoras e explicado no item Instrumentos.Para que a avalia\u00e7\u00e3o fosse de forma cega, foram convidados tr\u00eas ju\u00edzes n\u00e3o autores do estudo. Dessa forma, a banca avaliadora foi formada por dois fonoaudi\u00f3logos, um especialista na \u00e1rea de linguagem (com vasta experi\u00eancia na \u00e1rea de Lingu\u00edstica), outro especialista em voz e um psic\u00f3logo com experi\u00eancia em habilidades sociais.Tamb\u00e9m foram realizadas filmagens das apresenta\u00e7\u00f5es orais realizadas nos momentos de pr\u00e9 e p\u00f3s-interven\u00e7\u00e3o para a autoavalia\u00e7\u00e3o. As filmagens foram disponibilizadas aos participantes do estudo para que pudessem assistir e julgar seu desempenho. Junto \u00e0s filmagens, foi disponibilizado um formul\u00e1rio de autoavalia\u00e7\u00e3o, que possu\u00eda duas partes, as quais deveriam ser preenchidas em momentos diferentes. As filmagens do momento pr\u00e9 foram disponibilizadas uma semana ap\u00f3s o primeiro encontro, e os participantes tiveram o prazo de duas semanas para preencher o formul\u00e1rio de autoavalia\u00e7\u00e3o. As filmagens do momento p\u00f3s foram disponibilizadas uma semana ap\u00f3s o \u00faltimo encontro, e os participantes tamb\u00e9m tiveram o prazo de duas semanas para o preenchimento.Para considerar \u201cmelhora, piora ou neutralidade\u201d, considerou-se o mesmo crit\u00e9rio da avalia\u00e7\u00e3o dos ju\u00edzes. As filmagens foram realizadas com o equipamento Handycam Sony Hdr-CX405 HD, em full HD e disponibilizadas aos participantes via drive de compartilhamento. Cada participante tinha acesso apenas \u00e0s suas pr\u00f3prias filmagens.. Foi necess\u00e1ria a elabora\u00e7\u00e3o desse formul\u00e1rio, pois n\u00e3o foram encontrados protocolos validados que avaliassem a performance de cada participante de acordo com a necessidade deste estudo no momento da revis\u00e3o de literatura realizada. Tal fato se justifica uma vez que a an\u00e1lise da apresenta\u00e7\u00e3o teria que focar os itens trabalhados no material de apoio que foi disponibilizado e trabalhado com os participantes da pesquisa.O \u201cFormul\u00e1rio de avalia\u00e7\u00e3o da apresenta\u00e7\u00e3o oral - FAO\u201d (Anexo 2) foi elaborado pelas pesquisadoras deste estudo antes do in\u00edcio da interven\u00e7\u00e3o, baseado em protocolos de avalia\u00e7\u00e3o semelhantesO mesmo formul\u00e1rio foi utilizado na avalia\u00e7\u00e3o pr\u00e9 e p\u00f3s-interven\u00e7\u00e3o e os avaliadores n\u00e3o tiveram mais contato com o formul\u00e1rio da pr\u00e9-interven\u00e7\u00e3o no momento da p\u00f3s-interven\u00e7\u00e3o, para que n\u00e3o houvesse influ\u00eancia de uma avalia\u00e7\u00e3o sobre a outra. O formul\u00e1rio apresenta duas partes, ambas com crit\u00e9rios qualitativos e quantitativos, dado que a ambos foram atribu\u00eddos valores num\u00e9ricos na an\u00e1lise final (estat\u00edstica), sendo:Parte I - em que constam os seguintes aspectos a serem avaliados: Crit\u00e9rios lingu\u00edsticos (aspectos formais e informais) e Aspectos complementares \u00e0 comunica\u00e7\u00e3o (n\u00e3o-verbais)., Loudness, Contato Visual, Sorrir quando apropriado, Postura Adequada, Manter a Audi\u00eancia, Controle Emocional. Para esses, o crit\u00e9rio de an\u00e1lise era uma Escala Likert que variava de \u201cSempre\u201d , \u201cFrequentemente\u201d , \u201cAs vezes\u201d , \u201cRaramente\u201d  e \u201cNunca\u201d .Os componentes que compuseram os crit\u00e9rios lingu\u00edsticos considerados foram Vocabul\u00e1rio, Gram\u00e1tica, Pron\u00fancia, Entona\u00e7\u00e3o, Pausas, M\u00e9dia de Tempo da apresenta\u00e7\u00e3o. Os aspectos complementares \u00e0 comunica\u00e7\u00e3o (n\u00e3o-verbais) considerados foram Articula\u00e7\u00e3oParte II - em que constam os aspectos gerais da apresenta\u00e7\u00e3o oral, aos quais foram atribu\u00eddas notas de 0 (zero) a 10 (dez), que foram Planejamento, Conte\u00fado, Abordagem, Organiza\u00e7\u00e3o, Recurso Visual, Forma de Apresenta\u00e7\u00e3o, Controle Emocional, Linguagem, Avalia\u00e7\u00e3o Geral. O crit\u00e9rio de an\u00e1lise era a atribui\u00e7\u00e3o de uma nota de 0 (despreparado) a 10 (excelente).Para ser considerada \u201cmelhora\u201d o indiv\u00edduo deveria subir pelo menos um n\u00edvel da escala de Likert na FAO e o m\u00ednimo de um ponto na nota, comparando pr\u00e9 e p\u00f3s-interven\u00e7\u00e3o na Avalia\u00e7\u00e3o Geral. Para considerar \u201cpiora\u201d no desempenho, deveria diminuir um n\u00edvel na escala Likert e um ponto na nota e, para ser considerado neutro, deveria se manter na mesma pontua\u00e7\u00e3o, considerando a m\u00e9dia dos ju\u00edzes., que visa \u00e0 autoavalia\u00e7\u00e3o dos aspectos cognitivos em situa\u00e7\u00f5es que tenham como estressor o falar em p\u00fablico. A SSPS \u00e9 um instrumento autoaplic\u00e1vel, composto de duas subescalas, a de autoavalia\u00e7\u00e3o positiva e a de autoavalia\u00e7\u00e3o negativa, cada qual com cinco itens pontuados numa escala de zero a cinco, de acordo com a descri\u00e7\u00e3o original da escala. Foi solicitado aos participantes que preenchessem a escala assim que terminassem de apresentar, pois era necess\u00e1rio que o estudante colocasse o real sentimento diante daquela situa\u00e7\u00e3o, que \u00e9 a de exposi\u00e7\u00e3o em p\u00fablico.A primeira parte foi composta pela Escala para Autoavalia\u00e7\u00e3o ao Falar em P\u00fablico (Anexo 3), adapta\u00e7\u00e3o do \u201cSelf Statements during Public Speaking Scale - SSPS\u201dA escala SSPS possui duas subdivis\u00f5es, sendo elas autoafirma\u00e7\u00f5es positivas (SSPS-P) e negativas (SSPS-N). Os participantes deviam assinalar cada quest\u00e3o com a nota que mais se identificassem, indo de 0  a 5 .A segunda parte do instrumento de autoavalia\u00e7\u00e3o dessa pesquisa foi elaborada pelas pesquisadoras, com base na segunda parte do \u201cFAO\u201d, para que os participantes e ju\u00edzes pudessem avaliar as mesmas vari\u00e1veis. Os participantes deveriam responder essa parte julgando seus desempenhos ap\u00f3s assistirem suas pr\u00f3prias filmagens. As filmagens eram disponibilizadas a cada participante, sendo que cada um tinha contato apenas com a sua filmagem, n\u00e3o sendo disponibilizadas aos demais.,17,18, ferramentas da programa\u00e7\u00e3o neurolingu\u00edstica,19 e t\u00e9cnicas de proje\u00e7\u00e3o vocal e expressividade,15,17,20. O modelo taxon\u00f4mico de treinamento de comunica\u00e7\u00e3o utilizado foi baseado , para que pudessem acess\u00e1-lo quando necess\u00e1rio ao longo do per\u00edodo de treinamento.A pesquisa foi realizada num per\u00edodo de oito semanas, sendo o hor\u00e1rio vi\u00e1vel a todos os participantes da pesquisa.-3O programa de interven\u00e7\u00e3o foi constitu\u00eddo por dez encontros com conte\u00fados te\u00f3rico-pr\u00e1ticos, em regime semanal, com dura\u00e7\u00e3o m\u00e9dia de duas horas cada encontro. Contudo, o primeiro encontro foi realizado um m\u00eas antes de a interven\u00e7\u00e3o iniciar, para a explica\u00e7\u00e3o da pesquisa e assinatura dos termos de consentimento. O \u00faltimo encontro foi realizado para o feedback do desempenho aos participantes. O n\u00famero total de encontros justifica-se para que os participantes conclu\u00edssem o treinamento dentro do tempo estipulado de um bimestre no Ensino Superior, e tendo como base tamb\u00e9m os resultados do estudo piloto mencionado e outros estudos de comunica\u00e7\u00e3o realizadosO local de realiza\u00e7\u00e3o foi uma das salas de aula da universidade, constitu\u00edda por um espa\u00e7o amplo, com lugares para at\u00e9 50 alunos, cadeiras m\u00f3veis permitindo uso vari\u00e1vel, dependendo das din\u00e2micas realizadas no treinamento. O detalhamento do programa de interven\u00e7\u00e3o est\u00e1 dispon\u00edvel no A an\u00e1lise estat\u00edstica foi realizada de forma descritiva e inferencial. Utilizou-se o Statistic 10.0. Foi aplicado o teste de normalidade e, pela grande maioria das vari\u00e1veis n\u00e3o ter apresentado distribui\u00e7\u00e3o normal, foi utilizado o teste n\u00e3o-param\u00e9trico, Teste de Wilcoxon. O n\u00edvel de signific\u00e2ncia adotado para os resultados deste estudo serem considerados significantes foi de p\u22640,05%.A seguir ser\u00e3o descritos os resultados dos 38 participantes considerados na an\u00e1lise de dados. S\u00f3 foram considerados os dados dos participantes que cumpriram o treinamento na totalidade, sem faltas (100% de presen\u00e7a). Embora no in\u00edcio, houvesse 42 inscritos, 4  deles realizaram o treinamento, mas tiveram os dados desconsiderados por terem uma ou duas faltas durante o per\u00edodo da interven\u00e7\u00e3o.Os resultados a seguir ilustram a avalia\u00e7\u00e3o realizada pelos ju\u00edzes, comparando a an\u00e1lise pr\u00e9 e p\u00f3s-interven\u00e7\u00e3o. A Na A As queixas mais frequentes dos participantes do estudo em rela\u00e7\u00e3o a falar em p\u00fablico foram: nervosismo (76%), inseguran\u00e7a (74%), ansiedade (68%), n\u00e3o conseguir transmitir/expressar o que quer falar (63%), medo de esquecer ou errar (60%). Na sequ\u00eancia vieram: timidez (53%), saber qual melhor postura (53%), vergonha de falar em p\u00fablico (50%), falar com clareza (50%), projetar corretamente a voz (42%), e outros (8%).Os resultados apresentados na A O programa de treinamento proposto foi efetivo para melhorar as habilidades de comunica\u00e7\u00e3o em estudantes universit\u00e1rios. Houve melhora em todas as vari\u00e1veis mensuradas relacionadas aos recursos verbais e n\u00e3o verbais ap\u00f3s o treinamento tanto na avalia\u00e7\u00e3o dos ju\u00edzes quanto na autopercep\u00e7\u00e3o dos estudantes. Importante notar que, dos aspectos qualitativos analisados pelos ju\u00edzes, a melhoria mais ressaltada foi a de contato visual, sorrir quando apropriado e postura adequada durante a apresenta\u00e7\u00e3o. Quanto aos aspectos quantitativos, foram \u00e0 abordagem, organiza\u00e7\u00e3o da apresenta\u00e7\u00e3o, a linguagem utilizada e a forma de apresentar dos participantes.,10.Embora a melhoria mais acentuada percebida pelos estudantes em suas autoavalia\u00e7\u00f5es tenha coincidido, em termos qualitativos, com a avalia\u00e7\u00e3o dos ju\u00edzes nos itens organiza\u00e7\u00e3o da apresenta\u00e7\u00e3o e linguagem, grande parte desses estudantes teve uma percep\u00e7\u00e3o maior na pr\u00f3pria melhora do controle emocional e em sua avalia\u00e7\u00e3o geral . Pesquisas anteriores tamb\u00e9m afirmam que os aspectos anteriormente citados tanto pelos ju\u00edzes quanto pelos participantes do estudo aqui relatados s\u00e3o complementares, ou seja, as emo\u00e7\u00f5es habituais influenciam na express\u00e3o facial, na voz e na postura corporal,19,23-25 integradas em um material did\u00e1tico previamente elaborado, que serviu tanto para a elabora\u00e7\u00e3o do treinamento quanto como material de apoio para instruir o uso dos recursos lingu\u00edsticos nas apresenta\u00e7\u00f5es orais, em alunos de ensino superior. Especificamente sobre a postura corporal e a express\u00e3o facial, no estudo aqui apresentado esses foram dois itens avaliados tanto pelos ju\u00edzes quanto pelos participantes como itens com melhora acentuada, dado os valores de m\u00e9dias alcan\u00e7ados, expressados pela aumento no contato visual, no uso de sorriso em momentos adequados da apresenta\u00e7\u00e3o e a postura corporal mantida durante a mesma, quando comparados os momentos de avalia\u00e7\u00e3o antes e ap\u00f3s o treinamento aqui descrito, o que confirma achados em estudos e trabalhos similares das \u00e1reas relacionadas a treinamentos de comunica\u00e7\u00e3o,13,14,19.O presente estudo trouxe t\u00e9cnicas e ferramentas de diferentes \u00e1reas,19,23 demonstra que, durante a comunica\u00e7\u00e3o, a emo\u00e7\u00e3o pode ser expressa tanto de forma consciente como inconsciente, por meio de aspectos como o pr\u00f3prio enunciado lingu\u00edstico, caracter\u00edsticas paralingu\u00edsticas ou caracter\u00edsticas vocais. Esse dado se confirma no estudo aqui apresentado mais especificamente na autoavalia\u00e7\u00e3o dos participantes, os quais citam aumento em seu controle emocional, quando comparadas as medias antes e ap\u00f3s o treinamento.Ao se trabalhar com a comunica\u00e7\u00e3o humana, a emo\u00e7\u00e3o \u00e9 um dos fatores importantes para transmitir a inten\u00e7\u00e3o de forma convincente. Dessa forma, \u00e9 uma parte importante de uma comunica\u00e7\u00e3o humana natural e espont\u00e2nea. A literatura, essas queixas podem ser decorrentes de falta de pr\u00e1tica ao falar, dom\u00ednio insuficiente do t\u00f3pico e autoimagem negativa, sendo a falta de experi\u00eancia o fator mais importante,23, o que fez com que o treinamento aqui proposto alcan\u00e7asse resultados positivos.Essa autoavalia\u00e7\u00e3o positiva do aspecto emocional dos participantes \u00e9 importante e significativa, dado que as queixas mais frequentes dos participantes do estudo antes de iniciar a interven\u00e7\u00e3o e que pautaram a decis\u00e3o para se inscreverem e participarem do treinamento foram exatamente o nervosismo, inseguran\u00e7a, ansiedade e n\u00e3o conseguir transmitir/expressar o que quer falar. Conforme estudo anterior, as autoafirma\u00e7\u00f5es positivas tiveram um acr\u00e9scimo significativo. As autoafirma\u00e7\u00f5es negativas em rela\u00e7\u00e3o \u00e0s suas apresenta\u00e7\u00f5es tiveram um decr\u00e9scimo tamb\u00e9m significativo, refor\u00e7ando os resultados de estudos,8,22. Aponta-se nesses estudos que a autoimagem negativa impacta as apresenta\u00e7\u00f5es orais e que, quando o indiv\u00edduo se sente preparado, essa autoimagem tende a melhorar.Ainda sobre a autoimagem, na autoavalia\u00e7\u00e3o realizada pelos participantes e evidenciada por um dos instrumentos,14,19 como uma das ferramentas para elaborar o material did\u00e1tico e o treinamento, al\u00e9m de propor exercitar tamb\u00e9m a mudan\u00e7a de estado mental,19,26, pelo trabalho direcionado \u00e0s habilidades sociais, trazendo maior seguran\u00e7a e encorajamento na hora da apresenta\u00e7\u00e3o.Dada essa considera\u00e7\u00e3o em rela\u00e7\u00e3o a autoimagem de um bom comunicador, optou-se por seguir os pressupostos da Programa\u00e7\u00e3o Neurolingu\u00edstica - PNL,26, no treinamento proposto, os participantes tiveram uma parte te\u00f3rica sobre como uma apresenta\u00e7\u00e3o deve ser elaborada para diferentes tipos de p\u00fablico e a import\u00e2ncia da abrang\u00eancia de todos. Esse conceito foi posteriormente denominado na avalia\u00e7\u00e3o, assim como em estudos similares,12,27, como \u201cfazer contato de olhos com todos os presentes\u201d, \u201ccapacidade de manter o interesse da audi\u00eancia\u201d e tamb\u00e9m foi considerado dentro do crit\u00e9rio \u201cgeral\u201d. Tais aspectos tiveram similar avalia\u00e7\u00e3o quanto \u00e0 melhora na p\u00f3s-interven\u00e7\u00e3o tanto pelos ju\u00edzes quanto pelos pr\u00f3prios participantes, sendo itens com as mudan\u00e7as mais significativas, como os resultados obtidos nas pesquisas com popula\u00e7\u00f5es similares mostram,12,27.Para que a mudan\u00e7a de estado mental fosse poss\u00edvel,20,23. Essas atividades simularam situa\u00e7\u00f5es de exposi\u00e7\u00e3o oral com treinamento de proje\u00e7\u00e3o vocal, pausas, postura, gestos, e outras habilidades lingu\u00edsticas e comunicativas, como sugerido na literatura,24,27-29.No treinamento, as habilidades comunicativas foram trabalhadas por meio de atividades pr\u00e1ticas, nas quais os participantes realizaram exerc\u00edcios vocais e corporais, dadas as rela\u00e7\u00f5es entre voz e compet\u00eancia comunicativa demonstradas em trabalhos da \u00e1realoudness, entona\u00e7\u00e3o, pausas e da m\u00e9dia de tempo de apresenta\u00e7\u00e3o alcan\u00e7ados no treinamento aqui proposto deve-se \u00e0 utiliza\u00e7\u00e3o de t\u00e9cnicas vocais espec\u00edficas que tem como objetivos, segundo trabalhos da \u00e1rea de voz,20, melhorar o padr\u00e3o articulat\u00f3rio, favorecer a proje\u00e7\u00e3o vocal, suavizar a emiss\u00e3o e, ainda,28,29, melhorar a coordena\u00e7\u00e3o pneumofonoarticulat\u00f3ria e promover maior equil\u00edbrio da produ\u00e7\u00e3o vocal.Acredita-se que a melhora nos aspectos como articula\u00e7\u00e3o, loudness, contato visual, sorrir quando apropriado, postura adequada, manter a audi\u00eancia, entona\u00e7\u00e3o e pausas) integram a expressividade, sendo que o trabalho conjunto com todas essas vari\u00e1veis possibilita uma comunica\u00e7\u00e3o adequada ao contexto e ao discurso. Al\u00e9m disso, possibilita aprimorar a autopercep\u00e7\u00e3o sobre si mesmo e sobre a comunica\u00e7\u00e3o do falante, o que \u00e9 corroborado em estudos n\u00e3o somente com popula\u00e7\u00f5es similares como estudantes universit\u00e1rios,12,27, mas com outras popula\u00e7\u00f5es, inclusive envolvendo outros profissionais,2,7,20.Essas habilidades , seja na \u00eanfase dada \u00e0 uma prepara\u00e7\u00e3o te\u00f3rica e pr\u00e1tica da apresenta\u00e7\u00e3o, confirmou estudos que mostram que essa pr\u00e9via prepara\u00e7\u00e3o sobre o tema - como dom\u00ednio do assunto, a coer\u00eancia, o embasamento cient\u00edfico e a forma de conduzir a apresenta\u00e7\u00e3o - pode diminuir at\u00e9 75% o medo de falar em p\u00fablico.,30.O conhecimento do conte\u00fado afeta diretamente o estilo como ele \u00e9 conduzido pelo apresentador, podendo demonstrar maior ou menor grau de seguran\u00e7a e manejo cr\u00edtico do conte\u00fado, de forma a envolver a audi\u00eancia, conforme afirmam trabalhos anterioresOutro aspecto a ser discutido \u00e9 a Escala para Autoavalia\u00e7\u00e3o ao Falar em P\u00fablico (SSPS), pois uma das limita\u00e7\u00f5es desse estudo foi o fato de n\u00e3o serem encontrados question\u00e1rios validados que contemplassem os itens necess\u00e1rios para avaliar a performance dos participantes de acordo com a necessidade do estudo, portanto a escala SSPS foi traduzida e adaptada \u00e0s necessidades da pesquisa.Quanto aos resultados de aplica\u00e7\u00e3o da escala, analisando os seus escores, evidencia-se que, ao aumentar a pontua\u00e7\u00e3o da subescala SSPS-P (auto afirmativas positivas) e, ao diminuir a da SSPS-N (auto afirmativas negativas), os participantes se tornaram mais autoconfiantes e capazes de enfrentar a situa\u00e7\u00e3o de exposi\u00e7\u00e3o em p\u00fablico e tamb\u00e9m demostraram estar menos ansiosos, mais autoconfiantes e preparados ao passarem pelo treinamento de comunica\u00e7\u00e3o.,19 que utilizaram a mesma escala ressaltam que as autoafirma\u00e7\u00f5es negativas podem estar mais intimamente associadas \u00e0 ansiedade de falar em p\u00fablico do que as positivas. Isso pode apontar que os participantes, ao pontuarem menos as autoafirma\u00e7\u00f5es negativas, tornam-se menos propensos a reafirmar ou aumentar sua ansiedade ao falar em p\u00fablico e at\u00e9 mesmo desenvolver uma fobia social ou transtornos de ansiedade relacionados \u00e0 isso. Estudos na \u00e1rea,22,23,26 mostram que treinamentos de exposi\u00e7\u00e3o em p\u00fablico e de comunica\u00e7\u00e3o, assim como t\u00e9cnicas cognitivas-comportamentais e treinamento em habilidades sociais s\u00e3o eficazes para o tratamento da fobia social relacionada ao medo de falar em p\u00fablico.Estudos que tinha como objetivo analisar uma interven\u00e7\u00e3o fonoaudiol\u00f3gica junto a estudantes universit\u00e1rios em situa\u00e7\u00f5es de apresenta\u00e7\u00f5es de semin\u00e1rios, os resultados encontrados mostraram efeitos positivos da interven\u00e7\u00e3o nos aspectos orais, al\u00e9m de melhora na percep\u00e7\u00e3o de seguran\u00e7a relatadas pelos participantes quando conseguiam atingir melhor suas plateias. As fonoaudi\u00f3logas avaliadoras do estudo citado perceberam avan\u00e7os quanto aos aspectos orais, corporais e interacionais. Assim, os resultados gerais da pesquisa aqui apresentada corroboram os achados desse estudo e abrem uma reflex\u00e3o sobre o porqu\u00ea desse medo ainda ser um dos mais prevalentes entre os universit\u00e1rios. N\u00e3o seria papel das universidades prepararem os alunos para tal atividade?Em um estudo-3, cabe refletir sobre como tem procedido quanto a essa forma\u00e7\u00e3o.A cada ano, milhares de estudantes s\u00e3o admitidos nas universidades em busca de uma profiss\u00e3o e, no decorrer dos anos de forma\u00e7\u00e3o, encontram tarefas que demandam crescimento intelectual e aprimoramento de habilidades, tais como a de falar em p\u00fablico. Se uma Institui\u00e7\u00e3o de Ensino Superior entende que \u00e9 preciso preparar seus alunos para se comunicarem com efici\u00eancia em seus futuros ambientes de atua\u00e7\u00e3o profissional.Programas de interven\u00e7\u00e3o sobre orat\u00f3ria e melhora do desempenho da comunica\u00e7\u00e3o oral n\u00e3o deveriam integrar o curr\u00edculo de forma\u00e7\u00e3o profissional? A forma\u00e7\u00e3o de profissionais para o mercado de trabalho deveria privilegiar o ensino de compet\u00eancias e habilidades para al\u00e9m dos conte\u00fados t\u00e9cnicos de determinada profiss\u00e3o. \u00c9 necess\u00e1rio que as universidades proporcionem condi\u00e7\u00f5es para que o aluno possa conhecer, al\u00e9m do conte\u00fado da profiss\u00e3o, as exig\u00eancias comportamentais da fun\u00e7\u00e3o escolhidaO presente estudo teve um limitador por ter sido realizado com estudante universit\u00e1rios de uma \u00fanica institui\u00e7\u00e3o de ensino (embora de tr\u00eas cursos de gradua\u00e7\u00e3o diferentes), mas como seus participantes melhoraram seu desempenho em todos os aspectos analisados ap\u00f3s passarem pela interven\u00e7\u00e3o, demonstrou-se a aplicabilidade do treinamento proposto enquanto ferramenta auxiliar no planejamento e aprimoramento de treinamentos de comunica\u00e7\u00e3o para tal popula\u00e7\u00e3o. Portanto, fica aqui a contribui\u00e7\u00e3o dessa pesquisa para que sejam propostos por fonoaudi\u00f3logos nas universidades programas de treinamento e consultoria fonoaudiol\u00f3gica na \u00e1rea, sendo esse um campo promissor de atua\u00e7\u00e3o profissional.Sugerem-se estudos similares que utilizem o treinamento aqui proposto e sejam desenvolvidos em outras institui\u00e7\u00f5es de Ensino Superior, para que esse estudo contribua para o ensino de compet\u00eancias e habilidades al\u00e9m dos conte\u00fados t\u00e9cnicos dentro das universidades. Acredita-se tamb\u00e9m que o material elaborado possa integrar conte\u00fado de disciplinas em v\u00e1rias universidades e ser um suporte para os universit\u00e1rios na \u00e1rea de comunica\u00e7\u00e3o.O programa de treinamento proposto foi efetivo para melhorar as habilidades de comunica\u00e7\u00e3o de estudantes universit\u00e1rios em apresenta\u00e7\u00f5es orais. Houve melhora - tanto da perspectiva dos ju\u00edzes avaliadores quanto da dos pr\u00f3prios participantes - nas habilidades relacionadas aos recursos verbais e n\u00e3o verbais utilizados, nos aspectos qualitativos como contato visual, sorrir quando apropriado e postura adequada durante a apresenta\u00e7\u00e3o, bem como nos aspectos quantitativos como organiza\u00e7\u00e3o da apresenta\u00e7\u00e3o, a linguagem utilizada e o uso de recursos visuais.Na autoavalia\u00e7\u00e3o, os estudantes participantes do estudo tamb\u00e9m relataram melhoria do controle emocional durante as apresenta\u00e7\u00f5es orais e em suas avalia\u00e7\u00f5es gerais ap\u00f3s o treinamento. que inclui a clareza da mensagem, se esta alcan\u00e7ou os objetivos, se foi interessante, agrad\u00e1vel/ informativo ou instigante."}
+{"text": "Na Antropologia, as narrativas produzidas por adoecidose outros agentes com eles envolvidos, como profissionais de sa\u00fade, familiares ecomunidade, tornaram-se objeto de investiga\u00e7\u00e3o para muitas/os pesquisadoras/res 180\u00ba: Minhas Reviravoltas com o C\u00e2ncer deMama(mas que pode representar in\u00fameras mulheres), \u00e9desenvolvida em um formato original, ainda pouco utilizado no Brasil quando se trata daliteratura sobre sa\u00fade: as hist\u00f3rias em quadrinho (HQs), em suaforma estendida, as graphic novels. Diagnosticada com c\u00e2ncer de mamaaos 36 anos, a autora conta na apresenta\u00e7\u00e3o do livro como foi estimulada por outrasmulheres, entre elas a antrop\u00f3loga Soraya Fleischer da Universidade de Bras\u00edlia, aregistrar essa experi\u00eancia por meio da escrita. Desses registros nasceu a ideia dolivro, empreitada dividida com Fleischer, com a tamb\u00e9m antrop\u00f3loga Fabiene Gama, daUniversidade Federal do Rio Grande do Sul, e com a grafiteira e designer Camila Siren,autora das bel\u00edssimas ilustra\u00e7\u00f5es da obra. Essa rela\u00e7\u00e3o de amizade e trabalho, permeadapela influ\u00eancia da Antropologia, contribuiu para colocar em di\u00e1logo as perspectivas docuidado, a abordagem autoetnogr\u00e1fica e a Medicina Gr\u00e1fica, resultando em uma obrainovadora dentro do vasto universo de relatos pessoais sobre o c\u00e2ncer de mama, queemergiram a partir dos anos 1980 e se produzem com bastante intensidade nacontemporaneidade ,Nesse sentido, o livro graphic novel est\u00e1 dividida em tr\u00eas cap\u00edtulos de leitura flu\u00edda eleve, apesar do tema denso e dos termos t\u00e9cnicos que, por vezes, fazem parte do enredo.Al\u00e9m dos quadrinhos, o livro cont\u00e9m textos complementares que abordam desde o trabalhode concep\u00e7\u00e3o e produ\u00e7\u00e3o da obra at\u00e9 como ela poder\u00e1 ser utilizada por diferentespessoas, de pacientes a gestores em sa\u00fade. Acompanhamos a personagem principal em tr\u00easmomentos distintos: (1) a busca pelo diagn\u00f3stico;(2) a defini\u00e7\u00e3o dos tratamentos, fase permeada por muitasnegocia\u00e7\u00f5es (por vezes tensas e conflituosas) com profissionais desa\u00fade e apoiada na escuta de outras mulheres que passaram pela doen\u00e7a; e(3) a realiza\u00e7\u00e3o dos tratamentos, quando a vida passa girarn\u00e3o em torno da doen\u00e7a, mas com a doen\u00e7a, trazendo dores, limita\u00e7\u00f5es e perdas, mastamb\u00e9m aprendizados e constru\u00e7\u00e3o de projetos, como o pr\u00f3prio livro.A O fato de a personagem/autora ser uma pesquisadora em sa\u00fade coletiva \u00e9 central para aconstru\u00e7\u00e3o da narrativa, uma vez que esse pertencimento lhe deu, segundo ela,ferramentas t\u00e9cnicas e te\u00f3ricas para interpretar sua experi\u00eancia. No entanto, isso n\u00e3oquer dizer que o \u00fanico saber legitimado deve ser o da ci\u00eancia. Ao mesmo tempo que buscapesquisas cient\u00edficas e diferentes opini\u00f5es m\u00e9dicas sobre seu tratamento, nossapersonagem se envolve em redes de compartilhamento de informa\u00e7\u00f5es formadas por outrasmulheres que viveram ou est\u00e3o vivendo um c\u00e2ncer. Conversar com quem j\u00e1 trilhou essecaminho \u00e9 apresentado como algo fundamental para o enfrentamento da doen\u00e7a, uma vez quecoloca em di\u00e1logo saberes t\u00e9cnicos e pr\u00e1ticos.(\u201cquero ver minhas filhas crescerem\u201d) e dosefeitos colaterais dos tratamentos inicialmente indicados, entre eles 16 sess\u00f5es dequimioterapia. Sua postura questionadora e reflexiva muda radicalmente essa prescri\u00e7\u00e3o.O acesso a uma medicina de precis\u00e3o, ausente no sistema p\u00fablico de sa\u00fade e mesmo nosconv\u00eanios privados, a livra de uma quimioterapia desnecess\u00e1ria - e a autora temconsci\u00eancia do privil\u00e9gio de sua condi\u00e7\u00e3o. Nesse sentido, critica o termo \u201csobreviventedo c\u00e2ncer\u201d, pois reconhece que essa sobreviv\u00eancia nada tem a ver com uma lutaindividual, ela \u00e9 fruto de din\u00e2micas sociais como rede de apoio, cuidado de terceiros,acesso adequado a tratamentos e tecnologias em sa\u00fade.Como muitas mulheres, Carolina/Dulce sofre o impacto inicial do diagn\u00f3stico, o medo damorte sites voltados paradivulgar a crescente produ\u00e7\u00e3o da \u00e1rea.Dois textos curtos que tamb\u00e9m comp\u00f5em o livro apresentam alternativas textuais e te\u00f3ricaspara se pensar a populariza\u00e7\u00e3o da informa\u00e7\u00e3o m\u00e9dica e cient\u00edfica e a constru\u00e7\u00e3o deconhecimentos e cuidados em sa\u00fade. Explorando as rela\u00e7\u00f5es entre arte, literatura esa\u00fade, Dulce Ferraz exp\u00f5e dados interessantes sobre como a partir da segunda metade dos\u00e9culo XX emerge o campo da Medicina Narrativa, que valoriza as hist\u00f3rias contadas porpessoas doentes e por quem cuida delas, as chamadas patografias. Entre as formas deregistro dessas narrativas, as HQs despontaram como uma maneira mais direta, \u00edntima epessoal de narrar eventos de adoecimento e comunicar essa experi\u00eancia para fam\u00edlia,comunidade e profissionais de sa\u00fade ao ponto de tornar-se uma \u00e1rea espec\u00edfica conhecidacomo Medicina Gr\u00e1fica. Embora ainda t\u00edmida no Brasil, a Medicina Gr\u00e1fica est\u00e1 emexpans\u00e3o em contextos euro-americanos e j\u00e1 conta com congressos, publica\u00e7\u00f5es de dossi\u00ease artigos cient\u00edficos sobre o tema, al\u00e9m de o pessoal \u00e9 pol\u00edtico\u201d. No entanto,Gama nos lembra que, apesar de baseada em uma hist\u00f3ria individual, a Autoetnografia\u201c\u00e9 sempre constru\u00edda de forma dial\u00e9tica, relacional, contextual, levando emconsidera\u00e7\u00e3o experi\u00eancias de outras pessoas e tamb\u00e9m as pesquisas j\u00e1 realizadassobre o tema\u201d (p. 303). Na literatura sobre temas dasa\u00fade, reflex\u00f5es sociais baseadas em experi\u00eancias pessoais j\u00e1 se fazem presentes pelomenos desde a d\u00e9cada de 1980, sendo o trabalho de Susan Sontag ,180\u00ba: Minhas Reviravoltas com o C\u00e2ncer deMama realiza com maestria ao apostar no formato de HQs.Fabiene Gama, por sua vez, nos apresenta a Autoetnografia, proposta metodol\u00f3gica etextual que tem como base a reflexividade da pesquisadora sobre si mesma, tratando dequest\u00f5es de ordem social a partir de uma experi\u00eancia pessoal, aproximando-se, assim, dam\u00e1xima do feminismo que diz que \u201cgraphic novel m\u00e9dicos negros, cientistas mulheres, corposcom diferentes tons de pele e em pap\u00e9is sociais variados. Essa \u00e9 mais uma qualidade dasnarrativas, que aqui \u00e9 explorada est\u00e9tica e politicamente: possibilitar a constru\u00e7\u00e3osocial da realidade, e n\u00e3o meramente represent\u00e1-la.Por fim, um detalhe importante a mencionar s\u00e3o as escolhas feitas para representa\u00e7\u00e3oimag\u00e9tica das personagens. Como forma de questionar estere\u00f3tipos presentes no campo nasa\u00fade, em que m\u00e9dicos e especialistas s\u00e3o concebidos quase sempre como homens brancos,vemos nessa"}
+{"text": "The study aimed at the development and content validation of an Auditory Processing Intervention Program for school-aged European Portuguese speaking children with Auditory Processing Disorder.The first step was the program\u2019s development and its instructions manual, which includes objectives, activities, procedures, materials, reinforcement, instructions, and verbal stimuli used, for the following auditory skills: auditory discrimination, auditory attention; auditory memory; auditory closure; figure-ground; auditory separation; auditory integration; binaural fusion; content validation was performed next, with two expert panels analyzing the program, through the use of a questionnaire. Content validity was calculated using the content validity index.Program evaluation shows an excellent content validity. Some items were modified after analyzing the experts\u2019 comments and suggestions .This work allowed the development and content validation of an auditory processing intervention program, with verbal stimuli, selected according to strict linguistic criteria. In the future, the acceptability and efficacy of this program with the target population should be analyzed. It is expressed as difficulty in one or more auditory skills and culminates in an auditory information processing deficit, even with preserved peripheral hearing-4. The auditory skills that integrate Auditory Processing (AP) are: sound localization and lateralization, auditory discrimination, recognition of auditory patterns, temporal auditory processing , auditory performance with competitive acoustic signals (figure-ground), auditory performance in the presence of degraded acoustic signals (closure) and binaural fusion .Auditory Processing Disorder (APD) is currently defined as a dysfunction of the central auditory system's ability to use the information sent by the peripheral auditory system,7.APD has a multifactorial etiology and may result from neuroanatomical abnormalities, such as a delay in the maturation of the central nervous system or exposure to exogenous factors  during the critical periods of brain development-12. APD can also impair the children's social performance, for instance, by restricting classroom activities and participation.Individuals with APD generally present difficulties with language, learning, understanding verbal instructions, especially when the input is presented at a fast speech rate, with auditory discrimination of minimal pairs, identification of people's voices, sound localization, and musical or singing skills. However, it affects about 30% to 50% of children with learning disabilities, as well as about 52% of children with dyslexia and/or developmental language disorders.It is estimated that 2% to 5% of the school-aged population suffers from APDbottom-up  in addition to top-down  approaches. It should be planned by a multidisciplinary team that integrates speech-language pathologists (SLPs) and audiologists, and may also include psychologists, teachers and occupational therapists,10. This intervention should be implemented as early as possible, it requires intensive auditory training and must be consistent with the previous diagnosis, to develop the neuroplasticity that characterizes the auditory nervous system,3,8.APD intervention includes environmental modifications, compensatory strategies (cognitive-linguistic skills training), or direct remediation measures,3,10,16. Environmental modifications and compensatory strategies aim at reducing the impact of APD on individuals' daily lives, and direct remediation (auditory training) aims at reducing AP alterations.Such treatment may undergo ,17. These activities should include varied tasks; with comfortable stimulus intensity; they should be presented systematically and in increasing degrees of difficulty, to provide variation and motivation, with feedback and positive reinforcement; they must accommodate the differences between ears (left and right), advancing only when adequate performance is obtained for both ears, and should promote the intensive practice, preferably in a daily basis, during the established intervention period,9.Auditory training programs encompass activities that focus on the identified skills deficits. As for the difficulty level of the auditory training, a performance below 30% indicates that the task is too demanding. On the other hand, to achieve progress in the auditory training, the patient's success rate should be between 70% and 80%,17,18.Although the auditory training duration is not a consensus in the literature, twenty to thirty minutes of practice is usually recommended, from three to four times a week, for at least six weeks, varying according to the number of affected skills,17,19,20. Furthermore, when including activities that target temporal processing skills, also improves the children's reading performance.Auditory training is effective in the rehabilitation of auditory skills, improving the perception of more complex acoustic signals, such as speech,22-24.In recent years, several intervention programs have been developed to contemplate speech sounds and nonverbal vocalization and stimulate different auditory skills, combined with language and memory tasks , display a pleasant aesthetic format, with multisensory stimulation, feedback, positive reinforcement, and opportunity for intensive and adaptive training, thus becoming an effective tool, especially for the pediatric population presenting speech disorders, learning disabilities and reading difficulties concomitant with AP alterations.Many of these programs, adapted for tablets and smartphones (CBAT \u2013 computer-based auditory training).Nevertheless, in the case of European Portuguese (EP) speakers, there is no validated APD intervention program whose effectiveness has been actually assessed. That being said, in the case of nonverbal vocalizations, it is possible to use the programs available in other languages, while regarding verbal sounds, these programs are not directly functional for the population whose first language is EP, since the auditory training must occur in the patient's languageConsidering the scarcity of structured and validated programs for APD intervention with children, which constrains the SLPs' evidence-based practice, the present study's purpose was to develop and validate an AP intervention program for school-aged children (from six to ten years old), for EP speakers, which contemplated activities that stimulate auditory skills that are more dependent on verbal stimuli.. Since the study does not involve direct participation of human beings, it was not considered necessary to apply for ethics committee approval, nor was there a need for drafting informed consent forms.A cross-sectional exploratory and descriptive study were conducted with a quantitative approach, and content validation was performed with a Panel of Experts (PE)The present intervention program aims to stimulate auditory skills related to auditory discrimination, auditory attention; auditory memory; auditory closure; figure-ground; auditory separation; auditory integration, and binaural fusion. PIPA  comes with a playful activities framework that displays motivating scenarios and a reward system. The activities are hierarchized according to their difficulty degree, they are intended to meet specific objectives for the stimulation and to train each one of the targeted auditory skills.. As for the syllabic structure, stimuli with every possible syllabic format in EP were selected, respecting their frequency of occurrence,28. It was not possible to meet these linguistic criteria only in cases where the stimuli pertained to specific semantic fields.The verbal stimuli included in each activity were carefully chosen, based on strict linguistic criteria, namely extension and syllabic structure of the word. Thus, for all the PIPA activities, the stimuli contemplate monosyllabic, disyllabic, trisyllabic, and polysyllabic words in a percentage similar to the frequency of the occurrence in EPEach section was organized by levels, in an ascending order of difficulty, and all activities must be completed individually, monitored by an SLP. Both the child and the SLP must use headphones, not requiring an acoustic booth. In each game/task, about 10 to 15 consecutive stimuli are presented and, if the child scores 75% of correct answers, he/she can level up.In some games, the SLP may manipulate the conditions, such as the stimuli intensity variation, the signal-to-noise ratio, the temporal variation of the stimuli presentation in dichotic listening, and the selection of the ear for stimuli presentation (right ear vs. left ear). Additionally, it is possible to monitor the child's performance/progress.feedback/reward, the materials used, and the stimuli involved. Even though the program includes activities to stimulate various auditory skills, each child will only explore the spaces that the SLP determines, according to the established intervention plan, necessarily following an evaluation previously performed by an audiologist,4,26. The SLP is free to choose whether to start with the stimuli in the right ear or the left ear, and the child will have to perform the tasks in both ears to level up.PIPA also comes with a manual, which includes the program's objectives and respective tasks, the framework, the task's description/procedures, the instructions, the provided dolphin bay \u2013 auditory discrimination; pelican feeding \u2013 auditory attention; enchanted jungle \u2013 auditory memory; vibrant sky \u2013 binaural separation; crawlers' nest \u2013 binaural integration; Mr. Manel's farm \u2013 binaural fusion; prehistoric park \u2013 closure; enchanted forest \u2013 figure-ground). Each section of PIPA aims to train a basic auditory skill, and, of course, other abilities will be stimulated further on. PIPA's framework revolves around the story of a girl who visits a zoo, with several spaces/habitats where she can conquer the animals that are there. To do this, she has to perform the tasks that stimulate different auditory skills , namely, clinical experience in the AP field (minimum of 5 years) and theoretical knowledge in the area of study. The decision to select two different panels of experts was because a single PE was considered to be insufficient to assess such a wide range of tasks, associated with a broad amount of different stimuli.To validate PIPA's content, regarding the contents' scope, intelligibility, adequacy, and relevance, two panels of experts were constituted, based on the criteria outlined in the literatureExperts were selected according to the non-probability convenience sampling method. The first panel consisted of five experts who analyzed the tasks and the manual of auditory skills related to auditory discrimination, auditory attention, auditory memory, and closure, and the second panel consisted of six experts who analyzed skills related to binaural separation, binaural integration, binaural fusion, and figure-ground.,29. With this questionnaire, it was intended to attest to the fulfillment of the inclusion criteria to integrate the PE, and also to evaluate the opinion of the experts regarding the following items: program utility, suitability to the clinical practice and the target audience, selected auditory skills, instructions, framework, rewards, tasks, stimulus (quantity and selection) and organization.PIPA's manual was sent after the first contact by e-mail, requesting the collaboration of the experts in the study. The professionals were asked to complete a questionnaire divided into two parts: sociodemographic characterization and PIPA's content analysis The sociodemographic characterization of the experts who analyzed PIPA is described in All experts met the pre-defined criteria of clinical experience and specific knowledge in the AP field, highlighting the fact that out of the eleven experts, five had previous experience with AP training. At the time of the study, one of the experts (Subject 3 \u2013 PE 1) held a teaching position, and also had previous experience with APD intervention.The overall CVI obtained with PIPA's validation was 0.95. The quantitative results obtained by PE 1 and PE 2 are presented in Although it was not necessary to completely reformulate any item, since the content of all items was validated, a few modifications were made to PIPA to adhere to some of the experts' suggestions, documented in the observations/suggestions section.As for the program's framework, at the suggestion of the experts, we introduced the possibility for the child to choose the gender  of PIPA's main character.Vibrant Sky, Crawlers' Nest, Mr. Manel's Farm, and Enchanted Forest, striving to provide the SLP and the child with a better understanding of the activities, using shorter sentences and giving examples. Training components were added to all tasks, at the suggestion of the experts, to facilitate the understanding of the activities.Changes were made to the tasks' instructions of the following spaces: The Dolphin Jump, from the Dolphin Bay space, to increase the percentage of dissyllabic words with phonemes in the word-medial position. The number of stimuli was increased in the task The Seahorse's Kiss, in the Dolphin Bay space, going from five to ten pairs of pseudowords, according to the recommendation of the experts. Still regarding the stimuli, at the suggestion of the experts, some sentences were altered in the activities The Eagle's Flight, from the Vibrant Skyspace , and How Many Colors has the Chameleon?, from the Crawlers' Nest  to standardize its grammatical structure.In addition, three pairs of stimuli were altered in the task How Many Worms does the Salamander Eats? from the Crawlers' Nest space , opting for using phrases with only ungrammatical semantic elements. The lexicon of some phrases was also reviewed, on the grounds of being associated with a particular dialect, on the risk of not being familiar with children from other geographical locations.It was also accepted the suggestion of not inserting phrases with ungrammatical semantic and syntactic elements in the same group of stimulus sentences, in the task Vibrant Sky), the introduction of a greater intensity variation  was contemplated between the stimuli that come through the right side vs. left side, similarly, we accepted the suggestion of introducing the possibility of manipulating the intensity variation  in the tasks related to figure-ground (Enchanted Forest), to assure PIPA's applicability in the cases of children with a more severe disorder and/or with associated hearing loss issues.In the binaural separation tasks  was also reformulated, given that one of the experts pointed out potential color blindness complications. In these situations, the task can be performed with the support of the SLP, who can select the colors after the child indicates the sequence of colors they heard.The task-related to auditory memory of colors  amounts to an excellent content validity ranking, since it is greater than 0.90,17. In this sense, it was essential to carefully select PIPA's verbal stimuli, balancing the input according to the frequency patterns occurring in EP,28.The development and validation of an intervention program, particularly with regard to the AP field, is an innovative factor for EP. In this context, and given the scarcity of materials, it was decided to create a program in which verbal stimulus is used for the training of different auditory skills,9.For PIPA's elaboration, a careful selection of skills, objectives, tasks, and stimuli was undertaken, always being mindful of its use in the clinical context. At the same time, the fact that the program targets school-aged children were kept in mind, and, as such, the use of fun tools was considered necessary as a playful way of motivating and engaging kids,18. Moreover, it is in line with some programs available internationally, which show the child's progress with the auditory training activities,22.The inclusion of a system of rewards and monitoring of the children's correct answers, aside from the experts' unanimous validation, was deemed a fundamental factor for the child's continuous evaluation, for the (re)definition of intervention goals, and the maintenance of the task's motivational indexes, following what is endorsed in the literature for intervention in APD cases. Hence, given that APD can have negative consequences on the individuals' linguistic, social and academic performance,11, PIPA can have a positive impact on its users, concerning the personal factors that promote activity and participation in multiple contexts.The auditory skills developed with PIPA  allow for speech understanding since they demand discrimination, recognition, selective and sustained attention, as well as the ability to memorize sounds. PIPA thus paves the way for other studies in the context of APD intervention for children whose first language is EP, contributing to the improvement of the SLP's clinical practice in this field. As a future endeavor, studies must be conducted on PIPA's acceptability and efficacy for children with and without APD.In addition, evidence-based practice in decision making is essential to raise the quality of the therapeutic interventionThis research allowed for PIPA's development and validation, meeting the steps defined in the literature for the creation of new instruments. This is an innovative instrument for EP speakers, with an excellent CVI, with an acceptability and effectiveness analysis foreseen in future studies. ,2. Traduz-se por uma dificuldade numa ou mais compet\u00eancias auditivas e culmina num d\u00e9fice do processamento da informa\u00e7\u00e3o auditiva, mesmo com a audi\u00e7\u00e3o perif\u00e9rica preservada-4. As compet\u00eancias auditivas que integram o Processamento Auditivo (PA) s\u00e3o: a localiza\u00e7\u00e3o e lateraliza\u00e7\u00e3o sonora, a discrimina\u00e7\u00e3o auditiva, o reconhecimento de padr\u00f5es auditivos, o processamento auditivo temporal , o desempenho auditivo com sinais ac\u00fasticos competitivos (figura-fundo), o desempenho auditivo na presen\u00e7a de sinais ac\u00fasticos degradados (fechamento) e o processamento binaural .A Perturba\u00e7\u00e3o do Processamento Auditivo (PPA) \u00e9 atualmente definida como um d\u00e9fice na capacidade do sistema auditivo central para usar as informa\u00e7\u00f5es enviadas pelo sistema auditivo perif\u00e9rico,7.A PPA apresenta etiologia multifatorial, podendo ser resultado de uma anomalia neuroanat\u00f3mica, de um atraso na matura\u00e7\u00e3o do sistema nervoso central ou da exposi\u00e7\u00e3o a fatores ex\u00f3genos  durante per\u00edodos cr\u00edticos do desenvolvimento cerebral-12. A PPA pode prejudicar tamb\u00e9m o desempenho social das crian\u00e7as, restringindo, por exemplo a atividade e participa\u00e7\u00e3o na sala de aula.Os indiv\u00edduos com PPA apresentam, geralmente, dificuldades na linguagem, na aprendizagem, na compreens\u00e3o de instru\u00e7\u00f5es orais, sobretudo quando estas s\u00e3o apresentadas em velocidade de fala r\u00e1pida, na discrimina\u00e7\u00e3o de palavras com pares m\u00ednimos, na identifica\u00e7\u00e3o das vozes das pessoas, na localiza\u00e7\u00e3o dos sons e nas compet\u00eancias musicais ou de canto. Contudo, atinge cerca de 30% a 50% das crian\u00e7as com dificuldades de aprendizagem, bem como cerca de 52% das crian\u00e7as com dislexia e/ou perturba\u00e7\u00e3o do desenvolvimento da linguagem.Estima-se que a PPA afete cerca de 2% a 5% da popula\u00e7\u00e3o em idade escolarbottom-up  e top-down  e deve ser planeada no seio de uma equipa multidisciplinar que integre terapeutas da fala (TFs) e audiologistas, podendo tamb\u00e9m incluir psic\u00f3logos, professores e terapeutas ocupacionais,10. Esta interven\u00e7\u00e3o deve ser implementada o mais precocemente poss\u00edvel, deve incluir treino intensivo e deve estar de acordo com o diagn\u00f3stico previamente realizado, de modo a explorar a plasticidade neuronal que caracteriza o sistema nervoso auditivo,3,8.A interven\u00e7\u00e3o na PPA inclui abordagens modifica\u00e7\u00f5es ambientais, estrat\u00e9gias compensat\u00f3rias (treino de compet\u00eancias cognitivo-lingu\u00edsticas) ou remedia\u00e7\u00e3o direta,3,10,16. As modifica\u00e7\u00f5es ambientais e as estrat\u00e9gias compensat\u00f3rias visam a diminui\u00e7\u00e3o do impacto da PPA no dia-a-dia dos indiv\u00edduos e a remedia\u00e7\u00e3o direta (treino auditivo) visa a redu\u00e7\u00e3o do d\u00e9fice no PA.A interven\u00e7\u00e3o pode passar por ,17. Estas atividades devem incluir tarefas variadas; est\u00edmulos com n\u00edveis de intensidade confort\u00e1veis; devem ser apresentadas sistematicamente e em graus de dificuldade crescente, de modo a promover a mudan\u00e7a e a motiva\u00e7\u00e3o, com feedback e refor\u00e7o positivo; devem atender \u00e0s diferen\u00e7as entre ouvidos (esquerdo e direito), avan\u00e7ando somente quando se obt\u00e9m um desempenho adequado para os dois ouvidos e devem promover a pr\u00e1tica intensiva, se poss\u00edvel di\u00e1ria, durante o tempo estabelecido para a interven\u00e7\u00e3o,9.Os programas de treino auditivo incluem atividades focadas nas compet\u00eancias identificadas como deficit\u00e1rias. No que respeita \u00e0 dificuldade do treino auditivo, um desempenho abaixo dos 30% indica que a tarefa \u00e9 demasiado exigente. Por outro lado, para que o paciente possa avan\u00e7ar no treino auditivo, a taxa de acerto dever\u00e1 situar-se entre os 70% e os 80%,17,18.A dura\u00e7\u00e3o do treino auditivo n\u00e3o est\u00e1 bem estabelecida na literatura, por\u00e9m \u00e9 comum a indica\u00e7\u00e3o de que o mesmo dever\u00e1 ocorrer durante vinte a trinta minutos, entre tr\u00eas a quatro vezes por semana, durante pelo menos seis semanas, variando consoante o n\u00famero de compet\u00eancias alteradas,17,19,20. Para al\u00e9m disso, quando inclui atividades direcionadas para as compet\u00eancias de processamento temporal, tamb\u00e9m melhora o desempenho das crian\u00e7as ao n\u00edvel da leitura.O treino auditivo tem-se mostrado eficaz na reabilita\u00e7\u00e3o das compet\u00eancias auditivas, melhorando a perce\u00e7\u00e3o de sinais ac\u00fasticos mais complexos, como por exemplo, a fala,22-24.Nos \u00faltimos anos, t\u00eam sido desenvolvidos v\u00e1rios programas de interven\u00e7\u00e3o que contemplam sons verbais e n\u00e3o-verbais e estimulam diferentes compet\u00eancias auditivas, combinadas com algumas tarefas de linguagem e mem\u00f3ria tablets e smartphones (CBAT \u2013 computer-based auditory training), apresentam um formato est\u00e9tico agrad\u00e1vel, com estimula\u00e7\u00e3o multissensorial, feedback, refor\u00e7o positivo e oportunidade para treino intensivo e adaptativo, tornando-se assim numa ferramenta eficaz, sobretudo para a popula\u00e7\u00e3o pedi\u00e1trica que apresenta dificuldades de linguagem, de aprendizagem e de leitura concomitantes com as altera\u00e7\u00f5es no PA.Muitos destes programas, adaptados para .No entanto, para o Portugu\u00eas Europeu (PE) n\u00e3o se conhece nenhum programa de interven\u00e7\u00e3o em PPA validado e cuja efic\u00e1cia tenha sido aferida. Ainda que, no caso dos sons n\u00e3o verbais, seja poss\u00edvel recorrer aos programas dispon\u00edveis noutras l\u00ednguas, no que respeita aos sons verbais, estes programas n\u00e3o s\u00e3o diretamente utiliz\u00e1veis pela popula\u00e7\u00e3o cuja l\u00edngua materna \u00e9 o PE, uma vez que o treino auditivo dever\u00e1 ocorrer na l\u00edngua do pacienteTendo em conta a escassez de programas estruturados e validados para interven\u00e7\u00e3o com crian\u00e7as com PPA, o que condiciona a pr\u00e1tica baseada na evid\u00eancia por parte dos TFs, este estudo teve como prop\u00f3sito o desenvolvimento e valida\u00e7\u00e3o de um programa de interven\u00e7\u00e3o em PA para crian\u00e7as em idade escolar (dos seis aos dez anos), falantes do PE, que inclu\u00edsse atividades para estimular as compet\u00eancias auditivas mais dependentes dos est\u00edmulos verbais.. Dado que o estudo n\u00e3o envolve diretamente a participa\u00e7\u00e3o de seres humanos, n\u00e3o se considerou necess\u00e1rio proceder a qualquer pedido de parecer \u00e0 comiss\u00e3o de \u00e9tica, nem houve lugar a um termo de consentimento livre e esclarecido.O estudo desenvolvido \u00e9 explorat\u00f3rio, transversal e descritivo com uma abordagem quantitativa, sendo a valida\u00e7\u00e3o de conte\u00fado realizada atrav\u00e9s de um Painel de Peritos (PP)Este programa de interven\u00e7\u00e3o visa estimular as compet\u00eancias auditivas de discrimina\u00e7\u00e3o auditiva, aten\u00e7\u00e3o auditiva, mem\u00f3ria auditiva, fechamento, figura-fundo, separa\u00e7\u00e3o binaural, integra\u00e7\u00e3o binaural e fus\u00e3o binaural. O PIPA inclui atividades l\u00fadicas, com cen\u00e1rios motivadores e um sistema de recompensas. As atividades est\u00e3o hierarquizadas em fun\u00e7\u00e3o do grau de dificuldade e cumprem objetivos espec\u00edficos para a estimula\u00e7\u00e3o e treino de cada uma das compet\u00eancias auditivas selecionadas.. Quanto \u00e0 estrutura sil\u00e1bica, selecionaram-se est\u00edmulos com todos os formatos sil\u00e1bicos poss\u00edveis no PE, respeitando a sua frequ\u00eancia de ocorr\u00eancia,28. Apenas nos casos em que os est\u00edmulos dizem respeito a campos sem\u00e2nticos espec\u00edficos, n\u00e3o foi poss\u00edvel atender a estes crit\u00e9rios lingu\u00edsticos.Os est\u00edmulos verbais inclu\u00eddos em cada uma das atividades foram selecionados cuidadosamente, tendo por base crit\u00e9rios lingu\u00edsticos rigorosos, nomeadamente extens\u00e3o e estrutura sil\u00e1bica da palavra. Desta forma, para cada uma das atividades do PIPA, os est\u00edmulos contemplam palavras monossil\u00e1bicas, dissil\u00e1bicas, trissil\u00e1bicas e polissil\u00e1bicas numa percentagem pr\u00f3xima da frequ\u00eancia do PECada sec\u00e7\u00e3o est\u00e1 organizada por n\u00edveis, por ordem crescente de dificuldade, sendo que todas as atividades devem ser realizadas individualmente, com acompanhamento de um TF. Tanto a crian\u00e7a como o TF devem usar auscultadores, n\u00e3o sendo necess\u00e1ria uma cabine ac\u00fastica. Em cada jogo/tarefa s\u00e3o apresentados cerca de 10 a 15 est\u00edmulos consecutivos e, se a crian\u00e7a atingir 75% de acertos, pode avan\u00e7ar de n\u00edvel.vs. ouvido esquerdo). Poder\u00e1 ainda monitorizar o desempenho/progresso da crian\u00e7a.Em alguns jogos, o TF poder\u00e1 manipular as condi\u00e7\u00f5es, tais como desn\u00edveis de intensidade dos est\u00edmulos, rela\u00e7\u00e3o sinal-ru\u00eddo, desn\u00edvel temporal de apresenta\u00e7\u00e3o dos est\u00edmulos em escuta dic\u00f3tica e sele\u00e7\u00e3o do ouvido de apresenta\u00e7\u00e3o dos est\u00edmulos . Cada sec\u00e7\u00e3o do PIPA tem como objetivo o treino de uma compet\u00eancia auditiva principal, sendo que, naturalmente, haver\u00e1 outras compet\u00eancias estimuladas. A O enquadramento do PIPA consiste numa menina que visita um jardim zool\u00f3gico, com v\u00e1rios espa\u00e7os/habitats onde pode conquistar os animais que l\u00e1 se encontram. Para tal, ter\u00e1 de executar as tarefas que estimulam as diferentes compet\u00eancias auditivas , designadamente, experi\u00eancia cl\u00ednica na \u00e1rea do PA (m\u00ednimo 5 anos) e conhecimento te\u00f3rico na \u00e1rea de estudo. A sele\u00e7\u00e3o de dois pain\u00e9is de peritos diferentes deve-se ao facto de se ter considerado pouco vi\u00e1vel o mesmo PP avaliar um t\u00e3o vasto conjunto de tarefas, associadas a um grande n\u00famero de est\u00edmulos diferentes.Para validar o conte\u00fado do PIPA, relativamente \u00e0 sua abrang\u00eancia, clareza, adequa\u00e7\u00e3o e pertin\u00eancia dos conte\u00fados, constitu\u00edram-se dois pain\u00e9is de peritos, com base nos crit\u00e9rios definidos na literaturaOs peritos foram selecionados de acordo com o m\u00e9todo de amostragem n\u00e3o probabil\u00edstico por conveni\u00eancia. O primeiro painel foi constitu\u00eddo por cinco peritos que analisaram as tarefas e o manual das compet\u00eancias auditivas de discrimina\u00e7\u00e3o auditiva, aten\u00e7\u00e3o auditiva, mem\u00f3ria auditiva e fechamento e o segundo painel por seis peritos que analisaram as compet\u00eancias de separa\u00e7\u00e3o binaural, integra\u00e7\u00e3o binaural, fus\u00e3o binaural e figura-fundo.,29. Com este question\u00e1rio pretendeu-se atestar o cumprimento dos crit\u00e9rios de inclus\u00e3o para integrar o PP e tamb\u00e9m avaliar a opini\u00e3o dos especialistas relativamente aos seguintes itens: utilidade do programa, adequa\u00e7\u00e3o \u00e0 pr\u00e1tica cl\u00ednica e ao p\u00fablico-alvo, compet\u00eancias auditivas selecionadas, instru\u00e7\u00f5es, enquadramento, recompensas, tarefas, est\u00edmulos (quantidade e sele\u00e7\u00e3o) e organiza\u00e7\u00e3o.Depois de um primeiro contacto por correio eletr\u00f3nico, solicitando a colabora\u00e7\u00e3o dos peritos no estudo, foi enviado o manual do PIPA. Os peritos foram convidados a preencher um question\u00e1rio dividido em duas partes: caracteriza\u00e7\u00e3o sociodemogr\u00e1fica e an\u00e1lise do conte\u00fado do PIPA A caracteriza\u00e7\u00e3o sociodemogr\u00e1fica dos peritos que analisaram o PIPA est\u00e1 descrita na Todos os peritos cumpriram os crit\u00e9rios pr\u00e9-definidos de experi\u00eancia cl\u00ednica e de conhecimento espec\u00edfico na \u00e1rea do PA, destacando-se o facto de cinco dos onze peritos j\u00e1 terem ministrado forma\u00e7\u00e3o em PA. Um dos peritos (Sujeito 3 \u2013 PP 1), \u00e0 data do estudo, exercia fun\u00e7\u00f5es de doc\u00eancia, mas conta tamb\u00e9m com experi\u00eancia pr\u00e9via ao n\u00edvel da interven\u00e7\u00e3o em indiv\u00edduos com PPA.O IVC global obtido com a valida\u00e7\u00e3o do PIPA \u00e9 de 0,95. Os resultados quantitativos obtidos para o PP 1 e o PP 2 s\u00e3o apresentados na Apesar de n\u00e3o ter sido necess\u00e1ria a completa reformula\u00e7\u00e3o de qualquer item, j\u00e1 que foi validado o conte\u00fado de todos os itens, foram realizadas algumas modifica\u00e7\u00f5es ao PIPA, para atender \u00e0s sugest\u00f5es dos especialistas, registadas no campo destinado \u00e0s observa\u00e7\u00f5es/sugest\u00f5es.Relativamente ao enquadramento do programa, por sugest\u00e3o dos peritos, foi introduzida a possibilidade de a crian\u00e7a escolher o g\u00e9nero (masculino/feminino) da personagem principal do PIPA.\u00e9u colorido, Esconderijo dos rastejantes, A quinta do tio Manel e Floresta m\u00e1gica, tendo em vista uma melhor compreens\u00e3o das mesmas por parte do TF e da crian\u00e7a, tendo sido utilizadas frases mais curtas e fornecidos exemplos. Em todas as atividades, foram introduzidos itens de treino, por sugest\u00e3o dos peritos, no sentido de facilitar a compreens\u00e3o da tarefa.Foram realizadas altera\u00e7\u00f5es nas instru\u00e7\u00f5es das tarefas dos espa\u00e7os CO salto do golfinho, do espa\u00e7o Ba\u00eda dos golfinhos, de forma a aumentar a percentagem de palavras dissil\u00e1bicas com o fonema em posi\u00e7\u00e3o medial de palavra. Aumentou-se o n\u00famero de est\u00edmulos na tarefa O beijinho do cavalo marinho, no espa\u00e7o Ba\u00eda dos golfinhos, passando de cinco para dez pares de pseudopalavras, de acordo com a recomenda\u00e7\u00e3o dos peritos. Ainda no que reporta aos est\u00edmulos, por sugest\u00e3o dos peritos, foram alteradas algumas frases, nas atividades O voo da \u00e1guia, do espa\u00e7o C\u00e9u colorido , e Quantas cores tem o camale\u00e3o?, do espa\u00e7o Esconderijo dos rastejantes  tendo em vista a uniformiza\u00e7\u00e3o da sua estrutura gramatical.Para al\u00e9m disso, alteraram-se tr\u00eas pares de est\u00edmulos na tarefa Quantas minhocas come a salamandra?, do espa\u00e7o Esconderijo dos rastejantes , optando-se apenas pela utiliza\u00e7\u00e3o de frases com agramaticalidade sem\u00e2ntica. Foi tamb\u00e9m revisto o l\u00e9xico de algumas frases, que por estar associado a um dialeto particular, poderia n\u00e3o ser familiar para crian\u00e7as de outros pontos geogr\u00e1ficos.Foi ainda acolhida a sugest\u00e3o de n\u00e3o inserir no mesmo grupo de est\u00edmulos frases com agramaticalidade sem\u00e2ntica e frases com agramaticalidade sint\u00e1tica, na tarefa C\u00e9u colorido) foi contemplada a introdu\u00e7\u00e3o de um maior desn\u00edvel de intensidade  entre os est\u00edmulos que surgem no lado direito vs. esquerdo, assim como foi tida em conta a sugest\u00e3o de introduzir a possibilidade de manipular o desn\u00edvel de intensidade  nas tarefas de figura-fundo (Floresta-m\u00e1gica), para ser garantida a usabilidade do PIPA nos casos de crian\u00e7as com maior severidade de perturba\u00e7\u00e3o e/ou com perda auditiva associada.Nas tarefas de separa\u00e7\u00e3o binaural  foi igualmente reformulada, atendendo a que um dos peritos chamou a aten\u00e7\u00e3o para a quest\u00e3o do daltonismo. Nestas situa\u00e7\u00f5es, a tarefa poder\u00e1 ser realizada com o apoio do TF, que poder\u00e1 selecionar as cores, depois da crian\u00e7a indicar a sequ\u00eancia de cores que ouviu.A tarefa de mem\u00f3ria auditiva de cores  corresponde a uma validade de conte\u00fado excelente, uma vez que \u00e9 superior a 0,90,17. Neste sentido, foi fundamental a sele\u00e7\u00e3o cuidada dos est\u00edmulos verbais que foram inclu\u00eddos no PIPA, balanceados de acordo com os padr\u00f5es de frequ\u00eancia do PE,28.O desenvolvimento e valida\u00e7\u00e3o de um programa de interven\u00e7\u00e3o, particularmente no que reporta \u00e0 \u00e1rea do PA, constitui um fator inovador para o PE. Neste \u00e2mbito, e dada a escassez de materiais, optou-se por criar um programa em que s\u00e3o utilizados est\u00edmulos verbais para o treino das diferentes compet\u00eancias auditivas,9.Para a elabora\u00e7\u00e3o do PIPA procurou realizar-se uma sele\u00e7\u00e3o cuidada de compet\u00eancias, objetivos, tarefas e est\u00edmulos, tendo sempre em vista a sua utiliza\u00e7\u00e3o em contexto cl\u00ednico. Paralelamente, foi tido em considera\u00e7\u00e3o o facto de o programa ter como p\u00fablico-alvo crian\u00e7as em idade escolar e, como tal, ser necess\u00e1ria a utiliza\u00e7\u00e3o de ferramentas l\u00fadicas como forma de motiva\u00e7\u00e3o e ades\u00e3o \u00e0s mesmas,18. Para al\u00e9m disso, est\u00e1 em conformidade com alguns programas dispon\u00edveis internacionalmente, que mostram os progressos da crian\u00e7a nas atividades de treino auditivo,22.A inclus\u00e3o de um sistema de recompensas e de monitoriza\u00e7\u00e3o de acertos por parte da crian\u00e7a, para al\u00e9m de ter sido validada por unanimidade pelos peritos, constitui um fator fundamental na avalia\u00e7\u00e3o cont\u00ednua da crian\u00e7a, na (re)defini\u00e7\u00e3o de objetivos de interven\u00e7\u00e3o e na manuten\u00e7\u00e3o de \u00edndices motivacionais para a tarefa, estando de acordo com o que \u00e9 defendido na literatura para a interven\u00e7\u00e3o em casos de PPA. Desta forma, e atendendo a que a PPA pode ter consequ\u00eancias negativas para o desempenho lingu\u00edstico, social e acad\u00e9mico dos indiv\u00edduos,11, o PIPA poder\u00e1 ter um impacto positivo nos seus utilizadores, no que concerne aos fatores pessoais que promovem a atividade e participa\u00e7\u00e3o nos v\u00e1rios contextos.As compet\u00eancias auditivas desenvolvidas no PIPA  permitem a compreens\u00e3o de fala, uma vez que envolvem a discrimina\u00e7\u00e3o, o reconhecimento, a aten\u00e7\u00e3o seletiva e sustentada dos sons e a capacidade de memoriza\u00e7\u00e3o dos mesmos. O PIPA abre assim caminho para outros estudos no \u00e2mbito da interven\u00e7\u00e3o na PPA em crian\u00e7as cuja l\u00edngua materna \u00e9 o PE, contribuindo para melhoria da pr\u00e1tica cl\u00ednica dos TFs nesta \u00e1rea. Como trabalho futuro, est\u00e3o previstos estudos de aceitabilidade e efic\u00e1cia do PIPA, junto de crian\u00e7as com e sem PPA.Para al\u00e9m disso, a pr\u00e1tica baseada na evid\u00eancia na tomada de decis\u00f5es \u00e9 fundamental para elevar a qualidade da interven\u00e7\u00e3o terap\u00eauticaEste trabalho permitiu o desenvolvimento e valida\u00e7\u00e3o do PIPA, cumprindo com as etapas definidas na literatura para a cria\u00e7\u00e3o de novos instrumentos. Trata-se de um instrumento inovador para o PE, com um IVC excelente, cuja an\u00e1lise da sua aceitabilidade e efic\u00e1cia est\u00e1 prevista, como trabalho futuro."}
+{"text": "To verify the association between caregivers' and teachers' perceptions of the changes imposed by social isolation and the impact on students' learning.nd-grade students from a public financing school and their respective teachers. The caregivers were submitted to interviews by means of the questionnaires: Abilities and Difficulties Questionnaire, Family Environment Resources Inventory and COVID-19 monitoring questionnaire that checks the behavior of schoolchildren and families. The collection took place in two moments by telephone call: the first moment (M1) was started in June 2020, and the second, (M2) in December 2020. The progress reports prepared by the regular teachers were received in January 2021.This is an analytical observational and longitudinal study, with the participation of 19 caregivers (family members) of 2A negative implication was observed in the change of routine and an impact on the parents' lives. In parents' perceptions, significant and negative issues were also present in children's mental health, such as changes in routine. Teacher evaluation reports showed a similar pattern, with the vast majority of them lacking information about learning performance.This study pointed out the importance of accompanying schoolchildren and families in a period of social withdrawal, in order to guide and intervene together with parents and teachers. Governmental . School plays a crucial role in the development of children and with their closures lessons had to be adapted to an online format so that there was no interruption to classes. With this change came the need to adopt strategies that would help to reduce the impact caused by the suspension of in-person lessons. Considering such difficulties and limitations it is important to reflect on the impact caused to the process of learning to read and write during this period of online teaching, especially to children at the beginning of elementary school.Digital education in Brazil was already facing many challenges and impasses, such as difficulties to access the internet in the classroom, problems to train teachers in activity planning, among othersWhen comparing in-person teaching with online teaching it is necessary to take into account the issues and challenges faced, whether from the viewpoint of teachers, children, families or the technologies employed. The teacher has to adapt and learn how to use these new technologies in his or her professional daily life so that there can be an interaction with the students and to prepare videos and exercises among other activities. For the families the main challenge is the availability and awareness of those responsible, to be able to follow the lessons and or explain the content to children. Very often the parents or guardian did not have a sufficient level of education to do this. Children need motivation to maintain their attention and study pace, and to achieve this previous development of skills and academic content is essential.. Such questions lead us to ask whether the conditions of access that encompass the online schooling process are being sufficiently monitored.Technology includes access and the ability to use equipment and also connection quality, there is a strong link between these issues and socioeconomic status, since families with low socioeconomic status do not have sufficient access to technology and those responsible tend to have a poorer level of schooling, therefore it is important to accompany students in vulnerable situations, since access to schooling sometimes has further to go, becoming even more important in the context of online teaching and the return to in-person teaching. When one knows how the pace of development strategies can be employed to minimize the impact caused to families.It is a well-known fact that cognitive and linguistic development is associated with socioeconomic status, and children from low income families have a poorer academic performance-7. A study carried out in S\u00e3o Paulo with students from the 1st to 5th years showed that students who had poorer school performance in the opinion of those responsible are the ones with the greatest problems related to behavior and hyperactivity.Studies show that mental health and family resources are also associated with the academic performance of school children, when there is a family interaction with pre-established routines and greater access to extracurricular activities, the encouragement of reading and monitoring of school activities and the family-school relationship.In addition to the impact on mental health, the family environment also positively influences school performance. In addition children were socially isolated and missed out on opportunities for leisure and socializing with people outside of their families. Understanding how these families experienced and are experiencing this period of confinement is a way to help them to understand how to face such difficulties. The objective of this study was to analyze the changes brought about by social isolation and the impact on the learning development of students in the second year of a public elementary school from the viewpoint of parents and teachers.During social distancing the family-school relationship became distant in the context of the conventional classroom and there was a greater need for family participation and support during this timeThis is an analytical and longitudinal observational study approved by the Research Ethics Committee of the institution under protocol number 3,906,514. All guardians signed a consent form (FICT). Those who participated in the study were parents or guardians made up of the closest family members responsible for the children, and the teachers of 19 students from the 2nd year of an elementary school. Data collection was carried out by phone survey and parents and guardians who agreed to participate were interviewed by telephone and the interviewer read out the consent form and the interviewees responded by giving their names and agreement as requested by the ethics committee and each interview was recorded.This study is part of a larger project based on the Intervention Response Model (RTI) that began in February 2020 in-person. With the closure of schools, only children enrolled in classes of the second year of a public elementary school in the city of Bras\u00edlia who had a signed consent form before the school closures were included in this study. Childrens\u00b4 parents who did not take part in the two interviews were excluded.For data collection, the following instruments as answered by the (family members) were used:The Abilities and Difficulties Questionnaire (SDQ-Por)7 is an instrument used internationally to detect problems related to children's mental health, It consists of 25 items, 10 of which are about capabilities, 14 about difficulties and one neutral item, It is divided into five sub-scales each with five statements namely, emotional symptoms, conduct problems, hyperactivity, peer relationship problems and prosocial behavior. The questionnaire's score followed the proposal of the instrument itself, with the classification of the score of each scale and the total score as normal, borderline and altered. is a script with closed-ended questions that makes it possible to survey the resources of the family environment that can contribute to school performance during the elementary school years. It consists of 10 questions divided into three domains, proximal processes , stability in family life  and family-school relationship (parent participation in school life and meetings).The Inventory of Family Environment Resources (RAF)The COVID-19 Monitoring Questionnaire. Specially prepared for this study has 18 questions about the behavior of children and families as detailed below. The suspension of classes due to social isolation, family income during this period, how the child dealt with social isolation and information about preventative measures, and the child's routine and behavior during isolation. For each question a Likert scale of up to seven points was used. For the analysis of each variable, the Likert scale score of each item was added, with the following maximum total scores; parents explained preventative measures to schoolchildren 16 points, schoolchildren understood social distancing 12 points, knew that measures had to be taken 8 points, took or accepted to take preventive measures 16 points, leisure activities at home 10 points, impact of school suspension on parents' lives 12 points, changes in students' behavior 40 points, and changes in play 54 points. The closer to the maximum score, more positive the behavior.End of school year reports. The children's progress was analyzed by reading the end of the school year reports for 2020 as prepared by the teachers.th of July 2020 in public schools. During the previous months (April and June), a period in which there was no school, strategies were drawn up and improved on, to involve student through printed activities and an online platform.Data collection was carried out in three steps, the first two being interviews with the guardians or parents of the children, and the third reception of the progress reports. The interviews were carried out by phone by the first interviewer and questions were asked from the first questionnaires as described above. The first moment (M1) started in June 2020, and the second moment (M2) in December 2020. The progress reports prepared by the teachers were received in January 2021. It is worth mentioning that school activities were resumed in an online format on the 13The data was submitted for descriptive and inferential statistical analysis with a significance level of 5%. The analyzes were performed using the IBM SPSS statistical platform  version 21.0. The tests used to compare the two instances were, the Mcnemar Bowker, to measure the behavior at moment 1 (M1) and moment 2 (M2) of the same sample for dependent qualitative variables, and the Wilcoxon Rank Test for dependent quantitative variables . For correlation analysis the Spearman test was used for a non-normal distribution.Data analysis showed that more than 80% of respondents were mothers/fathers or grandmothers of the students. Regarding the suspension of classes, 94.7% agreed with the government's decision to suspend in-person classes as a coping measure imposed by COVID-19 and 68.4% agreed or strongly agreed to the suspension of classes for the same reasons mentioned above.The data collected from the COVID-19 Monitoring Questionnaire did not generate the same variables in M1 and M2. For M2, the following variables were collected and compared, family income, access to emergency assistance, changes in the child's behavior, access to remote classes and hours of study. Due to the difficulties faced by teachers in assessing the children's progress, online school reports show us a similar pattern, with the vast majority lacking information (with a little more than 60% of the sample missing information). For the analysis of the reports, we sought to identify the following elements about the children's development, carried out school activities, the family followed the activities, collective reading, silent reading, reading and interpretation of simple and complex texts, reading and interpretation of short and long texts, comprehension and syllable separation, ordering of words and phrases, writing simple and complex sentences, retelling of written text, and oral speech . It was The teachers' evaluations showed us that 36.8% of the 19 students were developing collective reading and 31.6%, silent reading. 36.8% read simple texts and 31.6% read complex, short and long texts and interpreted simple and complex, short and long texts .Regarding writing, 36.8% could write simple sentences and 31.6% could write complex sentences. Only 31.6% could order words in alphabetical order, and 36.8% of students could order sentences . 31.6% understood and could separate syllables. 36.8% of students could retell written texts . In the oral speech performed by the students the percentage was 36.8%. The psychogenesis levels evaluated by the teachers showed that 5.3% of the students were in the pre-syllabic level, 15.8% in the alphabetic II level and 15.8% in the alphabetic III level. Other tA crossing between the RAF and the COVID-19 Monitoring Questionnaire was performed at moments M1 and M2. The Spearman correlation was used for the analysis. Because there are many variables we chose to present only statistically significant results. According to the results presented in The purpose of this study was to verify the association between the changes imposed by social distancing, the learning development and the behavior of students. We present the results of 19 children from the second year of an Elementary School from the perspective of their parents and teachers as collected in June and December of 2020.The students were evaluated through questionnaires (parents' perspective) about the situation of school closures, the period of social isolation and the teachers' progress reports.. Although the study deals with young people, the similarity with the present study is due to the contextual analysis of the perspective of the parents.The data shows that the families agreed with the suspensions of classes due to the spread of the virus, but not everyone liked it. Similar findings were found in another survey carried out in the Czech Republic where despite a lack of technology and the difficulties in teaching school activities at home, parents still preferred to maintain social distancing and online teaching due to COVID-19.Most families did not have access to the emergency aid program in M2. It\u00b4s a well-known fact that a decrease in income is an aggravating factor in families and this was already being discussed well before the period of social isolation, however during the pandemic it was worse with an even greater impact with results dependent on the length of social isolation.Regarding how children coped with social isolation, most schoolchildren understood social distancing because parents were careful to explain about preventive measures that should be taken and when necessary. The influence of parents in health education is very important because children feel more comfortable and confident in the home environment, however results did not show this. Because the beginning of data collection took place two months after the school closures, it could be concluded that families were already adapting to the changes imposed by the pandemic.There were significant changes in leisure and play, children's behavior and parents' lives after the school closuresth of February 2020, however they were suspended on the 12th of March 2020 due to the COVID-19 pandemic. Online teaching started at SEE on the 13th of July 2020 and some difficulties were found in accessing the classes at M1, with more than 70% of students without any type of access. However in the M2 of the collection, all students already had access to classes, with classes between one and six times a week and each class containing one hour or more of school activities.Classes as authorized by the Municipal Secretary of Education (SEE) started on The 10.It is important to emphasize that even though the students did not have access to classes at M1, their parents/guardians were concerned enough to dedicate a few hours to school activities with books and others materials of choice. Similar data can be found in terms of both study hours and parents/guardians\u00b4 dedication to school assignments in a survey carried out in the Czech Republic. This study  surveyed data from 72% of students who dedicated between 2-4 hours of study per day, and 66% of their parents/guardians helped during half of this time with school activities. However, the results show us that when it came to books no differences were found between M1 and M2, in fact book collection decreased in M2.During social distancing, schoolchildren spent more time at home than usual. Regarding the resources of the family environment, the variable playing on the street did not change in both moments, but the amount of toys in M2 was greater, this may be because parents bought more toys to help improve the playtime of children, bringing a certain degree of comfort during self isolation, we did not find academic articles that focused on the variation of children's books available during the pandemic in Brazil. Despite not being a specific objective of this study, the limitation that it was not possible to verify the variability of books during the period should be taken into account, data that is needed by the instruments used.We can speculate that this decrease, could have been because of free access to virtual books, which were more accessible and accompanied by national campaigns or donations. However despite there being different studies on early childhood education during the pandemic.During social isolation family outings decreased considerably which shows the extent of caution that families took during social distancing in Brazil. The decrease in extracurricular activities during the pandemic had a negative effect because they are particularly important for children to help build relationships between peers and for socialization. Playing is one of the activities that most helps children in the process of affectivity, development and socialization. In the teachers' report, this relationship was seen with 78.9% of the families accompanying the activities.The school has always sought to involve children\u00b4s families in the students' learning process and the family is the first to start this process. Trust and commitment are part of the family school relationship and need to be in harmony to guarantee continued and effective education. In this study, we saw that families improved this relationship and they needed to have better contact with the school because they often accompanied their children during online classes, which can be explained by the fact that data collection started two months after the social distancing measures were adopted in the municipality in question. In the variable stability in family life, which surveys the times that the family usually spends time together, it was found that at almost all times the family was together, because they were spending more time at home due to social distancing. Changes in the family environment generate instabilities, directly affecting socialization (decreased contact between peers) and economics (decreased income).The routine did not change between the two moments of collection, changes in routine and family life were as expectedRegarding reading at home, there was an increase in students who dedicated themselves to reading in M2, and it can be reasoned that reading increased because it was a time when all the students had online access and classes, which gave them greater motivation to read. Additionally during this period it was easier for the students to read because of the availability of free online books which were made available through platforms such as Google Classroom.. Because families spent more time at home they correspondingly spent more time watching and talking about TV.Most parents/guardians said that they talked about school with their children even with the closures, probably because parents needed to supervise school activities more closely, whether it be teaching homework, collecting material from school or accompanying children in online classes, additionally they talked more about television. A study carried out with Brazilians aged 18 and over found that the average time spent watching television was longer after the COVID-19 pandemic, with 1 hour and 45 minutes more viewing time,24, we can see in nd-grade students (N=25), indicating an absence or difficulty in imposing limits on child development. It is important to emphasize that reports of emotional problems in the family environment were already common before the pandemic, however during social distancing these reports became more evident.When comparing the results of the SDQ-Por. This data lead to the hypothesis that they may be related to changes in routines, sometimes caused by disobedience and irritability, or the prevalence in this age group of a low socioeconomic level.Regarding behavioral problems, three students had an altered level (15.8%), corroborating a previous study with students with an average age of 8.18 years oldThe instrument's total score is the sum of the scores of 4 scales that refer to difficulties  and the 01 scale that refers to capabilities , found in able 3. No difference was found between the two moments, but 17 of the 19 students showed changes in M1, and in M2 this number dropped to 12. This event may have occurred because families and children were already used to the new reality that had been imposed on them.. Due to social isolation family income was affected which may have led to instability in the mental health of families, and consequently of the children.A study with the same objective carried out with 6,727 adolescents aged 11 to 17 years old reached a total score of 8.8% on the altered scale. In this same sample it was found that students with a low socioeconomic status had higher rates on all the scales of the SDQ.It is important to emphasize that the SDQ cannot be seen in isolation for pathological signs, it needs other assessments to complete it. It should be used as a screening for prevention strategies and new adaptations for children.Data taken from the teacher's assessment showed that 18 schoolchildren carried out their activities fully, effectively or partially. One of the objectives of school activities is to consolidate what was taught by the teacher and to measure what was learned in class by them. Many students may not have developed or their knowledge was not measured through reading, writing, text interpretation and comprehension, word ordering and text retelling activities, since in most school reports we did not find answers as to whether the student would be able or not according to the measurement of development. It is worth highlighting the difficulties the education system faced by teachers in evaluating students remotely, often needing to reinvent themselves as a matter of urgency to meet the demands that were imposed on them during the pandemicWhen we think about correlating the findings of the two questionnaires , the intention is that they should show us behavior of these students, as well as adjustments so that they can be worked on in a clinical and educational context. We also intended to understand whether having more resources in the family environment associated with pre-established routines lead children to adapt better to social isolation.Understanding of social distancing is positively related to the number of toys in M2. This may have happened because as children were given toys, which was a positive factor they began to understand the need for social isolation..Leisure is also positively related to book collections on various subjects. During social distancing students spent more leisure time reading in M1. This data was also found in a study using questionnaires with university students in Macap\u00e1 - AP. 456 questionnaires on leisure and the impact of the COVID-19 pandemic were analyzed, and reading was one of the leisure activities significantly marked (41.9%)General outings were positively related in M1 with understanding of social distancing. We can hypothesize that since schoolchildren understood about social distancing, they understood that they needed to stay at home longer and reduce outings and take preventive measures.. There was also a positive relationship in the routine, including an explanation of preventive measures to which the whole family were committed to caring for themselves and others. Before the pandemic families had routines but during the pandemic, it was necessary to include new information in the daily lives of these students, which resulted in a positive relationship.There was also a positive relationship in extracurricular activities and an impact on parents' lives. This relationship may have been brought about by the schoolchildren's routines which were divided into moments with the family and activities outside the home. Parents had to take on many new activities to occupy their children's time and this may have had a negative impact on their livesFamily stability refers to the times when the family is usually together. Here there was a positive relationship, since the family spent more time together, knowledge about preventative measures increased since more time was devoted to explanations and perhaps if the family spent less time together preventative knowledge would have been less as well.Another limitation of this research concerns the other relevant aspects related to learning, such as reading, writing and comprehension of texts. Although important, they were not part of the scope of this study and should be taken into account in this context when returning to in-person classes.In view of the findings presented and the changes brought about by social distancing during the attempt to combat the COVID-19 pandemic, these changes affected various areas in the families monitored in this study during the period from June 2020 to December 2020. There was a negative impact on parent\u2019s lives due to the suspension of in-person classes and extracurricular activities and parents had to adapt to new responsibilities and roles. The positive side was that there was an improvement in the family-school relationship, which should be explored further in the post-pandemic period.Negative changes in routines were also found through the SDQ-Por, causing instabilities in children's mental health.We propose that school-age children should be monitored, evaluated and given the opportunity of early multidisciplinary intervention, because despite having a less representative sample the study showed us the real situation of 19 families with negative factors that will be reflected in the school development of these children. This study points out as a limitation the description of the progress reports by teachers on school learning, since little more than 60% of the sample did not have this information. We suggest for future research a collection with a more representative sample and a comparison with children from other school years. We also suggest associating the assessment of the questionnaires with the reading performance of students from different socioeconomic levels. .O distanciamento social foi adotado em diferentes estados do Brasil como medida preventiva de combate \u00e0 COVID-19, incluindo o fechamento de escolas . A escola exerce um papel importante no desenvolvimento da crian\u00e7a, e com seu fechamento, as aulas precisaram ser adaptadas \u00e0 modalidade remota para que o ensino n\u00e3o fosse interrompido. Com isso, veio a necessidade de se tra\u00e7arem estrat\u00e9gias que auxiliassem na diminui\u00e7\u00e3o dos impactos provocados pela suspens\u00e3o das aulas presenciais. Considerando tais dificuldades e limita\u00e7\u00f5es encontradas, \u00e9 importante refletir sobre os impactos gerados no processo de aprendizagem da leitura e escrita nesse per\u00edodo de ensino remoto, principalmente em crian\u00e7as no in\u00edcio do Ensino Fundamental.O processo de inclus\u00e3o digital na educa\u00e7\u00e3o brasileira j\u00e1 vinha sofrendo desafios e impasses, como dificuldades de acesso \u00e0 internet na sala de aula, capacita\u00e7\u00e3o dos professores no planejamento de atividades, entre outros. Tais quest\u00f5es nos levam a questionar se as condi\u00e7\u00f5es de acesso que englobam o processo de escolariza\u00e7\u00e3o online est\u00e3o sendo monitoradas.Quando comparamos o ensino presencial com o ensino remoto, \u00e9 preciso levar em considera\u00e7\u00e3o quest\u00f5es ou desafios, sejam do ponto de vista do professor, das crian\u00e7as, das fam\u00edlias ou das tecnologias. O professor precisou se adaptar ao uso de tecnologias em seu dia a dia profissional para que houvesse intera\u00e7\u00e3o com os estudantes, elabora\u00e7\u00e3o de v\u00eddeos, question\u00e1rios, entre outros. Em rela\u00e7\u00e3o \u00e0s fam\u00edlias, o principal desafio foi a disponibilidade e consci\u00eancia dos respons\u00e1veis para acompanhar as aulas ou explicar o conte\u00fado para as crian\u00e7as, sendo que nem sempre tinham escolariza\u00e7\u00e3o suficiente para isso. As crian\u00e7as precisavam de motiva\u00e7\u00e3o para manter a aten\u00e7\u00e3o e o ritmo de estudo, e para isso, o desenvolvimento pr\u00e9vio de habilidades e conte\u00fados acad\u00eamicos foi fundamental. J\u00e1 quanto \u00e0 tecnologia, podemos pensar no acesso e dom\u00ednio de equipamentos e na qualidade da conex\u00e3o. Essas quest\u00f5es est\u00e3o fortemente associadas ao n\u00edvel socioecon\u00f4mico, pois fam\u00edlias de baixo n\u00edvel socioecon\u00f4mico n\u00e3o conseguem ter acesso suficiente \u00e0s tecnologias e os respons\u00e1veis tendem a ter menor escolaridade. Dessa forma, destaca-se a import\u00e2ncia de acompanhar escolares em situa\u00e7\u00e3o de vulnerabilidade, pois o acesso \u00e0 aprendizagem escolar \u00e9, por vezes, um caminho maior a percorrer, tornando-se ainda mais importante no contexto de ensino remoto e retorno do ensino presencial. A partir do momento em que se tem conhecimento de como eles est\u00e3o se desenvolvendo, estrat\u00e9gias podem ser utilizadas para minimizar os impactos causados \u00e0s fam\u00edlias.Sabe-se que o desenvolvimento cognitivo e lingu\u00edstico est\u00e1 associado ao n\u00edvel socioecon\u00f4mico, com pior desempenho entre as crian\u00e7as de baixa renda-7. Estudo realizado em S\u00e3o Paulo com escolares do 1\u00ba ao 5\u00ba ano evidenciou que escolares que possuem pior desempenho escolar na vis\u00e3o dos respons\u00e1veis s\u00e3o os que mais apresentam problemas relacionados \u00e0 conduta e hiperatividade.A literatura aponta que a sa\u00fade mental e os recursos do ambiente familiar tamb\u00e9m est\u00e3o associados ao desempenho acad\u00eamico de crian\u00e7as em idade escolar, quando proporciona: intera\u00e7\u00e3o familiar com rotinas pr\u00e9-estabelecidas e mais acesso a atividades extras; est\u00edmulo \u00e0 leitura e acompanhamento das atividades escolares; e rela\u00e7\u00e3o fam\u00edlia-escola.Al\u00e9m dos impactos da sa\u00fade mental, o ambiente familiar tamb\u00e9m influencia positivamente o desempenho escolar. Al\u00e9m disso, as crian\u00e7as ao ficarem isoladas socialmente, perderam oportunidades de lazer e intera\u00e7\u00e3o com pessoas fora do seu n\u00facleo familiar. Entender como essas fam\u00edlias vivenciaram e vivenciam esse per\u00edodo de confinamento \u00e9 uma forma de ajud\u00e1-las a entender como enfrentar tais dificuldades. Portanto, o objetivo deste trabalho foi verificar a associa\u00e7\u00e3o entre a percep\u00e7\u00e3o dos cuidadores e dos professores acerca das mudan\u00e7as impostas pelo isolamento social e o impacto na aprendizagem de estudantes do 2\u00ba ano do Ensino Fundamental de uma escola p\u00fablica da regi\u00e3o administrativa de Samambaia-Distrito Federal.Com o per\u00edodo de distanciamento social, a rela\u00e7\u00e3o fam\u00edlia-escola passou a ficar distante no contexto de sala de aula convencional, por\u00e9m houve uma maior necessidade de participa\u00e7\u00e3o e apoio da fam\u00edlia durante esse per\u00edodo remotoTrata-se de estudo observacional anal\u00edtico e longitudinal aprovado pelo Comit\u00ea de \u00c9tica em Pesquisa da institui\u00e7\u00e3o sob parecer n\u00ba 3.906.514. Todos os respons\u00e1veis assinaram o Termo de Consentimento Livre e Esclarecido (TCLE). Participaram do estudo cuidadores, compostos pelos familiares respons\u00e1veis mais pr\u00f3ximos \u00e0s crian\u00e7as, e professores de 19 escolares do 2\u00ba ano do Ensino Fundamental. Para a atender \u00e0s mudan\u00e7as no formato da coleta de dados, que passou a ser remota, os pais que concordaram em participar das entrevistas por telefone, ouviram a leitura do TCLE, falaram o nome e \u201cde acordo\u201d como solicita\u00e7\u00e3o do Comit\u00ea de \u00c9tica para a coleta de maneira remota, sendo esta informa\u00e7\u00e3o gravada.Este estudo faz parte de um projeto maior baseado no Modelo de Resposta \u00e0 Interven\u00e7\u00e3o (RTI) que se iniciou em fevereiro de 2020 de forma presencial. Com o fechamento das escolas, foram inclu\u00eddas para o presente artigo apenas as crian\u00e7as regularmente matriculadas nas turmas do 2\u00ba ano do Ensino Fundamental I de uma escola p\u00fablica da cidade de Samambaia- Distrito federal e que estavam com os TCLEs assinados antes do fechamento das escolas. Foram exclu\u00eddas as crian\u00e7as cujos pais n\u00e3o participaram das duas entrevistas.Para coleta dos dados, foram utilizados os seguintes instrumentos respondidos pelos respons\u00e1veis cuidadores (familiares):: instrumento utilizado internacionalmente para a detec\u00e7\u00e3o de problemas relacionados \u00e0 sa\u00fade mental infanto-juvenil. \u00c9 composto por 25 itens, sendo 10 itens sobre capacidades, 14 sobre dificuldades e um item neutro. Est\u00e1 dividido em cinco subescalas, cada uma com cinco afirma\u00e7\u00f5es, a saber: sintomas emocionais, problemas de conduta, hiperatividade, problemas de relacionamento com colegas e comportamento pr\u00f3-social. A pontua\u00e7\u00e3o do question\u00e1rio seguiu a proposta do pr\u00f3prio instrumento, com a classifica\u00e7\u00e3o da pontua\u00e7\u00e3o de cada escala e da pontua\u00e7\u00e3o total em: normal, lim\u00edtrofe e alterado.Question\u00e1rio de Capacidades e Dificuldades (SDQ-Por): roteiro com quest\u00f5es fechadas que possibilita o levantamento dos recursos do ambiente familiar que podem contribuir para o aprendizado escolar nos anos do ensino fundamental. \u00c9 constitu\u00eddo por 10 quest\u00f5es divididas em tr\u00eas dom\u00ednios: processos proximais , estabilidade na vida familiar  e v\u00ednculo fam\u00edlia-escola (participa\u00e7\u00e3o dos pais na vida escolar e reuni\u00f5es).Invent\u00e1rio de Recursos do Ambiente Familiar (RAF)Question\u00e1rio de monitoramento COVID-19: Elaborado para o presente estudo, conta com 18 quest\u00f5es sobre o comportamento das crian\u00e7as e fam\u00edlias detalhadas a seguir: a suspens\u00e3o das aulas devido \u00e0 necessidade de isolamento social; renda da fam\u00edlia nesse per\u00edodo; como a crian\u00e7a est\u00e1 lidando com o isolamento social e as informa\u00e7\u00f5es sobre as medidas de preven\u00e7\u00e3o; e a rotina e os comportamentos da crian\u00e7a durante o isolamento. Para cada pergunta, foi utilizada escala likert de at\u00e9 sete pontos. Para an\u00e1lise de cada vari\u00e1vel, somou-se a pontua\u00e7\u00e3o da escala likert de cada item, com a seguinte pontua\u00e7\u00e3o m\u00e1xima total: pais explicaram sobre as medidas de preven\u00e7\u00e3o para os escolares, 16 pontos; escolares compreendem o distanciamento social, 12 pontos; sabem que as medidas devem ser feitas, 8 pontos; fazem ou aceitam fazer as medidas de preven\u00e7\u00e3o, 16 pontos; atividades de lazer em casa, 10 pontos; impacto da suspens\u00e3o das aulas na vida dos pais, 12 pontos; mudan\u00e7as no comportamento dos escolares, 40 pontos; e mudan\u00e7as na brincadeira, 54 pontos. Quanto mais pr\u00f3ximo da pontua\u00e7\u00e3o m\u00e1xima, mais positivos os comportamentos.Relat\u00f3rio evolutivo das crian\u00e7as: Foi analisado o relat\u00f3rio evolutivo individual das crian\u00e7as elaborado pelo professor regente ao final do ano letivo de 2020.A coleta de dados foi realizada em tr\u00eas momentos, sendo as duas primeiras de entrevistas com os respons\u00e1veis das crian\u00e7as, e a terceira de recebimento dos relat\u00f3rios evolutivos. As entrevistas foram realizadas, pela primeira autora, por meio de liga\u00e7\u00f5es telef\u00f4nicas para aplica\u00e7\u00e3o dos question\u00e1rios descritos anteriormente. O primeiro momento (M1) foi iniciado em junho de 2020, e o segundo momento (M2) em dezembro de 2020. Os relat\u00f3rios evolutivos elaborados pelos professores regentes foram recebidos em janeiro de 2021. Vale ressaltar que as atividades escolares foram retomadas na modalidade de ensino remoto em 13 de julho de 2020 nas escolas p\u00fablicas. Durante os meses anteriores (abril e junho), per\u00edodo que n\u00e3o foi contabilizada presen\u00e7a, estrat\u00e9gias foram organizadas e aprimoradas buscando o envolvimento dos estudantes por meio de atividades impressas e plataforma on-line.Mcnemar Bowker, para medir o comportamento no momento 1 (M1) e momento 2 (M2) de uma mesma amostra para vari\u00e1veis qualitativas dependentes, e o Teste dos Postos de Wilcoxon para vari\u00e1veis quantitativas dependentes. Para a an\u00e1lise de correla\u00e7\u00e3o, foi utilizado o teste de Spearman para uma distribui\u00e7\u00e3o n\u00e3o normal.Os dados foram submetidos \u00e0 an\u00e1lise estat\u00edstica descritiva e inferencial com n\u00edvel de signific\u00e2ncia de 5%. As an\u00e1lises foram realizadas com o pacote estat\u00edstico IBM SPSS  na vers\u00e3o 21.0. Os testes utilizados para compara\u00e7\u00e3o entre os dois momentos foram: A an\u00e1lise dos dados demonstrou que mais de 80% dos respondentes eram m\u00e3e/pai ou av\u00f3 dos escolares. Em rela\u00e7\u00e3o \u00e0 suspens\u00e3o das aulas, 94,7% concordaram com a decis\u00e3o governamental de suspens\u00e3o, como medida de enfrentamento imposta pela COVID-19 e 68,4% gostaram ou adoraram a suspens\u00e3o das aulas pelos mesmos motivos citados acima.A coleta realizada por meio do Question\u00e1rio de monitoramento COVID-19 n\u00e3o levantou as mesmas vari\u00e1veis em M1 e M2. Para o M2, foram coletadas e comparadas as seguintes vari\u00e1veis: renda familiar, acesso ao aux\u00edlio emergencial, mudan\u00e7a no comportamento da crian\u00e7a, acesso \u00e0 aula remota e horas de estudo. A A Devido \u00e0s dificuldades enfrentadas pelos professores na avalia\u00e7\u00e3o remota, os relat\u00f3rios evolutivos das crian\u00e7as nos mostram um padr\u00e3o similar, com a grande maioria sem informa\u00e7\u00e3o (com um pouco mais de 60% da amostra sem informa\u00e7\u00e3o). Para a an\u00e1lise dos relat\u00f3rios, buscou-se identificar os seguintes elementos sobre o desenvolvimento das crian\u00e7as: realizou as atividades da escola; a fam\u00edlia acompanhou as atividades; leitura coletiva; leitura silenciosa; leitura e interpreta\u00e7\u00e3o de textos simples e complexos; leitura e interpreta\u00e7\u00e3o de textos curtos e longos; compreens\u00e3o e separa\u00e7\u00e3o de s\u00edlabas; ordena\u00e7\u00e3o de palavras e frases; escrita de frases simples e complexas; reconto de texto escrito; e discurso oral . ObservaA avalia\u00e7\u00e3o dos professores nos trouxe dados de que 36,8% dos 19 escolares est\u00e3o em desenvolvimento de leitura coletiva e 31,6%, de leitura silenciosa. Quanto \u00e0 leitura, 36,8% leem textos simples e 31,6% realizam leitura de textos complexos, curtos e longos e interpretam textos simples e complexos, curtos e longos .Em rela\u00e7\u00e3o \u00e0 escrita, 36,8% escrevem frases simples e 31,6% escrevem frases complexas. Na ordena\u00e7\u00e3o de palavras por ordem alfab\u00e9tica, apenas 31,6% a realizam, e na ordena\u00e7\u00e3o de frases , 36,8% dos escolares a realizam; 31,6% compreendem e separam s\u00edlabas. Quanto ao reconto de texto escrito, 36,8% dos escolares realizam esse tipo de atividade. No discurso oral realizado pelos escolares, a porcentagem \u00e9 de 36,8%. Nos n\u00edveis da psicog\u00eanese avaliado pelos professores, 5,3% dos escolares encontravam-se no n\u00edvel pr\u00e9-sil\u00e1bico, 15,8%, no alfab\u00e9tico II e 15,8%, no alfab\u00e9tico III . Os demaFoi realizado um cruzamento entre o RAF e o Question\u00e1rio de monitoramento COVID-19 nos momentos M1 e M2. Para essa an\u00e1lise, foi utilizada a correla\u00e7\u00e3o de Spearman. Como s\u00e3o muitas vari\u00e1veis, optou-se por apresentar apenas os resultados estatisticamente significativos. De acordo com os resultados apresentados na Este estudo verificou a associa\u00e7\u00e3o entre as mudan\u00e7as impostas pelo isolamento social, a aprendizagem e o comportamento dos escolares. Apresentamos resultados de 19 crian\u00e7as do 2\u00ba ano do Ensino Fundamental, na percep\u00e7\u00e3o de seus pais e professores, coletados em junho e dezembro de 2020. Os escolares foram avaliados por meio de question\u00e1rios (percep\u00e7\u00e3o dos pais) sobre a situa\u00e7\u00e3o do fechamento das escolas, per\u00edodo de isolamento social e relat\u00f3rio evolutivo dos professores.. Apesar do estudo tratar de jovens, a similaridade com o presente se d\u00e1 pela an\u00e1lise contextual na percep\u00e7\u00e3o de pais.Os dados mostram que as fam\u00edlias concordaram com as suspens\u00f5es das aulas por conta da dissemina\u00e7\u00e3o do v\u00edrus, por\u00e9m nem todos gostaram. Achados similares foram encontrados em uma pesquisa realizada na Rep\u00fablica Tcheca em que, apesar da falta de tecnologia e das dificuldades para o ensino das atividades escolares em casa, os pais ainda preferem manter o distanciamento social e o ensino remoto em raz\u00e3o da COVID-19.A maioria das fam\u00edlias n\u00e3o teve acesso ao programa de aux\u00edlio emergencial no M2. Sabe-se que a diminui\u00e7\u00e3o da renda \u00e9 um agravante que j\u00e1 vinha sendo discutido bem antes do per\u00edodo de isolamento social, por\u00e9m, nesse momento, foi mais intensificada com resultados ainda mais impactantes que depender\u00e3o de quanto tempo durar\u00e1 esse isolamento.Em rela\u00e7\u00e3o a como as crian\u00e7as lidaram com o isolamento social, a maioria dos escolares compreenderam o distanciamento social, pois os pais tiveram o cuidado de explicar sobre as medidas de preven\u00e7\u00e3o que devem ser feitas e tomadas quando necess\u00e1rio. A influ\u00eancia dos pais na educa\u00e7\u00e3o em sa\u00fade \u00e9 muito importante, pois as crian\u00e7as se sentem mais acolhidas, al\u00e9m de estarem em um ambiente que traz conforto e confian\u00e7a, entretanto, os resultados n\u00e3o mostraram isso. Como o in\u00edcio da coleta de dados ocorreu dois meses ap\u00f3s o fechamento das escolas, pode-se inferir que as fam\u00edlias j\u00e1 estavam se adequando \u00e0s mudan\u00e7as impostas pela pandemia.Esperava-se mudan\u00e7as significativas no lazer, brincadeiras, no comportamento das crian\u00e7as e na vida dos pais ap\u00f3s o fechamento das escolasAs aulas autorizadas pela Secretaria de Educa\u00e7\u00e3o (SEE) do munic\u00edpio se iniciaram em 10 de fevereiro de 2020, no entanto, foram suspensas no dia 12 de mar\u00e7o de 2020 em fun\u00e7\u00e3o da pandemia da COVID-19. O ensino remoto na SEE iniciou em 13 de julho de 2020 e foram observadas algumas dificuldades de acesso \u00e0s aulas no M1, com mais de 70% dos escolares sem nenhum tipo de acesso \u00e0 tecnologia. Por\u00e9m, no M2 da coleta, todos os escolares j\u00e1 estavam com acesso \u00e0s aulas, dividindo-se entre uma e seis vezes por semana de aula remota, entre 1h e mais de 1h nas atividades escolares..\u00c9 importante frisarmos que mesmo os escolares n\u00e3o tendo acesso \u00e0 aula no M1, seus cuidadores preocuparam-se em dedicar algumas horas de atividades escolares com livros e outras de livre escolha. Observa-se um dado semelhante tanto de horas de estudo como de dedica\u00e7\u00e3o dos cuidadores nas tarefas escolares em uma pesquisa realizada na Rep\u00fablica Tcheca. Esse estudo (N=9.810) obteve um dado de 72% dos escolares que dedicam entre duas a quatro horas de estudo por dia, e 66% dos seus cuidadores auxiliam com metade desse tempo nas atividades escolares. Por\u00e9m, os resultados mostram que, nos livros no geral, n\u00e3o foram observadas diferen\u00e7as nos M1 e M2, na verdade o acervo de livros diminuiu no M2.No per\u00edodo de distanciamento social, os escolares passaram mais tempo em casa do que o costume. Em rela\u00e7\u00e3o aos recursos do ambiente familiar, a vari\u00e1vel brincar na rua n\u00e3o mudou nos dois momentos, por\u00e9m a quantidade de brinquedos no M2 foi maior, isso pode ter ocorrido pelo fato dos pais investirem em brinquedos para suprir o lazer desses escolares, trazendo um certo grau de conforto no isolamento, n\u00e3o encontramos artigos acad\u00eamicos que se debru\u00e7assem sobre a varia\u00e7\u00e3o de livros infantis e o per\u00edodo da pandemia no Brasil. Apesar de n\u00e3o ser um objetivo espec\u00edfico do estudo, deve-se levar em conta a limita\u00e7\u00e3o de que n\u00e3o foi poss\u00edvel verificar a variabilidade de livros nesse per\u00edodo, quest\u00e3o que faz parte dos instrumentos utilizados.Algumas hip\u00f3teses podem ser levantadas aqui para justificar essa diminui\u00e7\u00e3o, como por exemplo, o acesso gratuito a livros virtuais, mais acess\u00edveis e com campanhas nacionais ou a doa\u00e7\u00f5es. Entretanto, apesar de termos diferentes estudos sobre a educa\u00e7\u00e3o infantil no per\u00edodo da pandemia.Com o isolamento social, os passeios em fam\u00edlia diminu\u00edram consideravelmente, demonstrando o cuidado que essas fam\u00edlias tiveram na situa\u00e7\u00e3o em que o pa\u00eds est\u00e1 vivendo de distanciamento social. As atividades extracurriculares tamb\u00e9m diminu\u00edram e elas t\u00eam como objetivo a socializa\u00e7\u00e3o do escolar e que no momento de isolamento social foi diminu\u00edda, sendo um ponto negativo para o relacionamento entre pares. O brincar, por exemplo, \u00e9 uma das atividades que mais auxilia a crian\u00e7a no processo de afetividade, desenvolvimento e socializa\u00e7\u00e3o. No relat\u00f3rio dos professores, esse relacionamento foi evidenciado com 78,9% das fam\u00edlias acompanhando as atividades.A escola tem sempre buscado o engajamento das fam\u00edlias no processo de aprendizagem dos escolares, visto que a fam\u00edlia \u00e9 a primeira a come\u00e7ar esse processo. A confian\u00e7a e o comprometimento s\u00e3o rela\u00e7\u00f5es que a fam\u00edlia e a escola precisam estar em harmonia para que haja uma educa\u00e7\u00e3o continuada. Neste estudo, vimos que as fam\u00edlias melhoraram esse relacionamento, precisando ter mais contato com a escola pelo fato de muitas vezes acompanharem seus filhos nas aulas remotas,o que pode ser explicado pela coleta ter se iniciado dois meses ap\u00f3s as medidas de distanciamento social implementadas no munic\u00edpio em quest\u00e3o. Na vari\u00e1vel estabilidade na vida familiar, que levanta os momentos que a fam\u00edlia costuma estar reunida, foi observado que em quase todos os momentos a fam\u00edlia estava reunida, tendo em vista estarem passando mais tempo em casa por conta do distanciamento social. Mudan\u00e7as ocorridas no ambiente familiar geram instabilidades, afetando diretamente os aspectos sociais (diminui\u00e7\u00e3o do contato entre pares) e econ\u00f4mico (diminui\u00e7\u00e3o da renda).A rotina n\u00e3o foi alterada entre os dois momentos da coleta, eram esperadas mudan\u00e7as na rotina e no conv\u00edvio familiar(google classroom).Em rela\u00e7\u00e3o \u00e0 leitura em casa, foi observado um aumento de escolares que se dedicaram \u00e0 leitura no M2, podendo-se inferir que a leitura aumentou por ter sido o momento em que todos os escolares j\u00e1 estavam com acesso \u00e0s aulas remotas e se sentiam mais motivados a ler. Durante esse per\u00edodo, tamb\u00e9m foi observada a facilidade da leitura atrav\u00e9s de plataformas que disponibilizaram livros de forma gratuita . Provavelmente, como as fam\u00edlias sa\u00edram menos de casa e tiveram mais tempo em frente \u00e0 televis\u00e3o, conversaram mais sobre o assunto.A maioria dos respons\u00e1veis relatou que conversaram sobre a escola com seus filhos mesmo com o fechamento, provavelmente porque os pais precisaram acompanhar mais de perto a vida escolar das crian\u00e7as, seja ensinando as tarefas, buscando materiais na escola ou acompanhando as crian\u00e7as nas aulas online. Da mesma forma, conversaram mais sobre assuntos da televis\u00e3o. Estudo realizado com brasileiros de 18 anos ou mais, observando que o tempo m\u00e9dio em frente \u00e0 televis\u00e3o foi maior ap\u00f3s a pandemia da COVID-19, com 1:45 minutos a mais de exposi\u00e7\u00e3o,24, podemos observar, na . \u00c9 importante ressaltar que relatos de problemas emocionais no ambiente familiar j\u00e1 eram comuns antes do per\u00edodo de pandemia. No entanto, com o per\u00edodo de distanciamento social, os relatos ficaram mais evidentes.Ao comparar os resultados do SDQ-Por. Esses dados levam a hip\u00f3tese de que podem estar relacionados \u00e0s mudan\u00e7as de rotinas, causadas \u00e0s vezes por desobedi\u00eancias e irritabilidade, ou \u00e0 preval\u00eancia, nessa faixa et\u00e1ria, de um n\u00edvel socioecon\u00f4mico baixo.Em rela\u00e7\u00e3o aos problemas de conduta, tr\u00eas escolares apresentaram n\u00edvel alterado , corroborando estudo anterior com escolares de m\u00e9dia de idade de 8,18 anosA pontua\u00e7\u00e3o total do instrumento \u00e9 a soma dos escores de 4 escalas que se referem a dificuldades  e 01 escala que se refere a capacidades , observado na . Por conta do isolamento social, a renda familiar foi alterada, podendo ter acarretado instabilidade na sa\u00fade mental das fam\u00edlias, consequentemente das crian\u00e7as.Nessa mesma perspectiva, observa-se um estudo realizado com 6.727 crian\u00e7as e adolescentes de 11 a 17 anos, que obtiveram uma pontua\u00e7\u00e3o total de 8,8% na escala alterada. Nessa mesma amostra, foi observado que escolares em n\u00edvel socioecon\u00f4mico baixo apresentaram \u00edndices mais altos em todas as escalas do SDQ.\u00c9 importante salientarmos que o SDQ n\u00e3o pode ser visto de forma isolada para sinais patol\u00f3gicos, necessita de outras avalia\u00e7\u00f5es para complementa\u00e7\u00e3o. Ele dever\u00e1 ser usado como triagem para estrat\u00e9gias de preven\u00e7\u00e3o e novas adapta\u00e7\u00f5es para as crian\u00e7as.Dados retirados da avalia\u00e7\u00e3o do professor revelaram que 18 escolares realizaram suas atividades de forma integral, efetiva ou parcial. As atividades escolares t\u00eam como um dos objetivos a consolida\u00e7\u00e3o do que foi ensinado pelo professor e medir o conhecimento adquirido em aula por elas. Portanto, muitos escolares podem n\u00e3o ter evolu\u00eddo ou n\u00e3o foram medidos seus conhecimentos pelas atividades de leitura, escrita, interpreta\u00e7\u00e3o e compreens\u00e3o de texto, ordena\u00e7\u00e3o de palavras e reconto de texto, pois, na maioria dos relat\u00f3rios escolares, n\u00e3o obtivemos respostas se o escolar estaria apto ou n\u00e3o de acordo com a medi\u00e7\u00e3o dos conhecimentos. Entretanto, vale destacar as dificuldades do sistema educacional enfrentadas pelos professores na avalia\u00e7\u00e3o dos escolares de forma remota, muitas vezes precisando se reinventar em car\u00e1ter de urg\u00eancia para suprir as demandas que no per\u00edodo de pandemia foram impostasQuando pensamos em correlacionar os achados dos dois question\u00e1rios , pretendemos que eles nos tragam indicadores do comportamento desses escolares, bem como ajustes para que possam ser trabalhados no contexto cl\u00ednico e educacional. Pretendemos tamb\u00e9m entender se o fato de ter mais recursos no ambiente familiar associado a rotinas pr\u00e9-estabelecidas levam a uma melhor adapta\u00e7\u00e3o das crian\u00e7as no per\u00edodo de isolamento social.A compreens\u00e3o sobre o distanciamento social est\u00e1 relacionada de forma positiva com a quantidade de brinquedos no M2. Isso pode ter acontecido, pois, \u00e0 medida que as crian\u00e7as foram ganhando brinquedos, que \u00e9 algo bom para eles, foram entendendo que precisam ficar isolados..O lazer tamb\u00e9m est\u00e1 relacionado de forma positiva com acervo de livros de variados temas. Com distanciamento social, os escolares dedicaram mais momentos de lazer com os livros no M1. Esse dado tamb\u00e9m pode ser evidenciado em um estudo com uma popula\u00e7\u00e3o de jovens universit\u00e1rios de Macap\u00e1 - AP atrav\u00e9s de question\u00e1rios. Foram analisados 456 question\u00e1rios sobre lazer e impactos da pandemia da COVID-19, e a leitura foi uma das atividades de lazer assinaladas de forma significativa Os passeios gerais foram relacionados de forma positiva no M1 com a compreens\u00e3o do distanciamento social. Podemos levantar a hip\u00f3tese de que, \u00e0 medida que os escolares compreendem sobre o distanciamento social, entendem que precisam ficar mais tempo em casa, diminuindo os passeios e fazendo as medidas de preven\u00e7\u00e3o.. Houve tamb\u00e9m uma rela\u00e7\u00e3o positiva na rotina, inclusive ao explicar sobre as medidas de preven\u00e7\u00e3o em que toda a fam\u00edlia empenhava-se pelo cuidado dos seus e dos outros. Antes da pandemia, a fam\u00edlia tinha uma rotina; com a pandemia, foi necess\u00e1rio inserir novas informa\u00e7\u00f5es no dia a dia desses escolares, o que ocasionou uma rela\u00e7\u00e3o positiva.Foi observado tamb\u00e9m uma rela\u00e7\u00e3o positiva nas atividades extracurriculares e um impacto na vida dos pais. Essa rela\u00e7\u00e3o pode ter acontecido, pois a rotina dos escolares dividia-se em momentos com a fam\u00edlia e as atividades fora do lar. Os pais precisaram assumir muitas atividades para preencher o tempo dos seus filhos e isso pode ter impactado de forma negativa na vida delesA estabilidade familiar diz respeito aos momentos em que a fam\u00edlia costuma estar reunida. Nesse \u00e2mbito, houve uma rela\u00e7\u00e3o positiva, tendo em vista que, \u00e0 medida que a fam\u00edlia ficava mais tempo reunida, o saber sobre as medidas de preven\u00e7\u00e3o aumentava, pois havia uma dedica\u00e7\u00e3o de mais tempo para tal explica\u00e7\u00e3o e que se caso esses momentos fossem menores, talvez o saber sobre as medidas de preven\u00e7\u00e3o seria mais resumido, pouco explicados.Outro limite desta pesquisa diz respeito aos demais aspectos relevantes relacionados \u00e0 aprendizagem, como leitura, escrita e compreens\u00e3o de texto. Apesar de importantes, n\u00e3o foram escopo deste estudo e devem ser levados em considera\u00e7\u00e3o nesse contexto de retorno \u00e0s aulas presenciais.Diante das reflex\u00f5es apresentadas, as mudan\u00e7as impostas pelo distanciamento social no per\u00edodo de combate \u00e0 pandemia da COVID-19 atingiram diferentes esferas nas fam\u00edlias acompanhadas neste estudo durante o per\u00edodo de junho de 2020 a dezembro de 2020. Houve uma implica\u00e7\u00e3o negativa na mudan\u00e7a de rotina e um impacto causado na vida dos pais, pois, com a suspens\u00e3o das aulas presenciais e das atividades extracurriculares, eles precisaram desempenhar novas fun\u00e7\u00f5es. De forma positiva, observou-se uma melhora na rela\u00e7\u00e3o fam\u00edlia-escola, que deve ser ainda mais explorada no momento p\u00f3s-pandemia.As mudan\u00e7as na rotina tamb\u00e9m foram observadas, de forma negativa, por meio do SDQ-Por, gerando instabilidades na sa\u00fade mental das crian\u00e7as.Propomos que crian\u00e7as em fase escolar sejam acompanhadas, avaliadas e tenham oportunidade de interven\u00e7\u00e3o multiprofissional precocemente, pois, apesar de apresentarmos uma amostra menos representativa, o estudo nos mostra a realidade de 19 fam\u00edlias com fatores negativos que ser\u00e3o refletidos no desenvolvimento escolar dessas crian\u00e7as. Este estudo aponta como limita\u00e7\u00e3o a descri\u00e7\u00e3o dos relat\u00f3rios evolutivos dos professores sobre a aprendizagem escolar, uma vez que um pouco mais de 60% da amostra est\u00e1 sem informa\u00e7\u00e3o nesse quesito. Sugerimos, para pesquisas futuras, uma coleta com amostra mais representativa e uma compara\u00e7\u00e3o com crian\u00e7as de outros anos escolares. Tamb\u00e9m sugerimos associar a avalia\u00e7\u00e3o dos question\u00e1rios com o desempenho de leitura em escolares de diferentes n\u00edveis socioecon\u00f4micos."}
+{"text": "Mini-InternationalNeuropsychiatric Interview (M.I.N.I.). Aqueles indiv\u00edduos quepreencheram os crit\u00e9rios diagn\u00f3sticos do Manual Diagn\u00f3stico eEstat\u00edstico de Transtornos Mentais (DSM-5) foram definidos comopositivos para TDAH. A regress\u00e3o de Poisson com ajuste robusto da vari\u00e2ncia foiusada para estimar a raz\u00e3o de preval\u00eancia (RP) ajustadas para sexo, cor da pelematerna, renda familiar, idade materna, escolaridade materna durante a gesta\u00e7\u00e3o,estado civil materno, paridade e tabagismo materno durante a gesta\u00e7\u00e3o. Apreval\u00eancia do TDAH adulto foi de 4,4% e 4,5% nas coortes de 1982 e 1993,respectivamente. A preval\u00eancia de TDAH foi maior naqueles que nasceram com menorpeso, mas n\u00e3o foi observada tendencia linear. Al\u00e9m disso, aqueles que nasceramcom peso entre 3.000 e 3.499 gramas (g) apresentaram maior risco para o transtorno. Para a idade gestacional, observamosuma rela\u00e7\u00e3o inversamente proporcional acerca da presen\u00e7a de TDAH, os pr\u00e9-termosapresentaram risco 33% maior  de ser considerado com TDAH doque os nascidos com 39 ou mais semanas, mas como o intervalo de confian\u00e7aincluiu a nulidade, essa associa\u00e7\u00e3o pode ter ocorrido ao acaso. Tais resultadosindicam que o peso ao nascer e a idade gestacional podem estar associados aoTDAH adulto.Este artigo avaliou a associa\u00e7\u00e3o das condi\u00e7\u00f5es de nascimento com o transtorno dod\u00e9ficit de aten\u00e7\u00e3o com hiperatividade (TDAH) em adultos utilizando dados de duascoorte de nascimento da cidade de Pelotas, Rio Grande do Sul, Brasil. Em 1982 e1993, todos os nascimentos ocorridos na cidade foram identificados eprospectivamente acompanhados. Nos acompanhamentos aos 30 e 22 anos das coortes1982 (n = 3.574) e 1993 (n = 3.780), respectivamente, os participantes foramexaminados e psic\u00f3logos treinados aplicaram a  Embora o TDAH tenha sidotradicionalmente associado \u00e0 inf\u00e2ncia, pesquisas t\u00eam demonstrado que uma propor\u00e7\u00e3osignificativa de indiv\u00edduos pode manter o diagn\u00f3stico at\u00e9 a idade adulta. Aindaassim, estima-se que apenas cerca de 15% dos indiv\u00edduos diagnosticados com TDAHinfantil mantenham o diagn\u00f3stico aos 25 anos de idade, sugerindo uma expressiva taxade remiss\u00e3o ,De acordo com o ,,O TDAH em adultos \u00e9 frequentemente associado a comportamentos de risco e comorbidadespsiqui\u00e1tricas ,Este artigo utilizou os dados de duas coortes de nascimento de base populacional ecom estrat\u00e9gias de recrutamento semelhantes conduzidas em Pelotas, uma cidade daRegi\u00e3o Sul do Brasil. Durante os per\u00edodos de 1\u00ba de janeiro a 31 de dezembro de 1982e 1993, equipes treinadas foram designadas para visitar todos os hospitais da cidadediariamente, com o prop\u00f3sito de recrutar m\u00e3es eleg\u00edveis - aquelas residentes na zonaurbana do Munic\u00edpio de Pelotas - para participar do estudo A coorte de 1982 incluiu 5.914 rec\u00e9m-nascidos, enquanto a de 1993 incluiu 5.249.Esses indiv\u00edduos foram prospectivamente acompanhados em diferentes idades. O \u00faltimoacompanhamento da coorte de 1982 foi realizado em 2012, quando os participantescompletaram 30 anos de idade. Foram entrevistados 3.701 indiv\u00edduos e foramidentificados 325 \u00f3bitos entre os participantes da coorte, o que representou umataxa de seguimento de 68,1% Mini-International Neuropsychiatric Interview (M.I.N.I.),vers\u00e3o 5.017, e aplicado por psic\u00f3logos treinados. O M.I.N.I. \u00e9 uma entrevistadiagn\u00f3stica curta e estruturada, a qual \u00e9 validada no Brasil O TDAH aos 22 e 30 anos nas coortes de 1993 e 1982 foi avaliado por meio do,Os crit\u00e9rios do DSM-5 foram utilizados para definir a presen\u00e7a de TDAH, uma vezque o M.I.N.I. abrange os principais sintomas atuais do transtorno No que diz respeito \u00e0s condi\u00e7\u00f5es de nascimento; logo ap\u00f3s o parto, osrec\u00e9m-nascidos foram pesados pela equipe do hospital, usando balan\u00e7aspedi\u00e1tricas, calibradas semanalmente pela equipe da pesquisa, com precis\u00e3o de10g. Essa vari\u00e1vel, originalmente num\u00e9rica, foi estratificada em: baixo peso aonascer (< 2.500g), entre 2.500g-2.999g, entre 3.000g-3.499g e \u2265 3.500g. Aidade gestacional foi medida por meio do relato sobre a data da \u00faltimamenstrua\u00e7\u00e3o (DUM) e classificada como prematuro (< 37 semanas), entre 37-38 e\u2265 39 semanas. O crescimento intrauterino foi medido com ajuda do peso ao nascer,idade gestacional e sexo. Foram definidos como \u201cpequeno para idade gestacional\u201dos indiv\u00edduos cujo peso ao nascer, conforme a idade gestacional e sexo, estavaabaixo do percentil 10 da popula\u00e7\u00e3o de refer\u00eancia de Williams et al. Os seguintes fatores de confus\u00e3o foram considerados: sexo; cor da pele materna;renda familiar em sal\u00e1rios m\u00ednimos; idade materna em anos completos;escolaridade materna na gesta\u00e7\u00e3o em anos completos; estado civil materno;paridade; e tabagismo materno na gesta\u00e7\u00e3o. Esses dados foram coletados nosinqu\u00e9ritos perinatais das coorte de 1982 e 1993 durante as entrevistasrealizadas com as m\u00e3es, logo ap\u00f3s o parto.Para avaliar o tabagismo materno durante a gesta\u00e7\u00e3o, na coorte de 1982, as m\u00e3esforam questionadas sobre a categoria de consumo de cigarros durante a gravidezque se enquadrava em: n\u00e3o fumou 1-14 cigarros por dia durante parte da gravidez;fumou 1-14 cigarros por dia durante toda a gravidez; fumou \u2265 15 cigarros por diadurante parte da gravidez; e fumou \u2265 15 cigarros por dia durante toda agravidez). J\u00e1 na coorte de 1993, o tabagismo materno durante a gesta\u00e7\u00e3o foiavaliado de forma mais detalhada, questionando as m\u00e3es sobre a quantidade di\u00e1riade cigarros fumados e o n\u00famero de dias em que isso ocorreu em cada trimestre dagesta\u00e7\u00e3o. Nesta pesquisa, as m\u00e3es que relataram o consumo de cigarros emqualquer momento da gesta\u00e7\u00e3o foram categorizadas como positiva para fumo nagesta\u00e7\u00e3o.Foi apresentada a preval\u00eancia do TDAH, bem como das demais vari\u00e1veis deinteresse, juntamente com seus valores absolutos. Foram realizados testes dequi-quadrado para comparar a distribui\u00e7\u00e3o das vari\u00e1veis peso ao nascer, a idadegestacional e o crescimento intrauterino no per\u00edodo perinatal com as dosacompanhamentos aos 22 e 30 anos, a fim de determinar se as perdas de seguimentopoderiam afetar as amostras.https://www.stata.com).Foi utilizada a regress\u00e3o de Poisson com ajuste robusto da vari\u00e2ncia para estimara raz\u00e3o de preval\u00eancia (RP) bruta e ajustada de TDAH adulto, agregando os dadosdas duas coortes, de acordo com o peso ao nascer, a idade gestacional e ocrescimento intrauterino. Os modelos de regress\u00e3o foram aplicados separadamentepara cada uma das vari\u00e1veis de exposi\u00e7\u00e3o de interesse. A an\u00e1lise ajustadaincluiu os fatores de confus\u00e3o descritos acima e uma vari\u00e1vel que indicava acoorte do participante. Para as vari\u00e1veis ordinais foi calculado o valor de p deheterogeneidade e de tend\u00eancia linear e aquele com menor valor foi apresentado.Ainda na an\u00e1lise multivariada, foi aplicado o teste de raz\u00e3o de verossimilhan\u00e7apara avalia\u00e7\u00e3o da poss\u00edvel intera\u00e7\u00e3o da coorte com as associa\u00e7\u00f5es de interesse.Foi estabelecido um valor de p < 0,05 para a obten\u00e7\u00e3o da signific\u00e2nciaestat\u00edstica e todas as an\u00e1lises foram realizadas usando Stata, vers\u00e3o 15.0.Em ambas coortes, as avalia\u00e7\u00f5es foram somente realizadas ap\u00f3s a assinatura doTermo de Consentimento Livre Esclarecido (TCLE).https://cadernos.ensp.fiocruz.br/static//arquivo/suppl-e00138122_1635.pdf).A Neste artigo, foram inclu\u00eddos 7.354 participantes das duas coortes. A amostraanalisada da coorte de 1993 apresentou diferen\u00e7as na distribui\u00e7\u00e3o do crescimentointrauterino em rela\u00e7\u00e3o \u00e0 coorte original (Material Suplementar: A Nosso estudo observou que indiv\u00edduos nascidos com peso menor do que 3.500gapresentavam maior risco para o TDAH. Al\u00e9m disso, observamos tend\u00eancia a maior riscode TDAH naqueles que nasceram com menor idade gestacional, mas n\u00e3o podemos descartarque essas associa\u00e7\u00f5es tenham ocorrido por acaso. Por outro lado, os indiv\u00edduosnascidos pequenos para a idade gestacional apresentavam tend\u00eancia a menor risco deserem considerados como tendo TDAH. O peso ao nascer est\u00e1 negativamente relacionadocom a idade gestacional e o crescimento intrauterino ,,No que diz respeito ao maior risco de TDAH em indiv\u00edduos que nasceram com peso menor,apesar da associa\u00e7\u00e3o n\u00e3o ter sido linear, os nossos resultados s\u00e3o condizentes com oque vem sendo observado na literatura ,,As condi\u00e7\u00f5es de nascimento t\u00eam sido usadas como um indicador da qualidade dascondi\u00e7\u00f5es do ambiente intrauterino e apresentam consequ\u00eancias em longo prazo sobre asa\u00fade do indiv\u00edduo, tais quais maiores riscos de doen\u00e7as cr\u00f4nicas respirat\u00f3rias,card\u00edacas, renais, sistema end\u00f3crino e psiqui\u00e1tricas ,,,Os mecanismos pelos quais as condi\u00e7\u00f5es de nascimentos contribuem para odesenvolvimento do TDAH ainda s\u00e3o pouco compreendidos. A menor dura\u00e7\u00e3o da gesta\u00e7\u00e3olevaria a interrup\u00e7\u00e3o no neurodesenvolvimento fetal, sobretudo por conta do \u00faltimotrimestre da gravidez ser um per\u00edodo bastante cr\u00edtico para os processos deorganiza\u00e7\u00e3o neuronal e neurog\u00eanese. El Marroun et al. Com rela\u00e7\u00e3o aos pontos positivos deste artigo, a coleta das informa\u00e7\u00f5es sobre ascondi\u00e7\u00f5es de nascimento foi feita imediatamente ap\u00f3s o nascimento, garantindo aqualidade das informa\u00e7\u00f5es obtidas e reduzindo a possibilidade de ocorr\u00eancia de errode mensura\u00e7\u00e3o. As vari\u00e1veis de confus\u00e3o foram medidas logo ap\u00f3s o nascimento,pr\u00f3ximo a sua ocorr\u00eancia, minimizando a possibilidade de confus\u00e3o residual. Aavalia\u00e7\u00e3o do TDAH foi realizada por psic\u00f3logos treinados, o que tamb\u00e9m reduziu apossibilidade de erro de classifica\u00e7\u00e3o. Al\u00e9m disso, esta pesquisa apresentou umpoder estat\u00edstico superior a 80%. Entre os pontos fracos, pode-se apontar que odiagn\u00f3stico de TDAH foi coletado aos 30 e 22 anos, utilizando um teste de rastreiocontendo componentes recordat\u00f3rios, sendo suscet\u00edvel a vieses de informa\u00e7\u00e3o,aumentando o risco de a preval\u00eancia ser subestimada.Esta pesquisa observou um maior risco para o TDAH adulto em nascidos com menor tempode gesta\u00e7\u00e3o ou com baixo peso utilizando dados agregados de duas coortes denascimentos em um acompanhamento de 22 e 30 anos. Embora os resultados tenhamalcan\u00e7ado a signific\u00e2ncia estat\u00edstica somente para o peso ao nascer, tamb\u00e9mobservamos um maior risco para o TDAH adulto em adultos nascidos pr\u00e9-termo, sendomaior que 30% naqueles nascidos com menos de 37 semanas de gesta\u00e7\u00e3o. Deve-se levarem conta que a baixa preval\u00eancia do nosso desfecho implica na redu\u00e7\u00e3o do poderestat\u00edstico. Nossos resultados refor\u00e7am a import\u00e2ncia do neurodesenvolvimento fetalsobre a sa\u00fade mental em longo termo, conforme vem sendo observado em estudossimilares, destacando a import\u00e2ncia sobre o cuidado e acompanhamento pr\u00e9-natal e seuimpacto sobre a sa\u00fade mental. Al\u00e9m disso, este artigo utilizou dados que representamuma popula\u00e7\u00e3o adulta de um pa\u00eds em desenvolvimento, ainda escassos naliteratura."}
+{"text": "Este artigo consiste em uma an\u00e1lise das redes sociais dos moradores de umacomunidade em Betim , visando compreender como elas podemser utilizadas nas estrat\u00e9gias de mobiliza\u00e7\u00e3o social para o enfrentamento dadengue, zika e chikungunya no territ\u00f3rio. Utilizou-se o m\u00e9todo da trajet\u00f3ria devida para analisar os eventos e os condicionantes sociais da forma\u00e7\u00e3o,manuten\u00e7\u00e3o e ruptura dessas redes, a qualidade e intensidade dos v\u00ednculos, ascaracter\u00edsticas do capital social e sua varia\u00e7\u00e3o ao longo da trajet\u00f3ria dosindiv\u00edduos. A compreens\u00e3o da estrutura das redes evidencia alguns aspectosimportantes para a elabora\u00e7\u00e3o de novas estrat\u00e9gias de mobiliza\u00e7\u00e3o social no\u00e2mbito da proposta de vigil\u00e2ncia em sa\u00fade a ser implementada no local. Natrajet\u00f3ria dos entrevistados, a vizinhan\u00e7a se mostrou como importante rede dereciprocidade e de provis\u00e3o de recursos no cotidiano, dada a proximidade f\u00edsicae a dura\u00e7\u00e3o das rela\u00e7\u00f5es. Al\u00e9m disso, as redes religiosas t\u00eam presen\u00e7asignificativa no cotidiano dos moradores, sendo fortemente ancoradas napresta\u00e7\u00e3o de \u201cajuda\u201d social e pautada por valores solid\u00e1rios. Acredita-se que oscomit\u00eas populares possam estimular essas redes, sobretudo as religiosas, autilizarem seu repert\u00f3rio cultural e simb\u00f3lico para trabalhar quest\u00f5es deinteresse dos bairros, como promo\u00e7\u00e3o da sa\u00fade, constru\u00e7\u00e3o de territ\u00f3riossaud\u00e1veis e sustent\u00e1veis, desenvolvimento local, gera\u00e7\u00e3o de renda, melhoria dainfraestrutura e preserva\u00e7\u00e3o ambiental.  Aedes aegyptiEm 2015 e 2016, o Brasil vivenciou a tr\u00edplice epidemia de dengue, zika e chikungunya, considerada uma das maiores trag\u00e9dias de sa\u00fade p\u00fablica do pa\u00eds A dificuldade de mobiliza\u00e7\u00e3o social para o enfrentamento das epidemias remete \u00e0 necessidade de refletir sobre estrat\u00e9gias pedag\u00f3gicas, de comunica\u00e7\u00e3o e de participa\u00e7\u00e3o civil e coletiva capazes de estimular o engajamento da popula\u00e7\u00e3o para quest\u00f5es pr\u00f3prias do seu territ\u00f3rio. Envolver as comunidades nas a\u00e7\u00f5es de vigil\u00e2ncia em sa\u00fade \u00e9 uma estrat\u00e9gia preconizada pela Organiza\u00e7\u00e3o Mundial da Sa\u00fade (OMS) em \u00e2mbito global, que reafirma a import\u00e2ncia de fomentar um processo ativo de participa\u00e7\u00e3o comunit\u00e1ria para identifica\u00e7\u00e3o, notifica\u00e7\u00e3o, resposta e monitoramento de eventos de sa\u00fade Proposta de Vigil\u00e2ncia em Sa\u00fade, de Base Territorial, Visando ao Fortalecimento da Mobiliza\u00e7\u00e3o Social para o Enfrentamento de Dengue, Zika, Chikungunya e Controle do Aedes aegypti em Minas Gerais . O projeto consiste na forma\u00e7\u00e3o de comit\u00eas populares para definir e implementar estrat\u00e9gias participativas para reconhecimento, an\u00e1lise e discuss\u00e3o sobre o territ\u00f3rio. A iniciativa visa \u00e0 elabora\u00e7\u00e3o de um diagn\u00f3stico da situa\u00e7\u00e3o de sa\u00fade e das condi\u00e7\u00f5es de vida que contribua para o planejamento de propostas de mobiliza\u00e7\u00e3o social para o controle do Aedes aegypti e para a cria\u00e7\u00e3o de ambientes favor\u00e1veis \u00e0 sa\u00fade. Os comit\u00eas t\u00eam um(a) coordenador(a), escolhido pelos integrantes, e toda a atividade \u00e9 realizada via plataforma online, criada para o desenvolvimento da proposta. Nela, os participantes encontram informa\u00e7\u00f5es sobre as doen\u00e7as e orienta\u00e7\u00f5es sobre as atividades a serem realizadas, intermediadas por tutores e pela equipe de pesquisa. O trabalho dos comit\u00eas consiste em realizar um diagn\u00f3stico do territ\u00f3rio, elaborar um planejamento de a\u00e7\u00f5es e acompanhar sua implementa\u00e7\u00e3o Partindo desses desafios, um grupo de pesquisadoras(es) vem desenvolvendo, desde 2016, a A primeira fase do projeto evidenciou alguns desafios para a participa\u00e7\u00e3o e para o envolvimento das comunidades locais. Sediados em escolas da rede p\u00fablica, os comit\u00eas foram, em sua maioria, formados por alunos, professores e demais funcion\u00e1rios. Consequentemente, a participa\u00e7\u00e3o ficou restrita ao ambiente e ao calend\u00e1rio escolar, gerando limita\u00e7\u00f5es tanto ao alcance quanto \u00e0 sustentabilidade do projeto.Com o intuito de estimular o protagonismo das comunidades para al\u00e9m dos muros das escolas, prop\u00f4s-se repensar as estrat\u00e9gias de mobiliza\u00e7\u00e3o social para ampliar o alcance do projeto por meio da inclus\u00e3o de outros grupos e esferas sociais existentes nos territ\u00f3rios. Para isso, iniciou-se uma pesquisa que visa analisar as redes sociais de uma comunidade em Betim , munic\u00edpio selecionado para o desenvolvimento da segunda etapa do projeto, a fim de identificar as esferas sociais mais atuantes e com maior concentra\u00e7\u00e3o de capital social que possam contribuir para o aumento da abrang\u00eancia do trabalho dos comit\u00eas populares. As redes sociais locais s\u00e3o fundamentais por serem geradoras de c\u00edrculos de reciprocidade e confian\u00e7a entre os moradores de um territ\u00f3rio. Compreender suas caracter\u00edsticas, din\u00e2micas e usos no cotidiano permitir\u00e1 utiliz\u00e1-las na mobiliza\u00e7\u00e3o social como canais de difus\u00e3o de informa\u00e7\u00f5es, de conhecimento e de outros recursos que as potencializem para construir formas de participa\u00e7\u00e3o em que a popula\u00e7\u00e3o, como protagonista, possa vocalizar suas necessidades, propor solu\u00e7\u00f5es e refletir sobre suas pr\u00e1ticas de sa\u00fade. Embora a literatura sobre redes sociais aponte para a maior presen\u00e7a de redes prim\u00e1rias, pautadas por la\u00e7os fortes, com elevado grau de homofilia . Permite, ainda, compreender de que forma a inser\u00e7\u00e3o nas redes condiciona as oportunidades e os limites de acesso a esses bens.,Cada esfera de sociabilidade \u00e9 caracterizada pelo tipo de la\u00e7o social estabelecido nas redes. Define-se sociabilidade prim\u00e1ria como aquela em que as rela\u00e7\u00f5es s\u00e3o estabelecidas por meio de la\u00e7os fortes, em que a relev\u00e2ncia das intera\u00e7\u00f5es est\u00e1 em seu car\u00e1ter pessoal, como as que se constituem na fam\u00edlia, na vizinhan\u00e7a e nas amizades. Sociabilidade secund\u00e1ria \u00e9 o tipo de rela\u00e7\u00e3o social regida pela impessoalidade, pautada por la\u00e7os fracos, como a que se constr\u00f3i nas esferas do mercado, dos \u00f3rg\u00e3os p\u00fablicos, das institui\u00e7\u00f5es cient\u00edficas, das associa\u00e7\u00f5es civis, das organiza\u00e7\u00f5es n\u00e3o governamentais (ONG), entre outras Na \u00e1rea da sa\u00fade, o conceito de redes sociais tem sido bastante \u00fatil para repensar as rela\u00e7\u00f5es entre as pol\u00edticas e institui\u00e7\u00f5es e as comunidades, havendo muitas abordagens te\u00f3rico-metodol\u00f3gicas e de interven\u00e7\u00e3o utilizadas. Bruno Fontes As redes de solidariedade s\u00e3o um importante instrumento de prote\u00e7\u00e3o, pois, al\u00e9m de oferecerem possibilidades de inser\u00e7\u00e3o social, estimulam a cidadania ao levar a sociedade civil \u00e0 participa\u00e7\u00e3o ativa no planejamento e na execu\u00e7\u00e3o de a\u00e7\u00f5es locais. Tanto as redes como a no\u00e7\u00e3o de solidariedade s\u00e3o cruciais para se pensar em pol\u00edticas sociais na contemporaneidade, especialmente em contextos em que se verifica uma consider\u00e1vel omiss\u00e3o do Estado no atendimento \u00e0s demandas sociais, criando espa\u00e7o para emerg\u00eancia de solidariedades locais e para a participa\u00e7\u00e3o local ,O estudo das redes sociais foi feito por meio do m\u00e9todo da trajet\u00f3ria de vida, que consiste na rela\u00e7\u00e3o entre as experi\u00eancias de vida e o contexto social em que os indiv\u00edduos est\u00e3o inseridos online das redes existentes no territ\u00f3rio. A partir da\u00ed, foi utilizada a t\u00e9cnica \u201cbola de neve\u201d, em que cada entrevistado indicou algu\u00e9m da sua rede. De novembro de 2020 a janeiro de 2021, foram feitas 30 entrevistas, abrangendo distintas faixas et\u00e1rias, n\u00edveis de escolaridade, profiss\u00f5es, locais de moradia e formas de atua\u00e7\u00e3o nos bairros estudados. O n\u00famero de entrevistas foi determinado pelo crit\u00e9rio de satura\u00e7\u00e3o, quando se chegou a um ponto de repeti\u00e7\u00e3o das informa\u00e7\u00f5es que j\u00e1 n\u00e3o alterava a compreens\u00e3o do fen\u00f4meno estudado.Os primeiros contatos com a comunidade foram feitos por meio do levantamento de lideran\u00e7as locais realizado junto \u00e0 administra\u00e7\u00e3o da regional que abrange os bairros estudados e do levantamento Para a realiza\u00e7\u00e3o das entrevistas, foi elaborado um roteiro pr\u00e9vio com t\u00f3picos centrais, cujos temas - relacionados ao problema de pesquisa - foram abordados dando-se espa\u00e7o para os entrevistados se expressarem da maneira mais livre poss\u00edvel. Foram feitas interven\u00e7\u00f5es apenas para esclarecer melhor algum ponto ou explorar algum assunto relevante, t\u00e9cnica denominada \u201centrevista centrada no problema de pesquisa\u201d Os resultados n\u00e3o t\u00eam a pretens\u00e3o de reduzir a complexidade das din\u00e2micas societ\u00e1rias do universo estudado, pois a an\u00e1lise diz respeito \u00e0s rela\u00e7\u00f5es sociais de uma parcela de moradores, n\u00e3o refletindo a totalidade das redes sociais dessa comunidade. Ainda assim, acredita-se que este estudo constitui um recorte relevante para se compreender parte dos mecanismos de solidariedade presentes naquele contexto.Os nomes referidos nas entrevistas s\u00e3o fict\u00edcios para resguardar a identidade das(os) moradoras(es). Os procedimentos de pesquisa foram aprovados pelo Comit\u00ea de \u00c9tica em Pesquisa do Instituto Ren\u00e9 Rachou, Funda\u00e7\u00e3o Oswaldo Cruz, Minas Gerais (parecer n\u00ba 3.324.161).2. O \u00cdndice de Desenvolvimento Humano (IDH) \u00e9 de 0,749 e o Produto Interno Bruto (PIB) per capita em 2020 foi de aproximadamente R$ 58.870,00 A comunidade estudada abrange tr\u00eas bairros de Betim, pertencentes \u00e0 Regional Alterosas: Alterosas II, Cruzeiro do Sul e Duque de Caxias. Os tr\u00eas foram selecionados por serem os bairros da regional com a maior incid\u00eancia de dengue, zika e chikungunya verificada nos \u00faltimos anos por meio dos levantamentos das autoridades municipais. O Munic\u00edpio de Betim faz parte da Regi\u00e3o Metropolitana de Belo Horizonte e \u00e9 um dos principais polos industriais do estado. Em 2020, tinha cerca de 440 mil habitantes, com densidade populacional de 1.102,8 habitantes/kmCenso Demogr\u00e1fico de 2010, o bairro Alterosas II \u00e9 o mais populoso dos tr\u00eas, com 19.536 habitantes. Nele, h\u00e1 5.956 domic\u00edlios, com ocupa\u00e7\u00e3o de 94% Com base no Foram entrevistados 16 homens e 14 mulheres, com idade entre 20 e 70 anos; 15 deles com Ensino Superior completo (oito com P\u00f3s-gradua\u00e7\u00e3o), 14 com Ensino M\u00e9dio completo e um com Ensino Fundamental completo; 23 se declararam negros (pretos e pardos) e sete se declararam brancos; 11 t\u00eam renda familiar de um a tr\u00eas sal\u00e1rios m\u00ednimos, nove t\u00eam renda familiar maior que tr\u00eas e menor ou igual a cinco sal\u00e1rios m\u00ednimos, sete t\u00eam renda familiar maior que cinco e menor ou igual a 10 sal\u00e1rios m\u00ednimos e tr\u00eas t\u00eam renda familiar maior que 10 sal\u00e1rios m\u00ednimos; 13 s\u00e3o moradores, ex-moradores ou atuam no bairro Alterosas II, nove s\u00e3o moradores, ex-moradores ou atuam no bairro Duque de Caxias e oito s\u00e3o moradores, ex-moradores ou atuam no bairro Cruzeiro do Sul. Ainda, 27 entrevistados t\u00eam v\u00ednculo com um dos tr\u00eas bairros por mais de 10 anos.As caracter\u00edsticas dos bairros s\u00e3o importantes para compreender a conforma\u00e7\u00e3o das redes sociais ao longo do tempo. A precariedade socioecon\u00f4mica, aliada \u00e0 car\u00eancia de infraestrutura urbana adequada, contribuiu para a constitui\u00e7\u00e3o de uma significativa rede de apoio social entre os primeiros moradores, marcada pela constante circula\u00e7\u00e3o de recursos (trocas) e pela forte coes\u00e3o social. De modo geral, as rela\u00e7\u00f5es de vizinhan\u00e7a podem ser assim tipificadas: no in\u00edcio da ocupa\u00e7\u00e3o dos bairros, eram pouco numerosas, o que favoreceu a cria\u00e7\u00e3o de v\u00ednculos estreitos entre os moradores. Praticamente todos relataram grande proximidade da vizinhan\u00e7a nessa \u00e9poca, com a presen\u00e7a de crian\u00e7as brincando nas ruas, intera\u00e7\u00f5es que se estendiam aos pais e \u00e0s fam\u00edlias, que frequentavam a casa uns dos outros; a vizinhan\u00e7a era vista como uma extens\u00e3o da casa. O fato de os moradores serem migrantes de cidades do interior do estado contribuiu bastante para esse tipo de intera\u00e7\u00e3o, j\u00e1 que muitos entrevistados afirmaram que a conviv\u00eancia entre os vizinhos lembrava muito as do interior. Pode-se dizer o mesmo das rela\u00e7\u00f5es de vizinhan\u00e7a de favelas e de bairros perif\u00e9ricos da Regi\u00e3o Metropolitana de Belo Horizonte, caracterizados pelos entrevistados como de muita proximidade, ajuda m\u00fatua e intimidade. Tal qual encontrado nas redes sociais estudadas por Fontes & Eichner at\u00e9 na congrega\u00e7\u00e3o da igreja existe muito isso, entre pessoas que se conhecem e cresceram junto, n\u00e9? Ainda existe isso, menos, mas existe. At\u00e9 por ser um bairro mais humilde, entre aspas, ainda persiste essa quest\u00e3o de amizade, comunh\u00e3o em alguns casos\u201d.Em contrapartida, as rela\u00e7\u00f5es de vizinhan\u00e7a mais t\u00edpicas de bairros de classe m\u00e9dia Contudo, a maioria relatou o enfraquecimento desses la\u00e7os ao longo dos anos, em decorr\u00eancia da urbaniza\u00e7\u00e3o, do aumento da viol\u00eancia e da chegada de novos moradores, vindos de outras cidades e at\u00e9 de outros pa\u00edses. Essa mudan\u00e7a alterou a intensidade dos v\u00ednculos - vizinhos deixam ou diminuem o costume de frequentar a casa e de participar da vida uns dos outros. No caso dos novos moradores, a rela\u00e7\u00e3o se limita \u00e0s intera\u00e7\u00f5es ocasionais e impessoais, como o cumprimento r\u00e1pido nas ruas. Alguns entrevistados ressaltaram o individualismo presente nas rela\u00e7\u00f5es atuais. Para eles, h\u00e1 uma tend\u00eancia dos vizinhos a se importar apenas consigo mesmos. Entretanto, mesmo com essas transforma\u00e7\u00f5es, verificou-se a manuten\u00e7\u00e3o de fortes v\u00ednculos entre os moradores antigos, motivados por um sentimento de pertencimento e de identidade em rela\u00e7\u00e3o ao bairro. Alguns, inclusive, se consideram como membros da fam\u00edlia:Na vizinhan\u00e7a, e a vizinhan\u00e7a que estou falando n\u00e3o era s\u00f3 vizinhan\u00e7a da frente, era do lado, era de baixo, da rua de cima, eram todos ao redor ali, e n\u00f3s fomos crescendo como se f\u00f4ssemos realmente um grupo familiar, al\u00e9m de sermos, l\u00f3gico, vizinhos, parec\u00edamos um grupo familiar, todo mundo conhecia todo mundo\u201d (\u00c9der).\u201cN\u00f3s somos muito pr\u00f3ximos, n\u00f3s somos muito amigos tamb\u00e9m, n\u00e3o \u00e9 \u00e0 toa que a [nome da vizinha] tem um filho e eu sou muito pr\u00f3ximo dela. Pra voc\u00ea ter ideia, eu n\u00e3o sou irm\u00e3o dela e o filho dela me chama de tio. Eu sou padrinho dele, entendeu? (...) Eu lembro, quando eu era pequeno, eu n\u00e3o lembro como foi, eu tinha um vizinho que ele veio a falecer esse ano, que \u00e9 meu tio, ele n\u00e3o \u00e9 meu tio, mas eu considero ele como se fosse um tio pra mim\u201d (Alex).\u201c,A qualidade dos v\u00ednculos sociais tem uma dimens\u00e3o central na estrutura\u00e7\u00e3o das redes sociais porque os la\u00e7os estabelecidos entre os sujeitos podem significar tanto prote\u00e7\u00e3o quanto limita\u00e7\u00e3o da mobilidade social. Assim, se por um lado a predomin\u00e2ncia de la\u00e7os fortes em uma comunidade \u00e9 fundamental para a coes\u00e3o social, contribuindo para gerar pertencimento, identifica\u00e7\u00e3o e fortalecimento das rela\u00e7\u00f5es identit\u00e1rias, por outro lado, \u00e9 um obst\u00e1culo para romper com a reprodu\u00e7\u00e3o das condi\u00e7\u00f5es de pobreza. \u00c9 o que afirma Mark Granovetter Na comunidade estudada, a intensidade dos v\u00ednculos foi explorada perguntando aos entrevistados em qual rede eles t\u00eam os v\u00ednculos mais fortes .Os entrevistados podiam citar mais de uma rede, por isso o n\u00famero de respostas ultrapassa o total de entrevistas. Como se v\u00ea, na percep\u00e7\u00e3o dos entrevistados, as redes familiares s\u00e3o as que concentram os la\u00e7os mais fortes. Antes disso, eles foram questionados sobre onde se localiza a maior parte de seus contatos, se dentro ou fora do bairro e/ou da Regional Alterosas, al\u00e9m de em quais redes se situam esses contatos .Embora tenha havido um equil\u00edbrio nas respostas \u00e0 primeira pergunta - metade respondeu ter mais contatos no bairro e/ou na Regional Alterosas e metade, fora -, quando se questionou em quais redes se situam esses contatos , as respA tend\u00eancia ao localismo das redes tamb\u00e9m reflete na dura\u00e7\u00e3o dos v\u00ednculos na trajet\u00f3ria dos entrevistados. Amizades feitas no bairro, sobretudo entre os moradores antigos, tendem a se manter mesmo com a mudan\u00e7a para outros locais. As amizades feitas na escola tendem a se manter entre as redes formadas durante o ensino fundamental, quando cursado em escola do bairro ou da Regional Alterosas. As redes constitu\u00eddas durante o ensino m\u00e9dio e cursos t\u00e9cnicos tendem a se romper, talvez porque as escolas perten\u00e7am a outras localidades, principalmente na regi\u00e3o central de Betim. As redes formadas em universidades n\u00e3o se mostraram muito relevantes, o que se justifica, de acordo com os entrevistados, pela fase da vida em que esses v\u00ednculos s\u00e3o constitu\u00eddos, com os integrantes estando j\u00e1 casados, com fam\u00edlia constitu\u00edda ou muito focados na vida profissional.conjunto de recursos atuais ou potenciais que est\u00e3o ligados \u00e0 posse de uma rede dur\u00e1vel de rela\u00e7\u00f5es mais ou menos institucionalizadas de interconhecimento e de inter-reconhecimento ou, em outros termos, \u00e0 vincula\u00e7\u00e3o a um grupo (...)\u201d, nos termos de Pierre Bourdieu ,Outro aspecto analisado foi a utiliza\u00e7\u00e3o das redes sociais para a mobiliza\u00e7\u00e3o de recursos, ou seja, o tipo de capital social presente nessas rela\u00e7\u00f5es, suas caracter\u00edsticas e sua distribui\u00e7\u00e3o, a partir das redes mais acessadas para obt\u00ea-lo. Com isso, \u00e9 poss\u00edvel identificar os padr\u00f5es de sociabilidade mais ou menos funcionais \u00e0 aloca\u00e7\u00e3o de estoques de capital social no territ\u00f3rio, de acordo com a natureza dos v\u00ednculos em cada esfera social. Compreende-se o conceito de capital social como o \u201cA Confirmando o car\u00e1ter local das redes, as mais utilizadas pelos entrevistados para a aquisi\u00e7\u00e3o de recursos s\u00e3o as da vizinhan\u00e7a e as da fam\u00edlia, respectivamente. Como dito anteriormente, apesar de as redes familiares serem apontadas como as de la\u00e7os mais fortes, \u00e9 na vizinhan\u00e7a (sobretudo os vizinhos antigos) que se concentra a maior parte do capital social acessado pelos entrevistados. Ressalta-se que esses dados se referem ao tipo e \u00e0s caracter\u00edsticas do capital social acessado em cada esfera, e n\u00e3o ao seu volume, que n\u00e3o \u00e9 poss\u00edvel apreender por t\u00e9cnicas qualitativas. O volume de capital social da comunidade ser\u00e1 medido na pr\u00f3xima etapa da pesquisa por meio de t\u00e9cnica espec\u00edfica.A vizinhan\u00e7a \u00e9 a esfera social em que se concentram os seguintes tipos de capital social, por ordem de import\u00e2ncia: (1) cuidados de sa\u00fade; (2) alimentos; (3) recursos financeiros; (4) cuidado de crian\u00e7as e parentes; (5) vigiar a casa em momentos de aus\u00eancia, empr\u00e9stimo de utens\u00edlios; (6) informa\u00e7\u00e3o/indica\u00e7\u00e3o para vaga de emprego, apoio emocional, ajuda em obras (constru\u00e7\u00e3o e pequenos reparos), aux\u00edlio com informa\u00e7\u00f5es e orienta\u00e7\u00f5es diversas. J\u00e1 a fam\u00edlia \u00e9 a esfera acessada para: (1) informa\u00e7\u00e3o/indica\u00e7\u00e3o para vaga de emprego; (2) apoio emocional; (3) ajuda financeira; (4) ajuda com moradia (empr\u00e9stimo ou doa\u00e7\u00e3o), aux\u00edlio com informa\u00e7\u00f5es e orienta\u00e7\u00f5es diversas. Ainda nas redes prim\u00e1rias, as amizades s\u00e3o acionadas pela maioria dos entrevistados para: (1) informa\u00e7\u00e3o/indica\u00e7\u00e3o para vaga de emprego; (2) apoio emocional ; (3) forma\u00e7\u00e3o e qualifica\u00e7\u00e3o (informa\u00e7\u00e3o sobre cursos e ajuda nos estudos); (4) aux\u00edlio com informa\u00e7\u00f5es e orienta\u00e7\u00f5es diversas.Com rela\u00e7\u00e3o \u00e0s redes secund\u00e1rias, os v\u00ednculos profissionais n\u00e3o se mostraram muito fortes nas entrevistas. As intera\u00e7\u00f5es, geralmente, se limitam ao ambiente de trabalho e, quando ultrapassam o espa\u00e7o profissional, se centram mais em encontros ocasionais. Essas redes s\u00e3o mais acessadas para provis\u00e3o de (1) apoio emocional e (2) informa\u00e7\u00e3o/indica\u00e7\u00e3o para vaga de emprego. De maneira bem menos expressiva, foram citadas as institui\u00e7\u00f5es de ensino como esferas sociais para aux\u00edlio em cursos de forma\u00e7\u00e3o e qualifica\u00e7\u00e3o na trajet\u00f3ria de alguns entrevistados, em especial a concess\u00e3o de bolsas de estudo. Por outro lado, grande parte do capital social presente nas redes de sociabilidade secund\u00e1ria dos entrevistados adv\u00e9m dos grupos religiosos que frequentam: (1) apoio emocional; (2) alimentos; (3) aux\u00edlio em informa\u00e7\u00f5es e orienta\u00e7\u00f5es diversas; (4) aux\u00edlio na forma\u00e7\u00e3o/qualifica\u00e7\u00e3o , esse \u00faltimo bem menos expressivo e proveniente de igrejas fora da regi\u00e3o de moradia - redes ex\u00f3genas. Por sinal, os entrevistados que tiveram as melhores oportunidades de forma\u00e7\u00e3o educacional/profissional em sua trajet\u00f3ria, com exce\u00e7\u00e3o dos oriundos da classe m\u00e9dia, tiveram ajuda de algum contato de uma rede externa, como a patroa da m\u00e3e, que \u00e9 empregada dom\u00e9stica, ou de igrejas.Como era de se esperar em raz\u00e3o do localismo das redes, o capital social do grupo de entrevistados est\u00e1 fortemente concentrado nas redes de sociabilidade prim\u00e1ria , o que remete \u00e0 discuss\u00e3o de Granovetter ,,Em contrapartida, o tipo de capital social presente nas redes estudadas, voltado para a provis\u00e3o de recursos b\u00e1sicos e imediatos (pr\u00e1ticas assistenciais), para a presta\u00e7\u00e3o de servi\u00e7os e para o apoio social, \u00e9 um importante fator de prote\u00e7\u00e3o social para as comunidades. Esse tipo de capital \u00e9 fundamental para fomentar o c\u00edrculo de reciprocidade, aumentando a capacidade potencial para a ajuda m\u00fatua No que se refere \u00e0s redes secund\u00e1rias ou associativas, as igrejas se destacaram como principal espa\u00e7o de sociabilidade. Quando solicitados a falar sobre sua participa\u00e7\u00e3o em grupos e associa\u00e7\u00f5es, a maioria (25) relatou suas experi\u00eancias em comunidades religiosas. \u00c9 a esfera social que re\u00fane a vizinhan\u00e7a, a fam\u00edlia, as amizades, sendo frequentada como miss\u00e3o , mas tamb\u00e9m como lazer , al\u00e9m dos pr\u00f3prios rituais (missas e cultos). As organiza\u00e7\u00f5es religiosas t\u00eam centralidade junto a essas comunidades, por meio de obras sociais, provis\u00e3o de recursos e suporte religioso. Por se localizarem, em sua maioria, no bairro onde os indiv\u00edduos moram, as redes religiosas ajudam a fortalecer (intensificar) os v\u00ednculos de vizinhan\u00e7a e de amizade porque concentram e re\u00fanem os moradores nas suas atividades. Nota-se que quando os moradores frequentam a mesma igreja, os v\u00ednculos de vizinhan\u00e7a parecem ser ainda mais fortes.Ao contr\u00e1rio do esperado, a participa\u00e7\u00e3o em grupos da igreja cat\u00f3lica predominou entre os entrevistados, assim como sua presen\u00e7a e atua\u00e7\u00e3o nos bairros. Dado o elevado n\u00famero de templos evang\u00e9licos na Regional Alterosas e, como afirma a literatura, uma crescente ades\u00e3o das periferias ao neopentecostalismo Outra rede secund\u00e1ria que apareceu nas entrevistas, por\u00e9m bem menos significativa (4), foi a dos grupos esportivos, destacando os times de v\u00f4lei e os grupos de corrida/caminhada. A participa\u00e7\u00e3o pol\u00edtica e o ativismo s\u00e3o pouco significativos entre os entrevistados, a maioria nunca participou de movimentos sociais, partidos pol\u00edticos, associa\u00e7\u00f5es, entre outros. Em Betim, \u00e9 muito comum a participa\u00e7\u00e3o na pol\u00edtica se dar em forma de apoio a candidatos durante as elei\u00e7\u00f5es. A pol\u00edtica formal, por sinal, foi bastante criticada. H\u00e1 uma indigna\u00e7\u00e3o com os representantes e com a maneira como eles, segundo os entrevistados, se aproveitam de quest\u00f5es sociais e comunit\u00e1rias para benef\u00edcio pr\u00f3prio. H\u00e1 um descr\u00e9dito na pol\u00edtica formal, e \u00e9 recorrente a fala de que projetos comunit\u00e1rios teriam apoio das comunidades se n\u00e3o estivessem atrelados a pol\u00edticos.Corroborando as hip\u00f3teses, as redes sociais dos entrevistados se mostraram bastante localistas , muito voltadas para a sociabilidade prim\u00e1ria (fam\u00edlia e vizinhan\u00e7a) e com baixa tend\u00eancia ao associativismo , sendo a sociabilidade secund\u00e1ria voltada, predominantemente, para a participa\u00e7\u00e3o em grupos religiosos. No que se refere \u00e0 intensidade dos v\u00ednculos, as entrevistas confirmam o que \u00e9 discutido pela literatura, isto \u00e9, a tend\u00eancia muito comum em bairros de periferias urbanas de haver la\u00e7os fortes entre os vizinhos, que se traduzem em um esquema de ajuda m\u00fatua (reciprocidade). Na trajet\u00f3ria dos entrevistados, a vizinhan\u00e7a se mostrou como importante rede de reciprocidade e de provis\u00e3o de recursos no cotidiano, dada a proximidade f\u00edsica e a dura\u00e7\u00e3o das rela\u00e7\u00f5es.A an\u00e1lise das redes sociais do territ\u00f3rio evidencia alguns aspectos importantes para a elabora\u00e7\u00e3o de novas estrat\u00e9gias de mobiliza\u00e7\u00e3o social no \u00e2mbito da proposta de vigil\u00e2ncia em sa\u00fade a ser implementada no munic\u00edpio. Embora as redes sociais caracterizadas pela presen\u00e7a de la\u00e7os fortes n\u00e3o favore\u00e7am o acesso \u00e0s oportunidades e aos bens sociais, dificultando a mobilidade social, esse tipo de sociabilidade \u00e9 um importante fator de integra\u00e7\u00e3o social e de ac\u00famulo de capital social comunit\u00e1rio. Com o apoio social representando o principal mecanismo de solidariedade, essas redes estimulam as trocas, a reciprocidade, a coopera\u00e7\u00e3o e a interdepend\u00eancia dos membros de uma comunidade. Por isso, elas s\u00e3o um importante instrumento para a implementa\u00e7\u00e3o de pol\u00edticas p\u00fablicas, na medida em que, quando mobilizadas, se tornam uma estrat\u00e9gia de refor\u00e7o do tecido social e, consequentemente, de amplia\u00e7\u00e3o da autonomia, da participa\u00e7\u00e3o social e da cidadania. As redes religiosas, inclusive, com presen\u00e7a significativa no cotidiano dos moradores, mesmo sendo do tipo associativo (secund\u00e1rias), se mostraram fortemente ancoradas na presta\u00e7\u00e3o de \u201cajuda\u201d social, pautada por valores solid\u00e1rios. Essas redes, como trata a literatura, operam como um fator de prote\u00e7\u00e3o social para as classes populares brokers) entre as a\u00e7\u00f5es dos comit\u00eas populares e o restante da comunidade, ampliando o alcance da proposta de vigil\u00e2ncia em sa\u00fade. A compreens\u00e3o da estrutura das redes permite identificar aquelas mais prop\u00edcias para o desenvolvimento de a\u00e7\u00f5es coletivas, especialmente quando seus padr\u00f5es de sociabilidade est\u00e3o intrinsecamente associados \u00e0 territorialidade, com base na proximidade espacial e social Assim, dada a centralidade dessas redes, concentrando grande parte do capital social presente no territ\u00f3rio, \u00e9 poss\u00edvel utiliz\u00e1-las como canais de media\u00e7\u00e3o ou pontes (Desse modo, os comit\u00eas populares podem operar como redes de media\u00e7\u00e3o entre as redes preexistentes no territ\u00f3rio e outras externas, j\u00e1 que elas n\u00e3o se conectam de forma espont\u00e2nea, mas a partir da elabora\u00e7\u00e3o de pol\u00edticas sociais que estimulem a forma\u00e7\u00e3o de capital social nas esferas de sociabilidade prim\u00e1ria"}
+{"text": "To describe the process and epidemiological implications of georeferencing in EpiFloripa Aging samples (2009\u20132019). The EpiFloripa Aging Cohort Study sought to investigate and monitor the living and health conditions of the older adult population (\u2265 60) of Florian\u00f3polis in three study waves . With an automatic geocoding tool, the residential addresses were spatialized, allowing to investigate the effect of the georeferencing sample losses regarding 19 variables, evaluated in the three waves. The influence of different neighborhood definitions  was examined in the results of seven variables: area, income, residential density, mixed land use, connectivity, health unit count, and public open space count. Pearson\u2019s correlation coefficients were calculated to evaluate the differences between neighborhood definitions according to three variables: contextual income, residential density, and land use diversity. The losses imposed by geocoding  caused no statistically significant difference between the total sample and the geocoded sample. The analysis of the study variables suggests that the geocoding process may have included a higher proportion of participants with better income, education, and living conditions. The correlation coefficients showed little correspondence between measures calculated by the three neighborhood definitions (r = 0.37\u20130.54). The statistical difference between the variables calculated by buffers and census tracts highlights limitations in their use in the description of geospatial attributes. Despite the challenges related to geocoding, such as inconsistencies in addresses, adequate correction and verification mechanisms provided a high rate of assignment of geographic coordinates, the findings suggest that adopting buffers, favored by geocoding, represents a potential for spatial epidemiological analyses by improving the representation of environmental attributes and the understanding of health outcomes. Planning and managing cities efficiently may promote health and well-being, as well as reduce the incidence of chronic non-communicable diseases3, with a lasting effect4. Geographic Information Systems (GIS) are a set of technologies that allow the integration, in the same environment, of variables about different aspects of reality and at different aggregation scales6. Geographic models based on GIS support in the analysis of health disparities concepts such as neighborhood context, health services availability, physical activity practice, and daily destination accessibility7, capable of contributing to work on health and quality of life in cities.With the increase in the world urban population, a growing number of investigations seek to understand the relationships between urbanized environments and health outcomes8. The GIS analyses in the Collective Health field are generally based on the residential location of an individual, which can be defined at various levels of geographic resolution, such as: a) administrative boundaries ; b) census tracts ; and, c) latitude and longitude of a residential address. For administrative limits and census tracts, converting the address into a coordinate is unnecessary; however, the correspondence of the address with the territorial limit under study should be observed. On the other hand, the latter requires a process of converting textual addresses into geographic coordinates, known as geocoding11.Advances in GIS in the last two decades have increased the specificity with which an individual\u2019s neighborhood environment can be spatially defined12.The importance of geocoding for analyzing health data has been evidenced by national surveys7. Despite the importance of the scale to aggregate the environment variables, few studies have examined the influence of different neighborhood definitions in the results of analyses13. Thus, the results of the objective attributes of the urban environment acquired with each type of geographical resolution may be different, overestimating or underestimating the real exposure that the participants of an epidemiological study have to the attributes of interest of the investigation.Geocoding allows the adoption of buffers, a zone around an individual\u2019s home address (point) that establishes a boundary area, defined by a specified maximum distance, where spatial data of interest is aggregated. Buffers define and characterize the neighborhood accurately, helping to manage census tract limitations and the modifiable area unit problem14. Errors can lead to incorrect descriptions of the built environment variables, distorted conclusions about the association between dependent and independent variables, and inadequate public health decisions11. International studies use ArcGIS(r)/ArcView(r), a software licensed for geocoding6, but point out risks of incorrect localization6 and errors when applied in other countries19. Other studies hire commercial companies with trained professionals, their own software, and continuous spatial corrections18. Therefore, to minimize internal geocoding expenses, high-quality locational data is critical.Although the agility in the spatialization of a large volume of sites is an advantage of geocoding, the conversion process increases the risk of position and classification errors. Previous works have reported variable geocoding rates and losses caused by problematic addresses and poor record quality20. Publications from this project have, so far, used the census tracts as a spatial unit of analysis and representation of the participants\u2019 neighborhoods22. With households geocoding, new studies can be developed, applying more specific units of analysis to the urban environment that can effectively be accessed within a certain time interval. However, this process imposes several technological and operational challenges that need to be addressed to ensure reliability and accuracy of the results.The EpiFloripa Aging Cohort Study, conducted in Florian\u00f3polis, Santa Catarina, sought to investigate and monitor the living and health conditions of the older population (60 years or older) living in the urban area of the municipalityThus, this study describes the process and epidemiological implications of geocoding the residences of the EpiFloripa Aging Cohort Study (2009\u20132019) participants. For the latter, more specifically, we: a) compare sociodemographic data, environment and health condition perception obtained for the total sample and the proportion that was geocoded, searching possible distortions; and b) compare the performance of three possible neighborhood definitions from geocoding  for some relevant variables, such as income, residential density, mixed land use, and connectivity.23. The spatial context of the study involves the entire city of Florian\u00f3polis (SC), with 421,240 inhabitants and 11.4% of the population over 60 years of age19. The sample selection process was carried out by clusters, in which the first stage units were the census tracts and those of the second stage were the households themselves. Initially, in 2009, the 420 urban census tracts of the municipality were organized according to the income deciles of the heads of households, and eight sectors were systematically drawn in each decile. Subsequently, a step was taken to reduce the coefficient of variation of the households in each sector, by dividing the sectors with the largest number of households (> 500) and grouping those with the lowest number (< 150), which resulted in 83 sectors, composed of a total of 22,846 households. At baseline, 1,911 older adults (\u2265 60 years old) were identified and considered eligible.The EpiFloripa Ageing project is a population-based cohort study developed by the Federal University of Santa CatarinaData collection was performed with a standardized questionnaire, applied as a face-to-face interviews at the participant\u2019s residence, which offered registration data necessary for geolocation, containing the participant\u2019s identification code (ID), name, telephone, street, residential number, residential postal code (ZIP code), and neighborhood.23. Further methodological details can be found in previous studies24.It had three waves of assessment\u2014baseline (2009\u20132010), follow-up after five years (2013\u20132014), and follow-up after 10 years (2017\u20132019)\u2014with the first wave involving 1,705 respondents. However, two duplicate participants and one with incompatible age took the sample to 1,702, keeping the response rate at 89.2%. The second wave reached 1,197 participants, and from the third, it became an open cohort with 1,335 participants, of which 743 were follow-up interviews, 105 were older adults from the EpiFloripa Adult sample, and 487 were new recruits9, suggesting corrections for invalid addresses.The geocoding procedure followed several steps in this study, with three main strategies: a) address standardization; b) manual correction; and c) coordinate assignment and conference . The rec11, a preliminary geocoding of the baseline was generated . It highlighted the need to correct the addresses, preparing them for a definitive importation.To assess the coverage (proportion of successfully geocoded addresses) and positional accuracy of the participants\u2019 households (how close the geocoded coordinates correspond to the true coordinates)11. Thus, addresses that were not found were verified on a case-by-case basis . Thus, data from individuals living at the edges of the census tract and who are within its zone of influence were safeguarded. For the participants in the three waves of the study, the location outside the tolerance margin of the Episector was disregarded as an error factor, favoring longitudinal studies.25. Therefore, for participants without records related to the residential number and without possibility of contact, the latitude/longitude coordinates of the centroids of the informed street were assigned. In extensive streets, the numbering of houses within the Episector in question was sought.In similar studies, inaccessible addresses were solved by generating a \u201cmidpoint of the street segment,\u201d deriving a centroidThe same spatialization criteria were followed for the second and third waves of the study. Participants who changed addresses between the waves of research had their new home address checked and formatted for a new geocoding.24. The data were compared according to the total samples, to identify the effect of georeferencing losses on the sample data of the three waves. The significance (95%) of the difference between the values for the total sample and the geocoded sample was calculated from a Z test for proportions.Participants with valid addresses were analyzed regarding 19 variables derived from the EpiFloripa Ageing, which encompass blocks of the questionnaire with sociodemographic data, data of perception of the environment, and health conditions along three waves of follow-up. The information collection method has been described in previous studies26 and on the average gait speed according to age group27, representing 10 minutes of walking from home.Neighborhood definitions were adopted according to three different units of spatial analysis . From th2), mean income per capita (census tracts28), residential density (housing per hectare), mixed land use (entropy), street connectivity (three intersections or more), and health units and public open spaces counts were calculated29. When using buffered census data, the sectors and the portion comprised by them were considered, weighting the values according to the area of each census tract contained therein. To perform the calculations, scripts were created in the QGIS Graphical Modeler, combining different analyses into a single process and containing the analysis unit as a calculation parameter.By investigating the differences regarding the three neighborhood definitions, seven environmental variables were calculated for each spatial unit of analysis. For the samples geocoded in the three waves, the variables area  and generated a higher number of losses than the other waves (nw1 = 132). Error correction and verification from the expanded limit of the Episector (census tract) identified addresses outside it, inconsistent, and without numerical data (geocoded by the centroid of the street). The second wave of the study (2013-2014) had 77 losses, and the third (2017\u20132019) had 31, most of which were due to the move to another municipality (nw3 = 22). Finally, reconsidering participants from the three study waves with residential locations outside the expanded limit of their respective Episector avoided 18 losses  were considered losses, and 1%  received coordinates corresponding to the centroid of their respective street, which led to the absence of statistically significant difference between the total sample and the georeferenced sample . This fact is partially justified by the physical-geographical characteristics of the municipality and its historical occupation process. The previous rural structuring and naval flows led to the formation of a disjointed and fragmentary urban fabric, with the presence of fishbone traces, varied easements, and disconnected and peripheral neighborhoods30. In addition, the slight difference in the proportion of income groups indicates possible problems related to geocoding populations of neighborhoods of lower socioeconomic status . These results reinforce the need for epidemiological studies to include in their planning training on ways to obtain address data with greater quality or accuracy, or to use other forms of geolocation, such as mobile devices for real-time location . This can ensure higher quality of the georeferenced data.Another factor that may justify the volume of losses is the small number of interviewers in the field in the first wave of the study, their turnover, and the need for replacement in the second waveRegarding the possibility of introducing a bias with the losses imposed by geocoding, the p-values in 6, suggesting that adopting buffers can help manage their limitations, representing a more effective aggregation unit of environmental data13.On the other hand, although the process caused sample losses, geocoding allowed the adoption of buffers, evidencing their statistical difference compared with measures calculated by census tracts, and highlighting flaws in describing the spatial attributes calculated on this territorial unit. The artificial spatial standardization of the census tract creates units of different dimensions and aggregation levels, which generated spatial measures with high variation (larger standard deviations) compared with buffer-based measures, especially for measures such as area, income, residential density, and mixed land use . Pearson9. The use of specific software and programming for normalization and search of the input addresses could have reduced the time spent updating the problematic addresses. Therefore, future studies may employ different geocoding methods, comprising address verification algorithms16, precision measurements of geocoded locations, and positional error assessments. Similarly, we recognize the need for a team familiar with geocoding and data manipulation software.Due to these problems, we recommend that household-based surveys standardize records, expanding the detailing of location informationFinally, the low quality of municipal records in peripheral areas highlights a problem that impacts knowledge about urban reality and limits the creation of evidence-based public policies aimed at the most vulnerable populations. Therefore, the need to improve municipal registries is highlighted, expanding the detailing of location information that serves as input for geocoding. 1. Planejar e gerir as cidades de forma eficiente possui potencial de promover a sa\u00fade e o bem-estar, al\u00e9m de reduzir a incid\u00eancia de doen\u00e7as cr\u00f4nicas n\u00e3o transmiss\u00edveis3, com um efeito duradouro4. Os Sistemas de Informa\u00e7\u00f5es Geogr\u00e1ficas (SIG) s\u00e3o um conjunto de tecnologias que permitem integrar, em um mesmo ambiente, vari\u00e1veis sobre diferentes aspectos da realidade e em diferentes escalas de agrega\u00e7\u00e3o6. Modelos geogr\u00e1ficos baseados em SIG sustentam na an\u00e1lise de disparidades de sa\u00fade conceitos como contexto de vizinhan\u00e7a, disponibilidade de servi\u00e7os de sa\u00fade, pr\u00e1tica de atividade f\u00edsica e acessibilidade a destinos cotidianos7, capazes de contribuir para trabalhos sobre sa\u00fade e qualidade de vida nas cidades.Com o aumento da popula\u00e7\u00e3o mundial urbana, um n\u00famero crescente de investiga\u00e7\u00f5es busca compreender as rela\u00e7\u00f5es entre os ambientes urbanizados e desfechos de sa\u00fade8. An\u00e1lises em SIG na \u00e1rea de Sa\u00fade Coletiva s\u00e3o geralmente baseadas na localiza\u00e7\u00e3o residencial de um indiv\u00edduo, que pode ser definida em v\u00e1rios n\u00edveis de resolu\u00e7\u00e3o geogr\u00e1fica, como: a) limites administrativos ; b) setores censit\u00e1rios ; e, c) latitude e longitude de um endere\u00e7o residencial. Para limites administrativos e setores censit\u00e1rios, n\u00e3o \u00e9 necess\u00e1rio converter o endere\u00e7o em coordenada, no entanto deve-se observar a correspond\u00eancia do endere\u00e7o com o limite territorial em estudo. Por outro lado, o \u00faltimo exige um processo de convers\u00e3o de endere\u00e7os textuais em coordenadas geogr\u00e1ficas, conhecido como geocodifica\u00e7\u00e3o11.Os avan\u00e7os em SIG nas \u00faltimas duas d\u00e9cadas aumentaram a especificidade com a qual o ambiente da vizinhan\u00e7a de um indiv\u00edduo pode ser espacialmente definido12.A import\u00e2ncia da geocodifica\u00e7\u00e3o para an\u00e1lise de dados de sa\u00fade tem sido evidenciada por pesquisas nacionaisbuffers, uma zona em torno do endere\u00e7o residencial de um indiv\u00edduo (ponto) que estabelece uma \u00e1rea limite, definida por uma dist\u00e2ncia m\u00e1xima especificada, onde s\u00e3o agregados dados espaciais de interesse. Os buffers definem e caracterizam a vizinhan\u00e7a com precis\u00e3o, ajudando a gerenciar limita\u00e7\u00f5es dos setores censit\u00e1rios e o problema da unidade de \u00e1rea modific\u00e1vel7. Apesar da import\u00e2ncia da escala para agregar as vari\u00e1veis do ambiente, poucas pesquisas examinaram a influ\u00eancia de diferentes defini\u00e7\u00f5es de vizinhan\u00e7a em resultados de an\u00e1lises13. A partir disso, percebe-se que os resultados dos atributos objetivos do ambiente urbano adquiridos com cada tipo de resolu\u00e7\u00e3o geogr\u00e1fica podem ser diferentes, superestimando ou subestimando a real exposi\u00e7\u00e3o que os participantes de um estudo epidemiol\u00f3gico t\u00eam aos atributos de interesse da investiga\u00e7\u00e3o.A geocodifica\u00e7\u00e3o permite a ado\u00e7\u00e3o de 14. Erros podem gerar descri\u00e7\u00f5es incorretas das vari\u00e1veis do ambiente constru\u00eddo, conclus\u00f5es distorcidas sobre a associa\u00e7\u00e3o entre vari\u00e1veis dependentes e independentes, e decis\u00f5es de sa\u00fade p\u00fablica inadequadas11. Estudos internacionais utilizam o ArcGIS(r)/ArcView(r), um software licenciado para a geocodifica\u00e7\u00e3o6, por\u00e9m apontam riscos de localiza\u00e7\u00e3o incorreta6 e erros quando aplicados em outros pa\u00edses19. Outras pesquisas contratam empresas comerciais com profissionais treinados, softwares pr\u00f3prios e corre\u00e7\u00f5es espaciais cont\u00ednuas18. Portanto, para minimizar as despesas de geocodifica\u00e7\u00e3o interna, dados locacionais de alta qualidade s\u00e3o fundamentais.Embora a agilidade na espacializa\u00e7\u00e3o de um grande volume de locais seja uma vantagem da geocodifica\u00e7\u00e3o, o processo de convers\u00e3o potencializa o risco de erros de posi\u00e7\u00e3o e classifica\u00e7\u00e3o. Trabalhos anteriores reportaram taxas de geocodifica\u00e7\u00e3o vari\u00e1veis e perdas causadas por endere\u00e7os problem\u00e1ticos e com m\u00e1 qualidade dos registros20. As publica\u00e7\u00f5es provenientes deste projeto t\u00eam utilizado, at\u00e9 ent\u00e3o, os setores censit\u00e1rios como unidade espacial de an\u00e1lise e representa\u00e7\u00e3o das vizinhan\u00e7as dos participantes22. Com a geocodifica\u00e7\u00e3o dos domic\u00edlios, novos estudos podem ser desenvolvidos, aplicando unidades de an\u00e1lise mais espec\u00edficas ao ambiente urbano que efetivamente possa ser acessado dentro de um determinado intervalo de tempo. Contudo, esse processo imp\u00f5e diversos desafios tecnol\u00f3gicos e operacionais que precisam ser enfrentados para assegurar confiabilidade e precis\u00e3o aos resultados.O estudo de coorte EpiFloripa Idoso, realizado em Florian\u00f3polis, Santa Catarina, buscou investigar e acompanhar as condi\u00e7\u00f5es de vida e sa\u00fade da popula\u00e7\u00e3o idosa (60 anos ou mais) residente na zona urbana do munic\u00edpioAssim, o objetivo deste estudo \u00e9 descrever o processo e as implica\u00e7\u00f5es epidemiol\u00f3gicas da geocodifica\u00e7\u00e3o das resid\u00eancias dos participantes da amostra do EpiFloripa Ageing Cohort Study (2009\u20132019). Para estas \u00faltimas, mais especificamente, fazemos: a) uma compara\u00e7\u00e3o entre dados sociodemogr\u00e1ficos, de percep\u00e7\u00e3o do ambiente e de condi\u00e7\u00e3o de sa\u00fade obtidos para a amostra total e aquela propor\u00e7\u00e3o que foi geocodificada, em busca de poss\u00edveis distor\u00e7\u00f5es; e b) uma compara\u00e7\u00e3o do desempenho de tr\u00eas defini\u00e7\u00f5es de vizinhan\u00e7a poss\u00edveis a partir da geocodifica\u00e7\u00e3o  para algumas vari\u00e1veis relevantes, como renda, densidade residencial, uso misto do solo e conectividade.23. O contexto espacial do estudo envolve todo o munic\u00edpio de Florian\u00f3polis (SC), com 421.240 habitantes, e 11,4% da popula\u00e7\u00e3o composta por pessoas acima de 60 anos de idade19. O processo de sele\u00e7\u00e3o da amostra foi realizado por conglomerados, nos quais as unidades de primeiro est\u00e1gio foram os setores censit\u00e1rios e as do segundo est\u00e1gio foram os pr\u00f3prios domic\u00edlios. Inicialmente foram organizados, em 2009, os 420 setores censit\u00e1rios urbanos do munic\u00edpio conforme os decis de renda dos chefes dos domic\u00edlios, e sorteados sistematicamente oito setores em cada decil. Posteriormente, foi realizada uma etapa para redu\u00e7\u00e3o do coeficiente de varia\u00e7\u00e3o dos domic\u00edlios de cada setor, por meio da divis\u00e3o dos setores com maior n\u00famero de domic\u00edlios (> 500) e agrupamento daqueles com menor n\u00famero (< 150), o que resultou em 83 setores, compostos por um total de 22.846 domic\u00edlios. Na linha de base, 1.911 idosos (\u2265 60 anos) foram identificados e considerados eleg\u00edveis.O projeto EpiFloripa Idoso \u00e9 um estudo de coorte de base populacional desenvolvido pela Universidade Federal de Santa CatarinaA coleta de dados foi realizada por meio de um question\u00e1rio padronizado, aplicado na forma de entrevista face-a-face na resid\u00eancia do participante, o qual ofereceu dados cadastrais necess\u00e1rios para a geolocaliza\u00e7\u00e3o, contendo o c\u00f3digo de identifica\u00e7\u00e3o do participante (ID), nome, telefone, logradouro, n\u00famero residencial, c\u00f3digo postal residencial (CEP) e bairro.23. Maiores detalhes metodol\u00f3gicos encontram-se em estudos pr\u00e9vios24.Com tr\u00eas ondas de avalia\u00e7\u00e3o \u2013 linha de base (2009\u20132010), acompanhamento ap\u00f3s cinco anos (2013\u20132014), e acompanhamento ap\u00f3s 10 anos (2017\u20132019) \u2013, a primeira onda envolveu 1.705 entrevistados. No entanto, dois participantes duplicados e um com idade incompat\u00edvel levaram a amostra para 1.702, mantendo a taxa de resposta em 89,2%. A segunda onda obteve 1.197 participantes, e, a partir da terceira, tornou-se uma coorte aberta, com 1.335 participantes, sendo 743 entrevistas de acompanhamento, 105 idosos oriundos da amostra EpiFloripa Adulto, e 487 novos recrutados9, sugerindo corre\u00e7\u00f5es para endere\u00e7os inv\u00e1lidos.O procedimento de geocodifica\u00e7\u00e3o seguiu neste estudo v\u00e1rias etapas, com tr\u00eas estrat\u00e9gias principais: a) padroniza\u00e7\u00e3o dos endere\u00e7os; b) corre\u00e7\u00e3o manual; e c) atribui\u00e7\u00e3o de coordenadas e confer\u00eancia . A recor11, foi gerada uma geocodifica\u00e7\u00e3o preliminar da linha de base . Ela evidenciou a necessidade de corre\u00e7\u00e3o dos endere\u00e7os, preparando-os para uma importa\u00e7\u00e3o definitiva.Para avaliar a cobertura (propor\u00e7\u00e3o de endere\u00e7os geocodificados com sucesso) e precis\u00e3o posicional dos domic\u00edlios dos participantes (qu\u00e3o pr\u00f3ximas as coordenadas geocodificadas correspondem \u00e0s coordenadas verdadeiras)11. Assim, a checagem dos endere\u00e7os n\u00e3o encontrados foi feita caso a caso . Dessa forma, dados de indiv\u00edduos residentes nas bordas do setor censit\u00e1rio e que se encontram dentro de sua zona de influ\u00eancia foram resguardados. Em casos de participantes das tr\u00eas ondas do estudo, foi desconsiderada a localiza\u00e7\u00e3o fora da margem de toler\u00e2ncia do Episetor como um fator de erro, favorecendo estudos longitudinais.25. Logo, para participantes sem registros relativos ao n\u00famero residencial e sem possibilidade de contato, foram atribu\u00eddas as coordenadas de latitude/longitude dos centroides dos logradouros informados. Em logradouros extensos, buscou-se a numera\u00e7\u00e3o de casas dentro do Episetor em quest\u00e3o.Em estudos semelhantes, endere\u00e7os inacess\u00edveis foram solucionados a partir da gera\u00e7\u00e3o de um \u201cponto m\u00e9dio do segmento de rua\u201d, derivando um centroidePara as segunda e terceira ondas do estudo, foram seguidos os mesmos crit\u00e9rios de espacializa\u00e7\u00e3o. Participantes que mudaram de endere\u00e7o entre as ondas de pesquisa tiveram seu novo endere\u00e7o residencial conferido e formatado para uma nova geocodifica\u00e7\u00e3o.24. Os dados foram comparados de acordo com as amostras totais, visando identificar o efeito das perdas de georreferenciamento nos dados amostrais das tr\u00eas ondas. A signific\u00e2ncia (95%) da diferen\u00e7a entre os valores para a amostra total e a amostra geocodificada foi calculada a partir de um teste Z para propor\u00e7\u00f5es.Participantes com endere\u00e7os v\u00e1lidos foram analisados em rela\u00e7\u00e3o a 19 vari\u00e1veis derivadas do EpiFloripa Idoso, as quais englobam blocos do question\u00e1rio com dados sociodemogr\u00e1ficos, dados de percep\u00e7\u00e3o do ambiente, e condi\u00e7\u00f5es de sa\u00fade ao longo de tr\u00eas ondas de acompanhamento. O m\u00e9todo de coleta dessas informa\u00e7\u00f5es est\u00e1 descrito em estudos pr\u00e9vios26 e na velocidade m\u00e9dia de marcha de acordo com a faixa et\u00e1ria27, representando 10 minutos de caminhada a partir do domic\u00edlio.Foram adotadas defini\u00e7\u00f5es de vizinhan\u00e7a de acordo com tr\u00eas diferentes unidades de an\u00e1lise espacial . A parti2), renda per capita m\u00e9dia (setores censit\u00e1rios28), densidade residencial (moradias por hectare), uso misto do solo (Entropia), conectividade das ruas (tr\u00eas intersec\u00e7\u00f5es ou mais), e contagem de unidades de sa\u00fade e de espa\u00e7os livres p\u00fablicos29. Ao utilizar dados censit\u00e1rios em buffer, considerou-se os setores e a por\u00e7\u00e3o compreendida por ele, ponderando os valores de acordo com a \u00e1rea de cada setor censit\u00e1rio nele contida. Para executar os c\u00e1lculos, foram criados scripts no Modelador Gr\u00e1fico do QGIS, combinando diferentes an\u00e1lises em um \u00fanico processo e contendo a unidade de an\u00e1lise como par\u00e2metro para os c\u00e1lculos.Ao investigar as diferen\u00e7as em rela\u00e7\u00e3o \u00e0s tr\u00eas defini\u00e7\u00f5es de vizinhan\u00e7a, foram gerados c\u00e1lculos de sete vari\u00e1veis ambientais calculadas por cada unidade espacial de an\u00e1lise. Para as amostras geocodificadas nas tr\u00eas ondas, foram calculadas as vari\u00e1veis \u00e1rea  e geraram um maior n\u00famero de perdas em rela\u00e7\u00e3o \u00e0s demais ondas (nw1 = 132). A corre\u00e7\u00e3o dos erros e sua verifica\u00e7\u00e3o a partir do limite expandido do Episetor (setor censit\u00e1rio) identificaram endere\u00e7os fora dele, inconsistentes e sem dados num\u00e9ricos (geocodificados pelo centroide do logradouro). A segunda onda do estudo (2013-2014) obteve 77 perdas, e a terceira (2017\u20132019) obteve 31, sendo a maior parte devido \u00e0 mudan\u00e7a para outro munic\u00edpio (nw3 = 22). Por fim, a reconsidera\u00e7\u00e3o de participantes das tr\u00eas ondas do estudo com localiza\u00e7\u00f5es residenciais fora do limite expandido de seu respectivo Episetor evitou 18 perdas  foram considerados perdas, e 1%  recebeu coordenadas correspondentes ao centroide de seus respectivos logradouros, o que levou \u00e0 aus\u00eancia de diferen\u00e7a estat\u00edstica significativa entre a amostra total e a amostra georreferenciada . Esse fato justifica-se, em parte, pelas caracter\u00edsticas f\u00edsico-geogr\u00e1ficas do munic\u00edpio e seu processo hist\u00f3rico de ocupa\u00e7\u00e3o. A pr\u00e9via estrutura\u00e7\u00e3o rural e os fluxos navais levaram \u00e0 forma\u00e7\u00e3o de um tecido urbano desarticulado e fragment\u00e1rio, com a presen\u00e7a de tra\u00e7ados em espinha de peixe, variadas servid\u00f5es, e bairros desconectados e perif\u00e9ricos30. Al\u00e9m disso, a ligeira diferen\u00e7a na propor\u00e7\u00e3o dos grupos de renda indica a chance de problemas relativos \u00e0 geocodifica\u00e7\u00e3o de popula\u00e7\u00f5es de bairros de menor n\u00edvel socioecon\u00f4mico . Esses resultados refor\u00e7am a necessidade de estudos epidemiol\u00f3gicos inclu\u00edrem em seus planejamentos treinamentos sobre formas de obter dados de endere\u00e7o com maior qualidade ou precis\u00e3o, ou utilizarem outras formas de geolocaliza\u00e7\u00e3o, como, por exemplo, dispositivos m\u00f3veis de localiza\u00e7\u00e3o em tempo real . Isso pode garantir maior qualidade dos dados georreferenciados.Outro fator que pode justificar o volume de perdas \u00e9 o pequeno n\u00famero de entrevistadores em campo na primeira onda do estudo, a sua rotatividade e a necessidade de reposi\u00e7\u00e3o na segunda ondaQuanto \u00e0 possibilidade de introdu\u00e7\u00e3o de um vi\u00e9s com as perdas impostas pela geocodifica\u00e7\u00e3o, os valores-p da 6 sugerindo que a ado\u00e7\u00e3o de buffers pode ajudar a gerenciar suas limita\u00e7\u00f5es, representando uma unidade de agrega\u00e7\u00e3o de dados ambientais mais eficaz13.Por outro lado, embora o processo tenha causado perdas amostrais, a geocodifica\u00e7\u00e3o permitiu a ado\u00e7\u00e3o de buffers, evidenciando sua diferen\u00e7a estat\u00edstica em rela\u00e7\u00e3o a medidas calculadas por setores censit\u00e1rios, e ressaltando falhas na descri\u00e7\u00e3o dos atributos espaciais calculados sobre essa unidade territorial. A padroniza\u00e7\u00e3o espacial artificial do setor censit\u00e1rio cria unidades de diferentes dimens\u00f5es e n\u00edveis de agrega\u00e7\u00e3o, o que gerou medidas espaciais com alta varia\u00e7\u00e3o (desvios padr\u00e3o maiores) em rela\u00e7\u00e3o \u00e0s medidas baseadas em buffers, principalmente para medidas como \u00e1rea, renda, densidade residencial e mix de uso do solo . Os coef9.O uso de softwares espec\u00edficos e programa\u00e7\u00e3o para a normaliza\u00e7\u00e3o e busca dos endere\u00e7os de entrada poderia ter reduzido o tempo gasto com a atualiza\u00e7\u00e3o dos endere\u00e7os problem\u00e1ticos. Portanto, estudos futuros podem empregar diferentes m\u00e9todos de geocodifica\u00e7\u00e3o, compreendendo algoritmos de verifica\u00e7\u00e3o de endere\u00e7o16, medidas de precis\u00e3o das localiza\u00e7\u00f5es geocodificadas, e avalia\u00e7\u00f5es de erro posicional. Da mesma forma, reconhecemos a necessidade de uma equipe familiarizada com softwares de geocodifica\u00e7\u00e3o e manipula\u00e7\u00e3o de dados.Em fun\u00e7\u00e3o dos problemas apontados, recomenda-se que inqu\u00e9ritos de base domiciliar realizem a padroniza\u00e7\u00e3o dos registros, ampliando o detalhamento de informa\u00e7\u00f5es de localiza\u00e7\u00e3oPor fim, a baixa qualidade dos registros municipais em \u00e1reas perif\u00e9ricas destaca um problema que impacta o conhecimento sobre a realidade urbana e limita a cria\u00e7\u00e3o de pol\u00edticas p\u00fablicas baseadas em evid\u00eancias e voltadas a popula\u00e7\u00f5es mais vulner\u00e1veis. Portanto, destaca-se a necessidade de aprimoramento dos cadastros municipais, ampliando o detalhamento das informa\u00e7\u00f5es de localiza\u00e7\u00e3o que servem de insumo para a geocodifica\u00e7\u00e3o."}
+{"text": "Medical progress and the huge accumulated volume of knowledge and techniques prompted the creation of medical specialties and the division of medicine into different areas, which is also the case of the surgical specialties. To a certain extent, this subdivision is even more extreme with regard to aortic surgery. Surgeons who have very different training, experience, and skills learn to manage the same vessel, but in different anatomic regions.Routinely, cardiac surgeons are more accustomed to dealing with the aortic root and the ascending aorta, for which a sternotomy is the most common approach. In turn, vascular surgeons have greater expertise with the descending thoracic aorta and abdominal aorta, where endovascular techniques constitute the main strategy. Endovascular techniques for all segments of the aorta have developed rapidly and the state of the art in radiology, anesthesiology, intensive care, genetics, and cardiology has advanced apace.2 The same principles that were initially employed in cases with favorable anatomy in the descending thoracic aorta and infrarenal aorta were then applied over the years that followed to treat practically any segment of the aorta, from the root to its bifurcation into the iliac arteries.Vascular surgery has undergone major changes over recent years, with the rapid rise of endovascular techniques. At the end of the 1980s and start of the 90s, vascular surgeons all over the world were responsible for some of the most important developments ever achieved in aortic surgery. Parodi, in Argentina, and Volodos, in Ukraine, were responsible for founding the principles of endovascular aortic surgery, constructing the first endografts by hand.However, the division of the aorta into ascending and descending segments and division of the professionals who work on each segment is arbitrary and it is not rare for diseases to fail to \u201crespect\u201d this segmentation, involving more than one region or areas where the expertise of different specialties intersects. The best example of this is the diseases that involve the aortic arch.3 This left a gap in the medical literature on aortic surgery that persisted for years.4The aortic arch is a transition zone between the ascending aorta and the thoracic descending aorta. The Stanford classification of aortic dissections is the most widely used worldwide and was first described in 1970. It classifies dissections involving the ascending aorta as type A and dissections restricted to the descending aorta after the origin of the left subclavian artery as type B.This gap is not merely theoretical. Since this is a complex region that has not been entirely mastered by heart surgery, by vascular surgery, or by endovascular surgery, it is an area that was neglected for some time. In many parts of the world, vascular surgeons and heart surgeons work on opposite sides, each seeking solutions for the aortic arch alone, and also for many other situations in which diseases of the aorta involve many segments, demanding a wider and more complementary approach.5Examples of the importance of a multidisciplinary approach to the aorta are type A dissections that cause remote ischemia. In up to 40% of type A dissection cases there is also malperfusion of organs, causing an important increase in mortality among these patients. Some groups now start by treating the ischemia, dealing with the ascending aorta in a later intervention. Involving the vascular surgery team from the initial management of these cases and taking a case-by-case approach is therefore essential to provide the best possible care for these patients.6In 2019 the European Society for Vascular Surgery and the European Association for Cardio-Thoracic Surgery published a consensus setting out the principal guidelines for diseases of the aorta involving the aortic arch. The first three recommendations were as follows: decision making by an aortic team is recommended; centralization of care is recommended; and treatment of elective cases is recommended to be performed in specialized centers providing open and endovascular, cardiac and vascular surgery at a single center.8The importance of collaboration within a team that includes vascular surgeons, cardiac surgeons, cardiologists, radiologists, anesthetists, intensive care specialists, and, when necessary, rheumatologists, nephrologists, and geneticists would appear to be evident. The literature shows that the individual experience of the surgeon and, primarily, the institution has a positive impact on patient outcomes and many authors have demonstrated improvement of results after implementation of centers dedicated to diseases of the aorta.In Brazil, experience with these models is limited and implementation involves changes that are not restricted to logistic and structural issues in hospitals or operating rooms. The most important change in this setting is cultural. For many years, there was limited dialog and interaction between surgeons and clinicians, and also between cardiac and vascular surgeons. For a long period, the aortic arch was neglected by many groups, but it has now been recognized as a bridge linking the two specialties.Without doubt, the surgeons and specialists who work in these teams and centers for treatment of the aorta will be involved in the next round of developments in surgery for this artery. Care must be based not only on anatomy, but also on collaboration, seeking solutions for diseases that are almost always complex and severe. Consolidation of these models will only be achieved through flexibility in decision-making, laying pride aside, and with dialog, modernization, and the understanding that care cannot be centralized in a specialist or a specialty, but that the aorta and the patient must be at the center of care. Os progressos da medicina e o grande volume de conhecimentos e t\u00e9cnicas acumulados levaram \u00e0 cria\u00e7\u00e3o das especialidades m\u00e9dicas e de suas divis\u00f5es em diferentes \u00e1reas, o que n\u00e3o foi diferente com especialidades cir\u00fargicas. Na cirurgia da aorta, essa divis\u00e3o foi, de certa forma, ainda mais marcante. Cirurgi\u00f5es com forma\u00e7\u00f5es, experi\u00eancias e habilidades bem distintas aprenderam a lidar com o mesmo vaso, mas em diferentes regi\u00f5es anat\u00f4micas.Efetivamente, cirurgi\u00f5es card\u00edacos est\u00e3o mais habituados a lidar com a raiz da aorta e a aorta ascendente, sendo a esternotomia a principal via de acesso; j\u00e1 cirurgi\u00f5es vasculares t\u00eam maior dom\u00ednio sobre a aorta tor\u00e1cica descendente e aorta abdominal, em que a via endovascular tornou-se a principal estrat\u00e9gia. As t\u00e9cnicas endovasculares evolu\u00edram de forma r\u00e1pida em todos os segmentos da aorta, assim como os conhecimentos em radiologia, anestesiologia, terapia intensiva, gen\u00e9tica e cardiologia.2 . Os mesmos princ\u00edpios, que inicialmente foram utilizados em casos com anatomias favor\u00e1veis da aorta tor\u00e1cica descendente e aorta infrarrenal, foram utilizados nos anos subsequentes para o tratamento de praticamente qualquer segmento da aorta desde a sua raiz at\u00e9 a bifurca\u00e7\u00e3o em art\u00e9rias il\u00edacas.A Cirurgia Vascular tem passado por grandes mudan\u00e7as nos \u00faltimos anos, com a r\u00e1pida ascens\u00e3o das t\u00e9cnicas endovasculares. Cirurgi\u00f5es vasculares, ao redor do mundo, proporcionaram, no fim da d\u00e9cada de 80 e in\u00edcio dos anos 90, alguns dos mais importantes avan\u00e7os j\u00e1 realizados nas cirurgias de aorta. Parodi na Argentina e Volodos na Ucr\u00e2nia foram respons\u00e1veis por forjar os princ\u00edpios da cirurgia endovascular da aorta, criando, de forma artesanal, as primeiras endopr\u00f3tesesEntretanto, a divis\u00e3o da aorta em ascendente e descendente, assim como a divis\u00e3o dos profissionais que atuam em cada segmento, \u00e9 arbitr\u00e1ria, e n\u00e3o raramente as doen\u00e7as n\u00e3o \u201crespeitam\u201d essas segmenta\u00e7\u00f5es e acometem mais que um territ\u00f3rio ou at\u00e9 mesmo territ\u00f3rios de intersec\u00e7\u00e3o entre as especialidades. O maior exemplo disso s\u00e3o as doen\u00e7as que acometem o arco a\u00f3rtico.3 . Ficou, assim, estabelecida uma lacuna na literatura m\u00e9dica, que perdurou por anos na cirurgia da aorta4 .O arco da aorta \u00e9 uma zona de transi\u00e7\u00e3o entre a aorta ascendente e a aorta tor\u00e1cica descendente. A classifica\u00e7\u00e3o de Stanford para dissec\u00e7\u00f5es da aorta \u00e9 a mais utilizada em todo o mundo, tendo sido descrita inicialmente em 1970. Ela classifica como tipo A as dissec\u00e7\u00f5es que envolvem a aorta ascendente e tipo B as dissec\u00e7\u00f5es que se restringem \u00e0 aorta descendente ap\u00f3s a origem da art\u00e9ria subcl\u00e1via esquerdaEssa lacuna n\u00e3o \u00e9 meramente te\u00f3rica. Por se tratar de um territ\u00f3rio complexo, n\u00e3o completamente dominado pela cirurgia card\u00edaca, nem sequer pela cirurgia vascular ou endovascular, esta \u00e1rea foi por muito tempo negligenciada. Em diversos locais do mundo, cirurgi\u00f5es vasculares e cirurgi\u00f5es card\u00edacos trabalharam em lados opostos, buscando sozinhos as solu\u00e7\u00f5es para o arco a\u00f3rtico, assim como para v\u00e1rias outras situa\u00e7\u00f5es em que as doen\u00e7as da aorta acometem diversos segmentos e necessitam de uma abordagem mais ampla e complementar.5 .Exemplos da import\u00e2ncia da abordagem multidisciplinar na aorta s\u00e3o as dissec\u00e7\u00f5es do tipo A que resultam em quadros isqu\u00eamicos a dist\u00e2ncia. Em at\u00e9 40% dos casos de dissec\u00e7\u00e3o tipo A, h\u00e1 tamb\u00e9m m\u00e1 perfus\u00e3o de \u00f3rg\u00e3os, que resulta em importante eleva\u00e7\u00e3o da mortalidade nesses pacientes. Alguns grupos t\u00eam realizado inicialmente o tratamento do quadro isqu\u00eamico, com a abordagem da aorta ascendente em um segundo momento. O envolvimento da cirurgia vascular desde o in\u00edcio desses atendimentos e uma abordagem individualizada dos pacientes \u00e9, portanto, fundamental para uma melhor condu\u00e7\u00e3o desses casos6 .Em 2019 a Sociedade Europeia de Cirurgia Vascular e a Associa\u00e7\u00e3o Europeia de Cirurgia Cardiotor\u00e1cica publicaram um consenso com as principais diretrizes para as doen\u00e7as da aorta envolvendo o arco a\u00f3rtico. As tr\u00eas primeiras recomenda\u00e7\u00f5es foram as seguintes: a tomada de decis\u00e3o deve ser realizada por um time de aorta; a centraliza\u00e7\u00e3o do cuidado \u00e9 recomendada; e o tratamento dos casos eletivos deve ser realizado em servi\u00e7os especializados, que ofere\u00e7am cirurgia aberta e endovascular, card\u00edaca e vascular em um \u00fanico centro8 .A import\u00e2ncia da colabora\u00e7\u00e3o de um time que envolva cirurgi\u00f5es vasculares, cirurgi\u00f5es card\u00edacos, cardiologistas, radiologistas, anestesistas, intensivistas e, quando necess\u00e1rio, reumatologistas, nefrologistas e geneticistas parece ficar evidente. A literatura mostra que a experi\u00eancia individual do cirurgi\u00e3o e principalmente da institui\u00e7\u00e3o tem impacto positivo no desfecho dos pacientes, e diversos autores t\u00eam demonstrado melhoria nos resultados ap\u00f3s a implementa\u00e7\u00e3o de centros dedicados \u00e0s doen\u00e7as da aortaNo Brasil, a experi\u00eancia com esses modelos \u00e9 pequena, e essa implementa\u00e7\u00e3o envolve mudan\u00e7as n\u00e3o somente log\u00edsticas e estruturais nos hospitais ou salas de cirurgia. A principal mudan\u00e7a nesse cen\u00e1rio \u00e9 cultural. Por muitos anos, o di\u00e1logo e a intera\u00e7\u00e3o entre cirurgi\u00f5es e cl\u00ednicos, assim como entre cirurgi\u00f5es card\u00edacos e vasculares, foram limitados. O arco da aorta, que por um longo per\u00edodo foi negligenciado por muitos grupos, representa hoje uma ponte que liga as duas especialidades.Certamente, os cirurgi\u00f5es e demais especialistas que se associarem a grupos e centros de cuidado da aorta vivenciar\u00e3o os pr\u00f3ximos avan\u00e7os da cirurgia dessa art\u00e9ria. Esse cuidado deve ser baseado n\u00e3o somente na anatomia, mas na colabora\u00e7\u00e3o e busca de solu\u00e7\u00f5es para doen\u00e7as quase sempre complexas e graves. A concretiza\u00e7\u00e3o destes modelos s\u00f3 ser\u00e1 poss\u00edvel com flexibilidade nas decis\u00f5es, despimento de vaidades, di\u00e1logo, atualiza\u00e7\u00e3o e entendimento de que o cuidado n\u00e3o deve ser centralizado em um m\u00e9dico ou em uma especialidade, mas que a aorta e o paciente precisam estar no centro do cuidado."}
+{"text": "To compare the introduction of consistencies during the period of complementary feeding of preterm and full-term newborns up to 12 months of life, as well as to evaluate the presence of oral motor dysfunction and its relation to difficulty in introducing food consistencies in these groups.This is an observational, analytical, cohort study, with ambispective data collection, carried out at the Municipal Department of Health of Mafra, state of Santa Catarina, Brazil. The study sample consisted of 87 newborns, 41 full-term and 46 preterm. While data was collected, interviews were held with the mothers/guardians. The anthropometric assessment was carried out by a nutritionist by measuring body weight, length, and head circumference, followed by assessment of oral and functional motor skills by the adapted Clinical Evaluation Protocol of Pediatric Dysphagia (PAD-PED), assessment of breastfeeding and neuropsychomotor development, and assessment of the presence of maternal depression and psychological risk of children with up to 12 months of corrected age.We verified oral motor dysfunction in 15 newborns, in both groups, in the liquid consistency in the first assessment, persisting in two cases in the full-term newborns and in three cases in the preterm infants, in the last assessment for the solid consistency.We observed no difference in the introduction of food consistencies between groups. Breastfeeding was more frequent in newborns in the first assessment and similar in other assessments. Regarding the predictors for oral motor dysfunction, bottle feeding increased the odds by about seven times and invasive oral procedures by about six times. However, despite reaching readiness at discharge, feeding problems are sometimes underestimated and persist in childhood in this group of patients, which can have an important impact on the health of this populationHence, there is a growing interest in studying oral, feeding, and neurodevelopment skills during early childhood, especially to understand which conditions may interfere in or predispose to difficulties in introducing consistencies during the period of complementary feeding in preterm infants..Technological advances increasingly favor the survival of preterm newborns (PTNB) and, consequently, there is also an increase in comorbidities and developmental delays, including feeding difficulties. Thus, oral stability depends on head and shoulder control, which are related to torso and pelvis stability.Although the ability to eat is a fine motor skill, global motor development is essential for an adequate oral function. Difficulties are already observed in the introduction of food and new consistencies, demonstrated through refusal, vomiting, crying, irritability, nausea, and frequent choking in this population.A literature review study suggests that PTNB born with very low birth weight, when compared with full-term newborns (FNB), have more feeding difficulties that persist in the long term, during and beyond the introduction of complementary feeding. Therefore, understanding the factors that interfere in the process of oral motor development and the introduction of complementary feeding of PTNB can direct strategies and interventions in such a way that this population is monitored, even before presenting difficulties, improving the overall development of this population.Although the literature reports such difficulties, there is still a scarcity of longitudinal studies that address the progression of food consistencies in the period of complementary feeding as well as the age at which complementary feeding started in the first year of lifeIn this context, the objective of this study was to compare the introduction of consistencies during the introduction of complementary feeding between PTNB and FNB and to evaluate the presence of Oral Motor Dysfunction (OMD) in these groups, as well as to evaluate whether there is a correlation between OMD and difficulty in introducing consistencies.This is an observational, analytical, cohort study, with ambispective data collection and approved by the Ethics Committee on Research Involving Human Beings of Universidade Federal do Paran\u00e1 (UFPR), Department of Health Sciences, under Opinion No.: 2.439.032.Servi\u00e7o Ambulatorial de Seguimento de Rec\u00e9m-nascido de Risco - SAS-RNR) aimed at PTNB, conducted by the interprofessional team of the Expanded Centers for Family Health and Primary Care (N\u00facleo Ampliado de Sa\u00fade da Fam\u00edlia - NASF-AB) composed of a speech therapist, a nutritionist, and a psychologist. The study was also developed in the Family Health Strategies (FHS) in which the FNB were evaluated by the same professionals. The three professionals participated and evaluated all newborns (NB) in the same consultation.The study was carried out from October 2017 to November 2020, at the Outpatient Follow-up Service for Newborns at Risk , in the same period of the day (morning - 7 am to 1 pm).PTNB and those who were admitted in the Neonatal Intensive Care Unit (NICU) were referred by the maternity hospital to the interprofessional follow-up at the NASF-AB. Notably, during the period of PTNB hospitalization, the institution had only one speech therapist at the time of the study, making it unfeasible to work with all PTNB. FNB who had difficulty breastfeeding, observed or reported at the time of performing the heel prick test up to the fifth day of life in the FHS, were referred to evaluation by the same team.The research included PTNB with gestational age (GA) \u02c2 37 weeks and FNB with GA > 37 weeks at birth, whose mothers and/or guardians signed an Informed Consent Form. In addition, they should have attended all stages of the study, that is, the five proposed evaluations.NB with any neurological or craniofacial alteration, and/or syndrome that interfered with normal orofacial and swallowing development, among other comorbidities, were excluded from both groups.In addition, NB who had Grade III or Grade IV Peri-Intraventricular Hemorrhage and who had critical heart disease and/or clinical decompensation with medical diagnosis at any time during the study were excluded.st consultation - from 7 to 15 days after discharge; 2nd consultation - at 4 months of life; 3rd consultation - at 6 months; 4th consultation - at 9 months; and 5th consultation - at 12 months of life. Parents and/or guardians would leave the service with a scheduled appointment for follow-up and reassessment.PTNB and FNB were submitted to the same evaluation protocols in the five consultations carried out during the follow-up proposed for this research: 1Data collection was carried out by the author with the participation of the nutritionist and the psychologist in the SAS-RNR of the municipality. Data collection was always carried out by the same professionals, previously trained to apply the study protocols. None of the instruments required a certificate for application.In the first consultation, an interview was conducted with the mothers/guardians, by the researcher, using the Data Record Form standardized for this study, consisting of sociodemographic questions related to pregnancy, birth, data on hospitalization, and hospital discharge.The anthropometric assessment was performed by the team\u2019s nutritionist by measuring body weight, length, and head circumference. To measure body weight, a Balmak\u00ae digital pediatric scale was used, with a maximum capacity of 25 kg. To measure length, a wooden infantometer was used with a range of 10 to 99 cm with subdivisions of millimeters.Prematurity, treated as an independent variable, was defined as gestational age < 37 weeks. It was also classified by the subcategories: Extreme Preterm (< 28 weeks), Very Preterm (28 to < 32 weeks), Moderate Preterm (32 to < 37 weeks), and Late Preterm (34 to < 37 weeks) according to the information recorded in the Child Health Handbook.As dependent variables, the following were considered:,7; this variable was obtained from the Adapted Protocol for the Assessment of Pediatric Dysphagia - PAD-PED. Both in the PTNB and in the FNB, the Structural and Functional Examination of the orofacial sensorimotor system was performed. NB were positioned on a stretcher in the supine position with the head elevated, to check the oral and non-nutritive sucking reflexes. With a glove on, the little finger was used in the perioral region to stimulate the search reflex; subsequently, the anterior portion of the hard palate and the tip of the tongue were touched to elicit sucking.1) Oral motor dysfunction: defined as functional alteration of oral skills, caused by immature sucking pattern, incoordination between sucking/swallowing/breathing, difficulty chewing and swallowing, as well as oral inabilities in the use of different utensilsLip, tongue, and cheek mobility and tonus were evaluated under observation of posture during rest and mobility during performance of stomatognathic functions. This procedure was performed at all stages of follow-up, covering all stages of development.. For this evaluation, the same adapted PAD-PED Protocol was used based on the data obtained during the food offer:2) Difficulty introducing food consistency: defined as oral motor alteration when faced with different food consistencies, different flavors and utensilsFor food offer, the following consistencies were used: thin liquid (breast milk/infant formula), thickened liquid (thickened milk), homogeneous pasty (mashed fruits/vegetables), heterogeneous pasty , and solid (fruits/vegetables in pieces); utensils were also used, depending on the age group. These foods were offered by the mother/caregiver in the usual feeding position, respecting what has been already introduced by the family.Difficulties introducing consistencies were considered when, during the periods in which consistencies were offered, the NB still did not accept them at the time of the assessment and/or had oral motor difficulty with such consistency; this evaluation was performed by behavioral observation when the food was offered. and the Child Development Clinical Risk Indicators (IRDI).3) Assessment of neuropsychomotor development, performed using the Denver Developmental Screening Test II (DDST-II), in which it is possible to observe behaviors favorable to breastfeeding or suggestive of difficulties, considering the body position of the mother and the NB during breastfeeding, onset of breastfeeding, efficiency of sucking, affective involvement between mother and baby, anatomical characteristics of the breast, and duration and termination of breastfeeding. Based on the frequency of unfavorable behaviors for each aspect of the investigated breastfeeding, breastfeeding was classified as Good, Regular, or Bad.Other interfering variables considered included the evaluation of breastfeeding observation, by the protocol disseminated by UNICEF, and the total score ranges from 0 to 30, with scores equal to or greater than 12 being considered a sign of depression.The mother\u2019s emotional state was assessed as another possible interfering variable using the Edinburgh Postpartum Depression Scale (EPDS), which has already been translated into several languages with validation in several countries, including Brazil. This is a self-reported protocol that aims to identify and assess the intensity of postpartum depression symptoms, consisting of ten items that receive scores from zero to three according to the reported intensity of depressive symptomsFinally, low birth weight data were also considered, with weight < 2500 grams; and invasive oral procedures such as: presence and time of use of enteral nutrition; presence and time of use of mechanical ventilation; presence and time of use of Continuous Positive Airway Pressure (CPAP); and presence and time of use of oxygen tent or helmet to supply supplemental O2.Data were collected and tabulated, exclusively by the researcher, by using a Microsoft Office Excel\u00ae spreadsheet (2013), and forwarded to a qualified professional for statistical analysis.Continuous variables were evaluated regarding their distribution and are presented as arithmetic mean and standard deviation, for continuous variables with normal distribution, and median with interquartile range (25-75%) for those with asymmetrical distribution. Categorical variables are presented with their absolute and relative frequencies.post-hoc test.To estimate the difference between continuous variables, the Student\u2019s t-test, Mann-Whitney test, and ANOVA were applied to repeated measures with Duncan\u2019s To estimate the difference between categorical variables, Fisher\u2019s exact test and Pearson\u2019s chi-square test were applied.post-hoc test. For asymmetric variables, the Mann-Whitney test was performed. Categorical variables were evaluated using Fisher\u2019s and Pearson\u2019s chi-square tests.The estimation of the difference between continuous variables with symmetrical distribution was performed using Student\u2019s t-test and ANOVA for repeated measures with Duncan\u2019s Statistica v.10.0 - Statsoft\u00ae).The Multivariate Logistic Regression model was applied to identify the main factors associated with oral motor dysfunction. Magnitude of effect size of 25% for the main outcome, whichever the proportion of FNB and PTNB with oral motor dysfunction, type I error of 5% and type II error of 10%, were considered. The estimated sample was 44 cases in each group, considering a test power of 90%  and due to the identification of a diagnosis of neurological alterations during follow-up (n = 3). The study sample consisted of 87 NB, of which 46 were in the PTNB group and 41 in the FNB group . In Tablvs. 0.0%, p < 0.001). The other characteristics\u2014gestational age, birth weight, head circumference, and length\u2014were evidently lower among PTNB (p < 0.001).In the PTNB group, we verified a higher frequency of twinning (26.1% Nine FNB (21.9%) and 26 PTNB (56.5%) required hospitalization in the NICU, and their length of stay had a median of 6.0 (3-10) days and 13.5 (5-21) days, respectively. The main cause of hospitalization between PTNB was respiratory distress syndrome .Among the 35 NB who required hospitalization in the NICU, all NB in both groups required an alternative feeding route; however, the time spent on enteral nutrition was, on average, significantly longer among PTNB (p = 0.03). Other invasive oral procedures were used in six FNB and 19 PTNB. Breast was the most used method of transition to the oral route in FNB; in PTNB, it was the use of a cup (p < 0.001); this is because it is a maternity that holds the title of Baby-Friendly Hospital Initiative, which uses this method as a way to carry out the transition and complement the diet of PTNB.vs. 57.7%), with a significant difference, and the length of stay had a median of 3 (1-6) days.With regard to oxygen therapy, of the 9 FNB, 3 required mechanical ventilation; and, among the PTNB, 7 (26.9%). The length of stay had a median of 6 (4-10) days and 10 (2-35) days, respectively. We also observed a higher frequency of use of CPAP among PTNB , with the most frequent disease in mothers of FNB being arterial hypertension and in mothers of PTNB, depression. Regarding the history of maternal mental health, 8 (19.5%) of the mothers of FNB had a history of mental disorder, and 13 (28.3%) mothers of PTNB presented depression as their main mental disorder.We observed a higher frequency of previous maternal disease among PTNB . As of the third evaluation, there was a decrease in the frequency of offering BM in both groups, being observed 32.4% vs. 30% in the last evaluation.Regarding the type of food offered to the NB, at hospital discharge there was a predominance of breast milk (BM) in both groups (p = 0.22). The frequency of feeding with BM was higher among the FNB in the 1st evaluation .The frequency of formula milk (FM) use was similar between groups (p > 0.05), while mixed feeding (BM + FM) was higher among PTNB in the 1st evaluation, we observed a significant difference only in relation to sucking between FNB and PTNB (p < 0.01), with a higher frequency of difficulty in PTNB (27.5% vs. 4.5%). In the other evaluations, in all assessed items, all NB in both groups presented a good classification, according to the applied protocol (p = 1.00). Difficulty breastfeeding was observed in 17 FNB (41.5%) and 15 PTNB (34.1%) (p = 0.50) without association with the type of feeding in the 1st evaluation (p = 0.87).During the breastfeeding assessment, in the 1nd and 3rd evaluations (p < 0.001). The duration of breastfeeding was significantly longer among the FNB in the 1st evaluation (p < .01), with no difference in the other evaluations (p > 0.05).In both groups, we verified a change from lying down to sitting position between the 2rd evaluation, a higher frequency of administration of thickened liquid consistency  and homogeneous pasty consistency was observed for PTNB . In the 4th evaluation, the administration of a heterogeneous pasty consistency was more frequent, also among PTNB .In st evaluation  and 2nd evaluation ; and the use of spoons and cups, among FNB in the 3rd evaluation  and 4th evaluation .The use of a bottle as a feeding utensil was more frequently used among PTNB in the 1In the case of EB, although the medians are the same, the variation around the median is different between groups. In the statistical analysis, considering dispersion, we verified p = 0.04, indicating that there is a difference, but not considerable, and therefore the p-value is close to 0.05.vs.37 (80.4%), respectively. Decreased tongue tonus was observed in one (2.4%) vs. six (13.0%).In the structural and functional examination of the lips and tongue, we found no difference between the groups (p > 0.05). The posture of parted lips was observed in 37 (90.2%) of the FNB and in 37 (80.4%) of the PTNB; and the posture of tongue on papilla, in 34 (82.9%) In the assessment of non-nutritive sucking, in both groups, a search reflex was observed in 29 (70.7%) of the FNB and 25 (54.3%) of the PTNB. We observed no significant difference in the sucking pattern between the FNB and PTNB groups, with 32 (78.1%) and 41 (89.1%) being adequate. Intraoral pressure was adequate in 32 (78.1%) of the FNB and 41 (89.1%) of the PTNB.vs. 32.5%, p = 0.03) and better latching among the PTNB . In the ratio between sucking/swallowing frequency and coordination, there was no significant difference.In the assessment with food, in relation to the mother\u2019s breast, a better lip tie was observed among the FNB .vs. 32.6%) in each group in the 1st evaluation. Among the NB with OMD, there was persistence in two cases among the FNB and three cases among the PTNB in the last evaluation; in the latter, we observed difficulty in preparing and chewing for heterogeneous pasty and solid consistencies, open-cup anterior leakage of liquid. In Considering the variables: coordination, latch, lip tie, leaking through the labial commissure, and inadequate sucking, we observed OMD in 15 cases (36.6% vs. 33.3%), NICU hospitalization (33.3% vs. 80%), use of CPAP (0% vs. 46.7%), and nasogastric tube (13.3% vs. 73.3%). In addition, FNB more frequently presented difficulty breastfeeding and poor sucking (p < 0.01), with a significant difference in the latter.Among the main differences between FNB and PTNB with OMD are twinning  and with OMD (n = 30), we observed that there was no difference in relation to the frequency of prematurity (p = 0.82) and neuropsychomotor development abnormalities (p = 0.20) between groups. The variables associated with OMD were: difficulty breastfeeding, response to breastfeeding, poor sucking, NICU hospitalization, invasive oral procedures, and use of a bottle at hospital discharge .In the analysis of the main predictive factors for OMD, using multivariate logistic regression, bottle feeding increased the odds of OMD by approximately seven times  and the occurrence of invasive oral procedures by about five times ; we did not observe the same relation to the indicators: NICU hospitalization, difficulty breastfeeding, and sucking.nd and 3rd evaluations.In the assessment of development using the Denver test, we observed a higher frequency of cases classified as abnormal among PTNB in the 2st evaluation among PTNB . We verified no significant difference in language classification between groups in any of the evaluations (p > 0.05).Among the items evaluated in the protocol in the personal-social component, a higher frequency of suspected and abnormal classification was observed in the 1nd evaluation  and 3rd evaluation , there was a higher frequency of suspicious and abnormal cases between PTNB.In the fine motor component, we observed no difference between groups (p > 0.05). For the gross motor component in the 2st evaluation, in three cases there was a delay in Denver in the Gross Motor item, one of them with OMD; in the 2nd evaluation, 18 cases, none with OMD; in the 3rd evaluation, 13 cases, none with OMD; and in the 4th evaluation, seven cases, one with OMD, with no difference between FNB and PTNB; there was no evidence of association between gross motor dysfunction and OMD (p > 0.05).When associating the records of the Denver II protocol with the OMD assessment, we observed that, in the 1We verified no significant difference between risk indicators for child development in all assessments (p > 0.05). However, we identified psychological risk at 2.2% only for the PTNB group (p = 1.00).st evaluation. In the 2nd evaluation, these frequencies decreased to 7.3% (three cases) and 2.2% (one case) (p = 0.33), all of whom were referred to psychological guidance and there were no cases or persistence of symptoms in the following evaluations.We used the Edinburgh Postpartum Depression Scale to screen the mother\u2019s emotional state, with the presence of signs of depression in 11 cases in the FNB group (26.8%) and seven cases in the PTNB group (15.2%) (p = 0.19) in the 1This study sought to assess the presence of OMD in PTNB and compare it with FNB, as well as to assess whether there is a correlation between OMD and difficulty introducing food consistencies in these populations; and our main result was that, although we observed OMD, there was no difference between PTNB and FNB. Moreover, despite the occurrence of OMD, there was no difficulty in starting complementary feeding, which occurred early. OMD was observed in 15 cases, in each group  in the first evaluation and there was persistence of OMD in two cases of FNB and three cases among PTNB in the last evaluation. In the latter, we observed difficulty in preparing and chewing for heterogeneous pasty and solid consistencies, corresponding to the difficulty for these consistencies and open-cup anterior leakage of liquid, corresponding to oral difficulty with this utensil.,16-18.The actual prevalence of swallowing problems and OMD in neonates and infants is unknown. Studies have shown that in the assessment of PTNB at four months, the presence of OMD ranged from 23% to 89% for pasty consistency; at six months, they identified OMD in approximately 40% of the PTNB in the sample for the semi-solid consistency; and at 12 months, a variation between 8% and 28% for the solid consistencyIn these studies, GA at birth was 32 weeks on average, whereas in the present study it was 34 weeks. It is noteworthy that this difference of two weeks of GA translates into a different neurophysiological evolution, i.e., there is a great difference in neurological maturity and, consequently, different levels of oral motor skills are observed.In our study, OMD was not associated with delays in neuropsychomotor development assessed by the Denver II, but high neurological risk patients were excluded from the sample. Moreover, the patients were followed up by an interdisciplinary team, and the necessary guidelines regarding food and nutrition, in addition to psychosocial interventions, were carried out at each evaluation. Therefore, a risk of intervention bias may have been responsible for the low frequency of alterations in this study. In addition, the population of this study was predominantly of late PTNB and not of extreme preterm infants, the latter being more predisposed to the risk of OMD than the former.. This study also relates persistent dietary changes in the first 15 months of life to delay in neuropsychomotor development. Conversely, feeding difficulties in the first four weeks of life are very common and do not have an important predictive value.The prevalence of feeding problems described in a population study in the United Kingdom in 2001, with 14 thousand preterm infants born at < 37 weeks of gestation, was 10.5%, and this frequency increased to 24.5% among those born with very low birth weight (< 1500 g)In the analysis of the 30 NB (15 in both groups) with OMD, we found no association with prematurity and neuropsychomotor development, but it was possible to verify the association with difficulty breastfeeding, NICU hospitalization, neonatal oral invasive procedures, and bottle feeding at hospital discharge.,20,21, with a potential risk of aversion to oral feeding in the medium and long term,17.Studies indicate that PTNB are exposed to prolonged and harmful external stimuli, such as endotracheal tubes and orogastric tubes, and that such interventions can negatively impact the oral skills of this populationRegarding the five NB with OMD in the last evaluation, four underwent invasive oral interventions and already had OMD in the first assessment. When performing the analysis of predictors for OMD, the occurrence of invasive oral procedures increased the odds of presenting such difficulty by six times..In a population study in the United Kingdom, using a questionnaire applied by telephone, comparing 1,130 PTNB with 1,255 FNB, PTNB had more feeding difficulties at two years of age. The relative risk of feeding difficulties was 1.57 and 1.62 for OMD, and the use of a nasogastric tube for more than two weeks was associated with feeding difficulties.In another Brazilian cross-sectional study on 62 PTNB, time spent using an enteral tube was also associated with feeding difficulties and defensive behaviors at 13 months of corrected age. However, no association was found between OMD and feeding difficulties,6. Another cross-sectional study, also on PTNB with an average GA of 32 weeks, did not find a relation between OMD and GA, as in our study. As aforementioned, the population of this study was late PTNB, which may explain the lack of association with GA.Two other studies report a significant association between eating difficulties and GA; the study population was extreme PTNB.The period of introduction of complementary feeding, as well as the appropriate age for starting oral feeding with exposure to textures and flavors, respecting the windows of opportunity and all the stimuli and experiences that involve the relationship with food and the development of oral and motor skills, may be involved in feeding difficulties in PTNB in the medium and long term,20,22-25.Our results demonstrated that both in the FNB and in the PTNB, the introduction of the pasty consistency occurred early, around four months of life, corroborating studies carried out with preterm infants, in which they were exposed to the offer of fruits/porridges before completing six months of corrected ageth evaluation, in which the NB had an average age of eight months (PTNB corrected age). Conversely, solid consistency started in both groups at around ten months, as expected for age. Nevertheless, we observed a small portion of NB that, in the 5th evaluation, still did not accept either small pieces or solids, being considered a delay in their introduction.The heterogeneous pasty consistency  was observed more frequently in the 4,9.When addressing the introduction of consistencies, the literature uses the ages of windows of opportunity as bases. At the sixth month of corrected age, complementary feeding is introduced, which should occur gradually in a pasty consistency; at eight months, the infant is already able to receive food in small pieces and/or shredded. This should not last longer than nine months, which could cause feeding problems in the future, and the introduction of a solid consistency similar to that of the family should be carried out up to 12 monthsIn addition, King (2009) stresses that the introduction of complementary feeding must respect the skills and pace of PTNB, so that they develop the appropriate skills for each progression of texture.. Both the Brazilian Ministry of Health and the Brazilian Society of Pediatrics do not recommend this practice, as it may lead to a decrease in exclusive breastfeeding or even weaning,27.The offer of food, water, teas, and juices before six months of life already characterizes the early introduction of complementary feeding.Despite the recommendation of the Ministry of Health (2010) that breast milk should be exclusive until six months of life for the PTNB population. The literature is still scarce and there is no consensus; however, there is a recommendation for the introduction of complementary feeding to start as of six months of corrected age, and the signs of readiness must also be present.Notably, when complementary feeding is introduced early, the child may develop allergic diseases or even alterations in oral development, resulting in chewing difficulties. Conversely, when it occurs late, there may be a growth deficit or anemia, compromising the growth and development of facial structures. In one study, of the NBs that required admission to the NICU, 18 were FNB (31.6%) and 17 were PTNB (56.7%). The average length of stay at the NICU was 6 (3-10) days in the FNB group and 13.5 (5-21) days in the PTNB group, the latter being more susceptible to peri- and postnatal complications, thus requiring intensive care. This data demonstrates that PTNB from the maternity hospital involved in the service were not highly complex patients. It also shows that many newborns in the studied group, instead of being discharged after 48 to 72 hours, remained hospitalized for a longer time, which indicates that the studied FNB population, although not having the risk of prematurity, had other risk factors, for example, admission to the NICU.With regard to the average length of stay at the NICU, the length of stay depends on the complexity and degree of prematurity of the patients treated at the service. Most studies with highly complex NICUs describe mean length of stay for PTNB and those with low birth weight of over one monthAn important sampling bias to report was that the FNB were also considered at risk, in addition to some requiring NICU hospitalization. Others were selected based on difficulties in breastfeeding during the heel prick test and were referred to the NASF for specialized evaluation. Anyhow, OMD was also observed in the FNB, which indicates that even in this group with a theoretically favorable prognosis, according to the gestational age, the risk exists, and a specialized evaluation and screening should be considered, mainly in those more exposed to NICU admission.In our study, 9 (21.9%) FNB were hospitalized in the NICU, with an average time of 6.0 (3-10) days remaining. Most of them had a cardiopulmonary diagnosis as the cause of hospitalization. Although no alterations were observed in the Development Screening, it must be considered that such a diagnosis can lead to delays in fine motor development..At hospital discharge, the frequency of breastfeeding was high: 100% in FNB and 97% in PTNB, mixed in 7.3% and 19.6%, respectively. The Baby-Friendly Hospital Initiative has played a crucial role in mobilizing the actors involved within hospital institutions, in the process of changing behaviors and routines in view of the high rates of early weaning. Mothers of PTNB remain hospitalized along with their children and are qualified and trained for breastfeeding, by assistance, strategies, and interventions that promote it effectively and safely before discharge.The Maternidade Dona Catarina Kuss is an institution that is part of the Baby-Friendly Hospital Initiative and has the Kangaroo Mother Care method, both of which provide, encourage, and promote breastfeeding, the municipality\u2019s numbers are much lower than expected; between hospital discharge and the 1st evaluation, we observed a decrease in the frequency of breastfeeding in both groups. However, this frequency was even lower in PTNB, becoming similar in the other evaluations. It is necessary to formulate strategies that can narrow the assistance to protect breastfeeding.Although there are the Breastfeeding Strategy and Feeding Brazil Strategy, which are actions to strengthen the promotion, protection, and support of breastfeeding and healthy complementary feeding for children under two years of ageWith regard to the characteristics of the assessment of breastfeeding, we observed a significant difference in the sucking item, with a higher frequency of difficulty in FNB. A better lip tie was observed in the FNB and a better latch in the PTNB. A hypothesis for this datum would be due to the fact that FNB were selected for this study based on the request for evaluation and management of breastfeeding, that is, they presented some degree of difficulty or complaint during breastfeeding, while PTNB already came from the maternity with these characteristics better established. This datum emphasizes that difficulties with breastfeeding do not occur only in the PTNB population; on the contrary, perhaps some FNB needed more time and more professional support to establish breastfeeding, as FNB exposed to risk factors for the development also deserve to receive specialized evaluation and follow-up.. The time of exclusive breastfeeding was below the recommended , in both groups with a mean age of 122 days (four months); and the mean age of weaning was eight months in the FNB and seven months of corrected age in PTNB.It should be noted that breast milk is the best and most complete food for newborns, whether they are preterm or full-term, and that after the introduction of complementary feeding, breastfeeding is recommended for up to two years of life or moreIn addition to organic, emotional, and environmental issues, when it comes to exclusive breastfeeding (EB), it must be considered that, currently, the Brazilian Labor Laws Consolidation do not corroborate the recommendations of the World Health Organization (WHO), with a four-month maternity leave. This, in addition to the little or limited support network, institutions/day-care centers that do not support the supply of breast milk, social vulnerability, among others, favors low EB rates.nd evaluation. Such results may be related to the very characteristics of Maternidade Dona Catarina Kuss, the maternity from which the NB came, in addition to the fact that they are all inserted in a Follow-up Service for NB at Risk regarding development directed, among other aspects, towards the promotion of maternal-infant mental health.In the results of the Child Development Clinical Risk Indicators (IRDI), despite some absences of two or more items being observed, most indicators were present; when absent, interprofessional intervention was carried out and the indicators were reassessed in the next consultation. Furthermore, it is worth noting that to be considered a psychological risk, the absent indicators must persist in the 2 are conducting a systematic review research in Canada with the aim of surveying the elements which lead to failures in the recruitment and retention of parents in studies and follow-up centers for children aged 0 to 36 months. At the end of the research, they aim to offer recommendations for future research to adopt more efficient strategies for recruiting and, especially, for retaining participants in this population. Overall, studies with larger samples are relevant for the evaluation of the variables described in this study, ideally with healthy FNB without intervention and with a large population of extreme PTNB. For the true prevalence of OMD, studies preferably without intervention bias are needed. Nonetheless, as the assessment of OMD is carried out by specialists in speech therapy, an intervention-free assessment would be contrary to an adequate conduct.As for the sample of this study, the proposed prolonged follow-up was affected by several variables that culminated in a significant loss of follow-up. Concerned about the loss of follow-up in prospective cohort studies in early childhood, as this is an issue faced worldwide, Keys et al.We observed no difference in the introduction of consistencies in the period of onset of complementary feeding between FNB and PTNB. Pasty consistency was introduced early in both groups.Difficulties in breastfeeding occurred only in the first evaluation and in a small proportion, with no difference between FNB and PTNB.The frequency of breastfeeding was higher among the FNB in the first evaluation, being similar as of the other evaluations; however, both EB and weaning are far below what is recommended in both groups.OMD occurred in a small portion of both groups in the first evaluation  and there was no persistence of difficulty in the different consistencies in the period of onset of food introduction. In the last evaluation, we observed OMD at a lower frequency than in the first, with a delay in the introduction of solids being observed in some cases.With regard to OMD predictors, we verified that the bottle increased the odds of OMD by about seven times, and invasive oral procedures by about six times.We observed no association between Neuropsychomotor Development, OMD and breastfeeding.We verified no association between maternal depression and breastfeeding. .A compet\u00eancia para alimenta\u00e7\u00e3o oral em prematuros \u00e9 considerada um requisito essencial para a alta hospitalar. Por\u00e9m, apesar de atingir a prontid\u00e3o na alta, problemas de alimenta\u00e7\u00e3o, por vezes, s\u00e3o subestimados e persistem na inf\u00e2ncia neste grupo de pacientes, o que pode gerar um impacto importante na sa\u00fade desta popula\u00e7\u00e3oDesta maneira, \u00e9 crescente o interesse em estudar as habilidades orais, alimentares e do neurodesenvolvimento durante a primeira inf\u00e2ncia, sobretudo entender quais condi\u00e7\u00f5es podem interferir ou predispor a dificuldades na introdu\u00e7\u00e3o das consist\u00eancias durante o per\u00edodo de alimenta\u00e7\u00e3o complementar em prematuros..Os avan\u00e7os tecnol\u00f3gicos cada vez mais favorecem a sobrevida dos rec\u00e9m-nascidos pr\u00e9-termo (RNPT), e consequentemente, h\u00e1 tamb\u00e9m um aumento nas comorbidades e atrasos do desenvolvimento, incluindo as dificuldades alimentares. Assim a estabilidade oral depende do controle de cabe\u00e7a e ombros, os quais se relacionam com a estabilidade de tronco e pelve.Embora a habilidade do comer se trate de uma habilidade motora fina, o desenvolvimento motor global \u00e9 essencial para uma adequada fun\u00e7\u00e3o oral. Observam-se dificuldades j\u00e1 na introdu\u00e7\u00e3o alimentar e na introdu\u00e7\u00e3o de novas consist\u00eancias, demonstradas por meio de recusa, v\u00f4mito, choro, irritabilidade, n\u00e1useas e engasgos frequentes nesta popula\u00e7\u00e3o.Um estudo de revis\u00e3o de literatura sugere que RNPT nascidos com muito baixo peso, quando comparados aos rec\u00e9m nascidos a termo (RNT), apresentam mais dificuldades alimentares que persistem em longo prazo, durante e al\u00e9m da introdu\u00e7\u00e3o da alimenta\u00e7\u00e3o complementar. Portanto, entender os fatores que interferem no processo de desenvolvimento motor oral e de introdu\u00e7\u00e3o da alimenta\u00e7\u00e3o complementar de RNPT pode direcionar estrat\u00e9gias e interven\u00e7\u00f5es para que esta popula\u00e7\u00e3o seja acompanhada, mesmo antes de apresentar dificuldades, melhorando o desenvolvimento global desta popula\u00e7\u00e3o.Embora a literatura relate tais dificuldades, ainda h\u00e1 uma escassez de estudos longitudinais que abordem a progress\u00e3o das consist\u00eancias alimentares no per\u00edodo de alimenta\u00e7\u00e3o complementar, bem como a idade de in\u00edcio destas no primeiro ano de vidaNeste contexto, o objetivo deste estudo foi comparar a introdu\u00e7\u00e3o das consist\u00eancias durante a introdu\u00e7\u00e3o da alimenta\u00e7\u00e3o complementar entre RNPT e RNT e avaliar a presen\u00e7a de Disfun\u00e7\u00e3o Motora Oral (DMO) nestes grupos, bem como avaliar se h\u00e1 correla\u00e7\u00e3o entre DMO e dificuldade na introdu\u00e7\u00e3o das consist\u00eancias.Trata-se de um estudo observacional, anal\u00edtico, coorte, com coleta de dados ambispectiva e aprovado pelo Comit\u00ea de \u00c9tica em Pesquisas em Seres Humanos, da Universidade Federal do Paran\u00e1 - UFPR - Setor de Ci\u00eancias da Sa\u00fade, Parecer N\u00ba: 2.439.032.Foi realizado no per\u00edodo de outubro de 2017 a novembro de 2020, no Servi\u00e7o Ambulatorial de Seguimento de Rec\u00e9m-nascido de Risco (SAS-RNR) destinado aos RNPT, conduzido pela equipe interprofissional do N\u00facleo Ampliado de Sa\u00fade da Fam\u00edlia (Nasf-AB) composta por fonoaudi\u00f3loga, nutricionista e psic\u00f3loga. O estudo, tamb\u00e9m, foi desenvolvido nas Estrat\u00e9gias de Sa\u00fade da Fam\u00edlia (ESF) em que os RNT foram avaliados pelas mesmas profissionais. As tr\u00eas profissionais participaram e avaliaram na mesma consulta todos os rec\u00e9m-nascidos (RN).A amostra foi selecionada de forma n\u00e3o probabil\u00edstica, por conveni\u00eancia, mas de forma sistematizada, com hor\u00e1rios agendados, sempre no mesmo dia da semana (sexta-feira), no mesmo per\u00edodo do dia (manh\u00e3 - 7h \u00e0s 13h).Os RNPT e aqueles que passaram pela Unidade de Terapia Intensiva Neonatal (UTIN) foram encaminhados pela maternidade para seguimento interprofissional no NASF-AB. Vale ressaltar que durante o per\u00edodo de interna\u00e7\u00e3o dos RNPT, a institui\u00e7\u00e3o contava na \u00e9poca do estudo, somente com uma fonoaudi\u00f3loga, tornando-se invi\u00e1vel o trabalho com todos os RNPT. E os RNT que apresentaram dificuldade no aleitamento materno, observada ou relatada no momento da realiza\u00e7\u00e3o do teste do pezinho at\u00e9 o quinto dia de vida na ESF foram encaminhados para avalia\u00e7\u00e3o pela mesma equipe.Foram inclu\u00eddos na pesquisa, RNPT com idade gestacional (IG) \u02c2 de 37 semanas e RNT, com IG > de 37 semanas ao nascimento, para os quais as m\u00e3es e/ou respons\u00e1veis assinaram o Termo de Consentimento Livre Esclarecido - TCLE. Al\u00e9m disso, deveriam ter comparecido a todas as etapas do estudo, ou seja, nas cinco avalia\u00e7\u00f5es propostas.Foram exclu\u00eddos RN com qualquer altera\u00e7\u00e3o neurol\u00f3gica, craniofacial e/ou s\u00edndrome que interfira no desenvolvimento normal orofacial e de degluti\u00e7\u00e3o entre outras comorbidades nos dois grupos.Tamb\u00e9m, foram exclu\u00eddos RN que apresentaram Hemorragia Peri-Intraventricular Grau III ou Grau IV e que apresentaram cardiopatia cr\u00edtica e/ou com descompensa\u00e7\u00e3o cl\u00ednica com diagn\u00f3stico m\u00e9dico em qualquer momento do estudo.Os RNPT e RNT foram submetidos aos mesmos protocolos avaliativos nos cinco atendimentos realizados durante o acompanhamento proposto para esta pesquisa: 1\u00b0 atendimento - de 7 a 15 dias ap\u00f3s a alta; 2\u00b0 atendimento - com 4 meses de vida; 3\u00b0 atendimento - com 6 meses; 4\u00b0 atendimento com 9 meses e 5\u00b0 atendimento - com 12 meses de vida. Os pais e/ou respons\u00e1veis saiam do atendimento com retorno agendado para acompanhamento e reavalia\u00e7\u00e3o.A coleta de dados foi realizada pela autora com coparticipa\u00e7\u00e3o da nutricionista e da psic\u00f3loga no SAS-RNR do munic\u00edpio. Esta foi realizada sempre pelas mesmas profissionais, previamente treinadas para a aplica\u00e7\u00e3o dos protocolos do estudo. Nenhum dos instrumentos necessitava de certificado para aplica\u00e7\u00e3o.No primeiro atendimento, foi realizada entrevista com as m\u00e3es/respons\u00e1veis, conduzida pela pesquisadora por meio da Ficha de Registro de Dados padronizada para este estudo, composta por quest\u00f5es sociodemogr\u00e1ficas, relacionadas \u00e0 gesta\u00e7\u00e3o, nascimento, dados da interna\u00e7\u00e3o e alta hospitalar.A avalia\u00e7\u00e3o antropom\u00e9trica foi realizada pela nutricionista da equipe por meio de mensura\u00e7\u00e3o do peso corporal, comprimento e per\u00edmetro cef\u00e1lico. Para aferi\u00e7\u00e3o do peso foi utilizada balan\u00e7a pedi\u00e1trica digital da marca Balmak\u00ae, com capacidade m\u00e1xima de 25 kg. Para mensurar o comprimento foi utilizado infant\u00f4metro de madeira com intervalo de 10 a 99 cm com subdivis\u00f5es de mil\u00edmetros.A prematuridade, tratada como vari\u00e1vel independente, foi definida por idade gestacional < 37 semanas. Tamb\u00e9m, foi classificada por meio das subcategorias: Pr\u00e9-termo Extremo (< 28 semanas), Muito Pr\u00e9-termo (28 a < 32 semanas), Pr\u00e9-termo Moderado (32 a < 37 semanas) e Pr\u00e9-termo Tardio (34 a < 37 semanas) por meio das informa\u00e7\u00f5es registradas na Caderneta de Sa\u00fade da Crian\u00e7a.Como vari\u00e1veis dependentes foram consideradas:,7; Esta vari\u00e1vel foi obtida por meio do Protocolo para Avalia\u00e7\u00e3o Cl\u00ednica da Disfagia Pedi\u00e1trica - PAD-PED adaptado. Tanto nos RNPT como nos RNT, foi realizado o Exame Estrutural e Funcional do sistema sens\u00f3rio motor orofacial. Os RN estavam posicionados sobre uma maca em posi\u00e7\u00e3o supino com cabe\u00e7a elevada, para verificar os reflexos orais e da suc\u00e7\u00e3o n\u00e3o nutritiva. Foi utilizado o dedo m\u00ednimo enluvado na regi\u00e3o perioral, para estimular reflexo de busca, e, em seguida, foi realizado toque na por\u00e7\u00e3o anterior do palato duro e na ponta da l\u00edngua para eliciar a suc\u00e7\u00e3o.Disfun\u00e7\u00e3o motora oral: definida como altera\u00e7\u00e3o funcional das habilidades orais, causadas por padr\u00e3o imaturo de suc\u00e7\u00e3o, incoordena\u00e7\u00e3o entre suc\u00e7\u00e3o/degluti\u00e7\u00e3o/respira\u00e7\u00e3o, dificuldade na mastiga\u00e7\u00e3o e degluti\u00e7\u00e3o, bem como inabilidades orais na utiliza\u00e7\u00e3o de diferentes utens\u00edliosA mobilidade e t\u00f4nus de l\u00e1bio, l\u00edngua, bochecha foram avaliados sob observa\u00e7\u00e3o da postura durante o repouso e da mobilidade durante desempenho das fun\u00e7\u00f5es estomatogn\u00e1ticas. Este procedimento foi realizado em todas fases do acompanhamento, contemplando todas as fases do desenvolvimento.. Para esta avalia\u00e7\u00e3o foi utilizado o mesmo Protocolo PAD-PED adaptado a partir dos dados obtidos durante a oferta alimentar:Dificuldade na introdu\u00e7\u00e3o da consist\u00eancia alimentar: definida como altera\u00e7\u00e3o motora oral frente a diferentes consist\u00eancias alimentares, diferentes sabores e utens\u00edliosPara oferta alimentar foram utilizadas as consist\u00eancias (l\u00edquido fino (leite materno/f\u00f3rmula infantil), l\u00edquido espessado (leite engrossado), pastoso homog\u00eaneo (frutas/legumes amassados), pastoso heterog\u00eaneo (frutas/legumes pequenos peda\u00e7os) e s\u00f3lido (frutas/legumes em peda\u00e7os) e utens\u00edlios dependendo da faixa et\u00e1ria. Foram ofertados pela m\u00e3e/cuidador (a) em posi\u00e7\u00e3o usual de alimenta\u00e7\u00e3o para oferta, respeitando o que j\u00e1 era introduzido pela fam\u00edlia.Foram consideradas dificuldades na introdu\u00e7\u00e3o das consist\u00eancias quando nos per\u00edodos em que foram realizadas a oferta das consist\u00eancias, o RN ainda n\u00e3o as aceitava no momento da avalia\u00e7\u00e3o e/ou apresentava dificuldade motora oral com o mesmo, realizada por meio da observa\u00e7\u00e3o comportamental frente \u00e0 alimenta\u00e7\u00e3o ofertada. e pela Avalia\u00e7\u00e3o dos Indicadores de Risco para o Desenvolvimento Infantil (IRDI).Avalia\u00e7\u00e3o do desenvolvimento neuropsicomotor, realizada por meio do Teste de Triagem do Desenvolvimento Neuropsicomotor Denver II (TTDD-R), no qual \u00e9 poss\u00edvel observar comportamentos favor\u00e1veis ao aleitamento materno, ou sugestivos de dificuldades, considerando posi\u00e7\u00e3o corporal da m\u00e3e e do RN durante a mamada, in\u00edcio da mamada, efici\u00eancia da suc\u00e7\u00e3o, envolvimento afetivo entre o bin\u00f4mio, caracter\u00edsticas anat\u00f4micas da mama e dura\u00e7\u00e3o e encerramento da mamada. A partir da frequ\u00eancia de comportamentos desfavor\u00e1veis para cada aspecto da mamada investigada foi utilizada a classifica\u00e7\u00e3o em Bom, Regular, Ruim.Outras vari\u00e1veis interferentes consideradas inclu\u00edram Avalia\u00e7\u00e3o da observa\u00e7\u00e3o da amamenta\u00e7\u00e3o, por meio do protocolo difundido pela UNICEF, e a pontua\u00e7\u00e3o total varia de 0 a 30, sendo considerada pontua\u00e7\u00e3o igual ou superior a 12, sinal de depress\u00e3o.O estado emocional da m\u00e3e foi avaliado como outra poss\u00edvel vari\u00e1vel interferente por meio da Escala de Depress\u00e3o P\u00f3s-parto de Edimburgo (EDPE), a qual j\u00e1 foi traduzida em v\u00e1rios idiomas com valida\u00e7\u00e3o em v\u00e1rios pa\u00edses, dentre eles, o Brasil. Trata-se de um protocolo de autopreenchimento que tem por finalidade a identificar e avaliar a intensidade dos sintomas de depress\u00e3o p\u00f3s-parto, sendo composta por 10 itens que recebem pontua\u00e7\u00e3o de zero a tr\u00eas de acordo com a intensidade relatado dos sintomas depressivosContinuos Positive Airway Pressure, presen\u00e7a e tempo de uso de Tenda ou Capacete para fornecimento de O2 suplementar.E, por fim, foram considerados, tamb\u00e9m, os dados de baixo peso ao nascer, com peso < 2500 gramas; e os procedimentos orais invasivos como: presen\u00e7a e tempo de uso de nutri\u00e7\u00e3o enteral; presen\u00e7a e tempo de uso de Ventila\u00e7\u00e3o Mec\u00e2nica; presen\u00e7a e tempo de uso de CPAP - Microsoft Office Excel\u00ae (2013), e encaminhados a um profissional habilitado para a an\u00e1lise estat\u00edstica.Os dados foram coletados e tabulados, exclusivamente pela pesquisadora, via planilha eletr\u00f4nica As vari\u00e1veis cont\u00ednuas foram avaliadas quanto a sua distribui\u00e7\u00e3o e est\u00e3o apresentadas como m\u00e9dia aritm\u00e9tica e desvio padr\u00e3o, para as vari\u00e1veis cont\u00ednuas de distribui\u00e7\u00e3o normal e mediana com intervalo interquart\u00edlico (25-75%), para as de distribui\u00e7\u00e3o assim\u00e9trica. As vari\u00e1veis categ\u00f3ricas est\u00e3o apresentadas com suas frequ\u00eancias absoluta e relativa.Student, teste de Mann-Whitney e Anova para medidas repetidas com teste post-hoc de Duncan.Para a estimativa da diferen\u00e7a entre vari\u00e1veis cont\u00ednuas foram aplicados os testes t de Para estimativa da diferen\u00e7a entre as vari\u00e1veis categ\u00f3ricas foi aplicado o teste exato de Fisher e o teste qui-quadrado de Pearson.A estimativa de diferen\u00e7a entre as vari\u00e1veis cont\u00ednuas de distribui\u00e7\u00e3o sim\u00e9trica foi realizada pelos testes t de Student e Anova para medidas repetidas com teste post-hoc de Duncan. Para as vari\u00e1veis assim\u00e9tricas, foi realizado o teste de Mann-Whitney. As vari\u00e1veis categ\u00f3ricas foram avaliadas pelos testes de Fisher e qui-quadrado de Pearson.Statistica v.10.0 - Statsoft\u00ae).O modelo de Regress\u00e3o Log\u00edstica Multivariada foi aplicado para identificar os principais fatores associados \u00e0 disfun\u00e7\u00e3o motora oral. Considerando magnitude de efeito de 25% para o desfecho principal, qual seja propor\u00e7\u00e3o de RNT e RNPT com disfun\u00e7\u00e3o oral motora, erro do tipo I de 5% e erro do tipo II de 10%. A amostra estimada foi de 44 casos em cada grupo, conferindo poder de teste de 90% (Durante o per\u00edodo do estudo foram eleg\u00edveis 153 RN que atenderam aos crit\u00e9rios de inclus\u00e3o. Ocorreram perdas durante o estudo devido \u00e0 desist\u00eancia (n = 63) e devido \u00e0 identifica\u00e7\u00e3o de diagn\u00f3stico de altera\u00e7\u00f5es neurol\u00f3gicas durante o acompanhamento (n = 3). Constitu\u00edram a amostra do estudo 87 RN, dos quais, 46 constitu\u00edram o grupo de RNPT e 41, o grupo de RNT . Na Tabevs 0,0%, p < 0,001). As demais caracter\u00edsticas - idade gestacional, peso ao nascimento, per\u00edmetro cef\u00e1lico e comprimento foram, evidentemente, menores entre os RNPT .No grupo de RNPT houve maior frequ\u00eancia de gemelaridade  e 26 RNPT  necessitaram de interna\u00e7\u00e3o em UTIN e o tempo de perman\u00eancia destes teve mediana de 6,0 (3-10) dias e de 13,5 (5-21), respectivamente. A principal causa de interna\u00e7\u00e3o entre os RNPT foi a s\u00edndrome de desconforto respirat\u00f3rio 18 .Entre os 35 RN que necessitaram de interna\u00e7\u00e3o em UTIN, todos os RN de ambos os grupos necessitaram de via alternativa de alimenta\u00e7\u00e3o, entretanto o tempo de nutri\u00e7\u00e3o enteral foi em m\u00e9dia significativamente maior entre os RNPT . Outros procedimentos orais invasivos foram utilizados em seis RNT e em 19 RNPT. Como m\u00e9todo de transi\u00e7\u00e3o para via oral nos RNT o seio foi o mais utilizado e nos RNPT foi o uso de copo , isto porque trata-se de uma maternidade que possui o t\u00edtulo de Iniciativa Hospital Amigo da Crian\u00e7a, que utiliza este m\u00e9todo como forma de realizar a transi\u00e7\u00e3o e complementar a dieta dos RNPT.No que se refere \u00e0 oxigenioterapia, dos nove RNT, tr\u00eas necessitaram de ventila\u00e7\u00e3o mec\u00e2nica, e, dentre os RNPT, sete , o tempo de perman\u00eancia teve uma mediana de 6 (4-10) dias e 10 (2-35) dias, respectivamente. Observou-se, tamb\u00e9m, maior frequ\u00eancia do uso de CPAP entre os RNPT , com diferen\u00e7a significativa, e o tempo de perman\u00eancia foi uma mediana de 3 (1-6) dias.N\u00e3o foi observada diferen\u00e7a significativa no tipo de alimenta\u00e7\u00e3o na alta hospitalar entre os dois grupos de RN, sendo que 100% de ambos os grupos sa\u00edram em aleitamento materno, tr\u00eas RNT e nove RNPT em aleitamento misto.Observou-se, entre os RNPT, maior frequ\u00eancia de doen\u00e7a materna pr\u00e9via , sendo que a doen\u00e7a mais frequente nas m\u00e3es de RNT foi a Hipertens\u00e3o arterial e nas m\u00e3es de RNPT, a Depress\u00e3o. No que diz respeito ao hist\u00f3rico de sa\u00fade mental materna, 8  das m\u00e3es dos RNT apresentaram hist\u00f3rico de transtorno mental e 13  dos RNPT, apresentaram como principal transtorno mental: Depress\u00e3o.Com rela\u00e7\u00e3o \u00e0s caracter\u00edsticas dos RN relacionados aos dados antropom\u00e9tricos como o comprimento, per\u00edmetro cef\u00e1lico e peso em todas as avalia\u00e7\u00f5es, est\u00e3o dispostos na vs 54,3%, p < 0,01). A partir da terceira avalia\u00e7\u00e3o houve queda na frequ\u00eancia do oferecimento de LM em ambos, sendo observado 32,4% vs 30% na \u00faltima avalia\u00e7\u00e3o.Em rela\u00e7\u00e3o ao tipo de alimento oferecido ao RN, na alta hospitalar houve predom\u00ednio de leite materno (LM) nos dois grupos . A frequ\u00eancia de alimenta\u00e7\u00e3o com LM, foi maior entre os RNT na 1\u00aa avalia\u00e7\u00e3o .A frequ\u00eancia do uso de leite de f\u00f3rmula foi semelhante entre os grupos , enquanto a alimenta\u00e7\u00e3o mista (LM + LF) foi maior entre os RNPT na 1\u00aa avalia\u00e7\u00e3o . Nas demais avalia\u00e7\u00f5es, em todos os itens avaliados, todos os RN dos dois grupos apresentaram classifica\u00e7\u00e3o boa, conforme o protocolo aplicado . Dificuldade na amamenta\u00e7\u00e3o foi observada em 17 RNT  e em 15 RNPT   sem associa\u00e7\u00e3o com o tipo de alimenta\u00e7\u00e3o na 1\u00aa avalia\u00e7\u00e3o .Durante a avalia\u00e7\u00e3o da amamenta\u00e7\u00e3o observou-se, na 1\u00aa avalia\u00e7\u00e3o, diferen\u00e7a significativa somente em rela\u00e7\u00e3o ao item suc\u00e7\u00e3o entre RNT e RNPT  com maior frequ\u00eancia de dificuldade nos RNT . A dura\u00e7\u00e3o da mamada foi significativamente maior entre os RNT na primeira avalia\u00e7\u00e3o , sem diferen\u00e7a nas demais avalia\u00e7\u00f5es .vs 65,8%, p = 0,04). Na 4\u00aa avalia\u00e7\u00e3o, foi mais frequente a administra\u00e7\u00e3o de consist\u00eancia pastosa heterog\u00eanea, tamb\u00e9m, entre os RNPT , p = 0,04).Na vs 45,6%, p < 0,001) e 2\u00aa avalia\u00e7\u00e3o  e o uso da colher e do copo entre os RNT na 3\u00aa avalia\u00e7\u00e3o  e 4\u00aa avalia\u00e7\u00e3o .O uso de mamadeira como utens\u00edlio de alimenta\u00e7\u00e3o foi mais frequentemente utilizado entre os RNPT na 1\u00aa avalia\u00e7\u00e3o .No exame estrutural e funcional dos l\u00e1bios e l\u00edngua, n\u00e3o se observou diferen\u00e7a entre os grupos . A postura de l\u00e1bios entreabertos foi observada em 37  dos RNT e em 37  dos RNPT e a postura de l\u00edngua em papila em 34  vs 37 , respectivamente. O t\u00f4nus de l\u00edngua diminu\u00eddo foi observado um  Na avalia\u00e7\u00e3o da suc\u00e7\u00e3o n\u00e3o nutritiva, nos dois grupos observou-se reflexo de procura presente em 29  dos RNT e 25  dos RNPT. N\u00e3o foi observada diferen\u00e7a significativa no padr\u00e3o de suc\u00e7\u00e3o entre os grupos RNT e RNPT, sendo que 32  e 41  estavam adequados. A press\u00e3o intraoral estava adequada em 32  dos RNT e 41  dos RNPT.vs 32,5%, p = 0,03) e melhor pega entre os RNPT . Na rela\u00e7\u00e3o frequ\u00eancia de suc\u00e7\u00e3o/degluti\u00e7\u00e3o e coordena\u00e7\u00e3o, n\u00e3o houve diferen\u00e7a significativa.Na avalia\u00e7\u00e3o com alimento, em rela\u00e7\u00e3o ao seio materno, observou-se melhor vedamento labial entre os RNT .vs 32,6%) em cada grupo na primeira avalia\u00e7\u00e3o. Dentre os RN com DMO, houve persist\u00eancia em dois casos entre os RNT e tr\u00eas casos entre os RNPT na \u00faltima avalia\u00e7\u00e3o, sendo observado nestes \u00faltimos, dificuldade no preparo e mastiga\u00e7\u00e3o para as consist\u00eancias pastoso heterog\u00eaneo e s\u00f3lido, escape anterior de l\u00edquido em copo aberto. Na Considerando as vari\u00e1veis: coordena\u00e7\u00e3o, pega, vedamento labial, escape pelas comissuras labiais e suc\u00e7\u00e3o inadequada, a DMO foi observada em 15 casos , interna\u00e7\u00e3o em UTIN , uso de CPAP  e de SNG . Al\u00e9m disso, os RNT apresentaram mais frequentemente dificuldade no aleitamento materno e suc\u00e7\u00e3o ruim  com diferen\u00e7a significativa neste \u00faltimo.Dentre as principais diferen\u00e7as entre os RN com DMO a termo e prematuros est\u00e3o a gemelaridade (0% Considerando a an\u00e1lise de todos sem DMO (n = 57) e com DMO (n = 30), observou-se que n\u00e3o houve diferen\u00e7a em rela\u00e7\u00e3o \u00e0 frequ\u00eancia de prematuridade  e anormalidades do desenvolvimento neuropsicomotor (DNPM)  entre os grupos. As vari\u00e1veis associadas a DMO foram: a dificuldade no aleitamento materno, a resposta \u00e0 amamenta\u00e7\u00e3o, suc\u00e7\u00e3o deficiente, interna\u00e7\u00e3o em UTIN, procedimentos orais invasivos e uso de mamadeira na alta hospitalar .Na an\u00e1lise dos principais fatores preditivos para DMO, por meio de regress\u00e3o log\u00edstica multivariada, o uso de mamadeira elevou a chance de DMO em cerca de 7 vezes  e a ocorr\u00eancia de procedimentos orais invasivos em cerca de 5 vezes  n\u00e3o sendo observada mesma rela\u00e7\u00e3o com os indicadores: interna\u00e7\u00e3o em UTIN, dificuldade na amamenta\u00e7\u00e3o e suc\u00e7\u00e3o.Na avalia\u00e7\u00e3o do desenvolvimento pelo teste de Denver observou-se maior frequ\u00eancia de casos classificados como anormal entre os RNPT na 2\u00aa e 3\u00aa avalia\u00e7\u00f5es.vs 2,4%; anormal: 8,7% vs 2,4%, p = 0,04). N\u00e3o se observou diferen\u00e7a significativa na classifica\u00e7\u00e3o da linguagem entre os grupos em nenhuma das avalia\u00e7\u00f5es .Dentre os itens avaliados no protocolo no componente pessoal-social, observou-se na 1\u00aa avalia\u00e7\u00e3o maior frequ\u00eancia de classifica\u00e7\u00e3o suspeita e anormal entre os RNPT  e 3\u00aa  observou-se maior frequ\u00eancia de casos suspeitos e anormais entre os RNPT.No componente motor fino n\u00e3o se observou diferen\u00e7a entre os grupos . Para o componente motor grosso na 2\u00aa avalia\u00e7\u00e3o .N\u00e3o se observou diferen\u00e7a significativa entre os indicadores de risco para o desenvolvimento infantil em todas as avalia\u00e7\u00f5es . Contudo identificou-se o risco ps\u00edquico em 2,2% somente para o grupo de RNPT .Para a triagem do estado emocional da m\u00e3e foi utilizada a escala de Depress\u00e3o P\u00f3s-parto de Edimburgo, com presen\u00e7a de sinais de depress\u00e3o em 11 casos no grupo de RNT  e sete casos no grupo de RNPT   na 1\u00aa avalia\u00e7\u00e3o. Na 2\u00aa avalia\u00e7\u00e3o, estas frequ\u00eancias se reduziram a 7,3% (tr\u00eas casos) e 2,2% (um caso) , tendo sido todas encaminhadas para orienta\u00e7\u00e3o psicol\u00f3gica e n\u00e3o houve casos nem persist\u00eancia de sintomas nas avalia\u00e7\u00f5es seguintes.O principal resultado deste estudo, que buscou avaliar a presen\u00e7a de DMO em RNPT e comparar com RNT, bem como avaliar se h\u00e1 correla\u00e7\u00e3o entre DMO e dificuldade na introdu\u00e7\u00e3o da consist\u00eancia alimentar nestas popula\u00e7\u00f5es, foi que, embora a DMO tenha sido observada, n\u00e3o houve diferen\u00e7a entre RNPT e RNT. Al\u00e9m disso, apesar da ocorr\u00eancia de DMO, n\u00e3o houve dificuldade no per\u00edodo de in\u00edcio da alimenta\u00e7\u00e3o complementar, que ocorreu de modo precoce. A DMO foi observada em 15 casos, em cada grupo  na primeira avalia\u00e7\u00e3o e houve persist\u00eancia da DMO em dois casos dos RNT e tr\u00eas casos entre os RNPT na \u00faltima avalia\u00e7\u00e3o. Foi observado nestes \u00faltimos, dificuldade no preparo e mastiga\u00e7\u00e3o para as consist\u00eancias pastoso heterog\u00eaneo e s\u00f3lido, correspondendo a dificuldade para estas consist\u00eancias e escape anterior de l\u00edquido em copo aberto, correspondendo a dificuldade oral com este utens\u00edlio.,16-18.A real preval\u00eancia dos problemas de degluti\u00e7\u00e3o e de DMO em neonatos e lactentes n\u00e3o \u00e9 conhecida. Estudos demonstraram que na avalia\u00e7\u00e3o de RNPT aos 4 meses, a presen\u00e7a de DMO variou entre 23% a 89% para a consist\u00eancia pastosa; aos seis meses, identificaram DMO em aproximadamente 40% dos RNPT da amostra para a consist\u00eancia semiss\u00f3lida e aos 12 meses uma varia\u00e7\u00e3o entre 8% a 28% para a consist\u00eancia s\u00f3lidaNesses estudos, a IG ao nascimento foi em m\u00e9dia de 32 semanas, enquanto que no presente estudo foi de 34 semanas. Vale ressaltar que esta diferen\u00e7a de duas semanas de IG traduz-se numa diferente evolu\u00e7\u00e3o neurofisiol\u00f3gica, isto \u00e9, h\u00e1 grande diferen\u00e7a na maturidade neurol\u00f3gica e, consequentemente, s\u00e3o observados diferentes n\u00edveis nas habilidades motoras oraisNo presente estudo, a DMO n\u00e3o apresentou rela\u00e7\u00e3o com atrasos no desenvolvimento neuropsicomotor avaliados pelo Denver II, por\u00e9m os pacientes de alto risco neurol\u00f3gico foram exclu\u00eddos da amostra. Al\u00e9m disso, os pacientes foram acompanhados por uma equipe interdisciplinar, e as orienta\u00e7\u00f5es necess\u00e1rias quanto \u00e0 alimenta\u00e7\u00e3o e nutri\u00e7\u00e3o, al\u00e9m de interven\u00e7\u00f5es psicossociais, foram realizadas a cada avalia\u00e7\u00e3o. Portanto, um risco de vi\u00e9s de interven\u00e7\u00e3o pode ter sido respons\u00e1vel pela baixa frequ\u00eancia de altera\u00e7\u00f5es no presente estudo. Al\u00e9m disso, a popula\u00e7\u00e3o deste estudo era predominantemente de RNPT tardios e n\u00e3o de prematuros extremos, esta mais predisposta ao risco de DMO que aquela.. Esse estudo, tamb\u00e9m, relaciona altera\u00e7\u00f5es alimentares persistentes nos primeiros 15 meses de vida com atraso no desenvolvimento neuropsicomotor. J\u00e1 as dificuldades alimentares nas primeiras quatro semanas de vida s\u00e3o muito frequentes e n\u00e3o t\u00eam um valor preditivo importante.A preval\u00eancia de problemas de alimenta\u00e7\u00e3o descrita em um estudo populacional no Reino Unido em 2001, com 14.000 RNPT nascidos com <37 semanas de gesta\u00e7\u00e3o foi de 10,5% e essa frequ\u00eancia aumentou para 24,5% entre aqueles nascidos com muito baixo peso (<1500 g)Na an\u00e1lise dos 30 RN (15 em ambos os grupos) com DMO, n\u00e3o foi observado rela\u00e7\u00e3o com a prematuridade e desenvolvimento neuropsicomotor, mas foi poss\u00edvel verificar a associa\u00e7\u00e3o com dificuldade de aleitamento materno, interna\u00e7\u00e3o em UTIN, procedimentos orais invasivos neonatais e uso de mamadeira na alta hospitalar.,20,21, com potencial risco de avers\u00e3o \u00e0 alimenta\u00e7\u00e3o oral a m\u00e9dio e longo prazo,17.Estudos apontam que os RNPT s\u00e3o expostos a est\u00edmulos externos prolongados e nocivos, como c\u00e2nulas orotraqueais e sondas orog\u00e1stricas e que tais interven\u00e7\u00f5es podem impactar negativamente as habilidades orais desta popula\u00e7\u00e3oCom rela\u00e7\u00e3o aos cinco RN com DMO na \u00faltima avalia\u00e7\u00e3o, quatro passaram por interven\u00e7\u00f5es orais invasivas, e j\u00e1 apresentavam DMO na primeira avalia\u00e7\u00e3o. Quando realizada a an\u00e1lise dos preditores para DMO, a ocorr\u00eancia de procedimentos orais invasivos aumentou em 6 vezes a chance de apresentar tal dificuldade..Em um estudo populacional no Reino Unido, por meio de question\u00e1rio aplicado por telefone, comparando 1130 RNPT com 1255 RNT, os RNPT apresentaram mais dificuldades alimentares aos dois anos. O risco relativo de dificuldades alimentares foi 1,57 e 1,62 para DMO e o uso de sonda nasog\u00e1strica por mais de 2 semanas foi associado a dificuldades alimentares.Em outro estudo transversal brasileiro de 62 RNPT, tamb\u00e9m, associou tempo de sonda enteral com dificuldades alimentares e comportamentos defensivos aos 13 meses de idade corrigida. Mas n\u00e3o encontrou associa\u00e7\u00e3o entre DMO e dificuldade alimentar,6. J\u00e1 outro estudo transversal, tamb\u00e9m, com RNPT com m\u00e9dia de IG de 32 semanas, n\u00e3o encontraram rela\u00e7\u00e3o entre DMO e IG, como no presente estudo. Como j\u00e1 observado, a popula\u00e7\u00e3o deste estudo foi de RNPT tardios, o que pode explicar a n\u00e3o associa\u00e7\u00e3o com IG.Outros dois estudos relatam associa\u00e7\u00e3o significativa entre dificuldades alimentares e IG, em tais estudos a popula\u00e7\u00e3o estudada foram RNPT extremos.O per\u00edodo de introdu\u00e7\u00e3o da alimenta\u00e7\u00e3o complementar, bem como a idade apropriada de in\u00edcio da alimenta\u00e7\u00e3o oral com a exposi\u00e7\u00e3o a texturas e sabores respeitando as janelas de oportunidade e todos os est\u00edmulos e experi\u00eancias que envolvem a rela\u00e7\u00e3o com o alimento e com o desenvolvimento das compet\u00eancias oro motoras, podem ter envolvimento nas dificuldades de alimenta\u00e7\u00e3o em RNPT a m\u00e9dio e longo prazo,20,22-25.Os resultados da presente pesquisa demonstraram que tanto nos RNT quanto nos RNPT, a introdu\u00e7\u00e3o da consist\u00eancia pastosa ocorreu precocemente, por volta dos quatro meses, corroborando com estudos realizados com prematuros, no qual os mesmos foram expostos \u00e0 oferta de frutas/papas antes de completar seis meses de idade corrigidaA consist\u00eancia pastosa heterog\u00eanea (pequenos peda\u00e7os) foi observada com maior frequ\u00eancia na 4\u00aa avalia\u00e7\u00e3o, na qual os RN tinham idade m\u00e9dia de oito meses (idade corrigida RNPT). J\u00e1 a consist\u00eancia s\u00f3lida foi iniciada em ambos os grupos, por volta dos dez meses, conforme esperado para a idade. Entretanto foi observada uma pequena parcela de RN que na 5\u00aa avalia\u00e7\u00e3o, ainda n\u00e3o aceitavam nem pequenos peda\u00e7os nem s\u00f3lidos, sendo considerado um atraso na introdu\u00e7\u00e3o dos mesmos.,9.Quando o assunto \u00e9 a introdu\u00e7\u00e3o das consist\u00eancias, a literatura traz como balizadoras as idades de janelas de oportunidade. No sexto m\u00eas de idade corrigida \u00e9 iniciada a alimenta\u00e7\u00e3o complementar que deve ocorrer de forma gradual na consist\u00eancia pastosa, aos oito meses, o lactente j\u00e1 est\u00e1 apto a receber alimentos em pequenos peda\u00e7os e/ou desfiados. Esta n\u00e3o deve passar dos nove meses, podendo ocasionar futuramente problemas alimentares e a introdu\u00e7\u00e3o para consist\u00eancia s\u00f3lida igual da fam\u00edlia, dever\u00e1 ser realizada at\u00e9 os 12 meses refor\u00e7a que a introdu\u00e7\u00e3o da alimenta\u00e7\u00e3o complementar deve respeitar as compet\u00eancias e o ritmo dos RNPT, para que desenvolvam as habilidades adequadas a cada progress\u00e3o de textura.Al\u00e9m disso, King. Tanto o Minist\u00e9rio da Sa\u00fade quanto a Sociedade Brasileira de Pediatria n\u00e3o recomendam esta pr\u00e1tica, pois pode acarretar em diminui\u00e7\u00e3o do aleitamento materno exclusivo ou at\u00e9 seu desmame,27.A oferta de alimentos, \u00e1gua, ch\u00e1s e sucos antes dos seis meses de vida, j\u00e1 caracteriza a introdu\u00e7\u00e3o precoce de alimenta\u00e7\u00e3o complementar.Apesar da recomenda\u00e7\u00e3o do Minist\u00e9rio da Sa\u00fade (2010) de que o leite materno deve ser exclusivo at\u00e9 os seis meses de vida para a popula\u00e7\u00e3o de RNPT. A literatura ainda \u00e9 escassa e n\u00e3o h\u00e1 consenso, entretanto h\u00e1 a recomenda\u00e7\u00e3o para que a introdu\u00e7\u00e3o da alimenta\u00e7\u00e3o complementar se inicie a partir de seis meses de idade corrigida, sendo que, tamb\u00e9m, devem estar presentes os sinais de prontid\u00e3o.Vale ressaltar que quando a introdu\u00e7\u00e3o da alimenta\u00e7\u00e3o complementar \u00e9 iniciada precocemente, a crian\u00e7a pode desenvolver doen\u00e7as al\u00e9rgicas ou at\u00e9 mesmo altera\u00e7\u00e3o no desenvolvimento oral, implicando em dificuldades na mastiga\u00e7\u00e3o. J\u00e1 quando ela ocorre tardiamente, poder\u00e1 ocorrer um d\u00e9ficit de crescimento ou anemia, e comprometer o crescimento e desenvolvimento das estruturas faciais. Em um estudo, os RNs necessitaram de interna\u00e7\u00e3o em UTIN 18  RNT vs 17  RNPT. A m\u00e9dia do tempo de interna\u00e7\u00e3o em UTIN foi de 6 (3-10) dias no grupo dos RNT e de 13,5 (5-21) dias no grupo de RNPT, esta mais suscet\u00edvel a intercorr\u00eancias peri e p\u00f3s- natal, necessitando, assim de cuidados intensivos. Este dado demonstra que os RNPT da maternidade envolvida no servi\u00e7o n\u00e3o eram pacientes de alta complexidade. Demonstra, tamb\u00e9m, que muitos RNT do grupo estudado, ao inv\u00e9s de receberem alta com 48h a 72h, permaneceram internados por mais tempo, o que indica que a popula\u00e7\u00e3o de RNT estudada, apesar de n\u00e3o ter o risco da prematuridade, tinha outros fatores de risco, por exemplo, interna\u00e7\u00e3o em UTIN.No que diz respeito \u00e0 m\u00e9dia de interna\u00e7\u00e3o em UTIN, o tempo de perman\u00eancia depende da complexidade e do grau de prematuridade dos pacientes atendidos no servi\u00e7o. A maioria dos estudos com UTIN de alta complexidade descrevem tempo m\u00e9dio de interna\u00e7\u00e3o dos RNPT e BPN acima de um m\u00easUm vi\u00e9s de amostragem importante de se relatar foi que os RNT tamb\u00e9m eram considerados de risco, al\u00e9m de alguns necessitarem de interna\u00e7\u00e3o em UTIN. Outros foram selecionados a partir de dificuldades no aleitamento materno durante a realiza\u00e7\u00e3o do teste do pezinho, sendo encaminhados ao NASF para avalia\u00e7\u00e3o especializada. De qualquer modo, a DMO foi observada, tamb\u00e9m nos RNT, o que indica que mesmo neste grupo teoricamente com progn\u00f3stico favor\u00e1vel, de acordo com a idade gestacional, o risco existe, e uma avalia\u00e7\u00e3o e triagem especializada devem ser consideradas, principalmente, naqueles mais expostos \u00e0 interna\u00e7\u00e3o em UTIN.No presente estudo, 9  RNT passaram por internamento em UTIN, permanecendo um tempo de m\u00e9dio de 6,0 (3-10) dias. A maioria destes teve como causa de internamento diagn\u00f3stico cardiopulmonar. Embora n\u00e3o tenham sido observadas altera\u00e7\u00f5es na Triagem do Desenvolvimento, h\u00e1 de se considerar que tal diagn\u00f3stico pode acarretar em atrasos no desenvolvimento motor fino..Na alta hospitalar, a frequ\u00eancia de AM foi elevada: 100% nos RNT e 97% nos RNPT, mista em 7,3% e em 19,6%, respectivamente. A Iniciativa Hospital Amigo da Crian\u00e7a tem desempenhado papel valioso na mobiliza\u00e7\u00e3o dos atores envolvidos dentro das institui\u00e7\u00f5es hospitalares, no processo de mudan\u00e7a de condutas e rotinas aos elevados \u00edndices de desmame precoce. As m\u00e3es dos RNPT permanecem internadas juntamente com seus filhos e s\u00e3o capacitadas e treinadas para o AM, por meio de aux\u00edlio, estrat\u00e9gias e interven\u00e7\u00f5es que o promovem com efetividade e seguran\u00e7a antes da alta.A Maternidade Dona Catarina Kuss \u00e9 uma institui\u00e7\u00e3o que faz parte da Iniciativa Hospital Amigo da Crian\u00e7a (IHAC) e possui o M\u00e9todo M\u00e3e Canguru e ambos propiciam, incentivam e promovem o aleitamento materno, os n\u00fameros do munic\u00edpio est\u00e3o muito aqu\u00e9m do esperado, entre a alta hospitalar at\u00e9 a 1a avalia\u00e7\u00e3o, foi observada diminui\u00e7\u00e3o da frequ\u00eancia de aleitamento materno em ambos os grupos, entretanto esta frequ\u00eancia foi ainda menor nos RNPT, passando a serem semelhantes nas demais avalia\u00e7\u00f5es, h\u00e1 de se pensar em estrat\u00e9gias que possam estreitar a assist\u00eancia, a fim de proteger o aleitamento materno.Embora exista e Estrat\u00e9gia Amamenta e Alimenta Brasil que s\u00e3o a\u00e7\u00f5es para o fortalecimento da promo\u00e7\u00e3o, prote\u00e7\u00e3o e apoio ao aleitamento materno e a alimenta\u00e7\u00e3o complementar saud\u00e1vel para crian\u00e7as menores de dois anos de idadeNo que diz respeito \u00e0s caracter\u00edsticas da avalia\u00e7\u00e3o da mamada foi observada diferen\u00e7a significativa no item suc\u00e7\u00e3o, com maior frequ\u00eancia de dificuldade nos RNT. Sendo observado melhor vedamento labial no RNT e melhor pega nos RNPT. Uma hip\u00f3tese para este dado seria por que os RNT foram selecionados para este estudo a partir da solicita\u00e7\u00e3o de avalia\u00e7\u00e3o e manejo do aleitamento materno, isto \u00e9, apresentavam algum grau de dificuldade ou queixa durante o aleitamento materno, enquanto os RNPT j\u00e1 vinham da maternidade com estas quest\u00f5es melhores estabelecidas. Este dado enfatiza que as dificuldades com o aleitamento materno n\u00e3o ocorrem apenas na popula\u00e7\u00e3o de RNPT, pelo contr\u00e1rio, talvez alguns RNT precisassem de mais tempo e de maior suporte e apoio profissional para estabelecimento do AM, pois os RNT expostos a fatores de risco para o desenvolvimento, tamb\u00e9m, merecem receber avalia\u00e7\u00e3o e acompanhamento especializado.. O tempo de Aleitamento Materno Exclusivo foi abaixo do preconizado 180 dias (seis meses), em ambos os grupos com idade m\u00e9dia de 122 dias (quatro meses) e a m\u00e9dia de idade de desmame do AM foi de oito meses nos RNT e de sete meses de idade corrigida nos RNPT.\u00c9 importante ressaltar que o leite materno \u00e9 o melhor e mais completo alimento para o rec\u00e9m-nascido, seja ele prematuro ou a termo, e que ap\u00f3s a introdu\u00e7\u00e3o da alimenta\u00e7\u00e3o complementar \u00e9 recomendada a continuidade do AM at\u00e9 os dois anos de vida ou maisAl\u00e9m de quest\u00f5es org\u00e2nicas, emocionais e ambientais, quando se trata de Aleitamento Materno Exclusivo (AME), h\u00e1 de se considerar que atualmente a Consolida\u00e7\u00e3o das Leis do Trabalho (CLT) n\u00e3o caminham paralelamente \u00e0s recomenda\u00e7\u00f5es da Organiza\u00e7\u00e3o Mundial da Sa\u00fade (OMS), com licen\u00e7a maternidade de quatro meses. Isso somado a pouca ou restrita rede de apoio, institui\u00e7\u00f5es/creches que n\u00e3o comportam a oferta de leite materno, vulnerabilidade social, entre outros, favorecem os baixos \u00edndices de AME.Nos resultados dos Indicadores de Risco para o Desenvolvimento Infantil (IRDI), apesar de serem observadas algumas aus\u00eancias de 2 ou mais itens, a maioria dos indicadores estavam presentes, e quando ausentes foi realizada interven\u00e7\u00e3o interprofissional e reavaliados na consulta seguinte. Al\u00e9m disso, vale ressaltar que para ser considerado risco ps\u00edquico \u00e9 necess\u00e1rio que os indicadores ausentes persistam na 2\u00aa avalia\u00e7\u00e3o. Tais resultados podem estar relacionados \u00e0s caracter\u00edsticas da pr\u00f3pria Maternidade Dona Catarina Kuss, da qual os RN eram provenientes, al\u00e9m do fato de estarem todos inseridos num Servi\u00e7o de Seguimento ao RN de Risco para o Desenvolvimento orientado, dentre outros eixos, \u00e0 promo\u00e7\u00e3o de sa\u00fade mental materno-infantil. est\u00e3o conduzindo uma pesquisa de revis\u00e3o sistem\u00e1tica no Canad\u00e1 com o objetivo de levantar os elementos que levam a falhas no recrutamento e reten\u00e7\u00e3o de pais nos estudos e centros de seguimento de crian\u00e7as de 0 a 36 meses. Objetivam ao t\u00e9rmino da pesquisa, oferecerem recomenda\u00e7\u00f5es para que pesquisas futuras adotem estrat\u00e9gias mais eficientes de recrutamento e, especialmente, de reten\u00e7\u00e3o dos participantes nesta popula\u00e7\u00e3o. De modo geral, estudos com amostras maiores se fazem pertinentes para a avalia\u00e7\u00e3o das vari\u00e1veis descritas neste estudo, idealmente com RNT saud\u00e1veis e sem interven\u00e7\u00e3o e com uma popula\u00e7\u00e3o grande de RNPT extremos. Para a real preval\u00eancia de DMO, estudos preferencialmente sem vi\u00e9s de interven\u00e7\u00e3o s\u00e3o necess\u00e1rios. Por\u00e9m como a avalia\u00e7\u00e3o da DMO \u00e9 feita por especialistas da fonoaudiologia, uma avalia\u00e7\u00e3o livre de interven\u00e7\u00e3o seria contr\u00e1ria a uma conduta adequada.Em rela\u00e7\u00e3o \u00e0 amostra deste estudo, o seguimento prolongado proposto foi acometido por diversas vari\u00e1veis que culminaram em relevante perda de seguimento. Preocupados com a perda de seguimento nos estudos de coorte prospectivos na primeira inf\u00e2ncia, pois trata-se de um problema enfrentado em todo o mundo, Keys e colaboradoresN\u00e3o foi observado diferen\u00e7a na introdu\u00e7\u00e3o das consist\u00eancias no per\u00edodo de in\u00edcio da alimenta\u00e7\u00e3o complementar entre RNT e RNPT. A consist\u00eancia pastosa foi introduzida precocemente em ambos os grupos.Dificuldades com aleitamento materno ocorreram apenas na primeira avalia\u00e7\u00e3o e em uma pequena propor\u00e7\u00e3o, n\u00e3o havendo diferen\u00e7a entre RNT e RNPT.A frequ\u00eancia de AM foi maior entre os RNT na 1\u00aa avalia\u00e7\u00e3o, sendo semelhante a partir das demais avalia\u00e7\u00f5es, entretanto tanto o AME quanto o desmame est\u00e3o muito aqu\u00e9m do preconizado em ambos os grupos.A DMO ocorreu numa pequena parcela de ambos os grupos na primeira avalia\u00e7\u00e3o  e n\u00e3o havendo persist\u00eancia de dificuldade nas diferentes consist\u00eancias no per\u00edodo de in\u00edcio da introdu\u00e7\u00e3o alimentar. E na \u00faltima avalia\u00e7\u00e3o a DMO foi observada numa frequ\u00eancia menor que na primeira, sendo observado atraso na introdu\u00e7\u00e3o de s\u00f3lidos em alguns casos.Com rela\u00e7\u00e3o aos preditivos para DMO, foi observado que a mamadeira elevou a chance de DMO em cerca de 7 vezes, e os procedimentos orais invasivos em cerca de 6 vezes.N\u00e3o foi observado associa\u00e7\u00e3o entre Desenvolvimento Neuropsicomotor com DMO e AM.N\u00e3o foi observado associa\u00e7\u00e3o entre depress\u00e3o materna e AM."}
+{"text": "Apesar dos relatos de redu\u00e7\u00e3o da aptid\u00e3o f\u00edsica em crian\u00e7as com cardiopatia cong\u00eanita (CC), n\u00e3o foram realizadas avalia\u00e7\u00f5es espec\u00edficas de desempenho para atividades de vida di\u00e1ria. O objetivo foi comparar as atividades de vida di\u00e1ria, qualidade de vida, postura, aptid\u00e3o f\u00edsica e n\u00edveis de atividade f\u00edsica entre crian\u00e7as com CC e controles saud\u00e1veis (CS).Pediatric Quality of Life Inventory (PedsQL) para avalia\u00e7\u00e3o da qualidade de vida, al\u00e9m de an\u00e1lises posturais. Valores de p < 0,05 foram considerados estatisticamente significativos. O estudo incluiu 30 crian\u00e7as, de 6 a 14 anos, com diagn\u00f3stico de CC moderada ou grave e 30 consideradas CS pareadas por idade e sexo. Os dados sociodemogr\u00e1ficos e cl\u00ednicos dos participantes foram registrados. Todos os participantes realizaram diversos testes: teste de TGlittre-P para atividades de vida di\u00e1ria; teste de caminhada de 6 minutos (TC6M) para capacidade funcional; bateria de testes Fitnessgram para aptid\u00e3o f\u00edsica; dinam\u00f4metro de m\u00e3o para medir a for\u00e7a de preens\u00e3o; ped\u00f4metro para medir a atividade f\u00edsica; al\u00e9m disso, a crian\u00e7a e os pais completaram o sit-ups, flex\u00f5es, eleva\u00e7\u00e3o do tronco e sentar e alcan\u00e7ar, dentro da bateria do Fitnessgram, al\u00e9m de for\u00e7a de preens\u00e3o, postura e qualidade de vida foram menores do que os do grupo CS. Os n\u00edveis de atividade f\u00edsica foram semelhantes entre os grupos. Indiv\u00edduos com CC apresentaram um tempo de conclus\u00e3o do teste TGlittre-P mais longo e uma dist\u00e2ncia de TC6M mais curta em compara\u00e7\u00e3o com o CS . Para o grupo CC, os resultados dos testes de  O desempenho das atividades de vida di\u00e1ria, a capacidade funcional, a aptid\u00e3o f\u00edsica, a postura e a qualidade de vida de crian\u00e7as com CC moderada e grave foram afetados em compara\u00e7\u00e3o com seus pares saud\u00e1veis. Estudos documentaram redu\u00e7\u00f5es na capacidade funcional, nas habilidades motoras e na for\u00e7a muscular perif\u00e9rica em crian\u00e7as com CC complexa devido a causas multifatoriais, como cianose, aumento da circula\u00e7\u00e3o pulmonar, interven\u00e7\u00f5es card\u00edacas e diagn\u00f3sticos m\u00faltiplos.4 Embora poucos estudos avaliem a aptid\u00e3o f\u00edsica em crian\u00e7as com CC,6 os n\u00edveis de atividade f\u00edsica diferem entre os estudos.10A aptid\u00e3o f\u00edsica e os n\u00edveis de atividade f\u00edsica s\u00e3o importantes preditores da sa\u00fade cardiovascular. Uma aptid\u00e3o f\u00edsica aprimorada nos est\u00e1gios iniciais da vida est\u00e1 associada a um perfil cardiovascular mais saud\u00e1vel na idade adulta.11 Al\u00e9m disso, a resist\u00eancia cardiovascular, a resist\u00eancia muscular, a for\u00e7a muscular, a flexibilidade e a composi\u00e7\u00e3o corporal, que s\u00e3o par\u00e2metros de aptid\u00e3o f\u00edsica, s\u00e3o componentes necess\u00e1rios para a obten\u00e7\u00e3o da postura ideal. Estudos na literatura mostraram o desenvolvimento frequente de escoliose e deformidades cif\u00f3ticas ap\u00f3s a realiza\u00e7\u00e3o de esternotomias medianas em crian\u00e7as com CC.13 No entanto, embora interven\u00e7\u00f5es cir\u00fargicas sejam frequentemente realizadas em crian\u00e7as com CC moderada e grave, os estudos que avaliam a postura s\u00e3o muito limitados.14Baixos n\u00edveis de atividade f\u00edsica e sedentarismo foram associados a defeitos posturais.16Os avan\u00e7os no setor de sa\u00fade aumentaram a expectativa de vida dos indiv\u00edduos com CC e, portanto, a import\u00e2ncia da qualidade de vida tamb\u00e9m aumentou. Estudos que avaliam a qualidade de vida relacionada \u00e0 sa\u00fade em pacientes com CC enfatizam que a qualidade de vida relacionada \u00e0 sa\u00fade f\u00edsica diminui devido \u00e0 gravidade da doen\u00e7a e o n\u00famero de interven\u00e7\u00f5es cir\u00fargicas nesses indiv\u00edduos, em compara\u00e7\u00e3o com indiv\u00edduos saud\u00e1veis.17 No entanto, o referido estudo utilizou apenas um question\u00e1rio, em vez de um teste de desempenho espec\u00edfico, para a avalia\u00e7\u00e3o de AVD. Diante de todos esses fatores, nosso estudo objetivou comparar as atividades de vida di\u00e1ria, a qualidade de vida, a postura, a aptid\u00e3o f\u00edsica e os n\u00edveis de atividade f\u00edsica entre crian\u00e7as com CC e crian\u00e7as saud\u00e1veis (CS).A diminui\u00e7\u00e3o da capacidade funcional e da aptid\u00e3o f\u00edsica pode afetar as atividades de vida di\u00e1ria. Um estudo avaliou as atividades de vida di\u00e1ria (AVD) de crian\u00e7as com CC complexa.Trata-se de um estudo de caso-controle em crian\u00e7as com cardiopatia cong\u00eanita (CC). O protocolo do estudo foi aceito pelo Comit\u00ea de \u00c9tica em Pesquisa N\u00e3o Intervencionista da Universidade de Dokuz Eyl\u00fcl, com o n\u00famero de aprova\u00e7\u00e3o 2020/29-58, em 12/07/2020. O estudo foi realizado entre novembro de 2020 e maio de 2022 no Hospital Universit\u00e1rio de Dokuz Eyl\u00fcl, Departamento de Pediatria, Divis\u00e3o de Cardiologia Pedi\u00e1trica. O consentimento informado por escrito foi obtido de todos os participantes e seus respons\u00e1veis.18 com diagn\u00f3stico de CC moderada ou grave . Utilizando o estudo de Warnes et al.,19 crian\u00e7as com CC moderada a grave foram inclu\u00eddas em nosso estudo e defeitos card\u00edacos menores isolados que n\u00e3o necessitaram de interven\u00e7\u00e3o cir\u00fargica foram exclu\u00eddos. Problemas ortop\u00e9dicos ou neurol\u00f3gicos que afetassem os testes, dist\u00farbios mentais ou psicol\u00f3gicos, infec\u00e7\u00e3o aguda ou fadiga geral, cirurgia card\u00edaca nos \u00faltimos seis meses e recusa em participar do estudo foram os crit\u00e9rios de exclus\u00e3o utilizados. As crian\u00e7as do grupo controle saud\u00e1vel foram selecionadas entre indiv\u00edduos saud\u00e1veis que se inscreveram no Departamento de Pediatria do Hospital Universit\u00e1rio de Dokuz Eyl\u00fcl e n\u00e3o haviam sido diagnosticados com qualquer doen\u00e7a. Trinta crian\u00e7as saud\u00e1veis volunt\u00e1rias de faixa et\u00e1ria e sexo semelhantes, n\u00e3o atletas, foram inclu\u00eddas no estudo.O grupo CC incluiu 30 crian\u00e7as com quadro cl\u00ednico est\u00e1vel, com idades entre 6 e 14 anos,18O teste TGlittre-P \u00e9 a vers\u00e3o pedi\u00e1trica do teste original de Glittre-ADL desenvolvido para avaliar as atividades de vida di\u00e1ria dos indiv\u00edduos. O teste foi considerado v\u00e1lido e confi\u00e1vel para crian\u00e7as saud\u00e1veis de 6 a 14 anos.18 com peso entre 0,5 kg e 2,5 kg, determinado de acordo com idade e sexo do indiv\u00edduo. O teste iniciava-se quando a crian\u00e7a se levantava de uma cadeira com a sola dos p\u00e9s tocando o solo. Em seguida, caminhavam por 5 metros, subiam e desciam dois lances de escada  e caminhavam mais 5 metros. Tr\u00eas pinos de boliche coloridos, pesando 0,5 kg, foram retirados um a um da prateleira, ajustados na altura dos olhos pela crian\u00e7a, e recolocados na prateleira enquanto eram ajustados de acordo com o n\u00edvel do umbigo, depois no ch\u00e3o, na prateleira no n\u00edvel do umbigo e, finalmente, de volta \u00e0 prateleira no n\u00edvel dos olhos. Voltando do mesmo percurso e sentando na cadeira, a bateria de exerc\u00edcios era conclu\u00edda, e a pr\u00f3xima era iniciada imediatamente. Durante as cinco rodadas, as crian\u00e7as moviam os pinos de boliche com uma das m\u00e3os \u00e0 escolha delas enquanto um ox\u00edmetro de pulso era acoplado ao dedo indicador da outra m\u00e3o. Durante o teste, as crian\u00e7as receberam comandos verbais padr\u00e3o, como \u201csente-se\u201d, \u201clevante-se\u201d e \u201ccontinue\u201d. O tempo esperado do teste desenvolvido por Martins et al.,20 foi calculado e comparado com os dados de desempenho do teste das crian\u00e7as.O fisioterapeuta explicou o teste para cada crian\u00e7a, em seguida o mostrava e pedia para que experimentassem. Esse teste de desempenho exigia que a crian\u00e7a completasse cinco voltas no menor tempo carregando uma mochila,21 comparando-a com os dados de desempenho no teste das crian\u00e7as.O teste de caminhada de 6 minutos (TC6M) foi utilizado para avaliar a capacidade de exerc\u00edcio funcional. Solicitou-se \u00e0s crian\u00e7as que caminhassem o mais rapidamente poss\u00edvel por um corredor de 30 m de comprimento, usando comandos verbais padr\u00e3o como \u201cvoc\u00ea est\u00e1 indo muito bem\u201d e \u201ccontinue assim\u201d ao final de cada minuto. Antes e ap\u00f3s o teste, a frequ\u00eancia card\u00edaca, a satura\u00e7\u00e3o perif\u00e9rica de oxig\u00eanio e a dist\u00e2ncia percorrida foram registradas. Al\u00e9m disso, calculou-se a dist\u00e2ncia esperada de caminhada, conforme relatada por Geiger et al.,sit-ups, flex\u00f5es, eleva\u00e7\u00e3o do tronco e sentar e alcan\u00e7ar, da bateria de testes Fitnessgram,23 foram utilizados para avaliar a aptid\u00e3o f\u00edsica das crian\u00e7as. O n\u00famero m\u00e1ximo de repeti\u00e7\u00f5es conclu\u00eddas corretamente foi medido para os testes de flex\u00f5es e sit-ups. A dist\u00e2ncia na posi\u00e7\u00e3o de teste foi medida e registrada em cent\u00edmetros para os testes de eleva\u00e7\u00e3o de tronco e de sentar e alcan\u00e7ar.Os testes de 24 As crian\u00e7as estavam sentadas com as costas eretas. Pediu-se que elas apertassem o dinam\u00f4metro de m\u00e3o com o m\u00e1ximo de for\u00e7a poss\u00edvel, com o cotovelo em 90\u00b0 de flex\u00e3o, o bra\u00e7o pr\u00f3ximo ao corpo e o punho em posi\u00e7\u00e3o neutra. As medi\u00e7\u00f5es foram repetidas tr\u00eas vezes para as m\u00e3os direita e esquerda, com intervalo de 15 segundos, sendo os maiores valores registrados em quilogramas.A for\u00e7a de preens\u00e3o manual foi avaliada por meio do dinam\u00f4metro de m\u00e3o Jamar .25 foi utilizada para determinar dist\u00farbios posturais. O formul\u00e1rio baseia-se na identifica\u00e7\u00e3o de dist\u00farbios posturais com observa\u00e7\u00e3o posterior e lateral, al\u00e9m de classifica\u00e7\u00e3o de acordo com a gravidade . Ele tamb\u00e9m permite classificar o estado postural de acordo com o escore total. As avalia\u00e7\u00f5es foram realizadas na posi\u00e7\u00e3o ortost\u00e1tica, sem sapatos e com roupas leves e confort\u00e1veis, adequadas para a avalia\u00e7\u00e3o da postura, e os achados apurados foram registrados.A ficha de an\u00e1lise postural de Corbin et al.,26 Os dispositivos foram usados para registrar o comprimento normal da passada e o peso corporal das crian\u00e7as. Ped\u00f4metros foram fixados em suas roupas, determinando-se a proje\u00e7\u00e3o do ponto m\u00e9dio da patela at\u00e9 a superf\u00edcie anterior da pelve. As crian\u00e7as foram solicitadas a usar o ped\u00f4metro continuamente por sete dias, exceto ao tomar banho e dormir. Ap\u00f3s sete dias de uso, uma contagem m\u00e9dia de passos em um dia foi calculada.Os n\u00edveis de atividade f\u00edsica das crian\u00e7as foram avaliados por meio de um ped\u00f4metro .27 Escores mais altos indicam melhor qualidade de vida relacionada \u00e0 sa\u00fade da crian\u00e7a. O formul\u00e1rio PedsQL 4.0 Generic Core Scales,27 para crian\u00e7as de 5-7, 8-12 e 13-18 anos de idade e seus pais, foram usados em nosso estudo. O escore total da escala, o escore de fun\u00e7\u00e3o f\u00edsica e o escore de sa\u00fade psicossocial foram calculados, consistindo em escores de funcionalidade escolar, social e emocional.O PedsQL \u00e9 uma escala de 23 itens que inclui fun\u00e7\u00e3o f\u00edsica, emocional, social e escolar.Foi explicado \u00e0s crian\u00e7as que deveriam dizer se sentiam tontura, palpita\u00e7\u00f5es, dor no peito, dificuldade para respirar ou cansa\u00e7o excessivo durante todos os testes. Elas poderiam descansar e continuar ou encerrar o teste, conforme necess\u00e1rio.28 Calculou-se que 36 participantes, incluindo pelo menos 18 crian\u00e7as em cada grupo, devem ser inclu\u00eddos no estudo, com um tamanho de efeito calculado de 0,97, probabilidade de erro alfa de 0,05 e um poder de 80%.Com base no estudo que compara o teste TGlittre-ADL em pacientes com doen\u00e7a pulmonar obstrutiva cr\u00f4nica e um grupo controle de indiv\u00edduos saud\u00e1veis, o menor tamanho de amostra foi calculado usando o programa G*Power 3.1.O programa IBM SPSS Statistics (Vers\u00e3o 26.0) foi utilizado para analisar os dados obtidos dos participantes. Foram usados valores de curtose/assimetria, testes de Shapiro-Wilk, gr\u00e1fico Q-Q normal sem tend\u00eancia e gr\u00e1ficos de histograma para determinar a conformidade das vari\u00e1veis com a distribui\u00e7\u00e3o normal. A diferen\u00e7a entre as vari\u00e1veis categ\u00f3ricas foi analisada pelo teste qui-quadrado. O teste de Mann-Whitney U foi usado para comparar as diferen\u00e7as entre os grupos para condi\u00e7\u00f5es que n\u00e3o se conformavam com a distribui\u00e7\u00e3o normal. Um teste t para grupos independentes foi usado para comparar as diferen\u00e7as entre os grupos para condi\u00e7\u00f5es que se conformavam \u00e0 distribui\u00e7\u00e3o normal. As vari\u00e1veis categ\u00f3ricas foram expressas em valores absolutos e percentuais. Vari\u00e1veis cont\u00ednuas com distribui\u00e7\u00e3o normal foram expressas como m\u00e9dia e desvio padr\u00e3o, e vari\u00e1veis cont\u00ednuas com distribui\u00e7\u00e3o anormal foram expressas como mediana e intervalo interquart\u00edlico. Valores de p < 0,05 foram considerados estatisticamente significativos.As caracter\u00edsticas demogr\u00e1ficas dos participantes s\u00e3o apresentadas na As caracter\u00edsticas cl\u00ednicas do grupo CC s\u00e3o apresentadas na 29 nos testes TGlittre-P e TC6M. Dessas crian\u00e7as, 10 apresentavam CC cian\u00f3tica e 1 atresia mitral, todas operadas. Observou-se uma diferen\u00e7a significativa entre os grupos nos testes de sit-ups, flex\u00f5es, eleva\u00e7\u00e3o de tronco e sentar e alcan\u00e7ar. Houve uma diferen\u00e7a significativa entre os grupos em rela\u00e7\u00e3o \u00e0s for\u00e7as de preens\u00e3o manual da m\u00e3o dominante e n\u00e3o dominante. Houve uma diferen\u00e7a significativa entre os escores de postura dos dois grupos. N\u00e3o houve diferen\u00e7a significativa entre os n\u00edveis de atividade f\u00edsica dos dois grupos. Os escores de qualidade de vida avaliados pelo PedsQL foram significativamente maiores no grupo controle do que no grupo CC, tanto na forma infantil quanto na forma parental.As compara\u00e7\u00f5es do grupo CC e controles saud\u00e1veis s\u00e3o mostradas na Nosso estudo mostrou que as atividades de vida di\u00e1ria, a capacidade funcional, a for\u00e7a de preens\u00e3o manual, a aptid\u00e3o f\u00edsica e a qualidade de vida de crian\u00e7as com CC diminu\u00edram em compara\u00e7\u00e3o com o grupo CS. Al\u00e9m disso, elas tamb\u00e9m apresentaram postura pior do que o CS, mas seus n\u00edveis de atividade f\u00edsica eram semelhantes.30 De forma consistente com nosso estudo, Feldt et al.,31 observaram pesos corporais mais baixos, alturas mais baixas e pesos mais afetados pela altura em compara\u00e7\u00e3o com crian\u00e7as saud\u00e1veis.Os pesos corporais e os \u00edndices de massa corporal do grupo CC foram significativamente menores do que os do CS. As cardiopatias cong\u00eanitas tamb\u00e9m s\u00e3o associadas com atraso no crescimento e desenvolvimento devido ao aumento das necessidades de energia e trabalho respirat\u00f3rio, hip\u00f3xia, que dificulta a ingest\u00e3o de alimentos, desnutri\u00e7\u00e3o e m\u00e1 absor\u00e7\u00e3o.Vinte e sete (27) crian\u00e7as em nosso grupo CC tiveram cirurgia card\u00edaca pr\u00e9via e tr\u00eas n\u00e3o tiveram interven\u00e7\u00e3o cir\u00fargica. A inclus\u00e3o de tr\u00eas pacientes que n\u00e3o foram submetidos \u00e0 cirurgia card\u00edaca em nosso estudo pode ter melhorado o desempenho do grupo CC, j\u00e1 que as interven\u00e7\u00f5es card\u00edacas foram associadas a um pior desempenho f\u00edsico.17 Em nosso estudo, usamos o teste TGlittre-P, um m\u00e9todo de avalia\u00e7\u00e3o diferente, e obtivemos resultados semelhantes. Usando a taxonomia de AVD, as crian\u00e7as s\u00e3o avaliadas com base em sua capacidade de realizar 11 atividades, incluindo comer e beber, mobilidade, usar o banheiro, vestir-se, higiene pessoal, cuidados pessoais, comunica\u00e7\u00e3o, transporte, compras e limpeza, mas o desempenho da vida di\u00e1ria n\u00e3o pode ser avaliado. Nosso estudo \u00e9 o primeiro a avaliar as atividades de vida di\u00e1ria em crian\u00e7as com CC complexa e a usar o teste TGlittre-P, que \u00e9 um teste de exerc\u00edcio.Em um estudo que examinou as atividades de vida di\u00e1ria de pacientes com CC complexa, a taxonomia de AVD foi utilizada, e observou-se que as AVDs dessas crian\u00e7as foram significativamente prejudicadas.32 Quanto menor o tempo de conclus\u00e3o do teste, melhor ser\u00e1 o desempenho da vida di\u00e1ria do indiv\u00edduo. Martins et al.,18 modificaram o teste original de Glittre-ADL para crian\u00e7as e mostraram que o teste TGlittre-P era v\u00e1lido e confi\u00e1vel para crian\u00e7as do grupo CS de 6 a 14 anos.18 Em estudos realizados em diferentes grupos de doen\u00e7as, observou-se que o tempo de conclus\u00e3o do teste dos pacientes \u00e9 maior em compara\u00e7\u00e3o com controles saud\u00e1veis.34 Al\u00e9m disso, Scalo et al.,35 relataram que crian\u00e7as com fibrose c\u00edstica necessitaram de mais tempo para concluir o teste em compara\u00e7\u00e3o com controles saud\u00e1veis, mas n\u00e3o houve diferen\u00e7a estat\u00edstica. Fernandes-Andrade et al.,36 avaliaram o teste Glittre-ADL em pacientes com idade entre 18-80 anos com doen\u00e7a cardiovascular e os indiv\u00edduos completaram o teste em m\u00e9dia em 3,24 min. Em nosso estudo, o grupo controle completou o teste TGlittre-P em 3,10 minutos, e as crian\u00e7as com CC moderada e grave completaram o teste TGlittre-P em mais tempo . Ao final do teste TGlittre-P, o grupo controle atingiu 69,14% da frequ\u00eancia card\u00edaca m\u00e1xima e completou o teste no n\u00edvel subm\u00e1ximo. J\u00e1 o grupo CC atingiu 53,60% da frequ\u00eancia card\u00edaca m\u00e1xima e completou o teste abaixo do n\u00edvel da frequ\u00eancia card\u00edaca subm\u00e1xima. Al\u00e9m disso, no TC6M, um teste de campo subm\u00e1ximo avaliado em nosso estudo, observou-se que a frequ\u00eancia card\u00edaca m\u00e1xima do grupo CC atingiu 53,11%, de forma semelhante ao teste TGlittre-P, e a frequ\u00eancia card\u00edaca subm\u00e1xima permaneceu abaixo do n\u00edvel. Esses dois resultados corroboram um ao outro e podem ser explicados pelas respostas cronotr\u00f3picas insuficientes de crian\u00e7as com CC. O cora\u00e7\u00e3o menor das crian\u00e7as resulta em um volume sist\u00f3lico menor. Por esse motivo, as crian\u00e7as aumentam principalmente seu d\u00e9bito card\u00edaco, aumentando a frequ\u00eancia card\u00edaca para atender \u00e0 maior demanda por oxig\u00eanio durante o exerc\u00edcio. No entanto, a atividade do sistema nervoso parassimp\u00e1tico e simp\u00e1tico, que desempenham um papel importante na regula\u00e7\u00e3o da frequ\u00eancia card\u00edaca em crian\u00e7as com CC, pode ser afetada por defeitos septais, procedimentos cir\u00fargicos e condi\u00e7\u00f5es induzidas por isquemia. Com isso, ocorre a incapacidade de aumentar a frequ\u00eancia card\u00edaca frente ao aumento da demanda metab\u00f3lica, ou seja, a insufici\u00eancia cronotr\u00f3pica.1 Em nosso estudo, a dessatura\u00e7\u00e3o observada em 11 crian\u00e7as do grupo CC nos testes TGlittre-P e TC6M indica que essas crian\u00e7as n\u00e3o foram capazes de regular o aumento da demanda metab\u00f3lica em suas atividades de vida di\u00e1ria. Devido \u00e0 patologia existente, esta situa\u00e7\u00e3o \u00e9 particularmente evidente em crian\u00e7as com CC cian\u00f3tica. Al\u00e9m disso, o tempo de conclus\u00e3o do grupo CC no teste TGlittre-P foi 22,67% maior do que o esperado, e o tempo de conclus\u00e3o do grupo controle foi 4,88% maior do que o esperado em nosso estudo . O fato de as atividades de vida di\u00e1ria de crian\u00e7as com CC serem inferiores tanto ao grupo controle quanto ao valor esperado \u00e9 resultado da incapacidade dessas crian\u00e7as de aumentar suficientemente sua frequ\u00eancia card\u00edaca.O teste Glittre-ADL original \u00e9 um teste subm\u00e1ximo desenvolvido para avaliar atividades  que os indiv\u00edduos com DPOC frequentemente repetem em suas vidas di\u00e1rias.1 Em nosso estudo, de modo semelhante \u00e0 literatura, observamos que houve diminui\u00e7\u00e3o da capacidade funcional, avaliada pela dist\u00e2ncia do TC6M, em pacientes com CC.De acordo com nosso estudo, a dist\u00e2ncia do TC6M foi significativamente menor no grupo CC do que no CS. Na literatura, afirma-se que a CC est\u00e1 associada a uma menor capacidade funcional em crian\u00e7as e adolescentes em compara\u00e7\u00e3o com seus pares saud\u00e1veis, sendo afetada por uma resposta cronotr\u00f3pica prejudicada.6 Em um estudo de Hock et al.,3 crian\u00e7as e adolescentes submetidos \u00e0 cirurgia de deriva\u00e7\u00e3o cavopulmonar total foram avaliados por meio da bateria de testes Fitnessgram, e foi relatado que essas crian\u00e7as apresentaram diminui\u00e7\u00e3o da resist\u00eancia e flexibilidade dos m\u00fasculos abdominais em compara\u00e7\u00e3o com o CS. Tamb\u00e9m obtivemos resultados semelhantes em nosso estudo. A diminui\u00e7\u00e3o da flexibilidade e resist\u00eancia muscular em crian\u00e7as com CC pode ser causada por raz\u00f5es multifatoriais, como cirurgias card\u00edacas pr\u00e9vias, gravidade da doen\u00e7a, comprometimento das atividades f\u00edsicas e habilidades di\u00e1rias da crian\u00e7a, superprote\u00e7\u00e3o dos pais, recomenda\u00e7\u00f5es dos m\u00e9dicos para restri\u00e7\u00e3o de atividades e o senso de autoinsufici\u00eancia da crian\u00e7a em atividades f\u00edsicas.37 Al\u00e9m de todos esses motivos, um estudo mostrou que adolescentes com cardiopatia cong\u00eanita complexa com IMC baixo apresentaram menor aptid\u00e3o f\u00edsica.38 Em nosso estudo, um dos fatores que causam diminui\u00e7\u00e3o da aptid\u00e3o f\u00edsica no grupo CC pode ser o baixo IMC. A aptid\u00e3o f\u00edsica \u00e9 muito importante na avalia\u00e7\u00e3o e tratamento desses pacientes; o n\u00famero limitado de estudos n\u00e3o \u00e9 suficiente para esclarecer esta quest\u00e3o, sendo necess\u00e1rios mais estudos no futuro.Embora saiba-se que as cardiopatias cong\u00eanitas afetam as habilidades motoras, poucos estudos avaliam a aptid\u00e3o f\u00edsica relacionada \u00e0 sa\u00fade dessas crian\u00e7as. Esses estudos relataram que a aptid\u00e3o f\u00edsica n\u00e3o foi afetada em crian\u00e7as com doen\u00e7a de baixa gravidade e diminuiu significativamente \u00e0 medida que a gravidade da doen\u00e7a aumentava.39 De acordo com dois estudos conduzidos em pacientes com CC leve e moderada, a for\u00e7a de preens\u00e3o foi semelhante \u00e0 de controles saud\u00e1veis.40 A for\u00e7a de preens\u00e3o do nosso grupo composto por casos de CC moderada e grave diminuiu. De forma consistente com nossos resultados, no estudo conduzido por Holm et al.,2 verificou-se que a for\u00e7a de preens\u00e3o estava reduzida em pacientes card\u00edacos cong\u00eanitos complexos de 7 a 12 anos. Al\u00e9m disso, resultados semelhantes foram relatados em um estudo abrangente comparando a for\u00e7a de preens\u00e3o de 385 pacientes card\u00edacos cong\u00eanitos com idade m\u00e9dia de 27,6 anos com controles saud\u00e1veis. Os dados obtidos neste estudo revelaram que a for\u00e7a de preens\u00e3o foi afetada pelo tipo e gravidade da doen\u00e7a, procedimentos cir\u00fargicos e intervencionistas anteriores, defeitos residuais e cianose.41Foi relatado que a for\u00e7a de preens\u00e3o manual \u00e9 um bom indicador da for\u00e7a muscular perif\u00e9rica, bem como da sobrevida na popula\u00e7\u00e3o em geral.13 No entanto, embora interven\u00e7\u00f5es cir\u00fargicas sejam frequentemente realizadas em crian\u00e7as com CC moderada e grave, estudos que avaliam a postura s\u00e3o muito limitados.14 Nosso estudo \u00e9 um dos raros exemplos que mostram deteriora\u00e7\u00e3o da postura na CC. A causa do dist\u00farbio pode ser devido \u00e0 diminui\u00e7\u00e3o da resist\u00eancia e flexibilidade muscular ou por procedimentos cir\u00fargicos pr\u00e9vios. Novas pesquisas, incluindo avalia\u00e7\u00f5es posturais est\u00e1ticas e tridimensionais em pacientes com CC, orientar\u00e3o as pr\u00e1ticas de exerc\u00edcios a serem adicionadas ao conte\u00fado dos programas de fisioterapia.Estudos da literatura relatam que escoliose e deformidades cif\u00f3ticas frequentemente se desenvolvem em crian\u00e7as com CC submetidas a esternotomia mediana.10 Embora existam diferen\u00e7as entre os estudos, a maioria deles, especialmente aqueles que usam m\u00e9todos de medi\u00e7\u00e3o objetivos, relataram que crian\u00e7as com CC apresentam n\u00edveis de atividade f\u00edsica semelhantes aos de seus pares saud\u00e1veis.9 Al\u00e9m disso, foi relatado que indiv\u00edduos com CC de gravidade diferente entre as idades de 8 a 19 anos apresentam n\u00edveis de atividade f\u00edsica semelhantes aos controles saud\u00e1veis, independentemente da gravidade da doen\u00e7a.7 Em nosso estudo, enquanto o grupo controle realizou uma m\u00e9dia de 7.455 (mediana de 6.566) passos di\u00e1rios, o grupo CC deu 6.825 (mediana 5.909) passos, e os n\u00edveis de atividade f\u00edsica dos dois grupos foram semelhantes. Embora a princ\u00edpio possa parecer promissor que crian\u00e7as com CC tenham n\u00edveis de atividade f\u00edsica semelhantes aos de seus pares saud\u00e1veis, \u00e9 preocupante que crian\u00e7as na popula\u00e7\u00e3o em geral tenham baixos n\u00edveis de atividade f\u00edsica. O v\u00edcio em jogos de computador, o avan\u00e7o da tecnologia e a transfer\u00eancia dos ambientes sociais infantis para o mundo virtual est\u00e3o entre os fatores que levam as crian\u00e7as a uma vida mais sedent\u00e1ria. Al\u00e9m disso, o per\u00edodo coincidente de nosso estudo com a pandemia da COVID-19 ocasionou a restri\u00e7\u00e3o de atividades f\u00edsicas de todos os indiv\u00edduos. No Canad\u00e1, observou-se uma diminui\u00e7\u00e3o de 21-24% na contagem di\u00e1ria de passos de crian\u00e7as com CC na fase inicial da pandemia de COVID-19, e a raz\u00e3o para esta diminui\u00e7\u00e3o foram as medidas contra a COVID-19.42 Considerando que a diminui\u00e7\u00e3o da atividade f\u00edsica e o sedentarismo est\u00e3o associados a todas as causas de mortalidade, medidas globais devem ser tomadas a esse respeito.Os resultados de estudos relacionados aos n\u00edveis de atividade f\u00edsica de crian\u00e7as com CC em compara\u00e7\u00e3o com seus pares saud\u00e1veis s\u00e3o contradit\u00f3rios. O fato de os resultados dos estudos serem diferentes pode ser devido ao resultado da escolha de diferentes m\u00e9todos para avaliar a atividade f\u00edsica. Estudos usando question\u00e1rios de atividade f\u00edsica relatados por crian\u00e7as e seus pais mostram que os n\u00edveis de atividade f\u00edsica de crian\u00e7as com CC s\u00e3o mais baixos do que seus pares saud\u00e1veis.15 Os baixos escores de funcionamento f\u00edsico relatados por crian\u00e7as e seus pais em pacientes com CC refletem as limita\u00e7\u00f5es f\u00edsicas que enfrentam devido ao comprometimento de seus sistemas cardiovasculares. Al\u00e9m disso, o fato de os escores de qualidade de vida relatados pelos pais em nosso grupo CC terem sido menores do que aqueles relatados pelas crian\u00e7as provavelmente se deve \u00e0 atitude superprotetora dos pais em rela\u00e7\u00e3o \u00e0 doen\u00e7a de seus filhos. Mais estudos s\u00e3o necess\u00e1rios para explicar essa situa\u00e7\u00e3o.Nosso estudo determinou que houve uma diminui\u00e7\u00e3o na qualidade de vida do grupo CC de acordo com os escores totais da escala de qualidade de vida relatados por crian\u00e7as e seus pais. Os resultados do nosso estudo s\u00e3o bastante consistentes com os resultados do estudo em que 1.138 crian\u00e7as e adolescentes com CC entre 8 e 18 anos de idade, com diferentes gravidades da doen\u00e7a, foram avaliados com o PedsQL.A limita\u00e7\u00e3o do nosso estudo \u00e9 que o per\u00edodo em que trabalhamos coincidiu com a pandemia da COVID-19 e medidas que afetam todos os indiv\u00edduos foram tomadas. Estudos futuros devem examinar os n\u00edveis de atividade f\u00edsica das crian\u00e7as e de quais par\u00e2metros eles dependem.O desempenho das atividades de vida di\u00e1ria, a capacidade funcional, a aptid\u00e3o f\u00edsica, a for\u00e7a de preens\u00e3o manual, a postura e a qualidade de vida de crian\u00e7as com CC moderada e grave diminu\u00edram em compara\u00e7\u00e3o com seus pares saud\u00e1veis. Crian\u00e7as com CC devem ser encaminhadas para programas de reabilita\u00e7\u00e3o para melhorar seu desempenho f\u00edsico reduzido. Avalia\u00e7\u00f5es de atividades de vida di\u00e1ria, da capacidade funcional, da aptid\u00e3o f\u00edsica, da for\u00e7a muscular, da postura, da atividade f\u00edsica e da qualidade de vida s\u00e3o fundamentais e orientam a cria\u00e7\u00e3o de programas de reabilita\u00e7\u00e3o para essa popula\u00e7\u00e3o pedi\u00e1trica. 3Congenital heart diseases cover a wide range from minor cardiac defects that are not noticed until adulthood or are detected during vigorous exercise, to serious cardiovascular malformations that can be life-threatening. Studies have documented decreases in functional capacity, motor skills, and peripheral muscle strength in children with complex CHD due to multifactorial causes such as cyanosis, increased pulmonary circulation, cardiac interventions, and multiple diagnoses.4 While very few studies evaluate physical fitness in children with CHD,6 physical activity levels differ between studies.10Physical fitness and physical activity levels are important predictors of cardiovascular health. Improved physical fitness in the early stages of life is associated with a healthier cardiovascular profile in adulthood.11 Additionally, cardiovascular endurance, muscular endurance, muscle strength, flexibility, and body composition, which are physical fitness parameters, are necessary components to create the ideal posture. Studies in the literature have shown that scoliosis and kyphotic deformities often develop after median sternotomies have been performed on children with CHD.13 However, although surgical interventions are frequently performed on children with moderate and severe CHD, studies evaluating posture are very limited.14Low levels of physical activity and a sedentary lifestyle have been reported to be associated with postural defects.16Developments in the healthcare sector have increased the life expectancy of individuals with CHD and, therefore, the importance of quality of life has also increased. Studies evaluating health-related quality of life in patients with CHD emphasize that especially physical health-related quality of life decreases due to disease severity and surgical interventions in these individuals compared to healthy individuals.17 However, in this study, only a questionnaire was used instead of a performance test specific to the ADL assessment. For all these reasons, our study aimed at comparing the activities of daily living, quality of life, posture, physical fitness, and physical activity levels among children with CHD and healthy children (HC).Decreased functional capacity and physical fitness can affect activities of daily living. There is a study evaluating activities of daily living (ADL) in children with complex CHD.We conducted a case-control study on children with CHD. The study protocol was accepted by Dokuz Eyl\u00fcl University Non-Interventional Research Ethics Committee with the approval number 2020/29-58 on 07/12/2020. It was held between November 2020 and May 2022 at Dokuz Eyl\u00fcl University Hospital, Department of Pediatrics, Division of Pediatric Cardiology. Written informed consent was obtained from all participants and their guardians.18 diagnosed with moderate or severe CHD . Using the study of Warnes et al.,19 we identified the children with moderate to severe CHD that we included in our study and excluded isolated minor cardiac defects that did not require surgical intervention. Orthopedic or neurological problems affecting the tests, mental or psychological problems, acute infection or general fatigue, cardiac surgery within the last six months, and refusal to participate in the study were determined as exclusion criteria. Healthy controls were selected from healthy individuals who applied to the Department of Pediatrics at Dokuz Eylul University Hospital and had not been diagnosed with any disease. Thirty healthy volunteer children of similar age and sex, non-athletes, were included in the study.The CHD group included 30 children with stable clinical status, aged 6-14,18The TGlittre-P test is the pediatric version of the original Glittre-ADL test developed to evaluate individuals\u2019 activities of daily living. It was found valid and reliable in healthy children aged 6-14.18 weighing between 0.5 kg and 2.5 kg, determined according to age and sex. It was initiated when the child got up from a chair with the soles of their feet touching the ground. Then, they walked for 5 m, went up and down two flights of stairs (17 cm high and 27 cm wide), and walked for another 5 m. Three colored bowling pins that weigh 0.5 kg were removed one by one from the shelf, adjusted at eye level by the child, and were placed back on the shelf while being adjusted according to the umbilicus level, then on the floor, then on the shelf at the level of the umbilicus, and finally back on the shelf at eye level. Returning from the same route and sitting on the chair, the tour ended, and the next tour started immediately. During the five rounds, the children moved the bowling pins with their chosen hand while a pulse oximeter device was attached to the other hand\u2019s index finger. During the test, children were given standard voice instructions such as \u201csit,\u201d \u201cstand up,\u201d and \u201ckeep going.\u201d The expected test time developed by Martins et al.20 was calculated and compared with the test performance data of the children.The physiotherapist explained the test to each child, showed it, and asked them to try it. This performance test required the child to complete five laps in the shortest amount of time while carrying a backpack,21 was calculated, and the test performance data of the children were compared and evaluated.The 6-minute walk test was used to evaluate functional exercise capacity. The children were asked to walk as fast as they could down a 30 m-long corridor, using the standard words \u201cyou\u2019re doing very well\u201d and \u201ckeep going\u201d at the end of each minute. Before and after the test, the heart rate, peripheral oxygen saturation, and distance walked were recorded. In addition, the expected distance walked reported by Geiger et al.23 test battery were used to evaluate children\u2019s physical fitness. The maximum number of repetitions correctly completed was measured for the sit-ups and push-ups tests. The distance in the test position was measured and recorded in centimeters for the trunk lift and sit-and-reach tests.Sit-ups, push-ups, trunk lift and sit-and-reach tests within the Fitnessgram24 The children were seated in an upright position. They were asked to squeeze the hand dynamometer with their maximum strength, with the elbow in 90\u00b0 flexion, the arm close to the body, and the wrist in the neutral position. Measurements were repeated three times for the right and left hands, with an interval of 15 seconds, and the highest values were recorded in kilograms.Hand grip strength was evaluated using the Jamar hand dynamometer .25 was used to determine postural disorders. The form is based on identifying postural disorders with posterior and lateral observation and scoring them according to severity . It also allows us to classify the postural status according to the total score. Evaluations were made in the standing position without shoes and wearing a thin, comfortable dress suitable for the assessment of posture, and the determined findings were recorded.The postural analysis form of Corbin et al.26 The devices were used to record the children\u2019s normal stride lengths and body weights. Pedometers were attached to their clothes by determining the projection of the kneecap\u2019s midpoint to the pelvis\u2019s anterior surface. The children were asked to use the pedometer continuously for seven days, except for bathing and sleeping hours. After seven days of use, a one-day average step count was calculated.Children\u2019s physical activity levels were evaluated using a pedometer .27 Higher scores indicate a better health-related quality of life for the child. The PedsQL 4.0 Generic Core Scales,27 5-7, 8-12 and 13-18 age child and parent forms were used in our study. The total scale score, physical functionality score, and psychosocial health score consisting of emotional, social, and school functionality scores were calculated.PedsQL is a 23-item scale including physical, emotional, social and school functionality.It was explained to the children that they should say if they felt dizzy, palpitations, chest pain, difficulty breathing or excessive fatigue during all the tests. They could rest and continue or finish the test if necessary.28 It was calculated that 36 participants, including at least 18 children in each group, should be included in the study, with a calculated effect size of 0.97, an alpha error probability of 0.05, and a power of 80%.Based on the study comparing the TGlittre-ADL test in chronic obstructive pulmonary patients and healthy controls, the smallest sample size was calculated using the G*Power 3.1 program.U test was used to compare the differences between groups for conditions that did not conform to the normal distribution. A t-test for independent groups was used to compare the differences between groups for conditions that conformed to the normal distribution. Categorical variables were expressed as absolute values and percentages. Continuous variables with normal distribution were expressed as mean and standard deviation, and continuous variables with non-normal distribution were expressed as median and interquartile range. Values of p < 0.05 were considered statistically significant.IBM SPSS Statistics (Version 26.0) program was used to analyze the data obtained from the participants. Kurtosis/skewness values, Shapiro-Wilk tests, detrended normal Q-Q plot, and histogram graphs were used to determine the conformity of the variables to the normal distribution. The difference between categorical variables was analyzed by the Chi-square test. The Mann-Whitney The demographic characteristics of the participants are shown in The clinical characteristics of the CHD group are shown in 29 in the TGlittre-P and 6MWT tests. Of these children, 10 had cyanotic CHD, and 1 had mitral atresia, all of whom had undergone surgery. There was a significant difference between the groups in sit-ups, push-ups, trunk lifts and sit-and-reach tests. There was a significant difference between the groups in dominant and non-dominant hand grip strengths. There was a significant difference between the posture scores of the two groups. There was no significant difference between the physical activity levels of the two groups. Quality of life scores assessed by PedsQL were significantly higher in the control group than in the CHD group in both the child and parent forms.Comparisons of the CHD group and healthy controls are shown in Our study showed that the activities of daily living, functional capacity, hand grip strength, physical fitness, and quality of life of children with CHD decreased compared to HC\u2019s. They also had worse posture than HC, but their physical activity levels were similar.30 Consistent with our study, in a study by Feldt et al.,31 it was shown that children with CHD had lower body weights, shorter heights, and weights affected more by their height than healthy children.The CHD group\u2019s body weights and body mass indexes were significantly lower than the HC\u2019s. Congenital heart diseases are associated with delayed growth and development due to increased energy requirements and respiratory workload, hypoxia that makes food intake difficult, malnutrition and malabsorption.While 27 children in our CHD group had previous cardiac surgery, three had no surgical intervention. Including three patients who had not undergone cardiac surgery in our study may have improved the performance of the CHD group, as cardiac interventions have been reported to be associated with worse physical performance.17In our study, we used the TGlittre-P test, a different evaluation method, and obtained similar results. Using the ADL Taxonomy, children are assessed based on their ability to perform 11 activities, including eating and drinking, mobility, going to the toilet, dressing, personal hygiene, personal care, communication, transportation, shopping, and cleaning, but their daily life performance cannot be evaluated. Our study is the first to evaluate activities of daily living in children with complex CHD and to use the TGlittre-P test, which is an exercise test.In a study examining the activities of daily living of patients with complex CHD, the ADL Taxonomy was used, and it was reported that the ADLs of these children were significantly lower.32 The shorter the test completion time, the better the individual\u2019s daily living performance. Martins et al.18 modified the original Glittre-ADL test for children and showed that the TGlittre-P test was valid and reliable for HC aged 6-14.18 In studies conducted in different disease groups, it has been reported that the test completion time of patients is longer compared to healthy controls.34 Scalo et al.35 reported that children with cystic fibrosis completed the test longer than healthy controls, but there was no statistical difference. Fernandes-Andrade et al.36 evaluated the Glittre-ADL test in patients aged between 18-80 years with cardiovascular disease, and individuals completed the test in an average of 3.24 min. In our study, while the control group completed the TGlittre-P test in 3.10 minutes, children with moderate and severe CHD completed the TGlittre-P test in a longer time (3.45 min) than the healthy children. At the end of the TGlittre-P test, the control group reached 69.14% of the maximum heart rate and completed the test at the submaximal level. The CHD group, on the other hand, reached 53.60% of the maximal heart rate and completed the test below the submaximal heart rate level. Additionally, in the 6MWT, a submaximal field test that we evaluated in our study, it was observed that the maximum heart rate of the CHD group reached 53.11%, similar to the TGlittre-P test, and the submaximal heart rate remained below the level. These two results support each other and can be explained by the insufficient chronotropic responses of children with CHD. Small heart size in children results in lower stroke volume. For this reason, children primarily increase their cardiac output by increasing their heart rate to meet the increased oxygen demand during exercise. However, parasympathetic and sympathetic nervous system activity, which plays an important role in heart rate regulation in children with CHD, may be affected by septal defects, surgical procedures and ischemia-induced conditions. As a result, the inability to increase the heart rate against the increased metabolic demand, that is, chronotropic insufficiency occurs.1 In our study, the desaturation observed in 11 children in the CHD group in the TGlittre-P and 6MWT tests indicates that these children could not regulate the increase in metabolic demand in their activities of daily living. Due to the existing pathology, this situation is particularly evident in children with cyanotic CHD. In addition, the completion time of the CHD group in the TGlittre-P test was 22.67% longer than expected, and the completion time of the control group was found to be 4.88% longer than expected in our study (expected mean test completion time of 2.84 min). The fact that the activities of daily living of children with CHD are lower than both the expected and control groups is a result of the inability of these children to raise their heart rates sufficiently.The original Glittre-ADL test is a submaximal test developed to evaluate the activities  that individuals with COPD frequently repeat in their daily living.1 In our study, similar to the literature, it was shown that there was a decrease in functional capacity, evaluated by the 6MWT distance, in patients with CHD.According to our study, the 6MWT distance was significantly shorter in the CHD group than in the HC. In the literature, it has been stated that CHD is associated with lower functional capacity in children and adolescents compared to their healthy peers and is affected by impaired chronotropic response.6 In a study by Hock et al.,3 children and adolescents who had undergone total cavopulmonary shunt surgery were evaluated using the Fitnessgram test battery, and it was reported that these children had decreased abdominal muscle endurance and flexibility compared to HC. We also obtained similar results in our study. Decreased flexibility and muscle endurance in children with CHD may be caused by multifactorial reasons such as previous cardiac surgeries, the severity of the disease affecting the child\u2019s daily physical activities and skills, parental overprotection, physicians\u2019 recommendations for activity restriction, and the child\u2019s sense of self-insufficiency in physical activity.37 In addition to all these reasons, it was reported in a study that adolescents with complex congenital heart disease with low BMI had lower physical fitness.38 In our study, one of the factors causing decreased physical fitness in the CHD group may be low BMI. Physical fitness is very important in the evaluation and treatment of these patients; the limited number of studies is not enough to illuminate this issue, and more studies are needed in the future.Although it is known that congenital heart diseases affect motor skills, very few studies evaluate these children\u2019s health-related physical fitness. These studies reported that physical fitness was not affected in children with low disease severity, and it decreased significantly as the disease severity increased.39 According to two studies conducted on patients with mild and moderate CHD, grip strength was similar to that of healthy controls.40 The grip strength of our group consisting of moderate and severe CHD cases decreased. Consistent with our results, in the study conducted by Holm et al.,2 it was found that the grip strength was decreased in complex congenital heart patients aged 7-12. In addition, similar results were reported in a comprehensive study comparing the grip strengths of 385 congenital heart patients with a mean age of 27.6 years with healthy controls. The data obtained from this study revealed that grip strength was affected by the type and severity of the disease, previous surgical and interventional procedures, residual defects and cyanosis.41It has been reported that hand grip strength is a good indicator of peripheral muscle strength as well as survival in the general population.13 However, although surgical interventions are frequently performed on children with moderate and severe CHD, studies evaluating posture are very limited.14 Our study is one of the rare studies showing deterioration of posture in CHD. The cause of the disorder may be due to decreased muscle endurance and flexibility or previous surgical procedures. Further research, including static and three-dimensional posture assessments in patients with CHD, will guide the exercise practices to be added to the content of physiotherapy programs.Studies in the literature report that scoliosis and kyphotic deformities often develop in children with CHD who underwent median sternotomy.10 Although there are differences between studies, most of them, especially those using objective measurement methods, have reported that children with CHD have similar physical activity levels to their healthy peers.9 In addition, it has been reported that individuals with CHD of different severity between ages 8-19 have similar physical activity levels to healthy controls, regardless of disease severity.7 In our study, while the control group took an average of 7455 (median 6566) daily steps, the CHD group took 6825 (median 5909) steps, and the physical activity levels of the two groups were found to be similar. Although it may seem promising at first that children with CHD have similar levels of physical activity as their healthy peers, it is worrisome that children in the general population have low levels of physical activity. Computer game addictions, the development of technology, and the transfer of children\u2019s social environments to the virtual world are among the factors that lead children to a sedentary life. In addition, the coinciding period of our study with the Covid-19 pandemic caused the restriction of physical activities of all individuals. In Canada, it was stated that there was a 21-24% decrease in the daily step count of children with CHD in the early phase of the Covid-19 pandemic, and the reason for this decrease was due to Covid-19 measures.42 Considering that decreased physical activity and sedentary life are associated with all causes of mortality, global measures should be taken in this regard.Results of studies related to physical activity levels of children with CHD compared to their healthy peers are contradictory. The fact that the results of the studies are different may be due to the result of choosing different methods to evaluate physical activity. Studies using physical activity questionnaires reported by children and their parents show that the physical activity levels of children with CHD are lower than their healthy peers.15 The low physical functioning scores reported by both children and their parents in patients with CHD reflect the physical limitations they face due to their impaired cardiovascular systems. In addition, the fact that the quality of life scores reported by the parents in our CHD group was lower than that reported by the children is likely due to the parents\u2019 overprotective attitude against their child\u2019s disease. Further studies are needed to explain this situation.Our study determined that there was a decrease in the quality of life of the CHD group according to the total quality of life scale scores reported by both children and their parents. The results of our study are quite consistent with the results of the study in which 1138 children and adolescents with CHD between ages 8-18 with different disease severity were evaluated with PedsQL.The limitation of our study is that the period we are working on overlaps with the Covid-19 pandemic, and measures that affect all individuals have been taken. Future studies should examine children\u2019s physical activity levels and what parameters it depends on.The performance of activities of daily living, functional capacity, physical fitness, hand grip strength, posture, and quality of life of children with moderate and severe CHD decreased compared to their healthy peers. Children with CHD should be referred to rehabilitation programs to improve their reduced physical performance. Assessments for activities of daily living, functional capacity, physical fitness, muscle strength, posture, physical activity, and quality of life are very important and guide the creation of rehabilitation programs for these children."}
+{"text": "Critical Epidemiology and the People\u2019s Health [Epidemiologia Cr\u00edtica e aSa\u00fade das Pessoas] Small Books, Big Ideas inPopulation Health ,organizada por Nancy Krieger para a Oxford University Press. Essa cole\u00e7\u00e3o conta aindacom outras duas obras. Trata-se de uma iniciativa editorial importante e estrat\u00e9gica dedivulga\u00e7\u00e3o da epidemiologia cr\u00edtica latino-americana para leitores de l\u00edngua inglesa. Olivro foi publicado originalmente em ingl\u00eas antes mesmo da edi\u00e7\u00e3o em espanhol. Aepidemiologia cr\u00edtica emergiu nos anos 1970 no interior do movimento da medicina sociallatino-americana e um de seus principais formuladores e autores \u00e9 o professor JaimeBreilh. Protagonista de uma rica trajet\u00f3ria acad\u00eamico-pol\u00edtica de mais de 50 anos,Breilh desenvolveu novos conceitos e instrumentos de investiga\u00e7\u00e3o buscando decifrar asrela\u00e7\u00f5es entre sa\u00fade e sociedade. A epidemiologia cr\u00edtica vem se consolidando em um novoparadigma, distinto e alternativo aos preceitos da epidemiologia cl\u00e1ssica. Sua principalcategoria de an\u00e1lise \u00e9 a determina\u00e7\u00e3o social da sa\u00fade (DSS). Esse novo livro apresentauma s\u00edntese e reflex\u00e3o cr\u00edtica desses v\u00e1rios momentos percorridos pelo autor e pelaepidemiologia cr\u00edtica, em que se percebe o caminhar de um robusto e dial\u00e9tico processode constru\u00e7\u00e3o-desconstru\u00e7\u00e3o-reconstru\u00e7\u00e3o s\u00f3cio-te\u00f3rico-metodol\u00f3gico.A obra em quest\u00e3o \u00e9 constitu\u00edda por quatro grandes partes e conta com expressivo e ricoconte\u00fado de refer\u00eancias, al\u00e9m de um providencial e amig\u00e1vel \u00edndex, para o deleite do(a)leitor(a).um ato de buscaintelectual cr\u00edtica compassiva e de resist\u00eancia audaciosa para se confrontar com ummundo doente\u201d (p. 1). Como \u00e9 caracter\u00edstico do autor, ficam explicitadosseus movimentos, sua postura, sua vis\u00e3o cr\u00edtica de mundo e alguns de seus valores. S\u00e3omencionados os limites do conhecimento, as rupturas e revolu\u00e7\u00f5escient\u00edfico-epistemol\u00f3gicas, as rela\u00e7\u00f5es n\u00e3o neutras das ci\u00eancias com as sociedades e acomplexidade do mundo contempor\u00e2neo sob a \u00e9gide do neoliberalismo. Al\u00e9m disso, realizauma cr\u00edtica \u00e0 epidemiologia cartesiana e prop\u00f5e formas alternativas te\u00f3rico-pr\u00e1ticas nadire\u00e7\u00e3o de uma epidemiologia cr\u00edtica. Essas quest\u00f5es s\u00e3o desenvolvidas e aprofundadas aolongo dos demais cap\u00edtulos do livro. Frisa-se tamb\u00e9m que al\u00e9m da profundidade ecomplexidade de pensamento e conte\u00fado, a forma pedag\u00f3gica da exposi\u00e7\u00e3o \u00e9 enriquecida comdiversos quadros, tabelas e figuras que facilitam o entendimento do(a) leitor(a).Na introdu\u00e7\u00e3o, Breilh apresenta a epidemiologia cr\u00edtica como \u201cO cap\u00edtulo 1 \u00e9 uma bela e did\u00e1tica reconstru\u00e7\u00e3o/reflex\u00e3o do movimento acad\u00eamico-social dasa\u00fade coletiva latino-americana desde seus prim\u00f3rdios at\u00e9 os anos recentes. Nele, Breilhmapeia e historiciza as origens, os contextos sociais, pol\u00edticos, culturais ecient\u00edficos, os principais autores e os conceitos centrais que deram formato epossibilitaram o processo de desenvolvimento da medicina social/sa\u00fade coletiva naregi\u00e3o. O autor identifica quatro momentos hist\u00f3ricos: nos anos 1970, um enfrentamentoao empirismo causal e ao funcionalismo; nos anos 1980, uma diversifica\u00e7\u00e3o de m\u00e9todos einstrumentos de pesquisa; nos anos 1990, uma \u00eanfase na transdisciplinaridade; e nos anos2000, um movimento rumo \u00e0 metacr\u00edtica intercultural. \u00c0s quest\u00f5es sociais, econ\u00f4micas epol\u00edticas s\u00e3o incorporados ao longo do tempo os temas ambientais, de g\u00eanero, de ra\u00e7a, decoloniza\u00e7\u00e3o e dos povos origin\u00e1rios.fake news. Do ponto de vista epidemiol\u00f3gico, o autor destaca o quese conhece por transi\u00e7\u00e3o epidemiol\u00f3gica incompleta, coexistindo doen\u00e7as comuns empopula\u00e7\u00f5es em situa\u00e7\u00e3o de vulnerabilidade extrema (desnutri\u00e7\u00e3o e agravosinfectoparasit\u00e1rios) com doen\u00e7as de sociedades industriais modernas . Breilh questiona o papel da ci\u00eancia edos cientistas e advoga uma transforma\u00e7\u00e3o audaciosa na \u00e1rea da sa\u00fade e nas ci\u00eancias davida e, mais uma vez, explicita as distin\u00e7\u00f5es entre os paradigmas cartesiano e cr\u00edtico.Discute, ainda, as diferen\u00e7as entre determina\u00e7\u00e3o social e determinismo; reforma radicale reformismo institucional; modo de vida e estilo de vida; bem-estar, bem viver e viverbem; e apresenta os princ\u00edpios do bem viver ou os quatro \u201cS\u201d da vida: sustentabilidade,soberania, solidariedade e seguridade.O cap\u00edtulo 2 retrata a epidemiologia cr\u00edtica como ci\u00eancia ousada e \u00e9tica na busca porcompreender uma civiliza\u00e7\u00e3o doentia. Breilh destaca as grandes mudan\u00e7as decorrentes deum novo est\u00e1gio do capitalismo neoliberal no s\u00e9culo XXI, caracterizado por umahiperacelera\u00e7\u00e3o do capital, com grande concentra\u00e7\u00e3o de renda, desigualdade social,aumento da precariza\u00e7\u00e3o do trabalho, informalidade e perda de direitos trabalhistas,al\u00e9m de graves amea\u00e7as autorit\u00e1rias \u00e0s democracias. Esse macrocen\u00e1rio \u00e9 detalhado nocap\u00edtulo 2, com seus impactos epidemiol\u00f3gicos, sanit\u00e1rios, sociais, ideol\u00f3gicos,ambientais, \u00e9ticos e culturais na sa\u00fade e nos sistemas de sa\u00fade. Os \u201cdeuses\u201d mercado,tecnologia, m\u00eddia, consumismo e individualismo s\u00e3o elevados e refor\u00e7ados comO cap\u00edtulo 3 prop\u00f5e uma inovadora matriz-ferramenta de an\u00e1lise e interven\u00e7\u00e3o, queconsidera o processo hist\u00f3rico-cr\u00edtico complexo de subsun\u00e7\u00e3o que incorpora as dimens\u00f5esgeral , particular  e individual , em um movimento dial\u00e9tico, n\u00e3odetermin\u00edstico, gerando processos protetores e destrutivos para a sa\u00fade e a vida. Breilhdefende uma nova interpreta\u00e7\u00e3o, que combina desenhos de pesquisa, m\u00e9todos quantitativose qualitativos, em uma perspectiva transdisciplinar, intercultural, ecol\u00f3gica,participativa, decolonial e emancipat\u00f3ria. Essa constru\u00e7\u00e3o te\u00f3rico-metodol\u00f3gica \u00e9chamada de metacr\u00edtica e envolve diversos grupos e movimentos sociais, como sindicatosde trabalhadores, feministas, grupos \u00e9tnicos, indigenistas, ambientalistas, equipes dedefesa dos consumidores, associa\u00e7\u00f5es comunit\u00e1rias, entre outros. O autor concluicriticando o tradicional modelo de vigil\u00e2ncia epidemiol\u00f3gica cartesiana e prop\u00f5e omonitoramento participativo (baseado na DSS e incorporando o princ\u00edpio da precau\u00e7\u00e3o),al\u00e9m de alertar sobre a import\u00e2ncia da universidade nos processos de repensar e deemancipa\u00e7\u00e3o social.,Todavia, o paradigma da DSS n\u00e3o \u00e9 consenso, inclusive no interior da sa\u00fade coletivalatino-americana. Atestando essa afirmativa, em 2021, foi publicado um instigante,provocativo, rico e caloroso debate sobre o tema por CSP entre renomados autores apartir de um texto de Minayo Lancet por Horton A constru\u00e7\u00e3o da DSS \u00e9 um processo hist\u00f3rico e se enriquece com esse pequeno/grande livrode Breilh, valioso e imprescind\u00edvel para os estudiosos e militantes da sa\u00fade coletiva eda epidemiologia, em particular para os inseridos na academia, nos servi\u00e7os de sa\u00fade enos movimentos sociais. Por certo contribuir\u00e1 muito para reflex\u00e3o e aprimoramento dapr\u00e1xis em sa\u00fade. \u00c9 uma obra de relevante conte\u00fado cient\u00edfico-social, citada recentementena"}
+{"text": "To depict the influence of discretionary actions exercised by frontline professionals and organizations on the implementation of diverse modalities of access to specialized dental care within the Care Network for Persons with Disabilities. A case study conducted in two Brazilian health regions characterized by distinct means of access to specialized dental care employing documentary analysis and interviews with key stakeholders across the period spanning from July to December 2019. In the referenced access region, there was a notable centrality of Primary Health Care (PHC) in caregiving, wherein planning and assessment were integral components of institutional routines. Where spontaneous demand scheduling was accepted, sporadic exchanges of information were evident between PHC units and specialized facilities. The coordination role in caregiving was not vested in PHC teams, and activities such as planning and assessment were not assimilated into organizational routines. The implementation of policies for specialized dental care for persons with disabilities relied on the coordination furnished by PHC and the orchestration of planning and assessment endeavors aimed at establishing an integrated care network. This implementation proved subject to the discretionary authority of frontline professionals and organizations, highlighting the significant role of relational and institutional environments in the context of public policy implementation within a decentralized and regionalized healthcare system. The implementation of health policies has become contingent upon diverse organizations and a multitude of public-private agreements at the local level. Within this context, discretion\u2014a pivotal concept in the theory of street-level bureaucracy2\u2014, has been scrutinized across various governing dimensions of decision-making, encompassing ethical values, rules, normative provisions, as well as professional and organizational aspects that translate into the expected roles of frontline professionals and organizations3.Over the past three decades, several strategies of decentralization and regionalization of healthcare services have gained traction2.The ways in which frontline organizations/professionals provide benefits and sanctions contribute to shaping and circumscribing individuals\u2019 lives, either by broadening or restricting opportunities. Enlisted as public utility services providers and public policy implementers, frontline professionals, along with the organizations dependent upon their operational costs, often find themselves at the strained core between the demands of service recipients seeking greater effectiveness and responsiveness, and the expectations of citizens, urging for heightened efficiency and efficacy from the organizations tasked with provisioning public services4. While the exercise of political discretion may weaken or bolster the general interest and legitimacy of a program, administrative discretion is perceived as a spectrum of choices existing within a set of parameters delineated through organizational rules. Frontline organizations/professionals utilize their discretion to form arrangements blending different dimensions aimed at attaining politically and socially desired outcomes within a legitimately defined direction. These arrangements could elucidate disparities in the frontline implementation of public policy3. Such arrangements are not solely born from interpersonal interactions but can result from the interplay of a network comprising diverse professionals and frontline organizations operating either in isolation or collaboratively5.Agents\u2019 discretion in the process of implementing a given public policy may vary in scope, contingent upon the degree of policy structure/detail and the comprehensiveness and ambiguity of rules upheld within the organizations where they belong6, as well as the role of street-level bureaucrats in executing the policy of water fluoridation at public supply plants in small Brazilian municipalities7. Studies investigating the discretion of street-level bureaucracy in the implementation of redes de aten\u00e7\u00e3o \u00e0 sa\u00fade  remain largely unexplored, making it opportune to investigate specialized dental care access within the framework of the Care Network for Persons with Disabilities (Rede de Cuidados \u00e0 Pessoa com Defici\u00eancia \u2013 RCPD). Access can be defined by the various strategies adopted by organizations to facilitate users\u2019 utilization of needed services8.The Brazilian literature lacks works that incorporate analytical models of health policy implementation and street-level bureaucracy. Some studies delve into the discretionary power of community health agents in implementing primary care policy actionsPol\u00edtica Nacional da Pessoa com Defici\u00eancia \u2013 PNPD) and the National Oral Health Policy  in Brazil propelled the integration of basic dental care structures, with oral health teams working in the primary health care (PHC) network, as well as specialized care, via dental specialty centers (DSC), to provide more complex ambulatory treatments for all in need, including persons with disabilities (PwD)9.In the first decade of the 21st century, the enactment of the National Policy for Persons with Disabilities  in 2012, stimulates intergovernmental coordination to ensure the access of PwD to various specialized treatments, via regional agreements and governance involving state/municipal authorities of a specific health region. Safeguarding the right to dental treatment and comprehensive care is no simple task and calls for harmonious coordination among different points of care within the RCPD10, but no study has explored this contrasting situation. It is conceivable that the implementation of this public policy hinges on the actions of frontline professionals and organizations. Producing scientific information on the interplay between PHC and specialized services aimed at PwD could enhance the understanding of progress and challenges in the development of integrated healthcare networks.A study encompassing 930 DSCs revealed that 85% of the units were municipally managed and 10% of them did not provide care for PwD, despite it being mandatory. User access was referred by the PHC in just over half of the specialized units. A significant share (42.7%) allowed for the scheduling through spontaneous demandThis study aims to depict the role of frontline professionals and organizations concerning the PHC and planning/assessment activities to grasp the exercise of discretion in implementing different means of specialized dental care access in the RCPD across two Brazilian health regions.11 was conducted in two regions with disparate access to specialized dental care. They were selected based on documentary data and interviews performed in a broader studya approved by the Research Ethics Committee Faculdade de Sa\u00fade P\u00fablica of Universidade de S\u00e10 Paulo, n\u00ba. 3,441,243.A case studyAccess to specialized care was referenced in the healthcare region of S\u00e3o Jos\u00e9 do Rio Preto (Region A), while access was mixed in Salvador (Region B). In Region B, a significant share of users accessed the specialized unit freely without the need for formal referral, subject to its own rules.12, they were classified as regions with high socioeconomic status, as well as a high supply and complexity of health services. Moreover, both regions had specialized rehabilitation centers (SRC), dental specialty centers, municipal and/or philanthropic specialty services with rehabilitation actions for users , and educational institutions .The two regions were intentionally chosen due to their similar socioeconomic characteristics and services provided. In a typology conducted by Viana et al.Data collection took place between July and December 2019 and was conducted by trained professionals. Five specialized dental care units for PwD and four primary care units under municipal management in the two regions agreed to participate in the research. Of the five specialized units, four were municipally managed (one in Region A and three in Region B), and one was state-managed (Region B). Nine frontline professionals were interviewed, represented in this study by their managers, and considered key actors within the organizations. When a unit did not have a manager, the key informant was the dentist responsible for the care of PwD.Structured (questionnaires) and semi-structured (scripts) instruments were used for data collection. In this study, respondents\u2019 answers regarding the frequency of PwD access to specialized units through the PHC, the prioritization criteria adopted, challenges for the PHC to act as the main gateway to services, PHC initiatives to coordinate care, and the use of monitoring/assessment instruments, their frequency, and participating actors were analyzed.Comiss\u00e3o Intergestores Bipartite (CIB \u2013 Bipartite Intermanagement Committee) and Comiss\u00e3o Intergestores Regional , made publicly available or provided by service technicians. The selection of document excerpts was based on keywords identifying nuclei of meaning13 related to the following categories: type of access; attribute of PHC related to care coordination; planning, evaluation, and monitoring.Technical reports and minutes of collegial meetings regarding content related to the implementation of the Care Network for Persons with Disabilities at the local-regional level, spanning events from 1988 to 2019, were examined to identify normative provisions and aspects related to PHC organization and planning/assessment activities. To achieve this, decrees, laws, and regulations related to the topic were consulted on the institutional websites of the regions , technical reports produced within the health regions, and minutes of meetings of the 8.Access can be defined by the various strategies adopted by organizations to facilitate users\u2019 utilization of needed services. Care coordination refers to the clinical management of cases through the integration of actions and services provided by different units in the care network to meet users\u2019 health needs and aim to reorient the care model. Planning, evaluation, and monitoring concern specific guiding instruments and indicators for the frontline professionals\u2019 work process, as well as the quality of the provided actionsR1, ER2, and ER3 for Region A, and from ER4 to ER9 for Region B.The results are presented according to theme categories and regions. The discussions between different levels of government within the CIB on the management and organization of RCPD started at the end of 2011 in Region A, while in Region B, they were only added to the agenda in 2013. In Region A, where access to specialized dental care only occurred through formal requests issued by a service unit in the network, it was observed that this reference happened when the PHC dentist lacked the necessary conditions to provide adequate treatment. This was also the case in Region B, where access was both through open demand and referral. In this mixed type of access, users could enter freely, without the need for a formal request, and according to the specialized unit\u2019s own rules.Ambulat\u00f3rio M\u00e9dico de Especialidade \u2013 AME [Specialty Outpatient Clinics]), being responsible for referring users to specialized services. Access to specialized units located in the main municipality was through the PHC, obligatorily. Cases that did not follow this criterion were admitted for guidance and redirected to the PHC.The UBS was the preferred access point in Region A, to access other specialized rehabilitation services included in the RCPD  in Region A. This effort involved the expansion of the availability of sanitary transport and assistance offering for the use of regular buses.Excerpts from documents pointed out that ensuring RCPD accessibility was a recurring theme in meetings of the In Region B, there were specialized dental care units managed either by the state or municipalities. It was observed that professionals from the state-affiliated unit did not communicate or interact with dentists working in PHC and specialized units belonging to the municipal network. In practice, that service had an entry point following pre-established rules. On the other hand, the relevance of networking in Region A was recognized to enhance care for PwD and, consequently, RCPD .The cost of transportation means in Region B and how hearing-impaired PwD were admitted to specialized units in Region A were identified as potential access barriers to services. The main municipality in Region A had a professional interpreter of Libras (Brazilian Sign Language) in place, who acted as a translator during specialized dental consultations through prior scheduling.It was noticeable that UBSs were not the preferred access point for health services for users in Region B. Their role as care coordinators was weakened by the low potential for population coverage and the fragmentation of care, pointing to the significant challenge of integrating the PHC with other specialized services. During CIB meetings, strategies were proposed for the development of the State Plan, such as establishing care pathways, organizing the flow of services, enrolling family health teams with oral health expertise, and expanding the PHC. However, no changes were observed at the frontline. The counter-referral of users back to the PHC by specialized unit professionals in Region B also did not take place .The PHC played a central role in health care across Region A, being primarily responsible for the care for PwD. Professionals participated in matrix support on the subject, providing rehabilitation actions and managing to schedule timely rehabilitation appointments for referred users. The DSC\u2019s matrix support agenda with the PHC was planned annually through team meetings. The UBSs which carried out oral health care support in both regions also provided care for PwD. The more complex cases, such as non-collaborative users needing restraint or more individualized intervention, were referred to DSCs.Planning, evaluation, and monitoring of actions were not a part of the institutional service routine in Region B. As a consequence, the work process was neither monitored nor guided by any pre-established criteria. Only a few units held regular team meetings and monitored indicators. It should be noted that the State Plan of the RCPD envisaged the production, follow-up, and monitoring of information, as well as professional qualification, as a management qualification guideline .Planning, evaluation, and monitoring were part of the institutional routine of services in Region A, and some managers (such as the DSC\u2019s) developed their own instrument for evaluating and monitoring specific indicators regarding user satisfaction, number of restorative dental procedures, absenteeism proportion, percentage of completed treatments, number of extractions, and amount of PwD served in all specialties, among others. The meetings of the RCPD Steering Group also recognized the importance of both action evaluation and monitoring for the consolidation of the RCPD through the situational diagnosis , and the role of management in using action monitoring tools and sharing information in meetings with the entire team.This case study described the role of professionals and frontline organizations in understanding the exercise of discretion in implementing different forms of access to specialized dental care in the RCPD across two Brazilian health regions.The findings highlighted distinct characteristics regarding the PHC, planning, and evaluation activities, as well as the access strategy in place. The PHC played a care coordination role in Region A, where access took place through referral, and planning/evaluation were part of the institutional routine of services. In Region B, which worked with mixed access, there was the occasional information exchange between PHCs and specialized units, and the care coordination role was not attributed to the PHC teams. There, planning/evaluation activities were not incorporated into the organizational routine, as guided by PNSB, as each service decided, through its implementers, whether to conduct them or not.3.As a result, the exercise of discretion in the way user access was regulated in each region was closely related to the PHC\u2019s role within the care network and the characteristics of specialized units concerning planning/evaluation activities. The distinct outcomes of implementation found in this case study confirmed the idea that effective implementation is usually based on the references implementers embrace to perform their functions and corroborate the notion that the exercise of discretion encompasses different dimensions aimed at achieving politically and socially desired outcomes in a direction legitimately defined by the relational and institutional environment present in the local-regional context, emphasizing both the administrative and political dimensions3. This case study refers to the use of communication channels and shared flows with the help of protocols and other common instruments to promote coordination between PHC units and specialized dental services aspiring to achieve increasing levels of care integration. It also includes the decision to produce both shared planning and evaluation spaces among managers of different programs and services within the same organization, or involving different units of equal or distinct technological density, as the use of discretionary action by public actors calls for governance skills developments3. The implementation of protocols and common flows throughout Region A\u2019s network was a characteristic that assisted in the coordination of primary and specialized level organizations, allowing for the adoption of referred access by specialized dental services.Administrative discretion is understood as the use of strategies to introduce procedural changes3. Although we can identify a component related to the individual trajectory of actors, those references are not only produced by individual choices but also engendered by influences derived from relationships established during implementation in specific institutional and relational contexts1, in which collaboration among stakeholders can help shorten the path to achieving the intended outcomes14.The political dimension concerns the values and references at play in the interaction of actors and the competence to combine them during the exercise of power to make them effective in the achievement of the desired endsA policy of general interest related to the construction of an integrated healthcare network was underway in Region A and was mentioned by interviewees from both PHCs and specialized units. On the other hand, in Region B, this construction was not from the actors\u2019 perspective. The material obtained evidenced that communication and interaction between professionals from the units were not structuring resources for care actions. In this relational environment, units operated in an isolated and fragmented logic of providing basic and specialized services.15. Although the strategy of open demand is generally regarded as negative as a means of accessing specialized services within a care network focused on integrated care delivery, it can be interpreted positively by users who do not resort to the PHC for subsequent consultations. In a relational and institutional context where units do not operate collaboratively or establish reciprocal commitments, and fragmented practices are the rule, resorting to another unit may lead to additional costs, uncertainty, and stress for the user. This gives way to distortions in the implementation of DSCs from the perspective of the public policy analyzed, allowing for their operation to respond to \u201ccounter\u201d logic focused on achieving politically and socially desired results, related to specific short-term interests that may lead to a client-focused perspective16.After the approval of the PNSB guidelines in 2004, over a thousand DSCs were created in Brazil to enable referred access for PwD and the general population to complex care by adhering to the principle of care comprehensiveness17.It is worth noting that, since the late 1990s in Brazil, the local level has been responsible for providing primary health care services, while the provision of specialized services depends on regional arrangements between the municipal and state levels. Decentralized systems in federal republics, similar to countries such as Canada and Australia, can represent a significant advantage by allowing cost containment at the central level and granting greater autonomy and responsibility to local governments in addressing the health needs of the population. However, it is also a challenge because municipalities and regions are subject to jurisdictional variations, and fragmentation in coordination, cooperation, and information sharing.6, it was found that activities varied considerably, although they performed the same function and were governed by the same policy. In addition to individual factors, organizational and contextual aspects would also influence the type of activity carried out by the agents in their routine. In this study, despite the services being provided by frontline professionals with backgrounds in the health field and governed by general interests defined by the guidelines of a public policy focused on RCPD implementation, the strategies for accessing specialized dental care were different. Despite similarities in socioeconomic conditions and service availability, the implementation outcomes differed, indicating the significant influence of the relational and institutional environments.Examining the performance of community health agents14. The analysis of this study did not encompass the viewpoint of service users. Further research that integrates the perspectives of both professionals and users could enhance and delve deeper into the insights presented here, aiming to investigate the consequences of discretion that may result in inclusion, equity, exclusion, and inequality. Sociocultural differences, the prevalence of PwD, and the number of users in each region were also not considered. Despite these points and the results being derived from a case study, the investigation is innovative in its use of the theory of public policy implementation from a bottom-up perspective. It explores analytical domains that are less investigated concerning the relational and institutional aspects that influence the frontline of the investigated public policy.In terms of the limitations of this study, it\u2019s important to highlight that implementation at the frontline is influenced by multiple forces, often competing in the implementation systemThe implementation of a specialized dental care policy for persons with disabilities is subject to the discretionary power of frontline professionals and organizations. This implies that the relational and institutional environment plays a significant role in the process of implementing public policies within a decentralized and regionalized healthcare system. In such a system, diverse strategies for accessing specialized services are linked to the coordinating role of PHC and the execution of planning and evaluation activities aimed at constructing an integrated healthcare network. 1. A implementa\u00e7\u00e3o de pol\u00edticas de sa\u00fade passou a depender de diferentes organiza\u00e7\u00f5es e uma infinidade de acordos p\u00fablico-privados em n\u00edvel local. Neste contexto, a discricionariedade, enquanto conceito-chave da teoria da burocracia de n\u00edvel de rua2, passou a ser investigada a partir de diferentes dimens\u00f5es que orientam a tomada de decis\u00e3o, desde valores \u00e9ticos, regras e dispositivos normativos, at\u00e9 aspectos profissionais e organizacionais que se manifestar\u00e3o nos pap\u00e9is esperados das organiza\u00e7\u00f5es e profissionais da linha de frente3.Nos \u00faltimos 30 anos, ganharam impulso diferentes estrat\u00e9gias de descentraliza\u00e7\u00e3o e regionaliza\u00e7\u00e3o de servi\u00e7os de sa\u00fade2.As formas pelas quais organiza\u00e7\u00f5es/profissionais da linha de frente proporcionam benef\u00edcios e san\u00e7\u00f5es contribuem para estruturar e delimitar a vida das pessoas, ampliando ou restringindo oportunidades. Como prestadores de servi\u00e7os de utilidade p\u00fablica e operadores da pol\u00edtica p\u00fablica, os profissionais da linha de frente, e as organiza\u00e7\u00f5es que t\u00eam seus custos operacionais deles dependentes, podem ser foco de tens\u00f5es entre as demandas dos destinat\u00e1rios dos servi\u00e7os, que querem maior efetividade e responsividade, e as demandas de cidad\u00e3os, cobrando mais efic\u00e1cia e efici\u00eancia das organiza\u00e7\u00f5es respons\u00e1veis pela oferta dos servi\u00e7os p\u00fablicos4. Enquanto o exerc\u00edcio da discricionariedade em sua dimens\u00e3o pol\u00edtica pode enfraquecer/fortalecer o interesse geral e a legitimidade do programa, a discricionariedade administrativa \u00e9 vista como uma gama de escolhas dentro de um conjunto de par\u00e2metros que se manifestam na forma de regras organizacionais. Organiza\u00e7\u00f5es/profissionais usam sua discricionariedade para fazer arranjos, que mesclam diferentes dimens\u00f5es voltadas \u00e0 obten\u00e7\u00e3o de resultados pol\u00edtica e socialmente desejados em uma dire\u00e7\u00e3o legitimamente definida, que podem explicar diferen\u00e7as na linha de frente da implementa\u00e7\u00e3o da pol\u00edtica p\u00fablica3. Estes arranjos n\u00e3o decorrem s\u00f3 da intera\u00e7\u00e3o entre pessoas, mas podem ser resultado da intera\u00e7\u00e3o de uma rede de diferentes profissionais e organiza\u00e7\u00f5es da linha de frente que atuam isolada ou colaborativamente5.A discricionariedade dos agentes no processo de implementa\u00e7\u00e3o de uma determinada pol\u00edtica p\u00fablica pode ser mais ampla ou restrita, conforme o grau de estrutura\u00e7\u00e3o/detalhamento da pol\u00edtica e a abrang\u00eancia/ambiguidade das regras mantidas pelas organiza\u00e7\u00f5es onde eles operam6, e a atua\u00e7\u00e3o de burocratas de n\u00edvel de rua na implementa\u00e7\u00e3o da pol\u00edtica de fluoreta\u00e7\u00e3o das \u00e1guas de abastecimento p\u00fablico em pequenos munic\u00edpios brasileiros7. Estudos sobre a discricionariedade da burocracia do n\u00edvel de rua na implementa\u00e7\u00e3o de pol\u00edticas de redes de aten\u00e7\u00e3o \u00e0 sa\u00fade (RAS) s\u00e3o pouco explorados, sendo oportuna a investiga\u00e7\u00e3o do acesso \u00e0 assist\u00eancia odontol\u00f3gica especializada no \u00e2mbito da Rede de Cuidados \u00e0 Pessoa com Defici\u00eancia (RCPD). O acesso pode ser definido pelas diferentes estrat\u00e9gias adotadas por organiza\u00e7\u00f5es para que os usu\u00e1rios consigam utilizar os servi\u00e7os de que necessitam8.Na literatura brasileira, trabalhos que incorporam modelos anal\u00edticos de implementa\u00e7\u00e3o de pol\u00edticas de sa\u00fade e burocracia de n\u00edvel de rua s\u00e3o escassos. H\u00e1 estudos que analisam o poder discricion\u00e1rio de agentes comunit\u00e1rios de sa\u00fade na implementa\u00e7\u00e3o de a\u00e7\u00f5es da pol\u00edtica de aten\u00e7\u00e3o b\u00e1sica9.Na primeira d\u00e9cada do s\u00e9culo XXI, a aprova\u00e7\u00e3o da Pol\u00edtica Nacional da Pessoa com Defici\u00eancia (PNPD) e da Pol\u00edtica Nacional de Sa\u00fade Bucal (PNSB) no Brasil impulsionaram a articula\u00e7\u00e3o da estrutura de cuidados odontol\u00f3gicos b\u00e1sicos, por meio de equipes de sa\u00fade bucal na rede de aten\u00e7\u00e3o prim\u00e1ria \u00e0 sa\u00fade (APS), e especializados, por meio de centros de especialidades odontol\u00f3gicas (CEO), a fim de oferecer tratamentos ambulatoriais mais complexos a todos que deles precisarem, incluindo as pessoas com defici\u00eancia (PcD)9, na qual deveria se destacar a APS como coordenadora dos cuidados \u00e0 sa\u00fade8.A RCPD, criada no SUS em 2012, suscita a articula\u00e7\u00e3o interfederativa a fim de promover o acesso das PcD aos diferentes tipos de tratamentos especializados, mediante pactua\u00e7\u00f5es e governan\u00e7a regionais nas quais participam dirigentes de estados/munic\u00edpios de uma determinada regi\u00e3o de sa\u00fade. A garantia do direito ao tratamento odontol\u00f3gico e ao cuidado integral n\u00e3o \u00e9 tarefa simples, e cobra uma articula\u00e7\u00e3o virtuosa entre os diferentes pontos de aten\u00e7\u00e3o da RCPD10, mas nenhum estudo investigou esta situa\u00e7\u00e3o contrastante. Pode-se admitir que a implementa\u00e7\u00e3o desta pol\u00edtica p\u00fablica depende de como organiza\u00e7\u00f5es/profissionais da linha de frente atuam. Produzir informa\u00e7\u00e3o cient\u00edfica sobre a interface entre os servi\u00e7os de APS e especializados voltados \u00e0 PcD pode ajudar na compreens\u00e3o dos avan\u00e7os e dos gargalos para a constru\u00e7\u00e3o das redes integradas de sa\u00fade.Estudo abrangendo 930 CEO mostrou que 85% estavam sob gest\u00e3o municipal, e 10% n\u00e3o ofereciam atendimento \u00e0 PcD, apesar de obrigat\u00f3rio. O acesso do usu\u00e1rio era referenciado pela APS em pouco mais da metade das unidades especializadas. Uma propor\u00e7\u00e3o expressiva  possibilitava o agendamento por meio da demanda espont\u00e2neaO objetivo deste trabalho \u00e9 descrever a atua\u00e7\u00e3o dos profissionais e das organiza\u00e7\u00f5es da linha de frente em rela\u00e7\u00e3o \u00e0 APS e \u00e0s atividades de planejamento/avalia\u00e7\u00e3o, a fim de compreender o exerc\u00edcio da discricionariedade na implementa\u00e7\u00e3o de diferentes formas de acesso \u00e0 assist\u00eancia odontol\u00f3gica especializada na RCPD em duas regi\u00f5es de sa\u00fade brasileiras.11 em duas regi\u00f5es cujo acesso \u00e0 assist\u00eancia odontol\u00f3gica especializada era distinto. As regi\u00f5es foram selecionadas com base em dados documentais e de entrevistas obtidos em um estudo mais amploa, aprovado pelo Comit\u00ea de \u00c9tica em Pesquisa da Faculdade de Sa\u00fade P\u00fablica-USP, n\u00ba 3.441.243.Realizou-se um estudo de casoO acesso \u00e0 assist\u00eancia especializada era referenciado na regi\u00e3o de sa\u00fade S\u00e3o Jos\u00e9 do Rio Preto, identificada como regi\u00e3o A, enquanto na regi\u00e3o Salvador (regi\u00e3o B) era misto, ou seja, importante propor\u00e7\u00e3o dos usu\u00e1rios acessava livremente a unidade especializada sem necessidade de um encaminhamento/refer\u00eancia formal, sujeitando-se a regras pr\u00f3prias desta.12, foram classificadas como regi\u00f5es com alta situa\u00e7\u00e3o socioecon\u00f4mica e alta oferta e complexidade dos servi\u00e7os da sa\u00fade. Al\u00e9m do mais, elas contavam com a presen\u00e7a de centros especializados de reabilita\u00e7\u00e3o (CER), centros de especialidades odontol\u00f3gicas (CEO), servi\u00e7os municipais e/ou filantr\u00f3picos de especialidades com a\u00e7\u00f5es de reabilita\u00e7\u00e3o ao usu\u00e1rio , e institui\u00e7\u00f5es formadoras .As duas regi\u00f5es foram selecionadas intencionalmente, porque ambas tinham caracter\u00edsticas socioecon\u00f4micas e de oferta de servi\u00e7os semelhantes. Em tipologia realizada por Viana et al.A coleta de dados ocorreu entre julho e dezembro de 2019, feita por profissionais previamente treinados. Concordaram em participar da pesquisa cinco unidades que prestavam assist\u00eancia odontol\u00f3gica especializada \u00e0s PcD, e quatro unidades da APS sob gest\u00e3o municipal das duas regi\u00f5es. Das cinco unidades especializadas, quatro estavam sob gest\u00e3o municipal (uma na regi\u00e3o A e tr\u00eas na regi\u00e3o B), e uma sob gest\u00e3o estadual (regi\u00e3o B). Foram entrevistados nove profissionais da linha de frente, representados neste estudo pelos gerentes, considerados atores-chaves dentro das organiza\u00e7\u00f5es. Quando a unidade n\u00e3o possu\u00eda gerente, o informante-chave foi o cirurgi\u00e3o-dentista respons\u00e1vel pelo atendimento \u00e0 PcD.Instrumentos estruturados (question\u00e1rios) e semiestruturados (roteiros) foram utilizados para a coleta dos dados. Neste estudo foram analisadas as respostas dos entrevistados relativas \u00e0 frequ\u00eancia de acesso da PcD \u00e0s unidades especializadas via APS, aos crit\u00e9rios de prioriza\u00e7\u00e3o que eram adotados, \u00e0s dificuldades para que a APS fossem a principal porta de acesso aos servi\u00e7os, \u00e0s iniciativas da APS para exercer a coordena\u00e7\u00e3o do cuidado, e ao uso de instrumentos de monitoramento/avalia\u00e7\u00e3o, sua frequ\u00eancia e os atores participantes.13 relacionados \u00e0s seguintes categorias: tipo de acesso; atributo da APS relativo \u00e0 coordena\u00e7\u00e3o do cuidado; planejamento, avalia\u00e7\u00e3o e monitoramento.Relat\u00f3rios t\u00e9cnicos e atas de reuni\u00f5es colegiadas que continham conte\u00fado relativo \u00e0 implementa\u00e7\u00e3o da RCPD no n\u00edvel loco-regional, abrangendo eventos de 1988 a 2019, foram examinados, buscando-se identificar dispositivos normativos e aspectos ligados \u00e0 organiza\u00e7\u00e3o da APS e das atividades de planejamento/avalia\u00e7\u00e3o. Para isso, foram consultados decretos, leis e portarias relacionados ao tema nos sites institucionais das regi\u00f5es , relat\u00f3rios t\u00e9cnicos produzidos no \u00e2mbito das regi\u00f5es de sa\u00fade, e atas de reuni\u00f5es de Comiss\u00e3o Intergestores Bipartite (CIB) e Comiss\u00e3o Intergestores Regional (CIR), disponibilizadas publicamente ou pelos t\u00e9cnicos dos servi\u00e7os. A sele\u00e7\u00e3o dos trechos dos documentos se deu a partir de palavras-chaves que identificassem n\u00facleos de sentido8.O acesso diz respeito \u00e0s estrat\u00e9gias adotadas para que os usu\u00e1rios consigam utilizar os servi\u00e7os de que necessitavam. A coordena\u00e7\u00e3o do cuidado refere-se \u00e0 condu\u00e7\u00e3o cl\u00ednica dos casos por meio da articula\u00e7\u00e3o entre a\u00e7\u00f5es e servi\u00e7os oferecidos por diferentes unidades da rede de aten\u00e7\u00e3o para responder \u00e0s necessidades de sa\u00fade dos usu\u00e1rios, visando \u00e0 reorienta\u00e7\u00e3o do modelo assistencial. O planejamento, avalia\u00e7\u00e3o e monitoramento dizem respeito aos instrumentos e indicadores espec\u00edficos que orientam o processo de trabalho dos profissionais da linha de frente, bem como a qualidade das a\u00e7\u00f5es ofertadasR1 , ER2 e ER3 para a regi\u00e3o A, e ER4 a ER9 para a regi\u00e3o B.Os resultados s\u00e3o apresentados segundo as categorias tem\u00e1ticas e a regi\u00e3o. Os As discuss\u00f5es entre diferentes n\u00edveis de governo no espa\u00e7o da CIB, sobre gest\u00e3o e organiza\u00e7\u00e3o da RCPD tiveram in\u00edcio no final de 2011 na regi\u00e3o A, enquanto na regi\u00e3o B entraram em pauta somente a partir de 2013. Na regi\u00e3o A, onde o acesso \u00e0 assist\u00eancia odontol\u00f3gica especializada ocorria apenas por meio de um pedido formal, expedido por uma unidade da rede de servi\u00e7os, observou-se que esta refer\u00eancia acontecia quando o cirurgi\u00e3o-dentista da APS considerava n\u00e3o dispor das condi\u00e7\u00f5es necess\u00e1rias para prover o tratamento adequado. Assim ocorria tamb\u00e9m na regi\u00e3o B, onde o acesso era por demanda espont\u00e2nea e referenciada. Neste tipo misto, o usu\u00e1rio podia ingressar livremente, sem necessidade de um pedido formal, e de acordo com as regras pr\u00f3prias da unidade especializada.Para acessar outros servi\u00e7os especializados em reabilita\u00e7\u00e3o que compunham a RCPD , a UBS era a porta preferencial de acesso na regi\u00e3o A, cabendo-lhe a refer\u00eancia de usu\u00e1rios aos servi\u00e7os especializados. O acesso \u00e0s unidades especializadas localizadas no munic\u00edpio polo se dava via APS, obrigatoriamente. Casos que n\u00e3o obedecessem a este crit\u00e9rio eram acolhidos para orienta\u00e7\u00e3o e redirecionados para a APS.Trechos de documentos mostraram que a necessidade de garantir a acessibilidade da RCPD era um tema recorrente nas reuni\u00f5es da Comiss\u00e3o Intersetorial de Aten\u00e7\u00e3o \u00e0 Pessoa com Defici\u00eancia, na regi\u00e3o A. Este esfor\u00e7o significava maior disponibilidade de transporte sanit\u00e1rio e oferta de aux\u00edlio para uso de \u00f4nibus de linha comum.Na regi\u00e3o B, havia unidades especializadas de assist\u00eancia odontol\u00f3gica administradas pelas esferas estadual e municipal. Observou-se que os profissionais vinculados \u00e0 unidade estadual n\u00e3o se comunicavam nem interagiam com os dentistas da rede municipal que atuavam nas unidades de APS e nas especializadas. Na pr\u00e1tica, aquele servi\u00e7o possu\u00eda uma porta de entrada que seguia regras pr\u00f3prias pr\u00e9-estabelecidas. Por outro lado, na regi\u00e3o A foi reconhecida a import\u00e2ncia do trabalho em rede para qualificar a assist\u00eancia \u00e0 PcD e, consequentemente, \u00e0 RCPD .O custo dos meios de transporte na regi\u00e3o B, e a maneira como PcD auditiva eram recebidas nas unidades especializadas da regi\u00e3o A foram identificados como poss\u00edveis barreiras de acesso aos servi\u00e7os. O munic\u00edpio polo da regi\u00e3o A ofertava uma profissional int\u00e9rprete da L\u00edngua Brasileira de Sinais (Libras), que atuava como tradutora durante a consulta odontol\u00f3gica especializada, mediante agendamento pr\u00e9vio.Identificou-se que as UBS n\u00e3o eram a porta preferencial de acesso aos servi\u00e7os de sa\u00fade para o usu\u00e1rio na regi\u00e3o B. Seu papel como coordenadora dos cuidados mostrava-se fragilizado, em decorr\u00eancia do baixo potencial de cobertura populacional e da fragmenta\u00e7\u00e3o da aten\u00e7\u00e3o, apontando para o enorme desafio de integrar a APS com os servi\u00e7os especializados. Em reuni\u00f5es de CIB, foram propostas estrat\u00e9gias para elabora\u00e7\u00e3o do Plano Estadual, como estabelecimento de linhas de cuidado, ordenamento do fluxo, cadastramento de equipes de sa\u00fade da fam\u00edlia com sa\u00fade bucal e expans\u00e3o da APS. Entretanto, n\u00e3o foram observadas mudan\u00e7as na linha de frente. A contrarrefer\u00eancia dos usu\u00e1rios \u00e0 APS pelos profissionais das unidades especializadas da regi\u00e3o B tamb\u00e9m n\u00e3o acontecia .Na regi\u00e3o A, a APS era central no cuidado, sendo a principal respons\u00e1vel pela assist\u00eancia \u00e0s PcD. Os profissionais participavam de matriciamento sobre o tema, ofertavam a\u00e7\u00f5es de reabilita\u00e7\u00e3o e conseguiam agendar, em tempo h\u00e1bil, consultas em reabilita\u00e7\u00e3o para os usu\u00e1rios encaminhados. A agenda de matriciamento do CEO com a APS era planejada anualmente em reuni\u00e3o de equipe. As UBS que possu\u00edam equipes de sa\u00fade bucal, em ambas as regi\u00f5es, realizavam atendimento \u00e0s PcD. Aos CEO eram encaminhados os casos mais complexos, como os de usu\u00e1rios n\u00e3o colaborativos, com necessidade de conten\u00e7\u00e3o ou de uma interven\u00e7\u00e3o mais individualizada.Planejamento, avalia\u00e7\u00e3o e monitoramento das a\u00e7\u00f5es n\u00e3o faziam parte da rotina institucional dos servi\u00e7os na regi\u00e3o B. Como consequ\u00eancia, o processo de trabalho n\u00e3o era monitorado, nem orientado por crit\u00e9rios previamente estabelecidos. Somente alguns servi\u00e7os realizavam reuni\u00f5es peri\u00f3dicas de equipes e monitoramento de indicadores. Cabe destacar que o Plano Estadual da RCPD previa como diretriz para qualifica\u00e7\u00e3o da gest\u00e3o a produ\u00e7\u00e3o, o acompanhamento e monitoramento das informa\u00e7\u00f5es, al\u00e9m da qualifica\u00e7\u00e3o profissional .Na regi\u00e3o A, o planejamento, avalia\u00e7\u00e3o e monitoramento eram parte da rotina institucional dos servi\u00e7os, e alguns gestores (como a gerente do CEO) desenvolveram instrumento pr\u00f3prio para avalia\u00e7\u00e3o e monitoramento de indicadores espec\u00edficos relacionados, entre outros, \u00e0 satisfa\u00e7\u00e3o do usu\u00e1rio, ao n\u00famero de procedimentos dent\u00e1rios restauradores, \u00e0 propor\u00e7\u00e3o de absente\u00edsmo, porcentagem de tratamento conclu\u00eddos, n\u00famero de exodontias, e quantidade de PcD atendidas em todas as especialidades. As reuni\u00f5es do Grupo Condutor da RCPD tamb\u00e9m reconheciam a import\u00e2ncia tanto da avalia\u00e7\u00e3o e monitoramento das a\u00e7\u00f5es para consolida\u00e7\u00e3o da RCPD, atrav\u00e9s do diagn\u00f3stico situacional , quanto do papel da ger\u00eancia no uso dos instrumentos de monitoramento das a\u00e7\u00f5es e compartilhamento das informa\u00e7\u00f5es em reuni\u00e3o com toda a equipe.Neste estudo de caso, descreveu-se a atua\u00e7\u00e3o dos profissionais e das organiza\u00e7\u00f5es da linha de frente, a fim de compreender o exerc\u00edcio da discricionariedade na implementa\u00e7\u00e3o de diferentes formas de acesso \u00e0 assist\u00eancia odontol\u00f3gica especializada na RCPD em duas regi\u00f5es de sa\u00fade brasileiras.Os achados evidenciaram distintas caracter\u00edsticas em rela\u00e7\u00e3o \u00e0 APS, \u00e0s atividades de planejamento e avalia\u00e7\u00e3o e \u00e0 estrat\u00e9gia de acesso adotada. Na regi\u00e3o A, onde o acesso era referenciado, observou-se que a APS tinha papel de coordena\u00e7\u00e3o do cuidado, e o planejamento/avalia\u00e7\u00e3o faziam parte da rotina institucional dos servi\u00e7os. Na regi\u00e3o B, de acesso misto, notou-se que a troca de informa\u00e7\u00e3o entre as unidades de APS e as unidades especializadas era espor\u00e1dica, e que o papel de coordena\u00e7\u00e3o do cuidado n\u00e3o era um atributo das equipes de APS. Nesta regi\u00e3o, as atividades de planejamento/avalia\u00e7\u00e3o n\u00e3o estavam incorporadas \u00e0 rotina das organiza\u00e7\u00f5es, conforme orienta a PNSB, pois cada servi\u00e7o decidia, atrav\u00e9s dos seus implementadores, se as realizava ou n\u00e3o.3.Com isso, o exerc\u00edcio da discricionariedade na forma pela qual o acesso do usu\u00e1rio era regulado em cada regi\u00e3o estava estreitamente relacionado ao papel da APS na rede assistencial e \u00e0s caracter\u00edsticas das unidades especializadas quanto \u00e0s atividades de planejamento/avalia\u00e7\u00e3o. Os distintos resultados de implementa\u00e7\u00e3o encontrados neste estudo de caso confirmaram a ideia de que a implementa\u00e7\u00e3o efetiva \u00e9 sempre realizada com base nas refer\u00eancias que os implementadores de fato adotam para desempenhar suas fun\u00e7\u00f5es, e corroboram a no\u00e7\u00e3o de que o exerc\u00edcio da discricionariedade encerra diferentes dimens\u00f5es voltadas \u00e0 obten\u00e7\u00e3o de resultados pol\u00edtica e socialmente desejados, em uma dire\u00e7\u00e3o legitimamente definida conforme o ambiente relacional e institucional presente no contexto loco-regional, sobressaindo-se tanto a dimens\u00e3o administrativa quanto a dimens\u00e3o pol\u00edtica3. Neste estudo de caso, diz respeito ao uso de canais de comunica\u00e7\u00e3o e fluxos compartilhados com aux\u00edlio de protocolos e outros instrumentos comuns, a fim de promover a articula\u00e7\u00e3o entre as unidades de APS e os servi\u00e7os odontol\u00f3gicos especializados, com vistas a obter n\u00edveis crescentes de integralidade do cuidado. Inclui tamb\u00e9m a decis\u00e3o de criar espa\u00e7os de planejamento e avalia\u00e7\u00e3o compartilhados entre gerentes de diferentes programas e servi\u00e7os mantidos dentro de uma mesma organiza\u00e7\u00e3o, ou envolvendo diferentes unidades de igual ou de distinta densidade tecnol\u00f3gica, uma vez que o uso da a\u00e7\u00e3o discricion\u00e1ria dos atores p\u00fablicos requer o desenvolvimento de habilidades de governan\u00e7a3. Na regi\u00e3o A, a implementa\u00e7\u00e3o de protocolos e fluxos comuns a toda a rede foi uma caracter\u00edstica que auxiliou a articula\u00e7\u00e3o das organiza\u00e7\u00f5es de n\u00edvel prim\u00e1rio e especializado, permitindo a ado\u00e7\u00e3o do acesso referenciado pelos servi\u00e7os odontol\u00f3gicos especializados.A discricionariedade administrativa \u00e9 entendida como o uso de estrat\u00e9gias para introduzir mudan\u00e7as procedimentais3. Embora seja poss\u00edvel identificar um componente relacionado \u00e0 trajet\u00f3ria individual dos atores, estes referenciais n\u00e3o s\u00e3o apenas produzidos por escolhas individuais, mas sim engendrados pelas influ\u00eancias derivadas das rela\u00e7\u00f5es estabelecidas no curso da implementa\u00e7\u00e3o em contextos institucionais e relacionais espec\u00edficos1, nos quais a colabora\u00e7\u00e3o entre as partes interessadas pode encurtar o caminho para o alcance dos desfechos pretendidos14.A dimens\u00e3o pol\u00edtica diz respeito aos valores e aos referenciais em jogo na intera\u00e7\u00e3o dos atores e \u00e0 compet\u00eancia de combin\u00e1-los durante o exerc\u00edcio de poder para torn\u00e1-los funcionais \u00e0 obten\u00e7\u00e3o dos fins desejadosNa regi\u00e3o A, uma pol\u00edtica de interesse geral relacionada \u00e0 constru\u00e7\u00e3o de uma rede de cuidados integrados de sa\u00fade estava em curso, sendo mencionada tanto pelos entrevistados das unidades de APS quanto das unidades especializadas. Por outro lado, na regi\u00e3o B essa constru\u00e7\u00e3o n\u00e3o pertencia \u00e0 perspectiva dos atores. O material obtido mostrou que a comunica\u00e7\u00e3o e a intera\u00e7\u00e3o entre os profissionais destas unidades n\u00e3o eram recursos estruturantes das a\u00e7\u00f5es de cuidado. Neste ambiente relacional, as unidades operavam em uma l\u00f3gica de presta\u00e7\u00e3o de servi\u00e7os b\u00e1sicos e especializados isolada e fragmentada.15. No que pese a estrat\u00e9gia por livre demanda ser considerada negativa como forma de acesso ao servi\u00e7o especializado dentro de uma rede de aten\u00e7\u00e3o voltada \u00e0 produ\u00e7\u00e3o de cuidados integrados, ela pode ser interpretada positivamente pelo usu\u00e1rio que n\u00e3o precisa recorrer \u00e0 unidade de APS nas consultas subsequentes. Em um contexto relacional e institucional no qual as unidades n\u00e3o operam de forma colaborativa, nem estabelecem compromissos rec\u00edprocos, e em que pr\u00e1ticas fragmentadas predominam, recorrer a outra unidade pode gerar custos, incerteza e estresse para o usu\u00e1rio. Do ponto de vista da pol\u00edtica p\u00fablica sob an\u00e1lise, gera distor\u00e7\u00f5es na implementa\u00e7\u00e3o dos CEO, criando condi\u00e7\u00f5es para que sua opera\u00e7\u00e3o passe a responder a l\u00f3gicas de \u201cguich\u00ea\u201d voltadas \u00e0 obten\u00e7\u00e3o de resultados pol\u00edtica e socialmente desejados, relacionados a interesses espec\u00edficos de curto prazo, que podem ensejar uma perspectiva clientel\u00edstica16.Ap\u00f3s a aprova\u00e7\u00e3o das diretrizes da PNSB, em 2004, mais de mil CEO foram criados no Brasil para possibilitar o acesso referenciado das PcD e da popula\u00e7\u00e3o, em geral, a cuidados complexos, atendendo ao princ\u00edpio da integralidade17.Cabe destacar que, no Brasil, desde o final dos anos 1990, o n\u00edvel local \u00e9 respons\u00e1vel pela provis\u00e3o dos servi\u00e7os de APS, sendo a provis\u00e3o de servi\u00e7os especializados dependente de arranjos regionais entre os n\u00edveis municipal e estadual. Sistemas descentralizados em rep\u00fablicas federativas, \u00e0 semelhan\u00e7a de pa\u00edses como Canad\u00e1 e Austr\u00e1lia, podem representar uma vantagem importante, ao possibilitarem a conten\u00e7\u00e3o de custos para o n\u00edvel central e darem maior autonomia e responsabilidade aos governos locais perante as necessidades de sa\u00fade da popula\u00e7\u00e3o. Mas \u00e9 tamb\u00e9m um desafio porque, os munic\u00edpios e as regi\u00f5es ficam sujeitos a varia\u00e7\u00f5es jurisdicionais, fragmenta\u00e7\u00f5es na coordena\u00e7\u00e3o, coopera\u00e7\u00e3o e compartilhamento das informa\u00e7\u00f5es6, verificou-se que as atividades diferiam bastante, embora exercessem a mesma fun\u00e7\u00e3o e fossem regidas por uma mesma pol\u00edtica. Al\u00e9m dos fatores individuais, aspectos organizacionais e de contexto exerceriam influ\u00eancia sobre o tipo de atividade desenvolvida pelos agentes em sua rotina. No presente estudo, a despeito dos servi\u00e7os serem providos por profissionais da linha de frente, com forma\u00e7\u00f5es ligadas \u00e0 \u00e1rea da sa\u00fade e regidos por interesses gerais definidos pelas diretrizes de uma pol\u00edtica p\u00fablica voltada \u00e0 implementa\u00e7\u00e3o da RCPD, as estrat\u00e9gias de acesso \u00e0 assist\u00eancia odontol\u00f3gica especializada eram distintas. Apesar de semelhan\u00e7as socioecon\u00f4micas e na oferta de servi\u00e7os, a resposta da implementa\u00e7\u00e3o n\u00e3o foi a mesma, sugerindo que o ambiente relacional e institucional exerce um papel importante.Examinando a atua\u00e7\u00e3o de agentes comunit\u00e1rios de sa\u00fade14. A opini\u00e3o dos usu\u00e1rios dos servi\u00e7os n\u00e3o foi inclu\u00edda na an\u00e1lise deste trabalho, e investiga\u00e7\u00f5es que incorporem tanto a vis\u00e3o dos profissionais quanto dos usu\u00e1rios poderiam complementar e aprofundar as considera\u00e7\u00f5es aqui levantadas, a fim de explorar efeitos da discricionariedade que poderiam gerar inclus\u00e3o, equidade, exclus\u00e3o e desigualdade. Diferen\u00e7as socioculturais, da preval\u00eancia de PcD e de n\u00famero de usu\u00e1rios em cada regi\u00e3o tamb\u00e9m n\u00e3o foram consideradas. Apesar destes pontos e dos resultados serem provenientes de um estudo de caso, a investiga\u00e7\u00e3o inova ao fazer uso da teoria de implementa\u00e7\u00e3o de pol\u00edtica p\u00fablica numa perspectiva bottom-up, e explora dom\u00ednios anal\u00edticos pouco investigados concernentes aos aspectos relacionais e institucionais que exerceriam influ\u00eancia na linha de frente da pol\u00edtica p\u00fablica aqui investigada.Em rela\u00e7\u00e3o \u00e0s limita\u00e7\u00f5es deste estudo, \u00e9 preciso destacar que a implementa\u00e7\u00e3o na linha de frente \u00e9 influenciada por m\u00faltiplas for\u00e7as, muitas vezes concorrentes no sistema de implementa\u00e7\u00e3oConclui-se que a implementa\u00e7\u00e3o da pol\u00edtica de assist\u00eancia odontol\u00f3gica especializada \u00e0 pessoa com defici\u00eancia est\u00e1 sujeita ao poder discricion\u00e1rio dos profissionais e das organiza\u00e7\u00f5es da linha de frente, sugerindo que o ambiente relacional e institucional joga um papel importante no processo de implementa\u00e7\u00e3o de pol\u00edticas p\u00fablicas em um sistema descentralizado e regionalizado de sa\u00fade, no qual diferentes estrat\u00e9gias de acesso aos servi\u00e7os especializados est\u00e3o associadas ao papel coordenador da APS e \u00e0 condu\u00e7\u00e3o de atividades de planejamento/avalia\u00e7\u00e3o voltadas \u00e0 constru\u00e7\u00e3o de uma rede de cuidados integrados de sa\u00fade."}
+{"text": "To identify the legal norms published in 2020 and 2021 aimed at directly or indirectly regulating telework in health in Brazil, focusing on these contexts: workday length; ergonomics; work environment; worker safety and health. Legislative and documentary research, with a descriptive qualitative approach. We collected and selected all legal norms dealing directly or indirectly with the regulation of telework in health in Brazil, published in the bases of the National Press and Health Professional Councils until June 2021. Until June 2021, there were 113 valid legal norms on the regulation of telework in health, and more than half of them (64) were published in 2020. We identified only a few norms aimed at regulating or guiding aspects related to workday length; ergonomics; work environment; and worker safety and health. From the 113 norms, only one deals with workday length and just 13 pointed out the importance of working environments for offering a good service. We identified that the selected legal norms lack of devices which regulate telework in health, failing to defend workers\u2019 and patients\u2019 rights, or to guarantee favorable remote work conditions, whether at home or somewhere else. The covid-19 pandemic brought to the center of the stage the deleterious state of work in health, especially those carried out on-site. Therefore, the precariousness of employment relationships, the lack of work environment safety, the workers\u2019 sub conditions and vulnerability were more evident when a health crisis is added on top of several other crises the country has been facing, potentially devastating public health policiesThe global pandemic also exposed that the aggravation of chronic problems that affect on-site health work conditions was followed by the emergence of new problems, typical of the digital society and expanded in the pandemic period, such as employees performing their tasks remotely through digital platforms and applications. Labor ties and relationships became, with the expansion of digital work, more flexible, unstable, intense and fragile.3. A study conducted in Argentina, Brazil, Chile, Colombia and Mexico revealed that, during the Pandemic, telework increased 324% between the first and second quarter of 20204. In this same direction, studies estimate that by 2050 half of the active population will work digitally5.Studies indicate that the employment of telework, coupled with the development of a new regulation created during the pandemic because of social distancing, will hardly return to the way it was before the pandemic5. In the post-pandemic scenario, it will become increasingly more difficult to distinguish work and non-work time1. These are some of the new and complex challenges that arise to the field of health work regulation.The digital legacies left by covid-19 on how we perform health work should remain even after the pandemic ends. Telework performed at home is one of these legaciesThis study aims at identifying the legal norms published in 2020 and 2021 focused on directly or indirectly regulating telework in health in Brazil, analyzing them under following perspectives: workday length; ergonomics; work environment; worker safety and health.The yet scarce scientific literature on telework in health makes it currently impossible to evaluate more widely the evidence of its effects on health services and worker management. It is essential to regulate telework in health in order to fully protect not only our right to health, but also patients and professionals in this area. Thus, we highlight here the need to carefully monitor the norms that were published to regulate telework in health, so that we can make a critical analysis for their constant improvement.It bears noticing that this article is an original analytical cutoff from the primary data and results of the research \u201cRegulation of Telework in Health in Brazil\u201d. This analysis had the objective of identifying and understanding how the Brazilian government is regulating remote work in health, through mapping and analyzing all legal norms  of regulation of telework in health published in Brazil.We collected and analyzed legal norms regulating health professions in Brazil in order to identify those that directly or indirectly deal with telework in health and to assess them focusing on understanding how the federal regulation is (or is not) protecting the workers\u2019 and patients\u2019 rights. In this sense, we identified and analyzed the legal norms and the specific devices in each of them that regulate the following relevant issues of Public Health and occupational health in the context of telework: workday length; ergonomics; work environment; safety and health of the worker.7, which encompasses 14 higher-level health professions working at the council. For these 14 professions, we mapped 13 legally competent professional councils publishing legal norms for the work regulation in each of these professions, and the Federal Council of Physiotherapy and Occupational Therapy is responsible for these two professions.The concept of Health Profession used here refers to resolution n. 287, of October 8, 1998, of the National Council of HealthWe designed a data collection form with the purpose of organizing and selecting general information about each normative act, such as publication date, the name and the issuing body, specific information regarding working conditions and information security and personal data protection. For the Bills, a specific form was prepared, highlighting the central information of the document, authorship, legislative chamber, publication dates, syllabus and whether or not the PL repealed the existing norm.We hosted the form on a platform at the Universidade Federal do Rio Grande do Norte (UFRN), allowing the research team safe and functional access to the instrument and feeding the database with the strategic information of the normative documents.Data collection on legal norms took place between February, March, April, May and June 2021, with June 30, 2021 being the research time frame. In this stage, we collected normative texts, as a priority, directly from the Official Diary of the Union. After this, we searched other websites of regulatory institutions. While we read and collected this data set, we continuously filled in the aforementioned form.Before the collection, we defined the modalities of legal norms we were interested in, which were: constitutional provisions, complementary laws, ordinary laws, presidential decrees, legislative decrees, delegated laws, provisional measures, ordinances, resolutions, normative resolutions, normative instructions, decisions, circulaires, communications and opinions. We previously excluded all legal norms relating to disciplinary, sanctioning and contracting administrative processes, for example, bidding.8 and the bases made available by Professional Councils. At first, the search strategy defined the following descriptors: teleconsultation, telehealth, teleworking, teleassistance, teleprofession (e.g. telemedicine), digital health, distance consultation, distance care, remote (masculine and feminine), home office, informatics, information and communication technologies.We selected the official base of the National PressThe search in the National Press database was carried out in the \u201cAct-by-Act search\u201d mode, which selects all the retrieved legal norms containing the indicated descriptor. We filtered the search according to institution or public body issuing the norm. The The National Press database allows the search of legal norms published between the search date (from February to June 2021) and 2018. This database gives access to all the Official Diary of the Union publications. The search focused on Section 1 of the Official Diary of the Union, composed by normative acts , excluding Section 2, composed by personnel acts and Section 3, composed by contracts, announcements and notices. We selected the legal norms published between January 2018 and June 30, 2021 regarding the Union. In the first analysis, we read these documents to identify direct references on norms prior to 2018 and, thus, to add these complementary norms to the set of collected norms.After that, the documentary bases of the Professional Councils  and public administration entities were sought, in an exploratory manner. This stage did not consider a time frame, since we carried out a floating reading in the documents published in each repository, based on the set of descriptors chosen for this research, so that we could understand discussions and current institutional frameworks on the topic.Finally, we also included, for all regulated professions, the location and analysis of each ethics code. Although most of these codes lack of the indicated descriptors, such norms often deal with treatment confidentiality and other relevant topics for understanding the regulation of distance therapy.Hence, we obtained all legal norms according to the aforementioned descriptors, including those repealed between January 2018 and June 2021, as well as all the legal norms in force that regulate teleworking in health.As a result of the research, 113 legal norms of the Union were selected for analysis.10. These are some of the old and current challenges faced by those who manage labor in public health institutions. Recently, with the growth of telework in health, new challenges related to its regulation have emerged10.The health sector in Brazil has always been the stage for regulatory conflicts that cover various topics, such as: the definition of the practice scopes of each profession; the definition of training requirements to work in certain activities; working hours; and the compensation for each different health professional11. In the health sector, this type of work has been increasingly present, with its expansion increasing during the covid-19 pandemic. However, it is important to emphasize that \u201cthe conversion of on-site work into a remote one, in the pandemic context, consisted of a health contingency\u201d11.A research published by the Institute for Applied Economic Research (Ipea) reveals that the amount of overall telework in Brazil is already quite significant when compared to other countries around the world, showing that, in a list of 86 countries ranked according to the proportion of telework use, Brazil places at the 45th position12. It is also important to ensure that teleworking in health does not compromise the quality and efficiency of the provided service, protecting patients from potential risks involved in this new way of providing service.Once this moment is over, the maintenance or reversal of remote work relationships should be well evaluated from the perspective of not increasing the precariousness of health work and intensifying the workers exploitation in the direction of digital servitude, as reflected by AntunesThe results of this research revealed that until June 30, 2021, Brazil had 113 legal norms in force regulating telework in health, and more than half of them (64 norms) were issued in 2020. In 2021, eight new published norms were identified \u2013 however, as part of the survey collection finished in March 2021, it is very likely that the number of norms published throughout 2021 on the topic should be higher than eight.Corroborating the data from the Ipea survey regarding overall telework, this study demonstrates that the topic had already been gaining importance in recent years, even before the pandemic. For instance, in 2018 and 2019 nine and 11 norms were published respectively, which is twice as much as what was previously published, as shown in the The legal norms that today regulate telework in Brazil were issued by different federal agencies and institutions. The federal and regional Professional Councils were responsible for publishing 97 norms regulating telework in health, divided as follows: Pharmacy Councils (2); Speech Therapy Councils (9); Psychology Councils (23); Nursing Councils (1); Medicine Councils (30); Nutrition Councils (4); Physical Education Councils (8); Dentistry Councils (8); Physiotherapy and Occupational Therapy Councils (3); Biomedicine Councils (1); Social Work Councils (7) and an Ordinance on the joint between Regional Councils of Psychology, Social Work and Physiotherapy and Occupational Therapy of the State of Minas Gerais (1).9The remaining 16 legal norms were published by the Presidency of the Republic (laws and decrees), the Ministry of Health, the Ministry of Labor and Employment, the Ministry of Economy and the National Supplementary Health Agency (ANS)When directing efforts to analyze the content of such norms, in the context of telework in health, it is observed that this field is little explored by the current regulation. The search for this type of content in the selected legal norms found that out of the 113 norms, only one deals with the workday length and another one has a device regulating the control of the daily teleworking hours; only one norm contains a device on ergonomics; seven norms have devices about worker safety and health, 12 norms regarding the guarantee of care quality; and 13 norms on the work environment.The in-depth analysis of these norms that regulate working hours, ergonomics and work environment brings important data. With regard to working hours, the only normative act found in the studied period was normative Instruction No. 65, of July 30, 2020, published by the Ministry of Economy, which presents the guidelines, criteria and general procedures to be observed by the bodies and entities that are part of the Civilian Personnel System of the Federal Administration (Sipec) regarding the implementation of a management program. This instruction states that, when the telework model to which the participant is subjected to comprises their entire workday, they are exempted from attendance control. This normative act says nothing about the length or workday time control.13.In the specific legal norm that deals with the time control of the working day , the text highlights that employees in a teleworking regime are not covered by the working day format, being excluded from this protection, as well as from the other rights arising from Title II of the Consolidation of Labor Laws (CLT), such as, night shift extra, overtime or any other compensation that is earned through controling the workday length. It should be noted that since the Labor Reform of 2017, remote work is no longer bound by the control of working hours, nor by the payment of overtime14; 2. Recommendation of the Regional Council for Social Work of the 1st Region No. 01/2020 of March 20, 202015; 3. Resolution of the Regional Council of Social Service of Sergipe (CRESS/SE) No. 01 of March 25, 202016; 4. Technical note No. 01/2020, issued by the Regional Council of Social Service of Acre17; 5. Resolution No. 007/2020 issued by the Regional Council of Dentistry of Minas Gerais18; 6. Resolution No. 02/2019, of January 16, 2019, issued by the Regional Council of Psychology \u2013 Federal District19; 7. Protocol of the Regional Council of Psychology for the \u201cCoexistence Plan of the State Office of Health of Pernambuco to face the Coronavirus Pandemic \u2013covid 19\u201d, published in June 202020; 8. Resolution of the Regional Council of Psychology 15, No. 003, of November 28, 201921; 9. Resolution of the Regional Council of Psychology -18 / MT No. 002/2019 of January 30, 201822; 10. Resolution No. 01, of January 11, 2019,issued by the Federal Council of Psychology23; 11. Normative Instruction No. 65 ofJuly 30, 2020, issued by the Ministry of Economy24; 12. Resolution of the Federal Council of Medicine No. 2.235/2019 of October 1, 201925; 13. Resolution of the Regional Council of Medicine of the State of Bahia No. 367/202026.Regarding the normative content that regulates ergonomics and the work environment, thirteen norms highlighted the importance of work environments meeting adequate conditions to offer a good service. They are: 1. Resolution No. 666 of September 30, 2020, issued by the Federal Nutrition Council24:Although such norms present devices that regulate ergonomics and the working environment, they say little about the employer\u2019s duties to ensure that this occurs.Sometimes the meaning is even reversed, for example, the content about working conditions contained in Article 23 of the Normative Instruction of the Ministry of Economy No. 65 of July 30, 2020When teleworking, it will be the responsibility of the participant to provide the necessary physical and technological structures, through the use of appropriate and ergonomic equipment and furniture, including the costs related to internet connection, electricity and telephone, among other expenses arising from the performance of their duties.27. In this sense, in Colombia, for example, the ABC of Teleworking about the management of occupational risks in teleworking presents a checklist that includes, among other aspects \u201cthe verification of jobs, in addition to proposing and implementing intervention measures associated with the workplace and raising awareness of self-reporting of working conditions\u201d28 (P. 96).Although in Brazil there is little concern about the risks arising from teleworking, it is necessary to remember that, if there is a process of implementing it, the employer should consider all strategies that can reduce or control occupational risk factors that can affect workers\u2019 healthAmong the advices and recommendations given for the implementation of teleworking,in the aforementioned document, are:28 (P. 99).affiliation to the Social Security System, knowing the teleworker\u2019s workplace conditions, ensuring that the teleworker self-reports their working conditions, adding in the internal Labor Regulations, the teleworking contracting model, defining the statutory hours of work per day and per week, making the necessary corrections to work environments, training processes, trainings, among others6 (P. 1).On the other hand, the agreement on teleworking between social agents in the European Union, in 2002, \u201cpoints out the difficulty of regulating this new form of work organization and the Prevention of possible injuries and associated diseases, especially mental illnesses and disorders\u201d9, the heaviest years of the covid-19 pandemic, which remain in force even after the end of the health emergency.The results found here attest to the rapid and exponential growth of telework in health in Brazil, reflected in the normative regulation issued by different bodies and regulatory institutions in the country. If even before the pandemic the use and regulation of remote work were timid and advanced gradually, the pandemic tried to accelerate this process of institutionalization of telework in health, in a seemingly irreversible way. It should be noted, in this sense, the large number of legal norms published in the years 2020 and 2021However, at the same time that the usage and regulation of this practice increased, there is no adequate protection for either the health professional or the patient in the published state regulation. Relevant topics such as the workday length, working time control, ergonomics and the working environment were completely ignored or insufficiently addressed, leaving workers and patients in a vulnerable situation.29 has long presented critical reflections on the precarious working conditions and their deleterious effects on workers\u2019 health, for example, Burnout syndrome, a type of occupational stress that affects professionals involved in any type of healthcare in a relationship of direct, continuous and highly emotional attention31.The understanding of this phenomenon cannot be dissociated from the movements of the world of work in general, about which the literature32. We observed that the evaluations were concentrated between reasonable and terrible, which makes evident the need to monitor the implementation of telework in health in Brazil and to give special attention to the publishing of negligent or even deleterious legal norms regarding the protection of teleworker rights in the health area in Brazil.A survey carried out on the ergonomic conditions in which workers from various economic sectors in Brazil who performed remote work in the first year of the covid-19 pandemic identified that a large part of them evaluates these conditions as \u201creasonable\u201d, because they have some technological equipment, or \u201cterrible\u201d, because they do not have space and conditions to work remotely.When assessing the selected material, we identified a lack of norms issued by health work regulatory agencies and institutions in Brazil that can defend decent working conditions in teleworking in health. Moreover, they are insufficient to induce employers to create favorable conditions for teleworking, whether at home or in another private space. This is a necessary, relevant and complex discussion that involves fundamental rights, such as the confidentiality and privacy of personal data; ethical duties; the responsibilities of health professionals; health protection; and the working conditions of the employee and the service provider. Therefore, health workers and managers must remain vigilant and act quickly to protect their work, employment, service and, above all, the user/patient.Studying teleworking and its effects on work, health services provision and worker integrity should be an urgent task for those who work with management and regulation of health work. Including this topic in the manager\u2019s agenda may minimize the possible deleterious effects on health work management and improve the content and respective applications of legal regulations. We draw attention to the importance of the worker\u2019s health and safety as one of the central elements in this discussion.There is much to learn about this new work modality, because, according to the results presented here, it is possible that the reality of teleworking will grow after the pandemic. Thus, we reinforce that vigilance is necessary, so that this new modality of health work and its technologies do not intensify existing inequalities in the labor world, nor contribute to the creation of hazardous working environments.This study shows a normative gap to be understood and overcome, as well as exposes the still primary, fragmented and hesitant treatment of the regulation of teleworking in health in its various aspects in Brazil. In this regard, we draw attention to the importance of improving teleworking regulation, so that it, contrary to the current scenario, is effectively protective towards the patient\u2019s right to health and the worker\u2019s rights of health professionals.Considering that teleworking is already present in the public and private health systems, its regulatory agenda is an urgent and current challenge since it is already part of the daily life of health institutions. 1 sobre um novo mundo do trabalho, no qual o trabalhador seria o centro do processo de trabalho.Quais t\u00eam sido as iniciativas adotadas pelo Estado brasileiro para a prote\u00e7\u00e3o da sa\u00fade do trabalhador durante o exerc\u00edcio do teletrabalho em sa\u00fade? O que dizem as normas emitidas pelas entidades profissionais e pelos \u00f3rg\u00e3os da administra\u00e7\u00e3o - direta e indireta - federal? Este trabalho versa acerca dessas quest\u00f5es, contextualizando-as numa sociedade cujas tecnologias digitais parecem criar ilus\u00f5es2.As condi\u00e7\u00f5es do exerc\u00edcio profissional da for\u00e7a de trabalho em sa\u00fade hoje no Brasil e no mundo representam um campo importante da sa\u00fade p\u00fablica que deve ser mais bem conhecido e analisado. A pandemia causada pelo coronav\u00edrus trouxe ao centro do palco as condi\u00e7\u00f5es delet\u00e9rias do trabalho em sa\u00fade, sobretudo, aqueles trabalhos que foram realizados de forma presencial. Assim, a precariza\u00e7\u00e3o dos v\u00ednculos empregat\u00edcios, a falta de prote\u00e7\u00e3o no ambiente de trabalho, as subcondi\u00e7\u00f5es e a vulnerabilidade do trabalhador ficaram mais evidentes em um contexto cuja crise sanit\u00e1ria se soma \u00e0s m\u00faltiplas crises que o pa\u00eds vem enfrentando, com efeitos potencialmente devastadores sobre as pol\u00edticas p\u00fablicas de sa\u00fadeA pandemia da covid-19 tamb\u00e9m deixou evidente que o aprofundamento dos problemas cr\u00f4nicos que impactam as condi\u00e7\u00f5es do trabalho em sa\u00fade desenvolvidos presencialmente foi acompanhado pelo surgimento de novos problemas, pr\u00f3prios da sociedade digital e ampliados no per\u00edodo pand\u00eamico, por exemplo, o exerc\u00edcio do trabalho domiciliar pelos empregados, que passam a realizar suas tarefas sob demandas virtuais, mediante plataformas e aplicativos digitais. Os v\u00ednculos e rela\u00e7\u00f5es trabalhistas tornaram-se, com a amplia\u00e7\u00e3o do trabalho digital, mais flex\u00edveis, inst\u00e1veis, intensos e fr\u00e1geis.3. Estudo realizado na Argentina, Brasil, Chile, Col\u00f4mbia e M\u00e9xico revelou que, durante a pandemia, houve um aumento de 324%, no teletrabalho, entre o primeiro e o segundo trimestre de 20204. Nessa mesma dire\u00e7\u00e3o, estima-se que at\u00e9 2050 metade da popula\u00e7\u00e3o ativa realizar\u00e1 seu trabalho por meios digitais5.A literatura sinaliza que a utiliza\u00e7\u00e3o do teletrabalho, aliado ao surgimento de uma nova regula\u00e7\u00e3o incrementada durante a pandemia como consequ\u00eancia do distanciamento social, dificilmente retornar\u00e1 \u00e0 forma como era antes da pandemia5. No cen\u00e1rio p\u00f3s-pand\u00eamico ficar\u00e1 cada vez mais dif\u00edcil distinguir o tempo do trabalho e do n\u00e3o trabalho1. Esses s\u00e3o alguns dos novos e complexos desafios que se apresentam para o campo da regula\u00e7\u00e3o do trabalho em sa\u00fade.As heran\u00e7as digitais deixadas pela covid-19 na forma de realizar trabalho em sa\u00fade dever\u00e3o permanecer mesmo ap\u00f3s superada a pandemia. O teletrabalho executado no domic\u00edlio se apresenta como uma dessas heran\u00e7asEste artigo pretende identificar as normas jur\u00eddicas publicadas nos anos de 2020 e 2021 para regular direta ou indiretamente o teletrabalho em sa\u00fade no Brasil, analisando-as sob o enfoque dos seguintes temas, no contexto do teletrabalho: tempo da jornada de trabalho; ergonomia; ambiente laboral; seguran\u00e7a e sa\u00fade do trabalhador.A ainda escassa literatura cient\u00edfica sobre teletrabalho em sa\u00fade impossibilita avaliar com maior amplitude, nesse momento, as evid\u00eancias dos seus efeitos nos servi\u00e7os de sa\u00fade e na gest\u00e3o do trabalhador. \u00c9 fundamental que a regula\u00e7\u00e3o do teletrabalho em sa\u00fade seja realizada para a plena prote\u00e7\u00e3o do direito \u00e0 sa\u00fade, englobando prote\u00e7\u00e3o aos pacientes e aos profissionais da \u00e1rea. Assim, o que se coloca em perspectiva neste artigo \u00e9 a necessidade de se acompanhar com aten\u00e7\u00e3o as normas que v\u00eam sendo editadas para regular o teletrabalho em sa\u00fade, possibilitando uma an\u00e1lise cr\u00edtica para o seu aperfei\u00e7oamento constante.Cumpre frisar que este artigo \u00e9 um recorte anal\u00edtico original dos dados prim\u00e1rios e resultado da pesquisa \u201cRegula\u00e7\u00e3o do Teletrabalho em Sa\u00fade no Brasil\u201d, cujo objetivo consistiu em identificar e compreender como o teletrabalho em sa\u00fade est\u00e1 sendo regulado no Brasil, por meio do mapeamento e an\u00e1lise de todas as normas jur\u00eddicas  de regula\u00e7\u00e3o do teletrabalho em sa\u00fade editadas no Brasil.Foram coletadas e analisadas as normas jur\u00eddicas que regulam as profiss\u00f5es de sa\u00fade no Brasil, para fins de identificar aquelas que tratam direta ou indiretamente do teletrabalho em sa\u00fade e analis\u00e1-las com enfoque para a compreens\u00e3o sobre de que forma a regula\u00e7\u00e3o estatal do teletrabalho em sa\u00fade no Brasil est\u00e1 (ou n\u00e3o est\u00e1) protegendo os direitos do trabalhador e dos pacientes. Nesse sentido, foram identificadas e analisadas as normas jur\u00eddicas e os dispositivos espec\u00edficos de cada uma delas que tratavam de regular os seguintes temas de sa\u00fade p\u00fablica e sa\u00fade do trabalhador, relevantes no contexto do teletrabalho: tempo da jornada de trabalho; ergonomia; ambiente laboral; seguran\u00e7a e sa\u00fade do trabalhador.7, que relaciona 14 profiss\u00f5es de sa\u00fade de n\u00edvel superior para os fins da atua\u00e7\u00e3o do conselho. Para essas 14 profiss\u00f5es foram mapeados 13 conselhos profissionais com compet\u00eancia legal de publicar normas jur\u00eddicas que para a regula\u00e7\u00e3o do exerc\u00edcio profissional para cada uma dessas profiss\u00f5es, sendo que o Conselho Federal de Fisioterapia e Terapia Ocupacional apresenta compet\u00eancia regulat\u00f3ria sobre essas duas profiss\u00f5es.O conceito de profiss\u00e3o de sa\u00fade utilizado tem como refer\u00eancia a Resolu\u00e7\u00e3o n. 287, de 8 de outubro de 1998, do Conselho Nacional de Sa\u00fadeO formul\u00e1rio que orientou a coleta de dados para a pesquisa foi elaborado com o fim de organizar e selecionar informa\u00e7\u00f5es gerais acerca de cada ato normativo encontrado, por exemplo, a data de publica\u00e7\u00e3o, o nome e o \u00f3rg\u00e3o emissor, informa\u00e7\u00f5es espec\u00edficas quanto \u00e0s condi\u00e7\u00f5es de trabalho e seguran\u00e7a da informa\u00e7\u00e3o e prote\u00e7\u00e3o de dados pessoais. Para os projetos de lei, foi elaborado formul\u00e1rio espec\u00edfico, destacando informa\u00e7\u00f5es centrais do documento, autoria, casa legislativa, data de publica\u00e7\u00e3o, ementas e se o PL revogava ou n\u00e3o a norma existente.O formul\u00e1rio foi hospedado em uma plataforma da Universidade Federal do Rio Grande do Norte (UFRN) desenvolvida para esse fim, permitindo \u00e0 equipe de pesquisa acesso seguro e funcional ao instrumento e a alimenta\u00e7\u00e3o da base de dados criada com as informa\u00e7\u00f5es estrat\u00e9gicas dos documentos normativos encontrados.sites das institui\u00e7\u00f5es reguladoras. Ao longo da leitura e da coleta desse conjunto de dados, o formul\u00e1rio foi preenchido de forma cont\u00ednua.A coleta de informa\u00e7\u00f5es associadas \u00e0s normas jur\u00eddicas aconteceu entre os meses de fevereiro, mar\u00e7o, abril, maio e junho de 2021, sendo 30 de junho de 2021 o recorte temporal da pesquisa. Nessa etapa metodol\u00f3gica a coleta dos textos normativos foi feita, de modo priorit\u00e1rio, diretamente nos di\u00e1rios oficiais da Uni\u00e3o. Em seguida, foram pesquisados outros Antes da coleta, foram definidas as modalidades de normas jur\u00eddicas de interesse para a pesquisa, sendo eles: dispositivos constitucionais, leis complementares, leis ordin\u00e1rias, decretos presidenciais, decretos legislativos, leis delegadas, medidas provis\u00f3rias, portarias, resolu\u00e7\u00f5es, resolu\u00e7\u00f5es normativas, instru\u00e7\u00f5es normativas, decis\u00f5es, circulares, comunicados e pareceres. Foram previamente exclu\u00eddas todas as normas jur\u00eddicas relativas aos processos administrativos disciplinares, sancionat\u00f3rios e de contrata\u00e7\u00e3o, por exemplo, licita\u00e7\u00e3o.8 e as bases disponibilizadas pelos pr\u00f3prios Conselhos Profissionais. A princ\u00edpio, a estrat\u00e9gia de busca definiu os seguintes descritores: teleconsulta, telessa\u00fade, teletrabalho, teleassist\u00eancia, teleprofiss\u00e3o , sa\u00fade digital, consulta \u00e0 dist\u00e2ncia, atendimento \u00e0 dist\u00e2ncia, remoto, remota, home office, inform\u00e1tica, tecnologias da informa\u00e7\u00e3o e comunica\u00e7\u00e3oAs bases oficiais selecionadas foram a da Imprensa NacionalA busca na base da Imprensa Nacional foi feita na modalidade \u201cPesquisa Ato a Ato\u201d, que seleciona todas as normas jur\u00eddicas encontradas que cont\u00e9m o descritor indicado. A busca foi filtrada conforme a institui\u00e7\u00e3o ou \u00f3rg\u00e3o p\u00fablico emissor da norma. O A base de dados da Imprensa Nacional permite a busca de normas jur\u00eddicas editadas entre a data da busca (de fevereiro a junho de 2021) e o ano de 2018. Essa base d\u00e1 acesso ao conjunto de todas as publica\u00e7\u00f5es do Di\u00e1rio Oficial da Uni\u00e3o. A busca centrou-se na Se\u00e7\u00e3o 1 do Di\u00e1rio Oficial da Uni\u00e3o, formada por atos normativos (normas jur\u00eddicas), excluindo-se a Se\u00e7\u00e3o 2, formada por atos de pessoal e a Se\u00e7\u00e3o 3, formada por contratos, editais e avisos. Foram inicialmente selecionadas as normas jur\u00eddicas publicadas entre janeiro de 2018 e 30 de junho de 2021 no \u00e2mbito da Uni\u00e3o. Esses documentos foram lidos, em primeira an\u00e1lise, a fim de identificar refer\u00eancias diretas sobre normas anteriores a 2018 e, assim, agregar essas normas complementares ao conjunto de normas coletadas.Em seguida, buscou-se as bases documentais dos pr\u00f3prios Conselhos Profissionais (federais e regionais) e entidades da administra\u00e7\u00e3o p\u00fablica, de maneira explorat\u00f3ria. Essa etapa n\u00e3o considerou um recorte temporal, uma vez que foi realizada uma leitura flutuante nos documentos publicados em cada reposit\u00f3rio, tendo como base o conjunto dos descritores escolhidos para esta pesquisa, pelo interesse em compreender discuss\u00f5es e marcos institucionais vigentes acerca do tema.Por fim, incluiu-se tamb\u00e9m, para todas as profiss\u00f5es reguladas, a localiza\u00e7\u00e3o e an\u00e1lise de cada C\u00f3digo de \u00c9tica. Ainda que boa parte desses C\u00f3digos n\u00e3o contenham os descritores indicados, tais normas frequentemente versam sobre confidencialidade do tratamento e outros temas relevantes para a compreens\u00e3o da regula\u00e7\u00e3o da terap\u00eautica \u00e0 dist\u00e2ncia.Desse modo, obteve-se assim todas as normas jur\u00eddicas, inclusive as revogadas, entre janeiro de 2018 e junho de 2021, bem como todas as normas jur\u00eddicas em vigor que regulam o teletrabalho em sa\u00fade, obtidos de acordo com os descritores mencionados.Como resultado da pesquisa, foram selecionadas para an\u00e1lise, no total, 113 normas jur\u00eddicas da Uni\u00e3o.10. Esses s\u00e3o alguns dos desafios antigos e atuais enfrentados por aqueles que fazem a gest\u00e3o do trabalho nas institui\u00e7\u00f5es p\u00fablicas de sa\u00fade. Recentemente, com o crescimento do teletrabalho na \u00e1rea da sa\u00fade, novos desafios relacionados \u00e0 regula\u00e7\u00e3o do exerc\u00edcio do teletrabalho das profiss\u00f5es de sa\u00fade surgiram10.O setor de Sa\u00fade no Brasil tem sido palco de conflitos regulat\u00f3rios que abrangem temas diversos, tais como: a defini\u00e7\u00e3o dos escopos de pr\u00e1tica de cada profiss\u00e3o; a defini\u00e7\u00e3o das exig\u00eancias de forma\u00e7\u00e3o para o exerc\u00edcio de determinadas atividades; as jornadas de trabalho; e as remunera\u00e7\u00f5es a serem percebidas pelos diferentes profissionais de sa\u00fade11. No setor de sa\u00fade, essa modalidade de trabalho vem se fazendo cada vez mais presente, tendo sua expans\u00e3o incrementada no per\u00edodo da pandemia covid-19. Contudo, \u00e9 importante frisar que \u201ca convers\u00e3o das formas de trabalho presenciais em remotas, no contexto pand\u00eamico, consistiu em conting\u00eancia sanit\u00e1ria\u201d11.Pesquisa publicada pelo Instituto de Pesquisa Econ\u00f4mica Aplicada (Ipea) revela que o uso do teletrabalho em geral no Brasil j\u00e1 \u00e9 bastante significativo quando comparado a outros pa\u00edses ao redor do mundo, mostrando que, em uma lista de 86 pa\u00edses classificados em rela\u00e7\u00e3o \u00e0 propor\u00e7\u00e3o de uso do teletrabalho, o Brasil ocupa a 45\u00aa posi\u00e7\u00e3o12. Tamb\u00e9m deve-se cuidar para que o teletrabalho em sa\u00fade n\u00e3o comprometa a qualidade e efici\u00eancia do servi\u00e7o prestado, protegendo os pacientes dos potenciais riscos que envolvem essa nova forma de prestar servi\u00e7o.Superado esse momento, a manuten\u00e7\u00e3o ou revers\u00e3o das rela\u00e7\u00f5es de trabalho remoto dever\u00e1 ser bem avaliada na perspectiva de n\u00e3o se ampliar a precariza\u00e7\u00e3o do trabalho em sa\u00fade e intensificar a explora\u00e7\u00e3o dos trabalhadores no sentido da servid\u00e3o digital, conforme reflete AntunesOs resultados desta pesquisa revelaram que at\u00e9 30 de junho de 2021, o Brasil tinha 113 normas jur\u00eddicas vigentes regulando o teletrabalho em sa\u00fade, sendo que mais da metade delas (64 normas) foram emitidas no ano de 2020. No ano de 2021 foram identificadas oito novas normas publicadas \u2013 no entanto, como parte da coleta da pesquisa foi encerrada em mar\u00e7o de 2021, \u00e9 muito prov\u00e1vel que o n\u00famero de normas editadas durante todo o ano de 2021 sobre o tema seja maior do que oito.Corroborando os dados da pesquisa do Ipea em rela\u00e7\u00e3o ao teletrabalho geral, a pesquisa ora apresentada demonstra que o tema j\u00e1 vinha ganhando import\u00e2ncia nos \u00faltimos anos, mesmo antes da pandemia, j\u00e1 que em 2018 e 2019 foram editadas nove e 11 normas respectivamente, n\u00famero que \u00e9 maior do que o dobro do que foi editado em todos os anos anteriores, conforme demonstrado na As normas jur\u00eddicas que hoje regulam o teletrabalho no Brasil foram emitidas por diferentes \u00f3rg\u00e3os e institui\u00e7\u00f5es federais. Os Conselhos Profissionais Federais e Regionais foram respons\u00e1veis pela edi\u00e7\u00e3o de 97 normas regulando teletrabalho em sa\u00fade, divididas da seguinte forma: Conselhos de Farm\u00e1cia (2); Conselhos de Fonoaudiologia (9); Conselhos de Psicologia (23); Conselhos de Enfermagem (1); Conselhos de Medicina (30); Conselhos de Nutri\u00e7\u00e3o (4); Conselhos de Educa\u00e7\u00e3o F\u00edsica (8); Conselhos de Odontologia (8); Conselhos de Fisioterapia e Terapia Ocupacional (3); Conselhos de Biomedicina (1); Conselhos de Servi\u00e7o Social (7) e uma Portaria em conjunto entre Conselhos Regionais de Psicologia, Servi\u00e7o Social e Fisioterapia e Terapia Ocupacional do Estado de Minas Gerais (1).9As 16 normas jur\u00eddicas restantes foram publicadas pela Presid\u00eancia da Rep\u00fablica (Leis e Decretos), pelo Minist\u00e9rio da Sa\u00fade, pelo Minist\u00e9rio do Trabalho e Emprego, pelo Minist\u00e9rio da Economia e pela Ag\u00eancia Nacional de Sa\u00fade Suplementar (ANS)Ao direcionar esfor\u00e7os para an\u00e1lise de conte\u00fado de tais normas no tema das condi\u00e7\u00f5es de trabalho, no contexto do teletrabalho em sa\u00fade, observa-se que esse tema constitui um campo pouco explorado pela regula\u00e7\u00e3o atual. A busca por esse tipo de conte\u00fado nas normas jur\u00eddicas selecionadas constatou que das 113 normas, apenas uma norma trata da jornada de trabalho e uma outra apresenta dispositivo regulando o controle do tempo da jornada de teletrabalho; somente uma norma cont\u00e9m dispositivo sobre ergonomia; sete normas apresentam dispositivos acerca da seguran\u00e7a e sa\u00fade do trabalhador, 12 normas quanto \u00e0 garantia da qualidade do cuidado; e 13 normas sobre ambiente de trabalho.A an\u00e1lise aprofundada dessas normas que regulam jornada de trabalho, ergonomia e ambiente do trabalho traz dados importantes. No que diz respeito \u00e0 jornada de trabalho, o \u00fanico ato normativo encontrado no per\u00edodo estudado foi a Instru\u00e7\u00e3o Normativa n\u00ba 65, de 30 de julho de 2020, publicada pelo Minist\u00e9rio da Economia, que apresenta as orienta\u00e7\u00f5es, crit\u00e9rios e procedimentos gerais a serem observados pelos \u00f3rg\u00e3os e entidades integrantes do Sistema de Pessoal Civil da Administra\u00e7\u00e3o Federal (Sipec) relativos \u00e0 implementa\u00e7\u00e3o de Programa de Gest\u00e3o. Essa instru\u00e7\u00e3o afirma que, quando a forma de teletrabalho a que est\u00e1 submetido o participante compreende a totalidade da sua jornada de trabalho, ele \u00e9 dispensado do controle de frequ\u00eancia. Esse ato normativo nada diz em rela\u00e7\u00e3o ao tempo ou controle de tempo da jornada.13.Na norma jur\u00eddica espec\u00edfica que trata do controle de tempo da jornada de trabalho , o texto da norma destaca que os empregados em regime de teletrabalho n\u00e3o est\u00e3o abrangidos pelo formato de jornada de trabalho, estando exclu\u00eddos dessa prote\u00e7\u00e3o, bem como dos demais direitos provenientes do T\u00edtulo II da Consolida\u00e7\u00e3o das Leis Do Trabalho (CLT), tais como, adicional noturno, horas extras ou qualquer outro que seja auferido por meio de controle da jornada de trabalho. Ressalta-se que desde a Reforma Trabalhista de 2017, o trabalho remoto n\u00e3o est\u00e1 mais sujeito ao controle de jornada, tampouco ao pagamento de horas extras14; 2. Recomenda\u00e7\u00e3o do Conselho Regional de Servi\u00e7o Social da 1\u00aa Regi\u00e3o n\u00ba 01/2020, de 20 de mar\u00e7o de 202015; 3. Resolu\u00e7\u00e3o do Conselho Regional de Servi\u00e7o Social de Sergipe (CRESS/SE) n\u00ba 01 de 25 de mar\u00e7o de 202016; 4. Nota T\u00e9cnica n\u00ba 01/2020, emitida pelo Conselho Regional de Servi\u00e7o Social do Acre17; 5. Resolu\u00e7\u00e3o n\u00ba 007/2020 emitida pelo Conselho Regional de Odontologia de Minas Gerais18; 6. Resolu\u00e7\u00e3o n\u00ba02/2019, de 16 de janeiro de 2019, emitida pelo Conselho Regional de Psicologia \u2013 Distrito Federal19; 7. Protocolo do Conselho Regional de Psicologia para o \u201cPlano de Conviv\u00eancia da Secretaria Estadual de Sa\u00fade de Pernambuco para Enfrentamento da Pandemia do Coronav\u00edrus \u2013 covid 19\u201d, publicado em junho de 202020; 8. Resolu\u00e7\u00e3o do Conselho Regional de Psicologia 15, n\u00ba 003, de 28 de novembro de 201921; 9. Resolu\u00e7\u00e3o do Conselho Regional de Psicologia - 18/MT n\u00ba002/2019 de 30 de janeiro de 201822; 10. Resolu\u00e7\u00e3o n\u00ba 01, de 11 de janeiro de 2019, emitida pelo Conselho Federal de Psicologia23; 11. Instru\u00e7\u00e3o Normativa n\u00ba 65, de 30 de julho de 2020, emitido pelo Minist\u00e9rio da Economia24; 12. Resolu\u00e7\u00e3o do Conselho Federal de Medicina n\u00ba 2.235/2019 de 1 de outubro de 201925; 13. Resolu\u00e7\u00e3o do Conselho Regional de Medicina do Estado da Bahia n\u00ba 367/202026.Quanto ao conte\u00fado normativo que regula ergonomia e ambiente de trabalho, treze normas destacaram a import\u00e2ncia de que os ambientes de trabalho atendam \u00e0s condi\u00e7\u00f5es para o oferecimento de um bom servi\u00e7o. S\u00e3o elas: 1. Resolu\u00e7\u00e3o n\u00ba 666, de 30 de setembro de 2020, emitido pelo Conselho Federal de Nutri\u00e7\u00e3o24:Embora tais normas apresentem em seu conte\u00fado dispositivos que regulam ergonomia e ambiente de trabalho, elas pouco dizem acerca dos deveres do empregador para garantir que isso ocorra. \u00c0s vezes o sentido \u00e9 at\u00e9 inverso, por exemplo, o conte\u00fado sobre condi\u00e7\u00f5es de trabalho que consta do artigo 23 da Instru\u00e7\u00e3o Normativa do Minist\u00e9rio da Economia n. 65, de 30 de julho de 2020Quando estiver em teletrabalho, caber\u00e1 ao participante providenciar as estruturas f\u00edsica e tecnol\u00f3gica necess\u00e1rias, mediante a utiliza\u00e7\u00e3o de equipamentos e mobili\u00e1rios adequados e ergon\u00f4micos, assumindo, inclusive, os custos referentes \u00e0 conex\u00e3o \u00e0 internet, \u00e0 energia el\u00e9trica e ao telefone, entre outras despesas decorrentes do exerc\u00edcio de suas atribui\u00e7\u00f5es.27. Nesse sentido, por exemplo, o ABC do Teletrabalho, na Col\u00f4mbia, sobre a gest\u00e3o de riscos ocupacionais no teletrabalho apresenta uma lista de verifica\u00e7\u00e3o que inclui, entre outros aspectos, \u201ca verifica\u00e7\u00e3o de empregos, al\u00e9m de propor e implementar medidas de interven\u00e7\u00e3o associadas ao local de trabalho e conscientizar sobre o autorrelato das condi\u00e7\u00f5es de trabalho\u201d28 (p. 96).Embora no Brasil haja pouca preocupa\u00e7\u00e3o com os riscos oriundos do teletrabalho, \u00e9 necess\u00e1rio lembrar que, se h\u00e1 um processo de implanta\u00e7\u00e3o de teletrabalho, o empregador dever\u00e1 considerar todas as estrat\u00e9gias que possam diminuir ou controlar os fatores de riscos ocupacionais que podem afetar a sa\u00fade do trabalhadorEntre os conselhos e recomenda\u00e7\u00f5es dadas para a implanta\u00e7\u00e3o do teletrabalho, no citado documento, est\u00e3o:28 (p. 99).filia\u00e7\u00e3o ao sistema integral de previd\u00eancia social, conhecer as condi\u00e7\u00f5es do local de trabalho do teletrabalhador, garantir que o teletrabalhador autorrelate suas condi\u00e7\u00f5es de trabalho, acrescentando no Regimento Interno do Trabalho, a modalidade de contrata\u00e7\u00e3o de teletrabalho, definir as horas estatut\u00e1rias de trabalho por dia e por semana, fazer as corre\u00e7\u00f5es necess\u00e1rias para os ambientes de trabalho, processos de treinamento, treinamentos e treinamentos, entre outros6 (p. 1).Por outro lado, o acordo acerca do teletrabalho entre agentes sociais na Uni\u00e3o Europeia, em 2002, \u201caponta a dificuldade de regulamentar essa nova forma de organiza\u00e7\u00e3o do trabalho e da preven\u00e7\u00e3o de poss\u00edveis les\u00f5es e doen\u00e7as associadas, especialmente transtornos mentais e dist\u00farbios\u201d9, anos mais pesados da pandemia da covid-19, normas essas que mant\u00e9m sua vig\u00eancia mesmo ap\u00f3s o final da emerg\u00eancia sanit\u00e1ria.Os resultados encontrados atestam o crescimento r\u00e1pido e exponencial do teletrabalho em sa\u00fade no Brasil, refletido na regula\u00e7\u00e3o normativa editada por diferentes \u00f3rg\u00e3os e institui\u00e7\u00f5es reguladoras do pa\u00eds. Se at\u00e9 antes da pandemia o uso e a regula\u00e7\u00e3o do teletrabalho eram t\u00edmidos e avan\u00e7avam de maneira gradual, a pandemia tratou de acelerar esse processo de institucionaliza\u00e7\u00e3o do teletrabalho em sa\u00fade no pa\u00eds, em um movimento que parece sem volta. Destaque-se, nesse sentido, o grande n\u00famero de normas jur\u00eddicas publicadas nos anos de 2020 e 2021No entanto, ao mesmo tempo em que se aumentou o uso e a regula\u00e7\u00e3o dessa pr\u00e1tica, n\u00e3o se verifica na regula\u00e7\u00e3o estatal editada uma prote\u00e7\u00e3o adequada seja do profissional de sa\u00fade, seja do paciente. Temas relevantes como os da jornada de trabalho, controle do tempo de trabalho, ergonomia e ambiente de trabalho foram completamente ignorados ou tratados de forma insuficiente, deixando trabalhadores e pacientes em situa\u00e7\u00e3o de vulnerabilidade.29 h\u00e1 muito apresenta reflex\u00f5es cr\u00edticas acerca das prec\u00e1rias condi\u00e7\u00f5es do trabalho e dos seus efeitos delet\u00e9rios \u00e0 sa\u00fade do trabalhador, por exemplo, a S\u00edndrome de Burnout, um tipo de estresse ocupacional que acomete profissionais envolvidos em qualquer tipo de cuidado em uma rela\u00e7\u00e3o de aten\u00e7\u00e3o direta, cont\u00ednua e altamente emocional31.A compreens\u00e3o do fen\u00f4meno do teletrabalho n\u00e3o pode ser dissociada dos movimentos do mundo do trabalho em geral, a respeito dos quais a literatura32. Observa-se que as avalia\u00e7\u00f5es se concentraram entre razo\u00e1vel e p\u00e9ssima, o que torna evidente a necessidade de acompanhar os movimentos de institui\u00e7\u00e3o de teletrabalho em sa\u00fade no Brasil e de dedicar especial aten\u00e7\u00e3o para a edi\u00e7\u00e3o de normas jur\u00eddicas negligentes ou at\u00e9 delet\u00e9rias no que se refere \u00e0 prote\u00e7\u00e3o dos direitos do teletrabalhador na \u00e1rea da sa\u00fade no Brasil.Uma pesquisa realizada sobre as condi\u00e7\u00f5es ergon\u00f4micas em que os trabalhadores de diversos setores econ\u00f4micos do Brasil exerceram o trabalho remoto no primeiro ano da pandemia causada pela covid-19 identificou que grande parte dos trabalhadores avalia essas condi\u00e7\u00f5es como \u201crazo\u00e1veis\u201d, por disporem de alguns equipamentos tecnol\u00f3gicos, ou \u201cp\u00e9ssimas\u201d, por n\u00e3o terem espa\u00e7o e condi\u00e7\u00f5es para exercer o trabalhoA an\u00e1lise das normas jur\u00eddicas selecionadas permite identificar a aus\u00eancia de normas editadas pelos \u00f3rg\u00e3os e institui\u00e7\u00f5es reguladoras do trabalho em sa\u00fade no Brasil aptas a defender condi\u00e7\u00f5es dignas de trabalho no campo do teletrabalho em sa\u00fade, e insuficientes para induzir empregadores a criarem condi\u00e7\u00f5es favor\u00e1veis \u00e0 realiza\u00e7\u00e3o do teletrabalho, seja ele realizado nos domic\u00edlios, seja em outro espa\u00e7o privado. Essa \u00e9 uma discuss\u00e3o necess\u00e1ria, relevante e complexa, que envolve direitos fundamentais, tais como, o sigilo e privacidade de dados pessoais; os deveres \u00e9ticos; as responsabilidades dos profissionais de sa\u00fade; a prote\u00e7\u00e3o da sa\u00fade; e as condi\u00e7\u00f5es de trabalho do empregado e do prestador de servi\u00e7os. Por isso, os trabalhadores e gestores da sa\u00fade devem se manter atentos e agir r\u00e1pido para proteger o trabalho, o emprego, o servi\u00e7o e, sobretudo, o usu\u00e1rio/paciente.Estudar o teletrabalho e seus efeitos no emprego, na presta\u00e7\u00e3o dos servi\u00e7os de sa\u00fade e na integridade do trabalhador deve se constituir uma tarefa urgente para aqueles que atuam na \u00e1rea da gest\u00e3o e da regula\u00e7\u00e3o do trabalho em sa\u00fade. Incluir esse tema na agenda do gestor poder\u00e1 minimizar os poss\u00edveis efeitos delet\u00e9rios para a gest\u00e3o do trabalho em sa\u00fade e melhorar os conte\u00fados e as respectivas aplica\u00e7\u00f5es das normativas legais. Destaca-se a import\u00e2ncia de se constar a sa\u00fade e a seguran\u00e7a do trabalhador como um dos elementos centrais nessa discuss\u00e3o.H\u00e1 muito o que se aprender sobre essa nova modalidade de trabalho, pois, conforme os resultados aqui apresentados, \u00e9 poss\u00edvel que a realidade do teletrabalho seja incrementada ap\u00f3s a pandemia. Dessa forma, refor\u00e7a-se a necess\u00e1ria vigil\u00e2ncia para que essa nova modalidade de trabalho em sa\u00fade e as tecnologias que lhe d\u00e3o sustenta\u00e7\u00e3o n\u00e3o aumentem as desigualdades j\u00e1 existentes no mundo do trabalho, nem contribuam para que os trabalhadores e usu\u00e1rios realizem suas atividades em ambientes inseguros.A pesquisa realizada evidencia uma lacuna normativa a ser compreendida e superada, bem como desnuda o tratamento ainda prim\u00e1rio, fragmentado e titubeante do Estado brasileiro para a regula\u00e7\u00e3o do teletrabalho em sa\u00fade em seus diversos aspectos. Nesse sentido, pretende-se chamar a aten\u00e7\u00e3o para a import\u00e2ncia de se aperfei\u00e7oar a regula\u00e7\u00e3o do teletrabalho, no sentido de que essa regulamenta\u00e7\u00e3o, ao contr\u00e1rio da realidade atual, seja efetivamente protetora do direito \u00e0 sa\u00fade dos pacientes e dos direitos do profissional da \u00e1rea da sa\u00fade.Considerando que o teletrabalho j\u00e1 est\u00e1 presente nos sistemas p\u00fablico e privado de sa\u00fade, a sua agenda regulat\u00f3ria \u00e9 um desafio urgente, e n\u00e3o do futuro, uma vez que essa realidade j\u00e1 faz parte do cotidiano das institui\u00e7\u00f5es de sa\u00fade."}
+{"text": "No Brasil, houve expans\u00e3o da cobertura de servi\u00e7os odontol\u00f3gicos na aten\u00e7\u00e3oprim\u00e1ria \u00e0 sa\u00fade (APS), e a \u00eanfase do trabalho dos profissionais mudou paraincluir mais esfor\u00e7os na preven\u00e7\u00e3o e no diagn\u00f3stico. Entretanto, pouco se sabesobre a influ\u00eancia da cobertura do Programa Bolsa Fam\u00edlia no uso dessesservi\u00e7os. Esta pesquisa avaliou a associa\u00e7\u00e3o entre cobertura municipal doPrograma Bolsa Fam\u00edlia e uso de servi\u00e7os odontol\u00f3gicos. Este estudo ecol\u00f3gico,realizado com dados dos 5.570 munic\u00edpios brasileiros, estimou, por meio deregress\u00f5es log\u00edsticas, o impacto da varia\u00e7\u00e3o de cobertura do Programa BolsaFam\u00edlia, das Estrat\u00e9gias Sa\u00fade da Fam\u00edlia (ESF) e das equipes de sa\u00fade bucal(EqSB) no n\u00famero de procedimentos odontol\u00f3gicos restauradores, coletivos,preventivos e exodontias realizados via Sistema \u00danico de Sa\u00fade (SUS) entre osper\u00edodos 2007/2008 e 2010/2011. Os percentuais de munic\u00edpios em que houveaumento das taxas de procedimentos preventivos, coletivos, restauradores eexodontias foram de 46%, 59,8%, 52,5% e 44,2%, respectivamente. No modeloajustado, em munic\u00edpios com maior cobertura do Bolsa Fam\u00edlia houve menos chancesde aumentar a ocorr\u00eancia de procedimentos coletivos  e preventivos  e mais chances de elevaras taxas de procedimentos restauradores  eexodontias . A expans\u00e3o na taxa de cobertura dasEqSB esteve associada significativamente a uma chance maior de aumento do n\u00famerode procedimentos preventivos, restauradores e exodontias. Conclui-se que acobertura das EqSB foi a principal vari\u00e1vel associada \u00e0 amplia\u00e7\u00e3o da quantidadede procedimentos odontol\u00f3gicos realizados no servi\u00e7o p\u00fablico. Programas de transfer\u00eancia de renda objetivam aliviar os efeitos da pobreza a curtoprazo e, a longo prazo, aspiram quebrar o ciclo intergeracional da pobreza.Centram-se, prioritariamente, nas crian\u00e7as, visando que se tornem adultos produtivose autossuficientes ,,,,,O Bolsa Fam\u00edlia, que em 2021 foi substitu\u00eddo por um novo programa de transfer\u00eancia derenda chamado Aux\u00edlio Brasil, foi um dos maiores programas de transfer\u00eancia de rendaa operar mundialmente. Ele foi criado no ano de 2004 ,,No Brasil, houve expans\u00e3o da cobertura de servi\u00e7os odontol\u00f3gicos na aten\u00e7\u00e3o prim\u00e1ria\u00e0 sa\u00fade (APS) REporting of studies Conducted usingObservational Routinely-collected Data (RECORD) Este \u00e9 um estudo ecol\u00f3gico em n\u00edvel municipal de agrega\u00e7\u00e3o que investiga mudan\u00e7asno tempo. O per\u00edodo inicial \u00e9 a m\u00e9dia dos anos 2007 e 2008 e o per\u00edodo final \u00e9 am\u00e9dia de 2010 e 2011. Esses dois per\u00edodos foram selecionados peladisponibilidade dos dados cruzados para as vari\u00e1veis de cobertura do ProgramaBolsa Fam\u00edlia e uso dos servi\u00e7os odontol\u00f3gicos, bem como pelas informa\u00e7\u00f5esobtidas do censo de 2010 para as demais covariadas. Foram coletados e analisadosos dados para todos os 5.570 munic\u00edpios brasileiros. A descri\u00e7\u00e3o do estudo segueos crit\u00e9rios indicados pelo Procedimentos odontol\u00f3gicos realizados no Sistema \u00danico de Sa\u00fade (SUS) foram asvari\u00e1veis dependentes deste estudo. Tais informa\u00e7\u00f5es foram coletadas do Sistemade Informa\u00e7\u00f5es Ambulatoriais do Sistema \u00danico de Sa\u00fade (SIA-SUS), por meio doTabnet, e divididas em quatro grupos, a saber: procedimentos coletivos,restauradores, preventivos e exodontias, conforme elencados por Celeste et al.per capita de at\u00e9 BRL 140,00). A partir de 2010, oindicador foi calculado adotando como denominador a vari\u00e1vel \u201cestimativa defam\u00edlias pobres - perfil Bolsa Fam\u00edlia - censo 2010\u201d. Os dados foram obtidos doDepartamento de Inform\u00e1tica do Sistema \u00danico de Sa\u00fade (DATASUS), por meio doaplicativo Tabnet (http://www2.datasus.gov.br/tabnetmobile/page_about2.html).A cobertura do Programa Bolsa Fam\u00edlia foi a principal vari\u00e1vel explicativa(independente) de interesse. Ela foi constru\u00edda da seguinte forma: percentual defam\u00edlias atendidas pelo programa em cada munic\u00edpio em rela\u00e7\u00e3o \u00e0 estimativa defam\u00edlias pobres que se enquadram no perfil de inclus\u00e3o do programa. Em 2007 e2008, o indicador foi calculado utilizando como denominador a vari\u00e1vel\u201cestimativa de fam\u00edlias pobres - PNAD 2006\u201d  e das equipes desa\u00fade bucal (EqSB) foram consideradas vari\u00e1veis independentes de confus\u00e3o. Elass\u00e3o percebidas como indicadores de acesso ao servi\u00e7o odontol\u00f3gico . Como numerador, foi extra\u00eddo o n\u00famero de equipes por munic\u00edpio doSistema de Cadastro Nacional de Estabelecimentos de Sa\u00fade (CNES) e comodenominador utilizou-se a popula\u00e7\u00e3o municipal estimada pelo Instituto Brasileirode Geografia e Estat\u00edstica (IBGE). Com isso, calculou-se a taxa de equipes por100 mil habitantes por ano em cada munic\u00edpio.percapita m\u00e9dia por habitante em n\u00edvel municipal; (b) popula\u00e7\u00e3o demulheres/popula\u00e7\u00e3o residente feminina por munic\u00edpio; (c) popula\u00e7\u00e3o idosa pormunic\u00edpio; (d) popula\u00e7\u00e3o de crian\u00e7as de at\u00e9 14 anos por munic\u00edpio; (e)porcentagem da popula\u00e7\u00e3o em situa\u00e7\u00e3o de extrema pobreza. Com exce\u00e7\u00e3o dacovariada \u201cpopula\u00e7\u00e3o de crian\u00e7as de at\u00e9 14 anos por munic\u00edpio\u201d, que foi extra\u00eddade dados do IBGE, todas as demais prov\u00eam do Atlas de Desenvolvimento Humano noBrasil As demais vari\u00e1veis independentes (covariadas) foram: (a) renda As taxas anuais para cada grupo de procedimento odontol\u00f3gico usado como vari\u00e1veldependente foram calculadas por 100 habitantes/ano, enquanto as taxas decobertura das ESF e das EqSB foram calculadas para cada 10 mil habitantes/ano.Posteriormente, as vari\u00e1veis foram categorizadas de forma a identificarmunic\u00edpios que aumentaram as taxas das quatro vari\u00e1veis dependentes entre osdois per\u00edodos e os que aumentaram, mantiveram ou reduziram as taxas de coberturade ESF e EqSB. A vari\u00e1vel de cobertura do Bolsa Fam\u00edlia na linha de base(2007/2008) foi categorizada em menor que 33 pontos percentuais (p.p.), entre 33e 66p.p. e maior que 66p.p. A mudan\u00e7a na cobertura do programa foi categorizadaem quatro aspectos: munic\u00edpios que aumentaram mais de 40p.p.; que aumentaramentre 20 e 40p.p.; que aumentaram at\u00e9 20p.p.; ou que reduziram a cobertura entreos per\u00edodos analisados. A categoriza\u00e7\u00e3o das demais covariadas aconteceu a partirda mediana, resultando em dois grupos de mesmo tamanho.stepwise backward foiexecutada inicialmente com o modelo cheio (todas as vari\u00e1veis) e considerando p> 0.25 para remo\u00e7\u00e3o. A vari\u00e1vel de cobertura do Programa Bolsa Fam\u00edlia foimantida fixa em todos os modelos testados, independentemente do valor de p. Aqualidade dos ajustes foi medida usando o crit\u00e9rio de informa\u00e7\u00e3o de Akaike(AIC). A edi\u00e7\u00e3o dos dados e a an\u00e1lise estat\u00edstica foram realizadas no softwarelivre R, vers\u00e3o 4.1.3 (http://www.r-project.org).A an\u00e1lise bivariada foi realizada por meio do teste qui-quadrado e a an\u00e1lise pormodelos de regress\u00e3o log\u00edstica foi feita utilizando como desfechos os quatrogrupos de procedimentos. A modelagem Entre os per\u00edodos de 2007/2008 e 2010/2011, os percentuais de munic\u00edpios em que houveaumento das taxas de procedimentos coletivos, preventivos, restauradores eexodontias foram de 59,8%, 46,0%, 52,5% e 44,2%, respectivamente . Dos 5.5Com rela\u00e7\u00e3o \u00e0 cobertura do Programa Bolsa Fam\u00edlia, as an\u00e1lises bivariadas e porregress\u00e3o n\u00e3o encontraram associa\u00e7\u00e3o significativa entre a cobertura do programa eos procedimentos odontol\u00f3gicos. Na an\u00e1lise bivariada, a taxa de cobertura das EqSBesteve associada com o aumento nas taxas de tr\u00eas das quatro categorias deprocedimentos odontol\u00f3gicos: preventivos, restauradores e exodontias. De formasemelhante, na an\u00e1lise final por regress\u00e3o ajustada, foi poss\u00edvel identificar que umaumento na taxa de cobertura das EqSB esteve significativamente associado a umamaior chance de as taxas de procedimentos preventivos ,restauradores  e exodontias  elevarem no munic\u00edpio, com exce\u00e7\u00e3o dos procedimentos coletivos , em compara\u00e7\u00e3o com aqueles que reduziram as taxas decobertura das EqSB .A expans\u00e3o da cobertura das EqSB esteve associada ao aumento de ocorr\u00eancia dosprocedimentos preventivos, restauradores e exodontias entre os per\u00edodos 2007/2008 e2010/2011. Os procedimentos coletivos foram exce\u00e7\u00e3o, os quais j\u00e1 t\u00eam altas taxas,sendo a categoria de procedimentos que mais aumentou entre os per\u00edodos avaliados. Aolongo desse tempo, 82% dos munic\u00edpios aumentaram as taxas de cobertura do ProgramaBolsa Fam\u00edlia, assim como 55% e 49% expandiram as taxas de cobertura das ESF e dasEqSB, respectivamente. Diferentemente da hip\u00f3tese inicialmente levantada, n\u00e3o foramidentificadas associa\u00e7\u00f5es estatisticamente significantes entre a amplia\u00e7\u00e3o dacobertura do Programa Bolsa Fam\u00edlia e o aumento nas taxas das quatro categorias deprocedimentos analisadas.A varia\u00e7\u00e3o da cobertura do Programa Bolsa Fam\u00edlia n\u00e3o impactou no uso dos servi\u00e7osodontol\u00f3gicos de forma consistente em todos os procedimentos. A disponibilidadeconjunta de um servi\u00e7o de APS e de um programa de transfer\u00eancia de renda parece teruma efic\u00e1cia adicional quando comparada com a oferta unicamente de um programa detransfer\u00eancia de renda Em cen\u00e1rios de piores condi\u00e7\u00f5es socioecon\u00f4micas se concentra o maior n\u00famero de jovensusu\u00e1rios do servi\u00e7o p\u00fablico odontol\u00f3gico ,,Pol\u00edtica Nacional de Sa\u00fadeBucalNossos achados mostram que a varia\u00e7\u00e3o da cobertura das EqSB impactou o uso deprocedimentos preventivos, restauradores e exodontias via SUS, confirmando estudospr\u00e9vios Caderno da Sa\u00fade Bucal doMinist\u00e9rio da Sa\u00fade sugere que as informa\u00e7\u00f5es do Minist\u00e9rio do DesenvolvimentoSocial, \u00e0 frente do Programa Bolsa Fam\u00edlia na \u00e9poca, sejam utilizadas paraorganiza\u00e7\u00e3o do acesso local Os achados desse estudo mostram que pol\u00edticas voltadas a grupos desfavorecidos podemn\u00e3o ter o efeito desejado e, por conseguinte, podem n\u00e3o reduzir desigualdades de usoe acesso. Assim, eles confirmam achados pr\u00e9vios que sugerem que o aumento de acesso\u00e0 sa\u00fade bucal na APS pode n\u00e3o reduzir ou eliminar as desigualdades no uso dosservi\u00e7os Uma limita\u00e7\u00e3o deste artigo \u00e9 a possibilidade de subnotifica\u00e7\u00e3o e erro de notifica\u00e7\u00e3onos sistemas consultados para obten\u00e7\u00e3o dos dados de procedimentos, e tais errostendem a reduzir a magnitude das associa\u00e7\u00f5es. Assim, as associa\u00e7\u00f5es relatadas podemestar subestimadas. Por outro lado, a dicotomiza\u00e7\u00e3o dos procedimentos odontol\u00f3gicostende a minimizar erros de mensura\u00e7\u00e3o, introduzidos pela falta de padroniza\u00e7\u00e3o dasnotifica\u00e7\u00f5es, removendo variabilidade n\u00e3o explic\u00e1vel por vari\u00e1veis do modelo.Adicionalmente, o perfil do estudo em n\u00edvel municipal n\u00e3o permite infer\u00eancias emn\u00edvel individual sem incorrer em fal\u00e1cia ecol\u00f3gica. Por fim, n\u00e3o h\u00e1 referencialte\u00f3rico espec\u00edfico sobre os impactos de programas de transfer\u00eancia de renda, nem emsa\u00fade bucal, nem em uso de servi\u00e7os Ainda n\u00e3o se sabe quais componentes do programa impactam o uso de servi\u00e7os, qual \u00e9 amagnitude desses impactos, nem mesmo por quais vias eles ocorrem. Os efeitos j\u00e1observados podem ser oriundos do aumento da renda e suas consequ\u00eancias"}
+{"text": "Tal abordagem se configura como uma ferramenta metodol\u00f3gica de an\u00e1lisecr\u00edtica de pol\u00edticas p\u00fablicas a partir de seis perguntas norteadoras. Foramselecionados dez documentos, publicados entre 2004 a 2021 pelo governobrasileiro. A an\u00e1lise cr\u00edtica resultou em tr\u00eas categorias: (i) causas daobesidade e narrativa dominante: quais s\u00e3o os problemas representados?; (ii)narrativa dominante e cuidado em sa\u00fade: quais s\u00e3o os efeitos para as pessoas comobesidade?; e (iii) obesidade e interseccionalidade: onde est\u00e3o os sil\u00eancios? Oconsumo de alimentos e o sedentarismo foram a narrativa dominante como causas daobesidade. A interseccionalidade, mediada pelas categorias de g\u00eanero/sexo,ra\u00e7a/cor e classe social, foi identificada como um sil\u00eancio na narrativa daspol\u00edticas p\u00fablicas de sa\u00fade. Tais categorias n\u00e3o foram consideradas como causasatreladas \u00e0 obesidade, tampouco foram inclu\u00eddas de forma efetiva nas a\u00e7\u00f5espropostas pelas pol\u00edticas p\u00fablicas de sa\u00fade. Os sil\u00eancios encontrados no estudodestacam a necessidade de inclus\u00e3o da interseccionalidade na elabora\u00e7\u00e3o eexecu\u00e7\u00e3o de pol\u00edticas p\u00fablicas de sa\u00fade e no cuidado das pessoas com obesidade.Tendo em vista as intersec\u00e7\u00f5es de g\u00eanero/sexo, ra\u00e7a/cor e classe social e suasformas de opress\u00e3o com o surgimento e agravo da obesidade, s\u00e3o de extremarelev\u00e2ncia an\u00e1lises cr\u00edticas sobre as narrativas simplistas nas pol\u00edticasp\u00fablicas de sa\u00fade para problematiza\u00e7\u00e3o das lacunas que repercutem no cuidado dosusu\u00e1rios com obesidade.Objetivou-se realizar uma an\u00e1lise cr\u00edtica da narrativa das pol\u00edticas p\u00fablicas desa\u00fade brasileiras no cuidado da obesidade a partir de uma perspectivainterseccional. Trata-se de estudo qualitativo explorat\u00f3rio, documental eanal\u00edtico, baseado na abordagem \u201cWhat\u2019s the problem represented to be?\u201d Como ferramenta anal\u00edtica, a interseccionalidade considera que as categorias de ra\u00e7a, classe, g\u00eanero, orienta\u00e7\u00e3o sexual, nacionalidade, capacidade, etnia e faixa et\u00e1ria - entre outras - s\u00e3o inter-relacionadas e moldam-se mutuamente. A interseccionalidade \u00e9 uma forma de entender e explicar a complexidade do mundo, das pessoas e das experi\u00eancias humanas\u201d. Para as autoras, o uso da interseccionalidade como ferramenta anal\u00edtica evoca seis ideias centrais: a desigualdade social, as rela\u00e7\u00f5es de poder interseccionais, o contexto social, a relacionalidade, a justi\u00e7a social e a complexidade.Para Collins & Bilge A partir de uma an\u00e1lise das inter-rela\u00e7\u00f5es entre g\u00eanero/sexo, ra\u00e7a/cor e obesidade, o estudo de Ferreira et al. ,,Tais achados revelam a correla\u00e7\u00e3o entre os marcadores sociais apresentados e a maior vulnerabilidade \u00e0 obesidade e refor\u00e7am a centralidade das pol\u00edticas p\u00fablicas de sa\u00fade nessa agenda como medidas de interven\u00e7\u00e3o nos problemas apontados. Entretanto, pol\u00edticas p\u00fablicas de sa\u00fade constru\u00eddas sem considerar os determinantes sociais da sa\u00fade tendem a perpetuar uma s\u00e9rie de desconex\u00f5es com a realidade vivida pelas pessoas que pretendem alcan\u00e7ar What\u2019s the problem represented to be?\u201d [\u201cQual \u00e9 o problema representado para ser?\u201d], conhecida como WPR ,,,,Trata-se de um estudo qualitativo explorat\u00f3rio, documental e anal\u00edtico, baseado na abordagem \u201c,,A abordagem WPR convida para uma mudan\u00e7a de foco na an\u00e1lise de pol\u00edticas p\u00fablicas, na medida em que se concentra em analisar criticamente como os problemas est\u00e3o representados e como eles s\u00e3o abordados nas pol\u00edticas p\u00fablicas ,,,Para conduzir uma an\u00e1lise cr\u00edtica de narrativa, a abordagem WPR apresenta um conjunto de seis quest\u00f5es facilitadoras  27,28,32sites oficiais e na biblioteca virtual do Minist\u00e9rio da Sa\u00fade. Um recorte temporal de vinte anos foi utilizado, considerando o intervalo de 2001 a 2021. Para facilitar o entendimento, optou-se no decorrer do estudo pela utiliza\u00e7\u00e3o do termo \u201cdocumentos\u201d, em refer\u00eancia aos documentos e \u00e0s pol\u00edticas p\u00fablicas de sa\u00fade analisados.Foram inclu\u00eddos no estudo pol\u00edticas p\u00fablicas de sa\u00fade e documentos oficiais que abordam a promo\u00e7\u00e3o \u00e0 sa\u00fade e a preven\u00e7\u00e3o da obesidade, com centralidade na aten\u00e7\u00e3o prim\u00e1ria \u00e0 sa\u00fade (APS), dispon\u00edveis em Os documentos que contemplavam os n\u00edveis de aten\u00e7\u00e3o \u00e0 sa\u00fade secund\u00e1rio e/ou terci\u00e1rio, sobre cuidados com a obesidade infantil e o tratamento da obesidade, foram ineleg\u00edveis ao estudo. Para a pesquisa dos documentos, foram utilizadas as palavras-chave: \u201cobesidade\u201d, \u201cmanejo da obesidade\u201d, \u201caten\u00e7\u00e3o prim\u00e1ria \u00e0 sa\u00fade\u201d, \u201cprogramas e pol\u00edticas de alimenta\u00e7\u00e3o e nutri\u00e7\u00e3o\u201d e \u201cpreven\u00e7\u00e3o da obesidade\u201d - isoladas e combinadas entre si.,,,https://products.office.com/).Ap\u00f3s a sele\u00e7\u00e3o dos documentos, a an\u00e1lise cr\u00edtica foi realizada em tr\u00eas etapas. Na primeira, foi feita a leitura na \u00edntegra dos documentos selecionados em busca de informa\u00e7\u00f5es-chave sobre os marcadores sociais g\u00eanero/sexo, ra\u00e7a/cor e classe social, orientada pela abordagem te\u00f3rico-metodol\u00f3gica da interseccionalidade ,,,,,,A segunda etapa consistiu em responder \u00e0s perguntas da WPR para cada documento analisado , com basResolu\u00e7\u00e3o n\u00ba 510, de 7 de abril de 2016, do Conselho Nacional de Sa\u00fade do Brasil.O estudo foi realizado com documentos de acesso p\u00fablico, portanto, isento de aprova\u00e7\u00e3o em Comit\u00ea de \u00c9tica em Pesquisa. Foram assegurados os preceitos \u00e9ticos legais estabelecidos pela Foram selecionados dez documentos, publicados entre 2004 at\u00e9 2021 . A an\u00e1liEstrat\u00e9gia Intersetorial de Preven\u00e7\u00e3o e Controle da Obesidade: Recomenda\u00e7\u00e3o para Estados e Munic\u00edpiosCadernos de Aten\u00e7\u00e3o B\u00e1sica n\u00ba 35 Os documentos analisados apresentaram discurso congruente sobre as causas da obesidade. A narrativa dominante, presente na extensa maioria dos documentos analisados, destaca que o balan\u00e7o energ\u00e9tico positivo, ou seja, o consumo excessivo de calorias associado \u00e0 inexist\u00eancia da pr\u00e1tica de atividade f\u00edsica, \u00e9 a causa central da obesidade. Como exemplos, destacam-se a Perspectivas e Desafios no Cuidado \u00e0s Pessoas com Obesidade no SUS: Resultados do Laborat\u00f3rio de Inova\u00e7\u00e3o no Manejo da Obesidade nas Redes de Aten\u00e7\u00e3o \u00e0 Sa\u00fadeA s\u00e9rie t\u00e9cnica Guia Alimentar para a Popula\u00e7\u00e3o BrasileiraOs determinantes sociais da sa\u00fade (DSS) e a vulnerabilidade social s\u00e3o apresentados de forma conceitual, e n\u00e3o atrelados \u00e0s causas da obesidade. Quando citada, a classe social \u00e9 mediada pela discuss\u00e3o da renda e assume posi\u00e7\u00e3o de destaque como uma das causas e/ou agravantes da obesidade, a exemplo do descrito na Pol\u00edtica Nacional de Alimenta\u00e7\u00e3o e Nutri\u00e7\u00e3o (PNAN) Os DSS s\u00e3o abordados a partir das possibilidades de auxiliar ou dificultar a narrativa dominante, centrada no balan\u00e7o energ\u00e9tico positivo. A classe social, por exemplo, \u00e9 referida nos documentos a partir do impacto da renda na aquisi\u00e7\u00e3o de alimentos, mas n\u00e3o \u00e9 contextualizada aos demais efeitos de tal determinante no cuidado das pessoas com obesidade.Cadernos de Aten\u00e7\u00e3o B\u00e1sica n\u00ba 35 O cuidado intersetorial \u00e9 citado como necess\u00e1rio na aten\u00e7\u00e3o \u00e0 sa\u00fade de indiv\u00edduos e coletividades com obesidade, mas, embora os documentos apresentem essa discuss\u00e3o conceitual, n\u00e3o foi percebida sua incorpora\u00e7\u00e3o nas a\u00e7\u00f5es, pois elas se concentram nas \u201csolu\u00e7\u00f5es\u201d para a narrativa dominante. Surge, assim, uma contradi\u00e7\u00e3o entre a narrativa da intersetorialidade e as a\u00e7\u00f5es propostas, como observado nos Perspectivas e Desafios no Cuidado \u00e0s Pessoas com Obesidade no SUS: Resultados do Laborat\u00f3rio de Inova\u00e7\u00e3o no Manejo da Obesidade nas Redes de Aten\u00e7\u00e3o \u00e0 Sa\u00fadeEstrat\u00e9gia Intersetorial de Preven\u00e7\u00e3o e Controle da Obesidade: Recomenda\u00e7\u00e3o para Estados e Munic\u00edpiosNo documento Perspectivas e Desafios no Cuidado \u00e0s Pessoas com Obesidade no SUS: Resultados do Laborat\u00f3rio de Inova\u00e7\u00e3o no Manejo da Obesidade nas Redes de Aten\u00e7\u00e3o \u00e0 Sa\u00fadeCaderno de Aten\u00e7\u00e3o B\u00e1sica n\u00ba 35Documentos que ampliam a discuss\u00e3o do cuidado intersetorial t\u00eam narrativas baseadas nos DSS da obesidade e na seguran\u00e7a alimentar e nutricional, a exemplo da s\u00e9rie t\u00e9cnica Tais representa\u00e7\u00f5es da narrativa dominante e da an\u00e1lise cr\u00edtica sobre as a\u00e7\u00f5es intersetoriais, muito descritas, mas pouco operacionalizadas nos documentos, apresentam caminhos para o entendimento dos efeitos no cuidado das pessoas com obesidade, mas reduzidas possibilidades de aprofundamento e constru\u00e7\u00e3o de afirma\u00e7\u00f5es neste estudo. Na an\u00e1lise, a discuss\u00e3o sobre a corresponsabiliza\u00e7\u00e3o do cuidado mostrou-se como uma lacuna.G\u00eanero/sexo, ra\u00e7a/cor e classe social surgem de forma coadjuvante e desmembrada nos documentos. Geralmente, s\u00e3o descritos nas apresenta\u00e7\u00f5es e introdu\u00e7\u00f5es como marcadores sociais importantes que t\u00eam rela\u00e7\u00e3o com a obesidade, mas tal rela\u00e7\u00e3o \u00e9 pouco explorada e/ou incorporada nas estrat\u00e9gias e a\u00e7\u00f5es. A PNAN Caderno de Aten\u00e7\u00e3o B\u00e1sica n\u00ba 38Perspectivas e Desafios no Cuidado \u00e0s Pessoas com Obesidade no SUS: Resultados do Laborat\u00f3rio de Inova\u00e7\u00e3o no Manejo da Obesidade nas Redes de Aten\u00e7\u00e3o \u00e0 Sa\u00fadeJ\u00e1 o marcador social g\u00eanero/sexo surgiu a partir de um recorte pontual, atrelado ao sistema reprodutor, como no A classe social foi apresentada com foco na renda e relacionada com as possibilidades de aquisi\u00e7\u00e3o e consumo de alimentos - outras intersec\u00e7\u00f5es n\u00e3o foram observadas. N\u00e3o houve, portanto, a problematiza\u00e7\u00e3o sobre renda e classe social relacionada a outros marcadores sociais, como g\u00eanero/sexo e ra\u00e7a/cor.A an\u00e1lise cr\u00edtica dos documentos identificou a interseccionalidade como um sil\u00eancio nas pol\u00edticas p\u00fablicas de sa\u00fade direcionadas ao cuidado da obesidade. N\u00e3o foi identificada tal abordagem te\u00f3rico-metodol\u00f3gica nos documentos analisados. Os marcadores sociais s\u00e3o apresentados nas pol\u00edticas p\u00fablicas de sa\u00fade de forma fragmentada e descontextualizados da sua intersec\u00e7\u00e3o com a obesidade. O g\u00eanero/sexo se relacionou aos ciclos reprodutivos de mulheres cisg\u00eanero e sua maior vulnerabilidade ao surgimento da obesidade. A classe social e a renda foram apenas determinantes para aquisi\u00e7\u00e3o e consumo de alimentos. Considerando a ra\u00e7a/cor, n\u00e3o foi encontrado documento que contemplasse o marcador social no cuidado da obesidade.,,,,,Os sil\u00eancios identificados no estudo evidenciam desafios para as pol\u00edticas p\u00fablicas de sa\u00fade relacionadas ao cuidado da obesidade, atrelados \u00e0 necessidade de inser\u00e7\u00e3o da interseccionalidade na constru\u00e7\u00e3o de estrat\u00e9gias de promo\u00e7\u00e3o \u00e0 sa\u00fade e preven\u00e7\u00e3o da obesidade. A narrativa dominante apresentada neste artigo coaduna com outros estudos O estudo de Salas et al. ,,A partir do entendimento do processo sa\u00fade-doen\u00e7a, mediado pelos DSS, \u00e9 poss\u00edvel compreender que o consumo de alimentos e a pr\u00e1tica de atividade f\u00edsica s\u00e3o condicionados a uma s\u00e9rie de determinantes, e n\u00e3o se configuram como o problema em si Estudo que analisou as diretrizes brasileiras de obesidade apresentou que, mesmo existindo a narrativa de que as causas da obesidade s\u00e3o multifatoriais, as recomenda\u00e7\u00f5es ainda se concentram prioritariamente nos aspectos biol\u00f3gicos e no cuidado em a\u00e7\u00f5es individualizadas focadas essencialmente no balan\u00e7o energ\u00e9tico Caterson et al. ,,,,\u00c0 medida que a narrativa dominante atribui como solu\u00e7\u00f5es para os problemas representados apenas a\u00e7\u00f5es de controle individual, h\u00e1 refor\u00e7o da culpabiliza\u00e7\u00e3o, estigmatiza\u00e7\u00e3o, preconceito e discrimina\u00e7\u00e3o das pessoas com obesidade Quanto \u00e0s caracter\u00edsticas de g\u00eanero/sexo, ra\u00e7a/cor e classe social de pessoas com obesidade, o estudo de Rubino et al. ,,,,,,,,,,Esses achados destacam que as intersec\u00e7\u00f5es atuam de forma ampla, potencializando iniquidades sociais e opress\u00f5es interseccionais, e n\u00e3o est\u00e3o ligadas apenas a quest\u00f5es biol\u00f3gicas, como as encontradas na narrativa dominante deste estudo. A interseccionalidade \u00e9 uma abordagem te\u00f3rico-metodol\u00f3gica ,,,A intersetorialidade \u00e9 uma ferramenta de potencializa\u00e7\u00e3o da resolutividade do cuidado em sa\u00fade \u00e0s pessoas com obesidade, a partir de um modelo assistencial integral e interprofissional A participa\u00e7\u00e3o e o controle social nas pol\u00edticas p\u00fablicas de sa\u00fade e na gest\u00e3o do cuidado em sa\u00fade s\u00e3o primordiais, especificamente das pessoas que convivem com a obesidade e t\u00eam interconex\u00f5es entre os marcadores sociais de g\u00eanero/sexo, ra\u00e7a/cor e classe social. Tal participa\u00e7\u00e3o ativa precisa ser um dos pilares para amplia\u00e7\u00e3o do olhar puramente te\u00f3rico sobre os problemas representados e para inclus\u00e3o do saber mediado pelas viv\u00eancias. Portanto, an\u00e1lises cr\u00edticas, como a realizada neste estudo, devem compor os processos de elabora\u00e7\u00e3o, implementa\u00e7\u00e3o e avalia\u00e7\u00e3o de pol\u00edticas p\u00fablicas de sa\u00fade, na inten\u00e7\u00e3o de superar a perpetua\u00e7\u00e3o de narrativas dominantes que desconsideram marcadores sociais diretamente relacionados \u00e0 obesidade.O estudo apresenta como limita\u00e7\u00e3o o n\u00e3o aprofundamento te\u00f3rico-conceitual dos sistemas de opress\u00e3o concebidos a partir dos marcadores sociais apontados, expressos pelo sexismo, racismo e capitalismo, sendo de extrema relev\u00e2ncia contemplar esses aspectos em estudos futuros. S\u00e3o importantes tamb\u00e9m a inclus\u00e3o e a problematiza\u00e7\u00e3o de marcadores sociais de identidade de g\u00eanero, uma vez que nos documentos analisados foram consideradas apenas a\u00e7\u00f5es com pessoas cisg\u00eanero. Estudos que contemplem, para al\u00e9m de an\u00e1lises documentais, o contexto assistencial tamb\u00e9m se fazem necess\u00e1rios, para que seja poss\u00edvel aprofundamento dos efeitos da narrativa dominante no cuidado das pessoas com obesidade.,A interlocu\u00e7\u00e3o entre a abordagem metodol\u00f3gica WPR e a perspectiva te\u00f3rico-metodol\u00f3gica da interseccionalidade na an\u00e1lise cr\u00edtica de narrativas das pol\u00edticas p\u00fablicas de sa\u00fade se configura como uma contribui\u00e7\u00e3o para as discuss\u00f5es no \u00e2mbito da elabora\u00e7\u00e3o e an\u00e1lise de pol\u00edticas p\u00fablicas de sa\u00fade voltadas ao cuidado de pessoas com obesidade para amplia\u00e7\u00e3o das narrativas, ultrapassando o dom\u00ednio biol\u00f3gico. A utiliza\u00e7\u00e3o da WPR para an\u00e1lise de pol\u00edticas p\u00fablicas de sa\u00fade com a tem\u00e1tica da obesidade e a incorpora\u00e7\u00e3o da interseccionalidade ainda s\u00e3o incipientes na realidade brasileira, apesar do uso em outros pa\u00edses N\u00e3o foram encontrados estudos brasileiros que discutam a obesidade a partir de uma abordagem interseccional, considerando os marcadores sociais aqui apresentados. Tais achados podem contribuir para a constru\u00e7\u00e3o de novos caminhos anal\u00edticos que superem a narrativa dominante simplista sobre obesidade nas pol\u00edticas p\u00fablicas de sa\u00fade, associados ao entendimento da necessidade de promover um cuidado integral, universal e equitativo \u00e0s pessoas com obesidade a partir da interseccionalidade.O balan\u00e7o energ\u00e9tico positivo \u00e9 a narrativa dominante das causas da obesidade, o que cria lacunas e repercute no cuidado das pessoas com obesidade, ao mesmo tempo que reduz a multidimensionalidade da obesidade a aspectos biol\u00f3gicos, desconsiderando as intersec\u00e7\u00f5es dos marcadores sociais e dos DSS. O sil\u00eancio da interseccionalidade nas pol\u00edticas p\u00fablicas de sa\u00fade que se relacionam ao cuidado na obesidade impacta negativamente a garantia de um cuidado integral, universal e equitativo. Contribui, ainda, para manuten\u00e7\u00e3o de uma narrativa simplista e individualizada sobre um fen\u00f4meno complexo e coletivo, fortalecendo compreens\u00f5es estigmatizantes, preconceituosas e discriminat\u00f3rias sobre pessoas com obesidade.Este estudo n\u00e3o teve como objetivo deslegitimar a narrativa das pol\u00edticas p\u00fablicas de sa\u00fade, tampouco reduzir a import\u00e2ncia dos aspectos biol\u00f3gicos como parte do cuidado da obesidade, mas sim refor\u00e7ar a partir da interseccionalidade a necessidade de ampliar tal compreens\u00e3o para al\u00e9m da narrativa dominante apresentada. Os sil\u00eancios encontrados no estudo destacam a import\u00e2ncia de inser\u00e7\u00e3o da interseccionalidade na constru\u00e7\u00e3o, implementa\u00e7\u00e3o e avalia\u00e7\u00e3o das pol\u00edticas p\u00fablicas de sa\u00fade para o cuidado das pessoas com obesidade. \u00c9 preciso contemplar os marcadores sociais de g\u00eanero/sexo, ra\u00e7a/cor e classe social e os impactos que os sistemas de opress\u00f5es existentes exercem sobre os indiv\u00edduos e coletividades no surgimento e agravo da obesidade, extrapolando, assim, a narrativa dominante. Logo, a an\u00e1lise cr\u00edtica de pol\u00edticas p\u00fablicas de sa\u00fade realizada no estudo, a partir da interseccionalidade, pode contribuir para a supera\u00e7\u00e3o das lacunas, visando o cuidado das pessoas com obesidade."}
+{"text": "Samples were collected in the tasks of spontaneous speech, reading, and text retelling through video calls made individually with the participants. The first 200 syllables expressed in each task were transcribed and analyzed according to the Fluency Profile Assessment Protocol (FPAP). The study compared the frequency of common and stuttering disfluencies and the speed in the different tasks surveyed. The Kruskal & Wallis test was used together with Duncan's multiple comparisons test to compare the medians and verify possible differences between the tasks researched with a significance level of 5%.The reading task presented a lower number of common disfluencies and a percentage of speech discontinuity about spontaneous speech and retelling tasks. No statistically significant differences were found between stuttering disfluencies in the three tasks surveyed.This study showed that there are differences in the occurrence of common disfluencies - hesitations, interjections, and revisions - and in the percentage of speech discontinuity during an oral reading of adults who stutter concerning spontaneous speech and text retelling. It has a multifactorial etiology with greater prevalence in men, and a relation to heredity in its emergence and development. There is consensus in the literature regarding the genetic factor in terms of increased risk of stuttering, as well as other still little understood factors. Breaks such as interruptions, repetitions, pauses, and prolongations among other types of disfluency can be observed in different cases of stuttering.Impaired fluency has motor, neurological, emotional, and linguistic dimensions that affect an individual\u2019s speed and flow of speech.Assessing fluency can be undertaken using clinical observation of the individual\u2019s speech, applying protocols and instruments that qualitatively and quantitatively describe fluency, the events that impair the fluency of spontaneous speech, and other tasks where the individual uses their mouth,5. Effective understanding of written linguistic codes relies on having adequate production of reading in a smooth and regular way,5.Reading, for instance, is an activity depending on a series of complex neurological and cognitive processes, in which fluency plays an important role. Efficient reading is directly related to the individual\u2019s reading and speech fluency, with speed and precision of the number of words read per minute being important for academic, social, linguistic, and cognitive development among other competencies and abilities,7.Reading fluency is the ability to evenly, spontaneously, easily, and continuously read texts. It is characterized by an absence of failures in the automatic identification of words, adequate speed, rhythm, and prosody. It is crucial for effective reading and contributes to processes of understanding and expression of the content of messages. Therefore, we expect that individuals who stutter may present difficulties when carrying out reading activities such as reading aloud. Studies that seek to compare performance during reading tasks, in both adults who stutter and those who do not, have shown a reduction in reading disfluencies in adults who stutterBeing a broad topic of significant interest in scientific and clinical contexts, more research is necessary to help professionals and researchers in their respective fields of activity. Studies that compare spontaneous speech, reading aloud, and text-retelling tasks can help to highlight the differences and similarities between occurrences of common and stuttering disfluencies, as well as changes in speed in adults who stutter. Thus, this study adopted the hypothesis that adults who stutter can present differences in the frequency and duration of these disfluencies as well as speed between spontaneous speech, reading aloud, and retelling tasks.Therefore, this study seeks to describe the fluency profile for spontaneous speech, reading, and retelling in adults who stutter and compare the fluency profile about the type and frequency of disfluencies and speed of speech.This study was approved by the Research Ethics Committee of the Federal University of Minas Gerais (UFMG) under the CAAE registration number 26669319.9.0000.5149, assessment number 4.458.559.It is a comparative, cross-sectional study with a sample consisting of 15 adults who stutter, recruited from support groups, sites, and social networks , and clinics and institutions focused on treating individuals who stutter. Data collection was undertaken remotely using the platform Zoom\u00ae observing social distancing measures during the Covid-19 pandemic period.The inclusion criteria were being older than or equal to 18 years old, presenting persistent stuttering, having a minimum education level of complete primary school, and being a native speaker of Brazilian Portuguese. The exclusion criteria were being diagnosed with a psychiatric disorder, disease, or neurological condition, or presenting auditory or visual alterations that made reading texts and understanding instructions impossible. All participants signed the Informed Consent Form (ICF) and agreed with the terms of the study., and retelling the same text. A transcription of the first 200 syllables from each sample for the fluency analysis was made. The reading and retelling samples were dealt with in the same manner as the spontaneous speech samples.During each interview, a protocol considering the clinical history and complaints, difficulties about stuttering, and family history of stuttering was adopted. The speech, reading, and retelling samples were collected with video and audio recordings during the interviews using the platform mentioned above with the following order and procedure: spontaneous speech using a script ; reading a text aloud for analysis of reading fluency. The FPAP includes an analysis of the transcriptions observing the occurrence of common disfluencies, stuttering disfluencies, per minute word and syllable flow, percentage of speech discontinuities, and stuttering disfluencies. Data collection and analysis were undertaken by the researchers.The speech, reading, and retelling samples were analyzed according to the types of common and stuttering disfluencies, frequency of interruptions, and speed of speech according to the Fluency Profile Assessment Protocol (FPAP)The data were stored in a data bank using the Excel\u24c7 software, version 2016. Statistical analysis was carried out with Statistical Package for Social Sciences\u24c7 (SPSS) software, version 24. The Shapiro & Wilk Test was used to assess the data probability distribution. The Kruskal & Wallis test was used together with Duncan\u2019s Multiple Range Test to compare the medians and determine any possible differences between spontaneous speech, reading aloud, and retelling samples in terms of the type of disfluency and percentage of common and stuttering disfluencies. The level of significance used for all analyses was 5% with significant p-values highlighted in bold.The sample consisted of five (5) female participants (N%=33.33) with an average age of 32 and SD=3.41 and ten (10) male participants (N%=66.67) with an average age of 27.1 and SD=9.16. The average age for all participants was 28.7 years with SD=8.0. All participants had the minimum education necessary to participate in the study, distributed as follows: one (1) (N%=6.67) participant with complete primary education, five (5) (N%=23.33) participants with incomplete/complete high school education, and nine (9) (N%=60) participants with incomplete/complete university education.st aunts/uncles.Data analysis related to the clinical history and complaints of participants showed that 6.67% (N=1) of the patients presented speech or language problems during childhood, being described as phonological impairment, exchange of sounds in speech, and delayed speech development. All participants self-described as being stutters and 60% (N=9) reported other family members who stuttered. Of the total sample 75% of participants with family members who stuttered (N=6) reported that this included either their father, mother, and/or 1Regarding the fluency analysis, the highest averages observed in different types of common disfluencies were in spontaneous speech and retelling, except for \u201cunfinished words\u201d and \u201cword repetition\u201d where the highest averages were in reading aloud .bloqueios\u201d) and \u201crepetition of monosyllabic words\u201d.Regarding stuttering disfluencies, higher averages were also observed in spontaneous speech and text retelling, except for \u201cblocks\u201d  showed a higher average for spontaneous speech and retelling, as well as in percentage for speech discontinuity and stuttering disfluencies. No statistically significant results were observed in the analysis of stuttering disfluencies and speech speed. The results for frequency of disfluencies showed statistical significance for the percentage of speech discontinuities .. Regarding hereditary, the literature reported that around two or more family members of individuals with persistent developmental stuttering also presented stuttering. In a study analyzing the family prevalence of stuttering, the authors observed a statistically significant difference between participants with family members who had first-degree relatives in comparison with second and third-degree relatives. The data from this study agree with the literature, given that nine participants in this study reported having other family members who stutter. Of these, six mentioned first-degree relatives.The final study sample presented a prevalence of men at a proportion of two men for every woman (2:1) partially corroborating the literature, which highlights a prevalence in the male sex during the adult phase, but of four to five men for every woman (4-5:1). This suggests that the time necessary to carry out the retelling of text is also not directly influenced by stuttering since there was no statistically significant relationship between these parameters. For the frequency of disfluencies, common disfluencies, that is, the types that occur in the speech of both individuals with and without stuttering, presented statistically significant values when comparing reading with spontaneous speech and retelling (p<0.001). These results agree with the literature, given that they show a greater quantity of common disfluencies in spontaneous speech than in reading aloud,11.In this study, the adults presented close averages for per-minute syllable and word speeds for the assessed tasks, which suggests that the speech and reading speeds are similar for adult individuals who stutter. A study that undertook a comparative analysis of adults with and without stuttering for spontaneous speech and reading tasks in terms of time spent, and per-minute word and syllable flow in 15 adults with stuttering, also found no significant difference between these parameters, agreeing with the findings from this sample,12. This finding leads us to speculate that the development of reading ability affects performance for reading speed. This explains the statistical differences observed in studies with school-aged children, different from those observed in this study with adults. The literature reports that reading speed tends to evolve with educational development, but reaches a plateau during the final years of primary school,7,13-15.In this study, no statistically significant differences were observed in speed for reading aloud, spontaneous speech, or retelling. In studies carried out with school-aged children with stuttering, statistically significant differences were observed in reading and speaking speeds,8,13,16.It is notable that in the group studied no participant reported problems for reading development during the literacy phase and at the time of data collection. Such difficulties could be obstacles when developing reading ability, and an impairment for their fluency and consequently for their academic development. As such, given the absence of complaints related to reading development, we do not expect to observe significant differences between parameters related to reading speed in the sample studied. The bibliography highlights that the higher the level of education the better the level of reading fluency, which reinforces that reading speed is determined over time by abilities related to the development of reading ability,17,18.Regarding the analysis of the percentage of stuttering disfluencies, no statistically significant relationship between the spontaneous speech, reading, and retelling samples was observed (p<0.349). However, the percentages for speech discontinuity presented statistically significant differences when comparing reading with spontaneous speech and retelling. These results corroborate other studies that found that reading is a less demanding task in terms of the mechanisms involved in the linguistic and motor processes for speech, in addition to the elaboration of discourse, leading to a reduction in the occurrence of disfluencies. For these adults, the authors mentioned that the presence of a higher number of stuttering disfluencies, such as blocks (bloqueios) and prolongations (prolongamentos) during spontaneous speech is explicable by the possible relationship between stuttering and basal ganglia functioning. The inadequate functioning of these structures in motor control of speech, associated with the temporal processing of the message to be expressed could, result in a greater occurrence of stuttering disfluencies during spontaneous speech,20. Another explanation for the low occurrence of stuttering disfluencies while reading aloud is that the cerebral processing for this task involves other areas such as the occipital lobe and areas related to visual processing. This suggests that reading has a positive effect on fluency, given that it modifies the neurophysiological and neurolinguistic mechanisms that directly involve speech production.Another study compared the performance of adults who stutter during spontaneous speech and reading aloud,22,23. Notably, the literature also highlights that hesitations, interjections, and revisions are related to difficulty in formulating and elaborating statements during discourse, and lexical, semantic, and syntactic recall. It also indicates that the occurrence of these disfluencies in adults who stutter is observed in greater numbers during spontaneous speech. These findings also suggest that common disfluencies occur more often during the retelling task in comparison with reading due to its closeness to the spontaneous speech task. That is, retelling, similar to spontaneous speech, favors the occurrence of common and stuttering disfluencies given that they are speech tasks where the individual elaborates the discourse being expressed,26. Notably, the retelling is directly affected by reading comprehension, and as reading ability develops together with the educational development of individuals, better reading comprehension is expected with improved literacy,27.A comparison of the disfluency types found a statistically significant difference in the presence of common disfluencies - hesitations, interjections, and revisions - when comparing the reading-aloud task with spontaneous speech and retelling. The reading task presented the lowest values of these disfluencies, which agrees with the findings from the literatureRegarding study limitations, the distinction of individuals in terms of the degree of severity of stuttering was not undertaken. As such, while we found no studies in the literature that compared the spontaneous speech and text retelling tasks, given the absence of a categorization of the sample in terms of the degree of severity of stuttering, the variability between the number of occurrences of the various types of disfluencies did not provide a clearer understanding of the data variability when assessing the fluency profile for the three tasks studied. To better establish standards of comparison for the data, further research should be undertaken with a larger number of subjects, mainly for adults who stutter, in which there is a scarcity of studies that more thoroughly investigate stuttering in other speech tasks beyond spontaneous speech.This study presents a novel comparison of the spontaneous speech profile with other tasks involving oral production, including reading aloud, with text retelling not being reported in other studies, in the literature considering the speech of adults who stuttered, up until the time of this research. Given the scarcity of studies about speech fluency in adults who stutter beyond those that investigated spontaneous speech, the present research fills an important gap in the literature.When analyzing the fluency profile of adults who stutter, this study found no difference in speed for the performance of spontaneous speech, reading aloud or retelling - in terms of per minute syllable or word flow. Reading aloud was different from spontaneous speech and retelling for the percentage of speech discontinuity, mainly when comparing the disfluency types of hesitation, interjection, and revision. No significant differences between the other disfluencies were observed, with greater similarity in the comparisons between spontaneous speech and retelling. .A gagueira \u00e9 um complexo transtorno da flu\u00eancia, caracterizado pela presen\u00e7a de rupturas na fala que interferem no fluxo cont\u00ednuo e suave da flu\u00eancia verbal do indiv\u00edduo que gagueja. Possui etiologia multifatorial com maior preval\u00eancia no sexo masculino tendo uma rela\u00e7\u00e3o com a hereditariedade para o seu surgimento e desenvolvimento. H\u00e1 um consenso na literatura sobre a influ\u00eancia do fator gen\u00e9tico aumentar o risco do surgimento da gagueira, al\u00e9m de outros fatores ainda n\u00e3o muito bem compreendidos. Desse modo, rupturas como bloqueios, repeti\u00e7\u00f5es, pausas, prolongamentos dentre outras tipologias de disflu\u00eancias podem estar presentes nos diferentes quadros da gagueira.Esse transtorno da flu\u00eancia possui diferentes tra\u00e7os motores, neurol\u00f3gicos, emocionais, e lingu\u00edsticos que comprometem a velocidade e o fluxo da fala de um indiv\u00edduo.A avalia\u00e7\u00e3o da flu\u00eancia pode ser realizada mediante a observa\u00e7\u00e3o cl\u00ednica da fala do indiv\u00edduo por meio de protocolos e instrumentos que descrevam a flu\u00eancia, de forma qualitativa e quantitativa, os eventos que venham a comprometer a flu\u00eancia da fala espont\u00e2nea, assim como em outras tarefas em que o indiv\u00edduo faz uso da oralidade,5. Para uma boa compreens\u00e3o do c\u00f3digo lingu\u00edstico escrito \u00e9 importante que haja a produ\u00e7\u00e3o adequada da leitura de forma suave e ritmada,5.Por sua vez, a leitura \u00e9 uma atividade resultante de uma s\u00e9rie de complexos processos neurol\u00f3gicos e cognitivos, na qual a flu\u00eancia exerce um importante papel. A efici\u00eancia da leitura est\u00e1 diretamente relacionada a fluidez da fala e leitura do indiv\u00edduo, velocidade e precis\u00e3o do n\u00famero de palavras lidas por minuto, sendo importante para o desenvolvimento escolar, social, lingu\u00edstico, cognitivo, dentre outras compet\u00eancias e habilidades,7.A flu\u00eancia leitora \u00e9 a habilidade de ler textos de maneira suave, espont\u00e2nea, f\u00e1cil e cont\u00ednua. Caracteriza-se por aus\u00eancia de comprometimento na identifica\u00e7\u00e3o autom\u00e1tica de palavras, adequada velocidade, ritmo e pros\u00f3dia. \u00c9 fundamental para a leitura eficiente e contribui para os processos de entendimento e express\u00e3o do conte\u00fado da mensagem. Logo \u00e9 esperado que indiv\u00edduos que gaguejam possam apresentar dificuldades na execu\u00e7\u00e3o de atividades leitoras como ler em voz alta. Estudos que se destinam a comparar o desempenho em tarefas de leitura, em adultos que gaguejam e adultos que n\u00e3o gaguejam, t\u00eam demonstrado uma diminui\u00e7\u00e3o das disflu\u00eancias na leitura nos adultos com gagueiraPor ser um tema abrangente e de amplo interesse no meio cl\u00ednico e cient\u00edfico, mais pesquisas s\u00e3o necess\u00e1rias para auxiliar profissionais e pesquisadores em suas \u00e1reas de atua\u00e7\u00e3o. Estudos que comparam as tarefas de fala espont\u00e2nea, leitura oral e o reconto de textos podem contribuir para investigar as diferen\u00e7as ou semelhan\u00e7as de ocorr\u00eancia de disflu\u00eancias comuns e gagas, al\u00e9m de mudan\u00e7as na velocidade em adultos que gaguejam. Dessa forma, esse estudo parte da hip\u00f3tese de que adultos que gaguejam possam apresentar diferen\u00e7as quanto a frequ\u00eancia e dura\u00e7\u00e3o das disflu\u00eancias assim como na velocidade entre as tarefas de fala espont\u00e2nea, leitura oral e reconto.Assim, este estudo tem como objetivo descrever o perfil da flu\u00eancia na fala espont\u00e2nea, na leitura e no reconto de texto de adultos que gaguejam e comparar o perfil da flu\u00eancia em rela\u00e7\u00e3o \u00e0 tipologia e frequ\u00eancia das disflu\u00eancias e velocidade de fala.Este estudo foi aprovado pelo Comit\u00ea de \u00c9tica em Pesquisa da Universidade Federal de Minas Gerais (UFMG) sob o n\u00famero de registro CAAE 26669319.9.0000.5149, parecer n\u00famero 4.458.559.sites, redes sociais, ambulat\u00f3rios e institui\u00e7\u00f5es voltadas para o atendimento de indiv\u00edduos que gaguejam. A coleta dos dados foi realizada de forma remota pela plataforma Zoom\u00ae respeitando as medidas de distanciamento social durante o per\u00edodo da pandemia provocada pelo v\u00edrus Covid-19.Trata-se de um estudo transversal comparativo com amostra composta por 15 adultos que gaguejam convidados em grupos de apoio \u00e0 gagueira, Os crit\u00e9rios de inclus\u00e3o foram: possuir idade maior ou igual a 18 anos, apresentar gagueira persistente, escolaridade m\u00ednima do ensino fundamental completo e ser falante nativo do portugu\u00eas brasileiro. Quanto aos crit\u00e9rios de exclus\u00e3o foram estabelecidos: presen\u00e7a de diagn\u00f3stico de desordens psiqui\u00e1tricas, doen\u00e7a ou transtorno neurol\u00f3gico, apresentar altera\u00e7\u00f5es visuais e auditivas que impossibilitassem a leitura de textos e compreens\u00e3o de comandos. Todos os participantes assinaram Termo de Consentimento Livre e Esclarecido (TCLE) e concordaram com os termos da pesquisa. e reconto do pr\u00f3prio texto. Foi realizada a transcri\u00e7\u00e3o literal das primeiras 200 s\u00edlabas de cada amostra para an\u00e1lise da flu\u00eancia. Ressalta-se que as amostras de leitura e reconto foram tratadas da mesma forma que as amostras de fala espont\u00e2nea.Durante cada entrevista foi utilizado com os participantes um protocolo de hist\u00f3ria cl\u00ednica para coleta de dados referentes \u00e0 queixa, dificuldades com rela\u00e7\u00e3o \u00e0 gagueira e antecedentes familiares para a gagueira. As amostras de fala, leitura e reconto foram coletadas com registro em \u00e1udio e v\u00eddeo durante a entrevista por meio da pr\u00f3pria plataforma mencionada com a seguinte ordem e procedimento: fala espont\u00e2nea: uso de roteiro elaborado ; leitura de texto para an\u00e1lise da flu\u00eancia leitora. O PAPF consiste na an\u00e1lise das transcri\u00e7\u00f5es observando a ocorr\u00eancia das disflu\u00eancias comuns, disflu\u00eancias gagas, fluxo de palavras por minuto e fluxo de s\u00edlabas por minuto, porcentagens de descontinuidade de fala e de disflu\u00eancias gagas. A coleta e an\u00e1lise das amostras foram realizadas pelos pr\u00f3prios pesquisadores.As amostras de fala, de leitura e do reconto foram analisadas segundo a tipologia das disflu\u00eancias gagas e comuns, frequ\u00eancia de rupturas e velocidade de fala de acordo com o Protocolo de Avalia\u00e7\u00e3o do Perfil da Flu\u00eancia (PAPF)software Excel\u24c7, vers\u00e3o 2016. A an\u00e1lise estat\u00edstica foi realizada com o software Statistical Package for Social Sciences\u24c7 (SPSS), vers\u00e3o 24. Para avaliar a distribui\u00e7\u00e3o de probabilidade dos dados foi utilizado o teste de Shapiro & Wilk. Adotou-se o teste de Kruskal & Wallis em conjunto com o de compara\u00e7\u00f5es m\u00faltiplas de Duncan para comparar as medianas e verificar poss\u00edveis diferen\u00e7as entre as amostras de fala espont\u00e2nea, leitura e reconto quanto a tipologias das disflu\u00eancias e porcentagem de disflu\u00eancias comuns e gagas. O n\u00edvel alfa de signific\u00e2ncia utilizado em todas as an\u00e1lises foi de 5% com valores de p significantes destacados em negrito.Os dados foram armazenados em um banco de dados por meio do A amostra foi composta por cinco (5) participantes do sexo feminino  com m\u00e9dia de idade de 32 anos e DP= 3,41 e dez (10) do sexo masculino  com m\u00e9dia de idade de 27,1 anos e DP= 9,16. A m\u00e9dia de idade entre todos os participantes foi de 28,7 anos com DP= 8,0. Todos os participantes possu\u00edam o grau de escolaridade m\u00ednimo para participar do estudo distribu\u00eddos da seguinte forma: um (1) participante  com ensino fundamental completo, cinco (5)  ensino m\u00e9dio incompleto/completo e nove (9) (N%= 60) apresentaram ensino superior incompleto/completo.A an\u00e1lise dos dados referentes \u00e0 hist\u00f3ria cl\u00ednica e a queixa dos participantes mostrou que 6,67% (N=1) dos pacientes apresentou problema de fala e ou linguagem durante a inf\u00e2ncia, sendo descrito como transtorno fonol\u00f3gico, troca de sons na fala, e atraso do desenvolvimento de fala. Todos os participantes se intitularam pessoas que gaguejam e 60% (N=9) relataram gagueira entre outros membros da fam\u00edlia. Do total da amostra 75% dos participantes que possu\u00edam familiares com gagueira (N=6) relataram que pai, m\u00e3e e/ou tios de 1\u00ba grau determinam o parentesco.Em rela\u00e7\u00e3o \u00e0s an\u00e1lises da flu\u00eancia observa-se que as maiores m\u00e9dias encontradas nos diferentes tipos de disflu\u00eancias comuns foram na fala espont\u00e2nea e no reconto, com exce\u00e7\u00e3o das \u201cpalavras n\u00e3o terminadas\u201d e \u201crepeti\u00e7\u00e3o de palavras\u201d, cuja maior m\u00e9dia foi na leitura .Quanto \u00e0s disflu\u00eancias gagas tamb\u00e9m se observou maiores m\u00e9dias na fala espont\u00e2nea e no reconto do texto, exceto para os \u201cbloqueios\u201d e a \"repeti\u00e7\u00e3o de palavras monossil\u00e1bicas\u201d.Ao se comparar as disflu\u00eancias comuns - hesita\u00e7\u00f5es, interjei\u00e7\u00f5es, revis\u00f5es e total - observa-se que os resultados foram estatisticamente significantes, caracterizando melhor desempenho na leitura em rela\u00e7\u00e3o \u00e0 fala espont\u00e2nea e ao reconto.A velocidade de fala apresentou maior m\u00e9dia na amostra de fala espont\u00e2nea e no reconto para o fluxo de palavras por minuto, por\u00e9m a leitura apresentou maior m\u00e9dia para o fluxo de s\u00edlabas por minuto. A frequ\u00eancia de rupturas (disflu\u00eancias) obteve maior m\u00e9dia de fala espont\u00e2nea e reconto, assim como nos percentuais de descontinuidade de fala e de disflu\u00eancias gagas. Em rela\u00e7\u00e3o \u00e0 an\u00e1lise das disflu\u00eancias gagas e da velocidade de fala n\u00e3o foram encontrados resultados estatisticamente significantes. Quanto \u00e0 frequ\u00eancia das disflu\u00eancias os resultados apontam signific\u00e2ncia estat\u00edstica no percentual de descontinuidade de fala .. Com rela\u00e7\u00e3o ao aspecto heredit\u00e1rio, a literatura relata que em torno de dois ou mais familiares de pessoas com gagueira desenvolvimental persistente tamb\u00e9m apresentam gagueira. Em um estudo que analisou a preval\u00eancia familiar da gagueira os autores mostraram que existe uma diferen\u00e7a estatisticamente significante entre os familiares que possuem parentesco de primeiro grau em rela\u00e7\u00e3o aos de segundo e terceiro grau. Os dados deste trabalho corroboram a literatura, uma vez que nove participantes deste estudo relataram apresentar outros membros na fam\u00edlia que gaguejam e destes, seis participantes mencionaram parentes de primeiro grau.A amostra final deste estudo apresentou preval\u00eancia do sexo masculino na propor\u00e7\u00e3o de dois homens para cada mulher (2:1) corroborando parcialmente a literatura que aponta que na fase adulta a preval\u00eancia \u00e9 do sexo masculino, mas de quatro a cinco homens para cada mulher (4-5:1). Esse achado sugere que o tempo necess\u00e1rio para a realiza\u00e7\u00e3o do reconto do texto tamb\u00e9m n\u00e3o \u00e9 influenciado diretamente pela gagueira pois n\u00e3o houve uma rela\u00e7\u00e3o estatisticamente significante nesses par\u00e2metros. Quanto \u00e0 frequ\u00eancia das disflu\u00eancias observa-se que as disflu\u00eancias comuns, ou seja, as tipologias que ocorrem na fala de indiv\u00edduos com e sem gagueira, apresentam valores estatisticamente significantes ao se comparar a leitura com a fala espont\u00e2nea e o reconto . Esses resultados corroboram a literatura, uma vez que mostram que a quantidade de disflu\u00eancias comuns \u00e9 maior na fala espont\u00e2nea em rela\u00e7\u00e3o \u00e0 leitura,11.Neste estudo, os adultos apresentaram m\u00e9dias quanto \u00e0 velocidade de s\u00edlabas e palavras por minuto pr\u00f3ximas entre as tarefas pesquisadas, o que sugere que a velocidade de fala e leitura s\u00e3o similares na pessoa adulta que gagueja. Em um estudo que realizou uma an\u00e1lise comparativa entre adultos com e sem gagueira nas tarefas de fala espont\u00e2nea e leitura quanto ao tempo gasto, fluxo de palavras e s\u00edlabas por minuto de 15 adultos com gagueira tamb\u00e9m mostrou que n\u00e3o h\u00e1 diferen\u00e7a significativa entre esses par\u00e2metros corroborando os achados dessa amostra,12. Tal achado leva a especular que o desenvolvimento da habilidade leitora influencia no desempenho da velocidade de leitura. Este resultado justifica tais diferen\u00e7as estat\u00edsticas encontradas nos estudos com escolares, diferentemente do observado nesta pesquisa com adultos. A literatura relata que a velocidade de leitura tende a evoluir com o avan\u00e7o da escolaridade, mas atinge um patamar de estabilidade dos anos finais do ensino fundamental II,7,13-15.Neste estudo n\u00e3o foram encontradas diferen\u00e7as estatisticamente significantes na velocidade da leitura, da fala espont\u00e2nea e do reconto. Em estudos realizados com escolares com gagueira, diferen\u00e7as estatisticamente significantes foram observadas na velocidade de fala e de leitura,8,13,16.Destaca-se o fato de que no grupo estudado nenhum participante relatou apresentar problemas quanto ao desenvolvimento da leitura durante a fase de alfabetiza\u00e7\u00e3o e no momento da coleta dos dados. Tais dificuldades podem representar obst\u00e1culos no desenvolvimento na habilidade de leitura, com comprometimento da sua flu\u00eancia e consequentemente no percurso acad\u00eamico. Logo, na aus\u00eancia de queixas relacionadas ao desenvolvimento da leitura, n\u00e3o \u00e9 esperado observar diferen\u00e7as significativas entre os par\u00e2metros relacionados \u00e0 velocidade de leitura na amostra estudada. A bibliografia aponta que quanto maior o n\u00edvel de escolaridade melhor ser\u00e1 a habilidade flu\u00eancia leitora, o que refor\u00e7a o fato de que a velocidade de leitura \u00e9 determinada pelas habilidades relacionadas ao desenvolvimento da habilidade leitora ao longo do tempo,17,18.Quanto \u00e0 an\u00e1lise do percentual das disflu\u00eancias gagas n\u00e3o houve rela\u00e7\u00e3o estatisticamente significante entre as amostras de fala espont\u00e2nea, leitura oral e reconto . Entretanto, os percentuais de descontinuidade de fala apresentaram diferen\u00e7as estatisticamente significantes quando se comparou a leitura com a fala espont\u00e2nea e o reconto. Esses resultados corroboram outros estudos que mostram que a leitura \u00e9 uma tarefa com menor exig\u00eancia quanto aos mecanismos envolvidos no processo lingu\u00edstico e motor da fala al\u00e9m da elabora\u00e7\u00e3o do discurso, ocasionando a diminui\u00e7\u00e3o da ocorr\u00eancia de disflu\u00eancias. Nele os autores mencionaram que a presen\u00e7a de um maior n\u00famero das disflu\u00eancias gagas, como os bloqueios e os prolongamentos, durante a fala espont\u00e2nea \u00e9 justificada pela poss\u00edvel rela\u00e7\u00e3o entre a gagueira e o funcionamento dos n\u00facleos da base. O funcionamento inadequado dessas estruturas para o controle motor da fala, associado ao processamento temporal da mensagem a ser expressa resultaria em uma maior ocorr\u00eancia das disflu\u00eancias durante a fala espont\u00e2nea,20. Outra justificativa para a baixa ocorr\u00eancia de disflu\u00eancias gagas durante a leitura oral \u00e9 que o processamento cerebral desta tarefa envolve outras \u00e1reas como a occipito temporal e \u00e1reas relacionadas ao processamento visual. Dessa forma, sugere-se que a leitura provoca um efeito positivo na flu\u00eancia, uma vez que ela modifica os mecanismos neurofisiol\u00f3gicos e neurolingu\u00edsticos que envolvem diretamente a produ\u00e7\u00e3o da fala.Outro estudo comparou a performance de adultos que gaguejam durante a fala espont\u00e2nea e a leitura oral,22,23. Destaca-se que a literatura tamb\u00e9m aponta que as hesita\u00e7\u00f5es, interjei\u00e7\u00f5es e revis\u00f5es est\u00e3o relacionadas com a dificuldade na formula\u00e7\u00e3o e elabora\u00e7\u00e3o de enunciados durante o discurso, resgate lexical, sint\u00e1tico e sem\u00e2ntico. Assim como refere tamb\u00e9m que a ocorr\u00eancia dessas disflu\u00eancias em adultos que gaguejam s\u00e3o observadas em maior n\u00famero na fala espont\u00e2nea. Esses achados sugerem ainda que as disflu\u00eancias comuns ocorreram em maior n\u00famero na tarefa do reconto em rela\u00e7\u00e3o \u00e0 leitura pelo fato da sua aproxima\u00e7\u00e3o com a tarefa da fala espont\u00e2nea. Ou seja, o reconto, assim como a fala espont\u00e2nea, favorece a ocorr\u00eancia das disflu\u00eancias comuns e gagas levando em considera\u00e7\u00e3o que s\u00e3o tarefas de fala em que o indiv\u00edduo precisa elaborar o discurso a ser expresso,26. Destaca-se que o reconto \u00e9 influenciado diretamente pela compreens\u00e3o leitora, e de acordo com o desenvolvimento da habilidade de leitura em rela\u00e7\u00e3o ao avan\u00e7o da escolaridade dos indiv\u00edduos, espera-se uma melhor compreens\u00e3o leitora com o avan\u00e7o da alfabetiza\u00e7\u00e3o,27.A compara\u00e7\u00e3o entre as tipologias das disflu\u00eancias mostra que h\u00e1 uma diferen\u00e7a estatisticamente significante quanto a presen\u00e7a das disflu\u00eancias comuns - hesita\u00e7\u00f5es, interjei\u00e7\u00f5es e revis\u00f5es - entre as tarefas de leitura oral quando comparada com a fala espont\u00e2nea e reconto. A tarefa de leitura foi a que apresentou menores valores dessas disflu\u00eancias, o que vai ao encontro dos achados da literaturaComo limita\u00e7\u00f5es deste estudo ressalta-se que n\u00e3o foi realizada distin\u00e7\u00e3o dos indiv\u00edduos quanto ao grau de gravidade da gagueira e na literatura n\u00e3o foram encontrados estudos que comparam a tarefa de fala espont\u00e2nea e o reconto de textos. Contudo, como n\u00e3o foi realizada uma categoriza\u00e7\u00e3o da amostra quanto ao n\u00edvel de gravidade da gagueira, a variabilidade entre o n\u00famero de ocorr\u00eancias das tipologias das disflu\u00eancias n\u00e3o possibilitou um melhor entendimento quanto a variabilidade dos dados no que se refere a avalia\u00e7\u00e3o do perfil da flu\u00eancia nas tr\u00eas tarefas pesquisadas. Para estabelecer melhores padr\u00f5es de compara\u00e7\u00e3o desses dados, outras pesquisas devem ser realizadas com maior n\u00famero de sujeitos, principalmente com adultos que gaguejam, onde h\u00e1 uma escassez de estudos que investiguem mais a fundo a gagueira em outras tarefas de fala que n\u00e3o somente a fala espont\u00e2nea.Como avan\u00e7o, o estudo comparou o perfil da fala espont\u00e2nea em outras tarefas que envolvem a produ\u00e7\u00e3o oral, como a leitura oral, sendo que o reconto de textos n\u00e3o foi descrito na literatura na fala de adultos que gaguejam at\u00e9 o momento em que essa pesquisa foi realizada. Mediante a escassez de estudos quanto \u00e0 flu\u00eancia na fala de adultos que gaguejam al\u00e9m da fala espont\u00e2nea, o presente trabalho preenche uma importante lacuna na literatura.Os resultados evidenciaram que na an\u00e1lise do perfil da flu\u00eancia de adultos que gaguejam n\u00e3o h\u00e1 diferen\u00e7a no desempenho durante a fala espont\u00e2nea, leitura oral e reconto quanto \u00e0 velocidade - fluxo de s\u00edlabas e palavras por minuto. A leitura oral se diferenciou da fala espont\u00e2nea e do reconto quanto \u00e0 porcentagem da descontinuidade de fala, principalmente quando comparadas as tipologias das disflu\u00eancias de hesita\u00e7\u00f5es, interjei\u00e7\u00f5es e revis\u00f5es. N\u00e3o foram encontradas diferen\u00e7as significativas entre as demais disflu\u00eancias, com maior semelhan\u00e7a nas compara\u00e7\u00f5es entre a fala espont\u00e2nea e o reconto."}
+{"text": "Este artigo analisa o processo de transforma\u00e7\u00e3o estrutural no mercado privado deservi\u00e7os de sa\u00fade brasileiro a partir dos anos 2000, com \u00eanfase na crescenteparticipa\u00e7\u00e3o de fundos financeiros e do capital estrangeiro no processo deexpans\u00e3o e consolida\u00e7\u00e3o do setor. A an\u00e1lise do movimento de ingresso do capitalestrangeiro nos servi\u00e7os e planos de sa\u00fade no Brasil foi desenvolvida a partirda constru\u00e7\u00e3o de uma base dados com um total de 297 opera\u00e7\u00f5es patrimoniaisenvolvendo empresas com atividades em servi\u00e7os de sa\u00fade, inclusive operadoras deplanos e seguros de sa\u00fade e administradoras de benef\u00edcios em sa\u00fade. A an\u00e1lisedessas opera\u00e7\u00f5es evidencia que o afluxo de capital estrangeiro foi fundamentalpara viabilizar a centraliza\u00e7\u00e3o de capital em determinadas empresas e catalisaro processo de concentra\u00e7\u00e3o e transforma\u00e7\u00e3o estrutural do setor de servi\u00e7os desa\u00fade ao longo das \u00faltimas duas d\u00e9cadas. Conclui-se que o acirramento da disputaintercapitalista no mercado de servi\u00e7os de sa\u00fade levou \u00e0 emerg\u00eancia de grandescorpora\u00e7\u00f5es no mercado e a novos modelos de neg\u00f3cio, com destaque especial parao surgimento de redes verticalizadas de atendimento . Este artigo discute o processo de transforma\u00e7\u00e3o estrutural no mercado privado deservi\u00e7os de sa\u00fade brasileiro, com o objetivo de produzir novas evid\u00eancias sobre aforma\u00e7\u00e3o de grupos econ\u00f4micos na sa\u00fade. Para isso, foi constru\u00edda e analisada umabase de dados com opera\u00e7\u00f5es patrimoniais envolvendo empresas com atividades emservi\u00e7os de sa\u00fade, incluindo as operadoras de planos de sa\u00fade, entre 1999 e 2018. Aan\u00e1lise permitiu evidenciar que o capital estrangeiro e empresas financeiras foramimportantes para capitalizar firmas que protagonizaram o processo de conglomera\u00e7\u00e3ono mercado privado de servi\u00e7os de sa\u00fade brasileiro.A an\u00e1lise da din\u00e2mica econ\u00f4mica na \u00e1rea da sa\u00fade constitui um grande desafio, tantodo ponto de vista acad\u00eamico como no tocante aos seus aspectos pol\u00edtico-normativos,tendo em vista a articula\u00e7\u00e3o entre sa\u00fade e desenvolvimento. Com base na perspectivado Complexo Econ\u00f4mico-Industrial da Sa\u00fade (CEIS) As atividades do CEIS, a base econ\u00f4mica e material da sa\u00fade, representam cerca de 9%dos empregos diretos formais; 1/3 do esfor\u00e7o de pesquisa do pa\u00eds e 9% do produtointerno bruto (PIB) brasileiro Apesar de a abordagem do CEIS destacar a import\u00e2ncia das diversas formas deorganiza\u00e7\u00e3o do sistema de sa\u00fade sobre a din\u00e2mica dos demais subsistemas, poucosestudos focaram especificamente a din\u00e2mica econ\u00f4mica do subsistema de servi\u00e7os desa\u00fade ,A mudan\u00e7a estrutural no mercado de servi\u00e7os de sa\u00fade, a partir da perspectiva doCEIS, relaciona-se a transforma\u00e7\u00f5es em tr\u00eas dimens\u00f5es inter-relacionadas: (i) asdimens\u00f5es econ\u00f4mica, produtiva e tecnol\u00f3gica, com a introdu\u00e7\u00e3o de inova\u00e7\u00f5es quegeram oportunidades, por meio de novas formas de organiza\u00e7\u00e3o do financiamento, daprodu\u00e7\u00e3o  dos servi\u00e7os de sa\u00fade e da apropria\u00e7\u00e3o das rendas geradasnesses servi\u00e7os; (ii) as dimens\u00f5es demogr\u00e1fica, epidemiol\u00f3gica e socioecon\u00f4mica dapopula\u00e7\u00e3o, que se traduzem em demandas de cuidado em sa\u00fade e na capacidade depagamento das fam\u00edlias; (iii) a dimens\u00e3o institucional, que envolve desde ascaracter\u00edsticas dos modelos assistenciais adotados, as pol\u00edticas p\u00fablicas para a\u00e1rea da sa\u00fade e a a\u00e7\u00e3o das ag\u00eancias regulat\u00f3rias, at\u00e9 aspectos culturais, como apercep\u00e7\u00e3o do direito \u00e0 sa\u00fade pela sociedade; e (iv) a intera\u00e7\u00e3o com os demaissubsistemas dos CEIS As transforma\u00e7\u00f5es nessas dimens\u00f5es devem ser apreendidas no contexto do processohist\u00f3rico, marcado por rupturas e continuidades, de evolu\u00e7\u00e3o do capitalismo, dodesenvolvimento brasileiro e, mais especificamente, da forma\u00e7\u00e3o do sistema de sa\u00fadebrasileiro, que influenciam, em um movimento dial\u00e9tico e n\u00e3o determin\u00edstico, aspossibilidades de acumula\u00e7\u00e3o privada na sa\u00fade e, consequentemente, sua articula\u00e7\u00e3ocom o Sistema \u00danico de Sa\u00fade (SUS). Acelerado a partir da virada do s\u00e9culo, esseconjunto de transforma\u00e7\u00f5es propiciou a emerg\u00eancia de novas estrat\u00e9gias empresariaise, como consequ\u00eancia, um vigoroso processo de reconfigura\u00e7\u00e3o do mercado. Aconglomera\u00e7\u00e3o e a concentra\u00e7\u00e3o do setor s\u00e3o express\u00f5es mais vis\u00edveis desse processo.Nessa perspectiva, o estudo da din\u00e2mica do mercado privado de assist\u00eancia \u00e0 sa\u00fade noBrasil passa a ser importante para entender a evolu\u00e7\u00e3o da rela\u00e7\u00e3o p\u00fablico-privada emsa\u00fade e suas consequ\u00eancias para o acesso universal \u00e0 sa\u00fade no pa\u00eds ,,Do ponto de vista institucional e organizacional, o sistema de sa\u00fade brasileirose revela como uma rede complexa de prestadores e compradores de servi\u00e7osp\u00fablicos e privados, financiada majoritariamente por estes \u00faltimos recursos, quecompetem entre si O mercado de servi\u00e7os privados de sa\u00fade compreende as formas de produ\u00e7\u00e3o, gest\u00e3oe realiza\u00e7\u00e3o de atividades de aten\u00e7\u00e3o \u00e0 sa\u00fade humana, com o objetivo de atendera determinada demanda ou clientela restrita. Ele \u00e9 composto por um grupoheterog\u00eaneo de agentes, que variam em termos de porte, fun\u00e7\u00f5es assistenciais en\u00edvel de complexidade tecnol\u00f3gica, natureza jur\u00eddica , al\u00e9m da possibilidade de aceitar diversos modelos depagamento . O pontoprimordial que caracteriza o mercado privado de sa\u00fade \u00e9 a restri\u00e7\u00e3o do acessomediante o pagamento pela utiliza\u00e7\u00e3o dos servi\u00e7os.Pode-se diferenciar as atividades do mercado em dois grupos. O primeiro se refereaos estabelecimentos, com ou sem fins lucrativos, que prestam servi\u00e7os deaten\u00e7\u00e3o \u00e0 sa\u00fade diretamente \u00e0 popula\u00e7\u00e3o ou a outros estabelecimentos de sa\u00fade. Ogrupo denominado \u201cservi\u00e7os de sa\u00fade\u201d pode ser subdividido entre hospitais,ambulat\u00f3rios e servi\u00e7os de apoio ao diagn\u00f3stico e tratamento (SADT). O segundogrupo abrange planos de sa\u00fade, seguros de sa\u00fade e administradoras de benef\u00edciosem sa\u00fade, denominados operadoras de planos de sa\u00fade (OPS). Apesar de seremcompostas por diversos tipos de organiza\u00e7\u00f5es empresariais, como as cooperativasm\u00e9dicas, medicina de grupo, planos de autogest\u00e3o e outras formas de associa\u00e7\u00e3o,essas atividades s\u00e3o reguladas desde 1999 pela Ag\u00eancia Nacional de Sa\u00fadeSuplementar (ANS).home care,oferta de servi\u00e7os ambulatoriais customizados ou de nicho, como o GrupoOncocl\u00ednicas), o aumento da efici\u00eancia operacional e a amplia\u00e7\u00e3o da remunera\u00e7\u00e3ojunto \u00e0s OPS e ao SUS Os principais desafios econ\u00f4micos para as OPS s\u00e3o aumentar a ades\u00e3o dos planos desa\u00fade, reduzir a taxa de sinistralidade, cumprir as exig\u00eancias regulat\u00f3rias econter o crescimento dos custos de acesso aos servi\u00e7os privados de sa\u00fade. Nosegmento dos servi\u00e7os, os principais desafios s\u00e3o a introdu\u00e7\u00e3o de inova\u00e7\u00f5es nomodelo de atendimento  \u00e9 o per\u00edodo de consolida\u00e7\u00e3o dos grandes gruposm\u00e9dicos empresariais nacionais. Observa-se um r\u00e1pido crescimento de planosempresariais e individuais no contexto de implementa\u00e7\u00e3o do SUS, incentivadopelos subs\u00eddios ao atendimento da demanda via sa\u00fade suplementar Lei n\u00ba 13.097A institucionaliza\u00e7\u00e3o e a regulamenta\u00e7\u00e3o do mercado de sa\u00fade suplementar no pa\u00edsno fim dos anos 1990, que, entre outras medidas, tamb\u00e9m autoriza a participa\u00e7\u00e3odo capital estrangeiro nas OPS, marcam o in\u00edcio do terceiro ciclo. Como diversasoperadoras tinham redes de atendimento pr\u00f3prias, na pr\u00e1tica, a lei abriu deforma disfar\u00e7ada a possibilidade da participa\u00e7\u00e3o do capital estrangeiro emservi\u00e7os de sa\u00fade ,,,Tais transforma\u00e7\u00f5es nos planos produtivo e institucional devem ser analisadas emconjunto com o processo de evolu\u00e7\u00e3o do regime de acumula\u00e7\u00e3o capitalista. Atransforma\u00e7\u00e3o do regime de acumula\u00e7\u00e3o capitalista tem sido denominadafrequentemente como financeiriza\u00e7\u00e3o ,,,Os sistemas de sa\u00fade, e mais especificamente o mercado privado de assist\u00eancia \u00e0sa\u00fade, t\u00eam sido fortemente influenciados pela difus\u00e3o do processo definanceiriza\u00e7\u00e3o, tanto em termos globais ,,,,,det\u00eam um poder de arbitragem crescente, capaz de criarmercados e nichos de mercado para produtos e servi\u00e7os e influenciar navaloriza\u00e7\u00e3o e desvaloriza\u00e7\u00e3o de ativos de natureza diversa incluindo, nocaso da assist\u00eancia, insumos para a sa\u00fade\u201d O processo de financeiriza\u00e7\u00e3o tem influenciado a atua\u00e7\u00e3o de grupos econ\u00f4micos eprovocado altera\u00e7\u00f5es em diversas atividades do CEIS brasileiro ,,Os estudos sobre a financeiriza\u00e7\u00e3o em pa\u00edses perif\u00e9ricos e no mercado da sa\u00fadebrasileiro, entretanto, apresentam diversos desafios te\u00f3ricos. As empresasfinanceirizadas nacionais, incluindo as que operam no mercado de assist\u00eancia \u00e0sa\u00fade, possuem caracter\u00edsticas qualitativas e quantitativas distintas emcompara\u00e7\u00e3o aos pares internacionais, sugerindo a necessidade de aprofundarestudos sobre o processo de concentra\u00e7\u00e3o das empresas do setor, seu padr\u00e3o definanciamento e de aplica\u00e7\u00e3o dos recursos obtidos no mercado financeiro O movimento de ingresso do capital estrangeiro nos servi\u00e7os e planos de sa\u00fade noBrasil foi analisado a partir da constru\u00e7\u00e3o de uma base de opera\u00e7\u00f5es patrimoniaisenvolvendo empresas com atividades em servi\u00e7os de sa\u00fade, inclusive as OPS initialpublic offering) ou secund\u00e1rias. Uma fus\u00e3o \u00e9 a uni\u00e3o de duas empresas,de porte semelhante, que resulta na dissolu\u00e7\u00e3o destas e na consequente cria\u00e7\u00e3o deuma nova empresa. A incorpora\u00e7\u00e3o \u00e9 a aquisi\u00e7\u00e3o de uma empresa alvo por uma empresaadquirente, que tem como resultado a dissolu\u00e7\u00e3o da empresa alvo e sua incorpora\u00e7\u00e3odentro do capital da adquirente. Uma aquisi\u00e7\u00e3o majorit\u00e1ria \u00e9 a aquisi\u00e7\u00e3o de parte docapital de uma empresa alvo que resulte no controle de mais 50% de seu capitalsocial ao final da opera\u00e7\u00e3o. Quando a aquisi\u00e7\u00e3o resulta no controle inferior a 50%do capital da empresa alvo, \u00e9 definida como minorit\u00e1ria. Finalmente, uma IPO \u00e9 avenda de parte do capital social de uma empresa em uma bolsa de valores.Nas opera\u00e7\u00f5es patrimoniais, parte do capital social de uma companhia \u00e9 transferidapara outra. Destacam-se as opera\u00e7\u00f5es de fus\u00e3o, incorpora\u00e7\u00e3o, aquisi\u00e7\u00e3o majorit\u00e1ria,aquisi\u00e7\u00e3o minorit\u00e1ria e as ofertas p\u00fablicas de a\u00e7\u00e3o iniciais (IPO - https://www.bvdinfo.com/en-us/our-products/data/greenfield-investment-and-ma/zephyr),organizada pela Orbis BvD, em outubro de 2019. Foram extra\u00eddas as opera\u00e7\u00f5escompletas ou assumidas como completas no per\u00edodo 1999 a 2018, envolvendo empresascom atividades no Brasil no segmento dos servi\u00e7os de sa\u00fade e planos, seguros eintermediadoras de benef\u00edcio em sa\u00fade.Os dados das opera\u00e7\u00f5es patrimoniais utilizadas para constru\u00e7\u00e3o da base foram obtidosjunto \u00e0 plataforma Zephyr (North American Industry Classification System - Sistema deClassifica\u00e7\u00e3o da Ind\u00fastria Norte-Americana). Cada empresa tem um c\u00f3digo de atividadeprincipal, referente ao seu core business, e um ou mais c\u00f3digos deatividade secund\u00e1rios relevantes para ela. Por exemplo: uma empresa pode identificar\u201cplanos de sa\u00fade, operadoras e intermediadoras de seguros de sa\u00fade\u201d como suaatividade principal, mas ter como atividades secund\u00e1rias \u201chospitais\u201d e\u201cempreendimentos imobili\u00e1rios\u201d. Foram selecionadas empresas com atividadeshospitalares, ambulatoriais, SADT, OPS e outros servi\u00e7os de aten\u00e7\u00e3o \u00e0 sa\u00fade,considerando os c\u00f3digos de atividades dos cap\u00edtulos 62  e outros selecionadosdos cap\u00edtulos 52 (Finance and insurance - Finan\u00e7as e seguros) e 54 do NAICS 2017.A Orbis BvD classifica o setor de atividade das empresas atrav\u00e9s dos c\u00f3digos NAICS2017 . Entretanto, considera-se que, a partirdo momento que o capital nacional foi transnacionalizado, ele assume caracter\u00edsticasdistintas do capital de origem nacional, radicado no Brasil.private equityadquirem a\u00e7\u00f5es de uma empresa de servi\u00e7os de diagn\u00f3stico. Dois hospitais realizamuma fus\u00e3o. Em cada um desses casos, a participa\u00e7\u00e3o de ao menos uma empresabrasileira com atividades em servi\u00e7os ou seguros de sa\u00fade foi considerada como ocrit\u00e9rio de sele\u00e7\u00e3o para a base.Uma opera\u00e7\u00e3o patrimonial pode ser realizada por uma, duas ou mais firmas. Uma rede dehospitais abre seu capital na bolsa de valores. Uma empresa de seguros de sa\u00fadeadquire uma operadora de planos de sa\u00fade, com atividades em hospitais, ambulat\u00f3rios,servi\u00e7os de diagn\u00f3stico e tratamento. Tr\u00eas fundos de Algumas opera\u00e7\u00f5es n\u00e3o exibiam informa\u00e7\u00f5es sobre as empresas adquirentes envolvidas.Para cada IPO, foi poss\u00edvel identificar e corrigir a participa\u00e7\u00e3o de investidoresestrangeiros na opera\u00e7\u00e3o. Os valores associados aos demais subscritores do IPO,incluindo fundos institucionais, foram classificados como \u201cindefinido\u201d, dada aimpossibilidade de identificar a origem do capital desses agentes nos documentosacessados. Muitas opera\u00e7\u00f5es de capta\u00e7\u00e3o realizadas por empresas m\u00e9dias ou pequenastamb\u00e9m n\u00e3o continham informa\u00e7\u00f5es do investidor.Os dados sobre fluxo de investimento direto no pa\u00eds (IDP), divulgados pelo BancoCentral do Brasil ,Quando consideramos tamb\u00e9m os segmentos de seguros, resseguro, previd\u00eanciacomplementar e planos de sa\u00fade, os dados do Banco Central apresentam entradas decapital estrangeiro com valores expressivos, especialmente na primeira metade dad\u00e9cada de 2010. Os elevados valores nos grupos supramencionados A forma de apresenta\u00e7\u00e3o dos dados do Banco Central, no entanto, torna opaca a atua\u00e7\u00e3odo capital estrangeiro no processo de mudan\u00e7a estrutural observado nos mercados desa\u00fade privada brasileiros at\u00e9 2015. A agrega\u00e7\u00e3o dos dados com o setor de seguros,resseguros e previd\u00eancia complementar, em conjunto com a impossibilidade deidentificar as opera\u00e7\u00f5es individualmente, dificulta uma associa\u00e7\u00e3o direta.Os resultados apresentam novas evid\u00eancias, baseadas em microdados ao n\u00edvel daempresa, que refor\u00e7am a hip\u00f3tese de que o capital estrangeiro j\u00e1 exercia papelrelevante no mercado de servi\u00e7os de sa\u00fade desde a primeira metade da d\u00e9cada de 2000.Adicionalmente, os dados apontam que o capital de origem estrangeira exerceu papelimportante no financiamento do processo de mudan\u00e7a estrutural no mercado de servi\u00e7osde sa\u00fade.joint ventures no segmento de planos de sa\u00fade dent\u00e1rios.Entre 1999 e 2018, foram registradas 297 opera\u00e7\u00f5es patrimoniais envolvendo empresascom atividades nos setores de servi\u00e7os de sa\u00fade ou em seguros de sa\u00fade no Brasil. Otipo de opera\u00e7\u00e3o mais comum foi a aquisi\u00e7\u00e3o majorit\u00e1ria (194), seguido das opera\u00e7\u00f5esde aquisi\u00e7\u00e3o minorit\u00e1rias (64). Foram identificadas oito IPO e 25 ofertassecund\u00e1rias para aumento de capital. Observou-se uma fus\u00e3o e a forma\u00e7\u00e3o de quatroO valor do neg\u00f3cio foi declarado em 165 opera\u00e7\u00f5es (55%) dentre as selecionadas. Entre1999 e 2018, essas opera\u00e7\u00f5es movimentaram USD 29,3 bilh\u00f5es, em valores corrigidospara 2018. O montante foi decomposto em tr\u00eas categorias, de acordo com a origem docapital da empresa adquirente. Quase metade do valor negociado est\u00e1 associada ao \u201ccapital estrangeiro\u201d. Cerca de 27% do valor  foiidentificado como \u201ccapital nacional\u201d e 25% do valor negociado tinha origem \u201cindefinida\u201d. A Nota-se uma acelera\u00e7\u00e3o da frequ\u00eancia e do volume financeiro movimentado nas opera\u00e7\u00f5espatrimoniais no segmento de servi\u00e7os e seguros de sa\u00fade a partir dos anos 2000. Essemovimento atinge seu auge em 2012, quando as opera\u00e7\u00f5es movimentaram USD 5,2 bilh\u00f5espela venda da Amil para o grupo UnitedHealth pelo valor de USD 3,5 bilh\u00f5es  e pelas duas opera\u00e7\u00f5es de venda de a\u00e7\u00f5es da Qualicorp, quemovimentaram, no conjunto, USD 950 milh\u00f5es , com oobjetivo de remunerar o investimento do grupo Carlyle na empresa.A Quando desconsideramos a aquisi\u00e7\u00e3o da Amil pela UnitedHealth, em 2012, por USD 3,5bilh\u00f5es , a m\u00e9dia dessastransa\u00e7\u00f5es \u00e9 reduzida para USD 277 milh\u00f5es. O valor se mant\u00e9m superior \u00e0 m\u00e9dia dasaquisi\u00e7\u00f5es com capital nacional, mas pr\u00f3ximo ao valor m\u00e9dio das aquisi\u00e7\u00f5esminorit\u00e1rias com capital estrangeiro, que foi de USD 253 milh\u00f5es.A A maior parte das opera\u00e7\u00f5es entre as empresas do mercado de servi\u00e7os de sa\u00fade podeser caracterizada como horizontal, na medida em que foram destinadas a obter alvoscom a mesma atividade da empresa adquirente , ambulatoriais (19), de SADT (25), empresas com atividades nosegmento de planos de sa\u00fade (42) ou empresas com outras atividades principais, masque tamb\u00e9m atuavam em servi\u00e7os de sa\u00fade (42). A maior parte dessas opera\u00e7\u00f5es foiclassificada como \u201copera\u00e7\u00f5es minorit\u00e1rias\u201d (39%), nas quais n\u00e3o houve transfer\u00eanciado controle.As opera\u00e7\u00f5es minorit\u00e1rias comandadas pelo capital financeiro somaram USD 7,9 bilh\u00f5es. Os resultados refor\u00e7am a hip\u00f3tese deque esse tipo de transa\u00e7\u00e3o, comandado por empresas financeiras, subsidiou o processode conglomera\u00e7\u00e3o do setor, propiciando os recursos necess\u00e1rios para as empresas domercado privado de sa\u00fade realizarem opera\u00e7\u00f5es patrimoniais.privateequity Patrim\u00f4nio, em 1999, a Dasa inicia um conjunto de opera\u00e7\u00f5espatrimoniais, adquirindo outros laborat\u00f3rios de diagn\u00f3stico. Em 2004, a empresa abreo capital (IPO) e a Patrim\u00f4nio encerra suas opera\u00e7\u00f5es para rentabilizar a posi\u00e7\u00e3o. Ainje\u00e7\u00e3o de capital adicional propiciada pelo IPO e ofertas secund\u00e1rias de a\u00e7\u00f5es(follow-on) propiciaram uma segunda rodada de aquisi\u00e7\u00f5es. Em2010, entretanto, a Amil realiza uma opera\u00e7\u00e3o de troca de a\u00e7\u00f5es com a Dasa, abrindoespa\u00e7o para o ingresso da fam\u00edlia controladora da Amil na Dasa. Ap\u00f3s a venda da Amilpara a UnitedHealth, a fam\u00edlia adquire o controle do Grupo Dasa e fecha o capital daempresa. Em 2021, segundo o ranking do Valor Econ\u00f4mico, o GrupoDasa foi a segunda maior empresa de servi\u00e7os de sa\u00fade do Brasil e a 99\u00ba maiorempresa brasileira.O ,O artigo agrega novas evid\u00eancias sobre o crescimento dos grupos econ\u00f4micos no mercadoda sa\u00fade via opera\u00e7\u00f5es patrimoniais. Os resultados refor\u00e7am a hip\u00f3tese de que asopera\u00e7\u00f5es patrimoniais no mercado de capitais permitiram a capitaliza\u00e7\u00e3o de gruposecon\u00f4micos da sa\u00fade junto a empresas financeiras para promover o crescimento pormeio de outras opera\u00e7\u00f5es patrimoniais no mercado dom\u00e9stico. Adicionalmente, suportama hip\u00f3tese de que a entrada do capital estrangeiro no setor de servi\u00e7os de sa\u00fadebrasileiro j\u00e1 vinha ocorrendo anos antes da aprova\u00e7\u00e3o da lei que libera sua atua\u00e7\u00e3ono setor de forma quase irrestrita proxy do porte da empresa adquirida,os resultados sugerem que o capital estrangeiro busca empresas de maior porte,enquanto as opera\u00e7\u00f5es nacionais estariam mais vinculadas a um processo deconglomera\u00e7\u00e3o do mercado interno, adquirindo empresas de menor porte.Ao considerar o conjunto de opera\u00e7\u00f5es patrimoniais, incluindo aquisi\u00e7\u00f5es minorit\u00e1riaslideradas por empresas financeiras, foi poss\u00edvel evidenciar um processo cont\u00ednuo deentrada do capital financeiro nas empresas privadas de servi\u00e7os de sa\u00fade. Tomando ovalor das opera\u00e7\u00f5es como uma follow-on). Muitas vezes, entretanto, essas opera\u00e7\u00f5estamb\u00e9m envolvem um aumento de seu capital, financiando um novo ciclo de expans\u00e3oatrav\u00e9s de opera\u00e7\u00f5es patrimoniais.O aporte de capital por parte de empresas financeiras em empresas de capital fechadopropicia caixa para remunerar antigos s\u00f3cios e financiar sua expans\u00e3o medianteopera\u00e7\u00f5es patrimoniais. O ciclo de crescimento remunera os novos investidores,normalmente por meio da abertura do capital da empresa (IPO) e de ofertassecund\u00e1rias  everticais, levando \u00e0 forma\u00e7\u00e3o de redes de atendimento integradas e de diversifica\u00e7\u00e3o(por meio da aquisi\u00e7\u00e3o de empresas n\u00e3o relacionadas ao mercado de servi\u00e7os desa\u00fade).Os resultados tamb\u00e9m sugerem que a participa\u00e7\u00e3o do capital nacional se deu de formamais associada do que subordinada aos fluxos de capital estrangeiro no mercado deservi\u00e7os de sa\u00fade. Este teve um papel fundamental para capitalizar as empresas desa\u00fade e financiar o processo de conglomera\u00e7\u00e3o do setor. A transfer\u00eancia do controledos grandes grupos para o capital estrangeiro , no entanto, foi uma exce\u00e7\u00e3o, e n\u00e3oa \u201cregra\u201d do processo.O controle da maior parte das empresas que lideraram o movimento de conglomera\u00e7\u00e3o semanteve com investidores nacionais, em muitos casos com acionistas das fam\u00edlias dosmesmos grupos que participaram do processo de empresariamento da sa\u00fade nas d\u00e9cadasanteriores, corroborando resultados de outros trabalhos O comportamento das maiores empresas privadas do setor de sa\u00fade brasileiro diferesubstancialmente das estrat\u00e9gias das maiores empresas privadas de sa\u00fade globais(majoritariamente dos Estados Unidos), nas quais o controle acion\u00e1rio \u00e9 pulverizado.O exemplo da trajet\u00f3ria do Grupo Dasa, ap\u00f3s movimento de inje\u00e7\u00e3o de capital deex-controladores da Amil, evidencia que o movimento concreto das empresas depende dequest\u00f5es espec\u00edficas do processo de forma\u00e7\u00e3o do mercado da sa\u00fade brasileiro, assimcomo da pr\u00f3pria forma de atua\u00e7\u00e3o dos grupos econ\u00f4micos nacionais e da sa\u00fade.Os resultados evidenciam que a domin\u00e2ncia financeira n\u00e3o implica, necessariamente,substitui\u00e7\u00e3o de investimentos produtivos por financeiros Os desafios provocados pelas transforma\u00e7\u00f5es econ\u00f4micas, sociais e institucionaislevaram \u00e0 emerg\u00eancia de novos modelos de neg\u00f3cio no mercado privado de assist\u00eancia \u00e0sa\u00fade brasileiro. O processo de financeiriza\u00e7\u00e3o ou domin\u00e2ncia financeira nasempresas n\u00e3o financeiras esteve associado ao aumento no uso de opera\u00e7\u00f5espatrimoniais Apesar das luzes lan\u00e7adas sobre o processo de conglomera\u00e7\u00e3o e forma\u00e7\u00e3o de grandesgrupos econ\u00f4micos na sa\u00fade, o esfor\u00e7o realizado ilumina apenas parcialmente esseprocesso. Ao considerar apenas as opera\u00e7\u00f5es patrimoniais como evid\u00eancia do processode mudan\u00e7a estrutural, podemos deixar de perceber movimentos importantes realizadospor empresas que n\u00e3o adotaram essa estrat\u00e9gia empresarial. A contribui\u00e7\u00e3o desteestudo deve se somar a outras pesquisas, que t\u00eam analisado o problema a partir deperspectivas distintas. Ao longo das \u00faltimas d\u00e9cadas, por exemplo, um grupo deinstitui\u00e7\u00f5es filantr\u00f3picas tem apresentado ritmo de crescimento intenso, seconstituindo como parte das maiores empresas de sa\u00fade do Brasil. Investigar osfatores ligados ao desenvolvimento dos grandes grupos, portanto, segue como umaagenda de pesquisa relevante.A an\u00e1lise hist\u00f3rica permite observar que o crescimento do mercado privado de sa\u00faden\u00e3o \u00e9 um processo natural. Historicamente, no Brasil, ele demandou intenso apoio dosetor p\u00fablico, mediante a garantia de compras p\u00fablicas, al\u00e9m do subs\u00eddio, da demandae da oferta privada. Al\u00e9m de utilizar recursos p\u00fablicos que poderiam ser mobilizadospara investimentos no SUS, o crescimento do mercado privado de sa\u00fade sedimenta umal\u00f3gica mercantil no acesso \u00e0 sa\u00fade, afastando da popula\u00e7\u00e3o a garantia do acessouniversal, integral e equ\u00e2nime \u00e0 sa\u00fade.lobby para autorizar a oferta de planos com cobertura limitadapara a popula\u00e7\u00e3o sem capacidade de pagamento para os planos atuais ou a obriga\u00e7\u00e3o daoferta de planos empresariais para todos os trabalhadores formais s\u00e3o exemplosdessas agendas.Al\u00e9m da introdu\u00e7\u00e3o de inova\u00e7\u00f5es e da manuten\u00e7\u00e3o dos subs\u00eddios tribut\u00e1rios, umaestrat\u00e9gia liderada pelo setor privado para expandir o mercado privado deassist\u00eancia \u00e0 sa\u00fade tem sido ampliar a segmenta\u00e7\u00e3o do acesso. OEm um cen\u00e1rio de estagna\u00e7\u00e3o econ\u00f4mica, as possibilidades de crescimento do setorprivado demandam uma interven\u00e7\u00e3o ainda maior do setor p\u00fablico. Aprofundar acompreens\u00e3o dos fatores de crescimento do setor privado e da rela\u00e7\u00e3o p\u00fablico-privadoem sa\u00fade, portanto, \u00e9 fundamental para compreender os novos desafios e oportunidadesque surgem para viabiliza\u00e7\u00e3o do SUS de forma integral, equ\u00e2nime e universal."}
+{"text": "Este estudo buscou analisar a rela\u00e7\u00e3o entre as hospitaliza\u00e7\u00f5es por agravosrespirat\u00f3rios e a queima regular da cana-de-a\u00e7\u00facar em Pernambuco, Brasil.Trata-se de um estudo ecol\u00f3gico de s\u00e9rie temporal correspondente ao per\u00edodo de2008 a 2018. Foram comparadas as taxas de hospitaliza\u00e7\u00f5es por agravosrespirat\u00f3rios em crian\u00e7as menores de 5 anos e em idosos maiores de 60 anos emmunic\u00edpios produtores e n\u00e3o produtores de cana-de-a\u00e7\u00facar, por meio da an\u00e1liseestat\u00edstica n\u00e3o param\u00e9trica de Mann-Whitney. Conjuntamente, foi observada adistribui\u00e7\u00e3o mensal das ocorr\u00eancias de focos de calor nos munic\u00edpios casos econtroles e aplicada a correla\u00e7\u00e3o de Pearson para analisar a associa\u00e7\u00e3o entreambas as vari\u00e1veis. Foi verificado que, para ambos os grupos et\u00e1rios, as taxasde hospitaliza\u00e7\u00f5es s\u00e3o maiores nos munic\u00edpios produtores de cana-de-a\u00e7\u00facar, comdiferen\u00e7a estat\u00edstica significativa p < 0,005. A taxa de interna\u00e7\u00e3ohospitalar em idosos \u00e9 28% mais elevada nos munic\u00edpios casos, sendo ainda maiorem crian\u00e7as menores de 5 anos, cuja raz\u00e3o das medianas \u00e9 40%. No entanto, foiidentificado que o comportamento sazonal das hospitaliza\u00e7\u00f5es por agravosrespirat\u00f3rios diverge do observado na distribui\u00e7\u00e3o mensal dos focos de calor,n\u00e3o havendo correla\u00e7\u00e3o estat\u00edstica significativa. Esses achados sugerem poss\u00edvelassocia\u00e7\u00e3o com a exposi\u00e7\u00e3o cr\u00f4nica aos particulados emitidos pela queima debiomassa, comprometendo a sa\u00fade de grupos vulner\u00e1veis, e endossam a necessidadede substitui\u00e7\u00e3o das queimadas no monocultivo da cana-de-a\u00e7\u00facar, bem como aestrutura\u00e7\u00e3o de pol\u00edticas p\u00fablicas de prote\u00e7\u00e3o \u00e0 sa\u00fade humana e ambiental. O Estado de Pernambuco, localizado na Regi\u00e3o Nordeste, destacou-se como o segundomaior produtor de a\u00e7\u00facar e terceiro maior produtor de etanol das regi\u00f5es Norte eNordeste no ano de 2020. Neste mesmo per\u00edodo, a produ\u00e7\u00e3o de etanol registrou umincremento de 22,9% a mais do que o ano anterior, sendo o 3\u00ba estado do pa\u00eds que maisampliou sua produ\u00e7\u00e3o no setor. Cerca de 99,3% da colheita realizada no estado ocorrea partir do corte manual e queima pr\u00e9via da palha da cana-de-a\u00e7\u00facar Trata-se de um estudo ecol\u00f3gico de tend\u00eancia temporal com abordagem descritiva eanal\u00edtica ,Foi realizado um comparativo das taxas de interna\u00e7\u00e3o hospitalar entre os conjuntos demunic\u00edpios casos e controles do Estado de Pernambuco. O crit\u00e9rio utilizado para adefini\u00e7\u00e3o dos cinco munic\u00edpios casos foi a condi\u00e7\u00e3o de serem os territ\u00f3rios de maior\u00e1rea plantada de cana-de-a\u00e7\u00facar no estado: \u00c1gua Preta, Alian\u00e7a, Sirinha\u00e9m, Itamb\u00e9 eGoiana Para an\u00e1lise estat\u00edstica das taxas de interna\u00e7\u00f5es hospitalares referentes \u00e0s doen\u00e7asrespirat\u00f3rias foi utilizado o teste n\u00e3o param\u00e9trico de Mann-Whitney. O m\u00e9todo \u00e9recomendado para comparar amostras independentes e utiliza a mediana como medida quemelhor representa o centro da distribui\u00e7\u00e3o ao longo da s\u00e9rie hist\u00f3rica, auxiliandona observa\u00e7\u00e3o dos valores e suas condi\u00e7\u00f5es de igualdades ou diferen\u00e7as estat\u00edsticashttp://terrabrasilis.dpi.inpe.br/queimadas/bdqueimadas/ do InstitutoNacional de Pesquisas Espaciais INPE, sistema que compila registros de queimadasdetectadas por um conjunto de sat\u00e9lites a partir de pontos de alta temperaturapresentes na superf\u00edcie terrestre. A identifica\u00e7\u00e3o das \u00e1reas de maior densidade decalor sujeita-se \u00e0 resolu\u00e7\u00e3o espacial do sistema sensor de cada sat\u00e9lite, sendo aextens\u00e3o m\u00ednima detect\u00e1vel correspondente a uma \u00e1rea de 30 metros de comprimento por1 metro de largura de \u00e1rea queimada, segundo valida\u00e7\u00e3o de campo. O comportamentosazonal de ambas as vari\u00e1veis foi descrito a partir de gr\u00e1ficos de s\u00e9rie hist\u00f3ricatemporal e a an\u00e1lise da associa\u00e7\u00e3o entre elas ocorreu pela correla\u00e7\u00e3o de Pearson,representada por gr\u00e1ficos de dispers\u00e3o.Para descrever uma poss\u00edvel rela\u00e7\u00e3o existente entre o aumento das hospitaliza\u00e7\u00f5es pordoen\u00e7as respirat\u00f3rias e a ocorr\u00eancia de queimadas da palha de cana-de-a\u00e7\u00facar, foramcruzados os dados mensais coletados a partir do SIH/SUS e os dados dos focos decalor, obtidos na plataforma BDQUEIMADAS Nos munic\u00edpios casos, as taxas de hospitaliza\u00e7\u00f5es por doen\u00e7as respirat\u00f3rias nosgrupos et\u00e1rios de menores de 5 anos e maiores de 60 anos foram superiores quandocomparadas \u00e0s taxas dos munic\u00edpios no grupo controle.Ao comparar as taxas de interna\u00e7\u00f5es hospitalares mensais nos munic\u00edpios casos econtroles, pode-se verificar, a partir do teste U de Mann-Whitney, que houvediferen\u00e7a estat\u00edstica significante em ambos os grupos et\u00e1rios p < 0,005,m\u00e9dia dos pontos de 106,39 para o grupo controle e 158,61 para o grupo de casosem crian\u00e7as menores de 5 anos, sendo U = 5.266 e p < 0,005, m\u00e9dia dos pontosde 101,92 para o grupo controle e 163,08 para o grupo de casos em idosos acimade 60 anos, sendo U = 4.676 Considerando-se as taxas de hospitaliza\u00e7\u00f5es, distribu\u00eddas mensalmente ao longo das\u00e9rie hist\u00f3rica analisada, observou-se que, em todos os percentis, a mediana dosmunic\u00edpios casos \u00e9 superior \u00e0 mediana dos munic\u00edpios controles para ambas asfaixas et\u00e1rias de maior vulnerabilidade.No percentil 50, para idosos acima de 60 anos, a raz\u00e3o das medianas aponta umataxa 28% mais elevada nos munic\u00edpios casos. Para crian\u00e7as menores de 5 anos, ataxa mediana das hospitaliza\u00e7\u00f5es por agravos respirat\u00f3rios \u00e9 40% maior nosmunic\u00edpios casos.O comportamento das taxas de interna\u00e7\u00f5es hospitalares por agravos respirat\u00f3riosem idosos e crian\u00e7as menores de 5 anos, ao longo do curso da s\u00e9rie hist\u00f3ricaanalisada, indica um padr\u00e3o sazonal semelhante em munic\u00edpios casos e controles.As hospitaliza\u00e7\u00f5es por estes agravos apresentam-se, em geral, mais baixas nosmeses de janeiro, sofrendo importante incremento no segundo trimestre, comregistros mais elevados nos meses de abril a julho Nos munic\u00edpios casos, o m\u00eas de fevereiro marca o fim do per\u00edodo da queima dapalha da cana-de-a\u00e7\u00facar. Em abril registra-se o in\u00edcio das chuvas deoutono/inverno na Zona da Mata pernambucana e o consequente aumento da umidaderelativa do ar que, devido \u00e0 proximidade com a costa litor\u00e2nea, pode chegar emtorno de 90% nos per\u00edodos mais chuvosos dos munic\u00edpios da regi\u00e3o.Excepcionalmente, no terceiro trimestre do ano 2011, houve um incrementodiscreto nas hospitaliza\u00e7\u00f5es para a faixa et\u00e1ria acima de 60 anos nos munic\u00edpioscasos A compara\u00e7\u00e3o das taxas de interna\u00e7\u00f5es hospitalares em ambos os grupos et\u00e1riosevidencia mais casos de hospitaliza\u00e7\u00e3o por este grupo de agravos entre crian\u00e7asmenores de 5 anos em todos os meses do ano.Observou-se que a ocorr\u00eancia de focos de calor nos munic\u00edpios que cultivam acana-de-a\u00e7\u00facar \u00e9 superior aos n\u00e3o produtores Entretanto, a an\u00e1lise da distribui\u00e7\u00e3o temporal das ocorr\u00eancias dos focos decalor, em associa\u00e7\u00e3o com as taxas de hospitaliza\u00e7\u00f5es mensais por agravosrespirat\u00f3rios em ambas as faixas et\u00e1rias, n\u00e3o apresentou correla\u00e7\u00e3o estat\u00edsticasignificativa de acordo com os par\u00e2metros obtidos pelo modelo de an\u00e1liseutilizado. Diferente do padr\u00e3o sazonal das hospitaliza\u00e7\u00f5es por agravosrespirat\u00f3rios, mais prevalentes entre os meses de abril a julho, a distribui\u00e7\u00e3omensal dos focos de calor nos munic\u00edpios canavieiros concentra-se entre os mesesde agosto e fevereiro Em ambos os grupos de munic\u00edpios analisados e para ambas as faixas et\u00e1rias maisvulner\u00e1veis, a tend\u00eancia \u00e9, inclusive, de leve queda nas taxas de interna\u00e7\u00e3o \u00e0medida que se aumentam os valores de focos de calor, embora estas soframincremento significativo nos tr\u00eas meses subsequentes ao in\u00edcio do per\u00edodo dequeima ,,,,,,,,Associa\u00e7\u00f5es significativas entre a ocorr\u00eancia de hospitaliza\u00e7\u00f5es por doen\u00e7asrespirat\u00f3rias e a polui\u00e7\u00e3o do ar t\u00eam sido observadas em diversos estudos ,,,,O aumento na taxa de interna\u00e7\u00e3o hospitalar por condi\u00e7\u00f5es respirat\u00f3rias emcrian\u00e7as menores de 5 anos tem sido associado \u00e0 queima de biomassa dacana-de-a\u00e7\u00facar em estudos desenvolvidos em regi\u00f5es produtoras no Brasil Em outros cen\u00e1rios, a exemplo das polui\u00e7\u00f5es emitidas na Regi\u00e3o Amaz\u00f4nica poroutras fontes de emiss\u00e3o de particulados de queimadas, Requia et al. No entanto, ainda que as condi\u00e7\u00f5es socioambientais de exposi\u00e7\u00e3o sejam asvariantes centrais para o surgimento das doen\u00e7as aqui analisadas, as condi\u00e7\u00f5esfisiol\u00f3gicas e patol\u00f3gicas t\u00edpicas de cada grupo et\u00e1rio podem constituir edistinguir suscetibilidades espec\u00edficas ao adoecimento ,,,,Por outro lado, a sobreposi\u00e7\u00e3o de variantes clim\u00e1ticas com os impactos dapolui\u00e7\u00e3o atmosf\u00e9rica proveniente da queima de biomassa \u00e9 um fen\u00f4meno influentenas taxas de hospitaliza\u00e7\u00f5es por agravos respirat\u00f3rios em grupos et\u00e1rios demaior vulnerabilidade. Nota-se um car\u00e1ter sazonal para os desfechosrespirat\u00f3rios mais sens\u00edveis \u00e0s condi\u00e7\u00f5es ambientais e sociais 10 e CO emsuspens\u00e3o atmosf\u00e9rica, seguida da umidade relativa e densidade demogr\u00e1fica.Chama aten\u00e7\u00e3o que, embora o incremento das taxas de hospitaliza\u00e7\u00f5es analisadasneste estudo n\u00e3o coincidam com o ciclo de queima da cana-de-a\u00e7\u00facar, elasconvergem para o per\u00edodo de chuvas no Nordeste brasileiro. Conforme aponta Gomeset al. 2,5 foi 50% maiornos per\u00edodos de seca, quando havia diminui\u00e7\u00e3o da umidade relativa do ar eaumento da temperatura ambiente. Ainda verificaram o aumento de10mg/m3 nos n\u00edveis de exposi\u00e7\u00e3o ao MP2,5 durante todoo ano, sendo associado ao incremento de 12,1% nas m\u00e9dias m\u00f3veis dehospitaliza\u00e7\u00f5es de crian\u00e7as por doen\u00e7as respirat\u00f3rias e 22% nos per\u00edodos deesta\u00e7\u00e3o seca. Vasconcellos et al. Ampliando as an\u00e1lises anteriores, outros autores t\u00eam relacionado os baixos\u00edndices de umidade com o adoecimento respirat\u00f3rio nas regi\u00f5es mais secas dopa\u00eds. Silva et al. Vasconcelos et al. ,,,,,A an\u00e1lise da distribui\u00e7\u00e3o das ocorr\u00eancias mensais de focos de calor neste estudoexp\u00f4s um padr\u00e3o de regularidade e de maiores frequ\u00eancias nos munic\u00edpiosprodutores de cana-de-a\u00e7\u00facar ao longo da s\u00e9rie hist\u00f3rica, conforme observado emoutros estudos Entretanto, no estudo de Paraiso & Gouveia Salienta-se que os desfechos na sa\u00fade respirat\u00f3ria podem n\u00e3o ocorrer de formainstant\u00e2nea e simult\u00e2nea ao evento das queimadas, variando seu surgimento aolongo do tempo e, conforme reportam Requia et al. A partir dos resultados compartilhados em nosso trabalho, levanta-se a hip\u00f3tesede que a exposi\u00e7\u00e3o persistente e sazonal, em territ\u00f3rios com maiores ocorr\u00eanciasde focos de calor, pode produzir hipersensibilidade populacional aosparticulados t\u00f3xicos e maior predisposi\u00e7\u00e3o aos agravos respirat\u00f3rios, comoobservado nas taxas elevadas de hospitaliza\u00e7\u00e3o nos munic\u00edpios casos ao longo detodos os meses do ano, no per\u00edodo analisado. Existem discuss\u00f5es acerca daplausibilidade biol\u00f3gica desta ocorr\u00eancia, ancoradas em evid\u00eancias anunciadaspor estudos antecedentes, como o de Goto et al. Mnatzaganian et al. Para al\u00e9m da sintomatologia cl\u00ednica dos agravos respirat\u00f3rios, a exposi\u00e7\u00e3o aomaterial particulado em suspens\u00e3o atmosf\u00e9rica incide diretamente sobremecanismos bioqu\u00edmicos, eventos intra, extra e intercelulares, estendendo suasconsequ\u00eancias para outros sistemas do corpo humano, a exemplo do homeost\u00e1tico,sangu\u00edneo e imune. Inclusive, seu potencial mutag\u00eanico precisa ser levado emconsidera\u00e7\u00e3o quando a exposi\u00e7\u00e3o persistente abrange dimens\u00f5es populacionaisComo visto, as elevadas taxas de hospitaliza\u00e7\u00f5es por agravos respirat\u00f3rios nosgrupos populacionais aqui estudados, nos munic\u00edpios produtores decana-de-a\u00e7\u00facar, sugerem poss\u00edvel associa\u00e7\u00e3o com a exposi\u00e7\u00e3o cr\u00f4nica aosparticulados t\u00f3xicos, emitidos pela queima regular de biomassa. Endossa anecessidade de revis\u00e3o e reestrutura\u00e7\u00e3o das pr\u00e1ticas seculares, e aindaoperantes, do monocultivo extrativista da cana-de-a\u00e7\u00facar, bem como demanda aconstru\u00e7\u00e3o de pol\u00edticas p\u00fablicas de prote\u00e7\u00e3o \u00e0 sa\u00fade humana e ambiental nosterrit\u00f3rios inseridos na cadeia produtiva sucroenerg\u00e9tica.Conforme Oliveira & Anuncia\u00e7\u00e3o \u00c9 urgente a estrutura\u00e7\u00e3o de uma vigil\u00e2ncia em sa\u00fade de base territorial nosmunic\u00edpios submetidos \u00e0s queimadas regulares. Certamente, o monitoramentoambiental e em sa\u00fade deve ser atrelado \u00e0 oferta de uma rede de assist\u00eanciaadequada e especializada com fluxos de refer\u00eancia e contrarrefer\u00eancia bemestabelecidos entre os servi\u00e7os, assegurando a continuidade do cuidado integradoem sa\u00fade. Ressalta-se a necessidade de outras an\u00e1lises futuras preocupadas com aelucida\u00e7\u00e3o da hip\u00f3tese que associa as altas taxas de hospitaliza\u00e7\u00f5es aosper\u00edodos de maiores concentra\u00e7\u00f5es atmosf\u00e9ricas dos particulados emitidos pelaqueima da palha da cana-de-a\u00e7\u00facar.Dados os limites relacionados \u00e0 natureza dos dados secund\u00e1rios analisados nesteartigo, n\u00e3o foi poss\u00edvel espacializar a influ\u00eancia dos focos de calor sobre osagravos respirat\u00f3rios que acometem a popula\u00e7\u00e3o exposta nos territ\u00f3rios eman\u00e1lise. Por um lado, as limita\u00e7\u00f5es que envolvem o uso dos dados de focos decalor variam desde restri\u00e7\u00f5es na detec\u00e7\u00e3o de ocorr\u00eancia e delimita\u00e7\u00e3o daextens\u00e3o da \u00e1rea queimada, at\u00e9 falhas devido \u00e0s influ\u00eancias de varia\u00e7\u00f5esnaturais A despeito da import\u00e2ncia da realiza\u00e7\u00e3o de estudos que evidenciem a polui\u00e7\u00e3oatmosf\u00e9rica pela queima de biomassa e sua rela\u00e7\u00e3o com doen\u00e7as respirat\u00f3rias, emparticular da cana-de-a\u00e7\u00facar, dada sua import\u00e2ncia na economia brasileira,observou-se uma escassez de pesquisas no Estado de Pernambuco e na Regi\u00e3oNordeste do pa\u00eds. Como a taxa de mecaniza\u00e7\u00e3o da colheita da cana-de-a\u00e7\u00facar \u00e9 deapenas 22,9% nas regi\u00f5es Norte e Nordeste, as queimadas e a colheita manualainda se mant\u00eam nesses territ\u00f3rios Os achados desta pesquisa sugerem poss\u00edvel associa\u00e7\u00e3o de problemas respirat\u00f3rios coma exposi\u00e7\u00e3o cr\u00f4nica aos particulados emitidos pela queima de biomassa, comprometendoa sa\u00fade de grupos vulner\u00e1veis nos territ\u00f3rios do agroneg\u00f3cio em Pernambuco. N\u00e3oobstante, endossam a necessidade de substitui\u00e7\u00e3o das queimadas no monocultivo dacana-de-a\u00e7\u00facar, bem como a estrutura\u00e7\u00e3o de pol\u00edticas p\u00fablicas de prote\u00e7\u00e3o \u00e0 sa\u00fadehumana e ambiental."}
+{"text": "Survivorship: A Sociology of Cancer in Everyday Life de AlexBroom & Katherine Kenny O livro governa corpos, identidadese rela\u00e7\u00f5es sociais\u201d (p. 8) e, de forma assim\u00e9trica, espelha as injusti\u00e7associais, a invisibilidade das dimens\u00f5es subjetivas, os fluxos temporais das rela\u00e7\u00f5es, osentrecruzamentos institucionais e apelos discursivos.Na introdu\u00e7\u00e3o, o leitor \u00e9 apresentado \u00e0 hist\u00f3ria centrada na doen\u00e7a e na ind\u00fastria dotratamento da sobreviv\u00eancia ao c\u00e2ncer nas \u00faltimas d\u00e9cadas. Entretanto, os cap\u00edtulossubsequentes apontam que a sobreviv\u00eancia ao c\u00e2ncer \u201cBodily Becomings, apresenta o c\u00e2ncer para al\u00e9m de um corpoadoecido e ajuda a repensar uma s\u00e9rie de relacionamentos e interconex\u00f5es dos sentimentosentre ser, estar e viver aqui, agora e para o futuro. Broom & Kenny afirmam que sevoltar a esse corpus \u00e9 entender que h\u00e1 um ator produtivo em cena e quedeve estar vis\u00edvel nos sistemas das rela\u00e7\u00f5es afetivas com familiares, cuidadores,profissionais e estruturas institucionais de tratamento e cuidado.O cap\u00edtulo 1, Waiting, Hauntings and Surviving, foi escrito a partir dosdi\u00e1rios que as pessoas com c\u00e2ncer foram convidadas a produzir e discute a \u201cespera noc\u00e2ncer\u201d. \u201cO que se espera, por quem esperar, com que fim se espera\u201d (p.49-50), \u201c...quando a espera termina?\u201d (p. 59). As rela\u00e7\u00f5es e asexpectativas produzem a espera como pr\u00e1tica social, que altera a linearidade do tempo ecria \u201cassombra\u00e7\u00f5es\u201d que colocam a doen\u00e7a em primeiro plano - o poder disciplinar enormativo - e a pessoa adoecida como plano de fundo - vivendo sob um progn\u00f3stico etolerando os efeitos das interven\u00e7\u00f5es tensionadas pela vigil\u00e2ncia, atribu\u00eddas sobmoralidades normativas e pesadas responsabilidades.O cap\u00edtulo 2, Malignant Attitudes, aborda a \u201catitude\u201d das pessoas nocontexto da vida com o c\u00e2ncer como uma entidade complexa, \u201cimplantadaculturalmente\u201d (p. 65), em conformidade com o dom\u00ednio moral e \u00e9tico. Osentrevistados apontam criticamente que a \u201catitude tem vida pr\u00f3pria no contextodo c\u00e2ncer\u201d (p. 66) e manter a \u201cboa atitude\u201d remete amoralidades e ideias dominantes relacionadas ao \u201cbom paciente\u201d (p. 77),\u00e0 \u201ccidadania produtiva\u201d (p. 66) e \u00e0 excel\u00eancia do comportamentodesej\u00e1vel, com a firmeza e coer\u00eancia do agir e reagir.O cap\u00edtulo 3, Entangled and Estrange, discute a sociabilidade doentrela\u00e7amento e da inclus\u00e3o nas rela\u00e7\u00f5es afetivas daqueles que vivem com o c\u00e2ncer e suarede de apoio. Os entrevistados destacaram, na sua vida cotidiana emsurvivorship (sobreviv\u00eancia), as rela\u00e7\u00f5es de des/continuidade, oevento de \u201cestar aqui\u201d e \u201cir embora\u201d, a presen\u00e7a do \u201ceu\u201d e do \u201coutro\u201d e a rumina\u00e7\u00e3o de\u201crever o passado, viver o momento e garantir o futuro\u201d (p. 96).Destacaram, ainda, a experi\u00eancia de \u201cexilados do passado, suspensos do presentee exclu\u00eddos do futuro\u201d (p. 96) estabelecendo emaranhados de corpos, de\u201ceus\u201d, de coisas, do tempo e das rela\u00e7\u00f5es no espectro de uma \u201cfenomenologia doviver com o c\u00e2ncer\u201d (p. 94).O cap\u00edtulo 4, Collective Emotions, Affective Relations, mostra que oc\u00e2ncer n\u00e3o \u00e9 um projeto individual e sim coletivo, ou \u201cmultiperspectivo dasrela\u00e7\u00f5es entre corpos, sujeitos, discursos e pr\u00e1ticas\u201d com\u201ccren\u00e7as, desejos e normas\u201d (p. 100). \u00c9 uma \u201ceconomia afetiva emoral\u201d de controle, modera\u00e7\u00e3o ou domina\u00e7\u00e3o. Por um lado, h\u00e1 uma din\u00e2mica de obriga\u00e7\u00e3odas pessoas se manterem perseverantes e otimistas mesmo estando em est\u00e1gio de\u201cmedo, pavor, desesperan\u00e7a e melancolia\u201d (p. 107) diante do c\u00e2ncer.Por outro lado, pergunta-se: ser obediente resulta numa vida boa ou numa vida apenasmais longa?O cap\u00edtulo 5, Enchantment, Acceleration and Innovation, debate a rela\u00e7\u00e3oentre a medicina de precis\u00e3o na sobrevida de pessoas com alguns tipos de c\u00e2ncer e osaspectos econ\u00f4micos, culturais, e profissionais no processo desurvivorship. Muitas quest\u00f5es ficam sinalizadas e n\u00e3o respondidas,entre elas: o projeto de precis\u00e3o valoriza o tempo de vida ou a extens\u00e3o da vida sobre afinitude? Ou ainda: a cura em oncologia \u00e9 um desejo humano ou uma imposi\u00e7\u00e3o da ind\u00fastriade inova\u00e7\u00e3o da sa\u00fade?O cap\u00edtulo 6, Participation and the Making of Possibility, complementa ocap\u00edtulo anterior acerca da \u201cascens\u00e3o da medicina de precis\u00e3o em oncologia, aacelera\u00e7\u00e3o dos ensaios cl\u00ednicos oferecidos\u201d (p. 137) e a mercantiliza\u00e7\u00e3oideol\u00f3gica e econ\u00f4mica. A obstina\u00e7\u00e3o terap\u00eautica para manter a vida e a sobreviv\u00eancia aoc\u00e2ncer curvam-se ao mercado e trazem novas quest\u00f5es sobre \u201cvalor, custo,investimentos e interesses, com distanciamento da assist\u00eancia social ebem-estar\u201d (p. 137).O cap\u00edtulo 7, survivorship. Ao longo de 160 p\u00e1ginas,Alex Broom & Katherine Kenny descrevem o c\u00e2ncer como um fen\u00f4meno social coletivopermeado por diferentes formas de relacionalidade e normatividade. Valorizam asexperi\u00eancias narrativas dos participantes, produzidas com diferentes m\u00e9todos de produ\u00e7\u00e3ode informa\u00e7\u00e3o  e mapeiam uma\u201csociologia cr\u00edtica da sobreviv\u00eancia\u201d (p. 6) que governa corpos,identidades e rela\u00e7\u00f5es sociais. Os autores expandem a compreens\u00e3o sobre a sobreviv\u00eanciaao c\u00e2ncer, avan\u00e7ando os debates para al\u00e9m dos eventos de diagn\u00f3stico, progn\u00f3stico,tratamento, remiss\u00e3o e desfecho. Exploram as experi\u00eancias daqueles que sobrevivem com oc\u00e2ncer e n\u00e3o daqueles que est\u00e3o al\u00e9m dele, com \u201cuma voz sociol\u00f3gica maisforte\u201d (p. 10) para responder \u00e0s quest\u00f5es silenciadas pela ind\u00fastria,cultura de tratamentos, pr\u00e1ticas terap\u00eauticas e modelos institucionais que, na maioriadas vezes, pouco valorizam a subjetividade no processo do sobreviver com o c\u00e2ncer.O livro apoia-se em referenciais te\u00f3ricos e ontol\u00f3gicos do c\u00e2ncer  que ampliam as reflex\u00f5es acerca da \u201csocio-l\u00f3gica\u201d do c\u00e2ncer e dasrela\u00e7\u00f5es de poder no processo de Produzir uma \u201csociologia do c\u00e2ncer\u201d exige contextualizar o evento nas diferentes esferasbiol\u00f3gicas, sociais, culturais, pol\u00edticas e econ\u00f4micas, das quais emergem as quest\u00f5esrelacionadas aos marcadores sociais das diferen\u00e7as com as in\u00fameras formas de estigma,preconceito, discrimina\u00e7\u00e3o, segrega\u00e7\u00e3o, medo, coer\u00e7\u00e3o, explora\u00e7\u00e3o, vulnerabilidade,encantamento, acelera\u00e7\u00e3o, inova\u00e7\u00e3o, precis\u00e3o, prazeres e outros. Portanto, exige umacomplexidade multidimensional que deve ser discutida, tamb\u00e9m, \u00e0 luz do paradigma dainterseccionalidade Survivorship: A Sociology of Cancer in Everyday Life \u00e9 umextenso exerc\u00edcio sociol\u00f3gico que deve ser explorado por pesquisadores, estudantes eprofissionais da sa\u00fade interessados n\u00e3o apenas em compreender a constru\u00e7\u00e3o social dasrela\u00e7\u00f5es entorno de uma doen\u00e7a, mas tamb\u00e9m os sentidos, significados e representa\u00e7\u00f5esculturais que povoam as mentes e os cora\u00e7\u00f5es daqueles que cuidam e que s\u00e3o cuidados.O livro"}
+{"text": "To compare the profile and prevalence of hospitalizations in Brazil based on estimates from the National Health Survey (PNS), 2013 and 2019. A cross-sectional study that used data from the 2013 PNS and the 2019 PNS. The outcome was having been hospitalized for 24 hours or more in the last 12 months. We calculated the proportion of the population in different categories of age group, presence or absence of chronic diseases, and perception of health status. We estimated the total number of hospitalizations and the proportion corresponding to each category of age group, chronic disease, and perceived health status. We calculated the prevalence of hospitalization according to geographic, socioeconomic, and health conditions. We compared the estimates of two editions of the PNS using Student\u2019s t-test for independent samples. We considered significant differences when the p-value was less than 0.01. And finally, we compared hospitalization estimates with administrative data to assess data consistency. We observed that the proportion of chronically ill people in the population increased from 15.04% to 31.48%. This group was responsible for 36.76% of the total number of hospitalizations in 2013 and 57.61% in 2019. The prevalence of hospitalizations increased significantly between the two surveys and the increases were higher in the Southeast region and among people who have private health insurance. A discrepancy was found between administrative data and survey estimates. Obstetric hospitalizations and health insurance hospitalizations were underestimated. There was an increase in overall hospitalization rates in the period between the PNS 2013 and PNS 2019, especially among people with better access to health services. The hospitalization profile also changed\u2014in the 2013 PNS, hospitalizations of people without chronic diseases predominated. This was reversed in PNS 2019. In 2019, spending on hospital and outpatient care accounted for 49.94% of public health expenditures in Brazil, more than double what was spent on primary care in the same year3. However, despite this large amount of resources, necessary to maintain hospital care, one cannot imagine doing without the effectiveness provided by the technological apparatus concentrated in a hospital, especially in critical health conditions.The hospital is the most expensive piece of equipment in a health system and can represent a significant source of wasted resources, to the point of compromising the efficiency and effectiveness of this system4and, gradually, the hospital has ceased to be the gateway to the health system. However, in 2019, more than 25% of people still sought the hospital as a place of first health care5.It is likely that the spending on hospital care in Brazil would have been proportionally higher without the expansion of investments in primary care that occurred after the creation of the Sistema \u00danico de Sa\u00fade  and, mainly, after the implementation of the Family Health Strategy. From these changes, there was a significant improvement in health care. The majority place of care migrated from the outpatient clinic to the health post/center6. In turn, the hospital must resolve certain complex situations, preferably infrequently. Therefore, the aim is a health system with robust and effective primary care, which provides the lowest possible hospitalization rates7.Hospital and primary care complement each other within a health system. Primary care has the function of comprehensive and longitudinal care for the individual\u2019s health. Within its scope, preventive and educational actions are promoted, to rehabilitation or even palliative care8. Conditions such as unemployment, low income, restrictions and lack of family involvement are, for example, predictors of a higher frequency of children\u2019s hospitalization9. In the United States, 11% of the variability in hospitalization due to influenza is determined by social factors10. Groups that have worse socioeconomic indicators, such as low income and education, are 2.4 times more likely to be hospitalized or have more severe respiratory diseases11. The supply of health services is another factor that strongly affects hospitalization rates. Castro et al.12showed in 2005 that \u201cthe greater the average number of beds per population, the greater the chance of hospitalization, and the greater the number of physicians per population, the lower the chance of hospitalization\u201d (our translation). Likewise, there are other factors associated with hospitalizations, albeit weakly, such as the percentage of illiteracy, the proportion of SUS beds, urbanization, and coverage by health insurance plans13.Hospitalization rates can be influenced by social, economic, behavioral, environmental, and demographic factors, the same factors that influence a population\u2019s health14. Likewise, the prevalence of hospitalization in people with multimorbidities is double that of people without multimorbidities15. These relationships between chronic diseases, comorbidities, and hospitalizations should produce important changes in hospitalizations in Brazil, since the country is undergoing a demographic and epidemiological transition with an increase in chronic diseases16.Although hospitalization rates are influenced by several variables, in different dimensions, the main factor associated with hospital admissions is the need for health. People who are hospitalized have a higher number of chronic diseases, worse health status, worse functional status, and more restrictions on carrying out usual activities17. With fewer births, the demand for obstetrics and pediatrics beds has been decreasing and naturally there has been a reduction in supply. However, the prevalence of chronic diseases increases with an aging population. Paradoxically, this reduction in the supply of beds and decrease in the hospitalization rate has also been observed in medical and surgical practice, although to a lesser extent17.The population\u2019s demographic and epidemiological profile influences the demand for hospitalization. In Brazil, since 1980, fertility and birth rates have decreased while life expectancy at birth has increasedPesquisa Nacional de Sa\u00fade . The research had many objectives, which included evaluating the national health system in terms of access to and use of its services, as well as measuring access to medical care at different levels of care18. The survey revealed that 53.4% of households were registered in Family Health Units, which correspond to Primary Care in Brazil19. Later, in 2019, the second edition of the survey was carried out, with changes in some questions and an expansion of the questionnaire20. Both editions of the PNS presented information on hospitalizations and, in this second edition, an increase in the registration of households in Primary Care was observed to 60.0%21.In 2013, the Brazilian Institute of Geography and Statistics (IBGE) in association with the Ministry of Health (MS) carried out the first 19, a prevalence that increased to 6.6% in PNS 201921. From 1999 to 2016, the rate of hospitalizations financed by the SUS had been gradually decreasing22. After this sustained reduction, in 2017 an increase in this rate was identified as compared to the previous year22, and this increase was also noticed in the last edition of the PNS, in 2019. It is still unclear whether these facts mean points outside the curve or a new growth trend of hospitalizations in Brazil. Our study intended to clarify this issue. Based on the 2013 and 2019 PNS estimates, we aimed to compare the prevalence of hospitalizations according to geographic, socioeconomic and health conditions and to identify any changes in the hospitalizations profile in Brazil.According to PNS 2013 data, 6.0% of individuals had been hospitalized for 24 hours or more in the last 12 months23, and between August 2019 and March 202020, whose object of study was the Brazilian population.This work is a serial cross-sectional study that used data from the PNS 2013 and PNS 2019, which took place respectively between August 2013 and February 201424, with information on 205,546 residents, referring to a population projection of 199,551,444 inhabitants. The PNS 2019 interviews were conducted in 94,114 households, referring to 279,382 residents and a population projection of 209,589,607 inhabitants. The two surveys followed a similar methodology. The items were divided into 3 groups. The first provided information about the household and visits by family health teams or endemic agents. The second investigated the general characteristics of each resident, income, health insurance coverage, use of health services, and health status of individuals. Questions in the third group were outside the scope of this study and were not used. The questionnaire, the interviewer\u2019s manual and the microdata are available from the IBGE website25.The 2013 PNS interviews were conducted in 64,348 households, in approximately 1,600 municipalities throughout BrazilIn this study, we used the following condition as the outcome: having been hospitalized for 24 hours or more in the last 12 months. As a health need is the main determinant of hospital use, we describe the participation of chronic illness and perception of poor health status in the Brazilian population and in total hospitalizations. The age group was also included in the description. From the microdata from the two PNS, we estimated the proportion of the population in different categories of age, presence or absence of chronic diseases and perception of health status, and the number of hospitalizations related to each category. With the estimated mean total numbers, and their respective confidence intervals, we calculated how much each category of these variables represented, proportionally, in the general total of hospitalizations, in eachPNS edition.30. We used the following variables: as predisposing factors \u2013 sex, age group, skin color, and level of education; as facilitating factors \u2013 urban or rural housing, usual place of care, presence or absence of medical health insurance, household income per capita, and region of the federation; and as health need \u2013 perception of health and presence or absence of chronic disease. In the age group variable, ages were grouped into 6 categories: 0\u20135 years, 6\u201317 years, 18\u201329 years, 30\u201339 years, 40\u201359 years, and 60 years of age or older. All variables are categorical. The prevalence of hospitalization and respective 95% confidence intervals were calculated according to the mentioned factors. In the prevalence calculations, hospitalizations for childbirth were excluded.To analyze changes in the prevalence of hospitalization, we used the factors described in Andersen\u2019s behavioral model of health service usep was less than 0.0131.The estimates found in the two editions of the PNS were compared using Student\u2019s t-test for independent samples. We considered significant differences when 32. Hospitalizations through the SUS in 2013 and 2019 were obtained from the SUS Hospital Information System (SIH/SUS)33. Information on hospitalizations covered partially or fully by private health insurance was obtained from the website of the Ag\u00eancia Nacional de Sa\u00fade Suplementar 34, and referred to the years 2014 and 2019. Data referring to the year 2013 were not found.The consistency of survey data was assessed by comparing administrative data with estimates from the two editions. Hospitalizations estimated by the PNS were broken down into hospitalizations covered by the SUS, hospitalizations covered by private health insurance, and obstetric hospitalizations. Information on births in hospitals in 2013 and 2019 was obtained from the website IBGE \u2013 Civil Registry Statistics, through the IBGE Automatic Recovery System (SIDRA)As this is a study that used complex sampling, we used the Stata\u00ae statistical software, version SE 15.1 for data analysis, which, through its survey module, takes into account the effect of the sampling plan. In the adjustment, strata, primary sampling units and sample weights were incorporated.PNS 2013 was approved by opinion no. 328.159 of the National Research Ethics Committee. PNS 2019 was approved by opinion no. 3,529,376 of the National Research Ethics Commission. All participants signed, in both editions, an informed consent form, assuring them anonymity and the possibility of withdrawing from the study at any time.According to the two surveys\u2019 estimates, there were changes in the demographic and epidemiological profile of the Brazilian population between 2013 and 2019. A significant change was observed among people aged 6 to 29 years and among people aged 40 years or older. The percentage of people with chronic diseases increased significantly between the two PNS editions, and the perception of health status changed in 4 of the 5 categories, with an increase in the very good, fair, and very poor categories. This information is detailed in Changes in the hospitalization profile were also observed. While hospitalizations by people without chronic diseases predominated in the 2013 PNS, patients with chronic diseases predominated in the 2019 PNS, as shown in per capita greater than 3 and up to 5 minimum wages. On the other hand, significant reductions in prevalence were observed in people with chronic disease and in people without chronic disease, as can be seen in Excluding hospitalizations for childbirth, the prevalence of hospitalization increased significantly from 5.32% in the 2013 PNS to 5.81% in the 2019 PNS. There was a statistically significant increase in prevalence between 2013 and 2019 in the Southeast Region in both sexes, in people with white skin color, in people with no schooling, in people with complete high school education, in people living in urban areas, in people with health insurance, in people who always go the same place when they need health care, and for people with a household income When analyzing admissions for childbirth, estimated in each survey, with administrative data, referring to live births in equivalents years, we noticed different values. Similarly, we noticed a difference in non-obstetric hospitalizations, both in those financed by the SUS and in those financed by health insurance. The values are shown in Our study shows an increase in the estimated prevalence of hospitalizations between the 2013 and 2019 PNS editions. This growth was accompanied by important changes in the population\u2019s epidemiological and demographic profile, especially in the doubling of the percentage of people with chronic diseases, along with a decrease in the percentage of those aged 6 to 29 and an increase among those aged 40 and over.36. The concomitant increase observed in the proportion of people with chronic diseases and people in middle age explains an apparently paradoxical finding. As can be seen in our results, there was a reduction in the prevalence of hospitalizations in people with chronic diseases. With a greater number of people in the middle age group, there are more individuals with chronic diseases, but who have not yet had complications. Consequently, there has been an increase in the proportion of people with chronic diseases who do not require hospitalization.Similarly, other studies, with data from the 2013 and 2019 PNS, show that the prevalence of chronic diseases has increased in BrazilAlthough the prevalence of hospitalization has decreased among people with chronic diseases, as they have proportionally increased, and hospitalization among them remains very high, there has been an increase in the general prevalence of the population. The participation of patients with chronic diseases in total hospitalizations increased from 36.76% to 57.61% between the two PNS editions. These findings demonstrate the influence of the epidemiological profile and demography on hospitalization rates in Brazil.37. In 2019, proportionally, the burden of IPD was higher in early childhood, the burden of external causes was higher in young male adults, and the burden of NTCDs increased with age37. According to PNS 2019 estimates, in more than 40% of hospitalizations, there was no diagnosis of chronic disease. If hospitalizations reflect the burden of disease, we will have a predominance of hospitalizations due to IPD, in early childhood, due to external causes, in young males, and due to obstetric causes in young females.In Brazil, the epidemiological transition is characterized by a triple burden of disease. Non-transmissible chronic diseases (NTCDs) coexist with a high incidence and prevalence of infectious and parasitic diseases (IPD) and external causes38.Emerging situations also influence hospitalizations. In 2020, due to the covid-19 pandemic, there was a 15% decrease in the hospital admission rate, accompanied by a 9% increase in in-hospital lethality of patients with cardiovascular diseases admitted through the SUS39. We estimate that people aged 60 or over accounted for 25.56% of all hospitalizations in the 2013 PNS and 28.35% in the 2019 PNS, but without a statistically significant difference between the two surveys. Brazil has been increasing life expectancy due to reductions in child mortality and cardiovascular disease mortality, despite the negative influence of mortality from external causes, which occurs mainly in young male adults40. The increase in life expectancy is due, in part, to the improvement in health care. The challenge is not only to increase life expectancy, but mainly years with quality of life41.A study on the profile of hospital admissions by the SUS between 2013 and 2017 showed that in 24.4% of hospitalizations, the patient was 60 years old or over14. Adequate primary care and an integrated health care network can reduce hospitalizations, reduce these people\u2019s hospital stay, and also reduce readmissions42.Similarly, we found that people with poor or very poor health status correspond to less than 5% of the population, but account for almost 20% of all hospitalizations. These people probably have worse health, and we already know that people in this situation are the ones who need hospitals the most36. This is probably a reflection of the primary care expansion policy, with the Family Health Strategy.In Brazil, between 2013 and 2019, the proportion of individuals who consulted a doctor in the last year increased. This increase was greater among SUS users than among health insurance holders43. A study carried out in 2018 demonstrated a reduction in hospitalizations for conditions sensitive to primary care44, associated with the advance of the Family Health Strategy\u2019s coverage in Brazil. On the other hand, we found a significant increase in the prevalence of hospitalizations among people with private health insurance and among those who always seek the same place when they need care, which probably represent the individuals with better access to health services45. Unlike the progress observed in primary care offered by the SUS, initiatives to invest in this level of care by the private sector, especially for people with chronic diseases, are still incipient in the country, which may have influenced this increase in hospitalizations. Complementarily, it is expected that there has been an increase in the diagnosis of conditions that occasionally require hospitalization, especially in people with poor health47.An adequate supply of physicians, associated with long-term relationships between physicians and their patients, can reduce hospitalizations due to chronic diseasesper capita, ranging from R$4.70 in the North region to R$70.04 in the Southeast region48. In addition, there are also differences in relation to age structures, HDI, provision of health services, and epidemiological profiles49.Our study found variations in the prevalence of hospitalizations across Brazilian regions. In both PNS editions, the South and Midwest regions have the highest prevalence. The Southeast region, on the other hand, had the highest prevalence increase across all regions, while the North and Northeast regions remained below the national average. These findings reflect the large historical regional differences observed in Brazil, in relation to socioeconomic characteristics and social and health investments. The 2018 IBGE Household Budget Survey showed, for example, a huge regional discrepancy in health expenditures 50. However, the discrepancy between the actual number of live births and the estimates of births in the two surveys may indicate the need for some methodological adjustment.In evaluating the estimates of hospitalizations from the two surveys, with the official number of hospitalizations, we found that the number of obstetric hospitalizations, in the public and supplementary health systems, was underestimated, as well as the number of non-obstetric hospitalizations covered by health insurance. Non-obstetric hospitalizations financed by the SUS were overestimated as well. As the information on hospital admissions referred to the last 12 months, there may have been a memory bias among the participants. In addition, the PNS items analyzed in this study refer to all of the household residents, but were answered by only one resident, which can lead to greater inaccuracy in the information. One of the limitations of household surveys is the bias associated with the use of secondary informants51. Nevertheless, it should be noted that this methodological decision may lead to losses in mean estimates and consequent reduction in statistical power, making it difficult to identify differences between editions. Our focus, however, is on information in which significant differences were observed.With the aim of ensuring greater homogeneity in gender distribution in the different age groups, in the calculations of the prevalence of hospitalizations, we chose not to include obstetric hospitalizations. Thus, the prevalence figures we found are lower than those previously published. This methodological decision has been observed in previous studiesOur study had as a limitation the absence of administrative data regarding hospitalizations by health insurance in 2013 and we used, as an alternative, data from 2014 in the comparison with the 2013 PNS, which may generate bias in the comparison. Likewise, the divergences between the administrative data and the estimates of the two PNS may represent a greater amplitude in the degree of uncertainty of our findings, resulting from under or overestimates observed in the two PNS editions. Another issue is that, due to the large sample size in both PNS editions, minimal differences can be considered statistically significant and the differences found in this work must be evaluated not only in statistical terms, but in their epidemiological significance.The 2019 PNS identified a predominance of hospitalizations by people with chronic diseases. This population subgroup should be better studied, identifying risk factors for hospitalization. Special attention should be given to heavy users, especially in the determinants of re-hospitalization. It is also necessary to evaluate the huge number of small hospitals that exist in Brazil. The effectiveness of the hospital care network should be investigated, bringing information to support new public policies, for a more rational use of financial resources.There was an increase in overall hospitalization rates in the period between the 2013 and 2019 PNS, especially among people with better access to health services. In addition, the hospitalization profile itself has changed. While in the 2013 edition, hospitalizations of people without chronic diseases predominated in the total number of hospitalizations, in the PNS 2019 more than half of the total number of hospitalizations were of people with chronic diseases.It was evident that changes in the demographic and epidemiological profile of the Brazilian population are already impacting hospitalization rates. The number of chronically ill people in the Brazilian population has doubled, but the prevalence of hospitalization among them has decreased, probably because they have not yet developed complications. In this context, accessible and effective Primary Health Care becomes even more relevant, otherwise more hospitalizations and higher costs can be expected in the medium term. In addition, the hospital care policy must be continuously improved, seeking efficiency and cost reduction. Without these measures, there is a serious risk of collapse of Brazil\u2019s health systems. 2. Em 2019 os gastos com assist\u00eancia hospitalar e ambulatorial corresponderam a 49,94% das despesas p\u00fablicas com a sa\u00fade no Brasil, mais que o dobro do que foi gasto com a aten\u00e7\u00e3o prim\u00e1ria, no mesmo ano3. No entanto, apesar desse grande montante de recursos, necess\u00e1rio \u00e0 manuten\u00e7\u00e3o da aten\u00e7\u00e3o hospitalar, n\u00e3o se imagina prescindir da efic\u00e1cia proporcionada pelo aparato tecnol\u00f3gico concentrado em um hospital, especialmente em condi\u00e7\u00f5es cr\u00edticas de sa\u00fade.O hospital \u00e9 o equipamento de mais alto custo em um sistema de sa\u00fade e pode representar uma fonte significativa de desperd\u00edcio de recursos, a ponto de comprometer a efici\u00eancia e efetividade desse sistema4 e, gradualmente, o hospital tem deixado de ser a porta de entrada do sistema de sa\u00fade. No entanto, em 2019, mais de 25% das pessoas ainda procuraram o hospital como local de primeiro atendimento em sa\u00fade5.\u00c9 prov\u00e1vel que o gasto com a aten\u00e7\u00e3o hospitalar no Brasil seria proporcionalmente maior sem a expans\u00e3o dos investimentos em aten\u00e7\u00e3o prim\u00e1ria que se deu ap\u00f3s a institui\u00e7\u00e3o do Sistema \u00danico de Sa\u00fade (SUS) e, principalmente, ap\u00f3s a implanta\u00e7\u00e3o da Estrat\u00e9gia de Sa\u00fade da Fam\u00edlia. A partir dessas mudan\u00e7as, houve uma melhoria significativa na aten\u00e7\u00e3o \u00e0 sa\u00fade. O local majorit\u00e1rio de atendimento migrou do ambulat\u00f3rio para o posto/centro de sa\u00fade6. Por sua vez, o hospital deve resolver determinadas situa\u00e7\u00f5es complexas, preferencialmente de modo pouco frequente. Portanto, o que se almeja \u00e9 um sistema de sa\u00fade com uma aten\u00e7\u00e3o prim\u00e1ria robusta e efetiva, que proporcione as menores taxas poss\u00edveis de hospitaliza\u00e7\u00e3o7.O hospital e a aten\u00e7\u00e3o prim\u00e1ria se completam dentro de um sistema de sa\u00fade. A aten\u00e7\u00e3o prim\u00e1ria tem como fun\u00e7\u00e3o o cuidado integral e longitudinal \u00e0 sa\u00fade do indiv\u00edduo. Em seu \u00e2mbito, s\u00e3o promovidas desde a\u00e7\u00f5es preventivas e educativas, at\u00e9 cuidados de reabilita\u00e7\u00e3o ou mesmo paliativos8. Condi\u00e7\u00f5es como desemprego, baixa renda, restri\u00e7\u00f5es e aus\u00eancia de envolvimento familiar s\u00e3o, como exemplo, preditoras de maior frequ\u00eancia de interna\u00e7\u00e3o de crian\u00e7as9. Nos Estados Unidos, 11% da variabilidade na interna\u00e7\u00e3o hospitalar por influenza \u00e9 determinada por fatores sociais10. Grupos que possuem piores indicadores socioecon\u00f4micos, como baixa renda e escolaridade, t\u00eam risco 2,4 vezes maior de admiss\u00e3o hospitalar ou t\u00eam doen\u00e7as respirat\u00f3rias em formas mais graves11. A oferta de servi\u00e7os de sa\u00fade \u00e9 outro fator que afeta fortemente as taxas de interna\u00e7\u00e3o hospitalar. Castro et al.12 mostraram em 2005 que \u201cquanto maior o n\u00famero m\u00e9dio de leitos por habitantes, maior a chance de interna\u00e7\u00e3o e quanto maior o n\u00famero de m\u00e9dicos por habitantes, menor a chance de interna\u00e7\u00e3o\u201d. Da mesma forma, h\u00e1 ainda outros fatores associados \u00e0s hospitaliza\u00e7\u00f5es, embora fracamente, como o percentual de analfabetismo, a propor\u00e7\u00e3o de leitos do SUS, a urbaniza\u00e7\u00e3o e a cobertura por planos de sa\u00fade13.As taxas de hospitaliza\u00e7\u00e3o podem ser influenciadas por fatores sociais, econ\u00f4micos, comportamentais, ambientais e demogr\u00e1ficos, os mesmos fatores que influenciam a sa\u00fade de uma popula\u00e7\u00e3o14. Da mesma forma, a preval\u00eancia de interna\u00e7\u00e3o hospitalar em pessoas com multimorbidades \u00e9 o dobro em rela\u00e7\u00e3o \u00e0s de pessoas sem multimorbidade15. Essas rela\u00e7\u00f5es entre doen\u00e7as cr\u00f4nicas, comorbidades e interna\u00e7\u00f5es hospitalares devem produzir mudan\u00e7as importantes nas hospitaliza\u00e7\u00f5es no Brasil, uma vez que o pa\u00eds est\u00e1 passando por uma transi\u00e7\u00e3o demogr\u00e1fica e epidemiol\u00f3gica com aumento de doen\u00e7as cr\u00f4nicas16.Ainda que as taxas de hospitaliza\u00e7\u00e3o sejam influenciadas por diversas vari\u00e1veis, em dimens\u00f5es distintas, o principal fator associado \u00e0s admiss\u00f5es hospitalares \u00e9 a necessidade de sa\u00fade. As pessoas que se internam apresentam maior n\u00famero de doen\u00e7as cr\u00f4nicas, pior estado de sa\u00fade, pior estado funcional e mais restri\u00e7\u00f5es \u00e0 realiza\u00e7\u00e3o de atividades habituais17. Com menos nascimentos, a demanda por leitos de obstetr\u00edcia e pediatria vem diminuindo e naturalmente houve uma redu\u00e7\u00e3o na oferta. No entanto, a preval\u00eancia de doen\u00e7as cr\u00f4nicas aumenta com o envelhecimento da popula\u00e7\u00e3o. Por\u00e9m, paradoxalmente, esta redu\u00e7\u00e3o na oferta de leitos e diminui\u00e7\u00e3o na taxa de hospitaliza\u00e7\u00e3o tamb\u00e9m tem sido observada na cl\u00ednica m\u00e9dica e na cl\u00ednica cir\u00fargica, ainda que em menor intensidade17.O perfil demogr\u00e1fico e epidemiol\u00f3gico da popula\u00e7\u00e3o influencia a demanda de hospitaliza\u00e7\u00e3o. No Brasil, desde 1980 as taxas de fecundidade e de natalidade t\u00eam diminu\u00eddo ao passo que a expectativa de vida ao nascer tem aumentado18. O inqu\u00e9rito revelou que 53,4% dos domic\u00edlios estavam cadastrados em Unidades de Sa\u00fade da Fam\u00edlia, que correspondem \u00e0 Aten\u00e7\u00e3o Prim\u00e1ria no Brasil19. Posteriormente, em 2019, foi realizada a segunda edi\u00e7\u00e3o do inqu\u00e9rito, com altera\u00e7\u00f5es em algumas quest\u00f5es e uma amplia\u00e7\u00e3o do question\u00e1rio20. Ambas as edi\u00e7\u00f5es da PNS apresentaram informa\u00e7\u00f5es sobre hospitaliza\u00e7\u00f5es e, nesta segunda edi\u00e7\u00e3o, foi observado um aumento no cadastro dos domic\u00edlios na aten\u00e7\u00e3o prim\u00e1ria para 60,0%21.Em 2013, o Instituto Brasileiro de Geografia e Estat\u00edstica (IBGE) em associa\u00e7\u00e3o com o Minist\u00e9rio da Sa\u00fade (MS) realizou a primeira Pesquisa Nacional de Sa\u00fade (PNS). A pesquisa tinha muitos objetivos, dentre eles o de avaliar o sistema de sa\u00fade nacional no que se refere ao acesso e uso de seus servi\u00e7os, assim como dimensionar o acesso \u00e0 assist\u00eancia m\u00e9dica em diferentes n\u00edveis de aten\u00e7\u00e3o19, preval\u00eancia essa que aumentou para 6,6% na PNS 201921. De 1999 at\u00e9 2016, a taxa de hospitaliza\u00e7\u00f5es financiadas pelo SUS vinha diminuindo gradativamente22. Ap\u00f3s essa redu\u00e7\u00e3o sustentada, em 2017 foi identificado um aumento dessa taxa em rela\u00e7\u00e3o ao ano anterior22, e esta eleva\u00e7\u00e3o tamb\u00e9m foi percebida na \u00faltima edi\u00e7\u00e3o da PNS, em 2019. Ainda n\u00e3o est\u00e1 claro se estes fatos significam pontos fora da curva ou uma nova tend\u00eancia de crescimento das hospitaliza\u00e7\u00f5es no Brasil. Nosso estudo pretendeu esclarecer esta quest\u00e3o. Com base nas estimativas das PNS de 2013 e de 2019, tivemos como objetivos comparar a preval\u00eancia de interna\u00e7\u00e3o segundo fatores geogr\u00e1ficos, socioecon\u00f4micos e condi\u00e7\u00f5es de sa\u00fade e identificar eventuais mudan\u00e7as no perfil das hospitaliza\u00e7\u00f5es no Brasil.Segundo os dados da PNS 2013, 6,0% dos indiv\u00edduos haviam ficado internados por 24 horas ou mais nos \u00faltimos 12 meses23, e entre agosto de 2019 e mar\u00e7o de 202020, cujo objeto de estudo foi a popula\u00e7\u00e3o brasileira.Este trabalho \u00e9 um estudo transversal seriado que utilizou os dados das PNS 2013 e PNS 2019, ocorridas respectivamente entre agosto de 2013 e fevereiro de 201424, com informa\u00e7\u00f5es sobre 205.546 moradores, referente a uma proje\u00e7\u00e3o populacional de 199.551.444 habitantes. As da PNS 2019 ocorreram em 94.114 domic\u00edlios, referentes a 279.382 moradores e uma proje\u00e7\u00e3o populacional de 209.589.607 habitantes. Os dois inqu\u00e9ritos seguiram uma metodologia similar. Os itens foram divididos em 3 grupos. O primeiro trazia informa\u00e7\u00f5es sobre o domic\u00edlio e sobre visitas das equipes de sa\u00fade da fam\u00edlia ou de agentes de endemia. O segundo investigava as caracter\u00edsticas gerais de cada morador, rendimento, cobertura de planos de sa\u00fade, utiliza\u00e7\u00e3o de servi\u00e7os de sa\u00fade e o estado de sa\u00fade dos indiv\u00edduos. As quest\u00f5es do terceiro grupo fugiram ao escopo deste estudo e n\u00e3o foram utilizadas. O question\u00e1rio, o manual do entrevistador e os microdados est\u00e3o dispon\u00edveis no site do IBGE25.As entrevistas da PNS 2013 ocorreram em 64.348 domic\u00edlios, em cerca de 1.600 munic\u00edpios de todo o BrasilNo presente estudo, n\u00f3s utilizamos como desfecho a seguinte condi\u00e7\u00e3o: ter ficado internado por 24 horas ou mais nos \u00faltimos 12 meses. Como necessidade de sa\u00fade \u00e9 o principal determinante da utiliza\u00e7\u00e3o de hospitais, descrevemos a participa\u00e7\u00e3o de doen\u00e7a cr\u00f4nica e de m\u00e1 percep\u00e7\u00e3o do estado de sa\u00fade na popula\u00e7\u00e3o do Brasil e no total de interna\u00e7\u00f5es. Na descri\u00e7\u00e3o, foi inclu\u00edda tamb\u00e9m a faixa et\u00e1ria. A partir dos microdados das duas PNS, n\u00f3s estimamos a propor\u00e7\u00e3o da popula\u00e7\u00e3o nas diversas categorias de faixa et\u00e1ria, de presen\u00e7a ou aus\u00eancia de doen\u00e7as cr\u00f4nicas e de percep\u00e7\u00e3o do estado de sa\u00fade, e o n\u00famero de interna\u00e7\u00f5es relacionados com cada categoria. Com os n\u00fameros totais m\u00e9dios estimados, e seus respectivos intervalos de confian\u00e7a, foi calculado o quanto cada categoria, destas vari\u00e1veis, representou, proporcionalmente, no total geral de interna\u00e7\u00f5es, em cada edi\u00e7\u00e3o da PNS.30. As vari\u00e1veis que utilizamos foram as seguintes: como fatores predisponentes \u2013 sexo, faixa et\u00e1ria, cor da pele e grau de instru\u00e7\u00e3o; como fatores facilitadores \u2013 moradia urbana ou rural, local habitual de atendimento, presen\u00e7a ou aus\u00eancia de plano de sa\u00fade m\u00e9dico, renda domiciliar per capita e regi\u00e3o da federa\u00e7\u00e3o; e como necessidade de sa\u00fade \u2013 percep\u00e7\u00e3o de sa\u00fade e presen\u00e7a ou aus\u00eancia de doen\u00e7a cr\u00f4nica. Na vari\u00e1vel faixa et\u00e1ria, as idades foram agrupadas em 6 categorias: 0 a 5 anos, 6 a 17 anos, 18 a 29 anos, 30 a 39 anos, 40 a 59 anos, e 60 anos ou mais. Todas as vari\u00e1veis s\u00e3o categ\u00f3ricas. As preval\u00eancias de interna\u00e7\u00e3o hospitalar e respectivos intervalos de confian\u00e7a de 95% foram calculados segundo os fatores mencionados. Nos c\u00e1lculos de preval\u00eancia, foram exclu\u00eddas as hospitaliza\u00e7\u00f5es para realiza\u00e7\u00e3o de partos.Para analisar as mudan\u00e7as na preval\u00eancia de hospitaliza\u00e7\u00e3o, utilizamos os fatores descritos no modelo comportamental de Andersen de uso de servi\u00e7os de sa\u00fade31.As estimativas encontradas nas duas edi\u00e7\u00f5es da PNS foram comparadas atrav\u00e9s do teste t de Student para amostras independentes. Consideramos as diferen\u00e7as significativas quando o valor de p foi menor que 0,0132. As interna\u00e7\u00f5es pelo SUS em 2013 e em 2019 foram obtidas no Sistema de Informa\u00e7\u00f5es Hospitalares do SUS (SIH/SUS)33. As informa\u00e7\u00f5es sobre hospitaliza\u00e7\u00f5es cobertas por planos de sa\u00fade, parcialmente ou totalmente, foram obtidas no site da Ag\u00eancia Nacional de Sa\u00fade Suplementar (ANS)34, e se referiam ao ano de 2014 e de 2019. N\u00e3o foram encontrados os dados referentes ao ano de 2013.A consist\u00eancia dos dados dos inqu\u00e9ritos foi avaliada atrav\u00e9s da compara\u00e7\u00e3o dos dados administrativos com as estimativas das duas edi\u00e7\u00f5es. As interna\u00e7\u00f5es estimadas pela PNS foram destrinchadas em interna\u00e7\u00f5es cobertas pelo SUS, interna\u00e7\u00f5es cobertas por planos de sa\u00fade e interna\u00e7\u00f5es obst\u00e9tricas. As informa\u00e7\u00f5es sobre nascimento em hospitais em 2013 e em 2019 foram obtidas no site do IBGE \u2013 Estat\u00edsticas do Registro Civil, atrav\u00e9s do Sistema IBGE de Recupera\u00e7\u00e3o Autom\u00e1tica (SIDRA)Por se tratar de um estudo que utilizou amostragem complexa, utilizamos para an\u00e1lise dos dados o software estat\u00edstico Stata\u00ae, vers\u00e3o SE 15.1 que, atrav\u00e9s do seu m\u00f3dulo survey, leva em considera\u00e7\u00e3o o efeito do plano de amostragem. No ajuste foram incorporados os estratos, as unidades prim\u00e1rias de amostragem e os pesos amostrais.A PNS 2013 foi aprovada pelo parecer N\u00b0 328.159 da Comiss\u00e3o Nacional de \u00c9tica em Pesquisa. A PNS 2019 foi aprovada pelo parecer N\u00b0 3.529.376 da Comiss\u00e3o Nacional de \u00c9tica em Pesquisa. Todos os participantes assinaram, nas duas edi\u00e7\u00f5es, Termo de Consentimento Livre e Esclarecido, assegurando-lhes anonimato e possibilidade de desist\u00eancia a qualquer momento do estudo.De acordo com as estimativas dos dois inqu\u00e9ritos, houve mudan\u00e7as no perfil demogr\u00e1fico e epidemiol\u00f3gico da popula\u00e7\u00e3o brasileira entre 2013 e 2019. Foi observada mudan\u00e7a significativa entre pessoas com 6 a 29 anos e nas pessoas com 40 anos ou mais. O percentual de pessoas com doen\u00e7as cr\u00f4nicas aumentou significativamente entre as duas edi\u00e7\u00f5es da PNS e a percep\u00e7\u00e3o do estado de sa\u00fade modificou-se em 4 das 5 categorias, com incremento nas categorias muito bom, regular e muito ruim. Essas informa\u00e7\u00f5es est\u00e3o detalhadas na Foram observadas tamb\u00e9m mudan\u00e7as no perfil de interna\u00e7\u00e3o hospitalar. Enquanto na PNS 2013 predominaram as interna\u00e7\u00f5es por pessoas sem doen\u00e7as cr\u00f4nicas, na PNS 2019 foi observado um predom\u00ednio dos portadores de doen\u00e7as cr\u00f4nicas, como encontra-se apresentado na per capita maior que 3 e at\u00e9 5 sal\u00e1rios m\u00ednimos. Em contrapartida, redu\u00e7\u00f5es significativas da preval\u00eancia foram observadas em pessoas com doen\u00e7a cr\u00f4nica e em pessoas sem doen\u00e7a cr\u00f4nica, como pode ser observado na Excluindo-se as interna\u00e7\u00f5es para realiza\u00e7\u00e3o de partos, a preval\u00eancia de hospitaliza\u00e7\u00e3o aumentou significantemente de 5,32%, na PNS 2013, para 5,81%, na PNS 2019. Verificou-se aumento estatisticamente significante da preval\u00eancia, entre 2013 e 2019, na Regi\u00e3o Sudeste, em ambos os sexos, em pessoas de cor de pele branca, em pessoas sem instru\u00e7\u00e3o, em pessoas com o grau de instru\u00e7\u00e3o m\u00e9dio completo, em pessoas de local de moradia urbano, em pessoas com plano de sa\u00fade, em pessoas que procuram sempre o mesmo local quando precisam de atendimento em sa\u00fade e em pessoas com rendimento domiciliar Ao analisarmos as interna\u00e7\u00f5es para realiza\u00e7\u00e3o de partos, estimadas em cada inqu\u00e9rito, com os dados administrativos, referentes a nascidos vivos nos anos equivalentes, percebemos valores diferentes. De modo an\u00e1logo, notamos diferen\u00e7a nas interna\u00e7\u00f5es n\u00e3o obst\u00e9tricas, tanto nas financiadas pelo SUS como nas financiadas por planos de sa\u00fade. Os valores s\u00e3o mostrados na No presente estudo foi demonstrado um aumento na estimativa da preval\u00eancia de hospitaliza\u00e7\u00f5es entre as edi\u00e7\u00f5es da PNS de 2013 e 2019. Esse crescimento foi acompanhado de mudan\u00e7as importantes no perfil epidemiol\u00f3gico e demogr\u00e1fico da popula\u00e7\u00e3o, em especial na duplica\u00e7\u00e3o do percentual de pessoas com doen\u00e7as cr\u00f4nicas, juntamente com uma redu\u00e7\u00e3o no percentual das pessoas com 6 a 29 e aumento entre as pessoas com 40 ou mais.36. A eleva\u00e7\u00e3o concomitante, observada na propor\u00e7\u00e3o de pessoas com doen\u00e7as cr\u00f4nicas e de pessoas na faixa da meia idade, explica um achado aparentemente paradoxal. Como pode ser visto em nossos resultados, houve uma redu\u00e7\u00e3o da preval\u00eancia de hospitaliza\u00e7\u00f5es nas pessoas com doen\u00e7as cr\u00f4nicas. Com um n\u00famero maior de pessoas na faixa da meia-idade, h\u00e1 mais indiv\u00edduos portadores de doen\u00e7as cr\u00f4nicas, mas que ainda n\u00e3o apresentaram complica\u00e7\u00f5es. Consequentemente, houve um aumento na propor\u00e7\u00e3o de portadores de doen\u00e7as cr\u00f4nicas que n\u00e3o necessitam de hospitaliza\u00e7\u00e3o.Assim como o nosso, outros estudos, com os dados das PNS 2013 e 2019, mostram que a preval\u00eancia de doen\u00e7as cr\u00f4nicas aumentou no BrasilApesar da preval\u00eancia de interna\u00e7\u00e3o ter diminu\u00eddo entre os portadores de doen\u00e7as cr\u00f4nicas, como proporcionalmente eles aumentaram, e a hospitaliza\u00e7\u00e3o entre eles continua muito alta, houve um aumento na preval\u00eancia geral da popula\u00e7\u00e3o. A participa\u00e7\u00e3o de portadores de doen\u00e7as cr\u00f4nicas no total de interna\u00e7\u00f5es aumentou de 36,76% para 57,61% entre as duas edi\u00e7\u00f5es da PNS. Esses achados demonstram a influ\u00eancia do perfil epidemiol\u00f3gico e da demografia sobre as taxas de hospitaliza\u00e7\u00e3o no Brasil.37. Em 2019, proporcionalmente, a carga de DIP foi maior na primeira inf\u00e2ncia, a carga de causas externas foi maior em adultos jovens do sexo masculino, e a carga de DCNT aumentou com a idade37. Pelas estimativas da PNS 2019, em mais de 40% das interna\u00e7\u00f5es, n\u00e3o havia diagn\u00f3stico de doen\u00e7a cr\u00f4nica. Se as interna\u00e7\u00f5es refletirem a carga de doen\u00e7a, teremos predom\u00ednio de interna\u00e7\u00f5es por DIP, na primeira inf\u00e2ncia, por causas externas, em jovens do sexo masculino, e por causas obst\u00e9tricas em jovens do sexo feminino.No Brasil, a transi\u00e7\u00e3o epidemiol\u00f3gica \u00e9 caracterizada por uma tripla carga de doen\u00e7as. As doen\u00e7as cr\u00f4nicas n\u00e3o transmiss\u00edveis (DCNT) coexistem com elevada incid\u00eancia e preval\u00eancia de doen\u00e7as infecto-parasit\u00e1rias (DIP), e com causas externas38.Situa\u00e7\u00f5es emergentes tamb\u00e9m influenciam as hospitaliza\u00e7\u00f5es. Em 2020, devido \u00e0 pandemia de covid-19, houve um decr\u00e9scimo de 15% na taxa de interna\u00e7\u00e3o hospitalar, acompanhado de um aumento de 9% na letalidade intra-hospitalar, de pacientes com doen\u00e7as cardiovasculares internadas pelo SUS39. Estimamos que as pessoas com 60 anos ou mais responderam por 25,56% do total de interna\u00e7\u00f5es, na PNS 2013, e por 28,35%, na PNS 2019, por\u00e9m sem diferen\u00e7a estatisticamente significativa entre os dois inqu\u00e9ritos. O Brasil vem aumentando a expectativa de vida devido a redu\u00e7\u00f5es da mortalidade infantil e da mortalidade por doen\u00e7as cardiovasculares, apesar da influ\u00eancia negativa da mortalidade por causas externas, que ocorre principalmente em adultos jovens do sexo masculino40. O aumento da expectativa de vida se deve, em parte, a melhora na assist\u00eancia \u00e0 sa\u00fade. O desafio \u00e9 n\u00e3o s\u00f3 aumentar a expectativa de vida, mas principalmente os anos de vida com qualidade41.Um estudo sobre o perfil de interna\u00e7\u00f5es hospitalares pelo SUS, entre 2013 e 2017, mostrou que em 24,4% das hospitaliza\u00e7\u00f5es o paciente tinha 60 anos ou mais14. Uma aten\u00e7\u00e3o prim\u00e1ria adequada e uma rede integrada de aten\u00e7\u00e3o \u00e0 sa\u00fade podem reduzir interna\u00e7\u00f5es, diminuir a perman\u00eancia hospitalar destas pessoas, e tamb\u00e9m reduzir as reinterna\u00e7\u00f5es42.De modo an\u00e1logo encontramos que as pessoas com percep\u00e7\u00e3o do estado de sa\u00fade como ruim ou muito ruim correspondem a menos de 5% da popula\u00e7\u00e3o, mas s\u00e3o respons\u00e1veis por quase 20% do total de interna\u00e7\u00f5es. Estas pessoas provavelmente t\u00eam uma pior sa\u00fade e j\u00e1 sabemos que as pessoas nesta situa\u00e7\u00e3o s\u00e3o as que mais precisam de hospitais36. Provavelmente isso \u00e9 um reflexo da pol\u00edtica de expans\u00e3o da aten\u00e7\u00e3o prim\u00e1ria, com a Estrat\u00e9gia de Sa\u00fade da Fam\u00edlia.No Brasil, entre 2013 e 2019, aumentou a propor\u00e7\u00e3o de indiv\u00edduos que se consultaram com um m\u00e9dico no \u00faltimo ano. Este aumento foi maior entre os usu\u00e1rios do SUS, do que entre os portadores de plano de sa\u00fade43. Um estudo realizado em 2018 demonstrou uma redu\u00e7\u00e3o das interna\u00e7\u00f5es por condi\u00e7\u00f5es sens\u00edveis \u00e0 aten\u00e7\u00e3o prim\u00e1ria44, associado ao avan\u00e7o da cobertura da Estrat\u00e9gia de Sa\u00fade da Fam\u00edlia no Brasil. Por outro lado, notamos um aumento significante na preval\u00eancia de interna\u00e7\u00f5es entre pessoas com plano de sa\u00fade privado e entre aquelas que procuram sempre o mesmo local quando precisam de atendimento, as quais representam, provavelmente, os indiv\u00edduos com melhor acesso aos servi\u00e7os de sa\u00fade45. Diferentemente do avan\u00e7o observado na aten\u00e7\u00e3o prim\u00e1ria ofertada pelo SUS, as iniciativas de investimento nesse n\u00edvel de cuidado pelo setor privado, em especial aos portadores de doen\u00e7as cr\u00f4nicas, ainda \u00e9 incipiente no pa\u00eds, o que pode ter influenciado esse aumento nas interna\u00e7\u00f5es. Complementarmente, \u00e9 esperado que tenha havido um aumento no diagn\u00f3stico de condi\u00e7\u00f5es que eventualmente necessitam de interna\u00e7\u00f5es, especialmente nas pessoas com sa\u00fade debilitada47.A oferta adequada de m\u00e9dicos, associada a rela\u00e7\u00f5es de longo prazo entre eles e seus pacientes pode reduzir as hospitaliza\u00e7\u00f5es por doen\u00e7as cr\u00f4nicasper capita com sa\u00fade, variando de R$ 4,70 na regi\u00e3o Norte a R$ 70,04 na regi\u00e3o Sudeste48. Al\u00e9m disso, existem diferen\u00e7as tamb\u00e9m em rela\u00e7\u00e3o \u00e0s estruturas et\u00e1rias, ao IDH, \u00e0 oferta de servi\u00e7os de sa\u00fade e aos perfis epidemiol\u00f3gicos49.Nosso estudo encontrou varia\u00e7\u00f5es na preval\u00eancia de hospitaliza\u00e7\u00f5es entre as regi\u00f5es brasileiras. Nas duas edi\u00e7\u00f5es da PNS, as regi\u00f5es Sul e Centro-Oeste apresentam a maior preval\u00eancia. A regi\u00e3o Sudeste, por outro lado, teve o maior incremento de preval\u00eancia entre todas as regi\u00f5es, enquanto as regi\u00f5es Norte e Nordeste permaneceram abaixo da m\u00e9dia nacional. Estes achados refletem as grandes diferen\u00e7as regionais hist\u00f3ricas observadas no Brasil, em rela\u00e7\u00e3o \u00e0s caracter\u00edsticas socioecon\u00f4micas e aos investimentos sociais e em sa\u00fade. A Pesquisa de Or\u00e7amentos Familiares 2018 do IBGE mostrou, por exemplo, uma enorme discrep\u00e2ncia regional nas despesas 50. Contudo, a discrep\u00e2ncia entre o n\u00famero real de nascidos vivos e as estimativas de partos dos dois inqu\u00e9ritos pode indicar a necessidade de algum ajuste metodol\u00f3gico.Na avalia\u00e7\u00e3o das estimativas de hospitaliza\u00e7\u00f5es dos dois inqu\u00e9ritos, com o n\u00famero oficial de interna\u00e7\u00f5es, foi identificado nas PNS que o n\u00famero de interna\u00e7\u00f5es obst\u00e9tricas, nos sistemas de sa\u00fade p\u00fablico e suplementar, foi subestimado, assim como o n\u00famero de interna\u00e7\u00f5es n\u00e3o obst\u00e9tricas cobertas por plano de sa\u00fade. Tamb\u00e9m houve superestima\u00e7\u00e3o das interna\u00e7\u00f5es n\u00e3o obst\u00e9tricas financiadas pelo SUS. Como as informa\u00e7\u00f5es sobre interna\u00e7\u00f5es hospitalares se referiam aos \u00faltimos 12 meses, pode ter ocorrido um vi\u00e9s de mem\u00f3ria entre os participantes. Al\u00e9m disso, os itens da PNS analisados neste estudo se referem a todos os moradores do domic\u00edlio, mas foram respondidos por apenas um morador, o que pode levar a uma maior imprecis\u00e3o nas informa\u00e7\u00f5es. Uma das limita\u00e7\u00f5es dos inqu\u00e9ritos domiciliares \u00e9 o vi\u00e9s associado ao uso de informantes secund\u00e1rios51. Apesar disso, deve-se ressaltar que essa decis\u00e3o metodol\u00f3gica pode acarretar perdas nas estimativas m\u00e9dias e consequente redu\u00e7\u00e3o do poder estat\u00edstico, dificultando a identifica\u00e7\u00e3o de diferen\u00e7as entre as edi\u00e7\u00f5es. Contudo, nosso foco s\u00e3o as informa\u00e7\u00f5es nas quais foram observadas diferen\u00e7as significantes.Com o objetivo de garantir maior homogeneidade na distribui\u00e7\u00e3o dos sexos entre os diversos grupos et\u00e1rios, nos c\u00e1lculos de preval\u00eancia das hospitaliza\u00e7\u00f5es n\u00f3s optamos por n\u00e3o incluir as interna\u00e7\u00f5es obst\u00e9tricas. Deste modo, as preval\u00eancias que encontramos s\u00e3o menores que aquelas previamente divulgadas. Essa decis\u00e3o metodol\u00f3gica tem sido observada em estudos anterioresNosso estudo teve como limita\u00e7\u00e3o a aus\u00eancia dos dados administrativos referentes \u00e0s interna\u00e7\u00f5es por plano de sa\u00fade do ano de 2013 e usamos, como alternativa, os dados de 2014 na compara\u00e7\u00e3o com a PNS 2013, o que pode gerar um vi\u00e9s na compara\u00e7\u00e3o. Da mesma forma, as diverg\u00eancias entre os dados administrativos e as estimativas das duas PNS podem representar uma maior amplitude no grau de incerteza dos nossos achados, resultante de sub ou superestimavas observadas nas duas edi\u00e7\u00f5es da PNS. Outra quest\u00e3o \u00e9 que, devido ao grande tamanho de amostra nas duas edi\u00e7\u00f5es da PNS, diferen\u00e7as m\u00ednimas podem ser consideradas estatisticamente significativas e as diferen\u00e7as encontradas neste trabalho devem ser avaliadas n\u00e3o apenas em termos estat\u00edsticos, mas em seu significado epidemiol\u00f3gico.A PNS 2019 identificou um predom\u00ednio de interna\u00e7\u00f5es por pessoas com doen\u00e7as cr\u00f4nicas. Este subgrupo populacional deve ser melhor estudado, identificando os fatores de risco para hospitaliza\u00e7\u00e3o. Especial aten\u00e7\u00e3o deve ser dada aos grandes usu\u00e1rios, principalmente nos determinantes de reospitaliza\u00e7\u00e3o. \u00c9 necess\u00e1rio, tamb\u00e9m, uma avalia\u00e7\u00e3o da enorme quantidade de hospitais de pequeno porte, que existem no Brasil. A efic\u00e1cia da rede de aten\u00e7\u00e3o hospitalar deve ser investigada, trazendo informa\u00e7\u00f5es para subsidiar novas pol\u00edticas p\u00fablicas, para uma utiliza\u00e7\u00e3o mais racional dos recursos financeiros.Houve um aumento nas taxas globais de hospitaliza\u00e7\u00e3o no per\u00edodo compreendido entre as PNS 2013 e 2019, principalmente entre as pessoas com melhor acesso aos servi\u00e7os de sa\u00fade. Al\u00e9m disto o pr\u00f3prio perfil de hospitaliza\u00e7\u00e3o mudou. Enquanto na edi\u00e7\u00e3o de 2013 predominaram, no total de hospitaliza\u00e7\u00f5es, as interna\u00e7\u00f5es de pessoas sem doen\u00e7as cr\u00f4nicas, na PNS 2019 mais da metade do total das interna\u00e7\u00f5es foi de portadores de doen\u00e7as cr\u00f4nicas.Ficou evidente que as altera\u00e7\u00f5es do perfil demogr\u00e1fico e epidemiol\u00f3gico da popula\u00e7\u00e3o brasileira j\u00e1 est\u00e3o impactando as taxas de interna\u00e7\u00e3o. O n\u00famero de doentes cr\u00f4nicos, na popula\u00e7\u00e3o brasileira, dobrou, por\u00e9m a preval\u00eancia de interna\u00e7\u00e3o, entre eles, diminuiu, provavelmente porque eles ainda n\u00e3o desenvolveram complica\u00e7\u00f5es. Neste contexto, uma aten\u00e7\u00e3o prim\u00e1ria \u00e0 sa\u00fade acess\u00edvel e eficaz passa a ser ainda mais relevante, do contr\u00e1rio pode-se esperar mais interna\u00e7\u00f5es e maiores custos em m\u00e9dio prazo. Al\u00e9m disto, a pol\u00edtica de aten\u00e7\u00e3o hospitalar deve ser continuamente aprimorada, buscando efic\u00e1cia e redu\u00e7\u00e3o de custos. Sem estas medidas, existe o s\u00e9rio risco de colapso dos sistemas de sa\u00fade do Brasil."}
+{"text": "Nesse sentido, medicamentoss\u00e3o registrados e a indica\u00e7\u00e3o de registro \u00e9 a indica\u00e7\u00e3o autorizada pelo pa\u00eds, comdiscricionariedade da Anvisa.O debate \u00e9 fundamental e agradecemos o interesse e a contribui\u00e7\u00e3o de tantos colegas emdiscutir nosso trabalho publicado em CSP. Nosso artigo Verificamos que o conte\u00fado da Carta \u00e0s Editoras off-label \u00e9 um instrumento que pode - e \u00e9 - usado pela ind\u00fastriapara cobrir seus interesses, de formas variadas off-label. Poroutro lado, em alguns nichos terap\u00eauticos de maior dinamismo tecnol\u00f3gico, com in\u00famerasop\u00e7\u00f5es terap\u00eauticas, esse uso j\u00e1 n\u00e3o se torna t\u00e3o interessante, pois haver\u00e1 maioresganhos com a multiplicidade de incorpora\u00e7\u00f5es. Assim, o contexto \u00e9 muito importante - \u00e9ele que determina qual a faceta a ser mobilizada pela ind\u00fastria para influenciar ou n\u00e3oo uso off-label.O uso off-label pode ser \u00fatil em situa\u00e7\u00f5es que gerem maioracesso e possibilidades de tratamento adequado em casos muito espec\u00edficos. H\u00e1 v\u00e1riosexemplos na pr\u00e1tica cl\u00ednica, sendo o mais contundente o uso pedi\u00e1trico. No entanto,institucionalizar, a priori, o uso off-label carreiariscos que n\u00e3o podem ser minimizados Outrossim, o uso off-label \u00e9 muitas vezes fr\u00e1gil,sobretudo porque os medicamentos n\u00e3o foram expostos \u00e0 testagem e avalia\u00e7\u00e3o quefundamentam o registro. O uso off-label pode \u201cliberar\u201d a ind\u00fastria dodesenvolvimento de novos ensaios para a nova indica\u00e7\u00e3o pretendida, auferindo economia derecursos e muitos lucros. No emprego off-label, as consequ\u00eancias do\u201cn\u00e3o uso\u201d n\u00e3o s\u00e3o apresentadas. A aus\u00eancia de aprova\u00e7\u00e3o pelo \u00f3rg\u00e3o regulador implicafalta de faixas de doses seguras e de informa\u00e7\u00f5es adequadas sobre contraindica\u00e7\u00f5es.Resultados de efic\u00e1cia negativos ou n\u00e3o significativos n\u00e3o s\u00e3o publicados. As evid\u00eanciasde eventos adversos s\u00e3o prejudicadas pela pequena abrang\u00eancia do uso na indica\u00e7\u00e3o n\u00e3oregistrada, e n\u00e3o h\u00e1 est\u00edmulo para estudos Fase IV ,,A qualidade das evid\u00eancias para uso off-label \u00e9 do profissionalprescritor, contrastando com a responsabilidade compartilhada do uso indicado, que temna ag\u00eancia reguladora seu garantidor. Os fabricantes t\u00eam pouca responsabilidade legal emrela\u00e7\u00e3o \u00e0 prescri\u00e7\u00e3o, pois s\u00f3 podem ser responsabilizados por problemas que surgemquando seu medicamento \u00e9 utilizado de acordo com as indica\u00e7\u00f5es aprovadas. O usooff-label promove crescimento do mercado sem aumento deresponsabilidades com as consequ\u00eancias do uso Ainda, a responsabilidade pelo uso ,on-label, em que anecessidade pode ser estimada com maior certeza, pela previsibilidade. A atualvariabilidade de abordagens terap\u00eauticas no \u00e2mbito do SUS j\u00e1 apresenta iniquidadeimportante e documentada ,off-label? E n\u00e3o estamosadentrando o contexto da aloca\u00e7\u00e3o de recursos, em que as prioridades deveriam estar empauta, em situa\u00e7\u00e3o de recursos limitados e judicializa\u00e7\u00e3o galopante.O contexto da provis\u00e3o, consequ\u00eancia necess\u00e1ria da incorpora\u00e7\u00e3o e parametrizada porprazos, \u00e9 de exame essencial. \u00c9 fato que nem sempre os prazos de disponibiliza\u00e7\u00e3o noSistema \u00danico de Sa\u00fade (SUS) s\u00e3o cumpridos expertise. Imaginarque outras inst\u00e2ncias estariam mais qualificadas para realizar o trabalho da ag\u00eanciaseria n\u00e3o apenas desconsiderar sua compet\u00eancia, mas abrir espa\u00e7o para que outros tamb\u00e9mdesqualifiquem a compet\u00eancia da inst\u00e2ncia respons\u00e1vel pela avalia\u00e7\u00e3o de tecnologias hojeempreendida para o SUS.\u00c9 de compet\u00eancia exclusiva da Anvisa a decis\u00e3o sobre como um medicamento deve ou n\u00e3o serregistrado, com processos definidos e equipe com Sobre a nova estrutura da Conitec, mantemos a impress\u00e3o de que atomiza a responsabilidadesobre as recomenda\u00e7\u00f5es e pode fragmentar a integralidade das decis\u00f5es, mas estamosabertos a novos desdobramentos positivos, no decorrer dos seus trabalhos no novoformato. Ressalta-se, ainda, que nosso trabalho n\u00e3o realizou uma an\u00e1lise da qualidadedos processos da Conitec. Sentimos que os autores da carta deveriam dedicar-se aescrever mais sobre essa relevante quest\u00e3o, o que seria de grande utilidade para aacademia e para o fortalecimento da Conitec.off-label, refor\u00e7ando a necessidade de estudos bemconduzidos, que possam garantir, no m\u00ednimo, efic\u00e1cia e seguran\u00e7a.Press\u00f5es sociais e pol\u00edticas fazem parte dos cen\u00e1rios de avalia\u00e7\u00e3o e de incorpora\u00e7\u00e3o emtodo o mundo. No Brasil, temos alguns bons exemplos, e outros nem tanto, como os casosda fosfoetanolamina, da cloroquina e de outros medicamentos reposicionados paraCOVID-19, em uso Concordamos com os colegas que a participa\u00e7\u00e3o dos segmentos sociais na Conitec \u00e9 aindainsuficiente, concentrando-se nos grupos com interesse expl\u00edcito nas incorpora\u00e7\u00f5es, porvariados motivos, e deixando de fora todos os que n\u00e3o t\u00eam os mesmos interesses - osquais representam, muitas vezes, a parcela mais significativa - e o SUS universal off-label abarca m\u00faltiplas vertentes e exigeconsciencializa\u00e7\u00e3o e responsabilidade constantes no seu exerc\u00edcio, tendo a Anvisacompet\u00eancia exclusiva por esse tipo de uso no Brasil.Esperamos ter gerado reflex\u00f5es sobre as eventuais consequ\u00eancias da legisla\u00e7\u00e3o citada. Oconceito"}
+{"text": "To estimate the prevalence of unplanned pregnancy in eight public university hospitals, distributed in the five regions that make up Brazil. A secondary analysis of a national multicenter cross-sectional study, carried out in eight public university hospitals between June 1 and August 31, 2020, in Brazil. Convenience sample including women who gave birth within sixty consecutive days and met the following criteria: over 18 years old; gestational age over 36 weeks at delivery; with a single and live newborn, without malformations. Sample composed of 1,120 postpartum women, of whom 756 (67.5%) declared that the pregnancy had not been planned. The median prevalence of unplanned pregnancy was 59.7%. The prevalence of unplanned pregnancy across hospitals differed significantly: Campinas (54.8%), Porto Alegre (58.2%), Florian\u00f3polis (59%), Teresina (61.2%), Bras\u00edlia (64.3%), S\u00e3o Paulo (64.6%), Campo Grande (73.9%) and Manaus (95.3%) (p < 0.001). Factors significantly associated with unplanned pregnancy were maternal age, black color, lower family income, greater number of children, greater number of people living in household, and not having a partner. In the studied sample, about two thirds of the pregnancies were declared as unplanned. The prevalence of unplanned pregnancies was related to social and demographic factors and varied significantly across the university hospitals evaluated. However, recent data indicate that 48% of the pregnancies that occurred in the world in the last five years were unplanned, which represents 121 million cases per year or a global annual rate of 64 unplanned pregnancies (UP) for every thousand women between 15 and 49 years old1 . The annual rate of unplanned pregnancies per thousand women of reproductive age is inversely proportional to each country\u2019s socioeconomic development level, and is 34 in developed countries, 66 in countries with medium development index, and 93 in those with a low index1 . Thus, countries with a low development index concentrate the highest UP rates.The reduction in family size due to postponed parenthood and lower birth rates is a global trend and suggests greater access to efficient contraceptive methods2 . A similar result was reported in a study carried out in 2010, which evaluated data from more than five thousand women in a capital city in the Northeast region and found a UP prevalence of 68%3 . In that same year, a questionnaire applied in all maternity hospitals in the city of Ribeir\u00e3o Preto, in the Southeast region of the country, found a UP prevalence of 54% in the 7,500 women interviewed4 . Of greater scope, the study \u201cBirth in Brazil\u201d, which evaluated 24,000 women who gave birth between 2011 and 2012, showed that 55% of pregnancies were unplanned and that there were important differences in access to perinatal health in different regions of Brazil4 . Data from all these studies convergently indicated that the group of women with unplanned pregnancies had a high degree of social vulnerability6 .In Brazil, a survey carried out in the South region investigated all births that occurred in a municipality throughout 2007 and found an unplanned pregnancy rate of 65% in the 2,500 women interviewedA decade after the last survey, we had the opportunity to explore the prevalence of unplanned pregnancies in maternity wards in different regions of the country. This study was designed to determine the frequency of UP in the maternity wards of eight public university hospitals distributed throughout Brazil\u2019s five geographic regions.7 , whose multicenter cross-sectional design allowed the collection of data in cities in the five regions of Brazil . Of the ten centers that participated in the larger study, two did not collect information regarding pregnancy planning, so the analysis included eight centers distributed in the five regions. The study protocol was approved by the National Research Ethics Committee \u2013 Conep (CAAE No. 31190120.6.1001.5505) \u2013 and by each Research Ethics Committee at the place where the data were collected. All participants signed an informed consent form.This is a secondary data analysis of a larger studyData were collected from June 1, 2020 to August 31, 2020, and enrollment took place over 60 consecutive days at each center. Women who gave birth in university hospitals located in the cities of Manaus, Campo Grande, Bras\u00edlia, Porto Alegre, Florian\u00f3polis, Campinas, S\u00e3o Paulo and Teresina were recruited to participate in the study. Each university hospital had a local coordinator and trained medical residents who participated in data collection.Inclusion criteria were: age greater than 18 years, single delivery after 36 weeks, live birth without malformations, absence of psychiatric or mental illness in the mother and good maternal health status after delivery. Eligible patients were interviewed in a calm environment on the first or second postpartum day.8 ) regardless of whether or not it was desired at the time of the interview. Therefore, the question presented in the questionnaire was: \u201cWas your pregnancy planned?\u201d and it was followed by two answer options: \u201cYes, I wanted to have a child this year\u201d or \u201cNo, I did not intend to have a child this year\u201d.During the preparation of the questionnaire, it was considered that the item should be able to identify a pregnancy that was not the result of a conscious decision by the woman or couple  stated that the pregnancy had not been planned. The median prevalence of UP in the eight participating hospitals was 59.7%. The prevalence of UP was significantly different as the centers were compared with each other (p < 0.0001)   .The median age of women with an unplanned pregnancy  was lower than that of those who had planned pregnancy  (p = 0.0001)   .Among the epidemiological factors, a greater probability of UP was observed in black women and in those who lived in households with more than four people, while the probability was lower in women who had a partner and in those who had a family income greater than two minimum wages.   . With rIn the studied sample, schooling, religion, history of abortion and consumption of tobacco, alcohol or illicit drugs were not significantly associated with the occurrence of UP   .Two-thirds of the women who participated in this study had not planned to become pregnant. Subsequently, to minimize the effect of extreme values, such as that observed in Manaus (95.3%), the median prevalence of the eight participating centers was obtained, whose value was 59.7%. This information can contribute to the understanding of the UP problem in Brazil, but, considering the convenience sampling, restricted to a small group of university hospitals, the results cannot be generalized.10 , while those carried out in countries in the African continent revealed a mean prevalence of 34% (ranging from 7.5 to 91%) and those in the Asian continent 20% (ranging from 12 to 28%)12 . Among the most relevant methodological differences, the criteria used to define pregnancy as unplanned and the time of pregnancy or puerperium in which the women were interviewed stand out. While in some studies all pregnancies that were not the result of a couple\u2019s conscious decision are considered unplanned, in others they are classified as untimely, when they occurred earlier than desired, and as unwanted, when the woman did not want to become a mother at any time11 . With regard to the time of the interview, most studies were based on information obtained from women who had just given birth, so they did not consider pregnancies that ended in miscarriage or abortion in the first half of pregnancy. This may underestimate the prevalence of UP, as it is estimated that between 2010 and 2014 more than half of the UP that occurred in the world ended in abortion11 .It is currently not possible to compare the prevalence of UP reported in different countries, as there are important methodological differences between studies. Surveys carried out in the last ten years in the United States and Great Britain showed a UP prevalence of around 45%8 .In view of this difficulty in comparing studies, longitudinal comparative analyses are essential to evaluate or adjust health policies, as evidenced in the study that showed that the United States reduced the UP rate from 51% to 45% between 2008 and 2011, a change that coincides with the increase in the use of contraceptive methods in all social strata, especially long-term ones, such as the intrauterine device, whose use rate increased from 4% to 12%13 . There was a prevalence of 63% and 66% of UP in the first two periods, falling to 52% in 2015. The change coincided with the record of a lower proportion of families earning less than the minimum wage, a higher proportion of mothers working outside the home, higher maternal educational level and lower proportion of women with two or more children, in addition to a reduction in teenage pregnancy and a higher proportion of mothers aged 30 years or older13 .The only Brazilian study that we are aware of that carried out a longitudinal comparison took place in the municipality of Pelotas, in the southern region, and evaluated the prevalence of UP in 1993, 2004 and 201514 . Although this study only included women aged 18 years or over, which may have underestimated the actual prevalence of UP, it seems clear that younger women are at greater risk and therefore should be the main focus of sexual and reproductive education programs. With regard to marital status, previous studies indicate that the absence of a partner or his negative reaction to the pregnancy are more common in women with unplanned pregnancies, which is consistent with the findings described here13 .The finding of younger age in women with UP found in this sample had already been observed in previous studies, pointing to an especially high prevalence among adolescents and women younger than 20 years13 . Likewise, multiparity, more people at home and lower family income, which were associated with UP in this study, reinforce the socially vulnerable profile of this group, as these factors were already evident in studies from the past decade5 . The continuity of the association between social vulnerability and UP is evident in the comparative study carried out in Pelotas, where a drop in the rate of UP from 66% to 52% between 2004 and 2015 was observed, except for the group of women under 24 years old, with more than two children, low educational level, income below the minimum wage and lack of a partner13 . A similar phenomenon occurred in the American comparative longitudinal study, in which, despite a drop in the UP rate in all social strata between 2008 and 2011, the rates remained higher in black, poor and Hispanic women, as compared to white women with higher incomes9 .The association between skin color and the risk of UP in Brazil had also been previously pointed out, indicating that women with black, brown or yellow skin have a higher proportion of UP than women with white skin10 . As regards education, it is noteworthy that 60% of the women in the sample had completed high school and 16.7% had completed higher education. If this observation is confirmed in further studies, it is worth reflecting on how school curricula contemplate aspects related to sexual and reproductive health. The lack of association between smoking, alcohol and illicit drug use can be ascribed to the fact that, in the present study, the question regarding exposure did not discriminate frequency or volume of exposure, which may have led to the inclusion of women with only occasional consumption as users.Other factors, such as low education and tobacco, alcohol or illicit drug use, were associated with a higher probability of UP in previous studies, but this association was not observed in our study7 . Therefore, considering that the pandemic was declared on March 11 of that year, it is important to emphasize that the women interviewed became pregnant before the start of the health emergency and therefore their responses regarding the pregnancy schedule were not influenced by this situation.The data presented here are derived from a multicenter cross-sectional study aimed at assessing the emotional impact of the covid-19 pandemic at the end of pregnancy and were collected from women who gave birth between June and August 2020Although conducting a nationwide survey was an opportunity to explore the prevalence of UP in hospitals in all regions of Brazil, the fact that the study was not specifically designed for this purpose imposed several limitations on it. Convenience sampling, restricted to university hospitals, which aimed to improve the quality of data collection, certainly selected a sample that is not representative of the universe of Brazilian pregnant women and, therefore, the data presented here cannot be generalized to the general population.1 . In the study that compared the prevalence of UP in the United States in 2008 and 2011, stability was observed in the proportion of UP culminating in abortion in these two periods, around 40%9 . Likewise, it is estimated that in France 38% of UP culminate in abortions16 . Therefore, when interviewing only women who maintained their pregnancies, it is possible that the prevalence of UP was underestimated.As in previous Brazilian studies, the fact that only women who had just given birth were questioned did not allow us to know the proportion of UP that ended in abortion. It is estimated that, globally, 61% of UP ends in abortion and that the percentage is higher in developing countries (66%) than in highly developed ones (43%)Another factor that compromises the reliability of the prevalence found is that the question regarding pregnancy planning was binary, so that it did not consider ambivalent feelings or the gradation of intentionality/pregnancy planning. Specifically, when asking the researchers who collected the data in Manaus about the very high prevalence of UP found, they reported the impression that the binary response option did not allow assessing the cultural lack of concern about the number and time of arrival of children, characteristic of the public served in this hospital.17 .Finally, the fact of excluding adolescent women and women with psychiatric illnesses may have underestimated the prevalence of UP, since it is well established that in adolescence there is a greater probability of accidental pregnancy and that UP is a risk factor for depressive conditions during pregnancyConsidering that the choice of the number of children and the moment to have them are reproductive rights that must be guaranteed to every human being and that the real prevalence of UP in Brazil remains unknown, the need for studies designed specifically for this purpose and using instruments created for that purpose is clear. Recently, the Brazilian Portuguese version of the London Measure of Unplanned Pregnancy (LMUP) was validated, a self-administered six-question scale that results in a score from 0 to 12 points concerning the intentionality/planning of pregnancy, where 0 to 3 characterizes it as unplanned, 4 to 9 as ambivalent, and 10 to 12 as planned. Hopefully, future studies with the application of this instrument in representative samples of the Brazilian population will bring to light more reliable and comparable information. 1 . No entanto, dados recentes apontam que 48% das gesta\u00e7\u00f5es ocorridas no mundo nos \u00faltimos cinco anos n\u00e3o foram planejadas, o que representa 121 milh\u00f5es de casos por ano ou uma taxa anual global de 64 gesta\u00e7\u00f5es n\u00e3o planejadas (GNP) para cada mil mulheres entre 15 e 49 anos1 . A taxa anual de gesta\u00e7\u00f5es n\u00e3o planejadas a cada mil mulheres em idade reprodutiva varia de forma inversamente proporcional ao grau de desenvolvimento socioecon\u00f4mico de cada pa\u00eds, sendo de 34 em pa\u00edses desenvolvidos, 66 em pa\u00edses com \u00edndice m\u00e9dio de desenvolvimento e 93 naqueles com baixo \u00edndice1 . Dessa forma, os pa\u00edses com baixo \u00edndice de desenvolvimento concentram as maiores taxas de GNP.A redu\u00e7\u00e3o do tamanho das fam\u00edlias decorrente do adiamento da parentalidade e das menores taxas de natalidade \u00e9 uma tend\u00eancia global e sugere maior acesso a m\u00e9todos contraceptivos eficientes2 . Resultado semelhante foi descrito em um estudo realizado em 2010, que avaliou os dados de mais de cinco mil mulheres em uma capital da regi\u00e3o Nordeste e encontrou preval\u00eancia de GNP de 68%3 . Nesse mesmo ano, um question\u00e1rio aplicado em todas as maternidades do munic\u00edpio de Ribeir\u00e3o Preto, na regi\u00e3o Sudeste do pa\u00eds, encontrou preval\u00eancia de GNP de 54% nas 7.500 mulheres entrevistadas4 . De maior envergadura, o estudo \u201cNascer no Brasil\u201d, que avaliou 24 mil mulheres que tiveram parto entre 2011 e 2012, mostrou que 55% das gesta\u00e7\u00f5es n\u00e3o tinham sido planejadas e que havia diferen\u00e7as importantes no acesso \u00e0 sa\u00fade perinatal nas distintas regi\u00f5es do Brasil4 . Os dados de todos esses estudos indicaram de forma convergente que o grupo de mulheres com gesta\u00e7\u00f5es n\u00e3o planejadas apresentava alto grau de vulnerabilidade social6 .No Brasil, um inqu\u00e9rito realizado na regi\u00e3o Sul investigou todos os partos ocorridos em um munic\u00edpio ao longo de 2007 e encontrou uma taxa de gesta\u00e7\u00e3o n\u00e3o planejada de 65% nas 2.500 mulheres entrevistadasTranscorrida uma d\u00e9cada desde o \u00faltimo inqu\u00e9rito, tivemos a oportunidade de explorar a preval\u00eancia de gesta\u00e7\u00f5es n\u00e3o planejadas em maternidades das distintas regi\u00f5es do pa\u00eds. O objetivo do presente estudo foi determinar a frequ\u00eancia de GNP nas maternidades de oito hospitais p\u00fablicos universit\u00e1rios distribu\u00eddos ao longo das cinco regi\u00f5es geogr\u00e1ficas do Brasil.7 cujo desenho transversal multic\u00eantrico permitiu a coleta de dados em cidades das cinco regi\u00f5es do Brasil . Dos dez centros que participaram do estudo maior, dois n\u00e3o levantaram informa\u00e7\u00f5es quanto ao planejamento da gesta\u00e7\u00e3o, de forma que a an\u00e1lise incluiu oito centros distribu\u00eddos nas cinco regi\u00f5es. O protocolo do estudo foi aprovado pelo Comit\u00ea Nacional de \u00c9tica em Pesquisa \u2013 Conep (CAAE n\u00ba 31190120.6.1001.5505) \u2013 e por cada comit\u00ea de \u00e9tica em Pesquisa do local onde os dados foram coletados. Todas as participantes assinaram um termo de consentimento informado.Esta \u00e9 uma an\u00e1lise de dados secund\u00e1ria de um estudo maior,Os dados foram coletados no per\u00edodo de 1\u00ba de junho de 2020 a 31 de agosto de 2020 e as inscri\u00e7\u00f5es ocorreram durante 60 dias consecutivos em cada centro. As mulheres que tiveram parto em hospitais universit\u00e1rios localizados nas cidades de Manaus, Campo Grande, Bras\u00edlia, Porto Alegre, Florian\u00f3polis, Campinas, S\u00e3o Paulo e Teresina foram recrutadas para participar do estudo. Cada hospital universit\u00e1rio tinha um coordenador local e residentes m\u00e9dicos treinados, que participaram da coleta de dados.Os crit\u00e9rios de inclus\u00e3o foram: idade maior que 18 anos, parto \u00fanico ap\u00f3s 36 semanas, rec\u00e9m-nascido vivo sem malforma\u00e7\u00f5es, aus\u00eancia de doen\u00e7a psiqui\u00e1trica ou mental na m\u00e3e e bom estado de sa\u00fade materna ap\u00f3s o parto. As pacientes eleg\u00edveis foram entrevistadas em um ambiente calmo no primeiro ou segundo dia p\u00f3s-parto.8 ) independentemente de ser ou n\u00e3o desejada no momento da entrevista. Para tanto, no question\u00e1rio foi apresentada a pergunta \u201cA sua gravidez foi programada?\u201d, seguida de duas op\u00e7\u00f5es de resposta: \u201cSim, eu queria ter um filho este ano\u201d ou \u201cN\u00e3o, eu n\u00e3o pretendia ter um filho este ano\u201d.Durante a elabora\u00e7\u00e3o do question\u00e1rio, ponderou-se que o item deveria ser capaz de identificar a gravidez que n\u00e3o resultou de decis\u00e3o consciente da mulher ou casal  declararam que a gravidez n\u00e3o tinha sido planejada. A mediana da preval\u00eancia de GNP nos oito hospitais participantes foi de 59,7%. A preval\u00eancia de GNP foi significativamente diferente ao comparar os centros entre si    .A mediana da idade das mulheres com gesta\u00e7\u00e3o n\u00e3o planejada  foi menor que a daquelas que tinham planejado a gravidez     .Entre os fatores epidemiol\u00f3gicos, observou-se maior probabilidade de GNP em mulheres negras e naquelas que viviam em casas com n\u00famero de pessoas superior a quatro, enquanto a probabilidade foi menor nas mulheres que tinham parceiro e nas que tinham renda familiar maior que dois sal\u00e1rios m\u00ednimos   . No queNa amostra estudada, escolaridade, religi\u00e3o, antecedente de aborto e consumo de tabaco, \u00e1lcool ou drogas il\u00edcitas n\u00e3o tiveram associa\u00e7\u00e3o significativa com a ocorr\u00eancia de GNP   .Dois ter\u00e7os das mulheres que participaram deste estudo n\u00e3o haviam planejado engravidar. Posteriormente, para minimizar o efeito de valores extremos, como o observado em Manaus , foi obtida a mediana da preval\u00eancia dos oito centros participantes, cujo valor foi 59,7%. Essa informa\u00e7\u00e3o pode contribuir para a compreens\u00e3o do problema da GNP no Brasil, mas, considerando a amostragem por conveni\u00eancia, restrita a um pequeno grupo de hospitais universit\u00e1rios, os resultados n\u00e3o podem ser generalizados.10 , enquanto os realizados em pa\u00edses do continente africano revelaram preval\u00eancia m\u00e9dia de 34%  e os do continente asi\u00e1tico 20% (varia\u00e7\u00e3o de 12 a 28%)12 . Dentre as diferen\u00e7as metodol\u00f3gicas mais relevantes destacam-se o crit\u00e9rio usado para definir a gravidez como n\u00e3o planejada e o momento da gravidez ou puerp\u00e9rio em que as mulheres foram entrevistadas. Enquanto em alguns estudos considera-se n\u00e3o planejada toda gravidez que n\u00e3o decorreu de decis\u00e3o consciente do casal, em outros essas s\u00e3o classificadas em inoportunas, quando ocorreram antes do desejado, e indesejadas, quando a mulher n\u00e3o queria se tornar m\u00e3e em momento algum11 . No que diz respeito ao momento da entrevista, a maior parte dos estudos se basearam em informa\u00e7\u00f5es obtidas em mulheres que acabaram de ter um parto, de forma que n\u00e3o consideraram as gravidezes que terminaram em aborto espont\u00e2neo ou intencional na primeira metade da gravidez. Isso pode subestimar a preval\u00eancia de GNP, pois se estima que entre 2010 e 2014 mais da metade das GNP ocorridas no mundo terminaram em aborto11 .Atualmente n\u00e3o \u00e9 poss\u00edvel comparar a preval\u00eancia de GNP reportada em diversos pa\u00edses, pois h\u00e1 importantes diferen\u00e7as metodol\u00f3gicas entre os estudos. Inqu\u00e9ritos realizados nos \u00faltimos dez anos nos Estados Unidos e na Gr\u00e3-Bretanha mostraram preval\u00eancia de GNP em torno de 45%8 .Em face dessa dificuldade de compara\u00e7\u00e3o entre estudos, an\u00e1lises comparativas longitudinais s\u00e3o essenciais para avaliar ou ajustar as pol\u00edticas de sa\u00fade, como ficou evidente no estudo que mostrou que os Estados Unidos reduziram a taxa de GNP de 51% para 45% entre os anos de 2008 e 2011, mudan\u00e7a coincidente com o aumento do uso de m\u00e9todos contraceptivos em todos os estratos sociais, principalmente os de longa dura\u00e7\u00e3o, como o dispositivo intrauterino, cuja taxa de uso passou de 4% para 12%13 . Observou-se preval\u00eancia de 63 e 66% de GNP nos dois primeiros per\u00edodos, com queda para 52% em 2015. A mudan\u00e7a coincidiu com o registro de menor propor\u00e7\u00e3o de fam\u00edlias recebendo menos de um sal\u00e1rio m\u00ednimo, maior propor\u00e7\u00e3o de m\u00e3es trabalhando fora do lar, maior n\u00edvel educacional materno e menor propor\u00e7\u00e3o de mulheres com dois ou mais filhos, al\u00e9m de redu\u00e7\u00e3o de gesta\u00e7\u00e3o na adolesc\u00eancia e maior propor\u00e7\u00e3o de m\u00e3es com idade igual ou superior a 30 anos13 .O \u00fanico estudo brasileiro de que temos conhecimento que fez uma compara\u00e7\u00e3o longitudinal ocorreu no munic\u00edpio de Pelotas, na regi\u00e3o Sul, e avaliou a preval\u00eancia de GNP nos anos de 1993, 2004 e 201514 . Apesar deste estudo ter inclu\u00eddo apenas mulheres com idade igual ou superior a 18 anos, o que pode ter subestimado a real preval\u00eancia de GNP, parece claro que as mulheres mais jovens t\u00eam mais risco e portanto devem ser foco principal dos programas de educa\u00e7\u00e3o sexual e reprodutiva. No que diz respeito ao estado conjugal, estudos anteriores indicam que a aus\u00eancia de parceiro ou a rea\u00e7\u00e3o negativa deste em rela\u00e7\u00e3o \u00e0 gesta\u00e7\u00e3o s\u00e3o mais comuns em mulheres com gesta\u00e7\u00f5es n\u00e3o planejadas, o que \u00e9 concordante com o resultado aqui descrito13 .O achado de menor idade em mulheres com GNP encontrado nesta amostra j\u00e1 tinha sido observado em estudos pr\u00e9vios, apontando preval\u00eancia especialmente alta entre adolescentes e mulheres menores de 20 anos13 . Igualmente, multiparidade, maior n\u00famero de pessoas em casa e menor renda familiar, que foram associados a GNP neste estudo, refor\u00e7am o perfil socialmente vulner\u00e1vel desse grupo, pois esses fatores j\u00e1 eram evidentes nos estudos da d\u00e9cada passada5 . A perenidade da associa\u00e7\u00e3o entre vulnerabilidade social e GNP fica patente no estudo comparativo realizado em Pelotas, onde se observou queda da taxa de GNP de 66% para 52% entre 2004 e 2015, exceto para o grupo de mulheres com menos de 24 anos, com mais de dois filhos, baixo n\u00edvel educacional, renda inferior a um sal\u00e1rio m\u00ednimo e aus\u00eancia de parceiro13 . Fen\u00f4meno semelhante ocorreu no estudo longitudinal comparativo americano, no qual, apesar de ter ocorrido queda da taxa de GNP em todos os estratos sociais entre 2008 e 2011, os \u00edndices permaneceram superiores em mulheres negras, pobres e hisp\u00e2nicas, quando comparadas a brancas de maior renda9 .A associa\u00e7\u00e3o entre a cor da pele e o risco de GNP no Brasil tamb\u00e9m j\u00e1 tinha sido previamente apontada, indicando de forma convergente que mulheres com pele preta, parda ou amarela apresentam maior propor\u00e7\u00e3o de GNP que mulheres com pele branca10 . No que diz respeito \u00e0 escolaridade, chama a aten\u00e7\u00e3o que 60% das mulheres que compuseram a amostra tinha conclu\u00eddo o ensino m\u00e9dio e 16,7% o ensino superior. Se essa observa\u00e7\u00e3o for confirmada em estudos posteriores, cabe a reflex\u00e3o sobre a forma como os curr\u00edculos escolares contemplam aspectos relacionados \u00e0 sa\u00fade sexual e reprodutiva. A falta de associa\u00e7\u00e3o entre tabagismo, uso de \u00e1lcool e drogas il\u00edcitas pode ser explicada porque no presente estudo a pergunta quanto \u00e0 exposi\u00e7\u00e3o n\u00e3o discriminava frequ\u00eancia ou volume da exposi\u00e7\u00e3o, o que pode ter levado a incluir como usu\u00e1rias mulheres com consumo apenas ocasional.Outros fatores, como baixa escolaridade e uso de tabaco, \u00e1lcool ou drogas il\u00edcitas, foram associados a maior probabilidade de GNP em estudos pregressos, mas essa associa\u00e7\u00e3o n\u00e3o foi observada em nosso estudo7 . Portanto, considerando que a pandemia foi declarada em 11 de mar\u00e7o desse ano, \u00e9 importante ressaltar que as mulheres entrevistadas engravidaram antes do in\u00edcio da emerg\u00eancia sanit\u00e1ria e por isso as suas respostas a respeito da programa\u00e7\u00e3o da gesta\u00e7\u00e3o n\u00e3o foram influenciadas por essa situa\u00e7\u00e3o.Os dados aqui apresentados s\u00e3o derivados de um estudo transversal multic\u00eantrico destinado a avaliar o impacto emocional da pandemia de covid-19 no final da gesta\u00e7\u00e3o e foram colhidos em mulheres que tiveram parto entre junho e agosto de 2020Apesar da realiza\u00e7\u00e3o de um inqu\u00e9rito de abrang\u00eancia nacional ter sido uma oportunidade de explorar a preval\u00eancia de GNP em hospitais de todas as regi\u00f5es do Brasil, o fato do estudo n\u00e3o ter sido especificamente desenhado para esse fim lhe imp\u00f4s v\u00e1rias limita\u00e7\u00f5es. A amostragem por conveni\u00eancia, restrita a hospitais universit\u00e1rios, que teve por objetivo aprimorar a qualidade da coleta de dados, certamente selecionou uma amostra que n\u00e3o \u00e9 representativa do universo de gestantes brasileiras e, portanto, os dados aqui apresentados n\u00e3o podem ser generalizados para a popula\u00e7\u00e3o.1 . No estudo que comparou a preval\u00eancia de GNP nos Estados Unidos nos anos 2008 e 2011 observou-se estabilidade da propor\u00e7\u00e3o de GNP culminadas em abortamento nesses dois per\u00edodos, em torno de 40%9 . Igualmente, estima-se que na Fran\u00e7a 38% das GNP culminam em abortamentos intencionais16 . Por tanto, ao entrevistar apenas mulheres que mantiveram a gravidez, \u00e9 poss\u00edvel que a preval\u00eancia de GNP tenha sido subestimada.\u00c0 semelhan\u00e7a dos estudos brasileiros anteriores, o fato de se ter interrogado apenas mulheres que tinham acabado de ter filho n\u00e3o permitiu conhecer a propor\u00e7\u00e3o de GNP terminadas em aborto. Estima-se que, globalmente, 61% das GNP terminam em abortamento intencional e que o percentual \u00e9 maior em pa\u00edses em desenvolvimento (66%) do que naqueles altamente desenvolvidos (43%)Outro fator que compromete a fidedignidade da preval\u00eancia encontrada \u00e9 que a pergunta quanto ao planejamento da gravidez foi bin\u00e1ria, de forma que n\u00e3o considerou sentimentos ambivalentes ou a grada\u00e7\u00e3o de intencionalidade/planejamento da gesta\u00e7\u00e3o. Especificamente, ao indagar aos pesquisadores que coletaram os dados em Manaus acerca da alt\u00edssima preval\u00eancia de GNP encontrada, relataram a impress\u00e3o de que a op\u00e7\u00e3o de resposta bin\u00e1ria n\u00e3o permitiu avaliar a despreocupa\u00e7\u00e3o cultural acerca do n\u00famero e momento de chegada dos filhos, caracter\u00edstica do p\u00fablico atendido nesse hospital.17 .Finalmente, o fato de ter exclu\u00eddo mulheres adolescentes e com doen\u00e7as psiqui\u00e1tricas pode ter subestimado a preval\u00eancia de GNP, uma vez que est\u00e1 bem definido que na adolesc\u00eancia h\u00e1 maior probabilidade de gravidez acidental e que a GNP \u00e9 fator de risco para quadros depressivos durante a gesta\u00e7\u00e3oLondon Measure of Unplanned Pregnancy (LMUP), escala autoaplic\u00e1vel com seis quest\u00f5es que resulta em um escore de 0 a 12 pontos referentes \u00e0 intencionalidade/planejamento da gravidez, que caracteriza 0 a 3 como n\u00e3o planejada, 4 a 9 como ambivalente e 10 a 12 como planejada. Espera-se que estudos futuros com a aplica\u00e7\u00e3o desse instrumento em amostras representativas da popula\u00e7\u00e3o brasileira tragam \u00e0 luz informa\u00e7\u00f5es mais fidedignas e compar\u00e1veis.Considerando que a escolha do n\u00famero de filhos e do momento de t\u00ea-los s\u00e3o direitos reprodutivos que devem ser assegurados a todo ser humano e que a real preval\u00eancia de GNP no Brasil permanece desconhecida, fica patente a necessidade de estudos desenhados especificamente para esse fim e utilizando instrumentos criados para esse prop\u00f3sito. Recentemente, foi validada a vers\u00e3o em portugu\u00eas brasileiro da"}
+{"text": "To identify the behavioral tests used to assess auditory processing throughout adulthood, focusing on the characteristics of the target population as an interest group.PubMed, CINAHL, Web of Science, and Scielo, databases were searched with descriptors: \u201cauditory perception\u201d or \u201cauditory perception disorders\u201d or \u201cauditory processing\u201d or \u201ccentral auditory processing\u201d or \u201cauditory processing disorders\u201d or \u201ccentral auditory processing disorders\u201d with adults OR aging.Studies with humans included, the adult population from 18 to 64 years old, who performed at least one behavioral test to assess auditory processing in the absence of hearing loss.Data extraction was performed independently, using a protocol developed by the authors that included different topics, mainly the behavioral auditory tests performed and the results found.Of the 867 records identified, 24 contained the information needed to answer the survey questions.Almost all studies were conducted verify performance in one or two auditory processing tests. The target target population was heterogeneous, with the most frequent persons with diabetes, stuttering, auditory processing disorder, and noise exposure. There is little information regarding benchmarks for testing in the respective age groups. The neurobiological deficit that affects this system is called central auditory processing disorder (CAPD). This condition may be related to the impairment of neural connectivity of bottom-up and / or top-down pathways; for the latter, the regulatory effects of cognitive processes  are involved,3.Central auditory processing (CAP) is responsible for the transformation, organization, decoding, and encoding of acoustic information over a short period of time. This action provides an effective and efficient analysis of verbal and nonverbal sounds by the central auditory nervous system (CANS),5. These findings characterize a unique clinical population but are not uncommon,6-11. One of the reasons for this complaint is the presence of CAPD; although its prevalence is not well established for the adult population under the age of 60, where estimates vary between 0.5%, 14%, and 23%,12,13.In the adult population with complaints about speech comprehension in a noisy environment, approximately 10% have hearing sensitivity within the normal range,14. A possible causal factor is the neural changes in the auditory pathways, which are independent of any type of peripheral hearing loss. These are attributed to the deterioration or decline of function throughout adult life before the cycle is understood as old age. A decrease in the neural network in areas responsible for speech processing has been described in post-mortem studies carried out by Brody. Even before 60 years of age, anatomical and physiological changes occur in the ventral cochlear nucleus, justifying the lower efficiency and accuracy of transmitting information in the CANS. The interhemispheric function remains relatively stable until close to 40 years of age, with a decline from this age onwards. Men showed a change in function around age 35, whereas women maintained a stable performance until age 55. Decreased estrogen levels in postmenopausal women may suppress the gamma-aminobutyric acid (GABA) inhibitor, contributing to changes in CAP around the age of 50 years. The decline of this inhibitor generates functional impairment, causing \u201cneural noise, \u201cwhich impairs speech perception. The decrease in GABA in the inferior colliculus as a function of increasing age was initially described in animals; however, similar results were found in humans, which were related to the deterioration in the performance of speech recognition.CAPD results from different structural and functional etiological factors that affect the CANS or even in their absence-35. The approach to increasing age has been less explored, especially in adults without hearing loss. Studies agree that young adults better understand speech in noise than older adults,36-39 and even middle-aged adults in temporal processing. A study with a population aged 50 to 70 years identified that the score on dichotic listening and temporal ordering tasks was only slightly lower than that expected for young adults. The authors inferred that if middle-aged adults were not included, the difference in performance between young and old adults would be greater.The main focus of studies with CAP behavioral tests in young and middle-aged adults compared the auditory mechanisms as a function of a specific condition or pathology , usually with better performance by the healthy population-46. A study showed that regardless of the auditory threshold, the amplitude of all auditory brainstem response (ABR) peaks decreases with advancing age, with an increase in the latency of waves I and III. Another study found that between the ages 25 and 55, wave V latency increases by approximately 0.2 ms, while amplitude decreases by approximately 10%. The frequency following response (FFR) wave amplitudes were also predominantly lower in older individuals. Advancing age promotes an increase in the amplitude of the Na, Na-Pa, and Nb-Pb components of the middle latency auditory evoked potential (MLAEP), indicating a decrease in the capacity of the subcortical system to inhibit auditory responses. Changes in auditory thalamocortical processes have also been reported in adults aged 19-45 years, with decreased P1 and N1 latencies throughout adulthood. In the P300 component, there was a decrease in amplitude and an increase in latency. These changes occur at the same time as different cognitive declines, beginning around the age of 30.Changes in electrophysiological processing patterns during adulthood have also been documented. Reports of differences in the latency, amplitude, and quality of tracings at the brainstem, thalamus, and cortex levels have been described with increasing age. A decline in working memory has a negative effect on speech recognition in noise,16. In environments where speech is degraded or competed with other acoustic stimuli, there is a greater perceptual demand and overload of this higher-order function. Between the ages of 30 and 50, cognitive functions undergo continuous and monotonous decline, contributing to speech perception difficulties.Another factor to be considered is the decline in cognitive functions, which, added to the impairment of auditory neural functions, can result in speech perception difficulties,50. The harmful consequences of these changes should be the focus of future investigations in young and middle-aged adults. However, in different aspects, this population is underrepresented in the literature. The need to expand knowledge regarding CAPD assessment should be recognized. The basic principles of the choice of tests based on the population addressed and their sensitivity and specificity to identify CANS dysfunction,14,52,53 need further consideration.The auditory system and areas of association undergo anatomical and physiological changes throughout life regardless of the type of pathologyThe present review aimed to identify the behavioral tests used to assess CAP throughout adulthood, focusing on the characteristics of the target population as an interest group. Additionally, aspects related to health conditions include, but are not limited to, occupational or leisure exposure to high sound intensities, test reference parameters, and the use of complementary assessments..The present systematic review was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 checklistThe search strategy was designed to identify potentially eligible records. The keywords were selected using the PubMed indexing vocabulary, Medical Subject Headings (MeSH Terms), and Health Science Descriptors library (DeCS) in English. From this, \u201cauditory perception\u201d or \u201cauditory perception disorders\u201d or \u201cauditory processing\u201d or \u201ccentral auditory processing\u201d or \u201cauditory processing disorders\u201d or \u201ccentral auditory processing disorders\u201d were combined with adults OR aging. The databases searched were PubMed (MEDLINE), CINAHL (EBSCO), Web of Science, and SciELO, which included the period , age (18 to 64 years), humans, and study type .The selection of studies was performed by two reviewers (PPL and SZ) independently and blindly through the screening of records based on their titles and abstracts. Studies with humans selected for full reading: a) addressed the adult population aged 18 to 64 years (because some of the selected databases did not present this variable as a filter), b) performed at least one behavioral test for CAP assessment, and c) included populations without hearing loss of any type and degree. The full text was obtained from all records that met the eligibility criteria. In a disagreement between the two reviewers at any point in the selection process, a third reviewer (ACGFS) was consulted about the analysis.The analysis of the articles was performed independently (ACGFS and PPL), and the collected data were compared. Initially, a pre-test was conducted with ten randomly selected articles to verify the occurrence of inaccuracies in the data extraction. The target information was distributed according to the different topics: a) basic data: year and date of publication; b) type of study; c) sample number; d) general age group and/or by groups; e) defined condition for constituting the groups and their eligibility criteria; f) criteria for defining hearing sensitivity; g) exposure to occupational noise; h) the processing tests performed and their respective mechanisms and abilities; i) standard of normality; and j) additional investigations: electrophysiological, electroacoustic, auditory self-perception, and mental state of consciousness. was used, which assesses aspects of group equality and the presence of bias. For observational studies, the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies was used.To assess the quality of nonrandomized, case-control studies, the Newcastle-Ottawa ScaleA total of 867 records were found, of which 53 were selected for reading in full, and 24 were classified as containing the information necessary to answer the research questions, corresponding to 2.7% (24/867) of the initial sample . The chaIn the analysis of the type of study, 70.8% (17/24) were of the case-control type, and 29.2% (7/24) were of the observational type.The case-control studies (17/24) evaluated different populations, with two studies each (11.7%) covering: diabetes mellitus (studies 13 and 15), stuttering (studies 07 and 17), and CAPD (studies 22 and 23). Other conditions which each addressed a single study (5.9%) were sleep deprivation (study 3), psychosis (study 5), arterial hypertension (study 9), speech comprehension complaint (study 11), tinnitus (study 14), mild traumatic brain injury (study 16), noise exposure (study 18), dyslexia (study 19), multiple sclerosis (study 20), post-menopause (study 21), and nicotine exposure (study 24).Of the observational studies (7/24), 43.9% (3/7) investigated performance between different ages , 28.6% (2/7) covered a population with a history of exposure to noise (studies 06 and 18). The other two investigations, each 14.3% (1/7), addressed hearing lateralization (study 04) and the correlation between hearing tests (study 10).Based on the Newcastle-Ottawa Scale criteria, 82.3% (14/17) of the studies  obtained a classification higher than six, indicating the quality of the studies. For observational studies, in the analysis using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies, 100% had a score that indicated good quality .Among the conditions evaluated in the case-control studies, 94.1% (16/17) identified that the \u201ccase group\u201d presented a worse performance in one or more auditory skills in relation to the control group. In studies in which more than one auditory ability was investigated, some of them differentiated the groups: sound localization for arterial hypertension (study 9); dichotic listening, auditory closure, and temporal resolution in CAPD (studies 22 and 23); non-verbal background figure and temporal ordering in stuttering (study 17); temporal resolution in psychosis (study 5); and postmenopausal auditory closure (study 21). For the mild traumatic brain injury condition (study 16), there was no difference between the groups, representing 5.9% (1/17) of the studies., which has been documented in cases of chronic metabolic,33, vascular, demyelinating, hormonal, psychiatric, sleep, learning, and fluency disorders,29.The criteria that led to the constitution of the \u201ccase group\u201d are diverse and reflect conditions and/or characteristics that have already been described as etiological or comorbid factors for CAPD. This fact is justified because there is an etiological heterogeneity for CAPD and developmental stuttering,29,32 are conditions present since childhood, and the relationship established with CAP negatively affects these individuals throughout their lives,29,32.In all of the conditions reported above, performance in auditory skills was lower in the case group. This is particularly true for temporal and auditory closure skills, validating the importance of assisting these populations. It is necessary to emphasize that the two conditions addressed do not start in adulthood. Dyslexia,58,62. One of its harmful effects is the damage in cortical areas responsible for CAP, which manifests as a speech comprehension complaint without alteration of the auditory thresholds,59. Establishing a relationship between noise exposure and auditory closure ability is a complex task because of the influence of supramodal factors on hearing. However, regardless of this, it is known that this population performs below expectations without spontaneous improvement even after years of exposure to loud noises,58,62. Finally, it is worth noting the conditions of nicotine exposure. This was the only study that investigated the possibility of treatment based on the hypothesis that this substance would increase auditory gating function in adverse listening situations. The manipulated use of nicotine favors selective attention and can be used in young adults with acetylcholinergic deficits.Another important consideration of the conditions studied is that exposure to noise is the most exploredOnly 12.5% (3/24) of the studies  measured differences in performance on CAP behavioral tests throughout adulthood. All of them evaluated auditory closure ability with different tests, namely the Listening in Spatialized Noise-Sentences (Study 1), low-pass filtered speech test (Study 2), time-compressed speech test, and speech perception in noise (Study 8). Three studies identified that older adults performed worse than younger adults. Specifically, Study 1 identified that the performance of speech understanding in noise by adults aged 30-60 years was lower than that of adults aged 18-30 years. Study 2 found that auditory closure ability improves up to 34 years of age and declines from this age onwards. Study 8 identified that adults aged 18 to 25 years presented a better performance in the two tests applied compared to adults aged 30 to 50 years.,37,39. All of them evaluated only auditory closure ability. Regardless of the type of stimulus used, words, or phrases, the findings between the studies were similar, indicating that adults under 60 years of age performed worse than young adults. From these studies, it can be inferred that adults over 30 years of age experience disadvantages in adverse listening conditions, even if their ability to analyze acoustic cues from sound stimuli does not suffer this decline,37,39.From these results, it is evident that few studies have investigated CAP in relation to the changes inherent in the increase in age in adulthoodThis knowledge supports the importance of investigating auditory disorders at the CANS level in the healthy adult population, including all auditory skills, and comparing groups with less variation in age. This would allow an understanding of this dynamic process of increasing age, both in terms of function and time of onset.Although it is challenging to identify the point at which the decline in CAP begins in adult life, this investigation is necessary for each of the mechanisms and skills. Since timely information processing is essential for communication, deceleration related to age is well documented in the cognitive and sensory domains.A single study (4.2%) characterized the investigated population in terms of independent variables, health status, and exposure to occupational and leisure noise (study 18). Health conditions were characterized by using potentially ototoxic drugs, contact with ototoxics in general, smoking history, ear infection, and tinnitus. Other studies performed some types of characterization but did not analyze them as independent variables for the conditions investigated.From the 24 studies included, it was possible to identify more than 20 variations in the behavioral tests. Of these, the test most applied was the Random Gap Detection Test (RGDT), present in 25% (6/24) of the studies, followed by the Pitch Pattern Sequence (PPS), Digit Dichotic Tests (DDT), and Staggered Spondaic Word (SSW) used in 20.8% (5/24) of the studies. Listening in spatialized noise sentences, gap in noise, duration pattern, and masking level difference tests were performed in 16.6% (4/24) of the studies. Other tests were conducted in three or fewer studies.Among the auditory skills evaluated, auditory closure was the most investigated , followed by resolution skills  and temporal ordering . Verbal figure-ground and binaural interaction skills were assessed in 29.1% (7/24) of the studies, and non-verbal figure-ground skills in 4.1% (1/24). Only 20.8% (5/24) of the studies evaluated a single auditory ability, 12.5% (3/24) evaluated temporal resolution and auditory closure, and 4.1% evaluated binaural interaction and verbal figure-ground.,52,53, and regarding a large number of tests found, probably because of the tests\u2019 necessary characteristics. These must be validated in the language of the evaluated population, and recording parameters such as frequency, resonance, vocal modulation, articulation, and speech rate must be as adequate and natural as possible. One should also consider the choice of the speech material and intrinsic redundancies, whether due to competitive stimuli or stimulus degradation, and the location of the sound source. These characteristics make the development and choice of these tests challenging, as the attempt is to get as close as possible to the adverse listening situations present in everyday life,65.Although the tests that appeared in a greater number of articles were the RGDT, PPS, DDT, and SSW, the low redundancy tests were identified with greater diversity, and more than 10 tests were intended to assess auditory closure ability. This finding needs to be discussed, as it is the most investigated auditory skill. This is possibly because it is intrinsically related to speech comprehension (study 22) and alterations in the dichotic tests of digits and/or frequency pattern (study 23).Regarding normative values, 33.3% (8/24) indicated the use of references intended for the adult population to classify performance in the behavioral tests as adequate or altered . Two (8.3%) of the 24 identified studies aimed to determine the presence of CAPD (studies 22 and 23), for which the criteria used were alterations in one or more auditory skills. The diagnosis of CAPD was the objective of two studies; however, only one of them was undertaken as recommended by experts in the field. It is well established in the literature that the diagnostic evaluation of CAPD should be performed through different behavioral tests that are sensitive and specific to identify CANS dysfunction,14,52,53.The application and interpretation of tests according to production and/or standardization recommendations reduces the variability of the interpretations and increases clinical consensus regarding resultsComplementary tests were applied to the CAP assessment in 58.3% (14/24) of the studies. Of these 14 studies, 28.6% (4/14) applied auditory electrophysiological tests with 21.4% (3/14) including the click ABR , and 7.1% applied the FFR (study 10), MLAEP (study 21), and LLAEP (study 7). The use of otoacoustic emissions occurred in 35.7% (5/14) of the studies, varying between distortion products  and transients (studies 14 and 17). Regarding self-perception, 50% (7/24) of the studies used questionnaires to characterize the participants' perception of auditory function . The state of mental consciousness, in the form of screening and assessment, was investigated in only 21.4% (3/24) of the studies .,2. However, the present review identified that this is not a common practice in studies including adults. Self-perception questionnaires were the most applied form of complementary assessment, possibly because some questionnaires showed a significant correlation with the findings of auditory behavioral tests,2,53. Electrophysiological and electroacoustic tests have been applied in several studies. The literature recommends that these be included in CAP assessments. They allow the assessment of the functional and structural integrity of the auditory pathway and expand the understanding of the findings of behavioral tests,14,53. Finally, mental status screening was the least performed complementary assessment, which ensured that the CAP findings were not consequences of significant cognitive changes and excluded this predictor factor. Therefore, it is worth reflecting that these factors that delimit the population and help in the diagnosis should be used because of the heterogeneity of CAPD and the influence of supramodal factors on hearing in the behavioral assessment.Complementary tests can help diagnose CAPD as well as in the delimitation of this typically heterogeneous populationMost eligible studies aimed to evaluate a specific auditory mechanism and/or task in specific populations, not the diagnosis of CAPD itself. The most commonly used test was the RGDT, while auditory closure ability was the most investigated, with the greatest diversity of tests. Heterogeneity was also identified in the studied population regarding the characteristics of the case groups. Complementary assessment forms included electrophysiological and electroacoustic tests, self-perception questionnaires, and mental status screenings. . O d\u00e9ficit neurobiol\u00f3gico que acomete este sistema \u00e9 denominado como Transtorno do Processamento Auditivo Central (TPAC). Esta condi\u00e7\u00e3o pode estar relacionada ao comprometimento da conectividade neural das vias bottom-up e/ou top down, nesta \u00faltima ocorre o envolvimento dos efeitos regulat\u00f3rios de processos cognitivos ,3.O Processamento Auditivo Central (PAC) \u00e9 respons\u00e1vel pela transforma\u00e7\u00e3o, organiza\u00e7\u00e3o, decodifica\u00e7\u00e3o e codifica\u00e7\u00e3o das informa\u00e7\u00f5es ac\u00fasticas em um breve per\u00edodo de tempo, a\u00e7\u00e3o que propicia uma an\u00e1lise eficaz e eficiente dos sons verbais e n\u00e3o verbais pelo Sistema Nervoso Auditivo Central (SNAC),5, esses achados caracterizam uma popula\u00e7\u00e3o cl\u00ednica \u00fanica, mas n\u00e3o incomum,6-11. Uma das justificativas para a referida queixa \u00e9 a presen\u00e7a de TPAC, ainda que sua preval\u00eancia n\u00e3o esteja bem estabelecida para a popula\u00e7\u00e3o adulta com idade inferior a 60 anos, as estimativas variam entre 0,5%, 14% e 23%,12,13.Na popula\u00e7\u00e3o adulta com queixa de compreens\u00e3o de fala no ru\u00eddo, cerca de 10% possui sensibilidade auditiva dentro dos padr\u00f5es de normalidade,14. Um poss\u00edvel fator causal s\u00e3o as mudan\u00e7as neurais das vias auditivas, que independem de qualquer tipo de perda auditiva perif\u00e9rica, estas s\u00e3o atribu\u00eddas \u00e0 deteriora\u00e7\u00e3o ou decl\u00ednio da fun\u00e7\u00e3o ao longo da vida adulta, antes do ciclo compreendido como velhice. A diminui\u00e7\u00e3o da rede neuronal em \u00e1reas respons\u00e1veis pelo processamento da fala foi descrita em estudos post-mortem realizados por Brody. Antes mesmo dos 60 anos de idade ocorrem altera\u00e7\u00f5es anat\u00f4micas e fisiol\u00f3gicas do n\u00facleo coclear ventral, justificando a menor efici\u00eancia e acur\u00e1cia na transmiss\u00e3o de informa\u00e7\u00f5es no SNAC. A fun\u00e7\u00e3o inter-hemisf\u00e9rica permanece relativamente est\u00e1vel at\u00e9 pr\u00f3ximo aos 40 anos, com decl\u00ednio a partir desta idade. Os homens apresentam altera\u00e7\u00e3o desta fun\u00e7\u00e3o pr\u00f3ximo aos 35 anos, enquanto as mulheres mant\u00eam o desempenho est\u00e1vel at\u00e9 os 55 anos de idade. A diminui\u00e7\u00e3o do estrog\u00eanio em mulheres ap\u00f3s a menopausa pode suprimir o inibidor \u00e1cido gama-aminobut\u00edrico (GABA), contribuindo para altera\u00e7\u00f5es do PAC por volta dos 50 anos. O decl\u00ednio deste inibidor gera um comprometimento funcional, resultando em \u201cru\u00eddo neural\u201d que prejudicaria a percep\u00e7\u00e3o de fala. A diminui\u00e7\u00e3o do GABA no col\u00edculo inferior em fun\u00e7\u00e3o do aumento da idade foi descrita inicialmente em animais, resultados semelhantes foram encontrados em humanos, correlacionados ao pior desempenho no reconhecimento de fala.O TPAC decorre de diferentes fatores etiol\u00f3gicos estruturais e funcionais que acometem o SNAC ou at\u00e9 mesmo na aus\u00eancia deles-35. O enfoque do aumento da idade \u00e9 menos explorado, principalmente em adultos sem perda auditiva. Os estudos concordam que jovens adultos apresentam melhor desempenho na compreens\u00e3o de fala no ru\u00eddo que adultos mais velhos,36-39 e at\u00e9 mesmo adultos de meia idade no processamento temporal. Um estudo com a popula\u00e7\u00e3o de 50 a 70 anos identificou que a pontua\u00e7\u00e3o nas tarefas de escuta dic\u00f3tica e ordena\u00e7\u00e3o temporal foi apenas ligeiramente inferior ao esperado para jovens adultos, os autores inferem que se n\u00e3o fosse inclu\u00eddo os adultos de meia idade a diferen\u00e7a de desempenho entre jovens e idosos seria maior.O principal enfoque dos estudos com testes comportamentais do PAC em adultos jovens e de meia idade comparam os mecanismos auditivos em fun\u00e7\u00e3o de uma condi\u00e7\u00e3o ou patologia espec\u00edfica  usualmente com melhor desempenho para a popula\u00e7\u00e3o h\u00edgida-46. Um estudo demonstrou que independente do limiar auditivo, a amplitude de todos os picos do Potencial Evocado Auditivo de Tronco Encef\u00e1lico (PEATE) diminuem com o avan\u00e7o da idade, com aumento da lat\u00eancia das ondas I e III. Outro estudo encontrou que entre as idades de 25 a 55 anos a lat\u00eancia da onda V aumenta cerca de 0,2 ms, enquanto a amplitude diminui em cerca de 10%. No Frequency Following Response (FFR) as amplitudes das ondas tamb\u00e9m foram predominantemente menores no grupo de indiv\u00edduos mais velhos. O avan\u00e7o da idade promoveu aumento na amplitude das componentes Na, Na-Pa e Nb-Pb do Potencial Evocado Auditivo de M\u00e9dia Lat\u00eancia (PEAML), indicando diminui\u00e7\u00e3o da capacidade do sistema subcortical em inibir respostas auditivas. Mudan\u00e7as nos processos tal\u00e1mo-corticais auditivos tamb\u00e9m foram relatadas em adultos com idades entre 19 e 45 anos, com diminui\u00e7\u00e3o das lat\u00eancias de P1 e N1 ao longo da vida adulta. Na componente P300 h\u00e1 diminui\u00e7\u00e3o da amplitude com aumento de lat\u00eancia. Estas mudan\u00e7as ocorrem no mesmo momento que diferentes decl\u00ednios cognitivos, com in\u00edcio pr\u00f3ximo aos 30 anos de idade.As mudan\u00e7as nos padr\u00f5es do processamento eletrofisiol\u00f3gico na vida adulta tamb\u00e9m s\u00e3o documentadas. O relato de diferen\u00e7as na lat\u00eancia, na amplitude e na qualidade dos tra\u00e7ados em n\u00edvel de tronco encef\u00e1lico, t\u00e1lamo e c\u00f3rtex foram descritas com o aumento da idade. O decl\u00ednio da mem\u00f3ria de trabalho exerce efeito nocivo no reconhecimento de fala no ru\u00eddo,16. Em ambientes em que a fala est\u00e1 degradada ou em competi\u00e7\u00e3o a outros est\u00edmulos ac\u00fasticos, h\u00e1 maior demanda perceptual e sobrecarga desta fun\u00e7\u00e3o de ordem superior. Entre os 30 e 50 anos as fun\u00e7\u00f5es cognitivas entram em decl\u00ednio cont\u00ednuo e mon\u00f3tono, contribuindo para as dificuldades de percep\u00e7\u00e3o de fala.Outro fator a ser considerado \u00e9 o decl\u00ednio das fun\u00e7\u00f5es cognitivas, que somado ao comprometimento das fun\u00e7\u00f5es neurais auditivas pode resultar em dificuldades de percep\u00e7\u00e3o de fala,50. As consequ\u00eancias nocivas destas altera\u00e7\u00f5es deveriam colocar os adultos jovens e de meia idade como foco de investiga\u00e7\u00e3o, entretanto em diferentes \u00e2mbitos esta \u00e9 uma popula\u00e7\u00e3o sub-representada pela literatura. Deve-se reconhecer a necessidade de ampliar os conhecimentos quanto \u00e0 avalia\u00e7\u00e3o do TPAC. Considerando os princ\u00edpios b\u00e1sicos da escolha dos testes pautada na popula\u00e7\u00e3o abordada e na sensibilidade e especificidade destes para identificar as disfun\u00e7\u00f5es do SNAC,14,52,53.O sistema auditivo e as \u00e1reas de associa\u00e7\u00e3o sofrem altera\u00e7\u00f5es anat\u00f4micas e fisiol\u00f3gicas ao longo da vida, independente de qualquer tipo de patologiaA presente revis\u00e3o tem como objetivo identificar os testes comportamentais utilizados para a avalia\u00e7\u00e3o do PAC ao longo da vida adulta, com enfoque nas caracter\u00edsticas da popula\u00e7\u00e3o alvo enquanto grupo de interesse. Assim como, os aspectos relacionados \u00e0s condi\u00e7\u00f5es de sa\u00fade, entre eles, mas n\u00e3o somente, a exposi\u00e7\u00e3o ocupacional ou de lazer a intensidades sonoras elevadas, os par\u00e2metros de refer\u00eancia dos testes e o uso de avalia\u00e7\u00f5es complementares.Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020.A reda\u00e7\u00e3o da presente revis\u00e3o sistem\u00e1tica foi realizada de acordo com os itens dos checklists Medical Subject Headings (MeSH Terms) e na biblioteca de Descritores em Ci\u00eancia da Sa\u00fade (DeCS), no idioma ingl\u00eas. A partir disto combinou-se \u201cauditory perception\u201d or \u201cauditory perception disorders\u201d or \u201cauditory processing\u201d or \u201ccentral auditory processing\u201d or \u201cauditory processing disorders\u201d or \u201ccentral auditory processing disorders\u201d com adults OR aging. As bases de dados pesquisadas foram a Pubmed (MEDLINE), CINAHL (EBSCO), Web of Science e Scielo, os filtros selecionados foram o per\u00edodo (01 de janeiro de 2010 at\u00e9 30 julho de 2021), idade (18 a 64 anos), humanos e tipo do estudo .A estrat\u00e9gia de busca foi delineada a fim de identificar os registros potencialmente eleg\u00edveis. A sele\u00e7\u00e3o dos unitermos foi realizada a partir do vocabul\u00e1rio de indexa\u00e7\u00e3o da PubMed, A sele\u00e7\u00e3o dos estudos foi realizada por dois revisores (PPL e SZ) de forma independente e cega, por meio da triagem dos registros a partir de seu t\u00edtulo e resumo. Foram selecionados para leitura na \u00edntegra os estudos com humanos que a) abordaram a popula\u00e7\u00e3o adulta, de 18 a 64 anos , b) realizaram pelo menos um teste comportamental para avalia\u00e7\u00e3o do PAC, c) popula\u00e7\u00f5es sem perda auditiva, de qualquer tipo e grau. O texto completo foi obtido para todos os registros que atenderam aos crit\u00e9rios de elegibilidade. Na presen\u00e7a de discord\u00e2ncia entre os dois revisores em algum momento no processo de sele\u00e7\u00e3o, um terceiro (ACGFS) revisor seria consultado para a an\u00e1lise.A an\u00e1lise dos artigos foi conduzida de forma independente (ACGFS e PPL) e, posteriormente, os dados coletados foram confrontados. Inicialmente conduziu-se um pr\u00e9-teste com 10 artigos selecionados aleatoriamente, a fim de verificar a ocorr\u00eancia de imprecis\u00f5es na extra\u00e7\u00e3o dos dados. As informa\u00e7\u00f5es alvo foram distribu\u00eddas em diferentes t\u00f3picos: a) dados b\u00e1sicos: ano e data da publica\u00e7\u00e3o; b) tipo de estudo; c) n\u00famero amostral; d) faixa et\u00e1ria geral e/ou por grupos; e) condi\u00e7\u00e3o definida para constitui\u00e7\u00e3o dos grupos e seus crit\u00e9rios de elegibilidade; f) crit\u00e9rios para defini\u00e7\u00e3o da sensibilidade auditiva; g) exposi\u00e7\u00e3o ao ru\u00eddo ocupacional; h) os testes de processamento realizados e seus respectivos mecanismos e habilidades; i) padr\u00e3o de normalidade; j) investiga\u00e7\u00f5es adicionais: eletrofisiol\u00f3gica, eletroac\u00fastica, auto-percep\u00e7\u00e3o auditiva e estado de consci\u00eancia mental.Newcastle-Ottawa Scale que avalia os aspectos de equipara\u00e7\u00e3o dos grupos e presen\u00e7a de vi\u00e9s; para os estudos do tipo observacional selecionou-se o Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies.Para a avalia\u00e7\u00e3o da qualidade dos estudos do tipo caso controle, n\u00e3o randomizado, utilizou-se a A partir da busca foram encontrados 867 registros, dos quais 53 foram selecionados para leitura na \u00edntegra e 24 foram classificados como contendo as informa\u00e7\u00f5es necess\u00e1rias para responder \u00e0s perguntas de pesquisa, correspondendo a 2,7% (24/867) da amostra inicial . As caraNa an\u00e1lise quanto ao tipo de estudo, identificou-se que 70,8% (17/24) eram do tipo caso controle e 29,2% (7/24) do tipo observacional.Os estudos do tipo caso-controle (17/24) avaliaram popula\u00e7\u00f5es diversas, com determinadas condi\u00e7\u00f5es, a diabetes mellitus (estudos 13 e 15), a gagueira (estudos 7 e 17) e o TPAC (estudos 22 e 23), tiveram ocorr\u00eancia de 11,7% (2/17); as demais condi\u00e7\u00f5es foram priva\u00e7\u00e3o de sono (estudo 3), psicose (estudo 5), hipertens\u00e3o arterial (estudo 9), queixa de compreens\u00e3o de fala (estudo 11), zumbido (estudo 14), les\u00e3o cerebral traum\u00e1tica leve (estudo 16), exposi\u00e7\u00e3o ao ru\u00eddo (estudo 18), dislexia (estudo 19), esclerose m\u00faltipla (estudo 20), p\u00f3s-menopausa (estudo 21) e por fim, a exposi\u00e7\u00e3o a nicotina (estudo 24), todos com ocorr\u00eancia de 5,9% (1/17).Dos estudos observacionais (7/24), 43,9% (3/7) investigou o desempenho entre as diferentes idades , 28,6% (2/7) a popula\u00e7\u00e3o com hist\u00f3ria de exposi\u00e7\u00e3o ao ru\u00eddo (estudos 6 e 18), 14,3% (1/7) a lateraliza\u00e7\u00e3o da escuta (estudo 4) e a correla\u00e7\u00e3o entre testes auditivos (estudo 10).Newcastle-Ottawa Scale, 82,3% (14/17) dos estudos  obtiveram classifica\u00e7\u00e3o superior a seis, indicando a qualidade dos estudos. Para os estudos observacionais, na an\u00e1lise pela Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies, identificou-se que 100% apresentaram pontua\u00e7\u00e3o que indica boa qualidade .A partir dos crit\u00e9rios da Dentre as condi\u00e7\u00f5es avaliadas nos estudos de caso-controle, 94,1% (16/17) identificou que o \u201cgrupo caso\u201d apresentou pior desempenho em uma ou mais habilidades auditivas em rela\u00e7\u00e3o ao grupo controle. Nos estudos em que mais de uma habilidade auditiva foi investigada, algumas delas diferenciam os grupos, a saber: a localiza\u00e7\u00e3o sonora para hipertens\u00e3o arterial (estudo 9); a escuta dic\u00f3tica, fechamento auditivo e resolu\u00e7\u00e3o temporal no TPAC (estudo 22 e 23); figura fundo n\u00e3o verbal e ordena\u00e7\u00e3o temporal na gagueira (estudo 17); resolu\u00e7\u00e3o temporal na psicose (estudo 5); e fechamento auditivo na p\u00f3s menopausa (estudo 21). Para a condi\u00e7\u00e3o de les\u00e3o cerebral traum\u00e1tica leve (estudo 16) n\u00e3o houve diferen\u00e7a entre os grupos, representando 5,9% (1/17) dos estudos., j\u00e1 documentada nos casos de desordens metab\u00f3licas cr\u00f4nicas,33, vasculares, desmielinizantes, hormonais, psiqui\u00e1tricas, do sono, de aprendizagem e de flu\u00eancia,29.Os crit\u00e9rios que conduziram \u00e0 constitui\u00e7\u00e3o do \u201cgrupo caso\u201d s\u00e3o diversos e refletem condi\u00e7\u00f5es e/ou caracter\u00edsticas que j\u00e1 foram descritas como fatores etiol\u00f3gicos ou com\u00f3rbidas ao TPAC. Este fato se justifica uma vez que existe uma heterogeneidade etiol\u00f3gica para o TPAC e a gagueira do desenvolvimento,29,32 s\u00e3o condi\u00e7\u00f5es presentes desde a inf\u00e2ncia e a rela\u00e7\u00e3o estabelecida com o PAC impacta negativamente estes indiv\u00edduos durante toda a vida,29,32.Em todas as condi\u00e7\u00f5es relatadas acima o desempenho nas habilidades auditivas foi inferior no grupo caso, principalmente para as habilidades temporais e de fechamento auditivo, validando a import\u00e2ncia de assistir estas popula\u00e7\u00f5es. \u00c9 necess\u00e1rio ressaltar que duas das condi\u00e7\u00f5es abordadas n\u00e3o iniciam-se na vida adulta, a dislexia,58,59. Um de seus efeitos nocivos \u00e9 o dano em \u00e1reas corticais respons\u00e1veis pelo PAC, que manifesta-se como queixa de compreens\u00e3o de fala, sem altera\u00e7\u00e3o dos limiares auditivos,61. O estabelecimento de uma rela\u00e7\u00e3o entre a exposi\u00e7\u00e3o ao ru\u00eddo e a habilidade de fechamento auditivo \u00e9 uma tarefa complexa, devido \u00e0 influ\u00eancia de fatores supramodais \u00e0 audi\u00e7\u00e3o. Entretanto, independente disto, sabe-se que esta popula\u00e7\u00e3o apresenta desempenho aqu\u00e9m ao esperado, sem melhora espont\u00e2nea mesmo ap\u00f3s anos sem estar exposta a ru\u00eddos de forte intensidade,58,62. Por fim, cabe apontar a condi\u00e7\u00e3o de exposi\u00e7\u00e3o \u00e0 nicotina, este foi o \u00fanico estudo que investigou uma possibilidade de tratamento a partir da hip\u00f3tese que esta subst\u00e2ncia aumentaria a fun\u00e7\u00e3o de gating auditivo em situa\u00e7\u00f5es adversas de escuta. O uso manipulado da nicotina favorece a aten\u00e7\u00e3o seletiva e pode ser utilizada em jovens adultos com d\u00e9ficits acetilcolin\u00e9rgicos.Outra considera\u00e7\u00e3o importante sobre as condi\u00e7\u00f5es estudadas \u00e9 a exposi\u00e7\u00e3o ao ru\u00eddo ser a mais exploradaListening in Spatialized Noise-Sentences (estudo 1), Low-pass Filtered Speech Test (estudo 2), Time-Compressed Speech Test e Speech Perception in Noise (estudo 8). Os tr\u00eas estudos identificaram que adultos mais velhos apresentaram pior desempenho que os adultos mais novos. Especificamente, o estudo 1 identificou que o desempenho da compreens\u00e3o de fala no ru\u00eddo de adultos de 30 a 60 anos foi inferior ao de adultos de 18 a 30 anos. O estudo 2 verificou que a habilidade de fechamento auditivo se aprimora at\u00e9 os 34 anos e entra em decl\u00ednio a partir desta idade. O estudo 8 identificou que adultos de 18 a 25 anos apresentaram melhor desempenho nos dois testes aplicados em compara\u00e7\u00e3o aos adultos de 30 a 50 anos.Apenas 12,5% (3/24) dos estudos  mensuraram as diferen\u00e7as de desempenho em testes comportamentais do PAC ao longo da vida adulta. Todos eles avaliaram a habilidade de fechamento auditivo, com diferentes testes, sendo eles o ,37,39. Todos eles avaliaram apenas a habilidade de fechamento auditivo. Independente do tipo de est\u00edmulo empregado, palavras ou frases, os achados entre os estudos foram semelhantes, indicando que adultos com menos de 60 anos apresentam desempenho inferior ao de jovens adultos. A partir destes estudos pode-se inferir que adultos com mais de 30 anos experienciam desvantagens em condi\u00e7\u00f5es adversas de escuta, mesmo que a capacidade de an\u00e1lise de pistas ac\u00fasticas dos est\u00edmulos sonoros n\u00e3o sofra este decl\u00ednio,37,39.A partir destes resultados evidencia-se que poucos estudos dedicam-se \u00e0 investiga\u00e7\u00e3o do PAC em rela\u00e7\u00e3o \u00e0s mudan\u00e7as inerentes ao aumento da idade na vida adultaEste conhecimento sustenta a import\u00e2ncia da investiga\u00e7\u00e3o dos dist\u00farbios auditivos em n\u00edvel do SNAC da popula\u00e7\u00e3o adulta saud\u00e1vel, incluindo todas as habilidades auditivas e comparando grupos com menor varia\u00e7\u00e3o de idade. Isto permitiria a compreens\u00e3o deste processo din\u00e2mico de aumento da idade tanto em fun\u00e7\u00e3o, quanto em tempo de in\u00edcio.Embora seja um desafio identificar em que momento da vida adulta inicia-se o decl\u00ednio do PAC, para cada um dos mecanismos e habilidades, esta investiga\u00e7\u00e3o \u00e9 necess\u00e1ria, uma vez que processamento de informa\u00e7\u00f5es em tempo h\u00e1bil \u00e9 essencial para comunica\u00e7\u00e3o e a desacelera\u00e7\u00e3o relacionada \u00e0 idade est\u00e1 bem documentada nos dom\u00ednios cognitivos e sensoriais.Um \u00fanico estudo  caracterizou a popula\u00e7\u00e3o investigada em fun\u00e7\u00e3o de vari\u00e1veis independentes, a condi\u00e7\u00e3o de sa\u00fade e a exposi\u00e7\u00e3o ao ru\u00eddo ocupacional e de lazer (estudo 18). A condi\u00e7\u00e3o de sa\u00fade foi caracterizada quanto ao uso de medicamentos potencialmente otot\u00f3xicos, contato com otot\u00f3xicos no geral, hist\u00f3ria de tabagismo, infec\u00e7\u00e3o de ouvido e zumbido. Outros estudos fizeram algum tipo de caracteriza\u00e7\u00e3o, mas n\u00e3o as analisaram como vari\u00e1vel independente para a condi\u00e7\u00e3o investigada.Random Gap Detection Test (RGDT) presente em 25% (6/24) dos estudos, seguido dos Testes Padr\u00e3o de Frequ\u00eancia (TPF), Dic\u00f3tico de D\u00edgitos (TDD) e Staggered Spondaic Word (SSW) em 20,8% (5/24) dos estudos. Os testes Listening in Spatialized Noise-Sentences, Gap in Noise, Padr\u00e3o de Dura\u00e7\u00e3o e Masking Level Difference foram realizados em 16,6% (4/24) dos estudos. Os outros testes foram aplicados em tr\u00eas ou menos estudos.A partir dos 24 estudos inclu\u00eddos foi poss\u00edvel identificar mais de 20 varia\u00e7\u00f5es de testes comportamentais. Destes o mais aplicado foi o Dentre as habilidades auditivas avaliadas, a de fechamento auditivo foi a mais investigada , seguida das habilidades de resolu\u00e7\u00e3o  e ordena\u00e7\u00e3o temporal . As habilidades de figura-fundo verbal e intera\u00e7\u00e3o binaural foram avaliadas em 29,1% (7/24) dos estudos e a de figura-fundo n\u00e3o verbal em 4,1% (1/24). Apenas 20,8% (5/24) dos estudos avaliaram exclusivamente uma \u00fanica habilidade auditiva, 12,5% (3/24) resolu\u00e7\u00e3o temporal e fechamento auditivo e 4,1% intera\u00e7\u00e3o binaural e figura-fundo verbal.,52,53, e quanto ao grande n\u00famero de testes encontrados, provavelmente pelas caracter\u00edsticas que estes devem possuir. Estes devem ser validados no idioma da popula\u00e7\u00e3o avaliada e os par\u00e2metros de grava\u00e7\u00e3o como frequ\u00eancia, resson\u00e2ncia e modula\u00e7\u00e3o vocal, articula\u00e7\u00e3o e velocidade de fala devem ser o mais adequados e naturais poss\u00edveis. Deve-se considerar tamb\u00e9m a escolha do material de fala e das redund\u00e2ncias intr\u00ednsecas, seja por est\u00edmulo competitivo ou pela degrada\u00e7\u00e3o do est\u00edmulo, e da localiza\u00e7\u00e3o da fonte sonora. Estas caracter\u00edsticas tornam o desenvolvimento e a escolha destes testes um desafio, pois a tentativa \u00e9 que se aproximem ao m\u00e1ximo das situa\u00e7\u00f5es adversas de escuta presentes no dia-a-dia,65.Embora os testes que constam em um maior n\u00famero de artigos sejam o RGDT, TPF, TDD e SSW, os testes de baixa redund\u00e2ncia foram identificados em maior diversidade, mais de 10 testes eram destinados \u00e0 avalia\u00e7\u00e3o da habilidade de fechamento auditivo. Este achado deve ser discutido quanto a esta ser a habilidade auditiva mais investigada, possivelmente por ser intrinsecamente relacionada \u00e0 compreens\u00e3o de fala (estudo 22) e altera\u00e7\u00e3o no testes dic\u00f3tico de d\u00edgitos e/ou padr\u00e3o de frequ\u00eancia (estudo 23).Em rela\u00e7\u00e3o a utiliza\u00e7\u00e3o de valores normativos, 33,3% (8/24) indicaram o uso de refer\u00eancias, destinadas \u00e0 popula\u00e7\u00e3o adulta, para classificar o desempenho nos testes comportamentais como adequado ou alterado  . Dois dos 24 estudos identificados  tiveram como objetivo determinar a presen\u00e7a de TPAC (estudos 22 e 23), para isto os crit\u00e9rios utilizados foram a altera\u00e7\u00e3o em uma ou mais habilidades auditivas. O diagn\u00f3stico do TPAC foi objetivo de dois estudos, entretanto apenas um deles o fez conforme recomenda\u00e7\u00e3o de especialistas da \u00e1rea. \u00c9 bem estabelecido na literatura que a avalia\u00e7\u00e3o diagn\u00f3stica do TPAC deve ser realizada por meio de diferentes testes comportamentais que sejam sens\u00edveis e espec\u00edficos para identificar disfun\u00e7\u00f5es no SNAC,14,52,53.A aplica\u00e7\u00e3o e interpreta\u00e7\u00e3o dos testes segundo as recomenda\u00e7\u00f5es de produ\u00e7\u00e3o e/ou padroniza\u00e7\u00e3o reduzem a variabilidade de interpreta\u00e7\u00f5es e aumentam o consenso cl\u00ednico quanto aos resultadosA aplica\u00e7\u00e3o de testes complementares a avalia\u00e7\u00e3o do PAC foi realizada em 58,3% (14/24) dos estudos. Destes 14 estudos, 28,6% (4/14) aplicaram testes eletrofisiol\u00f3gicos auditivos, sendo 75% (3/4) o PEATE clique  e 25% (1/4) o FFR (estudo 10), o PEAML (estudo 21) e o PEALL (estudo 7). O uso de emiss\u00f5es otoac\u00fasticas ocorreu em 35,7% (5/14) dos estudos, variando entre produto de distor\u00e7\u00e3o  e transiente (estudos 14 e 17). Quanto \u00e0 autopercep\u00e7\u00e3o, 50% (7/24) dos estudos aplicaram question\u00e1rios buscando caracterizar a percep\u00e7\u00e3o dos participantes sobre a fun\u00e7\u00e3o auditiva . O estado de consci\u00eancia mental, em forma de rastreio e avalia\u00e7\u00e3o, foi investigado em apenas 21,4% (3/24) dos estudos .,2, entretanto a presente revis\u00e3o identificou que em estudos com adultos esta n\u00e3o \u00e9 uma pr\u00e1tica comum. Os question\u00e1rios de autopercep\u00e7\u00e3o foram a forma de avalia\u00e7\u00e3o complementar mais aplicada, possivelmente porque alguns question\u00e1rios apresentaram correla\u00e7\u00e3o significativa com os achados dos testes comportamentais auditivos,2,53. Os testes objetivos, eletrofisiol\u00f3gicos e eletroac\u00fasticos, foram aplicados em poucos estudos. A literatura preconiza que estes sejam inclu\u00eddos na avalia\u00e7\u00e3o do PAC, uma vez que viabilizam a avalia\u00e7\u00e3o da integridade funcional e estrutural da via auditiva e ampliam a compreens\u00e3o dos achados dos testes comportamentais,14,53. Por fim, o rastreio do estado mental foi a avalia\u00e7\u00e3o complementar menos realizada, esta garante que os achados referentes ao PAC n\u00e3o s\u00e3o consequ\u00eancias de altera\u00e7\u00f5es cognitivas significativas, excluindo este fator preditor. A partir disto, cabe a reflex\u00e3o de que estes fatores que delimitam a popula\u00e7\u00e3o e auxiliam no diagn\u00f3stico devem ser empregados devido a heterogeneidade do TPAC e a influ\u00eancia de fatores supramodais na audi\u00e7\u00e3o na avalia\u00e7\u00e3o comportamental.Os testes aplicados como complementares podem auxiliar no diagn\u00f3stico do TPAC, bem como, na delimita\u00e7\u00e3o desta popula\u00e7\u00e3o tipicamente heterog\u00eaneaRGDT, enquanto que a habilidade de fechamento auditivo foi a mais investigada, com maior diversidade de testes. Tamb\u00e9m foi identificada uma heterogeneidade na popula\u00e7\u00e3o estudada, quanto \u00e0 caracter\u00edstica para forma\u00e7\u00e3o dos grupos caso. As formas de avalia\u00e7\u00e3o complementar foram testes eletrofisiol\u00f3gicos, eletroac\u00fasticos, question\u00e1rios de autopercep\u00e7\u00e3o e rastreio do estado mental.A maior parte dos estudos eleg\u00edveis objetivou a avalia\u00e7\u00e3o de determinado mecanismo e/ou tarefa auditiva em popula\u00e7\u00f5es espec\u00edficas, e n\u00e3o o diagn\u00f3stico do TPAC em si. O teste mais utilizado foi o"}
+{"text": "To map global scientific production on homoparenting in the field of collective health or public health.In terms of methodological procedures, a scoping review was carried out, guided by the following question: What are the aspects addressed in global scientific production regarding homoparental families in the field of collective or public health? The searches were carried out in seven sources of scientific literature, including 58 studies, involving scientific articles and dissertations. The analytical treatment given to the studies, most of which were qualitative, followed the content analysis technique in the thematic modality.The results indicate that the perceptions of homosexuals and professionals about the care provided and health services in general was the topic addressed by the largest number of studies (n = 31), followed by heteronormative context of health services (n = 26); disclosure of sexual orientation (n = 20); fertilization (n = 14); educational information and actions (n = 5).Although the issue of same-sex parenthood has been discussed in some health sectors, there is awareness that it is necessary to rely on a consolidated basis through numerous studies when discussing this issue. It is concluded that, among other aspects, the scope of this review is not sufficiently problematized within the scope of health professionals\u2019 training and performance. The family has been one of the central focuses in several instances of public health. As an example of this, the Family Health Strategy stands out, one of the models for organizing services in the Brazilian Unified Health System (SUS). In this and other instances, the commonly used family reference is the traditional model, which originates from the union between a cis man and a cis woman. This union establishes, in the contexts, texts and relationships of the health area in general, the hegemony of heterosexual parenting, disregarding homoparenting or same-sex parenting, which is the theme of this article. . Considering the different types of relationships, gay and lesbian families can include lovers, co-parenting, adopted children, children from a previous relationship, and children conceived through alternative insemination  .In order to discuss same-sex parenting, it is necessary\u2014based on anthropological studies\u2014to take into account that the types of relationships considered as family can be seen in different ways within their own societies, not being limited to genealogically defined relationships Although the issue of same-sex parenting has been discussed in some health sectors, the need to have a consolidated base with numerous studies when problematizing this issue is well-known. One of the dimensions to be covered is the formation of an analytical framework, considering the specialized literature, that can serve as a reference for incorporating the discussion about the object of study both in the logics and in the scenarios of collective health practices. notes that:Zambrano  .Homo-parenthood is a neologism, created in 1997 by the Association of parents and future gay and lesbian parents (APGL), in Paris, nominating a situation in which at least one adult refers to themselves as homosexual who is or wishes to be a father or mother of at least one child.   (p. 3592), based on Zambrano  , observe that homo-parenthood is constituted from at least four situations:Ribeiro et al.  .[\u2026] by children born in a previous heterosexual relationship, by legal or informal adoption, by the use of new reproductive technologies that enable the birth of biological children, and by coparenting, in which care for the child is exercised in a joint and egalitarian way by partners  .With the aim of placing same-sex parenting in the context of the changes that have been taking place in the family institution, it is observed that the patriarchal family has been questioned since the end of the last millennium. In recent years, the dissociation between heterosexuality, patriarchy and reproduction of the species reinforced the gay and lesbian movement\u2019s struggle to have legal recognition of getting married, starting a family, and having children  .In line with this claim, the exclusivity of having a cis man and a cis woman to form what is called a family is questioned, so that if the bond of affection is considered central to the family institution, the union between people of the same sex can be considered as family ANDsa\u00fade,\u201d found only two articles in the Scientific Electronic Library Online (SciELO) and four in thePortal Regional da Biblioteca Virtual em Sa\u00fade(BVS).Although the discussion of the subject is not new, it is inferred that\u2014in the health area in general in Brazil\u2014publications on same-sex parenting are scarce. A concise survey, carried out on July 7, 2021, with the expressions \u201chomoparentalidadeClearly, these quick surveys do not represent the state of the art of the subject within the scope of Brazilian scientific production, requiring more in-depth searches, in a systematic way, with a wide range of databases.In this sense, a scoping review is proposed to be carried out, with the aim of mapping global scientific production on homo-parenthood in the field of collective health or public health. , refers to a field integrated by knowledge, practice, and ideology, differentiating itself from both public health and the hegemonic medical model and articulating science and practices for the formulation and conduct of consequential policies. Thus, the collective is not just an abstract population or population segment, and actions aimed at the collective are not exclusive to the State. In the international panorama, in general, the term collective health does not appear, but rather public health, which encompasses measures designed and adopted mainly by the State to ensure the population\u2019s physical, mental, and social well-being. In this sense, the scope of this review is analyzed in the realm of collective health or public health so that production is not reduced to the Latin American sphere.In Brazil and in some Latin American countries, there is a difference between collective health and public health. The former, according to Paim  . For the reporting of this review, the recommendations of the PRISMA Extension for Scoping Reviews  tool were used. A research protocol has been registered in the Open Science Framework (OSF)  .We carried out a scoping review based on the methodological framework of the Joanna Briggs Institute The question \u201cWhat are the aspects addressed in global scientific production regarding homoparental families in the field of collective or public health?\u201d was constructed with the help of the acronym PCC . We decided to work with an open and broad question to obtain a greater diversity of scientific production on the subject.The inclusion criteria were primary and secondary studies, including documents, reports, dissertations, or theses, available in English, Portuguese or Spanish, which addressed issues related to policies, health programs and access to services for cisgender homoparental families in the context of public health or public.Studies that referred to contexts other than collective health, that analyzed configurations of non-cisgender same-sex families, or that were in languages other than those mentioned above, were excluded.Literatura Latino-Americana e do Caribe em Ci\u00eancias da Sa\u00fadein the Virtual Health Library (VHL/LILACS), SciELO, Scopus, Web of Science, Dimensions (July 2022), andBiblioteca Digital Brasileira de Teses e Disserta\u00e7\u00f5es(BDTD) (September 2022). Based on the combination of keywords structured from the acronym PCC, the MeSH terms  were used in PubMed and DeCS  in the VHL, adapting them to the other databases. The search strategies with the keywords used in each database are available in the protocol of this review registered in OSF  .The construction of strategies and the searches were carried out by a librarian in the following data sources: PubMed/MEDLINE, . Differences in judgment were resolved by consensus or by a third reviewer. Dissertations and theses were selected manually by reading the abstracts. Eligible studies were read in full by two reviewers, in a complementary manner, and validated by a third reviewer. The reference lists of included studies were checked to include other studies that might not have been retrieved in database searches.The studies retrieved from the information sources went through a selection process based on pre-defined inclusion and exclusion criteria. After excluding duplicates, two reviewers independently carried out the screening based on reading titles and abstracts, using the bibliographic manager Rayyan QCRI A spreadsheet for extraction was prepared in Excel (Microsoft), containing the following information: (1) Author and year of publication, (2) Purpose, (3) Study design, (4) Population analyzed, (5) Number of participants, ( 6) Age of participants, (7) Sex/gender, (8) Race/color, (9) Family characteristics, (10) Country where the study was carried out, (11) Place where the study was carried out, (12) Focus of the approach and central theme, (13) Outcomes or thematic categories, (14) Results, (15) Limitations, (16) Gaps, (17) Conclusion, (18) Financing, (19) Conflict of interest, and (20) Institution of affiliation of the author. The first extractions were carried out independently by three reviewers, until homogeneity of the process was achieved. Subsequently, the data were extracted by two reviewers, in a complementary manner, and validated by a third reviewer. from the thematic modality described by Bardin  . The results are presented descriptively and through tables.The extracted data was explored to present the state of the art regarding homoparental families in the cisgender population, seeking to report their needs and experiences related to the area of collective health. The results of the studies, mostly qualitative, were analyzed based on the content analysis technique adapted by Gomes  .The methodological quality of the included studies was not assessed because it was not part of the inclusion criteria and is considered optional in scoping reviews  .The searches retrieved 1,350 records and, after excluding duplicates, 725 records were screened by titles and abstracts. Forty eligible reports were read in full, 24 of which were included. Of ten non-duplicated dissertations and theses, two were included. Additionally, 32 reports were selected from the reference lists of the included studies. Therefore, a total of 58 studies were included and analyzed in this scoping review . The si , 40 were classified as primary studies (including two Brazilian master\u2019s theses)  , 2 as essays, and 16 as reviews, whose characteristics are briefly described below.Of 58 reports These studies were carried out in Australia (n = 10), Sweden (n = 8), Brazil (n = 4), United States of America (n = 4), Canada (n = 3), Norway (n = 3), United Kingdom (n = 3), Scotland (n = 1), Finland (n = 1), Italy (n = 1), New Zealand (n = 1), and several communities in the Pacific Northwest (n = 1).Most studies involved lesbian women (n = 32), gay men (n = 9), and healthcare professionals (n = 7). When provided, participants\u2019 age ranged from 20 to 59 years old, with a predominance of white people.The main characteristics of the 2 essays and 16 reviews  are shown inWhen analyzing the collection of selected sources, we observed themes that were implicit or explicit in the contents of these sources . Such tThe data extracted from the studies were grouped into five themes, presented together with their respective subthemes inThe scientific production in the health sector in general regarding homo-parenthood appears to be an issue whose approach requires the understanding of socio-structural aspects that go beyond this field of knowledge. At least two of these aspects can be highlighted. The first of these concerns heteronormativity, which, in a hegemonic way, means that\u2014consciously or unconsciously\u2014the first reference we have to family or parenting involves the union of a cis man with a cis woman. The existence of a homosexual couple means that this heterosexual norm is either reaffirmed to disqualify such a couple or deconstructed to accept homoaffective unions and parents. In this sense, it appears that much of the reviewed literature, before dealing with specific objects related to homoparenting, mentions the heteronormative context both as an explanatory model for the non-existence of specific health actions for lesbian or gay couples and as a dimension to be questioned or relativized as a unique reference to demand differentiated attention for these couples.Another aspect that emerges in the reviewed scientific production, which covers issues that go beyond the health area in dealing with same-sex parenthood, refers to the legislation, or lack thereof, that ensures or prohibits not only the union of same-sex persons but also the desire of these persons to have children. Such aspects, directly or indirectly, are associated with the heteronormative context. We observed that, regarding legal aspects, there is great variability between countries and even within the states that make up a country. The absence of legal provisions, their incompleteness and/or dubiousness directly reflect on the way couples are assisted or are unable to access care.Disclosing sexual orientation, both from the perspective of homosexual couples and from health professionals, emerges in the literature as something controversial. On the one hand, disclosure can contribute to specific health actions aimed at such couples. On the other hand, according to some studies, in the perception of lesbians and gays, disclosure can result in discrimination, invasive questioning, prejudice and even symbolic violence. The fear of disclosing homosexuality, in a certain way, can be linked to the heteronormative context and legal issues.Scientific production on fertilization involves issues related to legislation, rights, access difficulties, absence or insufficient information, exclusion of non-biological homosexual mothers or fathers, prenatal care, childbirth, postpartum, and methods. The literature that deals with this topic focuses mainly on lesbians. In the balance made in the results of the studies, difficulties in accessing fertilization technology predominate.Perceptions regarding attention to homoparenting, on the part of both homosexual couples and health professionals, are generally linked to the existence of dissatisfaction with the care received and negative attitudes on the part of those who should provide adequate care.Regarding information and educational actions, the literature reports some positive experiences. However, these experiences compete with the perception that information is insufficient. Still in educational terms, there is an issue that crosses all the themes identified, explicitly or implicitly in the results: the lack of health professionals\u2019 preparation to deal not only with homo-parenthood, but also with homosexuality.The revised collection constitutes a mosaic of themes that, directly or indirectly, are related to same-sex parenting. Each one of them, either by what is explicit or by inference of what is implicit, can provide principles for the field of collective health. In this sense, the results of this review are important, since they provide elements for, among other aspects, the organization of health services, the implementation of specific actions within the scope of promoting family health, and the adequate training of professionals to address gay and lesbian families.It is also observed that the mapping obtained regarding the scope of the study is a starting point to expand the discussion about the central theme. This expansion may be more successful to the extent that, anchored in socio-anthropological references, it can problematize issues focused on different family arrangements and other conceptions of kinship that are not limited to consanguinity.Finally, it is highlighted that, despite the vast collection identified, a limitation that can be pointed out for this review is language filtering, choosing only sources in Portuguese, Spanish, and English. Particularly noteworthy is the lack of studies in the French language, which gave rise to the term homo-parenthood. In addition to this, the bases chosen for the research may also have influenced the lack of studies in French.Among the main conclusions it is worth highlighting that, although the national literature on homoparenting in the health sector is still timid, the international discussion seems to be relatively expanding. In terms of evidence, we can highlight that the scope of this review is not sufficiently problematized in health professionals\u2019 training and performance; and quantitative studies are smaller in number compared to those of a qualitative nature. This, although it brings us the specificities of the central theme, does not allow us to understand the extent of the problem highlighted in most studies.Mapping the literature on the subject also revealed some gaps in the scientific production reviewed. In the context of collective health, it is worth highlighting the lack of studies focused on policies and programs and the absence of discussions on the health of children and adolescents from homo-parental families. A fam\u00edlia tem sido um dos focos centrais em diversas inst\u00e2ncias da sa\u00fade coletiva. A exemplo disso, destaca-se a Estrat\u00e9gia da Sa\u00fade da Fam\u00edlia, um dos modelos de organiza\u00e7\u00e3o dos servi\u00e7os no Sistema \u00danico de Sa\u00fade (SUS). Nessa e em outras inst\u00e2ncias, a refer\u00eancia de fam\u00edlia comumente utilizada \u00e9 o modelo tradicional, que se origina da uni\u00e3o entre um homem e uma mulher cis. Essa uni\u00e3o institui, nos contextos, nos textos e nas rela\u00e7\u00f5es da \u00e1rea da sa\u00fade em geral, a hegemonia da parentalidade heterossexual, desconsiderando a homoparentalidade ou parentalidade homoafetiva, que \u00e9 o tema deste artigo.. Levando em conta os diferentes tipos de relacionamentos, as fam\u00edlias de gays e l\u00e9sbicas podem abranger amantes, coparentalidade, filhos adotivos, filhos de relacionamento anterior e filhos concebidos por meio de insemina\u00e7\u00e3o alternativa.Para que se possa discutir a homoparentalidade, faz-se necess\u00e1rio \u2013 com base em estudos antropol\u00f3gicos \u2013 levar em conta que os tipos de relacionamentos tidos como fam\u00edlia podem ser vistos de formas diferenciadas dentro de suas pr\u00f3prias sociedades, n\u00e3o se limitando a relacionamentos definidos genealogicamenteEmbora a quest\u00e3o da homoparentalidade venha sendo discutida em alguns setores da sa\u00fade, h\u00e1 ci\u00eancia de que \u00e9 preciso contar com uma base consolidada por meio de in\u00fameros estudos ao se problematizar essa tem\u00e1tica. Uma das dimens\u00f5es a serem contempladas \u00e9 formar um quadro anal\u00edtico, \u00e0 luz da literatura especializada, que possa servir de refer\u00eancia para a inser\u00e7\u00e3o da discuss\u00e3o acerca do objeto de estudo tanto nas l\u00f3gicas quanto nos cen\u00e1rios das pr\u00e1ticas da sa\u00fade coletiva.observa que:Zambrano.Homoparentalidade \u00e9 um neologismo criado em 1997 pela Associa\u00e7\u00e3o de Pais e Futuros Pais Gays e L\u00e9sbicas (APGL), em Paris, nomeando a situa\u00e7\u00e3o na qual pelo menos um adulto que se autodesigna homossexual \u00e9 (ou pretende ser) pai ou m\u00e3e de, no m\u00ednimo, uma crian\u00e7a (p. 127)(p. 3592), com base em Zambrano, observam que a homoparentalidade se constitui a partir de, pelo menos, quatro situa\u00e7\u00f5es:Ribeiro et al.(p. 3592).[...] por filhos havidos em uma liga\u00e7\u00e3o heterossexual anterior, pela ado\u00e7\u00e3o legal ou informal, atrav\u00e9s de usos das novas tecnologias reprodutivas que possibilitam o nascimento de filhos biol\u00f3gicos, e pela coparentalidade, na qual os cuidados com a crian\u00e7a s\u00e3o exercidos de forma conjunta e igualit\u00e1ria pelos parceiros.Com o intuito de situar a homoparentalidade no contexto das mudan\u00e7as que v\u00eam ocorrendo na institui\u00e7\u00e3o fam\u00edlia, observa-se que a fam\u00edlia patriarcal vem sendo posta em quest\u00e3o desde o final do \u00faltimo mil\u00eanio. A dissocia\u00e7\u00e3o entre heterossexualidade, patriarcalismo e reprodu\u00e7\u00e3o da esp\u00e9cie refor\u00e7ou a luta do movimento gay e l\u00e9sbico nos \u00faltimos anos, para ter o reconhecimento legal de casar-se, formar fam\u00edlia e ter filhos.Em conson\u00e2ncia com esse pleito, a exclusividade de haver um homem e uma mulher cis para constituir o que se denomina fam\u00edlia \u00e9 questionada, de modo que, se o v\u00ednculo da afetividade for considerado como central da institui\u00e7\u00e3o familiar, a uni\u00e3o entre pessoas do mesmo sexo pode ser considerada como fam\u00edliaANDsa\u00fade\u201d, localizou apenas dois artigos naScientific Electronic Library Online(SciELO) e quatro no Portal Regional da Biblioteca Virtual em Sa\u00fade (BVS).Apesar de a discuss\u00e3o do assunto n\u00e3o ser nova, infere-se que \u2013 na \u00e1rea da sa\u00fade em geral do Brasil \u2013 as publica\u00e7\u00f5es sobre homoparentalidade s\u00e3o escassas. Um levantamento conciso, realizado no dia 7 de julho de 2021, com as express\u00f5es \u201chomoparentalidadeEvidentemente que esses r\u00e1pidos levantamentos n\u00e3o representam o estado da arte da tem\u00e1tica no \u00e2mbito da produ\u00e7\u00e3o cient\u00edfica brasileira, sendo necess\u00e1rias buscas mais aprofundadas, de forma sistem\u00e1tica, com uma grande abrang\u00eancia de bases de dados.Nesse sentido, prop\u00f5e-se realizar uma revis\u00e3o de escopo, com o objetivo de mapear a produ\u00e7\u00e3o cient\u00edfica global sobre homoparentalidade no campo da sa\u00fade coletiva ou sa\u00fade p\u00fablica., \u00e9 um campo integrado por saber, pr\u00e1tica e ideologia, diferenciando-se tanto da sa\u00fade p\u00fablica quanto do modelo m\u00e9dico hegem\u00f4nico e articulando a ci\u00eancia e pr\u00e1ticas para a formula\u00e7\u00e3o e condu\u00e7\u00e3o de pol\u00edticas consequentes. Assim, o coletivo n\u00e3o \u00e9 apenas uma popula\u00e7\u00e3o ou segmento populacional abstrato, e as a\u00e7\u00f5es voltadas para o coletivo n\u00e3o s\u00e3o de exclusividade do Estado. No panorama internacional, em geral, n\u00e3o aparece o termo sa\u00fade coletiva, e sim sa\u00fade p\u00fablica, que abrange medidas concebidas e adotadas principalmente pelo Estado para assegurar o bem-estar f\u00edsico, mental e social da popula\u00e7\u00e3o. Nesse sentido, analisa-se o escopo desta revis\u00e3o no \u00e2mbito da sa\u00fade coletiva ou da sa\u00fade p\u00fablica para que n\u00e3o se reduza a produ\u00e7\u00e3o ao \u00e2mbito latino-americano.No Brasil e em alguns pa\u00edses latino-americanos, h\u00e1 uma diferen\u00e7a entre sa\u00fade coletiva e sa\u00fade p\u00fablica. A primeira express\u00e3o, segundo PaimJoanna Briggs Institute. Para o relato desta revis\u00e3o foram utilizadas as recomenda\u00e7\u00f5es da ferramentaPRISMA Extension for Scoping Reviews. Um protocolo de pesquisa foi registrado naOpen Science Framework(OSF).Realizamos uma revis\u00e3o de escopo com base no referencial metodol\u00f3gico doA pergunta \u201cQuais s\u00e3o os aspectos abordados na produ\u00e7\u00e3o cient\u00edfica global a respeito de fam\u00edlias homoparentais no campo da sa\u00fade coletiva ou p\u00fablica?\u201d foi constru\u00edda com aux\u00edlio do acr\u00f4nimo PCC . Optou-se por trabalhar com uma pergunta aberta e ampla para obter uma maior diversidade da produ\u00e7\u00e3o cient\u00edfica acerca do assunto.Os crit\u00e9rios de inclus\u00e3o foram estudos prim\u00e1rios e secund\u00e1rios, entre documentos, relat\u00f3rios, disserta\u00e7\u00f5es ou teses, dispon\u00edveis em ingl\u00eas, portugu\u00eas ou espanhol, que abordaram quest\u00f5es relacionadas a pol\u00edticas, programas de sa\u00fade e acesso a servi\u00e7os para fam\u00edlias homoparentais cisg\u00eaneras no contexto da sa\u00fade coletiva ou p\u00fablica.Foram exclu\u00eddos estudos que se referiam a outros contextos que n\u00e3o a sa\u00fade coletiva, que analisaram configura\u00e7\u00f5es de fam\u00edlias homoparentais n\u00e3o cisg\u00eaneras ou que estavam em idiomas diferentes dos citados acima.Web of Science, Dimensions(julho de 2022) e Biblioteca Digital Brasileira de Teses e Disserta\u00e7\u00f5es (BDTD) (setembro de 2022). Com base na combina\u00e7\u00e3o de palavras-chave estruturadas a partir do acr\u00f4nimo PCC, foram utilizados os termos MeSH  no PubMed e DeCS (Descritores em Ci\u00eancias da Sa\u00fade) na BVS, adaptando-os para as demais bases de dados. As estrat\u00e9gias de busca com os descritores utilizados em cada base est\u00e3o dispon\u00edveis no protocolo desta revis\u00e3o registrado em OSF.A constru\u00e7\u00e3o das estrat\u00e9gias e as buscas foram realizadas por um bibliotec\u00e1rio nas seguintes fontes de dados: PubMed/MEDLINE, Literatura Latino-Americana e do Caribe em Ci\u00eancias da Sa\u00fade na Biblioteca Virtual em Sa\u00fade (BVS/LILACS), SciELO, Scopus,Rayyan QCRI. As diverg\u00eancias de julgamento foram resolvidas por consenso ou por um terceiro revisor. A sele\u00e7\u00e3o de disserta\u00e7\u00f5es e teses foi realizada manualmente por meio da leitura dos resumos. Os estudos eleg\u00edveis foram lidos na \u00edntegra por dois revisores, de modo complementar, e validados por um terceiro revisor. As listas de refer\u00eancias dos estudos inclu\u00eddos foram verificadas para inclus\u00e3o de outros estudos eventualmente n\u00e3o recuperados nas buscas em bases de dados.Os estudos recuperados das fontes de informa\u00e7\u00e3o passaram por um processo de sele\u00e7\u00e3o com base nos crit\u00e9rios de inclus\u00e3o e exclus\u00e3o pr\u00e9-definidos. Ap\u00f3s a exclus\u00e3o de duplicatas, dois revisores realizaram, de modo independente, a triagem com base na leitura de t\u00edtulos e resumos, utilizando o gerenciador bibliogr\u00e1ficosoftwareExcel, contendo as seguintes informa\u00e7\u00f5es: (1) Autor e ano de publica\u00e7\u00e3o, (2) Objetivo, (3) Delineamento do estudo, (4) Popula\u00e7\u00e3o analisada, (5) N\u00famero de participantes, (6) Idade dos participantes, (7) Sexo/g\u00eanero, (8) Ra\u00e7a/cor, (9) Caracter\u00edsticas da fam\u00edlia, (10) Pa\u00eds de realiza\u00e7\u00e3o do estudo, (11) Local de realiza\u00e7\u00e3o do estudo, (12) Foco da abordagem e tema central, (13) Desfechos ou categorias tem\u00e1ticas, (14) Resultados, (15) Limita\u00e7\u00f5es, (16) Lacunas, (17) Conclus\u00e3o, (18) Financiamento, (19) Conflito de interesse e (20) Institui\u00e7\u00e3o de filia\u00e7\u00e3o do(a) autor(a). As primeiras extra\u00e7\u00f5es foram realizadas, de modo independente, por tr\u00eas revisores, at\u00e9 se chegar a uma homogeneidade do processo. Posteriormente, os dados foram extra\u00eddos por dois revisores, de modo complementar, e validados por um terceiro revisor.Uma planilha para extra\u00e7\u00e3o foi elaborada noda modalidade tem\u00e1tica descrita por Bardin. Os resultados s\u00e3o apresentados de forma descritiva e por meio de quadros.Os dados extra\u00eddos foram explorados para apresentar o estado da arte acerca de fam\u00edlias homoparentais na popula\u00e7\u00e3o cisg\u00eanera, buscando relatar suas necessidades e experi\u00eancias relacionadas \u00e0 \u00e1rea de sa\u00fade coletiva. Os resultados dos estudos, em sua maioria qualitativos, foram analisados \u00e0 luz da t\u00e9cnica de an\u00e1lise de conte\u00fado adaptada por Gomes.N\u00e3o se realizou avalia\u00e7\u00e3o da qualidade metodol\u00f3gica dos estudos inclu\u00eddos, uma vez que ela n\u00e3o fez parte dos crit\u00e9rios de inclus\u00e3o, sendo considerada opcional em revis\u00f5es de escopo.As buscas recuperaram 1.350 registros e, ap\u00f3s exclus\u00e3o de duplicatas, 725 registros foram triados por t\u00edtulos e resumos. Quarenta relatos eleg\u00edveis foram lidos na \u00edntegra, sendo 24 inclu\u00eddos. De dez disserta\u00e7\u00f5es e teses n\u00e3o duplicadas, duas foram inclu\u00eddas. Adicionalmente, 32 relatos foram selecionados das listas de refer\u00eancias dos estudos inclu\u00eddos. Desse modo, no total 58 estudos foram inclu\u00eddos e analisados nesta revis\u00e3o de escopo . Os dez, 40 foram classificados como estudos prim\u00e1rios (incluindo duas disserta\u00e7\u00f5es de mestrado brasileiras), 2 ensaios e 16 revis\u00f5es, cujas caracter\u00edsticas s\u00e3o descritas brevemente a seguir.De 58 relatosAs principais caracter\u00edsticas dos estudos prim\u00e1rios s\u00e3o apresentadas noEsses estudos foram realizados na Austr\u00e1lia (n = 10), Su\u00e9cia (n = 8), Brasil (n = 4), Estados Unidos da Am\u00e9rica (n = 4), Canad\u00e1 (n = 3), Noruega (n = 3), Reino Unido (n = 3), Esc\u00f3cia (n = 1), Finl\u00e2ndia (n = 1), It\u00e1lia (n = 1), Nova Zel\u00e2ndia (n = 1) e v\u00e1rias comunidades no noroeste do Pac\u00edfico (n = 1).A maioria dos estudos envolveu mulheres l\u00e9sbicas (n = 32), homens gays (n = 9) e profissionais de sa\u00fade (n = 7). Quando informada, a idade dos participantes variou de 20 a 59 anos, com predomin\u00e2ncia da cor branca.As principais caracter\u00edsticas dos 2 ensaios e 16 revis\u00f5es  s\u00e3o apresentadas noAo analisarmos o acervo das fontes selecionadas, observamos tem\u00e1ticas que estavam impl\u00edcitas ou expl\u00edcitas nos conte\u00fados dessas fontes . Tais tOs dados extra\u00eddos dos estudos foram agrupados em cinco tem\u00e1ticas, apresentadas em conjunto com seus respectivos subtemas noA produ\u00e7\u00e3o cient\u00edfica da \u00e1rea da sa\u00fade em geral acerca da homoparentalidade afigura-se como uma quest\u00e3o cuja abordagem exige a compreens\u00e3o de aspectos socioestruturais que ultrapassam esse campo do conhecimento. Pelo menos dois desses aspectos podem ser destacados. O primeiro deles diz respeito \u00e0 heteronormatividade que, de uma forma hegem\u00f4nica, faz com que \u2013 consciente ou inconscientemente \u2013 a primeira refer\u00eancia que se tem de fam\u00edlia ou de parentalidade envolva a uni\u00e3o de um homem cis com uma mulher cis. A exist\u00eancia de um casal homossexual faz com que essa norma heterossexual seja ou reafirmada para desqualificar tal casal ou desconstru\u00edda para se aceitar uni\u00f5es e progenitores homoafetivos. Nesse sentido, constata-se que grande parte da literatura revisada, antes de tratar dos objetos espec\u00edficos relacionados \u00e0 homoparentalidade, menciona o contexto heteronormativo tanto como modelo explicativo para a n\u00e3o exist\u00eancia de a\u00e7\u00f5es de sa\u00fade espec\u00edficas para casais de l\u00e9sbicas ou de gays quanto como dimens\u00e3o a ser questionada ou relativizada como refer\u00eancia \u00fanica para se reivindicar uma aten\u00e7\u00e3o diferenciada voltada para esses casais.Outro aspecto que emerge na produ\u00e7\u00e3o cient\u00edfica revisada, que abrange quest\u00f5es que ultrapassam a \u00e1rea da sa\u00fade no trato da homoparentalidade, refere-se \u00e0 legisla\u00e7\u00e3o, ou aus\u00eancia dela, que assegura ou veta n\u00e3o s\u00f3 a uni\u00e3o de pessoas do mesmo sexo como tamb\u00e9m o desejo dessas pessoas de ter filhos. Tais aspectos, direta ou indiretamente, associam-se ao contexto heteronormativo. Observamos que, no que se refere aos aspectos legais, h\u00e1 uma variabilidade muito grande entre pa\u00edses e at\u00e9 mesmo no interior de estados que comp\u00f5em um pa\u00eds. A aus\u00eancia de dispositivos legais, sua incompletude deles e/ou dubiedade refletem diretamente na forma com os casais s\u00e3o atendidos ou n\u00e3o conseguem o acesso ao atendimento.Revelar a orienta\u00e7\u00e3o sexual, tanto na perspectiva de casais homossexuais quanto na de profissionais da sa\u00fade, emerge na literatura como algo pol\u00eamico. De um lado, a revela\u00e7\u00e3o pode contribuir para que haja uma especificidade nas a\u00e7\u00f5es de sa\u00fade voltadas para tais casais. Por outro lado, segundo alguns estudos, na percep\u00e7\u00e3o de l\u00e9sbicas e gays, a revela\u00e7\u00e3o pode ter como consequ\u00eancias discrimina\u00e7\u00f5es, questionamentos invasivos, preconceitos e at\u00e9 mesmo viol\u00eancia simb\u00f3lica. O medo de revelar a homossexualidade, de certa forma, pode se articular com o contexto heteronormativo e as quest\u00f5es legais.A produ\u00e7\u00e3o cient\u00edfica sobre fertiliza\u00e7\u00e3o envolve quest\u00f5es relacionadas a legisla\u00e7\u00e3o, direitos, dificuldades de acesso, aus\u00eancia ou insufici\u00eancia de informa\u00e7\u00f5es, exclus\u00e3o de m\u00e3es ou pais homossexuais n\u00e3o biol\u00f3gicos, pr\u00e9-natal, parto, p\u00f3s-parto e m\u00e9todos. A literatura que trata desta tem\u00e1tica se volta principalmente para l\u00e9sbicas. No balan\u00e7o feito nos resultados dos estudos, predominam as dificuldades de acesso \u00e0 tecnologia de fertiliza\u00e7\u00e3o.As percep\u00e7\u00f5es acerca da aten\u00e7\u00e3o \u00e0 homoparentalidade, tanto por parte de casais homossexuais quanto de profissionais de sa\u00fade, em geral vinculam-se \u00e0 exist\u00eancia de insatisfa\u00e7\u00e3o frente aos cuidados recebidos e a atitudes negativas por parte de quem deveria prestar cuidados adequados.No que se refere a informa\u00e7\u00f5es e a\u00e7\u00f5es educativas, a literatura registra algumas experi\u00eancias positivas. No entanto, concorre com essas experi\u00eancias a percep\u00e7\u00e3o de que as informa\u00e7\u00f5es s\u00e3o insuficientes. Ainda em termos educacionais, observa-se uma quest\u00e3o que atravessa todas as tem\u00e1ticas identificadas, de forma expl\u00edcita ou impl\u00edcita aos resultados: o despreparo dos profissionais de sa\u00fade para lidar n\u00e3o s\u00f3 com a homoparentalidade, mas tamb\u00e9m com a homossexualidade.O acervo revisado constitui-se num mosaico de temas que, direta ou indiretamente, relacionam-se \u00e0 homoparentalidade. Cada um deles, seja pelo que explicita seja por infer\u00eancia do que est\u00e1 impl\u00edcito, pode subsidiar princ\u00edpios para o campo da sa\u00fade coletiva. Nesse sentido, os resultados desta revis\u00e3o t\u00eam sua import\u00e2ncia, uma vez que trazem subs\u00eddios para, dentre outros aspectos, a organiza\u00e7\u00e3o dos servi\u00e7os de sa\u00fade, a implementa\u00e7\u00e3o de a\u00e7\u00f5es espec\u00edficas no \u00e2mbito da promo\u00e7\u00e3o da sa\u00fade da fam\u00edlia e a forma\u00e7\u00e3o adequada dos profissionais para abordar fam\u00edlias de gays e l\u00e9sbicas.Observa-se ainda que o mapeamento obtido acerca do escopo do estudo \u00e9 um ponto de partida para se ampliar a discuss\u00e3o acerca da tem\u00e1tica central. Essa amplia\u00e7\u00e3o poder\u00e1 ser mais exitosa na medida em que, ancorada nas refer\u00eancias socioantropol\u00f3gicas, possa problematizar quest\u00f5es voltadas para os diferentes arranjos familiares e outras concep\u00e7\u00f5es de parentescos que n\u00e3o se limitam \u00e0 consanguinidade.Por fim, destaca-se que, apesar do vasto acervo identificado, uma limita\u00e7\u00e3o que pode ser apontada para esta revis\u00e3o \u00e9 a filtragem de idioma, elegendo apenas as fontes em l\u00ednguas portuguesa, espanhola e inglesa. Destaca-se, principalmente, a aus\u00eancia de estudos na l\u00edngua francesa, a qual deu origem ao termo homoparentalidade. Junto a isso, as pr\u00f3prias bases escolhidas para a pesquisa tamb\u00e9m podem ter influenciado no sentido de n\u00e3o haver estudos em franc\u00eas.Dentre as principais conclus\u00f5es, destaca-se que, embora a literatura nacional localizada acerca da homoparentalidade na \u00e1rea da sa\u00fade ainda seja t\u00edmida, a discuss\u00e3o internacional parece relativamente em ampla expans\u00e3o. Em termos de evid\u00eancias, podemos ressaltar que o escopo desta revis\u00e3o n\u00e3o \u00e9 problematizado de forma suficiente na forma\u00e7\u00e3o e na atua\u00e7\u00e3o de profissionais de sa\u00fade; e os estudos quantitativos s\u00e3o inferiores em n\u00famero, comparados aos de natureza qualitativa. Isso, ainda que nos traga as especificidades do tema central, n\u00e3o nos permite perceber a extens\u00e3o da problem\u00e1tica apontada na maioria dos estudos.O mapeamento da literatura acerca do assunto tamb\u00e9m revelou algumas lacunas na produ\u00e7\u00e3o cient\u00edfica revisada. No \u00e2mbito da sa\u00fade coletiva, vale a pena ressaltar a insufici\u00eancia de estudos voltados para pol\u00edticas e programas e a aus\u00eancia de discuss\u00f5es sobre a sa\u00fade de crian\u00e7as e adolescentes de fam\u00edlias homoparentais."}
+{"text": "O Brasil \u00e9 um dos 30 pa\u00edses com maior incid\u00eancia de tuberculose (TB). Pessoas emsitua\u00e7\u00e3o de rua (PSR) t\u00eam 56 vezes mais riscos para o adoecimento do que apopula\u00e7\u00e3o geral por terem menor renda e acesso \u00e0 sa\u00fade. Os objetivos do estudoforam apresentar o perfil sociodemogr\u00e1fico e epidemiol\u00f3gico de PSR notificadaspara TB entre 2015 e 2019 na cidade do Rio de Janeiro e analisar rela\u00e7\u00f5es entreas vari\u00e1veis estudadas e desfechos da TB. Trata-se de estudo transversal comdados secund\u00e1rios das notifica\u00e7\u00f5es de TB em PSR no per\u00edodo e local do estudo.Foi realizada an\u00e1lise descritiva, seguida da verifica\u00e7\u00e3o de associa\u00e7\u00e3o entrevari\u00e1veis selecionadas e desfechos para TB, com teste qui-quadrado e regress\u00e3olog\u00edstica multinomial, para obten\u00e7\u00e3o da raz\u00e3o de chances (OR). O perfilpredominante das PSR com TB \u00e9 de homens , negros , com idade m\u00e9diade 43,3 anos  e faixa et\u00e1ria entre 30 e 59 anos . O desfechomais frequente foi abandono do tratamento , seguido por cura  e\u00f3bito . As an\u00e1lises mostraram que ra\u00e7a negra  euso de drogas  e \u00e1lcool foram fatores de risco para abandono do tratamento, enquanto faixas et\u00e1rias apartir de 30 anos  e forma extrapulmonar  foram aspectos de prote\u00e7\u00e3o. A vulnerabilidade das PSR separticulariza em perfis de ra\u00e7a e g\u00eanero, tal qual a TB, portanto, \u00e9 necess\u00e1riorefor\u00e7ar a\u00e7\u00f5es de preven\u00e7\u00e3o e tratamento efetivas para aumentar o acesso aosservi\u00e7os de sa\u00fade e o enfrentamento da TB nesse contexto, al\u00e9m de atentar para aalta propor\u00e7\u00e3o de dados incompletos que limitam as an\u00e1lises desse agravo. Mycobacterium tuberculosis, uma bact\u00e9riatransmitida por aeross\u00f3is ,A tuberculose (TB) \u00e9 uma doen\u00e7a infecciosa de grande relev\u00e2ncia para a sa\u00fade p\u00fablicamundial O Brasil se posiciona entre os 30 pa\u00edses com maiores incid\u00eancias da doen\u00e7a No entanto, mesmo passados cinco anos, o Brasil permanece entre os pa\u00edses com pioresindicadores para o agravo, com incid\u00eancia de 31,6 casos novos por 100 mil habitantesem 2020 e 4,5 mil \u00f3bitos em n\u00fameros absolutos em 2019 Historicamente, a TB na cidade do Rio de Janeiro se apresenta como a maiorrespons\u00e1vel pela mortalidade na popula\u00e7\u00e3o, sobretudo entre o fim do s\u00e9culo XIX ein\u00edcio do s\u00e9culo XX, \u00e9poca em que os mais acometidos eram indiv\u00edduos de menor rendae menor acesso \u00e0 sa\u00fade ,Na rede p\u00fablica de sa\u00fade no munic\u00edpio, o cuidado e controle da TB em toda a popula\u00e7\u00e3os\u00e3o realizados pela aten\u00e7\u00e3o b\u00e1sica, com acompanhamento dos pacientes e tratamentosupervisionado, al\u00e9m de contar com o Laborat\u00f3rio Central de Sa\u00fade P\u00fablica NoelNutels (Lacen/RJ) e o apoio de diversas institui\u00e7\u00f5es acad\u00eamicas para a\u00e7\u00f5es que v\u00e3odesde o diagn\u00f3stico at\u00e9 a aten\u00e7\u00e3o terci\u00e1ria, como no caso de acompanhamento de casosde TB resistentes Por\u00e9m, a cobertura geral pela aten\u00e7\u00e3o b\u00e1sica na cidade do Rio de Janeiro foi de47,29% em abril de 2020 e a da Estrat\u00e9gia Sa\u00fade da Fam\u00edlia (ESF) foi de 40,96% nomesmo per\u00edodo, segundo o Sistema de Informa\u00e7\u00e3o e Gest\u00e3o da Aten\u00e7\u00e3o B\u00e1sica (e-Gestor)do Minist\u00e9rio da Sa\u00fade ,,,Deve-se considerar que a TB acomete principalmente popula\u00e7\u00f5es dos estratossocioecon\u00f4micos com menor poder aquisitivo e, consequentemente, em condi\u00e7\u00f5es de vidamais precarizadas e vulnerabilizadas As PSR s\u00e3o caracterizadas como indiv\u00edduos com enfraquecimento de suas rela\u00e7\u00f5essociais e familiares, em situa\u00e7\u00e3o de extrema pobreza e inexist\u00eancia de moradiaregular convencional, usando espa\u00e7os p\u00fablicos como sua moradia e sustento, bem comoalbergues e abrigos, de forma permanente ou tempor\u00e1ria ,,Nessa popula\u00e7\u00e3o, as doen\u00e7as mais prevalentes entre transmiss\u00edveis e cr\u00f4nicas n\u00e3otransmiss\u00edveis s\u00e3o: TB, HIV e aids, hipertens\u00e3o arterial e diabetes, al\u00e9m dedist\u00farbios psicossociais advindos do abuso de drogas e \u00e1lcool As dificuldades inerentes \u00e0 vida na rua, o preconceito e a inseguran\u00e7a fazem com quea ades\u00e3o aos tratamentos de sa\u00fade seja menor entre PSR do que na popula\u00e7\u00e3o em geralA iniciativa do Consult\u00f3rio na Rua, implementado na aten\u00e7\u00e3o b\u00e1sica de sa\u00fadebrasileira em 2011 No Munic\u00edpio do Rio de Janeiro, percebe-se a falta de uniformidade na distribui\u00e7\u00e3o daestrat\u00e9gia Consult\u00f3rio na Rua entre suas regi\u00f5es. Entre as 10 \u00e1reas da coordena\u00e7\u00e3ode aten\u00e7\u00e3o prim\u00e1ria existentes, apenas seis contam com equipes para esse tipo deatendimento: Centro, Benfica, Jacarezinho, Acari, Realengo e Paci\u00eancia Existe uma grande lacuna de produ\u00e7\u00f5es cient\u00edficas em sa\u00fade para essa popula\u00e7\u00e3o,inclusive de dados oficiais sobre incid\u00eancia e mortalidade por TB nas PSR. Portanto,os benef\u00edcios esperados do artigo s\u00e3o que os resultados possam ser usados porpesquisadores para subsidiar hip\u00f3teses para suas futuras pesquisas e por gestoresdos servi\u00e7os de sa\u00fade, respons\u00e1veis pela formula\u00e7\u00e3o e implanta\u00e7\u00e3o de pol\u00edticasp\u00fablicas, tomada de decis\u00e3o, melhora da qualidade do atendimento das PSR nosservi\u00e7os de sa\u00fade, como subs\u00eddios para pol\u00edticas sociais e de sa\u00fade voltadas para apopula\u00e7\u00e3o do estudo.Nesse contexto, os objetivos deste artigo foram definir o perfil sociodemogr\u00e1fico eepidemiol\u00f3gico de PSR notificadas para TB entre os anos de 2015 e 2019 no Munic\u00edpiodo Rio de Janeiro e analisar poss\u00edveis rela\u00e7\u00f5es entre fatores de risco e desfechosda TB.Trata-se de um estudo do tipo transversal com dados secund\u00e1rios sobre a ocorr\u00eancia deTB entre PSR no per\u00edodo de janeiro de 2015 a dezembro de 2019 no Munic\u00edpio do Rio deJaneiro. Os dados foram provenientes do Sistema de Informa\u00e7\u00e3o de Agravos deNotifica\u00e7\u00e3o , cedidos pela Secretaria Municipal de Sa\u00fade doRio de Janeiro (SMS/RJ).A popula\u00e7\u00e3o do estudo foi definida como todos os registros notificados referentes aoscasos de TB nas PSR no per\u00edodo e local do estudo, os quais foram entregues \u00e0 autorano in\u00edcio de 2021 pela SMS/RJ.Os anos de estudo foram escolhidos por corresponderem \u00e0 maior quantidade de registrosatuais no SINAN, uma vez que a categoria de \u201cpopula\u00e7\u00e3o em situa\u00e7\u00e3o de rua\u201d s\u00f3 foiimplementada a partir de 2014 na ficha de notifica\u00e7\u00e3o e tabula\u00e7\u00e3o dos dados noDepartamento de Inform\u00e1tica do SUS (DATASUS). Ainda assim, ap\u00f3s analisar o conjuntode registros de 2014 a 2019 (2.198 notifica\u00e7\u00f5es), foram descartadas as notifica\u00e7\u00f5esdo ano de 2014 (n = 197) por apresentarem inconsist\u00eancias no preenchimento devari\u00e1veis, al\u00e9m de muitos campos ignorados ou n\u00e3o preenchidos. O total de registrospara as an\u00e1lises foi de 2.001 notifica\u00e7\u00f5es.Ap\u00f3s a organiza\u00e7\u00e3o e limpeza do banco de dados, foram selecionadas as seguintesvari\u00e1veis para an\u00e1lise: desfecho ; sexo (feminino e masculino); ra\u00e7a/cor ; HIV ;forma ; data de notifica\u00e7\u00e3o (data de nascimento);consumo de \u00e1lcool ; uso de tabaco ; uso dedrogas il\u00edcitas ; tratamento diretamente observado - TDO ; e c\u00f3digo do bairro de notifica\u00e7\u00e3o.A partir da \u201cdata de notifica\u00e7\u00e3o\u201d do agravo, o ano foi isolado e foi criada avari\u00e1vel \u201cano de notifica\u00e7\u00e3o\u201d, a fim de permitir a an\u00e1lise da varia\u00e7\u00e3o de n\u00famero decasos anuais e a constru\u00e7\u00e3o da s\u00e9rie hist\u00f3rica do per\u00edodo. Para a idade, foi criadaa vari\u00e1vel \u201cfaixa et\u00e1ria\u201d a partir da \u201cdata de notifica\u00e7\u00e3o\u201d subtra\u00edda da vari\u00e1vel\u201cdata de nascimento\u201d, resultando na idade em anos, que posteriormente foicategorizada em 0-29 anos, 30-59 anos e 60 anos ou mais. A seguir, para as vari\u00e1veisque apresentavam mais que quatro categorias e com frequ\u00eancia relativa abaixo de 5%,foi realizada a agrega\u00e7\u00e3o das categorias para viabilizar a an\u00e1lise de modelagemestat\u00edstica, resultando nas vari\u00e1veis \u201cra\u00e7a/cor\u201d  e \u201cdesfecho da TB\u201d . Dados faltantes nas vari\u00e1veis foram organizados na categoria \u201cignorado\u201d decada vari\u00e1vel.https://rstudio.com/). O programaTerraView, vers\u00e3o 4.2.2 (http://www.dpi.inpe.br/terraview), foi utilizado para produzir omapa da distribui\u00e7\u00e3o geogr\u00e1fica do n\u00famero de casos no per\u00edodo, segundo os bairros domunic\u00edpio.A an\u00e1lise estat\u00edstica descritiva (medidas resumo) precedeu a an\u00e1lise da associa\u00e7\u00e3oentre as vari\u00e1veis independentes e o desfecho para TB - vari\u00e1vel dependente. O teste qui-quadrado e/ou teste exato de Fisher com n\u00edvel designific\u00e2ncia de 5% foi usado para testar a hip\u00f3tese de independ\u00eancia entre odesfecho (infec\u00e7\u00e3o para TB) e as vari\u00e1veis independentes (vari\u00e1veissociodemogr\u00e1ficas e epidemiol\u00f3gicas). Posteriormente, efetuou-se a regress\u00e3olog\u00edstica multinomial, indicada para desfechos com mais de duas categorias, paraobten\u00e7\u00e3o da raz\u00e3o de chances (OR), medida de associa\u00e7\u00e3o e seus respectivosintervalos de 95% de confian\u00e7a (IC95%) https://conselho.saude.gov.br/plataforma-brasil-conep) e aprovadopelo Comit\u00ea de \u00c9tica em Pesquisa do Hospital Universit\u00e1rio Ant\u00f4nio Pedro daUniversidade Federal Fluminense (CAAE 25832719.6.0000.5243 e parecer n\u00ba 3.758.351).A pesquisa tamb\u00e9m foi aprovada pelo Comit\u00ea de \u00c9tica em Pesquisa da SMS/RJ (CAAE25832719.6.3001.5279 e parecer n\u00ba 4.034.26).O estudo foi cadastrado na Plataforma Brasil  e da ra\u00e7a/cor negra . Foiobservado o total de 151 dados ignorados para ra\u00e7a/cor  .A m\u00e9dia de idade foi de 39,3 anos , sendo de 35,1 anos  para mulheres e 40,7 anos  para homens. A faixa et\u00e1riapredominante foi 30-59 anos . Os resultados foram calculados segundo afrequ\u00eancia e os percentuais ajustados, portanto, os n\u00fameros podem variar devido adados faltantes.A forma de manifesta\u00e7\u00e3o mais comum da TB foi a pulmonar . A infec\u00e7\u00e3o pelo HIVfoi detectada em 16,5% das PSR notificadas com TB. Os usu\u00e1rios de tabaco e drogasil\u00edcitas representaram 49,3% e 63,2% da popula\u00e7\u00e3o em situa\u00e7\u00e3o de rua com TB,respectivamente, enquanto usu\u00e1rios de \u00e1lcool totalizaram 40,4%. Quanto ao TDO, 56,3%dos pacientes foram contemplados pelo programa e 18,1% n\u00e3o, devendo-se considerarque dados ignorados dessa vari\u00e1vel totalizaram 25,6%.No per\u00edodo estudado, o desfecho mais frequente foi o abandono do tratamento ,seguido por cura  e \u00f3bito por TB . Outros desfechos totalizaram 463observa\u00e7\u00f5es  .A an\u00e1lise bivariada mostrou que cor da pele negra , uso dedrogas  e de \u00e1lcool  foramassociados com maior chance de abandono do tratamento. A faixa et\u00e1ria 60 anos oumais , assim como manifestar a forma extrapulmonar dadoen\u00e7a , foram relacionadas com menor frequ\u00eancia deabandono do tratamento.A A s\u00e9rie hist\u00f3rica  mostra u,,,,Os resultados encontrados s\u00e3o compat\u00edveis com a literatura ,,Os resultados tamb\u00e9m mostram progn\u00f3stico desfavor\u00e1vel quanto aos desfechos poss\u00edveispara o acometimento pela TB, o que condiz com achados de outros estudos realizadosrecentemente ,Mesmo n\u00e3o havendo resultados neste estudo sobre a atua\u00e7\u00e3o do Consult\u00f3rio na Rua porn\u00e3o constar no SINAN, al\u00e9m do tratamento diretamente observado, \u00e9 importantecomentar que estrat\u00e9gia do Consult\u00f3rio na Rua apresenta boa aceita\u00e7\u00e3o pelas PSR\u00c9 pertinente apontar, ainda, que a maior concentra\u00e7\u00e3o de PSR ocorre em locais onde h\u00e1maior circula\u00e7\u00e3o de transeuntes, como na regi\u00e3o central da cidade, \u00e1rea contempladapela estrat\u00e9gia do Consult\u00f3rio na Rua, bem como na Zona Norte O tratamento diretamente observado de maneira flex\u00edvel tamb\u00e9m foi pontuado comoimportante, pois leva em considera\u00e7\u00e3o o fato de serem andarilhos e necessitaremdessa movimenta\u00e7\u00e3o para conseguirem recursos e alimenta\u00e7\u00e3o ,Ainda sobre o protocolo de tratamento, sabe-se que a interna\u00e7\u00e3o de PSR \u00e9 maiscomplicada, pois as submete a um conjunto de repress\u00f5es e regras que comprometem seuestilo de vida, coibindo o uso de tabaco, \u00e1lcool e drogas Atualmente, o contexto brasileiro de grave crise econ\u00f4mica, em parte em decorr\u00eanciada pandemia de COVID-19, afetou diretamente os estratos sociais mais economicamentee socialmente fragilizados. Nesse cen\u00e1rio, houve diminui\u00e7\u00e3o da oferta de empregosformais e informais, dificuldade de acesso ao aux\u00edlio emergencial e cortes doGoverno Federal, com o programa de transfer\u00eancia de renda Bolsa Fam\u00edlia, al\u00e9m dainstabilidade pol\u00edtica, ocasionando aumento da quantidade de PSR e da inseguran\u00e7aalimentar em todo o pa\u00eds A vulnerabilidade das PSR se particulariza em perfis de ra\u00e7a e g\u00eanero, dentro de umpadr\u00e3o j\u00e1 conhecido. Com isso, \u00e9 necess\u00e1rio refor\u00e7ar as a\u00e7\u00f5es de preven\u00e7\u00e3o etratamento, t\u00e3o fundamentais para enfrentar esse contexto da TB. Tendo em vista adificuldade de acesso aos servi\u00e7os de sa\u00fade por parte das PSR, o Consult\u00f3rio na Rua\u00e9 uma importante estrat\u00e9gia para o cuidado dessa popula\u00e7\u00e3o, j\u00e1 que realizaassist\u00eancia integral, promove o v\u00ednculo da equipe com a PSR e possibilita apreven\u00e7\u00e3o de doen\u00e7as e a promo\u00e7\u00e3o da sa\u00fade. A educa\u00e7\u00e3o permanente para profissionaisde sa\u00fade pode ser uma estrat\u00e9gia para manter o padr\u00e3o de aten\u00e7\u00e3o \u00e0 sa\u00fade das PSR esuperar estigmas sobre essa situa\u00e7\u00e3o sob uma perspectiva de humaniza\u00e7\u00e3o noatendimento dessa popula\u00e7\u00e3o Al\u00e9m disso, as notifica\u00e7\u00f5es da TB est\u00e3o distribu\u00eddas com maiores frequ\u00eancias nocentro do munic\u00edpio e em alguns bairros da Zona Norte, com grande varia\u00e7\u00e3o anual don\u00famero de casos nos anos da s\u00e9rie hist\u00f3rica do per\u00edodo estudado (2015-2019), semindica\u00e7\u00f5es de queda.\u00c9 importante chamar a aten\u00e7\u00e3o para a alta propor\u00e7\u00e3o de dados incompletos,dificultando as an\u00e1lises e indicando uma subnotifica\u00e7\u00e3o desse agravo. Em particular,identificou-se uma baixa quantidade das notifica\u00e7\u00f5es em 2014, possivelmente pormudan\u00e7as no protocolo de notifica\u00e7\u00e3o e carregamento no SINAN e por atrasos nacomputa\u00e7\u00e3o das notifica\u00e7\u00f5es de TB no DATASUS. Essas quest\u00f5es precisam ser superadas,e os dados regularizados com urg\u00eancia. Dessa forma, a educa\u00e7\u00e3o permanente pode seruma das ferramentas para as equipes de sa\u00fade, esclarecendo a import\u00e2ncia do adequadopreenchimento das vari\u00e1veis das fichas de notifica\u00e7\u00e3o do SINAN, pois aponta osindicadores locais dos agravos, os quais permitem que os profissionais atuem deforma diretiva nas fragilidades encontradas.O acompanhamento do perfil populacional \u00e9 imprescind\u00edvel para futuras an\u00e1lises, vistoque o aumento da quantidade de PSR durante a pandemia de COVID-19 pode ter alteradoas caracter\u00edsticas do perfil sociodemogr\u00e1fico dessa popula\u00e7\u00e3o, uma vez que fam\u00edliasinteiras perderam sua renda, sustento e abrigo nos \u00faltimos dois anos.Por fim, ser\u00e1 fundamental rever as pol\u00edticas de apoio social e distribui\u00e7\u00e3o de rendadiante do aumento do n\u00famero de PSR no per\u00edodo da pandemia e, paralelamente, equiparas unidades de sa\u00fade da aten\u00e7\u00e3o b\u00e1sica e Consult\u00f3rio na Rua com profissionaiscapacitados e insumos para o enfrentamento da TB.Neste artigo h\u00e1 limita\u00e7\u00f5es, uma vez que foram utilizados dados secund\u00e1rios em suarealiza\u00e7\u00e3o, apresentando muitas vari\u00e1veis com baixa ades\u00e3o no preenchimentopelos setores de atendimento aos pacientes, al\u00e9m de n\u00e3o contemplar a viv\u00eanciadas PSR."}
+{"text": "Este artigo discute a origem da quijila/kijila na cultura centro-ocidental africana, mais particularmente no universo cultural dos imbangalas (jagas) e das popula\u00e7\u00f5es ambundos e kimbundos, que viviam nas regi\u00f5es portuguesas de Angola e do Congo, nos s\u00e9culos XVII e XVIII. Em seguida, investiga como foi estruturado, compreendido e transformado o conceito de quijila tanto na \u00c1frica, basicamente um interdito alimentar, mas cujos significados e aplica\u00e7\u00f5es variam, quanto no Brasil, para onde foi transportado nos Setecentos, transformando-se numa doen\u00e7a que atacava os negros, especialmente os africanos de diversas origens, sendo enquadrada pelos m\u00e9dicos locais no universo da medicina hipocr\u00e1tica-galena vigente na \u00e9poca. Prodigiosa lagoa descoberta nas Congonhas das Minas do Sabar\u00e1 , formigueiros , erisipelas, e todos os tipos de chagas  e 25 eram mulheres . No c\u00f4mputo geral, 50 eram escravos(as) e 13 eram forros(as), equivalendo a 63 pessoas de cor, ou 55,75% dos doentes. Entre eles, estavam os seis doentes atacados pela quijila. Todas as doen\u00e7as foram descritas e classificadas a partir dos conceitos vigentes na medicina hipocr\u00e1tico-gal\u00eanica, sendo a quijila a \u00fanica que atacou apenas negros , as demais n\u00e3o distinguiram popula\u00e7\u00f5es brancas das de cor. Mas, devido \u00e0s p\u00e9ssimas condi\u00e7\u00f5es de vida e de alimenta\u00e7\u00e3o a que eram submetidos os cativos, as doen\u00e7as eram mais recorrentes ou mais graves entre eles. Como exemplos, Pedro, escravo de Luiz Cardoso, no Caet\u00e9, depois de dois banhos expeliu \u201ctr\u00eas lombrigas pretas de tr\u00eas palmos cada uma\u201d, o que lhe causava \u201cgrandes dores na barriga\u201d. Maria, escrava de Francisco Fernandes Braga, apresentava \u201cum papo havia anos\u201d, como se denominava o b\u00f3cio. Acidentes de trabalho, especialmente na minera\u00e7\u00e3o, eram inevit\u00e1veis, e Pedro, escravo de Alexandre Teixeira, tinha uma chaga aberta, havia um ano, depois de ter ca\u00eddo sobre seu p\u00e9 \u201cum grande pau\u201d; enquanto Ign\u00e1cia, escrava de Brites Correia, apareceu com tosse e dor no peito, \u201clan\u00e7ando algum sangue\u201d, depois de \u201clhe haver ca\u00eddo sobre os peitos, haveria quatro meses, uma gamela de roupas\u201d , diagnosticou como quigila (com \u201cg\u201d), nenhum branco sofria do mal. \u00c9 reveladora a compara\u00e7\u00e3o entre os casos de Antonio, escravo de Manoel Teixeira Lombo; de Jo\u00e3o de Ara\u00fajo, filho do \u00faltimo; e de Jo\u00e3o da Costa Ferreira. A doen\u00e7a do primeiro atacara-lhe os p\u00e9s e as m\u00e3os, que ficaram aleijados e estavam cobertos de chagas, o que lhe custara alguns dedos. Jo\u00e3o de Ara\u00fajo, branco livre de 18 anos, tamb\u00e9m apresentava o corpo coberto de chagas e as pernas entrevadas devido aos estragos feitos pelas feridas que as cobriam. O mesmo acontecia com Jo\u00e3o da Costa Ferreira, branco, de 13 anos, filho de Manuel Jorge da Costa Ferreira, que sofria \u201ccom duas chagas em uma perna\u201d e tinha \u201co dedo do polegar do p\u00e9 direito comido de outra\u201d . Dessa forma, o estudo do mal e de suas origens contribui para elucidar aspectos pr\u00f3prios da cultura dos escravizados em Minas Gerais, na Am\u00e9rica portuguesa, que foram, em geral, apagados, devido ao car\u00e1ter hegem\u00f4nico da cultura europeia em terras bras\u00edlicas, especialmente no que diz respeito \u00e0s doen\u00e7as e suas pr\u00e1ticas de cura.Comecemos com a origem do termo. Em kimbundu, l\u00edngua falada pelas popula\u00e7\u00f5es ambundo de Angola, o sentido b\u00e1sico de kijila \u00e9 proibi\u00e7\u00e3o ou ainda tabu. A palavra aparece muito cedo nos catecismos traduzidos para o kimbundu, como no de Francesco Pacconio e Ant\u00f3nio Couto, publicado em Lisboa, em 1642 , sendo usada para traduzir os tabus impostos pelos \u201c\u00eddolos\u201d. Na edi\u00e7\u00e3o de 1645, \u00e9 tamb\u00e9m empregada para se referir a um dos Dez Mandamentos, revelados por Deus a Mois\u00e9s, substituindo o termo \u201cmilongo\u201d, mais secular, que passou a ser empregado somente para se referir \u00e0s leis ou aos decretos emitidos pelo rei. Fica clara a distin\u00e7\u00e3o sem\u00e2ntica do sentido dos dois termos: kijila circunscrevendo-se \u00e0s regras impostas no universo propriamente religioso, e milongo, no secular.Grosso modo, os jagas passaram a ser descritos, nas fontes e na literatura europeias, como n\u00f4mades e que jamais constru\u00edram um Estado coeso. Eram antrop\u00f3fagos, viviam da razia e da guerra contra os povos bantos locais e resistiam \u00e0 penetra\u00e7\u00e3o e \u00e0 coloniza\u00e7\u00e3o dos portugueses. Opunham-se particularmente aos ambundo, mais numerosos, que eram sedent\u00e1rios, viviam da agricultura e do pastoreio e tinham sua organiza\u00e7\u00e3o sociopol\u00edtica assentada na linhagem, constituindo Estados, sendo o reino mais importante na regi\u00e3o o Ndongo ou Dongo  era um conjunto de leis que foi institu\u00eddo inicialmente pela rainha imbangala Temba-Ndumba, \u201caplaudida e respeitada como mulher de extraordin\u00e1ria coragem\u201d, e \u201cdividem-se em dom\u00e9sticas, religiosas e civis\u201d . As dom\u00e9sticas prescreviam \u201ca observ\u00e2ncia de algumas tradi\u00e7\u00f5es dos antepassados, como a abstin\u00eancia da carne de porco, de elefante, de serpente e de outros animais\u201d, embora assegure que \u201cisso tudo implique uma grande viol\u00eancia ao natural apetite que todos t\u00eam\u201d, devido \u00e0 antropofagia que praticavam .Um dos grandes informantes e divulgadores dos costumes e da barb\u00e1rie dos jagas foi o padre capuchinho italiano Giovanni Antonio Cavazzi (de Montecuccolo), que, em 1687, depois de missionar em Angola, publicou a De forma preconceituosa, a partir do ponto de vista cat\u00f3lico, Cavazzi considerou-as \u201crid\u00edculas e supersticiosas\u201d, afirmando que essas leis \u201ct\u00eam por objeto algumas prescri\u00e7\u00f5es que, de um momento para o outro, s\u00e3o inventadas pelos feiticeiros astuciosos e perspicazes, conforme a oportunidade e o g\u00eanio daqueles desgra\u00e7ados\u201d . Feiticeiros \u00e9 como se refere, pejorativamente, aos ngangas ou gangas, como eram chamados os sacerdotes africanos que, segundo ele, \u201ctratam da vida privada, das contendas, das doen\u00e7as, dos perigos de morte e de outros assuntos semelhantes\u201d . Para ele, a quijila era a nega\u00e7\u00e3o dos princ\u00edpios crist\u00e3os e s\u00edmbolo da barb\u00e1rie dos jagas. Tamb\u00e9m repercutia a vis\u00e3o que os pr\u00f3prios ambundos tinham desses mandamentos, que consideravam inumanos, j\u00e1 que na cosmologia Mbundu eles eram considerados cru\u00e9is.A partir da descri\u00e7\u00e3o do capuchinho, percebe-se que a interdi\u00e7\u00e3o alimentar n\u00e3o correspondia ao conjunto das ijila, mas era uma das quijila dom\u00e9sticas, imposta pelos sacerdotes e transmitida pelos antepassados por meio da tradi\u00e7\u00e3o oral. Interditada era \u201ca carne de porco, de elefante, de serpente e de outros animais\u201d , mas Cavazzi n\u00e3o especifica quais penalidades sofriam os infratores nem que a desobedi\u00eancia provocasse alguma doen\u00e7a. A proibi\u00e7\u00e3o de ingest\u00e3o de alguns animais, especialmente os de grande porte, n\u00e3o foi exclusiva dos povos africanos, mas recorrente em v\u00e1rias culturas, inclusive na europeia do s\u00e9culo XVIII, nas quais adquiria fun\u00e7\u00f5es diversas, como a reserva de carne de alguns animais, principalmente os de grande porte, a alguns indiv\u00edduos, geralmente de posi\u00e7\u00e3o hier\u00e1rquica superior, como os reis .As ijila foram adotadas por parte das popula\u00e7\u00f5es ambundo a partir do reinado da famosa rainha Jinga ou Njinga, que, em 1624, reivindicou para si o trono do Ndongo. Lutando contra os portugueses, que tinham o apoio de alguns grupos aliados de jagas (que imediatamente abandonavam as ijila), a rainha estabeleceu uma alian\u00e7a, em 1629, com o chefe imbangala Cassa, com quem acabou por se casar, adotando as tradi\u00e7\u00f5es jagas e assumindo a chefia do grupo. Acuada pela guerra, em 1630, acabou por estabelecer seu reino em Matamba, a oeste do rio Cuanza, de onde comandou a resist\u00eancia aos portugueses at\u00e9 1656, quando estabeleceu um tratado e se reconverteu ao catolicismo, que professara na juventude.Sem nunca abandonar a linhagem como identidade do grupo, inclusive levava consigo uma urna funer\u00e1ria com os ossos de seus antepassados, Njinga tamb\u00e9m adotou os preceitos e as interdi\u00e7\u00f5es da ijila , que advertiu em seus escritos que \u201cesses pretos praticam diversas supersti\u00e7\u00f5es\u201d, que n\u00e3o \u201cgostaria de narrar, pois s\u00e3o rid\u00edculas\u201d, desculpando-se de que, se o fazia, era \u201capenas para instruir os mission\u00e1rios, para que possam tirar os Pretos dos seus enganos\u201d. Entre esses enganos, sua maior condena\u00e7\u00e3o foi dirigida \u00e0 quijila que atribuiu aos jagas.Mesmo depois da chegada dos capuchinhos, Njinga se comportou de maneira paradoxal. Por um lado, transformou \u201cMatamba [n]um centro de irradia\u00e7\u00e3o do catolicismo\u201d , p.143, Sob press\u00e3o dos religiosos, no seu reinado, \u201cas leis kijila [teriam deixado] de vigorar, em favor das normas ambundas\u201d, e \u201cseu povo construiu novas identidades, resultantes das situa\u00e7\u00f5es ent\u00e3o vividas\u201d, que combinavam \u201celementos tradicionais com as inova\u00e7\u00f5es introduzidas pelos mission\u00e1rios\u201d \u201d, pois \u201celes t\u00eam de certo que v\u00e3o morrer em breve\u201d  n\u00e3o se refere mais a uma das regras das ijila, mas de um juramento; (2) se limita apenas a uma interdi\u00e7\u00e3o alimentar; (3) a transmiss\u00e3o principal da interdi\u00e7\u00e3o \u00e9 feita pela m\u00e3e e, somente na aus\u00eancia dela, pelos sacerdotes nativos; (4) os alimentos interditados diferenciam-se um pouco, e foram acrescentadas prescri\u00e7\u00f5es referentes ao modo de preparo dos alimentos; (5) o desrespeito \u00e0 interdi\u00e7\u00e3o resultava na morte do transgressor. Como se sabe que esse religioso foi leitor atento do livro de Cavazzi, que serviu de inspira\u00e7\u00e3o para o seu, essas diferen\u00e7as n\u00e3o podem ser creditadas a seu desconhecimento da obra ou do kikongo ou ainda \u00e0 dificuldade de compreens\u00e3o do que observou, mas \u00e0s transforma\u00e7\u00f5es que se operavam na cultura local sob o impacto do catolicismo e, principalmente, sob a progressiva hegemonia dos costumes ambundo sobre os jagas entre os bantos angolanos e mesmo entre os congoleses, pois trocas culturais entre esses povos eram frequentes. Os mission\u00e1rios foram implac\u00e1veis com os sacrif\u00edcios humanos, que constitu\u00edam parte importante das ijila, e perseguiam e deslegitimavam o poder dos l\u00edderes religiosos africanos.V\u00e1rios historiadores da \u00c1frica utilizam o conceito de criouliza\u00e7\u00e3o  como ferramenta te\u00f3rica para compreender as transforma\u00e7\u00f5es operadas na cultura africana centro-ocidental sob o impacto do cristianismo e das institui\u00e7\u00f5es sociopol\u00edticas introduzidas pelos portugueses, ainda que nem sempre concordem com seu significado. Para James No entanto, as mudan\u00e7as operadas ainda na \u00c1frica centro-ocidental e em curto espa\u00e7o de tempo somente em parte podem ser creditadas \u00e0 a\u00e7\u00e3o dos mission\u00e1rios cat\u00f3licos, que podiam ser condescendentes com as restri\u00e7\u00f5es alimentares, mas n\u00e3o com os sacrif\u00edcios humanos das ijila dos jagas. O fato de o principal elo de transmiss\u00e3o ter se transferido, conforme atesta Merolla da Sorrento, dos ngangas para a m\u00e3e, n\u00e3o ocorreu somente pelo impacto da a\u00e7\u00e3o dos religiosos crist\u00e3os, pois \u00e9 tamb\u00e9m um reflexo da progressiva hegemonia da cosmologia ambundo sobre as comunidades jaga-ambundos, que reuniam os que resistiam, no interior de Angola, aos portugueses. Para os ambundos, \u201co culto da ancestralidade tinha papel espec\u00edfico de articular as rela\u00e7\u00f5es sociais no interior do grupo de parentesco (as linhagens)\u201d , p.153, O manuscrito portugu\u00eas an\u00f4nimo \u201cRitos gent\u00edlicos e supersti\u00e7\u00f5es que observam os negros do gentio desse reino de Angola desde o seu nascimento at\u00e9 a morte\u201d, que n\u00e3o est\u00e1 datado, fornece outras pistas do processo de criouliza\u00e7\u00e3o que, ainda na \u00c1frica centro-ocidental, se operava no conceito de quijila. Entre outros t\u00f3picos, descreve as enfermidades e os ritos de cura vigentes em Angola que, como se observa pelo t\u00edtulo, s\u00e3o descritos a partir do ponto de vista do seu autor an\u00f4nimo, que os qualifica sempre de forma negativa, pejorativamente classificando-os como supersti\u00e7\u00f5es e ritos gent\u00edlicos, isto \u00e9, pag\u00e3os ou id\u00f3latras.Chama a aten\u00e7\u00e3o no texto o fato de que o papel dos ngangas seja apontado como restrito \u00e0 cura das doen\u00e7as, sendo eles descritos como um misto de feiticeiros e cirurgi\u00f5es. \u00c9 o \u00faltimo termo que o autor encontra, na cultura europeia, para, por analogia, identific\u00e1-los. Fica evidente ao leitor europeu que, como cirurgi\u00f5es, eles eram detentores de um saber pr\u00e1tico, sendo pouco instru\u00eddos e mal preparados, o que implicava a sua desqualifica\u00e7\u00e3o em rela\u00e7\u00e3o aos m\u00e9dicos, \u00fanicos detentores do saber erudito. O uso do termo cirurgi\u00e3o e a forma como seu papel \u00e9 descrito obliteram o importante papel religioso e na transmiss\u00e3o dos costumes e dos ritos dos antepassados que os ngangas ainda desempenhavam na \u00c1frica. No texto, sua a\u00e7\u00e3o foi circunscrita a cuidar dos doentes e a prescrever os tratamentos costumeiros, pois, sob a press\u00e3o dos portugueses, nas quest\u00f5es espirituais, eram cada vez mais substitu\u00eddos pelos padres cat\u00f3licos ou tinham que camuflar sua a\u00e7\u00e3o espiritual sob as pr\u00e1ticas curativas.Ritos gent\u00edlicos... , \u201cquando algum [indiv\u00edduo] padece enfermidade com les\u00e3o no seu entendimento se diz ter quilundos, [e] para estes se curarem consultam a um cirurgi\u00e3o chamado nganga de quilundos, ... e o dito cirurgi\u00e3o se recolhe para outro quarto sem pessoa alguma, aonde invoca ao diabo, com quem consulta a enfermidade\u201d. Uma vez \u201chavida a sa\u00fade, se faz festa ao quilunfo, que \u00e9 o \u00eddolo invocado com muita comiraina  em a\u00e7\u00e3o de gra\u00e7as\u201d. Para o autor an\u00f4nimo, medicina popular e feiti\u00e7aria se consubstanciavam na pr\u00e1tica dos ngangas, que invocavam, para realizar a cura, n\u00e3o s\u00f3 seus \u00eddolos, mas o pr\u00f3prio diabo em pessoa, o que significa a leitura de seus ritos e de suas cren\u00e7as a partir de um ponto vista cat\u00f3lico, condenando-as, j\u00e1 que idolatria e demonologia marcariam suas pr\u00e1ticas de cura. Os africanos s\u00e3o vistos como o outro, e sua religi\u00e3o, como coisa do diabo . O tratamento consistia no sacrif\u00edcio de cabritos e galinhas, oferecidos ao \u00eddolo que os ngangas invocavam. Uma vez recuperada a sa\u00fade, \u201co cirurgi\u00e3o ... dava aos tais curados seus preceitos de comer ou n\u00e3o comer isto ou aquilo, os quais preceitos se chamam Quigilles, que observam a risca\u201d (f.2). Quijila continua a se referir aos \u201cpreceitos de comer ou n\u00e3o comer isto ou aquilo\u201d, mas que, agora, s\u00e3o restritos ao per\u00edodo de convalescen\u00e7a de uma doen\u00e7a espec\u00edfica, o quibuco, e prescritas pelo nganga, recuperando, em parte, seu papel de intermedi\u00e1rio com o sobrenatural, mas restrito ao universo de cura das doen\u00e7as.Ainda que o texto n\u00e3o esteja datado, \u00e9 poss\u00edvel perceber que novas transforma\u00e7\u00f5es se operavam. Desconectada das ijila, das quais preservava apenas o nome, a quijila n\u00e3o era tamb\u00e9m uma regra nem uma interdi\u00e7\u00e3o alimentar cotidiana ampla, passando a se referir \u00e0 dieta alimentar, prescrita pelos ngangas, apenas depois da cura do mal do quibuco. Pela primeira vez, \u00e9 associada a uma doen\u00e7a espec\u00edfica, mesmo n\u00e3o sendo o mal em si, mas n\u00e3o s\u00e3o descritas as consequ\u00eancias da quebra da dieta. Dessa maneira, n\u00e3o mais se tratava exatamente de um tabu.Acima de tudo, essa descri\u00e7\u00e3o da quijila revela que, com o tempo, se tornara um rito observado por todos \u201cos negros do gentio desse reino de Angola\u201d, n\u00e3o sendo restrita aos jagas, nem mesmo circunscrita ao reino de Matamba. Despojada do sentido original, disseminara-se pelas popula\u00e7\u00f5es ambundo da regi\u00e3o da Angola portuguesa. Tal expans\u00e3o revela, mais uma vez, a criouliza\u00e7\u00e3o pela qual passavam as diferentes cosmologias dos povos bantos locais, que intercambiavam entre si ritos e cren\u00e7as. Uma chave para entender essa consubstancia\u00e7\u00e3o e sua dissemina\u00e7\u00e3o \u00e9 a afirma\u00e7\u00e3o de Cavazzi de que, depois da morte de Nzinga e de d. B\u00e1rbara, o sucessor Jinga-Mona invocou em pra\u00e7a p\u00fablica, por meio dos xinguilas, o esp\u00edrito da primeira, reencenando a import\u00e2ncia da linhagem para estruturar seu poder. Mas, em seguida, \u201cmandou que fossem sacrificados todos os prisioneiros da expedi\u00e7\u00e3o anterior\u201d e \u201cque fosse aberto o ventre a muitos dos presentes e que, com seu sangue, fossem borrifados os soldados e ele mesmo, fazendo alegres votos de prosperidade\u201d . Nesse caso, era uma reencena\u00e7\u00e3o da quijila mais importante dos jagas, a institu\u00edda pela rainha Temba-Ndumba, no que foi seguida por seus sucessores, inclusive Nijinga, que consistia em untar o corpo, antes da guerra, com um unguento m\u00e1gico que tinha como principal ingrediente o corpo de crian\u00e7as sacrificadas. Observa-se que Jinga-Mona legitimava seu poder na encena\u00e7\u00e3o de ritos importantes para os ambundos e jagas e, depois da cerim\u00f4nia, mandou \u201cmensageiros por todo o reino para que ... fossem renovadas as antigas cerim\u00f4nias e que, portanto, cada um pudesse viver livremente conforme os ritos dos Jagas ... e sem impedimento nenhum reintroduziu os antigos ritos\u201d .No come\u00e7o do s\u00e9culo XVIII, segundo o dicion\u00e1rio de portugu\u00eas, publicado em Lisboa em 1720, por Rafael Bluteau, a quigila (escrita no verbete com \u201cg\u201d) passou a ser uma \u201cmaldi\u00e7\u00e3o, que os pais dos negros de Angola d\u00e3o aos filhos, dizendo-lhes que se comerem veado, carneiro etc. lhes d\u00e3o a sua maldi\u00e7\u00e3o, e dizem que, comendo, lhes veem umas n\u00f3doas, ou outros sinais, e morrem\u201d . Mudan\u00e7as aconteceram mais uma vez no seu significado ou pelo menos no entendimento que os europeus, mais particularmente os portugueses, tinham da quijila africana. A interdi\u00e7\u00e3o alimentar, presente no tabu original, continuou a ser mencionada, por\u00e9m o termo se refere n\u00e3o propriamente a ela, mas \u00e0 maldi\u00e7\u00e3o causada pela quebra da dieta, ainda que Bluteau n\u00e3o se refira a essa maldi\u00e7\u00e3o como uma doen\u00e7a espec\u00edfica.O termo maldi\u00e7\u00e3o circunscreve a compreens\u00e3o da cultura africana como feiti\u00e7aria, tal qual era pr\u00f3prio dos europeus, que ecoavam os mission\u00e1rios cat\u00f3licos, intolerantes com seus ritos e cren\u00e7as. Havia por parte da igreja um modelo no qual \u201csenhores e escravos, brancos e negros deviam ser antes de tudo crist\u00e3os ... Nesse modelo, n\u00e3o havia toler\u00e2ncia com as pr\u00e1ticas de origem africana, vistas como demonizadoras\u201d , p.229. Ritos gent\u00edlicos... N\u00e3o \u00e9 explicado, ou n\u00e3o sabe o dicionarista, o significado e a raz\u00e3o de tais proibi\u00e7\u00f5es nem porque elas se limitam a apenas dois animais \u2013 veados e carneiros. A escolha deles parece ser resultado das disputas, na Europa, entre reis e s\u00faditos, e na Am\u00e9rica, entre senhores e escravos, pelo alimento de grande porte ca\u00e7ado nas matas e da necessidade de preserva\u00e7\u00e3o dos rebanhos dos primeiros da fome cotidiana dos cativos. Nesse sentido, a men\u00e7\u00e3o aos carneiros e veados e \u00e0 transmiss\u00e3o da maldi\u00e7\u00e3o pelos pais, e n\u00e3o somente pela m\u00e3e, adiciona um ingrediente \u00e0 criouliza\u00e7\u00e3o da quijila, o tr\u00e1fico atl\u00e2ntico de escravos e sua importa\u00e7\u00e3o maci\u00e7a para a Am\u00e9rica portuguesa, levando consigo um repert\u00f3rio de cren\u00e7as e costumes j\u00e1 em transforma\u00e7\u00e3o na \u00c1frica centro-ocidental e que, atravessado o Atl\u00e2ntico, sofria novas press\u00f5es por mudan\u00e7as.Para Bluteau, no in\u00edcio do s\u00e9culo XVIII, a cren\u00e7a na quijila era compartilhada por todos os africanos de Angola, sem distinguir o grupo a que pertencia, e incorporava elementos da cultura dos jagas, caso das restri\u00e7\u00f5es alimentares, e dos ambundo, como a import\u00e2ncia conferida \u00e0 linhagem \u2013 a maldi\u00e7\u00e3o passara a ser imposta pelos pais, e n\u00e3o apenas pela m\u00e3e, como aparecera entre os kimbundos. Nesse sentido, ele retoma a informa\u00e7\u00e3o de Merolla da Sorrento de que n\u00e3o era mais necess\u00e1ria a intermedia\u00e7\u00e3o dos sacerdotes nativos, revelando o decl\u00ednio do seu poder frente ao avan\u00e7o do catolicismo na \u00c1frica, mas tamb\u00e9m nas Am\u00e9ricas, onde os escravizados enfrentavam in\u00fameras dificuldades para transplantar intactos seus cultos, uma delas a aus\u00eancia dos seus l\u00edderes religiosos. Tamb\u00e9m n\u00e3o h\u00e1 men\u00e7\u00e3o a ser uma dieta guardada durante o per\u00edodo de convalescen\u00e7a, nem qualquer rela\u00e7\u00e3o com um culto em particular, caso do quibuco, como havia sido descrito nos As guerras que os portugueses desferiram no interior de Angola, ao longo do s\u00e9culo XVII, contra os jagas e, em especial, contra a resist\u00eancia que a rainha Njinga liderou no Ndongo e em Matamba, renderam muitos escravos ao tr\u00e1fico atl\u00e2ntico. A partir de 1649, o fluxo de escravos recrudesceu depois da derrota e da assinatura do acordo de paz com Njinga, quando foram reabertas as feiras do interior de Angola, onde os lusitanos se abasteciam de cativos. Nessa ocasi\u00e3o, a rainha mandou de presente ao governador, ao bispo e ao ouvidor geral de Luanda, \u201calgumas cabe\u00e7as de escravos da gente fugida\u201d, que viviam no reino h\u00e1 muito tempo, al\u00e9m dos 2 mil que enviou como resgate de sua irm\u00e3 que estava aprisionada na capital , suas cren\u00e7as cruzavam o Atl\u00e2ntico, cabe inquirir como o conhecimento da quijila foi transmitido entre os cativos em Minas Gerais, que significado adquiriu entre eles e se foi compartilhado com escravos de outras origens. Os estudos sobre a escravid\u00e3o no Brasil t\u00eam incorporado, de forma crescente, a problematiza\u00e7\u00e3o \u201cda \u2018sobreviv\u00eancia\u2019 das culturas africanas nas Am\u00e9ricas e das \u2018adapta\u00e7\u00f5es\u2019 que elas haviam sofrido no novo contexto\u201d , p.124. Ao se aceitar a ocorr\u00eancia de um processo de africaniza\u00e7\u00e3o nas senzalas mineiras, torna-se menos importante saber a origem dos negros acometidos de quijila que se banharam na lagoa. Cinco eram escravos e um era forro, sendo que s\u00f3 para dois deles h\u00e1 a certeza de serem africanos: o preto forro Francisco Xavier Barreto (caso 12), pois a designa\u00e7\u00e3o de cor, preto(a), era atribu\u00edda, na capitania, aos importados da \u00c1frica via tr\u00e1fico negreiro, diversamente dos crioulos, como eram chamados os nascidos no Brasil; e Manoel, escravo de Manoel Rodrigues (caso 75), pois contra\u00edra a doen\u00e7a na \u00c1frica 17 anos antes de chegar ao Brasil , mas, infelizmente, esse escrito encontra-se perdido.Segundo Antonio Cialli , as quijilas \u201ceram uma queixa verdadeiramente horrorosa e incur\u00e1vel, frequent\u00edssima nos Negros ..., sendo as verdadeiras chagas cancrosas  algumas vezes no decurso de dois meses, se achou s\u00e3o\u201d . Para surpresa de todos, com \u201cpoucas semanas contava de banhos, quando repararam que mais desembara\u00e7ado passeava, e que as chagas tinham j\u00e1 outra apar\u00eancia, at\u00e9 que admiraram finalmente indo as melhoras em conhecido aumento, estar em poucos meses de todo livre, e extinta t\u00e3o horrorosa queixa\u201d .Depois que frei Antonio de Miranda passou pela fazenda, as novas sobre as virtudes curativas das \u00e1guas da Lagoa Grande come\u00e7aram a se espalhar. No final de fevereiro de 1749, o religioso relatou, em Sabar\u00e1, entre outras, a cura da quijila no escravo Antonio, e a not\u00edcia voou entre os plant\u00e9is de escravos das redondezas. Ao chegar \u00e0 Lagoa, em 19 de mar\u00e7o, Cialli  l\u00e1 encontrou alguns doentes atacados do mal j\u00e1 banhando-se e revelou que eles estavam \u201ccom dedos j\u00e1 consumptos, ocularmente cicatrizando\u201d, revelando que os que buscaram a lagoa para se curar do mal eram mais numerosos, mas em seus manuscritos apontou apenas os primeiros que se curaram. Saliente-se que um n\u00famero significativo de escravos oriundos da Real Extra\u00e7\u00e3o dos Diamantes foi enviado do Tejuco, pelo m\u00e9dico do hospital local, para se banhar em suas \u00e1guas, mas n\u00e3o \u00e9 poss\u00edvel saber as doen\u00e7as que lhes acometiam .Em maio, al\u00e9m de Antonio, mais cinco doentes de quijila apresentavam melhoras acentuadas. Eram eles (1) Antonio, escravo do tenente Manoel Teixeira Lomba, que tinha as m\u00e3os e os p\u00e9s aleijados devido \u00e0 enfermidade, mas que, depois dos banhos, j\u00e1 foi capaz de andar; (2) o preto forro Francisco Xavier Barreto, morador no Funil, junto ao rio das Velhas, que estava \u201ccom as m\u00e3os aleijadas\u201d e que, \u201ccom alguns banhos, est\u00e3o quase naturalmente desfeitas\u201d; (3) Jorge, escravo de Jacinto de S\u00e1, que se encontrava imprest\u00e1vel por ter-lhe o mal atacado os p\u00e9s e comido os dedos, raz\u00e3o pela qual seu senhor tamb\u00e9m o havia expulsado de casa, mas que \u201ccom um m\u00eas de banhos se v\u00eam as chagas cicatrizadas, e quase todo fechadas\u201d; (4) Paulo, escravo de Ant\u00f4nio Carlos Moreira, morador na vila real de Sabar\u00e1, que sofria da doen\u00e7a h\u00e1 sete anos, e estava \u201ccom princ\u00edpio de quigila na perna esquerda\u201d, estando a metade inferior, junto \u00e0 t\u00edbia, bem inchada. A enfermidade, \u201ca modo de cupim\u201d, atacara-lhe um p\u00e9, que, coberto de feridas, quase se separara da perna, mas 17 dias de banhos foram suficientes para ela desinchar e voltar \u201cquase [ao] natural\u201d; (5) Manoel, escravo de Manoel Rodrigues, que havia 17 anos estava no Brasil, sofrendo da doen\u00e7a h\u00e1 trinta anos, iniciada ainda na \u00c1frica. Primeiro arrebentaram-lhe os metatarsos, depois ca\u00edram-lhe alguns dedos, ficando o restante muito inchado. Depois de tomar banhos \u201ch\u00e1 m\u00eas e meio esta[vam] fechada[s] mais\u201d da metade das chagas  \u00e9 definida como a \u201cantipatia, que os pretos de \u00c1frica t\u00eam com alguns comeres, ou a\u00e7\u00f5es, de sorte que, se os contrariam nisso, padecem doen\u00e7as, e talvez lhes segue a morte\u201d. Novamente n\u00e3o h\u00e1 refer\u00eancia de que a doen\u00e7a estivesse circunscrita apenas aos nativos de Angola, como tamb\u00e9m n\u00e3o distingue o local onde ela se disseminava, podendo ser a \u00c1frica, o Novo Mundo e mesmo Portugal, para onde eram destinados os escravos africanos. Tamb\u00e9m n\u00e3o s\u00e3o especificados quais alimentos eram interditados, e afirma que \u201cdizem alguns que estas antipatias de seus pais que os se contrav\u00eam a elas, vindo do outro mundo a isso as suas almas\u201d , p.277. A novidade que Cialli e Morais e Silva revelam \u00e9 que, no Brasil, a quijila que se transformara numa doen\u00e7a e, ainda que atacasse s\u00f3 os negros, teve sua cren\u00e7a compartilhada entre senhores e escravos, os primeiros exemplificados no m\u00e9dico e no dicionarista, e os segundos nos negros que buscaram a cura na lagoa. No verbete, sob o esp\u00edrito iluminista racional, a quijila foi enquadrada no sistema de simpatias e de antipatias, caracter\u00edstico da medicina hipocr\u00e1tica-gal\u00eanica, inserindo-a, da mesma forma que fizera Cialli, nas bases epistemol\u00f3gicas sob as quais se estruturava o conhecimento europeu. A cultura ocidental se apropriava, mas ao mesmo tempo modificava, a afro-americana que se formava no Novo Mundo, para ajust\u00e1-la \u00e0 sua maneira de compreender o mundo, o que pode ser entendido como um processo que denomino \u201cintertradu\u00e7\u00e3o\u201d. Esse conceito parte do princ\u00edpio de que transforma\u00e7\u00f5es s\u00e3o operadas enquanto as ideias (o conhecimento) circulam, independentemente de onde partam e de onde cheguem, quando s\u00e3o intertraduzidas e modificadas, sendo moldadas aos condicionamentos locais. Ao se adaptar \u00e0s novas culturas, as mesmas ideias voltam a se irradiar, chegando inclusive at\u00e9 os locais de onde partiram, modificando, por sua vez, a pr\u00f3pria cultura que as havia forjado. \u00c9 o que se observa com o conceito de quijila, que, sob o impacto do expansionismo portugu\u00eas e do escravismo colonial, mudava tanto na \u00c1frica quanto no Brasil, sofrendo transforma\u00e7\u00f5es dos dois lados do Atl\u00e2ntico, amalgamando-se como uma cultura afro-americana original que, n\u00e3o \u00e9 de estranhar, tamb\u00e9m incorporava elementos europeus e era compartilhada pelos escravos africanos.A cren\u00e7a no poder das \u00e1guas da Lagoa Grande na cura da quijila, compartilhada pelos negros que para ali se dirigiram, seus senhores que permitiram seu deslocamento e os m\u00e9dicos que recomendaram os banhos, tamb\u00e9m \u00e9 exemplar do processo de intertradu\u00e7\u00e3o que caracteriza essa nova cultura afro-americana.Ntinu-a-maza, que quer dizer \u2018rei da \u00e1gua\u2019, ... esconde seus amuletos debaixo da corrente de um rio\u201d (p.96), incorporando suas virtudes ben\u00e9ficas. Os Jagas tamb\u00e9m adoravam a \u00e1gua, e Cavazzi se ressente que essa adora\u00e7\u00e3o se \u201cmanifestava pela venera\u00e7\u00e3o que demonstravam pelos rios e pelas lagoas\u201d (p.215). Descreve que, \u201clogo que descobrem \u00e1gua de longe, prostram-se no ch\u00e3o para ador\u00e1-la, endere\u00e7am-lhe ora\u00e7\u00f5es, obla\u00e7\u00f5es e votos para n\u00e3o serem incomodados por ela, para sofrerem penas, para n\u00e3o sucumbirem \u00e0s doen\u00e7as e para serem socorridos nas suas dificuldades\u201d (p.215). Entre seus locais sagrados, destaca a grande lagoa de Saxia, situada no alto rio Cuanza, no extremo oeste de Angola, junto ao reino de Malemba, onde Cavazzi viu com seus pr\u00f3prios olhos esses ritos de adora\u00e7\u00e3o serem praticados entre as popula\u00e7\u00f5es locais (p.215).No universo cultural banto, \u201ca \u00e1gua era o elemento que dividia o mundo dos vivos, negros, do mundo dos mortos, brancos\u201d , p.148. Tamb\u00e9m segundo a medicina hipocr\u00e1tica-gal\u00eanica europeia, a \u00e1gua era considerada elemento com forte poder de cura, sendo parte fundamental dos corpos humanos, usada como salut\u00edfera para todos os \u00f3rg\u00e3os. Essa tradi\u00e7\u00e3o remontava \u00e0 medicina ocidental praticada desde a Antiguidade, sendo famosas as termas romanas. As ideias de simpatia e antipatia entre os quatro elementos de que se compunham a natureza e os corpos viventes eram aspectos fundamentais dessa teoria, e a cren\u00e7a no poder curativo da \u00e1gua ocorria por via simp\u00e1tica, pelos efeitos do vapor da \u00e1gua fervendo no corpo humano, que restauravam a sa\u00fade e combatiam as doen\u00e7as. Em Portugal e em Minas Gerais, v\u00e1rias fontes de \u00e1gua medicinal foram descobertas no s\u00e9culo XVIII , p.76-83Observa-se que a cren\u00e7a no poder reparador da \u00e1gua era compartilhada pelas culturas europeias e africanas, o que explica por que senhores e escravos, oriundos de Minas Gerais e de outras capitanias , buscaram os banhos curativos na Lagoa Grande e, num processo de intertradu\u00e7\u00e3o, redefiniram de maneira conjunta a compreens\u00e3o e a forma de cura da quijila. Para os europeus, mais que nenhuma outra, a lagoa simbolizava a prodigalidade com que a divina provid\u00eancia aben\u00e7oara suas \u00e1guas. Para os africanos, era uma das lagoas onde seus deuses \u201cse abrigaram em suas \u00e1guas\u201d . Se as almas de seus antepassados e suas maldi\u00e7\u00f5es eram capazes de atravessar a Calunga Grande, como denominavam o Atl\u00e2ntico, provocando doen\u00e7as, tamb\u00e9m o podiam seus deuses e suas cren\u00e7as, que protegiam seus corpos j\u00e1 fustigados pela dureza da escravid\u00e3o.Gazeta M\u00e9dica da Bahia, de 25 de setembro de 1866, o m\u00e9dico Julio Rodrigues de Moura, atuante no Rio de Janeiro, numa carta ao editor, considerou a quijila (com \u201cj\u201d), que para ele era apenas seu \u201cnome vulgar\u201d, uma mol\u00e9stia de atrofia muscular progressiva, associando-a \u00e0 elefant\u00edase-dos-gregos pelos seus \u201csintomas caracter\u00edsticos\u201d, entre os quais se encontrava a \u201canestesia cut\u00e2nea\u201d . Para tanto, apoiou-se no depoimento do m\u00e9dico Ant\u00f4nio Jos\u00e9 Alves, professor da Faculdade de Medicina da Bahia, mais conhecido como pai do poeta Castro Alves . Pelo menos a raiz africana da palavra era lembrada! Ainda que Alves reconhecesse que era mais recorrente nos que identificou como de \u201cra\u00e7a negra\u201d, escapou ao m\u00e9dico baiano que a raz\u00e3o disso residia na cultura de origem dos afetados, em que a quijila encontra seu significado, mais preocupado que estava em enquadrar a doen\u00e7a no quadro nosol\u00f3gico da medicina erudita ocidental.Na ro Alves , p.9-15,Ainda que escape ao recorte cronol\u00f3gico deste artigo, n\u00e3o deixa de ser instigante apontar que a s\u00e9tima edi\u00e7\u00e3o do dicion\u00e1rio de Morais e Silva, de 1878, \u201cmelhorada e aumentada com o grande n\u00famero de termos novos usados no Brasil\u201d, al\u00e9m do significado corrente na edi\u00e7\u00e3o de 1789, acrescenta que o substantivo \u201cquigila\u201d (com \u201cg\u201d) j\u00e1 era empregado com o sentido gen\u00e9rico, \u201cfamiliar\u201d, de \u201cantipatia, avers\u00e3o\u201d, e registra ainda que era \u201cvoc\u00e1bulo da l\u00edngua ambunda\u201d , p.540. Entre os s\u00e9culos XVI e XIX, a quijila se transformou entre a \u00c1frica e o Brasil, condicionada \u00e0s din\u00e2micas internas da \u00c1frica, ao avan\u00e7o dos europeus no continente e, por fim, \u00e0s din\u00e2micas do tr\u00e1fico de escravos e \u00e0s agruras da escravid\u00e3o na Am\u00e9rica. Num di\u00e1logo intertraduzido de lembran\u00e7as e esquecimentos, nos dois lados do Atl\u00e2ntico, europeus, brasileiros e africanos compartilharam e forjaram uma nova cultura, e a quijila \u00e9 exemplar dos limites, possibilidades e impossibilidades do seu di\u00e1logo cultural. Prodigiosa lagoa descoberta nas Congonhas das Minas do Sabar\u00e1 , located in the comarca of Sabar\u00e1, in Minas Gerais captaincy, in Brazil, and the cures of various sick people who drank from or bathed in its waters. It ends with a long list of the first 109 patients who bathed there and whose sicknesses were cured or mitigated, indicating their names, addresses, \u201cand the type of complaint\u201d , formigueiros (cutaneous wounds in the form of holes made by ants), erysipelas, and all types of sores  and 25 were women (22.1%). Overall, 50 were slaves and 13 were freed (forros), equivalent to 63 people of color, or 55.75% of those who were sick. Among these six were attacked by quijila. All diseases were described, classified, and framed through concepts in force in Hippocratic-Galenic medicine, though quijila was the only one which just attacked Black people , diagnosed as quigila, (spelt with a \u201cg\u201d in the text) no white person suffered from this disease. Comparing the cases of Antonio, a slave of Manoel Teixeira Lombo, Jo\u00e3o de Ara\u00fajo, son of the latter, and Jo\u00e3o da Costa Ferreira, is very revealing. In the first case the illness attacked his hands and feet, which were crippled and covered in wounds, resulting in the loss of some fingers. Jo\u00e3o de Ara\u00fajo, a free white only 18 years old, was also covered in sores and his legs were crippled due to the damage caused by the wounds in which they were covered. The same happened with Jo\u00e3o da Costa Ferreira, another white boy, aged 13, son of Manuel Jorge da Costa Ferreira, a resident of the village of S\u00e3o Sebasti\u00e3o, located on the banks of rio das Velhas, who suffered \u201cfrom two wounds on a leg\u201d and had \u201chis big toe on his right foot eaten by another\u201d . In this way, the study of the disease and its origins contribute to elucidate some of aspects of the culture of slaves in Minas Gerais, in Portuguese America, which in general were erased, due to the hegemonic nature of Europeans in Brazilian territory, especially in relation to its diseases and healing practices.We will begin with the origin of the term. In Kimbundu, a language spoken by the Ambundu populations of Angola, the basic sense of kijila is prohibition or even taboo. The word appears very early in the catechisms translated to Kimbundu, such as that of Francesco Pacconio and Ant\u00f3nio Couto, published in Lisbon in 1642 , being used to translate the taboos imposed by \u201cidols.\u201d In the 1645 edition, it is also used to refer to one of the Ten Commandments, revealed by God to Moses, replacing the more secular term \u201cmilongo,\u201d which came to be employed only in relation to laws or decrees issued by the king. The semantic distinction in the meaning of the two terms is clear, kijila is circumscribed to rules imposed by the religious universe and milongo to the secular.The word quijila or kijila appears directly linked to the customs of the group the Portuguese called the Jaga, but originally did not refer to a specific illness or disease. It was any of the 14 laws or prohibitions and rituals followed by this group who lived in the interior of Angola far from Luanda, who are identified in modern ethno-history as the Imbangala. These were accused of being bloodthirsty anthropophagic savages who lived by ravaging the nearby Ambundu populations  was a set of laws which were initially established by the Imbangala queen Temba-Ndumba, \u201capplauded and respected as a woman of extraordinary courage,\u201d and \u201cdivided into domestic, religious, and civil laws\u201d . The domestic ones prescribed \u201cthe observance of some ancestral traditions, such as abstinence from pork, elephant, snake, and some other animals,\u201d although he asserts that \u201call of this implies a great violence to the natural appetite which everyone has,\u201d due to the anthropophagy they practiced .One of the great informants and disseminators of the customs and the barbarity of the Jaga was the Italian Capuchin priest Giovanni Antonio Cavazzi (de Montecuccolo). In 1687, after working as a missionary in Angola, he published In a prejudicial manner, from a Catholic perspective, Cavazzi considers them \u201cridiculous and superstitious,\u201d stating that these laws \u201chave as their object some prescriptions which, from one moment to another, are invented by cunning and discerning sorcerers, according to the opportunity and genius of those wretches\u201d . Sorcerers is how he pejoratively refers to the ngangas, or gangas, as African priests were called, who, according to him, \u201cdeal with private life, disputes, diseases, the dangers of death, and other similar subjects\u201d . Quijila was in his perspective the negation of Christian principles and the symbol of the barbarity of the Jaga. It also echoed the view that the Ambundu had of these commandments, which they considered inhumane, since in Mbundu cosmology they were considered cruel.From the Capuchin\u2019s description, it can be seen that the alimentary prohibitions did not correspond to the entirety of the Ijila, but were part of the domestic quijila, imposed by priests and transmitted from ancestors by oral tradition. The prohibited animals were \u201cpork, elephant, snake, and other animals\u201d , however Cavazzi does not specify what penalties offenders suffered, nor that it caused a disease. The prohibition of the eating of certain animals, especially those of a large size, was not exclusive to African peoples, but recurrent in various cultures, including in seventeenth century Europe, in which it acquired various functions, especially the reservation of the meat of some animals, mainly of a large size, to privileged individuals, generally from a superior hierarchical position, such as kings .Ijila were first adopted by part of the Ambundu population during the reign of the famous queen Jinga or Njinga, who claimed for herself in 1624 the Ndongo throne. Fighting against the Portuguese, who had the support of some allied Jaga (who immediately abandoned ijila), she established an alliance in 1629 with the Imbangala chief Cassa, with whom she actually married, adopting the Jaga traditions and assuming chiefdom of the group. Under pressure from the war, in 1630 she established her kingdom in Matamba, west of the Cuanza river, from where she commanded resistance to the Portuguese until 1656, when she made a treaty with the Portuguese and reconverted to Catholicism, which she had professed during her youth.Without ever totally abandoning lineage as a group identity, as she carried with her a funerary urn with the bones of her ancestors, Njinga also adopted the ijila precepts and prohibitions  was one of the most important of these. In his writings the cleric warned that \u201cthese Blacks practice various superstitions,\u201d which he \u201cdid not like to narrate, since they are ridiculous,\u201d and apologized that he did so \u201conly to instruct missionaries, so that they could take the Blacks away from their errors.\u201d Among these errors, his greatest condemnation was aimed at the quijila which he attributed to the Jaga.Even after the arrival of the Capuchins, Nijinga behaved in a paradoxical manner. On the one hand, she transformed \u201cMatamba into a center for spreading Catholicism\u201d , p.143, Under the pressure of the clerics, during her reign, \u201cthe kijila laws [lost] force, in favor of Ambunu rules\u201d and \u201cher people constructed new identities, resulting from the situations then being experienced\u201d, which combined \u201ctraditional elements with the innovations introduced by the missionaries\u201d ,\u201d since \u201cthey are certain that they will die soon\u201d (Merolla da Sorrento\u2019s description of quijila was different from that of Cavazzi in a number of ways: (1) it no longer refers to one of the rules of ijila but to an oath; (2) it was limited only to the prohibition of food; (3) the main transmission of prohibition is through the mother and only in her absence through the native priests; (4) the forbidden food is slightly different and prescriptions have been added referring to the preparation of food; (5) disregarding the prohibition would result in the death of the transgressor. Since it is known that Sorrento was an attentive reader of Cavazzi\u2019s book, which also served as inspiration for his own, these differences could not be credited to his ignorance of the latter work or of Kiongo, or to difficulties of understanding what he had observed, but rather to the transformations which operated in the local culture under the impact of Catholicism and, especially, the progressive hegemony of Ambundu customs over the Jaga among the Angolan Bantu and even among the Congolese, since cultural exchanges among these peoples were frequent. The missionaries were implacable towards human sacrifice, which was an important part of ijila, and they persecuted and sought to delegitimate the power of African religious leaders.Various historians of Africa use the concept of creolization  as a theoretical tool to understand the transformations operated in Central West Africa under the impact of Christianity and the socio-political institutions introduced by the Portuguese, although they do not always agree on its meaning. According to James However, the transformations operated in Central West Africa in a short period of time in Africa can only in part be credited to the action of Catholic missionaries, who could be condescending towards alimentary restrictions, but not to the human sacrifices of the Jaga\u2019s ijila. The fact that the main transmission link was transferred, as Merolla da Sorrento certifies, from the nganga to the mother did not occur only due to the impact of Christian clerics. Rather it is also a reflection of the progressive hegemony of Ambundu cosmology in the Jaga-Ambundu communities, which brought together those who resisted the Portuguese in the interior of Angola. For the Ambundu, \u201cthe cult of ancestrality had a specific role in articulating social relations within the kinship group (lineages)\u201d , p.153 aThe undated and anonymous Portuguese manuscript \u201cRitos gent\u00edlicos e superti\u00e7\u00f5es que observam os negros do gentio desse reino de Angola desde o seu nascimento at\u00e9 a morte\u201d (Gentile rites and superstitions observed by the gentile blacks of this kingdom of Angola from birth to death) provides other clues about the creolization process which, still in West Central Africa, operated within the concept of quijila. Amongst other topics, it describes the infirmities and healing rites used in Angola which, as can be observed from the title, is described from the anonymous author\u2019s point of view, who always sees them negatively, pejoratively classifying them as superstitions and gentilic rites, in other words, pagan or idolatrous.What calls attention in the text is that the role of the ngangas is said to be restricted to the healing of illness, while they are described as a mixture of sorcerers and surgeons. The latter is the term which the author of the manuscript finds in European culture to identify to them by analogy. It is evident to the European reader that, as surgeons, they had practical knowledge, though they were badly educated and ill-prepared, which implied their disqualification in relation to doctors, the only ones who had erudite knowledge. The use of the term surgeon and the way their role is described obliterates the important religious roles and the part they played in the transmission of the customs and rites of the ancestors which the nganga still performed in Africa. In the text, their action was circumscribed to looking after the sick and to prescribing the customary treatment since, due to the pressure of the Portuguese, in spiritual questions they were increasingly replaced by Catholic priests or had to camouflage their spiritual actions as curative practices.Ritos gent\u00edlicos... , \u201cwhen some [individual] seems sick with a lesion, in their understanding they said he has quilundos, [and] for those who cure themselves they consult a surgeon called nganga de quilundos, ... and the so-called surgeon goes to another room without anyone, where they invoke the devil, whom he consults about the illness.\u201d Once \u201chealth is achieved, the quilunfo is celebrated, which is the idol invoked with much comiraina  in thanksgiving.\u201d For the anonymous author, popular medicine and sorcery were consubstantiated in the practice of the ngangas, who invoked for healing not only their idols, but the devil in person, which signified the reading of their rites and their beliefs from a Catholic point of view, condemning them, since idolatry and demonology marked their practices of cure. Africans were seen as others, and their religion as something of the devil . The treatment consisted of the sacrifice of goats and chickens, offered to the idol, whom the ngangas invoked. Once health is recovered, \u201cthe surgeon \u2026 gave those cured their precepts of eating or not eating this or that, precepts which were called Quigilles, which they strictly observe\u201d (f.2). Quijila continued to refer to the \u201cprecepts of eating or not eating this or that,\u201d but which now are restricted to the period of convalescence of a specific disease, quibuco, and prescribed by the nganga, recovering in part the latter\u2019s role as intermediary with the supernatural, but restricted to the universe of healing diseases.Although the text is not dated, it can be seen that new transformations were taking place. Disconnected from the ijila, of which only the name was preserved, quijila was no longer a rule, nor a broad set of food prohibitions, but had become restricted to an alimentary diet, prescribed by the ngangas, though only after the curing of the illness of quibuco. For the first time, quijila is associated with a specific disease, although it is not the disease in itself, but the consequences of breaking the diet are not described. It is thus not exactly a taboo.Above all, this description of quijila reveals that, over time, it became a rite observed by all the \u201cgentile Blacks in this kingdom of Angola,\u201d no longer being restricted to the Jaga, nor circumscribed to the Matamba kingdom. Stripped of its original meaning, it spread through the Ambundu populations in the region of Portuguese Angola. This expansion reveals once again the creolization which the different cosmologies of the local Bantu peoples underwent, as they exchanged rites and beliefs. A key to understanding this consubstantiation and its dissemination is Cavazzi\u2019s affirmation that after the deaths of Nzinga and d. B\u00e1rbara, her successor Jinga-Mona invoked through the xinguilas the spirit of the former in a public square, re-enacting the importance of lineage to structure his power. However, after this, \u201che ordered that all the prisoners from the previous expedition be sacrificed\u201d and \u201cand that the stomachs of many of those present be cut open and both he and the soldiers be sprinkled with their blood, making happy wishes for their prosperity\u201d . This was a restaging of the most important quijila of the Jaga, the one instituted by Queen Temba-Ndumba, which was followed by her successors, including Nijinga, which consisted of anointing the body before a war with a magical ointment, the principal ingredient of which was the bodies of the sacrificed children. It can be noted that Jinga-Mona legitimated his power by staging important rites for the Ambundu and Jaga and after the ceremony, he sent \u201cmessengers all over the kingdom that ... the old ceremonies be renewed and that each person could live freely according to the Jaga rites ... and without any impediment at all reintroduced the old rites\u201d .At the beginning of the eighteenth century, according to Rafael Bluteau\u2019s Portuguese dictionary, published in Lisbon in 1720, quigila (written with a \u201cg\u201d) came to be seen as a \u201ccurse, which the parents of the Blacks of Angola tell their children, saying that if they eat venison, lamb etc., it will curse them, and they say that if they eat it, they will see spots or other marks, and die\u201d , p.58. CThe term curse circumscribes the comprehension of African culture as sorcery, as was typical of Europeans, which echoed the intolerance of Catholic missionaries to African rites and beliefs. On the part of the Church, there was a model in which \u201cmasters and slaves, whites and Blacks had to be Christians above all ... In this model, there was no tolerance of practices of an African origin, seen as demonizing\u201d , p.229. Ritos gent\u00edlicos... Also missing is an explanation of the meaning and the reason for these prohibitions, or why they are limited to only two animals \u2013 deer and sheep. Perhaps the dictionarist did not know. The choice of these animals seems to have arisen out of disputes in Europe between kings and subjects and in the Americas between masters and slaves for large game hunted in the forests and the need to preserve the herds of the firsts in light of the daily hunger of the slaves. In this sense, the mention of sheep and deer and the transmission of the curse by parents and not only by the mother added a further ingredient to the creolization of quijila, the Atlantic slave trade and the massive importing of slaves into Portuguese America, which brought with it a repertoire of beliefs and customs already being transformed in West Central Africa and which, after crossing the Atlantic, suffered new pressure for change.According to Bluteau, at the beginning of the eighteenth century, the belief in quijila was shared by all Africans in Angola, without distinguishing the group to which they belonged, and incorporated elements of Jaga culture, the case of the food restrictions, and also of the Ambundu, with the importance given to lineage \u2013 the curse came to be imposed by the parents and not only by the mother, as had appeared among the Kimbundu. In this sense, he returned to Merolla da Sorrento\u2019s information that the intermediation of native priests was no longer necessary, revealing the decline in their power in light of the advance of Catholicism in Africa, but also in the Americas, where slaves faced numerous difficulties to transplant their cults intact, one of which was the absence of their religious leaders. Nor is there any mention of it being a diet followed during a period of convalescence, or any relationship with a cult in particular, the case of quibuco, as has been described in The wars which the Portuguese waged in the interior of Angola during the seventeenth century against the Jaga and especially against the resistance led by Queen Njinga in Ndongo and Matamba, produced numerous slaves for the Atlantic trade. After 1649, the flow of slaves increased following the defeat of Njinga and the signing of the peace treaty, which reopened the markets of the interior of Angola, allowing the Portuguese to supply themselves with slaves. On this occasion, the queen sent a present to the governor, the bishop, and the main judge  of Luanda, consisting of \u201csome heads of slaves from the runaway people,\u201d who had lived in the kingdom for a long time, as well as the 2000 she sent as a ransom for her sister who was imprisoned in the capital , their beliefs crossed the Atlantic, it is thus worth inquiring how knowledge of quijila was transmitted among slaves in Minas Gerais, what meaning it acquired among them, and if it spread to slaves with other origins. Studies of slavery in Brazil have increasingly incorporated the problematization of the \u2018survival\u2019 of African cultures in the Americas and the \u2018adaptations\u2019 which they underwent in the new context\u201d , p.124. In accepting the occurrence of a process of Africanization in the Minas senzalas, it becomes less important to know the origins of those affected by quijila who bathed in the lake. Five were slaves and one was a freedman, though for only two of them is it certain that they are African: the Black freedman Francisco Xavier Barreto (case 12), since the designation of color, Black man or woman, was attributed in the captaincy to those brought in from Africa via the slave trade, in contrast with the creoles, as those born in Brazil were called; and Manoel, the slave of Manoel Rodrigues (case 75), since he had contracted the disease in Africa 17 years before coming to Brazil . Unfortunately, this text has been lost.According to Antonio Cialli , Quijila \u201cwas a really horrible and incurable disease, very frequent among Blacks ..., with true cancerous wounds  various times during a two-month period, he found himself healthy\u201d . To the surprise of all, \u201cwithin a few weeks of these baths, they noticed that he was stronger and the sores had another appearance, until they finally admired the improvements, and within a few months, he was completely free and this horrible disease was extinct\u201d .After Father Antonio de Miranda visited the plantation, the news about the curative virtues of the waters of lagoa Grande began to spread. At the end of February 1749, the cleric reported in Sabar\u00e1, amongst other things, the curing of the slave Antonio\u2019s quijila and the news spread rapidly among the nearby slave plantations. Reaching the lake on 19 March, Cialli  found there some people suffering from the illness bathing there and revealed that \u201ctheir fingers were already consumed, clearly healing,\u201d revealing that those who came to the lake to cure themselves of the disease were more numerous, though his manuscripts mentioned only the first of those who were cured there. It should be noted that there was a significant number of slaves from the Real Extra\u00e7\u00e3o dos Diamantes , sent from Tejuco by the doctor of the local hospital, to bathe in its waters, but it is not possible to know the diseases which affected them .In May, as well as Antonio, another five people suffering from quijila showed marked improvements. These were, (1) Antonio, the slave of Lieutenant Manoel Teixeira Lomba, whose hands and feet were crippled by the disease, but who, after bathing in the lake, was capable of walking; (2) the Black freedman Francisco Xavier Barreto, a resident in Funil, near rio das Velhas, whose \u201chands were crippled\u201d and which, \u201cafter washing a few times, were almost naturally undone;\u201d (3) Jorge, a slave of Jacinto de S\u00e1, who found himself incapable of working since the illness had attacked his feet and eaten his toes, the reason for which his master had expelled him from the house, but who \u201cafter bathing himself for a month, found his sores healed, and almost all closed;\u201d (4) Paulo, the slave of Ant\u00f4nio Carlos Moreira, a resident in vila real de Sabar\u00e1, who had suffered from the disease for seven years, and who had \u201cthe beginning of quigila on his left leg,\u201d with the lower part, beside the tibia, being very swollen. The illness, \u201clike termites,\u201d had attacked one foot which, covered with wounds, had almost separated from the leg, but 17 days of bathing were sufficient for it to deflate and to return \u201calmost to natural\u201d size; (5) Manoel, a slave of Manoel Rodrigues, who had been in Brazil for 17 years, suffering from the disease for 30 years, as it had begun in Africa. First, his metatarsals were torn, after some of his toes fell, with the rest being very swollen. After bathing for \u201ca month and a half more than half\u201d of the sores were closed  is defined as the \u201cantipathy which the Blacks of Africa have to certain food or actions, so that, if they go against this, they suffer disease and perhaps even death follows.\u201d Once again there is no reference to the disease being limited to natives of Angola, nor does it distinguish the place where this spread, as it could be Africa, the New World, and even Portugal, to where the African slaves were sent. Nor are the types of prohibited food specified, while he adds that \u201csome say that these antipathies come from their parents and those who contravene them, come from another world to that of their souls\u201d , p.277. The novelty that Cialli and Morais e Silva show is that in Brazil quijila was transformed into a disease and, even though it only attacked Blacks, belief in its existence was shared among masters and slaves, the former exemplified in the doctor and dictionarist and the latter in the Blacks who looked for a cure in the lake. In the dictionary entry, under the rational enlightenment spirit, quijila was framed in the system of sympathies and antipathies, characteristic of Hippocratic-Galenic medicine, inserting this, in the same form as Cialli had done, in the epistemological foundations on which European knowledge was structured. Western culture appropriated, but at the same time modified, the Afro-American one forming in the New World, to adjust it to the European manner of comprehending the world, which can be understood as a process which I call \u201cinter-translation.\u201d This concept starts from the principle that transformations are operated while ideas (knowledge) circulate, either from where they start or where they arrive, when they are inter-translated and modified and thus molded to local conditions. When they adapt to new cultures, the same ideas irradiate again, even reaching the places from where they started, modifying in turn the culture which had forged them. This is what can be observed in the concept of quijila, which under the impact of Portuguese expansionism and colonial slavery, was transformed both in Africa and Brazil, undergoing transformation on both sides of the Atlantic, amalgamating itself as an original Afro-American culture which, unsurprisingly, also incorporated European elements and was shared by African slaves.Belief in the power of the waters of lagoa Grande to cure quijila, widely shared by the Blacks who headed there, their masters who allowed them travel, and the doctors who recommended the bathing, is also exemplary of the process of \u201cinter-translation\u201d which characterized this new original Afro-American culture.Ntinu-a-maza, which meant \u2018king of water,\u2019 ... hid his amulets under the current of a river\u201d (p.96), incorporating its beneficent virtues. The Jaga also adored water and Cavazzi felt that this adoration was \u201cmanifested in the veneration they demonstrated for rivers and lakes\u201d (p.215). He states that \u201cas soon as they discover water from afar, they prostrate themselves on the ground to worship it, address prayers, oblations, and vows to it in order not to be bothered by it, or to suffer penalties, not to succumb to diseases, and to be helped with their difficulties\u201d (p.215). Most important among their sacred places was the great lake of Saxia, located on the Upper Cuanza river, in the extreme west of Angola, beside the kingdom of Malemba, where Cavazzi saw with his own eyes these rites of adoration practiced among the local populations (p.215).In the Bantu cultural universe, \u201cwater was the element which divided the world of the living, of the Blacks, from the world of the dead, the whites\u201d , p.148. In European Hippocratic-Galenic medicine, water was also considered an element with a strong healing power, a fundamental part of the human body, and seen as healthy for all organs. This tradition went back to Western medicine practiced since Antiquity, with the Roman baths being famous. The idea of sympathy and antipathy among the four elements which composed nature and living bodies was a fundamental aspect of this theory and belief in the healing power of water followed the sympathetic path, due to the effects of the vapor from boiling water on the human body, which restored health and combated diseases. In Portugal and in Minas Gerais captaincy various sources of medicinal water were discovered in the eighteenth century , p.76-83It can be observed that the belief in the reparatory power of water was shared by European and African cultures, which explains why masters and slaves, coming from Minas Gerais and other captaincies  sought healing in the waters of lagoa Grande and, in a process of inter-translation, redefined in joint manner the comprehension and healing of quijila. For Europeans, more than any others, the lake symbolized the lavishness with which Divine Providence had blessed its waters. For Africans, it was one of the lakes where their gods \u201ctook shelter in its waters\u201d . If the souls of their ancestors and their curses were capable of crossing the Calunga Grande, as they called the Atlantic, and causing illnesses, so too could their gods and beliefs which protected their bodies already battered by the harshness of slavery.Gazeta M\u00e9dica da Bahia, on September 25, 1866, the doctor Julio Rodrigues de Moura, who worked in Rio de Janeiro, in a letter to the editor, considered quijila (with a \u201cj\u201d), which for him was only its \u201ccommon name,\u201d a disease of progressive muscular atrophy, associated with elephantiasis due to its \u201ccharacteristic symptoms,\u201d amongst which was \u201ccutaneous anesthesia\u201d . For this he drew on the statement by Doctor Ant\u00f4nio Jos\u00e9 Alves, professor of the Faculty of Medicine of Bahia, best known as the father of the poet Castro Alves . At least the African root of the word is remembered! Although Alves recognized that it was more frequent in those he identified as being from the \u201cBlack race,\u201d he did not grasp the fact that the reason for this resided in the culture of origin of those affected, where quijila found its meaning. He was more concerned in fitting the disease into the nosological framework of western erudite medicine.In ro Alves , p.9-15,quisilia to, to anger, to bother, to upset ... to enrage\u201d and the adjective \u201cquisilento,\u201d meaning \u201cprone to quisilia, which causes quisilia\u201d  was already used with the generic, \u201cfamiliar,\u201d meaning of \u201cantipathy, aversion,\u201d while it is also added that it was a \u201cword from Ambundu language\u201d , p.540. uisilia\u201d , p.1458.Between the seventeenth and nineteenth centuries, quijila was transformed between Africa and Brazil, as a result of the African internal dynamics, the advance of Europeans on the continent and, finally, the conditions imposed by the slave trade and the hardships of slavery in Americas. In an inter-translated dialogue of memories and forgetfulness, on both sides of the Atlantic, Europeans, Brazilians and Africans shared and shaped a new culture and quijila was an example of the limits, possibilities and impossibilities of their cultural dialogues."}
+{"text": "Programa Maior Cuidado (PMC \u2013 Greater Care Program), aiming at the development of actions that contribute to the improvement of the services provided. To understand the perception of different actors involved in the older adults care process in the intersectoral strategy of the  Eleven qualitative interviews guided by a semi-structured script were conducted in 2020 with key informants directly involved in the PMC: the older adults and their families, caregivers, health professionals and social assistance. In addition, to understand the functioning and proposals of the PMC, a documentary analysis was also carried out with the tracking of existing information on the guidelines, protocols, and management instruments. The content analysis technique was used to classify textual data, and the interpretation process was mediated by the theoretical-methodological framework of hermeneutic anthropology.Institui\u00e7\u00e3o de Longa Perman\u00eancia - ILPI in Portuguese). Chronic comorbidities increase the demands of health care and generate situations that can be managed by the PMC caregiver. Population aging requires the planning of strategies and public policies aimed at providing continuous care for the older adults, including those living in communities. The PMC emerges as an intersectoral alternative to assist in this issue. Two categories were identified: \u201cRepercussions of the care offered by the PMC: the \u2018little\u2019 that makes a difference\u201d and \u201cProblems beyond the PMC: the limits of family care in the face of violence against the older adults\u201d. For all interviewees, the perception the PMC is very necessary is unison, being able to minimize the occurrence of health problems and avoid transfers of the older adults to hospitals and Long Stay Institutions for the Elderly ( The PMC can be considered a good practice model to be expanded to other locations, however there are gaps that need to be rediscussed so that its processes are improved and its results enhanced. By extension, older adults can also have their life condition defined from the care offered to them2, favoring their stay at home and avoiding hospitalizations and institutionalizations, costly outcomes for the public system and society4. Even for independent individuals to perform activities of daily living the presence of close people is reflected in well-being and quality of life3.In parallel to demographic and socioeconomic issues, the provision of care to the older adults reflects multivariate perceptions about old age, family rearrangements and the greater role of women \u2013 the main caregiver \u2013 in addition to domestic tasksProgram Acompanhante do Idoso (PAI \u2013 Companion of the Older Adult), in the city of S\u00e3o Paulo (SP). There are 49 multidisciplinary teams, each of them working in a Basic Health Unit, with coordinator, physician, nurse, two nursing assistants/technicians, administrative assistant and ten older adult companions, to guide the provision of home care to about 5,800 older adults in fragile situations5. In Belo Horizonte (MG), in 2011, the Programa Maior Cuidado (PMC \u2013 Greater Care Program) was instituted, an intersectoral policy \u2013 co-management between the municipal secretariats of Health and Social Care \u2013 for home care for dependent and semi-dependent older adults living in conditions of clinical and social vulnerability. With simpler design, at the local level, the PMC is performed in all 34 Reference Centers in Social Assistance  and half (72) of the teams of Health Centers6. The PMC offers a \u201csocial caregiver\u201d \u2013 a professional trained for home care for the older adults \u2013 who works on days and times previously established by a multidisciplinary team, according to the degree of dependence and complexity of each case. The hiring of caregivers is carried out by a Civil Society Organization affiliated to the municipality. The care routine for the hired professionals includes support for personal hygiene, food, medication, guided physical exercises, diaper changes and dressings, as well as recreational and social activities that promote the participation of the older adults. Among the eligibility criteria for admission to the PMC, we highlight age ; the classification of the degree of functionality \u2013 dependent or semi-dependent \u2013 for the performance of activities of daily living and socioeconomic evaluation that confirms vulnerability. Currently, 167 social caregivers monthly assist about 650 families of the older adults within this and/or other support networks. The PMC is fully funded by the Municipal Treasury, without co-financing of federal policies. The objective of this article was to understand, with the help of the qualitative approach, the perception of actors involved in the older adults care process about the functioning of this intersectoral public program.In Brazil, since 2008, there is the 7, proposed by the Ren\u00e9 Rachou Institute (Fiocruz/MG) and approved by the institution\u2019s ethics committee (CAAE: 96033418.9.0000.5091). This is an international partnership signed between the Medical Research Council (UK), Funda\u00e7\u00e3o de Amparo \u00e0 Pesquisa do Estado de Minas Gerais and Funda\u00e7\u00e3o Cearense de Apoio ao Desenvolvimento Cient\u00edfico e Tecnol\u00f3gico, whose basic objective is to support public policies from the identification of successful practices that contribute to the reduction of unnecessary and prolonged admissions and hospitalizations of Brazilian older adults in hospitals and Institui\u00e7\u00f5es de Longa Perman\u00eancia para Idosos (ILPI).Data presented are based on the qualitative branch of a larger study, which used a multi-method approach8, the identification of potentialities, and possible bottlenecks faced in practice.Studies with qualitative components can help understanding the functioning of services based on the experience lived by the actors involved \u2013 professionals and users9. Due to the frailty of the older adults participants in this study , the reports of family caregivers were more prevalent compared to those of the assisted older adult.In 2020, 11 interviews were conducted with a semi-structured script together with key informants, being: four older adults ; two technical references of the PMC representatives of the Health and Social Assistance axes; two professionals of the Health Center and three caregivers of the Program . The final number of interviewees was regulated and determined by the criterion of empirical data saturationAll interviews were recorded and later transcribed literally. In addition, to understand the functioning and proposals of the PMC, existing information on the guidelines, protocols, and management instruments were analyzed.10, performed in three stages:Data were systematized using the Bardin content analysis techniquePre-analysis, in which each interview was transcribed and identified to facilitate the organization of the data;Exploration of the material, through fluctuating readings in all responses of each interviewee for the definition of categories of analysis; and also10, based on a careful and critical reading of the speeches, with the definition of codes to form categories of incidence and contextual similarity.The interpretation of the results after reflective analysis11.The data were organized in spreadsheets in the Excel Program and all excerpts were categorized and coded, allowing the identification of themes and subjects of greater relevance. From this categorization, were performed: 1) critical reading of responses; 2) analytical reflection; and 3) identification of final categories. To ensure the analysis validation, classification was performed independently by three researchers. The entire analysis process was emic and guided by the theoretical-methodological framework of hermeneutic anthropology, whose analysis is anchored to the interpretation of the meaning that social groups attribute to certain practices, considering the sociocultural context of action and the factors that influence itTo ensure anonymity, the participants were identified, respectively, according to the category belonging to the PMC \u2013 older adult user, family caregiver, social caregiver, Technical Reference (RT) of the PMC health and/or Social Assistance axis, gender  and their age.Regarding the characterization of the interviewees, two older adults were male and two were female, between 77 and 92 years old, and mean stay in the Program was 5.7 years. All three social caregivers were women between 25 and 44 years old, and had been working in the PMC for an average of 13 months. The four RT were women \u2013 three nurses and a social worker \u2013 with ages ranging from 43 to 60 years. The two family caregivers interviewed, one 42 years old and the other 61 years old, were daughters of the older adults.Repercussions of the care offered by the PMC: the \u2018little\u2019 that makes a difference\u201d and \u201c Problems beyond the PMC: the limits of family care in the face of violence against the older adults\u201d, each of them organized into subcategories as will be presented below.The content analysis identified two major categories: \u201c In this category, the elements linked to the care offered by the PMC at home and its impact on the various actors involved are presented. From it, three subcategories emerged, as presented below.Repercussions for the older adults \u2013 the interlocutors identify the effectiveness of the PMC in responding to conditions of social vulnerability and health of the older adults:In subcategory 1 \u2013 She [social caregiver] is here every day, looks at me, talks to me\u2026 helps me shower (\u2026) If I feel dizzy it\u2019s good to have someone to hold on to. (\u2026). This program serves me well. There wasn\u2019t even one that didn\u2019t take good care of me. They all take care of me with the \u201cgreatest care\u201d (Older adult 2. M. 92 years old).In the short time they are in residence, we noticed the older adults had improvement in conditions or some did not worsen, which is already a great gain (\u2026). This avoids not only hospitalization, but also (\u2026) an early death due to lack of care \u201d .We noticed improvement, both in mood and in coexistence. There are older adults who come to the house and they do not walk, because they have some difficulty. Then we start doing some activities, with the guidance of the physical therapist, and then they become more active and we see an improvement. Because let\u2019s think like this: the physical therapist gives some guidance there at the Post, but if there is no one to help you, it\u2019s no use. (\u2026) more often than not, the family member does not have time for these issues .a short time, as small actions that make a lot of difference, especially in the recovery of functionality of the older adults. In addition, the interlocutors consider that the health of the family nucleus is affected by the need for daily care, as explained in subcategory 2 \u2013 Repercussions for the family:In the universe researched, the role of caregivers at home is emphasized, albeit for The dependent or semi-dependent older adult makes an entire family sick (\u2026)..My mother was already gone [deceased] without the caregiver... because I had some phases of getting very tired, exhausted from having to take care of my mother (Family caregiver \u2013 daughter. F. 61 years old).I, as a caregiver, working in that house, at that time when the family member needs to leave, he will leave and return quietly and safely, for having left the older adult with someone .Repercussions for the social caregiver:In addition to observing the positive impact on reducing the burden of care imposed on the family member, the PMC functions as a source of income and a tool of social inclusion for the social caregivers themselves, as presented in subcategory 3 \u2013 It is a program that also helps caregivers. Also residents of areas with high social vulnerability, violence etc. This also influences their sensitivity with care for the older adults and also the pride of \u201cwearing the shirt\u201d of the Program. (\u2026) Some had long been unemployed and found this job opportunity. In one of the trainings that the central level does with these caregivers, (\u2026) the facilitator asked them to take an object that referred to the meaning of the Program in their lives (\u2026) several caregivers took the work card with the registration of the contract .Convinced that the Program avoids physical and mental problems, prevents early deaths, helps in functional recovery, allows a breath for family members and translates into care for the person assisted, the different actors also recognize their limits, as will be seen in the next analytical category.This category presents several factors and conditions that cross the performance of the Program, including the presentation of vulnerabilities, difficulties and insufficiencies that the PMC faces, organized into three subcategories.Subcategory 1 \u2013 Poverty, vulnerability, food insecurity:The program itself is very good, but it has some problems that go beyond that. How can we solve the problems of poverty and vulnerability? It\u2019s something that is a limit for us. (\u2026) The Program comes to help the older adults, unburden the family, go out with the older adults, give a bath. But sometimes we come to the house and have to use our imagination to try to make something for him to eat. Or what\u2019s worse: sometimes there\u2019s absolutely nothing to eat .We have many precarious conditions of hygiene, of food. So, it is not enough just to be careful with techniques. There really is a need for economic care, food, a decent place to live. Without the basics, it ends up aggravating a situation that could be minimally avoided if the family had any condition .Many of the low-income families assisted are unable to provide basic care, adequate food and sanitary conditions, or to hire caregivers or people to assist them in caring for the older adults.Subcategory 2 \u2013 Insufficiency of care linked to violation of rights:When the caregiver reports to us, with all care, that there is abandonment (\u2026): \u201cI have been trying to make tea for a week, but there is no tea. B-U-T\u201d. She has already asked the family to buy or that the family has the benefit card of the older adults and the food is missing. These are situations that go beyond the performance and attributions of the caregiver\u201d .There is a family that recognizes the caregiver more as an intruder inside the house, especially when it begins to realize that the caregiver acts as \u201ceyes and ears\u201d, and ends up no longer wanting this person inside the house\u201d (RT PMC \u2013 Sa\u00fade. F. 43 years old).Abandonment or neglect of the family reveals the insufficiency of care linked to the risk or violation of rights and, often, the caregivers of the PMC are spokespersons for situations that involve a myriad of complexities beyond professional performance.Subcategory 3 \u2013 Institutionalization as a last option:When we\u2019ve exhausted everything we could do. For example, changing caregivers at home. In some cases, we perceive a situation of violation with an accountability of the people who live in that house .When all possibilities of attempts to improve the bond of the older adults with the family are exhausted. Because\u2026 it\u2019s not always due to negligence (\u2026). It is the reflection of a construction well done or not, throughout the life story of that family. (\u2026) We also find it very difficult [to institutionalize], especially with vacancies. And even more, to prove that this situation is happening .One of the basic objectives of the PMC is to avoid and/or delay institutionalizations. However, there are issues of social vulnerability, violation of rights, and family dynamics that make the continuity of care unfeasible. In these cases, institutionalization appears as the last/only option.In 12, which are mainly responsible for hospital admissions and clinical emergencies for the Brazilian older adults13. Thus, it is crucial to create new strategies or restructure existing health services to prevent potential diseases that may affect the older adults population. Absent or insufficient socio-sanitary care can lead to overload of health services and, by cascading effect, result in hospitalizations and institutionalizations14.As seen in Transfer\u00eancia Evit\u00e1vel de Domic\u00edlio - TED in Portuguese), Lloyd-Sherlock et al.15 propose that policymakers define criteria to characterize unnecessary/prolonged hospital admissions and institutionalizations of the older adults and improve existing protocols and practices15. The PMC is able to minimize or avoid the number of TEDs by offering direct home care, which, by extension, enables a form of surveillance \u2013 based on adequate guidance and control \u2013 for older adults with high potential for clinical diseases. A quantitative study on the use of health services among PMC users showed that the assisted population has more access to rehabilitation and planned consultations in the health network than the unattended16. From this perspective, the PMC can be classified as a model of good practice, to be expanded to other Brazilian states and municipalities, in addition to being understood as a social innovation, a care technology that contributes to the prevention and treatment of this public in its own habitat, that is, the Aging in Place (AiP). AiP means having the health and social support needed to live safely at home or in the community in the aging process17.When analyzing the predictors of hospital admission and suggesting the new concept of Avoidable Displacement from Home 21.When discussing \u201c22. In this study, family caregivers were daughters of the older adult and reported work overload and abandonment of their own activities in favor of the care of the other. Women constitute the majority of the older adult population, spend more time exposed to pathophysiological risks and are the main caregivers22. As vulnerable to care issues, they deserve the attention of managers and health systems.Usually, the family caregiver does not have the preparation or technical skills necessary for the care of an older adult23. There is talk of family insufficiency, a condition that compromises the functionality and quality of life of the older adult. However, this is not a matter of family insufficiency, but of insufficient care policies to support families in their need for care23.In matters related to the family, the PMC contributes to family caregivers in practical day-to-day work, helping them to resume their daily activities and reducing part of the work overload imposed by care. When the family does not present conditions  for care, the older adult is exposed to risky situations24.In this context, once the possibilities of solving problems have been exhausted, institutionalization is considered the best care option. However, bottlenecks are identified in the public network to effect this form of care. A study carried out in 2014 identified that in Belo Horizonte, 73.1% of philanthropic ILPI had waiting lists, with 9.7% accepting only independent older adults; 20.1% only independent or semi-dependent older adults; 48.1% of ILPI did not receive older adults with dementia and 52.2% refused new residents who presented certain diseases, such as infectious ones23.Thus, care is assumed as a transversal dimension of the health and well-being of citizens of all ages, and it is up to the State and society to seek equity in resources, the sharing of tasks between genders, and dignity in the care of people of all ages6. Thus, the Program is part of the care networks, especially in primary care \u2013 a priority level to assist and monitor the health status of the older adults population25.A key point of the PMC is its intersectoriality that connects different actors and multidisciplinary teams and permeates all operations of the Program: joint meetings for case review, combined contributions in individualized care plans and continuous communication with caregivers26.Another important element related to the role of social caregivers in the Program is their social inclusion through formal work. With salary comes the definition of specific roles and clear responsibilities, including working time in each household. Experiences with volunteer caregivers in countries such as Costa Rica and Thailand show that while these provide some support, their contributions are limited and inconsistentThe Program operates in communities that face problems and deprivations of the most diverse orders, but a central issue of the PMC is not to be restricted to the physical-functional health of each older adult, but to consider the situational context to offer more comprehensive strategies of support, carry out direct monitoring of the assisted older adult and reach the other people and policies involved, beyond the home. In the universe researched, for all different actors the perception the Program is very important is unified and presents strategies and positive implications for different axes of action. Its objectives and actions are clear, however, gaps persist to be rediscussed in the performance scenarios so that the Program has increasingly successful processes and results.This study carried out a qualitative analysis of the PMC \u2013 intersectoral action strategy that offers care to the older adults in situations of high clinical and social vulnerability in Belo Horizonte. The Program, as a social innovation, provides the opportunity for participants to develop a dignified old age, with support in activities and relief for the work overload of family caregivers. With actions and basic care guidelines, it proved to be an initiative capable of minimizing the occurrence of health problems, so to avoid hospitalizations and institutionalizations.This article has as its main limitation the difficulties encountered during data collection due to the lack of registration and systematizations in regional health that adhered to the PMC, a situation that has been corrected from the research itself.In this context of aging, listening to the actors involved in the PMC enabled an expanded understanding of the multiple issues involved in care and public policies, especially in areas of greater social vulnerability, such as the PMC\u2019s locus of action. This research is expected to raise new discussions and strategies that contribute to the strengthening of the Program and construction of care policies for the older adults. 1, al\u00e9m de inaugurar discuss\u00f5es acerca da necessidade de pol\u00edticas de sa\u00fade voltadas ao provimento de cuidados a pessoas idosas dependentes2.O envelhecimento populacional introduz quest\u00f5es econ\u00f4micas, de prote\u00e7\u00e3o social e de melhorias na aten\u00e7\u00e3o \u00e0 sa\u00fade da pessoa idosa3. Por extens\u00e3o, as pessoas idosas tamb\u00e9m podem ter sua condi\u00e7\u00e3o de vida definida a partir do cuidado que lhes \u00e9 ofertado2, favorecendo a perman\u00eancia delas no domic\u00edlio e evitando hospitaliza\u00e7\u00f5es e institucionaliza\u00e7\u00f5es, desfechos onerosos para o sistema p\u00fablico e \u00e0 sociedade4. E, mesmo para indiv\u00edduos independentes realizarem as atividades de vida di\u00e1ria, a presen\u00e7a de pessoas pr\u00f3ximas reflete-se em bem-estar e qualidade de vida3.Em paralelo \u00e0s quest\u00f5es demogr\u00e1ficas e socioecon\u00f4micas, a oferta do cuidado \u00e0 pessoa idosa repercute percep\u00e7\u00f5es multivariadas sobre a velhice, rearranjos familiares e o maior protagonismo da mulher \u2013 principal cuidadora \u2013 para al\u00e9m das tarefas dom\u00e9sticas5. Em Belo Horizonte (MG), no ano de 2011, foi institu\u00eddo o Programa Maior Cuidado (PMC), uma pol\u00edtica intersetorial \u2013 cogest\u00e3o entre as Secretarias Municipais de Sa\u00fade e Assist\u00eancia Social \u2013 para o cuidado domiciliar a idosos dependentes e semidependentes que vivem em condi\u00e7\u00f5es de vulnerabilidade cl\u00ednica e social. De desenho mais simples, em n\u00edvel local, o PMC \u00e9 executado em todos os 34 Centros de Refer\u00eancia em Assist\u00eancia Social (Cras) e metade (72) das equipes dos centros de sa\u00fade6. O PMC oferece um \u201ccuidador social\u201d \u2013 profissional capacitado para o cuidado domiciliar a idosos \u2013, que trabalha em dias e hor\u00e1rios previamente estabelecidos por equipe multidisciplinar, conforme o grau de depend\u00eancia e a complexidade de cada caso. A contrata\u00e7\u00e3o dos cuidadores \u00e9 realizada por uma Organiza\u00e7\u00e3o da Sociedade Civil conveniada ao munic\u00edpio. A rotina de cuidado para os profissionais contratados inclui apoio para higiene pessoal, alimenta\u00e7\u00e3o, medica\u00e7\u00e3o, exerc\u00edcios f\u00edsicos orientados, trocas de fraldas e curativos, al\u00e9m de atividades recreativas e sociais que promovam a participa\u00e7\u00e3o do idoso. Dentre os crit\u00e9rios de elegibilidade para ingresso no PMC destacam-se a idade ; a classifica\u00e7\u00e3o do grau de funcionalidade \u2013 dependente ou semidependente \u2013 para a realiza\u00e7\u00e3o de atividades de vida di\u00e1ria e avalia\u00e7\u00e3o socioecon\u00f4mica que confirme a vulnerabilidade. Atualmente, 167 cuidadores sociais assistem, mensalmente, cerca de 650 fam\u00edlias dos idosos inseridos e/ou outras redes de apoio. O PMC \u00e9 totalmente custeado pelo Tesouro Municipal, sem cofinanciamento de pol\u00edticas federais. O objetivo deste artigo foi compreender, com a ajuda da abordagem qualitativa, a percep\u00e7\u00e3o de atores envolvidos no processo de cuidado ao idoso acerca do funcionamento desse programa p\u00fablico intersetorial.No Brasil, desde 2008, existe o Programa Acompanhante do idoso (PAI), na cidade de S\u00e3o Paulo (SP). S\u00e3o 49 equipes multidisciplinares, cada uma delas lotada em uma unidade b\u00e1sica de sa\u00fade, contando com coordenador, m\u00e9dico, enfermeiro, dois auxiliares/t\u00e9cnicos de enfermagem, auxiliar administrativo e dez acompanhantes de idosos, para orientar a presta\u00e7\u00e3o de cuidados domiciliares a cerca de 5.800 idosos em situa\u00e7\u00e3o de fragilidade7, proposto pelo Instituto Ren\u00e9 Rachou (Fiocruz/MG) e aprovado pelo comit\u00ea de \u00e9tica da institui\u00e7\u00e3o (CAAE: 96033418.9.0000.5091). Trata-se de uma parceria internacional firmada entre o Medical Research Council (Reino Unido), Funda\u00e7\u00e3o de Amparo \u00e0 Pesquisa do Estado de Minas Gerais e Funda\u00e7\u00e3o Cearense de Apoio ao Desenvolvimento Cient\u00edfico e Tecnol\u00f3gico , cujo objetivo basilar \u00e9 apoiar pol\u00edticas p\u00fablicas, a partir da identifica\u00e7\u00e3o de pr\u00e1ticas exitosas que contribuam para a redu\u00e7\u00e3o de admiss\u00f5es e interna\u00e7\u00f5es desnecess\u00e1rias e prolongadas de idosos brasileiros em hospitais e Institui\u00e7\u00f5es de Longa Perman\u00eancia para Idosos (Ilpi).Os dados apresentados baseiam-se no bra\u00e7o qualitativo de um estudo maior, que utilizou uma abordagem multim\u00e9todo8, da identifica\u00e7\u00e3o de potencialidades e poss\u00edveis gargalos enfrentados na pr\u00e1tica.Estudos com componentes qualitativos podem ajudar a entender o funcionamento dos servi\u00e7os a partir da experi\u00eancia vivida pelos pr\u00f3prios atores envolvidos \u2013 profissionais e usu\u00e1rios9. Devido \u00e0 fragilidade dos idosos participantes deste estudo , os relatos dos cuidadores familiares tiveram maior preponder\u00e2ncia, se comparados \u00e0queles da pessoa idosa assistida.Em 2020, foram realizadas 11 entrevistas guiadas por roteiro semiestruturado, junto a informantes-chave, sendo: quatro idosos ; duas refer\u00eancias t\u00e9cnicas do PMC representantes dos eixos Sa\u00fade e Assist\u00eancia Social; dois profissionais do Centro de Sa\u00fade e tr\u00eas cuidadores do Programa . O n\u00famero final de entrevistados foi regulado e determinado pelo crit\u00e9rio de satura\u00e7\u00e3o emp\u00edrica dos dadosTodas as entrevistas foram gravadas e, posteriormente, transcritas de modo literal. Adicionalmente, visando compreender o funcionamento e as propostas do PMC, foram analisadas informa\u00e7\u00f5es existentes sobre as diretrizes, os protocolos e os instrumentos de gest\u00e3o.10, realizada em tr\u00eas etapas:Os dados foram sistematizados a partir da t\u00e9cnica de an\u00e1lise de conte\u00fado de BardinPr\u00e9-an\u00e1lise, em que cada entrevista foi transcrita e identificada para facilitar a organiza\u00e7\u00e3o dos dados;Explora\u00e7\u00e3o do material, por meio de leituras flutuantes em todas as respostas de cada entrevistado para a defini\u00e7\u00e3o de categorias de an\u00e1lise; e ainda10, a partir de uma leitura atenta e cr\u00edtica das falas, com defini\u00e7\u00e3o de c\u00f3digos para formar categorias de incid\u00eancia e semelhan\u00e7a contextual.A interpreta\u00e7\u00e3o dos resultados ap\u00f3s a an\u00e1lise reflexiva11.Os dados foram organizados em planilhas no Programa Excel e todos os excertos categorizados e codificados, permitindo identificar temas e assuntos de maior relev\u00e2ncia. A partir dessa categoriza\u00e7\u00e3o aconteceram: 1) leitura cr\u00edtica das respostas; 2) reflex\u00e3o anal\u00edtica; e 3) identifica\u00e7\u00e3o de categorias finais. Para garantir a valida\u00e7\u00e3o da an\u00e1lise, a classifica\u00e7\u00e3o foi realizada de modo independente por tr\u00eas pesquisadores. Todo o processo de an\u00e1lise foi \u00eamico e orientado pelo referencial te\u00f3rico-metodol\u00f3gico da antropologia hermen\u00eautica, cuja an\u00e1lise ancora-se \u00e0 interpreta\u00e7\u00e3o do significado que os grupos sociais atribuem a determinadas pr\u00e1ticas, considerando-se o contexto sociocultural de a\u00e7\u00e3o e os fatores que o influenciamPara assegurar o anonimato, os participantes foram identificados, respectivamente, conforme a categoria pertencente no PMC \u2013 usu\u00e1rio idoso, cuidador familiar, cuidador social, Refer\u00eancia T\u00e9cnica (RT) do PMC eixo Sa\u00fade e/ou Assist\u00eancia Social, sexo (F para feminino e M para masculino) e a respectiva idade.Quanto \u00e0 caracteriza\u00e7\u00e3o dos entrevistados, dois idosos eram do sexo masculino e dois do sexo feminino, com idades entre 77 e 92 anos e m\u00e9dia de perman\u00eancia no Programa de 5,7 anos. Todas as tr\u00eas cuidadoras sociais eram mulheres, com idade entre 25 e 44 anos e trabalhavam no PMC em m\u00e9dia h\u00e1 13 meses. As quatro RT eram mulheres \u2013 tr\u00eas enfermeiras e uma assistente social \u2013, com idade entre 43 e 60 anos. As duas cuidadoras familiares entrevistadas, uma de 42 anos e outra de 61 anos, eram filhas dos idosos.Repercuss\u00f5es do cuidado ofertado pelo PMC: o \u2018pouco\u2019 que faz diferen\u00e7a\u201d e \u201cProblemas para al\u00e9m do PMC: os limites do cuidado familiar diante da viol\u00eancia contra a pessoa idosa\u201d, cada uma delas organizadas em subcategorias como ser\u00e1 apresentado a seguir.\u00c0 an\u00e1lise de conte\u00fado foram identificadas duas categorias maiores: \u201cNesta categoria, s\u00e3o apresentados os elementos vinculados ao cuidado ofertado pelo PMC no domic\u00edlio e seu impacto junto aos diversos atores envolvidos. Dela, emergiram tr\u00eas subcategorias apresentadas a seguir.Repercuss\u00f5es para a pessoa idosa \u2013 os interlocutores identificam a efetividade do PMC em responder a condi\u00e7\u00f5es de vulnerabilidade social e de sa\u00fade dos idosos:Na subcategoria 1 \u2013 Ela [cuidadora social] est\u00e1 aqui todo dia, me olha, conversa comigo\u2026 me ajuda a tomar banho (\u2026) Se eu tiver uma tontura \u00e9 bom ter algu\u00e9m para segurar. (\u2026). Esse Programa me atende at\u00e9 muito bem. N\u00e3o tem uma que n\u00e3o cuidou bem de mim. Todas cuidam de mim com o \u201cmaior cuidado\u201d (Idoso 2. M. 92 anos).No pouco tempo que eles est\u00e3o na resid\u00eancia, n\u00f3s notamos que os idosos tiveram melhora no quadro ou alguns n\u00e3o agravaram, o que j\u00e1 \u00e9 um grande ganho (\u2026). Isso evita n\u00e3o s\u00f3 interna\u00e7\u00e3o, mas tamb\u00e9m (\u2026) um \u00f3bito precoce por falta de cuidado \u201c (Enfermeira centro de sa\u00fade. F. 45 anos).Notamos melhora, tanto no humor quanto na conviv\u00eancia. Tem idosos que a gente chega na casa e eles n\u00e3o andam, por terem alguma dificuldade. A\u00ed a gente come\u00e7a a fazer algumas atividades, com a orienta\u00e7\u00e3o da fisioterapeuta e da\u00ed eles ficam mais ativos e a gente v\u00ea uma melhora. Porque vamos pensar assim: a fisioterapeuta orienta l\u00e1 no Posto, mas se n\u00e3o tem quem o ajude, n\u00e3o adianta. (\u2026) na maioria das vezes, o familiar n\u00e3o tem tempo para essas quest\u00f5es .pouco tempo, enquanto pequenas a\u00e7\u00f5es que fazem muita diferen\u00e7a, sobretudo na recupera\u00e7\u00e3o da funcionalidade do idoso. De forma complementar, os interlocutores consideram que a sa\u00fade do n\u00facleo familiar \u00e9 afetada pela necessidade de cuidado di\u00e1rio, como exposto na subcategoria 2 \u2013 Repercuss\u00f5es para a fam\u00edlia:No universo pesquisado, enfatiza-se a atua\u00e7\u00e3o dos cuidadores no domic\u00edlio, ainda que por O idoso dependente ou semidependente adoece uma fam\u00edlia inteira (\u2026).(RT PMC \u2013 Sa\u00fade. F. 43 anos).A minha m\u00e3e j\u00e1 tinha ido [falecido] sem o cuidador\u2026 porque eu tive umas fases de ficar muito cansada, esgotada por ter que cuidar da minha m\u00e3e (Cuidadora familiar \u2013 Filha. F. 61 anos).Eu, como cuidadora, atuando naquela casa, naquele hor\u00e1rio que o familiar precisa sair, ele vai sair e voltar tranquilo e com seguran\u00e7a, por ter deixado o idoso com algu\u00e9m .Repercuss\u00f5es para o cuidador social:Al\u00e9m de observar o impacto positivo na redu\u00e7\u00e3o da sobrecarga do cuidado imposta ao familiar, o PMC funciona como fonte de renda e ferramenta de inclus\u00e3o social para os pr\u00f3prios cuidadores sociais, como apresentado na subcategoria 3 \u2013 \u00c9 um Programa que tamb\u00e9m ajuda os profissionais cuidadores. Tamb\u00e9m moradores de \u00e1reas com alta vulnerabilidade social, viol\u00eancia etc. Isso tamb\u00e9m influencia nessa sensibilidade deles com o cuidado ao idoso e tamb\u00e9m ao orgulho de \u201cvestir a camisa\u201d do Programa. (\u2026) Alguns estavam h\u00e1 muito tempo desempregados e encontraram essa oportunidade de trabalho. Em um dos treinamentos que o n\u00edvel central faz com esses cuidadores, (\u2026) a facilitadora pediu para que eles levassem um objeto que remetesse ao significado do Programa na vida deles (\u2026) v\u00e1rios cuidadores levaram a carteira de trabalho com o registro do contrato (RT PMC \u2013 Sa\u00fade. F. 43 anos).Convencidos de que o Programa evita agravos f\u00edsicos e mentais, previne \u00f3bitos precoces, ajuda na recupera\u00e7\u00e3o funcional, possibilita um respiro para os familiares e se traduz em cuidado para a pessoa assistida, os diferentes atores tamb\u00e9m reconhecem os seus limites, como ser\u00e1 visto na pr\u00f3xima categoria anal\u00edtica.Essa categoria apresenta diversos fatores e condi\u00e7\u00f5es que atravessam a atua\u00e7\u00e3o do Programa, incluindo a apresenta\u00e7\u00e3o das vulnerabilidades, dificuldades e insufici\u00eancias que o PMC enfrenta, organizadas em tr\u00eas subcategorias.Subcategoria 1 \u2013 Pobreza, vulnerabilidade, inseguran\u00e7a alimentar:O Programa em si \u00e9 muito bom, mas tem alguns problemas que v\u00e3o al\u00e9m. Como resolver as quest\u00f5es de pobreza, da vulnerabilidade? \u00c9 algo que temos o nosso limite. (\u2026) O Programa vem para ajudar o idoso, desafogar a fam\u00edlia, sair com o idoso, dar um banho. Mas, \u00e0s vezes, a gente chega na casa e tem que usar a imagina\u00e7\u00e3o para tentar fazer alguma coisa para ele comer. Ou o que \u00e9 pior: \u00e0s vezes n\u00e3o tem absolutamente nada para comer .Temos muitas condi\u00e7\u00f5es prec\u00e1rias de higiene, de alimenta\u00e7\u00e3o. Ent\u00e3o, n\u00e3o basta somente o cuidado com t\u00e9cnicas. Precisa realmente do cuidado econ\u00f4mico, de comida, de lugar decente para viver (\u2026). Sem o b\u00e1sico acaba agravando um quadro que poderia ser minimamente evitado se a fam\u00edlia tivesse alguma condi\u00e7\u00e3o (Enfermeira centro de sa\u00fade. F. 45 anos).Muitas das fam\u00edlias de baixa renda assistidas n\u00e3o t\u00eam condi\u00e7\u00f5es de oferecer cuidados b\u00e1sicos, alimentos e condi\u00e7\u00f5es sanit\u00e1rias adequadas, nem de contratar cuidadores ou pessoas que as auxiliem no cuidado ao idoso.Subcategoria 2 \u2013 Insufici\u00eancia de cuidados ligada \u00e0 viola\u00e7\u00e3o de direitos:Quando a cuidadora nos reporta, com todo o cuidado, que h\u00e1 abandono (\u2026): \u201ctem uma semana que eu estou tentando fazer um ch\u00e1, s\u00f3 que n\u00e3o tem nenhum ch\u00e1. S-\u00d3 Q-U-E\u201d. Ela j\u00e1 pediu para que a fam\u00edlia comprasse ou que a fam\u00edlia est\u00e1 com o cart\u00e3o do idoso do benef\u00edcio e a comida falta. S\u00e3o situa\u00e7\u00f5es que v\u00e3o al\u00e9m da atua\u00e7\u00e3o e das atribui\u00e7\u00f5es da cuidadora\u201d .Tem fam\u00edlia que reconhece o cuidador mais como um intruso dentro da casa, principalmente quando come\u00e7a a perceber que o cuidador s\u00e3o \u201colhos e ouvidos\u201d, acaba n\u00e3o querendo mais essa pessoa dentro de casa\u201d (RT PMC \u2013 Sa\u00fade. F. 43 anos).Abandono ou neglig\u00eancia familiar revelam a insufici\u00eancia de cuidados ligada ao risco ou \u00e0 viola\u00e7\u00e3o de direitos e, muitas vezes, os cuidadores do PMC s\u00e3o porta-vozes de situa\u00e7\u00f5es que envolvem uma mir\u00edade de complexidades para al\u00e9m da atua\u00e7\u00e3o profissional.Subcategoria 3 \u2013 Institucionaliza\u00e7\u00e3o como \u00faltima op\u00e7\u00e3o:Quando a gente j\u00e1 esgotou tudo aquilo que a gente poderia fazer. Como por exemplo, troca de cuidador na casa. Em alguns casos, a gente percebe uma situa\u00e7\u00e3o de viola\u00e7\u00e3o com uma responsabiliza\u00e7\u00e3o das pessoas que vivem naquela casa .Quando esgotam todas as possibilidades de tentativas de melhorar o v\u00ednculo do idoso com a fam\u00edlia. Porque\u2026 nem sempre \u00e9 por neglig\u00eancia (\u2026). \u00c9 o reflexo de uma constru\u00e7\u00e3o bem-feita ou n\u00e3o, ao longo da hist\u00f3ria de vida daquela fam\u00edlia. (\u2026) A gente tamb\u00e9m encontra muita dificuldade [para institucionalizar], especialmente com vagas. E mais ainda, provar que essa situa\u00e7\u00e3o est\u00e1 acontecendo (RT PMC \u2013 Sa\u00fade. F. 43 anos).Um dos objetivos basilares do PMC \u00e9 evitar e/ou retardar as institucionaliza\u00e7\u00f5es. Por\u00e9m, h\u00e1 quest\u00f5es de vulnerabilidade social, de viola\u00e7\u00e3o de direitos e da din\u00e2mica familiar que inviabilizam a continuidade do cuidado. Nesses casos, a institucionaliza\u00e7\u00e3o aparece como \u00faltima/\u00fanica op\u00e7\u00e3o.Na 12, principais respons\u00e1veis por interna\u00e7\u00f5es hospitalares e emerg\u00eancias cl\u00ednicas para idosos brasileiros13. Assim, revela-se crucial criar novas estrat\u00e9gias ou reestruturar servi\u00e7os de sa\u00fade existentes para prevenir potenciais agravos que podem atingir a popula\u00e7\u00e3o idosa. Cuidados sociossanit\u00e1rios ausentes ou insuficientes podem levar \u00e0 sobrecarga dos servi\u00e7os de sa\u00fade e, por efeito cascata, resultar em hospitaliza\u00e7\u00f5es e institucionaliza\u00e7\u00f5es14.Como visto na 15 prop\u00f5em que os formuladores de pol\u00edticas definam crit\u00e9rios para caracterizar admiss\u00f5es desnecess\u00e1rias/prolongadas em hospitais e institucionaliza\u00e7\u00f5es de idosos e aprimorem os protocolos e as pr\u00e1ticas existentes15. O PMC \u00e9 capaz de minimizar ou evitar o n\u00famero de TED por meio da oferta do cuidado direto no domic\u00edlio, o que, por extens\u00e3o, viabiliza uma forma de vigil\u00e2ncia \u2013 a partir de orienta\u00e7\u00f5es e controle adequados \u2013 para idosos com alto potencial para agravos cl\u00ednicos. Um estudo quantitativo sobre a utiliza\u00e7\u00e3o de servi\u00e7os de sa\u00fade entre usu\u00e1rios do PMC evidenciou que a popula\u00e7\u00e3o assistida tem mais acesso \u00e0 reabilita\u00e7\u00e3o e consultas planejadas na rede de sa\u00fade do que a n\u00e3o assistida16. Nessa perspectiva, o PMC pode ser classificado como um modelo de boa pr\u00e1tica, a ser expandido para outros estados e munic\u00edpios brasileiros, al\u00e9m de ser compreendido como uma inova\u00e7\u00e3o social, uma tecnologia de cuidado que contribui para preven\u00e7\u00e3o e tratamento desse p\u00fablico no seu pr\u00f3prio habitat, isto \u00e9, o Aging in Place (AiP). O AiP significa ter sa\u00fade e apoio social necess\u00e1rios para viver com seguran\u00e7a em casa ou na comunidade no processo de envelhecimento17.Ao analisar os preditores de admiss\u00e3o hospitalar e sugerir o novo conceito de Transfer\u00eancia Evit\u00e1vel do Domic\u00edlio (TED), Lloyd-Sherlock et al.18. Um cuidado \u201cm\u00ednimo\u201d, como orientar sobre uma medica\u00e7\u00e3o, pode gerar repercuss\u00f5es positivas e significativas para a pessoa idosa, a sua fam\u00edlia e para o pr\u00f3prio sistema de sa\u00fade, ao reduzir as chances de complica\u00e7\u00f5es cl\u00ednicas19.Ademais, quanto maior a fragilidade e a depend\u00eancia funcional, em situa\u00e7\u00e3o de extrema vulnerabilidade social, como a popula\u00e7\u00e3o assistida pelo PMC, novas formas de abordagem para o cuidado se fazem necess\u00e1riaso pouco que faz diferen\u00e7a\u201d, relatado e/ou subentendido ao longo das entrevistas, revela-se que quem pratica e vive o Programa reconhece sua import\u00e2ncia, contudo a no\u00e7\u00e3o de cuidado como \u201cpouco\u201d talvez reflita a compreens\u00e3o do cuidado como algo natural, menor, ancorado na certeza de que algu\u00e9m, geralmente uma mulher, o far\u00e120. Os atores envolvidos no PMC parecem desconhecer que participam de uma das raras ofertas de pol\u00edtica p\u00fablica de cuidados continuados exclusivamente a idosos em pa\u00edses de baixa renda, conforme j\u00e1 reconhecido pela Organiza\u00e7\u00e3o Mundial da Sa\u00fade (OMS)21.Ao discutir \u201c22. Neste estudo, as cuidadoras familiares eram filhas dos idosos e relatavam a sobrecarga de trabalho e o abandono das suas pr\u00f3prias atividades em prol do cuidado do outro. As mulheres constituem a maior parte da popula\u00e7\u00e3o idosa, passam mais tempo expostas aos riscos fisiopatol\u00f3gicos e s\u00e3o as principais cuidadoras22. Como vulner\u00e1veis a quest\u00f5es do cuidado, elas merecem a aten\u00e7\u00e3o dos gestores e dos sistemas de sa\u00fade.Usualmente, o cuidador familiar n\u00e3o disp\u00f5e de preparo ou habilidades t\u00e9cnicas necess\u00e1rias para o cuidado a uma pessoa idosa23. Fala-se de insufici\u00eancia familiar, condi\u00e7\u00e3o que compromete a funcionalidade e a qualidade de vida dos idosos. Por\u00e9m, n\u00e3o se trata de insufici\u00eancia familiar, mas sim da insufici\u00eancia de pol\u00edticas de cuidados que apoiem as fam\u00edlias na sua necessidade de cuidar23.Nas quest\u00f5es relativas \u00e0 fam\u00edlia, o PMC contribui com os cuidadores familiares no trabalho pr\u00e1tico do dia a dia, auxiliando-os a retomar suas atividades cotidianas e reduzindo parte da sobrecarga de trabalho imposta pelo cuidado. Quando a fam\u00edlia n\u00e3o apresenta condi\u00e7\u00f5es  de cuidar, a pessoa idosa fica exposta a situa\u00e7\u00f5es de risco24.Nesse contexto, esgotadas as possibilidades de resolu\u00e7\u00f5es dos problemas, a institucionaliza\u00e7\u00e3o \u00e9 considerada a melhor op\u00e7\u00e3o de cuidado. Contudo, gargalos s\u00e3o identificados na rede p\u00fablica para efetivar esta forma de cuidado. Um estudo realizado em 2014, identificou que em Belo Horizonte, 73,1% das Ilpi filantr\u00f3picas apresentavam listas de espera, sendo que 9,7% aceitavam somente idosos independentes; 20,1% apenas idosos independentes ou semidependentes; 48,1% das Ilpi n\u00e3o recebiam idosos com dem\u00eancias e 52,2% recusavam novos residentes que apresentassem certas doen\u00e7as, como as infecciosas23.Assume-se, assim, o cuidado como uma dimens\u00e3o transversal da sa\u00fade e do bem-estar dos cidad\u00e3os de todas as idades, cabendo ao Estado e \u00e0 sociedade buscar pela equidade nos recursos, pela partilha das tarefas entre os g\u00eaneros e pela dignidade no cuidado das pessoas de todas as idades6. Assim, o Programa insere-se nas redes de aten\u00e7\u00e3o, sobretudo, da aten\u00e7\u00e3o prim\u00e1ria \u2013 n\u00edvel priorit\u00e1rio para assistir e monitorar o estado de sa\u00fade da popula\u00e7\u00e3o idosa25.Um ponto-chave do PMC \u00e9 sua intersetorialidade que conecta diferentes atores e equipes multidisciplinares e permeia todas as opera\u00e7\u00f5es do Programa: reuni\u00f5es conjuntas para revis\u00e3o de casos, contribui\u00e7\u00f5es combinadas em planos de cuidados individualizados e comunica\u00e7\u00e3o cont\u00ednua com os cuidadores26.Outro elemento importante interligado \u00e0 atua\u00e7\u00e3o dos cuidadores sociais no Programa \u00e9 a inclus\u00e3o social deles pelo trabalho formal. Com o sal\u00e1rio, vem tamb\u00e9m a defini\u00e7\u00e3o de fun\u00e7\u00f5es espec\u00edficas e responsabilidades claras, incluindo o tempo de trabalho em cada domic\u00edlio. Experi\u00eancias com cuidadores volunt\u00e1rios em pa\u00edses como Costa Rica e Tail\u00e2ndia mostram que, embora estes forne\u00e7am algum apoio, suas contribui\u00e7\u00f5es s\u00e3o limitadas e inconsistentesO Programa atua em comunidades que enfrentam problemas e priva\u00e7\u00f5es das mais diversas ordens, mas uma quest\u00e3o central do PMC \u00e9 n\u00e3o se restringir \u00e0 sa\u00fade f\u00edsico-funcional de cada idoso, mas considerar o contexto situacional para oferecer estrat\u00e9gias mais abrangentes de apoio, realizar o acompanhamento direto dos idosos assistidos e alcan\u00e7ar as demais pessoas e pol\u00edticas envolvidas, para al\u00e9m do domic\u00edlio. No universo pesquisado, para os diferentes atores \u00e9 un\u00edssona a percep\u00e7\u00e3o de que o Programa \u00e9 muito importante e apresenta estrat\u00e9gias e implica\u00e7\u00f5es positivas para diferentes eixos de atua\u00e7\u00e3o. Seus objetivos e a\u00e7\u00f5es s\u00e3o claros, entretanto persistem lacunas a serem rediscutidas nos cen\u00e1rios de atua\u00e7\u00e3o para que o Programa tenha processos e resultados cada vez mais exitosos.Este estudo realizou uma an\u00e1lise qualitativa do PMC \u2013 estrat\u00e9gia de a\u00e7\u00e3o intersetorial que oferta cuidados a idosos em situa\u00e7\u00f5es de alta vulnerabilidade cl\u00ednica e social em Belo Horizonte. O Programa, enquanto uma inova\u00e7\u00e3o social, oferece a oportunidade aos participantes de desenvolver uma velhice digna, com suporte em atividades e al\u00edvio para a sobrecarga de trabalho dos cuidadores familiares. Com a\u00e7\u00f5es e orienta\u00e7\u00f5es b\u00e1sicas de cuidado, ele se mostrou uma iniciativa capaz de minimizar a ocorr\u00eancia de agravos em sa\u00fade, de modo a evitar hospitaliza\u00e7\u00f5es e institucionaliza\u00e7\u00f5es.Este artigo tem como principal limita\u00e7\u00e3o as dificuldades encontradas durante a coleta de dados devido \u00e0 falta de registro e sistematiza\u00e7\u00f5es nas regionais de sa\u00fade que aderiram ao PMC, situa\u00e7\u00e3o que vem sendo corrigida a partir da pr\u00f3pria pesquisa.Nesse contexto de envelhecimento, a escuta dos atores envolvidos no PMC possibilitou um entendimento ampliado das m\u00faltiplas quest\u00f5es envolvidas no cuidado e nas pol\u00edticas p\u00fablicas, especialmente em \u00e1reas de maior vulnerabilidade social, como \u00e9 o l\u00f3cus de atua\u00e7\u00e3o do PMC. Espera-se que esta pesquisa levante novas discuss\u00f5es e estrat\u00e9gias que contribuam para o fortalecimento do Programa e constru\u00e7\u00e3o de pol\u00edticas de cuidado \u00e0 pessoa idosa."}
+{"text": "To evaluate congenital syphilis prevention actions in primary health care services in the state of S\u00e3o Paulo.Avalia\u00e7\u00e3o e Monitoramento de Servi\u00e7os da Aten\u00e7\u00e3o B\u00e1sica\u2013 QualiAB) in the state of S\u00e3o Paulo in 2017. An evaluative matrix composed of 31 indicators of prevention of congenital syphilis, categorized into four domains of analysis: diagnosis and treatment of acquired syphilis (10); basic infrastructure and resources (7); prevention of congenital syphilis during prenatal care (7); and educational actions and prevention of sexually transmitted infections (7). The frequency of services with positive responses for each indicator and the percentage of service performance were calculated based on the proportion of indicators reported per service and the overall average observed. Subsequently, services were classified into four quality groups, and associations between groups and each indicator, type of organizational arrangement and location were estimated.Cross-sectional evaluative research that used indicators extracted from the Survey of Evaluation and Monitoring of Primary Care Services , followed by \u201cinfrastructure and basic resources\u201d (79.5%), \u201cprevention of congenital syphilis in prenatal care\u201d (73.3%) and \u201ceducational actions and prevention of sexually transmitted infections\u201d (56.8%). There was a significant difference between quality groups and all indicators and types of organizational arrangements.The evaluated services have limitations in the development of actions to prevent congenital syphilis, mainly related to health education and actions included in prenatal care, such as screening and adequate treatment of pregnant women and their partners. Changes are needed in the work process, with the expansion of educational and surveillance actions, as well as the qualification of the teams to effectively comply with the protocols. Worldwide data indicate that, in 2016, the occurrence of maternal syphilis caused about 355,000 adverse outcomes in pregnancies, including approximately 140,000 early fetal deaths and stillbirths, 14,000 neonatal deaths, 41,000 premature or low birth weight children and 109 thousand cases of clinical signs in newborns. In that same year, the incidence rate of congenital syphilis in the world was 4.73/1,000 live births, with 660,000 reported cases  .Despite the extensive knowledge on its prevention, the high incidence rates, complications, and deaths related to congenital syphilis maintain it as one of the main causes of child morbidity and mortality  .Faced with the magnitude and serious repercussion of congenital syphilis on maternal and child health, the World Health Organization (WHO) established the reduction of the annual incidence rate to 0.5/1,000 live births Guia para Certifica\u00e7\u00e3o da Elimina\u00e7\u00e3o da Transmiss\u00e3o Vertical de HIV e/ou S\u00edfilis) in 2021  . In 2020, 22,065 cases of congenital syphilis were reported in Brazil, corresponding to an incidence rate of 7.7/1,000 live births, with the Southeast  being the region with the highest incidence rate in the country. This year, the state of S\u00e3o Paulo had the lowest incidence rate in the region , reversing the progressive increase observed by 2018  .In Brazil, the goal of eliminating mother-to-child transmission of syphilis was included in the Ministry of Health\u2019s Guide for the Certification of the Elimination of Vertical Transmission of HIV and/or Syphilis  services are highlighted since congenital syphilis can be avoided through various actions related to prenatal care, screening, and treatment of maternal infection at this level of care  .Currently, there are well-established protocols and guidelines that address the prevention of mother-to-child transmission of syphilis  , its occurrence represents a sentinel event of the quality of care provided in prenatal care  . In this sense, the high number of cases in Brazil and in the state of S\u00e3o Paulo  indicates the loss of the opportunity to interrupt the transmission chain in PHC, suggesting flaws in the organization of services at this level of care.Considering that congenital syphilis is a preventable disease with resources available in the Brazilian Unified Health System (SUS)  in PHC services allows identifying process variables that indicate the expected results, as proposed in the Donabedian model  . In this sense, evaluating the actions for congenital syphilis prevention allows us to understand how much the practices included in the services\u2019 routines are close to the recommendations of national and international protocols and guidelines  .The evaluation focused on the organization of the work process Considering the importance of PHC in congenital syphilis prevention and the gap between accumulated knowledge and practice in services, this study aims to evaluate the organization of actions for congenital syphilis prevention in PHC services in the state of S\u00e3o Paulo. and an evaluation matrix defined the election of the indicators selected for the evaluation. We used secondary data from the survey carried out in the state of S\u00e3o Paulo, in 2017, with the Questionnaire for the Evaluation and Monitoring of Primary Care Services .This is an evaluative, cross-sectional study focused on the organization of actions to prevent congenital syphilis in PHC services. In it, the construction of a logical model  . Due to its scope, it allows the assessment of different dimensions of health care based on the performance measured in relation to the PHC guidelines in SUS  .The QualiAB is a validated, electronically self-applied instrument, composed of structure and process indicators of the diversified set of actions under the responsibility of PHC services QualiAB was made available electronically to all S\u00e3o Paulo municipalities in 2017, with the support of the S\u00e3o Paulo State Health Department. A total of 2,739 services, located in 514 municipalities, responded the survey. Notably, the city of S\u00e3o Paulo did not join the survey. To ensure the representativeness of the set of services evaluated, those that reported not having prenatal care were excluded from the analysis. .For the selection of variables related to the evaluative dimension \u201cprevention of congenital syphilis in PHC,\u201d a matrix composed of 31 variables was developed, considered indicators of the organizational quality of services. The indicators were grouped into four domains of analysis: infrastructure and basic resources (10); educational actions and prevention of sexually transmitted infections (STIs) (7); diagnosis and treatment of acquired syphilis (7); and prevention of congenital syphilis during prenatal care (7) . The evFor services characterization, variables related to location  and type of organizational arrangement  were included.The extraction of information from the original database of the QualiAB application in 2017 allowed the construction of a database composed of variables related to the evaluative dimension \u201cprevention of congenital syphilis in PHC.\u201d The services\u2019 responses to the indicators were dichotomously categorized: 1 corresponds to what the service is referred to do and 0 to what it did not refer to.At first, the absolute and relative frequencies of services with positive responses for each of the 31 indicators were estimated, that is, the proportion of services that reported carrying out the recommended actions.Next, the performance per service was analyzed based on the proportion of indicators achieved. The average of positive responses in each domain was initially calculated (sum of positive responses divided by the number of indicators and multiplied by 100), with the result varying, therefore, between 0% and 100% within that domain. The performance of each service in the evaluative dimension \u201cprevention of congenital syphilis in PHC\u201d was calculated by the average performance in the four domains (sum of the performance in the domains divided by four).The performance percentage of the set of participating services was evaluated according to the distribution of performances per service in the evaluative dimension \u201cprevention of congenital syphilis in PHC,\u201d using measures of central tendency and dispersion .In the end, the participating services were classified into quality groups (clusters), based on the distribution of performance per service in the evaluative dimension \u201cprevention of congenital syphilis in PHC\u201d in quartiles. Chi-square tests were used to estimate associations between each indicator and quality groups, followed by Z tests. The same strategy was used to estimate associations between quality groups and service characterization variables: type of organizational arrangement and location. Variables with p-values < 0.05 were considered statistically significant. Calculations were performed using the IBM/SPSS v. 26.0.The study was approved by the Research Ethics Committee of the Faculdade de Medicina de Botucatu of Universidade Estadual Paulista \u201cJ\u00falio de Mesquita Filho\u201d (CAAE: 83473518.1.0000.5411), under opinion no. 4,552,843, on February 23, 2021.In this study we evaluated 2,565 PHC services, located in 503 municipalities in the state of S\u00e3o Paulo, of which 91.5% were located in urban areas and 8.5% in rural areas. Distribution by organizational arrangement showed 47.2% of USF; 27.2% of UBS with PACS or ESF; 22.5% from traditional UBS; and 3.1% from other types of arrangements, such as UBS with emergency care or polyclinics.As for \u201ceducational actions and STI prevention,\u201d a predominance of actions that address STIs, aids, and viral hepatitis developed regularly in adult care in 80% of the services, and the STI/aids theme in education actions performed at the unit in 76.8%, were highlights. STI/aids prevention addressed in community health education actions was little explored, being reported by 39.5%. People who abuse alcohol and other drugs, as well as vulnerable groups, were not a frequent target audience for STI/aids prevention actions carried out by the units, only in 42.3% and 34.5%, respectively .Regarding the domain \u201cdiagnosis and treatment of acquired syphilis,\u201d 94% of the services reported providing guidance on care for sexual partners and 93.7% guidance on diagnosis and treatment. However, only 84.4% reported treating and following up these cases in the unit itself .In the domain \u201cprevention of congenital syphilis in prenatal care,\u201d recommended strategies, such as carrying out six or more prenatal care visits and calling pregnant women who miss appointments, were followed by most services, with a frequency of 95.6% and 92.4%, respectively. The offer of syphilis treatment for pregnant women and their partners in the unit was mentioned by 77.7% of the services, and the request for rapid test or serology for syphilis in the first and third trimester of pregnancy was mentioned by 69.8%. The absence of cases of congenital syphilis in the area covered by the unit in the three years prior to the assessment was reported by 49.8% .Based on the distribution of the performance of the set of services in the dimension \u201cprevention of congenital syphilis in PHC,\u201d quality groups were constructed to analyze the variation in performance across services . G4 gatConsidering the quality groups, the four groups for each indicator used in the evaluation matrix were compared . AccordThe crossing between the four quality groups and the types of organizational arrangements  showed a significant difference in the chi-square test (p < 0.001). Regarding the USF, the best quality group (G4) was the one with the highest proportion of these services in its composition , and almost all groups differed from each other, except for G2 and G3, which were similar, according to the Z test.In the case of traditional UBS, the group with the lowest quality (G1) was the one with the highest proportion , with all groups differing from each other. Mixed units, although distributed heterogeneously across the four groups, also have a higher proportion in the higher quality group . It is worth mentioning that, when comparing the quality groups and the service location variables, the chi-square test did not show a significant association.The evaluation carried out, although based on descriptive data, allowed identifying some of the main points of the work process that require qualification to strengthen the prevention of congenital syphilis in the PHC of the state of S\u00e3o Paulo, such as screening for syphilis in prenatal care, adequate treatment of gestational and acquired syphilis with the use of benzathine penicillin, and the incorporation of health education actions in the unit and in the territory. . Although the data refer to a survey carried out in 2017, the incidence rates of congenital syphilis in the state of S\u00e3o Paulo  indicate the likely persistence of the identified issues. The changes that were introduced after the covid-19 pandemic altered the routine of PHC services, compromising programmatic actions, such as prenatal care and health surveillance, which may have contributed to the maintenance of the points identified in 2017  .The average performance of the evaluated services reveals that, although the prevention of congenital syphilis relies on actions that belong to the PHC work routine, there are still many services that fail to adequately comply with the recommendations established by protocols and guidelines, as pointed out by other studies  . However, the literature shows that, among the notified cases of congenital syphilis, a large number of mothers did receive prenatal care  , indicating that simple access to consultations has not guaranteed a reduction in the incidence rate  .The Brazilian protocols that address the prevention of congenital syphilis emphasize the importance of prenatal care since it is during the follow-up of the pregnant woman in PHC that actions are developed toward the early diagnosis of maternal infection and its timely treatment The challenge of preventing mother-to-child transmission of syphilis in Brazil is mainly centered on the compromising of the quality of care offered. The results presented here bring data that corroborate this hypothesis, since the domain \u201cprevention of congenital syphilis in prenatal care\u201d had the second lowest performance, that is, even in actions prioritized exhaustively by the protocols, such as screening and early treatment of gestational syphilis, there are important gaps both in relation to the offer and in the availability of inputs for its implementation. . Among the services analyzed, few followed this recommendation (69.8%), limiting themselves to requesting only one test for syphilis during the first trimester (95.3%). This highlights the difficulty of services in adapting their routine to the recommendations and even the lack of knowledge of professionals and managers regarding protocols, impact, and cost-effectiveness of adequate screening  .Screening for syphilis is recommended at two moments during prenatal care in PHC: in the first and third trimesters of pregnancy  .Clinical protocols and guidelines act as essential tools to guide and support the practices carried out by health services, but their existence alone does not guarantee the quality of care. Factors involving the units\u2019 organization, such as the management model and, mainly, the operational work process, can bring technical-operational limitations, impairing the quality and effectiveness of health care  . This has been a tool used by most of the services studied and needs continuous strengthening and encouragement for its implementation.The rapid test for syphilis is one of the screening strategies highlighted as an easy-to-perform and highly cost-effective resource. When carried out in the first appointment with the pregnant woman, it provides early diagnosis and timely treatment of maternal infection  and fear of adverse reactions from its administration  .Difficulties in the prevention of congenital syphilis in PHC extend to the problem of using benzathine penicillin as the first-choice drug in the treatment of gestational syphilis, often sustained by the professionals\u2019 lack of knowledge about the most appropriate therapeutic schemes  . This difficulty is sustained in this study, with indicators showing that a significant portion of the units do not offer treatment to pregnant women and partners and do not administer benzathine penicillin as a routine procedure.It is the only drug capable of crossing the placental barrier and reaching the fetus, therefore, the existing weaknesses in its offer as a routine procedure for the treatment of pregnant women and partners, put access to safe, effective, and timely treatment of syphilis during pregnancy at risk  , a better performance is observed in the indicators related to administration of benzathine penicillin in the unit and in the provision of treatment for pregnant women and partners, in 2017 compared to 2010. This improvement possibly reflects the training efforts and technical measures undertaken by both the Ministry of Health  and by the S\u00e3o Paulo State Health Department  .Despite the insufficient performance expressed by treatment indicators, it is important to emphasize that there have been advances. When comparing results of this study with that conducted by Sanine et al. In addition to prenatal care, the evaluation model for the prevention of congenital syphilis presented considers the importance of practices that favor the interruption of the syphilis transmission chain in other life stages through prevention actions, early diagnosis, and management of syphilis in women of childbearing age and their sexual partners. .The evaluated services have a good performance related to STI care, and the domain \u201cdiagnosis and treatment of acquired syphilis\u201d was the one that obtained the highest mean among the services, and none of its indicators had a frequency lower than 80%. This result may be a reflection of the tradition of assistance to STIs in PHC in S\u00e3o Paulo, since the state was a pioneer in organizing the network\u2019s responses to the aids epidemic in the country and, since then, has assumed a strong role in the line of prevention and assistance to STIs/aids, undertaking initiatives that aim to strengthen the integration of these actions  . However, the domain \u201ceducational actions and STI prevention\u201d was the one with the lowest performance, with low frequencies in all indicators, especially in those that address health education practices developed in the community and that involve vulnerable groups. These results corroborate the literature, which indicates that STI/aids prevention practices and health education occupy a secondary place in the health work process  .In the search for the elimination of congenital syphilis, it is important that educational actions are carried out with the community, pregnant women and families, with the aim of increasing these actors\u2019 knowledge about maternal and child health and guaranteeing greater autonomy in care The high and similar means and medians between the quality groups indicate the occurrence of a small percentage interval between them, with the exception of G1, indicating that about 70% of the services had an average performance above 70%. However, for a disease that is preventable through different practices developed in PHC services at different times, this performance can be considered insufficient.All the indicators included in the evaluation matrix were capable of differentiating the groups from each other, a fact that can be statistically justified by the large number of services in the sample , but, on the other hand, reflects the differentiation between the services and the capacity of the matrix proposal to identify distinct attributes that qualify the prevention of congenital syphilis. , and the evaluation carried out reaffirms this tendency. On the other hand, the USF and the UBS with integrated ESF or PACS also require a greater investment in order to provide comprehensive care since many of these units also showed low performance.The better performance of units organized according to family health guidelines is well demonstrated in the literature One of the limits of this work is the generalizability of the results since they refer only to the participating services. Another limit concerns the use of secondary data from a survey that evaluated the set of PHC actions, with the prevention of congenital syphilis being a part of this set. In addition, descriptive cross-sectional studies have limits given by the time frame they make of reality. However, the evaluation of service performance points out issues that require procedural changes and planning and management measures, contributing to quality improvement.The weaknesses identified in the organization of services have great local governance and point to priorities that need to be incorporated and that represent the consolidation of policies and guidelines already available. The need for investments in the technical capacity of the services and in professional qualification for the effective execution of the protocols is highlighted.The results confirm the importance of qualifying prenatal care, already pointed out in other studies, and highlight the value of carrying out assessments that induce reflections in the teams on the organization of work processes and, thus, contribute to the establishment of change processes that have an effect on the prevention of congenital syphilis. . Dados mundiais apontam que, em 2016, a ocorr\u00eancia de s\u00edfilis materna causou cerca de 355 mil resultados adversos em gesta\u00e7\u00f5es, entre os quais est\u00e3o aproximadamente 140 mil \u00f3bitos fetais precoces e natimortos, 14 mil \u00f3bitos neonatais, 41 mil crian\u00e7as prematuras ou com baixo peso e 109 mil casos de sinais cl\u00ednicos em rec\u00e9m-nascidos. Nesse mesmo ano, a taxa de incid\u00eancia de s\u00edfilis cong\u00eanita no mundo foi de 4,73/1.000 nascidos vivos, com 660 mil casos notificados.Apesar do extenso conhecimento sobre a preven\u00e7\u00e3o da s\u00edfilis cong\u00eanita, as altas taxas de incid\u00eancia, as complica\u00e7\u00f5es e os \u00f3bitos relacionados a esse agravo a mant\u00eam como uma das principais causas de morbimortalidade infantil.Diante da magnitude e grave repercuss\u00e3o da s\u00edfilis cong\u00eanita na sa\u00fade materno-infantil, a Organiza\u00e7\u00e3o Mundial da Sa\u00fade (OMS) estabeleceu como meta para a elimina\u00e7\u00e3o da s\u00edfilis cong\u00eanita como um problema de sa\u00fade p\u00fablica a redu\u00e7\u00e3o da taxa de incid\u00eancia anual para 0,5/1.000 nascidos vivos. Em 2020, foram notificados 22.065 casos de s\u00edfilis cong\u00eanita no Brasil, que correspondem a uma taxa de incid\u00eancia de 7,7/1.000 nascidos vivos, sendo o Sudeste  a regi\u00e3o com a maior taxa de incid\u00eancia no pa\u00eds. Neste ano, o estado de S\u00e3o Paulo apresentou a menor taxa de incid\u00eancia da regi\u00e3o , invertendo a tend\u00eancia de aumento progressivo verificada at\u00e9 2018.No Brasil, a meta de elimina\u00e7\u00e3o da transmiss\u00e3o vertical da s\u00edfilis foi inclu\u00edda no Guia para Certifica\u00e7\u00e3o da Elimina\u00e7\u00e3o da Transmiss\u00e3o Vertical de HIV e/ou S\u00edfilis, do Minist\u00e9rio da Sa\u00fade, em 2021. Nesse sentido, os servi\u00e7os de aten\u00e7\u00e3o prim\u00e1ria \u00e0 sa\u00fade (APS) recebem destaque, pois a s\u00edfilis cong\u00eanita pode ser evitada por meio de diversas a\u00e7\u00f5es relacionadas \u00e0 aten\u00e7\u00e3o pr\u00e9-natal, ao rastreamento e ao tratamento da infec\u00e7\u00e3o materna neste n\u00edvel de aten\u00e7\u00e3o.Atualmente h\u00e1 protocolos e diretrizes bem estabelecidos que abordam a preven\u00e7\u00e3o da transmiss\u00e3o vertical da s\u00edfilis, sua ocorr\u00eancia representa um evento sentinela da qualidade da assist\u00eancia prestada no pr\u00e9-natal. Nesse sentido, o elevado n\u00famero de casos no Brasil e no estado de S\u00e3o Pauloindica a perda da oportunidade de interromper a cadeia de transmiss\u00e3o na APS, sugerindo falhas na organiza\u00e7\u00e3o dos servi\u00e7os desse n\u00edvel de aten\u00e7\u00e3o.Considerando que a s\u00edfilis cong\u00eanita \u00e9 uma doen\u00e7a evit\u00e1vel com recursos dispon\u00edveis no Sistema \u00danico de Sa\u00fade (SUS)em servi\u00e7os de APS permite identificar vari\u00e1veis de processo que indicam os resultados esperados, como proposto no modelo donabediano. Nesse sentido, avaliar as a\u00e7\u00f5es de preven\u00e7\u00e3o da s\u00edfilis cong\u00eanita permite compreender o quanto as pr\u00e1ticas inseridas nas rotinas dos servi\u00e7os se aproximam das recomenda\u00e7\u00f5es de protocolos e diretrizes nacionais e internacionais.A avalia\u00e7\u00e3o com foco na organiza\u00e7\u00e3o do processo de trabalhoConsiderando a import\u00e2ncia da APS na preven\u00e7\u00e3o da s\u00edfilis cong\u00eanita e a lacuna entre o conhecimento acumulado e a pr\u00e1tica nos servi\u00e7os, este estudo teve como objetivo avaliar a organiza\u00e7\u00e3o de a\u00e7\u00f5es de preven\u00e7\u00e3o da s\u00edfilis cong\u00eanita em servi\u00e7os de APS do estado de S\u00e3o Paulo.e uma matriz avaliativa definiram a elei\u00e7\u00e3o dos indicadores selecionados para a avalia\u00e7\u00e3o. Foram utilizados dados secund\u00e1rios do inqu\u00e9rito realizado no estado de S\u00e3o Paulo, em 2017, com o Question\u00e1rio de Avalia\u00e7\u00e3o e Monitoramento de Servi\u00e7os de Aten\u00e7\u00e3o B\u00e1sica .Trata-se de uma pesquisa avaliativa, de corte transversal e com foco na organiza\u00e7\u00e3o das a\u00e7\u00f5es de preven\u00e7\u00e3o \u00e0 s\u00edfilis cong\u00eanita em servi\u00e7os de APS. Nela, a constru\u00e7\u00e3o de um modelo l\u00f3gico. Por sua abrang\u00eancia, permite a avalia\u00e7\u00e3o de diferentes dimens\u00f5es da aten\u00e7\u00e3o \u00e0 sa\u00fade a partir do desempenho mensurado em rela\u00e7\u00e3o \u00e0s diretrizes da APS no SUS.O QualiAB \u00e9 um instrumento validado, autoaplicado eletronicamente, composto de indicadores de estrutura e processo do conjunto diversificado de a\u00e7\u00f5es sob responsabilidade dos servi\u00e7os de APSO QualiAB foi disponibilizado eletronicamente para todos os munic\u00edpios paulistas, em 2017, com o apoio da Secretaria de Sa\u00fade do Estado de S\u00e3o Paulo. Responderam ao inqu\u00e9rito 2.739 servi\u00e7os, localizados em 514 munic\u00edpios. Cabe aqui destacar que n\u00e3o houve ades\u00e3o do munic\u00edpio de S\u00e3o Paulo ao inqu\u00e9rito. Para garantir a representatividade do conjunto de servi\u00e7os avaliados, foram exclu\u00eddos da an\u00e1lise aqueles que informaram n\u00e3o realizar acompanhamento pr\u00e9-natal..Para a sele\u00e7\u00e3o das vari\u00e1veis relacionadas \u00e0 dimens\u00e3o avaliativa \u201cpreven\u00e7\u00e3o da s\u00edfilis cong\u00eanita na APS\u201d, foi desenvolvida uma matriz composta de 31 vari\u00e1veis, consideradas indicadores da qualidade organizacional dos servi\u00e7os. Os indicadores foram reunidos em quatro dom\u00ednios de an\u00e1lise: infraestrutura e recursos b\u00e1sicos (10); a\u00e7\u00f5es educativas e preven\u00e7\u00e3o de infec\u00e7\u00f5es sexualmente transmiss\u00edveis (IST) (7); diagn\u00f3stico e tratamento da s\u00edfilis adquirida (7); e preven\u00e7\u00e3o da s\u00edfilis cong\u00eanita no pr\u00e9-natal (7) . Os padPara a caracteriza\u00e7\u00e3o dos servi\u00e7os, foram inclu\u00eddas vari\u00e1veis referentes \u00e0 localiza\u00e7\u00e3o  e ao tipo de arranjo organizacional .A extra\u00e7\u00e3o de informa\u00e7\u00f5es do banco original da aplica\u00e7\u00e3o do QualiAB em 2017 permitiu a constru\u00e7\u00e3o de uma base composta por vari\u00e1veis relativas \u00e0 dimens\u00e3o avaliativa \u201cpreven\u00e7\u00e3o da s\u00edfilis cong\u00eanita na APS\u201d. As respostas dos servi\u00e7os aos indicadores foram dicotomicamente categorizadas: 1 corresponde ao que o servi\u00e7o referia fazer e 0 ao que n\u00e3o referia.Em um primeiro momento, foram estimadas as frequ\u00eancias absolutas e relativas de servi\u00e7os com respostas positivas para cada um dos 31 indicadores, ou seja, a propor\u00e7\u00e3o de servi\u00e7os que referem realizar as a\u00e7\u00f5es preconizadas.A seguir, foi analisado o desempenho por servi\u00e7o a partir da propor\u00e7\u00e3o de indicadores alcan\u00e7ados. Calculou-se inicialmente a m\u00e9dia das respostas positivas em cada dom\u00ednio (soma das respostas positivas dividida pelo n\u00famero de indicadores e multiplicada por 100), com o resultado variando, portanto, entre 0% e 100% dentro daquele dom\u00ednio. O desempenho de cada servi\u00e7o na dimens\u00e3o avaliativa \u201cpreven\u00e7\u00e3o da s\u00edfilis cong\u00eanita na APS\u201d foi calculado pela m\u00e9dia do desempenho nos quatro dom\u00ednios (soma do desempenho nos dom\u00ednios dividida por quatro).O percentual de desempenho do conjunto de servi\u00e7os participantes foi avaliado segundo a distribui\u00e7\u00e3o dos desempenhos por servi\u00e7o na dimens\u00e3o avaliativa \u201cpreven\u00e7\u00e3o da s\u00edfilis cong\u00eanita na APS\u201d, por meio de medidas de tend\u00eancia central e dispers\u00e3o .clusters), com base na distribui\u00e7\u00e3o do desempenho por servi\u00e7o na dimens\u00e3o avaliativa \u201cpreven\u00e7\u00e3o da s\u00edfilis cong\u00eanita na APS\u201d em quartis. Foram utilizados os testes qui-quadrado para estimar associa\u00e7\u00f5es entre cada indicador e os grupos de qualidade, seguidos por testes Z. A mesma estrat\u00e9gia foi utilizada para estimar associa\u00e7\u00f5es entre os grupos de qualidade e as vari\u00e1veis de caracteriza\u00e7\u00e3o dos servi\u00e7os: tipo de arranjo organizacional e localiza\u00e7\u00e3o. Foram consideradas estatisticamente significativas as vari\u00e1veis com valores-p < 0,05. Os c\u00e1lculos foram realizados utilizando o pacote IBM/SPSS v. 26.0.Ao final, os servi\u00e7os participantes foram classificados em grupos de qualidade , sob o parecer n\u00ba 4.552.843, em 23 de fevereiro de 2021.Foram avaliados neste estudo 2.565 servi\u00e7os de APS, localizados em 503 munic\u00edpios paulistas, dos quais 91,5% estavam localizados em zona urbana e 8,5% em zona rural. A distribui\u00e7\u00e3o por arranjo organizacional mostrou 47,2% de USF; 27,2% de UBS com PACS ou ESF; 22,5% de UBS tradicionais; e 3,1% de outros tipos de arranjos, como UBS com pronto atendimento ou policl\u00ednicas.As frequ\u00eancias dos servi\u00e7os segundo os indicadores de cada dom\u00ednio da dimens\u00e3o \u201cpreven\u00e7\u00e3o da s\u00edfilis cong\u00eanita na APS\u201d s\u00e3o apresentadas naQuanto \u00e0s \u201ca\u00e7\u00f5es educativas e preven\u00e7\u00e3o de IST\u201d, destacou-se o predom\u00ednio de a\u00e7\u00f5es que abordam IST, aids e hepatites virais desenvolvidas com regularidade na aten\u00e7\u00e3o ao adulto em 80% dos servi\u00e7os, e do tema IST/aids em a\u00e7\u00f5es de educa\u00e7\u00e3o em sa\u00fade realizadas na unidade em 76,8%. A preven\u00e7\u00e3o de IST/aids abordada em a\u00e7\u00f5es de educa\u00e7\u00e3o em sa\u00fade realizadas na comunidade foi pouco explorada, sendo relatada por 39,5%. Pessoas que fazem uso abusivo de \u00e1lcool e outras drogas, assim como grupos em situa\u00e7\u00e3o de vulnerabilidade, n\u00e3o foram p\u00fablico-alvo frequente das a\u00e7\u00f5es de preven\u00e7\u00e3o de IST/aids realizadas pelas unidades, apenas de 42,3% e 34,5%, respectivamente .No que diz respeito ao dom\u00ednio \u201cdiagn\u00f3stico e tratamento da s\u00edfilis adquirida\u201d, 94% dos servi\u00e7os relataram realizar orienta\u00e7\u00f5es sobre cuidados com as parcerias sexuais e 93,7% orienta\u00e7\u00f5es sobre diagn\u00f3stico e tratamento. Entretanto, somente 84,4% afirmaram fazer o tratamento e seguimento desses casos na pr\u00f3pria unidade .No dom\u00ednio \u201cpreven\u00e7\u00e3o da s\u00edfilis cong\u00eanita no pr\u00e9-natal\u201d, estrat\u00e9gias preconizadas, como a realiza\u00e7\u00e3o de seis ou mais consultas durante o pr\u00e9-natal e a convoca\u00e7\u00e3o de gestantes faltosas, foram seguidas pela maioria dos servi\u00e7os, com frequ\u00eancia de 95,6% e 92,4%, respectivamente. A oferta do tratamento da s\u00edfilis para gestante e parceria na unidade foi citada por 77,7% dos servi\u00e7os, e a solicita\u00e7\u00e3o de teste r\u00e1pido ou sorologia para s\u00edfilis no primeiro e terceiro trimestre gestacional foi referida por 69,8%. A aus\u00eancia de casos de s\u00edfilis cong\u00eanita na \u00e1rea de abrang\u00eancia da unidade nos tr\u00eas anos anteriores \u00e0 avalia\u00e7\u00e3o foi relata por 49,8% .NaCom base na distribui\u00e7\u00e3o do desempenho do conjunto dos servi\u00e7os na dimens\u00e3o \u201cpreven\u00e7\u00e3o da s\u00edfilis cong\u00eanita na APS\u201d, foram constru\u00eddos grupos de qualidade para analisar a varia\u00e7\u00e3o no desempenho entre os servi\u00e7os . O G4 rConsiderando os grupos de qualidade, realizou-se uma compara\u00e7\u00e3o entre os quatro grupos para cada indicador utilizado na matriz avaliativa . SegundO cruzamento entre os quatro grupos de qualidade e os tipos de arranjos organizacionais  mostrou uma diferen\u00e7a significativa no teste qui-quadrado . Em rela\u00e7\u00e3o \u00e0s USF, o grupo de melhor qualidade (G4) foi o que apresentou maior propor\u00e7\u00e3o desses servi\u00e7os na sua composi\u00e7\u00e3o , sendo que quase todos os grupos se diferenciaram entre si, exceto G2 e G3, que se assemelharam, segundo teste Z.No caso das UBS tradicionais, o grupo de menor qualidade (G1) foi o que apresentou maior propor\u00e7\u00e3o , com todos os grupos se diferenciando entre si. As unidades mistas, embora se distribuam heterogeneamente entre os quatro grupos, tamb\u00e9m apresentam maior propor\u00e7\u00e3o no grupo de maior qualidade . Vale destacar que, ao comparar os grupos de qualidade e as vari\u00e1veis de localiza\u00e7\u00e3o dos servi\u00e7os, o teste qui-quadrado n\u00e3o mostrou associa\u00e7\u00e3o significativa.A avalia\u00e7\u00e3o realizada, ainda que baseada em dados descritivos, permitiu identificar alguns dos principais pontos do processo de trabalho que necessitam de qualifica\u00e7\u00e3o para o fortalecimento da preven\u00e7\u00e3o da s\u00edfilis cong\u00eanita na APS paulista, como o rastreamento da s\u00edfilis no pr\u00e9-natal, o tratamento adequado da s\u00edfilis gestacional e adquirida com o uso de penicilina benzatina e a incorpora\u00e7\u00e3o de a\u00e7\u00f5es de educa\u00e7\u00e3o em sa\u00fade na unidade e no territ\u00f3rio.. Embora os dados se refiram a um inqu\u00e9rito realizado em 2017, as taxas de incid\u00eancia de s\u00edfilis cong\u00eanita no estado de S\u00e3o Pauloindicam a prov\u00e1vel persist\u00eancia dos problemas identificados. As mudan\u00e7as que foram introduzidas a partir da pandemia da covid-19 alteraram a rotina dos servi\u00e7os de APS, comprometendo a\u00e7\u00f5es program\u00e1ticas, como o pr\u00e9-natal e a vigil\u00e2ncia em sa\u00fade, o que pode ter contribu\u00eddo para a manuten\u00e7\u00e3o dos pontos identificados em 2017.O desempenho m\u00e9dio dos servi\u00e7os avaliados revela que, apesar de a preven\u00e7\u00e3o da s\u00edfilis cong\u00eanita contar com a\u00e7\u00f5es que pertencem \u00e0 rotina de trabalho da APS, ainda s\u00e3o muitos os servi\u00e7os que falham em cumprir adequadamente as recomenda\u00e7\u00f5es estabelecidas por protocolos e diretrizes, conforme apontado por outros estudos. Todavia, observa-se na literatura que, entre os casos notificados de s\u00edfilis cong\u00eanita, uma grande parcela das m\u00e3es realizou o pr\u00e9-natal, indicando que o simples acesso \u00e0s consultas n\u00e3o tem garantido a redu\u00e7\u00e3o da taxa de incid\u00eancia.Os protocolos brasileiros que abordam a preven\u00e7\u00e3o da s\u00edfilis cong\u00eanita enfatizam a import\u00e2ncia do pr\u00e9-natal, uma vez que \u00e9 durante o seguimento da gestante na APS que s\u00e3o desenvolvidas a\u00e7\u00f5es que possibilitam o diagn\u00f3stico precoce da infec\u00e7\u00e3o materna e seu tratamento oportunoO desafio da preven\u00e7\u00e3o da transmiss\u00e3o vertical da s\u00edfilis no Brasil est\u00e1 centrado, principalmente, no comprometimento da qualidade do cuidado ofertado. Os resultados aqui apresentados trazem dados que corroboram essa hip\u00f3tese, uma vez que o dom\u00ednio \u201cpreven\u00e7\u00e3o da s\u00edfilis cong\u00eanita na aten\u00e7\u00e3o pr\u00e9-natal\u201d teve o segundo menor desempenho, ou seja, mesmo em a\u00e7\u00f5es priorizadas exaustivamente pelos protocolos, como o rastreamento e tratamento precoce da s\u00edfilis gestacional, existem lacunas importantes tanto em rela\u00e7\u00e3o \u00e0 oferta como na disponibiliza\u00e7\u00e3o de insumos para sua realiza\u00e7\u00e3o.. Entre os servi\u00e7os analisados, poucos seguiam essa recomenda\u00e7\u00e3o , limitando-se \u00e0 solicita\u00e7\u00e3o de apenas uma testagem para s\u00edfilis durante o primeiro trimestre . Isso destaca a dificuldade dos servi\u00e7os em adequar sua rotina \u00e0s recomenda\u00e7\u00f5es e at\u00e9 mesmo a falta de conhecimento dos profissionais e gestores quanto a protocolos, impacto e custo-benef\u00edcio do rastreamento adequado.O rastreamento da s\u00edfilis \u00e9 preconizado em dois momentos durante o acompanhamento pr\u00e9-natal na APS: no primeiro e no terceiro trimestre gestacional.Protocolos e diretrizes cl\u00ednicas atuam como ferramentas essenciais para direcionar e respaldar as pr\u00e1ticas realizadas pelos servi\u00e7os de sa\u00fade, mas somente sua exist\u00eancia n\u00e3o garante a qualidade do cuidado. Fatores que envolvem a organiza\u00e7\u00e3o das unidades, como o modelo de gest\u00e3o e, principalmente, o processo de trabalho operacionalizado, podem trazer limita\u00e7\u00f5es t\u00e9cnico-operacionais, prejudicando a qualidade e a efetividade da assist\u00eancia \u00e0 sa\u00fade. Essa tem sido uma ferramenta utilizada por grande parte dos servi\u00e7os estudados e necessita de cont\u00ednuo fortalecimento e incentivo \u00e0 sua execu\u00e7\u00e3o.O teste r\u00e1pido para s\u00edfilis \u00e9 uma das estrat\u00e9gias de rastreamento que recebe destaque como recurso de f\u00e1cil execu\u00e7\u00e3o e alto custo-efetividade. Quando realizado logo no primeiro atendimento \u00e0 gestante, propicia diagn\u00f3stico precoce e tratamento oportuno da infec\u00e7\u00e3o maternae pelo medo das rea\u00e7\u00f5es adversas de sua aplica\u00e7\u00e3o.As dificuldades na preven\u00e7\u00e3o da s\u00edfilis cong\u00eanita na APS se estendem \u00e0 problem\u00e1tica do uso da penicilina benzatina como medicamento de primeira escolha no tratamento da s\u00edfilis gestacional, muitas vezes sustentada pela falta de conhecimento dos profissionais sobre os esquemas terap\u00eauticos mais adequados. Essa dificuldade \u00e9 sustentada neste estudo, com indicadores mostrando que uma parcela significativa das unidades n\u00e3o oferece o tratamento a gestantes e parcerias e n\u00e3o aplica penicilina benzatina como procedimento de rotina.Trata-se do \u00fanico medicamento capaz de atravessar a barreira placent\u00e1ria e chegar at\u00e9 o feto, portanto, as fragilidades existentes na sua oferta como um procedimento de rotina para tratamento de gestantes e parcerias, colocam em risco o acesso a um tratamento seguro, eficaz e oportuno da s\u00edfilis na gesta\u00e7\u00e3o, observa-se melhor desempenho nos indicadores relacionados \u00e0 aplica\u00e7\u00e3o da penicilina benzatina na unidade e na oferta de tratamento para gestantes e parcerias, em 2017 comparado a 2010. Essa melhoria possivelmente reflete os esfor\u00e7os de capacita\u00e7\u00e3o e medidas t\u00e9cnicas empreendidas tanto pelo Minist\u00e9rio da Sa\u00fadecomo pela Secretaria de Estado da Sa\u00fade de S\u00e3o Paulo.Apesar do desempenho insuficiente expresso pelos indicadores de tratamento, \u00e9 importante ressaltar que houve avan\u00e7os. Ao comparar resultados deste estudo com o desenvolvido por Sanine et al.Para al\u00e9m da aten\u00e7\u00e3o ao pr\u00e9-natal, o modelo de avalia\u00e7\u00e3o da preven\u00e7\u00e3o da s\u00edfilis cong\u00eanita apresentado considera a import\u00e2ncia de pr\u00e1ticas que favorecem a interrup\u00e7\u00e3o da cadeia de transmiss\u00e3o da s\u00edfilis em outras fases da vida por meio de a\u00e7\u00f5es de preven\u00e7\u00e3o, diagn\u00f3stico precoce e manejo da s\u00edfilis em mulheres em idade f\u00e9rtil e em suas parcerias sexuais..Os servi\u00e7os avaliados possuem um bom desempenho relacionado \u00e0 aten\u00e7\u00e3o \u00e0s IST, sendo que o dom\u00ednio \u201cdiagn\u00f3stico e tratamento da s\u00edfilis adquirida\u201d foi o que obteve maior m\u00e9dia entre os servi\u00e7os, e nenhum de seus indicadores teve uma frequ\u00eancia menor que 80%. Tal resultado pode ser reflexo da tradi\u00e7\u00e3o da assist\u00eancia \u00e0s IST na APS paulista, uma vez que o estado foi pioneiro na organiza\u00e7\u00e3o de respostas da rede \u00e0 epidemia de aids no pa\u00eds e, desde ent\u00e3o, assume forte papel na linha de preven\u00e7\u00e3o e assist\u00eancia a IST/aids, empreendendo iniciativas que t\u00eam o objetivo de fortalecer a integra\u00e7\u00e3o dessas a\u00e7\u00f5es. Entretanto, o dom\u00ednio \u201ca\u00e7\u00f5es educativas e preven\u00e7\u00e3o de IST\u201d foi o que obteve menor desempenho, com frequ\u00eancias baixas em todos os indicadores, especialmente nos que abordam pr\u00e1ticas de educa\u00e7\u00e3o em sa\u00fade desenvolvidas na comunidade e que envolvem grupos em situa\u00e7\u00e3o de vulnerabilidade. Esses resultados corroboram a literatura, que indica que as pr\u00e1ticas de preven\u00e7\u00e3o \u00e0s IST/aids e de educa\u00e7\u00e3o em sa\u00fade ocupam um lugar secund\u00e1rio no processo de trabalho em sa\u00fade.Na busca pela elimina\u00e7\u00e3o da s\u00edfilis cong\u00eanita, \u00e9 importante que a\u00e7\u00f5es educativas sejam realizadas junto \u00e0 comunidade, \u00e0s gestantes e \u00e0s fam\u00edlias, com o objetivo de aumentar o conhecimento desses atores sobre a sa\u00fade materno-infantil e garantir uma maior autonomia no cuidadoAs m\u00e9dias e medianas altas e semelhantes entre os grupos de qualidade aponta a ocorr\u00eancia de um pequeno intervalo percentual entre eles, com exce\u00e7\u00e3o de G1, indicando que cerca de 70% dos servi\u00e7os tiveram desempenho m\u00e9dio acima de 70%. Entretanto, para uma doen\u00e7a evit\u00e1vel por meio de diversas pr\u00e1ticas desenvolvidas nos servi\u00e7os de APS em diferentes momentos, esse desempenho pode ser considerado insuficiente.Todos os indicadores inclu\u00eddos na matriz avaliativa foram capazes de diferenciar os grupos entre si, fato que estatisticamente pode ser justificado pelo grande n\u00famero de servi\u00e7os da amostra (2.565), mas, por outro lado, reflete a diferencia\u00e7\u00e3o entre os servi\u00e7os e a capacidade da matriz proposta em identificar atributos distintos que qualificam a preven\u00e7\u00e3o da s\u00edfilis cong\u00eanita., e a avalia\u00e7\u00e3o realizada reafirma essa tend\u00eancia. Por outro lado, \u00e9 fato que mesmo as USF, e as UBS que possuem ESF ou PACS integradas, tamb\u00e9m requerem um maior investimento para que efetivem uma aten\u00e7\u00e3o integral, visto que muitas dessas unidades tamb\u00e9m apresentaram baixo desempenho.O melhor desempenho de unidades organizadas segundo as diretrizes de sa\u00fade da fam\u00edlia est\u00e1 bem demonstrado na literaturaUm dos limites deste trabalho \u00e9 o poder de generaliza\u00e7\u00e3o dos resultados, uma vez que se referem apenas aos servi\u00e7os participantes. Outro limite diz respeito ao uso de dados secund\u00e1rios oriundos de um inqu\u00e9rito que avaliou o conjunto de a\u00e7\u00f5es da APS, sendo a preven\u00e7\u00e3o da s\u00edfilis cong\u00eanita um recorte desse conjunto. Al\u00e9m disso, estudos transversais descritivos t\u00eam limites dados pelo pr\u00f3prio recorte temporal que fazem da realidade. Entretanto, a avalia\u00e7\u00e3o de desempenho de servi\u00e7os aponta quest\u00f5es que exigem mudan\u00e7as processuais e medidas de planejamento e gest\u00e3o, contribuindo para a melhoria da qualidade.As fragilidades identificadas na organiza\u00e7\u00e3o dos servi\u00e7os t\u00eam grande governabilidade local e apontam prioridades que precisam ser incorporadas e que representam a consolida\u00e7\u00e3o de pol\u00edticas e diretrizes j\u00e1 dispon\u00edveis. Destaca-se a necessidade de investimentos na capacidade t\u00e9cnica dos servi\u00e7os e na qualifica\u00e7\u00e3o profissional para execu\u00e7\u00e3o dos protocolos de maneira efetiva.Os resultados confirmam a import\u00e2ncia da qualifica\u00e7\u00e3o do pr\u00e9-natal, j\u00e1 apontada em outros estudos, e evidenciam o valor da realiza\u00e7\u00e3o de avalia\u00e7\u00f5es que induzem reflex\u00f5es nas equipes sobre a organiza\u00e7\u00e3o dos processos de trabalho e que, assim, contribuem para a instaura\u00e7\u00e3o de processos de mudan\u00e7a que produzam impacto na preven\u00e7\u00e3o da s\u00edfilis cong\u00eanita."}
+{"text": "A varfarina \u00e9 um anticoagulante oral \u00fatil para preven\u00e7\u00e3o de tromboembolismo, embora seja considerado f\u00e1rmaco de alto risco de causar eventos adversos. Considerando os desafios pr\u00e1ticos no controle da anticoagula\u00e7\u00e3o oral, os pacientes poderiam se beneficiar de estrat\u00e9gias educacionais que visem mudan\u00e7a de comportamento, participa\u00e7\u00e3o ativa no autocuidado e ades\u00e3o \u00e0 farmacoterapia. Construir e validar o protocolo EmpoderACO para mudan\u00e7a de comportamento em pacientes em uso de varfarina. As etapas metodol\u00f3gicas foram: defini\u00e7\u00e3o de conceitos e dom\u00ednios do autocuidado, identifica\u00e7\u00e3o dos objetivos, constru\u00e7\u00e3o e sele\u00e7\u00e3o dos itens, avalia\u00e7\u00e3o da validade de conte\u00fado e pr\u00e9-teste na popula\u00e7\u00e3o alvo. Relev\u00e2ncia, adequa\u00e7\u00e3o, clareza e confiabilidade interna dos itens do instrumento foram avaliadas por comit\u00ea de ju\u00edzes multiprofissional pela plataforma web E-surv, obtendo-se m\u00e9dia de concord\u00e2ncia \u22650,91. A compreens\u00e3o do instrumento pela popula\u00e7\u00e3o-alvo teve clareza adequada com m\u00e9dia de 0,96. O EmpoderACO poder\u00e1 contribuir para qualificar o processo de comunica\u00e7\u00e3o entre profissionais e pacientes, melhorar a ades\u00e3o ao tratamento e os resultados cl\u00ednicos, podendo ser replicado nos servi\u00e7os de sa\u00fade. A constru\u00e7\u00e3o de um protocolo voltado para a anticoagula\u00e7\u00e3o oral com varfarina, baseado nos princ\u00edpios de mudan\u00e7a de comportamento do PMC, poderia promover melhores resultados cl\u00ednicos e uma sistematiza\u00e7\u00e3o do canal de comunica\u00e7\u00e3o entre o paciente e o profissional de sa\u00fade. Al\u00e9m disso, poderia aumentar a satisfa\u00e7\u00e3o do paciente com seu tratamento, melhorar a ades\u00e3o, reduzir a ocorr\u00eancia de eventos adversos e possibilitar que o usu\u00e1rio/paciente reconhe\u00e7a a necessidade da mudan\u00e7a de comportamento.26 a saber: defini\u00e7\u00e3o de conceitos e dom\u00ednios do autocuidado na anticoagula\u00e7\u00e3o com varfarina; identifica\u00e7\u00e3o dos objetivos do instrumento; constru\u00e7\u00e3o do instrumento e sele\u00e7\u00e3o dos itens conforme o objetivo do instrumento; avalia\u00e7\u00e3o da validade de conte\u00fado pelo Comit\u00ea de Ju\u00edzes (CJ); realiza\u00e7\u00e3o da valida\u00e7\u00e3o pr\u00e9-teste em pacientes em uso de varfarina e descri\u00e7\u00e3o das vari\u00e1veis e an\u00e1lise estat\u00edstica. As etapas do estudo ocorreram no per\u00edodo de dezembro de 2017 a junho de 2019.O estudo foi desenvolvido em etapas seguindo a metodologia proposta por Coluci et al.,25 a saber: 1\u00ba Passo: defini\u00e7\u00e3o do problema; 2\u00ba Passo: identifica\u00e7\u00e3o e abordagem dos sentimentos; 3\u00ba Passo: defini\u00e7\u00e3o de metas; 4\u00ba Passo: elabora\u00e7\u00e3o do plano de cuidados para conquista da(s) meta(s); 5\u00ba Passo: Avalia\u00e7\u00e3o e experi\u00eancia do usu\u00e1rio sobre o plano de cuidados. A pesquisa foi aprovada pelo Comit\u00ea de \u00c9tica em Pesquisa da Universidade Federal de Minas Gerais (UFMG), sob parecer n\u00ba 2.018.850, CAAE: 65928316.3.0000.5149. Ap\u00f3s esclarecimentos sobre o objetivo da investiga\u00e7\u00e3o e a natureza da coleta de dados, todos os participantes assinaram o termo de consentimento livre e esclarecido.A estrutura dos itens do protocolo EmpoderACO seguiram os cinco passos para mudan\u00e7a de comportamento, conforme o estudo de empoderamento PMC,29 a constru\u00e7\u00e3o de uma estrutura conceitual \u00e9 a etapa respons\u00e1vel por definir o contexto do instrumento e sustentar o desenvolvimento de sua dimensionalidade. Desta forma, um mapa conceitual foi constru\u00eddo, utilizando o programa CmapTolls vers\u00e3o 6.02 (2017), para a identifica\u00e7\u00e3o dos dom\u00ednios do autocuidado nos quais o instrumento deveria se embasar. Identificou-se a necessidade de constru\u00e7\u00e3o de itens espec\u00edficos para o p\u00fablico-alvo envolvendo pacientes com cardiopatias com alta complexidade do quadro cl\u00ednico e especificidades inerente ao anticoagulante oral. Estas etapas foram conduzidas no per\u00edodo de dezembro de 2017 a agosto de 2018. De acordo com o estudo de Snyder et al.,30 \u00e9 fundamental que os objetivos do instrumento de sa\u00fade sejam pr\u00e9-definidos antes de sua constru\u00e7\u00e3o e que esses objetivos tenham conex\u00e3o com dom\u00ednios e conceitos a serem inseridos no instrumento.De acordo com o Pasquali,26 e Pasquali.29 Incialmente, o instrumento foi constru\u00eddo por um comit\u00ea de especialistas (CE) interno, o qual apresentava ampla viv\u00eancia em cl\u00ednica de anticoagula\u00e7\u00e3o, composto por tr\u00eas farmac\u00eauticas cl\u00ednicas, uma enfermeira e uma linguista com dom\u00ednio no processo de adapta\u00e7\u00e3o e valida\u00e7\u00e3o de instrumentos empregados na \u00e1rea da sa\u00fade. Foram conduzidas reuni\u00f5es para discuss\u00e3o da pertin\u00eancia e adequa\u00e7\u00e3o de cada item para o contexto da anticoagula\u00e7\u00e3o oral. Coube ao CE interno a defini\u00e7\u00e3o dos dom\u00ednios de autocuidados, mensurados na etapa anterior do mapa conceitual, a serem inclu\u00eddos no protocolo. Observou-se a necessidade da elabora\u00e7\u00e3o pelo CE interno, de 12 novos itens para que o novo instrumento atendesse \u00e0 popula\u00e7\u00e3o-alvo e estivesse voltado para o autocuidado na anticoagula\u00e7\u00e3o oral. Nesta fase, foram constru\u00eddas oito vers\u00f5es diferentes do protocolo (V1-V8) antes do encaminhamento ao CE externo .A constru\u00e7\u00e3o e valida\u00e7\u00e3o do instrumento, em quest\u00e3o, foram realizadas seguindo etapas metodol\u00f3gicas abordadas propostas pelos estudos de Coluci et al.Survey E-surv. Nesta avalia\u00e7\u00e3o piloto, foram convidados cinco profissionais da \u00e1rea da sa\u00fade, todos com conhecimento e experi\u00eancia em anticoagula\u00e7\u00e3o composto por um m\u00e9dico, dois farmac\u00eauticos e dois enfermeiros. O CE externo analisou cada item do protocolo e sugeriu novas adequa\u00e7\u00f5es na estrutura e conte\u00fado. Ap\u00f3s as adapta\u00e7\u00f5es sugeridas e julgadas pertinentes pelo CE interno, foi constru\u00edda uma vers\u00e3o inicial do instrumento (V9) que, posteriormente, foi entregue a ao Comit\u00ea de Ju\u00edzes (CJ). Estas etapas foram conduzidas no per\u00edodo de setembro de 2018 a mar\u00e7o de 2019.A vers\u00e3o V8 definida como vers\u00e3o-teste foi submetida \u00e0 avalia\u00e7\u00e3o piloto do CE externo por meio da plataforma web 31 O CJ realizou esta an\u00e1lise por meio da avalia\u00e7\u00e3o de conte\u00fado, seguindo a recomenda\u00e7\u00e3o da literatura em rela\u00e7\u00e3o ao n\u00famero m\u00ednimo de ju\u00edzes e composi\u00e7\u00e3o de especialistas na \u00e1rea de instrumentos de medidas.32 As an\u00e1lises pelos ju\u00edzes envolveram procedimentos avaliativos e quantitativos.26 A sele\u00e7\u00e3o dos profissionais que integraram o CJ foi realizada considerando os seguintes crit\u00e9rios: possuir gradua\u00e7\u00e3o na \u00e1rea da Sa\u00fade e apresentar conhecimento e/ou viv\u00eancia com a pr\u00e1tica cl\u00ednica envolvendo cuidado ao paciente em anticoagula\u00e7\u00e3o oral com varfarina e/ou profissionais com experi\u00eancia no processo de adapta\u00e7\u00e3o e valida\u00e7\u00e3o de instrumentos.O CJ estava composto por 34 profissionais e tinha um perfil multidisciplinar, cuja fun\u00e7\u00e3o era o julgamento e a an\u00e1lise de todos os itens do protocolo. Posteriormente, a estrutura\u00e7\u00e3o e organiza\u00e7\u00e3o do instrumento foram testadas quanto \u00e0 hip\u00f3tese de que os itens escolhidos contemplavam adequadamente os dom\u00ednios do constructo desejado.online de avalia\u00e7\u00e3o (Survey E-surv). Em seguida, os participantes foram convidados a avaliar a vers\u00e3o V9 e registrar suas opini\u00f5es a fim de avaliar o grau de relev\u00e2ncia, adequa\u00e7\u00e3o e clareza do instrumento, tendo estipulado prazo de um m\u00eas para o retorno das avalia\u00e7\u00f5es. Tamb\u00e9m foi solicitado ao CJ que analisasse o grau de pertin\u00eancia dos itens do protocolo e informasse qual(is) categoria(s) o item era capaz de mensurar. Nessa an\u00e1lise de pertin\u00eancia, o juiz tinha acesso ao significado de cada categoria e poderia selecionar mais de uma categoria correspondente para o mesmo item. O objetivo dessa an\u00e1lise foi agrupar os itens de acordo com os dom\u00ednios de autocuidado para pacientes em uso de anticoagulante oral. Estas etapas foram conduzidas no per\u00edodo entre mar\u00e7o e abril de 2019.Os integrantes do CJ preencheram um question\u00e1rio introdut\u00f3rio por meio da mesma plataforma Likert de tr\u00eas pontos: a) Muito claro, b) Claro e c) Pouco claro. Estas etapas foram conduzidas no per\u00edodo entre abril e maio de 2019. Ap\u00f3s o pr\u00e9-teste n\u00e3o houve necessidade de modifica\u00e7\u00e3o dos itens constru\u00eddos e adaptados e, portanto, a vers\u00e3o V10 constituiu a vers\u00e3o final do protocolo EmpoderACO.A an\u00e1lise sem\u00e2ntica e valida\u00e7\u00e3o do instrumento foram realizadas por meio do pr\u00e9-teste que consistiu em um teste de campo com a popula\u00e7\u00e3o-alvo utilizando a vers\u00e3o pr\u00e9-final do instrumento (V10). Os participantes avaliaram a clareza de cada item do instrumento a fim de estimar o entendimento do instrumento. Esta etapa foi realizada na cl\u00ednica de anticoagula\u00e7\u00e3o do Hospital das Cl\u00ednicas - UFMG por dois pesquisadores da \u00e1rea da sa\u00fade experientes em aplica\u00e7\u00e3o de question\u00e1rio para pacientes. O pr\u00e9-teste foi aplicado em 30 pacientes. As quest\u00f5es foram lidas aos participantes pelos pesquisadores, pois alguns deles n\u00e3o tinham letramento suficiente. Coube aos participantes responderem quanto \u00e0 clareza dos itens, em uma escala tipo Survey E-surv. Esses dados inclu\u00edram: nome, institui\u00e7\u00e3o de trabalho, forma\u00e7\u00e3o e experi\u00eancia na pr\u00e1tica profissional com varfarina. As avalia\u00e7\u00f5es do instrumento obtidas pelo CJ foram exportadas da plataforma online para uma planilha eletr\u00f4nica do editor Microsoft Excel (vers\u00e3o 2019) para posterior realiza\u00e7\u00e3o das an\u00e1lises estat\u00edsticas. Todos os dados foram devidamente codificados para assegurar o anonimato dos participantes.Os dados descritivos dos integrantes do CJ foram coletados por meio da aplica\u00e7\u00e3o de question\u00e1rio inicial, via plataforma web Durante o pr\u00e9-teste, foi aplicado um question\u00e1rio para coleta dos dados sociodemogr\u00e1ficos dos pacientes, abrangendo sexo, idade e escolaridade, de forma de caracterizar a amostra. Esta etapa foi conduzida em junho de 2019.33 e, preferencialmente superior a 0,90.34 Para avaliar a relev\u00e2ncia de cada item do instrumento, o CJ julgou o item de acordo com as respostas: 1=Sem relev\u00e2ncia, 2=Relevante, 3=Muito relevante. A adequa\u00e7\u00e3o e clareza foram avaliadas seguindo uma escala Likert de tr\u00eas pontos, sendo: 1=N\u00e3o adequado, 2=Adequado e 3=Muito adequado, para o grau de adequa\u00e7\u00e3o e 1=Sem clareza, 2=Claro e 3=Muito claro, para o grau de clareza. O c\u00e1lculo foi realizado a partir do somat\u00f3rio das respostas \u201c2\u201d e \u201c3\u201d de cada juiz em cada item do protocolo e dividiu-se esta soma pelo n\u00famero total de ju\u00edzes . A etapa do pr\u00e9-teste foi realizada por 30 pacientes, cujo quantitativo amostral foi considerado suficiente para tal avalia\u00e7\u00e3o.29 O mesmo c\u00e1lculo de CVC foi utilizado na fase pr\u00e9-teste aplicada em campo para a avalia\u00e7\u00e3o quanto \u00e0 clareza dos itens. Os dados sociodemogr\u00e1ficos foram tabulados e apresentados de modo descritivo utilizando frequ\u00eancias absoluta e relativa com c\u00e1lculo de propor\u00e7\u00f5es e medidas de tend\u00eancia central. Esta etapa foi conduzida em junho de 2019.A valida\u00e7\u00e3o do instrumento, neste estudo, foi computada por meio do Coeficiente de validade de conte\u00fado (CVC) por ser uma medida capaz de avaliar a relev\u00e2ncia e representatividade dos itens. Foi definida uma concord\u00e2ncia m\u00ednima de CVC igual a 0,80Os dom\u00ednios do autocuidado representados no mapa conceitual  foram di35 A distribui\u00e7\u00e3o das categorias profissionais dos participantes do estudo foi: 40  farmac\u00eauticos; 17  enfermeiros; 16  m\u00e9dicos; tr\u00eas  nutricionistas; tr\u00eas  linguistas e uma pedagoga . Os farmac\u00eauticos representaram a categoria profissional de maior predomin\u00e2ncia no CJ, seguidos de enfermeiros, m\u00e9dicos, nutricionistas, linguistas e pedagoga. A m\u00e9dia geral dos itens avaliados pelo CJ apresentou CVC igual ou superior a 0,91 para todas as an\u00e1lises: grau de relev\u00e2ncia, adequa\u00e7\u00e3o e clareza. As exce\u00e7\u00f5es foram quanto aos itens 4, 16, 19, 22 e 24, conforme apresentado na Dos 80 profissionais convidados para participar do CJ, 34  enviaram as avalia\u00e7\u00f5es do protocolo e o n\u00famero total de ju\u00edzes participantes mostrou ser adequado, conforme preconizado pela literatura.Verificou-se que houve consist\u00eancia e homogeneidade na an\u00e1lise do grau de pertin\u00eancia da vers\u00e3o V9, feita pelo CJ. Os resultados da concord\u00e2ncia est\u00e3o apresentados na A etapa do pr\u00e9-teste foi realizada com 30 pacientes que representaram uma amostra heterog\u00eanea quanto a idade, sexo e n\u00edvel de escolaridade, sendo que, 50,0% dos participantes corresponderam ao sexo feminino e 50,0% tinham escolaridade no n\u00edvel do ensino fundamental incompleto. A m\u00e9dia de idade observada foi 61,7\u00b114,5 anos e 33,3% dos pacientes tinha entre 45 e 60 anos . Nesta e35 Por meio da an\u00e1lise do grau de pertin\u00eancia da vers\u00e3o V9, feita pelo CJ, foi observado que, de forma geral, a maioria dos itens era representada por mais de uma categoria. Contudo, verificou-se que houve consist\u00eancia e homogeneidade dos resultados da avalia\u00e7\u00e3o.Instrumentos como o EmpoderACO podem ser de grande utilidade no contexto da sa\u00fade p\u00fablica no Brasil, pois at\u00e9 o momento n\u00e3o se identificou instrumento pautado no empoderamento e mudan\u00e7a de comportamento voltado ao paciente com doen\u00e7as cardiovasculares. O presente estudo permitiu construir o instrumento cujos desempenhos na relev\u00e2ncia, adequa\u00e7\u00e3o, clareza e valida\u00e7\u00e3o foram considerados bastante satisfat\u00f3rios. A elabora\u00e7\u00e3o do mapa conceitual que precedeu o desenvolvimento do instrumento possibilitou a identifica\u00e7\u00e3o de dom\u00ednios de autocuidado na anticoagula\u00e7\u00e3o oral que deveriam ser abordados no EmpoderACO. Todos os 30 itens da vers\u00e3o V9 julgados pelo CJ foram analisados pelo CE interno e os itens foram adaptados, exclu\u00eddos ou invertidos segundo a sequ\u00eancia do instrumento. Conforme a literatura, os itens que apresentam CVC menor que 0,78 n\u00e3o necessariamente devem ser exclu\u00eddos, embora obrigatoriamente necessitem sofrer modifica\u00e7\u00f5es, como \u00e9 o caso dos itens 4 e 16.29 Nenhum paciente fez sugest\u00e3o de modifica\u00e7\u00e3o ou acr\u00e9scimo de quest\u00f5es durante a etapa de pr\u00e9-teste. Nessa etapa, as modifica\u00e7\u00f5es devem ser consideradas somente se 15% ou mais dos participantes apresentarem dificuldades de compreens\u00e3o, conforme proposto pelos autores Ciconelli et al.36 e Ramada-Rodilla et al.37O CVC calculado pelas respostas dos pacientes no pr\u00e9-teste apresentou resultado muito satisfat\u00f3rio .39 A constru\u00e7\u00e3o de instrumentos com obten\u00e7\u00e3o de dados em sa\u00fade possibilita organizar as informa\u00e7\u00f5es de forma clara e objetiva para uma assist\u00eancia de qualidade e embasar interven\u00e7\u00f5es em sa\u00fade.40 Estrat\u00e9gias pautadas no empoderamento que se prop\u00f5em a elaborar plano de cuidados para pacientes com doen\u00e7as cr\u00f4nicas demonstraram resultados favor\u00e1veis para controle glic\u00eamico, autocuidado e empoderamento dos usu\u00e1rios como apontado pelos estudos de Macedo et al.;41 Cortez et al.;25 Chaves et al.;24 Barbosa et al.9 No que se refere ao uso do anticoagulante, estas estrat\u00e9gias s\u00e3o necess\u00e1rias para aumento da efetividade e diminui\u00e7\u00e3o dos eventos adversos associados ao uso da varfarina.10Promover mudan\u00e7as de comportamento como ingesta regular de alimentos ricos em vitamina K, monitoramento frequente dos exames de RNI, evitar a automedica\u00e7\u00e3o e realizar inspe\u00e7\u00e3o do corpo quanto a sinais e sintomas de hemorragia s\u00e3o exemplos relevantes de a\u00e7\u00f5es para monitoramento de efetividade e seguran\u00e7a do tratamento em pacientes em uso de varfarina.O protocolo EmpoderACO poder\u00e1 ser aplicado na pr\u00e1tica cl\u00ednica como suporte no cuidado ao paciente sendo utilizado pelos profissionais de sa\u00fade e pela equipe multiprofissional de modo a fortalecer a qualidade das interven\u00e7\u00f5es e abordagens educacionais. Como perspectivas desse estudo, podemos citar a realiza\u00e7\u00e3o de novas investiga\u00e7\u00f5es como a valida\u00e7\u00e3o do PMC em grupos aleat\u00f3rios de modo a testar o impacto do EmpoderACO nos desfechos da terapia e seguran\u00e7a, frente a um grupo controle, bem como o emprego em futuros estudos na \u00e1rea da anticoagula\u00e7\u00e3o. Dessa forma, poder\u00e1 ser utilizado para discuss\u00f5es adicionais, aprofundamento da percep\u00e7\u00e3o do protocolo pelos profissionais de sa\u00fade, avalia\u00e7\u00e3o dos resultados e dos impactos cl\u00ednicos, ades\u00e3o ao tratamento e promo\u00e7\u00e3o da seguran\u00e7a do paciente.A relev\u00e2ncia cl\u00ednica do EmpoderACO deve-se \u00e0 possibilidade de o instrumento sistematizar a comunica\u00e7\u00e3o, nortear abordagens educacionais multidisciplinares em sa\u00fade coletiva, estimular a humaniza\u00e7\u00e3o do cuidado, bem como a abordagem individualizada e centrada no paciente. Al\u00e9m disso, espera-se que o empoderamento do usu\u00e1rio para mudan\u00e7as de comportamento possa fortalecer a rela\u00e7\u00e3o profissional-paciente e aumento da compreens\u00e3o da terapia, o que pode favorecer a ades\u00e3o ao tratamento. Almeja-se que o instrumento possa auxiliar os pacientes de alta complexidade, em uso de anticoagulantes orais, a se tornarem mais capazes de tomar decis\u00f5es em prol de seu autocuidado e aprimorar a qualidade do processo assistencial, a fim de melhorar os resultados cl\u00ednicos, bem como a redu\u00e7\u00e3o dos eventos adversos associados ao uso de anticoagulantes orais.33 Outro ponto positivo observado foi facilidade de compreens\u00e3o do instrumento e boa aceita\u00e7\u00e3o pela popula\u00e7\u00e3o que n\u00e3o sabe ler e com baixa escolaridade. Atenta-se como limita\u00e7\u00e3o do estudo o fato dos itens com necessidade de reformula\u00e7\u00e3o n\u00e3o terem sido submetidos novamente \u00e0 an\u00e1lise de CVC pelo CJ. Desta forma, n\u00e3o foi poss\u00edvel a mensura\u00e7\u00e3o do CVC dos itens adaptados. Entretanto, tais itens foram reformulados conforme as sugest\u00f5es do mesmo CJ e observou-se que a clareza destes itens n\u00e3o foi comprometida, visto que, na etapa pr\u00e9-teste houve compreens\u00e3o adequada dos itens da vers\u00e3o V10 pela popula\u00e7\u00e3o-alvo. Observa-se tamb\u00e9m limita\u00e7\u00f5es inerentes aos dados coletados diretamente com os pacientes, tais como desconforto para o paciente ao responder a uma pergunta, bem como vi\u00e9s das informa\u00e7\u00f5es coletadas.O instrumento EmpoderACO apresentou como ponto positivo o cumprimento do requisito de concord\u00e2ncia geral m\u00ednima de 0,80 para constru\u00e7\u00e3o e valida\u00e7\u00e3o de novos instrumentos em todos os graus avaliados: relev\u00e2ncia , adequa\u00e7\u00e3o  e clareza .O instrumento EmpoderACO se mostrou adequado e de f\u00e1cil compreens\u00e3o pelos usu\u00e1rios de varfarina, sobretudo apresentou potencial para uso em pessoas com baixo grau de escolaridade, podendo ser relevante em p\u00fablicos com escolaridade semelhante. O emprego do protocolo EmpoderACO no campo da anticoagula\u00e7\u00e3o permitir\u00e1 utilizar dos princ\u00edpios de problematiza\u00e7\u00e3o, autocuidado, empoderamento e cuidado centrado no indiv\u00edduo como estrat\u00e9gias para melhorar os resultados terap\u00eauticos da anticoagula\u00e7\u00e3o oral. 1 Even with the advent of direct oral anticoagulants, warfarin is still the main oral anticoagulant provided by the Brazilian Unified Health System .2 However, inadequate control of this medication may cause adverse events, such as hemorrhage and thromboembolism, which may occur due to exacerbating the anticoagulant effect or therapeutic failure, respectively.4 The introduction of educational interventions may contribute to reaching the therapeutic results of this medication, improving the patient\u2019s knowledge of oral anticoagulants and consequently improving adherence and satisfaction with the treatment.8 Desirable changes in behavior, actions aimed at health education, and the empowerment of patients have been seen as important elements for success in anticoagulant treatments.11Warfarin is a coumarin-derivative oral anticoagulant widely used for primary and secondary prevention against thromboembolism.14 The risk of having adverse effects from the treatment increases when the medication is used incorrectly, such as serious hemorrhagic events, like hemorrhagic and/or thrombotic strokes, these events being triggered by the exacerbation of the anticoagulant effect or by therapeutic failure, respectively.16In such a context, adherence to pharmacotherapy represents a necessary condition to improve the effectiveness and safety of the treatment, avoiding additional challenges in the patient care process.16Treatment requires frequent laboratorial monitoring, and reaching the therapeutic target group may be difficult due to the multiple factors which interfere with the treatment, such as dose-response variability, the influence of genetic polymorphism, the presence of comorbidities, high number of interactions with other medications or foods, low level of health education, and concerns by the patients regarding adverse reactions, which can lead to self-interruption of the medication, and those who may require frequent dose adjustments.20 In the context of chronic diseases, the Behavior Change Protocol (BCP) was proposed, which was originally developed by researchers from the University of Michigan for type 2 diabetes mellitus patients 23 and was later translated and validated for the Brazilian population.25Currently, there is a scarcity of instruments and directives that guide practices related to empowerment, self-care, and behavioral changes in patients undergoing anticoagulation treatment. Moreover, they are not always conscious and mobilized regarding the importance of this kind of educational approach.25Empowerment is quite useful in increasing the feeling of control, self-efficiency, coping ability, management of the treatment, and the individual\u2019s ability to reflect on his/her contribution in the process, as well as to achieve a change in behavior regarding the individual\u2019s own health condition.28 This study aims to construct and validate the EmpoderACO protocol to produce behavioral changes in patients undergoing oral treatment with warfarin.Using standardized strategies based on empowerment may guide health professionals towards more active participation of the patients in self-care and adherence to pharmacotherapy by patients taking oral anticoagulants. Creating a protocol for oral treatment with warfarin, based on principles of behavioral changes guided by the BCP, may promote better clinical results and help systematize the communication channels between patients and health professionals. Moreover, it could also increase the patient\u2019s satisfaction with the treatment, improve adherence, reduce adverse effects, and allow the patient/user to recognize the need for changes in behavior. 26 methodology, which are: definitions of concepts and domains of self-care in anticoagulation treatment with warfarin; identification of the instrument\u2019s objectives and selection of items according to the instrument\u2019s objective; evaluation of content validity by the Judges Committee (JC); performance of pre-test validation with warfarin patients; and description of the variables and statistical analysis. The stages of the process took place from December 2017 to June 2019.This study was developed in stages, following Coluci et al.25empowerment study, as follows: Step 1: Definition of the problem; Step 2: Identification and approach to the feelings; Step 3: Definition of the target(s); Step 4: Elaboration of the care plan for reaching the targets; and Step 5: Evaluation and user experience regarding the care plan. This study was approved by the Research Ethics Committee from the Universidade Federal de Minas Gerais (UFMG), Decision no. 2,018,850, CAAE: 65928316.3.0000.5149. After being informed about the study\u2019s objectives and the nature of the data collection, all participants signed the free and informed consent form.The structure of the items in the EmpoderACO protocol follows the five steps for behavioral change, according to the BCP29 the construction of a conceptual structure is the stage which defines the context of the instrument and supports the development of its dimensionality. Therefore, a conceptual map was produced using the CmapTolls program, version 6.02 (2017), to identify the domains of self-care on which the instrument should be based. We identified the need to construct specific items for the target public: patients with cardiopathies with highly complex clinical conditions and specificities regarding oral anticoagulant treatment. The stages were conducted from December 2017 to August 2018. According to a study by Snyder et al.30 it is crucial that the objectives of the health instrument be pre-defined before its construction and that these objectives be connected to domains and concepts that will be inserted in the instrument.According to Pasquali,26 and Pasquali.29 The instrument was initially constructed by an internal committee of experts (CE) with broad experience in clinical anticoagulation, consisting of three clinical pharmacists, one nurse, and one linguist capacitated in adapting and validating instruments used in the health area. Meetings were conducted to discuss the pertinence and adequation of each item in the context of oral anticoagulation. The internal CE defined self-care domains, measured in the previous stage of the conceptual map, which would be included in the protocol. The internal CE needed to elaborate 12 new items so that the new instrument could address the target population and aimed at self-care and oral anticoagulation. In this stage, eight protocol versions were constructed (V1-V8) before sending it to the external CE .The construction and validation of the instrument were conducted according to methodological stages proposed in the studies by Coluci et al.Survey E-surv web platform. In the pilot evaluation, five health professionals were invited, all with experience and knowledge in anticoagulation, including one physician, two pharmacists, and two nurses. The external CE analyzed each protocol item and suggested new adaptations to the structure and content. After the adaptations had been suggested and deemed relevant by the internal CE, an initial version of the instrument was constructed (V9), which, later was delivered to the JC. These stages were conducted from September 2018 to March 2019.The V8 version, defined as the test version, was submitted to the pilot evaluation of the external CE by the 31 The JC conducted the analysis by evaluating the content and following the recommendations in the literature regarding the minimum number of judges and participation of experts in the area of measuring instruments.32 The analyses by the judges involved qualitative and quantitative procedures.26 Professionals were chosen to be part of the JC according to the following criteria: have a degree in the field of health and have knowledge and/or experience with clinical practice in caring for patients with the oral anticoagulant warfarin and/or professionals with experience in the process of adaptation and validation of instruments.The JC consisted of 34 professionals with a multidisciplinary profile, and its function was to judge and analyze all of the protocol\u2019s items. After, the structure and organization of the instrument were tested according to the hypothesis that the chosen items properly represented the domains of the desired construct.Survey E-surv). Next, the participants were invited to evaluate the V9 version and register their opinions to evaluate the level of relevance, adequation, and clarity of the instrument. The participants had one month to turn in the evaluations. The JC was also asked to analyze the level of the pertinence of the protocol items and to inform which categories the items could measure. In this analysis of pertinence, the judges had access to the meaning of each category and could select more than one category corresponding to the same item. This analysis aimed to group the items according to the domains of self-care for patients taking oral anticoagulants. Those stages were conducted between March and April 2019.The JC members completed an introductory questionnaire using the same online platform . The participants evaluated the clarity of each instrument item, aimed at estimating how understandable the instrument was. This stage was conducted at the anticoagulation clinic of the UFMG Hospital das Cl\u00ednicas by two researchers from the health area with experience in the application of questionnaires for patients. The pre-test was applied to 30 patients. The researchers read the questions to the participants since some were not literate enough to read. The participants were asked to answer about the clarity of the items according to a Likert scale of three points: a) Very Clear, b) Clear, and c) Not Clear. Those stages were conducted in April and May 2019. After the pre-test, there was no need for modifications in the adapted and constructed items; therefore, the V10 version became the final version of the EmpoderACO protocol.Survey E-surv web platform. The data included: name, place of work, education, and professional practice experience with warfarin. The evaluations of the instrument provided by the JC were exported from the online platform to a digital spreadsheet using Microsoft Excel (version 2019) for subsequent statistical analysis. All of the data was properly codified to ensure the participants\u2019 anonymity.The descriptive data from the JC members was collected by applying an initial questionnaire using the During the pre-test, a questionnaire to collect sociodemographic data from the patients was applied, covering sex, age, and education to characterize the sample. This stage took place in June 2019.33 and, preferably, higher than 0.90.34 To evaluate the relevance of each item of the instrument, the JC judged the items according to the answers: 1=Not relevant, 2=Relevant, 3=Very relevant. Adequation and clarity were evaluated according to a three-point Likert scale: 1=Not adequate, 2=Adequate, and 3=Very adequate (for the level of adequation), and 1=Unclear, 2=Clear, and 3=Very clear (for the level of clarity). The calculation was made by the sum of answers \u201c2\u201d and \u201c3\u201d from each judge for each item in the protocol, and that sum was divided by the total number of judges . The pre-test stage was conducted with 30 patients, a sampling size which was considered sufficient for such an evaluation.29 The same calculation for CVC was used in the pre-test stage applied in the field to evaluate the clarity of the items. The sociodemographic data were tabulated and presented descriptively using absolute and relative frequencies to calculate proportions and measures for a central tendency. This stage took place in June 2019.The instrument\u2019s validation was computed using the Content Validity Coefficient (CVC), a measure capable of evaluating the relevance and representativeness of the items. A minimum CVC agreement was established, equal to 0.80The domains of self-care represented in the conceptual map  were div35 The distribution of participants in professional categories was: 40 (50.0%) pharmacists; 17 (21.3%) nurses; 16 (20.0%) physicians; three (3.7%) nutritionists; three (3.7%) linguists, and one pedagogue (1.3%). Pharmacists were the predominant professional category in the JC, followed by nurses, physicians, nutritionists, linguists, and one pedagogue. The general average of the items evaluated by the JC presented CVC above or equal to 0.91 for all analyses: level of relevance, adequation, and clarity. The exceptions were items 4, 16, 19, 22, and 24, as presented in Of the 80 professionals invited to participate in the JC, 34 (42.5%) sent evaluations of the protocol, and the number of judges proved adequate, according to recommendations in the literature.We verified that there was consistency and homogeneity in the analysis of the level of the pertinence of version V9 conducted by the JC. The results of the pertinence are presented in The pre-test stage was conducted with a group of 30 patients, representing a heterogeneous sample in terms of age, sex, and level of education, in which 50.0% of the participants were female, and 50.0% had incomplete Elementary School education. The average age was 61.7\u00b114.5 years, and 33.3% of the patients were between 45 and 60 . In this35 After the agreement analysis of version V9, conducted by the JC, we observed that, in general, most of the items were represented by more than one category. However, consistency and homogeneity could be verified in the evaluation results.Instruments, such as EmpoderACO, may be very useful in the context of public health in Brazil since, to date, no instruments have been based on empowerment and changes in behavior aimed at patients with cardiovascular diseases. The present study allowed us to build an instrument in which adequacy, clarity, and validation were considered highly satisfactory. The elaboration of the conceptual map that preceded the instrument\u2019s development enabled the identification of the self-care domains of anticoagulation treatment, which EmpoderACO should cover. All of the 30 items of version V9 were analyzed by the internal CE, and the items were adapted, excluded, or inverted according to the sequence of the instrument. According to the literature, the items which presented a CVC of lower than 0.78 did not necessarily need to be excluded, although they did have to be modified, as in the case of items 4 and 16.29 None of the patients suggested modifications or adding questions during the pre-test stage. In that stage, the modifications must be considered only when 15% or more of the participants had difficulty in understanding and comprehension, according to that defined by Ciconelli et al.36 and Ramada-Rodilla et al.37The CVC calculated by the patient\u2019s answers in the pre-test showed highly satisfactory results (0.96).39 The construction of instruments to collect health data allows one to organize the information clearly and objectively, thus contributing to quality care and supporting health interventions.40 Strategies based on empowerment which propose the elaboration of a health care plan for patients with chronic diseases, have demonstrated favorable results in terms of glycemic control, self-care, and the empowerment of the users, as discussed in the studies by Macedo et al.;41 Cortez et al.;25 Chaves et al.;24 and Cardoso Barbosa et al.9 As far as the use of anticoagulant is concerned, such strategies are necessary to increase effectiveness and reduce adverse effects associated with warfarin.10The promotion of behavior changes, such as the regular consumption of foods rich in Vitamin K, frequent monitoring of INR, avoiding self-medication, and conducting the self-body inspection for signs of hemorrhage, are relevant examples of actions necessary to monitor the effectiveness and safety of the treatment of patients with warfarin.The EmpoderACO can be used in clinical practice to support patient care and employed by health professionals and multidisciplinary teams to improve the quality of interventions and educational initiatives. The strengths of this study include the performance of new investigations, such as the validation of the BCP in random groups in order to test the impact of EmpoderACO in the outcomes of therapy and safety, as compared to a control group, as well as its use in future studies regarding anticoagulation. Therefore, this study can be used for additional discussions, further examining health professionals\u2019 perceptions of the protocol, evaluating results and clinical impacts, adherence to treatment, and patient safety.The clinical relevance of EmpoderAco stems from the instrument\u2019s ability to systematize communication, guide multidisciplinary educational approaches in public health, encourage more humanized care, and follow a more individualized approach focused on the patient. Moreover, we hope that patient empowerment may strengthen the doctor-patient relationship and improve one\u2019s understanding of the therapy, thereby increasing adherence to the treatment. We hope that the instrument may help high-complexity patients who take oral anticoagulants to become more capable of making their own decisions in favor of self-care and improve the quality of the care process, thus improving both clinical results and the reduction of adverse events associated with oral anticoagulants.33 An additional positive aspect was the easy understanding of the instrument and its satisfactory acceptance by illiterate patients and those with a low-level education. One limitation of the study is that the items that need reformulating were not re-submitted to the CVC analysis by the JC. Therefore, we were unable to measure the CVC of the adapted items. However, these items were reformulated according to the suggestions from the JC, and it was noticed that the clarity of the items was not compromised, given that, in the pre-test stage, the target population showed an adequate understanding of the items in the V10 version. We also observed limitations inherent to the data collected directly from patients, such as the patient\u2019s embarrassment in answering some of the questions and information bias within the collected data.One positive aspect of the EmpoderACO instrument was compliance with the requirement of a general minimum agreement of 0.80 for the construction and validation of new instruments in all of the evaluated categories: relevance (0.92), adequation (0.92), and clarity (0.91).EmpoderACO proved adequate and easily understandable by warfarin users and showed potential for use among people with a low-level education. Hence, the use of EmpoderACO proved to be relevant for that population. The use of the EmpoderACO protocol in the field of anticoagulation enables the use of the principles of problematization, self-care, and person-centered care as strategies to improve the therapeutic results of oral anticoagulation."}
+{"text": "To estimate the association between negative self-perception of hearing and depression in older adults in Southern Brazil. This is a cross-sectional study conducted with data from the third wave of the EpiFloripa Idoso 2017/19 study, a population-based cohort of older adults (60+). A total of 1,335 older adults participated in this wave. The dependent variable was self-reported depression, and the main exposure was self-perception of hearing . For both the crude (bivariate) and adjusted analysis, the odds ratio (OR) was used as a measure of association and estimated by means of binary logistic regression analysis. The exposure variable was adjusted by sociodemographic and health covariates. A p value < 0.05 was adopted as statistically significant. The prevalence of negative self-perception of hearing and depression was 26.0% and 21.8%, respectively. In the adjusted analysis, the older adults with negative self-perception of hearing were 1.96 times more likely to report depression when compared to the ones with positive self-perception of hearing (p = 0.002). The association between negative self-perception of hearing and depression reflects the importance of reviewing health care actions for older adults, incorporating hearing-related issues, to ensure comprehensive care for this growing segment of the population. The coexistence of multiple morbidities affects not only the risk of loss of functionality and quality of life, but also on the increase of healthcare expenses.The increase in life expectancy and the number of older adults in the population represents of late an important challenge for health policies regarding the guarantee of comprehensive care and the maintenance of autonomy and functional capacity of older adults.Among the most prevalent morbidities with aging, age-related hearing loss (ARHL) stands out. It is progressive and bilateral, compromising speech intelligibility, having a negative impact on social engagement and cognitive skills in the elderly, representing risks of cognitive decline, social isolation and depression, thus being an important risk factor for healthy aging. Estimates indicate that this disorder will represent the greatest global burden of disease by 2030, being more impactful in low-income countries due to the lack of diagnosis and treatment.On the other hand, depression is one of the most common mental disorders in the world, affecting about 350 million people and being regarded as a chronic disease. Regarding aging, this scenario may be even more serious due to decline in bio-psycho-functional capabilities which, along with the worsening of pre-existing diseases and the negative perception of the aging process, may represent an important risk factor for the development of depression.Depression is associated with the loss of interest for previously pleasurable activities, lack of energy, and even suicidal thoughts \u2014as well as neuropathological ones \u2014associated with the perception of hearing and mood regulation to enhance the planning of actions aimed at improving the quality of life of this population segment.Hearing loss and depression are prevalent morbidities in older adults, and studies have tried to identify psychosocial and health mechanisms, others failed to find them.Some studies have investigated the association between hearing loss and depression in population samples of older adults. However, the results are conflicting. While some studies have reported significant associations.The new demands generated by aging lead to the emerging need for actions geared towards prevention, diagnosis, and early treatment for comorbidities affecting older adults, in order to adapt the healthcare system to these changes, especially in low-income countriesTherefore, this study sought to investigate the association between negative self-perception of hearing and depression in older adult\u2019s participants in a population-based study in Southern Brazil.EpiFloripa Idoso: condi\u00e7\u00f5es de sa\u00fade de idosos,a home-based cohort with older adults (60 years or older) living in the urban area of the municipality of Florian\u00f3polis (SC), whose main objective was to investigate the living and health conditions of this population. The research has had two previous waves: the first started in 2009/2010, in which 1,705 older adults from the municipality were interviewed, and the second in 2013/2014 . The third wave took place between 2017 and 2019, involving 1,335 older adults (epifloripaidoso.paginas.ufsc.br).This is a cross-sectional analysis conducted with data from the study. In this study, data from the third wave of the survey (2017-2019) were used, since it was the one to originate the investigation on the auditory aspects of the participants.Detailed procedures on sample planning, operational aspects, and strategies used in the first two waves have been previously describedThe sampling plan for 2017-2019 was assembled based on the sampling processes conducted in previous waves and on the data from the Census conducted by the Brazilian Institute of Geography and Statistics (IBGE) in 2010, in order to maintain the representativeness of the population of older adults of Florianopolis. From the third wave, the study became an open cohort, i.e., new older adults were included.For the follow-up of the participants of the previous waves, the registration data were updated by telephone contact and the survey of deaths with the aid of data from the Mortality Information System (SIM). For the insertion of new subjects, the sample size was reassessed based on the older adult population of the municipality referring to the 2010 Census \u2013 48,423 inhabitants. The parameters previously used for the prevalence calculation were maintained, with simple causal sample added to a value related to the effect of the estimated design \u2014 sample by conglomerates \u2014 of a proportion of expected losses and control for confounding factors. Considering the selection of the conglomerate sample, the same sectors of the baseline were maintained as the first stage unit. However, it was necessary to update the second-stage unit: the households. The number of households in each sector (census) was updated by the research technical team, since the most recent Census took place in 2010, following the same procedures. The data collection instrument, structured as a questionnaire and applied in a face-to-face interview format by trained interviewers, was assembled with the collaboration of the research technical team. The team held weekly meetings to update the questionnaire to be applied in the third wave. Priority was given to maintaining most of the questions applied in 2013 and 2014 because it is a longitudinal study. The content, clarity, and adequacy of the interview time were checked by supervisors and interviewers, and the questionnaire was applied with older adult\u2019s non-participants of the research.The dependent variable of this study was self-reported depression , collected by the question: \u201cHas a doctor or health professional ever said that you have or have had depression?\u201dThe main exposure variable was self-perception of hearing , collected using the question: \u201cIn general, would you say that your hearing is: (a) excellent, (b) very good, (c) good, (d) fair, (e) poor, or (f) very poor?\u201d. For those who used hearing aids, the questioning referred to the quality of hearing during the use of the device. In this study, the categories \u201cexcellent,\u201d \u201cvery good,\u201d and \u201cgood\u201d were considered as positive self-perception of hearing, and the categories \u201cregular,\u201d \u201cbad,\u201d and \u201cvery bad\u201d as negative self-perception of hearing.The covariates in this study referred to the sociodemographic characteristics and health status of the individuals: sex ; self-reported skin color ; age group ; schooling level ; self-reported comorbidities (Diabetes Mellitus (DM) , systemic arterial hypertension (SAH) , stroke , and use of hearing aid ); physical condition of the participant .To describe the categorical variables of the sample, data were represented by absolute and relative frequencies, with their respective 95% confidence intervals (95%CI). The prevalence of the outcome (%) was estimated for all variables of the study.For both the crude (bivariate) and adjusted analysis, the OR was used as a measure of association, estimated by means of the binary logistic regression analysis. The main exposure variable was adjusted by all study covariates, regardless of p value, to evaluate the effect of all exposure variables on the outcome. Variables were included simultaneously in the adjusted analysis and a 5% significance level was adopted.Data analysis was conducted in the Stata program version 14.0, considering the study design and the sample weight of the database (svy command).The EpiFloripa Idoso 2017/2019 study was approved as an amendment of the previous study by the Committee for Ethics in Research with Human Beings (CEPSH) under number 1,957,977 on March 9, 2017. All the subjects who agreed to participate in the research provided an informed consent form.Most participants (63.7%) were female, aged from 70 to 79 years (43.6%), White (88.3%), and with lower schooling level (54.9%). The prevalence of depression reported was 21.8% and the prevalence of negative self-perception of hearing was 26.0%. Regarding morbidities, 59.5% reported hypertension, 25.7% diabetes, and 9.5% stroke. The use of hearing aids was reported by 7.5% of the sample and most older adults were ambulant (98.1%) .The prevalence of depression was higher among women (27.5%), Blacks (27.0%), and people in the younger age group (25.2%). We observed a higher prevalence of depression in older people with negative self-perception of hearing (29.9%) when compared to those with positive self-perception (19.2%). Subjects with lower schooling levels had a higher prevalence of depression (25.3%). Depression was also more prevalent in subjects with comorbidities \u2014diabetes, hypertension, and history of stroke \u2014and among wheelchair users (36.4%) .In the crude analysis, older adults with negative self-perception of hearing were 1.58 times more likely  to report depression when compared to those with positive self-perception of hearing .In the analysis adjusted for sociodemographic covariates and health conditions, the association remained with a odds ratio almost twice as high  .This study, conducted with older adults in Southern Brazil, investigated the association between negative self-perception of hearing and depression. Our findings showed that subjects with a negative self-perception of hearing were almost twice as likely to report depression compared to those with a positive self-perception.. The other covariates \u2014schooling level, skin color, and age group \u2014 which also showed differences between the subgroups, were included in the adjustments, since their possible influence has already been described in the literature.In the crude analysis, we highlight the higher prevalence of depression in women, of low schooling level, and with chronic diseases, corroborating the findings of a previous study and stressing the importance of using these covariates in the adjustments of the other analyses to minimize their influence. As previously mentioned, this variation in prevalence is possibly related to methodological differences among these studies \u2014study design, classification criteria, and adjustment covariates \u2014and with the different populations studied.Studies have evaluated self-reported depression in older adults and found a prevalence that varied from 24% to 30.6%, corroborating our findings. Hearing loss affects more than 30% of adults over 50 years, and the prevalence almost doubles the more decades of life the individual accumulates. Moreover, most people with hearing loss remain undiagnosed and untreated for many years.The most commonly used indicator of hearing loss in Brazilian population studies is self-reported hearing loss, investigated by using questions related to the perception of hearing difficulty and hearing assessment. The prevalence of self-reported hearing loss in older adults obtained in previous studies ranged from 5.2% to 30.4%, as well as it may generate communication difficulties and compromise social functioning.For this reason, the negative self-perception of hearing by older adults should be used as an important indicator, since hearing loss may be associated with adverse health outcomes during the aging process, including anxiety and depression. The plasticity resulting from hearing loss, which affects the most central regions of the cortex, make it likely that neurophysiological mechanisms also participate in this process. However, future clinical and experimental studies should clarify these links and mechanisms.Although some studies show an association between hearing loss and depression, the underlying etiological mechanisms have not yet been well established. As already mentioned, hearing loss can lead to isolation and frustration, especially when communication is compromised. The social impact, the reduction in quality of life, and the economic burden for the patient and the family have also been described as having an influence on this relation.The association between negative perception of hearing and depression found in this study may be linked to the fact that hearing loss affects the communication process, contributing to a process of isolation and to the development of depressive conditions, agreeing with studies that found an association between hearing loss and depression.Recent studies have shown that hearing rehabilitation, including the use of sound amplification devices, helps improve mental health, but evidence is still scarce, and the subject needs further studies. We also highlight the possible reverse causality bias, inherent to cross-sectional analyses.Some elements should be considered when interpreting the results of this study. The use of self-reported measures may be considered a limitation since prevalence may be under or overestimated. However, studies showed that self-reported hearing loss, especially among older adults, has validity in population studies with reliable sensitivity and specificity valuesEpifloripa idoso study represents an important uniqueness since it is a representative study of the Florian\u00f3polis population and allows a future longitudinal analysis of these subjects from the perspective of integrality of care for healthy aging.As a potentiality, we highlight the fact that the study is of interest in the context of population aging and involves prevalent morbidities. Moreover, the insertion of auditory data in theThus, the association found between the negative self-perception of hearing and the report of depression alerts to the importance of investigating these morbidities in the context of aging. Hearing loss should not be regarded as a natural aging process without perspectives for treatment and rehabilitation, since, besides being prevalent, it is a risk factor for several negative health outcomes, including negative impacts on mental and physical health of older adults. The social engagement and participation of older adults may be protective factors of several adverse outcomes. Thus, we highlight the importance of developing preventive techniques in primary care and expanding the assessment, diagnosis, and access to rehabilitation services that make up the planning agenda for support to older adults at all points of the health care network, ensuring the principle of integrality in health care for this population. . A coexist\u00eancia de m\u00faltiplas morbidades reflete n\u00e3o somente no risco de perda de funcionalidade e de qualidade de vida, mas tamb\u00e9m no aumento dos gastos em sa\u00fade.O aumento da expectativa de vida e do n\u00famero de idosos na popula\u00e7\u00e3o tem representado um importante desafio para as pol\u00edticas de sa\u00fade no que se refere \u00e0 garantia da integralidade do cuidado e da manuten\u00e7\u00e3o da autonomia e da capacidade funcional dos idososage-related hearing loss(ARHL), de car\u00e1ter progressivo e bilateral, que compromete a inteligibilidade de fala, impactando negativamente no engajamento social e nas habilidades cognitivas do idoso, representando riscos de decl\u00ednio cognitivo, isolamento social e depress\u00e3o, sendo, portanto, um importante fator de risco ao envelhecimento saud\u00e1vel.Dentre as morbidades mais prevalentes com o envelhecimento, destaca-se a. Estimativas apontam que este transtorno representar\u00e1 a maior carga global de doen\u00e7as at\u00e9 2030, sendo mais impactante em pa\u00edses de baixa renda devido \u00e0 falta de diagn\u00f3stico e tratamento.Por outro lado, a depress\u00e3o \u00e9 um dos transtornos mentais mais frequentes no mundo, acometendo cerca de 350 milh\u00f5es de pessoas e sendo considerada uma doen\u00e7a cr\u00f4nica. No contexto do envelhecimento, este quadro pode ser ainda mais grave em fun\u00e7\u00e3o do decl\u00ednio das capacidades biopsicofuncionais, que, aliado ao agravamento de morbidades preexistentes e \u00e0 percep\u00e7\u00e3o negativa do processo do envelhecimento, pode representar um importante fator de risco para o desenvolvimento da depress\u00e3o.A depress\u00e3o apresenta-se associada \u00e0 perda de interesse por atividades anteriormente prazerosas, \u00e0 falta de energia e, at\u00e9 mesmo, aos pensamentos suicidas\u2013 assim como neuropatol\u00f3gicos \u2013 associados \u00e0 percep\u00e7\u00e3o da audi\u00e7\u00e3o e da regula\u00e7\u00e3o do humor a fim de potencializar o planejamento de a\u00e7\u00f5es voltadas \u00e0 qualidade de vida desse segmento populacional.A perda auditiva e a depress\u00e3o s\u00e3o morbidades prevalentes nos idosos e estudos tentam identificar mecanismos psicossociais e de sa\u00fade, enquanto outros n\u00e3o verificaram tal associa\u00e7\u00e3o.Alguns estudos v\u00eam investigando a associa\u00e7\u00e3o entre a perda auditiva e a depress\u00e3o em amostras populacionais de idosos. No entanto, os resultados s\u00e3o conflitantes. Alguns estudos relataram associa\u00e7\u00f5es significativas.As novas demandas geradas pelo envelhecimento remetem \u00e0 necessidade emergente de a\u00e7\u00f5es voltadas \u00e0 preven\u00e7\u00e3o, ao diagn\u00f3stico e ao tratamento precoce para as comorbidades que acometem o idoso para, assim, adequar o sistema de sa\u00fade frente a essas mudan\u00e7as, especialmente nos pa\u00edses de baixa rendaDiante disso, o objetivo deste estudo foi investigar a associa\u00e7\u00e3o entre a autopercep\u00e7\u00e3o negativa da audi\u00e7\u00e3o e a depress\u00e3o em idosos participantes de um estudo de base populacional no sul do Brasil.EpiFloripa Idoso: condi\u00e7\u00f5es de sa\u00fade de idosose de coorte de base domiciliar com idosos (60 anos ou mais) residentes na zona urbana do munic\u00edpio de Florian\u00f3polis (SC), cujo objetivo principal foi investigar as condi\u00e7\u00f5es de vida e sa\u00fade da popula\u00e7\u00e3o idosa. A pesquisa j\u00e1 contou com duas ondas anteriores: a primeira iniciou em 2009/2010, na qual foram entrevistados 1.705 idosos da cidade, e a segunda em 2013/2014 (1.197 idosos). A terceira onda se realizou entre 2017 e 2019, envolvendo 1.335 idosos (epifloripaidoso.paginas.ufsc.br).Trata-se de uma an\u00e1lise transversal realizada com dados do estudo. Neste estudo, foram utilizados os dados da terceira onda da pesquisa (2017\u20132019), pois foi a partir desta que se iniciou a investiga\u00e7\u00e3o sobre os aspectos auditivos dos participantes.Procedimentos detalhados sobre o planejamento amostral, aspectos operacionais e estrat\u00e9gias utilizadas nas duas primeiras ondas foram descritos previamenteO plano amostral de 2017\u20132019 foi constru\u00eddo com base nos processos de amostragem realizados nas ondas anteriores e nos dados do Censo realizado pelo Instituto Brasileiro de Geografia e Pesquisa (IBGE) de 2010, com a finalidade de manter a representatividade da popula\u00e7\u00e3o idosa de Florian\u00f3polis. A partir da terceira onda, o estudo tornou-se uma coorte aberta, ou seja, novos idosos foram incorporados.Para o acompanhamento dos idosos participantes das ondas anteriores, realizou-se a atualiza\u00e7\u00e3o dos dados cadastrais via contato telef\u00f4nico e levantamento dos \u00f3bitos com aux\u00edlio dos dados do Sistema de Informa\u00e7\u00f5es de Mortalidade (SIM). Para a inser\u00e7\u00e3o de novos idosos, foi reavaliado o tamanho da amostra com base na popula\u00e7\u00e3o idosa do munic\u00edpio referente ao Censo de 2010 \u2013 48.423 habitantes. Mantiveram-se os par\u00e2metros usados anteriormente para o c\u00e1lculo de preval\u00eancia, com amostra causal simples adicionada de um valor relativo ao efeito do delineamento estimado \u2013 amostra por conglomerados \u2013 de uma propor\u00e7\u00e3o de perdas previstas e controle para fatores de confus\u00e3o. Considerando a sele\u00e7\u00e3o da amostra por conglomerados, foram mantidos como unidade de primeiro est\u00e1gio os mesmos setores da linha de base. Contudo, foi necess\u00e1rio atualizar a unidade de segundo est\u00e1gio: os domic\u00edlios. O n\u00famero de domic\u00edlios em cada setor (arrolamento) foi atualizado pela equipe t\u00e9cnica da pesquisa, uma vez que o Censo mais recente ocorreu em 2010, seguindo-se os mesmos procedimentos. O instrumento de coleta de dados, estruturado por meio de um question\u00e1rio e aplicado em formato de entrevista presencial por entrevistadores treinados, foi constru\u00eddo com a colabora\u00e7\u00e3o da equipe t\u00e9cnica da pesquisa. A equipe realizou encontros semanais para atualiza\u00e7\u00e3o do question\u00e1rio a ser aplicado na terceira onda. Priorizou-se a manuten\u00e7\u00e3o da maioria das quest\u00f5es aplicadas em 2013 e 2014 por se tratar de um estudo longitudinal. O conte\u00fado, a clareza e a adequa\u00e7\u00e3o do tempo de entrevista foram verificados pelos supervisores e entrevistadores, sendo aplicado o question\u00e1rio com idosos n\u00e3o participantes da pesquisa.\u201cAlgum m\u00e9dico ou profissional de sa\u00fade j\u00e1 disse que o(a) Sr.(a.) tem/teve depress\u00e3o?\u201d.A vari\u00e1vel dependente deste estudo foi a depress\u00e3o autorreferida , coletada por meio da pergunta:\u201cEm geral, o(a) Sr.(a.) diria que sua audi\u00e7\u00e3o \u00e9: (a) excelente, (b) muito boa, (c) boa, (d) regular, (e) ruim ou (f) muito ruim?\u201d. Para aqueles que usavam aparelho auditivo, o questionamento se referia \u00e0 qualidade da audi\u00e7\u00e3o durante o uso do aparelho. Neste estudo, as categorias \u201cexcelente\u201d, \u201cmuito boa\u201d e \u201cboa\u201d foram consideradas como autopercep\u00e7\u00e3o positiva da audi\u00e7\u00e3o, e as categorias \u201cregular\u201d, \u201cruim\u201d e \u201cmuito ruim\u201d como autopercep\u00e7\u00e3o negativa da audi\u00e7\u00e3o.A vari\u00e1vel de exposi\u00e7\u00e3o principal foi a autopercep\u00e7\u00e3o auditiva , coletada por meio da pergunta:As covari\u00e1veis deste estudo foram referentes \u00e0s caracter\u00edsticas sociodemogr\u00e1ficas e \u00e0 situa\u00e7\u00e3o de sa\u00fade dos indiv\u00edduos: sexo ; cor da pele autorreferida ; faixa et\u00e1ria ; escolaridade ; comorbidades autorreferidas (diabetes mellitus (DM) , hipertens\u00e3o arterial sist\u00eamica (HAS) , acidente vascular cerebral  e uso de aparelho auditivo ); condi\u00e7\u00e3o f\u00edsica do participante .Para a descri\u00e7\u00e3o das vari\u00e1veis categ\u00f3ricas da amostra, os dados foram representados por frequ\u00eancias absolutas e relativas, com seus respectivos Intervalos de 95% de Confian\u00e7a (IC95%). Foram estimadas as preval\u00eancias do desfecho (%) para todas as vari\u00e1veis do estudo.Tanto para a an\u00e1lise bruta (bivariada) quanto para a ajustada, a OR foi utilizada como medida de associa\u00e7\u00e3o, estimada por meio da an\u00e1lise de Regress\u00e3o Log\u00edstica Bin\u00e1ria. A vari\u00e1vel de exposi\u00e7\u00e3o principal foi ajustada por todas as covari\u00e1veis do estudo, independentemente do valor de p, com o intuito de avaliar o efeito de todas as vari\u00e1veis de exposi\u00e7\u00e3o sobre o desfecho. As vari\u00e1veis foram inclu\u00eddas de forma simult\u00e2nea na an\u00e1lise ajustada e adotou-se o n\u00edvel de signific\u00e2ncia de 5%.comando svy).A an\u00e1lise dos dados foi conduzida no software Stata vers\u00e3o 14.0, considerando-se o delineamento do estudo e o peso amostral do banco de dados (O estudo EpiFloripa Idoso 2017/2019 foi aprovado como uma emenda do estudo anterior pelo Comit\u00ea de \u00c9tica em Pesquisa com Seres Humanos (CEPSH), sob n\u00famero 1.957.977, em 9 de mar\u00e7o de 2017. Todos os idosos que aceitaram participar da pesquisa assinaram um termo de consentimento livre e esclarecido.A maioria dos participantes  era do sexo feminino, faixa et\u00e1ria entre 70 e 79 anos de idade , pele branca  e com menor n\u00edvel de escolaridade . A preval\u00eancia de depress\u00e3o relatada pelos idosos foi igual a 21,8%, enquanto a da autopercep\u00e7\u00e3o negativa da audi\u00e7\u00e3o foi de 26,0%. Com rela\u00e7\u00e3o \u00e0s morbidades, 59,5% dos idosos relataram hipertens\u00e3o arterial, 25,7% diabetes e 9,5% acidente vascular cerebral (AVC). O uso de aparelhos auditivos foi relatado por 7,5% da amostra e a maioria dos idosos era deambulante  .A preval\u00eancia de depress\u00e3o foi maior entre mulheres , negros/pretos , na faixa et\u00e1ria mais jovem . Maior preval\u00eancia de depress\u00e3o foi observada em idosos com autopercep\u00e7\u00e3o negativa da audi\u00e7\u00e3o  quando comparados aos idosos com autopercep\u00e7\u00e3o positiva . Observou-se que idosos com menor n\u00edvel de escolaridade apresentaram maior preval\u00eancia de depress\u00e3o . A depress\u00e3o foi mais prevalente tamb\u00e9m em idosos com comorbidades \u2013 diabetes, hipertens\u00e3o e hist\u00f3rico de AVC \u2013 e entre os indiv\u00edduos cadeirantes  .Na an\u00e1lise bruta, idosos com autopercep\u00e7\u00e3o negativa da audi\u00e7\u00e3o apresentaram 1,58 vezes mais chance  de relatarem depress\u00e3o quando comparados aos idosos com autopercep\u00e7\u00e3o positiva da audi\u00e7\u00e3o .Na an\u00e1lise ajustada pelas covari\u00e1veis s\u00f3ciodemogr\u00e1ficas e condi\u00e7\u00f5es de sa\u00fade, a associa\u00e7\u00e3o manteve-se com uma raz\u00e3o de chances quase duas vezes maior  .Este estudo, realizado com idosos na regi\u00e3o sul do Brasil, investigou a associa\u00e7\u00e3o entre autopercep\u00e7\u00e3o negativa da audi\u00e7\u00e3o e depress\u00e3o. Nossos achados demonstraram que idosos com autopercep\u00e7\u00e3o negativa da audi\u00e7\u00e3o apresentaram quase o dobro de chance de relatarem ter depress\u00e3o se comparados aos idosos com autopercep\u00e7\u00e3o positiva.. As demais covari\u00e1veis \u2013 escolaridade, ra\u00e7a/etnia e faixa-et\u00e1ria \u2013, que tamb\u00e9m mostraram diferen\u00e7as entre os subgrupos, foram inclu\u00eddas nos ajustes, uma vez que j\u00e1 foi descrito na literatura a poss\u00edvel influ\u00eancia dessas vari\u00e1veis sobre a depress\u00e3o.Na an\u00e1lise bruta, destaca-se a maior preval\u00eancia de depress\u00e3o em idosos do sexo feminino, baixa escolaridade e com as doen\u00e7as cr\u00f4nicas, corroborando os achados de estudo pr\u00e9vio e ressaltando a import\u00e2ncia de utilizar essas covari\u00e1veis nos ajustes das demais an\u00e1lises para minimizar a sua influ\u00eancia. Conforme j\u00e1 mencionado, esta varia\u00e7\u00e3o na preval\u00eancia est\u00e1 relacionada, possivelmente, com as diferen\u00e7as metodol\u00f3gicas \u2013 desenho do estudo, crit\u00e9rios de classifica\u00e7\u00e3o e covari\u00e1veis de ajuste \u2013 entre os estudos e com as diferentes popula\u00e7\u00f5es estudadas.Estudos avaliaram a depress\u00e3o autorreferida por idosos e encontraram uma preval\u00eancia que variou de 24% a 30,6%, corroborando nossos achados. Sabe-se, ainda, que a perda auditiva afeta mais de 30% dos adultos acima de 50 anos, sendo que a preval\u00eancia quase dobra conforme mais d\u00e9cadas de vida o indiv\u00edduo acumula. Al\u00e9m disso, a maioria das pessoas com perda auditiva permanece sem diagn\u00f3stico e tratamento por muitos anos.O indicador de perda auditiva mais usado em estudos populacionais brasileiros \u00e9 a perda auditiva autorreferida, investigada por meio do uso de perguntas relacionadas \u00e0 percep\u00e7\u00e3o da dificuldade auditiva e da avalia\u00e7\u00e3o da audi\u00e7\u00e3o. A preval\u00eancia da perda auditiva autorreferida por idosos obtida em estudos pr\u00e9vios variou entre 5,2% a 30,4%, bem como pode gerar dificuldades de comunica\u00e7\u00e3o e comprometer o funcionamento social.Por este motivo, a autopercep\u00e7\u00e3o negativa da audi\u00e7\u00e3o por idosos deve ser utilizada como um importante indicador, uma vez que a perda auditiva pode estar associada a desfechos adversos em sa\u00fade durante o processo de envelhecimento, incluindo a ansiedade e a depress\u00e3o. A plasticidade decorrente da perda auditiva, que atinge as regi\u00f5es mais centrais do c\u00f3rtex, n\u00e3o torna improv\u00e1vel que mecanismos neurofisiol\u00f3gicos tamb\u00e9m participem deste processo. No entanto, estudos cl\u00ednicos e experimentais futuros devem esclarecer essas redes e mecanismos.Apesar de alguns estudos mostrarem que existe uma associa\u00e7\u00e3o entre a perda auditiva e a depress\u00e3o, os mecanismos etiol\u00f3gicos subjacentes ainda n\u00e3o foram bem estabelecidos. Conforme j\u00e1 mencionado, a perda auditiva pode levar ao isolamento e \u00e0 frustra\u00e7\u00e3o, principalmente quando a comunica\u00e7\u00e3o fica comprometida. O impacto social, a diminui\u00e7\u00e3o na qualidade de vida e a carga econ\u00f4mica para o paciente e para a fam\u00edlia tamb\u00e9m j\u00e1 foram descritos como tendo influ\u00eancia nesta rela\u00e7\u00e3o.A associa\u00e7\u00e3o verificada neste estudo entre percep\u00e7\u00e3o negativa da audi\u00e7\u00e3o e depress\u00e3o pode estar atrelada ao fato de a perda auditiva comprometer o processo de comunica\u00e7\u00e3o, contribuindo para um processo de isolamento e para o desenvolvimento de quadros depressivos, o que vai de acordo com estudos que verificaram associa\u00e7\u00e3o entre perda auditiva e depress\u00e3o.Estudos recentes v\u00eam mostrando que a reabilita\u00e7\u00e3o auditiva, incluindo o uso de dispositivos de amplifica\u00e7\u00e3o sonora, auxilia na melhora da sa\u00fade mental, mas as evid\u00eancias ainda s\u00e3o escassas e o tema necessita de estudos adicionais. Tamb\u00e9m destaca-se o poss\u00edvel vi\u00e9s de causalidade reversa, inerente \u00e0s an\u00e1lises transversais.Destacam-se alguns elementos que devem ser considerados ao interpretar os resultados deste estudo. O uso de medidas autorreferidas pode ser considerado uma limita\u00e7\u00e3o, visto que pode haver preval\u00eancia sub ou superestimada. Contudo, estudos apontaram que o autorrelato da perda auditiva, especialmente entre idosos, apresenta validade em estudos de n\u00edvel populacional com valores de sensibilidade e especificidade confi\u00e1veisEpifloripa idosorepresenta um importante diferencial, uma vez que se trata de um estudo representativo da popula\u00e7\u00e3o de Florian\u00f3polis e possibilita uma futura an\u00e1lise longitudinal desses idosos na perspectiva da integralidade do cuidado para um envelhecimento saud\u00e1vel.Como potencialidade, destaca-se o fato de o estudo envolver morbidades prevalentes e de interesse no contexto do envelhecimento populacional. Al\u00e9m disso, a inser\u00e7\u00e3o de dados auditivos no estudoSendo assim, a associa\u00e7\u00e3o encontrada entre a autopercep\u00e7\u00e3o negativa da audi\u00e7\u00e3o e o relato de depress\u00e3o alerta para a import\u00e2ncia da investiga\u00e7\u00e3o dessas morbidades no contexto do envelhecimento. A perda auditiva n\u00e3o pode ser considerada um processo natural do envelhecimento sem perspectivas para tratamento/reabilita\u00e7\u00e3o, pois, al\u00e9m de prevalente, \u00e9 fator de risco para v\u00e1rios desfechos negativos em sa\u00fade, incluindo impactos negativos sobre a sa\u00fade mental e f\u00edsica do idoso. Sabe-se que o engajamento e a participa\u00e7\u00e3o social dos idosos podem ser fatores protetores de v\u00e1rios desfechos adversos. Assim, destaca-se a import\u00e2ncia de elaborar t\u00e9cnicas preventivas na aten\u00e7\u00e3o prim\u00e1ria e ampliar a avalia\u00e7\u00e3o, o diagn\u00f3stico e o acesso aos servi\u00e7os de reabilita\u00e7\u00e3o que comp\u00f5em a agenda de planejamento para suporte ao idoso em todos os pontos da rede de aten\u00e7\u00e3o \u00e0 sa\u00fade, garantindo o princ\u00edpio da integralidade na aten\u00e7\u00e3o \u00e0 sa\u00fade dessa popula\u00e7\u00e3o."}
+{"text": "To compare the results of fluency and self-perception of the impact of stuttering on the lives of adults who stutter, before and after undergoing intensive speech-language pathology therapy.This is a descriptive and longitudinal study with data collection before and after intensive therapy in four patients who stutter. The intensive care program consisted of thirty one-hour sessions held in five individual sessions a week. Speech samples collected before and after therapy were analyzed by two fluency experts. Descriptive data analysis was performed through the frequency distribution of categorical variables and analysis of measures of central tendency and dispersion of continuous variables. The verification of agreement between the evaluations carried out by the two judges was performed using the intraclass correlation coefficient (ICC). Correlation analysis was also performed using Spearman's rank correlation coefficient between the variables in the speech sample and the OASES-A scores.There was a reduction of the percentage of stuttering disfluencies, increasing the flow of words per minute of the participants. The descriptive analysis of the OASES-A showed a decrease in the degree of impact of stuttering on the participants' lives in all parts of the questionnaire.There was an improvement in all variables analyzed after intensive care, including an improvement in speech fluency and a reduction in the impact of stuttering on the participants' lives, which suggests the relevance of the intensive speech therapy proposal for stuttering. Stuttering can be understood as a result of a central nervous system dysfunction, with a genetic origin, which appears in the period of language development, between 18 months and seven years of age. The disorder becomes chronic in 20% of cases, which means a prevalence of 1% in adulthood, with a higher occurrence in males.Developmental stuttering is a fluency disorder characterized by the presence of involuntary interruptions in the speech flow, such as repetitions of sounds, syllables and monosyllabic words, prolongations of sounds, blocks, extensive pauses and intrusions that interrupt the smooth and continuous speech flow. Although the etiology of stuttering has not yet been precisely identified, some studies,3 have shown that genetic factors are related to susceptibility to the disorder.Stuttering is a developmental disorder with a multidimensional aspect, which can be impacted by several factors, such as family history, environment, linguistic and cognitive abilities of the individual.Speech-language pathology intervention is essential in individuals who stutter, as the treatment aims to promote fluency and reduce disfluencies, providing a greater flow of information and continuous and smooth speech, as natural as possible, for both the speaker and the listener-7 that claim that intensive programs are an alternative to achieve a more fluent speech pattern in less time. In this sense, the proposal of intensive therapy for fluency is based on the North American, Canadian and European models of therapeutic programs for the stimulation of oral language, speech and/or fluency, and is characterized by daily sessions, individual or in groups, for about 30 consecutive days. Given the proximity and frequency of the sessions, it is believed that daily therapy can allow the gradual observation of changes in patients' communicative behavior, helping them to perceive their difficulties and the functional use of language. In addition, intensive care can also be an initial module of conventional therapy or a comprehensive intervention proposal. Generally, speech-language pathology programs for adults, both intensive and conventional, have a mixed approach that involves strategies to promote fluency, modify stuttering and improve communicative skills,9.Although speech-language pathology therapy is traditionally performed with one to two sessions per week, there are proposalsIn this context, this study aimed to compare the results of fluency and self-perception of the impact of stuttering on the lives of adults who stutter before and after undergoing intensive speech-language pathology therapy.CAAE 02470618.1.0000.5149.This is a preliminary descriptive and longitudinal study, of an experimental type and of a quantitative nature that analyzed the results of intensive speech-language pathology therapy in four male patients between 20 and 31 years of age, who stutter. The study was approved by the Research Ethics Committee of UFMG, trough n. . In turn, the exclusion criteria were the following: cognitive, psychological and/or neurological impairment, other associated language and neurodevelopmental disorders (self-reported by the participants) and having undergone treatment for stuttering in the last year. The study was carried out at the Speech-Language Pathology Clinic of Hospital S\u00e3o Geraldo, which is part of the Hospital das Cl\u00ednicas of the UFMG. The following data collection instruments and procedures were applied: Clinical History; Questionnaire about stuttering; Fluency Profile Assessment Protocol (PAPF), Overall Assessment of the Speaker's Experience of Stuttering - Adults (OASES-A), translated into Brazilian Portuguese and an intensive care program for stuttering prepared by the authors based on the literature,9.Participants were recruited through an invitation to the population that stutters in Belo Horizonte. The inclusion criteria included the availability to participate in the intensive intervention (five hours/week), the signing of the Informed Consent Form and the presence of a stuttering complaint confirmed by a minimum of 3% of stuttering disfluencies in the analysis of the speech sampleInitially, the researchers collected the patient's medical history by collecting general information, such as family history of stuttering, history of general health and speech-language disorders, participant's general knowledge of stuttering, main associated factors, onset and severity of stuttering, feelings related to stuttering, impact of stuttering on activities of daily living, and expectations regarding treatment.Aiming at carrying out the Fluency Profile Assessment Protocol, the researchers obtained the audio and video recording of the participants' spontaneous linked speech sample through the personal presentation and description of a thematic figure, before and after 30 hours of speech-language pathology therapy. instrument was applied before the start of therapy and at the last therapy session. In this context, the instrument applied is organized into four sections, and each section addresses a different theme, as follows: General Information on Speech, Reaction to Stuttering, Communication in Everyday Situations and Quality of Life. Data were analyzed based on the theoretical frameworks that support the instrument, while the score per section and the global score are obtained by adding the scores of the four sections of the instrument. When interpreting the assessment result, the impact of stuttering on the individual can be understood as mild, mild to moderate, moderate, moderate to severe or severe.It should be noted that the OASES-A,9.The intensive care program consisted of thirty terapy sessions, which were carried out in five individual sessions a week, totaling a period of approximately two months of consultations. The proposal  was desiThe reassessment was performed after 30 hours of therapy, using the same assessment instruments. Thus, this study will present the data referring to the speech samples and obtained in the application of the OASES-A from before and after undergoing intensive speech-language pathology therapy. The analysis of speech samples was performed by two evaluators, who were experts in Fluency. The number of syllables in each sample ranged from 210 to 232 syllables, except for the sample of a more severe participant, who did not include the 200 syllables proposed by the author of the PAPF, presenting 67 and who presented 67 and 147 syllables in the pre- and post-therapy samples, respectively.Descriptive data analysis was performed through the frequency distribution of categorical variables and analysis of measures of central tendency and dispersion of continuous variables. The agreement between the evaluations performed by the two evaluators was verified using the intraclass correlation coefficient (ICC). In this sense, the following results were considered to assess agreement: Insignificant if <0; Weak = 0.00-0.20; Fair = 0.21-0.40; Moderate = 0.41-0.60; Strong = 0.61-0.80; Almost Perfect = 0.81-1.00; and Perfect = 1.00. The researchers also used Spearman's rank correlation coefficient to perform the correlation analysis between the speech sample variables  and the OASES- A . In this context, the evaluation of the magnitude of the correlation adopted the following parameters: Weak = 0.0-0.4; Moderate = 0.4-0.7 and Strong = 0.7-1.0; provided that the value of p\u22640.05. Finally, the researchers used SPSS v25.0 software for data entry, processing and analysis.The mean age of the sample was 26 years (Median=26.5 SD=4.55), and the four participants were male. Three participants reported no other cases of stuttering in their families (75%). Two participants classified their stuttering, in the clinical history, as moderate (50%), while one (25%) as severe and another (25%) as very severe. With regard to educational level, two participants (50%) had completed higher education, one participant (25%) had incomplete higher education and one (25%) reported having completed high school.The descriptive analysis of the speech samples of the four participants of the intensive care program shows that there was a decrease in the percentage of speech discontinuity (mean before=43.15% and after=16.76%) and stuttering disfluencies (mean before=30.85% and after=10.61%) after intensive care. On the other hand, there was an increase in the flow of words per minute (mean before=60.10 and after=82.33) and syllables per minute (mean before=119.10 and after=156.55).When comparing the descriptive analysis of OASES-A pre and post intensive care, there was a decrease in the mean and median in the post therapy assessment in all parts of the questionnaire, as well as in the total score. The findings in the analysis of the degrees of impact of OASES-A, pre and post therapy, show that: Part 1 : Improvement in the impact, since, after intensive care, two participants were classified as having mild to moderate impact and the other two as moderate; Part 2 (Reaction to Stuttering): Improvement in the impact, since, after intensive care, two participants were classified as having mild to moderate impact, which had not occurred in the first evaluation; Part 3 (Communication in Everyday Situations): worsening on impact, as the percentage of moderate to severe increased to 50.0% after intensive care, while the percentage of moderate decreased to 25.0%; and Part 4 : Improvement in impact after intensive care, as participants were classified as mild to moderate (50.0%) and no participants were classified as moderate to severe. The degree of total impact had the same result as in part 4. Then, correlation analyzes were performed between the variables of the analysis of speech samples and the OASES-A scores in the pre- and post-therapy moments. There was no correlation with statistical significance in any of the variables analyzed - p-value>0.05.In turn, there was strong agreement in all items analyzed (greater than 0.900) in the assessment of agreement between evaluators.-3 that also reported a higher prevalence of stuttering in males. Three participants reported that they did not have other cases of stuttering in family members, which is in line with the literature that reports that most cases have a genetic origin, although there are reports of cases with other origins. It is inferred that the participants may be unaware of cases in their families, probably due to the possibility of remission of stuttering in childhood. In addition, stuttering is a multidimensional disorder that can be impacted by multiple factors, such as pre-peri-postnatal history, family history, environmental factor, and linguistic and cognitive abilities of the individual.The four study participants are male, corroborating other studies Therefore, these results corroborate the therapeutic benefits of the intensive care program. Other studies-7 found in the literature also reported a significant decrease in disfluencies after intensive treatment, in addition to finding a significant decrease in the duration (in seconds) of disfluencies and an increase in speech flow after treatment,12. It is worth mentioning that the data were obtained immediately before and after intensive care, with no time to identify the effects of generalization or use of the acquired therapeutic strategies on the participant's daily life. The semi-annual follow-up of the participants for an extended period was proposed in order to observe in another study whether the effects of intensive care were maintained and consolidated.Regarding the results presented regarding the analysis of the speech samples before and after therapy, there was an improvement in the fluency profile - with a decrease in the percentage of speech discontinuity and stuttering disfluencies of all participants after intensive care. The findings show that the reduction of disfluencies led to an increase in the flow of words and syllables per minute in three of the four participants. It should be noted that the only participant whose flow of words and syllables per minute decreased had values higher than expected before intensive care,13, which reports that the impact of stuttering is directly related to quality of life in adults who stutter. In this sense, it is inferred that the intervention resulted in better knowledge about stuttering, awareness of the body and speech and perception of the individual's feelings regarding their verbal production, assuming the proposals of awareness and modification of stuttering,9.The description of the results of the OASES-A pre and post therapy show that there was an improvement in the degree of impact on the participants' lives after intensive care. This finding is in line with the literature.Regarding the correlation analyzes between the variables of the speech samples and the OASES-A scores in the pre- and post-therapy moments, there was no correlation with statistical significance in any of the analyzed variables. This finding may be related to the time when the questionnaire response was collected, which was immediately after the last therapy session. In this context, the time for the perception of the acquired skills and use of the strategies learned may not have been enough for the participants to perceive the changes caused by the therapy. In addition, the reduced number of participants may also have influenced the analysis. There are many cases in clinical practice in which the self-perception of stuttering and its impact on the individual's life is not proportional to the analysis of the individual's stuttering when performed by the interlocutor. This means that an individual with a mild stutter can have a much more negative impact on communicative experiences than an individual with a severe stutter, and vice versaFinally, the analysis of agreement between the evaluators shows a strong agreement in the items analyzed pre and post therapy, which indicates that the results obtained in the study are considered reliable.In turn, the small number of participants may be a limitation of the study, which is due to the difficulty in performing speech-language pathology therapy on a daily basis. Intensive care involves socioeconomic factors, in addition to demanding longitudinal, daily follow-up, which makes it difficult to perform. In this sense, some factors such as availability of time and daily mobility are complicating factors for those interested in intensive care. On the other hand, this intervention can be an excellent strategy given the small number of specialists in the field of Fluency in the country, which compromises the feasibility of adequate treatment for all people who stutter, and who live far from places where professionals with expertise in the area work. The intensive care solution could provide adequate care for people who stutter, with intensive treatment in a shorter period of time, such as a vacation away from their hometowns.This study provides contributions to Speech-Language Pathology so that individuals who stutter can improve speech fluency in a shorter period of time. The study findings were relevant to identify the benefits of intensive care in developmental stuttering and to present the therapeutic model used. The researchers decided to use a mixed model addressing strategies to promote fluency, modify stuttering and improve communicative skills, providing a reduction in the number of disfluencies and an increase in the flow of speech. Finally, the researchers recommend that the study be replicated in a larger sample of adults who stutter and that other intervention proposals can be made based on these findings, since although positive changes were observed, some results analyzed were not statistically significant.Given that there was an improvement in speech fluency, a reduction in the percentages of speech discontinuity of stuttering disfluencies, in addition to a reduction in the impact of stuttering on the lives of the participants, which suggests the relevance of the proposal of intensive speech-language pathology therapy, it is possible to conclude that there was an improvement of all variables assessed after intensive care. The findings detail the content of an intensive speech-language pathology therapy program for stuttering, thus allowing other speech-language pathologists to use the proposed intervention. It should be noted that the improvement in fluency and impact of stuttering after intensive speech-language pathology therapy in adults who stutter was verified by descriptive and concordance analyses. . Pode ser definida como resultado de uma disfun\u00e7\u00e3o do sistema nervoso central, com base gen\u00e9tica, que aparece no per\u00edodo de desenvolvimento da linguagem, entre 18 meses e sete anos de idade. Em 20% dos casos o dist\u00farbio torna-se cr\u00f4nico, resultando em uma preval\u00eancia de 1% na idade adulta, com maior ocorr\u00eancia no sexo masculino.A gagueira do desenvolvimento \u00e9 um transtorno da flu\u00eancia definido pela presen\u00e7a de rupturas involunt\u00e1rias do fluxo da fala, caracterizadas por repeti\u00e7\u00f5es de sons, s\u00edlabas e palavras monossil\u00e1bicas, prolongamentos de sons, bloqueios, pausas extensas e intrus\u00f5es que interrompem o fluxo cont\u00ednuo e suave da fala. Embora a etiologia da gagueira ainda n\u00e3o tenha sido precisamente identificada, pesquisas,3 t\u00eam mostrado que fatores gen\u00e9ticos est\u00e3o envolvidos na suscetibilidade do transtorno.A gagueira \u00e9 um transtorno do desenvolvimento de aspecto multidimensional, na qual fatores como hist\u00f3rico familial, ambiente, capacidades lingu\u00edsticas e cognitivas do indiv\u00edduo podem interferir.A interven\u00e7\u00e3o fonoaudiol\u00f3gica \u00e9 imprescind\u00edvel em indiv\u00edduos com gagueira, uma vez que o objetivo do tratamento \u00e9 a promo\u00e7\u00e3o da flu\u00eancia e redu\u00e7\u00e3o das disflu\u00eancias, propiciando maior fluxo de informa\u00e7\u00e3o e fala cont\u00ednua e suave, o mais natural poss\u00edvel, tanto para o falante como para o ouvinte-7 afirmando que programas intensivos s\u00e3o uma alternativa para se conseguir um padr\u00e3o de fala mais fluente em menor tempo. A proposta de terapia intensiva para flu\u00eancia baseia-se nos modelos norte-americanos, canadenses e europeus de programas terap\u00eauticos para estimula\u00e7\u00e3o da linguagem oral, fala e/ou flu\u00eancia. Possui como caracter\u00edstica encontros di\u00e1rios, individuais ou em grupo, em torno de 30 dias consecutivos. Pressup\u00f5e-se que a terapia di\u00e1ria, pela proximidade e frequ\u00eancia dos encontros, possibilita a observa\u00e7\u00e3o gradativa das modifica\u00e7\u00f5es nos comportamentos comunicativos dos pacientes, auxiliando-os na percep\u00e7\u00e3o de suas dificuldades e no uso funcional da linguagem. A terapia intensiva pode ser um m\u00f3dulo inicial da terapia convencional ou uma proposta integral de interven\u00e7\u00e3o. Os programas fonoaudiol\u00f3gicos de interven\u00e7\u00e3o em adultos, tanto intensiva quanto convencional, geralmente apresentam uma abordagem mista, envolvendo estrat\u00e9gias de promo\u00e7\u00e3o da flu\u00eancia, modifica\u00e7\u00e3o da gagueira e aprimoramento de habilidades comunicativas,9.Tradicionalmente, a terapia fonoaudiol\u00f3gica \u00e9 realizada com um a dois atendimentos semanais. Existem propostasO presente estudo teve por objetivo comparar os resultados da flu\u00eancia e da autopercep\u00e7\u00e3o do impacto da gagueira na vida de adultos que gaguejam antes e depois de terapia fonoaudiol\u00f3gica intensiva.CAAE: 02470618.1.0000.5149.Trata-se de um estudo preliminar descritivo longitudinal, do tipo experimental e de car\u00e1ter quantitativo que analisou os resultados da terapia fonoaudiol\u00f3gica intensiva em quatro pacientes do sexo masculino entre 20 e 31 anos de idade, que gaguejam. O estudo foi aprovado pelo Comit\u00ea de \u00c9tica em Pesquisa da UFMG, por meio do protocolo . Os crit\u00e9rios de exclus\u00e3o foram: comprometimento cognitivo, psicol\u00f3gico, neurol\u00f3gico, outros transtornos de linguagem e do neurodesenvolvimento associados (autorreferidos pelos participantes) e ter realizado tratamento para gagueira no \u00faltimo ano. O estudo foi realizado no Ambulat\u00f3rio de Fonoaudiologia do Hospital S\u00e3o Geraldo, complexo do Hospital das Cl\u00ednicas da UFMG. Os instrumentos e procedimentos de coleta de dados foram: Hist\u00f3ria Cl\u00ednica; Question\u00e1rio sobre a gagueira; Protocolo de avalia\u00e7\u00e3o do perfil da flu\u00eancia (PAPF), Instrumento Overall Assessment of the Speaker\u2019s Experience of Stuttering - Adults (OASES-A), traduzido para o Portugu\u00eas Brasileiro e programa de terapia intensiva para gagueira elaborado pelas autoras, baseado na literatura,9.Os participantes foram recrutados por meio de convite \u00e0 popula\u00e7\u00e3o que gagueja de Belo Horizonte. Como crit\u00e9rio de inclus\u00e3o foi adotada a disponibilidade em participar da interven\u00e7\u00e3o intensiva (cinco horas/semanais), assinatura do Termo de Consentimento Livre e Esclarecido e queixa de gagueira confirmada pelo percentual de no m\u00ednimo 3% de disflu\u00eancias gagas, na an\u00e1lise da amostra de falaInicialmente, foi levantada a hist\u00f3ria cl\u00ednica do paciente por meio da coleta de informa\u00e7\u00f5es gerais, hist\u00f3rico de gagueira na fam\u00edlia, hist\u00f3rico de sa\u00fade geral e de problemas fonoaudiol\u00f3gicos, conhecimento geral do participante sobre gagueira, principais fatores associados, in\u00edcio e gravidade da gagueira, sentimentos relacionados \u00e0 gagueira, impacto da gagueira nas atividades de vida di\u00e1ria e expectativas em rela\u00e7\u00e3o ao tratamento., obteve-se o registro em \u00e1udio e v\u00eddeo de amostra de fala encadeada espont\u00e2nea dos participantes por meio da apresenta\u00e7\u00e3o pessoal e descri\u00e7\u00e3o de figura tem\u00e1tica, antes e ap\u00f3s as 30 horas de terapia fonoaudiol\u00f3gica.Para realizar o protocolo de avalia\u00e7\u00e3o do perfil da flu\u00eancia da fala foi realizada antes do in\u00edcio da terapia e na \u00faltima sess\u00e3o de terapia. O instrumento \u00e9 organizado em quatro se\u00e7\u00f5es, e cada se\u00e7\u00e3o abrange uma tem\u00e1tica diferente: Informa\u00e7\u00f5es Gerais sobre a Fala, Rea\u00e7\u00e3o \u00e0 Gagueira, Comunica\u00e7\u00e3o em Situa\u00e7\u00f5es Cotidianas e Qualidade de Vida. Os dados foram analisados com base nos referenciais te\u00f3ricos que respaldam o instrumento. O escore por se\u00e7\u00e3o e o escore global s\u00e3o obtidos pela soma dos escores das quatro se\u00e7\u00f5es do instrumento. Na interpreta\u00e7\u00e3o do resultado da avalia\u00e7\u00e3o, o impacto da gagueira sobre o falante pode ser considerado como leve, leve a moderado, moderado, moderado a severo ou severo.A aplica\u00e7\u00e3o do OASES-A,9.O programa de terapia intensiva constituiu-se em trinta sess\u00f5es de terapia, realizadas em cinco encontros individuais na semana, totalizando um per\u00edodo de cerca de dois meses de atendimentos. A proposta  foi elabA reavalia\u00e7\u00e3o ocorreu ap\u00f3s 30 horas de terapia, utilizando os mesmos instrumentos da avalia\u00e7\u00e3o. Nesse estudo ser\u00e3o apresentados os dados referentes \u00e0s amostras de fala e obtidos na aplica\u00e7\u00e3o do OASES-A antes e ap\u00f3s terapia fonoaudiol\u00f3gica intensiva. As an\u00e1lises das amostras de fala foram realizadas por dois ju\u00edzes, especialistas em Flu\u00eancia. O n\u00famero de s\u00edlabas em cada amostra variou de 210 a 232 s\u00edlabas, com exce\u00e7\u00e3o da amostra de um participante, mais grave, que n\u00e3o contemplou as 200 s\u00edlabas propostas pela autora do PAPF, apresentando 67 e 147 s\u00edlabas, nas amostras pr\u00e9 e p\u00f3s terapia, respectivamente.A an\u00e1lise descritiva dos dados foi realizada por meio da distribui\u00e7\u00e3o de frequ\u00eancia das vari\u00e1veis categ\u00f3ricas e an\u00e1lise das medidas de tend\u00eancia central e de dispers\u00e3o das vari\u00e1veis cont\u00ednuas. A verifica\u00e7\u00e3o da concord\u00e2ncia entre as an\u00e1lises realizadas pelos dois ju\u00edzes foi realizada por meio do coeficiente de correla\u00e7\u00e3o intraclasse (CCI). A concord\u00e2ncia foi considerada insignificante se < 0, fraca = 0,00-0,20, razo\u00e1vel = 0,21-0,40, moderada = 0,41-0,60, forte = 0,61-0,80, quase perfeita = 0,81-1,00, e perfeita = 1,00. Realizou-se tamb\u00e9m a an\u00e1lise de correla\u00e7\u00e3o pelo coeficiente de correla\u00e7\u00e3o de Spearman, entre as vari\u00e1veis da amostra de fala  e os escores do OASES-A . Para tal, a magnitude da correla\u00e7\u00e3o foi medida seguindo o seguinte par\u00e2metro: fraca = 0,0-0,4; moderada = 0,4-0,7 e forte = 0,7-1,0; desde que com valor de p\u22640,05. Para entrada, processamento e an\u00e1lise dos dados utilizou-se o software SPSS, vers\u00e3o 25.0.A m\u00e9dia de idade da amostra foi de 26 anos , sendo os quatro participantes do sexo masculino. Tr\u00eas participantes n\u00e3o relataram outros casos de gagueira na fam\u00edlia (75%). Dois classificaram sua gagueira, na hist\u00f3ria cl\u00ednica, como moderada (50%), um (25%) classificou como grave e outro (25%) como muito grave. Quanto \u00e0 escolaridade, dois participantes (50%) conclu\u00edram o curso superior, um participante (25%) superior incompleto e um (25%) relatou ter conclu\u00eddo o ensino m\u00e9dio.A an\u00e1lise descritiva das amostras de fala dos quatro participantes do programa de terapia intensiva permitiu descrever que o percentual de descontinuidade de fala  e o percentual de disflu\u00eancias gagas  diminu\u00edram ap\u00f3s a terapia intensiva. Por outro lado, os fluxos de palavras por minuto  e de s\u00edlabas por minuto  aumentaram.Comparando-se a an\u00e1lise descritiva do OASES-A pr\u00e9 e p\u00f3s terapia intensiva observa-se que em todas as partes do question\u00e1rio, bem como em seu escore total, houve diminui\u00e7\u00e3o da m\u00e9dia e da mediana na avalia\u00e7\u00e3o p\u00f3s terapia. Na an\u00e1lise dos graus de impacto do OASES-A, pr\u00e9 e p\u00f3s terapia, verificou-se que: Parte 1 (Informa\u00e7\u00f5es Gerais), melhora do impacto, em que dois participantes do p\u00f3s foram classificados como impacto leve a moderado e a outros dois como moderado; Parte 2 (Suas rea\u00e7\u00f5es \u00e0 gagueira), melhora do impacto, em que dois do p\u00f3s foram classificados como impacto leve a moderado, o que n\u00e3o havia ocorrido na primeira avalia\u00e7\u00e3o; Parte 3 (Comunica\u00e7\u00e3o nas situa\u00e7\u00f5es di\u00e1rias), piora no impacto em que a porcentagem do moderado a severo do p\u00f3s aumentou para 50,0%, enquanto o moderado caiu para 25,0%; Parte 4 , melhora no impacto no p\u00f3s com participantes classificados no grau leve a moderado  e aus\u00eancia de participantes no moderado a severo. O grau de impacto total teve o mesmo resultado da parte 4. A Em seguida foram realizadas an\u00e1lises de correla\u00e7\u00e3o entre as vari\u00e1veis da an\u00e1lise das amostras de fala e os escores do OASES-A nos momentos pr\u00e9 e p\u00f3s terapia. N\u00e3o houve correla\u00e7\u00e3o com signific\u00e2ncia estat\u00edstica em quaisquer das vari\u00e1veis analisadas - valor de p>0,05.Na an\u00e1lise de concord\u00e2ncia entre os ju\u00edzes observou-se que houve concord\u00e2ncia forte em todos os itens analisados .-3 cujos autores relataram maior preval\u00eancia de gagueira no sexo masculino. Tr\u00eas participantes relataram n\u00e3o possuir outros membros na fam\u00edlia que gaguejam. Tal fato vai de encontro \u00e0 literatura que relata que a maioria dos casos tem origem gen\u00e9tica, embora haja relatos de casos com outras origens. Infere-se que os participantes podem desconhecer casos em suas fam\u00edlias, provavelmente pela possibilidade de remiss\u00e3o da gagueira na inf\u00e2ncia. Al\u00e9m disso, a gagueira \u00e9 um transtorno de aspecto multidimensional, no qual in\u00fameros fatores podem interferir, como hist\u00f3rico pr\u00e9-peri-p\u00f3s-natal, hist\u00f3rico familiar, fator ambiental, capacidades lingu\u00edsticas e cognitivas do indiv\u00edduo.Os quatro participantes do estudo s\u00e3o do sexo masculino, corroborando outras investiga\u00e7\u00f5es. Estes resultados confirmam os benef\u00edcios terap\u00eauticos do programa de terapia intensiva. Na literatura, outros estudos-7 confirmam diminui\u00e7\u00e3o significativa das disflu\u00eancias ap\u00f3s tratamento intensivo. Al\u00e9m disso, apontam diminui\u00e7\u00e3o significativa da dura\u00e7\u00e3o (em segundos) de disflu\u00eancias e aumento do fluxo de fala ap\u00f3s o tratamento,12. Vale ressaltar que os dados foram obtidos imediatamente antes e ap\u00f3s a terapia intensiva, sem tempo para identificar os efeitos da generaliza\u00e7\u00e3o ou uso das estrat\u00e9gias terap\u00eauticas adquiridas, no dia a dia do participante. O acompanhamento semestral dos participantes por um tempo estendido foi proposto com vistas a observar, em outro estudo, se os efeitos da terapia intensiva foram mantidos e consolidados.Em rela\u00e7\u00e3o aos resultados apresentados acerca das an\u00e1lises das amostras de fala pr\u00e9 e p\u00f3s terapia, observou-se melhora no perfil da flu\u00eancia - com diminui\u00e7\u00e3o da porcentagem de descontinuidade de fala e de disflu\u00eancias gagas de todos os participantes ap\u00f3s terapia intensiva. Os achados indicam que a redu\u00e7\u00e3o das disflu\u00eancias, levou ao aumento no fluxo de palavras e s\u00edlabas por minuto, em tr\u00eas dos quatro participantes Ressalta-se que o \u00fanico participante cujo fluxo de palavras e de s\u00edlabas por minuto diminuiu apresentava antes da terapia intensiva valores acima do esperado,13, que aponta que o impacto da gagueira est\u00e1 diretamente relacionado \u00e0 qualidade de vida em pessoas adultas que gaguejam. Infere-se que a interven\u00e7\u00e3o resultou em melhor conhecimento sobre a gagueira, conscientiza\u00e7\u00e3o do corpo e da fala e percep\u00e7\u00e3o dos sentimentos do sujeito frente a sua produ\u00e7\u00e3o verbal, assumindo as propostas de conscientiza\u00e7\u00e3o e modifica\u00e7\u00e3o da gagueira,9.A descri\u00e7\u00e3o dos resultados do OASES-A, pr\u00e9 e p\u00f3s terapia, indicam que ap\u00f3s a terapia intensiva houve melhora no grau do impacto na vida dos participantes. Tal achado corrobora a literatura.Em rela\u00e7\u00e3o \u00e0s an\u00e1lises de correla\u00e7\u00e3o entre as vari\u00e1veis das amostras de fala e os escores do OASES-A nos momentos pr\u00e9 e p\u00f3s terapia, n\u00e3o houve correla\u00e7\u00e3o com signific\u00e2ncia estat\u00edstica em quaisquer das vari\u00e1veis analisadas. Tal fato pode estar relacionado ao momento de resposta do question\u00e1rio - imediatamente ap\u00f3s a \u00faltima sess\u00e3o de terapia. O tempo para percep\u00e7\u00e3o das habilidades adquiridas e de uso das estrat\u00e9gias aprendidas pode n\u00e3o ter sido suficiente para que os participantes percebessem as modifica\u00e7\u00f5es ocasionadas com a terapia. O n\u00famero reduzido de participantes pode, tamb\u00e9m, ter influenciado a an\u00e1lise. Na pr\u00e1tica cl\u00ednica observa-se que muitas vezes a autopercep\u00e7\u00e3o da gagueira e o impacto da mesma na vida do falante n\u00e3o \u00e9 proporcional \u00e0 an\u00e1lise da gagueira deste mesmo falante, realizada pelo interlocutor, ou seja, um falante que gagueja levemente pode ter uma interfer\u00eancia muito mais negativa nas experi\u00eancias comunicativas que um falante com gagueira severa, e vice-versaPor fim, a an\u00e1lise de concord\u00e2ncia entre os ju\u00edzes aponta para concord\u00e2ncia forte nos itens analisados pr\u00e9 e p\u00f3s terapia, sendo assim, os resultados obtidos no estudo s\u00e3o considerados confi\u00e1veis.Como limita\u00e7\u00e3o do estudo considera-se o pequeno n\u00famero de participantes decorrente da dificuldade em realizar diariamente a terapia fonoaudiol\u00f3gica. A terapia intensiva envolve fatores socioecon\u00f4micos, al\u00e9m de demandar o acompanhamento longitudinal, di\u00e1rio, que dificulta a realiza\u00e7\u00e3o. Fatores como disponibilidade de hor\u00e1rio e de locomo\u00e7\u00e3o di\u00e1rios s\u00e3o complicadores para os interessados na terapia intensiva. Em contrapartida infere-se que seja uma excelente estrat\u00e9gia a ser considerada levando-se em conta o pequeno n\u00famero de especialistas na \u00e1rea da Flu\u00eancia no pa\u00eds, comprometendo a viabilidade de tratamento adequado a todas as pessoas que gaguejam, distantes de locais onde atuam profissionais com expertise na \u00e1rea. A terapia intensiva viabiliza que a pessoa que gagueja possa receber atendimento adequado, intensivamente, em um espa\u00e7o de tempo mais curto, longe da sua cidade de origem, em seu per\u00edodo de f\u00e9rias, por exemplo.Como avan\u00e7o, este estudo traz contribui\u00e7\u00f5es para a Fonoaudiologia e para que falantes que gaguejam possam melhorar a flu\u00eancia da fala em um espa\u00e7o de tempo menor. Os resultados foram importantes para identificar os benef\u00edcios da terapia intensiva na gagueira do desenvolvimento e apresentar o modelo terap\u00eautico utilizado. Optou-se por utilizar um modelo misto abordando estrat\u00e9gias de promo\u00e7\u00e3o da flu\u00eancia, modifica\u00e7\u00e3o da gagueira e aprimoramento das habilidades comunicativas, propiciando a redu\u00e7\u00e3o no n\u00famero de disflu\u00eancias e aumento do fluxo de fala. Sugere-se que esse estudo seja replicado numa amostra maior de adultos que gaguejam e que outras propostas de interven\u00e7\u00e3o possam vir a ser feitas com base nesses achados, uma vez que apesar de mudan\u00e7as positivas terem sido observadas, alguns resultados analisados n\u00e3o foram estatisticamente significantes.Conclui-se que houve melhora de todas vari\u00e1veis analisadas ap\u00f3s terapia intensiva. Observou-se melhora na flu\u00eancia da fala, redu\u00e7\u00e3o dos percentuais de descontinuidade de fala de disflu\u00eancias gagas, al\u00e9m da redu\u00e7\u00e3o do impacto da gagueira na vida dos participantes, o que sugere a relev\u00e2ncia da proposta de terapia fonoaudiol\u00f3gica intensiva. Os dados expostos possibilitam mostrar o conte\u00fado de um programa de terapia fonoaudiol\u00f3gica intensiva da gagueira permitindo que outros fonoaudi\u00f3logos possam utilizar a interven\u00e7\u00e3o proposta, cuja melhora da flu\u00eancia e do impacto da gagueira ap\u00f3s terapia fonoaudiol\u00f3gica intensiva em adultos que gaguejam foram constatados pelas an\u00e1lises descritivas e de concord\u00e2ncia."}
+{"text": "Myotherapy intervention in facial aesthetics aims to attenuate wrinkles and signs of facial aging. The relationship between accentuated muscle contraction during chewing, swallowing and speaking and the appearance of facial wrinkles has been suggested by speech-language pathology literature. This study aimed to report the effect of electromyographic biofeedback associated with training of chewing, swallowing, and smiling patterns, during speech therapy intervention aimed at reducing the signs of facial wrinkles and furrows, in a 55-year-old woman. The therapy also included isotonic and isometric exercises and clinical procedures to decrease the contraction of facial mimicry muscles, which were not associated with training using electromyographic biofeedback. Signal collection and training were performed using the Biotrainer software on the New Miotool Face by Miotec, over nine weekly sessions. Two assessments were performed (before and after the nine sessions), using the MBGR Protocol  and validated scales described in the literature . In the reported case, the usefulness of electromyographic biofeedback was verified for learning trained orofacial myofunctional patterns, as well as to improve chewing and swallowing functions and decrease signs of facial aging. However, further research is needed to demonstrate the positive effects of electromyographic biofeedback associated with myofunctional therapy aimed at attenuating the signs of facial aging. Additionally, other intrinsic and extrinsic factors contribute to lost skin elasticity and appearance of facial wrinkles and furrows. Intrinsic aging results from physiological and histological changes such as reduced thickness and variation in size and shape of epidermal cells, reduction in fibroblasts, reduction in melanocytes and a reduction in collagen. Extrinsic aging is caused by environmental factors such as conditions of hydration, nutrition, smoking, stress, sleep deprivation, and mainly ultraviolet radiation (UV), which leads to photoaging.The appearance of wrinkles and signs of facial aging can be related to genetic factors and changes that occur in facial structures, such as reabsorption of facial bones, reduction in facial fat and increased contraction of mimicry muscles,3,4. More studies are necessary however, to demonstrate this correlation frequently described by speech therapists.In addition to extrinsic and intrinsic aging, inadequate facial muscle contractions, performed when chewing, swallowing, and speaking, can produce static and/or dynamic wrinkles, in periorbital, perioral, frontal, and cervical areas, more or less evident depending on the intensity, frequency and duration of the contractions and on individual dentoskeletal characteristics,3. Surface electromyography (SE) or electromyographic biofeedback remains one clinical resource little investigated by speech therapists in this area.The speech therapy proposal to reduce wrinkles and signs of facial aging is a non-invasive therapeutic intervention, with numerous clinical resources being used, including isotonic and isometric exercises, face muscle stretches and orofacial function conditioning. Electromyographic biofeedback has been used in association with various speech therapy techniques, to rehabilitate patients with central and peripheral neurological damage, dentoskeletal alterations, and respiratory, voice and functional disorders,6. However, publications that report on electromyographic biofeedback used in speech therapy are scarce. Research presenting greater methodological rigor to obtain positive results when using these resources is necessary,6.SE makes functional neuromuscular analysis possible, being considered a valuable tool for both diagnosis and rehabilitation of individuals with orofacial myofunctional alterations observed that electromyographic biofeedback associated with traditional myofunctional therapy favored control of orofacial muscles while chewing and swallowing, in a 10-year-old child, who presented dentoskeletal and myofunctional alterations. In the only publication regarding the use of electromyographic biofeedback in speech therapy for facial aesthetics, Bernardes described the positive effects of this resource on reducing muscle contraction involved in chewing, swallowing and speech functions, and consequently on reducing facial wrinkles.In the area of orofacial motricity, Rosell-ClariAs such, the aim of this study was to present the effects of using electromyographic biofeedback associated with functional training of chewing, swallowing, and smiling, during speech therapy interventions seeking to reduce signs of facial aging.The present study is a clinical case, associated with the research project approved by the Ethics Committee of the Bauru School of Dentistry - University of S\u00e3o Paulo, reference number 2235918-CAAE: 71680017.0.0000.5417. The female client was duly informed of the aims and procedures to be adopted in the study and signed the Free and Informed Consent.The client decided to participate in the study due to wanting to undergo a non-invasive treatment to reduce facial wrinkles, having met the following exclusion criteria: realization of invasive facial procedures  and non-invasive  in the year prior to the treatments and during participation in the research, a history of skeletal dentofacial deformity, absence of temporomandibular dysfunction, presence of snoring, absence of more than one dental element.. The aesthetic and orofacial myofunctional aspects were analyzed using photographic documentation and in video, by two previously trained speech therapists, specialists in orofacial motricity, applying the Orofacial Myofunctional Evaluation Protocol MBGR and the validated scales described in the literature-13. Following the initial evaluation, we performed nine sessions undertaking electromyographic biofeedback training associated with chewing, swallowing and mild smiling without labial sealing. During this period, isometric and isotonic exercises were also realized in therapy, to condition the cheek, tongue and suprahyoid muscles , the palpebral portion of the orbicularis oculi muscle  and a speaking exercise with a wine cork between the teeth (opening held at the diameter of the cork - requesting the production of three phrases), as a technique for pronunciation (\u201cspeaking with cork\u201d). The client was asked to carry out these exercises daily at home , as well as using a TransporeTM inelastic bandage once a day while sleeping at night, over the frontal portion of the right and left occipitofrontal muscle, of the right and left eyebrow corrugator muscle and over the inferior orbital portion of the orbicularis oculi muscle  and during the day, a small strip of latex (2cm long and 5mm in diameter) in the oral vestibule  except at meals and while sleeping.A speech therapy evaluation was performed before and after the therapeutic intervention. The same physical space, equipment, patient position and room lighting were used to collect the images, as recommended by Fraz\u00e3o and ManziDuring the electromyographic feedback training we used the Biotrainer software on the New Miotec Miotool Face USB NM600FO device. It has eight channels connected to differential active sensors, with 16bit resolution, a 2Khz sampling frequency, 20Hz low pass filter, 500Hz high pass filter, 60Hz notch, a clamp connection, and a reference electrode (ground). To capture the electric signal, we used the same device with Double Trace LH-ED4020 differential passive dual electrodes, with dimensions 44 mm long, 21 mm wide, and 20 mm from center to center, placed over the muscles engaged when chewing, swallowing, and smiling ; suprahyoids; inferior orbital portion of the orbicularis oculi muscle). The reference electrode (ground) was positioned over the styloid process of the ulna of the right arm. The facial areas and regions where we positioned the electrodes were sterilized with cotton wool soaked in alcohol 77% GL (70% INPM) prior to placing the electrodes for all sessions when electromyographic biofeedback was employed.In the initial evaluation, no alterations to chewing function were observed . For swallowing, a marked contraction of the orbicularis oris and mentalis muscles, during routine swallowing of chewed, solid food and guided swallowing of liquid was observed (score 8 out of 28). The analysis of signs of facial aging showed an absence of static perioral wrinkles (score zero), moderate dynamic perioral wrinkles (score two out of four), moderate nasolabial grooves (score two out of four) and mild labiomentonian grooves (score one out of four). The smile evaluation score obtained using video image capture of the dynamic periorbital wrinkles, in the third execution of the \u201copen smile\u201d and of the photographic image of the static periorbital wrinkles in diagonal position (45\u00ba), showed accentuated dynamic periorbital wrinkles (score of three out of four) and moderate static periorbital wrinkles (score of two out of four).For training with electromyographic biofeedback, the electrodes were placed in a sequence favoring progressive control by the client of the movements of the different muscle groups when executing trained orofacial functions. As such, to train alternating unilateral chewing in the second session, the electrodes were positioned parallel to the direction of the muscle fiber, over the right and left masseter muscles. For the third and fourth sessions, the electrodes were placed over these muscles as well as over the orbicularis oris muscle (upper lip). This position was maintained for the fifth to the ninth sessions, to train alternating bilateral chewing. To train the swallowing function, initiated in the third session with swallowing pasty food (Greek yogurt), the electrodes were initially placed over the suprahyoid muscle region; in the fourth and fifth sessions electrodes were placed over the orbicularis oris muscle (upper lip); these electrodes were maintained to train liquid swallowing in the fifth session, and chewed solid food in the sixth session, when an electrode over the right and left masseter muscles was added and kept until the ninth session. The gradual training sequence performed using electromyographic biofeedback in therapy is found in Maximal voluntary contraction (MVC) of the selected muscles was verified using the Biotrainer software and a 50% MVC value was the parameter established to increase or reduce muscular contraction during training, seeking to attenuate contraction of masseter, orbicularis oris (upper lip), zygomaticus major and minor, and orbicularis oculi muscles, and increase contraction of the levator palpebrae superioris and suprahyoid muscles. The percentage of muscle contraction intensity can be determined using the software, in the Collection Configuration, Protocols tab, Activities tab, New Activity window, intensity (%). The client was instructed to increase muscle contraction to go above the target line or reduce muscle contraction, remaining below the target line.The client remained seated on her hamstrings, with her feet supported on the ground or on a support stool, maintaining an angle of 90\u00ba in the hips, knees, and ankles to perform the electromyographic biofeedback for therapy. The following foods were used to engage swallowing and chewing functions: Greek yogurt, water, and raisins. For the smile, the participant was instructed to smile lightly without lip sealing, while she thought about something happy, keeping her eyes wide open.Training protocols were created using the Biotrainer software, allowing protocol configuration wherein the activity  and its duration  could be indicated. The activities were then inserted into the Protocol Timeline. The training duration for each orofacial function using electromyographic biofeedback was determined by the therapist (author of the present article), producing the following description: alternate unilateral chewing, duration of two minutes and 30 seconds, repeated twice in each session; altered bilateral chewing, duration of one minute and 40 seconds, repeated twice in each session in which this chewing pattern was trained until the conclusion of the program; swallowing of pasty food, duration of one minute and 40 seconds, repeated three times, in the two sessions in which this pattern was trained; swallowing of liquid, duration of one minute and 40 seconds, repeated twice in the first two sessions when this pattern was trained and repeated once a session until the end of the program following this; swallowing of solids , duration of one minute and 40 seconds, repeated twice a session until the end of the program; smile, one minute duration, repeated twice in each session in which this pattern was trained until the end of the program. The client was instructed to control the chewing, swallowing, and smiling patterns at home, in line with the activities performed during therapy.The benefits of functional training were observed in the scores obtained from MBGR and through the analysis of signs of facial aging after nine sessions performed over nine weeks. The scores obtained in the MBGR were the following: for chewing, the initial score was maintained (score zero out of 10); for swallowing, the score was lower (score two out of 28), with reduced mentalis muscle contraction in guided swallowing of liquid and routine solids swallowing; reduced orbicularis oris muscle contraction for swallowing liquid, without change for swallowing solid food. For signs of facial aging, resulting from excessive contraction of perioral muscles during chewing and swallowing functions, there was an increase in static perioral wrinkles (score one out of four) and reduction of dynamic perioral wrinkles (score of one out of four), of the nasolabial grooves (score of one out of four) and labiomentonian grooves (score of zero out of four). For periorbital wrinkles, which result from exaggerated contraction of the orbicularis oculi muscles while smiling, the score for dynamic periorbital wrinkles remained the same (score of three out of four) and there was a reduction of static periorbital wrinkles (score of one out of four).-13; dynamic perioral wrinkles in the frontal position (Aesthetic changes were observed in the photos and videos (screen capture) performed in the initial and final evaluations, according to the validated scale parameters described in the literatureposition , static position , static position , static position .. However, in the field of speech therapy only one publication was observed with a description of three examples in which electromyographic biofeedback was found to be effective to increase awareness and reduce contraction of the muscles involved in chewing, swallowing and speaking. We believe that these satisfactory results need to be consolidated in future studies.This study aims to present the effects of using electromyographic biofeedback when training chewing, swallowing, and smiling functions, during speech therapy interventions focused on reducing signs of facial aging, in a 55-year-old woman. Positive results from the use of electromyographic biofeedback associated with speech therapy treatments have been described in some studies-3. In the present study we observed static and dynamic wrinkles on the client\u2019s face, who, while not contracting the perioral musculature excessively while chewing, presented intense contraction of the orbicularis oris and mentalis muscles during swallowing (liquid and solid) and of the orbicularis oculi muscle when smiling and speaking. In the first session, the client was surprised when she looked at her photographs and the video recorded in the initial session. This shows that she was unaware of her oral motor habits, presenting exaggerated orofacial muscle contraction, and was also unaware of the correlation of this with the emergence of facial wrinkles. This understanding was important to increase awareness of altered orofacial movements and for proprioception of adequate orofacial motor patterns to be learnt.The correlation between the presence of wrinkles and signs of facial aging and excessive contraction of mimicry muscles and those used for chewing and swallowing has been described by dermatologists and speech therapists,3. In the second session, training with electromyographic biofeedback to condition chewing, swallowing, and smiling habits was initiated. Using the visualization of muscular activity, with a corresponding image on the computer screen, the client participated more actively and with greater control over her orofacial muscles, being one of the advantages cited by researchers, when using electromyographic biofeedback,15.Adequacy of orofacial functions was one of the procedures proposed by speech therapists to attenuate wrinkles and signs of facial aging, on the suprahyoid and sternocleidomastoid muscles in alternating voice therapy sessions, and on the masseter and orbicularis oris muscles in therapy focusing on facial aesthetics. In the present study electrode placement was performed in a sequence favoring the client\u2019s progressive control, giving her awareness and proprioception of the adequate recruitment of the involved muscles to the extent that electrodes were added. Training of alternated unilateral chewing was initiated by the control of masseter movement and subsequently, of the orbicularis oris muscle (upper lip). For swallowing training, in addition to the electrode placement sequence, initially on the suprahyoid muscles and subsequently on the orbicular oris and masseter muscles, there was progression of food consistency. Pasty food (Greek yogurt) was initially offered, followed by liquid (room temperature water) and, finally solid food (raisins). For smile conditioning, the control of the risorius and orbicularis oris muscles associated with happy thinking, contributed to a change in initial habits and a reduction of static periorbital wrinkles. The client was instructed to smile with contraction of risorius muscle towards the ears, keeping the eyes well open, thereby contracting the levator palpebrae superioris muscle.The placement and number of electrodes used for training can vary depending on therapeutic aims. As such, electrodes can only be positioned on the suprahyoid muscles when training swallowing.According to the client, viewing the image corresponding to the muscular contraction on the computer screen favored awareness, control and learning of the movements necessary to perform adequate chewing, swallowing, and facial muscle movement, during the sessions and through fixation of these movements at home. The positive impact provided by visual feedback was also reported in another study involving healthy and dysphagic subjectsAfter nine sessions performed over nine weeks, it was possible to observe functional and aesthetic changes, leading to more harmonious facial muscle movements. We noted reduced values attributed to swallowing and to signs of facial aging. We also observed a reduction in contraction of the orbicularis oris and mentalis muscles while swallowing and reduced nasolabial and labiomentonian grooves and static periorbital wrinkles. Awareness and proprioception of tongue contraction and position during swallowing and of mimicry muscle contraction during smiling and speech, contributed to reduced perioral muscle contraction and attenuated labiomentonian and nasolabial grooves..The results presented in this study suggest that electromyographic biofeedback improved uptake of more adequate orofacial habits. However, future studies with a larger number of subjects and control group should be carried out, given that currently no studies were found that demonstrated differences between the outcome of interventions performed with and without the association of this therapeutic resourceIn the present study, we described the use of electromyographic biofeedback in a speech therapy intervention seeking to reduce signs of facial aging. We noted the beneficial effect of electromyographic biofeedback in learning the trained orofacial myofunctional patterns, and functional and aesthetic improvements, following the realization of nine speech therapy sessions, with a consensus that this technical resource represents a useful tool for therapeutic contexts. . Al\u00e9m destes, outros fatores, intr\u00ednsecos e extr\u00ednsecos, concorrem para perda da elasticidade da pele e o aparecimento de rugas e vincos faciais. O envelhecimento intr\u00ednseco decorre de mudan\u00e7as fisiol\u00f3gicas e histol\u00f3gicas tais como, diminui\u00e7\u00e3o da espessura, varia\u00e7\u00e3o no tamanho e na forma das c\u00e9lulas da epiderme, redu\u00e7\u00e3o de fibroblastos, diminui\u00e7\u00e3o de melan\u00f3citos e redu\u00e7\u00e3o de col\u00e1geno. O envelhecimento extr\u00ednseco \u00e9 causado por fatores ambientais, tais como condi\u00e7\u00e3o de hidrata\u00e7\u00e3o, de nutri\u00e7\u00e3o, tabagismo, estresse, priva\u00e7\u00e3o do sono e, principalmente, a radia\u00e7\u00e3o ultravioleta (UV), que resulta no fotoenvelhecimento.O aparecimento das rugas e dos sinais de envelhecimento facial pode estar relacionado aos fatores gen\u00e9ticos e \u00e0s mudan\u00e7as que ocorrem nas estruturas faciais, como a reabsor\u00e7\u00e3o dos ossos faciais, a diminui\u00e7\u00e3o da gordura facial e o aumento da contra\u00e7\u00e3o dos m\u00fasculos m\u00edmicos,3,4. Por\u00e9m, mais estudos s\u00e3o necess\u00e1rios para comprovar esta correla\u00e7\u00e3o frequentemente descrita por fonoaudi\u00f3logos.Al\u00e9m do envelhecimento intr\u00ednseco e extr\u00ednseco, as contra\u00e7\u00f5es inadequadas dos m\u00fasculos faciais, realizadas nas fun\u00e7\u00f5es mastiga\u00e7\u00e3o, degluti\u00e7\u00e3o e fala, poderiam resultar em rugas est\u00e1ticas e/ou din\u00e2micas, nas \u00e1reas periorbit\u00e1rias, periorais, frontais e cervicais, mais ou menos evidentes, de acordo com a intensidade, a frequ\u00eancia e a dura\u00e7\u00e3o destas contra\u00e7\u00f5es e, tamb\u00e9m, com as caracter\u00edsticas dentoesquel\u00e9ticas dos indiv\u00edduos,3, por\u00e9m a eletromiografia de superf\u00edcie (EMGs) ou o biofeedback eletromiogr\u00e1fico s\u00e3o recursos cl\u00ednicos ainda pouco explorados por fonoaudi\u00f3logos neste campo de atua\u00e7\u00e3o.A proposta fonoaudiol\u00f3gica para atenuar as rugas e sinais de envelhecimento facial seria a interven\u00e7\u00e3o terap\u00eautica n\u00e3o invasiva, sendo diversos os recursos cl\u00ednicos utilizados com esta finalidade, tais como, os exerc\u00edcios isom\u00e9tricos e isot\u00f4nicos, o alongamento dos m\u00fasculos faciais e a adequa\u00e7\u00e3o das fun\u00e7\u00f5es orofaciais. O biofeedback eletromiogr\u00e1fico tem sido utilizado, associado a v\u00e1rias t\u00e9cnicas fonoaudiol\u00f3gicas, para reabilita\u00e7\u00e3o de pacientes com comprometimento neurol\u00f3gico central, perif\u00e9rico, altera\u00e7\u00f5es dentoesquel\u00e9ticas, dist\u00farbios respirat\u00f3rios, vocais e funcionais,6. Por\u00e9m, as publica\u00e7\u00f5es que descrevem a utiliza\u00e7\u00e3o do biofeedback eletromiogr\u00e1fico associado \u00e0 terapia fonoaudiol\u00f3gica s\u00e3o escassas, sendo necess\u00e1ria uma comprova\u00e7\u00e3o dos resultados positivos do uso deste recurso por meio de pesquisas que apresentem maior rigor metodol\u00f3gico,6.A EMGs possibilita uma an\u00e1lise neuromuscular funcional, sendo considerada instrumento valioso tanto para diagn\u00f3stico, como para reabilita\u00e7\u00e3o de indiv\u00edduos com altera\u00e7\u00f5es miofuncionais orofaciais observou que o biofeedback eletromiogr\u00e1fico associado \u00e0 terapia miofuncional tradicional favoreceu o controle dos m\u00fasculos orofaciais durante a mastiga\u00e7\u00e3o e degluti\u00e7\u00e3o, em uma crian\u00e7a de dez anos de idade, que apresentou altera\u00e7\u00f5es dentoesquel\u00e9ticas e miofuncionais orofaciais. Em uma \u00fanica publica\u00e7\u00e3o sobre o uso do biofeedback eletromiogr\u00e1fico na terapia fonoaudiol\u00f3gica em est\u00e9tica facial, Bernardes descreveu os efeitos positivos do recurso para reduzir a contra\u00e7\u00e3o dos m\u00fasculos envolvidos nas fun\u00e7\u00f5es mastiga\u00e7\u00e3o, degluti\u00e7\u00e3o e fala e, consequentemente, diminuir as rugas faciais.Na \u00e1rea da Motricidade Orofacial, Rosell-Claribiofeedback eletromiogr\u00e1fico associado a um treinamento funcional da mastiga\u00e7\u00e3o, degluti\u00e7\u00e3o e sorriso, durante a interven\u00e7\u00e3o fonoaudiol\u00f3gica direcionada \u00e0 atenua\u00e7\u00e3o dos sinais de envelhecimento facial.Sendo assim, o objetivo do presente estudo foi relatar o efeito da utiliza\u00e7\u00e3o do Trata-se de caso cl\u00ednico, vinculado ao projeto de pesquisa aprovado pelo Comit\u00ea de \u00c9tica em Pesquisa, sob n\u00famero 2235918-CAAE: 71680017.0.0000.5417. A cliente do sexo feminino com 55 anos de idade foi devidamente informada sobre os objetivos e procedimentos realizados no estudo e assinou o Termo de Consentimento Livre e Esclarecido.A cliente decidiu participar da pesquisa por desejar se submeter a um tratamento n\u00e3o invasivo que atenuasse suas rugas faciais, tendo preenchido os seguintes crit\u00e9rios de exclus\u00e3o: realiza\u00e7\u00e3o de procedimentos faciais invasivos  e n\u00e3o invasivos  no ano anterior aos atendimentos e durante a participa\u00e7\u00e3o na pesquisa, hist\u00f3rico de deformidade dentofacial esquel\u00e9tica, aus\u00eancia de disfun\u00e7\u00e3o temporomandibular, presen\u00e7a de ronco, aus\u00eancia de mais de um elemento dent\u00e1rio.. Os aspectos miofuncionais orofaciais e est\u00e9ticos foram analisados pela documenta\u00e7\u00e3o fotogr\u00e1fica e em v\u00eddeo, por duas fonoaudi\u00f3logas previamente calibradas, especialistas em Motricidade Orofacial, por meio do Protocolo de Avalia\u00e7\u00e3o Miofuncional Orofacial MBGR e de escalas validadas descritas na literatura-13. Ap\u00f3s a avalia\u00e7\u00e3o inicial, foram realizadas nove sess\u00f5es quando foi efetuado o treinamento com biofeedback eletromiogr\u00e1fico associado \u00e0 mastiga\u00e7\u00e3o, degluti\u00e7\u00e3o e sorriso suave, sem selamento labial. Neste per\u00edodo foram realizados, tamb\u00e9m em terapia, exerc\u00edcios isom\u00e9tricos, exerc\u00edcios isot\u00f4nicos para condicionar os m\u00fasculos da regi\u00e3o das bochechas, os supra-hioideos, os linguais , a por\u00e7\u00e3o palpebral do m\u00fasculo orbicular do olho  e exerc\u00edcio de falar com rolha de vinho entre os dentes (abertura mantida pelo di\u00e2metro da rolha - solicita\u00e7\u00e3o para produ\u00e7\u00e3o de tr\u00eas frases), como t\u00e9cnica para articula\u00e7\u00e3o . A cliente foi orientada a realizar estes exerc\u00edcios em seu domicilio diariamente  e, tamb\u00e9m diariamente, durante o per\u00edodo de sono noturno, usar bandagem inel\u00e1stica TransporeTM sobre a por\u00e7\u00e3o frontal do m\u00fasculo occiptofrontal direito e esquerdo, do m\u00fasculo corrugador do superc\u00edlio direito e esquerdo e sobre a por\u00e7\u00e3o orbital inferior do m\u00fasculo orbicular do olho (canto externo dos olhos - direito e esquerdo) e durante o dia, um pequeno peda\u00e7o de garrote (2cm de comprimento e 5mm de di\u00e2metro) no vest\u00edbulo oral , exceto nas refei\u00e7\u00f5es e ao dormir.Uma avalia\u00e7\u00e3o fonoaudiol\u00f3gica foi realizada antes e ap\u00f3s interven\u00e7\u00e3o terap\u00eautica. A mesma padroniza\u00e7\u00e3o do espa\u00e7o f\u00edsico, equipamentos utilizados, posicionamento do paciente e ilumina\u00e7\u00e3o da sala foi mantida para a documenta\u00e7\u00e3o das imagens, conforme preconizado por Fraz\u00e3o e Manzibiofeedback eletromiogr\u00e1fico foi utilizado o software Biotrainer no aparelho New Miotool Face USB NM600FO, da Miotec, que possui oito canais conectados a sensores ativos diferenciais, com resolu\u00e7\u00e3o de 16bits, frequ\u00eancia de amostragem 2Khz, filtro passa-baixa 20Hz, filtro passa-alta 500Hz, notch 60Hz, com conex\u00e3o de garras e um de refer\u00eancia (terra). Para a capta\u00e7\u00e3o do sinal el\u00e9trico, realizado com o mesmo aparelho, foram utilizados eletrodos duplos passivos diferenciais, Double Trace LH-ED4020; dimens\u00f5es: 44 mm de comprimento, 21 mm de largura, 20 mm de centro a centro, colocados sobre m\u00fasculos envolvidos na mastiga\u00e7\u00e3o, degluti\u00e7\u00e3o e sorriso . O eletrodo de refer\u00eancia (terra) foi posicionado sobre o processo estiloide da ulna do bra\u00e7o direito. As \u00e1reas da face e a regi\u00e3o em que o eletrodo de refer\u00eancia foi colocado foram higienizadas com gaze embebida em \u00e1lcool 77\u00ba GL (70\u00ba INPM) em todas as sess\u00f5es em que o treino com biofeedback eletromiogr\u00e1fico foi realizado, antes da coloca\u00e7\u00e3o dos eletrodos.No treino com Na avalia\u00e7\u00e3o inicial, n\u00e3o foram observadas altera\u00e7\u00f5es na fun\u00e7\u00e3o mastiga\u00e7\u00e3o . Em rela\u00e7\u00e3o \u00e0 degluti\u00e7\u00e3o, constatou-se contra\u00e7\u00e3o acentuada dos m\u00fasculos orbicular da boca e mentual, durante degluti\u00e7\u00e3o habitual de alimento s\u00f3lido triturado e degluti\u00e7\u00e3o dirigida de l\u00edquido (pontua\u00e7\u00e3o oito em 28). A an\u00e1lise dos sinais de envelhecimento facial revelou aus\u00eancia de rugas periorais est\u00e1ticas (pontua\u00e7\u00e3o zero), rugas periorais din\u00e2micas moderadas (pontua\u00e7\u00e3o dois em quatro), sulco nasolabial moderado (pontua\u00e7\u00e3o dois em quatro) e labiomentoniano suave (pontua\u00e7\u00e3o um em quatro). A pontua\u00e7\u00e3o na avalia\u00e7\u00e3o do sorriso, obtida por meio da captura da imagem de v\u00eddeo das rugas periorbit\u00e1rias din\u00e2micas, na terceira execu\u00e7\u00e3o do \u201csorriso aberto\u201d e da imagem fotogr\u00e1fica das rugas periorbit\u00e1rias est\u00e1ticas na posi\u00e7\u00e3o diagonal (45\u00ba), revelou a presen\u00e7a de rugas periorbit\u00e1rias din\u00e2micas acentuadas (pontua\u00e7\u00e3o tr\u00eas em quatro) e rugas periorbit\u00e1rias est\u00e1ticas moderadas (pontua\u00e7\u00e3o dois em quatro).biofeedback eletromiogr\u00e1fico, os eletrodos foram colocados em uma sequ\u00eancia para favorecer o controle progressivo da cliente sobre os movimentos dos diferentes grupos musculares na execu\u00e7\u00e3o da fun\u00e7\u00f5es orofaciais treinadas. Assim, para o treino da mastiga\u00e7\u00e3o unilateral alternada, na segunda sess\u00e3o, os eletrodos foram posicionados, paralelamente ao sentido da fibra muscular, sobre os m\u00fasculos masseteres direito e esquerdo; na terceira e quarta sess\u00f5es, os eletrodos foram posicionados sobre estes m\u00fasculos e, tamb\u00e9m, sobre o m\u00fasculo orbicular da boca (l\u00e1bio superior); este posicionamento foi mantido da quinta \u00e0 nona sess\u00e3o, para o treino da mastiga\u00e7\u00e3o bilateral alternada. Para o treino da fun\u00e7\u00e3o degluti\u00e7\u00e3o, iniciado na terceira sess\u00e3o com a degluti\u00e7\u00e3o de alimento pastoso (iogurte grego), os eletrodos foram posicionados, inicialmente, na regi\u00e3o dos m\u00fasculos supra-hioideos; na quarta e quinta sess\u00f5es foram acrescentados eletrodos sobre o m\u00fasculo orbicular da boca (l\u00e1bio superior); estes eletrodos foram mantidos no treinamento da degluti\u00e7\u00e3o de l\u00edquido, na quinta sess\u00e3o, do alimento s\u00f3lido triturado na sexta sess\u00e3o, quando foi acrescentado o eletrodo sobre m\u00fasculos masseteres direito e esquerdo e mantidos at\u00e9 a nona sess\u00e3o. A cross talk). Ainda assim, durante o treinamento foi poss\u00edvel comparar a contra\u00e7\u00e3o dos m\u00fasculos da regi\u00e3o do ris\u00f3rio e por\u00e7\u00e3o orbital inferior do m\u00fasculo orbicular do olho, isto \u00e9, a cliente conseguia reduzir a contra\u00e7\u00e3o muscular na regi\u00e3o dos olhos ao sorrir, com consequente atenua\u00e7\u00e3o de rugas periorbit\u00e1rias est\u00e1ticas e din\u00e2micas.Para o treinamento com biofeedback eletromiogr\u00e1fico e o posicionamento dos eletrodos no treino das fun\u00e7\u00f5es de mastiga\u00e7\u00e3o e degluti\u00e7\u00e3o. Na imagem da tela do computador a cliente pode visualizar o tra\u00e7ado-alvo (tarjas verde clara e azul clara) e os tra\u00e7os (linha cont\u00ednua), representando seu controle sobre o recrutamento dos m\u00fasculos masseter direito e esquerdo, orbicular da boca (l\u00e1bio superior) e supra-hioideos na mastiga\u00e7\u00e3o (tarja verde clara) e degluti\u00e7\u00e3o (tarja azul clara). O tra\u00e7o cont\u00ednuo revelou que durante a mastiga\u00e7\u00e3o ocorreu atividade ritmada dos m\u00fasculos masseteres (duas faixas superiores na tela), pouca ativa\u00e7\u00e3o do m\u00fasculo orbicular da boca (terceira faixa na tela - l\u00e1bio superior) e praticamente nenhum recrutamento dos m\u00fasculos supra-hioideos (quarta faixa na tela). Na degluti\u00e7\u00e3o observou-se apenas o recrutamento dos m\u00fasculos supra-hioideos .A A sequ\u00eancia do treinamento gradual realizado por meio do biofeedback eletromiogr\u00e1fico em terapia se encontra ilustrada no software Biotrainer e o valor de 50% da CVM foi o par\u00e2metro estabelecido para o aumento ou diminui\u00e7\u00e3o da contra\u00e7\u00e3o muscular durante os treinos, cujo objetivo foi atenuar a contra\u00e7\u00e3o dos m\u00fasculos masseteres, orbicular da boca (l\u00e1bio superior), zigom\u00e1ticos maior e menor, orbicular do olho e aumentar a contra\u00e7\u00e3o do m\u00fasculo levantador da p\u00e1lpebra superior e supra-hioideos. O percentual da intensidade da contra\u00e7\u00e3o muscular pode ser estabelecido no software, na janela Configura\u00e7\u00e3o de Coleta, aba Protocolos, aba Atividades, janela Nova Atividade, Intensidade(%). A cliente foi orientada a aumentar a contra\u00e7\u00e3o muscular, ultrapassando o tra\u00e7ado-alvo ou reduzir a contra\u00e7\u00e3o muscular mantendo-se abaixo deste tra\u00e7ado.A contra\u00e7\u00e3o volunt\u00e1ria m\u00e1xima (CVM) dos m\u00fasculos selecionados foi aferida por meio do biofeedback eletromiogr\u00e1fico em terapia. Os seguintes alimentos foram utilizados para trabalhar as fun\u00e7\u00f5es de mastiga\u00e7\u00e3o e degluti\u00e7\u00e3o: iogurte grego, \u00e1gua e uva passa. Para o sorriso, a participante foi orientada a fazer um sorriso suave sem selamento labial, enquanto pensava em algo alegre, mantendo os olhos bem abertos.A cliente permaneceu sentada sobre os \u00edsquios, com p\u00e9s apoiados no ch\u00e3o ou banco de apoio, mantendo angulo de 90\u00ba em quadris, joelhos e tornozelos para a realiza\u00e7\u00e3o do software Biotrainer, que permite a configura\u00e7\u00e3o de protocolos nos quais \u00e9 poss\u00edvel nomear a atividade  e sua dura\u00e7\u00e3o . As atividades s\u00e3o, ent\u00e3o, inseridas na Linha do Tempo do Protocolo. A dura\u00e7\u00e3o do treinamento de cada uma das fun\u00e7\u00f5es orofaciais utilizando o biofeedback eletromiogr\u00e1fico foi determinada pela terapeuta (autora do presente artigo), resultando na seguinte descri\u00e7\u00e3o: mastiga\u00e7\u00e3o unilateral alternada, dura\u00e7\u00e3o de dois minutos e 30 segundos, repetido duas vezes na sess\u00e3o; mastiga\u00e7\u00e3o bilateral alternada, dura\u00e7\u00e3o de um minuto e 40 segundos, repetido duas vezes em cada sess\u00e3o em que esse padr\u00e3o mastigat\u00f3rio foi treinado at\u00e9 a conclus\u00e3o do programa; degluti\u00e7\u00e3o de pastoso, dura\u00e7\u00e3o de um minuto e 40 segundos, repetido tr\u00eas vezes, nas duas sess\u00f5es em que este padr\u00e3o foi treinado; degluti\u00e7\u00e3o de l\u00edquido, dura\u00e7\u00e3o de um minuto e 40 segundos, repetido duas vezes nas duas primeiras sess\u00f5es em que esse padr\u00e3o foi treinado e repetido uma vez na sess\u00e3o at\u00e9 o final do programa; degluti\u00e7\u00e3o de s\u00f3lido , dura\u00e7\u00e3o de um minuto e 40 segundos, repetido duas vezes nas sess\u00f5es at\u00e9 o final do programa; sorriso, dura\u00e7\u00e3o de um minuto, repetido duas vezes nas sess\u00f5es em que esse padr\u00e3o foi treinado at\u00e9 o final do programa. A cliente recebeu orienta\u00e7\u00f5es para controlar os padr\u00f5es de mastiga\u00e7\u00e3o, degluti\u00e7\u00e3o e sorriso, de acordo com o treino realizado em terapia, em sua resid\u00eancia.Os protocolos de treino foram criados no Ap\u00f3s nove sess\u00f5es realizadas semanalmente, os escores aferidos no MBGR e na an\u00e1lise dos sinais de envelhecimento facial revelaram os benef\u00edcios do treinamento funcional realizado. As pontua\u00e7\u00f5es obtidas no MBGR foram as seguintes: na mastiga\u00e7\u00e3o, o escore inicial foi mantido (pontua\u00e7\u00e3o zero em 10); na degluti\u00e7\u00e3o, houve redu\u00e7\u00e3o do escore (pontua\u00e7\u00e3o dois em 28), com diminui\u00e7\u00e3o da contra\u00e7\u00e3o do m\u00fasculo mentual na degluti\u00e7\u00e3o dirigida de l\u00edquido e degluti\u00e7\u00e3o habitual de s\u00f3lido; diminui\u00e7\u00e3o da contra\u00e7\u00e3o do m\u00fasculo orbicular da boca na degluti\u00e7\u00e3o de l\u00edquido, sem mudan\u00e7a para a degluti\u00e7\u00e3o de alimento s\u00f3lido. Em rela\u00e7\u00e3o aos sinais de envelhecimento facial, que seriam resultantes da contra\u00e7\u00e3o excessiva dos m\u00fasculos periorais durante as fun\u00e7\u00f5es mastiga\u00e7\u00e3o e degluti\u00e7\u00e3o, houve aumento das rugas periorais est\u00e1ticas (pontua\u00e7\u00e3o um em quatro) e diminui\u00e7\u00e3o das rugas periorais din\u00e2micas (pontua\u00e7\u00e3o um em quatro), do sulco nasolabial (pontua\u00e7\u00e3o um em quatro) e sulco labiomentoniano (pontua\u00e7\u00e3o zero em quatro). Em rela\u00e7\u00e3o \u00e0s rugas periorbit\u00e1rias, que seriam resultantes da contra\u00e7\u00e3o exagerada do orbicular do olho durante sorriso, o escore das rugas periorbit\u00e1rias din\u00e2micas manteve-se inalterado (pontua\u00e7\u00e3o tr\u00eas em quatro) e houve diminui\u00e7\u00e3o das rugas periorbit\u00e1rias est\u00e1ticas (pontua\u00e7\u00e3o um em quatro).-13: rugas periorais din\u00e2micas na posi\u00e7\u00e3o frontal  realizadas nas avalia\u00e7\u00f5es inicial e final, de acordo com os par\u00e2metros das escalas validadas descritas na literatura frontal , rugas p frontal , rugas p frontal , rugas p frontal .biofeedback eletromiogr\u00e1fico associado ao treinamento dos padr\u00f5es de mastiga\u00e7\u00e3o, degluti\u00e7\u00e3o e sorriso, durante interven\u00e7\u00e3o fonoaudiol\u00f3gica direcionada \u00e0 atenua\u00e7\u00e3o dos sinais de envelhecimento facial, em mulher de 55 anos de idade. Resultados positivos sobre o uso do biofeedback eletromiogr\u00e1fico associado \u00e0s terapias fonoaudiol\u00f3gicas foram descritos em alguns estudos. Por\u00e9m, no campo da fonoaudiologia em est\u00e9tica facial foi encontrada apenas uma publica\u00e7\u00e3o com a descri\u00e7\u00e3o de tr\u00eas exemplos em que o biofeedback eletromiogr\u00e1fico mostrou-se efetivo para conscientizar e diminuir a contra\u00e7\u00e3o dos m\u00fasculos envolvidos na mastiga\u00e7\u00e3o, na degluti\u00e7\u00e3o e articula\u00e7\u00e3o da fala. Considerou-se que estes resultados satisfat\u00f3rios precisam ser consolidados em futuras pesquisas.O objetivo do presente estudo foi relatar o efeito da utiliza\u00e7\u00e3o do -3. Observou-se, no presente estudo, a presen\u00e7a de rugas est\u00e1ticas e din\u00e2micas na face da cliente, que, embora n\u00e3o tenha contra\u00eddo a musculatura perioral exageradamente durante a mastiga\u00e7\u00e3o, apresentou contra\u00e7\u00e3o intensa dos m\u00fasculos orbicular da boca e mentual na degluti\u00e7\u00e3o (l\u00edquido e s\u00f3lido) e do m\u00fasculo orbicular do olho, no sorriso e na fala. Na primeira sess\u00e3o, a cliente demonstrou surpresa ao olhar suas fotografias e v\u00eddeo registrados na avalia\u00e7\u00e3o inicial; revelou que nunca havia percebido seu padr\u00e3o motor oral, com presen\u00e7a de contra\u00e7\u00e3o exagerada da musculatura orofacial e desconhecia a correla\u00e7\u00e3o entre esta contra\u00e7\u00e3o e o aparecimento de rugas faciais. Esta percep\u00e7\u00e3o foi importante para o trabalho de conscientiza\u00e7\u00e3o dos movimentos orofaciais alterados e de propriocep\u00e7\u00e3o do padr\u00e3o motor orofacial adequado a ser aprendido.A correla\u00e7\u00e3o entre a presen\u00e7a de rugas e sinais de envelhecimento na face e a contra\u00e7\u00e3o excessiva dos m\u00fasculos m\u00edmicos e daqueles utilizados na mastiga\u00e7\u00e3o e degluti\u00e7\u00e3o foi descrita por alguns dermatologistas e fonoaudi\u00f3logos,3. Na segunda sess\u00e3o o treinamento com biofeedback eletromiogr\u00e1fico, para adequar o padr\u00e3o de mastiga\u00e7\u00e3o, degluti\u00e7\u00e3o e sorriso, foi iniciado. Por meio da visualiza\u00e7\u00e3o da atividade muscular, representada por imagem correspondente na tela do computador, a cliente pode manter uma participa\u00e7\u00e3o mais ativa e maior controle sobre sua musculatura orofacial, sendo esta uma das vantagens citada por pesquisadores, para a utiliza\u00e7\u00e3o do biofeedback eletromiogr\u00e1fico,15.A adequa\u00e7\u00e3o das fun\u00e7\u00f5es orofaciais foi um dos procedimentos propostos por fonoaudi\u00f3logos para atenuar rugas e sinais de envelhecimento facial, sobre os m\u00fasculos supra-hioideos e esternocleidomast\u00f3ideo, em sess\u00f5es alternadas de terapia vocal, sobre os m\u00fasculos masseteres e orbicular da boca, na terapia direcionada para a est\u00e9tica facial. No presente estudo a coloca\u00e7\u00e3o dos eletrodos foi realizada em uma sequ\u00eancia para favorecer o controle progressivo da cliente, que adquiriu conscientiza\u00e7\u00e3o e propriocep\u00e7\u00e3o sobre o recrutamento adequado dos m\u00fasculos abordados, \u00e0 medida que eletrodos eram acrescentados. O treino da mastiga\u00e7\u00e3o unilateral alternada foi iniciado pelo controle da movimenta\u00e7\u00e3o dos masseteres e, posteriormente, do m\u00fasculo orbicular da boca (l\u00e1bio superior). No treino da degluti\u00e7\u00e3o, al\u00e9m da sequ\u00eancia para a coloca\u00e7\u00e3o dos eletrodos, inicialmente, posicionados sobre os m\u00fasculos supra-hioideos, em seguida sobre os m\u00fasculos orbicular da boca e masseteres, houve progress\u00e3o da consist\u00eancia do alimento; foi oferecido, inicialmente, alimento pastoso (iogurte grego), em seguida l\u00edquido (\u00e1gua em temperatura ambiente) e, finalmente, s\u00f3lido (uva passa). Na adequa\u00e7\u00e3o do sorriso, o controle sobre os m\u00fasculos ris\u00f3rio e orbicular do olho associado a um pensamento alegre, contribuiu para mudan\u00e7a do padr\u00e3o inicial e diminui\u00e7\u00e3o das rugas periorbit\u00e1rias est\u00e1ticas. A cliente foi orientada a sorrir com contra\u00e7\u00e3o do m\u00fasculo ris\u00f3rio em dire\u00e7\u00e3o \u00e0s orelhas, mantendo os olhos bem abertos, com contra\u00e7\u00e3o do m\u00fasculo levantador da p\u00e1lpebra superior.O posicionamento e n\u00famero de eletrodos utilizados no treinamento pode variar de acordo com os objetivos terap\u00eauticos. Assim, eletrodos podem ser posicionados apenas sobre os m\u00fasculos supra-hioideos, durante o treinamento degluti\u00e7\u00e3ofeedback visual foi tamb\u00e9m relatado em outro estudo, em que participaram sujeitos saud\u00e1veis e disf\u00e1gicos.Segundo a cliente, a visualiza\u00e7\u00e3o na tela do computador, de uma imagem correspondente a uma contra\u00e7\u00e3o muscular, favoreceu a conscientiza\u00e7\u00e3o, o controle e o aprendizado de movimentos necess\u00e1rios para a realiza\u00e7\u00e3o dos padr\u00f5es adequados de mastiga\u00e7\u00e3o, degluti\u00e7\u00e3o e movimenta\u00e7\u00e3o dos m\u00fasculos faciais, durante as sess\u00f5es e a fixa\u00e7\u00e3o destes padr\u00f5es em sua resid\u00eancia. O impacto positivo proporcionado pelo Ap\u00f3s nove sess\u00f5es realizadas semanalmente, foi poss\u00edvel constatar mudan\u00e7as est\u00e9ticas e funcionais, resultando em movimenta\u00e7\u00e3o mais harm\u00f4nica dos m\u00fasculos faciais. Constatou-se diminui\u00e7\u00e3o dos valores atribu\u00eddos \u00e0 degluti\u00e7\u00e3o e aos sinais de envelhecimento facial. Observou-se redu\u00e7\u00e3o na contra\u00e7\u00e3o dos m\u00fasculos orbicular da boca e mentual, na degluti\u00e7\u00e3o, atenua\u00e7\u00e3o dos sulcos nasolabial e labiomentoniano e das rugas periorbit\u00e1rias est\u00e1ticas. A conscientiza\u00e7\u00e3o e propriocep\u00e7\u00e3o da posi\u00e7\u00e3o e contra\u00e7\u00e3o da l\u00edngua na degluti\u00e7\u00e3o e da contra\u00e7\u00e3o dos m\u00fasculos m\u00edmicos no sorriso e na fala, contribu\u00edram para diminuir a contra\u00e7\u00e3o dos m\u00fasculos periorais e atenuar os sulcos nasolabial e labiomentoniano.biofeedback eletromiogr\u00e1fico potencializou o aprendizado de padr\u00f5es orofaciais mais adequados. Por\u00e9m, estudos futuros com maior n\u00famero de sujeitos e grupo controle dever\u00e3o ser realizados, uma vez que at\u00e9 o presente momento n\u00e3o foram encontrados estudos que comprovem diferen\u00e7as entre os desfechos finais de interven\u00e7\u00f5es realizadas com e sem a associa\u00e7\u00e3o deste recurso terap\u00eautico.Os resultados apresentados no presente estudo sugerem que o biofeedback eletromiogr\u00e1fico na interven\u00e7\u00e3o fonoaudiol\u00f3gica direcionada \u00e0 atenua\u00e7\u00e3o dos sinais de envelhecimento facial. Constatou-se efeito adjuvante do biofeedback eletromiogr\u00e1fico no aprendizado dos padr\u00f5es miofuncionais orofaciais treinados, melhorias est\u00e9ticas e funcionais, ap\u00f3s a realiza\u00e7\u00e3o de nove sess\u00f5es de terapia fonoaudiol\u00f3gica, havendo consenso que este recurso t\u00e9cnico representa uma modalidade coadjuvante promissora no processo terap\u00eautico.No presente estudo foi descrita a utiliza\u00e7\u00e3o do"}
+{"text": "Family Health Scale  para a l\u00edngua portuguesa brasileira e analisar evid\u00eanciasde validade psicom\u00e9tricas dessa escala. Os 32 itens sobre a sa\u00fade familiar foramadaptados transculturalmente. Para a mensura\u00e7\u00e3o das evid\u00eancias de validade doconte\u00fado, utilizou-se o c\u00e1lculo do \u00edndice de validade de conte\u00fado dascaracter\u00edsticas sem\u00e2ntica, idiom\u00e1tica, cultural e conceitual de cada item e daescala. Um pr\u00e9-teste para identifica\u00e7\u00e3o de evid\u00eancia de validade foi realizadocom 40 fam\u00edlias. Em outro momento, a aplica\u00e7\u00e3o do instrumento foi executada com354 fam\u00edlias, em uma cidade no Nordeste do Brasil. O \u00edndice de concord\u00e2nciaentre os ju\u00edzes variou de 0,84, para os itens da escala, a 0,98, para a escalatotal, conforme o coeficiente de Kendall. As evid\u00eancias de validadepsicom\u00e9tricas mostram-se adequadas, conforme alfa de Cronbach. A maior parte dasfam\u00edlias teve um grau de sa\u00fade moderado, conforme aplica\u00e7\u00e3o da escala. Assim, aFamily Health Scale, vers\u00e3o brasileira, apresentouequival\u00eancia conceitual, sem\u00e2ntica, cultural e operacional em rela\u00e7\u00e3o aos itensoriginais e propriedades psicom\u00e9tricas satisfat\u00f3rias para a aplica\u00e7\u00e3odirecionada \u00e0 popula\u00e7\u00e3o brasileira, atestando efic\u00e1cia e seguran\u00e7a de suautiliza\u00e7\u00e3o. Os objetivos deste estudo foram realizar a tradu\u00e7\u00e3o e adapta\u00e7\u00e3o transcultural da A ado\u00e7\u00e3o de uma abordagem proativa na promo\u00e7\u00e3o da sa\u00fade e preven\u00e7\u00e3o de doen\u00e7as eagravos \u00e9 necess\u00e1ria devido, principalmente, ao aumento global da preval\u00eancia dedoen\u00e7as cr\u00f4nicas n\u00e3o transmiss\u00edveis ,A fam\u00edlia pode favorecer, por exemplo, um melhor comportamento de sa\u00fade, a ades\u00e3o aotratamento, o letramento funcional em sa\u00fade, o conforto e o cuidado, dispensadosdurante a aten\u00e7\u00e3o \u00e0 sa\u00fade nos cuidados prim\u00e1rios ,,Ainda que haja uma ampla gama de instrumentos que visam identificar necessidades decuidado \u00e0 pessoa e a suas fam\u00edlias na aten\u00e7\u00e3o prim\u00e1ria \u00e0 sa\u00fade (APS) Family Health Scale, em tradu\u00e7\u00e3o livre, em conjunto compesquisadores da Universidade Brigham Young , Universidade deMinnesota  e Universidade de Buffalo Com base nisso, em 2020, foi criada a Family Health Scale para o Brasil; e (2) analisarevid\u00eancias de validade psicom\u00e9tricas da Family Health Scale (vers\u00e3obrasileira) com fam\u00edlias acompanhadas pela ESF.Assim, os objetivos deste estudo foram: (1) realizar a tradu\u00e7\u00e3o e adapta\u00e7\u00e3otranscultural da Family HealthScale para o contexto brasileiro.Este \u00e9 um estudo metodol\u00f3gico, com delineamento transversal e abordagemquantitativa, de tradu\u00e7\u00e3o e adapta\u00e7\u00e3o transcultural da Family Health ScaleA As op\u00e7\u00f5es de resposta em todos os itens est\u00e3o em uma escala Likert de 5 pontos,sendo que as respostas pontuadas de 1 a 3 recebem 0 ponto e as assinaladas em 4ou 5 recebem 1 ponto. De modo geral, os itens a serem assinalados na escalavariam de \u201cdiscordo totalmente\u201d a \u201cconcordo totalmente\u201d. Entretanto, os itens 1,5, 20-24, 29-32 da escala longa pontuam de forma reversa, ou seja, itensmarcados de 1 a 3 passam a valer 1 ponto; e aqueles selecionados em 4 ou 5, 0ponto. Da mesma forma, os itens 23, 31 e 32 do question\u00e1rio curto sofrem talrevers\u00e3o. Ap\u00f3s o compilado de respostas assinaladas, chega-se \u00e0 classifica\u00e7\u00e3o dasa\u00fade da fam\u00edlia, adotando como base a escala curta: sa\u00fade ruim = 0-5 pontos;sa\u00fade familiar moderada = 6-8 pontos; sa\u00fade familiar excelente = 9-10 pontosEm nosso estudo, seguimos o percurso metodol\u00f3gico composto pelas seguintesetapas: (a) preparo; (b) tradu\u00e7\u00e3o; (c) concilia\u00e7\u00e3o das tradu\u00e7\u00f5es; (d)retrotradu\u00e7\u00e3o; (e) revis\u00e3o; (f) pr\u00e9-teste; e (g) valida\u00e7\u00e3o Durante a etapa de preparo do estudo, a verifica\u00e7\u00e3o da exist\u00eancia de outrosinstrumentos validados no Brasil que aferiram os mesmos desfechos foi realizadapor buscas nas bases e bibliotecas virtuais PubMed, SciELO, BIREME e naliteratura cinza. Em seguida, foi realizada a equival\u00eancia conceitual entre aescala e os valores culturais da popula\u00e7\u00e3o-alvo. Ademais, foi solicitadaautoriza\u00e7\u00e3o para adapta\u00e7\u00e3o transcultural \u00e0 equipe que construiu o instrumentooriginal. Por fim, foram avaliados o cronograma e os custos envolvidos paracumprir essas etapas.A etapa de tradu\u00e7\u00e3o do instrumento original para o portugu\u00eas brasileiro foirealizada por dois tradutores nativos do Brasil, fluentes na l\u00edngua inglesa eresidentes no pa\u00eds. Um dos tradutores era leigo na \u00e1rea e construiu a tradu\u00e7\u00e3oT1. J\u00e1 a tradu\u00e7\u00e3o T2 foi desenvolvida por outro tradutor, com doutorado emEnfermagem e especializa\u00e7\u00e3o na \u00e1rea. Na sequ\u00eancia, foram realizadas compara\u00e7\u00f5esentre elas, eliminando discrep\u00e2ncias e assegurando uma sem\u00e2ntica adequada eclara para a compreens\u00e3o do instrumento.,Ap\u00f3s isso, foi feita a retrotradu\u00e7\u00e3o, tamb\u00e9m chamada de vers\u00e3o T12. Para tal, umtradutor estrangeiro, que tinha a l\u00edngua inglesa como nativa e era fluente emportugu\u00eas brasileiro, sem conhecimento do assunto, desenvolveu essa etapa. Emseguida, duas revis\u00f5es foram realizadas. Primeiro, pelos autores da vers\u00e3ooriginal do instrumento, que fizeram uma compara\u00e7\u00e3o da T12 com a vers\u00e3ooriginal, constatando a equival\u00eancia e a qualidade. Em seguida, foi constitu\u00eddoum comit\u00ea de ju\u00edzes multidisciplinar. Para selecionar a quantidade ideal deju\u00edzes, a literatura foi consultada Por fim, a etapa de pr\u00e9-teste consistiu na aplica\u00e7\u00e3o da escala traduzida e davers\u00e3o adaptada ao Brasil, a fim de verificar se esta conseguiu extrair dorespondente o quadro de sa\u00fade da sua fam\u00edlia. Para tanto, essa fase do estudofoi realizada em uma unidade b\u00e1sica de sa\u00fade (UBS), localizada na cidade deFortaleza (Cear\u00e1).Para a sele\u00e7\u00e3o da amostra, foi utilizada uma ferramenta virtual, que sorteounomes de sete ruas adscritas pela UBS. Ap\u00f3s isso, os pesquisadores decidiram,por conveni\u00eancia, que apenas uma numera\u00e7\u00e3o de cada rua seria contemplada. Nototal, 40 resid\u00eancias foram elencadas. No entanto, para participar do estudo, aspessoas deveriam: ter idade entre 18 e 69 anos, com pelo menos cinco anos deestudo e gozando de boa sa\u00fade mental. Foram exclu\u00eddos da pesquisa aqueles quehabitualmente n\u00e3o atendem \u00e0s visitas dos agentes comunit\u00e1rios de sa\u00fade, pessoasque estavam em \u00e1reas em situa\u00e7\u00e3o de perigo e aqueles que n\u00e3o estavam maisresidindo no endere\u00e7o selecionado. Quando isso acontecia, uma outra casa eralistada. Em seguida, deu-se in\u00edcio \u00e0 coleta de dados.https://products.office.com/). Para a mensura\u00e7\u00e3o das evid\u00eanciasde validade do conte\u00fado, optamos pelo c\u00e1lculo do \u00edndice de validade de conte\u00fado(IVC) das caracter\u00edsticas sem\u00e2ntica, idiom\u00e1tica, cultural e conceitual de cadaitem (I-IVC) e da escala (E-IVC). Consideramos o valor m\u00ednimo de 0,8 para oI-IVC de itens e E-IVC na avalia\u00e7\u00e3o geral do instrumento ,Com base nos instrumentos aplicados junto aos ju\u00edzes  e \u00e0s fam\u00edlias (vers\u00e3o traduzida e adaptada), elaboramos um banco dedados com dupla entrada no Excel (https://www.ibm.com/), comintervalo de 95% de confian\u00e7a (IC95%).Para avaliar o grau de concord\u00e2ncia entre os ju\u00edzes, empregamos o coeficiente deconcord\u00e2ncia de Kendall, uma vez que \u00e9 capaz de medir os graus de associa\u00e7\u00e3oentre especialistas na classifica\u00e7\u00e3o de vari\u00e1veis qualitativas ordinais com \u2265 3n\u00edveis. Ademais, avaliamos o resultado desse coeficiente, sendo: < 0,2(concord\u00e2ncia ruim); 0,21-0,4 (concord\u00e2ncia regular); 0,41-0,6 (concord\u00e2nciamoderada); 0,61-0,8 (concord\u00e2ncia boa); 0,81-1,0 (concord\u00e2ncia muito boa) Family HealthScale, um enfermeiro da ESF e mais quatro agentes comunit\u00e1rios desa\u00fade realizaram visitas domiciliares a 354 fam\u00edlias da cidade de Fortaleza. Aamostra foi calculada conforme o n\u00famero de itens da escala, multiplicado por1.010. A sele\u00e7\u00e3o das fam\u00edlias aconteceu por meio de um sorteio, realizado poruma ferramenta virtual. Nomes de ruas adscritos pela UBS em que trabalhavam oenfermeiro e os agentes comunit\u00e1rios de sa\u00fade foram utilizados. Nessa ocasi\u00e3o,os pesquisadores aplicaram as vers\u00f5es curta e longa da escala, anteriormentesubmetida ao pr\u00e9-teste com 40 fam\u00edlias. Para participar do estudo, as pessoasdeveriam: ter idade entre 18 e 69 anos, com pelo menos cinco anos de estudo egozando de boa sa\u00fade mental.Para mensura\u00e7\u00e3o das evid\u00eancias de validade da Analisamos a avalia\u00e7\u00e3o da estrutura interna e a aplicabilidade do instrumento pormeio da an\u00e1lise fatorial explorat\u00f3ria (AFE) e da an\u00e1lise fatorial confirmat\u00f3ria(AFC), ap\u00f3s a avalia\u00e7\u00e3o dos especialistas. A verifica\u00e7\u00e3o da adequa\u00e7\u00e3o da amostra\u00e0 an\u00e1lise fatorial foi avaliada pelo teste de Kaiser-Meyer-Olkin (KMO),adotando-se valor maior que 0,60 como crit\u00e9rio de adequa\u00e7\u00e3o de ajuste do modeloe teste de esfericidade de Bartlett .Promin robusta para extra\u00e7\u00e3o dosfatores. A confiabilidade foi avaliada pelo coeficiente alfa(\u03b1) de Cronbach, correla\u00e7\u00e3o item-total e o estimador \u00f4mega (\u03c9) de McDonald. Ossoftwares utilizados na an\u00e1lise foram o JASP 0.17 (https://jasp-stats.org/previous-versions/) e o JAMOVI vers\u00e3o 1.6(https://www.jamovi.org/download.html).Utilizou-se m\u00ednimo quadrado robusto com peso diagonal (RDWLS) e a correla\u00e7\u00e3opolic\u00f3rica, com rota\u00e7\u00e3o O trabalho foi aprovado pelo Comit\u00ea de \u00c9tica e Pesquisa com Seres Humanos daUniversidade Federal do Cear\u00e1 (parecer n\u00ba 5.418.800/2022).O processo de tradu\u00e7\u00e3o (T1 e T2) gerou resultados muito pr\u00f3ximos, n\u00e3ocomprometendo as equival\u00eancias relevantes da escala. Ap\u00f3s isso, no processo deretrotradu\u00e7\u00e3o, verificamos que a vers\u00e3o traduzida para o ingl\u00eas se manteve muitofiel \u00e0 vers\u00e3o original do instrumento, sendo esta revisada e aprovada pelospr\u00f3prios criadores da escala original. Por sua vez, na an\u00e1lise de conte\u00fado dositens , realizadapor ju\u00edzes, identificou-se que apenas em sete deles n\u00e3o houve resultado igual a1 . J\u00e1 o c\u00e1lculo de E-IVC verificado foi de0,98. Assim, com base na an\u00e1lise dos ju\u00edzes, observamos que o grau deconcord\u00e2ncia entre eles foi elevado .FamilyHealth Scale foram reorganizados e agrupados em quatro fatores: (1)processo de sa\u00fade social e emocional da fam\u00edlia - itens 1 a 13 , sendo que os itens 18 e 19 foram trocados pelos itens 12e 13; (2) estilo de vida saud\u00e1vel da fam\u00edlia - itens 14 a 19 (anteriormente 12 a17), sendo que os itens 12 e 13 da vers\u00e3o anterior passaram a ser 18 e 19; (3)apoio social externo \u00e0 fam\u00edlia - itens 20 a 23 (anteriormente 25 a 28); (4)recursos de sa\u00fade da fam\u00edlia - itens 24 a 32 (anteriormente 20 a 24 e 29 a 32).As mudan\u00e7as foram realizadas sem que ocorresse perda de equival\u00eancia oualtera\u00e7\u00e3o na pontua\u00e7\u00e3o preestabelecida.Ap\u00f3s a verifica\u00e7\u00e3o das sugest\u00f5es dos especialistas, os itens da A vers\u00e3o traduzida e adaptada ao cen\u00e1rio da ESF foi aplicada junto a 40 fam\u00edliasbrasileiras na cidade de Fortaleza, na etapa do pr\u00e9-teste. Durante a entrevistapara o teste do instrumento, o representante familiar era majoritariamente dog\u00eanero feminino , com m\u00e9dia de idade de 45 anos  e Ensino M\u00e9dio completo (60%). As fam\u00edlias eram compostas, em boa parte,por quatro pessoas .Family Health Scale (vers\u00e3o curta), 82,5% (n =33) das fam\u00edlias tiveram sa\u00fade familiar \u201cmoderada\u201d, seguida de \u201cruim\u201d  e \u201cexcelente\u201d . J\u00e1 na vers\u00e3o estendida, 52,5% (n = 21), 42,5% (n= 17) e 5% (n = 2) das fam\u00edlias foram classificadas com sa\u00fade familiar\u201cmoderada\u201d, \u201cexcelente\u201d e \u201cruim\u201d, respectivamente. A apresenta\u00e7\u00e3o das vers\u00f5es emingl\u00eas e tradu\u00e7\u00f5es da Family Health Scale podem ser conferidasno Material Suplementar .Na aplica\u00e7\u00e3o da Um total de 354 pessoas comp\u00f4s a amostra e respondeu \u00e0 vers\u00e3o final da escala. Osparticipantes foram, predominantemente, mulheres, de cor de pele parda e nafaixa et\u00e1ria de 41-65 anos de idade, com m\u00e9dia de idade de 44,8 anos (\u00b1 15.3).Em 50,6% das fam\u00edlias entrevistadas, os lares eram coabitados por outros membrosda fam\u00edlia. O percentual de pessoas casadas ou em uni\u00e3o est\u00e1vel foi quase odobro do percentual de solteiros. Nessas fam\u00edlias, predominou uma situa\u00e7\u00e3oeconomicamente baixa. Em mais da metade das fam\u00edlias entrevistadas ,observou-se que a renda familiar mensal para custear as despesas da casa vem deapenas uma pessoa, que geralmente \u00e9 do g\u00eanero masculino  .Com base no teste KMO, um pr\u00e9-requisito para verifica\u00e7\u00e3o de amostragem adequada,obteve-se valor de 0,808, evidenciando que n\u00e3o \u00e9 necess\u00e1rio retirar nenhumaquest\u00e3o da vers\u00e3o final do instrumento. Ademais, o teste de esfericidade deBartlett  evidenciou que h\u00e1 rela\u00e7\u00e3o entre as quest\u00f5es. O modeloapresentou \u00edndices adequados, n\u00e3o necessitando ajustes em rela\u00e7\u00e3o \u00e0svari\u00e1veis.Com a observa\u00e7\u00e3o do diagrama fatorial, \u00e9 poss\u00edvel observar as rela\u00e7\u00f5es entre osfatores: fator I - processo de sa\u00fade social e emocional da fam\u00edlia; fator II -estilo de vida saud\u00e1vel da fam\u00edlia; fator III - apoio social externo \u00e0 fam\u00edlia;e fator IV - recursos de sa\u00fade da fam\u00edlia. Nesse caso, \u00e9 importante observar queexiste rela\u00e7\u00e3o relevante entre os fatores I e III; II e IV; e entre os fatores Ie IV de forma mais abrangente. Observamos que houve uma rela\u00e7\u00e3o sistem\u00e1ticaentre os fatores da escala, em alguma medida. Entre os fatores I e II, h\u00e1 umacorrela\u00e7\u00e3o positiva moderada. Por outro lado, os fatores I e IV apresentam umacorrela\u00e7\u00e3o moderada negativa .Os valores identificados pela confiabilidade interna das quest\u00f5es do instrumentoforam satisfat\u00f3rios, conforme demonstrado na Observamos uma forte covari\u00e2ncia negativa entre as vari\u00e1veis fatoriais I e II,enquanto no comparativo dos fatores II e III, III e IV a rela\u00e7\u00e3o foi positiva esignificativa. As outras estimativas de covari\u00e2ncia fatorial seguem um padr\u00e3osemelhante .Family Health Scale,um instrumento criado originalmente para avaliar a sa\u00fade das fam\u00edliasestadunidenses. Como parte das etapas de adapta\u00e7\u00e3o transcultural e mensura\u00e7\u00e3o dasevid\u00eancias de validade, foi realizado um pr\u00e9-teste, que contou com a participa\u00e7\u00e3o de40 fam\u00edlias acompanhadas pela ESF de uma UBS, corroborando especialistas ,Este estudo traduziu, adaptou culturalmente e mensurou as evid\u00eancias de validadepsicom\u00e9tricas para o portugu\u00eas brasileiro da No que se refere aos fatores encontrados na escala, identificamos que h\u00e1 rela\u00e7\u00f5esentre eles . Esses fatoresapontam para contribui\u00e7\u00f5es substanciais para a sa\u00fade da fam\u00edlia e, consequentemente,para os servi\u00e7os da ESF no Brasil.,Por exemplo, no fator I , podemosavaliar as condi\u00e7\u00f5es de comunica\u00e7\u00e3o, seguran\u00e7a emocional, conex\u00e3o interpessoal,satisfa\u00e7\u00e3o e enfrentamento no contexto familiar. A literatura mostra que oenfrentamento dos processos de sa\u00fade-doen\u00e7a, apoiado pelos membros da fam\u00edlia,minimiza desfechos negativos, como sintomas depressivos, e cria ambientes para odesenvolvimento de compet\u00eancias voltadas \u00e0 resolu\u00e7\u00e3o de problemas ,,Em nosso estudo, os itens desse fator tiveram associa\u00e7\u00e3o com aqueles do fator III, que explora as caracter\u00edsticas externas de apoiopessoal e financeiro, e do fator IV (recursos de sa\u00fade da fam\u00edlia), em que s\u00e3oavaliadas as condi\u00e7\u00f5es internas e externas de sa\u00fade, incluindo padr\u00f5es individuaisde sa\u00fade, preocupa\u00e7\u00f5es familiares, recursos socioecon\u00f4micos e efic\u00e1cia na busca porajuda. O apoio social pode ser um pilar para promover a sa\u00fade dos membros de umafam\u00edlia, ou da pr\u00f3pria fam\u00edlia como um todo, em distintos est\u00e1gios da vida,minorando condi\u00e7\u00f5es de adoecimento, como as ligadas \u00e0 sa\u00fade mental ,,Sobre o acesso aos recursos de sa\u00fade e apoios externos, evid\u00eancias apontam que baixosrecursos familiares aumentam as chances de problemas mentais e estresse Family Health Scale foi observado entre osfatores II (estilo de vida saud\u00e1vel da fam\u00edlia) e IV. O ambiente familiar tem umimpacto significativo no desenvolvimento do comportamento alimentar e na pr\u00e1tica deatividade f\u00edsica em crian\u00e7as Family Health Scale mostrou que fam\u00edliass\u00e3o saud\u00e1veis em v\u00e1rios contextos, n\u00e3o dependendo, exclusivamente, de umstatus socioecon\u00f4mico alto. No entanto, a renda familiar maisalta esteve associada \u00e0 melhor sa\u00fade familiar, provavelmente porque aumenta o acessoaos recursos e diminui a exposi\u00e7\u00e3o a outros determinantes arrolados Outro elo dos itens da A maior preocupa\u00e7\u00e3o com comportamentos e o apoio a escolhas promissoras t\u00eam fortevincula\u00e7\u00e3o com as rela\u00e7\u00f5es familiares, o est\u00edmulo entre os membros de uma unidadefamiliar e os recursos e as condi\u00e7\u00f5es individuais. Logo, utilizar um instrumentopara melhor compreender essa din\u00e2mica contribui para a melhor tomada de decis\u00e3o emsa\u00fade no que diz respeito a interven\u00e7\u00f5es mais precoces e efetivas para cada membroda fam\u00edlia, focando o trabalho multi e interdisciplinar em sa\u00fade.Family Health Behavior Scale, Escala de Vulnerabilidade de Coelho eSavassiEscala de Performance Paliativacoping, sa\u00fade mental, suporte emocional eecon\u00f4mico, comportamentos saud\u00e1veis e cuidados adequados, ou seja, temastransversais, aqui explorados de modo breve.Embora existam no Brasil algumas escalas e question\u00e1rios que facilitam a elabora\u00e7\u00e3ode diagn\u00f3sticos no contexto familiar, orientando o desenho de interven\u00e7\u00f5es, taiscomo Family Health Scale,mostrando que ela \u00e9 precisa, reprodut\u00edvel e consistente, o que foi confirmado pelosvalores de coeficiente \u03b1 de Cronbach, correla\u00e7\u00e3o item-total e coeficiente \u03c9 deMcDonald. Ademais, o instrumento demonstrou evid\u00eancias de validade convergente.Conforme avaliado por meio do coeficiente de Kendall, houve uma concord\u00e2ncia muitoboa  entre as avalia\u00e7\u00f5es dos ju\u00edzes, al\u00e9m do IVC predominante de 1 e um E-IVCde 0,98. Isso representa uma significativa concord\u00e2ncia entre os especialistas emrela\u00e7\u00e3o aos itens e ao instrumento. Em sua vers\u00e3o original, as duas vers\u00f5es daescala (curta e longa) demonstraram boa validade e confiabilidade para avaliar asa\u00fade da fam\u00edlia em servi\u00e7os de cuidados prim\u00e1rios Family HealthScale fora do cen\u00e1rio estadunidense ocorreu, recentemente, na ChinaO \u00fanico estudo que observou evid\u00eancias de validade da Family Health Scale foi invariante em rela\u00e7\u00e3oa sexo, idade e estado civil A maioria dos itens da Family Health Scale mostra-se como um recurso adequado ev\u00e1lido para que pesquisadores e profissionais da sa\u00fade consigam mensurar a sa\u00fade dafam\u00edlia, suas tend\u00eancias e interse\u00e7\u00f5es individuais, familiares e comunit\u00e1rias, epossam, assim, medir fatores interdisciplinares essenciais para captar a din\u00e2mica deuma fam\u00edlia. Ademais, essa \u00e9 uma escala que pode ser autoaplic\u00e1vel, ainda que suainterpreta\u00e7\u00e3o seja \u00fatil para profissionais que desejem complementar suas a\u00e7\u00f5es emsa\u00fade.Portanto, a Uma limita\u00e7\u00e3o deste estudo \u00e9 a necessidade da realiza\u00e7\u00e3o de outras investiga\u00e7\u00f5es paraobten\u00e7\u00e3o de mais evid\u00eancias de validade e confiabilidade da escala, usando outrasamostras representativas, considerando as diferentes regi\u00f5es do Brasil. Outrossim,sugere-se a realiza\u00e7\u00e3o de pesquisas longitudinais, as quais seriam \u00fateis paraavalia\u00e7\u00e3o do question\u00e1rio quanto \u00e0 sensibilidade \u00e0 mudan\u00e7a.Family Health Scale, vers\u00e3o para l\u00edngua portuguesa do Brasil,apresenta equival\u00eancia conceitual, sem\u00e2ntica, cultural e operacional em rela\u00e7\u00e3o aositens originais, al\u00e9m de propriedades psicom\u00e9tricas satisfat\u00f3rias para a aplica\u00e7\u00e3odirecionada \u00e0 popula\u00e7\u00e3o brasileira.A"}
+{"text": "Corpos inscritos: vacina e biopoder: Londres e Rio de Janeiro,1840-1904, da historiadora Myriam Bahia O livro Assim, embora cada cap\u00edtulo possua a sua pr\u00f3pria \u201cindividualidade\u201d, o conjunto da obravai, progressivamente, complicando as certezas oriundas do senso comum: as diferen\u00e7asentre os que s\u00e3o favor\u00e1veis e contr\u00e1rios \u00e0 vacina\u00e7\u00e3o ganham complexidade ao serinvestigadas \u00e0 luz de seus contextos culturais, dos sentidos adquiridos pela no\u00e7\u00e3o deprogresso e pelos interesses que motivaram cada nova descoberta cient\u00edfica e cadacr\u00edtica publicada pela imprensa. Rio de Janeiro e Londres ocupam o centro das aten\u00e7\u00f5esda autora, que desenvolveu uma minuciosa pesquisa em arquivos nacionais einternacionais, contribuindo para esclarecer algumas das tentativas de construir cidadessalubres e popula\u00e7\u00f5es imunizadas. A compara\u00e7\u00e3o entre cidades e pa\u00edses revela que odebate sobre o advento da t\u00e9cnica da vacina\u00e7\u00e3o foi bem mais restrito no Brasil do que naInglaterra. As fontes sobre os antivacinistas, mostra a autora, abundam entre osingleses e s\u00e3o escassas entre os brasileiros. Os adeptos da antivacina v\u00e3o sendo, a cadap\u00e1gina, dissecados em seus significados sociais e questionados em suas convic\u00e7\u00f5es.A autora conhece as armadilhas da pesquisa junto a diferentes acervos e o quanto ainvestiga\u00e7\u00e3o hist\u00f3rica exige o conhecimento apurado das fontes analisadas e daetimologia de cada conceito. Por isso, ela perscruta os sentidos dos termos cient\u00edficose populares, al\u00e9m de dedicar uma parte importante do livro \u00e0 an\u00e1lise da caricatura e dohumor, justamente quando a forma\u00e7\u00e3o da opini\u00e3o p\u00fablica era mobilizada tanto a favor comocontra a vacina antivari\u00f3lica.O texto n\u00e3o apresenta uma compara\u00e7\u00e3o entre Inglaterra e Brasil com todos os elementosdistintos e similares em rela\u00e7\u00e3o ao tema analisado, mas oferece ao leitor um panoramageral dos significados e da hist\u00f3ria da vacina\u00e7\u00e3o dentro do qual a caricatura possuilugar de destaque. Nas imprensas estrangeira e brasileira, a caricatura expressou asdisputas entre charlatanismo e cientificismo durante o processo de moderniza\u00e7\u00e3o damedicina, assim como algumas especificidades dos ve\u00edculos de comunica\u00e7\u00e3o e dosinteresses nacionais.Ao longo dos cap\u00edtulos, os discursos m\u00e9dicos, as refer\u00eancias \u00e0 biologia, ao urbanismo euma inspiradora an\u00e1lise da imprensa ilustrada concedem ao livro o poder de transportar oleitor para per\u00edodos epid\u00eamicos distintos: primeiramente, o tempo da pr\u00e1ticaantivari\u00f3lica lan\u00e7ada por Jenner, mais tarde, a intensifica\u00e7\u00e3o dos estudos sobre a\u201cverdadeira\u201d e a \u201cfalsa\u201d vacina \u2013 ou \u201cvacina bastarda\u201d \u2013 e, ainda, o movimentoantivacinista das capitais portu\u00e1rias de Londres e Rio de Janeiro, entre 1870 e 1904. Oporto \u2013 porta e filtro \u2013 funcionando como \u201cheterotopia do s\u00e9culo XIX\u201d  \u00e9 uma daNada mais atual e necess\u00e1rio, portanto, do que abordar o tema da vacina a partir dasdisputas que caracterizaram a hist\u00f3ria contempor\u00e2nea da imuniza\u00e7\u00e3o dos corpos e astentativas para evitar os entraves que as epidemias colocam aos fluxos comerciais e aodesenvolvimento capitalista. Afinal, n\u00e3o seria justamente o problema do mercado e dacircula\u00e7\u00e3o global de bens e pessoas um dos grandes desafios que o advento da atualpandemia provocada pelo novo coronav\u00edrus teria vindo atualizar?"}
+{"text": "Adicionalmente, pouco tem sido executado para o melhor controle e conhecimento da utiliza\u00e7\u00e3o dos recursos destinados \u00e0 sa\u00fade, impactando em barreiras para a ado\u00e7\u00e3o de terapias baseadas em evid\u00eancias. A mortalidade hospitalar por doen\u00e7as cardiovasculares no Brasil \u00e9 ainda alta, e programas robustos de melhoria da qualidade s\u00e3o desej\u00e1veis e necess\u00e1rios.O sistema de sa\u00fade p\u00fablico no Brasil se ocupa da alta demanda de atendimento, atuando na preven\u00e7\u00e3o prim\u00e1ria, secund\u00e1ria e terci\u00e1ria. A despeito de in\u00fameros esfor\u00e7os e iniciativas e considerando a melhoria destes atendimentos, os resultados ainda est\u00e3o aqu\u00e9m das necessidades, carecendo de implementa\u00e7\u00e3o de novas frentes de a\u00e7\u00e3o.Dois ensaios randomizados realizados no Brasil (BRIDGE-ACS e IMPACT-AF) para testar interven\u00e7\u00f5es multifacetadas para melhorar a ades\u00e3o \u00e0s recomenda\u00e7\u00f5es de diretrizes mostraram que a implementa\u00e7\u00e3o de interven\u00e7\u00f5es de melhoria da qualidade (MQ) \u00e9 vi\u00e1vel e pode ser eficaz. Este importante programa descreveu com primor as caracter\u00edsticas populacionais, o tratamento hospitalar e os desfechos de pacientes admitidos em hospitais p\u00fablicos no Brasil, avaliando a efetividade dos programas de qualidade assistencial, baseados em diretrizes e recomenda\u00e7\u00f5es. Desta forma, com importante contribui\u00e7\u00e3o, neste artigo podemos observar os resultados deste projeto, vendo a melhoria nas taxas destes desfechos cardiovasculares no Brasil. Um total de 12.167 pacientes com diagn\u00f3stico de SCA, IC, ou FA foram inclu\u00eddos, provenientes de 19 institui\u00e7\u00f5es de diferentes regi\u00f5es brasileiras.Dentro deste cen\u00e1rio, destacamos o Programa Boas Pr\u00e1ticas em Cardiologia (BPC no Brasil), que visa o incremento de a\u00e7\u00f5es no cuidado na s\u00edndrome coron\u00e1ria aguda (SCA), na insufici\u00eancia card\u00edaca (IC), e na fibrila\u00e7\u00e3o atrial (FA).American College of Cardiology /American Heart Association. Medidas de desempenho para cada condi\u00e7\u00e3o cr\u00edtica foram analisadas para cada centro antes e ap\u00f3s a participa\u00e7\u00e3o no programa BPC. Como resultados, observou-se uma taxa de prescri\u00e7\u00e3o de AAS  de 96,2%, que \u00e9 compar\u00e1vel a outros pa\u00edses, como o Reino Unido  e a Su\u00e9cia . Ainda, a taxa de uso de betabloqueadores por ocasi\u00e3o da alta hospitalar foi 88,6%, tamb\u00e9m compar\u00e1vel \u00e0s taxas dos pa\u00edses supracitados.As medidas de desempenho foram delineadas para avaliar a qualidade do tratamento de pacientes com SCA, IC e FA. As medidas foram desenvolvidas de acordo com as diretrizes da Sociedade Brasileira de Cardiologia e doUm aspecto de fundamental import\u00e2ncia refere-se aos resultados obtidos na qualidade de vida dos pacientes com IC, uma vez que esse \u00e9 um preditor de desfechos cl\u00ednicos adversos, tais como mortalidade em curto prazo e reinterna\u00e7\u00e3o precoce desses pacientes. No presente estudo, foi poss\u00edvel observar que interven\u00e7\u00f5es farmacol\u00f3gicas e n\u00e3o farmacol\u00f3gicas melhoram a qualidade de vida em pacientes com IC ap\u00f3s seis meses da alta hospitalar.Entretanto, apesar da exist\u00eancia de tratamentos farmacol\u00f3gicos seguros e eficazes para a preven\u00e7\u00e3o do AVC entre pacientes com FA, apenas 40% a 60% dos pacientes estavam sob tratamento regular. Ainda, apenas dois ter\u00e7os dos pacientes com FA que tiveram um AVC estavam tomando ACO no momento do evento agudo.Assim, existe uma necessidade m\u00e9dica n\u00e3o atendida de estudos que desenvolvam interven\u00e7\u00f5es baseadas em evid\u00eancias, e que possam levar a um maior uso de ACO em pacientes com FA que correm risco de AVC.Um interessante estudo de interven\u00e7\u00e3o educativa multifacetada e multin\u00edvel, destinada a melhorar o uso de anticoagula\u00e7\u00e3o oral (ACO) em pacientes com FA e em risco de acidente vascular cerebral (AVC), resultou em aumento significativo na propor\u00e7\u00e3o de pacientes tratados, com potencial de melhorar a preven\u00e7\u00e3o do AVC.O ACCEPT, um estudo observacional prospectivo incluiu pacientes internados com diagn\u00f3stico de SCA em 47 hospitais brasileiros. Os pacientes foram seguidos por 1 ano e coletaram-se dados sobre prescri\u00e7\u00e3o m\u00e9dica e ocorr\u00eancia de eventos cardiovasculares maiores. A prescri\u00e7\u00e3o completa de terapias baseadas em evid\u00eancia na admiss\u00e3o hospitalar foi de apenas 62%, mostrando a necessidade de elabora\u00e7\u00e3o de estrat\u00e9gias para melhorar o uso de terapias espec\u00edficas, no sentido de minimizar os eventos cardiovasculares na popula\u00e7\u00e3o brasileira.O programa BPC determina e mensura as m\u00e9tricas de qualidade assistencial, pautado por diretrizes especializadas, aplic\u00e1veis no manejo de algumas doen\u00e7as cardiovasculares, em destaque para a FA, a IC e SCA. Additionally, little has been carried out to better control and understand the use of resources destined for health, impacting barriers to adopting evidence-based therapies. Hospital mortality from cardiovascular diseases in Brazil is still high, and robust quality improvement programs are desirable and necessary.The public health system in Brazil deals with the high demand for care, acting in primary, secondary, and tertiary prevention. Despite countless efforts and initiatives and considering the improvement of these services, the results are still below the needs, requiring the implementation of new fronts of action.Two randomized trials conducted in Brazil (BRIDGE-ACS and IMPACT-AF) to test multifaceted interventions to improve adherence to guideline recommendations showed that implementing quality improvement (QI) interventions is feasible and can be effective.This important program exquisitely described the population characteristics, hospital treatment, and outcomes of patients admitted to public hospitals in Brazil, evaluating the effectiveness of quality care programs based on guidelines and recommendations. Thus, with an important contribution in this article, we can observe the results of this project, seeing the improvement in the rates of these cardiovascular outcomes in Brazil. Twelve thousand one hundred sixty-seven patients diagnosed with ACS, HF, or AF were included from 19 institutions in different Brazilian regions.Within this scenario, we highlight the Good Practices in Cardiology Program (BPC in Brazil), which aims to increase actions in care for acute coronary syndrome (ACS), heart failure (HF), and atrial fibrillation (AF).Performance measures were designed to assess the quality of treatment for patients with ACS, HF, and AF. The measures were developed following the Sociedade Brasileira de Cardiologia and the American College of Cardiology/American Heart Association guidelines. Performance measures for each critical condition were analyzed for each center before and after participation in the BPC program. As a result, a prescription rate for ASA  of 96.2% was observed, which is comparable to other countries, such as the United Kingdom (98.1%) and Sweden (94.6%). Furthermore, the rate of beta-blocker use at the time of hospital discharge was 88.6%, also comparable to the rates in the countries mentioned above.An aspect of fundamental importance refers to the results obtained in the quality of life of patients with HF since this is a predictor of adverse clinical outcomes, such as short-term mortality and early readmission of these patients. In the present study, it was possible to observe that pharmacological and non-pharmacological interventions improve the quality of life in patients with HF six months after hospital discharge.However, despite the existence of safe and effective pharmacological treatments for stroke prevention among patients with AF, only 40% to 60% of patients were under regular treatment. Still, only two-thirds of patients with AF who had a stroke took OCs at the time of the acute event.Thus, there is an unmet medical need for studies that develop evidence-based interventions that could lead to greater use of OAC in patients with AF who are at risk of stroke.An interesting multifaceted, multilevel educational intervention study aimed at improving the use of oral anticoagulation (OAC) in patients with AF and at risk of stroke resulted in a significant increase in the proportion of patients treated, with the potential to improve stroke prevention.ACCEPT, a prospective observational study, included patients admitted with a diagnosis of ACS in 47 Brazilian hospitals. Patients were followed for 1 year, and data on medical prescriptions and the occurrence of major cardiovascular events were collected. The complete prescription of evidence-based therapies upon hospital admission was only 62%, showing the need to develop strategies to improve the use of specific therapies to minimize cardiovascular events in the Brazilian population.The BPC program determines and measures care quality metrics, guided by specialized guidelines, applicable in managing some cardiovascular diseases, especially AF, HF, and ACS."}
+{"text": "To translate and cross-culturally adapt the Noise Exposure Questionnaire (NEQ) and 1-Minute Noise Screen (NEQ-S) instruments to Brazilian Portuguese.Procedures widely known in health research were used in the translation and cross-cultural adaptation process, comprising the following steps: initial translation, synthesis of translations, back-translation, expert committee, pretest, and content and layout validation. Altogether, 60 workers participated in the pretest by answering the questionnaires and then evaluating them in terms of understandability, layout, clarity, and writing. Reliability was verified with Cohen's kappa test, and the internal consistency was analyzed with Cronbach\u2019s alpha coefficient.The translated and adapted versions of NEQ and NEQ-S were similar in terms of general and referential meanings. However, some modifications and adaptations were made to adapt them to the Brazilian reality. The kappa test indicated moderate agreement and Cronbach\u2019s alpha coefficient, substantial internal consistency.The translation and cross-cultural adaptation were carried out according to the methodology recommended in the national and international literature, performing the necessary equivalences to maintain the face and content validity with the original instrument. The availability of NEQ and NEQ-S in Brazilian Portuguese opens new fields of research to quantify yearly noise exposure more in-depth. In guinea pig studies, noise-exposure variables can be carefully controlled , ensuring precise estimates of the association between noise exposure and hearing loss. In human studies, dosimetry is the recommended technique in prospective assessments of these variables. However, retrospective estimates depend predominantly on self-reports of cumulative noise exposure, in which questionnaires are the indicated instruments to obtain such information,3.Studies increasingly address the knowledge about noise-related hearing loss, probably due to important research results involving guinea pigs. Moreover, NIHL is still the second most self-reported occupational disease, despite the regulations and interventions at the workplaces,6.Approximately 27.7 million people aged 20 to 69 years in the United States are estimated to live with noise-induced hearing loss (NIHL).The high prevalence of NIHL has been associated with increased industrialization, difficulties developing and implementing adequate public policies and preventive measures against noise, and difficulties related to information systems and data collection to generate consistent and comparable indicators.Hence, given the limited evidence on NIHL prevention and control and the high NIHL rates worldwide, further studies must be developed in this area, including the development of instruments to estimate occupational and non-occupational noise exposure, as gaps still exist. These include the unstandardized procedures to collect self-reported information, estimate the auditory risk , and establish validated instruments (accessing instruments or instructions for their use),8,9.Standardizing instruments in the self-report process can minimize the effects of the subjective perception of risk - as there are different notions of the risk to which workers are exposed even when they have identical functions in common settings. These notions are based on practical knowledge, deductions, conversations with workmates, and information provided by the company.In this perspective, the task-based Noise Exposure Questionnaire (NEQ) was developed in detail to quantify people\u2019s history of exposure to occupational and non-occupational noise. Also, the 1-Minute Noise Screen (NEQ-S) was developed to identify individuals at greater risk of developing NIHLThus, given the scarcity of such tools in Brazil, the objective of this research was to translate and cross-culturally adapt NEQ and NEQ-S to Brazilian Portuguese.This study was approved by the institution\u2019s Ethics Committee (no. 858/08), and the use of NEQ to this end was authorized by one of its authors.The original NEQ has 10 questions that estimate people\u2019s yearly noise exposure. Their answer options vary - \u201cNever; Every few months; Monthly; Weekly; Daily\u201d; \u201c8 or more; 4 hours up to 8 hours; 1 hour up to 4 hours; Less than 1 hour\u201d (referring to various noise-exposure situations), as well as \u201cNever; Sometimes; Always\u201d . There is also the screening instrument, NEQ-S, which can be used to estimate people\u2019s risk of developing NIHL. It has three questions with the following answer options: \u201cNever; Every few months; Monthly; Weekly; Daily\u201d, whose scores are respectively 0 to 4. Screening scores equal to or higher than 5 indicate a greater risk of developing NIHL.The participants who agreed to participate in the research signed an informed consent form.,12.The study was conducted between March 2020 and December 2020. The translation and cross-cultural adaptation process followed procedures widely used in the health literature,12 , idiomatic equivalence (proposing substitutes to idioms that are difficult to translate), experiential equivalence , and linguistic or conceptual equivalence (for words with different meanings in different cultures) with the original English questionnaires.Pretest: The preliminary final versions were used in a pretest with a group of workers to verify whether the questions were clear and easy to answer and identify possible comprehension problems in the questionnaires.\u2022 Final stage: After applying the pretest, all reports made throughout the process were submitted to the expert committee along with the preliminary translated version to verify whether the recommended stages had been followed and whether the reports reflected the process. Based on pretest results, small necessary final adjustments to the questionnaires were proposed.. The sample inclusion criteria were as follows: individuals older than 18 years; of both sexes; actively working at the university where the study was conducted; able to read and write; not having neurological, cognitive, and/or psychiatric disorders that might keep them from understanding the questions; having been submitted to audiometry at the institution\u2019s audiology service within the previous year. The exclusion criteria were as follows: having any limiting factor that kept them from reading and filling out the questionnaires; having a conductive hearing loss.To ensure that the pretest stage was adequate, the instrument was applied to a sample of individuals with similar characteristics to those for whom it had been designed. Two participants were excluded for not presenting the audiological examination in the stipulated time. Hence, the final sample had 60 participants.Altogether, 62 workers participated in this stage. They worked in various areas  at the institution (public university) where the study was conducted, as recommended by the methodological reference usedWorkers were contacted and invited to participate in the research. After agreeing and signing an informed consent form, participants answered the full questionnaires (including NEQ and NEQ-S). Then, they evaluated the questionnaires regarding comprehension, layout, clarity, and writing. They were also encouraged to suggest improvements when they found them appropriate..Reliability was verified with Cohen\u2019s kappa test, and the internal consistency was analyzed with Cronbach\u2019s alpha coefficient. Alpha (or kappa) values lower than 0.21 indicate weak; from 0.21 to 0.40, fair; from 0.41 to 0.60, moderate; from 0.61 to 0.80, substantial; and higher than 0.80, almost perfect internal consistency (or agreement)The 60 participants had a mean age of 44 years ; 70% were males. Regarding educational attainment, most of them (47%) had a bachelor\u2019s degree, followed by 43% with a high school degree; 10% of the participants had completed middle school.As for the main characteristics of noise exposure, 52% were exposed to occupation noise and 48%, to non-occupational noise. In the audiometry, 68% of the assessed workers had normal hearing thresholds (up to 25 dB HL) in the left ear and 63%, in the right ear .In general, the translated and back-translated NEQ and NEQ-S versions were similar regarding the general and reference meanings. Nonetheless, some changes  were made because some questions did not reflect Brazilian reality. Divergences were solved by consensus in the expert committee to make the questionnaires easier for the study population to understand.The changes made were related to native language situations, colloquialisms, verbal phrases, and more than one possible translation.The original versions, synthesis of the translations, synthesis of back-translations, and preliminary version  are presented in When translations were synthesized, it was decided to merge questions 10 and 11 into one (question 10), adjusting it to the Brazilian situation. These questions in the original NEQ use seasons of the year as a reference, addressing climatic conditions of the place of origin of the questionnaire and the local \u201csummer job\u201d tradition .  or the services carried out in noisy environments.After the pretest, the content and layout of the questionnaires were submitted for validation. In this stage, the reports with the comments of the target population and the observations of the researcher who accompanied the application of the instruments were presented to the expert committee. Some sentences and specific words needed small changes; they were adapted with experiential/semantic equivalence while maintaining them as close as possible to the original version. The final versions are presented in Intra-subject NEQ reliability was tested by assessing two questions on noisy work (Question 10 in NEQ and Question 2 in NEQ-S). The kappa agreement test between these combined data was 0.550 (p < 0.001), indicating moderate agreement.The internal consistency was analyzed with Cronbach's alpha coefficient, whose result was 0.711, indicating substantial internal consistency.,15.Foreign instruments have been increasingly translated and cross-culturally adapted in the last years, enabling their use in other cultures. Hence, their data are ensured to express what they were meant to measure, making it possible to compare such data between different cultures that use standardized instruments. Moreover, they save the time and money spent on producing new instruments,16. Although there is no gold-standard model of translation and cross-cultural adaptation, four essential stages  are recommended to ensure the validity and reliability of the original instrument.There are currently various translation and cross-cultural adaptation strategies, in which all stages must be given due importance to minimize errors and losses regarding the original characteristics of the instruments - which may occur in such a process, which is widely used both nationally and internationally, all the abovementioned stages were followed. They aimed at semantic, idiomatic, experiential, and conceptual equivalence between the original text and its translation, trying to solve the difficulties caused by multiple meanings and grammar issues that arose in the process and might have kept the target population from understanding the instrument.According to the methodological reference,16,18-21. Nevertheless, despite all the care taken in sample selection, there may have been some influence from selection bias, which is inherent to any research with a convenience sample.Special care was taken when choosing translators and expert committee members, including professionals with expertise in Audiology and Occupational Health. The sample, in its turn, included different age groups and levels of educational attainment, either exposed or not to occupational noise, thus verifying whether the items were understandable - as well as the applicability of the instrument to a diversified sample, larger than commonly used in the literature, which investigate symptoms  that may be present after exposure to intense noise.After applying the pretest, some changes were made to NEQ and NEQ-S questions regarding punctuation, context, and the literal translation process. Two important changes were necessary, namely: merging questions 10 and 11 into one in NEQ (question 10) and replacing items in question 1 in NEQ-S with some of those in the appendix of the original instrument. These changes were made to ensure the compatibility of the questions with the Brazilian reality, making them easier for the target population to understand. It must be pointed out that the expert committee proposed merging questions 10 and 11 of the original instrument to adapt them to the Brazilian reality (climate and tradition), as summer jobs are not usual in our culture. Likewise, question 1 in NEQ-S had to be changed because this screening is meant to indicate the risk for NIHL based on the score of three questions. Since hunting and using firearms are not usual for most Brazilians, the expert committee decided to use another three questions taken from an additional instrument developed by the authors and observed in the present study.The need to change questions or statements from original instruments is reported by researchers in the area, who emphasize that cultural differences may require such changes, especially when they involve specific conditions, as previously mentioned. Therefore, no other studies on their translation and cross-cultural adaptation to other languages and countries were found, preventing comparison with other versions.NEQ and NEQ-S are relatively new instruments, published in 2017 used the same methodology, comparing two repeated questions on the same topic (noisy work). Their results were similar to ours (kappa = 0.590 - moderate agreement).Regarding the intra-subject reliability of the instrument, the original study, as the one verified in this study.Cronbach\u2019s alpha coefficient was 0.711, indicating substantial internal consistency in this instrument analysis. This is a reliability measure that reflects how questionnaire items are mutually related. It is important and desirable that this value be between 0.70 and 0.95, NEQ uses simple task-based questions. Hence, it can be used to estimate people\u2019s yearly exposure to either occupational or non-occupational noise. It also has the screening version (NEQ-S), which quickly and easily identifies individuals at risk of NIHL.Even though other instruments quantify yearly noise exposure, Spankovich et al., Bernard et al., Athirah and Shahida, Powell. They used this instrument to calculate cumulated yearly doses of noise based on self-reported activities.Some studies have been using NEQ to characterize participants\u2019 doses of noise exposure - e.g., Grinn et al.,16,19,20.Hence, standardizing new instruments and making them available are important strategies to develop science and have them used by health professionals, with an impact on clinical practice. They may also be useful as screening instruments to identify harmful day-to-day noises, helping better plan interventions, especially in the occupational areaIn the next stage of our study, the translated and adapted instrument will be applied in order to determine NEQ diagnostic values , comparing it with the gold-standard examination (audiometry) to identify NIHL.The translation and cross-cultural adaptation were made according to the methodology indicated in the national and international literature. They followed the stages of translation, back-translation, expert committee, and pretest, including the equivalences necessary to maintain the face and content validity of the original instrument. Making NEQ and NEQ-S available in Brazilian Portuguese opens new fields of research to address yearly noise exposure quantification more in-depth. , que demonstraram sinaptopatia coclear induzida por ru\u00eddo. Nestes estudos com cobaias, as vari\u00e1veis de exposi\u00e7\u00e3o ao ru\u00eddo podem ser cuidadosamente controladas , permitindo estimativas precisas da associa\u00e7\u00e3o entre exposi\u00e7\u00e3o ao ru\u00eddo e danos auditivos. Em estudos com humanos, a t\u00e9cnica recomendada em avalia\u00e7\u00f5es prospectivas destas vari\u00e1veis \u00e9 a dosimetria; contudo, as estimativas retrospectivas dependem predominantemente do autorrelato da exposi\u00e7\u00e3o cumulativa ao ru\u00eddo, sendo o question\u00e1rio o instrumento indicado para obter estas informa\u00e7\u00f5es,3.Estudos voltados ao conhecimento quanto aos danos auditivos relacionados ao ru\u00eddo t\u00eam aumentado a cada dia e acredita-se que este cen\u00e1rio seja decorrente dos importantes resultados de pesquisas envolvendo cobaias. Al\u00e9m disso, a PAIR continua sendo a segunda doen\u00e7a ocupacional autorreferida mais comum, apesar da exist\u00eancia de regulamenta\u00e7\u00f5es e interven\u00e7\u00f5es nos locais de trabalho,6.Estima-se que, nos Estados Unidos, aproximadamente 27,7 milh\u00f5es de indiv\u00edduos com idades entre 20 e 69 anos vivam com perda auditiva induzida por ru\u00eddo (PAIR).A alta preval\u00eancia da PAIR tem sido associada ao aumento da industrializa\u00e7\u00e3o, juntamente com as dificuldades na formula\u00e7\u00e3o e implementa\u00e7\u00e3o de pol\u00edticas p\u00fablicas e de medidas preventivas adequadas contra o ru\u00eddo, al\u00e9m das dificuldades relacionadas aos sistemas de informa\u00e7\u00e3o e coleta de dados para gera\u00e7\u00e3o de indicadores consistentes e compar\u00e1veis.Sendo assim, em virtude das evid\u00eancias ainda limitadas relacionadas \u00e0 preven\u00e7\u00e3o e controle da PAIR, bem como em virtude dos \u00edndices elevados de PAIR no mundo, \u00e9 necess\u00e1rio o desenvolvimento de mais estudos na \u00e1rea, incluindo o desenvolvimento de instrumentos para estimar a exposi\u00e7\u00e3o ao ru\u00eddo ocupacional e n\u00e3o ocupacional, uma vez que ainda existem lacunas. Dentre elas, a falta de padroniza\u00e7\u00e3o nos procedimentos para coleta de informa\u00e7\u00f5es autorreferidas; nas estimativas de risco auditivo (defini\u00e7\u00e3o de fatores de risco n\u00e3o-ocupacionais); e na defini\u00e7\u00e3o de instrumentos validados (acesso ao instrumento ou \u00e0s instru\u00e7\u00f5es para o uso),8,9.A padroniza\u00e7\u00e3o dos instrumentos, dentro do processo do autorrelato, pode minimizar os efeitos subjetivos da percep\u00e7\u00e3o do risco, j\u00e1 que se observa concep\u00e7\u00f5es diferentes dos riscos a que est\u00e3o expostos em trabalhadores desempenhando fun\u00e7\u00f5es id\u00eanticas em locais comuns. Suas percep\u00e7\u00f5es se fundamentam nos seus conhecimentos pr\u00e1ticos, dedu\u00e7\u00f5es e conversas com colegas de trabalho, bem como de informa\u00e7\u00f5es recebidas da empresaNoise Exposure Questionnaire (NEQ)\u201d foi desenvolvido como um question\u00e1rio detalhado baseado em tarefas, buscando quantificar a hist\u00f3ria de exposi\u00e7\u00e3o ao ru\u00eddo de um indiv\u00edduo, proveniente de fontes ocupacionais e n\u00e3o ocupacionais. Al\u00e9m disso, foi desenvolvido um screening \u201c1-Minute Noise Screen (NEQ-S), para a identifica\u00e7\u00e3o de indiv\u00edduos com maior risco de desenvolverem PAIR.Nesta perspectiva, o \u201cNEQ e NEQ-S para o portugu\u00eas brasileiro.Desta forma, em virtude da escassez de ferramentas deste tipo no Brasil, o objetivo da presente pesquisa foi traduzir e realizar a adapta\u00e7\u00e3o transcultural das ferramentas Noise Exposure Questionnaire (NEQ) para este fim foi autorizado por uma das autoras.Este trabalho foi aprovado pelo Comit\u00ea de \u00c9tica da institui\u00e7\u00e3o (n\u00ba 858/08). Al\u00e9m disso, o uso do instrumento screening (o NEQ-S ou 1-Minute Noise Screen), que pode ser utilizado para estimar o risco do indiv\u00edduo em desenvolver perda auditiva induzida por ru\u00eddo (PAIR). Este screening \u00e9 composto por tr\u00eas quest\u00f5es com as seguintes alternativas: \u201cNunca; A cada 2 ou 3 meses; Mensalmente; Semanalmente; Diariamente\u201d; que s\u00e3o pontuadas de 0 a 4, respectivamente. Pontua\u00e7\u00f5es no screening iguais ou maiores que 5 indicam risco mais elevado para o desenvolvimento de PAIR.O NEQ original \u00e9 composto por 10 quest\u00f5es que visa estimar a exposi\u00e7\u00e3o anual ao ru\u00eddo de um indiv\u00edduo. Por isso, as alternativas de resposta variam entre \u201cNunca; A cada 2 ou 3 meses; Mensalmente; Semanalmente; Diariamente\u201d; \u201c8 horas ou mais; De 4 a 8 horas; De 1 a 4 horas; Menos de 1 hora\u201d; referentes a diversas situa\u00e7\u00f5es de exposi\u00e7\u00e3o ao ru\u00eddo, bem como \u201cNunca; \u00c0s vezes; Sempre\u201d, quando diz respeito ao uso de dispositivos de prote\u00e7\u00e3o individual. Al\u00e9m disso, existe um instrumento de Os participantes que aceitaram participar da pesquisa, assinaram o Termo de Consentimento Livre e Esclarecido.,12.O estudo foi realizado entre mar\u00e7o de 2020 e dezembro de 2020. O processo de tradu\u00e7\u00e3o e adapta\u00e7\u00e3o transcultural contou com procedimentos amplamente utilizados na literatura, para a \u00e1rea da sa\u00fade,12 , idiom\u00e1tica (propondo substitui\u00e7\u00f5es para express\u00f5es idiom\u00e1ticas dif\u00edceis de serem traduzidas), experiencial (propondo substitui\u00e7\u00f5es para experi\u00eancias n\u00e3o dispon\u00edveis no pa\u00eds) e lingu\u00edstica ou conceitual  das vers\u00f5es traduzidas, em compara\u00e7\u00e3o aos question\u00e1rios originais em ingl\u00eas.Pr\u00e9-teste: As vers\u00f5es finais preliminares foram utilizadas em um pr\u00e9-teste para testar a clareza das perguntas e a facilidade de respostas, em um grupo de trabalhadores, com a finalidade de identificar poss\u00edveis problemas na compreens\u00e3o dos question\u00e1rios.\u2022 Etapa final: Ap\u00f3s a aplica\u00e7\u00e3o do pr\u00e9-teste, foram submetidos todos os relat\u00f3rios realizados ao longo de todo processo ao comit\u00ea de especialistas, acompanhado da vers\u00e3o traduzida preliminar, com o objetivo de verificar se as etapas recomendadas foram seguidas, e se os relat\u00f3rios refletem o processo. Conforme a necessidade, a partir dos resultados do pr\u00e9-teste, pequenos ajustes finais aos question\u00e1rios foram propostos.. Os crit\u00e9rios de inclus\u00e3o da casu\u00edstica foram: indiv\u00edduos com idade acima de 18 anos; de ambos os sexos; ser trabalhador ativo da universidade onde o estudo foi desenvolvido; saber ler e escrever; n\u00e3o apresentar dist\u00farbios neurol\u00f3gicos, cognitivos e/ou psiqui\u00e1tricos que pudessem interferir na compreens\u00e3o das quest\u00f5es; ter realizado audiometria no servi\u00e7o de audiologia da institui\u00e7\u00e3o com intervalo inferior a um ano. Os crit\u00e9rios de exclus\u00e3o foram: possuir qualquer fator limitante que impossibilitasse a leitura e o preenchimento dos question\u00e1rios; apresentar laudo audiom\u00e9trico de perda auditiva do tipo condutiva.Para garantir a adequa\u00e7\u00e3o da etapa de pr\u00e9-teste, procedeu-se \u00e0 aplica\u00e7\u00e3o do instrumento numa amostra de indiv\u00edduos com caracter\u00edsticas semelhantes \u00e0queles a quem se destina o instrumento. Houve a exclus\u00e3o de dois participantes por n\u00e3o apresentarem o exame audiol\u00f3gico no per\u00edodo exigido. Desta forma, a amostra final contou com um total de 60 participantes.Participaram desta etapa 62 trabalhadores de \u00e1reas diversas  da institui\u00e7\u00e3o onde o estudo foi desenvolvido (universidade p\u00fablica), conforme recomendado pelo referencial metodol\u00f3gico utilizadoOs trabalhadores foram contactados e convidados a participar da pesquisa. Ap\u00f3s o aceite e assinatura do TCLE, os participantes responderam aos question\u00e1rios completos (incluindo o NEQ e o NEQ-S). Posteriormente, os indiv\u00edduos avaliaram os question\u00e1rios quanto ao: entendimento, apar\u00eancia, clareza e escrita. Tamb\u00e9m foram incentivados a fornecer sugest\u00f5es de melhorias, quando considerassem pertinentes..Para a verifica\u00e7\u00e3o da confiabilidade, foi utilizado o teste kappa de Cohen e para a an\u00e1lise da consist\u00eancia interna foi aplicado o coeficiente alfa de Cronbach. Valores de alfa (ou kappa) menores do que 0,21 indicam consist\u00eancia interna (ou concord\u00e2ncia) fraca; de 0,21 a 0,40 razo\u00e1vel; de 0,41 a 0,60 moderada; de 0,61 a 0,80 substancial e maior do que 0,80, quase perfeitaOs 60 participantes tinham m\u00e9dia de idade de 44 anos , sendo 70% do sexo masculino. Com rela\u00e7\u00e3o \u00e0 escolaridade, a maioria (47%) possu\u00eda ensino superior completo, seguido por 43% com ensino m\u00e9dio completo; e 10% dos participantes com ensino fundamental completo.Em rela\u00e7\u00e3o as caracter\u00edsticas principais da exposi\u00e7\u00e3o ao ru\u00eddo, observou-se que 52% t\u00eam exposi\u00e7\u00e3o a ru\u00eddo ocupacional e 48% t\u00eam exposi\u00e7\u00e3o a ru\u00eddo n\u00e3o ocupacional. Quanto ao laudo audiom\u00e9trico, 68% dos trabalhadores avaliados apresentaram limiares auditivos dentro do padr\u00e3o de normalidade (at\u00e9 25dBNA) para a orelha esquerda e 63% para a orelha direita .NEQ e NEQ-S mostraram-se semelhantes em rela\u00e7\u00e3o ao significado geral e referencial. Entretanto, algumas modifica\u00e7\u00f5es  foram realizadas, uma vez que algumas quest\u00f5es n\u00e3o retratavam a realidade brasileira, e as diverg\u00eancias foram sanadas por consenso pelo comit\u00ea de especialistas, com o intuito de facilitar a compreens\u00e3o dos question\u00e1rios pela popula\u00e7\u00e3o estudada.Em geral, as vers\u00f5es traduzidas e retrotraduzidas do As mudan\u00e7as realizadas relacionaram-se \u00e0 presen\u00e7a de situa\u00e7\u00f5es do idioma nativo, coloquialismos, express\u00f5es verbais e a possibilidade de mais de uma tradu\u00e7\u00e3o.As vers\u00f5es originais, s\u00edntese das tradu\u00e7\u00f5es, s\u00edntese das retrotradu\u00e7\u00f5es e vers\u00e3o preliminar  foram apresentadas nos Na realiza\u00e7\u00e3o da s\u00edntese das tradu\u00e7\u00f5es, optou-se por agrupar as quest\u00f5es 10 e 11, na quest\u00e3o 10, adequando-as \u00e0 situa\u00e7\u00e3o brasileira, j\u00e1 que se observou que estas quest\u00f5es, presentes no question\u00e1rio NEQ original, utilizam como refer\u00eancia a esta\u00e7\u00e3o do ano, devido \u00e0s condi\u00e7\u00f5es clim\u00e1ticas presentes no local de origem do question\u00e1rio e a tradi\u00e7\u00e3o local de \u201ctrabalhos de ver\u00e3o\u201d .  ou dos servi\u00e7os realizados em ambiente ruidoso.Ap\u00f3s a etapa de pr\u00e9-teste, foi realizada a valida\u00e7\u00e3o do conte\u00fado e apar\u00eancia dos question\u00e1rios, por meio da apresenta\u00e7\u00e3o ao comit\u00ea de especialistas, dos relat\u00f3rios contendo os coment\u00e1rios referidos pelo p\u00fablico-alvo, bem como das observa\u00e7\u00f5es da pesquisadora que acompanhou a aplica\u00e7\u00e3o dos instrumentos. Identificou-se a necessidade de pequenas modifica\u00e7\u00f5es de senten\u00e7as e palavras espec\u00edficas, adaptando-as para equival\u00eancia experiencial/sem\u00e2ntica, mantendo-se, entretanto, a m\u00e1xima proximidade com a vers\u00e3o original. As vers\u00f5es finais encontram-se nos Para testar a confiabilidade do NEQ intra-sujeito, foram avaliadas duas perguntas sobre trabalho ruidoso (Quest\u00e3o 10 do NEQ e Quest\u00e3o 2 do NEQ-S). O teste kappa de concord\u00e2ncia entre esses dados combinados foi de 0,550 , representando concord\u00e2ncia moderada.J\u00e1 a an\u00e1lise da consist\u00eancia interna foi feita por meio do coeficiente alfa de Cronbach, que resultou num valor de 0,711, que indica consist\u00eancia interna substancial.,15.A tradu\u00e7\u00e3o e a adapta\u00e7\u00e3o transcultural de instrumentos estrangeiros v\u00eam crescendo nos \u00faltimos anos, permitindo seu uso em outras culturas, garantindo que os dados obtidos expressem o que almejam mensurar e possibilitem a compara\u00e7\u00e3o desses dados entre diferentes culturas pela utiliza\u00e7\u00e3o de instrumentos padronizados, bem como minimizem gastos de tempo e dinheiro na produ\u00e7\u00e3o de novos instrumentos,16. Embora n\u00e3o exista um modelo padr\u00e3o-ouro para a tradu\u00e7\u00e3o e adapta\u00e7\u00e3o transcultural, quatro etapas s\u00e3o essenciais e recomendadas: tradu\u00e7\u00e3o, retrotradu\u00e7\u00e3o, revis\u00e3o por comit\u00ea de especialistas, pr\u00e9-teste, de forma a garantir a validade e confiabilidade do instrumento original.Atualmente, existem diversas estrat\u00e9gias para o processo da tradu\u00e7\u00e3o e adapta\u00e7\u00e3o transcultural, sendo necess\u00e1ria a valoriza\u00e7\u00e3o de todas as etapas, a fim de minimizar erros e perdas das caracter\u00edsticas originais dos instrumentos, que podem ocorrer durante este processo, a qual \u00e9 amplamente adotada nacional e internacionalmente, todas as etapas acima mencionadas foram seguidas. O objetivo foi a equival\u00eancia sem\u00e2ntica, idiom\u00e1tica, experiencial e conceitual entre o texto original e sua tradu\u00e7\u00e3o, buscando equacionar as dificuldades causadas por significados m\u00faltiplos, al\u00e9m de problemas gramaticais, que pudessem surgir durante o processo, que prejudicassem a compreens\u00e3o do instrumento pelos membros da popula\u00e7\u00e3o a que se destina.De acordo com a refer\u00eancia metodol\u00f3gica utilizadaexpertise na \u00e1rea de Audiologia e Sa\u00fade Ocupacional. Em rela\u00e7\u00e3o a composi\u00e7\u00e3o amostral, foram inclu\u00eddos diferentes grupos et\u00e1rios e n\u00edveis de escolaridade, expostos e n\u00e3o expostos a ru\u00eddo ocupacional, garantindo assim a verifica\u00e7\u00e3o da compreens\u00e3o dos itens, mas tamb\u00e9m da aplicabilidade do instrumento em uma amostra diversificada e com um n\u00famero de participantes maior do que o comumente utilizado na literatura,16,18-21. No entanto, mesmo com todo cuidado durante a sele\u00e7\u00e3o da amostra, pode ter havido a influ\u00eancia de um vi\u00e9s de sele\u00e7\u00e3o, que \u00e9 inerente a qualquer pesquisa que utiliza uma amostra de conveni\u00eancia.Durante as etapas de tradu\u00e7\u00e3o e composi\u00e7\u00e3o do comit\u00ea de especialistas, houve cuidado na escolha dos integrantes, incluindo profissionais com  e que investigam sintomas que podem estar presentes ap\u00f3s a exposi\u00e7\u00e3o a ru\u00eddos intensos: zumbido, sensa\u00e7\u00e3o de ouvido tampado, dores ou inc\u00f4modo nos ouvidos.Ap\u00f3s a aplica\u00e7\u00e3o do pr\u00e9-teste, algumas modifica\u00e7\u00f5es nas quest\u00f5es do NEQ e NEQ-S foram feitas, no que diz respeito tanto a pontua\u00e7\u00e3o e contexto, como no processo de tradu\u00e7\u00e3o literal. Houve a necessidade de duas modifica\u00e7\u00f5es importantes . Estas modifica\u00e7\u00f5es foram feitas para garantir a compatibilidade das perguntas com a realidade brasileira, permitindo melhor compreens\u00e3o pela popula\u00e7\u00e3o-alvo. Deve-se mencionar que o comit\u00ea de especialistas prop\u00f4s a jun\u00e7\u00e3o das quest\u00f5es 10 e 11 do instrumento original para adequa\u00e7\u00e3o da quest\u00e3o \u00e0 realidade brasileira (clima e tradi\u00e7\u00e3o), uma vez que n\u00e3o h\u00e1 costume de execu\u00e7\u00e3o de empregos de ver\u00e3o. Da mesma forma, a quest\u00e3o 1 do NEQ-S precisou ser modificada, pois esta \u00e9 uma triagem para indicar risco para PAIR baseada na pontua\u00e7\u00e3o de tr\u00eas perguntas. Como n\u00e3o h\u00e1 tradi\u00e7\u00e3o de ca\u00e7a e uso de armas de fogo pela maioria da popula\u00e7\u00e3o brasileira, o comit\u00ea de especialistas optou por utilizar tr\u00eas outras quest\u00f5es que estavam presentes em um instrumento adicional elaborado pelos autores e como observado no presente estudo.A necessidade de modifica\u00e7\u00e3o de perguntas ou enunciados do instrumento original \u00e9 relatada por pesquisadores da \u00e1rea, que enfatizam que as diferen\u00e7as culturais podem exigir tais mudan\u00e7as, principalmente daqueles que envolvem condi\u00e7\u00f5es espec\u00edficas, como citado anteriormente, n\u00e3o encontramos outros estudos sobre a tradu\u00e7\u00e3o e adapta\u00e7\u00e3o transcultural do NEQ e NEQ-S para outras l\u00ednguas e pa\u00edses, o que n\u00e3o permite a compara\u00e7\u00e3o com outras vers\u00f5es.Por tratar-se de um instrumento relativamente novo, publicado em 2017 utilizou a mesma metodologia, comparando duas quest\u00f5es repetidas sobre a mesma tem\u00e1tica  e obtiveram resultados semelhantes aos nossos .Em rela\u00e7\u00e3o \u00e0 confiabilidade do instrumento intra-sujeito, o estudo original, como o verificado no presente estudo.Na an\u00e1lise da consist\u00eancia interna do instrumento, o coeficiente alfa de Cronbach foi de 0,711, indicando consist\u00eancia interna substancial. A consist\u00eancia interna \u00e9 uma medida de confiabilidade, que reflete como os itens do question\u00e1rio est\u00e3o correlacionados entre si. \u00c9 importante e desej\u00e1vel que este valor varie entre 0,70 a 0,95, o NEQ utiliza-se de quest\u00f5es simples baseadas em tarefas, que pode ser usado para estimar a exposi\u00e7\u00e3o do sujeito ao ru\u00eddo ocupacional e n\u00e3o ocupacional anual. Al\u00e9m disso, possui a vers\u00e3o triagem (NEQ-S), que possibilita a identifica\u00e7\u00e3o de indiv\u00edduos que est\u00e3o em risco para PAIR, de forma r\u00e1pida e de f\u00e1cil aplica\u00e7\u00e3o.Embora existam outros instrumentos que busquem quantificar a exposi\u00e7\u00e3o anual ao ru\u00eddo, Spankovich et al., Bernard et al., Athirah e Shahida, Powell. Eles utilizaram este instrumento para calcular a dose de ru\u00eddo acumulada anual com base nas atividades auto-relatadas.Alguns estudos v\u00eam utilizando o NEQ como forma de caracterizar as doses de exposi\u00e7\u00e3o ao ru\u00eddo dos participantes. Dentre eles, pode-se citar: Grinn et al.,16,19,20.Sendo assim, a padroniza\u00e7\u00e3o de novos instrumentos, assim como sua disponibiliza\u00e7\u00e3o, representa uma importante estrat\u00e9gia para o desenvolvimento da ci\u00eancia, e para o uso por profissionais de sa\u00fade, gerando impacto na pr\u00e1tica cl\u00ednica. Al\u00e9m disso, podem representar instrumentos de rastreio para a identifica\u00e7\u00e3o de ru\u00eddos prejudiciais presentes no dia-dia, permitindo o melhor planejamento das interven\u00e7\u00f5es, principalmente na \u00e1rea ocupacionalA pr\u00f3xima etapa do nosso estudo visa aplicar o instrumento traduzido e adaptado, para determinar os valores diagn\u00f3sticos  do NEQ comparando-o com o padr\u00e3o-ouro (audiometria) para a identifica\u00e7\u00e3o da PAIR.A tradu\u00e7\u00e3o e adapta\u00e7\u00e3o transcultural foram realizadas de acordo com a metodologia preconizada na literatura nacional e internacional, seguindo as etapas de tradu\u00e7\u00e3o, retrotradu\u00e7\u00e3o comit\u00ea de especialistas e pr\u00e9-teste, incluindo-se as equival\u00eancias necess\u00e1rias para a manuten\u00e7\u00e3o da validade de face e conte\u00fado com o instrumento original. A disponibiliza\u00e7\u00e3o dos question\u00e1rios NEQ e NEQ-S na vers\u00e3o da l\u00edngua portuguesa brasileira abre novos campos de pesquisa para aprofundamento da quantifica\u00e7\u00e3o de exposi\u00e7\u00e3o anual ao ru\u00eddo."}
+{"text": "Ass\u00e9dio emocional, discrimina\u00e7\u00e3o, ser divorciado e idade inferior a 55 anos foram fatores predisponentes. O estudo \u00e9 internacional e incluiu 5931 cardiologistas entrevistados em 2019, abrangendo todos os continentes. Os respondedores \u00e0 pesquisa representam apenas 8% dos convidados a participarem dela. A maioria s\u00e3o europeus, brancos, casados e com filhos. Indiv\u00edduos em come\u00e7o de carreira foram os mais afetados. A Am\u00e9rica Latina contribuiu com 17,7% das respostas. Homens constitu\u00edram 77,4% da amostra e mulheres, 22,6%. Portanto, trata-se de amostra seleta que pode n\u00e3o representar todo espectro da popula\u00e7\u00e3o cardiol\u00f3gica. Dist\u00farbios emocionais foram relatados por 28% dos entrevistados. Houve consider\u00e1vel varia\u00e7\u00e3o regional, mas a Am\u00e9rica do Sul mostrou o maior \u00edndice de dist\u00farbios psicol\u00f3gicos, chegando a 39,3%; j\u00e1 na \u00c1sia observaram-se os \u00edndices mais baixos . Mulheres foram mais propensas a esses dist\u00farbios, mas tamb\u00e9m procuraram ajuda psicol\u00f3gica com maior frequ\u00eancia. Esse achado corrobora pesquisa anterior que observou que suic\u00eddios s\u00e3o mais frequentes entre mulheres m\u00e9dicas do que na popula\u00e7\u00e3o geral.2Estudo recente6 Por exemplo, pesquisas recentes nos EUA documentaram que 42% dos cardiologistas sofrem de \u201c burnout \u201d (exaust\u00e3o) e 83% tem algum grau de depress\u00e3o.2 A COVID-19 acentuou muito esses problemas. O fen\u00f4meno \u00e9 universal e parece afetar especialmente as mulheres. Os achados preocupam porque influenciam o desempenho dos m\u00e9dicos e, portanto, impactam diretamente na pr\u00e1tica m\u00e9dica.Outros pesquisadores j\u00e1 haviam documentado diversos dist\u00farbios emocionais entre m\u00e9dicos, tais como ansiedade, depress\u00e3o, idea\u00e7\u00e3o suicida e suic\u00eddios.V\u00e1rias causas, possivelmente, podem explicar tais achados. Escolha errada da profiss\u00e3o \u00e9 uma delas; muitos m\u00e9dicos n\u00e3o t\u00eam voca\u00e7\u00e3o para medicina. A escolha da profiss\u00e3o pode sofrer influ\u00eancias familiares, ambientais ou econ\u00f4micas e n\u00e3o se basear nas verdadeiras aptid\u00f5es e inclina\u00e7\u00f5es pessoais do candidato. Tamb\u00e9m contribui o total desconhecimento da natureza da profiss\u00e3o m\u00e9dica pelo jovem aspirante. Por exemplo, lidar com pessoas doentes exige certas caracter\u00edsticas de personalidade que nem todos t\u00eam; exige paci\u00eancia, compreens\u00e3o humana, desapego, solidariedade, capacidade de doa\u00e7\u00e3o; enfim, exige amor ao pr\u00f3ximo. Mas al\u00e9m do aspecto humano, requer tamb\u00e9m curiosidade cient\u00edfica, dedica\u00e7\u00e3o profunda e cont\u00ednua ao trabalho e certo desapego aos valores materiais. Medicina n\u00e3o \u00e9 profiss\u00e3o para enriquecer.Al\u00e9m disso, h\u00e1 a quest\u00e3o da dura\u00e7\u00e3o da carreira; com o envelhecimento de todos, a carreira m\u00e9dica se tornou mais longa; quem se formou aos 27 anos, por exemplo, vai trabalhar at\u00e9 os 80 ou mais; s\u00e3o mais de 50 anos. \u00c9 muito tempo para exercer uma profiss\u00e3o que n\u00e3o lhe d\u00ea satisfa\u00e7\u00e3o. Tudo isso deve ser levado em conta quando se escolhe uma profiss\u00e3o.7 da Inglaterra, demonstrou quanto a insatisfa\u00e7\u00e3o no trabalho impacta negativamente na sobrevida e qualidade de vida das pessoas.Hoje a profiss\u00e3o \u00e9 assalariada e n\u00e3o mais liberal como antes; portanto os m\u00e9dicos t\u00eam que se submeter a regimes de trabalho estabelecidos pelos empregadores, com hor\u00e1rios e regras que nem sempre s\u00e3o de seu agrado. Essa circunst\u00e2ncia retira do profissional uma vari\u00e1vel essencial para a boa qualidade de vida: liberdade para escolher como, onde e quanto trabalhar. O estudo Whitehall,8 Os pacientes se queixam dessa dissocia\u00e7\u00e3o; mas essa rotura afeta tamb\u00e9m os m\u00e9dicos. No entanto, atualmente, \u00e9 a institui\u00e7\u00e3o que prevalece! A rotatividade de plantonistas ou de m\u00e9dicos de ambulat\u00f3rio obriga a trocas cont\u00ednuas. O tempo de atendimento pelo SUS e conv\u00eanios \u00e9 ex\u00edguo, por volta de 8 minutos.Outro ponto cr\u00edtico \u00e9 a rela\u00e7\u00e3o \u00edntima m\u00e9dico/paciente que vem se deteriorando. Com frequ\u00eancia o paciente n\u00e3o tem mais o seu m\u00e9dico e o m\u00e9dico n\u00e3o tem mais o seu paciente; ora, essa rela\u00e7\u00e3o \u00e9 a base da confian\u00e7a que alicer\u00e7a o exerc\u00edcio da profiss\u00e3o.Nesse per\u00edodo n\u00e3o d\u00e1 para conhecer uma pessoa; o atendimento m\u00e9dico se torna mecanizado, e o paciente n\u00e3o passa de um n\u00famero. Por\u00e9m, a doen\u00e7a n\u00e3o \u00e9 apenas uma quest\u00e3o f\u00edsica ou bioqu\u00edmica \u2013 ela afeta a pessoa toda, afeta sentimentos, cria inseguran\u00e7a e medo; em suma, afeta a alma da pessoa doente. O m\u00e9dico tamb\u00e9m sente falta dessa liga\u00e7\u00e3o afetuosa com seus pacientes. O respeito e admira\u00e7\u00e3o que o paciente sente pelo seu m\u00e9dico evanesce quando esse elo se desfaz.Por outro lado, os honor\u00e1rios pagos pelos sistemas de sa\u00fade s\u00e3o baixos, o que exige que os profissionais vejam muitos pacientes em pouco tempo, contribuindo para o distanciamento das pessoas. O retorno econ\u00f4mico tornou-se ex\u00edguo considerando o grande investimento que o estudante tem de fazer para se tornar m\u00e9dico. S\u00e3o 6 anos de gradua\u00e7\u00e3o mais 3 ou 4 de especializa\u00e7\u00e3o, com grandes exig\u00eancias mentais, dedica\u00e7\u00e3o e responsabilidades. Embora escolas p\u00fablicas sejam gratuitas, a concorr\u00eancia \u00e9 grande e nem todos conseguem vagas. Enormes gastos financeiros em faculdades privadas s\u00e3o hoje a norma; fam\u00edlias se endividam para formar um m\u00e9dico e este carrega um fardo para a vida.Tamb\u00e9m muitos m\u00e9dicos esperam reconhecimento e gratid\u00e3o quando ajudaram pessoas doentes oferecendo-lhes ora cura, ora conforto, mas isso nem sempre ocorre; ali\u00e1s, o mais comum \u00e9 o esquecimento quando n\u00e3o a pura ingratid\u00e3o. Al\u00e9m disso, processos judiciais contra m\u00e9dicos se tornaram comuns. Portanto, a aura de bem feitor que circundava o m\u00e9dico no passado hoje est\u00e1 em extin\u00e7\u00e3o. O desejo de reconhecimento \u00e9 inerente ao g\u00eanero humano e a falta dele certamente retira um pouco do encanto da profiss\u00e3o.Por outro lado, a assist\u00eancia m\u00e9dica pura pode ser rotina cansativa; para quem tem experi\u00eancia n\u00e3o \u00e9 mentalmente desafiador. Com frequ\u00eancia os casos s\u00e3o repetitivos, as perguntas dos pacientes s\u00e3o ing\u00eanuas demais. Isso cansa. Mesmo relacionamentos entre pessoas normais podem ser dif\u00edceis: diferen\u00e7as de personalidades, culturas, religi\u00e3o, pol\u00edtica, empatia ou antipatia, gostos em geral aproximam ou afastam pessoas. Quando as pessoas est\u00e3o doentes, demandas se acentuam. Particularmente em medicina todo mundo tem opini\u00e3o. Agora, com \u201cDr. Google\u201d, os pacientes j\u00e1 chegam no m\u00e9dico com diagn\u00f3stico e tratamento. Portanto, \u00e9 precisa muita paci\u00eancia! O resultado \u00e9: para quem n\u00e3o tem voca\u00e7\u00e3o, o exerc\u00edcio da profiss\u00e3o \u00e9 sacrificado. S\u00e3o muitas horas de trabalho, sem privacidade nem respeito por hor\u00e1rios. J\u00e1 para quem gosta do que faz, a profiss\u00e3o representa oportunidade \u00fanica de conhecer pessoas, ajudar quem sofre, sentir-se \u00fatil. Nada \u00e9 mais gratificante do que o sorriso agradecido de quem esteve \u00e0 beira da morte e foi salvo. Essa \u00e9 a ess\u00eancia da profiss\u00e3o \u2013 prestar servi\u00e7os indispens\u00e1veis \u00e0 vida e \u00e0 sa\u00fade.10 Portanto, os m\u00e9dicos precisam se atualizar para n\u00e3o se tornarem obsoletos rapidamente. E \u2013 Pesquisar/associar-se a grupos de pesquisa pode ser uma maneira inteligente de tornar o exerc\u00edcio profissional excitante; descobrir coisas novas sempre representa motivo de justa satisfa\u00e7\u00e3o pessoal. F \u2013 Terapia Cognitiva Comportamental (TCC)11 \u00e9 a abordagem psicol\u00f3gica mais usada dentro da medicina, porque basicamente trabalha com o presente e capacita os pacientes a desenvolver recursos emocionais adequados para o enfrentamento de dist\u00farbios psicol\u00f3gicos frequentemente associados a problemas m\u00e9dicos org\u00e2nicos. Neste cen\u00e1rio, incluem-se perdas concretas e simb\u00f3licas bem como mudan\u00e7as de estilo de vida, altera\u00e7\u00f5es comportamentais e ajustes familiares e profissionais. Assim, TCC \u00e9 um recurso \u00fatil, eficaz, que deveria ser usado pelos pr\u00f3prios m\u00e9dicos para preservar sua sa\u00fade mental. G \u2013 Dividir responsabilidades com outros especialistas \u00e9 uma necessidade e uma arma para evitar frustra\u00e7\u00f5es. Hoje os avan\u00e7os s\u00e3o muitos, em todas as \u00e1reas, e o conhecimento profundo, integral e abrangente tornou-se virtualmente imposs\u00edvel para um s\u00f3 indiv\u00edduo. \u00c9 preciso compartilhar conhecimentos e dividir responsabilidades para o bem de todos. H \u2013 Escolas m\u00e9dicas podem contribuir selecionando candidatos pelo perfil de personalidade, interesses, voca\u00e7\u00e3o e n\u00e3o apenas pelo conhecimento te\u00f3rico de disciplinas; entrevista pessoal com o candidato seria valiosa. I \u2013 Entidades m\u00e9dicas e sistemas de sa\u00fade em geral devem velar pela qualidade emocional de seus m\u00e9dicos adotando regimes de trabalho mais satisfat\u00f3rios.Como enfrentar essa crise emocional dos m\u00e9dicos atuais \u00e9 um desafio consider\u00e1vel. Embora psic\u00f3logos e psiquiatras sejam os profissionais mais preparados para indicar abordagens espec\u00edficas neste cen\u00e1rio, permito-me sugerir algumas medidas gerais, com base em experi\u00eancias acad\u00eamicas e de pr\u00e1tica cl\u00ednica. V\u00e1rios caminhos podem ser propostos: A \u2013 Fazer o que gosta e para o que se tem aptid\u00e3o. Hoje os estudantes se qualificam mentalmente muito cedo; aprendem ci\u00eancias e humanidades rapidamente, mas a maturidade emocional \u00e9 mais lenta; a escolha da profiss\u00e3o requer maturidade e isso s\u00f3 a viv\u00eancia proporciona. Talvez os aspirantes a m\u00e9dicos devessem ser expostos, por certo tempo, \u00e0s realidades da profiss\u00e3o antes de ingressarem nas faculdades. B \u2013 Hoje a medicina tem muitas subespecialidades, algumas das quais n\u00e3o envolvem contatos diretos com pacientes nem requerem aceita\u00e7\u00e3o da responsabilidade direta na condu\u00e7\u00e3o de casos; exemplos incluem exames de imagem e intelig\u00eancia artificial. Atualmente, s\u00e3o de fundamental import\u00e2ncia no diagn\u00f3stico e encaminhamento de casos. Portanto, existem oportunidades diferentes do cuidado tradicional de pacientes. C \u2013 Conviver com jovens \u00e9 outra maneira eficiente de tornar o exerc\u00edcio profissional estimulante e inspirador. O jovem traz entusiasmo, ideias novas, questionamentos que contribuem para tornar a profiss\u00e3o sempre atrativa. Os mais experientes ensinam e orientam, mas tamb\u00e9m aprendem e se renovam. Na verdade, \u00e9 uma maneira de assegurar a amplia\u00e7\u00e3o, divulga\u00e7\u00e3o e perpetua\u00e7\u00e3o de seu trabalho. Compartilhar experi\u00eancias \u00e9 uma via para deixar um legado. D \u2013 Atualizar-se sempre foi uma necessidade imperiosa na pr\u00e1tica m\u00e9dica, mas nunca t\u00e3o decisiva quanto hoje. A velocidade com que os conhecimentos cient\u00edficos e as novas tecnologias se desenvolvem n\u00e3o tem paralelo na hist\u00f3ria humana.Em suma a profiss\u00e3o m\u00e9dica \u00e9 \u00fanica, composta de ci\u00eancia e humanismo, cujo objetivo maior \u00e9 o bem da humanidade. Desafios, como a preserva\u00e7\u00e3o da sa\u00fade mental dos pr\u00f3prios m\u00e9dicos, devem ser enfrentados, mas n\u00e3o devem nos afastar dos objetivos maiores da nossa profiss\u00e3o. Nossa miss\u00e3o \u00e9 curar quando poss\u00edvel, mitigar sofrimentos e consolar sempre. 1 has shown that 1 in 4 cardiologists suffer from emotional disturbances, including stress and other psychiatric disorders. Emotional harassment, discrimination, divorce, and age under 55 years were predisposing factors. The international study included 5931 cardiologists interviewed in 2019, covering all continents. Survey respondents represent only 8% of those invited to participate in the survey. The majority were European, White, married, and with children. Individuals at the beginning of their careers were the most affected. Latin America contributed with 17.7% of responses. Men constituted 77.4% of the sample, and women constituted 22.6%. Therefore, it was a select sample that may not represent the entire spectrum of the population of cardiologists. Emotional disturbances were reported by 28% of respondents. There was considerable regional variation, but South America showed the highest rate of psychological disorders, reaching 39.3%; in Asia, the lowest indexes were observed (20.1%). Women were more prone to these disorders, but they also sought psychological help more frequently. This finding corroborates previous research which observed that suicide is more frequent among women doctors than in the general population.2A recent study6 For example, recent research in the United States has documented that 42% of cardiologists suffer from burnout, and 83% have some degree of depression.2 COVID-19 has greatly accentuated these problems. The phenomenon is universal and seems to affect women in particular. These findings are a cause of concern, because they influence the performance of physicians and, therefore, have a direct impact on medical practice.Other researchers had already documented several emotional disorders among physicians, such as anxiety, depression, suicidal ideation, and suicide.Multiple causes could possibly explain these findings. Wrong choice of profession is one of them; many doctors do not have a vocation for medicine. The choice of profession may be influenced by family, environment, or economic reasons and may not be based on the candidate\u2019s true aptitudes and personal inclinations. Total lack of knowledge regarding the nature of the medical profession by young candidates. also contributes to this. For example, dealing with people who are ill requires certain personality traits that not everyone possesses; it demands patience, human understanding, detachment, solidarity, and generosity; finally, it requires love of others. Beyond the human aspect, it also requires scientific curiosity, profound and continuous dedication to work, and a certain detachment from material values. Medicine is not a profession for becoming rich.Furthermore, there is the issue of career duration; with population aging, the medical career lasts longer. Those who graduated at 27, for example, will work until they are 80 or older, for more than 50 years, which is a too long time to pursue a profession that does not provide satisfaction. All this must be taken into account when choosing a profession.7 from England, demonstrated the extent to which dissatisfaction at work negatively impacts people\u2019s survival and quality of life.Nowadays, the profession is salaried and no longer liberal as it was in the past; therefore, doctors have to submit to work regimes established by employers, with schedules and rules that are not always to their liking. This circumstance means that professionals lose an essential variable for good quality of life: freedom to choose how, where, and how much to work. The Whitehall study8 Patients complain about this dissociation, but this rupture also affects doctors. However, currently, it is the institution that comes first! The rotation of doctors on duty or outpatient doctors requires continuous changes. The consultation time through the Brazilian Unified Health System (SUS) and private health insurance plans is short, approximately 8 minutes.Another critical point is the intimate doctor-patient relationship that has been deteriorating. Often patients no longer have their doctors, and doctors no longer have their patients; this relationship is the basis of trust that provides the foundation for exercising the profession.During such a short period, it is not possible to know a person; medical care becomes mechanized, and the patient becomes nothing more than a number. However, illness is not just a physical or biochemical issue. Illness affects the person as a whole; it influences feelings, creating insecurity and fear. In short, illness affects the person\u2019s soul. Doctors also miss this affectionate connection with their patients. The respect and admiration that patients feel for doctors vanish when that bond is not maintained.On the other hand, the fees paid by health systems are low, making it necessary for professionals to see many patients in a short time, contributing to distancing between people. The economic return has become insufficient considering the major investment that students must make to become doctors. It takes 6 years to graduate, plus 3 or 4 to complete a specialization, with immense mental demands, dedication, and responsibilities. Although public schools are free, competition is fierce, and not everyone manages to be admitted. Huge financial expenses at private medical school are now the norm. Families become indebted to pay the education of a doctor, who will carry a lifelong burden.Many doctors also expect recognition and gratitude when they help patients, offering them either healing or comfort, but this is not always the case; in fact, they most commonly deal with forgetfulness, or else pure ingratitude. In addition to this, lawsuits against doctors have become commonplace. Therefore, the beneficent aura that once surrounded doctors is now in extinction. The desire for recognition is inherent to humankind and the lack thereof certainly takes away some of the charm of the profession.On the other hand, pure medical care can be a tiresome routine; for those with experience, it is not mentally challenging. The cases are often repetitive, and the patients\u2019 questions are too naive. This is tiring. Even normal relationships between people can become strained; differences in personalities, cultures, religion, politics, empathy, aversion, and tastes in general bring people closer or farther apart. When people are sick, demands are accentuated. Particularly in medicine, everyone has an opinion. Nowadays, with \u201cDr. Google\u201d, patients already come to the doctor with a diagnosis and treatment. Therefore, it takes lots of patience! The result is that, for those who do not have a vocation, the exercise of the profession is burdensome. There are many hours of work, without privacy or respect for schedules. For those who enjoy what they do, the profession represents a unique opportunity to meet people, help those who suffer, and feel useful. Nothing is more rewarding than the grateful smile of someone who was on the verge of death and was saved. This is the essence of the profession: providing services that are indispensable to life and health.10 Therefore, doctors need to remain up to date in order not to become rapidly obsolete. E \u2013 Researching/joining research groups can be an intelligent way to make professional practice exciting; discovering new things always provides a reason for well-deserved personal satisfaction. F \u2013 Cognitive Behavioral Therapy11 is the most widely used psychological approach within medicine, because it basically works with the present and enables patients to develop adequate emotional resources for coping with psychological disorders often associated with organic medical problems. In this scenario, concrete and symbolic losses are included, as well as lifestyle changes, behavioral changes, and family and professional adjustments. Thus, Cognitive Behavioral Therapy is a useful, effective resource that should be used by doctors themselves to preserve their mental health. G \u2013 Sharing responsibilities with other specialists is a necessity and a means to avoid frustration. There are currently many advances, in all areas, and profound, integral and comprehensive knowledge has become virtually impossible for a sole individual. It is necessary to share knowledge and responsibilities for the good of all. H \u2013 Medical schools can contribute by selecting candidates based on their personality profile, interests, vocation and not merely on theoretical knowledge of disciplines; personal interviews with candidates would be valuable. I \u2013 Medical entities and health systems in general must ensure the emotional quality of doctors by adopting more satisfactory work regimes.Facing this current emotional crisis is a considerable challenge for doctors. Although psychologists and psychiatrists are the professionals best prepared to indicate specific approaches in this scenario, I would like to suggest some general measures, based on academic experience and clinical practice. The followings paths can be proposed: A \u2013 Do what you like and what you have the aptitude for. Today students qualify mentally very early; they learn science and humanities quickly, but emotional maturity is slower; the choice of profession requires maturity, and only experience can provide that. Perhaps aspiring doctors should be exposed to the realities of the profession for a while before entering college. B \u2013 Medicine currently has many subspecialties, some of which do not involve direct contact with patients or require accepting direct responsibility for managing cases; examples include imaging and artificial intelligence. Currently, they are of fundamental importance for diagnosis and referral of cases. Thus, there are different opportunities, other than traditional patient care. C \u2013 Working with young people is another efficient way to make professional practice stimulating and inspiring. Young people bring enthusiasm, new ideas, and questions that contribute to keeping the profession attractive. Those with more experience teach and guide, but they also learn and renew themselves. In fact, it is a way of ensuring the expansion, dissemination, and perpetuation of their work. Sharing experiences is a way to leave a legacy. D \u2013 Staying up to date has always been an imperative need in medical practice, but it has never been as decisive as it is today. The speed with which scientific knowledge and new technologies are developing is unparalleled in human history.In conclusion, the medical profession is unique, composed of science and humanism, and its main objective is the good of humanity. It is necessary to face challenges, such as preserving the mental health of doctors, but these challenges must not lead us away from the greater goals of our profession. Our mission is to heal whenever possible, to mitigate suffering, and always to console."}
+{"text": "Para nove dos 15 direitosselecionados, a propor\u00e7\u00e3o de pacientes eleg\u00edveis foi superior a 10%, variando de17,7% para \u201csaque do Fundo de Garantia por Tempo de Servi\u00e7o (FGTS)\u201d a 100% para\u201cprioridade na tramita\u00e7\u00e3o de processos\u201d. No entanto, o \u00fanico desses direitosconhecido por pelo menos 50% dos pacientes eleg\u00edveis foi o \u201caux\u00edlio-doen\u00e7a\u201d, sendo que para tr\u00eas direitos as respectivas propor\u00e7\u00f5es n\u00e3o chegaram a5% . Os pacientes oncol\u00f3gicos necessitam ter seus cuidadosintegrais fortalecidos. Dessa forma, \u00e9 fundamental aumentar o acesso \u00e0informa\u00e7\u00e3o sobre os benef\u00edcios que eles podem obter de um Estado democr\u00e1tico dedireito.A legisla\u00e7\u00e3o brasileira assegura aos pacientes com c\u00e2ncer direitos que auxiliamno tratamento e atenuam os gastos despendidos na jornada de adoecimento. Oobjetivo do estudo foi calcular a propor\u00e7\u00e3o de indiv\u00edduos em tratamentooncol\u00f3gico de um centro de refer\u00eancia do Sistema \u00danico de Sa\u00fade (SUS) quereferiram conhecer 15 direitos espec\u00edficos previstos em lei, segundo o subgrupopopulacional eleg\u00edvel para solicitar cada direito. Foram entrevistados todos ospacientes oncol\u00f3gicos adultos em in\u00edcio de tratamento no Hospital Associa\u00e7\u00e3oFeminina de Preven\u00e7\u00e3o e Combate ao C\u00e2ncer de Juiz de Fora (ASCOMCER), MinasGerais, entre mar\u00e7o e julho de 2022 (n = 62). Cerca de 60% desses pacientes eramanalfabetos ou n\u00e3o tinham completado o ensino fundamental, aproximadamente 75%viviam em domic\u00edlios em que a renda  O c\u00e2ncer \u00e9 um problema mundial cuja incid\u00eancia e mortalidade v\u00eam aumentando, estandoentre as quatro principais causas de morte precoce na maioria dos pa\u00edses. No Brasil,estimam-se, para o tri\u00eanio 2023-2025, 704 mil novos casos de c\u00e2ncer por ano 2. \u00c9 fundamental, portanto, estar preparado parao crescimento dessas enfermidades nos sistemas de sa\u00fade, adotando medidas depreven\u00e7\u00e3o, diagn\u00f3stico precoce, distribui\u00e7\u00e3o de recursos para tratamento apropriado,tendo em vista um aumento na complexidade e nos custos anuais ,Nos pa\u00edses em desenvolvimento, observa-se uma transi\u00e7\u00e3o na incid\u00eancia dos tipos dec\u00e2ncer, com queda daqueles predominantemente associados a infec\u00e7\u00f5es e aumentodaqueles relacionados \u00e0 melhoria das condi\u00e7\u00f5es socioecon\u00f4micas e \u00e0 incorpora\u00e7\u00e3o deh\u00e1bitos e atitudes relativos \u00e0 urbaniza\u00e7\u00e3o, tais como sedentarismo e comportamentosalimentares inadequados ,,,Especificamente no Brasil, o Sistema \u00danico de Sa\u00fade (SUS) proporcionou, com suaregulamenta\u00e7\u00e3o em 1990, o acesso universal, sem discrimina\u00e7\u00e3o, ao sistema p\u00fablico desa\u00fade ,,,,H\u00e1 poucos estudos relacionados ao conhecimento do paciente portador de c\u00e2ncer sobreseus direitos sociais Trata-se de um estudo observacional descritivo. A pesquisa foi planejada e executadapelo servi\u00e7o social do Hospital Associa\u00e7\u00e3o Feminina de Preven\u00e7\u00e3o e Combate ao C\u00e2ncerde Juiz de Fora (ASCOMCER), Minas Gerais, Brasil, onde o tratamento \u00e9primordialmente direcionado a pacientes do SUS (94%). O crit\u00e9rio de inclus\u00e3o para oestudo foi definido como todos os pacientes oncol\u00f3gicos maiores de idade queagendaram consulta para serem tratados pela primeira vez nos ambulat\u00f3rios deradioterapia e quimioterapia do Hospital ASCOMCER entre mar\u00e7o e julho de 2022.Aqueles casos com recidiva de c\u00e2ncer, casos de segundo (ou mais) c\u00e2ncer e/oupacientes sem condi\u00e7\u00f5es cl\u00ednicas para participar da pesquisa foram exclu\u00eddos doestudo.https://cadernos.ensp.fiocruz.br/static//arquivo/suppl-e00096023-1_1023.pdf;e Material Suplementar 2: https://cadernos.ensp.fiocruz.br/static//arquivo/suppl-e00096023-2_8377.pdf). Em raz\u00e3o dos dados do registro hospitalar de c\u00e2ncer sobre os casos novos anal\u00edticosem que os pacientes realizaram algum tipo de tratamento espec\u00edfico de controle deneoplasias malignas no Hospital ASCOMCER (cerca de 500 em 2020) O desfecho principal do estudo, ou seja, o conhecimento sobre cada direitoselecionado, foi avaliado a partir de duas quest\u00f5es:(1) uma pergunta sobre conhecimento espont\u00e2neo: O(A) Sr(a) conhece algum direito dopaciente oncol\u00f3gico? Se a resposta for afirmativa, qual(is)?;(2) uma pergunta sobre conhecimento direcionado: O(A) Sr(a) sabe se o pacienteoncol\u00f3gico tem direito a [direito espec\u00edfico baseado no Para o conjunto de todos os pacientes, foi calculada a propor\u00e7\u00e3o de \u201cconhecimento depelo menos algum dos direitos selecionados\u201d, baseada na pergunta de conhecimentoespont\u00e2neo ou na de conhecimento direcionado.https://cadernos.ensp.fiocruz.br/static//arquivo/suppl-e00096023-1_1023.pdf;e Material Suplementar 2: https://cadernos.ensp.fiocruz.br/static//arquivo/suppl-e00096023-2_8377.pdf).Calcularam-se as propor\u00e7\u00f5es de pacientes eleg\u00edveis para solicitar cada direitoselecionado e, posteriormente, as propor\u00e7\u00f5es de conhecimento espont\u00e2neo oudirecionado espec\u00edfico por direito, adotando como denominador a popula\u00e7\u00e3o eleg\u00edvel(ou a n\u00e3o eleg\u00edvel) para solicitar o direito. A elegibilidade para poder solicitardeterminado direito foi definida a partir das exig\u00eancias estabelecidas em lei deacordo com a condi\u00e7\u00e3o socioecon\u00f4mica e/ou de sa\u00fade em que o paciente estivesse nomomento da entrevista .Todas as an\u00e1lises foram realizadas com o programa estat\u00edstico Stata, vers\u00e3o 15.0 no dia 25 defevereiro de 2022.per capita deno m\u00e1ximo um sal\u00e1rio m\u00ednimo (75%), aposentados , atendidos pelo SUS  eprovenientes da cidade de Juiz de Fora . Predominaram, ainda, pacientes comc\u00e2ncer de mama (21%) ou de pr\u00f3stata (21%) e em estadiamento III  (dados n\u00e3omostrados em tabela).No total, 88 pacientes chegaram para iniciar pela primeira vez o tratamento noHospital ASCOMCER. Destes, cerca 26,1% n\u00e3o apresentaram condi\u00e7\u00f5es cl\u00ednicas paraserem entrevistados e 3,4% se recusaram a assinar o consentimento informado e foramexclu\u00eddos do estudo. Dos 62 pacientes entrevistados, predominaram mulheres ,indiv\u00edduos com idade superior a 64 anos , com n\u00edvel educacional abaixo doEnsino M\u00e9dio , vivendo em domic\u00edlios com renda vs. 11,8%). A altapropor\u00e7\u00e3o de pacientes eleg\u00edveis para os direitos \u201cisen\u00e7\u00e3o do imposto de renda\u201d, \u201cisen\u00e7\u00e3o de imposto sobre propriedade predial e territorial urbana\u201d e \u201cprioridade na tramita\u00e7\u00e3o de processos\u201d (100%) foi acompanhada de baix\u00edssimapropor\u00e7\u00e3o de conhecimento sobre eles . Finalmente,vale a pena destacar a aus\u00eancia total de conhecimento sobre o direito ao \u201csaque doPrograma de Integra\u00e7\u00e3o Social (PIS) ou do Programa de Forma\u00e7\u00e3o do Patrim\u00f4nio doServidor P\u00fablico (Pasep)\u201d entre os quase 20% de pacientes eleg\u00edveis para ele.Entre todos os pacientes, a propor\u00e7\u00e3o de \u201cconhecimento de pelo menos algum dosdireitos selecionados\u201d baseada na pergunta de conhecimento espont\u00e2neo (21%) foimenor quando comparada \u00e0 respectiva propor\u00e7\u00e3o fundamentada na pergunta deconhecimento direcionado  .Nota-seA propor\u00e7\u00e3o de conhecimento dos direitos espec\u00edficos por meio de perguntasdirecionadas entre todos os pacientes oncol\u00f3gicos atendidos no Hospital ASCOMCER(eleg\u00edveis ou n\u00e3o para os direitos) esteve sempre abaixo de 40% (com exce\u00e7\u00e3o do\u201caux\u00edlio-doen\u00e7a\u201d), sendo que, para cerca de 70% dos direitos selecionados, essapropor\u00e7\u00e3o ficou abaixo de 10%. Ao analisar a propor\u00e7\u00e3o de pacientes que \u201cconheciampelo menos algum dos direitos selecionados\u201d, o percentual encontrado foi de62,9%.Estudo realizado em 2008 em uma unidade de tratamento oncol\u00f3gico para pacientes comperfil socioecon\u00f4mico mais elevado do que o dos atendidos no Hospital ASCOMCERencontrou percentual relativamente parecido (55%) ,,,,,Aproximadamente 1/3 dos direitos selecionados apresentaram uma \u201crela\u00e7\u00e3odesequilibrada\u201d entre a propor\u00e7\u00e3o de pacientes eleg\u00edveis (> 50%) e a propor\u00e7\u00e3o deconhecimento do direito entre a popula\u00e7\u00e3o eleg\u00edvel (< 50%). Considerando que amaioria das pessoas atendidas para tratamento pela primeira vez no Hospital ASCOMCERtinha condi\u00e7\u00e3o socioecon\u00f4mica prec\u00e1ria, o impacto populacional obtido com adissemina\u00e7\u00e3o desse tipo de informa\u00e7\u00e3o em pacientes com c\u00e2ncer atendidos pelo SUSpode ser, portanto, relevante para atenuar as desigualdades sociais do pa\u00eds. Nesseponto, o profissional de sa\u00fade, sobretudo o assistente social do Hospital ASCOMCER, \u00e9 fundamental, tendo em vista que ele atua comofacilitador para que o paciente e seus familiares tenham acesso \u00e0s informa\u00e7\u00f5es sobreseus direitos e saibam como solicit\u00e1-los ,\u00c9 interessante notar que, no caso do \u201cpasse livre municipal\u201d e do \u201ctratamento fora dedomic\u00edlio\u201d, provavelmente, muitos dos pacientes eleg\u00edveis que j\u00e1 usufruem dessesdireitos nem percebem que eles somente s\u00e3o concedidos sob determinadas condi\u00e7\u00f5es \u00e0squais os pacientes fazem jus. De fato, quando vemos a enorme diferen\u00e7a entre aresposta \u00e0 pergunta de conhecimento espont\u00e2neo e a resposta \u00e0 pergunta deconhecimento direcionado fica ainda mais evidente a necessidade de refor\u00e7ar paraessa popula\u00e7\u00e3o que uma parte dela j\u00e1 est\u00e1, provavelmente, sendo beneficiada. Al\u00e9mdos benef\u00edcios econ\u00f4micos advindos do direito, a consci\u00eancia de ter acesso a algumdireito garantido em lei em raz\u00e3o da sua condi\u00e7\u00e3o de sa\u00fade pode refor\u00e7ar sentimentosimportantes de pertencimento social, os quais auxiliam na jornada do tratamentoInfelizmente, a quantidade de pacientes atendidos pela primeira vez no HospitalASCOMCER entre os meses de mar\u00e7o e julho de 2022 ficou bem aqu\u00e9m daquelainicialmente prevista, o que acabou prejudicando a signific\u00e2ncia estat\u00edstica dealgumas compara\u00e7\u00f5es realizadas. Houve, de fato, perda diferencial de quase 30% dospotenciais pacientes eleg\u00edveis para este estudo, muito em raz\u00e3o do agravamento dascondi\u00e7\u00f5es cl\u00ednicas daqueles que provavelmente retardaram o in\u00edcio do tratamentodevido \u00e0 pandemia de COVID-19 A propor\u00e7\u00e3o de conhecimento dos pacientes acerca dos direitos para os quais eles erameleg\u00edveis ficou abaixo de 10% para mais da metade dos direitos pesquisados. \u00c9fundamental orientar os pacientes quanto aos seus direitos e benef\u00edcios, de forma aauxiliar na identifica\u00e7\u00e3o de recursos que favore\u00e7am o processo de tratamento dadoen\u00e7a."}
+{"text": "To analyze the trends of cervical cancer mortality in Brazilian Southeastern states, and to compare them to Brazil and other regions between 1980 and 2020.Sistema de Informa\u00e7\u00f5es de Mortalidade . Death data were corrected by proportional redistribution of deaths from ill-defined causes and cervical cancer of unspecified portion. Age-standardized and age-specific rates were calculated by screening target  and non-target (65 years or older) age groups. Annual percentage changes (APC) were estimated by linear regression model with breakpoints. The coverage of Pap Smear exam in the Unified Health System (SUS) was evaluated between 2009 and 2020 according to age group and locality. Time series study based on data from the  There were increases in corrected mortality rates both in 1980 and in 2020 in all regions, with most evident increments at the beginning of the series. There was a decrease in mortality nationwide between 1980\u20132020; however, the state of S\u00e3o Paulo showed a discrete upward trend in 2014\u20132020 . Noteworthy is the trend increment in the 25\u201339 year-old group in all study localities, being sharper in the Southeast region in 2013\u20132020 . Screening coverage rates were highest in S\u00e3o Paulo and lowest in Rio de Janeiro, with a consistent decline from 2012 onwards at all ages. S\u00e3o Paulo is the first Brazilian state to show a reversal trend in mortality from cervical cancer. The changes in mortality patterns identified in this study point to the need for reorganization of the current screening program, which should be improved to ensure high coverage, quality, and adequate follow-up of all women with altered test results. With large global variations in mortality rates, it is the leading cancer type related to death among women in 36 countries2 . In recent decades, significant reductions in mortality and incidence have occurred in countries that have implemented Pap Smear-based vaginal cytology3 screening programs, with better results found in those with organized screening4 .Cervical cancer is a disease necessarily caused by the persistent infection by high-risk human papillomavirus (HPV) types6 , which highlights the need for investments in more efficient strategies for organizing screening programs8 .Adversely, some countries that have seen significant declines in morbidity and mortality from organized Pap Smear-based screening have started to witness smaller declines, stability or even increases in mortality from the disease9 . To monitor screening tests and diagnostic confirmation in the Unified Health System (SUS), the MoH implemented information systems called SISCOLO  and SISCAN .The first initiatives for early detection of cervical cancer in Brazil were isolated, within restricted populations and occurred in the late 1980s. It was only after 1998, with the development of a control program for this cancer by the Brazilian Ministry of Health (MoH), that cervical screening practices were structured on an opportunistic basis throughout the country. The current guidelines recommend the Pap Smear test for women aged 25\u201364 years10 and problems in the follow-up of screened women11 , which may impact the trend of decreasing mortality in the medium and long term. The objective of this study is to analyze the trends of cervical cancer mortality in Brazilian Southeastern states, and to compare them to Brazil and other regions between 1980 and 2020.In the state of S\u00e3o Paulo, data available from the State Health Secretariat indicate a decline in the coverage of Pap Smear exams performed at SUS as of 2010Sistema de Informa\u00e7\u00e3o sobre Mortalidade , SIM) in the period 1980\u20132020. The data were obtained from the DATASUS12 website, with data for 2020 still preliminary. For 1980\u20131995 the ninth edition of the International Statistical Classification of Diseases, Injuries and Causes of Death (ICD-9) was used, and between 1996\u20132020 the tenth edition (ICD-10) was used.Time-series study using data of deaths among women recorded in the Mortality Information System ( 13 according to: 1) 1980\u20132012 data from the Censuses , Count (1996) and Intercensal Projections (1981\u20132012); and, 2) 2013\u20132020 data from the Population Estimates Study.Populations for each locality were obtained from tabulations in DATASUSMortality data and populations were aggregated in 5-year intervals from 15 to 79 years old  according to the Federation Unit for the Southeast, Brazil and Brazilian regions of residence. Deaths records without age information were proportionally distributed among the seven age groups according to the underlying cause of death, place of residence and year of death.14 (2003) and adapted by Girianelli et al.15 (2014), which consists on proportionally redistributing 50% of deaths with an ill-defined underlying cause . This correction is identified in this study as Correction 1.We corrected the information on the underlying cause of death applying the methodology proposed by Mathers et al.16 . Corrections were applied proportionally to the registered deaths according to calendar year, place of residence and age group.For deaths registered as from cervical cancer , an additional correction (Correction 2) was performed, with redistribution of deaths classified as malignant neoplasm of uterus, part unspecified , maintaining the proportion registered as deaths from cervical and uterine body cancer17 (1960). In addition to standardized rates, age-specific rates were calculated for ages 25\u201339, 40\u201364 and 65 years or older.For each locality and calendar year in the period 1980\u20132020, age-standardized mortality rates were calculated, considering data without and with correction, using as standard the world population proposed by Segi18 . Since these are time series with trends that vary over time in a non-regular manner, a linear model for the overall trend for the entire period would not be adequate. In order to consider the existence of structural breaks, the time variable was introduced into the model by means of piecewise linear splines that allowed the identification of inflection moments in the series. With this, models with different break points around the points identified with the splines were tested. The models were compared using Akaike\u2019s criterion (AIC)19 to define the points that offered the best fit to the model.To estimate the general and specific mortality trend, a linear regression model was applied, according to the methodology used in a previously published study20 was used.The residuals-based evaluation of the models was performed to verify if the usual assumptions were met, and to check for residual autocorrelation by autocorrelation functions (FAC) and partial autocorrelation (FACP). Models that showed significant autocorrelation or with an absolute value greater than 0.5 were re-estimated using generalized least squares with first-order autoregressive model AR (1), allowing the modeling of autocorrelation and correction of the variance from coefficient estimators. The function \u201cgls\u201d with restricted maximum likelihood estimation (REML) from the package \u201cnlme\u201dThe coefficient of the term for each segment expresses the logarithm of the trend in that interval. Thus, the annual percent change (APC) of mortality rates was calculated by the formula, with respective 95% confidence intervals (95%CI) and p values. For the interpretation of trends, statistical non-significance  was used as a criterion to characterize an APC as stable. The statistically significant PCA, when positive, indicated an increasing trend, and when negative, a decreasing trend.21 Outpatient Information System  and 1/3 of the female population13 excluding the percentage of beneficiaries of health insurance plans, in each age group and locality, obtained from the Brazilian National Agency for Supplementary Health22 . Dividing the population into 1/3 is justified by the recommendation that an exam be performed every three years23 .The coverage of screening by cytopathological exam of the uterine cervix (Pap Smear) in women aged 25\u201339 years, 40\u201364 and 65 years or older in 2009\u20132020 was evaluated by the ratio between the total number of exams with codes 0203010019 , and 0203010086 recorded in the SUSAll analyses were performed in the R Software, version 4.1.0.In the Southeast region, between 1980 and 2020, there were 63,889 deaths from malignant neoplasm of the cervix (without correction), 665,231 deaths with an ill-defined or unknown underlying cause, and 41,006 deaths from malignant neoplasm of uterus, part unspecified. In Brazil, the respective numbers of deaths were 165,087, 2,178,355 and 83,748.The correction with redistribution of deaths from an ill-defined or unknown underlying cause led to an increase of 15.38% in the rates for Brazil in 1980, ranging from 7.69% in the Southeast to 35.56% in the Northeast. The increase with this correction was smaller in 2020 . Adding to this correction the redistribution of deaths from cervical cancer in the unspecified portion, the rates in 1980 increased by 68.33% for Brazil (ranging from 36.36% in the Midwest to 98.18% in the South). By 2020, smaller increases occurred  (data not shown).Comparing age-adjusted  and age-standardized mortality rates, the highest ones were in the North region and the lowest in the Southeast, with a ratio between these in 2020 of 2.47   .In Brazil, a decrease in the magnitude of mortality rates was observed between 1980 and 2020   , a pattThe temporal distribution of age-specific adjusted mortality rates shows that, in general, the Southeast region and the state of S\u00e3o Paulo had lower rates compared to the country. This divergence is particularly noticeable from the year 2000 onwards. Even though the lowest mortality rates were observed in the 25\u201339 age group, the increase in the risk of death in this age group is noteworthy in all spatial cuts examined   . The trIn the 40\u201364 age group, marked declines occurred in both Brazil and the Southeast region, as well as in S\u00e3o Paulo between the years 1990 and 2013, after which mortality rates remained decreasing in the country but became stable in the Southeast and S\u00e3o Paulo. In ages 65 years or older, it is worth noting the prominent decline in mortality in S\u00e3o Paulo in the 1999\u20132015 period , followed by stability in 2015\u20132020    .Regarding the performance of cervical cytopathological exam in the Southeast in 2009\u20132020, the highest coverage was observed in S\u00e3o Paulo and the lowest in Rio de Janeiro   . In all24 . The highest mortality rates were observed in regions with lower socioeconomic status25 and less access to health services, such as the North and Northeast regions26 . In four decades there was a downward trend throughout the country, with the exception of the interior of the North region, which in 2017 showed rates three times higher than the Southeast, unveiling the extreme inequality in the risk of becoming ill and dying from this cancer18 .The Brazilian scenario is compatible with the inverse correlation between the occurrence of cervical cancer and the level of socioeconomic development27 and, to some extent, to the opportunistic screening started in 1998, the speed of the decline in mortality was slower than that observed in other Latin American countries such as Chile28 .Although the downward curves in mortality may be attributed to the greater health equity resulting from the implementation of the SUS in 199029 . In the Latin American and Caribbean region and Asia, the incidence of cervical cancer is relatively high. Favorable trends in incidence have been observed in several countries; however, but preventive actions are inefficient and probably this decrease is related to other factors such as decreased fertility and birth rate, hygiene conditions, or improved socioeconomic status30 . In Brazil, Chile, and Colombia, positive outlook for cervical cancer is related to better structured screening programs and relatively higher coverage rates than other Latin American countries31 , although the impact of these programs is limited by inequalities in access to diagnostic and treatment services and suboptimal coverage and follow-up rates32 .In the United States, the decline in incidence and mortality has also been observed with the implementation of cytological screening, but many racial and socioeconomic inequalities exist33 . In S\u00e3o Paulo, the increase observed in the 25\u201339 age group , stability in the 40\u201364 age group , and the only one to show stability in ages 65 years or older are noteworthy. This finding points out that S\u00e3o Paulo is the first Brazilian state to show a reversal trend in mortality from cervical cancer.In this study, the trend of increasing cervical cancer mortality among women aged 25\u201339 years in Brazil was very pronounced in the Southeastern states, especially Minas Gerais and Sao Paulo. This phenomenon has been seen in other countries recently33 . Despite the finding that there it is a cancer in decline in several countries, recent trends of increasing incidence among young women, more marked in high-income countries, have been observed35 . For birth cohorts from 1940 or 1950 onwards an increase in incidence was observed in European countries and Japan, while the incidence remained stable in the United States3 . The same has been described in Central Europe, Eastern Europe, and Central Asia33 . This increase has raised debate around the need to review and implement more effective screening strategies.The increased incidence and mortality among younger women has been attributed to changes in sexual behavior that increase the risk of persistent HPV infectionAt younger ages, cancer mortality rates are lower than those at older ages, and are therefore more prone to fluctuations due to fewer deaths. In this study, the trend of increasing mortality among young women was verified through positive and statistically significant annual percentage changes. For this reason, we consider it relevant to show this situation that has been reported in other countries. In Brazil, this finding demands attention to the screening coverage indicators in this specific age group, as well as to indicators of access to diagnosis and treatment, since fewer cervical cancer deaths are expected at these age groups. Knowing the prevalence of HPV infection over time and whether the disease has affected these women earlier would bring important contributions to the direction of specific actions at all levels of healthcare.36 and 80% in the capital cities37 , proportions that may be considered high. Since these are based on self-reported information from women interviewed in population surveys, they may not reflect the actual screening coverage. At the same time, the incidence and mortality rates for cervical cancer remain high compared to other countries2 , with great disparity between regions38 . In this aspect, it is worth noting that the actual coverage is certainly lower than those reported in population surveys.The self-reported coverage of Pap Smear for all women in the target age group was 78.8% in the country39 . Moreover, the availability of exams for diagnostic confirmation in SUS is deficient, which impairs following-up of screened women40 .Lower coverages are observed from the SUS databases - SISCOLO, SISCAN, and SIA. Recently, a drop was identified in the number of women who performed cytopathological exam for the first time in SISCOLO, reaching 41% between the years 2012 and 2013In the Southeast, especially in S\u00e3o Paulo, SUS screening coverage tends to be higher compared to other states in the country. In 2009\u20132020, declines in the percentages of screening test coverage were observed in all states and age groups, indicating that access to the exam in the SUS has been reduced. The lowest level of coverage occurred in 2020, which can be explained by the Covid-19 pandemic.41 found a significant reduction in the proportion of exams performed outside the screening target age group in Campinas, a municipality located in the state of S\u00e3o Paulo, between 2010 and 2016, especially in women under 25 years old. According to the authors, the better alignment of local practices with national guidelines could explain the declines observed in coverage rates in recent years. In addition to a reduction in the excess of exams, Vale et al.41 found increases in the proportions of exams performed among women aged 25 and 64 years, a fact not observed in this study. The data presented for the Southeast region showed that the reductions observed since 2009 in the group aged 65 and over were also verified in the age group of 25\u201364 years. This fact suggests there are other factors related to the decline in screening coverage in the Southeast region, in addition to those pointed out in the Campinas study41 .Vale et al.Sistema de Interna\u00e7\u00f5es Hospitalares, SIH) reviewed the quality of follow-up of screened women in the state of S\u00e3o Paulo and found that for 35.2% of women with abnormal cytology, there were no data found on the diagnosis in the information systems11 . It also identified a median time greater than six months between the altered test and diagnosis and almost three months between diagnosis and the beginning of treatment. These prolonged times were associated with worse conditions of care in the regional healthcare units of the state. Reinforcing these findings, another study also conducted in S\u00e3o Paulo concluded that access to colposcopy is limited in the state, impairing diagnosis and consequently treatment42 .In addition to the decrease in coverage, there are problems in the follow-up of the abnormal results. A study based on linkage of data from SISCAN, SIA, and Hospital Admissions System , in 53.5% of cases in 20121 entails the need to reformulate primary and secondary prevention of cervical cancer6 . The introduction of HPV testing can optimize and make screening more effective, especially in low-income countries45 . Data from large randomized studies have shown that protection against invasive carcinoma with screening based on HPV testing from 30 years of age and at 5-year intervals is 60\u201370% higher compared to oncotic cytology7 .The discovery of the causal role of HPV46 . Even with the availability of the HPV test as a recommended screening test, challenges inherent to the organization of the program will continue to exist. More than the screening test, the use of the most appropriate approach to organize all components, including quality aspects, are determining factors for the success of a screening program8 .There are issues that deserve investigation in order to make decisions about strategic and cost-effective measures that should be implemented in cervical cancer control programs. Some of these are the definition of screening intervals, ways to motivate women to adhere, and the organization of services from access to screening to improved infrastructure for diagnosis and treatmentAnalyses of trends of mortality from cervical cancer are often impaired by inaccuracies when filling in the underlying cause of death, since a portion is registered as malignant neoplasm of uterus, part unspecified, which does not allow knowledge of the true anatomical origin of the tumor (cervix or body of the uterus). To deal with this limitation, a technique was employed to correct the deaths from cervical cancer originally recorded in the SIM, allowing more realistic analyses. It should be highlighted that in 2020 the correction for ill-defined causes was low in all regions (ranged from 1.96% in the Midwest to 4.21% in the North). However, the redistribution by uterus part unspecified led to an increase of 28.57% in the Southeast region, a higher percentage if compared to the other regions.After significant progress in the accuracy of death information in the 1980\u20132020 period and decades of decline in mortality from cervical cancer, recent trends of stability in Brazil and increase in the state of S\u00e3o Paulo point to the need for reorganizing the current screening program to achieve improvements in coverage and quality in all its stages - screening, diagnosis, and treatment. Immunization against HPV will bring positive results in the long term, but its implementation does not minimize the role of secondary prevention; rather, it reinforces the immediate need for planning for implementation in the medium term of a more cost-effective and sensitive screening test.An organized screening program will make it possible to actively reach women in the target age group, and especially women 25\u201339 years old, in which a sharp increase in mortality from cervical cancer has been observed in the country. These are women in full sexual activity and also clearly integrated into the economically active population and, thus, with greater difficulties in adhering to screening.47 .Only with a broad approach including high coverage, quality of examinations, and follow-up throughout the cancer care pathway, will greater reductions not only in mortality, but also in incidence be achieved. This will ensure Brazil\u2019s alignment with the global strategy of eliminating cervical cancer as a public health issue 1 e, apesar de potencialmente evit\u00e1vel, ainda \u00e9 um grave problema de sa\u00fade em pa\u00edses de m\u00e9dia e baixa renda2 . Com grandes varia\u00e7\u00f5es globais nas taxas de mortalidade, ele se apresenta como o principal tipo de c\u00e2ncer relacionado ao \u00f3bito entre mulheres em 36 pa\u00edses2 . Nas \u00faltimas d\u00e9cadas, redu\u00e7\u00f5es expressivas na mortalidade e incid\u00eancia ocorreram em pa\u00edses que implementaram programas de rastreamento baseados na citologia vaginal pelo Papanicolaou3 , com melhores resultados encontrados naqueles com rastreamento organizado4 .O c\u00e2ncer de colo do \u00fatero \u00e9 uma doen\u00e7a que tem como causa necess\u00e1ria a infec\u00e7\u00e3o persistente por tipos de papilomav\u00edrus humano (HPV) de alto risco6 , levando \u00e0 necessidade de investimentos em estrat\u00e9gias mais eficientes para organiza\u00e7\u00e3o dos programas de rastreamento8 .Adversamente, alguns pa\u00edses que tiveram importante queda na morbimortalidade decorrente do rastreamento organizado com base no Papanicolaou come\u00e7aram a mostrar quedas em menor intensidade na mortalidade pela doen\u00e7a, estabilidade ou mesmo aumento9 . Para monitoramento dos exames de rastreamento e de confirma\u00e7\u00e3o diagn\u00f3stica no Sistema \u00danico de Sa\u00fade (SUS), o MS implantou sistemas de informa\u00e7\u00f5es denominados SISCOLO (Sistema de Informa\u00e7\u00e3o do C\u00e2ncer do Colo do \u00datero) e SISCAN (Sistema de Informa\u00e7\u00e3o do C\u00e2ncer).As primeiras iniciativas de detec\u00e7\u00e3o precoce do c\u00e2ncer de colo do \u00fatero no Brasil foram isoladas, com popula\u00e7\u00f5es restritas e ocorreram no final da d\u00e9cada de 1980. Somente a partir de 1998, com o desenvolvimento de um programa de controle desse c\u00e2ncer pelo Minist\u00e9rio da Sa\u00fade (MS), as pr\u00e1ticas de rastreamento foram estruturadas em car\u00e1ter oportun\u00edstico em todo o territ\u00f3rio nacional. As diretrizes atuais recomendam o Papanicolaou para mulheres de 25\u201364 anos de idade10 e problemas no seguimento de mulheres rastreadas11 , o que pode impactar a tend\u00eancia de queda da mortalidade a m\u00e9dio e longo prazos. Este estudo tem o objetivo de analisar as tend\u00eancias da mortalidade do c\u00e2ncer de colo do \u00fatero nos estados da regi\u00e3o Sudeste e compar\u00e1-las com o Brasil e demais regi\u00f5es entre 1980 e 2020.No estado de S\u00e3o Paulo, dados dispon\u00edveis na Secretaria Estadual de Sa\u00fade indicam decl\u00ednio na cobertura dos exames de Papanicolaou realizados no SUS a partir de 201012 , sendo os dados de 2020 ainda preliminares. Para 1980-1995 foi utilizada a nona edi\u00e7\u00e3o da Classifica\u00e7\u00e3o Estat\u00edstica Internacional de Doen\u00e7as, Les\u00f5es e Causas de \u00d3bito (CID-9) e entre 1996\u20132020 a d\u00e9cima edi\u00e7\u00e3o (CID-10).Estudo de s\u00e9rie temporal utilizando dados dos \u00f3bitos entre mulheres registrados no Sistema de Informa\u00e7\u00e3o sobre Mortalidade (SIM) no per\u00edodo 1980\u20132020. Os dados foram obtidos na p\u00e1gina do DATASUS13 de acordo com: 1) 1980\u20132012 dados dos Censos , Contagem (1996) e Proje\u00e7\u00f5es intercensit\u00e1rias (1981\u20132012); e 2) 2013\u20132020 dados do Estudo de Estimativas Populacionais.As popula\u00e7\u00f5es para cada localidade foram obtidas a partir de tabula\u00e7\u00f5es no DATASUSOs dados de mortalidade e popula\u00e7\u00f5es foram agregados em intervalos de 5 em 5 anos a partir dos 15 at\u00e9 79 anos de idade  segundo Unidade da Federa\u00e7\u00e3o para o Sudeste, Brasil e regi\u00f5es brasileiras de resid\u00eancia. Os \u00f3bitos sem informa\u00e7\u00e3o de idade foram proporcionalmente distribu\u00eddos entre os sete grupos et\u00e1rios de acordo com a causa b\u00e1sica de morte, local de resid\u00eancia e ano de \u00f3bito.14 (2003) e adapta\u00e7\u00e3o feita por Girianelli et al.15 (2014), que consiste em redistribuir proporcionalmente 50% dos \u00f3bitos com causa b\u00e1sica mal definida . Esta corre\u00e7\u00e3o est\u00e1 identificada neste estudo como Corre\u00e7\u00e3o 1.Foi realizada corre\u00e7\u00e3o da informa\u00e7\u00e3o sobre a causa b\u00e1sica de \u00f3bito seguindo metodologia proposta por Mathers et al.16 . As corre\u00e7\u00f5es foram aplicadas de maneira proporcional aos \u00f3bitos registrados segundo ano-calend\u00e1rio, local de resid\u00eancia e faixa et\u00e1ria.Para os \u00f3bitos registrados como c\u00e2ncer de colo do \u00fatero , realizou-se corre\u00e7\u00e3o adicional (Corre\u00e7\u00e3o 2), com redistribui\u00e7\u00e3o dos \u00f3bitos classificados como neoplasia maligna do \u00fatero de por\u00e7\u00e3o n\u00e3o especificada , mantendo a propor\u00e7\u00e3o registrada como \u00f3bitos por c\u00e2ncer de colo e de corpo uterino17 (1960). Al\u00e9m das taxas padronizadas, foram calculadas as taxas espec\u00edficas por faixas et\u00e1rias de 25-39 anos, 40\u201364 e 65 anos ou mais.Para cada localidade e ano-calend\u00e1rio em 1980-2020 foram calculadas as taxas de mortalidade padronizadas por idade, considerando os dados sem corre\u00e7\u00e3o e com corre\u00e7\u00e3o, tendo como padr\u00e3o a popula\u00e7\u00e3o mundial proposta por Segi18 . Por se tratar de s\u00e9ries temporais com tend\u00eancias que variam no tempo de forma n\u00e3o regular, um modelo linear para tend\u00eancia global para todo o per\u00edodo n\u00e3o seria adequado. Para considerar a exist\u00eancia de quebras estruturais, a vari\u00e1vel tempo foi introduzida ao modelo por meio de spline linear por partes que permitiram identificar os momentos de inflex\u00e3o na s\u00e9rie. Com isso, foram testados modelos com diferentes pontos de quebra no entorno dos pontos identificados com as splines . Os modelos foram comparados pelo crit\u00e9rio de Akaike (AIC)19 para definir os pontos que ofereceram melhor ajuste ao modelo.Para estimar a tend\u00eancia da mortalidade geral e espec\u00edfica aplicou-se um modelo de regress\u00e3o linear, conforme metodologia utilizada em estudo previamente publicado20 .A avalia\u00e7\u00e3o dos modelos via res\u00edduos foi realizada para verificar se os pressupostos usuais foram atendidos e para verificar a exist\u00eancia de autocorrela\u00e7\u00e3o residual por fun\u00e7\u00f5es de autocorrela\u00e7\u00e3o (FAC) e autocorrela\u00e7\u00e3o parcial (FACP). Os modelos que apresentaram autocorrela\u00e7\u00e3o significativa ou com valor absoluto maior que 0,5 foram estimados novamente usando m\u00ednimos quadrados generalizados com modelo autorregressivo de primeira ordem AR (1), permitindo modelar a autocorrela\u00e7\u00e3o e corrigir a vari\u00e2ncia dos estimadores dos coeficientes. Foi utilizada a fun\u00e7\u00e3o \u201cgls\u201d com estima\u00e7\u00e3o por m\u00e1xima verossimilhan\u00e7a restrita (REML) do pacote \u201cnlme\u201dannual percent change \u2013 APC) das taxas de mortalidade pela f\u00f3rmula, com respectivos intervalos de confian\u00e7a de 95% (IC95%) e valores de p. Para a interpreta\u00e7\u00e3o das tend\u00eancias, a n\u00e3o signific\u00e2ncia estat\u00edstica  foi utilizada como crit\u00e9rio para caracterizar uma APC como est\u00e1vel. A APC estatisticamente significante, quando positiva, indicou tend\u00eancia crescente e, quando negativa, decrescente.O coeficiente do termo referente a cada segmento expressa o logaritmo da tend\u00eancia naquele intervalo. Assim, foram calculadas as varia\u00e7\u00f5es percentuais anuais ( 21 (SIA) e 1/3 da popula\u00e7\u00e3o feminina13 excluindo-se o percentual de benefici\u00e1rias de planos de sa\u00fade, em cada grupo et\u00e1rio e localidade, obtido da Ag\u00eancia Nacional de Sa\u00fade Suplementar22 . A divis\u00e3o da popula\u00e7\u00e3o a 1/3 justifica-se pela recomenda\u00e7\u00e3o de que um exame seja realizado a cada tr\u00eas anos23 .A cobertura de rastreamento pelo exame citopatol\u00f3gico do colo uterino (Papanicolaou) em mulheres de 25-39 anos, 40-64 e 65 anos ou mais em 2009-2020 foi avaliada pela raz\u00e3o entre o n\u00famero total de exames com c\u00f3digos 0203010019  e 0203010086 registrados no Sistema de Informa\u00e7\u00f5es Ambulatoriais do SUSTodas as an\u00e1lises foram realizadas no Programa R, vers\u00e3o 4.1.0.Na regi\u00e3o Sudeste, entre 1980 e 2020 ocorreram 63.889 mortes por neoplasia maligna do colo do \u00fatero (sem corre\u00e7\u00e3o), 665.231 mortes com causa b\u00e1sica mal definida ou desconhecida e 41.006 mortes por neoplasia maligna do \u00fatero, por\u00e7\u00e3o n\u00e3o especificada. No Brasil, os respectivos n\u00fameros de mortes foram 165.087, 2.178.355 e 83.748.Pela corre\u00e7\u00e3o com redistribui\u00e7\u00e3o dos \u00f3bitos por causa b\u00e1sica mal definida ou desconhecida, as taxas para o Brasil em 1980 aumentaram em 15,38%, variando de 7,69% na regi\u00e3o Sudeste a 35,56% no Nordeste. O aumento com essa corre\u00e7\u00e3o foi menor em 2020 . Acrescentando-se a esta corre\u00e7\u00e3o a redistribui\u00e7\u00e3o dos \u00f3bitos por c\u00e2ncer do \u00fatero por\u00e7\u00e3o n\u00e3o especificada, as taxas em 1980 aumentaram em 68,33% para o Brasil . Em 2020, aumentos menores ocorreram  (dados n\u00e3o apresentados).Comparando-se taxas de mortalidade corrigidas  e padronizadas por idade, observam-se que as mais altas foram as da regi\u00e3o Norte e as mais baixas no Sudeste, com raz\u00e3o entre estas em 2020 de 2,47   .No Brasil, verificou-se queda na magnitude das taxas de mortalidade entre 1980 e 2020   , padr\u00e3oA distribui\u00e7\u00e3o temporal das taxas de mortalidade corrigidas espec\u00edficas por faixas et\u00e1rias mostra que, de forma geral, a regi\u00e3o Sudeste e o estado de S\u00e3o Paulo apresentaram taxas menores em compara\u00e7\u00e3o com o pa\u00eds. Esse afastamento \u00e9 particularmente percept\u00edvel a partir dos anos 2000. Ainda que as menores taxas de mortalidade tenham sido observadas no grupo de 25\u201339 anos, destaca-se o aumento do risco de morte nessa faixa et\u00e1ria em todos os recortes espaciais examinados   . Pela aNo grupo de 40\u201364 anos, tanto no Brasil como na regi\u00e3o Sudeste e S\u00e3o Paulo, decl\u00ednios marcantes ocorreram entre os anos 1990 e 2013, a partir de quando as taxas de mortalidade permaneceram em redu\u00e7\u00e3o no pa\u00eds, mas tornaram-se est\u00e1veis no Sudeste e S\u00e3o Paulo. Nas idades de 65 anos ou mais, vale destacar o proeminente decl\u00ednio na mortalidade em S\u00e3o Paulo no per\u00edodo 1999\u20132015 , seguido de estabilidade em 2015\u20132020    .Em rela\u00e7\u00e3o \u00e0 realiza\u00e7\u00e3o do exame citopatol\u00f3gico do colo uterino no Sudeste em 2009\u20132020, as maiores coberturas foram observadas em S\u00e3o Paulo e as menores no Rio de Janeiro   . Em tod24 . As maiores taxas de mortalidade foram observadas em regi\u00f5es de menor n\u00edvel socioecon\u00f4mico25 e com menor acesso aos servi\u00e7os de sa\u00fade, como Norte e Nordeste26 . Em quatro d\u00e9cadas houve tend\u00eancia de redu\u00e7\u00e3o em todo o pa\u00eds, com exce\u00e7\u00e3o do interior da regi\u00e3o Norte que, em 2017, apresentou taxas tr\u00eas vezes mais altas do que o Sudeste, demarcando a extrema desigualdade no risco de adoecimento e morte por esse c\u00e2ncer18 .O cen\u00e1rio brasileiro mostra-se compat\u00edvel com a correla\u00e7\u00e3o inversa entre a ocorr\u00eancia do c\u00e2ncer de colo do \u00fatero e o n\u00edvel de desenvolvimento socioecon\u00f4mico27 e, em certa medida, ao rastreamento oportun\u00edstico iniciado em 1998, a velocidade da queda da mortalidade foi inferior \u00e0 observada em outros pa\u00edses da Am\u00e9rica Latina como o Chile28 .Embora as curvas descendentes na mortalidade possam ser atribu\u00eddas \u00e0 maior equidade em sa\u00fade decorrente da implanta\u00e7\u00e3o do SUS em 199029 . Na regi\u00e3o da Am\u00e9rica Latina e Caribe e na \u00c1sia, a incid\u00eancia de c\u00e2ncer de colo do \u00fatero \u00e9 relativamente alta. Tend\u00eancias favor\u00e1veis da incid\u00eancia foram observadas em v\u00e1rios pa\u00edses, contudo as a\u00e7\u00f5es de preven\u00e7\u00e3o s\u00e3o ineficientes e provavelmente essa queda est\u00e1 relacionada a outros fatores como diminui\u00e7\u00e3o da fertilidade e natalidade, condi\u00e7\u00f5es de higiene ou melhora do n\u00edvel socioecon\u00f4mico30 . No Brasil, Chile e Col\u00f4mbia, perspectivas positivas do c\u00e2ncer de colo do \u00fatero t\u00eam rela\u00e7\u00e3o com programas de rastreamento melhor estruturados e taxas de cobertura relativamente mais altas do que outros pa\u00edses da Am\u00e9rica Latina31 , embora o impacto desses programas seja limitado por desigualdades no acesso aos servi\u00e7os para diagn\u00f3stico e tratamento e taxas de cobertura e seguimento abaixo do ideal32 .Nos Estados Unidos, o decl\u00ednio da incid\u00eancia e da mortalidade tamb\u00e9m foi observado com a implementa\u00e7\u00e3o do rastreamento citol\u00f3gico, mas muitas desigualdades raciais e socioecon\u00f4micas existem35 . Em S\u00e3o Paulo chama aten\u00e7\u00e3o o aumento observado na faixa de 25-39 anos (tamb\u00e9m observado em Minas Gerais e Rio de Janeiro), estabilidade no grupo de 40\u201364 anos (tamb\u00e9m visto no Esp\u00edrito Santo e Rio de Janeiro) e o \u00fanico a mostrar estabilidade nas idades de 65 anos ou mais. Esse achado indica que S\u00e3o Paulo \u00e9 o primeiro estado brasileiro a apresentar invers\u00e3o de tend\u00eancia de mortalidade pelo c\u00e2ncer de colo do \u00fatero.Neste estudo, a tend\u00eancia de aumento da mortalidade pelo c\u00e2ncer de colo do \u00fatero entre mulheres de 25-39 anos no Brasil foi bem pronunciada nos estados do Sudeste, em especial em Minas Gerais e S\u00e3o Paulo. Esse fen\u00f4meno vem sendo verificado em outros pa\u00edses recentemente33 . Apesar da constata\u00e7\u00e3o de que se trata de um c\u00e2ncer em decl\u00ednio em v\u00e1rios pa\u00edses, tend\u00eancias recentes de aumento da incid\u00eancia entre mulheres jovens, mais marcadas em pa\u00edses de alta renda, t\u00eam sido observadas35 . Para coortes de nascimento a partir de 1940 ou 1950 observou-se um aumento da incid\u00eancia em pa\u00edses da Europa, Jap\u00e3o e estabilidade nos Estados Unidos3 . Da mesma forma foi descrito na Europa Central, no Leste Europeu e na \u00c1sia Central33 . Esse aumento tem suscitado debate em torno da necessidade de se rever e implementar estrat\u00e9gias de rastreamento mais efetivas.O aumento da incid\u00eancia e da mortalidade entre mulheres mais jovens vem sendo atribu\u00eddo a mudan\u00e7as no comportamento sexual que aumentam o risco de infec\u00e7\u00e3o persistente pelo HPVNas idades mais jovens, as taxas de mortalidade por c\u00e2ncer s\u00e3o mais baixas do que as taxas nas idades mais avan\u00e7adas, sendo, portanto, mais propensas a flutua\u00e7\u00f5es devido ao menor n\u00famero de mortes. Neste estudo, a tend\u00eancia de aumento da mortalidade em mulheres jovens foi verificada a partir de varia\u00e7\u00f5es percentuais anuais positivas e estatisticamente significativas. Por esse motivo, consideramos relevante mostrar essa situa\u00e7\u00e3o que vem sendo relatada em outros pa\u00edses. No Brasil, esse achado requer aten\u00e7\u00e3o aos indicadores de cobertura do rastreamento nesse grupo et\u00e1rio espec\u00edfico, bem como aos indicadores de acesso ao diagn\u00f3stico e tratamento, j\u00e1 que nessas idades s\u00e3o esperados menor n\u00famero de mortes por c\u00e2ncer de colo do \u00fatero. Conhecer a preval\u00eancia da infec\u00e7\u00e3o por HPV ao longo do tempo e se a doen\u00e7a tem acometido essas mulheres mais precocemente trariam contribui\u00e7\u00f5es importantes para o direcionamento de a\u00e7\u00f5es espec\u00edficas em todos os n\u00edveis de aten\u00e7\u00e3o \u00e0 sa\u00fade.36 e de 80% nas capitais37 , propor\u00e7\u00f5es que podem ser consideradas elevadas. Por serem baseadas em informa\u00e7\u00f5es autorrelatadas por mulheres entrevistadas em inqu\u00e9ritos populacionais, elas podem n\u00e3o refletir a real cobertura do rastreamento. Ao mesmo tempo, observa-se que as taxas de incid\u00eancia e mortalidade por c\u00e2ncer de colo do \u00fatero permanecem altas se comparadas a de outros pa\u00edses2 , com grande disparidade entre regi\u00f5es38 . Nesse aspecto, vale ressaltar que a cobertura real \u00e9 certamente menor do que as referidas em inqu\u00e9ritos populacionais.As coberturas de Papanicolaou autorreferidas para todas as mulheres na faixa et\u00e1ria alvo foram de 78,8% no pa\u00eds39 . Al\u00e9m disso, a oferta de exames no SUS para confirma\u00e7\u00e3o diagn\u00f3stica \u00e9 deficit\u00e1ria, o que prejudica o seguimento de mulheres rastreadas40 .A partir das bases de dados do SUS \u2013 SISCOLO, SISCAN e SIA s\u00e3o observadas coberturas mais baixas. Recentemente, foi identificada queda no n\u00famero de mulheres que realizaram exame citopatol\u00f3gico pela primeira vez no SISCOLO, chegando a 41% entre os anos de 2012 e 2013No Sudeste, especialmente em S\u00e3o Paulo, a cobertura do rastreamento no SUS tende a ter n\u00edveis mais altos se comparada aos demais estados do pa\u00eds. Em 2009\u20132020, as quedas nos percentuais de cobertura do exame de rastreamento foram observadas em todos os estados e faixas et\u00e1rias, indicando que o acesso ao exame no SUS vem sendo reduzido. O n\u00edvel mais baixo de cobertura ocorreu em 2020, o que pode ser explicado pela pandemia de covid-19.41 encontraram para Campinas, munic\u00edpio localizado no estado de S\u00e3o Paulo, redu\u00e7\u00e3o significativa na propor\u00e7\u00e3o de exames realizados fora do grupo et\u00e1rio alvo do rastreamento entre 2010 e 2016, especialmente, em mulheres com idades inferiores a 25 anos. Segundo os autores, o melhor alinhamento das pr\u00e1ticas locais \u00e0s diretrizes nacionais poderia explicar as quedas observadas nos percentuais de cobertura nos \u00faltimos anos. Al\u00e9m de redu\u00e7\u00e3o no excesso de exames, Vale et al.41 encontraram aumentos nas propor\u00e7\u00f5es de exames realizados entre 25 e 64 anos, fato n\u00e3o observado neste estudo. Nos dados apresentados para a regi\u00e3o Sudeste, as redu\u00e7\u00f5es observadas desde 2009 no grupo de 65 anos ou mais tamb\u00e9m foram verificadas nas idades de 25\u201364 anos. Esse fato sugere que existem outros fatores relacionados \u00e0 queda da cobertura de exames na regi\u00e3o Sudeste, al\u00e9m daqueles apontados no estudo de Campinas41 .Vale et al.11 . Al\u00e9m disso, identificou tempo mediano maior que seis meses entre o exame alterado e o diagn\u00f3stico e quase tr\u00eas meses entre o diagn\u00f3stico e o in\u00edcio do tratamento. Esses tempos prolongados se associaram a piores condi\u00e7\u00f5es de assist\u00eancia nas regionais de sa\u00fade do estado. Refor\u00e7ando esses achados, outro estudo conduzido tamb\u00e9m em S\u00e3o Paulo concluiu que o acesso \u00e0 colposcopia \u00e9 limitado no estado, prejudicando o diagn\u00f3stico e, consequentemente, o tratamento42 .Al\u00e9m da queda de cobertura, h\u00e1 problemas no seguimento dos resultados alterados. Estudo que analisou a qualidade do seguimento de mulheres rastreadas no estado de S\u00e3o Paulo, a partir do relacionamento das bases de dados do SISCAN, SIA e Sistema de Interna\u00e7\u00f5es Hospitalares (SIH), mostrou que para 35,2% das mulheres com citologias alteradas n\u00e3o foram encontrados dados sobre o diagn\u00f3stico nos sistemas de informa\u00e7\u00e3oAtrasos no diagn\u00f3stico levam a diagn\u00f3sticos em fases mais avan\u00e7adas. Nesse aspecto, as a\u00e7\u00f5es de rastreamento para o c\u00e2ncer de colo uterino t\u00eam papel importante, n\u00e3o apenas na redu\u00e7\u00e3o da incid\u00eancia da doen\u00e7a, mas tamb\u00e9m na redu\u00e7\u00e3o da mortalidade por propiciarem diagn\u00f3stico precoce.43 . Em S\u00e3o Paulo, dados hospitalares de tumores invasivos de colo uterino44 , diagnosticados em 2017, apontaram que 39,2% dos casos em mulheres de 25\u201339 anos foram diagnosticados em est\u00e1dios III\u2013IV. Nas faixas et\u00e1rias de 40\u201364 e 65 anos ou mais, as respectivas propor\u00e7\u00f5es foram 51,7% e 62,3%. Esses dados sugerem um cen\u00e1rio preocupante, considerando que o programa nacional de controle do c\u00e2ncer de colo do \u00fatero est\u00e1 implantado em todo o pa\u00eds desde o final da d\u00e9cada de 1990. Melhorias na detec\u00e7\u00e3o precoce desse c\u00e2ncer teriam importante efeito na redu\u00e7\u00e3o da mortalidade no pa\u00eds.Estudo conduzido no Brasil, a partir de dados de registros hospitalares de c\u00e2ncer, mostrou que o diagn\u00f3stico do c\u00e2ncer de colo do \u00fatero ocorreu tardiamente (est\u00e1dios III\u2013IV), em 53,5% dos casos em 20121 traz como consequ\u00eancia a necessidade de reformular a preven\u00e7\u00e3o prim\u00e1ria e secund\u00e1ria do c\u00e2ncer de colo do \u00fatero6 . A introdu\u00e7\u00e3o do teste de HPV pode otimizar e tornar o rastreamento mais efetivo, especialmente em pa\u00edses de baixa renda45 . Dados de grandes estudos randomizados evidenciaram que a prote\u00e7\u00e3o contra o carcinoma invasivo \u2013 com rastreamento baseado nos testes de HPV a partir dos 30 anos de idade e com intervalo de 5 anos \u2013 \u00e9 60\u201370% maior se comparado \u00e0 citologia onc\u00f3tica7 .A descoberta do papel causal do HPV46 . Mesmo com a disponibilidade do teste de HPV como exame recomendado para rastreamento, desafios inerentes \u00e0 organiza\u00e7\u00e3o do programa continuar\u00e3o existindo. Mais do que o teste de rastreio, o emprego da abordagem mais adequada para organizar todos os componentes, incluindo os aspectos de qualidade, representam fatores determinantes para o sucesso de um programa de rastreamento8 .Existem, contudo, quest\u00f5es que merecem investiga\u00e7\u00e3o para tomada de decis\u00f5es sobre medidas estrat\u00e9gicas e custo-efetivas que devem ser implementadas nos programas de controle do c\u00e2ncer de colo do \u00fatero. Entre elas, defini\u00e7\u00e3o dos intervalos do rastreamento, formas para motivar a ades\u00e3o de mulheres e organiza\u00e7\u00e3o dos servi\u00e7os contemplando desde o acesso ao rastreamento at\u00e9 o aumento da infraestrutura para diagn\u00f3stico e tratamentoAs an\u00e1lises de tend\u00eancia de mortalidade por c\u00e2ncer de colo do \u00fatero s\u00e3o frequentemente comprometidas por imprecis\u00f5es no preenchimento da causa b\u00e1sica de morte, pelo fato de uma parcela ser registrada como c\u00e2ncer de \u00fatero de por\u00e7\u00e3o n\u00e3o especificada, o que n\u00e3o permite o conhecimento da verdadeira origem anat\u00f4mica do tumor (colo ou corpo do \u00fatero). Para lidar com essa limita\u00e7\u00e3o, foi empregada t\u00e9cnica de corre\u00e7\u00e3o dos \u00f3bitos por c\u00e2ncer de colo do \u00fatero originalmente registrados no SIM, possibilitando an\u00e1lises mais realistas. \u00c9 importante destacar que em 2020 a corre\u00e7\u00e3o por causas mal definidas foi baixa em todas as regi\u00f5es . No entanto, a redistribui\u00e7\u00e3o por \u00fatero por\u00e7\u00e3o n\u00e3o especificada levou a um aumento de 28,57% na regi\u00e3o Sudeste, percentual maior se comparado \u00e0s demais regi\u00f5es.Ap\u00f3s significativo progresso na acur\u00e1cia da informa\u00e7\u00e3o acerca do \u00f3bito no per\u00edodo 1980\u20132020 e d\u00e9cadas de decl\u00ednio na mortalidade pelo c\u00e2ncer de colo do \u00fatero, tend\u00eancias recentes de estabilidade no Brasil e de aumento no estado de S\u00e3o Paulo apontam para a necessidade de reorganiza\u00e7\u00e3o do atual programa de rastreamento para se alcan\u00e7ar melhorias na cobertura e na qualidade em todas as suas etapas \u2013 rastreio, diagn\u00f3stico e tratamento. A imuniza\u00e7\u00e3o contra o HPV trar\u00e1 resultados positivos a longo prazo, mas sua implementa\u00e7\u00e3o n\u00e3o minimiza o papel da preven\u00e7\u00e3o secund\u00e1ria; pelo contr\u00e1rio, refor\u00e7a a necessidade imediata de planejamento para implementa\u00e7\u00e3o a m\u00e9dio prazo de um exame de rastreamento mais custo-efetivo e de maior sensibilidade.Um programa de rastreamento organizado permitir\u00e1 alcan\u00e7ar ativamente as mulheres da faixa et\u00e1ria alvo e, em especial, as de 25\u201339 anos, em que se observou aumento acentuado da mortalidade por c\u00e2ncer de colo do \u00fatero no pa\u00eds. S\u00e3o mulheres em plena atividade sexual e, tamb\u00e9m, claramente integradas \u00e0 popula\u00e7\u00e3o economicamente ativa, portanto, com maiores dificuldades de ades\u00e3o ao rastreamento.47 .Somente com abordagem ampla, que inclua alta cobertura, qualidade dos exames e seguimento em toda a linha de cuidado, ser\u00e3o alcan\u00e7adas maiores redu\u00e7\u00f5es n\u00e3o s\u00f3 da mortalidade, mas tamb\u00e9m da incid\u00eancia. Assim, ser\u00e1 garantido o alinhamento do Brasil \u00e0 estrat\u00e9gia global de elimina\u00e7\u00e3o do c\u00e2ncer de colo do \u00fatero como problema de sa\u00fade p\u00fablica"}
+{"text": "Recomenda\u00e7\u00f5es Gerais 81.1. Sala Cir\u00fargica de DCEI 81.1.1. Recursos Humanos81.1.2. Recursos Materiais91.1.2.1. Radioscopia91.1.2.2. Monitoriza\u00e7\u00e3o91.1.2.3. Materiais Cir\u00fargicos91.2. Cl\u00ednica de Avalia\u00e7\u00e3o e Programa\u00e7\u00e3o Eletr\u00f4nica de DCEI 91.3. Avalia\u00e7\u00e3o Cl\u00ednica antes do Implante de DCEI 91.4. Procedimento Cir\u00fargico e Tipos de DCEI 102. Recomenda\u00e7\u00f5es para Implante de Marca-passo Convencional 102.1. Doen\u00e7a do N\u00f3 Sinusal 102.2. Bloqueios Atrioventriculares e Bloqueios Intraventriculares 122.2.1. Bloqueios Atrioventriculares122.2.2. Bloqueios Intraventriculares (BIV) com Condu\u00e7\u00e3o Atrioventricular 1:1142.3. S\u00edndrome da Hipersensibilidade do Seio Carot\u00eddeo 142.4. S\u00edncope Vasovagal 162.5. Cardiomiopatia Hipertr\u00f3fica 172.6. Doen\u00e7as Neuromusculares 182.7. S\u00edndrome da Apneia Obstrutiva do Sono 182.8. S\u00edndrome do QT Longo Cong\u00eanito (SQTLc) 192.9. Cora\u00e7\u00e3o Transplantado 202.10. Escolha do Tipo de Marca-passo e do Modo de Estimula\u00e7\u00e3o 202.11. Estimula\u00e7\u00e3o Direta do Sistema Excito-condutor Card\u00edaco  212.12. Estimula\u00e7\u00e3o sem Cabo-eletrodo (Leadless Pacemaker) 223. Recomenda\u00e7\u00f5es para Implante de Marca-passo Multiss\u00edtio/Terapia de Ressincroniza\u00e7\u00e3o Card\u00edaca (TRC) 243.1. Paciente em Ritmo Sinusal 243.2. Paciente com Fibrila\u00e7\u00e3o Atrial 25Upgradede Marca-passo Convencional 273.3.3.4. Na Indica\u00e7\u00e3o de Maca-passo Antibradicardia (1\u00ba Implante) 273.5. Na Indica\u00e7\u00e3o de Cardio-desfibrilador Implant\u00e1vel (TRC-D) 283.6. Estimula\u00e7\u00e3o Direta do Sistema Excito-condutor Card\u00edaco 283.6.1. Modula\u00e7\u00e3o de Contratilidade Card\u00edaca294. Recomenda\u00e7\u00f5es para Indica\u00e7\u00e3o de Cardioversor-desfibrilador Implant\u00e1vel 304.1. Preven\u00e7\u00e3o Prim\u00e1ria de Morte S\u00fabita 304.1.1. Miocardiopatia Isqu\u00eamica304.1.2. Miocardiopatia N\u00e3o Isqu\u00eamica314.1.3. Cardiomiopatia Hipertr\u00f3fica324.1.4. Cardiomiopatia Chag\u00e1sica344.1.5. Cardiomiopatia Arritmog\u00eanica do Ventr\u00edculo Direito364.1.6. Miocardiopatia N\u00e3o Compactada384.1.7. S\u00edndrome do QT Longo e S\u00edndrome do QT Curto Cong\u00eanito394.1.8. S\u00edndrome de Brugada394.1.9. Taquicardia Ventricular Polim\u00f3rfica Catecolamin\u00e9rgica (TVPC)404.1.10. Taquicardia Ventricular Idiop\u00e1tica404.2. Preven\u00e7\u00e3o Secund\u00e1ria de Morte S\u00fabita 414.2.1. Recuperados de Parada Card\u00edaca ou Taquicardia Ventricular Sustentada414.2.1.1. Recuperados de Parada Card\u00edaca ou Taquicardia Ventricular Sustentada na Presen\u00e7a de Cardiopatia Estrutural414.2.1.2. Recuperados de Parada Card\u00edaca ou Taquicardia Ventricular Sustentada na Aus\u00eancia de Cardiopatia Estrutural424.2.2. S\u00edncope e Taquicardia/Fibrila\u00e7\u00e3o Ventricular no Estudo Eletrofisiol\u00f3gico424.3. Crian\u00e7as, Adolescentes e Cardiopatia Cong\u00eanita 434.4. Escolha do Tipo de CDI e Modo de Estimula\u00e7\u00e3o 464.4.1. T\u00e9cnica de Implante464.4.2. Modo de Estimula\u00e7\u00e3o464.5. Custo-efetividade do CDI na Preven\u00e7\u00e3o Prim\u00e1ria e Secund\u00e1ria de Morte S\u00fabita 464.5.1. Preven\u00e7\u00e3o Prim\u00e1ria474.5.2. Preven\u00e7\u00e3o Secund\u00e1ria475. Recomenda\u00e7\u00f5es para Monitor de Eventos (Loop Recorder) Implant\u00e1vel 486. Recomenda\u00e7\u00f5es para Avalia\u00e7\u00e3o e Programa\u00e7\u00e3o Eletr\u00f4nica dos DCEI 496.1. Marca-passo Convencional 496.1.1. Doen\u00e7a do N\u00f3 Sinusal496.1.2. Bloqueio Atrioventricular506.1.3. Fibrila\u00e7\u00e3o Atrial506.1.4. S\u00edncope Neuromediada e S\u00edndrome do Seio Carot\u00eddeo506.2. Terapia de Ressincroniza\u00e7\u00e3o Card\u00edaca 506.3. Cardioversor-desfibrilador Implant\u00e1vel 52Loop Recorder) 536.4. Monitor de Eventos Implant\u00e1vel (Via Web) 536.5. Monitoramento Remoto (7. Recomenda\u00e7\u00f5es para Preven\u00e7\u00e3o e Tratamento de Infec\u00e7\u00f5es e Explante de DCEI 547.1. Preven\u00e7\u00e3o e Tratamento de Infec\u00e7\u00f5es 547.2. Remo\u00e7\u00e3o de Cabos-eletrodos de Dispositivos Card\u00edacos Eletr\u00f4nicos Implant\u00e1veis 598. Recomenda\u00e7\u00f5es para preven\u00e7\u00e3o de interfer\u00eancias eletromagn\u00e9ticas 648.1. Cirurgia com Uso de Eletrocaut\u00e9rio 648.2. Resson\u00e2ncia Magn\u00e9tica 648.3. Radioterapia 669. Conclus\u00e3o 66Refer\u00eancias 68Apesar da normatiza\u00e7\u00e3o e simplifica\u00e7\u00e3o das t\u00e9cnicas de implante de dispositivos card\u00edacos eletr\u00f4nicos implant\u00e1veis (DCEI), al\u00e9m do conhecimento m\u00e9dico e da experi\u00eancia cir\u00fargica, s\u00e3o necess\u00e1rios local e materiais adequados. O conhecimento de eletrocardiografia, principalmente das arritmias card\u00edacas e dos princ\u00edpios de eletrofisiologia card\u00edaca, \u00e9 fundamental.Os procedimentos cir\u00fargicos de estimula\u00e7\u00e3o card\u00edaca artificial s\u00e3o realizados por m\u00e9dicos cirurgi\u00f5es cardiovasculares ou cardiologistas com \u00e1rea de atua\u00e7\u00e3o em estimula\u00e7\u00e3o card\u00edaca eletr\u00f4nica implant\u00e1vel . Os procedimentos devem ser realizados em centro cir\u00fargico, laborat\u00f3rio de hemodin\u00e2mica ou de eletrofisiologia. A sala operat\u00f3ria deve ter dimens\u00f5es, ilumina\u00e7\u00e3o e ventila\u00e7\u00e3o adequadas, lavat\u00f3rio para a antissepsia e sistema de eletricidade bivolt (com aterramento que elimine interfer\u00eancias eletromagn\u00e9ticas e prote\u00e7\u00e3o dos equipamentos).Os profissionais envolvidos na realiza\u00e7\u00e3o de procedimentos cir\u00fargicos de DCEI s\u00e3o:M\u00e9dicos com forma\u00e7\u00e3o em estimula\u00e7\u00e3o card\u00edaca eletr\u00f4nica implant\u00e1vel (ECEI), respons\u00e1vel e auxiliarM\u00e9dico anestesiologistaInstrumentador cir\u00fargico, preferencialmente com treinamento na \u00e1rea de ECEIProfissional de enfermagem, preferencialmente com treinamento na \u00e1rea de ECEIT\u00e9cnico em ECEIT\u00e9cnico de radiologiaRequisito ainda fundamental, a radioscopia (intensificador de imagem) pode ser fixa, como nos laborat\u00f3rios de hemodin\u00e2mica, ou port\u00e1til (arco cir\u00fargico). A qualidade da imagem e os recursos de grava\u00e7\u00e3o e espelhamento de imagens facilitam bastante o procedimento, especialmente para terapia de ressincroniza\u00e7\u00e3o card\u00edaca (TRC). O intensificador de imagem deve possibilitar a visibiliza\u00e7\u00e3o de fios-guia de pequeno calibre e movimentos em diferentes proje\u00e7\u00f5es (obl\u00edquas).A monitoriza\u00e7\u00e3o eletrocardiogr\u00e1fica deve ser cont\u00ednua, com a possibilidade de armazenamento dos tra\u00e7ados. As deriva\u00e7\u00f5es dispon\u00edveis devem permitir adequada avalia\u00e7\u00e3o intraoperat\u00f3ria de TRC e de estimula\u00e7\u00e3o fisiol\u00f3gica do sistema de condu\u00e7\u00e3o card\u00edaco ; ademais, nesses casos, \u00e9 fundamental a an\u00e1lise de eletrogramas intracavit\u00e1rios (pol\u00edgrafo).A monitoriza\u00e7\u00e3o n\u00e3o invasiva da press\u00e3o arterial e o ox\u00edmetro de pulso devem estar dispon\u00edveis.Caixa de instrumental cir\u00fargico apropriadoEletrocaut\u00e9rioCardioversor-desfibrilador externoMarca-passo (MP) externo tempor\u00e1rioEstrutura de suporte avan\u00e7ado de vidaMateriais e medicamentos para anestesia e estabilidade cardiovascular .Gerador de pulsos, cabos-eletrodos, introdutores, bainhas para cateteriza\u00e7\u00e3o de seio coron\u00e1rio e sistema de condu\u00e7\u00e3oProgramador e analisador espec\u00edfico do DCEI em uso ou a ser implantado.Ultrassonografia para acesso venoso pode ser \u00fatil para redu\u00e7\u00e3o de complica\u00e7\u00f5es relacionadas \u00e0 pun\u00e7\u00e3o venosa profunda Ecocardiograma transesof\u00e1gico: \u00fatil durante extra\u00e7\u00e3o percut\u00e2nea de cabos-eletrodos para diagn\u00f3stico precoce de tamponamento card\u00edacoO m\u00e9dico respons\u00e1vel pela cl\u00ednica de seguimento eletr\u00f4nico de DCEI deve ter \u00e1rea de atua\u00e7\u00e3o em estimula\u00e7\u00e3o card\u00edaca eletr\u00f4nica implant\u00e1vel . A cl\u00ednica deve ter, em sua estrutura os seguintes recursos:Equipamento de eletrocardiograma (ECG)Programadores dos diversos fabricantes de DCEInobreakEquipamentoCardioversor-desfibrilador externo com MP transcut\u00e2neoIm\u00e3Ecocardiograma transtor\u00e1cicoHolter-24h, e exames de imagem . O exame de teste de inclina\u00e7\u00e3o (Tilt Table Test) deve estar dispon\u00edvel na pr\u00f3pria cl\u00ednica de avalia\u00e7\u00e3o de DCEI ou em outra estrutura referenciada.Acesso a exames complementares como teste ergom\u00e9trico,Acesso a engenheiro especializado em ECEIA avalia\u00e7\u00e3o cl\u00ednica inicial do paciente, antes da cirurgia de DCEI, deve incluir:a) Anamnese e exame f\u00edsicoA anamnese deve incluir investiga\u00e7\u00e3o de sinais e sintomas relacionados \u00e0s arritmias card\u00edacas, como s\u00edncope, pr\u00e9-s\u00edncope, tonturas, palpita\u00e7\u00f5es, sinais e sintomas de insufici\u00eancia card\u00edaca (IC). Hist\u00f3ria de morte s\u00fabita familiar, principalmente precoce e em parentes de primeiro grau, tem grande relev\u00e2ncia.O exame f\u00edsico deve incluir inspe\u00e7\u00e3o, palpa\u00e7\u00e3o dos pulsos perif\u00e9ricos, aferi\u00e7\u00e3o da press\u00e3o arterial, ausculta card\u00edaca e de car\u00f3tidas, frequ\u00eancia card\u00edaca e perfus\u00e3o perif\u00e9rica. Outros f\u00e1rmacos, geralmente, n\u00e3o precisam ser suspensos preventivamente. Pacientes com sinais de infec\u00e7\u00e3o ativa n\u00e3o devem receber implantes de dispositivos at\u00e9 a resolu\u00e7\u00e3o do quadro.Anticoagulantes orais e antiagregantes plaquet\u00e1rios devem ser suspensos temporariamente antes do procedimento cir\u00fargico, se poss\u00edvel.b) Exames complementares pr\u00e9-operat\u00f3riosECG em repousoRadiografia de t\u00f3rax (PA + perfil esquerdo)Exames laboratoriais: todos os pacientes devem realizar hemograma completo e de coagula\u00e7\u00e3o. Para procedimentos em que se usa contraste endovenoso, como na TRC ou obstru\u00e7\u00e3o venosa, \u00e9 fundamental avalia\u00e7\u00e3o da fun\u00e7\u00e3o renal com dosagem de eletr\u00f3litos. Nos pacientes diab\u00e9ticos, a glicemia de jejum deve ser avaliada. Os exames de urina tipo I e urocultura devem ser indicados aos pacientes com queixas urin\u00e1rias.Holter-24h, estudo eletrofisiol\u00f3gico e ultrassom ou flebografia de membros superiores est\u00e3o indicados somente quando a condi\u00e7\u00e3o cl\u00ednica justificarOutros exames como ecocardiograma, devem seguir protocolo institucional.Os pacientes devem permanecer em jejum absoluto por pelo menos 6 a 8 horas antes da cirurgia, dependendo da complexidade da cirurgia e do tipo de anestesia. Tricotomia, antissepsia local e antibioticoterapia profil\u00e1ticaa) Procedimentos cir\u00fargicosAntes da cirurgia, as equipes m\u00e9dica e de enfermagem devem seguir os protocolos de cirurgia segura: confirmar nome do paciente, data de nascimento, n\u00famero de registro hospitalar e lateralidade. Tamb\u00e9m devem confirmar a indica\u00e7\u00e3o do procedimento e checar os exames pr\u00e9-operat\u00f3rios.O procedimento cir\u00fargico de DCEI deve ser realizado em centro cir\u00fargico ou laborat\u00f3rio de hemodin\u00e2mica/eletrofisiologia sob vis\u00e3o fluorosc\u00f3pica, com monitoriza\u00e7\u00e3o eletrocardiogr\u00e1fica cont\u00ednua, oximetria de pulso e registros intermitentes ou cont\u00ednuos da press\u00e3o arterial. Dispositivos como os cardioversores-desfibriladores implant\u00e1veis (CDI) subcut\u00e2neos e os monitores de eventos implant\u00e1veis dispensam o uso do intensificador de imagem durante o implante.A anestesia pode ser local, preferencialmente associada \u00e0 seda\u00e7\u00e3o, ou geral. A escolha do tipo de anestesia depende da complexidade do procedimento, da via de acesso e das condi\u00e7\u00f5es cl\u00ednicas do paciente.leadless pacemaker, CDI subcut\u00e2neo). Outras vari\u00e1veis que podem influenciar na escolha da estrat\u00e9gia cir\u00fargica s\u00e3o: uso de MP tempor\u00e1rio e cateteres venosos, cirurgias tor\u00e1cicas pr\u00e9vias, necessidade de radioterapia (RT), caracter\u00edsticas anat\u00f4micas, infec\u00e7\u00f5es de pele, membro superior dominante.Para escolha do acesso cir\u00fargico, deve-se levar em considera\u00e7\u00e3o o local de implante do gerador de pulsos, o acesso ao cora\u00e7\u00e3o para implante dos cabos-eletrodos (via transvenosa ou epic\u00e1rdica) e a possibilidade de implante de sistemas sem cabo-eletrodo transvenoso (screw-in) em rela\u00e7\u00e3o aos de fixa\u00e7\u00e3o passiva, de acordo com a experi\u00eancia profissional.A regi\u00e3o da bolsa do gerador de pulso geralmente \u00e9 peitoral, podendo ser abdominal em situa\u00e7\u00f5es espec\u00edficas, em posi\u00e7\u00e3o subcut\u00e2nea ou submuscular. O acesso venoso \u00e9 realizado por dissec\u00e7\u00e3o da veia cef\u00e1lica ou pun\u00e7\u00e3o de veia axilar, subcl\u00e1via, jugular ou femoral. O n\u00famero de cabos-eletrodos varia de acordo com o sistema implantado , sendo preferidos atualmente os cabos-eletrodos de fixa\u00e7\u00e3o ativa  pelo seio coron\u00e1rio, s\u00e3o necess\u00e1rios acess\u00f3rios espec\u00edficos para essa abordagem como bainhas, cateter de eletrofisiologia e cateter para venografia para escolha da melhor veia tribut\u00e1ria para implante do cabo-eletrodo.Durante o procedimento cir\u00fargico, \u00e9 fundamental aferir os limiares de estimula\u00e7\u00e3o, de sensibilidade e as imped\u00e2ncias dos cabos-eletrodos, al\u00e9m do eletrograma endocavit\u00e1rio ou epic\u00e1rdico. Em caso de CDI, deve ser inclu\u00edda medida de imped\u00e2ncia de choque; a avalia\u00e7\u00e3o de limiar de desfibrila\u00e7\u00e3o \u00e9 opcional para sistemas de CDI transvenosos , mas recomend\u00e1vel em implantes \u00e0 direita, abdominal e CDI subcut\u00e2neo.O relat\u00f3rio de cirurgia de DCEI deve incluir identifica\u00e7\u00e3o do paciente, descri\u00e7\u00e3o do ato operat\u00f3rio, dados t\u00e9cnicos do sistema e a ocorr\u00eancia ou n\u00e3o de complica\u00e7\u00f5es , estimula\u00e7\u00e3o diafragm\u00e1tica, hematoma na bolsa do gerador, contamina\u00e7\u00e3o e arritmias). O registro brasileiro de marca-passos e cardioversores-desfibriladores (RBM) deve ser preenchido.Avalia\u00e7\u00e3o no p\u00f3s-operat\u00f3rio e per\u00edodo de interna\u00e7\u00e3oAp\u00f3s a cirurgia de DCEI, \u00e9 necess\u00e1rio realizar avalia\u00e7\u00e3o cl\u00ednica do paciente, avalia\u00e7\u00e3o eletr\u00f4nica do sistema implantado e exames de ECG e radiografia de t\u00f3rax para confirmar o funcionamento adequado do DCEI, a posi\u00e7\u00e3o dos cabos-eletrodos e diagnosticar poss\u00edveis disfun\u00e7\u00f5es e complica\u00e7\u00f5es.O paciente geralmente permanece internado em ambiente hospitalar por 12 a 24h. Pacientes submetidos a procedimentos sem necessidade de acesso intravascular (troca de gerador de pulsos ou implante de dispositivo subcut\u00e2neo) habitualmente permanecem em observa\u00e7\u00e3o p\u00f3s-operat\u00f3ria pelo per\u00edodo de 6 a 12 horas .b) Tipos de DCEIOAs disfun\u00e7\u00f5es do n\u00f3 sinusal, quando resultam em sintomas, s\u00e3o denominadas doen\u00e7a do n\u00f3 sinusal (DNS) e costumam ser a mais comum indica\u00e7\u00e3o para estimula\u00e7\u00e3o card\u00edaca artificial em \u00e2mbito global, correspondendo a aproximadamente metade dos implantes de MP definitivo.A DNS \u00e9 caracterizada, do ponto de vista eletrocardiogr\u00e1fico, por uma ou mais das seguintes manifesta\u00e7\u00f5es: bradicardia sinusal, pausa ou parada sinusal, bloqueio sinoatrial, taquiarritmias atriais  associadas a bradiarritmias (pausas sinusais): s\u00edndrome bradi-taqui e incompet\u00eancia cronotr\u00f3pica (resposta inadequada da frequ\u00eancia card\u00edaca ao exerc\u00edcio ou estresse).Os sintomas atribu\u00edveis \u00e0 DNS ocorrem devido \u00e0 baixa frequ\u00eancia card\u00edaca ou de acordo com a dura\u00e7\u00e3o da pausa dos batimentos card\u00edacos; os sintomas mais comuns s\u00e3o: palpita\u00e7\u00e3o, cansa\u00e7o e dispneia, tontura, pr\u00e9-s\u00edncope ou s\u00edncope. A s\u00edncope \u00e9 um sintoma cl\u00ednico comum, podendo estar presente em aproximadamente 50% dos pacientes encaminhados para implante de MP em decorr\u00eancia de DNS.Embora possa ocorrer em qualquer idade, a DNS aumenta com a idade, afetando 1 em cada 600 pacientes com idade superior a 65 anos, n\u00e3o havendo prefer\u00eancia por sexo.Sua etiologia pode ser dividida em causas intr\u00ednsecas e extr\u00ednsecas.A fisiopatologia da DNS \u00e9 variada e geralmente envolve remodelamento eletrofisiol\u00f3gico e estrutural complexo.Al\u00e9m disso, a resposta barorreflexa e a variabilidade da FC encontram-se diminu\u00eddas na popula\u00e7\u00e3o idosa.As causas intr\u00ednsecas de DNS incluem processos inflamat\u00f3rios, infecciosos e imunol\u00f3gicos, fibrose degenerativa, disfun\u00e7\u00e3o de canais i\u00f4nicos e remodelamento do n\u00f3 sinusal. A fibrose degenerativa idiop\u00e1tica, relacionada com a idade, \u00e9 a causa intr\u00ednseca mais comum; no entanto, pesquisas recentes t\u00eam demonstrado que uma disfun\u00e7\u00e3o dos canais i\u00f4nicos herdadas geneticamente tamb\u00e9m pode participar na g\u00eanese da disfun\u00e7\u00e3o sinusal resultante do envelhecimento.crista terminalis) e coronariopatia cr\u00f4nica . An\u00e1lises gen\u00f4micas j\u00e1 identificaramlocusnas prote\u00ednas que interagem com canais i\u00f4nicos e canais relacionados \u00e0s frequ\u00eancias card\u00edacas normais e anormais em repouso, fornecendo informa\u00e7\u00f5es sobre os mecanismos que controlam a frequ\u00eancia card\u00edaca.Outros mecanismos intr\u00ednsecos de DNS incluem: doen\u00e7as infiltrativas , inflamat\u00f3rias , IC e FA  da epilepsia pode levar a regulariza\u00e7\u00e3o da disfun\u00e7\u00e3o sinusal e/ou bloqueio atrioventricular (BAV) sem a necessidade do implante de MP definitivo. As mesmas considera\u00e7\u00f5es s\u00e3o v\u00e1lidas para uma outra condi\u00e7\u00e3o rara, a neuralgia do glossofar\u00edngeo associada \u00e0 assistolia e s\u00edncope.Anormalidades metab\u00f3licas, tais como acidose sist\u00eamica grave, hipercalemia, hipocalemia ou hipocalcemia, podem causar bradicardia sinusal, incomum em situa\u00e7\u00f5es agudas. Outros fatores extr\u00ednsecos poss\u00edveis s\u00e3o hipotireoidismo, hip\u00f3xia, hipotermia e toxinas. Tamb\u00e9m tem sido descrita a associa\u00e7\u00e3o entre a s\u00edndrome de Brugada, um tipo de canalopatia, e a ocorr\u00eancia de DNS.Os pacientes com DNS s\u00e3o geralmente assintom\u00e1ticos nas fases iniciais no curso da doen\u00e7a, com os sintomas ocorrendo ap\u00f3s v\u00e1rios anos de evolu\u00e7\u00e3o. \u00c9 tamb\u00e9m importante identificar quadros de bradicardia funcional assintom\u00e1tica, como ocorre durante o sono, em jovens saud\u00e1veis e em atletas, que n\u00e3o representam risco e n\u00e3o devem ser tratadas de forma geral.Holter, monitor de eventos externo ou monitor de eventos implant\u00e1vel. O estudo eletrofisiol\u00f3gico invasivo (EEF) n\u00e3o deve ser utilizado regularmente na pr\u00e1tica cl\u00ednica devido \u00e0 aus\u00eancia de dados conclusivos sobre a real indica\u00e7\u00e3o de MP definitivo nos pacientes que apresentem um tempo de recupera\u00e7\u00e3o do n\u00f3 sinusal (TRNS) ou tempo de condu\u00e7\u00e3o sinoatrial (TCSA) alterado.A documenta\u00e7\u00e3o da correla\u00e7\u00e3o das altera\u00e7\u00f5es eletrocardiogr\u00e1ficas com as manifesta\u00e7\u00f5es cl\u00ednicas \u00e9 essencial para o diagn\u00f3stico da DNS, seja por meio de ECG convencional de 12 deriva\u00e7\u00f5es ou outros m\u00e9todos, comoPara defini\u00e7\u00e3o de conduta e eventual indica\u00e7\u00e3o de implante de MP em pacientes com DNS, \u00e9 fundamental a correla\u00e7\u00e3o entre os sintomas cl\u00ednicos e a bradicardia, al\u00e9m da identifica\u00e7\u00e3o de causas revers\u00edveis.Contudo, o implante de MP melhora significativamente a qualidade de vida, pode reduzir o risco de FA e tromboembolismo sist\u00eamico, permite o uso de f\u00e1rmacos antiarr\u00edtmicos que podem causar bradicardia e possibilita monitoramento cont\u00ednuo do ritmo card\u00edaco. As recomenda\u00e7\u00f5es para implante de MP definitivo na DNS encontram-se naNa aus\u00eancia de causas revers\u00edveis e na presen\u00e7a de sintomas, o implante de MP definitivo representa o tratamento de escolha para a DNS, embora n\u00e3o haja evid\u00eancias de que a estimula\u00e7\u00e3o card\u00edaca artificial tenha impacto quanto \u00e0 sobrevida ou ao risco de morte s\u00fabita card\u00edaca dos pacientes com DNS em rela\u00e7\u00e3o \u00e0 popula\u00e7\u00e3o em geral. Em uma revis\u00e3o sistem\u00e1tica dos grandes estudos randomizados, houve significativa redu\u00e7\u00e3o de acidente vascular cerebral (AVC)  e FA  com a estimula\u00e7\u00e3o AAI e/ou DDD comparada com a estimula\u00e7\u00e3o VVI.O impacto do modo de estimula\u00e7\u00e3o na preven\u00e7\u00e3o de IC ou AVC e a melhora na qualidade de vida s\u00e3o menos evidentes.Quanto ao modo de estimula\u00e7\u00e3o, os grandes estudos randomizados n\u00e3o evidenciaram melhora da sobrevida com a estimula\u00e7\u00e3o atrial (AAI) ou atrioventricular (DDD) em rela\u00e7\u00e3o \u00e0 ventricular (VVI); entretanto, houve benef\u00edcios, como redu\u00e7\u00e3o de taxas de FA, incid\u00eancia de s\u00edncopes e s\u00edndrome do MP. que analisou a estimula\u00e7\u00e3o AAIversusDDD em pacientes com DNS, mostraram que a estimula\u00e7\u00e3o AAIR associou-se a maiorincid\u00eanciade FA parox\u00edstica  e o dobro de reopera\u00e7\u00f5es quando comparada com a estimula\u00e7\u00e3o DDDR. As reopera\u00e7\u00f5es ocorreram principalmente pela necessidade deupgrade de AAIR para DDDR, em decorr\u00eancia do desenvolvimento de BAV durante o acompanhamento. Outro aspecto relevante observado nesse estudo foi que o benef\u00edcio da estimula\u00e7\u00e3o AAI pode ser atenuado em pacientes com longos intervalos PR que podem resultar em insufici\u00eancia mitral diast\u00f3lica.Os resultados do estudo DANPACE,A estimula\u00e7\u00e3o preferencial atrial (AAIR ou DDDR) \u00e9 o modo predileto em pacientes com DNS . Em decorr\u00eancia disso, em pacientes sem BAV associado, utiliza-se a programa\u00e7\u00e3o de algoritmos que buscam diminuir a estimula\u00e7\u00e3o ventricular desnecess\u00e1ria, como a histerese atrioventricular e a mudan\u00e7a autom\u00e1tica do modo DDD para AAI.A maioria dos pacientes com DNS apresenta condu\u00e7\u00e3o atrioventricular preservada. Por outro lado, sabe-se que a estimula\u00e7\u00e3o do VD tem sido associada a consequ\u00eancias fisiol\u00f3gicas negativas como resultado da dissincronia ventricular: remodelamento e redu\u00e7\u00e3o da fra\u00e7\u00e3o de eje\u00e7\u00e3o do VE (FEVE) e insufici\u00eancia mitral funcional.overpaceatrial) ou estimula\u00e7\u00e3o atrial desencadeada pela sensibilidade de atividade atrial intrinseca, isoladamente ou em combina\u00e7\u00e3o, n\u00e3o t\u00eam seus beneficios comprovados. Da mesma forma, s\u00edtios alternativos de estimula\u00e7\u00e3o \u2013 tais como estimula\u00e7\u00e3o do fasc\u00edculo de Bachmann, estimula\u00e7\u00e3o biatrial ou multiss\u00edtio atrial \u2013 falharam em mostrar efeitos consistentes.Algoritmos para suprimir a ocorr\u00eancia de FA, como estimula\u00e7\u00e3o atrial cont\u00ednua  ou ventila\u00e7\u00e3o/volume minuto. O objetivo principal dos sensores \u00e9 aumentar a frequ\u00eancia card\u00edaca de maneira fisiol\u00f3gica e n\u00e3o necessariamente alterar os resultados cl\u00ednicos. Embora o dispositivo n\u00e3o consiga avaliar com precis\u00e3o a resposta cronotr\u00f3pica atrial, ele pode fornecer indicadores da progress\u00e3o da doen\u00e7a atrial atrav\u00e9s dos histogramas de frequ\u00eancia e arritmia, porcentagem de estimula\u00e7\u00e3o atrial e atividade di\u00e1ria do paciente. Tais dados podem ser \u00fateis para a programa\u00e7\u00e3o do sensor. N\u00e3o existem evid\u00eancias de que a utiliza\u00e7\u00e3o de uma combina\u00e7\u00e3o de sensores  possa proporcionar melhora da qualidade de vida.O est\u00edmulo el\u00e9trico originado no n\u00f3 sinusal \u00e9 propagado pelo mioc\u00e1rdio pelo sistema de condu\u00e7\u00e3o especializado. O retardo ou a falha na propaga\u00e7\u00e3o do est\u00edmulo entre os \u00e1trios e os ventr\u00edculos caracterizam os BAV. Essa altera\u00e7\u00e3o da propaga\u00e7\u00e3o do est\u00edmulo pode corresponder a uma altera\u00e7\u00e3o patol\u00f3gica ou ser um fen\u00f4meno funcional decorrente da refratariedade fisiol\u00f3gica (propriedade intr\u00ednseca das c\u00e9lulas do sistema de condu\u00e7\u00e3o).Do ponto de vista eletrocardiogr\u00e1fico, os BAV s\u00e3o classificados em 1\u00ba grau, 2\u00ba grau  e 3\u00ba grau.O BAV de 1\u00ba grau corresponde ao retardo na condu\u00e7\u00e3o do est\u00edmulo do \u00e1trio ao ventr\u00edculo com um intervalo PR > 200ms.MobitzI), o bloqueio ocorre ap\u00f3s prolongamento gradual dos intervalos PR (fen\u00f4meno deWenckebach), com uma onda P bloqueada ao final. No BAV de 2\u00ba grau tipo II (MobitzII), a onda P \u00e9 subitamente bloqueada, ou seja, sem o alargamento progressivo do intervalo PR. Quando a condu\u00e7\u00e3o AV ocorre com um padr\u00e3o 2:1, o bloqueio de segundo grau habitualmente n\u00e3o pode ser classificado inequivocamente como tipo I ou tipo II sem o aux\u00edlio de manobras auton\u00f4micas, f\u00e1rmacos ou mesmo o estudo eletrofisiol\u00f3gico invasivo. O BAV avan\u00e7ado refere-se ao bloqueio de duas ou mais ondas P consecutivas com alguns batimentos conduzidos, o que indica alguma preserva\u00e7\u00e3o da condu\u00e7\u00e3o AV. Na presen\u00e7a de FA com pausas significativas (> 5s), deve ser considerada a possibilidade de BAV de alto grau.No BAV de 2\u00ba grau tipo I  \u00e9 definido como aus\u00eancia de condu\u00e7\u00e3o AV .Existem in\u00fameras patologias, cong\u00eanitas ou mais frequentemente adquiridas, que podem afetar a condu\u00e7\u00e3o AV. As causas degenerativas s\u00e3o as mais comuns na pr\u00e1tica cl\u00ednica e est\u00e3o associadas ao aumento da idade, hipertens\u00e3o arterial sist\u00eamica e diabetes melito. Entre as causas infecciosas, em nosso meio, destacam-se a miocardite cr\u00f4nica da doen\u00e7a de Chagas e, em menor propor\u00e7\u00e3o, as miocardites agudas virais, que podem ocasionar bloqueios intermitentes agudos e definitivos.O BAV atribu\u00edvel \u00e0 isquemia da parede inferior ou ao infarto agudo do mioc\u00e1rdio pode ser revers\u00edvel, assim como os bloqueios mediados pelo sistema nervoso aut\u00f4nomo.Causas iatrog\u00eanicas, principalmente por a\u00e7\u00e3o farmacol\u00f3gica, tamb\u00e9m devem ser lembradas na depend\u00eancia da situa\u00e7\u00e3o cl\u00ednica.O BAV pode ser classificado anatomicamente, de acordo com o s\u00edtio do bloqueio, em nodal AV, intra-His e infra-His. O BAV nodal est\u00e1 associado a progress\u00e3o mais lenta, escape juncional mais r\u00e1pido e confi\u00e1vel e melhor resposta \u00e0 manipula\u00e7\u00e3o auton\u00f4mica como administra\u00e7\u00e3o de atropina, isoproterenol e epinefrina. Em contraste, os BAV intra-His ou infra-His progridem mais rapidamente e est\u00e3o associados a escape ventricular mais lento e imprevis\u00edvel, QRS mais largos e que respondem mal \u00e0 atividade adren\u00e9rgica ou bloqueio vagal. Os bloqueios de alto grau (avan\u00e7ados ou 3\u00ba grau) apresentam maior risco de baixo d\u00e9bito e assistolias graves, o que implica necessidade de terap\u00eautica urgente. Na presen\u00e7a de FA, identifica-se BAVT quando a resposta ventricular est\u00e1 baixa (< 50bpm) com intervalo RR regular. Da mesma forma, o BAV de 2\u00ba grau tipo I \u00e9 frequentemente assintom\u00e1tico e observado em pacientes ativos e saud\u00e1veis com ou sem hist\u00f3rico de doen\u00e7a card\u00edaca, principalmente durante atividade parassimp\u00e1tica. No entanto, se ocorrer com frequ\u00eancia ou durante o exerc\u00edcio, pode causar sintomas de intoler\u00e2ncia ao esfor\u00e7o ou tontura.O BAV de 1\u00ba grau geralmente \u00e9 assintom\u00e1tico, mas pode resultar em fadiga ou intoler\u00e2ncia ao esfor\u00e7o se o intervalo PR for longo o suficiente para permitir a perda do sincronismo AV. Essa altera\u00e7\u00e3o, \u201cpseudoss\u00edndrome do MP\u201d, pode ocorrer com intervalo PR > 300ms.Em 61% dos pacientes com s\u00edncopes e bloqueio de ramo subjacente ou bloqueio bifascicular, podem estar presentes anormalidades da condu\u00e7\u00e3o no sistema His-Purkinje significativas e clinicamente relevantes, identificados no EEF.Em pacientes com BAV, a avalia\u00e7\u00e3o cl\u00ednica pode ajudar a definir causas transit\u00f3rias ou revers\u00edveis, e o tratamento ou resolu\u00e7\u00e3o pode tornar desnecess\u00e1ria a estimula\u00e7\u00e3o artificial permanente. Nos casos assintom\u00e1ticos, o acompanhamento regular com exames complementares \u00e9 necess\u00e1rio para avaliar a FC m\u00e9dia, o intervalo QT, pausas, arritmia ventricular, dist\u00farbio de condu\u00e7\u00e3o intraventricular (DCIV), presen\u00e7a ou surgimento de doen\u00e7a card\u00edaca estrutural, baixo desenvolvimento cognitivo-pondero-estatura e intoler\u00e2ncia ao exerc\u00edcio f\u00edsico, a fim de verificar a necessidade de MP definitivo. Tamb\u00e9m recomenda-se implante de MP profil\u00e1tico, ou CDI, em alguns pacientes assintom\u00e1ticos com disfun\u00e7\u00f5es neuromusculares e outras doen\u00e7as gen\u00e9ticas.No BAVT cong\u00eanito, a indica\u00e7\u00e3o de MP definitivo \u00e9 mandat\u00f3ria na presen\u00e7a de sintomas ou quando a crian\u00e7a apresenta frequ\u00eancia card\u00edaca de repouso < 55 bpm ou < 70 bpm, se associada \u00e0 doen\u00e7a card\u00edaca estrutural.Em pacientes com bradicardia indicativa de implante de MP e disfun\u00e7\u00e3o ventricular esquerda, o implante de CDI deve ser considerado (ver item 4).O implante de MP n\u00e3o \u00e9 indicado em pacientes assintom\u00e1ticos com FA permanente com frequ\u00eancia card\u00edaca baixa em repouso, que apresentam resposta cronotr\u00f3pica apropriada na vig\u00edlia, independentemente da ocorr\u00eancia e dura\u00e7\u00e3o das pausas. J\u00e1 nos casos com pausas significativas (> 3s) sintom\u00e1ticas ou atribu\u00edveis a bloqueio infranodal, indica-se MP.O implante de MP para suporte terap\u00eautico, especialmente em pacientes com IC ou doen\u00e7a coron\u00e1ria, pode ser necess\u00e1rio, especialmente frente \u00e0 necessidade de uso cr\u00f4nico de betabloqueadores.Para se determinar o melhor tipo de dispositivo e modo de estimula\u00e7\u00e3o artificial para pacientes com BAV, duas vari\u00e1veis cl\u00ednicas devem ser consideradas: porcentagem de estimula\u00e7\u00e3o ventricular esperada e fun\u00e7\u00e3o sist\u00f3lica do VE (FEVE).Estudos que compararam a estimula\u00e7\u00e3o com preserva\u00e7\u00e3o da ativa\u00e7\u00e3o atrioventricular sequencial com a estimula\u00e7\u00e3o unicameral ventricular em pacientes com BAV  n\u00e3o demonstraram redu\u00e7\u00e3o significativa da mortalidade ou da taxa de AVC. J\u00e1 no estudo UKPace (pacientes \u2265 75 anos), n\u00e3o ficou demonstrado benef\u00edcio da estimula\u00e7\u00e3o AV em termos de mortalidade, incid\u00eancia de FA ou IC quando comparada \u00e0 estimula\u00e7\u00e3o ventricular. Tamb\u00e9m observou taxas similares de AVC e maior taxa de complica\u00e7\u00f5es relacionadas ao procedimento cir\u00fargico nos pacientes submetidos ao implante de MP bicameral . Assim, \u00e9 razo\u00e1vel indicar implante de MP unicameral (VVI) em pacientes com fragilidade ou comorbidades significativas, idade avan\u00e7ada, estilo de vida muito sedent\u00e1rio ou pouca necessidade di\u00e1ria de estimula\u00e7\u00e3o nessa popula\u00e7\u00e3o de pacientes.Por outro lado, em uma revis\u00e3o sistem\u00e1tica, os autores identificaram que a estimula\u00e7\u00e3o bicameral seria a mais recomendada por diminuir a incid\u00eancia de FA e reduzir a preval\u00eancia de s\u00edndrome do MP quando comparado \u00e0 estimula\u00e7\u00e3o unicameral ventricular (VVI).Em pacientes que apresentam condu\u00e7\u00e3o retr\u00f3grada VA, a estimula\u00e7\u00e3o ventricular pode ocasionar sintomas da \u201cs\u00edndrome do MP\u201d. Nesses casos, deve-se preferir estimula\u00e7\u00e3o bicameral para evitar a dissincronia atrioventricular.Nesse sentido, pacientes com disfun\u00e7\u00e3o de VE e indica\u00e7\u00e3o de MP devido a BAV foram avaliados nos estudos COMBAT (FEVE < 35%) e BLOCK-HF (FEVE \u2264 50%). Nesses estudos, que compararam a TRCversusa estimula\u00e7\u00e3o convencional do VD, demostrou-se melhora cl\u00ednica (NYHA) e remodelamento reverso do VE (com aumento da FEVE) com a TRC, com redu\u00e7\u00e3o significativa de desfechos prim\u00e1rios.Os efeitos delet\u00e9rios da estimula\u00e7\u00e3o cr\u00f4nica do VD foram demonstrados em v\u00e1rios estudos, embora apenas uma minoria (5% a 9%) de indiv\u00edduos com estimula\u00e7\u00e3o cr\u00f4nica do VD desenvolva disfun\u00e7\u00e3o ventricular grave com sintomas de IC.Em pacientes com FA e disfun\u00e7\u00e3o de VE, submetidos \u00e0 abla\u00e7\u00e3o do n\u00f3 AV para controle de FC, a estimula\u00e7\u00e3o com TRC ou do sistema excito-condutor card\u00edaco (feixe de His ou ramo esquerdo) parece estar associada a melhores resultados em compara\u00e7\u00e3o com a estimula\u00e7\u00e3o convencional do VD.As recomenda\u00e7\u00f5es para indica\u00e7\u00e3o de MP nos BAV est\u00e3o sumarizadas naAs anormalidades do complexo QRS, representadas pelos bloqueios fasciculares ou bloqueios de ramo, s\u00e3o causadas por atraso da condu\u00e7\u00e3o ou bloqueio de um ou mais ramos do sistema His-Purkinje.O atraso de condu\u00e7\u00e3o ou bloqueio do ramo direito associado a boqueio de um dos fasc\u00edculos do ramo esquerdo \u00e9 denominado bloqueio bifascicular (a mesma terminologia cabe no caso do bloqueio de ramo esquerdo [BRE]). Condi\u00e7\u00f5es cl\u00ednicas que podem ocasionar BIV incluem: gen\u00e9tico-heredit\u00e1rias, inflamat\u00f3rias, infecciosas, infiltrativas, metab\u00f3licas, isqu\u00eamicas e degenerativas.A progress\u00e3o do BRE ou bloqueio bifascicular para BAV avan\u00e7ado \u00e9 baixa, cerca de 1%/ano. A presen\u00e7a de BRE costuma estar associada a maior mortalidade que os demais dist\u00farbios da condu\u00e7\u00e3o intraventricular. O implante de MP \u00e9 recomendado em pacientes com BIV em algumas doen\u00e7as neuromusculares devido \u00e0 alta incid\u00eancia de BAVT e morte s\u00fabita card\u00edaca.A presen\u00e7a isolada de BIV s\u00e3o raramente associados a sintomas, mas pode ser marcador de doen\u00e7a card\u00edaca estrutural; a presen\u00e7a ou surgimento de BRE pode causar dissincronia card\u00edaca e disfun\u00e7\u00e3o progressiva do VE. Alguns estudos demonstram correla\u00e7\u00e3o do BRE com doen\u00e7a coronariana e IC.O EEF pode identificar dist\u00farbios da condu\u00e7\u00e3o de alto risco; no entanto, \u00e9 um procedimento com sensibilidade vari\u00e1vel e n\u00e3o \u00e9 isento de riscos. Em pacientes com s\u00edncope, a presen\u00e7a de BIV \u00e9 preditor de anormalidades ao EEF.O bloqueio de ramo alternante, independentemente de sintomas, quando a morfologia do complexo QRS alterna espontaneamente entre BRE e BRD, tamb\u00e9m \u00e9 indicativo de implante de MP, pois denota doen\u00e7a do sistema de condu\u00e7\u00e3o em n\u00edvel infranodal, com alto risco de BAVT grave.As recomenda\u00e7\u00f5es para indica\u00e7\u00e3o de MP nos BIV est\u00e3o sumarizadas na A s\u00edncope \u00e9 consequente \u00e0 bradicardia e/ou hipotens\u00e3o arterial significativas, deflagradas por movimentos da cabe\u00e7a ou situa\u00e7\u00f5es que ocasionam compress\u00e3o involunt\u00e1ria do pesco\u00e7o e seio carot\u00eddeo, embora esta correla\u00e7\u00e3o n\u00e3o seja clinicamente evidente em muitos pacientes.A s\u00edndrome da hipersensibilidade do seio carot\u00eddeo (SHSC) \u00e9 caracterizada pela hist\u00f3ria de s\u00edncope associada \u00e0 resposta reflexa exacerbada decorrente da estimula\u00e7\u00e3o mec\u00e2nica do seio carot\u00eddeo, espont\u00e2nea ou por massagem (MSC). A reprodu\u00e7\u00e3o da s\u00edncope durante a MSC aumenta a especificidade do teste diagn\u00f3stico, e a compress\u00e3o carot\u00eddea na posi\u00e7\u00e3o inclinada aumenta sua sensibilidade.O diagn\u00f3stico de SHSC \u00e9 feito quando, na aus\u00eancia de f\u00e1rmacos depressores do sistema excito-condutor, ocorre pausa > 3s  e/ou queda da press\u00e3o arterial sist\u00f3lica (PAS) \u2265 50mmHg, com reprodu\u00e7\u00e3o da s\u00edncope, durante manobra de compress\u00e3o sequencial dos seios carot\u00eddeos direito e esquerdo, por 5 a 10s, realizada na posi\u00e7\u00e3o supina e inclinada (teste de inclina\u00e7\u00e3o), em pacientes com mais de 40 anos de idade.As respostas reflexas na SHSC podem ser classificadas, quanto ao perfil hemodin\u00e2mico, em tr\u00eas tipos: cardioinibidora (pausa ventricular > 3s), mista (pausa ventricular > 3s associada \u00e0 queda da PA sist\u00f3lica \u2265 50mmHg) ou vasodepressora (queda isolada da PAS \u2265 50mmHg). A incid\u00eancia de SHSC aumenta com a idade .As evid\u00eancias que suportam o implante de MP definitivo na SHSC s\u00e3o baseadas em pequenos estudos controlados e estudos observacionais retrospectivos. A metan\u00e1lise de tr\u00eas estudos controlados, com seguimento m\u00e9dio de 3,3 anos, demonstrou redu\u00e7\u00e3o significativa (76%) na taxa de recorr\u00eancia de s\u00edncope nos pacientes tratados com MPversuso grupo controle .Em uma revis\u00e3o de 12 estudos, com 601 pacientes tratados com MP e 305 controles, apesar da heterogeneidade quanto \u00e0 sele\u00e7\u00e3o dos pacientes, posi\u00e7\u00e3o durante a MSC , tempo de seguimento e modo de estimula\u00e7\u00e3o, observaram-se taxas menores de recorr\u00eancia de s\u00edncope nos pacientes tratados (0% a 20%) quando comparados aos controles (20% a 60%). que avaliou 175 pacientes idosos com quedas recorrentes inexplicadas, aparentemente sem perda de consci\u00eancia e resposta cardioinibit\u00f3ria durante compress\u00e3o do seio carot\u00eddeo, sugere que o diagn\u00f3stico de SHSC deve ser considerado nesses casos. No grupo randomizado para implante de MP definitivo, observou-se redu\u00e7\u00e3o significativa na taxa de eventos  durante o seguimento.O estudo SAFE PACE,vs.0,04 epis\u00f3dio por paciente/ano, IC 95% 0,038-0,042). Na investiga\u00e7\u00e3o de s\u00edncopes inexplicadas em pacientes com mais de 40 anos, os monitores de eventos implant\u00e1veis podem ser \u00fateis no diagn\u00f3stico da SHSC, assim como na s\u00edncope vasovagal, atrav\u00e9s do registro de pausas espont\u00e2neas, quando a investiga\u00e7\u00e3o inicial atrav\u00e9s de MSC e teste de inclina\u00e7\u00e3o \u00e9 negativa.As recomenda\u00e7\u00f5es para implante de MP na SHSC est\u00e3o listadas naEm um estudo no qual o diagn\u00f3stico de SHSC foi complementado com o registro de pausas espont\u00e2neas por meio de monitores de eventos implantados, ocorreu redu\u00e7\u00e3o de 98% na carga de s\u00edncope ap\u00f3s o implante de MP , podem se beneficiar do MP definitivo. Estudos subsequentes comparando o modo de estimula\u00e7\u00e3o unicameral com o bicameral no longo prazo evidenciaram tend\u00eancia de menores taxas de recorr\u00eancia de s\u00edncope e pr\u00e9-s\u00edncope em pacientes com estimula\u00e7\u00e3o dupla-c\u00e2mara esteve associado a maior queda da PAS e maior taxa de persist\u00eancia dos sintomas do que a estimula\u00e7\u00e3o em modo DVI (dupla-c\u00e2mara).-c\u00e2mara.A s\u00edncope vasovagal \u00e9 caracterizada pela hist\u00f3ria de perda da consci\u00eancia associada a reflexo neuromediado exacerbado que cursa com redu\u00e7\u00e3o s\u00fabita do fluxo sangu\u00edneo cerebral secund\u00e1ria \u00e0 vasodilata\u00e7\u00e3o e/ou redu\u00e7\u00e3o da frequ\u00eancia card\u00edaca. Na maioria dos casos, a s\u00edncope \u00e9 secund\u00e1ria \u00e0 queda s\u00fabita e significativa da PA, acompanhada de graus vari\u00e1veis de bradicardia e geralmente precedida de manifesta\u00e7\u00f5es prodr\u00f4micas, tais como: mal-estar, sudorese, sensa\u00e7\u00e3o de calor, palidez e tontura, e seguida de fadiga. A s\u00edncope vasovagal, frequentemente, \u00e9 desencadeada por um gatilho, como um estresse emocional importante, medo ou dor, e representa a principal causa de s\u00edncope, principalmente em indiv\u00edduos jovens. S\u00e3o fatores predisponentes: ortostatismo prolongado, ambientes fechados ou quentes, pun\u00e7\u00e3o venosa, traumatismo f\u00edsico e outros.De acordo com altera\u00e7\u00f5es observadas na PA e na FC, classifica-se a resposta vasovagal em tr\u00eas tipos: tipo 1 ou resposta mista (queda significativa da PA acompanhada de diminui\u00e7\u00e3o discreta da FC); tipo 2 ou resposta cardioinibidora (diminui\u00e7\u00e3o importante da FC < 40 bpm ou assistolia > 3s); e tipo 3 ou resposta vasodepressora (queda significativa da PA sem diminui\u00e7\u00e3o significativa da FC).Apesar de, eventualmente, estar relacionada a traumatismos f\u00edsicos e inaptid\u00e3o para realizar atividades de risco pessoal ou coletivo, a s\u00edncope vasovagal apresenta progn\u00f3stico benigno a longo prazo, e o tratamento, na maioria das vezes, \u00e9 n\u00e3o farmacol\u00f3gico, por meio de orienta\u00e7\u00f5es e mudan\u00e7as de h\u00e1bitos de vida. Entretanto, cerca de 14% dos pacientes apresentam formas severas de s\u00edncope vasovagal e necessitam de tratamento adicional . A idade do paciente \u00e9 o fator mais importante na escolha da terapia mais apropriada.Existem poucas op\u00e7\u00f5es terap\u00eauticas baseadas em evid\u00eancias na s\u00edncope vasovagal. A estimula\u00e7\u00e3o card\u00edaca artificial pode ser efetiva em pacientes com s\u00edncope vasovagal e reflexo cardioinibidor dominante; portanto, o foco da investiga\u00e7\u00e3o cl\u00ednica deve ser a documenta\u00e7\u00e3o da correla\u00e7\u00e3o entre a s\u00edncope e a bradicardia.rate-drop response) ou tratamento cl\u00ednico. A recorr\u00eancia de s\u00edncope ap\u00f3s 12 meses de seguimento foi 22% (6/27) no grupo MP e 70% (19/27) no grupo de tratamento cl\u00ednico . O estudo SYDIT, randomizado aberto, incluiu pacientes com s\u00edncopes recorrentes (tr\u00eas ou mais) e teste de inclina\u00e7\u00e3o positivo (bradicardia) para tratamento com MP (DDDrate-drop response) ou tratamento cl\u00ednico (atenolol 100mg/dia). A recorr\u00eancia de s\u00edncope no grupo MP foi 4,3% (2/46), e no grupo atenolol foi 25,5% (12/47), ap\u00f3s seguimento m\u00e9dio de 135 dias . No estudo VASIS, randomizado aberto, os pacientes foram randomizados para MP (DDI histerese de FC) ou nenhum tratamento. A recorr\u00eancia de s\u00edncope, ap\u00f3s seguimento m\u00e9dio de 3,7 anos, foi 5% (1/19) no grupo MP e 61% (14/23) no grupo controle . No estudo VPS II, randomizado cego, foram selecionados pacientes com s\u00edncopes recorrentes (seis ou mais), por\u00e9m bradicardia significativa no teste de inclina\u00e7\u00e3o n\u00e3o foi crit\u00e9rio de inclus\u00e3o. Todos os pacientes foram submetidos a implante de MP, programados em \u201cativado/ON\u201d ou \u201cdesativado/OFF\u201d. A taxa de recorr\u00eancia de s\u00edncope foi 33% (16/48) no grupo MP bicameral (rate-drop response) ativado e 42% (22/52) no grupo MP desativado (modo ODO), sem redu\u00e7\u00e3o significativa no risco de s\u00edncope . No estudo randomizado duplo-cego mais importante publicado, o ISSUE-3, pacientes com mais de 40 anos de idade e documenta\u00e7\u00e3o da s\u00edncope espont\u00e2nea por meio de monitor de eventos implant\u00e1vel associada \u00e0 assistolia >3s, ou assistolia > 6s na aus\u00eancia de s\u00edncope, foram randomizados para MP bicameral (rate drop response) \u201cativado/ON\u201d ou \u201cdesativado/OFF\u201d. Durante seguimento m\u00e9dio de 2 anos, ocorreu redu\u00e7\u00e3o significativa (57%) na taxa de recorr\u00eancia de s\u00edncope . Nos principais estudos, utilizou-se MP bicameral com o modorate drop response.A efetividade do MP definitivo foi avaliada em alguns estudos randomizados. O estudo VPS-I, randomizado aberto, avaliou pacientes com s\u00edncopes recorrentes (seis ou mais) e teste de inclina\u00e7\u00e3o positivo (bradicardia < 60bpm ou pausa > 1s) randomizados para tratamento com MP (DDDclosed-loop stimulation (CLS) ativado, foi comparado com o modo desativado, com demonstra\u00e7\u00e3o de menores taxas de recorr\u00eancia de s\u00edncope.Em um pequeno estudo retrospectivo, o MP bicameral com o modoAs recomenda\u00e7\u00f5es para implante de MP definitivo na s\u00edncope vasovagal est\u00e3o resumidas na Em sua forma obstrutiva, existe um gradiente de press\u00e3o no trato de sa\u00edda do VE, sendo que gradientes maiores est\u00e3o associados a sintomas mais graves e aumento de mortalidade.A cardiomiopatia hipertr\u00f3fica (CMH) \u00e9 uma doen\u00e7a cardiovascular gen\u00e9tica comum, caracterizada por hipertrofia ventricular esquerda, na aus\u00eancia de outras altera\u00e7\u00f5es card\u00edacas ou doen\u00e7as sist\u00eamicas capazes de produzir a magnitude de hipertrofia ventricular encontrada em seus portadores.Em paciente com sintomas causados por obstru\u00e7\u00e3o da via de sa\u00edda do VE (VSVE), as op\u00e7\u00f5es terap\u00eauticas incluem f\u00e1rmacos com efeitos inotr\u00f3picos negativos, miectomia septal cir\u00fargica, abla\u00e7\u00e3o alco\u00f3lica septal e transplante card\u00edaco. Entretanto, a dissincronia ventricular ocasionada pela ativa\u00e7\u00e3o com QRS largo, por si s\u00f3, reduz a contratilidade do VE e pode levar \u00e0 redu\u00e7\u00e3o do gradiente no trato de sa\u00edda. Assim, o benef\u00edcio, neste caso, estaria relacionado a um efeito colateral do MP.Em pacientes com obstru\u00e7\u00e3o da VSVE, a estimula\u00e7\u00e3o da ponta do VD promove altera\u00e7\u00f5es no padr\u00e3o de contra\u00e7\u00e3o ventricular e cria uma dissincronia regional, que tem como resultado a ativa\u00e7\u00e3o tardia da parte basal do septo e a redu\u00e7\u00e3o da contratilidade do VE, que, por sua vez, acarreta na redu\u00e7\u00e3o do movimento sist\u00f3lico anterior da valva mitral e reduz o gradiente press\u00f3rico na VSVE. Em um estudo, a an\u00e1lise de subgrupos sugere que pacientes com mais de 65 anos de idade apresentam maior chance de benef\u00edcio.A redu\u00e7\u00e3o nos gradientes da VSVE com estimula\u00e7\u00e3o ventricular foi demonstrada em tr\u00eas pequenos estudos randomizados e controlados e em diversos estudos observacionais; contudo, a melhora dos sintomas e a qualidade de vida apresentaram resultados vari\u00e1veis. Al\u00e9m disso, em geral, a magnitude de redu\u00e7\u00e3o dos gradientes \u00e9 menor quando comparada com a miectomia ou a abla\u00e7\u00e3o septal. Desse modo, a indica\u00e7\u00e3o de MP dupla-c\u00e2mara unicamente para reduzir o gradiente na VSVE est\u00e1 restrita a condi\u00e7\u00f5es muito espec\u00edficas: pacientes com mais de 65 anos de idade, com hipertrofia moderada, com sintomas definidos devido \u00e0 obstru\u00e7\u00e3o da VSVE e que n\u00e3o tenham indica\u00e7\u00e3o de CDI.Em uma revis\u00e3o da base de dados da Cochrane, os autores conclu\u00edram que os dados de benef\u00edcio da estimula\u00e7\u00e3o ventricular na CMH s\u00e3o baseados em medidas de gradientes, sem evid\u00eancias em rela\u00e7\u00e3o a desfechos cl\u00ednicos relevantes.Em geral, pacientes com CMH obstrutiva, com sintomas refrat\u00e1rios ao tratamento farmacol\u00f3gico, devem ser considerados para miectomia ou abla\u00e7\u00e3o septal como primeira escolha. Casos muito graves poder\u00e3o precisar de transplante card\u00edaco. Adicionalmente, deve-se programar a frequ\u00eancia m\u00e1xima de seguimento atrial maior que a frequ\u00eancia m\u00e1xima apresentada pelo paciente durante teste de esfor\u00e7o. Geralmente, pacientes com CMH, que toleram muito mal frequ\u00eancia card\u00edaca elevada, utilizam betabloqueadores \u2013 o que resulta em frequ\u00eancia m\u00e1xima menor durante o esfor\u00e7o; por outro lado, s\u00e3o pacientes suscet\u00edveis ao desenvolvimento de FA. Assim, deve-se programar a revers\u00e3o autom\u00e1tica de modo (automatic mode switch[mas]) para DDI(R), evitando-se estimula\u00e7\u00e3o ventricular com frequ\u00eancia alta no caso de FA. Caso o eletrodo atrial seja pouco eficiente na detec\u00e7\u00e3o de FA, a frequ\u00eancia m\u00e1xima de seguimento deve ser programada em valor reduzido.Nos pacientes submetidos a implante de MP para redu\u00e7\u00e3o do gradiente da VSVE, a programa\u00e7\u00e3o de intervalo AV curto \u00e9 crucial , para obter pr\u00e9-excita\u00e7\u00e3o m\u00e1xima do VD sem comprometer o enchimento ventricular diast\u00f3lico.Por fim, um significante n\u00famero de pacientes com CMH recebe CDI para preven\u00e7\u00e3o de morte s\u00fabita. Para esses pacientes, um dispositivo bicameral programado em DDD com intervalo AV curto pode reduzir o gradiente na VSVE e prevenir ou retardar a necessidade de interven\u00e7\u00f5es complementares.As recomenda\u00e7\u00f5es para o implante de MP definitivo em pacientes com CMH est\u00e3o elencadas nagravis, a distrofia miot\u00f4nica e a ataxia de Friedreich.Certas doen\u00e7as neuromusculares podem provocar progressiva e insidiosa doen\u00e7a do sistema excito-condutor card\u00edaco. Entre elas, est\u00e3o a distrofia muscular de Duchene, a distrofia muscular fascioesc\u00e1puloumeral, a distrofia ligada ao cromossomo X, a miasteniaAs principais manifesta\u00e7\u00f5es identificadas est\u00e3o relacionadas a dist\u00farbios da condu\u00e7\u00e3o infranodal, resultando em bloqueios fasciculares e BAV de 3\u00ba grau. Tais achados s\u00e3o particularmente observados na s\u00edndrome de Kearns-Sayre , na s\u00edndrome de Guillain-Barr\u00e9, na distrofia muscular miot\u00f4nica, na distrofia muscular de Becker e na distrofia muscular fascioesc\u00e1puloumeral.A distrofia muscular miot\u00f4nica e a s\u00edndrome de Kearns-Sayre s\u00e3o, ambas, associadas com alta incid\u00eancia de doen\u00e7a do sistema de condu\u00e7\u00e3o, que frequentemente progride rapidamente e n\u00e3o pode ser prevista por registros eletrocardiogr\u00e1ficos ou intracavit\u00e1rios. A doen\u00e7a acomete quase sempre o sistema His-Purkinje e pode culminar ataques de Stokes-Adams ou morte s\u00fabita, exceto quando antecipados pelo implante de MP. Os autores conclu\u00edram que o implante de MP definitivo deve ser considerado em pacientes com distrofia miot\u00f4nica com intervalo HV aumentado (\u2265 70ms), mesmo quando assintom\u00e1ticos ou com bradicardia ao ECG.Em um estudo com 49 pacientes com distrofia miot\u00f4nica , BAV de alto grau foi registrado em 47% dos pacientes ap\u00f3s o implante do MP, mesmo sem evid\u00eancia de bradicardia no in\u00edcio do estudo.Nos pacientes com doen\u00e7as neuromusculares, a espera pela documenta\u00e7\u00e3o de BAVT pode resultar em significante risco de morte s\u00fabita ou s\u00edncope. Por isso, o implante de MP definitivo deve ser considerado precocemente no curso da doen\u00e7a neuromuscular, assim que houver qualquer anormalidade da condu\u00e7\u00e3o, mesmo em assintom\u00e1ticos .Anormalidades eletrocardiogr\u00e1ficas como ritmo n\u00e3o sinusal, QRS > 120ms, PRi > 240ms, BAV de 2\u00ba ou 3\u00ba graus e taquiarritmias atriais foram preditores independentes de morte s\u00fabita em pacientes com distrofia muscular miot\u00f4nica tipo 1.Bradiarritmias, como bradicardia sinusal, pausas sinusais, BAV de 2\u00ba grau tipo I ou de grau avan\u00e7ado e ritmo de escape juncional s\u00e3o frequentes durante o sono, principalmente em jovens saud\u00e1veis com bom condicionamento f\u00edsico. Dados diretos e indiretos t\u00eam mostrado rela\u00e7\u00e3o com hipertonia vagal. Na maioria absoluta dos casos, esses achados s\u00e3o fisiol\u00f3gicos, sem indica\u00e7\u00e3o de tratamento espec\u00edfico. Entretanto, t\u00eam sido observadas arritmias card\u00edacas na s\u00edndrome da apneia obstrutiva do sono (SAOS).Os casos mais importantes est\u00e3o relacionados com s\u00edndrome de Pickwick, obesidade, hipertens\u00e3o arterial sist\u00eamica, s\u00edndrome metab\u00f3lica, obstru\u00e7\u00e3o anat\u00f4mica e/ou funcional das vias a\u00e9reas , doen\u00e7as pulmonares cr\u00f4nicas, doen\u00e7as neurol\u00f3gicas e outras.Quando h\u00e1 obstru\u00e7\u00e3o de vias a\u00e9reas, durante a apneia, ocorre dessatura\u00e7\u00e3o de oxig\u00eanio que pode resultar em hipoxemia grave com consequente surgimento de bradi e taquiarritmias atriais e ventriculares. Assim, n\u00e3o h\u00e1 indica\u00e7\u00e3o prim\u00e1ria de MP para as bradiarritmias relacionadas \u00e0 SAOS.O tratamento principal \u00e9 dirigido \u00e0 corre\u00e7\u00e3o da apneia e perda de peso. O uso de aparelhos de press\u00e3o positiva em vias a\u00e9reas superiores (CPAP) para suporte respirat\u00f3rio durante o sono pode ser de grande import\u00e2ncia, tendo sido observado, inclusive, desaparecimento das bradiarritmias em boa parte dos casos.Quando a corre\u00e7\u00e3o da obstru\u00e7\u00e3o das vias a\u00e9reas n\u00e3o \u00e9 suficiente para melhorar o quadro, a abla\u00e7\u00e3o por cateter de radiofrequ\u00eancia pode ser indicada (cardioneuroabla\u00e7\u00e3o e/ou abla\u00e7\u00e3o da FA). Em casos excepcionais, o implante de MP pode facilitar o tratamento da FA (betabloqueadores ou outros antiarr\u00edtmicos).Na pr\u00e1tica cl\u00ednica, \u00e9 frequente que esta condi\u00e7\u00e3o fa\u00e7a parte de um cen\u00e1rio caracterizado por hipertonia vagal, bradiarritmia noturna e FA comumente deflagrada pela bradicardia (s\u00edndrome braditaquicardia).Holter-24h, comparando-se os per\u00edodos de vig\u00edlia e sono. A variabilidade RR e o n\u00famero de pausas maiores que 2,5s pr\u00e9 e 1 ano p\u00f3s-cardioneuroabla\u00e7\u00e3o foram comparados em um estudo que incluiu 18 pacientes com hist\u00f3ria de SAOS e braditaquicardia e/ou hipertonia vagal. Nesse estudo, os autores demonstraram importante redu\u00e7\u00e3o da variabilidade RR . Ademais, o n\u00famero de pausas reduziu significativamente, de 6,5 \u00b1 9,4 pr\u00e9-CNA para 1,1 \u00b1 3 ap\u00f3s 11 meses da CNA, p = 0,03. Nenhum paciente recebeu implante de MP. Dessa maneira, habitualmente, o implante de MP est\u00e1 reservado aos casos em que se identifica comprometimento do sistema de condu\u00e7\u00e3o  e hist\u00f3ria de s\u00edncope e/ou de morte s\u00fabita. Em geral, existe hist\u00f3ria familiar em parentes pr\u00f3ximos e pode ser autoss\u00f4mica recessiva (muito rara), acompanhada de surdez (s\u00edndrome de Jervell-Lange Nielsen) ou autoss\u00f4mica dominante, mais frequente (s\u00edndrome de Romano Ward). Esses dois tipos perfazem 90% dos casos de SQTLc; por\u00e9m, atualmente, s\u00e3o conhecidos pelo menos 14 tipos diferentes da forma cong\u00eanita dessa s\u00edndrome.A s\u00edndrome do QT longo cong\u00eanito (SQTLc) \u00e9 uma canalopatia causada por uma anormalidade da repolariza\u00e7\u00e3o card\u00edaca e \u00e9 caracterizada pela presen\u00e7a de intervalo QT prolongado, arritmias ventriculares , cujo limite normal \u00e9 450ms e 460ms, respectivamente, para os g\u00eaneros masculino e feminino. Intervalo QTc > 480ms 4 minutos ap\u00f3s teste de esfor\u00e7o \u00e9 altamente sugestivo desta s\u00edndrome. Aproximadamente 20% dos casos com gen\u00f3tipo positivo apresentam QT normal.A medida do intervalo QT (QTi) pode ser realizada em qualquer deriva\u00e7\u00e3o, por\u00e9m, mais frequentemente, s\u00e3o utilizadas as deriva\u00e7\u00f5es D2 e V5.torsade de pointes, fibrila\u00e7\u00e3o ventricular e morte s\u00fabita.Nos diversos tipos de s\u00edndrome de SQTLc, seja por redu\u00e7\u00e3o na fun\u00e7\u00e3o dos canais de pot\u00e1ssio ou por aumento na fun\u00e7\u00e3o do canal de s\u00f3dio (retardo na inativa\u00e7\u00e3o dos canais), ocorre retardo na repolariza\u00e7\u00e3o celular que se manifesta por aumento do QTi. Aparentemente, as anormalidades eletrofisiol\u00f3gicas s\u00e3o heterog\u00eaneas e se tornam muito mais acentuadas diante de algumas condi\u00e7\u00f5es como estimula\u00e7\u00e3o auton\u00f4mica, estresse f\u00edsico e mental, altera\u00e7\u00f5es eletrol\u00edticas, a\u00e7\u00e3o de f\u00e1rmacos, isquemia etc., resultando em instabilidade el\u00e9trica, extrassistolia, taquicardia polim\u00f3rfica,\u00c9 fundamental, sempre que poss\u00edvel, definir o tipo de SQTLc  de acordo com a manifesta\u00e7\u00e3o cl\u00ednica e eletrocardiogr\u00e1fica, tendo em vista o tratamento recomendado para cada tipo. Tipicamente, as manifesta\u00e7\u00f5es da SQTLc tendem a surgir na inf\u00e2ncia ou adolesc\u00eancia. Geralmente s\u00e3o mais precoces no sexo masculino (adolesc\u00eancia) do que no feminino (idade adulta). A s\u00edncope \u00e9 a manifesta\u00e7\u00e3o mais frequente, ocorrendo geralmente entre 5 e 15 anos de idade. Hist\u00f3ria familiar de morte s\u00fabita \u00e9 forte preditor de mortalidade. De modo geral, quanto maior o QTc, maior o risco de morte s\u00fabita.Os tipos 1 e 2 s\u00e3o mais frequentes, ocasionados por diminui\u00e7\u00e3o da fun\u00e7\u00e3o de canais de pot\u00e1ssio; o tipo 3 ocorre por aumento da fun\u00e7\u00e3o dos canais de s\u00f3dio.A SQTLc tipo 1 geralmente tem as arritmias deflagradas durante esfor\u00e7o f\u00edsico, notadamente a nata\u00e7\u00e3o. J\u00e1 o tipo 2, mais comumente, apresenta arritmias induzidas por estresse mental ocasionado, por exemplo, por fortes ru\u00eddos, principalmente durante descanso ou sono. O tipo 3 tipicamente apresenta as arritmias em repouso ou durante o sono, sem rela\u00e7\u00e3o clara com uma condi\u00e7\u00e3o de estresse.sitesque listam f\u00e1rmacos com potencial risco de prolongamento do QTc (http://www.crediblemeds.org), e devem ser sempre consultados antes do uso de algum medicamento.\u00c9 absolutamente fundamental que esses pacientes evitem dist\u00farbios eletrol\u00edticos como a hipopotassemia e estejam atentos para evitar o uso de f\u00e1rmacos que podem desencadear arritmias fatais. Est\u00e3o dispon\u00edveis na internet diversosCerta liberdade para esportes recreacionais n\u00e3o competitivos pode ser considerada, com cautela, para os pacientes com SQTL3, condicionado ao f\u00e1cil acesso de um desfibrilador externo autom\u00e1tico (DEA) no ambiente. Est\u00e3o absolutamente contraindicados os medicamentos e as subst\u00e2ncias que prolongam a repolariza\u00e7\u00e3o, tais como os bloqueadores dos canais de pot\u00e1ssio, que podem induzirtorsade de pointesmesmo em casos assintom\u00e1ticos. Da mesma forma, tamb\u00e9m devem ser evitados os simpaticomim\u00e9ticos. \u00c9 recomend\u00e1vel que esses pacientes sejam portadores de um documento com a lista dos medicamentos proibidos.Todos os pacientes, sintom\u00e1ticos, assintom\u00e1ticos e portadores \u201csilenciosos\u201d devem reduzir acentuadamente a atividade f\u00edsica. Os esportes competitivos est\u00e3o contraindicados. Certos deflagradores relacionados ao tipo, tais como nata\u00e7\u00e3o extenuante no SQTL1 e ru\u00eddos muito altos na SQTL2, devem ser evitados.O tratamento farmacol\u00f3gico baseia-se no uso de betabloqueadores, sendo os mais eficazes o propranolol e o nadolol, essencialmente na SQTL tipos 1 e 2. O metoprolol parece ser menos eficaz e n\u00e3o deve ser preferido.versus60% no grupo sem tratamento.Estudos retrospectivos t\u00eam demonstrado benef\u00edcio inquestion\u00e1vel de betabloqueadores ou denerva\u00e7\u00e3o cir\u00fargica (retirada do g\u00e2nglio estrelado esquerdo), com mortalidade de 9% no grupo tratadoO QTc pode ser reduzido experimentalmente com agentes potencializadores da bomba de pot\u00e1ssio, como o nicorandil na SQTL1, ou espironolactona combinada com pot\u00e1ssio oral na SQTL2. A SQTL3 pode ser beneficiada com bloqueadores de canal de s\u00f3dio, como mexiletine ou flecainida, que podem encurtar o QTc, mas este \u00faltimo pode induzir um fen\u00f3tipo de Brugada. Existem relatos de tratamento com sucesso de tempestade el\u00e9trica na SQTL3 com mexiletine, que \u00e9 recomendada por alguns profissionais quando h\u00e1 um QTc muito longo. Entretanto, o MP pode ser indicado em casos em que se identifica BAV ou quando existem arritmias ventriculares deflagradas ou agravadas por bradicardia ou pausas, desde que n\u00e3o haja hist\u00f3ria de morte s\u00fabita recuperada e que estejam ausentes os sinais de alto risco: surdez cong\u00eanita, s\u00edncope, arritmias ventriculares complexas documentadas, hist\u00f3ria familiar de morte s\u00fabita, sexo feminino, QTc > 0,60s. Eventualmente, o MP pode ter indica\u00e7\u00e3o em conjunto com a terapia betabloqueadora para evitar bradicardia resultante da pr\u00f3pria a\u00e7\u00e3o farmacol\u00f3gica. A estimula\u00e7\u00e3o card\u00edaca em uma frequ\u00eancia acima da frequ\u00eancia sinusal espont\u00e2nea pode, reflexamente, inibir a a\u00e7\u00e3o simp\u00e1tica e ser bastante \u00fatil para controle de tempestades arr\u00edtmicas. O MP deve estimular somente \u00e1trio (evitar dissincronia ventricular) e pode ser programado com frequ\u00eancia mais elevada , que pode reduzir a dura\u00e7\u00e3o do QTc. Ademais, a ativa\u00e7\u00e3o do sensor de resposta de frequ\u00eancia pode garantir adapta\u00e7\u00e3o cronotr\u00f3pica, prejudicada devido ao uso de betabloqueadores  .A taxa de implante de MP definitivo ap\u00f3s o transplante card\u00edaco varia entre 2% e 24% e tem apresentado queda significativa com emprego da t\u00e9cnica de anastomose bicaval, em rela\u00e7\u00e3o \u00e0s t\u00e9cnicas de anastomose biatrial.A maioria dos estudos reporta a DNS como a anormalidade mais comum encontrada. As causas de DNS s\u00e3o variadas e incluem: traumatismo cir\u00fargico, danos \u00e0 art\u00e9ria do n\u00f3 sinusal por traumatismo e isquemia, tempos prolongados de isquemia card\u00edaca, denerva\u00e7\u00e3o card\u00edaca e caracter\u00edsticas basais do cora\u00e7\u00e3o doado.Cerca de 10% dos pacientes que necessitam de MP apresentam dist\u00farbios da condu\u00e7\u00e3o AV, principalmente BAV de 2\u00ba e 3\u00ba graus, sendo postulado que essas altera\u00e7\u00f5es provavelmente estejam relacionadas com preserva\u00e7\u00e3o inadequada do enxerto.A bradicardia \u00e9 comum no per\u00edodo precoce ap\u00f3s transplante card\u00edaco, ocorrendo em cerca de dois ter\u00e7os dos pacientes; por\u00e9m, frequentemente, tende a resolver espontaneamente. Se a bradicardia perdurar por algumas semanas e cursar com sintomas, o implante de MP pode ser necess\u00e1rio. e FA  com a estimula\u00e7\u00e3o atrioventricular sequencial em compara\u00e7\u00e3o com a estimula\u00e7\u00e3o ventricular.Estudos cl\u00ednicos randomizados n\u00e3o evidenciaram impacto na sobrevida com a estimula\u00e7\u00e3o atrial ou atrioventricular (AAI/DDD) em rela\u00e7\u00e3o \u00e0 estimula\u00e7\u00e3o ventricular exclusiva (VVI); entretanto, demonstraram benef\u00edcios em rela\u00e7\u00e3o \u00e0 redu\u00e7\u00e3o de ocorr\u00eancia de FA, incid\u00eancia de s\u00edncopes e s\u00edndrome do MP. A estimula\u00e7\u00e3o ventricular deve ser evitada em pacientes em ritmo sinusal, uma vez que pode causar FA e piora de IC  e o dobro de reopera\u00e7\u00f5es quando comparada com a estimula\u00e7\u00e3o DDDR. de IC . RessalversusDDD em termos de melhoria de qualidade de vida em 872 pacientes com incompet\u00eancia cronotr\u00f3pica. Aos 6 meses de seguimento, os pacientes randomizados para o modo DDDR tiveram maior pico de frequ\u00eancia card\u00edaca em compara\u00e7\u00e3o com aqueles em modo DDD . Contudo, com 1 ano, n\u00e3o ocorreram diferen\u00e7as significativas entre os dois grupos com respeito \u00e0 escala de atividade ou desfechos secund\u00e1rios de qualidade de vida.A ativa\u00e7\u00e3o do sensor de varia\u00e7\u00e3o de frequ\u00eancia pode ser ben\u00e9fica em pacientes com incompet\u00eancia cronotr\u00f3pica. O estudo ADEPT comparou os modos DDDRO remodelamento e a consequente disfun\u00e7\u00e3o ventricular esquerda promovidos pela dissincronia associada \u00e0 estimula\u00e7\u00e3o artificial do VD s\u00e3o desfechos que justificam a busca por s\u00edtios alternativos para estimula\u00e7\u00e3o em pacientes com bradiarritmias que necessitam de estimula\u00e7\u00e3o ventricular artificial. Mais importante ainda: esses eventos adversos estiveram diretamente relacionados ao percentual cumulativo de estimula\u00e7\u00e3o ventricular.O estudo MOST demonstrou que, em pacientes com disfun\u00e7\u00e3o sinusal, a estimula\u00e7\u00e3o ventricular na ponta do VD determinou aumento significativo de epis\u00f3dios de FA e interna\u00e7\u00e3o por IC.Dessa maneira, a busca por uma forma de estimula\u00e7\u00e3o artificial que mantenha o sincronismo intra e interventricular, al\u00e9m da corre\u00e7\u00e3o da bradiarritmia, \u00e9 uma necessidade de relev\u00e2ncia cl\u00ednica que vem sendo remetida \u00e0 chamada estimula\u00e7\u00e3o fisiol\u00f3gica.A estimula\u00e7\u00e3o direta do sistema de condu\u00e7\u00e3o \u00e9 a maneira mais fisiol\u00f3gica de estimula\u00e7\u00e3o ventricular artificial porque mant\u00e9m a ativa\u00e7\u00e3o el\u00e9trica natural do cora\u00e7\u00e3o, uma vez que o est\u00edmulo segue pelas vias normais de condu\u00e7\u00e3o especializada (His-Purkinje), evitando a dissincronia induzida pela estimula\u00e7\u00e3o muscular do VD.vs.2% p = 0,02).Sharma et al. demonstraram, em estudo n\u00e3o randomizado com 202 pacientes em seguimento de 2 anos, que a estimula\u00e7\u00e3o pelo feixe de His foi superior \u00e0 estimula\u00e7\u00e3o convencional pela ponta do VD. Nos pacientes com mais de 40% de percentual de estimula\u00e7\u00e3o ventricular, houve redu\u00e7\u00e3o significativa da necessidade de interna\u00e7\u00e3o por IC , limiares de estimula\u00e7\u00e3o mais elevados, menor amplitude de sinal intracavit\u00e1rio e possibilidade de inibi\u00e7\u00e3o anormal porA estimula\u00e7\u00e3o direta do ramo esquerdo ou de regi\u00e3o pr\u00f3xima por via septal profunda  \u00e9 alternativa vi\u00e1vel para manuten\u00e7\u00e3o de QRS estreito e preven\u00e7\u00e3o de dissincronia. Apesar da diferen\u00e7a t\u00e9cnica entre a captura direta do ramo esquerdo e a captura da regi\u00e3o do ramo esquerdo, do ponto de vista funcional, a estimula\u00e7\u00e3o da regi\u00e3o do ramo esquerdo \u00e9 capaz de promover sincronismo equivalente \u00e0 estimula\u00e7\u00e3o direta do feixe de His.performancehemodin\u00e2mica (mensurada pela dP/dT) do que com a estimula\u00e7\u00e3o apical do VD. Mais tarde, Huang demonstrou a possibilidade de captura direta do ramo esquerdo por meio da estimula\u00e7\u00e3o septal profunda, corrigindo o BRE em pacientes com essa abordagem, e estabeleceu crit\u00e9rios para defini\u00e7\u00e3o de captura do ramo esquerdo que incluem pelo menos tr\u00eas crit\u00e9rios: 1) presen\u00e7a de potencial de ramo esquerdo captado no sinal do EGM do eletrodo; 2) tempo de ativa\u00e7\u00e3o da parede livre do VE (LVAT) menor que 90ms sem modifica\u00e7\u00e3o com energia de estimula\u00e7\u00e3o de 2V ou 5V; 3) padr\u00e3o de BRD incompleto ao ECG; 4) evid\u00eancia de captura seletiva e n\u00e3o seletiva do ramo esquerdo; 5) evid\u00eancia de estimula\u00e7\u00e3o direta do ramo esquerdo atrav\u00e9s de eletrodo concomitante no His ou no septo esquerdo.Mafi-Rad et al. demonstraram, em uma pequena serie de 10 pacientes com DNS, a viabilidade de estimular a regi\u00e3o esquerda do septo interventricular resultando em QRS estreito, com padr\u00e3o de atraso final pelo ramo direito, com limiares est\u00e1veis e melhorA estimula\u00e7\u00e3o fisiol\u00f3gica atrav\u00e9s do feixe de His ou do ramo esquerdo vem sendo utilizada com efici\u00eancia em v\u00e1rios cen\u00e1rios de bradiarritmias com necessidade de estimula\u00e7\u00e3o ventricular .Ambas as estrat\u00e9gias de estimula\u00e7\u00e3o  t\u00eam demonstrado seguran\u00e7a, estabilidade e melhores resultados de medidas de sincronia, dura\u00e7\u00e3o do QRS e tend\u00eancia de melhora da fun\u00e7\u00e3o ventricular nas s\u00e9ries que compararam com a estimula\u00e7\u00e3o pelo VD. Quando comparadas as duas t\u00e9cnicas, a estimula\u00e7\u00e3o direta do feixe de His \u00e9 capaz de promover um QRS normal e, aparentemente, ainda mais fisiol\u00f3gico, mas \u00e0 custa de tempo maior de implante, limiares mais elevados e menor valor de onda R que a estimula\u00e7\u00e3o do ramo esquerdo.A evolu\u00e7\u00e3o da tecnologia das ferramentas de implante, a disponibilidade de geradores dedicados que possibilitem algoritmos espec\u00edficos para detec\u00e7\u00e3o e gasto de energia proporcional e os resultados de estudos controlados a longo prazo determinar\u00e3o o papel das t\u00e9cnicas de estimula\u00e7\u00e3o fisiol\u00f3gica possivelmente como preferencial em futuro pr\u00f3ximo.A estimula\u00e7\u00e3o card\u00edaca artificial n\u00e3o \u00e9 isenta de problemas. A incid\u00eancia de complica\u00e7\u00f5es com cabos-eletrodos e o gerador de pulsos, especialmente em loja subcut\u00e2nea, aumenta ao longo dos anos de seguimento e pode afetar mais de 10% dos portadores desses dispositivos. De todas as complica\u00e7\u00f5es descritas, a endocardite infecciosa merece especial destaque pela elevada morbidade e mortalidade associadas.O implante de sistemas convencionais associa-se a risco de pneumot\u00f3rax, hemot\u00f3rax, deslocamento dos cabos-eletrodos, oclus\u00e3o venosa, insufici\u00eancia da valva tric\u00faspide e infec\u00e7\u00e3o . Ademais, o implante subcut\u00e2neo tamb\u00e9m se associa \u00e0 ocorr\u00eancia de hematoma da loja e infec\u00e7\u00e3o, que podem ocorrer n\u00e3o s\u00f3 na primeira cirurgia, mas tamb\u00e9m no momento da troca do gerador.leadless pacemaker) \u00e9 uma evolu\u00e7\u00e3o tecnol\u00f3gica que traz algumas vantagens potenciais em rela\u00e7\u00e3o aos sistemas convencionais. Inicialmente, foram lan\u00e7ados no mercado dois sistemas \u2013 Nanostim  e MICRA TPS , mas, atualmente, apenas o MICRA TPS \u00e9 comercializado.Sendo o cabo-eletrodo de MP a fonte principal de problemas e complica\u00e7\u00f5es, \u00e9 natural que a tecnologia tenha avan\u00e7ado no sentido de privilegiar solu\u00e7\u00f5es em que fosse poss\u00edvel dispens\u00e1-lo. Neste sentido, o MP sem cabo-eletrodo  em que est\u00e1 contido o eletrodo e o gerador de pulsos, que \u00e9 implantado na cavidade card\u00edaca por via transvenosa. Todo o processo \u00e9 relativamente simples e envolve a cateteriza\u00e7\u00e3o da veia femoral, passando uma bainha  pela veia cava inferior at\u00e9 ao \u00e1trio direito. Um sistema de entrega segue depois, dentro dessa bainha, e permite libertar o dispositivo no VD. A posi\u00e7\u00e3o inicial recomendada para o implante era o apex do VD, mas atualmente tem sido preconizado que seja implantado no septo interventricular.vs.3,9%) e de necessidade de revis\u00e3o de sistema . Destaca-se, ainda, baixa taxa de infec\u00e7\u00f5es, n\u00e3o relacionados com o implante ou com a presen\u00e7a do dispositivo. Esses resultados foram depois confirmados no seguimento anual dessa popula\u00e7\u00e3o. A an\u00e1lise dessa mesma coorte mostrou melhoria de par\u00e2metros de qualidade de vida aos 3 e 12 meses e elevados n\u00edveis de satisfa\u00e7\u00e3o. No mesmo estudo, o sistema MICRA foi associado a menos restri\u00e7\u00f5es na atividade que os sistemas convencionais.O sistema MICRA foi avaliado em um ensaio cl\u00ednico prospetivo, multic\u00eantrico (MICRA IDE), de bra\u00e7o \u00fanico, que incluiu 725 pacientes  com indica\u00e7\u00e3o de implante de MP definitivo de c\u00e2mara \u00fanica. O objetivo principal foi avaliar a efic\u00e1cia (limiar de captura no seguimento de 6 meses) e seguran\u00e7a (complica\u00e7\u00f5es maiores). O implante foi bem-sucedido em 99,2% dos casos. Ocorreram 28 complica\u00e7\u00f5es maiores em 3,4% dos pacientes, tendo sido registados perfura\u00e7\u00e3o ou derrame peric\u00e1rdico , complica\u00e7\u00f5es no local de acesso vascular  e limiar de estimula\u00e7\u00e3o elevado . N\u00e3o ocorreram deslocamentos ou emboliza\u00e7\u00f5es do dispositivo. Os valores m\u00e9dios de onda R, limiar de estimula\u00e7\u00e3o e imped\u00e2ncia permaneceram est\u00e1veis. Nesse estudo, a taxa de complica\u00e7\u00f5es foi comparada com uma popula\u00e7\u00e3o de mais de 2.000 pacientes (controles hist\u00f3ricos de outros ensaios cl\u00ednicos de MP convencionais da mesma marca), tendo-se verificado menor taxa de complica\u00e7\u00f5es maiores , incluindo menor n\u00famero de hospitaliza\u00e7\u00f5es  e pretende incluir 1.830 doentes. O desfecho prim\u00e1rio do estudo \u00e9 a ocorr\u00eancia de complica\u00e7\u00f5es nos primeiros 30 dias p\u00f3s procedimento. Os resultados dos primeiros 795 doentes foram j\u00e1 publicados e demonstraram elevada taxa de sucesso no implante , com baixa taxa de complica\u00e7\u00f5es maiores . Cerca de 20% dos pacientes desse registo tinham contraindica\u00e7\u00e3o para implante de sistema convencional (sobretudo por problemas relacionados com acesso vascular). Na popula\u00e7\u00e3o estudada, ocorreram 5 derrames peric\u00e1rdicos (dois com necessidade de drenagem).A seguran\u00e7a do implante do sistema tamb\u00e9m foi avaliada em popula\u00e7\u00f5es especiais, como pacientes em hemodi\u00e1lise (HD) e ap\u00f3s extra\u00e7\u00e3o de dispositivos convencionais por infec\u00e7\u00e3o. cujos resultados obtidos at\u00e9 6 meses de seguimento n\u00e3o diferem dos resultados obtidos com os estudos do MICRA. O motivo para ter sido retirado do mercado tem a ver com fal\u00eancia inesperada da bateria, que impede estimula\u00e7\u00e3o ventricular e comunica\u00e7\u00e3o com o dispositivo em cerca de 0,5% dos casos.O dispositivo Nanostim foi tamb\u00e9m avaliado em estudo multic\u00eantrico e observacional, Outro estudo mais recente, que incluiu 53 pacientes, concluiu que oleadless pacemakerinterfere na fun\u00e7\u00e3o da v\u00e1lvula e pode causar ou agravar insufici\u00eancia tric\u00faspide. O mecanismo mais prov\u00e1vel \u00e9 a interfer\u00eancia mec\u00e2nica do dispositivo com o aparelho subvalvular, sendo a les\u00e3o aguda (durante o implante) da v\u00e1lvula ou a dissincronia induzida pelo MP as causas menos prov\u00e1veis. Os autores desse estudo descrevem, ainda, que os doentes em que o dispositivo fica em posi\u00e7\u00e3o septal  s\u00e3o aqueles em que mais vezes se observou insufici\u00eancia tric\u00faspide, provavelmente pela maior proximidade \u00e0 v\u00e1lvula e ao aparelho subvalvular.Al\u00e9m das complica\u00e7\u00f5es intraoperat\u00f3rias que j\u00e1 foram referidas, existem duas situa\u00e7\u00f5es que constituem, ainda, uma \u00e1rea de incerteza. Em primeiro lugar, ainda n\u00e3o est\u00e1 claro se o dispositivo tem interfer\u00eancia ou n\u00e3o na fun\u00e7\u00e3o da v\u00e1lvula tric\u00faspide. Em um estudo inicial, com 2 meses de seguimento de 23 pacientes, concluiu-se que n\u00e3o existia interfer\u00eancia na fun\u00e7\u00e3o da v\u00e1lvula tric\u00faspide. Est\u00e1 tamb\u00e9m publicado um relato de um caso cl\u00ednico em que foi poss\u00edvel extrair o dispositivo, por via percut\u00e2nea, 4 anos ap\u00f3s o implante. \u00c9, no entanto, desconhecido qual vai ser o comportamento em seguimento de longo prazo e se ser\u00e1 poss\u00edvel a extra\u00e7\u00e3o .Outra \u00e1rea de incerteza \u00e9 a atitude a tomar no fim da vida do gerador. Est\u00e1 publicada a experi\u00eancia mundial com o explante precoce do sistema MICRA \u2013 entre o primeiro e o 95\u00aa dia \u2013 com bons resultados e baixa taxa de complica\u00e7\u00f5es.leadless pacemaker.\u00c9 necess\u00e1rio, tamb\u00e9m, n\u00e3o esquecer que, com o aparecimento de novas tecnologias, podem surgir novas complica\u00e7\u00f5es n\u00e3o descritas \u2013 que poder\u00e3o aparecer quando existirem seguimentos mais longos. Importante tamb\u00e9m recordar que n\u00e3o existe, at\u00e9 a data presente, qualquer compara\u00e7\u00e3o randomizada entre sistemas de MP convencionais eO dispositivo dispon\u00edvel atualmente \u00e9 de c\u00e2mara \u00fanica e permite resposta em frequ\u00eancia (VVIR). As indica\u00e7\u00f5es, em termos gerais, s\u00e3o as mesmas de um MP de c\u00e2mara \u00fanica \u2013 de forma muito gen\u00e9rica: bradicardia sintom\u00e1tica em que se considera n\u00e3o ser necess\u00e1rio eletrodo atrial .surveyrecente da EHRA.Um dos principais fatores limitantes \u00e0 utiliza\u00e7\u00e3o desse tipo de dispositivo \u00e9 o pre\u00e7o elevado, como ficou demonstrado em leadless pacemakernesses subgrupos. Esses pacientes est\u00e3o tamb\u00e9m representados nos estudos de \u201cvida real\u201d j\u00e1 referidos.Conceitualmente, os melhores candidatos seriam aqueles com contraindica\u00e7\u00f5es relativas aos dispositivos convencionais, por exemplo, por aus\u00eancia de acessos vasculares, pacientes com risco de nova cirurgia, hemodi\u00e1lise e ap\u00f3s infec\u00e7\u00e3o de sistemas convencionais. Existem estudos (a maioria de centro \u00fanico) que demostram efic\u00e1cica doA t\u00e9cnica de implante \u00e9 distinta da t\u00e9cnica convencional; por isso, \u00e9 importante ter experi\u00eancia em estimula\u00e7\u00e3o card\u00edaca, em acessos vasculares femorais, em manipula\u00e7\u00e3o de bainhas de grande calibre e manipula\u00e7\u00e3o de eletrodos no VD. A perfura\u00e7\u00e3o card\u00edaca n\u00e3o \u00e9 frequente  e, quando ocorre, faz com que exija habitualmente resolu\u00e7\u00e3o cir\u00fargica de emerg\u00eancia.performancedo VE.A despeito da TFO, muitos pacientes com IC com FEVE reduzida (ICFEr) evoluem com persist\u00eancia de sintomas e importante disfun\u00e7\u00e3o sist\u00f3lica do VE. Os fatores mais comuns relacionados com a baixa resposta \u00e0 TFO s\u00e3o a insufici\u00eancia mitral moderada ou grave, reserva funcional mioc\u00e1rdica reduzida e a dissincronia ventricular (DV). Com rela\u00e7\u00e3o a esta \u00faltima, a TRC, por meio da estimula\u00e7\u00e3o card\u00edaca atriobiventricular, associada ou n\u00e3o ao CDI, tem sido considerada excelente op\u00e7\u00e3o terap\u00eautica para pacientes com BRE. A TRC tem o prop\u00f3sito de corrigir disfun\u00e7\u00f5es eletromec\u00e2nicas em pacientes com ICFEr que apresentem a DV e, por consequ\u00eancia, melhorar a O estudo COMPANION  e o CARE-HF (Cardiac Resynchronisation in Heart Failure Study) foram os primeiros estudos randomizados de larga escala testando a TRC em desfechos cl\u00ednicos de mortalidade total e taxa de hospitaliza\u00e7\u00e3o. Os achados desses estudos demonstraram aumento da sobrevida proporcionado pelo acr\u00e9scimo da TRC \u00e0 TFO.O ECG de superf\u00edcie \u00e9 o m\u00e9todo de elei\u00e7\u00e3o na pesquisa de DV e sele\u00e7\u00e3o de pacientes para a TRC. Apesar de os m\u00e9todos de imagem, como o ecocardiograma, serem capazes de detectar a DV mec\u00e2nica, o estudo PROSPECT (Predictors of Response to CRT) demonstrou que o doppler tecidual n\u00e3o conseguiu identificar os pacientes respondedores \u00e0 TRC. Em seguimento m\u00e9dio de 29,4 meses, foram observados 524 \u00f3bitos, com redu\u00e7\u00e3o marcante da mortalidade  e da taxa de hospitaliza\u00e7\u00f5es por IC  com a TRC. Em todos os estudos inclu\u00eddos, houve melhora significativa da qualidade de vida (3 a 6 meses), apesar da heterogeneidade dos crit\u00e9rios de tempo de avalia\u00e7\u00e3o. Ademais, o n\u00famero necess\u00e1rio para tratar (NNT) foi estimado em 11 . Considerando-se a longevidade m\u00e9dia dos aparelhos de TRC (6 anos), seria necess\u00e1rio implantar 5 dispositivos para evitar 1 \u00f3bito.Esses resultados foram confirmados por metan\u00e1lise publicada em 2006, que incluiu oito ensaios cl\u00ednicos com o total de 3.380 pacientes.Esses estudos embasaram as primeiras indica\u00e7\u00f5es da TRC como terap\u00eautica coadjuvante \u00e0 TFO na ICFEr avan\u00e7ada  NYHA III ou IV a despeito da TFO por mais de 3 meses) que apresentassem DV, constatada pela presen\u00e7a de dist\u00farbio da condu\u00e7\u00e3o intraventricular (DCIV) no ECG. Ressalta-se que o estudo COMPANION tamb\u00e9m demonstrou maiores benef\u00edcios cl\u00ednicos com o acr\u00e9scimo do CDI \u00e0 TRC (TRC-D). REVERSE (Resynchronization Reverses Remodeling in Systolic Left Ventricular Dysfunction) e RAFT . Esses estudos compararam o TRC-Dversuso CDI isolado, em pacientes com FEVE \u2264 40% (REVERSE) ou \u2264 30% (MADIT-CRT e RAFT) e CF NYHA I-II (REVERSE e MADIT-CRT) ou II-III (RAFT). Os resultados, ressaltados em metan\u00e1lise, permitiram comprovar os benef\u00edcios da TRC, n\u00e3o s\u00f3 como terap\u00eautica adicional \u00e0 TFO, mas tamb\u00e9m ao CDI na redu\u00e7\u00e3o da mortalidade total.Subsequentemente, foram publicados os estudos MADIT-CRT , Destaca-se que apenas 9% dos pacientes estudados tinham CF NYHA I e, nessa popula\u00e7\u00e3o, a TRC reduziu significativamente a taxa de hospitaliza\u00e7\u00e3o por IC, mas n\u00e3o a mortalidade total. Esses resultados demonstram que a TRC, institu\u00edda precocemente nos pacientes com ICFEr assintom\u00e1ticos, pode reduzir a progress\u00e3o da IC, possivelmente por meio do remodelamento reverso ventricular. Entretanto, os potenciais benef\u00edcios da TRC em pacientes com ICFEr e CF NYHA I devem ser cuidadosamente avaliados em rela\u00e7\u00e3o aos poss\u00edveis eventos adversos e custos associados ao implante da TRC.Em rela\u00e7\u00e3o aos pacientes com ICFEr assintom\u00e1ticos (CF NYHA I) ou em CF NYHA II inclu\u00eddos em cinco estudos cl\u00ednicos randomizados, metan\u00e1lise demonstrou redu\u00e7\u00e3o significativa da mortalidade total e taxa de hospitaliza\u00e7\u00e3o por IC nos pacientes com CF NYHA II. e CARE-HF. Por\u00e9m, em 2013, houve as publica\u00e7\u00f5es dos resultados do estudo ECHO CRT que demonstraram aumento da mortalidade cardiovascular no subgrupo de pacientes com QRS < 130ms submetidos a TRC. Esses achados foram corroborados em metan\u00e1lise que demonstrou pouco benef\u00edcio da TRC nos pacientes com QRS < 140ms. De fato, quanto maior a dura\u00e7\u00e3o do QRS, melhor \u00e9 a resposta \u00e0 TRC. Ademais, os pacientes com BRE e dura\u00e7\u00e3o do QRS \u2265 150ms s\u00e3o os que mais se beneficiam da TRC. Esse dado tamb\u00e9m foi confirmado na metan\u00e1lise que reuniu 12.638 pacientes de 13 grandes estudos, corroborando o benef\u00edcio da TRC em pacientes com BRE e o maior risco de morte por fal\u00eancia da bomba card\u00edaca nos pacientes com QRS mais alargados.A dura\u00e7\u00e3o do QRS \u2265 120ms como ponto de corte na indica\u00e7\u00e3o da TRC foi baseada nos crit\u00e9rios de inclus\u00e3o dos estudos COMPANIONversusdesligado, mostrou que pacientes n\u00e3o BRE apresentaram aus\u00eancia de remodelamento reverso do VE, independentemente da dura\u00e7\u00e3o do QRS. Da mesma forma, estudo utilizando a popula\u00e7\u00e3o do MADIT-CRT tamb\u00e9m demonstrou aus\u00eancia de benef\u00edcios cl\u00ednicos da TRC-D em 537 pacientes com ICFEr leve e n\u00e3o BRE, independentemente da morfologia e da dura\u00e7\u00e3o do QRS.Em rela\u00e7\u00e3o ao tipo de DCIV, suban\u00e1lise de grandes estudos sugerem que pacientes com QRS largo n\u00e3o BRE apresentam pior resposta \u00e0 TRC. Dados do estudo REVERSE, comparando o ressincronizador card\u00edaco ligadoImportante ressaltar que poucos pacientes com bloqueio do ramo direito (BRD) foram inclu\u00eddos nos grandes estudos, dificultando uma conclus\u00e3o definitiva em rela\u00e7\u00e3o aos efeitos da TRC nessa popula\u00e7\u00e3o.versusCDI em 11.505 pacientes n\u00e3o BRE. Este estudo demonstrou que, em pacientes com DCIV inespec\u00edfico com QRS \u2265 150ms, a TRC reduziu mortalidade e taxa de hospitaliza\u00e7\u00e3o por IC, enquanto aqueles com QRS < 150ms tiveram m\u00e1 resposta cl\u00ednica \u00e0 TRC, com aumento de mortalidade e taxa de hospitaliza\u00e7\u00e3o. Finalmente, esse mesmo estudo constatou aumento no risco de morte e na taxa de hospitaliza\u00e7\u00e3o por IC em pacientes com BRD tratados com a TRC-D. Essa conclus\u00e3o foi consistente com resultados de Bilchick et al., publicado em 2010, que utilizaram as informa\u00e7\u00f5es do Medicare. Adicionalmente, Pastore et al. demonstraram que pacientes com BRD t\u00edpico, definido classicamente como QRS > 120ms de dura\u00e7\u00e3o, padr\u00e3o rsr\u2019, rsR\u2019 ou rSR\u2019 na deriva\u00e7\u00e3o V1 ou V2 e onda S maior que onda R ou > 40ms de dura\u00e7\u00e3o nas deriva\u00e7\u00f5es D1 e aVL, apresentavam m\u00e1 resposta \u00e0 TRC. Portanto, os dados dispon\u00edveis na literatura at\u00e9 o momento apontam para a indica\u00e7\u00e3o da TRC em pacientes com ICFEr e DCIV inespec\u00edfico com dura\u00e7\u00e3o do QRS \u2265 150ms, e refor\u00e7am a necessidade de maior cautela na indica\u00e7\u00e3o desta terap\u00eautica nos pacientes com BRD t\u00edpico.Por outro lado, apesar de as suban\u00e1lises desses estudos n\u00e3o observarem benef\u00edcios da TRC em pacientes n\u00e3o BRE, recente estudo observacional, de mundo real, utilizando informa\u00e7\u00f5es do National Cardiovascular Data Registry (EUA), avaliou a resposta cl\u00ednica da TRC-DAs indica\u00e7\u00f5es de TRC em pacientes em ritmo sinusal est\u00e3o listadas naA preval\u00eancia de FA em pacientes com IC varia de acordo com a gravidade, ocorrendo em 5% dos pacientes em classe funcional I (NYHA) e chegando a 40% em pacientes em classe funcional IV (NYHA).Os dados sobre a TRC em pacientes com FA e IC s\u00e3o limitados, mas sugerem benef\u00edcios ainda que sejam menores que em pacientes em ritmo sinusal. Isso ocorre devido a algumas peculiaridades relacionadas com a FA, tais como perda do sincronismo atrioventricular, maior risco de falha da estimula\u00e7\u00e3o ventricular sincronizada devido \u00e0 dificuldade de controle da frequ\u00eancia card\u00edaca e ocorr\u00eancia de batimentos de fus\u00e3o e pseudofus\u00e3o, maior incid\u00eancia de disparo de choques de CDI (apropriados ou inapropriados), al\u00e9m de maior incid\u00eancia de hospitaliza\u00e7\u00e3o e mortalidade.Ritmo de FA ocorre em cerca de um quarto dos pacientes submetidos \u00e0 TRC; entretanto, a maioria dos ensaios cl\u00ednicos controlados e randomizados que demonstraram o benef\u00edcio da TRC excluiu pacientes com FA .No estudo CARE-HF, que comparou TRC com TFO, embora a mortalidade tenha sido mais elevada em pacientes que desenvolveram FA durante o seguimento, esses pacientes se beneficiaram da TRC quando considerados os principais objetivos do estudo.A associa\u00e7\u00e3o de TRC com CDI (TRC-D) n\u00e3o foi superior ao CDI isoladamente no subgrupo de 229 pacientes com FA do estudo RAFT. Entretanto, menos de um ter\u00e7o dos pacientes recebeu mais que 95% de estimula\u00e7\u00e3o biventricular nos 6 meses de seguimento. que incluiu cinco estudos (quatro coortes prospectivas e o ensaio cl\u00ednico randomizado MUSTIC) comparou as respostas \u00e0 TRC em 797 pacientes em ritmo sinusal e 367 pacientes em FA . N\u00e3o houve diferen\u00e7a na melhora da classe funcional (NYHA) entre os pacientes, embora os resultados do teste de caminhada de 6 minutos e qualidade de vida (escore de Minnesota) tenham sido melhores no grupo em ritmo sinusal.Uma metan\u00e1lise com 23 estudos observacionais, que incluiu 7.495 pacientes submetidos \u00e0 TRC, os pacientes com FA (25%) tiveram maior taxa de n\u00e3o respondedores  e maior taxa de mortalidade  quando comparados com pacientes em ritmo sinusal. Ademais, a presen\u00e7a de FA foi associada com menor impacto da TRC na qualidade de vida, no teste de caminhada de 6 minutos e no volume diast\u00f3lico final do ventr\u00edculo esquerdo, mas com resultado semelhante na melhora da fra\u00e7\u00e3o de eje\u00e7\u00e3o do ventr\u00edculo esquerdo.Em outra metan\u00e1lise, incluiu 59 pacientes com IC e FA com bradicardia (estimula\u00e7\u00e3o ventricular com QRS estimulado \u2265 200ms), randomizados para estimula\u00e7\u00e3o de VD ou biventricular, comcrossoverno terceiro m\u00eas. Abla\u00e7\u00e3o do n\u00f3 AV foi realizada em 63% dos pacientes. O estudo teve como limita\u00e7\u00e3o um n\u00famero baixo decrossover, o que limitou qualquer conclus\u00e3o (somente 39%). N\u00e3o houve diferen\u00e7a significativa na toler\u00e2ncia ao esfor\u00e7o e pico de consumo de oxig\u00eanio entre os dois grupos quando se considerou a inten\u00e7\u00e3o de tratar. Entretanto, ao considerar os 37 pacientes que receberam terapia adequada (97% a 100% de estimula\u00e7\u00e3o biventricular), encontrou-se um aumento significativo na dist\u00e2ncia da caminhada em 6 minutos e no pico de consumo de oxig\u00eanio.O estudo MUSTIC-AF OPSITE e AVIL CLS/CRT mostraram que a TRC acrescentou um modesto, mas significante, efeito na qualidade de vida, classe funcional (NYHA) e FEVE em compara\u00e7\u00e3o com estimula\u00e7\u00e3o apical de VD, em pacientes com FA submetidos \u00e0 abla\u00e7\u00e3o do n\u00f3 AV, com v\u00e1rios graus de disfun\u00e7\u00e3o de VE.Os estudos PAVE, comparou pacientes com IC, QRS \u2265 120ms e FEVE \u2264 35% submetidos a TRC-CDI (n = 4.471) com pacientes que n\u00e3o foram submetidos a implante de dispositivo (n = 4.888). O uso de TRC-D foi associado a menor risco de mortalidade e interna\u00e7\u00e3o hospitalar. Esta associa\u00e7\u00e3o foi observada tamb\u00e9m no subgrupo de 3.357 pacientes com FA.O registo ADHEREO benef\u00edcio da TRC requer estimula\u00e7\u00e3o biventricular na maior parte do tempo, evitando ao m\u00e1ximo a condu\u00e7\u00e3o intr\u00ednseca. Em pacientes com FA com condu\u00e7\u00e3o atrioventricular r\u00e1pida, essa condi\u00e7\u00e3o pode ser dificultada. avaliaram 1.404 pacientes submetidos \u00e0 TRC em seguimento m\u00e9dio de 18 meses. Todos estavam em ritmo sinusal no momento da inclus\u00e3o no estudo, tendo sido documentada FA em 443 pacientes (32%). A dura\u00e7\u00e3o dos epis\u00f3dios variou de >10 minutos a semanas e ocorreu tanto em pacientes sem hist\u00f3ria (22%) quanto em pacientes com hist\u00f3ria de FA (16%). A porcentagem de estimula\u00e7\u00e3o biventricular no grupo que apresentou FA foi de 95%versus98% no total de pacientes. Quando os pacientes que apresentaram em FA estavam em ritmo sinusal, a porcentagem de estimula\u00e7\u00e3o biventricular foi de 98%versus71% durante os epis\u00f3dios de FA . Estimula\u00e7\u00e3o biventricular < 95% foi definida como sub\u00f3tima, a qual foi correlacionada com a ocorr\u00eancia de FA persistente ou permanente , e frequ\u00eancia ventricular n\u00e3o controlada . A porcentagem de estimula\u00e7\u00e3o biventricular foi inversamente proporcional \u00e0 frequ\u00eancia card\u00edaca em pacientes com FA, reduzindo em 7% para cada aumento de 10 batimentos na frequ\u00eancia ventricular.Boriani et al. A mortalidade foi inversamente proporcional \u00e0 porcentagem de estimula\u00e7\u00e3o biventricular, tanto em ritmo sinusal quanto em FA ou estimula\u00e7\u00e3o atrial. A maior redu\u00e7\u00e3o na mortalidade foi observada com estimula\u00e7\u00e3o biventricular > 98%. Pacientes com estimula\u00e7\u00e3o biventricular > 99,6% tiveram redu\u00e7\u00e3o de mortalidade de 24% , enquanto os que tiveram estimula\u00e7\u00e3o biventricular < 94,8% tiveram aumento de 19%. O tempo ideal de estimula\u00e7\u00e3o biventricular foi \u2265 98,7%.A import\u00e2ncia da alta taxa de estimula\u00e7\u00e3o biventricular foi confirmada em uma grande coorte de 36.395 pacientes que participaram do US LATITUDE Patient Management System, na qual os pacientes foram seguidos por monitoramento remoto. Todos foram submetidos a abla\u00e7\u00e3o do n\u00f3 AV e implante de MP multiss\u00edtio e randomizados para TRC guiada por ecocardiograma (97 pacientes) ou estimula\u00e7\u00e3o apical de VD (89 pacientes). No seguimento m\u00e9dio de 20 meses, a TRC reduziu o evento composto por hospitaliza\u00e7\u00e3o ou morte por IC, ou piora da IC . A TRC reduziu hospitaliza\u00e7\u00e3o e piora da IC. A mortalidade total foi similar entre os grupos.No estudo APAF, prospectivo e multic\u00eantrico, foram inclu\u00eddos 186 pacientes com FA permanente sintom\u00e1tica com frequ\u00eancia ventricular n\u00e3o controlada ou IC refrat\u00e1ria, disfun\u00e7\u00e3o sist\u00f3lica de VE e QRS largo. Entre os 162 pacientes com FA permanente dessa coorte, 48 receberam medica\u00e7\u00e3o para controle da frequ\u00eancia card\u00edaca e 114 pacientes foram submetidos \u00e0 abla\u00e7\u00e3o do n\u00f3 AV. Em 4 anos de seguimento, o remodelamento reverso e a toler\u00e2ncia ao esfor\u00e7o foram similares entre os pacientes com FA e ritmo sinusal. Entre pacientes com FA, o benef\u00edcio da TRC foi observado somente nos pacientes que tinham sido submetidos \u00e0 abla\u00e7\u00e3o do n\u00f3 AV. A despeito da estimula\u00e7\u00e3o biventricular >85% do tempo, os pacientes com controle medicamentoso da FC n\u00e3o tiveram melhora na fun\u00e7\u00e3o do VE e da capacidade funcional.A abla\u00e7\u00e3o do n\u00f3 atrioventricular (AV) elimina a condu\u00e7\u00e3o intr\u00ednseca, resultando em estimula\u00e7\u00e3o biventricular em 100% do tempo em pacientes com TRC. Esta estrat\u00e9gia foi avaliada em uma s\u00e9rie de 673 pacientes . Entre os 1.285 pacientes avaliados, 243 estavam em FA. O controle da FC (85% de estimula\u00e7\u00e3o biventricular) foi realizado por abla\u00e7\u00e3o do n\u00f3 AV em 188 pacientes, e terapia medicamentosa em 55. No seguimento de 34 meses, a mortalidade foi significativamente menor em pacientes submetidos \u00e0 abla\u00e7\u00e3o do n\u00f3 AV . Esses resultados sugerem que a meta em TRC deve ser 100% de estimula\u00e7\u00e3o biventricular, visando ao benef\u00edcio m\u00e1ximo da terapia.Gasparini e colaboradores demonstraram, em um estudo observacional, que abla\u00e7\u00e3o do n\u00f3 AV associada \u00e0 TRC melhorou significativamente a sobrevida quando comparada \u00e0 TRC isolada.vs. 6,1 por 100 pessoas ano) e mortalidade cardiovascular  similares nos pacientes com FA + abla\u00e7\u00e3o do n\u00f3 AV e ritmo sinusal. Em contraste, os pacientes com FA + controle medicamentoso tiveram maior mortalidade total e cardiovascular  (O estudo CERTIFY ratificou a import\u00e2ncia da abla\u00e7\u00e3o do n\u00f3 AV em pacientes com FA submetidos \u00e0 TRC. O estudo comparou a evolu\u00e7\u00e3o cl\u00ednica dos pacientes com FA permanente submetidos \u00e0 TRC combinada com abla\u00e7\u00e3o do n\u00f3 AV (n = 443) ou controle de frequ\u00eancia com medicamentos (n = 895) com pacientes em ritmo sinusal (n = 6.046). Os resultados mostraram, em seguimento m\u00e9dio de 37 meses, mortalidade por todas as causas  . Para esse diagn\u00f3stico, deve-se documentar alta taxa de estimula\u00e7\u00e3o ventricular, afastadas outras causas de disfun\u00e7\u00e3o de VE, como isquemia mioc\u00e1rdica, valvopatias e arritmias sem controle adequado.Pacientes submetidos \u00e0 estimula\u00e7\u00e3o cr\u00f4nica do VD por MP convencional ou CDI podem evoluir com disfun\u00e7\u00e3o sist\u00f3lica progressiva do VE em decorr\u00eancia de dissincronia el\u00e9trica e mec\u00e2nica. Dados de registros indicam que a disfun\u00e7\u00e3o do VE induzida por MP pode ocorrer em 12 a 30% dos pacientes. A melhora ou recupera\u00e7\u00e3o da FEVE observada nesses estudos ocorreu em at\u00e9 86% dos pacientes. Assim, portadores de MP ou CDI com alta taxa de estimula\u00e7\u00e3o ventricular, que apresentam piora cl\u00ednica e/ou ecocardiogr\u00e1fica, podem ser considerados paraupgradede sistema para TRC  \u00e9 maior quando a taxa de estimula\u00e7\u00e3o ventricular excede a 40%, ou at\u00e9 mesmo 20%. A FEVE pr\u00e9via ao implante e a dura\u00e7\u00e3o do QRS tamb\u00e9m foram preditores da ocorr\u00eancia de disfun\u00e7\u00e3o ventricular induzida por MP. Esses estudos foram avaliados conjuntamente em metan\u00e1lise que comparou a estimula\u00e7\u00e3o convencional do VD com a estimula\u00e7\u00e3o biventricular ou do feixe de His. A estimula\u00e7\u00e3o biventricular, em compara\u00e7\u00e3o com a estimula\u00e7\u00e3o do VD, foi associada a maior FEVE e redu\u00e7\u00e3o de volumes finais sist\u00f3lico e diast\u00f3lico do VE (maior probabilidade de benef\u00edcio com FEVE entre 36% e 52%). A melhora no teste de caminhada de 6 minutos ocorreu de modo significativo apenas em um estudo que incluiu pacientes com FA permanente que foram submetidos \u00e0 abla\u00e7\u00e3o de n\u00f3 AV (pacientes com FEVE < 45% e com IC NYHA II/III apresentaram melhor resultado no teste). Os dados relacionados \u00e0 estimula\u00e7\u00e3o do feixe de His est\u00e3o apresentados em outra sess\u00e3o deste documento.Ensaios cl\u00ednicos randomizados avaliaram se a TRC seria superior \u00e0 estimula\u00e7\u00e3o convencional do VD para reduzir a ocorr\u00eancia de remodelamento do VE e desfechos cl\u00ednicos em pacientes com FEVE > 35%. Os pacientes foram randomizados para estimula\u00e7\u00e3o convencional do VD ou estimula\u00e7\u00e3o biventricular. A FEVE m\u00e9dia foi de 43%, sendo que 87% apresentavam FEVE > 35%. O desfecho prim\u00e1rio composto de morte por qualquer causa, atendimento de urg\u00eancia por IC com necessidade de diur\u00e9tico intravenoso e aumento de 15% ou mais no volume sist\u00f3lico final do VE ocorreu mais frequentemente no grupo de estimula\u00e7\u00e3o do VD. O estudo APAF incluiu pacientes com FA permanente submetidos \u00e0 abla\u00e7\u00e3o de n\u00f3 AV e implante de TRC. Os pacientes foram randomizados para estimula\u00e7\u00e3o biventricular ou estimula\u00e7\u00e3o de VD. O desfecho prim\u00e1rio composto por morte por IC, hospitaliza\u00e7\u00e3o ou piora da IC ocorreu em 26% dos pacientes no grupo VD e 11% no grupo TRC. O benef\u00edcio da estimula\u00e7\u00e3o biventricular ocorreu independentemente da FEVE e da dura\u00e7\u00e3o do QRS. A FEVE m\u00e9dia dos pacientes foi de 38%, sendo que 53% apresentavam FE > 35%.Importantes estudos n\u00e3o foram inseridos nesta metan\u00e1lise por inclu\u00edrem tamb\u00e9m pacientes com FEVE < 35%. O estudo BLOCK HF incluiu pacientes com indica\u00e7\u00e3o de MP por bloqueio AV, com IC NYHA I-III e FEVE \u2264 50%.), prospectivo, multic\u00eantrico, randomizado, duplo-cego e cruzado, incluiu 60 pacientes com CF II-IV (NYHA), FEVE < 40% e bloqueio AV como indica\u00e7\u00e3o de MP. Todos os pacientes foram submetidos a implante de ressincronizador card\u00edaco; no entanto, a cada 3 meses, alternaram estimula\u00e7\u00e3o biventricular com estimula\u00e7\u00e3o convencional de VD (grupo A: VD-TRC-VD e grupo B: TRC-VD-TRC). Ao final de cada trimestre, os pacientes foram avaliados, tendo sido encontrado melhora significativa da qualidade de vida, CF, e volume sist\u00f3lico final do VE com a TRC em compara\u00e7\u00e3o com a estimula\u00e7\u00e3o do VD. Ademais, a taxa de mortalidade foi maior com estimula\u00e7\u00e3o de VD.Um estudo brasileiro . Muitos desses pacientes apresentam tamb\u00e9m disfun\u00e7\u00e3o de VE e bloqueio de ramo esquerdo (BRE), atendendo a crit\u00e9rios de indica\u00e7\u00e3o para TRC (ver item 3). Desta forma, h\u00e1 pacientes que podem se beneficiar de ambas as terapias (TRC-D). MIRACLE ICD II e RethinQ, todos os pacientes foram submetidos a implante de TRC-D, sendo que um grupo permanecia com a TRC ativada, e o outro, n\u00e3o.Ensaios cl\u00ednicos randomizados avaliaram os resultados do implante de CDI ou TRC-D em pacientes com disfun\u00e7\u00e3o de VE e DCIV. Nos estudos CONTAK, MIRACLE ICD,2, teste da caminhada e FEVE. O MIRACLE ICD incluiu 369 pacientes, tamb\u00e9m com indica\u00e7\u00e3o convencional para implante de CDI, com FEVE \u2264 35%, NYHA III-IV, QRS \u2265 130ms. A TRC-D foi associada a melhora da qualidade de vida e consumo de O2. No MIRACLE ICD II, foram inclu\u00eddos 186 pacientes, indica\u00e7\u00e3o convencional de CDI, FE \u2264 35%, NYHA II, QRS \u2265 130ms. A TRC-D foi associada \u00e0 redu\u00e7\u00e3o dos volumes do VE, melhora da FEVE e da classe funcional (NYHA). No estudo RethinQ, foram inclu\u00eddos 172 pacientes com indica\u00e7\u00e3o e CDI, FE \u2264 35%, NYHA III, QRS \u2264 130ms e evid\u00eancia de dissincronia por ecocardiograma. N\u00e3o houve benef\u00edcios da TRC-D para o desfecho de consumo O2.No estudo CONTAK, foram inclu\u00eddos 490 pacientes com indica\u00e7\u00e3o convencional para implante de CDI, com FEVE \u2264 35%, NYHA II-IV, QRS \u2265 120ms. N\u00e3o houve diferen\u00e7a significativa no desfecho prim\u00e1rio composto incluindo morte por qualquer causa, hospitaliza\u00e7\u00e3o por IC e arritmia ventricular com necessidade de interven\u00e7\u00e3o do CDI. A TRC-D melhorou de modo significativo o consumo de O e RAFT, os pacientes foram submetidos a implante de TRC-D ou de CDI isolado. No MADIT CRT, participaram 1.820 pacientes com FEVE \u2264 30%, NYHA I-II, QRS \u2265 130ms. Houve redu\u00e7\u00e3o significativa do desfecho combinado de morte por qualquer causa ou evento n\u00e3o fatal de IC com a TRC-D. No estudo RAFT, foram inclu\u00eddos 1.798 pacientes com FEVE \u2264 30%, NYHA II-III, QRS \u2265 120ms ou QRS estimulado por MP \u2265 200ms. A TRC-D reduziu significativamente o desfecho combinado de morte por qualquer causa ou interna\u00e7\u00e3o por IC. Como desfecho secund\u00e1rio, foram analisados separadamente morte e interna\u00e7\u00f5es por IC, havendo redu\u00e7\u00e3o significativa dos dois desfechos.J\u00e1 nos estudos MADIT CRT Tamb\u00e9m foi demonstrada redu\u00e7\u00e3o significativa de hospitaliza\u00e7\u00f5es .An\u00e1lise conjunta dos resultados desses ensaios cl\u00ednicos evidenciou que a TRC-D reduziu mortalidade total em compara\u00e7\u00e3o com CDI isolado . Em an\u00e1lise do estudo RAFT, o benef\u00edcio sobre desfecho prim\u00e1rio ocorreu apenas nos pacientes com QRS > 150ms. Nos pacientes com padr\u00e3o de BRE, houve rela\u00e7\u00e3o cont\u00ednua entre dura\u00e7\u00e3o do QRS e benef\u00edcio cl\u00ednico. Nos pacientes com padr\u00e3o n\u00e3o BRE, o benef\u00edcio ocorreu apenas com QRS > 160ms  pode ser a alternativa \u00fatil.A TRC \u00e9 um tratamento n\u00e3o farmacol\u00f3gico bem estabelecido para tratamento de pacientes com IC sintom\u00e1ticos, FEVE reduzida e QRS largo. A despeito do avan\u00e7o dessa modalidade terap\u00eautica, ainda se observa taxa de n\u00e3o respondedores de 20 a 40%.et al., descreveram uma s\u00e9rie de 16 pacientes com IC grave em que houve falha na estimula\u00e7\u00e3o do VE atrav\u00e9s do seio coron\u00e1rio. Nessa s\u00e9rie, foi poss\u00edvel obter-se a corre\u00e7\u00e3o do dist\u00farbio de condu\u00e7\u00e3o (BRE) com a estimula\u00e7\u00e3o direta do feixe de His em 81% dos casos. Lustgartenet al. apresentaram outro estudo que envolveu 29 pacientes, randomizados para estimula\u00e7\u00e3o do feixe de His ou TRC convencional. Os resultados quanto ao teste de caminhada de 6min, classe funcional, question\u00e1rio de qualidade de vida e FEVE foram semelhantes entre os grupos.Em 2012, PichardoEm uma metan\u00e1lise que envolveu 11 estudos e 494 pacientes submetidos \u00e0 estimula\u00e7\u00e3o do feixe de His, observou-se sucesso do implante em 82,4%. Foram inclu\u00eddos pacientes com FA em programa\u00e7\u00e3o de abla\u00e7\u00e3o do n\u00f3 AV e indica\u00e7\u00e3o de TRC. A estimula\u00e7\u00e3o hissiana demonstrou, em pequenos estudos observacionais, resultados promissores apontando a necessidade de estudos randomizados.crossoverpara o grupo convencional. O principal motivo para a troca da terapia foi a falta de corre\u00e7\u00e3o do dist\u00farbio de condu\u00e7\u00e3o, mais distal, com a estimula\u00e7\u00e3o do feixe de His. Este achado est\u00e1 em linha com estudos subsequentes que demonstraram corre\u00e7\u00e3o do bloqueio de ramo em torno de 60% dos casos com a estimula\u00e7\u00e3o hissiana. N\u00e3o obstante, 26% dos pacientes do grupo de TRC convencional tamb\u00e9m cruzaram para o grupo da estimula\u00e7\u00e3o do His devido a dificuldades t\u00e9cnicas. Os pacientes do grupo de estimula\u00e7\u00e3o hissiana tiveram maior estreitamento do QRS  e melhora de par\u00e2metros ecocardiogr\u00e1ficos superior em compara\u00e7\u00e3o ao grupo TRC (80% dos pacientes de estimula\u00e7\u00e3o hissiana apresentaram aumento absoluto > 5% FEVE). As medidas de di\u00e2metros card\u00edacos e volumes foram semelhantes em ambos os grupos. Estes achados sugerem que as terapias possam ser complementares, principalmente devido a dificuldades anat\u00f4micas do seio coron\u00e1rio e impossibilidade de corre\u00e7\u00e3o do dist\u00farbio da condu\u00e7\u00e3o em todos os pacientes com BRE.Um recente estudo randomizado comparou a estimula\u00e7\u00e3o hissiana com a estimula\u00e7\u00e3o biventricular convencional em 41 pacientes. Dos 21 pacientes randomizados para estimula\u00e7\u00e3o do feixe de His, 10 (48%) necessitaram deet al. descreveram uma s\u00e9rie de 11 pacientes consecutivos com BRE e indica\u00e7\u00e3o cl\u00e1ssica de TRC, que foram submetidos \u00e0 estimula\u00e7\u00e3o direta do ramo esquerdo. Observou-se expressivo encurtamento do QRS . Os autores conclu\u00edram que a estimula\u00e7\u00e3o septal profunda em pacientes com disfun\u00e7\u00e3o sist\u00f3lica e BRE \u00e9 fact\u00edvel, resultando em melhora funcional e remodelamento reverso. Huanget al. acompanharam uma coorte prospectiva de 63 pacientes com miocardiopatia dilatada, BRE e FEVE < 35% submetidos \u00e0 estimula\u00e7\u00e3o do ramo esquerdo, em que foi poss\u00edvel corrigir o dist\u00farbio de condu\u00e7\u00e3o em 61 pacientes. Em 1 ano de seguimento, houve aumento significativo da FEVE, remodelamento reverso e melhora da classe funcional. Ademais, 75% dos pacientes foram classificados como hiper-respondedores, com normaliza\u00e7\u00e3o da FEVE.Zhanget al., em estudo n\u00e3o randomizado, avaliaram 137 pacientes com IC sintom\u00e1tica e QRS largo acompanhados por 1 ano. Nesse estudo, 49 pacientes foram submetidos \u00e1 estimula\u00e7\u00e3o do feixe de His, 32 do ramo esquerdo, e 54 pacientes foram submetidos \u00e0 estimula\u00e7\u00e3o biventricular. Os pacientes submetidos \u00e0 estimula\u00e7\u00e3o do sistema excito-condutor (feixe de His ou ramo esquerdo) obtiveram maior incremento da FEVE em compara\u00e7\u00e3o \u00e0 estimula\u00e7\u00e3o biventricular . A melhora funcional foi semelhante nos dois grupos de estimula\u00e7\u00e3o do sistema excito-condutor; contudo, os limiares de estimula\u00e7\u00e3o foram menores com a estimula\u00e7\u00e3o do ramo esquerdo .Wuet al. prop\u00f5em que essa modalidade terap\u00eautica possa ser utilizada como estrat\u00e9gia inicial para TRC ou como terapia de resgate nos casos de insucesso da t\u00e9cnica convencional, por cateterizar\u00e3o do seio coron\u00e1rio. Tamb\u00e9m consideram a associa\u00e7\u00e3o dos m\u00e9todos (estimula\u00e7\u00e3o simult\u00e2nea His-TRC) como um novo conceito de estimula\u00e7\u00e3o para TRC em casos selecionados com dist\u00farbios mais difusos da condu\u00e7\u00e3o intraventricular  ou s\u00e3o n\u00e3o respondedores \u00e0 TRC, ou, ainda, se deve ser usada em conjunto com os ressincronizadores card\u00edacos convencionais. Os estudos at\u00e9 ent\u00e3o publicados s\u00e3o pequenos e, talvez por isso, incapazes para detectar diferen\u00e7as significativas.A modula\u00e7\u00e3o da contratilidade card\u00edaca (MCC) \u00e9 uma op\u00e7\u00e3o terap\u00eautica utilizada para IC em pacientes que n\u00e3o t\u00eam indica\u00e7\u00e3o convencional para a TRC, com QRS estreito (< 130ms) e FEVE entre 25% e 45%. Nessa modalidade de terapia, promove-se a estimula\u00e7\u00e3o artificial do septo interventricular direito com alta voltagem 30 a 40ms ap\u00f3s a ativa\u00e7\u00e3o dos cardiomi\u00f3citos durante o per\u00edodo refrat\u00e1rio absoluto. Em teoria, essa estimula\u00e7\u00e3o otimiza a din\u00e2mica do c\u00e1lcio, aumentando a contratilidade ventricular, resultando em melhora na toler\u00e2ncia ao exerc\u00edcio e capacidade funcional dos pacientes.A morte s\u00fabita (MS) causada por arritmias ventriculares \u00e9 uma das principais causas de morte em pacientes com IC com FEVE reduzida (ICFER), em especial na popula\u00e7\u00e3o de pacientes com cardiopatia isqu\u00eamica em que a incid\u00eancia de fibrose mioc\u00e1rdica ventricular e, consequentemente, circuitos de reentrada \u00e9 mais prevalente.\u00c9 importante frisar que os estudos que avaliaram o impacto do CDI na cardiopatia isqu\u00eamica definiram essa doen\u00e7a, de forma geral, como disfun\u00e7\u00e3o ventricular secund\u00e1ria a pelo menos uma les\u00e3o severa em uma das tr\u00eas principais art\u00e9rias coron\u00e1rias, ou hist\u00f3ria pr\u00e9via documentada de IAM.e MUSTT  testaram o CDI em pacientes com TVNS, disfun\u00e7\u00e3o ventricular esquerda e com indu\u00e7\u00e3o de arritmias ventriculares sustentadas no EEF. O estudo MADIT incluiu pacientes com FEVE < 35%, classe funcional (NYHA) I, II e III, hist\u00f3ria pr\u00e9via de IAM, TVNS assintom\u00e1ticas registradas e arritmias ventriculares induz\u00edveis ao EEF, refrat\u00e1rias ao uso de procainamida, ou antiarr\u00edtmico equivalente. Os 196 pacientes inclu\u00eddos foram randomizados para implante de CDIversustratamento m\u00e9dico otimizado (TMO), seguimento m\u00e9dio de 27 meses. A mortalidade no grupo CDI foi 15,7% e, no grupo TMO, 38,6%, com redu\u00e7\u00e3o de risco relativo para mortalidade total o grupo CDI de 64% . O estudo MUSTT incluiu pacientes com FE \u2264 40%, CF I, II e III e registro de TVNS assintom\u00e1ticas. O objetivo inicial do estudo MUSTT foi comparar a efic\u00e1cia de f\u00e1rmacos antiarr\u00edtmicos capazes de suprimir as arritmias ventriculares no EEFversusplacebo. Devido aos resultados do MADIT, o protocolo foi modificado para implante de CDI nos casos em que havia indu\u00e7\u00e3o de arritmias ventriculares e falha na revers\u00e3o com pelo menos um antiarr\u00edtmico. O resultado do estudo MUSTT demonstrou que a diminui\u00e7\u00e3o na mortalidade n\u00e3o foi significativa com o uso de antiarr\u00edtmico, mas sim com o CDI com redu\u00e7\u00e3o relativa de risco de morte de 76% .V\u00e1rios estudos importantes testaram o impacto do CDI na profilaxia prim\u00e1ria para MS em pacientes com cardiopatia isqu\u00eamica. Os estudos MADIT Embora o estudo eletrofisiol\u00f3gico n\u00e3o seja utilizado de forma corrente para indica\u00e7\u00e3o de CDI devido ao baixo valor preditivo negativo, os estudos MADIT e MUSTT apresentaram resultados importantes nessa popula\u00e7\u00e3o .vsCDI. Foram randomizados 1.232 pacientes e, em um seguimento m\u00e9dio de 20 meses, a mortalidade no grupo CDI foi 19% e, no grupo TMO, 24%, com redu\u00e7\u00e3o relativa de risco de mortalidade total de 31% . O estudo SCD-HeFT ampliou os crit\u00e9rios de inclus\u00e3o, randomizando pacientes com FE \u2264 35%, CF II e III, isqu\u00eamicos e n\u00e3o isqu\u00eamicos. Durante seguimento m\u00e9dio de 45,5 meses, o grupo CDI teve redu\u00e7\u00e3o relativa da mortalidade de 23% , sendo que 52% da popula\u00e7\u00e3o inclu\u00edda foi de pacientes com cardiopatia isqu\u00eamica.O estudo MADIT II randomizou pacientes com FE \u2264 30%, CF I, II e III e IAM h\u00e1 mais de 30 dias, para TMO An\u00e1lise posterior demonstrou aumento da taxa de infec\u00e7\u00e3o no grupo do CDI . O estudo DINAMIT  randomizou 332 pacientes para implante de CDI e 342 para o grupo sem CDI, 6 a 40 dias ap\u00f3s IAM. Os pacientes inclu\u00eddos deveriam apresentar FE \u2264 35% e diminui\u00e7\u00e3o da variabilidade card\u00edaca aoHolter. Durante seguimento de 30 \u00b1 13 meses, n\u00e3o houve diferen\u00e7a na mortalidade total entre os grupos, com 62 mortes no grupo CDI e 58 mortes no grupo controle .Por outro lado, os estudos que testaram o implante precoce do CDI ap\u00f3s revasculariza\u00e7\u00e3o ou eventos isqu\u00eamicos mioc\u00e1rdicos foram neutros e at\u00e9 mesmo negativos em alguns desfechos secund\u00e1rios. O estudo CABG (Coronary Artery Bypass Graft) Patch randomizou 900 pacientes para implante de CDI profil\u00e1tico no intraoperat\u00f3rio de cirurgia de revasculariza\u00e7\u00e3o mioc\u00e1rdica, em pacientes com < 80 anos, FE < 36% e altera\u00e7\u00f5es no ECG de alta resolu\u00e7\u00e3o. Ap\u00f3s seguimento m\u00e9dio de 32 \u00b1 16 meses, o estudo foi neutro em rela\u00e7\u00e3o \u00e0 mortalidade total . Na an\u00e1lise de subgrupos dos estudos SCD-HeFT e MADIT II, pacientes em CF I e II foram os que mais se beneficiaram do CDI, ao passo que, em pacientes em CF III, o benef\u00edcio n\u00e3o foi t\u00e3o importante. N\u00e3o h\u00e1 ensaios cl\u00ednicos robustos que demonstrem benef\u00edcio do CDI em pacientes em CF IV (apenas dados de coortes retrospectivas de pacientes em lista de transplante ou submetidos a implante de dispositivos de assist\u00eancia ventricular [DAV]). Em um estudo retrospectivo que incluiu 1.089 pacientes em lista de transplante card\u00edaco, 550 possu\u00edam CDI . Durante seguimento m\u00e9dio de somente 8 meses, morreram 39 pacientes (18%) do grupo CDI (profilaxia prim\u00e1ria), 89 (27%) do grupo CDI (profilaxia secund\u00e1ria) e 162 (30%) do grupo sem CDI. Na an\u00e1lise multivariada, a presen\u00e7a do CDI foi preditor independente para diminui\u00e7\u00e3o de mortalidade . O mesmo achado foi encontrado analisando a popula\u00e7\u00e3o do UNOS (United Network for Organ Sharing) em seguimento de 1999 a 2014, em que foram inclu\u00eddos 32l.599 pacientes, com seguimento m\u00e9dio de 154 dias. Nessa popula\u00e7\u00e3o, 3.638 pacientes (11%) morreram na lista de transplante card\u00edaco, tendo sido de 9% a mortalidade no grupo CDI e 15% no grupo sem CDI, com redu\u00e7\u00e3o relativa de risco de 13% . Nesse mesmo estudo de coorte, no subgrupo de pacientes submetidos a implante de DAV (9.478 pacientes), a presen\u00e7a do CDI foi associada \u00e0 redu\u00e7\u00e3o de risco relativo de mortalidade de 19% . Uma revis\u00e3o sistem\u00e1tica analisou o CDI em pacientes com DAV, incluindo 937 pacientes . Durante seguimento m\u00e9dio de 7 meses, 16% dos pacientes morreram no grupo CDI e 26% no grupo sem CDI, com redu\u00e7\u00e3o relativa de risco para morte de 39%  , sabe-se que a taxa de MS decresce de forma proporcional com a piora da CF (NYHA). 0,01) .A IC \u00e9 uma condi\u00e7\u00e3o cl\u00ednica muito prevalente, com elevada morbidade e mortalidade. Em 20% a 30% dos casos, a etiologia \u00e9 definida como n\u00e3o isqu\u00eamica, o que significa que h\u00e1 aus\u00eancia de les\u00f5es significativas na angiografia coronariana ou resultado negativo em m\u00e9todo de imagem para investiga\u00e7\u00e3o de isquemia. A causa da disfun\u00e7\u00e3o ventricular esquerda pode ser desconhecida, sendo chamada miocardiopatia dilatada idiop\u00e1tica, ou pode ser atribu\u00edda a fatores como infec\u00e7\u00e3o viral, hipertens\u00e3o arterial sist\u00eamica, exposi\u00e7\u00e3o a agentes potencialmente t\u00f3xicos , doen\u00e7a de Chagas, doen\u00e7as infiltrativas, periparto, valvulopatias, doen\u00e7as gen\u00e9ticas e autoimunes.As estrat\u00e9gias de preven\u00e7\u00e3o prim\u00e1ria de MSC nos pacientes com MNI incluem tratamento farmacol\u00f3gico, CDI e TRC. Ensaios cl\u00ednicos randomizados demonstraram que o emprego de f\u00e1rmacos  reduz significativamente as taxas de MSC neste grupo de pacientes.Mesmo que avan\u00e7os na terap\u00eautica da miocardiopatia n\u00e3o isqu\u00eamica (MNI) tenham trazido redu\u00e7\u00e3o significativa da mortalidade nas \u00faltimas d\u00e9cadas, a morte s\u00fabita card\u00edaca (MSC) permanece como problema importante, sendo respons\u00e1vel por 30% dos \u00f3bitos. Outras vari\u00e1veis cl\u00ednicas associadas a maior risco de eventos arr\u00edtmicos nesta popula\u00e7\u00e3o s\u00e3o o n\u00e3o uso de betabloqueadores e a press\u00e3o arterial sist\u00f3lica. Exames laboratoriais, como hemoglobina, \u00e1cido \u00farico e pept\u00eddio natriur\u00e9tico atrial (BNP), aparecem como preditores de mortalidade e eventos arr\u00edtmicos em alguns estudos.A estratifica\u00e7\u00e3o de risco inclui avalia\u00e7\u00e3o cl\u00ednica e laboratorial. Quanto pior a classe funcional , maior o risco absoluto de mortalidade geral e de MSC. A MSC \u00e9 a causa de 64% dos \u00f3bitos de pacientes em CF II, 50% em CF III e 33% em CF IV (progress\u00e3o da IC \u00e9 a causa de 50% dos \u00f3bitos em CF IV). A ocorr\u00eancia de s\u00edncope \u00e9 importante fator de risco para MSC em pacientes com MNI.A redu\u00e7\u00e3o da FEVE \u00e9 considerada o principal fator de risco para MSC e mortalidade total em pacientes com IC. Poucos trabalhos, por\u00e9m, avaliaram a FEVE como fator de risco para MSC em pacientes com MNI. O estudo MACAS (Marburg Cardiomyopathy Study), coorte prospectiva com 343 pacientes com MNI, demonstrou que, para cada 10% de redu\u00e7\u00e3o da FEVE, houve risco relativo de 2,28 para eventos arr\u00edtmicos maiores .A preval\u00eancia de QRS largo em pacientes com IC varia de 20% a 50%, estando associado ao aumento de MSC e mortalidade total; entretanto, nos estudos de coorte espec\u00edficos de pacientes com MNI, n\u00e3o foi demonstrada rela\u00e7\u00e3o significativa entre prolongamento do QRS e aumento do risco de MSC.Holterpode ser \u00fatil na avalia\u00e7\u00e3o de risco por meio da an\u00e1lise de presen\u00e7a de taquicardia ventricular n\u00e3o sustentada (TVNS) e medidas da atividade auton\u00f4mica (variabilidade da frequ\u00eancia card\u00edaca [VFC] e turbul\u00eancia da frequ\u00eancia card\u00edaca [TFC]). A incid\u00eancia de TVNS em pacientes com MNI varia de 30% a 79% e sua utiliza\u00e7\u00e3o na estratifica\u00e7\u00e3o de risco de eventos arr\u00edtmicos \u00e9 controversa.O2), inclina\u00e7\u00e3o do equivalente ventilat\u00f3rio de CO2 (VE/VCO2slope) e presen\u00e7a de ventila\u00e7\u00e3o peri\u00f3dica indicam de modo independente aumento do risco de eventos combinados .Dados de metan\u00e1lise indicam que vari\u00e1veis derivadas do teste ergoespirom\u00e9trico como consumo de oxig\u00eanio  com estimula\u00e7\u00e3o ventricular programada mostrou-se capaz de identificar pacientes com risco de eventos arr\u00edtmicos graves. Entre as condi\u00e7\u00f5es melhor investigadas, est\u00e3o as muta\u00e7\u00f5es do gene da l\u00e2mina A/C (LMNA). Tais muta\u00e7\u00f5es s\u00e3o encontradas em 6% a 8% dos casos de MNI, podendo chegar a 30% nos casos de associa\u00e7\u00e3o com doen\u00e7a do sistema de condu\u00e7\u00e3o e envolvimento da musculatura esquel\u00e9tica.H\u00e1 v\u00e1rios estudos avaliando a associa\u00e7\u00e3o entre muta\u00e7\u00f5es gen\u00e9ticas com a fisiopatologia e o progn\u00f3stico de pacientes com MNI, particularmente naqueles com doen\u00e7a familiar.Esses pacientes apresentam maior mortalidade, arritmias ventriculares e hospitaliza\u00e7\u00f5es por IC. Para cada percentual de aumento no volume de realce tardio, h\u00e1 um aumento estimado de risco para mortalidade ou eventos arr\u00edtmicos de 3% a 20% . Gulati et al. publicaram os resultados da maior coorte de pacientes com MNI submetidos \u00e0 RM, em que o desfecho combinado MSC e PCR recuperada ocorreu em 29,6% dos pacientes com fibrose mioc\u00e1rdica e em 7,0% dos pacientes sem fibrose. Para esse desfecho, a presen\u00e7a de fibrose apresentouhazard ratiode 4,61  e a extens\u00e3o da fibrose umhazard ratiode 1,10 . Esses resultados indicam que a RM pode ser \u00fatil na estratifica\u00e7\u00e3o de risco de pacientes com MNI.A fibrose mioc\u00e1rdica, importante substrato arritmog\u00eanico, est\u00e1 presente em cerca de 44% dos pacientes com MNI, de acordo com recente metan\u00e1lise que incluiu 34 estudos e 4.554 pacientes.que incluiu pacientes com cardiopatia isqu\u00eamica e n\u00e3o isqu\u00eamica, com IC NYHA II-III. No seguimento dos pacientes que implantaram CDI, 33,2% receberam algum choque, 22,4% receberam choque apropriado e 10,7% receberam apenas choques inapropriados.No DANISH Trial, estudo randomizado com pacientes com MNI que tinha como desfecho prim\u00e1rio mortalidade por qualquer causa, 556 receberam CDI e 560 receberam somente tratamento cl\u00ednico otimizado. Ap\u00f3s mediana de seguimento de 67,6 meses, o desfecho prim\u00e1rio ocorreu em 21,6% dos pacientes no grupo CDI, e 23,4% no grupo controle, sem diferen\u00e7a significativa .Diversos estudos avaliaram o impacto do CDI em pacientes com MNI. O maior deles foi o SCD-HeFT ,As recomenda\u00e7\u00f5es atuais para implante de CDI na MNI est\u00e3o listadas na \u00c9 caracterizada pela presen\u00e7a de graus variados de hipertrofia ventricular esquerda assim\u00e9trica, na aus\u00eancia de condi\u00e7\u00f5es que possam resultar em sobrecarga que expliquem as altera\u00e7\u00f5es, podendo ocasionar IC diast\u00f3lica, obstru\u00e7\u00e3o da via de sa\u00edda do VE, arritmias atriais e ventriculares e, em alguns casos, a morte s\u00fabita card\u00edaca (MSC). A maioria dos pacientes n\u00e3o apresenta qualquer sintoma, e a MSC, n\u00e3o raramente, \u00e9 a primeira manifesta\u00e7\u00e3o da doen\u00e7a.A cardiomiopatia hipertr\u00f3fica (CMH) \u00e9 uma doen\u00e7a gen\u00e9tica causada por uma muta\u00e7\u00e3o autoss\u00f4mica dominante em genes que codificam as prote\u00ednas dos sarc\u00f4meros, com preval\u00eancia em torno de 1:500 indiv\u00edduos.Teare publicou, em 1958, os primeiros relatos de uma s\u00e9rie de oito pacientes com hipertrofia mioc\u00e1rdica assim\u00e9trica  e considerou a possibilidade diagn\u00f3stica de hamartoma muscular, tendo correlacionado os achados anat\u00f4micos com maior ocorr\u00eancia de MSC em adultos jovens. O aspecto anatomopatol\u00f3gico era de desarranjo grosseiro dos feixes musculares com hipertrofia da fibra muscular individualmente e dos seus n\u00facleos. Na era \u201cpr\u00e9-CDI\u201d, a taxa de mortalidade girava em torno de 1,5% ao ano; com a introdu\u00e7\u00e3o do CDI, essa taxa tem sido reduzida para 0,5% ao ano.Os pacientes com diagn\u00f3stico de CMH apresentam aproximadamente 1% de risco anual para MSC; por\u00e9m, alguns pacientes podem ter esse risco bem maior de acordo com determinadas caracter\u00edsticas de risco.et al.publicaram, em 2019, um estudo longitudinal e unic\u00eantrico, envolvendo uma grande coorte de 2.094 pacientes com CMH com seguimento de 17 anos. Dentre 527 pacientes que tinham pelo menos um fator de risco convencional e que receberam CDI para preven\u00e7\u00e3o prim\u00e1ria, 15,6% apresentaram terapias apropriadas (TV/FV), correspondendo a quase 50 vezes o n\u00famero de eventos em compara\u00e7\u00e3o com o grupo sem CDI.Maron A sele\u00e7\u00e3o de pacientes pode ser dif\u00edcil em virtude de caracter\u00edsticas individuais, manifesta\u00e7\u00f5es cl\u00ednicas, hist\u00f3ria fam\u00edliar e defini\u00e7\u00f5es dos fatores de risco, al\u00e9m de a MSC ser um achado infrequente na pr\u00e1tica cl\u00ednica. A maior probabilidade de benef\u00edcio do CDI \u00e9 baseada em testes n\u00e3o invasivos incluindo a hist\u00f3ria cl\u00ednica, ECG, teste de esfor\u00e7o,Holter, ecocardiograma e resson\u00e2ncia magn\u00e9tica do cora\u00e7\u00e3o (RMC). Os fatores de risco de MSC convencionais s\u00e3o: hist\u00f3ria familiar de MSC relacionada \u00e0 CMH, s\u00edncope inexplicada ocorrendo em at\u00e9 6 meses da avalia\u00e7\u00e3o, taquicardia ventricular n\u00e3o sustentada (TVNS), espessura septal \u2265 30mm e modificadores de risco incluindo resposta hipotensora ao teste de esfor\u00e7o, fibrose do VE e IC com FEVE < 50%. Recomenda-se que a estratifica\u00e7\u00e3o de risco para indica\u00e7\u00e3o de CDI deve ser realizada periodicamente a cada 1 ou 2 anos em pacientes com CMH.A CMH \u00e9 a causa mais comum de MSC em indiv\u00edduos < 40 anos de idade, e a maioria dos epis\u00f3dios \u00e9 devido \u00e0 fibrila\u00e7\u00e3o ventricular; dessa forma, a abordagem mais efetiva para reduzir a mortalidade de pacientes de alto risco \u00e9 com o implante de CDI, que n\u00e3o \u00e9 isento de complica\u00e7\u00f5es e pode ocasionar desconforto, estresse psicol\u00f3gico e tem custos elevados. Neste contexto, a probabilidade de ocorr\u00eancia de terapias apropriadas parece ser similar em pacientes com 1, 2, 3 ou mais fatores de risco convencionais (preven\u00e7\u00e3o prim\u00e1ria), levando \u00e0 conclus\u00e3o de que a presen\u00e7a de um \u00fanico marcador pode justificar o implante do CDI. Dentre os fatores de risco convencionais, a hist\u00f3ria familiar de MSC, definitivamente, ou provavelmente, relacionada a CMH, em parentes de primeiro grau com idade \u2264 50 anos, principalmente na inf\u00e2ncia e adolesc\u00eancia, tem import\u00e2ncia bastante significativa. Outro marcador de risco de MSC consiste na extens\u00e3o e na magnitude da hipertrofia, sendo mais importante quando \u2265 30mm; espessamento lim\u00edtrofe (28 a 29mm) pode ser considerado a crit\u00e9rio do cardiologista. Spiritoet al.demonstraram, em 480 pacientes, que a incid\u00eancia de MSC foi aproximadamente duas vezes maior a cada aumento de 5mm na espessura mioc\u00e1rdica ventricular, sendo de 1,8%/ano em casos com espessura \u2265 30mm.A indica\u00e7\u00e3o de CDI na CMH n\u00e3o est\u00e1 embasada em estudos cl\u00ednicos randomizados, mas, sim, em dados de estudos observacionais. Adicionalmente, estudos com pacientes com CMH portadores de CDI demonstraram que a taxa de eventos potencialmente fatais, com terapias apropriadas do dispositivo, ocorrem em 12%/ano na preven\u00e7\u00e3o secund\u00e1ria e em 4%/ano na preven\u00e7\u00e3o prim\u00e1ria.A presen\u00e7a de s\u00edncope inexplicada, sendo improv\u00e1vel ou afastada a possibilidade de s\u00edncope vasovagal e n\u00e3o relacionada \u00e0 obstru\u00e7\u00e3o da via de sa\u00edda do VE, foi fortemente associada ao risco de MSC em um estudo com pacientes com CMH, principalmente se ocorreu at\u00e9 6 meses da avalia\u00e7\u00e3o inicial, com o risco 5 vezes maior do que aqueles sem s\u00edncope. Epis\u00f3dios remotos  n\u00e3o se correlacionaram a aumento no risco de MSC.Holterde 24 a 48 horas. A incid\u00eancia de TVNS tem sido relatada em 20% a 46% de pacientes com CMH. Epis\u00f3dios de taquicardia ventricular (TV) est\u00e3o claramente associados a MSC em pacientes com CMH; entretanto, os dados s\u00e3o menos robustos em demonstrar que a presen\u00e7a isolada de TVNS seja um fator de risco independente. Por outro lado, o risco aumenta na presen\u00e7a de modificadores de risco, especialmente fibrose do VE.A TVNS \u00e9 definida com a presen\u00e7a de 3 ou mais epis\u00f3dios com 3 ou mais batimentos ventriculares repetitivos e/ou 1 ou mais epis\u00f3dios prolongados com 10 ou mais batimentos a 130bpm ou mais, detectados emO aconselhamento gen\u00e9tico \u00e9 importante em pacientes com CMH. A identifica\u00e7\u00e3o do portador de muta\u00e7\u00e3o gen\u00e9tica espec\u00edfica pode auxiliar na investiga\u00e7\u00e3o da doen\u00e7a em parentes pr\u00f3ximos. Indiv\u00edduos com genes positivos podem desenvolver CMH; por isso, devem ser acompanhados com aten\u00e7\u00e3o para a presen\u00e7a de caracter\u00edsticas da doen\u00e7a ou fatores de risco ao longo do tempo.Em estudo brasileiro envolvendo pacientes com CMH de alto risco portadores de CDI, Shiozakiet al.demonstraram que a presen\u00e7a de fibrose mioc\u00e1rdica foi identificada em 96,4% desses pacientes, com taxa de fibrose m\u00e9dia de 15,96%, sugerindo que esse fator possa ter maior sensibilidade em rela\u00e7\u00e3o aos demais marcadores de risco convencionais. Chan RHet al.demonstraram na CMH que a detec\u00e7\u00e3o de \u00e1rea de fibrose maior que 15% da massa ventricular esquerda se associou ao dobro do risco de MSC em pacientes considerados inicialmente de baixo risco.Existe evid\u00eancia cada vez mais forte da rela\u00e7\u00e3o entre fibrose mioc\u00e1rdica (RMC) e risco de MSC, sendo considerado modificador de risco.et al.avaliaram prospectivamente 328 pacientes com CMH submetidos \u00e0 RMC com o objetivo de avaliar a import\u00e2ncia da localiza\u00e7\u00e3o da fibrose como ferramenta auxiliar na estratifica\u00e7\u00e3o de risco de MSC. \u00c1reas de realce tardio indicando a presen\u00e7a de fibrose al\u00e9m da regi\u00e3o do septo interventricular em paciente com CMH foram associadas a maior risco de MSC ou equivalente, como TV inst\u00e1vel ou terapia apropriada do CDI. Esse estudo sugere, considerando a calculadora de risco elaborada pela Sociedade Europeia de Cardiologia (ESC), que, em pacientes classificados de risco intermedi\u00e1rio, a presen\u00e7a de fibrose al\u00e9m da regi\u00e3o do septo interventricular pode identificar o paciente com maior benef\u00edcio ao uso do CDI, favorecendo a indica\u00e7\u00e3o do dispositivo.KlopotowskiO uso da calculadora de escore de risco na CMH tem sido incentivado pela ESC, mas tem baixa sensibilidade para a decis\u00e3o de implante de CDI em pacientes de alto risco. A estrat\u00e9gia da sociedade americana de cardiologia de analisar fatores de risco individualmente ou associado a modificadores de risco em cada paciente com CMH apresenta sensibilidade de 95% em predizer eventos de TV potencialmente fatais, sendo superior ao modelo matem\u00e1tico do escore de risco da ESC que apresenta sensibilidade em torno de 34%. Por outro lado, a calculadora da ESC apresenta maior sensibilidade em identificar os pacientes verdadeiramente de baixo risco, com menor probabilidade de eventos (em torno de 92% comparado a 78% da sociedade americana), evitando implantes de CDI desnecess\u00e1rios.Resposta anormal ou hipotens\u00e3o ao exerc\u00edcio ocorre em 1 a cada 3 pacientes com CMH. O mecanismo reflete queda exacerbada na resist\u00eancia vascular sist\u00eamica devido \u00e0 disfun\u00e7\u00e3o auton\u00f4mica e/ou obstru\u00e7\u00e3o din\u00e2mica da via de sa\u00edda do VE. Em pacientes jovens, a resposta anormal da PA est\u00e1 associada a aumento do risco de MSC. Rowinet al.avaliaram, retrospectivamente, 1.940 pacientes com CMH e identificaram aneurisma de VE em 93 pacientes  com taxa de eventos adversos de 6,4%/ano, correspondendo a 3 vezes mais que nos pacientes sem aneurisma, incluindo MSC, terapia apropriada do CDI, eventos tromboemb\u00f3licos e evolu\u00e7\u00e3o terminal de IC com FEVE < 50%. O CDI foi indicado como preven\u00e7\u00e3o prim\u00e1ria em 54 destes pacientes, considerando o aneurisma isolado como fator de risco em 19 casos, ocorrendo terapia apropriada do CDI para TV/FV em 20%. A taxa de eventos arr\u00edtmicos foi de aproximadamente 5%/ano, sendo mais que 5 vezes a taxa de ocorr\u00eancia em pacientes sem aneurisma, sugerindo equival\u00eancia a outros marcadores de risco convencionais nos pacientes com CMH de alto risco.Aneurisma apical de VE identificado por ecocardiografia ou RMC, independentemente do tamanho, pode estar associado a maior risco de TV sustentada monom\u00f3rfica.O CDI subcut\u00e2neo tem vantagens potenciais especialmente em jovens, uma vez que preserva o sistema venoso e evita complica\u00e7\u00f5es cr\u00f4nicas dos cabos-eletrodos (desde que n\u00e3o seja necess\u00e1rio estimula\u00e7\u00e3o ventricular). Por outro lado, a efic\u00e1cia do CDI subcut\u00e2neo em abortar a FV em pacientes com CMH ainda permanece incerta.  na estratifica\u00e7\u00e3o de risco para MSC em pacientes com CMH n\u00e3o observaram benef\u00edcio nessa estrat\u00e9gia; com isso, n\u00e3o deve ser indicado com essa finalidade .Trypanosoma cruzi, transmitido aos seres humanos pelas fezes de um inseto hemat\u00f3fago, da fam\u00edliaTriatominae, na maioria dos casos. Geralmente, a infec\u00e7\u00e3o ocorre na inf\u00e2ncia e a fase aguda tem per\u00edodo de incuba\u00e7\u00e3o de 1 a 2 semanas, podendo durar at\u00e9 3 meses. Segue-se a fase cr\u00f4nica, na qual, por muito tempo , os pacientes apresentam apenas sorologia positiva, sem sintomas ou outros sinais de doen\u00e7a clinicamente aparente.Tais pacientes apresentam, portanto, a chamada forma indeterminada da DCh, cujo progn\u00f3stico \u00e9 essencialmente benigno.Enquanto, por mecanismos patogen\u00e9ticos ainda incompletamente entendidos, muitos pacientes permanecem por toda a vida com essa forma da doen\u00e7a, cerca de 30% a 50% dos indiv\u00edduos infectados evoluem para as formas determinadas: card\u00edaca, digestiva ou mista.A doen\u00e7a de Chagas (DCh) \u00e9 causada pelo protozo\u00e1rio parasitaA cardiopatia chag\u00e1sica cr\u00f4nica (CCC) tem peculiaridades fisiopatol\u00f3gicas muito acentuadas e constitui a forma cl\u00ednica mais comum e mais grave da DCh, sendo respons\u00e1vel por expressiva morbimortalidade na Am\u00e9rica Latina e em pa\u00edses com expressiva imigra\u00e7\u00e3o.Trypanosoma cruzina na Am\u00e9rica Latina e em outros pa\u00edses. Considerando o pior cen\u00e1rio, com base nas estimativas anteriores, pode-se deduzir que 3 a 5 milh\u00f5es de indiv\u00edduos infectados manifestar\u00e3o formas cl\u00ednicas da doen\u00e7a em sua fase cr\u00f4nica.Estima-se que 8 a 10 milh\u00f5es de pessoas estejam infectadas peloA taxa de mortalidade anual m\u00e9dia atribu\u00edda \u00e0 CCC \u00e9 estimada em 4%, podendo variar de 1% a 10% conforme estratifica\u00e7\u00e3o de risco embasada em caracter\u00edsticas cl\u00ednicas e exames cardiol\u00f3gicos simples.Caracter\u00edsticas como pr\u00e9-s\u00edncope e s\u00edncope, disfun\u00e7\u00e3o ventricular esquerda e IC, taquicardia ventricular sustentada (TVS) ou n\u00e3o sustentada (TVNS), bradiarritmia grave (DNS e BAV) e parada card\u00edaca recuperada foram identificadas como marcadores de risco de MSC. Por outro lado, extrass\u00edstoles ventriculares isoladas (Holter) e bloqueio de ramo direito n\u00e3o interferem significativamente no progn\u00f3stico da CCC.Al\u00e9m dos crit\u00e9rios empregados na estratifica\u00e7\u00e3o de risco, diversos marcadores de pior progn\u00f3stico t\u00eam sido identificados por v\u00e1rios autores, especialmente no que se refere \u00e0 MSC em diversos contextos cl\u00ednicos. A IC refrat\u00e1ria \u00e9 causa de morte em cerca de 25% a 30% dos pacientes. A correla\u00e7\u00e3o entre os est\u00e1gios da CCC e causas de mortalidade foi descrita recentemente: a MSC \u00e9 mais prevalente no est\u00e1gio III da doen\u00e7a, enquanto preval\u00eancia de morte por IC aumenta progressivamente do est\u00e1gio I a IV.A MSC, respons\u00e1vel por aproximadamente 55% a 65% de todas as causas de \u00f3bitos, frequentemente se associa a manifesta\u00e7\u00f5es de IC, mas pode tamb\u00e9m ocorrer em pacientes com disfun\u00e7\u00e3o de VE assintom\u00e1tica. Nesse sentido, as anormalidades estruturais da CCC  constituem o substrato anat\u00f4mico ideal porque promovem bloqueios unidirecionais e \u00e1reas de condu\u00e7\u00e3o lenta prop\u00edcias para desencadeamento de reentrada el\u00e9trica. Os disparadores que incidem sobre esse substrato anat\u00f4mico, as extrass\u00edstoles ventriculares, tamb\u00e9m invariavelmente presentes, completam os elementos essenciais para a instala\u00e7\u00e3o da taquiarritmia ventricular por reentrada. Assim, TVNS pode ocorrer em cerca de 40% dos pacientes com CCC e altera\u00e7\u00f5es regionais da mobilidade segmentar, e em praticamente todos os pacientes com disfun\u00e7\u00e3o sist\u00f3lica global de VE e IC. A TVS, de progn\u00f3stico mais ominoso, ocorre espontaneamente e pode ser reproduzida em cerca de 80% a 85% dos pacientes durante estudo eletrofisiol\u00f3gico.O principal mecanismo de morte s\u00fabita na CCC \u00e9 arritmog\u00eanico, sendo que a TVS com fibrila\u00e7\u00e3o ventricular (FV) subsequente \u00e9 respons\u00e1vel pela imensa maioria dos eventos letais.O BAV total \u00e9 outra causa, mas menos comum, de MSC na CCC, como consequ\u00eancia da degenera\u00e7\u00e3o necr\u00f3tica e fibrose difusa, predominantemente na regi\u00e3o atrioventricular.Como j\u00e1 referido, a MSC tamb\u00e9m pode ser resultante de tromboembolismo pulmonar maci\u00e7o ou de tromboembolismo sist\u00eamico em \u00f3rg\u00e3os vitais. Excepcionalmente, a MSC pode ocorrer em consequ\u00eancia de rompimento de aneurisma apical de VE.et al.desenvolveram um escore para estratifica\u00e7\u00e3o de risco para mortalidade de pacientes com CCC, com base em vari\u00e1veis cl\u00ednicas e exames cardiol\u00f3gicos b\u00e1sicos.Este escore tamb\u00e9m foi aplicado por outros investigadores em coorte retrospectiva (149 pacientes) que tamb\u00e9m propuseram que a presen\u00e7a de TV (teste ergom\u00e9trico ouHolter), FEVE < 0,50 e QRS > 150ms (ECGAR) possa identificar pacientes com CCC e risco de morte em 5 anos. A aus\u00eancia ou presen\u00e7a de um fator caracterizaria grupo de baixo risco; risco intermedi\u00e1rio quando ocorrem dois fatores; e alto risco quando h\u00e1 presen\u00e7a dos tr\u00eas fatores.Rassi Nao h\u00e1, entretanto, evid\u00eancia cient\u00edfica que sustente a indica\u00e7\u00e3o de CDI na preven\u00e7\u00e3o prim\u00e1ria de MSC na CCC. H\u00e1 muitas particularidades patogen\u00e9ticas e fisiopatol\u00f3gicas que dificultam qualquer compara\u00e7\u00e3o direta com os resultados da literatura em outras cardiopatias.A peculiaridade mais marcante \u00e9 a de que muitos pacientes com CCC, mesmo com fun\u00e7\u00e3o de VE preservada, j\u00e1 possu\u00edrem substrato para arritmias potencialmente letais \u00e9 uma cardiomiopatia de heran\u00e7a autoss\u00f4mica dominante e penetr\u00e2ncia vari\u00e1vel, que provoca muta\u00e7\u00e3o de genes que codificam prote\u00ednas de ades\u00e3o celular, os desmossomos. A CAVD afeta predominantemente o VD, mas pode afetar o VE em cerca de 0,5% dos casos, determinando substitui\u00e7\u00e3o do tecido mioc\u00e1rdico por fibrose e tecido adiposo. Tais altera\u00e7\u00f5es estruturais frequentemente causam arritmias ventriculares e morte s\u00fabita card\u00edaca (MSC).Extrass\u00edstoles ventriculares frequentes, taquicardia ventricular n\u00e3o sustentada (TVNS) e taquicardia ventricular sustentada (TVS) s\u00e3o preditores importantes de eventos card\u00edacos. A ocorr\u00eancia de TVS \u00e9 preditora importante de MSC e de terapias apropriadas do CDI. A MSC pode ser a primeira manifesta\u00e7\u00e3o da CAVD.As arritmias ventriculares t\u00eam origem geralmente no VD (morfologia de BRE), mas o eixo do QRS durante a TVS geralmente difere da via de sa\u00edda do VD (VSVD); muitos pacientes podem ter QRS de m\u00faltiplas morfologias.\u00e9psilon) e potenciais tardios ao ECGAR. Em pacientes com suspeita de CAVD, o ECGAR pode ser \u00fatil para diagn\u00f3stico e estratifica\u00e7\u00e3o de risco . Achados anormais ao ECGAR est\u00e3o relacionados com a GRAVIDADE da CAVD na RMC e ocorr\u00eancia de eventos adversos.As regi\u00f5es de tecido fibrogorduroso criam \u00e1reas de ativa\u00e7\u00e3o ventricular retardada, causando deflex\u00f5es fracionadas no final do complexo QRS  tem valor incerto na CAVD assintom\u00e1tica como preditor do risco de MSC . Em pacientes com CDI para preven\u00e7\u00e3o prim\u00e1ria, a indu\u00e7\u00e3o de TVS n\u00e3o \u00e9 preditor de choques apropriados.Os testes gen\u00e9ticos realizados em probandos com suspeita de CAVD s\u00e3o positivos em 30% a 54%. Importante ressaltar que um teste negativo n\u00e3o exclui a doen\u00e7a, e um teste positivo n\u00e3o define a terap\u00eautica. A CAVD \u00e9 detectada em aproximadamente 35% a 40% dos parentes de primeiro grau, e o rastreamento cl\u00ednico com ECG, Holter, teste ergom\u00e9trico e exames de imagem card\u00edaca pode identificar familiares sob risco de CAVD.N\u00e3o h\u00e1 estudos randomizados avaliando a melhor op\u00e7\u00e3o de antiarr\u00edtmicos para tratamento da TVS. Um estudo observacional demonstrou supress\u00e3o de TV induzida em 58% dos pacientes e apenas 10% apresentaram recorr\u00eancia da arritmia com o uso de sotalol. Em outro registro observacional, betabloqueadores ou sotalol n\u00e3o estiveram associados \u00e0 redu\u00e7\u00e3o de arritmias ventriculares; amiodarona foi superior para sua preven\u00e7\u00e3o em pequena coorte.Abla\u00e7\u00e3o de TVS reduz a sua recorr\u00eancia, mas n\u00e3o elimina a necessidade de implante de CDI.Pacientes assintom\u00e1ticos e sem arritmias ventriculares devem receber apenas betabloqueadores e avaliados periodicamente quanto a fun\u00e7\u00e3o ventricular e ocorr\u00eancia de arritmias.Revis\u00e3o sistem\u00e1tica recente incluindo 610 pacientes seguidos por 3,8 anos (m\u00e9dia) demonstrou taxa anual de 9,5% e 3,7% de choques apropriados e inapropriados, respectivamente.Pacientes com hist\u00f3ria de MSC abortada, TVS mal tolerada e s\u00edncope t\u00eam maior risco de MSC, com taxa anual >10%, sendo indicado implante de CDI. Fatores de risco para MSC ou choque apropriado reportados em diferentes coortes s\u00e3o: TVS, s\u00edncope inexplicada, TVNS frequente, hist\u00f3ria familiar de MSC precoce, comprometimento extenso do VD, QRS muito prolongado, realce tardio na RMC, disfun\u00e7\u00e3o de VE e indu\u00e7\u00e3o de TVS no EEF.A indica\u00e7\u00e3o de CDI na CAVD para preven\u00e7\u00e3o prim\u00e1ria \u00e9 medida de dif\u00edcil avalia\u00e7\u00e3o e deve contar com uma avalia\u00e7\u00e3o cl\u00ednica detalhada considerando hist\u00f3ria familiar, severidade da disfun\u00e7\u00e3o de VD e VE, complica\u00e7\u00f5es a longo prazo do CDI, impacto psicol\u00f3gico e econ\u00f4mico. A As vari\u00e1veis preditoras foram: sexo masculino, idade, s\u00edncope nos \u00faltimos 6 meses, TVNS pr\u00e9via, n\u00famero de extrass\u00edstoles ventriculares noHolter-24h, n\u00famero de deriva\u00e7\u00f5es com onda T invertida nas deriva\u00e7\u00f5es inferiores e anteriores e fra\u00e7\u00e3o de eje\u00e7\u00e3o do VD. Esse novo modelo determinou maior refinamento na sele\u00e7\u00e3o de pacientes para implante de CDI quando comparado ao Fluxograma da International Task Force, publicado em 2015, reduzindo em 20,6% a indica\u00e7\u00e3o de implante.Os autores do novo modelo disponibilizaram uma calculadora de riscoonline(www.arvcrisk.com) que calcula o risco de arritmia ventricular em 5 anos; embora n\u00e3o determine o limiar de risco aceit\u00e1vel para implante do CDI, acredita-se que o modelo auxilia no processo de decis\u00e3o para preven\u00e7\u00e3o prim\u00e1ria.Um novo modelo preditor de arritmias ventriculares na CAVD foi recentemente publicado. O comprometimento de ambos os ventr\u00edculos ocorre em 22% a 38% dos pacientes. A n\u00e3o compacta\u00e7\u00e3o do VE ocorre em associa\u00e7\u00e3o com outras cardiopatias cong\u00eanitas ou de forma isolada.A miocardiopatia n\u00e3o compactada (MNC) \u00e9 uma rara anormalidade cong\u00eanita, caracterizada pela forma\u00e7\u00e3o de trabecula\u00e7\u00f5es proeminentes e recessos intertrabeculares profundos nos ventr\u00edculos esquerdo (VE) e direito (VD), que ocorre durante a fase de embriog\u00eanese do endomioc\u00e1rdio , atingindo mais comumente o \u00e1pice do VE.A heran\u00e7a gen\u00e9tica surge padr\u00e3o autoss\u00f4mico dominante em pelo menos 30% a 50% dos pacientes; v\u00e1rios genes que causam n\u00e3o compacta\u00e7\u00e3o do VE j\u00e1 foram identificados. Esses genes geralmente codificam prote\u00ednas do sarc\u00f4mero (aparelho contr\u00e1til) ou citoesquel\u00e9ticas.A apresenta\u00e7\u00e3o cl\u00ednica da MNC \u00e9 heterog\u00eanea, variando de casos totalmente assintom\u00e1ticos at\u00e9 casos com manifesta\u00e7\u00f5es graves e fatais como IC, tromboembolismo, BAV e intraventricular, arritmia ventricular e morte s\u00fabita card\u00edaca (MSC). Idade, di\u00e2metro diast\u00f3lico final do VE, IC sintom\u00e1tica, FA permanente ou persistente, bloqueio de ramo e doen\u00e7a neuromuscular associada s\u00e3o preditores de maior mortalidade. A RMC possibilita a visibiliza\u00e7\u00e3o da propor\u00e7\u00e3o de mioc\u00e1rdio n\u00e3o compactado e compactado e permite a identifica\u00e7\u00e3o de trombos e fibrose mioc\u00e1rdica.O ecocardiograma (ECO) \u00e9 rotineiramente realizado na investiga\u00e7\u00e3o inicial, e o uso de contraste pode melhorar a sensibilidade do diagn\u00f3stico. O exame histol\u00f3gico evidencia continuidade entre o endoc\u00e1rdio ventricular e os recessos intertrabeculares profundos que podem facilitar a arritmog\u00eanese pela forma\u00e7\u00e3o de circuitos reentrantes subjacentes ao tecido cicatricial, predominando no \u00e1pice do VE e segmentos m\u00e9dio-apicais.A MSC \u00e9 a principal causa de morte na MNC, podendo ocorrer em qualquer idade; n\u00e3o existem ferramentas diagn\u00f3sticas precisas para a estratifica\u00e7\u00e3o de risco nesses pacientes. Arritmias ventriculares s\u00e3o relatadas em 38% a 47% e a MSC ocorre em 13% a 18% dos pacientes.et al. demonstraram que a indu\u00e7\u00e3o de TV sustentada no EEF para estratifica\u00e7\u00e3o de risco tem pouco valor na MCN; por outro lado, a n\u00e3o indu\u00e7\u00e3o pode identificar pacientes de baixo risco.A abla\u00e7\u00e3o por cateter endo e/ou epic\u00e1rdica parece ser \u00fatil em portadores de CDI com arritmias ventriculares frequentes.A taxa de choques apropriados nesses pacientes, na preven\u00e7\u00e3o secund\u00e1ria, \u00e9 de 33% a 37% em seguimento m\u00e9dio de 34 a 40 meses.SteffelNo entanto, Caliskanet al., em estudo que incluiu 77 pacientes com MNC, demonstraram que, entre os pacientes que receberam CDI para preven\u00e7\u00e3o secund\u00e1ria, a disfun\u00e7\u00e3o de VE ou sua dilata\u00e7\u00e3o n\u00e3o eram proeminentes, tornando esses crit\u00e9rios fr\u00e1geis para a indica\u00e7\u00e3o de preven\u00e7\u00e3o prim\u00e1ria. Por outro lado, a presen\u00e7a de TVNS foi mais frequente na preven\u00e7\u00e3o secund\u00e1ria em rela\u00e7\u00e3o aos pacientes que receberam CDI para preven\u00e7\u00e3o prim\u00e1ria ou n\u00e3o foram submetidos ao implante de CDI. Outros fatores de risco que devem ser considerados s\u00e3o hist\u00f3ria familiar e ocorr\u00eancia de s\u00edncope.N\u00e3o existem dados convincentes demonstrando que a n\u00e3o compacta\u00e7\u00e3o do VE, por si s\u00f3, seja suficiente para indica\u00e7\u00e3o de implante de CDI. Tal indica\u00e7\u00e3o deve ser guiada pela gravidade da disfun\u00e7\u00e3o sist\u00f3lica do VE e presen\u00e7a de arritmia ventricular sustentada (como na cardiomiopatia dilatada idiop\u00e1tica)., como nos tipos LQT 1 a 6; autoss\u00f4mico recessivo, associado a surdez cong\u00eanita e intervalos QT muito prolongados (Lange-Nielsen); e autoss\u00f4mico dominante, associado a defeitos extracard\u00edacos em associa\u00e7\u00e3o a dismorfismos e paralisia peri\u00f3dica hipo ou hipercalemica .Centenas de muta\u00e7\u00f5es j\u00e1 foram descritas em mais de 13 genes diferentes respons\u00e1veis por canais i\u00f4nicos restauradores do potencial de repouso da c\u00e9lula mioc\u00e1rdica. O padr\u00e3o de heran\u00e7a pode ser autoss\u00f4mico dominante  ou com s\u00edncope recorrente podem ter risco anual de morte s\u00fabita de at\u00e9 5%.A s\u00edndrome do QT curto \u00e9 definida por intervalo QTc < 340ms ou < 360ms em sobreviventes de parada card\u00edaca por FV/TV, hist\u00f3ria familiar de morte s\u00fabita com menos de 40 anos de idade, presen\u00e7a de muta\u00e7\u00e3o confirmada ou hist\u00f3ria familiar de QT curto. Trata-se de doen\u00e7a rara em que muta\u00e7\u00f5es em genes de canais de pot\u00e1ssio podem ser encontrados em at\u00e9 20% dos casos.Alguns pacientes com QT curto podem se beneficiar do uso de quinidina. Sobreviventes de parada card\u00edaca devem ser submetidos a implante de CDI, enquanto os assintom\u00e1ticos devem ser acompanhados. As recomenda\u00e7\u00f5es para implante de CDI para preven\u00e7\u00e3o prim\u00e1ria na s\u00edndrome do QT longo e QT curto est\u00e3o listadas nacoved type) no 2\u00ba, 3\u00ba ou 4\u00ba espa\u00e7o intercostal, espont\u00e2neo ou induzido por bloqueador de canal de s\u00f3dio , associado \u00e0 ocorr\u00eancia de arritmia ventricular polim\u00f3rfica, s\u00edncope ou parada card\u00edaca.A s\u00edndrome de Brugada \u00e9 caracterizada pelo supradesnivelamento do segmento ST > 2mm nas deriva\u00e7\u00f5es V1 e V2 ( (Pacientes com o padr\u00e3o eletrocardiogr\u00e1fico t\u00edpico (\u201ctipo 1\u201d) espont\u00e2neo associado \u00e0 s\u00edncope inexplicada ou parada card\u00edaca recuperada s\u00e3o os que apresentam maior risco de morte s\u00fabita. O implante de CDI est\u00e1 associado \u00e0 redu\u00e7\u00e3o do risco nesses pacientes sintom\u00e1ticos .O aspecto fenot\u00edpico da s\u00edndrome de Brugada est\u00e1 associado a defeitos gen\u00e9ticos detect\u00e1veis em at\u00e9 30% dos casos. O gene SCN5A est\u00e1 envolvido na maioria das altera\u00e7\u00f5es encontradas, mas a pesquisa gen\u00e9tica negativa n\u00e3o afasta o diagn\u00f3stico.Diversos fatores podem deflagrar as manifesta\u00e7\u00f5es eletrocardiogr\u00e1ficas ou precipitar epis\u00f3dios arr\u00edtmicos, como febre, agentes anest\u00e9sicos e diversos psicotr\u00f3picos (www.brugadadrugs.org).et al. encontraram associa\u00e7\u00e3o entre a indu\u00e7\u00e3o de TV polim\u00f3rfica com aplica\u00e7\u00e3o de at\u00e9 2 extraest\u00edmulos no VD e o risco de morte em pacientes assintom\u00e1ticos. J\u00e1 a indu\u00e7\u00e3o de arritmia com 3 extraest\u00edmulos reduz a especificidade e deve ser evitada. Outros autores encontraram redu\u00e7\u00e3o do valor preditivo positivo da EVP ao longo do tempo.Pacientes assintom\u00e1ticos t\u00eam menor risco de morte s\u00fabita. O papel da estimula\u00e7\u00e3o ventricular programada (EVP) na estratifica\u00e7\u00e3o de risco \u00e9 controversa. BrugadaPacientes com tempestade el\u00e9trica e disparo e terapias de choque pelo CDI podem se beneficiar de controle cl\u00ednico com quinidina e com abla\u00e7\u00e3o epic\u00e1rdica de \u00e1reas de ativa\u00e7\u00e3o anormal do VD identificados no mapeamento eletroanat\u00f4mico.A TVPC \u00e9 uma rara doen\u00e7a arritmog\u00eanica, de origem gen\u00e9tica, caracterizada por taquicardia ventricular bidirecional e polim\u00f3rfica, adren\u00e9rgico-dependente. A preval\u00eancia estimada \u00e9 de 1 em 10.000 indiv\u00edduos. J\u00e1 foram identificados dois tipos de genes: uma variante dominante secund\u00e1ria \u00e0 muta\u00e7\u00e3o no gene do receptor card\u00edaco do rianodinio (RyR2) e uma rara variante recessiva causada por muta\u00e7\u00e3o do gene da calsequestrina card\u00edaca (CASQ2).A manifesta\u00e7\u00e3o cl\u00ednica usualmente ocorre na 1\u00aa ou 2\u00aa d\u00e9cada de vida, sendo desencadeada por exerc\u00edcio f\u00edsico ou estresse emocional. Em geral, o ECG e o ecocardiograma s\u00e3o normais, mas o teste ergom\u00e9trico desencadeia arritmias atriais e ventriculares .O tratamento de escolha \u00e9 o uso de betabloqueador em dose m\u00e1xima toler\u00e1vel. A flecainida e a simpatectomia card\u00edaca esquerda podem ser associadas como terapias coadjuvantes. , al\u00e9m da chance de complica\u00e7\u00f5es devido \u00e0 baixa faixa et\u00e1ria dos pacientes.Em revis\u00e3o sistem\u00e1tica recentemente publicada, a incid\u00eancia de choque foi de 40%, tempestade el\u00e9trica 19,6%, mortalidades ap\u00f3s implante atingiu 1,4% e complica\u00e7\u00f5es adicionais chegaram a 32,4% , em um faixa et\u00e1ria m\u00e9dia de 15 anos (11 a 21 anos).Arritmias ventriculares em pacientes com cora\u00e7\u00e3o estruturalmente normal s\u00e3o, na grande maioria das vezes, benignas. Contudo, uma pequena parcela de pacientes pode apresentar formas malignas de taquicardia ventricular monom\u00f3rfica, polim\u00f3rfica e at\u00e9 mesmo fibrila\u00e7\u00e3o ventricular.Muitas dessas taquicardias s\u00e3o desencadeadas por ectopias ventriculares originadas em regi\u00f5es muito similares \u00e0quelas de car\u00e1ter benigno . O mecanismo exato dessas arritmias ventriculares malignas ainda n\u00e3o \u00e9 completamente esclarecido. A anisotropia associada a condu\u00e7\u00e3o lenta e bloqueio funcional causados por focos arritmog\u00eanicos r\u00e1pidos provavelmente causa degenera\u00e7\u00e3o do ritmo para TV polim\u00f3rfica e FV. ACaracter\u00edsticas de alto risco est\u00e3o relacionadas com a ocorr\u00eancia de s\u00edncope ou parada card\u00edaca e achados eletrocardiogr\u00e1ficos de intervalo de acoplamento curto da primeira ou segunda extrass\u00edstole, TVNS com ciclos curtos, QRS alargado  e TV polim\u00f3rfica. Al\u00e9m disso, esses poucos pacientes que conseguem sobreviver \u00e0 PCR por TV/FV apresentam alto risco de recorr\u00eancia de taquiarritmias potencialmente fatais, tornando fundamental a ado\u00e7\u00e3o de medidas preventivas, que inclui o tratamento da cardiopatia de base, das comorbidades, do uso de f\u00e1rmacos antiarr\u00edtmicos e da sele\u00e7\u00e3o de pacientes para implante de CDI.A parada cardiorrespirat\u00f3ria (PCR) por taquicardia ventricular ou fibrila\u00e7\u00e3o ventricular (TV/FV) e, subsequentemente, a morte s\u00fabita card\u00edaca (MSC) constituem um grave problema de sa\u00fade p\u00fablica, representando aproximadamente 50% de todas as mortes cardiovasculares. Adicionalmente, dos pacientes que apresentam PCR fora do ambiente hospitalar, a taxa de sobrevida \u00e9 bastante baixa, entre 6 e 10%.Nos pacientes com cardiopatia isqu\u00eamica ou dilatada, \u00e9 bastante conhecido o papel protetor de f\u00e1rmacos como os betabloqueadores, inibidores da enzima conversora de angiotensina (IECA), bloqueadores do receptor da angiotensina (BRA) e estatinas, que reduzem a mortalidade total, a mortalidade cardiovascular e a mortalidade s\u00fabita. envolvendo mais que 35.000 pacientes com disfun\u00e7\u00e3o ventricular esquerda (FEVE < 40%), demostrou que f\u00e1rmacos como betabloqueadores, IECA, BRA e antagonistas dos receptores mineralocorticoides reduzem o risco de MSC quando comparados ao placebo . Quando associado \u00e0 TFO, o implante de CDI traz benef\u00edcio adicional ao tratamento cl\u00ednico, reduzindo ainda mais a taxa de MSC . Mais recentemente, a combina\u00e7\u00e3o de um inibidor (LCZ696) da neprilisina com BRA  mostrou-se ainda mais eficiente que o enalapril na redu\u00e7\u00e3o tanto da mortalidade por IC quanto da mortalidade arr\u00edtmica. Questiona-se se o LCZ696 teria a\u00e7\u00e3o antiarr\u00edtmica prim\u00e1ria ou se a redu\u00e7\u00e3o das arritmias card\u00edacas seria resultado de melhora cl\u00ednica da IC.Uma metan\u00e1liseHolter-24h. Em seguimento de 6 anos, a sobrevida livre de eventos (morte card\u00edaca ou TV) foi de 41% no grupo amiodaronaversus20% no grupo de terapia convencional. No entanto, a falta de grupo placebo n\u00e3o permite concluir se os resultados decorreram de benef\u00edcio do uso da amiodarona ou dos riscos associados \u00e0s outras drogas antiarr\u00edtmicas.O emprego de f\u00e1rmacos antiarr\u00edtmicos foi, durante muitos anos, a principal estrat\u00e9gia de preven\u00e7\u00e3o secund\u00e1ria de MSC, ainda que fundamentado em poucos estudos e com elevada taxa de recorr\u00eancia de eventos. At\u00e9 o in\u00edcio dos anos 1990, aceitava-se que antiarr\u00edtmicos da Classe I  reduziam as extrass\u00edstoles ventriculares e a mortalidade. Com a demonstra\u00e7\u00e3o subsequente dos efeitos delet\u00e9rios desses f\u00e1rmacos p\u00f3s-IAM e na IC, a amiodarona passou a ser a escolha para esses pacientes. O estudo CASCADE envolveu 228 pacientes recuperados de PCR que foram randomizados para tratamento emp\u00edrico com amiodarona ou f\u00e1rmacos da classe I, orientadas por EEF ou comparou a terapia antiarr\u00edtmica versusCDI em 1.016 pacientes recuperados de PCR por TV/FV, com TV associada \u00e0 s\u00edncope ou com instabilidade hemodin\u00e2mica e FEVE < 40%. A sobrevida foi significativamente maior no grupo CDI em 1 ano , 2 anos  e 3 anos , p < 0,02. A principal cr\u00edtica a esse estudo refere-se ao maior n\u00famero de pacientes em uso de betabloqueador no grupo CDI em rela\u00e7\u00e3o ao grupo de terapia antiarr\u00edtmica. Em an\u00e1lise posterior, observou-se que o benef\u00edcio do CDI ocorreu principalmente nos pacientes com FEVE mais baixa. Nos pacientes com FEVE > 35%, n\u00e3o houve diferen\u00e7a de sobrevida significativa. Nos pacientes com FEVE entre 20% e 34%, a sobrevida em 1 ano foi de 89,6%versus79,8% e em 2 anos de 82,5%versus71,8% . Nos pacientes com FEVE < 20%, a sobrevida em 1 ano foi de 82,4%versus73% e, em 2 anos 71,6%versus63,8%, sem diferen\u00e7a significativa.O CDI \u00e9 considerado o principal avan\u00e7o para a preven\u00e7\u00e3o secund\u00e1ria da MSC. Seus benef\u00edcios foram avaliados em uma s\u00e9rie de ensaios cl\u00ednicos randomizados. O estudo AVID avaliou o uso de amiodaronaversusCDI em 659 pacientes com FV documentada, PCR recuperada, TV associada \u00e0 s\u00edncope, TV > 150 bpm/min com pr\u00e9-s\u00edncope ou angina e FEVE < 35% ou s\u00edncope associada \u00e0 TV indut\u00edvel ou com epis\u00f3dio de TV espont\u00e2nea documentada. A mortalidade total ap\u00f3s seguimento m\u00e9dio de 4 anos foi de 27% no grupo CDI e 33% no grupo amiodarona, sendo que essa diferen\u00e7a n\u00e3o foi significativa. Em an\u00e1lise subsequente, foi demonstrado que, em pacientes com dois dos seguintes crit\u00e9rios: FEVE < 35%, CF III ou IV e idade > 70 anos, o implante do CDI foi superior. Ap\u00f3s acompanhamento m\u00e9dio de 5,6 \u00b1 2,6 anos, a mortalidade foi de 47% no grupo amiodarona comparada a 27% no grupo CDI .O estudo CIDS incluiu 349 pacientes recuperados de PCR que foram randomizados para tratamento com propafenona, amiodarona, metoprolol ou implante de CDI. O tratamento com propafenona foi suspenso ap\u00f3s uma an\u00e1lise interina verificar aumento de mortalidade em compara\u00e7\u00e3o aos pacientes com CDI. Ap\u00f3s seguimento m\u00e9dio de 2 anos, a mortalidade total foi de 12,1% no grupo CDIversus19,6% nos grupos amiodarona e metoprolol combinados, sendo que a diferen\u00e7a igualmente n\u00e3o foi significativa.O estudo CASH O benef\u00edcio foi maior em pacientes com FEVE < 35% e considerando seguimento de 6 anos .A metan\u00e1lise que avaliou os resultados desses tr\u00eas estudos demonstrou 50% de redu\u00e7\u00e3o relativa na mortalidade arr\u00edtmica  e 28% na mortalidade total entre os pacientes com CDI em compara\u00e7\u00e3o aos que receberam tratamento antiarr\u00edtmico, com NNT = 29 .versusamiodarona emp\u00edrica em pacientes com TV sustentada ou PCR recuperada. Os resultados demostraram redu\u00e7\u00e3o de mortalidade no grupo de pacientes com CDI. A realiza\u00e7\u00e3o de EEF n\u00e3o demonstrou benef\u00edcio.O estudo MAVERIC comparou terapia guiada por EEF As recomenda\u00e7\u00f5es para implante de CDI na preven\u00e7\u00e3o secund\u00e1ria s\u00e3o baseadas nesses estudos .As canalopatias representam um grupo de patologias geneticamente determinadas que envolvem diversos tipos de disfun\u00e7\u00f5es dos canais i\u00f4nicos dos cardiomi\u00f3citos, seja aumentando ou reduzindo suas fun\u00e7\u00f5es e gerando desequil\u00edbrio i\u00f4nico que aumentam o risco de taquiarritmias potencialmente fatais e de MSC.A gama de muta\u00e7\u00f5es gen\u00e9ticas \u00e9 extremamente ampla, com grande sobreposi\u00e7\u00e3o de express\u00f5es fenot\u00edpicas. S\u00e3o classificadas como canalopatias a s\u00edndrome do QT longo cong\u00eanito (SQTL), s\u00edndrome de Brugada (SB), taquicardia ventricular catecolamin\u00e9rgica (TVC), s\u00edndrome do QT curto (SQTC), s\u00edndrome do ponto J (SPJ), repolariza\u00e7\u00e3o precoce (RP). A fibrila\u00e7\u00e3o ventricular idiop\u00e1tica, a s\u00edndrome de morte s\u00fabita arr\u00edtmica e a s\u00edndrome de morte s\u00fabita na inf\u00e2ncia, ainda que possam ter outros mecanismos envolvidos que n\u00e3o somente os gen\u00e9ticos, s\u00e3o discutidos tamb\u00e9m nessa categoria, pela manifesta\u00e7\u00e3o arr\u00edtmica predominante de TV/FV na aus\u00eancia de cardiopatia estrutural. N\u00e3o est\u00e1 no escopo desta Diretriz a discuss\u00e3o detalhada de particularidades de cada express\u00e3o fenot\u00edpica das canalopatias, sendo poss\u00edvel encontrar extensa refer\u00eancia na literatura. A decis\u00e3o cl\u00ednica para o implante de CDI tamb\u00e9m deve considerar outras op\u00e7\u00f5es terap\u00eauticas ou terapias coadjuvantes em situa\u00e7\u00f5es especiais, como a denerva\u00e7\u00e3o simp\u00e1tica esquerda na s\u00edndrome do QT longo  \u00e9 preditor de risco de MSC; risco .Frequentemente, as indica\u00e7\u00f5es de CDI na faixa et\u00e1ria pedi\u00e1trica seguem crit\u00e9rios similares aos adultos, tanto para preven\u00e7\u00e3o prim\u00e1ria como para preven\u00e7\u00e3o secund\u00e1ria, em que pese a import\u00e2ncia do bom senso na avalia\u00e7\u00e3o desses pacientes.As indica\u00e7\u00f5es de CDI em crian\u00e7as n\u00e3o t\u00eam sido adequadamente contempladas nas \u00faltimas diretrizes internacionais devido ao limitado n\u00famero de trabalhos publicados sobre o assunto at\u00e9 o momento. Dessa forma, algumas publica\u00e7\u00f5es de pequenas s\u00e9ries t\u00eam direcionado a maioria das indica\u00e7\u00f5es atuais.Recentemente, SOBRAC e DCC-CP publicaram a Diretriz de Arritmias Card\u00edacas em Crian\u00e7as e Cardiopatias Cong\u00eanitas, a qual veio normatizar o diagn\u00f3stico e o tratamento de crian\u00e7as com arritmias card\u00edacas.\u00c9 extremamente importante que o m\u00e9dico busque alternativas para evitar a indica\u00e7\u00e3o de CDI em crian\u00e7as, sem que isso represente aumento de risco. Deve-se esgotar o tratamento cl\u00ednico adequado e, quando indicada, a abla\u00e7\u00e3o dos focos arritmog\u00eanicos deve ser considerada.N\u00e3o existem evid\u00eancias que suportam a utiliza\u00e7\u00e3o rotineira de CDI na popula\u00e7\u00e3o pedi\u00e1trica com base apenas na disfun\u00e7\u00e3o ventricular esquerda, como ocorre em algumas situa\u00e7\u00f5es da popula\u00e7\u00e3o adulta. Devido \u00e0 dimens\u00e3o do gerador de pulsos e calibre do cabo-eletrodo de choque, a indica\u00e7\u00e3o de CDI nessa popula\u00e7\u00e3o deve ser exce\u00e7\u00e3o em virtude de v\u00e1rios fatores: dificuldade t\u00e9cnica para implante devido \u00e0 dimens\u00e3o do corpo da crian\u00e7a, limita\u00e7\u00e3o para confec\u00e7\u00e3o da loja do gerador (muitas vezes no abdome), reduzidas op\u00e7\u00f5es de via de acesso, risco de tromboses/obstru\u00e7\u00f5es venosas e maior risco de extrus\u00e3o.Para o seguimento cl\u00ednico e eletr\u00f4nico, al\u00e9m do ECG e da avalia\u00e7\u00e3o rotineira por telemetria, \u00e9 fundamental a avalia\u00e7\u00e3o radiol\u00f3gica peri\u00f3dica, para acompanhar o comportamento do cabo-eletrodo de acordo com o crescimento da crian\u00e7a. Esse cabo deve ser implantado deixando uma curva redundante para permitir o crescimento do paciente sem a necessidade de m\u00faltiplas interven\u00e7\u00f5es.A programa\u00e7\u00e3o eletr\u00f4nica tamb\u00e9m apresenta diferen\u00e7as em rela\u00e7\u00e3o ao adulto. A fun\u00e7\u00e3o de MP deve considerar frequ\u00eancia b\u00e1sica de estimula\u00e7\u00e3o apropriada \u00e0 idade e \u00e0 cardiopatia, habitualmente variando de 90 a 160ppm (adolescentes costumam acompanhar protocolos de adultos). Outros fatores importantes s\u00e3o a programa\u00e7\u00e3o de intervalo AV adaptativo e per\u00edodo refrat\u00e1rio atrial p\u00f3s-ventricular curto, mas adequado para prevenir a ocorr\u00eancia de taquicardia por reentrada eletr\u00f4nica, uma vez que esses pacientes costumam ter boa condu\u00e7\u00e3o ventriculoatrial. A facilidade que as crian\u00e7as apresentam em desenvolver taquicardia sinusal com frequ\u00eancia elevada pode resultar em choques inapropriados com grande impacto psicol\u00f3gico. Choques inapropriados, principalmente logo ap\u00f3s o implante, podem afetar a confian\u00e7a no equipamento e na equipe m\u00e9dica, com desenvolvimento des\u00edndrome do p\u00e2nicode dif\u00edcil controle.A programa\u00e7\u00e3o eletr\u00f4nica do CDI e o seguimento cl\u00ednico devem ser ainda mais cuidadosos.antitachycardia pacing), visto que s\u00e3o raras as situa\u00e7\u00f5es em que as arritmias potencialmente fatais se apresentam como TV monom\u00f3rfica. Quando ocorrem TV monom\u00f3rficas, devem ser tratadas com abla\u00e7\u00e3o sempre que poss\u00edvel.As TV polim\u00f3rficas respondem melhor ao disparo precoce de choques, al\u00e9m disso, essas arritmias facilmente degeneram para FV durante as tentativas de ATP.Os crit\u00e9rios de discrimina\u00e7\u00e3o de arritmias e a frequ\u00eancia de detec\u00e7\u00e3o devem ser rigorosamente bem ajustados. \u00c9 recomend\u00e1vel que as terapias sejam restritas a choques, evitando-se o uso de terapias antitaquicardia . Hipertrofia e dilata\u00e7\u00e3o do VD, al\u00e9m da obstru\u00e7\u00e3o ou regurgita\u00e7\u00e3o residual da via de sa\u00edda do VD, s\u00e3o consideradas fatores de risco para a ocorr\u00eancia de TV e MSC. Abordagem h\u00edbrida, combinando a estrat\u00e9gia cir\u00fargica para o reparo das altera\u00e7\u00f5es estruturais com abla\u00e7\u00e3o da arritmia guiada pelo mapeamento pr\u00e9-operat\u00f3rio ou intraoperat\u00f3rio, tem sido utilizada com sucesso na tentativa de reduzir a incid\u00eancia de arritmias. A troca da v\u00e1lvula pulmonar isoladamente nos pacientes comT4Fresulta em melhora hemodin\u00e2mica e funcional, mas n\u00e3o elimina o risco de TV, sendo necess\u00e1ria avalia\u00e7\u00e3o p\u00f3s-operat\u00f3ria de risco de MSC e eventual indica\u00e7\u00e3o de CDI.Existe extensa correla\u00e7\u00e3o entre anormalidades hemodin\u00e2micas residuais e a ocorr\u00eancia de TV em pacientes submetidos \u00e0 corre\u00e7\u00e3o cir\u00fargica de Esses pacientes apresentam choques apropriados entre 3 e 6% ao ano e taxas de complica\u00e7\u00f5es (26% a 45%) e choques inapropriados (15% a 25%) maiores que outras popula\u00e7\u00f5es. Por isso, o custo-benef\u00edcio e o impacto psicol\u00f3gico devem ser considerados quando da indica\u00e7\u00e3o de CDI nesta popula\u00e7\u00e3o.Aproximadamente 50% dos implantes de CDI em adultos com cardiopatia cong\u00eanita s\u00e3o indicados para preven\u00e7\u00e3o secund\u00e1ria, entre 36 e 41 anos de idade.Os desafios do implante de CDI em adultos com cardiopatia cong\u00eanita incluem a complexidade anat\u00f4mica, os desvios intracard\u00edacos e acesso vascular limitado ao cora\u00e7\u00e3o. O CDI subcut\u00e2neo pode ser uma boa op\u00e7\u00e3o para esses pacientes.et al. propuseram um escore de risco para pacientes submetidos \u00e0 corre\u00e7\u00e3o cir\u00fargica deT4Fem que a pontua\u00e7\u00e3o > 5 seria suficiente para a indica\u00e7\u00e3o de CDI. Os crit\u00e9rios considerados nesse escore inclu\u00edram: cirurgia de desvio sist\u00eamico-pulmonar paliativo pr\u00e9via (2), indu\u00e7\u00e3o de TVS ao EEF (2), QRS \u2265 180ms (1), ventriculotomia (2), TVNS (2) e press\u00e3o diast\u00f3lica final do VE \u2265 12mmHg (3).A indica\u00e7\u00e3o de CDI para preven\u00e7\u00e3o prim\u00e1ria em pacientes com cardiopatia cong\u00eanita \u00e9 controversa. KairyT4Frepresentam cerca de 50% dos implantes de CDI na popula\u00e7\u00e3o de cardiopatia cong\u00eanita do adulto. Nessa popula\u00e7\u00e3o, choques apropriados ocorrem em at\u00e9 7,7%/ano na preven\u00e7\u00e3o prim\u00e1ria e 9,8%/ano na preven\u00e7\u00e3o secund\u00e1ria. A TVS induzida no EEF em pacientes com cardiopatia cong\u00eanita parece n\u00e3o se correlacionar com a ocorr\u00eancia de choques apropriados.A abla\u00e7\u00e3o por cateter de TVS monom\u00f3rfica recorrente pode ser alternativa eficaz, dispensando o implante de CDI em alguns casos.Os pacientes com reparo cir\u00fargico deswitchatrial, anomalia da v\u00e1lvula tric\u00faspide tipoEbstein, estenose a\u00f3rtica e fisiologia univentricular.O maior risco de MSC em pacientes com cardiopatia cong\u00eanita operada, de acordo com dados de grandes coortes, est\u00e1 na popula\u00e7\u00e3o com transposi\u00e7\u00e3o das grandes art\u00e9rias comSenningouMustardapresentam maior risco de MSC principalmente durante o esfor\u00e7o f\u00edsico. Nesses pacientes, oswitchatrial pode resultar em aumento do volume e consequente estenose das veias pulmonares e aumento das press\u00f5es diast\u00f3licas finais. Al\u00e9m disso, isquemia e infarto do VD j\u00e1 foram identificados em estudos de perfus\u00e3o mioc\u00e1rdica em mais de 40% desses pacientes. Os fatores de risco para PCR em pacientes comswitchatrial incluem o fechamento pr\u00e9vio de CIV, sintomas de IC, arritmia atrial, FEVD < 30% a 35% e QRS > 140ms.Em estudo multic\u00eantrico que avaliou pacientes comswitchatrial ap\u00f3s implante de CDI, a falta de betabloqueadores foi associada a alto risco de terapia apropriada do CDI.As arritmias atriais frequentemente precedem a TVS em pacientes com transposi\u00e7\u00e3o, devendo o tratamento para taquicardia atrial ser intensificado.Os pacientes com antecedente de cirurgia de Pacientes com cardiopatia cong\u00eanita de complexidade moderada ou grave apresentam risco ainda maior de MSC, correspondendo a aproximadamente 25% das causas de morte card\u00edaca.O risco de MSC \u00e9 maior entre os pacientes com doen\u00e7a card\u00edaca cong\u00eanita do adulto  em compDefeitos septais com hist\u00f3ria familiar, cardiomiopatia ou bloqueio do sistema de condu\u00e7\u00e3o podem estar relacionados com muta\u00e7\u00e3o do gene NKX2-5, que est\u00e1 associado a risco de MSC precoce, justificando implante de CDI quando o teste gen\u00e9tico \u00e9 positivo.Pacientes com formas complexas de cardiopatia cong\u00eanita e v\u00e1rias interven\u00e7\u00f5es cir\u00fargicas nas primeiras d\u00e9cadas de vida e aqueles que apresentam hipertrofia com subsequente isquemia subendoc\u00e1rdica apresentam maior risco de arritmias ventriculares potencialmente fatais. Outros fatores de risco para MSC em pacientes com cardiopatia cong\u00eanita incluem maior complexidade da cardiopatia, arritmias ventriculares e supraventriculares, aumento progressivo da dura\u00e7\u00e3o do QRS, disfun\u00e7\u00e3o ventricular sist\u00eamica e disfun\u00e7\u00e3o ventricular subpulmonar. Hist\u00f3ria de s\u00edncope inexplicada em adultos com cardiopatia cong\u00eanita de complexidade moderada ou grave pode ser ind\u00edcio de risco de MSC, devendo ser considerado o EEF para avaliar a necessidade de CDI. Em pacientes sem acesso vascular ou cirurgia deFontanpr\u00e9via, o risco de implante de CDI epic\u00e1rdico pode superar os benef\u00edcios potenciais, devendo-se considerar a possibilidade de CDI subcut\u00e2neo ou transplante card\u00edaco.Os adultos na faixa et\u00e1ria de 40 a 50 anos de idade representam 40% a 67% dos pacientes com cardiopatia cong\u00eanita que recebem CDI para preven\u00e7\u00e3o prim\u00e1ria. Nesses pacientes, choques apropriados ocorrem em 14% a 22% nos primeiros 3 a 5 anos de acompanhamento. Por outro lado, a amiodarona \u00e9 geralmente reservada para pacientes com arritmias sintom\u00e1ticas ou para prevenir piora da fun\u00e7\u00e3o ventricular.A seguran\u00e7a em rela\u00e7\u00e3o ao uso de f\u00e1rmacos antiarr\u00edtmicos em pacientes com cardiopatia cong\u00eanita pode ser influenciada pela presen\u00e7a de hipertrofia e disfun\u00e7\u00e3o ventricular. O uso de flecainida foi associado \u00e0 pr\u00f3-arritmia em 5,8% dos pacientes e MSC em 3,9% em um estudo.As principais recomenda\u00e7\u00f5es para indica\u00e7\u00e3o de CDI em pacientes adultos com cardiopatia cong\u00eanita est\u00e3o listadas naUma vez indicado o implante de CDI para preven\u00e7\u00e3o de MSC, as pr\u00f3ximas etapas consistem em escolher a t\u00e9cnica de implante  e escolher o modo de estimula\u00e7\u00e3o . Caso n\u00e3o seja necess\u00e1rio o suporte de bradicardia com indica\u00e7\u00e3o de MP , o CDI subcut\u00e2neo pode ser boa op\u00e7\u00e3o.Na aus\u00eancia de comunica\u00e7\u00e3o intracard\u00edaca, em pacientes com peso superior a 15kg, habitualmente, a prefer\u00eancia \u00e9 pela t\u00e9cnica transvenosa. Ademais, em pacientes que j\u00e1 apresentam remodelamento do VE no momento do implante  e que necessitar\u00e3o de estimula\u00e7\u00e3o ventricular, a estimula\u00e7\u00e3o biventricular \u00e9 superior \u00e0 estimula\u00e7\u00e3o isolada do VD.Nos pacientes que necessitam da fun\u00e7\u00e3o MP, a escolha do modo de estimula\u00e7\u00e3o \u00e9 fundamental. Modos que priorizam a preserva\u00e7\u00e3o da condu\u00e7\u00e3o atrioventricular e intraventricular espont\u00e2neas est\u00e3o associados a menor incid\u00eancia de FA e remodelamento ventricular relacionado ao BRE induzido pelo est\u00edmulo do VD.Assim sendo, diante da indica\u00e7\u00e3o de CDI, a escolha do modo de estimula\u00e7\u00e3o deve considerar se o cronotropismo e a condu\u00e7\u00e3o atrioventricular s\u00e3o normais, se a condu\u00e7\u00e3o intraventricular ocorre com padr\u00e3o de BRE espont\u00e2neo ou induzido por MP e se existe ou n\u00e3o remodelamento do VE.Em pacientes com DNS e condu\u00e7\u00e3o atrioventricular e intraventricular normais, pode-se optar tanto por CDI unicamerais quanto bicamerais, desde que sejam programados algoritmos de busca de condu\u00e7\u00e3o intr\u00ednseca para se evitar a dissincronia induzida pelo MP.Os CDI aumentam a sobrevida de pacientes com disfun\u00e7\u00e3o ventricular esquerda e risco de morte s\u00fabita card\u00edaca (MSC). No entanto, os custos dessa terapia s\u00e3o elevados e constituem limita\u00e7\u00e3o para sua aplica\u00e7\u00e3o. Esses custos referem-se ao dispositivo propriamente, gastos hospitalares, honor\u00e1rios m\u00e9dicos, complica\u00e7\u00f5es, reinterna\u00e7\u00f5es e trocas de gerador de pulsos e cabos-eletrodos.quality-adjusted life yearsou anos de vida ajustados por qualidade). Outra forma de an\u00e1lise de custo-efetividade refere-se ao custo por anos de vida ganhos. Essas an\u00e1lises variam de acordo com as condi\u00e7\u00f5es socioecon\u00f4micas e culturais da popula\u00e7\u00e3o estudada.A an\u00e1lise de custo-efetividade \u00e9 definida pelo custo em moeda corrente por QALY  n\u00e3o foi diferente entre o grupo que recebeu CDI e o grupo controle. No estudo CABG Patch, a popula\u00e7\u00e3o consistiu em pacientes com doen\u00e7a ateroscler\u00f3tica coronariana com FE \u2264 35%, ECG de alta resolu\u00e7\u00e3o alterado e que se submeteram \u00e0 cirurgia de revasculariza\u00e7\u00e3o mioc\u00e1rdica (CRVM). O implante profil\u00e1tico de CDI durante a CRVM tamb\u00e9m n\u00e3o mostrou redu\u00e7\u00e3o do desfecho prim\u00e1rio de morte por qualquer causa. Dessa forma, o implante profil\u00e1tico de CDI em pacientes com alto risco de morte s\u00fabita  n\u00e3o foi custo-efetivo nos primeiros 40 dias p\u00f3s infarto ou imediatamente ap\u00f3s CRVM.Nos estudos DINAMIT e CABG Patch trial, A rela\u00e7\u00e3o de custo-efetividade foi de R$ 68.318 por QALY no cen\u00e1rio da sa\u00fade p\u00fablica e R$ 90.942 por QALY na sa\u00fade suplementar. Os autores conclu\u00edram que o custo do CDI, o tempo para troca do gerador e a efetividade do CDI foram as vari\u00e1veis mais influentes na an\u00e1lise realizada. Em cen\u00e1rio com pacientes mais complexos, como os do estudo MADIT, a custo-efetividade foi bem mais favor\u00e1vel no cen\u00e1rio p\u00fablico  do que no privado .Um estudo brasileiro de Ribeiro et al., publicado em 2010, avaliou a custo-efetividade em pacientes com IC sob a perspectiva da sa\u00fade p\u00fablica e de sa\u00fade suplementar (a efetividade foi aferida em QALY). O estudo utilizou a unidade de custo por ano de vida ganho (AVG). O custo por AVG alcan\u00e7ado foi de R$ 20.530,00  na \u00e9poca. Esse indicador de efetividade foi calculado com base nos par\u00e2metros de custo incremental de R$ 54.200,00 e expectativa de vida de 2,64 anos, decorrente do uso do CDI comparado com tratamento cl\u00ednico. Concluiu-se que o \u00edndice de custo-efetividade foi favor\u00e1vel sob as condi\u00e7\u00f5es da realidade brasileira.Outro trabalho brasileiro, de Matos et al. (2007), analisou a rela\u00e7\u00e3o de custo-efetividade do CDI comparado com o tratamento medicamentoso. Os autores conclu\u00edram que o uso do CDI poderia ser custo-efetivo se utilizado para pacientes com baixa FEVE, incorporando subgrupos de mais alto risco, mas n\u00e3o para uso generalizado.No Reino Unido, Buxton et al. (2006) encontraram valores de \u00a3 57.000 por AVG e \u00a3 76.000 por QALY em longo per\u00edodo de acompanhamento. A estimativa m\u00e9dia de AVG e QALY foi de 1.88 e 1.57, respectivamente, e a estimativa m\u00e9dia de custo por QALY foi de \u20ac 31.717. Tais achados foram reproduzidos em outro registro europeu em an\u00e1lise de preven\u00e7\u00e3o prim\u00e1ria.Em 2009, Cowie et al. realizaram metan\u00e1lise de estudos de preven\u00e7\u00e3o prim\u00e1ria, no contexto europeu, em pacientes com FEVE reduzida e indica\u00e7\u00f5es conforme a diretrizes europeias. Nesse cen\u00e1rio, os autores tamb\u00e9m encontraram boa rela\u00e7\u00e3o de custo-efetividade. Fatores como efic\u00e1cia e seguran\u00e7a, impacto na qualidade de vida, custo do dispositivo (implante e trocas), caracter\u00edsticas dos pacientes e risco de MSC foram as vari\u00e1veis influenciadoras nessa an\u00e1lise.Gialama et al. (2014), em revis\u00e3o sistem\u00e1tica de avalia\u00e7\u00e3o econ\u00f4mica sobre o assunto, mostraram que o CDI pode apresentar boa custo-efetividade em grupos selecionados, sendo compar\u00e1vel a outras terapias cardiovasculares e n\u00e3o cardiovasculares j\u00e1 estabelecidas.et al. analisaram a custo-efetividade do CDI no estudo AVID, em que o CDI foi comparado ao tratamento antiarr\u00edtmico  em pacientes que sobreviveram \u00e0 TVS ou FV. A custo-efetividade do CDI por \u201canos de vida ganhos\u201d foi calculada em U$ 66.677,00 d\u00f3lares  comparada ao tratamento antiarr\u00edtmico para o per\u00edodo de 3 anos do estudo. A proje\u00e7\u00e3o para 6 e 20 anos manteve os custos estimados em cerca de US$ 68.000 e US$ 80.000 por anos de vida ganhos. Em an\u00e1lise de subgrupo, o CDI foi mais custo-efetivo nos pacientes com FV e menos com FE >35%.Larsenet al.avaliaram a custo-efetividade do CDI e demonstraram resultado aceit\u00e1vel em compara\u00e7\u00e3o com outros tratamentos pelo sistema de sa\u00fade p\u00fablica, como eritropoetina em pacientes dial\u00edticos, certas quimioterapias para leucemia em idosos, transplante de pulm\u00f5es e neurocirurgias para tumores malignos intracranianos. O custo por QALY foi semelhante ao de transplante de cora\u00e7\u00e3o, hemodi\u00e1lise e di\u00e1lise peritoneal. Deve-se considerar, ainda, que alguns fatores podem reduzir consideravelmente a custo-efetividade, como complica\u00e7\u00f5es, infec\u00e7\u00f5es e comorbidades que reduzam a sobrevida do paciente e a longevidade do CDI.Thjissen Dessa forma, programa\u00e7\u00f5es menos agressivas s\u00e3o capazes de melhorar a custo-efetividade dos CDI.Choques apropriados ou inapropriados podem reduzir a sobrevida e a qualidade de vida e, portanto, a custo-efetividade. V\u00e1rios estudos avaliaram a import\u00e2ncia da programa\u00e7\u00e3o do CDI, com tempo de detec\u00e7\u00e3o de TVS mais prolongado e frequ\u00eancia card\u00edaca de detec\u00e7\u00e3o mais elevada. Essas programa\u00e7\u00f5es foram capazes de prevenir choques inapropriados e choques \u201cdesnecess\u00e1rios\u201d, com melhora de sobrevida e/ou redu\u00e7\u00e3o de hospitaliza\u00e7\u00e3o. Os autores avaliaram a custo-efetividade em v\u00e1rios subgrupos de pacientes, com base em crit\u00e9rios cl\u00ednicos como a classe funcional, a dura\u00e7\u00e3o do QRS, a idade, a presen\u00e7a de BRE e a etiologia isqu\u00eamica. Considerando-se um custo aceit\u00e1vel at\u00e9 o limite de \u00a3 30.000 por QALY, os CDI foram custo-efetivos em pacientes com IC e disfun\u00e7\u00e3o sist\u00f3lica ventricular esquerda, em classe funcional NYHA < IV e QRS < 120ms. Para pacientes com QRS entre 120 e 149ms, o CDI foi custo-efetivo apenas nas NYHA I e II. Para pacientes em NYHA IV, a custo-efetividade s\u00f3 foi comprovada para CDI associado ao ressincronizador em pacientes com BRE e QRS >120ms.Mealings et al. analisaram 13 estudos de custo-efetividade de CDI e ressincronizadores e usaram um m\u00e9todo anal\u00edtico para adapta\u00e7\u00e3o do tratamento aos custos do Reino Unido. Dados de mundo real revelam que cerca de 8% a 12% dos implantes nos EUA e Canad\u00e1 ocorrem em pacientes com mais de 80 anos. A rela\u00e7\u00e3o morte s\u00fabita/morte por qualquer causa decresce com a idade, sendo de 0,51 em idade < 50 anos e de 0,26 para > 80 anos.Como o n\u00famero de acionamentos apropriados do CDI \u00e9 semelhante em todas as faixas et\u00e1rias, tanto na preven\u00e7\u00e3o prim\u00e1ria quanto na secund\u00e1ria, a rela\u00e7\u00e3o morte s\u00fabita/morte por qualquer causa diminui no idoso devido ao aumento das mortes relacionadas \u00e0s demais comorbidades.Em rela\u00e7\u00e3o aos pacientes muito idosos, particularmente > 80 anos, a efic\u00e1cia cl\u00ednica e a custo-efetividade do CDI s\u00e3o duvidosas. A idade m\u00e9dia de entrada dos pacientes nos estudos de preven\u00e7\u00e3o prim\u00e1ria e secund\u00e1ria foi de 58 a 66 anos e 58 a 65 anos, respectivamente. No entanto, estima-se que cerca de 28% dos pacientes eleg\u00edveis para implante de CDI tenham mais de 80 anos. Os pacientes foram estratificados para faixa et\u00e1ria < 65 anos, 65 a 75 anos e > 75 anos. Os pacientes com mais de 75 anos tiveram sobrevida m\u00e9dia de 5,3 anos ap\u00f3s o implante do CDI (metade dos outros dois grupos). Os autores calcularam que, para uma sobrevida menor que 5 anos, o custo por QALY subiria de U$ 34.000 a U$ 70.200 (no estudo de Sanders) para U$ 90.000 a U$ 250.000. Nesse caso, o CDI n\u00e3o seria custo-efetivo se o paciente morrer em menos de 5 anos ap\u00f3s o implante.Pellegrini et al. estudaram o impacto da idade no momento do implante do CDI na sobrevida.A rela\u00e7\u00e3o de custo-efetividade para o CDI no Brasil e em pa\u00edses em desenvolvimento precisa ser analisada dentro do contexto socioecon\u00f4mico, levando-se em conta aspectos locais, PIB, efic\u00e1cia e complica\u00e7\u00f5es. Nesse sentido, deve-se priorizar situa\u00e7\u00f5es que incluam pacientes de maior risco de morte por arritmia,fun\u00e7\u00e3o ventricular esquerda mais comprometida e menos comorbidades.A redu\u00e7\u00e3o do pre\u00e7o dos dispositivos e baterias mais duradouras pode aumentar significativamente a rela\u00e7\u00e3o de custo-efetividade. Da mesma forma, todos os esfor\u00e7os devem ser realizados para se evitar choques inapropriados ou desnecess\u00e1rios, o que melhora a qualidade de vida  e aumenta a longevidade da bateria.looperimplant\u00e1vel \u00e9 uma ferramenta diagn\u00f3stica bastante atrativa para investiga\u00e7\u00e3o de sintomas pouco frequentes  com caracter\u00edsticas suspeitas de serem atribu\u00eddos a bradi ou taquiarritmias.O monitor de eventos implant\u00e1vel \u00e9 um dispositivo que possibilita o monitoramento cont\u00ednuo do ritmo card\u00edaco independentemente da participa\u00e7\u00e3o ativa do paciente. Com capacidade de armazenamento de eventos diversos  e bateria com durabilidade de at\u00e9 cerca de 3 a 4 anos, o monitor de eventos oulooperimplant\u00e1vel demonstrou ser superior \u00e0 estrat\u00e9gia convencional de investiga\u00e7\u00e3o, incluindo o Tilt Test e o estudo eletrofisiol\u00f3gico invasivo. Particularmente em pacientes idosos e com dist\u00farbio da condu\u00e7\u00e3o intraventricular, a principal causa encontrada nesses estudos foi por bradiarritmia. Nesses casos, bradiarritmia foi encontrada em at\u00e9 41% dos casos, sendo 70% delas BAVT intermitente.Em pacientes com s\u00edncope inexplicada, em que a investiga\u00e7\u00e3o n\u00e3o invasiva inicial com ECG, Holter de 24 horas ou monitoriza\u00e7\u00e3o estendida n\u00e3o tenham esclarecido a natureza dos sintomas, oA detec\u00e7\u00e3o de FA nesses pacientes pode determinar mudan\u00e7a no tratamento, o que pode significar respaldo para anticoagula\u00e7\u00e3o plena por tempo indeterminado. Contudo, faltam estudos randomizados que corroborem a efic\u00e1cia da terapia anticoagulante em pacientes com FA silenciosa detectada por monitoriza\u00e7\u00e3o prolongada no AVC criptog\u00eanico.Em pacientes com AVC isqu\u00eamico criptog\u00eanico, em que n\u00e3o h\u00e1 documenta\u00e7\u00e3o de FA, a busca ativa com ECG seriado e monitoriza\u00e7\u00e3o prolongada pode detectar epis\u00f3dios silenciosos de FA em at\u00e9 cerca de 23% dos casos. Em 6 meses de seguimento, 8,9% dos pacientes com monitor implantado tiveram registro de FA com mais de 30s de dura\u00e7\u00e3o. Em 12 meses, esse n\u00famero chegou a 12%, enquanto, no grupo de seguimento convencional, foi detectado FA em 2% .O estudo Crystal AF randomizou 441 pacientes com AVC criptog\u00eanico ap\u00f3s investiga\u00e7\u00e3o inicial, para implante de monitor de eventos ou rastreamento convencional.late-breaking abstract6). Entre os pacientes com monitor implantado, epis\u00f3dios de FA com dura\u00e7\u00e3o superior a 2 minutos ocorreram em 12%versus1,8% . Pacientes com monitor implantado receberam maior n\u00famero de terapia de anticoagula\u00e7\u00e3o e menor recorr\u00eancia de AVC. Esses dados, embora limitados, pois n\u00e3o s\u00e3o estudos controlados para avaliar a compara\u00e7\u00e3o entre duas estrat\u00e9gias de interven\u00e7\u00e3o terap\u00eautica, sugerem algum benef\u00edcio na monitoriza\u00e7\u00e3o prolongada.O STROKE-AF trial incluiu 496 pacientes acima de 50 anos de idade e foi apresentado no International Stroke Conference (ISC) 2021  e familiares, sintomatologia e exame f\u00edsico, a avalia\u00e7\u00e3o cl\u00ednica deve incluir o ECG de 12 deriva\u00e7\u00f5es, fundamental para avaliar fun\u00e7\u00f5es de sensibilidade, captura e arritmias. O ecocardiograma, habitualmente realizado antes do implante, pode ser essencial durante o seguimento para monitorar o remodelamento do VE em virtude de poss\u00edveis efeitos delet\u00e9rios da estimula\u00e7\u00e3o cr\u00f4nica do VD e da s\u00edndrome de MP.A avalia\u00e7\u00e3o eletr\u00f4nica \u00e9 realizada por meio de telemetria e deve contemplar o gerador de pulsos, os cabos-eletrodos e a recupera\u00e7\u00e3o de informa\u00e7\u00f5es armazenadas na mem\u00f3ria do dispositivo, principalmente eventos arr\u00edtmicos e disfun\u00e7\u00f5es.A interroga\u00e7\u00e3o do sistema permite avaliar a dura\u00e7\u00e3o da bateria do gerador, integridade dos cabos-eletrodos e medidas dos limiares de estimula\u00e7\u00e3o e sensibilidade. A inibi\u00e7\u00e3o tempor\u00e1ria do MP confirma o ritmo intr\u00ednseco, fundamental para a melhor programa\u00e7\u00e3o do sistema. Dados estat\u00edsticos relacionados a cada c\u00e2mara card\u00edaca e os eventos arr\u00edtmicos devem ser acessados, bem como o registro dos eletrogramas intracavit\u00e1rios.A escolha do modo de estimula\u00e7\u00e3o deve considerar o ritmo intr\u00ednseco do paciente: sinusal normal, FA, DNS e/ou BAV.A estimula\u00e7\u00e3o unicameral ventricular (VVI) foi amplamente utilizada inicialmente, independentemente do tipo de bradicardia, devido a simplicidade e seguran\u00e7a. Mais de um quarto dos pacientes em estimula\u00e7\u00e3o VVI, contudo, desenvolve s\u00edndrome do MP , com comprometimento significativo da qualidade de vida. Dessa forma, na DNS, a estimula\u00e7\u00e3o atrial permite condu\u00e7\u00e3o AV e IV espont\u00e2neas, evitando perda do sincronismo atrioventricular, s\u00edndrome de MP e dissincronia IV secund\u00e1ria \u00e0 estimula\u00e7\u00e3o do VD.A estimula\u00e7\u00e3o atrial pode ser realizada em modo AAI ou DDD; neste \u00faltimo, pode-se preservar a condu\u00e7\u00e3o intr\u00ednseca por meio de algoritmos espec\u00edficos. O modo DDD tem mais complica\u00e7\u00f5es relacionadas a desposicionamento de cabos-eletrodos quando comparado ao VVI; por outro lado, dispositivos AAI apresentam o dobro de reopera\u00e7\u00f5es em rela\u00e7\u00e3o ao modo DDD, muitas vezes, devido ao desenvolvimento de BAV (progress\u00e3o da les\u00e3o). BAV em pacientes com DNS ocorre em 0,6% a 1,9% ao ano, resultando em necessidade de mudan\u00e7a do sistema para DDD.O modo AAI est\u00e1 relacionado a menor ocorr\u00eancia de FA e eventos tromboemb\u00f3licos em compara\u00e7\u00e3o ao modo VVI em pacientes com DNS. Resultados similares s\u00e3o observados em modo DDD, que tamb\u00e9m se associa a menores taxas de FA e melhor qualidade de vida que o modo VVI. Tais benef\u00edcios, no entanto, n\u00e3o impactam em desfechos de mortalidade, IC ou morte cardiovascular.back-upventricular), a fim de evitar estimula\u00e7\u00e3o desnecess\u00e1ria de VD em pacientes com condu\u00e7\u00e3o AV preservada. Dados iniciais com esses algoritmos apontam redu\u00e7\u00e3o significativa do percentual de estimula\u00e7\u00e3o ventricular  e de redu\u00e7\u00e3o de FA (40%). Pacientes com BAV de 1\u00ba grau associado a DNS podem perder esses benef\u00edcios quando o intervalo PR \u00e9 muito prolongado.O efeito delet\u00e9rio da estimula\u00e7\u00e3o artificial do VD pode resultar em IC e pior sobrevida como consequ\u00eancia de dissincronia induzida. Por isso, em MP bicameral, \u00e9 fundamental a programa\u00e7\u00e3o de algoritmos de preserva\u00e7\u00e3o da condu\u00e7\u00e3o AV intr\u00ednseca, que prolongam automaticamente o intervalo AV ou promovem a mudan\u00e7a do modo de estimula\u00e7\u00e3o para AAI . Esses sensores t\u00eam por objetivo aumentar FC em situa\u00e7\u00f5es de aumento da demanda metab\u00f3lica, como o exerc\u00edcio f\u00edsico. Tr\u00eas pequenos estudos demonstraram melhora na qualidade de vida e toler\u00e2ncia ao esfor\u00e7o com a ativa\u00e7\u00e3o do sensor, cujos resultados n\u00e3o foram reproduzidos no estudo ADEPT.automatic mode switch(AMS) consiste na revers\u00e3o do modo DDD(R) para VVI(R), em caso de surgimento de FA. Apesar de n\u00e3o haver fortes evid\u00eancia comprovando seu benef\u00edcio, recomenda-se a programa\u00e7\u00e3o, principalmente em pacientes com FA parox\u00edstica, para al\u00edvio de sintomas.A fun\u00e7\u00e3ovs.3,2%), especialmente desposicionamento, aumento de limiares e infec\u00e7\u00e3o.No BAV, a estimula\u00e7\u00e3o do VD, necess\u00e1ria, \u00e9 usualmente realizada em modo DDD ou VVI. O modo DDD mant\u00e9m sincronismo AV mas est\u00e1 relacionado a mais complica\u00e7\u00f5es ; dessa forma, esse modo \u00e9 alternativa aceit\u00e1vel para idosos com baixa expectativa de vida e restri\u00e7\u00e3o a atividades f\u00edsicas.Em estudos que comparam os modos DDD e VVI em pacientes com BAVT e DNS , o modo DDD n\u00e3o se associou a redu\u00e7\u00e3o de mortalidade e interna\u00e7\u00f5es cardiovasculares. O estudo CTOPP evidenciou redu\u00e7\u00e3o de FA com o modo DDD (benef\u00edcio maior em pacientes com DNS); entretanto, 26% dos casos em modo VVI apresentaram s\u00edndrome de MP, com necessidade deEm FA permanente, quando n\u00e3o h\u00e1 perspectiva de revers\u00e3o para ritmo sinusal, apenas a c\u00e2mara ventricular necessita de estimula\u00e7\u00e3o. Neste caso, o modo VVI(R) \u00e9 recomendado. O sensor de varia\u00e7\u00e3o de frequ\u00eancia se associa a melhor capacidade funcional e qualidade de vida em pequenos estudos.S\u00edncope neuromediada com resposta cardioinibit\u00f3ria caracteriza-se por per\u00edodos de bradicardia intermitente, necessitando de curtos per\u00edodos de estimula\u00e7\u00e3o artificial, com frequ\u00eancia b\u00e1sica elevada para compensar a s\u00fabita instabilidade que ocorre durante o evento. Nesses casos, a estimula\u00e7\u00e3o deve ser de curta dura\u00e7\u00e3o, apenas durante os epis\u00f3dios sintom\u00e1ticos (fun\u00e7\u00e3o histerese). Os modos utilizados podem ser DDI, DVI ou DDD com algoritmo para preserva\u00e7\u00e3o de condu\u00e7\u00e3o intr\u00ednseca. O modo VVI esteve mais associado \u00e0 ocorr\u00eancia de s\u00edncope e pr\u00e9-s\u00edncope que a estimula\u00e7\u00e3o bicameral (DDD e DVI) em alguns estudos.Rate Drop Response(RDR)\u00ae eSudden Bradi Response(SBR)\u00ae identificam redu\u00e7\u00f5es abruptas da frequ\u00eancia card\u00edaca, instituindo frequ\u00eancia de interven\u00e7\u00e3o acelerada a intervalos program\u00e1veis. Tais algoritmos s\u00e3o eficazes na redu\u00e7\u00e3o de sintomas em pacientes com s\u00edncope neuromediada (cardioinibit\u00f3ria), em compara\u00e7\u00e3o a tratamento convencional sem MP. Embora n\u00e3o tenham sido testados contra outros modos de estimula\u00e7\u00e3o, tais algoritmos s\u00e3o eficazes e possibilitam que o MP seja programado para manter-se inibido a maior parte do tempo. No estudo ISSUE III, a estimula\u00e7\u00e3o DDD + RDR reduziu em 57% a chance de recorr\u00eancia da s\u00edncope. O RDR foi programado para intervir quando a FC chegasse a 40bpm ou apresentasse queda de 20 batimentos em rela\u00e7\u00e3o \u00e0 FC basal (90bpm por 1 minuto).Algoritmos comoClosed Loop Selection(CLS)\u00ae utiliza a bioimped\u00e2ncia intramioc\u00e1rdica para avaliar a varia\u00e7\u00e3o da contratilidade mioc\u00e1rdica para prever o in\u00edcio da s\u00edncope e instituir a interven\u00e7\u00e3o .O algoritmo , com sensor de varia\u00e7\u00e3o de frequ\u00eancia desligado. Pacientes com FA devem ser programados em DDI na presen\u00e7a de eletrodo atrial, VVI se n\u00e3o houver eletrodo atrial, e DDD se houver FA parox\u00edstica. Nesses casos, a frequ\u00eancia sugerida \u00e9 de 60bpm na aus\u00eancia de incompet\u00eancia cronotr\u00f3pica.O modo de estimula\u00e7\u00e3o utilizado na maioria dos grandes estudos foi DDD ou VDD 35 a 60bpm, com objetivo de reduzir estimula\u00e7\u00e3o atrial, o que poderia comprometer o sincronismo atrioventricular em casos de condu\u00e7\u00e3o intra-atrial retardada, prejudicando o enchimento ventricular. Diretrizes de IC recomendam o uso de f\u00e1rmacos para redu\u00e7\u00e3o da FC quando est\u00e1 acima de 70bpm apesar de betabloqueadores, corroborando a programa\u00e7\u00e3o de frequ\u00eancias b\u00e1sicas baixas e sensores de frequ\u00eancia desligados rotineiramente.Intervalo AV curto, 100 a 120ms, visa atingir estimula\u00e7\u00e3o biventricular pr\u00f3ximo a 100%, evitando perda de captura biventricular associada a encurtamento do intervalo PR. O ajuste dos intervalos AV e VV pelo ecocardiograma, ou por outros m\u00e9todos, \u00e9 habitualmente reservado aos n\u00e3o respondedores, uma vez que falta consenso quanto \u00e0 real utilidade desses m\u00e9todos quando aplicados rotineiramente.A frequ\u00eancia m\u00e1xima de sincronismo atrioventricular deve ser programada ao m\u00e1ximo, considerando-se a FC m\u00e1xima predita para idade e eventuais limita\u00e7\u00f5es relacionadas \u00e0 cardiopatia de base.A abla\u00e7\u00e3o da FA parox\u00edstica e persistente (isolamento das veias pulmonares) deve ser considerada em pacientes com IC. A an\u00e1lise detalhada das situa\u00e7\u00f5es cl\u00ednicas que favorecem a indica\u00e7\u00e3o de abla\u00e7\u00e3o foge do escopo desta diretriz.Pacientes com estimula\u00e7\u00e3o acima de 93% t\u00eam redu\u00e7\u00e3o de 44% nas taxas de mortalidade e interna\u00e7\u00e3o por IC (desfechos combinados), sendo os melhores resultados alcan\u00e7ados acima de 98%. Batimentos de fus\u00e3o e pseudofus\u00e3o podem superestimar o percentual de estimula\u00e7\u00e3o biventricular. Em pacientes com FA, quando o controle da FC n\u00e3o \u00e9 alcan\u00e7ado com o tratamento cl\u00ednico otimizado, a abla\u00e7\u00e3o do n\u00f3 AV deve ser realizada, uma vez que se associa \u00e0 redu\u00e7\u00e3o de mortalidade.Extrass\u00edstoles ventriculares est\u00e3o relacionadas \u00e0 redu\u00e7\u00e3o na taxa de estimula\u00e7\u00e3o biventricular e redu\u00e7\u00e3o do remodelamento reverso, mesmo com incid\u00eancia relativamente baixa. F\u00e1rmacos antiarr\u00edtmicos e, eventualmente, abla\u00e7\u00e3o devem ser considerados em pacientes n\u00e3o respondedores.Intervalos atrioventriculares curtos resultam em s\u00edstole ventricular precoce, n\u00e3o permitindo que a fase de contra\u00e7\u00e3o atrial ocorra integralmente (onda A truncada). Nesses casos \u00e9 necess\u00e1rio prolongar o intervalo AV at\u00e9 que a onda A fique evidente. Intervalos AV prolongados, inversamente, geram fus\u00e3o das ondas E e A. Nesses casos, \u00e9 necess\u00e1rio encurtamento do intervalo AV.Dois m\u00e9todos s\u00e3o habitualmente recomendados para o ajuste do intervalo AV: o m\u00e9todo interativo e o m\u00e9todo de Ritter. No m\u00e9todo interativo, programa-se intervalo AV longo (200ms) e reduz-se gradativamente (20ms por vez) at\u00e9 60ms analisando o fluxo mitral. O menor intervalo AV capaz de manter as ondas E e A sepradas (sem fus\u00e3o), sem deforma\u00e7\u00e3o da onda A e mantendo 40ms de dist\u00e2ncia do final da onda A ao in\u00edcio do QRS \u00e9 o intervalo AV \u00f3timo. O m\u00e9todo de Ritter \u00e9 realizado aferindo o intervalo QA  em dois intervalos AV diferentes, um curto (60ms) e um longo (200ms). O intervalo AV ideal \u00e9 calculado pela f\u00f3rmula IAV = IAV longo \u2013 (QA[IAVcurto] \u2013 QA[IAV longo]). Assim, recomenda-se realizar ECO com avalia\u00e7\u00e3o do fluxo mitral ap\u00f3s implante para analisar o sincronismo atrioventricular: se as ondas E e A se apresentarem separadas e o intervalo do final da onda A acima de 40ms, n\u00e3o h\u00e1 necessidade de ajuste de intervalo AV.O intervalo VV pode ser programado empiricamente, ou ajustado tamb\u00e9m por ECO, ECG e algoritmos espec\u00edficos. Com ECO, o ajuste \u00e9 realizado testando-se diversos intervalos e avaliando a dissincronia. O intervalo que resultar em menor dissincronia deve ser o intervalo VV programado. Deve-se testar estimula\u00e7\u00e3o simult\u00e2nea, estimula\u00e7\u00e3o precoce no VE e diferentes intervalos VV, 60, 40, 20ms. Posteriormente, deve-se testar os mesmos intervalos com estimula\u00e7\u00e3o precoce do VD. Os m\u00e9todos mais utilizados s\u00e3o o modo M, com ou sem doppler tissular, e a velocidade de encurtamento longitudinal do VE, aferida pelo Doppler tissular.Assim como o ajuste do intervalo AV, a programa\u00e7\u00e3o do intervalo VV guiado por ECO deve ser realizada em n\u00e3o respondedores e em condi\u00e7\u00f5es espec\u00edficas.Alguns dispositivos disp\u00f5em de algoritmos autom\u00e1ticos de ajuste de IAV e IVV, cuja efic\u00e1cia ainda \u00e9 controversa. De qualquer forma, n\u00e3o parecem ser inferiores ao ajuste emp\u00edrico ou guiado pelo ECO.Correla\u00e7\u00e3o entre diminui\u00e7\u00e3o da dura\u00e7\u00e3o do QRS com a estimula\u00e7\u00e3o biventricular e a taxa de respondedores foi evidenciada em estudos retrospectivos, dando suporte \u00e0 hip\u00f3tese de que ajuste de intervalo AV e VV visando a QRS mais curto pode aumentar a taxa de resposta \u00e0 TRC.versusestimula\u00e7\u00e3o convencional, com resultados semelhantes entre as duas formas de programa\u00e7\u00e3o, signific\u00e2ncia estat\u00edstica para n\u00e3o inferioridade. No entanto, entre os pacientes com estimula\u00e7\u00e3o multiponto com 30mm de dist\u00e2ncia entre os dois pontos de estimula\u00e7\u00e3o de VE e com o menor intervalo (5ms), houve menor taxa de n\u00e3o respondedores. Esses resultados foram reproduzidos na primeira fase do estudo MORE-CRT e, mais uma vez, os pacientes com programa\u00e7\u00e3o de 30mm de dist\u00e2ncia entre os pontos de estimula\u00e7\u00e3o do VE associado ao menor intervalo intra e interventricular apresentaram melhores resultados.A estimula\u00e7\u00e3o multiponto fundamenta-se no princ\u00edpio de estimular as regi\u00f5es com ativa\u00e7\u00e3o mais tardia do VE, por meio de eletrodo quadripolar, especialmente \u00e1reas basais e apicais, permitindo ativa\u00e7\u00e3o de maior massa ventricular de forma mais r\u00e1pida e homog\u00eanea. O estudo MPP trial comparou a estimula\u00e7\u00e3o multipontos com eletrodo quadripolarA programa\u00e7\u00e3o do CDI deve ser voltada a quatro princ\u00edpios b\u00e1sicos: 1) reduzir a mortalidade por meio da terapia efetiva na revers\u00e3o de arritmias ventriculares potencialmente fatais; 2) priorizar a revers\u00e3o de arritmias ventriculares por meio das terapias antitaquicardia sem choque (ATP), sempre que poss\u00edvel; 3) evitar choques inapropriados; e 4) reduzir ao m\u00e1ximo o percentual de estimula\u00e7\u00e3o artificial do VD (terapia antibradicardia).antitachycardia pacing [ATP]) que podem reverter TV monom\u00f3rficas sem a aplica\u00e7\u00e3o de choques, de modo indolor e com redu\u00e7\u00e3o do dano mioc\u00e1rdico eventualmente provocado pelos choques.As terapias apropriadas para revers\u00e3o de FV e TV sustentadas s\u00e3o os pilares da redu\u00e7\u00e3o de mortalidade na interven\u00e7\u00e3o com CDI. Para isso, devem ser programadas terapias escalonadas em diferentes zonas de frequ\u00eancia, classificadas como TV (1 ou 2 zonas) e FV. As terapias program\u00e1veis incluem choques (at\u00e9 35 ou 40J) e terapias com estimula\u00e7\u00e3o artificial de 3 a 20 pulsos com frequ\u00eancia superior \u00e0 da taquicardia . Estudos subsequentes comprovaram ser desnecess\u00e1ria essa estrat\u00e9gia, uma vez que medidas intraoperat\u00f3rias normais  se correlacionam com efetividade adequada na revers\u00e3o de arritmias de ocorr\u00eancia espont\u00e2nea.Burst) ou com acelera\u00e7\u00e3o entre os pulsos (Ramp).\u00c9 bem conhecida a efic\u00e1cia do ATP como primeira linha nas arritmias ventriculares. Taquicardias ventriculares monom\u00f3rficas, organizadas, com ciclo est\u00e1vel e especialmente sem repercuss\u00e3o hemodin\u00e2mica, podem ser facilmente revertidas com ATP, incluindo pulsos com intervalo fixo , podem ser interrompidas com ATP antes do disparo de choques programados naquela zona. Nesse caso, uma tentativa de ATP durante ou antes do carregamento da energia de choque \u00e9 programada; em caso de revers\u00e3o da arritmia, o choque \u00e9 abortado. O estudo PainFREE II utilizou o ATP como primeira linha de tratamento em zona de 188 a 250bpm, com redu\u00e7\u00e3o significativa de 71% do risco relativo de choque, sem comprometimento da seguran\u00e7a dos pacientes.Para isso, os princ\u00edpios b\u00e1sicos de programa\u00e7\u00e3o devem incluir:A programa\u00e7\u00e3o adequada de detec\u00e7\u00e3o e terapia escalonada \u00e9 capaz de reduzir choques inapropriados, proporcionar mais terapia apropriada com ATP e reduzir a mortalidade.Zona de FV programada com frequ\u00eancia acima de 233bpm , com pelo menos 30 batimentos em 40 (x em y) para detec\u00e7\u00e3o. Essa estrat\u00e9gia permite evitar choques em arritmias n\u00e3o sustentadas e choques inapropriados em situa\u00e7\u00f5es de ru\u00eddos intermitentes, dupla contagem ou extrassistolia isolada.Em pacientes de preven\u00e7\u00e3o prim\u00e1ria, uma \u00fanica zona de detec\u00e7\u00e3o de FV pode ser suficiente. Zonas de monitoramento de TV sem terapias (monitor) podem ser programadas a crit\u00e9rio m\u00e9dico. Nos casos de preven\u00e7\u00e3o secund\u00e1ria, terapias focadas para TV devem ser programadas com corte de detec\u00e7\u00e3o de 10-20bpm menores que a frequ\u00eancia da taquicardia documentada. De acordo com o crit\u00e9rio cl\u00ednico, podem ser programada zonas de terapia com frequ\u00eancia mais baixa, na depend\u00eancia do risco de TV mais lenta, sempre priorizando o ATP.oversensing,como a detec\u00e7\u00e3o de onda T.Algoritmos de monitoramento de ru\u00eddos e danos dos cabos-eletrodos devem ser programados, assim como recursos de autoajuste e supress\u00e3o deBostonScientific) eTimeout, sejam desabilitados, pois esses recursos ignoram a discrimina\u00e7\u00e3o de um evento classificado como TSV ap\u00f3s o per\u00edodo preestabelecido e liberam a terapia que seria inapropriada.Programa\u00e7\u00e3o adequada dos algoritmos de discrimina\u00e7\u00e3o de arritmias supraventriculares, especificamente no crit\u00e9rio de avalia\u00e7\u00e3o da morfologia nos dispositivos unicamerais e na avalia\u00e7\u00e3o de algoritmos baseados na rela\u00e7\u00e3o atrioventricular nos dispositivos bicamerais. \u00c9 interessante que os limitadores de tempo, como SRD  ou da programa\u00e7\u00e3o de intervalo AV longo o suficiente para evitar a estimula\u00e7\u00e3o ventricular desnecess\u00e1ria. Em pacientes com necessidade de estimula\u00e7\u00e3o ventricular por bloqueio da condu\u00e7\u00e3o AV, deve-se considerar, de acordo com a fun\u00e7\u00e3o ventricular, a possibilidade de estimula\u00e7\u00e3o de s\u00edtios alternativos como a estimula\u00e7\u00e3o biventricular (TRC) ou do sistema excito-condutor (His/ramo esquerdo).undersensing) e semoversensingde ru\u00eddos que prejudiquem a identifica\u00e7\u00e3o do ritmo.O monitor de eventos implant\u00e1vel deve ser programado de maneira adequada a detectar a atividade el\u00e9trica ventricular, sem perdas de sensibilidade sinal  por 16 ou mais batimentos;Fibrila\u00e7\u00e3o atrial: > 2 minutos classificado como ritmo de FA.undersensingintermitente do QRS. Em estudo recente, a an\u00e1lise de 695 transmiss\u00f5es espont\u00e2neas ou agendadas, Afzal et al. encontraram at\u00e9 81% de falsos eventos.A programa\u00e7\u00e3o adequada do crit\u00e9rio de detec\u00e7\u00e3o e a an\u00e1lise posterior dos tra\u00e7ados \u00e9 fundamental na otimiza\u00e7\u00e3o do monitoramento.\u00c9 necess\u00e1ria a adjudica\u00e7\u00e3o cuidadosa dos epis\u00f3dios registrados no monitor, uma vez que falsas detec\u00e7\u00f5es podem estar presentes na mem\u00f3ria. Epis\u00f3dios classificados como FA, por exemplo, podem ser mal classificados em virtude de varia\u00e7\u00f5es de intervalo RR por extrassistolia ventricular ouweb\u00e9 uma realidade no seguimento dos portadores de DCEI. A transmiss\u00e3o de dados \u00e9 poss\u00edvel via conex\u00e3o do dispositivo a uma banda larga de internet ou, em dispositivos mais recentes, viabluetoothconectado a um smartphone. Por meio dessa tecnologia, \u00e9 poss\u00edvel acessar diversos par\u00e2metros de programa\u00e7\u00e3o como frequ\u00eancia e modo de estimula\u00e7\u00e3o, energia de estimula\u00e7\u00e3o, par\u00e2metros de detec\u00e7\u00e3o e sensibilidade, assim como registros de diagn\u00f3sticos estatusda bateria.O monitoramento remoto viaA transmiss\u00e3o de dados precisa ser ajustada, pois algumas informa\u00e7\u00f5es ser\u00e3o transmitidas de forma ativa ap\u00f3s acionamento de algum alarme, ou de forma passiva atrav\u00e9s do acionamento pelo paciente ou, ainda, de forma programada, mediante cronograma de transmiss\u00f5es. O acesso remoto \u00e0s informa\u00e7\u00f5es \u00e9 disponibilizado ao servi\u00e7o que acompanha o paciente mediante acesso privado ao servidor do sistema e resguardadas as garantias de privacidade de dados do paciente.Publica\u00e7\u00f5es recentes t\u00eam mostrado aumento da incid\u00eancia de processos infecciosos relacionados a DCEI. Fatores demogr\u00e1ficos e cl\u00ednicos, como o envelhecimento populacional e comorbidades, podem influenciar tanto as contamina\u00e7\u00f5es hematog\u00eanicas quanto aquelas diretamente relacionadas ao implante e troca dos dispositivos. Um levantamento recente conduzido pela EHRA demonstrou que infec\u00e7\u00f5es relacionadas a DCEI s\u00e3o mais frequentes ap\u00f3s reopera\u00e7\u00f5es, inclusive trocas isoladas de gerador de pulsos.Os consensos mais recentes t\u00eam chamado a aten\u00e7\u00e3o para a necessidade de padroniza\u00e7\u00e3o de condutas e para a forma\u00e7\u00e3o de times de especialistas para a abordagem desse tipo particular e pouco frequente de infec\u00e7\u00e3o, com a finalidade de mitigar as controv\u00e9rsias entre especialistas, ainda frequentes.Essa contamina\u00e7\u00e3o pode ocorrer durante bacteremia causada por foco infeccioso distante, como tromboflebite s\u00e9ptica, osteomielite, pneumonia, infec\u00e7\u00e3o do s\u00edtio cir\u00fargico, cateteres vasculares contaminados ou infec\u00e7\u00e3o bacteriana originada da pele, boca, trato gastrointestinal ou urin\u00e1rio.Processos infecciosos que envolvem DCEI manifestam-se de duas formas principais: envolvimento da loja do gerador de pulsos ou exclusivamente intravascular. O acometimento exclusivo da loja \u00e9 mais frequente, ocorrendo em aproximadamente 60% dos casos . A eros\u00e3o da pele tardiamente pode ocorrer devido a/ou resultar em infec\u00e7\u00e3o da loja; em ambos os casos, a infec\u00e7\u00e3o pode progredir para infec\u00e7\u00e3o sist\u00eamica. O acometimento da loja associado \u00e0 infec\u00e7\u00e3o intravascular ocorre em aproximadamente 20% das infec\u00e7\u00f5es e habitualmente \u00e9 secund\u00e1rio \u00e0 demora ou a condutas inadequadas. O acometimento intravascular exclusivo tamb\u00e9m ocorre em cerca de 20% dos casos, por contamina\u00e7\u00e3o sangu\u00ednea na maior parte das vezes. NaUm consenso de especialistas, encabe\u00e7ado pela EHRA e endossado por outras sociedades internacionais, teve como objetivo principal definir a terminologia que deve ser utilizada em registros e estudos cl\u00ednicos para a abordagem terap\u00eautica das infec\u00e7\u00f5es e remo\u00e7\u00e3o de DCEI.O diagn\u00f3stico definitivo de infec\u00e7\u00e3o relacionada a DCEI baseia-se em tr\u00eas achados principais: 1) presen\u00e7a de cole\u00e7\u00e3o purulenta ou exterioriza\u00e7\u00e3o do DCEI ao exame cl\u00ednico; 2) crescimento de microrganismos em hemoculturas e 3) presen\u00e7a de vegeta\u00e7\u00f5es na valva tric\u00faspide ou em cabos-eletrodos evidenciada pelo ecocardiograma transesof\u00e1gico (ETE). Quando n\u00e3o se consegue definir o diagn\u00f3stico da infec\u00e7\u00e3o relacionada ao DCEI com esses crit\u00e9rios, outros exames complementares (como PET-CT) podem ser necess\u00e1rios. Os crit\u00e9rios modificados da Duke University para diagn\u00f3stico de infec\u00e7\u00e3o de DCEI est\u00e3o elencados nas Tabelas 40 e 41.A comprova\u00e7\u00e3o de que o DCEI est\u00e1 definitivamente contaminado \u00e9 fundamental para o tratamento adequado do paciente, uma vez que, comprovada a contamina\u00e7\u00e3o, sua remo\u00e7\u00e3o completa ser\u00e1 fundamental para o sucesso do tratamento. Por outro lado, se n\u00e3o houver o DCEI, estiver livre de contamina\u00e7\u00e3o e o processo infeccioso estiver relacionado a outro foco, a remo\u00e7\u00e3o desnecess\u00e1ria do dispositivo implicar\u00e1 custo desnecess\u00e1rio e risco cir\u00fargico relacionado \u00e0 extra\u00e7\u00e3o dos cabos-eletrodos. O fluxograma para diagn\u00f3stico e tratamento de infec\u00e7\u00f5es de DCEI est\u00e1 representado naExames de imagem s\u00e3o importantes tanto para o diagn\u00f3stico quanto para a condu\u00e7\u00e3o do tratamento. Nesse sentido, algumas informa\u00e7\u00f5es obtidas por imagem podem ser relevantes: 1) identifica\u00e7\u00e3o do tipo de DCEI; 2) identifica\u00e7\u00e3o de cabos-eletrodos abandonados; 3) achado de vegeta\u00e7\u00f5es intracard\u00edacas e seu tamanho; 4) sinais sugestivos de emboliza\u00e7\u00e3o s\u00e9ptica para os pulm\u00f5es.No caso de febre em portador de DCEI em que n\u00e3o se consegue definir infec\u00e7\u00e3o pela avalia\u00e7\u00e3o da loja do gerador, hemoculturas ou ecocardiografia transesof\u00e1gica e exames de imagem baseados na capta\u00e7\u00e3o de radiof\u00e1rmacos podem ser importantes.Embora a remo\u00e7\u00e3o completa do gerador de pulsos e de todos os cabos-eletrodos seja essencial, o tratamento da infec\u00e7\u00e3o deve ser feito, fundamentalmente, com o uso de antimicrobianos. A escolha do antibi\u00f3tico deve ser estabelecida a partir das culturas de sangue, de fragmentos da loja e dos cabos-eletrodos removidos. Quando n\u00e3o \u00e9 poss\u00edvel a defini\u00e7\u00e3o do microrganismo, o uso emp\u00edrico de antibi\u00f3ticos deve ser definido por crit\u00e9rios cl\u00ednicos. Da mesma forma, o tempo de tratamento tamb\u00e9m deve ser definido em fun\u00e7\u00e3o do quadro cl\u00ednico, sempre contado a partir da remo\u00e7\u00e3o completa do DCEI .A remo\u00e7\u00e3o completa do DCEI \u00e9 fundamental para evitar a recorr\u00eancia da infec\u00e7\u00e3o. A extra\u00e7\u00e3o dos cabos-eletrodos, entretanto, raramente deve ser considerada emerg\u00eancia, mesmo em choque s\u00e9ptico. \u00c0 exce\u00e7\u00e3o dos implantes recentes que costuma ser tecnicamente mais f\u00e1cil, a extra\u00e7\u00e3o somente dever\u00e1 ser realizada quando o paciente estiver com boas condi\u00e7\u00f5es hemodin\u00e2micas e com o quadro infeccioso estabilizado, face aos riscos associados ao procedimento (ader\u00eancias \u00e0s veias e ao cora\u00e7\u00e3o).A t\u00e9cnica de extra\u00e7\u00e3o dos cabos-eletrodos deve ser preferencialmente transvenosa, exceto quando os cabos-eletrodos s\u00e3o epic\u00e1rdicos ou quando houver vegeta\u00e7\u00e3o intracavit\u00e1ria maior que 2,5cm em seu maior di\u00e2metro. As recomenda\u00e7\u00f5es para remo\u00e7\u00e3o do gerador de pulsos e dos cabos-eletrodos est\u00e3o listadas naO implante do novo DCEI deve ser realizado somente ap\u00f3s remiss\u00e3o completa do processo infeccioso, e deve ser definido em fun\u00e7\u00e3o do quadro cl\u00ednico. At\u00e9 que o quadro infeccioso seja totalmente debelado, pacientes dependentes de estimula\u00e7\u00e3o artificial devem ser mantidos com MP tempor\u00e1rio. Pacientes n\u00e3o dependentes devem permanecer sob monitoramento do ritmo card\u00edaco, at\u00e9 que o implante seja realizado. Em alguns casos, o implante do novo DCEI pode n\u00e3o ser necess\u00e1rio devido \u00e0 altera\u00e7\u00e3o no padr\u00e3o da doen\u00e7a ou por mudan\u00e7a de conduta. Por isso, a reavalia\u00e7\u00e3o da necessidade do DCEI \u00e9 sempre fundamental. As recomenda\u00e7\u00f5es relacionadas ao implante do novo DCEI est\u00e3o listadas naV\u00e1rios fatores de risco para o desenvolvimento de infec\u00e7\u00e3o relacionada ao DCEI t\u00eam sido detectados. Esses fatores podem estar relacionados ao pr\u00f3prio indiv\u00edduo, a procedimentos m\u00e9dicos realizados ou ao pr\u00f3prio DCEI. Os principais fatores para infe\u00e7\u00e3o de DCEI est\u00e3o listados naCuidados preventivos s\u00e3o fundamentais para a redu\u00e7\u00e3o da ocorr\u00eancia de infec\u00e7\u00f5es relacionadas a procedimentos m\u00e9dicos nesses indiv\u00edduos. NaIdosos, crian\u00e7as e adultos com cardiopatias cong\u00eanitas representam subgrupos que merecem aten\u00e7\u00e3o especial quanto \u00e0 possibilidade de infec\u00e7\u00e3o de DCEI. Loja submuscular em pacientes com pouco tecido subcut\u00e2neo para preven\u00e7\u00e3o de eros\u00e3o da pele \u00e9 fundamental. Em pacientes pedi\u00e1tricos, especialmente com cardiopatia cong\u00eanita, o operador deve ter experi\u00eancia em abordagens cir\u00fargicas m\u00faltiplas e alternativas. CDI extravascular ou subcut\u00e2neo deve ser considerado em crian\u00e7a de menor idade, pacientes com cardiopatia cong\u00eanita e com acesso venoso limitado ou inexistente. demonstra taxa de infec\u00e7\u00e3o de DCEI superior ao reportado em estudos prospectivos . Este fen\u00f4meno pode estar relacionado \u00e0 maior ades\u00e3o a procedimentos preventivos nos estudos cl\u00ednicos em compara\u00e7\u00e3o ao que ocorre na pr\u00e1tica cl\u00ednica di\u00e1ria. Dentre os fatores operat\u00f3rios mais relacionados ao risco de infec\u00e7\u00e3o, destacam-se o hematoma de loja, os procedimentos de longa dura\u00e7\u00e3o e as reinterven\u00e7\u00f5es para reposicionamento de cabo-eletrodo. Especificamente sobre reopera\u00e7\u00f5es para troca de gerador de pulsos, corre\u00e7\u00e3o de disfun\u00e7\u00e3o de cabos-eletrodos ou mudan\u00e7a de modo de estimula\u00e7\u00e3o, o adequado tratamento da loja do gerador de pulsos, seja pela remo\u00e7\u00e3o completa da carapa\u00e7a fibrosa ou pelo uso de envelope antibacteriano, reduz a ocorr\u00eancia de infec\u00e7\u00f5es.Curioso destacar que a an\u00e1lise de registros retrospectivosA profilaxia antibi\u00f3tica pr\u00e9-operat\u00f3ria, com o uso de uma dose de cefalosporina de primeira gera\u00e7\u00e3o (cefazolina), \u00e9 fortemente recomend\u00e1vel, o que n\u00e3o ocorre quanto ao uso sistem\u00e1tico de antibi\u00f3tico no per\u00edodo p\u00f3s-operat\u00f3rio.O intervalo de tempo entre o diagn\u00f3stico e o tratamento adequado da infec\u00e7\u00e3o relacionada a DCEI \u00e9 fundamental. Dados da literatura mostram que se a remo\u00e7\u00e3o do dispositivo for feita at\u00e9 3 dias ap\u00f3s a hospitaliza\u00e7\u00e3o, tanto o tempo de interna\u00e7\u00e3o quanto a mortalidade hospitalar s\u00e3o significativamente reduzidos. Nesse sentido, quando n\u00e3o existem dados suficientes para o estabelecimento do diagn\u00f3stico de infec\u00e7\u00e3o, baseada na tr\u00edade composta por sinais infecciosos na loja do gerador de pulsos, crescimento bacteriano nas hemoculturas e identifica\u00e7\u00e3o de vegeta\u00e7\u00f5es no ecocardiograma esof\u00e1gico, outros recursos devem ser utilizados.S. aureusna presen\u00e7a de DCEI. Pun\u00e7\u00e3o aspirativa e desbridamento cir\u00fargico em casos de infec\u00e7\u00e3o da loja do gerador, como tentativa para evitar a extra\u00e7\u00e3o de cabo-eletrodo, devem ser fortemente desencorajados.Recomenda-se a varredura por [18F] PET/CT FDG ou cintilografia WBC radiomarcada ou TC com contraste se houver suspeita de endocardite infecciosa relacionada ao DCEI, hemoculturas positivas e ecocardiografia negativa ou nos casos de bacteremia porPara monitorar o n\u00famero de casos de infec\u00e7\u00e3o relacionada a DCEI e o resultado das atitudes preventivas e terap\u00eauticas, \u00e9 fundamental a implementa\u00e7\u00e3o de grandes registros, n\u00e3o volunt\u00e1rios, de f\u00e1cil preenchimento e com grande qualidade. Cada servi\u00e7o deve estabelecer rotinas para o diagn\u00f3stico preciso e tratamento em tempo adequado. A reavalia\u00e7\u00e3o constante do desempenho de cada centro \u00e9 altamente recomend\u00e1vel.A necessidade de remover cabos-eletrodos de DCEI cresceu nos \u00faltimos anos em fun\u00e7\u00e3o, principalmente, de dois fatores: 1) crescimento da taxa de infec\u00e7\u00f5es relacionadas a DCEI e 2) desenvolvimento dos MP e CDI multiss\u00edtios, que utilizam maior n\u00famero de cabos-eletrodos.As indica\u00e7\u00f5es para a remo\u00e7\u00e3o de cabos-eletrodos podem ser: (a) obrigat\u00f3rias, como no tratamento de infec\u00e7\u00f5es; (b) necess\u00e1rias, para obten\u00e7\u00e3o de acesso para novos cabos-eletrodos em pacientes com oclus\u00f5es venosas; ou (c) opcionais, como em pacientes com acesso venoso adequado, quando s\u00e3o submetidos \u00e0 substitui\u00e7\u00e3o de cabo-eletrodo.Como a maioria dos dispositivos necessita de acesso venoso para o implante dos cabos-eletrodos, as t\u00e9cnicas de extra\u00e7\u00e3o transvenosa s\u00e3o as mais utilizadas. Na atualidade, a abertura do t\u00f3rax para a remo\u00e7\u00e3o de cabos-eletrodos \u00e9 muito pouco utilizada, sendo necess\u00e1ria, quase exclusivamente, para a retirada de cabos-eletrodos epic\u00e1rdicos ou para a corre\u00e7\u00e3o de complica\u00e7\u00f5es que ocorrem em extra\u00e7\u00f5es transvenosas.O panorama atual da extra\u00e7\u00e3o de cabos-eletrodos mostra indica\u00e7\u00f5es e t\u00e9cnicas operat\u00f3rias bem estabelecidas. As ferramentas utilizadas est\u00e3o bem desenvolvidas e os resultados dos diferentes procedimentos s\u00e3o bem conhecidos, com altas taxas de sucesso. Complica\u00e7\u00f5es catastr\u00f3ficas, entretanto, podem ocorrer durante procedimentos de extra\u00e7\u00e3o. Tais complica\u00e7\u00f5es, embora raras, s\u00e3o potencialmente letais e costumam requerer cirurgia a c\u00e9u aberto de emerg\u00eancia.Neste item, s\u00e3o apresentadas as recomenda\u00e7\u00f5es para extra\u00e7\u00e3o em pacientes n\u00e3o infectados, uma vez que o manejo de infec\u00e7\u00f5es j\u00e1 foi abordado.A remo\u00e7\u00e3o de cabos-eletrodos epic\u00e1rdicos \u00e9 feita, obrigatoriamente, pela reabertura da cavidade tor\u00e1cica, preferencialmente pelo mesmo acesso por onde o eletrodo foi implantado. A remo\u00e7\u00e3o de cabos-eletrodos transvenosos deve ser feita, preferencialmente, por acesso intravascular. Excepcionalmente, pode ser necess\u00e1ria uma abordagem transtor\u00e1cica, com ou sem o aux\u00edlio de circula\u00e7\u00e3o extracorp\u00f3rea, como na falha da extra\u00e7\u00e3o transvenosa ou quando existem grandes vegeta\u00e7\u00f5es aderidas aos cabos-eletrodos. A escolha do tipo de abordagem para a extra\u00e7\u00e3o transvenosa de cabos-eletrodos depende, fundamentalmente, da possibilidade de se obter acesso ao cabo-eletrodo alvo da remo\u00e7\u00e3o. Infelizmente, muitos pacientes s\u00e3o portadores de cabos-eletrodos completamente intravasculares, por ter apresentado fratura espont\u00e2nea do cabo ou por iatrogenia durante procedimentos de remo\u00e7\u00e3o.venous entry site approach). Essa abordagem consiste na introdu\u00e7\u00e3o na veia de uma bainha que \u00e9 guiada pelo pr\u00f3prio cabo-eletrodo a ser removido. Essa bainha \u00e9 utilizada para desfazer as ader\u00eancias que se formam entre o cabo-eletrodo e o endot\u00e9lio venoso ou o endoc\u00e1rdio. Quando o paciente tem mais que um cabo-eletrodo transvenoso implantado, frequentemente, existem ader\u00eancias entre os cabos. Ap\u00f3s se desfazerem todas as ader\u00eancias e se atingir o local onde o eletrodo est\u00e1 fixado ao cora\u00e7\u00e3o, essa mesma bainha \u00e9 utilizada para se fazer press\u00e3o contra o m\u00fasculo card\u00edaco enquanto se traciona o cabo-eletrodo (manobra de contratra\u00e7\u00e3o). Existem v\u00e1rias ferramentas especificamente desenvolvidas para esse tipo de abordagem, a saber:Quando o cabo-eletrodo a ser removido est\u00e1 \u00edntegro ou apresenta um segmento extravascular, por menor que esse segmento seja, devemos utilizar a abordagem pelo local de entrada do eletrodo na veia (locking stylets), que s\u00e3o estiletes revestidos por uma fina malha de a\u00e7o que se expande na luz do cabo-eletrodo conferindo a este a sustenta\u00e7\u00e3o necess\u00e1ria para sua tra\u00e7\u00e3o.Guias de travamento (Bainhas para dissec\u00e7\u00e3o de ader\u00eancia e contratra\u00e7\u00e3o:Bainhas mec\u00e2nicas n\u00e3o energizadas(non-powered sheaths): conjuntos de tubos r\u00edgidos met\u00e1licos e tubos flex\u00edveis de teflon ou polipropileno, utilizados para desfazer ader\u00eancias por dissec\u00e7\u00e3o romba, com intensidade determinada pela for\u00e7a da m\u00e3o do m\u00e9dico que faz o procedimento.Bainhas mec\u00e2nicas com l\u00e2minas rotacionais:seccionam as ader\u00eancias e s\u00e3o ativadas por um gatilho na m\u00e3o do operador ou por um motor el\u00e9trico.Bainhas energizadas por raios LASER: seccionam as ader\u00eancias por foto-abla\u00e7\u00e3o. As Tabelas 46 e 47 mostram as defini\u00e7\u00f5es recomendadas para as ferramentas e para as abordagens usadas em extra\u00e7\u00e3o de cabos-eletrodos.Quando o cabo-eletrodo que precisa ser removido n\u00e3o apresenta um segmento extravascular, torna-se obrigat\u00f3ria a sua captura intravascular. Existem ferramentas com o formato de la\u00e7o ou de cesta, feitas com arames met\u00e1licos muito male\u00e1veis, desenvolvidas para capturar esses fragmentos. Tais ferramentas s\u00e3o introduzidas habitualmente por pun\u00e7\u00e3o das veias femoral ou jugular. Uma vez capturado, o cabo-eletrodo pode ser tracionado diretamente. Em casos espec\u00edficos, pode ser necess\u00e1rio associar manobra de contratra\u00e7\u00e3o ap\u00f3s a captura do cabo-eletrodo.remo\u00e7\u00e3otem sido utilizado, genericamente, para designar a retirada de cabos-eletrodos de DCEI, independentemente do tipo de abordagem. Pode ser realizada pela simples tra\u00e7\u00e3o de um cabo-eletrodo transvenoso, sem a utiliza\u00e7\u00e3o de nenhuma ferramenta; por toracotomia, para a retirada de cabo-eletrodo epic\u00e1rdico ou por toracotomia com o aux\u00edlio de circula\u00e7\u00e3o extracorp\u00f3rea para a retirada de cabo-eletrodo transvenoso. O termoextra\u00e7\u00e3odeve ser utilizado exclusivamente para os casos em que t\u00e9cnicas e ferramentas s\u00e3o utilizadas para: 1) dilatar o trajeto por onde o cabo-eletrodo passa no interior das veias; 2) desfazer ader\u00eancias; 3) realizar manobra de contratra\u00e7\u00e3o ou 4) capturar fragmentos de cabos-eletrodos no interior dos vasos ou das cavidades card\u00edacas.O termoA conclus\u00e3o de um procedimento de remo\u00e7\u00e3o ou de extra\u00e7\u00e3o de cabo-eletrodo pode resultar em: 1) retirada completa do cabo-eletrodo-alvo; 2) retirada parcial; ou 3) insucesso da retirada. Dependendo do tipo de indica\u00e7\u00e3o para a retirada do cabo-eletrodo, pode-se considerar que houve sucesso cl\u00ednico do procedimento, mesmo que nem todo o cabo-eletrodo tenha sido removido. Considera-se que houve falha do procedimento quando: 1) n\u00e3o \u00e9 obtido o sucesso cl\u00ednico; 2) ocorre qualquer complica\u00e7\u00e3o permanentemente incapacitante ou 3) ocorre a morte do paciente. NaDiversos motivos podem justificar a desativa\u00e7\u00e3o de um cabo-eletrodo: 1) perda da capacidade de estimular adequadamente o cora\u00e7\u00e3o; 2) necessidade de se mudar o tipo de dispositivo e 3) problemas relacionados \u00e0 sua fabrica\u00e7\u00e3o.in locoa crit\u00e9rio da equipe m\u00e9dica que opera o paciente. Existem, entretanto, desvantagens de se abandonar um cabo-eletrodo: 1) risco de fen\u00f4menos tromb\u00f3ticos; 2) restri\u00e7\u00f5es para realiza\u00e7\u00e3o de exames de RM; 3) aumento do risco em extra\u00e7\u00e3o futura, uma vez que, quanto maior for o tempo de perman\u00eancia do cabo-eletrodo, maior ser\u00e1 o risco de insucesso da extra\u00e7\u00e3o. O principal argumento para se abandonarin loco um cabo-eletrodo n\u00e3o infectado \u00e9 o risco de complica\u00e7\u00f5es graves associadas ao procedimento de extra\u00e7\u00e3o. Uma publica\u00e7\u00e3o recente mostra que a expectativa de sobreviv\u00eancia no primeiro ano que se segue a um procedimento de troca de eletrodo \u00e9 semelhante para os casos em que se realiza a extra\u00e7\u00e3o ou o abandonoin loco do cabo-eletrodo. Diante disso, na atualidade, a decis\u00e3o de se extrair ou n\u00e3o um cabo-eletrodo que ser\u00e1 desativado depende, essencialmente, daexpertisede cada servi\u00e7o. NaCabos-eletrodos n\u00e3o infectados podem ser abandonadosA durabilidade de um DCEI depende tanto de aspectos relacionados \u00e0 sua fabrica\u00e7\u00e3o  quanto de seu modo de utiliza\u00e7\u00e3o. Cabos-eletrodos, especificamente, sofrem influ\u00eancia direta da t\u00e9cnica operat\u00f3ria utilizada, que pode influenciar negativamente sua durabilidade. Independentemente desses fatos, estrat\u00e9gias espec\u00edficas de tecnovigil\u00e2ncia devem ser adotadas pelos fabricantes e pelas ag\u00eancias regulat\u00f3rias para avaliar a durabilidade dos componentes dos DCEI.in locode cabos-eletrodos por disfun\u00e7\u00e3o, necessidade de mudan\u00e7a do modo de estimula\u00e7\u00e3o ou, de maneira inadequada, para o tratamento de uma infec\u00e7\u00e3o relacionada a DCEI, cuidados devem ser seguidos, uma vez que a forma como esse cabo-eletrodo \u00e9 abandonado pode dificultar sua extra\u00e7\u00e3o no futuro. Recomenda\u00e7\u00f5es para o abandono de cabos-eletrodos est\u00e3o listadas naAo se optar pelo abandonoEm determinadas situa\u00e7\u00f5es cl\u00ednicas, a retirada de um cabo-eletrodo n\u00e3o infectado pode ser obrigat\u00f3ria, tais como: 1) para o tratamento da s\u00edndrome da veia cava superior provocada pela presen\u00e7a de cabos-eletrodos; 2) para o tratamento de arritmia card\u00edaca grave provocada mecanicamente por um fragmento de cabo-eletrodo; 3) para evitar uma les\u00e3o card\u00edaca por um cabo-eletrodo fraturado ou 4) para permitir o tratamento radioter\u00e1pico na regi\u00e3o em que o dispositivo est\u00e1 implantado.Outras vezes, a extra\u00e7\u00e3o de um cabo-eletrodo pode ser necess\u00e1ria, como nos casos em que oclus\u00e3o ou obstru\u00e7\u00e3o venosa grave impedem a passagem de um novo cabo-eletrodo.expertisedo profissional que realiza o procedimento \u00e9 mandat\u00f3ria para a defini\u00e7\u00e3o da conduta. NaEm muitos casos, entretanto, a extra\u00e7\u00e3o dos cabos-eletrodos \u00e9 opcional, e pode ser definida por um conjunto de fatores menos objetivos, tais como: 1) idade do paciente ou sua expectativa de vida; 2) necessidade futura de realizar exames de RM; 3) risco de desenvolver obstru\u00e7\u00f5es venosas graves; ou 4) risco de infec\u00e7\u00e3o pela via hematog\u00eanica, como ocorre em pacientes com insufici\u00eancia renal dial\u00edtica. Nessas ocasi\u00f5es, aDurante um procedimento de extra\u00e7\u00e3o transvenosa de cabos-eletrodo, veias ou estruturas card\u00edacas podem ser lesionadas. Les\u00f5es das veias axilares ou subcl\u00e1vias, dos troncos venosos braquiocef\u00e1licos ou da veia cava superior podem provocar hemorragia grave com necessidade de transfus\u00e3o sangu\u00ednea ou at\u00e9 mesmo corre\u00e7\u00e3o cir\u00fargica. Avuls\u00e3o muscular do \u00e1trio direito ou do VD, assim como perfura\u00e7\u00e3o de veia tribut\u00e1ria do seio coron\u00e1rio, pode acarretar tamponamento card\u00edaco. A lacera\u00e7\u00e3o da veia cava superior em seu trajeto extraperic\u00e1rdico, entretanto, \u00e9 a complica\u00e7\u00e3o catastr\u00f3fica mais frequente e mais letal. Outras complica\u00e7\u00f5es, como arritmias card\u00edacas autolimitadas, pneumot\u00f3rax ou reten\u00e7\u00e3o de fragmentos de cabos-eletrodos, tamb\u00e9m podem ocorrer e necessitar de cuidados espec\u00edficos.De maneira geral, as complica\u00e7\u00f5es s\u00e3o agrupadas em maiores e menores, em fun\u00e7\u00e3o de sua gravidade e do tipo de corre\u00e7\u00e3o que demandam. Na NaV\u00e1rios estudos t\u00eam sido desenhados para identificar fatores de risco determinantes da morbimortalidade relacionada \u00e0 extra\u00e7\u00e3o transvenosa de cabos-eletrodos. Esses estudos t\u00eam demonstrado baixa taxa de ocorr\u00eancia de complica\u00e7\u00f5es catastr\u00f3ficas e de morte perioperat\u00f3ria, n\u00e3o permitindo a identifica\u00e7\u00e3o de fatores de risco para esses eventos. Por outro lado, v\u00e1rios fatores demogr\u00e1ficos, cl\u00ednicos e cir\u00fargicos est\u00e3o associados \u00e0 mortalidade nos 30 primeiros dias que se seguem a um procedimento de extra\u00e7\u00e3o. Fatores associados a complica\u00e7\u00f5es e morte tardias tamb\u00e9m foram identificados. mostra a estreita rela\u00e7\u00e3o entre o n\u00famero de procedimentos realizados pelo m\u00e9dico e a taxa de complica\u00e7\u00f5es associadas \u00e0 extra\u00e7\u00e3o de eletrodos. Operadores em in\u00edcio de experi\u00eancia devem realizar os primeiros 40 procedimentos de extra\u00e7\u00e3o transvenosa sob a supervis\u00e3o de operadores mais experientes. Recomenda-se um volume m\u00ednimo de 20 procedimentos de extra\u00e7\u00e3o transvenosa por ano, a fim de manuten\u00e7\u00e3o da capacidade t\u00e9cnica, para todos os operadores.Diante da dificuldade de se prever a ocorr\u00eancia de complica\u00e7\u00f5es catastr\u00f3ficas perioperat\u00f3rias, torna-se fundamental a preven\u00e7\u00e3o da morte relacionada a esses eventos, o que implica treinamento dos profissionais envolvidos e capacita\u00e7\u00e3o t\u00e9cnica dos servi\u00e7os que realizam extra\u00e7\u00e3o de cabos-eletrodo. Uma revis\u00e3o sistem\u00e1tica recenteA eletrocirurgia compreende o uso de corrente alternada de alta frequ\u00eancia , que \u00e9 convertida em calor ao sofrer resist\u00eancia ao passar pelos tecidos, o que permite efetuar os efeitos desej\u00e1veis: coagula\u00e7\u00e3o e corte. O bisturi el\u00e9trico \u00e9 usado na maioria das especialidades cir\u00fargicas.Por ser mais efetiva, a eletrocirurgia monopolar \u00e9 a mais empregada na pr\u00e1tica. Nessa modalidade, o eletrodo ativo est\u00e1 no s\u00edtio cir\u00fargico (haste do bisturi), enquanto o eletrodo indiferente \u00e9 uma placa colocada em contato com a pele do paciente, em local afastado. A corrente flui entre os eletrodos, atravessando o corpo.Um n\u00famero crescente de pacientes com DCEI \u00e9 submetido a interven\u00e7\u00f5es cir\u00fargicas, o que exp\u00f5e esses pacientes \u00e0s interfer\u00eancias eletromagn\u00e9ticas. A eletrocirurgia monopolar pode provocar v\u00e1rias anormalidades nos DCEI, tais como reprograma\u00e7\u00e3o do gerador de pulsos, inibi\u00e7\u00e3o tempor\u00e1ria da estimula\u00e7\u00e3o, deflagra\u00e7\u00e3o de estimula\u00e7\u00e3o em frequ\u00eancia elevada, deple\u00e7\u00e3o da bateria e falha de estimula\u00e7\u00e3o, dano ao circuito, aumento de limiares, e disparo de terapia inapropriada (choques) em caso de CDI.Para minimizar os riscos do uso do eletrocaut\u00e9rio, alguns cuidados devem ser tomados no perioperat\u00f3rio: (1) a aplica\u00e7\u00e3o do bisturi monopolar deve ser intermitente, em pulsos de curta dura\u00e7\u00e3o e com menor energia; (2) a placa indiferente deve ser posicionada em local de modo que a energia n\u00e3o flua atrav\u00e9s do gerador ou eletrodos. Em cirurgia de cabe\u00e7a e pesco\u00e7o, a placa indiferente do bisturi monopolar deve ser colocada na parte posterior do ombro contralateral \u00e0 da loja do dispositivo. Assim, por exemplo, no caso de gerador implantado na regi\u00e3o infraclavicular esquerda, a placa do bisturi deve ser colocada sob o ombro direto.Em geral, quando o s\u00edtio cir\u00fargico \u00e9 localizado acima da cicatriz umbilical ou a uma dist\u00e2ncia menor que 15cm do gerador, o uso de bisturi monopolar deve ser evitado. Nesse cen\u00e1rio, deve-se preferir o bisturi bipolar, que \u00e9 seguro, mas que tamb\u00e9m n\u00e3o deve ser aplicado diretamente sobre o gerador. A aplica\u00e7\u00e3o do \u00edm\u00e3 sobre a loja do gerador causa a revers\u00e3o do MP para o modo ass\u00edncrono, ou seja, desabilita a sensibilidade e modifica a frequ\u00eancia de estimula\u00e7\u00e3o para a frequ\u00eancia magn\u00e9tica, que \u00e9 geralmente maior que a frequ\u00eancia b\u00e1sica programada.Com a finalidade de proteger o paciente e o DCEI dos efeitos indesej\u00e1veis do eletrocaut\u00e9rio, duas abordagens t\u00eam sido empregadas: aposi\u00e7\u00e3o de magneto sobre o gerador de pulsos e reprograma\u00e7\u00e3o do dispositivo antes do procedimento. Em caso de MP, o uso do magneto durante a cirurgia \u00e9 op\u00e7\u00e3o quando o gerador desativar o circuito de sensibilidade sob efeito magn\u00e9tico (modo ass\u00edncrono) e apresentar bateria em bom estado.versusa reprograma\u00e7\u00e3o em pacientes com CDI submetidos \u00e0 cirurgia utilizando eletrocaut\u00e9rio monopolar, a uma dist\u00e2ncia maior de 15 cm do gerador; os autores conclu\u00edram que as duas estrat\u00e9gias s\u00e3o seguras. A aplica\u00e7\u00e3o do magneto sobre a loja do CDI desabilita somente a terapia para as taquiarritmias, n\u00e3o alterando a fun\u00e7\u00e3o de MP. No paciente com CDI e dependente de MP, o dispositivo deve ser reprogramado para modo ass\u00edncrono, antes do procedimento. A reprograma\u00e7\u00e3o do DCEI deve ser realizada logo antes da interven\u00e7\u00e3o cir\u00fargica e revertida para a programa\u00e7\u00e3o basal logo ap\u00f3s o t\u00e9rmino do procedimento  tem se apresentado como ferramenta diagn\u00f3stica cada vez mais \u00fatil e acess\u00edvel, com crescente relev\u00e2ncia para avalia\u00e7\u00e3o diagn\u00f3stica e progn\u00f3stica.O n\u00famero de exames de RM apresentou um crescimento substancial nos \u00faltimos 20 anos, com mais de 60 milh\u00f5es de exames anualmente ao redor do mundo. Estima-se que um paciente tem 50% a 75% de probabilidade de receber indica\u00e7\u00e3o de realiza\u00e7\u00e3o de RM ap\u00f3s implante de um DCEI durante o tempo de vida do dispositivo.et al. e adotado pelo2017 HRS expert consensus. A zona 4 refere-se \u00e0 sala do exame, sendo o espa\u00e7o com maior risco para pacientes e equipe de sa\u00fade, incluindo o risco potencial de deslocamento de objetos met\u00e1licos. A zona 3 \u00e9 o espa\u00e7o fora da sala de exame, incluindo a sala de controle. Existe, nessa \u00e1rea, um risco potencial, devendo ser reservada a pessoal treinado. A zona 2 inclui \u00e1rea de recep\u00e7\u00e3o, e a zona 1 corresponde \u00e0s regi\u00f5es acess\u00edveis ao p\u00fablico geral.O ambiente de realiza\u00e7\u00e3o do exame pode ser dividido em zonas, conforme descrito por KanalCom rela\u00e7\u00e3o aos DCEI durante a realiza\u00e7\u00e3o de RM, podem ser definidos como:Seguros: n\u00e3o representam perigo para realiza\u00e7\u00e3o da RM.Condicionados: n\u00e3o representam perigo para realiza\u00e7\u00e3o da RM, desde que atendidas determinadas especifica\u00e7\u00f5es. Tais condi\u00e7\u00f5es podem incluir par\u00e2metros como: regi\u00e3o do corpo a ser examinada, for\u00e7a do campo magn\u00e9tico, gradiente espacial, tempo de exposi\u00e7\u00e3o ao campo magn\u00e9tico, campo de radiofrequ\u00eancia e taxa de absor\u00e7\u00e3o espec\u00edfica. Condi\u00e7\u00f5es adicionais podem ser requeridas, incluindo uso de combina\u00e7\u00f5es espec\u00edficas de gerador e eletrodos, bem como modo de programa\u00e7\u00e3o do dispositivo. As condi\u00e7\u00f5es espec\u00edficas podem variar entre fabricantes e entre aparelhos de um mesmo fabricante.N\u00e3o condicionados: representam perigo para realiza\u00e7\u00e3o da RM. Incluem todos os sistemas de estimula\u00e7\u00e3o card\u00edaca que n\u00e3o s\u00e3o condicionados para realiza\u00e7\u00e3o do exame. Isso inclui geradores condicionados associados a eletrodos n\u00e3o condicionados ou sistemas totalmente condicionados implantados em pacientes que n\u00e3o preenchem todas as condi\u00e7\u00f5es espec\u00edficas de uso, como aqueles com eletrodos abandonados.seguro, e os novos DCEI que foram constru\u00eddos com tecnologia apropriada s\u00e3o consideradoscondicionadospara realiza\u00e7\u00e3o do exame.Os DCEI n\u00e3o s\u00e3o classificados comoNa pr\u00e1tica cl\u00ednica, os aparelhos precisam ser programados antes da realiza\u00e7\u00e3o de RM, com um n\u00edvel de seguran\u00e7a bastante aceit\u00e1vel.oversensing, undersensinge arritmias. A influ\u00eancia desses par\u00e2metros nos DCEI pode ser dividida em dois grupos: os que prejudicam o funcionamento do DCEI de maneira transit\u00f3ria e os que o fazem de modo permanente.A intera\u00e7\u00e3o do campo magn\u00e9tico est\u00e1tico, gradiente magn\u00e9tico e radiofrequ\u00eancia sobre o DCEI pode prejudicar o funcionamento de componentes eletr\u00f4nicos, causar migra\u00e7\u00e3o ou deslocamento de componentes do sistema, gera\u00e7\u00e3o de corrente de energia que pode danificar o aparelho e/ou o mioc\u00e1rdio e provocarAs respostas a essas fontes de interfer\u00eancia podem ser variadas:Campo magn\u00e9tico est\u00e1tico: deslocamento do dispositivo, ativa\u00e7\u00e3o de sensores, perda s\u00fabita da fun\u00e7\u00e3o do dispositivo, mudan\u00e7as no ECG.Gradiente de campo magn\u00e9tico: indu\u00e7\u00e3o de arritmias (raro); oversensingouundersensing.Campo de radiofrequ\u00eancia: aquecimento tissular adjacente aos eletrodos; indu\u00e7\u00e3o de arritmias (raro); reprograma\u00e7\u00e3o do dispositivo (reset); intera\u00e7\u00f5es deoversensingouundersensing.Efeitos combinados: perda s\u00fabita da fun\u00e7\u00e3o do dispositivo; altera\u00e7\u00e3o de fun\u00e7\u00e3o (par\u00e2metros); for\u00e7as mec\u00e2nicas (vibra\u00e7\u00e3o);resetdo dispositivo; dano do gerador e/ou dos eletrodos.Relacionados \u00e0 imagem: artefatos que prejudiquem a imagem adequada do dispositivo.As intera\u00e7\u00f5es potenciais entre DCEI e interfer\u00eancia eletromagn\u00e9tica pela RM incluem:Campo magn\u00e9tico induzido e torque devido a materiais ferromagn\u00e9ticos: movimento de gerador \u00e9 extremamente improv\u00e1vel pelo confinamento e pelo tecido subcut\u00e2neo adjacente. Eletrodos n\u00e3o cont\u00eam material ferromagn\u00e9tico suficiente para causar movimentos.Corrente el\u00e9trica induzida por gradiente de campo magn\u00e9tico: gradientes de campo magn\u00e9tico podem induzir corrente, o que pode levar a captura mioc\u00e1rdica e, potencialmente, causar arritmias atriais ou ventriculares.Calor e dano tecidual: campos de radiofrequ\u00eancia podem levar a aquecimento de componentes n\u00e3o condicionados, levando a aquecimento e dano t\u00e9rmico ao tecido adjacente . Mudan\u00e7as de sensibilidade e limiar de captura podem ocorrer como resultado do dano tecidual pr\u00f3ximo aos eletrodos.Efeitos na atividade do dispositivo: o dispositivo de estimula\u00e7\u00e3o card\u00edaca pode ser programado por meio da coloca\u00e7\u00e3o de um \u00edm\u00e3, liberando o dispositivo para a intera\u00e7\u00e3o. Os campos magn\u00e9ticos podem, portanto, afetar a atividade de um dispositivo condicional, com possibilidade de alterar a programa\u00e7\u00e3o do dispositivo.Resetel\u00e9trico: a interfer\u00eancia eletromagn\u00e9tica de alta energia pode levar aresetel\u00e9trico. Pode ocorrer acionamento de um modo de demanda debackup. Os par\u00e2metros deresetde energia variam de acordo com o fornecedor e o tipo de dispositivo e podem incluir um conjunto de varia\u00e7\u00f5es. Inibi\u00e7\u00e3o da fun\u00e7\u00e3o de estimula\u00e7\u00e3o por sinais gerados por RM ou energia de estimula\u00e7\u00e3o abaixo do limiar (bipolar ou unipolar) em um paciente dependente de MP pode ocorrer. Al\u00e9m disso, ostatusda bateria pode ser afetado, principalmente para dispositivos pr\u00f3ximos de um intervalo de substitui\u00e7\u00e3o eletiva (ERI), que pode resultar em fun\u00e7\u00f5es n\u00e3o confi\u00e1veis.Fun\u00e7\u00f5es inapropriadas e terapias: interfer\u00eancias eletromagn\u00e9ticas por pulsos de radiofrequ\u00eancia ou mudan\u00e7as r\u00e1pidas de gradientes de campo magn\u00e9tico podem causaroversensingque podem levar \u00e0 inibi\u00e7\u00e3o inapropriada da estimula\u00e7\u00e3o e possibilidade de assistolia em pacientes dependentes de estimula\u00e7\u00e3o do MP, ou indu\u00e7\u00e3o de terapias levando a choques inapropriados em pacientes com CDI.Esses efeitos s\u00e3o influenciados por v\u00e1rios fatores, incluindo for\u00e7a do campo magn\u00e9tico, pot\u00eancia de RF, posi\u00e7\u00e3o do paciente e do dispositivo em rela\u00e7\u00e3o \u00e0 m\u00e1quina de RM, caracter\u00edsticas do dispositivo e tamanho do paciente.Tradicionalmente, a realiza\u00e7\u00e3o de RM em portadores de DCEI costumava ser contraindicada. O primeiro sistema condicionado para a realiza\u00e7\u00e3o de RM foi introduzido na Europa em 2010 e liberado pelo Food and Drug Administration (FDA) em 2011, nos EUA.softwareque reduzem ou eliminam potenciais efeitos adversos. Uma vez acionada a programa\u00e7\u00e3o especial (modo RM), o aparelho reverte o modo de estimula\u00e7\u00e3o para ass\u00edncrono e aumenta a energia de estimula\u00e7\u00e3o para evitar inibi\u00e7\u00e3o da estimula\u00e7\u00e3o ou falha de captura durante o exame. Nos CDI, a fun\u00e7\u00e3o antitaquicardia \u00e9 desabilitada temporariamente. No momento do exame, portanto, esses pacientes est\u00e3o desprotegidos em caso de arritmias ventriculares.Para tornarem-se condicionados para RM, os DCEI sofreram mudan\u00e7as estruturais  e altera\u00e7\u00f5es deA decis\u00e3o de realizar RM em um paciente com DCEI envolve riscos e benef\u00edcios; assim, os fatores potenciais de risco devem ser identificados. Em pacientes com DCEI condicionais, o exame pode ser realizado sem riscos adicionais ao paciente, seguindo recomenda\u00e7\u00f5es e protocolos estabelecidos.Antes da realiza\u00e7\u00e3o do exame, \u00e9 importante identificar o ritmo de base do paciente e se o paciente \u00e9 dependente de MP, ativar a programa\u00e7\u00e3o espec\u00edfica para a realiza\u00e7\u00e3o de RM; confirmar se todo o sistema \u00e9 condicional para RM; verificar presen\u00e7a de eletrodos abandonados ou epic\u00e1rdicos.De modo geral, a maioria dos sistemas \u00e9 aprovada para exames de RM de 1,5T, gradiente com taxa de varia\u00e7\u00e3o de 200 T/m/s, SAR m\u00e1xima de SAR 2 W/kg, n\u00famero limitado de sequ\u00eancias e comprimento de imagens. Em novos dispositivos, o exame pode ser tamb\u00e9m seguro sob condi\u00e7\u00f5es mais amplas. A maioria dos sistemas novos permite o exame de RM do corpo inteiro.Um sistema condicional de RM consiste em uma combina\u00e7\u00e3o de eletrodos e gerador que foi especificamente testada para garantir condi\u00e7\u00f5es de uso seguras durante o exame. A presen\u00e7a de qualquer componente do dispositivo que n\u00e3o atenda aos crit\u00e9rios de condicionalidade de RM o classifica como n\u00e3o condicional. Isso inclui um gerador condicional de RM combinado com componentes n\u00e3o condicionais e sistemas de dispositivos que combinam componentes individuais de eletrodos e gerador condicionais de RM de v\u00e1rios fabricantes, dado que essas n\u00e3o s\u00e3o combina\u00e7\u00f5es especificamente testadas em conjunto para a seguran\u00e7a do exame.A rotulagem de condicional tamb\u00e9m especifica a localiza\u00e7\u00e3o do gerador: localiza\u00e7\u00e3o peitoral para sistemas transvenosos. Outros exemplos de componentes n\u00e3o condicionais incluem eletrodos epic\u00e1rdicos, eletrodos abandonados, eletrodos fraturados ou um dispositivo n\u00e3o card\u00edaco ativo.A programa\u00e7\u00e3o do dispositivo fora do modelo de programa\u00e7\u00e3o condicional para RM tamb\u00e9m torna o dispositivo n\u00e3o condicional. O estado da bateria deve estar adequado para considerar o dispositivo condicional .N\u00famero crescente de pacientes que se submetem \u00e0 RT \u00e9 portador de DCEI. Embora a ocorr\u00eancia de disfun\u00e7\u00f5es induzidas por RT seja rara, recomenda\u00e7\u00f5es de seguran\u00e7a s\u00e3o importantes.complementary metal-oxide-semiconductor) do gerador. A gera\u00e7\u00e3o secund\u00e1ria de n\u00eautrons \u00e9 a maior preditora de disfun\u00e7\u00e3o dos DCEI no contexto da RT. Os geradores de pulsos mais modernos t\u00eam menor consumo de energia e circuitos menores, constitu\u00eddos de metal semicondutor. Isso leva a maior suscetibilidade desses dispositivos a poss\u00edveis danos causados por radia\u00e7\u00e3o ionizante.A radia\u00e7\u00e3o ionizante pode causar interfer\u00eancia em componentes do CMOS , que pode ser corrigida com a reprograma\u00e7\u00e3o, \u00e9 uma das disfun\u00e7\u00f5es mais relatadas. Defeitos permanentes tamb\u00e9m podem ocorrer, como a perda da telemetria e deple\u00e7\u00e3o prematura da bateria. A fal\u00eancia do dispositivo, com perda completa da fun\u00e7\u00e3o do DCEI, j\u00e1 foi descritain vitro.Altas doses de radia\u00e7\u00e3o, especialmente com energia > 6MV, podem ocasionar erros deDisfun\u00e7\u00f5es dos dispositivos s\u00e3o relatadas em at\u00e9 3% dos cursos de RT. Eventos clinicamente relevantes s\u00e3o muito raros, dependem do tipo de dispositivo e da toler\u00e2ncia do paciente \u00e0s altera\u00e7\u00f5es. Por exemplo, o paciente dependente de MP pode apresentar bradicardia e sintomas relacionados.\u00c9 importante considerar, ainda, que os defeitos nos DCEI podem aparecer semanas ou meses ap\u00f3s o t\u00e9rmino da RT (defeitos latentes).O planejamento da RT deve considerar as especifica\u00e7\u00f5es do DCEI, bem como as caracter\u00edsticas dos pacientes  .Muitas evid\u00eancias cient\u00edficas surgiram desde a publica\u00e7\u00e3o das \u00faltimas diretrizes brasileiras de DCEI da SBC/SOBRAC. A evolu\u00e7\u00e3o da tecnologia e do pr\u00f3prio conhecimento deve estar alinhada com a pr\u00e1tica cl\u00ednica e com a aten\u00e7\u00e3o \u00e0 sa\u00fade p\u00fablica. Dessa maneira, o presente documento destaca a evolu\u00e7\u00e3o do tratamento das arritmias card\u00edacas, mas n\u00e3o se furta em destacar a necessidade premente do uso racional dos recursos financeiros em favor do bem maior, qual seja, a sa\u00fade coletiva. 1. General Recommendations 81.1 Operating Room 81.1.1. Human Resources81.1.2. Material Resources91.1.2.1. Fluoroscopy91.1.2.2. Monitoring91.1.2.3. Surgical Instruments91.2. CIED Evaluation and Programming Clinic 91.3. Clinical Evaluation Prior to CIED Implantation 91.4. Surgical Procedure and Types of CIED 92. Recommendations for Conventional Pacemaker Implantation 102.1. Sinus Node Disease 102.2. Atrioventricular and Intraventricular Blocks 122.2.1. Atrioventricular Blocks122.2.2. Intraventricular Blocks with 1:1 Atrioventricular Conduction142.3. Carotid Sinus Syndrome 142.4. Vasovagal Syndrome 162.5. Hypertrophic Cardiomyopathy 162.6. Neuromuscular Diseases 172.7 Obstructive Sleep Apnea Syndrome 182.8. Congenital Long QT Syndrome 182.9. Cardiac Transplantation 192.10. Choosing the Type of Pacemaker and Pacing Mode 202.11. Direct Stimulation of the Cardiac Conduction System  202.12. Leadless Pacing 213. Recommendations for Multisite Pacemaker Implantation/Cardiac Resynchronization Therapy 223.1. Patients in Sinus Rhythm 223.2. Patients with Atrial Fibrillation 243.3. Conventional PM Upgrade 253.4. Indication for Antibradycardia Pacing (First Implant) 263.5. Indication for Implantable Cardioverter-defibrillator Combined with Cardiac Resynchronization Therapy 263.6. Direct Stimulation of the Cardiac Conduction System 273.6.1. Cardiac Contractility Modulation284. Recommendations for Placement of Implantable Cardioverter-defibrillators 284.1. Primary Prevention of Sudden Death 284.1.1. Ischemic Cardiomyopathy284.1.2. Nonischemic Cardiomyopathy294.1.3. Hypertrophic Cardiomyopathy304.1.4. Chagas Cardiomyopathy324.1.5. Arrhythmogenic Right Ventricular Cardiomyopathy334.1.6. Noncompaction Cardiomyopathy344.1.7. Congenital Long and Short QT Syndromes374.1.8. Brugada Syndrome374.1.9. Catecholaminergic polymorphic ventricular tachycardia384.1.10. Idiopathic Ventricular Tachycardia384.2. Secondary prevention of sudden death 384.2.1. Recovered cardiac arrest or sustained ventricular tachycardia384.2.1.1. Recovered cardiac arrest or sustained ventricular tachycardia in the presence of structural heart disease384.2.1.2. Survivors of Cardiac Arrest or Sustained Ventricular Tachycardia in the Absence of Structural Heart Disease404.2.2. Syncope and Ventricular Tachycardia/Fibrillation on Electrophysiology Study404.3. Children, Adolescents, and Congenital Heart Disease 414.4. Choosing Implantable Cardioverter-defibrillator Type and Pacing Mode 444.4.1. Implantation Technique444.4.2. Pacing Mode444.5. Cost-effectiveness of Implantable Cardioverter-defibrillators in Primary and Secondary Prevention of Sudden Death 444.5.1. Primary Prevention444.5.2. Secondary Prevention 455. Recommendations for Implantable Loop Recorders 456. Recommendations for CIED Evaluation and Programming 466.1. Conventional Pacemakers 466.1.1. Sinus Node Disease466.1.2. Atrioventricular Block476.1.3. Atrial Fibrillation476.1.4. Neurally Mediated Syncope and Carotid Sinus Syndrome476.2. Cardiac Resynchronization Therapy476.3. Implantable Cardioverter-defibrillator496.4. Implantable Loop Recorder506.5. Remote Monitoring (Online)507. Recommendations for Prevention and Treatment of CIED infecTions and for System Removal 517.1. Prevention and Treatment of Infections 517.2. Lead Removal from Cardiac Implantable Electronic Devices 558. Recommendations for the prevention of electromagnetic interference 588.1. Surgery Using Electrocautery 598.2. Magnetic Resonance Imaging 608.3. Radiotherapy 629. Conclusion 62References 64Although implantation techniques for cardiac implantable electronic devices (CIEDs) have been standardized and simplified, adequate settings and materials, as well as medical knowledge and surgical experience, remain necessary. Electrocardiographic (ECG) knowledge, especially of cardiac arrhythmias and the principles of cardiac electrophysiology, is essential.Surgical procedures involving artificial cardiac pacing are performed by cardiovascular surgeons or cardiologists with cardiac pacing training . The procedures should be performed in an operating room or a catheterization/electrophysiology laboratory. The operating room should have adequate size, lighting, and ventilation, a sink for surgical hand antisepsis, and a dual-voltage electrical system .Professionals involved in surgical procedures for CIED implantation include:Attending and assisting physicians with cardiac pacing trainingAnesthesiologistScrub nurse preferably with cardiac pacing trainingNursing professional preferably with cardiac pacing trainingPacemaker (PM) technicianRadiology technicianA fluoroscopy system (with an image intensifier) remains essential during CIED procedures. The equipment may be fixed, as in catheterization laboratories, or portable (C-arm). Image quality and image recording and mirroring resources facilitate the procedure, especially for cardiac resynchronization therapy (CRT). The image intensifier should allow visualization of small-caliber guidewires and movements from different views (including oblique views).Continuous ECG monitoring should be performed, and ECG tracings may be stored. Available leads should allow proper intraoperative assessment of CRT and physiological pacing of the conduction system . In these cases, an intracavitary ECG (polygraph) should be analyzed.Noninvasive monitoring of blood pressure and pulse oximetry should be available.A tray with the adequate surgical instrumentsElectrocautery deviceExternal cardioverter-defibrillatorTemporary external PMAdvanced life support systemMaterials and drugs for anesthesia and cardiovascular stability Pulse generator, leads, introducers, and sheaths for catheterization of the coronary sinus and conduction systemCIED-specific programmer and analyzer being used or to be implantedUltrasound for venous access may reduce complications related to deep vein puncture Transesophageal echocardiography: helpful during percutaneous lead extraction for early diagnosis of cardiac tamponadeThe physician in charge of a CIED follow-up clinic should have cardiac pacing training . The clinic\u2019s structure should include:ECG machineCIED programmer devices from different manufacturersUninterruptible power supplyExternal cardioverter-defibrillator with transcutaneous PMMagnetTransthoracic echocardiogramAccess to additional tests such as cardiac stress test, 24-hour Holter monitoring, and imaging tests . The tilt table test must be available at the clinic or at a referral facility.Access to an engineer specializing in cardiac pacinga) Initial clinical evaluation prior to CIED implantation should include:Patient history and physical examinationPatient history should investigate signs and symptoms of cardiac arrhythmias, such as syncope, presyncope, dizziness, and palpitations, and signs and symptoms of heart failure (HF). A family history of sudden death is highly relevant, especially if occurring prematurely or affecting first-degree relatives.Physical examination should include inspection, peripheral pulse palpation, blood pressure measurement, cardiac and carotid auscultation, heart rate, and peripheral perfusion.Preventive interruption of other drugs is generally unnecessary. Patients with signs of active infection must not undergo device implantation until the infection is resolved.If possible, oral anticoagulants and antiplatelets should be temporarily interrupted before the surgical procedure.b) Preoperative additional testsResting ECG;Chest radiograph (posteroanterior view plus left profile);Laboratory tests: complete blood count and coagulation profile tests are required for all patients. For procedures that require intravenous contrast , a renal function evaluation with electrolyte measurement should be performed. In patients with diabetes, fasting glucose should be assessed. Urinalysis and urine culture tests are indicated for patients with urinary complaints;Tests such as echocardiogram, 24-hour Holter monitoring, electrophysiology study (EPS), and upper-limb ultrasound or venography should be performed only if the clinical condition requires.should follow institutional protocols.Patients should fast for at least 6 to 8 hours before surgery depending on the complexity of the procedure and type of anesthesia. Trichotomy, local antisepsis, and prophylactic antibiotic therapya) Surgical proceduresBefore surgery, medical and nursing staff must follow safe surgery protocols by checking patient\u2019s name, date of birth, hospital record number, and laterality. The staff should also confirm the indication for the procedure and check preoperative test results.CIED procedures should be performed in an operating room or a catheterization/electrophysiology laboratory under fluoroscopic guidance with continuous ECG monitoring, pulse oximetry, and intermittent or continuous blood pressure measurement. Devices such as subcutaneous implantable cardioverter-defibrillators (ICDs) and implantable loop recorders do not require the use of an image intensifier during implantation.Anesthesia is either local, preferably combined with sedation, or general. The type of anesthesia depends on the complexity of the procedure, access route, and patient\u2019s clinical status.The choice of surgical access should consider the following: pulse generator implantation site, heart access for lead implantation , and the possibility of implanting devices without transvenous leads (leadless PM and subcutaneous ICD). The use of a temporary PM and venous catheters, previous thoracic surgeries, need for radiotherapy, anatomical characteristics, skin infections, and dominant arm may also influence the choice of surgical strategy.The pulse generator pocket is generally created in the pectoral region, although it may be abdominal in specific situations, and the device is placed in a subcutaneous or submuscular position. Venous access is achieved by cephalic vein dissection or puncture of the axillary, subclavian, jugular, or femoral vein. The number of leads varies according to the type of implanted device, usually ranging from one to three. Active-fixation (screw-in) leads are currently preferred to passive-fixation leads according to professional experience.Multisite pacing systems with lead implantation for left ventricular (LV) pacing through the carotid sinus require specific tools, such as sheaths, electrophysiology catheter, and venography catheter for choosing the best tributary vein for lead implantation.During the surgical procedure, pacing and sensing thresholds and lead impedance parameters should be obtained, and an endocavitary or epicardial electrogram should be performed. For patients undergoing ICD implantation, shock impedance should be measured; defibrillation threshold testing is optional for patients undergoing transvenous ICD implantation  but recommended for patients undergoing right pectoral subcutaneous ICD implantation.The CIED implantation report should include patient identification, surgery description, technical data regarding the system, and if there were any complications  perforation, diaphragmatic stimulation, pocket hematoma, contamination, and arrhythmias). The Brazilian Pacemaker Registry must be completed.Postoperative and inpatient evaluationAfter CIED implantation, the patient should be clinically evaluated, and the implanted device should undergo electronic assessment. ECG and chest radiography should be performed to confirm proper device function and lead position and to identify any dysfunctions or complications.Patients are generally hospitalized for 12 to 24 hours. Those undergoing procedures that do not require intravascular access (pulse generator replacement or subcutaneous device implantation) usually remain under postoperative observation for 6 to 12 hours .b) Types of CIEDThe main types of CIED and their characteristics are summarized in Symptomatic sinus node dysfunctions are named sinus node disease (SND) and tend to be the most common indication for artificial cardiac pacing worldwide, accounting for approximately half of permanent PM implants.From an ECG perspective, SND is characterized by the presence of one or more of the following manifestations: sinus bradycardia, sinus pause or arrest, sinoatrial block, and atrial tachyarrhythmias  associated with bradyarrhythmias (sinus pauses), such as tachycardia-bradycardia syndrome and chronotropic incompetence (inadequate heart rate response to exercise or stress).SND symptoms are related to low heart rate or to the duration of sinus pause. The most common symptoms include palpitation, tiredness, dyspnea, dizziness, and presyncope or syncope. Syncope is a common clinical symptom and may affect approximately 50% of patients referred to PM implantation due to SND.Although SND may occur at any time in life, the incidence increases with age, affecting 1 in 600 patients older than 65 years. Men and women are affected equally.Etiology can be divided into intrinsic and extrinsic factors.SND pathophysiology is diverse and usually involves complex electrophysiological and structural remodeling.In addition, baroreflex response and heart rate variability are reduced in older patients.Intrinsic causes of SND include inflammatory, infectious, and immunological processes, degenerative fibrosis, ion channel dysfunction, and sinoatrial node remodeling. Age-related idiopathic degenerative fibrosis is the most common intrinsic cause of SND. However, recent studies have demonstrated that an inherited ion channel dysfunction may also play a role in the genesis of age-related sinus dysfunction.Other intrinsic mechanisms of SND include infiltrative  and inflammatory  diseases, HF and AF , and chronic coronary heart disease . Genomic analyses have identified loci in proteins that interact with ion channels and channels related to normal and abnormal resting heart rates, providing insights into the mechanisms that control heart rate.Lithium may also be associated with SND, often permanent.The main extrinsic causes of SND include pharmacological agents, metabolic disorders, and autonomic dysfunction. Betablockers, calcium channel blockers, digitalis, antiarrhythmics, and sympatholytic drugs are the pharmacological agents most commonly associated with the development of SND.Autonomic dysfunction with cardioinhibitory manifestations can mimic or intensify SND in vasovagal syncope and carotid sinus hypersensitivity.Another rare cause of recurrent bradycardia and syncope is cardiac asystole induced by temporal lobe epilepsy. Although temporary PM implantation may be fundamental in the acute phase of this condition, specific management  of epilepsy may often regulate sinus dysfunction and/or atrioventricular (AV) block with no need for permanent PM implantation. The same considerations are applicable to another rare condition, namely glossopharyngeal neuralgia associated with cardiac asystole and syncope.Metabolic abnormalities, such as severe systemic acidosis, hyperkalemia, hypokalemia, and hypocalcemia, may cause sinus bradycardia, which is uncommon in acute cases. Other possible extrinsic factors include hypothyroidism, hypoxia, hypothermia, and toxins. The association between Brugada syndrome and the occurrence of SND has also been described.Patients with SND are usually asymptomatic in the initial phases of the disease and develop symptoms after several years. It is also important to identify cases of asymptomatic functional bradycardia, such as nocturnal bradycardia, in healthy young people and athletes, although this condition poses no health risks and requires no intervention.Invasive EPS should not be regularly used in clinical practice because there are no conclusive data on the true indication for permanent PM implantation in patients with abnormal sinus node recovery time or sinoatrial conduction time.Documenting a correlation between ECG changes and clinical manifestations is essential to SND diagnosis. Twelve-lead ECG or other methods, such as Holter monitoring  and external or implantable loop recorders, may be used.Before choosing the best approach and deciding if PM implantation should be performed in patients with SND, establishing a correlation between bradycardia and clinical symptoms is crucial as well as identifying reversible causes.However, PM implantation significantly increases quality of life, possibly reduces the risk of AF and systemic thromboembolism, allows the use of antiarrhythmics that may cause bradycardia, and provides continuous monitoring of heart rhythm.The recommendations for permanent PM implantation in SND are described inIn symptomatic SND without a reversible cause, permanent PM implantation is the treatment of choice, although there is no evidence that artificial cardiac pacing has any impact on survival or risk of sudden death in these patients compared with the general population.A systematic review of these major randomized studies identified a significant reduction in stroke (hazard ratio [HR]: 0.81) and AF (HR: 0.80) rates with AAI and/or DDD pacing compared with VVI pacing.The effect of pacing mode on HF and stroke prevention and quality-of-life improvement is less evident. The Danish Multicenter Randomized Trial on Single Lead Atrial Pacing versus Dual Chamber Pacing in Sick Sinus Syndrome (DANPACE)analyzed AAI vs DDD pacing in patients with SND and showed that AAIR pacing was associated with a higher incidence of paroxysmal AF (HR: 1.24) and a two-fold increase in reoperations compared with DDDR pacing. Reoperations were mostly due to the need for an upgrade from AAIR to DDDR pacing in patients who developed AV block during follow-up. Another relevant aspect in that study is that the benefit of AAI pacing may be attenuated in patients with long PR intervals that may trigger diastolic mitral regurgitation.Regarding pacing mode, major randomized studies have reported no improved survival with atrial (AAI) or AV (DDD) pacing compared with ventricular (VVI) pacing; however, benefits such as reductions in AF, syncope, and PM syndrome rates have been observed.Atrial pacing (AAIR or DDDR) is the preferred pacing mode for patients with SND .Therefore, algorithms that reduce unnecessary ventricular pacing, such as AV hysteresis and automatic switch from DDD to AAI mode, should be programmed in patients without associated AV block.Most patients with SND present with preserved AV conduction. Conversely, RV pacing has been known to be associated with negative physiological consequences resulting from ventricular dyssynchrony (VD), such as LV remodeling, reduced LV ejection fraction (LVEF), and functional mitral regurgitation.Algorithms that suppress AF occurrence, such as continuous atrial pacing  or atrial pacing induced by intrinsic atrial activity sensing, either alone or combined, have no proven benefits. Similarly, alternative pacing sites \u2013 such as Bachmann bundle pacing and dual-site or multisite atrial pacing \u2013 have failed to show consistent effects.Current devices have one or more mechanisms of frequency response sensors usually based on body movement  or ventilation/minute volume. The main purpose of the sensors is to physiologically increase heart rate and not necessarily change clinical outcomes. Although devices cannot accurately assess atrial chronotropic response, they can provide indicators of atrial disease progression through rate and arrhythmia histograms, atrial pacing percentage, and patient daily activity. Such data may be useful for sensor programming. There is no evidence that the use of combined sensors  improves quality of life.An electrical stimulus originating in the sinus node is propagated through the myocardium by the conduction system. A delay or failure in propagating the stimulus between atria and ventricles characterizes an AV block. This change in stimulus propagation may be a pathological change or a functional phenomenon resulting from physiological refractoriness (an intrinsic characteristic of conduction system cells).From an ECG perspective, AV blocks are classified into first-degree, second-degree , and third-degree.First-degree AV block is defined by a delay in stimulus conduction from the atrium to the ventricle with a PR interval > 200ms.In type I second-degree AV block (Mobitz I), the block occurs after progressive prolongation of the PR interval (Wenckebach phenomenon), with a blocked P wave at the end. In type II second-degree AV block (Mobitz II), the P wave is suddenly blocked, ie, there is no progressive prolongation of the PR interval. When AV conduction occurs with a 2:1 ratio, second-degree block usually cannot be classified unequivocally as type I or type II without the support of autonomic maneuvers, drugs, or even invasive EPS. Advanced AV block refers to the blocking of two or more consecutive P waves with some conducted beats, which indicates some preservation of AV conduction. In AF with prolonged pauses (> 5s), advanced second-degree AV block should be considered.Finally, third-degree AV block (complete AV block) is defined as the absence of AV conduction .There are numerous congenital and, most often, acquired conditions that may affect AV conduction. Degenerative causes are commonly observed in clinical practice and are associated with aging, hypertension, and diabetes mellitus. The most common infectious causes in Brazil are chronic Chagas myocarditis and, to a lesser extent, viral acute myocarditis, which may cause definitive intermittent acute blocks.AV blocks resulting from inferior-wall ischemia or acute myocardial infarction as well as autonomic nervous system-mediated blocks may be reversible.Iatrogenic causes, especially from pharmacological action, should also be considered depending on clinical status.Anatomically, AV blocks are defined as AV nodal, intra-Hisian, or infra-Hisian according to block site. AV nodal block is associated with slower progression, a faster and more reliable junctional escape, and improved response to autonomic manipulation with the administration of atropine, isoproterenol, and epinephrine. In contrast, intra-Hisian or infra-Hisian AV blocks progress more rapidly and are associated with a slower and more unpredictable ventricular escape, a wider QRS with poor response to adrenergic activity, and vagal block. High-degree blocks (advanced or third-degree) have a higher risk of low output and severe asystole and require urgent therapy. In the setting of AF, complete AV block is characterized by a low ventricular response (< 50bpm) and a regular RR interval.Likewise, type I second-degree AV block is often asymptomatic and affects healthy, active patients with or without a history of heart disease, particularly during parasympathetic activity. However, if it occurs frequently or during exercise, it may cause exertion intolerance or dizziness.First-degree AV block is generally asymptomatic but may result in fatigue or exertion intolerance if the PR interval is long enough to allow loss of AV synchrony. This change is called pseudo-PM syndrome and may occur when the PR interval is > 300ms.In 61% of patients with syncope and underlying bundle branch block or bifascicular block, significant and clinically relevant conduction abnormalities in the His-Purkinje system may be detected on EPS.In patients with AV block, clinical evaluation may help identify transient or reversible causes, and treatment or resolution may make permanent artificial pacing unnecessary.In asymptomatic patients, regular follow-up with additional tests that assess mean heart rate, QT interval, pauses, ventricular arrhythmia, intraventricular (IV) conduction disorders (IVCD), presence or emergence of structural heart disease, low cognitive development and low weight and height gain, and exercise intolerance should be conducted to evaluate the need for permanent PM implantation.Prophylactic PM or ICD implantation is also recommended in some asymptomatic patients with neuromuscular dysfunctions or other genetic disorders.In congenital complete AV block, permanent PM implantation must be indicated when symptoms are present or when the child has a resting heart rate < 55bpm or < 70bpm, if associated with structural heart disease.In patients with bradycardia indicative of PM implantation and LV dysfunction, ICD implantation should be considered (see item 4).PM implantation is not indicated for asymptomatic patients with permanent AF and low resting heart rate who have an appropriate chronotropic response while awake, regardless of pause occurrence and duration. Conversely, for symptomatic patients with prolonged pauses (> 3s) that may have resulted from an infranodal block, PM implantation is indicated.Prophylactic PM implantation may be necessary especially in patients with HF or coronary artery disease (CAD) requiring chronic use of betablockers.To determine the best type of device and pacing mode for patients with AV block, the following clinical variables should be considered: expected ventricular pacing percentage and LV systolic function .Studies comparing pacing with preservation of sequential AV activation vs single-chamber ventricular pacing in patients with AV block  showed no significant reduction in mortality or stroke rates.However, the United Kingdom Pacing and Cardiovascular Events (UKPACE) trial (patients aged \u226575 years) found no benefits of AV pacing on mortality or AF and HF incidence compared with ventricular pacing. Similar stroke rates and higher rates of complications related to the surgical procedure were also observed in patients undergoing dual-chamber PM implantation .Therefore, the indication for single-chamber PM (VVI) is reasonable in frail patients or those with significant comorbidities, older age, a very sedentary lifestyle, or reduced daily need for pacing.Conversely, a systematic review revealed that dual-chamber pacing is the preferred choice for reducing AF incidence and PM syndrome prevalence compared with single-chamber ventricular pacing (VVI).In patients with retrograde VA conduction, ventricular pacing may trigger symptoms of PM syndrome. In these cases, dual-chamber pacing should be preferred to avoid AV dyssynchrony.Patients with LV dysfunction and indication for PM due to AV block were evaluated in the Conventional versus Multisite Pacing for Bradyarrhythmia Therapy (COMBAT)(LVEF < 35%) and Biventricular versus Right Ventricular Pacing in Heart Failure Patients with Atrioventricular Block (BLOCK-HF)(LVEF \u2264 50%) studies. The studies compared CRT vs conventional RV pacing and demonstrated clinical improvement  and reverse LV remodeling (increased LVEF) with CRT, with a significant reduction in primary outcomes.The deleterious effects of chronic RV pacing have been demonstrated in several studies, although only a minority (5% to 9%) of patients with chronic RV pacing develop severe ventricular dysfunction with symptoms of HF.In patients with AF and LV dysfunction undergoing AV node ablation for heart rate control, CRT or conduction system (His bundle or LBB) pacing seems to be associated with better outcomes compared with conventional RV pacing.The recommendations for PM implantation in AV block are summarized inQRS complex abnormalities  are caused by a conduction delay or a block within one or more branches of the His-Purkinje system.Conduction delay or right bundle branch block (RBBB) associated with a block in one fascicle of the LBB is named bifascicular block (the same terminology is used for LBB block [LBBB]). Clinical conditions that may result in IV block include genetic/hereditary, inflammatory, infectious, infiltrative, metabolic, ischemic, and degenerative causes.The prevalence of progression of LBBB or bifascicular block to advanced AV block is low, approximately 1% per year.LBBB is usually associated with higher mortality compared with other IVCDs.In some neuromuscular diseases, PM implantation is recommended in patients with IV block because of the high incidence of complete AV block and sudden cardiac death.The presence of IV block alone is rarely associated with symptoms but may be a marker of structural heart disease; the presence or development of LBBB may result in cardiac dyssynchrony and progressive LV dysfunction. Some studies have demonstrated a correlation between LBBB and CAD and HF.Although an EPS may identify high-risk conduction disorders, this study is characterized by a variable degree of sensitivity and some degree of risks. In patients with syncope, the presence of IV block is a predictor of electrophysiological abnormalities.Regardless of symptoms, alternating bundle branch blocks  are also indicative of PM implantation because their presence suggests infranodal conduction system disease with high risk for severe complete AV block.The recommendations for PM implantation in IV blocks are summarized inSyncope results from significant bradycardia and/or hypertension triggered by head movements or situations that cause involuntary compression of the neck and carotid sinus, although this correlation is not clinically evident in many patients.Carotid sinus syndrome (CSS) is characterized by a history of syncope associated with an exaggerated reflex response to mechanical stimulation of the carotid sinus occurring either spontaneously or with carotid sinus massage (CSM).Reproducing syncope during CSM increases test specificity, whereas performing CSM in the supine position increases test sensibility.CSS is diagnosed by a pause > 3s (sinus node arrest or AV block) or a fall in systolic blood pressure (SBP) \u2265 50mmHg in the absence of conductor system depressants combined with reproduction of syncope during right- and left-sided CSM (5 to 10 s) in patients aged > 40 years. The patient should be placed in the supine position and tilted (tilt table test).Reflex responses in CSS can be classified according to their hemodynamic profile into three types: cardioinhibitory (ventricular pause > 3s), mixed , or vasodepressor . The incidence of CSS increases with age .The evidence supporting permanent PM implantation in patients with CSS is based on small, controlled studies and retrospective observational studies.A meta-analysis of three controlled studies with a mean follow-up duration of 3.3 years showed a significant reduction (76%) in syncopal recurrence in patients treated with PM compared with controls .A literature review of 12 studies including 601 patients treated with PM and 305 controls found lower rates of syncopal recurrence in treated patients (0% to 20%) compared with controls (20% to 60%), although patient selection, patient position during CSM , follow-up duration, and pacing mode were heterogeneous among studies.evaluated 175 older patients with recurrent unexplained falls, no reported loss of consciousness, and cardioinhibitory response during CSM and suggested that a diagnosis of CSS should be suspected in such cases. The group that was randomly assigned to permanent PM implantation showed a significantly reduced rate of events  during follow-up.The Syncope And Falls in the Elderly \u2013 Pacing And Carotid Sinus Evaluation (SAFE PACE) studyWhen initial investigation with CSM and head-up tilt table test is negative, unexplained syncope and vasovagal syncope in patients aged > 40 years may be diagnosed with the help of an implantable loop recorder.The recommendations for PM implantation in CSS are summarized inA study in which the diagnosis of CSS also included spontaneous pauses recorded by an implantable loop recorder found a 98% reduction in syncope burden after PM implantation (1.68 episodes per patient/year [95% CI 1.66-1.70] vs 0.04 episodes per patient/year [95% CI 0.038-0.042]).Importantly, asymptomatic older patients may present with carotid sinus hypersensitivity but no characterization of CSS and no indication for PM implantation. Conversely, patients with recurrent unexplained falls and cardioinhibitory response to carotid sinus compression (carotid sinus hypersensitivity) may benefit from a permanent PM.Subsequent studies comparing long-term single-chamber vs dual-chamber pacing showed a trend towards lower rates of recurrent syncope and presyncope in patients with dual-chamber pacing pacing was associated with an increased fall in SBP and an increased rate of persisting symptoms compared with DVI  pacing. pacing.Vasovagal syncope is characterized by a history of loss of consciousness associated with an exaggerated neurally-mediated reflex that progresses with a sudden reduction in cerebral blood flow secondary to vasodilation and/or reduced heart rate. In most cases, syncope is secondary to a sudden and significant fall in blood pressure followed by varying degrees of bradycardia and generally preceded by prodromal manifestations such as malaise, sweating, feeling hot, pallor, dizziness, and then fatigue. Vasovagal syncope is often triggered by significant emotional stress, fear, or pain and is the main cause of syncope, especially in young people. Predisposing factors include prolonged orthostatism, closed or hot environments, venipuncture, and physical trauma, among others.Based on changes in blood pressure and heart rate, vasovagal response can be classified into three types: type 1, or mixed response ; type 2, or cardioinhibitory response (a significant reduction in heart rate < 40bpm or asystole > 3s); and type 3, or vasodepressor response .Despite sometimes being related to physical trauma and inability to perform activities that pose personal or collective risks, vasovagal syncope has a favorable long-term prognosis. Treatment is most often nonpharmacological, including guidance and changes in lifestyle. However, approximately 14% of patients present with severe forms of vasovagal syncope and require additional treatment . Patient age is the most important factor for choosing the best therapy.There are few evidence-based therapeutic options for vasovagal syncope. Artificial cardiac pacing may be effective in patients with vasovagal syncope and dominant cardioinhibitory reflex; thus, clinical investigation should be focused on documenting the correlation between syncope and bradycardia.Syncopal recurrence at 12 months was 22% (6/27) in the PM group vs 70% (19/27) in the clinical treatment group . The Syncope Diagnosis and Treatment (SYDIT) study randomly assigned patients with recurrent syncope  and a positive tilt table test (bradycardia) to receive a PM (DDD mode with rate-drop response function) or clinical treatment (atenolol 100 mg/day).Syncopal recurrence after a median follow-up of 135 days was 4.3% (2/46) in the PM group vs 25.5% (12/47) in the atenolol group . In the Vasovagal Syncope International Study (VASIS), patients were randomly assigned to receive a PM (DDI mode with rate hysteresis) or no treatment.Syncopal recurrence after a mean follow-up of 3.7 years was 5% (1/19) in the MP group vs 61% (14/23) in the control group (p = 0.0006). The Vasovagal Pacemaker Study II (VPS-II) included patients with recurrent syncope , although significant bradycardia during the tilt table test was not an inclusion criterion.After PM implantation, patients were randomized to dual-chamber pacing (DDD) or sensing without pacing (ODO). Syncopal recurrence rates were 33% (16/48) in the DDD group vs 42% (22/52) in the ODO group, with no significant reduction in the risk of syncope . In the Third International Study on Syncope of Uncertain Etiology (ISSUE-3), the most important double-blind randomized trial published to date, patients aged > 40 years with spontaneous syncope documented by an implantable loop recorder associated with asystole > 3s or asystole > 6s without syncope were randomly assigned to dual-chamber pacing with rate-drop response function (PM ON) or sensing without pacing (PM OFF).During a mean follow-up of 2 years, there was a significant reduction (57%) in the risk of syncopal recurrence . All studies used dual-chamber pacing with rate-drop response function.The effectiveness of permanent PM insertion has been assessed in some randomized studies. The Vasovagal Pacemaker Study I (VPS-I) evaluated patients with recurrent syncope  and a positive tilt table test (bradycardia < 60bpm or pause > 1s) who were randomly assigned to receive a PM (DDD mode with rate-drop response function) or clinical treatment.A small retrospective study compared conventional dual-chamber pacing with closed-loop stimulation (CLS) pacing and reported lower rates of syncopal recurrence in the latter.Recommendations for permanent PM implantation in vasovagal syncope are summarized inIn hypertrophic obstructive cardiomyopathy (HOCM), there is a pressure gradient in the LV outflow tract (LVOT) \u2013 larger gradients are associated with more severe symptoms and increased mortality.Hypertrophic cardiomyopathy (HCM) is a common genetic cardiovascular disease characterized by LV hypertrophy in the absence of other cardiac abnormalities or systemic disorders capable of producing a degree of hypertrophy equivalent to that found in patients with this condition.In these patients, RV apical pacing changes the pattern of ventricular contraction and generates regional dyssynchrony. This results in late basal septal activation and reduced LV contractility, which reduces both the systolic anterior motion of the mitral valve and the LVOT pressure gradient.However, VD caused by activation with a wide QRS complex alone reduces LV contractility and may lead to a reduced outflow tract gradient. Thus, in this case, the benefit is related to an adverse effect of the PM.For patients with symptoms caused by LVOT obstruction, therapeutic options include negative inotropic drugs, septal myotomy-myectomy operation, alcohol septal ablation, and heart transplantation.A subgroup analysis suggests that patients aged > 65 years are more likely to benefit from dual-chamber pacing.Reduced LVOT gradients with ventricular pacing have been demonstrated in three small randomized, controlled studies and several observational studies. However, improvement of symptoms and quality of life varied among studies.In addition, gradient reduction is generally smaller in ventricular pacing compared with septal myectomy or ablation. Thus, the indication of dual-chamber pacing solely to reduce the LVOT gradient is restricted to very specific conditions: patients aged > 65 years with moderate hypertrophy, defined symptoms due to LVOT obstruction, and no indication for ICD.A Cochrane systematic review has concluded that the benefits of ventricular pacing in HCM are based on gradient measurements and that evidence regarding relevant clinical endpoints are lacking.Overall, septal myectomy or ablation should be considered a first-line therapy in patients with HOCM and symptoms refractory to pharmacological treatment. Very severe cases may require heart transplantation.In addition, maximal atrial pacing rate should be higher than the maximal rate exhibited by the patient during the stress test. Patients with HCM and very poor tolerance to an elevated heart rate are usually on beta-blockers, which results in a lower maximal rate during exertion; conversely, these patients are more susceptible to developing AF. Thus, automatic mode switching to DDI(R) mode should be used to avoid high-rate ventricular pacing in AF. If the atrial lead is inefficient in detecting AF, the maximal rate should be lowered.In patients undergoing PM implantation for LVOT gradient reduction, a short AV interval must be programmed  to obtain maximal RV preexcitation without compromising diastolic ventricular filling.Finally, a significant number of patients with HCM receive an ICD for preventing sudden death. For these patients, a dual-chamber DDD pacing device with a short AV interval may reduce the LVOT gradient and prevent or delay the need for additional interventions.The recommendations for permanent PM implantation in patients with HCM are described inSome neuromuscular conditions may cause progressive and insidious disease of the cardiac conduction system, such as Duchenne muscular dystrophy, facioscapulohumeral muscular dystrophy, X-linked dystrophy, myasthenia gravis, myotonic dystrophy, and Friedreich ataxia.Most manifestations are related to infranodal conduction disorders, resulting in fascicular blocks and third-degree AV blocks. Such findings are typical of Kearns-Sayre syndrome , Guillain-Barr\u00e9 syndrome, myotonic dystrophy, Becker muscular dystrophy, and facioscapulohumeral muscular dystrophy.Myotonic dystrophy and Kearns-Sayre syndrome are associated with a high incidence of conduction system disease, which often progresses rapidly and cannot be predicted by ECG or intracavitary recordings. The disease almost always affects the His-Purkinje system and can lead to Stokes-Adams attacks or sudden death, except when prevented by PM implantation.The authors concluded that permanent PM implantation should be considered in patients with myotonic dystrophy and prolonged HV interval (\u2265 70ms) even if they are asymptomatic or if bradycardia is found on ECG.In a study of 49 patients with myotonic dystrophy , high-degree AV blocks were recorded in 47% of patients after PM implantation, despite no documented evidence of bradycardia at baseline.In patients with neuromuscular diseases, waiting for a documented AV block may result in significant risk of sudden death or syncope. Thus, permanent PM implantation should be considered early in the course of neuromuscular disease upon the presence of conduction abnormalities even if the patient is asymptomatic .ECG abnormalities such as nonsinus rhythm, QRS > 120ms, PRi > 240ms, second- or third-degree AV block, and atrial tachyarrhythmias were independent predictors of sudden death in patients with myotonic dystrophy type I.Bradyarrhythmias, such as sinus bradycardia, sinus pauses, advanced or type I second-degree AV block, and junctional escape rhythm, are common during sleep, especially in young healthy people who are physically fit. Direct and indirect data have shown an association with vagal hypertonia. In nearly all cases, these findings are physiological and require no specific treatment. However, cardiac arrhythmias have been observed in obstructive sleep apnea (OSA) syndrome.The most significant cases are related to Pickwick syndrome, obesity, hypertension, metabolic syndrome, anatomic and/or functional airway obstruction , chronic lung diseases, and neurological diseases, among others.During apnea, airway obstruction leads to oxygen desaturation that may result in severe hypoxemia with consequent development of atrial and ventricular brady- and tachyarrhythmias.Thus, there is no primary indication for PM implantation in OSA-related bradyarrhythmias.Primary treatment is intended for apnea correction and weight loss. Continuous positive airway pressure devices for respiratory support during sleep may be of great importance, as their use has resolved bradyarrhythmias in a large number of cases.When airway obstruction correction is not sufficient to improve the status, radiofrequency ablation may be indicated (cardioneuroablation [CNA] and/or AF ablation). In exceptional cases, MP implantation may facilitate the treatment of AF (beta-blockers or other antiarrhythmics).In clinical practice, OSA is commonly observed in a setting characterized by vagal hypertonia, nocturnal bradyarrhythmia, and AF commonly triggered by bradycardia (bradycardia-tachycardia syndrome).Thus, PM implantation is currently reserved for patients with a compromised conduction system . Furthermore, the number of pauses significantly decreased from 6.5 \u00b1 9.4 pre-CNA to 1.1 \u00b1 3 within 11 months of CNA (p = 0.03). No patient received a PM. system .Congenital long QT syndrome (LQTS) is a channelopathy caused by abnormal cardiac repolarization and features a prolonged QT interval, ventricular arrhythmias , and a history of syncope and/or sudden death. There is generally a family history of LQTS in close relatives, and the most common pattern of inheritance is autosomal dominant (Romano-Ward syndrome), although the condition may also be autosomal recessive (very rare) with associated deafness. These two types account for 90% of cases; however, there are currently 14 known different types of congenital LQTS.Some patients with LQST do not present with spontaneous clinical manifestations, although certain conditions, such as medication use, physical stress, and electrolyte changes, may be triggers.5are more commonly used.The QTi is measured from the beginning of the QRS complex to the end of the T wave, excluding the U wave. Given that QTi physiology changes inversely to heart rate, the original value should be corrected for heart rate, most commonly with the Bazett formula.In this formula, the measured QTi is divided by the square root of the preceding RR interval (the units are measured in seconds), resulting in the corrected QT (QTc) interval. The normal limits are 450ms and 460ms for men and women, respectively. A QTc interval > 480ms 4 minutes after the stress test is highly suggestive of LQST. Approximately 20% of cases with a positive genotype have a normal QTi.The QT interval (QTi) can be measured in any lead, although leads II and VIn different types of congenital LQST, a delay in cellular repolarization occurs either due to a reduction in potassium channel function or an increase in sodium channel function (delayed channel inactivation) and manifests as an increased QTi. Electrophysiological abnormalities are apparently heterogeneous and become significantly prominent in the presence of conditions such as autonomic stimulation, physical and mental stress, electrolyte changes, drug action, and ischemia, among others, resulting in electrical instability, extrasystole, polymorphic tachycardia, torsade de pointes, ventricular fibrillation, and sudden death.Whenever possible, the type of LQTS  should be defined according to clinical and ECG manifestations, as there is a recommended treatment for each type.Congenital LQTS manifestations typically appear during childhood or adolescence and usually affect male patients (adolescence) earlier than female patients (adulthood). Syncope is the most common manifestation and usually occurs between 5 and 15 years of age. A family history of sudden death is a strong predictor of mortality. Overall, the longer the QTc interval, the higher the risk of sudden death.Types I and II are the most common and originate from a decrease in potassium channel function, whereas type III is caused by an increase in sodium channel function.In congenital LQTS type I, arrhythmias are usually triggered by physical exertion, especially swimming. In type II, they are commonly induced by mental stress caused, for example, by loud noises, especially during rest or sleep. As for type III, arrhythmias typically occur during rest or sleep without a clear relationship with stress.It is absolutely essential that patients avoid electrolyte disturbances such as hypokalemia and the use of drugs that may trigger fatal arrhythmias. Several websites provide a list of drugs that may potentially increase the QTc interval (http://www.crediblemeds.org) and should always be consulted before taking any medication.Noncompetitive recreational sports may be cautiously considered in patients with LQTS type III if there is easy access to an automated external defibrillator. Drugs and substances that prolong repolarization, such as potassium channel blockers, which can induce torsade de pointes even in asymptomatic cases, are absolutely contraindicated. Sympathomimetics should also be avoided. Patients are advised to carry a list of prohibited drugs.All patients  should significantly reduce the level of physical activity. Competitive sports are contraindicated. Certain type-related triggers, such as strenuous swimming in LQTS type I and very loud noises in LQTS type II, should be avoided.Pharmacological treatment of LQTS types I and II is based on beta-blockers, and propranolol and nadolol are the most effective drugs. Metoprolol appears to be less effective and should be avoided.Retrospective studies have demonstrated the unquestionable benefits of beta-blockers and denervation surgery , with a mortality of 9% in the treated group vs 60% in the untreated group.The QTc interval can be experimentally reduced with potassium-channel activators such as nicorandil in LQTS type I or spironolactone combined with oral potassium in LQTS type II. LQTS type III may benefit from sodium-channel blockers such as mexiletine and flecainide, which can shorten the QTc interval; however, flecainide may induce a Brugada phenotype. There are reports of successful treatment of electrical storms in LQTS type III with mexiletine, which is recommended by some professionals when the QTc interval is very long.However, a PM may be recommended for patients with AV block or ventricular arrhythmias triggered or aggravated by bradycardia or pauses, provided there is no history of recovered sudden death or high-risk signs such as congenital deafness, syncope, documented complex ventricular arrhythmias, family history of sudden death, female sex, and QTc > 0.60s. PM insertion combined with beta-blocker therapy is occasionally indicated to avoid drug-induced bradycardia. A cardiac pacing rate above the spontaneous sinus rate can reflexively inhibit sympathetic action and be quite helpful in controlling arrhythmic storms. A PM should only stimulate the atrium (avoid VD) and can be programmed to a higher rate , which shortens QTc duration. Furthermore, activation of the frequency response sensor can ensure chronotropic adaptation, which is impaired by beta-blockers  cannot be prescribed .The rates of permanent PM implantation after cardiac transplantation vary between 2% and 24% and have significantly decreased in patients undergoing bicaval anastomosis vs those undergoing biatrial anastomosis.SND is the most commonly reported disorder in these patients, and possible causes include surgical trauma, damage to the sinoatrial artery due to trauma or ischemia, prolonged ischemic time of the donor heart, cardiac denervation, and baseline characteristics of the donor heart.Approximately 10% of patients requiring a PM have an AV conduction disorder , which are probably due to inadequate graft lpreservation.Bradycardia often occurs in the early postoperative period following cardiac transplantation and affects approximately two thirds of patients, although it tends to remit spontaneously. However, if bradycardia persists for a few weeks and the patient develops symptoms, PM implantation may be necessary. and AF (HR: 0.80) incidence rates with sequential AV pacing compared with ventricular pacing.Randomized clinical trials have not reported any impact of atrial or AV pacing (AAI/DDD) on survival compared with ventricular pacing (VVI) alone; however, AF occurrence, syncopal incidence, and PM syndrome rates were reduced.Ventricular pacing should be avoided in patients in sinus rhythm as it may cause AF and worsening HF found that AAIR pacing was associated with a higher incidence of paroxysmal AF (HR: 1.24) and a two-fold increase in reoperations compared with DDDR pacing.ning HF. ImportHowever, at 1 year, the Specific Activity Scale scores and the secondary quality-of-life endpoints did not differ significantly between groups.Activation of the rate variation sensor may be beneficial in patients with chronotropic incompetence. The Advanced Elements of Pacing Trial (ADEPT) compared the impact of DDDR vs DDD mode on quality-of-life improvement in 872 patients with chronotropic incompetence. At 6-month follow-up, patients randomly assigned to DDDR mode had a higher peak heart rate compared with those assigned to DDD mode .LV remodeling and consequent LV dysfunction promoted by RV pacing-induced dyssynchrony warrants the search for alternative pacing sites in patients with bradyarrhythmias requiring artificial ventricular pacing.More importantly, these adverse events were directly associated with the cumulative percentage of ventricular pacing.The MOST study reported that RV apical pacing in patients with sinus dysfunction led to a significant increase in AF episodes and HF hospitalizations.Consequently, the search for a pacing strategy that preserves interventricular and IV synchrony and corrects bradyarrhythmias is a relevant clinical necessity that has led to physiological pacing.Direct stimulation of the conduction system is the most physiological form of artificial pacing because it reproduces the natural electrical activation of the heart. The stimulus travels through the specialized conduction pathways (His-Purkinje system) and avoids RV pacing-induced dyssynchrony.A nonrandomized study of 202 patients who were followed-up for 2 years reported that His bundle pacing was superior to RV apical pacing. In patients with 40% of ventricular pacing, hospitalizations due to HF were significantly reduced .His bundle pacing has some limitations, including technical difficulties to identify the best pacing site (higher implant times), higher pacing thresholds, lower intracavitary sensing amplitudes, and abnormal inhibition by cross-sensing.Deep septal pacing with direct capture of the LBB or a nearby area (the lead is inserted with a sheath into the left side of the interventricular septum) is a viable option that preserves narrow QRS complexes and prevents dyssynchrony. From a functional perspective, despite technical differences between direct capture of the LBB and capture of the LBB area, pacing of the LBB area promotes synchronism equivalent to that of direct His bundle pacing.Subsequently, Huang et al. demonstrated the feasibility of direct LBB capture via deep septal pacing for LBBB correction. Some criteria for defining LBB capture were established, and patients should meet at least 3 of the following: 1) presence of LBB potential recorded on the lead electrogram; 2) LV activation time < 90ms with a stable pacing output of 2V or 5V; 3) incomplete RBBB on ECG; 4) evidence of selective and nonselective LBB capture; and 5) evidence of direct LBB pacing via a concomitant lead in the His bundle or the left septum.In a small series of 10 patients with SND, Mafi-Rad et al. demonstrated the feasibility of LV pacing of the interventricular septum resulting in a narrow RBBB-like QRS morphology, stable thresholds, and improved hemodynamic performance (measured by dP/dt) compared with RV apical pacing.Physiological pacing via His bundle or LBB has been effectively used in different settings of bradyarrhythmia requiring ventricular pacing .Compared with RV pacing, both His bundle and LBB pacing modalities have been shown to be safe and stable, to improve synchrony and QRS duration measurements, and to tend to improve ventricular function. Compared with LBB pacing, direct His bundle pacing generates a normal and apparently more physiological QRS complex, but at the expense of higher implant times, higher thresholds, and lower R-wave amplitudes.The evolution of implantable technologies, the availability of generators with specific algorithms for detection of proportional energy expenditure, and the results of long-term controlled studies will potentially establish physiological pacing as the preferred strategy in the near future.Artificial cardiac pacing is not free of problems. The incidence of complications involving leads and pulse generators, especially in the subcutaneous pocket, increases over the follow-up period and may affect more than 10% of patients with CIEDs.Of all complications listed, infective endocarditis warrants special attention because of its association with increased morbidity and mortality.Implantation of conventional systems is associated with risk of pneumothorax, hemothorax, lead dislodgement, venous occlusion, tricuspid valve insufficiency, and infection . Furthermore, subcutaneous implantation is associated with occurrence of pocket hematoma and infection not only during the first surgical procedure but also during the generator replacement procedure.Since PM leads are the main source of problems and complications, implantable technologies have naturally advanced towards prioritizing solutions that do not require them. Within this context, leadless pacing has emerged as a technological evolution with potential advantages over conventional pacing. Two leadless systems were initially introduced in the market, Nanostim leadless cardiac pacemaker  and Micra transcatheter pacing system , but only the latter is currently available.The Micra system is a small \u201ccapsule\u201d (26mm in length x 6.7 mm in diameter) containing a lead and a pulse generator which is implanted in the cardiac chamber via transvenous route. The procedure is relatively simple and involves femoral vein catheterization. A large-caliber sheath (24 French) in introduced in the inferior vena cava and advanced into the right atrium. A delivery system is then inserted inside the sheath, allowing deployment of the device in the RV. Initially, the RV apex was the recommended site for device implantation, but interventricular septal implantation is currently recommended.These results were then confirmed at 1-year follow-up.Another analysis of the same cohort reported improved quality-of-life parameters at 3 and 12 months and high levels of patient satisfaction. The Micra system was also associated with less activity restrictions compared with conventional systems.A multicenter, single-arm, prospective clinical trial evaluated the Micra system and included 725 patients  with an indication for single-chamber permanent PM implantation. The primary objective was to evaluate device efficacy (threshold capture at 6-month follow-up) and safety (major complications). Implantation was successful in 99.2% of cases. There were 28 major complications in 3.4% of patients, including perforation or pericardial effusion (1.6%), complications in the venous access site (0.7%), and elevated pacing threshold (0.3%). There were no dislodgements or device emboli. The mean values of R-wave amplitude, pacing threshold, and impedance remained stable. The rate of complications was compared with that of a population of more than 2,000 patients . The Micra study found a lower rate of major complications , including fewer hospitalizations (2.3% vs 3.9%) and fewer system revisions (0.4% vs 3.5%). There was also a low rate of infections, which were unrelated to the implantation or the device.Small single-center studies evaluating leadless PMs in real-world settings have confirmed the findings of high implant success rates and low complication rates.The Micra system has also been evaluated in \u201creal-world\u201d registries. The largest is a multicenter registry (96 centers in 20 countries) that aims to include 1,830 patients. The primary endpoint is occurrence of complications within 30 days of implantation. The published results of the first 795 patients showed a high implant success rate (99.6%) and a low rate of major complications (1.5%). Conventional system implantation was contraindicated in approximately 20% of patients, mainly due to vascular access problems. In addition, there were five pericardial effusion events in the study population, two of which had to be drained.The safety of leadless system implantation has also been evaluated in specific populations, such as patients undergoing hemodialysis or conventional device extraction due to infection.whose results at 6-month follow-up did not differ from those obtained in the Micra studies. However, Nanostim was withdrawn from the market because of unexpected rates of battery failure causing loss of pacing output and PM communication in approximately 0.5% of cases.The Nanostim device was assessed in a multicenter observational study,A more recent study including 53 patients revealed that leadless PMs affect valve function and may cause or worsen tricuspid regurgitation,probably due to mechanical interference of the device in the subvalvular apparatus. Acute complications of the procedure and PM-induced dyssynchrony are the least likely causes. Patients with septal positioning of the leadless PM (currently recommended because of lower risk of perforation) were associated with tricuspid regurgitation, which was probably explained by greater proximity to the valve and the subvalvular apparatus.In addition to the previously mentioned intraoperative complications, there are two situations that remain uncertain. First, the impact of the device on tricuspid valve function is still unknown. An initial study of 23 patients reported no effect on tricuspid valve function at 2-month follow-up.A case report of percutaneous device extraction performed 4 years after implantation has also been published.However, how the device will behave in the long term and whether extraction is possible (or whether another device should be implanted in another site) remain unknown.Another situation that remains unresolved is how to manage the device at end of service. A worldwide experience with early retrieval of the Micra system \u2013 range 1 to 95 days \u2013 reported good outcomes and low complication rates.Importantly, with the emergence of new technologies, unreported complications may arise as the follow-up periods become longer. In addition, there are no current randomized studies comparing conventional PMs with leadless PMs.The currently available device is single-chamber and rate-responsive (VVIR). Overall, the indications for leadless PMs are the same as those for single-chamber PMs \u2013 mostly for symptomatic bradycardia not requiring an atrial lead .One of the main factors limiting the use of leadless PMs is the high cost of the devices, as demonstrated in a recent survey by the European Heart Rhythm Association (EHRA).who were also evaluated in the aforementioned \u201creal-life\u201d studies.Conceptually, the best candidates for leadless PM implantation would be those with contraindications to conventional devices, such as no vascular access, risk of new surgery, hemodialysis, and previous infection of conventional systems. Some studies (mostly single-center) have demonstrated the effectiveness of leadless PMs in this subgroup of patients,The implant technique for leadless PMs is different from that of conventional PMs; thus, physicians should be experienced in cardiac pacing, femoral vascular access, and handling of large-caliber sheaths and RV leads. Cardiac perforation is uncommon but, when it occurs, it may affect the RV or the atrium and auricle and usually requires emergency surgical intervention.Despite ODT, many patients with HF with reduced LVEF (HFrEF) develop persistent symptoms and significant LV systolic dysfunction. Moderate or severe mitral regurgitation, reduced myocardial functional reserve, and VD are the most common factors related to poor response to ODT. In VD settings, CRT alone (through atrio-biventricular pacing) or combined with an ICD has been considered an excellent therapeutic option for patients with LBBB. CRT is intended to correct electromechanical dysfunctions in patients with HFrEF and VD and, consequently, improve LV performance.The Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure (COMPANION)and the Cardiac Resynchronization in Heart Failure (CARE-HF) studieswere the first large-scale randomized trials to test the effect of CRT on the clinical outcomes of total mortality and hospitalization rate. The studies found that CRT increased survival when combined with ODT.A surface ECG is the method of choice when investigating VD symptoms and selecting patients for CRT. Although imaging methods such as echocardiography can detect mechanical VD, tissue Doppler was unable to identify patients who responded to CRT in the Predictors of Response to CRT (PROSPECT) study.In a mean follow-up duration of 29.4 months, there were 524 deaths, with significant reductions in mortality  and HF hospitalization rates  with CRT. All trials reported a significant improvement in quality of life (3 to 6 months), although follow-up criteria were heterogenous among studies. Furthermore, the number needed to treat (NNT) was estimated at 11 (11 devices need to be implanted to save 1 life in 2.5 years). Considering the average longevity of CRT devices (6 years), five devices would need to be implanted to avoid 1 death.Those results were corroborated by a 2006 meta-analysis of 8 clinical trials including a total of 3,380 patients.Those trials supported the first recommendations for CRT as an adjunctive therapy to ODT in patients with advanced HFrEF  and VD. VD was confirmed by the presence of IVCD on ECG. It should be noted that the COMPANION study also observed greater clinical benefits when combining CRT with ICD (CRT-D).the Resynchronization Reverses Remodeling in Systolic Left Ventricular Dysfunction (REVERSE) study,and the Resynchronization-Defibrillation for Ambulatory Heart Failure Trial (RAFT) were subsequently published.These studies compared CRT-D vs ICD alone in patients with LVEF \u2264 40% (REVERSE) or \u2264 30% (MADIT-CRT and RAFT) and NYHA functional class I-II (REVERSE and MADIT-CRT) or II-III (RAFT). Study results, which were later corroborated by a meta-analysis, confirmed that both CRT plus ODT and CRT-D were beneficial in reducing total mortality.The Multicenter Automatic Defibrillator Implantation Trial With Cardiac Resynchronization Therapy (MADIT-CRT),Only 9% of patients had NYHA functional class I HF, and CRT significantly reduced HF hospitalization but not total mortality among them.The results show that early CRT in asymptomatic patients with HFrEF may reduce HF progression possibly by means of reverse ventricular remodeling. However, the potential benefits of CRT in patients with NYHA functional class I HFrEF should be carefully weighed against possible adverse events and costs associated with CRT implantation.A meta-analysis of 5 randomized clinical trials including patients with asymptomatic HFrEF  or NYHA functional class II HF demonstrated a significant reduction in total mortality and HF hospitalization rates in patients with NYHA functional class II HF.and CARE-HF studies.However, the results of the Echocardiography Guided Cardiac Resynchronization Therapy (EchoCRT) study revealed that cardiovascular mortality increased in the subgroup of patients with QRS <130 ms undergoing CRT.These findings were corroborated by a meta-analysis showing limited benefits of CRT in patients with QRS < 140ms. Indeed, the longer the QRS duration, the better the response to CRT.Furthermore, patients with LBBB and a QRS duration \u2265 150ms benefit the most from CRT.A meta-analysis of 13 large studies including 12,638 patients confirmed the benefit of CRT in patients with LBBB and the higher risk of death from heart pump failure in patients with wider QRS complexes.A QRS duration \u2265 120ms as a cutoff point for CRT indication is based on the inclusion criteria of the COMPANIONSimilarly, a study evaluating the MADIT-CRT population demonstrated no clinical benefits from CRT-D in 537 patients with mild HFrEF and no LBBB, regardless of QRS morphology and duration.As for IVCD type, a subanalysis of large studies suggests that patients with a wide QRS complex and no LBBB respond poorly to CRT. Data from the REVERSE study, which compared an active CRT group (CRT ON) vs a control group (CRT OFF), revealed that patients without LBBB had no reverse LV remodeling regardless of QRS duration.Importantly, only a small number of patients with RBBB were included in the large studies, which precludes any definitive conclusions about the effects of CRT on this patient population.There were also increases in risk of death and HF hospitalization rate in patients with RBBB treated with CRT-D. These findings are consistent with those reported by Bilchick et al.,whose study included Medicare data. Additionally, Pastore et al.reported that patients with typical RBBB responded poorly to CRT. Therefore, the current literature suggests that CRT is indicated in patients with HFrEF, nonspecific IVCD, and a QRS duration \u2265 150ms and that greater caution is required when recommending this therapy for patients with typical RBBB.Conversely, although CRT was not beneficial in patients without LBBB, a recent real-world observational study using information from the National Cardiovascular Data Registry (USA) evaluated the clinical response to CRT-D vs ICD in 11,505 patients without LBBB. In patients with nonspecific IVCD and QRS \u2265 150ms, CRT reduced mortality and HF hospitalization rates, whereas those with QRS < 150ms responded poorly to CRT, with increased mortality and hospitalization rates.Indications for CRT in patients in sinus rhythm are listed inThe prevalence of AF in patients with HF varies according to HF severity. The condition affects 5% of patients with NYHA functional class I HF and 40% of those with NYHA functional class IV HF.Data on the effect of CRT on patients with AF and HF are limited but suggest benefits, although less so than in patients in sinus rhythm. This is explained by some unique AF features, such as loss of AV synchronism, higher risk of synchronized ventricular pacing failure due to difficulties in controlling heart rate and occurrence of fusion and pseudofusion beats, and increased incidence of ICD shock delivery (appropriate or inappropriate), hospitalization, and mortality.Approximately one-quarter of patients undergoing CRT develop AF; however, most randomized controlled trials demonstrating the benefit of CRT excluded patients with AF .The CARE-HF study compared CRT vs ODT and found that, although mortality was higher in patients who developed AF during follow-up, they still benefited from CRT according to the primary objectives of the study.CRT-D was not superior to ICD alone in the subgroup of 229 patients with AF in the Resynchronization-Defibrillation for Ambulatory Heart Failure Trial (RAFT). However, less than one-third of patients received more than 95% of biventricular pacing during 6-month follow-up.of 5 studies  compared the impact of CRT on 797 patients in sinus rhythm vs 367 patients with AF (AV junction [AVJ] ablation was performed in 56 patients). Improvement in NYHA functional class did not differ between groups, although the Minnesota quality-of-life scores and the 6-minute walk test results were significantly improved in the sinus rhythm group.A meta-analysisof 23 observational studies including 7,495 patients undergoing CRT, patients with AF (25%) showed higher rates of nonresponse to CRT (34.5% vs 26.7%) and mortality (10.8% vs 7.1%) compared with patients in sinus rhythm. Furthermore, the presence of AF was associated with lower impact of CRT on quality of life, 6-minute walk distance test and LV end-diastolic volume, but with similar result in the improvement of the LVEF.In a meta-analysisstudy enrolled 59 patients with HF, AF, and bradycardia (ventricular pacing with paced QRS \u2265 200ms) who were randomly assigned to RV pacing or biventricular pacing with 3-month crossover phases. AV node ablation was performed in 63% of patients. Study limitations included the small number of patients that concluded the crossover phases (only 39%), which precludes any conclusions. In the intention-to-treat analysis, exercise tolerance and peak oxygen uptake did not differ between groups. However, in the 37 patients who received effective therapy (97-100% of biventricular pacing), 6-minute walked distance and peak oxygen uptake increased significantly.The Multisite Stimulation in Cardiomyopathies (MUSTIC-AF)Optimal Pacing Site (OPSITE),and AVIn the Post AV Nodal Ablation Evaluation (PAVE),studies, CRT moderately but significantly improved quality of life, NYHA functional class, and LVEF compared with RV apical pacing in patients with AF and varying degrees of LV dysfunction undergoing AV node ablation.Node Ablation with CLS and CRT Pacing Therapies for Treatment of AF (AVIL CLS/CRT)compared patients with HF, QRS \u2265 120ms, and LVEF \u2264 35% undergoing CRT-D implantation  vs those who did not undergo device implantation . CRT-D was associated with lower risks of mortality and readmissions. The same association was observed in the subgroup of 3,357 patients with AF.The Acute Decompensated Heart Failure National Registry (ADHERE)CRT requires biventricular pacing for most of the time to be beneficial, avoiding intrinsic conduction as much as possible. In patients with AF and rapid AV conduction, this requirement may be difficult to meet.evaluated 1,404 patients undergoing CRT for a mean follow-up duration of 18 months. All patients were in sinus rhythm at the time of study enrollment, and 443 patients had documented AF (32%). AF episodes occurred in patients with (22%) and without (16%) a history of AF, lasting from 10 minutes to several weeks. Percent biventricular pacing was 95% in patients with AF vs 98% in the entire patient population. In patients with AF, percent biventricular pacing was 98% during sinus rhythm vs 71% during AF episodes (p < 0.001). Biventricular pacing <95% was defined as suboptimal and was associated with the occurrence of persistent or permanent AF (p < 0.001) and uncontrolled ventricular rate (p = 0.002) The percentage of biventricular pacing was inversely proportional to heart rate in patients with AF, decreasing by 7% for each 10-bpm increase in ventricular rate.Boriani et al.Mortality was inversely proportional to the percentage of biventricular pacing both in sinus rhythm and AF or atrial pacing. The highest mortality reduction was observed in those with biventricular pacing < 98%. Patients with biventricular pacing > 99.6% had a mortality reduction of 24% (p < 0.001), whereas those with biventricular pacing < 94.8% had a mortality increase of 19%. Optimal percentage of biventricular pacing was set at \u2265 98.7%.The importance of achieving high percentages of biventricular pacing was demonstrated in a large cohort of 36,395 patients included in the US LATITUDE Patient Management System who were remotely monitored.All patients underwent AVJ ablation and multisite CRT implantation and were randomly assigned to receive echo-guided CRT (97 patients) or RV apical pacing (89 patients). During a median follow-up period of 20 months, CRT reduced the composite endpoint of death or hospitalization due to HF and worsening HF . CRT reduced hospitalization and worsening HF, while total mortality was similar in both groups.The multicenter, prospective Ablate and Pace in Atrial Fibrillation (APAF) study included 186 patients with symptomatic permanent AF, uncontrolled ventricular rate or refractory HF, LV systolic dysfunction, and a wide QRS complex.Among 162 patients with permanent AF in this cohort, 48 received rate control drugs and 114 underwent AVJ ablation. At 4-year follow-up, reverse remodeling and exercise tolerance were similar between patients with AF and those in sinus rhythm. In patients with AF, CRT benefited only those undergoing AVJ ablation. Despite > 85% biventricular pacing time, LV function and functional capacity were not improved in patients on rate control drugs.AVJ ablation eliminates intrinsic conduction, resulting in 100% biventricular pacing in patients with CRT. This strategy was evaluated in a series of 673 patients .Among 1,285 patients evaluated, 243 had AF. Rate control (85% biventricular pacing) was achieved by AVJ ablation in 188 patients and drug therapy in 55. At 34-month follow-up, mortality was significantly reduced in patients undergoing AVJ ablation . These results suggest that CRT should achieve 100% biventricular pacing for maximum therapeutic benefit.In an observational study, Gasparini et al. reported that AVJ ablation combined with CRT significantly improved survival when compared with CRT alone.The Cardiac Resynchronization Therapy in Atrial Fibrillation Patients Multinational Registry (CERTIFY) corroborated the importance of AVJ ablation in patients with AF undergoing CRT. The study compared patients with permanent AF undergoing CRT combined with AVJ ablation or rate control drugs (n = 895) vs patients in sinus rhythm . The results showed that, within 37 months, all-cause mortality (6.8 vs 6.1 per 100 person-years) and cardiovascular mortality (4.2 vs. 4.0) were similar in patients with AF plus AVJ ablation and patients in sinus rhythm. In contrast, patients with AF plus rate control drugs had higher total and cardiovascular mortality rates  .This condition is diagnosed by the presence of a high ventricular pacing rate and no other cause of LV dysfunction, such as untreated myocardial ischemia, valvular heart disease, or arrhythmias.Patients undergoing permanent RV pacing with a conventional PM or an ICD may develop progressive LV systolic dysfunction due to mechanical and electrical dyssynchrony. Registry data indicate that PM-induced LV dysfunction may occur in 12 to 30% of patients.LVEF recovery or improvement occurred in up to 86% of patients in those studies. Thus, patients with a PM or an ICD with high percent ventricular pacing showing worsening clinical and/or echocardiographic status may be candidates for CRT upgrade . Pre-implant LVEF and QRS duration were additional predictors of PM-induced LV dysfunction.A meta-analysis of those studies compared conventional RV pacing vs biventricular or His bundle pacing.Biventricular pacing compared with RV pacing was associated with increased LVEF and reduced end-diastolic and end-systolic LV volumes (patients with LVEF between 36% and 52% are more likely to benefit). Only 1 study reported significant improvement in the 6-minute walk distance test, which included patients with permanent AF who underwent AV node ablation . Data on His bundle pacing are summarized elsewhere in this guideline.Randomized clinical trials have evaluated whether CRT is superior to conventional RV pacing in reducing the occurrence of LV remodeling and improving clinical outcomes in patients with LVEF > 35%.and they were randomly assigned to receive conventional RV pacing or biventricular pacing. Mean LVEF was 43%, and 87% of patients had LVEF > 35%. The primary composite outcome of death from any cause, urgent health care visit for HF requiring intravenous diuretic, and an increase \u2265 15% in LV end-systolic was more common in the RV pacing group. The APAF study evaluated patients with permanent AF undergoing AV junction (AVJ) ablation and CTR implantation who were randomly assigned to biventricular pacing or RV pacing.The composite primary outcome of death from HF, hospitalization, or worsening HF occurred in 26% of patients in the RV group and 11% in the CRT group. Biventricular pacing was beneficial regardless of LVEF and QRS duration. Mean LVEF was 38%, and 53% of patients had LVEF > 35%.The meta-analysis excluded some important studies because they included patients with LVEF < 35%. The Biventricular versus Right Ventricular Pacing in Heart Failure Patients with Atrioventricular Block (BLOCK HF) study enrolled patients with indication for PM implantation due to AV block, NYHA functional class I-III HF, and LVEF \u2264 50%,was a prospective, multicenter, randomized, double-blind, crossover study that included 60 Brazilian patients with NYHA functional class II-IV HF, LVEF < 40%, and AV block as an indication for pacing. All patients underwent biventricular system implantation and were crossed over to conventional RV pacing after every 3 months (group A: RVP-BiVP-RVP and group B: BiVP-RVP-BiVP). Patients were evaluated at the end of each 3-month period. There were significant improvements in quality of life, functional class, and LV end-systolic volume compared with RV pacing. Also, the mortality rate was higher in the RV pacing group.COMBATRecommendations for CRT in patients with a conventional PM indication for the treatment of bradyarrhythmias are summarized inICD implantation is indicated in patients with different clinical conditions for primary or secondary prevention of sudden death (see item 4). Many of these patients also have LV dysfunction and LBBB and meet the criteria for CRT indication (see item 3). Thus, there are patients that may benefit from both therapies (CRT-D).MIRACLE ICD II, and Cardiac Resynchronization Therapy in Patients with Heart Failure and Narrow QRS (RethinQ) studiesunderwent CRT-D implantation. The groups were active CRT vs no pacing.Randomized clinical trials have evaluated the effects of ICD and CRT-D implantation on patients with LV dysfunction and IVCD. All patients participating in the CONTAK CD, Multicenter InSync ICD Randomized Clinical Evaluation (MIRACLE ICD),The CONTAK CD study evaluated 490 patients with a standard indication for ICD implantation, LVEF \u2264 35%, NYHA functional class II-IV HF, and QRS \u2265 120ms. There was no significant difference in the composite primary outcome of death from any cause, HF hospitalization, and ventricular arrhythmia requiring ICD intervention. CRT-D significantly improved oxygen uptake, 6-minute hall walk distance, and LVEF. The MIRACLE ICD study included 369 patients who also had a standard indication for ICD implantation, LVEF \u2264 35%, NYHA functional class III-IV HF, and QRS \u2265 130ms. CRT-D was associated with improved quality of life and oxygen uptake. The MIRACLE ICD II study included 186 patients with a standard indication for ICD, ejection fraction (EF) \u2264 35%, NYHA functional class II HF, and QRS \u2265130ms. CRT-D was associated with reduced LV volumes and improved LVEF and NYHA functional class. The RethinQ enrolled 172 patients with an indication for ICD, EF \u2264 35%, NYHA functional class III HF, QRS \u2264 130 ms, and echocardiographic evidence of dyssynchrony. CRT-D did not improve the endpoint of peak oxygen consumption.and RAFT studies,patients were assigned to CRT-D or ICD alone. The MADIT CRT evaluated 1,820 patients with LVEF \u2264 30%, NYHA functional class I-II HF, and QRS \u2265 130ms. The composite endpoint of death from any cause or a nonfatal HF event was significantly reduced with CRT-D. The RAFT study included 1,798 patients with LVEF \u2264 30%, NYHA functional class II-III HF, and QRS \u2265120 ms or paced QRS \u2265200 ms. CRT-D significantly reduced the combined outcome of death from any cause or HF hospitalization. Mortality and HF hospitalization were analyzed separately as secondary outcomes and were significantly reduced.In the MADIT CRTThere was also a significant reduction in hospitalizations .A pooled analysis of the trial results showed that CRT-D reduced total mortality compared with ICD alone .The RAFT studyreported that CRT-D only reduced the primary outcome of deathThe clinical decision on whether to implant a CRT-D device in patients with an indication for ICD should consider the pattern of IV block and the QRS complex duration. Results from meta-analyses suggest that the benefits of CRT are mostly restricted to patients with an LBBB pattern.from any cause or HF hospitalization in patients with QRS > 150ms. In patients with an LBBB pattern, there was a continuous relationship between QRS duration and clinical benefit, whereas patients with a non-LBBB pattern only benefited when QRS > 160ms .In this setting, direct stimulation of the cardiac conduction system (His bundle or LBB pacing) may be a useful alternative.CRT is a well-established nonpharmacological treatment for patients with symptomatic HF, reduced LVEF, and wide QRS complex. Although this therapeutic modality has advanced, 20 to 40% of patients still do not respond to CRT.In another study, Lustgarten et al. reported on 29 patients who were randomly assigned to His bundle pacing or conventional CRT. Six-minute hall walk distance, NYHA functional class, quality-of-life score, and LVEF were similar between groups.Barba-Pichardo et al. described in 2012 a series of 16 patients with severe HF in whom LV pacing via the coronary sinus was not achievable. Direct His-bundle pacing was able to correct the conduction disorder (LBBB) in 81% of cases.A meta-analysis of 11 studies including 494 patients undergoing His bundle pacing reported a successful implantation rate of 82.4%. The studies evaluated patients with AF undergoing AV node ablation and patients with CRT indication. His bundle pacing had promising results in small, observational studies, which suggests the need for randomized trials.A recent randomized trial compared His bundle pacing vs standard biventricular pacing in 41 patients. Of 21 patients randomly assigned to His bundle pacing, 10 (48%) had to cross over to biventricular pacing. The main reason for therapy crossover was that His bundle pacing failed to correct the conduction disorder. This finding is in line with those of subsequent studies that reported bundle branch block correction with His bundle pacing in approximately 60% of cases. Nevertheless, 26% of patients in the conventional CRT group crossed over to His bundle pacing due to technical difficulties. The His bundle pacing group had greater QRS narrowing  and greater improvement of echocardiographic parameters compared with the CRT group (80% of patients with His bundle pacing had an absolute LVEF improvement > 5%). Measurements of cardiac diameters and volumes were similar in both groups. These findings suggest that CRT and His bundle pacing may be complementary therapies considering the anatomical challenges of the coronary sinus and the failure to correct the disorder in all patients with LBBB.In a prospective cohort of 63 patients with nonischemic cardiomyopathy, LBBB, and LVEF < 35% undergoing LBB pacing, Huang et al. reported that LBB pacing was successful in 61 patients. Significant LVEF increase, reverse remodeling, and improved functional class were found at 1-year follow-up. Furthermore, a hyperresponse with normalized LVEF was observed in 75% of patients.Zhang et al. described a series of 11 consecutive patients with LBBB and a conventional indication for CRT undergoing direct LBB pacing. QRS complex was significantly shortened . Deep septal pacing was found to be feasible in patients with systolic dysfunction and LBBB, resulting in functional improvement and reverse remodeling.Wu et al. conducted a nonrandomized study of 137 patients with symptomatic HF and wide QRS complex who were followed up for 1 year. Forty-nine patients underwent His bundle pacing, 32 underwent LBB pacing, and 54 patients underwent biventricular pacing. Conduction system pacing (His bundle or LBB) showed greater LVEF improvement compared with biventricular pacing . Functional improvement was similar in both groups of conduction system pacing; however, LBB pacing was associated with lower pacing thresholds .(A recent review addressing direct stimulation of the cardiac conduction system suggests that His bundle pacing may be used as a primary strategy to achieve CRT or as a rescue strategy in patients in whom the standard technique (via coronary sinus catheterization) is unsuccessful. The combination of both methods (simultaneous His-CRT pacing) is considered a new concept of pacing for CRT in selected patients with more disseminated IVCDs.However, it remains unclear whether CCM should be routinely indicated in patients who are unfit candidates (narrow QRS) or who do not respond to CRT. It also remains unclear whether CCM should be used in combination with conventional CRTs.The available studies are small and, perhaps because of that, were unable to detect significant differences.Cardiac contractility modulation (CCM) is a therapeutic option for HF in patients with no conventional indication for CRT, narrow QRS complex (< 130ms), and LVEF 25-45%. CCM promotes high-voltage (30 to 50ms) stimulation of the right interventricular septum after myocyte activation during the absolute refractory period. This type of stimulation theoretically optimizes calcium dynamics, resulting in increased ventricular contractility and improved exercise tolerance and functional capacity.Sudden death from ventricular arrhythmias is one of the main causes of death in patients with HFrEF, especially in those with ischemic heart disease in whom the incidence of ventricular myocardial fibrosis and, consequently, reentry circuits is more prevalent.Importantly, studies evaluating the impact of ICDs on ischemic heart disease have broadly defined this condition as ventricular dysfunction secondary to at least 1 severe lesion in 1 of the 3 main coronary arteries or a previous history of documented AMI.and MUSTTstudies tested ICD placement in patients with nonsustained ventricular tachycardia (NSVT), LV dysfunction, and inducible sustained ventricular arrhythmias (SVA) on EPS. The MADIT study enrolled 196 patients with LVEF < 35%, NYHA functional class I-III HF, a previous history of AMI, recorded asymptomatic NSVTs, and inducible SVAs on EPS refractory to procainamide or an equivalent antiarrhythmic drug. The patients were randomly assigned to ICD implantation vs optimized medical treatment (OMT) for a mean follow-up period of 27 months. The mortality rate was 15.7% in the ICD group and 38.6% in the OMT group, with a 64% relative risk reduction in total mortality in the ICD group . The MUSTT study evaluated patients with EF \u2264 40%, NYHA functional class I-III HF, and recorded asymptomatic NSVTs. The initial objective of the study was to compare the efficacy of antiarrhythmic medications capable of suppressing ventricular arrhythmias on EPS vs placebo. As a consequence of the MADIT results, the protocol was modified to ICD implantation in patients with inducible ventricular arrhythmias and reverse failure with at least one antiarrhythmic drug. Patients treated with antiarrhythmic medications did not show a significant decrease in mortality, whereas patients treated with an ICD had a 76% relative risk reduction in mortality .Several important studies have evaluated the impact of ICDs on primary prophylaxis of sudden death in patients with ischemic heart disease. The MADITAlthough the EPS is not normally used for ICD indication because of the low negative predictive value, the MADIT and MUSTT trials showed important results in this population .The Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) expanded the inclusion criteria and enrolled patients with ischemic and nonischemic heart disease, LVEF \u2264 35%, and NYHA functional class II and III HF. During a mean follow-up period of 45.5 months, there was a 23% relative risk reduction in mortality in the ICD group , in which 52% of patients had ischemic heart disease.The MADIT II study randomly assigned 1,232 patients with EF \u2264 30%, NYHA functional class I-III HF, and AMI for more than 30 days to ODT vs ICD. During a mean follow-up period of 20 months, the mortality rate was 19% in the ICD group and 24% in the ODT group, with a 31% relative risk reduction in overall mortality .A subsequent analysis showed an increased rate of infection in the ICD group .The Defibrillator after Acute Myocardial Infarction (DINAMIT) trial randomly assigned 332 patients to ICD therapy and 342 to no ICD therapy 6 to 40 days after AMI.Inclusion criteria were patients with LVEF \u2264 35% and depressed heart-rate variability on Holter monitoring. In a mean follow-up duration of 30 \u00b1 13 months, total mortality did not differ between groups, with 62 deaths in the ICD group and 58 deaths in the control group .Conversely, studies evaluating early ICD implantation after revascularization or myocardial ischemic events found a neutral or even negative effect on some secondary outcomes. The Coronary Artery Bypass Graft (CABG) Patch trial randomly assigned 900 patients aged < 80 years with EF < 36% and signal-averaged ECG (SAECG) abnormalities to prophylactic ICD implantation at the time of bypass surgery. During a mean follow-up period of 32 \u00b1 16 months, the results regarding overall mortality were neutral .In a subgroup analysis of the SCD-HeFT and MADIT II trials, patients with NYHA functional class I and II HF benefited the most from ICD therapy, whereas patients with NYHA functional class III HF did not benefit significantly. There are no robust clinical trials demonstrating the benefit of ICD placement in patients with NYHA functional class IV HF, only data from retrospective cohorts of patients waiting for a transplant or undergoing ventricular assist device (VAD) implantation. A retrospective study including 1,089 patients on the heart transplant waiting list revealed that 550 patients had an ICD implant (216 for primary prevention and 334 for secondary prevention). In a mean follow-up duration of only 8 months, 39 patients (18%) in the primary prophylaxis ICD group, 89 (27%) in the secondary prophylaxis ICD group, and 162 (30%) in the no ICD group died. In multivariate analysis, the presence of an ICD was an independent predictor of reduced mortality .The same finding was reported by a study that identified patients listed for heart transplantation between 1999 and 2014 in the United Network for Organ Sharing (UNOS) registry. Data from 32,599 patients were analyzed, with a mean follow-up duration of 154 days. A total of 3,638 patients (11%) died while waiting for a heart transplant, with a mortality rate of 9% in the ICD group and 15% in the no ICD group and a relative risk reduction of 13% .In the subgroup of patients undergoing VAD implantation , the presence of an ICD was associated with a 19% relative risk reduction in mortality . A systematic review analyzed the use of ICDs in 937 patients with VADs . During a mean follow-up period of 7 months, 16% of patients in the ICD group and 26% in the no ICD group died, with a 39% relative risk reduction in mortality , the rate of sudden death has been known to decrease proportionally to worsening HF (NYHA class).< 0.01).HF is a highly prevalent clinical condition with significant morbidity and mortality. HF etiology is defined as nonischemic in 20% to 30% of cases, which means that no significant lesions are seen on coronary angiography or that the imaging test result for ischemia is negative. LV dysfunction may result from unknown causes (idiopathic dilated cardiomyopathy) or viral infections, hypertension, exposure to potentially toxic agents , Chagas disease, infiltrative diseases, peripartum cardiomyopathy, valvular heart disease, or genetic and autoimmune diseases.Primary prevention strategies for SCD in patients with NICM include pharmacological treatment, ICD implantation, and CRT. Randomized clinical trials have shown that drug therapy  significantly reduces the rates of SCD in this group of patients.Although advances in the treatment of nonischemic cardiomyopathy (NICM) have significantly reduced mortality in recent decades, sudden cardiac death (SCD) remains a major problem that accounts for 30% of deaths.Other clinical variables associated with a higher risk of arrhythmic events in this population include not using beta-blockers and SBP.Laboratory tests, such as hemoglobin, uric acid, and atrial natriuretic peptide (brain natriuretic peptide [BNP]), were predictors of mortality and arrhythmic events in some studies.Risk stratification should include clinical and laboratory assessment. The worse the NYHA functional class, the greater the absolute risk of overall mortality and SCD. SCD accounts for 64%, 50%, and 33% of deaths in patients with NYHA functional class II, III, and IV HF, respectively (HF progression accounts for 50% of deaths in NYHA class IV patients). Syncope is an important risk factor for SCD in patients with NICM.LVEF reduction is considered the main risk factor for SCD and total mortality in patients with HF. However, few studies have evaluated LVEF as a risk factor for SCD in patients with NICM. The Marburg Cardiomyopathy Study (MACAS), a prospective cohort of 343 patients with NICM, revealed that for every 10% reduction in LVEF, there was a relative risk of 2.28 for major arrhythmic events (patients in sinus rhythm).The prevalence of wide QRS complexes among patients with HF ranges from 20% to 50% and is associated with increased SCD and total mortality rates; however, in cohort studies of patients with NICM, there was no significant relationship between QRS prolongation and increased risk of SCD.Holter monitoring may be useful for risk assessment as it allows investigating the presence of NSVT and measuring autonomic activities (heart rate variability and heart rate turbulence). The incidence of NSVT among patients with NICM ranges from 30% to 79%, but its use in the risk stratification of arrhythmic events is controversial.2), minute ventilation/carbon dioxide production (VE/VCO2) slope, and presence of periodic breathing are independently associated with an increased risk of combined events. Combinations include total mortality, cardiac mortality, heart transplantation, hospitalization, and need for VAD.A meta-analysis has suggested that cardiopulmonary exercise testing variables such as oxygen uptake  gene are among the most studied conditions. Such mutations are found in 6% to 8% of NICM cases and may reach up to 30% when combined with conduction system diseases and skeletal muscle involvement.Several studies have evaluated the association between genetic mutations and the pathophysiology and prognosis of NICM, particularly in patients with familial disease.These patients show higher rates of mortality, ventricular arrhythmias, and HF hospitalizations.For each percent increase in late gadolinium enhancement (LGE) volume, the risk of mortality or arrhythmic events is estimated to increase by 3% to 20% . In the largest cohort of patients with NICM undergoing CABG surgery,Gulati et al. reported that the combined endpoint of SCD and aborted SCD occurred in 29.6% of patients with myocardial fibrosis and in 7.0% of patients without fibrosis. The HR for presence of fibrosis was 4.61 , and the HR for extent of fibrosis was 1.10 . These results suggest that MRI may be useful for the risk stratification of patients with NICM.According to a recent meta-analysis of 34 studies including 4,554 patients, approximately 44% of patients with NICM have myocardial fibrosis (an important arrhythmogenic substrate).is the largest study and included patients with ischemic and nonischemic heart disease and NYHA functional class II-III HF. Among patients implanted with an ICD, 33.2% received at least one shock, with 22.4% receiving only appropriate shocks and 10.7% receiving only inappropriate shocks.In the DANISH study, a randomized trial of patients with NICM whose primary endpoint was all-cause mortality, 556 patients received ICD therapy and 560 received only ODT.In a median follow-up duration of 67.6 months, the primary outcome occurred in 21.6% of the ICD group and in 23.4% of the control group, with no significant differences (p = 0.28).Several studies have evaluated the impact of ICDs on patients with NICM. The SCD-HeFTThe current recommendations for ICD implantation in patients with NICM are listed inHCM is characterized by the presence of varying degrees of asymmetric LV hypertrophy, provided that there are no other conditions that may explain this abnormality. It may result in diastolic HF, LVOT obstruction, atrial and ventricular arrhythmias, and, in some cases, SCD.Most patients have no symptoms, with SCD often being the first manifestation of the disease.Hypertrophic cardiomyopathy (HCM) is a genetic disease caused by an autosomal dominant mutation in genes encoding sarcomere proteins, with a prevalence of approximately 1:500.In 1958, Teare reported on a series of eight patients with asymmetric myocardial hypertrophy (the nomenclature was not consolidated at the time) or hamartoma and correlated the anatomical findings with a higher occurrence of SCD in young adults. Pathology findings consisted of a coarse disarray of the muscle bundles with hypertrophy of the individual muscle fibers and their nuclei.Before the ICD was introduced, the mortality rate was approximately 1.5% per year; after its introduction, the mortality rate has decreased to 0.5% per year.The annual risk of SCD in patients with an HCM diagnosis is approximately 1%; however, some patients may be at higher risk because of certain characteristics.Maron et al. conducted a longitudinal, single-center study including a large cohort of 2,094 patients with HCM followed up for 17 years. Of 527 patients with a primary prevention ICD implanted based on at least one conventional risk factor, 15.6% experienced appropriate ICD interventions (ventricular tachycardia [VT]/ventricular fibrillation [VF]), corresponding to almost 50 times the number of events in the non-ICD group.Individual characteristics, clinical manifestations, family history, and definitions of risk factors may hinder patient selection, in addition to the fact that SCD is uncommon in clinical practice.Patients who are more likely to benefit from ICDs are identified through noninvasive tests such as clinical history, ECG, stress test, Holter monitoring, echocardiography, and cardiac magnetic resonance (CMR). Conventional risk factors for SCD include a family history of HCM-related SCD, unexplained syncope occurring within 6 months of evaluation, NSVT, septal thickness \u2265 30mm, and risk modifiers such as a hypotensive response during stress test, LV fibrosis, and HF with LVEF < 50%.Risk stratification for an ICD indication in patients with HCM should be performed periodically, every 1 or 2 years.HCM is the leading cause of SCD in patients aged < 40 years, mostly resulting from VF. Thus, ICD implantation is the most effective strategy to reduce mortality in high-risk patients despite higher costs and the possibility of complications, discomfort, and psychological stress.In this setting, the likelihood of experiencing appropriate ICD therapies seems to be similar among patients with 1, 2, 3, or more conventional risk factors (primary prevention), which suggests that the presence of a single marker may justify ICD implantation. Among conventional risk factors, a family history of SCD likely or definitely due to HCM in first-degree relatives aged \u2264 50 years, especially during childhood or adolescence, is highly significant.Another risk marker for SCD is the extent and magnitude of hypertrophy, especially when wall thickness \u2265 30mm; borderline thickening (28 to 29 mm) may be considered at the cardiologist\u2019s discretion. Spirito et al. evaluated 480 patients and reported that SCD incidence was almost twice as high for each 5-mm increase in ventricular myocardial thickness, reaching 1.8% per year in those with wall thickness \u2265 30mm.An ICD indication for HCM is not based on randomized clinical trials but rather on observational studies. Studies of patients with HCM and implanted ICDs reported that life-threatening events with appropriate ICD therapy occur at rates of 12% per year in secondary prevention and 4% per year in primary prevention.The presence of unexplained syncope  has been strongly associated with SCD risk in patients with HCM, especially if occurring within 6 months of initial evaluation. These patients had a 5-fold higher risk compared with those without syncope. Remote episodes of syncope  did not correlate with an increased risk of SCD.NSVT is defined by the presence of 3 or more episodes with 3 or more repetitive ventricular beats and/or 1 or more prolonged episode with 10 or more beats at a rate of \u2265 130bpm on 24-hour or 48-hour Holter monitoring. Reported NSVT incidence in patients with HCM has ranged from 20% to 46%. In patients with HCM, VT episodes are undoubtedly associated with SCD; however, data are less robust for demonstrating that the presence of NSVT alone is an independent risk factor. Conversely, the risk increases in the presence of risk modifiers, especially LV fibrosis.Genetic counseling is important in patients with HCM. Identifying carriers of specific genetic mutations may help investigating the disease in close relatives. Because patients with positive gene tests are likely to develop HCM, they should be closely monitored for symptoms and risk factors over time.A Brazilian study of high-risk patients with HCM and implanted ICDs found myocardial fibrosis in 96.4%, with a mean fibrosis rate of 15.96%. This suggests that fibrosis may be more sensitive than other conventional risk markers.Chan et al. reported that LGE \u2265 15% of LV mass was associated with a 2-fold higher risk of SCD in patients otherwise considered low risk.There is growing evidence of the relationship between myocardial fibrosis on CMR and SCD risk, which is considered a risk modifier.Klopotowski et al. prospectively analyzed 328 patients with HCM undergoing CMR to evaluate whether LGE location could be used as an auxiliary tool in the risk stratification of SCD. LGE suggesting the presence of fibrosis outside the interventricular septal region in patients with HCM was associated with an increased risk of SCD or its equivalent, such as unstable VT or appropriate ICD therapy. Considering the risk calculator developed by the European Society of Cardiology (ESC), the presence of fibrosis outside the interventricular septal region in intermediate-risk patients may help identify those who are more likely to benefit from ICD and thus favor an ICD indication.Although the ESC has encouraged the use of the risk calculator in patients with HCM, the tool has a low sensitivity to determine whether an ICD should be implanted in high-risk patients. The American society strategy is to analyze risk factors alone or combined with risk modifiers in each patient with HCM. This strategy has a sensitivity of 95% for predicting potentially fatal VT events, being superior to the mathematical model of the ESC risk score, whose sensitivity is approximately 34%. Conversely, the ESC risk calculator is more sensitive for identifying patients who are truly low-risk (those with a lower likelihood of events), approximately 92% vs 78% of the American society strategy, and this avoids unnecessary ICD implantations.Abnormal responses or exercise-induced hypotension affect 1 in 3 patients with HCM. The mechanism reflects an exacerbated fall in systemic vascular resistance due to an autonomic dysfunction and/or dynamic obstruction of the LVOT. In young patients, an abnormal blood pressure response is associated with an increased risk of SCD.Rowin et al. retrospectively evaluated 1,940 patients with HCM and found LV aneurysms in 93 of them (4.8%). The adverse event rate was 6.4% per year, which is 3 times higher than that observed in patients without aneurysms, and included SCD, appropriate ICD therapy, thromboembolic events, and end-stage HF with LVEF < 50%. Fifty-four patients were implanted with an ICD for primary prevention, including 19 in whom the aneurysm alone was considered a risk factor. Appropriate ICD interventions for VT/VF were experienced by 20% of patients. Patients with apical aneurysms had an arrhythmic event rate of almost 5% per year, over 5-fold higher than that in patients without aneurysms, suggesting an equivalence to other conventional risk markers in high-risk HCM populations.The identification of a LV apical aneurysm on echocardiography or CMR regardless of size may be associated with an increased risk of sustained monomorphic VT.Subcutaneous ICDs are potentially advantageous, especially in young people, considering the device capability to preserve the venous system and avoid chronic lead complications (as long as ventricular pacing is not required). Conversely, the effectiveness of subcutaneous ICDs in aborting VF in patients with HCM remains uncertain..Chagas disease is caused by the protozoanChronic Chagas cardiomyopathy (CCC) has very marked pathophysiological characteristics and is the most common and severe clinical form of the disease, with increased morbidity and mortality rates in Latin America and in countries with significant immigration.Trypanosoma cruziin Latin American and other countries.Based on previous estimates and considering the worst-case scenario, 3 to 5 million infected individuals are expected to manifest clinical forms of the disease in the chronic phase.Eight to 10 million people are estimated to be infected withThe estimated average annual mortality rate of CCC is 4% but may range from 1% to 10% according to risk stratifications based on clinical characteristics and simple cardiac tests.Variables such as presyncope and syncope, LV dysfunction and HF, sustained ventricular tachycardia (SVT) or NSVT, severe bradyarrhythmia (SND and AV block), and recovered cardiac arrest were identified as risk markers for SCD. Conversely, ventricular extrasystoles alone on Holter monitoring and RBBB do not significantly affect the prognosis of CCC.In addition to risk stratification criteria, several markers of poor prognosis have been identified by different studies, especially regarding SCD in different clinical settings.Refractory HF accounts for approximately 25% to 30% of deaths. The correlation between CCC stages and causes of death was recently described: SCD is more prevalent in stage III, whereas the prevalence of death from HF progressively increases from stage I to IV.SCD accounts for approximately 55% to 65% of all death causes and is often associated with HF manifestations, although it may also occur in patients with asymptomatic LV dysfunction.Thus, the structural abnormalities of CCC  represent the ideal anatomical substrate because they promote unidirectional blocks and slow conduction areas favorable to electrical reentry triggering. The triggers that affect this anatomical substrate, named ventricular extrasystoles, are invariably present and complete the key elements for the onset of reentry ventricular tachyarrhythmia.Thus, NSVT may affect approximately 40% of patients with CCC and abnormal segmental mobility and practically all patients with global LV systolic dysfunction and HF.SVT, which has a more ominous prognosis, occurs spontaneously and can be reproduced on EPS in approximately 80% to 85% of patients.The main mechanism of sudden death in CCC is arrhythmogenic, and SVT with subsequent VF accounts for the vast majority of fatal events.Complete AV block, although less common, is another cause of SCD in CCC, resulting from necrotic degeneration and diffuse fibrosis predominantly in the AV region.As previously mentioned, SCD may also result from massive pulmonary thromboembolism or systemic thromboembolism in vital organs. Exceptionally, SCD may be due to a ruptured LV apical aneurysm.The score was also used elsewherein a retrospective cohort of 149 patients. The hypothesis that the presence of VT on cardiac stress test or Holter monitoring, LVEF < 0.50, and QRS > 50ms on SAECG could identify patients with CCC at risk of death in 5 years was raised. Low-risk groups are characterized by the absence or presence of one risk factor, intermediate-risk groups by the presence of two risk factors, and high-risk groups by the presence of three risk factors.Rassi et al. developed a risk score to predict death in patients with CCC based on clinical variables and routine cardiac tests.However, there is no scientific evidence to support an ICD indication for primary prevention of SCD in CCC. There are many pathogenetic and pathophysiological characteristics that hinder any direct comparison with the results of studies evaluating other heart diseases.The most significant characteristic is that many patients with CCC, even those with preserved LV function, already have substrates for potentially fatal arrhythmias study is an ongoing open-label, randomized, multicenter clinical trial whose aim is to compare the efficacy of ICD therapy vs amiodarone for the primary prevention of all-cause mortality in patients with CCC and NSVT stratified by the Rassi risk score.The estimated prevalence of ARVC ranges from 1:1,000 to 1:5,000 in the general population, representing a leading cause of SCD in athletes and young adults.Arrhythmogenic RV cardiomyopathy (ARVC) has an autosomal dominant mode of inheritance and variable penetrance, which causes mutations in genes encoding cell adhesion proteins, named desmosomes. ARVC predominantly affects the RV but may also affect the LV in approximately 0.5% of cases, resulting in myocardial tissue replacement by fibrosis and adipose tissue. Such structural changes often cause ventricular arrhythmias and SCD.Ventricular arrhythmias, syncope, and SCD occur particularly in the second and third decades of life, usually during a physical activity. Syncope is reported in 16% to 39% of patients with ARVC at the time of diagnosis, is often related to physical activity, and has been associated with an increased risk of arrhythmias.Frequent ventricular extrasystoles, NSVT, and SVT are important predictors of cardiac events, and SVT is an important predictor of SCD and appropriate ICD therapies. SCD may be the first manifestation of ARVC.Ventricular arrhythmias usually originate in the RV (LBBB morphology), but the QRS axis during SVT often differs from the RV outflow tract (RVOT). Many patients may have QRS complexes with different morphologies.Regions of fibrofatty tissue create areas of delayed ventricular activation, resulting in fractional deflections at the end of the QRS complex (epsilon waves) and late potentials on SAECG. In patients with suspected ARVC, performing an SAECG may be useful for diagnosis and risk stratification . On CMR, SAECG abnormalities are related to ARVC severity and the occurrence of adverse events.CMR uses LGE to provide information regarding ventricular function, cardiac chamber size, segmental abnormalities, and extent of fibrosis. LGE has demonstrated biventricular and LV involvement alone in 34% to 56% and 4% to 9% of patients, respectively. LGE areas on CMR are related to the location of the ventricular arrythmia substrate, identified by endocardial and epicardial electrophysiological mapping.The diagnostic criteria for ARVC are listed inThe value of EPS as a risk predictor of SCD in asymptomatic ARVC is uncertain . In patients implanted with an ICD for primary prevention, inducible SVT is not a predictor of appropriate shocks.Genetic tests performed on probands with suspected ARVC are positive in 30% to 54% of cases. Importantly, a negative test does not rule out the disease, and a positive test does not define the course of treatment. ARVC is detected in approximately 35% to 40% of first-degree relatives, and clinical screening with ECG, Holter monitoring, stress test, and cardiac imaging may identify family members at risk for ARVC.Randomized trials evaluating the best option among antiarrhythmic drugs for the treatment of SVT are lacking. An observational study reported suppression of inducible VT with sotalol in 58% of patients; only 10% of patients had recurrent arrhythmias.In another observational registry, beta-blockers and sotalol were not associated with a reduction in ventricular arrhythmias, whereas amiodarone was superior in preventing them in a small cohort.Finally, SVT ablation reduces recurrent arrhythmias but does not eliminate the need for ICD implantation.Asymptomatic patients without ventricular arrhythmias should receive only beta-blockers and undergo periodical evaluations of ventricular function and arrhythmia.A recent systematic review including 610 patients followed up for a mean period of 3.8 years revealed annual rates of appropriate and inappropriate shocks of 9.5% and 3.7%, respectively.Patients with a history of aborted SCD, poorly tolerated SVT, and syncope are at increased risk of SCD, with an annual rate > 10%. ICD implantation is indicated in these cases. Different cohorts have shown SVT, unexplained syncope, frequent NSVT, family history of early SCD, extensive RV involvement, very prolonged QRS complexes, LGE on CMR, LV dysfunction, and inducible SVT on EPS as risk factors for SCD or appropriate shock.An ICD indication for primary prevention of ARVC is difficult to assess and should rely on detailed clinical evaluation, including family history, RV and LV dysfunction severity, long-term ICD complications, and psychological and economic impacts. ICD indications for primary prevention of ARVC are listed inPredictive variables included male sex, age, syncope in the last 6 months, previous NSVT, number of ventricular extrasystoles on 24-hour Holter monitoring, number of leads with inverted T wave in the inferior and anterior leads, and RV ejection fraction. This new model allowed greater refinement in patient selection for ICD implantation when compared with the 2015 International Task Force flowchart, reducing the rate of implant indication by 20.6%.The authors of the new model have launched an online risk calculator (www.arvcrisk.com) that calculates the risk of ventricular arrhythmia in 5 years. Although it does not determine an acceptable risk threshold for ICD implantation, the model is believed to help in the decision-making process for primary prevention.A new model for predicting ventricular arrhythmias in ARVC was recently published.Both ventricles are involved in 22% to 38% of patients. Left ventricular noncompaction (LVNC) occurs alone or in combination with other congenital heart diseases.Noncompaction cardiomyopathy (NCCM) is a rare congenital abnormality characterized by the formation of prominent trabeculations and deep intertrabecular recesses in the LV and RV. It occurs during the endomyocardial morphogenesis phase , most commonly reaching the LV apex.An autosomal dominant mode of inheritance is present in at least 30% to 50% of patients. Several genes that cause LVNC have already been identified, and they generally encode sarcomere (contractile apparatus) or cytoskeletal proteins.The clinical manifestations of NCCM are heterogeneous, ranging from completely asymptomatic cases to cases of severe and fatal manifestations such as HF, thromboembolism, AV and IV blocks, ventricular arrhythmia, and SCD. Predictors of higher mortality include age, LV end-diastolic diameter, symptomatic HF, permanent or persistent AF, bundle branch block, and associated neuromuscular diseases.CMR allows visualization of noncompacted and compacted myocardial segments and is able to identify thrombi and myocardial fibrosis.Echocardiography is routinely performed during initial investigations, and contrast use may improve diagnostic sensitivity.Histological examination shows continuity between the ventricular endocardium and the deep intertrabecular recesses; the latter may facilitate arrhythmogenesis by forming reentry circuits underlying the scar tissue, predominantly at the LV apex and mid-apical segments.SCD is the leading cause of death in NCCM and may occur at any age. There are no diagnostic tools for accurate risk stratification in these patients. Ventricular arrhythmias are reported in 38% to 47% of cases, and SCD occurs in 13% to 18% of patients.Endocardial and/or epicardial catheter ablation seems to be useful in patients implanted with an ICD who have frequent ventricular arrhythmias.The rate of appropriate shocks in these patients, in secondary prevention, ranged from 33% to 37% during a mean follow-up period of 34 to 40 months.Steffel et al. showed that SVT inducibility on EPS has limited value in the risk stratification of NCCM; in contrast, noninducibility may identify low-risk patients.However, a study of 77 patients with NCCM showed that LV dysfunction and dilation were not prominent in patients receiving an ICD for secondary prevention, which means that these criteria are fragile for primary prevention indication. Conversely, the presence of NSVT was more common in patients receiving secondary prevention compared with those receiving an ICD for primary prevention or those who did not undergo ICD implantation. Other risk factors that should be considered are family history and syncope.There are no convincing data demonstrating that LVNC alone is sufficient for an ICD indication. The indication should be guided by the severity of LV systolic dysfunction and the presence of sustained ventricular arrhythmia (similar to idiopathic dilated cardiomyopathy). is characterized by QT interval prolongation and polymorphic ventricular arrhythmias often triggered by adrenergic stimulation.Hundreds of mutations have been described in more than 13 different genes encoding ion channels that restore cardiomyocyte resting potential. LQTS may be inherited via an autosomal dominant pattern of transmission (Romano-Ward), such as in LQTS types 1 to 6; an autosomal recessive pattern associated with congenital deafness and very prolonged QT intervals (Lange-Nielsen); or an autosomal dominant pattern associated with extracardiac disorders, dysmorphism, and hypokalemic or hyperkalemic periodic paralysis .The risk of sudden death depends on several factors, such as the type of mutation causing the phenotype, QT interval duration, and the presence of symptoms. Patients with a very prolonged QT interval (QTc > 500ms) or recurrent syncope may be at an annual risk of sudden death of up to 5%.Short QT syndrome (SQTS) is defined by a QTc interval < 340ms or < 360ms in survivors of cardiac arrest due to VF/VT, a family history of sudden death in those aged < 40 years, and the presence of a confirmed mutation or a family history of short QT. SQTS is a rare condition in which mutations in genes encoding potassium channels can be found in up to 20% of cases.Some patients with short QT may benefit from quinidine. Survivors of cardiac arrest should undergo ICD implantation, whereas asymptomatic patients should be closely monitored. The recommendations for ICD implantation for primary prevention of long and short QT syndromes are listed in1and V2(coved type) in the second, third, or fourth intercostal space in combination with the occurrence of polymorphic ventricular arrhythmia, syncope, or cardiac arrest. ST-segment elevation may occur spontaneously or be induced by sodium channel blockers such as ajmaline and procainamide.Brugada syndrome is characterized by ST-segment elevation > 2mm in leads V(Patients with a spontaneous ECG pattern (type 1) associated with unexplained syncope or recovered cardiac arrest are at greatest risk of sudden death. ICD implantation is associated with risk reduction in symptomatic patients.SCN5Agene is involved in most mutations, but a negative genetic test does not rule out the diagnosis.The phenotype of Brugada syndrome is associated with detectable genetic defects in up to 30% of cases. TheSeveral factors may trigger ECG manifestations or precipitate arrhythmic episodes, such as fever, anesthetic agents, and various psychotropic drugs (www.brugadadrugs.org).Asymptomatic patients are at lower risk of sudden death. The role of programmed electrical stimulation (PES) in risk stratification is controversial. Brugada et al. found an association between polymorphic VT induction with up to 2 extrastimuli in the RV and the risk of death in asymptomatic patients. Arrhythmia induction with 3 extrastimuli reduces specificity and should be avoided. Other studies reported reductions in the positive predictive value of PES over time.Patients in electrical storm triggering ICD shock therapy may benefit from clinical management with quinidine and from epicardial ablation of abnormal RV activation regions identified by electroanatomical mapping.RyR2) and a rare recessive variant caused by a mutation in the cardiac calsequestrin gene (CASQ2).Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a rare arrhythmogenic genetic disorder characterized by adrenergic-induced bidirectional and polymorphic VT. The estimated prevalence of the disease is 1:10,000. Two types of genes have been identified: a dominant variant secondary to a mutation in the cardiac ryanodine receptor gene .A maximally tolerated beta-blocker dose is the treatment of choice. Flecainide and left thoracoscopic cardiac sympathectomy may be used as adjunctive therapies. and the chance of complications associated with young patient age.A recent systematic review reported incidence rates of 40% for shocks, 19.6% for electrical storms, 1.4% for post-implant mortality, and 32.4% for additional complications  in patients whose mean age was 15 years (11 to 21 years).Ventricular arrhythmias in patients with normally structured hearts are mostly benign. However, a small number of patients may have malignant forms of monomorphic or polymorphic VTs and even ventricular fibrillation.Many of these tachycardias are triggered by ventricular ectopics originating in very similar locations compared to those of benign aspect . The exact mechanism of malignant ventricular arrhythmias is not completely understood yet. Anisotropy associated with slow conduction and functional block caused by rapid arrhythmogenic foci likely results in rhythm degeneration to VF and polymorphic VT.The recommendations for ICD implantation for primary prevention of idiopathic ventricular arrhythmias are listed inHigh-risk characteristics are related to syncope or cardiac arrest and ECG findings of a short coupling interval in the first or second extrasystole, NSVT with short cycles, wide QRS complex (in VT or sinus rhythm), and polymorphic VT.The few patients who survive cardiac arrest due to VT/VF are at high risk of recurrence of potentially fatal tachyarrhythmias. Thus, preventive measures are essential and include treatment of underlying heart disease and comorbidities, use of antiarrhythmic drugs, and adequate patient selection for ICD implantation.Cardiac arrest due to VT/VF and subsequent SCD constitute a serious public health issue, accounting for approximately 50% of all cardiovascular deaths. Additionally, the survival rate of out-of-hospital cardiac arrest is significantly low, ranging from 6% to 10%.In patients with ischemic or dilated heart disease, the protective role of drugs such as beta-blockers, angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), and statins, which reduce total, cardiovascular, and sudden deaths, is well known.including more than 35,000 patients with LV dysfunction (LVEF <40%) revealed that beta-blockers, ACEIs, ARBs, and mineralocorticoid receptor antagonists reduce the risk of SCD compared with placebo . When combined with ODT, ICD implantation provides additional benefits by reducing SCD rates . More recently, the combination of a neprilysin inhibitor (LCZ696) with an ARB  was shown to be even more efficient than enalapril in reducing both HF and arrhythmic deaths.Thus, whether LCZ696 has a primary antiarrhythmic function or whether cardiac arrhythmia reduction results from clinical HF improvement remains unknown.A meta-analysisAt 6-year follow-up, event-free survival (cardiac death or VT) was 41% in the amiodarone group vs 20% in the standard therapy group. However, the absence of a placebo group prevents a conclusion on whether the outcomes could be explained by amiodarone use or by the risks associated with other antiarrhythmic drugs.For several years, antiarrhythmic drugs were the main strategy for secondary SCD prevention, although their use was based on only a few studies that reported a high rate of recurrent events. Until the early 1990s, class I agents  were believed to reduce ventricular extrasystoles and mortality. A subsequent demonstration of the deleterious effects of these drugs after AMI and in HF led amiodarone to become the treatment of choice in these patients. The Cardiac Arrest in Seattle: Conventional versus Amiodarone Drug Evaluation (CASCADE) study enrolled 228 survivors of cardiac arrest who were randomly assigned to empiric treatment with amiodarone or class I drugs guided by EPS or 24-hour Holter monitoring.study compared antiarrhythmic therapy  vs ICD in 1,016 patients with either recovered cardiac arrest due to VT/VF, VT causing syncope, or hemodynamic compromise and LVEF < 40%. Survival was significantly improved in the ICD group at 1 year (89.3% vs 82.3%), 2 years (81.6% vs 74.7%), and 3 years (75.4% vs 64.1%) (p < 0.02). The study was mostly criticized for the greater number of patients on beta-blockers in the ICD group compared with the antiarrhythmic therapy group. A subsequent analysis reported that ICD implantation mostly benefited patients with lower LVEF.Survival did not differ significantly among patients with LVEF > 35%. In patients with LVEF between 20% and 34%, 1-year survival was 89.6% vs 79.8% and 2-year survival was 82.5% vs 71.8% (p < 0.05) in the ICD and antiarrhythmic groups, respectively. In patients with LVEF < 20%, 1-year survival was 82.4% vs 73% and 2-year survival was 71.6% vs 63.8%, with no significant differences.The ICD is considered a major advance in secondary SCD prevention, and its benefits have been evaluated in several randomized clinical trials. The Antiarrhythmics Versus Implantable Defibrillators (AVID)evaluated amiodarone vs ICD in 659 patients with documented VF, recovered cardiac arrest, VT causing syncope, VT > 150bpm/min causing presyncope or angina in patients with LVEF <35%, or syncope associated with inducible VT or documented spontaneous VT. Total mortality after a mean follow-up period of 4 years was 27% in the ICD group vs 33% in the amiodarone group, with no significant differences. A subsequent analysis reported that ICD implantation was superior in patients with two of the following criteria: LVEF < 35%, NYHA functional class III or IV HF, and age > 70 years.After a mean follow-up period of 5.6 \u00b1 2.6 years, mortality was 47% in the amiodarone group vs 27% in the ICD group (p = 0.002).The Canadian Implantable Defibrillator Study (CIDS)included 349 survivors of cardiac arrest who were randomly assigned to treatment with propafenone, amiodarone, metoprolol, or an ICD. Propafenone treatment was discontinued after an interim analysis found increased mortality compared with ICD implantation. After a mean follow-up period of 2 years, total mortality was 12.1% in the ICD group vs 19.6% in the amiodarone and metoprolol groups combined, with no significant differences.The Cardiac Arrest Study Hamburg (CASH)Patients with LVEF <35% benefited the most at 6-year follow-up .A meta-analysis evaluating the results of those 3 studies demonstrated relative reductions of 50% in arrhythmic mortality (p < 0.0001) and 28% in total mortality among patients with an ICD compared with those who received antiarrhythmic treatment .The results showed reduced mortality in the ICD group and no benefits from performing an EPS.The Midlands Trial of Empirical Amiodarone versus Electrophysiology-guided Interventions and Implantable Cardioverter-defibrillators (MAVERIC) compared EPS-guided therapies  vs empirical amiodarone in patients with SVT or recovered cardiac arrest.The recommendations for ICD implantation in secondary prevention are based on those studies .Channelopathies are genetically determined diseases involving different types of cardiac ion channel dysfunctions, such as increased or reduced ion channel function and ionic imbalance These conditions increase the risk of potentially fatal tachyarrhythmias and SCD.The range of genetic mutations is extremely wide, with a large overlap of phenotypic expressions. Congenital LQTS, Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia (CPVT), SQTS, J-wave syndrome, and early repolarization are classified as channelopathies. Although other mechanisms may be involved in the development of idiopathic VF, sudden arrhythmic death syndrome, and sudden childhood death syndrome, these are included in this section because of the predominant arrhythmic manifestation of VT/VF in the absence of structural heart disease. A detailed discussion of the characteristics of each channelopathy phenotypic expression is outside the scope of this guideline, but an extensive literature is available.In special situations, the clinical decision to implant an ICD should also consider other therapeutic options or adjuvant therapies, such as left cardiac sympathetic denervation in LQTS  may indicate the need for an ICD for SCD prevention given the strong association between syncope and potentially fatal ventricular arrhythmias.whereas inducible VF is considered a nonspecific finding.Conversely, patients without inducible SVT are considered low-risk and the Department of Congenital Heart Diseases and Pediatric Cardiology (DCC-CP) have recently published the Cardiac Arrhythmias in Children and Congenital Heart Diseases Guideline with the aim of standardizing the diagnosis and treatment of children with cardiac arrhythmias.It is extremely important that physicians seek alternatives to avoid an ICD indication in children, as long as they do not result in increased risk. Adequate options of clinical treatment should be exhausted and, when indicated, ablation of arrhythmogenic foci should be considered.Unlike in the adult population, there is no evidence to support routine use of ICDs in pediatric patients based on LV dysfunction alone. ICD implantation in children should be an exception because pulse generator size and lead caliber are associated with technical difficulties due to small body size, limited sites for generator pocket creation , limited access routes, risk of venous thrombosis/obstructions, and increased risk of extrusion.Clinical and electronic follow-up should include ECG and routine assessment by telemetry as well as periodic radiological assessment, which is essential to monitor lead behavior as the child grows. Lead implantation should be careful to leave a redundant curve to allow for patient growth without the need for multiple interventions.Electronic programming of the device in children also differs from that in adults. The PM function should consider a baseline pacing rate adjusted for age and type of heart disease, usually ranging from 90 to 160 ppm . Importantly, a rate-adaptive AV interval and a short but adequate post-ventricular atrial refractory period should be programmed to avoid tachycardia due to electronic reentry, given that these patients usually exhibit good ventriculoatrial conduction.Children may develop sinus tachycardia with increased heart rates very easily, which could result in inappropriate shock delivery with a major psychological impact. Inappropriate shocks, especially if immediately after implantation, may lead the patient to distrust the device and medical staff and develop difficult-to-treat panic syndrome.Electronic ICD programming and clinical follow-up should be even more careful.In case of monomorphic VT development, ablation should be conducted whenever possible.Polymorphic VTs respond better to early shock delivery and commonly deteriorate to VF during ATP attempts.The criteria for arrhythmic detection and classification must be rigorously defined. Therapies should be restricted to shocks, and antitachycardia pacing (ATP) should be avoided because potentially fatal arrhythmias rarely manifest as monomorphic VTs.However, use of larger generators and parasternal leads may cause local discomfort and image issues in thinner patients. Another limitation of subcutaneous ICDs is the inability to provide long-term antibradycardia pacing. These devices have been associated with inappropriate shocks due to a greater susceptibility to extracardiac noise detection.In adolescents, subcutaneous ICD placement may be an interesting option given that subcutaneous systems do not require intravascular leads.The main indications for ICD implantation in children and adolescents are summarized inThe evolution of surgical treatment for congenital heart diseases has led to increased survival rates among young adults. The presence of myocardial scarring secondary to the underlying congenital heart disease or to surgical treatment may result in complex ventricular arrhythmias or even SCD in these patients.A hybrid approach combining surgical repair of structural abnormalities and arrhythmia ablation guided by pre- or intraoperative mapping has been successfully used for reducing the incidence of arrhythmias.Pulmonary valve replacement alone in patients with TOF results in hemodynamic and functional improvement but does not eliminate VT risk. SCD risk assessment should be conducted postoperatively to evaluate whether an ICD should be indicated.There is a significant correlation between residual hemodynamic abnormalities and VT in patients undergoing surgical correction of tetralogy of Fallot (TOF). RV hypertrophy and dilation together with residual RVOT obstruction and regurgitation are considered risk factors for VT and SCD.The rate of appropriate shocks in these patients ranged from 3% to 6% per year, and the rates of inappropriate shocks (15% to 25%) and complications (26% to 45%) were higher than those of other populations.Thus, an ICD indication in this population should consider cost-effectiveness and psychological impact.Approximately 50% of ICD implants in adults with congenital heart disease are indicated for secondary prevention in patients between 36 and 41 years of age.ICD implantation in adults with congenital heart disease may be challenging because of anatomical complexity, intracardiac shunts, and limited vascular access. A subcutaneous ICD may be a good option for these patients.An ICD indication for primary prevention in patients with congenital heart disease is controversial. Kairy et al. proposed a risk score for patients undergoing surgical correction of TOF in which a score > 5 is considered sufficient to indicate an ICD. The score included the following criteria: previous palliative shunt (2), inducible SVT on EPS (2), QRS \u2265 180ms (1), ventriculotomy (2), NSVT (2), and LV end-diastolic pressure \u2265 12mmHg (3).Inducible SVT on EPS in patients with congenital heart disease does not seem to correlate with the occurrence of appropriate shocks.In some cases, catheter ablation of recurrent monomorphic SVT may be an effective alternative to prevent ICD implantation.Patients with surgically repaired TOF account for approximately 50% of ICD implantations in adults with congenital heart disease. Annual rates of appropriate shocks in this population have been reported at up to 7.7% in primary prevention and 9.8% in secondary prevention.Among patients with operated congenital heart disease, those with transposition of the great arteries (TGA) via atrial switch procedure, Ebstein anomaly, aortic valve stenosis, and single ventricle physiology are at higher risk for SCD.Additionally, myocardial perfusion studies have identified RV ischemia and infarction in more than 40% of patients.Risk factors for cardiac arrest in patients who had atrial switch procedures include previous ventricular septal defect closure, HF symptoms, atrial arrhythmia, right ventricular ejection fraction between < 30% and 35%, and QRS > 140ms.A multicenter study evaluating patients who had atrial switch procedures and ICD implants reported that the lack of beta-blockers was associated with a high risk of appropriate ICD therapy.Since atrial arrhythmias often precede SVT in patients with TGA, atrial tachycardia treatment should be intensified.Patients with a previous Senning or Mustard procedure are at higher risk for SCD, especially during exercise. In these patients, atrial switch procedures may result in increased volume and consequent stenosis of the pulmonary veins and increased end-diastolic pressures.Patients with moderate to severe congenital heart disease are at even greater risk of SCD, accounting for approximately 25% of all causes of cardiac death.SCD risk is higher among patients with adult congenital heart disease  compareNKX2-5gene, which is associated with early SCD risk. A positive genetic test warrants ICD implantation.Family history and presence of septal defects, cardiomyopathy, or conduction system blocks may be related to a mutation in thePatients with complex forms of congenital heart disease and multiple surgical interventions in the first decades of life and patients with hypertrophy with subsequent subendocardial ischemia are at increased risk of potentially fatal ventricular arrhythmias. Other risk factors for SCD in patients with congenital heart disease include greater disease complexity, ventricular and supraventricular arrhythmias, progressive increase in QRS duration, systemic ventricular dysfunction, and subpulmonary ventricular dysfunction. A history of unexplained syncope in adults with moderate to severe congenital heart disease may be suggestive of SCD risk; in such cases, an EPS may be performed to assess the need for an ICD.In patients without vascular access or with a previous Fontan procedure, the risks of epicardial ICD implantation may outweigh the potential benefits; therefore, subcutaneous ICD implantation or heart transplantation should be considered.Adults aged 40 to 50 years account for 40% to 67% of patients with congenital heart disease who receive an ICD for primary prevention. In these patients, the rates of appropriate shocks ranged from 14% to 22% in the first 3 to 5 years of follow-up.Conversely, amiodarone is usually reserved for patients with symptomatic arrhythmias or for prevention of worsening ventricular function.The safety of antiarrhythmic therapy in patients with congenital heart disease may be affected by the presence of ventricular hypertrophy and dysfunction. Flecainide use was associated with proarrhythmia in 5.8% of patients and SCD in 3.9%.The main recommendations for ICD placement in adult patients with congenital heart disease are listed inChoosing Implantable Cardioverter-defibrillator Type and Pacing ModeOnce an ICD is indicated for SCD prevention, the physician must choose the surgical technique for device implantation  and pacing mode .If antibradycardia pacing  is not required, a subcutaneous ICD may be a good option.In the absence of an atrial septal defect, patients weighing > 15kg normally undergo transvenous implantation.Furthermore, in patients with LV remodeling at the time of implantation (LVEF \u2264 40% and LV end-diastolic diameter \u2265 60mm) requiring ventricular pacing, biventricular pacing is superior to RV pacing alone.In patients requiring a PM function, the choice of pacing mode is crucial. Pacing modes that prioritize the preservation of spontaneous AV and IV conductions are associated with a lower incidence of AF and ventricular remodeling related to RV pacing-induced LBBB.Therefore, after an ICD indication, the choice of pacing mode should consider whether chronotropism and AV conduction are normal, whether IV conduction follows a spontaneous or PM-induced LBBB pattern, and whether there is LV remodeling.Patients with SND and normal AV and IV conductions may receive either single- or dual-chamber ICDs provided that intrinsic conduction search algorithms are programmed to avoid PM-induced dyssynchrony.Although ICDs increase survival in patients with LV dysfunction at risk of SCD, their use is limited by high therapy costs. These costs refer to the device itself, hospital expenses, medical fees, complications, readmissions, and pulse generator and lead replacement.or life years gained (LYG),varying according to socioeconomic and cultural factors specific to each study population.Cost-effectiveness analyses consider the cost in local currency per quality-adjusted life years (QALYs)Cost-effectiveness should be analyzed in terms of mortality, based on multicenter studies. For example, if the ICD does not improve survival, it is not cost-effective. Therefore, expected survival is a key factor in cost-effectiveness analyses.Cost-effectiveness studies evaluating ICD implantation for less common diseases, such as hypertrophic cardiomyopathy and channelopathies, are lacking.The risk of death from nonarrhythmic causes should also be considered given that ICDs are not recommended for this purpose. The cost-effectiveness ratio becomes unfavorable when the survival rate of ICD candidates is < 1 year; therefore, ICD implantation in patients with high morbidity and mortality may not be cost-effective. In older patients, some studies suggest that the expected survival should be > 5 years to achieve cost-effectiveness.analyzed the results of the MADIT, MADIT II,COMPANION,MUSTT,SCD-HeFT,and DEFINITEstudies and projected that ICD use would provide a gain of 1.01 to 2.99 QALYs at a cost of US$68,300,00 to US$101,500.00. Assuming that the generator would be replaced every 5 years, cost-effectiveness was estimated at US$30,000.00 to US$70,200.00 for each QALY gained compared with the results for controls. The authors estimated that cost-effectiveness would be less than US$100,000 per QALY if the ICD reduced mortality for \u22657 years.Sanders et al.did not experience mortality reductions compared with controls; therefore, ICD implantation was not cost-effective. In the DINAMIT trial, an ICD was implanted 6 to 40 days after myocardial infarction in patients with LVEF \u2264 35% and depressed heart rate variability. The primary outcome (death from any cause) did not differ between the ICD group and the control group. The CABG Patch trial enrolled patients with coronary heart disease, EF \u2264 35%, and abnormalities on SAECG undergoing CABG surgery. Prophylactic ICD implantation at the time of CABG surgery did not reduce the primary endpoint of death from any cause. Thus, prophylactic ICD implantation in patients at high risk for sudden death  was not cost-effective in the first 40 days post-infarction or immediately after CABG surgery.In another analysis conducted by Sanders et al., patients treated with an ICD in the DINAMIT and CABG Patch trialsRibeiro et al.reported that the cost-effectiveness ratio was R$68,318 per QALY in the public setting and R$ 90,942 per QALY in the private setting. The variables with the highest impact in the analysis were the costs of ICD implantation, the frequency of generator replacement, and ICD effectiveness. In more complex study populations, such as the MADIT population, cost-effectiveness was much more favorable in the public setting  than in the private setting .A 2010 Brazilian study evaluated the cost-effectiveness of ICDs in patients with HF from both public and private health perspectives (effectiveness was measured in QALYs).The calculated cost per LYG was R$20,530.00  at the time. This calculation was based on the parameters of an incremental R$54,200.00 cost and a life expectancy of 2.64 years gained from ICD implantation compared with clinical treatment. The cost-effectiveness ratio was considered favorable for Brazilian standards.In a 2007 Brazilian study, Matos et al. evaluated the cost-effectiveness ratio of ICDs vs drug treatment per LYG.The authors concluded that cost-effectiveness would be more favorable in patients with low LVEF, including higher-risk subgroups, but not for routine use.In the UK, Buxton et al. (2006) reported costs of \u00a357,000 per LYG and \u00a376,000 per QALY over a long-term follow-up period.Estimated mean LYG and QALY were 1.88 and 1.57, respectively, and mean estimated cost per QALY was \u20ac31,717. These findings were reproduced in another European registry evaluating a primary prevention setting.Cowie et al. conducted in 2009 a meta-analysis of primary prevention studies in the European setting including patients with reduced LVEF and ICD indications according to European guidelines. Prophylactic ICD implantation was found to have a good cost-effectiveness ratio.comparable to other established therapies for cardiovascular and noncardiovascular diseases. Variables such as ICD efficacy and safety, device costs (implantation and replacement), patient characteristics, and SDC risk had the highest impact in the analysis.In a systematic review of economic evaluations, Gialama et al. (2014) reported that ICDs may have a good cost-effectiveness ratio in selected patient groups,At 3 years, ICD cost-effectiveness per LYG was estimated at $66,677.00  compared with antiarrhythmic drug therapy. The 6- and 20-year projections estimated costs of approximately $68,000 and $80,000 per LYG. In the subgroup analysis, ICD implantation was more cost-effective in patients with VF and less cost-effective in patients with EF > 35%.In the Antiarrhythmics Versus Implantable Defibrillators (AVID) study, Larsen et al. evaluated the cost-effectiveness of ICDs compared with antiarrhythmic drugs (mostly amiodarone) in survivors of SVT and VF.evaluated ICD cost-effectiveness and found acceptable results compared with those of other treatments available in the public health system, such as erythropoietin in patients on dialysis, some chemotherapies for leukemia in older patients, lung transplantation, and neurosurgery for malignant intracranial tumors. The cost per QALY was similar to those of heart transplantation, hemodialysis, and peritoneal dialysis. Importantly, some factors may considerably reduce cost-effectiveness, such as complications, infections, and comorbidities that negatively impact patient survival and ICD longevity.Thijssen et al.Thus, less aggressive programming may improve the cost-effectiveness of ICDs.Appropriate and inappropriate shocks may reduce survival and quality of life and, consequently, cost-effectiveness. Several studies have analyzed the importance of programming ICDs with longer SVT detection times and increased heart rate detection. These features were able to avoid inappropriate and \u201cunnecessary\u201d shocks, with improved survival rates and/or reduced hospitalization rates.Cost-effectiveness was evaluated in several subgroups of patients based on clinical criteria such as functional class, QRS duration, age, presence of LBBB, and ischemic etiology. At a maximum acceptable cost of \u00a330,000 per QALY, ICDs were cost-effective in patients with HF, LV systolic dysfunction, NYHA functional class < IV, and QRS <120ms. In patients with QRS between 120 and 149 ms, the ICD was cost-effective only in those with NYHA functional class I and II HF. In patients with NYHA functional class IV HF, ICD was cost-effective only when combined with CRT in patients with LBBB and QRS >120ms.Mealings et al. analyzed 13 cost-effectiveness studies of ICDs and CRTs using an analytical method to adapt treatment costs to the UK setting.Real-world data revealed that approximately 8% to 12% of implants in the USA and Canada are placed in patients aged > 80 years. The sudden death/death from any cause ratio decreases with age, being 0.51 in patients aged < 50 years and 0.26 in patients aged > 80 years.Given that the number of appropriate ICD therapy is similar in all age groups in both primary and secondary prevention, the sudden death/death from any cause ratio decreases in older patients because of an increase in deaths from other comorbidities.In older patients, especially those aged >80 years, the clinical efficacy and cost-effectiveness of ICDs are uncertain. Mean patient age at the time of enrollment in primary and secondary prevention studies was 58 to 66 years and 58 to 65 years, respectively. However, approximately 28% of eligible patients for ICD implantation are estimated to be over 80 years of age.Patients were categorized as < 65, 65 to 75, and > 75 years of age.Mean survival after ICD implantation in patients aged > 75 years was 5.3 years . For survival rates < 5 years, the cost per QALY would increase from $34,000-$70,200 (Sanders) to $90,000-$250,000. In this scenario, the ICD would not be cost-effective if the patient died less than 5 years after implantation.Pellegrini et al. evaluated the impact of age at the time of ICD implantation on survival.The cost-effectiveness ratio of ICDs in Brazil and other developing countries needs to be assessed within the socioeconomic context of each country considering local aspects, gross domestic product, effectiveness, and complications. Thus, patients with compromised LV function, fewer comorbidities, and at higher risk of death from arrhythmia should be prioritized.Reducing the cost of long-lasting devices and batteries can significantly increase cost-effectiveness. Additionally, every effort should be made to avoid inappropriate or unnecessary shocks, which would improve quality of life (a positive impact on the QALY index assessment) and increase battery longevity.Implantable loop recorders allow continuous heart rhythm monitoring regardless of active patient participation. With the ability to record different events  and a battery life of approximately 3 to 4 years, the implantable loop recorder is an extremely attractive diagnostic tool in the investigation of unusual symptoms  that may be attributed to bradyarrhythmias or tachyarrhythmias.In patients with unexplained syncope in whom initial noninvasive investigation with ECG, 24-hour Holter, or prolonged monitoring could not explain the nature of the symptoms, implantable loop recorders have been superior to conventional investigation strategies, such as tilt table test and invasive EPS. Several studies have identified bradyarrhythmia as the main cause of syncope, particularly in older patients with an IVCD. In these cases, bradyarrhythmia was identified in up to 41% of cases, 70% of which were intermittent complete AV blocks.AF detection in these patients may change the course of treatment, and full anticoagulation therapy may be required indefinitely. However, randomized trials are still needed to support the efficacy of anticoagulant therapy in patients with silent AF detected by prolonged monitoring in cryptogenic stroke.In patients with cryptogenic ischemic stroke without documented AF, active investigation with serial ECG and prolonged monitoring can detect silent AF episodes in up to 23% of cases.At 6-month follow-up, AF > 30s was detected in 8.9% of patients with an implantable loop recorder. At 12 months, AF was detected in 12% of these patients vs 2% of patients with conventional follow-up (p < 0.001).The Cryptogenic Stroke and Underlying AF  study randomly assigned 441 patients with cryptogenic stroke after initial investigation to monitoring by an implantable loop recorder or conventional follow-up.The Stroke of Known Cause and Underlying Atrial Fibrillation (STROKE-AF) trial enrolled 496 patients aged > 50 years and was presented at the 2021 International Stroke Conference (late-breaking abstract 6). AF episodes > 2 minutes occurred in 12% of patients with an implantable loop recorder vs 1.8% in the control group (p < 0.001). Patients with an implantable loop recorder received more anticoagulation therapy and had reduced stroke recurrence. Although not derived from controlled studies comparing different therapeutic interventions, the data suggest that prolonged monitoring may be beneficial.The current recommendations for implantable loop recorders are listed inPM programming should adhere to the following basic principles:To preserve or restore baseline resting heart rate and adapt it to stress demands, as well as to restrict pacing to the condition for which it was indicated, avoiding pacing when there are no proven benefits.To preserve intrinsic atrioventricular conduction whenever possible.To increase the longevity of the pulse generator battery while providing clinical benefits to the patient without compromising safety.To detect arrhythmias and system malfunctions.The care of patients with a PM should include electronic and clinical evaluation. In addition to personal (including current medications) and family history, investigation of symptoms, and physical examination, a 12-lead ECG should be performed, which is essential to assess sensing, capture, and arrhythmia functions. Echocardiography, although usually performed before implantation, may be required in the follow-up period to monitor LV remodeling due to the possible deleterious effects of chronic RV pacing and PM syndrome.The electronic evaluation is performed by telemetry and should include the pulse generator, the leads, and the retrieval of data stored in the device\u2019s memory, especially arrhythmic events and malfunctions.System interrogation allows the assessment of generator battery longevity, lead integrity, and pacing and sensing threshold measurements. Temporarily inhibiting the PM function allows the identification of intrinsic rhythm, which is essential for optimal system programming. Statistical data related to each cardiac chamber and to arrhythmic events should be accessed, as well as intracavitary electrogram recordings.The choice of pacing mode should consider the patient\u2019s intrinsic rhythm: normal sinus, AF, SND, and/or AV block.Single-chamber ventricular pacing (VVI) was initially widely used regardless of bradycardia type because of its simplicity and safety. However, more than a quarter of patients with VVI pacing develop PM syndrome , with significantly impaired quality of life. Thus, atrial pacing allows spontaneous AV and IV conduction in SND, preventing loss of AV synchronism, PM syndrome, and IV dyssynchrony secondary to RV pacing.Atrial pacing may be programmed to AAI or DDD mode. The DDD mode allows the preservation of intrinsic conduction through specific algorithms but has more complications, such as lead dislodgement, than the VVI mode. Conversely, AAI devices require twice as many reoperations compared with DDD devices, often due to AV block development (injury progression). AV blocks in patients with SND occur between 0.6% and 1.9% per year, requiring system upgrade to DDD mode.AAI mode is associated with a lower occurrence of AF and thromboembolic events compared with VVI mode in patients with SND. Similar results were observed with DDD mode, which is also associated with lower rates of AF and better quality of life compared with VVI mode. However, these benefits have no impact on the outcomes of mortality, HF, and cardiovascular death.The deleterious effects of RV pacing may result in HF and poor survival as a consequence of induced dyssynchrony. Thus, algorithms that preserve intrinsic AV conduction, automatically prolong the AV interval, or promote device upgrade to AAI mode (with ventricular backup) should be programmed when using a dual-chamber PM to avoid unnecessary RV pacing in patients with preserved AV conduction. Initial data suggest that these algorithms promote significant reductions in ventricular pacing percentage  and AF (40%). Patients with SND-related first-degree AV block may lose these benefits if the PR interval is too long.In the DANPACE study, which enrolled 1,415 patients with SND, DDDR mode with a maximum AV interval of 220ms was associated with a lower occurrence of paroxysmal AF; a very prolonged AV interval was associated with mitral regurgitation, increased preload, and AF, suggesting that there is a limit to AV interval prolongation. Thus, programming AV intervals > 220ms is not usually recommended.Sensors for rate-responsive pacing are another important PM feature in SND. These sensors aim to increase heart rate in cases of increased metabolic demand, such as during physical exercise. Three small studies reported improved quality of life and increased exercise tolerance during sensor activation; however, these findings were not reproduced in the ADEPT study.The automatic mode switching (AMS) function reverses DDD(R) to VVI(R) mode in case of AF development. Although there is no strong evidence supporting the benefits of AMS, it should be programmed particularly in patients with paroxysmal AF for symptom relief.RV pacing in AV block may be programmed to DDD or VVI mode. DDD mode maintains AV synchrony but is associated with more complications (6.2% vs 3.2%), especially lead dislodgement, threshold increases, and infection.In patients aged > 70 years, DDD mode did not seem to be superior to VVI mode in those with complete AV block after a 3-year follow-up period (including PM syndrome). Therefore, DDD mode is a suitable alternative in older patients with low life expectancy and physical activity restrictions.In studies comparing DDD vs VVI mode in patients with complete AV block and SND , DDD mode was not associated with reduced cardiovascular mortality or hospitalizations. The CTOPP study reported AF reduction with DDD mode (greater benefit in patients with SND); however, 26% of patients in VVI mode had PM syndrome and had to be crossed over to DDD mode. Patients\u2019 conditions improved significantly after upgrade to DDD mode.In patients with permanent AF and no possibility of reversion to sinus rhythm, only ventricular pacing is required. In these cases, VVI(R) mode is recommended. Sensors for rate-responsive pacing have been associated with improved functional capacity and quality of life in small studies.Neurally mediated syncope with a cardioinhibitory response is characterized by periods of intermittent bradycardia, requiring limited pacing periods with increased baseline rate to compensate for the sudden instability occurring during the event. In these cases, pacing should last for only a short period of time, only during symptomatic episodes (hysteresis function). DDI, DVI, or DDD mode may be programmed in combination with an algorithm that preserves intrinsic conduction. VVI mode has been more closely associated with syncope and presyncope occurrence than dual-chamber pacing (DDD and DVI) in some studies.\u00aeand Sudden Brady Response (SBR)\u00aecan identify abrupt drops in heart rate and respond by applying an accelerated intervention rate at programmable intervals. These algorithms are effective for symptom improvement in patients with neurally mediated syncope (cardioinhibitory) compared with conventional treatment without a PM. Although these algorithms have not been compared with other pacing modes, they are effective and allow PM inhibition for most of the time. In the International Study on Syncope of Uncertain Etiology III (ISSUE III), DDD mode plus RDR reduced the chance of syncope recurrence by 57%. RDR was programmed to intervene if heart rate reached 40 bpm or dropped by 20 beats from baseline heart rate (90bpm for 1 minute).Algorithms such as the Rate Drop Response (RDR)\u00aealgorithm uses intracardiac impedance measurements to assess myocardial contractility changes in order to predict syncope onset and initiate intervention .The Closed Loop Selection (CLS), with deactivation of sensors for rate-responsive pacing. Patients with AF should be programmed to DDI mode if there is an atrial lead, VVI if there is no atrial lead, and DDD if there is paroxysmal AF. In these cases, a rate of 60bpm is recommended in the absence of chronotropic incompetence.Most large studies use DDD or VDD mode with a rate between 35 and 60bpm to reduce atrial pacing, which could compromise AV synchrony in patients with delayed interatrial conduction and impair ventricular filling. HF guidelines recommend the use of heart rate-lowering drugs when heart rate is > 70bpm despite the use of beta-blockers, which supports the programming of low baseline rates and routine deactivation of rate-responsive pacing sensors.A short AV interval (100 to 120ms) aims to achieve a biventricular pacing percentage of approximately 100%, avoiding biventricular capture loss associated with PR interval shortening. AV and VV interval optimization by echocardiography or other methods is usually reserved for patients who do not respond to CRT, since there is no consensus on the real usefulness of these methods in routine practice.The maximum rate of atrioventricular synchrony should be programmed to the maximum, considering the maximum predicted heart rate for age and any limitations related to the underlying heart disease.Paroxysmal and persistent AF ablation (pulmonary vein isolation) should be considered in patients with HF.A detailed analysis of clinical situations with an indication for ablation is outside the scope of this Guideline.Patients with pacing > 93% have a 44% reduction in mortality and HF hospitalization rates (combined outcomes), with optimal results being achieved with pacing > 98%. Fusion and pseudofusion beats may overestimate the biventricular pacing percentage. When heart rate control in patients with AF cannot be achieved by ODT, AV node ablation should be performed as it is associated with reduced mortality.Ventricular extrasystoles are related to reduced biventricular pacing percentages and reduced reverse remodeling, even with a relatively low incidence. Antiarrhythmics and, eventually, ablation should be considered in patients who do not respond to CRT.Short AV intervals result in early ventricular systole, preventing the completion of the atrial contraction phase (A-wave truncation). In these cases, the AV interval should be prolonged until the A wave is evident. Conversely, prolonged AV intervals result in E and A wave fusion; in these cases, the AV interval should be shortened.Two methods are commonly recommended for AV delay optimization: the interactive method and the Ritter method. In the interactive method, a long AV delay (200ms) is programmed and gradually reduced (20ms at a time) to 60ms while the mitral flow is observed. The shortest AV delay capable of maintaining the E and A waves separated (without fusion), without deformation of the A wave, and maintaining a 40ms distance from the end of the A wave to the beginning of the QRS complex is considered the optimal AV delay. Ritter\u2019s method consists of measuring the QA interval (beginning of the QRS complex to the end of the A wave) with two different AV delays, one short (60ms) and one long (200ms). The optimal AV delay is calculated using the following formula: AV delay = long AV delay \u2212 (QA[shortAVdelay] \u2212 AQ[longAVdelay]). Thus, an echocardiogram with mitral flow assessment should be conducted after implantation to evaluate AV synchrony: if the E and A waves are separated and the interval at the end of the A wave is above 40 ms, there is no need for AV delay optimization.The interventricular delay may be programmed empirically or optimized by echocardiography, ECG, or specific algorithms. Optimization by echocardiography is performed by testing different delays and assessing dyssynchrony. The delay resulting in the least dyssynchrony should be programmed. Simultaneous pacing, early LV pacing, and different interventricular delays  should be tested. Subsequently, the same delays should be tested with early RV pacing. M mode, with or without tissue Doppler, and LV longitudinal shortening velocity, measured by tissue Doppler, are the most commonly used methods.As in AV delay optimization, echocardiography-guided interventricular delay programming should be performed under specific conditions in patients who do not respond to CRT.Some devices have automatic AV- and interventricular-delay optimization algorithms, whose effectiveness remains controversial but does not seem to be inferior to that of empirical or echocardiography-guided optimization.A correlation between decreased QRS duration with biventricular pacing and the rate of CRT responders has been observed in retrospective studies, supporting the hypothesis that AV- and interventricular-delay optimization aiming at a shorter QRS may increase the response rate to CRT.Multipoint pacing consists of stimulating regions  with delayed LV activation with a quadripolar lead, allowing capture of greater ventricular mass in a faster and more homogeneous way. The MultiPoint Pacing (MPP) trial compared multipoint pacing with a quadripolar lead vs conventional pacing. The results were similar in both groups, with a statistically significant value for noninferiority. However, there was a lower rate of nonresponders among patients with multipoint pacing programmed with an LV lead distance \u2265 30mm and the shortest delay (5ms). These results were reproduced in the first phase of the More Response on Cardiac Resynchronization Therapy With MultiPoint Pacing (MORE-CRT MPP) study. Patients programmed with an LV lead distance \u2265 30mm combined with the shortest intraventricular and interventricular delays also had better results.ICD programming should follow four basic principles: 1) reduce mortality by effectively reversing potentially fatal ventricular arrhythmias; 2) prioritize reversing ventricular arrhythmias with ATP whenever possible; 3) avoid inappropriate shocks; and 4) reduce RV pacing percentage as much as possible (antibradycardia pacing).Appropriate therapies for sustained VF and VT termination are the cornerstone for mortality reduction in ICD intervention. To this end, tiered therapies should be programmed in different zones, which are classified into VT (one or two zones) and VF zones. Programmable therapies include shocks (up to 35 or 40 J), as well as pacing therapies with 3 to 20 pulses and a pacing rate faster than that of tachycardia (ATP) that can terminate monomorphic VTs without painful shocks, reducing shock-related myocardial damage.Thus, certain complications due to intraoperative VF induction and shock-related myocardial damage can be avoided. VF zones should therefore be programmed with reversed polarity shocks with the highest possible energy. Conversely, VT zones may be programmed with lower-energy shocks, which are usually preceded by an ATP attempt.The effectiveness of shock delivery in ventricular arrhythmia termination used to be evaluated intraoperatively by defibrillation threshold testing . Subsequent studies have demonstrated that this strategy is unnecessary, since standard intraoperative measurements  are sufficient for effective termination of spontaneous arrhythmias.The effectiveness of ATP as first-line treatment for VTs is well known. Monomorphic, organized VTs with stable cycles and no hemodynamic repercussions can be easily terminated by both burst ATP  and ramp ATP .Some unstable arrhythmias, even in high-rate zones (in the VF range), may be terminated by ATP before the delivery of programmed shocks. In these cases, an ATP attempt should be programmed during or before shock energy load; if the arrhythmia is terminated, the shock should be aborted. The Pacing Fast VT Reduces Shock Therapies II (PainFREE II) study used ATP as first-line treatment in a fast VT zone (188 to 250bpm) and reported a significant relative reduction in the risk of shock of 71%, without compromising patient safety.To this end, basic programming principles should include:Adequate programming of detection and tiered therapy reduces inappropriate shocks, promotes higher rates of appropriate ATP, and reduces mortality.A VF zone programmed with a rate > 233bpm (> 188 for Medtronic devices), with at least 30 beats out of 40 (x in y) for detection. This strategy avoids shocks in nonsustained arrhythmias and inappropriate shocks due to intermittent noise, double counting, or extrasystoles.In primary prevention patients, a single VF detection zone may be sufficient. VT monitoring zones without therapies (monitoring) may be programmed at the physician\u2019s discretion. In secondary prevention patients, VT-targeted therapies should be programmed with a detection cutoff of 10-20bpm lower than the documented tachycardia rate. Based on clinical criteria, low-rate therapy zones may be programmed according to the risk of slower VT, but ATP should always be prioritized.Noise and lead integrity monitoring algorithms should be programmed, as well as automatic adjustment and oversensing prevention features, such as T-wave detection.Adequate programming of supraventricular arrhythmia discrimination algorithms, particularly in the morphology discrimination criterion (single-chamber devices) and in the evaluation of algorithms based on the atrioventricular relationship . Timers, such as the Sustained Rate Duration (Boston Scientific) and Timeout, should be deactivated, as they ignore the discrimination of events classified as SVT after the preestablished period and deliver inappropriate therapies.Finally, the need for concomitant antibradycardia pacing must be carefully evaluated. Most patients with an ICD do not require antibradycardia therapy, especially for primary prevention. However, conventional RV pacing is known to increase the risk of ventricular dysfunction and mortality. ICD programming should, whenever possible, prioritize RV pacing percentage reduction. To this end, single-chamber ICDs should be programmed to VVI mode with 40 ppm, whereas dual-chamber ICDs should prioritize atrial pacing alone by using ventricular pacing minimization algorithms  or by programming an AV interval long enough to avoid unnecessary ventricular pacing. In patients requiring ventricular pacing due to AV conduction block, the possibility of pacing alternative sites, such as biventricular pacing (CRT) or conduction system pacing (His bundle/LBB), should be considered according to ventricular function.Implantable loop recorders should be adequately programmed to detect ventricular electrical activity without undersensing and without noise oversensing, which could impair rhythm identification.The automatic detection function, regardless of manual activation by the patient, a memory with electrogram storage capacity, and a battery life of 3 to 4 years help to identify arrhythmic events that have not been documented by conventional tests.Some manufacturers suggest an initial empirical programming as follows:The implantation technique is similar for all available models. The adequacy of electrical signal at the position chosen for device placement should be confirmed intraoperatively. After confirmation of adequate signal capture, the implantable loop recorder should be programmed to detect arrhythmias on an individual basis.Pauses: 3 sBradycardia: heart rate \u2264 30bpm for more than 4 consecutive beatsTachycardia: heart rate > maximum predicted heart rate for age (220 - age) for 16 beats or moreAtrial fibrillation: episodes > 2 minutes are characterized as AF rhythmAdequate programming of the detection criterion and subsequent analysis of tracings is essential for optimal monitoring.Careful adjudication of the episodes recorded by the implantable loop recorder is required, as false detections may have been stored. Episodes classified as AF, for example, may be misclassified due to RR interval variations resulting from ventricular extrasystoles or intermittent QRS undersensing. An analysis of 695 spontaneous or scheduled transmissions revealed a false-positive transmission rate of up to 81%.Online remote monitoring is a reality for patients with CIEDs. Data from the device can be transmitted via a broadband Internet connection. Newer devices allow data transmission via a Bluetooth connection in a smartphone. Remote monitoring allows access to several programming features, such as pacing rate and mode, pacing output, sensing and detection algorithms, as well as to diagnostic records and battery status.Data transmission needs to be adjusted because information may be automatically transmitted by the device after a trigger or manually transmitted by the patient. A scheduled transmission may also be programmed. Remote access to device information is given to the service responsible for monitoring the patient through private access to the system\u2019s server, provided that patients\u2019 data privacy is protected.Recent publications have shown an increased incidence of CIED-related infectious processes. Demographic and clinical factors, such as population aging and comorbidities, may influence both hematogenous seeding and direct contamination from device implantation and replacement. A recent EHRA survey reported that CIED infections are more frequent after reoperations, including those for isolated pulse generator replacement.The most recent consensus statements have emphasized the need for standardizing management strategies and forming expert teams to address this particular and uncommon type of infection with the aim of mitigating the still frequent controversies over the topic.Such contamination may occur during bacteremia caused by a distant infectious focus, such as septic thrombophlebitis, osteomyelitis, pneumonia, surgical site infection, contaminated vascular catheters, or bacterial infection originating from the skin, mouth, or gastrointestinal or urinary tract.CIED-related infectious processes manifest as either involvement of the pulse generator pocket or exclusive intravascular involvement. Exclusive pocket involvement is more frequent and accounts for approximately 60% of cases . Late skin erosion may be due to or result in pocket infection; in both cases, this may progress to a systemic infection. Pocket involvement associated with intravascular infection accounts for approximately 20% of infections and is usually secondary to delayed or inadequate management. Exclusive intravascular involvement also represents approximately 20% of cases and results from bloodstream contamination in most cases.An expert consensus statement issued by the EHRA and endorsed by other international societies aimed to define the terminology that should be used in clinical studies and registries for the therapeutic approach to CIED infections and for system removal.A definite diagnosis of CIED infection is based on three major findings: 1) presence of purulent drainage or CIED exposure on clinical examination; 2) growth of microorganisms in blood cultures, and 3) presence of tricuspid valve or lead vegetations seen on transesophageal echocardiogram (TEE). When the diagnosis of CIED infection cannot be defined using these criteria, additional tests  may be needed. The modified Duke University criteria for diagnosing CIED infections are listed in Tables 40 and 41.Proof that the CIED is definitely contaminated is essential for proper treatment because, once contamination is confirmed, complete device removal will be necessary for a successful outcome. Conversely, if the CIED is free from contamination and the infectious process is related to a different focus, unnecessary device removal will imply avoidable cost and surgical risk related to lead extraction. A flowchart for diagnosing and treating CIED infections is shown inImaging tests are useful for both diagnosis and treatment. Thus, some imaging information may be relevant, including 1) identification of CIED type; 2) identification of abandoned leads; 3) findings of intracardiac vegetations and their size; and 4) signs suggestive of septic pulmonary embolism.In cases of fever in which a CIED pocket evaluation is unable to determine the infection, blood cultures or TEE and radiopharmaceutical-based imaging tests may be relevant.Although complete removal of the pulse generator and all leads is essential, the infection must be treated with antimicrobial therapy. Antibiotic choice should be based on blood cultures and removed pocket/lead fragment cultures. When the microorganism cannot be identified, empirical antibiotic use should be defined by clinical criteria. Likewise, treatment duration should also be defined according to the clinical status, and the starting point should always be complete CIED removal .Complete CIED removal is critical to preventing recurrent infections. Lead extraction, however, should rarely be considered an emergency, even in cases of septic shock. With the exception of recent implants, which tend to be technically easier, extraction should only be performed when the hemodynamic status and the infection have stabilized, given the risks associated with the procedure (vein and heart adhesions).Transvenous lead extraction should be the preferred technique, except when leads are epicardial or when intracavitary vegetations are greater than 2.5cm (largest diameter). Recommendations for removing the pulse generator and leads are listed inImplantation of a new CIED should only be performed after complete remission of the infectious process, based on the clinical status. Until the infection has completely resolved, patients dependent on artificial pacing should maintain treatment with a temporary PM. Nondependent patients should remain under cardiac rhythm monitoring until the implant is performed. In some cases, implantation of a new CIED may not be necessary because of a change in the disease pattern or a revision in the management strategy. Therefore, reassessing the need for a CIED is always essential. Recommendations for implantation of a new CIED are listed inSeveral risk factors for the development of CIED infection have been reported. These factors may be related to the patient, the medical procedures performed, or the CIED itself. Major factors for CIED infection are listed inPreventive care is crucial to reducing the occurrence of procedure-related infections.Older people, children, and adults with congenital heart disease constitute subgroups that deserve special attention regarding CIED infections. Submuscular positioning of pocket in patients with limited subcutaneous tissue is essential to preventing skin erosion. In pediatric patients, especially those with congenital heart disease, the operator should be experienced in multiple and alternative surgical approaches. Extravascular or subcutaneous ICD implantation should be considered in younger children, patients with congenital heart disease, and those with limited or no venous access.have reported higher CIED infection rates than those of prospective studies(3.4% vs 1.2%). This phenomenon may reflect greater adherence to preventive procedures in clinical studies compared to daily clinical practice. The most important procedure-related factors for risk of infection include pocket hematoma, long procedure duration, and reinterventions for lead repositioning. Regarding reoperations for pulse generator replacement, lead dysfunction correction, or pacing mode change, appropriate management of the pulse generator pocket, either by complete removal of the fibrotic capsule or by use of antibacterial envelopes, reduces the number of infections.Interestingly, retrospective registriesPreoperative antibiotic prophylaxis with a single dose of first-generation cephalosporins (cefazolin) is strongly recommended, which is not the case with systematic postoperative antibiotic use.The time interval between diagnosis and appropriate treatment of CIED infections is critical. Literature data show that if the device is removed within 3 days of hospitalization, both length of stay and in-hospital mortality are significantly reduced. Thus, when there are no sufficient data to establish the diagnosis of infection based on the triad of infectious signs in the pulse generator pocket, bacterial growth in blood cultures, and vegetations on TEE, additional resources should be employed.F]FDG PET/CT scanning or radiolabeled WBC scintigraphy or contrast-enhanced CT are recommended in cases of suspected CIED-related infective endocarditis, positive blood cultures, and negative echocardiogram, or in patients withS. aureusbacteremia in the presence of CIED. Needle aspiration and surgical debridement in cases of generator pocket infection, in an attempt to avoid lead extraction, should be strongly discouraged.[Large, nonvoluntary, easy-to-fill, high-quality registries are essential to monitoring the number of cases of CIED infection and the outcomes of preventive and therapeutic measures. Each center should establish routines for accurate diagnosis and timely treatment. Constant reassessment of the performance of each center is highly recommended.There has been a growing demand for CIED lead removal in recent years because of two major factors: 1) increase in CIED infection rates and 2) development of multisite PM and ICD systems with a higher number of leads.Indications for lead removal may be (a) mandatory for treating infections; (b) necessary for obtaining access for new leads in patients with venous occlusions; or (c) optional for performing lead replacement in patients with appropriate venous access.As most devices require venous access for lead implantation, transvenous extraction techniques are most commonly used. Currently, open-chest lead removal is rarely performed as few scenarios require this method, such as removal of epicardial leads or correction of complications occurring in transvenous extraction procedures.The current panorama of lead extraction shows well-established indications and operative techniques. The tools used are well developed, and the outcomes of different procedures are well known, with high success rates. Catastrophic complications, however, may occur during extraction procedures. Such complications, although rare, are potentially lethal and often require emergency open surgery.This item presents the recommendations for extraction in noninfected patients, as the management of infections has been previously addressed.Epicardial lead removal is necessarily performed by reopening the thoracic cavity preferably using the same access through which the lead was implanted. Transvenous lead removal should preferably be done by intravascular access. Exceptionally, a transthoracic approach may be used with or without cardiopulmonary bypass . The choice of transvenous lead extraction approach depends essentially on the possibility of obtaining access to the lead targeted for removal. Unfortunately, many patients have entirely intravascular leads because of spontaneous lead fractures or iatrogenic events during removal procedures.When the lead to be removed is intact or has an extravascular segment, however small this segment may be, the venous entry site approach must be used. This approach consists of introducing a sheath into the vein which is guided by the lead to be removed. This sheath is used to cut through adhesions that form between the lead and the venous endothelium or the endocardium. When the patient has more than one transvenous lead implanted, adhesions are often seen between the leads. After all adhesions have been removed and the site where the lead is attached to the heart has been reached, the same sheath is used to apply pressure against the heart muscle while pulling the lead (countertraction maneuver). There are several tools specifically developed for this type of approach, namely:Locking stylets, which are stylets coated with a fine steel mesh that expands in the light of the lead, providing the lead with the necessary support for its traction.Sheaths for adhesion dissection and countertraction:Nonpowered sheathsare sets of rigid metal and flexible Teflon or polypropylene tubes that cut through adhesions by blunt dissection, with an intensity level determined by the strength of the operator\u2019s hand.Rotational mechanical sheathsare activated by a trigger in the operator\u2019s hand or by an electric motor and cut through adhesions.Laser sheathsuse photoablation to cut through adhesions.Tables 46 and 47 show recommended definitions for tools and approaches used in lead extraction.When the lead that needs to be removed does not have an extravascular segment, intravascular extraction is mandatory. There are tools in the shape of a loop or basket made with very malleable metal wires and designed to grasp these fragments. Such tools are usually introduced by puncturing the femoral or jugular veins. Once grasped, the lead can be pulled directly. Specific cases may require a combined countertraction maneuver after grasping the lead.removalhas been generically used to refer to CIED lead removal regardless of the type of approach. It can be performed by simple traction of the transvenous lead without using any tools; by thoracotomy for removing epicardial leads; or by thoracotomy with cardiopulmonary bypass for removing transvenous leads. The termextractionshould be reserved for cases requiring the use of techniques and tools to 1) dilate the venous path through which the lead passes; 2) cut through adhesions; 3) perform a countertraction maneuver; or 4) grasp lead fragments inside the heart vessels or chambers.The termCompletion of a lead removal or lead extraction procedure may result in 1) complete removal of the targeted lead; 2) partial removal; or 3) unsuccessful removal. Depending on the type of indication for lead removal, the procedure may be considered clinically successful even if the lead was not entirely removed. The procedure is considered unsuccessful when 1) clinical success is not achieved; 2) any permanently disabling complication occurs; or 3) the patient dies.Leads may be deactivated for several reasons, such as 1) loss of ability to adequately stimulate the heart, 2) need to change the device type, and 3) manufacturing-related problems.Therefore, the decision to extract or not a lead that will be deactivated essentially depends on the expertise of each center.Noninfected leads may be abandoned in situ at the discretion of the surgical team. There are, however, disadvantages to abandoning a lead, including 1) risk of thrombotic phenomena, 2) limitations to MRI scans, and 3) increased risk in a future extraction procedure, since the longer the lead remains, the higher the risk of unsuccessful extraction. The main argument for abandoning a noninfected lead in situ is the risk of severe complications associated with the extraction procedure. A recent publication shows that 1-year expected survival following a lead replacement procedure is similar for cases of lead extraction vs in situ abandonment.CIED durability depends on both manufacturing  and usage aspects. Leads are directly influenced by the operative technique used, which may negatively impact their durability. Nonetheless, specific surveillance strategies must be adopted by manufacturers and regulatory agencies to assess the durability of CIED components.In cases of in situ lead abandonment due to a dysfunction or need to change the pacing mode, or, inappropriately, in cases of treatment of a CIED infection, caution is required because how leads are abandoned may hinder future extraction procedures. Recommendations for lead abandonment are listed inNoninfected lead removal may be mandatory in certain clinical situations, such as for 1) treatment of superior vena cava syndrome caused by the presence of leads; 2) treatment of severe cardiac arrhythmia mechanically caused by a lead fragment; 3) prevention of cardiac injury from a fractured lead; or 4) radiation therapy in the region where the device is implanted.Also, lead extraction may be necessary in cases of severe venous occlusion or obstruction preventing the passage of a new lead.In many cases, however, lead extraction is optional and can be defined by evaluation of less objective factors, such as 1) patient\u2019s age or estimated life expectancy; 2) future need for MRI scans; 3) risk of developing severe venous obstructions; or 4) risk of infection via a hematogenous route . Such situations require the expertise of the professional who performs the procedure for defining an appropriate management strategy.During transvenous lead extraction procedures, veins or cardiac structures may be injured. Injuries to the axillary or subclavian veins, brachiocephalic veins, or superior vena cava may cause severe hemorrhage requiring blood transfusion or even surgical correction. Muscle avulsion of the right atrium or RV and perforation of coronary sinus tributaries may lead to cardiac tamponade. Extrapericardial laceration of the superior vena cava, however, is the most frequent and most lethal catastrophic complication. Other complications, such as self-limiting cardiac arrhythmias, pneumothorax, or lead fragment retention, may also occur and require specific care.Complications are generally grouped into major and minor according to severity and type of correction required.Several studies have been designed to identify risk factors that determine morbidity and mortality in transvenous lead extraction procedures. These studies have reported low rates of catastrophic complications and perioperative death, not allowing proper identification of those risk factors. Conversely, several demographic, clinical, and surgical factors are associated with 30-day mortality following an extraction procedure. Factors associated with late complications and death have also been described.shows the close relationship between the volume of procedures performed at the center and the rate of complications associated with lead extraction. Naive operators should be supervised by more experienced operators during the first 40 transvenous extraction procedures. A minimum volume of 20 transvenous extraction procedures per year is recommended for all operators to maintain their technical skills.Given the difficulty of predicting perioperative catastrophic complications, prevention of associated deaths becomes crucial, which implies training the staff and providing centers with the technical skills required for lead extraction. A recent systematic reviewElectrosurgery uses high-frequency alternating current (200kHz to 2.2MHz), which is converted into heat when passing through tissue with sufficient resistance, allowing the desired effects to be achieved: coagulation and cutting. An electric scalpel is used in most surgical specialties.Monopolar electrosurgery is the most effective and therefore most widely used technique in surgical practice. In this modality, the active electrode is located at the surgical site , whereas the indifferent (return) electrode is a plate placed on the patient\u2019s skin at a distance. The current flows between the electrodes, passing through the body.An increasing number of patients with CIEDs are treated surgically, which exposes these patients to electromagnetic interference. Monopolar electrosurgery can cause a number of CIED abnormalities, such as pulse generator reprogramming, temporary pacing inhibition, high-frequency pacing triggering, battery depletion and pacing failure, circuit damage, threshold elevation, and triggering of inappropriate therapy (shocks) in the case of ICDs.To minimize the risks of using electrocautery, some precautions should be taken perioperatively: (1) the monopolar probe should be used intermittently, with short bursts of current and low energy levels; (2) the indifferent plate should be positioned so that the current does not flow through the generator or electrodes.In head and neck surgery, the indifferent plate of the monopolar probe should be placed on the posterior shoulder contralateral to the device pocket. For example, if the generator is placed on the left infraclavicular region, the probe plate should be placed on the right shoulder.In general, when the surgical site is located above the umbilicus or at a distance of less than 15 cm from the generator, the use of a monopolar probe should be avoided. In this scenario, a bipolar probe should be preferred as it is safer, but it should not be applied directly to the generator.Placing a magnet over the generator pocket causes the PM to revert to asynchronous mode, that is, it disables the sensors and changes to magnet pacing rate, which is often higher than the programmed pacing rate.In order to protect both patients and CIEDs from the undesirable effects of electrocautery, two approaches have been used: placing a magnet over the pulse generator and reprogramming the device before the procedure. In the case of PMs, magnet use during surgery is an option when circuit sensing has been deactivated by the generator under magnetic effect (asynchronous mode) and the battery is in good condition.Magnet application to the ICD pocket only disables tachyarrhythmia therapy, it does not change PM function. In PM-dependent patients with ICDs, the device should be reprogrammed to asynchronous mode before the procedure. CIED reprogramming should be performed immediately before the surgical intervention and reverted to original programming immediately after the end of the procedure , oversensing or undersensing.Radiofrequency field: heating of tissue adjacent to lead electrodes, induction of arrhythmias (rare), device reprogramming (reset), oversensing or undersensing interactions.Combined field effects: sudden loss of device function, alteration of device function (parameters), mechanical forces (vibration), device reset, damage to generator and/or leads.Imaging-related: artifacts that prevent adequate device image visualization.Potential interactions between CIEDs and MRI electromagnetic interference include:Magnetic field-induced force and torque due to ferromagnetic materials: generator movement is extremely unlikely due to confinement and adjacent subcutaneous tissues. Leads do not contain sufficient ferromagnetic material to cause movement.Gradient magnetic field-induced electrical current: gradient magnetic fields can induce current, which can lead to myocardial capture and potentially cause atrial or ventricular arrhythmias.Heating and tissue damage: radiofrequency fields can lead to nonconditional CIED component heating, causing heating of and thermal damage to the adjacent tissue . Changes in sensing or capture thresholds can occur as a result of tissue damage near lead electrodes.Effects on device activity: the CIED can be programmed by placement of a magnet, thus allowing device interactions. Magnetic fields might therefore affect the activity of a nonconditional device, possibly changing the programming of the device.Electrical reset: High-energy electromagnetic interference can lead to electrical power-on reset, and a backup demand mode may be activated. Power-on reset parameters vary among vendors and device types and can include a set of variations. Inhibition of pacing function by MRI-generated signals or pacing at an output below threshold (bipolar or unipolar) in a PM-dependent patient may occur. Additionally, battery status can be affected, particularly for devices that are near an elective replacement interval (ERI), which may result in unreliable function.Inappropriate function and therapies: electromagnetic interference from radiofrequency energy pulses or rapidly changing magnetic field gradients might cause oversensing that can lead to inappropriate pacing inhibition and possibility asystole in PM pacing-dependent patients, or induction of therapies leading to inappropriate shocks in patients with ICDs.These effects are influenced by many factors, including magnetic field strength, radiofrequency power, position of the patient and device inside the MRI bore, device characteristics, and the size of the patient.Traditionally, MRI scanning has been contraindicated in patients with CIEDs. The first MRI-conditional system was introduced in Europe in 2010 and approved by the Food and Drug Administration (FDA) in 2011 for use in the United States.To render CIEDs MRI conditional, structural changes  and software changes have been made to reduce or eliminate potential adverse effects. Once the special programming mode (MRI mode) has been activated, the device reverts to an asynchronous pacing mode and increases the pacing outputs to avoid inhibition of pacing during MRI scanning. In ICDs, the antitachycardia function is temporarily disabled. Therefore, patients with ICDs will be unprotected from ventricular arrhythmias during MRI scanning.Because the decision to perform MRI scanning in a patient with a CIED system involves risks and benefits, potential risk factors should be identified. Patients with MRI-conditional CIEDs may undergo MRI scanning without additional risks if established recommendations and protocols are followed.Before MRI scanning, it is important to identify the patient\u2019s baseline rhythm and whether the patient is PM dependent, activate the specific MRI programming mode, confirm that the entire system is MRI conditional, and check for the presence of abandoned or epicardial leads.In general, most CIED systems have been approved for MRI scanning with 1.5T, a gradient slew rate of 200 T/m/s, a maximum specific absorption rate of 2 W/kg, and a limited number and length of imaging sequences. New devices allow safe MRI scanning under broader conditions. Most new systems allow full-body MRI scanning.An MRI-conditional system consists of a combination of leads and generator that has been specifically tested to ensure safe conditions of use during MRI scanning. The presence of any device component that does not meet the criteria for MRI conditionality renders the CIED MRI nonconditional. This includes an MRI-conditional generator combined with nonconditional components and device systems that combine individual MRI lead components and MRI-conditional generators from various manufacturers, as these are not combinations specifically tested together for MRI scanning safety.Conditional labeling also specifies the location of the generator . Other examples of nonconditional components include epicardial leads, abandoned leads, fractured leads, and active noncardiac devices.Programming of the device outside the MRI-conditional programming mode also renders the device MRI nonconditional. Battery status must be adequate to consider the device MRI conditional .An increasing number of patients undergoing radiotherapy have a CIED. Although radiotherapy-induced malfunction is rare, safety recommendations are important.Ionizing radiation can interfere with the complementary metal oxide semiconductor (CMOS) components of the generator. The production of secondary neutrons is the strongest predictor of CIED malfunction in the setting of radiotherapy. Modern pulse generators have lower power consumption and smaller circuits, made of semiconductor metal. This renders modern devices more susceptible to possible damage caused by ionizing radiation.High radiation doses, especially with energy > 6MV, can cause software and hardware errors. These disturbances are usually transient, such as pacing inhibition, sensing abnormalities, and inappropriate pacing at the maximum sensor rate. Reset to backup mode, which can be corrected with reprogramming, is one of the most reported malfunctions. Permanent damage to the device may also occur, such as loss of telemetry and premature battery depletion. CIED failure, with complete interruption of device functioning, has been described in vitro.Device malfunction has been reported in up to 3% of radiotherapy courses. Clinically relevant events are rare and dependent on the type of device and patient\u2019s tolerance to changes. For example, a PM-dependent patient may have bradycardia and associated symptoms.It is also important to consider that damage to the CIED may appear weeks or months after the end of radiotherapy (latent damage).Radiotherapy planning should consider the conditions specified for the CIED and patient characteristics, such as whether the patient is pacing-dependent or not and has a history of ventricular tachycardia or ventricular fibrillation (VT/VF) .Much scientific evidence has emerged since the latest Brazilian guidelines for CIEDs were published by SOBRAC/SBC. Advances in technology and knowledge must be in line with clinical practice and public health care. In this respect, the present document highlights the evolution of the treatment of cardiac arrhythmias, but it does not shy away from highlighting the pressing need for the rational use of financial resources in favor of the greater good, that is, collective health."}
+{"text": "Admite-se tamb\u00e9m que o \u00edndice n\u00e3o abarca todas as dimens\u00f5es relevantes da experi\u00eancia da condi\u00e7\u00e3o humana nas sociedades e contribui por aproximar-se de vari\u00e1veis indicadoras. Ainda que muito \u00fatil, o \u00edndice de desenvolvimento humano \u00e9 reconhecido como n\u00e3o abrangente - por exemplo, escapam ao \u00edndice as dimens\u00f5es de desigualdade, pobreza, inseguran\u00e7a, empoderamento. Isto posto, \u00e9 sempre oportuno para a comunidade m\u00e9dico-cient\u00edfica ter em mente as dimens\u00f5es examinadas no \u00edndice de desenvolvimento humano e desenvolver estudos recorrentes e atualiza\u00e7\u00f5es no decorrer do tempo, pois din\u00e2micas s\u00e3o as condi\u00e7\u00f5es nas quais vivem sociedades humanas.O \u00edndice de desenvolvimento humano sintetiza dimens\u00f5es das sociedades humanas expressas em expectativa de vida, educa\u00e7\u00e3o e o padr\u00e3o de vida da popula\u00e7\u00e3o. A expectativa de vida seria uma express\u00e3o das condi\u00e7\u00f5es de sa\u00fade da popula\u00e7\u00e3o. A educa\u00e7\u00e3o seria expressa pelos anos de escolaridade. O padr\u00e3o de vida seria expresso pela renda os autores examinaram o \u00edndice de desenvolvimento humano no Brasil no decorrer de quatro d\u00e9cadas, com base nos dados disponibilizados pelo DATASUS com emprego de s\u00e9ries temporais com taxas de mortalidade (causa b\u00e1sica de \u00f3bito) por doen\u00e7as cr\u00f4nicas n\u00e3o transmiss\u00edveis padronizadas por 100.000 habitantes divididos por quartis em cada unidade da Federa\u00e7\u00e3o brasileira. No c\u00f4mputo global houve redu\u00e7\u00e3o das taxas de mortalidade padronizadas de mortalidade por 100.000 habitantes em todas as faixas et\u00e1rias por doen\u00e7as do aparelho circulat\u00f3rio. De modo interessante, a atualiza\u00e7\u00e3o trazida pelo estudo dos autores indica que a participa\u00e7\u00e3o das doen\u00e7as cr\u00f4nico-degenerativas, ainda que com redu\u00e7\u00e3o no \u00e2mbito nacional geral, n\u00e3o se verificou de modo homog\u00eaneo em todas as unidades da Federa\u00e7\u00e3o. Na Tabela 1 foram apresentados os \u00edndices de mortalidade que revelaram ter diminu\u00eddo a participa\u00e7\u00e3o dessas doen\u00e7as em estados da regi\u00e3o Sudeste, Sul e Centro-Oeste, diferentemente da participa\u00e7\u00e3o que se verificou elevar-se em outras regi\u00f5es do pa\u00eds.No estudo ora apresentado,Desse modo os autores fizeram uma contribui\u00e7\u00e3o que pode ser mais um dado a auxiliar as diferentes inst\u00e2ncias voltadas para a preven\u00e7\u00e3o e o tratamento das doen\u00e7as cr\u00f4nico-degenerativas n\u00e3o transmiss\u00edveis. Na Figura 4 demonstrou-se que quanto maior foi o \u00edndice de desenvolvimento humano a varia\u00e7\u00e3o da mortalidade por doen\u00e7as cr\u00f4nico-degenerativas foi menor. A redu\u00e7\u00e3o foi maior nas unidades da Federa\u00e7\u00e3o com \u00edndice de desenvolvimento humano maior ou igual a 0,7. Associaram essa evolu\u00e7\u00e3o \u00e0 melhoria das condi\u00e7\u00f5es socioecon\u00f4micas, um dos pilares \u2013 ainda que n\u00e3o o \u00fanico \u2013 do \u00edndice de desenvolvimento humano. Diferen\u00e7as foram relatadas em experi\u00eancia de outro pa\u00eds quanto a etnia e foram consideradas oportunidades de cont\u00ednuo trabalho. Mais recentemente depois de seguimento m\u00e9dico de mediana de 23,6 anos  as comorbidades m\u00faltiplas foram identificadas em participantes h\u00edgidos h\u00e1 50 anos como mecanismo de influ\u00eancia na mortalidade, mesmo em pa\u00edses com acesso universal ao atendimento de cuidados com a sa\u00fade no sistema p\u00fablico. Em outro estudo, a diferen\u00e7a entre a expectativa de vida entre estados da mesma federa\u00e7\u00e3o tamb\u00e9m demonstrou varia\u00e7\u00e3o ainda que pudesse haver eleva\u00e7\u00e3o de renda; essa varia\u00e7\u00e3o foi observada particularmente na popula\u00e7\u00e3o de menor renda, causada por doen\u00e7as card\u00edacas ou c\u00e2ncer. A popula\u00e7\u00e3o de renda mais alta obteve expectativa de vida semelhante. Foi sugerido que essas ocorr\u00eancias se deveriam mais a comportamento  do que acesso a servi\u00e7os de sa\u00fade, diferen\u00e7as de moradia ou \u00edndice de desenvolvimento humano (\u00edndice GINI). Os autores formularam a hip\u00f3tese de que fatores locais contribuiriam para a natureza do comportamento social e exposi\u00e7\u00e3o a fatores de risco \u00e0 sa\u00fade.Mais recentemente outras vari\u00e1veis foram inclu\u00eddas como objeto de estudo no \u00e2mbito do desenvolvimento humano e nas suas rela\u00e7\u00f5es com a sa\u00fade a respeito dos determinantes sociais da sa\u00fade: gradiente social, estresse, cuidados na inf\u00e2ncia, exclus\u00e3o social, trabalho, desemprego, suporte social, depend\u00eancia qu\u00edmica, alimenta\u00e7\u00e3o, transporte.Dessa forma temos mais um estudo de dados brasileiros a demonstrar que os cuidados \u00e0 sa\u00fade d\u00e3o oportunidade a abordagem ampla em vari\u00e1veis que podem ser convergentes e aditivas do ponto de vista de preven\u00e7\u00e3o e tratamento de doen\u00e7as que conforme sugeridos na literatura podem tamb\u00e9m sofrer influ\u00eancia de vari\u00e1veis relacionadas \u00e0 educa\u00e7\u00e3o, renda per capita, gradiente social, estresse, cuidados na inf\u00e2ncia, exclus\u00e3o social, trabalho, desemprego, suporte social, depend\u00eancia qu\u00edmica, alimenta\u00e7\u00e3o, transporte, entre outras vari\u00e1veis poss\u00edveis. That said, it is always opportune for the medical-scientific community to bear in mind the dimensions examined in the human development index and to develop recurrent studies and updates over time, as the conditions in which human societies live are dynamic.The human development index synthesizes dimensions of human societies taking into consideration life expectancy at birth, education, and standard of living. Life expectancy is an expression of the health conditions of a particular population. Education is expressed as years of schooling. The standard of living is indicated by gross national income per capita. It is recognized that the human development index does not encompass every social determinant of the experience of citizens of a specific human society. Nonetheless, it is useful and a recognized methodological approach for measurements and comparisons; however, inequalities, poverty, human security, empowerment, and other characteristics may be missed.the authors evaluated the human development index in Brazil over four decades (1980-2019). The data (the underlying cause of death) were retrieved from death certificates in a Unified Health System (SUS) public database relative to chronic non-infectious diseases with time series analyses. Mortality was corrected for 100.000 inhabitants distributed in quartiles in each Brazilian state.In the current study,There was an overall decrease in mortality rate through ages for circulatory system diseases. Interestingly, the update of this study demonstrated that despite an overall decrease in mortality rate from a national perspective, this decrease was not homogeneous in the different states. In Table 1, the mortality rates revealed that the participation of these diseases in the Southeast, South, and Middle-west; in other states, the participation of chronic degenerative non-infectious diseases increased.The authors\u2019 contribution is one more step in preventing and treating chronic degenerative non-infectious diseases. Figure 4 demonstrates that the higher the human development index, the lower mortality due to chronic degenerative diseases. The decrease was higher in the states with a human development index higher the 0.7. They inferred that this observation resulted from better socioeconomic conditions, one of the pillars of the human development index.Significant differences were reported in other experiences for ethnic issues and regarded as an opportunity for improvement.Additional variables were addressed as relevant for human development in relationship with health conditions considered social determinants of health: social gradient, stress, early infancy, social exclusion, work conditions, unemployment, social support, addiction, nutrition, and transportation.In another study, differences between life expectations in states of the same countries were reported despite increases in financial incomes;the difference was more noticeable in lower income strata due to heart disease and cancer. Higher financial income strata demonstrated similar life expectancy. It was suggested that these findings might be due more to lifestyles  than to access to health care, housing, or human development (GINI). The authors hypothesized that local environmental factors might contribute to unhealthy life styles.Recently, multiple co-morbidities were identified as a significant influence on mortality after a median of 23.6 years of follow-up  participants healthy 50 years before in a country with universal access to care in the public health system.This is one more study of Brazilian databases to demonstrate that in health care delivery, we may have opportunities for a broad view of socioeconomic dimensions that may add each other and converge to better prevention and treatment of chronic diseases through variables recently reemphasized such as education, gross national product per capita, social gradient, stress, early infancy care, social exclusion, work, unemployment, social support, addiction, diet, transportation among other potentially associated variables."}
+{"text": "Manuscrito in\u00e9dito, datado de 1802, que trata dos m\u00e9todos a utilizar na recolha eremessa de sementes, tub\u00e9rculos e bulbos das col\u00f4nias da \u00c1frica e do Brasil parao Complexo de Hist\u00f3ria Natural da Ajuda, em Portugal. Entre os pap\u00e9is referentes a Mo\u00e7ambique, que integram o acervo do Arquivo Hist\u00f3ricoUltramarino, em Lisboa, encontra-se um manuscrito ainda in\u00e9dito que trata dos m\u00e9todos autilizar na recolha e remessa de sementes, tub\u00e9rculos e bulbos das col\u00f4nias paraPortugal. A instru\u00e7\u00e3o, datada de 18 de outubro de 1802, vem assinada por Ant\u00f4nio Jos\u00e9 deCarvalho Chaves, que era secret\u00e1rio de Governo de Mo\u00e7ambique e chegara \u00e0 col\u00f4nia naqueleexato ano. Formara-se em c\u00e2nones pela Universidade de Coimbra em 1799 e n\u00e3o parece tertido maiores interesses pelas ci\u00eancias naturais. Sua forma\u00e7\u00e3o na \u00e1rea devia-se \u00e0 reformapombalina da Universidade de Coimbra, de 1772, que obrigava todos os estudantes,independentemente de seus cursos, a frequentar disciplinas de ci\u00eancias naturais, f\u00edsicae qu\u00edmica , que continuaramsob sua dire\u00e7\u00e3o direta .Conforme indicado na carta de encaminhamento, a Manuais e instru\u00e7\u00f5es de recolha de \u201cprodutos da natureza\u201d, como o elaborado porChaves, pertencem a uma conjuntura cient\u00edfica muito espec\u00edfica. Em meados do s\u00e9culoXVIII, o naturalista sueco Carlos Lineu desenvolveu as premissas daquilo que setornaria a base epistemol\u00f3gica das modernas ci\u00eancias da natureza. O paradigma seapoiava no trip\u00e9: (1) ado\u00e7\u00e3o do modelo taxon\u00f4mico por ele desenvolvido, (2)expedi\u00e7\u00f5es explorat\u00f3rias e (3) cria\u00e7\u00e3o de complexos de hist\u00f3ria natural. Essescomplexos eram centrais ao processo e passaram a ser reproduzidos por todo lado.Joseph Banks tornou-se figura central dos Royal Botanic Gardens de Kew e assumiu ocontrole da pol\u00edtica de envio de naturalistas nas expedi\u00e7\u00f5es inglesas despachadaspara todos os continentes. Buffon conduziu um processo semelhante de recolha, apartir do Jardin du Roi. Na Espanha, o Real Gabinete e o Real Jardim Bot\u00e2nico deMadri passariam a centralizar a pol\u00edtica imperial de recolha e cataloga\u00e7\u00e3o deesp\u00e9cimes. Em Portugal, o naturalista paduano Domingos Vandelli seguiria a mesmacartilha, ao implantar, a partir de 1768, o Museu e Jardim Bot\u00e2nico da Ajuda. Portoda a Europa, e mesmo nas col\u00f4nias, novas instala\u00e7\u00f5es foram fundadas, e as antigasforam adaptadas para atender \u00e0s novas demandas . Um formato corrente foi o dasorienta\u00e7\u00f5es espec\u00edficas sobre as formas de recolher, preparar e conservar osprodutos da natureza coletados por leigos ou em expedi\u00e7\u00f5es explorat\u00f3rias. Ren\u00e9-Antoine Ferchault de R\u00e9aumur foi pioneironessa \u00e1rea. Dono de um saber enciclop\u00e9dico, dedicou-se tamb\u00e9m \u00e0 entomologia e \u00e0ornitologia. Entre 1737 e 1748, R\u00e9aumur publicou diversas obras sobre aconserva\u00e7\u00e3o de p\u00e1ssaros e insetos. A Instructio peregrinatoris. Outro de seus disc\u00edpulos, DavidA tradi\u00e7\u00e3o dos manuais de viagens cient\u00edficas iniciada por Boyle e Woodward tevesequ\u00eancia quando Eric Mem\u00f3ire instructif sur la mani\u00e8re de rassembler, de preparer, deconserver et d\u00b4envoyer les diverses curiosit\u00e9s d\u2019histoire naturell.Trazia anexado o Avis pour le transport par mer des arbres, deNa segunda metade do s\u00e9culo XVIII, as instru\u00e7\u00f5es de cunho geral sobre viagensfilos\u00f3ficas \u2013 o que e como olhar, instrumentos necess\u00e1rios etc. \u2013 acabaram porser reunidas em novos comp\u00eandios que continham tamb\u00e9m orienta\u00e7\u00f5es b\u00e1sicas derecolha e conserva\u00e7\u00e3o de esp\u00e9cimes. O primeiro com essas caracter\u00edsticas foipublicado pelo naturalista amador \u00c9tienne-Fran\u00e7ois M\u00e9thoden\u00e9cessaire aux marins et aux voyageurs, de M. Instructions forcollecting and preserving insects. Sobre taxidermia e prepara\u00e7\u00e3o deesp\u00e9cimes foram publicados os manuais do abade Na sequ\u00eancia, apareceram diversas instru\u00e7\u00f5es especializadas. O The naturalist\u2019s and traveller\u2019s companion, no qual, pelaprimeira vez, foram reunidos num \u00fanico manual a qualifica\u00e7\u00e3o doviajante-fil\u00f3sofo, orienta\u00e7\u00f5es gerais e os m\u00e9todos de recolha e conserva\u00e7\u00e3o.Trazia ainda instru\u00e7\u00f5es para um levantamento exaustivo de dados sobre aeconomia, a hist\u00f3ria e a organiza\u00e7\u00e3o social das regi\u00f5es visitadas.Numa perspectiva mais ampla, o m\u00e9dico John Coakley Lettson (1772) fez editarNa d\u00e9cada de 1770, a Coroa de Espanha iniciou um processo de recolha e estudo dafauna e da flora na escala planet\u00e1ria de suas col\u00f4nias. O primeiro manualespanhol de instru\u00e7\u00f5es deve-se a Pedro Franco D\u00e1vila, naturalista que viveu porduas d\u00e9cadas em Paris, onde reuniu um imenso gabinete de hist\u00f3ria natural , ele buscoucobrir diversos aspectos das viagens filos\u00f3ficas, da import\u00e2ncia e de como fazerdi\u00e1rios, o que observar e os meios de preservar os produtos da naturezarecolhidos.Em Portugal, o naturalista Domingo Vandelli foi respons\u00e1vel por difundir essesmanuais entre seus alunos. Tamb\u00e9m foi um dos respons\u00e1veis pela implementa\u00e7\u00e3o doprojeto de viagens filos\u00f3ficas \u00e0s col\u00f4nias portuguesas, para o qual foram convocadosdiversos estudantes rec\u00e9m-formados da Universidade de Coimbra, todos elesluso-brasileiros. Na fase preparat\u00f3ria do projeto, ele elaborou um rol de instru\u00e7\u00f5es\u00e0s quais deu o t\u00edtulo de observar . Como taBreves instru\u00e7\u00f5es aos correspondentes da Academia das Ci\u00eancias de Lisboasobre as remessas dos produtos e not\u00edcias pertencentes a hist\u00f3ria da naturezapara formar um museu nacional  . Na composi\u00e7\u00e3o de suas instru\u00e7\u00f5es,o estudante reporta-se a uma mem\u00f3ria sobre recolher produtos da natureza, de \u201cautordesconhecido\u201d, ou seja, a obra de Turgot, publicada anonimamente. Outra instru\u00e7\u00e3oreferenciada \u00e9 o M\u00e9thode de O viajante naturalista, a vers\u00e3o em franc\u00eas  da obra de Em data posterior \u00e0s Instru\u00e7\u00e3o, tinham amplo acesso \u00e0literatura mundial especializada sobre o tema. Al\u00e9m disso, j\u00e1 contavam com um corpode manuais elaborados no pr\u00f3prio pa\u00eds.Um dos aspectos de maior interesse das instru\u00e7\u00f5es de Vidigal \u00e9 o fato de serassumidamente uma compila\u00e7\u00e3o. Em decorr\u00eancia, s\u00e3o expl\u00edcitas as refer\u00eancias aostextos que serviram de base para a sua elabora\u00e7\u00e3o. A bibliografia utilizada d\u00e1 umamostra da produ\u00e7\u00e3o internacional das orienta\u00e7\u00f5es para viajantes naturalistas e quaisestavam sendo lidas em Portugal. Conforme se observa, os estudantes de Coimbra, comoCarvalho Chaves, autor da Instru\u00e7\u00e3o completa sobre o m\u00e9todo de apanhar,manejar, conservar e empacotar os insetos , muito provavelmente uma tradu\u00e7\u00e3o ap\u00f3crifa de obra inglesa ou francesa. N\u00e3o \u00e9poss\u00edvel ter certeza se se tratava de uma iniciativa privada ou oficial, uma vez queessa tipografia era usada por dom Rodrigo de Souza Coutinho para imprimir uma s\u00e9riede obras traduzidas por sua orienta\u00e7\u00e3o.O passo seguinte na publica\u00e7\u00e3o oficial de instru\u00e7\u00f5es em Portugal inscreve-se natradi\u00e7\u00e3o das obras sobre procedimentos especializados. Em 1798, a tipografia deThadeo Ferreira publicou uma Naturalista instru\u00eddo. Todavia, numprimeiro momento, foi publicado apenas um tomo, sobre o reino animal  pelaUniversidade de Coimbra.A biografia do autor da Como vimos, a primeira comiss\u00e3o que recebeu da Coroa foi na \u00c1frica, em 1802.Posteriormente, foi nomeado para uma magistratura no Brasil, onde fez uma carreirabem-sucedida e viveu o resto de sua vida. Laurenio Formou-se em Leis pela Universidade de Coimbra, conforme carta de Bacharel datadade 23 de novembro de 1809.Em decreto de 13 de maio de 1811, foi nomeado Juiz de Fora da comarca de Cuiab\u00e1,obtendo por alvar\u00e1 de 4 de fevereiro de 1812, o lugar de Provedor da Fazenda dosDefuntos e Ausentes, Res\u00edduos e Capelas enquanto exercesse aquele lugar.Havendo bem desempenhado o mesmo lugar, foi a ele reconduzido com o predicamentodo primeiro banco, em decreto de 13 de mar\u00e7o de 1815.Foi nomeado Desembargador da Rela\u00e7\u00e3o da Bahia, pela imediata resolu\u00e7\u00e3o de 6 deagosto de 1821, tomada sobre consulta da Mesa do Desembargo do Pa\u00e7o.Passou para a Casa da Suplica\u00e7\u00e3o como Desembargador Ordin\u00e1rio e de Agravos, emdecretos de 12 de outubro de 1827 e 18 de outubro de 1829.Em decreto desta \u00faltima data, foi nomeado Corregedor do Crime da Corte eCasa.Com a extin\u00e7\u00e3o da Casa da Suplica\u00e7\u00e3o ficou pertencendo \u00e0 Rela\u00e7\u00e3o do Rio deJaneiro, conforme foi declarado em portaria de 11 de mar\u00e7o de 1833 do Ministroda Justi\u00e7a.Foi nomeado Ministro do Supremo Tribunal de Justi\u00e7a, em decreto de 15 de setembrode 1842, na vaga proveniente do falecimento de Euz\u00e9bio de Queiroz Coutinho daSilva, tomando posse em 27 do mencionado m\u00eas.Foi agraciado por D. Pedro I com o grau de Cavaleiro da Ordem do Cruzeiro, emdecreto de 2 de agosto de 1826, o foro de Fidalgo Cavaleiro, em decreto de 18 dejaneiro de 1830, e Oficialato da Ordem da Rosa, em decreto de 17 de outubro domesmo ano, e por D. Pedro II com o t\u00edtulo do Conselho, em carta de 26 desetembro de 1842.O Conselheiro Antonio Jos\u00e9 de Carvalho Chaves faleceu em Niter\u00f3i, prov\u00edncia doRio de Janeiro, no dia 29 de julho de 1847, conforme se verifica do registro de\u00f3bitos da Igreja de S. Jo\u00e3o Batista da mesma cidade, sendo sepultado nascatacumbas da Igreja da Concei\u00e7\u00e3o.1Esses dados est\u00e3o basicamente corretos, mas \u00e9 preciso corrigir alguns pormenores.Lago afirma que Chaves formou-se em leis pela Universidade de Coimbra, em 1809. Naverdade, ele cursou c\u00e2nones entre 1794 e 1799.Anais do Senado daC\u00e2mara de Cuiab\u00e1 .Em 1802, apenas dois anos ap\u00f3s se formar, recebeu o H\u00e1bito da Ordem de Cristo e ganhou o cargo de secret\u00e1rio deGoverno em Mo\u00e7ambique, o que \u00e9 um indicativo de que era \u201cbem nascido\u201d. Foi paraaquela col\u00f4nia na condi\u00e7\u00e3o de letrado, e n\u00e3o com uma patente militar, como costumamafirmar. Quando voltou a Portugal, foi agraciado com a magistratura de juiz de forade Cuiab\u00e1. Sua chegada ao Mato Grosso ficou anotada nos No dia 30 de Outubro [de 1812] chegou a esta vila com feliz sucesso o Dr. Juiz deFora Ant\u00f4nio Jos\u00e9 de Carvalho Chaves, cavaleiro professo na Ordem de Cristo, en\u00e3o entrou no governo da justi\u00e7a por ser haver dado parte da sua chegada, como \u00e9de costume, ao Ilmo. e Exmo. Sr. Governador e Capit\u00e3o-general. \u2026 No dia 10 destem\u00eas deu posse o Senado da C\u00e2mara ao Dr. Ant\u00f4nio Jos\u00e9 de Carvalho Chaves do cargode Juiz de Fora em consequ\u00eancia da r\u00e9gia provis\u00e3o que apresentou, na presen\u00e7a danobreza e povo que assistiram a este solene ato, e igualmente foi empossado docargo de Provedor das Fazendas dos Defuntos e Ausentes, Capelas e Res\u00edduos, emconsequ\u00eancia de outra r\u00e9gia provis\u00e3o que apresentou; e neste mesmo atolevantando-se da sua cadeira o dito Dr. Juiz de Fora, fez uma elegante fala.Chaves manteve-se naquela capitania por uma d\u00e9cada. O padr\u00e3o de perman\u00eancia dessesoficiais em col\u00f4nias long\u00ednquas e desprestigiadas, como Mato Grosso, era de tr\u00easanos , p.289. Curiosidades em Cuiab\u00e1, em cujasp\u00e1ginas sobrantes um de seus filhos anotou diversos dados sobre a fam\u00edlia. L\u00ea-se nomanuscrito que ele \u201cPerfilhou filhos leg\u00edtimos a Ant\u00f4nio Lucas Chaves, Luiz Ant\u00f4nioChaves e Ant\u00f4nio [?] Maria Chaves todos filhos da cidade de Cuiab\u00e1 na Prov\u00edncia deMato Grosso\u201d . Permaneceu no cargoat\u00e9 julho de 1823. A atua\u00e7\u00e3o nesse per\u00edodo no governo da capitania foi por ele beminflada e serviu para alavancar suas pretens\u00f5es futuras. Ao solicitar a Ordem doCruzeiro, argumentaria que no governo provis\u00f3rio de Mato Grosso \u201cadvogou a causa daindepend\u00eancia e do Imp\u00e9rio\u201d , levando as vilas de Cuiab\u00e1 e MatoGrosso a aderir \u00e0 causa da Independ\u00eancia ("}
+{"text": "To identify the main categories of the Activities and Participation component of the International Classification of Functioning, Disability, and Health and to verify the association with age, gender, education, and speech therapy diagnosis in children who are assisted by an oral language clinic.This is an analytical and cross-sectional observational study, carried out with secondary data from 32 medical records of children with the majority male, mean age of 41.03 months, in early childhood education and language disorder associated with other conditions. The main speech-language pathology manifestations were coded according to the pre-selected categories of the Activities and Participation component, and descriptive and bivariate statistical analyzes were performed, and the Fisher's Exact test was used with a significance level of 5%.The descriptive analysis of the pre-selected categories allowed us to verify a high number of \u201cNot informed\u201d answers, with a higher percentage in vocal expression without speech (d331) performance (93.8%), making decisions (d177) ability (90.6%), problem solving (d175) performance (65.6%) and capacity (87.5%), reception of oral messages (d310) performance (65.6%) and eating (d550) capacity (65.6%). Among the 24 categories selected, 12 jointly contemplated the Qualifiers of Performance and Capacity. There was a statistically significant association between the three categories with sociodemographic data and speech therapy diagnoses.Difficulties were identified in several categories of the Activities and Participation component and statistically significant associations between them and sociodemographic data and speech therapy diagnoses, showing the impacts of oral language disorders on the activities and participation of children assisted in an outpatient speech therapy service. Acquiring and refining speech and language skills throughout child development enable them to have greater control of their lives as they express their needs, feelings, and ideas. Child language impairments can impair or have an impact on their psychosocial and cognitive development and quality of life.Child language assessment and therapeutic strategy planning in rehabilitation should address not only organic aspects but also the influence of environmental, psychosocial, and cognitive aspects. Such an approach provides a wider understanding of language, encompassing its use in the various contexts of life and how it shapes children\u2019s functioning. Hence, the tool classifies functioning, disability, and contextual factors associated with health conditions from a biopsychosocial perspective.The International Classification of Functioning, Disability, and Health (ICF) belongs to the family of international classifications of the World Health Organization (WHO), whose purpose is to describe health and related statuses and provide a unified and standardized language.Using ICF to monitor the progress of functioning helps identify, understand, and monitor the impacts language impairment may have on children\u2019s overall and social development, besides favoring assistance based on comprehensive health attention and care and related statuses. As it helps identify aspects of functioning, especially the ones related to activity limitations and participation restrictions, ICF characterization can help plan interventions to overcome barriers in different life contexts.The American Speech-Language-Hearing Association (ASHA) recommends incorporating ICF in all healthcare components to integrate the influence of contextual factors of functioning and promote the development of functional objectives and collaborative practices in clinical decisions. There must also be studies associating categories relevant to oral language changes with personal factors and clinical diagnoses, thus helping understand language impairment in greater depth and consider its individual and social consequences.Given its complexity and size and the lack of studies and reference tools, ICF use in speech-language-hearing (SLH) practice must increase by developing standardized clinical instruments to guide and help its clinical application.ICF is structured in two parts. The first one, Functioning and Disability, includes the components of Body Functions and Structures, and Activities and Participation. The second part addresses information on the context, including the components of Environmental Factors and Personal Factors. Positive aspects  are named Functioning. Negative aspects  make up Disability. Concerning environmental factors, positive aspects are the facilitators, and negative ones are the barriers. Language changes in children can hinder them from carrying out tasks and actions (Activities) and getting involved in daily life situations (Participation), respectively causing limitations and restrictions. Therefore, it is greatly important to investigate changes in Language and Functioning.This study focused on Activities and Participation, a component that encompasses the qualifiers of Capacity and Performance and includes domains that indicate individual and social aspects of functioning; hence, it represents the ICF \u201cinformation matrix\u201dThus, this study aimed to identify the main categories of ICF Activities and Participation and the possible Capacity and Performance qualifiers and verify their associations with age, sex, educational attainment, and overall SLH diagnosis in children in oral language outpatient care.This research was approved by the Research Ethics Committee of the Federal University of Minas Gerais under number 3.172.707 and CAAE: 02470618.1.0000.5149.This cross-sectional analytical observational study analyzed secondary data collected from the medical records of patients attending an SLH outpatient service at a public hospital.The service in question is a pediatric oral language therapy outpatient center that treats children with language disorders associated with Down syndrome and other genetic or sensory conditions; autism spectrum disorder; developmental language disorder, and speech sound disorder.The sample comprised the data collected from the medical records of 32 patients - i.e., all those who attended the service between August 2018 and March 2021. They were 14 months to 8 years old and had been diagnosed with pediatric oral language disorder. All research participants\u2019 parents/guardians signed an informed consent form and authorized the access to the participants\u2019 medical records.Firstly, the following data were collected from the initial assessment reports: sex, date of birth, educational attainment, and overall SLH diagnosis. Then, the main SLH manifestations and diagnoses were classified according to the ICG Activities and Participation, using its Capacity and Performance qualifiers., Language Development Assessment (ADL), Behavior Observation Protocol for children up to 6 years old, ABFW Child Language Test, USP Picture Vocabulary Test (TVfusp), Auditory Vocabulary Test (TVAud), and Expressive Vocabulary Test (TVExp). Hearing assessment results, when present, were also considered.The survey considered the SLH manifestations and suspected diagnoses related to language changes in its receptive and expressive aspects; the phonological, morphosyntactic, pragmatic, and semantic subsystems; and the cognitive development aspects described in the reports based on the results of the following tests: Behavioral Observation Protocol ICF categories were defined by preselecting Activities and Participation chapters that were related to pediatric oral language changes. The preselection was open - i.e., considering the SLH manifestations and diagnoses listed in the reports. This study included five chapters: \u201cLearning and applying knowledge\u201d, \u201cGeneral tasks and demands\u201d, \u201cCommunication\u201d, \u201cSelf-care\u201d, and \u201cMajor life areas\u201d .After defining the chapters, their set of categories was selected, and then associating their Performance and Capacity qualifier codes with the report findings. This study used only the following qualifiers: .0 (no difficulties), .8 (not specified difficulty), and .9 (not applicable), not specifying the degree of difficulty.Altogether, 24 categories were selected: 10 from \u201cLearning and applying knowledge\u201d, three from \u201cGeneral tasks and demands\u201d, five from \u201cCommunication\u201d, four from \u201cSelf-care\u201d, and two from \u201cMajor life areas\u201d, as shown in Collected data were tabulated in an Excel spreadsheet and compiled to characterize the children\u2019s profiles and SLH manifestations and construct the category list. Data on the process of classifying the manifestations present in the reports were gathered for analysis.Descriptive and bivariate analyses were performed. The descriptive analysis was based on the distribution of absolute and relative frequencies of categorical variables and the numerical synthesis of continuous variables. The ICF Activities and Participation categories were defined as the response variables, and the sex, age, educational attainment, and overall SLH diagnosis were defined as the explanatory variables. The qualifier .9 (not applicable) was removed for statistical analyses to make data synthesis easier.The bivariate analysis used Fisher\u2019s exact test for all categorical variables. This analysis required the recategorization and creation of new variables because of the few observations in certain categories of variables. \u201cEducational attainment\u201d was reclassified into two categories in the new variable: \u201cAttends school\u201d (yes for \u201cPreschool education\u201d and \u201cElementary school\u201d and no for \u201cDoes not attend\u201d). \u201cAge\u201d was symmetrically distributed  and was categorized according to the cutoff (median of the distribution), which was 37.5 months. Hence it was divided into two categories: the first one \u2264 37.5 months and the second one > 37.5 months. In all analyses, the level of significance was set at 5%.The descriptive analysis of sociodemographic data showed that 59.4% of participants were males, and 40.6% were females. Their mean age was 41.03 months, with a standard deviation of 19.77, a minimum of 14, and a maximum of 96. As for educational attainment, 19 participants (60.7%) attended preschool, five participants (14.3%) attended elementary school, and eight participants (25%) did not attend school. The analysis of the overall SLH diagnosis indicated a prevalence of language disorders associated with other conditions (60%), followed by developmental language disorder (40%).The descriptive analysis of the preselected ICF Activities and Participation categories showed \u201cNot reported\u201d was a recurrent answer, with the highest percentages in Non-speech vocal expression (d331) performance (93.8%), Making decisions (d177) capacity (90.6%), Solving problems (d175) performance (65.6%) and capacity (87.5%), Communicating with - receiving - spoken messages (d310) performance (65.6%), and Eating (d550) capacity (65.6%). Twelve out of the 24 selected categories encompassed the Performance and Capacity qualifiers together.The following \u201cLearning and applying knowledge\u201d categories had the highest percentage of descriptions as \u201csome difficulty\u201d: Acquiring language (d132) - performance (68.8%) and capacity (96.9%); Learning through actions with objects (d131) - capacity (75%); Acquiring concepts (d137) - capacity (62.5%); Focusing attention (d160) - capacity (59.4%).The three selected \u201cGeneral tasks and demands\u201d categories were described with a higher prevalence of \u201csome difficulty\u201d, as follows: Handling stress and other psychological demands (d240) - performance (59.4%); Undertaking a single task (d210) - performance (50%); Carrying out daily routine (d230) - performance (50%).Of the five selected \u201cCommunication\u201d categories, the following were described with a higher percentage of \u201csome difficulty\u201d, as follows: Speaking (d330) - performance (62.5%) and capacity (100%); Conversation (d350) - capacity (75%); Communicating with - receiving - spoken messages (d310) - capacity (53.1%). The following categories were described with a higher percentage of \u201cno difficulties\u201d: Producing nonverbal messages (d335) - capacity (59.4%) and Non-speech vocal expression (d331) - capacity (50%).There were many \u201cnot reported\u201d answers in \u201cSelf-care\u201d. Washing oneself (d510), Caring for body parts (d520), and Dressing (d540) had only the performance qualifier, and they were all described as having \u201csome difficulty\u201d more often (34.4%). Eating (d550) was described as having \u201cno difficulty\u201d in 46.9% in performance and 34.4% in capacity.In \u201cMajor life areas\u201d, Preschool education (d815) and School education (d820) likewise only had performance. School education was described as \u201cnot applicable\u201d in 87.5% of patients. Preschool education was described as \u201cno difficulties\u201d in 37.5% and as \u201csome difficulties\u201d in 31.3%.The association analysis between ICF Activities and Participation categories and the patients\u2019 sex had no statistically significant results.The association analysis between ICF Activities and Participation categories and the patients\u2019 ages, categorized based on the median, found a statistically significant result between age and Solving problems (d175) - performance, with a p-value of 0.045. Among participants with difficulties, 71.4% were \u2264 37.5 months old. The association analysis between ICF Activities and Participation categories and \u201cSchool attendance\u201d (yes and no) found a statistically significant result with Preschool education (d815) - performance, with a p-value of 0.003; all patients who had no difficulties attended school .The association between ICF categories and \u201cSLH diagnosis\u201d  found statistical significance between SLH diagnosis and Conversation (d350) - capacity (p = 0.013); 77.3% of participants with difficulties had an SLH diagnosis of language disorder associated with other conditions .The diversity of ICF Activities and Participation categories found in this study led to reflections on the impacts oral language disorders may have on child development, especially regarding activity limitations and participation restrictions. Hence, the study aimed to identify ICF Activities and Participation categories and their associations with age, sex, educational attainment, and overall SLH diagnosis in the context of a pediatric language outpatient center.-19. Concerning the findings related to age and educational attainment in the sample, a study on the prevalence of SLH changes in children verified a prevalence of communication changes in preschoolers (48.7% of participants aged 36 to 72 months). It must be pointed out that the present study has a wide age range, from 14 to 96 months - a much wider range to consider and refer to developmental stages and communication changes.As for sociodemographic data, the study shows that most participants were males -similar results to that of other studies that associated the prevalence of child language changes with males due to neurological, hormonal, and social factors.The predominating SLH diagnosis of language disorder associated with other conditions corroborates a study on diagnostic profiles at an SLH outpatient center in the field of child language. It verified a high prevalence of comorbidities (76.9%), with the greatest occurrence of associations with neurological diseases and neuropsychomotor developmental delay-23 - which demonstrates the diversity of SLH manifestations present in a language diagnosis. A study on expectations and results found after speech and language therapy in preschoolers verified that most concerns, expectations, and progress perceived by the parents and physicians were related to activity limitations. This shows the importance of integrating aspects of functioning (particularly those related to activity limitations and participation restrictions) in SLH practice regarding child oral language disorders.Regarding the ICF Activities and Participation categories, the results show that preselecting chapters and categories related to pediatric oral language changes favors their application, as all selected chapters and categories were included in this study. The importance of considering factors associated with activity limitations and participation restrictions is reflected in the multiple categories also found in other studies. The study reported a greater occurrence of difficulties described in categories of chapters on basic learning and knowledge application, namely: Learning not read (d140) - performance; Focusing attention (d161) - performance; Writing (d170) - capacity; and Learning to write (d145) - capacity. The studies coincide with the prevalence of difficulties described in \u201cLearning and applying knowledge\u201d. However, they differ regarding the categories described with the highest percentage of \u201csome difficulty\u201d. Such a difference can be explained by the setting, characterization of the sample, age range, and changes patients had in each study. The cited study analyzed medical records of patients treated at an assessment outpatient center, aged 5 to 16 years, whose changes may not have been related to oral languages; moreover, the patients could have other types of changes, such as in reading and writing. As for the characterization of the sample, the exclusion criteria in that study encompassed patients with suspected or confirmed diagnoses of global developmental delay.A study on the characterization of outpatients\u2019 performance in SLH aspects according to the ICF version for children and youth (ICF-CY) verified the prevalence of difficulties described in categories related to language, learning, and school issues. This is similar to the results in the present study regarding the chapters with the most recurrent description of difficulties, as well as Speaking (d330) and Conversation (d350), which were also described with a higher percentage of \u201csome difficulties\u201d.On the other hand, a study identified ICF categories in cases of language and speech disorders and found that the most frequent Activities and Participation categories - Communicating with - receiving - spoken messages (d310), Speaking (d330), Acquiring skills (d155), and Conversation (d350) - were related to the chapters on Basic learning and Communication. Educational settings favor the progress of cognitive stages, strengthening their abilities to deal with adversities and encouraging creative solutions to their problems.Studies associating categories relevant to oral language changes with personal factors and clinical diagnoses help understand health conditions. The analyses in this study verified an association between age and Solving problems (d175) - performance, in which most participants with difficulties were \u2264 37.5 months old. This can be explained by the development of autonomy, social skills, entering school, or a combination of two or more factors. Thus, regardless of the language diagnosis, developmental factors play a major role. Another important factor is the school experience, which is essential to social and educational acquisition in the first years at school.The association between attending school and Preschool education (d815) - performance  can be explained by the fact that the complaints of preschoolers\u2019 parents were not yet related to school issues - which begin in school age. After they enter school, parents tend to broaden their perception of complaints related to school difficulties. A study in schoolchildren\u2019s relatives found that the main complaints that motivated referrals to the clinic were related to writing and reading difficulties, while complaints on psychological/behavioral aspects were less frequent. Even though the studies are different regarding analysis variables, school age can be related to the greatest school demands and difficulties observed in the cited study. This reflects the importance that SLH practices encompass oral and written language, even before starting formal education, because mastering the oral linguistic system and developing metacognitive and metalinguistic skills are essential to learning to read and write.Another study, conducted in an SLH assessment outpatient center, verified an association between educational attainment and the ICF Activities and Participation factor named \u201cFamily/school\u201d, which comprises \u201cHousehold relationships - performance\u201d and \u201cSchool education - performance\u201d. This factor obtained higher scores among older patients who attended elementary or middle school, which are explained by the greater school demands on elementary school or more advanced students.The association verified between SLH diagnoses and Conversation d350 - capacity (in which most participants with difficulties were diagnosed with language disorders associated with other conditions) can be explained by the patients\u2019 profile in the service. The hospital to which the outpatient center in question belongs provides medium- and high-complexity care and is a reference in referrals to services such as neurology and genetics and receives mostly patients with autism spectrum disorder and Down syndrome. Pragmatic skill impairments are frequent in these conditions, which causes interaction, social communication, and conversation difficultiesBecause the analysis was based on secondary data collected from medical records, the limitation of this study involves missing information, as demonstrated in the many \u201cnot reported\u201d answers in the descriptive analysis of ICF categories. This can be explained by medical history survey and assessment tools used in the service, which may have had little association with ICF functioning aspects. This indicates the need for developing standardized clinical instruments with categories relevant to child language changes, enabling their implementation in clinical practice at the service and minimizing the loss of information in medical record analysis. The study also has limitations regarding its sample size. However, it involved an outpatient center whose population is not large, and the sample was representative of the service\u2019s profile.Concerning advancements, the study made it possible to identify the main categories relevant to pediatric oral language changes, understand activity limitations and participation restrictions resulting from this condition, and implement the list of categories constructed at the service. Hence, it enabled the application of ICF in its clinical practice and the development of a future longitudinal study with the same population, expanding the use of qualifiers that specify the degree of difficulty to compare before and after SLH therapy. This study can also motivate SLH therapists of other services whose patients have a similar profile to include and operationalize ICF in the clinical assistance flow.The study results show the importance of using ICF as a tool to integrate the impacts of language changes on functioning and the expansion of the biopsychosocial approach in SLH clinical practice.The study selected 24 ICF Activities and Participation categories, 12 of which encompassed both performance and capacity qualifiers in children with oral language disorders undergoing SLH therapy at a public outpatient service. Difficulties were described most often in the categories of Learning and applying knowledge and Communication and were related to activities such as Acquiring language, Learning through actions with objects, Speaking, and Conversation.It also found statistically significant associations between sociodemographic data and SLH diagnoses and ICF Activities and Participation categories. -3.A linguagem \u00e9 um sistema de comunica\u00e7\u00e3o fundamental para a funcionalidade humana e por meio dela o ser humano interage na sociedade. A aquisi\u00e7\u00e3o e o refinamento das habilidades de fala e linguagem no decorrer do desenvolvimento infantil, permitem que a crian\u00e7a exer\u00e7a maior controle sobre sua vida por meio da express\u00e3o de suas necessidades, sentimentos e ideias. Comprometimentos na linguagem infantil podem gerar impacto ou preju\u00edzo ao desenvolvimento psicossocial e cognitivo, bem como \u00e0 qualidade de vida da crian\u00e7a.A avalia\u00e7\u00e3o da linguagem infantil e o planejamento das estrat\u00e9gias terap\u00eauticas na reabilita\u00e7\u00e3o n\u00e3o devem se restringir aos aspectos org\u00e2nicos, mas integrar a influ\u00eancia dos aspectos ambientais, psicossociais e cognitivos. Tal abordagem permite uma compreens\u00e3o mais ampla da linguagem, que considera seu uso nos diferentes contextos da vida e a maneira que esta molda a funcionalidade da crian\u00e7a. Dessa forma, a ferramenta permite classificar, por meio de uma perspectiva biopsicossocial, a funcionalidade, a incapacidade e os fatores contextuais associados \u00e0s condi\u00e7\u00f5es de sa\u00fade.A Classifica\u00e7\u00e3o Internacional de Funcionalidade, Incapacidade e Sa\u00fade (CIF) \u00e9 uma classifica\u00e7\u00e3o pertencente \u00e0 Fam\u00edlia de Classifica\u00e7\u00f5es Internacionais da Organiza\u00e7\u00e3o Mundial de Sa\u00fade (OMS), que se prop\u00f5e a descrever a sa\u00fade e seus estados relacionados e proporcionar uma linguagem unificada e padronizada.O uso da CIF como ferramenta para monitorar a evolu\u00e7\u00e3o da funcionalidade contribui para identificar, compreender e monitorar os impactos que o comprometimento de linguagem pode representar ao desenvolvimento global e social da crian\u00e7a, al\u00e9m de favorecer uma assist\u00eancia fundamentada na aten\u00e7\u00e3o e cuidado integral \u00e0 sa\u00fade e seus estados relacionados. Ao auxiliar na identifica\u00e7\u00e3o dos aspectos da funcionalidade, principalmente aqueles relacionados \u00e0s limita\u00e7\u00f5es de atividades e restri\u00e7\u00f5es de participa\u00e7\u00e3o, a caracteriza\u00e7\u00e3o realizada por meio da CIF pode auxiliar no planejamento de interven\u00e7\u00f5es para a supera\u00e7\u00e3o das barreiras nos diferentes contextos da vida.A American Speech-Language-Hearing Association (ASHA) recomenda a incorpora\u00e7\u00e3o da CIF em todos os componentes de aten\u00e7\u00e3o \u00e0 sa\u00fade a fim de integrar, nas decis\u00f5es cl\u00ednicas, a influ\u00eancia dos fatores contextuais \u00e0 funcionalidade e promover o desenvolvimento de objetivos funcionais e pr\u00e1ticas colaborativas. Al\u00e9m disso, o desenvolvimento de estudos que associem as categorias relevantes \u00e0s altera\u00e7\u00f5es de linguagem oral, com os fatores pessoais e diagn\u00f3sticos cl\u00ednicos, favorece uma compreens\u00e3o mais ampla do comprometimento de linguagem, e considera suas repercuss\u00f5es individuais e sociais.Diante de sua complexidade e extens\u00e3o, assim como da car\u00eancia de estudos e ferramentas de refer\u00eancia, evidencia-se a necessidade de ampliar o uso da CIF na pr\u00e1tica fonoaudiol\u00f3gica, por meio do desenvolvimento de instrumentos cl\u00ednicos padronizados que norteiem e auxiliem sua aplica\u00e7\u00e3o cl\u00ednica.A CIF \u00e9 estruturada em duas partes. A primeira, Funcionalidade e Incapacidade, inclui os componentes Fun\u00e7\u00f5es e Estruturas do Corpo e, Atividades e Participa\u00e7\u00e3o. A segunda parte traz as informa\u00e7\u00f5es do contexto, incluindo os componentes Fatores Ambientais e Fatores Pessoais. Os aspectos positivos  s\u00e3o denominados Funcionalidade. Os aspectos negativos  constituem a Incapacidade. Em rela\u00e7\u00e3o aos fatores ambientais, os aspectos positivos s\u00e3o os facilitadores e os aspectos negativos s\u00e3o barreiras. Por entender que as altera\u00e7\u00f5es de linguagem em crian\u00e7as podem comprometer execu\u00e7\u00f5es de tarefas ou a\u00e7\u00f5es (Atividades) e o envolvimento em situa\u00e7\u00f5es de vida di\u00e1ria (Participa\u00e7\u00e3o) configurando limita\u00e7\u00f5es e restri\u00e7\u00f5es, respectivamente, \u00e9 de suma import\u00e2ncia investigar as intera\u00e7\u00f5es entre os construtos Linguagem e Funcionalidade.No presente estudo, o foco ser\u00e1 o componente Atividades e Participa\u00e7\u00e3o, que contempla os qualificadores de Capacidade e Desempenho e inclui dom\u00ednios que indicam os aspectos da funcionalidade no n\u00edvel individual e social, e, por isso, representa a \u201cmatriz da informa\u00e7\u00e3o\u201d gerada pela CIFPortanto, os objetivos do presente estudo foram identificar as principais categorias, referentes ao componente Atividades e Participa\u00e7\u00e3o da CIF, bem como os poss\u00edveis qualificadores de Capacidade e Desempenho, e verificar suas associa\u00e7\u00f5es com idade, sexo, escolaridade e diagn\u00f3stico fonoaudiol\u00f3gico global em crian\u00e7as atendidas em um ambulat\u00f3rio de linguagem oral.Esta pesquisa foi aprovada pelo Comit\u00ea de \u00c9tica em Pesquisa da Universidade Federal de Minas Gerais sob n\u00famero 3.172.707 e CAAE: 02470618.1.0000.5149.Trata-se de estudo observacional anal\u00edtico, de car\u00e1ter transversal, com base na an\u00e1lise de dados secund\u00e1rios, coletados em prontu\u00e1rios de pacientes atendidos em um servi\u00e7o fonoaudiol\u00f3gico ambulatorial pertencente a um hospital da rede p\u00fablica.O servi\u00e7o em quest\u00e3o \u00e9 um ambulat\u00f3rio de terapia de linguagem oral infantil, que presta assist\u00eancia a crian\u00e7as com Transtornos de Linguagem associados \u00e0 S\u00edndrome de Down e outras condi\u00e7\u00f5es gen\u00e9ticas ou sensoriais; Transtorno do Espectro Autista; Transtorno do Desenvolvimento da Linguagem e Transtornos dos Sons da Fala.A amostra refere-se aos dados coletados de 32 prontu\u00e1rios de pacientes, configurando a totalidade dos atendidos no per\u00edodo de agosto de 2018 a mar\u00e7o de 2021, com faixa et\u00e1ria entre 14 meses e 8 anos e que apresentavam diagn\u00f3stico de transtorno de linguagem oral infantil. Todos os respons\u00e1veis pelos participantes da pesquisa assinaram o Termo de Consentimento Livre e Esclarecido, e autorizaram o acesso aos prontu\u00e1rios dos participantes.Inicialmente, foram coletados os seguintes dados nos relat\u00f3rios de avalia\u00e7\u00e3o inicial: sexo, data de nascimento, escolaridade e diagn\u00f3stico fonoaudiol\u00f3gico global. Em seguida, foi realizada a classifica\u00e7\u00e3o das principais manifesta\u00e7\u00f5es e diagn\u00f3sticos fonoaudiol\u00f3gicos segundo o componente Atividades e Participa\u00e7\u00e3o da CIF, utilizando seus qualificadores de Capacidade e Desempenho., Avalia\u00e7\u00e3o do Desenvolvimento da Linguagem (ADL), Protocolo de Observa\u00e7\u00e3o de Comportamentos de crian\u00e7as at\u00e9 6 anos de idade , Teste de Linguagem Infantil ABFW, Teste de Vocabul\u00e1rio por Figuras USP (TVfusp), Teste de Vocabul\u00e1rio Auditivo (TVAud) e Teste de Vocabul\u00e1rio Expressivo (TVExp). Foram considerados tamb\u00e9m os resultados da avalia\u00e7\u00e3o auditiva, quando presentes.Foram consideradas as manifesta\u00e7\u00f5es e hip\u00f3teses diagn\u00f3sticas fonoaudiol\u00f3gicas relacionadas \u00e0s altera\u00e7\u00f5es de linguagem, em seus aspectos receptivos, expressivos e seus subsistemas fonol\u00f3gico, morfossint\u00e1tico, pragm\u00e1tico e sem\u00e2ntico, assim como dos aspectos do desenvolvimento cognitivo, descritos nos relat\u00f3rios conforme os resultados dos seguintes testes: Protocolo de Observa\u00e7\u00e3o Comportamental (PROC)Para a defini\u00e7\u00e3o das categorias da CIF, foi realizada a pr\u00e9-sele\u00e7\u00e3o dos cap\u00edtulos do componente Atividades e Participa\u00e7\u00e3o que se relacionam \u00e0s altera\u00e7\u00f5es de linguagem oral infantil. Vale destacar que a pr\u00e9-sele\u00e7\u00e3o foi feita de forma aberta, ou seja, considerando a descri\u00e7\u00e3o das manifesta\u00e7\u00f5es e diagn\u00f3sticos fonoaudiol\u00f3gicos elencados nos relat\u00f3rios. Foram inclu\u00eddos cinco no presente estudo, sendo eles: \u201cAprendizagem e aplica\u00e7\u00e3o de conhecimento\u201d, \u201cTarefas e demandas gerais\u201d, \u201cComunica\u00e7\u00e3o\u201d, \u201cCuidado pessoal\u201d e \u201c\u00c1reas principais da vida\u201d .Ap\u00f3s a defini\u00e7\u00e3o dos cap\u00edtulos, foi realizada a sele\u00e7\u00e3o do conjunto de categorias de cada um destes e posterior codifica\u00e7\u00e3o dos achados nos relat\u00f3rios, com os respectivos qualificadores de Desempenho e Capacidade. Para o presente estudo foram utilizados apenas os qualificadores .0 (nenhuma dificuldade), .8 (dificuldade n\u00e3o especificada) e .9 (n\u00e3o aplic\u00e1vel), n\u00e3o especificando o grau de dificuldade.Foram selecionadas 24 categorias: dez do cap\u00edtulo \u201cAprendizagem e aplica\u00e7\u00e3o de conhecimento\u201d, tr\u00eas do cap\u00edtulo \u201cTarefas e demandas gerais\u201d, cinco do cap\u00edtulo \u201cComunica\u00e7\u00e3o\u201d, quatro do cap\u00edtulo \u201cCuidado pessoal\u201d e duas do cap\u00edtulo \u201c\u00c1reas principais da vida\u201d, conforme descrito no Excel e compilados para caracteriza\u00e7\u00e3o do perfil, das manifesta\u00e7\u00f5es fonoaudiol\u00f3gicas e constru\u00e7\u00e3o da lista de categorias. Os dados referentes ao processo de classifica\u00e7\u00e3o das manifesta\u00e7\u00f5es presentes nos relat\u00f3rios foram compilados para an\u00e1lise.Os dados coletados foram tabulados em planilha constru\u00edda no programa Foram realizadas an\u00e1lises descritiva e bivariada. A an\u00e1lise descritiva foi realizada por meio de distribui\u00e7\u00e3o de frequ\u00eancia absoluta e relativa das vari\u00e1veis categ\u00f3ricas, e de s\u00edntese num\u00e9rica das vari\u00e1veis cont\u00ednuas. Foram definidas como vari\u00e1veis resposta as categorias do componente Atividades e Participa\u00e7\u00e3o da CIF e como as vari\u00e1veis explicativas sexo, idade, escolaridade e diagn\u00f3stico fonoaudiol\u00f3gico global. Vale destacar que para as an\u00e1lises estat\u00edsticas o qualificador .9 (n\u00e3o aplic\u00e1vel) foi retirado para facilitar a s\u00edntese dos dados.Na an\u00e1lise bivariada foi utilizado o teste Exato de Fisher para todas as vari\u00e1veis categ\u00f3ricas. Para a realiza\u00e7\u00e3o da an\u00e1lise bivariada foi necess\u00e1rio realizar a recategoriza\u00e7\u00e3o e cria\u00e7\u00e3o de novas vari\u00e1veis, devido ao pequeno n\u00famero de observa\u00e7\u00f5es em determinadas categorias das vari\u00e1veis. A vari\u00e1vel \u201cEscolaridade\u201d foi reclassificada em duas categorias na nova vari\u00e1vel: \u201cFrequenta escola\u201d . A vari\u00e1vel \u201cIdade\u201d teve distribui\u00e7\u00e3o assim\u00e9trica  e optou-se por categoriz\u00e1-la usando como ponto de corte a mediana da distribui\u00e7\u00e3o, que foi de 37,5 meses, sendo esta realizada em duas categorias, sendo a primeira \u226437,5 meses e a segunda categoria >37,5 meses. Para todas as an\u00e1lises foi considerado o n\u00edvel de signific\u00e2ncia de 5%.A an\u00e1lise descritiva dos dados sociodemogr\u00e1ficos revelou que 59,4% dos participantes pertenciam ao sexo masculino e 40,6% ao sexo feminino. A m\u00e9dia de idade foi de 41,03 meses, desvio padr\u00e3o 19,77, m\u00ednimo 14 e m\u00e1ximo 96. Em rela\u00e7\u00e3o \u00e0 escolaridade, 19 participantes  cursavam o ensino infantil, cinco participantes  cursavam o ensino fundamental e oito participantes (25%) n\u00e3o frequentavam a escola. A an\u00e1lise do diagn\u00f3stico fonoaudiol\u00f3gico global permitiu verificar preval\u00eancia de transtorno de linguagem associado a outras condi\u00e7\u00f5es (60%), seguido de transtorno do desenvolvimento da linguagem (40%).Quanto ao componente Atividades e Participa\u00e7\u00e3o da CIF, a an\u00e1lise descritiva das categorias pr\u00e9-selecionadas permitiu verificar um n\u00famero alto de respostas \u201cN\u00e3o informado\u201d, com maior porcentagem em express\u00e3o vocal sem fala (d331) desempenho , tomar decis\u00f5es (d177) capacidade , resolver problemas (d175) desempenho  e capacidade , recep\u00e7\u00e3o de mensagens orais (d310) desempenho  e comer (d550) capacidade . Dentre as 24 categorias selecionadas, 12 contemplaram conjuntamente os qualificadores de Desempenho e Capacidade.Para as categorias referentes ao cap\u00edtulo \u201cAprendizagem e aplica\u00e7\u00e3o de conhecimento\u201d, as que foram descritas em maior porcentagem como \u201ch\u00e1 dificuldade\u201d foram: aquisi\u00e7\u00e3o de linguagem (d132) - desempenho  e capacidade ; aprender por meio de a\u00e7\u00f5es com objetos (d131) - capacidade (75%); aquisi\u00e7\u00e3o de conceitos (d137) - capacidade  e concentrar a aten\u00e7\u00e3o (d160) - capacidade .No cap\u00edtulo \u201cTarefas e demandas gerais\u201d, as tr\u00eas categorias selecionadas foram descritas em maior preval\u00eancia como \u201ch\u00e1 dificuldade\u201d, sendo elas: lidar com o estresse e outras demandas psicol\u00f3gicas (d240) - desempenho ; realizar uma \u00fanica tarefa (d210) - desempenho (50%) e realizar a rotina di\u00e1ria (d230) - desempenho (50%).Das cinco categorias selecionadas do cap\u00edtulo \u201cComunica\u00e7\u00e3o\u201d, as que em maior porcentagem foram descritas como \u201ch\u00e1 dificuldade\u201d foram: fala (d330) - desempenho  e capacidade (100%); conversa\u00e7\u00e3o (d350) - capacidade (75%) e recep\u00e7\u00e3o de mensagens orais (d310) - capacidade . As categorias descritas em maior porcentagem como \u201cn\u00e3o h\u00e1 dificuldade\u201d foram: produ\u00e7\u00e3o de mensagens n\u00e3o verbais (d335) - capacidade  e express\u00e3o vocal sem fala (d331) - capacidade (50%).No cap\u00edtulo \u201cCuidado pessoal\u201d verificou-se um n\u00famero alto de respostas \u201cN\u00e3o informado\u201d. As categorias lavar-se (d510), cuidado das partes do corpo (d520) e vestir-se (d540) contemplaram apenas o qualificador de desempenho e todas foram mais frequentemente descritas como \u201ch\u00e1 dificuldade\u201d . A categoria comer (d550) foi descrita como \u201cn\u00e3o h\u00e1 dificuldade\u201d em 46,9% no qualificador de desempenho e em 34,4% no qualificador de capacidade.No cap\u00edtulo \u201c\u00c1reas principais da vida\u201d, as categorias educa\u00e7\u00e3o infantil (d815) e educa\u00e7\u00e3o escolar (d820) tamb\u00e9m contemplaram apenas o qualificador de desempenho. A categoria educa\u00e7\u00e3o escolar foi descrita como \u201cn\u00e3o se aplica\u201d em 87,5% dos pacientes. A categoria educa\u00e7\u00e3o infantil foi descrita como \u201cn\u00e3o h\u00e1 dificuldade\u201d em 37,5% e como \u201ch\u00e1 dificuldade\u201d em 31,3%.A an\u00e1lise de associa\u00e7\u00e3o entre as categorias do componente Atividades e Participa\u00e7\u00e3o da CIF e o sexo dos pacientes n\u00e3o apresentou resultado com signific\u00e2ncia estat\u00edstica.Na an\u00e1lise de associa\u00e7\u00e3o entre as categorias do componente Atividades e Participa\u00e7\u00e3o da CIF e a idade dos pacientes, categorizada segundo a mediana, houve resultado com signific\u00e2ncia estat\u00edstica entre a idade e a categoria resolver problemas (d175) - desempenho, com valor-p de 0,045. Entre os participantes que apresentaram dificuldade, 71,4% tinham idade \u2264 37,5 meses. A an\u00e1lise de associa\u00e7\u00e3o entre as categorias da CIF e a vari\u00e1vel \u201cFrequenta escola\u201d (sim e n\u00e3o) demonstrou resultado com signific\u00e2ncia estat\u00edstica com a categoria educa\u00e7\u00e3o infantil (d815) - desempenho, com valor-p de 0,003, sendo que entre os pacientes que n\u00e3o apresentaram dificuldade, todos frequentam a escola .Quanto a associa\u00e7\u00e3o entre as categorias da CIF e a vari\u00e1vel \u201cDiagn\u00f3stico Fonoaudiol\u00f3gico\u201d (transtorno do desenvolvimento de linguagem e transtorno de linguagem associado a outras condi\u00e7\u00f5es) houve signific\u00e2ncia estat\u00edstica entre o diagn\u00f3stico fonoaudiol\u00f3gico e a categoria conversa\u00e7\u00e3o (d350) - capacidade , em que entre os participantes que apresentaram dificuldade, 77,3% apresentaram como diagn\u00f3stico fonoaudiol\u00f3gico Transtorno de Linguagem associado a outras condi\u00e7\u00f5es .A diversidade de categorias do componente Atividades e Participa\u00e7\u00e3o da CIF encontradas no presente estudo, permitiu a reflex\u00e3o sobre os impactos que os transtornos de linguagem oral podem representar ao desenvolvimento infantil, principalmente com rela\u00e7\u00e3o a limita\u00e7\u00f5es de atividades e restri\u00e7\u00f5es de participa\u00e7\u00e3o. Deste modo, o estudo buscou identificar as categorias referentes ao componente Atividades e Participa\u00e7\u00e3o da CIF, e suas associa\u00e7\u00f5es com idade, sexo, escolaridade e diagn\u00f3stico fonoaudiol\u00f3gico global, no contexto de um ambulat\u00f3rio de linguagem infantil.-19. Quanto aos achados na amostra referentes a idade e escolaridade, em estudo sobre a preval\u00eancia das altera\u00e7\u00f5es fonoaudiol\u00f3gicas em crian\u00e7as, foi observado a preval\u00eancia das altera\u00e7\u00f5es comunicativas na idade pr\u00e9-escolar . Vale destacar ainda que o presente estudo apresenta uma faixa et\u00e1ria ampla, 14 a 96 meses, o que configura uma amplitude bem maior para se pensar e referir \u00e0s etapas do desenvolvimento e altera\u00e7\u00f5es comunicativas.Quanto aos dados sociodemogr\u00e1ficos, o presente estudo revela que a maioria dos participantes pertence ao sexo masculino, resultado similar a outros estudos, que associam a preval\u00eancia de altera\u00e7\u00f5es de linguagem infantil para o sexo masculino devido a fatores neurol\u00f3gicos, hormonais e sociais.A predomin\u00e2ncia do diagn\u00f3stico fonoaudiol\u00f3gico de Transtorno de linguagem associado a outras condi\u00e7\u00f5es corrobora estudo sobre o perfil diagn\u00f3stico de um ambulat\u00f3rio de Fonoaudiologia na \u00e1rea de Linguagem infantil, em que foi verificado uma alta preval\u00eancia de comorbidades , sendo que as doen\u00e7as neurol\u00f3gicas e o atraso do desenvolvimento neuropsicomotor foram as associa\u00e7\u00f5es de maior ocorr\u00eancia-23, que evidencia a diversidade de manifesta\u00e7\u00f5es fonoaudiol\u00f3gicas presentes em um mesmo diagn\u00f3stico de linguagem. Em estudo sobre as expectativas e os resultados observados ap\u00f3s a terapia de fala e linguagem de crian\u00e7as em idade pr\u00e9-escolar, foi verificado que a maioria das preocupa\u00e7\u00f5es, expectativas e evolu\u00e7\u00f5es observadas pelos pais e m\u00e9dicos estavam relacionadas a limita\u00e7\u00f5es de atividades, o que demonstra a import\u00e2ncia da integra\u00e7\u00e3o dos aspectos da funcionalidade, principalmente aqueles relacionados \u00e0s limita\u00e7\u00f5es de atividades e restri\u00e7\u00f5es de participa\u00e7\u00e3o, na atua\u00e7\u00e3o fonoaudiol\u00f3gica dos transtornos de linguagem oral infantil.Em rela\u00e7\u00e3o \u00e0s categorias do componente Atividades e Participa\u00e7\u00e3o da CIF, os resultados demonstram que, a pr\u00e9-sele\u00e7\u00e3o dos cap\u00edtulos e categorias que se relacionam \u00e0s altera\u00e7\u00f5es de linguagem oral infantil favorece sua aplica\u00e7\u00e3o, uma vez que todos os cap\u00edtulos e categorias selecionados foram contemplados no presente estudo. A import\u00e2ncia da considera\u00e7\u00e3o dos fatores associados \u00e0s limita\u00e7\u00f5es de atividades e restri\u00e7\u00f5es de participa\u00e7\u00e3o \u00e9 refletida na multiplicidade de categorias tamb\u00e9m encontrada em outros estudos. O estudo referiu com maior ocorr\u00eancia a descri\u00e7\u00e3o de dificuldade nas categorias pertencentes aos cap\u00edtulos de aprendizado b\u00e1sico e aplica\u00e7\u00e3o de conhecimentos, sendo elas: aprender a ler (d140) - desempenho, dirigir a aten\u00e7\u00e3o (d161) - desempenho, escrever (d170) - capacidade e aprender a escrever (d145) - capacidade. Os estudos se coincidem quanto a preval\u00eancia da descri\u00e7\u00e3o da dificuldade no cap\u00edtulo \u201cAprendizagem e aplica\u00e7\u00e3o de conhecimento\u201d, no entanto, se diferem quanto \u00e0s categorias descritas em maior porcentagem como \u201ch\u00e1 dificuldade\u201d. Tal diferen\u00e7a pode ser justificada pelo cen\u00e1rio, caracteriza\u00e7\u00e3o da amostra, faixa et\u00e1ria e altera\u00e7\u00f5es apresentadas pelos pacientes de cada estudo. O estudo referenciado foi realizado com base na an\u00e1lise de prontu\u00e1rios de pacientes atendidos em um ambulat\u00f3rio de avalia\u00e7\u00e3o, com idades entre 5 e 16 anos, em que as altera\u00e7\u00f5es poderiam n\u00e3o estar relacionadas \u00e0 linguagem oral, al\u00e9m da possibilidade de os pacientes apresentarem outros tipos de altera\u00e7\u00f5es, como de leitura e escrita. Al\u00e9m disso, com rela\u00e7\u00e3o \u00e0 caracteriza\u00e7\u00e3o da amostra, o estudo apresentou como crit\u00e9rios de exclus\u00e3o pacientes com suspeita ou confirma\u00e7\u00e3o dos diagn\u00f3sticos de Transtornos Globais do Desenvolvimento (TGD).Em estudo sobre a caracteriza\u00e7\u00e3o do desempenho, em aspectos fonoaudiol\u00f3gicos, de pacientes ambulatoriais segundo a vers\u00e3o da CIF para Crian\u00e7as e Jovens (CIF-CJ), foi verificada a preval\u00eancia da descri\u00e7\u00e3o das dificuldades nas categorias relacionadas com quest\u00f5es de linguagem, aprendizagem ou escolares, o que se assemelha aos resultados do presente estudo quanto aos cap\u00edtulos em que a descri\u00e7\u00e3o da dificuldade ocorreu com maior frequ\u00eancia e quanto \u00e0s categorias fala (d330) e conversa\u00e7\u00e3o  que tamb\u00e9m foram umas das descritas com maior porcentagem como \u201ch\u00e1 dificuldade\u201d.Por outro lado, em estudo, que realizou a identifica\u00e7\u00e3o das categorias da CIF em quadros de Transtornos de Linguagem e de Fala, as categorias mais frequentes do componente Atividades e Participa\u00e7\u00e3o - comunica\u00e7\u00e3o-recep\u00e7\u00e3o de mensagens orais (d310), fala (d330), aquisi\u00e7\u00e3o de habilidades (d155) e conversa\u00e7\u00e3o (d350) - estiveram relacionadas aos cap\u00edtulos de aprendizagem b\u00e1sica e de comunica\u00e7\u00e3o. A escola favorece a evolu\u00e7\u00e3o de est\u00e1gios cognitivos, fortalecendo suas habilidades de enfrentamento das adversidades e incentivando solu\u00e7\u00f5es criativas para seus problemas.Estudos que associam as categorias relevantes \u00e0s altera\u00e7\u00f5es de linguagem oral com os fatores pessoais e diagn\u00f3sticos cl\u00ednicos favorecem a compreens\u00e3o das condi\u00e7\u00f5es de sa\u00fade. As an\u00e1lises realizadas no presente estudo permitiram verificar associa\u00e7\u00e3o entre a idade e a categoria resolver problemas (d175) - desempenho, em que a maioria dos participantes que apresentaram dificuldade tinha idade \u2264 37,5 meses, o que pode ser justificada pelo desenvolvimento da autonomia, habilidades sociais ou inser\u00e7\u00e3o no ambiente escolar, ou a intera\u00e7\u00e3o de dois ou mais fatores. Assim, independente do diagn\u00f3stico de linguagem, os fatores do desenvolvimento t\u00eam papel preponderante. Outro fator importante \u00e9 a experi\u00eancia escolar, fundamental para as aquisi\u00e7\u00f5es sociais e educacionais nos primeiros anos escolares.A associa\u00e7\u00e3o entre frequentar a escola e a categoria educa\u00e7\u00e3o infantil (d815) - desempenho, em que todos os participantes que n\u00e3o apresentaram dificuldade frequentam a escola, pode ser justificada pelo fato de as queixas dos pais de crian\u00e7as em idade pr\u00e9-escolar ainda n\u00e3o estarem voltadas \u00e0s quest\u00f5es escolares, que se iniciam na idade escolar. Ap\u00f3s a inser\u00e7\u00e3o na escola, os pais tendem a ampliar a percep\u00e7\u00e3o de queixas relacionadas \u00e0s dificuldades escolares. Em estudo realizado com familiares de crian\u00e7as em idade escolar, as principais queixas que motivaram os encaminhamentos \u00e0 cl\u00ednica estavam vinculadas a dificuldades de escrita e leitura, enquanto as queixas relacionadas a aspectos psicol\u00f3gicos/comportamentais foram menos frequentes. Embora os estudos se diferenciem quanto \u00e0s vari\u00e1veis analisadas, \u00e9 poss\u00edvel relacionar a idade escolar \u00e0s maiores demandas e dificuldades escolares observadas no estudo referenciado. Tal fato reflete a import\u00e2ncia da atua\u00e7\u00e3o fonoaudiol\u00f3gica englobar a linguagem oral e escrita, antes mesmo da entrada no ensino formal, uma vez que o dom\u00ednio do sistema lingu\u00edstico em sua modalidade oral e o desenvolvimento das habilidades metacognitivas e metalingu\u00edsticas s\u00e3o fundamentais para o aprendizado de leitura e escrita.Em outro estudo, realizado em um ambulat\u00f3rio de avalia\u00e7\u00e3o fonoaudiol\u00f3gica, foi verificada associa\u00e7\u00e3o entre a escolaridade e o Fator denominado \u201cFam\u00edlia/escola\u201d, pertencente ao componente Atividades e Participa\u00e7\u00e3o da CIF e composto pelas categorias \u201cRelacionamentos familiares - Desempenho\u201d e \u201cEduca\u00e7\u00e3o escolar - Desempenho\u201d, em que o Fator apresentou maiores pontua\u00e7\u00f5es entre os pacientes de maior idade que cursavam o ensino fundamental, explicada pelas maiores demandas escolares apresentadas por indiv\u00edduos no ensino fundamental ou mais velhos.A associa\u00e7\u00e3o verificada entre o diagn\u00f3stico fonoaudiol\u00f3gico e a categoria d350 - capacidade, em que a maioria dos participantes com dificuldade apresentou como diagn\u00f3stico Transtorno de Linguagem associado a outras condi\u00e7\u00f5es, pode ser explicada pelo perfil dos pacientes atendidos no servi\u00e7o, uma vez que o hospital ao qual o ambulat\u00f3rio em quest\u00e3o pertence realiza atendimentos de m\u00e9dia e alta complexidade, sendo refer\u00eancia no encaminhamento de servi\u00e7os como neurologia e gen\u00e9tica, e recebendo, em sua maioria, pacientes com Transtorno do Espectro Autista (TEA) e S\u00edndrome de Down, condi\u00e7\u00f5es em que o preju\u00edzo nas habilidades pragm\u00e1ticas \u00e9 frequente, o que gera dificuldades de intera\u00e7\u00e3o, comunica\u00e7\u00e3o social e conversa\u00e7\u00e3oPor se tratar de uma an\u00e1lise com base em dados secund\u00e1rios, coletados em prontu\u00e1rios, a limita\u00e7\u00e3o do estudo envolve a perda de informa\u00e7\u00f5es, como evidenciado pelo n\u00famero alto de respostas \u201cN\u00e3o informado\u201d na an\u00e1lise descritiva das categorias da CIF, que pode ser justificado pelos instrumentos de anamnese e avalia\u00e7\u00e3o utilizados no servi\u00e7o ainda terem pouca associa\u00e7\u00e3o com os aspectos de funcionalidade descritos na CIF. Isso evidencia a necessidade do desenvolvimento de instrumentos cl\u00ednicos padronizados com categorias relevantes \u00e0s altera\u00e7\u00f5es de linguagem infantil, que viabilizem sua implementa\u00e7\u00e3o na pr\u00e1tica cl\u00ednica do servi\u00e7o e minimizem a perda de informa\u00e7\u00f5es gerada na an\u00e1lise dos prontu\u00e1rios. Al\u00e9m disso, o estudo apresenta limita\u00e7\u00f5es quanto ao tamanho da amostra pesquisada, no entanto, por se tratar de um ambulat\u00f3rio cuja popula\u00e7\u00e3o n\u00e3o \u00e9 extensa, a amostra foi representativa do perfil do servi\u00e7o.Como avan\u00e7os, o estudo permite a identifica\u00e7\u00e3o das principais categorias relevantes \u00e0s altera\u00e7\u00f5es de linguagem oral infantil, a compreens\u00e3o das limita\u00e7\u00f5es de atividades e restri\u00e7\u00f5es de participa\u00e7\u00e3o decorrentes dessa condi\u00e7\u00e3o, assim como a implementa\u00e7\u00e3o da lista de categorias constru\u00edda no servi\u00e7o, viabilizando a aplica\u00e7\u00e3o da CIF em sua pr\u00e1tica cl\u00ednica e o desenvolvimento de um estudo longitudinal futuro com a mesma popula\u00e7\u00e3o, ampliando o uso dos qualificadores que especificam o grau de dificuldade para fazer um comparativo pr\u00e9 e p\u00f3s terapia fonoaudiol\u00f3gica. Al\u00e9m disso, o presente estudo pode motivar fonoaudi\u00f3logos de outros servi\u00e7os que atuam com perfil de pacientes semelhantes \u00e0 incorpora\u00e7\u00e3o e operacionaliza\u00e7\u00e3o da CIF no fluxo cl\u00ednico-assistencial.Diante dos resultados encontrados, observa-se a import\u00e2ncia do uso da CIF como uma ferramenta para a integra\u00e7\u00e3o dos impactos decorrentes das altera\u00e7\u00f5es de linguagem \u00e0 funcionalidade e a amplia\u00e7\u00e3o da abordagem biopsicossocial na cl\u00ednica fonoaudiol\u00f3gica.Foram selecionadas 24 categorias do componente Atividades e Participa\u00e7\u00e3o da CIF, das quais 12 contemplaram conjuntamente os qualificadores de Desempenho e Capacidade, em crian\u00e7as com transtornos de linguagem oral e que se encontram em terapia fonoaudiol\u00f3gica em um servi\u00e7o ambulatorial da rede p\u00fablica. A descri\u00e7\u00e3o da dificuldade ocorreu com maior frequ\u00eancia nas categorias pertencentes aos cap\u00edtulos de aprendizagem e aplica\u00e7\u00e3o de conhecimento e comunica\u00e7\u00e3o, e estiveram relacionadas a atividades como adquirir linguagem, aprender por meio de a\u00e7\u00f5es com objetos, falar e conversar.Al\u00e9m disso, foi poss\u00edvel verificar associa\u00e7\u00f5es com signific\u00e2ncia estat\u00edstica entre os dados sociodemogr\u00e1ficos e os diagn\u00f3sticos fonoaudiol\u00f3gicos com as categorias do componente Atividades e Participa\u00e7\u00e3o da CIF."}
+{"text": "Mapping the role of telemedicine in the health access of patients with chronic diseases in continuous care actions (except for covid-19) during the pandemic. This is a scoping review, with an adapted version of the Prisma-Scr methodology and using the Population (patients with chronic diseases), Concept  and Context (covid-19 pandemic) strategy. We searched through the following databases: PubMed, Scopus, Embase, Web of Science, Lilacs and SciELO, resulting in 18 articles at the end of the review. We used the technological, sociocultural and assistance analysis dimensions. Eighty-eight percent of the analyzed papers posited that telemedicine use to provide care increased during the pandemic. We identified that this use was positively related to the reduction of complications and the absence of physical displacement for care, expanding it to rural areas. Important barriers were presented, most importantly the digital exclusion, language sociocultural barriers, and inaccessibility to technological instruments for disabled people. Innovation in care arrangements calls attention to how living labor is important to produce healthcare, using various technologies, and reveals tensions caused by the forces acting on healthcare micro politics. We conclude that, despite important barriers, telemedicine contributed to the care of chronic patients during the covid-19 pandemic. Recommendations included supporting fragile health systems, developing immunizers, as well as therapeutic strategies, combating misinformation, strengthening diagnostic mechanisms with an emphasis nor only on isolation, but also transmission prevention, and stimulating the sharing of scientific knowledge and international cooperation.The organization and preparation of international health systems changed after the declaration of the Public Health Emergency of International Concern (PHEIC) issued by the World Health Organization (WHO) in January, 2020, due to the global outbreak of coronavirus2.The first months of viral contamination posed enormous challenges to treating infected patients, overstretching health systems and demanding health services, such as hospitals and outpatient clinics, to change their routine immediately. The concentration of efforts in treating cases of severe acute respiratory syndrome (SARS) caused postponements and cancellation of face-to-face health actions to protect patients from exposure to the virus7;. The need to reorganize services, tasks and reinvent ways of doing health was strongly evidenced and considered fundamental8. Thus, the technology use gained global prominence in health actions, work and educational activities, as well as to financial and commercial transactions2.The high case incidence during the pandemic created new strains of SARS-CoV-2, collapsing many health systems, which made it urgent to resume the care of non-covid patients and the chronically ill, offering continuous care2 to guide the general population. These tools served as an initial screening to measure the severity of cases, helping to guide the users\u2019 search for health services, with the objective of prioritizing demand. Countries such as France and the United Kingdom implemented telemedicine actions early, ensuring the compensation of the procedures through the National Health Insurance9 and using voice and video resources that also increased the self-care of patients with respiratory diseases10.The first pandemic confronting reports indicate the monitoring of suspected and confirmed cases by phone or smartphone application, as well as the deployment of telemedicine tools11. For Cordioli12, telemedicine comprises the service provision related to healthcare in cases where distance is a critical factor, and can be used both for urgent consultations, in the context of covid-19, and routine appointments, given the need of overcoming access barriers, ensuring data protection and providing alternatives to physical examination.Even before the emergence of the new coronavirus, several factors contributed to the growth of telemedicine, such as technological advances in communication and information. This a result of the increasing use of high-speed internet and the rise in the number of files in electronic medical records in health services13. Currently, the term telemedicine is associated with the terms telehealth and e-Health, with imprecise conceptual distinctions14. During the expanded literature search, it was possible to distinguish the use of telemedicine in two large groups: the use of technology as a care arrangement for infected patients and the use of technology as a care arrangement for non-covid patients, a possibility for which this study is interested, regarding access and continuity of care.In this context, telemedicine  has different applications, such as teleconsultation, telemonitoring, teleregulation, teleorientation, among others15.This scoping review aims at mapping the contribution of telemedicine to health access of patients with chronic diseases in continuous care actions \u2013 non-covid \u2013 in the context of the pandemic. The chosen methodology makes it possible to identify the existing literature on the subject, providing elements to analyze the use of telemedicine in the context of covid-19, recognize innovations and new care arrangements, and locate barriers to health access. The analysis of healthcare produced during the pandemic, in the different dimensions, can help us elaborate more balanced public policies and build resilient health systems, with immediate emergency response, and also improve healthcare of chronic patients17. In order to do so, we used an adapted version of the Prisma-scr manual18, which clusters 22 verification steps concerning the title, abstract, introduction, method and discussion.This is a scoping review, which is a literature review modality that has been widely used in mapping the existing literature on a given topic, allowing us to recognize and clarify definitions and conceptual limits19. The searches in the databases were carried out between January and March, 2022.We initially used the population, concept and context (PCC) strategy to direct and define the scope of the study, with P (population) = patients with chronic diseases, C (concept) = telemedicine as a tool for access to health and C (context) = covid-19 pandemic. Using the PCC allowed us to formulate our research question \u201cdid telemedicine contribute to access to health services for patients with chronic diseases during the covid-19 pandemic?\u201d. This question directed the searches for scientific papers indexed in PubMed, Scopus, Embase, Web of Science, Lilacs and SciELO, selected from the Academic Information Agency of the Universidade de S\u00e3o Paulo with the indexing criterion defined for journals in Public HealthThe search of scientific papers which integrated the review occurred from the search command-line built with the Health Science Descriptors - DeCs , including the period from March, 2020 to March, 2022 for publications in English, followed by double-blind evaluation for the scope assessment stages. All types of scientific papers were included, as well as scientific reviews, without geographical limitation and regardless of publication type. Regarding the results shown in In these results, the following exclusion criteria were applied: articles which did not address the use of telemedicine, directed to populations that were not formed by chronic patients, outside the covid-19 pandemic period, discussing specialties that do not fit the chronic criterion and addressing issues related to mental health (n = 98 papers). In the Rayyan platform, duplicates were removed (n = 80 papers) and articles from additional sources were inserted (n = 2 papers), in addition to performing a second double-blind evaluation of the previous results, considering title and abstract (n = 166 papers). At this stage, the inclusion conflicts (n = 11 papers) were sent to new reviewers in double-blind evaluation for final decision, in which n = 5 papers were included.The analysis included n = 49 papers for full content evaluation; from which, only n = 18 papers were selected for the scope study, because they present elements that can help us answer the research question. We analyzed the following dimensions: technological , sociocultural  and assistance . After extracting the results, they were categorized and discussed by the authors.The results identified in the scope of the 18 selected articles are presented in the 20 and n = 1 was a study performed in Latin America30. Southeast Asia, on the other hand, was cited in n = 1 paper31, and Italy32, the United Kingdom33, Germany34, Canada35 and Turkey36 also contributed with n = 1 paper each. We identified only one study with a systematic review methodology, which mentioned having considered studies from five regions of the World Health Organization (WHO), with a predominance of articles from Europe37.All papers were published in English, but differed in geographical distribution: n = 10 of the papers were produced in the United StatesAs for the publication date of the studies, 77% of them were published in 2021, while 16% correspond to the first year of the covid-19 pandemic. In addition, only n = 1 paper was published more recently, in 2022. Regarding the type of study and data source, 44% of the studies are quantitative, with primary data sources and collected through questionnaires applied by telephone or via the internet. Only n = 4 studies used qualitative methods, and n = 2 papers presented narratives as data source; besides, there were systematic reviews, evaluation and mixed methods papers, each of them corresponding to 11% of the total.21. Telehealth was cited in 27% of the analyzed articles 27, telerehabilitation in 11%32 and teleneurology24, video consultation34 and remote monitoring35 accounted for 15% of the total. It bears noticing that we mainly considered the technology cited in the study, since some authors used more than one technology.Concerning the type of digital health care technology used, 44% of the studies referred to the use of telemedicine23.Chronic respiratory diseases represented 50% of the articles, being the disease group that relied the most on telemedicine, especially chronic obstructive pulmonary disease (COPD) (n = 4 papers) and cystic fibrosis (n = 2 papers). Only 22% of the articles did not delimit the type of chronic disease, characterizing them as chronic diseases in general. We also included studies on diabetes, cancer and chronic neurological diseases, which corresponded to 15% of the total. Half of the identified articles presented the increased use of telemedicine for the care of patients with chronic diseases during the covid-19 pandemic as the main result37. We identified other results related to the use of telemedicine in the healthcare of chronic patients, such as the improvement of indicators33 decrease in complications36, increased patient receptivity29, video consultations with concrete clinical recommendations / medicine change34 and identification of benefits in pre-and postoperative care35. On the other hand, there were unfavorable results regarding the use of telemedicine, such as the identification of patients\u2019 inability to use26, lower patient engagement29, problems with emotional responses and approach to complex issues29 and access difficulty, including to electronically prescribed medicines30.The beginning of telemedicine activities was also reported In n = 3 papers34.The innovations incorporated in the scope of care performed by telemedicine presented structural and assistance characteristics. Among the structural innovations, sending equipment to monitor and measure vital signs  to the patients was the most common arrangement, being present in 27% of the studies20, deployment of drive-thru labs19 and the delivery of medicine at home36 were also listed. Other structural arrangements are related to the offered technology itself, such as the availability of e-learning platforms to train patients33 and the possibility of using multiple platforms24 enabling access for those who have less technological aptitude, in addition to partnerships with University Hospitals and medical schools31.Blood collection at home36, use telemedicine for comprehensive patient care28, including pre-and postoperative care37, acting in the regulation and management of complex cases31, adoption of detailed pre-consultation protocols28 and hybrid care protocols, including face-to-face and online consultations, when necessary26, and the service performed by multiprofessional team25.The technological arrangements of care identified as assistance are those invented, adapted or used for the care performed by the health professional or the care chain, through digital technologies. In this sense, it is possible to list prescriptions online26, internet access difficulties35, connection problems36 sociocultural barriers (low purchasing power being the main one)37, related to language29, age34, disability29, the type of health insurance and the telemedicine funding, as well as the assistance access (22%). Among the most important are the limitation in the physical examination of the patient28, lack of professionals26 and aspects regarding specifically the disease or age group, such as hearing problems23. All these barriers are mainly related to vulnerable populations, including refugee and immigrant groups20.Regarding access to health services through telemedicine for patients with chronic diseases during the covid-19 pandemic, 88% of the articles reported access barriers to the use of telemedicine. These were: technological barriers resulting from digital exclusion31, factors related to saving time and resources with commuting24 (11%) and the increased involvement of family members and caregivers20 (5%) \u2013 are pointed out as benefits of the implementation of the remote system. With regard to the future of telemedicine in health systems, the recommendation for the development of guidelines and protocols enabling safe and effective service provision with good digital infrastructure is identified in 83% of studies.In addition, aspects that facilitate patients\u2019 access to health care through telemedicine \u2013 such as expanding the offer to residents in remote or rural areas (16%)From the mapping and analysis of the data provided by the literature used in this review, we identified the exponential increase in the use of telemedicine and other remote care modalities during the covid-19 pandemic aimed at the care of chronic patients in continuous care. We know that this is an even more comprehensive concept, if we consider here the use of telemedicine forms excluded by the adopted methodological criteria.After the organization and analysis of the results, we identified three dimensions: trends in telemedicine, innovations in care and access barriers, as shown in 32 these procedures in the USA. In addition, the incorporation of telemedicine in the list of reimbursable procedures by US health plans has served as an incentive since the beginning of the pandemic21. A study involving a large American telehealth provider also highlighted the increase in demand for care due to chronic diseases and mental health issues, surpassing the search for care motivated by the coronavirus27.The scope of the selected articles highlights the predominance of studies produced in the United States, especially in scenarios where telemedicine had already been used before the pandemic. The availability of technological structure made it possible to quickly implement38.On the other hand, in many other locations, such as in China, latent structures gained visibility and could be used in the care of patients because of the health emergency. The authors argue that the structures unveiled in the pandemic should be kept after the mitigation of cases and control of the situation39. The use of telemedicine in pulmonology is not recent: Zamith and Gomes40 identified studies performed since 1993 containing the association of words \u201ctelemedicine\u201d and \u201clung\u201d. Additionally, the shortage of professionals specialized in pulmonology had already been observed years before the pandemic, and studies that pointed to the use of technological arrangements that could contribute to improving this scenario and guarantee patient access had already been published, such as the described experiences of matrix support and shared care in pulmonology42.We also observed a predominance of papers on the use of telemedicine aimed at the care of patients with chronic respiratory diseases (CRD), a condition that appears among the main causes of morbidity and mortality worldwide. Commonly found, COPD and asthma are among the 20 diseases that disable the most amount of people on a global scale24, although there are limitations identified in the access of patients27.Besides, the increased demand caused by the pandemic and the potential risk to patients with CRD are also points that contribute to the understanding of the predominance of studies in Pulmonology. Pulmonary telerehabilitation, on the other hand, showed promising results regarding the progression of exercises and improvement of disease indicators32. The possibility of providing self-monitoring instruments and the good results the use of equipment at home have demonstrated seem to be factors that give advantages in the monitoring of chronic respiratory diseases, when talking about advances in telemedicine34.In Italy, patients with COPD reported receiving twice as many telemedicine visits from pulmonologists as from family doctors43. Brazilian authors emphasize that it is necessary to discuss policies and identify strategies that allow continuity of care, minimizing interruptions and adapting to the new scenario, taking risks of reinforcing or widening inequalities45.The social distancing recommendation adopted by several countries during the pandemic had great adherence among patients with chronic diseases and accentuated difficulties in accessing care, warning about the risk of increased morbidity, disability and avoidable mortality47 already evidenced the urgency in identifying possibilities for care, encouraging innovations, in an attempt to circumvent the imposed difficulties. Based on the results, telemedicine, generally, presented itself as one of the most important of these innovations, offering powerful mechanisms to act in a scenario of fast-paced contamination49. Although it was not exactly a new arrangement, telemedicine contributed to the diversification of care, using characteristics such as versatility and broad capacity to reach different populations and health needs. The described innovations demonstrated the importance of offering patient-centered, multilevel, multidisciplinary and continuous care32.Based on the conjuncture established by covid-19, the first publications50. Thus, considering that certain arrangements relied more heavily on hegemonic instruments, tools and knowledge \u2013 also known as \u201cHard technologies \u201c and \u201dSoft-hard Technologies\u201d \u2013 while others were built based on relational aspects, produced in the overlap between health professionals and the patient \u2013 known as \u201cSoft technologies\u201d51. From this perspective, we identified relevant aspects in each one of them.The identification of innovative structural arrangements and innovative care arrangements alludes, although in a rudimentary way, to the models of care production and the importance of living labor in the process of care production52.The innovative structural arrangements, represented here by sending equipment to the patients\u2019 homes, online prescriptions, drive thru laboratories, among others, raise the issue of telemedicine regulation and funding, inside and outside Brazil. Aspects such as differences in nomenclature and scope, security and protection of patient data, and compensation of services often represent obstacles that must be overcome through defining specific policies and broadly discussing the topic53. With the pandemic outbreak, the Ministry of Health published the ordinance nr. 467, on March 20, 202054, with temporary provisions for telemedicine actions, supported by Law nr. 13.979, of February 06, 202055, which defined the health emergency in Brazil. The legal device supported the use of telemedicine in Brazil during the emergency, which was declared terminated by the Ministry of Health in the ordinance nr. 913 of April 22, 2022, returning to the Federal Council of Medicine (CFM) the task of regulating telemedicine. More recently, the CFM published resolution nr. 2.314/2022, regulating telemedicine, which still lacks detailed analysis. At the same time, legislative bodies debate a bill on the topic, which expresses the timeliness, urgency and controversy surrounding it.In Brazil, the regulation in health had been discussed and was moving forward in the Federal Council of Medicine, which published resolution nr. 2.227/2018 at the end of the year, defining important aspects of telemedicine practice. However, institutional disputes motivated its repeal a few days later, conserving the regulatory gap of telemedicine in Brazil56. The results found in this review express the tensions experienced in the daily life of services, from bureaucracy to the freedom experienced by health professionals, rooting from unknown situations. The professional performance took place in adverse conditions, outside the comfort zone and with the need to adapt to the unusual scenario. These circumstances made everyday tasks more flexible and enabled the professionals to assume new roles8.On the other hand, innovative care arrangements, in turn, portray aspects of the relationships and micro politics of health services28. The \u201ctemporal window of opportunities\u201d57, which opened due to the health crisis, brings complex existential challenges to Public Health in the \u201cpost-\u201d pandemic moment. Decentralized caring and integrative practices42 are important elements in the analysis of the response to the pandemic.In many cases, since there was little regulation and/or a character of exception leveraged by the pandemic, new possibilities of care have emerged, in addition to experiments and incorporation of new protocols20. On the other hand, they require in-depth studies regarding cost-effectiveness, quality and user satisfaction; however, the unavailability of data weakens their advancement, regulation, financing and use58.Finally, the results showed that telemedicine practices have good acceptance rates, both among patients and families and among health professionals and managers20. Observing that telemedicine has expanded its borders and is consolidating itself as a care arrangement(s) for chronic diseases59 should not be dissociated from the dimension of access and, especially, from the identified barriers. The formulation and implementation of health policies based on technology-mediated care, such as telemedicine and its variations, can both contribute to reducing barriers in health access and highlight inequalities that may compromise the universality of access to health services.The trends and innovations arising from the use of telemedicine for the care of chronically ill patients during the pandemic identified in this review are relevant and offer clues both for policy formulation and for the development of new studies. However, regarding access to health care for the chronically ill using telemedicine, most of the papers included in this review point to numerous barriers60, the resilience of health systems goes beyond the \u201cfulfillment of the right to health\u201d and encompasses social and economic activities, reproducing the experience of the pandemic. Therefore, early identification of the barriers caused by the use of telemedicine in the health care of chronic patients can prevent the increase of inequities in access to care. In addition, it is essential to include the patient\u2019s dimension, with its diagnostic specificities, in the formulation of policies and protocols21.Analyzing the effect that the pandemic has produced on access to health is one of the main current challenges for building resilient health systems. For some authorsAlthough the main challenge regarding access is linked to digital illiteracy , the gap evidenced by technology reflects social and health inequalities of the population, whose reduction should guide the construction of quality health systems, with guaranteed access and equity.31, and they can serve as a starting point for policymaking and service implementation. The improvement of the use of digital technologies is central to this discussion and demands political and management efforts in digital infrastructure investment37.However, we also identified factors that can help the patient\u2019s access We concluded that the increase in telemedicine throughout the covid-19 pandemic presented innovative technological arrangements that, at the same time, collaborated with the expansion of access and with the implementation of this modality of care in the daily life of Health Services. However, issues related to digital exclusion and sociocultural and care conditions were pointed out as access barriers to the use of telemedicine that must be overcome in order to expand, in fact, its use value, caregiver potential and innovation in health systems.The implementation of specific policies and the elaboration of protocols that guide the work of professionals, particularly for chronic conditions, are important recommendations for incorporating telemedicine as a safe, accessible and care-producing technology for health systems and services around the world. 1 e emitida pela Organiza\u00e7\u00e3o Mundial de Sa\u00fade (OMS) em janeiro de 2020, em que se recomendava o apoio a sistemas de sa\u00fade fr\u00e1geis e o desenvolvimento de imunizantes e estrat\u00e9gias terap\u00eauticas, combate \u00e0 desinforma\u00e7\u00e3o, fortalecimento de mecanismos de diagn\u00f3stico com \u00eanfase no isolamento e preven\u00e7\u00e3o da transmiss\u00e3o, est\u00edmulo ao compartilhamento de conhecimento cient\u00edfico e \u00e0 coopera\u00e7\u00e3o internacional .A organiza\u00e7\u00e3o e prepara\u00e7\u00e3o dos sistemas de sa\u00fade internacionais ocorreu de maneira diversa ap\u00f3s a declara\u00e7\u00e3o da Emerg\u00eancia de Sa\u00fade P\u00fablica de Import\u00e2ncia Internacional (ESPII), motivada pelo surto global de coronav\u00edrus2.Os primeiros meses de dissemina\u00e7\u00e3o do v\u00edrus imputaram desafios gigantescos em rela\u00e7\u00e3o ao cuidado dos doentes infectados, exercendo enorme press\u00e3o sobre os sistemas de sa\u00fade e demandando modifica\u00e7\u00e3o imediata na rotina dos servi\u00e7os de sa\u00fade como hospitais e ambulat\u00f3rios. A concentra\u00e7\u00e3o de esfor\u00e7os no atendimento dos casos de s\u00edndrome respirat\u00f3ria aguda grave (SRAG) gerou adiamentos e cancelamento de a\u00e7\u00f5es presenciais de sa\u00fade, a fim de proteger os pacientes da exposi\u00e7\u00e3o ao v\u00edrus7; e a necessidade de reorganizar os servi\u00e7os, tarefas e reinventar formas de fazer sa\u00fade foi fortemente evidenciada e posta como fundamental8. Desse modo, a utiliza\u00e7\u00e3o da tecnologia ganhou destaque globalmente nas a\u00e7\u00f5es de sa\u00fade, atividades laborais e educacionais, al\u00e9m das transa\u00e7\u00f5es financeiras e comerciais, por exemplo2.A grande incid\u00eancia de casos durante a pandemia culminou no surgimento de novas cepas do SARS-CoV-2, contribuindo para o colapso de muitos sistemas de sa\u00fade, o que tornou urgente retomar o cuidado dos pacientes n\u00e3o-covid e dos doentes cr\u00f4nicos, oferecendo cuidados continuadossmartphone e a implanta\u00e7\u00e3o de ferramentas de telessa\u00fade2 para a orienta\u00e7\u00e3o da popula\u00e7\u00e3o em geral, o que serviu como triagem inicial para mensurar a gravidade dos casos, auxiliando na orienta\u00e7\u00e3o durante a busca dos usu\u00e1rios por servi\u00e7os de sa\u00fade, com o objetivo de priorizar a demanda. Pa\u00edses como Fran\u00e7a e Reino Unido implantaram a\u00e7\u00f5es de telessa\u00fade precocemente, assegurando a remunera\u00e7\u00e3o dos procedimentos pelo seguro nacional de sa\u00fade9 e utilizando recursos de voz e v\u00eddeo que tamb\u00e9m incrementaram o autocuidado de pacientes portadores de doen\u00e7as respirat\u00f3rias10.Os primeiros relatos de enfrentamento \u00e0 pandemia indicam a realiza\u00e7\u00e3o de monitoramento dos casos suspeitos e confirmados por telefone ou aplicativo de 11. Para Cordioli12, a telemedicina compreende a oferta de servi\u00e7os ligados aos cuidados com a sa\u00fade nos casos em que a dist\u00e2ncia \u00e9 um fator cr\u00edtico, e pode ser utilizada tanto para consultas de urg\u00eancia, no contexto da covid-19, como para consultas de rotina, diante da necessidade de superar barreiras de acesso, garantir a prote\u00e7\u00e3o de dados e fornecer alternativas ao exame f\u00edsico.Antes mesmo do surgimento do novo coronav\u00edrus, diversos fatores contribu\u00edram para o crescimento da telemedicina, como os avan\u00e7os tecnol\u00f3gicos das \u00e1reas de comunica\u00e7\u00e3o e informa\u00e7\u00e3o, que decorreram do uso crescente da internet de alta velocidade e do aumento do n\u00famero de registros em prontu\u00e1rios eletr\u00f4nicos nos servi\u00e7os de sa\u00fade13. Atualmente, o termo telemedicina \u00e9 associado aos termos telessa\u00fade e e-Health, com distin\u00e7\u00f5es conceituais imprecisas14. Durante a busca ampliada da literatura foi poss\u00edvel distinguir o uso da telemedicina em dois grandes grupos: o uso da tecnologia como arranjo de cuidado para pacientes infectados e o uso da tecnologia como arranjo de cuidado para pacientes n\u00e3o-covid, possibilidade pela qual este estudo se interessa, no sentido do acesso e continuidade do cuidado.Neste contexto, a telemedicina (ou telessa\u00fade) possui diferentes aplica\u00e7\u00f5es, como teleconsulta, telemonitoramento, telerregula\u00e7\u00e3o, teleorienta\u00e7\u00e3o, entre outras15.A presente revis\u00e3o de escopo tem o objetivo de mapear a contribui\u00e7\u00e3o da telemedicina para o acesso \u00e0 sa\u00fade dos pacientes portadores de doen\u00e7as cr\u00f4nicas em a\u00e7\u00f5es de cuidados continuados \u2013 n\u00e3o-covid \u2013 no contexto da pandemia. A metodologia escolhida possibilita a identifica\u00e7\u00e3o da literatura existente sobre o tema, fornecendo elementos para analisar o uso da telemedicina no contexto da covid-19, reconhecer inova\u00e7\u00f5es e novos arranjos de cuidado e localizar barreiras de acesso \u00e0 sa\u00fade. A an\u00e1lise dos cuidados em sa\u00fade produzidos no contexto da pandemia, nas diferentes dimens\u00f5es, pode colaborar para a elabora\u00e7\u00e3o de pol\u00edticas p\u00fablicas mais equilibradas e a constru\u00e7\u00e3o de sistemas de sa\u00fade resilientes, com prontid\u00e3o de resposta a emerg\u00eancias, e ainda no aperfei\u00e7oamento do cuidado de pacientes cr\u00f4nicosscoping review), modalidade de revis\u00e3o bibliogr\u00e1fica que vem sendo amplamente utilizada no mapeamento da literatura existente sobre determinado tema, colaborando no reconhecimento e esclarecimento de defini\u00e7\u00f5es e limites conceituais17. Para o cumprimento das etapas requeridas para a metodologia, utilizou-se de forma adaptada o manual Prisma-scr18, que concentra 22 etapas de verifica\u00e7\u00e3o concernentes ao t\u00edtulo, abstract, introdu\u00e7\u00e3o, m\u00e9todo e discuss\u00e3o.O estudo trata de uma revis\u00e3o de escopo  para direcionar e delimitar o escopo do estudo, sendo P (popula\u00e7\u00e3o) = Pacientes portadores de doen\u00e7as cr\u00f4nicas, C (Conceito) = Telemedicina como ferramenta de acesso \u00e0 sa\u00fade e C (contexto) = Pandemia de covid-19. O uso do acr\u00f4nimo contribuiu na formula\u00e7\u00e3o da pergunta de pesquisa \u201cA telemedicina contribuiu para o acesso aos servi\u00e7os de sa\u00fade para pacientes portadores de doen\u00e7as cr\u00f4nicas durante a pandemia de covid-19?\u201d, que direcionou as buscas de artigos indexados nas bases de dados PubMed, Scopus, Embase, Web of Science, LILACS e SciELO, selecionadas a partir da Ag\u00eancia de Informa\u00e7\u00e3o Acad\u00eamica da Universidade de S\u00e3o Paulo com o crit\u00e9rio de indexa\u00e7\u00e3o definido para peri\u00f3dicos na \u00e1rea de Sa\u00fade P\u00fablicaTelemedicine AND Chronic Diseases AND COVID-19 AND Access to health care), utilizando como crit\u00e9rio de inclus\u00e3o o per\u00edodo de mar\u00e7o de 2020 a mar\u00e7o de 2022 para publica\u00e7\u00f5es em l\u00edngua inglesa, sucedido de avalia\u00e7\u00e3o duplo-cego para as etapas de avalia\u00e7\u00e3o de escopo. Foram inclu\u00eddos todos os tipos de artigos, incluindo revis\u00f5es, sem limita\u00e7\u00e3o geogr\u00e1fica ou tipo de publica\u00e7\u00e3o. Em rela\u00e7\u00e3o aos resultados, demonstrados na A busca dos artigos que integram a revis\u00e3o ocorreu a partir da linha de comando de busca constru\u00edda com os descritores DeCs (abstract (n = 166 artigos). Nesta etapa, os conflitos de inclus\u00e3o (n = 11 artigos) foram encaminhados para o parecer de novos revisores em avalia\u00e7\u00e3o duplo-cego para decis\u00e3o final, em que foram inclu\u00eddos n = 5 artigos.Nesses resultados, foram aplicados os seguintes crit\u00e9rios de exclus\u00e3o: artigos que n\u00e3o abordaram o uso da telemedicina, direcionados a popula\u00e7\u00f5es que n\u00e3o fossem formadas por doentes cr\u00f4nicos, fora do per\u00edodo de pandemia da covid-19, discutindo especialidades que n\u00e3o se enquadram no crit\u00e9rio cr\u00f4nico e abordando quest\u00f5es relacionadas \u00e0 sa\u00fade mental (n = 98 artigos). Na plataforma Rayyan, as duplicatas foram removidas (n = 80 artigos) e foram inseridos artigos de fontes adicionais (n = 2 artigos), al\u00e9m de se realizar uma segunda avalia\u00e7\u00e3o duplo-cego dos resultados anteriores, considerando t\u00edtulo e A an\u00e1lise incluiu n = 49 artigos para avalia\u00e7\u00e3o em inteiro teor; desses, apenas n = 18 artigos foram selecionados para o estudo de escopo, em raz\u00e3o de apresentarem elementos que podem auxiliar na resposta \u00e0 pergunta de pesquisa. Foram analisadas as seguintes dimens\u00f5es: tecnol\u00f3gica , sociocultural  e assistencial . Ap\u00f3s a extra\u00e7\u00e3o dos resultados, eles foram categorizados e discutidos pelos autores.Os resultados identificados no escopo dos 18 artigos selecionados est\u00e3o apresentados no 20 e n = 1 foi estudo feito na regi\u00e3o da Am\u00e9rica Latina30. J\u00e1 o Sudeste Asi\u00e1tico foi citado em n = 1 estudo31, e It\u00e1lia32, Reino Unido33, Alemanha34, Canad\u00e135 e Peru36 tamb\u00e9m contribu\u00edram com n = 1 artigo cada. Identificamos apenas um trabalho com metodologia de revis\u00e3o sistem\u00e1tica que mencionou ter considerado estudos de cinco regi\u00f5es da Organiza\u00e7\u00e3o Mundial de Sa\u00fade (OMS), com predom\u00ednio de artigos da Regi\u00e3o Europeia37.Todos os artigos foram publicados em ingl\u00eas, diferindo na distribui\u00e7\u00e3o geogr\u00e1fica: n = 10 dos artigos foram produzidos nos Estados UnidosQuanto \u00e0 data de publica\u00e7\u00e3o dos estudos, 77% dos estudos foram publicados em 2021, enquanto 16% das publica\u00e7\u00f5es correspondem ao primeiro ano da pandemia de covid-19. Al\u00e9m disso, apenas n = 1 artigo foi publicado mais recentemente, em 2022. Em rela\u00e7\u00e3o ao tipo de estudo e \u00e0 fonte de dados, 44% dos trabalhos s\u00e3o quantitativos, com fonte de dados prim\u00e1rias e coletados atrav\u00e9s de question\u00e1rios aplicados pelo telefone ou via internet. Apenas n = 4 estudos utilizaram m\u00e9todos qualitativos, sendo que n = 2 artigos apresentaram narrativas como fonte de dados; al\u00e9m disso, houve artigos de revis\u00e3o sistem\u00e1tica, de avalia\u00e7\u00e3o e de m\u00e9todos mistos, cada um deles correspondendo a 11% do total.21. J\u00e1 a telessa\u00fade foi citada em 27% dos artigos analisados27, a telerreabilita\u00e7\u00e3o em 11%32 e a teleneurologia24, a v\u00eddeo consulta34 e o monitoramento remoto35 representaram 15% do total. Cabe ressaltar que consideramos sobretudo a tecnologia citada no estudo, visto que alguns autores utilizaram mais de uma tecnologia.Em rela\u00e7\u00e3o ao tipo de tecnologia digital de cuidado em sa\u00fade utilizada, 44% dos estudos se referiram ao uso da telemedicina23.As doen\u00e7as cr\u00f4nicas respirat\u00f3rias representaram 50% dos artigos, sendo o conjunto de doen\u00e7as que mais utilizou a telemedicina, com destaque para a doen\u00e7a pulmonar obstrutiva cr\u00f4nica (DPOC) (n = 4 artigos) e a fibrose c\u00edstica (n = 2 artigos). Apenas 22% dos artigos n\u00e3o delimitaram o tipo de doen\u00e7a cr\u00f4nica, caracterizando-nas como doen\u00e7as cr\u00f4nicas em geral. Inclu\u00edmos ainda trabalhos sobre diabetes, c\u00e2ncer e doen\u00e7as cr\u00f4nicas neurol\u00f3gicas, que corresponderam a 15%. Metade dos artigos identificados apresentaram como principal resultado o aumento do uso da telemedicina para o atendimento de pacientes portadores de doen\u00e7as cr\u00f4nicas durante a pandemia de covid-1937. Outros resultados relacionados ao uso da telemedicina no cuidado de doentes cr\u00f4nicos, como a melhora de indicadores33, diminui\u00e7\u00e3o de complica\u00e7\u00f5es36, maior receptividade por parte dos pacientes29, v\u00eddeo consultas com recomenda\u00e7\u00f5es cl\u00ednicas concretas/troca de medicamento34 e identifica\u00e7\u00e3o de benef\u00edcios no pr\u00e9 e p\u00f3s-operat\u00f3rio35foram identificados. Por outro lado, houve resultados desfavor\u00e1veis quanto ao uso da telemedicina, como a identifica\u00e7\u00e3o de incapacidade de uso por parte dos pacientes26, menor engajamento dos pacientes29, problemas com respostas emocionais e abordagem de assuntos complexos29 e dificuldade de acesso, incluindo aos medicamentos prescritos eletronicamente30.O in\u00edcio de atividades de telemedicina tamb\u00e9m foi relatado em n = 3 artigos34.As inova\u00e7\u00f5es incorporadas no escopo do atendimento realizado por telemedicina apresentaram caracter\u00edsticas estruturais e assistenciais. Entre as inova\u00e7\u00f5es estruturais, o envio de equipamentos de monitoriza\u00e7\u00e3o e medi\u00e7\u00e3o de sinais vitais  para o domic\u00edlio dos pacientes foi o arranjo mais comum, estando presente em 27% dos estudos20, implanta\u00e7\u00e3o de laborat\u00f3rio funcionando em formato drive-thru19 e a entrega de medicamento em domic\u00edlio36 tamb\u00e9m foram listados. Outros arranjos estruturais est\u00e3o relacionados \u00e0 tecnologia ofertada em si, como por exemplo a disponibiliza\u00e7\u00e3o de plataformas e-learning para o treinamento de pacientes33 e a possibilidade do uso de m\u00faltiplas plataformas24 viabilizando o acesso daqueles que apresentam menor habilidade com o universo virtual, al\u00e9m de parcerias com hospitais universit\u00e1rios e faculdades de medicina31.A coleta de sangue domiciliaronline36, utiliza\u00e7\u00e3o de telemedicina para cuidado integral do paciente28, incluindo cuidados pr\u00e9 e p\u00f3s-operat\u00f3rios37, atua\u00e7\u00e3o na regula\u00e7\u00e3o e gest\u00e3o de casos complexos31, ado\u00e7\u00e3o de protocolos de pr\u00e9-consulta detalhados28 e protocolos h\u00edbridos de atendimento, incluindo consultas presenciais e online, quando necess\u00e1rio26, e o atendimento por equipe multiprofissional25.Os arranjos tecnol\u00f3gicos do cuidado identificados como assistenciais s\u00e3o aqueles inventados, adaptados ou utilizados para o cuidado realizado pelo profissional de sa\u00fade ou da cadeia de cuidados, atrav\u00e9s de tecnologias digitais. Neste sentido \u00e9 poss\u00edvel listar prescri\u00e7\u00f5es 26, dificuldades de acesso \u00e0 internet35, problemas de conex\u00e3o36; barreiras socioculturais 37, relacionadas ao idioma29, idade34, defici\u00eancias29, relacionadas ao tipo de seguro-sa\u00fade e ao financiamento da telemedicina, de acesso assistencial (22%). Entre as mais importantes, est\u00e3o a limita\u00e7\u00e3o no exame f\u00edsico do paciente28, a falta de profissionais26 e aspectos pr\u00f3prios da doen\u00e7a ou da faixa et\u00e1ria, como, por exemplo, problemas de audi\u00e7\u00e3o23. Todas estas barreiras est\u00e3o relacionadas principalmente \u00e0s popula\u00e7\u00f5es vulnerabilizadas, incluindo grupos de refugiados e imigrantes20.Em rela\u00e7\u00e3o ao acesso aos servi\u00e7os de sa\u00fade atrav\u00e9s da telemedicina para pacientes portadores de doen\u00e7as cr\u00f4nicas durante a pandemia de covid-19, 88% dos artigos relataram barreiras de acesso ao uso da telemedicina: barreiras tecnol\u00f3gicas decorrentes de exclus\u00e3o digital31, fatores relacionados \u00e0 economia de tempo e recursos com o deslocamento24 (11%) e o maior envolvimento de familiares e cuidadores20 (5%) \u2013 s\u00e3o apontados como benef\u00edcios da implementa\u00e7\u00e3o do sistema remoto. No que tange ao futuro da telemedicina nos sistemas de sa\u00fade, a recomenda\u00e7\u00e3o de desenvolvimento de guidelines e protocolos que possibilitem a atua\u00e7\u00e3o segura e eficaz com boa infraestrutura digital \u00e9 identificada em 83% dos estudos.Al\u00e9m disso, os aspectos que facilitam o acesso dos pacientes ao cuidado em sa\u00fade atrav\u00e9s da telemedicina \u2013 como a amplia\u00e7\u00e3o da oferta para residentes em \u00e1reas remotas ou rurais (16%)A partir do mapeamento e an\u00e1lise dos dados fornecidos pela literatura utilizada na presente revis\u00e3o, identificamos o aumento exponencial do uso da telemedicina e demais modalidades de cuidado \u00e0 dist\u00e2ncia durante a pandemia de covid-19 voltadas para o atendimento de doentes cr\u00f4nicos em cuidados continuados. Sabe-se que o universo \u00e9 ainda mais abrangente, se consideradas aqui as formas de uso da telemedicina exclu\u00eddas com base nos crit\u00e9rios metodol\u00f3gicos adotados.Ap\u00f3s a organiza\u00e7\u00e3o e an\u00e1lise dos resultados, tr\u00eas dimens\u00f5es foram identificadas: tend\u00eancias em telemedicina, inova\u00e7\u00f5es no cuidado e barreiras de acesso, conforme demonstrado na 32desses procedimentos no territ\u00f3rio americano. Somada a isso, a incorpora\u00e7\u00e3o da telemedicina no rol de procedimentos reembols\u00e1veis por planos de sa\u00fade estadunidenses serviu como incentivo desde o in\u00edcio da pandemia21. Um estudo envolvendo um grande provedor de telessa\u00fade americano destacou ainda o aumento da procura de atendimento para doen\u00e7as cr\u00f4nicas e quest\u00f5es de sa\u00fade mental, superando a busca por atendimento motivada pelo coronav\u00edrus27.O escopo dos artigos selecionados destaca o predom\u00ednio de estudos produzidos nos Estados Unidos, especialmente em cen\u00e1rios onde a telemedicina j\u00e1 vinha sendo utilizada anteriormente \u00e0 pandemia. A disponibilidade de estrutura tecnol\u00f3gica possibilitou r\u00e1pida implementa\u00e7\u00e3o38.Por outro lado, em muitas outras localidades, como na pr\u00f3pria China, estruturas latentes ganharam visibilidade e puderam ser utilizadas no atendimento dos pacientes em decorr\u00eancia da emerg\u00eancia sanit\u00e1ria. Os autores defendem que as estruturas desveladas na pandemia n\u00e3o sejam abandonadas ap\u00f3s a mitiga\u00e7\u00e3o dos casos e controle da situa\u00e7\u00e3o39. O uso de telemedicina em pneumologia n\u00e3o \u00e9 recente: Zamith e Gomes40 identificaram estudos feitos desde 1993 contendo a associa\u00e7\u00e3o das palavras \u201ctelemedicine\u201d e \u201clung\u201d. Adicionalmente, a escassez de profissionais especializados em pneumologia j\u00e1 havia sido constatada anos antes, sendo encontrados estudos que apontaram a utiliza\u00e7\u00e3o de arranjos tecnol\u00f3gicos que pudessem contribuir para melhorar esse cen\u00e1rio e garantissem o acesso de pacientes, como as experi\u00eancias descritas de matriciamento e cuidado compartilhado em pneumologia42.A outra tend\u00eancia observada foi o predom\u00ednio de artigos sobre o uso da telemedicina voltada ao cuidado de pacientes com doen\u00e7as respirat\u00f3rias cr\u00f4nicas (DRC), condi\u00e7\u00e3o que aparece entre as principais causas de morbimortalidade em todo o mundo. Comumente encontradas, a DPOC e asma est\u00e3o entre as 20 doen\u00e7as que mais causam incapacidade no mundo24, ainda que haja limita\u00e7\u00f5es identificadas no acesso dos pacientes27.Al\u00e9m disso, o aumento da demanda ocasionado pela pandemia e o potencial risco aos pacientes portadores de DRC s\u00e3o tamb\u00e9m pontos que contribuem para a compreens\u00e3o da predomin\u00e2ncia de estudos na \u00e1rea da pneumologia. J\u00e1 a telerreabilita\u00e7\u00e3o pulmonar apresentou resultados promissores em rela\u00e7\u00e3o \u00e0 progress\u00e3o dos exerc\u00edcios e melhora de indicadores da doen\u00e7a32. A possibilidade de disponibilizar instrumentos de automonitoramento e os bons resultados que o uso dos equipamentos em domic\u00edlio tem demonstrado parecem ser fatores que conferem vantagens no acompanhamento de doen\u00e7as respirat\u00f3rias cr\u00f4nicas, quando fala em avan\u00e7os em telemedicina34.Na It\u00e1lia, pacientes portadores de DPOC relataram que receberam o dobro de atendimentos por telemedicina de pneumologistas que por m\u00e9dicos de fam\u00edlia43. Autores brasileiros enfatizam que \u00e9 necess\u00e1ria a discuss\u00e3o de pol\u00edticas e a identifica\u00e7\u00e3o de estrat\u00e9gias que permitam a continuidade do cuidado, minimizando interrup\u00e7\u00f5es e adapta\u00e7\u00e3o ao novo cen\u00e1rio, sob o risco de refor\u00e7ar ou ampliar as desigualdades45.A recomenda\u00e7\u00e3o de distanciamento social adotada por diversos pa\u00edses durante a pandemia teve grande ades\u00e3o entre os portadores de doen\u00e7as cr\u00f4nicas e acentuou dificuldades de acesso ao cuidado, alertando sobre o risco de aumento da morbidade, incapacidade e mortalidade evit\u00e1vel47 j\u00e1 sinalizavam a urg\u00eancia na identifica\u00e7\u00e3o de possibilidades para o atendimento dos usu\u00e1rios, suscitando inova\u00e7\u00f5es do cuidado, na tentativa de driblar as dificuldades impostas. Com base nos resultados, a telemedicina, de maneira ampla, se apresentou como uma das mais importantes dessas inova\u00e7\u00f5es, oferecendo mecanismos potentes para atuar em um cen\u00e1rio de r\u00e1pida dissemina\u00e7\u00e3o49. Ainda que n\u00e3o fosse um arranjo exatamente novo, a telemedicina contribuiu na diversifica\u00e7\u00e3o do cuidado, valendo-se de caracter\u00edsticas como versatilidade e ampla capacidade de atua\u00e7\u00e3o para atingir diferentes popula\u00e7\u00f5es e necessidades de sa\u00fade. As inova\u00e7\u00f5es descritas demonstraram a import\u00e2ncia de ofertar cuidados centrados no paciente, multin\u00edvel, multidisciplinares e continuados32.Com base na conjuntura estabelecida pela covid-19, as primeiras publica\u00e7\u00f5es50. Assim, considerar que determinados arranjos se apoiaram mais fortemente em instrumentos, ferramentas e saberes hegem\u00f4nicos \u2013 tamb\u00e9m chamados de \u201ctecnologias duras\u201d e \u201ctecnologias leve-duras\u201d \u2013 enquanto outros se constitu\u00edram levando em conta aspectos relacionais, produzidos no encontro entre o profissional de sa\u00fade e o paciente \u2013 chamados de \u201ctecnologias leves\u201d51. A partir deste olhar, identificamos aspectos relevantes em cada uma delas.A identifica\u00e7\u00e3o de arranjos inovadores estruturais e assistenciais, alude, ainda que de forma rudimentar, aos modelos de produ\u00e7\u00e3o do cuidado e \u00e0 import\u00e2ncia do trabalho vivo no processo de produ\u00e7\u00e3o do cuidadodrive thru, entre outros, fazem emergir a problem\u00e1tica da regulamenta\u00e7\u00e3o e do financiamento da telemedicina, dentro e fora do Brasil. Aspectos como diverg\u00eancias de nomenclatura e escopo, seguran\u00e7a e prote\u00e7\u00e3o de dados do paciente e remunera\u00e7\u00e3o dos servi\u00e7os representam, muitas vezes, obst\u00e1culos que devem ser superados por interm\u00e9dio da defini\u00e7\u00e3o de pol\u00edticas espec\u00edficas e ampla discuss\u00e3o da tem\u00e1tica52.Os arranjos inovadores estruturais, aqui representados pelo envio de equipamentos ao domic\u00edlio, prescri\u00e7\u00f5es online, laborat\u00f3rios no formato 53. Com a eclos\u00e3o da pandemia, o Minist\u00e9rio da Sa\u00fade publicou a Portaria n\u00ba 467, em 20 de mar\u00e7o de 202054, com disposi\u00e7\u00f5es tempor\u00e1rias para a\u00e7\u00f5es de telemedicina, amparadas na Lei n\u00ba 13.979, de 06 de fevereiro de 202055, que definiu a emerg\u00eancia sanit\u00e1ria no Brasil. O dispositivo legal amparou o uso da telemedicina no territ\u00f3rio brasileiro durante a vig\u00eancia da emerg\u00eancia, que foi declarada encerrada pelo Minist\u00e9rio da Sa\u00fade na Portaria n\u00ba 913 de 22 de abril de 2022, devolvendo ao CFM a tarefa de regulamentar a telemedicina. Mais recentemente, houve a publica\u00e7\u00e3o da Resolu\u00e7\u00e3o CFM n\u00ba 2.314/2022, regulamentando a telemedicina, que ainda carece de an\u00e1lise detalhada. Ao mesmo tempo, inst\u00e2ncias legislativas debatem um projeto de lei sobre o tema, o que expressa a atualidade, urg\u00eancia e controv\u00e9rsia que o cercam.No Brasil, a discuss\u00e3o da regulamenta\u00e7\u00e3o vinha caminhando a passos largos no Conselho Federal de Medicina, que publicou a Resolu\u00e7\u00e3o n\u00ba2.227/2018 no final do ano, definindo aspectos importantes para a pr\u00e1tica da telemedicina. No entanto, disputas institucionais motivaram sua revoga\u00e7\u00e3o poucos dias depois, conservando o vazio normativo da telemedicina no Brasil56. Os resultados encontrados nesta revis\u00e3o exprimem as tens\u00f5es vivenciadas no cotidiano dos servi\u00e7os, da captura da telemedicina pela burocracia at\u00e9 as experi\u00eancias de liberdade vivenciadas por profissionais de sa\u00fade, forjados inclusive no desconhecido. A atua\u00e7\u00e3o profissional se deu em condi\u00e7\u00f5es adversas, fora da zona de conforto e com a necessidade de adapta\u00e7\u00e3o ao cen\u00e1rio inusitado. Estas circunst\u00e2ncias flexibilizaram as tarefas cotidianas e possibilitaram a assun\u00e7\u00e3o de novos pap\u00e9is8.Em contrapartida, os arranjos inovadores assistenciais, por sua vez, retratam aspectos das rela\u00e7\u00f5es e da micropol\u00edtica dos servi\u00e7os de sa\u00fade28. A \u201cjanela temporal de oportunidades\u201d57 que se abriu, em decorr\u00eancia da crise sanit\u00e1ria, traz desafios existenciais complexos no \u00e2mbito da sa\u00fade p\u00fablica para o momento \u201cp\u00f3s\u201d pandemia. As pr\u00e1ticas cuidadoras e integrais42 descentralizadas s\u00e3o elementos importantes na an\u00e1lise da resposta \u00e0 pandemia.Em muitos casos, sob a \u00e9gide da pouca regulamenta\u00e7\u00e3o e/ou do car\u00e1ter de exce\u00e7\u00e3o alavancados pela pandemia, surgiram novas possibilidades de cuidado, al\u00e9m de experimentos e incorpora\u00e7\u00e3o de novos protocolos20. Por outro lado, requerem estudos aprofundados quanto ao custo-efetividade, qualidade e satisfa\u00e7\u00e3o do usu\u00e1rio; entretanto, a indisponibilidade dos dados fragiliza o seu avan\u00e7o, regulamenta\u00e7\u00e3o, financiamento e utiliza\u00e7\u00e3o58.Por fim, os resultados demonstraram que as pr\u00e1ticas de telemedicina apresentam bons \u00edndices de aceita\u00e7\u00e3o, tanto entre pacientes e familiares quanto entre profissionais de sa\u00fade e gestores20. A constata\u00e7\u00e3o que a telemedicina expandiu suas fronteiras e vem se consolidando como arranjo(s) do cuidado para doen\u00e7as cr\u00f4nicas59 n\u00e3o deve se dissociar da dimens\u00e3o do acesso e, principalmente, das barreiras identificadas. A formula\u00e7\u00e3o e implementa\u00e7\u00e3o de pol\u00edticas de sa\u00fade baseadas em cuidados mediados pela tecnologia, como a telemedicina e suas varia\u00e7\u00f5es, pode tanto contribuir para diminuir as barreiras de acesso \u00e0 sa\u00fade quanto evidenciar desigualdades que possam comprometer a universalidade do acesso aos servi\u00e7os de sa\u00fade.As tend\u00eancias e inova\u00e7\u00f5es advindas do uso da telemedicina para o cuidado de doentes cr\u00f4nicos durante a pandemia identificadas nesta revis\u00e3o s\u00e3o relevantes e oferecem pistas tanto para a formula\u00e7\u00e3o de pol\u00edticas quanto para a elabora\u00e7\u00e3o de novos estudos. No entanto, em resposta \u00e0 garantia de acesso a cuidados de sa\u00fade por doentes cr\u00f4nicos com o uso da telemedicina, a maior parte dos artigos inclu\u00eddos nesta revis\u00e3o aponta para in\u00fameras barreiras60, a resili\u00eancia dos sistemas de sa\u00fade ultrapassa a \u201cefetiva\u00e7\u00e3o do direito \u00e0 sa\u00fade\u201d e engloba as atividades sociais e econ\u00f4micas, reproduzindo a experi\u00eancia da pandemia. Portanto, identificar precocemente as barreiras causadas em virtude do uso da telemedicina para o cuidado de doentes cr\u00f4nicos pode evitar o aumento de iniquidades no acesso ao cuidado. Al\u00e9m disso, \u00e9 imprescind\u00edvel incluir a dimens\u00e3o do paciente, com suas especificidades de diagn\u00f3stico, na formula\u00e7\u00e3o das pol\u00edticas e protocolos21.Analisar o efeito que a pandemia produziu no acesso \u00e0 sa\u00fade \u00e9 um dos principais desafios atuais para a constru\u00e7\u00e3o de sistemas de sa\u00fade resilientes. Para alguns autoresAinda que o principal desafio em rela\u00e7\u00e3o ao acesso esteja vinculado ao analfabetismo digital , o abismo evidenciado pela tecnologia reflete desigualdades sociais e de sa\u00fade da popula\u00e7\u00e3o, cuja redu\u00e7\u00e3o deve guiar a constru\u00e7\u00e3o de sistemas de sa\u00fade de qualidade, com garantia de acesso e equidade.31, e podem servir como ponto de partida para elabora\u00e7\u00e3o de pol\u00edticas e implementa\u00e7\u00e3o de servi\u00e7os. O aprimoramento do uso de tecnologias digitais \u00e9 central nesta discuss\u00e3o e demanda esfor\u00e7os pol\u00edticos e de gest\u00e3o no investimento em infraestrutura digital37.Todavia, fatores capazes de facilitar o acesso dos pacientes tamb\u00e9m foram identificadosConclui-se que o incremento da telemedicina ao longo da pandemia de covid-19 apresentou arranjos tecnol\u00f3gicos inovadores que, ao mesmo tempo, colaboraram com a amplia\u00e7\u00e3o do acesso e com a implementa\u00e7\u00e3o dessa modalidade de atendimento no cotidiano dos servi\u00e7os de sa\u00fade. No entanto, foram apontadas quest\u00f5es relacionadas \u00e0 exclus\u00e3o digital e \u00e0s condi\u00e7\u00f5es socioculturais e assistenciais como barreiras de acesso para o uso da telemedicina que devem ser superadas para que se ampliem, de fato, seu valor de uso, potencial cuidador e a inova\u00e7\u00e3o nos sistemas de sa\u00fade.A implementa\u00e7\u00e3o de pol\u00edticas espec\u00edficas e a elabora\u00e7\u00e3o de protocolos que norteiem a atua\u00e7\u00e3o dos profissionais, particularmente para as condi\u00e7\u00f5es cr\u00f4nicas, se apresentam como recomenda\u00e7\u00f5es importantes no sentido de incorporar a telemedicina como tecnologia segura, acess\u00edvel e produtora de cuidado para os sistemas e servi\u00e7os de sa\u00fade de todo o mundo."}
+{"text": "Social History of Medicine, Journal ofContemporary History ou Medical History .Samu\u00ebl Coghe, pesquisador p\u00f3s-doutoral em hist\u00f3ria global na Universidade de Berlim, temestudado o colonialismo europeu em \u00c1frica, em particular o controlo de doen\u00e7as, a sa\u00fadep\u00fablica, as pol\u00edticas populacionais e, mais recentemente, o gado como mercadoriaimperial. Os resultados das suas pesquisas t\u00eam sido publicados em revistas cient\u00edficascom elevado fator de impacto, como as Esse livro, baseado na tese de doutoramento do autor, defendida em 2014 no EuropeanUniversity Institute, em Floren\u00e7a, corresponde a um exigente processo de matura\u00e7\u00e3o erevis\u00e3o cient\u00edfica. O resultado \u00e9 um estudo inovador que contribui para o avan\u00e7o doconhecimento sobre Angola na primeira metade do s\u00e9culo XX, nas vertentes da sa\u00fade, dademografia e da emigra\u00e7\u00e3o, e o colonialismo portugu\u00eas coevo. Por\u00e9m, \u00e9 muito mais do queisso. Inscrito numa hist\u00f3ria global que extravasa os quadros nacionais ir\u00e1, seguramente,afirmar-se como refer\u00eancia na historiografia sobre pol\u00edticas populacionais na \u00c1fricacolonial.boom da fixa\u00e7\u00e3o de colonos brancos e pela persist\u00eancia da ideia deum vasto e rico territ\u00f3rio fracamente povoado, quando noutras paragens se adensavam aspreocupa\u00e7\u00f5es com o sobrepovoamento.Escrita com eleg\u00e2ncia e clareza, e editada com esmero na cole\u00e7\u00e3o \u201cGlobal HealthHistories\u201d, da prestigiada Cambridge University Press, a obra inclui um \u00edndice remissivoe um conjunto de mapas, tabelas, reprodu\u00e7\u00f5es de documentos e imagens que acrescentaminforma\u00e7\u00e3o ao texto e, no caso das fotografias, a presen\u00e7a da experi\u00eancia humana.Nota-se uma verdadeira articula\u00e7\u00e3o entre os seis cap\u00edtulos, al\u00e9m do encadeamentocronol\u00f3gico, o que ajuda a progress\u00e3o na leitura e o entendimento dos argumentos doautor. Esses s\u00e3o sintetizados em conclus\u00f5es parcelares no fim de cada cap\u00edtulo e numaconclus\u00e3o geral. Um ep\u00edlogo remete-nos ao per\u00edodo temporal seguinte, entre o fim daSegunda Guerra Mundial e a independ\u00eancia de Angola (1945-75), marcado peloin loco , que tiveram lugar naprimeira d\u00e9cada do s\u00e9culo XX.\u00c0 literatura sobre a hist\u00f3ria da doen\u00e7a do sono nas col\u00f3nias portuguesas em \u00c1frica  , Coghe Deborah O programa de sa\u00fade dirigido aos africanos, iniciado em 1926, no contexto da ditaduramilitar e depois do Estado Novo portugu\u00eas, denominado Assist\u00eancia M\u00e9dica aos Ind\u00edgenas(AMI), \u00e9 estudado em profundidade pela primeira vez, com a preocupa\u00e7\u00e3o de iluminar osdebates que precederam seus estabelecimento, estrutura e objetivos, e ainda osconstrangimentos estruturais que acabaram por limitar a sua expans\u00e3o na d\u00e9cada de 1930.S\u00e3o colocados em evid\u00eancia o papel do m\u00e9dico e alto funcion\u00e1rio colonial Ant\u00f3nio DamasMora e dois momentos de aprendizagem interimperial que reverteram para a cria\u00e7\u00e3o da AMI:a primeira confer\u00eancia da \u00c1frica ocidental sobre medicina tropical ,organizada por Damas Mora; e a viagem de estudo que Mora e Jo\u00e3o Augusto Ornelas fizeram\u00e0 \u00c1frica ocidental em 1926. Uma das mais-valias do livro \u00e9 demonstrar como a hist\u00f3ria daAMI e das medidas contra a doen\u00e7a do sono foram profundamente determinadas por processosde compara\u00e7\u00e3o e trocas interimperiais, o que permite desmontar a narrativa doexcepcionalismo do colonialismo portugu\u00eas.Ao descortinar o papel dos m\u00e9dicos como \u201cdem\u00f3grafos de campo\u201d, assunto em grande medidain\u00e9dito, Coghe exp\u00f5e a agenda transformadora daqueles actores: usaram os dados querecolhiam (em circunst\u00e2ncias dif\u00edceis e com precis\u00e3o duvidosa), que apontavam para umaestabilidade da popula\u00e7\u00e3o, para legitimar uma reorienta\u00e7\u00e3o da AMI no sentido da sa\u00fadeinfantil. Percebemos como essa mudan\u00e7a se operacionalizou, olhando para as interven\u00e7\u00f5esdestinadas a combater a mortalidade materno-infantil nos anos 1920 a 1940, em conex\u00e3ocom os debates e as pol\u00edticas seguidas na metr\u00f3pole e noutras col\u00f3nias africanas:estabelecimento de maternidades estatais e a forma\u00e7\u00e3o de parteiras angolanas;dispens\u00e1rios em meios urbanos, fruto da filantropia; e as maternidades e o treino departeiras africanas por iniciativa das miss\u00f5es protestantes no universo rural. Emboraesses esquemas correspondessem a uma vis\u00e3o negativa das m\u00e3es africanas, nas quais sepretendia incutir a \u201carte da maternidade\u201d, a resist\u00eancia passiva ou as escolhasecl\u00e9ticas das mulheres angolanas acabaram por condicionar as suas caracter\u00edsticas,levando, por exemplo, \u00e0 inclus\u00e3o da medicina curativa nos dispens\u00e1rios.Rompendo com abordagens estanques da realidade, o livro contempla por \u00faltimo a quest\u00e3o daemigra\u00e7\u00e3o de angolanos para as col\u00f3nias lim\u00edtrofes, analisando as ansiedades e asrespostas pol\u00edticas que o despovoamento por essa via gerou entre os funcion\u00e1rios daadministra\u00e7\u00e3o colonial portuguesa. N\u00e3o se conhecia a real dimens\u00e3o da sa\u00edda de angolanospara trabalhar em minas, planta\u00e7\u00f5es e infraestruturas de territ\u00f3rios vizinhos, em buscade melhores condi\u00e7\u00f5es de vida, e para evitar impostos mais altos e o trabalho for\u00e7ado nacol\u00f3nia portuguesa. Embora parcial e impreciso, o conhecimento demogr\u00e1fico sobre essestr\u00e2nsitos refor\u00e7ou os medos quanto ao decl\u00ednio da popula\u00e7\u00e3o e do prest\u00edgio de Portugalcomo pot\u00eancia colonial e conduziu \u00e0 ado\u00e7\u00e3o de medidas pela administra\u00e7\u00e3o colonial emAngola que procuravam evitar esses fluxos, como a redu\u00e7\u00e3o de impostos, o refor\u00e7o docontrolo administrativo e a instala\u00e7\u00e3o de miss\u00f5es cat\u00f3licas nas regi\u00f5esfronteiri\u00e7as.Entre os m\u00e9ritos dessa obra, destaco a riqueza e diversidade da bibliografia, das fontesimpressas e dos arquivos consultados, muitos deles in\u00e9ditos, em seis pa\u00edses e quatrol\u00ednguas; a aplica\u00e7\u00e3o consistente da perspetiva comparativa e transimperial \u2013 Coghe n\u00e3ose limita a olhar para Angola, vai fazendo compara\u00e7\u00f5es com o que se passava nas outrascol\u00f3nias portuguesas em \u00c1frica, no Portugal metropolitano e noutros imp\u00e9rios coloniais;a capacidade de combinar contributos de diferentes subdisciplinas da hist\u00f3ria; asolidez, pertin\u00eancia e novidade da sua an\u00e1lise. A obra aproveita a todos os que seinteressam pela hist\u00f3ria de \u00c1frica, da sa\u00fade, da demografia e das migra\u00e7\u00f5es, e \u00e9 umexerc\u00edcio ex\u00edmio de hist\u00f3ria transimperial da circula\u00e7\u00e3o do conhecimento (m\u00e9dico edemogr\u00e1fico), a partir de um local \u2013 a col\u00f3nia portuguesa de Angola \u2013 ainda largamenteinexplorado. Embora Coghe n\u00e3o dialogue com a recente historiografia sobre diplomaciacient\u00edfica    parapr"}
+{"text": "A VPA foi quantificada pelo coeficiente de varia\u00e7\u00e3o de tr\u00eas medidas padronizadas da PAS realizadas com um oscil\u00f4metro. Medidas antropom\u00e9tricas e exames laboratoriais tamb\u00e9m foram realizados. O risco cardiovascular foi avaliado pelo estimador de risco de doen\u00e7a cardiovascular ateroscler\u00f3tica empregando an\u00e1lise de regress\u00e3o log\u00edstica multivariada, com n\u00edvel de signific\u00e2ncia de 5%. Os autores observaram que o risco cardiovascular significativamente maior foi associado com VPA elevada para ambos os sexos. Uma preval\u00eancia significativamente maior de alto risco foi observada mais em homens que em mulheres em todos os quartis, com a maior diferen\u00e7a observada no quarto quartil de variabilidade.3 Um maior consumo de alimentos ultraprocessados (UP) foi associado a maior risco de incid\u00eancia e mortalidade por DCV, sugerindo que os alimentos UP devam ser banidos da dieta ou minimamente consumidos.25 Entre os alimentos UP, as bebidas energ\u00e9ticas (BEs) s\u00e3o amplamente consumidas no meio esportivo para melhorar o desempenho aer\u00f3bico, mas os efeitos agudos sobre a fisiologia cardiovascular s\u00e3o poucos conhecidos. Porto et al.5 avaliaram o efeito agudo de uma BE (250 mL) com valor energ\u00e9tico de 45 kcal  sobre a variabilidade da frequ\u00eancia card\u00edaca e a recupera\u00e7\u00e3o cardiovascular ap\u00f3s exerc\u00edcio aer\u00f3bico moderado precedido pelo consumo da BE. O estudo foi randomizado, duplo-cego, cruzado, controlado por placebo e feito com 28 jovens adultos divididos em dois grupos de acordo com o pico de consumo de oxig\u00eanio (pico de VO2): (1) pico de VO2 alto (AO) \u2013 pico de VO2 > 52,15 mL/kg/min; e (2) pico de VO2 baixo (BO) \u2013 pico de VO2 < 52,15 mL/kg/min. Os autores conclu\u00edram que a ingest\u00e3o aguda de BE n\u00e3o teve efeito sobre a PAS e press\u00e3o diast\u00f3lica, a satura\u00e7\u00e3o arterial de oxig\u00eanio por oximetria de pulso (SpO2) e a taxa respirat\u00f3ria, mas atrasou a recupera\u00e7\u00e3o da frequ\u00eancia card\u00edaca ap\u00f3s o exerc\u00edcio em indiv\u00edduos com baixa ou alta capacidade cardiorrespirat\u00f3ria. Os autores ainda chamaram a aten\u00e7\u00e3o para que os indiv\u00edduos com doen\u00e7as cardiovasculares e metab\u00f3licas evitem o uso de BE (como um suplemento) antes da pr\u00e1tica de exerc\u00edcio f\u00edsico.Al\u00e9m da eleva\u00e7\u00e3o da PAS, os FR diet\u00e9ticos e metab\u00f3licos justificaram uma maior varia\u00e7\u00e3o da carga de DCV, correlacionada com o SDI nos PLP.3 N\u00edveis sangu\u00edneos elevados de LDL-C ocorrem na hipercolesterolemia familiar (HF), uma doen\u00e7a autoss\u00f4mica dominante associada \u00e0 ocorr\u00eancia de DCV ateroscler\u00f3tica precoce. O HipercolBrasil \u00e9 um programa de rastreamento em cascata para HF que j\u00e1 identificou mais de 2.000 indiv\u00edduos com variantes gen\u00e9ticas causadoras de HF, atrav\u00e9s do rastreamento em cascata de casos \u00edndices referidos, indiv\u00edduos com hipercolesterolemia e suspeita cl\u00ednica de HF. Um estudo que realizou o rastreamento em cascata direcionado a 11 pequenos munic\u00edpios brasileiros com suspeita de alta preval\u00eancia de indiv\u00edduos com HF  identificou 105 casos \u00edndices e 409 familiares de primeiro grau com rendimento de 4,67 familiares por caso \u00edndice. Os autores sugeriram que regi\u00f5es geogr\u00e1ficas espec\u00edficas com suspeita de alta preval\u00eancia de HF justificariam uma abordagem em cascata direcionada para a identifica\u00e7\u00e3o de aglomera\u00e7\u00f5es de indiv\u00edduos com HF.6Os riscos diet\u00e9ticos, a glicemia de jejum elevada, o colesterol de lipoprote\u00edna de baixa densidade (LDL-C) elevado e a polui\u00e7\u00e3o do ar estiveram entre os cinco FR mais importantes na maioria dos PLP em 1990 e em 2019, e houve uma tend\u00eancia \u00e0 correla\u00e7\u00e3o inversa entre o SDI e o percentual de mudan\u00e7a, com signific\u00e2ncia estat\u00edstica para os riscos diet\u00e9ticos, LDL-C elevado e PAS elevada nos PLP, sendo importante fazer o rastreamento desses FR.3 \u00c9 importante ressaltar que mais de 1 bilh\u00e3o de pessoas no mundo s\u00e3o obesas \u2013 650 milh\u00f5es de adultos, 340 milh\u00f5es de adolescentes e 39 milh\u00f5es de crian\u00e7as. A Organiza\u00e7\u00e3o Mundial da Sa\u00fade (OMS) estima que, at\u00e9 2025, aproximadamente 167 milh\u00f5es de pessoas \u2013 adultos e crian\u00e7as \u2013 se tornar\u00e3o menos saud\u00e1veis por estarem com sobrepeso ou obesidade.26 Kravchychyn et al.7 estudaram a hip\u00f3tese de que a terapia cl\u00ednica interdisciplinar para perda de peso poderia melhorar a preval\u00eancia da s\u00edndrome metab\u00f3lica (Smet) e os riscos cardiometab\u00f3licos em adolescentes com obesidade e que essa melhora seria associada a mudan\u00e7as nos n\u00edveis de pept\u00eddeo natriur\u00e9tico atrial (ANP). Os autores avaliaram 73 adolescentes com obesidade submetidos a terapia interdisciplinar para perda de peso de 20 semanas, incluindo abordagem cl\u00ednica, nutricional, psicol\u00f3gica e de exerc\u00edcios f\u00edsicos. A composi\u00e7\u00e3o corporal, as an\u00e1lises bioqu\u00edmicas e a press\u00e3o sangu\u00ednea foram tamb\u00e9m medidas. Ap\u00f3s o tratamento, os volunt\u00e1rios foram divididos de acordo com os n\u00edveis de plasma do ANP aumentado (n = 31) ou ANP reduzido (n = 19). Observou-se redu\u00e7\u00e3o significativa na gordura corporal, na raz\u00e3o de triglicer\u00eddeos/colesterol de lipoprote\u00edna de alta densidade (TG/HDL-c) e na preval\u00eancia de Smet (de 23% para 6%) somente no grupo com ANP aumentado, ainda que ambos os grupos tivessem redu\u00e7\u00f5es significativas de peso corporal, do IMC e das circunfer\u00eancias de cintura, pesco\u00e7o e quadril e aumento da massa livre de gordura.A obesidade, caracterizada pelo aumento do \u00edndice de massa corporal (IMC), foi o sexto FR mais importantes na maioria dos PLP em 1990 e em 2019.17 Foram avaliados dados de 1.650 pacientes, sendo que cerca de 21% tinham valores elevados de BNP. Tal como seria de esperar, observou-se que as pessoas com valores mais elevados de BNP eram mais idosas, tinham mais comorbilidades, menor fra\u00e7\u00e3o de eje\u00e7\u00e3o e maior gravidade de doen\u00e7a coron\u00e1ria. Observou-se ainda que, mesmo ap\u00f3s a utiliza\u00e7\u00e3o de t\u00e9cnicas de propensity matching score , a presen\u00e7a de valores mais elevados de BNP (> 400 pg/mL) foi um importante marcador de progn\u00f3stico, quer de mortalidade intra-hospitalar, quer de mortalidade ao fim de 1 ano. Esse estudo sugere que a dosagem dos valores de BNP \u00e9 uma ferramenta simples e facilmente acess\u00edvel para a estratifica\u00e7\u00e3o adicional de risco em pacientes admitidos com SCA com supradesnivelamento do segmento ST.A procura por novos marcadores de progn\u00f3stico em pessoas com s\u00edndrome coron\u00e1ria aguda (SCA) continua. Em um estudo proveniente do Registo Nacional de SCA da Sociedade Portuguesa de Cardiologia, em que participaram dezenas de centros de Portugal, os autores pretenderam avaliar o impacto progn\u00f3stico dos valores de pept\u00eddeo natriur\u00e9tico cerebral (BNP) durante a hospitaliza\u00e7\u00e3o por SCA com supradesnivelamento do segmento ST.18 analisaram a express\u00e3o prote\u00f4mica de trombos intracoron\u00e1rios extra\u00eddos por trombectomia aspirativa de pacientes com SCA com supradesnivelamento do segmento ST (n = 30). Esse estudo \u00e9 potencialmente relevante porque estudos pr\u00e9vios demonstraram que a an\u00e1lise prote\u00f4mica pode ser \u00fatil na identifica\u00e7\u00e3o de novos biomarcadores e novos alvos terap\u00eauticos em v\u00e1rias doen\u00e7as. Nesse estudo, observou-se um aumento significativo da express\u00e3o da prote\u00edna SGK1 no trombo dos pacientes comparativamente ao grupo controle . A cinase 1 induzida pelo soro/glicocorticoide (SGK1) \u00e9 um efetor da via de sinaliza\u00e7\u00e3o do fosfatidilinositol-3\u2019-cinase (PI3K), podendo representar um novo alvo terap\u00eautico na preven\u00e7\u00e3o de eventos aterotromb\u00f3ticos, sendo necess\u00e1rios mais estudos para confirmar essa hip\u00f3tese.Na fisiopatologia da SCA, a trombose desempenha um papel essencial no desenvolvimento do evento, sendo importante continuar a explorar os mecanismos fisiopatol\u00f3gicos e as vias envolvidas no desencadear do processo de trombose intracoron\u00e1rio. Em um estudo publicado na Revista Portuguesa de Cardiologia, Cai et al.8 analisaram os impactos da implanta\u00e7\u00e3o do atendimento pr\u00e9-hospitalar nas taxas de mortalidade geral e intra-hospitalar por IAM e na taxa de interna\u00e7\u00e3o por IAM em 853 munic\u00edpios de Minas Gerais, de 2008 a 2016, empregando o modelo hier\u00e1rquico de Poisson. A implanta\u00e7\u00e3o do Servi\u00e7o de Atendimento M\u00f3vel de Urg\u00eancia (SAMU) foi associada \u00e0 diminui\u00e7\u00e3o da mortalidade por IAM  e da mortalidade intra-hospitalar por IAM , sem associa\u00e7\u00e3o significativa com interna\u00e7\u00f5es . Os autores concluiram que esses achados refor\u00e7am o papel fundamental do cuidado pr\u00e9-hospitalar no cuidado do IAM e a necessidade de investimentos nesse servi\u00e7o para melhorar os desfechos cl\u00ednicos em pa\u00edses de baixa e m\u00e9dia renda.O manejo efetivo dos pacientes com IAM est\u00e1 diretamente ligado ao tempo para assist\u00eancia m\u00e9dica, e aproximadamente metade dos \u00f3bitos atribu\u00eddos a IAM resultam de parada card\u00edaca fora do hospital, refor\u00e7ando a import\u00e2ncia do atendimento pr\u00e9-hospitalar e do desenvolvimento de sistemas de aten\u00e7\u00e3o para IAM baseados em evid\u00eancias. Vieira et al.9Durante o processo diagn\u00f3stico cl\u00ednico e eletrocardiogr\u00e1fico do IAM, podem surgir diferen\u00e7as em rela\u00e7\u00e3o a como os sintomas s\u00e3o tratados, especialmente em subgrupos espec\u00edficos, como mulheres ou pessoas mais idosas. Um estudo com 2.290 pacientes reportou que as mulheres apresentaram alta preval\u00eancia de sintomas at\u00edpicos; maior tempo entre o in\u00edcio dos sintomas e a procura por atendimento; e atraso entre a chegada ao pronto-socorro e a fibrin\u00f3lise. A mortalidade hospitalar foi de 5,6%. As taxas de mortalidade hospitalar eram mais altas em mulheres, em pacientes com diabetes melito, obesidade, doen\u00e7a renal cr\u00f4nica e acidentes vasculares pr\u00e9vios e em idosos. A disparidade relacionada a sexo persiste nas mulheres, com demoras no reconhecimento dos sintomas de isquemia e no in\u00edcio imediato de terapia fibrinol\u00edtica, levando a piores resultados cl\u00ednicos. Os autores salientaram que a aplicabilidade do escore de Killip-Kimball para prever eventos fatais com precis\u00e3o deve ser destacada, independentemente da apresenta\u00e7\u00e3o cl\u00ednica do evento isqu\u00eamico agudo, medido na primeira consulta m\u00e9dica, especialmente na estrat\u00e9gia f\u00e1rmaco-invasiva.A pandemia pelo coronav\u00edrus 2 da s\u00edndrome respirat\u00f3ria aguda grave (SARS-CoV-2) teve um enorme impacto nos sistemas de sa\u00fade em todo o mundo, nomeadamente nos cuidados prestados aos pacientes com doen\u00e7a cardiovascular. Durante o ano de 2022, foram publicados v\u00e1rios artigos que mostraram o impacto que a covid-19 teve na doen\u00e7a cardiovascular. Apesar de, atualmente, ser clara a enorme disrup\u00e7\u00e3o que a covid-19 teve nos cuidados prestados aos pacientes cardiovasculares, falta ainda estudar e determinar os impactos que ter\u00e1 a m\u00e9dio e longo prazo.10A International Atomic Energy Agency realizou uma pesquisa mundial avaliando mudan\u00e7as nos volumes diagn\u00f3sticos card\u00edacos decorrentes da covid-19 entre mar\u00e7o e abril de 2020 e comparados com mar\u00e7o de 2019. Foram coletados dados de distanciamento social a partir dos Relat\u00f3rios de Mobilidade da Comunidade da empresa Google e a incid\u00eancia de covid-19 por pa\u00eds a partir de Our World in Data. Os autores analisaram 194 centros que realizam procedimentos diagn\u00f3sticos card\u00edacos em 19 pa\u00edses da Am\u00e9rica Latina e observaram que, em compara\u00e7\u00e3o com o m\u00eas de mar\u00e7o de 2019, os volumes dos procedimentos diagn\u00f3sticos card\u00edacos diminu\u00edram 36% em mar\u00e7o de 2020 e 82% em abril de 2020. As maiores redu\u00e7\u00f5es ocorreram em rela\u00e7\u00e3o aos testes de estresse ecocardiogr\u00e1fico (91%), testes ergom\u00e9tricos de esteira (88%) e escore de c\u00e1lcio por tomografia computadorizada (87%), com pequenas varia\u00e7\u00f5es entre as sub-regi\u00f5es da Am\u00e9rica Latina. As mudan\u00e7as em padr\u00f5es de distanciamento social  estavam mais fortemente associadas com a redu\u00e7\u00e3o do volume do que a incid\u00eancia de covid-19 .15 Nesse estudo, foram analisados os dados de 17 pa\u00edses inclu\u00eddos no projeto \u201cStent Save a Life\u201d. Foi poss\u00edvel observar que, nos 2 primeiros meses da pandemia, houve uma redu\u00e7\u00e3o global de 27,5% nas admiss\u00f5es hospitalares por infarto do mioc\u00e1rdio e uma redu\u00e7\u00e3o de 20% das admiss\u00f5es por infarto do mioc\u00e1rdio com supradesnivelamento do segmento ST. \u00c9 interessante ressaltar que essa redu\u00e7\u00e3o foi observada em todos os pa\u00edses, exceto no Egito e na R\u00fassia, porque foram pa\u00edses em que a pandemia teve um atingimento mais tardio.Em outro artigo multic\u00eantrico publicado na Revista Portuguesa de Cardiologia, os autores pretenderam avaliar o impacto da covid-19 na admiss\u00e3o de pacientes com infarto do mioc\u00e1rdio.27 avaliaram retrospectivamente o impacto da covid-19 em dois centros portugueses, tendo demonstrado uma redu\u00e7\u00e3o de 26% do n\u00famero de infarto com supradenivelamento do segmento ST. Observou-se tend\u00eancia para um aumento dos tempos de atraso do sistema e aumento do n\u00famero de complica\u00e7\u00f5es mec\u00e2nicas, com consequente aumento da mortalidade dos pacientes . Esses dados s\u00e3o muito significativos e devem suscitar uma reflex\u00e3o sobre os efeitos indiretos da pandemia por covid-19,28 mas tamb\u00e9m devem obrigar a preparar melhor a organiza\u00e7\u00e3o dos sistemas de sa\u00fade para eventuais novas pandemias. Esses resultados s\u00e3o semelhantes aos de outro estudo publicado em 2022,29 que tamb\u00e9m avaliou o impacto da covid-19 em um dos maiores hospitais do Norte de Portugal. Observou-se uma redu\u00e7\u00e3o global das admiss\u00f5es hospitalares por infarto do mioc\u00e1rdio e geralmente casos mais graves com maior disfun\u00e7\u00e3o ventricular esquerda \u00e0 data da alta (55% versus 39%).Esses resultados s\u00e3o semelhantes aos observados em dois outros estudos que analisaram em maior detalhe a realidade portuguesa. No primeiro estudo, Oliveira et al.16 os autores analisaram o impacto de um programa de reabilita\u00e7\u00e3o card\u00edaca a dist\u00e2ncia  desenvolvido durante a pandemia de covid-19, que inclui consultas a dist\u00e2ncia, sess\u00f5es de grupo de exerc\u00edcio e educa\u00e7\u00e3o em sa\u00fade e psicol\u00f3gica. Foram inclu\u00eddas nesse programa 95 pessoas com doen\u00e7a cardiovascular, tendo sido demonstrado que esse programa de reabilita\u00e7\u00e3o card\u00edaca a dist\u00e2ncia aumentava o tempo de atividade f\u00edsica dos pacientes e diminu\u00eda os n\u00edveis de sedentarismo. Foi demonstrado que a utiliza\u00e7\u00e3o desses programas de reabilita\u00e7\u00e3o card\u00edaca a dist\u00e2ncia foi segura e podem ser utilizados em pacientes selecionados, embora a popula\u00e7\u00e3o escolhida nesse estudo tenha sido selecionada por todos j\u00e1 terem tido contato pr\u00e9vio com programas presenciais de reabilita\u00e7\u00e3o card\u00edaca. Em termos de implica\u00e7\u00f5es cl\u00ednicas, esse estudo abre a oportunidade para a implementa\u00e7\u00e3o de programas de reabilita\u00e7\u00e3o card\u00edaca a dist\u00e2ncia que possam ser usados como complemento dos programas tradicionais ou que possam ser usados em pessoas provenientes de zonas rurais, longe dos grandes centros hospitalares.Contudo, a pandemia por covid-19 n\u00e3o trouxe apenas aspectos negativos; obrigou tamb\u00e9m a uma adapta\u00e7\u00e3o dos profissionais e dos sistemas de sa\u00fade para melhorar a assist\u00eancia aos pacientes no \u00e2mbito da telemedicina. Em um artigo publicado por Pinto et al.,30 nos primeiros momentos da pandemia essa terap\u00eautica foi considerada uma alternativa de tratamento. Al\u00e9m da efic\u00e1cia, alguns estudos sugeriram que o tratamento com hidroxicloroquina podia ter efeitos laterais significativos sobre o sistema cardiovascular. Em um estudo publicado em 2022, Hormigo et al.23 avaliaram o risco de cardiotoxicidade associado \u00e0 hidroxicloroquina em uma popula\u00e7\u00e3o de pacientes pedi\u00e1tricos infectados com covid-19, atrav\u00e9s da monitoriza\u00e7\u00e3o de v\u00e1rios par\u00e2metros do eletrocardiograma (ECG), nomeadamente o intervalo QTc. Nesse estudo, dois dos 14 pacientes precisaram interromper temporariamente o tratamento com hidroxicloroquina devido a um prolongamento do intervalo QTc (> 500 ms), mas todos os pacientes conseguiram completar o tratamento. Esse estudo mostrou, assim, a necessidade de monitorar o risco de cardiotoxicidade da hidroxicloroquina na popula\u00e7\u00e3o pedi\u00e1trica.Na fase inicial da pandemia de covid-19, existiu muita diverg\u00eancia sobre o tratamento recomendado a esses pacientes. Apesar de atualmente sabermos que o tratamento com hidroxicloroquina \u00e9 ineficaz em pessoas infectadas por SARS-CoV-2,14 fizeram a an\u00e1lise de bi\u00f3psias do mioc\u00e1rdio obtidas de 56 pacientes submetidos a cirurgia de substitui\u00e7\u00e3o valvular a\u00f3rtica por estenose a\u00f3rtica grave. Em concreto, os autores utilizaram essas bi\u00f3psias para quantificar a fra\u00e7\u00e3o de volume de col\u00e1geno do mioc\u00e1rdio por histopatologia, com o objetivo de avaliar se a quantidade de fibrose intersticial se associava a pior progn\u00f3stico. Os autores demonstraram que a fra\u00e7\u00e3o de volume de col\u00e1geno  era um preditor independente de eventos cardiovasculares e de mortalidade em pacientes com estenose a\u00f3rtica. Esses resultados podem ter implica\u00e7\u00f5es significativas na abordagem e no tratamento dos pacientes com estenose a\u00f3rtica grave. Por um lado, esses dados demonstram que a presen\u00e7a de uma quantidade significativa de fibrose intersticial se associa a pior progn\u00f3stico, o que levanta a hip\u00f3tese da necessidade de se incorporarem formas n\u00e3o invasivas de avalia\u00e7\u00e3o da fibrose do mioc\u00e1rdio  na estratifica\u00e7\u00e3o de risco dos pacientes com estenose a\u00f3rtica moderada ou grave. Al\u00e9m disso, esses resultados sugerem a necessidade de se desenvolverem novos f\u00e1rmacos que possam impedir ou atrasar a fibrose mioc\u00e1rdica e, assim, melhorar o progn\u00f3stico da estenose a\u00f3rtica (e outras doen\u00e7as).Em outro artigo, que mostra a import\u00e2ncia da medicina translacional, Gavina et al.19 os autores pretenderam analisar a epidemiologia da EI ao longo de um per\u00edodo de 16 anos, de janeiro de 1998 a dezembro de 2013. Nesse estudo, observou-se que, ao longo do tempo, houve uma altera\u00e7\u00e3o do perfil de pacientes internados com EI, tendo ocorrido aumento da porcentagem de idosos, maior frequ\u00eancia de doen\u00e7a cardiovascular concomitante e aumento da propor\u00e7\u00e3o de pacientes com pr\u00f3tese valvular ou endocardite associada a dispositivos . Em rela\u00e7\u00e3o aos microrganismos identificados, o Staphylococcus aureus continuou a ser o agente mais frequente, mas, ao longo dos anos, observou-se um aumento das infec\u00e7\u00f5es por Enterococcus . Nesse estudo, a mortalidade por EI permaneceu muito elevada, com mortalidade intra-hospitalar de 14,5%, mortalidade ao fim de 1 ano de 38% e mortalidade ao fim de 5 anos de 47%, tal como reportado em outras s\u00e9ries hospitalares.32 O estudo da EI \u00e9 uma \u00e1rea que necessita de mais investiga\u00e7\u00e3o. Contudo, atendendo \u00e0 complexidade crescente desses pacientes, \u00e9 importante discutir tamb\u00e9m uma melhor organiza\u00e7\u00e3o dos cuidados de sa\u00fade dos pacientes com EI, que deve passar pela constitui\u00e7\u00e3o de centros multidisciplinares de excel\u00eancia/refer\u00eancia para o tratamento desses pacientes.33Apesar dos avan\u00e7os no diagn\u00f3stico e tratamento da endocardite infecciosa (EI), essa doen\u00e7a permanece associada a elevada morbimortalidade. Nos \u00faltimos anos, alguns estudos t\u00eam mostrado uma altera\u00e7\u00e3o da epidemiologia da EI, sobretudo em pa\u00edses desenvolvidos. Em um estudo unic\u00eantrico, publicado por Apolin\u00e1rio et al.,21 Os autores relataram a experi\u00eancia na utiliza\u00e7\u00e3o de oxigena\u00e7\u00e3o por membrana extracorp\u00f3rea  em pacientes com mediana de idade de 18 meses, de assist\u00eancia ventricular paracorporal puls\u00e1til em pacientes com mediana de idade de 23 meses e de assist\u00eancia ventricular paracorporal de fluxo cont\u00ednuo (AVPFC) em crian\u00e7as com mediana de idades de 13 anos. As complica\u00e7\u00f5es hemorr\u00e1gicas e tromboemb\u00f3licas foram as mais frequentes, estando sobretudo relacionadas com a gravidade da doen\u00e7a de base da crian\u00e7a, com o seu peso e com o tipo de dispositivo utilizado. Esse estudo, sendo descritivo, \u00e9 relevante por mostrar as enormes dificuldades na abordagem desses pacientes, mas tamb\u00e9m por mostrar a tenacidade e determina\u00e7\u00e3o das equipes cl\u00ednicas na tentativa de melhorar o progn\u00f3stico dessas crian\u00e7as.A utiliza\u00e7\u00e3o de dispositivos de assist\u00eancia ventricular tem tido uma grande evolu\u00e7\u00e3o nos \u00faltimos anos, mas permanece um grande desafio \u2013 sobretudo a sua utiliza\u00e7\u00e3o em idade pedi\u00e1trica. Em um artigo publicado em 2022, Abreu et al. reportaram a experi\u00eancia cl\u00ednica de um hospital central no tratamento de 22 casos com dispositivos de assist\u00eancia ventricular ao longo de v\u00e1rios anos.34 Alguns estudos t\u00eam sugerido que \u00e9 poss\u00edvel que o ensino das medidas de SBV possa ser feito por professores, e n\u00e3o apenas por profissionais de sa\u00fade. Em um estudo com desenho quase experimental publicado na Revista Portuguesa de Cardiologia, os investigadores compararam os resultados e os custos do ensino das medidas de SBV realizado por professores  e por profissionais de sa\u00fade (controle) em 362 alunos dos anos 10\u00ba a 12\u00ba de escolaridade.22 Primeiro, nesse estudo observou-se que os resultados foram semelhantes em termos de efic\u00e1cia da forma\u00e7\u00e3o na avalia\u00e7\u00e3o realizada 2,5 meses ap\u00f3s o evento formativo. Contudo, a forma\u00e7\u00e3o administrada por professores estava associada a custos significativamente inferiores . Esse estudo \u00e9 relevante do ponto de vista da sociedade, mostrando que a forma\u00e7\u00e3o generalizada nas escolas das medidas de SBV pode ser efetiva quando realizada pelos professores estando associada a um custo significativamente menor, o que pode representar um passo fundamental na dissemina\u00e7\u00e3o do ensino do SBV na sociedade.V\u00e1rios estudos t\u00eam mostrado a import\u00e2ncia fundamental de ensinar \u00e0s crian\u00e7as as medidas de suporte b\u00e1sico de vida (SBV), com objetivo de melhorar os resultados das v\u00edtimas de paradas cardiorrespirat\u00f3rias.20 mostraram os resultados de um dos primeiros passos necess\u00e1rios para a utiliza\u00e7\u00e3o da intelig\u00eancia artificial nessa \u00e1rea: a segmenta\u00e7\u00e3o autom\u00e1tica das art\u00e9rias coron\u00e1rias. Utilizando os dados de 1.664 imagens, os autores mostraram que \u00e9 poss\u00edvel o desenvolvimento de modelos de intelig\u00eancia artificial para essa tarefa com uma boa performance de avalia\u00e7\u00e3o ap\u00f3s valida\u00e7\u00e3o por cardiologistas de interven\u00e7\u00e3o.A intelig\u00eancia artificial est\u00e1 revolucionando a pr\u00e1tica da medicina, sobretudo na an\u00e1lise de dados de sa\u00fade, no suporte \u00e0 decis\u00e3o cl\u00ednica e na educa\u00e7\u00e3o m\u00e9dica. Uma das \u00e1reas da medicina cardiovascular que tem tido maior desenvolvimento da intelig\u00eancia artificial \u00e9 a an\u00e1lise da imagem m\u00e9dica, nomeadamente da resson\u00e2ncia card\u00edaca, da tomografia computadorizada card\u00edaca e da ecocardiografia. Apesar de a utiliza\u00e7\u00e3o de intelig\u00eancia artificial na cardiologia de interven\u00e7\u00e3o estar menos desenvolvida, o potencial \u00e9 enorme, permitindo, por exemplo, a identifica\u00e7\u00e3o anat\u00f4mica autom\u00e1tica das estruturas, a avalia\u00e7\u00e3o autom\u00e1tica do grau de estenose das art\u00e9rias coron\u00e1rias, a melhor identifica\u00e7\u00e3o das les\u00f5es e eventualmente a avalia\u00e7\u00e3o funcional das les\u00f5es. Em um estudo publicado em 2022, Menezes et al.35 A estimula\u00e7\u00e3o do ramo esquerdo (RE) do sistema His-Purkinje pode evitar desfechos indesejados da estimula\u00e7\u00e3o ventricular direita. Forno et al.11 avaliaram retrospectivamente os desfechos intraoperat\u00f3rios, eletrocardiogr\u00e1ficos e os dados cl\u00ednicos do seguimento inicial de 50 pacientes submetidos \u00e0 estimula\u00e7\u00e3o do RE com sucesso no procedimente (n = 52), sendo a maioria do sexo masculino  e com mediana de idade de 73,5 anos . Os autores conclu\u00edram que a estimula\u00e7\u00e3o do RE do sistema His-Purkinje \u00e9 uma t\u00e9cnica segura e exequ\u00edvel, com alta taxa de sucesso, realizada com tempo de procedimento e fluoroscopia baixos, tempo de ativa\u00e7\u00e3o ventricular esquerdo curto e medidas eletr\u00f4nicas adequadas.A estimula\u00e7\u00e3o ventricular direita \u00e9 a modalidade de estimula\u00e7\u00e3o mais utilizada em todo o mundo para corre\u00e7\u00e3o de dist\u00farbios da condu\u00e7\u00e3o atrioventricular. Entretanto, esse tipo de estimula\u00e7\u00e3o aumenta o risco de fibrila\u00e7\u00e3o atrial, pode piorar a classe funcional de insufici\u00eancia card\u00edaca e pode aumentar a necessidade de hospitaliza\u00e7\u00e3o por insufici\u00eancia card\u00edaca em at\u00e9 20% dos pacientes em 4 anos, especialmente quando a estimula\u00e7\u00e3o ventricular se faz necess\u00e1ria > 40% do tempo e em pacientes com disfun\u00e7\u00e3o ventricular pr\u00e9via ao implante.12 empregando dados do estudo RECOPA, analisaram os dados de 156 les\u00f5es de 141 pacientes e relacionaram os preditores de discord\u00e2ncia em rela\u00e7\u00e3o \u00e0 FFR na \u201czona cinzenta\u201d da RFR , construindo posteriormente um \u00edndice (\u201cRFR ajustada\u201d) que pondera a RFR juntamente com os preditores de discord\u00e2ncia. Na sequ\u00eancia, os autores avaliaram a concord\u00e2ncia desse \u00edndice com a FFR. Eles observaram que os preditores de discord\u00e2ncia foram doen\u00e7a renal cr\u00f4nica, cardiopatia isqu\u00eamica pr\u00e9via, les\u00f5es n\u00e3o envolvendo a art\u00e9ria descendente anterior esquerda e s\u00edndrome coronariana aguda. Reportaram tamb\u00e9m que a \u201cRFR ajustada\u201d melhorou a capacidade diagn\u00f3stica em compara\u00e7\u00e3o com a RFR na \u201czona cinzenta\u201d (\u00e1rea sob a curva (AUC)-RFR = 0,651 versus AUC-\u201cRFR ajustada\u201d = 0,749), com melhora em todos os \u00edndices diagn\u00f3sticos quando foram estabelecidos limiares de corte otimizados . Os autores conclu\u00edram que a constru\u00e7\u00e3o de um \u00edndice cl\u00ednico-fisiol\u00f3gico modificado (\u201cRFR ajustada\u201d) incluindo informa\u00e7\u00f5es sobre a RFR e preditores de discord\u00e2ncia melhorou a capacidade diagn\u00f3stica na \u201czona cinzenta\u201d, sendo \u00fatil para melhorar a acur\u00e1cia da RFR e de outros \u00edndices da fisiologia coron\u00e1ria.Os \u00edndices da fisiologia coron\u00e1ria s\u00e3o uma ferramenta essencial na tomada de decis\u00e3o relacionada a pacientes com doen\u00e7a isqu\u00eamica do cora\u00e7\u00e3o. Por\u00e9m, foram documentados pontos de cortes diferentes para a rela\u00e7\u00e3o do ciclo completo de repouso (RFR) que podem ser influenciados pela popula\u00e7\u00e3o e preditores de discord\u00e2ncia entre a RFR e a reserva de fluxo fracionado (FFR), dificultando o uso em larga escala dessas t\u00e9cnicas, especialmente na chamda \u201czona cinzenta\u201d. Fern\u00e1ndez-Rodr\u00edguez et al.,36 Soares et al.13 estudaram ratos Wistar machos  para investigar se o treinamento f\u00edsico resistido (TFR) de intensidade baixa a moderada  seria ben\u00e9fico para fun\u00e7\u00f5es contr\u00e1teis do VE e de cardiomi\u00f3citos em ratos durante o desenvolvimento de HAP induzida por monocrotalina (MCT). Para testar os efeitos do TFR, os ratos foram divididos entre grupos-controle sedent\u00e1rios , hipertens\u00e3o com sedentarismo  e hipertens\u00e3o com treinamento . Os autores observaram que o TFR melhorou a toler\u00e2ncia ao esfor\u00e7o f\u00edsico (cerca de 55%) e atenuou as disfun\u00e7\u00f5es de contratilidade de VE e de cardiomi\u00f3citos promovidas pela MCT, preservando a fra\u00e7\u00e3o de eje\u00e7\u00e3o e o encurtamento fracional, a amplitude do encurtamento e as velocidades de contra\u00e7\u00e3o e relaxamento nos cardiomi\u00f3citos. O TFR tamb\u00e9m preveniu os aumentos de fibrose e col\u00e1geno tipo I no VE causados pela MCT, al\u00e9m de manter as dimens\u00f5es de mi\u00f3citos e col\u00e1geno tipo III reduzidas por MCT. Os autores sugerem que o treinamento resistido de intensidade baixa a moderada seja testado em pacientes com HAP, embora um longo caminho tenha que ser percorrido at\u00e9 que possamos desenhar um estudo dessa natureza em pacientes com alto grau de complexidade cl\u00ednica.Aumentos na resist\u00eancia da vasculatura pulmonar, causados principalmente pela disfun\u00e7\u00e3o endotelial, levam \u00e0 hipertens\u00e3o arterial pulmonar (HAP). A resist\u00eancia da vasculatura pulmonar sobrecarrega o ventr\u00edculo direito, resultando em remodela\u00e7\u00e3o patol\u00f3gica e disfun\u00e7\u00e3o devido a hipertrofia e dilata\u00e7\u00e3o. Essa remodela\u00e7\u00e3o afeta a din\u00e2mica do ventr\u00edculo esquerdo (VE) por causa da intera\u00e7\u00e3o ventricular direta, especialmente pelo achatamento do septo interventricular.\u00c9 uma honra renovada este ano para os autores deste artigo poder escrever sobre as melhores publica\u00e7\u00f5es cient\u00edficas no ano de 2022 no Arquivos Brasileiros de Cardiologia e na Revista Portuguesa de Cardiologia.Novamente, trazemos os achados mais relevantes e seu contexto dentro do cen\u00e1rio da pesquisa em doen\u00e7as cardiovasculares. Os artigos de 2022 selecionados tiveram tanto tem\u00e1ticas tradicionais como tamb\u00e9m inova\u00e7\u00e3o e tecnologias avan\u00e7adas. Nas tem\u00e1ticas tradicionais, estiveram presentes estudos investigando e avaliando fatores de risco cardiovascular, promo\u00e7\u00e3o de sa\u00fade cardiovascular, covid-19 e doen\u00e7a cardiovascular, doen\u00e7a card\u00edaca isqu\u00eamica, doen\u00e7a valvar, insufici\u00eancia card\u00edaca, EI e hipertens\u00e3o pulmonar. Nas tem\u00e1ticas envolvendo tecnologias avan\u00e7adas, relatamos o uso da intelig\u00eancia artificial para a segmenta\u00e7\u00e3o de art\u00e9rias coron\u00e1rias, novas abordagens de estimula\u00e7\u00e3o el\u00e9trica card\u00edaca e novos \u00edndices para a avalia\u00e7\u00e3o da fisiologia do fluxo coron\u00e1rio, al\u00e9m de potenciais usos de t\u00e9cnicas avan\u00e7adas para avalia\u00e7\u00e3o de fibrose mioc\u00e1rdica baseada em dados de estudo translacional na estenose a\u00f3rtica.Em 2022, a qualidade cient\u00edfica das publica\u00e7\u00f5es nos peri\u00f3dicos cient\u00edficos mais importantes da Cardiologia em l\u00edngua portuguesa foi elevad\u00edssima e tornou ainda mais desafiador o trabalho dos autores desta sele\u00e7\u00e3o dos 10 melhores artigos. Todos os autores que publicaram em nossas revistas merecem nossos cumprimentos e rever\u00eancia pela excel\u00eancia da ci\u00eancia produzida e pela iniciativa de prestigiar nossas revistas do Brasil e Portugal como ve\u00edculos para divulga\u00e7\u00e3o dos seus dados originais e inovadores. Contamos com as comunidades cient\u00edficas portuguesa e brasileira para continuar prestigiando nossos peri\u00f3dicos cient\u00edficos de maior relev\u00e2ncia em Cardiologia em 2023. J\u00e1 antevemos que a pesquisa e o desenvolvimento cient\u00edfico e tecnol\u00f3gico em Cardiologia ir\u00e3o se manter intensos e inovadores no Brasil e em Portugal em 2023. 2 the Revista Portuguesa de Cardiologia and Arquivos Brasileiros de Cardiologia are publishing a special article this year with the 10 best original articles published in each journal  conducted in these Portuguese-speaking countries.3 Thus, it is important to share successful experiments from these countries, where the respective journals originate.This joint effort to share the best cardiology research in Portuguese-speaking countries is of great importance, especially due to the significant reduction between 1990 and 2019 in age-standardized cardiovascular mortality rates attributable to risk factors, especially in Brazil and Portugal, which have better socioeconomic indices than other Portuguese-speaking countries.3 However, the leading cause of CVD mortality remained high systolic blood pressure (SBP) in all Portuguese-speaking countries between 1990 and 2019, with greater reductions in Portugal and Brazil.The importance of dietary and metabolic risk factors increased in parallel with reduced smoking rates in Portuguese-speaking countries and the negative correlation between cardiovascular disease (CVD) mortality attributable to risk factors and the sociodemographic index.4 Joint actions, such as developing arterial hypertension treatment guidelines for primary care in Portuguese-speaking countries, especially regarding primary prevention measures, could reduce hypertensive disease outcomes, particularly stroke and acute myocardial infarction (AMI), which are the main causes of mortality in these countries.24A 2008-2010 cross-sectional study used baseline data from 14,357 participants of the ELSA-Brasil study with no history of CVD to determine the association between blood pressure variability, measured in a single visit, and cardiovascular risk. Blood pressure variability was quantified using a coefficient of variation of 3 standardized SBP measurements with an oscillometer. Anthropometric measurements and laboratory tests were also performed. Cardiovascular risk was determined with the atherosclerotic cardiovascular disease risk estimator, using multivariate logistic regression analysis and a significance level of 5%. In both sexes, significantly higher cardiovascular risk was associated with elevated blood pressure variability. Significantly higher risk was observed in men than in women across all quartiles, with the greatest difference being in the fourth quartile.3 Higher consumption of ultra-processed foods was associated with increased risk of CVD incidence and mortality, suggesting that these foods should be drastically reduced or avoided altogether.25 Energy drinks are an ultra-processed food widely consumed to improve aerobic performance, although little is known of their acute effects on cardiovascular physiology. Porto et al.5 evaluated the acute effects of a 45-kcal energy drink  on heart rate variability and cardiovascular recovery after moderate aerobic exercise. The randomized, double-blind, crossover, placebo-controlled study was conducted with a sample of 28 young adults divided into 2 groups according to peak oxygen consumption (VO2): (1) high peak VO2(peak VO2> 52.15 mL/kg/min) and (2) low peak VO2(peak VO2< 52.15 mL/kg/min). Acute energy drink ingestion had no effect on diastolic or SBP, arterial oxygen saturation by pulse oximetry, or respiratory rate, but it delayed heart rate recovery after exercise in participants with low or high cardiorespiratory capacity. The authors advised individuals with cardiovascular or metabolic diseases to avoid energy drinks prior to exercise.In addition to increased SBP, dietary and metabolic risk factors explained the greater variation in CVD burden, which was correlated with the sociodemographic index in Portuguese-speaking countries.3 Elevated low-density lipoprotein cholesterol occurs in familial hypercholesterolemia (FH), an autosomal dominant disease associated with early atherosclerotic CVD. HipercolBrasil is a cascade screening program for FH that has already identified more than 2000 individuals with genetic variants that cause FH through cascade screening of referred index cases, in addition to individuals with hypercholesterolemia and clinical suspicion of FH. A study that performed cascade screening in 11 small Brazilian municipalities suspected of a high prevalence of individuals with FH  found 105 index cases and 409 first-degree relatives, averaging 4.67 relatives per index case. The authors suggested that specific geographic regions suspected of having a high prevalence of FH warrant a cascade approach to identify clusters of individuals with FH.6Diet, elevated fasting blood glucose, elevated low-density lipoprotein cholesterol, and air pollution were among the top five risk factors for CVD in most Portuguese-speaking countries in both 1990 and 2019, including a trend towards an inverse correlation between the sociodemographic index and the percentage of change. Dietary risk, elevated low-density lipoprotein cholesterol, and high SBP, all statistically significant factors, should be tracked.3 It should be pointed out that more than 1 billion people in the world are obese . The World Health Organization estimates that by 2025 the health of approximately 167 million people, both adults and children, will deteriorate due to overweight or obesity.26 Kravchychyn et al.7 investigated the hypothesis that interdisciplinary clinical weight loss therapy could reduce the prevalence of metabolic syndrome and cardiometabolic risks in obese adolescents and that such improvement would be associated with changes in atrial natriuretic peptide levels. A sample of 73 obese adolescents underwent a 20-week interdisciplinary weight loss program, including exercise, clinical, nutritional, and psychological approaches. Body composition, biochemical analyses and blood pressure were also measured. After the program, volunteers were classified according to increased (n = 31) or reduced plasma levels of atrial natriuretic peptide (n = 19). Significant reductions in body fat, the triglyceride/high-density lipoprotein cholesterol ratio, and metabolic syndrome (from 23% to 6%) only occurred in the group with increased ANP, although both groups had significantly higher fat-free mass and significantly lower body weight, BMI, and waist, neck, and hip circumference.Obesity, characterized as a high body mass index (BMI), was the sixth most important risk factor in most Portuguese-speaking countries in both 1990 and 2019.17 Data from 1650 patients were evaluated, of whom approximately 21% had elevated BNP values. As expected, those with higher BNP values were older, had more comorbidities, a lower ejection fraction, and more severe CVD. It was also observed that, even after using propensity matching score techniques, a high BNP value (> 400 pg/mL) was an important prognostic marker for both in-hospital and 1-year mortality. This study suggested that BNP measurement is a simple and accessible tool for additional risk stratification in cases of ST-segment elevation ACS.The search for new prognostic markers in people with acute coronary syndrome (ACS) continues. A study by the National ACS Registry of the Portuguese Society of Cardiology, in which dozens of Portuguese centers participated, the authors investigated the prognostic impact of brain natriuretic peptide (BNP) level during hospitalization for ACS with ST-segment elevation.Revista Portuguesa de Cardiologia , Cai et al.18 analyzed proteomic expression in intracoronary thrombi extracted by aspiration from patients with ST-segment elevation ACS (n = 30). This report is relevant because previous studies in a number of diseases have shown that proteomic analysis can help identify new biomarkers and new therapeutic targets. In this study, serum/glucocorticoid-induced kinase 1 protein expression was significantly higher in thrombus patients than the control group . Serum/glucocorticoid-induced kinase 1 is an effector of the phosphatidylinositol-3\u2019-kinase signaling pathway and may be a new therapeutic target for atherothrombotic event prevention, although further studies are needed to confirm this hypothesis.Thrombosis plays an essential role in the pathophysiology of ACS, and it is important to continue exploring the pathophysiological mechanisms and pathways involved in triggering intracoronary thrombosis. In a study published in the 8 analyzed the impact of pre-hospital care on general and in-hospital AMI mortality rates and the AMI hospitalization rate in 853 municipalities in Minas Gerais between 2008 to 2016, using hierarchical Poisson regression modeling. Implementation of a Mobile Emergency Care Service was associated with decreases in overall AMI mortality  and in-hospital AMI mortality , but it was not significantly associated with hospitalization . The authors concluded that these findings reinforce the fundamental role of prehospital care in AMI treatment and that further investment is needed in such services to improve clinical outcomes in low- and middle-income countries.Effective AMI treatment is directly linked to the time that elapses between the event and medical assistance, with approximately half of AMI deaths occurring outside the hospital environment, which highlights the importance of pre-hospital care and the development of evidence-based AMI care systems. Vieira et al.9During the clinical and electrocardiographic diagnostic process for AMI, differences may arise in how symptoms are treated, especially in specific subgroups, such as women and older adults. A study of 2290 patients found that women had a high prevalence of atypical symptoms, a longer time between the symptom onset and treatment seeking, and delay between arrival at the emergency department and fibrinolysis. In-hospital mortality was 5.6%. Hospital mortality rates were higher among women, older adults, and individuals with diabetes mellitus, obesity, chronic kidney disease, or previous strokes. The sex disparity persists for female patients, including delayed recognition of ischemia symptoms and prompt initiation of fibrinolytic therapy, resulting in worse clinical outcomes. The authors pointed out that Killip-Kimball scores, measured during the first medical consultation, accurately predict fatal events, regardless of the clinical presentation of the acute ischemic event, especially in pharmaco-invasive strategies.The SARS-CoV-2 pandemic has had a huge impact on health systems around the world, particularly CVD care. Several 2022 articles showed the impact of COVID-19 on CVD. Although COVID-19\u2019s enormous disruption to CVD care is quite evident, its medium- and long-term impact remains to be seen.10The International Atomic Energy Agency conducted a worldwide survey on changes in cardiac diagnostic volumes due to COVID-19 between March 2019 and March/April 2020. Social distancing data were collected from Google Community Mobility Reports, while COVID-19 incidence data for each country were collected from Our World in Data. The authors analyzed 194 centers that perform cardiac diagnostic procedures in 19 countries in Latin America, finding that, compared to March 2019, the volumes of cardiac diagnostic procedures decreased by 36% in March 2020 and 82% in April 2020. The largest reductions occurred in echocardiographic stress tests (91%), treadmill exercise tests (88%), and computed tomography calcium scores (87%), with small variations between Latin American subregions. Changes in social distancing patterns (p < 0.001) were more strongly associated with these reductions than COVID-19 infection rates (p = 0.003).Portuguese Journal of Cardiology assessed the impact of COVID-19 on the admission of myocardial infarction patients.15 In this study, data from 17 countries participating in the \u201cStent Save a Life\u201d project were analyzed. In the first 2 months of the pandemic, there was a 27.5% overall reduction in hospital admissions for AMI and a 20% reduction in admissions for ST-segment elevation AMI. It is interesting to note that this reduction was observed in all countries except Egypt and Russia, where the pandemic\u2019s impact came later.Another multicenter article published in the 27 retrospectively evaluated the impact of COVID-19 on two Portuguese centers, finding a 26% reduction in ST-segment elevation AMI cases. There was a trend towards greater system delay times and more mechanical complications, with a consequent increase in patient mortality (1.9% vs 12.1%). These data are very significant and should prompt reflection on the indirect effects of the COVID-19 pandemic,28 but they should also oblige health systems to be better prepared for new pandemics. These results are similar to those of another 2022 study29 on the impact of COVID-19 on one of the largest hospitals in northern Portugal. There was an overall reduction in hospital admissions due to AMI and an increase in more cases with greater left ventricular dysfunction at the time of discharge (55% vs 39%).These results are similar to 2 other studies that analyzed the Portuguese situation in greater detail. In the first study, Oliveira et al.16 analyzed the impact of a distance cardiac rehabilitation program developed during the pandemic that included remote consultations, group exercise sessions, and health and psychological education. A total of 95 CVD patients were included in this program, which resulted in increased physical activity time and reduced levels of sedentary lifestyle. The authors concluded that distance cardiac rehabilitation programs are safe and can be used in selected patients, although their population had previously participated in face-to-face cardiac rehabilitation programs. In terms of clinical implications, this study shows the feasibility of distance cardiac rehabilitation programs as a complement to traditional programs and for use in rural areas, far from hospital centers.However, apart from its negative effects, the COVID-19 pandemic has also forced health systems to improve patient care through telemedicine. Pinto et al.30 at the beginning of the pandemic it was considered an alternative treatment. In addition to efficacy issues, some studies have suggested that hydroxychloroquine treatment could have significant side effects on the cardiovascular system. In a 2022 study, Hormigo et al.23 evaluated the risk of cardiotoxicity associated with hydroxychloroquine use in a population of pediatric patients infected with COVID-19, monitoring several electrocardiogram parameters, principally the QTc interval. Hydroxychloroquine treatment was temporarily discontinued 2 of the 14 patients due to QTc prolongation (> 500 ms), but all patients completed the course of treatment. This study thus showed the need to monitor hydroxychloroquine cardiotoxicity risk in pediatric populations.In the initial phase of the pandemic, there was much disagreement about the best treatment for COVID-19 infection. Although we currently know that hydroxychloroquine treatment is ineffective against SARS-CoV-2,14 analyzed myocardial biopsies from 56 patients who underwent aortic valve replacement surgery for severe aortic stenosis. Specifically, the myocardial collagen volume fraction was assessed by histopathology to determine whether the quantity of interstitial fibrosis was associated with a worse prognosis. The collagen volume fraction, especially when > 15.4%, was an independent predictor of cardiovascular events and mortality in patients with aortic stenosis. These results may have significant implications for severe aortic stenosis treatment. On the one hand, these data show that a significant amount of interstitial fibrosis is associated with a worse prognosis, which highlights the need to incorporate non-invasive methods of assessing myocardial fibrosis  to stratify risk in patients with moderate or severe aortic stenosis. On the other hand, these results suggest that new drugs are needed to prevent or delay myocardial fibrosis and thus improve the prognosis of aortic stenosis (and other diseases).In another article on the importance of translational medicine, Gavina et al.19 analyzed the epidemiology of IE over 16 years (January 1998 to December 2013), finding that the profile of hospitalized IE patients changed over time, with a higher percentage of older adults, a higher frequency of concomitant CVD, and a higher percentage of patients with prosthetic valves or device-related endocarditis (18% before 2008 vs. 34.6% after 2008). Staphylococcus aureus continued to be the most frequent agent, but Enterococcus infections increased over the study period. IE mortality remained very high, with in-hospital mortality of 14.5%, 1-year mortality of 38%, and 5-year mortality of 47%; these rates have been corroborated by other hospital series.32 Given the growing complexity of the patient profile, IE requires further investigation. Health care for patients with IE must also be better organized, including the creation of multidisciplinary centers of excellence/reference.33Despite advances in the diagnosis and treatment of infective endocarditis (IE), this disease remains associated with high morbidity and mortality. Recent studies have shown a change in the epidemiology of IE, especially in developed countries. In a single-center study, Apolin\u00e1rio et al.21 including groups that received an extracorporeal membrane oxygenator (median age: 18 months), a pulsatile paracorporeal ventricular assist device (median age: 23 months), and a paracorporeal continuous flow ventricular assist device (median age: 13 years). Hemorrhagic and thromboembolic complications were the most frequent types, mainly related to underlying disease severity, weight, and device type. This descriptive study is relevant in that it shows the enormous treatment difficulties, as well as the tenacity and determination of the clinical teams who are trying to improve the prognosis of these children.The use of ventricular assist devices has evolved greatly in recent years, although their use in pediatric patients remains a major challenge. In 2022, Abreu et al. reported a central hospital\u2019s clinical experience with 22 cases requiring ventricular assist devices over several years,34 Some studies have suggested that BLS measures can be taught by schoolteachers, not just health professionals. In a quasi-experimental design study published in the Revista Portuguesa de Cardiologia , the investigators compared the costs and results of BLS seminars taught by teachers  and health professionals (control) to 362 10th to 12th grade students.22 First, the effectiveness results were similar in an assessment 2.5 months after the training event. However, teacher-led training had a significantly lower cost . This shows that general BLS training can be as effective and with a significantly lower cost when performed by schoolteachers, which could be a fundamental step toward broadly disseminating BLS in society.Several studies have shown the fundamental importance of teaching children and adolescents basic life support (BLS) to improve results for cardiorespiratory arrest victims.20 tested an initial step for artificial intelligence use in this field: automatic segmentation of coronary arteries. Using data from 1664 images, the authors showed that it is possible to develop artificial intelligence models for this task, which received a good performance evaluation after validation by interventional cardiologists.Artificial intelligence is revolutionizing medical practice, particularly health care data analysis, clinical decision support, and medical education. The greatest development of artificial intelligence in cardiovascular medicine has been in medical image analysis, namely cardiac magnetic resonance imaging, cardiac computed tomography, and echocardiography. Although artificial intelligence in interventional cardiology is less developed, the potential is enormous, including automatic identification of anatomical structures, automatic assessment of the degree of coronary artery stenosis, better lesion identification, and even functional lesion assessment. In 2022, Menezes et al.35 Pacing the left bundle branch of the His-Purkinje system can prevent unwanted outcomes from right ventricular pacing. Forno et al.11 retrospectively evaluated intraoperative, electrocardiographic, and clinical data from the initial follow-up of 50 patients who underwent a successful left bundle branch pacing procedure (n = 52): mostly men (69.2%) with a median age of 73.5 years (65.0-80.0). The authors concluded that pacing the left bundle branch of the His-Purkinje system is a safe and feasible technique with a high success rate that involves low procedure and fluoroscopy time, short left ventricular activation time, and adequate electronic measurements.Right ventricular pacing is the most widely used pacing modality to correct atrioventricular conduction disorders. However, it increases the risk of atrial fibrillation, could worsen heart failure functional class, and could increase hospitalization for heart failure in up to 20% of patients over 4 years, especially when ventricular pacing is required > 40% of the time and in patients with ventricular dysfunction prior to implantation.12 using data from the RECOPA study to analyze 156 lesions in 141 patients, related predictors of discordance to fractional flow reserve in the RFR \u201cgrey zone\u201d (0.86 to 0.92), developing an \u201cAdjusted RFR\u201d index that weighs RFR and predictors of discordance. They then evaluated this index\u2019s agreement with fractional flow reserve, finding that the predictors of discordance included chronic kidney disease, previous ischemic heart disease, lesions not involving the left anterior descending artery, and acute coronary syndrome. They also reported that the Adjusted RFR increased diagnostic ability in comparison to the RFR \u201cgrey zone\u201d (area under the curve: RFR = 0.651 vs Adjusted RFR = 0.749), improving all diagnostic indices when optimized cut-off thresholds were established . They concluded that this modified clinical-physiological index improved diagnostic capacity in the \u201cgray zone\u201d, thus improving the accuracy of RFR and other indices of coronary physiology.Coronary physiology indices are an essential tool in decision-making for patients with ischemic heart disease. However, cutoff thresholds for the resting full-cycle ratio (RFR) can vary, perhaps influenced by population characteristics and predictors of discordance between RFR and fractional flow reserve, impeding large-scale use of these techniques, especially in the \u201cgrey zone\u201d. Fern\u00e1ndez-Rodr\u00edguez et al.,36 In male Wistar rats (body weight: ~200 g), Soares et al.13 investigated whether low-to-moderate intensity resistance training  would improve LV contractile and cardiomyocyte contractions during the development of monocrotaline-induced pulmonary hypertension (MCT-PH). To test the effects of resistance training, the rats were divided into the following groups: sedentary controls (n = 7), hypertension + sedentary lifestyle (n = 7) and hypertension + training (n = 7). Resistance training improved physical exertion tolerance (~55%) and attenuated left ventricular and cardiomyocyte contractility dysfunction due to MCT-PH, preserving ejection fraction and fractional shortening, the shortening amplitude, and contraction and relaxation velocities in cardiomyocytes. Resistance training also prevented increases in left ventricular fibrosis and type I collagen due to MCT-PH, in addition to maintaining the myocyte dimensions and type III collagen reduced by MCT-PH. The authors suggested that low-to-moderate intensity resistance training should be tested in patients with pulmonary arterial hypertension, although there is much ground to cover before a study of this nature can be designed in patients with high clinical complexity.Increased resistance in pulmonary vasculature, mainly due to endothelial dysfunction, leads to pulmonary arterial hypertension. Pulmonary vasculature resistance overloads the right ventricle, resulting in pathological remodeling and dysfunction due to hypertrophy and dilation. This remodeling affects left ventricular dynamics due to direct ventricular interaction, particularly by flattening the interventricular septum.Arquivos Brasileiros de Cardiologia and in the Revista Portuguesa de Cardiologia . We have described the most relevant findings and their context in CVD research. The selected articles for 2022 involved traditional themes, as well as innovation and advanced technologies. Traditional themes included cardiovascular risk factors, cardiovascular health promotion, COVID-19 and cardiovascular disease, ischemic heart disease, valve disease, heart failure, IE, and pulmonary hypertension. Advanced technology themes included using artificial intelligence in coronary artery segmentation, new approaches to electric cardiac stimulation, and new indices for assessing coronary flow physiology, in addition to advanced techniques in myocardial fibrosis assessment based on data from a translational study on aortic stenosis.Once again, it is an honor to report the best scientific publications in the The scientific quality of publications in the most important Portuguese-language cardiology journals was extremely high in 2022, making selection of the 10 best articles a great challenge. All authors who published in our journals deserve our respect for their excellent studies and for choosing our journals as vehicles for disseminating their original and innovative content. We are counting on the continued support of the Portuguese and Brazilian scientific communities in 2023. We can already foresee that cardiology research and technological development will remain intense and innovative in Brazil and Portugal in 2023."}
+{"text": "Grande Sert\u00e3o:Veredasp\u00f3s-bolson\u00e1rie. Sua equipe tem pela frente o enormedesafio de enfrentar os efeitos danosos da sinergia pandemencial que se instalou emnossos sert\u00f5es quando menos se esperava, esperando (inspirado em uma conhecida frase deum atilado personagem infantil mexicano).Antes de dar in\u00edcio \u00e0 proposta espec\u00edfica de uma breve apresenta\u00e7\u00e3o da consistente obrade Tamara Rangel Vieira regi\u00e3o agreste,afastada dos n\u00facleos urbanos e das terras cultivadas; A terra e a povoa\u00e7\u00e3o dointerior; o interior do pa\u00eds; Toda regi\u00e3o pouco povoada deste \u2018interior\u2019, emespecial a zona mais seca que a caatinga, ligada ao ciclo do gado e onde permanecemtradi\u00e7\u00f5es e costumes antigos\u201d \u00c9 preciso destacar que aspectos importantes tamb\u00e9m envolvem o termo \u201csert\u00e3o\u201d e arespectiva percep\u00e7\u00e3o de como esse nome tamb\u00e9m \u00e9 fundamental para se tentar explicar eenfrentar neste pa\u00eds as renitentes e graves mazelas sanit\u00e1rias que nos assolam h\u00e1bastante tempo. Se fizermos uma busca r\u00e1pida na internet, obtemos uma defini\u00e7\u00e3o quecoincide com o senso comum no entendimento de seu sentido: \u201cDecerto essa quest\u00e3o vai se complexificar enormemente se estivermos preocupados comrespectivos determinantes sociopol\u00edticos, geogr\u00e1ficos e hist\u00f3ricos que n\u00e3o pertencem aoescopo desta resenha. Mas, ainda assim, n\u00e3o merecem ser desconsiderados . Ou seja, grosso modo, em anos recentes - mas n\u00e3o apenas - permaneceram escassosinvestimentos mais significativos em infraestrutura, recursos humanos, entre outras\u00e1reas, para superar de maneira efetiva as condi\u00e7\u00f5es limitadas de sa\u00fade que continuamexistindo em v\u00e1rias regi\u00f5es brasileiras.Em s\u00edntese, essa briosa obra se aventura na saga dos m\u00e9dicos que atuaram nessa regi\u00e3o,empregando uma denomina\u00e7\u00e3o essencialmente brasileira para designar a paisagem marcantedos chamados sert\u00f5es brasileiros.Segundo uma resenha de Rezende & Silva Dessa maneira, devido \u00e0s limita\u00e7\u00f5es da atividade de subsist\u00eancia, havia um verdadeiroestado cr\u00f4nico de carestia e de crise alimentar, que, de forma constante, se tornavafome declarada e generalizada. A citada autora constatou que os goianos continuaram aingerir ingerindo alimentos com baixo teor nutritivo, cuja alimenta\u00e7\u00e3o era baseada emmilho, mandioca, arroz, feij\u00e3o e carne seca, temperados com baixa quantidade de sal. Noentanto, apesar de tal comida ter saciado a fome de muitos, em longo prazo, contribuiupara a dissemina\u00e7\u00e3o de doen\u00e7as, principalmente no \u00e2mbito nutricional.Deve-se enfatizar que, no processo de institucionaliza\u00e7\u00e3o da medicina em Goi\u00e1s,verificou-se um movimento pela defini\u00e7\u00e3o dos espa\u00e7os ocupados pelos que atuavam aservi\u00e7o da sa\u00fade. Assim, a forma\u00e7\u00e3o acad\u00eamica passou a ser requisito obrigat\u00f3rio para apr\u00e1tica m\u00e9dico-sanit\u00e1ria.A incurs\u00e3o pelos males do sert\u00e3o \u00e9 repleta de eventos que t\u00eam como refer\u00eancia o pr\u00f3priosert\u00e3o, usualmente caracterizado como atrasado, in\u00f3spito, \u00e1rido - pass\u00edvel, inclusive,de ser considerado um n\u00facleo de elementos essenciais para a compreens\u00e3o da pr\u00f3pria na\u00e7\u00e3obrasileira. Essa perspectiva, em si, demonstra cabalmente a relev\u00e2ncia do livro deTamara Vieira para, entre outros aspectos relevantes, tamb\u00e9m enfocar a dimens\u00e3osert\u00e3og\u00eanica deste pa\u00eds."}
+{"text": "Inqu\u00e9ritoTelef\u00f4nico de Fatores de Risco para Doen\u00e7as Cr\u00f4nicas N\u00e3o Transmiss\u00edveis emTempos de Pandemia (Covitel), desenvolvido no Brasil em 2022. OCovitel \u00e9 um inqu\u00e9rito de base populacional, com representatividade para oBrasil e suas cinco macrorregi\u00f5es: Centro-oeste, Nordeste, Norte, Sudeste e Sul.O inqu\u00e9rito apresenta informa\u00e7\u00f5es sobre o impacto dos principais fatores derisco para as doen\u00e7as cr\u00f4nicas n\u00e3o transmiss\u00edveis (DCNT) na popula\u00e7\u00e3o adulta,com 18 anos ou mais, residente em domic\u00edlios servidos por linhas telef\u00f4nicasfixas e m\u00f3veis. O estudo tem por objetivo colaborar para o desenvolvimento eacompanhamento de pol\u00edticas p\u00fablicas voltadas para a promo\u00e7\u00e3o da sa\u00fade para apopula\u00e7\u00e3o, bem como obter resultados que visem contribuir para o conhecimentosobre a influ\u00eancia da COVID-19 nos fatores de risco para as DCNT no pa\u00eds. Foramavaliados 9 mil indiv\u00edduos e coletadas informa\u00e7\u00f5es sobre alimenta\u00e7\u00e3o, atividadef\u00edsica, sa\u00fade mental, estado de sa\u00fade, hipertens\u00e3o arterial, diabetes edepress\u00e3o, al\u00e9m do consumo de \u00e1lcool e tabaco, comparando os momentospr\u00e9-pandemia e o primeiro trimestre de 2022. Al\u00e9m disso, o estudo coletouinforma\u00e7\u00f5es acerca do esquema vacinal da popula\u00e7\u00e3o e da infec\u00e7\u00e3o porCOVID-19.Este artigo descreve a metodologia utilizada na realiza\u00e7\u00e3o do  Tendo em vista o momento pand\u00eamico enfrentado, se feznecess\u00e1ria a realiza\u00e7\u00e3o emergencial de coletas de dados que forne\u00e7am evid\u00eancias nocontexto brasileiro. O Trata-se de um inqu\u00e9rito de representatividade nacional e das cinco macrorregi\u00f5es dopa\u00eds, que apresenta informa\u00e7\u00f5es robustas e atualizadas sobre o impacto dosprincipais fatores de risco para DCNT na popula\u00e7\u00e3o adulta, com 18 anos ou mais.Cientes da import\u00e2ncia desses dados para a vigil\u00e2ncia em sa\u00fade e para o planejamentode pol\u00edticas p\u00fablicas nessa \u00e1rea, temos como objetivo apresentar os aspectosmetodol\u00f3gicos do Covitel.Como plano amostral, adotou-se a estrat\u00e9gia de obten\u00e7\u00e3o de amostrasprobabil\u00edsticas da popula\u00e7\u00e3o brasileira, tendo como dom\u00ednios as macrorregi\u00f5esestabelecidas pela divis\u00e3o do Instituto Brasileiro de Geografia e Estat\u00edstica(IBGE): Norte, Nordeste, Centro-oeste, Sudeste e Sul. O estudo teve comopopula\u00e7\u00e3o-alvo indiv\u00edduos com idade superior ou igual a 18 anos que tivessemlinhas telef\u00f4nicas fixa ou m\u00f3vel.A amostra foi composta por 1.800 indiv\u00edduos de cada regi\u00e3o brasileira (900 paratelefonia fixa e outros 900 para telefonia m\u00f3vel), totalizando 9 mil pessoas.Esse n\u00famero foi escolhido para se obter estimativas de preval\u00eancia confi\u00e1veispara qualquer fator de risco na popula\u00e7\u00e3o estudada, com n\u00edvel de 95% deconfian\u00e7a e margem de erro de cerca de tr\u00eas pontos percentuais para cada granderegi\u00e3o.random digit dialing). Para garantira representatividade de cada uma das cinco regi\u00f5es, foi considerada a propor\u00e7\u00e3odos c\u00f3digos de discagem direta \u00e0 dist\u00e2ncia (DDD) de cada regi\u00e3o. Esseprocedimento era realizado da seguinte forma: (1) em uma planilha de Excel(https://products.office.com/), eram identificados e listados osn\u00fameros de DDD de cada uma das regi\u00f5es; (2) foi gerado aleatoriamente o primeirod\u00edgito do telefone, limitando-se aos n\u00fameros entre 2 e 5 para telefonia fixa e 6a 9 para telefonia m\u00f3vel ; (3) os demais, com algarismos de 0 a 9, eram posteriormente gerados deforma aleat\u00f3ria. As duplicatas foram removidas e os n\u00fameros restantes eramselecionados por sorteio e enviados para valida\u00e7\u00e3o mec\u00e2nica, por meio do uso deuma discadora eletr\u00f4nica. Foram considerados n\u00fameros inv\u00e1lidos os telefonesinexistentes ou empresariais, representando um total de 14,7% das liga\u00e7\u00f5estotais .A sele\u00e7\u00e3o de linhas telef\u00f4nicas ocorreu por meio do m\u00e9todo de discagem aleat\u00f3riade d\u00edgitos  caracter\u00edsticas sociodemogr\u00e1ficas;(2) caracter\u00edsticas sobre frequ\u00eancia de consumo de alimentos e obesidade; (3)atividade f\u00edsica  e tempo detela; (4) frequ\u00eancia de consumo de cigarros e bebidas alco\u00f3licas; (5)informa\u00e7\u00f5es sobre morbidade e autopercep\u00e7\u00e3o do estado de sa\u00fade; e (6)informa\u00e7\u00f5es sobre infec\u00e7\u00e3o por COVID-19 e vacina\u00e7\u00e3o contra a doen\u00e7a.Com o objetivo de comparar diferentes momentos temporais, as quest\u00f5es foramestruturadas de modo a abordar os per\u00edodos atual (\u00faltimos tr\u00eas meses) epr\u00e9-pandemia (tr\u00eas meses anteriores ao in\u00edcio da pandemia). Dessa forma, arespeito das caracter\u00edsticas sobre padr\u00e3o de alimenta\u00e7\u00e3o, os indiv\u00edduos foramquestionados sobre a frequ\u00eancia do consumo de verduras ou legumes, frutas,refrigerantes ou sucos artificiais e bebidas alco\u00f3licas. Quanto \u00e0scaracter\u00edsticas sobre padr\u00e3o de atividade f\u00edsica, eram abordadas quest\u00f5esreferentes \u00e0 pr\u00e1tica de atividade f\u00edsica nos dom\u00ednios de lazer, deslocamento,ocupacional e dom\u00e9stico, al\u00e9m do uso de telas. Por fim, o bloco sobre estado desa\u00fade englobava perguntas sobre percep\u00e7\u00e3o do estado de sa\u00fade (bom ou muito bom)e diagn\u00f3sticos autorreferidos de hipertens\u00e3o, diabetes e depress\u00e3o.http://observatoriodaaps.com.br/covitel/). As informa\u00e7\u00f5esutilizadas para a constru\u00e7\u00e3o de indicadores de interesse est\u00e3o descritas noA partir dessas quest\u00f5es, foram desenvolvidos indicadores de interesse paraelabora\u00e7\u00e3o do relat\u00f3rio final do Covitel. Eles est\u00e3o dispon\u00edveis no endere\u00e7oeletr\u00f4nico citado anteriormente  A amostra foi dividida em estratos, considerando regi\u00e3o geogr\u00e1fica , sexo (masculino e feminino), idade  e escolaridade (0-11 e 12 anos deescolaridade completos ou mais). Para calcular o peso amostral, visandorepresentar a popula\u00e7\u00e3o brasileira e dessas regi\u00f5es, foram obtidos dados doSistema IBGE de Recupera\u00e7\u00e3o Autom\u00e1tica  Idade - o IBGE trabalha com uma categoria de 15 a 19 anos. Para chegar aon\u00famero da popula\u00e7\u00e3o de 18 e 19 anos, foi feita uma estimativa simples de que afaixa de 18-19 anos corresponde a 2/5 da popula\u00e7\u00e3o de 15-19 anos. Visto que n\u00e3oexiste grande varia\u00e7\u00e3o no n\u00famero de nascimentos ano a ano, a aproxima\u00e7\u00e3o pareceser adequada. Em seguida, os grupos do IBGE foram somados de forma a produzir osII) Escolaridade - o IBGE apresenta os dados por etapas de ensino. Todos osgrupos abaixo do Ensino M\u00e9dio foram inseridos na categoria de 0 a 11 anos deestudo; e o restante na categoria de 12 anos ou mais. Existe tamb\u00e9m um grupoindeterminado que foi somado ao grupo de 0-11 anos de estudo.Assim, estimamos a popula\u00e7\u00e3o em 60 estratos, considerando a macrorregi\u00e3ogeogr\u00e1fica (5) X sexo (2) X idade (3) X escolaridade (2). N\u00e3o houve necessidadede serem utilizadas proje\u00e7\u00f5es de popula\u00e7\u00e3o, visto que nos interessava apenas apropor\u00e7\u00e3o do nosso tamanho amostral em rela\u00e7\u00e3o \u00e0 popula\u00e7\u00e3o.Como a amostra do Covitel elenca indiv\u00edduos com base no DDD de registro da linhatelef\u00f4nica, estrat\u00e9gia equivalente a uma amostragem por conglomerados, esseponto deve ser levado em considera\u00e7\u00e3o durante a an\u00e1lise, juntamente com os pesosamostrais. Dessa forma, as estimativas do Covitel devem ser corrigidas paraefeito de conglomerado, al\u00e9m de se usar a pondera\u00e7\u00e3o descrita, de forma aproduzir valores que representem a popula\u00e7\u00e3o das regi\u00f5es e do pa\u00eds.https://cadernos.ensp.fiocruz.br/static//arquivo/suppl-e00248922_8637.pdf).Para mais detalhes sobre tamanho, peso amostral e estimativas de precis\u00e3o, verinforma\u00e7\u00f5es no Material Suplementar , relativa \u00e0 pesquisa com seres humanos, o Covitel foi submetido aoComit\u00ea de \u00c9tica em Pesquisa da Escola Superior de Educa\u00e7\u00e3o F\u00edsica daUniversidade Federal de Pelotas, sendo aprovado sob o n\u00famero 5.125.635.Em acordo com a A coleta de dados foi executada entre os meses de janeiro e mar\u00e7o de 2022, comdivulga\u00e7\u00e3o de resultados preliminares em abril de 2022. Foram realizadas 114.188liga\u00e7\u00f5es totais, sendo 60.371 para linhas fixas e 53.815 para m\u00f3veis. Destas, 16.766chamadas foram ineleg\u00edveis (n\u00fameros n\u00e3o existentes e/ou telefones empresariais),29.865 chamadas de sucesso e 67.557 chamadas sem sucesso . Sendo assim, representando 26,2% de taxade sucesso, entre as 29.864 liga\u00e7\u00f5es v\u00e1lidas, 16.099 aconteceram no telefone fixo e13.765 no celular. Quanto ao n\u00famero de liga\u00e7\u00f5es realizadas nas diferentes regi\u00f5es dopa\u00eds, \u00e9 poss\u00edvel observar que a Regi\u00e3o Nordeste apresentou o menor n\u00famero deliga\u00e7\u00f5es realizadas; e as regi\u00f5es Sul e Sudeste, os maiores. O n\u00famero de liga\u00e7\u00f5espor regi\u00e3o foi demonstrado na Considerando resultados num\u00e9ricos da aplica\u00e7\u00e3o das entrevistas, das liga\u00e7\u00f5esconsideradas sucesso, houve 10.937 recusas em participar da entrevista,representando 36,6% do total. Quando estratificado por tipo de telefone, opercentual de recusa no telefone fixo foi de 34,6%; e no telefone celular, 39%. Otempo m\u00e9dio de dura\u00e7\u00e3o da aplica\u00e7\u00e3o das entrevistas foi de 14 minutos e 53 segundos.\u00c9 importante ressaltar que, tendo em vista a infer\u00eancia para a popula\u00e7\u00e3o maior de 18anos, existiu uma varia\u00e7\u00e3o significativa dos pesos amostrais. Os pesos menores s\u00e3oda ordem de 1.342, chegando a um m\u00e1ximo de 214 mil. Os menores pesos se concentramnas regi\u00f5es menos populosas (Norte e Centro-oeste), enquanto os maiores (fra\u00e7\u00f5esamostrais menores) se concentram no Sudeste e Nordeste, entre os grupos mais jovense de escolaridade mais alta.Este artigo apresenta aspectos metodol\u00f3gicos para a execu\u00e7\u00e3o do Covitel, inqu\u00e9ritotelef\u00f4nico realizado entre janeiro e mar\u00e7o de 2022. Analisando quest\u00f5es referentes \u00e0aplica\u00e7\u00e3o do question\u00e1rio, podem ser apontados aspectos positivos e quest\u00f5es querepresentam desafios para experi\u00eancias futuras. Entre os pontos positivos,destacam-se principalmente aqueles que garantem visibilidade ao Covitel, como o usoda tecnologia de entrada eletr\u00f4nica de dados. Isso evidencia grande relev\u00e2ncia paraseguran\u00e7a e qualidade dos dados produzidos, bem como rapidez na elabora\u00e7\u00e3o do bancode dados. Esse tipo de tecnologia empregada para a realiza\u00e7\u00e3o de inqu\u00e9ritos devigil\u00e2ncia tem sido utilizado em estudos similares Outro ponto importante em rela\u00e7\u00e3o \u00e0 metodologia do Covitel diz respeito ao m\u00e9todoadotado para obten\u00e7\u00e3o da amostra, que considera as complexidades das caracter\u00edsticasdemogr\u00e1ficas da popula\u00e7\u00e3o brasileira. Portanto, o desenho amostral conseguiu comporuma amostra que permite estimar preval\u00eancias de fatores de risco com precis\u00e3orazo\u00e1vel. Diante disso, do ponto de vista operacional, a metodologia utilizada nesteestudo se mostrou positiva para a elabora\u00e7\u00e3o de novas pesquisas em n\u00edvel nacional,al\u00e9m de poder ser implementada como procedimento padr\u00e3o para aplica\u00e7\u00e3o de inqu\u00e9ritostelef\u00f4nicos de base populacional.A inclus\u00e3o de telefones celulares foi o grande avan\u00e7o metodol\u00f3gico do Covitel. Oestudo mostrou que \u00e9 poss\u00edvel incluir esses aparelhos, cada vez mais frequentes nocotidiano da popula\u00e7\u00e3o, em sistemas de monitoramento da sa\u00fade da popula\u00e7\u00e3o,aumentando a representatividade da amostra quando comparada com estudos de basedomiciliar. Outro destaque de sucesso do inqu\u00e9rito realizado por telefone foi terresultados representativos para o Brasil e para as grandes regi\u00f5es. Os resultadosoportunos do inqu\u00e9rito aqui descrito, realizado em um momento de pandemia,constituem importante entrega para o pa\u00eds. Eles apresentaram resultados relevantespara a constru\u00e7\u00e3o de conhecimento sobre a influ\u00eancia da COVID-19 nos fatores derisco para as DCNT no Brasil, por meio da an\u00e1lise da situa\u00e7\u00e3o de sa\u00fade da popula\u00e7\u00e3oem um momento \u00edmpar, que, provavelmente, acarretar\u00e1 muitos desafios para as pessoasnos pr\u00f3ximos anos.A respeito das limita\u00e7\u00f5es do estudo, destacam-se tr\u00eas pontos principais: apossibilidade de introdu\u00e7\u00e3o de um vi\u00e9s de mem\u00f3ria relativo \u00e0 abordagem do per\u00edodorecordat\u00f3rio para o momento pr\u00e9-pandemia; a exist\u00eancia de diferen\u00e7as em rela\u00e7\u00e3o aon\u00famero de linhas telef\u00f4nicas, pois sabe-se que em regi\u00f5es com maior densidadepopulacional, geralmente capitais e regi\u00f5es metropolitanas, a abrang\u00eancia telef\u00f4nica\u00e9 maior e, dessa forma, pode introduzir um vi\u00e9s de sele\u00e7\u00e3o, que \u00e9 minimizado quandose realiza a estratifica\u00e7\u00e3o por regi\u00e3o e pesos amostrais; e uma limita\u00e7\u00e3o decorrentedo perfil do entrevistado, visto que, de modo geral, indiv\u00edduos que atendem otelefone fixo s\u00e3o pessoas que est\u00e3o em casa, sem emprego e com mais idade, ou seja,est\u00e3o mais suscet\u00edveis a responder pesquisas.A vigil\u00e2ncia em sa\u00fade proporciona para os gestores p\u00fablicos orienta\u00e7\u00f5es para suasa\u00e7\u00f5es, permitindo planejamento e racionaliza\u00e7\u00e3o dos recursos, bem como propicia paraa sociedade a conscientiza\u00e7\u00e3o dos problemas encontrados, que pode ocasionar melhoresescolhas individuais e coletivas em prol de uma sa\u00fade melhor."}
+{"text": "To evaluate the evolution of household availability of regional foods in the state of Amazonas, their distribution according to sociodemographic characteristics, and potential differences when compared to the remaining areas of Brazil.Pesquisa de Or\u00e7amentos Familiares (POFs \u2013 Consumer Expenditure Surveys) were analyzed, covering, respectively, 48,470, 55,970, and 57,920 households in Brazil, of which 1,075, 1,344, and 1,833 are in Amazonas. Foods were categorized into three groups: cassava and its derivatives, freshwater fish, and regional fruits. The study analyzed the amount of regional food purchased, expressed in relative household caloric share, for the entire area of Amazonas. Additionally, the data was stratified and analyzed according to sociodemographic variables, with differences assessed through the overlapping of 95% confidence intervals. Data on food acquisition for home consumption from the 2002-2003, 2008-2009, and 2017-2018  The household caloric share of the total regional foods in Amazonas was 22.54% in 2002-2003, 18.18% in 2008-2009, and 6.49% in 2017-2018. Across Brazil, those percentages were much lower in the same period: 3.67%, 3.34%, and 1.82%, respectively. Changes in Amazonas were primarily attributed to the steep drop in the cassava and derivatives group, which decreased from 14.30% in 2002-2003 to 12.74% in 2008-2009 and further declined to 3.09% in 2017-2018. Additionally, there was a gradual decline in household availability of freshwater fish, decreasing from 7.30% in 2002-2003 to 4.85% in 2008-2009 and reaching 2.90% in 2017-2018. Households in rural areas and with lower per capita income presented a higher proportion of calories from total regional foods; this particular stratum also experienced the most significant reductions in their consumption. During the study period, there was a significant decrease in the consumption of regional foods in Amazonas, particularly in lower income households in rural areas. Among them, the family reference person was typically a younger male with a lower educational background. However, this transformation does not seem to occur uniformly across all regions of the country.From a national standpoint, the process of food transition in recent decades has witnessed substantial dietary composition changes, with traditional staples such as rice, beans, milk, flour, soy oil, and sugar being supplanted by ready meals and industrialized mixes, widely known for their poor nutritional quality5. For instance, the national trend of a decrease in the consumption of cereals and legumes is not mirrored in Amazonas, where a certain stability of items perceived as foundational in the Brazilian diet, such as rice, beans, and wheat flour7, is observed. Similarly, a study on dietary behaviors found a prevailing \u201crice and beans\u201d pattern across all regions of the country, except in the North Region, where the primary diets featured cassava flour, fish, and oilseeds, representing typical regional foods8.Although different food availability and consumption profiles linked to the dietary habits of the five Brazilian macro-regions are recognized, these differences have not been thoroughly investigated or analyzed in terms of dietary particularities at the state level9.Regional food means all that which is regarded as local, native, characteristic, or adapted within the region and is also considered a significant marker of cultural identity. It typically consists of fresh, easily accessible, and affordable products that contribute to sustainability by generating income, jobs, and facilitating a closer connection between production and consumption11 and institutional meals13.Despite being rooted in the habits and preferences of the population, regional food has been underutilized as evidenced by a few specific studies in school15.In Amazonas, food has distinct peculiarities, heavily influenced by Indigenous traditions and boasting a diverse array of natural resources that hold the potential to support a well-balanced diet. However, there is little information concerning food in the state, particularly regarding how the consumption of regional foods has evolved in recent years. Existing local and national publications barely highlight the prominent inclusion of fish and cassava flour in the Amazonian dietUnderstanding food within its various regional contexts is crucial to ensuring that initiatives aimed at promoting healthy eating align with the specific circumstances and feasibility of each region. With this in mind, our study seeks to assess the trends in household availability of regional foods in Amazonas while examining their distribution across a range of sociodemographic characteristics and exploring potential disparities in comparison to the rest of Brazil.Pesquisa de Or\u00e7amentos Familiares (POF \u2013 Consumer Expenditure Survey), conducted by the Brazilian Institute of Geography and Statistics (IBGE), encompassing the years 2002-2003, 2008-2009, and 2017-2018. POF employed a complex sampling plan using conglomerates in two stages involving census sectors and households to ensure representative results for households across different regions and urban/rural areas of the country, as detailed in its issues16.The study utilized data from three editions of the 16.The study included data from a total of 48,470 households interviewed in 2002-2003, 55,970 households in 2008-2009, and 57,920 households in 2017-2018 throughout Brazil. Specifically focusing on the state of Amazonas, where 1,075 households were interviewed in 2002-2003, 1,344 in 2008-2009, and 1,833 in 2017-2018. The sampling of sectors for data collection was uniformly distributed across the four quarters, considering the seasonal variations in budget and expenses during the study period16. The researchers referred to relevant literature sources to identify regional foods specific to Amazonas17. Based on this information, they were classified into three groups:It was found that Brazilian households purchased approximately 5,400 food and beverage items during a seven-day period in POF 2002-2003, with an increase to around 7,900 items in 2008-2009, and approximately 8,300 items in 2017-2018. Residents of the households or interviewers recorded the details of the items purchased, including the quantities and how they were purchased, in an acquisition bookCassava and derivatives \u2013 include various types of cassava, flour, and cassava starch, along with tapioca gum.Freshwater fish \u2013 encompasses all types of freshwater and unspecified fish.Regional fruits \u2013 abiu, apricot, acerola, ara\u00e7\u00e1, bacuri, plantain banana, birib\u00e1, cocoa, cajarana cherry, carambola, cupua\u00e7u, sugar apple, breadfruit, soursop, guarana, ing\u00e1, jambo, genipap, mangaba, murici, pitanga, pitomba, sapote, sapoti, tamarind, tapereb\u00e1 (brazilian apricot), umari, uxi, a\u00e7a\u00ed, bacaba, buriti, brazil nut, inaj\u00e1, patau\u00e1, piqui\u00e1 nut, pupunha, and tucum\u00e3.18. The total amounts of each food item, measured in grams of the edible fraction, were then converted into kilocalories  using the Tables of Nutritional Composition of Food Consumed in Brazil19. Next, the purchased amounts of each regional food within each group, in kilocalories, were summed up per household, considering the data aggregated over seven consecutive days, and then divided by the collection period to match it to the information from a single day of effective acquisition. A variable describing the total calories from regional foods purchased by households was obtained by summing the total calories of the three groups listed.A corresponding correction factor was applied, as needed, to determine the edible fraction from the gross quantities of purchased foodsThe caloric contribution of regional foods for each household was calculated as a percentage, representing the ratio between the calories of regional items and the sum of the calories from all food purchased by the household, multiplied by 100. The amount of regional food purchased was expressed as the relative household caloric participation (indicated as a percentage) for both the total of regional foods and each of the three specific food groups.st quarter), gender, age, and education of the reference person in the family. Additionally, regional food procurement was analyzed for the remainder of Brazil as a whole, aiming to make comparisons with the estimates for the state of Amazonas.The acquisition of regional foods in Amazonas was analyzed in its entirety and further examined based on sociodemographic variables, including household situation , per capita family monthly income each quarter , employing the The analysis of the first two editions of the POF revealed that the total number of calories available at home from regional foods accounted for 22.54% in 2002-2003 and 18.18% in 2008-2009 in Amazonas. In contrast, in the rest of Brazil, the relative caloric participation of regional foods was much smaller during the same period, amounting to 3.67% and 3.34%, respectively. However, the subsequent edition of the POF in 2017-2018 showed that this difference became less pronounced, with regional foods contributing to only 6.49% of total calories in Amazonas and 1.82% in the rest of the country. The magnitude of the difference between the share of regional foods in Amazonas and the rest of the country was halved from 2002-2003 to 2017-2018 .In Amazonas, these changes were primarily driven by a significant cut in the cassava and derivatives group, which dropped from 14.30% in 2002-2003 to 3.09% in 2017-2018. Another notable trend was the gradual decline in household availability of freshwater fish, decreasing from 7.30% (2002-2003) to 4.85% (2008-2009) and 2.90% (2017-2018). In contrast, the participation of the freshwater fish group across Brazil fluctuated from 0.19% in 2002-2003 to 0.36% in 2008-2009 and 0.26% in 2017-2018.The group of regional fruits had a relatively small share in the total calories available in households in Amazonas and showed a slight decrease throughout the study period, remaining below 1.00% in all editions of the research .The examination of total regional food purchases by household situation revealed that in the rural environment, the average relative caloric participation exceeded that of the urban environment by approximately three times in 2002-2003, two times in 2008-2009, and four times in 2017-2018. This difference was statistically significant in all periods and was primarily driven by the freshwater fish group. In 2002-2003, nearly half (47.09%) of the total calories available in rural households were derived from regional foods. However, this share decreased to about one-third (33.61%) in 2008-2009 and further reduced to less than one-fifth (18.48%) in 2017-2018 .Furthermore, when analyzing the data by household location, it was observed that the cassava and derivatives group experienced a decrease in both urban and rural areas, but the decline was more pronounced in rural areas, particularly in the last period. In 2017-2018, the share of the group in rural households dropped to 5.31% compared to 21.84% in 2008-2009. The freshwater fish group displayed a significant reduction in the urban environment only from 2008-2009 (3.50%) to 2017-2018 (1.45%). However, in rural areas, the decline in this group was more prominent in the first period, decreasing from 21.46% in 2002-2003 to 10.45% in 2008-2009, with a slight increase in 2017-2018 (11.92%), although not statistically significant. On the other hand, the regional fruits group showed a reduction solely in the urban area, between the first and second surveys, dropping from 0.97% to 0.34%. In rural areas, regional fruits showed a slight increase, although not statistically significant .per capita income tended to have a greater relative caloric share of freshwater fish, cassava, and derivatives, as well as total regional food. However, there was no relationship between regional fruits and yields at any time  to 4.90% (2008-2009). In 2017-2018, the decline of the group reached the income strata of the 3rd and 4th quarters. The reduction in household purchases of regional fruits between 2008-2009 and 2017-2018 stands out only in the 4th quarter, dropping from 0.76% to 0.19%. For total regional foods, a statistically significant reduction was observed in the lowest income quarters from 2002-2003 to 2008-2009 and in all income strata in the following period , individuals up to 39 years old (from 22.19% to 16.61%), and those who attended 0-4 years of schooling (from 32.44% to 24.51%). However, POFs from 2008-2009 to 2017-2018 did not follow the same trend. The reduction in relative caloric participation of total regional food occurred in all analyzed subgroups, irrespective of gender, age group, and education level of the household\u2019s reference person .20.The analysis of the household share of regional foods in Amazonas over the 15-year period covered by the three POFs has revealed a shifting scenario in the state\u2019s food framework. The comparison between Amazonas and the rest of the country highlights the clear significance that regional foods once held in the local diet. However, the current results evidence that Amazonas is experiencing losses of its distinctive food characteristics, which previously set the state apart from the national context. This trend is consistent with a recent study based on POF data, which found low household availability of regional foods across the country\u2019s macro-regions, signaling a loss of regionality and a downward trend for these items in the Brazilian diet, followed by stagnation, between 2002 and 2018in natura or minimally processed. The traditional food profile in Amazonas, which consisted of fresh foods and culinary preparations, aligned with the recommendations of the Food Guide for the Brazilian population21. However, as regional food groups experienced reduced acquisition, there may be inadequate substitutions occurring, impacting food quality. This mirrors the national trend of a progressive shift away from fresh and minimally processed foods, with processed and ultra-processed foods gaining prominence, a pattern also observed in the North Region22.Besides the possible effect of such changes, this transformation in food consumption patterns raises concerns about the potential impact on food cultural identity in Amazonas. A significant share of the calories available in households, particularly in rural and lower-income strata, were contributed by cassava and its derivatives, as well as freshwater fish\u2014foods classified as either 9. Cassava flour is a valuable source of energy and complex carbohydrates, with a high fiber content (6.5g per 100g of the product) exceeding that of polished rice (1.6g), and brown rice (2.8g). It also contains appreciable amounts of pyridoxine, manganese, magnesium, iron, calcium, and zinc18. The potential physiological benefits of cassava flour, attributed to its fiber and resistant starch content, have led to its exploration as a promising functional food23.Furthermore, cassava and its derivatives, particularly cassava flour, play a core role in the local food routine and hold cultural significance inherited from the region\u2019s native Indigenous culture25, this food is also sought after for its well-known nutritional quality. Scientific evidence consistently supports fish as an excellent alternative for adequate protein intake due to the high amount of essential fatty acids and micronutrients, making it a regularly recommended component of a balanced diet26.Fish, in turn, is one of the most abundant natural resources in the region, and its decrease in household purchases is increasingly negative. Besides holding meaning for the Amazonian population that goes beyond the food issue, with extreme cultural and socioeconomic relevance27. The need for daily adaptations due to these environmental fluctuations, combined with financial vulnerability and the allure of modern food choices, may be contributing to the incorporation of new items into families\u2019 eating habits in a more permanent manner.However, the reduction in the share of regional foods in rural areas, particularly in Amazonas, is influenced by the seasonality of rivers  directly interferes with fishing activity and local food production. Communities may need to search for alternative sources of nutrients during certain periods of the year when fishing is not as abundant. The last decade has seen notable occurrences of major floods  and severe droughts  in the region, attributed to climate changes, which further exacerbate the challenges faced by rural communities in maintaining access to traditional food sources28.Qualitative analyses of food transformations within the urban network of Alto Solim\u00f5es, southwest of Amazonas, have revealed a strong presence of industrialized frozen chicken in the municipalities, partly due to economic reasons29. In fact, the study that sought to assess the panorama of fish consumption by the Brazilian population identified the North region as the only one in which the population has a preference for fish in their meals30. In fact, in 2008-2009, chicken accounted for 7.1% of the calories available in households in Amazonas, surpassing fish and becoming the main source of protein in the Amazonian diet7.Similarly, research conducted with low-income families within the Metropolitan Area of Manaus showed that, while fish was the preferred source of animal protein for respondents (41%), chicken was the most frequent food on their tables (69%), regardless of it hardly being their favorite (3%), likely due to income limitations1.Considering these dynamics, it is paramount to ensure access to food of proper quality and in sufficient quantity, promoting health-conscious practices that respect biodiversity. The economic and ecological dimensions of food production, marketing, and consumption must be harmonized with socio-environmental sustainability30.Fishing and the cultivation of cassava play crucial roles in the primary sector of Amazonas, generating employment and income for various socioeconomic levels. Particularly for populations living along riverbanks, fishing provides a means of livelihood and helps anchor them to their place of origin. However, fishing in the region still requires improvements in handling, processing, conservation, waste management, marketing, and logistics processes31.Likewise, the cultivation of cassava in the state primarily involves artisanal and family production. It represents an activity that demands minimal investment and simple processing to yield by-products such as flour and starches, which are easily preservable and marketable. Recent local initiatives have aimed to enhance the value of cassava flour by ensuring its origin, environmental sustainability, and support for traditional populations, thus adding value to the regional product and encouraging its consumptionDespite the strong incentives for cassava flour production, further investments in research and proper management of the flour activity are still needed to promote greater quality control, professionalize the workforce, and enhance the sector\u2019s competitiveness, thereby stimulating the families whose livelihoods are dependent on it. Consequently, fishing activities and the production of cassava flour in Amazonas demand greater attention from official bodies to ensure that they are conducted with social and environmental responsibility, thereby contributing to food security in the region.16. Additionally, research on food consumption outside of the household has revealed that this practice has been more prevalent in urban areas, among younger individuals and those with higher incomes, unlike our study, where the greatest reduction in regional foods occurred in rural areas and among lower-income groups32.One limitation of the study is certainly the omission of food consumption outside of the household. However, the North region has demonstrated the lowest percentages of expenses on food in this context: 19.1% in 2002-2003, 21.4% in 2008-2008, and the same level in 2017-2018, compared to 24.1%, 31.1%, and 32.8% across Brazil, respectively, during the three POF periodsFurthermore, part of the observed differences between groups may be attributed to seasonality. The primary initiation units were randomly distributed across the four quarters of the year, ensuring the representation of economic strata in the selected households. However, it does not guarantee an equal distribution of groups, particularly in terms of age and sex, across quarters. In this scenario, the comparison between these categories may be partially distorted.A notable strength of the study lies in its pioneering analysis of the POF data, with a focus on the purchase of foods endemic to a state. Given Brazil\u2019s diverse food, socioeconomic, and cultural contexts, it is relevant to analyze whether other locations are also experiencing a similar phenomenon of reduced participation of regional items in the diet. Identifying traditional foods that offer incentives in production, reception, and consumption can serve as a relevant initial stage in the process of promoting healthy eating in a manner that aligns with the local culture.The analysis of the evolution of household availability of regional foods in Amazonas, presumed based on the POFs of 2002-2003, 2008-2009, and 2017-2018, made it possible to comprehend their food characteristics simultaneously, suggesting that the food transition at the local level may not be occurring in the same way as in the framework across the country. There was a significant reduction in the presence of regional foods in the three analyzed periods, primarily affecting households in the rural area and with lower income, as well as families whose reference person was a younger male, with a lower educational background. 2.O resgate da alimenta\u00e7\u00e3o como um constructo amplo, que inclui o consumo alimentar tradicional, econ\u00f4mico e ambientalmente sustent\u00e1vel, e que respeite as especificidades regionais como estrat\u00e9gia para a melhoria da sa\u00fade, tem permeado as pol\u00edticas p\u00fablicas de alimenta\u00e7\u00e3o e nutri\u00e7\u00e3o no pa\u00eds4. Entretanto, este processo parece n\u00e3o ocorrer de forma homog\u00eanea em todas as regi\u00f5es do pa\u00eds.Numa perspectiva nacional, o processo de transi\u00e7\u00e3o alimentar nas \u00faltimas d\u00e9cadas tem sido marcado por significativas modifica\u00e7\u00f5es na composi\u00e7\u00e3o dos card\u00e1pios, com a substitui\u00e7\u00e3o de itens tradicionais como o arroz, feij\u00e3o, leite, farinhas, \u00f3leo de soja e a\u00e7\u00facar por refei\u00e7\u00f5es prontas e misturas industrializadas, essas \u00faltimas caracterizadas pela baixa qualidade nutricional5. Por exemplo, a tend\u00eancia nacional observada de redu\u00e7\u00e3o da participa\u00e7\u00e3o de cereais e leguminosas n\u00e3o se repete no Amazonas, onde se percebe certa estabilidade dos itens considerados b\u00e1sicos na dieta brasileira, como arroz, feij\u00e3o e farinha de trigo7. Da mesma forma, estudo de padr\u00f5es diet\u00e9ticos encontrou predomin\u00e2ncia de um padr\u00e3o denominado \u201carroz com feij\u00e3o\u201d em todas as regi\u00f5es do pa\u00eds, exceto na Regi\u00e3o Norte, onde o primeiro padr\u00e3o foi caracterizado por farinha de mandioca, peixe e oleaginosos, alimentos tipicamente regionais8.Apesar de reconhecer a exist\u00eancia de perfis diferenciados de disponibilidade e de consumo de alimentos relacionados aos h\u00e1bitos das cinco macrorregi\u00f5es brasileiras, essas diferen\u00e7as n\u00e3o t\u00eam sido investigadas de forma mais detida, ou as an\u00e1lises n\u00e3o exploram particularidades alimentares por estado9.Alimento regional \u00e9 aquele considerado local, nativo, pr\u00f3prio, caracter\u00edstico da regi\u00e3o ou adaptado, sendo tamb\u00e9m apontado como um importante marcador da identidade cultural. Geralmente \u00e9 um produto fresco, de f\u00e1cil acesso, baixo custo e que contribui para a sustentabilidade, devido \u00e0 gera\u00e7\u00e3o de renda, de empregos e da aproxima\u00e7\u00e3o entre produ\u00e7\u00e3o e consumoa priori, o h\u00e1bito e a prefer\u00eancia da popula\u00e7\u00e3o, sua subutiliza\u00e7\u00e3o tem sido registrada por alguns poucos estudos pontuais na merenda escolar11 e na alimenta\u00e7\u00e3o institucional13.Embora o alimento regional constitua, 15.No Amazonas a alimenta\u00e7\u00e3o possui peculiaridades, com forte influ\u00eancia ind\u00edgena, e disp\u00f5e de recursos naturais diversificados, potencialmente capazes de viabilizar uma dieta equilibrada. Entretanto, h\u00e1 pouca informa\u00e7\u00e3o sobre a alimenta\u00e7\u00e3o no estado, em particular como se deu a evolu\u00e7\u00e3o da participa\u00e7\u00e3o de alimentos regionais nos \u00faltimos anos. As publica\u00e7\u00f5es locais e nacionais apenas evidenciam a relevante presen\u00e7a do peixe e da farinha de mandioca na dieta amazonenseCompreender a alimenta\u00e7\u00e3o em seus diferentes contextos regionais \u00e9 essencial para assegurar que as a\u00e7\u00f5es de promo\u00e7\u00e3o de alimenta\u00e7\u00e3o saud\u00e1vel sejam consistentes e fact\u00edveis. Nesse sentido, o presente trabalho teve como objetivo avaliar a evolu\u00e7\u00e3o da disponibilidade domiciliar de alimentos regionais no Amazonas, sua distribui\u00e7\u00e3o segundo caracter\u00edsticas sociodemogr\u00e1ficas, e potenciais diferen\u00e7as em rela\u00e7\u00e3o ao restante do Brasil.16.O estudo utilizou dados das tr\u00eas \u00faltimas edi\u00e7\u00f5es da Pesquisa de Or\u00e7amentos Familiares (POF), 2002\u20132003, 2008\u20132009 e 2017\u20132018, conduzidas pelo Instituto Brasileiro de Geografia e Estat\u00edstica (IBGE). A POF utiliza plano amostral complexo, por conglomerados em dois est\u00e1gios, com sorteio de setores censit\u00e1rios e de domic\u00edlios, sendo representativa do conjunto de domic\u00edlios do pa\u00eds por regi\u00e3o, situa\u00e7\u00e3o urbana e rural, conforme descrito em suas publica\u00e7\u00f5es16.Foram utilizados dados referentes ao total de domic\u00edlios entrevistados em 2002\u20132003, 2008\u20132009 e 2017\u20132018 no Brasil , dos quais, 1.075, 1.344 e 1.833 pertencentes ao estado do Amazonas. Os setores foram distribu\u00eddos ao longo dos quatro trimestres da coleta de dados de maneira uniforme, contemplando as sazonalidades do or\u00e7amento e das despesas no per\u00edodo16. A partir dessa lista os alimentos foram classificados como regionais do Amazonas, com base na literatura espec\u00edfica17, sendo reunidos em tr\u00eas grupos:Foi relatada pelos domic\u00edlios brasileiros a aquisi\u00e7\u00e3o de aproximadamente 5.400 (POF 2002-2003), 7.900 (POF 2008\u20132009) e 8.300 (POF 2017\u20132018) itens de alimentos e bebidas durante um per\u00edodo de sete dias consecutivos. Os itens adquiridos, a quantidade e a forma de aquisi\u00e7\u00e3o foram registrados pelos moradores do domic\u00edlio ou pelo entrevistador em uma caderneta de aquisi\u00e7\u00e3oMacaxeira e derivados \u2013 macaxeira, farinha e f\u00e9cula de mandioca de diferentes tipos, incluindo goma de tapioca.Peixes de \u00e1gua doce \u2013 todos os peixes de \u00e1gua doce e peixe n\u00e3o especificado;Frutos regionais \u2013 abiu, abric\u00f3, acerola, ara\u00e7\u00e1, bacuri, banana pacov\u00e3, birib\u00e1, cacau, cajarana, carambola, cupua\u00e7u, fruta de conde, fruta p\u00e3o, graviola, guaran\u00e1, ing\u00e1, jambo, jenipapo, mangaba, murici, pitanga, pitomba, sapota, sapoti, tamarindo, tapereb\u00e1, umari, uxi, a\u00e7a\u00ed, bacaba, buriti, castanha do Brasil, inaj\u00e1, patau\u00e1, piqui\u00e1, pupunha e tucum\u00e3.18. As quantidades totais de cada item, em gramas da fra\u00e7\u00e3o comest\u00edvel, foram convertidas em quilocalorias  com aux\u00edlio das Tabelas de Composi\u00e7\u00e3o Nutricional dos Alimentos Consumidos no Brasil19. Em seguida, as quantidades adquiridas de cada um dos alimentos regionais dentro de cada grupo, em Kcal, foram somadas por domic\u00edlio. A informa\u00e7\u00e3o de aquisi\u00e7\u00e3o, agregada em sete dias consecutivos, foi dividida pelo seu per\u00edodo de coleta, equiparando-a ao per\u00edodo de informa\u00e7\u00e3o de um dia de aquisi\u00e7\u00e3o efetiva. Uma vari\u00e1vel descrevendo o total de calorias a partir dos alimentos regionais adquiridos pelos domic\u00edlios foi obtida a partir do somat\u00f3rio do total cal\u00f3rico dos tr\u00eas grupos listados acima.Para obten\u00e7\u00e3o da fra\u00e7\u00e3o comest\u00edvel a partir das quantidades brutas dos alimentos adquiridos, foi aplicado, quando apropriado, o fator de corre\u00e7\u00e3o correspondenteA contribui\u00e7\u00e3o cal\u00f3rica dos alimentos regionais (em porcentagem) foi calculada para cada domic\u00edlio como a raz\u00e3o entre as calorias dos itens regionais e o somat\u00f3rio das calorias do total de alimentos adquiridos pelo domic\u00edlio, multiplicado por 100. A quantidade de alimento regional adquirido foi expressa em participa\u00e7\u00e3o cal\u00f3rica relativa domiciliar (apresentada em porcentagem) para o total de alimentos regionais e para cada um dos tr\u00eas grupos de alimentos definidos.A aquisi\u00e7\u00e3o de alimentos regionais foi analisada para o Amazonas como um todo e segundo as vari\u00e1veis sociodemogr\u00e1ficas: situa\u00e7\u00e3o do domic\u00edlio ; quartos de renda mensal familiar per capita ; sexo, idade e escolaridade da pessoa de refer\u00eancia da fam\u00edlia. Adicionalmente, a aquisi\u00e7\u00e3o de alimentos regionais foi analisada para o restante do Brasil como um todo, com o objetivo de a comparar com as estimativas do Amazonas.A compara\u00e7\u00e3o das m\u00e9dias de contribui\u00e7\u00e3o cal\u00f3rica dos alimentos regionais entre as categorias das vari\u00e1veis utilizadas neste estudo se deu pelos intervalos de confian\u00e7a de 95%. Foram consideradas diferen\u00e7as estatisticamente significativas quando os intervalos de confian\u00e7a n\u00e3o se sobrepuseram.survey, que considera a amostragem complexa da POF.As an\u00e1lises foram realizadas utilizando o software Stata, vers\u00e3o 13.0  no m\u00f3dulo Nas duas primeiras edi\u00e7\u00f5es da POF, o total de calorias dispon\u00edveis no domic\u00edlio com alimentos regionais alcan\u00e7ou, no Amazonas, 22,54%, em 2002\u20132003, e 18,18% em 2008-2009, enquanto, no restante do Brasil, apresentaram uma participa\u00e7\u00e3o cal\u00f3rica relativa bem menor no mesmo per\u00edodo, 3,67% e 3,34%, respectivamente. Contudo, em 2017\u20132018 essa diferen\u00e7a deixou de ser t\u00e3o evidente, com o total de alimentos regionais correspondendo somente a 6,49% das calorias totais no Amazonas e 1,82% no restante do pa\u00eds. Com isso, a magnitude da diferen\u00e7a entre a participa\u00e7\u00e3o de alimentos regionais no estado selecionado e no restante do pa\u00eds foi reduzida pela metade de 2002\u20132003 para 2017\u20132018 .As mudan\u00e7as observadas no Amazonas ocorreram, principalmente, pela dr\u00e1stica redu\u00e7\u00e3o do grupo de macaxeira e derivados, que, de 14,30%, em 2002-2003, passou para 3,09% em 2017-2018. Outro destaque foi o decl\u00ednio gradativo da disponibilidade domiciliar de peixes de \u00e1gua doce, de 7,30% (2002\u20132003) para 4,85% (2008\u20132009) e 2,90% (2017\u20132018). Em oposi\u00e7\u00e3o, no restante do Brasil, a participa\u00e7\u00e3o desse grupo oscilou de 0,19%, em 2002\u20132003, para 0,36%, em 2008\u20132009, e 0,26% em 2017\u20132018 .O grupo dos frutos regionais teve participa\u00e7\u00e3o relativamente pequena no total de calorias dispon\u00edveis nos domic\u00edlios do Amazonas. Apresentou, no per\u00edodo estudado, decr\u00e9scimo, embora n\u00e3o significativo, mantendo-se abaixo de 1,00% em todas as edi\u00e7\u00f5es da pesquisa .A verifica\u00e7\u00e3o da aquisi\u00e7\u00e3o do total de alimentos regionais por situa\u00e7\u00e3o do domic\u00edlio demonstrou que, no meio rural, a participa\u00e7\u00e3o m\u00e9dia cal\u00f3rica relativa excedeu em cerca de tr\u00eas (2002\u20132003), duas (2008\u20132009) e quatro vezes (2017\u20132018) a do meio urbano. Essa diferen\u00e7a se mostrou significativa em todos os momentos e ocorreu, principalmente, devido ao grupo de peixes de \u00e1gua doce. Em 2002\u20132003, quase metade  das calorias totais dispon\u00edveis nos domic\u00edlios do meio rural eram contempladas por alimentos regionais, participa\u00e7\u00e3o que reduziu para cerca de um ter\u00e7o  e para menos de um quinto , nos anos de 2008\u20132009 e 2017\u20132018, respectivamente .Ademais, a an\u00e1lise por localiza\u00e7\u00e3o do domic\u00edlio indicou que o grupo de macaxeira e derivados teve decr\u00e9scimo em ambos os estratos, por\u00e9m de forma mais acentuada no meio rural, em especial no \u00faltimo per\u00edodo, quando reduziu de 21,84%, em 2008\u20132009, para 5,31%, em 2017-2018. J\u00e1 o grupo de peixes de \u00e1gua doce teve redu\u00e7\u00e3o significativa no meio urbano somente de 2008\u20132009  para 2017\u20132018 . Contudo, no meio rural, o decl\u00ednio desse grupo foi mais acentuado apenas no primeiro per\u00edodo: de 21,46%, em 2002\u20132003, para 10,45% em 2008-2008, havendo, inclusive, um leve aumento em 2017\u20132018 , embora n\u00e3o significativo. J\u00e1 o grupo de frutos regionais apresentou redu\u00e7\u00e3o apenas na \u00e1rea urbana, e entre o primeiro e o segundo inqu\u00e9rito, passando de 0,97% para 0,34%. Na zona rural os frutos regionais apresentaram at\u00e9 leve aumento, embora sem significado estat\u00edstico .per capita tenderam \u00e0 maior participa\u00e7\u00e3o cal\u00f3rica relativa dos grupos de peixes de \u00e1gua doce, de macaxeira e derivados, e do total de alimentos regionais. No entanto, n\u00e3o houve rela\u00e7\u00e3o entre frutos regionais e rendimentos em nenhum momento  para 4,90% (2008\u20132009). J\u00e1, em 2017-2018, a redu\u00e7\u00e3o desse grupo atingiu os estratos de renda dos 3\u00ba e 4\u00ba quartos. No grupo dos frutos regionais, destaca-se a redu\u00e7\u00e3o da aquisi\u00e7\u00e3o domiciliar entre 2008\u20132009 e 2017\u20132018, apenas do 4\u00ba quarto, passando de 0,76% para 0,19%. Para o total de alimentos regionais foi observada redu\u00e7\u00e3o estatisticamente significativa nos quartos de rendas mais baixos de 2002\u20132003 para 2008\u20132009 e, em todos os estratos de renda, no per\u00edodo seguinte .Ao analisar a disponibilidade domiciliar do total de alimentos regionais no Amazonas conforme caracter\u00edsticas da pessoa de refer\u00eancia da fam\u00edlia, foi observado que, em todos os per\u00edodos pesquisados, houve uma tend\u00eancia de maior participa\u00e7\u00e3o cal\u00f3rica relativa quando essa pessoa era do sexo masculino, mais velho e com menor escolaridade. Em rela\u00e7\u00e3o \u00e0s altera\u00e7\u00f5es, de 2002\u20132003 para 2008\u20132009 foi poss\u00edvel constatar que a redu\u00e7\u00e3o foi significativa quando se tratava de pessoa do sexo masculino , at\u00e9 39 anos  e com 0 a 4 anos de escolaridade . J\u00e1 as altera\u00e7\u00f5es de 2008\u20132009 para 2017\u20132018 n\u00e3o seguiram essa tend\u00eancia, ocorrendo em todos os extratos, independentemente de sexo, faixa et\u00e1ria e escolaridade da pessoa de refer\u00eancia do domic\u00edlio .20.A an\u00e1lise da participa\u00e7\u00e3o domiciliar dos alimentos regionais no Amazonas ao longo dos 15 anos compreendidos pelas tr\u00eas POFs revelou que um novo cen\u00e1rio vem se configurando no estado. Comparado com o restante do pa\u00eds, fica evidente a expressividade que os alimentos regionais j\u00e1 tiveram na alimenta\u00e7\u00e3o local. Entretanto, os resultados indicam que o Amazonas parece estar passando por perdas de suas caracter\u00edsticas alimentares t\u00edpicas, que justamente o diferenciavam do contexto nacional. De modo semelhante, um estudo recente que tamb\u00e9m se baseou em dados das POFs identificou baixa disponibilidade domiciliar de alimentos regionais nas macrorregi\u00f5es do pa\u00eds, indicando perda da regionalidade com tend\u00eancia de queda desses itens na dieta dos brasileiros, seguida de estagna\u00e7\u00e3o, no per\u00edodo entre 2002 e 2018in natura ou minimamente processados. Este perfil correspondia ao recomendado pelo Guia alimentar para a popula\u00e7\u00e3o brasileira, que baseia a alimenta\u00e7\u00e3o em alimentos frescos e em prepara\u00e7\u00f5es culin\u00e1rias21. Entretanto, \u00e0 medida que tais grupos de alimentos regionais tiveram a aquisi\u00e7\u00e3o reduzida, as substitui\u00e7\u00f5es podem n\u00e3o estar ocorrendo de forma adequada, afetando, assim a qualidade da alimenta\u00e7\u00e3o, pois tem se reproduzido tamb\u00e9m na Regi\u00e3o Norte a tend\u00eancia nacional de perda progressiva de espa\u00e7o dos alimentos in natura ou minimamente processados, e de ingredientes culin\u00e1rios para os alimentos processados e ultraprocessados22.Al\u00e9m do poss\u00edvel efeito dessas mudan\u00e7as na identidade cultural alimentar, que por si s\u00f3 j\u00e1 \u00e9 preocupante, outros aspectos merecem reflex\u00e3o em rela\u00e7\u00e3o ao Amazonas. Boa parte das calorias dispon\u00edveis nos domic\u00edlios, principalmente nos estratos rurais e de menores rendas, eram preenchidas pelos grupos de macaxeira e derivados e peixes de \u00e1gua doce, alimentos classificados como 9. A farinha de mandioca representa importante fonte de energia e carboidratos complexos. Seu conte\u00fado de fibras por 100g do produto  \u00e9 superior ao do arroz polido , e at\u00e9 mesmo ao do arroz integral , contendo, ainda, quantidades apreci\u00e1veis de piridoxina, mangan\u00eas, magn\u00e9sio, ferro, c\u00e1lcio e zinco18. A farinha de mandioca tamb\u00e9m tem sido explorada como um promissor alimento funcional, podendo apresentar benef\u00edcios fisiol\u00f3gicos devido ao seu conte\u00fado em fibras e amido resistente23Ademais, a macaxeira e seus derivados fazem parte do cotidiano alimentar local, especialmente na forma de farinha de mandioca, considerada um alimento tradicional da regi\u00e3o amaz\u00f4nica, herdado da cultura dos \u00edndios nativos25. E, segundo, pela reconhecida qualidade nutricional desse alimento. In\u00fameras evid\u00eancias cient\u00edficas demonstram que o peixe \u00e9 uma excelente alternativa para adequa\u00e7\u00e3o da ingest\u00e3o de prote\u00ednas, em fun\u00e7\u00e3o da elevada quantidade de \u00e1cidos graxos essenciais e micronutrientes, sendo consensual recomendar seu consumo regular como parte de uma dieta equilibrada26.O peixe, por sua vez, \u00e9 um dos recursos naturais mais abundantes na regi\u00e3o, sendo seu decr\u00e9scimo na aquisi\u00e7\u00e3o domiciliar duplamente negativo. Primeiro, porque o peixe possui um significado para a popula\u00e7\u00e3o amazonense que extrapola a quest\u00e3o alimentar, apresentando extrema relev\u00e2ncia cultural e socioecon\u00f4mica27. Tais oscila\u00e7\u00f5es nos regimes dos rios t\u00eam obrigado a popula\u00e7\u00e3o a realizar adapta\u00e7\u00f5es cotidianas, que, aliadas \u00e0 vulnerabilidade financeira e \u00e0 busca por uma modernidade alimentar, podem estar ocasionando a incorpora\u00e7\u00e3o, de modo definitivo, de novos itens aos h\u00e1bitos alimentares das fam\u00edlias.Em rela\u00e7\u00e3o \u00e0 redu\u00e7\u00e3o da participa\u00e7\u00e3o dos alimentos regionais no meio rural, existe uma compreens\u00e3o de que a sazonalidade dos rios  interfere diretamente na atividade pesqueira e na produ\u00e7\u00e3o local de alimentos. Logo, em determinadas \u00e9pocas do ano \u00e9 comum ocorrer a busca por fontes alternativas de nutrientes. Entretanto, na \u00faltima d\u00e9cada foi registrada ocorr\u00eancia de maiores enchentes  e grandes secas , atribu\u00eddas \u00e0s mudan\u00e7as clim\u00e1ticas mais recentes28.A an\u00e1lise qualitativa das transforma\u00e7\u00f5es na rede urbana no Alto Solim\u00f5es (sudoeste do Amazonas) pela perspectiva da alimenta\u00e7\u00e3o observou marcante presen\u00e7a do frango industrializado congelado nos munic\u00edpios estudados, devido, em parte, \u00e0s quest\u00f5es econ\u00f4micas29. De fato, o estudo que buscou avaliar o panorama do consumo de peixes pela popula\u00e7\u00e3o brasileira identificou a regi\u00e3o Norte como a \u00fanica em que a popula\u00e7\u00e3o possui prefer\u00eancia por peixes em suas refei\u00e7\u00f5es30. Apesar disso, em 2008-2009 o frango passou a responder por 7,1% das calorias dispon\u00edveis nos domic\u00edlios do estado, superando o peixe e passando a ser a principal fonte de prote\u00ednas do card\u00e1pio amazonense7.Pesquisa realizada com fam\u00edlias de baixa renda da Regi\u00e3o Metropolitana de Manaus tamb\u00e9m observou que, apesar do pescado ser a fonte de prote\u00edna animal preferida dos entrevistados (41%), o frango era o alimento mais frequente em suas mesas (69%), mesmo com a baixa aceitabilidade deste (3%), sendo sugerido que tais escolhas seriam consequ\u00eancias da limita\u00e7\u00e3o de renda1.Diante disso, torna-se importante assegurar o acesso a alimentos em qualidade e quantidade adequadas, baseado em pr\u00e1ticas promotoras da sa\u00fade, que respeitem a biodiversidade. As dimens\u00f5es econ\u00f4micas e biol\u00f3gicas da produ\u00e7\u00e3o, comercializa\u00e7\u00e3o e utiliza\u00e7\u00e3o dos alimentos devem estar articuladas \u00e0 sustentabilidade socioambiental30.A pesca \u00e9 um dos segmentos do setor prim\u00e1rio que mais produz empregos no Amazonas, gerando renda a um contingente de diferentes n\u00edveis socioecon\u00f4micos. \u00c9 particularmente fundamental \u00e0s popula\u00e7\u00f5es que residem \u00e0s margens dos rios, pois representa uma forma de fixar essas pessoas em seu local de origem. Todavia, a pesca na regi\u00e3o precisa ainda aperfei\u00e7oar os processos de manejo, beneficiamento, conserva\u00e7\u00e3o, gerenciamento de res\u00edduos, comercializa\u00e7\u00e3o e log\u00edstica31.Da mesma forma, o cultivo da mandioca no estado envolve essencialmente produ\u00e7\u00e3o artesanal e familiar. Constitui numa atividade que requer pouco investimento e processamento simples para obten\u00e7\u00e3o dos seus subprodutos, farinhas e f\u00e9culas, que s\u00e3o de f\u00e1cil conserva\u00e7\u00e3o e comercializa\u00e7\u00e3o. Iniciativas locais recentes t\u00eam buscado agregar valor \u00e0 farinha de mandioca, garantindo sua origem, respeito ao meio ambiente e \u00e0s popula\u00e7\u00f5es tradicionais, sendo essa uma forma de valorizar o produto regional e estimular seu consumoContudo, apesar do forte incentivo para sua produ\u00e7\u00e3o, h\u00e1 ainda a necessidade de investimentos em pesquisa e gest\u00e3o adequada da atividade farinheira, de modo a promover um maior controle da qualidade, profissionalizar a m\u00e3o-de-obra e aumentar a competitividade do setor, estimulando, assim, as fam\u00edlias que dela dependem para seu sustento. Portanto, a atividades pesqueira e a produ\u00e7\u00e3o de farinha de mandioca no Amazonas requerem maior aten\u00e7\u00e3o dos \u00f3rg\u00e3os oficiais, para que sejam conduzidas com responsabilidade social e ambiental, contribuindo, assim, para a seguran\u00e7a alimentar da regi\u00e3o.16. Al\u00e9m disso, pesquisa sobre o consumo de alimentos fora do domic\u00edlio demonstrou que essa pr\u00e1tica tem sido mais prevalente na \u00e1rea urbana, entre os mais jovens e com maior renda, diferente do presente estudo, cuja maior redu\u00e7\u00e3o dos alimentos regionais foi encontrada na \u00e1rea rural e entre as menores faixas de renda32.Uma limita\u00e7\u00e3o do estudo seria n\u00e3o computar o consumo de alimentos fora do domic\u00edlio. Contudo, a regi\u00e3o Norte tem apresentado os menores percentuais de despesas com alimenta\u00e7\u00e3o neste contexto: 19,1% em 2002-2003, 21,4% em 2008-2008, e se manteve nesse mesmo patamar em 2017-2018, contra 24,1%, 31,1% e 32,8% no Brasil, respectivamente, nos tr\u00eas per\u00edodos da POFPor fim, \u00e9 poss\u00edvel que parte das diferen\u00e7as observadas entre os grupos possa ter sido em fun\u00e7\u00e3o da sazonalidade. As unidades prim\u00e1rias de amostragem foram distribu\u00eddas aleatoriamente entre os quatro trimestres do ano, assegurando que nestes os estratos econ\u00f4micos estejam representados pelos domic\u00edlios selecionados. Isto, contudo, n\u00e3o necessariamente garante que os grupos, especialmente de idade e sexo, estejam igualmente distribu\u00eddos entre os trimestres. Nesta situa\u00e7\u00e3o, a compara\u00e7\u00e3o entre estas categorias estaria parcialmente distorcida.Como ponto forte do estudo, destaca-se a an\u00e1lise pioneira dos dados da POF, com \u00eanfase na aquisi\u00e7\u00e3o de alimentos t\u00edpicos de um estado. Considerando os diversos contextos alimentares, socioecon\u00f4micos e culturais que o Brasil possui, torna-se relevante analisar se outras localidades tamb\u00e9m n\u00e3o est\u00e3o vivenciando fen\u00f4meno semelhante, de redu\u00e7\u00e3o da participa\u00e7\u00e3o de itens regionais da dieta. Identificar alimentos tradicionais que necessitam de incentivo na produ\u00e7\u00e3o, na comercializa\u00e7\u00e3o e no consumo pode constituir um est\u00e1gio inicial relevante no processo de promo\u00e7\u00e3o da alimenta\u00e7\u00e3o saud\u00e1vel de forma contextualizada com a cultura local.A an\u00e1lise da evolu\u00e7\u00e3o da disponibilidade domiciliar de alimentos regionais no Amazonas, estimada com base nas POFs 2002-2003, 2008-2009 e 2017-2018, possibilitou o entendimento de suas caracter\u00edsticas alimentares pr\u00f3prias, sugerindo que a transi\u00e7\u00e3o alimentar em n\u00edvel local pode n\u00e3o estar ocorrendo da mesma forma que no cen\u00e1rio nacional. Houve redu\u00e7\u00e3o significativa da presen\u00e7a de alimentos regionais nos tr\u00eas per\u00edodos analisados, atingindo principalmente os domic\u00edlios da zona rural e com menor renda, bem como as fam\u00edlias cuja pessoa de refer\u00eancia era do sexo masculino, mais jovem e com menor escolaridade."}
+{"text": "O fato de a taquiarritmia ventricular ser a causa mais frequente de morte s\u00fabita card\u00edaca (MSC) nas cardiomiopatias (CM) n\u00e3o significa que todos as CM apresentem altera\u00e7\u00f5es estruturais e funcionais equipar\u00e1veis e que os resultados de exames complementares, por exemplo, a an\u00e1lise de altera\u00e7\u00f5es na despolariza\u00e7\u00e3o e repolariza\u00e7\u00e3o ventricular, podem colaborar, de maneira semelhante, na preven\u00e7\u00e3o prim\u00e1ria da MSC.1 revelam que a microaltern\u00e2ncia da onda T (MAOT) n\u00e3o est\u00e1 associada \u00e0 MSC e/ou arritmias ventriculares malignas em pacientes com cardiomiopatia hipertr\u00f3fica (CMH).1 Isso sugere que os m\u00e9todos diagn\u00f3sticos usados para estratifica\u00e7\u00e3o da cardiomiopatia n\u00e3o isqu\u00eamica (CMNI) podem n\u00e3o ser aplicados universalmente em um conjunto heterog\u00eaneo de patologias.Na edi\u00e7\u00e3o atual do ABC Cardiol, Antunes et al.2 Pastore et al.3 foram os primeiros a estabelecer uma liga\u00e7\u00e3o direta entre a MAOT e o in\u00edcio da reentrada ventricular,3 contribuindo para a aprova\u00e7\u00e3o da MAOT pelo FDA como um m\u00e9todo n\u00e3o invasivo para avaliar as necessidades de implanta\u00e7\u00e3o de CDI em diversas cardiomiopatias.4Sabe-se h\u00e1 muito tempo que altera\u00e7\u00f5es na repolariza\u00e7\u00e3o ventricular sinalizam um alto risco de arritmias ventriculares malignas e podem servir como um marcador de risco n\u00e3o invasivo para MSC.5A Sociedade Internacional de Holter e Eletrocardiologia N\u00e3o Invasiva (ISH-NIE) recomenda a avalia\u00e7\u00e3o da MAOT quando h\u00e1 suspeita de vulnerabilidade a arritmias card\u00edacas letais. No entanto, nenhum dos estudos prospectivos analisados mencionou especificamente a CMH.6 maior associa\u00e7\u00e3o com achados ecocardiogr\u00e1ficos e densidade de arritmias ventriculares e heterogeneidade de locais de fibrose7 e com ocorr\u00eancia de nVT8 mas n\u00e3o podendo se mostrar preditor de eventos arr\u00edtmicos graves.Estudos realizados em pacientes com CMH, em geral com amostras pequenas e curto seguimento cl\u00ednico, sinalizaram correla\u00e7\u00e3o entre a presen\u00e7a de MAOT e maior grau de desarranjo miofibrilar;9 como o ALPHA TRIAL, que teve como foco principal a cardiomiopatia dilatada idiop\u00e1tica.10 Apesar disso, os autores seguem a mesma abordagem simplista e dicot\u00f4mica e recomendam a incorpora\u00e7\u00e3o da avalia\u00e7\u00e3o da MAOT nos crit\u00e9rios terap\u00eauticos do CDI para cardiomiopatia n\u00e3o isqu\u00eamica (CMNI) classe funcional II/III da NYHA.10Estudos ainda maiores tiveram um n\u00famero limitado de pacientes com CMH,11No entanto, o presente estudo mostra que a MAOT n\u00e3o \u00e9 um preditor confi\u00e1vel de eventos fatais em pacientes com CMH. Isso se deve principalmente \u00e0 baixa taxa de eventos da doen\u00e7a e, principalmente, por ser caracterizada por heterogeneidade morfol\u00f3gica, funcional, cl\u00ednica e progn\u00f3stica, na qual a demonstra\u00e7\u00e3o de novos marcadores de risco (e independentes dos convencionais) \u00e9 uma tarefa desafiadora.5Outro ponto de interesse \u00e9 a suspens\u00e3o ou n\u00e3o da medica\u00e7\u00e3o betabloqueadora antes da an\u00e1lise da MAOT. O ISH-NIE recomenda a realiza\u00e7\u00e3o de testes de MAOT sem alterar os regimes de medica\u00e7\u00e3o para garantir que os resultados dos testes reflitam os efeitos da terapia medicamentosa cr\u00f4nica.12\u00c9 importante observar que os estudos sobre MAOT t\u00eam variado em seus protocolos em rela\u00e7\u00e3o \u00e0 suspens\u00e3o da terapia com betabloqueadores, apesar das evid\u00eancias de que esses medicamentos afetam a amplitude da MAOT e a presen\u00e7a de MAOT durante os testes.5 Na metan\u00e1lise de 9 estudos prospectivos em pacientes de preven\u00e7\u00e3o prim\u00e1ria com disfun\u00e7\u00e3o ventricular esquerda, o poder preditivo da MAOT variou amplamente com base na suspens\u00e3o da terapia com betabloqueadores antes de sua avalia\u00e7\u00e3o. Os autores propuseram que esta observa\u00e7\u00e3o pode explicar os resultados inconsistentes dos estudos de MAOT nesta popula\u00e7\u00e3o.12A frequ\u00eancia card\u00edaca n\u00e3o \u00e9 o \u00fanico determinante da MAOT porque os neurotransmissores auton\u00f4micos e as altera\u00e7\u00f5es no substrato mioc\u00e1rdico podem levar a n\u00edveis elevados de MAOT durante a estimula\u00e7\u00e3o de frequ\u00eancia fixa.1O achado significativo do presente estudo foi que a MAOT alterada esteve associada aos crit\u00e9rios da AHA considerados de alto risco sem que isso se refletisse no poder de predi\u00e7\u00e3o do desfecho prim\u00e1rio. Os autores sinalizaram corretamente que na CMH outros mecanismos arritmog\u00eanicos, n\u00e3o adequadamente detect\u00e1veis por valores elevados de MAOT, est\u00e3o envolvidos na origem das arritmias ventriculares e da MSC.14O resultado do presente estudo corrobora uma observa\u00e7\u00e3o que se tornou mais relevante nos \u00faltimos anos com o melhor entendimento da fisiopatologia da CMNI, achados de estudos in vivo e experimentais, resultados de exames de imagem (resson\u00e2ncia magn\u00e9tica) e, por fim, avan\u00e7os na pesquisa gen\u00e9tica.15 Assim, embora cada subtipo de CMH seja definido pelo seu principal fen\u00f3tipo morfofuncional, uma avalia\u00e7\u00e3o cl\u00ednica criteriosa demonstra alta variabilidade fenot\u00edpica com as devidas implica\u00e7\u00f5es progn\u00f3sticas e terap\u00eauticas.14 Outro aspecto importante \u00e9 que a CMH \u00e9 uma doen\u00e7a com express\u00e3o fenot\u00edpica vari\u00e1vel que pode progredir e mudar no mesmo paciente.16As observa\u00e7\u00f5es acima s\u00e3o particularmente aplic\u00e1veis quando se trata de CMH. Um exemplo desta complexidade \u00e9 a forma apical da CMH, que \u00e9 uma express\u00e3o fenot\u00edpica cl\u00e1ssica ligada a um bom progn\u00f3stico cl\u00ednico, mas que, nas suas formas ditas at\u00edpicas , apresenta um progn\u00f3stico cl\u00ednico mais reservado.17Esse achado reflete que a complexidade do substrato arritmog\u00eanico da CMH decorre de uma combina\u00e7\u00e3o de altera\u00e7\u00f5es e arranjo de mi\u00f3citos, anormalidades microvasculares, fibrose intersticial/de substitui\u00e7\u00e3o, modula\u00e7\u00e3o auton\u00f4mica e possivelmente muta\u00e7\u00f5es patog\u00eanicas no gene do sarc\u00f4mero. No entanto, o papel das variantes sarcom\u00e9ricas como preditor de MSC ainda precisa ser demonstrado.18 Esses dados, combinados com marcadores cl\u00ednicos, em um novo espa\u00e7o, o da correla\u00e7\u00e3o fen\u00f3tipo-gen\u00f3tipo, permitiram individualizar o risco do paciente e compartilhar a tomada de decis\u00e3o quanto \u00e0 necessidade ou n\u00e3o de um implante de CDI para preven\u00e7\u00e3o prim\u00e1ria da MSC.Nesta era da medicina de precis\u00e3o, o futuro \u00e9 uma grande promessa para uma melhor estratifica\u00e7\u00e3o de risco de cardiomiopatias. Possivelmente, caminharemos na dire\u00e7\u00e3o de que, mais do que a an\u00e1lise de altera\u00e7\u00f5es na despolariza\u00e7\u00e3o ventricular  ou na repolariza\u00e7\u00e3o ventricular , as respostas vir\u00e3o da detec\u00e7\u00e3o de altera\u00e7\u00f5es funcionais, estruturais e morfol\u00f3gicas altera\u00e7\u00f5es, biomarcadores gen\u00e9ticos e an\u00e1lise de potenciais fatores epigen\u00e9ticos. The fact that ventricular tachyarrhythmia is the most frequent cause of sudden cardiac death (SCD) in cardiomyopathies (CM) does not mean that all CM exhibit similar structural and functional alterations that, identified in advance, for example, by analyzing changes in ventricular depolarization and repolarization, may collaborate in the primary prevention of SCD.1 reveals that altered T-wave alternans (TWA) is not associated with SCD and/or malignant ventricular arrhythmias in hypertrophic cardiomyopathy (HCM) patients.1 This suggests that diagnostic methods used for non-ischemic cardiomyopathies (NICM). stratification may not universally apply across a heterogeneous set of pathologies.In the current edition of ABC Cardiol, Antunes et al.2 Pastore et al. were the first to establish a direct link between TWA and the onset of ventricular reentry,3 contributing to the FDA\u2019s approval of TWA as a non-invasive method for evaluating ICD implantation needs in various cardiomyopathies.4Electrical alterations in ventricular repolarization have long been known to signal a high risk of malignant ventricular arrhythmias and could serve as a non-invasive risk marker for SCD.5The International Society for Holter and Non-invasive Electrocardiology (ISH-NIE) recommends TWA evaluation when suspected of vulnerability to lethal cardiac arrhythmias. However, none of the prospective studies they analyzed mentioned HCM specifically.6 a greater association with echocardiographic findings and ventricular arrhythmia density and heterogeneity of fibrosis sites7 and with the occurrence of nVT8 but not being able to prove to be a predictor of serious arrhythmic events.Studies carried out in patients with HCM, in general with small samples and a short clinical follow-up, signaled a correlation between the presence of TWA and a higher degree of myofibrillar disarrangement;9 such as the ALPHA TRIAL, which primarily focused on idiopathic dilated cardiomyopathy.10 Despite this, the authors follow the same simplistic and dichotomous approach and recommend incorporating TWA evaluation into the ICD therapy criteria for NYHA functional class II/III NICM.10Even larger studies have had limited HCM patient numbers,11However, the present study shows that TWA is not a reliable predictor of fatal events in HCM patients. This is primarily due to the disease\u2019s low event rate and, principally, for being characterized by morphological, functional, clinical, and prognostic heterogeneity in which demonstrating new  risk markers is a challenging task.5Another point of interest is whether or not to discontinue beta-blocker medication before TWA analysis. The ISH-NIE recommends performing TWA tests without altering medication regimens to ensure that test results reflect the effects of chronic drug therapy.12It is important to note that studies on TWA have varied in their protocols regarding the suspension of beta-blocker therapy despite evidence that these drugs affect TWA amplitude and the presence of TWA during testing.5 Meta-analysis of 9 prospective studies in primary prevention patients with left ventricular dysfunction, the predictive power of TWA varied widely based on whether beta-blocker therapy was withheld prior to its assessment. The authors proposed that this observation may explain the inconsistent results of TWA studies in this population.12Heart rate is not the sole determinant of TWA because autonomic neurotransmitters and changes in myocardial substrate can lead to elevated levels of TWA during fixed rate pacing.1The significant finding of the present study was that altered TWA was associated with the AHA criteria considered high risk without this being reflected in the power to predict the primary outcome. The authors properly signaled that in HCM, other arrhythmogenic mechanisms, not adequately detectable by high TWA values, are involved in the origin of ventricular arrhythmias and SCD.14The result of the present study corroborates an observation that has become more relevant in recent years with a better understanding of the pathophysiology of NICM, findings from in-vivo and experimental studies, results of imaging tests (magnetic resonance imaging), and, finally, advances in genetic research.15 Thus, although each subtype of HCM is defined by its main morphofunctional phenotype, a careful clinical evaluation demonstrates high phenotype variability with due prognostic and therapeutic implications.14 Another important aspect is that HCM is a disorder with variable phenotype expression that may progress and change in the same patient.16The above observations are particularly applicable when dealing with HCM. The apical form of HCM is an example of this complexity, which is a classic phenotypic expression linked to a good clinical prognosis but which, in its so-called atypical forms , presents a more reserved clinical prognosis.17This finding reflects that the complexity of the HCM arrhythmogenic substrate stems from a combination of alterations and arrangement of myocytes, microvascular abnormalities, interstitial/replacement fibrosis, autonomic modulation, and possibly pathogenic sarcomere gene mutations. However, the role of sarcomeric variants as a predictor of SCD remains to be demonstrated.18 These data, combined with clinical markers, in a new space, that of the phenotype-genotype correlation, allowed individualizing the patient\u2019s risk and shared decision-making regarding the need or not for an ICD implant for the primary prevention of SCD.In this era of precision medicine, the future holds great promise for improved risk stratification of cardiomyopathies. Possibly, we will move in the direction that, more than the analysis of changes in ventricular depolarization  or ventricular repolarization , the answers will come from the detection of functional, structural, and morphological alterations, genetic biomarkers and analysis of potential epigenetic factors"}
+{"text": "Sum\u00e1rio1. Carta de Apresenta\u00e7\u00e3o 52. Objetivos do Documento 63. Defini\u00e7\u00e3o de Graus de Recomenda\u00e7\u00e3o e N\u00edveis de Evid\u00eancia 64. Defini\u00e7\u00e3o de Hipertrigliceridemia (>150mg/dL), Hipertrigliceridemia Grave (>500mg/dL) e Quilomicronemia (>1.000mg/dL) 74.1. Introdu\u00e7\u00e3o 74.2. Defini\u00e7\u00e3o de Hipertrigliceridemia 75. Defini\u00e7\u00e3o de Quilomicronemia \u2013 S\u00edndrome da Quilomicronemia Familiar e S\u00edndrome da Quilomicronemia Multifatorial: Crit\u00e9rios Cl\u00ednicos, Laboratoriais e Modo de Transmiss\u00e3o da Doen\u00e7a 75.1. Introdu\u00e7\u00e3o 75.2. Conceitos 85.2.1. S\u00edndrome da Quilomicronemia Familiar 85.2.2. S\u00edndrome da Quilomicronemia Multifatorial 86. Epidemiologia da S\u00edndrome da Quilomicronemia Familiar no Mundo e no Brasil 96.1. Defini\u00e7\u00e3o de S\u00edndrome da Quilomicronemia Familiar e Aspectos Cl\u00ednicos 96.1.1. Primeiros Casos de S\u00edndrome da Quilomicronemia 96.2. Epidemiologia da S\u00edndrome da Quilomicronemia Familiar no Mundo 96.3. Epidemiologia da S\u00edndrome da Quilomicronemia Familiar em Crian\u00e7as 116.4. Epidemiologia da S\u00edndrome da Quilomicronemia Familiar no Brasil 117. Manifesta\u00e7\u00f5es Cl\u00ednicas na S\u00edndrome da Quilomicronemia Familiar, Diagn\u00f3stico Diferencial e Abordagem das Complica\u00e7\u00f5es 127.1. Manifesta\u00e7\u00f5es Cl\u00ednicas na S\u00edndrome da Quilomicronemia Familiar 127.1.1. Hipertrigliceridemia 127.1.2. Dor Abdominal e Pancreatite Aguda 127.1.3. Manifesta\u00e7\u00f5es Neurol\u00f3gicas 127.1.4. Hepatosplenomegalia 127.1.5. Xantomas Eruptivos 137.1.6. Lipemia Retinalis 137.1.7. Qualidade de Vida 137.1.8. Escore Diagn\u00f3stico 137.2. Diagn\u00f3stico Diferencial 137.2.1. S\u00edndrome da Quilomicronemia Multifatorial 137.2.2. Lipodistrofias 147.3. Abordagem das Complica\u00e7\u00f5es da S\u00edndrome da Quilomicronemia Familiar 147.3.1. Pancreatite Aguda 148. Diagn\u00f3stico Laboratorial da S\u00edndrome da Quilomicronemia Familiar 158.1. Fase Pr\u00e9-anal\u00edtica (Orienta\u00e7\u00f5es para Pacientes) 158.1.1. Instru\u00e7\u00f5es para Coleta 158.1.2. Interferentes Pr\u00e9-anal\u00edticos para An\u00e1lise dos Triglic\u00e9rides 158.1.3. Orienta\u00e7\u00f5es para o Laborat\u00f3rio  158.2. Fase Anal\u00edtica 158.2.1. Metodologias que Avaliam os Quilom\u00edcrons 158.2.1.1. Ultracentrifuga\u00e7\u00e3o 158.2.1.2. Aspecto do Soro 158.2.1.3. Eletroforese de Lipoprote\u00ednas 168.2.2. Metodologias que Avaliam os Triglic\u00e9rides 168.2.3. Interfer\u00eancia no Resultado dos Triglic\u00e9rides 168.2.4. Interfer\u00eancia dos Triglic\u00e9rides em Outros Analitos 168.2.4.1. LDL-C 168.2.4.2. Plaquetas 168.2.4.3. Analitos com Avalia\u00e7\u00e3o Colorim\u00e9trica 168.2.4.4. Enzimas 168.2.4.5. Eletr\u00f3litos 178.2.5. An\u00e1lises Laboratoriais para Diagn\u00f3stico Diferencial 178.2.5.1. Atividade da LPL com Heparina 178.2.5.2. Dosagem de Apolipoprote\u00edna C3 Plasm\u00e1tica 178.3. Fase P\u00f3s-anal\u00edtica 178.3.1. Recomenda\u00e7\u00f5es para as NOTAS nos Laudos Laboratoriais 179. Aconselhamento Gen\u00e9tico e as Etapas no Diagn\u00f3stico e Acompanhamento das Hipertrigliceridemias Graves 1710. Orienta\u00e7\u00e3o Nutricional na Quilomicronemia em Adultos, Crian\u00e7as e Adolescentes 1910.1. Classifica\u00e7\u00e3o e Absor\u00e7\u00e3o dos \u00c1cidos Graxos 1910.2. Absor\u00e7\u00e3o das Gorduras 2010.3. Tratamento Nutricional 2010.3.1. Gorduras 2010.3.2. Triglic\u00e9rides de Cadeia M\u00e9dia 2110.3.3. Carboidratos 2110.3.4. \u00c1lcool 2110.3.5. Lactentes e Primeira Inf\u00e2ncia 2110.3.6. Gestantes 2210.3.7. Recomenda\u00e7\u00f5es Gerais 2210.4. Exemplos de Card\u00e1pios 2311. Af\u00e9rese 2711.1. Diagn\u00f3stico e Tratamento 2711.2. Tratamento N\u00e3o Medicamentoso 2711.3. Tratamento Farmacol\u00f3gico 2711.4. Af\u00e9rese 2711.5. Gesta\u00e7\u00e3o e PH nos Pacientes com S\u00edndrome da Quilomicronemia Familiar 2812. Novas Terap\u00eauticas para Tratamento da S\u00edndrome da Quilomicronemia familiar 2812.1. ApoC3 2812.1.1 Antissentido Anti-APOC3 2913. Aspectos Sociais, Psicol\u00f3gicos e Impacto Econ\u00f4mico da Doen\u00e7a 3113.1. Aspecto Social na S\u00edndrome da Quilomicronemia Familiar 3213.2. Aspectos Psicol\u00f3gicos na S\u00edndrome da Quilomicronemia Familiar 3213.2.1. Os Pais das Crian\u00e7as com Diagn\u00f3stico de S\u00edndrome da Quilomicronemia Familiar 3313.3. Para Reduzir os Impactos da Doen\u00e7a: Modos de Enfrentamento 3313.3.1. Modelos Ativos e Passivos de Enfrentamento: Foco no Paciente 3313.3.2. Modelo Social de Enfrentamento: Foco nos Pares 3313.4. Custo-efetividade do Manejo de Riscos Psicossociais 3114. Resumo das Recomenda\u00e7\u00f5es 34Refer\u00eancias 35A s\u00edndrome da quilomicronemia familiar (SQF) \u00e9 uma forma grave de dislipidemia e compreende um conjunto de m\u00faltiplos sinais e sintomas causados pela defici\u00eancia da enzima lipoprote\u00edna lipase (LPL) ou de um de seus cofatores, comprometendo o metabolismo de triglic\u00e9rides. Apresenta modo de heran\u00e7a autoss\u00f4mico recessivo e acomete cerca de 1 a 2 pessoas por milh\u00e3o de indiv\u00edduos, mas pode ser mais frequente quando existe consanguinidade.retinalis , hepatoesplenomegalia, al\u00e9m do aspecto cremoso do soro.Existe grande desconhecimento sobre essa condi\u00e7\u00e3o e, por esse motivo, o seu diagn\u00f3stico ocorre tardiamente, quando complica\u00e7\u00f5es j\u00e1 se instalaram. O paciente portador de SQF pode se apresentar com dores abdominais recorrentes, epis\u00f3dios de pancreatite, xantomas eruptivos, lipemia Nas formas cl\u00e1ssicas e mais graves, os achados cl\u00ednicos podem ser reconhecidos logo ao nascimento, ou ainda na inf\u00e2ncia, mas estes podem se apresentar em qualquer idade, especialmente nos portadores de novas muta\u00e7\u00f5es. N\u00e3o \u00e9 infrequente que o paciente com SQF tenha consultado v\u00e1rias especialidades m\u00e9dicas antes de ter seu diagn\u00f3stico firmado.A apresenta\u00e7\u00e3o cl\u00ednica da SQF pode, ainda, ser indistingu\u00edvel da s\u00edndrome da quilomicronemia multifatorial (SQM), mais frequente e que tamb\u00e9m tem uma base gen\u00e9tica, mas sofre influ\u00eancia de fatores ambientais e ligados ao estilo de vida. Al\u00e9m disso, o quadro cl\u00ednico pode ser secund\u00e1rio a condi\u00e7\u00f5es como hipotireoidismo, diabetes n\u00e3o controlado, doen\u00e7as renais, consumo abusivo de \u00e1lcool e uso de certos medicamentos, o que dificulta ainda mais seu diagn\u00f3stico.A confirma\u00e7\u00e3o gen\u00e9tica, com um painel de genes causais para a SQF, \u00e9, atualmente, realizada em poucos centros em nosso meio. No entanto, quando uma muta\u00e7\u00e3o em homozigose em um dos genes causais, ou duas muta\u00e7\u00f5es em um mesmo gene (heterozigoto composto), ou em diferentes genes causais (heterozigoto duplo), for encontrada, confirma-se a condi\u00e7\u00e3o de SQF, embora exista um percentual em que nenhuma muta\u00e7\u00e3o causal esteja presente. Algoritmos validados podem auxiliar na suspei\u00e7\u00e3o cl\u00ednica da SQF e indicar quem deve realizar o teste gen\u00e9tico.O tratamento da SQF requer uma abordagem multiprofissional, incluindo nutricionista, psic\u00f3logo, entre outros profissionais de sa\u00fade, visando manter o bem-estar do indiv\u00edduo e o estado nutricional. Restri\u00e7\u00e3o do consumo de gorduras e de carboidratos simples, suplementa\u00e7\u00e3o de vitaminas lipossol\u00faveis e de \u00e1cidos graxos essenciais devem ser recomendados ao longo da vida. O suporte psicol\u00f3gico visa ajudar o indiv\u00edduo a conviver com as restri\u00e7\u00f5es diet\u00e9ticas impostas.O tratamento farmacol\u00f3gico convencional frequentemente se associa a uma resposta inferior a 20% na redu\u00e7\u00e3o dos triglic\u00e9rides, raz\u00e3o pela qual a grande esperan\u00e7a desses pacientes reside na chegada de novos f\u00e1rmacos ao Brasil, com benef\u00edcio comprovado em reduzir os triglic\u00e9rides nessa popula\u00e7\u00e3o. Situa\u00e7\u00f5es peculiares no manuseio da SQF s\u00e3o a gesta\u00e7\u00e3o e os epis\u00f3dios de pancreatite recorrentes, em que a mortalidade pode ser elevada e tratamentos individualizados s\u00e3o requeridos.O intuito deste documento \u00e9 conscientizar profissionais de sa\u00fade dos aspectos peculiares \u00e0 SQF, capacitando-os no reconhecimento e na abordagem precoces da condi\u00e7\u00e3o, mitigando o sofrimento do paciente e as complica\u00e7\u00f5es pelo retardo do diagn\u00f3stico.Membros do Departamento de Aterosclerose da Sociedade Brasileira de Cardiologia e renomados especialistas de nosso pa\u00eds reuniram-se com o objetivo de transmitir as melhores informa\u00e7\u00f5es cient\u00edficas dispon\u00edveis sobre a SQF para melhoria da pr\u00e1tica cl\u00ednica, de forma clara e objetiva.Sinceramente,Prof. Dra. Maria Cristina de Oliveira IzarProf. Dr. Raul Dias SantosProf. Dr. Antonio Carlos Palandri ChagasDr. Marcelo Heitor Vieira AssadCoordenadoresEste documento tem por objetivo conscientizar profissionais de sa\u00fade, especialmente cardiologistas, cl\u00ednicos e endocrinologistas, de uma doen\u00e7a muito rara, subdiagnosticada, que causa intenso sofrimento \u00e0s pessoas acometidas e que, at\u00e9 recentemente, n\u00e3o era diagnosticada, al\u00e9m de ser subtratada.Escrito por especialistas na \u00e1rea, o Posicionamento Brasileiro sobre S\u00edndrome da Quilomicronemia Familiar vem suprir uma lacuna no conhecimento dos dados epidemiol\u00f3gicos no mundo e em nosso pa\u00eds de manifesta\u00e7\u00f5es cl\u00ednicas, diagn\u00f3stico laboratorial e gen\u00e9tico, e diagn\u00f3stico diferencial com outras formas de hipertrigliceridemia (HTG) graves. Al\u00e9m disso, o manejo nutricional, peculiar, e a abordagem de neonatos e crian\u00e7as, gestantes e das complica\u00e7\u00f5es, como a pancreatite, s\u00e3o destacados neste documento. Vale ressaltar que, recentemente, tivemos em nosso pa\u00eds a aprova\u00e7\u00e3o de uma nova terapia antissentido anti-APOC3, com evid\u00eancias de redu\u00e7\u00e3o dos triglic\u00e9rides e perspectivas de prevenir as complica\u00e7\u00f5es e melhorar a qualidade de vida dos pacientes.Classes (graus) de recomenda\u00e7\u00e3o:Classe I \u2013 Condi\u00e7\u00f5es para as quais h\u00e1 evid\u00eancias conclusivas, ou, na sua falta, consenso geral de que o procedimento \u00e9 seguro e \u00fatil/eficaz.Classe II \u2013 Condi\u00e7\u00f5es para as quais h\u00e1 evid\u00eancias conflitantes e/ou diverg\u00eancia de opini\u00e3o sobre seguran\u00e7a e utilidade/efic\u00e1cia do procedimento.Classe IIa \u2013 Peso ou evid\u00eancia/opini\u00e3o a favor do procedimento. A maioria aprova.Classe IIb \u2013 Seguran\u00e7a e utilidade/efic\u00e1cia menos bem estabelecida, n\u00e3o havendo predom\u00ednio de opini\u00f5es a favor.Classe III \u2013 Condi\u00e7\u00f5es para as quais h\u00e1 evid\u00eancias e/ou consenso de que o procedimento n\u00e3o \u00e9 \u00fatil/eficaz e, em alguns casos, pode ser prejudicial.N\u00edveis de evid\u00eancia:N\u00edvel A \u2013 Dados obtidos a partir de m\u00faltiplos estudos randomizados de bom porte, concordantes e/ou de metan\u00e1lise robusta de estudos cl\u00ednicos randomizadosN\u00edvel B \u2013 Dados obtidos a partir de metan\u00e1lise menos robusta, a partir de um \u00fanico estudo randomizado ou de estudos n\u00e3o randomizados (observacionais).N\u00edvel C \u2013 Dados obtidos de opini\u00f5es consensuais de especialistas.Primeiramente, antes de definirmos valores e classificar a HTG em discreta, moderada ou grave, devemos levar em considera\u00e7\u00e3o alguns fatores relevantes.Para avalia\u00e7\u00e3o do perfil lip\u00eddico, recomenda-se estado metab\u00f3lico est\u00e1vel e dieta habitual. Entretanto, orienta-se suspender o consumo et\u00edlico com 5 dias de anteced\u00eancia.1Ao interpretar o perfil lip\u00eddico, deve-se levar em considera\u00e7\u00e3o a possibilidade de varia\u00e7\u00e3o biol\u00f3gica intraindividual e poss\u00edveis varia\u00e7\u00f5es interlaboratoriais. Tais varia\u00e7\u00f5es podem atingir valores de 10% para o colesterol total, HDL-c e LDL-c e de at\u00e9 25% para os triglic\u00e9rides.3 Nessa situa\u00e7\u00e3o, com HTG >400mg/dL, deixamos de utilizar a f\u00f3rmula de Friedewald, habitualmente usada para c\u00e1lculo das fra\u00e7\u00f5es do colesterol.4 Algumas publica\u00e7\u00f5es sugerem maior risco cardiovascular relacionado \u00e0 HTG p\u00f3s-prandial.6 Em 2016, as diretrizes da European Atherosclerosis Society (EAS) e da European Federation of Clinical Chemistry and Laboratory Medicine retiraram a recomenda\u00e7\u00e3o de jejum para coleta do perfil lip\u00eddico.7As mais recentes diretrizes brasileiras de dislipidemia e de diabetes adotam como norma a dispensa do jejum para determina\u00e7\u00e3o dos triglic\u00e9rides s\u00e9ricos. Contudo, na presen\u00e7a de concentra\u00e7\u00e3o plasm\u00e1tica de triglic\u00e9rides >400mg/dL, deve-se realizar uma nova dosagem, em jejum de 12h, diante da poss\u00edvel exist\u00eancia de HTG prim\u00e1ria, na qual o jejum \u00e9 necess\u00e1rio.A Diretriz Brasileira de Dislipidemia e Aterosclerose classifica laboratorialmente as dislipidemias conforme a 9A classifica\u00e7\u00e3o fenot\u00edpica de Fredrickson, demonstrada na 1Do ponto de vista laboratorial, define-se HTG quando a concentra\u00e7\u00e3o plasm\u00e1tica de triglic\u00e9rides estiver >150mg/dL. No entanto, quando a coleta do perfil lip\u00eddico n\u00e3o for realizada em jejum, considera-se HTG com valores >175mg/dL.10 em:Desse modo, podemos classificar as HTGDiscretas: triglic\u00e9rides plasm\u00e1ticos >150mg/dL;Moderadas: entre 151 e 499mg/dL;Graves: entre 500 e 1.000mg/dL;Muito graves: >1.000mg/dL.11As HTG resultam do ac\u00famulo de lipoprote\u00ednas ricas em \u00e1cidos graxos e glicerol . A principal anormalidade lipoproteica nas formas graves e muito graves \u00e9 a quilomicronemia, definida como a presen\u00e7a de quilom\u00edcrons circulantes no estado de jejum. Com concentra\u00e7\u00f5es de triglic\u00e9rides >1.000mg/dL, j\u00e1 se pode detectar a presen\u00e7a de quilom\u00edcrons no sangue; contudo, a quilomicronemia \u00e9 mais prov\u00e1vel quando essas concentra\u00e7\u00f5es ultrapassarem 1.500mg/dL. A relev\u00e2ncia cl\u00ednica das formas graves e muito graves da HTG deve-se \u00e0 sua associa\u00e7\u00e3o com um risco duas vezes maior de pancreatite aguda, cuja incid\u00eancia aumenta em 3% para cada 100mg/dL >1.000mg/dL de trigliceridemia.Quilomicronemia \u00e9 caracterizada por ac\u00famulo de quilom\u00edcrons na circula\u00e7\u00e3o e aumento importante da concentra\u00e7\u00e3o plasm\u00e1tica de triglic\u00e9rides.retinalis , xantomas eruptivos, hepatoesplenomegalia e, principalmente, pancreatites agudas, que ajudariam a confirmar o diagn\u00f3stico de SQF.12Quanto maior a concentra\u00e7\u00e3o de triglic\u00e9rides plasm\u00e1tico, maior o risco de ocorrer pancreatite. Entretanto, casos de valores >1.000mg/dL ou quadro de HTG muito grave s\u00e3o mais propensos a desenvolver pancreatite aguda. Essas altera\u00e7\u00f5es laboratoriais devem ser associadas a altera\u00e7\u00f5es cl\u00ednicas que estariam presentes desde a inf\u00e2ncia ou adolesc\u00eancia, para suspeitar-se do diagn\u00f3stico de SQF. Entre essas altera\u00e7\u00f5es, estariam: lipemia mellitus .13A relev\u00e2ncia cl\u00ednica das formas graves e muito graves da HTG deve-se \u00e0 sua associa\u00e7\u00e3o com um risco duas vezes maior de pancreatite aguda. Al\u00e9m de ser uma emerg\u00eancia m\u00e9dica potencialmente fatal, a pancreatite aguda tamb\u00e9m pode levar a v\u00e1rias complica\u00e7\u00f5es cl\u00ednicas, tais como pancreatite cr\u00f4nica, insufici\u00eancia pancre\u00e1tica e diabetes 14 A LPL \u00e9 uma enzima que se localiza na superf\u00edcie endotelial dos capilares do tecido adiposo e de m\u00fasculos, que, ao ser ativada, inicia o processo de hidr\u00f3lise dos triglic\u00e9rides dos quilom\u00edcrons, gerando os remanescentes de quilom\u00edcrons. A atividade da LPL \u00e9 modulada pela a\u00e7\u00e3o da APOC2 e da APOA5, que atuam como cofatores na sua ativa\u00e7\u00e3o; pelo fator de matura\u00e7\u00e3o da lipase 1 , necess\u00e1rio para a produ\u00e7\u00e3o de LPL em adip\u00f3citos e mi\u00f3citos; e pela GPIHBP1 ( glycosylphosphatidylinositol anchored high-density lipoprotein binding protein 1 ), que transporta LPL do espa\u00e7o intersticial para o l\u00famen capilar. Qualquer altera\u00e7\u00e3o na fun\u00e7\u00e3o e/ou ativa\u00e7\u00e3o da LPL resulta em aumento da meia-vida dos quilom\u00edcrons na corrente sangu\u00ednea e, consequentemente, quilomicronemia.14Os quilom\u00edcrons s\u00e3o formados pela incorpora\u00e7\u00e3o dos l\u00edpides provenientes da dieta com as apolipoprote\u00ednas  e secretados na linfa mesent\u00e9rica.15Existem duas formas distintas de quilomicronemia: a SQF e a SQM. Estas s\u00e3o, respectivamente, os prot\u00f3tipos das condi\u00e7\u00f5es monog\u00eanicas e polig\u00eanicas subjacentes \u00e0 HTG grave de origem gen\u00e9tica. Estima-se que a quilomicronemia possa ser encontrada em 1:600 adultos, mas os pacientes com SQF representam apenas 5% desses indiv\u00edduos.A diferencia\u00e7\u00e3o entre as duas doen\u00e7as pode ser feita pelas caracter\u00edsticas cl\u00ednicas e/ou laboratoriais de seus portadores. Pacientes com SQF costumam se apresentar geralmente com pancreatite, e os com SQM s\u00e3o mais propensos a terem doen\u00e7a cardiovascular ateroscler\u00f3tica. O diagn\u00f3stico precoce e correto das duas entidades \u00e9 fundamental para o sucesso terap\u00eautico e a preven\u00e7\u00e3o de mortalidade.Devido \u00e0 sua consider\u00e1vel sobreposi\u00e7\u00e3o fenot\u00edpica, as duas formas s\u00e3o dif\u00edceis de distinguir, e ainda existem v\u00e1rias perguntas sem resposta relacionadas \u00e0 preval\u00eancia, \u00e0s caracter\u00edsticas cl\u00ednicas e gen\u00e9ticas e ao manuseio cl\u00ednico.A SQF \u00e9 uma doen\u00e7a metab\u00f3lica grave e muito rara, caracterizada por quilomicronemia associada a epis\u00f3dios recorrentes de dor abdominal e/ou pancreatite.16 Frequentemente, manifesta-se na inf\u00e2ncia ou adolesc\u00eancia e tem sido descrita em todas as etnias, com maior preval\u00eancia em algumas \u00e1reas geogr\u00e1ficas, como Quebec, devido ao efeito fundador.17A estimativa mundial \u00e9 que a SQF ocorra em 1 para cada 500.000 a 1.000.000 pessoas.15 a SQF \u00e9 um dist\u00farbio lip\u00eddico monog\u00eanico, autoss\u00f4mico recessivo, cujo diagn\u00f3stico \u00e9 baseado na detec\u00e7\u00e3o de muta\u00e7\u00f5es raras, bial\u00e9licas (homozigoto ou heterozigoto composto) na LPL (>80% dos casos) e em outros genes que codificam as prote\u00ednas necess\u00e1rias para sua atividade, tais como APOC2 , APOA5 , GPIHBP1 e LMF1 , levando a uma redu\u00e7\u00e3o dr\u00e1stica da depura\u00e7\u00e3o dos quilom\u00edcrons.18 Normalmente, esses pacientes t\u00eam pouca resposta a medicamentos para reduzir os triglic\u00e9rides plasm\u00e1ticos, de modo que seu tratamento representa um desafio cl\u00ednico. A pedra angular da terapia da SQF \u00e9 representada por uma redu\u00e7\u00e3o dr\u00e1stica da ingest\u00e3o de gordura , terap\u00eautica esta dif\u00edcil de ser mantida ao longo do tempo. A ades\u00e3o a restri\u00e7\u00f5es alimentares dessa magnitude ao longo da vida do paciente \u00e9 dif\u00edcil, afeta negativamente a qualidade de vida e n\u00e3o elimina completamente o risco de pancreatite em todos os pacientes. A pancreatite aguda recorrente ocorre em 50% dos pacientes com SQF; a taxa geral de mortalidade associada \u00e9 de 5 a 6%, mas aumenta para 30% em subgrupos de pacientes que evoluem com necrose pancre\u00e1tica ou fal\u00eancia persistente de m\u00faltiplos \u00f3rg\u00e3os.19Tamb\u00e9m chamada de hiperlipoproteinemia tipo I de Fredrickson,20 A ocorr\u00eancia de SQM tende a crescer de forma linear com o aumento da preval\u00eancia de obesidade, s\u00edndrome metab\u00f3lica e diabetes tipo 2 na popula\u00e7\u00e3o mundial. Nos portadores dessa s\u00edndrome, a quilomicronemia \u00e9 flutuante e, na grande maioria, se manifesta tardiamente.15 Respondem bem a modifica\u00e7\u00f5es no estilo de vida e ao tratamento de fatores secund\u00e1rios, com boa resposta \u00e0s farmacoterapias redutoras de triglic\u00e9rides. Caracteriza-se por um risco aumentado de pancreatite aguda, mas o odds ratio estimado em 50 \u00e9 claramente menor que o odds ratio de 360 relatado em pacientes com SQF.21A SQM, tamb\u00e9m chamada de hiperlipoproteinemia tipo V de Fredrickson, \u00e9 um dist\u00farbio lip\u00eddico oligog\u00eanico ou polig\u00eanico agravado pela presen\u00e7a de comorbidades conhecidas por aumentar a trigliceridemia , fatores ambientais (consumo abusivo de \u00e1lcool e dieta rica em gorduras e a\u00e7\u00facares simples) e certos medicamentos, como glicocorticoides, etinilestradiol e neurol\u00e9pticos.22 Como o tratamento dessas duas formas de quilomicronemia \u00e9 muito diferente, \u00e9 importante fazer um diagn\u00f3stico apropriado. Novas terapias, como inibidores da APOC3, est\u00e3o em desenvolvimento para diminuir os triglic\u00e9rides em indiv\u00edduos com SQF.23\u00c9 poss\u00edvel diferenciar essas duas formas de quilomicronemia com base na eletroforese de lipoprote\u00ednas ou na ultracentrifuga\u00e7\u00e3o . O procedimento padr\u00e3o-ouro atual para identificar pacientes com SQF continua sendo o teste gen\u00e9tico ou a atividade da LPL p\u00f3s-heparina.retinalis , dores abdominais recorrentes, xantomas eruptivos, epis\u00f3dios de pancreatites de repeti\u00e7\u00e3o, dist\u00farbios cognitivos e neurol\u00f3gicos e comprometimento da qualidade de vida e da sociabilidade.24A SQF \u00e9 uma doen\u00e7a herdada, muito rara, acometendo cerca de 1-2:1.000.000 de indiv\u00edduos, com modo de transmiss\u00e3o autoss\u00f4mico recessivo, caracterizada por concentra\u00e7\u00f5es muito elevadas de triglic\u00e9rides , acompanhada de soro lip\u00eamico com aspecto cremoso, lipemia retinalis , em 4 a 36%; hepatoesplenomegalia ou esplenomegalia isolada, em 12% a 25%; dor abdominal, em 26 a 63%; pancreatite, em 60% a 88%; com m\u00faltiplas pancreatites, em 17 a 48% dos pacientes com SQF.26 O aspecto do soro \u00e9 importante para diferenciar situa\u00e7\u00f5es que causam o aumento do glicerol livre no sangue, levando a uma superestima\u00e7\u00e3o dos n\u00edveis de triglic\u00e9rides, sem a turva\u00e7\u00e3o do soro, observado ap\u00f3s permanecer por 12h em geladeira e excluindo-se causas de aumento de hiperglicerolemia .28As manifesta\u00e7\u00f5es cl\u00ednicas, no entanto, aparecem em frequ\u00eancia vari\u00e1vel nos portadores de SQF. Os xantomas eruptivos foram descritos em 17 a 23%; a lipemia 20 Na SQF, os quilom\u00edcrons, os quilom\u00edcrons remanescentes e as lipoprote\u00ednas ricas em triglic\u00e9rides n\u00e3o podem ser metabolizados e se acumulam no plasma. Dessa forma, o ac\u00famulo de triglic\u00e9rides pode prejudicar o fluxo sangu\u00edneo pancre\u00e1tico e ativar processos inflamat\u00f3rios, resultando em pancreatite aguda.30Na SQF, a HTG grave resulta da incapacidade da metaboliza\u00e7\u00e3o dos triglic\u00e9rides e outras gorduras. As gorduras s\u00e3o absorvidas pelo intestino delgado, no qual os quilom\u00edcrons s\u00e3o formados. Quando a LPL tem sua atividade normal, ela participa da hidr\u00f3lise dos triglic\u00e9rides de quilom\u00edcrons em \u00e1cidos graxos livres, por meio da via dependente da LPL.24 A s\u00edntese de LPL ocorre no intracelular de adip\u00f3citos e c\u00e9lulas musculares lisas. Ela \u00e9 produzida como um mon\u00f4mero, e o fator de matura\u00e7\u00e3o da lipase (LMF-1) \u00e9 necess\u00e1rio para que ocorra a correta homodimeriza\u00e7\u00e3o da LPL. Ap\u00f3s esse passo, a GPIHBP1, uma glicoprote\u00edna envolvida no transporte da LPL no l\u00famen dos capilares, facilita a ancoragem da LPL aos capilares endoteliais, em que hidrolisa os triglic\u00e9rides dos quilom\u00edcrons e de VLDL . As apolipoprote\u00ednas C2 e A5 participam como cofatores na ativa\u00e7\u00e3o da LPL. A hidr\u00f3lise dos triglic\u00e9rides dessas lipoprote\u00ednas libera \u00e1cidos graxos livres e monoglicer\u00eddeos, que s\u00e3o transportados aos mi\u00f3citos ou adip\u00f3citos, em que s\u00e3o utilizados para produ\u00e7\u00e3o de energia ou para estocar l\u00edpides.24O papel da LPL e de seus cofatores \u00e9 crucial para se entender o metabolismo das lipoprote\u00ednas ricas em triglic\u00e9rides.LPL levando a n\u00edveis de quilom\u00edcrons extremamente elevados na circula\u00e7\u00e3o e, portanto, HTG grave. Outros genes tamb\u00e9m foram descritos como cofatores na ativa\u00e7\u00e3o da LPL, a saber: APOC2 , APOA5 , LMF1 e GPIHBP1 .15Muta\u00e7\u00f5es em 5 genes diferentes t\u00eam sido implicadas no desenvolvimento de SQF, todas com efeito sobre a atividade da LPL, respons\u00e1vel pela remo\u00e7\u00e3o dos triglic\u00e9rides dos quilom\u00edcrons e de outras lipoprote\u00ednas ricas em triglic\u00e9rides na circula\u00e7\u00e3o, quebrando-os em \u00e1cidos graxos livres. Pacientes com SQF t\u00eam perda de fun\u00e7\u00e3o do gene et al .,28 em 1953, quando acompanhou tr\u00eas casos em uma fam\u00edlia de oito pessoas, com diagn\u00f3stico de hiperlipoproteinemia familiar idiop\u00e1tica. Os pacientes apresentavam soro leitoso, com triglic\u00e9rides muito elevados, e a dieta restrita em gorduras, seguida da administra\u00e7\u00e3o de heparina endovenosa, reduzia muito os triglic\u00e9rides, sugerindo que o defeito fosse relacionado \u00e0 remo\u00e7\u00e3o de triglic\u00e9rides da circula\u00e7\u00e3o.28A primeira descri\u00e7\u00e3o da SQF foi feita por Gaskins 31 Ao estudar tr\u00eas irm\u00e3os afetados pela condi\u00e7\u00e3o, os autores tamb\u00e9m sugeriram que outro defeito, al\u00e9m da LPL, poderia causar a ent\u00e3o chamada s\u00edndrome da hiperlipoproteinemia familiar idiop\u00e1tica.Em 1960, essa fam\u00edlia foi estudada e suspeitou-se que a LPL, enzima ancorada ao endot\u00e9lio vascular e liberada da parede pela heparina, seria a respons\u00e1vel pelo defeito lip\u00eddico.et al .32 reportaram que, de uma s\u00e9rie de amostras biol\u00f3gicas de 381 pacientes com triglic\u00e9rides >1.000mg/dL, quatro pacientes (ou 1%) apresentavam duas muta\u00e7\u00f5es com largo efeito por perda de fun\u00e7\u00e3o em ambos os alelos do gene da LPL , caracterizando a cl\u00e1ssica defici\u00eancia da LPL autoss\u00f4mica recessiva. Quando foram considerados pacientes com muta\u00e7\u00f5es em ambos os alelos dos quatro genes ditos menores , que modulam a atividade da LPL \u2013 a saber, apolipoprote\u00edna C2 ( APOC2 ), apolipoprote\u00edna A5 ( APOA5 ), fator de matura\u00e7\u00e3o da lipase 1 ( LMF1 ), e no gene glycoprotein-inositol high-density lipoprotein\u2013binding protein 1 ( GPIHBP1 ) \u2013, foram encontrados outros quatro pacientes, ou seja, mais 1%.34Por ser uma doen\u00e7a muito rara, os relatos de especialistas contribuem grandemente nas estimativas de preval\u00eancia. Hegele LPL ou em seus genes reguladores, os heterozigotos compostos, possuem duas muta\u00e7\u00f5es diferentes com perda de fun\u00e7\u00e3o, e aqueles com duas muta\u00e7\u00f5es em heterozigose em dois genes causais distintos, ou seja, heterozigotos duplos, somaram mais 1%.34Pacientes com duas muta\u00e7\u00f5es no gene LPL ou seus cofatores e outras variantes de menor impacto, ou, ainda, possuem forte componente de fatores ambientais. H\u00e1, assim, uma base polig\u00eanica com muitas variantes poss\u00edveis em diferentes combina\u00e7\u00f5es que est\u00e3o super-representadas entre esses pacientes com HTG graves, que perfazem a forma multifatorial (SQM).37Assim, estimou-se que cerca de 3% dos pacientes com HTG grave (triglic\u00e9rides \u22651.000mg/dL) dessa amostra tinham muta\u00e7\u00f5es em ambos os alelos dos genes que codificam a LPL ou uma das prote\u00ednas moduladoras de sua atividade. Esses pacientes podem ser homozigotos, heterozigotos compostos ou heterozigotos duplos. Essas condi\u00e7\u00f5es foram descritas entre os franco-canadenses da prov\u00edncia de Quebec, onde a porcentagem de pacientes com dois alelos mutantes \u00e9 maior devido a efeito fundador. Tal preval\u00eancia pode parecer pequena se comparada \u00e0 imensa maioria de pacientes com HTG grave. Contudo, na aus\u00eancia de teste gen\u00e9tico, n\u00e3o se pode separar a SQF (tipo I) da SQM (ou tipo V) em pacientes com triglic\u00e9rides \u22651.000mg/dL. Na verdade, a maioria dos pacientes com HTG grave (97%) apresenta uma base gen\u00e9tica, ainda n\u00e3o muito bem esclarecida, que inclui heterozigose para uma muta\u00e7\u00e3o com perda de fun\u00e7\u00e3o no gene et al .33 mostram que dos cinco genes causais, 34% das muta\u00e7\u00f5es encontradas foram no gene LPL .33 Comparando-se os dados cl\u00ednicos e laboratoriais de pacientes com SQF de v\u00e1rias etiologias gen\u00e9ticas, as SQF decorrentes de defeito no gene LPL s\u00e3o fenotipicamente muito semelhantes aos defeitos n\u00e3o relacionados ao gene LPL . No entanto, pacientes com defeito no gene LPL apresentam menor atividade da lipase p\u00f3s-heparina e tendem a ter triglic\u00e9rides mais elevados. J\u00e1 as concentra\u00e7\u00f5es de LDL-C s\u00e3o, em geral, maiores entre os portadores de defeitos em genes que n\u00e3o a LPL .38Os dados de Surendran National Health and Nutrition Examination Survey (NHANES) de 2001 a 2006, estimou-se a preval\u00eancia de HTG grave entre 5.680 adultos com mais de 20 anos, que dispunham de resultados de triglic\u00e9rides obtidos em jejum. Nesses, a preval\u00eancia de triglic\u00e9rides entre 500 e 2.000mg/dL foi de 1,7% (87 indiv\u00edduos), e >2.000mg/dL, encontrou-se apenas em tr\u00eas indiv\u00edduos.20 Esses dados extrapolados para a popula\u00e7\u00e3o norte-americana dariam uma estimativa de 3.357.214 de adultos com HTG grave com triglic\u00e9rides entre 500 e 2.000mg/dL e 81.877 \u22652.000mg/dL.39Utilizando-se dos dados do Oregon Health & Science University de julho de 2012 a julho de 2017.40 Foram revisados os dados eletr\u00f4nicos dos pacientes atendidos naquele per\u00edodo baseando-se em quatro crit\u00e9rios: triglic\u00e9rides \u2265880mg/dL, hist\u00f3ria de pancreatite aguda, aus\u00eancia de causas secund\u00e1rias de HTG e resposta insuficiente (<20%) \u00e0 terapia redutora de triglic\u00e9rides. Quando tr\u00eas desses quatro crit\u00e9rios eram preenchidos, considerava-se prov\u00e1vel SQF. Na presen\u00e7a de quatro crit\u00e9rios, ou se houvesse confirma\u00e7\u00e3o da presen\u00e7a de muta\u00e7\u00e3o em genes causais, considerava-se diagn\u00f3stico definitivo de SQF. Dos 2.342.136 dados eletr\u00f4nicos avaliados, 578 pacientes tinham triglic\u00e9rides \u2265880mg/dL , dos quais 86 tinham hist\u00f3ria documentada de pancreatite. Cinco pacientes que preencheram os crit\u00e9rios de SQF foram identificados e tr\u00eas obtiveram confirma\u00e7\u00e3o gen\u00e9tica, resultando em uma preval\u00eancia estimada de 1-2 por 1.000.000 de pessoas. J\u00e1 a SQM foi identificada em 186 pacientes, correspondendo a uma preval\u00eancia estimada de 1 em 12.000 pessoas. Houve 5.181 casos de pancreatite , 86 destes ocorreram em indiv\u00edduos com triglic\u00e9rides \u2265880mg/dL . As taxas de pancreatite nesta subamostra se elevaram para 6,5%, 100%, e 17,8% entre pacientes com SQM, SQF e HTG de causas secund\u00e1rias, respectivamente.40Um estudo retrospectivo transversal avaliou pacientes da Cleveland Clinic Lipid Center de janeiro a dezembro de 2006, usando o valor de corte de triglic\u00e9rides \u2265750mg/dL e a presen\u00e7a de pancreatite pr\u00e9via como crit\u00e9rios, foram encontrados 369 indiv\u00edduos que perfaziam essas condi\u00e7\u00f5es. Desses, 333 correspondiam a causas secund\u00e1rias, ou os dados eram inconsistentes ou faltantes e foram exclu\u00eddos. Dos 36 participantes restantes, 14 tinham crit\u00e9rios de SQF.41 Segundo os autores, nessa coorte de SQF, a preval\u00eancia encontrada foi de pelo menos 1:5.000, com base em crit\u00e9rios diagn\u00f3sticos estabelecidos.42 Esses dados representam uma preval\u00eancia >20-200 vezes os dados de preval\u00eancia de relatos anteriores. Um rastreamento de pacientes com triglic\u00e9rides \u22651.000mg/dL e hist\u00f3ria de pancreatite a partir dos dados eletr\u00f4nicos da North Texas Division of the Baylor Scott & White Health System , no per\u00edodo de setembro de 2015 a setembro de 2016, evidenciou que de 297.891 pacientes adultos com valores dispon\u00edveis de triglic\u00e9rides, 334  tinham valores de triglic\u00e9rides \u22651.000mg/dL, e 30 (9%) desses tiveram pancreatite. Desses, seis casos foram exclu\u00eddos devido a causas secund\u00e1rias. Dos 24 casos restantes, os maiores valores m\u00e9dios de triglic\u00e9rides encontrados foram de 3.085 +/- 1.211mg/dL. Assim, o rastreio eletr\u00f4nico dos triglic\u00e9rides \u22651.000mg/dL e a hist\u00f3ria de pancreatite permitiram afastar 99,99% das HTG graves, restando 24 casos em que a SQF n\u00e3o p\u00f4de ser exclu\u00edda, sugerindo uma preval\u00eancia de 1 em 12.413 pessoas. Uma importante limita\u00e7\u00e3o aos dados desses dois estudos foi a indisponibilidade de confirma\u00e7\u00e3o gen\u00e9tica.43Em outro estudo retrospectivo, com dados de 70.201 pacientes atendidos na APOE , E2E2), 182 com HTG tipo IV e 82 pacientes com HTG tipo V. Do ponto de vista cl\u00ednico, quanto maiores as concentra\u00e7\u00f5es de triglic\u00e9rides e quanto mais leitoso o plasma, houve maior risco de pancreatites. O exame visual do plasma e o fen\u00f3tipo cl\u00ednico foram \u00fateis para estabelecer o risco cardiometab\u00f3lico dos pacientes, sendo o reconhecimento do plasma lactescente uma ferramenta diagn\u00f3stica simples que pode auxiliar na identifica\u00e7\u00e3o daqueles de maior risco.44Outro estudo em Quebec avaliou a apar\u00eancia do plasma e classificou os pacientes de acordo com os valores de triglic\u00e9rides, a prov\u00e1vel etiologia e as caracter\u00edsticas bioqu\u00edmicas. Um total de 354 pessoas com plasma lactescente foi comparado a 482 pacientes com plasma claro, mas com triglic\u00e9rides >5mmol/L (cerca de 440mg/dL) e com 364 controles normolipid\u00eamicos . Os autores observaram que o plasma lactescente representava um grupo heterog\u00eaneo de pacientes de alto risco e, entre aqueles, foram encontrados 28 pacientes com SQF, 62 com disbetalipoproteinemia  73 genes e 185 polimorfismos de nucleot\u00eddeo \u00fanico (SNPs) associados com hiperlipidemia, al\u00e9m dos cinco genes causais para SQF , encontrou-se que 1,1% tinha variantes bial\u00e9licas raras, 14,4% tinham variantes raras em heterozigose e 32% dispunham de um ac\u00famulo de variantes comuns, ou seja, um escore polig\u00eanico elevado, e 52% permaneceram n\u00e3o identificados. Os pacientes com HTG grave eram 5,77 vezes mais propensos a carrear uma dessas variantes de suscetibilidade do que os controles.36J\u00e1 os dados de Dron et al.45 O caso \u00edndice era de uma mulher com m\u00faltiplos epis\u00f3dios de pancreatite, um deles durante a gesta\u00e7\u00e3o e que necessitou de plasmaf\u00e9rese. Foi tamb\u00e9m avaliada a preval\u00eancia de HTG grave a partir de dados populacionais obtidos de um laborat\u00f3rio de refer\u00eancia onde foram afastadas causas secund\u00e1rias  e diabetes. A mulher de 28 anos tinha HTG e pancreatites recorrentes, com in\u00edcio aos 3 meses de idade. Obtinha controle razo\u00e1vel dos triglic\u00e9rides com dieta pobre em gorduras at\u00e9 os 20 anos, quando passou a apresentar epis\u00f3dios recorrentes de pancreatites, e triglic\u00e9rides em jejum >2.000mg/dL, necessitando de m\u00faltiplas hospitaliza\u00e7\u00f5es, a despeito do tratamento. Al\u00e9m da dieta restrita, recebeu fenofibrato, triglic\u00e9rides de cadeia m\u00e9dia, \u00e1cido nicot\u00ednico e \u00e1cidos graxos \u00f4mega-3, sem resposta satisfat\u00f3ria. Durante a gesta\u00e7\u00e3o, aos 30 anos, necessitou de plasmaf\u00e9rese semanal ou a cada 2 semanas, at\u00e9 o parto. Seus pais e uma irm\u00e3 tinham HTG e hist\u00f3ria de pancreatite. A paciente era heterozig\u00f3tica composta para muta\u00e7\u00f5es no gene LPL (dele\u00e7\u00e3o c.708delA [p.G237fs*15] e variante missense c.644G.A [p.G215E]), que comprometem a fun\u00e7\u00e3o da LPL. O pai apresentava a variante com dele\u00e7\u00e3o c.708delA (p.G237fs*15), a m\u00e3e e a irm\u00e3, a variante c.644G.A (p.G215E). A an\u00e1lise de 207.926 indiv\u00edduos da popula\u00e7\u00e3o encontrou 25 com triglic\u00e9rides em jejum >2.000mg/dL, sem evid\u00eancias de causas secund\u00e1rias, estimando-se uma preval\u00eancia de 120/1 milh\u00e3o de indiv\u00edduos.45Um relato de SQF em uma fam\u00edlia com tr\u00eas membros afetados que apresentavam HTG grave e epis\u00f3dios de pancreatite teve seu painel gen\u00e9tico analisado.46Em outro estudo, a preval\u00eancia de SQF foi avaliada em uma \u00e1rea basicamente rural na regi\u00e3o central do estado de Nova York com uma popula\u00e7\u00e3o estimada em 870.000 habitantes. Analisando-se os dados de prontu\u00e1rios eletr\u00f4nicos de 385.000 pacientes, foram encontrados 998 com triglic\u00e9rides >750mg/dL, sendo que 994 foram eliminados por causas secund\u00e1rias de HTG, resposta satisfat\u00f3ria ao tratamento ou por dados incompletos. Restaram 4 pacientes com crit\u00e9rios de SQF. Assim, a chance de encontrar 4 casos em 870.000 seria de 0,01, o que sugere que a preval\u00eancia de 1/1.000.000 seja subestima\u00e7\u00e3o. Atribuiu-se a alta preval\u00eancia a um prov\u00e1vel efeito fundador.47A preval\u00eancia de SQF foi tamb\u00e9m avaliada de maneira retrospectiva a partir de dados de prontu\u00e1rios eletr\u00f4nicos de 7.699.288 pacientes da Universidade da Calif\u00f3rnia do Sul, com triglic\u00e9rides >880mg/dL, pelo menos um epis\u00f3dio de pancreatite, resposta \u00e0 terapia hipolipemiante <20% e afastadas causas secund\u00e1rias. Essa an\u00e1lise mostrou uma preval\u00eancia de SQF de 0,26 a 0,65 por milh\u00e3o de indiv\u00edduos.48 Foram revistos dados de 1.627.763 pacientes atendidos no Hospital Johns Hopkins de 2013 a 2017. O crit\u00e9rio para SQF incluiu pacientes com a) triglic\u00e9rides >750mg/dL em pelo menos uma dosagem, b) hist\u00f3ria de pancreatite aguda, dores abdominais recorrentes n\u00e3o explicadas e/ou hist\u00f3ria familiar de HTG e c) aus\u00eancia de causas secund\u00e1rias de HTG. Foram encontrados 21 casos de SQF e 89 de causas secund\u00e1rias de HTG. A preval\u00eancia de SQF nesse estudo foi de 13:1.000.000 (IC95% 8-20).48Finalmente, a preval\u00eancia de SQF foi determinada em um centro de aten\u00e7\u00e3o quatern\u00e1ria.Children\u2019s Medical Center , Dallas ) e dos dados do NHANES de 2000-2015 foram pesquisados. De 30.623 crian\u00e7as do Children\u2019s Medical Center , 36 (1 em 1.000) tinham triglic\u00e9rides com eleva\u00e7\u00e3o extrema (\u22652.000mg/dL), e um ter\u00e7o dessas desenvolveu pancreatite aguda. A maioria desses casos correspondia a causas secund\u00e1rias de HTG, sendo a preval\u00eancia estimada de SQF em crian\u00e7as de 1:6.000 em um centro de aten\u00e7\u00e3o terci\u00e1ria e de 1:300.000 em crian\u00e7as da popula\u00e7\u00e3o geral. Dos dados do NHANES 2.000-2015, nenhuma das 2.362 crian\u00e7as preencheu os crit\u00e9rios de HTG extrema, enquanto, nos adultos do NHANES, a preval\u00eancia estimada era de 0,02%.49Em crian\u00e7as, n\u00e3o existem dados acerca da preval\u00eancia de HTG grave e de SQF. An\u00e1lise retrospectiva de prontu\u00e1rios eletr\u00f4nicos de um hospital pedi\u00e1trico terci\u00e1rio ; Chr8:19.813.385 G>A, promovendo a substitui\u00e7\u00e3o do amino\u00e1cido arginina no c\u00f3don 270 por histidina (p.Arg270His); e Chr8:19.811.823 T>C, promovendo a substitui\u00e7\u00e3o do amino\u00e1cido isoleucina no c\u00f3don 245 por treonina (p.Ile245Thr). A conduta diet\u00e9tica foi leite desnatado, triglic\u00e9rides de cadeia m\u00e9dia (TCM) e vitaminas A, D, E e K. Ap\u00f3s a alta, foi mudada a dieta, recebendo f\u00f3rmula l\u00e1ctea que levou a aumento dos triglic\u00e9rides (11760mg/dL). Foi institu\u00eddo jejum e restitu\u00edda a conduta diet\u00e9tica anterior, o que permitiu controle razo\u00e1vel da trigliceridemia, crescimento e ganho ponderal adequados.55Dois outros casos de irm\u00e3os com SQF com confirma\u00e7\u00e3o gen\u00e9tica de muta\u00e7\u00e3o no gene 56 publicaram recentemente 12 casos de SQF em pacientes com muta\u00e7\u00e3o em homozigose em regi\u00e3o intr\u00f4nica do gene GPIHBP1 , todos com HTG grave (2351mg/dL [885-20600mg/dL]), HDL-c baixo (18mg/dL [5-41mg/dL]) e 33% com epis\u00f3dios de pancreatite aguda. Todos os pacientes eram oriundos de cidades do Nordeste do pa\u00eds, sugerindo um efeito fundador.56Lima et al.A falta de crit\u00e9rios cl\u00ednicos padronizados, a semelhan\u00e7a com a SQM, a escassez de testes gen\u00e9ticos confirmat\u00f3rios, a falta de registros nacionais e internacionais e, ainda, o efeito fundador dos genes causais fazem com que os dados de preval\u00eancia da SQF sejam t\u00e3o vari\u00e1veis de estudo para estudo.2As manifesta\u00e7\u00f5es cl\u00ednicas das formas monog\u00eanicas de quilomicronemia, em geral, ocorrem na inf\u00e2ncia ou in\u00edcio da vida adulta. Entretanto, por se tratar de uma doen\u00e7a relativamente rara, atrasos no diagn\u00f3stico s\u00e3o comuns, fazendo com que o mesmo ocorra na vida adulta, quando as complica\u00e7\u00f5es j\u00e1 est\u00e3o estabelecidas.57 Outras s\u00e9ries descrevem uma m\u00e9dia de avalia\u00e7\u00e3o por cinco m\u00e9dicos diferentes antes de o diagn\u00f3stico vir a ser estabelecido.58Uma revis\u00e3o de base de dados do estudo APPROACH demonstrou que a m\u00e9dia de idade ao diagn\u00f3stico era 24 anos, com mais da metade dos 66 pacientes tendo sido diagnosticados ap\u00f3s os 20 anos de idade. Ao diagn\u00f3stico, 75% j\u00e1 haviam apresentado o primeiro epis\u00f3dio de pancreatite.Estes refor\u00e7am a import\u00e2ncia do diagn\u00f3stico precoce e oportuno. As principais manifesta\u00e7\u00f5es cl\u00ednicas da SQF est\u00e3o descritas a seguir.very low-density lipoproteins ) e, principalmente, quilom\u00edcrons circulantes. Como uma pequena quantidade de colesterol tamb\u00e9m \u00e9 transportada e encontra-se presente nos quilom\u00edcrons, o colesterol total pode estar elevado, em geral em uma propor\u00e7\u00e3o triglic\u00e9rides/colesterol <5:1. Muitos pacientes t\u00eam aumento moderado da VLDL-c, mas com n\u00edveis de LDL-colesterol e apolipoprote\u00edna B <100mg/dL.21Na avalia\u00e7\u00e3o laboratorial, os pacientes afetados t\u00eam hiperquilomicronemia, apresentando-se com grande aumento dos triglic\u00e9rides \u2013 em geral, na faixa de 1.500 a 5.000mg/dL \u2013, \u00e0s custas de aumento de VLDL-colesterol . N\u00e3o raramente, a severidade da dieta dificulta a ades\u00e3o dos pacientes ao tratamento a longo prazo e impacta de forma significativa a sua qualidade de vida.27Dor abdominal recorrente \u00e9 uma manifesta\u00e7\u00e3o presente em at\u00e9 50% dos pacientes e n\u00e3o \u00e9 necessariamente associada com os quadros de pancreatite aguda, podendo ser incapacitante.59Em m\u00e9dia, a partir do n\u00edvel de triglic\u00e9rides >1.000mg/dL, ocorre aumento da incid\u00eancia de 3% no risco de pancreatite a cada eleva\u00e7\u00e3o de 100mg/dL de triglic\u00e9rides.22 Provavelmente, isso decorre de um maior tempo de exposi\u00e7\u00e3o \u00e0 hiperquilomicronemia, que, no caso da SQF, tende a ocorrer nos primeiros anos de vida.Um estudo canadense comparou um grupo de 25 indiv\u00edduos com SQF e outro com 36 pacientes com SQM e demonstrou que, apesar de apresentarem mesmos n\u00edveis m\u00e9dios de triglic\u00e9rides, o grupo com SQF apresentou 10 vezes mais risco (60 x 6%) de pancreatite.59Os m\u00faltiplos epis\u00f3dios de pancreatite aguda e a severidade das restri\u00e7\u00f5es alimentares impactam de forma negativa a qualidade da vida do paciente e aumentam consideravelmente a morbimortalidade pela doen\u00e7a. Pancreatite recorrente ocorre em 50% dos pacientes com SQF; a taxa geral de mortalidade associada \u00e9 de 5 a 6%, podendo chegar a 30% em subgrupos de pacientes que evoluem com necrose pancre\u00e1tica ou fal\u00eancia persistente de m\u00faltiplos \u00f3rg\u00e3os.mental fog \u201d \u2013 est\u00e3o entre os sintomas mais comumente descritos entre os pacientes acometidos com SQF.58Fadiga, confus\u00e3o mental, irritabilidade e d\u00e9ficits cognitivos \u2013 descritos como \u201c 57A hepatosplenomegalia \u00e9 um dos achados revers\u00edveis com o tratamento e resulta do ac\u00famulo do excesso de quilom\u00edcrons nos macr\u00f3fagos do sistema reticuloendotelial na SQF.27Os xantomas correspondem a les\u00f5es cut\u00e2neas eruptivas, de colora\u00e7\u00e3o amarelada, geralmente com halo eritematoso e cerca de 2 a 5 mm de di\u00e2metro. S\u00e3o encontrados em superf\u00edcies extensoras (cotovelos e joelhos) e n\u00e1degas. Sua preval\u00eancia \u00e9 baixa (acomete de 17 a 33% dos pacientes), e nem sempre se correlacionam com a ocorr\u00eancia dos epis\u00f3dios de pancreatite.57Trata-se da apar\u00eancia leitosa do sangue nos vasos retinianos ao fundo de olho, e pode ser observada em at\u00e9 30% dos pacientes, correlacionando-se com n\u00edveis maiores de triglic\u00e9rides.58O estudo IN-FOCUS, com 166 pacientes com SQF, mostrou o importante impacto da doen\u00e7a na qualidade de vida. As taxas de interna\u00e7\u00e3o podem interferir nas condi\u00e7\u00f5es sociais e possibilidades de emprego, e mais de 22% referiram depress\u00e3o ou ansiedade relacionada \u00e0 dor ou a epis\u00f3dios de pancreatite.21 Adicionalmente, sua aplicabilidade \u00e9 question\u00e1vel, visto que utilizam a presen\u00e7a de epis\u00f3dios de pancreatite pr\u00e9vios nos seus crit\u00e9rios de pontua\u00e7\u00e3o.59 Fundamentalmente, o objetivo de utiliza\u00e7\u00e3o de escores de diagn\u00f3stico consiste em rastreamento de pacientes assintom\u00e1ticos e preven\u00e7\u00e3o de complica\u00e7\u00f5es como a pancreatite aguda. A avalia\u00e7\u00e3o de bases de dados com maior n\u00famero de pacientes com SQF e o detalhamento de formas cl\u00ednicas dever\u00e3o contribuir para elabora\u00e7\u00e3o de crit\u00e9rios com melhor sensibilidade e especificidade para o diagn\u00f3stico da SQF.Algumas escalas ou escores de pontua\u00e7\u00e3o a partir das manifesta\u00e7\u00f5es cl\u00ednicas t\u00eam sido propostas para diagn\u00f3stico de SQF; entretanto, sua valida\u00e7\u00e3o precisa ser feita em maiores amostras de popula\u00e7\u00f5es com HTG grave.21 que utiliza como crit\u00e9rio de sele\u00e7\u00e3o a presen\u00e7a de HTG grave (>1.000mg/dL em jejum e fora da fase aguda), e pontua quando h\u00e1 presen\u00e7a de valores elevados de triglic\u00e9rides, afastadas causas secund\u00e1rias, hist\u00f3ria de pancreatite, dor abdominal recorrente, falta de resposta ao tratamento usual para redu\u00e7\u00e3o de triglic\u00e9rides, al\u00e9m de idade de in\u00edcio dos sintomas  e condi\u00e7\u00f5es fisiol\u00f3gicas como gesta\u00e7\u00e3o, principalmente no terceiro trimestre.60 Em geral, a preval\u00eancia de SQM tende a crescer de forma linear com o aumento da preval\u00eancia das causas secund\u00e1rias mais comuns . Entre os portadores da SQM, a quilomicronemia \u00e9 flutuante e se manifesta em fases mais tardias da vida quando comparada \u00e0 SQF. Adicionalmente, a SQM tende a apresentar melhor resposta terap\u00eautica \u00e0s modifica\u00e7\u00f5es no estilo de vida e ao tratamento dos fatores secund\u00e1rios, bem como \u00e0s farmacoterapias redutoras de triglic\u00e9rides. A SQM caracteriza-se por um risco aumentado de pancreatite, por\u00e9m menor que aquele relatado em pacientes com SQF.60Em adultos, o principal diagn\u00f3stico diferencial da SQF \u00e9 com a SQM. Anteriormente denominada hiperlipoproteinemia tipo V de Fredrickson ou HTG severa polig\u00eanica, a HTG multifatorial \u00e9 um dist\u00farbio polig\u00eanico, que inclui variantes heterozigotas raras nos cinco genes SQF ou variantes comumente associadas a hipetrigliceridemia, agravado pela presen\u00e7a de comorbidades ou causas secund\u00e1rias de aumento dos triglic\u00e9rides como diabetes n\u00e3o controlado, hipotireoidismo, obesidade e s\u00edndrome metab\u00f3lica.62Outro relevante diagn\u00f3stico diferencial da SQF s\u00e3o as lipodistrofias, um grupo heterog\u00eaneo de enfermidades caracterizadas pela perda seletiva de tecido adiposo e que podem cursar com HTG grave e pancreatite. As lipodistrofias podem ser herdadas ou adquiridas e, quanto \u00e0 extens\u00e3o do acometimento, generalizadas ou parciais, sendo as formas parciais associadas \u00e0 infec\u00e7\u00e3o pelo HIV as mais comuns. As lipodistrofias herdadas s\u00e3o dist\u00farbios raros, que podem se manifestar no nascimento ou apresentar perda de gordura em fases mais tardias da vida. Tais condi\u00e7\u00f5es ainda s\u00e3o um desafio diagn\u00f3stico, principalmente as formas parciais, que devem ter sua suspeita diagn\u00f3stica considerada na presen\u00e7a de HTG moderada a grave associada \u00e0 medida de prega cut\u00e2nea da coxa <22mm em mulheres, ou menor que 10 mm em homens, e/ou casos de diabetes com necessidade de uso de insulina subcut\u00e2nea em doses di\u00e1rias >2UI/kg.63 Apesar de ser uma causa menos frequente, valores elevados de trigliceridemia em pacientes com pancreatite se associam com maior mortalidade e pior progn\u00f3stico.65 Na gesta\u00e7\u00e3o, o estr\u00f3geno estimula a produ\u00e7\u00e3o de VLDL hep\u00e1tico e reduz a remo\u00e7\u00e3o de triglic\u00e9rides pela LPL no f\u00edgado e tecido adiposo, de modo que a HTG passa a ser a causa mais frequente de pancreatite aguda.66Pancreatite aguda \u00e9 um evento relativamente frequente, com diferentes causas, incluindo a HTG. Identificar a causa espec\u00edfica \u00e9 fundamental para estabelecer o tratamento e prevenir futuros epis\u00f3dios. Nas diversas s\u00e9ries, colelit\u00edase \u00e9 a principal causa, seguida por consumo de \u00e1lcool e HTG (menos de 10%).67 Esse risco, bem como a severidade, aumenta mais ainda naqueles pacientes com valores >2.000mg/dL.69 Isso independe de a causa b\u00e1sica da HTG ser prim\u00e1ria (gen\u00e9tica) ou secund\u00e1ria. Contudo, as causas gen\u00e9ticas geralmente cursam com valores mais elevados de trigliceridemia e, consequentemente, apresentam risco mais elevado de pancreatite.Os epis\u00f3dios de pancreatite em decorr\u00eancia de HTG geralmente acontecem com valores de trigliceridemia >1.000mg/dL.Na classifica\u00e7\u00e3o de Fredrickson, os tipos I (quilom\u00edcron), IV (VLDL) e V (quilom\u00edcron e VLDL) apresentam HTG, sendo que a SQF (tipo I) apresenta valores mais elevados e podem evoluir com pancreatites independentemente de fatores desencadeantes .70 Outro potencial mecanismo \u00e9 decorrente do ac\u00famulo de GAD (descarboxilase do \u00e1cido glut\u00e2mico). Na falta de a\u00e7\u00e3o da LPL e consequente ac\u00famulo de quilom\u00edcrons, h\u00e1 tamb\u00e9m aumento de GAD que desencadeia inflama\u00e7\u00e3o mediada por TNF-alfa e IL6. Tamb\u00e9m, o pr\u00f3prio quilom\u00edcron pode obstruir a circula\u00e7\u00e3o pancre\u00e1tica distal e causar isquemia.O mecanismo causador da pancreatite n\u00e3o \u00e9 totalmente conhecido, mas os triglic\u00e9rides, por si s\u00f3, n\u00e3o parecem atuar diretamente no p\u00e2ncreas. O ac\u00famulo de \u00e1cidos graxo livre nas c\u00e9lulas pancre\u00e1ticas acontece na presen\u00e7a de lipase pancre\u00e1tica e desencadeia a les\u00e3o celular e a inflama\u00e7\u00e3o pancre\u00e1tica.58 Alguns pacientes at\u00e9 evitam ir para festas e reuni\u00f5es, porque temem comer e desencadear a pancreatite. Crian\u00e7as precisam de vigil\u00e2ncia constante dos pais, pois, uma vez que n\u00e3o entendem adequadamente a doen\u00e7a, querem comer como os colegas que n\u00e3o apresentam a doen\u00e7a. Ap\u00f3s apresentarem um primeiro epis\u00f3dio de pancreatite , a dor do quadro agudo e a necessidade do internamento hospitalar s\u00e3o fatores que motivam seguir mais rigorosamente a dieta restritiva exigida para o controle da HTG severa.Independentemente da etiologia, a apresenta\u00e7\u00e3o cl\u00ednica da pancreatite \u00e9 semelhante. N\u00e3o raramente, pacientes com SQF apresentam epis\u00f3dios repetidos de pancreatite, e alguns referem na anamnese que n\u00e3o sabem quantos foram, mas que foram muitos. Isso desencadeia altera\u00e7\u00f5es psicol\u00f3gicas, comprometendo a qualidade de vida.Xantomas eruptivos n\u00e3o s\u00e3o frequentes, mesmo com a HTG severa. No entanto, quando presentes em um paciente com pancreatite aguda, sugerem a HTG como causa etiol\u00f3gica. Superf\u00edcies extensoras de bra\u00e7os e pernas s\u00e3o os locais mais frequentes. Infiltra\u00e7\u00e3o gordurosa de f\u00edgado e ba\u00e7o, levando \u00e0 hepatoesplenomegalia, tamb\u00e9m pode acontecer, mas \u00e9 mais inespec\u00edfica.67O diagn\u00f3stico da pancreatite aguda deve se iniciar com uma suspeita cl\u00ednica , sendo confirmada por exames laboratoriais  e de imagem . Pelo menos dois desses tr\u00eas achados devem estar presentes para confirma\u00e7\u00e3o diagn\u00f3stica, e isso independe da etiologia da pancreatite. N\u00e3o raramente, pacientes podem apresentar dor abdominal isolada, sem altera\u00e7\u00f5es laboratoriais ou de imagem. Na aus\u00eancia de um quadro cl\u00ednico sugestivo, dosagens de lipase e amilase podem mais confundir que ajudar. Valores de triglic\u00e9rides <1.000mg/dL durante o epis\u00f3dio cl\u00ednico sugestivo de pancreatite deixam a HTG como causa improv\u00e1vel da pancreatite.63Uma vez confirmado o diagn\u00f3stico, o tratamento dever\u00e1 objetivar reduzir/eliminar a dor, bem como manter hidrata\u00e7\u00e3o adequada e, mesmo com dieta oral suspensa, permitir nutri\u00e7\u00e3o adequada ao quadro agudo. A redu\u00e7\u00e3o da trigliceridemia \u00e9 fundamental para reverter o processo inflamat\u00f3rio e, sendo ela \u00e0s custas de quilom\u00edcron, responder\u00e1 mais facilmente \u00e0 restri\u00e7\u00e3o da dieta oral. Nos casos mais severos , com necessidade de uma redu\u00e7\u00e3o mais r\u00e1pida da trigliceridemia, plasmaf\u00e9rese pode ser utilizada. Se uma dieta adequada n\u00e3o for institu\u00edda ou fator desencadeante n\u00e3o forem controlados, a remiss\u00e3o do quadro \u00e9 mais dif\u00edcil. Insulina estimula LPL e tamb\u00e9m pode ser utilizada em alguns casos . Da mesma forma, heparina tamb\u00e9m atua estimulando a LPL, mas seu uso deve ser avaliado, pois pode n\u00e3o trazer benef\u00edcios ao m\u00e9dio prazo (aumenta risco de sangramento e de libera\u00e7\u00e3o de componentes t\u00f3xicos dos triglic\u00e9rides).Uma vez que o paciente saia do quadro agudo da pancreatite, deve-se avaliar e tratar o fator que desencadeou o processo inflamat\u00f3rio. Manter peso adequado, praticar exerc\u00edcios regularmente e evitar medica\u00e7\u00f5es ou outros fatores desencadeantes de HTG ajudam a prevenir novos eventos de pancreatite.23 Do ponto de vista fisiopatol\u00f3gico e considerando os benef\u00edcios demonstrados nos estudos cl\u00ednicos, pacientes com SQF se beneficiam do uso de volanesorsen. Entretanto, aqueles pacientes com pancreatites frequentes  e com dificuldade para controlar a trigliceridemia com o tratamento usual diet\u00e9tico teriam maior benef\u00edcio.Diferentemente de outras causas de HTG que respondem bem aos fibratos, a SQF, caracteristicamente, n\u00e3o apresenta redu\u00e7\u00e3o significativa da trigliceridemia com essas medica\u00e7\u00f5es, n\u00e3o sendo utilizada com finalidade de prevenir pancreatites nesses pacientes. A apo C3 \u00e9 um fator inibit\u00f3rio da LPL, e sua inibi\u00e7\u00e3o com o volanesorsen (um oligonucleot\u00eddeo antissentido da apo C3), com uma aplica\u00e7\u00e3o por semana, reduziu significativamente (77%) a trigliceridemia e, consequentemente, a chance de pancreatite.O laborat\u00f3rio cl\u00ednico tem um papel coadjuvante no diagn\u00f3stico da SQF. O aspecto do soro leitoso \u00e9 o principal indicador da presen\u00e7a de quilom\u00edcrons e acompanha os altos n\u00edveis de triglic\u00e9rides. Algumas considera\u00e7\u00f5es devem ser observadas para que o diagn\u00f3stico laboratorial seja eficaz no rastreamento da SQF. As fases respons\u00e1veis pelo resultado da an\u00e1lise laboratorial dos exames que fazem parte da investiga\u00e7\u00e3o da SQF s\u00e3o: pr\u00e9-anal\u00edtica, anal\u00edtica e p\u00f3s-anal\u00edtica.73 Para crian\u00e7as, o tempo varia de acordo com a faixa et\u00e1ria. Para lactentes, at\u00e9 1 ano, o jejum \u00e9 de 3 horas ou imediatamente antes da pr\u00f3xima mamada; em n\u00e3o lactentes, de 2 a 5 anos, o jejum \u00e9 de 6 horas. E para crian\u00e7as acima de 5 anos e adolescentes, o jejum \u00e9 de 12 horas.O jejum deixou de ser obrigat\u00f3rio para o exame do perfil lip\u00eddico; no entanto, em situa\u00e7\u00f5es como nos dist\u00farbios no metabolismo dos triglic\u00e9rides, ele se imp\u00f5e para a confirma\u00e7\u00e3o diagn\u00f3stica da SQF. Nesses casos, o jejum deve ser de 12 horas para os adultos acima de 20 anos.74O preparo para a coleta da amostra para o exame dos triglic\u00e9rides para o adulto (>20 anos) consta de jejum pr\u00e9vio de 12 horas, em que o paciente deve estar com a sua alimenta\u00e7\u00e3o habitual mantida; o consumo de \u00e1lcool deve ser evitado nas 72 horas antes, e n\u00e3o deve realizar exerc\u00edcios f\u00edsicos extenuantes nas 24 horas anteriores.74Algumas situa\u00e7\u00f5es causam o aumento do glicerol livre no sangue, levando a uma superestima\u00e7\u00e3o dos n\u00edveis de triglic\u00e9rides, sem o acompanhamento de turva\u00e7\u00e3o do soro. Nesses casos, deve ser observado se o paciente teve um dos eventos descritos na literatura: exerc\u00edcio f\u00edsico recente, ingest\u00e3o alc\u00f3olica, doen\u00e7a hep\u00e1tica aguda, diabetes descompensado, nutri\u00e7\u00e3o parenteral ou medica\u00e7\u00e3o intravenosa contendo glicerol.74Na HTG, o aspecto do soro varia de turvo para leitoso. Grau I \u2013 levemente turvo; Grau 2 \u2013 turvo; Grau 3 \u2013 muito turvo; Grau 4 \u2013 leitoso. Como o aspecto do soro \u00e9 subjetivo, somente ap\u00f3s a dosagem de triglic\u00e9rides e o repouso de 12 horas do soro em geladeira teremos a informa\u00e7\u00e3o da observa\u00e7\u00e3o visual.As metodologias que podem ser utilizadas para indicar a presen\u00e7a de quilom\u00edcrons (Q) no soro s\u00e3o mostradas a seguir.8.2.1.1. Ultracentrifuga\u00e7\u00e3o\u00c9 o m\u00e9todo padr\u00e3o-ouro que separa as fra\u00e7\u00f5es de lipoprote\u00ednas de acordo com o teor de l\u00edpides e a sua densidade. Contudo, esse m\u00e9todo apresenta limita\u00e7\u00f5es inerentes, entre as quais falta de disponibilidade em laborat\u00f3rios cl\u00ednicos, alto custo e morosidade para a realiza\u00e7\u00e3o da t\u00e9cnica, tornando-se invi\u00e1vel nos laborat\u00f3rios brasileiros.8.2.1.2. Aspecto do Soro75 Quando n\u00e3o for poss\u00edvel, depois da centrifuga\u00e7\u00e3o e da retirada do volume para as an\u00e1lises laboratoriais, fazer a transfer\u00eancia de 1mL de soro para um tubo de hem\u00f3lise descart\u00e1vel transparente . O soro leitoso obtido, em qualquer situa\u00e7\u00e3o, dever\u00e1 ficar em repouso na geladeira por 12 horas para ser observada a forma\u00e7\u00e3o de uma capa cremosa, na superf\u00edcie do tubo, indicando a presen\u00e7a de quilom\u00edcrons que deve ser reportada no laudo do paciente.74Para a observa\u00e7\u00e3o de quilom\u00edcrons no soro leitoso, recomendamos o uso de tubo coletor de sangue total com sistema de separa\u00e7\u00e3o de fases na centrifuga\u00e7\u00e3o e obten\u00e7\u00e3o do soro no sobrenadante.8.2.1.3. Eletroforese de Lipoprote\u00ednas76 Contudo, esse m\u00e9todo de separar as fra\u00e7\u00f5es lip\u00eddicas no soro deixou de ser utilizado na rotina cl\u00ednica por ser semiquantitativo e porque as fra\u00e7\u00f5es de colesterol foram adotadas como marcadores de risco para a doen\u00e7a cardiovascular (DCV), n\u00e3o sendo recomendado o uso dessa metodologia por este documento.O teste de eletroforese de lipoprote\u00ednas, tamb\u00e9m chamado de lipidograma, pode auxiliar na confirma\u00e7\u00e3o de presen\u00e7a de quilom\u00edcrons com uma banda colorida no ponto de aplica\u00e7\u00e3o da amostra.Das tr\u00eas metodologias mencionadas, a mais acess\u00edvel em todos os laborat\u00f3rios \u00e9 o aspecto do soro, que \u00e9 a recomendada por este documento.8.2.2. Metodologias que Avaliam os Triglic\u00e9rides75 Portanto, para cada mol\u00e9cula de triglic\u00e9rides, teremos uma mol\u00e9cula de glicerol que ir\u00e1 reagir e dar a concentra\u00e7\u00e3o de triglic\u00e9rides naquela amostra. Qualquer situa\u00e7\u00e3o fisiol\u00f3gica que elevar o glicerol no soro ir\u00e1 superestimar os n\u00edveis de triglic\u00e9rides. Est\u00e1 descrita uma doen\u00e7a gen\u00e9tica rara, glycerol kinase deficiency (GKD), tamb\u00e9m chamada de pseudo-hipertrigliceridemia, que causa a hiperglicerolemia e a HTG sem observa\u00e7\u00e3o de soro lip\u00eamico.77A metodologia para dosar os triglic\u00e9rides pode ser por rea\u00e7\u00e3o enzim\u00e1tica colorim\u00e9trica e ou enzim\u00e1tica UV. Os m\u00e9todos s\u00e3o precisos e de baixo custo. A rea\u00e7\u00e3o inicia com a hidrolise de triglic\u00e9rides em tr\u00eas \u00e1cidos graxos e um glicerol.75A lipemia, dependendo da sua intensidade, acarreta concentra\u00e7\u00f5es falsamente elevadas de triglic\u00e9rides devido \u00e0 associa\u00e7\u00e3o da colora\u00e7\u00e3o do m\u00e9todo e a turbidez do soro. Nesse caso, para obten\u00e7\u00e3o de resultado fidedigno, ser\u00e1 necess\u00e1ria uma dilui\u00e7\u00e3o da amostra, em salina tamponada  ou com o diluente da automa\u00e7\u00e3o, que \u00e9 plataforma-dependente.A dilui\u00e7\u00e3o do soro pode seguir uma escala em rela\u00e7\u00e3o aos valores de triglic\u00e9rides e ao intervalo anal\u00edtico do m\u00e9todo. Por exemplo, se o intervalo anal\u00edtico for de 8 a 885mg/dL, pode-se estipular as dilui\u00e7\u00f5es sugeridas: diluir 1:4 (triglic\u00e9rides 400 a 600), 1:6 (triglic\u00e9rides 601 a 1.000), 1:10 (triglic\u00e9rides 1.001 a 2.000), ou 1:20 (triglic\u00e9rides \u22652.001).FUNDAMENTAL: Mesmo ap\u00f3s realizar a dilui\u00e7\u00e3o, deve-se manter os resultados obtidos inseridos na faixa din\u00e2mica; isso \u00e9 indispens\u00e1vel para mantermos a linearidade e/ou reprodutibilidade do m\u00e9todo em uso.IMPORTANTE: A utiliza\u00e7\u00e3o de um branco da amostra, usando-se a amostra dilu\u00edda, para descontar a turva\u00e7\u00e3o mesmo ap\u00f3s dilui\u00e7\u00e3o. Usar a diferen\u00e7a (delta) das leituras = amostra dilu\u00edda \u2013 branco amostra dilu\u00edda, multiplicando esse \u201cdelta\u201d pela dilui\u00e7\u00e3o utilizada, e somente ap\u00f3s isso associ\u00e1-la aos controles e/ou calibradores da plataforma.EXEMPLO: Se o resultado do soro dilu\u00eddo 1:4 foi de 250mg/dL, multiplica-se por 4, e o resultado ser\u00e1 de 1.000mg/dL de triglic\u00e9rides. Por\u00e9m, ao realizar o branco da amostra e obtiver 50mg/dL, subtrair esse valor do soro dilu\u00eddo 1:4 (250 \u2013 50 = 200) e, multiplicando por 4, o resultado ser\u00e1 de 800mg/dL de triglic\u00e9rides. Portanto, \u00e9 fundamental descontar a turva\u00e7\u00e3o no soro dilu\u00eddo. Quanto maior a dilui\u00e7\u00e3o, maior poder\u00e1 ser a superestima\u00e7\u00e3o de triglic\u00e9rides, caso o branco da amostra n\u00e3o seja utilizado.75Assim, \u00e9 indispens\u00e1vel analisarmos a descri\u00e7\u00e3o t\u00e9cnica da metodologia em uso para obtermos informa\u00e7\u00f5es e indica\u00e7\u00f5es, tais como intervalo anal\u00edtico (faixa din\u00e2mica), rela\u00e7\u00e3o da dilui\u00e7\u00e3o a ser utilizada, material diluente, uso de branco da amostra ou mesmo altera\u00e7\u00e3o na programa\u00e7\u00e3o em uso (automa\u00e7\u00e3o). Essas descri\u00e7\u00f5es s\u00e3o m\u00e9todo-plataforma e fabricante-dependentes, e devem ser seguidas de acordo com as suas informa\u00e7\u00f5es.8.2.4.1. LDL-C73A an\u00e1lise laboratorial do LDL-C \u00e9 prejudicada pela elevada quantidade de triglic\u00e9rides no soro lip\u00eamico. O c\u00e1lculo do LDL-C pela f\u00f3rmula de Friedewald, de uso comum, al\u00e9m de ser limitado aos n\u00edveis de triglic\u00e9rides at\u00e9 400mg/dL, tamb\u00e9m pode ser subestimado, e deixa-se de tratar o paciente pela interfer\u00eancia de triglic\u00e9rides. No entanto, a f\u00f3rmula de Martin aplica fatores de corre\u00e7\u00e3o na f\u00f3rmula de Friedewald que permitem estimar com maior fidedignidade o LDL-C e pode ser aplicada com valores de triglic\u00e9rides de at\u00e9 13.975mg/dL. Al\u00e9m disso, a dosagem pela metodologia direta pode ser usada, mas ir\u00e1 apresentar uma limita\u00e7\u00e3o, a depender do grau da lipemia.78Na SQF, ou na SQM, a HTG \u00e9 severa pela presen\u00e7a de Q, VLDL e seus remanescentes. O paciente apresenta uma redu\u00e7\u00e3o da hidr\u00f3lise da lipoprote\u00edna VLDL que leva a uma diminui\u00e7\u00e3o da produ\u00e7\u00e3o da lipoprote\u00edna LDL no plasma e elevada quantidade de part\u00edculas grandes e ricas em triglic\u00e9rides (Q e VLDL), quando comparado no mesmo volume de amostra do indiv\u00edduo normal. Nesse caso, n\u00e3o importa a metodologia, o LDL-C calculado ou dosado pelo m\u00e9todo direto, os valores sempre se apresentam inferiores \u00e0 sensibilidade anal\u00edtica do m\u00e9todo. Recomendamos para os laborat\u00f3rios liberarem os valores de LDL-C muito baixo ou negativos como sendo <10mg/dL.8.2.4.2. Plaquetas75A contagem das plaquetas em automa\u00e7\u00f5es de hematologia \u00e9 realizada com o efeito de imped\u00e2ncia e, no caso da lipemia, a interfer\u00eancia possivelmente acarretar\u00e1 redu\u00e7\u00e3o de sua contagem. Essa mesma associa\u00e7\u00e3o ocorre com a determina\u00e7\u00e3o do hemat\u00f3crito \u2013 nesse caso, com uma importante informa\u00e7\u00e3o, e seus resultados s\u00e3o calculados a partir da associa\u00e7\u00e3o entre determina\u00e7\u00e3o da hemoglobina e a contagem de eritr\u00f3citos.8.2.4.3. Analitos com Avalia\u00e7\u00e3o Colorim\u00e9trica75Os m\u00e9todos com leituras colorim\u00e9tricas de \u201cponto final\u201d geralmente apresentam maiores restri\u00e7\u00f5es frente \u00e0 lipemia. Isso tamb\u00e9m pode ocorrer, mesmo em menor intensidade, nos sistemas de leitura em UV. Tal interfer\u00eancia \u00e9 diretamente proporcional \u00e0 turbidez do soro, mas nem sempre proporcional \u00e0 concentra\u00e7\u00e3o dos triglic\u00e9rides. Deve-se considerar que as lipoprote\u00ednas apresentam diferentes tamanhos e percentuais de triglic\u00e9rides em sua constitui\u00e7\u00e3o.8.2.4.4. Enzimas75As rea\u00e7\u00f5es enzim\u00e1ticas cin\u00e9ticas, colorim\u00e9tricas e/ou UV podem sofrer interfer\u00eancia da lipemia, dependendo da sua intensidade. Assim, temos fosfatase alcalina e a gama GT que se apresentam com maiores limita\u00e7\u00f5es, pois empregam em seus ensaios o p-nitrofenilfosfato (m\u00e9todo colorim\u00e9trico). Contudo, o uso de m\u00e9todos exclusivamente UV tamb\u00e9m pode ter restri\u00e7\u00f5es com a lipemia.8.2.4.5. Eletr\u00f3litos75Na determina\u00e7\u00e3o do s\u00f3dio, no soro e/ou plasma, com valores elevados de triglic\u00e9rides, o resultado ser\u00e1 falsamente baixo. Nesse caso, pode-se usar um c\u00e1lculo para corre\u00e7\u00e3o do valor do s\u00f3dio: triglic\u00e9rides (g/dL) x 4 \u2013 0,60 = fator percentual.Exemplo: Na+ 122 mmol/L e triglic\u00e9rides 2.100mg/dL, ter\u00edamos: 8.2.5.1. Atividade da LPL com HeparinaoC, e o plasma dever\u00e1 ser separado imediatamente. Armazenar o tubo com o plasma a -80oC at\u00e9 o dia da realiza\u00e7\u00e3o da an\u00e1lise, seguindo o protocolo adotado ou enviar para um laborat\u00f3rio de refer\u00eancia em dislipidemias.A atividade da LPL n\u00e3o \u00e9 realizada em rotina laboratorial, mas pode ser \u00fatil em triagem para a realiza\u00e7\u00e3o do diagn\u00f3stico gen\u00e9tico da SQF. Quando o laborat\u00f3rio permite que o ensaio de atividade de LPL seja realizado antes e 10 minutos ap\u00f3s a inje\u00e7\u00e3o de heparina (heparina IV [50UI/kg]), o sangue total deve ser obtido do outro bra\u00e7o, em tubo heparinizado, e transportado em gelo \u00famido para o laborat\u00f3rio. O tubo da coleta dever\u00e1 ser centrifugado durante 10 minutos, 3.000 rpm a 479A atividade de LPL \u00e9 encontrada drasticamente diminu\u00edda em SQF pela altera\u00e7\u00e3o gen\u00e9tica da LPL em homozigose, e frequentemente reduzida quando as altera\u00e7\u00f5es ocorrem em cofatores da LPL , em casos de homozigose ou em heterozigose composta. No entanto, foi demonstrado por pesquisadores que a capacidade discriminativa desse teste na identifica\u00e7\u00e3o de portadores de variantes comuns nos genes LPL \u00e9 limitada, o que justifica n\u00e3o ser recomendado neste documento.8.2.5.2. Dosagem de Apolipoprote\u00edna C3 Plasm\u00e1tica71N\u00edveis plasm\u00e1ticos elevados de apolipoprote\u00edna C3 (APOC3) s\u00e3o um importante fator de risco para HTG. Estudos recentes conclu\u00edram que APOC3 tamb\u00e9m inibe uma via independente de LPL de lipoprote\u00edna rica em triglic\u00e9rides. A dosagem de APOC3 \u00e9 vi\u00e1vel nos laborat\u00f3rios cl\u00ednicos de grande porte ou nos laborat\u00f3rios de apoio aos demais laborat\u00f3rios.- Em adultos, valores de triglic\u00e9rides >1.000mg/dL, avaliados ap\u00f3s jejum de 12 horas, em tr\u00eas coletas diferentes e descartadas causas secund\u00e1rias de HTG, o diagn\u00f3stico de hiperquilomicronemia deve ser considerado.- Em crian\u00e7as e adolescentes, valores de triglic\u00e9rides >880mg/dL, independentemente do tempo de jejum, em tr\u00eas coletas diferentes e descartadas causas secund\u00e1rias de HTG, o diagn\u00f3stico de hiperquilomicronemia deve ser considerado.- Em crian\u00e7as ou adultos, a presen\u00e7a de uma dosagem de triglic\u00e9rides <170mg/dL EXCLUI a investiga\u00e7\u00e3o de hiperquilomicronemia.Recomenda\u00e7\u00e3o: O adulto deve ficar em jejum de 12h, alimenta\u00e7\u00e3o habitual, sem \u00e1lcool (72 horas) e sem exerc\u00edcios f\u00edsicos (24 horas). Para crian\u00e7as, o tempo varia de acordo com a faixa et\u00e1ria. Para lactentes, at\u00e9 1 ano, o jejum \u00e9 de 3 horas ou imediatamente antes da pr\u00f3xima mamada; n\u00e3o lactentes, de 2 a 5 anos, o jejum \u00e9 de 6 horas. E para crian\u00e7as acima de 5 anos e adolescentes, o jejum \u00e9 de 12 horas. O excesso de glicerol livre no sangue superestima os n\u00edveis de triglic\u00e9rides. O soro leitoso deve ficar na geladeira por 12 horas para verificar a presen\u00e7a de quilom\u00edcrons. Na dosagem dos triglic\u00e9rides, observar o intervalo anal\u00edtico, a rela\u00e7\u00e3o da dilui\u00e7\u00e3o, o material diluente e o uso de branco da amostra ou a altera\u00e7\u00e3o na automa\u00e7\u00e3o. Na HTG severa, SQF ou SQM, os valores do LDL-C calculado ou dosado pelo m\u00e9todo direto, muito baixo ou negativos, devem ser liberados como sendo <10mg/dL. A lipemia, dependendo da sua intensidade, interfere na contagem das plaquetas, nos m\u00e9todos colorim\u00e9tricos, nas rea\u00e7\u00f5es enzim\u00e1ticas  e na determina\u00e7\u00e3o do s\u00f3dio. A atividade da LPL com heparina n\u00e3o \u00e9 recomendada neste documento. A dosagem de APOC3 \u00e9 vi\u00e1vel nos laborat\u00f3rios cl\u00ednicos. Recomendamos constar nos laudos laboratoriais que o diagn\u00f3stico de SQF, ap\u00f3s descartadas as causas secund\u00e1rias de HTG, deve ser considerado nas situa\u00e7\u00f5es: 1) adultos em jejum de 12 horas com triglic\u00e9rides >1.000mg/dL, em tr\u00eas coletas diferentes; 2) crian\u00e7as e adolescentes, com valores de triglic\u00e9rides >880mg/dL, independentemente do tempo de jejum, em tr\u00eas coletas diferentes; 3) em crian\u00e7as e adultos, a presen\u00e7a de uma dosagem de triglic\u00e9rides <170mg/dL EXCLUI a investiga\u00e7\u00e3o de hiperquilomicronemia. .80A Sociedade Americana de Gen\u00e9tica Humana define o aconselhamento gen\u00e9tico como um processo de comunica\u00e7\u00e3o que lida com problemas humanos associados com a ocorr\u00eancia, o risco de ocorr\u00eancia ou de recorr\u00eancia de uma determinada doen\u00e7a gen\u00e9tica em uma fam\u00edlia.81 como uma forma de, em um mundo p\u00f3s-segunda guerra mundial, enfrentar os conceitos eugenistas que permeavam muito a sociedade cient\u00edfica e m\u00e9dica quanto \u00e0s doen\u00e7as gen\u00e9ticas e \u00e0s defici\u00eancias de modo geral. A partir de ent\u00e3o, passou a munir-se dos princ\u00edpios do modelo psicossocial de abordagem ao paciente, utilizando como base a empatia e as habilidades da comunica\u00e7\u00e3o humana, de reconhecer o processo do luto e dos procedimentos de autodefesa. O profissional utiliza a neutralidade moral e a n\u00e3o diretividade \u2013 dois princ\u00edpios fundamentais do Aconselhamento Gen\u00e9tico \u2013 para orientar o paciente e a fam\u00edlia, fornecendo respostas e informa\u00e7\u00f5es mais completas poss\u00edveis para que o pr\u00f3prio consulente possa tomar suas decis\u00f5es, consciente dos riscos e das alternativas.O termo aconselhamento gen\u00e9tico surgiu pela primeira vez em 1947, utilizado por Sheldon Reed,genetic counseling ,82 seria consultoria gen\u00e9tica : o objetivo \u00e9, como dito, orientar para que o paciente sinta seguran\u00e7a na tomada de decis\u00f5es, entendendo que n\u00e3o existe certo ou errado, t\u00e3o qual n\u00e3o deve existir uma sugest\u00e3o de conduta. Dito isso, \u00e9 importante entender que ao realizar o aconselhamento gen\u00e9tico, o profissional deve respeitar os valores \u00e9ticos e religiosos da fam\u00edlia, seguindo sempre os tr\u00eas princ\u00edpios que regem a \u00e9tica m\u00e9dica: autonomia, benefic\u00eancia e n\u00e3o malefic\u00eancia.83O termo Aconselhamento, na realidade, n\u00e3o exp\u00f5e o verdadeiro objetivo da orienta\u00e7\u00e3o, pois a etimologia do verbo aconselhar indica \u201cdar conselhos\u201d, quando, na realidade, n\u00e3o \u00e9 esse o objetivo do procedimento. O mais pr\u00f3ximo da tradu\u00e7\u00e3o original, 85 O Aconselhamento Gen\u00e9tico envolve, no total, cinco fases:Vale observar que, o que muitos chamam de aconselhamento gen\u00e9tico, \u00e9 uma etapa do processo como um todo.Estabelecimento e/ou confirma\u00e7\u00e3o do diagn\u00f3stico, que envolve a realiza\u00e7\u00e3o de anamnese, exame f\u00edsico, elabora\u00e7\u00e3o de hip\u00f3tese diagn\u00f3stica, solicita\u00e7\u00e3o e interpreta\u00e7\u00e3o de exames complementares, podendo levar semanas, meses ou anos at\u00e9 o diagn\u00f3stico;C\u00e1lculo do risco gen\u00e9tico, uma fase mais te\u00f3rica e muitas vezes fora do contato familiar, cujo objetivo \u00e9 calcular o risco de ocorr\u00eancia ou de recorr\u00eancia de uma determinada condi\u00e7\u00e3o de origem gen\u00e9tica. Essa condi\u00e7\u00e3o pode ter etiologia monog\u00eanica, cromoss\u00f4mica, multifatorial ou, ainda, desconhecida. Para cada situa\u00e7\u00e3o, um risco diferente pode ser calculado, e a necessidade de conhecer a etiologia \u00e9 fundamental para estabelecer o risco mais preciso poss\u00edvel;Comunica\u00e7\u00e3o, a fase no qual se orienta sobre os riscos, muitas vezes envolvendo tamb\u00e9m conversas sobre op\u00e7\u00f5es terap\u00eauticas e progn\u00f3sticos. A combina\u00e7\u00e3o entre a fase 2 e a fase 3 \u00e9 aquela que comumente as pessoas se referem quando usam o termo Aconselhamento Gen\u00e9tico;Decis\u00f5es e A\u00e7\u00e3o, fase que envolve auxiliar a fam\u00edlia e o paciente frente \u00e0s decis\u00f5es tomadas na fase de comunica\u00e7\u00e3o, tanto em rela\u00e7\u00e3o ao tratamento como poss\u00edveis decis\u00f5es quanto a m\u00e9todos contraceptivos;Seguimento, representando uma fase cont\u00ednua no qual o paciente ou a fam\u00edlia s\u00e3o acompanhados, observando as necessidades individuais e a hist\u00f3ria natural da condi\u00e7\u00e3o gen\u00e9tica diagnosticada.85Dito isso, vale a pena observar que algumas etapas do aconselhamento gen\u00e9tico envolvem condutas m\u00e9dicas, enquanto outras podem ser realizadas por diversos profissionais da sa\u00fade, desde que devidamente treinados nas habilidades de comunica\u00e7\u00e3o citadas anteriormente e nos conhecimentos de gen\u00e9tica humana e m\u00e9dica.As duas fases que mais representam o aconselhamento gen\u00e9tico, sem d\u00favida, s\u00e3o as fases de c\u00e1lculo de risco gen\u00e9tico e a de comunica\u00e7\u00e3o. Apesar de parecerem simples, concluir o risco de ocorr\u00eancia ou de recorr\u00eancia de determinada condi\u00e7\u00e3o gen\u00e9tica envolve um amplo conhecimento sobre as bases da gen\u00e9tica e da hereditariedade. Falar de um risco de recorr\u00eancia compat\u00edvel com uma heran\u00e7a autoss\u00f4mica dominante ou autoss\u00f4mica recessiva parece simples quando pensamos nas Leis da Hereditariedade de Mendel, mas basta lembrarmos de alguns fatores confundidores para as leis da hereditariedade, como os conceitos de penetr\u00e2ncia incompleta, expressividade vari\u00e1vel, mosaicismo ou a heterogeneidade g\u00eanica. Cada um desses fatores pode dificultar o diagn\u00f3stico cl\u00ednico entre formas diferentes da doen\u00e7a, tornando a orienta\u00e7\u00e3o sobre o risco um desafio.85A confirma\u00e7\u00e3o de uma variante patog\u00eanica que explique o fen\u00f3tipo pode ser fundamental para considerar o risco correto nesses casos. Tamb\u00e9m \u00e9 importante observar que diferentes modos de heran\u00e7a, fora ao mendelismo, podem apresentar riscos mais complexos de serem calculados. Por exemplo, no risco multifatorial, devemos levar em considera\u00e7\u00e3o o n\u00famero de afetados na fam\u00edlia, a proximidade com o probando, al\u00e9m de fatores que podem variar caso a caso, como idade de in\u00edcio dos sintomas, gravidade e fatores ambientais envolvidos. Em um contexto de heran\u00e7a multifatorial, identificar esses riscos e considerar o quanto eles influenciam no risco total pode ser totalmente imposs\u00edvel, e, por isso, consideramos um risco de recorr\u00eancia sempre aproximado ou emp\u00edrico, levando em conta o conhecimento emp\u00edrico e os riscos de recorr\u00eancia calculados com base em estudos populacionais.20 ou de SQM36 deve ser conhecida.Assim, fica mais n\u00edtida a compreens\u00e3o de que, para falarmos sobre risco de ocorr\u00eancia ou de recorr\u00eancia, a defini\u00e7\u00e3o clara entre SQFA SQF \u00e9 herdada de uma maneira autoss\u00f4mica recessiva, ou seja, \u00e9 necess\u00e1rio que o indiv\u00edduo tenha uma variante em homozigose ou duas variantes em heterozigose composta, ambas patog\u00eanicas ou provavelmente patog\u00eanicas, para que o indiv\u00edduo apresente o fen\u00f3tipo.APOC2 , APOA5 , GPIHBP1 e LMF.86Essa forma de heran\u00e7a autoss\u00f4mica recessiva, por muta\u00e7\u00e3o bial\u00e9lica em homozigose (mesma muta\u00e7\u00e3o nas duas c\u00f3pias) ou em heterozigose composta (uma muta\u00e7\u00e3o em cada c\u00f3pia) est\u00e1 presente tanto nos casos de LPL como dos demais genes envolvidos com as formas monog\u00eanicas: 18Dessa forma, sabemos que os progenitores de um indiv\u00edduo com SQF ter\u00e3o uma variante em uma das c\u00f3pias do gene afetado cada. Assim sendo, a irmandade de uma pessoa que apresenta SQF tem 25% de risco de tamb\u00e9m herdar a s\u00edndrome. Por fim, um indiv\u00edduo com SQF ir\u00e1 sempre passar uma das variantes para seus filhos. Caso a(o) companheira(o) tamb\u00e9m tenha uma variante no mesmo gene em quest\u00e3o, o risco para os filhos \u00e9 de 50% a partir dessa combina\u00e7\u00e3o.86Uma vez que foi reconhecido que o fen\u00f3tipo de HTG pode tamb\u00e9m ser mais causado pela presen\u00e7a de variantes comuns raras ou funcionais em genes que aumentam triglic\u00e9rides, configurando um modo de heran\u00e7a polig\u00eanico, faz-se necess\u00e1rio diagn\u00f3stico molecular para adequado aconselhamento gen\u00e9tico.86As chances de que outras pessoas na fam\u00edlia apresentem tamb\u00e9m SQF vai depender da hist\u00f3ria familiar; portanto, a realiza\u00e7\u00e3o de um heredograma deve ser sempre considerada para auxiliar no c\u00e1lculo do risco. Cabe aqui citar que, embora indiv\u00edduos com variante patog\u00eanica em heterozigose possam apresentar n\u00edveis elevados de triglic\u00e9rides, a dosagem individualmente n\u00e3o deve ser usada para considerar o estado de portador, visto que indiv\u00edduos com a variante em heterozigose podem apresentar triglic\u00e9rides em n\u00edveis normais, ao passo que indiv\u00edduos que n\u00e3o tenham a variante podem apresentar varia\u00e7\u00e3o nos n\u00edveis de triglic\u00e9rides por fatores ambientais.87Apenas 1% dos casos de HTG apresenta muta\u00e7\u00f5es bial\u00e9licas. Por outro lado, estima-se que 14% dos pacientes com HTG sejam portadores de muta\u00e7\u00f5es raras em heterozigose, o que \u00e9 3 a 5 vezes maior que o da popula\u00e7\u00e3o geral. O uso de calculadoras de risco polig\u00eanico pode ser \u00fatil para identificar esses indiv\u00edduos.87A indica\u00e7\u00e3o de testagem gen\u00e9tica avalia pontos  que auxiliam na interpreta\u00e7\u00e3o dos exames e, por conseguinte, no aconselhamento gen\u00e9tico acerca do risco de recorr\u00eancia familiar.88 com a finalidade de prevenir a s\u00edntese de quilom\u00edcrons, part\u00edculas formadas exclusivamente no enter\u00f3cito e que s\u00e3o respons\u00e1veis pelo transporte da gordura e colesterol de origem alimentar.90 Pelo fato de os portadores de SQF apresentarem muta\u00e7\u00f5es associadas \u00e0 enzima lipoprote\u00edna lipase ou a seus cofatores, a hidr\u00f3lise dos triglic\u00e9rides alimentares se encontra comprometida.91 Por esse motivo, a dieta recomendada \u00e9 bastante restrita e deve fornecer, no m\u00e1ximo, 10% das calorias ou 15 a 20g na forma de gorduras.92O tratamento da SQF baseia-se no seguimento de dieta com restri\u00e7\u00e3o severa de gorduras,25 A SQF impacta de forma adversa a qualidade de vida dos pacientes pela dificuldade em seguir dieta com restri\u00e7\u00e3o rigorosa, o que compromete de maneira significante o conv\u00edvio social.24 O desconhecimento da SQF impede a compreens\u00e3o sobre a seriedade da doen\u00e7a por amigos e familiares. O estudo IN-FOCUS,93 conduzido em 166 portadores de SQF de 10 pa\u00edses, mostrou que mais de 90% dos participantes apresentaram elevada dificuldade na ader\u00eancia ao seguimento da dieta. A avalia\u00e7\u00e3o do banco de dados de um subgrupo (n=60) de participantes do mesmo estudo58 mostrou que 22% dos participantes relataram ansiedade, medo e preocupa\u00e7\u00e3o em rela\u00e7\u00e3o \u00e0 quantidade e qualidade dos alimentos que devem ser consumidos, especialmente em situa\u00e7\u00f5es sociais e de trabalho. Esses sintomas foram experimentados pelo menos uma vez ao m\u00eas, ou v\u00e1rias vezes durante a semana.Em fun\u00e7\u00e3o da gravidade da doen\u00e7a, os pacientes devem ser muito bem orientados quanto \u00e0 import\u00e2ncia do seguimento rigoroso das orienta\u00e7\u00f5es, e o nutricionista deve indicar op\u00e7\u00f5es alimentares que contribuam com maior ader\u00eancia ao tratamento. Alguns autores apontam a SQF como condi\u00e7\u00e3o devastadora para os pacientes e frustrante para m\u00e9dicos e nutricionistas, no tocante ao principal alvo da terapia \u2013 o controle da HTG severa.92 Isso auxiliar\u00e1 o paciente a elaborar seu plano alimentar com aux\u00edlio do nutricionista e compreender sua responsabilidade no autogerenciamento da doen\u00e7a.A equipe de sa\u00fade pode utilizar entrevistas motivacionais para auxiliar os conflitos internos dos portadores de SQF e promover maior ader\u00eancia ao seguimento de dieta restrita em gorduras.92 por induzirem vias lipog\u00eanicas hep\u00e1ticas. A dieta tamb\u00e9m deve ser isenta de \u00e1lcool, cujo consumo se associa de forma linear \u00e0 concentra\u00e7\u00e3o plasm\u00e1tica de triglic\u00e9rides.91 Al\u00e9m disso, o monitoramento da ingest\u00e3o de vitaminas lipossol\u00faveis, minerais e \u00e1cidos graxos essenciais \u00e9 recomendado, e a sua suplementa\u00e7\u00e3o pode ser necess\u00e1ria.95 Especificamente em rela\u00e7\u00e3o \u00e0s gorduras da dieta, \u00e9 fundamental considerar o tipo e o comprimento de cadeia dos \u00e1cidos graxos, uma vez que apresentam formas distintas de absor\u00e7\u00e3o e influenciam a concentra\u00e7\u00e3o plasm\u00e1tica de triglic\u00e9rides e a produ\u00e7\u00e3o de quilom\u00edcrons.Embora a restri\u00e7\u00e3o de gorduras seja o ponto mais importante no tratamento da SQF, a dieta tamb\u00e9m deve ser isenta de a\u00e7\u00facares de adi\u00e7\u00e3o, como sacarose e xarope de milho,96 Os \u00e1cidos graxos de cadeia curta s\u00e3o provenientes da fermenta\u00e7\u00e3o bacteriana no intestino, enquanto os de cadeia m\u00e9dia s\u00e3o encontrados nos \u00f3leos de coco e de palma.97 A principal fonte do \u00e1cido l\u00e1urico na dieta \u00e9 a gordura de coco, e \u00e9 encontrada em m\u00ednimas quantidades em outros alimentos. O \u00e1cido graxo mais abundante na dieta \u00e9 o palm\u00edtico, cujas principais fontes s\u00e3o as carnes vermelhas e o \u00f3leo de palma. Por ser uma gordura estruturalmente est\u00e1vel, tornou-se muito utilizada nos alimentos industrializados.98 As principais fontes de \u00e1cido mir\u00edstico s\u00e3o gordura de coco, leite e derivados, enquanto o \u00e1cido este\u00e1rico tem o cacau como fonte refer\u00eancia.99 Todos os \u00e1cidos graxos insaturados apresentam cadeia longa e s\u00e3o classificados em monoinsaturados (MONO) ou poli-insaturados (POLI). Os principais \u00e1cidos graxos monoinsaturados s\u00e3o o palmitoleico (C16:1 \u03c97) e oleico , com apenas uma dupla liga\u00e7\u00e3o em sua estrutura.101 A principal fonte alimentar de palmitoleico \u00e9 a macad\u00e2mia, enquanto o oleico \u00e9 encontrado principalmente nos \u00f3leos de oliva e canola, e tamb\u00e9m em oleaginosas como amendoim, avel\u00e3, macad\u00e2mia, am\u00eandoas e castanha-de-caju.102 Encontram-se presentes tamb\u00e9m nas gorduras da carne de boi, frango e porco, podendo representar entre 40% e 50% das gorduras totais desses alimentos.104Os \u00e1cidos graxos saturados (SAT) s\u00e3o classificados em fun\u00e7\u00e3o do tamanho da cadeia carbox\u00edlica em curta, m\u00e9dia ou longa, caracter\u00edsticas que influenciam seu processo de absor\u00e7\u00e3o. Os \u00e1cidos graxos de cadeia curta s\u00e3o acetato (C2:0), propionato (C3:0) e butirato (C4:0), e os de cadeia m\u00e9dia classificam-se em caproico (C6:0), capr\u00edlico (C8:0) e c\u00e1prico (C10:0). J\u00e1 os \u00e1cidos graxos com mais de 12 carbonos s\u00e3o classificados como de cadeia longa: l\u00e1urico (C12:0), mir\u00edstico (C14:0), palm\u00edtico (C16:0) e este\u00e1rico (C18:0).105 Os \u00e1cidos graxos \u03c93 de origem animal s\u00e3o o eicosapentaenoico (EPA [C20:5]) e docosaexaenoico (DHA [C22:6]), encontrados nos \u00f3leos de peixes e crust\u00e1ceos, principalmente nos habitats de \u00e1guas frias e profundas.108 Os \u00e1cidos graxos linoleico e linol\u00eanico s\u00e3o considerados essenciais, pois n\u00e3o s\u00e3o sintetizados no organismo de humanos, raz\u00e3o pela qual devem ser providos pela dieta, e, em condi\u00e7\u00f5es especiais de car\u00eancia, recomenda-se sua suplementa\u00e7\u00e3o.88Os \u00e1cidos graxos poli-insaturados cont\u00eam duas ou mais duplas liga\u00e7\u00f5es e fazem parte das s\u00e9ries \u00f4mega-6 (\u03c96) ou \u00f4mega-3 (\u03c93), em fun\u00e7\u00e3o da localiza\u00e7\u00e3o da primeira dupla liga\u00e7\u00e3o na cadeia carb\u00f4nica a partir do terminal metila. \u00c1cidos graxos da s\u00e9rie \u03c96 s\u00e3o representados pelo linoleico (C18:2), cujas principais fontes s\u00e3o \u00f3leos vegetais , nozes e castanhas. O \u00e1cido araquid\u00f4nico (C20:4), outro representante \u03c96, \u00e9 sintetizado endogenamente por meio de a\u00e7\u00e3o enzim\u00e1tica a partir do \u00e1cido linoleico. O \u00e1cido alfalinol\u00eanico (ALA [C18:3]), da s\u00e9rie \u03c93, tem origem nos \u00f3leos vegetais, principalmente nos \u00f3leos de canola e soja, e tamb\u00e9m na linha\u00e7a e chia.trans tamb\u00e9m apresentam cadeia longa, categoria representada principalmente pelo \u00e1cido ela\u00eddico , encontrado em gorduras vegetais, provenientes da hidrogena\u00e7\u00e3o parcial de \u00f3leos vegetais durante sua confec\u00e7\u00e3o.110 Os \u00e1cidos graxos trans s\u00e3o encontrados em m\u00ednimas quantidades nas carnes e leite sob a forma de \u00e1cido vac\u00eanico , que \u00e9 produzido por meio da bio-hidrogena\u00e7\u00e3o de gorduras sob a\u00e7\u00e3o da microbiota do r\u00famen de animais ruminantes.109Os \u00e1cidos graxos 111 O processo tem continuidade no intestino, que, sob a\u00e7\u00e3o da lipase pancre\u00e1tica, induz hidr\u00f3lise dos triglic\u00e9rides remanescentes, liberando \u00e1cidos graxos e monoacilglicerol.113As gorduras presentes nos alimentos s\u00e3o compostas por triglic\u00e9rides (90 a 95%), fosfol\u00edpides, colesterol e vitaminas lipossol\u00faveis. Embora o principal local para digest\u00e3o das gorduras seja o intestino, esse processo inicia-se minimamente na boca, por meio da lipase lingual, seguindo ao est\u00f4mago, no qual ocorre a libera\u00e7\u00e3o de 10 a 30% de \u00e1cidos graxos, com in\u00edcio do processo de emulsifica\u00e7\u00e3o das gorduras.114 Os \u00e1cidos graxos de cadeia curta  s\u00e3o primariamente absorvidos por transporte ativo dependente ou n\u00e3o de s\u00f3dio, por meio de transportadores monocarbox\u00edlicos. Contudo, receptores acoplados \u00e0 prote\u00edna G (GPCRs), como os GPR41 e GPR43, tamb\u00e9m podem participar do processo absortivo desses \u00e1cidos graxos. Os \u00e1cidos graxos de cadeia m\u00e9dia  s\u00e3o absorvidos predominantemente por transporte passivo, mas o GPR84 tamb\u00e9m pode participar de sua incorpora\u00e7\u00e3o na superf\u00edcie do enter\u00f3cito.115 Ap\u00f3s absor\u00e7\u00e3o, s\u00e3o conjugados \u00e0 albumina, direcionados ao f\u00edgado, via sistema porta.114 Por outro lado, os \u00e1cidos graxos de cadeia longa, saturados, insaturados ou trans , necessitam de mecanismos mais complexos envolvidos no processo de absor\u00e7\u00e3o, e seu transporte no plasma depende da forma\u00e7\u00e3o de quilom\u00edcrons.97 Podem ser absorvidos por difus\u00e3o passiva, quando a concentra\u00e7\u00e3o do l\u00famen \u00e9 superior que a intracelular, ou por meio de receptores/transportadores de membrana. Por exemplo, o transportador CD36 ( cluster of differentiation 36) possibilita capta\u00e7\u00e3o de \u00e1cidos graxos de cadeia longa, mesmo quando suas concentra\u00e7\u00f5es luminais s\u00e3o menores que as intracelulares.116 A prote\u00edna FATP4 (prote\u00edna-4 transportadora de \u00e1cidos graxos) \u00e9 amplamente distribu\u00edda no intestino, sendo um dos principais transportadores de \u00e1cidos graxos de cadeia longa.117 No interior dos enter\u00f3citos, os AGs s\u00e3o transportados pelas prote\u00ednas FABP1 e 2 (prote\u00edna ligadora de \u00e1cido graxo 1 e 2)116 e reesterificados, retornando ao formato de triglic\u00e9rides por meio da enzima diacilglicerol aciltransferase.89 A seguir, os triglic\u00e9rides s\u00e3o incorporados \u00e0s apolipoprote\u00ednas B48 (ApoB48) por meio da prote\u00edna microssomal de transfer\u00eancia de triglic\u00e9rides (MTP), que d\u00e1 in\u00edcio \u00e0 forma\u00e7\u00e3o dos quilom\u00edcrons.118 Os quilom\u00edcrons s\u00e3o processados no complexo de Golgi e, posteriormente, secretados na linfa e direcionados \u00e0 circula\u00e7\u00e3o sist\u00eamica, via ducto tor\u00e1cico.90O mecanismo de absor\u00e7\u00e3o dos \u00e1cidos graxos \u00e9 complexo, pois conta com m\u00faltiplos sistemas absortivos.119 Com a hidr\u00f3lise dos quilom\u00edcrons, s\u00e3o formados os remanescentes de quilom\u00edcrons (remQM), que s\u00e3o removidos da circula\u00e7\u00e3o por meio de sua intera\u00e7\u00e3o com receptores hep\u00e1ticos do tipo B/E e LRP (prote\u00edna relacionada ao receptor de LDL).120Na circula\u00e7\u00e3o sangu\u00ednea, os triglic\u00e9rides dos quilom\u00edcrons s\u00e3o hidrolisados pela enzima LPL, que se encontra aderida ao endot\u00e9lio dos tecidos extra-hep\u00e1ticos, liberando \u00e1cidos graxos livres, posteriormente ligados \u00e0 albumina, que seguem para armazenamento no tecido adiposo e minimamente no tecido muscular.GPIHBP1 , LMF1 , APOA5 ou APOC2 ), os \u00e1cidos graxos de cadeia longa devem ser minimamente consumidos, com finalidade de prevenir a eleva\u00e7\u00e3o da concentra\u00e7\u00e3o plasm\u00e1tica de quilom\u00edcron.27 Recomenda-se, assim, o consumo de 10% do valor cal\u00f3rico total (VCT), na forma de gorduras da dieta.92 No entanto, dependendo da gravidade da doen\u00e7a, a restri\u00e7\u00e3o pode ser ainda mais severa, chegando \u00e0 recomenda\u00e7\u00e3o m\u00e1xima de 5% na forma de gorduras.91Como na SQF ocorre comprometimento da lip\u00f3lise dos triglic\u00e9rides pela presen\u00e7a de muta\u00e7\u00f5es na LPL ou de seus cofatores .123Al\u00e9m de manter limite severo com rela\u00e7\u00e3o \u00e0 quantidade total de gorduras, alimentos ricos em \u00e1cidos graxos saturados devem ser consumidos em menor quantidade. Os \u00e1cidos graxos saturados est\u00e3o envolvidos em importantes vias lipog\u00eanicas hep\u00e1ticas ao ativarem a prote\u00edna ligadora ao elemento responsivo ao esterol-1c (SREBP1c), que atua como fator de transcri\u00e7\u00e3o codificador dos genes da acetil-CoA carboxilase (ACC), \u00e1cido graxo sintase (FAS) e estearoil-CoA-dessaturase (SCD1),27Importante salientar que, embora os \u00e1cidos graxos insaturados do tipo \u03c93 regulem a s\u00edntese de triglic\u00e9rides ao bloquearem a SREBP1c, n\u00e3o s\u00e3o recomendados para o tratamento da SQF, mesmo em doses elevadas, pois os indiv\u00edduos n\u00e3o apresentam defeito na s\u00edntese hep\u00e1tica de triglic\u00e9rides, mas, sim, em sua hidr\u00f3lise.Global Burden of Disease Study,124 estudo conduzido em 197 pa\u00edses, sugere consumo ideal de \u03c96 de 11% do VCT, embora o consumo m\u00e9dio global seja de 4,5% do VCT. Quanto ao \u03c93, o consumo \u00f3timo indicado \u00e9 de 0,25g/d, sendo o consumo m\u00e9dio global de 0,1g/d.124 J\u00e1 o Recommended Dietary Allowences (RDA) preconiza o consumo di\u00e1rio de w3 entre 0,5g e 1,4g, dependendo da faixa et\u00e1ria.125Por outro lado, por serem considerados essenciais, pode ser necess\u00e1ria a suplementa\u00e7\u00e3o tanto do \u00e1cido alfalinol\u00eanico (\u03c93) como do \u00e1cido linoleico (\u03c96) para portadores de SQF, com a finalidade de evitar sua defici\u00eancia. O 127 O uso de TCM \u00e9 permitido para indiv\u00edduos portadores de SQF, uma vez que esses \u00e1cidos graxos s\u00e3o absorvidos quase em sua totalidade via sistema portal, sendo minimamente incorporados aos quilom\u00edcrons.129 \u00c9 importante refor\u00e7ar a ideia de que o \u00e1cido l\u00e1urico (C12:0) \u00e9 considerado de cadeia longa, e seu transporte ocorre principalmente via quilom\u00edcron. Somente ocorre via porta quando excede a sua capacidade de armazenamento nessa lipoprote\u00edna.130 Assim, \u00e9 fundamental observar com aten\u00e7\u00e3o a composi\u00e7\u00e3o de \u00e1cidos graxos do produto, devendo este, preferencialmente, ser isento ou conter concentra\u00e7\u00f5es m\u00ednimas de l\u00e1urico, a fim de evitar o incremento nas concentra\u00e7\u00f5es de quilom\u00edcrons.Os triglic\u00e9rides de cadeia m\u00e9dia s\u00e3o constitu\u00eddos por \u00e1cidos graxos saturados caproico (C6:0), capr\u00edlico (C8:0) ou c\u00e1prico (C10:0), obtidos pelo fracionamento do \u00f3leo de coco ou palma e s\u00e3o encontrados comercialmente, juntos ou isolados. Podem apresentar pequena quantidade de \u00e1cido l\u00e1urico .92O uso de TCM para portadores de SQF \u00e9 indicado com a finalidade de contribuir com aporte cal\u00f3rico tanto para lactentes, crian\u00e7as e adultos, sendo coadjuvante ao tratamento, mas sua tolerabilidade deve ser testada, visto que diversas pessoas relatam desconforto gastrintestinal com seu uso.92 Quanto aos a\u00e7ucares de adi\u00e7\u00e3o (sacarose e xarope de milho), devem ser exclu\u00eddos totalmente, por induzirem aumento da s\u00edntese hep\u00e1tica de \u00e1cidos graxos, contribuindo \u00e0 eleva\u00e7\u00e3o da concentra\u00e7\u00e3o plasm\u00e1tica de triglic\u00e9rides. Os a\u00e7ucares s\u00e3o constitu\u00eddos por glicose e frutose, sendo que a frutose promove intensa lipog\u00eanese hep\u00e1tica, n\u00e3o somente por servir como substrato \u00e0 s\u00edntese de \u00e1cidos graxos, mas por estimular express\u00e3o de enzimas envolvidas na de novo lipog\u00eanese via ativa\u00e7\u00e3o da prote\u00edna ligadora ao elemento responsivo a carboidratos (ChREBP) e esterol (SREBP1c).133 Al\u00e9m disso, o excesso de frutose diminui a betaoxida\u00e7\u00e3o de \u00e1cidos graxos, por induzir modifica\u00e7\u00f5es p\u00f3s-traducionais nas prote\u00ednas mitocondriais, diminuindo o n\u00famero e o tamanho dessas organelas.134Recomenda-se consumo de alimentos fontes de carboidratos complexos, ricos em fibras, como . A ingest\u00e3o de frutas \u00e9 recomendada em quantidades adequadas, sendo, no m\u00e1ximo, 3 a 4 por\u00e7\u00f5es ao dia, para n\u00e3o extrapolar o consumo de a\u00e7\u00facar. Alguns autores preconizam o limite de 60% das calorias na forma de carboidratos totais.Em virtude da intensa atividade lipog\u00eanica induzida pela frutose, sucos de frutas concentrados devem ser exclu\u00eddos para portadores de SQF.135 O acetato pode ser convertido a \u00e1cidos graxos, precursor da s\u00edntese de triglic\u00e9rides.136As bebidas alco\u00f3licas devem ser totalmente exclu\u00eddas por elevarem a concentra\u00e7\u00e3o plasm\u00e1tica de triglic\u00e9rides. O processo de metaboliza\u00e7\u00e3o do \u00e1lcool se inicia minimamente no est\u00f4mago pela a\u00e7\u00e3o da enzima \u00e1lcool desidrogenase (ADH), mas \u00e9 principalmente metabolizado no f\u00edgado, por meio de tr\u00eas vias: citocromo P450 2E1, catalase e ADH. Durante o processo de metaboliza\u00e7\u00e3o do \u00e1lcool, ocorre forma\u00e7\u00e3o de acetalde\u00eddo, que \u00e9 convertido em acetado, pela enzima alde\u00eddo desidrogenase (ALDH), com participa\u00e7\u00e3o principal da ADH.A alimenta\u00e7\u00e3o nos 2 primeiros anos de vida com quantidade e qualidade adequados de nutrientes \u00e9 imprescind\u00edvel para promover crescimento e desenvolvimento cognitivo adequados, al\u00e9m de consolidar h\u00e1bitos alimentares saud\u00e1veis. No entanto, a elabora\u00e7\u00e3o do plano alimentar para lactentes e crian\u00e7as portadoras de SQF \u00e9 desafiadora para o nutricionista e para a fam\u00edlia, a fim de garantir quantidades recomendadas de macro e micronutrientes, em fun\u00e7\u00e3o da rigorosa restri\u00e7\u00e3o de gorduras. A capacita\u00e7\u00e3o do nutricionista nessa \u00e1rea \u00e9 de fundamental import\u00e2ncia para harmonizar a dieta, oferecer sugest\u00f5es de card\u00e1pios para a fam\u00edlia e acompanhar de forma intensiva a implementa\u00e7\u00e3o dos novos h\u00e1bitos alimentares. A fam\u00edlia deve estar ciente de que o consumo de gorduras al\u00e9m do permitido, mesmo em quantidades m\u00ednimas, pode provocar eleva\u00e7\u00e3o indesej\u00e1vel da concentra\u00e7\u00e3o plasm\u00e1tica de quilom\u00edcrons.137 Os triglic\u00e9rides do leite s\u00e3o formados predominantemente por \u00e1cidos graxos de cadeia longa saturados (35 a 40%), monoinsaturados (45 a 50%) e poli-insaturados (15%), com predom\u00ednio do palm\u00edtico, oleico e linoleico, respectivamente.138 \u00c1cidos graxos insaturados com mais de 20 carbonos na cadeia, contendo duas ou mais duplas liga\u00e7\u00f5es, representam apenas 2% do total de \u00e1cidos graxos do leite.138 \u00c1cidos graxos da s\u00e9rie \u03c93 encontram-se em pequenas quantidades no leite materno: alfalinol\u00eanico , EPA  e DHA .140Para beb\u00eas portadores de SQF em aleitamento materno, a amamenta\u00e7\u00e3o deve ser interrompida assim que o diagn\u00f3stico for confirmado, o que traz frusta\u00e7\u00e3o e tristeza para o lactente e a m\u00e3e. O leite materno tem aproximadamente 3,2% de gorduras, com fra\u00e7\u00e3o lip\u00eddica composta em aproximadamente 98% de triglic\u00e9rides. A composi\u00e7\u00e3o exata em \u00e1cidos graxos depende da alimenta\u00e7\u00e3o materna e varia significativamente durante o per\u00edodo de amamenta\u00e7\u00e3o.European Childhood Obesity Project) acompanhou 174 crian\u00e7as desde o nascimento at\u00e9 completarem 1 ano, e contribuiu para melhor compreender o consumo cal\u00f3rico de l\u00edpides, carboidratos e prote\u00ednas nesse est\u00e1gio de vida, cujos resultados podem ser extrapolados para orienta\u00e7\u00e3o alimentar de crian\u00e7as impossibilitadas de receber leite materno.139 O consumo cal\u00f3rico di\u00e1rio m\u00e9dio foi de 419kcal no primeiro m\u00eas, 589kcal no sexto m\u00eas e 860kcal em 12 meses. O consumo de gorduras foi de 21g/dia at\u00e9 os 6 primeiros meses, com aumento gradativo at\u00e9 34,2g no final de 12 meses. Com rela\u00e7\u00e3o aos \u00e1cidos graxos essenciais, at\u00e9 o terceiro m\u00eas com aleitamento materno praticamente exclusivo, o consumo m\u00e9dio di\u00e1rio de alfalinol\u00eanico (\u03c93) foi de 0,118g, e linoleico (\u03c96) de 2,40g. Quanto aos \u00e1cidos graxos marinhos, o consumo de EPA foi de 0,022g e de DHA foi de 0,048g.139 De acordo com a Academy of Nutrition and Dietetics , a recomenda\u00e7\u00e3o de \u00e1cidos graxos \u03c93 para lactentes e crian\u00e7as de 0 a 12 meses \u00e9 de 0,5g e, para crian\u00e7as de 1 a 3 anos, \u00e9 de 0,7g/dia, enquanto para os \u00e1cidos graxos \u03c96, a recomenda\u00e7\u00e3o \u00e9 de 4,6g para crian\u00e7as de 0 a 6 meses, e 7g/dia para a faixa de 7 a 12 anos.125Importante estudo conduzido na Europa ,92 Com rela\u00e7\u00e3o ao teor de gorduras, as f\u00f3rmulas devem ser exclusivamente preparadas com \u00e1cidos graxos de cadeia m\u00e9dia , al\u00e9m de fornecer vitaminas lipossol\u00faveis e quantidades permitidas de \u00e1cidos graxos essenciais. Al\u00e9m disso, o TCM pode ser recomendado para alcance do aporte cal\u00f3rico ideal, de acordo com a toler\u00e2ncia, uma vez que s\u00e3o minimamente transportados pelos quilom\u00edcrons.129Em substitui\u00e7\u00e3o ao leite materno, recomendam-se f\u00f3rmulas l\u00e1cteas especiais, que se assemelham parcialmente \u00e0 composi\u00e7\u00e3o nutricional do leite materno.A inclus\u00e3o de alimentos s\u00f3lidos como hortali\u00e7as, frutas, carnes magras  gr\u00e3os etc. deve seguir as recomenda\u00e7\u00f5es das sociedades nacionais e internacionais de Pediatria, mantendo, no m\u00e1ximo, 10% das calorias na forma de gordura.92Recomenda-se consumo de l\u00edquidos em quantidades adequadas e suficientes para manuten\u00e7\u00e3o do balan\u00e7o h\u00eddrico, que ir\u00e1 contribuir com a fun\u00e7\u00e3o pancre\u00e1tica. \u00c9 sabido que desidrata\u00e7\u00e3o prolongada induzida por v\u00f4mitos e diarreia pode aumentar o risco para pancreatite associada \u00e0 SQF.A orienta\u00e7\u00e3o alimentar deve ser individualizada e agrad\u00e1vel, respeitar h\u00e1bitos culturais e ser sustent\u00e1vel a longo prazo. Crian\u00e7as devem ser aconselhadas quanto \u00e0 import\u00e2ncia da leitura dos r\u00f3tulos dos alimentos, e a fam\u00edlia deve ser orientada quanto a prepara\u00e7\u00f5es contendo quantidades m\u00ednimas de gordura, al\u00e9m de informar sobre a import\u00e2ncia de refei\u00e7\u00f5es/alimentos preparados em casa.clearance reduzido, consecutivamente, permitindo eleva\u00e7\u00e3o nas concentra\u00e7\u00f5es plasm\u00e1ticas de triglic\u00e9rides.142Durante a gesta\u00e7\u00e3o, sobretudo ao final do 2\u00ba e 3\u00ba trimestre, o aumento das concentra\u00e7\u00f5es plasm\u00e1ticas de l\u00edpides \u00e9 esperado, com concentra\u00e7\u00f5es de triglic\u00e9rides aumentadas de 2 a 4 vezes, mas bem toleradas. Nessa fase, o aumento da resist\u00eancia \u00e0 insulina e a a\u00e7\u00e3o de horm\u00f4nios placent\u00e1rios contribuem para maior lip\u00f3lise do adiposo. Al\u00e9m disso, h\u00e1 maior produ\u00e7\u00e3o hep\u00e1tica de VLDL e diminui\u00e7\u00e3o da atividade da lipase hep\u00e1tica. A atividade da LPL tamb\u00e9m se encontra diminu\u00edda, o que prejudica a hidr\u00f3lise de triglic\u00e9rides das lipoprote\u00ednas. Em virtude dessas altera\u00e7\u00f5es, as lipoprote\u00ednas ricas em triglic\u00e9rides t\u00eam seu 94O aumento de triglic\u00e9rides durante a gesta\u00e7\u00e3o implica maior risco de complica\u00e7\u00f5es para m\u00e3e e beb\u00ea, pois eleva o risco de pancreatite aguda, podendo induzir antecipa\u00e7\u00e3o do parto, aborto e mortalidade. Na gesta\u00e7\u00e3o, apesar de rara, a pancreatite aguda \u00e9 normalmente causada por lit\u00edase biliar. A eleva\u00e7\u00e3o das concentra\u00e7\u00f5es de colesterol e a hipomotilidade da ves\u00edcula biliar ocasionada pelo perfil hormonal caracter\u00edstico da gesta\u00e7\u00e3o predisp\u00f5em \u00e0 forma\u00e7\u00e3o de c\u00e1lculos que podem vir a obstruir o ducto pancre\u00e1tico. Por outro lado, mulheres portadoras de SQF apresentam eleva\u00e7\u00e3o pronunciada das concentra\u00e7\u00f5es de triglic\u00e9rides, que pode desencadear pancreatite aguda. Gestantes portadoras de SQF apresentam eleva\u00e7\u00e3o de 4% no risco para pancreatite aguda, com concentra\u00e7\u00f5es de triglic\u00e9rides >1.000mg/dL, bem como aumento de 14% quando >2.600mg/dL.143 e vitaminas lipossol\u00faveis.92O tratamento dietoter\u00e1pico de gestantes portadoras de SQF tem como objetivo manter as concentra\u00e7\u00f5es plasm\u00e1ticas de triglic\u00e9rides inferiores a 500mg/dL ao longo da gesta\u00e7\u00e3o. Para isso, \u00e9 necess\u00e1rio o seguimento de dieta, com restri\u00e7\u00e3o de gorduras (inferior a 20g/dia), adequa\u00e7\u00e3o do consumo de vitaminas, minerais e \u00e1cidos graxos essenciais, de acordo com as recomenda\u00e7\u00f5es de ingest\u00e3o para o est\u00e1gio de vida, incluindo monitoramento do ganho de peso. Dietas com restri\u00e7\u00e3o severa do consumo de gorduras devem ser constantemente monitoradas, para garantir adequa\u00e7\u00e3o da ingest\u00e3o de calorias, macro e micronutrientes, em especial os \u00e1cidos graxos essenciaismellitus tipo 2 ou ao diabetes gestacional necessitam maior aten\u00e7\u00e3o na adequa\u00e7\u00e3o da dieta, requerendo acompanhamento multidisciplinar, a fim de controlar as concentra\u00e7\u00f5es lip\u00eddicas e glic\u00eamicas, bem como desenvolvimento fetal.92O uso de TCM (livre de \u00e1cidos graxos de cadeia longa) pode ser indicado a fim de alcan\u00e7ar aporte de calorias, quando necess\u00e1rio. Al\u00e9m disso, recomenda-se salientar a import\u00e2ncia do consumo adequado de l\u00edquidos a fim de se manter o balan\u00e7o hidroeletrol\u00edtico adequado. Gestantes com SQF associada ao diabetes 144At\u00e9 o momento, tratamento dietoter\u00e1pico da SQF \u00e9 a \u00fanica ferramenta dispon\u00edvel para controle das concentra\u00e7\u00f5es plasm\u00e1ticas de triglic\u00e9rides nesta condi\u00e7\u00e3o, conforme demonstrado em recente publica\u00e7\u00e3o do acompanhamento de gestante que apresentava concentra\u00e7\u00e3o plasm\u00e1tica de triglic\u00e9rides de 8.683mg/dL e que referia epis\u00f3dios de pancreatites anteriores.92O nutricionista deve auxiliar a paciente a elaborar o plano alimentar, fornecendo aux\u00edlio com receitas e estrat\u00e9gias que facilitem o seguimento da dieta. Prefer\u00eancias alimentares, h\u00e1bitos culturais e estilo de vida devem ser considerados, bem como adequa\u00e7\u00e3o nutricional e de calorias. A severa restri\u00e7\u00e3o de alimentos dificulta o seguimento da dieta; assim, \u00e9 de extrema import\u00e2ncia que haja acompanhamento por equipe multidisciplinar para que se mantenha o controle das concentra\u00e7\u00f5es de l\u00edpides e minimize o risco de complica\u00e7\u00f5es.Restringir a ingest\u00e3o de gordura na dieta (10% a 15% do VCT);Exclus\u00e3o de a\u00e7\u00facares de adi\u00e7\u00e3o (sacarose e xarope de milho);Exclus\u00e3o de sucos de frutas concentrados;Exclus\u00e3o de bebidas alco\u00f3licas;Consumo de carboidratos complexos em quantidades adequadas;Garantia da adequa\u00e7\u00e3o de \u00e1cidos graxos essenciais;Monitoramento do consumo de vitaminas lipossol\u00faveis, com suplementa\u00e7\u00e3o quando necess\u00e1rio;Inclus\u00e3o de TCM com a finalidade de aporte cal\u00f3rico, de acordo com toler\u00e2ncia.Alimentos com baixo teor de gordura (< 5g por por\u00e7\u00e3o)Valores de triglic\u00e9rides >1.000mg/dL aumentam o risco de pancreatite nos pacientes com SQF. Classe IIA, N\u00edvel C.145 Valores de triglic\u00e9rides plasm\u00e1ticos >1.000mg/dL aumentam, em muito, o risco, ou podem ser indicativos da presen\u00e7a de pancreatite hipertriglicrid\u00eamica (PH).Nos pacientes com SQF, a pancreatite aguda (PA) \u00e1 a complica\u00e7\u00e3o mais frequente, com preval\u00eancia de 60 a 88%.147 Estudos de coorte t\u00eam demonstrado evolu\u00e7\u00e3o mais grave desses pacientes, com preval\u00eancia maior de complica\u00e7\u00f5es , quando comparados a outras etiologias de PA.149A mortalidade da PA nesses pacientes \u00e9 em torno de 6%, podendo chegar at\u00e9 30%, conforme a presen\u00e7a de complica\u00e7\u00f5es.150Os procedimentos diagn\u00f3sticos e terap\u00eauticos iniciais da PH devem seguir as mesmas recomenda\u00e7\u00f5es de pr\u00e1ticas estabelecidas para quadros de PA em geral . A determina\u00e7\u00e3o mais precoce poss\u00edvel dos n\u00edveis s\u00e9ricos de triglic\u00e9rides \u00e9 crucial, pois esses podem diminuir seus n\u00edveis s\u00e9ricos nas primeiras 48 horas, ap\u00f3s o in\u00edcio da pancreatite, pelo jejum inicialmente estabelecido.mellitus n\u00e3o controlado, uso abusivo de \u00e1lcool, gravidez e medicamentos .68Nos pacientes com SQF, a PH pode ocorrer espontaneamente, sem causa aparente, ou ser desencadeada por fatores secund\u00e1rios que incluem: diabetes A base da terapia inicial da pancreatite aguda consiste em interna\u00e7\u00e3o em unidade de terapia intensiva (UTI), bem como a restri\u00e7\u00e3o da ingest\u00e3o oral, de fluidos intravenosos e analgesia.A evolu\u00e7\u00e3o cl\u00ednica \u00e9 dependente da redu\u00e7\u00e3o dos triglic\u00e9rides plasm\u00e1ticos nas primeiras 24 a 48 horas.151 Uma vez que a dor desapare\u00e7a e o tr\u00e2nsito intestinal esteja estabelecido, uma dieta oral sem gordura pode ser reiniciada.A maioria dos pacientes com PH apresenta curso cl\u00ednico n\u00e3o complicado, com bom progn\u00f3stico. Em geral, os n\u00edveis s\u00e9ricos de triglic\u00e9rides diminuem nas 24 a 48 horas e alcan\u00e7am valores <500mg/dL, no quarto ou quinto dia, apenas com medidas de suporte.A infus\u00e3o de heparina endovenosa na PH nos pacientes com SQF n\u00e3o \u00e9 recomendada. Classe de recomenda\u00e7\u00e3o: III, N\u00edvel de evid\u00eancia: C.156As infus\u00f5es de heparina e insulina t\u00eam sido usadas como terapia principal para PH. A maioria das evid\u00eancias para ambas as drogas vem de casos isolados ou s\u00e9ries de casos.159 Al\u00e9m disso, alguns autores relutam em usar heparina endovenosa em pacientes com necrose pancre\u00e1tica, pelo risco de transforma\u00e7\u00e3o hemorr\u00e1gica.151A infus\u00e3o de heparina n\u00e3o fracionada \u00e9 capaz de liberar a lipase lipoproteica (LLP) ligada \u00e0s c\u00e9lulas endoteliais, com redu\u00e7\u00e3o transit\u00f3ria dos triglic\u00e9rides s\u00e9ricos. Nos quadros de PH grave, a infus\u00e3o de heparina endovenosa a longo prazo pode esgotar a LLP da superf\u00edcie das c\u00e9lulas endoteliais, permitindo que os n\u00edveis de triglic\u00e9rides s\u00e9ricos se elevem novamente.O uso de heparina de baixo peso molecular est\u00e1 indicado como profilaxia para trombose venosa profunda na PH nos pacientes com SQF. Classe de recomenda\u00e7\u00e3o: IIa, N\u00edvel de evid\u00eancia: C.160 como profilaxia para trombose venosa profunda na PH.N\u00e3o h\u00e1 contraindica\u00e7\u00e3o para o uso de heparina de baixo peso molecularA insulina endovenosa deve ser utilizada apenas em pacientes com diabetes tipo 1 e 2 descompensado, para controle glic\u00eamico, na PH nos pacientes com SQF . Classe de recomenda\u00e7\u00e3o: IIa, N\u00edvel de evid\u00eancia: C.19A insulina aumenta a atividade da LLP e ajuda a reverter os efeitos hep\u00e1ticos da resist\u00eancia \u00e0 insulina. A infus\u00e3o de insulina \u00e9 especialmente \u00fatil em pacientes com diabetes n\u00e3o controlado e hiperglicemia, al\u00e9m da HTG. N\u00e3o h\u00e1 evid\u00eancia clara do benef\u00edcio de insulina nos pacientes com PH, que n\u00e3o sejam diab\u00e9ticos.162 A insulina endovenosa deve ser usada em pacientes com HTG grave e PH, com diabetes tipo 2 descompensado.165A terap\u00eautica com insulina intravenosa \u00e9 obrigat\u00f3ria para pacientes com diabetes tipo 1 descompensado e HTG grave com PH.A plasmaf\u00e9rese deve ser indicada para pacientes com PH nos portadores de SQF de forma individualizada. Os candidatos potenciais seriam os pacientes que apresentam PH grave, ou que persistem com valores de triglic\u00e9rides >1.000mg/dL, ap\u00f3s as primeiras 24 a 48 horas. Classe de recomenda\u00e7\u00e3o: IIb, N\u00edvel de evid\u00eancia: C.170Relatos e s\u00e9ries de casos t\u00eam demonstrado efic\u00e1cia da plasmaf\u00e9rese na remo\u00e7\u00e3o dos triglic\u00e9rides da circula\u00e7\u00e3o dos pacientes com PH, com redu\u00e7\u00e3o m\u00e9dia dos valores de triglic\u00e9rides entre 65 e 85% ap\u00f3s uma ou duas sess\u00f5es.172 O mecanismo da pancreatite aguda induzida por HTG \u00e9 provavelmente causado pelo excesso de triglic\u00e9rides, que, ao sofrerem hidr\u00f3lise pela lipase pancre\u00e1tica, extravasam das c\u00e9lulas acinares para o leito vascular do p\u00e2ncreas, resultando em ac\u00famulo de \u00e1cidos graxos livres e lisolecitina. Os \u00e1cidos graxos livres s\u00e3o t\u00f3xicos e podem causar danos \u00e0s c\u00e9lulas acinares e ao endot\u00e9lio capilar.173 Al\u00e9m disso, as concentra\u00e7\u00f5es elevadas de quilom\u00edcrons aumentam a viscosidade sangu\u00ednea das veias com preju\u00edzo do fluxo sangu\u00edneo local, resultando em isquemia pancre\u00e1tica e piora da les\u00e3o tecidual.174 Os \u00e1cidos graxos livres ativam o tripsinog\u00eanio que inicia o edema local e a pancreatite necrotizante.173 Em s\u00e9rie de casos publicada em hospital terci\u00e1rio da Turquia, com 33 pacientes admitidos com pancreatite aguda relacionada \u00e0 HTG, foi demonstrada redu\u00e7\u00e3o m\u00e9dia de triglic\u00e9rides de 54,4% ap\u00f3s uma \u00fanica sess\u00e3o. Ap\u00f3s uma segunda sess\u00e3o, houve redu\u00e7\u00e3o de triglic\u00e9rides de 79,4%. Durante a evolu\u00e7\u00e3o, 13 pacientes apresentaram cole\u00e7\u00e3o pancre\u00e1tica; 1 paciente com pancreatite necrotizante, n\u00e3o sendo observados casos de pseudocisto. A mortalidade nos pacientes com PH grave foi de 33,3%, e a mortalidade geral foi de 3%, sem casos relacionados ao procedimento de plasmaf\u00e9rese. Esse estudo demonstrou que a plasmaf\u00e9rese \u00e9 um tratamento seguro e eficaz para pacientes com PH. S\u00e3o necess\u00e1rios mais estudos que comparem af\u00e9rese + tratamento conservador e apenas tratamento conservador nos pacientes com PH.175Pelo fato de a PH ser uma condi\u00e7\u00e3o com risco de vida, alguns centros utilizam a plasmaf\u00e9rese como procedimento de escolha na redu\u00e7\u00e3o r\u00e1pida dos quilom\u00edcrons circulantes, t\u00e3o logo seja estabelecido o diagn\u00f3stico, removendo assim o agente causador do dano pancre\u00e1tico. A utiliza\u00e7\u00e3o desse procedimento precocemente na redu\u00e7\u00e3o dos triglic\u00e9rides plasm\u00e1ticos preveniria a gera\u00e7\u00e3o e o ac\u00famulo de \u00e1cidos graxos livres, diminuindo seus efeitos locais e sist\u00eamicos.167 analisaram retrospectivamente os resultados cl\u00ednicos em pacientes com PH antes (n = 34) e ap\u00f3s (n = 60) a disponibilidade de af\u00e9rese na institui\u00e7\u00e3o. Esses grupos apresentavam caracter\u00edsticas cl\u00ednicas semelhantes. Nos 20 pacientes do \u00faltimo grupo, foi optado por plasmaf\u00e9rese, com tempo m\u00e9dio de 3 dias para a realiza\u00e7\u00e3o do procedimento, ap\u00f3s os sintomas iniciais. N\u00e3o houve diferen\u00e7as significativas quanto \u00e0 mortalidade e complica\u00e7\u00f5es entre os pacientes submetidos ou n\u00e3o \u00e0 plasmaf\u00e9rese. As limita\u00e7\u00f5es desse estudo se devem ao seu desenho retrospectivo, experi\u00eancia de um \u00fanico centro e pequeno tamanho da amostra.167Chen et al.167Alguns centros realizam plasmaf\u00e9rese na admiss\u00e3o, pouco antes de 24 horas, enquanto outros incluem pacientes entre 24 e 72 horas da admiss\u00e3o. Estudos t\u00eam enfatizado a import\u00e2ncia do in\u00edcio precoce da plasmaf\u00e9rese na PH, enquanto outros n\u00e3o detectaram qualquer diferen\u00e7a na morbidade ou mortalidade relativa a um in\u00edcio precoce ou tardio do procedimento.Um benef\u00edcio claro da plasmaf\u00e9rese na redu\u00e7\u00e3o da gravidade de pacientes com PH ainda n\u00e3o foi demonstrado de forma conclusiva.175A plasmaf\u00e9rese n\u00e3o \u00e9 isenta de riscos, al\u00e9m de ser um procedimento com custo elevado. Requer acesso intravenoso central e anticoagula\u00e7\u00e3o transit\u00f3ria com complica\u00e7\u00f5es associadas que incluem bacteremia, trombose venosa e sangramento. Os candidatos potenciais seriam os que apresentam PH grave, ou os que continuam com n\u00edveis persistentes de triglic\u00e9rides maiores que 1.000mg/dL ap\u00f3s as primeiras 24 a 48 horas.Pela falta de evid\u00eancias, as recomenda\u00e7\u00f5es para o procedimento de plasmaf\u00e9rese em adultos com PH nos portadores de SQF devem ser individualizadas.176Nas recentes diretrizes da American Society for Apheresis (ASFA), a recomenda\u00e7\u00e3o de plasmaf\u00e9rese em pacientes com PH \u00e9 de 2C (recomenda\u00e7\u00e3o fraca) com n\u00edvel de evid\u00eancia III.A indica\u00e7\u00e3o de plasmaf\u00e9rese na gesta\u00e7\u00e3o, apesar de segura e eficaz, deve ser individualizada, pela escassez de evid\u00eancias at\u00e9 o momento. Classe de recomenda\u00e7\u00e3o: IIb, N\u00edvel de evid\u00eancia: C.178 Pacientes com altera\u00e7\u00f5es do metabolismo lip\u00eddico geneticamente determinadas, caracterizadas por redu\u00e7\u00e3o da lip\u00f3lise intravascular, podem evoluir durante a gesta\u00e7\u00e3o com HTG grave e pancreatite.179A gravidez normal \u00e9 caracterizada por altera\u00e7\u00f5es adaptativas do metabolismo lip\u00eddico, destinadas a garantir as necessidades da placenta e as necessidades de glicose e lip\u00eddios para o crescimento fetal, incluindo aumento da produ\u00e7\u00e3o de glicose, s\u00edntese de progesterona, lipog\u00eanese e redu\u00e7\u00e3o da lip\u00f3lise.180O quadro de PH aparece no terceiro trimestre da gesta\u00e7\u00e3o ou no in\u00edcio do per\u00edodo p\u00f3s-parto, com impacto elevado na morbidade e mortalidade materno-fetal.183J\u00e1 foram descritas taxas de mortalidade materna consequente a quadros de PH de 37% e de mortalidade fetal de 60%, mas, atualmente, esses n\u00fameros est\u00e3o em decl\u00ednio pelos avan\u00e7os diagn\u00f3sticos e terap\u00eauticos.146 Nos casos de PH, o escore de gravidade e o pior progn\u00f3stico s\u00e3o mais prevalentes que as outras etiologias de PA.184Quadros de pancreatite associada \u00e0 gravidez podem ocorrer no contexto de doen\u00e7a do c\u00e1lculo biliar, uso abusivo de \u00e1lcool e HTG.188 Pela escassez de evid\u00eancias, a indica\u00e7\u00e3o de plasmaf\u00e9res na gesta\u00e7\u00e3o complicada com PH, em pacientes com SQF, deve ser individualizada.Relatos de casos cl\u00ednicos t\u00eam demonstrado que o uso de plasmaf\u00e9rese em gestantes tem se mostrado eficaz e seguro.24 O uso de terapia g\u00eanica com AAV1-LPL(S447X) utilizando um v\u00edrus adenoassociado foi testado na SQF , visando expressar a LPL(S447X). No entanto, a despeito de resultados promissores, seu uso comercial n\u00e3o foi poss\u00edvel devido ao elevado custo.189 Assim, a \u00fanica terap\u00eautica que reduz os triglic\u00e9rides <880mg/dL, ou 10mmol/L, nesses pacientes, e que parece reduzir o risco de pancreatite, \u00e9 a dieta com grande restri\u00e7\u00e3o de gordura associada \u00e0 restri\u00e7\u00e3o de \u00e1lcool e certas medica\u00e7\u00f5es.92 A ades\u00e3o ao longo da vida a essas restri\u00e7\u00f5es \u00e9 dif\u00edcil, e epis\u00f3dios de quilomicronemia, dores abdominais e pancreatites recorrentes s\u00e3o comuns. Assim, terapias adicionais s\u00e3o necess\u00e1rias para manter os triglic\u00e9rides <880mg/dL.Os tratamentos dispon\u00edveis para tratamento da SQF, visando \u00e0 redu\u00e7\u00e3o da trigliceridemia, n\u00e3o s\u00e3o efetivos para controle da quilomicronemia nesses pacientes.very-low density lipoprotein ), bem como as HDLs ( high-density lipoprotein ).192 Em estudos gen\u00e9ticos, pr\u00e9-cl\u00ednicos e estudos de fase 1, a APOC3 surgiu como um regulador das concentra\u00e7\u00f5es plasm\u00e1ticas de triglic\u00e9rides.192 A APOC3 \u00e9 um inibidor da atividade da LPL,190 sendo um potente inibidor da ativa\u00e7\u00e3o da LPL, que \u00e9 mediada pela APOC2, resultando em inibi\u00e7\u00e3o da lip\u00f3lise de lipoprote\u00ednas ricas em triglic\u00e9rides.190 A APOC3 inibe a atividade da lipase hep\u00e1tica, para promover a montagem e a secre\u00e7\u00e3o da VLDL193 e inibir o clareamento das lipoprote\u00ednas remanescentes ricas em triglic\u00e9rides.194 Contudo, a import\u00e2ncia desses mecanismos independentes da LPL n\u00e3o \u00e9 bem compreendida.A APOC3 \u00e9 uma glicoprote\u00edna que consiste em 79 amino\u00e1cidos, sintetizada principalmente no f\u00edgado e, em menor propor\u00e7\u00e3o, no intestino, e est\u00e1 associada \u00e0s lipoprote\u00ednas contendo ApoB, incluindo os quilom\u00edcrons e as VLDLs .191Como os pacientes com SQF apresentam atividade da LPL muito baixa e por ser um modo de a\u00e7\u00e3o da APOC3, a inibi\u00e7\u00e3o da lip\u00f3lise pela via LPL-dependente, seria predito que o ISIS 304801 seria inefetivo na redu\u00e7\u00e3o dos triglic\u00e9rides ou tivessem um efeito m\u00ednimo na redu\u00e7\u00e3o dos triglic\u00e9rides em portadores dessa s\u00edndrome. No entanto, deve existir um mecanismo de escape independente da via da LPL para a sobreviv\u00eancia desses pacientes. Estudos pr\u00e9-cl\u00ednicos sugerem que a APOC3 modula os n\u00edveis de triglic\u00e9rides por uma via independente da LPL. Para isso, foi feito um estudo com o ISIS 304801 em pacientes com SQF e triglic\u00e9rides de 1.406 a 2.083mg/dL. Ap\u00f3s 13 semanas de tratamento com 300mg de volanesorsena, as concentra\u00e7\u00f5es plasm\u00e1ticas de APOC3 foram reduzidas de 71 a 90% e os triglic\u00e9rides, de 56 a 86%. Durante o tratamento, todos os pacientes apresentaram triglic\u00e9rides <500mg/dL. Os dados iniciais mostraram o papel da APOC3 como um regulador na via LPL-independente no metabolismo dos triglic\u00e9rides.57 um estudo de fase 3 duplo-cego, randomizado, com dura\u00e7\u00e3o de 52 semanas, que avaliou a efic\u00e1cia e a seguran\u00e7a de volanesorsena em 66 pacientes com SQF. Os pacientes foram randomizados em uma propor\u00e7\u00e3o de 1:1 para receber volanesorsena ou placebo. O desfecho prim\u00e1rio foi a varia\u00e7\u00e3o percentual dos triglic\u00e9rides em jejum do per\u00edodo basal aos 3 meses (na semana 12 ou na semana 13). Nove desfechos secund\u00e1rios foram priorizados e analisados em ordem hier\u00e1rquica. Se a an\u00e1lise do primeiro desfecho fosse significante, o segundo desfecho seria analisado quanto \u00e0 signific\u00e2ncia em ordem hier\u00e1rquica, e assim por diante. Se, na sequ\u00eancia hier\u00e1rquica, um desfecho n\u00e3o fosse significante, os seguintes teriam an\u00e1lise explorat\u00f3ria. As varia\u00e7\u00f5es percentuais entre o per\u00edodo basal e os 6 e os 12 meses foram comparadas entre os tratamentos por ANCOVA.Esses dados foram replicados no estudo cl\u00ednico Approach,LPL , e 11 pacientes apresentavam muta\u00e7\u00f5es bial\u00e9licas em prote\u00ednas acess\u00f3rias ou eram heterozigotos duplos para muta\u00e7\u00f5es nos genes LPL e APOA5 ou LMF1 ; 14 pacientes n\u00e3o apresentavam muta\u00e7\u00f5es definidas, mas foram inclu\u00eddos com base no seu fen\u00f3tipo e na baixa atividade da LPL.23Foram selecionados 130 pacientes e, destes, 67 foram randomizados, e 1 no grupo placebo retirou o consentimento. Dos 66 pacientes randomizados, 41 eram homozigotos ou heterozigotos compostos para uma das 25 muta\u00e7\u00f5es inativadoras do gene retinalis estava presente em 21%, e xantomas eruptivos em 23; 76% tinham hist\u00f3ria de pancreatite documentada e, destes, 23 pacientes tiveram 53 epis\u00f3dios adjudicados nos 5 anos anteriores. Sete pacientes tinham pancreatite cr\u00f4nica. No per\u00edodo basal, 53% usavam fibratos, \u00e1cidos graxos \u00f4mega-3 ou ambos, e 20% recebiam estatinas. Sete pacientes tinham sido tratados previamente com alipogene tiparvovec (Glybera) mais de 2 anos antes da inclus\u00e3o no estudo. Os valores basais de triglic\u00e9rides eram elevados e n\u00e3o diferiram entre o grupo recebendo a medica\u00e7\u00e3o e o placebo (2.209\u00b11.199mg/dL), bem como os quilom\u00edcrons de VLDL (1.849\u00b11.176mg/dL) e APOB48 . A APOC3 era elevada . O tratamento com volanesorsena reduziu os n\u00edveis m\u00e9dios de APOC3 em 84% do basal aos 3 meses, e em 83% ao sexto m\u00eas , com correspondente redu\u00e7\u00e3o de 25,7 e 25,6mg/dL, respectivamente. Houve aumento de APOC3 de 6,1%  ap\u00f3s 3 meses e redu\u00e7\u00e3o de 5,2%  ap\u00f3s 6 meses entre os pacientes que receberam placebo. O desfecho prim\u00e1rio de efic\u00e1cia, ou seja a varia\u00e7\u00e3o percentual dos triglic\u00e9rides entre o per\u00edodo basal e 3 meses, foi a redu\u00e7\u00e3o de 77% no grupo volanesorsena versus aumento de 18% no grupo placebo , o que correspondeu \u00e0 redu\u00e7\u00e3o de 1.712mg/dL, intervalo de confian\u00e7a \u2013 IC 95% 1.330 a 2.094mg/dL no grupo recebendo a volanesorsena, comparado a um aumento de 92,0mg/dL (IC 95%: 301 a 486mg/dL) no grupo placebo . Foram significantes os resultados da an\u00e1lise do primeiro desfecho secund\u00e1rio, ou seja, a taxa de resposta, definidos como alcance de triglic\u00e9rides em jejum <750mg/dL aos 3 meses. No grupo volanesorsena, 77% dos pacientes, em compara\u00e7\u00e3o a 10% dos pacientes que receberam placebo, alcan\u00e7aram n\u00edveis de triglic\u00e9rides <750mg/dL . O desfecho secund\u00e1rio subsequente, varia\u00e7\u00e3o percentual dos triglic\u00e9rides em jejum do basal aos 6 meses, tamb\u00e9m foi significante, com redu\u00e7\u00e3o de 53% nos triglic\u00e9rides correspondendo a 1.380mg/dL, comparado ao placebo com aumento de 25% ou 224mg/dL. A diferen\u00e7a entre os grupos foi de \u221277,8% . A an\u00e1lise do terceiro desfecho secund\u00e1rio, varia\u00e7\u00e3o percentual dos triglic\u00e9rides em jejum do basal aos 12 meses, foi significante, e a volanesorsena reduziu triglic\u00e9rides em 40% (986mg/dL) e o placebo teve aumento de 9%, ou 39mg/dL, com uma diferen\u00e7a entre os grupos de \u221249,1% . O desfecho subsequente, a m\u00e9dia da m\u00e1xima intensidade das dores abdominais autorreferidas pelos pacientes durante o tratamento na an\u00e1lise hier\u00e1rquica, n\u00e3o foi significante.23Os pacientes inclu\u00eddos tinham entre 20 e 75 anos, 80% brancos, 55% mulheres, e o \u00edndice de massa corporal foi de 25,0 \u00b1 5,7, O diagn\u00f3stico de SQF foi feito com idades entre 1 e 75 anos. Lipemia 23Entre os pacientes do grupo recebendo volanesorsena, 19 completaram as 52 semanas de tratamento. Seis receberam 300mg por semana por todo o per\u00edodo de tratamento; entre os 13 restantes, a frequ\u00eancia das doses foi reduzida para 300mg a cada 2 semanas, foi pausada, ou ambas. Entre os pacientes que n\u00e3o tiveram redu\u00e7\u00e3o de dose, a redu\u00e7\u00e3o de triglic\u00e9rides do basal ao terceiro m\u00eas foi de 79%, de 80% aos 6 meses e 72% aos 12 meses . Entre os seis pacientes cujas doses n\u00e3o foram reduzidas, 5 alcan\u00e7aram triglic\u00e9rides <750mg/dL aos 6 meses, e 4 alcan\u00e7aram n\u00edveis de triglic\u00e9rides <750mg/dL aos 12 meses. Dos 13 pacientes que tiveram redu\u00e7\u00e3o de doses, 6 alcan\u00e7aram valores de triglic\u00e9rides <750mg/dL aos 6 meses e 6 alcan\u00e7aram triglic\u00e9rides <750mg/dL aos 12 meses; 3 pacientes alcan\u00e7aram triglic\u00e9rides <750mg/dL aos 6 e aos 12 meses.23Em an\u00e1lise explorat\u00f3ria, os pacientes que receberam volanesorsena reduziram os triglic\u00e9rides dos quilom\u00edcrons em 83%, APOB48 em 76%, n\u00e3o HDL-c em 46%, e VLDL-c em 58%, e aumento de HDL-c em 46%, APOA1 em 14%, LDL-c em 136%, e APOB em 20%.LPL , e em 75% nos 9 pacientes com defeitos gen\u00e9ticos n\u00e3o relacionados \u00e0 LPL . Pacientes com muta\u00e7\u00f5es nos genes APOC2, GPIHBP1, APOA5 e LMF1 , todos, mostraram redu\u00e7\u00e3o de triglic\u00e9rides de 69 a 88%. O tratamento foi efetivo independentemente dos valores basais de triglic\u00e9rides, e foi igualmente efetivo nos pacientes recebendo terapia concomitante com fibratos, \u00e1cidos graxos \u00f4mega-3 ou ambos, e os pacientes n\u00e3o recebendo essas terapias .23A volanesorsena reduziu os triglic\u00e9rides independentemente do diagn\u00f3stico gen\u00e9tico ou do tipo de muta\u00e7\u00e3o. Aos 3 meses, os valores m\u00e9dios de triglic\u00e9rides foram reduzidos em 65% em 17 pacientes com muta\u00e7\u00f5es bial\u00e9licas no gene 23Devido ao tamanho do estudo, por tratar-se de doen\u00e7a rara, a mudan\u00e7a no n\u00famero de epis\u00f3dios de pancreatite n\u00e3o foi um desfecho pr\u00e9-especificado. No entanto, foi feita an\u00e1lise explorat\u00f3ria dos epis\u00f3dios de pancreatite adjudicados que ocorreram durante o estudo. No per\u00edodo de tratamento, tr\u00eas pacientes no grupo placebo tiveram quatro epis\u00f3dios de pancreatite, enquanto um paciente no grupo volanesorsena teve um epis\u00f3dio 9 dias ap\u00f3s ter recebido a \u00faltima dose.Os efeitos adversos mais comuns durante o per\u00edodo de tratamento foram as rea\u00e7\u00f5es no local da inje\u00e7\u00e3o e plaquetopenia.20 o protocolo inicial requeria monitoramento da contagem de plaquetas a intervalos de 4 a 6 semanas. Entretanto, durante o estudo, trombocitopenia grau 4 (<25.000 plaquetas por microlitro) foi observada em dois pacientes no grupo volanesorsena, e o tratamento foi descontinuado. N\u00e3o houve sangramentos maiores em nenhum desses pacientes, e ambos alcan\u00e7aram valores normais de plaquetas em 23 e 33 dias ap\u00f3s descontinua\u00e7\u00e3o do f\u00e1rmaco. Um paciente recebeu prednisona oral na dose de 60mg por 23 dias. O outro paciente recebeu metilprednisolona na dose de 125mg por 11 dias, seguida de prednisona oral na dose de 70mg, reduzida para 50mg por 21 dias, bem como imunoglobulina na dose de 60g e 80g em dias sucessivos, seguida de 4 dias de imunoglobulina na dose 40g diariamente por mais 5 dias. Tr\u00eas outros pacientes com menor grau de plaquetopenia (grau 1 ou 2) foram retirados do estudo por parte dos investigadores. Ap\u00f3s os dois casos de trombocitopenia, um protocolo de monitoramento de plaquetas com dosagens a cada 2 semanas foi estabelecido, com um limiar de <100.000 plaquetas para redu\u00e7\u00e3o da frequ\u00eancia das doses para cada 2 semanas, e um novo limiar passando de 75.000 para 50.000 plaquetas por microlitro para interrup\u00e7\u00e3o da medica\u00e7\u00e3o. Ap\u00f3s essas medidas, nenhum paciente apresentou decl\u00ednio de plaquetas <50.000 por microlitro, e n\u00e3o ocorreu descontinua\u00e7\u00e3o das doses relacionada \u00e0 plaquetopenia. Ocorreu redu\u00e7\u00e3o da frequ\u00eancia das doses de volanesorsena em 13 pacientes, sendo que, em 9 pacientes, estas foram relacionadas \u00e0 plaquetopenia. Houve 14 pacientes randomizados para volanesorsena versus 2 no grupo placebo que n\u00e3o completaram as 52 semanas de tratamento. Nove descontinuaram por eventos adversos, sendo 5 por plaquetopenia e 4 por outros efeitos adversos relacionados \u00e0 volanesorsena. Outros 4 retiraram voluntariamente o consentimento. N\u00e3o houve morte durante o estudo.23No grupo volanesorsena, 20 (61%) pacientes tiveram pelo menos uma rea\u00e7\u00e3o no local da inje\u00e7\u00e3o, em grau leve a moderado e, em m\u00e9dia, 12% das aplica\u00e7\u00f5es de volanesorsena versus zero% das inje\u00e7\u00f5es de placebo foram associadas com essas rea\u00e7\u00f5es. Um paciente foi retirado do estudo devido \u00e0 rea\u00e7\u00e3o no local da inje\u00e7\u00e3o. Plaquetopenia confirmada <140.000 por microlitro foi observada em 25 (76%) pacientes no grupo recebendo a volanesorsena e em 8 (24%) pacientes no grupo placebo; plaquetopenia confirmada <100.000 por microlitro foi observada em 16 pacientes (48%) que receberam volanesorsena, mas em nenhum dos que receberam placebo. Como n\u00e3o havia hist\u00f3ria documentada de plaquetopenia importante em humanos tratados com essa classe de drogas antissentido,196 foi uma pesquisa retrospectiva global, aberta, realizada com pacientes com SQF que receberam volanesorsena por 3 meses ou mais na fase de extens\u00e3o aberta do estudo. A pesquisa incluiu quest\u00f5es sobre experi\u00eancias dos pacientes antes e ap\u00f3s o tratamento com volanesorsena. Vinte e dois participantes tinham recebido volanesorsena por uma mediana de 222 dias. Volanesorsena reduziu significantemente o n\u00famero de sintomas por paciente nos dom\u00ednios f\u00edsico, emocional e cognitivo. Houve redu\u00e7\u00e3o significante nos epis\u00f3dios de esteatorreia, dor pancre\u00e1tica, e constante preocupa\u00e7\u00e3o sobre um ataque de dor ou de pancreatite. Os participantes reportaram, ainda, que volanesorsena melhorou o manejo dos sintomas e reduziu a interfer\u00eancia da SQF nas responsabilidades do trabalho, ou na vida escolar. Houve redu\u00e7\u00f5es no impacto negativo da SQF na vida pessoal, profissional ou social. O tratamento com volanesorsena teve o potencial de reduzir a carga da doen\u00e7a em pacientes com SQF pela modula\u00e7\u00e3o nos m\u00faltiplos dom\u00ednios de sintomas.O estudo Re-FOCUS197 O f\u00e1rmaco tem aprova\u00e7\u00e3o da ag\u00eancia europeia (European Medicines Agency) para uso em adultos com SQF desde 2014.A volanesorsena foi aprovada pela Anvisa em 23 de agosto de 2021com base nos dados do estudo Approach e Compass, e tem indica\u00e7\u00e3o para pacientes adultos (acima de 18 anos) com confirma\u00e7\u00e3o gen\u00e9tica de SQF e alto risco de pancreatite.A volanesorsena n\u00e3o foi aprovada pela Food and Drug Administration (FDA), embora tenha sido avaliada no estudo Approach em pacientes com SQF. A doen\u00e7a \u00e9 considerada ultrarrara e debilitante. A SQF causa pancreatites de ocorr\u00eancia imprevis\u00edvel e potencialmente fatais, complica\u00e7\u00f5es cr\u00f4nicas decorrentes de dano permanente ao \u00f3rg\u00e3o e impacto severo na vida di\u00e1ria dos pacientes. A caracter\u00edstica t\u00edpica da SQF consiste nos n\u00edveis muito elevados de triglic\u00e9rides. Os resultados do estudo de fase 3 Approach \u2013 o maior estudo conduzido com pacientes portadores de SQF \u2013 mostraram que, em compara\u00e7\u00e3o ao placebo, o tratamento com a volanesorsena reduziu os triglic\u00e9rides em 77% (-94% quando comparado ao placebo). As recomenda\u00e7\u00f5es das sociedades m\u00e9dicas s\u00e3o para a redu\u00e7\u00e3o dos triglic\u00e9rides como alvo do tratamento dos pacientes com SQF. Os eventos adversos mais comuns foram as rea\u00e7\u00f5es no local de inje\u00e7\u00e3o e redu\u00e7\u00e3o na contagem de plaquetas.A alega\u00e7\u00e3o do FDA foram quest\u00f5es de seguran\u00e7a, especialmente risco de sangramento devido \u00e0 plaquetopenia, apesar das recomenda\u00e7\u00f5es para mitigar efeitos adversos. Durante o estudo, quando foi detectada a possibilidade de ocorr\u00eancia de plaquetopenia, o manejo desse evento adverso foi feito com monitoramento de plaquetas a cada 15 dias, podendo ser mais frequente conforme os exames subsequentes. Da mesma maneira, foi recomendado o espa\u00e7amento de doses de acordo com a contagem de plaquetas.198 A articula\u00e7\u00e3o de todos esses aspectos citados e de outros aspectos contextuais agrega complexidade ao manejo da SQF, podendo, al\u00e9m de interferir na habilidade adaptativa dos pacientes e cuidadores, demandar diferentes desenhos de interven\u00e7\u00e3o m\u00e9dica centrados na singularidade das pessoas afetadas.A variabilidade na precocidade, as diferen\u00e7as na severidade dos sintomas e as varia\u00e7\u00f5es no grau de limita\u00e7\u00f5es funcionais decorrentes do estado f\u00edsico dos pacientes s\u00e3o caracter\u00edsticas da express\u00e3o da SQF que interagem com outros aspectos, tais como perfil sociodemogr\u00e1fico e econ\u00f4mico; caracter\u00edsticas de personalidade; fatores psicossociais e sociocognitivos; habilidades pessoais de enfrentamento de situa\u00e7\u00f5es adversas em sa\u00fade; capacidade de exercer a autorregula\u00e7\u00e3o e manter o sentido de efic\u00e1cia no contexto do adoecimento.199 estabelece um padr\u00e3o de sil\u00eancio acerca da SQF. A falta de familiaridade para com essa condi\u00e7\u00e3o, na sociedade m\u00e9dica, \u00e9 agravante do estresse biopsicossocial experimentado pelas pessoas afetadas, o que leva a empreender uma peregrina\u00e7\u00e3o entre especialidades em busca da realiza\u00e7\u00e3o do diagn\u00f3stico, que, via de regra, acontece tardiamente e n\u00e3o conduz a resposta terap\u00eautica medicamentosa eficaz. As lacunas na comunica\u00e7\u00e3o e no conhecimento imp\u00f5em aos pacientes e cuidadores o desafio de conviver com uma doen\u00e7a que provoca limitadas rea\u00e7\u00f5es emp\u00e1ticas, uma vez que n\u00e3o apresenta sentido e significado socialmente constru\u00eddo e tampouco identidade clinicamente reconhecida.199 Nesse panorama, para al\u00e9m do grave efeito delet\u00e9rio da doen\u00e7a no estado de sa\u00fade e na capacidade funcional, \u00e9 relevante o desdobramento do estado da arte na vida real.A falta de reverbera\u00e7\u00e3o da fala dos pacientes na comunica\u00e7\u00e3o social, causada pela aus\u00eancia do tema no discurso comum e sua restri\u00e7\u00e3o no discurso cient\u00edfico,200 sobre a qualidade de vida dos pacientes com SQF, ao demonstrar a validade dos instrumentos de autorrelato, no contexto da doen\u00e7a rara, coloca em evid\u00eancia o forte impacto negativo do tratamento, realizado fundamentalmente por meio de restritivo controle alimentar. Ao dar a conhecer qual a experi\u00eancia da doen\u00e7a no cotidiano,201 o quanto adoecer prejudica a percep\u00e7\u00e3o pessoal de satisfa\u00e7\u00e3o com a qualidade de vida e o estado de sa\u00fade,202 e deixar entrever o impacto do tratamento na capacidade adaptativa das pessoas afetadas,203 amplia a conscientiza\u00e7\u00e3o acerca dos desdobramentos psicossociais da SQF. Na Estudo199 Embora os estudos de doen\u00e7as de baixa preval\u00eancia contemplem n\u00famero reduzido de sujeitos, em compara\u00e7\u00e3o aos realizados no enquadre das doen\u00e7as cr\u00f4nicas e frequentes, s\u00e3o capazes de retratar a realidade dos pacientes e cuidadores e apontar tend\u00eancias, e podem colaborar na orienta\u00e7\u00e3o de estrat\u00e9gias comportamentais de enfrentamento.Ao possibilitar a escuta das pessoas afetadas pela doen\u00e7a, de modo estruturado e padronizado, o emprego do instrumento psicom\u00e9trico de autorrelato permite romper com o padr\u00e3o de silenciamento, caracter\u00edstico das doen\u00e7as raras ou pouco conhecidas.198 Estudo204 evidencia que o forte sentimento de incompreens\u00e3o pode impulsionar os pacientes e cuidadores a criarem respostas adaptativas restauradoras de familiaridade e pertencimento em ambientes religiosos.O paciente diagnosticado com doen\u00e7a rara, tamb\u00e9m nomeada doen\u00e7a \u00f3rf\u00e3, \u00e9 uma pessoa que, em alguma medida, perde suas refer\u00eancias sociais e se afasta do modo de cuidado \u00e0 sa\u00fade usual, de senso comum, passando a depender dos norteamentos t\u00e9cnico-cient\u00edficos na condu\u00e7\u00e3o da doen\u00e7a. A car\u00eancia de informa\u00e7\u00f5es sobre a hist\u00f3ria da doen\u00e7a na vida real e a falta de diretrizes, ou posicionamentos norteadores de condutas e orienta\u00e7\u00f5es m\u00e9dicas seguras e eficazes, impactam a habilidade pessoal na constru\u00e7\u00e3o das rotinas, de projetos e manuten\u00e7\u00e3o das rela\u00e7\u00f5es interpessoais como idealizadas pelos pacientes. O desconhecimento sobre a doen\u00e7a interfere no sentido de pertencimento, sustenta sentimentos de desamparo e isolamento. A invisibilidade da doen\u00e7a no cotidiano reduz a chance de os pacientes e cuidadores contarem com suporte social.204 que as lacunas no conhecimento m\u00e9dico sobre a SQF dificultam a comunica\u00e7\u00e3o na pr\u00e1xis cl\u00ednica. A falta de entendimento acerca dos objetivos da proposta terap\u00eautica pode conduzir os pacientes a alimentarem expectativas pouco realistas quanto ao alcance do tratamento. A 202Tem se evidenciado204Evidenciados os aspectos f\u00edsicos e psicossociais mais gravemente afetados pela SQF, na perspectiva do paciente, vale sublinhar que a cren\u00e7a de recupera\u00e7\u00e3o da condi\u00e7\u00e3o de normalidade experimentada antes da experi\u00eancia de adoecimento, a esperan\u00e7a depositada no tratamento, pode ser melhor manejada conforme os profissionais se encontrem mais atualizados e h\u00e1beis a realizar e comunicar o diagn\u00f3stico e as evid\u00eancias que sustentam orienta\u00e7\u00f5es terap\u00eauticas, e conversar sobre os resultados esperados.206 Depress\u00e3o, sentimentos de constrangimento, vergonha e inadequa\u00e7\u00e3o social, percep\u00e7\u00e3o de mudan\u00e7as no funcionamento cognitivo, por influ\u00eancia de dificuldades de concentra\u00e7\u00e3o e mem\u00f3ria, s\u00e3o aspectos da doen\u00e7a que corroboram para o decl\u00ednio na qualidade de vida pessoal e profissional dos afetados.207 Segundo os pacientes conviver com a SQF consome o tempo e exaure a energia f\u00edsica e mental, tornando-os incapazes de se projetarem na vida.208 Revis\u00e3o sistem\u00e1tica199 indica que os adultos com diagn\u00f3stico de SQF podem expressar significativos preju\u00edzos psicol\u00f3gicos relacionados \u00e0 falta de autonomia e de liberdade na condu\u00e7\u00e3o da vida, para al\u00e9m da doen\u00e7a. Tal aspecto precisa ser mais bem conhecido na SQF.Sentimento de impot\u00eancia diante da doen\u00e7a, sintomas de fadiga e confus\u00e3o mental s\u00e3o aspectos de campo interdisciplinar que podem persistir durante toda a vida dos pacientes com SQF. A preocupa\u00e7\u00e3o quanto ao efeito da doen\u00e7a na sa\u00fade e na vida, ao longo do tempo, o desejo de ser capaz de viver uma vida normal e a preocupa\u00e7\u00e3o com o impacto financeiro da doen\u00e7a afetam sobremaneira a estabilidade emocional dos pacientes e cuidadores, podendo produzir sentimentos de baixa autoestima e ansiedade, interferir na habilidade de racioc\u00ednio e de elabora\u00e7\u00e3o de solu\u00e7\u00f5es, e reduzir a qualidade do sono.209 Doen\u00e7as raras s\u00e3o desafiadoras n\u00e3o somente para os pacientes, mas tamb\u00e9m para aqueles familiares que lhes oferecem cuidado. Estudo210 identifica a elevada frequ\u00eancia de relatos parentais acerca da falta de suporte social e aus\u00eancia de empatia por parte dos profissionais de sa\u00fade, o que se expressa em forma de queixas recorrentes de falta de informa\u00e7\u00e3o e orienta\u00e7\u00e3o, de modo geral, e de falta de aconselhamento quanto ao modo adequado de interagir/agir com a crian\u00e7a doente. Tal estudo mostra que os pais tendem a expressar mais preocupa\u00e7\u00f5es com o futuro, e as m\u00e3es, com o tempo presente. Al\u00e9m disso, evidencia que o relato sobre a avalia\u00e7\u00e3o pessoal de preju\u00edzo na qualidade das rela\u00e7\u00f5es sociais, familiares e profissionais \u00e9 mais comum entre as m\u00e3es, pois tende a ocupar mais de seu tempo com os cuidados b\u00e1sicos e a rotina di\u00e1ria. Tais diferen\u00e7as, interpretadas com rela\u00e7\u00e3o \u00e0s quest\u00f5es de g\u00eanero, precisam ser melhor conhecidas.A SQF \u00e9 uma doen\u00e7a que se apresenta no final da inf\u00e2ncia e adolesc\u00eancia, embora alguns casos sejam encontrados nos primeiros anos de vida e entre neonatos.211 Vale lembrar que a proposta de ader\u00eancia terap\u00eautica total e permanente pode gerar conflitos pessoais e sociais, e encontrar resist\u00eancia por parte dos pacientes ou falta de colabora\u00e7\u00e3o social, na medida em que pode impactar projetos de vida pactuados/interpessoais ao interferir na decis\u00e3o de ter filhos, na capacidade de trabalhar, no tempo livre para aproveitar momentos de lazer etc.207A ader\u00eancia \u00e0s recomenda\u00e7\u00f5es gerais, usualmente dispostas como consensos m\u00e9dicos, \u00e9 essencial para a promo\u00e7\u00e3o e a preven\u00e7\u00e3o da sa\u00fade em \u00e2mbito prim\u00e1rio, secund\u00e1rio e nos processos de reabilita\u00e7\u00e3o. Entre os comportamentos em sa\u00fade, a ader\u00eancia terap\u00eautica \u00e9 um dos comportamentos de autorregula\u00e7\u00e3o mais estudados, e refere-se \u00e0 participa\u00e7\u00e3o ativa do paciente no manejo da doen\u00e7a para fim de preserva\u00e7\u00e3o da sa\u00fade e qualidade de vida no contexto do adoecimento.199 mostram que s\u00e3o exemplos de abordagens passivas de enfrentamento: obten\u00e7\u00e3o/busca por informa\u00e7\u00e3o; aconselhamento cl\u00ednico; aconselhamento gen\u00e9tico; educa\u00e7\u00e3o em sa\u00fade. S\u00e3o exemplares de abordagens ativas de enfrentamento na atua\u00e7\u00e3o/a\u00e7\u00e3o comportamental, no caso da SQF: autocontrole na restri\u00e7\u00e3o no consumo de gorduras, \u00e1lcool e carboidratos; autorregula\u00e7\u00e3o na ingest\u00e3o de rem\u00e9dios sem indica\u00e7\u00e3o m\u00e9dica, evitando a intera\u00e7\u00e3o medicamentosa prejudicial; autoadministra\u00e7\u00e3o dos f\u00e1rmacos indicados para redu\u00e7\u00e3o das concentra\u00e7\u00f5es plasm\u00e1ticas de triglic\u00e9rides; realiza\u00e7\u00e3o de exames de acompanhamento na frequ\u00eancia indicada pelo m\u00e9dico de refer\u00eancia.Visando a maior sucesso na ader\u00eancia terap\u00eautica na SQF, \u00e9 indispens\u00e1vel o envolvimento do paciente nas decis\u00f5es. Para tanto, preconiza-se lan\u00e7ar m\u00e3o de estrat\u00e9gias passivas e ativas de enfrentamento. Dados da revis\u00e3o sistem\u00e1tica211 que investigou o efeito do uso da internet na capacidade adaptativa de pais de crian\u00e7as com doen\u00e7as raras mostrou que o ganho de conhecimento \u00e9 essencial para a adapta\u00e7\u00e3o gradual ao contexto de sa\u00fade. O referido estudo ressalta que a livre busca por expertise pelo paciente tanto pode elevar seu sentido de efic\u00e1cia como aumentar a express\u00e3o de sintomas de ansiedade. Enquanto realidade contempor\u00e2nea, o impacto da busca por forma\u00e7\u00e3o/informa\u00e7\u00e3o online pelos pacientes e cuidadores, no processo adaptativo \u00e0 SQF, precisa ser mais bem conhecido.Estudo212 O estudo CONNEC213 mostra que as pessoas afetadas pela SQF podem se beneficiar ao estabelecer contato com outros portadores da doen\u00e7a. Esse estudo sugere que a participa\u00e7\u00e3o em grupos afins, seja por meio de leitura de textos, participa\u00e7\u00e3o em sites e rodas de conversa presencial ou online , interagindo ou apenas observando as narrativas de outros pacientes, pode influenciar positivamente a autopercep\u00e7\u00e3o de qualidade de vida, a reavalia\u00e7\u00e3o da severidade dos sintomas f\u00edsicos e a redu\u00e7\u00e3o da sintomatologia psiqui\u00e1trica, al\u00e9m de mitigar o estresse psicossocial. Como parte da implanta\u00e7\u00e3o de medidas amplas de enfrentamento e manejo da doen\u00e7a, preconiza-se o preenchimento das lacunas t\u00e9cnico-cient\u00edficas, o incentivo dos pacientes \u00e0 socializa\u00e7\u00e3o terap\u00eautica e a difus\u00e3o do conhecimento sobre o efeito psicossocial adverso da SQF, o que pode colaborar acelerando processos de constru\u00e7\u00e3o da identidade social da doen\u00e7a e estabelecimento de expertise na aten\u00e7\u00e3o \u00e0 sa\u00fade.94Sabe-se que o suporte social obtido em grupos de pares pode contribuir melhorando a percep\u00e7\u00e3o de bem-estar geral e gerar motiva\u00e7\u00e3o para o exerc\u00edcio da autorregula\u00e7\u00e3o.214 \u00e9 de se admitir que a aplica\u00e7\u00e3o em recursos terap\u00eauticos colaborativos, que contemplem interven\u00e7\u00f5es atentas aos aspectos cl\u00ednicos e sintomas psicoemocionais,215 traga retorno custo-eficaz, visto que manifesta\u00e7\u00f5es psiqui\u00e1tricas, embora n\u00e3o espec\u00edficas da SQF, prejudicam a ader\u00eancia terap\u00eautica e precipitam recorrentes urg\u00eancias e interna\u00e7\u00f5es hospitalares. 219 Nesse sentido, corrobora a revis\u00e3o de literatura216 que mostra haver robusta evid\u00eancia de que o investimento em a\u00e7\u00f5es combinadas, de interven\u00e7\u00e3o nas doen\u00e7as cardiovasculares junto \u00e0 interven\u00e7\u00f5es nos quadros de ansiedade e depress\u00e3o, acarreta resultado custo-eficaz positivo. Finalmente, o estudo ReFOCUS196 mostra que o tratamento farmacol\u00f3gico adequado pode produzir o controle da evolu\u00e7\u00e3o da doen\u00e7a, reduzir o estresse gerado pelo controle alimentar restritivo severo e, inclusive, modificar expectativas em rela\u00e7\u00e3o ao futuro. Nessa perspectiva, n\u00e3o cabe d\u00favida acerca da estreita articula\u00e7\u00e3o da SQF com aspectos psicossociais, e do potencial custo-eficaz projetado nos estudos e interven\u00e7\u00f5es que buscam desenvolver tratamento medicamentoso efetivo para pacientes diagnosticados para SQF.217Sabendo-se que a avalia\u00e7\u00e3o custo-efic\u00e1cia das interven\u00e7\u00f5es em sa\u00fade busca apontar solu\u00e7\u00f5es de menor gasto n\u00e3o relacionado \u00e0 doen\u00e7a, por meio das quais, a aloca\u00e7\u00e3o do investimento para que seja contabilizado o melhor resultado, Contents1. Cover Letter 52. Document Objectives 63. Definition of Grades of Recommendation and Levels of Evidence 64. Definition of Hypertriglyceridemia (> 150 mg/dL), Severe Hypertriglyceridemia (> 500 mg/dL), and Chylomicronemia  64.1. Introduction 64.2. Definition of Hypertriglyceridemia 75. Definition of Chylomicronemia \u2013 Familial Chylomicronemia Syndrome and Multifactorial Chylomicronemia Syndrome: Clinical and Laboratory Criteria and Patterns of Transmission 75.1. Introduction 75.2. Concepts 85.2.1. Familial Chylomicronemia Syndrome 85.2.2. Multifactorial Chylomicronemia Syndrome 86. Epidemiology of Familial Chylomicronemia Syndrome in the World and in Brazil 86.1. Definition of Familial Chylomicronemia Syndrome and Clinical Aspects 86.1.1. First Cases of Familial Chylomicronemia Syndrome 96.2. Epidemiology of Familial Chylomicronemia Syndrome in the World 96.3. Epidemiology of Familial Chylomicronemia Syndrome in Children 116.4. Epidemiology of Familial Chylomicronemia Syndrome in Brazil 117. Clinical Manifestations of Familial Chylomicronemia Syndrome, Differential Diagnosis, and Management of Complications 117.1. Clinical Manifestations in Familial Chylomicronemia Syndrome 117.1.1. Hypertriglyceridemia 127.1.2. Abdominal Pain and Acute Pancreatitis 127.1.3. Neurological Manifestations 127.1.4. Hepatosplenomegaly 127.1.5. Eruptive Xanthomas 127.1.6. Lipemia Retinalis 127.1.7. Quality of Life 127.1.8. Diagnostic Score 127.2. Differential Diagnosis 127.2.1. Multifactorial Chylomicronemia Syndrome 127.2.2. Lipodystrophies 137.3. Managing Complications of Familial Chylomicronemia Syndrome 137.3.1. Acute Pancreatitis 138. Laboratory Diagnosis of Familial Chylomicronemia Syndrome 148.1. Pre-analytical Phase (Patient Instructions) 148.1.1. Collection Instructions 148.1.2. Pre-analytical Causes of Interference in Triglyceride Analyses 148.1.3. Pre-analytical Phase (Laboratory Instructions) 148.2. Analytical Phase 158.2.1. Methodologies Assessing Chylomicrons 138.2.1.1. Ultracentrifugation 158.2.1.2. Serum Appearance 158.2.1.3. Lipoprotein Electrophoresis 158.2.2. Methodologies for Assessing Triglycerides 158.2.3. Interferences to Triglyceride Results 158.2.4. Interferences of Triglycerides to Other Analytes 158.2.4.1. LDL-C 158.2.4.2. Platelets 168.2.4.3. Analytes with Colorimetric Analysis 168.2.4.4. Enzymes 168.2.4.5. Electrolytes 168.2.5. Laboratory Analyses for Differential Diagnosis 168.2.5.1. Post-heparin Lipoprotein Lipase Activity 168.2.5.2. Plasma ApoC3 Measurement 168.3. Post-analytical Phase 168.3.1. Recommendations for NOTES in Laboratory Reports 169. Genetic Counseling and Stages of Diagnosis and Follow\u2013up of Severe Hypertriglyceridemia 1710. Nutritional Guidance for Chylomicronemia in Adults, Children, and Adolescents 1810.1. Fatty Acid Classification and Absorption 1810.2. Fat Absorption 1910.3. Nutritional Treatment 1910.3.1. Fats 1910.3.3. Carbohydrates 2010.3.4. Alcohol 2010.3.5. Infants and Early Childhood 2010.3.6. Pregnant Women 2110.3.7. General Recommendations 2110.4. Sample Menus 2111. Apheresis 2611.1. Diagnosis and Treatment 2611.2. Nondrug Therapy 2611.3. Pharmacological Treatment 2611.4. Apheresis 2612. New Therapies for the Treatment of Familial Chylomicronemia Syndrome 2712.1. APOC3 2712.1.1 Antisense Inhibition of ApoC3 2713. Social and Psychological Aspects and Economic Impact of the Disease 2713.1. Social Aspects in Familial Chylomicronemia Syndrome 2913.2. Psychological Aspects in Familial Chylomicronemia Syndrome 3013.2.1. Parents of children diagnosed with Familial Chylomicronemia Syndrome 3013.3. Reducing the Impact of the Disease: Ways of Coping 3013.3.1. Active and Passive Models for Coping: Focus on the Patient 3113.3.2. Social Model for Coping: Focus on Peers 3113.4. Cost-effectiveness in the Management of Psychosocial Risks 3114. Summary of Recommendations 32References 33lipemia retinalis , hepatosplenomegaly, and a milky appearance of serum.Familial chylomicronemia syndrome (FCS) is a severe form of dyslipidemia characterized by multiple signs and symptoms associated with a deficiency in lipoprotein lipase or one of its cofactors, leading to compromised triglyceride metabolism. FCS has an autosomal recessive pattern of inheritance and affects approximately 1 to 2 people per million, but it may be more frequent in consanguineous relationships. Knowledge of this condition is still limited, often contributing to delayed diagnosis when complications have already set in. Patients with FCS may have recurrent abdominal pain, episodes of pancreatitis, eruptive xanthomas, In classic, severe forms, clinical symptoms are present at birth or even in childhood, but they may manifest at any age, especially in carriers of new mutations. Patients with FCS usually see several specialists before a diagnosis is made. The clinical presentation of FCS may also be indistinguishable from that of multifactorial chylomicronemia syndrome, which is more common and also has a genetic basis, although it is influenced by environmental and lifestyle factors. In addition, multifactorial chylomicronemia syndrome may result from conditions such as hypothyroidism, uncontrolled diabetes, kidney disease, alcohol abuse, and use of certain medications, which makes its diagnosis even more difficult.A few centers in Brazil use a panel of causal genes to genetically confirm FCS. FCS diagnosis can be confirmed by the presence of a homozygous mutation in one of the causal genes or two different mutations in the same gene (compound heterozygote) or in different causal genes (double heterozygote), although in some cases, a causal mutation cannot be found. Validated algorithms may assist in the clinical suspicion of FCS and indicate which patients should undergo genetic testing.FCS treatment requires a multidisciplinary approach, including a nutritionist and psychologist, among other health professionals, with the aim to maintain the individual\u2019s well-being and nutritional status. Restriction of fats and simple carbohydrates and supplementation with fat-soluble vitamins and essential fatty acids should be recommended for life. Psychological support aims to help patients live with strict dietary restrictions.Conventional pharmacological treatment is often less than 20% effective in reducing triglycerides, which is why patients\u2019 hopes lie on the approval of new medications in Brazil that have proven beneficial in triglyceride reduction. Peculiar situations in the management of FCS are pregnancy and episodes of recurrent pancreatitis, for which mortality rates can be high and individualized treatment is required.The purpose of this document is to make health professionals aware of the peculiar characteristics of FCS and to help them recognize early signs and symptoms and develop an adequate approach, mitigating patients\u2019 suffering and the complications caused by a delayed diagnosis. Members of the Atherosclerosis Department of the Brazilian Society of Cardiology and renowned specialists from Brazil gathered together with the aim of describing in a clear and objective way the best scientific information available on FCS to improve clinical practice.Yours sincerely,Prof. Dra. Maria Cristina de Oliveira IzarProf. Dr. Raul Dias SantosProf. Dr. Antonio Carlos Palandri ChagasDr. Marcelo Heitor Vieira AssadCoordinatorsThis document aims to make health professionals, especially cardiologists, clinicians, and endocrinologists, aware of a very rare, underdiagnosed, and undertreated disease that causes intense suffering in those affected and which was not diagnosed until recently. Written by experts in the field, the Brazilian Position Statement for Familial Chylomicronemia Syndrome (FCS) fills a gap in the knowledge of epidemiological data in Brazil and the world about clinical manifestations, laboratory and genetic diagnoses, and differential diagnosis of other forms of severe hypertriglyceridemia (HTG). In addition, the peculiar nutritional management associated with the condition and the treatment of infants, children, and pregnant women and complications such as pancreatitis are highlighted in this document. Of note, a new antisense therapy against apolipoprotein C3 (ApoC3) has been recently approved in Brazil, with evidence of triglyceride reduction and prospects of preventing complications and improving the quality of life of patients.Classes (grades) of recommendation:Class I \u2013 Conditions for which there is conclusive evidence or, if not, a consensus that the procedure is safe and useful/effective.Class II \u2013 Conditions for which there is conflicting evidence and/or divergence of opinions on the safety and usefulness/efficacy of the procedure.Class IIa \u2013 Evidence or opinion in favor of the procedure. The majority agrees.Class IIb \u2013 Safety and usefulness/efficacy are less well established, and there is no predominance of opinions in favor of the procedure.Class III \u2013 Conditions for which there is evidence and/or a consensus that the procedure is not useful/effective, and in some cases may be harmful.Levels of evidence:Level A \u2013 Data obtained from several large, randomized studies showing concurring results and/or a robust meta-analysis of randomized controlled trials.Level B \u2013 Data obtained from a less robust meta-analysis, a single randomized study, or from nonrandomized  studies.Level C \u2013 Data obtained from consensual expert opinions.1Some relevant factors should be considered before defining values and classifying HTG as mild, moderate, or severe. For lipid profile assessment, patients should maintain a stable metabolic state and their usual diet but should not consume alcohol 5 days before blood collection. Possible within-person biological variations and variations between laboratories should be considered when interpreting lipid measurements. Such variations can reach values of 10% for total cholesterol, high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C) and up to 25% for triglycerides.3 For HTG values > 400 mg/dL, the Friedewald formula, which is commonly used to calculate cholesterol fractions, is no longer used.4 Some publications suggest increased cardiovascular risk associated with postprandial HTG.6 In 2016, the European Atherosclerosis Society (EAS) and the European Federation of Clinical Chemistry and Laboratory Medicine guidelines stated that fasting was no longer required for lipid profile assessment.7The most recent Brazilian guidelines for dyslipidemia and diabetes state that fasting is not required for serum triglyceride assessment. However, if plasma triglyceride concentrations are > 400 mg/dL, plasma triglycerides should be measured again after a 12-hour fast due to the possibility of primary HTG, for which fasting is required.The Brazilian Guidelines for Dyslipidemia and Atherosclerosis classification of dyslipidemia is described in 9Fredrickson\u2019s classification of phenotypes    is base1In laboratory tests, HTG is defined as plasma triglyceride concentrations > 150 mg/dL. However, if the lipid profile is measured without fasting, HTG is defined as triglycerides > 175 mg/dL.10 :Thus, HTG may be classified intoMild: plasma triglycerides > 150 mg/dL;Moderate: plasma triglycerides from 151 to 499 mg/dL;Severe: plasma triglycerides from 500 to 1,000 mg/dL;Very severe: plasma triglycerides > 1,000 mg/dL.11HTG results from the accumulation of lipoproteins rich in fatty acids and glycerol . Chylomicronemia is the main lipoprotein abnormality in severe and very severe forms, defined as the presence of circulating chylomicrons during fasting. The presence of chylomicrons can be detected in the blood if triglyceride concentrations are > 1,000 mg/dL; however, chylomicronemia is more likely to be detected when concentrations exceed 1,500 mg/dL. The severe and very severe forms of HTG are clinically relevant because of their association with a 2-fold increased risk of acute pancreatitis (AP), whose incidence increases by 3% for each 100 mg/dL > 1,000 mg/dL of triglyceridemia.Chylomicronemia is characterized by an accumulation of chylomicrons in the circulation and a significant increase in plasma triglyceride concentrations.lipemia retinalis , eruptive xanthomas, hepatosplenomegaly, and especially AP, which would help confirm the diagnosis of FCS.12The higher the plasma triglyceride concentration, the greater the risk of pancreatitis. However, patients with concentrations > 1,000 mg/dL or very severe HTG are more likely to develop AP. To consider a diagnosis of FCS, laboratory abnormalities should be associated with the presence of clinical abnormalities since childhood or adolescence. Such abnormalities include 13The severe and very severe forms of HTG are clinically relevant because of their association with a 2-fold increased risk of AP. AP is a potentially life-threatening condition that may also lead to a number of clinical complications, such as chronic pancreatitis, pancreatic insufficiency, and diabetes.14 Lipoprotein lipase (LPL) is an enzyme located on the endothelial surface of adipose and muscle tissue capillaries; when activated, it initiates the process of hydrolysis of chylomicron triglycerides, generating chylomicron remnants. LPL activity is modulated by the action of apoC2 and apoA5, which act as cofactors in its activation, lipase maturation factor 1 (LMF1), which is necessary for the production of LPL in adipocytes and myocytes, and by the action of glycosylphosphatidylinositol anchored high-density lipoprotein binding protein 1 (GPIHBP1), which transports LPL from the interstitial space to the capillary lumen. Any alteration in the function and/or activation of LPL results in an increase in the half-life of chylomicrons in the bloodstream, consequently leading to chylomicronemia.14Chylomicrons are formed by the incorporation of dietary lipids into Apos  and then secreted into the mesenteric lymph.15There are two distinct forms of chylomicronemia: FCS and multifactorial chylomicronemia syndrome (MCS). These are, respectively, the prototypes of the monogenic and polygenic conditions underlying severe HTG of genetic origin. Chylomicronemia is estimated to affect 1:600 adults, but patients with FCS account for only 5%.The two forms of the disease can be differentiated by clinical and/or laboratory characteristics of patients. Patients with FCS usually present with pancreatitis, whereas those with MCS are more likely to have atherosclerotic cardiovascular disease. Early and accurate diagnosis of both conditions is essential for therapeutic success and mortality prevention.The two forms are difficult to distinguish due to a considerable phenotypic overlap, and there are still many unanswered questions related to prevalence, clinical and genetic features, and clinical management.FCS is a serious and very rare metabolic disease characterized by chylomicronemia associated with recurrent episodes of abdominal pain and/or pancreatitis.16 The condition often manifests in childhood or adolescence and has been described in all ethnicities, with a higher prevalence in some geographic areas, such as Quebec, due to the founder effect.17The worldwide estimate is that FCS affects 1 in every 500,000 to 1,000,000 people.15 FCS is a monogenic, autosomal recessive lipid disorder whose diagnosis is based on the detection of rare, biallelic mutations (homozygous or compound heterozygous) in LPL (> 80% of cases) or other genes that encode the proteins necessary for their activity , leading to a dramatic reduction in chylomicron clearance.18 Typically, patients\u2019 response to lipid-lowering drugs is limited, and thus treatment represents a clinical challenge. The cornerstone of FCS therapy consists of a dramatic reduction in fat intake , which is difficult to maintain over time. Lifetime adherence to such an extremely restrictive treatment is difficult, negatively impacts quality of life, and does not completely eliminate the risk of pancreatitis in all patients. Recurrent AP occurs in 50% of patients with FCS; the overall associated mortality rate is 5% to 6% but increases to 30% in subgroups of patients who develop pancreatic necrosis or persistent multiple organ failure.19Also called Fredrickson type I hyperlipoproteinemia,20 MCS incidence tends to increase linearly with the increase in the prevalence of obesity, metabolic syndrome, and type 2 diabetes in the world population. In patients with this syndrome, chylomicronemia is intermittent and, in most cases, manifests later.15 It responds well to changes in lifestyle and treatment of secondary factors, with good response to triglyceride-lowering agents. MCS is characterized by an increased risk of AP, but the estimated odds ratio (OR) of 50 is clearly lower than the OR of 360 reported in patients with FCS.21MCS, also called Fredrickson type V hyperlipoproteinemia, is an oligogenic or polygenic lipid disorder aggravated by the presence of comorbidities known to increase triglycerides , environmental factors , and certain drugs, such as glucocorticoids, ethinylestradiol, and neuroleptics.22 Considering that the treatment for the two forms of the disease is very different, a correct diagnosis must be made. New therapies, such as apoC3 inhibitors, are under development to lower triglycerides in people with FCS.23The two forms of chylomicronemia can be differentiated on the basis of lipoprotein electrophoresis or ultracentrifugation . The current gold standard procedure for identifying patients with FCS is genetic testing or post-heparin LPL activity.lipemia retinalis , recurrent abdominal pain, eruptive xanthomas, episodes of recurrent pancreatitis, cognitive and neurological disorders, and impaired quality of life and sociability.24FCS is a very rare inherited disease that affects approximately 1-2:1,000,000 people. It has an autosomal recessive mode of transmission and is characterized by very high concentrations of triglycerides , turbid lipemic serum, with a milky aspect, lipemia retinalis in 4% to 36%, hepatosplenomegaly or splenomegaly alone in 12% to 25%, abdominal pain in 26% to 63%, pancreatitis in 60% to 88%, and multiple pancreatitis in 17% to 48%.26 Serum appearance is important to differentiate between the situations that increase free glycerol in the blood, leading to an overestimation of triglyceride levels, with no serum turbidity after 12 hours of refrigeration and excluding causes of hyperglycerolemia .28However, the frequency of clinical manifestations in patients with FCS is variable. Eruptive xanthomas have been described in 17% to 23% of patients with FCS, 20 In FCS, chylomicrons, chylomicron remnants, and triglyceride-rich lipoproteins cannot be metabolized and accumulate in the plasma. Thus, the accumulation of triglycerides can impair pancreatic blood flow and activate inflammatory processes, resulting in AP.30In FCS, severe HTG results from the inability to metabolize triglycerides and other fats. Fats are absorbed by the small intestine, where chylomicrons are formed. When LPL activity is normal, LPL participates in the hydrolysis of chylomicron triglycerides into free fatty acids via the LPL-dependent pathway.24 LPL synthesis occurs intracellularly in adipocytes and smooth muscle cells. It is produced as a monomer, and adequate LPL dimerization is dependent on LMF-1. After this step, GPIHBP1, a glycoprotein involved in the transport of LPL to the capillary lumen, facilitates anchorage of LPL to the endothelial capillary, where it hydrolyzes the triglyceride content of chylomicrons and VLDL. ApoC2 and apoA5 participate as cofactors in LPL activation. Hydrolysis of triglycerides from these lipoproteins releases free fatty acids and monoglycerides, which are transported into myocytes or adipocytes, where they are used for energy production or lipid storage.24The role of LPL and its cofactors is crucial for understanding the metabolism of triglyceride-rich lipoproteins.LPL gene, leading to extremely high levels of chylomicrons in the circulation and, therefore, severe HTG. Other genes have also been described as cofactors in LPL activation, namely: APOC2 , APOA5 , LMF1 , and GPIHBP1 .15Mutations in five different genes have been implicated in the development of FCS, all of which have an effect on LPL activity, which is responsible for removing triglycerides from chylomicrons and other triglyceride-rich lipoproteins in the circulation, breaking them down into free fatty acids. Patients with FCS have loss-of-function mutations in the 28 in 1953, when they followed up three cases of familial idiopathic hyperlipoproteinemia in a family of eight people. The patients had a milky appearance of serum and markedly increased triglycerides. A low-fat diet followed by the administration of intravenous heparin greatly reduced triglycerides, suggesting that the defect was related to triglyceride removal from the circulation.28FCS was first described by Gaskins et al.31 When studying three brothers affected by the condition, the authors also suggested that another defect in addition to LPL could cause the so-called familial idiopathic hyperlipoproteinemia syndrome.This family was studied in 1960 and LPL, an enzyme anchored to the vascular endothelial surface and released from the wall by heparin, was suspected to be responsible for the lipid defect.32 reported that, in a series of biological samples from 381 patients with triglycerides > 1,000 mg/dL, four patients (or 1%) had two large-effect loss-of-function mutations on both alleles of the LPL gene, which characterizes the classic autosomal recessive LPL deficiency. When considering patients with mutations in both alleles of the four so-called minor genes that modulate LPL activity \u2013 namely, APOC2 , APOA5 , LMF1 , and GPIHBP1 \u2013, another four patients were identified, that is, another 1%.34Because FCS is a very rare disease, expert reports contribute greatly to prevalence estimates. Hegele et al.LPL gene or in its regulatory genes (compound heterozygotes) have two different loss-of-function mutations, and those with two heterozygous mutations in two different causal genes (double heterozygotes) added up to 1% more.34Patients with two mutations in the LPL gene or its cofactors and other minor variants, or a strong component of environmental factor. There is, therefore, a polygenic basis with several possible variants in different combinations that are overrepresented among patients with severe HTG, which correspond to the multifactorial form (MCS).37Thus, it was estimated that approximately 3% of patients with severe HTG  in this sample had mutations in both alleles of genes that encode LPL or one of the proteins that modulate its activity. These patients may be homozygous, compound heterozygous, or double heterozygous. These conditions have been described among French Canadians from the province of Quebec, where the percentage of patients with two mutant alleles is higher due to a founder effect. Such prevalence may seem small compared to the vast majority of patients with severe HTG; however, in the absence of genetic testing, one cannot separate FCS (type I) from MCS (type V) in patients with triglycerides \u2265 1,000 mg/dL. In fact, most patients with severe HTG (97%) have a genetic basis for a heterozygous loss-of-function mutation in the 33 reported that among five causal genes, 34% of identified mutations were in the LPL gene.33 Comparing the clinical and laboratory data of patients with FCS of various genetic etiologies, FCS resulting from a defect in the LPL gene is phenotypically very similar to that resulting from defects unrelated to the LPL gene. However, patients with a defect in the LPL gene have lower post-heparin lipase activity and tend to have higher triglycerides. Conversely, LDL-C concentrations are generally higher among people with defects in genes other than LPL .38Surendran et al.20 If these data were extrapolated to the North American population, they would indicate an estimated 3,357,214 adults with severe HTG  and 81,877 with triglycerides \u2265 2,000 mg/dL.39Using data from the National Health and Nutrition Examination Survey (NHANES) from 2001 to 2006, severe HTG was estimated to affect 5,680 adults over 20 years of age whose fasting triglyceride results were available. In these patients, the prevalence of triglycerides between 500 and 2,000 mg/dL was 1.7% , and levels > 2,000 mg/dL were found in only three patients.40 The electronic records of patients seen during that period were reviewed based on 4 criteria: triglycerides \u2265 880 mg/dL, history of AP, absence of secondary HTG, and lack of response to triglyceride-lowering pharmacotherapy (< 20%). When 3 of 4 criteria were met, patients were considered to have likely FCS. When all 4 criteria were met, or if there was confirmation of culprit mutations by genetic testing, patients were considered to have definite FCS. Of 2,342,136 electronic records evaluated, 578 patients showed triglyceride measurements \u2265 880 mg/dL (0.025%), of whom 86 also had a history of pancreatitis. Five patients who met FCS criteria were identified and 3 of them had genetically confirmed FCS, resulting in an estimated prevalence of 1-2 per 1,000,000 people. MCS was identified in 186 patients, suggesting an estimated prevalence of 1 in 12,000 people. There were 5,181 cases of pancreatitis (0.22% of the entire cohort), 86 of which occurred in those with triglycerides \u2265 880 mg/dL (1.7% of pancreatitis cases). The rates of pancreatitis in this subsample increased to 6.5%, 100%, and 17.8% in patients with MCS, FCS, and secondary causes of HTG, respectively.40A retrospective cross-sectional study evaluated patients from Oregon Health & Science University from July 2012 to July 2017.41 In this cohort of FCS, the authors reported the prevalence to be at least 1:5,000 based on established diagnostic criteria.42 The prevalence reported in this study is > 20-200 times higher than the prevalence reported in previous reports. Using electronic data from the North Texas Division of the Baylor Scott & White Health System from September 2015 to September 2016, a screening of patients with triglycerides \u2265 1,000 mg/dL and a history of pancreatitis showed that, of 297,891 adult patients with available triglyceride levels, 334 (0.11%) had triglyceride levels \u2265 1,000 mg/dL and 30 (9%) of them had pancreatitis. Of these, six cases were excluded due to secondary causes. Of the 24 remaining cases, the average maximum triglyceride level was 3.085 \u00b1 1.211 mg/dL. Thus, electronic screening of triglycerides \u2265 1,000 mg/dL and a history of pancreatitis allowed ruling out 99.99% of severe HTG cases, resulting in 24 cases in which FCS could not be excluded, suggesting a prevalence of 1 in 12,413 people. An important data limitation in both studies is the lack of genetic confirmation.43In a retrospective study with data from 70,201 patients treated at the Cleveland Clinic Lipid Center from January to December 2006, 369 met the criteria of triglycerides \u2265 750 mg/dL and previous pancreatitis. Of these, 333 cases were due to secondary causes or had missing data and were excluded. Of the remaining 36 patients, 14 met criteria for FCS.APOE gene, E2E2), 182 had type IV HTG, and 82 had type V HTG. From a clinical point of view, the higher the triglyceride concentrations and the more lactescent the plasma, the greater the risk of pancreatitis. Visual examination of plasma and clinical phenotype were useful to establish the cardiometabolic risk in these patients, and identification of lactescent plasma is a simple diagnostic tool that can help identify those at increased risk.44Another study in Quebec evaluated plasma appearance and classified patients according to triglyceride values, probable etiology, and biochemical characteristics. A total of 354 people with lactescent plasma were compared with 482 patients with clear plasma but triglycerides > 5 mmol/L (approximately 440 mg/dL) and with 364 normolipidemic controls . The authors observed that lactescent plasma represented a heterogeneous group of high-risk patients among whom 28 had FCS, 62 had dysbetalipoproteinemia , was conducted. The authors found that 1.1% had biallelic rare variants, 14.4% had heterozygous rare variants, 32% had an extreme accumulation of common variants , and 52% remained genetically undefined. Patients with severe HTG were 5.77 times more likely to carry one of these variants of genetic susceptibility compared with controls.36Dron et al.45 The index case was a woman with multiple episodes of pancreatitis, one of them during pregnancy, requiring plasmapheresis. The prevalence of severe HTG was also evaluated based on population data obtained from a reference laboratory where secondary causes  and diabetes were ruled out. The 28-year-old woman had recurrent HTG and pancreatitis with onset at 3 months of age. Triglyceride levels were reasonably well-controlled with a low-fat diet until her early 20s, when she experienced recurrent attacks of pancreatitis and fasting triglyceride levels > 2,000 mg/dL, requiring multiple hospitalizations despite treatment. In addition to a restricted diet, she was placed on fenofibrate, niacin, medium chain triglycerides (MCTs), and omega-3 (\u03c93), with poor response. She became pregnant at age 30 and required weekly or biweekly plasma exchanges until delivery. Her father and sister had HTG and a history of pancreatitis. The patient was a compound heterozygote for two LPL mutations: c.708delA (p.G237fs*15) deletion and c.644G.A (p.G215E), which are known to impair LPL function. Her father had the c.708delA (p.G237fs*15) deletion variant, whereas her mother and sister had the c.644G.A (p.G215E) variant. Of 207,926 participants, 25 had fasting triglycerides > 2,000 mg/dL with no evidence of secondary causes, suggesting an estimated prevalence of 120/1 million people.45A family with three members affected by FCS who had severe HTG and episodes of pancreatitis underwent genetic panel analysis.46In another study, the prevalence of FCS was assessed in a largely rural area in central New York State with an estimated population of 870,000. A review of electronic medical records from 385,000 patients identified 998 patients with triglycerides > 750 mg/dL, of whom 994 were excluded for secondary causes of HTG, satisfactory response to therapy, or lack of complete information. Four patients met criteria for FCS. Thus, the probability of finding 4 out of 870,000 would be 0.01, suggesting that the 1/1,000,000 prevalence is an underestimation. The high prevalence was attributed to a probable founder effect.47The prevalence of FCS was also retrospectively assessed by reviewing the electronic medical records from 7,699,288 patients from the University of Southern California who had triglycerides > 880 mg/dL, at least one episode of pancreatitis, response to lipid-lowering therapy < 20%, and no documented secondary causes. The analysis showed an FCS prevalence of 0.26 to 0.65 per million individuals.48 Data from 1,627,763 patients seen at Johns Hopkins Hospital from 2013 to 2017 were reviewed. FCS criteria included patients with a) at least one fasting triglyceride value > 750 mg/dL, b) history of AP, unexplained recurrent abdominal pain, and/or family history of HTG, and c) absence of secondary causes of HTG. Twenty-one patients with FCS and 89 with secondary HTG were identified, and FCS prevalence in this study was 13:1.000.000 .48Finally, the prevalence of FCS was determined in a quaternary care center.49There are no data regarding the prevalence of severe HTG and FCS among children. A retrospective analysis of electronic medical records from a tertiary pediatric hospital  and NHANES data from 2000-2015 showed that, of 30,623 children at the Children\u2019s Medical Center, 36  had extremely elevated triglyceride levels , and one-third of them developed AP. Most of these cases corresponded to secondary causes of HTG, with an estimated prevalence of FCS of 1:6,000 in children in a tertiary care center and 1:300,000 in children in the general population. According to the 2000-2015 NHANES data, none of the 2,362 children met the criteria for severe HTG, whereas the estimated prevalence among adults was 0.02%.In Brazil, case reports of FCS are very scarce. Although cases of FCS have been described in several regions of the country, with a higher concentration in regions with a founder effect , no publications on the subject have been found except for conference publications published in annals.50The first case report consisted of a 3-year-old boy who presented with lipemic serum and plasma triglyceride concentrations of 25,000 mg/dL at 3 months of age with exclusive breastfeeding. At 3 years of age, he developed hepatosplenomegaly and, after a diet restricted in fat and skim milk, triglycerides reached 990 mg/dL. He had zero LPL activity, and a G188E mutation was detected in exon 5 of LPL in homozygosis for him and in heterozygosis for the parents.51Another report consisted of two children, one aged 21 days and the other aged 4 months and 15 days. In both cases, HTG was casually diagnosed by the xanthochromic aspect of blood during sample collection. Triglyceride levels at diagnosis were 18,019 mg/dL and 5,333 mg/dL, respectively. After in-hospital and outpatient dietary intervention, the lowest triglyceride levels achieved were 602 mg/dL and 615 mg/dL. One of the patients developed recurrent episodes of AP related to high triglyceride levels.52 Another publication reported the case of a 45-year-old woman with severe HTG, diabetes, and profuse eruptive xanthomas.53There was a report of a 15-month-old infant from the state of Rio Grande do Norte with chylothorax and a lipid profile suggestive of FCS, with triglycerides > 1,000 mg/dL and no documented pancreatitis.LPL gene were identified in the rural area of Para\u00edba.54 Another report consisted of a 45-day-old infant experiencing vomiting and irritability, with triglycerides of 6,541 mg/dL and altered molecular analysis in 3 variants: Chr8:19,811,733 G>A, promoting the replacement of the amino acid glycine at codon 215 by glutamate (p.Gly215Glu); Chr8:19,813,385 G>A, promoting the replacement of the amino acid arginine in codon 270 by histidine (p.Arg270His); and Chr8:19,811,823 T>C, promoting the replacement of the amino acid isoleucine at codon 245 by threonine (p.Ile245Thr). Dietary behavior consisted of skim milk, MCTs, and vitamins A, D, E, and K. After the patient was discharged, the diet was changed to include infant formula, which led to an increase in triglycerides . The patient underwent fasting and the previous dietary behavior was subsequently restored, which allowed reasonable control of triglyceridemia, adequate growth, and weight gain.55Two other cases of siblings with FCS with a genetically confirmed mutation in the 56 recently reported 12 cases of FCS in patients with a homozygous mutation in the intronic region of the GPIHBP1 gene, all with severe HTG  and low HDL-C (18 mg/dL [5-41 mg/dL]) and 33% with episodes of AP. All patients were from cities in the Northeast of the country, suggesting a founder effect.56Lima et al.Data on the prevalence of FCS varies greatly between studies due to the lack of standardized clinical criteria, the similarity with MCS, the scarcity of tests for genetic confirmation, the lack of national and international registries, and the founder effect of causal genes.2Clinical manifestations of monogenic forms of chylomicronemia usually happen during childhood or in the beginning of adult life. However, as this is a relatively rare disease, diagnostic delays are common and lead to diagnosis in adult life, when complications are already established.57 Other series describe a mean assessment by five different medical professionals before reaching a diagnosis.58A review of the APPROACH study database demonstrated that the mean age at diagnosis was 24 years; more than half of the 66 patients were diagnosed after 20 years old. At diagnosis, 75% of patients had already presented an episode of pancreatitis.These data reinforce the importance of early and timely diagnosis. The main clinical manifestations of FCS are described in the following sections.21On laboratory assessment, the affected patients presented hyperchylomicronemia, with sharp increases in triglycerides \u2013 in general, between 1,500 and 5,000 mg/dL \u2013 at the expense of increased VLDL cholesterol (VLDL-C) and especially circulating chylomicrons. Since a small amount of cholesterol is also transported by and is present in chylomicrons, total cholesterol may be increased, usually in triglycerides: cholesterol ratio > 5:1. Many patients have a moderate increase in VLDL-C, with LDL-C and ApoB levels < 100 mg/dL.21According to the Fredrickson Classification, although type V phenotype is more common, type I seems to be more specific for the diagnosis of FCS in adults. In children, type I phenotype is more frequently observed.5Severe HTG in patients with FCS usually presents a poor response to fibrates and/or other lipid-lowering drugs. In these cases, which comprise a huge challenge to clinical practice, the main therapeutic alternative is a diet with a drastic reduction in fat intake . The strictness of this diet not rarely makes adhesion to long-term treatment difficult and also significantly affects the patients\u2019 quality of life.27Recurrent abdominal pain is present in up to 50% of patients, is not necessarily associated with AP, and can be debilitating.59When triglyceride levels are > 1,000 mg/dL, the risk of pancreatitis increases in 3% for every 100 mg/dL.22 This is probably due to a longer duration of exposure to hyperchylomicronemia, which in FCS tends to happen in the first years of life.A Canadian study compared a group of 25 individuals with FCS to a group of 36 patients with MCS and demonstrated that, despite presenting similar mean triglyceride levels, the group with FCS presented a 10-fold higher risk (60% vs 6%) of pancreatitis.59Multiple episodes of AP and the severity of dietary restrictions negatively affect the patient\u2019s quality of life and considerably increase morbidity and mortality by the disease. Recurrent pancreatitis occurs in 50% of patients with FCS; the overall associated mortality rate is of 5% to 6% and can reach 30% in subgroups of patients who progress to pancreatic necrosis or persistent multiple organ failure.58Fatigue, mental confusion, irritability, and cognitive deficit \u2013 described as \u201cmental fog\u201d \u2013 are the most described symptoms among patients with FCS.57Hepatosplenomegaly is one of the findings that are reversible with treatment and results from excess chylomicrons in macrophages of the reticuloendothelial system in FCS.27Xanthomas correspond to yellow, eruptive skin lesions with an erythematous halo measuring around 2 to 5 mm diameter. These are found on extensor surfaces (elbows and knees) and on the buttocks. Their prevalence is low (affecting 17% to 33% of the patients), and they are not always correlated with episodes of pancreatitis.57Milky white appearance of the blood in retinal vessels on fundus examination, which can be seen in up to 30% of the patients and is correlated with higher levels of triglycerides.58The IN-FOCUS study, with 166 patients with FCS, showed an important impact of the disease on quality of life. Hospitalization rates can interfere with social conditions and job possibilities, and more than 22% of patients reported depression or anxiety related to the pain or pancreatitis episodes.21 Additionally, their applicability is questionable because they include previous pancreatitis episodes among their scoring criteria.59 Fundamentally, the aim of using diagnostic scores consists in screening asymptomatic patients and preventing complications such as AP. The assessment of databases with a larger number of patients with FCS and further detailing of clinical forms should contribute to the elaboration of criteria with higher sensitivity and specificity for diagnosing FCS.Some scales or scores that consider clinical manifestations have been proposed for diagnosing FCS; however, they need to be validated in larger samples of populations with severe HTG.21 which uses as selection criteria the presence of severe HTG  and attributes points to increased triglyceride levels once secondary causes are ruled out, to a history of pancreatitis, recurrent abdominal pain, unresponsiveness to usual triglyceride-lowering treatment, and age of symptom onset  and physiological conditions such as pregnancy, especially in the third trimester.22 The prevalence of MCS usually tends to grow linearly with the increase in prevalence of the most common secondary causes . Among patients with MCS, chylomicronemia fluctuates and is manifested in later stages of life when compared to FCS. Additionally, MCS tends to have a better therapeutic response to lifestyle changes and treatment of secondary factors, as well as triglyceride-lowering pharmacotherapies. MCS is characterized by an increased risk of pancreatitis, albeit lower than that reported in patients with FCS.60In adults, the main differential diagnosis for FCS is MCS. Previously named Fredrickson type V hyperlipoproteinemia or severe polygenic HTG, multifactorial HTG is a polygenic disorder that includes rare heterozygous variants in the five FCS genes or variants commonly associated with HTG, being worsened by the presence of comorbidities or secondary causes of increased triglycerides such as uncontrolled diabetes, hypothyroidism, obesity, and metabolic syndrome.61Other relevant differential diagnoses for FCS are lipodystrophies, which are a heterogeneous group of diseases characterized by the selective loss of adipose tissue that can progress with severe HTG and pancreatitis. Lipodystrophies can be inherited or acquired and are classified as generalized or partial as to their extension; partial forms associated with HIV infection are the most common ones. Inherited lipodystrophies are rare disorders that can manifest at birth or display loss of fat in later stages of life. These conditions still represent a diagnostic challenge, especially considering the partial forms, whose diagnostic suspicion should be raised in the presence of moderate to severe HTG associated with a thigh skinfold measurement < 22 mm in women or < 10 mm in men, and/or cases of diabetes that require subcutaneous insulin in daily doses > 2 IU/kg.63 Despite being a less frequent cause, increased triglyceride levels in patients with pancreatitis are associated with higher mortality and a worse prognosis.64 During pregnancy, estrogen stimulates liver VLDL production and reduces the removal of triglycerides by LPL in the liver and fatty tissue, which makes HTG the most frequent cause of AP.66AP is a relatively frequent event, with different causes that include HTG. Identifying the specific cause is fundamental for establishing treatment and preventing future episodes. In various case series, cholelithiasis is the main cause, followed by alcohol consumption and HTG (less than 10%).67 The risk and disease severity increase even further in patients with levels > 2,000 mg/mL.68 This happens regardless of whether the basic cause of HTG is primary (genetic) or secondary. However, genetic causes usually come with higher triglyceride levels and, consequently, a higher risk of pancreatitis.Episodes of pancreatitis due to HTG usually occur with triglyceride levels > 1,000 mg/dL.According to the Fredrickson classification, type I (chylomicron), IV (VLDL), and V (chylomicron and VLDL) present HTG, of which FCS (type I) has higher levels and can lead to pancreatitis regardless of triggering factors .70 Another potential mechanism stems from the accumulation of glutamic acid decarboxylase (GAD). In the absence of LPL activity and consequent accumulation of chylomicrons, there is also an increase in GAD that triggers TNF-alpha- and IL-6-mediated inflammation. Chylomicrons themselves can also obstruct distal pancreatic blood flow and cause ischemia.The mechanism causing pancreatitis is not completely understood, but triglycerides themselves do not seem to act directly in the pancreas. The accumulation of free fatty acids in the pancreatic cells happens in the presence of pancreatic lipase and triggers cell injury and pancreatic inflammation.58 Some patients even avoid going to parties and gatherings, because they fear eating could trigger pancreatitis. Children require constant vigilance, as they do not fully understand the disease and want to eat just as their colleagues who do not have the disease. After a first pancreatitis episode , the acute pain and need for hospitalization are factors that motivate a more rigorous adherence to the restrictive diet required for controlling severe HTG.The clinical presentation of pancreatitis is similar regardless of its etiology. Patients with FCS not rarely present recurrent pancreatitis episodes, and some of them report an unknown number during anamnesis. This triggers psychological changes, compromising quality of life.Eruptive xanthomas are infrequent even in severe HTG. However, when present in a patient with AP, these lesions suggest HTG as etiology. Extensor surfaces of the arms and legs are the most frequent sites. Fatty infiltration in the liver and spleen can occur, leading to hepatosplenomegaly, but these are unspecific findings.67The diagnosis of AP should begin with a clinical suspicion , confirmed by laboratory examinations  and imaging tests . At least 2 of these 3 findings should be present for diagnostic confirmation, and this does not depend on the etiology of pancreatitis. Not rarely, patients present only abdominal pain, without laboratory or imaging alterations. In the absence of a suggestive clinical picture, lipase and amylase analyses may be more of a hindrance than a help. Triglyceride levels < 1,000 mg/dL during a clinical episode suggesting pancreatitis leave HTG as an unlikely cause of pancreatitis.2< 32 mmHg; leukocytes > 12,000 or < 4,000/mL), requiring a faster reduction of triglyceride levels, plasmapheresis may be used. In case an adequate diet is not instituted or triggering factors are not controlled, achieving remission becomes more difficult. Insulin stimulates LPL and can also be used in some cases . Similarly, heparin also acts by stimulating LPL, but its use should be carefully considered because it may not bring benefits in the medium term (increases risk of bleeding and release of toxic components of triglycerides).63Once diagnosis is confirmed, treatment should aim to reduce/relieve pain and maintain adequate hydration; even though oral nutrition is suspended, adequate nutrition should be provided to a patient in an acute setting as early as possible. Reducing triglyceride levels is fundamental for reversing the inflammatory process, and considering this happens through chylomicrons, greater reduction should be achieved when interrupting oral nutrition. In the most severe cases  and difficulties controlling triglyceride levels with usual diet treatment would benefit from it the most.Differently from other HTG causes that respond well to fibrates, FCS does not present a significant reduction of triglyceride levels with these drugs, which are not used to prevent pancreatitis in these patients. ApoC3 is an inhibitor of LPL; its inhibition by volanesorsen (an antisense oligonucleotide against ApoC3) used once a week significantly reduced (77%) triglyceride levels and, consequently, the chances of pancreatitis.Clinical laboratories have a supporting role in the diagnosis of FCS. Lactescent (milky white) serum is the main indicator of the presence of chylomicrons and follows high triglyceride levels. Some aspects should be considered for the effective laboratory diagnosis of FCS. The phases responsible for the result of a laboratory analysis comprising an FCS investigation are: pre-analytical, analytical, and post-analytical.73 In children, this duration varies according to the age group. Infants (up to 1 year) should fast for 3 hours or collection should be done immediately before the next feeding; non-infants (2 to 5 years) should fast for 6 hours. Children over 5 years old and adolescents should fast for 12 hours.Fasting is no longer mandatory for lipid panels; however, in situations such as triglyceride metabolism disorders, it is required for diagnostic confirmation of FCS. In these cases, adults over 20 years old should fast for 12 hours.74The preparation for sample collection considering triglyceride analyses in adults (> 20 years) consists in the patient\u2019s usual diet, with 12 hours of fasting; alcohol consumption should be avoided at least 72 hours before the test; and no strenuous exercise should be performed 24 hours before the test.74Some situations increase the free glycerol blood level, leading to an overestimation of triglyceride levels with no serum cloudiness. In these cases, the patient should be evaluated for one of the events described in the literature: recent physical exercise, alcohol consumption, acute liver disease, decompensated diabetes, parenteral nutrition, or intravenous glycerol-containing drugs.74In HTG, the serum varies from cloudy to lactescent. Grade 1 \u2013 slightly cloudy; Grade 2 \u2013 cloudy; Grade 3 \u2013 very cloudy; Grade 4 \u2013 lactescent. Since serum appearance is a subjective issue, only after measuring triglyceride levels and storing the serum for 12 hours under refrigeration that we can proceed with visual inspection.Methodologies that can be used to indicate the presence of chylomicrons in serum are demonstrated in the following paragraphs.8.2.1.1. UltracentrifugationThe gold standard for separating fractions of lipoproteins according to their lipid content and density. However, this method has inherent limitations that include its lack of availability at clinical laboratories, high cost, and delays in executing the technique, becoming unfeasible for Brazilian laboratories.8.2.1.2. Serum Appearance75 When this is not possible, after centrifuging and removing samples for laboratory analyses, 1 mL of serum should be transferred to a transparent disposable hemolysis tube. The lactescent serum obtained in any situation should sit in a refrigerator for 12 hours so that a creamy layer is observed on its surface, indicating the presence of chylomicrons, which should be specified in the patient\u2019s report.74For observing chylomicrons in the lactescent serum, we recommend the use of whole blood collection tubes with serum-separating devices for centrifugating and collecting the serum from the supernatant.8.2.1.3. Lipoprotein Electrophoresis76 However, this method of separating serum lipid fractions is no longer used in routine clinical practice because it is semiquantitative and cholesterol fractions were adopted as risk markers for cardiovascular disease; therefore, we do not recommend the use of this methodology in this document.Lipoprotein electrophoresis, also named lipidogram, can help confirm the presence of chylomicrons with a colorful band at the site of sample application.Out of the three mentioned methodologies, the most widely accessible at various laboratories is serum appearance, which is the one recommended by this document.75 Therefore, for each triglyceride molecule, one glycerol molecule will react and provide the triglyceride concentration in the sample. Any physiological situation that increases serum glycerol levels will overestimate triglyceride levels. The literature describes a rare genetic disease, glycerol kinase deficiency, also named pseudohypertriglyceridemia; this disorder causes hyperglycerolemia and HTG without the lipemic appearance of the serum.77The methodology for measuring triglycerides can use an enzymatic colorimetric reaction and/or ultraviolet (UV) detection. These methods are precise and inexpensive. The reaction begins with the hydrolysis of triglycerides into three fatty acids and one glycerol molecule.75Lipemia, depending on its intensity, leads to falsely increased triglyceride levels due to the association between the method coloration and serum cloudiness. In this case, the sample should be diluted in buffered saline solution (pH 7.4) or in the automation diluent (platform-dependent) for obtaining a reliable result.Serum dilution may follow a scale according to triglyceride levels and the method\u2019s analytical range. For example, if the analytical range is 8 to 885 mg/dL, the following dilutions may be suggested: 1:4 (triglycerides 400-600), 1:6 , 1:10 , or 1:20 .FUNDAMENTAL: Even after diluting the sample, the obtained results should be kept in the dynamic range; this is essential for maintaining the method\u2019s linearity and reproducibility.IMPORTANT: Using a sample blank (diluted sample) for considering cloudiness even after the dilution. The difference (delta) between reads should be used = diluted sample - diluted sample blank, multiplying the delta value by the dilution rate; only then the value should be associated with control and/or platform calibrator samples.EXAMPLE: If the result of a diluted (1:4) sample was 250 mg/dL, it should be multiplied by 4, and the result will be 1,000 mg/dL triglycerides. However, if the sample blank reads 50 mg/dL, this value should be subtracted from the diluted (1:4) sample (250 - 50 = 200); this value is then multiplied by 4 and the result will be 800 mg/dL triglycerides. Therefore, it is essential to account for the cloudiness of the diluted serum. The greater the dilution, the higher the overestimation of triglyceride levels in case the sample blank is not accounted for.75Therefore, the methodology\u2019s technical description must be analyzed for obtaining information and instructions, such as its analytical range (dynamic range), possible dilutions that can be done, the diluent material, use of sample blank, or even changes to the automated program. These descriptions are method-platform-, and manufacturer-dependent, and should be followed according to their respective information.8.2.4.1. LDL-C73The laboratory analysis of LDL-C is hindered by increased triglyceride levels in the lipemic serum. LDL-C calculation via the commonly used Friedewald formula not only is limited to patients with triglyceride levels up to 400 mg/dL but can also be underestimated, and the patient ends up not receiving treatment due to triglyceride interference. On the other hand, Martin\u2019s equation applies correction factors to the Friedewald formula, allowing a more reliable estimation of LDL-C, and can be applied with triglyceride levels up to 13,975 mg/dL. In addition, the direct method can be used to measure LDL-C but will present limitations depending on the degree of lipemia.73In FCS or in MCS, HTG is severe due to the presence of chylomicrons, VLDL, and their remaining components. The patient presents a reduction in VLDL lipoprotein lipolysis, which leads to a decrease in LDL lipoprotein production in the plasma and a high amount of large and triglyceride-rich particles (chylomicrons and VLDL) when compared to a normal individual. In this case, no matter the methodology , the values are always lower than the method\u2019s analytical sensitivity. We recommend that laboratories release LDL-C results that are extremely low or negative as < 10 mg/dL.8.2.4.2. Platelets75Platelet counts in automated hematology are performed by using impedance and, in case of lipemia, interferences will possibly decrease their count. The same association happens when determining hematocrit \u2013 in this case, with an important piece of information, and the results are calculated from the association between hemoglobin and erythrocyte count.8.2.4.3. Analytes with Colorimetric Analysis75Methods with colorimetric endpoint readings usually present more restrictions regarding lipemia. This can also happen less intensely in systems with UV detection. This interference is directly proportional to serum cloudiness but is not always proportional to triglyceride concentration. It should be noted that lipoproteins have different sizes and are constituted by different percentages of triglycerides.8.2.4.4. Enzymes75Kinetic, colorimetric, and/or UV enzymatic reactions can suffer interferences by lipemia, depending on its intensity. Therefore, alkaline phosphatase and gamma-glutamyl transferase have greater limitations, because they employ p-nitrophenyl phosphate in their assays (colorimetric methods). However, the use of exclusively UV-based methods can also face restrictions with lipemia.8.2.4.5. Electrolytes75When determining sodium in the serum and/or plasma with increased triglyceride levels, results will be falsely low. In this case, the sodium value can be corrected by calculating: triglycerides (g/dL) x 4 - 0.60 = percentage factor.+122 mmol/L and triglycerides 2,100 mg/dL; Example: Na8.2.5.1. Post-heparin LPL ActivityLPL activity is not measured in laboratory routine analysis, but it may be useful when screening for genetic testing for FCS. When the laboratory allows the LPL activity assay to be performed before and 10 minutes after heparin injection (IV heparin [50IU/kg]), whole blood should be collected from the other arm using a heparinized tube and transported on ice to the laboratory. The collection tube should be centrifuged for 10 minutes at 3,000 rpm and 4\u00baC, and plasma should be immediately separated. The tube with plasma should be stored at -80\u00baC until the day of analysis using the adopted protocol or sent to a specialized laboratory.APOC2 , APOA5 , GPIHBP1 , and LMF1 genes) in cases of homozygosity or compound heterozygosity. However, researchers have demonstrated that the discriminating capacity of this test for identifying patients with common variants of LPL genes is limited, which justifies the absence of a recommendation in this document.79LPL activity is drastically decreased in FCS by homozygous genetic alterations to LPL, and it is frequently reduced when these alterations occur in LPL cofactors  and exercise (24 hours). For children, fasting periods vary according to the age group. Infants (up to 1 year) should fast for 3 hours or collection should be done immediately before the next feed; non-infants (2 to 5 years) should fast for 6 hours. Children over 5 years old and adolescents should fast for 12 hours. Excess free glycerol in the blood leads to an overestimation of triglyceride levels. Lactescent serum should sit in the fridge for 12 hours for verifying the presence of chylomicrons. When measuring triglycerides, the analytical range, dilution rate, diluent material, and use of sample blank or changes to automation should be kept in mind. In severe HTG, FCS, or MCS, LDL-C levels  that are too low or negative should be reported as < 10 mg/dL. Lipemia, depending on its intensity, interferes with platelet counts, colorimetric methods, enzymatic reactions , and sodium determination. The post-heparin LPL activity assay is not recommended in this document. ApoC3 measurement is viable at clinical laboratories. We recommend that laboratory reports mention that an FCS diagnosis, after ruling out the secondary causes of HTG, should be considered in the following situations: 1) Adults with 12 hours of fasting and triglyceride levels > 1,000 mg/dL, in 3 different collections; 2) children and adolescents with triglyceride levels > 880 mg/dL, regardless of fasting, in 3 different collections; 3) in children and adults, a triglyceride level < 170 mg/dL EXCLUDES the investigation of hyperchylomicronemia. .80The American Society of Human Genetics defines genetic counseling as a communication process that handles human problems associated with the occurrence and risk of occurrence or recurrence of a certain genetic disease in a family.81 as a way of, in a world post-World War II, face the eugenic concepts that permeated the scientific and medical societies as to genetic diseases and disabilities in general. Since then, it incorporated the principles of the psychosocial model of patient care, using as foundation the empathy and human skills involving communication, recognizing the grieving process, and self-defense mechanisms. The professional should use ethical neutrality and nondirectivity \u2013 two fundamental principles of genetic counseling \u2013 for guiding the patient and the family, providing answers and information as completely as possible so that the individual seeking guidance can make his or her decisions, being aware of the risks and alternatives.The term genetic counseling was used for the first time in 1947 by Sheldon Reed,82 would be \u201cconsultoria gen\u00e9tica\u201d: its goal is to provide guidance so that the patient feels secure when making decisions, understanding that there is no right or wrong and no conduct should be suggested. That being said, it is important to understand that, when performing genetic counseling, the professional should respect the family\u2019s ethical and religious values, following the three principles that govern medical ethics: autonomy, beneficence, and nonmaleficence.83The term \u201caconselhamento,\u201d used in the Portuguese translation, actually does not indicate the true objective of this process, because the etymology of the verb indicates \u201cto give advice,\u201d when in reality, this is not the goal of this procedure. The closest Portuguese translation for genetic counseling84 Genetic counseling involves, in total, five phases:It is worth noting that what many call genetic counseling is just a stage of the whole process.Establishing and/or confirming diagnosis, which involves anamnesis, physical examination, elaboration of a diagnostic hypothesis, request and interpretation of complementary examinations; this could last for weeks, months, or years until diagnosis is achieved.Calculating genetic risk: a more theoretical phase that is many times separated from the family; it aims to calculate the risk of occurrence or recurrence of a certain genetic condition. The condition\u2019s etiology can be monogenic, chromosomal, multifactorial, or even unknown. For each situation, a different risk can be calculated, thus disease etiology is fundamental for establishing risk as precisely as possible.Communication; in this phase, patients receive guidance regarding the risks, many times involving conversations about therapeutic and prognostic options. The combination between phases 2 and 3 represents what is commonly referred to as genetic counseling.Decisions and Action: phase that involves helping the family and the patient with the decisions taken in the Communication phase, regarding both the treatment and possible contraceptive methods.Follow-up, representing a continuous phase where the patient or the family are followed up, observing their individual needs and the natural history of the genetic condition.84It is important to note that some stages of genetic counseling involve medical conducts, whereas others can be performed by various health professionals, as long as they are properly trained on the previously mentioned communication abilities and human and medical genetics.The two phases that represent genetic counseling the most are undoubtedly those of genetic risk calculation and communication. Although apparently simple, defining the risk of occurrence or recurrence of a certain genetic condition involves broad knowledge of the basis of genetics and inheritance. Talking about a risk of recurrence compatible with autosomal dominant or recessive inheritance seems simple when considering Mendel\u2019s laws of genetic inheritance, but some confounding factors should be kept in mind, such as incomplete penetrance, variable expression, mosaicism, or genetic heterogeneity. Each of these factors can interfere with the clinical diagnosis of different forms of the disease, making a challenge out of adequately guiding patients through the risks.84The confirmation of a pathogenic variant explaining a phenotype can be fundamental for considering the correct risk in these cases. It is also important to note that different inheritance patterns (apart from mendelian inheritance) can present risks that require a more complex estimation. For example, in multifactorial risk, one should consider the number of affected individuals in a family, relationship with the proband, and factors that may vary from case to case, such as the age of symptom onset, symptom severity, and environmental factors. In a context of multifactorial inheritance, identifying these risks and considering how much they affect the total risk may be completely impossible, thus we consider a risk of recurrence that is always approximate or empirical, considering the whole empirical knowledge and risks of recurrence calculated based on population-based studies.20 or MCS36 should be established.This way, in order to talk about risk of occurrence or recurrence, a clear definition between FCSFCS is inherited in an autosomal recessive pattern, that is, an individual needs a homozygous variant or two variants in compound heterozygosity, both of which pathogenic or probably pathogenic, in order to present the phenotype.APOC2 , APOA5 , GPIHBP1, and LMF1 .86This pattern of autosomal recessive inheritance, by biallelic homozygous mutation (same mutation in both copies) or compound heterozygosity (one mutation in each copy), is present both in cases of LPL and other genes involved with the monogenic forms: 18It is known that the progenitors of an individual with FCS will each have a copy of the affected variant. This way, the siblings of a person with FCS have 25% of risk of also inheriting the syndrome. Finally, an individual with FCS will always pass one of the variants to his or her children. In case the person\u2019s partner also has a variant of the same gene, the risk to their children from this combination is 50%.86Since the HTG phenotype can also be caused by the presence of common or rare functional variants of genes that increase triglyceride levels, making up a polygenic inheritance pattern, molecular diagnosis is required for proper genetic counseling.86The chances of other family members also presenting FCS will depend on their family history; therefore, a pedigree should always be considered to help with risk calculation. It is important to mention that, although individuals with a heterozygous pathogenic variant may present increased triglyceride levels, individual triglyceride measurement should not be used for considering a carrier status, as individuals with a heterozygous variant may present normal levels of triglycerides while individuals without the variant may present variations in triglyceride levels due to environmental factors.87Only 1% of HTG cases present biallelic mutations. On the other hand, 14% of patients with HTG are estimated to carry rare heterozygous mutations, a rate 3 to 5 times higher than that the general population. The use of polygenic risk scores may be useful for identifying these individuals.87The indication of genetic testing evaluates aspects  that help interpret test results and consequently help with genetic counseling regarding the risk of family recurrence.88 to prevent the synthesis of chylomicrons, particles formed exclusively in the enterocyte which are responsible for the transport of dietary fat and cholesterol.90 Patients with FCS have mutations associated with LPL or its cofactors, which compromise the hydrolysis of dietary triglycerides.91 For this reason, a fat-restricted diet is recommended, limiting fat to a maximum of 10% of daily total energy intake (TEI) (15 to 20 g of fat per day).92The treatment of FCS is based on severe dietary fat restriction25 FCS adversely impacts patients\u2019 quality of life because of the difficulty in following a strictly restricted diet, which significantly compromises social interaction.24 Limited knowledge of FCS prevents friends and family from apprehending the seriousness of the disease. The IN-FOCUS study,93 involving 166 patients with FCS from 10 countries, showed that more than 90% of the participants found following a strict diet to be difficult. Database evaluation of a subgroup (n = 60) of participants from the same study58 showed that 22% of the participants reported anxiety, fear, and worry about the quantity and quality of food to be consumed, especially in social and work situations. These symptoms were experienced at least once a month, or several times a week.Because of the severity of the disease, patients should be very well informed of the importance of strictly following the guidelines, and the nutritionist should indicate food options that contribute to greater adherence to treatment. Some authors consider FCS to be a devastating condition for patients and a frustrating one for physicians and nutritionists regarding the main treatment target \u2013 controlling severe HTG.92 This may help patients develop their own eating plan with the assistance of a nutritionist and accept their personal responsibility for self-management of the disease.The health care team can use motivational interviews to help patients with FCS resolve their internal conflicts and to promote greater adherence to a fat-restricted diet.92 because they induce hepatic lipogenic pathways. Patients should also abstain from consuming alcohol, because its consumption is linearly associated with plasma triglyceride levels.91 In addition, monitoring dietary intake of fat-soluble vitamins, minerals, and essential fatty acids is recommended, and their supplementation may be necessary.95 Specifically concerning dietary fat, it is essential to consider fatty acid type and chain length, because they are absorbed differently and can influence the plasma concentration of triglycerides and the production of chylomicrons.Although fat restriction is the mainstay of FCS treatment, patients should also avoid foods with added sugars, such as sucrose and corn syrup,96 Short-chain fatty acids are produced by colonic bacterial fermentation, whereas medium-chain fatty acids are found in coconut and palm oils.97 Coconut fat is the main dietary source of lauric acid, which is found in minute amounts in other foods. Palmitic acid is the most abundant fatty acid in the diet, and the main sources are red meat and palm oil. Because palm oil is a structurally stable fat, it has been widely used in the food industry.98 The main sources of myristic acid are coconut fat, milk, and dairy products, whereas the main source of stearic acid is cocoa.99 All unsaturated fatty acids have a long chain and are classified as monounsaturated (MUFAs) or polyunsaturated fatty acids (PUFAs). The main MUFAs are palmitoleic (C16:1 \u03c97) and oleic  acids, with a single double bond in their structure.101 The main dietary source of palmitoleic acid is macadamia, whereas oleic acid is found mainly in olive and canola oils, and also in nuts such as peanuts, hazelnuts, macadamia nuts, almonds, and cashew nuts.102 They are also present in beef, chicken, and pork fats, accounting for 40% to 50% of total fat content in these foods.104Saturated fatty acids (SFAs) are classified according to chain length of the carboxylic acid into short-, medium-, or long-chain, and these characteristics influence their absorption process. Short-chain fatty acids include acetate (C2:0), propionate (C3:0), and butyrate (C4:0), whereas medium-chain fatty acids include caproic (C6:0), caprylic (C8:0), and capric (C10:0) acids. Long-chain fatty acids contain more than 12 carbons and include lauric (C12:0), myristic (C14:0), palmitic (C16:0), and stearic (C18:0) acids.105 The \u03c93 fatty acids of animal origin are eicosapentaenoic acid (EPA [C20:5]) and docosahexaenoic acid (DHA [C22:6]), found in the oils of fish and crustaceans mainly from cold- and deep-water habitats.108 Linoleic and linolenic acids are considered essential fatty acids because they are not synthesized in the human body. They should therefore be provided by the diet, and their supplementation is recommended in special conditions of deficiency.88PUFAs contain two or more double bonds and are part of the omega-6 (\u03c96) or \u03c93 series depending on the position of the first double bond counted from the methyl end of the carbon chain. Fatty acids of the \u03c96 series are represented by linoleic acid (C18:2), whose main sources are vegetable oils , walnuts, and chestnuts. The \u03c96 series also includes arachidonic acid (C20:4), which is synthesized endogenously from linoleic acid by enzymatic activity. Alpha-linolenic acid (ALA [C18:3]), of the \u03c93 series, is obtained from vegetable oils, mainly canola and soybean oils, and also from flaxseeds and chia seeds.110 Trans fatty acids are found in minute amounts in meat and milk in the form of vaccenic acid , which is produced through the biohydrogenation of fats under the action of the rumen microbiota of ruminants.109Trans fatty acids also have a long chain and are mainly represented by elaidic acid , found in vegetable fats resulting from the partial hydrogenation of vegetable oils during preparation.111 Digestion continues in the intestine, where hydrolysis of the remaining triglycerides is induced by pancreatic lipase activity, releasing fatty acids and monoacylglycerol.113Dietary fats include triglycerides (90% to 95%), phospholipids, cholesterol, and fat-soluble vitamins. Although the intestine is the major site for digestion of fats, this process begins minimally in the oral cavity, through exposure to lingual lipases, followed by the stomach, where 10% to 30% of fatty acids are released, starting the process of fat emulsification.114 Short-chain fatty acids  are absorbed primarily via sodium-dependent or non-sodium-dependent active transport mediated by monocarboxylate transporters. However, G protein-coupled receptors (GPCRs) may also participate in the absorption of these fatty acids, such as GPR41 and GPR43. Medium-chain fatty acids  are absorbed mainly via passive transport, but GPR84 may also play a role in their incorporation into the enterocyte surface.115 After absorption, they bind to albumin and travel via the portal circulation to the liver.114 Conversely, more complex mechanisms are required to absorb long-chain fatty acids , and their transport in the plasma depends on the formation of chylomicrons.97 They can be absorbed by passive diffusion, when the luminal concentration is higher than the intracellular concentration, or through membrane receptors/transporters. For example, the transporter cluster of differentiation 36 (CD 36) allows the uptake of long-chain fatty acids even when their luminal concentrations are lower than those inside the cell.116 The fatty acid transporter protein 4 (FATP4) is widely distributed in the intestine and one of the main long-chain fatty acid transporters.117 Within enterocytes, fatty acids are transported by proteins such as fatty acid-binding protein 1 (FABP1) and FABP2116 and re-esterified, returning to the form of triglyceride by the action of the diacylglycerol acyltransferase (DGAT) enzyme.89 Triglycerides are then incorporated into ApoB48 via the microsomal triglyceride transfer protein, which initiates the formation of chylomicrons.118 Chylomicrons are processed in the Golgi complex and subsequently secreted into the lymph, entering the blood circulation via the thoracic duct.90The mechanism of fatty acid absorption is complex because of multiple absorption systems.119 Chylomicron hydrolysis generates chylomicron remnants, which are removed from the circulation through their interaction with hepatic B/E receptors and LDL receptor-related protein.120In the bloodstream, chylomicron triglycerides are hydrolyzed by LPL, which is adhered to the endothelium of extrahepatic tissues, releasing free fatty acids that subsequently bind to albumin, being stored mostly in adipose tissue and only minimally in muscle tissue.LPL gene or its cofactors , so long-chain fatty acids should be minimally consumed to prevent elevated plasma chylomicron concentrations.27 Restricting dietary fat intake to 10% of daily TEI is therefore recommended.92 However, depending on the severity of the disease, total fat intake can be further restricted to less than 5% daily calories.91Triglyceride lipolysis is defective in FCS because of mutations in the 122 enzymes involved in fatty acid synthesis, precursors of the synthesis of triglycerides, by the action of DGAT.123In addition to strict adherence to a very-low-fat diet, SFA-rich foods should be consumed in small amounts. SFAs are involved in important hepatic lipogenic pathways by activating the sterol regulatory element binding protein-1c (SREBP-1c), which acts as a transcription factor coding for the genes of acetyl-CoA carboxylase, fatty acid synthase, and stearoyl-CoA desaturase-1,27 However, because they are considered essential fatty acids, both ALA (\u03c93) and linoleic acid (\u03c96) supplementation may be necessary for patients with FCS to prevent deficiency. The Global Burden of Disease Study ,124 a study conducted in 197 countries, suggests an optimal intake of \u03c96 of 11% of daily TEI, although the global average consumption is 4.5% of TEI. Regarding \u03c93, the optimal intake is 0.25 g/d, with a global average consumption of 0.1 g/d.124 The Recommended Dietary Allowances (RDA) recommend a daily \u03c93 intake of 0.5 to 1.4 g, depending on the age group.125Although \u03c93 unsaturated fatty acids regulate triglyceride synthesis by blocking SREBP-1c, they are not recommended for the treatment of FCS even at high doses, because individuals do not have a defect in the hepatic synthesis of triglycerides, but rather in triglyceride hydrolysis.127 Individuals with FCS are allowed to consume MCTs because these fatty acids are absorbed almost entirely via the portal circulation, being minimally incorporated into chylomicrons.129 It is important to note that lauric acid (C12:0) is considered a long-chain fatty acid that is transported mainly via chylomicrons, being transported via the portal circulation only when its storage capacity in this lipoprotein is exceeded.130 Therefore, it is essential to carefully observe the fatty acid composition of the product, which should preferably contain no or minimal concentrations of lauric acid to prevent an increase in chylomicron concentrations.MCTs contain caproic (C6:0), caprylic (C8:0), or capric (C10:0) SFAs, which are obtained by fractionating coconut or palm oils and are commercially available, together or separately. They may have a small amount of lauric acid (maximum of 1% to 2%).92MCTs are indicated to contribute to energy intake in infants, children, and adults with FCS, as an adjunct to treatment. However, tolerability must be tested because people have reported gastrointestinal discomfort after use of MCTs.92 Added sugars (sucrose and corn syrup) should be avoided because they induce an increase in the hepatic synthesis of fatty acids, contributing to elevated plasma triglyceride concentrations. Sugars contain glucose and fructose, and the latter promotes intense hepatic lipogenesis not only by serving as a substrate for fatty acid synthesis but also by stimulating the expression of enzymes involved in de novo lipogenesis via activation of carbohydrate-responsive element binding protein and SREBP-1c.133 In addition, excessive fructose intake decreases fatty acid beta-oxidation by inducing post-translational modifications in mitochondrial proteins, reducing the number and size of these organelles.134Food sources of complex carbohydrates, rich in fiber, should be consumed, such as brown rice, beans, peas, lentils, and chickpeas. Fruit intake is recommended in adequate amounts, with a maximum of 3 to 4 servings per day, so as not to exceed the recommended daily sugar intake. Some authors suggest limiting total carbohydrate intake to 60% of daily TEI.Therefore, patients with FCS should avoid the consumption of concentrated fruit juices because of intense fructose-induced lipogenic activity.135 Acetate can be converted to fatty acids, precursors of triglyceride synthesis.136Patients should abstain from consuming alcohol because it can elevate plasma triglyceride concentrations. Alcohol metabolization begins minimally in the stomach by the action of alcohol dehydrogenase (ADH), but it is metabolized mainly by the liver through three pathways: cytochrome P450 2E1, catalase, and ADH. Alcohol metabolization leads to form acetaldehyde, which is converted into acetate by aldehyde dehydrogenase, with the main participation of ADH.Providing infants with adequate quantity and quality of nutrients during the first 2 years of life is essential to promote adequate growth and cognitive development, in addition to consolidating healthy eating habits. However, developing an eating plan for infants and children with FCS that ensures proper dietary intake of recommended amounts of macronutrients and micronutrients is a challenging task for the nutritionist and the family because of the severe dietary fat restriction. Nutritionist training in this area is of paramount importance to balance the diet, to develop sample menus for the family, and to closely monitor the implementation of new eating habits. The family should be aware that dietary fat intake above the recommended amount, even in minimal amounts, can cause an undesirable increase in plasma chylomicron concentrations.137 Milk triglycerides consist mainly of long-chain SFAs (35% to 40%), MUFAs (45% to 50%), and PUFAs (15%), with a predominance of palmitic, oleic, and linoleic acids, respectively.138 Unsaturated fatty acids with a chain length of more than 20 carbons, containing two or more double bonds, represent only 2% of the total fatty acids present in breast milk.138 Fatty acids of the \u03c93 series are found in small amounts in breast milk: ALA (0.019 g/100 mL), EPA (0.003 g/100 mL), and DHA (0.008 g/100 mL).140For breastfed infants with FCS, breastfeeding must be discontinued as soon as the diagnosis is confirmed, which can cause frustration and sadness for both the mother and child. Breast milk has approximately 3.2% fat, with triglycerides accounting for approximately 98% of the lipid fraction. The exact fatty acid composition depends on the mother\u2019s diet and varies significantly during the breastfeeding period.139 Average daily energy intake was 419 kcal at 1 month, 589 kcal at 6 months, and 860 kcal at 12 months. Fat intake was 21 g/day within the first 6 months, gradually increasing to 34.2 g at the end of 12 months. Regarding essential fatty acids, considering exclusive breastfeeding up to 3 months of age, the average daily intake of ALA (\u03c93) was 0.118 g and of linoleic acid (\u03c96) was 2.40 g. Regarding marine fatty acids, the average daily intake of EPA was 0.022 g and of DHA was 0.048 g.139 According to the Academy of Nutrition and Dietetics, the recommended intake of \u03c93 fatty acids is 0.5 g/day for infants aged 0 to 12 months and 0.7 g/day for children aged 1 to 3 years, whereas the recommended intake of \u03c96 fatty acids is 4.6 g/day for infants aged 0 to 6 months and 7 g/day for children aged 7 to 12 years.125An important study conducted in Europe (European Childhood Obesity Project) followed up 174 children from birth to age 1 year and contributed to a better understanding of the caloric intake of lipids, carbohydrates, and proteins through the first year of life, with results that can be extrapolated to provide dietary guidance for infants who cannot be breastfed.92 and the RDA for infants and children are available in the table of the Dietary Reference Intakes.95Given the severe dietary fat restriction, monitoring dietary intake of fat-soluble vitamins  is recommended,92 Regarding fat content, formulas should be prepared only with medium-chain fatty acids , in addition to providing fat-soluble vitamins and allowed amounts of essential fatty acids. In addition, MCTs can be recommended to achieve optimal energy intake, according to tolerance, because they are minimally transported by chylomicrons.129Special infant formulas that partially resemble the nutritional composition of breast milk are recommended as a substitute for breast milk.The introduction of solid foods such as vegetables, fruits, and lean meats , and grains should follow the recommendations of national and international pediatric societies, limiting dietary fat intake to 10% of daily TEI.92Adequate fluid intake is recommended to maintain fluid balance, which will contribute to pancreatic function. Prolonged dehydration induced by vomiting and diarrhea is known to increase the risk of pancreatitis associated with FCS.Dietary guidelines should be individualized and enjoyable, respect cultural habits, and be sustainable in the long term. Children should be informed of the importance of reading food labels, and the family should be instructed to prepare meals containing minimal amounts of fat, in addition to highlighting the importance of preparing meals/foods at home.142During pregnancy, a rise in plasma lipid concentrations is expected especially at the end of the second and third trimesters, with two- to four-fold increased triglyceride concentrations, which are well tolerated by the patient. In this phase, increased insulin resistance and the action of placental hormones contribute to greater adipose tissue lipolysis. In addition, there is increased hepatic output of VLDL and decreased hepatic lipase activity. LPL activity is also reduced, which impairs the hydrolysis of lipoprotein triglycerides. Because of these alterations, hepatic clearance of triglyceride-rich lipoproteins is consecutively reduced, leading to elevated plasma triglyceride concentrations.94Increased triglyceride levels during pregnancy are associated with an increased risk of complications for the mother and child by increasing the risk of AP, which may lead to miscarriage, early delivery, and even death. During pregnancy, although rare, AP is often caused by biliary lithiasis. Elevated cholesterol concentrations and gallbladder hypomotility caused by the hormonal profile characteristic of pregnancy predisposes women to calculus formation, which may obstruct the pancreatic duct. Women with FCS show a marked increase in triglyceride concentrations, which may trigger AP. Pregnant women with FCS are at a 4% increased risk of developing AP with triglyceride levels > 1,000 mg/dL, and at a 14% increased risk with levels > 2,600 mg/dL.143 and fat-soluble vitamins.92The dietary treatment of pregnant women with FCS aims to maintain plasma triglyceride levels less than 500 mg/dL throughout pregnancy. To this end, a fat-restricted diet (less than 20 g/day) is required, along with adequate intake of vitamins, minerals, and essential fatty acids, according to the recommended intake for the stage of pregnancy, including monitoring of maternal weight gain. Patients following a very-low-fat diet should be monitored regularly to ensure proper dietary intake of calories, macronutrients, and micronutrients, especially essential fatty acids92MCTs (without long-chain fatty acids) may be indicated to achieve optimal energy intake if necessary. In addition, adequate fluid intake is recommended to maintain adequate fluid and electrolyte balance. Pregnant women with FCS associated with type 2 diabetes mellitus or gestational diabetes need greater attention for proper adherence to the diet, requiring multidisciplinary follow-up to manage lipid levels, glycemia, and fetal development.144Dietary management of FCS is the only tool available to control plasma triglyceride levels in this condition, as demonstrated in a recent case report of a pregnant woman with plasma triglyceride levels of 8,683 mg/dL who experienced previous episodes of pancreatitis.92The nutritionist should help patients develop their own eating plan, providing assistance with recipes and strategies that facilitate adherence to the diet. Dietary preferences, cultural habits and lifestyle should be considered, as well as nutritional adequacy of the diet and energy intake. An extreme very-low-fat diet is difficult to maintain. Therefore, monitoring by a multidisciplinary team is extremely important to manage lipid levels and minimize the risk of complications.Restricting dietary fat intake (10% to 15% of TEI);Avoiding added sugars (sucrose and corn syrup);Avoiding concentrated fruit juices;Abstaining from consuming alcohol;Consuming complex carbohydrates in adequate amounts;Ensuring adequate intake of essential fatty acids;Monitoring the intake of fat-soluble vitamins, with supplementation if necessary;Introducing MCTs to achieve adequate energy intake, according to tolerance.LOW-FAT FOODS (< 5 g per serving)Triglycerides > 1,000 mg/dL increase the risk of pancreatitis in patients with FCS. Class IIA, Level C.145 Plasma triglycerides > 1,000 mg/dL may be indicative or greatly increase the risk of hypertriglyceridemic pancreatitis (HP).AP is the most frequent complication in patients with FCS, with a prevalence of 60% to 88%.147 Cohort studies have demonstrated a more severe evolution in these patients, with a higher prevalence of complications  compared with other etiologies of AP.149AP mortality in patients with FCS is approximately 6% but may reach up to 30%, depending on the presence of complications.150The initial diagnostic and therapeutic procedures for HP should follow the same practices recommended for AP cases in general . The earliest possible determination of serum triglyceride levels is crucial, as they may decrease in the first 48 hours after the onset of pancreatitis as a result of fasting.68In patients with FCS, HP may occur spontaneously, with no apparent cause, or be triggered by secondary factors including uncontrolled diabetes, alcohol abuse, pregnancy, and medications .151 Once the pain subsides and gastrointestinal transit is established, an oral fat-free diet may be reinstated.The mainstay of initial AP therapy is admission to the intensive care unit, as well as oral intake restriction, intravenous fluids, and analgesia. Clinical evolution depends on the reduction of plasma triglycerides within the first 24 to 48 hours of admission. Most patients with HP have an uncomplicated clinical course, with good prognosis. In general, serum triglyceride levels decrease within 24 to 48 hours of admission and reach values < 500 mg/dL on the fourth or fifth day only with support measures.Intravenous heparin infusion for HP is not recommended in patients with FCS. Class of recommendation: III, Level of evidence: C.156 The infusion of unfractionated heparin can release LPL bound to endothelial cells, leading to a temporary reduction in serum triglycerides. In severe cases of HP, long-term intravenous heparin infusion can deplete LPL from the surface of endothelial cells, allowing serum triglyceride levels to rise again.159 In addition, some authors are reluctant to recommend the use of intravenous heparin in patients with pancreatic necrosis due to the risk of hemorrhagic transformation.151Heparin and insulin infusions have been used as the main therapy for HP, with most evidence coming from single cases or case series.The use of low-molecular-weight heparin is indicated as prophylaxis for deep venous thrombosis in HP in patients with FCS. Class II A, level C.160 as prophylaxis for deep vein thrombosis in HP.There are no contraindications for the use of low-molecular-weight heparinIntravenous insulin should only be used for glycemic control in HP in patients with FCS and decompensated type 1 or 2 diabetes. Class of recommendation: IIa, Level of evidence: C.19Insulin increases LPL activity and helps to reverse the effects of insulin resistance on the liver. Insulin infusion is especially useful in patients with uncontrolled diabetes and hyperglycemia in addition to HTG. There is no clear evidence of the benefit of insulin in patients with HP who are not diabetic.162 Intravenous insulin should be initiated in patients with severe HTG and HP who also have decompensated type 2 diabetes.165Intravenous insulin therapy must be initiated in patients with severe HTG and HP who also have uncompensated type 1 diabetes.Plasmapheresis should be indicated in patients with FCS and HP on an individual basis. Potential candidates are patients with severe HP or persistent triglycerides > 1,000 mg/dL after the first 24 to 48 hours. Class of recommendation: IIb, Level of evidence: C.170Case reports and series have demonstrated the efficacy of plasmapheresis in removing triglycerides from the circulation of patients with HP, with a mean reduction in triglyceride levels between 65% and 85% after 1 or 2 sessions.172 The mechanism of HTG-induced AP is probably caused by excess triglycerides, which leak from acinar cells into the vascular bed of the pancreas when hydrolyzed by pancreatic lipase, resulting in accumulation of free fatty acids and lysolecithin. Free fatty acids are toxic and can cause damage to acinar cells and the capillary endothelium.173 In addition, elevated concentrations of chylomicrons increase the blood viscosity of veins with impaired local blood flow, resulting in pancreatic ischemia and worsening of tissue damage.174 Free fatty acids activate trypsinogen, which leads to local edema and necrotizing pancreatitis.173 A case series published in a tertiary hospital in Turkey included 33 patients with HTG-related AP and showed a mean triglyceride reduction of 54.4% after a single session of plasmapheresis. After a second session, there was a 79.4% reduction in triglycerides. During clinical course, 13 patients had pancreatic fluid collection, with 1 case of necrotizing pancreatitis and no cases of pseudocyst. Mortality in patients with severe HP was 33.3%, and overall mortality was 3%, with no cases related to plasmapheresis. The study demonstrated that plasmapheresis is a safe and effective treatment for patients with HP. More studies are needed to compare apheresis + conservative treatment with only conservative treatment in patients with HP.175Because HP is a life-threatening condition, some centers use plasmapheresis as the procedure of choice to rapidly reduce circulating chylomicrons as soon as the diagnosis is established, thus removing the agent responsible for pancreatic damage. The early use of this procedure to reduce plasma triglycerides would prevent the production and accumulation of free fatty acids, reducing their local and systemic effects.167 retrospectively analyzed clinical outcomes in patients with HP before (n = 34) and after (n = 60) the availability of apheresis at their institution. The groups had similar clinical features. In 20 patients from the second group, plasmapheresis was initiated with a mean time of 3 days after symptom onset. There were no significant differences in terms of mortality and complications between patients undergoing or not undergoing plasmapheresis. Study limitations include the retrospective design, single-center experience, and small sample size.167Chen et al.167 A clear benefit of plasmapheresis in reducing HP severity has yet to be conclusively demonstrated.Some centers perform plasmapheresis on admission, shortly before 24 hours, whereas others perform the procedure within 24 to 72 hours of admission. Studies have emphasized the importance of early initiation of plasmapheresis in HP, whereas others have not detected any difference in morbidity and mortality with early or late initiation of the procedure.175Plasmapheresis is not risk-free and is a costly procedure. It requires central intravenous access and temporary anticoagulation, with associated complications that include bacteremia, venous thrombosis, and bleeding. Potential candidates are those with severe HP or persistent triglyceride levels > 1,000 mg/dL after the first 24 to 48 hours of admission.176Due to the lack of evidence, recommendations for plasmapheresis in adults with HP and FCS should be individualized. In recent American Society for Apheresis (ASFA) guidelines, the recommendation for plasmapheresis in patients with HP is 2C (weak recommendation), with a level of evidence of III.The indication of plasmapheresis during pregnancy, although safe and effective, should be individualized due to the scarcity of evidence to date. Class of recommendation: IIb, Level of evidence: C.178 Patients with genetically determined alterations in lipid metabolism, characterized by reduced intravascular lipolysis, may evolve during pregnancy with severe HTG and pancreatitis.179Normal pregnancy is characterized by adaptive changes in lipid metabolism to meet the needs of the placenta and the glucose and lipid requirements for fetal growth, including increased glucose production, progesterone synthesis, lipogenesis, and reduced lipolysis.180 Rates of maternal and fetal mortality due to HP of 37% and 60%, respectively, have already been described, but these numbers are currently declining due to diagnostic and therapeutic advances.183HP is developed in the third trimester of pregnancy or at the beginning of the postpartum period, with a major impact on maternal and fetal morbidity and mortality.146 In cases of HP, the severity score and the worst prognosis are more prevalent than other etiologies of AP.184 Clinical case reports have shown that the use of plasmapheresis in pregnant women is effective and safe.188 However, due to the scarcity of evidence, the indication of plasmapheresis in pregnancy complicated by HP, in patients with FCS, should be individualized.Pregnancy-associated pancreatitis may occur in the setting of gallstone disease, alcohol abuse, and HTG.24 Gene therapy with AAV1-LPL(S447X) using an adeno-associated virus was tested in the setting of FCS  with the aim of expressing LPL(S447X). However, despite promising results, the commercial use of AAV1-LPL (S447X) was not possible due to its high cost.189 Thus, the only therapy that reduces triglycerides to < 880 mg/dL, or 10 mmol/L, in patients with FCS and which seems to reduce the risk of pancreatitis is a fat-restricted diet associated with alcohol restriction and certain medications.92 Lifelong adherence to these restrictions is difficult, and episodes of chylomicronemia, abdominal pain, and recurrent pancreatitis are common. Thus, additional therapies are needed to maintain triglycerides levels < 880 mg/dL.Treatments available for patients with FCS aimed at reducing triglyceride levels are not effective in controlling chylomicronemia.192 In genetic, preclinical, and phase 1 studies, ApoC3 has emerged as a regulator of plasma triglyceride concentrations.192 ApoC3 is an inhibitor of LPL activity190 and a potent inhibitor of LPL activation that is mediated by ApoC2, resulting in the inhibition of lipolysis of triglyceride-rich lipoproteins.190 ApoC3 has also been shown to inhibit hepatic lipase activity, to promote VLDL assembly and secretion,193 and to inhibit clearance of triglyceride-rich lipoproteins remnants.194 However, the importance of these LPL-independent mechanisms is not well understood.ApoC3 is a glycoprotein consisting of 79 amino acids, synthesized primarily in the liver and to a lesser extent in the intestine, and is associated with ApoB-containing lipoproteins, including chylomicrons, VLDLs, and HDLs.192 Inhibition of ApoC3 synthesis in the liver occurs through sequence-specific binding of ISIS 304801 to APOC3 mRNA, which in turn leads to the degradation of APOC3 mRNA by RNase H1, an endogenous ribonuclease expressed in mammalian cells.191 In phase 1 studies with healthy volunteers, ISIS 304801 promoted a dose-dependent and prolonged reduction of ApoC3 plasma concentrations with concomitant triglyceride lowering.192 In phase 2 studies, ISIS 304801 was effective in lowering triglycerides in patients with elevated VLDL due to different conditions.195Volanesorsen is a second-generation antisense drug that inhibits the synthesis of modified apoC3. ISIS 304801 has a 2\u2019-O-(2-methoxyethyl) end.191Because patients with FCS have very low LPL activity and because lipolysis inhibition by the LPL-dependent pathway is a mechanism of action of ApoC3, ISIS 304801 would be predicted to be ineffective or to have a minimal effect in lowering triglycerides in patients with this syndrome. However, there must be an LPL-independent escape mechanism for the survival of these patients. Preclinical studies suggest that ApoC3 modulates triglyceride levels through an LPL-independent pathway. A study was conducted with ISIS 304801 in patients with FCS and triglycerides levels from 1,406 to 2,083 mg/dL. After 13 weeks of treatment with 300 mg of volanesorsen, plasma concentrations of ApoC3 and triglycerides were reduced in 71% to 90% and from 56% to 86%, respectively. During treatment, all patients had triglycerides < 500 mg/dL. Initial data showed the role of ApoC3 as a regulator of triglyceride metabolism through LPL-independent pathways.57 a 52-week, randomized, double-blind, phase 3 study that evaluated the efficacy and safety of volanesorsen in 66 patients with FCS. Patients were randomly assigned in a 1:1 ratio to receive volanesorsen or placebo. The primary endpoint was the percentage change in fasting triglycerides from baseline to 3 months (at week 12 or week 13). Nine secondary endpoints were prioritized and analyzed in hierarchical order. If analysis of the first endpoint was significant, the second endpoint in the hierarchy would be analyzed for significance, and so on. If an endpoint was nonsignificant in the hierarchy, analysis of all subsequent endpoints would be exploratory. Percentage changes from baseline to 6 months and to 12 months were compared between treatments using analysis of covariance (ANCOVA).These outcomes were replicated in the Approach clinical trial,LPL , and 11 patients had biallelic mutations in accessory proteins or were double heterozygous for LPL and APOA5 or LMF1 mutations. Fourteen patients had no defined mutations but were included on the basis of their clinical phenotype and low LPL activity.23A total of 130 patients were selected, of whom 67 underwent randomization; 1 patient from the placebo group withdrew consent. Of the 66 patients, 41 were homozygous or compound heterozygous for at least 1 of 25 inactivating mutations in Lipemia retinalis occurred in 21% and eruptive xanthomas in 23% of patients; 76% had a documented history of AP, of whom 23 had had 53 adjudicated AP episodes in the previous 5 years. Seven patients had chronic pancreatitis.Included patients were aged 20 to 75 years, 80% were white, and 55% were women; the mean body mass index was 25.0 \u00b1 5.7. Age at FCS diagnosis ranged from 1 to 75 years. At baseline, 53% of patients were taking fibrates, \u03c93 fatty acids, or both, and 20% were receiving statins. Seven patients had been treated with alipogene tiparvovec (Glybera) more than 2 years before they were included in the study. Baseline triglyceride levels were elevated and did not differ between patients who were receiving medication and those who were receiving placebo , likewise VLDL chylomicrons  and ApoB48 (10.2 \u00b1 6.6mg/dL). ApoC3 levels were elevated (30.2 \u00b1 14.2 mg/dL).Treatment with volanesorsen reduced mean ApoC3 levels from baseline by 84% after 3 months and by 83% after 6 months (P < 0.001 for both comparisons), corresponding to decreases of 25.7 mg/dL and 25.6 mg/dL, respectively. APOC3 levels increased by 6.1% (1.9 mg/dL) after 3 months and decreased by 5.2% (1.7 mg/dL) after 6 months among patients receiving placebo. The primary efficacy endpoint, ie, the percentage change in triglycerides between baseline and 3 months, was a 77% decrease in the volanesorsen group vs an 18% increase in the placebo group (P < 0.001), corresponding to a decrease of 1,712 mg/dL  in the volanesorsen group compared with an increase of 92.0 mg/dL  in the placebo group (p < 0.001).23The results of the analysis of the first-ranked secondary endpoint  were significant. Compared with 10% of patients in the placebo group, 77% of patients in the volanesorsen group achieved triglyceride levels < 750 mg/dL . The results of the second-ranked secondary endpoint  were also significant: there was a 53% reduction in triglyceride levels in the volanesorsen group  vs a 25% increase in the placebo group (224 mg/dL). The mean difference between groups was -77.8% . The analysis of the third-ranked secondary endpoint  was significant; volanesorsen reduced triglyceride levels by 40% (986 mg/dL), whereas there was a 9% increase (39 mg/dL) in the placebo group. The between-group difference was -49.1% . The subsequent endpoint  was not significant.23 In exploratory analysis, the levels of chylomicron triglycerides, ApoB48, non-HDL-C, and VLDL-C in patients receiving volanesorsen were reduced by 83%, 76%, 46%, and 58%, respectively; in the same patients, the levels of HDL-C, ApoA1, LDL-C, and ApoB were increased by 46%, 14%, 136%, and 20%, respectively.23Among patients in the volanesorsen group, 19 completed the full 52-week treatment period. Six patients received 300 mg per week for the entire treatment period; among the remaining 13 patients, dose frequency was reduced to 300 mg every 2 weeks, treatment was paused, or both. Among patients who did not have a dose reduction, the decrease in triglyceride levels from baseline was 79% at 3 months, 80% at 6 months, and 72% at 12 months . Absolute decreases in triglyceride levels among the 13 patients whose doses were reduced was 71% at 3 months, 52% at 6 months, and 54% at 12 months . Among the 6 patients whose doses were not reduced, 5 had triglyceride levels < 750 mg/dL at 6 months, and 4 had triglyceride levels < 750 mg/dL at 12 months. Of the 13 patients whose doses were reduced, 6 had triglyceride levels < 750 mg/dL at 6 months, and 6 had triglyceride levels < 750 mg/dL at 12 months; 3 patients achieved triglycerides < 750 mg/dL at 6 and 12 months.LPL gene and by 75% in the 9 patients with non- LPL genetic deficiencies. Patients with mutations in the APOC2 , GPIHBP1 , APOA5 , and LMF1 genes all showed triglyceride decreases from 69% to 88%. Treatment was also effective irrespective of baseline triglyceride levels and was equally effective in patients receiving concomitant fibrate therapy, \u03c93 fatty acids, or both and patients not receiving those therapies .23Volanesorsen reduced triglyceride levels irrespective of patients\u2019 genetic diagnoses or type of mutation. At 3 months, mean triglyceride levels were decreased by 65% in the 17 patients with biallelic mutations in the 23Because of the limited sample size due to the rarity of FCS, a change in the number of AP episodes was not a prespecified endpoint. However, exploratory analysis of adjudicated episodes of AP that occurred during the trial was conducted. During the treatment period, 3 patients in the placebo group had 4 episodes of AP, whereas 1 patient in the volanesorsen group had 1 episode 9 days after receiving the final dose.20 the initial protocol required platelet count monitoring at intervals of 4 to 6 weeks. However, during the trial, grade 4 thrombocytopenia  was observed in 2 patients in the volanesorsen group, and the treatment was discontinued. There were no major bleeding events in any of these patients, and both patients reached normal platelet counts 23 and 33 days after drug discontinuation. One patient received oral prednisone at a dose of 60 mg for 23 days. The other patient received methylprednisolone at a dose of 125 mg for 11 days, followed by oral prednisone at a dose of 70 mg tapered to 50 mg for 21 days, as well as immunoglobulin at a dose of 60 g and 80 g on successive days, followed 4 days later by immunoglobulin at a dose of 40 g daily for 5 more days. Three other patients with lower grades (1 or 2) of thrombocytopenia were withdrawn from the trial by the investigators. After the two cases of thrombocytopenia, a platelet monitoring program consisting of assessments every 2 weeks was established, with a threshold of < 100,000 platelets per microliter for reduction in dose frequency to every 2 weeks, and a new threshold of 75,000 platelets per microliter  for medication interruption. After these measures were implemented, no patient presented platelet-count declines to < 50,000 per microliter, and no thrombocytopenia-related dose discontinuation occurred. There was a reduction in the frequency of volanesorsen doses in 13 patients, and in 9 patients this was due to thrombocytopenia. Fourteen patients randomly assigned to volanesorsen vs 2 patients randomly assigned to placebo did not complete the 52-week treatment period. Nine discontinued the trial because of adverse events, which included 5 cases of platelet decreases and 4 cases of other volanesorsen-related adverse effects. Four other patients voluntarily withdrew consent. There were no deaths during the study.23The most common adverse events during the treatment period were injection-site reactions and thrombocytopenia. In the volanesorsen group, 20 patients (61%) had at least one mild-to-moderate injection-site reaction and, on average, 12% of volanesorsen injections vs 0% of placebo injections were associated with these reactions. One patient was excluded from the trial due to an injection-site reaction. Confirmed thrombocytopenia < 140,000 per microliter was observed in 25 patients (76%) in the volanesorsen group and in 8 patients (24%) in the placebo group; confirmed thrombocytopenia < 100,000 per microliter was observed in 16 patients (48%) who received volanesorsen but in no patients who received placebo. Because there was no documented history of marked thrombocytopenia in humans treated with this class of antisense drugs,196 was a retrospective global web-based survey conducted with patients with FCS who received volanesorsen for \u2265 3 months in an open-label extension study. The survey included questions about patients\u2019 experiences before and after treatment with volanesorsen. Twenty-two participants had received volanesorsen for a median of 222 days. Volanesorsen significantly reduced the number of symptoms per patient on the physical, emotional, and cognitive domains. There were significant reductions in episodes of steatorrhea, pancreatic pain, and constant worry about an attack of pain or AP. Respondents also reported that volanesorsen improved overall management of symptoms and reduced interference of FCS with work/school responsibilities. Reductions in the negative impact of FCS on personal, social, and professional life were also reported. Treatment with volanesorsen has the potential to reduce disease burden in patients with FCS through modulation of multiple symptom domains.The Re-FOCUS197 The drug has been approved by the European Medicines Agency for use in adults with FCS since 2014.Volanesorsen was approved by Anvisa on August 23, 2021, based on data from the Approach and Compass studies. It is indicated for adult patients (> 18 years old) with genetic confirmation of FCS and high risk of pancreatitis.Volanesorsen is not approved by the FDA, although it was investigated in the Approach study in patients with FCS. The disease is considered ultra-rare and debilitating. FCS causes unpredictable and potentially fatal pancreatitis, chronic complications resulting from permanent organ damage, and severe impact on patients\u2019 daily lives. The typical feature of FCS is very high levels of triglycerides. Results from the phase 3 Approach study \u2013 the largest study conducted in patients with FCS \u2013 showed that, compared with placebo, treatment with volanesorsen reduces triglycerides by 77% (-94% compared with placebo). Medical societies recommend triglyceride reduction as the treatment target for patients with FCS. The most common adverse events are injection-site reactions and reduction in platelet counts.The FDA\u2019s claim for not approving the drug was safety concerns, especially risk of bleeding due to thrombocytopenia, despite recommendations to mitigate adverse effects. If a possibility for thrombocytopenia was detected during the trial, management with platelet monitoring every 15 days was conducted, which may be more frequent depending on subsequent tests. Likewise, reduction of dose frequency according to platelet count was recommended.198 The link between all these aspects and other contextual aspects makes the management of FCS more complex, which may, in addition to interfering with the adaptive ability of patients and caregivers, demand different medical interventions that are centered on the uniqueness of each patient.Variability in early development, differences in symptom severity, and variations in the degree of functional limitations due to physical condition are characteristics of FCS manifestation that interact with other aspects, such as sociodemographic and economic profiles, personality traits, psychosocial and sociocognitive factors, personal skills for coping with adverse health situations, and ability for self-regulation and maintaining a sense of efficacy in the setting of illness.199 has promoted a pattern of silence surrounding FCS. The lack of familiarity with this condition in the medical community aggravates the biopsychosocial stress experienced by patients, as they have to consult several different specialties in the search for a diagnosis, which usually happens late and does not lead to an effective response to drug therapy. Communication and knowledge gaps challenge patients and caregivers to live with a disease that is often associated with limited empathy, since it lacks socially constructed meaning and a clinically recognized identity.199 Therefore, further developing the state of the art of FCS in real life is relevant for reasons beyond the severe deleterious effects of the disease on health and functional capacity.The lack of dissemination of patient statements in the media, caused by the absence of the theme on popular discourse and its limited presence in scientific discourse,200 on the quality of life of patients with FCS demonstrated the validity of self-report instruments in the setting of a rare disease and highlighted the strong negative impact of FCS treatment, which fundamentally consists of restrictive dietary control. Reporting how the disease affects everyday life,201 how getting sick affects the perception of satisfaction with quality of life and health status,202 and how treatment affects the adaptive capacity of patients203 helps to promote awareness of the psychosocial burden of FCS. Topics covered by the self-evaluation of quality of life instrument are listed in A study199 Although studies of low prevalence diseases include a small number of participants compared with those of chronic and common diseases, they are able to portray the reality of patients and caregivers and point out trends, as well as collaborate in the recommendation of behavioral coping strategies.By providing a standardized and structured instrument to listen to patients with FCS, the psychometric self-report instrument allows to break the pattern of silence, which is characteristic of rare or uncommon diseases.198 A study204 showed that strong feelings of misunderstanding may drive patients and caregivers to create adaptive responses that restore familiarity and belonging in religious environments.Patients diagnosed with a rare disease  lose, to some extent, their social references and, as they begin to rely more on technical and scientific guidelines to manage their condition, move away from usual health care practices. The lack of information on the history of the disease in real life and the lack of guidelines or position statements for safe and effective medical conduct and guidance impact the personal ability to establish a routine and projects and to maintain interpersonal relationships, as idealized by patients. Lack of knowledge of the disease interferes with the sense of belonging and sustains feelings of helplessness and isolation. Disease invisibility in everyday life reduces the chances of patients and caregivers receiving social support.204 Not understanding the objectives of a therapeutic proposal may lead patients to have unrealistic expectations of treatment scope. The most frequent expectations regarding adherence to treatment among patients with FCS are shown in 202Gaps in the medical knowledge of FCS have been shown to hinder communication in clinical practice.204Having described the physical and psychosocial aspects most severely affected by FCS from a patient perspective, it is worth mentioning that patients\u2019 hopes of restoring a normal lifestyle with treatment can be better managed if professionals are up to date and capable of communicating the diagnosis and the evidence supporting therapeutic recommendations, as well as talk about expected results.206 Depression, feelings of embarrassment, shame, and social inadequacy, and perception of changes in cognitive function due to concentration and memory problems contribute to the decline in the personal and professional quality of life of those affected.207 According to patients, living with FCS is time-consuming and drains physical and mental energy, making them unable to plan their lives.208 A systematic review199 suggests that adults diagnosed with FCS may express significant psychological damage related to the lack of autonomy and freedom in controlling their lives beyond the disease. Those treating or caring for patients with FCS need to be more aware of the psychological aspects associated with the disease.Feelings of impotence in the face of the disease, fatigue, and mental confusion are interdisciplinary symptoms that may persist throughout the lives of patients with FCS. Concerns about the impact of the disease on health and life over time, the desire to restore a normal lifestyle, and concerns about the financial impact of the disease greatly affect the emotional stability of patients and caregivers and may produce feelings of low self-esteem and anxiety, interfere with the ability to reason and come up with solutions, and reduce sleep quality.209 Rare diseases are challenging not only for patients, but also for family members who care for them. A study210 found an increased frequency of parental reports of lack of social support and empathy from health professionals, including complaints about general lack of information and guidance and lack of advice regarding the appropriate way to interact/act with the child. The study showed that fathers tend to be more concerned about the future, whereas mothers are more concerned about the present. The study also revealed that mothers are more likely to report impairments in the quality of social, family, and professional relationships, as they tend to occupy more of their time with basic care and daily routine. Such differences among genders need to be more well known.FCS manifests in late childhood and adolescence, but some cases have been reported to occur in the first years of life and in neonates.211 It should be noted that the proposal of total and permanent therapeutic adherence may generate personal and social conflicts, as well as find resistance on the part of patients or lack of social collaboration, insofar as it can impact interpersonal life projects by interfering with the decision to have children, ability to work, free leisure time, etc.207Adherence to general recommendations, usually presented as medical consensus, is essential for health promotion and prevention in primary and secondary health care, as well as for rehabilitation processes. Among health behaviors, therapeutic adherence is one of the most studied self-regulation behaviors, and refers to patients\u2019 active participation in disease management to preserve health and quality of life in the setting of illness.199 show that passive coping approaches include obtaining/searching for information, clinical advice, genetic counseling, and health education. Examples of active coping approaches in behavioral performance/action in FCS include self-control in restricting fat, alcohol, and carbohydrate consumption; self-regulation in self-medication, avoiding harmful drug interactions; self-administration of drugs for reduction of plasma triglyceride concentrations; and attending follow-up consultations as indicated by the primary care physician.Aiming at greater success in therapeutic adherence to FCS treatment, patient involvement in decision-making is essential. For this purpose, the use of passive and active coping strategies is recommended. Data from a systematic review211 investigating the effect of Internet use on the adaptive capacity of parents of children with rare diseases showed that gaining knowledge is essential for gradually adapting to the new health reality. The study emphasized that searching for information about the disease can both increase patients\u2019 sense of efficacy and increase anxiety symptoms. As a contemporary reality, the impact of searching for training/information on the Internet by patients and caregivers on the adaptive process of FCS needs to be better understood.A study212 The CONNEC study213 showed that people affected by FCS may benefit from having contact with other people affected by the disease. The study suggests that participating in support groups, whether by reading texts, joining websites and face-to-face or online conversation circles, interacting with or just learning about other patients, positively affects perception of quality of life and reduces perception of symptom severity and psychological distress, in addition to mitigating psychosocial stress. The implementation of comprehensive measures for coping with and managing the disease such as filling technical and scientific gaps, encouraging patients to engage in therapeutic socialization, and disseminating information about the adverse psychosocial effects of FCS can help promote the construction of a social identity for the disease and establish expertise in health care.94Obtaining social support through peer groups is known to help improve the perception of general well-being and promote motivation for self-regulation.214 it can be assumed that investing in collaborative therapeutic resources for interventions focused on clinical aspects and psychoemotional symptoms215 would have a cost-effective return, given that although psychiatric manifestations are not specific to FCS, they hinder therapeutic adherence and lead to recurrent urgencies and hospital admissions.219In this sense, it supports data from literature review216 showing robust evidence that investing in combined interventions for cardiovascular diseases and anxiety and depression conditions leads to a positive cost-effective result. Finally, the ReFOCUS196 study shows that adequate pharmacological treatment can promote symptom control, reduce stress generated by severe dietary restriction, and modify expectations regarding the future. From this perspective, there is no doubt about the close link between FCS and psychosocial aspects and about the potential cost-effectiveness projected in studies and interventions that seek to develop effective drug treatments for patients diagnosed with FCS.217Knowing that the cost-effectiveness evaluation of health interventions seeks solutions with lower disease-related costs, through which investment allocation can achieve the best results,"}
+{"text": "To evaluate the trend and seasonality of cerebrovascular mortality rates in the adult population of Brazilian capitals from 2000 to 2019. This is an ecological and descriptive study of a time series of mortality due to cerebrovascular causes in adults (\u2265 18 years) living in Brazilian capitals from 2000 to 2019, based on the Brazilian Mortality Information System. Descriptive statistical techniques were applied in the exploratory analysis of data and in the summary of specific, standardized rates and ratios by sociodemographic characteristics. The jointpoint regression model was used to estimate the trend of cerebrovascular mortality rates by gender, age groups, and geographic regions. The seasonal variability of rates by geographic regions was estimated using the generalized additive model by smoothing cubic splines. People aged over 60 years comprised 77% of all cerebrovascular deaths. Women (52%), white individuals (47%), single people (59%), and those with low schooling  predominated in our sample. Recife  and Vit\u00f3ria  showed the highest crude mortality rates. Recife  and Palmas  prevailed after we applied standardized rates. Cerebrovascular mortality rates in Brazil show a favorable declining trend for adults of all genders. Seasonality influenced rate increase from July to August in almost all region capitals, except in the North, which rose in March, April, and May. Deaths due to cerebrovascular causes prevailed in older single adults with low schooling. The trend showed a tendency to decline and winter, the greatest risk. Regional differences can support decision-makers in implementing public policies to reduce cerebrovascular mortality. In 2019, about 6.55 million deaths occurred from CBVD globally , with little difference between ischemic (3.29 [95%CI: 2.93\u20133.61]) and hemorrhagic causes (3.27 million [95%CI: 2.91\u20133.61])1. In Latin America, CBVD also remained among the leading causes of death for decades, despite the steady decrease in the number of deaths from 1990 to 20191.Cerebrovascular diseases (CBVD) feature among the first causes of death and permanent neurological sequelae in adults worldwide2.Similarly, CBVD remain among the leading causes of death in Brazil, with a variable evolution in their trend over the last 30 years. Their spatial distribution also behaved unevenly in the country, with greater decreases in mortality rates in states with greater economic development. However, populations with low development indicators showed the greatest negative impacts5. In turn, metropolitan regions in Brazil have higher health coverage and better mortality records, enabling analyses in these areas to be representative of the population\u2019s health condition8.Epidemiological studies have contributed to the understanding and analysis of CBVD factors and determinants and to the support of policies, projects, and programs to promote health and prevent diseases. Thus, they better control this type of disease and reduce spending on specialized treatments and the psychological disorders of patients and families, especially in urban areas, which concentrate most of the population both worldwide and in Brazil 2. The impacts of temperature on cerebrovascular mortality have been widely documented. Epidemiological evidence suggests a strong U- or V-shaped relation between temperature and number of deaths, confirming the hypothesis that mortality progressively increases at extreme temperatures, both high and low9. The involved pathophysiological mechanisms, although still only partially understood, depend on individuals\u2019 hydration state, sympathetic autonomic nervous system reactivity, activation of the renin-angiotensin-aldosterone system, and systemic inflammatory responses, which, together with other multiple risk factors , act negatively contributing to cause stroke9.Studies on CBVD mortality often focus on trend analyses associated with epidemiological and sociodemographic profiles but few publications have considered their seasonal variability10 brings numerous challenges and impacts on the population\u2019s health.The analysis of the seasonal component, which directly impacts the exposed population, adds knowledge about the behavior and evolution of this disease in different periods of the year and configures a relevant indicator to predict and adopt control measures, especially in the current scenario of climate change, in which the great heterogeneity, complexity, and social, ecological, and climatic diversity of Brazilian municipalities and regionsIn this perspective, this study aimed to evaluate the trend and seasonality characteristics of CBVD mortality in adults aged over 18 years living in Brazilian capitals from 2000 to 2019 to update this epidemiological profile and provide objective and useful information to assist health decision-making.6. In 2010, the total population aged 18 years and above living in Brazilian capitals totaled 33,423,348 inhabitants6.This is an ecological and descriptive study of a time series of mortality due to cerebrovascular diseases occurring in the population (aged \u2265 18 years) living in the 26 Brazilian capitals and Federal District (DF) from 2000 to 2019. Capitals were grouped by geographic regions: South [SR]; Southeast [SER]; Northeast [NER]; North [NR]; and MidwestInstituto Brasileiro de Geografia e Estat\u00edstica (IBGE), were obtained from the Datasus Information System of the Ministry of Health6. Descriptive statistical techniques were applied for data exploratory analysis and summary by age, gender , race , marital status , and schooling . Health indicators, such as the sociodemographic characteristic and mortality rate ratios, were evaluated according to the equations below:Daily deaths  and the population estimates of each year (on July 1st), projected by the 11. The WHO world population (2000\u20132025) was adopted as our standard population, thus defined to reflect the average age structure of the world population (https://seer.cancer.gov/stdpopulations/world.who.html).To adjust the confounding effect in the comparisons of rates in the period between capital populations according to age groups , the direct method of standardization was usedel was used12. This method selects the best fits from the sections of the continuous log-linear regression model and identifies the year(s) in which a trend change is produced, calculates the annual percent change (APC) between trend change points, and estimates the annual average percent change (AAPC) over the entire studied period. The number of junction points is obtained using the Monte Carlo permutation test . Once the k number of junction points is obtained, the different models are compared by the Bayesian Information Criterion.To estimate the trend of annual cerebrovascular mortality rates adjusted by gender, age groups, geographic regions, and Brazil, the jointpoint regression modSeasonality was also analyzed by geographic regions and the country. Descriptive statistical techniques were applied to observe the monthly and seasonal variability of the monthly time series of cerebrovascular mortality rate. Then, the mean values of the observations for each month of the year and their standard deviation with 95% confidence intervals were summarized.13 was used to estimate the seasonal variability of monthly cerebrovascular mortality rates over the studied period by smoothing cubic splines. GAM is used to interpret nonlinear relationships between variables based on nonparametric functions called smoothing curves, in which the form of association is defined by the data themselves. The basic structure fitted to model seasonal variability corresponds to the following equation:For the temporal analysis, the generalized additive model (GAM)2), deviance explained (DE), cross generalized validation (GCV), and residue analysis14.in which g = additive binding function of the predictor variables; \u03bc = mean value of monthly cerebrovascular mortality rates; \u03b1 = intercept; s = smoothing spline function; month = month of the year; and time = number of months over the studied period. The models were evaluated by the adjustment coefficient , R , and jointpoint (version 4.9.0.1) were used for data downloading, management, statistical analysis, and graphical representation.During the studied period, 593,173 adults died from CBVD in Brazilian capitals, with a 2,474 mean monthly mortality . Older adults comprised 77% of all deaths. S\u00e3o Paulo and Rio de Janeiro, the largest cities in Brazil, showed the highest values during the studied period, with 120,124 and 91,987 deaths, respectively.Regarding the sociodemographic characteristics of the total number of studied deaths, 23% of individuals were aged under 60 years and 52% were women. Regarding race, white (47%) individuals showed a higher incidence rate than Black people (44%). Regarding marital status, 59% of individuals were single. Low schooling also prevailed, 19% of victims had no education and 57% only attended elementary school.In Regarding mortality rates in the period, 13 capitals showed values above the national average, with the highest values in Recife  and Vit\u00f3ria . After standardization by age, results showed 20 capitals with values above the Brazilian average , especially Recife , Palmas , Macei\u00f3 , and Aracaju  .On the other hand, Considering geographical distribution, the results in Regarding seasonal behavior, we can establish that the smoothing curves estimated by GAM of cerebrovascular mortality rates as a function of the studied period fit seasonal variability, with a pattern consistent with the intervals of average behavior of these rates  in each In general, mortality rates showed their highest values in the middle of each year, pointing to July and August as offering the most risk , except for the Brazilian North, whose capitals showed the highest peaks from March to May. On the other hand, February showed the lowest rates in all Brazilian capitals and thus in the country, except for the North and Midwest.We should mention that, except for the Brazilian North, the summer months in the Southern Hemisphere (December to February) showed the lowest values of mortality rates due to CBVD. However, the autumn (April to June) and spring (September to November) month behave as transition periods .1. By cause of failures in adaptation responses due to internal changes in their regulatory systems, older adults are also more susceptible to environments with a high pollution load and extreme temperatures (minimum and maximum)9.The higher frequency of deaths in older adults confirms that age is an important variable, often associated with multiple risk factors: cerebral vascular atherosclerosis, arterial hypertension (AHT), diabetes mellitus and metabolic syndrome, smoking, among others, whose evolution, together with genetic and immunological factors, contribute to the deterioration of individuals\u2019 health15also target young adults  despite a trend decline. Global incidence increases in those aged below 45 years have been reported, with the greatest impacts in low- and middle-income economies16. National studies have also characterized cerebrovascular morbidity and mortality in young people17, featuring among the foremost specific causes of death in those aged from 5 to 29 and 30 to 69 years14. Regarding risk factors, estimates suggest that the increased incidence of cerebrovascular episodes in young adults is related with the increasing trend of the aforementioned multiple risk factors. Other etiological factors that favor the occurrence of cerebrovascular episodes at these ages  include HIV, sickle cell anemia, rheumatic heart disease, Chagas disease, tuberculosis, arterial dissection, and moyamoya disease14.However, CBVD4. Lotufo et al.18, in a study on cerebrovascular mortality and race, found a predominance of Black And Brown individuals in Brazil, a result that contrasts with ours (in which white people showed the highest incidences), probably due to the age restriction (30\u201369 years) and short study period chosen by those authors. However, Dorlens et al.2reported the highest rates in older single men with low schooling from 1996 to 2015, results similar to ours.Several national studies have widely addressed the distribution of CBVD associated with gender, race, marital status, schooling, and years of potential life lost19.In total, three characteristics resulting from our analyses enable us to consider the protective effect of the hormone estrogen, which eventually contributes to decreasing the risk of vascular accidents, increasing life expectancy in women. Firstly, the predominance of mortality rates in men aged 30 to 59 years, compared to the same group in women ; secondly, the larger significant reductions in the mortality trend in women aged 30 to 59 years compared to men of the same age group ; and finally, the increase in mortality rates in women aged above 60 years compared to those under it . Estrogen has been reported as positively affecting the human immune system, stimulating the production of antibodies, regulating lymphopoiesis, increasing HDL cholesterol levels, lowering LDL, and relaxing, softening, and dilating blood vessels. It also shows antioxidant, anti-inflammatory, and cell membrane stabilizing properties2, a behavior also observed on a global scale16. In this line, Southern and Southeastern capitals, with the highest economic growth, outlined the largest reductions in APC and AAPC, unlike the less economically developed North and Northeast regions.Our findings agree with the literature regarding mortality rate trends. Despite the increase in the absolute number of cases and incidence in some Brazilian states and municipalities, in general, a decline in mortality rates took place from the end of the 20th century to 2017, being more accentuated in regions with greater socioeconomic development and technological advances in high-complexity medicine20.Taking Brazilian socioeconomic and health resource data in 2010 as reference, the Brazilian North and Northeast showed the lowest gross domestic product , per capita expenditures on public health actions and services in general , number of medical professionals , number of hospital beds , and number of neuroimaging devices for diagnosis: CT scanners  and magnetic resonance imaging 22.On the other hand, the expansion of access to health services; the use of medications for acute cerebrovascular disease, chronic diseases, and lipid disorders; the greater control over modifiable risk factors; the increase in the number of intensive care units and availability of neuroimaging for diagnosis; and the implementation of promotion and prevention programs configure other factors that have favored the reduction of mortality rates23 showed risk factors for CBVD above the national average for the Brazilian North and Northeast: the proportion of adults who never had their blood pressure measured , hospitalizations for AHT , hospitalizations for diabetes , and proportion of people with a previous diagnosis of CBVD . Other harmful risk factors with indicators below the national average include the proportion of hypertensive adults who had access to at least one drug in the Brazilian Popular Pharmacy Program , mean age of the beginning of alcohol consumption , and proportion of people with the recommended rates of physical activity .The National Health Survey (PNS)24 found similar findings in South Korea (2011\u20132015), describing increased cerebrovascular mortality rates in regions with lower socioeconomic development and an association with overweight, alcohol consumption, number of hospital beds, and number of neuroimaging devices available to the population. Yanez et al.25also reported increases in poorer Colombian regions, with greater difficulties accessing pre-hospital and hospital health services and the correlation with AHT, obesity, and smoking. However, in the prefecture of Iwate (Japan), Omama et al.22 reported a decrease in the incidence rate trend of cerebrovascular diseases from 2008 to 2017 in those aged above and below 55 years of both genders.Lee et al.26. However, in Northern capitals (excluding their southern parts), the pattern of rate behavior differs, probably because the region shows no important minimum temperatures during this period, which are much higher (18\u00b0 to 23\u00b0C) than in the rest of the country26.Regarding seasonal behavior, the increase in rates in the middle of each year refers us, from the climatic point of view, to the fact that in the winter period, the risk of cerebrovascular mortality increases, specifically during July and August, except in Northern capitals. At this time of year, the country shows the lowest regional temperatures9.During winter, we find multiple pathophysiological mechanisms linked to the occurrence of cardiovascular deaths: increased catecholamine levels, vasoconstriction, tachycardia, and blood pressure; hemoconcentration due to cold-related polyuria, and increased blood viscosity due to concentrations of coagulation factors, platelets, cholesterol, fibrinogen, and erythrocytes9. Northern capitals behave unlike other Brazilian capitals as they follow the change in the climatic pattern, since September and October, the hottest months of the year in this region27, coincide with the lowest rates of cerebrovascular death, unlike other regions, in which rates decrease from December to February. However, the geographical location of capitals between the equatorial, tropical, and subtropical zones in Brazil suggests that the population, constantly exposed to environmental changes, adapts better to hot temperatures than to cold ones, regardless of other factors, which this this research ignored, that may determine this behavior.Note that the risk of mortality persists in the summer, despite its lowest values. The increase in mortality in hot climate conditions is associated with extreme temperatures and heat waves, with more pronounced negative consequences in older adults27  and Su et al.28 (in 17 Chinese cities) reported a higher annual number of deaths and a relative risk of cold-related cardiovascular mortality, establishing regional differences and pointing to a small proportion of deaths unrelated to seasonal variability.In agreement with our results, both Keatinge et al.29 concluded that both low and high temperatures in Brazil add to the risk of cardiovascular mortality in most Brazilian capitals, with variations according to geographic location. In general, the authors observed a U-shaped exposure-response relationship, with more pronounced consequences in low temperatures and places with greater thermal amplitude.Silveira et al.2. Data generated by the Mortality Information System (SIM) can reproduce the spatiotemporal dynamics of mortality, generating subsidies and priorities for policies and actions to promote health14. Another limitation to be considered is that the types of cerebral vascular arteries remained unspecified, despite the different pathophysiological mechanisms between them.Regarding the potential limitations of this research, we should point out that the use of secondary data, subject to different levels of quality related to underreporting and ill-defined causes, may have partially influenced our results. Thus, regarding scope, coverage, and veracity, studies confirm important advances in the quality of mortality data in Brazil, especially in areas with greater socioeconomic developmentOur grouping of data by region configures another limitation, which probably reduces an accurate capture of local mortality behaviors. However, we find that this study estimates the significant trend and seasonality changes, enabling us to synthesize characteristics related to cerebrovascular mortality of interest to public health in areas with a high population concentration and subject to the influence of common environmental, social, and economic factors.We conclude that our findings enabled us to characterize the epidemiological and sociodemographic profile of Brazilian capitals and the Federal District regarding cerebrovascular mortality from 2000 to 2019, pointing to single older adults of all with low schooling as the most affected population and, therefore, with a higher degree of social vulnerability. Depending on the region, white  and Black individuals  show the highest incidence rates. In the evaluation of the mortality rate trend, although it has decreased over the period, its behavior remains concerning due to the multifactorial character of its origin and evolution. Seasonality analysis showed winter as the period of highest risk of mortality in the national territory. Regional differences enable the definition of priorities and subsidizing decision-makers with medium and long-term actions toward planning and implementing policies and programs to reduce, promote, and prevent cerebrovascular mortality.However, this study emphasizes the need to further develop and broaden research considering other risk factors outside the scope of this study. 1. Em 2019 ocorreram aproximadamente 6,55 milh\u00f5es de \u00f3bitos por DCBV globalmente , com pouca diferen\u00e7a entre os de causa isqu\u00eamica  e hemorr\u00e1gica 1. Na Am\u00e9rica Latina as DCBV tamb\u00e9m se mantiveram entre as primeiras causas de morte por d\u00e9cadas, apesar do decr\u00e9scimo est\u00e1vel no n\u00famero de \u00f3bitos entre 1990\u201320191.As doen\u00e7as cerebrovasculares (DCBV) est\u00e3o entre as primeiras causas de morte e sequelas neurol\u00f3gicas permanentes no adulto no mundo2.Similarmente no Brasil ainda est\u00e3o entre as principais causas de morte, com uma evolu\u00e7\u00e3o vari\u00e1vel na tend\u00eancia ao longo dos \u00faltimos 30 anos. A distribui\u00e7\u00e3o espacial tamb\u00e9m se comportou de maneira desigual no pa\u00eds, com maiores quedas das taxas de mortalidade nos estados com maior desenvolvimento econ\u00f4mico, entretanto os maiores impactos negativos foram observados em popula\u00e7\u00f5es com baixos indicadores de desenvolvimento5. Por sua vez, no Brasil, as regi\u00f5es metropolitanas apresentam maior cobertura de sa\u00fade e melhor qualidade nos registros de mortalidade, permitindo que as an\u00e1lises nessas \u00e1reas sejam representativas da situa\u00e7\u00e3o de sa\u00fade8.Estudos epidemiol\u00f3gicos t\u00eam contribu\u00eddo na compreens\u00e3o e an\u00e1lise dos fatores e determinantes das DCBV, assim como no subs\u00eddio de pol\u00edticas, projetos e programas de promo\u00e7\u00e3o da sa\u00fade e preven\u00e7\u00e3o de doen\u00e7as. Com isso, proporcionam um melhor controle desse tipo de doen\u00e7a, al\u00e9m da redu\u00e7\u00e3o dos gastos em tratamentos especializados e transtornos psicol\u00f3gicos de pacientes e familiares, particularmente em zonas urbanas, onde se concentra a maior parte da popula\u00e7\u00e3o, tanto mundial quanto nacional (84% da popula\u00e7\u00e3o brasileira reside em zonas urbanas e 24% nas capitais)2. Os impactos da temperatura na mortalidade cerebrovascular t\u00eam sido amplamente documentados. Evid\u00eancias epidemiol\u00f3gicas sugerem que existe forte rela\u00e7\u00e3o em forma de U (ou de V) entre a temperatura e o n\u00famero de \u00f3bitos, confirmando a hip\u00f3tese de que a mortalidade aumenta progressivamente em temperaturas extremas, tanto altas quanto baixas9. Os mecanismos fisiopatol\u00f3gicos envolvidos, embora n\u00e3o totalmente esclarecidos, dependem do estado de hidrata\u00e7\u00e3o, da reatividade do sistema nervoso aut\u00f4nomo simp\u00e1tico, da ativa\u00e7\u00e3o do sistema renina-angiotensina-aldosterona e da resposta inflamat\u00f3ria sist\u00eamica, que junto a outros m\u00faltiplos fatores de risco  refletem negativamente9.Os estudos sobre mortalidade por DCBV frequentemente s\u00e3o focados em an\u00e1lises de tend\u00eancia associados a perfis epidemiol\u00f3gicos e sociodemogr\u00e1ficos, por\u00e9m poucas publica\u00e7\u00f5es consideraram a variabilidade sazonal desse evento10 traz in\u00fameros desafios e impactos sobre a sa\u00fade da popula\u00e7\u00e3o.A an\u00e1lise da componente sazonal, que impacta diretamente a popula\u00e7\u00e3o exposta, adiciona conhecimento sobre o comportamento e evolu\u00e7\u00e3o dessa doen\u00e7a nos diferentes per\u00edodos do ano, al\u00e9m de ser um indicador relevante na previs\u00e3o e ado\u00e7\u00e3o de medidas de controle, sobretudo no atual cen\u00e1rio de mudan\u00e7a clim\u00e1tica, em que a grande heterogeneidade, complexidade, diversidade social, ecol\u00f3gica e clim\u00e1tica dos munic\u00edpios e regi\u00f5es do BrasilNessa perspectiva, objetivou-se avaliar as caracter\u00edsticas de tend\u00eancia e sazonalidade da mortalidade por DCBV em adultos maiores de 18 anos, residentes nas capitais brasileiras no per\u00edodo de 2000 a 2019, com o prop\u00f3sito de atualizar o perfil epidemiol\u00f3gico e fornecer informa\u00e7\u00f5es objetivas e \u00fateis para auxiliar a tomada de decis\u00f5es em sa\u00fade.6. Em 2010, o total da popula\u00e7\u00e3o a partir de 18 anos de idade nas capitais era de 33.423.348 habitantes6.Trata-se de um estudo ecol\u00f3gico e descritivo de s\u00e9ries temporais de mortalidade por doen\u00e7as cerebrovasculares ocorridas na popula\u00e7\u00e3o (\u2265 18 anos) residente nas 26 capitais do Brasil e no Distrito Federal (DF), no per\u00edodo 2000\u20132019. As capitais foram agrupadas por regi\u00f5es geogr\u00e1ficas: regi\u00e3o Sul [RS]; regi\u00e3o Sudeste [RSD]; regi\u00e3o Nordeste [RND]; regi\u00e3o Norte [RN]; e regi\u00e3o Centro-Oeste [RCO]6. T\u00e9cnicas de estat\u00edstica descritiva foram aplicadas para a an\u00e1lise explorat\u00f3ria e o resumo dos dados por idade, sexo (masculino e feminino), ra\u00e7a , estado civil  e escolaridade . Foram avaliados indicadores de sa\u00fade, tais como raz\u00f5es por caracter\u00edsticas sociodemogr\u00e1ficas e taxas de mortalidade, calculadas de acordo com as equa\u00e7\u00f5es abaixo:Os \u00f3bitos di\u00e1rios, dos c\u00f3digos I60 a I69, segundo a d\u00e9cima Classifica\u00e7\u00e3o Internacional de Doen\u00e7as, e as estimativas populacionais de cada ano (em 1\u00ba de julho) projetadas pelo Instituto Brasileiro de Geografia e Estat\u00edstica (IBGE), foram obtidos do Sistema de Informa\u00e7\u00f5es Datasus, do Minist\u00e9rio da Sa\u00fade11. Adotou-se como popula\u00e7\u00e3o padr\u00e3o a popula\u00e7\u00e3o mundial da OMS (2000\u20132025), definida para refletir a estrutura et\u00e1ria m\u00e9dia da popula\u00e7\u00e3o mundial (https://seer.cancer.gov/stdpopulations/world.who.html).Para ajustar o efeito do confundimento nas compara\u00e7\u00f5es das taxas do per\u00edodo entre as popula\u00e7\u00f5es das capitais, segundo os grupos et\u00e1rios , se utilizou o m\u00e9todo direto de padroniza\u00e7\u00e3ojointpoint regression model)12. O m\u00e9todo seleciona os melhores ajustes do modelo de regress\u00e3o log-linear cont\u00ednuo por partes e identifica o(s) ano(s) em que uma mudan\u00e7a de tend\u00eancia \u00e9 produzida, calcula a varia\u00e7\u00e3o percentual anual  entre os pontos de mudan\u00e7a de tend\u00eancia e estima a varia\u00e7\u00e3o percentual m\u00e9dia anual  em todo o per\u00edodo estudado. O n\u00famero de pontos de jun\u00e7\u00e3o \u00e9 obtido usando o teste de permuta\u00e7\u00e3o de Monte Carlo . Uma vez que o n\u00famero k de pontos de jun\u00e7\u00e3o s\u00e3o obtidos, os diferentes modelos s\u00e3o comparados pelo Crit\u00e9rio de Informa\u00e7\u00e3o Bayesiano (BIC).Para estimar a tend\u00eancia das taxas anuais de mortalidade cerebrovascular, ajustadas por sexo, grupos et\u00e1rios, regi\u00f5es geogr\u00e1ficas e para Brasil, se utilizou a regress\u00e3o de pontos de jun\u00e7\u00e3o 13, o qual estimou a variabilidade sazonal das taxas mensais de mortalidade cerebrovascular ao longo do per\u00edodo de estudo por meio de splines de suaviza\u00e7\u00e3o c\u00fabica. O GAM \u00e9 usado na interpreta\u00e7\u00e3o das rela\u00e7\u00f5es n\u00e3o lineares entre vari\u00e1veis, baseia-se em fun\u00e7\u00f5es n\u00e3o param\u00e9tricas, denominadas curvas de alisamento, em que a forma de associa\u00e7\u00e3o \u00e9 definida pelos pr\u00f3prios dados. A estrutura b\u00e1sica ajustada para modelar a variabilidade sazonal corresponde \u00e0 seguinte equa\u00e7\u00e3o:Para a an\u00e1lise temporal utilizou-se o modelo aditivo generalizado , a devia\u00e7\u00e3o explicada (deviance explained \u2013 DE), a valida\u00e7\u00e3o cruzada generalizada  e pelas an\u00e1lises de res\u00edduos14.Onde g = fun\u00e7\u00e3o de liga\u00e7\u00e3o aditiva das vari\u00e1veis preditoras; \u00b5 = valor da m\u00e9dia da taxa mensal de mortalidade cerebrovascular; \u03b1 = intercepto; s = fun\u00e7\u00e3o download, manejo, an\u00e1lises estat\u00edsticas e representa\u00e7\u00f5es gr\u00e1ficas dos dados.Estabeleceu-se um n\u00edvel de signific\u00e2ncia de 5% para os testes estat\u00edsticos. Os softwares Microsoft Excel (vers\u00e3o 2108), R  e jointpoint (vers\u00e3o 4.9.0.1) foram utilizados para o Durante o per\u00edodo do estudo 593.173 adultos foram a \u00f3bito por DCBV nas capitais do Brasil, com uma mortalidade m\u00e9dia mensal de 2.474  casos. Os idosos representaram 77% dos \u00f3bitos. S\u00e3o Paulo e Rio de Janeiro, maiores cidades do Pa\u00eds, atingiram os maiores valores durante o per\u00edodo do estudo, com 120.124 e 91.987, respectivamente.Sobre as caracter\u00edsticas sociodemogr\u00e1ficas do total de \u00f3bitos estudados, 23% eram menores de 60 anos e 52% eram mulheres. Em rela\u00e7\u00e3o \u00e0 ra\u00e7a, a branca (47%) superou a preta (44%). Quanto ao estado civil, 59% eram solteiros. A baixa escolaridade tamb\u00e9m prevaleceu, sendo que 19% n\u00e3o tinham nenhum grau de instru\u00e7\u00e3o e 57% s\u00f3 tinham cursado o ensino fundamental.Na Sobre as taxas de mortalidade do per\u00edodo, 13 capitais apresentaram valores acima da m\u00e9dia do pa\u00eds, com os maiores valores em Recife (20/10.000 hab.) e Vit\u00f3ria (16/10.000 hab.). Ap\u00f3s padroniza\u00e7\u00e3o por idade, os resultados mostraram 20 capitais com valores superiores \u00e0 m\u00e9dia do Brasil (24/10.000 hab.), se destacando Recife (49/10.000 hab.), Palmas (47/10.000 hab.), Macei\u00f3 (45/10.000 hab.) e Aracaju (44/10.000 hab.) .Por outro lado, a Considerando a distribui\u00e7\u00e3o geogr\u00e1fica, os resultados apresentados na Com rela\u00e7\u00e3o ao comportamento sazonal, pode-se afirmar que as curvas de alisamento estimadas pelo GAM da taxa de mortalidade cerebrovascular em fun\u00e7\u00e3o do per\u00edodo do estudo se ajustaram \u00e0 variabilidade sazonal, cujo padr\u00e3o condiz com os intervalos de comportamento m\u00e9dio dessas taxas  em cada De maneira geral, as taxas de mortalidade apresentaram seus maiores valores em meados de cada ano, apontando para os meses de julho e agosto como os de maior risco, per\u00edodo de inverno no Hemisf\u00e9rio Sul, \u00e0 exce\u00e7\u00e3o da regi\u00e3o Norte, cujas capitais apresentaram os maiores picos entre mar\u00e7o e maio. Por outro lado, as menores taxas se apresentaram no m\u00eas de fevereiro em todas as capitais das regi\u00f5es geogr\u00e1ficas e consequentemente no Brasil, exceto nas regi\u00f5es Norte e Centro-Oeste.Vale ressaltar que, com exce\u00e7\u00e3o do Norte do pa\u00eds, os meses de ver\u00e3o no Hemisf\u00e9rio Sul (dezembro a fevereiro) se caracterizaram por apresentar os menores valores das taxas de mortalidade por DCBV, entretanto, os meses de outono (abril a junho) e primavera (setembro a novembro) se comportam como per\u00edodos de transi\u00e7\u00e3o .1. Devido \u00e0s falhas nas respostas de adapta\u00e7\u00e3o pelas mudan\u00e7as internas dos sistemas regulat\u00f3rios do organismo, os idosos tamb\u00e9m s\u00e3o mais suscet\u00edveis na presen\u00e7a de ambientes com elevada carga de polui\u00e7\u00e3o e temperaturas extremas (m\u00ednimas e m\u00e1ximas)9.A maior frequ\u00eancia de \u00f3bitos em pessoas idosas confirma a idade como fator importante, associada frequentemente a m\u00faltiplos fatores de risco: aterosclerose vascular cerebral, hipertens\u00e3o arterial (HTA), diabetes mellitus e s\u00edndrome metab\u00f3lica, fumo, entre outros, cuja evolu\u00e7\u00e3o, unida a fatores gen\u00e9ticos e imunol\u00f3gicos, contribuem com a deteriora\u00e7\u00e3o da sa\u00fade15, com taxas de mortalidade n\u00e3o desprez\u00edveis, como revelado neste estudo, apesar do decl\u00ednio na tend\u00eancia. Globalmente tem-se reportado incrementos na incid\u00eancia em menores de 45 anos, com os maiores impactos em economias de baixa e m\u00e9dia renda16. Estudos nacionais tamb\u00e9m caracterizaram a morbimortalidade cerebrovascular em jovens17, estando nas primeras causas espec\u00edficas de morte de 5 a 29 e 30 a 69 anos de idade14. Em rela\u00e7\u00e3o aos fatores de risco, estima-se que o aumento da incid\u00eancia de causa cerebrovascular em adultos jovens \u00e9 atribu\u00edda \u00e0 tend\u00eancia crescente dos m\u00faltiplos fatores de risco citados. Outros fatores etiol\u00f3gicos que favorecem a ocorr\u00eancia de epis\u00f3dios cerebrovasculares nessas idades, tamb\u00e9m presentes no Brasil s\u00e3o: HIV, anemia falciforme, cardiopatia reum\u00e1tica, doen\u00e7a de Chagas, tuberculose, dissec\u00e7\u00e3o arterial e doen\u00e7a de moyamoya14.No entanto, os adultos jovens tamb\u00e9m s\u00e3o alvo das DCBV4. Lotufo et al.18, em um estudo sobre mortalidade cerebrovascular e ra\u00e7a, encontraram predom\u00ednio da ra\u00e7a negra e parda no Brasil, resultado que contrasta com os nossos, onde prodominou a branca, provavelmente pela restri\u00e7\u00e3o et\u00e1ria (30\u201369 anos) e o curto per\u00edodo de estudo selecionado por esse autor; no entanto, Dorlens et al.2reportaram as maiores taxas em idosos masculinos, solteiros e de baixa escolaridade entre 1996 e 2015, resultados similares aos nossos.Diversas pesquisas nacionais t\u00eam abordado amplamente a distribui\u00e7\u00e3o das DCBV associada ao sexo, \u00e0 ra\u00e7a, ao estado civil, \u00e0 escolaridade e anos de vida potencialmente perdidos (APVP)19.Tr\u00eas caracter\u00edsticas decorrentes das an\u00e1lises permitem considerar o efeito protetor do horm\u00f4nio estrog\u00eanio, o qual eventualmente contribui para a diminui\u00e7\u00e3o do risco de acidentes vasculares, aumentando a expectativa de vida na mulher: primeiramente, o predom\u00ednio das taxas de mortalidade nos homens de 30 a 59 anos, em compara\u00e7\u00e3o com o mesmo grupo em mulheres ; em segundo lugar, as maiores redu\u00e7\u00f5es significativas da tend\u00eancia de mortalidade em mulheres de 30 a 59 anos em rela\u00e7\u00e3o aos homens da mesma faixa et\u00e1ria ; e por \u00faltimo o incremento das taxas de mortalidade em mulheres maiores de 60 anos em compara\u00e7\u00e3o com as menores de 60 anos . Ao estrog\u00eanio se atribuem efeitos positivos no sistema imune, estimulando a produ\u00e7\u00e3o de anticorpos e regulando a linfopoiese; al\u00e9m disso, aumenta os n\u00edveis de colesterol HDL, reduz o LDL, e relaxa, suaviza e dilata os vasos sangu\u00edneos. Outras propriedades s\u00e3o as antioxidantes, anti-inflamat\u00f3rias e estabilizadoras das membranas celulares2, comportamento tamb\u00e9m observado a escala global16. Nessa linha, foram as capitais das regi\u00f5es Sul e Sudeste, de maior crescimento econ\u00f4mico, as que delinearam as maiores redu\u00e7\u00f5es dos APC e AAPC, ao contr\u00e1rio das regi\u00f5es Norte e Nordeste, menos desenvolvidas economicamente.No que se refere \u00e0 tend\u00eancia das taxas de mortalidade, nossos achados s\u00e3o concordantes com a literatura. Apesar do incremento no n\u00famero absoluto de casos e da incid\u00eancia em alguns estados e munic\u00edpios do Brasil, de maneira geral se reporta um decl\u00ednio nas taxas de mortalidade desde finais do s\u00e9culo XX at\u00e9 2017, sendo mais acentuado em regi\u00f5es com maior desenvolvimento socioecon\u00f4mico e avan\u00e7os tecnol\u00f3gicos na medicina de alta complexidade20.Tomando como refer\u00eancia dados socioecon\u00f4micos e de recursos de sa\u00fade do Brasil de 2010, as regi\u00f5es Norte e Nordeste eram as menores em produto interno bruto , em gastos per capita com a\u00e7\u00f5es e servi\u00e7os p\u00fablicos de sa\u00fade em geral , e em n\u00famero de profissionais m\u00e9dicos , n\u00famero de leitos hospitalares  e em n\u00famero de aparelhos de neuroimagens para diagn\u00f3stico: tom\u00f3grafos  e resson\u00e2ncias magn\u00e9ticas 22.Por outro lado, a amplia\u00e7\u00e3o do acesso aos servi\u00e7os de sa\u00fade e ao uso de medicamentos para a doen\u00e7a cerebrovascular aguda, doen\u00e7as cr\u00f4nicas e transtornos lip\u00eddeos, bem como o maior controle sobre fatores de risco modific\u00e1veis, o incremento no n\u00famero de unidades de cuidados intensivos, a disponibilidade de neuroimagem para diagn\u00f3stico e a implementa\u00e7\u00e3o de programas de promo\u00e7\u00e3o e preven\u00e7\u00e3o, s\u00e3o outros fatores que t\u00eam favorecido a redu\u00e7\u00e3o das taxas de mortalidade23 revelou fatores de risco para DCBV que se encontravam acima da m\u00e9dia do pa\u00eds: propor\u00e7\u00e3o de adultos que nunca mediram sua press\u00e3o arterial , interna\u00e7\u00f5es por HTA , interna\u00e7\u00f5es por diabetes  e propor\u00e7\u00e3o de pessoas com diagn\u00f3stico pr\u00e9vio de DCBV . Outros fatores de risco prejudiciais com indicadores abaixo da m\u00e9dia nacional foram: propor\u00e7\u00e3o de adultos hipertensos que tiveram acesso no m\u00ednimo a um medicamento no Programa Farm\u00e1cia Popular , idade m\u00e9dia de in\u00edcio do consumo de \u00e1lcool  e propor\u00e7\u00e3o de pessoas com pr\u00e1tica de atividade f\u00edsica recomendada .Nas regi\u00f5es Norte e Nordeste a Pesquisa Nacional de Sa\u00fade (PNS)24 encontraram achados similares na Coreia do Sul (2011\u20132015), descrevendo aumento das taxas de mortalidade cerebrovascular em regi\u00f5es de menor desenvolvimento socioecon\u00f4mico, assim como associa\u00e7\u00e3o com sobrepeso, consumo de \u00e1lcool, n\u00famero de leitos hospitalares e n\u00famero de aparelhos de neuroimagem dispon\u00edveis para a popula\u00e7\u00e3o. Yanez et al.25na Col\u00f4mbia tamb\u00e9m referiram incrementos nas regi\u00f5es mais pobres, com maiores dificuldades de acesso aos servi\u00e7os de sa\u00fade pr\u00e9-hospitalar e hospitalar, al\u00e9m da correla\u00e7\u00e3o com HTA, obesidade e tabagismo. Por\u00e9m no munic\u00edpio de Iwate (Jap\u00e3o) Omama et al.22 reportaram queda na tend\u00eancia das taxas de incid\u00eancia por doen\u00e7as cerebrovasculares entre 2008 e 2017 em maiores e menores de 55 anos de ambos os sexos.Lee et al.26. No entanto, nas capitais da RN, excluindo sua parte meridional, o padr\u00e3o do comportamento das taxas difere, provavelmente porque durante esse per\u00edodo a regi\u00e3o n\u00e3o apresenta temperaturas m\u00ednimas importantes, as que s\u00e3o bem mais altas (18\u00baC a 23\u00baC) do que no resto do pa\u00eds26.No concernente ao comportamento sazonal, a eleva\u00e7\u00e3o das taxas em meados de cada ano nos remete, desde o ponto de vista clim\u00e1tico, a que no per\u00edodo de inverno, exceto nas capitais da RN, o risco de mortalidade cerebrovascular aumenta, especificamente durante os meses de julho e agosto. Nessa \u00e9poca do ano se registram as temperaturas regionais mais baixas do pa\u00eds9.No per\u00edodo de inverno, m\u00faltiplos s\u00e3o os mecanismos fisiopatol\u00f3gicos ligados \u00e0 ocorr\u00eancia de \u00f3bitos cardiovasculares: aumento dos n\u00edveis de catecolaminas, vasoconstri\u00e7\u00e3o, taquicardia e aumento da press\u00e3o arterial, hemoconcentra\u00e7\u00e3o devido \u00e0 poli\u00faria relacionada ao frio, aumento da viscosidade sangu\u00ednea por concentra\u00e7\u00f5es de fatores de coagula\u00e7\u00e3o, plaquetas, colesterol, fibrinog\u00eanio e eritr\u00f3citos9. As capitais da RN se afastam do comportamento do resto das capitais do pa\u00eds, acompanhando a mudan\u00e7a do padr\u00e3o clim\u00e1tico, uma vez que setembro e outubro, meses mais quentes do ano nessa regi\u00e3o27, coincidem com as menores taxas de \u00f3bito cerebrovascular, ao contr\u00e1rio das outras regi\u00f5es, cujo decl\u00ednio ocorre de dezembro a fevereiro. No entanto, a localiza\u00e7\u00e3o geogr\u00e1fica das capitais entre as zonas equatorial, tropical e subtropical sugere que a popula\u00e7\u00e3o, constantemente exposta \u00e0s mudan\u00e7as ambientais, se adapta melhor \u00e0s temperaturas quentes do que \u00e0s frias, independente de que outros fatores n\u00e3o explorados nesta pesquisa, podem estar determinando esse comportamento.Cabe destacar que no ver\u00e3o, embora as taxas apresentem seus valores mais baixos, o risco est\u00e1 presente. O incremento da mortalidade em condi\u00e7\u00f5es de clima quente se associa \u00e0s temperaturas extremas e ondas de calor, com consequ\u00eancias negativas mais acentuadas em pessoas idosas27 em v\u00e1rias regi\u00f5es europeias quanto Su et al.28 em 17 cidades chinesas reportaram maior n\u00famero anual de \u00f3bitos e maior risco relativo de mortalidade cardiovasculares relacionadas ao frio, ainda estabelecendo diferen\u00e7as regionais e apontando para pequena propor\u00e7\u00e3o de \u00f3bitos n\u00e3o relacionados \u00e0 variabilidade sazonal.Em concord\u00e2ncia com nossos resultados, tanto Keatinge et al.29, no Brasil, conclu\u00edram que, tanto as baixas quanto as altas temperaturas acrescentam o risco de mortalidade cardiovascular na maioria das capitais brasileiras, com varia\u00e7\u00f5es de acordo \u00e0 localiza\u00e7\u00e3o geogr\u00e1fica. Em geral, foi observada uma rela\u00e7\u00e3o exposi\u00e7\u00e3o-resposta em forma de U, com consequ\u00eancias mais acentuadas em condi\u00e7\u00f5es de baixas temperaturas e locais com maior amplitude t\u00e9rmica.Silveira et al.2. Acredita-se que os dados gerados pelo Sistema de Informa\u00e7\u00e3o de Mortalidade (SIM) s\u00e3o capazes de reproduzir a din\u00e2mica espa\u00e7o-temporal sobre a situa\u00e7\u00e3o de mortalidade, gerando subs\u00eddios e prioridades para pol\u00edticas e a\u00e7\u00f5es \u00e0 promo\u00e7\u00e3o de sa\u00fade14. Outra limita\u00e7\u00e3o a ser considerada \u00e9 que n\u00e3o foram especificados os tipos de vasculares cerebrais, mesmo havendo diferentes mecanismos fisiopatol\u00f3gicos entre eles.Acerca de potenciais limita\u00e7\u00f5es desta pesquisa, vale apontar que o uso de dados secund\u00e1rios, sujeitos a diferentes n\u00edveis de qualidade relacionados \u00e0 subnotifica\u00e7\u00e3o e causas mal definidas, pode ter influenciado parcialmente nos resultados. Neste particular, no que tange \u00e0 abrang\u00eancia, cobertura e veracidade, estudos confirmam avan\u00e7os importantes na qualidade dos dados de mortalidade no Brasil, com destaque para as \u00e1reas de maior desenvolvimento socioecon\u00f4micoTamb\u00e9m constitui uma limita\u00e7\u00e3o a abordagem dos dados agrupados por regi\u00f5es, o que provavelmente n\u00e3o permite captar com precis\u00e3o comportamentos da mortalidade a n\u00edvel local. No entanto, considera-se que o estudo estima as mudan\u00e7as significativas da tend\u00eancia e sazonalidade, permitindo sintetizar caracter\u00edsticas de interesse para a sa\u00fade p\u00fablica relacionada \u00e0 mortalidade cerebrovascular, em \u00e1reas de alta concentra\u00e7\u00e3o populacional e sujeitas \u00e0 influ\u00eancia de fatores comuns, tanto ambientais como sociais e econ\u00f4micos.Conclui-se que os achados permitiram caracterizar o perfil epidemiol\u00f3gico e sociodemogr\u00e1fico nas capitais brasileiras e o DF quanto \u00e0 mortalidade cerebrovascular entre 2000\u20132019, apontando principalmente as pessoas idosas de ambos os sexos, solteiras e com baixa escolaridade como as mais atingidas e, portanto, com maior grau de vulnerabilidade social. A depender da regi\u00e3o, predominou a ra\u00e7a branca  e preta . Na avalia\u00e7\u00e3o da tend\u00eancia das taxas de mortalidade, embora venha reduzindo ao longo do per\u00edodo, seu comportamento ainda preocupa, devido ao car\u00e1ter multifatorial da sua origem e evolu\u00e7\u00e3o. A an\u00e1lise da sazonalidade mostrou o inverno como o per\u00edodo de maior risco de mortalidade no territ\u00f3rio nacional. As diferen\u00e7as regionais permitem definir prioridades e subsidiar os tomadores de decis\u00f5es, com a\u00e7\u00f5es de m\u00e9dio e longo prazo, em rela\u00e7\u00e3o ao planejamento e implementa\u00e7\u00e3o de pol\u00edticas e programas de redu\u00e7\u00e3o, promo\u00e7\u00e3o e preven\u00e7\u00e3o da mortalidade cerebrovascular.Contudo, o estudo ressalta a necessidade de aprofundar e ampliar as pesquisas considerando outros fatores de risco que n\u00e3o fizeram parte do escopo deste estudo."}
+{"text": "To estimate the prevalence of exposure to the SARS-CoV-2 virus among individuals living in restricted freedom. A seroprevalence survey was carried out with the population of the female penitentiary of the Centro de Progress\u00e3o Penitenci\u00e1ria (CPP) in Butantan , between June 24 and August 20, 2020. During this period, according to the Secretariat of Penitentiary Administration (SAP), the positivity of rapid tests among inmates ranged from 65% to 78%. The evaluation method used in the study was the \u201cOne Step COVID-19\u201d rapid test (chromatography), from the company Wondfo, also using the RT-PCR method in symptomatic participants to confirm the viral condition. The study population consisted of 879 female inmates and 170 employees of the institution. The prevalence of total antibodies (IgG/IgM) against the SARS-CoV-2 virus in the total population of 1049 study participants was 6.1%; among the population of 879 inmates,a prevalence of 5.8% was observed, and among the institution\u2019s employees, 7.5%. The prevalence of covid-19 at the Butantan CPP was low, which is due to the implementation of simple prevention measures at the institution, such as the use of masks (with appropriate changes), emphasis on hygiene, hand washing and social distancing, in addition to other strategies, such as suspending inmates\u2019 visits from relatives and friends and cutting back on elective medical appointments and outside work. As of March 2020, such an infection, called covid-19 (coronavirus disease-2019), was considered pandemic. From that moment on, the world faced dramatic numbers, with more than 544 million cases and more than 6.33 million deaths recorded by June 20224. In the same period, Brazil recorded more than 32.1 million cases and more than 670,000 deaths5.In December 2019, the World Health Organization (WHO) was alerted to several cases of atypical pneumonia caused by a new strain of coronavirus, named SARS-CoV-26.The covid-19 pandemic brought significant challenges to health care, as well as the need for advances in the knowledge of the epidemiology of the disease. Measures to try to contain the spread of SARS-CoV-2 have been adopted around the world, such as restrictions on international travel, implementation of lockdowns, orders for the population to stay at home in certain critical periods of the disease\u2019s incidence, interruption of face-to-face classes, dissemination of a universal hand hygiene guide, physical distancing and use of face masksInfection with SARS-CoV-2 can present different clinical pictures, ranging from asymptomatic and oligosymptomatic cases to severe symptomatic cases. If, on the one hand, the occurrence of asymptomatic and oligosymptomatic cases made actions to mitigate transmission more challenging for interrupting the transmission chain, on the other hand, the frequency of severe cases significantly impacted the care capacity of the available health services.8.Considering the complexity of diagnosing cases of SARS-CoV-2 infection and the limited resources for this diagnosis, the registered epidemiological curve, based on case reports, did not express the spread of infection. Thus, some investigators estimate underreporting at around 10 to 12 times9.Faced with this pandemic scenario, the WHO began to recommend carrying out seroprevalence surveys with the aim of estimating seropositivity and, thus, quantifying the real extent of infection in the general population and in specific populations \u2013 with regard to both age and to socioeconomic conditions or other risk factors \u2013, aiming to develop public policies and more effective interventions to face this scourge. That is, knowledge of seroprevalence is strategic information in public health, especially in times of pandemic. Knowing the immunity of the population, guaranteed by infection or even vaccine, allows better regional organization of the health organization. In fact, following this WHO request, in 2020 the Ministry of Health launched a research project with 211,129 Brazilians, in more than 62,000 households in 2,474 municipalities, to estimate the seroprevalence achieved by our population12. In this sense, it is expected that liberty-deprived populations are at risk in pandemic situations. However, considering the transmission of SARS-CoV-2 through the air, prison environments offer an even greater risk of contagion. It is estimated, for example, that a positive case infects up to 10 incarcerated people, while under normal conditions this number should not exceed 2\u20133 people13.Morbidity and mortality from SARS-CoV-2 is related to social determinants of health and the vulnerability of some specific populations. A study carried out in S\u00e3o Paulo, for example, showed higher mortality associated with lower educational and income levels, living in crowded households, and subnormal clustersScientific publications related to the incidence of covid-19, as well as other infectious diseases, in the prison population are scarce, pointing to a possible lack of interest in this topic by the scientific community and public authorities, which may result from the stigma and difficulty of access to that group.14. These particularities increased their susceptibility to the rapid spread of covid-19, a well-documented fact for such other infectious diseases as influenza, tuberculosis and other respiratory diseases16. In addition to being a major risk for liberty-deprived people, the high incidence of covid-19 in prisons would serve as a source of infection for the general population, considering the movement of employees and the entire social circle involved17. The coronavirus can transit between the bars of the prison system itself, given the transfers of prisoners between multiple establishments18. In the state of S\u00e3o Paulo alone, the estimated prison population in 2020 was around 231,287 individuals19.An additional concern for this social segment includes the conditions in prison units in Brazil, with overcrowded and poorly ventilated cells, limited access to water and basic sanitation, and prison units lacking structured health modules, including service rooms scattered wherever there is space available and the frequent movement of inmates through the physical areas of the institutions21.In the context of overcrowding, often present in prisons, it is difficult to avoid overcrowding and maintain enhanced hygiene conditions. This is compounded by the fact that the physical structure of prison units, for the most part, has not been planned for air circulation and access to sunlight. Finally, social isolation becomes even more challenging, since, in addition to new individuals joining the system daily, civil servants transit in different spaces, as they return to their homes after working hours within the units10.The prison population is very vulnerable to physical and mental problems, both due to the fragility caused by social isolation itself and the stress of liberty deprivation. In addition, it is much more susceptible to infectious diseasesThus, estimating the prevalence of exposure to the SARS-CoV-2 virus in individuals living in restricted environments was essential to assess the speed of spread of the disease, as well as to make decisions that could minimize this spread. In order to assess the seroprevalence of SARS-CoV-2 in prisons, the Butantan Institute carried out a seroepidemiological survey of inmates at the Penitentiary Progression Center (CPP) \u201cMarina Marigo Cardoso de Oliveira\u201d in Butantan located in the municipality of S\u00e3o Paulo, Brazil.Cross-sectional study carried out between June and September 2020, designed to estimate the prevalence of antibodies against SARS-CoV-2 in the Butantan CPP population.The Butantan CPP is a semi-open female prison whose mission is to house inmates in preparation for social life, before final release after serving their sentence. It receives liberty-deprived women (inmates) from various women\u2019s prisons in the State of S\u00e3o Paulo: State Female Penitentiary (FP); FP of the Capital; FP of Trememb\u00e9, FP of Campinas, FP Franco da Rocha, FP of Mogi Gua\u00e7u, CPP of S\u00e3o Miguel Paulista, among others. It has the capacity to receive 1,110 women and, at the time of the pandemic, it housed 879 individuals.The site features a vertical architecture, with four four-story buildings, accessed only by stairs, and a fifth two-story building, where the health management sector is located, on the ground floor. Patients who need further medical care remain in the same building, but on the first floor, adjacent to the health care center.The study population consisted of inmates residing at the Butant\u00e3 CPP and employees who worked there during the research, totaling 879 inmates, 159 employees and service providers. At the time the study was carried out, visits were suspended as a measure to prevent contamination with SARS-CoV-2.To be inmates of the establishment, to be employees of the Butantan CPP in the health sector ; to be administrative employees or penitentiary agents, regardless of age, who showed interest in participating in the study by signing the free and informed consent form (TCLE).Potential participants who show no interest in participating in the study.The population under study is characterized by high turnover, as it includes inmates in a semi-open regime in the final phase of serving their sentence. However, since the beginning of the pandemic, those responsible for the prison system have implemented strategies to contain SARS-CoV-2 infection. Thus, visits from friends and family have been prohibited since April 29, 2020. In addition, the inmates did not go out to work, study or to carry out consultations and elective exams.In addition, an explanatory lecture was held in the chapel of the prison system, for all employees and representatives of the inmates (approximately 250 people), about the disease, with infection control strategies, including guidance on the importance of using masks, cleaning of hands with gel alcohol, and social isolation. Immediately, the use of a mask was recommended, with changes established at most every three hours, and distancing for all employees and inmates. It should be noted that the masks were produced in the prison itself and provided to everyone.Pregnant women, elderly women and the chronically ill were placed in an isolated ward close to the health sector, as this was the highest risk group among liberty-deprived people. In addition, all public servants were trained to screen suspected cases. Even in the absence of health workers, everyone knew how to screen cases. Inputs were also stocked  to ensure that all procedures could be carried out in appropriate conditions, minimizing transmission risks.The Health Sector and the Butantan CPP Board of Directors also created specific strategies to contain the infection, suspending consultations and elective exams, except in cases of chronically ill and HIV-seropositive patients. In urgent cases, the inmates were sent to hospital and, as soon as they returned, they remained in isolation for fifteen days.During the pandemic period, two floors, with individual cells, were separated from the common population for suspected cases of covid-19. The symptomatic prisoners were isolated with control of vital data, blood pressure, pulse and oxygen saturation. In the event of hemodynamic instability and drop in oxygen saturation, they were promptly referred to external emergency services. After returning to the prison system, they remained in isolation for 15 days in an individual cell.Health and administrative employees and penitentiary agents were subjected, still at the entrance, before entering the building, to temperature and oxygen saturation measurement. If there was any abnormality, they were instructed to seek the external health sector. In severe cases, like the inmates, they were sent by ambulance for an external health assessment.Potential participants from each subgroup were invited to participate in the study by the research physicians responsible for the institution\u2019s health management center. All study procedures were performed at the CPP itself.After signing the TCLE, participants were submitted to biological sampling: blood for the rapid serological test, for all participants, and secretion from the nasopharynx and oropharynx using a swab for carrying out the RT-PCR test, only for individuals who reported symptoms at the time of the survey. The inmates were tested following an organized flow through the four buildings and through the four floors.The type of sample collected varied depending on the subgroup to which the participant was included in the study. Asymptomatic participants had a blood sample collected by venipuncture (with serum separation) for use in the rapid test. Participants presenting any symptoms suspected of infection were assigned to the symptomatic subgroup and had the material for nasopharyngeal or oropharyngeal swabs measured for RT-PCR analysis, in addition to blood sampling.The collected blood samples were reserved for a minimum of 30\u201345 minutes at room temperature to be analyzed. If they were not processed immediately, after 45 minutes, the samples were kept under refrigeration at 2\u20138\u00b0C for a maximum of 72 hours following collection, when they were then evaluated.The secretion samples collected with the swab were stored for up to 72 hours under refrigeration, at 2\u20138\u00b0C, until processing and analysis. If these samples were not processed within 72 hours, they were kept frozen at -70\u00b0C until processing and analysis.22. The processing of the collected samples was carried out at the Covid-19 Diagnostics Laboratory at the Butantan Institute.The rapid test provided for the study, based on Technical Opinion 03/2020 \u2013 DHEM/DIR GENERAL/HCF, was used to perform serological screening in suspected cases of SARS-CoV-2 infection. Positive results indicate that there was previous exposure of the participant to the SARS-CoV-2 virus, but negative results do not rule out asymptomatic infection or previous contact with the virus after long periods of time. The test has a sensitivity of 98.11% and a specificity of 99.72%, according to the data in the test package insert23.RT-PCR performance followed the execution protocol used at the Butantan Institute for the diagnosis of SARS-CoV-2 infectionInterviews were carried out with the participants with the collection of identification, sociodemographic and clinical data, recorded in a standardized form on the same day of biological sampling. These data, as well as test results, were fed into an electronic information capture system  specifically designed for this survey. All participants received reports of individual results and were instructed individually according to the result obtained. The management of the database and the analysis of the results was carried out by the Center for Clinical Safety and Risk Management at the Butantan Institute.Data from this study were analyzed using the statistical program Stata version 13.0 .In the descriptive analysis of sociodemographic, clinical and laboratory variables, the prevalence of antibodies against SARS-CoV-2 and their respective 95% confidence intervals (95%CI) were calculated for each subgroup of the study population (inmates and employees). The chi-square test was used to test the association between the subgroups of the studied population and the prevalence of antibodies against SARS-CoV-2, with a statistical significance level of 5%.This study was conducted in full compliance with relevant Brazilian and international ethical regulations or guidelines, and was approved by the Ethics Committee for Analysis of Research Projects (CAPPesq) of the Hospital das Cl\u00ednicas of the Faculty of Medicine of the University of S\u00e3o Paulo (USP).Information was collected from 1,038 participants. Among them, 879 inmates and 159 servants of the Butantan CPP. The median age in the general sample was 36 years; among inmates it was 34.3 years and among civil servants 42.2 years. The group of inmates was formed by female participants in its entirety. Among servers, 82.8% were female .In the general sample, 45.1% were brown, 38.7% white and 12.6% black. Among the inmates, 49.4% were brown, 33.8% were white and 12.9% were black, and among public servants 66% were white, 21.4% brown and 11.3% black .The prevalence of total antibodies against SARS-Cov-2 found in the general study population was 6.1% (95%CI 4.7\u20137.7). Specifically among inmates, the prevalence was 5.8% (95%CI 4.3\u20137.6), and among civil servants, 7.5% (95%CI 4.0\u201312.8).Among inmates, the prevalence was detected more frequently (12.5% [95%CI 0.3\u201348.2]) in younger women (< than 20 years). Among women aged 20 to 29 years, the prevalence was 8.1% [95%CI 5.4\u201312.1]; among those aged 30 to 39 years, 40 to 49 years and 50 to 59 years, it was 6.1%, 2.5% and 3.2%, respectively; among those over 60 years of age, the prevalence was 8.3% [95%CI 0.1\u201327.0]). Seropositivity was higher among white women (6.15%) than among black and brown women (5.5%).The prevalence observed among civil servants was also higher at the extremes of age in the sample, being 12.5% (95%CI 1.6\u201338.3) among civil servants aged 20 to 29 years and 12.8%  among those aged 50 to 59 years. A higher prevalence was observed in male than in female servants, being 13.8% and 6.2%, respectively. In the white population, the prevalence was 9.5%, and in the black population, 3.8%  and 3.24. The infrastructure of prisons, in general, is conducive to the spread of infectious diseases, mainly respiratory, such as covid-19. During the testing, the inmates were not visited by family and friends, nor were they allowed to leave the prison, but they were still exposed, as agents and employees frequently leave and return from the facilities.The prison population is very vulnerable to physical and mental problems, due to both the fragility caused by social isolation itself and the stress of liberty deprivation, in addition to being much more susceptible to infectious diseases24.In the history of viral infections, it is worth mentioning that, in 1918, during the Spanish flu, the disease spread rapidly as a result of the inmates\u2019 close confinement and an inability to isolate the sick. In the prison of San Quentin, state of California, United States, half of the 1900 inmates contracted the disease during the first wave of the epidemic; sick calls increased from 150 to 700 daily24.Distancing becomes unfeasible and the risks of infection increase, resulting in serious cases and death. At the Butantan CPP, these two consequences were avoided, since the restriction of visits and hygiene measures were efficiently taken, in time to minimize inmates\u2019 infection during the studyHowever, the population under study shows high turnover and displacement, since it includes inmates in a semi-open regime and who are allowed to work outside the walls in the final phase of serving their sentences. However, since the beginning of the pandemic, those responsible for the prison system have implemented general strategies to contain the SARS-CoV-2 infection, such as the ban on visits by friends and family since April 29, 2020. The inmates remained in the establishment, without permission for work or study trips, or even for appointments and elective exams. Only cases of chronically ill and HIV-seropositive patients were treated otherwise.25.Among some solutions to mitigate the damage caused by covid-19 in the penitentiary system were the release of inmates at high risk of infection, such as those of advanced age, those convicted of non-violent crimes and those with clinical comorbidities, in addition to releasing prisoners in freedom parole, without serious crimes, with a remaining sentence of less than two years, always in an attempt to reduce the establishment\u2019s populationAs for the health, administrative and penitentiary staff, they were all submitted, still at the entrance, before entering the building, to temperature and oxygen saturation measurement. In cases of abnormality, they were instructed to seek the external health sector. In serious cases, just like the inmates, they were all sent by ambulance for an external assessment of their health.The major limitation of the study was the testing of penitentiary agents, who can work as day laborers or on duty. The strategy was to carry out tests within the two teams on duty. There was a loss of testing in six employees, removed from the service during the study.Another limitation concerns the evaluation method for detecting infection: the rapid test. The study did not have a qualified professional to evaluate the result obtained and associate it with the patient\u2019s clinical profile or other laboratory test results. The test in question was not developed for the detection of SARSCoV-2 antigens in human samples, thus, it is a qualitative assay.26and Switzerland27. However, studies conducted in Brazil29, France30and the United States31did not identify significant gender differences.The results of this survey indicated a higher serum prevalence (6.1%) among the study population; in individuals with a positive serological test (n = 63), with 69.8% asymptomatic. Regarding the prevalence of total antibodies in the inmate population, the prevalence was 5.8%, and, among civil servants, the prevalence was 7.5%. Differences in prevalence with regard to age group \u2013 12.5% among younger women, aged less than 20 years, and civil servants between 20 and 29 years old (12.5%) compared to civil servants aged 50 to 59 years old (12.8%) \u2013 did not appear to be significant. Some population-based studies have shown differences in prevalence rates between men and women, with a higher prevalence for men in New York33. It is known that most people with covid-19 develop mild or moderate symptoms (80%), around 15% develop severe symptoms, and among the symptoms most associated with covid-19, which at the time of the epidemiological survey were more frequent, are fever (83%\u201399% of patients), cough (59%\u201382%), fatigue (44%\u201370%), anorexia (40%\u201384%), dyspnea (31%\u201340%) and myalgias (11%\u201335%)34. Other nonspecific symptoms such as sore throat, headache and diarrhea have been reported35. Anosmia and ageusia usually appear at the onset of symptoms37.The observed results showed that there was no direct association between the presence or absence of symptoms with positive results in the study population. The symptoms most associated with positive cases for the prevalence of the SARS-Cov-2 antibody were chills, wheezing, chest pain, nausea/vomiting, loss of smell and loss of taste. When evaluating reports of symptoms presented by individuals participating in other surveys, with a positive test for SARS-CoV-2, it is observed that the report of anosmia and ageusia are the most frequent, followed by fatigue, cough, myalgia and diarrhea19.A nationwide epidemiological study, carried out with the prison population, during the period from April 14 to August 31, 2020, reported that there were reports of approximately 4,724 confirmed cases of covid-19. Only in the state of S\u00e3o Paulo, about 25.17% of the prison population was contaminated, indicating an alarming growth in the spread of the disease in this population and placing the state as having the highest rate of confirmed cases in an incarcerated population in all of Brazil21in relation to the incarcerated population through Recommendation 62/2020 of the National Council of Justice (CNJ)38. The Brazilian Society of Family and Community Medicine issued a document highlighting the need for other measures, such as educational actions, combating fake news, individual and collective hygiene, hygiene of environments, provision of information to family members, and cleaning of hygiene material for security professionals, involving prisoners and several penitentiary professionals39.The country complied with the measures proposed by the WHO40. In just 20 days, the numbers jumped from 1 to over 10041. It is noteworthy that, of the 603 cases of covid-19 in Brazilian prisons, 444 (74%) were in the Penitentiary Complex of Papuda42, in the Federal District, an institution that houses many imprisoned politicians and criminals with greater purchasing power. Such data shows an inequality in the penitentiary system that reproduces that of society in general, in which there is more access to tests for the new coronavirus for people who occupy a privileged social or financial position43.As of May 11, 2020, there were 603 confirmed cases of covid-19 in Brazilian prisons, resulting in 23 deaths44, and REACT245, conducted in the United Kingdom, reported a decrease in the percentage of the population that presents antibodies, as the pandemic progressed and vaccination actions intensified. Differences in results may occur due to the type of serological test used. In these two cited studies, rapid tests were used through lateral flow immunoassay, while in ours, a chemiluminescent immunoassay was used.As this cross-sectional study portrayed a moment of the disease among the inmates, possible fluctuations in the number of cases of covid-19 were not recorded, since longitudinal studies would be necessary. Some population-based studies, with Epicovid-19, carried out in Brazil29. In Brazil, there are few population-based seroprevalence studies. Only one of them is national in scope, with a sample that includes 133 municipalities distributed in the 27 federative units of Brazil \u2013 the Epicovid epidemiological survey \u2013 carried out at multiple moments of the pandemic51.Since April 2020, seroprevalence studies have been reported in several countries, including Brazil, China, France, Germany, Iran, Italy, Spain, England, Peru, Chile, Switzerland, Austria, and United StatesCovid-19 Newsletter, from SAP, provides the following data on the results of the rapid test of servers and inmates on the date of our research: in July 2020, 11.90% of positive cases among servers and 65.00% of the inmates; in August 2020, 11.48% positive cases and 68.47% of inmates; in September 2020, 12.73% of civil servants and 78.23% of inmates. It should also be considered that among the system\u2019s servants, 82% were male and 18% female, while among the prison population, 98% were male and 2% female during this period51.The The authors of the study interpret that the implementation of simple prevention measures in this institution, such as the use of masks (with appropriate changes), emphasis on hygiene, hand washing and social distancing, in addition to other strategies, such as suspending inmates\u2019 family and friends visits, cuts in elective medical appointments and outside work, led to the low prevalence of covid-19 in the Butantan CPP. 1. A partir de mar\u00e7o de 2020, tal infec\u00e7\u00e3o, chamada de covid-19 (coronavirus disease-2019), foi considerada pand\u00eamica. A partir desse momento, o mundo se deparou com n\u00fameros dram\u00e1ticos, sendo contabilizados mais de 544 milh\u00f5es de casos e mais de 6,33 milh\u00f5es de \u00f3bitos at\u00e9 junho de 20224. No mesmo per\u00edodo, o Brasil registrou mais de 32,1 milh\u00f5es de casos e mais de 670 mil \u00f3bitos5.Em dezembro de 2019, a Organiza\u00e7\u00e3o Mundial da Sa\u00fade (OMS) foi alertada sobre v\u00e1rios casos de pneumonia at\u00edpica causada por uma nova cepa de coronav\u00edrus, nominada SARS-CoV-2lockdowns, ordens para a popula\u00e7\u00e3o ficar em casa em determinados per\u00edodos cr\u00edticos da incid\u00eancia da doen\u00e7a, interrup\u00e7\u00e3o de aulas presenciais, divulga\u00e7\u00e3o de um guia universal de higieniza\u00e7\u00e3o das m\u00e3os, distanciamento f\u00edsico e uso de m\u00e1scaras faciais6.A pandemia da covid-19 trouxe expressivos desafios \u00e0 assist\u00eancia em sa\u00fade, bem como a necessidade de avan\u00e7os no conhecimento da epidemiologia da doen\u00e7a. Medidas para tentar conter o avan\u00e7o da dissemina\u00e7\u00e3o do SARS-CoV-2 foram adotadas em todo o mundo, como restri\u00e7\u00f5es a viagens internacionais, implementa\u00e7\u00e3o de A infec\u00e7\u00e3o pelo SARS-CoV-2 pode apresentar quadros cl\u00ednicos diversos, envolvendo desde casos assintom\u00e1ticos e oligossintom\u00e1ticos, at\u00e9 sintom\u00e1ticos graves. Se, por um lado, a ocorr\u00eancia de casos assintom\u00e1ticos e oligossintom\u00e1ticos tornaram as a\u00e7\u00f5es de mitiga\u00e7\u00e3o da transmiss\u00e3o mais desafiadoras para a interrup\u00e7\u00e3o da cadeia de transmiss\u00e3o, por outro, a frequ\u00eancia de casos graves impactou significativamente a capacidade assistencial dos servi\u00e7os de sa\u00fade dispon\u00edveis.8.Diante da complexidade para diagnosticar os casos de infec\u00e7\u00e3o pelo SARS-CoV-2 e da limita\u00e7\u00e3o de recursos para esse diagn\u00f3stico, a curva epidemiol\u00f3gica registrada, baseada na notifica\u00e7\u00e3o de casos, n\u00e3o expressava a dissemina\u00e7\u00e3o da infec\u00e7\u00e3o. Assim, alguns investigadores estimam subnotifica\u00e7\u00e3o em cerca de 10 a 12 vezes11.Diante desse cen\u00e1rio de pandemia, a OMS passou a recomendar a realiza\u00e7\u00e3o de inqu\u00e9ritos de soropreval\u00eancia com objetivo de estimar a soropositividade e, dessa forma, quantificar a real extens\u00e3o da infec\u00e7\u00e3o na popula\u00e7\u00e3o geral e em popula\u00e7\u00f5es espec\u00edficas \u2013com rela\u00e7\u00e3o tanto \u00e0 idade, como tamb\u00e9m a condi\u00e7\u00f5es socioecon\u00f4micas ou a outros fatores de risco \u2013, visando elaborar pol\u00edticas p\u00fablicas e interven\u00e7\u00f5es mais eficazes para o enfrentamento desse flagelo. Ou seja, o conhecimento da soropreval\u00eancia \u00e9 uma informa\u00e7\u00e3o estrat\u00e9gica em sa\u00fade p\u00fablica, especialmente em momentos de pandemia. Conhecer a imunidade da popula\u00e7\u00e3o, garantida por infec\u00e7\u00e3o ou mesmo vacina, permite melhor organiza\u00e7\u00e3o regional da organiza\u00e7\u00e3o em sa\u00fade. Inclusive, seguindo essa solicita\u00e7\u00e3o da OMS, o Minist\u00e9rio da Sa\u00fade lan\u00e7ou em 2020 um projeto de pesquisa com 211.129 brasileiros, em mais de 62 mil domic\u00edlios de 2474 munic\u00edpios, para estimar a soropreval\u00eancia alcan\u00e7ada por nossa popula\u00e7\u00e3o12. Nesse sentido, \u00e9 esperado que popula\u00e7\u00f5es privadas de liberdade se apresentem como de risco em situa\u00e7\u00f5es pand\u00eamicas. N\u00e3o obstante, considerando a transmiss\u00e3o do SARS-CoV-2 pelo ar, ambientes prisionais oferecem ainda maior risco quanto ao cont\u00e1gio. Estima-se, por exemplo que um caso positivo contamine at\u00e9 10 pessoas encarceradas, enquanto em condi\u00e7\u00f5es habituais esse n\u00famero n\u00e3o deve passar de 2-3 pessoas13A morbimortalidade pelo SARS-CoV-2 est\u00e1 relacionada a determinantes sociais em sa\u00fade e \u00e0 vulnerabilidade de algumas popula\u00e7\u00f5es espec\u00edficas. Estudo realizado em S\u00e3o Paulo, por exemplo, evidenciou maior mortalidade associada a menor n\u00edvel educacional e de renda, a vida em aglomera\u00e7\u00e3o familiar e a aglomerados subnormaisPublica\u00e7\u00f5es cient\u00edficas relacionadas \u00e0 incid\u00eancia de covid-19, bem como de outras doen\u00e7as infecciosas, na popula\u00e7\u00e3o prisional s\u00e3o escassas, apontando para um poss\u00edvel desinteresse por esse tema pela comunidade cient\u00edfica e pelo poder p\u00fablico, o que pode resultar do estigma e da dificuldade de acesso a esse grupo.14. Essas particularidades aumentaram a suscetibilidade destes \u00e0 r\u00e1pida dissemina\u00e7\u00e3o da covid-19, fato bem documentado para outras doen\u00e7as infecciosas como influenza, tuberculose e outras doen\u00e7as respirat\u00f3rias16. Al\u00e9m de ser um grande risco para as pessoas privadas de liberdade, a alta incid\u00eancia de covid-19 em pres\u00eddios serviria de fonte de infec\u00e7\u00e3o para a popula\u00e7\u00e3o geral, considerando-se a movimenta\u00e7\u00e3o de funcion\u00e1rios e todo o c\u00edrculo social envolvido17. O coronav\u00edrus pode transitar entre as grades do pr\u00f3prio sistema prisional, haja vista as transfer\u00eancias de detentos entre os m\u00faltiplos estabelecimentos18. Somente no estado de S\u00e3o Paulo a popula\u00e7\u00e3o prisional estimada em 2020 era cerca de 231.287 indiv\u00edduos19.Uma preocupa\u00e7\u00e3o adicional a esse segmento social inclui as condi\u00e7\u00f5es nas unidades prisionais do Brasil, com celas superlotadas e pouco ventiladas, acesso limitado a \u00e1gua e a saneamento b\u00e1sico e unidades prisionais carentes de m\u00f3dulos de sa\u00fade estruturados, contemplando salas de atendimento espalhadas por onde houver espa\u00e7o dispon\u00edvel e a locomo\u00e7\u00e3o frequente dos detentos pelas \u00e1reas f\u00edsicas das institui\u00e7\u00f5es21No contexto de superlota\u00e7\u00e3o, muitas vezes presentes das pris\u00f5es, \u00e9 dif\u00edcil evitar a aglomera\u00e7\u00e3o e manter condi\u00e7\u00f5es refor\u00e7adas de higiene. Soma-se a isso o fato de a estrutura f\u00edsica das unidades prisionais, em grande parte, n\u00e3o ter sido planejada para a circula\u00e7\u00e3o de ar e o acesso \u00e0 luz solar. Por fim, o isolamento social fica ainda mais desafiador, pois, al\u00e9m de novos indiv\u00edduos ingressando no sistema diariamente, os servidores transitam em diferentes espa\u00e7os, j\u00e1 que retornam \u00e0s suas casas ap\u00f3s o expediente dentro das unidades10.A popula\u00e7\u00e3o carcer\u00e1ria \u00e9 muito vulner\u00e1vel a problemas f\u00edsicos e mentais, tanto pela fragilidade causada pelo pr\u00f3prio isolamento social, quanto pelo estresse de priva\u00e7\u00e3o da liberdade. Ademais, \u00e9 muito mais suscet\u00edvel \u00e0s doen\u00e7as infectocontagiosasAssim, estimar a preval\u00eancia da exposi\u00e7\u00e3o ao v\u00edrus SARS-CoV-2 em indiv\u00edduos vivendo em restri\u00e7\u00e3o de liberdade foi fundamental para avaliar a velocidade de dissemina\u00e7\u00e3o da doen\u00e7a, bem como tomar decis\u00f5es que minimizassem essa propaga\u00e7\u00e3o. Com o intuito de avaliar a soropreval\u00eancia de SARS-CoV-2 em estabelecimentos prisionais, o Instituto Butantan realizou um inqu\u00e9rito soroepidemiol\u00f3gico nas reeducandas do Centro de Progress\u00e3o Penitenci\u00e1ria (CPP) do Butantan \u201cMarina Marigo Cardoso de Oliveira\u201d, munic\u00edpio de S\u00e3o Paulo, Brasil.Estudo transversal realizado entre os meses de junho e setembro de 2020, planejado para estimar a preval\u00eancia de anticorpos contra o SARS-CoV-2 na popula\u00e7\u00e3o do CPP do Butantan.O CPP do Butantan \u00e9 um pres\u00eddio feminino semiaberto cuja miss\u00e3o \u00e9 abrigar detentas em preparo ao conv\u00edvio social, antes da liberdade final ap\u00f3s o cumprimento de pena. Recebe mulheres privadas de liberdade (reeducandas) provenientes de v\u00e1rias pris\u00f5es femininas do Estado de S\u00e3o Paulo: Penitenci\u00e1ria Feminina (PF) do Estado; PF da Capital; PF de Trememb\u00e9, PF de Campinas, PF Franco da Rocha, PF de Mogi Gua\u00e7u, CPP de S\u00e3o Miguel Paulista, dentre outras. Tem capacidade para receber 1.110 mulheres e no momento da pandemia acolhia 879 indiv\u00edduos.O local apresenta uma arquitetura vertical, com quatro pr\u00e9dios de quatro andares, acessados somente por escadas, e um quinto pr\u00e9dio de dois andares, onde se localiza o setor de gerenciamento da sa\u00fade, no piso t\u00e9rreo. Os pacientes que necessitam de mais cuidados m\u00e9dicos permanecem no mesmo pr\u00e9dio, por\u00e9m no primeiro andar, adjacente ao centro de cuidados em sa\u00fade.A popula\u00e7\u00e3o do estudo constituiu-se das reeducandas residentes do CPP do Butant\u00e3 e dos funcion\u00e1rios que atuaram l\u00e1 durante a realiza\u00e7\u00e3o da pesquisa, totalizando 879 reeducandas, 159 funcion\u00e1rios e prestadores de servi\u00e7os. Na \u00e9poca de realiza\u00e7\u00e3o do estudo, as visitas estavam suspensas como medida de preven\u00e7\u00e3o \u00e0 contamina\u00e7\u00e3o pelo SARS-CoV-2.Ser reeducandas do estabelecimento, ser funcion\u00e1rios do CPP do Butantan do setor da sa\u00fade ; ser funcion\u00e1rios administrativos ou agentes penitenci\u00e1rios, independentemente da idade, que demonstrassem interesse em participar do estudo por meio da assinatura do termo de consentimento livre e esclarecido (TCLE).Potenciais participantes que n\u00e3o demonstrem interesse em participar do estudo.A popula\u00e7\u00e3o em estudo caracteriza-se por ser de grande rotatividade, uma vez que inclui reeducandas em regime semiaberto em fase final do cumprimento de pena. No entanto, desde o in\u00edcio da pandemia, os respons\u00e1veis pelo sistema carcer\u00e1rio implementaram estrat\u00e9gias para conter a infec\u00e7\u00e3o pelo SARS-CoV-2. Assim, foram proibidas as visitas de amigos e familiares desde 29 de abril de 2020. Al\u00e9m disso, as reeducandas n\u00e3o sa\u00edram para trabalhar, estudar e nem para realizar consultas e exames eletivos.Ademais, foi realizada palestra explicativa na capela do sistema prisional, para todos os funcion\u00e1rios e para as representantes da reeducandas (aproximadamente 250 pessoas), sobre a doen\u00e7a, com estrat\u00e9gias de controle da infec\u00e7\u00e3o, incluindo orienta\u00e7\u00f5es quanto \u00e0 import\u00e2ncia do uso de m\u00e1scaras, limpeza das m\u00e3os com \u00e1lcool em gel e isolamento social. De imediato, recomendou-se o uso de m\u00e1scara, com trocas estabelecidas no m\u00e1ximo a cada tr\u00eas horas, e distanciamento para todos os funcion\u00e1rios e reeducandas. Ressalta-se que as m\u00e1scaras foram produzidas no pr\u00f3prio pres\u00eddio e fornecidas para todos.Gestantes, idosas e doentes cr\u00f4nicos foram colocados em ala isolada pr\u00f3xima ao setor da sa\u00fade por tratar-se de grupo do mais alto risco dentre as pessoas privadas de liberdade. Al\u00e9m disso, todos os servidores foram treinados para realizar a triagem dos casos suspeitos. Mesmo na aus\u00eancia de servidores da sa\u00fade, todos sabiam triar casos. Ainda foi realizado estoque de insumos  para garantir que todos os procedimentos pudessem ser feitos em condi\u00e7\u00f5es adequadas, minimizando riscos de transmiss\u00e3o.O Setor da Sa\u00fade e a Diretoria do CPP do Butantan criaram ainda estrat\u00e9gias especificas de conten\u00e7\u00e3o da infec\u00e7\u00e3o, suspendendo consultas e exames eletivos, exceto nos casos de doentes cr\u00f4nicos e soropositivos para HIV. Nos casos de urg\u00eancia, as reeducandas eram encaminhadas ao hospital e, t\u00e3o logo retornassem, permaneciam em isolamento durante quinze dias.No per\u00edodo da pandemia dois andares, com celas individuais, foram separados da popula\u00e7\u00e3o comum para casos suspeitos de covid-19. As reeducandas sintom\u00e1ticas foram isoladas com controle de dados vitais, press\u00e3o arterial, pulso e satura\u00e7\u00e3o de oxig\u00eanio. Nas ocorr\u00eancias de instabilidade hemodin\u00e2mica e queda da satura\u00e7\u00e3o de oxig\u00eanio, elas eram encaminhadas prontamente para os servi\u00e7os externos de urg\u00eancia. Ap\u00f3s o retorno ao sistema prisional, permaneciam em isolamento por 15 dias em cela individual.Funcion\u00e1rios da sa\u00fade e administrativos e agentes penitenci\u00e1rios eram submetidos, ainda na portaria, antes da entrada no pr\u00e9dio, \u00e0 mensura\u00e7\u00e3o da temperatura e satura\u00e7\u00e3o de oxig\u00eanio. Se houvesse qualquer anormalidade, eram orientados a procurar o setor externo de sa\u00fade. Nos casos graves, assim como as reeducandas, eram encaminhados de ambul\u00e2ncia para avalia\u00e7\u00e3o externa de sa\u00fade.Os potenciais participantes de cada subgrupo foram convidados a participar do estudo pelos m\u00e9dicos pesquisadores respons\u00e1veis pelo centro gerenciador de sa\u00fade da institui\u00e7\u00e3o. Todos os procedimentos do estudo foram realizados no pr\u00f3prio CPP.swab para realiza\u00e7\u00e3o do teste de RT-PCR, apenas para indiv\u00edduos que relatassem sintomas no momento do inqu\u00e9rito. As reeducandas foram testadas seguindo um fluxo organizado dos quatro pr\u00e9dios e pelos quatro andares.Ap\u00f3s assinarem o TCLE, os participantes foram submetidos \u00e0 coleta de amostra biol\u00f3gica: de sangue para o teste sorol\u00f3gico r\u00e1pido, para todos os participantes, e de secre\u00e7\u00e3o de nasofaringe e orofaringe por meio de O tipo de amostra coletada variou na depend\u00eancia do subgrupo ao qual o participante fora inserido no estudo. Participantes assintom\u00e1ticos tiveram a coleta da amostra de sangue por pun\u00e7\u00e3o venosa (com separa\u00e7\u00e3o do soro) para uso no teste r\u00e1pido. Participantes apresentando algum sintoma suspeito de infec\u00e7\u00e3o foram alocados no subgrupo de sintom\u00e1ticos e tiveram o material para swab nasofar\u00edngeo ou orofar\u00edngeo para an\u00e1lise de RT-PCR aferido, al\u00e9m da coleta de sangue.As amostras de sangue coletadas foram reservadas por tempo m\u00ednimo de 30-45 minutos, em temperatura ambiente, para seguirem \u00e0 an\u00e1lise. Caso n\u00e3o fossem processadas imediatamente, ap\u00f3s os 45 minutos, as amostras eram mantidas sob refrigera\u00e7\u00e3o de 2\u00b0C a 8\u00b0C por no m\u00e1ximo 72h ap\u00f3s a coleta, quando eram ent\u00e3o avaliadas.swab eram armazenadas por at\u00e9 72h sob refrigera\u00e7\u00e3o, 2\u00b0C a 8\u00b0C, at\u00e9 o processamento e an\u00e1lise. Caso essas amostras n\u00e3o fossem processadas dentro de 72h, elas eram ser mantidas congeladas a -70\u00b0C at\u00e9 o momento de processamento e an\u00e1lise.As amostras de secre\u00e7\u00e3o coletadas com o 22. O processamento das amostras coletadas foi realizado no Laborat\u00f3rio de Diagn\u00f3sticos de covid-19 do Instituto Butantan.O teste r\u00e1pido fornecido para o estudo, com base no Parecer T\u00e9cnico 03/2020 \u2013 DHEM/DIR GERAL/HCF, foi utilizado para a realiza\u00e7\u00e3o da triagem sorol\u00f3gica em casos suspeitos de infec\u00e7\u00e3o por SARS-CoV-2. Resultados positivos indicam que houve exposi\u00e7\u00e3o pr\u00e9via do participante ao v\u00edrus SARS-CoV-2, por\u00e9m resultados negativos n\u00e3o descartam infec\u00e7\u00e3o assintom\u00e1tica ou contato pr\u00e9vio com o v\u00edrus ap\u00f3s longos per\u00edodos de tempo. O teste apresenta sensibilidade de 98,11% e especificidade de 99,72%, de acordo com os dados presentes na bula do teste23.A realiza\u00e7\u00e3o do RT-PCR seguiu o protocolo de execu\u00e7\u00e3o em utiliza\u00e7\u00e3o no Instituto Butantan para o diagn\u00f3stico da infec\u00e7\u00e3o pelo SARS-CoV-2Foram realizadas entrevistas com os participantes com coleta de dados de identifica\u00e7\u00e3o, sociodemogr\u00e1ficos e cl\u00ednicos, registrados em formul\u00e1rio padronizado no mesmo dia da coleta das amostras biol\u00f3gicas. Esses dados, bem como os resultados dos testes, foram inseridos em um sistema eletr\u00f4nico de capta\u00e7\u00e3o de informa\u00e7\u00f5es  elaborado especificamente para esse inqu\u00e9rito. Todos os participantes receberam os laudos dos resultados individuais e foram orientados individualmente de acordo com o resultado obtido. O gerenciamento do banco de dados e de an\u00e1lise dos resultados foi realizado pelo Centro de Seguran\u00e7a Cl\u00ednica e Gest\u00e3o de Risco do Instituto Butantan.Os dados oriundos deste estudo foram analisados utilizando o programa estat\u00edstico Stata vers\u00e3o 13.0 .Na an\u00e1lise descritiva das vari\u00e1veis sociodemogr\u00e1ficas, cl\u00ednicas e laboratoriais, calcularam-se a preval\u00eancia de anticorpos contra o SARS-CoV-2 e seus respectivos intervalos com 95% de confian\u00e7a (IC95%) para cada subgrupo da popula\u00e7\u00e3o do estudo (reeducandas e funcion\u00e1rios). Foi utilizado o teste qui-quadrado para testar associa\u00e7\u00e3o entre os subgrupos da popula\u00e7\u00e3o estudada e a preval\u00eancia de anticorpos contra o SARS-CoV-2, tendo como n\u00edvel de signific\u00e2ncia estat\u00edstica 5%.Este estudo foi conduzido em plena conformidade com os regulamentos ou diretrizes \u00e9ticas brasileiras e internacionais pertinentes, e foi aprovado pela Comiss\u00e3o de \u00c9tica para An\u00e1lise de Projetos de Pesquisa (CAPPesq) do Hospital das Cl\u00ednicas da Faculdade de Medicina da Universidade de S\u00e3o Paulo (USP).Foram coletadas informa\u00e7\u00f5es de 1.038 participantes. Dentre eles, 879 reeducandas e 159 servidores do CPP do Butantan. A mediana de idade na amostra geral foi de 36 anos; entre as reeducandas foi de 34,3 anos e entre os servidores 42,2 anos. O grupo de reeducandas foi formado por participantes do sexo feminino em sua totalidade. Entre os servidores, 82,8% eram do sexo feminino .Na amostra geral, 45,1% eram pardos, 38,7% brancos e 12,6% pretos. Entre as reeducandas, 49,4% eram pardas, 33,8% eram brancas e 12,9% eram pretas, e entre os servidores 66% eram brancos, 21,4% pardos e 11,3% pretos .A preval\u00eancia de anticorpos totais contra SARS-Cov-2 encontrada na popula\u00e7\u00e3o geral do estudo foi de 6,1% . Especificamente entre as reeducandas, a preval\u00eancia foi de 5,8% , e entre os servidores, 7,5% .Entre as reeducandas, a preval\u00eancia foi detectada com maior frequ\u00eancia  em mulheres mais jovens, menores de 20 anos. Entre as mulheres de 20 a 29 anos a preval\u00eancia foi de 8,1% ; entre as de 30 a 39 anos, 40 a 49 anos e 50 a 59 anos, foi de 6,1%, 2,5% e 3,2 %, respectivamente; entre as maiores de 60 anos a preval\u00eancia foi de 8,3% ). A soropositividade foi maior entre as mulheres brancas  do que entre as pretas e pardas .A preval\u00eancia observada entre os servidores foi maior tamb\u00e9m nos extremos de idade da amostra, sendo 12,5% IC95%1,6\u201338,3) entre os servidores de 20 a 29 anos e 12,8%  entre os de 50 a 59 anos. Maior preval\u00eancia foi observada entre os servidores do sexo masculino em rela\u00e7\u00e3o \u00e0s do sexo feminino, sendo 13,8% e 6,2%, respectivamente. Na popula\u00e7\u00e3o branca, a preval\u00eancia foi de 9,5%, e na preta, 3,8%  e 3.8,3 entreA 24. A infraestrutura dos pres\u00eddios, em geral, \u00e9 prop\u00edcia \u00e0 propaga\u00e7\u00e3o de doen\u00e7as infectocontagiosas, principalmente respirat\u00f3rias, como a covid-19. Durante a testagem as detentas n\u00e3o receberam visita de familiares e amigos, nem tiveram permiss\u00e3o de sair do pres\u00eddio, por\u00e9m ficaram, ainda assim, expostas, pois os agentes e funcion\u00e1rios saem e retornam frequentemente das instala\u00e7\u00f5es.A popula\u00e7\u00e3o carcer\u00e1ria \u00e9 muito vulner\u00e1vel a problemas f\u00edsicos e mentais, tanto pela fragilidade causada pelo pr\u00f3prio isolamento social, quanto pelo estresse de priva\u00e7\u00e3o da liberdade, al\u00e9m de ser muito mais suscet\u00edvel \u00e0s doen\u00e7as infectocontagiosas24.Na hist\u00f3ria das infec\u00e7\u00f5es virais cabe ressaltar que, em 1918, durante a gripe espanhola, a doen\u00e7a se espalhou rapidamente como resultado do confinamento dos internos, com incapacidade de isolamento dos doentes, fazendo com que, na pris\u00e3o de San Quentin, estado da Calif\u00f3rnia, nos Estados Unidos, metade dos 1.900 presos contra\u00edssem a doen\u00e7a durante a primeira onda da epidemia: 150 infectados, rapidamente passaram para 700 detentos infectados ao dia24.O distanciamento torna-se invi\u00e1vel e os riscos de infec\u00e7\u00e3o aumentam, tendo como consequ\u00eancia casos graves e morte. No CPP do Butantan, essas duas consequ\u00eancias foram evitadas, j\u00e1 que a restri\u00e7\u00e3o de visitas e as medidas de higiene foram tomadas eficientemente, a tempo de minimizar a infec\u00e7\u00e3o das detentas durante a realiza\u00e7\u00e3o do estudoEntretanto, a popula\u00e7\u00e3o em estudo apresenta grande rotatividade e deslocamento, uma vez que inclui reeducandas em regime semiaberto e que tem permiss\u00e3o para trabalhar extramuros na fase final do cumprimento de suas penas. No entanto, desde o in\u00edcio da pandemia, os respons\u00e1veis pelo sistema carcer\u00e1rio implementaram estrat\u00e9gias gerais para conter a infec\u00e7\u00e3o pelo SARS-CoV-2, como a proibi\u00e7\u00e3o de visitas de amigos e familiares desde 29 de abril de 2020. As reeducandas permaneceram no estabelecimento, sem permiss\u00e3o para as sa\u00eddas de trabalho ou estudo, ou ainda para consultas e exames eletivos. Apenas casos de doentes cr\u00f4nicos e soropositivos para HIV foram tratados diferenciadamente.25.Entre algumas solu\u00e7\u00f5es para mitigar danos do covid-19 no sistema penitenci\u00e1rio constaram a libera\u00e7\u00e3o de detentos de alto risco de infec\u00e7\u00e3o, tais como aqueles com idade avan\u00e7ada, os condenados por crimes n\u00e3o violentos e os portadores de comorbidades cl\u00ednicas, al\u00e9m de liberar encarcerados em liberdade condicional, sem crimes graves, com pena restante menor do que dois anos, sempre na tentativa de diminuir a popula\u00e7\u00e3o do estabelecimentoQuanto aos funcion\u00e1rios da sa\u00fade, administrativos e agentes penitenci\u00e1rios, todos eram submetidos, ainda na portaria, antes da entrada no pr\u00e9dio, \u00e0 mensura\u00e7\u00e3o da temperatura e satura\u00e7\u00e3o de oxig\u00eanio. Em casos de anormalidade, eles eram orientados a procurar o setor externo de sa\u00fade. Nos casos graves, assim como as reeducandas, todos eram encaminhados, de ambul\u00e2ncia, para avalia\u00e7\u00e3o externa de sua sa\u00fade.A grande limita\u00e7\u00e3o do estudo foi a testagem dos agentes penitenci\u00e1rios, que podem trabalhar como diaristas ou plantonistas. A estrat\u00e9gia foi realizar a testagens dentro das duas equipes de plant\u00e3o. Houve uma perda de testagem em seis funcion\u00e1rios, afastados do servi\u00e7o, durante a realiza\u00e7\u00e3o do estudo.Outra limita\u00e7\u00e3o diz respeito ao m\u00e9todo de avalia\u00e7\u00e3o para detec\u00e7\u00e3o da infec\u00e7\u00e3o: o teste r\u00e1pido. O estudo n\u00e3o dispunha de um profissional qualificado para avaliar o resultado obtido e associ\u00e1-lo ao perfil cl\u00ednico do paciente ou a outros resultados de exames laboratoriais. O teste em quest\u00e3o n\u00e3o foi desenvolvido para detec\u00e7\u00e3o de ant\u00edgenos de SARSCoV-2 em amostras humanas, assim, trata-se de um ensaio qualitativo.26e na Su\u00ed\u00e7a27. Entretanto, estudos realizados no Brasil29, na Fran\u00e7a30 e nos Estados Unidos31 n\u00e3o identificaram diferen\u00e7as significativas entre os sexos.Os resultados desta pesquisa indicaram uma soropreval\u00eancia mais alta  entre a popula\u00e7\u00e3o do estudo; nos indiv\u00edduos com teste sorol\u00f3gico positivo (n = 63), sendo que 69,8% se apresentavam assintom\u00e1ticos. Em rela\u00e7\u00e3o \u00e0 preval\u00eancia de anticorpos totais na popula\u00e7\u00e3o de reeducandas, a preval\u00eancia foi de 5,8%, e, entre os servidores, a preval\u00eancia foi de 7,5%. As diferen\u00e7as de preval\u00eancia com rela\u00e7\u00e3o \u00e0 faixa et\u00e1ria \u2013 12,5% entre as mulheres mais jovens, com idade inferior a 20 anos, e servidores entre 20 e 29 anos  comparados aos servidores de 50 a 59 anos  \u2013 n\u00e3o pareceram ser significativas. Alguns estudos de base populacional demonstraram diferen\u00e7as nas taxas de preval\u00eancia entre homens e mulheres, com maior preval\u00eancia para homens em Nova York33. Sabe-se que a maioria das pessoas com covid-19 desenvolvem sintomas leves ou moderados (80%), em torno de 15% desenvolvem grave, e entre os sintomas mais associados ao covid-19, que no momento do inqu\u00e9rito epidemiol\u00f3gico eram mais frequentes, est\u00e3o febre (83\u201399% dos pacientes), tosse (59%\u201382%), fadiga (44%\u201370%), anorexia (40%\u201384%), dispneia (31%\u201340%) e mialgias (11%\u201335%)34. Outros sintomas inespec\u00edficos, como dor de garganta, cefaleia e diarreia t\u00eam sido relatados35. Anosmia e ageusia normalmente s\u00e3o apresentados no in\u00edcio dos sintomas37.Os resultados observados mostraram que n\u00e3o houve associa\u00e7\u00e3o direta entre a presen\u00e7a ou aus\u00eancia de sintomas com os resultados positivos na popula\u00e7\u00e3o do estudo. Os sintomas mais associados com os casos positivos para a preval\u00eancia do anticorpo SARS-Cov-2 foram calafrios, chiado, dor no peito, n\u00e1usea/v\u00f4mitos, perda de olfato e perda de paladar. Quando se avaliam relatos de sintomas apresentados por indiv\u00edduos participantes de outros inqu\u00e9ritos, com teste positivo para SARS-CoV-2, observa-se que o relato de anosmia e ageusia s\u00e3o os mais frequentes, seguidos de fadiga, tosse, mialgia e diarreia19.Um estudo epidemiol\u00f3gico de abrang\u00eancia nacional, realizado com a popula\u00e7\u00e3o prisional, durante o per\u00edodo de 14 de abril a 31 de agosto de 2020, relatou que houve relatos de cerca de 4.724 casos confirmados de covid-19. Somente no estado de S\u00e3o Paulo, cerca de 25,17% da popula\u00e7\u00e3o prisional se contaminou, indicando crescimento alarmante de propaga\u00e7\u00e3o da doen\u00e7a nessa popula\u00e7\u00e3o e colocando o estado como detentor da maior taxa de casos confirmados em popula\u00e7\u00e3o isenta de liberdade em todo o Brasil21em rela\u00e7\u00e3o \u00e0 popula\u00e7\u00e3o privada de liberdade por meio da Recomenda\u00e7\u00e3o 62/2020 do Conselho Nacional de Justi\u00e7a (CNJ)38. A Sociedade Brasileira de Medicina de Fam\u00edlia e Comunidade emitiu um documento salientando a necessidade de outras medidas, como a\u00e7\u00f5es educativas, combate \u00e0s fake news, higiene individual e coletiva, higiene dos ambientes, fornecimento de informa\u00e7\u00f5es aos familiares e limpeza do material de higiene dos profissionais de seguran\u00e7a, envolvendo prisioneiros e diversos profissionais penitenci\u00e1rios39.O pa\u00eds acatou as medidas propostas pela OMS40. Com o decorrer de apenas 20 dias, os n\u00fameros saltaram de 1 para mais de 10041. Chama a aten\u00e7\u00e3o que, dos 603 casos de covid-19 em pres\u00eddios brasileiros, 444 (74%) estavam no Complexo Penitenci\u00e1rio da Papuda42, no Distrito Federal, institui\u00e7\u00e3o que abriga muitos pol\u00edticos presos e criminosos de maior poder aquisitivo. O dado evidencia uma desigualdade no sistema penitenci\u00e1rio que reproduz a da sociedade em geral, na qual h\u00e1 mais acesso a testes para o novo coronav\u00edrus para as pessoas que ocupam posi\u00e7\u00e3o social ou financeira privilegiadas43.At\u00e9 o dia 11 de maio de 2020, havia 603 casos de covid-19 confirmados em pris\u00f5es brasileiras, resultando em 23 \u00f3bitos44, e o REACT245, conduzido no Reino Unido, reportaram diminui\u00e7\u00e3o do percentual da popula\u00e7\u00e3o que apresenta anticorpos, conforme a pandemia avan\u00e7ou e as a\u00e7\u00f5es de vacina\u00e7\u00e3o se intensificaram. Diferen\u00e7as nos resultados podem ocorrer devido ao tipo de teste sorol\u00f3gico utilizado. Nesses dois estudos citados foram utilizados testes r\u00e1pidos por meio de imunoensaio de fluxo lateral, enquanto no nosso foi empregada imunoiluminesc\u00eancia.Como este estudo transversal retratou um momento da doen\u00e7a entre as reeducandas, poss\u00edveis oscila\u00e7\u00f5es nos n\u00fameros de casos de covid-19 n\u00e3o foram registrados, j\u00e1 que para isso seriam necess\u00e1rios estudos longitudinais. Alguns estudos de base populacional, com o Epicovid-19, realizado no Brasil29. No Brasil, h\u00e1 poucos estudos de soropreval\u00eancia de base populacional. Apenas um deles \u00e9 de abrang\u00eancia nacional, com amostra que inclui 133 munic\u00edpios distribu\u00eddos nas 27 unidades federativas do Brasil \u2013 o inqu\u00e9rito epidemiol\u00f3gico Epicovid \u2013 realizado em m\u00faltiplos momentos da pandemia51.Desde abril de 2020, estudos de soropreval\u00eancia t\u00eam sido reportados em v\u00e1rios pa\u00edses, incluindo Brasil, China, Fran\u00e7a, Alemanha, Ir\u00e3, It\u00e1lia, Espanha, Inglaterra, Peru, Chile, Su\u00ed\u00e7a, \u00c1ustria e Estados Unidos51.O Boletim Informativo Covid-19, da SAP, aponta os seguintes dados sobre os resultados de teste r\u00e1pido dos servidores e detentos na data da nossa pesquisa: em julho de 2020, 11,90% dos casos positivos entre os servidores e 65,00% dos detentos; em agosto de 2020, 11,48% casos positivos e 68,47% dos detentos; em setembro de 2020, 12,73% dos servidores e 78,23% dos detentos. Deve-se considerar ainda que entre os servidores do sistema 82% eram do sexo masculino e 18% do feminino, enquanto que entre a popula\u00e7\u00e3o carcer\u00e1ria 98% era do masculino e 2% do feminino nesse per\u00edodoOs autores do estudo interpretam que a implementa\u00e7\u00e3o de medidas de preven\u00e7\u00e3o simples, nessa institui\u00e7\u00e3o, como o uso de m\u00e1scaras (com trocas adequadas), \u00eanfase na higiene, lavagem das m\u00e3os e distanciamento social, al\u00e9m de outras estrat\u00e9gias, como suspens\u00e3o de visitas de familiares e amigos das reeducandas, cortes de consultas m\u00e9dicas eletivas e do trabalho externo, levou \u00e0 baixa preval\u00eancia da covid-19 no CPP do Butantan."}
+{"text": "Resultados falsos positivos na mamografia de rastreamento s\u00e3o comuns a essa interven\u00e7\u00e3o e trazem \u00f4nus para as mulheres e o sistema de sa\u00fade. O objetivo deste estudo foi estimar o risco de resultado falso positivo no rastreamento mamogr\u00e1fico brasileiro com base em dados de sistemas de informa\u00e7\u00e3o do Sistema \u00danico de Sa\u00fade (SUS). Foi realizado estudo de coorte hist\u00f3rica de mulheres de 40-69 anos, que realizaram mamografia de rastreamento e exame histopatol\u00f3gico de mama no SUS, nos anos de 2017 a 2019. A taxa de resultados falsos positivos foi estimada a partir da preval\u00eancia de resultados BI-RADS alterados na mamografia de rastreamento e da propor\u00e7\u00e3o de resultados benignos no exame histopatol\u00f3gico de mama. Das 10.671 mulheres com exame histopatol\u00f3gico no SUS, 46,2% apresentaram resultado benigno, sendo essa propor\u00e7\u00e3o significativamente maior em mulheres de 40-49 anos comparada \u00e0 de mulheres de 50-69 anos. A estimativa de resultados falsos positivos foi de 8,18 casos por 100 mulheres na faixa et\u00e1ria de 40-49 anos, e de 6,06 por 100 mulheres na faixa de 50-69 anos. Essas informa\u00e7\u00f5es s\u00e3o \u00fateis aos gestores na avalia\u00e7\u00e3o de programas de rastreamento do c\u00e2ncer de mama, assim como aos profissionais de sa\u00fade, para que orientem a mulher sobre as implica\u00e7\u00f5es do rastreamento mamogr\u00e1fico. O rastreamento mamogr\u00e1fico \u00e9 uma das principais estrat\u00e9gias para a detec\u00e7\u00e3o precoce do c\u00e2ncer de mama e consiste na realiza\u00e7\u00e3o peri\u00f3dica de mamografia por mulheres assintom\u00e1ticas O Brasil oferece mamografia de rastreamento, de forma oportun\u00edstica, na rotina da aten\u00e7\u00e3o prim\u00e1ria do Sistema \u00danico de Sa\u00fade (SUS) ,,Estudos sobre a efetividade do rastreamento apontam que o benef\u00edcio desejado de redu\u00e7\u00e3o da mortalidade por c\u00e2ncer de mama, estimados em torno de 20% por estudos internacionais, convive com riscos e malef\u00edcios comuns ao processo e que devem ser conhecidos pelas mulheres ,Dentre os riscos mais comuns, destacam-se os resultados incorretos, principalmente os falsos positivos, decorrentes de um resultado anormal que n\u00e3o se confirma como c\u00e2ncer. Tais resultados imp\u00f5em a necessidade de exames adicionais, como novas imagens e bi\u00f3psias, que ocasionam danos psicol\u00f3gicos, como ansiedade, estresse, e danos f\u00edsicos decorrentes de exames invasivos ,,,O debate sobre as implica\u00e7\u00f5es do rastreamento mamogr\u00e1fico vem avan\u00e7ando em v\u00e1rios pa\u00edses, como Canad\u00e1, Estados Unidos e pa\u00edses da Europa. Destacadamente, a magnitude e as consequ\u00eancias do falso positivo na disposi\u00e7\u00e3o da mulher para o rastreio subsequente, na qualidade de vida, no uso de servi\u00e7os de sa\u00fade e no risco de c\u00e2ncer de mama s\u00e3o tematizados em pesquisas contempor\u00e2neas Com o avan\u00e7o da implementa\u00e7\u00e3o do Sistema de Informa\u00e7\u00e3o do C\u00e2ncer (SISCAN) no Brasil, sistema que registra dados de mamografias e exames citopatol\u00f3gicos e histopatol\u00f3gicos de mama realizados no SUS, individualizados por mulher Diante desse contexto, o presente estudo tem como objetivo estimar o risco de resultado falso positivo no rastreamento mamogr\u00e1fico brasileiro com base em dados de sistemas de informa\u00e7\u00e3o do SUS. Estudo de coorte hist\u00f3rica de mulheres de 40-69 anos, que realizaram mamografia de rastreamento e exame histopatol\u00f3gico de mama no SUS, com a reconstitui\u00e7\u00e3o do seguimento feita pelo relacionamento determin\u00edstico de bases de dados secund\u00e1rios, para estimar a taxa de falsos positivos na mamografia.Foram utilizados os dados de mamografia e de exame histopatol\u00f3gico de mama registrados no SISCAN Breast Imaging Reporting and Data System (BI-RADS), do Col\u00e9gio Americano de Radiologia O SISCAN utiliza a classifica\u00e7\u00e3o radiol\u00f3gica do Adicionalmente, foram utilizados dados de exames citopatol\u00f3gicos de mama registrados no SISCAN para excluir mulheres com resultado maligno anterior \u00e0 mamografia de rastreamento. Tamb\u00e9m foi utilizado o PAINEL-Oncologia, ferramenta que integra informa\u00e7\u00f5es de diagn\u00f3stico e primeiro tratamento de c\u00e2ncer a partir de outros sistemas de informa\u00e7\u00e3o j\u00e1 consolidados, mediante o n\u00famero do cart\u00e3o SUS Mulheres de 40-69 anos que realizaram mamografia de rastreamento, nos anos de 2017 a 2019 no SUS. Foi selecionada a primeira mamografia da mulher nesse per\u00edodo.Foram exclu\u00eddas as mulheres com registro de informa\u00e7\u00e3o de tratamento radioter\u00e1pico pr\u00e9vio nas mamas e mulheres com n\u00f3dulo mam\u00e1rio maior que 2cm. Sup\u00f4s-se que n\u00f3dulos na mamografia de rastreamento acima de 2cm s\u00e3o provavelmente les\u00e3o palp\u00e1vel A partir das informa\u00e7\u00f5es registradas no SISCAN foi formada uma base de dados com mulheres que fizeram a primeira mamografia de rastreamento no per\u00edodo entre 2017 e 2019. Para as mulheres com resultado anormal, sendo considerado os BI-RADS 0, 3, 4 e 5, foi feito relacionamento determin\u00edstico pelo n\u00famero do cart\u00e3o SUS com os registros de exames histopatol\u00f3gicos de mama dessas mulheres, realizados at\u00e9 o primeiro trimestre de 2021.O diagn\u00f3stico de c\u00e2ncer foi estabelecido com o resultado de malignidade do exame histopatol\u00f3gico de mama. Nas situa\u00e7\u00f5es em que havia registro no SISCAN e tamb\u00e9m no PAINEL-Oncologia, foi utilizado o exame com a data mais pr\u00f3xima \u00e0 mamografia de rastreamento, desde que o exame histopatol\u00f3gico registrado no SISCAN tamb\u00e9m apresentasse malignidade. Se a informa\u00e7\u00e3o diagn\u00f3stica proveniente do SISCAN fosse n\u00e3o maligna, foi considerada a informa\u00e7\u00e3o do PAINEL-Oncologia.Foram mantidos os casos com tempo de confirma\u00e7\u00e3o em at\u00e9 dois anos (730 dias). O tempo de diagn\u00f3stico foi calculado pela diferen\u00e7a entre a data de libera\u00e7\u00e3o da mamografia e a data de libera\u00e7\u00e3o\\diagn\u00f3stico do exame histopatol\u00f3gico, registrado no SISCAN ou no Painel. Ap\u00f3s a organiza\u00e7\u00e3o dos dados, a base foi composta por 10.671 mulheres com resultado anormal na mamografia de rastreamento  registrado no SISCAN e com resultado de exame histopatol\u00f3gico em at\u00e9 dois anos, conforme ilustrado na A preval\u00eancia dos resultados BI-RADS na mamografia de rastreamento foi obtida pela distribui\u00e7\u00e3o percentual nas faixas et\u00e1rias de 40-49 e 50-69 anos de cada categoria em rela\u00e7\u00e3o ao total de mulheres rastreadas. A propor\u00e7\u00e3o de benignidade  no exame,O resultado falso positivo foi considerado como o resultado anormal na mamografia de rastreamento que n\u00e3o se confirmou como c\u00e2ncer, pelo resultado do exame histopatol\u00f3gico de mama, no intervalo de at\u00e9 dois anos A taxa de falso positivo  no rastra) foi verificada a preval\u00eancia de resultados anormais  na popula\u00e7\u00e3o de mulheres que realizou o rastreamento mamogr\u00e1fico nos anos de 2017 a 2019;b) foi aplicada nessa popula\u00e7\u00e3o a propor\u00e7\u00e3o de benignidade encontrada nas mamografias de rastreamento com resultados anormais que tinham exame histopatol\u00f3gico no SUS.Essa forma de c\u00e1lculo foi particular ao presente estudo, em fun\u00e7\u00e3o da disponibilidade atual dos dados secund\u00e1rios no contexto brasileiro.A an\u00e1lise comparativa foi realizada para Brasil e regi\u00f5es, e considerou dois grupos et\u00e1rios: mulheres de 50-69 anos, popula\u00e7\u00e3o alvo do rastreamento mamogr\u00e1fico no Brasil; e mulheres de 40-49 anos, segundo grupo com maior registro de rastreio A an\u00e1lise por regi\u00f5es foi realizada para verificar poss\u00edveis diferen\u00e7as de padr\u00e3o devido \u00e0 diversidade brasileira em rela\u00e7\u00e3o \u00e0 magnitude do c\u00e2ncer de mama O teste qui-quadrado de ader\u00eancia foi utilizado para comparar a distribui\u00e7\u00e3o das categorias BI-RADS de cada regi\u00e3o com a distribui\u00e7\u00e3o no pa\u00eds. Para situa\u00e7\u00f5es em que o teste foi significativo, ou seja, mostrou diferen\u00e7a entre a distribui\u00e7\u00e3o das categorias da regi\u00e3o e a distribui\u00e7\u00e3o no Brasil, foi realizada an\u00e1lise de res\u00edduos padronizados ajustados para identificar que categorias BI-RADS de cada regi\u00e3o diferiam da distribui\u00e7\u00e3o nacional.O teste qui-quadrado de independ\u00eancia foi utilizado para avaliar se havia diferen\u00e7as entre as mulheres com resultado anormal na mamografia de rastreamento que tinham ou n\u00e3o resultado histopatol\u00f3gico dispon\u00edvel no SISCAN. A compara\u00e7\u00e3o do perfil dos dois grupos foi realizada por grupo et\u00e1rio e para cada resultado anormal , com as vari\u00e1veis regi\u00e3o de resid\u00eancia, alto risco de c\u00e2ncer e m\u00e9dia de idade. N\u00e3o foram observadas diferen\u00e7as estatisticamente significativas nas mulheres de 40-49 anos quanto \u00e0 informa\u00e7\u00e3o de alto risco e m\u00e9dia de idade para as categorias BI-RADS 3, 4 e 5 . Em mulheres de 50-69 anos, apenas a m\u00e9dia de idade na categoria 3 foi estatisticamente diferente. Na avalia\u00e7\u00e3o da regi\u00e3o de resid\u00eancia, independente da categoria BI-RADS e faixa et\u00e1ria, os grupos diferiram significativamente . Em fun\u00e7\u00e3o dessas diferen\u00e7as, a an\u00e1lise se aplica apenas no grupo de mulheres da base de refer\u00eancia.Para o grupo de mulheres com resultados anormais na mamografia de rastreamento e diagn\u00f3stico histopatol\u00f3gico em at\u00e9 dois anos, foi verificada a exist\u00eancia de diferen\u00e7as na propor\u00e7\u00e3o de resultados benignos dos exames histopatol\u00f3gicos entre os grupos de mulheres de 40-49 anos e de 50-69 anos para cada regi\u00e3o e para o Brasil, utilizando-se o teste qui-quadrado de independ\u00eancia. Foram considerados estatisticamente significativos valores de p < 0,05.A propor\u00e7\u00e3o de benignidade foi apresentada separadamente para as categorias BI-RADS 0 e 3 e, de forma agrupada, para dois conjuntos de resultados anormais: categorias 4 e 5 e categorias 0, 3, 4 e 5. Os resultados BI-RADS 4 e 5 foram agrupados considerando a classifica\u00e7\u00e3o de suspeita de malignidade.,Na estimativa da taxa de falso positivo, devido \u00e0 falta de consenso na literatura sobre a categoria BI-RADS 3 representar um resultado anormal na mamografia de rastreamento http://www.r-project.org), utilizando os pacotes tidyverse, rstatix e psych. Todas as an\u00e1lises foram realizadas utilizando o programa R vers\u00e3o 4.0.4 (O estudo foi aprovado pelo comit\u00ea de \u00e9tica do INCA (CAAE: 26944219.5.0000.5274).No per\u00edodo de 2017 a 2019, 5.785.652 mulheres entre 40 e 69 anos realizaram mamografia de rastreamento no SUS com registro no SISCAN. No Brasil, a preval\u00eancia de BI-RADS 0 e 1 foi maior em mulheres de 40-49 anos, enquanto a preval\u00eancia de resultados nas demais categorias foi maior para mulheres de 50-69 anos. Esse padr\u00e3o ocorreu em todas as regi\u00f5es, com exce\u00e7\u00e3o da categoria BI-RADS 4 na Regi\u00e3o Nordeste, que foi 0,55%, na faixa et\u00e1ria de 40-49 anos e 0,54% na de 50-69 anos. Entre as regi\u00f5es e nos dois grupos et\u00e1rios, Norte e Nordeste apresentaram maior preval\u00eancia de BI-RADS 0 e menor de BI-RADS 3; Norte e Centro-oeste maior preval\u00eancia de BI-RADS 4; e Sul maior preval\u00eancia de BI-RADS 5 .A preval\u00eancia de resultados BI-RADS, para todas as categorias e em todas as regi\u00f5es, difere da distribui\u00e7\u00e3o observada para o Brasil  para os dois grupos et\u00e1rios analisados .A an\u00e1lise de res\u00edduos padronizados mostrou que a categoria BI-RADS 5 nas regi\u00f5es Norte, Nordeste, Sudeste, Centro-oeste e as categorias 0 e 3 da Regi\u00e3o Centro-oeste foram as \u00fanicas que n\u00e3o diferiram significativamente da distribui\u00e7\u00e3o no Brasil em mulheres com idade entre 40 e 49 anos. Em rela\u00e7\u00e3o \u00e0s mulheres de 50-69 anos, apenas a distribui\u00e7\u00e3o da categoria BI-RADS 5 da regi\u00e3o Centro-oeste n\u00e3o diferiu da do Brasil .A preval\u00eancia de exames com resultados anormais  no Brasil foi 13%, em mulheres com idade de 40-49 anos, e 12,6%, na faixa et\u00e1ria de 50-69 anos.Das 727.625 mulheres com mamografias de rastreamento anormal, 10.671  possu\u00edam exame histopatol\u00f3gico de mama no SISCAN, com distribui\u00e7\u00e3o semelhante entre as regi\u00f5es: maior valor no Sul , seguido do Nordeste , Centro-oeste , Sudeste  e Norte . As mulheres com o seguimento informado tinham idade entre 40 e 49 anos (3.553) e 50 e 69 anos (7.118), 33,3% e 66,7%, respectivamente. Dessas 10.671 mulheres com exame histopatol\u00f3gico, 46,2% apresentaram resultado benigno, 52,7% c\u00e2ncer e 1,1% (n = 121) foram classificadas como resultado suspeito ou indeterminado, provenientes de core bi\u00f3psia, as quais n\u00e3o foram consideradas no c\u00e1lculo da propor\u00e7\u00e3o de benignidade. A propor\u00e7\u00e3o de benignidade nos exames histopatol\u00f3gicos foi significativamente maior em mulheres de 40-49 anos, em todos os resultados anormais, comparada a de mulheres de 50-69 anos. Considerando os resultados anormais agregados , a propor\u00e7\u00e3o de benignidade foi de 63,1% em mulheres de 40-49 anos e 48,4% em mulheres de 50-59 anos .Em rela\u00e7\u00e3o \u00e0s regi\u00f5es, observaram-se varia\u00e7\u00f5es entre os resultados anormais e faixas et\u00e1rias. Na Norte, a propor\u00e7\u00e3o de benignidade das mulheres com BI-RADS 3 foi 3,4 vezes maior em mulheres de 40-49 anos (comparadas ao grupo das mais velhas), seguida do Sudeste, que foi 1,3 vezes maior. A propor\u00e7\u00e3o de benignidade entre as categorias foi maior no BI-RADS 0 nas duas faixas et\u00e1rias e variou de 67,6% no Sul a 79,3% no Centro-oeste, em mulheres de 40-49 anos, e de 44,6% a 70,6%, em mulheres de 50-69 anos, nas regi\u00f5es Norte e Centro-oeste, respectivamente.Em mamografias de rastreamento com suspei\u00e7\u00e3o de c\u00e2ncer, categorias 4 e 5, a Regi\u00e3o Centro-oeste apresentou a maior propor\u00e7\u00e3o de benignidade em ambas as faixas et\u00e1rias, e a menor foi verificada na Regi\u00e3o Sudeste , em mulheres de 50-69 anos, e na Regi\u00e3o Sul , no grupo de 40-49 anos. Nas regi\u00f5es Centro-oeste, Nordeste, Norte e Sul, a propor\u00e7\u00e3o de benignidade nas categorias 4 e 5 n\u00e3o foi estatisticamente diferente nos dois grupos et\u00e1rios, assim como na categoria 3 das regi\u00f5es Centro-Oeste, Nordeste e Sul .A taxa estimada de falso positivo foi de 8,18 casos por 100 mulheres, na faixa et\u00e1ria de 40-49 anos, e de 6,06 por 100 mulheres, na faixa de 50-69 anos. Sem considerar o BI-RADS 3 na taxa estimada de falso positivo, os valores reduzem para 7,16 e 5,03 por 100 mulheres, respectivamente . Em todaEntre as regi\u00f5es, a taxa estimada para 0, 3, 4 e 5 variou de 6,56 por 100 mulheres, no Sul, a 9,18 no Nordeste, e para mulheres de 50-69 anos variou de 5,3, no Sul, a 7,7 no Centro-oeste. Sem considerar o BI-RADS 3, os valores variaram de 5,5 por 100 no Sul a 6,9 no Centro-oeste (Tabela 3). O presente estudo apresenta estimativas ainda n\u00e3o identificadas na literatura brasileira sobre a ocorr\u00eancia de resultados falsos positivos no rastreamento do c\u00e2ncer de mama no SUS, sistema de sa\u00fade utilizado por cerca de 75% da popula\u00e7\u00e3o A preval\u00eancia de resultados BI-RADS na primeira mamografia de rastreamento da mulher no per\u00edodo do estudo foi similar \u00e0 encontrada em estudos nacionais com dados de mamografias realizadas no SUS, sendo a propor\u00e7\u00e3o de resultados anormais um pouco menor que as observadas nos estudos de Azevedo e Silva et al. A propor\u00e7\u00e3o de benignidade nos exames histopatol\u00f3gicos de mama no Brasil, na faixa et\u00e1ria de 50-69 anos, ficou pr\u00f3xima ao dado apresentado no estudo de Lewin et al. As taxas estimadas de falsos positivos de 8,2%, em mulheres de 40-49 anos, e de 6,1%, nas de 50-69 anos, obtidas a partir do percentual de benignidade do histopatol\u00f3gico subsequentes \u00e0s mamografias de rastreamento, podem ser apreciadas \u00e0 luz da literatura, ressalvando-se a heterogeneidade metodol\u00f3gica dos estudos e de seus resultados. 7 29,4%, em sete anos. Em estudos com mulheres de 40-49 anos, que avaliaram a ocorr\u00eancia do falso positivo com base em uma mamografia de rastreamento, similar ao aqui apresentado, Payne et al. Para mulheres de 50-69 anos, considerando a ocorr\u00eancia de falso positivo com base em uma mamografia de rastreamento, Tsuruda et al. ,,,,As taxas mais elevadas de falso positivo para mulheres de 40-49 anos em compara\u00e7\u00e3o com as de 50-69 anos \u00e9 recorrente em diversos estudos No contexto brasileiro, as taxas menores de falsos positivos na Regi\u00e3o Sul comparadas \u00e0s mais elevadas na Regi\u00e3o Centro-oeste, em mulheres de 50-69 anos, e ao Norte e Nordeste, em mulheres de 40-49 anos, podem ter rela\u00e7\u00e3o com a qualidade do equipamento de mamografia, o tipo de tecnologia utilizada, o desempenho do radiologista (treinamento e experi\u00eancia) e caracter\u00edsticas da mulher, tal como sugerido por Goossens et al. Resultados falsos positivos s\u00e3o esperados no rastreamento ,,,,Cabe lembrar que resultados falsos positivos ocasionam exposi\u00e7\u00e3o adicional \u00e0 radia\u00e7\u00e3o ionizante, no caso de complemento mamogr\u00e1fico ou controle radiol\u00f3gico em menos tempo, e desperd\u00edcio de recursos pela realiza\u00e7\u00e3o de exames desnecess\u00e1rios Ressalta-se que, na avalia\u00e7\u00e3o do risco de resultados falsos positivos, estudos consideram a tecnologia dos mam\u00f3grafos, que v\u00eam transitando de sistema anal\u00f3gico para o digital. N\u00e3o foi poss\u00edvel estabelecer essa especifica\u00e7\u00e3o neste estudo, em fun\u00e7\u00e3o da indisponibilidade dessa informa\u00e7\u00e3o no SISCAN. \u00c9 importante refor\u00e7ar que a heterogeneidade metodol\u00f3gica dos estudos deve ser sempre considerada na avalia\u00e7\u00e3o de falso positivo no rastreamento mamogr\u00e1fico Como limites do estudo, destaca-se que o desenho metodol\u00f3gico n\u00e3o incluiu na an\u00e1lise os resultados falsos positivos oriundos de novos exames radiol\u00f3gicos realizados ap\u00f3s um resultado anormal da mamografia de rastreamento. Ao restringir a an\u00e1lise aos casos que demandaram bi\u00f3psia e que possu\u00edam exame histopatol\u00f3gico, as estimativas de falsos positivos aqui apresentadas podem estar subestimadas, em fun\u00e7\u00e3o da perda de casos no seguimento, especialmente dos resultados BI-RADS 0 e 3. ,Outra limita\u00e7\u00e3o foi a perda de dados das mulheres com resultado anormal e sem confirma\u00e7\u00e3o diagn\u00f3stica registrada no sistema em dois anos, o que representou 98,5% das mulheres, com poucas diferen\u00e7as regionais, sendo a menor na Regi\u00e3o Sul  e a maior na Norte . Como o perfil de mulheres com seguimento informado diferiu do grupo de mulheres n\u00e3o inclu\u00eddas por aus\u00eancia de informa\u00e7\u00e3o, n\u00e3o \u00e9 poss\u00edvel extrapolar os resultados para todas as mulheres da base de refer\u00eancia. O acompanhamento da mulher com exame de mamografia alterada tem sido apontado como uma das dificuldades nos estudos de rastreamento, sobretudo quando s\u00e3o necess\u00e1rios exames diagn\u00f3sticos Por fim, o SISCAN n\u00e3o est\u00e1 ainda implantado em todos os servi\u00e7os que realizam exames no SUS. No entanto, o sistema vem sendo crescentemente utilizado e, em 2019, estava em uso em 74% dos servi\u00e7os que realizaram mamografia e em 82% dos laborat\u00f3rios que realizaram exames histopatol\u00f3gicos de mama no SUS O estudo estimou o risco de a mulher ter um resultado falso positivo no rastreamento mamogr\u00e1fico no Brasil, encontrando maior taxa em mulheres de 40-49 anos  comparadas \u00e0s de 50-69 anos , com diferen\u00e7as regionais que podem se relacionar a n\u00edveis desiguais de desenvolvimento socioecon\u00f4mico e do SUS no pa\u00eds.Essas informa\u00e7\u00f5es s\u00e3o \u00fateis aos gestores como refer\u00eancia na avalia\u00e7\u00e3o do rastreamento do c\u00e2ncer de mama, nos estados e munic\u00edpios, e tamb\u00e9m aos profissionais de sa\u00fade, para que orientem a mulher sobre as poss\u00edveis implica\u00e7\u00f5es do rastreamento mamogr\u00e1fico, subsidiando-as para que possam decidir de forma mais esclarecida sobre realizar ou n\u00e3o esses exames, especialmente quando feitos fora da faixa et\u00e1ria recomendada para rastreamento. Seguir a diretriz da faixa et\u00e1ria pode reduzir danos associados ao rastreamento e otimizar a rede para agilizar o diagn\u00f3stico oportuno de c\u00e2ncer de mama ao conjunto das mulheres. Aponta-se tamb\u00e9m para a import\u00e2ncia de se avan\u00e7ar para o rastreamento organizado e de melhorias tecnol\u00f3gicas e de qualifica\u00e7\u00e3o profissional que reduzam as taxas de falsos positivos e a necessidade de procedimentos invasivos.Espera-se que, com a plena consolida\u00e7\u00e3o do SISCAN e a maior completude de suas informa\u00e7\u00f5es, novos estudos aprofundem quest\u00f5es aqui trazidas e ampliem o conhecimento sobre o risco de falso positivo no rastreamento mamogr\u00e1fico brasileiro e suas diferen\u00e7as nos sistemas locais de sa\u00fade."}
+{"text": "Estudo Longitudinal de Sa\u00fade do Adulto(ELSA-Brasil) - COVID, realizado de 2020 a 2021, que foramanalisados por meio do teste qui-quadrado e regress\u00e3o log\u00edstica multinomial. Aamostra \u00e9 composta por 5.440 participantes. A medida preventiva com maior ades\u00e3ofoi o uso de m\u00e1scara facial . Houve maior ades\u00e3o pelo sexo feminino emenor chance de ades\u00e3o pela ra\u00e7a/cor branca, por aqueles que consomem bebidasalco\u00f3licas, aposentados, assim como para aqueles que moram sozinhos ou quepossuem familiares que n\u00e3o seguiram as recomenda\u00e7\u00f5es de ficar em casa. A maiorades\u00e3o aos comportamentos preventivos foi verificada em apenas um ter\u00e7o dapopula\u00e7\u00e3o participante, o que demonstra que havia a necessidade de uma maiorconscientiza\u00e7\u00e3o quanto aos riscos em popula\u00e7\u00f5es espec\u00edficas. Os achadoscontribuem para melhorar o conhecimento sobre promo\u00e7\u00e3o da sa\u00fade e preven\u00e7\u00e3o daCOVID-19.O objetivo deste estudo foi avaliar a ades\u00e3o a medidas de preven\u00e7\u00e3o recomendadasdurante a pandemia de COVID-19 e investigar os fatores associados a essa ades\u00e3ona popula\u00e7\u00e3o adulta. Por meio de delineamento transversal, utilizam-se dados doestudo complementar  No ano de 2019, uma nova cepa de coronav\u00edrus (o SARS-CoV-2) foi relatada. A naturezainfecciosa da doen\u00e7a, a mortalidade di\u00e1ria e sua capacidade de causar complica\u00e7\u00f5esgraves em um per\u00edodo curto, como pneumonia aguda, s\u00edndrome do desconfortorespirat\u00f3rio (SDR), insufici\u00eancia card\u00edaca, tempestade de citocinas e disfun\u00e7\u00e3o dem\u00faltiplos \u00f3rg\u00e3os Diante do cen\u00e1rio severo ocasionado pela pandemia, devido \u00e0 aus\u00eancia de tratamentoseficazes, o acesso e a disponibilidade limitada de vacinas durante o primeiro ano dapandemia, medidas de preven\u00e7\u00e3o contra a COVID-19 foram estabelecidas para mitigar apropaga\u00e7\u00e3o comunit\u00e1ria do COVID-19 em todo o territ\u00f3rio global, incluindo oisolamento de pacientes infectados ou suspeitos, uso de equipamentos de prote\u00e7\u00e3oindividual (EPIs) como m\u00e1scaras faciais, lavagem de m\u00e3os, uso de \u00e1lcool em gel,distanciamento social, quarentenas e bloqueios obrigat\u00f3rios ,,Uma pesquisa evidenciou que o uso consistente de m\u00e1scaras, lavagem das m\u00e3os edistanciamento f\u00edsico s\u00e3o eficazes na preven\u00e7\u00e3o da COVID-19 Lei n\u00ba 13.979, de 2020, dentre elas, a ado\u00e7\u00e3o deisolamento e quarentena A sustentabilidade e a efetividade destas medidas coexistiram com o estabelecimentode pol\u00edticas de prote\u00e7\u00e3o social e apoio \u00e0 popula\u00e7\u00e3o vulner\u00e1vel durante as restri\u00e7\u00f5esda pandemia ,,,,Alguns estudos mostram que os comportamentos de preven\u00e7\u00e3o \u00e0 COVID-19 podem serinfluenciados pela compreens\u00e3o de fatores sociodemogr\u00e1ficos Estudo Longitudinal de Sa\u00fade do Adulto (ELSA-Brasil) Mesmo com o grande n\u00famero de pesquisas brasileiras voltadas para o tema \u201cCOVID-19\u201d,ainda h\u00e1 uma escassez de estudos que investigaram a ades\u00e3o \u00e0s medidas preventivas eos seus fatores relacionados. Nesse \u00ednterim, verificar a ades\u00e3o e entender como apreven\u00e7\u00e3o foi influenciada por diferentes fatores dentro da amostra pertencente aoFoi executado um delineamento transversal e utilizam-se dados do estudo complementaraninhado ao ELSA-Brasil para avaliar os impactos de curto e longo prazo daCOVID-19.O ELSA-Brasil \u00e9 uma coorte prospectiva composta por cinco universidades e uminstituto de pesquisa de cidades brasileiras , iniciada em agosto de 2008, com funcion\u00e1rios ativos ouaposentados, com idade entre 35 e 74 anos ,,,,As avalia\u00e7\u00f5es de linha de base ocorreram em 2008-2010 e inclu\u00edram 15.105participantes com 35 a 74 anos de idade que foram submetidos a exames cl\u00ednicos eentrevistas. A primeira onda de acompanhamento ocorreu em 2012-2014 com amostrafinal de 14.014 e a segunda onda de seguimento nos anos de 2017 a 2019 com amostrade 12.636, sem recrutamento de novos participantes De junho de 2020 a mar\u00e7o de 2021, os participantes da segunda onda de acompanhamento(n = 12.636), exceto os de S\u00e3o Paulo (n = 4.194), foram convidados a participar doestudo complementar sobre dados da COVID-19, de forma que 5.639 participantes(66.79%) aceitaram, assinaram o Termo de Consentimento Livre e Esclarecido eresponderam aos question\u00e1rios. Destes, utilizamos dados de 5.440 , poisforam exclu\u00eddos aqueles que n\u00e3o responderam sobre as vari\u00e1veis de interesse.online pelo celularou computador, por meio de um aplicativo desenvolvido especialmente para o estudo,ou por contato telef\u00f4nico com aux\u00edlio de um profissional treinado e equipecertificada. O estudo foi aprovado pelos comit\u00eas de \u00e9tica de todos os centros depesquisa do ELSA-Brasil e pelo Comit\u00ea Nacional de \u00c9tica em Pesquisa .Os dados do estudo complementar foram coletados O question\u00e1rio do \u201cELSA-Brasil COVID\u201d foi dividido em quatro m\u00f3dulos para aaplica\u00e7\u00e3o, foram feitas perguntas contidas em tr\u00eas dos quatro m\u00f3dulos: M\u00f3dulo I, M\u00f3dulo II e M\u00f3dulo III (impacto na renda).Para verificar a ades\u00e3o aos comportamentos preventivos foi realizada a constru\u00e7\u00e3o deum escore a partir de seis perguntas contidas no M\u00f3dulo I: \u201clavar as m\u00e3os com \u00e1gua esab\u00e3o por 20 segundos; usar \u00e1lcool 70% gel/l\u00edquido nas m\u00e3os; cobrir o nariz e a bocaao tossir e espirrar; retirar os sapatos antes de entrar em casa; trocar de roupa aochegar em casa; usar m\u00e1scara sempre que sair de casa; lavar as embalagens dosprodutos de mercado ou farm\u00e1cia antes de guard\u00e1-los; n\u00e3o cumprimentar as pessoas combeijo no rosto ou aperto de m\u00e3os\u201d. Com cinco op\u00e7\u00f5es de resposta, categorizadas emdados cont\u00ednuos: sempre = 5, quase sempre = 4, \u00e0s vezes = 3, raramente = 2 e nunca =1 ; obtendo um escore com variabilidade de 5 a 30 pontos ecategorizada em tercil.Al\u00e9m disso, foram utilizados dados sociodemogr\u00e1ficos para caracteriza\u00e7\u00e3o dapopula\u00e7\u00e3o, como sexo, idade, ra\u00e7a/cor , situa\u00e7\u00e3o atual detrabalho  e estado civil ;solteiro(a)), tamb\u00e9m foi perguntado se houve mudan\u00e7a na renda durante a pandemia. Vari\u00e1veis de h\u00e1bitos de vida tamb\u00e9m foram aferidas, atrav\u00e9s dasseguintes perguntas: \u201cNas \u00faltimas trinta noites com que frequ\u00eancia teve dificuldadeem pegar no sono?\u201d ; \u201cDesde o in\u00edcio dodistanciamento social voc\u00ea consumiu algum tipo de bebida alco\u00f3lica?\u201d ;\u201cFuma cigarros atualmente?\u201d ; \u201cVoc\u00ea percebeualguma altera\u00e7\u00e3o de peso ou de medidas corporais durante o per\u00edodo de distanciamentosocial?\u201d .https://www.stata.com). As vari\u00e1veis categ\u00f3ricas foram analisadaspor meio do teste estat\u00edstico qui-quadrado para verificar a distribui\u00e7\u00e3o dasvari\u00e1veis de exposi\u00e7\u00e3o \u00e0 ades\u00e3o de comportamentos preventivos pelos participantes dapesquisa. Para analisar os fatores associados ao desfecho, foi realizada regress\u00e3olog\u00edstica multinominal em cada tercil de ades\u00e3o, da seguinte forma: modelo bruto,ap\u00f3s ajustado por modelo 1: vari\u00e1veis sociodemogr\u00e1ficas ; modelo 2: modelo 1 + h\u00e1bitosde vida  e modelo 3: modelo 1 + modelo 2 + vari\u00e1veis derecomenda\u00e7\u00e3o de isolamento social . Adotou-se emtodas as an\u00e1lises estat\u00edsticas, n\u00edvel de signific\u00e2ncia de 5%.As an\u00e1lises estat\u00edsticas foram todas realizadas no Stata 16.0 , seguida de \u201cn\u00e3o cumprimentar aspessoas com beijo no rosto ou aperto de m\u00e3os\u201d , j\u00e1 \u201ctrocar de roupa ao chegarem casa\u201d (56%) foi a medida menos realizada .De acordo com a Quanto a J\u00e1 na A pesquisa fornece dados importantes sobre as vari\u00e1veis associadas \u00e0 ades\u00e3o doscomportamentos preventivos dos participantes do ELSA-Brasil COVID durante a pandemiada COVID-19.,Nossos resultados evidenciam que ser mulher \u00e9 um fator positivamente associado \u00e0presen\u00e7a de comportamentos preventivos, sendo consistente com estudos realizados emoutras partes do mundo fast food e aumento naingest\u00e3o de refei\u00e7\u00f5es caseiras ,O relato de perda de peso tamb\u00e9m esteve associado a uma maior ades\u00e3o, a perda de pesopode ter sido influenciada pela apreens\u00e3o e incerteza sobre situa\u00e7\u00e3o de sa\u00fade globalnessa popula\u00e7\u00e3o, levando a modifica\u00e7\u00f5es comportamentais e no estilo de vida ealimenta\u00e7\u00e3o. Al\u00e9m do mais, j\u00e1 \u00e9 conhecido que o bem-estar emocional pode afetar oapetite Identificou-se que ser aposentado e n\u00e3o exercer outra fun\u00e7\u00e3o empregat\u00edcia teve maiorpropens\u00e3o a n\u00e3o seguir as recomenda\u00e7\u00f5es de ades\u00e3o preventiva, isso tamb\u00e9m \u00e9 vistopara aqueles que relataram sair mais vezes de casa durante a semana. De acordo comShati et al. De acordo com Flett & Heisel Em estudo realizado com sul-asi\u00e1ticos, o conhecimento inadequado sobre a COVID-19esteve associado a menor ades\u00e3o a atitudes relacionadas \u00e0 preven\u00e7\u00e3o ,,Estudos que analisam a associa\u00e7\u00e3o entre a ado\u00e7\u00e3o de medidas preventivas \u00e0 COVID-19 evari\u00e1veis sobre comportamento em sa\u00fade, como o uso de bebidas alc\u00f3olicas, forammenos explorados na literatura. Em nosso estudo, ser consumidor de bebidasalco\u00f3licas associa-se \u00e0 redu\u00e7\u00e3o em 76% na realiza\u00e7\u00e3o de comportamentos preventivosdurante a pandemia comparado a quem n\u00e3o fez uso de bebidas alco\u00f3licas. Tal fato foiverificado em outros estudos ,O isolamento e o estresse v\u00eam sendo sugeridos na literatura como fatoressignificativos para o consumo de bebidas alco\u00f3licas ,A coorte do ELSA-Brasil \u00e9 bem definida, o que aumenta a validade externa e ageneraliza\u00e7\u00e3o dos dados, contudo, este estudo apresenta limita\u00e7\u00f5es, pois suaamostragem \u00e9 ocupacional e n\u00e3o populacional, visto que \u00e9 composta por servidoresp\u00fablicos de universidades participantes da pesquisa, que possuem renda m\u00e9diasalarial superior a nacional. Al\u00e9m disso, os participantes desta pesquisa realizaramo preenchimento dos question\u00e1rios de forma volunt\u00e1ria, o que pode gerar um vi\u00e9s desele\u00e7\u00e3o e influenciar as informa\u00e7\u00f5es sobre a ades\u00e3o \u00e0s medidas de preven\u00e7\u00e3o. Tallimita\u00e7\u00e3o tamb\u00e9m foi observada em outros estudos realizados durante o per\u00edodopand\u00eamico com amostra de conveni\u00eancia e obedecem ao distanciamento socialrecomendado Apesar disso, o este estudo inova ao verificar a ades\u00e3o aos comportamentospreventivos recomendados pelas institui\u00e7\u00f5es de sa\u00fade, trazendo \u00e0 luz informa\u00e7\u00f5esimportantes e pouco investigadas que podem contribuir para melhor esclarecimentosobre o tema e as vari\u00e1veis correlacionadas.,A maioria dos estudos Lei n\u00ba 13.979/2020O estudo foi realizado de junho de 2020 a mar\u00e7o de 2021, quando o governo brasileiroj\u00e1 havia sancionado a Por fim, apenas um ter\u00e7o da popula\u00e7\u00e3o analisada apresentou uma maior ades\u00e3o aoscomportamentos preventivos para essa doen\u00e7a que mobilizou a ci\u00eancia e sa\u00fade dediferentes pa\u00edses. A neglig\u00eancia e demora na implementa\u00e7\u00e3o de medidas pelasinstitui\u00e7\u00f5es brasileiras podem ter afetado, e muito, a ades\u00e3o da popula\u00e7\u00e3o \u00e0smedidas preventivas."}
+{"text": "For data collection and analysis, the Vocalgram software (CTS Inform\u00e1tica) was used, which recorded the emission of the vowel / \u0190 / in ascending and descending glissando, up to the lowest and highest note in the weakest and strongest intensities possible.passaggio were identified in ascending and descending, strong and weak emissions in all voice types. There was a higher occurrence of voice break in the high voices, compared to the low ones. The average values \u200b\u200bof the frequencies found corresponded to different tones from those established in the literature for all voice types.The values of frequencies and respective intensities of the passaggio identified in the vocal range profile of choristers, based on their frequencies and intensities were more frequent in soprano na tenor, compared to alto and bass, in changes to the low and high registers.The  Despite the controversies regarding its voice type attributes, it is used as one of the parameters to classify singers\u2019 voices,2.One of the main characteristics of changes in untrained singers\u2019 vocal register is the \u201cvoice break\u201d, identified as . Passaggio, in their turn, are sudden variations in the vibratory mass in actions triggered by changes in vocal fold strain - which can be gradual, as when producing a glissando.Register classification is based on the action of the predominant muscle group in the emission and its resonance effects, whether speaking or singing,4.Transitions in the register can be identified with instrumental measures, even if the singer is skillful enough to attenuate them, leaving no audibly perceivable changespassaggio notes and be a possible resource to analyze vocal behavior during register changes. This would be useful to follow up on therapy and vocal improvement results, providing visual feedback during exercises proposed to minimize such breaks - which bother singers considerably but can be disguised with constant training. Moreover, given their importance to voice classification, these notes can be better assessed with such measures, which, along with auditory-perceptual analyses, can furnish more objective data on study parameters.Hence, computed acoustic measures can minimize divergences in the identification of -7. In this regard, the Vocalgrama\u00ae software, by CTS Inform\u00e1tica, assesses the intensity and frequency of singing voices based on VRP records. To this end, singers emit the vowel / \u0190 / in ascending and descending glissando, from the minimum to the maximum possible tone, at strong and weak intensities.Thus, speech-language-hearing therapists are increasingly adhering to these new technologies - such as phonetography, which can assess people\u2019s voice range profiles (VRP) through the relationship between frequency and intensity, helping analyze vocal performance. These results reinforce the importance of using this instrument to record results and provide biofeedback to subjects submitted to therapy or vocal improvement.Besides furnishing information on voice ranges, VRP analysis generates charts that make it possible to investigate other parameters and visualize vocal changes not perceived by hearing, this program stands out as a great ally in speech-language-hearing practice with singers, as - among other aspects - it is useful to visually and auditorily monitor the patient\u2019s progress. Hence, this study aimed to analyze passaggio notes in choir singers\u2019 VRP, stratified by voice types, identifying their fundamental frequency (f0) and intensity, in changes to both high (ascending emissions) and low pitches (descending emissions).Since the acoustic effect of transitions in registers can be disguised with constant trainingThis study was approved by the Research Ethics Committee from the Center for Health Sciences at the Federal University of Pernambuco under evaluation report no. 1.455.166. Participants signed an informed consent form before collecting data.The sample comprised 67 adult choir singers from different choirs, divided into voice types, according to the classification given by their respective choir directors/singing teachers, namely: soprano (n = 20), contralto (n = 17), tenor (n = 15), and bass (n = 15). Their mean age was 27.79 (\u00b17.50) years. None of the singers in the sample had voice complaints.Data were collected and analyzed with Vocalgrama, by CTS Inform\u00e1tica, installed in an HP Notebook PC, with Karsect HT-2 headset earphones, and an Andrea PureAudio\u2122 USB-AS external sound card to filter and reduce noise. The voices were recorded in the program, and the microphone was adjusted 4 centimeters away from the singer\u2019s corner of the mouth.To record VRPs, singers were asked to emit a vowel /\u0190/ in ascending and descending glissando, reaching the lowest and highest frequency they could produce, at weak and strong intensities. These data were collected three times from each singer to ensure measure reproducibility. The charts selected for analysis were the ones with the subjects\u2019 best emissions..VRP results are calculated by the program, based on a chart outlined along with the emissions. It shows the frequencies in Hertz (Hz) and intensities in decibels (dB), respectively located in the abscissa and ordinate axespassaggio note identification (in %); f0 in Hertz (Hz); vocal intensity (in decibels) (dB); 2) Independent variables: /\u0190/ glissando emission mode .This study considered the following analysis variables: 1) Dependent variables: passaggio notes were investigated through visual and auditory-perceptual analysis of the chart generated by the software. Two researchers (speech-language-hearing therapists experienced in singing) verified the data in consensus; if they had any divergence, a third one was invited. In emission analysis, the researchers observed the charts while playing the recording of the vowel /\u0190/ in ascending and descending glissando. The \u201cbreak\u201d was visually identified when the signal in the chart was discontinued, and auditory-perceptually identified by the typical vocal instability perceived by the researchers while they listened to the recording  had greater percentages than low ones . Tenors and sopranos together add up to 70% of the subjects identified.Considering the total of passaggio voice broke and the corresponding notes, stratified by voice type, in the ascending, descending, strong, and weak emissions.passaggio notes are different in the ascending and descending and in the strong and weak emissions - the tenors\u2019 and basses\u2019 notes were quite near in the ascending emissions, and the sopranos\u2019 and contraltos\u2019 notes were the same in the descending emissions. However, in the inferential analysis, considering the whole group together due to the few subjects in the sample, no difference in f0 was found between ascending and descending or between strong and weak emissions. Concerning intensity, as expected, there was a difference between strong and weak emissions, but not between ascending and descending ones.Individual results per voice type show that . Computer resources can help speech-language-hearing therapists and singing teachers control transitions from one to another register, considering the visual feedback these resources provide. Thus, this study aimed to study preliminarily the characterization of passaggio notes by identifying their frequency and intensity in both ascending and descending transitions.Vocal registers are not as studied in the literature as other vocal parameters, and professionals have conceptual differences on the topicpassaggio notes were identified in no more than 30% of the total subjects. This can be justified by the fact that the sample comprised trained singers who participated in choirs. Even though the singing practice time was not controlled, it can be assumed that more trained singers were the ones whose passaggio notes were not evident. To demonstrate this hypothesis, future studies should control the singing practice time.This study in 67 choir singers verified that in all emission modes, ,11, more breaks were expected to be identified in the weak emissions. On the other hand, singing practices also aim to control such support; hence, it can be inferred that singers in the sample did not have differences between these two modes thanks to their training.Since emission power, projection, and control improve with better respiratory support conditions. A suggestion for future studies is to compare the two types of emission (in glissandos and note-to-note) to test these results.It could also be explained by the sound emission form (in glissandos), which, though nearer the singing voices, may induce a greater voice range limitation than in note-to-note emissionspassaggio notes was identified in high voice types (tenors and sopranos), to which a hypothesis may be a wider phonatory range in high voices, which would increase the odds of detecting passaggio notes. This hypothesis could be confirmed by comparing phonatory ranges between voice types. Hence, this study may be continued to analyze this variable.A greater percentage of passaggio notes\u2019 f0, they were compared with the notes each frequency represents, also considering their applicability in voice classification. Sopranos presented notes that do not corroborate those described in the literature, namely: from Mi3 to Fa3 , or between Mi4 and Fa4 and Fa#4 .Since few studies address  , Re3, and from Re4 to Mi4 , and Re4 , while in the present study passaggio notes were higher in weak ascending emissions, and lower in strong descending emissions than in the cited studies.The same happened with the contraltos, whose break is defined from Do3 to Reb3passaggio notes ranged from Mi3 to Fa3 (E4 to F4) and Si#3 (B#4). Even though this information diverges from other authors, La2 (A3) cited as this group\u2019s passaggio note was corroborated in the present study, which also found this note in the weak low emission. Contrarily, Re3 (D4) was present in the weak ascending emission.The authors\u2019 considered that the tenors\u2019  (Eb4) but agrees partly with the study that admits that the \u201cbreak\u201d can be found from Do3 to Reb3 (C4 to Db4). By considering Mi#2 (E#3), Sol2 (G3), Re3 (D4), and Sol3 (G4) as this voice type\u2019s passaggio notes, the findings in this study corroborate in part such propositions.The basses\u2019 notes in the weak and strong ascending emissions were respectively Do3 (C4) and Re3 (D4), while the ones in the weak and strong descending emissions were La2 (A3) and Do3 (C4). This finding differs from Mib3. Only La2 (A3), found in the tenors\u2019 weak descending emissions, belongs to the second octave and, therefore, was not expected.Despite the differences in note analysis, the assessment per octave showed that notes identified from the four voice types belong to the indicated octaves: the third and fourth octaves in sopranos and contraltos; the third octave and the transition between the third and fourth octaves in tenors; and second and third octaves in bassesConcerning divergences between this study and the literature, the analysis method may have interfered, as the collection used a voice range test, in which choir singers emit from low to high notes and vice-versa. Thus, future studies should use the central Do as the starting point for ascending and descending emissions.passaggio notes were identified was not enough for statistical comparisons. Therefore, future studies should have larger samples to compare differences in this variable between voice types.No comparative data was found in the literature regarding the intensity of notes in the weak and strong emissions, and the number of subjects per voice type whose Passaggio notes were identified in all voice types in both weak and strong emissions. Median frequency values corresponded to notes different from those established in the literature for all voice types. As for passaggio note intensity, studies with larger samples are needed to establish reference values.passaggio notes. The visual chart feedback of this event may help both classify voices and follow up on treatment or vocal improvement results in singers and non-singers. Hence, it is useful as a voice analysis record and as a therapy resource.This preliminary study also demonstrated Vocalgrama\u2019s applicability to identify instrumentally the physiological phenomenon of Moreover, this study differs from other ones in important aspects, namely: 1) it took frequency measures, rather than using musical instruments, making data more precise and allowing for the calculation of means and medians; 2) with glissando instead of note-to-note emissions because glissando emissions are comparatively nearer the singing voice; 3) in the strong and weak emissions, which in the singing voice have an essential value in aerodynamic control and musical expressiveness.-15, demonstrating that there is no consensus between authors. The lack of studies whose analyses consider different emission conditions - such as ascending, descending, strong, and weak - also hinders analyses per note or frequency.It must be also highlighted that differences on the topic are evident in the literatureHence, given the current possibility of new and less subjective analysis instruments than those traditionally used, this study should be continued with a larger sample, comparing trained and untrained singers, and comparing instrumental data with auditory-perceptual analysis results.Passaggio notes identified in choir singers\u2019 VRP based on their frequencies and intensities occurred more often in sopranos and tenors than in contraltos and basses in the changes to low and high registers. ,2.Uma das principais caracter\u00edsticas da mudan\u00e7a de registro do cantor n\u00e3o treinado \u00e9 a \u201cquebra na voz\u201d, identificada como nota de passagem. A despeito das controv\u00e9rsias quanto \u00e0s suas atribui\u00e7\u00f5es aos naipes, ela \u00e9 utilizada como um dos par\u00e2metros para a classifica\u00e7\u00e3o vocal de cantores. As notas de passagem, por sua vez, representam varia\u00e7\u00f5es repentinas da massa vibrat\u00f3ria em a\u00e7\u00f5es ocasionadas por modifica\u00e7\u00f5es na tens\u00e3o das pregas vocais, que podem ser de forma gradual, como durante a produ\u00e7\u00e3o de um glissando.A classifica\u00e7\u00e3o dos registros tem como base a a\u00e7\u00e3o do grupo muscular predominante na emiss\u00e3o, bem como seus efeitos de resson\u00e2ncia, seja na voz falada ou cantada,4.A transi\u00e7\u00e3o no registro pode ser identificada por medidas instrumentais, ainda que o cantor seja habilidoso o suficiente para suaviz\u00e1-la, sem que sejam produzidas mudan\u00e7as auditivamente percept\u00edveisfeedback visual durante a execu\u00e7\u00e3o dos exerc\u00edcios propostos para minimiza\u00e7\u00e3o dessas quebras, t\u00e3o inc\u00f4modas para o cantor, mas que podem ser ocultadas com treino constante. Al\u00e9m disso, devido \u00e0 sua import\u00e2ncia para a classifica\u00e7\u00e3o vocal, essas notas podem ser melhor avaliadas com tais medidas que, somadas \u00e0s an\u00e1lises perceptivo-auditivas, s\u00e3o capazes de fornecer dados mais objetivos sobre os par\u00e2metros estudados.Desse modo, o uso de medidas ac\u00fasticas computadorizadas poderia minimizar as diverg\u00eancias quanto \u00e0 identifica\u00e7\u00e3o das notas de passagem, al\u00e9m de ser um poss\u00edvel recurso para a an\u00e1lise do comportamento vocal durante as mudan\u00e7as de registro, para acompanhamento de resultados terap\u00eauticos e do aprimoramento vocal, permitindo o -7. Nesse sentido, o Vocalgrama\u00ae da CTS Inform\u00e1tica \u00e9 um software que pode ser utilizado para avaliar a intensidade e frequ\u00eancia da voz cantada pelo registro do perfil de extens\u00e3o vocal (PEV). Para tal, emite-se a vogal / \u0190 / em glissando ascendente e descendente, da tonalidade m\u00ednima \u00e0 m\u00e1xima poss\u00edvel, nos n\u00edveis de intensidade fraco e forte.Por isso, a ades\u00e3o dos fonoaudi\u00f3logos a essas novas tecnologias \u00e9 crescente, como ocorre com a fonetografia, capaz de avaliar o perfil de extens\u00e3o vocal (PEV) dos indiv\u00edduos por meio da rela\u00e7\u00e3o entre frequ\u00eancia e intensidade, favorecendo a an\u00e1lise da performance vocal. Tais resultados refor\u00e7am a import\u00e2ncia do uso desse instrumento para o registro de resultados e para o biofeedback dos sujeitos submetidos \u00e0 terapia ou aprimoramento vocais.Al\u00e9m de fornecer informa\u00e7\u00f5es sobre a extens\u00e3o vocal, a an\u00e1lise gerada pelo PEV resulta em gr\u00e1ficos que propiciam a investiga\u00e7\u00e3o de outros par\u00e2metros, al\u00e9m de auxiliar na visualiza\u00e7\u00e3o de mudan\u00e7as vocais n\u00e3o percebidas auditivamente, este programa desponta como um grande aliado na atua\u00e7\u00e3o fonoaudiol\u00f3gica com cantores, pois - dentre outras coisas - \u00e9 \u00fatil no monitoramento visual e auditivo da evolu\u00e7\u00e3o do paciente. Desse modo, o objetivo deste trabalho foi analisar a nota de passagem no perfil de extens\u00e3o vocal de coristas, identificando a frequ\u00eancia fundamental e a intensidade, tanto na mudan\u00e7a para o registro agudo (emiss\u00f5es ascendentes), quanto para o grave (emiss\u00f5es descendentes), em coristas, estratificados por naipes.Considerando-se que os efeitos ac\u00fasticos da transi\u00e7\u00e3o de registros podem ser ocultados com o treino constanteEste trabalho foi aprovado pelo Comit\u00ea de \u00c9tica em Pesquisa do Centro de Ci\u00eancias da Sa\u00fade da Universidade Federal de Pernambuco, sob o parecer 1.455.166. Os participantes assinaram o Termo de Consentimento Livre e Esclarecido, antes da coleta dos dados.Participaram 67 coristas adultos de diferentes corais, divididos em naipes, segundo a classifica\u00e7\u00e3o dada por seus respectivos regentes/professores de canto, a saber: soprano (n=20), contralto (n=17), tenor (n=15) e baixo (n=15). A m\u00e9dia de idade foi de 27,79  anos. Toda a amostra foi composta por cantores sem queixas vocais.software Vocalgrama, da CTS Inform\u00e1tica, instalado em um computador HP Notebook PC, com microfone Auricular Karsect HT-2 e um Adaptador Andrea PureAudio\u2122 USB-AS, para filtragem e redu\u00e7\u00e3o dos ru\u00eddos. Os registros vocais foram gravados no pr\u00f3prio programa, e o microfone foi ajustado a quatro cent\u00edmetros da comissura labial do cantor.Para coleta e an\u00e1lise dos dados utilizou-se o Para a grava\u00e7\u00e3o do PEV, o cantor foi solicitado a emitir a vogal /\u0190/ em glissando ascendente e descendente, chegando \u00e0 frequ\u00eancia mais grave e a mais aguda que era capaz de produzir, nas intensidades fraca e forte. Esses dados foram coletados tr\u00eas vezes, para cada cantor, a fim de se garantir a reprodutibilidade das medidas. O gr\u00e1fico selecionado para an\u00e1lise foi sempre o que representava a melhor emiss\u00e3o do sujeito..Os resultados do PEV s\u00e3o calculados pelo pr\u00f3prio programa, a partir de um gr\u00e1fico, delineado \u00e0 medida em que a emiss\u00e3o \u00e9 realizada. Nele \u00e9 poss\u00edvel identificar as frequ\u00eancias em Hertz (Hz) e as intensidades em decibel (dB), localizadas no eixo das abscissas e ordenadas, respectivamenteVari\u00e1veis dependentes: identifica\u00e7\u00e3o das notas de passagem (em %); frequ\u00eancia fundamental (f0) em Hertz (Hz); intensidade vocal em decibel (dB); 2) Vari\u00e1veis independentes: Modo de emiss\u00e3o do/\u0190/ glissando  e descendente (para o registro grave) e naipes .Para este estudo, foram consideradas as seguintes vari\u00e1veis de an\u00e1lise: 1) A investiga\u00e7\u00e3o da nota de passagem foi realizada atrav\u00e9s da an\u00e1lise do gr\u00e1fico gerado pelo software, de forma visual e perceptivo-auditiva. Os dados foram averiguados por dois pesquisadores (fonoaudi\u00f3logos com experi\u00eancia em canto), em consenso, sendo um terceiro convocado quando houve diverg\u00eancia entre os dois primeiros. Os pesquisadores observavam o gr\u00e1fico, enquanto reproduziam a grava\u00e7\u00e3o da vogal /\u0190/ em glissando (nos momentos ascendente e descendente) durante a an\u00e1lise das emiss\u00f5es. A \u201cquebra\u201d era identificada visualmente no momento em que ocorria a descontinuidade do sinal no gr\u00e1fico e, de forma perceptivoauditiva, pela instabilidade vocal t\u00edpica percebida pelos pesquisadores, enquanto ouviam tal reprodu\u00e7\u00e3o .A confirma\u00e7\u00e3o da presen\u00e7a da nota de passagem foi poss\u00edvel pela an\u00e1lise visual do gr\u00e1fico gerado pelo programa, pois este as representa como uma descontinuidade no tra\u00e7ado produzido. Dessa forma, para identifica\u00e7\u00e3o da frequ\u00eancia e intensidade das notas de passagem, posicionou-se o cursor do computador no centro do ponto que corresponde ao \u00faltimo registro anterior \u00e0 quebra. Para as emiss\u00f5es ascendentes, esse momento ocorre da esquerda para direita, enquanto que para as descendentes, da direita para a esquerda .. A nota\u00e7\u00e3o musical utilizada foi segundo a nota\u00e7\u00e3o americana, em que o D\u00f3 central  do teclado de um piano de sete oitavas, corresponde a C4.Para identifica\u00e7\u00e3o das notas correspondentes \u00e0s frequ\u00eancias encontradas utilizou-se o \u201cfrequency to musical note converter\u201dMann-Whitney. Todas as an\u00e1lises foram realizadas considerando-se o n\u00edvel de signific\u00e2ncia de 5%.Para testar a normalidade dos dados de f0 e intensidade, foi utilizado o teste de Shapiro-Wilk, rejeitando-se a hip\u00f3tese de distribui\u00e7\u00e3o normal quando p<0,05. Para compara\u00e7\u00e3o entre os naipes, quanto \u00e0 porcentagem de notas de passagem identificadas, utilizou-se o teste Qui-Quadrado para an\u00e1lise de propor\u00e7\u00f5es entre mais de duas amostras independentes e para a compara\u00e7\u00e3o entre as medianas de f0 e de intensidade das notas de passagem, utilizou-se o teste Os resultados quanto \u00e0 porcentagem de sujeitos cujas notas de passagem foram identificadas, por meio da an\u00e1lise perceptivo-auditiva e visual, est\u00e3o expressos na Quanto \u00e0s emiss\u00f5es no modo ascendente, houve diferen\u00e7a entre os naipes quanto \u00e0 identifica\u00e7\u00e3o das notas de passagem e no grupo dos tenores as quebras foram mais evidentes, comparativamente aos demais naipes, tanto nas emiss\u00f5es fracas, quanto nas fortes.Em rela\u00e7\u00e3o \u00e0s emiss\u00f5es no modo descendente, n\u00e3o houve diferen\u00e7a entre os naipes quanto \u00e0 ocorr\u00eancia das notas de passagem. Na compara\u00e7\u00e3o entre os modos ascendente e descendente e entre as emiss\u00f5es forte e fraca, n\u00e3o houve diferen\u00e7as na porcentagem de identifica\u00e7\u00e3o das notas de passagem.Ao considerar o total das notas de passagem identificadas, a maior porcentagem est\u00e1 nos naipes caracterizados pelas vozes mais agudas (soprano e tenor) comparativamente aos das vozes graves . A soma de tenores e sopranos representa 70% dos sujeitos identificados.A Ao considerar os resultados individuais, por naipe, observa-se que as notas de passagem s\u00e3o diferentes nos momentos ascendentes e descendentes e nos modos fraco e forte, sendo que as notas dos tenores e baixos foram muito pr\u00f3ximas, nas emiss\u00f5es ascendentes e a de sopranos e contraltos foi a mesma, nas emiss\u00f5es descendentes. No entanto, na an\u00e1lise inferencial, em que o grupo foi considerado em sua totalidade, devido ao n\u00famero pequeno de sujeitos na amostra, n\u00e3o houve diferen\u00e7a na f0 entre as emiss\u00f5es ascendentes e descendentes e entre os momentos fraco e forte. Quanto \u00e0 intensidade, como esperado, houve diferen\u00e7a entre os momentos fraco e forte, mas n\u00e3o entre as emiss\u00f5es ascendentes e descendentes.. Recursos computadorizados podem ajudar fonoaudi\u00f3logos e professores de canto no controle das transi\u00e7\u00f5es entre um registro e outro, considerando-se o feedback visual que esses recursos permitem. Portanto, este estudo se prop\u00f4s a estudar de forma preliminar a caracteriza\u00e7\u00e3o da nota de passagem por meio da identifica\u00e7\u00e3o da frequ\u00eancia e intensidade, tanto na transi\u00e7\u00e3o de notas ascendentes quanto descendentes.O estudo dos registros vocais n\u00e3o \u00e9 t\u00e3o salientado na literatura, comparativamente aos demais par\u00e2metros vocais, al\u00e9m de apresentar diverg\u00eancias conceituais entre profissionaisNeste estudo, com 67 coristas, p\u00f4de-se notar que, em todos os modos de emiss\u00e3o, a identifica\u00e7\u00e3o das notas de passagem n\u00e3o ultrapassou 30% do total de sujeitos. Isso pode se justificar pelo fato de que a amostra \u00e9 constitu\u00edda de cantores treinados, por serem participantes de Coral. A despeito de n\u00e3o se ter controlado a vari\u00e1vel tempo de treinamento em canto, pode-se supor que os cantores mais treinados tenham sido os que n\u00e3o apresentaram a nota de passagem evidenciada. Para a comprova\u00e7\u00e3o dessa hip\u00f3tese, sugere-se controlar a vari\u00e1vel tempo de treinamento em canto, em estudos futuros.,11, esperava-se maior identifica\u00e7\u00e3o da quebra nas emiss\u00f5es fracas. Por outro lado, considerando-se que o treino do canto visa tamb\u00e9m o controle desse apoio, pode-se inferir que, na amostra estudada, os cantores n\u00e3o apresentaram diferen\u00e7as entre esses dois modos, em consequ\u00eancia de seu treino.Uma vez que a pot\u00eancia, proje\u00e7\u00e3o e controle da emiss\u00e3o s\u00e3o aprimorados quando se obt\u00eam melhores condi\u00e7\u00f5es de apoio respirat\u00f3rio. Uma sugest\u00e3o para futuros estudos \u00e9 a de se comparar os dois tipos de emiss\u00e3o: em glissando e nota a nota, para se testar esses resultados.Outra poss\u00edvel explica\u00e7\u00e3o estaria na forma de emiss\u00e3o dos sons (em glissandos) que, a despeito de serem emiss\u00f5es mais pr\u00f3ximas da voz cantada, podem induzir \u00e0 maior limita\u00e7\u00e3o da extens\u00e3o vocal, comparativamente \u00e0 emiss\u00e3o nota a nota, que aumentariam as chances de evidencia\u00e7\u00e3o da nota de passagem. Essa hip\u00f3tese poderia ser confirmada por meio da compara\u00e7\u00e3o das extens\u00f5es fonat\u00f3rias entre os naipes. Sugere-se portanto, a continuidade deste estudo, para an\u00e1lise dessa vari\u00e1vel.Quanto \u00e0 distribui\u00e7\u00e3o entre os naipes da ocorr\u00eancia de identifica\u00e7\u00e3o das notas de passagem, cuja maior porcentagem ocorreu nos naipes de vozes agudas (tenores e sopranos) uma hip\u00f3tese para tal seria a poss\u00edvel maior extens\u00e3o fonat\u00f3ria das vozes agudas , ou entre Mi4 a Fa4 e Fa#4 .Devido \u00e0 escassez de estudos que levem em considera\u00e7\u00e3o a frequ\u00eancia fundamental das notas de passagem, optou-se por compar\u00e1-las \u00e0s notas que cada frequ\u00eancia representa, tendo em vista, tamb\u00e9m, sua aplicabilidade na classifica\u00e7\u00e3o vocal. O naipe dos sopranos apresentou notas que n\u00e3o corroboram as descritas na literatura, a saber: de Mi3 a Fa3 , em Re3 e entre Re4 e Mi4  e em R\u00e94 , enquanto que no presente estudo a nota de passagem foi mais aguda nas emiss\u00f5es ascendentes, no modo fraco; e mais grave nas emiss\u00f5es descendentes, no modo forte, comparativamente aos estudos citados.O mesmo aconteceu com o grupo dos contraltos, cuja quebra \u00e9 definida de Do3 a Reb3 e Si#3 (B#4). Embora sendo um dado que diverge dos demais autores, o La2 (A3) citado como a nota de passagem para esse grupo foi corroborado pelo presente estudo, que tamb\u00e9m encontrou essa nota na emiss\u00e3o grave fraca. O mesmo n\u00e3o aconteceu com a nota R\u00e93 (D4), presente na emiss\u00e3o ascendente fraca.Para os tenores, os autores assumem que as notas de passagem v\u00e3o de Mi3 a Fa3 (E4 a F4) (Eb4), mas concorda em parte com o estudo que admite que a \u201cquebra\u201d pode ser encontrada de D\u00f33 a Reb3 (C4 a Db4). Ao assumir Mi#2 (E#3), Sol2 (G3), R\u00e93 (D4) e Sol3 (G4) como notas de passagem para esse naipe, os achados do presente estudo corrobora, em parte, tais proposi\u00e7\u00f5es.No naipe dos baixos, as notas das emiss\u00f5es ascendentes fraca e forte foram D\u00f33 (C4) e R\u00e93 (D4), respectivamente, ao passo que aquelas encontradas nos descendentes fraco e forte foram L\u00e12 (A3) e D\u00f33 (C4). Tal achado difere do Mib3. Apenas o L\u00e12 (A3), encontrado na emiss\u00e3o descendente fraca do tenor, encontra-se na segunda oitava e, portanto, fora do que seria esperado.Ainda que apresente diferen\u00e7as na an\u00e1lise das notas, a avalia\u00e7\u00e3o por oitava permitiu observar que as notas identificadas para as quatro vozes pertencem \u00e0s oitavas indicadas: terceira e quarta oitava, para sopranos e contraltos, terceira oitava e a transi\u00e7\u00e3o entre a terceira e a quarta oitavas para os tenores, e segunda e terceira oitavas para os baixosPara as diverg\u00eancias encontradas entre este estudo e a literatura, pode-se inferir que o m\u00e9todo de an\u00e1lise tenha interferido, por serem coletados em um teste de extens\u00e3o vocal, no qual o corista vai da emiss\u00e3o mais grave \u00e0 mais aguda e vice-versa. Sugere-se, portanto, que estudos futuros adotem o D\u00f3 central como ponto inicial para as emiss\u00f5es ascendentes e descendentes.Quanto \u00e0 intensidade das notas, nas emiss\u00f5es fracas e fortes, n\u00e3o h\u00e1 dados comparativos na literatura e o n\u00famero de sujeitos, por naipe, cujas notas de passagem foram identificadas, n\u00e3o permitiu a compara\u00e7\u00e3o estat\u00edstica. Portanto, sugere-se aumento da amostra para estudos futuros, no intuito de se comparar a diferen\u00e7a dessa vari\u00e1vel, por naipe.Portanto, as notas de passagem foram identificadas em todos os naipes, tanto nas emiss\u00f5es fracas, quanto nas emiss\u00f5es fortes. Os valores medianos das frequ\u00eancias encontradas foram correspondentes a notas diferentes das estabelecidas na literatura, para todos os naipes. Quanto \u00e0s intensidades das notas de passagem, h\u00e1 necessidade de estudos com amostras maiores para o estabelecimento de valores de refer\u00eancia.feedback visual gr\u00e1fico desse evento pode auxiliar tanto na classifica\u00e7\u00e3o vocal quanto no acompanhamento de resultados de tratamento ou de aprimoramento vocal de cantores e n\u00e3o cantores, sendo \u00fatil para o registro da an\u00e1lise da voz e como recurso terap\u00eautico.Ressalte-se que este estudo preliminar permitiu ainda elucidar a aplicabilidade do Vocalgrama na identifica\u00e7\u00e3o, de forma instrumental, do fen\u00f4meno fisiol\u00f3gico da nota de passagem. O Ademais, o presente estudo se diferencia dos demais em pontos importantes, a saber: 1) realizou medidas de frequ\u00eancia, em vez de uso de instrumentos musicais, tornando os dados mais precisos e poss\u00edveis de serem calculadas as m\u00e9dias e medianas; 2) com emiss\u00f5es em glissando, em vez de nota a nota, por ser a emiss\u00e3o em glissando mais pr\u00f3xima da produ\u00e7\u00e3o de voz cantada, comparativamente; 3) nos modos de emiss\u00e3o forte e fraco, que, na voz cantada, t\u00eam um valor imprescind\u00edvel no controle aerodin\u00e2mico e na expressividade musical.-15, demonstrando que n\u00e3o h\u00e1 um consenso entre os autores. A car\u00eancia de estudos que fa\u00e7am uma an\u00e1lise considerando as diferentes condi\u00e7\u00f5es de emiss\u00e3o, como ascendente e descendente, forte e fraco, tamb\u00e9m dificultam a an\u00e1lise por nota ou frequ\u00eancia.Vale ressaltar, ainda, que as diferen\u00e7as sobre o tema s\u00e3o evidentes na pr\u00f3pria literaturaPortanto, tendo em vista a possibilidade atual de novos instrumentos de an\u00e1lise de car\u00e1ter menos subjetivo, como os utilizados tradicionalmente, sugere-se a continuidade do estudo com o aumento da amostra, a compara\u00e7\u00e3o de cantores treinados e n\u00e3o treinados e a compara\u00e7\u00e3o dos dados instrumentais com os resultados de an\u00e1lise perceptivoaudititva.As notas de passagem identificadas no perfil de extens\u00e3o vocal de coristas, a partir de suas frequ\u00eancias e intensidades, obtiveram maior ocorr\u00eancia nos naipes soprano e tenor, comparativamente ao contralto e baixo, nas mudan\u00e7as para os registros graves e agudos."}
+{"text": "They were randomized into two groups: traditional phonological therapy (control group - CG) and phonological therapy associated with a gamification strategy mediated by computer (gamification group - GG). The phonological intervention comprised, for both groups, stages of speech perception and production. Interventions differed in the perception stage, in which the GG was submitted to the game with gamification strategies. At the end of each session, individuals speech production (% of correct answers) were registered for each therapeutic stage, based on target words and sounding words. For analysis the following were considered: The individuals mean of correct answers for each therapeutic stage; PCC-R value (percentage of correct consonants) pre and post therapy; beyond of the number of sessions used to reach 85% of correct production.there was no statistical difference between the types of intervention considering the average of correct answers of the productions and the number of sessions. There was a significant effect for pre- and post-therapy conditions in the comparison PCC-R values \u200b\u200bfor both models. The individuals in the GC had the PCC-R values higher than those of GG.both models of intervention present similar results, providing an improvement in the individuals phonological performance from the first session. These strategies make up game-design resources and game elements in non-game contexts, with their differential being the ability to establish rewards, scoring, challenges, reinforcement, feedback and ranking-6.Among the areas of knowledge that can benefit from strategies associated with gamification is Speech Therapy, which can be employed in the evaluation and/or intervention stages. In recent years, gamification strategies have emerged in all areas of Speech Therapy, and their use has gradually increased, associated or not with games. Consequently, a product of this resource is the proposition and sale of various software involving games for assessing and treating subjects with different communication disorders. For example, Pedro\u2019s Spooky Night (Pedro em uma Noite Assustadora) stimulates phonological and phonoarticulatory awareness. Additionally, the Phonological Assessment Instrument  facilitates the assessment process of subjects with speech disorders, and the Hearing Disorders Rehabilitation Aid (Auxiliar na Reabilita\u00e7\u00e3o de Dist\u00farbios Auditivos - SARDA) stimulates cognitive-auditory-visual processing skills.Notably, among the potential users of these materials, some subjects present the diagnosis of Speech Sound Disorder, specifically Phonological Disorder (PD). Subjects with PD presented unexpected speech production for their age and development stage. In other words, they continue to use simplification rules  beyond the expected age without any apparent organic etiology-11. However, for this to happen, the subjects need to be motivated to carry out the activities proposed in the therapy that involves the ability in which they have the greatest difficulty, speech production.Over the years, studies that include phonological intervention have intensified to ascertain its efficacy and efficiency in the adult Brazilian Portuguese population. The intervention process in individuals with PD primarily aims to reorganize the altered phonological system and improve speech intelligibility. Thus, computer-based gamification strategies in the context of phonological therapy could be essential and/or complementary to traditional therapy methods.In this sense, it becomes a daily challenge for clinical speech therapists to develop strategies that motivate individuals with PD to help them work on their production difficulties, considering that, in general, the interest of children is focused on different technologies, like computers and other electronic devices, which aids in the acquisition and training of phonemes and activities elaborated in the Microsoft Office PowerPoint program, the authors verified that the therapy group submitted to computer-based gamification strategies obtained a more significant number of correct productions when compared to the group of subjects submitted to traditional therapy, without gamification. In Brazil, a study using the software FonoSpeak aiming to evaluate the effectiveness of therapeutic programs with the use of computer in subjects with Speech Sound Disorders, including PD, from the literature review of 14 studies, found that although the evidence based on computer use is still gaining ground, the literature has shown that this resource can be a valuable adjunct to therapy.In agreement with the study mentioned above, a research. This study compared the performance of PD subjects using three groups: subjects submitted to a gamification strategy therapy , traditional therapy and no therapy. No significant difference existed between the groups based on analyzing the subjects' speech production performance.However, there is contradictory evidence in the literature about the benefit of using gamification strategies with computer resources in treating individuals with PD, the effectiveness of the traditional phonological intervention was compared with the phonological intervention based on the use of the tablet, therefore, the subjects were randomized for each group. The authors concluded that there was no statistical difference between the groups, which means that regardless of the group, the subjects obtained percentages of correct speech production in the post-therapy condition.Similarly, in another study different from those mentioned above, which sought to describe the frequency of the tablet tool during intervention of subjects with PD. The gamification games used on the tablet were not of a speech-language nature but adapted to work on imitation/naming tasks at the levels of syllables, words and phrases. The tablet was used as an auxiliary route; therefore, it was available for the subject to request or not use during therapy. The study included four subjects aged between five years and five months to five years and eleven months. All subjects requested the tablet with significant frequency during the sessions, functioning as a motivating resource; however, not decisive for the evolution of the cases.There is also in the national literature, a researchThe studies, taken together, show not only contradictory results about the advantage of using gamification strategies in phonological therapy but also offer little scientific evidence insofar as the sampling was not random or the method used did not allow the comparison between proposals of different therapies.Assuming that the use of gamification strategies in the therapeutic process of subjects with PD could favor their engagement in activities and, consequently, favor the learning of the speech production skill worked on in therapy, it was hypothesized that subjects who receive phonological intervention associated with gamification strategies would present a better performance in terms of percentage of correct answers for the worked skill and a shorter therapeutic time when compared to subjects submitted to traditional phonological therapy. Therefore, the present study aimed to compare the effectiveness of phonological therapy associated with the gamification strategy with the efficacy of traditional therapy in subjects with PD.This study was prospective and longitudinal. It was approved by the Research Ethics Committee of the Faculty of Philosophy and Sciences/S\u00e3o Paulo State University (FFC/UNESP), Campus Mar\u00edlia, under protocol n\u00ba 4.615.118.The subjects' parents and/or guardians signed the Informed Consent Form, authorizing their participation in the project and the publication of the results. At the beginning of each therapeutic intervention session, the participating subjects were asked if they would agree to participate. All children expressed their respective acceptance.The recruited sample totaled 86 subjects and was based on speech-language screening, which included speech and language assessment, on Basic Health Unit and the Specialized Center in Rehabilitation. Both sites are located in the interior of S\u00e3o Paulo state, in the city of Mar\u00edlia. Therefore, the sampling process of the present study was for convenience.The research inclusion criteria required that the children were between four and eight years of age, diagnosed with PD, with the presence of the process of substituting a non-lateral liquid for a lateral one or vice versa (/\u027e/ \ud83e\udc6a [l] or /l/ \ud83e\udc6a [\u027e]), regardless of the severity of the PD or other associated phonological processes, and that the parents and/or guardians demonstrated interest and availability to participate in the proposed therapeutic intervention program.Exclusion criteria included significant structural alterations of the phonoarticulatory organs; the presence of comorbidities in addition to the speech production complaint; complaints of hearing and/or hearing disorders, and non-adherence to the proposed intervention program or possible dropouts.Ultimately, ten subjects participated in the study, six males and four females, aged between four years and eleven months to seven years and three months old, with a diagnosis of PD and who presented the phonological process of substituting non-lateral liquid for sideways or vice versa.. This instrument consists of 96 words that include all consonant phonemes in Brazilian Portuguese (BP) in the context of /i to u/ in accented positions. For this evaluation, 28 words were used, in which all BP phonemes occur only in the context of the vowel /a/.All subjects were submitted to a phonological assessment with the \u201cSpeech Assessment Instrument for Acoustic Analysis\u201d  to establish the PD diagnosis and characterize the phonological processes.Furthermore, the PD severity index was calculated using the Percent Consonants Correct - Revised (PCC-R), which refers to the percentage of consonants produced correctly in relation to the percentage of the total number of consonants contained in the obtained speech sample. For the calculation of this index, only substituted or omitted phonemes are considered errors.The following criteria were considered: a) mild: above 85% of correct answers; b) slightly moderate: between 65% and 85% of correct answers; c) moderately severe: between 50% and 65% of correct answers; d) severe: below 50% of correct answers to classify the different degrees of PDThe subjects were also submitted to an audiological assessment to investigate auditory thresholds to rule out possible alterations.After the characterization of the subjects, they were randomly selected and randomized into two groups: traditional phonological therapy (control group - CG) and phonological therapy associated with a computer-mediated gamification strategy (gamification group - GG). Both groups (CG and GG) had five subjects each. The subject profiles are presented in In the phonological-based intervention program for the CG and GG groups, there were 16 individual speech therapy sessions, with a frequency of two weekly 50-minute sessions, during the subjects' after-school hours.Thirty target words were selected with the phonemes /l/ and /\u027e/ in ISDP criteria (beginning of a syllable and within a word), worked on during the intervention stages, and another 30 probe words that were not worked on in therapy that served to observe the generalizations made by the subjects were used to conduct the intervention. As illustrated in The 16 speech therapy sessions for the CG and GG consisted of speech perception and production stages, namely: 1) pre-intervention: initial collection/presentation and contextualization of the pictures corresponding to the selected words; 2) explanation of the phonological process, based on the contrastive value of the target words, it was explained to the subject, through a prototype of phonoarticulatory organs, that there are sounds that the language hits slowly as is the case of /l/ and there are sounds that the language hits fast as in the production of /\u027e/; 3) perception in the other, the subject performed auditory-visual perception immediately after speech production of the target sounds of the other (therapist); 4) perception itself, based on the production of the target sounds, the subject simultaneously performed auditory-visual proprioception. In this skill, the correct production of the target sound was not required; the subject should only perform his proprioception; 5) production: the subject should correctly produce the target sound (based on facilitating cues) in an isolated word and the construction of sentences; and 6) post-intervention: final collection.The interventions differed in stage 3, related to the perception of the other, in which the CG relied exclusively on ludic activities with physical material, while the GG was submitted to the gamification game \u201cHo-ho roubaram as palavras\u201d (English \u201cHo-ho stole the words\u201d) mediated by the computer. Therefore, this group's subjects should perceive the target sounds from the speech of the other through the game.. The game interface is shown in The game was developed in partnership with a team of professionals from Faculty of Technology (FATEC) of S\u00e3o Jos\u00e9 do Rio Preto in the interior of S\u00e3o Paulo state coordinated by Dr. Henrique Dezani. The developed platform can be used on computers, available online and free of charge. \u201cHo-ho roubaram as palavras\u201d/\u201dHo-ho stole the words\u201d has as its main character Santa Claus. The game aims to engage the subject to find the 30 target words hidden in the game scenario. As the subject finds the target words, the auditory stimuli corresponding to each figure, produced by the other, are presented so that the subject can identify the target sounds. It can be accessed via the link found in the referencesFor both interventions, each subject's performance was recorded through speech production recordings, calculated from the percentage of correct answers for each therapeutic skill worked out of the 30 target and 30 probe words. The recordings of the subjects' speech productions were made only at the end of each session for subsequent auditory-perceptual analyses.The recordings of speech productions were analyzed by at least two referees who performed the judgment based on three criteria: (A) target sound production success, (E) target sound production error or (G) gradient production. A total of 960 recordings were made for each subject. A third referee was necessary to confirm the analysis of 281 (118 recordings for target words and 163 recordings for probe words) recordings of all subjects in the sample.For each therapeutic stage , the averages of correct answers were considered in terms of percentage for each CG and GG subject.PCC-R values were compared in pre- and post-therapy conditions in both groups. An analysis was also made of the number of sessions required to reach 85% correct production between the types of intervention. The 16 proposed sessions were carried out regardless of whether they reached the established correct production.Descriptive and inferential statistical analyzes were performed using the STATISTICA software (version 7.0). Repeated Measures ANOVA was utilized to compare group performance (CG vs. GG) in the therapeutic intervention stages and the PCC-R pre- and post-therapy values. The Post hoc test used was the Scheff\u00e9 test. One-way ANOVA was used to compare the number of sessions in the two interventions. A value of \u03b1>0.05 was established.Regarding the comparison of the number of sessions necessary for the subjects to reach at least 85% of correct production of the worked target sounds (/\u027e/) or (/l/), there was no significant difference based on the One-Way ANOVA results =0.80, p=0.39). Moreover, there was no difference between the number of sessions as a function of the type of therapy. These results are presented in The present study aimed to compare the effectiveness of phonological therapy associated with the gamification strategy and traditional therapy in subjects with PD. It was expected that the subjects submitted to the phonological intervention associated with the gamification strategies would present a better performance in terms of the percentage of correct answers of the worked skills and a shorter therapeutic time when compared to the subjects submitted to the traditional phonological therapy.Concerning group performance, we found no differences in accuracy or intervention stage  or the n,15 that did not detect a statistically significant difference in speech production performance when evaluating interventions with and without gamification strategies. These results are consistent with previous studies, the authors proposed that this result is due to the intervention consisting of only one weekly 30-minute session for eight weeks, a relatively short period to detect differences between the two interventions. In the present study, the consultations were also carried out for eight weeks but with two 50-minute sessions per week and did not yield significant differences.In a study mentioned1 reported that a computer-based gamification strategy favors more changes in the subjects' phonological system when compared to traditional therapy. However, the authors of this study warned of the need to conduct further research with an expansion of the sample to confirm the findings, considering that only four subjects participated in the study. On the other hand, in another study. The authors found that SIFALA improved correct speech sound production, facilitated lexical representation and augmented phonetic-phonological system information storage. Another study applied questionnaires aimed at speech therapists and individuals with PD to verify the usability and usefulness of the KeRa Puzzle digital game in therapeutic intervention. The findings showed that gamification had satisfactory usability and made the sessions more playful.Additionally, another study showed a gamification strategy using the Speech Intervention Software (SIFALA), which allows subjects to explore and achieve treatment objectivesFactors such as familiarity with the computer, subject age, motivational aspects, family participation, number of subjects and intra-group heterogeneity could account for the lack of difference between the interventions.Although the familiarity with the computer was not an analyzed variable, in the present study, three GG subjects  had knowledge and interest in operating the computer and electronic games. This fact favored engagement throughout the use of the tool in the sessions. In contrast, subjects S3 and S8  never used a computer and, initially, had difficulties handling the electronic device, making it challenging to engage and motivate with the proposed game immediately.Concerning age, the GG subjects S2, S7 and S9, aged 5:11, 5:5 and 6:11, respectively, showed more interest in and sustained attention to the game than subjects S3 and S7, aged 4:11 and 5:0. A vital factor in younger subjects was the need to enhance gamification elements such as ranking, scoring and interactive awards during the activity to arouse their interest and encourage them to continue and to recognize their potential.,2. It was observed that the effective combination of intrinsic  and extrinsic (proposed gamification) motivations contributed to the level of motivation and engagement of the GG subjects. However, this aspect was the same compared to CG subjects.One of the elements of gamification is the motivational aspect-25. This aspect was not considered in the analysis of the study. The family participation  of the subjects participating in the present study was quite heterogeneous. This result could be an influential factor in the performance and therapeutic interest of the subjects, regardless of the type of intervention.Regarding family participation, previous studies have highlighted the relevance of family participation of parents/guardians in the intervention process to contribute to therapeutic efficacyConcerning the number of subjects, our sample size did not allow for a generalization of the results. Due to this limitation, it is recommended that future randomized studies be carried out with more participants.Furthermore, intra-group heterogeneity in the degree of PD severity within each group could account for the lack of difference between the interventions. In the CG , most suppressed the liquid replacement processes at the end of the therapeutic process, except for S10, who presented 75% of correct production of the contrastive phoneme /\u027e/. When comparing subject S10 with the other subjects belonging to the same group, it was noted that he presented a higher degree of TF severity (slightly-moderate) and other phonological processes beyond the liquid class.In contrast, in the GG, composed of subjects S2, S3, S7, S8 and S9, only S2 suppressed the worked phonological process. This subject was the only case that presented mild severity of PD and phonological processes only in the liquid class. The other group participants displayed higher PD severity and other phonological processes involving different classes.Although the main focus of the present study was not to compare the performance of the subjects in relation to the skills worked on in therapy, it was observed that in both groups, the pre-therapy conditions showed a low percentage of the correctness of the target sounds compared to the stages of perception (in the other and oneself) and speech production. This result means that from the beginning of the intervention process, all subjects already present a change in accuracy. exploring the possibility that the perception skill precedes the speech production skill. In other words, for an individual to appropriately produce a specific contrastive phoneme, they must perceive the phonetic properties- phonological and then substantiate these properties in their productions.Among the stages, the accuracy (% of correct answers) and perception (in the other and oneself) differ from the accuracy of speech production in both groups. The subjects showed better performance in perception than in speech production. This result corroborates the assumption of a study, the authors point out that the existing correlation between production and perception depends on the phonological class and that speech perception errors do not mirror speech production errors. Another study reported a significant correlation between speech production skills and perception of the subject's atypical speech production. This result suggests that assessing these skills seems to access the same underlying phonological representation. In this sense, if a subject has not established the underlying representation for a given phonological contrast, it will affect both skills: perception of the other's speech and perception of their speech, since the performance in perception skills requires access to a symbolic system, which may cause or contribute to deficits in speech production and perception. Therefore, considering the studies mentioned above, the speech perception ability directs us to an important implication in the rehabilitation process in phonological-based models since its inclusion in the evaluation and intervention could maximize therapeutic efficacy.Another aspect to consider is that no univocal correlation exists between speech production and perception. As mentioned in a previous studyRegarding PCC-R, differences were observed when comparing pre- and post-therapy and group values . As prevBoth intervention models  improve the subject's phonological performance from the first session. There was no difference in therapy time or between the mean percentage of correct answers in the production of target words between the two approaches. A notable therapeutic implication is the possibility of using a computer-based gamification strategy to obtain results similar to those expected in traditional therapy.The development of the present study aimed to contribute to the scientific discussions about therapy in the field of Clinical Phonology, favor the establishment of interventional processes of speech therapy mediation with gamification strategies and encourage the construction of new gamification strategies considering stages of perception and speech production. gamification, refere-se ao uso de mecanismos de jogos, brinquedo, brincadeira ou ludicidade  orientados com o objetivo de despertar engajamento entre um p\u00fablico espec\u00edfico. Essas estrat\u00e9gias comp\u00f5em recursos de game-design e elementos de jogos em contextos n\u00e3o-game, sendo o seu diferencial a capacidade de estabelecer recompensas, pontua\u00e7\u00e3o, desafios, refor\u00e7os, feedback e ranking-2.A gamifica\u00e7\u00e3o, advinda do ingl\u00eas Dentre as \u00e1reas do conhecimento que podem se beneficiar de estrat\u00e9gias associadas \u00e0 gamifica\u00e7\u00e3o encontra-se a Fonoaudiologia; que pode fazer uso destas estrat\u00e9gias, tanto no processo de avalia\u00e7\u00e3o, quanto no processo de interven\u00e7\u00e3o.softwares envolvendo jogos para avalia\u00e7\u00e3o e terapia de sujeitos com distintas altera\u00e7\u00f5es da comunica\u00e7\u00e3o, tais como: \u201cPedro em uma noite Assustadora\u201d, cuja finalidade \u00e9 estimular a consci\u00eancia fonol\u00f3gica e fonoarticulat\u00f3ria; o Instrumento de Avalia\u00e7\u00e3o Fonol\u00f3gica (INFONO), voltado para facilitar o processo de avalia\u00e7\u00e3o de sujeitos com altera\u00e7\u00f5es de fala; al\u00e9m do \u201cAuxiliar na Reabilita\u00e7\u00e3o de Dist\u00farbios Auditivos (SARDA)\u201d, que inclui a fun\u00e7\u00e3o de estimular as habilidades de processamento cognitivo-auditivo-visual-6.Nos \u00faltimos anos, em todas as \u00e1reas da Fonoaudiologia vem aumentando paulatinamente o uso de estrat\u00e9gias de gamifica\u00e7\u00e3o, associadas ou n\u00e3o a jogos. Como consequ\u00eancia, observa-se como um produto concreto da utiliza\u00e7\u00e3o deste recurso a proposi\u00e7\u00e3o e a comercializa\u00e7\u00e3o de diversos .Particularmente, dentre os potenciais usu\u00e1rios desses materiais, encontram-se aqueles sujeitos que apresentam o diagn\u00f3stico de Transtorno dos Sons da Fala - especificamente Transtorno Fonol\u00f3gico (TF). Os sujeitos com TF apresentam produ\u00e7\u00e3o de fala n\u00e3o esperada para a idade e est\u00e1gio de desenvolvimento, ou seja, continuam a empregar regras de simplifica\u00e7\u00e3o, designadas de processos fonol\u00f3gicos, para al\u00e9m da idade esperada sem que haja etiologia org\u00e2nica aparente-11.Ao longo dos anos, tem se intensificado estudos que englobam a interven\u00e7\u00e3o fonol\u00f3gica com o intuito de averiguar sua efic\u00e1cia e efici\u00eancia nessa popula\u00e7\u00e3o, uma vez que o processo de interven\u00e7\u00e3o em sujeitos com TF tem como objetivo principal reorganizar o sistema fonol\u00f3gico alterado, de modo a atingir o sistema de um adulto t\u00edpico para o Portugu\u00eas Brasileiro melhorando, consequentemente, a inteligibilidade de falaPara tanto, os sujeitos precisam estar motivados - o suficiente - para realizarem atividades propostas na terapia que envolva a habilidade em que eles t\u00eam maior dificuldade: a produ\u00e7\u00e3o de fala..Nesse sentido, torna-se um desafio di\u00e1rio para o fonoaudi\u00f3logo cl\u00ednico pensar em estrat\u00e9gias que motivem os sujeitos com TF propiciando trabalhar as suas dificuldades de produ\u00e7\u00e3o, tendo em vista que, em geral, o interesse do p\u00fablico infantil est\u00e1 voltado \u00e0s diversas tecnologias, tal como o uso do computadorConstata-se que estrat\u00e9gias de gamifica\u00e7\u00e3o com o uso do computador no \u00e2mbito da terapia fonol\u00f3gica podem ser ferramentas essenciais e complementares quando comparadas aos m\u00e9todos tradicionais de terapia, ou seja, aqueles em que s\u00e3o propostas figuras, associadas ou n\u00e3o \u00e0 jogos, para que o sujeito as nomeie.software FonoSpeak - cujo objetivo \u00e9 auxiliar na aquisi\u00e7\u00e3o e treinamento de fonemas - em conjunto com atividades elaboradas no programa Microsoft Office Power Point, os autores verificaram que o grupo de terapia submetido a estrat\u00e9gias de gamifica\u00e7\u00e3o com o recurso do computador obteve maior n\u00famero de produ\u00e7\u00f5es corretas quando comparado ao grupo de sujeitos submetidos \u00e0 terapia tradicional, ou seja, sem uso de estrat\u00e9gias de gamifica\u00e7\u00e3o.No Brasil, uma pesquisa realizada com o uso do  com objetivo de avaliar a efic\u00e1cia de programas terap\u00eauticos com o uso do computador em sujeitos com Dist\u00farbio dos Sons da Fala, incluindo o TF, a partir da revis\u00e3o de literatura de 14 estudos, verificou que embora a base de evid\u00eancias com o uso do computador ainda esteja ganhando espa\u00e7o, de modo geral, a literatura mostrou que esse recurso pode ser um complemento \u00fatil para a terapia.Em concord\u00e2ncia com o estudo citado acima, uma pesquisa, particularmente, foi comparado o desempenho de sujeitos com TF a partir da divis\u00e3o de tr\u00eas grupos: sujeitos submetidos \u00e0 terapia com o uso de estrat\u00e9gias de gamifica\u00e7\u00e3o ; sujeitos submetidos \u00e0 terapia tradicional; e sujeitos que n\u00e3o foram submetidos a qualquer terapia. A partir da an\u00e1lise do desempenho de produ\u00e7\u00e3o de fala dos sujeitos, n\u00e3o houve diferen\u00e7a significativa entre nenhum dos tr\u00eas grupos.Todavia, h\u00e1 evid\u00eancias contradit\u00f3rias na literatura sobre o benef\u00edcio do uso de estrat\u00e9gias de gamifica\u00e7\u00e3o com o recurso do computador na terapia de sujeitos com TF. Neste estudo foi feita a compara\u00e7\u00e3o da efic\u00e1cia da interven\u00e7\u00e3o fonol\u00f3gica tradicional com a interven\u00e7\u00e3o fonol\u00f3gica baseada no uso do tablet, sendo assim, os sujeitos foram randomizados para cada grupo. Os autores conclu\u00edram que n\u00e3o houve diferen\u00e7a estat\u00edstica entre os grupos, isso significa que independente do grupo, os sujeitos obtiveram porcentagens de produ\u00e7\u00f5es de fala corretas na condi\u00e7\u00e3o p\u00f3s-terapia.Semelhantemente, em outro estudo distinta das supracitadas, que buscou descrever a frequ\u00eancia da ferramenta do tablet durante interven\u00e7\u00e3o de sujeitos com TF. Os jogos de gamifica\u00e7\u00e3o utilizados no tablet n\u00e3o eram de cunho fonoaudiol\u00f3gico, mas sim adaptados ao trabalho em tarefas de imita\u00e7\u00e3o/nomea\u00e7\u00e3o aos n\u00edveis de s\u00edlabas, palavras e frases. O tablet, era utilizado como uma via auxiliar, sendo assim, ficava dispon\u00edvel para que o sujeito solicitasse ou n\u00e3o sua utiliza\u00e7\u00e3o durante a terapia. No estudo citado, pertenceu quatro sujeitos com faixas et\u00e1rias entre cinco anos e cinco meses a onze meses e, como resultado, apontou que todos os sujeitos solicitaram o tablet com frequ\u00eancia significativa no decorrer das sess\u00f5es, funcionando como recurso motivador, contudo, n\u00e3o decisivo para evolu\u00e7\u00e3o dos casos.H\u00e1 ainda na literatura nacional, uma pesquisaOs estudos, tomados juntos, mostram n\u00e3o apenas resultados divergentes sobre a vantagem do uso de estrat\u00e9gias de gamifica\u00e7\u00e3o na terapia fonol\u00f3gica, como tamb\u00e9m mostram baixa evid\u00eancia cient\u00edfica, na medida em que a amostragem n\u00e3o foi aleat\u00f3ria ou o m\u00e9todo utilizado n\u00e3o permitiu a compara\u00e7\u00e3o entre propostas terap\u00eauticas distintas.Assumindo que o uso de estrat\u00e9gias de gamifica\u00e7\u00e3o no processo terap\u00eautico de sujeitos com TF poderia favorecer o engajamento dos sujeitos nas atividades e, consequentemente, favorecer o aprendizado da habilidade de produ\u00e7\u00e3o de fala trabalhado na terapia; hipotetizou-se que sujeitos que recebem interven\u00e7\u00e3o fonol\u00f3gica associada \u00e0s estrat\u00e9gias de gamifica\u00e7\u00e3o apresentariam melhor desempenho em termos de porcentagem de acerto da habilidade trabalhada e um menor tempo terap\u00eautico, quando comparadas com os sujeitos submetidos \u00e0 terapia fonol\u00f3gica tradicional.Portanto, este estudo objetivou comparar a efic\u00e1cia da terapia fonol\u00f3gica associada \u00e0 estrat\u00e9gia de gamifica\u00e7\u00e3o com a efic\u00e1cia da terapia tradicional em sujeitos com TF.Trata-se de um estudo longitudinal prospectivo. Este estudo foi aprovado pelo Comit\u00ea de \u00c9tica em Pesquisa (CEP) da Faculdade de Filosofia e Ci\u00eancias/Universidade Estadual Paulista (FFC/UNESP), Campus Mar\u00edlia, sob o protocolo n\u00ba 4.615.118.Os pais e/ou respons\u00e1veis pelos sujeitos assinaram o Termo de Consentimento Livre e Esclarecido, autorizando a participa\u00e7\u00e3o dos mesmos no projeto, bem como a publica\u00e7\u00e3o dos resultados. Esclarece-se, ainda, que a cada in\u00edcio das sess\u00f5es de interven\u00e7\u00e3o terap\u00eautica, era perguntado para os sujeitos participantes se eles aceitariam participar da sess\u00e3o. Portanto, todos os sujeitos expressaram o seus respectivos aceites.Participaram do estudo dez sujeitos, seis do g\u00eanero masculino e quatro do feminino na faixa et\u00e1ria entre quatro anos e onze meses a sete anos e tr\u00eas meses de idade, com diagn\u00f3stico de TF e que apresentavam o processo fonol\u00f3gico de substitui\u00e7\u00e3o de l\u00edquida n\u00e3o-lateral por lateral ou vice-versa (/\u027e/ \u2192 [l] ou /l/ \u2192 [\u027e]).A amostra recrutada totalizou-se em 86 sujeitos a partir de triagem fonoaudiol\u00f3gica, que incluiu avalia\u00e7\u00e3o de fala e de linguagem, na Unidade B\u00e1sica de Sa\u00fade e no Centro Especializado em Reabilita\u00e7\u00e3o (CER II). Ambos s\u00e3o localizados no interior do Estado de S\u00e3o Paulo, na cidade de Mar\u00edlia, portanto, o processo de amostragem do presente estudo foi por conveni\u00eancia.Os crit\u00e9rios de inclus\u00e3o da pesquisa foram ter idade entre quatro a oito anos; apresentar diagn\u00f3stico de TF - com a presen\u00e7a do processo de substitui\u00e7\u00e3o de l\u00edquida n\u00e3o-lateral por lateral ou vice-versa, independente da gravidade do TF e de outros processos fonol\u00f3gicos associados; pais e/ou respons\u00e1veis demonstrarem interesse e disponibilidade para participar do programa de interven\u00e7\u00e3o terap\u00eautico proposto.Os crit\u00e9rios de exclus\u00e3o foram altera\u00e7\u00e3o estrutural significativa dos \u00f3rg\u00e3os fonoarticulat\u00f3rios; presen\u00e7a de comorbidades al\u00e9m da queixa de produ\u00e7\u00e3o de fala; queixa e/ou altera\u00e7\u00f5es auditivas e a n\u00e3o ades\u00e3o ao programa de interven\u00e7\u00e3o proposto ou poss\u00edveis desist\u00eancias.. Esse instrumento \u00e9 composto por 96 palavras que contemplam todos os fonemas consonantais do Portugu\u00eas Brasileiro (PB) em contexto de /i a u/ nas posi\u00e7\u00f5es acentuadas. Para essa avalia\u00e7\u00e3o, foram utilizadas apenas 28 palavras, em que todos os fonemas do PB ocorrem apenas no contexto da vogal /a/.Para estabelecer o diagn\u00f3stico de TF e caracterizar os processos fonol\u00f3gicos, todos os sujeitos foram submetidos \u00e0 avalia\u00e7\u00e3o fonol\u00f3gica com o \u201cInstrumento de Avalia\u00e7\u00e3o de Fala para An\u00e1lise Ac\u00fastica\u201d - IAFAC.Ademais, foi realizado o c\u00e1lculo do \u00edndice de gravidade do TF por meio da Porcentagem de Consoantes Corretas-Revisado (PCC-R) que se refere \u00e0 porcentagem de consoantes produzidas corretamente em rela\u00e7\u00e3o percentual ao total de consoantes contidas na amostra de fala obtida, al\u00e9m disso, para o c\u00e1lculo deste \u00edndice s\u00e3o considerados como erros somente os fonemas substitu\u00eddos ou omitidos.Para classifica\u00e7\u00e3o dos diferentes graus do TF, foram considerados os crit\u00e9rios: a) leve: acima de 85% de acertos; b) levemente moderado: entre 65% e 85% de acertos; c) moderadamente severo: entre 50% e 65% de acertos; d) severo: abaixo de 50% de acertosOs sujeitos tamb\u00e9m foram submetidos \u00e0 avalia\u00e7\u00e3o audiol\u00f3gica para pesquisa de limiares auditivos para descarte de poss\u00edveis altera\u00e7\u00f5es.Ap\u00f3s a caracteriza\u00e7\u00e3o dos sujeitos, os mesmos foram submetidos a um sorteio e randomizados em dois grupos, sendo eles: terapia fonol\u00f3gica tradicional (grupo controle - GC) e terapia fonol\u00f3gica associada \u00e0 estrat\u00e9gia de gamifica\u00e7\u00e3o mediada por computador (grupo gamifica\u00e7\u00e3o - GG). Ambos os grupos (GC e GG), pertenceram 5 sujeitos cada um, conforme descrito na No programa de interven\u00e7\u00e3o de base fonol\u00f3gica realizado para os grupos GC e GG, totalizaram-se 16 sess\u00f5es de atendimentos fonoaudiol\u00f3gicos individuais, com frequ\u00eancia de duas vezes por semana e dura\u00e7\u00e3o de 50 minutos cada -, no contraturno escolar dos sujeitos.Para a realiza\u00e7\u00e3o da interven\u00e7\u00e3o, foram selecionadas 30 palavras-alvo com os fonemas /l/ e /\u027e/ em crit\u00e9rio de ISDP , trabalhadas durante as etapas de interven\u00e7\u00e3o e outras 30 palavras-sondagem, isto \u00e9, palavras n\u00e3o trabalhadas em terapia que serviram para observar as generaliza\u00e7\u00f5es realizadas pelos sujeitos. Al\u00e9m disso, parte das palavras selecionadas se referem \u00e0 pares-m\u00ednimos, ou seja, palavras que se diferem em apenas um fonema, conforme ilustrado no As 16 sess\u00f5es de interven\u00e7\u00e3o fonoaudiol\u00f3gica destinadas ao GC e GG foram compostas por etapas de percep\u00e7\u00e3o e produ\u00e7\u00e3o de fala, sendo elas: 1) pr\u00e9-interven\u00e7\u00e3o - coleta inicial/ apresenta\u00e7\u00e3o e contextualiza\u00e7\u00e3o das gravuras correspondentes \u00e0s palavras selecionadas; 2) explica\u00e7\u00e3o do processo fonol\u00f3gico - a partir do valor contrastivo das palavras-alvo, foi explicado para o sujeito, por meio de um prot\u00f3tipo de \u00f3rg\u00e3os fonoarticulat\u00f3rios, que existem sons que a l\u00edngua bate devagar como \u00e9 o caso do /l/ e existem sons que a l\u00edngua bate r\u00e1pido como na produ\u00e7\u00e3o de /\u027e/; 3) percep\u00e7\u00e3o no outro - o sujeito realizou percep\u00e7\u00e3o auditiva-visual imediatamente ap\u00f3s a produ\u00e7\u00e3o de fala dos sons-alvo do outro (terapeuta); 4) percep\u00e7\u00e3o em si - a partir da pr\u00f3pria produ\u00e7\u00e3o dos sons-alvo, o sujeito realizou simultaneamente a propriocep\u00e7\u00e3o auditiva-visual. Nesta habilidade, n\u00e3o foi exigida a produ\u00e7\u00e3o correta do som-alvo, o sujeito deveria realizar apenas sua propriocep\u00e7\u00e3o; 5) produ\u00e7\u00e3o - o sujeito deveria produzir o som-alvo corretamente (a partir de pistas facilitadoras) em palavra isolada e na constru\u00e7\u00e3o de frases; e 6) p\u00f3s interven\u00e7\u00e3o - coleta final.As interven\u00e7\u00f5es se diferenciaram na etapa 3, relativa \u00e0 percep\u00e7\u00e3o no outro, na qual o GC contou exclusivamente com atividades l\u00fadicas de material f\u00edsico na 3 e nas demais etapas, enquanto o GG, somente nessa etapa, foi submetido ao jogo de gamifica\u00e7\u00e3o \u201cHo-ho roubaram as palavras\u201d mediado pelo computador. Sendo assim, os sujeitos desse grupo deveriam perceber os sons-alvo a partir da fala do outro por meio do game.O jogo foi desenvolvido em parceria com a equipe de profissionais da Faculdade de Tecnologia (FATEC) de S\u00e3o Jos\u00e9 do Rio Preto, no interior do estado de S\u00e3o Paulo, coordenado pelo Dr. Henrique Dezani.. Na A plataforma elaborada tem seu uso para computadores, com disponibilidade online e gratuita. \u201cHo-ho roubaram as palavras\u201d, tem como personagem principal um papai-noel, no qual o intuito do game \u00e9 engajar o sujeito a encontrar as 30 palavras-alvo escondidas pelo cen\u00e1rio do jogo, conforme pode-se acessar atrav\u00e9s do link apresentado nas refer\u00eanciasA medida em que o sujeito encontra as palavras-alvos, s\u00e3o apresentados os est\u00edmulos auditivos correspondentes \u00e0 cada figura, produzidas pelo outro, para que o sujeito identifique os sons-alvos.Para ambos os tipos de interven\u00e7\u00e3o, foi realizado o registro do desempenho de cada sujeito, por meio de grava\u00e7\u00f5es de produ\u00e7\u00e3o de fala, calculado a partir da porcentagem de acerto de cada habilidade terap\u00eautica trabalhada das 30 palavras-alvo e 30 palavras-sondagem. As grava\u00e7\u00f5es de produ\u00e7\u00f5es de fala dos sujeitos foram realizadas apenas ao final de cada sess\u00e3o para posteriormente serem feitas as an\u00e1lises perceptivo-auditivas.As grava\u00e7\u00f5es de produ\u00e7\u00f5es de fala, foram postas sob an\u00e1lise de, ao menos, dois ju\u00edzes que realizaram o julgamento baseado em tr\u00eas crit\u00e9rios: (A) acerto de produ\u00e7\u00e3o do som-alvo, (E) erro de produ\u00e7\u00e3o do som-alvo ou (G) produ\u00e7\u00e3o gradiente. Totalizou-se 960 grava\u00e7\u00f5es para cada sujeito e foi necess\u00e1rio a presen\u00e7a de um terceiro juiz para confirmar a an\u00e1lise de 281 grava\u00e7\u00f5es de todos os sujeitos da amostra, sendo 118 grava\u00e7\u00f5es para palavras-alvo e 163 grava\u00e7\u00f5es para palavras-sondagem.Para cada etapa terap\u00eautica  foram consideradas as m\u00e9dias de acerto, em termos de porcentagem para cada sujeito do GC e GG.Os valores de PCC-R foram comparados nas condi\u00e7\u00f5es pr\u00e9 e p\u00f3s-terapia em ambos os grupos. Tamb\u00e9m foi feita a an\u00e1lise do n\u00famero de sess\u00f5es utilizadas para se atingir 85% de produ\u00e7\u00e3o correta entre os tipos de interven\u00e7\u00e3o. As 16 sess\u00f5es propostas foram realizadas, independentemente se atingiram ou n\u00e3o a produ\u00e7\u00e3o correta estabelecida.software STATISTICA (vers\u00e3o 7.0). Utilizou-se a ANOVA de Medidas Repetidas para a compara\u00e7\u00e3o entre os desempenhos dos grupos (GC e GG) nas etapas de interven\u00e7\u00e3o do processo terap\u00eautico e nos valores do PCC-R pr\u00e9- e p\u00f3s-terapia. O teste Pos hoc utilizado foi o de Scheff\u00e9. Para a compara\u00e7\u00e3o entre o n\u00famero de sess\u00f5es nos dois tipos de interven\u00e7\u00e3o, utilizou-se a ANOVA One-way. Estabeleceu-se um valor de \u03b1>0,05.An\u00e1lises estat\u00edsticas descritiva e inferencial foram feitas com o uso do A Post Hoc de Scheff\u00e9 mostrou diferen\u00e7a estat\u00edstica entre a pr\u00e9-terapia e as demais sess\u00f5es da interven\u00e7\u00e3o terap\u00eautica e, ainda, entre as etapas de percep\u00e7\u00e3o (no outro e em si) e a produ\u00e7\u00e3o  para ambos os grupos, conforme ilustrado na A Anova de medidas repetidas somente mostrou efeito significante para as etapas do processo terap\u00eautico =32,452, p<0,01), ou seja, avalia\u00e7\u00e3o inicial da produ\u00e7\u00e3o (ou pr\u00e9-terapia), percep\u00e7\u00e3o no outro, percep\u00e7\u00e3o em si e produ\u00e7\u00e3o; mas n\u00e3o apresentou efeito significante nem para o tipo de interven\u00e7\u00e3o (GC e GG) e nem para intera\u00e7\u00e3o entre interven\u00e7\u00e3o*etapas do processo terap\u00eautico. O teste A Na compara\u00e7\u00e3o entre os valores do PCC-R pr\u00e9 e p\u00f3s-terapia do grupo de sujeitos submetidos \u00e0 terapia tradicional (GC) e terapia mediada por estrat\u00e9gia de gamifica\u00e7\u00e3o (GG), utilizou-se a ANOVA de Medidas Repetidas. Como resultados, houve efeito significante para as condi\u00e7\u00f5es pr\u00e9 e p\u00f3s-terapia =39,31, p>0,00) e para o tipo de interven\u00e7\u00e3o =7,08, p<0,00), mas n\u00e3o houve efeito significante para a intera\u00e7\u00e3o entre pr\u00e9-p\u00f3s*tipo de terapia =0,39,p=0,54). Embora os valores de PCC-R aumentaram para todos os sujeitos na compara\u00e7\u00e3o das condi\u00e7\u00f5es pr\u00e9 e p\u00f3s-terapia, os sujeitos do GC tiveram os valores de PCC-R maiores do que os sujeitos do GG, tal como ilustra a One-Way n\u00e3o mostrou diferen\u00e7a significante =0,80, p=0,39). Isto \u00e9, n\u00e3o houve diferen\u00e7a entre o n\u00famero de sess\u00f5es em fun\u00e7\u00e3o do tipo de terapia. A Em rela\u00e7\u00e3o \u00e0 compara\u00e7\u00e3o do n\u00famero de sess\u00f5es necess\u00e1rias para que os sujeitos atingissem pelo menos 85% de produ\u00e7\u00e3o correta do sons-alvo trabalhados (/\u027e/) ou (/l/) a ANOVA O presente estudo objetivou comparar as efic\u00e1cias da terapia fonol\u00f3gica associada \u00e0 estrat\u00e9gia de gamifica\u00e7\u00e3o e a terapia tradicional em sujeitos com TF. Esperava-se que os sujeitos submetidos \u00e0 interven\u00e7\u00e3o fonol\u00f3gica associada \u00e0s estrat\u00e9gias de gamifica\u00e7\u00e3o apresentassem melhor desempenho em termos de porcentagem de acerto das habilidades trabalhadas e um menor tempo terap\u00eautico, quando comparados aos sujeitos submetidos \u00e0 terapia fonol\u00f3gica tradicional.No tocante ao desempenho dos grupos, os achados obtidos apontaram que n\u00e3o houve diferen\u00e7a, tanto em rela\u00e7\u00e3o \u00e0 acur\u00e1cia nas etapas de interven\u00e7\u00e3o  quanto a,15 que n\u00e3o mostraram diferen\u00e7a estatisticamente significante em rela\u00e7\u00e3o ao desempenho da produ\u00e7\u00e3o de fala entre interven\u00e7\u00f5es com e sem estrat\u00e9gias de gamifica\u00e7\u00e3o.Esses resultados concordam com os estudos, o resultado apresentado pode ser explicado devido \u00e0 realiza\u00e7\u00e3o de apenas um atendimento semanal com dura\u00e7\u00e3o de 30 minutos, no per\u00edodo de 8 semanas de interven\u00e7\u00e3o; fato que poderia ser um considerado um espa\u00e7o curto de tempo para evidenciar diferen\u00e7as entre os dois tipos de interven\u00e7\u00e3o.Em um dos estudos mencionadosNo presente estudo, os atendimentos tamb\u00e9m foram realizados em 8 semanas com dois atendimentos semanais com dura\u00e7\u00e3o de 50 minutos, n\u00e3o sendo observada diferen\u00e7a entre os grupos quanto ao n\u00famero de sess\u00f5es., no qual verificou-se que a estrat\u00e9gia de gamifica\u00e7\u00e3o com o uso do computador favorece mais mudan\u00e7as no sistema fonol\u00f3gico dos sujeitos quando comparado com a terapia tradicional. Todavia, os autores deste estudo alertaram para a necessidade de realizar outras pesquisas com amplia\u00e7\u00e3o da casu\u00edstica para confirma\u00e7\u00e3o dos achados, considerando que apenas quatro sujeitos participaram da pesquisa.Em contrapartida, esses achados divergem daqueles apresentados em outro estudo, como demonstrado com o uso Software de Interven\u00e7\u00e3o para Fala (SIFALA), j\u00e1 que o mesmo permitiu explorar e alcan\u00e7ar os objetivos do tratamento de sujeitos com TF que inclu\u00edram ensinar a produ\u00e7\u00e3o correta dos sons da fala, facilitar a representa\u00e7\u00e3o lexical e o armazenamento das informa\u00e7\u00f5es a respeito do sistema fon\u00e9tico-fonol\u00f3gico.Outrossim, outros autores tamb\u00e9m concordaram em uma pesquisa com os benef\u00edcios dos jogos de gamifica\u00e7\u00e3o em terapia, realizaram a aplica\u00e7\u00e3o de question\u00e1rios direcionados para fonoaudi\u00f3logos e sujeitos com TF para verificar a usabilidade e utilidade do jogo digital KeRa Puzzle em interven\u00e7\u00e3o terap\u00eautica, e, os achados mostraram que o jogo de gamifica\u00e7\u00e3o possuiu usabilidade satisfat\u00f3ria, al\u00e9m de poder ser um recurso interessante para tornar as sess\u00f5es mais l\u00fadicas.Demais pesquisadoresFatores como familiaridade com o computador, idade do sujeito, aspectos motivacionais, participa\u00e7\u00e3o familiar, n\u00famero de sujeitos e heterogeneidade intra-grupo podem estar na base da explica\u00e7\u00e3o da n\u00e3o diferen\u00e7a entre os tipos de interven\u00e7\u00e3o.Embora a familiaridade com o computador n\u00e3o tenha sido considerada como uma vari\u00e1vel a ser analisada, observou-se que tr\u00eas sujeitos do GG  j\u00e1 tinham conhecimento e interesse em manusear o computador e jogos eletr\u00f4nicos, esse fato favoreceu o engajamento durante todo o uso da ferramenta nas sess\u00f5es. Entretanto, os sujeitos S3 e S8 (tamb\u00e9m pertencentes ao GG) nunca tinham utilizado o computador e, inicialmente, apresentaram dificuldades com o manuseio do dispositivo eletr\u00f4nico, o que dificultou o engajamento e a motiva\u00e7\u00e3o com o game proposto de modo imediato.ranking, pontua\u00e7\u00e3o e premia\u00e7\u00e3o interativa para despertar o interesse dos envolvidos, encorajando-os a continuar e respeitando suas potencialidades.Outra poss\u00edvel hip\u00f3tese explicativa diz respeito \u00e0 idade dos sujeitos do GG, pois observou-se que os sujeitos S2, S7 e S9 com idades de 5:11, 5:5 e 6:11, respectivamente, apresentaram maior interesse no game e aten\u00e7\u00e3o sustentada ao compar\u00e1-los com os sujeitos S3 e S7 com idades de 4:11 e 5:0. Um fator importante nos sujeitos de idades menores, foi a necessidade de potencializar durante a atividade os elementos da gamifica\u00e7\u00e3o, como ,2, foi observado que a combina\u00e7\u00e3o efetiva das motiva\u00e7\u00f5es intr\u00ednseca (desejo pr\u00f3prio e interno) e extr\u00ednseca (jogo de gamifica\u00e7\u00e3o proposto) contribu\u00edram para n\u00edvel de motiva\u00e7\u00e3o e engajamento dos sujeitos do GG. Entretanto, n\u00e3o foi observado diferen\u00e7a entre este aspecto no GC.Considerando que um dos elementos da gamifica\u00e7\u00e3o \u00e9 o aspecto motivacional-25. Esse aspecto n\u00e3o foi um fator considerado na an\u00e1lise do estudo. Por\u00e9m, evidentemente, a participa\u00e7\u00e3o familiar dos sujeitos participantes da pesquisa, traduzida na realiza\u00e7\u00e3o de atividades domiciliares solicitadas durante o processo terap\u00eautico, foi bastante heterog\u00eanea, podendo ser considerada um fator influente no desempenho e interesse terap\u00eautico dos sujeitos independentemente do tipo de interven\u00e7\u00e3o aplicada.No que se refere \u00e0 participa\u00e7\u00e3o familiar, estudos em \u00e2mbito nacional e internacional t\u00eam destacado a relev\u00e2ncia da participa\u00e7\u00e3o familiar dos pais/respons\u00e1veis no processo de interven\u00e7\u00e3o para contribui\u00e7\u00e3o da efic\u00e1cia terap\u00eauticaEm rela\u00e7\u00e3o ao n\u00famero de sujeitos, a limita\u00e7\u00e3o do estudo est\u00e1 em rela\u00e7\u00e3o ao tamanho da amostra, o que n\u00e3o permite uma generaliza\u00e7\u00e3o dos resultados. Em raz\u00e3o disso, recomenda-se que sejam feitos estudos futuros randomizados e com amostra ampliada.Destaca-se tamb\u00e9m a heterogeneidade, em termos de grau de severidade do TF, presente no interior de cada grupo. No GC composto pelos sujeitos S1, S4, S5, S6 e S10, no final do processo terap\u00eautico, a maioria destes suprimiram os processos de substitui\u00e7\u00e3o de l\u00edquidas, exceto o S10 que ainda apresentou 75% de produ\u00e7\u00e3o correta do fone contrastivo /\u027e/. Ao comparar o sujeito S10 com os demais sujeitos pertencentes ao mesmo grupo, notou-se que este apresentou maior grau de severidade do TF (levemente-moderado) e outros processos fonol\u00f3gicos para al\u00e9m da classe das l\u00edquidas.Diferentemente, no GG, composto pelos sujeitos S2, S3, S7, S8 e S9, apenas o S2 suprimiu o processo fonol\u00f3gico trabalhado, considerando que este foi o \u00fanico que apresentou gravidade Leve do TF e processos fonol\u00f3gicos somente na classe das l\u00edquidas. Os demais participantes do grupo, por sua vez, apresentaram maior grau de severidade do TF e outros processos fonol\u00f3gicos os quais envolviam diferentes classes.Embora o foco principal do presente estudo n\u00e3o tenha sido comparar o desempenho dos sujeitos em rela\u00e7\u00e3o \u00e0s habilidades trabalhadas em terapia, observou-se que nos dois grupos as condi\u00e7\u00f5es pr\u00e9-terapia mostraram uma baixa porcentagem de acerto dos sons-alvo comparativamente com as etapas de percep\u00e7\u00e3o (no outro e em si) e produ\u00e7\u00e3o de fala. Isso significa dizer que a partir do in\u00edcio do processo de interven\u00e7\u00e3o todos sujeitos j\u00e1 apresentam uma mudan\u00e7a em termos de acur\u00e1cia. sobre a possibilidade de a habilidade de percep\u00e7\u00e3o preceder a habilidade de produ\u00e7\u00e3o de fala, ou seja, para que um sujeito produza apropriadamente determinado fone contrastivo, \u00e9 necess\u00e1rio que o mesmo perceba as propriedades fon\u00e9ticas-fonol\u00f3gicas para depois fundamentar essas propriedades em suas pr\u00f3prias produ\u00e7\u00f5es.Dentre as etapas, a acur\u00e1cia (% de acerto) de percep\u00e7\u00e3o (no outro e em si) se diferenciam da acur\u00e1cia da produ\u00e7\u00e3o de fala para os dois grupos. Os sujeitos apresentaram melhores desempenhos de percep\u00e7\u00e3o do que de produ\u00e7\u00e3o de fala. Este resultado corrobora a assun\u00e7\u00e3o de um estudo, os autores ressaltam que a correla\u00e7\u00e3o existente entre produ\u00e7\u00e3o e percep\u00e7\u00e3o \u00e9 dependente da classe fonol\u00f3gica e, ainda, que os erros de percep\u00e7\u00e3o de fala n\u00e3o espelham os erros de produ\u00e7\u00e3o de fala.Outro aspecto a ser considerado \u00e9 o de que n\u00e3o existe uma correla\u00e7\u00e3o un\u00edvoca entre produ\u00e7\u00e3o e percep\u00e7\u00e3o de fala. Conforme mencionado em estudo anterior, particularmente, refere que a presen\u00e7a de uma correla\u00e7\u00e3o significativa entre as habilidades de produ\u00e7\u00e3o de fala e percep\u00e7\u00e3o da pr\u00f3pria produ\u00e7\u00e3o de fala at\u00edpica do sujeito sugere que a avalia\u00e7\u00e3o de tais habilidades parece acessar a mesma forma de representa\u00e7\u00e3o fonol\u00f3gica subjacente. Ou seja, se um sujeito que n\u00e3o estabeleceu a representa\u00e7\u00e3o subjacente para um determinado contraste fonol\u00f3gico afetar\u00e1 ambas as habilidades: percep\u00e7\u00e3o da fala do outro e percep\u00e7\u00e3o de sua pr\u00f3pria fala, uma vez que o desempenho nas habilidades de percep\u00e7\u00e3o requer o acesso a um sistema simb\u00f3lico, podendo causar ou contribuir para d\u00e9ficits na produ\u00e7\u00e3o e percep\u00e7\u00e3o da fala.Outro estudoAo considerar os supracitados, portanto, a habilidade de percep\u00e7\u00e3o de fala nos direciona para uma importante implica\u00e7\u00e3o no processo de reabilita\u00e7\u00e3o nos modelos de base fonol\u00f3gica, visto que, sua inclus\u00e3o na avalia\u00e7\u00e3o e interven\u00e7\u00e3o \u00e9 uma medida valiosa para se atingir a efic\u00e1cia terap\u00eautica.Em rela\u00e7\u00e3o \u00e0 compara\u00e7\u00e3o dos valores do PCC-R, observou-se diferen\u00e7as tanto em rela\u00e7\u00e3o \u00e0s condi\u00e7\u00f5es pr\u00e9 versus p\u00f3s, quanto em rela\u00e7\u00e3o aos grupos . Como apNo entanto, cabe destacar que mesmo antes da interven\u00e7\u00e3o terap\u00eautica (pr\u00e9-terapia) os sujeitos do GC j\u00e1 apresentavam valores de PCC-R superiores do que o GG. Tal fato ressalta uma limita\u00e7\u00e3o consider\u00e1vel deste estudo, posto que, o ideal seria equilibrar a distribui\u00e7\u00e3o dos sujeitos em cada grupo de acordo com a gravidade do TF .Ambos os modelos de interven\u00e7\u00e3o  propiciam melhora no desempenho fonol\u00f3gico do sujeito a partir da primeira sess\u00e3o. N\u00e3o houve diferen\u00e7a no tempo de terapia nem entre a m\u00e9dia da porcentagem de acerto na produ\u00e7\u00e3o das palavras-alvo entre as duas abordagens.Uma importante implica\u00e7\u00e3o terap\u00eautica refere-se \u00e0 possibilidade do uso de estrat\u00e9gia de gamifica\u00e7\u00e3o com o uso do computador, podendo se obter resultados semelhantes \u00e0queles esperados na terapia tradicional.O desenvolvimento do presente estudo visou contribuir com as discuss\u00f5es cient\u00edficas acerca da terapia no campo da Fonologia Cl\u00ednica, favorecer com o estabelecimento de processos interventivos de media\u00e7\u00e3o fonoaudiol\u00f3gica com estrat\u00e9gias de gamifica\u00e7\u00e3o e incentivar a constru\u00e7\u00e3o de novos jogos de gamifica\u00e7\u00e3o que envolvam etapas de percep\u00e7\u00e3o e produ\u00e7\u00e3o de fala."}
+{"text": "Objetivos\u2003Avaliar a variabilidade da contagem autom\u00e1tica tridimensional dos fol\u00edculos ovarianos que mediram 2 a 6\u2009mm e 2 a 10\u2009mm durante o ciclo menstrual. Verificar se este exame pode ser aplicado fora da fase folicular precoce do ciclo.M\u00e9todo\u2003Prospectivo observacional. Foram inclu\u00eddas todas as pacientes inf\u00e9rteis submetidas \u00e0 monitoriza\u00e7\u00e3o da ovula\u00e7\u00e3o de 20 de abril de 2013 a 30 de outubro de 2014, com 18 a 35 anos; IMC de 18 a 25 kg/m2, eumenorr\u00e9icas; sem hist\u00f3ria de cirurgia ovariana e sem altera\u00e7\u00f5es nas dosagens do TSH, prolactina, insulina e glicemia. Foram exclu\u00eddas aquelas que apresentaram cistos ovarianos e as que faltaram algum dia da monitoriza\u00e7\u00e3o. A contagem ultrassonogr\u00e1fica dos fol\u00edculos foi feita pelo modo 3D com SonoAVC na fase folicular precoce, folicular media, periovulat\u00f3ria e l\u00fatea do ciclo.Resultados\u2003Quarenta e cinco mulheres foram inclu\u00eddas. Houve diferen\u00e7a entre as m\u00e9dias das contagens dos fol\u00edculos com 2 a 6\u2009mm  e 2 a 10\u2009mm  pelo teste de Friedman que avaliou conjuntamente as quatro fases do ciclo. Quando se aplicou o teste t-Student pareado, houve aumento significativo na contagem dos fol\u00edculos de 2 a 6\u2009mm quando se comparou a contagem desses fol\u00edculos na fase folicular m\u00e9dia e periovulat\u00f3ria com a contagem da fase l\u00fatea. N\u00e3o houve diferen\u00e7a significante entre a contagem destes fol\u00edculos pequenos nas fases folicular precoce, m\u00e9dia e periovulat\u00f3ria.Conclus\u00f5es\u2003A varia\u00e7\u00e3o da contagem autom\u00e1tica tridimensional dos fol\u00edculos de 2 a 6\u2009mm, nas fases folicular precoce, folicular m\u00e9dia e periovulat\u00f3ria, n\u00e3o mostrou signific\u00e2ncia estat\u00edstica. Houve uma varia\u00e7\u00e3o significativa da contagem autom\u00e1tica 3D dos fol\u00edculos ovarianos de 2 a 10\u2009mm durante o ciclo. A variabilidade significativa da contagem dos fol\u00edculos de 2 a 10\u2009mm durante o ciclo n\u00e3o permite que este exame seja realizado fora da fase folicular precoce. Fol\u00edculos antrais s\u00e3o unidades histol\u00f3gicas do ov\u00e1rio que se formam ap\u00f3s uma cavita\u00e7\u00e3o que ocorre na camada granulosa dos fol\u00edculos pr\u00e9-antrais. O n\u00famero de fol\u00edculos ovarianos que chegam ao est\u00e1dio ovulat\u00f3rio \u00e9 muito pequeno. Mais de 99% de todos os fol\u00edculos sofrem um processo degenerativo apopt\u00f3tico conhecido por atresia. Este processo pode ocorrer em qualquer est\u00e1gio do desenvolvimento dos fol\u00edculos e em qualquer fase do ciclo menstrual. Pela ultrassonografia \u00e9 poss\u00edvel visualizar os fol\u00edculos que t\u00eam antro e s\u00e3o maiores que 2\u2009mm mas n\u00e3o \u00e9 poss\u00edvel identificar quais est\u00e3o em processo de atresia. Padronizou-se que a contagem ultrassonogr\u00e1fica dos fol\u00edculos ovarianos deve incluir todas as imagens anec\u00f3icas, que medem 2 a 10\u2009mm, e est\u00e3o distribu\u00eddas no par\u00eanquima ovariano.Foram publicados recentemente alguns trabalhos com a contagem ultrassonogr\u00e1fica dos fol\u00edculos de 2 a 6 mm. Os autores justificaram que a somat\u00f3ria dos fol\u00edculos ovarianos menores poderia melhorar o valor preditivo deste teste.Somente com o aperfei\u00e7oamento recente das imagens ultrassonogr\u00e1ficas e o desenvolvimento de um software dedicado foi poss\u00edvel fazer a contagem autom\u00e1tica tridimensional dos fol\u00edculos. A medida do tamanho e do volume dos fol\u00edculos \u00e9 mais precisa quando avaliada pela ultrassonografia tridimensional. Estudos recentes mostram que o duplo processamento das imagens proporciona alto grau de reprodutibilidade para a contagem ultrassonogr\u00e1fica dos fol\u00edculos ovarianos, sendo superior \u00e0s t\u00e9cnicas bidimensionais.A maioria dos estudos sobre a confiabilidade e a validade dos v\u00e1rios testes da reserva ovariana \u00e9 baseada em exames realizados durante a fase folicular precoce do ciclo menstrual. Esta janela de oportunidade relativamente pequena \u00e9 restritiva tanto para os pacientes quanto para as cl\u00ednicas que executam os testes.V\u00e1rios grupos t\u00eam sugerido uma boa estabilidade dos n\u00edveis do horm\u00f4nio anti-M\u00fclleriano ao longo do ciclo menstrual,Os objetivos deste estudo foram avaliar a variabilidade da contagem autom\u00e1tica tridimensional dos fol\u00edculos ovarianos que mediram 2 a 6\u2009mm e 2 a 10\u2009mm durante o ciclo menstrual. Tamb\u00e9m teve o objetivo de verificar se este teste pode ser aplicado fora da fase folicular precoce do ciclo ovariano.Foi feito um estudo prospectivo observacional no per\u00edodo de 20 de abril de 2013 a 30 de outubro de 2014, em uma cl\u00ednica de Reprodu\u00e7\u00e3o Assistida, a Humana Medicina Reprodutiva. O projeto foi aprovado pelo Comit\u00ea de \u00c9tica em Pesquisa do Hospital das Cl\u00ednicas da Universidade Federal de Goi\u00e1s.2, ciclos menstruais regulares com um intervalo de 26 a 32 dias, sem hist\u00f3ria de cirurgia ovariana e sem altera\u00e7\u00f5es hormonais sugestivas de doen\u00e7a end\u00f3crina como altera\u00e7\u00e3o da dosagem do TSH, prolactina, insulina de jejum e glicemia de jejum.Foram inclu\u00eddas neste estudo, todas as pacientes que foram submetidas a monitoriza\u00e7\u00e3o da ovula\u00e7\u00e3o para avalia\u00e7\u00e3o do casal inf\u00e9rtil, que estavam na faixa et\u00e1ria de 18 a 35 anos, tinham \u00edndice de massa corporal (IMC) entre 18 e 25 kg/mForam exclu\u00eddas deste estudo, as pacientes que apresentaram cistos ovarianos e as que n\u00e3o compareceram em um ou mais dias da monitoriza\u00e7\u00e3o da ovula\u00e7\u00e3o.O primeiro dia do ciclo das pacientes foi contado a partir do primeiro dia de sangramento vivo da menstrua\u00e7\u00e3o. A contagem ultrassonogr\u00e1fica dos fol\u00edculos ovarianos foi realizada no in\u00edcio do ciclo menstrual (2\u00b0 ao 5\u00b0 dia), na fase folicular media (6\u00b0 ao 10\u00b0 dia), no per\u00edodo periovulat\u00f3rio (12\u00b0 ao 16\u00b0 dia) e na fase l\u00fatea (20\u00b0 ao 26\u00b0 dia). A avalia\u00e7\u00e3o da fase periovulat\u00f3ria teve in\u00edcio no 12\u00b0 dia do ciclo ovariano. A partir do 12\u00b0 dia foi feita monitoriza\u00e7\u00e3o di\u00e1ria at\u00e9 o instante que foi percebido um fol\u00edculo dominante maior que 16 mm. Este dia foi considerado como momento periovulat\u00f3rio. A avalia\u00e7\u00e3o da fase l\u00fatea foi feita sete dias ap\u00f3s este momento.As ultrassonografias foram realizadas somente pelo pesquisador. Foi utilizado um equipamento Voluson\u00ae E6  no modo tridimensional, sistema de alta resolu\u00e7\u00e3o e ferramenta de automa\u00e7\u00e3o . As imagens foram captadas com transdutor transvaginal de 5 a 9 MHz.A t\u00e9cnica ultrassonogr\u00e1fica empregada para a contagem e medi\u00e7\u00e3o dos fol\u00edculos ovarianos foi iniciada com o delineamento do ov\u00e1rio ainda no modo bidimensional. Esta imagem inicial foi selecionada com a digita\u00e7\u00e3o da tecla [3D] para gerar um volume tridimensional que englobou todo o ov\u00e1rio e excluiu as imagens extraovarianas. Uma vez que este conjunto de dados foi corretamente posicionado, o modo de varredura lenta do equipamento foi predefinido para percorrer um feixe com \u00e2ngulo de 95\u00b0. Foi ent\u00e3o digitado a tecla [Freeze] do ultrassom para a capta\u00e7\u00e3o do volume ovariano. Neste momento, o sistema apresentou na tela do aparelho uma imagem que permitiu nova adequa\u00e7\u00e3o da regi\u00e3o tridimensional para inclus\u00e3o de todo o ov\u00e1rio. Para a an\u00e1lise do volume selecionado, o bot\u00e3o [SonoAVC Follicles] foi digitado. Na nova tela de comandos, foi digitado [Right Ovary Start] para o ov\u00e1rio direito. Com isso foi exibida automaticamente, no canto superior esquerdo da tela do ultrassom, uma lista com a descri\u00e7\u00e3o dos volumes e dimens\u00f5es correspondentes \u00e0s imagens hipoecog\u00eanicas que pertenciam ao ov\u00e1rio e \u00e0s regi\u00f5es adjacentes. O contorno de cada fol\u00edculo aparecia desenhado por cores diferentes. Todos os fol\u00edculos detectados foram descritos e listados de acordo com o tamanho e a cor de cada um deles.Ap\u00f3s o processamento inicial das imagens, explicitado acima, fez-se um segundo processamento manual que consistiu na identifica\u00e7\u00e3o e delimita\u00e7\u00e3o dos fol\u00edculos que n\u00e3o foram contados e medidos automaticamente. Com o segundo processamento, tamb\u00e9m foi poss\u00edvel a exclus\u00e3o de \u00e1reas hipoecog\u00eanicas adjacentes ao ov\u00e1rio que a imagem ultrassonogr\u00e1fica indicava que n\u00e3o eram pertencentes a este \u00f3rg\u00e3o. Essa verifica\u00e7\u00e3o posterior foi feita para assegurar que todos os fol\u00edculos haviam sido contados e medidos corretamente.Para o ov\u00e1rio esquerdo foi realizada a mesma sequ\u00eancia. Por\u00e9m, ap\u00f3s a segunda sele\u00e7\u00e3o da regi\u00e3o tridimensional de interesse, realizava-se a digita\u00e7\u00e3o de [Left Ovary Start] e em seguida iniciava-se o segundo processamento. O di\u00e2metro m\u00e9dio de cada fol\u00edculo dos dois ov\u00e1rios foi gravado e utilizado para an\u00e1lise posterior dos dados.O Statistical Package for Social Sciences  foi utilizado para a an\u00e1lise estat\u00edstica. O teste de Friedman foi aplicado para avaliar se havia uma varia\u00e7\u00e3o significativa da contagem autom\u00e1tica dos fol\u00edculos ovarianos nas quatro fases do ciclo menstrual analisadas. O teste t-Student pareado foi utilizado para fazer a compara\u00e7\u00e3o entre duas fases do ciclo.Foram submetidas a monitoriza\u00e7\u00e3o da ovula\u00e7\u00e3o no per\u00edodo do estudo 45 mulheres; o SonoAVC foi empregado em trezentos e sessenta ocasi\u00f5es uma vez que dois ov\u00e1rios foram examinados em quatro fases do ciclo menstrual.2.A m\u00e9dia da idade das pacientes foi de 30,1 anos com desvio padr\u00e3o de 3,9 e a m\u00e9dia do IMC foi 22,6 com desvio padr\u00e3o de 3,0 kg/mp\u2009=\u20090,001) que avaliou conjuntamente a contagem dos fol\u00edculos das quatro fases do ciclo ovariano   .Por \u00faltimo, foi realizado o pareamento das m\u00e9dias da contagem dos fol\u00edculos de 2 a 10\u2009mm nas quatro fases do ciclo ovulat\u00f3rio. Nesta an\u00e1lise foi poss\u00edvel perceber, pelo teste t-Student pareado, que a m\u00e9dia das contagens da fase folicular precoce apresentou diferen\u00e7a estatisticamente significante com este mesmo dado calculado na fase folicular m\u00e9dia .No presente estudo, todas as contagens foliculares foram feitas por um examinador \u00fanico e experiente para descartar a possibilidade da varia\u00e7\u00e3o que pode acontecer nos laudos emitidos por observadores diferentes. Esta pesquisa n\u00e3o encontrou diferen\u00e7a na contagem autom\u00e1tica tridimensional, dos fol\u00edculos de 2 a 6\u2009mm, realizada na fase folicular precoce, folicular m\u00e9dia e periovulat\u00f3ria. Entretanto, houve aumento no n\u00famero destes fol\u00edculos quando os mesmos foram contados na fase l\u00fatea do ciclo. Houve variabilidade significativa da contagem dos fol\u00edculos de 2 a 10\u2009mm nas diferentes fases do ciclo.Foram encontrados, at\u00e9 o momento, poucos estudos em que se analisou a variabilidade da contagem ultrassonogr\u00e1fica dos fol\u00edculos ovarianos no ciclo menstrual. Desde o final da d\u00e9cada passada, os autores j\u00e1 acreditavam que a maior variabilidade da contagem bidimensional dos fol\u00edculos era decorrente de uma menor reprodutibilidade deste m\u00e9todo.No final de 2007, especialistas em medicina reprodutiva se reuniram para sistematiza\u00e7\u00e3o dos conhecimentos sobre a contagem ultrassonogr\u00e1fica dos fol\u00edculos ovarianos.Em 2010, um trabalho pioneiro no qual se analisou a varia\u00e7\u00e3o da contagem dos fol\u00edculos ovarianos no ciclo menstrual, usando a ultrassonografia no modo 2D. Foi publicado um estudo prospectivo com quarenta e quatro mulheres. Estes autores foram os primeiros a estratificar a contagem dos fol\u00edculos em tamanhos diferentes. O grupo concluiu que a diferen\u00e7a das contagens nas diversas fases do ciclo n\u00e3o eram grandes mesmo usando o modo manual 2D da ultrassonografia. Verificou-se que as flutua\u00e7\u00f5es das contagens, que ocorriam no ciclo, tinham pouca import\u00e2ncia e que poderiam ser consideradas como achados fortuitos ou causadas por vi\u00e9s de mensura\u00e7\u00e3o. A contagem dos fol\u00edculos de 2 a 5\u2009mm mostrou maior variabilidade ao longo do ciclo ovulat\u00f3rio do que a contagem dos fol\u00edculos de 2 a 10\u2009mm e recomendaram a contagem destes fol\u00edculos maiores para a avalia\u00e7\u00e3o da reserva ovariana.Os resultados do presente estudo est\u00e3o discordantes dos achados de van Disseldorp et alEm uma padroniza\u00e7\u00e3o da contagem dos fol\u00edculos ovarianos com ultrassonografia 2D foi recomendada a contagem dos fol\u00edculos de 2 a 10\u2009mm de di\u00e2metro para evitar o processo moroso de medi\u00e7\u00e3o de cada fol\u00edculo por se acreditar que este seria um m\u00e9todo mais pr\u00e1tico para contagem dos fol\u00edculos ovarianos na cl\u00ednica. Preconizava tamb\u00e9m que a contagem dos fol\u00edculos deveria ser feita na fase folicular precoce para minimizar a flutua\u00e7\u00e3o das medidas que poderiam ocorrer durante o ciclo menstrual.Uma quest\u00e3o, ainda n\u00e3o respondida, \u00e9 se a nova ultrassonografia tridimensional com software de automa\u00e7\u00e3o melhorou a versatilidade da contagem dos fol\u00edculos ovarianos ap\u00f3s o conhecido aumento da reprodutibilidade que este exame proporcionou. Outro ponto importante \u00e9 que a necessidade da contagem de fol\u00edculos ovarianos menores aumenta muito a dificuldade do exame no modo 2D, principalmente nas mulheres que apresentam grande quantidade de fol\u00edculos.O \u00fanico estudo, que avaliou os fol\u00edculos ovarianos pela ultrassonografia, utilizando o SonoAVC, foi o de Deb et al.Os resultados do presente estudo, que tamb\u00e9m utilizou o SonoAVC, est\u00e3o parcialmente de acordo com os resultados de Deb et alAs diferen\u00e7as dos resultados entre os trabalhos que utilizaram a ultrassonografia 2D e os estudos que est\u00e3o utilizando a ultrassonografia 3D com automa\u00e7\u00e3o est\u00e1 na melhor reprodutibilidade desta nova metodologia e a confiabilidade do novo m\u00e9todo foi bem documentada1.Para se estabelecer as doses de gonadotrofinas ex\u00f3genas usa-se contagem dos fol\u00edculos de 2 a 10\u2009mm que devem ser aplicadas nos ciclos de fertiliza\u00e7\u00e3o in vitro."
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